DISCLAIMER This paper was submitted to the Bulletin of the World Health Organization and was posted to the COVID-19 open site, according to the protocol for public health emergencies for international concern as described in Vasee Moorthy et al. (http://dx.doi.org/10.2471/BLT.20.251561). The information herein is available for unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited as indicated by the Creative Commons Attribution 3.0 Intergovernmental Organizations licence (CC BY IGO 3.0).

Background Although almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients. Methods In this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/kg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8). Results There were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040). Conclusion In hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone. Trial registration The trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1).

Background: In March 2020, the WHO declared the novel coronavirus (COVID-19) outbreak a global pandemic. Although the number of infected cases is increasing, information about its clinical characteristics in the Middle East, especially in Iran, a country which is considered to be one of the most important focal points of the disease in the world, is lacking. To date, there is no available literature on the clinical data on COVID-19 patients in Iran. Methods: In this multicenter retrospective study, 113 hospitalized confirmed cases of COVID-19 admitted to university affiliated hospitals in Shiraz, Iran from February 20 to March 20 were entered in the study. Results: The mean age was 53.75 years and 71 (62.8%) were males. The most common symptoms at onset were fatigue (75: 66.4%), cough (73: 64.6%), and fever (67: 59.3%). Laboratory data revealed significant correlation between lymphocyte count (P value = 0.003), partial thromboplastin time (P value = 0.000), international normalized ratio (P value = 0.000) with the severity of the disease. The most common abnormality in chest CT scans was ground-glass opacity (77: 93.9%), followed by consolidation (48: 58.5%). Our results revealed an overall 8% (9 out of 113 cases) mortality rate among patients, in which the majority was among patients admitted to the ICU (5: 55.6%). Conclusion: Evaluating the clinical data of COVID-19 patients and finding the source of infection and studying the behavior of the disease is crucial for understanding the pandemic.

Background In March 2020, WHO has declared pandemic on COVID-19. Although the number of infected cases is increasing, information about its clinical characteristics in the Middle East especially in Iran, a country which is considered as one of the most important foci of the disease in the world is lacking. Till date, there is no available literature on the clinical data on COVID-19 patients in Iran. Method and Material: In this multicenter retrospectively registered study, 113 hospitalized confirmed cases of COVID-19 admitted in university affiliated hospitals in Shiraz, Iran in from February 20 to March 20 were enrolled. Results The median age was 53 years and 71 (62.8%) were males. The most common symptoms at onset were fatigue (75: 66.4%), cough (73: 64.6%), and fever (67: 59.3%). Laboratory data revealed significant correlation between lymphocyte count, partial thromboplastin time, international normalized ratio with the severity of the disease (P value = 0.003, 0.000, 0.000, respectively). The most common abnormality in chest CT scan was ground-glass opacity (77: 93.9%), followed by consolidation (48: 58.5%). Our results revealed an overall 8% (9 out of 113 cases) mortality rate among the patients, in which the majority was among the ICU admitted patients (5: 55.6%). Also, 68 (60.2%) of our patients achieved total recovery and 7 (6.2%) were discharged with follow-up and home isolation. Conclusion In this multi-center study which included 113 hospitalized patients with diagnosis of COVID-19, 9.7% of cases were transferred to ICU and mortality rate was 8%. Furthermore, finding the source of infection and studying the behavior of COVID-19 is crucial for understanding the pandemic.

Introduction Residency applications via virtual-interview could potentially mitigate the extensive cost and time required for customary in-person interviews. We outline the perception of medical students and residents on the use of virtual-interview for residency applications in lieu of in-person interviews. Methods We obtained 1824 responses from medical students and residents through an online questionnaire between March2019-Feb2020 in Texas-United States. The survey had 11 statements (five in favor of in-person interviews and 6 in favor of virtual interviews) that respondents could rank on a 5-point Likert scale. All statements' scores were summed based on the response given by each participant to create a total score between 11 and 55. The perception of the two groups was analyzed using an independent sample T-test and ANOVA. Results We received a total of 1711 responses from medical students and 113 from medical residents. Respondents were more female (82.2% of medical students and 47.8% of residents), with a mean age of 22.87±3.42 years old for medical students and 28.72±4.35 years old for residents. Both groups preferred in-person interviews; however, the residents were significantly more in favor (P = 0.03). Both groups agree that virtual-interviews should be as an option, though this was considerably higher in the medical students (P = 0.001). In the multivariate analysis, "travel distance" and "type of medical school" had a significant impact on choosing the virtual-interviews in both groups (p<0.01). Conclusions In-person interviews are favored by both medical students and residents compared to virtual-interview services in normal circumstances. However, both groups agree that programs should offer the option of having virtual-interviews as an available choice. Distance to an

Objective: To estimate the prevalence of waterpipe smoking among rural pregnant women in Southern Iran and to identify the impact of maternal waterpipe smoking on baby’s birth weight. Subjects and Methods: A population-based survey was conducted in rural areas of Southern Iran in 2004 using existing health records and interviewing all mothers during the 10 days after delivery. Maternal exclusion criteria included cigarette smoking during pregnancy, a history or occurrence of epilepsy, diabetes and hypertension (gestational and/or essential) during pregnancy, factors that have been proved to have detrimental effects on birth weight. Results: Of the 2,808 mothers interviewed, 224 (8%) were waterpipe smokers of which 90 (3.2%) and 134 (4.8%) were occasional (smoking less than once per day) and daily (at least once per day) smokers, respectively. Six hundred and seventy-four (24%) were passively exposed to waterpipe smoke during pregnancy and 322 (11.5%) were exposed to second-hand cigarette smoke. Mothers who started smoking during the first trimester had lower birth weight babies (3,215 ± 612 g) compared to those who started smoking during the second or third trimesters (3,447 ± 550 g, p = 0.04). Conclusion: Waterpipe smoking during pregnancy is prevalent in Southern Iran and appears to be a risk factor for low birth weight babies.

Background Disease outbreak not only carries the risk of death to the public due to the infection, but it also can lead to unbearable psychological impact on the mental health of the individuals. This study aims to explore and evaluate the burden of psychological problems on the Iranian general population during the outbreak of COVID-19. Method A cross-sectional web-based survey was conducted among the general population of Iran age 15 and above. Demographic variables, depression, and anxiety symptoms were evaluated using the Patient Health Questionnaire-9 and General Anxiety Disorder-7 questionnaires. Results Among the 8591 participants, the mean age was 34.37 (± 11.25) years and 66.4% were female while 33.6% were male. Based on our results, 1295 (15.1%) and 1733 (20.1%) of the general population had clinically significant depressive and anxiety symptoms, respectively. Based on the demographic variables, female gender was associated with a higher risk for developing depression and anxiety symptoms, whereas getting information about the disease from medical journals and articles, being older, and being married were considered as associated protective factors. In terms of depression, being a healthcare worker was an associated risk factor. On the other hand, for anxiety, having higher education was a protective factor while a higher number of individuals in a household was considered as a risk factor. Conclusions This study identified a major mental health problem in the Iranian population during the time of the COVID-19 outbreak. Therefore, establishing a targeted mental health support program during the time of public emergencies, such as the disease outbreak, is advised.

Introduction: The prevalence of type 2 diabetes mellitus (T2D) has increased considerably while the outcome of diabetic management is suboptimal. In order to promote diabetic management, associated factors for adherence to medications, diet, and physical activity (PA) need to be more clearly identified amongst patients with T2D. Methods: This cross-sectional study was conducted on 206 men and 294 women amongst patients with diabetes who were registered in ten special diabetic clinics in Shiraz, Iran from November 2018 to April 2019. Levels of adherence to medication, Mediterranean diet (MD), and physical activity were measured with validated and appropriate questionnaires. Results: Mean age (± SD) was 56.92 ± 0.52 years and 294 (58.8%) were female. Data showed that reduced adherence to medication, MD, and PA increased glycated hemoblobin (HbA1c). Adherence to medication among low, moderate, and high levels was 27.2%, 59.2%, and 13.6%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, divorced widow, smoker, and exsmoker had a significant influence on adherence to medication, P = 0.017, P = 0.018, P = 0.008. P = 0.045, P = 0.026, P\0.004, and P = 0.001, respectively. In addition, adherence to MD among low, moderate, and high levels was 5.4%, 77.2%, and 17.4%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, and smoker had a significant influence on adherence to MD, P = 0.011, P = 0.046, P = 0.002, P\0.001, and P = 0.032, respectively. Furthermore, adherence to PA among low, moderate, and high levels was 21%, 68.6%, and 10.4%, respectively. Only the non-smoker factor played a significant role in PA adherence, P = 0.010. Conclusion: Levels of adherence to medications, diet, and PA amongst patients with T2D are not within the acceptable range. Recognized associated factors that contribute to adherence might improve diabetes management and allow one to tailor the appropriate message to improve glycemic indices.Enhanced Digital Features To view enhanced digital features for this article go to https://doi.org/10.6084/ m9.figshare.11358593. A. Mirahmadizadeh Key Summary PointsWhy carry out this study?In order to promote diabetic management, the associated factors for adherence to medications, diet, and physical activity (PA) need to be more clearly identified amongst patients with type 2 diabetes (T2D).Although the levels of adherence to medication, diet, and physical activity have been evaluated separately in other studies in patients with T2D, few studies have simultaneously evaluated the adherence to these factors.What was learned from the study?Reduced adherence to medication, Mediterranean diet (MD), and PA increased HbA1c.Adherence to medication among low, moderate, and high levels was 27.2%, 59.2%, and 13.6%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, divorced widow, smoker, and exsmoker had a significant influence on adherence to medication...