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Abstract Atrial fibrillation (AF)/atrial flutter (AFL) is the most common cardiac tachyarrhythmia, with an increasing trend in its burden in recent years. However, the burden of AF/AFL in Iran remains unclear. This study aimed to estimate the burden of AF/AFL and its attributable risk factors from 1990 to 2019 at national and subnational levels. Using the comparative risk assessment method of the Global Burden of Disease (GBD) Study 2019, we extracted data on AF/AFL incidence, prevalence, deaths, disability-adjusted life years (DALYs), and their age-standardized rates from 1990 to 2019 and analyzed them based on by age, sex, and socio-demographic index (SDI). The percentage contribution of AF/AFL major risk factors was calculated. Moreover, the AF/AFL burden in 2050 was projected using the United Nations world population prospect data. In 2019, there were 339.1 (259.4–433.7) thousand AF/AFL patients in Iran, with 30.2 (23.2–38.5) thousand new cases, 1.7 (1.5–2) thousand deaths and 48 (37.7–60.5) thousand DALYs. Females and 50–69-year-old patients recorded a higher burden for AF/AFL; however, the increasing trend was more pronounced in males and more than 85-year-old patients. High systolic blood pressure and elevated body mass index (BMI) were the predominant attributable risk factors for AF/AFL-related deaths and DALYs. It is estimated that in 2050, the number of AF/AFL patients will increase to 1.1 million people, the incidence of AF/AFL will increase to 91 thousand patients, and the number of AF/AFL-related deaths and DALYs will surge to 7.2 and 170.8 thousand, respectively. Despite advancements in prevention and treatment, AF/AFL remains a major public health problem in Iran. Given its largely preventable and treatable nature, more cost-effective strategies are required to target modifiable risk factors, especially within susceptible age and sex groups.

Abstract Alcohol production and consumption have been prohibited in Iran for over four decades, leading to a typical underestimation of its consumption. This study aimed to assess the prevalence of alcohol consumption, its associated factors, and estimate per capita alcohol consumption among Iran’s adult population. In this population-based survey, 27,874 adults from across Iran were selected using systematic proportional-to-size cluster sampling. Alcohol consumption was evaluated through a modified Persian version of the STEPS questionnaires from previous studies, applied over different timespans. Per capita consumption was calculated using the quantity-frequency method, expressed in liters of pure alcohol. Adjusted odds ratios were reported for associates of alcohol consumption concerning metabolic risk factors, sociodemographic elements, and lifestyle variables. The prevalence of lifetime alcohol consumption was 6.9% (95% CI 6.5–7.2) in the adult population, with a notable sex difference (males: 13.7% [95% CI 13–14.4]; females: 1.4% [95% CI 1.1–1.6]). The 12 month prevalence was 3.8% (95% CI 3.6–4.1). For individuals aged 18 and older, the per capita alcohol consumption in Iran was 0.12 L. Factors such as being a lifetime smoker, younger, wealthier, and having 7–12 years of education were significantly linked to higher alcohol consumption. Significant associations were also observed between alcohol consumption and having a history of heart attacks (OR = 2.04, 95% CI 1.44–2.89), and physical injuries (OR = 1.88, 95% CI 1.34–2.64). The estimated lifetime and 12-month prevalence of alcohol use in our study were higher among some of the subpopulations. The findings also revealed a complex relationship between alcohol consumption, behavioral risk factors, and metabolic profiles. Consequently, immediate preventive measures tailored to each factor’s association with alcohol use are recommended.

Giant cell tumor (GCT) is typically a benign tumor of the skeletal system that mainly presents with bone pain. Pulmonary metastasis is one of the distant presentations of GCT in patients who have previously undergone surgical resection of the tumor. Among the various presentations of pulmonary metastasis in GCT, lesions with arteriovenous malformation (AVM) features are rare and have only been reported in a few cases. In this case report, we present the case of a 29-year-old female patient who had previously undergone surgical resection of a GCT in her right lower extremity 4 years ago. The patient was referred to us with progressive dyspnea, and a lesion resembling an AVM was found during radiologic evaluation using chest computed tomography. Pathologic evaluation of the lesion after biopsy revealed that it was a metastasis of GCT presenting with vascular-like features in the lung. This study reports on a very rare occurrence of GCT pulmonary metastasis with an AVM appearance on imaging, highlighting the clinical importance of atypical presentations of pulmonary metastasis in patients with a history of GCT. Appropriate and timely screening and management of such lesions may prevent adverse outcomes such as massive hemorrhage and deterioration of lung function.

Abstract Background Cancer is most commonly associated with aging. It is necessary to gain a better understanding of cancer's trend and distribution among elderlies and provide comprehensive cancer care for this population. Aims The aim of the current study was to show the trends in cancer incidence focusing on the population aged 60+ from 1990 to 2016 in Iran. Material and Results We used the dataset of the Iran Cancer Registry to estimate cancer incidences by sex, age, province, and year. In order to account for incomplete data we used a two‐stage spatiotemporal model along with random intercept mixed effect models. We calculated annual age‐standardized incidence rates (ASIRs) for age groups 60+ and 5‐interval age groups. There was an increasing trend of 25.3% to 936.9% (95% uncertainty interval: 769.6–1141.8) in ASIR in the elderly in 2016. ASIR of all cancers were 889.7 (731.3–1083.6) in women and 988.1 (811.1–1205) in men in 2016, per 100 000 respectively, which had an increasing trend comparing 1990. Skin, breast, and stomach cancers in women and prostate, skin, and stomach cancers in men were the most common types in 2016. All the most incident cancer subtypes underwent an increasing trend in both sexes, except for the bladder, esophageal, and skin cancers which almost had a similar level in 1990 and 2016. Most provinces had an increasing trend in ASIR in all cancers combined from 1990 to 2016 except Zanjan with a decreasing trend. Conclusion Regarding the persistent increasing trend of most elderly cancers' incidence, this is crucial for policymakers to establish preventive plans, determine proper resource allocation, and develop specific treatments for elderly cancer patients.

Abstract The study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (

Abstract This study aimed to investigate the diabetes mellitus (DM) and prediabetes epidemiology, care cascade, and compliance with global coverage targets. We recruited the results of the nationally representative Iran STEPS Survey 2021. Diabetes and prediabetes were two main outcomes. Diabetes awareness, treatment coverage, and glycemic control were calculated for all population with diabetes to investigate the care cascade. Four global coverage targets for diabetes developed by the World Health Organization were adopted to assess the DM diagnosis and control status. Among 18,119 participants, the national prevalence of DM and prediabetes were 14.2% (95% confidence interval 13.4–14.9) and 24.8% (23.9–25.7), respectively. The prevalence of DM treatment coverage was 65.0% (62.4–67.7), while the prevalence of good (HbA1C

Background: Hospital-acquired infection (HAI) or nosocomial infection is a major public health concern. In this study, the status of knowledge, attitude, and practice (KAP) of service staff and nurse aids in reference to HAI was investigated. Methods: This descriptive-analytic study was carried out to investigate KAP in two steps design and measurement. Twenty-five hospitals were included in this study. To collect data, a questionnaire comprised of 8 divisions and 45 questions was designed and validated, and the three sections of KAP were listed. The questionnaire was distributed to 405 nurse aids and service staff to determine their level of KAP towards HAI. The data were analyzed using SPSS 18. Results: The mean ± standard deviation values of KAP of the included staff were 7.07 ± 1.97, 23.08 ± 4.38, and 35.83 ± 8.25, respectively. A statistically significant difference was observed in the level of KAP of personnel among different hospitals (P < 0.001). The type of employment status and education was found to be significantly influential on knowledge (P = 0.027, P < 0.001) and level of education. Marital status, education and career experience were found to be significantly influential on attitude (P = 0.034, P = 0.004 and 0.045). Level of education, job category, career experience, and gender were the significant influential factors on practice (P < 0.05). Conclusion: The knowledge and practice levels were low in many nurse aids and service staff. An educational plan and compiled programs in hospital infection control seem to be necessary to effectively control the major concern of HAI in hospitals in Iran.

Abstract Scarcity of ventilators during COVID-19 pandemic has urged public health authorities to develop prioritization recommendations and guidelines with the real-time decision-making process based on the resources and contexts. Nevertheless, patients with COVID-19 who will benefit the most from ventilation therapy have not been well-defined yet. Thus, the objective of this study was to investigate the benefit of ventilation therapy among various patient groups with COVID-19 admitted to hospitals, based on the real-world data of hospitalized adult patients. Data used in the longitudinal study included 599,340 records of hospitalized patients who were admitted from February 2020 to June 2021. All participants were categorized based on sex, age, city of residence, the hospitals' affiliated university, and their date of hospitalization. Age groups were defined as 18–39, 40–64, and more than 65-year-old participants. Two models were used in this study: in the first model, participants were assessed by their probability of receiving ventilation therapy during hospitalization based on demographic and clinical factors using mixed-effects logistic regression. In the second model, the clinical benefit of receiving ventilation therapy among various patient groups was quantified while considering the probability of receiving ventilation therapy during hospital admission, as estimated in the first model. The interaction coefficient in the second model indicated the difference in the slope of the logit probability of recovery for a one-unit increase in the probability of receiving ventilation therapy between the patients who received ventilation compared to those who did not while considering other factors constant. The interaction coefficient was used as an indicator to quantify the benefit of ventilation reception and possibly be used as a criterion for comparison among various patient groups. Among participants, 60,113 (10.0%) cases received ventilation therapy, 85,158 (14.2%) passed away due to COVID-19, and 514,182 (85.8%) recovered. The mean (SD) age was 58.5 (18.3) [range = 18–114, being 58.3 (18.2) among women, and 58.6 (18.4) among men]. Among all groups with sufficient data for analysis, patients aged 40–64 years who had chronic respiratory diseases (CRD) and malignancy benefitted the most from ventilation therapy; followed by patients aged 65 + years who had malignancy, cardiovascular diseases (CVD), and diabetes (DM); and patients aged 18–39 years who had malignancy. Patients aged 65 + who had CRD and CVD gained the least benefit from ventilation therapy. Among patients with DM, patients aged 65 + years benefited from ventilation therapy, followed by 40–64 years. Among patients with CVD, patients aged 18–39 years benefited the most from ventilation therapy, followed by patients aged 40–64 years and 65 + years. Among patients with DM and CVD, patients aged 40–64 years benefited from ventilation therapy, followed by 65 + years. Among patients with no history of CRD, malignancy, CVD, or DM, patients aged 18–39 years benefited the most from ventilation therapy, followed by patients aged 40–64 years and 65 + years. This study promotes a new aspect of treating patients for ventilators as a scarce medical resource, considering whether ventilation therapy would improve the patient's clinical outcome. Should the prioritization guidelines for ventilators allocation take no notice of the real-world data, patients might end up being deprived of ventilation therapy, who could benefit the most from it. It could be suggested that rather than focusing on the scarcity of ventilators, guidelines focus on evidence-based decision-making algorithms to also take the usefulness of the intervention into account, whose beneficial effect is dependent on the selection of the right time in the right patient.

Background: The updated epidemiology of injuries at the national and sub-national levels are required for policymakers to effectively handle the burden of injuries. This paper aimed to assess the incidence and risk factors of different injuries in Iran based on a recent national survey. Methods: We used data from Iran Stepwise approach to surveillance (STEPS) Survey 2021, a population-based study in urban and rural areas of Iran's 31 provinces. A multistage clustered probability design and weighting adjustments were used to select eligible individuals and generate estimations. We estimated the incidence of injuries, assessed sociodemographic variables, and identified potential behavioral risk factors associated with injuries, and results were reported for sociodemographic and geographic stratifications. Result: Data from 27,874 participants of the STEPS survey were assessed, of which 1538 (5.5 %, 95 % CI: [5.2–5.8]) reported having an injury in the past 12 months. Falls (44.4 %) were the most common cause of injury, followed by road traffic injury (21.7 %) and exposure to mechanical forces (16.5 %). Except for falls and burns, males had a higher proportion of all types of injuries. Logistic regression analysis showed that being male (OR: 1.7, [1.5, 2.0]) and being an occasional or heavy alcohol drinker (OR: 2.0, [1.3, 3.0] and OR: 2.7, [1.7, 4.1] respectively) were significant risk factors associated with road traffic injuries. Seatbelt use was 90.0 % among both drivers and front-seat passengers, while the use of safety car seats for children was as low as 9.4 %. Injury incidence varied significantly among provinces, with the highest incidence among males observed in Razavi Khorasan (11.2 %) and among females observed in Tehran (12.0 %). Conclusion: This study investigated the updated epidemiology of injuries in Iran and revealed socioeconomic and geographic disparities across country. This epidemiological information can be used to modify injury prevention programs.

Summary: Background: The causes for immune-mediated inflammatory diseases (IMIDs) are diverse and the incidence trends of IMIDs from specific causes are rarely studied. The study aims to investigate the pattern and trend of IMIDs from 1990 to 2019. Methods: We collected detailed information on six major causes of IMIDs, including asthma, inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, psoriasis, and atopic dermatitis, between 1990 and 2019, derived from the Global Burden of Disease study in 2019. The average annual percent change (AAPC) in number of incidents and age standardized incidence rate (ASR) on IMIDs, by sex, age, region, and causes, were calculated to quantify the temporal trends. Findings: In 2019, rheumatoid arthritis, atopic dermatitis, asthma, multiple sclerosis, psoriasis, inflammatory bowel disease accounted 1.59%, 36.17%, 54.71%, 0.09%, 6.84%, 0.60% of overall new IMIDs cases, respectively. The ASR of IMIDs showed substantial regional and global variation with the highest in High SDI region, High-income North America, and United States of America. Throughout human lifespan, the age distribution of incident cases from six IMIDs was quite different. Globally, incident cases of IMIDs increased with an AAPC of 0.68 and the ASR decreased with an AAPC of −0.34 from 1990 to 2019. The incident cases increased across six IMIDs, the ASR of rheumatoid arthritis increased (0.21, 95% CI 0.18, 0.25), while the ASR of asthma (AAPC = −0.41), inflammatory bowel disease (AAPC = −0.72), multiple sclerosis (AAPC = −0.26), psoriasis (AAPC = −0.77), and atopic dermatitis (AAPC = −0.15) decreased. The ASR of overall and six individual IMID increased with SDI at regional and global level. Countries with higher ASR in 1990 experienced a more rapid decrease in ASR. Interpretation: The incidence patterns of IMIDs varied considerably across the world. Innovative prevention and integrative management strategy are urgently needed to mitigate the increasing ASR of rheumatoid arthritis and upsurging new cases of other five IMIDs, respectively. Funding: The Global Burden of Disease Study is funded by the Bill and Melinda Gates Foundation. The project funded by Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38).

Abstract Introduction Despite the significant burden of childhood and adolescent cancers, no specific studies recently discussed the burden of cancer in this group in the North Africa and the Middle East (NAME) region. Therefore, we aimed to study the burden of cancers in this group in this region. Materials and methods We retrieved the Global Burden of Disease (GBD) data for children and adolescent cancers (0–19 years old) in the NAME region from 1990 to 2019. 21 types of neoplasms were grouped as “neoplasms”, comprising 19 specific cancer groups as well as “other malignant neoplasms” and “other neoplasms”. Three significant parameters of incidence, deaths, and Disability-Adjusted Life Years (DALYs) were studied. The data are presented with 95% uncertainty intervals (UI), and reported rates per 100,000. Results In 2019, almost 6 million (95% UI: 4.166 M–8.405 M) new cases and 11,560(9770-13,578) deaths due to neoplasms occurred in the NAME region. Incidence was higher in females (3.4 M), while deaths (6226 of overall 11,560) and DALYs (501,118 of overall 933,885) were estimated as higher in males. Incidence rates did not significantly change since 1990, while deaths and DALYs rates declined significantly. After excluding “other malignant neoplasms” and “other neoplasms”, leukemia was responsible for the highest number of incidence and deaths (incidence: 10,629(8237-13,081), deaths: 4053(3135-5013), followed by brain and central nervous system cancers (incidence: 5897(4192-7134), deaths: 2446(1761-2960)), and non-Hodgkin lymphoma (incidence: 2741 (2237-3392), deaths: 790(645–962)). Incidence rates of neoplasms were similar for most countries, but countries varied more in terms of death rates. Afghanistan 8.9(6.5–11.9), Sudan 6.4(4.5–8.6), and the Syrian Arab Republic 5.6(4.3–8.3) had the highest overall death rates. Conclusion The NAME region is observing relatively constant incidence rates and a decreasing pattern in the deaths and DALYs. Despite this success, several countries are lagging behind in development. Different issues such as economic problems, armed conflicts and political instabilities, lack of equipment or experienced staff or poor distribution, stigmatization and disbelief in the healthcare systems account for unfavorable numbers in some countries. Such problems require urgent solutions as new sophisticated and personalized cares raise the alarm for even more inequalities between high and low-income countries.

Abstract Background Breast cancer (BC), as the top neoplasm in prevalence and mortality in females, imposes a heavy burden on health systems. Evaluation of quality of care and management of patients with BC and its responsible risk factors was the aim of this study. Methods We retrieved epidemiologic data of BC from the Global Burden of Disease (GBD) 1990–2019 database. Epidemiology and burden of BC and its risk factors were explored besides the Quality of Care Index (QCI) introduced before, to assess the provided care for patients with BC in various scales. Provided care for BC risk factors was investigated by their impact on years of life lost and years lived with disability by a novel risk factor quality index (rQCI). We used the socio‐demographic index (SDI) to compare results in different socio‐economic levels. Results In 2019, 1,977,212 (95% UI: 1,807,615–2,145,215) new cases of BC in females and 25,143 (22,231–27,786) in males was diagnosed and this major cancer caused 688,562 (635,323–739,571) deaths in females and 12,098 (10,693–13,322) deaths in males, globally. The all‐age number of deaths and disability‐adjusted life years attributed to BC risk factors in females had an increasing pattern, with a more prominent pattern in metabolic risks. The global estimated age‐standardized QCI for BC in females in 2019 was 78.7. The estimated QCI was highest in high SDI regions (95.7). The top countries with the highest calculated QCI in 2019 were Iceland (100), Japan (99.8), and Finland (98.8), and the bottom countries were Mozambique (16.0), Somalia (8.2), and Central African Republic (5.3). The global estimated age‐standardized rQCI for females was 82.2 in 2019. Conclusion In spite of the partially restrained burden of BC in recent years, the attributable burden to risk factors has increased remarkably. Countries with higher SDI provided better care regarding both the condition and its responsible risk factors.

BackgroundBreast cancer (BC) is the most common cancer in women globally. The North Africa and Middle East (NAME) region is coping hard with the burden of BC. We aimed to present the latest epidemiology of BC and its risk factors in this region.MethodsWe retrieved the data on BC burden and risk factors from the Global Burden of Disease Study 2019 to describe BC status in the 21 countries of the NAME region from 1990 to 2019. We explored BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to seven risk factors of female BC, namely, alcohol use, diet high in red meat, low physical activity, smoking, secondhand smoke, high body mass index, and high fasting plasma glucose. Decomposition analysis on BC incidence trend was done to find out the contributing factors to this cancer’s growth.ResultsIn 2019, there were 835,576 (95% uncertainty interval: 741,968 to 944,851) female and 10,938 (9,030 to 13,256) male prevalent cases of BC in the NAME region. This number leads to 35,405 (30,676 to 40,571) deaths among female patients and 809 (654 to 1,002) deaths in male patients this year. BC was responsible for 1,222,835 (1,053,073 to 1,411,009) DALYs among female patients in 2019, with a greater proportion (94.9%) of burden in years of life lost (YLLs). The major contributor to female BC incidence increase in the past three decades was found to be increase in age-specific incidence rates of BC (227.5%), compared to population growth (73.8%) and aging (81.8%). The behavioral risk factors were responsible for majority of attributable female BC burden (DALYs: 106,026 [66,614 to 144,247]). High fasting plasma glucose was found to be the risk factor with the largest effect (DALYs: 84,912 [17,377 to 192,838]) on female BC burden.ConclusionThe increasing incidence and burden of BC in the NAME region is remarkable, especially when considering limited resources in the developing countries of this region. Proper policies like expanding screening programs and careful resource management are needed to effectively manage BC burden.

Abstract Background Lung cancer is one of the leading cancers, with a high burden worldwide. As a developing country, Iran is facing with population growth, widespread tobacco use, demographic and epidemiologic changes, and environmental exposures, which lead to cancers becoming a severe concern of public health in Iran. We aimed to examine the burden of lung cancer and its risk factors in Iran. Methods We utilized the Global Burden of Disease 2019 data and analyzed the total burden of the lung cancer and seven related risk factors by sex, age at national and sub‐national levels from 1990 to 2019. Results The lung cancer age‐standardized death rate increased from 11.8 (95% Uncertainty Interval: 9.7–14.4) to 12.9 (11.9–13.9) per 100,000 between 1990 and 2019. This increase was among women from 5 (4.2–7.1) to 8 (7.2–8.8) per 100,000; in contrast, there was a decline among men from 18.5 (14.8–22.6) to 17.8 (16.2–19.4) per 100,000. The burden of lung cancer is concentrated in the advanced age groups. Smoking with 53.5% of total attributable deaths (51.0%–55.9%) was the leading risk factor. At the provincial level, there was a wide range between the lowest and highest, from 8.3 (7.0–10.0) to 19.1 (16.4–22.0) per 100,000 population in the incidence rate and from 8.7 (7.3–10.3) to 20.6 (17.7–24.0) per 100,000 population in mortality rate, respectively in Tehran and West Azerbaijan provinces in 2019. Conclusion The increasing trend of lung cancer burden among the entire Iranian population, the inter‐provincial disparities, and the significant rise in burden of this cancer in women necessitate the urgent implementation and development of policies to prevent and manage lung cancer burden and strategies to reduce exposure to risk factors.

Abstract An updated exploration of the burden of thyroid cancer across a country is always required for making correct decisions. The objective of this study is to present the thyroid cancer burden and attributed burden to the high Body Mass Index (BMI) in Iran at national and sub-national levels from 1990 to 2019. The data was obtained from the GBD 2019 study estimates. To explain the pattern of changes in incidence from 1990 to 2019, decomposition analysis was conducted. Besides, the attribution of high BMI in the thyroid cancer DALYs and deaths were obtained. The age-standardized incidence rate of thyroid cancer was 1.57 (95% UI: 1.33–1.86) in 1990 and increased 131% (53–191) until 2019. The age-standardized prevalence rate of thyroid cancer was 30.19 (18.75–34.55) in 2019 which increased 164% (77–246) from 11.44 (9.38–13.85) in 1990. In 2019, the death rate, and Disability-adjusted life years of thyroid cancer was 0.49 (0.36–0.53), and 13.16 (8.93–14.62), respectively. These numbers also increased since 1990. The DALYs and deaths attributable to high BMI was 1.91 (0.95–3.11) and 0.07 (0.04–0.11), respectively. The thyroid cancer burden and high BMI attributed burden has increased from 1990 to 2019 in Iran. This study and similar studies’ results can be used for accurate resource allocation for efficient management and all potential risks’ modification for thyroid cancer with a cost-conscious view.

BackgroundThe most recent emerging infectious disease, coronavirus disease 2019 (COVID-19), is pandemic now. Iran is a country with community transmission of the disease. Telehealth tools have been proved to be useful in controlling public health disasters. We developed an online self-screening platform to offer a population-wide strategy to control the massive influx to medical centers. MethodsWe developed a platform operating based on given history by participants, including sex, age, weight, height, location, primary symptoms and signs, and high risk past medical histories. Based on a decision-making algorithm, participants were categorized into four levels of suspected cases, requiring diagnostic tests, supportive care, not suspected cases. We made comparisons with Iran STEPs (STEPwise approach to Surveillance) 2016 study and data from the Statistical Centre of Iran to assess population representativeness of data. Also, we made a comparison with officially confirmed cases to investigate the effectiveness of the platform. A multilevel mixed-effects Poisson regression was used to check the association of visiting platform and deaths caused by COVID-19. ResultsAbout 310 000 individuals participated in the online self-screening platform in 33 days. The majority of participants were in younger age groups, and males involved more. A significant number of participants were screened not to be suspected or needing supportive care, and only 10.4% of males and 12.0% of females had suspected results of COVID-19. The penetration of the platform was assessed to be acceptable. A correlation coefficient of 0.51 was calculated between suspected results and confirmed cases of the disease, expressing the platform’s effectiveness. ConclusionImplementation of a proper online self-screening tool can mitigate population panic during wide-spread epidemics and relieve massive influx to medical centers. Also, an evidence-based education platform can help fighting infodemic. Noticeable utilization and verified effectiveness of such platform validate the potency of telehealth tools in controlling epidemics and pandemics.

Abstract Background While several studies investigated the epidemiology and burden of stroke in the North Africa and Middle East region, no study has comprehensively evaluated the age-standardized attributable burden to all stroke subtypes and their risk factors yet. Objective The aim of the present study is to explore the regional distribution of the burden of stroke, including ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage, and the attributable burden to its risk factors in 2019 among the 21 countries of North Africa and Middle East super-region. Methods The data of the Global Burden of Disease Study (GBD) 2019 on stroke incidence, prevalence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs) rates, and attributed deaths, DALYs, YLLs, and YLDs to stroke risk factors were used for the present study. Results The age-standardized deaths, DALYs, and YLLs rates were diminished statistically significant by 27.8, 32.0, and 35.1% from 1990 to 2019, respectively. Attributed deaths, DALYs, and YLLs to stroke risk factors, including high systolic blood pressure, high body-mass index, and high fasting plasma glucose shrank statistically significant by 24.9, 25.8, and 28.8%, respectively. Conclusion While the age-standardized stroke burden has reduced during these 30 years, it is still a concerning issue due to its increased burden in all-age numbers. Well-developed primary prevention, timely diagnosis and management of the stroke and its risk factors might be appreciated for further decreasing the burden of stroke and its risk factors and reaching Sustainable Development Goal 3.4 target for reducing premature mortality from non-communicable diseases.

Summary: Background: The objective of this study is to investigate the trends of exposure and burden attributable to the four main metabolic risk factors, including high systolic blood pressure (SBP), high fasting plasma glucose (FPG), high body-mass index (BMI), and high low-density lipoproteins cholesterol (LDL) in North Africa and the Middle East from 1990 to 2019. Methods: The data were retrieved from Global Burden of Disease Study 2019. Summary exposure value (SEV) was used for risk factor exposure. Burden attributable to each risk factor was incorporated in the population attributable fraction to estimate the total attributable deaths and disability-adjusted life-years (DALYs). Findings: While age-standardized death rate (ASDR) attributable to high-LDL and high-SBP decreased by 26.5% (18.6–35.2) and 23.4% (15.9–31.5) over 1990–2019, respectively, high-BMI with 5.1% (−9.0–25.9) and high-FPG with 21.4% (7.0–37.4) change, grew in ASDR. Moreover, age-standardized DALY rate attributed to high-LDL and high-SBP declined by 30.2% (20.9–39.0) and 25.2% (16.8–33.9), respectively. The attributable age-standardized DALY rate of high-BMI with 8.3% (−6.5–28.8) and high-FPG with 27.0% (14.3–40.8) increase, had a growing trend. Age-standardized SEVs of high-FPG, high-BMI, high-SBP, and high-LDL increased by 92.4% (82.8–103.3), 76.0% (58.9–99.3), 10.4% (3.8–18.0), and 5.5% (4.3–7.1), respectively. Interpretation: The burden attributed to high-SBP and high-LDL decreased during the 1990–2019 period in the region, while the attributable burden of high-FPG and high-BMI increased. Alarmingly, exposure to all four risk factors increased in the past three decades. There has been significant heterogeneity among the countries in the region regarding the trends of exposure and attributable burden. Urgent action is required at the individual, community, and national levels in terms of introducing effective strategies for prevention and treatment that account for local and socioeconomic factors. Funding: Bill & Melinda Gates Foundation.

IntroductionMetabolic risk factors (MRFs) predispose populations to a variety of chronic diseases with a huge burden globally. With the increasing burden of these risk factors in Iran, in this study, we aimed to report the estimated burden attributed to MRFs at national and subnational scales in Iran, from 1990 to 2019.MethodsBased on the comparative risk assessment method of the Global Burden of Disease (GBD) Study 2019, data of deaths and disability-adjusted life years (DALYs) attributable to four top MRFs in Iran including high systolic blood pressure (SBP), high fasting plasma glucose (FPG), high body mass index (BMI), and high low-density lipoprotein (LDL) for the 1990–2019 period, were extracted. The socio-demographic index (SDI) was used to report the data based on the corresponding socio-economic stratifications. The results were reported in national and subnational 31 provinces of Iran to discover disparities regarding the attributable burden to MRFs. Furthermore, we reported the causes of diseases to which the attributable burden to MRFs was related.ResultsOverall, the age-standardized high LDL, high SBP, high BMI, and high FPG-attributed death rate changed by −45.1, −35.6, +2.8, and +19.9% from 1990 to 2019, respectively. High SBP was the leading risk factor regarding attributed age-standardized death rates reaching 157.8 (95% uncertainty interval: 135.3–179.1) and DALY rates reaching 2973.4 (2652.2–3280.2) per 100,000 person-years, in 2019. All rates increased with aging, and men had higher rates except for the +70 years age group. At the subnational level, provinces in the middle SDI quintile had the highest death and DALY rates regarding all four MRFs. Total deaths, DALYs, YLLs and YLDs number by the causes of diseases linked to MRFs increased over the study period. Cardiovascular diseases, diabetes mellitus, and kidney diseases were the main causes of burden of disease attributable to MRFs.ConclusionHerein, we found divergent patterns regarding the burden of MRFs as well as disparities in different regions, sex, and age groups for each risk factor and related causes. This could provide policymakers with a clearer vision toward more appropriate decision-making and resource allocation to prevent the burden of MRFs in Iran.

BackgroundThe huge burden of breast cancer (BC) necessitates the profound and accurate knowledge of the most recent cancer epidemiology and quality of care provided. We aimed to evaluate BC epidemiology and quality of care and examine the effects of socioeconomic development and healthcare expenditure on disparities in BC care.MethodsThe results from the GLOBOCAN 2020 study were utilized to extract data on female BC, including incidence and mortality numbers, crude rates, and age-standardized rates [age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs)]. The mortality-to-incidence ratio (MIR) was calculated for different locations and socioeconomic stratifications to examine disparities in BC care, with higher values reflecting poor quality of care and vice versa. In both descriptive and analytic approaches, the human development index (HDI) and the proportion of current healthcare expenditure (CHE) to gross domestic product (CHE/GDP%) were used to evaluate the values of MIR.ResultsGlobally, 2,261,419 (95% uncertainty interval (UI): 2,244,260–2,278,710) new cases of female BC were diagnosed in 2020, with a crude rate of 58.5/100,000 population, and caused 684,996 (675,493–694,633) deaths, with a crude rate of 17.7. The WHO region with the highest BC ASIR (69.7) was Europe, and the WHO region with the highest ASMR (19.1) was Africa. The very high HDI category had the highest BC ASIR (75.6), and low HDI areas had the highest ASMR (20.1). The overall calculated value of female BC MIR in 2020 was 0.30, with Africa having the highest value (0.48) and the low HDI category (0.53). A strong statistically significant inverse correlation was observed between the MIR and HDI values for countries/territories (Pearson's coefficient = −0.850, p-value < 0.001). A significant moderate inverse correlation was observed between the MIR and CHE/GDP values (Pearson's coefficient = −0.431, p-value < 0.001).ConclusionsThis study highlighted that MIR of BC was higher in less developed areas and less wealthy countries. MIR as an indicator of the quality of care showed that locations with higher healthcare expenditure had better BC care. More focused interventions in developing regions and in those with limited resources are needed to alleviate the burden of BC and resolve disparities in BC care.

Abstract Background Data on the burden of stroke and changing trends at national and subnational levels are necessary for policymakers to allocate recourses appropriately. This study presents estimates of the stroke burden from 1990 to 2019 using the results of the Global Burden of Disease (GBD) 2019 study. Methods For the GBD 2019, verbal autopsy and vital registration data were used to estimate stroke mortality. Cause‐specific mortality served as the basis for estimating incidence, prevalence, and disability‐adjusted life years (DALYs). The burden attributable to stroke risk factors was calculated by a comparative risk assessment. Decomposition analysis was applied to determine the contribution of population aging, population growth, and changes in the age‐specific incidence rates. Results In 2019, the number of prevalent cases, incident cases, and deaths due to stroke in Iran were 963,512; 102,778; and 40,912, respectively. The age‐standardized incidence rate (ASIR) and the age‐standardized death rate (ASDR) decreased from 1990 to 2019. Of national stroke ASDRs in 2019, 44.7% (35.7–54.7%) were attributable to hypertension and 28.8% (15.2–57.4) to high fasting plasma glucose. At the subnational level, the trend of the stroke incidence and mortality rate decreased in all provinces. Stroke was responsible for 4.48% of total DALYs in 2019 (3.38% due to ischemic stroke, 0.87% due to intracerebral hemorrhage, and 0.22% due to subarachnoid hemorrhage). Conclusion ASIR and ASDR of stroke are decreasing nationally and subnationally; however, the number of incident cases and deaths are increasing in all SDI quintiles, possibly due to population growth.

BackgroundKidney dysfunction is a risk factor for cardiovascular disease and chronic kidney disease. Herein, we aimed to describe the attributable burden of kidney dysfunction at the national and sub-national levels in Iran.MethodsThe Global Burden of Disease (GBD) 2019 data were extracted on the deaths, disability-adjusted life years (DALYs), years of life lost, and years lived with disability attributed to the risk factor of kidney dysfunction by age and sex at the national and provincial levels from 1990-2019. Also, risk exposure was reported by summary exposure value (SEV) with a range of 0 to 100. The estimated values were based on a comparative risk assessment framework.ResultsIn 2019, the age-standardized death rate and age-standardized DALYs rate attributable to kidney dysfunction were 58.2 (95% uncertainty interval of 48.8-68.1) and 1127.2 (981.1-1282.7) per 100,000 population in Iran, respectively. Also, the Sistan and Baluchistan province (1729.3 [1478.3-2006.4]) and the province of Tehran (681.9 [571.4-809.8]) had the greatest and lowest age-standardized DALYs rates, respectively. Nationally, SEVs increased from 22.8 to 26.2. The age-standardized burden attributable to kidney dysfunction had a positive association with age advancement. The attributable age-standardized deaths and DALYs rates in all socio-demographic index regions decreased from 1990-2019. Also, the highest and lowest attributable age-standardized DALYs rates of kidney dysfunction came from ischemic heart disease and peripheral artery disease in 2019, respectively.ConclusionAlthough the attributed age-standardized DALYs and death rates decreased from 1990-2019, risk exposure increased and remains a crucial risk factor in Iran. Therefore, policymakers should consider preparing a preventive program that takes into account different levels of prevention of kidney dysfunction.

ObjectiveTo provide estimates on the regional and national burden of tracheal, bronchus, and lung (TBL) cancer and its attributable risk factors from 1990 to 2019 in the North Africa and Middle East (NAME) region.Methods and materialsThe Global Burden of Disease (GBD) 2019 data were used. Disability-adjusted life years (DALYs), death, incidence, and prevalence rates were categorized by sex and age groups in the NAME region, in 21 countries, from 1990 to 2019. Decomposition analysis was performed to calculate the proportion of responsible factors in the emergence of new cases. Data are presented as point estimates with their 95% uncertainty intervals (UIs).ResultsIn the NAME region, TBL cancer caused 15,396 and 57,114 deaths in women and men, respectively, in 2019. The age-standardized incidence rate (ASIR) increased by 0.7% (95% UI -20.6 to 24.1) and reached 16.8 per 100,000 (14.9 to 19.0) in 2019. All the age-standardized indices had a decreasing trend in men and an increasing trend in women from 1990 to 2019. Turkey (34.9 per 100,000 [27.6 to 43.5]) and Sudan (8.0 per 100,000 [5.2 to 12.5]) had the highest and lowest age-standardized prevalence rates (ASPRs) in 2019, respectively. The highest and lowest absolute slopes of change in ASPR, from 1990 to 2019, were seen in Bahrain (-50.0% (-63.6 to -31.7)) and the United Arab Emirates (-1.2% (-34.1 to 53.8)), respectively. The number of deaths attributable to risk factors was 58,816 (51,709 to 67,323) in 2019 and increased by 136.5%. Decomposition analysis showed that population growth and age structure change positively contributed to new incident cases. More than 80% of DALYs could be decreased by controlling risk factors, particularly tobacco use.ConclusionThe incidence, prevalence, and DALY rates of TBL cancer increased, and the death rate remained unchanged from 1990 to 2019. All the indices and contribution of risk factors decreased in men but increased in women. Tobacco is still the leading risk factor. Early diagnosis and tobacco cessation policies should be improved.

BackgroundThe aim of this study was to examine the quality of care by age and gender in oesophageal cancer using Global Burden of Disease (GBD) database.MethodsPatients aged 20 and over with oesophageal cancer were included in this longitudinal study using GBD 1990-2019 data. We used the Socio-Demographic Index (SDI) to classify the regions. We used Principal Component Analysis (PCA) method to calculate the Quality of Care Index (QCI). The QCI was rescaled into a 0-100 single index, demonstrating that the higher the score, the better the QC.ResultsThe age-standardized QCI for oesophageal cancer dramatically increased from 23.5 in 1990 to 41.1 in 2019 for both sexes, globally. The high SDI regions showed higher QCI than the rest of the regions (45.1 in 1990 and 65.7 in 2019) whereas the low SDI regions had the lowest QCI, which showed a 4.5% decrease through the years (from 13.3 in 1990 to 12.7 in 2019). Globally, in 2019, the QCI showed the highest scores for patients aged 80-84, reported 48.2, and the lowest score for patients aged 25-29 reported 31.5, for both sexes. Globally, in 2019, age-standardized Gender Disparity Ratio (GDR) was 1.2, showing higher QCI in females than males.ConclusionThere were fundamental differences in the QCI both globally and regionally between different age groups as well as between males and females. To achieve the goal of providing high-quality services equally to people in need in all over the world, health systems need to invest in effective diagnostic services, treatments, facilities, and equipment and to plan for screening and surveillance of high-risk individuals.

Abstract Background To measure the quality of care for lip and oral cavity cancer worldwide using the data from the Global Burden of Disease (GBD) Study 2017. Methods After devising four main indices of quality of care for lip and oral cavity cancer using GBD 2017 study’s measures, including prevalence, incidence, years of life lost, years lived with disability, and disability-adjusted life years, we utilised principal component analysis (PCA) to determine a component that bears the most proportion of info among the others. This component of the PCA was considered as the Quality-of-Care Index (QCI) for lip and oral cavity cancer. The QCI score was then reported in both men and women worldwide and different countries based on the socio-demographic index (SDI) and World Bank classifications. Results Between 1990 and 2017, care quality continuously increased globally (from 53.7 to 59.6). In 1990, QCI was higher for men (53.5 for men compared with 50.8 for women), and in 2017 QCI increased for both men and women, albeit a slightly higher rise for women (57.2 for men compared with 59.9 for women). During the same period, age-standardised QCI for lip and oral cavity cancer increased in all regions (classified by SDI and World Bank). Globally, the highest QCI scores were observed in the elderly age group, whereas the least were in the adult age group. Five countries with the least amount of QCIs were all African. In contrast, North American countries, West European countries and Australia had the highest indices. Conclusion The quality of care for lip and oral cavity cancer showed a rise from 1990 to 2017, a promising outcome that supports patient-oriented and preventive treatment policies previously advised in the literature. However, not all countries enjoyed such an increase in the QCI to the same extent. This alarming finding could imply a necessary need for better access to high-quality treatments for lip and oral cavity cancer, especially in central African countries and Afghanistan. More policies with a preventive approach and paying more heed to the early diagnosis, broad insurance coverage, and effective screening programs are recommended worldwide. More focus should also be given to the adulthood age group as they had the least QCI scores globally.

BackgroundThyroid cancer is the leading cause of mortality and morbidity among cancers of the endocrine system. We aimed to describe the trends of thyroid cancer burden in North Africa and Middle East for 1990–2019.MethodsData on burden of thyroid cancer in North Africa and Middle East from 1990 to 2019 were obtained from the Global Burden of Disease (GBD) Study 2019. Decomposition analysis was used to estimate the effects of population growth, aging, and change in incident numbers on overall change of thyroid cancer incidence. Also, we used the comparative risk assessment framework of GBD to determine the burden of thyroid cancer attributable to a high body mass index (BMI).ResultsIn 2019, the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) of thyroid cancer were 3.5 (2.9–4) and 0.5 (0.5–0.7) per 100,000, respectively. The highest age-standardized incidence, deaths, and disability-adjusted life year (DALY) rate were in Lebanon, Afghanistan, and United Arab Emirates, respectively. The ASIR of thyroid cancer in region was about 2.5 times higher among women, which had a positive association with increasing age. In 2019, the age-standardized deaths attributable to a high BMI was 16.7% of all deaths due to thyroid cancer. In 1990–2019, the overall change in thyroid cancer incident cases was a 396% increase which was mostly driven by the increase in disease-specific incidence rate (256.8%).ConclusionsWomen, the elderly above about 60 years old, and countries with a higher sociodemographic index showed higher incidence rates of thyroid cancer. Regarding our findings, it is recommended to establish preventive plans by modification in life style like weight reduction programs.

BackgroundProstate cancer (PCa) is the second most prevalent cancer among men worldwide. This study presents estimates of PCa prevalence, incidence, death, years-of-life-lost (YLLs), years-lived-with-disability (YLDs), disability-adjusted-life-years (DALYs), and the burden attributable to smoking during 1990-2019 in North Africa and Middle East using data of Global Burden of Diseases (GBD) Study 2019.MethodsThis study is a part of GBD 2019. Using vital registration and cancer registry data, the estimates on PCa burden were modeled. Risk factor analysis was performed through the six-step conceptual framework of Comparative Risk Assessment.ResultsThe age-standardized rates (95% UI) of PCa incidence, prevalence, and death in 2019 were 23.7 (18.5-27.9), 161.1 (126.6-187.6), and 11.7 (9.4-13.9) per 100,000 population. While PCa incidence and prevalence increased by 77% and 144% during 1990-2019, respectively, the death rate stagnated. Of the 397% increase in PCa new cases, 234% was due to a rise in the age-specific incidence rate, 79% due to population growth, and 84% due to population aging. The YLLs, YLDs, and DALYs of PCa increased by 2% (-11.8-23.1), 108% (75.5-155.1), and 6% (-8.9-28.1). The death rate and DALYs rate attributable to smoking have decreased 12% and 10%, respectively. The DALYs rate attributable to smoking was 37.4 (15.9-67.8) in Lebanon and 5.9 (2.5-10.6) in Saudi Arabia, which were the highest and lowest in the region, respectively.ConclusionsThe PCa incidence and prevalence rates increased during 1990-2019; however, the death rate stagnated. The increase in the incidence was mostly due to the rise in the age-specific incidence rate, rather than population growth or aging. The burden of PCa attributable to smoking has decreased in the past 30 years.

BackgroundThe adherence to speed limits can reduce deaths associated with road traffic injuries (RTIs) by more than a quarter. This study aimed to evaluate the effective factors on the speeding behavior of Iranian taxi drivers around fixed speed cameras.MethodTelematics devices used in this study collected the location and speed of the vehicles. The units of analysis in this study were trips per camera, including 2.5 km before and after each camera. Linear regression analysis was used to identify kangaroo driving (KD), defined as trips with a significant V-shape in speed distribution around the camera. In the clustered camera zones, cameras were placed at regular intervals of approximately 3.5 km.FindingsA total of 93,160 trips were recorded from 13,857,443 data points. There was an inverse association between drivers' age and KD with an odds ratio (OR) of 0.98 (95% confidence interval: 0.98–0.98). The intercity trips had a substantially higher probability of KD than urban trips (OR: 4.94 [4.73–5.16]). The tendency of drivers toward KD during the daylight hours vs. nighttime was significant for both urban (OR: 1.15 [1.06–1.25]) and intercity (OR: 1.18 [1.14–1.22]) trips. The 4 −8 a.m. period had the highest chance of KD in both urban (10.71% [7.41–14.53]) and intercity (44.13% [41.18–47.09]) trips. There was a significant decrease in the odds of KD inside the clustered camera zones (OR: 0.22 [0.20–0.25]).ConclusionThe heterogeneous occurrence of KD in different locations and times indicates the necessity of evidence-based decision-making in urban planning to improve safe driving behaviors. The lower occurrence of KD in clustered camera zones could be a practical key to the effective control of speeding behaviors by helping in the efficient placement of cameras through sustainable development of cities and roads.

Abstract Background Thyroid cancer (TC) is the most prevalent malignancy of the endocrine system. Over the past decades, TC incidence rates have been increasing. TC quality of care (QOC) has yet to be well understood. We aimed to assess the quality of TC care and its disparities. Methods We retrieved primary epidemiologic indices from the Global Burden of Disease (GBD) 1990–2017 database. We calculated four secondary indices of mortality to incidence ratio, disability‐adjusted life years (DALYs) to prevalence ratio, prevalence to incidence ratio, and years of life lost (YLLs) to years lived with disability (YLD) ratio and summarized them by the principal component analysis (PCA) to produce one unique index presented as the quality of care index (QCI) ranged between 0 and 100, to compare different scales. The gender disparity ratio (GDR), defined as the QCI for females divided by QCI for males, was applied to show gender inequity. Results In 2017, there were 255,489 new TC incident cases (95% uncertainty interval [UI]: 245,709–272,470) globally, which resulted in 41,235 deaths (39,911–44,139). The estimated global QCI was 84.39. The highest QCI was observed in the European region (93.84), with Italy having the highest score (99.77). Conversely, the lowest QCI was seen in the African region (55.09), where the Central African Republic scored the lowest (13.64). The highest and lowest socio‐demographic index (SDI) regions scored 97.27 and 53.85, respectively. Globally, gender disparity was higher after the age of 40 years and in favor of better care in women. Conclusion TC QOC is better among those countries of higher socioeconomic status, possibly due to better healthcare access and early detection in these regions. Overall, the quality of TC care was higher in women and younger adults. Countries could adopt the introduced index of QOC to investigate the quality of provided care for different diseases and conditions.

Abstract Background Hematologic malignancies (HMs) are a heterogeneous group of cancers that comprise diverse subgroups of neoplasms. So far, despite the major epidemiologic concerns about the quality of care, limited data are available for patients with HMs. Thus, we created a novel measure—Quality of Care Index (QCI)—to appraise the quality of care in different populations. Methods The Global Burden of Disease data from 1990 to 2017 applied in our study. We performed a principal component analysis on several secondary indices from the major primary indices, including incidence, prevalence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) to create the QCI, which provides an overall score of 0–100 of the quality of cancer care. We estimated the QCI for each age group on different scales and constructed the gender disparity ratio to evaluate the gender disparity of care in HMs. Results Globally, while the overall age-standardized incidence rate of HMs increased from 1990 to 2017, the age-standardized DALYs and death rates decreased during the same period. Across countries, in 2017, Iceland (100), New Zealand (100), Australia (99.9), and China (99.3) had the highest QCI scores for non-Hodgkin lymphoma, multiple myeloma, Hodgkin lymphoma, and leukemia. Conversely, Central African Republic (11.5 and 6.1), Eritrea (9.6), and Mongolia (5.4) had the lowest QCI scores for the mentioned malignancies respectively. Overall, the QCI score was positively associated with higher sociodemographic of nations, and was negatively associated with age advancing. Conclusions The QCI provides a robust metric to evaluate the quality of care that empowers policymakers on their responsibility to allocate the resources effectively. We found that there is an association between development status and QCI and gender equity, indicating that instant policy attention is demanded to improve health-care access.

Background Development of surveillance systems based on big data sources with spatial information is necessitated more than ever during this pandemic. Here, we present our pilot results of a new technique for the incorporation of spatial information of transactions and a vital registry of COVID-19 to evaluate the disease spread. Methods We merged two databases of laboratory-confirmed national COVID-19 registry of Iran and financial transactions of point-of-sale devices from February to March 2020 as our training data sources. Spatial information was used for the visualization of maps and movements of sick individuals. We used the point-of-sale devices-related guild to check for the dynamics of financial transactions and effectiveness of quarantines. Findings In the study period, 174,428 confirmed cases were in the COVID-19 registry with accompanying transactions information. In total, 13,924,982 financial transactions were performed by them, with a mean of 1.2 per day for each person. All guilds had a decreasing pattern of “risky” transactions except for grocery stores and pharmacies. The latter showed a decreasing pattern by impose of lockdowns. Different cities were the hotspot of disease transmission as many “high-risk” transactions were performed in them, among which Tehran (mainly its central neighborhoods) and southern cities of Lake Urmia predominated. Lockdowns indicated that the disease gradually became less transmissible. Interpretation Financial transactions can be readily used for epidemics surveillance. Semi real-time results of such iterations can be informative for policy makers, guild owners, and general population to prepare safer commuting and merchandise spaces.

Introduction Bladder cancer (BCa) is the second most common genitourinary cancer and among the leading causes of cancer-related deaths. We aimed to assess BCa quality of care (QOC) utilizing a novel multi-variable quality of care index (QCI). Materials and methods Data were retrieved from the Global Burden of Disease 1990–2019 database. QCI scores were calculated using four indices of prevalence-to-incidence ratio, Disability-Adjusted Life Years-to-prevalence ratio, mortality-to-incidence ratio, and Years of Life Lost-to-Years Lived with Disability ratio. We used principal component analysis to allocate 0–100 QCI scores based on region, age groups, year, and gender. Results Global burden of BCa is on the rise with 524,305 (95% UI 475,952–569,434) new BCa cases and 228,735 (95% UI 210743–243193) deaths in 2019, but age-standardized incidence and mortality rates did not increase. Global age-standardized QCI improved from 75.7% in 1990 to 80.9% in 2019. The European and African regions had the highest and lowest age-standardized QCI of 89.7% and 37.6%, respectively. Higher Socio-demographic index (SDI) quintiles had better QCI scores, ranging from 90.1% in high SDI to 30.2% in low SDI countries in 2019; however, 5-year QCI improvements from 2014 to 2019 were 0.0 for high and 4.7 for low SDI countries. Conclusion The global QCI increased in the last 30 years, but the gender disparities remained relatively unchanged despite substantial improvements in several regions. Higher SDI quintiles had superior QOC and less gender- and age-based inequalities compared to lower SDI countries. We encourage countries to implement the learned lessons and improve their QOC shortcomings.

Background Peptic ulcer disease (PUD) affects four million people worldwide annually and has an estimated lifetime prevalence of 5−10% in the general population. Worldwide, there are significant heterogeneities in coping approaches of healthcare systems with PUD in prevention, diagnosis, treatment, and follow-up. Quantifying and benchmarking health systems’ performance is crucial yet challenging to provide a clearer picture of the potential global inequities in the quality of care. Objective The objective of this study was to compare the health-system quality-of-care and inequities for PUD among age groups and sexes worldwide. Methods Data were derived from the Global Burden of Disease Study 1990–2019. Principal-Component-Analysis was used to combine age-standardized mortality-to-incidence-ratio, disability-adjusted-life-years-to-prevalence-ratio, prevalence-to-incidence-ratio, and years-of-life-lost-to-years-lived-with-disability-into a single proxy named Quality-of-Care-Index (QCI). QCI was used to compare the quality of care among countries. QCI’s validity was investigated via correlation with the cause-specific Healthcare-Access-and-Quality-index, which was acceptable. Inequities were presented among age groups and sexes. Gender Disparity Ratio was obtained by dividing the score of women by that of men. Results Global QCI was 72.6 in 1990, which increased by 14.6% to 83.2 in 2019. High-income-Asia-pacific had the highest QCI, while Central Latin America had the lowest. QCI of high-SDI countries was 82.9 in 1990, which increased to 92.9 in 2019. The QCI of low-SDI countries was 65.0 in 1990, which increased to 76.9 in 2019. There was heterogeneity among the QCI-level of countries with the same SDI level. QCI typically decreased as people aged; however, this gap was more significant among low-SDI countries. The global Gender Disparity Ratio was close to one and ranged from 0.97 to 1.03 in 100 of 204 countries. Conclusion QCI of PUD improved dramatically during 1990–2019 worldwide. There are still significant heterogeneities among countries on different and similar SDI levels.

IntroductionBladder cancer (BCa) is the second most common genitourinary cancer and among the leading causes of cancer-related deaths. We aimed to assess BCa quality of care (QOC) utilizing a novel multi-variable quality of care index (QCI).Materials and methodsData were retrieved from the Global Burden of Disease 1990-2019 database. QCI scores were calculated using four indices of prevalence-to-incidence ratio, Disability-Adjusted Life Years-to-prevalence ratio, mortality-to-incidence ratio, and Years of Life Lost-to-Years Lived with Disability ratio. We used principal component analysis to allocate 0-100 QCI scores based on region, age groups, year, and gender.ResultsGlobal burden of BCa is on the rise with 524,305 (95% UI 475,952-569,434) new BCa cases and 228,735 (95% UI 210743-243193) deaths in 2019, but age-standardized incidence and mortality rates did not increase. Global age-standardized QCI improved from 75.7% in 1990 to 80.9% in 2019. The European and African regions had the highest and lowest age-standardized QCI of 89.7% and 37.6%, respectively. Higher Socio-demographic index (SDI) quintiles had better QCI scores, ranging from 90.1% in high SDI to 30.2% in low SDI countries in 2019; however, 5-year QCI improvements from 2014 to 2019 were 0.0 for high and 4.7 for low SDI countries.ConclusionThe global QCI increased in the last 30 years, but the gender disparities remained relatively unchanged despite substantial improvements in several regions. Higher SDI quintiles had superior QOC and less gender- and age-based inequalities compared to lower SDI countries. We encourage countries to implement the learned lessons and improve their QOC shortcomings.

Background Colorectal cancer (CRC) is among the five most incident and lethal cancers in world and its burden varies between countries and sexes. We aimed to present a comprehensive measure called the quality of care index (QCI) to evaluate the inequity and healthcare quality of care regarding CRC by sex and location. Methods Data on the burden of CRC were extracted from the Global Burden of Disease study 2019. It was transformed to four ratios, including mortality-to-incidence, disability-adjusted life years (DALYs)-to-prevalence, prevalence-to-incidence, and years of life lost (YLLs)-to-years lived with disability (YLDs). Principal component analysis was implemented on the four ratios and the most influential component was considered as QCI with a score ranging from zero to 100, for which higher scores represented better quality of care. Gender Disparity Ratio (GDR) was calculated by dividing QCI for females by males. Results The global incidence and death numbers of CRC were 2,166,168 (95% uncertainty interval: 1,996,298–2,342,842) and 1,085,797 (1,002,795–1,149,679) in 2019, respectively. Globally, QCI and GDR values were 77.6 and 1.0 respectively in 2019. There was a positive association between the level of quality of care and socio-demographic index (SDI) quintiles. Region of the Americas and African Region had the highest and lowest QCI values, respectively (84.4 vs. 23.6). The QCI values started decreasing beyond the age of 75 in 2019 worldwide. Conclusion There is heterogeneity in QCI between SDI quintiles. More attention should be paid to people aged more than 75 years old because of the lower quality of care in this group.

Background The increasing burden of hypertension in low- to middle-income countries necessitates the assessment of care coverage to monitor progress and guide future policies. This study uses an ensemble learning approach to evaluate hypertension care coverage in a nationally representative Iranian survey. Methods The data source was the cross-sectional 2016 Iranian STEPwise approach to risk factor surveillance (STEPs). Hypertension was based on blood pressure ≥140/90 mmHg, reported use of anti-hypertensive medications, or a previous hypertension diagnosis. The four steps of care were screening (irrespective of blood pressure value), diagnosis, treatment, and control. The proportion of patients reaching each step was calculated, and a random forest model was used to identify features associated with progression to each step. After model optimization, the six most important variables at each step were considered to demonstrate population-based marginal effects. Results The total number of participants was 30541 (52.3% female, median age: 42 years). Overall, 9420 (30.8%) had hypertension, among which 89.7% had screening, 62.3% received diagnosis, 49.3% were treated, and 7.9% achieved control. The random forest model indicated that younger age, male sex, lower wealth, and being unmarried/divorced were consistently associated with a lower probability of receiving care in different levels. Dyslipidemia was associated with reaching diagnosis and treatment steps; however, patients with other cardiovascular comorbidities were not likely to receive more intensive blood pressure management. Conclusion Hypertension care was mostly missing the treatment and control stages. The random forest model identified features associated with receiving care, indicating opportunities to improve effective coverage.

BackgroundThe increasing burden of hypertension in low- to middle-income countries necessitates the assessment of care coverage to monitor progress and guide future policies. This study uses an ensemble learning approach to evaluate hypertension care coverage in a nationally representative Iranian survey.MethodsThe data source was the cross-sectional 2016 Iranian STEPwise approach to risk factor surveillance (STEPs). Hypertension was based on blood pressure ≥140/90 mmHg, reported use of anti-hypertensive medications, or a previous hypertension diagnosis. The four steps of care were screening (irrespective of blood pressure value), diagnosis, treatment, and control. The proportion of patients reaching each step was calculated, and a random forest model was used to identify features associated with progression to each step. After model optimization, the six most important variables at each step were considered to demonstrate population-based marginal effects.ResultsThe total number of participants was 30541 (52.3% female, median age: 42 years). Overall, 9420 (30.8%) had hypertension, among which 89.7% had screening, 62.3% received diagnosis, 49.3% were treated, and 7.9% achieved control. The random forest model indicated that younger age, male sex, lower wealth, and being unmarried/divorced were consistently associated with a lower probability of receiving care in different levels. Dyslipidemia was associated with reaching diagnosis and treatment steps; however, patients with other cardiovascular comorbidities were not likely to receive more intensive blood pressure management.ConclusionHypertension care was mostly missing the treatment and control stages. The random forest model identified features associated with receiving care, indicating opportunities to improve effective coverage.

BackgroundPeptic ulcer disease (PUD) affects four million people worldwide annually and has an estimated lifetime prevalence of 5-10% in the general population. Worldwide, there are significant heterogeneities in coping approaches of healthcare systems with PUD in prevention, diagnosis, treatment, and follow-up. Quantifying and benchmarking health systems' performance is crucial yet challenging to provide a clearer picture of the potential global inequities in the quality of care.ObjectiveThe objective of this study was to compare the health-system quality-of-care and inequities for PUD among age groups and sexes worldwide.MethodsData were derived from the Global Burden of Disease Study 1990-2019. Principal-Component-Analysis was used to combine age-standardized mortality-to-incidence-ratio, disability-adjusted-life-years-to-prevalence-ratio, prevalence-to-incidence-ratio, and years-of-life-lost-to-years-lived-with-disability-into a single proxy named Quality-of-Care-Index (QCI). QCI was used to compare the quality of care among countries. QCI's validity was investigated via correlation with the cause-specific Healthcare-Access-and-Quality-index, which was acceptable. Inequities were presented among age groups and sexes. Gender Disparity Ratio was obtained by dividing the score of women by that of men.ResultsGlobal QCI was 72.6 in 1990, which increased by 14.6% to 83.2 in 2019. High-income-Asia-pacific had the highest QCI, while Central Latin America had the lowest. QCI of high-SDI countries was 82.9 in 1990, which increased to 92.9 in 2019. The QCI of low-SDI countries was 65.0 in 1990, which increased to 76.9 in 2019. There was heterogeneity among the QCI-level of countries with the same SDI level. QCI typically decreased as people aged; however, this gap was more significant among low-SDI countries. The global Gender Disparity Ratio was close to one and ranged from 0.97 to 1.03 in 100 of 204 countries.ConclusionQCI of PUD improved dramatically during 1990-2019 worldwide. There are still significant heterogeneities among countries on different and similar SDI levels.

BackgroundColorectal cancer (CRC) is among the five most incident and lethal cancers in world and its burden varies between countries and sexes. We aimed to present a comprehensive measure called the quality of care index (QCI) to evaluate the inequity and healthcare quality of care regarding CRC by sex and location.MethodsData on the burden of CRC were extracted from the Global Burden of Disease study 2019. It was transformed to four ratios, including mortality-to-incidence, disability-adjusted life years (DALYs)-to-prevalence, prevalence-to-incidence, and years of life lost (YLLs)-to-years lived with disability (YLDs). Principal component analysis was implemented on the four ratios and the most influential component was considered as QCI with a score ranging from zero to 100, for which higher scores represented better quality of care. Gender Disparity Ratio (GDR) was calculated by dividing QCI for females by males.ResultsThe global incidence and death numbers of CRC were 2,166,168 (95% uncertainty interval: 1,996,298-2,342,842) and 1,085,797 (1,002,795-1,149,679) in 2019, respectively. Globally, QCI and GDR values were 77.6 and 1.0 respectively in 2019. There was a positive association between the level of quality of care and socio-demographic index (SDI) quintiles. Region of the Americas and African Region had the highest and lowest QCI values, respectively (84.4 vs. 23.6). The QCI values started decreasing beyond the age of 75 in 2019 worldwide.ConclusionThere is heterogeneity in QCI between SDI quintiles. More attention should be paid to people aged more than 75 years old because of the lower quality of care in this group.

Primary brain and other central nervous system (CNS) cancers cause major burdens. In this study, we introduced a measure named the Quality of Care Index (QCI), which indirectly evaluates the quality of care given to patients with this group of cancers. Here we aimed to compare different geographic and socioeconomic patterns of CNS cancer care according to the novel measure introduced. In this regard, we acquired age-standardized primary epidemiologic measures were acquired from the Global Burden of Disease (GBD) study 1990-2017. The primary measures were combined to make four secondary indices which all of them indirectly show the quality of care given to patients. Principal Component Analysis (PCA) method was utilized to calculate the essential component named QCI. Further analyses were made based on QCI to assess the quality of care globally, regionally, and nationally (with a scale of 0-100 which higher values represent better quality of care). For 2017, the global calculated QCI was 55.0. QCI showed a desirable condition in higher socio-demographic index (SDI) quintiles. Oppositely, low SDI quintile countries (7.7) had critically worse care quality. Western Pacific Region with the highest (76.9) and African Region with the lowest QCIs (9.9) were the two WHO regions extremes. Singapore was the country with the maximum QCI of 100, followed by Japan (99.9) and South Korea (98.9). In contrast, Swaziland (2.5), Lesotho (3.5), and Vanuatu (3.9) were countries with the worse condition. While the quality of care for most regions was desirable, regions with economic constraints showed to have poor quality of care and require enforcements toward this lethal diagnosis.

BackgroundCOVID-19 has triggered an avalanche of research publications, the various aspects of which need to be assessed. The objective of this study is to determine the scientific community's response patterns to COVID-19 through a bibliometric analysis of the time-trends, global contribution, international collaboration, open-access provision, science domains of focus, and the behavior of journals.MethodsThe bibliographic records on COVID-19 literature were retrieved from both PubMed and Scopus. The period for searching was set from November 1, 2019, to April 15, 2021. The bibliographic data were coupled with COVID-19 incidence to explore possible association, as well as World Bank indicators and classification of economies.ResultsA total of 159132 records were included in the study. Following the escalation of incidences of COVID-19 in late 2020 and early 2021, the monthly publication count made a new peak in March 2021 at 20505. Overall, 125155 (78.6%) were national, 22548 (14.2%) were bi-national, and 11429 (7.2%) were multi-national. Low-income countries with 928 (66.8%) international publications had the highest percentage of international. The open-access provision decreased from 85.5% in February 2020 to 62.0% in April 2021. As many as 82841 (70.8%) publications were related to health sciences, followed by life sciences 27031 (23.1%), social sciences 20291 (17.3%), and physical sciences 15141 (12.9%). The top three medical subjects in publications were general internal medicine, public health, and infectious diseases with 28.9%, 18.3%, and 12.6% of medical publications, respectively.ConclusionsThe association between the incidence and publication count indicated the scientific community's interest in the ongoing situation and timely response to it. Only one-fifth of publications resulted from international collaboration, which might lead to redundancy without adding significant value. Our study underscores the necessity of policies for attraction of international collaboration and direction of vital funds toward domains of higher priority.