BackgroundClinical governance (CG) is among the different frameworks proposed to improve the quality of healthcare. Iran, like many other countries, has put healthcare quality improvement in its top health policy priorities. In November 2009, implementation of CG became a task for all hospitals across the country. However, it has been a challenge to clarify the notion of CG and the way to implement it in Iran. The purpose of this action research study is to understand how CG can be defined and implemented in a selected teaching emergency department (ED).Methods/designWe will use Soft Systems Methodology for both designing the study and inquiring into its content. As we considered a complex problem situation regarding the quality of care in the selected ED, we initially conceptualized CG as a cyclic set of purposeful activities designed to explore the situation and find relevant changes to improve the quality of care. Then, implementation of CG will conceptually be to carry out that set of purposeful activities. The activities will be about: understanding the situation and finding out relevant issues concerning the quality of care; exploring different stakeholders’ views and ideas about the situation and how it can be improved; and defining actions to improve the quality of care through structured debates and development of accommodations among stakeholders. We will flexibly use qualitative methods of data collection and analysis in the course of the study. To ensure the study rigor, we will use different strategies.DiscussionSuccessful implementation of CG, like other quality improvement frameworks, requires special consideration of underlying complexities. We believe that addressing the complex situation and reflections on involvement in this action research will make it possible to understand the concept of CG and its implementation in the selected setting. By describing the context and executed flexible methods of implementation, the results of this study would contribute to the development of implementation science and be employed by boards and executives governing other clinical settings to facilitate CG implementation.

Noscapine, possibly by inhibition of bradykinin synthesis, eliminates ACEI-induced cough in the majority of patients and allows them to continue with ACEI therapy.

Background. Some recent suggestions could show omega-3 condition deficiency following prolonged hemodialysis; however, these claims and speculations have not been well demonstrated with sufficient evidences. Hence, we attempted to assess the beneficial effects of omega-3 on lipid profile in patients with end-stage renal disease (ESRD) undergoing hemodialysis.Methods. One hundred and seventeen ESRD patients who were on maintenance dialysis in Rasoul-e-Akram and Madaen Hospitals were enrolled in this randomized clinical trial. These patients were divided into two groups randomly using block randomization method (57 patients as the case group receiving omega-3 for 12 weeks and 60 as the control group). Blood sample was taken from all patients for measurement of lipid profile, serum hemoglobin, and C-reactive protein at baseline as well as after the completion of interventions (after 12 weeks).Results. The average change in the value of HDL-C was significantly more in the patients who received omega-3 than in the control group (MD, -7 mg/dL; 95% CI, -11 to 0 p = 0.000). Also, the reduction in serum creatinine level was more in the omega-3 group than in the control group (MD, 0.7 mg/dL; 95% CI, -0.4 to 2.1 p = 0.023). The change in other indices including serum triglyceride, total cholesterol, and serum hemoglobin levels was not different between the two groups. The multivariable linear regression analysis showed no difference in serum HDL level between the two groups adjusted for sex, age, and time of dialysis, while the level of serum HDL-C could be adversely predicted by duration time. Similar regression model showed a between-group difference in serum creatinine in the presence of potential confounders.Conclusion. The change in serum HDL level following use of omega-3 supplement is influenced by time of dialysis, not by drug effect. However, consumption of omega-3 can significantly reduce serum creatinine.

BackgroundWe performed comprehensive transmitral and pulmonary venous Doppler echocardiographic studies to devise a novel index of diastolic function. This is the first study to assess the utility of the acceleration rate (AR) of the E wave of mitral inflow as a primary diagnostic modality for assessing diastolic function.MethodsStudy group consisted of 84 patients (53 + 11 years) with left ventricle (LV) diastolic dysfunction and 34 healthy people (35 ± 9 years) as control group, who were referred for clinically indicated two-dimensional transthoracic echocardiogram (TTE) during 2012 and 2013 to Imam Hospital. Normal controls were defined as patients without clinical evidence of cardiac disease and had normal TTE. LV diastolic function was determined according to standardized protocol of American Society of Echocardiography (ASE). As our new parameter, AR of E wave of mitral inflow was also measured in all patients. It was represented by the slope of the line between onset of E wave and peak of it. Correlation between AR of E wave and LV diastolic function grade was measured using the Spearman correlation coefficient. Receiver operating characteristic (ROC) curve was used to determine the sensitivity and specificity of AR of E wave in diagnosing LV diastolic dysfunction in randomly selected two-thirds of population then its derived cutoff was evaluated in rest of the population. The institutional review board of the hospital approved the study protocol. All participants gave written informed consent. This investigation was in accordance with the Declaration of Helsinki.ResultsThe mean value of AR was 1010 ± 420 cm/s2 in patients whereas the mean value for the normal controls was 701 ± 210 cm/s2. There was a strong and graded relation between AR of E wave of mitral inflow and LV diastolic function grade (Spearman P ≤0.0001, rs =0.69). ROC curve analysis revealed that AR of E wave of mitral inflow =750 cm/s2 predicted moderate or severe LV diastolic dysfunction with 89 % sensitivity and 89 % specificity (area under curve [AUC] = 0.903, P <0.0001). Application of this cutoff on test group showed 96 % sensitivity and 77 % specificity with AUC = 0.932 and P <0.0001.ConclusionAR of E wave of mitral inflow could be used for assessment of diastolic function, especially moderate or severe diastolic dysfunction. However, before its clinical application, external validation should be considered.

Background: Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD) leading high mortality and even long-term morbidity. SHPT is manifested by elevation of parathyroid hormone (PTH) and accurate determining the level of serum PTH is very essential for early diagnosis of SHPT secondary to CKD. It is very important to match the values obtained for intact parathormone (iPTH) and 1– 84 PTH with the minimized measurement bias. Objectives: The present study aimed to first determine the agreement value between the iPTH and 1– 84 PTH measures in patients with hyperparathyroidism secondary to endstage renal disease under chronic hemodialysis. Then, we attempted to determine the best cutoff values for these two measurements for detecting SHPT in such patients. Patients and Methods: This cross-sectional study was conducted on hemodialysis patients. The value of study biomarkers including iPTH and 1– 84 PTH was assessed. Results: A strong positive association was revealed between the two indicators of iPTH and 1-84 PTH (r = 0.800, P < 0.001). The linear association between these two parameters is independent to baseline characteristics including gender, age, body mass index, and medical history. Among all biochemical elements, the value of 1-84 PTH was only associated with serum calcium level negatively (r = -0.267, P = 0.027) and alkaline phosphatase positively (r = 0.359, P = 0.003). Considering iPTH as the reference and according to the area under the ROC curve (AUC), 1-84 PTH had high value to predict hyperparathyroidism (AUC = 0.926, P < 0.001). The best cutoff point for 1-84 PTH to discriminate hyperparathyroidism from normal condition was 60 yielding a sensitivity of 92.3% and a specificity of 79.1%. Among other baseline laboratory parameters, only alkaline phosphatase had an acceptable value for diagnosing hyperparathyroidism (AUC = 0.731, P = 0.001). Conclusions: The measurement of both iPTH and 1-84 PTH is valuable for predicting hyperparathyroidism secondary to CKD, but according to lower cost and comparableeffectiveness of iPTH measurement, this assay may be comparable to 1-84 PTH to predict this consequence.

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Introduction: Contrast-induced nephropathy (CIN) is one of the major causes of acute kidney injury. Objectives: Regarding an increase in mortality and morbidity in patients with CIN, this study aimed to evaluate the effect of oxygen therapy in prevention of the CIN in individuals with acute coronary syndrome undergoing emergent angiography. Patients and Methods: This study was a double-blinded clinical trial with control group (parallel design), randomized, and with a sample size of 204 individuals conducted on male or female patients over 35 years old and suspected of coronary artery disease undergoing emergent angiography refereed to Rasoul Akram hospital in 2018. Participants were divided into 2 groups (supplementary oxygen and oxygen-free groups). The first group received two to three liters of oxygen per minute from 10 minutes before the start of the procedure until the end of the procedure, and the second group inhaled the oxygen in the room air. Arterial blood gas (ABG) was taken prior to receiving oxygen and at the end of the procedure. Serum creatinine level was tested for all individuals before and 48 hours after the procedure. Results: The mean age in intervention and control groups was 61.66 ± 14.64 years and 60.49 ± 11.59 years, respectively (P=0.54). Mean glomerular filtration rate (GFR) and serum creatinine before and after angiography was not significantly different (P>0.05). There was a significant difference between the two genders regarding the development of CIN (P=0.002), which was higher in women from that of men. Female gender was a strong risk factor and approximately increased four times the risk of CIN (OR = 4.1; (P=0.001). History of chronic kidney disease (CKD) and hypertension (HTN) also produced such a situation (OR = 22.37; P=0.007). Conclusion: According to the results, oxygen therapy has no effect on the occurrence of CIN. It is also found that female gender, history of CKD and hypertension are risk factors for CIN.