Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study.

INTRODUCTION: Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran. METHODS: This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach. RESULTS: Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants. CONCLUSION: This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.

Comparison of the efficacy of microneedling versus CO2 fractional laser to treat striae alba: A randomized clinical trial.

Striae distensae (SD) are common skin conditions that have posed a significant challenge regarding their assessment and treatment. The present study aimed to evaluate the efficacy of microneedling in comparison to fractional CO2 laser therapy. Similar striae were selected and photographed. Each side was randomly assigned to be treated with CO2 fractional laser or microneedling four times at monthly intervals and followed up for 10 months. Outcome measures including the length and width of the largest striae, dermatologist assessed improvement, patients' satisfaction, and visual analog scale (VAS) were assessed. Wilcoxon signed-rank test and Mann-Whitney U test were used to assess the efficacy of treatments. Forty patients with a mean age of 28.1 years were included. The median cross-section of the largest striae decreased significantly in both groups (P-value <0.001), without statistically significant differences between the two groups before and 6 months after treatment. VAS also improved significantly in both groups, and there were no statistically significant differences between the two treatments in all visits. No clinically significant adverse effects were observed. Fractional CO2 laser and microneedling are both efficient treatments to resolve SD. A new light should be shed on the microneedling modality as it is more economical than the other treatment options.

Toward facial rejuvenation; A clinical trial to assess the efficacy of nano fat grafting on wrinkles.

INTRODUCTION: With increasing age, patients' facial volume decrease. For this reason, nano fat grafting has recently gained popularity as adjunctive treatment to facial rejuvenation procedures. However, few quantitative studies have been conducted to investigate the impact of nano fat on facial wrinkles. AIMS: In the present study, authors aim to investigate the therapeutic effect of intradermal injection of nano fat on fine facial wrinkles and assess their changes over 7 months of follow-up. METHODS: In this randomized trial, 15 patients with fine facial wrinkles were enrolled. The fat was harvested from the abdomen and processed into nano fat. Nano fat was injected into the facial wrinkles intradermally with a needle of 27 gauge. The patients were evaluated before and 7 months postinjection utilizing Visio face 1000D (CK electronic, manufactured in Germany); and four parameters of wrinkles (area, volume, depth, and percent area) were evaluated before and after the nano fat injection. RESULTS: Our evaluation with Visio face showed that nano fat injection was significantly reduced the volume, area, depth, and percent area of wrinkles after 7 months of follow-up without serious long-lasting adverse effects. Moreover, wrinkles with higher percent area, depth and volume loss show greater improvement after the treatment. Our results also indicate that males and females equally benefit from this treatment except for the percent area parameter that was improved more significantly in male patients. CONCLUSION: Our study showed that intradermal injection of nano fat significantly decreases the volume, area, depth, and percent area of fine facial wrinkles. Further quantitative studies with control groups and larger sample sizes are required.

Silymarin in combination with hair follicle transplantation as a potential treatment for refractory vitiligo: A double-blind randomized controlled trial.

BACKGROUND: There is still no certain effective treatment for vitiligo as a common chronic skin disorder characterized by depigmented patches and loss of skin melanocytes. OBJECTIVES: This study evaluates the efficacy of oral silymarin combined with hair follicle transplantation compared to follicle transplantation alone in the treatment of refractory vitiligo. MATERIALS AND METHODS: Twenty refractory vitiligo patients were enrolled in this randomized controlled clinical trial, following up for 3 months. One group underwent hair transplantation plus oral silymarin, while the other group underwent follicle transplantation alone. We assessed the progress with Vitiligo Extent Tensity Index (VETI) in both groups and the peri-follicular pigmentation diameter was estimated monthly. The Friedman test for comparing two groups at the end and the Mann-Whitney test for comparing two groups during each month was used. RESULTS: The mean age was 30.22 (18-59) years, with the male to female ratio of 1:1. The decrease in the VETI and increase in the perifollicular pigmentation was statistically significant between silymarin and another group in monthly follow-up (p-value: 0.019, 0.019, and 0.035, respectively). Finally, the re-pigmentation was notable in silymarin group (p-value <0.001 vs. 0.029, respectively). In addition, both genders had a significant increase in peri-follicular re-pigmentation in the last follow-up (p-value: 0.012 and 0.044, respectively); although the improvement was not statistically significant between genders in each month. CONCLUSION: According to our study, silymarin in combination with hair transplantation could be a potential medical treatment for vitiligo; however, further trials are needed to establish the efficacy of combination therapies.

Trichoepithelioma presenting as leonine facies in a young female.

Trichoepithelioma is a rare benign tumour of the pilosebaceous unit that originates from the hair follicles. Although it rarely results in facial disfigurement, it is thought to be the cause of leonine facies. We discuss a 27-year-old woman who presented with facies Leonine caused by trichoepitheliomas. The first line of treatment for these multiple symmetrical, firm, and round papules or nodules is excisional surgery.

The Efficacy of Cryotherapy and Zinc Gluconate in Management of Anogenital Warts: A Randomized Double-Blind, Split-Side, Placebo-Controlled Trial.

Anogenital warts are the most common sexually transmitted infection causing economic and psychosocial issues. Efficacy of zinc has been proved in treating nongenital warts, but its role in treating anogenital warts is not clear. This study was conducted to assess whether oral zinc gluconate in combination with cryotherapy effectively treated anogenital warts. A randomized double-blind, split-side, placebo-controlled trial was conducted on 50 patients suffering from genital warts. The patients were treated for 2 months with a combination of four sessions of cryotherapy and oral zinc gluconate versus placebos. Follow-up was performed at every 2 weeks based on the number of warts. The number of genital warts reduced significantly in both groups during treatment with cryotherapy, but no significant differences were observed between treatment with zinc and placebo. Patients in the zinc gluconate group reported significantly higher gastrointestinal adverse effects than those in the placebo group. This indicates that using oral zinc gluconate appeared to have no significant advantage over placebo in treating and reducing the number of genital warts; however, a longer duration of follow-up and pre-intervention serum level of zinc were necessary to evaluate the role of oral zinc therapy. (SKINmed. 2023;21:21-26).

Prevalence of congenital heart disease according to the echocardiography findings in 8145 neonates, multicenter study in southern Iran.

Introduction: Congenital heart disease (CHD), the lethal congenital anomaly in newborns, is multifactorial, with environmental and genetic factors contributing to its occurrence. Although some studies on the prevalence of CHD have been conducted throughout the country, this large-scale study aims to provide information on the prevalence of various types of CHDs in newborns according to the echocardiography findings. Patients and Methods: Over 3 years, 8145 neonates with suspected CHD who underwent echocardiography by a trained pediatric cardiologist were included in this multicenter, cross-sectional observational study. CHD was categorized into two major groups; cyanotic and acyanotic heart disease. The SPSS version 22 software was used to analyze the data with a significance level set at 0.05. Results: Of 8145 neonates who were referred to our centers with CHD symptoms, 6307 were indicated for echocardiography. The mean age of the studied population was 8.5 ± 9.3 days and the male-to-female ratio was 2.6, especially in the arterial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) groups. 77.2% of patients had acyanotic heart disease (100 in 1000 neonates) with ASD as the most common one and 9% were diagnosed with cyanotic heart disease (11 in 1000 neonates) with transposition of the great arteries as the most common form and the aortopulmonary window was the rarest form. Conclusion: This large prospective, multicenter screening study reported arterial septal defect (85%) and patents with ductus arteriosus (32%) as the most frequent type of CHD. Moreover, the prevalence of male patients was significantly higher. This information would be helpful for health policy makers, stakeholders, and general practitioners in regions where there are no trained pediatric cardiologist fellowships and limited access to echocardiography devices for better management of CHD.

The efficacy of adding topical 5-fluorouracil to micro-needling in the treatment of vitiligo: A randomized controlled trial.

BACKGROUND AND AIM: Vitiligo is an autoimmune skin disorder characterized by circumscribed depigmented macules and patches caused by the loss of functional melanocytes. Although there is no definitive treatment for vitiligo, several treatment options have been associated with relative satisfactory outcomes. The purpose of this study was to compare the efficacy of micro-needling in conjunction with topical 5-fluorouracil (5-FU) versus topical tacrolimus ointment in treating vitiligo patches. PATIENTS AND METHODS: This study included nineteen participants, each of whom received both treatments on two randomly selected vitiligo patches of approximately the same size and location. On one patch, a combination of weekly micro-needling and topical application of 5-FU solution was used every other day, while on the other, 0.1% tacrolimus topical ointment was applied twice daily. The G-score was used to compare treatment outcomes after 3 months. RESULTS: The median duration of the disease in our population was 7 years. Six patients (32%) in the micro-needling plus topical 5-FU treated group showed a moderate to excellent response, indicating a significant improvement between both treatments (p-value = 0.019). In contrast, all other patches treated with topical tacrolimus showed poor improvement. Lower extremity and trunk responded more to treatment with micro-needling plus topical 5-FU than upper extremity and acral areas. Moreover, none of those who have had the disease for more than ten years have responded to treatment. Mild erythema, pinpoint bleeding, and irritation were detected only in the micro-needling treated group. CONCLUSION: The current study showed that using micro-needling in conjunction with 5-FU could treat vitiligo patients more efficiently than tacrolimus monotherapy. Despite showing moderate to excellent improvement in patches treated with micro-needling and 5-FU, this well-tolerated office-based modality still requires additional research.

"The efficacy and adverse effects of treatment options for facial pores: A review article".

INTRODUCTION: Skin pores are enlarged openings of the pilosebaceous follicles that can be affected by age, gender, genetics, exposure to UV light, ethnicity, and sebum secretion. Many treatment modalities reduce facial pores' count and area, including oral and topical medications as well as different wavelengths of lasers. Finding a safe and cost-effective treatment protocol is necessary since facial pores are one of the main reasons for cosmetic complaints. AIM: This review compares available treatment options for reducing facial pores' number and area according to the published clinical trials. METHODS: A search on PubMed and Google Scholar was performed. Nineteen published clinical trials regarding treatment options for facial pores were included and reviewed based on the authors' clinical experience. RESULTS: A total number of 591 cases (83.7% female) aged 18-80 years were included. Three assessment methods including digital imaging, physician assessment, and patient' satisfaction were used in the studies to evaluate the therapeutic efficacy of each modality. Furthermore, combining different modalities increased the efficacy of reducing pores' size and number. Mild, reversible burning and erythema were common side effects. CONCLUSION: Multiple sessions and combination therapies improve facial pores' area and number. In young patients, the focus should be on controlling sebum production, while in older patients, the focus should be on rejuvenation in addition to the control of sebum production.

Early cryptococcosis infection in a liver transplant patient: A case report.

Key Clinical Message: In order to early diagnose and prevent the infection dissemination in both suspected solid organ donors and recipients after transplantation, pretransplantation screening tests for rare etiologies like Cryptococcus neoformans should be necessitated, as they can affect many vital organs, especially the brain, liver, and lungs. Abstract: Cryptococcosis is a systemic fungal infection mainly affecting immunocompromised patients. The infection is occasionally seen in 16-21 months after organ transplantation, while early involvement is uncommon within <30 days posttransplantation. In the present study, we reported an unusual case of cryptococcosis infection 21 days after transplantation, limited to the transplanted liver in a 60-year-old male. Treatment with an antifungal agent showed prompt improvement in his clinical condition.

The relation between epidermal growth factor receptor mutations profiles and smoking patterns in patients with lung adenocarcinoma: A cross-sectional study.

Background: Non-small cell lung cancer (NSCLC) accounts for 85% of lung cancer cases, with smoking being a critical risk factor. The identification of NSCLC patients harboring epidermal growth factor receptor (EGFR) mutations, sensitized to tyrosine kinase inhibitors, has revolutionized treatment plans, resulting in improved clinical responses and reduced chemotherapy toxicity. This study aimed to assess the relationship between EGFR mutations and smoking patterns in patients diagnosed with lung adenocarcinoma referred to major pathologic laboratories. Methods: This cross-sectional study included 217 NSCLC patients aged above 18 years. Molecular abnormalities of the EGFR gene were analyzed by polymerase chain reaction amplification of exons 18-21 accompanied by Sanger sequencing. Then, the data were analyzed using the SPSS 26 software. Logistic regression analysis, χ 2 test, and Mann-Whitney U test were used to evaluate the relation between EGFR mutations and smoking patterns. Results: EGFR mutations were identified in 25.3% of patients, predominantly involving deletion in exon 19 (61.8%). For most of the mutant EGFR patients, the majority were nonsmokers (81.8%), and 52.7% were female patients. Besides, the median duration of smoking was 26 years and the median frequency of smoking was 23 pack-years in the mutant EGFR group, both of which were lower compared to the wild mutant group. Moreover, female gender, current, and heavy smoking were significantly correlated with EGFR mutations based on the univariate logistic regression analysis (p: 0.004, 0.005, and 0.001, respectively). Conclusions: Female gender and nonsmoker status were strongly associated with positive EGFR mutations. While guidelines traditionally recommended EGFR testing primarily for female nonsmokers with advanced NSCLC, our study in line with the recently published evidence has shown a significant prevalence of positive EGFR mutations among male patients and smokers. Therefore, routine mutation testing is suggested for all NSCLC patients. Considering the limited access to EGFR testing laboratories in developing countries, the results of such epidemiological surveys can assist oncologists in choosing the most suitable treatment plan.

Epidemiology of burn injuries among adult females in southern Iran; a retrospective study from 2007 to 2022.

Burn -by flame, flush, scald, electrical, and chemical types- accounts for 5-12% of trauma injuries worldwide. In Iranian studies, females were the main victims of domestic burns with higher mortality and frequencies. This retrospective study evaluates the epidemiology and etiology of burn injuries in females aged 25-64 years between October 2007 to May 2022 in southern Iran. Demographics and burn etiology information were collected by questionnaires at admission. Univariate and multivariate regression analysis was used to determine the relationship between variables and burn mortality. Pearson's Chi-Square and One-way ANOVA tests were utilized to compare different burn etiologies. Of 3212 females with burn injuries, 1499 (46.6%) were included with a mean age of 38.5 ± 10.8 years. Flame (59.7%) and flush (28.9%) were significantly the most common injuries mechanism. Burn was most common in rural areas (53.9%) and indoor settings (62.1%) (P-value < 0.001). 77.9% of the population were under-diploma (P-value < 0.001), and 3.5% were divorced with higher burn-suicide attempts. The mean Total Body Surface Area (TBSA%) was 41.1 ± 28.3%, and the mean Length of Stay (LOS) was 14.5 ± 13.2 days with a 39.1% mortality rate. With univariate and multivariate analysis, TBSA%, indoor places, flame, flush, and urban living were risk factors for burn mortality. Briefly, flame in indoor settings is the most common type of burn injury affecting adult females with lower educational levels living in rural areas. Such epidemiological studies of burns in adult females may be helpful for health policymakers to develop burn prevention programs.

Intradermal Injection of 100mg Tranexamic Acid Versus Topical 4% Hydroquinone for the Treatment of Melasma: A Randomized, Controlled Trial.

Objective: Melasma is an acquired and chronic hyperpigmentation disorder associated with a negative impact on patients' quality of life. This study compares the efficacy of 100mg/mL intradermal TA with 4% topical HQ on female patients presenting with melasma lesions. Methods: In this randomized double-blind controlled trial, 48 women with melasma were allocated into two groups, treated with either 100mg/mL intradermal TA or topical 4% HQ. The MASI (Melasma Area and Severity Index) score was assessed by paired t-tests and repeated measured ANOVAs. The Dynamic Physician General Assessment (PGA) was also performed by taking photographs with a digital camera. Results: The average MASI score for the HQ and TA groups was 7.7 (3.0 SD) and 5.9 (2.5 SD), respectively. In both groups, the MASI decreased significantly after three months of treatment; however, the decrease was not significant between the two groups (P=0.1). All participants developed mild degrees of burning pain in the injection site without serious adverse effects. Limitations: First, we only used the MASI score to measure melasma degree. Second, this is a single-center study with a small sample size. Third, the before-after photos were not taken with a high-quality camera. Conclusion: The results of our study showed that both TA and continuous HQ significantly reduced the MASI score of patients without any significant differences and serious side effects. Although many treatment modalities are available for melasma, this condition is still challenging for dermatologists with a high recurrence rate after treatment.

The Revolutionary Impacts of the COVID-19 Pandemic on Mobile Health; Highlights of the Fourth Shiraz International Congress on Mobile Health.

Mobile health (m-health) is considered an undeniable part of health service delivery, planning, and marketing, which has dramatically changed due to the unique situation caused by the COVID-19 pandemic. The Forth International Congress of Mobile Health, from February 14th to 16th, 2021, in Shiraz, Iran, aimed to provide a venue to exchange ideas, techniques, relevant experiments, and applications with a particular focus on the COVID-19 pandemic impacts. More than 70 experts from different countries in engineering, biomedical sciences, and humanities presented their recent experiences in m-health advancements, particularly in response to the COVID-19 outbreak. In this article, highlights of the most valuable ideas presented at the congress are concisely summarized to give scientists, entrepreneurs, policymakers, and other stakeholders a better understanding of the growing opportunities, and challenges toward the development of m-health.

The characteristics of foreign bodies aspirated by children across different continents: A comparative review.

BACKGROUND: Foreign body aspiration (FBA) is a common issue in pediatric emergencies, with regional variations. Various cultures and foods, parents' and physicians' inadequate experience, and lack of bronchoscopy equipment are some attributable factors in the regional variation of FBA. AIM: To more accurately represent the demographic characteristics of aspirated foreign bodies (FBs) across various continents, this review attempted to provide organized information based on the reviewed articles. METHODOLOGY: A search was conducted in PubMed/PubMed Central, EMBASE, and google scholar. From the 36 included articles, information on age, gender, bronchoscopy type, type of FB, location, history of choking, and time elapsed between aspiration and admission were extracted. RESULTS: A total of 14,469 cases were evaluated. According to the findings, children under two accounted for more than 75% of FBAs. Nuts and seeds were the most common FBs in most countries, whereas plastic and metal objects had higher rates in Brazil, and calcified objects were more prevalent in Thailand. The right bronchus was the most frequent location, and rigid bronchoscopy was the most often utilized type of bronchoscope. In addition, a significant percentage of patients were referred to the emergency rooms in the first 12-24 h following the aspiration incident. Moreover, Asian patients reported more choking history, and Europeans had fewer witnesses of FBA. CONCLUSIONS: There is a lack of standardized reporting systems and organized guidelines in pediatric FBA. To select the ideal time for endoscopies and create educational programs, a collaboration between experienced researchers, pediatric pulmonologists, radiologists, and otolaryngologists is required.

Prevalence of anxiety, depression, stress, and perceived stress and their relation with resilience during the COVID-19 pandemic, a cross-sectional study.

BACKGROUND AND AIMS: Home quarantine and physical distancing at the time of coronavirus disease 2019 (COVID-19) had a severe effect on the mental health of the populations. Resilience has been reported previously to be a protective factor against anxiety, stress, and depression. This study evaluates the prevalence and severity of depression, anxiety, stress, and perceived stress and their relation with resilience associated with the COVID-19 pandemic among a sample of the general population in Southern Iran. METHODS: In this cross-sectional web-based survey, from April 12 to May 13, 2020, stress, anxiety, depression, perceived stress, and resilience were measured using the Persian version of Depression Anxiety and Stress Scale (DASS-21), Perceived Stress Scale (PSS-14), and Connor-Davidson Resilience Scale (CD-RISC). Statistical analyses were carried out using the IBM Statistical Package for Social Sciences. Mean ± standard deviation (SD) and frequencies were used to describe demographic data. Independent sample t-test, Spearman correlation, and the Pearson correlation coefficient were performed to examine anxiety, depression, stress, and resilience. RESULTS: Among a total of 538 participants, the overall prevalence of moderate-to-extremely severe depression, anxiety, and stress was found to be 26.1%, 33.2%, and 5.8%, respectively. The overall median PSS and resilience score were 30 and 70, respectively. There was a significant association between higher age and perceived stress. Male and high income were related to higher resilience scores. Perceived stress positively correlates with resilience, whereas depression significantly correlates with anxiety and stress. Individuals with underlying disease demonstrated significantly higher scores for depression and anxiety. Also, perceived stress had a significant but weak, positive correlation with age and the number of quarantine days. CONCLUSION: The occurring COVID-19 pandemic could be the culprit of psychological distress, anxiety, and depression of large population quantities. Our results showed a subordinate overall resilience in the general Iranian population during the COVID-19 pandemic.

Efficacy of intradermal injection of tranexamic acid and ascorbic acid versus tranexamic acid and placebo in the treatment of melasma: A split-face comparative trial.

Background and Aims: Melasma is a common dermatologic disorder characterized by symmetrical hyperpigmented lesions on the face. Although various therapeutic options are available for melasma, its treatment remains challenging. The present study evaluated the safety and efficacy of intradermal microinjection of tranexamic acid (TA) plus ascorbic acid in treating melasma lesions compared with TA and placebo. Methods: From September 2019 to May 2020, 24 patients with symmetrical melasma were enrolled in a prospective, double-blind, split-face, randomized controlled clinical trial. Each patient received 50 mg/ml TA and 50 mg/ml ascorbic acid for one side of the face (A) and 50 mg/ml TA and placebo for the other side (B) every 2 weeks for 12 weeks. The Melasma Area and Severity Index (MASI) score, Physician Global Assessment, and pain were measured at baseline and at 4, 8, 12, and 24 weeks. Statistical analysis was done using SPSS software version 16, and data were reported as mean ± standard deviation or median and interquartile range. χ 2 and Fisher's exact tests were used to test differences between the groups. Results: Both groups experienced a significant decrease in MASI scores compared with the baseline. The MASI score was significantly less in the intervention group than the placebo group at the 8th and 12th weeks. However, burning pain was significantly more prominent in the intervention group. Conclusion: Intradermal injection of ascorbic acid combined with TA can be beneficial in treating melasma. Currently, there are numerous treatment modalities for melasma. However, the results still vary, and satisfactory outcomes are yet to be reached.