Tehran University Medical Journal

Background: Unnecessary patient admission to a hospital refers to the hospitalization of a patient without clinical indications and criteria. Various factors related to the patient (e.g., age, disease severity, payment method, and admission route and time), the physician and the hospital and its facilities and diagnostic technologies affect a patient unnecessary admission in a hospital. Unnecessary patient hospitalization increases nosocomial infections, morbidity and mortality, and decreases patient satisfaction and hospital productivity. This study aimed to measure unnecessary patient admissions in hospitals in Iran.
Methods: This study was conducted using a systematic review and meta-analysis at Tehran University of Medical Science in August 2019. Seven electronic databases were searched and evaluated for original research papers published between March 2006 and 2018 on patients’ unnecessary admission to a hospital. Finally, 12 articles were selected and analyzed using comprehensive meta-analysis software.
Results: All studies used the appropriateness evaluation protocol (AEP) for assessing patients’ unnecessary hospitalization in the hospitals. Overall, 2.7% of hospital admissions were rated as inappropriate and unnecessary (CI 95%: 1.5-4.9%). The highest unnecessary patients’ admissions were 11.8% in a teaching hospital in Meshginshahr city in 2016, (CI 95%: 8.8%-15.8%) and the lowest unnecessary patients’ admissions was 0.3% in a teaching hospital in Yasuj city in 2016 (CI 95%: 0%-3.6%). Unnecessary patient admission in public hospitals was higher than private hospitals. A significant statistical correlation was observed between unnecessary patient admission, and sample size (P<0.05).
Conclusion: The rate of unnecessary hospital admission in Iran is low. However, hospital resources are wasted due to unnecessary admissions. Expanding the primary health care network, reducing hospital beds, introducing an effective and efficient patient referral system, using a fixed provider payment method, and promoting residential and social services care at macro level, and establishing utilization management committee, using the appropriateness evaluation protocol, establishing short-stay units, and implementing quality management strategies at the hospital level are useful strategies for reducing avoidable hospital admissions.

Background: Coronary artery disease today is a major contributor to mortality and morbidity from cardiovascular disease. The drug, interventional and surgical methods are used to treat coronary artery stenosis. Statins are the most commonly used drugs for stenosis and coronary artery disease. Low-density lipoprotein (LDL) The purpose of this study was to evaluate the effect of atorvastatin on LDL and C-reactive protein (CRP) reduction in patients.
Methods: This study was a systematic review and meta-analysis. Articles were selected using the keywords of atorvastatin, LDL, C-reactive protein (CRP) and reduction, and searches in Scopus, Google Scholar and PubMed databases from March 2003 to February 2018. For this purpose, all analytical, clinical trials, cross-sectional, and case-control studies were searched and collected in association with the efficacy of atorvastatin on low density lipoprotein and CRP.
Results: In the initial search, 90 papers were found and evaluated. Finally, 20 papers were analyzed. The studies were published. The total sample size was 21609 persons with an average sample size of 1080 in each study. Twenty studies were entered into the final analysis. The LDL-lowering rate was 51 mg/dl with atorvastatin (I2=98.48, P<0.001). Also, CRP reduction before and after administration of atorvastatin was   1.99 (0.96-3.03) and 0.76 (0.08-1.43), respectively. The results of meta-regression of age-related studies showed that LDL levels were low in studies with lower age, and LDL levels were low in studies with higher age. The results of a meta-regression study of atorvastatin in terms of body mass and the association of low-density lipoprotein with atorvastatin showed that in those with a higher body mass, low-density lipoprotein decreased.
Conclusion: According to the results, the use of atorvastatin reduces the amount of C-reactive protein (CRP). The rate of low density lipoprotein (LDL) reduction was better and faster in young and obese people. It is recommended that people have a proper diet and regular exercise in their daily schedule.

Background: Infant mortality is important as a standard indicator for the development of health, educational and social health systems in each country. Considering the fact that in different studies of the country there are different statistics on the prevalence of infant mortality in the intensive care unit and the general statistics on the prevalence of mortality in neonates in the country are unclear and unclear, the aim of this study was systematic review and meta-analysis for determine the prevalence of mortality in infants admitted to the intensive care unit (ICU) of hospitals in Iran.
Methods: A meta-analysis was performed for relevant articles in scientific databases including scientific information database (SID) and Magiran, ScienceDirect, Scopus, Medline (PubMed) and Google Scholar. Entrance criteria included cross-sectional studies between March 2000 to September 2018. The search process in these databases was performed using keywords: Neonatal, Intensive Care Unit, Mortality, and Iran. Non-relevant articles included review articles, interventions, cohorts and case-control studies, excluded from the study list. Heterogeneity of study was checked using I2 index and the possibility of publication bias by funnel plot and Egger test. Data were analyzed using the comprehensive meta-analysis software, version 3 (Biostat, Englewood, NJ, USA).
Results: The overall prevalence of infant mortality in ICU hospitals was 21.8% (95% CI 14.4-31.6%), the highest prevalence of infant mortality in Isfahan was 64.4% percentage (95% CI 57.5-70.9%) and the lowest mortality rate in babies in Babol's intensive care unit with 5.1% (95% CI 3.8-6.7%). The results of the study showed that the prevalence of infant mortality was significantly reduced with increasing sample size (P<0.05). Also, with an increase in years of research, the frequency of infant mortality in the intensive care unit increases, which is also statistically significant respectively (P<0.05).
Conclusion: Considering the high prevalence of infant mortality in ICU hospitals in Iran, health policy makers need to take effective measures to raise awareness of parents as well as effective measures to reduce infant mortality.

Background: Emergence from general anesthesia and removing of tracheal tube can be associated with coughing, agitation, and hemodynamic disturbances. Dexmedetomidine is an alpha two adrenoceptor agonist that has effective sedation with less cardiovascular unstability and respiratory depression and may be useful for extubation and prevention of hemodynamic response during tracheal tube removing. The aim of this study was to evaluate the effect of dexmedetomidine on hemodynamic responses during endotracheal extubation and sedation level in recovery room.
Methods: In an analytical study, fifty women aged 20-50 years old candidate to cholecystectomy under general anesthesia and tracheal intubation were entered randomly to this study in two groups (no. 25) at Imam Khomeini Hospital, Urmia, Iran, and under support of Urmia University of Medical Sciences Urmia, Iran, from May 2017 to May 2018. Ten minutes before end of surgery, 0.8 µg/kg dexmedetomidine in the study group and for the other patients in control group normal saline as placebo were infused over ten minutes. During the emergence phase, blood pressure, heart rate and oxygen saturation were recorded at 0,1,2,3 and 5 minutes after extubation. Also, sedation index was evaluated via the Ramsay sedation score and recorded at recovery room.
Results: Heart rate, systolic blood pressure and diastolic blood pressure in patient with infusion of dexmedetomidine were lower significantly at 1,2,3 and 5 minutes after extubation than control group. Data for heart rate, systolic and diastolic pressure, at min 1 after extubation were 81±6 vs. 88±9, 120.64±13.21 vs. 137.52±11.06, 72.84±8.32 vs. 81.36±9.26 in dexmedetomidine and control groups respectively. Data for heart rate, systolic and diastolic pressure, at min 5 after extubation were 73±6 vs. 80±8, 110.64±10.68 vs. 119.88±10.01, 69.84±8.32 vs. 73.48±5.13 in study and control groups, respectively. As well as 80% of the patients in dexmedetomidine group had satisfactory sedation and cooperation in compare to the 28% in control group (P=0.001).
Conclusion: Intravenous infusion of 0.8 µg/kg dexmedetomidine 10 minutes before extubation of endotracheal tube and during emergence, facilitate extubation and lead to hemodynamic stability and satisfactory sedation.

Background: Medical errors are those errors or mistakes committed by healthcare professionals due to errors of omission, errors in planning, and errors of execution of a planned healthcare action whether or not it is harmful to the patient. Medical error in hospitals increases morbidity and mortality and decreases patient satisfaction and hospital productivity. This study aimed to determine the prevalence of medical errors in Iranian hospitals.
Methods: This study was conducted using systematic review and meta-analysis approaches. All articles written in English and Persian on the prevalence of medical errors in Iranian hospitals up to March 2019 were searched in Web of Science, PubMed, Elsevier, Scopus, Magiran, IranMedex and Scientific Information Database (SID) databases, and Google and Google Scholar search engines. In addition, reference lists of the retrieved papers were hand-searched. A total of 9 studies matching the inclusion criteria were identified, reviewed, and analyzed using comprehensive meta-analysis software.

Background: Coronary artery ectasia (CAE) is dilatation of an arterial segment to a diameter at least 1.5 times that of the adjacent normal coronary artery. The incidence of coronary artery ectasia is distinct in different countries that can be found in 1.2% to 5% of angiographic examinations.
Methods: This is a retrospective study that was conducted from September 2019 to February 2020 in Kermanshah University of Medical Sciences and the results were reported briefly. To obtain the desired articles, electronic searches were conducted in databases including the Scopus, PubMed, and Science Direct databases without time limited until October 2019. The keywords used were Coronary Artery Ectasia AND (Diabetes OR "Diabetes Mellitus"). This was done by two individuals separately and the final results were confirmed by a third person. Mixed method appraisal tool (MMAT) was used to evaluate the quality of studies. The structure of writing and the process of performing and reporting the study are based on the PRISMA checklist.

Background: Currently, cutaneous leishmaniasis (CL) as a parasitic disease is treated with Glucantime and Pentostam in most of the endemic countries. This study aimed to identify factors affecting the glucantime therapy duration rate in patients with CL using a survival analysis model.
Methods: This retrospective descriptive-analytic study was conducted on 1017 CL patients that were referred to the urban and rural comprehensive health centers of Qom Province under the supervision of Qom University of Medical Sciences, Qom, Iran, from April 2014 to March 2019 through the census. The recovery time was measured by the Kaplan-Meier method, and then the survival function was plotted based on each variable. The Log-Rank test was applied to analyze the differences among variables, and after the evaluation of the PH assumption by Shoenfeld residuals, a stepwise forward Cox progressive regression was used to determine factors affecting intralesional or systematic treatment duration in the patients involved with cutaneous leishmaniasis. 

Background: Marital satisfaction is considered to be the feelings and understanding of the couple about their marital relationship and their two-way relationship. Many factors play a role in creating marital satisfaction, and on the other hand, marital satisfaction is one of the concepts that cause sexual health in a person. Sexual health has many dimensions and includes coordination and adaptation of physical, emotional, intellectual, and social aspects of sexual affairs in humans. This study was conducted to assess the marital satisfaction of working women in Iran through meta-analysis.
Methods: In this meta-analytic study, the issue of marital satisfaction amongst Iranian working women which has been published in local articles was evaluated. To find pertaining studies, Magiran, IranDoc, SID, Iranmedex, and Pubmed websites were used. Statistical society in this research consists of all studies in Iran in regard to the relationship between being a working woman and having marital satisfaction that has been accomplished since 2001-2018 and was indexed in one of the scientific informative websites.
  To access desired articles we used the English keywords of ‘Sexual dysfunction’, ‘Iran’, ‘Sexual function’, ‘Marital satisfaction’, ‘Working women’ and ‘women’ and their Persian equivalents. After the selection process of articles related to the research objectives, 10 articles were selected and assessed as final samples.

Background: Asthma is the most prevalent chronic disease in childhood and has been growing globally over the last three decades. Studies in this regard indicate different and irrelevant results in Iran. Different prevalence of asthma has been reported in industrialized countries, prevalence of 25.9% in the United Kingdom, 12.8% in Spain and 31% in Australia. This study aimed to evaluate asthma in Iranian children through systematic review and meta-analysis.
Methods: This study was performed as a systematic review and meta-analysis from January 2001 to December 2018. Related articles to the reviewed subject were obtained through searches of Scopus, ScienceDirect, Magiran, SID, Medline (PubMed), and Google Scholar databases. Cross-sectional studies were selected for inclusion in the study and observational studies as well as review studies were excluded from the study. Searches on Google search engine and the inspection of sites related to the topic were also incorporated to examine the grays literature. Duplicate articles and articles that were similar and obtained from the same source were removed through the EndNote software. The total number of articles was 896. Subsequently, the number of articles and studies that met the requirements of the first stage was 274. Ultimately after the elimination of 236 irrelevant articles and the elimination of 5 articles in the secondary examination, eventually 33 articles were added to the final stage. By the I² index, the heterogeneity of the studies was investigated and reported.

Background: Examining the course of changes in predictive indicators of future diabetes, such as blood sugar in high-risk individuals including pre-diabetic patients, can provide valuable information about the incidence of diabetes in these individuals. This study aimed to classify people at risk (pre-diabetes) based on the course of changes in their blood sugar and blood lipid and to investigate the incidence of diabetes in these classes on a sample of patients who were referred to the Endocrine and Metabolism Research Center of Isfahan.
Methods: This cohort study was performed based on the information of the Isfahan Diabetes Prevention Plan (IDPs). This project was implemented from April 2004 to March 2018 in the clinics of the Endocrine and Metabolism Research Center of Isfahan. The subjects in this study include 1228 pre-diabetic patients who participated in this project. Demographic and clinical variables of patients including blood sugar and lipid-blood variables were obtained using a questionnaire and laboratory measurements. Also in this study, the number of clinical variables was recorded 3 times. Data analysis was performed using the latent class growth trees model in R software version v4. (R v4.1.0)

Results: The mean (standard deviation) age of participants was 44 (6.86) years. Subjects were classified into two classes of low-risk impaired blood sugar (n=1165) and high-risk impaired blood sugar (n=63) based on the trend of changes in blood sugar levels. Blood sugar levels were reported in the first class (104.28) and the second class (132.41). Conclusion: In the present study, it was concluded that there is a significant relationship between the incidence of diabetes and the different classes formed based on the course of changes in blood sugar of at-risk individuals. Therefore, by classifying people at risk, the incidence of this disease can be predicted and thus prevented. Also,measures such as managing the blood sugar and lifestyle variables of pre-diabetic patients through nutrition counseling classes and regular periodic tests can be used to reduce the incidence of diabetes in the future is used in people with pre-diabetes who are at high risk for the disease.

Background: The training and education of competent and qualified surgeons have been one of the challenges of the surgical profession. The concept of surgical competence has been affected widely due to a series of developments in the new disease emergence, various surgical techniques and the introduction of advanced tools and equipment into the operating. The development of surgical competence and achieving this goal requires accurate identification and analysis of the dimensions of competence. This study was done to explain the concept of surgical competence using the 8-step Walker and Avant approach.
Methods: This study is a qualitative study that was conducted from May- October 2016 at Shahid Beheshti University of Medical Sciences. The present study is a qualitative and conceptual analysis study, which is done with Walker&Avant's eight-step approach to determine the defining characteristics of the concept of surgical competence. A systematic search was conducted between 1990 and 2020 by keywords search such as surgery, surgical, operation OR laparoscopy AND competence competency development competency proficient, proficiency, expertise, clinical, in the database like Google Scholar, PubMed, SID, Magiran, Scopus, Web of Science. Twenty articles were included in the study based on inclusion and exclusion criteria. Moreover, the defining features of the concept were extracted from it.

Results: Based on the results of this study, the concept of surgical competence was defined and the four dimensions of elements, goals, components and the process of developing surgical competence were identified. Then, by clarifying the characteristics of surgical competence, a model of surgical competence development was drawn. Surgical competence development depends on the acquisition of specialized knowledge and numerous skills that are acquired through experience and deliberated practice under the supervision of others in the surgical community of practice and over time. Conclusion: Surgical competence is a set of observable and measurable skills that allows a surgeon to manage the surgical process independently pbt while maintaining the patient's safety. It includes specialized knowledge, communication skills, cognitive and technical skills, and basic surgical skills.

Background: Radiomics is a noninvasive method that reveals information from medical images that are not recognizable by the naked eye. Radiomics has shown a high potential in the accurate diagnosis and prognosis of liver lesions in ultrasound images. Despite this high potential, changes in imaging parameters affect the reproducibility of ultrasound radiomics results. Therefore, the present study aims to investigate the reproducibility of the radiomics features extracted from the images of patients with hepatocellular carcinoma under changes in ultrasound scan parameters.
Methods: This was a cross-sectional study conducted from July 2020 to July 2021 in the radiology department of Tabriz Paramedical Faculty. The images of 20 patients with hepatocellular carcinoma were obtained from the Cancer Imaging Archive database. These images were taken under different imaging conditions and parameters. The areas related to the lesion were manually extracted from the images with software tools. Then, in order to radiomics analysis, different radiomics features, including 24 gray level co-occurrence matrix (GLCM) and 16 gray level run length matrix (GLRLM), were extracted from the images. Then, using the coefficient of variation (CV%) and intraclass correlation coefficient (ICC) statistical tests, the reproducibility of radiomics features under changes in scan parameters was investigated. The values of ICC≥0.90 and CV<20% were considered reproducible in this study.

Results: Among the 40 features extracted from ultrasound images, eight showed high reproducibility in both CV% and ICC tests. These features were joint entropy, Idmn, Imc2, correlation, MCC, sum entropy, gray level non-uniformity normalized, and run entropy in which the two features, Idmn and gray level non-uniformity normalized, showed the highest (CV%=0.24) and the lowest (CV%=14.90) stability against the changes of ultrasound scan parameters, respectively. The average ICC value of these features was obtained at 0.977. Conclusion: Despite the high potential of radiomics in diagnosing liver lesions, changes in imaging parameters directly affect the reproducibility of results. However, some radiomics features still show high stability and reproducibility under changes in imaging parameters.

Background: Medical Laboratories have a great impact on patient safety and 80-90% of medical diagnoses are based on the results of laboratory tests. Medical procedures from the initial diagnostic steps such as a test or a simple injection to specialized treatment steps may be erroneous. The aim of this study was to determine the type and rate of human error, equipment, materials and procedures in all stages including before analysis, during analysis and after analysis to analyze the causes and find logical solutions to reduce of them.
Methods: This cross-sectional descriptive study was performed in a medical center in Tehran, Iran during the years 1400-1401. Data collection was considered in accordance with the instructions of the Laboratory Affairs Department of the Ministry of Health and Medical Education regarding the type of errors in the field of job description in each of the technical and non-technical sections. Data was analyzed by IBM SPSS software, version 22 (SPSS Inc., Chicago, IL, USA) software.

Results: During the period of study, the number of  referred patients was about 45,000 and the number of tests 594,000. The total number of errors was 837. The ratio of errors to the patients was 1.9% and to the tests 0.15%. The 37 types of errors were identified and reported in this study. Of these, 11 types of errors were in the pre-analysis, 14 types during the analysis and 12 types of errors in the post-analysis stage. The frequency of errors in the three stages was 180(21.5%), 312(37.3%) and 345(41.2%), respectively that the errors rate did not have a normal distribution and a significant difference was observed (P<0.05, df=2). Conclusion: Due to the variety of reported errors and the importance of their role in other stages of diagnosis and treatment, it is necessary that all human, equipment and process errors in all stages of laboratory analysis be carefully recorded and corrective and preventive measures be taken to minimize them.

Background: Due to the fact that various factors are involved in the development of chronic kidney disease, this disease appears with different clinical and laboratory symptoms. The variety in type and number of clinical symptoms often misguides the treating physician. The aim of this study is to extract the key features of the disease and find the best data mining methods to improve the accuracy of kidney disease diagnosis.
Methods: This cross-sectional study was conducted from September 2021 to March 2023 for 30 months at Rafsanjan Ali Ebn Abi Taleb Hospital. Predictive models were developed and tested using different combinations of disease characteristics and seven data mining methods in RapidMiner Studio software. The limitations of the study are as follows: 1) The models were based on 40-year-old and older patients records, which may limit the generalization of results to a wider age group. 2) Despite the high accuracy and comprehensiveness of the method, the models were based only on the information of kidney disease patients at Ali Ibn Abi Talib Rafsanjan Hospital. 3) The climate parameter has not been considered in the data set of the investigation to discover the hidden relationships of this parameter with the kidney disease.

Results: The results of the experiments in this study showed that the proposed prediction model using the Bayes method and eight identified key features (age, renal biopsy, uremia, sedimentation, albumin, edema, nocturnal enuresis, and urine-specific gravity), can detect kidney disease in people of different clinical characteristics, with 99.38% accuracy. Conclusion: Considering that the early diagnosis of kidney disease and the adoption of appropriate treatment methods can prevent the progression of kidney damage, in this study, an attempt has been made to achieve this goal by using new statistical methods and artificial intelligence techniques. Based on the proposed method and the conducted experiments, the most important features and the best data mining method were obtained, and finally, kidney disease prediction was possible with high accuracy.

Background: Identifying factors that influence the length of hospital stay for suspected stroke patients is crucial for optimizing the utilization of hospital resources. This study aimed to determine the factors associated with the length of hospital stay for suspected stroke patients transferred to Qaem Hospital in Mashhad through emergency services using survival analysis.
Methods: In this historical cohort study, general information was gathered for all suspected stroke patients who sought emergency services in Mashhad, the largest city in northeast Iran, from March 21, 2018, to March 20, 2019, and were then transferred to the Emergency Department of Qaem Hospital. Pre-hospital emergency data were integrated with hospital records using the mission ID. The primary outcome assessed in the study was the length of hospital stay, with model implementation carried out using the statistical software Stata.

Results: The median hospitalization time until patients' recovery was  seven days. Out of the 578 participants, 386 cases (66.8%) recovered, while the remaining 190 cases (33.2%) were censored (83 individuals had died during the study, and 107 individuals had exited the hospital for other reasons). The average age of patients at the time of hospitalization was 71.13±13.01 years. Statistical analysis employing Log-rank and Breslow tests identified a significant difference in hospitalization duration among patients receiving various levels of care and based on their insurance status. During multivariate analysis, the Cox regression model was considered unsuitable due to some variables not meeting the proportional hazards assumption, leading to the utilization of AFT models. Following the evaluation of AFT models, including Log-normal, Log-logistic, Exponential, and Weibull, the log-normal model emerged as the most suitable choice, exhibiting AIC and BIC values of 1273.909 and 1356.740, respectively. Significant variables influencing length of stay included patient admission priority, insurance status, season, and residency status. Conclusion: The study suggests that parametric survival models are effective for analyzing lifetime data. Additionally, in light of the significant variables identified, enhancing facility readiness and resource allocation could facilitate more efficient planning and implementation.

Results: exploratory factor analysis is a statistical method that is used by reducing the number of variables and exploring the underlying structure of a large set of variables with the aim of discovering factors or hidden variables, and its basic assumption is that any variable may be related to any factor. It tries to use factor loadings to discover the factorial structure of the data and by identifying the basic structures, grouping the factors by considering the common meaning of the variables. Conclusion: Reliability means repeatability and validity of the degree of accuracy of the results which are measured through different methods. Exploratory factor analysis uses construct validity measurement methods to simplify the data and provide more reliable and valid tools, so it is very important to pay attention to the accurate and correct measurement of the results in the validation of health system tools.

Background: One of the main causes of death in the world is cardiovascular disease. While there is no denying that lipids play a risk factor in cardiovascular disease, statins are effective medications for treating this condition. We used network meta-analysis to compare the impact of three drugs atorvastatin, simvastatin, and rosuvastatin on lipids.
Methods: Type of study of this research was a systematic review and network meta-analysis. Databases such as Scopus, PubMed, ISI, Science Direct, Google Scholar, SID, MagIran, web of Science, and Cochrane Library were searched. Keywords atorvastatin, simvastatin, and rosuvastatin were used in the search strategy. We did both standard meta-analyses and network meta-analyses. Consistency was checked by comparing direct and indirect effect sizes. The time period for searching articles was from 2000 to June 2024. All relevant articles published in English or Persian were reviewed. Paired wised comparisons were made using the intervalplot command in STATA. The surface under the cumulative ranking (SUCRA) was used to rank the efficacy of treatments. The Q test and I2 index were used to assess the heterogeneity of the studies.  Data were analyzed using STATA Ver. 17.
Results: From the 61 articles that were included in the network meta-analysis (atorvastatin 43 studies, rosuvastatin 22 studies, simvastatin 21 studies, and placebo 15 studies). The total sample size was 62178 patients.  The results showed that the effect of, atorvastatin, rosuvastatin, and simvastatin with placebo on fat lipids was significant (P<0.001). Still, there was not a substantial difference between the effects of the three drugs. The best treatment for reducing LDL was atorvastatin (standard mean difference (SMD) =-5.18, 95% confidence interval (CI);-7.42,-2.95, P<.001). SMD LDL for rosuvastatin and simvastatin were -4.35(95% CI; -6.81,-1.89), and -3.44(95% CI;-5.89,-.98) respectively.  The surface under the cumulative ranking (SUCRA) showed that the probability that Rosuvastatin was the best drug for reducing triglycerides was 82.4% and the likelihood that atorvastatin was the best drug for reducing cholesterol was 80.3%.
Conclusion: Atorvastatin, rosuvastatin, and simvastatin have a better effectiveness than placebo in reducing fat lipids. Atorvastatin was the best treatment to reduce LDL, and TC and increase HDL. Rosuvastatin was the best drug to reduce TG. Atorvastatin, rosuvastatin, and simvastatin were the effective treatments to reduce fat lipids respectively.

Background: Autism spectrum disorder (ASD) represents one of the most significant neurodevelopmental disorders in early childhood, where early diagnosis, particularly in children under five years of age, is crucial for effective interventions. Although global autism incidence has risen due to improved awareness, enhanced screening programs, and broader diagnostic criteria, epidemiological data from middle-income countries like Iran remain limited, especially for children under five. This study aimed to examine autism incidence trends among Iranian children under five from 1990 to 2021, stratified by sex and province. 
Methods: This ecological study was conducted from October 2024 to March 2025, analyzing data extracted from the Global burden of disease (GBD) database (1990-2021). Age-specific incidence data for children under five were obtained by sex and province. Incidence rates per 100,000 population were calculated for gender and provincial comparisons. Joinpoint regression analysis assessed annual trends and identified significant inflection points. Heat maps illustrated geographical distributions, while trend graphs stratified by sex and province were generated using GraphPad Prism. 
Results: The incidence rate of autism in children under five gradually increased from 1990 to 2005, followed by a sharp rise between 2005 and 2009, reaching its peak during this period. A subsequent decline was observed from 2009 to 2021. The male-to-female ratio remained consistently stable at approximately 3:1 throughout the study period and across all provinces. Notable provincial disparities were observed, with border provinces exhibiting greater fluctuations compared to central regions.
Conclusion: In contrast to the continuous global increase, autism incidence among Iranian children under five demonstrated an initial rise followed by a sustained decline after 2009. This trend may be attributed to declining birth rates, demographic shifts, evolving diagnostic criteria, improved prenatal care, and persistent challenges in early screening and case registration, alongside regional disparities in access to diagnostic services. These findings emphasize the need for enhanced early-screening programs, equitable resource distribution, and evidence-based child mental health policies in Iran.