Serious educational games for children: A comprehensive framework.

Introduction: Serious educational games are digital games designed to support teaching or learning objectives that have become popular among children. However, a set of principles is needed to develop a successful educational game. Therefore, this study aimed to provide a comprehensive and valid framework for designing children's serious educational games. Methods: The conceptual framework is developed in two phases. First, a scoping review was conducted in PubMed, Ovid (APA PsycInfo), EMBASE, Scopus, Web of Science, ProQuest, and gray literature on August 1, 2022. Papers in English that reported the serious educational games' principles for children were included. Second, the extracted data from the previous step was reviewed and discussed by the research team to develop the initial framework. Then, it was distributed to 20 experts with relevant knowledge and experience in two rounds to validate and apply their comments within the framework. Results: Of the 12916 papers identified, 15 were included in this study. In the proposed framework named CoDHP, the results were classified into four topics, including (a) content aspects, (b) design requirements, (c) highlighted attributes, and (d) children's preferences. Content aspects comprise four classes (goals and limits, child learning content, learning context, and a long-term program) with 16 principles. Design requirements contain 11 classes (stories and storylines, player characters, game mechanics, interactivity, game challenge, game rules, game help, entertaining games, user interface, accessibility, and setting) with 47 principles, of which 15 are highlighted. Regarding children's preferences for the game elements, various similarities and differences were extracted. For instance, both girls and boys prefer fun and popular games. Based on experts' comments, 21 supplementary principles were recommended to complete the content and design requirements. Conclusion: Game designers or researchers can use the proposed framework as a formative guide to design successful serious games or evaluate children's digital games.

Sex-specific association of exposure to air pollutants and Nrf2 gene expression and inflammatory biomarkers in exhaled breath of healthy adolescents.

Studies investigating the nuclear factor erythroid 2-related factor 2 (Nrf2) expression levels in the respiratory system of healthy subjects are scarce. Moreover, separate studies on the health-related outcomes of air pollution for each sex are limited. The current panel study investigated sex-specific Nrf2 expression levels and related oxidative stress and inflammatory responses among healthy adolescents exposed to PM2.5, PM10, O3, and PM2.5-bounded metals in a high traffic region. Forty-nine healthy nonsmoking subjects participated in the study for five consecutive months (Nov. 2019 to Feb. 2020). Each subject was asked to provide 1 mL of exhaled breath condensate (EBC). Data were analyzed using linear mixed-effects models. The results showed that PM10, PM2.5, O3, and PM2.5-bounded metals were negatively linked to Nrf2 expression level in EBC of females with -58.3% (95% CI: 79.5, -15.4), -32.1% (95% CI: -50.3, -7.1), -76.2% (95% CI: -92.6, -23.9), and -1.9 (95% CI: -3.4, -0.4), respectively. While our results presented no significant association between the studied pollutants and Nrf2 gene expression in males, significant associations were observed between the pollutants and total nitric oxide (NOx), interleukins 6 (IL-6), and tumor necrosis factor-alpha (TNF-α) in the EBC of females. In the case of males, only EBC cytokines showed a significant association with air pollutants. Overall, this study suggests that exposure to ambient air pollutants may affect the respiratory system with biologically different mechanisms in males and females. PM2.5 concentration had a positive correlation with exhaled TNF-α and IL6 values in females while positive correlation with TNF-α and negative correlation with IL6 values in males. O3 had a negative correlation with TNF-α in males.

Upper lip bite test compared to modified Mallampati test in predicting difficult airway in obstetrics: A prospective observational study.

Difficult airway and intubation can have dangerous sequela for patients if not managed promptly. This issue is even more challenging among obstetric patients. Several studies have aimed to determine whether the test to predict a difficult airway or difficult intubation, is higher in accuracy. This study aims to compare the upper lip bite test with the modified Mallampati test in predicting difficult airway among obstetric patients. During this prospective observational study, 184 adult pregnant women, with ASA physical status of II, were enrolled. Difficult intubations of Cormack-Lehane grade III and IV were defined as difficult airways and difficult intubation in this study. Upper lip bite test, modified Mallampati test, thyromental distance and sternomental distance were noted for all patients. Modified Mallampati test, upper lip bite test and sternomental distance had highest specificity. Based on regression analysis, body mass index and Cormack-Lehane grade have a significant association. Modified Mallampati test was the most accurate test for predicting difficult airway. The best cut-off points of thyromental distance and sternomental distance in our study were 5cm and 15cm, respectively, by receiver operating characteristic curve analysis. Based on the results of the present study, it can be concluded that in the obstetric population, modified Mallampati test is practically the best test for predicting difficult airway. However, combining this test with upper lip bite test, thyromental distance and sternomental distance might result in better diagnostic accuracy.

Digital games and virtual reality applications in child abuse: A scoping review and conceptual framework.

Child abuse refers to any form of maltreatment, including physical abuse, sexual abuse, emotional abuse, and neglect that occurs to children under 18 years of age. Digital games and virtual reality (VR) can be used as beneficial solutions for dealing with child maltreatment concerns. This study aimed to present a conceptual framework for showing the applications of these technologies in managing child abuse. The framework is developed in two stages: (1) a scoping review to gather digital games and VR applications for child abuse issues through the search in PubMed, Ovid (APA PsycInfo), Scopus, Web of Science, ProQuest, Institute of Electrical and Electronics Engineers (IEEE), Cochrane Database of Systematic Reviews, and grey literature and (2) developing a conceptual framework based on the review results and validating it by 12 experts. The proposed conceptual framework shows that digital games and VR have been used for six main topics: (1) medical education, (2) prevention, (3) screening, (4) diagnosis, (5) treatment, and (6) forensic medicine in response to child abuse issues. Studies have more focused on child sexual abuse prevention, behavioral monitoring of sexual offenders in forensic medicine, and knowledge or performance assessment of students in medical education. Serious games (SGs), computer simulation, and immersive VR were common technologies for children, students, and forensic medicine, respectively. The experts believe the combination of immersive features of VR with SGs can further encourage user engagement. It appears that digital games and VR can play a positive role in child abuse management. Given the extensive capabilities of these technologies, further studies are needed to show all their potential applications for child abuse problems.

Cataract Grading in Pure Senile Cataracts: Pentacam versus LOCS III.

Purpose: To determine the diagnostic accuracy of Pentacam Cataract Grading Scale (PCGS) versus the Lens Opacities Classification System (LOCS III) in scaling pure age-related cataract. Methods: Between April 2016 and May 2017, eyes of 281 patients were evaluated for grading of lens opacity. We used LOCS III and PCGS. Patients with pure age-related cataract with no previous history of eye surgery, eye trauma, or chronic systemic disease between 50 and 95 years of age were included. The examination of the patients was done, using slit lamp and LOCS III grading chart. The second examination was done a week later, using Oculus Pentacam. Next, we graded them using a PNS grading score. Spearman's rank correlation and a Bland-Altman Plot were implemented for analysis using MedCalc 14. 8.1. P < O.05 was considered as statistically significant. Results: Three hundred eyes were examined. Of them, 189 patients were male, and patients between 70 to 80 years old were the most common group. The correlation between grades of two methods was 0.47 (P < 0.001). Results of the Bland-Altman plot showed a moderate alignment between the two methods. Conclusion: The association between LOCSIII and PCGS is not so favorable, however, it is an economical and effective method to assess lens opacities is LOCSIII. PCGS can be used in early diagnosis. For a definitive diagnosis and appropriate therapeutic intervention, an ophthalmological examination is needed.

Assessment of Social Trust in Relatives of Discharged Patients With Personal Consent and Other Relatives of Patients.

Lack of social trust in the physician-patient relationship will disrupt health. Since social trust has not been sufficiently studied in patients' companions, this study investigates and compares social trust and its dimensions in companions of patients discharged against medical advice with total patients' companions in the emergency room. In this cross-sectional descriptive-comparative study, 385 patients' companions were enrolled. This study was done by a questionnaire with five subscales: honesty, frankness, cooperative tendency, confidence, and trust. Data were analyzed using descriptive statistics and analytical statistics methods. In this study, there was no significant difference between the mean score of social trust between companions of patients discharged against medical advice (61.11 ± 9.01) and patients discharged after treatment (62.27 ± 6.97). There was a significant relationship between the mean score of the 2 groups only in the frankness domain (P-value = .001). The level of social trust in the patients' companions was moderate in both groups. Companions of discharged patients after completing the treatment process are more explicit than the companions of patients discharged against medical advice.

Association between nitrate concentration in drinking water and rate of colorectal cancer: a case study in northwestern Iran.

Nitrate, as a major pollutant of drinking water, is associated with colorectal cancer (CRC) and serves as an environmental health concern, especially in the districts with unregulated agriculture. In this case study in northwestern Iran, we used two databases of nitrate concentration (1999-2013) and age-standardized incidence rate (ASR) for CRC (2002-2012) from 19 counties of East Azerbaijan province. The trend and correlation between nitrate and ASR was investigated. Inverse distance weighted technique was used to spatially interpolate the maps. Expectedly, drinking water nitrate has increased throughout the province (8-20.5 mg/L) as well as the ASR for CRC of men (from 2.07 to 18.05 mg/L) and women (from 1.57 to 10.94 mg/L). While ASR for CRC of men was positively correlated to nitrate (Pearson's r = 0.624, p-value = 0.040), no statistically significant correlation was found between nitrate and ASR for women's CRC (Pearson's r = 0.289, p-value = 0.351). According to our findings, the incidence of CRC was not higher for those residing in the regions with higher nitrate, suggesting that risk factors such as genetic predisposition and diet that were not taken into account could be determinants of this pattern. However, even a small increase in CRC rate due to water nitrate could translate into a large public health concern. The incremental pattern observed in nitrate levels of different counties over the years gives the health policymakers a better perspective of the problem and how the control of water nitrate level as a CRC risk factor might contribute to the prevention of CRC.

Acute responses of airway oxidative stress, inflammation, and hemodynamic markers to ambient PM2.5 and their trace metal contents among healthy adolescences: A panel study in highly polluted versus low polluted regions.

Particulate air pollutants are known contributors to global cardiorespiratory mortality through several pathways. We examined the effects of varied exposure to PM2.5 and trace metals on biological markers of airway inflammation, oxidative stress, and hemodynamic function of young individuals living in two different exposure settings. We enrolled and followed a panel of 97 healthy nonsmoking participants aged 15-18 years living in a highly polluted metropolitan city of Tabriz (TBZ) and a much less polluted semi-urban town of Hadishahr (HDS). For five consecutive months, the subjects were examined by a physician, and fractional exhaled nitric oxide levels (FENO) were measured. Samples of exhaled breath condensation (EBC) were obtained for measuring interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), and total nitric oxide (NOx). We measured daily outdoor PM2.5 mass concentration in a fixed station in each location for all this period. The PM-metal content was analyzed by ICP-MS. The linear mixed-effects regression models were applied for data analysis. The averages of PM2.5 mass and total metals in TBZ were nearly two and four times higher than in HDS, respectively. In TBZ, an increased IQR of PM2.5 mass during 0-5 days was -correlated with a significant rise in diastolic blood pressure, heart rate, TNF-α, FENO, and NOx and reduction of IL-6. Moreover, exposure to low PM2.5 concentration is significantly -correlated with an elevation in diastolic blood pressure in HDS. We also observed that exposure to metal constituents in the highly polluted region is correlated with increased TNF-α and IL-6 with 131.80% (95% CI: 56.01, 244.39) and 47.51% (95% CI: 33.01, 62.05) per IQR of Hg, respectively. This study suggests that exposure to ambient PM2.5 and their metal contents in highly polluted areas may incite significant changes in airway inflammation, oxidative stress, and hemodynamic parameters in healthy subjects.

Effectiveness of extracorporeal shock wave therapy versus standard care in the treatment of neck and upper back myofascial pain: a single blinded randomised clinical trial.

OBJECTIVES: To compare the efficacy of extracorporeal shock wave therapy versus standard care (ultrasound + hot pack + self-stretch-exercises) in treatment of neck and upper back myofascial pain syndrome. DESIGN: Single-blind randomised clinical trial. SETTING: Outpatients setting. SUBJECTS: Patients with neck and upper back myofascial pain. INTERVENTION: Participants were randomly allocated into shock wave group (n = 24), standard care (ultrasound + hot pack + self-stretch-exercises) group (n = 24) and control (self-stretch-exercises) group (n = 24) for four weeks. MAIN MEASURES: The primary outcomes were pain intensity (visual analogue scale), pain pressure threshold (algometer) and disability (neck disability index). Measures were performed at baseline (week 0), week 1 and post-intervention (week 4). RESULTS: Shock wave and ultrasound improved visual analogue scale (7.50 ± 1.71 to 5.72 ± 2.20 and 6.22 ± 2.54 to 4.95 ± 2.86, respectively, P = 0.083) and disability index (54.24 ± 15.53 to 39.04 ± 19.58 50.23 ± 19.57 to 32.10 ± 18.34, respectively, P = 0.495) similarly at first week examinations that were significantly higher than control (P < 0.05). In week 4 measurements, additional improvements were achieved concerning visual analogue scale and disability index in the shock wave (-4.00 ± 2.22 and -20.24 ± 16.56, respectively) and ultrasound (-2.18 ± 2.71 and -21.79 ± 10.56, respectively) groups. However, visual analogue scale improved more significantly in shock wave group than ultrasound group in fourth week measurements (P = 0.012). CONCLUSION: Extracorporeal shock wave therapy was more effective in controlling of the pain intensity compared to ultrasound one month after treatment. However it had no superiority over ultrasound in improving neck disability index at this time point.Trial registrationwww.irct.ir, IRCT201608154104N5, registered 2016-09-25.

Diagnostic and prognostic role of ascitic fluid calprotectin level: six-month outcome findings in cirrhotic patients.

AIM: To assess the role of ascites calprotectin in early detection of SBP in patients with cirrhosis and to investigate its prognostic value in determination of the 6-month outcome. Methods and material: In this cross-sectional study, patients with liver cirrhosis who were consecutively referred to Imam Reza hospital, tertiary referral center in the northwest of Iran, underwent abdominal paracentesis. The samples were collected for measurement of calprotectin, albumin, total protein, WBCs, and PMNs. RESULTS: The mean age of a total of 87 included patients was 56.86 (SD 16.05) years old with over half of the subjects (55.2%) being female. About 28.7% of performed paracenteses tested positive for SBP. Ascitic calprotectin was positively correlated to the PMN counts. Patients with SBP were found to have higher levels of ascites albumin, total protein, and calprotectin. Only 51 individuals survived the 6-month follow-up period and mortality outcomes were significantly related to the levels of aforementioned biochemical markers (p-value <.05). CONCLUSION: Alongside with standard PMN counts, calprotectin measurement in the ascitic fluid could be used as an available test for early diagnosis of SBP. Calprotectin can also serve as a valuable prognostic marker in the evaluation of cirrhotic patients.

The predictive value of red cell distribution width for stroke severity and outcome.

OBJECTIVES: In the present study, we sought to investigate the association between red cell distribution width (RDW) and stroke severity and outcome in patients who underwent anti-thrombolytic therapy with tissue plasminogen activator (tPA). RESULTS: In this prospective study, 282 stroke patients who underwent tPA injection were included. The categorization of RDW to < 12.9% and > 13% values revealed insignificant difference in stroke severity score, accounting for the mean 36-h NIHSS of 8.19 ± 8.2 in normal RDW values and 9.94 ± 8.28in higher RDW group (p = 0.64). In seventh day, NIHSS was 6.46 ± 7.28 in normal RDW group and was 8.52 ± 8.35 in increased RDW group (p = 0.058). Neither the 36-h, nor the seventh day and 3-month mRS demonstrated significant difference between those with normal and higher RDW values.

Diagnostic Value of Elastography, Strain Ratio, and Elasticity to B-Mode Ratio and Color Doppler Ultrasonography in Breast Lesions.

PURPOSE: The aim of this study was to investigate the sensitivity, specificity, and diagnostic accuracy of sonoelastography (SE), strain ratio (SR), elasticity to B-mode (E/B) ratio, and color Doppler ultrasonography (US) in suspected breast lesions. MATERIALS AND METHODS: This prospective study was conducted on women referred to Alzahra university hospital of Tabriz for annual screening of breast cancer between May 2017 and December 2018. B-mode US, SE, and color Doppler imaging were conducted in females with suspected mammography reports. The lesions in B-mode were classified according to the Breast Imaging Reporting and Data System (B-RADS). The results of SE imaging were graded based on five-grade SE score. SR and E/B ratio of each lesion were also analyzed in SE images. Color Doppler findings were categorized from 0 (no visible vessel) to 2 (> two vessels) based on the vascularity of the tumor. Pathology results were used as the gold standard to measure the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and diagnostic accuracy of each modality. RESULTS: One-hundred and ten breast lesions of 104 women aged 42.05±10.33 years were included in the study. Seventy-seven of the lesions were benign and 3 were malignant. Sensitivity and specificity of 97.0% and 77.9% for B-mode US, 93.9% and 87.0% for SE score, 81.8% and 66.2% for color Doppler US, 72.7% and 77.6% for E/B ratio (cutoff: 1.05), and 77.3% and 79.6% for SR (cutoff: 1.90) were obtained, respectively. Addition of SE score to B-mode US increased the sensitivity to 93.9%, specificity to 93.5%, and AUC from 0.95 to 0.97. Cumulative color Doppler US with B-mode US did not enhance the diagnostic accuracy of B-mode US. CONCLUSION: SE was more effective than color Doppler US for distinguishing malignant from benign breast lesion. Among the three different SE features, five-grade SE score was superior to E/B ratio and SR.

Asymmetry of Height and Width of Ethmoid Sinus and Its Association with Chronic Sinusitis: A Cross Sectional Study.

BACKGROUND: In this study, we aimed to investigate the association between chronic anterior sinusitis with the width and height of ethmoid sinus and also assess the ethmoid length and roof asymmetry in the Iranian adult population. Material and Methods: This cross-sectional study was carried out on 422 patients who were referred with clinical signs of rhinosinusitis to the ENT Center of Tabriz University of Medical Sciences. Study participants were divided into healthy and sinusitis groups based on the level of sinus involvement. Computed tomography images were applied to calculate ethmoid height and width. A paired t-test was used to assess the roof and width asymmetry and an independent t-test was used to investigate the association between ethmoid height and width with the incidence of rhinosinusitis. RESULTS: The mean age of sinusitis and healthy groups was 42.5±18.9 and 38.4±17.1 years, respectively. Of a total 422 subjects, 63.4% of whom were men. The overall prevalence of rhinosinusitis was 28.0%. We observed a statistically significant difference in terms of ethmoid height, and in both healthy and sinusitis group right ethmoid roof was statistically lower (P<0.05). However, no statistical difference was observed between the left and right side regarding the ethmoid sinus width (P>0.05). We also estimated correlation coefficients for rhinosinusitis score and ethmoid sinus height and width, which were not statistically significant (P>0.05). CONCLUSION: Our study shows that the right side of the ethmoid roof was lower in comparison to the left side, and it should be fully understood and regarded in rhino sinus surgery. We also observed no association between sinusitis score and height and width of the ethmoid sinus.

In-hospital outcome of patients with post-MI VSD: a single-center study.

INTRODUCTION: Ventricular septal defect (VSD) is a rare but life-threatening complication of acute myocardial infarction (AMI). There is a paucity of data regarding the natural history of this devastating complication of myocardial infarction in the Middle East region with restricted financial resources and unsolved major health problems. AIM: To evaluate the clinical presentation and in-hospital outcome of patients with post-infarction VSD over a 10-year period in a tertiary center in northwest Iran. MATERIAL AND METHODS: Data from 64 consecutive patients with VSD complicating AMI were retrospectively analyzed from March 2005 to May 2015. RESULTS: The mean age of the patients was 71.62 ±9.38 years with 57.8% of them being female. The VSDs were anterior in 52 (82%) patients. More than half of patients were in cardiogenic shock during the initial presentation. Multivessel coronary artery disease was found on coronary angiography in 70.3% of patients. In-hospital mortality was 82.8%. Multivariate analysis revealed cardiogenic shock (HR = 12.5, p = 0.001) as the only independent predictor of in-hospital mortality and surgical treatment as the only predictor of in-hospital survival (HR = 0.2, p = 0.02). CONCLUSIONS: Our study demonstrated that VSD complicating myocardial infarction had an extremely high in-hospital mortality rate. Cardiogenic shock was the only independent predictor of in-hospital mortality and surgical treatment was the only predictor of in-hospital survival.

Lactobacillus intake for 60 days favors antioxidant status of human breast milk: an RCT.

BACKGROUND AND OBJECTIVES: This study aimed to evaluate the effects of lactobacillus supplementation on trends of breast milk antioxidant parameters. METHODS AND STUDY DESIGN: In an interventional study, 50 lactating women were randomly allocated to receive a daily supplement of lactobacillus (n=25) or a placebo (n=25) for 60 days. Daily dietary intake, anthropometric measures and breast milk antioxidant parameters were determined at the onset, and days 30 and 60 of the study. Repeated-measures ANOVA were performed to assess the change over time in the anthropometric and biochemical parameters between the two groups. The main effect of treatment was compared by using Bonferroni's procedure for CI adjustment. The significance level was set at p<0.05. RESULTS: There was a significant increase in breast milk total antioxidant capacity (TAC) between onset of study and day 30 (p=0.01) and day 60 (p=0.001) after lactobacillus supplementation; however, breast milk TAC level did not change significantly between days 30 and 60 (p=0.7). In the placebo group, breast milk TAC levels decreased significantly after 60 days (p=0.001). Breast milk malondialdehyde (MDA) levels decreased progressively during the study in the lactobacillus group (p=0.001); however, there was a significant increase in MDA with time in breast milk samples in the placebo group (p=0.015). CONCLUSIONS: Based on the findings, lactobacillus supplementation for 60 days could significantly increase breast milk TAC and decrease breast milk MDA levels, compared with baseline; however, further studies are needed to confirm these results.

Congenital anomalies and termination of pregnancy in Iran.

The aim of this study was to document some epidemiological features of termination of pregnancy for birth defects in Iran. We studied 603 pregnant women who were diagnosed/recommended for the termination of pregnancy as having a fetus with some types of birth defect(s). Most women (87.2 percent) had at least one ultrasound examination. The proportion of other screening tests including amniocentesis and genetic tests were 2.8 and 4.6 percent, respectively. Of 603 women, 201 terminated the pregnancy giving a prevalence rate of 33.3 percent (CI 95%: 29.6-37.6). The remaining 402 subjects were unable to get the permission for abortion because of untimely diagnosis/application for termination (20th week of pregnancy and/or later). Forty-eight percent of termination of pregnancies was performed before the 18th week of pregnancy. Neural tube defects, limb deformation, hydrops fetalis, hydrocephaly, and chromosomal anomalies including Down syndrome accounted proportionally for about 65 percent of defects eligible for abortion in the region. Although the rate of termination of pregnancy for birth defects is acceptable at the current situation in the country, more efforts should still be made to convince the community authorities to give more possibility and ease for the termination of pregnancy for congenital anomalies.

Folic acid and birth defects: a case study (Iran).

The aim of this study was to evaluate the impact of folic acid use in pregnancy for the reduction of neural tube defects (NTDs) in the northwest region of Iran. We studied 243 women with pregnancies complicated by some forms of birth defect(s). These patients were identified by medical diagnostic tests as having a fetus with some types of congenital anomalies. The prevalence of NTDs among pregnant women who were referred for therapeutic termination of pregnancy was 24.7 percent. Consumption of folic acid prevented NTDs by 79 percent (Odds Ratio = 0.21, CI 95%: 0.12-0.40) and 94 percent (Odds Ratio = 0.06, CI 95%: 0.03-0.15) compared to pregnancies complicated by other anomalies and normal pregnancies, respectively. Hydrops fetalis, hydrocephaly, Down syndrome, and limb anomalies did not have any significant association with the folic acid use. Along with the advice for the consumption of folic acid for pregnant women, they should be offered prenatal screening or diagnostic tests to identify fetal abnormalities for possible termination of pregnancy.