Using meta-learning to recommend an appropriate time-series forecasting model.

BACKGROUND: There are various forecasting algorithms available for univariate time series, ranging from simple to sophisticated and computational. In practice, selecting the most appropriate algorithm can be difficult, because there are too many algorithms. Although expert knowledge is required to make an informed decision, sometimes it is not feasible due to the lack of such resources as time, money, and manpower. METHODS: In this study, we used coronavirus disease 2019 (COVID-19) data, including the absolute numbers of confirmed, death and recovered cases per day in 187 countries from February 20, 2020, to May 25, 2021. Two popular forecasting models, including Auto-Regressive Integrated Moving Average (ARIMA) and exponential smoothing state-space model with Trigonometric seasonality, Box-Cox transformation, ARMA errors, Trend, and Seasonal components (TBATS) were used to forecast the data. Moreover, the data were evaluated by the root mean squared error (RMSE), mean absolute error (MAE), mean absolute percentage error (MAPE), and symmetric mean absolute percentage error (SMAPE) criteria to label time series. The various characteristics of each time series based on the univariate time series structure were extracted as meta-features. After that, three machine-learning classification algorithms, including support vector machine (SVM), decision tree (DT), random forest (RF), and artificial neural network (ANN) were used as meta-learners to recommend an appropriate forecasting model. RESULTS: The finding of the study showed that the DT model had a better performance in the classification of time series. The accuracy of DT in the training and testing phases was 87.50% and 82.50%, respectively. The sensitivity of the DT algorithm in the training phase was 86.58% and its specificity was 88.46%. Moreover, the sensitivity and specificity of the DT algorithm in the testing phase were 73.33% and 88%, respectively. CONCLUSION: In general, the meta-learning approach was able to predict the appropriate forecasting model (ARIMA and TBATS) based on some time series features. Considering some characteristics of the desired COVID-19 time series, the ARIMA or TBATS forecasting model might be recommended to forecast the death, confirmed, and recovered trend cases of COVID-19 by the DT model.

Laparoscopic splenectomy in patients with idiopathic thrombocytopenic purpura and very low platelet count.

Background: Chronic idiopathic thrombocytopenic purpura (ITP), is an autoimmune disease associated with a reduction in circulating blood platelets under 150±109g/L which persists longer than 6 months without any specific cause. With the current study, we aimed to evaluate the efficacy and safety of laparoscopic splenectomy in ITP patients with a very low platelet count and normal coagulation status. Methods: From April 2007 to January 2012, laparoscopic splenectomy was performed on 60 patients with chronic ITP who could not achieve a sustained recovery after steroid therapy. Results: Patients consisted of male/female ratio of 24 (40%):36 (60%) with the mean age of 53±15.1 years. All patients had normal coagulation state even with very low platelet count (below 5×103) before laparoscopic splenectomy. The mean operative time was 140.00±15.00 minutes. Blood transfusion was required in 10 (16.7%) and 8 (13.3%) patients before and after the operation, respectively. Preoperative transfusion of PRBC was not statistically significant between groups (P=0.265). Bleeding complications during within or after surgery was rare (5.0%). Convalescence was rapid and the mean hospital stay was 3.58±0.68 days (1-14 days) which shows that there was no significant difference in operative time and after operative hospitalization time among the three groups (P=0.070). The patients made a good uneventful recovery and were followed for at least one week who exhibited no postoperative problems. Conclusion: Laparoscopic splenectomy should be considered initially in the management of ITP. Also, very low platelet count should not be contraindicated for laparoscopic splenectomy in ITP patients and sometimes perioperative platelet transfusion may be unnecessary.

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications.

BACKGROUND: Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE. METHODS: A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected. RESULTS: Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033). CONCLUSION: Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient's co-morbidities, cancer stage, tumor location and surgeon's experience.

Expression and Prognostic Significance of Cancer/Testis Antigens, MAGE-E1, GAGE, and SOX-6, in Glioblastoma: An Immunohistochemistry Evaluation.

BACKGROUND & OBJECTIVE: Glioblastoma is the most common primary malignancy of the brain, the prognosis of which is poor. Immunotherapy with cancer/testis (CT) antigens is a novel therapeutic approach for glioblastoma. This study aimed to investigate the expression rate of MAGE-E1, GAGE, and SOX-6 in glioblastoma tumors using the method of immunohistochemistry (IHC). METHODS: Expression of MAGE-E1, GAGE, and SOX-6 were determined by IHC in 50 paraffin blocks of glioblastoma. The results were compared between variables including age, gender, tumor location, and Karnofsky performance status (Kps) score. Survival analysis was also performed. RESULTS: The expression levels of SOX-6, MAGE-E1, and GAGE were 82%, 78%, and 76%, respectively. The relationship between CT antigens and age, gender, and tumor location was not significant, while the association between MAGE-E1 expression and age was statistically significant (P=0.002). High expression levels of SOX-6 and MAGE-E1 were associated with low Kps scores (P=0.034 and P<0.001, respectively). Survival analysis showed that age >40 and Kps score <80 were associated with significant relationship with shorter survival rate. (P=0.005 and P=0.018, respectively). Expression of MAGE-E1 and GAGE was negatively associated with overall 2-year survival rate (P=0.001 and P=0.021, respectively). CONCLUSION: The expression of all the three CT antigens, especially MAGE-E1 and SOX-6, was high in patients with glioblastoma. It can be concluded that these markers could be ideal targets for immunotherapy in such patients. MAGE-E1 and SOX-6 can be considered as important markers in determining the prognosis of glioblastoma.

Modeling and forecasting number of confirmed and death caused COVID-19 in IRAN: A comparison of time series forecasting methods.

BACKGROUND: The COVID-19 pandemic conditions are still prevalent in Iran and other countries and the monitoring system is gradually discovering new cases every day. Therefore, it is a cause for concern around the world, and forecasting the number of future patients and death cases, although not entirely accurate, helps the governments and health-policy makers to make the necessary decisions and impose restrictions to reduce prevalence. METHODS: In this study, we aimed to find the best model for forecasting the number of confirmed and death cases in Iran. For this purpose, we applied nine models including NNETAR, ARIMA, Hybrid, Holt-Winter, BSTS, TBATS, Prophet, MLP, and ELM network models. The quality of forecasting models is evaluated by three performance metrics, RMSE, MAE, and MAPE. The best model is selected by the lowest value of performance metrics. Then, the number of confirmed and the death cases forecasted for the 30 next days. The used data in this study is the absolute number of confirmed, death cases from February 20 to August 15, 2020. RESULTS: Our findings suggested that based on existing data in Iran, the suitable model with the lowest performance metrics for confirmed cases data obtained MLP network and the Holt-Winter model is the suitable model for forecasting death cases in the future. These models forecasted on September 14, 2020, we will have 2484 new confirmed and 114 new death cases of COVID-19. CONCLUSION: According to the results of this study and the existing data, we concluded that the MLP and Holt-Winter models had the lowest error in forecasting in comparison to other methods. Some models had fitted poorly in the test phase and this is because many other factors that are either not available or have been ignored in this study and can affect the accuracy of forecast results. Based on the trend of data and forecast results, the number of confirmed cases and death cases are almost constant and decreasing, respectively. However, due to disease progression and ignoring the recommendations and protocols of the Ministry of health, there is a possibility of re-emerging this disease more seriously in Iran and this requires more preventive care.

Is visuomotor training an effective intervention for children with autism spectrum disorders?

PURPOSE: Investigation of autism spectrum disorder (ASD) is somewhat dependent on addressing main core features of ASD. But it is not clear which kind of investigation can effect on more difficulties features. So, this study examines the effect of the visuomotor, motor, and computer-based training programs on social behavior, motor skills, and repetitive behaviors of children with ASD. PATIENTS AND METHODS: Sixty children with ASD aged 6-12 years were recruited and assigned to one of the three experimental groups and the control group (each group n=15). Training was provided in 30 sessions, scheduled 3 times a week. Social behavior and repetitive behaviors were determined objectively using the observation method, and motor skills were evaluated by the Test of Gross Motor Development-2. RESULTS: Our results suggested that children in the visuomotor group showed a significant reduction in the repetitive behaviors and an increase in gross motor skill scores in the post-test and follow-up. Also, the results exhibited that motor training group significantly improved in social behavior either in the post-test or follow-up. Although the post-test illustrated a considerable improvement of gross motor skills, this difference was not significant in follow-up. Similarly, no significant change was observed in visual training and control groups in relation to study variables. CONCLUSION: Given the improvement of repetitive behaviors and gross motor skills in post-test and follow-up, it seems that this investigation had a positive effect with a good retention effect on two core features of children with ASD. But according to group-based training protocol in motor training group and improvement in social communication, and mutual effect on gross motor skills, it seems that group-based practice can also be used to achieve the benefits of social communication in the investigations.

Effects of a Motor Intervention Program on Motor Skills and Executive Functions in Children With Learning Disabilities.

This study examined the effect of a motor intervention based on the attention, balance, and coordination (ABC) learning approach on motor proficiency and executive functions in children with learning disabilities (LD). Forty-five male elementary school students with LD aged 7-9 years were recruited and randomly assigned into one of three groups: two experimental groups and one control group. Experimental Group A received only the motor intervention. Experimental Group B simultaneously received both motor intervention and regular educational services. The control group received only regular educational services. The motor intervention involved sequential station exercises based on ABC; this training took place in 24 sessions, scheduled three times a week for eight weeks. We obtained children's scores on the Bruininks-Oseretsky Tests of Motor Proficiency, N-Back Test, Tower of London, and Continuous Performance Tests at pretest, posttest, and follow-up testing. Our results showed that both experimental groups significantly improved their motor skills and most measures of executive functions, relative to no significant improvement for the control group. The improvements on some measures of executive functions in Experimental Group B were just slightly better than in Experimental Group A. This study supported Blythe's ABC learning approach emphasizing ABC, and it extended earlier findings of benefits of this approach to populations of children with LD.

Using quantile regression for fitting lactation curve in dairy cows.

The main objective of this study was to compare the performance of different 'nonlinear quantile regression' models evaluated at the τth quantile (0·25, 0·50, and 0·75) of milk production traits and somatic cell score (SCS) in Iranian Holstein dairy cows. Data were collected by the Animal Breeding Center of Iran from 1991 to 2011, comprising 101 051 monthly milk production traits and SCS records of 13 977 cows in 183 herds. Incomplete gamma (Wood), exponential (Wilmink), Dijkstra and polynomial (Ali & Schaeffer) functions were implemented in the quantile regression. Residual mean square, Akaike information criterion and log-likelihood from different models and quantiles indicated that in the same quantile, the best models were Wilmink for milk yield, Dijkstra for fat percentage and Ali & Schaeffer for protein percentage. Over all models the best model fit occurred at quantile 0·50 for milk yield, fat and protein percentage, whereas, for SCS the 0·25th quantile was best. The best model to describe SCS was Dijkstra at quantiles 0·25 and 0·50, and Ali & Schaeffer at quantile 0·75. Wood function had the worst performance amongst all traits. Quantile regression is specifically appropriate for SCS which has a mixed multimodal distribution.

Frequency of Different Types of Diagnostic Errors in Patients with Central Nervous System Infections: A Cross-Sectional Observational Study.

OBJECTIVES: To assess the frequency of different types of diagnostic errors in patients with central nervous system (CNS) infection from the onset of symptoms to admission to the hospital, where the correct diagnosis was made. METHODS: A cross-sectional observational design was used, and the information was collected by interviewing patients and/or their knowledgeable relatives as well as reviewing the accompanying medical record documents and hospital records. RESULTS: Of 169 adult patients with CNS infection, 129 (76.33%) were subject to diagnostic errors. Failure in ordering tests and hypothesis generation were the most common types of diagnostic errors that accounted for more than 70% of errors. Several contributing factors that were associated with incorrect diagnostic hypotheses included failure in taking a patient's comprehensive history such as detecting relevant epidemiological clues, conducting a full clinical examination, and interpreting diagnostic evidence. The relationship between poor clinical outcome and longer delay from the onset of illness to diagnosis, inappropriate empirical antibiotic therapy, and lower level of consciousness on admission were found to be statistically significant. CONCLUSIONS: Although diagnosis and management of CNS infection in some patients are straightforward, clinical decision making in facing patients with complex scenarios often requires clinical reasoning instead of relying only on intuitive diagnosis. Justification in requesting diagnostic measures and interpretation of their results based on clinical findings and patient information could be a critical factor in preventing a substantial number of diagnostic errors in patients with CNS infection.

Validation of the influencing factors associated with traffic violations and crashes on freeways of developing countries: A case study of Iran.

Among the rural roads, freeways have the maximum allowable speed limit. This subject increases the tendency of drivers to use these kinds of roads, and despite its positive effects, it has caused numerous problems. One of them is the increase in the rate of traffic violations and crashes. The amount of crashes per kilometer in Iran's freeways is almost twice the other rural roads. Hence, finding a solution to this problem is of particular importance. This research intends to validate some of the influencing factors which cause traffic violations and crashes in freeways and determine their amount of influence through statistical models. For this purpose, the authors considered violations and crashes for 36 road segments as dependent variables and other factors as independent ones. Since dependent variables were count, discrete, and non-zero, the proposed models were Poisson and Zero-truncated Poisson. The processing of the models indicated that the amounts of Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) indices for the Zero-truncated Poisson model are less than those of the Poisson model and the result of the Pseudo-R2 test for this model is within the acceptable range. Moreover, the result of Chi-square test which shows the proximity of expected and observed amounts was better for Zero-truncated Poisson model. Thus, this model has a considerable advantage against Poisson model. Final models indicated that the average speed has a positive correlation with the number of violations and crashes and as it increases, they increase too. Besides, peripheral landscapes, number of interchanges, number of passing lanes, and exemption from paying toll have an opposite relationship with violations and crashes.

The Etiological Spectrum of Febrile Encephalopathy in Adult Patients: A Cross-Sectional Study from a Developing Country.

The profile of febrile encephalopathy varies based on different demographic and geographical characteristics of the study population. This retrospective, cross-sectional study was conducted to evaluate the etiological spectrum of febrile encephalopathy in hospitalized adult patients. A total of 293 patients with the mean age of 49.7 ± 23 were evaluated of whom 77.1% presented with encephalopathy syndrome. The most common diagnosis in patients with clinical syndromes suggestive of central nervous system (CNS) infection was sepsis associated encephalopathy (SAE) (22.9%), followed by bacterial meningitis (14%) and neurotuberculosis (9.9%). The comparison between the elderly and young adults showed that, in the young adults, bacterial meningitis and neurotuberculosis, and in the elderly SAE, are among the most common causes of clinical syndromes suggestive of CNS infection including febrile encephalopathy in our region. Moreover, we illustrated an upward trend for the proportion of diagnosing CNS infections among those who underwent diagnostic LP, from 40.4% in 2011 to 70% in 2015, that could be indicative of an increasing threshold for performing LP at least in our center in recent years. Whether these changes have been associated with increasing the rate of diagnostic errors or not needs to be evaluated in future studies.

Three Anastomotic Techniques Following Laparoscopic Rectal Cancer Resection: Our Experience in 155 Patients.

PURPOSE: This study aimed to assess the impact of 3 anastomotic techniques after laparoscopic rectal cancer resection. METHODS: In a cross-sectional study, the data of 155 patients who underwent surgery for rectal cancer were retrieved. An anastomosis was created between the left colon and anal canal with 3 different methods: coloanal anastomosis with protective ileostomy (group A), coloanal anastomosis without ostomy (group B), and delayed coloanal anastomosis (group C). The rates of anastomotic problems (leakage, peritonitis, and collection) were calculated for each treatment method. Multivariate analysis was used to verify the effect of anastomosis techniques. RESULTS: In 5 (3.2%) patients, peritonitis was observed in which 3 (9.7%) of them belonged to group B and 2 (4.1%) belonged to group C. In 9 (5.8%) patients, presacral collection and anastomotic leakage were observed; 4 (8.2%) patients belonged to group C, 4 (12.9%) patients to group B, and 1 (1.3%) patient to group A. Postoperative obstructions occurred in 5 (10.2%) patients of group C, 2 (6.5%) patients of group B, and 2 (2.7%) patients of group A. Rectovaginal fistula was detected in 2 patients from group B. CONCLUSIONS: Laparoscopic surgery of rectal cancer with transanal method is reliable and acceptable in terms of oncologic and surgical results. This study showed the best results in patients who had protective ostomy.

Can Skin Allograft Occasionally Act as a Permanent Coverage in Deep Burns? A Pilot Study.

BACKGROUND: Skin allograft is the gold standard of wound coverage in patients with extensive burns; however, it is considered as a temporary wound coverage and rejection of the skin allograft is considered inevitable. In our study, skin allograft as a permanent coverage in deep burns is evaluated. METHODS: Skin allograft survival was assessed in 38 patients from March 2009 to March 2014, retrospectively. Because of the lack of tissue specimen from the skin donors, patients with long skin allograft survival in whom the gender of donor and recipient of allograft was the same were excluded. Seven cases with skin allograft longevity and opposite gender in donor and recipient were finally enrolled. A polymerase chain reaction (PCR) test on the biopsy specimen from recipients and donors were undertaken. RESULTS: PCR on the biopsy specimen from recipients confirmed those specimens belong to the donors. All patients received allograft from the opposite sex. Two (28.57%) patients received allograft from their first-degree blood relatives, and in one (14.29%) case, the allograft was harvested from an alive individual with no blood relation. The rest were harvested from multiorgan donors. In eight months of follow up, no clinical evidence of graft rejection was noted. CONCLUSION: Long term persistence of skin allograft in patients is worthy of more attention. Further studies An increase in knowledge of factors influencing this longevity could realize the dream of burn surgeons to achieve a permanent coverage other than autograft for major burn patients.

Difficulties in the diagnosis and management of alveolar hydatid disease: A case series.

BACKGROUND: Alveolar echinococcosis (AE) is a chronic, rare and sometimes lethal parasitic infection in humans, caused by the larval stage of the fox tapeworm Echinococcus multilocularis. This study aimed to investigate the clinical aspects and treatment outcomes of patients with alveolar hydatid disease. METHODS: The medical records of patients with alveolar echinococcosis admitted between 1997 and 2012 were reviewed. Diagnosis was confirmed by physical examination, ultrasonography and CT scanning and MRI. Various treatment techniques were used such as complete liver resection in seven (38.89%) patients, biliary bypass in two (11.11%) patients, laparotomy and tumor biopsy in eight (44.44%) patients and long term medical treatment in one (5.56%) patient. After discharge, all patients were followed to determine the effect of treatment, complications, recurrences and survival. RESULTS: A total of 18 patients with mean age of 46.11±15.14 years (range 23-74 years) were studied. The disease was more prevalent in women than men (78.9% vs 4, 21.1%, P=0.021). Fourteen (77.78%) patients live in Chenaran, a town located in Khorasan, Iran). Death occurred in (22.22%) patients after an average period of 45.70±7.50 months after disease onset. 14 remaining patients survived after a mean follow-up duration of 54.60±29.17 months. CONCLUSION: Diagnosis of alveolar echinococcosis should be considered in endemic area. Early diagnosis and treatment is associated with excellent outcome.

Evaluation and Comparison of the Early Outcomes of Open and Laparoscopic Surgery of Liver Hydatid Cyst.

BACKGROUND AND AIM: Surgery is the mainstay for treatment of liver hydatid cyst. Different surgical procedures have been suggested, but it is important to select the most appropriate treatment to obtain the best results with the lowest rate of recurrence and minimal morbidity and mortality. The aim of this study was to evaluate the early outcomes of open and laparoscopic surgery of hydatidosis. MATERIALS AND METHODS: In this study, 75 patients with uncomplicated liver hydatid cyst were assigned prospectively to either groups of laparoscopic surgery (37, 50.68%) or open procedure (36, 49.32%) during the period of 2007 to 2012. Conversion to open surgery was required in 2 patients (2.67%), who were excluded from the study. Patients were followed for about 17.86±17.64 months. RESULTS: Participants included 73 patients: 49 (67.12%) female and 24 (32.88%) male patients, with the mean age of 38.97±16.48 years. There was no statistically significant difference between the 2 groups with regard to the sex, the occupation, and the mean diameter of the cysts. Bilious staining of the cyst content was observed in 23 (35.94%) patients during surgery, and a maximum diameter of 91 mm was considered as a cut point for predicting postoperative fistula with 69.2% sensitivity and 41.1% specificity. The mean duration of operation, postoperative pain, the hospitalization time, and the time to return to work were significantly lower in the laparoscopic group. Postoperative biliary fistula, cyst cavity infection, and wound infection were not different between the 2 groups. CONCLUSIONS: Laparoscopic surgery seems to be effective and safe, with low morbidity rates for uncomplicated cysts in accessible segments of the liver.

Methimazole discontinuation before radioiodine therapy in patients with Graves' disease.

INTRODUCTION: Although radioiodine therapy (RIT) has been used for the treatment of hyperthyroidism for many decades, there is no consensus on the optimal time of methimazole (MMI) discontinuation before RIT. The aim of this clinical trial is to study the effect of three different time points of MMI discontinuation on response to RIT. METHOD AND PATIENTS: Overall, 151 patients (18-65 years old), with Graves' disease who were taking MMI and referred to I-131 therapy, were consecutively assigned to one of three groups, and MMI was discontinued for 24-48, 48.1-72, and 72.1-168 h in group, 1, 2, and 3, respectively. Radioiodine uptake was measured in all patients and the radioiodine dose was calculated according to the Quimby formula to deliver 7.4 MBq of I-131 per gram of thyroid weight. Response to RIT was assessed at 1, 3, 6, and 12 months after RIT. RESULTS: A total of 102 women and 49 men were included in the study. The mean administered dose of I-131 was 362.9±188.7 MBq (9.8±5.1 mCi) and the mean time to response for radioiodine was 4.1±3.6 months. There was no significant difference between the three groups in age, thyroid weight, anti-TPO level, radioactive iodine uptake level, and radioiodine dose (P>0.1). Response to RIT at 1, 3, 6, and 12 months after administration was also not different between the three groups (P>0.57). CONCLUSION: No difference was found in the response to treatment between patients with MMI discontinuation for 24-48, 48.1-72, and 72.1-96 h before RIT. Shorter discontinuation of MMI before RIT may be preferable in most patients. Video Abstract: http://links.lww.com/NMC/A39.

Etiological Diagnosis of Community-Acquired Pneumonia in Adult Patients: A Prospective Hospital-Based Study in Mashhad, Iran.

BACKGROUND: Pneumonia is the third most common cause of death in the world, and mortality is highest for patients who require hospitalization. OBJECTIVES: This prospective observational study is an etiological survey of community-acquired pneumonia (CAP) over a 12-month period in the Iranian city of Mashhad. To our knowledge, this is one of the first prospective hospital-based studies to comprehensively evaluate the epidemiological, demographical, clinical, and prognostic factors of patients with CAP in Iran. PATIENTS AND METHODS: We studied all adult patients (aged ≥ 16 years) with CAP admitted to Imam Reza Hospital, Mashhad, Iran, between February 2013 and January 2014. The etiological diagnosis of CAP was made through conventional culturing and staining of respiratory secretions (i.e. sputum and pleural fluid), standard BACTEC™ Plus Aerobic/F bottles for blood cultures, and the immunochromatographic assays BinaxNOW(®) Streptococcus pneumoniae antigen and BinaxNOW(®) Legionella pneumophila antigen for the detection of S. pneumoniae antigen and L. pneumophila serogroup 1 antigen, respectively. RESULTS: Among 120 patients with CAP, the most common etiology was S. pneumoniae (24.4%), followed by Mycobacterium tuberculosis (17.5%), S. aureus (6.7%), polymicrobial agents including anaerobes (4.2%), complicated hydatid cyst (2.5%), Influenza A virus (4.2%; including 2 cases of mixed Influenza A-bacterial infection), and Klebsiella pneumoniae, Brucella melitensis, Mucor, and varicella, each in 0.8% of the patients. The diagnosis of pneumonia remained unknown in 49 (40%) patients. CONCLUSIONS: Tuberculosis was an important cause of CAP in our region. Hence, it should be considered in all patients admitted with a CAP diagnosis.

The role of prophylactic cefazolin in the prevention of infection after various types of abdominal wall hernia repair with mesh.

OBJECTIVE: There are controversies about the benefits of prophylactic antibiotics in the prevention of postoperative surgical site infection (SSI) in mesh herniorrhaphy for a long time. This study aimed to evaluate the effectiveness and efficacy of systemic prophylactic cefazolin in prevention of wound infection in various types of hernia repair with mesh materials. METHODS: This is a prospective randomized control study. We evaluated wound infection rates in 395 patients with various kinds of hernia who underwent elective mesh repair using polypropylene mesh from 2007 to 2011. A total of 237 (60.0%) patients received prophylactic cefazolin (study group) and the remaining 158 (40.0%) patients did not receive any prophylactic antibiotics (control group). Patients were followed for infection at the following periods after the operation by an independent surgeon: 10 days, 30 days, 12 months, and then annually for at least 2 years. RESULTS: Eight (2.03%) patients had infection in the site of surgery [2 (1.27%) in the control group and 6 (2.53%) in the study group]. The distribution of infection was not significantly different between the two groups (p = 0.364). The superficial infections were managed by drainage and irrigation. One patient from the study group developed deep SSI and was readmitted and subsequently received antibiotic therapy, drainage, and debridement. CONCLUSION: Preoperative administration of single-dose cefazolin for prosthetic hernia repairs did not markedly decrease the risk of wound infection. Our results do not support the use of cefazolin as a prophylactic antibiotic for various kinds of abdominal wall hernia repair with mesh.

Preoperative anxiety in candidates for heart surgery.

OBJECTIVE: The goal of this study was to evaluate preoperative anxiety and its predisposing factors in a group of adult patients who were candidate for any kind of heart surgery. METHODS: We evaluated preoperative anxiety in 300 patients undergoing heart surgery whose ages ranged between 18-65 years. Relationship of probable demographic factors like gender, educational level, marital status, number of children, family support, opium addiction, occupational status, and left ventricular ejection fraction (LVEF) with anxiety level of the patients were evaluated. To determine anxiety, the State-Trait Anxiety Inventory (STAI) was completed by the subjects. RESULTS: Descriptive anxiety levels showed that mean of state and trait anxiety of our studied patients were in moderate scaling. Correlation between state and trait anxiety was more prominent in females (r = 0.80) than in males (r = 0.70) (p < 0.001). Distribution of males and females was significantly different (p = 0.048). All the patients had significantly different underlying diseases (p = 0.018), opioid addiction (yes/no) was significantly different in all of the patients (p < 0.001), while family support (yes/no) was not significantly different in all of the patients (p = 0.453). There were significant differences between mean of preoperative anxiety at different LVEF values of any EF level (p < 0.001, F = 6.47); those who had LVEF of more than 50% had significantly lower mean anxiety scores. CONCLUSION: Preoperative psychiatric consultation should be focused more on women and patients with higher EF. Moreover, physical activity strength may be effective on reducing preoperative anxiety.

Evaluation of the incidence of complications of lost gallstones during laparoscopic cholecystectomy.

BACKGROUND AND AIM: Recently, an increasing number of reports in the literature have shown various complications of lost gallstones. This study aimed to evaluate patients with lost stones in the peritoneal cavity for any related complications for at least 12 months after the operation. MATERIALS AND METHODS: In a 3-year prospective study, of 900 patients with laparoscopic cholecystectomy, 50 patients with lost stones in the peritoneal cavity were enrolled as the case group. On the same day or the day after, an uncomplicated case was assigned to the control group. Postoperative complications were checked on the 10th day and 1, 6, and 12 months after surgery. They were also visited if they had any complaints at any time. All suspicious cases and also all patients in the last follow-up visit underwent abdominal ultrasonography and were observed for signs of abdominal and port site collections, abdominal and port site stone, abscess, and mass. RESULTS: In 50 cases (34 female and 16 male with a mean age of 59 y), the surgeon was doubtful about proper stone extraction. The mean duration of operation for patients with a ruptured gall bladder was 49.6+30.3 minutes, and in others, it was 27.9+11.7 minutes. During the early postoperative period, fever was detected in 3 (6%) patients in the case group and in 1 (2%) patient in the control group, which was resolved spontaneously. Postoperative pain on the 10th and the 30th days, unrelated to the lost stone, was resolved with analgesics. Abdominal collection was found in 8 (16%) patients in the case group and 5 (10%) patients in the control group, which was not significant. All these patients underwent ultrasonography-guided percutaneous aspiration. The aspirate was serous, and the patients' clinical findings were not clinically significant. CONCLUSIONS: According to the study, serious complications related to the lost stones indicate prophylaxis as the best therapeutic approach for such patients. The patients should be informed about lost stones and their possible complications. Also, conversion to open surgery is not advised.