Causes of futile life-sustaining interventions from the perspective of physicians and nurses in university hospitals in Tehran

Background
Providing futile interventions can lead to moral distress for healthcare providers and impose high costs on healthcare systems. Despite this, evidence demonstrates that such interventions still continue in many parts of the world, particularly in Low and Middle Income Countries (LMICs). Therefore, this current study was conducted to investigate reasons for providing futile interventions from the perspective of physicians and nurses working at hospitals affiliated to Tehran University of Medical Sciences (TUMS)

Method
In this cross-sectional (descriptive-analytical) study, 249 participants including 128 physicians and 121 nurses working in hospitals affiliated to TUMS were recruited through convenience sampling. Data was collected using a 25-item questionnaire assessing causes of providing futile medical and life-sustaining interventions, grouped into 3 domains of “demands of patients/relatives”, “personal reasons of the healthcare team” and “organisation/infrastructural” limitations. Data was analysed using SPSS 16 and the extent to which participants agreed with each of the causes of futile interventions was expressed as a percentage. Comparisons between the views of physicians and nurses on individual questionnaire items was performed using the Chi-squared test. A linear regression analysis was used to compare the views of physicians and nurses in each of the 3 domains of the questionnaire, and for intra-group comparisons.

Results
For both physicians and nurses, the most common reasons for futile interventions related to patients and their relatives including demands/insistence on the continuation of treatment and false hope for the patient’s recovery. Compared to physicians, nurses gave greater importance to the domains of patient/relatives’ demands as well as personal reasons of the healthcare team. Physicians expressed strongest agreement with the domain of organisation/infrastructural limitations, including lack of guidelines and palliative care centres.

Conclusion
This study demonstrates that despite awareness of the healthcare team members regarding the futility of some interventions, they are still performed due to the reasons highlighted. Therefore, it clinical guidelines should be developed for appropriate end-of-life care, including restricting the use of futile interventions, increase public and professional awareness and knowledge around futile end-of-life interventions and strengthen palliative care services, thereby leading to greater efficiency and justice in the healthcare system.

The Standardization of Hospital-Acquired Infection Rates Using Prediction Models in Iran: Observational Study of National Nosocomial Infection Registry Data

Background:
Many factors contribute to the spreading of hospital-acquired infections (HAIs).

Objective:
This study aimed to standardize the HAI rate using prediction models in Iran based on the National Healthcare Safety Network (NHSN) method.

Methods:
In this study, the Iranian nosocomial infections surveillance system (INIS) was used to gather data on patients with HAIs (126,314 infections). In addition, the hospital statistics and information system (AVAB) was used to collect data on hospital characteristics. First, well-performing hospitals, including 357 hospitals from all over the country, were selected. Data were randomly split into training (70%) and testing (30%) sets. Finally, the standardized infection ratio (SIR) and the corrected SIR were calculated for the HAIs.

Results:
The mean age of the 100,110 patients with an HAI was 40.02 (SD 23.56) years. The corrected SIRs based on the observed and predicted infections for respiratory tract infections (RTIs), urinary tract infections (UTIs), surgical site infections (SSIs), and bloodstream infections (BSIs) were 0.03 (95% CI 0-0.09), 1.02 (95% CI 0.95-1.09), 0.93 (95% CI 0.85-1.007), and 0.91 (95% CI 0.54-1.28), respectively. Moreover, the corrected SIRs for RTIs in the infectious disease, burn, obstetrics and gynecology, and internal medicine wards; UTIs in the burn, infectious disease, internal medicine, and intensive care unit wards; SSIs in the burn and infectious disease wards; and BSIs in most wards were >1, indicating that more HAIs were observed than expected.

Conclusions:
The results of this study can help to promote preventive measures based on scientific evidence. They can also lead to the continuous improvement of the monitoring system by collecting and systematically analyzing data on HAIs and encourage the hospitals to better control their infection rates by establishing a benchmarking system.

A minimum data set for traumatic brain injuries in Iran

Purpose
Traumatic brain injury (TBI) is one of the major public health concerns worldwide. Developing a TBI registry could facilitate characterizing TBI, monitoring the quality of care, and quantifying the burden of TBI by collecting comparable and standardized epidemiological and clinical data. However, a national standard tool for data collection of the TBI registry has not been developed in Iran yet. This study aimed to develop a national minimum data set (MDS) for a hospital-based registry of patients suffering from TBI in Iran.

Methods
The MDS was designed in two phases, including a literature review and a Delphi study with content validation by an expert panel. After the literature review, a comprehensive list of administrative and clinical items was obtained. Through a two-round e-Delphi approach conducted by invited experts with clinical and research experience in the field of TBI, the final data elements were selected.

Results
An MDS of TBI was assigned to two parts: administrative part with five categories including 52 data elements, and clinical part with nine categories including 130 data elements.

Conclusion
For the first time in Iran, we developed an MDS specified for TBI consisting of 182 data elements. The MDS would facilitate implementing a TBI’s national level registry and providing essential, comparable, and standardized information.

Evaluating mechanism and severity of injuries among trauma patients admitted at Sina Hospital, the National Trauma Registry of Iran

Abstract
Purpose
Injuries are one of the leading causes of death and lead to a high social and financial burden. Injury patterns can vary significantly among different age groups and body regions. This study aimed to evaluate the relationship between mechanism of injury, patient comorbidities and severity of injuries.

Methods
The study included trauma patients from July 2016 to June 2018, who were admitted to Sina Hospital, Tehran, Iran, for 2 years. The inclusion criteria were all injured patients who had at least one of the following: hospital length of stay more than 24 h, death in hospital, and transfer from the intensive care unit of another hospital. Data collection was performed using the National Trauma Registry of Iran (NTRI) minimum dataset.

Results
The most common injury mechanism was road traffic injuries (49.0%), followed by falls (25.5%). The mean age of those who fell was significantly higher in comparison with other mechanisms (p < 0.001). Severe extremity injuries occurred more often in the fall group than in the vehicle collision group (69.0% vs. 43.5%, p < 0.001). Moreover, cases of severe multiple trauma were higher amongst vehicle collisions than injuries caused by falls (27.8% vs. 12.9%, p = 0.003). Conclusion Comparing falls with motor vehicle collisions, patients who fell were older and sustained more extremity injuries. Patients injured by motor vehicle collision were more likely to have sustained multiple trauma than those presenting with falls. Recognition of the relationship between mechanisms and consequences of injuries may lead to more effective interventions.

Developing a National Integrated Road Traffic Injury Registry System: A Conceptual Model for a Multidisciplinary Setting

Introduction: Despite a high burden of traffic injuries, effective integrated or linked injury surveillance systems are rarely available in many low- and middle-income countries (LMICs). The aim of the current study was to define a conceptual model for developing a national integrated traffic injury registry in Iran.
Methods: A mult-method study financially and technically supported by the World Health Organization, Iranian Ministry of Health, Iranian Traffic Police, and the Iranian Legal Medicine Organization was conducted. A theoretical framework, forming the core conceptual components, was developed based on expert reviews. The preliminary conceptual model was developed by a panel of experts and tailored through a national workshop of 50 scientists, authorities and experts from nearly all sectors related to road safety promotion and injury management. It was then sent out to external reviewers in order to assess and improve the content validity of the model.
Results: The conceptual model was developed to have six components. These included 1) aims and core definitions; 2) content and core measurements; 3) data flow; 4) data collection routines; 5) organizational matrix; 6) implementation organization. The Haddon’s matrix was adapted to be used as the theoretical framework in defining the content and data flow components of IRTIR. Five subcomponents were defined in the content and core measurements component with each having several subcategories. Each subcomponent/subcategory was finally divided into several item groups to guide defining the final data measurement variables. The data flow component was defined with six data sequence stations. Through the organizational matrix component, five major organizations relevant to road traffic safety were defined as core data production contributors. Some organizations also owned several sub-organizations which contributed in this regard.
Conclusion: It is concluded that the IRTIR conceptual model includes the required six components for developing a national integrated registry for Iran. Its main component called, content and core measurements, leads the researchers in developing final data collection tools in developing the national registry of road traffic injuries in Iran.

Using modified Delphi method to propose and validate components of child injury surveillance system for Iran

Purpose
Child injuries are a public health concern globally. Injury Surveillance Systems (ISSs) have a beneficial impact on child injury prevention. There is a need for evidence-based consensus on frameworks to establish child ISSs. This research aims to investigate the key components of a child ISS for Iran and to propose a framework for implementation.

Methods
Data were gathered through interview with experts using unstructured questions from January 2017 to December 2018 to identify child ISS functional components. Qualitative data were analyzed using content analysis method. Then, modified Delphi method was used to validate the functional components. Based on the outcomes of the content analysis, a questionnaire with closed questions was developed to be presented to a group of experts. Consensus was achieved in two rounds.

Results
In round one, 117 items reached consensus. In round two, 5 items reached consensus and were incorporated into final framework. Consensus was reached for 122 items comprising the final framework and representing 7 key components: goals of the system, data sources, data set, coalition of stakeholders, data collection, data analysis and data distribution. Each component consisted of several sub-components and respective elements.

Conclusion
This agreed framework will assist in standardizing data collection, analysis and distribution to detect child injury problems and provide evidence for preventive measures.

Comparison on Frequencies of Pericardial Effusion and Tamponade Following Open Heart Surgery in Patients With or Without Low Negative Pressure Suction on Chest Tube

Introduction
Pericardial effusion and tamponade are accounted as the two most important complications following open-heart surgeries which are known to increase mortality and morbidity rates. Putting a low negative pressure suction on the chest tube of patients might be a useful way for better drainage and also reducing the occurrence of pericardial effusion and tamponade. In the present study, we aimed to compare the prevalence of pericardial effusion and tamponade in patients undergoing open-heart surgeries with and without low negative pressure suction on the chest tube.
Methods
This clinical trial was performed in 2018-2019 in Tehran, Iran. 100 patients who were candidates for open-heart surgery were entered. After surgeries, patients were divided into two groups: group 1 had a low negative pressure suction on their chest tube and group 2 had no suction. Patients were then observed for clinical and imaging characteristics of pleural effusion and tamponade. Data were gathered and analyzed using SPSS software.
Results
In the present study, we indicated that the prevalence of pericardial effusion is significantly lower in patients with low negative pressure on their chest tube (P=0.04). No significant differences were observed between two groups regarding to: frequency of tamponade and post-operative ejection fraction (P> 0.05).
Conclusion
The usage of a low negative pressure suction on the chest tube following open cardiac surgeries is associated with a lower prevalence of pericardial effusion. We suggest that such systems could be commonly used in cardiac surgeries or surgeries of the thorax.

Effect of Dexmedetomidine Combined with Inhalation of Isoflurane on Oxygenation Following One-Lung Ventilation in Thoracic Surgery

Background: One-lung ventilation (OLV) is commonly used during thoracic surgery. At this time, hypoxemia is considered one of the remarkable consequences of the anesthesia management. Hypoxic pulmonary vasoconstriction (HPV) is the defense mechanism against hypoxia.
Objectives: The aim of the present study was to investigate the effect of infusion of dexmedetomidine on improving the oxygenation during OLV among the adult patients undergoing thoracic surgery.
Methods: A total of 42 patients undergoing OLV by general anesthesia with isoflurane inhalation were randomly assigned into two groups: IV infusion of dexmedetomidine at 0.3 microgram/kg/h (DISO) and IV infusion of normal saline (NISO). Three Arterial Blood Gas (ABG) samples were obtained throughout the surgery. Hemodynamic parameters, PaO2, PaCO2, and complications at recovery phase were recorded. The collected information was analyzed using SPSS software version 22.
Results: In the dexmedetomidine group, the mean hemodynamic parameters had a significant reduction at 30 and 60 minutes following OLV. Administration of dexmedetomidine resulted in a significant increase in the PaCO2 and a reduction in the PaO2 when changing from two-lung ventilation to OLV, where PaO2 reached its maximum value within 10 minutes after OLV in the DISO group, and it began to gradually increase to the end of operation. The duration of the recovery phase, also complications at the recovery phase decreased significantly in DISO group.
Conclusions: The results of the study showed that, dexmedetomidine may improve arterial oxygenation during OLV in adult patients undergoing thoracic surgery, and can be a suitable anesthetic agent for thoracic surgery.

Global Unmet Needs in Cardiac Surgery.

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

Visual impairment and blindness in a population-based study of Mashhad, Iran.

Purpose
To determine the prevalence of visual impairment and blindness and related factors in the 1- to 90-year-old urban population of Mashhad.

Methods
In this cross-sectional study of 1- to 90-year-old residents of Mashhad, in northeastern Iran, sampling was done through random stratified cluster sampling (120 clusters). After selecting the samples and their participation in the study, all subjects had vision testing including measurement of visual acuity and refraction, as well as examinations with the slit-lamp and ophthalmoscopy. Visual impairment (primary outcomes) was defined as a visual acuity worse than of 0.5 logMAR (20/60) in the better eye.

Results
Of the 4453 selected persons, 3132 (70.4%) participated in the study. The prevalence of visual impairment based on presenting vision and best-corrected vision was 3.95% (95% confidence interval [CI]: 3.13–4.77) and 2.23 (95% CI: 1.54–2.91), respectively. The prevalence of presenting visual impairment increased from 1.59% in children under 5 years of age to 43.59% in people older than 65 years of age; these figures were respectively 1.59% and 42.31% based on corrected visual acuity. In the logistic regression model, older age (OR = 1.06, 95% CI: 1.04–1.07, P < 0.001), higher education (OR = 0.16, 95% CI: 0.06–0.38, P < 0.001), and low income (OR = 1.36, 95% CI: 1.21–1.72, P < 0.001) correlated with impaired sight. Based on presenting vision and best-corrected vision, the prevalence of blindness was 0.86% (95% CI: 0.51–1.22) and 0.32% (95% CI: 0.1–0.55). The most common causes of visual impairment were uncorrected refractive error (41.8%) and cataract (20%).

Conclusions
According to our findings, the prevalence of visual impairment was intermediate in comparison with other studies. The prevalence of visual impairment in our study was similar to the global average; however, it was markedly high at older ages. Nonetheless, refractive errors and cataracts remain as the main causes of impaired vision and blindness in this population, while these two conditions are easily treatable with correction or surgery.