mHOMR: a feasibility study of an automated system for identifying inpatients having an elevated risk of 1-year mortality.

OBJECTIVE: The need for clinical staff to reliably identify patients with a shortened life expectancy is an obstacle to improving palliative and end-of-life care. We developed and evaluated the feasibility of an automated tool to identify patients with a high risk of death in the next year to prompt treating physicians to consider a palliative approach and reduce the identification burden faced by clinical staff. METHODS: Two-phase feasibility study conducted at two quaternary healthcare facilities in Toronto, Canada. We modified the Hospitalised-patient One-year Mortality Risk (HOMR) score, which identifies patients having an elevated 1-year mortality risk, to use only data available at the time of admission. An application prompted the admitting team when patients had an elevated mortality risk and suggested a palliative approach. The incidences of goals of care discussions and/or palliative care consultation were abstracted from medical records. RESULTS: Our model (C-statistic=0.89) was found to be similarly accurate to the original HOMR score and identified 15.8% and 12.2% of admitted patients at Sites 1 and 2, respectively. Of 400 patients included, the most common indications for admission included a frailty condition (219, 55%), chronic organ failure (91, 23%) and cancer (78, 20%). At Site 1 (integrated notification), patients with the notification were significantly more likely to have a discussion about goals of care and/or palliative care consultation (35% vs 20%, p = 0.016). At Site 2 (electronic mail), there was no significant difference (45% vs 53%, p = 0.322). CONCLUSIONS: Our application is an accurate, feasible and timely identification tool for patients at elevated risk of death in the next year and may be effective for improving palliative and end-of-life care.

Influence of the construction of porous spargers on lovastatin production by Aspergillus terreus ATCC 20,542 in a laboratory bubble column.

In bubble column bioreactors, the hydrodynamic behavior like mixing time, bubble size and morphology of filamentous fungi are influenced by the construction of spargers. Sparger pore size is an important factor influencing formation of bubbles. In this study for the first time, a 5-L bubble column bioreactor with different porous spargers was used to investigate the effect of mean air bubble diameter (at 0.36, 0.18 and 0.09 cm) on fungal growth, broth viscosity, fungal pellet morphology and lovastatin production by the filamentous fungus Aspergillus terreus. All cultivations were carried out at air flow rate equal to 0.5 Lair L-1 min-1. The viscosity of the broth was influenced by both biomass concentration and size of the fungal pellets. The highest values of viscosity were observed at bubbles of 0.09 cm diameter after 192 h of cultivation. The largest fluffy pellets and the highest yield of lovastatin (443 mg/L) were obtained at air bubbles diameter of 0.18 cm. Lovastatin yield on biomass growth in this condition was, respectively, 1.7-fold and 3.5-fold higher than in the cultivations performed with air bubbles of 0.36 and 0.09 cm diameters. These laboratory scale experiment indicates that air bubble diameter has the impact on lovastatin production and A. terreus culture conditions.

A web-based patient education system and self-help group in Persian language for inflammatory bowel disease patients.

BACKGROUND AND AIMS: To study the use patterns of a Persian web-based patient education system for inflammatory bowel disease (IBD) patients in Iran. METHODS: A web-based patient education system was developed with Persian content in three sections: general, ulcerative colitis (UC), and Crohn's disease (CD). The website included a forum for patients to communicate as a self-help group. A customized web tracking system recorded web use statistics. Polls at the bottom of each page collected the visitors' opinion on the extent of helpfulness and readability of page contents. Web use data were analyzed for an 18-month period from October 2004 to April 2006. RESULTS: Having excluded page visits from search engine robots, the website's homepage was visited 4452 times (mean of monthly visits: 234, range: 102-330). The web pages titled Anatomy of gastrointestinal system, Nutrition in IBD, Diagnostic tests, How to cope with IBD, and IBD in women were the most favorite in general section. The web page titled IBD treatment was the most visited in both CD and UC sections followed by the web pages on cause of disease, diagnostic procedures and complications in CD section; and those titled symptoms, cause of disease and risk factors in the UC section. Overall, the content evaluation polls received 294 hits (from 186 unique visitors) of which, 196 (67%) were from patients, 30 (10%) from patients' relatives/friends, 21 (7%) from doctors, and 47 (16%) from other groups. During the 18-month period, 47 patients registered in the self-help forum, 24 threads were opened, and 97 posts (33 in CD and 64 in UC section) were sent. CONCLUSIONS: Considering the increasing trend of Internet use in developing countries like Iran, and the consequent increase in the proportion of Internet-using patients, and finally the time constraints gastroenterologists face answering patients' questions; similar websites seem to be effective ways of patient education in close future.

Serum measures of iron status and HFE gene mutations in patients with hepatitis B virus infection.

AIM: We tested associations between HFE mutations and hepatitis B virus (HBV) infection. We also explored measures of total body iron status and their association with chronic HBV infection. METHODS: Serum measures of iron status and HFE mutations (C282Y, H63D, and S65C) were assessed in 344 Iranian patients with chronic HBV infection (214 asymptomatic carriers, 130 patients with chronic progressive liver disease [CPLD]) and 302 controls. RESULTS: Frequencies of HFE mutations did not differ between patients with chronic HBV infection and controls (C282Y: P=0.9, H63D: P= 0.8, S65C: P=0.9). By logistic regression, advanced hepatic fibrosis was associated with HFE H63D mutation (OR=13.1, P=0.006; 95% CI=2.0-84.1). Higher levels of serum ferritin and transferrin saturation were observed in patients with CPLD than in healthy controls (P=0.0001 and 0.01, respectively, adjusted for age and sex). None of the serum iron measures was related to liver fibrosis stage or necroinflammatory grade. CONCLUSION: Serum iron measures are associated with chronic progressive hepatitis B. Carriage of HFE mutations is not associated with the presence of chronic HBV infection or values of serum iron measures in this population, although HFE H63D is associated with more advanced hepatic fibrosis.

Knowledge of disease and health information needs of the patients with inflammatory bowel disease in a developing country.

BACKGROUND AND AIMS: This study was performed to have a first-time assessment on the knowledge level of a population of inflammatory bowel disease (IBD) patients in a developing country like Iran and to identify their health information preferences. METHODS: One hundred over 18-year-old IBD patients presenting to an outpatient gastroenterology clinic in Tehran from April to November 2004 were asked to complete Persian-translated version of 24-item Crohn's and Colitis Knowledge (CCKNOW) score questionnaire and an additional questionnaire collecting their favorite disease-related knowledge topics. RESULTS: All of the patients (64 females, 36 males) wished to know more about their disease. The cause of IBD and the medications were the most favorite knowledge topics. The mean and median of CCKNOW score of the patients was 4.65 and 4.0 (out of 24), respectively. Women showed significantly higher scores than men (p=0.006). There was also a weak positive correlation between the level of education and CCKNOW score (Spearman's rho=0.23, p=0.02). No significant correlation was found between age, duration of disease, self-estimated level of suffering from disease, and CCKNOW score. The most severe knowledge deficit was evident in knowledge on IBD complications. CONCLUSION: Despite the overt inclination of Iranian IBD patients to know more about their disease, their knowledge levels were significantly lower than the IBD patients in developed countries. The more profound knowledge deficit in IBD complications may lead to disastrous aftermaths such as late diagnosis of colorectal cancer induced by prolonged IBD. Vigorous patient education programs for the Iranian IBD patient are suggested focusing on areas of knowledge deficit and their favorite topics.

Intra-familial prevalence of hepatitis B virologic markers in HBsAg positive family members in Nahavand, Iran.

AIM: To determine the prevalence of hepatitis B in Nahavand and evaluate the HBsAg positive prevalence in families with a member who was confirmed to have HBV infection. METHODS: This study was performed in two phases. In the first phase, 1 824 subjects in Nahavand city were selected. The interviewers visited the houses of chosen families to fill the questionnaire and take the blood samples. All subjects signed an informed consent before interviews and blood sampling. The samples were evaluated for HBV virologic markers. In the second phase, 115 HBsAg-positive cases were enrolled and evaluated for HBV virologic markers. RESULTS: The prevalence of positive HBsAg in Nahavand was 2.3%. The most frequent relatives of index cases were sons and daughters (32.2% and 23.5% respectively). Twelve (11%) of all family members were HBsAg positive. Fifty (56.2%) were isolated HBsAb positive and only one person (2.5%) was isolated HBcAb positive. The higher rates of HBsAg marker were detected in the brothers (1-25%) and fathers (1-12.5%). The infection rate in husbands and wives of index cases was 10%. Only two (16.7%) of all HBsAg-positive participants reported previous HBV vaccination. CONCLUSION: The prevalence of intra-familial HBV infection is lower in Nahavand of Iran compared to other studies. More attention should be paid to HBV vaccination and risk-lowering activities.

Internet use by a referral gastroenterology clinic population and their medical information preferences.

BACKGROUND: Internet use is growing rapidly in Iran. However, little is known about the rate of Internet access and Internet use habits of gastroenterology patients and their health information preferences in the country. METHODS: A two-part questionnaire was presented to a convenience sample of 401 consecutive outpatients (mean age: 43.7 years) of a referral gastroenterology clinic in Tehran from February 21 to March 13, 2004. RESULTS: Of all literate patients (92%), 62% self-estimated their disease-related knowledge as nothing to little. The most common sources of information were media (62%) and printed materials (58%). Printed material (57%) and media (35%) were the most preferred means of receiving health information; the Internet was the most preferred means among Internet users and almost all of them were interested in getting online medical services. The cause (65%) and treatment (56%) of disease were the most favorite knowledge topics. Of all patients 28% could use Internet. Males, more educated and younger subjects were more likely to use the Internet. Of the Internet users, 37% had already performed at least one search for medical information. CONCLUSION: Though Internet is not yet a popular means of patient education in Iran, considering the speedy growth of Internet use and its undeniable advantages and prospects in a young country like Iran, it seems wise for private and public health sectors to start more vigorous planning to develop web-based patient education systems run by trusted bodies and encourage and cultivate its use among patients.

An economic analysis of premarriage prevention of hepatitis B transmission in Iran.

BACKGROUND: To assess the economic aspects of HBV (hepatitis B virus) transmission prevention for premarriage individuals in a country with cultural backgrounds like Iran and intermediate endemicity of HBV infection. METHODS: A cost-effectiveness analysis model was used from the health care system and society perspectives. The effectiveness was defined as the number of chronic HBV infections averted owing to one of the following strategies:1) HBsAg screening to find those would-be couples one of whom is HBsAg positive and putting seronegative subjects on a protection protocol comprising HBV vaccination, single dose HBIG and condom protection.2) HBsAg screening as above, in addition to performing HBcAb screening in the HBsAg negative spouses of the HBsAg positive persons and giving the protocol only to HBcAb negative ones.Sensitivity and threshold analyses were conducted. RESULTS: The cost of each chronic infection averted was 202$ and 197$ for the strategies 1 and 2, respectively. Sensitivity analysis showed that strategy 2 was always slightly cheaper than strategy 1. The discounted threshold value for the lifetime costs of chronic liver disease, above which the model was cost saving was 2818$ in strategy 1 and 2747$ in strategy 2. CONCLUSIONS: Though premarriage prevention of HBV transmission in the countries with cultural backgrounds similar to Iran seems cost saving, further studies determining precise costs of HBV infection in Iran can lead to a better analysis.