Medical Journal of the Islamic Republic of Iran最新文献

Background: The main advantage of tax-based financing is its sustainability, as well as the participation of all members of society, regardless of their health status, risk pooling, and the spread of risk among members of society. Therefore, the aim of the present study is a comprehensive review of sustainable tax-based financing strategies in the health system.

Methods: In this scoping review based on PRISMA-ScR guidelines, PubMed, Scopus, Web of Science, ProQuest, and Google Scholar were searched by the keywords of sustainable financing and tax-based financing in the healthcare system without time limitation in August 2024. Finally, the thematic content analysis method was used to extract the strategies of sustainable tax-based financing in MS Word 2016.

Results: The initial search in the selected databases retrieved 10083 records, of which 24 ones from them were related to the research aim. Most of the reviewed studies were performed in 2018 (16%) in the USA (18%) with a literature review method (38%). The main strategies for sustainable tax-based financing in healthcare systems include direct and indirect taxes.

Conclusion: The results showed that income tax and direct taxes are more progressive than taxes on consumer goods and services and indirect taxes in general. It is necessary for each country to consider sustainable tax-based financing solutions for its health system. Using the combined methods of receiving direct and indirect taxes can be another key solution in this regard.

Background: Increased protein intake is recommended for critically ill patients to prevent muscle breakdown and weakness. In this study, researchers compared protein delivery and muscle loss in mechanically ventilated intensive care unit (ICU) patients receiving high-protein enteral nutrition with those receiving standard care.

Methods: This was a randomized, open-label, controlled clinical trial conducted at a mixed medical-surgical ICU. Mechanically ventilated adult patients (age ≥18 years) who required enteral nutrition (EN) for at least 72 hours were randomized to receive either the intervention (target protein delivery of 1.5 g/kg per day) or standard care (provide 1.0 g/kg/day protein). Ultrasonography measured the muscle thickness of the biceps brachii for assessment at baseline and days 3, 6, 9, 12, 15, 18, and 21 after randomization. Adequacy of nutritional support was determined by measuring nitrogen balance (NB) at days 3 and 5 after the intervention. Descriptive statistics were used to summarize patient characteristics, and baseline demographic and clinical data were compared between groups using chi-square tests and independent samples t tests. Generalized estimating equations (GEE) were employed to analyze longitudinal data, assessing the effects of time, treatment group, and diabetes mellitus on muscle outcomes, while addressing missing data with the Last Observation Carried Forward method. The primary outcomes, changes in muscle mass and mid-upper arm circumference, were compared between treatment groups using independent samples t tests and further evaluated with analysis of covariance models adjusted for covariates.

Results: A total of 100 patients were studied in high protein (n = 50) and low protein (n = 50) groups. The mean muscle loss in the high-protein group [mean, -0.06 [95% CI, -0.09 to -0.02)] was significantly lower than the low-protein group [mean, -0.27 [95% CI, -0.34 to -0.22)] (P < 0.001). Patients in the high-protein group exhibited significantly higher nitrogen balance values compared to those in the low-protein group on day 3 (P < 0.001) and day 5 (P < 0.001).

Conclusion: This study showed that high-protein EN might have positive effects to attenuate the muscle loss and improve the nutritional status of mechanically ventilated ICU admitted patients.

Background: The Social Vulnerability Index (SVI) is a practical metric that operationalizes the social determinants of health. This study aimed to develop a composite SVI for Iran and to measure the social vulnerability status across its provinces.

Methods: This ecological study utilized a composite indicator construction method to create a social vulnerability index for the provinces of Iran. Relevant indicators for the social vulnerability index were selected through the Delphi method. Factor analysis was employed to validate the index construction and select appropriate indicators and dimensions. Varimax rotation was used to rotate the indicators, and Principal Component Analysis was conducted for indicator extraction. The data were standardized using the Z-score method and aggregated through a linear aggregation technique. Weighting was performed based on the squared factor loadings, and sensitivity analysis was conducted to assess the robustness of the index.

Results: Based on the research findings, the SVI, tailored to the context and structure of Iranian society, comprises 17 indicators categorized into five dimensions. These dimensions include lack of social insurance and low education, household poverty and disability, household structure and population dependency, economic vulnerability, and unemployment and housing vulnerability. The spatial distribution map of social vulnerability across Iran's provinces reveals that Sistan and Baluchistan (2.40) is the most socially vulnerable province, followed by North Khorasan (1.68) and Golestan (1.62). Overall, peripheral and border provinces exhibit higher levels of social vulnerability compared to the central provinces. Among all provinces, Yazd (0.01) demonstrates the lowest level of social vulnerability.

Conclusion: The composite social vulnerability index for Iran's provinces can serve as a key tool for evidence-based and equitable policy-making and planning in the health sector. By identifying vulnerable provinces, this index can support prevention efforts and facilitate appropriate responses during disease outbreaks and other health emergencies.

Background: Motor skills are crucial predictors of academic achievement in preschool children; effective motor skill interventions require assessment tools to evaluate motor performance and intervention efficacy. This study aimed to evaluate motor skill assessment tools in terms of their domains and psychometric properties to determine and understand the effect of motor ability on academic performance.

Methods: A comprehensive electronic search was performed in PubMed, Scopus, ProQuest databases, and Google Scholar motor engine between January 2013 and May 2025 for all accessible articles involving the application of standardized, psychometrically sound motor proficiency skill tools.

Results: A total of eight motor proficiency assessment tools were identified. The MABC-2 and BOT-2 were the most commonly used for predicting academic performance. The psychometric properties and applications of all tools were appraised and compared.

Conclusion: Applying these standardized and psychometrically sound tools provides crucial insights into the link between motor competence and students' academic achievement, which has important implications for early identification, intervention, and educational practices.

Background: Total hip arthroplasty (THA) has changed significantly since its inception, with various bearing surfaces affecting clinical outcomes. This systematic review aimed to assess the functional results of various bearing surfaces in total hip arthroplasty using validated scoring systems.

Methods: This systematic review was carried out in accordance with PRISMA guidelines, and the protocol was registered in PROSPERO under CRD42025634591. Studies were included based on predefined criteria for population, intervention type, and reported clinical outcomes. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and SF-12 were analyzed closely.

Results: 18 clinical trials with a mean follow-up of 100.69 months were included. MoM implants showed superior HHS, WOMAC, and SF-12 scores compared to CoC, CoP, and MoP (P<0.001), suggesting better quality of life and improved functional outcomes. CoM showed slightly better WOMAC scores over MoM, but the difference was not statistically significant. The most common reason for revision was dislocation (36 cases), while osteolysis was the most common complication (43 cases).

Conclusion: MoM implants demonstrated better quality of life and functional outcomes, but their use has declined due to safety concerns. Other implants may reduce complications related to metal ion release. These findings help surgeons choose THA implants by weighing benefits against long-term risks. Further research is necessary to refine implant selection criteria and long-term performance.

Background: Early detection of lymphatic metastasis (LNM) in gastric cancer (GC) is essential to determine the treatment strategy. Conventional methods exhibit limited efficacy, highlighting the need for more reliable approaches. Deep learning (DL) models show promise for LNM detection in computed tomography (CT); their performance requires comprehensive evaluation. This systematic review and meta-analysis evaluate the diagnostic performance of CT-based DL models for detecting LNM in GC patients.

Methods: A systematic review and meta-analysis was conducted according to PRISMA-DTA guidelines. PubMed, Embase, and Web of Science were searched up to May 5, 2025. The focus was on studies that used DL models to detect LNM in CT in GC. Using a bivariate random effect model, Pooled estimates were calculated, heterogeneity and publication bias were assessed, and clinical utility was evaluated via Fagan plots and likelihood ratio matrices. Validation type, input data types, CT phases, segmentation techniques, and DL architectures stratified subgroup analyses. The quality was assessed with QUADAS-2.

Results: From the 14 included studies, 11 studies with 5296 patients were analyzed. In internal validation, DL feature-based models achieved a pooled area under the curve (AUC) of 0.91 (95% CI: 0.88-0.93), sensitivity of 0.86 (95% CI: 0.75-0.92), and specificity of 0.83 (95% CI: 0.67-0.92). Performance degraded in external validation, with specificity dropping to 0.59 (95% CI: 0.26-0.85). Models that integrated DL features with radiomics features showed similar overall performance but were noted to have a higher confirmatory power. In terms of clinical utility, although the models could significantly alter post-test probabilities, they ultimately lacked the certainty required to serve as standalone diagnostic tools.

Conclusion: CT-based DL models show high diagnostic accuracy but limited generalizability across external datasets, indicating overfitting. A key finding of this meta-analysis is that pervasive and asymmetric heterogeneity, particularly in specificity, suggests that technical standardization alone is insufficient. Integrating clinical variables reduces heterogeneity; however, prospective, multicenter studies are needed to further enhance reproducibility.

Background: Medication adherence in stroke patients remains a significant challenge, impacting treatment efficacy and patient outcomes. This study aimed to model the structural relationships predicting medication adherence based on social support and social health in stroke patients, focusing on the mediating roles of self-esteem and leisure time in Tehran.

Methods: This correlational study used structural equation modeling. The statistical population included all stroke patients referred to the Neurology Clinic of Firoozgar Hospital in Tehran in 2021. A sample of 255 participants was selected through a convenience sampling method. Participants completed questionnaires on medication adherence (Lin & et al, 2018), social support (Wax and Reader, 1986), self-esteem(Rosenberg, 1965), social health (Keyes, C. L., & Shapiro, A. D, 2004), and leisure time (Wang, 2019 ). Data were analyzed using Pearson correlation and structural equation modeling methods.

Results: The results indicate that SEM analysis demonstrated excellent model fit (χ²/df=2.91, CFI=0.97, RMSEA=0.062). Significant direct effects were found: social support → self-esteem (β=0.34, *P*<0.001), social health → medication adherence (β=0.45, *P*<0.001). Key indirect effects via mediators: social health → leisure time → adherence (β=0.15, *P*=0.001) and social support → self-esteem → adherence (β=0.15, *P*=0.001). All standardized coefficients (*P*<0.05) confirmed the hypothesized pathways.

Conclusion: The findings demonstrate that psychological factors significantly influence medication adherence and, ultimately, patient recovery. Strengthening social support, self-esteem, social health, and leisure time can enhance treatment outcomes and facilitate better management of stroke patients.

Background: Ensuring precise measurement of blood pressure (BP) is crucial for effectively diagnosing and treating hypertension in atrial fibrillation patients. However, the reliability and agreement between the two commonly utilized techniques, oscillometric and auscultatory methods, remain unclear in these individuals. This study seeks to bridge this gap by examining the consistency of BP measurements using these methods in atrial fibrillation patients.

Methods: This cross-sectional study included 100 patients with atrial fibrillation and sinus rhythm. BP was measured using both methods (three times with each method): 1) the auscultatory method based on Korotkoff sounds and 2) the oscillometric method. The SPSS version 25 software was used for data analysis. In all steps, P-values < 0.05 are considered significant.

Results: The mean systolic blood pressure (SBP) measured by the oscillometric method was 116.38±16.73 mmHg in the sinus group and 127.29±21.51 mmHg in the atrial fibrillation (AF) group. In contrast, the mean by the auscultatory method was 116.18 ±15.46 mmHg in the Sinus rhythm group and 131.07±23.72 mmHg in the AF group (respectively P=0.006, P<0.001). This study shows a significant difference in the SBP measured using the two methods in patients with AF (P=0.003). We also found that the significant difference between the two methods only applies to heart rates of 80 beats per minute and higher (P=0.017).

Conclusion: The findings of this study indicated that although there is a significant correlation between oscillometric and auscultatory methods for assessing blood pressure in patients with atrial fibrillation, a significant difference was observed in the measurement of systolic blood pressure.

Background: Spinal anesthesia is widely used in urological surgeries but is often associated with hemodynamic instability, insufficient sedation, and postoperative nausea and vomiting (PONV). While ketamine and tramadol have been employed as adjuncts, their comparative effects on perioperative parameters remain underexplored. This study aimed to compare the efficacy of intravenous ketamine and tramadol in modulating hemodynamic stability, sedation, pain, and PONV in patients undergoing urological surgery under spinal anesthesia.

Methods: In this triple-blind randomized clinical trial, 90 patients undergoing transurethral or ureteroscopic urological surgeries under spinal anesthesia were randomly allocated into 3 equal groups: ketamine (0.5 mg/kg IV), tramadol (0.5 mg/kg IV), or saline. Hemodynamic parameters, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and oxygen saturation (SpO₂), were recorded at multiple intraoperative and postoperative time points. Secondary outcomes included pain scores, sedation levels, and incidence of PONV. The data were entered into SPSS software, Version 21, and analyzed using the chi-square test, independent sample t-test, and repeated-measures analysis of variance with post-hoc Bonferroni tests.

Results: The study population exhibited demographic consistency. Ketamine demonstrated significantly superior hemodynamic stability compared to tramadol and saline, with less reduction in SBP, DBP, and MAP over time (MAP: P < 0.001, η² = 0.33). The heart rate was also more stable in the ketamine group (P < 0.001, η² = 0.11). The ketamine group showed the highest sedation scores (mean increase: -0.91, P ≤ 0.001) and the lowest incidence of PONV (3.3%) compared to tramadol (16.7%) and saline (10%) (P = 0.017, φ = 0.34). Pain scores showed no significant differences among groups. No serious adverse effects, including hallucinations or hypersensitivity reactions, were reported.

Conclusion: Intravenous ketamine significantly enhances hemodynamic stability, increases sedation, and reduces PONV when used as an adjunct to spinal anesthesia in urological surgeries. These findings support the clinical use of ketamine to optimize perioperative outcomes and patient safety. These findings possess external validity and may be extrapolated to broader populations undergoing urological procedures under spinal anesthesia.

Background: Fractionated gamma knife surgery (f-GKS) is an effective and safe procedure for treating various intracranial lesions, including pituitary adenomas and meningiomas. It offers noninvasive treatment with short hospitalization periods. This study aims to assess the long-term outcomes of f-GKS in patients at the Iran Gamma Knife Center (IGKC).

Methods: This cross-sectional study examined patients who underwent at least 2 GKS sessions between 2011 and 2018. Lesion sizes in 2-dimensional slices were compared before and after the procedure. Data were analyzed using descriptive statistics in SPSS software Version 22.

Results: The study included 106 patients (32 male, 74 female), with a mean age of 49.95 ± 16.6 years. The follow-up period was 24.98 ± 19.01 months. The most common pathology was meningioma, with f-GKS typically performed 3 times at 1-day intervals. The median change in lesion area was 185.67 mm². Out of 36 patients at the last visit, 26 (72.2%) showed improved prognosis. The maximum radiation dose used was 13.05 ± 5.21 Gy. The pathology coverage was 98.69% ± 2.15%, with a mean and mode of 99%.

Conclusion: In this study, we examined various factors, including lesion levels from brain Magnetic Resonance Imaging findings, patient prognosis, and changes after f-GKS. Our results confirm those of previous studies, highlighting the significant role of noninvasive GKS in improving patient prognosis and reducing tumor size.