Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy.

INTRODUCTION: Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS: Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS: Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS: This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

Measuring Equity of Geographical Distribution of Specialist Physicians in Iran's Health System.

Background: Equitable distribution of health care sector resources is one of the most important goals of health systems in all countries. The purpose of this study is to measure equity of geographical distribution of active specialist physicians in Iran's health system. Methods: The present study was a descriptive-cross-sectional. The statistical population included: all active specialist physicians working in the public, private, social insurance organization, military, charity, and the other health service providers in Iran in 2019. Studied demographic data were collected from Iran's national statistic center. Also, information of specialist physicians was obtained from several databases. Finally, duplicated records were removed, and the number of specialist physicians extracted. Data analysis was performed using Stata V.16 and ArcGIS 10.4 software. Results: The results showed that the number of specialist physicians per 100,000 population who worked in Iran's health system was 46.81. The provinces of Tehran had the highest and Sistan and Baluchestan had the lowest number of specialist physicians. Also, 52.63% of active specialist physicians provide health services in four provinces, whereas these provinces are 37.13% of the country's population. Total Gini coefficient of the distribution of active physicians in Iran in 2019 was 0.23. Conclusions: Distribution of specialist physician was different but somewhat equitable in the provinces. However, in some provinces, the ratio of specialist physicians to the population was still low. Therefore, when the number of specialist physicians increased, their distribution should be considered concurrently.

Resource Use and Costs Associated to the Initial Phase of Treatment for Patients with Colorectal Cancer Receiving Post-Surgery Chemotherapy: A Cost Analysis from a Healthcare Perspective.

BACKGROUND: To estimate the resource use and costs associated to the initial phase of treatment for colorectal cancer in Iran. METHODS: A retrospective study was conducted using routinely collected data within Electronic Health Records System (SEPAS), a national database representing public hospitals in Iran between March 20, 2016 and March 19, 2017. Primary end points included healthcare resource use, direct medical and non-medical costs of care in the 12-month study period. RESULTS: The study population included 657 patients with colorectal cancer who underwent surgery and the follow-up chemotherapy. We estimated a total direct cost of $21,407 per patient. The results indicated that direct medical costs were primarily driven by inpatient hospital care, followed by surgery, chemotherapy, and diagnostic services. CONCLUSION: The initial 12-month of treatment for colorectal cancer, including surgery and the follow-up chemotherapy, is resource intensive. The total direct costs associated to the disease are remarkable, with Inpatient hospital services being the main contributor followed by surgery and chemotherapy.

Applying ethical theories to the Iranian health system governance: a critical empirical assessment.

The policies of health systems are inspired by ethical priorities. A critical review of policies can reveal the ethical theories/justice schools behind them. This study aimed to identify the ethical theory(ies) underpinning the Iranian health system governance over the past 50 years. This was a qualitative study conducted in two stages during 2019. First, we identified and constructed the key concepts and distinctive notions of prominent ethical theories/justice schools. Then, we spotted and selected 24 strategic laws and policy documents in the Iranian health system governance during the past 50 years and analyzed their content to surmise their underlying ethical theory. The results showed that the dominant theory affecting the policies of the Iranian health system governance over the past 50 years was egalitarian liberalism and then objective utilitarianism and relativist communitarianism. Retrospective empirical application of ethical theories to health system governance is methodologically doable, and this application reveals the mood or priorities of the politics. Also, highlighting the underpinning ethical theories of health system governance as well as the gap between ambitions versus realization are insightful and may prospectively empower and strengthen egalitarianism.

Internal Jugular Vein Thrombosis Following Different Types of Neck Dissection.

INTRODUCTION: During functional neck dissection, the surgeon tries to preserve the internal jugular vein (IJV); however, the incidence of its narrowing or obstruction following modified radical neck dissection (MRND) or selective neck dissection (SND) varies between 0% and 29.6%. The most distressing complication of IJV thrombosis (IJVT) is pulmonary embolism. This study aimed to evaluate the incidence of IJVT following selective or modified radical neck dissection. MATERIALS AND METHODS: In this study, 109 neck dissections were performed with the preservation of the IJV on 89 patients from March 2011 to December 2012 in the Cancer Institute of Imam Khomeini Hospital Complex, Tehran, Iran. Ultrasound evaluation of the IJV was performed in the early postoperative period and three months after the surgery. RESULTS: The study population consisted of 62 male and 27 female patients with a mean age of 57+17.57 years. Ultrasound evaluation of the IJV among the participants (109 veins) indicated thrombosis in nine veins (8.25%) in the early postoperative period, four of which remained thrombotic and without flow three months after the surgery. Moreover, 96.33% of the IJVs were patent with a normal blood flow three months after the neck dissection. Among the evaluated IJVs, the only factor that showed a significant association with IJVT was the incidence of postoperative complications, including hematoma and seroma (P=0.01). CONCLUSION: It seems that the most important factor for the prevention of the IJVT is a meticulous surgery and surgical complication avoidance during neck dissection.

How health transformation plan was designed and implemented in the Islamic Republic of Iran?

Following his inauguration in late 2013, President Rouhani aimed to boost quality and equity in the health care delivery system. To fulfill this aim, a set of interventions, called Health Transformation Plan (HTP), were implemented. So far, it has been a heated debate whether HTP breathes a spirit of a new reform. HTP has targeted long-standing historical deficits of the Iranian health system as well as urgent problems, both of which have been, to some extent, resolved. To decrease Out-Of-Pocket (OOP) health expenditures, HTP has presented new financing mechanisms to expand a safety net to Iranian citizens fundamentally. HTP also encompassed interventions to overcome problems in the provision of health care by recruitment of health workforces, establishing new health facilities, and expanding primary health care to urban and peri-urban areas. Furthermore, performance indicators including access, quality, and patient satisfaction have been affected. Given these changes, HTP is entitled to be a health system reform. However, a new agenda within HTP is required so that the Iranian health system can obtain better value for money that is to be spending on it.

An analysis of financial protection before and after the Iranian Health Transformation Plan.

BACKGROUND: Protecting people against the financial consequences of health-care payments is a key objective of health systems. AIMS: We carried out a descriptive analysis of changes in health spending associated with the implementation of the latest health sector reform in the Islamic Republic of Iran, the Health Transformation Plan (HTP). METHODS: The study relied on 2 rounds of data from the Household Expenditure and Income Survey (2014 and 2015). Key indicators of financial protection in health expenditure were estimated. The Kakwani index was used for out-of-pocket (OOP) health expenditure to measure the degree of progressivity in the distribution of such payments. RESULTS: Total OOP per capita health expenditure showed a 2.5% relative decrease in real terms in 2015 compared to 2014. Estimation of the Kakwani index suggested OOP spending became slightly more progressive over the time period of HTP reform. The share of the population facing catastrophic health expenditure also decreased significantly from 2.9% to 2.1% at the national level. However, the incidence of impoverishment due to OOP payments increased slightly between preand post-HTP, from 0.2% to 0.5%. CONCLUSION: Our findings suggest that the new policies have a positive association in improving financial protection against health costs among Iranians, albeit slightly less so for the poor. Future efforts to increase public spending for financial protection would be challenging and should rely on efficiency gains such as a move from fee-for-service to performance- based payment systems and more organized OOP collection mechanisms involving prepayment and risk pooling.

Psychometric evaluation of Azeri version of the head and neck cancer specific quality of life questionnaire (EORTC QLQ-H&N43).

BACKGROUND: Oral cancer surgery can have a deep effect on the quality of life in the patient both in terms of functional and psychological aspects. This study aimed to translate and validate the European Organization for Research and Treatment of Cancer head and neck cancer specific quality of life questionnaire (EORTC QLQ-H&N43) in Azerbaijan. METHODS: Forward-backward translation was applied in order to translate the EORTC QLQ-H&N43 from English into Azeri. Then, a sample of patients with oral cancer attending a teaching hospital affiliated to Azerbaijan Medical University completed the EORTC QLQ-C30 (the core cancer specific questionnaire), and the EORTC QLQ-H&N43. To evaluate psychometric properties of the QLQ-H&N43, known groups validity, convergent and divergent validity was performed. Internal consistency reliability was examined by estimating the Crornbach's alpha coefficient. RESULTS: Ninety-six patients with confirmed diagnosis of oral cancer were entered into the study. The mean age of patients was 59.6 (SD = 10.7) years and 36 patients (37.5%) diagnosed as having stage IV and 10 patients (10.5%) were metastatic. The results obtained from comparing quality of life scores among these patients showed that the questionnaire was able to differentiate among patients who differed in stage and metastasis lending support to its validity. In addition convergent and divergent validity showed satisfactory results. The internal consistency of the multi-item scales as assessed by the Cronbach's alpha coefficient showed acceptable results (alpha ranging from 0.66 to 0.78). CONCLUSION: The findings suggest that in general the Azeri version of EORTC QLQ-H&N43 has satisfactory internal consistency reliability and validity, but additional psychometric evaluation is needed to draw firm conclusions.

Association of physical activity, body mass index and reproductive history with breast cancer by menopausal status in Iranian women.

BACKGROUND: The incidence rate of breast cancer (BC) is increasing in low- and middle-income countries (LMICs), including Iran. We investigated the association between BC risk and physical activity (PA), body mass index (BMI), and reproductive history among Iranian women. METHODS: We conducted a large hospital-based case-control study and compared 958 BC cases with 967 controls at the Cancer Institute of Iran during 2011-2016. We used multiple logistic regression models and adjusted for potential confounders to estimate odds ratios (ORs) and 95% confidence intervals (95%CIs) for the associations between BC and different risk factors, including low physical activity. RESULTS: Women with high levels of physical activity had a lower risk of BC compared to those who were inactive (OR = 0.55, 95%CI: 0.41, 0.75). In premenopausal women, the association was observed only in normal-weight women (OR = 0.31, 95%CI: 0.13, 0.75), while it was limited to obese women in the postmenopausal group (OR = 0.29, 95%CI: 0.12, 0.66). We found a high risk of postmenopausal BC among overweight (OR = 1.69; 95%CI: 1.01, 2.81) and obese women (OR = 1.9; 95%CI: 1.14, 3.14) compared to women with a normal BMI. We observed an inverse association among postmenopausal women who had between three and five children (OR = 0.31, 95%CI 0.14, 0.64) and more than six children (OR = 0.21, 95%CI 0.12, 0.42) compared to nulliparous women. CONCLUSIONS: Low levels of physical activity, low parity, and being overweight or obese were major risk factors for BC. For the first time, we report a strong association between physical activity and BC risk in Iranian women.

Expanding Fiscal Space for Healthcare System through Efficiency: A Qualitative Study from Iran.

BACKGROUND: Healthcare systems are always facing increasing public demands to provide better services. Therefore, countries always need more resources and are constantly seeking more fiscal space for health. Freeing up resources through improving efficiency can be a practical option for all settings, particularly countries with low resources. This study aimed to identify feasible options for expanding fiscal space through efficiency within Iran's healthcare system. METHODS: This was a qualitative study. We conducted 29 semi-structured in-depth interviews with stakeholders at various levels of healthcare system in 2017 and 2018. We used mixed method (deductive and inductive) qualitative content analysis. Pre-defined themes extracted from literature and meanwhile new subthemes were developed and added to the initial framework. RESULTS: We identified three main themes that affect the efficiency of healthcare system in Iran: administration, implementation, and monitoring. Problematic administration, inappropriate implementation and lack of good monitoring in healthcare initiatives may lead to inefficiencies and wasting resources. Recognizing these leakages in every healthcare system can free up some resources. CONCLUSION: Irrespective of their economic development, all countries may, to some extent, face limited resources to address ever-increasing needs in their healthcare systems. While generating new resources is not always possible, enhancing efficiency to expand fiscal space might be a feasible option. Healthcare systems should identify the leakages and respond to wastages with appropriate planning. Getting the most out of current resources is possible through proper administration, good implementation and a well-established monitoring system for healthcare initiatives.

Health Status in the Islamic Republic of Iran, Middle East and North Africa Countries: Implications for Global Health.

BACKGROUND: The aim of this study was to evaluate the health status of the Iranians following the sustainable development goals' (SDGs) introduction and the recent health reform implementation in Iran and to compare with those of the Middle East and North Africa region (MENA) and global average. METHODS: This comparative study used secondary data to investigate socio-demographic and health status indicators. The sources included census, population-based surveys and death registries. Global and regional health status indicators were obtained from international databases including WHO, the World Bank and the Institute for Health Metric and Evaluation (IHME). RESULTS: Life expectancy and human development index improved following the reform implementation. Among causes of death, 74.6% were attributed to non-communicable diseases (NCDs). There was an increasing trend in risk factors for NCDs in Iran, while at the same time neonatal, infant and under-5 mortality rates reduced. Compared to the MENA, Iran has a lower maternal mortality ratio, neonatal, infant, and under-5 mortality rates, and a higher life expectancy. NCDs and road traffic injuries accounted for a larger portion of disability-adjusted life years in Iran compared to the MENA and worldwide. CONCLUSION: Actions against communicable diseases and road traffic injuries are required together with continued efforts to address NCDs. Although based on the results, Iran has relatively high rankings, there is a need to develop a roadmap to accelerate achieving global health goals and SDGs targets.

The Azeri Version of European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30): Translation and Validation.

OBJECTIVE: Quality of life in cancer patients has become an important outcome measure. This study aimed to translate and validate the European Cancer Research and Treatment Core Quality of Life Questionnaire (EORTC QLQ-C30) in Azerbaijan. METHODS: Forward-backward procedure was applied to translate the EORTC QLQ-C30 from English into Azeri. Then a cross sectional study was conducted to validate the questionnaire in Azerbaijan. A sample of patients with confirmed diagnosis of oral cancer completed the Azeri version of the questionnaire from January 2017 to December 2018. Construct validity was assessed by performing know groups comparison and item-scale correlation matrix. Reliability was examined by estimating the Cronbach's alpha coefficient for internal consistency. RESULTS: In all 141 patients with oral cancer participated in the study. Known groups comparison indicated that the Azeri version of EORTC QLQ-C30 well differentiated between patients who differed in the disease stage. Those with higher stage reported lower functioning and higher symptoms. In addition item-scale correlation matrix showed a good correlation between items and its own hypothesized subscales as expected (Pearson correlation coefficient ranging from 0.735-0.978). The Cronbach's alpha coefficient ranged form 0.68 to 0.94 indicating acceptable results for the internal consistency of the questionnaire. CONCLUSION: This preliminary validation study proved that the Azeri version of EORTC QLQ-C30 is a valid measure of quality of life in cancer patients. However, studies with other cancer patients and stronger psychometric evaluations are recommended.

Evaluation of quality of life in patients with oral cancer after mandibular resection: Comparing no reconstruction, reconstruction with plate, and reconstruction with flap.

This cross-sectional study aimed to assess and compare quality of life in patients with advanced oral cavity tumors after mandibular resection in 3 groups (no reconstruction, reconstruction with plate, and reconstruction with flap) at the Cancer Institute, affiliated to Tehran University of Medical Sciences. Quality of life was measured using the European Organization for Research and Treatment of Cancer core quality of life questionnaire and European Organization for Research and Treatment of Cancer head and neck cancer-specific quality of life questionnaire-35 items. The comparison was tested using Kurskal-Wallis analysis. All 120 patients were entered into the study. The mean age of patients was 48.5 (standard deviation = 18.1) years. Patients presented with advanced stage of the disease and underwent mandibular resection with no reconstruction (n = 40), reconstruction with plate (n = 41), and reconstruction with flap (n = 39). The findings showed that in general, there were no statistically significant differences in quality of life among 3 groups except for speech problem (P = .4), dry mouth (P = .03), and feeling ill (P = .04). Although there were no significant differences in quality of life among patients in 3 groups, overall patients who received reconstruction with flap reported better functioning and fewer symptoms. Those who did not receive any reconstruction reported the worse conditions.

Factors Associated with Dual Practice in Surgery Specialists: Application of Multi-Level Analysis on National Registry Data.

BACKGROUND: Dual practice by surgery specialists is a widespread issue across health systems. This study aimed to determine the level of dual practice engagement and its related factors among Iran's surgery specialists. METHODS: A pre-structured form was developed to collect the data about surgery specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes and eventually a combination of the first name, surname and father's name. Multilevel logistic regression was used to assessing the association between dual practice with study variables. RESULTS: Overall, 14931 surgeons were participated (93% response rate) and 6405 (57% of) engaged in DP on total. Urinary tract & genital and neurosurgery specialties had the highest rank with 69%. DP was more frequent in specialists with higher age and experience, populated provinces, higher deprivation, and share of private hospitals. Faculty physicians (OR=0.69), full-time geographic physicians (OR=0.17), specialists with more than 25 years' experience (OR=2.59) and age more than 40 yr (OR=1.3) had significant association with dual practice. CONCLUSION: Multi-approach strategy is needed to control dual practice through tax regulations, income cap, and limitations in work hours and number of visits in private sector.

The NCCN Criterion "Young Age at Onset" Alone is Not an Indicator of Hereditary Breast Cancer in Iranian Population.

Because the contribution of genetic factors to the burden of breast cancer is not well investigated in Iran, we aimed to examine the prevalence of mutations in breast cancer susceptibility genes, BRCA1/2 and PALB2, and to investigate the predictive potential of hereditary breast cancer risk criteria for genetic testing in Iranian population. Next-generation sequencing was conducted on a population consisting of 299 and 125 patients with breast cancer, with and without hereditary cancer risk criteria for genetic testing, respectively. The pathogenic mutation frequency rate was 10.7% in patients with hereditary cancer criteria versus 1.6% in no criteria group (P = 0.0017). None of the 107 tested patients with only young age at onset (<40) criterion had a pathogenic mutation. Patients who had only a single heritable risk criterion [OR, 6.15; 95% confidence interval (CI), 1.26-58.59; P = 0.009] and patients with multiple heritable risk criteria (OR, 22.5; 95% CI, 5.19-201.31; P < 0.0001) had higher probabilities of carrying a mutation compared with no criteria group. Our results showed that young age at onset alone is not an indicator of hereditary breast cancer at least in the Iranian population. This is while women with multiple hereditary breast cancer risk criteria were enriched for BRCA1/2 mutations. Given such high risk of identification of a disease-causing mutation, multiple hereditary criteria should be regarded as a strong predictor for a hereditary breast cancer syndrome. These findings are important concerning the optimization of genetic counseling and furthermore establishing criteria for BRCA1/2 testing of the Iranian population.

The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review.

OBJECTIVES: To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care. METHODS: Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis. RESULTS: Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes. CONCLUSION: The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.

Promoter DNA Methylation and mRNA Expression Level of p16 Gene in Oral Squamous Cell Carcinoma: Correlation with Clinicopathological Characteristics.

The aim of this study was to investigate the relationship between p16 methylation and its expression in oral squamous cell carcinoma (OSCC). Also the contribution of clinicopathological factors, HPV infection and smoking in p16 expression and promoter methylation has been investigated. In this study 67 consecutive OSCC patients and 59 normal individuals were enrolled. All patients were candidates for surgery of oral cavity and fresh tumor biopsies were collected and processed for DNA and RNA extraction. Normal gingival tissues were collected from individuals referred to dentistry clinic and considered as controls. All the cases and controls were checked for HPV infection and then promoter methylation and expression of p16 gene were determined using Methylation-specific PCR (MSP) and real-time PCR (QPCR), respectively. Methylation of p16 in tumors and normal tissues were 59.7 and 38.9%, respectively. Most of hypermethylated samples (>82%) were in high grades. P16 methylation was comparable in HPV+ and HPV- patients or smokers. P16 was overexpressed (~3 fold; p = 0.044) in HPV+ tumors, but it was significantly down-regulated in smoker patients (40% of all tumors). Comparison of P16 expression in OSCC tumors with different degrees of promoter methylation further suggest the relationship of methylation rate and down-regulation of P16 expression. The p16 methylation and expression was differentially affected in patients with HPV infection and the smoker cases. Regardless of the influence of environmental factors, it appears that P16 status is useful for classifying patients with OSCC and for influencing treatment strategies in accordance with this classification. Moreover, targeting the upregulation of p16 could be a promising therapeutic option.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016.

BACKGROUND: One of the work patterns which affects the supply of specialists is the phenomenon of dual practice (DP), i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services. AIMS: The aim of this article is to examine the impact of DP on service delivery time by surgeons. METHODS: We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age. RESULTS: The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 (standard deviation 0.33) hours full-time equivalent (FTE) on health care service delivery. Specialists with DP had long service delivery time (ß = 0.427). Female specialists (ß = -0.049) and full-time specialists (ß = -0.082) spent less time on health care service delivery. Permanent specialists had higher FTE (P < 0.001) and as the population increases, FTE increases (P < 0.05). CONCLUSIONS: Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.