Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes.

BACKGROUND: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. METHODS: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. RESULTS: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. CONCLUSION: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

Patient experience with chronic obstructive pulmonary disease: a nationally representative demonstration study on quality and cost of healthcare services.

Introduction: Due to insufficient data on patient experience with healthcare system among patients with chronic obstructive pulmonary disease (COPD), particularly in developing countries, this study attempted to investigate the journey of patients with COPD in the healthcare system using nationally representative data in Iran. Methods: This nationally representative demonstration study was conducted from 2016 to 2018 using a novel machine-learning based sampling method based on different districts' healthcare structures and outcome data. Pulmonologists confirmed eligible participants and nurses recruited and followed them up for 3 months/in 4 visits. Utilization of various healthcare services, direct and indirect costs (including non-health, absenteeism, loss of productivity, and time waste), and quality of healthcare services (using quality indicators) were assessed. Results: This study constituted of a final sample of 235 patients with COPD, among whom 154 (65.5%) were male. Pharmacy and outpatient services were mostly utilized healthcare services, however, participants utilized outpatient services less than four times a year. The annual average direct cost of a patient with COPD was 1,605.5 USDs. Some 855, 359, 2,680, and 933 USDs were imposed annually on patients with COPD due to non-medical costs, absenteeism, loss of productivity, and time waste, respectively. Based on the quality indicators assessed during the study, the focus of healthcare providers has been the management of the acute phases of COPD as the blood oxygen levels of more than 80% of participants were documented by pulse oximetry devices. However, chronic phase management was mainly missed as less than a third of participants were referred to smoking and tobacco quit centers and got vaccinated. In addition, less than 10% of participants were considered for rehabilitation services, and only 2% completed four-session rehabilitation services. Conclusion: COPD services have focused on inpatient care, where patients experience exacerbation of the condition. Upon discharge, patients do not receive appropriate follow-up services targeting on preventive care for optimal controlling of pulmonary function and preventing exacerbation.

Global, Regional, and National Quality of Care Index (QCI) of Gastric Cancer: A Systematic Analysis for the Global Burden of Disease Study 1990-2017.

BACKGROUND: Gastric Cancer (GC)is the third leading cause of cancer death worldwide. We aimed to compare the quality of care of GC at global, regional, and national levels from 1990 to 2017 in different age, sex, and socio-demographic groups using the quality-of-care index. MATERIAL: METHOD: We used Mortality to Incidence Ratio, DALY to Prevalence Ratio, YLL to YLD Ratio, and Prevalence to Incidence Ratio, that all indicate the quality of care. Then, using Principal Component Analysis (PCA), these values are combined. A new index called QCI (Quality of Care Index), which indicates quality, is introduced to compare the quality of care in different countries in 1990 and 2017. Scores were calculated and scaled 0-100, with higher scores indicating better status. RESULTS: The global QCI of GC in 1990 and 2017 was 35.7 and 66.7, respectively. The QCI index is 89.6 and 16.4 in high and low SDI countries, respectively. In 2017, Japan had the highest QCI with a 100 score. Japan was followed by South Korea, Singapore, Australia, and the United States with 99.5, 98.4, 98.3, and 90.0. On the other hand, the Central African Republic, Eritrea, Papua New Guinea, Lesotho, and Afghanistan with 11.6, 13.0, 13.1, 13.5, and 13.7 had the worst QCI, respectively. CONCLUSION: The quality of care of GC has increased worldwide from 1990 to 2017. Also, higher SDI was associated with more quality of care. We recommend conducting more screening and therapeutic programs for early detection and to improve gastric cancer treatment in developing countries.

Quality and cost of healthcare services in patients with diabetes in Iran: Results of a nationwide short-term longitudinal survey.

Aims: To investigate the journey of patients with diabetes in the healthcare system using nationally-representative patient-reported data. Methods: Participants were recruited using a machine-learning-based sampling method based on healthcare structures and medical outcome data and were followed up for three months. We assessed the resource utilization, direct/indirect costs, and quality of healthcare services. Results: One hundred fifty-eight patients with diabetes participated. The most utilized services were medication purchases (276 times monthly) and outpatient visits (231 times monthly). During the previous year, 90% of respondents had a laboratory fasting blood glucose assessment; however, less than 70% reported a quarterly follow-up physician visit. Only 43% had been asked about any hypoglycemia episodes by their physician. Less than 45% of respondents had been trained for hypoglycemia self-management. The annual average health-related direct cost of a patient with diabetes was 769 USD. The average out-of-pocket share of direct costs was 601 USD (78.15%). Medication purchases, inpatient services, and outpatient services summed up 79.77% of direct costs with a mean of 613 USD. Conclusion: Healthcare services focused solely on glycemic control and the continuity of services for diabetes control was insufficient. Medication purchases, and inpatient and outpatient services imposed the most out-of-pocket costs.

Prevalence of comorbidities in patients with multiple sclerosis using administrative data from 2007 to 2016 in Iran.

BACKGROUND: Research interest in the impact of comorbidities in MS has been expanding. Based on studies, certain comorbidities are more prevalent in MS population such as depression, anxiety, hypertension and hypercholesterolemia, diabetes, and hypothyroidism. OBJECTIVE: This study aims to describe the prevalence of comorbidities in MS population based on the health insurance claims data. METHOD: This retrospective database analysis was conducted using patient-level medicinal and pharmacy claims data from a leading insurance group (Iranian health insurance) in 2007-2016. MS population was identified based on their Disease Modifying Therapies prescribed by a neurologist (qualified to diagnose MS). Comorbidities in MS and non-MS population were assessed by their prescriptions. Crude and age-standardized prevalence rate (ASPR) of coverage of comorbidities in different age and sex groups and their odds ratio versus non-MS population were assessed. RESULTS: The most common comorbidities were depression (15.50%) and anxiety (10.1%). Hypercholesterolemia, diabetes, hypertension, and hypothyroidism were prevalent in 6%, 3.6%, 3.5%, and 2.7% respectively. Anxiety and depression were more prevalent in middle age group (45-65 years old). But other comorbidities were more prevalent in older age groups. All comorbidities were more prevalent in female except hypertension in patients ≥45 years old. The odds of all comorbidities were higher for male patients with MS rather than their parallel age group in non-MS patients. These also applied for female patients with MS 18-44 years old (except hypertension). CONCLUSION: Using claims data, the prevalence of taking treatment for selected comorbidities in MS population and their association with sex and age, can guide patients, healthcare providers, and policy makers to help improve MS patients' wellbeing.

The incremental cost of implementing the world health organization Package of essential non-communicable (PEN) diseases interventions in Iran.

World-Health-Organization's PEN package proposes a minimum set of cost-effective interventions for early diagnosis and management of Non-Communicable-Disease (NCD). IraPEN (the PEN package implemented in Iran), adopted from PEN and Iran National Action Plans for NCDs, addresses challenges regarding NCD prevention and control. IraPEN was piloted in four districts of Iran. In this research, we estimate incremental per-capita cost of IraPEN program implementation in two of the pilot districts. We utilized a bottom-up, ingredient-based costing approach. Institutional expenditure data was collected via information forms. Information pertaining to personnel costs was gathered by performing task time measurements using Direct Observation Method. An individual-level survey was conducted in under-study districts to determine program coverage and its users' demographic information via systematic random cluster sampling. Sampling of districts was based on systematic random cluster sampling. In each district, 250 families in 25 clusters proportional to urban or rural populations were randomly selected by postal codes. All family members eligible for the program were interviewed. Interviews were organized and conducted in each district by NCD experts in provincial Universities of Medical Sciences. Costs were re-categorized into fixed and variable costs based on their dependency on the program's coverage. Fixed and variable costs were, respectively, divided by total eligible populations and covered populations in each district to calculate cost per-capita for each protocol. Total per-capita cost per-service was then calculated for each protocol and whole program by adding these figures. All costs are reported in US$ 2015-2016. The incremental costs of IraPEN implementation per user, with and without introduction cost, were US$24.90 and US$25.32, respectively. Total incremental cost per-capita for each protocol ranged between US$1.05 to US$7.45. The human resources and supplies had the highest contribution in total program cost (74.97% and 15.76%, respectively). The present study shows that IraPEN program implementation to be a high-cost package within Iranian context, that necessitates cautions in other similar contexts for implementation. It is, however, difficult to make decisions on implementation of NCD prevention and control programs purely based on their cost. Informed decision making requires assessment of a programs' effectiveness and justifications and alterations to the current package could reduce the costs, leading to increased efficiency of the program.

Estimation of myocardial infarction death in Iran: artificial neural network.

BACKGROUND: Examining past trends and predicting the future helps policymakers to design effective interventions to deal with myocardial infarction (MI) with a clear understanding of the current and future situation. The aim of this study was to estimate the death rate due to MI in Iran by artificial neural network (ANN). METHODS: In this ecological study, the prevalence of diabetes, hypercholesterolemia over 200, hypertension, overweight and obesity were estimated for the years 2017-2025. ANN and Linear regression model were used. Also, Specialists were also asked to predict the death rate due to MI by considering the conditions of 3 conditions (optimistic, pessimistic, and probable), and the predicted process was compared with the modeling process. RESULTS: Death rate due to MI in Iran is expected to decrease on average, while there will be a significant decrease in the prevalence of hypercholesterolemia 1.031 (- 24.81, 26.88). Also, the trend of diabetes 10.48 (111.45, - 132.42), blood pressure - 110.48 (- 174.04, - 46.91) and obesity and overweight - 35.84 (- 18.66, - 5.02) are slowly increasing. MI death rate in Iran is higher in men but is decreasing on average. Experts' forecasts are different and have predicted a completely upward trend. CONCLUSION: The trend predicted by the modeling shows that the death rate due to MI will decrease in the future with a low slope. Improving the infrastructure for providing preventive services to reduce the risk factors for cardiovascular disease in the community is one of the priority measures in the current situation.

Social, Economic, Technological, and Environmental Factors Affecting Cardiovascular Diseases: A Systematic Review and Thematic Analysis.

Background: Today, cardiovascular disease (CVD) is the leading cause of mortality in both sexes. There are several risk factors for heart diseases; some controllable, others not. However, socioeconomic, technological, and environmental factors can impact CVD as well as exclusive risk factors. Accurate identification and assessment of these factors are often difficult. In the present systematic review, we aimed to explore factors affecting CVD. Methods: Multiple databases (MEDLINE, Scopus, ISI Web of Science, and Cochrane) and gray literature were searched. The included studies described at least one determinant of CVD. The framework method was applied to analyze the qualitative data. Results: A total of 64 studies from 26 countries were included. The contextual determinants of CVD were categorized into 45 determinants, 15 factors, and 4 main social, economic, technological, and environmental categories. The 15 potentially reversible factors were identified as sociodemographic, violence, smoking, occupation, positive childhood experience, social inequalities, psychological distress, eating habits, neighborhood, family income, rapid technology, environmental pollution, living environments, noise, and disaster. Conclusions: Devolution and more efficient health policies are required to achieve further sustained reduction in CVD mortality, increase life expectancy, and reduce its associated risk factors. Policymakers should fully address the value of social, economic, technological, and environmental factors. In fact, a prevention agenda should be developed and updated collaboratively in terms of the determinant factors.

A pilot study using financial transactions' spatial information to define high-risk neighborhoods and distribution pattern of COVID-19.

BACKGROUND: Development of surveillance systems based on big data sources with spatial information is necessitated more than ever during this pandemic. Here, we present our pilot results of a new technique for the incorporation of spatial information of transactions and a vital registry of COVID-19 to evaluate the disease spread. METHODS: We merged two databases of laboratory-confirmed national COVID-19 registry of Iran and financial transactions of point-of-sale devices from February to March 2020 as our training data sources. Spatial information was used for the visualization of maps and movements of sick individuals. We used the point-of-sale devices-related guild to check for the dynamics of financial transactions and effectiveness of quarantines. FINDINGS: In the study period, 174,428 confirmed cases were in the COVID-19 registry with accompanying transactions information. In total, 13,924,982 financial transactions were performed by them, with a mean of 1.2 per day for each person. All guilds had a decreasing pattern of "risky" transactions except for grocery stores and pharmacies. The latter showed a decreasing pattern by impose of lockdowns. Different cities were the hotspot of disease transmission as many "high-risk" transactions were performed in them, among which Tehran (mainly its central neighborhoods) and southern cities of Lake Urmia predominated. Lockdowns indicated that the disease gradually became less transmissible. INTERPRETATION: Financial transactions can be readily used for epidemics surveillance. Semi real-time results of such iterations can be informative for policy makers, guild owners, and general population to prepare safer commuting and merchandise spaces.

Prevalence of Diabetes and Prediabetes, and Achievements in Diabetes Control in Iran; The Results of the STEPS of 2016.

BACKGROUND: Using the WHO STEPwise approach to NCD risk factor surveillance (STEPS), first round of Iran's STEPS completed in 2005. It has been repeated six times afterward. Here we report the results of 2016 round on the population characteristics and prevalence of diabetes and prediabetes, along with an assessment of the country-level performance on diabetes care in Iran. METHODS: Using a proportional-to-size cluster random sampling method, the STEPS 2016 included 18947 subjects aged≥25 years who matched the criteria (non-missing information on diabetes self-report, and biomarkers). For the analyses, survey design methods with weighted samples were employed. Different definitions of diabetes (biomarker-based, self-report, anti-diabetes medication use, or a combination) and prediabetes (different cutpoints of the biomarker) were calculated and presented. RESULTS: An estimated 5171035 persons aged≥25 years or 10.6% (95% CI: 10.0%-11.1%) had diabetes according to the serologic diagnosis of diabetes (FPG≥126 mg/dL) or the use of at least one anti-diabetes medication (1896 out of 18947). Employing the serologic diagnosis of diabetes among those who responded no to the self-reported question, 2.7% (2.5%-3.0%) of the population were not aware of their diabetes compared to 11.5% (10.9%-12.0%) who were diabetics according to the just self-reported question. Defining prediabetes as 100≤FPG<126 mg/dL or 5.7≤HbA1c<6.5%, an estimated 15244299 persons had prediabetes (5885 out of 18947). Overall, 52.1% (49.4%-54.7%) of patients with self-reported diabetes were under strict glycemic control (HbA1c<7%). Poor diabetes control (HbA1c>9%) was found in 18.4% (16.3%-20.6%) of the patients with self-reported diabetes. CONCLUSION: Since 2005, the prevalence of diabetes in Iran has been on a gradual increase in both genders with an increasing gap between females and males.

The levels of BMI and patterns of obesity and overweight during the COVID-19 pandemic: Experience from the Iran STEPs 2021 survey.

Background: Obesity and its increasing burden have become an urgent health problem all over the world. Benefiting from a national representative sample, the present study aimed to estimate the distribution of body mass index (BMI) levels and its association with metabolic and lifestyle risk factors in an Iranian adult population by sex, age, and geographical distribution. Methods: This study involves a national survey of noncommunicable disease risk factor surveillance (STEPs) in Iran. Through systematic random sampling, in compliance with safety considerations during the COVID-19 pandemic, of the 28,520 adults who gave voluntary consent and included in the study, 27,874 participants completed the questionnaires (step 1), 27,745 individuals were anthropometrically measured (step 2), and 18,119 individuals completed laboratory evaluation (step 3). Anthropometric measurements followed based on standard protocols and by using calibrated instruments. Results: In 2021, the national prevalence of normal weight, obesity, and overweight/obesity in ≥18-year-old Iranian adults was estimated at 33.61% (95% CI: 32.99-34.23), 24.96% (24.39-25.53), and 63.02% (62.39-63.65), respectively. Compared to women, Iranian men had a lower mean BMI [25.54 (24.95-26.13 vs. 27.6 (27.07-28.12) kg/m2] (p < 0.001). There was also a significant difference in the national prevalence rate of overweight/obesity [women: 66% (61-71), men: 53% (46-60) (p < 0.001)]. The prevalence of obesity was significantly higher in participants suffering from metabolic and lifestyle risk factors. The study of the geographical extent of obesity and overweight shows that compared to national levels, the highest prevalence of being underweight was seen in the southeastern provinces. On the other hand, the highest prevalence of obesity belonged to the northeastern and central provinces. The highest provincial prevalence of obesity was almost 2.5-fold higher than the lowest provincial prevalence. Conclusion: The study reveals a significant difference between the prevalence of obesity in male and female participants and between different regions of the country. These findings will help policymakers, clinicians, and researchers to more accurately estimate the obesity/overweight problem and to implement more effective interventional programs to promote strategies of prevention and control of weight gain.

A Report on Statistics of an Online Self-screening Platform for COVID-19 and Its Effectiveness in Iran.

BACKGROUND: The most recent emerging infectious disease, coronavirus disease 2019 (COVID-19), is pandemic now. Iran is a country with community transmission of the disease. Telehealth tools have been proved to be useful in controlling public health disasters. We developed an online self-screening platform to offer a population-wide strategy to control the massive influx to medical centers. METHODS: We developed a platform operating based on given history by participants, including sex, age, weight, height, location, primary symptoms and signs, and high risk past medical histories. Based on a decision-making algorithm, participants were categorized into four levels of suspected cases, requiring diagnostic tests, supportive care, not suspected cases. We made comparisons with Iran STEPs (STEPwise approach to Surveillance) 2016 study and data from the Statistical Centre of Iran to assess population representativeness of data. Also, we made a comparison with officially confirmed cases to investigate the effectiveness of the platform. A multilevel mixed-effects Poisson regression was used to check the association of visiting platform and deaths caused by COVID-19. RESULTS: About 310 000 individuals participated in the online self-screening platform in 33 days. The majority of participants were in younger age groups, and males involved more. A significant number of participants were screened not to be suspected or needing supportive care, and only 10.4% of males and 12.0% of females had suspected results of COVID-19. The penetration of the platform was assessed to be acceptable. A correlation coefficient of 0.51 was calculated between suspected results and confirmed cases of the disease, expressing the platform's effectiveness. CONCLUSION: Implementation of a proper online self-screening tool can mitigate population panic during wide-spread epidemics and relieve massive influx to medical centers. Also, an evidence-based education platform can help fighting infodemic. Noticeable utilization and verified effectiveness of such platform validate the potency of telehealth tools in controlling epidemics and pandemics.

Routine COVID-19 testing may not be necessary for most cancer patients.

Cancer patients are at risk for severe complications or death from COVID-19 infection. Therefore, the need for routine COVID-19 testing in this population was evaluated. Between 1st August and 30th October 2020, 150 cancer patients were included. Symptoms of COVID-19 infection were evaluated. All eligible individuals went through RT-PCR and serological tests for COVID-19. At the same time, 920 non-cancer patients were recruited from a random sample of individuals who were subject to routine molecular and anti-body screening tests. Of 150 cancer patients, 7 (4.7%) were RT-PCR positive. Comorbidity made a significant difference in the RT-PCR positivity of cancer patients, 71.4% positive versus 25.8% negative (P-value = 0.02). The average age for negative and positive groups was 53.3 and 58.2 respectively (P-value = 0.01). No significant difference was observed between cancer and non-cancer patients regarding COVID-19 antibody tests. However, cancer patients were 3 times less likely to have a positive RT-PCR test result OR = 0.33 (CI: 0.15-0.73). The probability of cancer patients having a positive routine test was significantly lower than non-cancer patients, and the concept that all cancer patients should be routinely tested for COVID-19 may be incorrect. Nevertheless, there may be a subgroup of patients with comorbidities or older age who may benefit from routine COVID-19 testing. Importantly, these results could not be subjected to multivariate analysis.

Improved Population Health in Iran from 1979 to 2019; Decreasing Mortality Rates and Increasing Life Expectancy.

BACKGROUND: In this study, we seek to evaluate the population health improvements during the previous four decades in Iran. We have estimated the levels and trends of child and adult mortality in addition to life expectancy from 1979 to 2019 at national and sub-national levels using all the available data. METHODS: In this study, we used data from National and Sub-National Burden of Diseases study and employed Bayesian Averaging Model (BAM) to predict mortality rates and life expectancy from 1979 to 2019. By including all available data sources of death information of Iran, including national level data from the Institute for Health Metrics and Evaluation (IHME), national censuses, Demographic and Health Survey (DHS), and Death Registration System (DRS) and using Spatio-Temporal and Gaussian Process Regression (ST-GPR) models, we estimated mortality rates and life expectancy from 1990 to 2015. We also used a BAM to project our desired indices until 2019. RESULTS: Both child and adult mortality rates decreased dramatically over the period. At the national level in Iran, in 2019, child mortality rate (deaths per 1000 livebirths), was 16.0 (95%UI: 13.0-19.6), adult mortality rates [probability of death (%)] for females and males were 6.1 (5.4-6.8) and 11.5 (10.3-12.8), respectively. Also, life expectancy values for females and males were 81.6 (80.7-82.2) and 76.1 (75.3-76.6), respectively. The results were consistent for both sexes. Despite the total narrowing gaps among provinces, a difference can still be observed particularly for the border provinces regarding child mortality rates. However, the difference in the other measures are inconsiderable. From 1979 to 2019, the overall change percent in child mortality rate, adult mortality rate for females and males and life expectancy for females and males were -86.3% (-89.0%--83.1%), -52.5% (-60.9%--42.9%), -48.7% (-56.9%- -39.6%), 25.3% (20.8%-31.5%), and 31.3% (25.5%-41.3%), respectively. CONCLUSION: This study provides an overview of the previous 40 years of mortality rates (child and adult) and life expectancy. The provided framework of national and sub-national evaluation can be used by researchers to continue the path of providing information for prioritization and evaluation of programs and also performing cost-effectiveness analysis for proposing efficient strategies to policy makers.

Estimating the attributable risk of vascular disorders in different ranges of fasting plasma glucose and assessing the effectiveness of anti-diabetes agents on risk reduction; questioning the current diagnostic criteria.

INTRODUCTION: Attributable risk of cardiovascular disorders (CVDs) and chronic kidney disease (CKD) in association with diabetes and pre-diabetes is under debate. Moreover, the role of anti-diabetes agents in risk reduction of such conditions is obscure. The purpose of this work is to define the population attributable fraction (PAF) of CVDs and CKD in different rages of plasma glucose. METHOD: Iranian stepwise approach for surveillance of non-communicable disease risk factors (STEPs) was used to calculate PAF in four subsequent phases. Phase 0: whole population regardless of diagnosis; Phase I: in three CVD risk groups: minimal risk (FPG < 100 mg/dL), low risk (FPG 100-126 mg/dL), and high risk (FPG ≥ 126 mg/dL) groups; Phase II: three diagnostic groups: normal, pre-diabetes, and diabetes; Phase III: diabetes patients either receiving or not receiving anti-diabetes agents. RESULT: A total of 19,503 participants [female-to-male ratio 1.17:1] had at least one FPG measurement and were enrolled. Phase 0: PAF of young adults was lower in the general population (PAF range for CVDs 0.05 ─ 0.27 [95% CI 0.00 ─ 0.32]; CKD 0.03 ─ 0.41 [0.00 ─ 0.62]). Phase I: High-risk group comprised the largest attributable risks (0.46 ─ 0.97 [0.32 ─ 1]; 0.74 ─ 0.95 [0.58 ─ 1]) compared to low-risk (0.16 ─ 0.41 [0.04 ─ 0.66]; 0.29 ─ 0.35 [0.07 ─ 0.5]) and minimal risk groups (negligible estimates) with higher values in young adults. Phase II: higher values were detected in younger ages for diabetes (0.38 ─ 0.95 [0.29 ─ 1]; 0.65 ─ 0.94 [0.59 ─ 1] and pre-diabetes patients (0.15 ─ 0.4 [0.13 ─ 0.45]; 0.26 ─ 0.35 [0.22 ─ 0.4]) but not normal counterparts (negligible estimates). Phase III: Similar estimates were found in both treatment (0.31 ─ 0.98 [0.17 ─ 1]; 0.21 ─ 0.93 [0.12 ─ 1]) and drug-naïve (0.39 ─ 0.9 [0.27 ─ 1]; 0.63 ─ 0.97 [0.59 ─ 1]) groups with larger values for younger ages. CONCLUSION: Globalized preventions have not effectively controlled the burden of vascular events in Iran. CVDs and CKD PAFs estimated for pre-diabetes were not remarkably different from normal and diabetes counterparts, arguing current diagnostic criteria. Treatment strategies in high-risk groups are believed to be more beneficial. However, the effectiveness of medical interventions for diabetes in controlling CVDs and CKD burden in Iran is questionable.

An Approach Towards Reducing Road Traffic Injuries and Improving Public Health Through Big Data Telematics: A Randomised Controlled Trial Protocol.

OBJECTIVE: Deaths due to road traffic accidents (RTAs) are a major public health concern around the world. Developing countries are over-represented in these statistics. Punitive measures are traditionally employed to lower RTA related behavioural risk factors. These are, however, resource intensive and require infrastructure development. This is a randomised controlled study to investigate the effect of non-punitive behavioural intervention through peer-comparison feedback based on driver behaviour data gathered by an in-vehicle telematics device. DESIGN, SETTING, AND PARTICIPANTS: A randomised controlled trial using repeated measures design conducted in Iran on the drivers of 112 public transport taxis in Tehran province and 1309 inter-city busses operating nationwide. Driving data is captured by an in-vehicle telematics device and sent to a centrally located data centre using a mobile network. The telematics device is installed in all vehicles. Participants are males aged above 20 who have had the device operating in their vehicles for at least 3 months prior to the start of the trial. INTERVENTION: The study had three stages: 1- Driver performance was monitored for a 4-week period after which they were randomised into intervention and control groups. 2- Their performance was monitored for a 9-week period. At the end of each week, drivers in the intervention group received a scorecard and a note informing them of their weekly behaviour and ranking within their peer group. Drivers in the control group received no feedback via short messaging service (SMS). 3- Drivers did not receive further feedback and their behaviour was monitored for another 4 weeks. PRIMARY AND SECONDARY OUTCOME MEASURE: Primary outcome was changes in weekly driving score in intervention and control groups during stage 2 of intervention. Taxis and busses were analysed separately using generalised estimating equation analysis. FUNDING AND ETHICAL APPROVAL: This project was funded by the National Institute for Medical Research Development (Grant No.940576) and approved by its ethics committee (Code: IR.NIMAD.REC.1394.016). This trial was registered at www.irct.ir as IRCT20180708040391N1.

Effects of gold nanoparticles on the stability of microbubbles.

Surfactant-coated microbubbles are utilized in a wide variety of applications, from wastewater purification to contrast agents in medical ultrasound imaging. In many of these applications, the stability of the microbubbles is crucial to their effectiveness. Controlling this, however, represents a considerable challenge. In this study, the potential for stabilizing microbubbles using solid nanoparticles adsorbed onto their surfaces was explored. A new theoretical model has been developed to describe the influence of interfacially adsorbed solid particles upon the dissolution of a gas bubble in a liquid. The aim of this work was to test experimentally the prediction of the model that the presence of the nanoparticles would inhibit gas diffusion and coalescence/disproportionation, thus increasing the life span of the bubbles. Near-monodisperse microbubbles (~100 µm diameter) were prepared using a microfluidic device and coated with a surfactant, with and without the addition of a suspension of spherical gold nanoparticles (~15 nm diameter). The experimental results confirmed the theoretical predictions that as the surface concentration of gold nanoparticles increased the bubbles underwent negligible changes in their size and size distribution over a period of 30 days at the ambient temperature and pressure. Under the same conditions, bubbles coated with the same surfactant but no nanoparticles survived only a matter of hours.