Models to predict length of stay in the emergency department: a systematic literature review and appraisal.

INTRODUCTION: Prolonged Length of Stay (LOS) in ED (Emergency Department) has been associated with poor clinical outcomes. Prediction of ED LOS may help optimize resource utilization, clinical management, and benchmarking. This study aims to systematically review models for predicting ED LOS and to assess the reporting and methodological quality about these models. METHODS: The online database PubMed, Scopus, and Web of Science (10 Sep 2023) was searched for English language articles that reported prediction models of LOS in ED. Identified titles and abstracts were independently screened by two reviewers. All original papers describing either development (with or without internal validation) or external validation of a prediction model for LOS in ED were included. RESULTS: Of 12,193 uniquely identified articles, 34 studies were included (29 describe the development of new models and five describe the validation of existing models). Different statistical and machine learning methods were applied to the papers. On the 39-point reporting score and 11-point methodological quality score, the highest reporting scores for development and validation studies were 39 and 8, respectively. CONCLUSION: Various studies on prediction models for ED LOS were published but they are fairly heterogeneous and suffer from methodological and reporting issues. Model development studies were associated with a poor to a fair level of methodological quality in terms of the predictor selection approach, the sample size, reproducibility of the results, missing imputation technique, and avoiding dichotomizing continuous variables. Moreover, it is recommended that future investigators use the confirmed checklist to improve the quality of reporting.

Predicting the risk of neurocognitive decline after brain irradiation in adult patients with a primary brain tumor.

BACKGROUND: Deterioration of neurocognitive function in adult patients with a primary brain tumor is the most concerning side effect of radiotherapy. This study was aimed to develop and evaluate Normal-Tissue Complication Probability (NTCP) models using clinical and dose-volume measures for 6-month, 1-year and 2-year Neurocognitive Decline (ND) post-radiotherapy. METHODS: A total of 219 patients with a primary brain tumor treated with radical photon and/or proton radiotherapy (RT) between 2019 and 2022 were included. Controlled Oral Word Association (COWA) test, Hopkins Verbal Learning Test-Revised (HVLTR) and Trail Making Test (TMT) were used to objectively measure ND. A comprehensive set of potential clinical and dose-volume measures on several brain structures were considered for statistical modelling. Clinical, dose-volume and combined models were constructed and internally tested in terms of discrimination (Area Under the Curve, AUC), calibration (Mean Absolute Error, MAE) and net benefit. RESULTS: 50%, 44.5% and 42.7% of the patients developed ND at 6-month, 1-year and 2-year timepoints, respectively. Following predictors were included in the combined model for 6-month ND: age at radiotherapy>56 years (OR=5.71), overweight (OR=0.49), obesity (OR=0.35), chemotherapy (OR=2.23), brain V20Gy≥20% (OR=3.53), brainstem volume≥26cc (OR=0.39) and hypothalamus volume≥0.5cc (OR=0.4). Decision curve analysis showed that the combined models had the highest net benefits at 6-month (AUC=0.79, MAE=0.021), 1-year (AUC=0.72, MAE=0.027) and 2-year (AUC=0.69, MAE=0.038) timepoints. CONCLUSION: The proposed NTCP models use easy-to-obtain predictors to identify patients at high-risk of ND after brain RT. These models can potentially provide a base for RT-related decisions and post-therapy neurocognitive rehabilitation interventions.

Quantitative MRI-based radiomics analysis identifies blood flow feature associated to overall survival for rectal cancer patients.

Radiomics objectively quantifies image information through numerical metrics known as features. In this study, we investigated the stability of magnetic resonance imaging (MRI)-based radiomics features in rectal cancer using both anatomical MRI and quantitative MRI (qMRI), when different methods to define the tumor volume were used. Second, we evaluated the prognostic value of stable features associated to 5-year progression-free survival (PFS) and overall survival (OS). On a 1.5 T MRI scanner, 81 patients underwent diagnostic MRI, an extended diffusion-weighted sequence with calculation of the apparent diffusion coefficient (ADC) and a multiecho dynamic contrast sequence generating both dynamic contrast-enhanced and dynamic susceptibility contrast (DSC) MR, allowing quantification of Ktrans, blood flow (BF) and area under the DSC curve (AUC). Radiomic features were extracted from T2w images and from ADC, Ktrans, BF and AUC maps. Tumor volumes were defined with three methods; machine learning, deep learning and manual delineations. The interclass correlation coefficient (ICC) assessed the stability of features. Internal validation was performed on 1000 bootstrap resamples in terms of discrimination, calibration and decisional benefit. For each combination of image and volume definition, 94 features were extracted. Features from qMRI contained higher prognostic potential than features from anatomical MRI. When stable features (> 90% ICC) were compared with clinical parameters, qMRI features demonstrated the best prognostic potential. A feature extracted from the DSC MRI parameter BF was associated with both PFS (p = 0.004) and OS (p = 0.004). In summary, stable qMRI-based radiomics features was identified, in particular, a feature based on BF from DSC MRI was associated with both PFS and OS.

The Association of Gross Tumor Volume and Its Radiomics Features with Brain Metastases Development in Patients with Radically Treated Stage III Non-Small Cell Lung Cancer.

PURPOSE: To identify clinical risk factors, including gross tumor volume (GTV) and radiomics features, for developing brain metastases (BM) in patients with radically treated stage III non-small cell lung cancer (NSCLC). METHODS: Clinical data and planning CT scans for thoracic radiotherapy were retrieved from patients with radically treated stage III NSCLC. Radiomics features were extracted from the GTV, primary lung tumor (GTVp), and involved lymph nodes (GTVn), separately. Competing risk analysis was used to develop models (clinical, radiomics, and combined model). LASSO regression was performed to select radiomics features and train models. Area under the receiver operating characteristic curves (AUC-ROC) and calibration were performed to assess the models' performance. RESULTS: Three-hundred-ten patients were eligible and 52 (16.8%) developed BM. Three clinical variables (age, NSCLC subtype, and GTVn) and five radiomics features from each radiomics model were significantly associated with BM. Radiomic features measuring tumor heterogeneity were the most relevant. The AUCs and calibration curves of the models showed that the GTVn radiomics model had the best performance (AUC: 0.74; 95% CI: 0.71-0.86; sensitivity: 84%; specificity: 61%; positive predictive value [PPV]: 29%; negative predictive value [NPV]: 95%; accuracy: 65%). CONCLUSION: Age, NSCLC subtype, and GTVn were significant risk factors for BM. GTVn radiomics features provided higher predictive value than GTVp and GTV for BM development. GTVp and GTVn should be separated in clinical and research practice.

Computed tomography-based radiomics for the differential diagnosis of pneumonitis in stage IV non-small cell lung cancer patients treated with immune checkpoint inhibitors.

INTRODUCTION: Immunotherapy-induced pneumonitis (IIP) is a serious side-effect which requires accurate diagnosis and management with high-dose corticosteroids. The differential diagnosis between IIP and other types of pneumonitis (OTP) remains challenging due to similar radiological patterns. This study was aimed to develop a prediction model to differentiate IIP from OTP in patients with stage IV non-small cell lung cancer (NSCLC) who developed pneumonitis during immunotherapy. METHODS: Consecutive patients with metastatic NSCLC treated with immunotherapy in six centres in the Netherlands and Belgium from 2017 to 2020 were reviewed and cause-specific pneumonitis events were identified. Seven regions of interest (segmented lungs and spheroidal/cubical regions surrounding the inflammation) were examined to extract the most predictive radiomic features from the chest computed tomography images obtained at pneumonitis manifestation. Models were internally tested regarding discrimination, calibration and decisional benefit. To evaluate the clinical application of the models, predicted labels were compared with the separate clinical and radiological judgements. RESULTS: A total of 556 patients were reviewed; 31 patients (5.6%) developed IIP and 41 patients developed OTP (7.4%). The line of immunotherapy was the only predictive factor in the clinical model (2nd versus 1st odds ratio = 0.08, 95% confidence interval:0.01-0.77). The best radiomic model was achieved using a 75-mm spheroidal region of interest which showed an optimism-corrected area under the receiver operating characteristic curve of 0.83 (95% confidence interval:0.77-0.95) with negative and positive predictive values of 80% and 79%, respectively. Good calibration and net benefits were achieved for the radiomic model across the entire range of probabilities. A correct diagnosis was provided by the radiomic model in 10 out of 12 cases with non-conclusive radiological judgements. CONCLUSION: Radiomic biomarkers applied to computed tomography imaging may support clinicians making the differential diagnosis of pneumonitis in patients with NSCLC receiving immunotherapy, especially when the radiologic assessment is non-conclusive.

Prediction models for brachytherapy-induced rectal toxicity in patients with locally advanced pelvic cancers: a systematic review.

Purpose: Rectal toxicity remains a major threat to quality of life of patients, who receive brachytherapy to the abdominal pelvic area. Estimating the risk of toxicity development is essential to maximize therapeutic benefit without impairing rectal function. This study aimed to abstract and evaluate studies, which have developed prediction models for rectal toxicity after brachytherapy (BT) in patients with pelvic cancers. Material and methods: To identify relevant studies since 1995, MEDLINE database was searched on August 31, 2021, using terms related to "pelvic cancers", "brachytherapy", "prediction models", and "rectal toxicity". Papers were excluded if model specifications were not reported. Risk of bias was assessed using prediction model risk of bias assessment tool. Results: Thirty models (n = 16 cervical cancer, n = 13 prostate cancer, and n = 1 rectal cancer), including 60 distinct predictors were published. Rectal toxicity varied significantly between studies (median, 25.4% for cervix, and median, 8.8% for prostate cancer). High-, low-, and pulsed-dose-rate BT were applied in 15 (50%), 13 (43%), and 1 (3%) studies, respectively. Most common predictors that retained in final models were age (n = 5, 17%), EBRT (n = 5, 17%), V100% rectum (BT) (n = 5, 17%), and dose at rectal point (n = 3, 10%). None of the studies were considered to be at low-risk of bias due to deficiencies in the analysis domain. Conclusions: Existing models have limited clinical application due to poor quality of methodology. The following key issues should be considered in future studies: 1) Measuring patient-reported outcomes to address underestimation of true frequencies of rectal toxicity events; 2) Giving higher priority to reliable dose-volume parameters; 3) Avoiding overfitting by considering an event per candidate predictor rate ≥ 20; 4) Calculating detailed performance measures.

Evaluation of Normal Renal Size and its Influencing Factors: A Cross-Sectional Study on the Adult Population of Mashhad.

Background: The normal range of kidney size is a controversial issue among different populations given to its impressibility by multiple factors, therefore, this study aimed to provide valid reference ranges for kidney dimensions in the adult population of Mashhad. Also, we assessed the association of kidney size characteristics with some personal predisposing factors. Methods: This cross-sectional study was conducted on 938 healthy individuals. Ultrasound measurement, physical examination, and laboratory analysis were performed. Demographic, dietary, and anthropometric data were obtained. The variables were categorized into 5 groups each, and data analysis were performed using the following statistical tests: Pearson correlation test, variance analysis, t-test, and chi-square test. A value of p<0.05 was considered statistically significant. Results: Weight had the most association with kidney size followed to a lesser extent by height and age. Even after adjustment for other confounding variables, weight remained as an independent factor, while this effect was resolved for height and age. Also, all values for renal function, body bio-impedance, blood pressure components, and water intake were notably correlated with kidney size. Conclusion: This study determined the normal kidney size in healthy adults. We also declared the normal range of kidney size is a dynamic concept and should be assessed for each individual separately according to their personal determinative factors.

Spectral-domain optical coherence tomography assessment of retinal and choroidal changes in patients with coronavirus disease 2019: a case-control study.

OBJECTIVES: This study aimed to evaluate the retinal and choroidal changes in the macular region of patients with Coronavirus Disease 2019 (COVID-19) using structural spectral-domain optical coherence tomography (SD-OCT) analysis. METHODS: This cross-sectional observational case-control study included patients recovered from COVID-19. The COVID-19 in all participants was confirmed using the reverse transcription-polymerase chain reaction (RT-PCR) technique. The participants had mild to moderate degree of disease without a history of hospitalization, steroid usage, or blood saturation below 92%. Macular SD-OCT was performed at least two weeks and up to one month after recovery from systemic COVID-19. Quantitative and qualitative changes detected by macular SD-OCT imaging were evaluated in COVID-19 recovered patients and compared with the results of age-matched normal controls. RESULTS: Participants in this study included 30 cases (60 eyes) and 60 healthy controls (120 eyes). In total, 17 (28.3%) eyes in patient group showed at least one abnormal finding indicated by macular SD-OCT imaging included hyperreflective lesions in different retinal layers. In addition, dilated choroidal vessels and retinal pigment epitheliopathy were evident in 41 (68.3.6%) and 4 (6.6%) eyes in patient group, respectively, and their OCT findings resembled those with pachychoroid spectrum. No statistically significant differences were observed in retinal layers or retinal volume between the two groups. The mean ± SD subfoveal choroidal thickness (SFCT) was determined at 380.3 ± 12.40 µm, which was significantly thicker than that in control group (310.7 ± 57.5 µm) (P < 0.001). CONCLUSION: Regarding retinal thickness, no significant change was observed in different retina layers of patients with COVID-19; however, there were striking qualitative changes, such as hyperreflective lesions in different retinal layers. The evaluation of choroidal structure and thickness demonstrated remarkable abnormal pachyvessels and significant thickening of the SFCT but the clinical significance of these findings is unknown.

Prediction Models for Radiation-Induced Neurocognitive Decline in Adult Patients With Primary or Secondary Brain Tumors: A Systematic Review.

Purpose: Although an increasing body of literature suggests a relationship between brain irradiation and deterioration of neurocognitive function, it remains as the standard therapeutic and prophylactic modality in patients with brain tumors. This review was aimed to abstract and evaluate the prediction models for radiation-induced neurocognitive decline in patients with primary or secondary brain tumors. Methods: MEDLINE was searched on October 31, 2021 for publications containing relevant truncation and MeSH terms related to "radiotherapy," "brain," "prediction model," and "neurocognitive impairments." Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool. Results: Of 3,580 studies reviewed, 23 prediction models were identified. Age, tumor location, education level, baseline neurocognitive score, and radiation dose to the hippocampus were the most common predictors in the models. The Hopkins verbal learning (n = 7) and the trail making tests (n = 4) were the most frequent outcome assessment tools. All studies used regression (n = 14 linear, n = 8 logistic, and n = 4 Cox) as machine learning method. All models were judged to have a high risk of bias mainly due to issues in the analysis. Conclusion: Existing models have limited quality and are at high risk of bias. Following recommendations are outlined in this review to improve future models: developing cognitive assessment instruments taking into account the peculiar traits of the different brain tumors and radiation modalities; adherence to model development and validation guidelines; careful choice of candidate predictors according to the literature and domain expert consensus; and considering radiation dose to brain substructures as they can provide important information on specific neurocognitive impairments.

Internal validation and evaluation of the predictive performance of models based on the PRISM-3 (Pediatric Risk of Mortality) and PIM-3 (Pediatric Index of Mortality) scoring systems for predicting mortality in Pediatric Intensive Care Units (PICUs).

PURPOSE: The study was aimed to assess the prognostic power The Pediatric Risk of Mortality-3 (PRISM-3) and the Pediatric Index of Mortality-3 (PIM-3) to predict in-hospital mortality in a sample of patients admitted to the PICUs. DESIGN AND METHODS: The study was performed to include all children younger than 18 years of age admitted to receive critical care in two hospitals, Mashhad, northeast of Iran from December 2017 to November 2018. The predictive performance was quantified in terms of the overall performance by measuring the Brier Score (BS) and standardized mortality ratio (SMR), discrimination by assessing the AUC, and calibration by applying the Hosmer-Lemeshow test. RESULTS: A total of 2446 patients with the median age of 4.2 months (56% male) were included in the study. The PICU and in-hospital mortality were 12.4 and 16.14%, respectively. The BS of the PRISM-3 and PIM-3 was 0.088 and 0.093 for PICU mortality and 0.108 and 0.113 for in-hospital mortality. For the entire sample, the SMR of the PRISM-3 and PIM-3 were 1.34 and 1.37 for PICU mortality and 1.73 and 1.78 for in-hospital mortality, respectively. The PRISM-3 demonstrated significantly higher discrimination power in comparison with the PIM-3 (AUC = 0.829 vs 0.745) for in-hospital mortality. (AUC = 0.779 vs 0.739) for in-hospital mortality. The HL test revealed poor calibration for both models in both outcomes. CONCLUSIONS: The performance measures of PRISM-3 were better than PIM-3 in both PICU and in-hospital mortality. However, further recalibration and modification studies are required to improve the predictive power to a clinically acceptable level before daily clinical use. PRACTICE IMPLICATIONS: The calibration of the PRISM-3 model is more satisfactory than PIM-3, however both models have fair discrimination power.

Prediction models for treatment-induced cardiac toxicity in patients with non-small-cell lung cancer: A systematic review and meta-analysis.

BACKGROUND: To maximize the likelihood of positive outcome in non-small-cell lung cancer (NSCLC) survivors, potential benefits of treatment modalities have to be weighed against the possibilities of damage to normal tissues, such as the heart. High-quality data-driven evidence regarding appropriate risk stratification strategies is still scarce. The aim of this review is to summarize and appraise available prediction models for treatment-induced cardiac events in patients with NSCLC. METHODS: A systematic search of MEDLINE was performed using a Boolean combination of appropriate truncation and indexing terms related to "NSCLC", "prediction models", "cardiac toxicity", and "treatment modalities". The following exclusion criteria were applied: sample-size of less than 100, no significant predictors in multivariate analysis, lack of model specifications, and case-mix studies. The generic inverse variance method was used to pool the summary effect estimate for each predictor. The quality of the papers was assessed using the Prediction model Risk Of Bias Assessment Tool. RESULTS: Of the 3,056 papers retrieved, 28 prediction models were identified, including seven for (chemo-)radiotherapy, one for immunotherapy, and 20 for surgical resection. Forty-one distinct predictors were entered in the prediction models. The pooled effect estimate of the mean heart dose (HR = 1.06, 95%CI:1.04-1.08) and history of cardiovascular diseases (HR = 3.1, 95%CI:1.8-5.36) were shown to significantly increase the risk of developing late cardiac toxicity after (chemo-)radiotherapy. Summary estimates of age (OR = 1.17, 95%CI:1.06-1.29), male gender (OR = 1.61, 95%CI:1.4-1.85), and advanced stage (OR = 1.34, 95%CI:1.06-1.69) were significantly associated with higher risk of acute cardiac events after surgery. Risk of bias varied across studies, but analysis was the most concerning domain where none of the studies were judged to be low risk. CONCLUSION: This review highlights the need for a robust prediction model which can inform patients and clinicians about expected treatment-induced heart damage. Identified clues suggest incorporation of detailed cardiac metrics (substructures' volumes and doses).

Optic Nerve Head Parameters and Peripapillary Retinal Nerve Fiber Layer Thickness in Patients with Coronavirus Disease 2019.

PURPOSE: To quantify the optic nerve head (ONH) and peripapillary retinal nerve fiber layer (pRNFL) thickness in patients with Coronavirus Disease-2019 (COVID-19) and compare the measurements with a healthy control group. METHODS: In a comparative cross-sectional observational study, ONH and pRNFL thickness were evaluated in patients with a history of COVID-19, at least 2 weeks after recovery from the systemic disease, and compared with an age-matched, normal control group. RESULTS: Thirty COVID-19 patients along with 60 age- and gender-matched healthy controls were studied. Mean average pRNFL thickness was 105.0 ± 16.3 µm in the COVID-19 patients, compared to 99.0 ± 9.0 µm in the controls (p = .31). The pRNFL thicknesses in all sectors was higher in patients with a history of COVID-19; however, this did not reach statistical significance. Similarly, ONH parameters were not significantly different between the groups. CONCLUSION: Patients recovered from COVID-19 had unremarkable alterations in the peripapillary RNFL thickness. ABBREVIATIONS: ONH: Optic Nerve HeadRNFL: Retinal Nerve Fiber LayerSD-OCT: Spectral-Domain Optical Coherence TomographyCOVID-19: Coronavirus Disease 2019SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2CNS: Central Nervous SystemACE: Angiotensin-Converting EnzymeRT-PCR: Reverse Transcription-Polymerase Chain Reaction.

Internal validation and comparison of the prognostic performance of models based on six emergency scoring systems to predict in-hospital mortality in the emergency department.

BACKGROUND: Medical scoring systems are potentially useful to make optimal use of available resources. A variety of models have been developed for illness measurement and stratification of patients in Emergency Departments (EDs). This study was aimed to compare the predictive performance of the following six scoring systems: Simple Clinical Score (SCS), Worthing physiological Score (WPS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), and Routine Laboratory Data (RLD) to predict in-hospital mortality. METHODS: A prospective single-center observational study was conducted from March 2016 to March 2017 in Edalatian ED in Emam Reza Hospital, located in the northeast of Iran. All variables needed to calculate the models were recorded at the time of admission and logistic regression was used to develop the models' prediction probabilities. The Area Under the Curve for Receiver Operating Characteristic (AUC-ROC) and Precision-Recall curves (AUC-PR), Brier Score (BS), and calibration plots were used to assess the models' performance. Internal validation was obtained by 1000 bootstrap samples. Pairwise comparison of AUC-ROC was based on the DeLong test. RESULTS: A total of 2205 patients participated in this study with a mean age of 61.8 ± 18.5 years. About 19% of the patients died in the hospital. Approximately 53% of the participants were male. The discrimination ability of SCS, WPS, RAPS, REMS, MEWS, and RLD methods were 0.714, 0.727, 0.661, 0.678, 0.698, and 0.656, respectively. Additionally, the AUC-PR of SCS, WPS, RAPS, REMS, EWS, and RLD were 0.39, 0.42, 0.35, 0.34, 0.36, and 0.33 respectively. Moreover, BS was 0.1459 for SCS, 0.1713 for WPS, 0.0908 for RAPS, 0.1044 for REMS, 0.1158 for MEWS, and 0.073 for RLD. Results of pairwise comparison which was performed for all models revealed that there was no significant difference between the SCS and WPS. The calibration plots demonstrated a relatively good concordance between the actual and predicted probability of non-survival for the SCS and WPS models. CONCLUSION: Both SCS and WPS demonstrated fair discrimination and good calibration, which were superior to the other models. Further recalibration is however still required to improve the predictive performance of all available models and their use in clinical practice is still unwarranted.

The Effect of Curcumin Supplementation on Pulse Wave Velocity in Patients with Metabolic Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial.

Cardiovascular disease is a leading cause of death in many societies. Arterial stiffness is an initial sign of structural and functional changes in the arterial wall. Pulse wave velocity (PWV) is the gold standard for non-invasive evaluation of aortic stiffness and a modifiable cardiovascular risk factor. Curcumin is a major component of turmeric with known anti-inflammatory and anti-oxidative effects. Since arterial stiffness is affected by inflammation and oxidative stress, it may be improved by curcumin supplementation. The purpose of this clinical trial was to investigate the potential effects of curcumin on improving arterial stiffness in patients with metabolic syndrome. This placebo-controlled, double-blind, randomized clinical trial was conducted among metabolic syndrome patients. Sixty-six eligible individuals were randomly assigned to active intervention or control groups. The active intervention group received curcumin supplement at a dose of 500 mg daily for 12 weeks, whereas the control group received placebo capsule. Physical activity, daily dietary energy intake, anthropometric body composition, and biochemical hemodynamic and arterial stiffness parameters were evaluated at baseline and at the end of the study. Body weight decreased significantly in the curcumin group compared to placebo. Also, curcumin intervention improved PWV, which remained significant after adjustment for potential confounding factors (p = 0.011). The current clinical trial demonstrated that daily intake of 500 mg of curcumin for 12 weeks can lead to the improvement of arterial stiffness and weight management among subjects with metabolic syndrome.

Effectiveness of IT-based interventions on self-management in adult kidney transplant recipients: a systematic review.

BACKGROUND: Kidney transplant outcomes are broadly associated with transplant recipients' capacity in following a complex and continuous self-management regimen. Health information technology has the potential to empower patients. This systematic review aimed to determine the impacts of IT-based interventions for self-management in kidney transplant recipients. METHODS: A comprehensive investigation was performed in MEDLINE (via PubMed) and EMBASE (via Scopus) in April 2019. Eligible studies were the randomized controlled trials which aimed to design an automated IT-based intervention. All English papers including adult kidney transplant recipients were included. To assess the clinical trial's quality, Cochrane Collaboration's assessment tool was employed. The articles were integrated based on category of outcomes, characteristics of interventions, and their impact. The interventions were classified based on the used IT-based tools, including smart phones, coverage tools, computer systems, and a combination of several tools. The impact of interventions was defined as: (1) positive effect (i.e. statistically significant), and (2) no effect (i.e. not statistically significant). RESULTS: A total of 2392 articles were retrieved and eight publications were included for full-text analysis. Interventions include those involving the use of computerized systems (3 studies), smart phone application (3 studies), and multiple components (2 studies). The studies evaluated 30 outcomes in total, including 24 care process and 6 clinical outcomes. In 18 (80%) out of 30 outcomes, interventions had a statistically significant positive effect, 66% in process and 33% in clinical outcomes. CONCLUSIONS: IT-based interventions (e.g. mobile health applications, wearable devices, and computer systems) can improve self-management in kidney transplant recipients (including clinical and care process outcomes). However, further evaluation studies are required to quantify the impact of IT-based self-management interventions on short- and long-term clinical outcomes as well as health care costs and patients' quality of life.

The burden and predisposing factors of non-communicable diseases in Mashhad University of Medical Sciences personnel: a prospective 15-year organizational cohort study protocol and baseline assessment.

BACKGROUND: The rising burden of premature mortality for Non-Communicable Diseases (NCDs) in developing countries necessitates the institutionalization of a comprehensive surveillance framework to track trends and provide evidence to design, implement, and evaluate preventive strategies. This study aims to conduct an organization-based prospective cohort study on the NCDs and NCD-related secondary outcomes in adult personnel of the Mashhad University of Medical Sciences (MUMS) as main target population. METHODS: This study was designed to recruit 12,000 adults aged between 30 and 70 years for 15 years. Baseline assessment includes a wide range of established NCD risk factors obtaining by face-to-face interview or examination. The questionnaires consist of demographic and socioeconomic characteristics, lifestyle pattern, fuel consumption and pesticide exposures, occupational history and hazards, personal and familial medical history, medication profile, oral hygiene, reproduction history, dietary intake, and psychological conditions. Examinations include body size and composition test, abdominopelvic and thyroid ultrasonography, orthopedic evaluation, pulse wave velocity test, electrocardiography, blood pressure measurement, smell-taste evaluation, spirometry, mammography, and preferred tea temperature assessment. Routine biochemical, cell count, and fecal occult blood tests are also performed, and the biological samples (i.e., blood, urine, hair, and nail) are stored in preserving temperature. Annual telephone interviews and repeated examinations at 5-year intervals are planned to update information on health status and its determinants. RESULTS: A total of 5287 individuals (mean age of 43.9 ± 7.6 and 45.9% male) were included in the study thus far. About 18.5% were nurses and midwives and 44.2% had at least bachelor's degree. Fatty liver (15.4%), thyroid disorders (11.2%), hypertension (8.8%), and diabetes (4.9%) were the most prevalent NCDs. A large proportion of the population had some degree of anxiety (64.2%). Low physical activity (13 ± 22.4 min per day), high calorie intake (3079 ± 1252), and poor pulse-wave velocity (7.2 ± 1.6 m/s) highlight the need for strategies to improve lifestyle behaviors. CONCLUSION: The PERSIAN Organizational Cohort study in Mashhad University of Medical Sciences is the first organizational cohort study in a metropolitan city of Iran aiming to provide a large data repository on the prevalence and risk factors of the NCDs in a developing country for future national and international research cooperation.

Prognostic utilization of models based on the APACHE II, APACHE IV, and SAPS II scores for predicting in-hospital mortality in emergency department.

BACKGROUND: This study was designed to evaluate and compare the prognostic value of the APACHE II, APACHE IV, and SAPSII scores for predicting in-hospital mortality in the ED on a large sample of patients. Earlier studies in the ED setting have either used a small sample or focused on specific diagnoses. METHODS: A prospective study was conducted to include patients with higher risk of mortality from March 2016 to March 2017 in the ED of Emam Reza Hospital, northeast of Iran. Logistic regression was used to develop three models. Evaluation was performed in terms of the overall performance (Brier Score, BS, and Brier Skill Score, BSS), discrimination (Area Under the Curve, AUC), and calibration (calibration graph). RESULTS: A total of 2205 patients met the study criteria (53% male and median age of 64, IQR: 50-77). In-hospital mortality amounted to 19%. For APACHE II, APACHE IV, and SAPS II the BS was 0.132, 0.125 and 0.133 and the BSS was 0.156, 0.2, and 0.144, respectively. The AUC was 0.755 (0.74 to 0.779) for APACHE II, 0.794 (0.775 to 0.818) for APACHE IV, and 0.751 (0.727 to 0.776) for SAPS II. The APACHE IV showed significantly greater AUC in comparison to the APACHE II and SAPS II. The graphical evaluation revealed good calibration of the APACHE IV model. CONCLUSION: APACHEIV outperformed APACHEII and SAPSII in terms of discrimination and calibration. More validation is needed for using these models for decision-making about individual patients, although they would perform best at a cohort level.

Ocular Manifestations of Hospitalized Patients with COVID-19 in Northeast of Iran.

PURPOSE: To evaluate ocular findings in patients with Coronavirus Disease 2019 (COVID-19) in the Northeast of Iran. METHODS: In a cross-sectional, observational study all consecutive patients with confirmed COVID-19 diagnosis at the central referral center of these patients in northeast of Iran were included. Ocular examinations (external and slit) were randomly performed for the patients who were admitted to the Intensive Care Unit (ICU) and six COVID wards of the hospital. Moreover, Chart records and serum chemistry results were collected. RESULTS: A total of 142 patients with the mean age of 62.6 ± 15 years (range: 23-96 years) and almost equal gender distribution (male: N = 77, 54.2%) were included in the study. During the initial external examination by the ophthalmologist, 44 (31%) patients were found to have conjunctival hyperemia and 22 (15.5%) patients had chemosis. Consecutive slit examination showed 41 (28.9%) conjunctival hyperemia, 22 (15.5%) chemosis, 11 (7.7%) cataract, and 9 (6.3%) diabetic retinopathy. The patients with at least one ocular manifestation had significantly higher blood urea levels at the time of admission compared to those with no obvious ocular involvement (median: 41.5, IQR: 28-66.3 vs. median: 33, IQR: 23.8-51.8, P = .023). Moreover, a significant difference was observed in the total white blood cell count, lymphocyte percent, neutrophil count, Erythrocyte Sedimentation Rate (ESR), and blood urea level between patients with positive and negative Polymerase Chain Reaction (PCR) for SARS-CoV-2 virus. None of the patients reported ocular symptoms prior to systemic involvement. The proportion of patients with at least one ocular manifestation was significantly higher in those admitted in the ICU compared to the non-ICU wards. wards. While conjunctival hyperemia was the most prevalent ocular finding in all patients, chemosis was the most common ocular manifestation in ICU admitted patients. CONCLUSION: Ocular manifestation was observed in more than half of our COVID-19 patients. Hence, it seems important to involve ophthalmologist in the diagnosis and management of these patients.

Socioeconomic-related inequalities in oral hygiene behaviors: a cross-sectional analysis of the PERSIAN cohort study.

BACKGROUND: Socioeconomic-related inequality in oral hygiene behaviors in Iran is poorly understood. This study aims to measure and decompose socioeconomic-related inequalities in oral hygiene behaviors among middle-aged and elderly adults in Iran. METHODS: A cross-sectional analysis was performed using data from the Prospective Epidemiological Research Studies in IrAN (PERSIAN), a large national cohort study. A total of 130,016 individuals aged 35 years and above from 17 cohort centers in Iran were included in the study. The normalized concentration index (Cn) was used to measure the magnitude of inequality in oral hygiene behaviors, i.e. brushing at least twice and flossing once daily, among middle-aged and elderly Iranian adults included in the cohort centers. Decomposition analysis was performed to quantify the contribution of each determinant to the observed inequality in oral hygiene behaviors. RESULTS: Totally, 65.5% of middle-aged and elderly adults brushed their teeth twice a day or more, 7.6% flossed at least once a day and 3.48% had both habits. The estimated Cn of the two habits combined, i.e. tooth brushing and dental flossing, for all provinces taken part in the PERSIAN cohort study was 0.399 (95% confidence interval [CI]: 0.383 to 0.417), indicating that the prevalence of the two habits combined is more concentrated among individuals with higher socioeconomic status. Inequality in oral hygiene behaviors was pro-rich in all cohort centers. The decomposition results suggested socioeconomic status as the main factor contributing to the overall inequality, followed by the level of education, and the province of residence. CONCLUSION: A low prevalence of oral hygiene behaviors among middle-aged and elderly Iranian adults was observed. There was also a pro-rich inequality in oral hygiene behaviors among middle-aged and elderly adults in all cohort centers. These results suggest an urgent need for targeted policy interventions to increase the prevalence of preventive oral hygiene behaviors among the poor and less-educated middle-aged and elderly adults in Iran.

Factors Associated With Adherence To Immunosuppressive Therapy And Barriers In Asian Kidney Transplant Recipients.

BACKGROUND: Medication non-adherence is the major risk factor for rejection episodes. The aim of this study was to determine the risk factors associated with adherence to immunosuppressive regimen and its barriers among kidney transplant (KT) recipients. METHODS: A cross-sectional study was performed in two outpatient post-transplant clinics in Mashhad, northeast of Iran. All patients who attended the clinics from August to October 2017 were included. Patients's knowledge, adherence to immunosuppressive regimen, and quality of life were measured using the Kidney Transplant Understanding Tool, Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS), and SF-12V2 questionnaire, respectively. The barriers in adhering immunosuppressive regimen were investigated by Immunosuppressive Therapy Barriers Scale. Logistic regression was used to screen the significant risk factors of medication non-adherence. RESULTS: In this study, 244 KT recipients were included with a mean age of 39.6±12.5 years. Based on the BAASIS score, 111 (45.5%) patients were adherent to immunosuppressive regimen. Female patients were more likely to be adherent (OR=0.48, p<0.01). The patients with higher level of quality of life were more likely to follow immunosuppressive medications (OR=1.078, p<0.05). The main barriers were as follows: concurrent use of many immunosuppressants, lack of knowledge about the usefulness of immunosuppressive medications, confusion in medication taking, and difficulty in remembering medication taking. CONCLUSION: More than half of the KT recipients were non-adherence to immunosuppressive regimen. These findings highlight the need for designing interventions in order to reduce or eliminate these barriers and consequently increase medication adherence among KT recipients.