PErspective and current status of Radiotherapy Service in IRan (PERSIR)-1 study: assessment of current external beam radiotherapy facilities, staff and techniques compared to the international guidelines.

BACKGROUND AND PURPOSE: Radiotherapy (RT) is an essential treatment modality against cancer and becoming even more in demand due to the anticipated increase in cancer incidence. Due to the rapid development of RT technologies amid financial challenges, we aimed to assess the available RT facilities and the issues with achieving health equity based on current equipment compared to the previous reports from Iran. MATERIALS AND METHODS: A survey arranged by the Iran Cancer Institute's Radiation Oncology Research Center (RORC) was sent to all of the country's radiotherapy centers in 2022. Four components were retrieved: the reimbursement type, equipment, human resources, and patient load. To calculate the radiotherapy utilization rate (RUR), the Lancet Commission was used. The findings were compared with the previous national data. RESULTS: Seventy-six active radiotherapy centers with 123 Linear accelerators (LINACs) were identified. The centers have been directed in three ways. 10 (20 LINACs), 36 (50 LINACs), and 30 centers (53 LINACs) were charity-, private-, and public-based, respectively. Four provinces had no centers. There was no active intraoperative radiotherapy machine despite its availability in 4 centers. One orthovoltage X-ray machine was active and 14 brachytherapy devices were treating patients. There were 344, 252, and 419 active radiation oncologists, medical physicists, and radiation therapy technologists, respectively. The ratio of LINAC and radiation oncologists to one million populations was 1.68 and 4.10, respectively. Since 2017, 35±5 radiation oncology residents have been trained each year. CONCLUSION: There has been a notable growth in RT facilities since the previous reports and Iran's situation is currently acceptable among LMICs. However, there is an urgent need to improve the distribution of the RT infrastructure and provide more facilities that can deliver advanced techniques.

Effect of Postoperative Kinesio Taping on Knee Edema, Pain, and Range of Motion After Total Knee Arthroplasty and Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Kinesio taping (KT) has been shown to be clinically effective in a wide range of musculoskeletal disorders. Despite evidence supporting KT, there still needs to be more certainty regarding its clinical worthiness in managing postoperative conditions. This study aims to assess the effect of postoperative KT on knee edema, pain, and range of motion (ROM) when added to routine physiotherapy after knee surgery. METHODS: In this systematic review and meta-analysis, MEDLINE, Embase, Scopus, Web of Science, and CENTRAL databases were searched from their inception to July 2023. Randomized controlled trials (RCTs) comparing routine physiotherapy with and without KT were included. Random-effect models were used to calculate the standardized mean difference (SMD), confidence interval, and heterogeneity (I2). RESULTS: Sixteen RCTs on 842 operated knees were included. KT reduced knee edema in first week (SMD, -0.59, p < 0.001), 14th postoperative day (POD) (SMD, -0.78, p < 0.001), and 28 to 42 days postop (SMD, -0.66, p < 0.001). The KT demonstrated significant pain improvement in second week (SMD, -0.87, p < 0.001) and the fourth week (SMD, -0.53, p < 0.001). The KT groups demonstrated ROM improvement within second week (SMD, 0.69, p = 0.010) and in the 28th POD (SMD, 0.89, p = 0.009). Subgroup analysis demonstrated minimal heterogeneity in anterior cruciate ligament reconstruction (ACLR) cases. However, it did not show significant superiority regarding ankle, calf, or thigh edema and Lysholm scale. CONCLUSION: This study suggests that adding KT to routine postoperative physiotherapy reduces pain and knee edema after total knee arthroplasty or ACLR. Low to very low certainty of evidence for all outcomes and the limited number of studies emphasize the need for more high-quality primary studies to explore the optimal method of KT application and its effectiveness in specific knee surgeries. LEVEL OF EVIDENCE: Level I. See Instructions for Authors for a complete description of levels of evidence.

Prevalence, Complications, and Risk Factors of Falls and Fear of Falling Among Older Adults; Based on Ardakan Cohort Study on Aging (ACSA).

Introduction: The objective of this study was to assess the prevalence of falls, fear of falling (FOF), complications arising from falls, and identify possible sociodemographic and health-related factors associated with these outcomes among older adults. Methods: This cross-sectional study was based on the first wave of the Ardakan Cohort Study on Aging (ACSA), which includes participants over 50 years of age residing in Ardakan, Iran. Fall history, number of fall events, FOF, hospitalizations, and fractures in the past 12 months were assessed through a face-to-face interview. Health-related factors were recorded on a self-expressed basis. Associations were assessed using multiple logistic regression. Results: Among the 4,990 participants, fall history in the past 12 months was prevalent in 19.9%, with 10.1% reporting more than two fall events. Women (p < 0.001) and older participants (p< 0.001) had a higher prevalence. In females, 28.8% reported moderate to severe FOF, while 21% experienced disruptions in their daily activities as a result of this fear. The prevalence of fractures following falls was 5.1% in males and 8.6% in females. After adjusting for confounding factors, FOF (OR: 1.59, 95% CI: 1.33-1.91, p<0.001), imbalance (OR: 2.45, 95% CI: 1.68-3.58, p<0.001), urinary incontinence (OR: 1.44, 95% CI: 1.04-1.9, p=0.025), cognitive impairment (OR: 1.21, 95% CI: 1.01-1.46, p=0.049), vertigo or dizziness (OR: 1.39, 95% CI: 1.15-1.68, p<0.001), osteoporosis (OR: 1.24, 95% CI: 1.03-1.50, p=0.023), osteoarthritis (OR: 1.33, 95% CI: 1.13-1.56, p=0.001), depression (OR: 1.30, 95% CI: 1.06-1.60, p=0.010), and Central Nervous System (CNS)-affecting diseases (OR: 1.99, 95% CI: 1.33-2.97, p=0.001) were found to have positive associations with falls. Conclusion: This study showed that about one-fifth of those over 50 in Iran have experienced at least one fall within a year. Self-expressed imbalance, FOF, and urinary incontinence were the most prominent risk factors. Due to resulting in hospitalization and fractures, falls also lead to fear of falling and the associated limitation of activities.

Prevalence and associated factors of mild cognitive impairment among middle-aged and older adults: Results of the first phase of Ardakan Cohort Study on Aging.

Background and Aims: Data on mild cognitive impairment (MCI) in low- to middle-income countries are still being determined, despite the fact that most future older adults are expected to reside in these regions. This study aimed to investigate the prevalence and associated factors of MCI in Iran. Methods: A cross-sectional study was conducted on 4938 community-dwelling subjects aged 50 years or above in the first wave of the Ardakan Cohort Study on Aging. MCI was evaluated using the Mini-Mental State Examination (MMSE) and the Abbreviated Mental Test Score (AMTS) in literate and illiterate individuals. The relationship between factors associated with the odds of MCI was assessed through logistic regression. Results: The prevalence of MCI among all participants, the literates and illiterates, was 15.8%, 6.3%, and 36.4%, respectively. It was found that failure to accomplish any of the MMSE or AMTS items was significantly related to MCI (p < 0.001). Age ([odds ratio (OR): 1.05; p < 0.001 in the literates], [OR: 1.06; p < 0.001 in the illiterates]), sex (OR: 0.13; p < 0.001 in the illiterates), history of stroke ([OR: 2.86; p = 0.006 in the literates], [OR: 2.04; p = 0.045 in the illiterates]), and depression ([OR: 1.87; p < 0.001 in the literates], [OR: 1.41; p = 0.008 in the illiterates]) were significantly associated with MCI. Conclusion: This study highlights the significant associations between age, education, depression, stroke, and MCI in Iranian participants. These findings emphasize the need for targeted interventions in low-literacy populations, mental health screening, and stroke prevention strategies to mitigate the burden of MCI and enhance cognitive health.

Intra-Operative Adjunctive Magnesium Sulfate in Pain Management of Total Knee Arthroplasty; a Systematic Review and Meta-analysis.

Introduction: There has been growing interest in the potential role of adjunctive magnesium sulfate in improving pain management. This systematic review and meta-analysis aimed to assess the effect of intra-operative adjunctive magnesium sulfate on pain management and opioid consumption in total knee arthroplasty (TKA). Methods: A comprehensive search was conducted in Medline, Embase, Scopus, Web of Science, and Cochrane Library databases, covering studies up to April 2023. The extracted data included pain management outcomes, opioid consumption, and adverse effects from the selected studies. Standardized mean differences (SMDs) were calculated for continuous outcomes, while risk ratios (RRs) were calculated for dichotomous outcomes. Meta-analysis was conducted employing random-effects models in STATA 17. Results: In this meta-analysis of 8 randomized controlled trials involving 536 patients, adjunctive magnesium sulfate in TKA was found to significantly reduce opioid consumption during the first 24 hours after operation (SMD: -1.88, 95% confidence interval (CI): [-3.66 to -0.10]; p = 0.038). It also resulted in lower pain scores at rest 24 hours after surgery (SMD: -1.53, 95% CI: [-2.70 to -0.37]; p = 0.010). There were no significant differences in time to first rescue analgesic and adverse effects between the groups. The included studies were assessed to have low to high levels of risk of bias. Conclusion: This study presents evidence at low to moderate levels supporting the use of intra-operative adjunctive magnesium sulfate in TKA for improved pain management and reduced opioid consumption. However, further research is needed to address the heterogeneity and to explore optimal dosing regimens and routes of administration to maximize the benefits of magnesium sulfate in TKA.

Effect of duloxetine on opioid consumption and pain after total knee and hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials.

OBJECTIVES: The purpose of this study was to investigate the analgesic effects of duloxetine, specifically on postoperative pain, opioid consumption, and related side effects following total hip or knee arthroplasty. METHODS: In this systematic review and meta-analysis, Medline, Cochrane, EMBASE, Scopus, and Web of Science were searched until November 2022 for studies which compared duloxetine with placebo when added to routine pain management protocols. Individual study risk of bias assessment was conducted based on Cochrane risk of bias tool 2. Random effect model meta-analysis was done on mean differences, to evaluate the outcomes. RESULTS: Nine randomized clinical trials (RCT) were included in the final analysis, totaling 806 patients. Duloxetine reduced opioid consumption (oral morphine milligram equivalents) on postoperative days (POD) 2 (mean difference (MD): -14.35, P = .02), POD 3 (MD: -13.6, P < .001), POD 7 (MD: -7.81, P < .001), and POD 14 (MD: -12.72, P < .001). Duloxetine decreased pain with activity on POD 1, 3, 7, 14, 90 (All P < .05), and pain at rest on POD 2, 3, 7, 14, and 90 (all P < .05). There was no significant difference in the prevalence of the side effects, except for increased risk of somnolence/drowsiness (risk ratio: 1.87, P = .007). CONCLUSION: Current evidence shows low to moderate opioid sparing effects of perioperative duloxetine and a statistically but not clinically significant reduction in pain scores. Patients treated with duloxetine had an increased risk for somnolence and drowsiness.

Recovery of Acute Ophthalmoplegia after Hyaluronic Acid Filler Injections to the Temples: A Case Report and Review of the Literature.

Soft tissue filler injection is the second most common nonsurgical cosmetic procedure. Despite the safety of fillers, as use has grown, so has the number of patients affected by adverse events. Ophthalmoplegia following cosmetic filler injection is a rare complication, mostly occurring after injection to the glabella, nasolabial fold, periorbital, and lateral nasal site. In all cases where ophthalmoplegia has been reported following fillers, patients have simultaneously experienced vision loss and other ocular symptoms. We report a case of isolated acute ophthalmoplegia following hyaluronic acid injection solely in the temple region. A 40-year-old woman, 3 hours after the procedure, presented to our hospital with left eye ophthalmoplegia, ptosis, and hypotropia. Treatment started with hyaluronidase, steroids, and anticoagulants. After 4 weeks, left eye ophthalmoplegia remained unchanged, and through a 10-week follow-up, all left ocular movements improved, and only mild hypotropia and ptosis persisted. This case report shows that ophthalmoplegia may also happen with temple region filler injections. We also review available prevention techniques and treatments to avoid such complications when performing soft tissue fillers for gaunt appearance correction.

Implications for pelvic lymph node irradiation in definitive chemoradiotherapy of node negative muscle invasive bladder cancer based on predictive factors of clinicopathologic discrepancy.

PURPOSE: To identify pre-surgical imaging predictive value and factors associated with the clinicopathologic discrepancy for implication of definitive pelvic radiotherapy in clinically node-negative bladder cancer. METHOD: The documented data of bladder cancer patients who underwent radical cystectomy plus pelvic lymphadenectomy were collected retrospectively. Patients' characteristics, last imaging, pathology reports, disease-specific survival and overall survival were retrieved. RESULTS: From 142 patients, pre-surgical imaging had a sensitivity of 76.4%, specificity of 73.7%, positive predictive value (PPV) of 94.9%, and negative predictive value (NPV) of 32.6% (p value < 0.0001) for detection of muscle invasion. Also, for detection of positive lymph nodes, imaging had a sensitivity of 31.8%, specificity of 85.7%, PPV of 50%, and NPV of 73.7% (p value: 0.022). 44.4% of study population were upstaged after surgery (24.6% associated with N-upstaging) and 18.3% were downstaged (12% associated with N-downstaging). Receipt of neoadjuvant chemotherapy and T-stage were not correlated with N-upstaging. On multivariate analysis, lymphovascular invasion (LVI) maintained its significance for independent prediction of upstaging (OR 3.3, 95% CI 1.5-7.5, p value: 0.004) and inversely with downstaging (OR 0.34, 95% CI 0.12-0.96, p value: 0.04). Older age (OR 1.03, 95% CI 1.0-1.05, p value 0.047), positive margins (OR 2.1, 95% CI 1.2-3.8, p value 0.011), presence of LVI (OR 2.5, 95% CI 1.4-4.7, p value 0.003), perineural invasion (OR 2.0, 95% CI 1.2-3.4, p value 0.013), and lymph node ratio (OR 1.011, 95% CI 1.001-1.021, p value 0.03) were associated with worse survival. Also, N-upstaging independently predicted a worse survival after controlling for surgical pathology stage (OR 2.3, 95% CI 1.2-4.5, p value 0.011). CONCLUSIONS: The optimal target volume in definitive chemoradiotherapy of node-negative bladder cancer patients remains to be established. Since then, customizing the treatment is considered especially for positive LVI in TURBT specimen.

Evaluation of Survival Rate and Associated Factors in Patients with Cervical Cancer: A Retrospective Cohort Study.

BACKGROUND: Cervical cancer, the most common gynecological cancer, is a matter of concern, especially in developing countries. The present study investigates survival rates, associated factors, and post-treatment follow-up status in cervical cancer patients. STUDY DESIGN: A retrospective cohort study. METHODS: This study was conducted on 187 patients referred to an academic referral cancer center in Iran from 2014-2020. Overall survival (OS) and event-free survival (EFS) were evaluated using Kaplan Meyer analysis. The event was defined as recurrence, metastasis, or death. RESULTS: The patients came for post-treatment visits for a median of 36 months (interquartile range [IQR]: 18-51). The median OS and EFS were 24 and 18 months, respectively. The 1- and 3- year OS rates were 90% and 72%, respectively. The 1- and 3- year EFS rates were 76% and 61%, respectively. Stage ≥ III (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.5, 6.5, P < 0.001) and tumor size > 4 cm (HR: 2.5, 95% CI: 1.2, 4.9, P = 0.006) predicted lower OS. The most common histopathology was squamous cell carcinoma (SCC) (71.1%) with non-significant higher 3- year OS (HR: 0.62, 95% CI: 0.33, 1.16, P = 0.13). No significant difference in OS was found between adjuvant and definitive radiotherapy in both early and advance-staged patients (Log-rank = 0.7 P = 0.4, log-rank = 1.6, P = 0.2, respectively). CONCLUSION: As evidenced by the obtained results, the survival of patients was lower compared to that in developed countries. Higher stage and tumor size led to shorter survival. The histopathology and type of treatment in comparable stages did not have any significant impact on survival.

Lactate Dehydrogenase to Albumin ratio as a Predictive Factor of COVID-19 Patients' Outcome; a Cross-sectional Study.

Introduction:  Despite the increasing vaccination coverage, COVID-19 is still a concern. With the limited health care capacity, early risk stratification is crucial to identify patients who should be prioritized for optimal management. The present study investigates whether on-admission lactate dehydrogenase to albumin ratio (LAR) can be used to predict COVID-19 outcomes. Methods: This retrospective cross-sectional study evaluated hospitalized COVID-19 patients in an academic referral center in Iran from May 2020 to October 2020. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the value of LAR in the prediction of mortality. The Yuden index was used to find the optimal cut-off of LAR to distinguish severity. Patients were classified into three groups (LAR tertiles), first: LAR<101.46, second: 101.46≤LAR< 148.78, and third group: LAR≥148.78. Logistic regression analysis was used to identify the association between tertiles of LAR, as well as the relationship between each one-unit increase in LAR with mortality and ICU admission in three models, based on potential confounding variables. Results: A total of 477 patients were included. Among all patients, 100 patients (21%) died, and 121 patients (25.4%) were admitted to intensive care unit (ICU). In the third group, the risk of mortality and ICU admission increased 7.78 times (OR=7.78, CI: 3.95-15.26; p <0.0001) and 4.49 times (OR=4.49, CI: 2.01-9.04; p <0.0001), respectively, compared to the first group. The AUC of LAR for prediction of mortality was 0.768 (95% CI 0.69- 0.81). LAR ≥ 136, with the sensitivity and specificity of 72% (95%CI: 62.1-80.5) and 70% (95%CI: 64.9-74.4), respectively, was the optimal cut-off value for predicting mortality. Conclusion: High LAR was associated with higher odds of COVID-19 mortality, ICU admission, and length of hospitalization. On-admission LAR levels might help health care workers identify critical patients early on.