Validation of Farsi Translation of the Ocular Surface Disease Index.

PURPOSE: To develop and validate a Farsi version of Ocular Surface Disease Index (OSDI) for the Iranian population. METHODS: This study was a translation and cross-cultural adaptation and validation of Farsi version of OSDI. Four bilingual (English-Persian) individual including three physicians and one native English teacher were asked to translate the original English OSDI questionnaire in Farsi. Following back and forth translation, integration and pilot check, the translation team came to consensus on translation. Consecutive patients visited in ophthalmology clinic, underwent comprehensive general ophthalmology exam and specific assessments for dry eye including non-anesthetic Schirmer's test, fluorescein tear break-up time, Fluorescein and Rose Bengal staining and Farsi OSDI (F-OSDI). F-OSDI was again rechecked within 2-7 days after the examination. RESULTS: Forty-four participants were enrolled into study. Thirty-two (72.7%) were male and 12 (27.3%) female. Mean age of participants was 45.5 (SD = ±15.97, range = 18-80) years. Twenty five percent were less than 31 years old and 10% percent older than 65. The cronbach's alpha for the questionnaire was 0.807. Questions number 7, 8 showed excellent, and question12 showed good internal consistency, respectively. There was a significant correlation between all pre measures and post assessments. CONCLUSION: The obtained F-OSDI showed acceptable internal consistency and test-retest reliability. This F-OSDI could be used for assessment of dry eye, ocular surface discomfort and quality of life in Iranian and Farsi speaking populations.

Application of media literacy education for changing attitudes about self-medication of slimming supplements.

Background: Self-medication of slimming supplements has increased, and media advertising has a role in this. The present study aimed at determining the effect of media literacy educational intervention on attitudes about self-medication of slimming supplements among the female students at dormitories of Iran University of Medical Sciences. Methods: In this quasi-experimental study with a control group, 98 students were selected by multistage cluster sampling method and were randomly divided into 2 equal groups of test and control. The data collecting instrument was a researcher-made questionnaire about media literacy and attitude on self-medication of slimming pills. Based on the results obtained from the early completion of the questionnaires, an appropriate educational intervention was designed and implemented. Data were analyzed 1 and 3 months after the intervention using the following statistical methods: repeated measurements, Friedman test, Chi square, independent T-test and MannWhitney test. Results: Before the intervention, the mean scores of attitude and dimensions of media literacy were moderate in both groups, and there was no significant difference between them. However, positive correlations were observed among attitude and knowledge (r=0.99, p= 0.001), critical thinking (r= 0.61, p= 0.001), and analysis (r= 0.37, p= 0.009) in the experimental group. The mean scores of attitudes and dimensions of media literacy were found to be significant in both groups 1 and 3 months after the intervention (p<0.05). Conclusion: Media literacy education was effective in promoting a positive attitude about slimming supplements.

Individualized predictions of time to menopause using multiple measurements of antimüllerian hormone.

OBJECTIVE: The ability of antimüllerian hormone (AMH) to predict age at menopause has been reported in several studies, and a decrease in AMH level has been found to increase the probability of menopause. The rate of decline varies among women, and there is also a variability of decline between women's cycles. As a result, individualized evaluation is required to accurately predict time of menopause. To this end, we have used the AMH trajectories of individual women to predict each one's age at menopause. METHODS: From a cohort study, 266 women (ages 20-50 y) who had regular and predictable menstrual cycles at the initiation of the study were randomly selected from among 1,265 women for multiple AMH measurements. Participants were visited at approximately 3-year intervals and followed for an average of 6.5 years. Individual likelihood of menopause was predicted by fitting the shared random-effects joint model to the baseline covariates and the specific AMH trajectory of each woman. RESULTS: In total, 23.7% of the women reached menopause during the follow-up period. The estimated mean (SD) AMH concentration at the time of menopause was 0.05 ng/mL (0.06 ng/mL), compared with 1.36 ng/mL (1.85 ng/mL) for those with a regular menstrual cycle at their last assessment. The decline rate in the AMH level varied among age groups, and age was a significant prognostic factor for AMH level (P < 0.001). Adjusting for age and body mass index, each woman had her own specific AMH trajectory. Lower AMH and older age had significant effects on the onset of menopause. Individualized prediction of time to menopause was obtained from the fitted model. CONCLUSIONS: Longitudinal measurements of AMH will enable physicians to individualize the prediction of menopause, thereby facilitating counseling on the timing of childbearing or medical management of health issues associated with menopause.

Evaluation of parametric models by the prediction error in colorectal cancer survival analysis.

AIM: The aim of this study is to determine the factors influencing predicted survival time for patients with colorectal cancer (CRC) using parametric models and select the best model by predicting error's technique. BACKGROUND: Survival models are statistical techniques to estimate or predict the overall time up to specific events. Prediction is important in medical science and the accuracy of prediction is determined by a measurement, generally based on loss functions, called prediction error. PATIENTS AND METHODS: A total of 600 colorectal cancer patients who admitted to the Cancer Registry Center of Gastroenterology and Liver Disease Research Center, Taleghani Hospital, Tehran, were followed at least for 5 years and have completed selected information for this study. Body Mass Index (BMI), Sex, family history of CRC, tumor site, stage of disease and histology of tumor included in the analysis. The survival time was compared by the Log-rank test and multivariate analysis was carried out using parametric models including Log normal, Weibull and Log logistic regression. For selecting the best model, the prediction error by apparent loss was used. RESULTS: Log rank test showed a better survival for females, BMI more than 25, patients with early stage at diagnosis and patients with colon tumor site. Prediction error by apparent loss was estimated and indicated that Weibull model was the best one for multivariate analysis. BMI and Stage were independent prognostic factors, according to Weibull model. CONCLUSION: In this study, according to prediction error Weibull regression showed a better fit. Prediction error would be a criterion to select the best model with the ability to make predictions of prognostic factors in survival analysis.

A comprehensive model for executing knowledge management audits in organizations: a systematic review.

A knowledge management audit (KMA) is the first phase in knowledge management implementation. Incomplete or incomprehensive execution of the KMA has caused many knowledge management programs to fail. A study was undertaken to investigate how KMAs are performed systematically in organizations and present a comprehensive model for performing KMAs based on a systematic review. Studies were identified by searching electronic databases such as Emerald, LISA, and the Cochrane library and e-journals such as the Oxford Journal and hand searching of printed journals, theses, and books in the Tehran University of Medical Sciences digital library. The sources used in this study consisted of studies available through the digital library of the Tehran University of Medical Sciences that were published between 2000 and 2013, including both Persian- and English-language sources, as well as articles explaining the steps involved in performing a KMA. A comprehensive model for KMAs is presented in this study. To successfully execute a KMA, it is necessary to perform the appropriate preliminary activities in relation to the knowledge management infrastructure, determine the knowledge management situation, and analyze and use the available data on this situation.

Coenzyme Q10 supplementation ameliorates inflammatory markers in patients with multiple sclerosis: a double blind, placebo, controlled randomized clinical trial.

OBJECTIVES: Multiple sclerosis (MS) is an immune-mediated neurodegenerative disease of central nervous system and recent studies show that inflammatory processes are highly associated with neurodegeneration in the brain. The purpose of this study was to investigate the effect of coenzyme Q10 supplementation on inflammatory and anti-inflammatory markers in patients with MS. METHODS: This randomized, double-blind, placebo-controlled clinical study was performed among 48 patients with relapsing-remitting MS. Subjects were randomly assigned to a placebo group (n = 24) or coenzyme Q10 (CoQ10)-supplemented group (500 mg/day, n = 24). The intervention was administered for 12 weeks. Peripheral blood samples were collected at baseline and after 12-week intervention, to measure inflammatory (tumor necrosis factor-α (TNF-α), interleukin (IL)-6, and matrix metalloproteinase (MMP)-9) and anti-inflammatory (IL-4 and TGF-ß) markers. RESULTS: Forty-five patients completed the study. After 12 weeks of intervention, the TNF-α levels (P = 0.003) decreased significantly in the CoQ10 group. Subjects in the CoQ10 group had significantly lower IL-6 levels (P = 0.037), compared to the placebo group. CoQ10 supplementation also resulted in decreased serum levels of MMP-9 as compared to the placebo group (P = 0.011). However, CoQ10 supplementation did not alter the IL-4 and TGF-ß levels (P = 0.16 and P = 0.81, respectively). DISCUSSION: CoQ10 supplementation at a dosage of 500 mg appears to decrease the inflammatory markers (TNF-α, IL-6, and MMP-9) in patients with MS.

Zinc monotherapy increases serum brain-derived neurotrophic factor (BDNF) levels and decreases depressive symptoms in overweight or obese subjects: a double-blind, randomized, placebo-controlled trial.

OBJECTIVE: Previous studies have shown a positive effect of zinc as an adjunctive therapy on reducing depressive symptoms. However, to our knowledge, no study has examined the effect of zinc monotherapy on mood. The aim of the present study was to determine the effects of zinc monotherapy on depressive symptoms and serum brain-derived neurotrophic factor (BDNF) levels in overweight or obese subjects. METHODS: Fifty overweight or obese subjects were randomly assigned into two groups and received either 30 mg zinc or placebo daily for 12 weeks. At baseline and post-intervention, depression severity was assessed using Beck depression inventory II (BDI II), and serum BDNF and zinc levels were determined by enzyme-linked immunosorbent assay and atomic absorption spectrophotometry, respectively. RESULTS: The trial was completed with 46 subjects. After a 12-week supplementation, serum zinc and BDNF levels increased significantly in the zinc-supplemented group compared with the placebo group. BDI scores declined in both the groups at the end of the study, but reduction in the zinc-supplemented group was significantly higher than the placebo group. More analysis revealed that following supplementation, BDI scores decreased in subgroup of subjects with depressive symptoms (BDI ≥ 10) (n = 30), but did not change in the subgroup of non-depressed subjects (BDI < 10) (n = 16). Moreover, a significant inverse correlation was observed between serum BDNF levels and depression severity in all participants. Interestingly, a significant positive correlation was found between serum BDNF and zinc levels at baseline. CONCLUSION: Zinc monotherapy improves mood in overweight or obese subjects most likely through increasing BDNF levels.

Application of Rasch model for evaluating the quality of life in blind war veterans.

UNLABELLED: Background Quality of life evaluates the general well-being of individuals and it can be considered as one of the important aspects in programming and giving service to disabled people. Blindness is one of the most important kinds of physical disability that has a direct effect on quality of life, so this study aimed to explore how war blindness influences the quality of life. METHODS: In this cross-sectional study, data from 71 blind war (Iran-Iraq) veterans in 2010 were collected using the Short Form Health Survey instrument (SF36). Rasch model was fitted by running WINSTEPS software and then item parameter (ß), i.e. difficulty of items, and person parameter ([Formula: see text] ), i.e. the ability or attainment level of respondents, were estimated. RESULTS: In a total of 71 cases, 69 cases (97 %) were male with a mean (±SD ) age and blindness duration range of 48.97 (±10.655) yrs and 25.74 (±3.692) yrs, respectively. Item difficulty ranged from 2.962 to 4.441. Comparison of the SF36 scores and Rasch measurements showed that standard error of Rasch model estimates in physical and total scores are less than SF36 scores. CONCLUSION: Due to the advantages and higher accuracy of the Rasch model, using this model can be a good alternative for the traditional models. With due regard to the relative low quality of life of blind war veterans in this study and other similar study, further investigation are recommended to be carried out to this group of society.

Changes in daily activities of cancer patients after diagnosis: how do canadian and Iranian patients perceive the change?

BACKGROUND: Being diagnosed with cancer has major impacts on a patient's life. This study was conducted to explore how specific daily activities of patients change as a result of cancer diagnosis or its treatment and how these patients feel about such changes. METHODS: This was a cross-sectional descriptive study. Cancer patients referred to our clinics and by completing a questionnaire, they reported their daily activities and how they changed after diagnosis. A total of 201 patients in Canada and 167 patients in Iran completed the questionnaire. The research setting was the outpatient cancer clinics of the Jewish General Hospital in Montreal, Canada (February to April 2008) and Imam Reza Hospital and Ghaem Hospital in Mashhad, Iran (March to August 2008). RESULTS: More than 40 percent of the patients reported changes after the diagnosis in at least 8 out of 22 daily activities listed in the questionnaire. While a negative perception towards the changes was more common, some patients also perceived some changes as positive. More than half of the participants (56.9%) who were employed at the time of diagnosis experienced changes in the amount or type of their paid work after being diagnosed with cancer. CONCLUSION: The impact of a cancer diagnosis and treatment on a patient's daily activities is drastic. There is a need to provide support and interventions to help patients maintain daily activities they need and/or like. Further studies are needed to better understand the nature of such interventions.

Estimation of the cure rate in Iranian breast cancer patients.

BACKGROUND: Although the Cox's proportional hazard model is the popular approach for survival analysis to investigate significant risk factors of cancer patient survival, it is not appropriate in the case of log-term disease free survival. Recently, cure rate models have been introduced to distinguish between clinical determinants of cure and variables associated with the time to event of interest. The aim of this study was to use a cure rate model to determine the clinical associated factors for cure rates of patients with breast cancer (BC). MATERIALS AND METHODS: This prospective cohort study covered 305 patients with BC, admitted at Shahid Faiazbakhsh Hospital, Tehran, during 2006 to 2008 and followed until April 2012. Cases of patient death were confirmed by telephone contact. For data analysis, a non-mixed cure rate model with Poisson distribution and negative binomial distribution were employed. All analyses were carried out using a developed Macro in WinBugs. Deviance information criteria (DIC) were employed to find the best model. RESULTS: The overall 1-year, 3-year and 5-year relative survival rates were 97%, 89% and 74%. Metastasis and stage of BC were the significant factors, but age was significant only in negative binomial model. The DIC also showed that the negative binomial model had a better fit. CONCLUSIONS: This study indicated that, metastasis and stage of BC were identified as the clinical criteria for cure rates. There are limited studies on BC survival which employed these cure rate models to identify the clinical factors associated with cure. These models are better than Cox, in the case of long-term survival.

Triple p-positive parenting program for mothers of ADHD children.

OBJECTIVE: Attention deficit hyperactivity disorder (ADHD) is a chronic, highly prevalent neurodevelopmental disorder which affects 9% of school-age children. Triple P-Positive Parenting Program is an evidence-based parenting program reported to be useful in the management of this disorder. The aim of this randomized controlled trial was to evaluate the effectiveness of Triple P in mothers of ADHD children. METHODS: In this study, 30 mothers with ADHD children aged between 6 to 10 were randomly assigned to two groups (15 participants in each group). Parenting style, mother-child relationship, maternal depression, anxiety and stress, and children's behavioral problems were evaluated. The intervention group received 120 minute sessions for 5 weeks and 15-30 minute telephone contacts for 3 weeks while no intervention was done for the control group. RESULTS: Analysis of covariance revealed that mothers of the Triple P group showed significant (p < 0.01) improvements in parenting style, mother-child relationship, and considerable decrease in depression, anxiety and stress. Women trained in the Triple P group also reported significantly lower rates of child misbehavior than women of the control group. CONCLUSION: Triple P-Positive Parenting intervention is effective and acceptable for mothers of ADHD children. DECLARATION OF INTEREST: None. Clinical Trial Registration-URL: http://www.irct.ir. Unique identifier: IRCT201111288234N1.

Developing and testing a measurement tool for assessing predictors of breakfast consumption based on a health promotion model.

OBJECTIVE: To develop an instrument for measuring Health Promotion Model constructs in terms of breakfast consumption, and to identify the constructs that were predictors of breakfast consumption among Iranian female students. DESIGN: A questionnaire on Health Promotion Model variables was developed and potential predictors of breakfast consumption were assessed using this tool. PARTICIPANTS: One hundred female students, mean age 13 years (SD ± 1.2 years). SETTINGS: Two middle schools from moderate-income areas in Qom, Iran. VARIABLES MEASURED: Health Promotion Model variables were assessed using a 58-item questionnaire. Breakfast consumption was also measured. ANALYSIS: Internal consistency (Cronbach alpha), content validity index, content validity ratio, multiple linear regression using stepwise method, and Pearson correlation. RESULTS: Content validity index and content validity ratio scores of the developed scale items were 0.89 and 0.93, respectively. Internal consistencies (range, .74-.91) of subscales were acceptable. Prior related behaviors, perceived barriers, self-efficacy, and competing demand and preferences were 4 constructs that could predict 63% variance of breakfast frequency per week among subjects. CONCLUSIONS AND IMPLICATIONS: The instrument developed in this study may be a useful tool for researchers to explore factors affecting breakfast consumption among students. Students with a high level of self-efficacy, more prior related behavior, fewer perceived barriers, and fewer competing demands were most likely to regularly consume breakfast.

The impact of training on women's capabilities in modifying their obesity-related dietary behaviors: applying family-centered empowerment model.

BACKGROUND: Dietary behaviors affect obesity; therefore, it seems necessary to conduct interventions to modify behavioral patterns leading to weight-gain in the family. Our goal was to determine the impact of training on women's capabilities in modifying their obesity-related dietary behaviors in Urmia, West Azerbaijan Province, Iran: applying family-centered empowerment model. METHODS: A quasi-experimental study with Pretest-Posttest design was conducted on 90 over-weight/obese women in 2012 in two Health Centers of Urmia. Convenience sampling was done and the participants were randomly assigned to two 'test' and 'control' groups. Data collection was done by completing the demographic data questionnaire, the empowerment tool and dietary behavior checklist. The intervention was conducted in the form of 6 educational classes held for the 'test' group. After two months, posttest was performed by completing the forms once again. Data were analyzed with descriptive tests, t-tests, Chi2 and Fischer's test. RESULTS: The dietary behavior scores of the intervention group had risen from 7.4 ± 2.11 to 9.95 ± 2.41 (P<0.001), and the good dietary behaviors had risen from 21.4% to 61.9% (P=0.002). The 'good' capability level of this group had risen from 23.8% to 97.61% (P<0.001), and their mean capability score had risen from 54.61 ± 7.34 to 70.26 ± 6.04 (P<0.001). However, the changes were not significant in the control group. CONCLUSIONS: The educational intervention performed whit applying family-centered empowerment model in this study was proven effective in women. Hence it is advised to consider it in behavior changing interventions to promote the health of the family and community.

Effect of nutrition education intervention based on Pender's Health Promotion Model in improving the frequency and nutrient intake of breakfast consumption among female Iranian students.

OBJECTIVE: To determine the effectiveness of nutrition education intervention based on Pender's Health Promotion Model in improving the frequency and nutrient intake of breakfast consumption among female Iranian students. DESIGN: The quasi-experimental study based on Pender's Health Promotion Model was conducted during April-June 2011. Information (data) was collected by self-administered questionnaire. In addition, a 3 d breakfast record was analysed. P < 0·05 was considered significant. SETTING: Two middle schools in average-income areas of Qom, Iran. SUBJECTS: One hundred female middle-school students. RESULTS: There was a significant reduction in immediate competing demands and preferences, perceived barriers and negative activity-related affect constructs in the experimental group after education compared with the control group. In addition, perceived benefit, perceived self-efficacy, positive activity-related affect, interpersonal influences, situational influences, commitment to a plan of action, frequency and intakes of macronutrients and most micronutrients of breakfast consumption were also significantly higher in the experimental group compared with the control group after the nutrition education intervention. CONCLUSIONS: Constructs of Pender's Health Promotion Model provide a suitable source for designing strategies and content of a nutrition education intervention for improving the frequency and nutrient intake of breakfast consumption among female students.

Thyroid function in pregnant women: iodine deficiency after iodine enrichment program.

OBJECTIVE: Significant changes in thyroid function occur during pregnancy which can complicate the interpretation of thyroid function tests. Therefore, normative gestational related reference ranges for thyroid hormones tests are required. The aim of this study was to determine the reference ranges for free triiodothyronine (FT3), free thyroxin (FT4) and thyroid stimulating hormone (TSH) in Iranian pregnant women. METHODS: This study was a cross-sectional observational study conducted in the Obstetrics and Gynecology department, Akbarabadi University Hospital. A single blood sample from 584 pregnant women was analyzed for thyroid function. Serum levels of TSH, FT4, FT3, total T4 (TT4), T3 resin uptake (T3RU) and anti-thyroid peroxidase antibody (TPO Ab) were measured. Urinary iodine was determined in some cases. Reference intervals based on 2.5th and 97.5th percentiles were calculated. RESULTS: The composition of reference population comprising 584 women included 162 in first trimester and 422 in the third trimester. The 2.5th and 97.5th percentiles values were used to determine the reference ranges for FT3, FT4, TT4, T3RU and TSH. These values were T3 1.4 and 2.9 pmol/L, FT4 7.1 and 18 pmol/L, TT4 7.2 and 13.5 µg/dL and TSH 0.5 and 3.9 µg/L, respectively. The level of urinary iodine in 80.5% of the subjects was less than normal. CONCLUSIONS: Serum levels of thyroid hormones are different in Iranian population that could be due to racial differences or differences in iodine intake.

The effects of road traffic noise on mental performance.

BACKGROUND: Noise is one of the more widespread pollutions of road transportation system, which can cause deterioration in performance. This experimental study was designed to assess the effect of road traffic noise on performance with regard to extra/introversion and sex of participants. The personality trait of extra/introversion has been remarked as relevant factor to mental performance. RESULTS: Thirty six (26 males and 10 females) medical sciences students of Tehran University participated in the study. The students were placed in an unechoing room and performed the Cognitrone test from Vienna Test System in quiet condition and under road traffic noise (71 dBA). The results of this study pointed out that noise increased the percentage of sum of correct answers but had no effect on the speed of performance. Furthermore this study showed that performance was enhanced in extroverts (P=0.001) but no significant difference was found in introverts (P ≤0.05). CONCLUSIONS: The regression analysis revealed that extra/introversion was more important than sex to predict the performance parameters.

Modeling age at menopause using serum concentration of anti-mullerian hormone.

CONTEXT: Anti-Mullerian hormone (AMH) has already been used for prediction of age at menopause with promising results. OBJECTIVE: We aimed to improve our previous prediction of age at menopause in a population-based cohort by including all eligible subjects and additional follow-up time. DESIGN AND SETTING: All reproductive-aged women who met our eligibility criteria were selected from the Tehran Lipid and Glucose Study. The serum concentration of AMH was measured at the time of recruitment, and participant's date of menopause was recorded over a 10-year follow-up. SUBJECTS: A total of 1015 women, aged 20 to 50 years, with regular and predictable menstrual cycles at the initiation of the study were recruited. MAIN OUTCOME MEASURE: The actual ages at menopause were compared with the predicted ones obtained from accelerated failure time model. RESULTS: We observed 277 occurrences of menopause. Median menopausal age was 50 years (range 30.1-58.2 years). The median (SD) of differences between the actual menopausal age and those predicted by our model was 0.5 (2.5) years. Model adequacy (measured by C-statistics) for correct prediction of age at menopause was 92%. The estimated ages at menopause and their 95% confidence intervals for a range of values of AMH and age were calculated and summarized in a table. CONCLUSIONS: Using a model built on age and AMH, we can predict age at menopause many years earlier. This could provide opportunities for interventions in those who are at risk of early or late menopause.

The association between dietary antioxidant intake and semen quality in infertile men.

BACKGROUND: Oxidative stress is detrimental to semen quality and has a significant role in the etiology of malesubfertility. METHODS: Dietary intake of antioxidants were compared between thirty two men with oligolastheno/ teratazoospermic(cases) and 32 normospermic volunteers (controls) attending fertility clinic in Mirza Koochak-khanHospital in Tehran, Iran. All participants were nonsmokers and matched according their age and Body MassIndex (BMI). Nutrient consumption was calculated using a semi- quantitative food frequency questionnaire.Semen samples were collected and were assessed by measuring volume, concentration, motility and morphology. RESULTS: infertile subjects had a significantly lower intake of zinc and folate compare to control ones(p<0.001). Dietary intake of vitamin C and E was lower than recommended values in 59.4% of case group thatwas significantly different from control ones (p<0.05). In control group, 36.4 and 40.9% of participants had insufficientdietary intake of vitamin C and E, respectively. Significant correlations were found between folate(r=0.5, p<0.001), zinc (r=0.6, p<0.001) and percentage of motility and also between vitamin E and morphology(r=0.3, p=0.03), zinc and concentration (r=0.4, p=0.004) in all participants. CONCLUSION: summary, a low intake of folate, zinc, and vitamin E were related to poor sperm concentrationand motility.

Introducing a new measure for assessing self-efficacy in response to air pollution hazards for pregnant women.

A self-efficacy instrument should be condition-specific. There are several instruments for measuring self-efficacy, but none are air pollution-specific. This study aimed to develop a self-efficacy measure for assessing pregnant women's responses to air pollution hazards. A random sample of pregnant women aged between 18 and 35 years attending three prenatal care centers were entered into the study. Prenatal care centers randomly selected from a list of centers located in different geographical regions of Tehran, Iran. After careful consideration and performing content and face validity, a 4-item measure was developed and participants completed the questionnaire. Reliability was estimated using internal consistency and validity was assessed by performing confirmatory factor analysis (CFA) and known group comparison. In all 200 eligible pregnant women were studied. The mean age of participants was 26.9 (SD = 4.8) years and it was 27.9 (SD = 9.1) weeks for gestational age. The findings showed almost perfect results for both content validity ratio (CVR = 1) and content validity index (CVI = 1). The confirmatory factor analysis indicated a good fit to the data, and known group comparison revealed satisfying results. Internal consistency as measured by the Cronbach's alpha coefficient was found to be 0.74. In general, the findings suggest that this new generated scale is a reliable and valid specific measure of self-efficacy in response to air pollution hazards for pregnant women. However, further studies are needed to establish stronger psychometric properties for the questionnaire.

The impact of multiple recurrences in disease-free survival of breast cancer: an extended Cox model.

AIMS AND BACKGROUND: Identifying the risk factors of recurrence of breast cancer is important for both the physician and patient. Analysis of the first recurrence may lead to an inaccurate evaluation of the factor's effects because it does not completely reflect the history of the disease and may result in the loss of valuable information. The present study aimed to determine the factors that influence breast cancer recurrence and to estimate disease-free survival, adjusting for multiple metastases in breast cancer patients. METHODS AND STUDY DESIGN: Patients were selected from a longitudinal study carried out at Fayazabakhsh Hospital in Tehran, Iran. Women who were diagnosed with breast cancer and who underwent either modified radical mastectomy or breast-conserving surgery between January 2006 and April 2008 were recruited to take part in the study. Breast cancer recurrence was defined as the occurrence of a tumor in the contralateral breast, local-regional relapse, or distant metastasis to other organs. Using an extended Cox model, the effect of age, tumor size, estrogen receptors, HER2, progesterone receptors as well as lymph node ratio was analyzed. RESULTS: Over a 5833 person-month follow-up, 25 of 133 patients (18.8%) had died and 108 patients (81.2%) were still alive, 9 of them with metastasis. Thirty-four patients (25.6%) experienced their first disease recurrence. A total of 11 patients had a second metastasis. The mean time to first metastasis was 19.93 months, and mean gap time between two metastases was 7.15 months. Risk of experiencing a metastasis or death in the third and fifth year after surgery was approximately 22% and 28%, respectively. Fitting multiple recurrent regression shows that high lymph node ratio, high histologic grade, large tumor size and HER2-positive tumors are prognostic factors for shorter disease-free survival. CONCLUSIONS: Our novel approach might be helpful in clinical practice to predict breast cancer recurrence after surgery and might be adapted to be used in other malignancies as well.