Iranian Journal of Public Health
Volume:53 Issue: 4, Apr 2024

Health information systems are critically important in disaster management. It supports disaster management activities and the information needed for decision-making support. We aimed to evaluate comprehensively published literature on disaster health information systems designed to identify and extract the required framework and components.

A systematic review approach was used to systematically seek, screen, and synthesize data extracted from papers on using health information systems in disasters from the electronic databases (Scopus, PubMed, ProQuest, and SAGE) with no limit up to Jan 2022 following the PRISMA declaration for reporting. The inclusion criteria consisted of full-text journal articles, publications in English, and studies focusing on disaster health information systems, critically evaluated articles using the Joanna Brigg Institute (JBI). Content analysis was used to analyze extracted data.

Of 998 identified references, 18 articles were finally included and analyzed in this study and they are good quality according to appraisal results using JBI. Most reports described research of development or working prototypes and working framework; only two referred to early research or proposed design or framework. Of 18 articles; identified into 3 themes; 4 DHISs in pre-disaster, thirteen DHISs used during the disaster, and one DHIS in post-disaster were identified.

All the systems have a design or framework starting from strategies and plans, information flow, disaster management, and operation engagement, and involve all stakeholders, including the community. Its systems are supported by the latest technology and methods and the principles of integration and interoperability to obtain a DHIS that can assist decision-making processes.

Several observational studies have suggested that maternal exposure during pregnancy to arsenic is associated with the risk of preterm birth (PTB); however, available evidence is inconsistent. Therefore, we aimed to explore the relation of maternal exposure to arsenic to PTB risk.

A comprehensive systematic search was carried out from inception to April 2023 in PubMed and Scopus to retrieve all relevant studies. A pooled odds ratio (OR) with corresponding 95% confidence interval (CI) was employed using a random effects model to test the association.

As a result, 14 eligible studies, with 12,619 participants, were included in the meta-analysis. Overall, the pooled OR of all analyzed studies indicated that higher maternal arsenic exposure is significantly related to the 1.12-fold increased odds of PTB (OR = 1.12, 95% CI = 1.04-1.21), with a remarkable heterogeneity across studies (P = <0.001, I2 = 70.9%). This association was found in prospective cohort studies (OR = 1.15, 95% CI = 1.05-1.26), but not in non-cohort studies. In the stratified analysis, the majority of subgroups supported the association of arsenic with PTB.

Maternal exposure to arsenic during pregnancy is directly linked to the odds of PTB. Future studies are suggested to investigate the effectiveness of specific measures to decrease exposure to arsenic in high-risk communities, particularly in pregnant women.

Brisk walking exercise is an aerobic exercise with the moderate intensity that can reduce the risk in people with hypertension. This systematic review and meta-analysis aimed to investigate the effects of interventions related to brisk walking and blood pressure reduction in hypertensive patients.

Search strategy through the PubMed, Science Direct, ProQuest, and Google Scholar databases limited from 2018 to 2023. The components measured are systolic blood pressure and diastolic blood pressure. This study uses the Black and Downs checklist to measure the quality of the study, which consists of 3, namely high quality, medium quality, and low quality. Effect size analysis of the study used the standard mean difference between brisk walking exercise and not doing brisk walking exercise.

The results of the identification of the database obtained 1700 articles, then limited by title, year, abstract (n = 381), and full-text article feasibility (n = 76) to obtain nine articles included. Nine articles were included in the systematic review and meta-analysis by study quality: six studies of high quality, 2 of medium quality, and 1 of low quality. Systolic blood pressure had a substantial effect size in all studies (P<0.05; SMD: -0.55) while diastolic blood pressure had an effect medium size (P=0.05; SMD: 0.13).

Brisk walking exercise can significantly reduce blood pressure in people with hypertension—recommendations for the future to carry out community-based physical activity in improving physical health, including heart health.

We aimed to analyze the prevalence of depression among the global public during COVID-19, identify its influencing factors in order to provide reference, and help safeguard public mental health.

A comprehensive literature on global public depression in various countries during the COVID-19 pandemic was obtained through electronic searches of PubMed, Web of Science, and other databases, combined with literature tracing from Dec 2019 to Mar 2023. Then a meta-analysis was conducted using the random effects model by Stata 16.0. The heterogeneity was evaluated by I2. Subgroup analysis, sensitivity analysis, and meta-regression analysis were used to explore the sources of heterogeneity and the factors influencing public depression. Egger's test was used to test publication bias.

Overall, 68 articles with 234,678 samples were included in the study. Analysis revealed that the overall prevalence of depression among the population during COVID-19 was 32.0% (95% CI: 29.0%-35.0%). Of these, marital status (OR=0.65, 95% CI: 0.47-0.87), presence of infected cases (OR=2.45, 95% CI: 1.82-3.30), and fear of being infected by the virus (OR=9.31, 95% CI: 6.03-14.37) were the main factors influencing people’s depression and the main source of heterogeneity.

The prevalence of depression among the global public is at a high level during COVID-19. The prevalence of depression among people unmarried, divorced, or widowed, surrounded by infected cases, contact infection cases, and worried about being were higher than others.

Brucellosis is one of the most common zoonotic infections. Although culture is the gold standard diagnostic method, bacterial growth in blood cultures may not always occur due to various factors. We aimed to investigate demographic, clinical, and laboratory findings that may have predictive significance for bacteremia in brucellosis.

Patients older than 18 years of age followed up with a diagnosis of brucellosis between 2012 and 2022 were included in this retrospective multicenter study. They were divided into two main subgroups according to their Brucella species reproductive status as bacteremic and non-bacteremic.

A total of 743 patients, 370 (49.80%) bacteremic and 373 (50.20%) non-bacteremic brucellosis patients, were enrolled. The mean age of the bacteremic group (36.74 years) was lower than the non-bacteremic group (43.18 yr). High fever, chills/cold, sweating, nausea, vomiting, and weight loss were more common in the bacteremic group. In the bacteremic group, white blood cell count, platelet count, hemoglobin level, mean platelet volume, eosinophil, and neutrophil counts were lower, and lymphocyte, erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and ferritin levels were higher. According to the receiver operating characteristic (ROC) analysis, when the cut-off value of ferritin was considered 67, it was the parameter with the strongest predictive significance in Brucella bacteremia.

High ferritin level, low eosinophil count, and increased erythrocyte sedimentation rate were determined as the most critical laboratory findings in predicting bacteremia in brucellosis.

Middle-aged women have lower health-related quality of life (HRQoL) than men, and women's participation in economic activities is an important issue. In this study, the middle-aged female population was classified by economic activity participation to explore HRQoL and to identify related factors.

We obtained data from the 2017 Korea Health Panel Survey (N = 1857 women aged 50–64 years), analyzed with chi-squared tests, t-tests, analyses of variance, and multiple regression analyses. HRQoL was measured with the Euro QoL-5 Dimensions index, and four demographic factors, four health behavior factors, and ten health status factors were entered.

HRQoL was lower in the economically inactive group compared to the active group. Education, physical activity, chronic disease, vision problem, dental problem, activity restriction, frustration, and anxiety were associated with HRQoL in both groups. Spouse and household income were additional predictors identified only in the economically inactive group, and the 10 factors explained 36.0% of the variance. In the economically active group, drinking, sleeping time, hearing problem, stress, and depression were additional predictors identified, and the 13 factors explained 23.0% of the variance.

Healthcare providers should consider both common predictors between economically active and inactive middle-aged women as well as predictors that were unique to each group to improve their HRQoL.

COVID-19 infection is transmitted easily and quickly, exposing medical care workers, especially nursing workers, to tremendous stress. Therefore, identifying the factors influencing the sleep quality of nurses and implementing corresponding interventions are conducive to improving the sleep quality of nurses and enhancing their nursing quality.

Form September to December 2022, a survey-based evaluation was conducted on 1074 front-line clinical nurses randomly selected from three hospitals in Zhejiang Province, China. Based on the survey results, 152 nurses were selected and randomly divided into the experimental group and the control group, with 76 nurses in each group. A 2-month psychological intervention based on the self-transcendence theory was conducted, and the two groups were compared before and after the intervention.

The average PSQI score of nurses was 7.19±3.65, with 471 of them suffering from poor sleep (PSQI>7), accounting for 45.46%. In addition, 57.10% of the nurses were under excessive stress, whereas 62% of them had a Self-Rating Anxiety Scale score of ≥50. After the intervention, the PSQI score of the experimental group was significantly lower than that of the control group, with the difference being statistically significant (P<0.05).

Clinical nurses in tertiary hospitals have poor sleep quality and more severe stress and anxiety problems during COVID-19 than during non-epidemic periods. Clinical interventions based on the self-transcendence theory can effectively improve the sleep quality of nurses. Results of this study provide reference for enhancing the sleep quality of nurses and ensuring their physical and mental health during epidemic.

We aimed to investigating the sex-specific and age-specific melanoma mortality trends observed on the territory of Serbia between 2000 and 2021.

This population-based study used data from the Statistical Office of the Republic of Serbia database during the period 2000–2021. The calculation of the gender and age-standardized rates (ASR) was performed. We used a regression analysis complete with linear trend model.

The mean ASR was 1.77 per 100,000 people, meaning that male mortality rates (2.24 per 100,000) was higher than female mortality rates (1.34 per 100,000). During the observation period, a rising trend in mortality from melanoma skin cancer was reported. Observed by gender, the change of melanoma mortality trend was significant in men (P=0.021), but not in women (P=0.747). The annual growth rate of ASRs values was 1.43%. A increase in the melanoma mortality rate was observed since 2000 by 2.44% annually in males and by 2.79% annually in females. Mortality rates were increasing in both sexes as they aged, and the greatest number of deaths was recorded in the group of those aged 80 yr or above (16.25 per 100,000 for men; 10.45 per 100,000 for women).

Our study findings underline the importance of launching more effective public health awareness campaigns to educate people about the dangers of melanoma and its symptoms’ detection along with establishing a diagnosis at an early stage of the disease, especially among male patients and those at an advanced age.

We aimed to compare the difference of the chromosomal abnormalities using karyotype analysis and chromosomal microarray (CMA) as well as to evaluate their application in different prenatal diagnosis indications.

Overall, 3007 pregnant women with prenatal diagnosis indications from Medical Genetics Department of Linyi Women and Children’s Health Care Hospital, who underwent standard G-banded karyotype analysis and CMA, were enrolled from 2018-2022. G-banded karyotype analysis and CMA were undergone simultaneously. All fetuses with genetic variants were enrolled for further analyzing. The frequency and differences of chromosomal abnormalities of the two methods were compared in different prenatal diagnosis indications groups.

CMA improved 4.09% (123/3007) of genetic changes compared karyotype analysis. CMA is on par with karyotyping for detection of aneuploidies and gross unbalanced rearrangements. Serological screening and ultrasound abnormalities were the main indications of prenatal diagnosis. The detection rate of chromosomal abnormalities was highest in non-invasive prenatal testing (NIPT) abnormal group. In the ultrasound abnormality group, the detection rate of genetic variants in nuchal translucency (NT) increased group was higher than other subgroups and there was statistically significant difference in the detection rate of pCNVs. CMA can detect 5.57% (40/718) more genetic abnormalities in ultrasound abnormality group on the normal karyotype. CMA improved 0.67% (20/3007) of genetic changes with clinically significant compared karyotype, brought 3.42% (103/3007) of variants with uncertain significance (VOUS).

CMA identified additional, clinically significant genetic variants on the basis of normal karyotype analysis, brought a proportion of unclear significant variants. All the pregnant women accepted amniocentesis should be informed about their characteristics of karyotype analysis and CMA by genetic counselors.

Obesity is becoming a real challenge for public health among pregnant women. This study aimed to identify sociodemographic and lifestyle risk factors and outcomes linked to maternal obesity and overweight.

A cross-sectional study was carried out from Nov 2021 to Dec 2022 in the maternity health facility of Mohammed VI Hospital, as well as in one of the main health centers with a delivery unit in Marrakech, Morocco. Parturients were divided into four categories according to their pre pregnancy BMI: underweight, normal weight, overweight and obese. We used the chi-square test (χ²) to analyze the sociodemographic and lifestyle factors associated with maternal obesity and overweight. The same tool was utilized to explore maternal and neonatal complications.

Overall, 400 parturient women with singleton pregnancies were included in the study. The prevalence of overweight and obesity was 29.8% and 31.5% respectively. Maternal age, type of housing, practicing sports, feelings about pregnancy were correlated with an increased risk of maternal obesity and being overweight. The risks of gestational diabetes, hypertension, anemia, cesarean delivery, and fetal macrosomia were higher among overweight and obese women compared to normal weight ones. The differences were significant (P<0.05).

Maternal overweight and obesity are strongly linked with socio-economic, lifestyle, and psychological factors which can lead to serious complications for both mother and baby. Further research is needed to develop appropriate preventive measures and interventions for maternal obesity and overweight.

We started with RNA-seq analysis and aimed to investigate the possibility of secretory protein matrix metalloproteinase-3(MMP3) as a new diagnosis and therapeutic target in cervical cancer.

The study was conducted on Nov 2021 at the Second Affiliated Hospital of Qiqihar Medical University, Qiqihar, China. Through conjoint analysis of gene expression data as well as survival rate data, we explored the potential secretary proteins associated with cervical cancer carcinogenesis. One hundred patients aged 38-72 years with clinical stage I-IV cervical cancer, and 100 age-matched healthy women were included. The expression changes in serum of clinical patients was detected. We knockdown or overexpressed the secretory proteins then explored its influence on biological function of cervical cancer cells.

By cross-analysis of The Cancer Genome Atlas (TCGA) database and MetazSecKB database, MMP3 gene was most significantly upregulated in cervical cancer patients (P < 0.05). Furthermore, MMP3 protein was remarkably increased in the serum of clinical cervical cancer patients and decreased after receiving treatment. Overexpression of MMP3 in HT-3 cells or culturing new cells using the supernatant of the medium after MMP3 overexpression could increase cell viability (P < 0.05) as well as proliferation (P < 0.05). Knockdown of MMP3 reduced the phosphorylation of PI3K as well as AKT proteins, while the PI3K phosphorylation inhibitors could suppress the impact of MMP3 on increasing cell proliferation as well as viability.

MMP3 could be an underlying target for early diagnosis and treat cervical cancer in the future.

Lower socioeconomic groups were more affected by depressive symptoms among adults of Serbia. In this study, we tested a model that examines association between sociodemographic factors and depressive symptoms among adult population in Serbia.

The study was conducted within the National Health Survey of the Serbian population in 2019. The questionnaires used as instruments in this study were created in accordance with the questionnaires of the European Health Interview Survey –Third Wave. The Patient Health Questionnaire - 8 was used to evaluate the presence of depressive symptoms to the adult population aged 20 years and over. The relations between depression symptoms and a set of independent variables were examined with univariate and multivariate logistic regression analyses.

The prevalence of mild depressive symptoms was 6.6%, %, the prevalence of depressive episodes was 2.2%, while 91.2% of respondents had no depressive symptoms. In the univariate regression model, depressive episodes is 1.9 times more frequent in women (OR=1.909), 6.6 times more frequent in persons over 80 years of age (OR=6.610 ), 3.1 times more frequent in divorced or without a partner (OR=3.143 ), 6.6 times more frequent in persons with low education (OR=6.609), 3.3 times more frequent in persons with a poor well-being index (OR=3.373), 3.6 times more frequent in persons inactive (OR=3.649) and 1.9 times more frequent in persons from Vojvodina (OR=1.902).

Sociodemographic factors should be considered for policymaking and for the development of new interventions to lower prevalence of depressive symptoms in adults.

Adolescence is an important period of growth and development. We aimed to analyz the factors affecting the subjective health and physical fitness perceptions of Korean adolescents.

This cross-sectional study used data from 2,599 Korean adolescents who participated in the Korea National Life and Sports Surveys during 2020-2022, along with secondary data analysis. The study included frequency analysis of the demographic variables and chi-square tests to examine the relationship between the variables and subjective health and fitness perceptions. Multivariate logistic regression was also used to explore the factors affecting adolescent subjective perceptions.

The study revealed significant factors influencing health perceptions in Korean adolescents, including male gender, lack of regular physical activity, adequate rest, adherence to a consistent diet, and use of nutritional supplements (P<0.05).

Key factors, such as rest, diet, and nutritional supplements should be considered while developing policies that support adolescent health. Unfortunately, there has been a decline in the physical activity of adolescents in Korea. Therefore, a variety of physical activity programs that consider the characteristics of each student need to be developed to address adolescent health issues.

Triglyceride-glucose index is a product of triglycerides and fasting plasma glucose (FPG) and is a new index of insulin resistance found to correlate with direct measurements. This study aimed to evaluate the relationship between gallstones and triglyceride-glucose index (TGI).

A total of 210 patients were included in this retrospective study. Overall, 105 patients with gallstones were included in the patient group. Patients with diabetes mellitus, chronic diseases, malignant diseases, and patients using cholesterol-lowering drugs were excluded from the study. Healthy individuals (105 cases) were selected for the control group. TGI was calculated separately for each individual using the following formula: (TGI) = ln (fasting TG (mg/dL) x fasting glucose (mg/dL)/2)

Plasma triglyceride levels were significantly higher in patients with gallstones compared to the control group (P=0.001). Plasma HDL, LDL, and total cholesterol did not differ between the groups (P>0.05). Fasting blood glucose was significantly higher in patients with gallstones compared to the control group (P=0.001). The triglyceride glucose index was significantly higher in patients with gallstones compared to the control group (P<0.001). When the relationship between body mass index and TGI was analyzed, TGI was lower in patients with normal BMI compared to overweight or obese patients (P<0.001).

Increased triglyceride/glucose index in patients with gallstones is an indicator of insulin resistance. It is instrumental in demonstrating the presence of insulin resistance in patients with gallstones and may be a useful guide in earlier detection, prevention, and treatment of insulin resistance.

The global phenomenon of population aging requires an understanding of the factors influencing the health of the elderly becomes imperative. We aimed to focus on South Korea, a nation set to become an aging society by 2025.  The study examined the influence of regular exercise and exercise types on the health of the elderly with particular attention to South Korea's unique sociodemographic context.

We targeted individuals aged 50 yr and above. The study was conducted through online surveys from August to September 2023.  Utilizing Logistic Regression analysis and Chi-Square tests, the research explored correlations, trends, and influencing factors affecting elderly exercise behaviors, encompassing demographic variables, health status, and exercise types.

The analysis of demographic characteristics revealed that marital status, education level, and financial status displayed diverse representations within the sample. Comparisons between health status and exercise groups suggested potential health benefits for the Regular Exercise group. Logistic Regression analysis identified significant influences of gender and financial status on regular exercise engagement. Additionally, a strong relationship between health status and exercise preferences, notably strength training, emerged.

Regular exercise and exercise types benefit elderly individuals. Men and those with better financial status are more likely to exercise regularly. Strength training emerges as a significant contributor to better health across various health status categories. Policymakers and healthcare professionals should consider these insights to develop targeted interventions for promoting healthy aging, acknowledging the cultural and socioeconomic factors of South Korea's aging population.

We aimed to investigate the impact of multidisciplinary educational team-based clinical nursing pathway on the psychological resilience, treatment adherence, pain management and quality of life in cancer patients.

From 2019 to 2020, eighty two cancer patients were selected and randomly divided into the control group and the observational group. Both groups were treated with routine oncology nursing and the multidisciplinary educational team-based clinical nursing pathway, respectively. Psychological resilience, pain management and qualify of life were assessed by the Chinese version of the Connor-Davidson resilience scale, revised American Pain Society Patient Outcome Questionnaire and the Nottingham health profile, respectively. Treatment adherence was semi-quantitatively classified as “good”, ”fair” and “bad”.

Patient’s psychological resilience, compliance, pain outcome and quality of life were similar between the control group and the observational group on admission. Patient’s psychological resilience, compliance and pain outcome in the observational group were significantly superior to those in the control group one day prior to discharge and 2 months post-discharge (all P<0.05). The scores of energy, emotions, sleep and mobility were significantly different between the observational group and the control group one day prior to discharge and 2 months post-discharge (all P<0.05). Significant improvements were observed with regard to the scores of energy, sleep and mobility in the control group 2 months post-discharge, whereas the scores of energy, emotions, sleep and mobility improved dramatically in the observational group (all P<0.05).

Compared with routine oncology nursing, multidisciplinary educational team-based clinical nursing pathway could improve patient’s psychological resilience, treatment adherence, pain management and quality of life.

This study presents estimates for type 2 diabetes mellitus (T2DM) burden and attributable risk factors in Iran from 1990–2019, using data from the 2019 Global Burden of Disease study.

This study reports prevalence, incidence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) of T2DM in Iran, by sex, age, and province, from 1990 to 2019. We also present the T2DM burden attributable to risk factors. Results are reported in absolute number and age-standardized rates.

Overall, the burden of T2DM had increased greatly since 1990. In 2019, the T2DM incidence and prevalence cases were 291,482 (a 374% increase) and 5,035,012 (a 417% increase) respectively. Moreover, the number of death and DALYs were 14,191 (a 488% increase) and 716,457 (a 417% increase) respectively. DALYs and YLDs in women were consistently higher than men were, whereas women experienced slower increases in YLLs from 1990 to 2019. The age-standardized DALYs rate increased for all Iranian provinces during study period. High body-mass index, ambient particulate matter pollution, and low physical activity remained the three major attributable risk factors in all provinces in 2019.

T2DM constitutes a major health burden in Iran. The remarkable upsurge in the T2DM burden represents an ongoing challenge, given the rapidly aging population in Iran. Thus, integrated and multi-sectoral actions that decrease exposure to risk factors and improve the prevention and early diagnosis are needed.

Identifying different groups of customers and their preferences and needs enable countries to gain a competitive advantage in the medical tourism market. We aimed to segment medical tourists from West Asian countries seeking medical services in Iran.

This cross-sectional study was conducted on 596 medical tourists who sought medical services in Iran in 2021. Data were collected using a valid questionnaire. Segmentation was performed based on medical tourism attributes (medical, destination, and tourism attributes), using cluster analysis methods; wards, and K means. The segments ' evaluation and profiling were conducted using discriminant analysis, chi-square, and one-way ANOVA tests.

Our study divided the market into five segments: health seekers (3.8%), health and destination seekers (8.9%), tourism seekers (17.8%), infrastructure seekers (10.23%), and perfectionism (59.45%). In all segments, the health attributes were of high importance. The perfectionism segment registered the highest score in all three attributes (more than 5 of 6).

Improving health attributes and offering luxurious medical services can be the main strategy for Iran to attract the most medical tourists and achieve a good position in this marketplace. The implication of this study is policymaking for targeting the most profitable segment of this marketplace.

The lncRNAs has been linked to several malignancies, including breast cancer. Our objective was to investigate the impact of urothelial carcinoma associated 1 (UCA1) on cellular growth and death by a CRISPR/Cas9 knockdown technique.

In 2020, the CHOPCHOP program was utilized to design two sgRNAs targeting the UCA gene. sgRNA1 and sgRNA2 were inserted into two different CRISPR plasmids to produce two recombinant plasmids. These recombinant plasmids were simultaneously transfected into MCF-7 and MDA-MB 231 carcinoma of the breast cells. Proliferation and apoptosis were compared using the MTT test, CCK-8 assay, and flow cytometry evaluation. RNA-hybrid software, quantitative reverse transcription PCR, and luciferase assays were utilized to confirm the relationship between UCA1 and miR-143.

Proliferated cells were less active in MTT and CCK-8 tests and fellow cytometry analysis. The PX459-sgRNA1,2 group had elevated levels of the cancer biomarker Caspase-3 gene expression (P<0.001). When WT-UCA1 and miR-143 were co-transfected, the luciferase activity was drastically decreased.

One very effective method of regulating cellular proliferation in vitro is the deletion of UCA1, which CRISPR/Cas9 accomplishes.

Decision-making is choosing one option from among different options. Most decision-making models were developed in the general industry. Specific decision-making models are needed due to the special nature of the hospital and its services. We aimed to propose and validate a decision-making model for hospital managers.

This research used the modified Delphi technique to develop and validate a decision-making model for hospital managers. A data collection form was used to collect data. The search of English databases covered the period from 1990 to 2020. The first draft of the model was introduced through a scoping review and semi-structured interviews. Two rounds of Delphi were conducted with 33 experts to verify the proposed model.

Many factors affect the quality and outcome of a hospital manager's decision. The decision- making model developed in this study has 10 constructs grouped into three components (i.e., inputs, processes, and outputs). These constructs include decision maker, decision implementer, organization, client, subject, analysis, identification, evaluation & selection, implementation and control. This model provides a guide for each decision stage and determines the conditions necessary for a good decision.

Using the decision-making puzzle and considering the set of inputs, processes, and outcomes of the decision making together alongside with specifying the details of each decision-making stage make it easy for hospital managers to decide. Such a scientific, objective and systematic approach in decision-making will result in desired results for staff, patients, managers and the hospital. This puzzle is also a good tool for pathology of hospital managers' decisions.

High frequency of insecticide used to control German cockroaches may lead to insecticide resistance development. We aimed to compare the level of insecticide resistance and heterogeneity in insecticide resistance of field-collected German cockroaches in eight selected zones of Mashhad City, Razavi Khorasan Province, Iran.

The present study was conducted from October 2019 to May 2021. Adult and nymphs of German cockroaches were collected from infested restaurants or hotels in eight zones of Mashhad City and then colonized in an insectarium. The cockroaches were subjected to bioassay against cypermethrin insecticide. In addition, the genomic DNA of each cockroach population was analyzed in the region where the kdr mutations reside in the German cockroach.

The LT50 values against cypermethrin in the susceptible strain (SS) and eight field-collected strains so varied from 17.52 to 95.36 min. The resistance ratio of the strains was also different in response to the insecticide. The similarity of multiple sequence alignments at the amino acid level was 97.5%-100%. An exon 20 transversion mutation and a nonsynonymous substitution were found. The L1014F substitution was detected in 83.4% of the cockroach samples.

The field-collected strains were resistant to cypermethrin at different levels. Furthermore, the molecular study confirms the heterogeneity in the level of resistance among eight strains. Therefore, eight strains might have a different history of insecticide treatment.