The effects of mobile apps on stress, anxiety, and depression: overview of systematic reviews.

OBJECTIVES: Despite a large number of mobile apps in the field of mental health, it is difficult to find a useful and reliable one, mainly due to the fact that the effectiveness of many apps has not been assessed scientifically. The present study aimed to assess the effects of mental health apps on managing the symptoms of stress, anxiety, and depression. METHODS: A comprehensive literature search was conducted in PubMed, Scopus, EMBASE, Cochrane, and Web of Science databases for the papers published from 2000 to 2019. Studies were included if they reviewed articles or mobile apps for their effectiveness in stress, anxiety, and depression. The reviews that had considered mobile apps or web-based mobile applications as an intervention or part of intervention were included, as well. RESULTS: A total of 4,999 peer-reviewed articles were identified, out of which nine systematic reviews met the inclusion criteria. Seven systematic reviews measured depression outcomes, three measured stress, and five systematic reviews measured anxiety symptoms. The applications that used behavior change strategies, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and Behavioral Activation, reported significant effects on depression, anxiety, and stress. CONCLUSION: It seems that mental health apps can be promising media for reducing depressive symptoms. This field is an emerging area of mobile health, and further research should be done in future in order to reach conclusive evidence.

Moving toward community based telehealth services using mhealth for hypertensive patients.

BACKGROUND: Although self-care can control and prevent complications in hypertensive patients, self-care adherence is relatively low among these patients. Community-based telehealth services through mhealth can be an effective solution. OBJECTIVE: This study aimed to evaluate the effect and acceptance of an mhealth application as a community-based telehealth intervention on self-care behavior adherence. METHOD: This clinical trial included sixty hypertensive patients and their matched controls from two heart clinics affiliated to Shiraz University of Medical Sciences (SUMS). Self-care behaviors were assessed using Hill-Bone questionnaire before and after the intervention. Acceptability was evaluated in the intervention group at the end of the study period. The data were analyzed via SPSS 18 software using descriptive and inferential statistics. RESULT: The results showed a significant difference between the intervention and control groups regarding the mean score of self-care behaviors (4.13 ± 0.23 versus 3.18 ± 0.27, p < .001). Additionally, a significant difference was observed between the two groups concerning the mean scores of the two subscales of self-care behaviors, including "medication taking" and "proper diet". However, no significant difference was observed between the two groups regarding the mean score of "appointment keeping" (p = .075). Overall, the intervention group participants were satisfied (4.27 ± 0.34) with this approach for managing hypertension. CONCLUSION: Community-based telehealth services through mhealth had the potential to improve self-care behaviors in hypertensive patients and seemed to be accepted by the patients in the intervention group.

Modeling of carbon dioxide absorption into aqueous alkanolamines using machine learning and response surface methodology.

This research focuses on modeling CO2 absorption into alkanolamine solvents using multilayer perceptron (MLP), radial basis function network (RBF), Support Vector Machine (SVM), networks, and response surface methodology (RSM). The parameters, including solvent density, mass fraction, temperature, liquid phase equilibrium constant, CO2 loading, and partial pressure of CO2, were used as input factors in the models. In addition, the value of CO2 mass flux was considered as output in the models. Trainlm, trainbr, and trainscg algorithms trained the networks. The results showed that the best number of neurons for MLP with one layer is 16; with two layers, 5 neurons in the first layer and 12 neurons in the second layer; and with three layers, 9 neurons in the first layer, 5 neurons in the second layer, and 1 neuron in the third layer. The best spread in RBF was found to be 2.202 for optimal network performance. Furthermore, statistical data analysis revealed that the trainlm function performs best. The coefficients of determination for RSM, MLP, RBF, and SVM for optimized structures are obtained at 0.9802, 0.9996, 0.9940, and 0.8946, respectively. The results demonstrate that MLP and RBF networks can model CO2 absorption using the trainlm, trainbr, and trainscg algorithms.

Improving adsorption performance of L-ascorbic acid from aqueous solution using magnetic rice husk as an adsorbent: experimental and RSM modeling.

In this research, rice husk (RH) was utilized to prepare a magnetic adsorbent for adsorption of ascorbic acid (AA). The magnetic agent is iron(III) chloride (FeCl3). The impact of acid concentration in the range of 400-800 ppm, adsorbent dosage in the range of 0.5-1 g, and contact time in the range of 10-130 min were studied. The Langmuir model had the highest R2 of 0.9982, 0.9996, and 0.9985 at the temperature of 15, 25, and 35 °C, respectively, and the qmax values in these temperatures have been calculated at 19.157, 31.34, and 38.75 mg/g, respectively. The pseudo-second-order kinetic model had the best agreement with the experimental results. In this kinetic model, the values of q have been measured at 36.496, 45.248, and 49.019 mg/g at the acid concentration of 418, 600, and 718 ppm, respectively. The values of ΔHo and ΔSo were measured 31.972 kJ/mol and 120.253 kJ/mol K, respectively, which proves the endothermic and irregularity nature of the adsorption of AA. Besides, the optimum conditions of the design-expert software have been obtained 486.929 ppm of acid concentration, 0.875 g of the adsorbent dosage, and 105.397 min of the contact time, and the adsorption efficiency in these conditions was determined at 92.94%. The surface area of the RH and modified RH was determined of 98.17 and 120.23 m2/g, respectively, which confirms the high surface area of these two adsorbents.

Iranian University students' stressors and coping strategies: A qualitative study.

BACKGROUND: Although a certain amount of stress is essential, excessive stress can adversely influence the physiological and mental health. Hence, this study aims to assess common stressors and coping strategies among university students. MATERIALS AND METHODS: This qualitative study was conducted from October to November 2019 in Iran. Twelve students were recruited based on purposeful sampling to participate focus group discussions (FGD). Transcripts of three sessions of FGD were analyzed applying Graneheim and Lundman (2004) approach, and a thematic network was applied to illustrate the findings. RESULTS: The finding emerged 78 codes, 14 subthemes, and 4 main themes. Stressors were classified in two main themes, including individual stressors and the social ones. Behavioral strategies and the cognitive ones were among two categories of coping strategies. According to the thematic network, a full stress student affecting the precious stressors and the social, cultural, and the economic context may manage his/her stress applying the coping strategies. CONCLUSION: The findings revealed that university students experienced different kinds of stress, and usually, they do not apply right coping strategies. It is important to establish stress counseling programs for university students. Besides, it is proposing to provide 1st year university students with workshops about the cause of stress and effective coping strategies.

Web-based health Information Seeking and eHealth Literacy among College students. A Self-report study.

OBJECTIVES: This study aimed to assess web-based health information seeking and eHealth literacy among Iranian college students. METHODS: The study was conducted in five colleges of the Shiraz University of Medical Sciences in Iran during 2018. The data were collected by a researcher-made questionnaire consisting of seven questions on a 4-point Likert-type scale, with scores ranging from 7 to 28. These questions were: 'I know how to use the Internet to answer my questions about health', 'I think there is enough information about health-related issues on the Internet', 'I know the vocabulary used in health issues on the Internet', 'I can tell high-quality health resources from low-quality health resources on the Internet', 'I know how to use the health information I find on the Internet to help me', 'I feel confident in using information from the Internet to make health decisions', and 'Searching for health-related information on the Internet will increase my knowledge in this field'. High eHealth literacy level is defined as above the total mean score and low eHealth literacy level is defined as lower than the total mean score. RESULTS: In all, 386 college students participated in the study. The results showed that the mean score of eHealth literacy was 19.11 out of 28; 205 participants (54.4%) had low eHealth literacy. In addition, the students used the Internet to search for information regarding diseases symptoms (70%), physical illnesses (67.1%), existing treatments (65%), and diagnosis (63.1%). CONCLUSIONS: The results showed that participants in this study usually searched for illnesses, symptoms, and treatments after they got sick and paid little attention to other aspects related to integral health.

Efficacy of a web application for stress management among Iranian college students during COVID-19 outbreak: a study protocol for randomized controlled trials.

BACKGROUND: The prevalence of mental health disorders is increasing globally, and the prevalence of COVID-19 has made it worse. Evidence has indicated a major mental health burden and elevated anxiety associated with the new coronavirus outbreak in the general population. This study aims to evaluate an evidence-based web application (Naranj) for stress management among Iranian college students. METHODS AND DESIGN: This study aims to present a protocol related to a randomized controlled trial among Iranian college students. The study will be conducted on 100 students from two colleges of Shiraz University of Medical Sciences in Iran. The participants will be randomly assigned to the intervention and control groups. The intervention group participants will be provided with a web application, whereas the control group ones will be provided with an app unrelated to stress management. The primary outcome for this study will be the Perceived Stress Scale, and the two groups will be compared with respect to stress level and sleep quality. DISCUSSION: A web application will be developed according to psychological theories and will be scientifically approved for managing college students' stress and improving their sleep quality during the COVID-19 outbreak. TRIAL REGISTRATION: Iranian Registry of Clinical Trials IRCT20160427027647N2 . Registered on 14 May 2020.

Development and Pilot Testing of a Mobile Based Patient Decision Aid for Childbirth Decision Making.

INTRODUCTION: Patient Decision Aids (PtDA) facilitates Shared Medical Decision-Making (SDM). This study aims to facilitate the childbirth decision-making process by a decision aid mobile application. METHOD: The model development process for decision aids was used and a master group supervised it. The assessment of study was made by a face-to-face interview and prototype was also developed for it. Then Alpha test was performed with 10 pregnant women and 10 experts. 60 pregnant women and 9 clinical professionals participated in a beta test. RESULT: The modules of our PtDA consisted of health record, decision aid, educational content, frequently asked questions and help. The result of alpha test revealed that this system had high usability. After increasing intervention, the intervention group had more knowledge of women in comparison with the control group. Moreover, the reduction of decisional conflict in the intervention group was statistically significant compared with the control group. In addition, the preference for women was changed from cesarean section (CS) to vaginal delivery in the intervention group. In the beta test, the result of the ultimate usability evaluation showed that this system was usable and easy. CONCLUSION: According to the results, it seems that PtDAs can be effective for empowering women in order to choose the mode of delivery.

Development and Usability Evaluation of Web-Based Telerehabilitation Platform for Patients After Myocardial Infarction.

INTRODUCTION: Cardiac rehabilitation (CR) is a multidisciplinary intervention that improves quality of life and reduces the risk of recurrent heart attack. Unlike all known benefits for CR, the patient participation in CR is low. Telerehabilitation has the potential to improve lifestyle and helps patients having long-term compliance with clinician advice. The objective of this study was the development of a web-based cardiac telerehabilitation platform to engage the post-myocardial infarction (MI) patients in self-management of disease. METHOD: Development process of creating and evaluating a telerehabilitation platform included four phases: (1) need assessment, (2) design the prototype, (3) implement the cardiac telerehabilitation platform, (4) usability evaluation. RESULT: Cardiac telerehabilitation platform consists of an Android-based application for patients and web-based dashboard for rehabilitation mentors. The modules of the application are daily self-assessment, weekly self-assessment, educational content, stress and sleep improvement skills, medication reminder, online chat, prescribed diet, prescribed physical activity and rehabilitation records. The self-assessment modules allow users to enter the data such as physical activity, diet, blood pressure, heart rate, and body weight. The patient data entries are interpreted in the system knowledge base and colored symbol feedbacks display for patients and mentors. In the dashboard, the mentors review the patient data entries and set the rehabilitation plan for next week. In a beta test of usability evaluation, the mean of SUS score for patients was 75.16, for clinicians was 73.33 and for medical informatics specialist was 72.33. These results showed that the usability of our system was at an acceptable level. CONCLUSION: The cardiac telerehabilitation platform is a convenient tool for post-MI patients who cannot attend at outpatient cardiac rehabilitation centers for any reason.

A Comprehensive Tool for Usability Evaluation of Telehealth.

INTRODUCTION: Telehealth has a high potential for delivering healthcare by overcoming the geographical distance, increased access to care, and efficiency. To obtain the potential benefits of telehealth, this system should be usable to the patients and healthcare providers. The aim of this study was to report a new comprehensive tool for assessing the usability of telehealth services and systems, covering different aspects of usability. METHOD: We searched the keywords, such as telemedicine, telehealth, usability, satisfaction, questionnaires, and evaluation in Google, Scopus, PubMed, and Google Scholar from 1988 to 2019. All the studies that used the Telehealth services and computer& information technology evaluation tools were included. RESULT: We identified 204 items and extracted 10 criteria that were classified into two categories. The first category is system usability, which includes Efficiency, Memorability, Learnability, Usefulness, and Satisfaction. Second category system reliability, included Interaction, Interface design, Saving, System capabilities, and Getting rid of Errors. This tool consider many aspects of telehealth service evaluation from the usability aspect. CONCLUSION: Further studies are warranted to evaluate other aspects of Telehealth services and measuring reliability so that researchers can have access to a comprehensive tool for assessing interventions in the field of Telemedicine and Telehealth.

Critical Appraisal of Mental Health Applications.

BACKGROUND: Using mobile applications in health is progressing rapidly; hence, assessing them is essential to ensure their quality and standards. The present study was designed to critically evaluate the quality of existing applications in the field of mental health. METHODS: In this is review the related keywords "Health and Mental health" were used in Persian and English to search in 4 application platforms: App Store, Google Play, Bazar (Persian version of Google Play), Sib app (Persian version of App Store). Inclusion criteria for the applications were either in Persian or English language and compatible with Android or IOS. The exclusion criteria were any application downloaded less than 100 times and those that were one dimensional such as only focusing on sleep disorder. A team of researchers reviewed each app in terms of two sets of criteria: 1) Mobile App Rating Scale (MARS) subdomain scores for reviewing engagement, functionality, esthetics, and information; and 2) personalization level. RESULT: The search resulted in 958 apps, of which 61 had the inclusion criteria. Most of them (n=59, 97%) were rated as appropriate for all age groups and only two were designed for children. In MARS score, thirty-three percent (n=5) of the Persian apps received the rating of 2.5 or higher, while this score was 53 percent (n=27) for English applications. Eight application (13%) used dialogue boxes for personalization and 11 (18%) had feedback capability. None of the Persian apps could be personalized. CONCLUSION: Although numerous apps are available, there are only few apps with personalization features, which should be considered as one of the key features when developing this type of apps.

Developing an Android-Based Patient Decision Aid Based on Ottawa Standards for Patients After Kidney Transplant and Its Usability Evaluation.

OBJECTIVES: This study was conducted to develop an android based patient decision aid (PDA) as a self-care instrument for patients after kidney transplant and its usability evaluation. METHODS: In this study, the systematic development process of Android-based self-care application for patients after kidney transplant based on Ottawa standard was included: scoping, assemble steering group, analysis of requirements, designing, develop of a prototype and system evaluation. The PDA is a self-triage system that will help early identification of risk symptoms in patients, and help manage them. System recommendations for risk signs are: Refer to the nearest hospital or healthcare center without delay, refer to the doctor and tell your doctor in the next visit. To identify patient care needs, a semi-structured interview with members of steering group, including patients and clinical experts, was conducted by the researchers. A prototype of the decision aid was made according to identified needs in the previous step. Finally, in order to evaluate its usability rate by using the System Usability Scale (SUS) questionnaire, it was used by exerts and patients. RESULTS: This study identified information needs, risk signs and steps that patients need to make appropriate decisions about them. The main capabilities of the decision aid are features such as reminders for appointment/test, time of taking medication, registration of symptoms, weight, blood pressure, body temperature, advising to patient in case of signs of risk, weight, blood pressure, body temperature and test results which were reported in the diagram. The mean score of system's usability evaluated by medical informatics specialists, clinicians, and patients were 88.33, 95, and 91. CONCLUSIONS: PDAs was usable and desirable from the point of view of medical informatics specialists, clinicians and patients.

Patient Decision Aid Systems: An Overview.

Patients often become confused when selecting a therapy. They usually decide not to participate in the selection process due to lack of information, having stress for making the wrong choice or the lack of effective communication with their physician. The aim of patient decision aids (PDAs) are to promote counseling between patients and healthcare providers on the available options as a tool to assist the decision making process. This paper, various PDAs definitions were investigated and their variation were discussed in different formats. Therefore, there are obstacles that are commonly found in patients' decision-making, which can be avoided through PDAs.

Web-based health Information Seeking and eHealth Literacy among College students. A Self-report study

Objective. This study aimed to assess web-based health information seeking and eHealth literacy among Iranian college students. Methods. The study was conducted in five colleges of the Shiraz University of Medical Sciences in Iran during 2018. The data were collected by a researcher-made questionnaire consisting of seven questions on a 4-point Likert-type scale, with scores ranging from 7 to 28. These questions were: 'I know how to use the Internet to answer my questions about health', 'I think there is enough information about health-related issues on the Internet', 'I know the vocabulary used in health issues on the Internet', 'I can tell high-quality health resources from low-quality health resources on the Internet', 'I know how to use the health information I find on the Internet to help me', 'I feel confident in using information from the Internet to make health decisions', and 'Searching for health-related information on the Internet will increase my knowledge in this field'. High eHealth literacy level is defined as above the total mean score and low eHealth literacy level is defined as lower than the total mean score. Results. In all, 386 college students participated in the study. The results showed that the mean score of eHealth literacy was 19.11 out of 28; 205 participants (54.4%) had low eHealth literacy. In addition, the students used the Internet to search for information regarding diseases symptoms (70%), physical illnesses (67.1%), existing treatments (65%), and diagnosis (63.1%). Conclusion. The results showed that participants in this study usually searched for illnesses, symptoms, and treatments after they got sick and paid little attention to other aspects related to integral health.

Objetivo. Evaluar la búsqueda de información de salud en línea y el nivel de alfabetización en eSalud entre los estudiantes universitarios iraníes. Métodos. El estudio se realizó en cinco colegios de la Universidad de Ciencias Médicas de Shiraz, Irán, durante 2018. Los datos se recopilaron con la ayuda de un cuestionario realizado por los investigadores que consta de 7 afirmaciones con opciones de respuesta tipo Likert de 4 puntos, con un rango de puntaje de 7-28 puntos: 1. "Sé cómo usar Internet para responder mis preguntas sobre salud"; 2. "Creo que hay suficiente información sobre problemas relacionados con la salud en Internet"; 3. "Conozco el vocabulario utilizado en temas de salud en Internet"; 4. "Puedo distinguir en Internet los recursos de salud de alta calidad de los que son de baja calidad"; 5. "Sé cómo usar la información de salud que encuentro en Internet para ayudarme"; 6. "Me siento seguro al usar la información de Internet para decisiones de salud", y 7. "Buscar en Internet información relacionada con la salud aumentará mi conocimiento en este campo". Se estableció que se tenía alfabetización en eSalud alta si el puntaje estaba por encima de la media total y alfabetización en eSalud baja si este puntaje era inferior a la puntuación media. Resultados. 386 estudiantes universitarios participaron en el estudio. La puntuación media de alfabetización en eSalud fue de 19,11 de los 28 puntos máximos posibles. 205 participantes (54.4%) tenían baja alfabetización en eSalud. Además, los estudiantes utilizaron Internet para buscar información sobre síntomas de enfermedades (70%), enfermedades físicas (67.1%), tratamientos existentes (65%) y diagnóstico (63.1%). Conclusión. Los resultados mostraron que los participantes de este estudio buscaban generalmente información en Internet acerca de enfermedades, síntomas y tratamientos después de enfermarse y prestaban poca atención a otros aspectos relacionados con la salud integral.

Objetivo. Este estudo teve como objetivo avaliar a busca de informações sobre saúde on-line e o nível de alfabetização em eSaúde entre estudantes universitários iranianos. Métodos. O estudo foi realizado em cinco faculdades da Universidade de Ciências Médicas de Shiraz, Irã, durante 2018. Os dados foram coletados com a ajuda de um questionário conduzido pelos pesquisadores, composto por 7 declarações com opções de resposta tipo Likert de 4 pontos, com uma faixa de pontuação de 7-28 pontos. Essas perguntas foram: 'Eu sei como usar a Internet para responder às minhas perguntas sobre saúde', 'Eu acho que há informações suficientes sobre problemas relacionados à saúde na Internet', 'Eu conheço o vocabulário usado nas questões de saúde na Internet', 'Eu posso distinguir em Recursos de saúde de alta qualidade na Internet que são de baixa qualidade ',' Eu sei como usar as informações de saúde encontradas na Internet para me ajudar ',' Sinto-me seguro ao usar informações da Internet para decisões de saúde 'e' A busca de informações relacionadas à saúde na Internet aumentará meu conhecimento neste campo '. Foi estabelecido que havia alta alfabetização em eSaúde se a pontuação estivesse acima da média total e baixa literacia em eSaúde se essa pontuação fosse menor que a média. Resultados 386 universitários participaram do estudo. A pontuação média em alfabetização em eSaúde foi 19,11 dos 28 pontos máximos possíveis. 205 participantes (54,4%) tinham baixa alfabetização em eSaúde. Além disso, os estudantes usaram a Internet para buscar informações sobre sintomas da doença (70%), doenças físicas (67,1%), tratamentos existentes (65%) e diagnóstico (63,1%). Conclusão. Os resultados mostraram que os participantes deste estudo geralmente buscavam informações na Internet sobre doenças, sintomas e tratamentos após adoecer e prestavam pouca atenção a outros aspectos relacionados à saúde integral.

The impact of a computerized decision aid on empowering pregnant women for choosing vaginal versus cesarean section delivery: study protocol for a randomized controlled trial.

BACKGROUND: Cesarean delivery on maternal request (CDMR) is one of the main reasons for cesarean delivery in Iran, and women often need help in making a decision about the delivery options available to them. The main objective of this study is to evaluate the effect of a computerized decision aid (CDA) system on empowering pregnant women in choosing an appropriate mode of delivery. This CDA contrasts the advantages and disadvantages of vaginal versus cesarean section delivery in terms of their value to the individual woman. METHODS/DESIGN: The protocol concerns a randomized trial study that will be performed among Iranian women. Four hundred pregnant women will be recruited from two private and two public prenatal centers in Mashhad, Iran. They will be randomly assigned to either an intervention or a control group. The designed CDA will be provided to the intervention group, whereas the control group will only receive routine care. The CDA provides educational contents as well as some recommendations. The CDA's knowledge base is obtained from the results of studies on predictors of cesarean delivery. The CDA's software will be installed on women's computers for use at home. The two primary outcomes for the study are O'Connor's Decisional Conflict Scale and knowledge as measured by true/false questions. Actual mode of delivery (vaginal versus cesarean) will be compared in the two groups. DISCUSSION: We investigate the effect of a CDA on empowering pregnant women in terms of reducing their decisional conflict as well as on improving their clinical knowledge pertaining to mode of delivery. TRIAL REGISTRATION: This trial is registered with the Iran Trial Registrar under registration number IRCT2015093010777N4 and registration date 26 October 2015.

The impact of computerized decision aid on mode of delivery - a study protocol.

The paper describes the design of computerized decision aid (DA) and a protocol for a cluster randomized controlled trial to study the effects of computerized DA on decisional conflict and knowledge of pregnant Iranian women pertaining to the mode of delivery: Caesarean section vs. vaginal delivery.

Web-site evaluation tools: a case study in reproductive health information.

BACKGROUND AND OBJECTIVE: Internet forms an opportunity to inform, teach, and connect professionals and patients. However, much information on Internet is incomplete, inaccurate, or misleading, and not only in the medical domain. Because of the potential for damage from misleading and inaccurate health information, many organizations and individuals have published or implemented scoring tools for evaluating the appropriateness or quality of these resources. The objective of this study is to identify and summarize scoring tools that have evaluated web-sites providing reproductive health information in order to compare them and recommend an overarching evaluation tool. METHODS: We searched Ovid MEDLINE(R) (1946 to July 2013) and OVID Embase (1980 to July 2013); and included English language studies that have evaluated the quality of websites providing reproductive health information. Studies only assessing the content of websites were excluded. RESULTS: We identified 5 scoring tools: 1-The HON (health on the net) Code of Conduct for medical and health Web sites, 2-Silberg scores, 3-Hogne Sandvik scale, 4-Jim Kapoun's Criteria for Evaluating Web Pages, and 5-The Health Information Technology Institute (HITI) criteria. We have compared these scales and identified 14 criteria: authorship, ownership, currency, objectivity/content, transparency/source, interactivity, privacy/ethics, financial disclosure, navigability/links, complementarity, advertising policy, design, quantity, and accessibility. We integrated these criteria and introduced a new tool with 10 criteria. CONCLUSION: Website evaluation tools differ in their evaluation criteria and there is a lack of consensus about which to use; therefore, an integrated easy to use set of criteria is needed.

Impact of computer-based pregnancy-induced hypertension and diabetes decision AIDS on empowering pregnant women.

OBJECTIVES: We designed a computer-based decision aid (CDA) for use by pregnant women at home to investigate and participate in solving their pregnancy problems related to pregnancy-induced hypertension (PIH) and gestational diabetes (GD). The system cannot and is not intended to replace visits to physicians; rather it can help women focus on the most important symptoms and provides guidance on when to see a doctor. METHODS: The study is a randomized controlled trial, which is performed among Iranian pregnant women. For subjects, 420 healthy pregnant women have been recruited from two private and two public prenatal centers. The intervention group will receive the CDA for use at home, and the control group will receive care as usual. The CDA relies on knowledge extracted from the national guidelines on PIH and GD. RESULTS: The two primary outcomes for the study are self-efficacy and knowledge. Self-efficacy will be measured by the Stanford self-efficacy scale and knowledge will be evaluated by 15 binary (true/false) questions provided by the researchers. Secondary outcomes include type and frequency of doctor and/or medical center visits; blood pressure and blood sugar changes based on the national guidelines and according to pregnancy records, and anxiety will be assessed by the state component of the short Spielberger anxiety scale. CONCLUSIONS: This paper describes the design of a CDA and a protocol for a randomized controlled trial to study the effects of the CDA on self-efficacy and knowledge of pregnant women pertaining to PIH and GD. Differences in the primary outcomes will be analyzed using 'intention-to-treat' principles.

Inter-observer and Intra-observer Agreement in Pathological Evaluation of Non-alcoholic Fatty Liver Disease Suspected Liver Biopsies.

BACKGROUND: Histopathologic assessment of liver tissue is an essential step in management and follow-up of non-alcoholic fatty liver disease (NAFLD) while inter- and intra-observer variations limit the accuracy of these assessments. OBJECTIVES: The aim of this study was to assess the inter- and intra-observer reproducibility of histopathologic assessment of liver biopsies based on NAFLD activity score (NAS) scoring system. MATERIALS AND METHODS: The anonymous liver biopsy samples of 100 consecutive NAFLD suspected adults were randomly assigned to four pathologists. Then, the samples were randomly reassigned to the pathologists for the second time in a way that each sample would be evaluated by two different pathologists. Biopsies were revisited by their first evaluator after two months. The results were reported based on NAS scoring system. RESULTS: Inter-observer agreement of the pathology scores based on NAS scoring system was acceptable for steatosis, lobular inflammation, and fibrosis, but not for hepatocyte ballooning. The intra-observer agreement was acceptable in all scales, with lowest intra-class correlation observed for lobular inflammation. CONCLUSIONS: NAS scoring system has good overall inter- and intra-observer agreement, but more attention should be given to defining the hepatocyte ballooning and lobular inflammation, and training the pathologists to improve the accuracy of pathology reports.