Financial challenges in the family physician programme in Iran: A systematic review of qualitative research.

Introduction: The family physician programme (FPP) was implemented nearly two decades ago as a major health reform. Since the health system and FPP function in a rapidly changing social and economic environment, successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system. This systematic review aimed to assess the challenges in the FPP relative to its financing. Method: All published articles related to the FPP in Iran were included in this study. In particular, original qualitative studies published in English or Persian from 2011 to 2021 were included. In January 2022, international credible scholarly databases and Persian databases were searched. All selected articles were carefully studied, and the data were extracted using the sample, phenomenon of interest, design, evaluation and research type technique. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in preparing the study report. Results: Among 491 articles retrieved from the search strategy, 50 met the inclusion criteria after their titles and abstracts were screened. Twenty-nine studies were excluded after their full texts were reviewed. A total of 11 eligible empirical studies were finally included. Based on the results, six broad categories (budget and funding, insurance system, tariffs, payments, accountability and injustice) were identified as financial challenges. Conclusion: This study identified the challenges associated with financing among family physicians, and the results could provide guidance for policy-making in the expansion of the FPP.

Referral System Challenges of the Family Physician Program in Iran: A Systematic Review.

Background: Iran has implemented the Family Physician Program (FPP) in 2005 in 4 provinces. This program was supposed to be expanded across the country; however, it faced various challenges. Considering the impact of the referral system on the quality of the FPP implementation, different studies were conducted to evaluate the performance of this system. Therefore, this systematic review of the literature was conducted to investigate the challenges of the referral system of the FPP in Iran. Methods: All published original articles, reviews, or case studies published in English or Persian related to the challenges in the referral system FPP in Iran from 2011 to September 2022 were included in this study. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. Results: Out of 3910 articles identified by the search strategy, considering the inclusion and exclusion criteria and relevance of the study, and accreditation of the studies, 20 studies were included. The referral system suffers from different challenges in the areas associated with policy and planning, management, referral process, and health service recipients. Conclusion: The inefficient gatekeeping role of family physicians was one of the most important challenges of the referral system. The referral system should be improved by having evidence-based guidelines and policy documents, unified stewardship, integrated insurance schemes, and effective communication between different levels of care.

Near Two Decades of the Family Physician Program in Iran and the Structural Challenges: A Systematic Review.

The family physician program (FPP) is one of the most significant health care reforms in Iran; however, many studies showed that this program has not been able to achieve its intended objectives because of a variety of challenges. This program, despite the existing challenges, is going to be expanded across the country. To improve the likelihood of its success, identification of the structural and infrastructural challenges is necessary. This systematic review was conducted to assess the structural and infrastructural challenges of FPP in Iran. This systematic review of the literature was conducted in order to investigate the infrastructure and structure needs of the current program in Iran. All published articles related to the FPP in Iran were the subject of this study. The eligibility criteria included original articles, reviews, or case studies published in English or Persian during 2011-2021 related to the challenges in the referral system of FPP in Iran. Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type technique and were reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. This study identified different challenges of the referral system in the areas associated with legal structure, administration, and social structure. The identified challenges in this program should be addressed in order to ensure that this program will lead to improved quality of care and equity in Iran health care system.

Personalized predictions of adverse side effects of the COVID-19 vaccines.

Background: Misconceptions about adverse side effects are thought to influence public acceptance of the Coronavirus disease 2019 (COVID-19) vaccines negatively. To address such perceived disadvantages of vaccines, a novel machine learning (ML) approach was designed to generate personalized predictions of the most common adverse side effects following injection of six different COVID-19 vaccines based on personal and health-related characteristics. Methods: Prospective data of adverse side effects following COVID-19 vaccination in 19943 participants from Iran and Switzerland was utilized. Six vaccines were studied: The AZD1222, Sputnik V, BBIBP-CorV, COVAXIN, BNT162b2, and the mRNA-1273 vaccine. The eight side effects were considered as the model output: fever, fatigue, headache, nausea, chills, joint pain, muscle pain, and injection site reactions. The total input parameters for the first and second dose predictions were 46 and 54 features, respectively, including age, gender, lifestyle variables, and medical history. The performances of multiple ML models were compared using Area Under the Receiver Operating Characteristic Curve (ROC-AUC). Results: The total number of people receiving the first dose of the AZD1222, Sputnik V, BBIBP-CorV, COVAXIN, BNT162b2, and mRNA-1273 were 6022, 7290, 5279, 802, 277, and 273, respectively. For the second dose, the numbers were 2851, 5587, 3841, 599, 242 and 228. The Logistic Regression model for predicting different side effects of the first dose achieved ROC-AUCs of 0.620-0.686, 0.685-0.716, 0.632-0.727, 0.527-0.598, 0.548-0.655, 0.545-0.712 for the AZD1222, Sputnik V, BBIBP-CorV, COVAXIN, BNT162b2 and mRNA-1273 vaccines, respectively. The second dose models yielded ROC-AUCs of 0.777-0.867, 0.795-0.848, 0.857-0.906, 0.788-0.875, 0.683-0.850, and 0.486-0.680, respectively. Conclusions: Using a large cohort of recipients vaccinated with COVID-19 vaccines, a novel and personalized strategy was established to predict the occurrence of the most common adverse side effects with high accuracy. This technique can serve as a tool to inform COVID-19 vaccine selection and generate personalized factsheets to curb concerns about adverse side effects.

Prescribing pattern of antibiotics by family physicians in primary health care.

PURPOSE: Irrational prescription of antibiotics is an ongoing global public health concern, leading to antibiotic resistance. Understanding the prescribing pattern of antibiotics is important to tackling mal-prescription and antibiotic resistance. We aimed to investigate the pattern and factors affecting outpatients' antibiotic prescribing by family physicians in Primary Health Care (PHC). METHODS: A cross-sectional study was conducted in 19 PHC facilities in Alborz province. Prescribing pattern of antibiotics was evaluated among 1068 prescriptions by family physicians. Prescribing pattern of antibiotics included prescriptions containing antibiotics, the number of antibiotics per prescription, type, name of antibiotic, and mal-prescription. Multiple logistic regression analysis was used to estimate the adjusted odds ratios and 95% confidence intervals. RESULTS: Overall, 57% of the prescriptions had ≥ 1 antibiotic and the average number of antibiotics per prescription was 1.27. Amoxicillin was the commonly prescribed antibiotic. There was a significant relationship between age, sex, type of health insurance, work experience of the physician, and seasons with antibiotic prescribing (P < 0.05). In 59.31% of antibiotic prescriptions at least one of the scientific criteria was not fulfilled. In the final analysis, after adjusting for the potential confounders, field experts of physicians (OR = 1.59; 95% CI: 1.08-6.17), female sex (OR = 2.23; 95% CI: 1.18-4.21), and winter season (OR = 3.34; 95% CI: 1.26-8.15) were found associated factors with antibiotic prescribing. CONCLUSION: The average number of antibiotics per prescription and the percentage of irrational prescriptions were relatively high in this study. There is need to improve antibiotic prescribing patterns among family physicians working in primary health care.

Correlation of nuchal translucency and thyroxine at 11-13 weeks of gestation.

OBJECTIVE: Nuchal translucency (NT) thickness is one of the major screening markers during the first trimester that could be influenced by several factors. Here, we investigated the association between NT thickness and thyroid related hormones. METHODS: NT thickness was measured with transabdominal ultrasound in 643 pregnant women between 11 and 13 weeks of gestation. Maternal thyroxine (T4), free thyroxine (fT4) and thyroid-stimulating hormone (TSH) were evaluated. Bivariate correlations were assessed and thyroid profile was subcategorized with regard to the calculated reference ranges. RESULTS: An inverse relation was found between serum levels of maternal T4 with NT thickness (r = -0.128, p = 0.001) and CRL (r = -0.168, p < 0.001). TSH and hCG were also found to be correlated (Spearman's correlation coefficient = -0.092, p = 0.019). Prevalence of maternal hypothyroidism and subclinical hypothyroidism were 1.1% and 3.7%, respectively. CONCLUSION: Thyroid function tests are found to independently influence NT measurements in the first trimester. Assessment of hormones such as thyroxine could optimize the interpretation of screening tests for pathological conditions during pregnancy.

Comparison of the effects of acute and chronic psychological stress on metabolic features in rats.

This study was aimed to compare the effects of acute and chronic psychological stress on metabolic factors. Forty-two male Wistar rats were divided into control and stressed groups. Stress was applied by a communication box acutely (1 d) and chronically (15 and 30 d). Blood sampling was carried out by retro-orbital-puncture method. The plasma levels of glucose, cholesterol, triglyceride, insulin, and corticosterone were measured. In addition, feed and water intake, latency to eat and drink, adrenal and body weights were determined. Acute and chronic psychological stress did not significantly change basal plasma corticosterone levels. However, immediately (1 min) after acute exposure to stress, plasma corticosterone level increased compared to that before stress exposure. Acute stress increased plasma insulin levels significantly. Fifteen days of stress exposure resulted in plasma glucose increase. Chronic stress significantly increased feed intake, latency to eat, and adrenal weight compared to acute stress. The body weights of both control and stressed groups increased markedly during the experiment. Homeostasis model assessment of insulin resistance (HOMA-IR) index did not change significantly in the stressed group. In conclusion, application of acute and chronic psychological stress leads to different metabolic and/or behavioral changes but the metabolic changes resulting from acute exposure to stress seem to be more pronounced.

Association between the evidence of human papilloma virus infection in bladder transitional cell carcinoma in men and cervical dysplasia in their spouses.

BACKGROUND: Cervical cancer is one of the most common tumors in women. One of its risk factors is direct contact with viruses, in particular human papillomavirus (HPV). Recent studies have shown a prevalence of 2%-35% for HPV in cases with bladder cancer. In addition, some malignancies of the urogenital organs in males may promote the probability of cervical cancer in their spouses.  In this study, the relationship between cervical dysplasia in women and evidence of HPV infection in tissue specimens obtained from their spouses' bladders has been investigated. METHODS: This cross-sectional study was conducted on 82 male patients with bladder tumors and their spouses between February 2004 and February 2007 in Tehran. We gathered data related to the histopathology of the transitional cell carcinoma (TCC) in men and Pap smear tests of their spouses. Tissue specimens of patients with bladder TCC were analyzed for HPV infection using polymerase chain reaction (PCR). HPV-positive specimens were tested for subtypes 16 and 18. RESULTS: In 24 (29.3%) men, bladder tumor samples were positive for HPV infection. Of these, we found HPV-18 infection in 9 (37.5%), while 3 (12.5%) were infected with HPV-16. In the spouses of those men with HPV-infected bladder tumors, 4 (4.9%) cases had cellular dysplasia noted on their Pap smear tests. We found no dysplasia in those women whose husbands had bladder TCC, but no HPV infection (P = 0.006). CONCLUSION: It is possible to decrease the incidence of bladder TCC in men and cervical cancer in women through public education regarding the methods of transmission and avoidance of risky sexual behaviors.

Effects of acute and chronic psychological stress on isolated islets' insulin release.

This study investigated the effects of acute and chronic psychological stress on glucose-stimulated insulin secretion from isolated pancreatic islets. Male Wistar rats were divided into two control and stressed groups; each further was allocated into fed and fasted groups. Stress was induced by communication box for one (acute), fifteen and thirty (chronic) days. After islet isolation, their number, size and insulin output were assessed. Plasma corticosterone level was determined. In fasted animals, acute stress increased basal and post stress plasma corticosterone level, while 30 days stress decreased it compared to day 1. In fed rats, acute stress increased only post stress plasma corticosterone concentration, however, after 15 days stress, it was decreased compared to day 1. Acute stress did not change insulin output; however, the insulin output was higher in the fed acutely stressed rats at 8.3 and 16.7 mM glucose than fasted ones. Chronic stress increased insulin output on day 15 in the fasted animals but decreased it on day 30 in the fed animals at 8.3 and 16.7 mM glucose. In the fasted control rats insulin output was lower than fed ones. In the chronic stressed rats insulin output at 8.3 and 16.7 mM glucose was higher in the fasted than fed rats. The number of islets increased in the fasted rats following 15 days stress. This study indicated that the response of the isolated islets from acute and chronically stressed rats are different and depends on the feeding status.

Soluble Fas in pemphigus vulgaris.

BACKGROUND: The Fas/Fas ligand (FasL) system has been recognized as an important pathway for apoptosis induction in cells and tissues. It has recently been shown that skin lesions of pemphigus vulgaris are associated with Fas mediated apoptosis. The aim of this study was to evaluate the level of serum soluble Fas of ten newly diagnosed patients with pemphigus vulgaris. METHODS: Sera were collected from ten patients with pemphigus vulgaris. Commercial sandwich enzyme-linked immunosorbent assay (ELISA) for quantitative detection of soluble Fas was applied. RESULTS: Patients with mucosal skin involvement had higher median values in contrast to patients with cutaneous involvement. CONCLUSION: Elevation of soluble Fas in our study may give insights for the pathogenesis of pemphigus vulgaris. Suppression of this underlying mechanism may be an important target for novel therapies and relapse prevention.

High-fat diet did not change metabolic response to acute stress in rats.

This study investigated the effects of high-fat diet on metabolic factors in the presence of acute foot-shock and psychological stresses in male Wistar rats. The animals were divided into high-fat (45 % cow intra-abdominal fat) and normal (standard pellets) diet groups; then, each group was allocated into stressed and control groups. Stress was induced by a communication box. Blood samples were collected by retro-orbital-puncture method under isoflurane anesthesia. Plasma levels of glucose, insulin, triglyceride, cholesterol, free fatty acid and corticosterone were measured. Water and food intake significantly decreased in high-fat diet group; however, their weight did not change compared with the normal diet group. The level of fasting plasma glucose in the high-fat diet group decreased whereas, the fasting plasma insulin level did not significantly change. Stress increased the plasma glucose level 15 minutes after oral glucose tolerance test (OGTT) in both diet subgroups. The concentration of plasma insulin increased after stress induction in fasting and 15 minutes after performing OGTT. The increase in the plasma level of corticosterone was significant in both diet subgroups of only the foot-shock stress group. Plasma level of cholesterol and triglyceride in the high-fat diet group significantly increased; however, foot-shock stress decreased only triglyceride concentration. Plasma level of the fatty acids did not change in any of the groups. Statistical analysis showed no significant interaction between high-fat diet and stress. As a whole, the results showed that the high-fat diet used in the present study did not noticeably affect metabolic parameters even in the presence of acute stress.

Iranian black tea and cowslip extracts induce tumor necrosis factor-alpha secretion from mouse macrophage cell culture.

Many species of tea (Camellia sinensis) and cowslip (Echium amoenum) are used in Iranian traditional medicine. The aim of this study was to conduct the survey on the ability of Iranian black tea and cowslip extracts on secretion of tumor necrosis factor-alpha (TNF-alpha) by non-infected and infected mouse macrophages. A macrophage infection model with Legionella pneumophila and enzyme linked immunosorbent assay (ELISA) technique was used in this study. Research showed that the concentrations of TNF-alpha in non-infected and infected macrophage culture supernatant treated with various concentrations of Iranian black tea and cowslip extracts was significantly higher than the control. Various concentrations of cowslip (0.5, 5 and 50 µg/mL) had significantly a great effect on the induction of TNF-alpha secretion in comparison with the Iranian black tea extract (P < 0.0001). In conclusion, we demonstrated the ability of Iranian black tea and cowslip on the induction of TNF-alpha, which can exert an anti-L. pneumophila activity on macrophages at a low dose. However, further studies to elucidate the mechanism(s) of the induction of macrophages by Iranian black tea and cowslip as well as their potential inhibitory effects on the growth of infected cells and their possible antitumor effects should be carried out in future works.

Release of sFasL by Monocytes and Lymphocytes Triggered by Betaglucan and Zymosan.

BACKGROUND: Polysaccharides have long been used as immune-modulators in various pathologic conditions including inflammation and solid malignancies. OBJECTIVE: To evaluate the effects of Zymosan and Betaglucan on cytotoxic reactions in an effector-target conjugate system. METHODS: Blood was obtained from 20 healthy subjects; purified mononuclear leukocytes (monocytes and lymphocytes) were extracted and cultured as effector cells by a cytotoxic method. Both adherent and non-adherent cells interacted with the K562 myeloid cell line. The effector-target (E:T) ratio was 1:1, 1:10, and 1:20. To evaluate stimulatory effects of Betaglucan and Zymosan on cytotoxic reactions, samples were divided into case and control groups based on the presence or absence of Betaglucan and Zymosan. MTT assay and sFas ligand (sFasL) concentrations were used to assess the increased killing capacity of effector cells. RESULTS: Our results revealed that Zymosan and Betaglucan can induce cytotoxic responses in macrophages and lymphocytes (p<0.05). The best result was achieved with E:T ratio of 1:1. Both macrophages and lymphocytes produced sFasL following stimulation by Zymosan and Betaglucan, however, the level of production was not statistically significant (p>0.05). CONCLUSION: Zymosan and Betaglucan can be used as enhancers of the killing capacity of the immune cells; therefore, Betaglucan and Zymosan can be applied as systemic stimulators of the immune response in inflammation and chronic infection.