In recent years Pakistan has faced frequent measles outbreaks killing hundreds of children despite the availability of vaccine for decades. This study was undertaken to determine the persistence of maternal transferred measles antibody levels in infants before measles vaccination with relation to their feeding practices.A cross sectional study was conducted at district Islamabad over 1 year between 1st October 2013 to 30th Sept. 2016. Any infant less than 9 months of age, not suffering from an acute or debilitating illness and not vaccinated was enrolled in the study. After taking written informed consent from parents / guardians, information was collected on a pretested questionnaire. About 3 cc venous blood was taken to quantify any measles IgG antibodies. Data was analyzed by using Epi Info 7.2 version.P value: < 0.000063).Three hundred eighty-four infants were enrolled and were divided into three age groups, 1–90, 91–180 and 181–270 days age groups. Mean age of infants was 4.4 months ±3.2 SD. Male to female ratio was 1.2:1. A level of maternal measles IgG antibodies ≥12 U/ml was taken as protective. Of total 384 infants, 91(24%) had protective measles antibody titters (> 12 U/ml). and 65 (73%) of them were on breast milk. Highest antibody levels were found in 1–90 days age group. Analysis showed that 181–270 days aged infants had 3.1875 more odds of having unprotected/ low levels of antibodies against measles than children aged less than 180 days. Age group < 180 days found to be statistically significant with protective IgG levels (OR: 3.1875, Measles protective antibodies were found in infants < 180 days age group. Breast feeding provides early protection against measles. Levels drop down to low levels immediately after birth and then after 06 months. It is, therefore, recommended that measles vaccination should be considered for administration at 6 months or even earlier if measles immunity is desired. Measles is one of the most common childhood fevers which is highly contagious and characterized by coryza, cough, conjunctivitis and specific exanthema followed by generalized maculo-papular eruption . TransmiIn Pakistan measles vaccination coverage has increased and its reported first dose coverage reached 88% in 2012 . HoweverThe sources of maternally transmitted antibodies  in childThis passive immunity to measles, mumps and rubella usually lasts for about a year . About 1Considering these facts this study was undertaken to determine specific antibodies (IgG) against measles to evaluate the immune status of the under 9 months aged children before the start of immunization to provide evidence to policy makers regarding the measles vaccination schedule.A cross sectional community based survey was conducted in Islamabad, Pakistan over 12 months (1st Oct. 2015 to 30th Sept. 2016). Cluster sampling technique was used for selection of study site. In the first phase Islamabad was divided into urban and rural strata and then six clusters each from urban and rural strata were selected.For urban; list of sectors was obtained and only three sectors were selected while in case of rural cluster, three villages/ suburban areas were selected by convenience sampling however the households were selected randomly. Rural population is defined as people living in rural areas as determined by national statistical offices of Pakistan and it is calculated as the difference between total population and urban population excluding army. Fifty samples were collected from each locality.Healthy infants aged < 09 months of either gender with informed consent of participation by their parents / guardians.Children with the recent history of an acute illness/ chronic illness such as tuberculosis, hepatitis etc. and children suffering from laboratory confirmed measles illness.Sample size: Sample size was calculated on the basis of population under 1 year in 2012 (24.3 births/ 1000 population in midyear or 4 million/ year) with 5% margin of error, 95% confidence interval and with 10% refusal rate as 384 infants.The study had been ethically approved by Institutional Review Board (IRB) of Pakistan Medical Research Council (PMRC), Islamabad.The Lady Health Workers (LHWs) of selected areas were used as community gate keepers. A lady health worker is a female who has secondary level of education. She is selected from the same community where she will serve after training by the health department. She is a paid worker and works within the community, collects data about different diseases and shares this data on a monthly basis to her supervisor. LHWS in the selected study area helped the team in their communications about the study starting a day before survey.The research team consisting of one male, one female data collector and a phlebotomist. They started identifying houses from periphery and worked systematically towards the center of the selected area - which was a mosque or common sitting place for villagers in rural areas and in case of urban sectors, it was central market “MARKAZ”. After arriving at the periphery, the right or left lane was selected by tossing a coin and then the first house was selected randomly. Every second house was knocked to enquire about the presence of child as per inclusion criteria. If the door was locked or child was not found or in case of refusal, the next second house was selected. Within the selected house, in case of more than one eligible child, children were selected randomly.The questionnaire was formulated and shared with subject experts for construct and conduct validity. Suggestions were incorporated and field testing was done. Feedback received after pretesting was also incorporated in final data collection tool. The final questionnaire had three sections: demographic information of the mother and the child, history of duration of pregnancy and mode of delivery, feeding practices of the newborn and third sections about measles vaccination. Written informed consent was taken from parents/ guardians, before starting recording the information on the questionnaire.Blood samples (3.0 cc) were drawn in gel tube from all study participants and was labeled. Samples were centrifuged and sera were analyzed to detect Measles antibodies (IgG) using ELISA. The ELISA Measles IgG titer of ≥12 U/ml was considered “protective” or “positive.” whereas titers below 12 U/ ml were reported as “unprotective” or “Negative”. In this study, we expressed the measles IgG in U/ml according to the reference provided by the ELISA kit manufacturer, rather than in milli-international units per milliliter based on the international standards. Simple criteria based on the detection limit of < 0.00 for measles antibody was used to exclude low concentration data (relative variance).The serum samples were tested for the measles IgG antibodies. Technique: Measles IgG antibodies were tested using ELISA kits at central Research Centre, PMRC, NIH, Islamabad.We analyzed data using Epi Info version 7.2. The percentages of positive and negative sera were calculated. Means were computed for age and IgG titers. For testing the association between continuous variables, multiple linear regression was used.Three hundred eighty-four infants were enrolled. Once the infants were enrolled, participants were divided into three age groups and included 1–90 days, 91–180 days and 181–270 days age groups.Mean age of infants was 4.4 months ±3.2 SD. Male to female ratio was 1.2:1 whereas mean maternal age was 26.8 ± 4.9 SD. A level of maternal measles IgG antibodies ≥12 U/ml was taken as protective as well as positive for presence of measles antibodies after vaccination. Mean titer of IgG antibody was 0.57 U/ml. Of total 384 infants, 91(24%) were found to have protective measles antibody titers (> 12 U/ml), remaining 293 (76%) infants had lower levels. Out of 91infants who had protective measles antibodies, 65 (73%) infants were on breast milk,  were of term gestation and delivered normally while 106 were delivered through C-Section with mean IgG values of .569 and .596 respectively.Based on current study findings, the odds of contracting measles is 1.26 times greater in children aged 6–9 months than children less than 6 months of age. However, it should be noted that transmission, or contracting measles, is complex and potentially requires lack of herd immunity, exposure to measles, nutritional status, vaccine technique, unprotective titers at birth, etc. Table Out of 384 participants, there were 143 (37%), 108 (28%) and 134 (35%) infants in age groups of 1–90, 91–180 and 181–270 days respectively. Mean IgG levels in the 1–90 days group was > 8.0 U/ml, > 12 U/ml in 91–180 days group and > 8.0 U/ml in group 181–270 days age group whereas p. values were .0001, .608 and .484 respectively.In this study we found that in the 1–90 days age group the mean measles IgG level was > 8.0 U/ml, in the 91–180 days group < 12 U/ml and in the 181–270 days age group it was > 8.0 U/ml with respective p. values of 0.0001 (significant), 0.608 (Not significant) and 0.484 (Not significant). Regarding the feeding practices, IgG antibodies were 0.574 (8-12 U), 0.466 (< 8.0 U) and 0.634 (> 12 U) in breast feed group, animal feed group and breast milk+ top feed group respectively. Out of 483, 71.8% (275) were of term gestation and delivered normally while 106 were delivered through C-Section with mean IgG values of 0.569 and 0.596 respectively which are not statistically significant. These findings are in accordance with other studies –16 reveaThis study revealed that the measles protective measles antibodies were present in 91–180 days age group as compared to 1–90 days age group and 181–270 age groups. Muscat et al. in their study discussed that there is waning of the maternal transferred measles antibodies in the infants before vaccination age e.g., < 1 year, therefore measles risk and severity are greater than the risk and severity among those aged ≥1 year . It is cA Nigerian study revealed that 58% of children had lost the protective maternal antibody by the age of 4 months and only 3% of the children had enough antibodies to protect them between the ages of 6–9 months . Our stuSandra et al. in their study found that the estimated duration of protection by maternal antibodies among infants was short e.g. 3.3 months for measles , and ourIn Pakistan, not every child is born with enough trans-placentally transferred anti-measles antibody levels to protect the child during infancy. Further, most of the maternal acquired antibodies wane before reaching the current recommended age for vaccination e.g. 09 months. It is, therefore suggested that vaccine may need to be repeated (> 2 doses) and that the measles first dose is delivered before 09 months of age, if measles immunity is desired. It calls an urgent need to review the measles vaccination schedule from 09 months to 06 months to protect these susceptible infants.In our current study, measles protective antibodies were found mostly among infants < 180 days age group. Of total 384 infants, 91(24%) had protective measles antibody titters (> 12 U/ml) and 65 (73%) of them were on breast milk. This implies that breast feeding provides early protection against measles however, these acquired levels drop down to low levels immediately after birth and then after 06 months. In Pakistan, though women tend to breast-feed their babies, however due to poor maternal nutritional status coupled with repeated pregnancies; don’t allow mothers to nurse their babies with exclusive feeding. Secondly, measles is endemic in Pakistan so the current schedule to give first measles shot at the age of 09 months leaves the child vulnerable to this preventable illness. Based on the results of this study, we urge further consideration to the possibility of earlier measles vaccination administration, such as at 6 months, to attempt to save more infants from this fatal infection.


This study assessed clinical and radiographic outcomes of oblique lumbar interbody fusion (OLIF) in comparison with posterior reoperation for adjacent segment disease (ASD).A total of 26 patients with symptomatic ASD after lumbar fusion were included in this retrospective case-controlled study conducted from January 2013 to December 2018. Twelve patients underwent single-segment OLIF with or without posterior instrumentation (OLIF group), whereas 14 patients underwent posterior reoperation (posterior approach group). The clinical outcomes included operative time, blood loss, hospital stay, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and complications. Preoperative and postoperative radiographic outcomes were compared.P < 0.05) and the blood loss in the OLIF group 89.2 ± 49.0 ml vs. 340.7 ± 130.2 ml, respectively; P < 0.05) were significantly lower than those in the posterior group. The hospital stay was lower in the OLIF group than in the posterior approach group . In the posterior approach group, 6 of 14 patients (42.8%) had issue with dural tear, while none in the OLIF group had such issue (P < 0.05). The ODI score  and the VAS back pain score were lower in the OLIF group postoperatively and at last follow-up. In the OLIF group, the radiographic outcomes were significantly improved postoperatively.The operative time (60.6 ± 16.1 min vs. 150.9 ± 28.5 min, respectively; Due to our results and early experiences, we proposed that OLIF was safe and effective for ASD. Compared with posterior reoperation, OLIF results in shorter operative time and hospital stay, lesser blood loss, and lower risk of dural injury. Adjacent segment disease (ASD) is one of the most common complications of lumbar spine fusion . RecentlSurgical intervention is considered when conservative therapies fail to relieve symptoms associated with ASD. There have been many surgical procedures described for the treatment of ASD, including the posterior approach with decompression and extended fusion , anterioOblique lumbar interbody fusion (OLIF) was first described by Michael Mayer in 1977 , which iThis study was a retrospective case-controlled study conducted at Shaoxing People’s Hospital from January 2013 to December 2018. Data were analyzed after obtaining approval from the Medical Ethics Committee of Shaoxing People’s Hospital (NO2019012) on January 15, 2019. Informed consent was obtained from all individual participants included in this study. The surgeries were performed by two senior surgeons. The radiographic evaluations were performed by two independent senior radiologists, and the final result was the average of the two testing values.The inclusion criteria for this study were single-level symptomatic ASD with failed conservative treatment for more than 3 months, age 18–65 years, MRI images showing inclusive disc herniation or mild degenerative spondylolisthesis (I or II)  at the aThere were 26 patients with symptomatic ASD after posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) included in this study, of which 12 patients underwent single-segment OLIF with or without posterior internal fixation (OLIF group) and 14 patients underwent posterior approach with extended fusion and decompression (posterior approach group). Demographic data including age, sex, body mass index (BMI), bone mineral density (BMD), number of initial fusion segments, level of ASD, time to reoperation, and follow-up time were recorded.< − 1.0, additional posterior internal fixations were performed.In the OLIF group, patients were placed in the lateral decubitus position on their right side after the induction of general anesthesia. Under fluoroscopy, the center of the targeted disc was marked on the skin. A 4-cm skin incision was made 4–6 cm anterior to the center of the marked disc. External oblique, internal oblique, and transverse abdominal muscles were then dissected along the direction of their fibers in this muscle-splitting approach. Then, the retroperitoneal space was accessed by blunt dissection, and the peritoneal content was mobilized anteriorly. The psoas muscle was identified and retracted posteriorly. After the targeted disc was exposed and fluoroscopically verified, subtotal discectomy was performed and vertebral endplates were prepared. Afterwards, a cage  filled with bone allograft was inserted, and its position was fluoroscopically confirmed. Rubber drains were placed, and the incision was closed in a layered fashion. For patients with preoperative BMD In the posterior approach group, a posterior midline incision was made. Partial laminectomy and partial facetectomy were performed for decompression. Then, discectomy and endplate preparation were performed. An interbody fusion cage  filled with autograft bone was inserted into the intervertebral space. Initial rods were removed, and extended internal fixation with pedicle screw system  was applied.All patients were allowed weight-bearing for 3 days after surgery, and they wore a lumbar brace for 3 months postoperatively.The clinical data, including operative time, blood loss, and length of hospital stay, were obtained. The perioperative complications, including incision infection, dural tear, nerve injury, ureteral injury, peritoneal content injury, cage displacement, and reoperation, were also recorded. The Oswestry Disability Index (ODI)  for low Lateral radiography of the lumbar spine was performed preoperatively and postoperatively to measure the IVH, intervertebral foraminal height (IFH), and intervertebral foraminal area (IFA) at the targeted segment Fig. a. The IVt tests were used to compare demographic data including age, BMI, BMD, time to reoperation, and follow-up time between the two groups. Fisher’s exact test and χ2 test were used to examine the differences in sex, number of fusion segments, level of ASD, and complications between the two groups. Paired t tests were used to compare the ODI score, VAS score, and radiographic parameters preoperatively and postoperatively. Independent t tests were used to compare the ODI score, VAS score, and radiographic parameters between the two groups. Shapiro-Wilk test was used to ensure the normal distribution before t test conducted. SPSS software  was used for statistical analysis. The level of significance was set at P < 0.05.Continuous variables were measured as mean ± standard deviation, and categorical variables were expressed as frequency or percentages. Independent From January 2013 to December 2018, a total of 26 patients were enrolled in this retrospective study. There were 12 patients in the OLIF group and 14 patients in the posterior approach group. In the OLIF group, 9 patients underwent OLIF without posterior internal fixation, while 3 patients underwent OLIF with posterior instrumentation. There were no statistically significant differences between the OLIF and posterior approach groups in terms of age, sex, BMI, BMD, number of initial fusion segments, level of ASD, time to reoperation, and follow-up time (Tables P = 0.000). The blood loss in the OLIF group (89.2 ± 49.0 ml) was significantly lower than that in the posterior approach group . The hospital stay was 6.6 ± 1.3 days in the OLIF group and 9.5 ± 2.5 days in the posterior approach group (P = 0.001) . In the posterior approach group, 6 out of 14 patients (42.8%) had issues with the complication of dural tear, whereas none in the OLIF group had issues; this difference was statistically significant (P = 0.010). Incision infection occurred in 1 out of 14 (7.1%) patients in the posterior approach group, which was successfully treated with dressings and oral antibiotics. In the OLIF group, lumbar plexus injury occurred in one patient with a clinical presentation of transient numbness and left leg pain; fortunately, the patient recovered spontaneously 3 months postoperatively. Furthermore, 1 out of 12 patients (8.3%) in the OLIF group required posterior instrumentation as a result of cage subsidence . ODI scores were lower in the OLIF group than in the posterior approach group at the last follow-up . The VAS back pain score was significantly lower in the OLIF group than in the posterior approach group postoperatively . In addition, the VAS back pain score in the OLIF group was 2.1 ± 0.7, which was also significantly lower than 3.6 ± 1.2 in the posterior approach group at the last follow-up (P = 0.015). The VAS leg pain score in the OLIF group improved from 7.0 ± 1.1 preoperatively to 1.3 ± 0.9 postoperatively with a significant difference (P = 0.000). There were no significant differences in the VAS leg pain score between the two groups postoperatively, 3 months postoperatively, and at the last follow-up . The IFH was significantly higher postoperatively than preoperatively in the OLIF group . Furthermore, the IFA was 2.91 ± 0.19 cm2 postoperatively, which was also significantly larger than 1.77 ± 0.23 cm2 preoperatively (P = 0.000). The postoperative APD was 8.5 ± 0.9 mm, which was higher than 7.8 ± 0.7 mm preoperatively; however, the difference was not statistically significant (P = 0.053). Moreover, the CSA was significantly larger postoperatively than preoperatively . All the radiographic outcomes, including the IVH, IFH, IFA, APD, and CSA, were comparable between the two groups postoperatively (P > 0.05) , and access the disc space via an anterolateral approach between the aorta and psoas muscle. LLIF was recommended by some experts for the treatment of ASD with less postoperative pain and favorable radiographic outcomes . MoreoveThe results showed that during OLIF, blood loss was apparently lesser and the operative time shorter compared with those during posterior approaches. In this study, the blood loss and operative time were 89.2 ± 49.0 ml and 60.6 ± 16.1 min, respectively, in the OLIF group; this was consistent with the findings of previous studies. For instance, Silvestre et al. reported that the OLIF procedure was associated with minimal blood loss (57 ± 131 ml) and a short operation time (32.5 ± 13.2 min) in 179 patients . This maAnother finding of this study was that the complication of dural tear in OLIF was apparently lower than that in the posterior approach, which is an important advantage of OLIF. In the current study, we approached the disc between the aorta and the psoas muscle in the OLIF group, and consequently, the occurrence of lumbar plexus injury decreased compared with XLIF. Nevertheless, one patient presented with transient numbness and pain on the left leg that resolved spontaneously within 3 months after surgery. In this study, 1 out of 12 patients (8.3%) required posterior reoperation as a result of cage subsidence; this was similar with the findings of previous studies. For example, Ohtori et al. reported that the reoperation rate of stand-alone OLIF was 9.5% . Some reThe findings showed that the OLIF group demonstrated better clinical improvement in terms of ODI and VAS back pain scores in the early postoperative period compared with the posterior approach group. In previous studies, clinical improvement in leg pain following OLIF was observed with a 3.2–7.2 score reduction in the VAS score, while an improvement in lower back pain was quantified by a 34–50 point reduction in the ODI score . This ma2 preoperatively to 134.3 mm2 postoperatively in OLIF [In this study, effective decompression was achieved by OLIF for the treatment of ASD. In OLIF, an intervertebral cage with a larger area and volume can be implanted, which can effectively restore the disc space and intervertebral foramen height, thus allowing indirect spinal canal decompression. It has been reported that the average CSA of the thecal sac increased from 99.6 mm in OLIF . Moreove in OLIF . SimilarThere are several limitations to the current study. First, the study was conducted retrospectively by case selection and was not randomized and controlled. Second, the duration of follow-up was short and the sample size was relatively small. Nevertheless, future prospective randomized studies involving a long-term follow-up with a larger number of patients are needed to elucidate the advantages of OLIF over posterior reoperation for ASD treatment.Due to our results and early experiences, we proposed that OLIF was safe and effective for ASD. Furthermore, compared to posterior reoperation, OLIF results in shorter operative time and hospital stay, lesser blood loss and lower risk of dural injury.


Azadirachta indica and Cymbopogon citratus were collected from the premises of Covenant University, Nigeria. The plants were dried, pulverized and extracted with ethanol, distilled water and ethanol:water (50:50), before phytochemical screening , FTIR and GC–MS analyses were carried out. The dataset provides insight into the presence of bioactive phyto-constituents such as polyphenols and tannins as potential precursors for green-based nanoparticle synthesis.The dataset for this article contains phytochemical and FTIR data for three different extracts from two indigenous medicinal plants obtained from Ogun State, Southwest Nigeria and the GC–MS characterisation data for their ethanolic extracts. To obtain this data, the leaves of  Specifications TableValue of the data•The dataset provides insight into the exact phyto-constituents, which are responsible for stabilization and reduction of metal ions during nanoparticles formation, thereby aiding proposition of mechanistic pathways for these reactions.•The data provides information on the most potent of the locally selected plants for biosynthesis of nanoparticles using readily available indigenous plants in Southwest Nigeria.•The methods used can be extended to other indigenous plants, forming a large database capable of informing researchers on the active plant(s) for nanoparticle synthesis.•The dataset can be used for educational purposes, drug synthesis and multidisciplinary research. Similar data articles can be found in 1Azadirachta indica and Cymbopogon citratus is presented in The dataset on phytochemical screening of three extracts of 22.1Cymbopogon citratus and Azadirachta indica were collected in March 2018 from Covenant University, Nigeria. The leaf samples were thoroughly washed in distilled water before air-drying at room temperature for 21 days. Dried leaves were then pulverized and preserved in airtight containers until further use.Fresh leaves of two (2) indigenous plants namely 2.2For phytochemical screening, 25 g of pulverized plant leaves was extracted with 125 mL of three solvents namely; ethanol, distilled water and ethanol/water (1:1) for 72 h. The plant extracts were filtered and concentrated using rotary evaporator under reduced pressure. Preliminary phytochemical analysis was carried out to test for the presence of tannins, saponins, flavonoids, alkaloids, anthocyanins, betacyanins, quinones, glycosides, cardiac glycosides, terpenoids, triterpenoids, phenols, coumarins, steroids and acids in all the three extracts following the standard test methods Also, 10 g of each powdered plant material was extracted with ethanol, distilled water and ethanol/distilled water (1:1), respectively, for 72 h. The extracts were filtered and concentrated to 1 mL using BUCHI rotary evaporator under reduced pressure. Then, 1 mL of crude ethanolic, water and ethanol/water extracts were taken for FTIR analysis, while 1 mL ethanolic extracts were taken in amber GC vials for GC–MS analysis.2.3−1 and scan range of 4000 cm−1 to 650 cm−1.The extracts were analysed using Agilent Cary 630 FTIR spectrometer equipped with Microlab PC software with ATR sampling unit with a resolution of 8 cm2.4The GC–MS analysis was carried out using Agilent 7890 A gas chromatograph coupled with a 5977 A mass spectrometer. The temperature programme of the GC was maintained at an initial temperature of 50 °C with a hold for 1 min, followed by gradual increase to 300 °C at 7 °C/min for 14 min. 1 µL of each sample was injected in the split mode (split ratio 1:10). The identification of components was based on retention time on the capillary column and matching the GC mass spectra with the National Institute of Standards and Technology (NIST) library.


Risk prediction tools are lacking for patients with stable disease some years after myocardial infarction (MI).A practical long‐term cardiovascular risk index can be developed.The long‐Term rIsk, Clinical manaGement and healthcare Resource utilization of stable coronary artery dISease in post‐myocardial infarction patients prospective global registry enrolled patients 1 to 3 years post‐MI , all with ≥1 risk factor . Self‐reported health was assessed with EuroQoL‐5 dimensions. Multivariable Poisson regression models were used to determine key predictors of the primary composite outcome  over 2 years.c‐statistic; 0.686, and 0.768, respectively). External validation was performed using the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events registry .The primary outcome occurred in 621 (6.9%) of 9027 eligible patients: death 295 (3.3%), MI 195 (2.2%), UA 103 (1.1%), and stroke 58 (0.6%). All events accrued linearly. In a multivariable model, 11 significant predictors of primary outcome , medical management (index MI), on diuretic, and poor self‐reported health) were identified and combined into a user‐friendly risk index. Compared with lowest‐risk patients, those in the top 16% had a rate ratio of 6.9 for the primary composite, and 18.7 for all‐cause death (overall In patients >1‐year post‐MI, recurrent cardiovascular events and deaths accrue linearly. A simple risk index can stratify patients, potentially helping to guide management. Our goal was to develop a user‐friendly risk index incorporating readily available items, see how strongly it facilitated risk discrimination for the primary endpoint and for all‐cause death, and validate against an external population. Finally, we discuss how this risk index may be used in patients with stable coronary disease to determine those with relatively good prognosis and those at higher risk who may benefit from more intensive management.2That a practical cardiovascular risk index could be developed using data from a global registry of patients >1 year post‐MI, followed up for 2 years.33.1TIGRIS is a prospective, global registry of patients enrolled 1 to 3 years post‐MI in 25 countries in Europe, North America, Latin America, Asia, and Australia, followed for 2 years. The study design and patient characteristics have been described.https://ClinicalTrials.gov .TIGRIS was performed in accordance with ethical principles that are consistent with the Declaration of Helsinki, the International Conference on Harmonization Good Clinical Practice Guidelines, and applicable legislation on nonintervention studies. All patients provided written informed consent. The study protocol and informed consent was reviewed and approved by the corresponding health authorities and ethics boards for all participating study sites. This includes China HGR approval of inclusion of 750 Chinese patients. The study was registered at Eligible patients who had survived an acute coronary syndrome (ACS) were enrolled at discharge from participating centers and subsequently contacted every 6 months by phone or at study sites to ascertain outcome events and changes in medications. All outcome events reported by patients and relatives  were confirmed by the study sites.3.2The predefined primary composite endpoint of MI, unstable angina with urgent revascularization (UA), stroke, and all‐cause death showed a linear accumulation of events over time.P < .05 for inclusion. A final condensed Poisson model for the primary endpoint was obtained by only including variables significant at P < .01, and by modeling age (<65 and ≥65 years) and diabetes as binary variables.We used forward stepwise variable selection to derive a preliminary multivariable predictive model for risk of the primary outcome. The five high‐risk eligibility criteria were forced into this model, as were sex and geographic region. All other variables needed to achieve To assess the risk impact of self‐reported health, the 3‐level EuroQoL‐5 dimensions (EQ‐5D‐3L) survey instrumentThe final predictive model was converted into an integer risk index: variables with rate ratios ranging from 1.33 (congestive heart failure) to 1.69 (prior major bleed) were each assigned 1 point, while the strongest predictor EQ‐5D‐3L overall score ≥4 with rate ratio 2.06 was assigned 2 points.c‐statistic summarized the strength of discrimination.This risk index was formed into six ordered categories from 0 points to ≥5 points. Risk discrimination was quantified using incidence rates, IRRs using 0 points as reference, and Kaplan‐Meier plots over 2 years. Harrell's 3.3External validation of the risk index used the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), which included 4672 post‐MI patients seen 6 months post‐discharge.All statistical analyses used Stata version 15.1.44.1From June 2013 to November 2014, 9225 patients were enrolled; median 1.8 years post‐MI with at least one pre‐defined risk factor. From these, 9027 (97.9%) had baseline and follow‐up data: age ≥65 years (5626 [62.3%] patients), diabetes mellitus requiring medication (3018 [33.4%]), a second prior MI (924 [10.2%]), multivessel disease (5941 [65.8%]), and chronic non‐end‐stage renal dysfunction (691 [7.7%]). Patient characteristics recorded at enrollment and numbers enrolled by country are provided in 4.2The primary outcome occurred in 621 (6.9%) from 9027 patients over 2 years, with all‐cause death in 295 (3.3%), MI in 195 (2.2%), unstable angina requiring revascularization in 103 (1.1%), and stroke in 58 (0.6%) patients.For the primary outcome and components, a steady linear accumulation of events occurred over time.4.3Univariate associations of patient characteristics to the primary outcome incidence rate are provided in To identify which variables remained statistically significant independent risk predictors in multivariable analyses, forward stepwise variable selection was used to derive a preliminary predictive model for risk of the primary outcome Table . The infThe EQ‐5D findings indicate the prognostic importance of patient‐reported heath status with each constituent item showing increased univariate trends of risk from no‐to‐some‐to‐severe problems . Their sSex, multivessel disease, and region were not statistically significant independent predictors. Patients on single antiplatelet therapy at enrollment appeared to have a lower risk. The underlying selection processes are unknown so this factor was not considered further. Variables expected to predict risk  were not independent predictors.4.4A final refined predictive model for the primary outcome is shown in Table To make this prediction model more user‐friendly, we propose a risk index for each patient Table . All itec‐Statistics for the risk index are 0.686 for the primary outcome and 0.768 for all‐cause death.Figures 4.5c‐Statistics for the primary outcome (c = 0.748) and all‐cause death (c = 0.849) are somewhat greater than in the TIGRIS population. It is difficult to attribute a definitive cause for this. Notably, associations for age, congestive heart failure, and cardiovascular events are stronger in CONCORDANCE than TIGRIS. It follows, therefore, that the presence of one of these characteristics will have a larger impact on underlying risk in the former, making it easier to discriminate patients  to 7.4% of patients with ≥5 points (13.7 per 100 patient‐years): IRR 9.8. The risk gradient for primary outcome is steep, whereby each added point contributed ≥30% extra cumulative risk. For all‐cause death, the gradient becomes steeper with ≥75% extra cumulative mortality risk per point.Independent contribution of increasing age is best captured by age over 65 years with increased risk represented by increased susceptibility to comorbidities and poorer quality of life included separately in the risk index.Other concomitant conditions  all contribute to increased risk. These likely reflect the greater burden of vascular disease in these patients. Having their MI medically managed only, and history of major bleeding also contributed to increased risk, possibly reflecting failure to tolerate or be offered prognostically important therapies. All of these factors have contributed to other risk scores in stable and unstable populations.A more innovative contributor to our risk index is patient self‐reported health status, using a simple overall score derived from the EQ‐5D‐3L. Patients with poor self‐reported health (3 points) had around a 50% increase in cardiovascular incidence rate, while those with very poor self‐reported health ≥4 points) had around a doubling of incidence rate Table . This si points hWe also studied the UK‐weighted index score for the EQ‐5D‐3L, revealing results comparable to our easier‐to‐use overall score.For external validation, we used the CONCORDANCE registryc‐statistic 0.62 compared with 0.69 for ours.Reported risk models for patients with stable coronary disease post‐MI are sparse. Closest is perhaps the Reduction of Atherothrombosis for Continued Health (REACH) Registry,c‐statistic 0.63 and 0.70 for the primary outcome and all‐cause death, respectively. However, we acknowledge that the c‐statistic for our own risk score may be slightly optimistic, given that it is derived and assessed in the same population.Based on the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P‐TIMI 50) trial,c‐statistics were 0.73 and 0.63, respectively, a weaker prediction than we found. Rapsomaniki et alc‐statistics were 0.81 and 0.78, respectively. While these showed excellent predictive power, model complexity may limit practical value. Clayton et alBattes et alP < .01 as entry criterion, risk is relatively low. The most novel highly significant predictor is EQ‐5D overall score, while other risk index items are not surprising, having rational explanations based on prior studies. One problem potentially affecting the widespread use of our risk index may be that patients self‐reported health status by EQ‐5D is not routinely collected in most clinical settings. This is an emerging concern given the recognition of the importance of patient reported outcomes as indicators of the quality of care they receive.Regarding our study's limitations, based on 50 candidate predictors, there is risk of “false positives” entering our risk model. However, with While TIGRIS was designed to recruit representative patients in representative centers in each country, we cannot verify a truly generalizable population. Also, TIGRIS recruitment required each patient to have ≥1 of 5 risk criteria, four of which  are in the risk model. Thus, in applying our risk index to an unselected population of patients, a higher proportion may be identified as low risk.We have successful external validation for our risk index using the CONCORDANCE registry and would encourage further validation studies in other relevant populations. While we studied patients recruited 1 to 3 years post‐MI, it would be interesting to see how our risk index performs in a broader class of patients with stable coronary disease.6We have described how risk of subsequent cardiovascular events and death varies substantially among patients 1 to 3 years post‐MI. A risk index based on 11 readily available items enables stratification of such patients into markedly different risk categories. Such knowledge could help identify very high‐risk patients in need of more intensive management.7Baseline patient characteristics and data on long‐term oral antiplatelet use and event rates in the TIGRIS registry have been published elsewhere .Richard Grieve declares no potential conflict of interest. Stuart J. Pocock reports research grant support from AstraZeneca. David Brieger reports speaker/consulting honoraria and/or research grant support from Amgen Inc., AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Merck, Sanofi. John Gregson reports grants from AstraZeneca during the conduct of the study and outside the submitted work. Ji Y. Chen reports research grant support from AstraZeneca; consulting honoraria from MicroPort, APT Medical and JW Medical. Mauricio G. Cohen Speaker/consulting honoraria and/or research grant support from AstraZeneca, Medtronic, Abiomed, Merit Medical. Shaun G. Goodman reports speaker/consulting honoraria and/or research grant support from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, Daiichi Sankyo, Eli Lilly, Fenix Group International, Ferring Pharmaceuticals, GlaxoSmithKline, Janssen/Johnson & Johnson, Luitpold Pharmaceuticals, Matrizyme, Merck, Novartis, Pfizer, Regeneron, Sanofi, Servier, Tenax Pharmaceuticals. Christopher B. Granger reports consulting honoraria and/or research grant support from Armetheon, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol‐Myers Squibb, Daiichi Sankyo Eli Lilly, Gilead, Glaxo SmithKline, Hoffmann‐La Roche, Janssen Pharmaceuticals, Metronic, Pfizer, Salix Pharmaceuticals, Sanofi, Takeda, The Medicines Company. Jose C. Nicolau reports speaker/consulting honoraria and/or research grant support from Amgen, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, GSK, Merck, Novartis, Pfizer, Sanofi. Tabassome Simon reports speaker/consulting honoraria and/or research grant support from Astellas, Amgen Inc, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi. Dirk Westermann Speaker/consulting honoraria and/or research grant support from AstraZeneca, Bayer, Berlin‐Chemie, Biotronik, Novartis. Satoshi Yasuda reports speaker/consulting honoraria and/or research grant support from Takeda, Daiichi‐Sankyo, AstraZeneca, Boehringer Ingelheim, Bristol‐Myers. Katarina Hedman reports employee of AstraZeneca. Kirsten L. Rennie is an employee of OXON Epidemiology Ltd., and a paid consultant to AstraZeneca in connection with the conduct, data management, and analyses of this study. Karolina A. Sundell is an employee of AstraZeneca.Appendix S1: Supplementary MaterialClick here for additional data file.


Phragmites australis) simulated floating treatment wetlands (FTWs) and were used to improve the remediation performance of synthetic greywater (SGW). The aim of the study was to investigate the behaviour of FTWs for treatment of key contaminants within artificial greywater.Buckets containing floating reed  and cement–ochre pellets.Pelletized ochre based on acid mine water sludge was introduced to selected FTWs, because of its capability in sequestration phosphorus and other trace elements. The impact of the following four operational variables were tested in the experimental set–ups of the FTWs (four replicates each): pollutant strength (high– (HC) and low– (LC) concentrations), treatment time (2– or 7–days of hydraulic retention time (HRT)), presence or absence of macrophytes (p < 0.05) reduced in all wetlands. Nitrate–nitrogen (NO3–N) concentrations were significantly (p < 0.05) higher, and those measurements for PO4–P were significantly (p < 0.05) lower than the corresponding ones determined for the influent. The existence of ochre pellets with P. australis significantly (p < 0.05) decreased B, Cd, Cr, Cu, Mg, Ni and Zn concentrations, but increased Al, Ca, Fe and K concentrations in the effluent, with the exception of sodium (Na).The results showed that 5 − day biochemical oxygen demand (BOD) and chemical oxygen demands (COD) were significantly  contains supplementary material, which is available to authorized users. Urbanisation and industrial development coupled with increasing world population have led to intensive demands on water resources. Consequently, increased volumes of wastewater have provided the motivation to explore economical methods of collection, treatment and disposal, benefiting public health and the environment .Household wastewater includes two types of discharge; black and grey wastewaters. Blackwater is defined as the derived effluent from toilets, bidets and urinals. Greywater refers to untreated domestic sewage generated from bathrooms, washing basins, laundry equipment, dishwashers and kitchen sinks, workplace buildings, schools, etc. –4. OccasPathogens and nutrients in greywater are significantly less common than in black wastewater. Moreover, there is commonly a high variation in trace element concentrations . HoweverAmong different treatment technologies, constructed wetlands have been a widely accepted option for treatment and recycling of greywater , 14 due P. australis  and Canna indica showed a decrease in nitrogen due to nitrification–denitrification processes, while the phosphorus removal was influenced by filtration and sedimentation actions. Protozoa predation and oxidation processes in this system affected positively the removal rates of Escherichia coli. This system showed greater removal of nutrients and E. coli during the dry period [Phytoremediation is a vital natural process of pollutant removals from aquatic ecosystem. Saeed et al.  undertooy period . Furthery period  as well y period .Eichhornia crassipes, Hydrocotyle umbellata, and Pistia stratiotes to evaluate the quality improvement of wastewater from anaerobically digested flushed dairy manure in terms of nutrients, COD, solids and salinity. Other free–floating aquatic macrophytes such as Ipomoea aquatica, Paspalum repens, Azolla microphylla, Salvinia minima Baker and Lemna minor have been examined for their effectiveness in treating organic matter and nutrients in wastewater from a dairy farm, a dairy processing plant, a banana paper plant and a landfill [Carex acutiformis, Carex virgata, Cyperus ustulatus, Juncus edgariae and Schoenoplectus tabernaemontani have been investigated for their ability to tolerate high fluctuations in water depths that are typical of storm water ponds [Carex virgata for remediation of suspended solids, particulate zinc as well as particulate and dissolved copper compared to parallel storm water treatment ponds monitored in a field trial study. In addition, the floating treatment wetland has shown an increase in adsorption processes for insoluble copper sulphides and direct copper uptake by plants at presence of high humic content, low dissolved oxygen and natural water pH. Ladislas et al. [Juncus effusus and Carex riparia roots for remediation of cadmium, nickel and zinc from urban water runoff, which demonstrated a high capacity to adsorb dissolved metals and filter particulates. An alternative method for the selection of vegetation species is to select according to their efficiency of nutrient removal [The common criteria to select wetland macrophytes depend on their availability and abundance in the corresponding region of study. Sooknah and Wilkie  selectedlandfill . Floatiner ponds , 31. Borer ponds  reporteds et al.  assessed removal –36.Floating treatment wetlands are simple in design and require no additional land resulting in savings compared to conventional constructed wetlands . The immP. australis, and contribution of cement–ochre solids in treatment processes; b) to evaluate and analyse cement–ochre pellets for accumulative trace elements during the treatment period; and c) to evaluate and analyse biomass tissues of P. australis for accumulative trace elements and their distribution in individual plant parts.This study evaluated the purification of artificially prepared greywater by floating reed beds , 44 in cDomestic greywater was made synthetically by applying adopted analytical–grade substances , which wOchre was obtained from the mine sludge handling and treatment works at the Deerplay coal mine (53°44′06”N 2°11′49”W), which is located just north of Rochdale (OL13 8RD), UK. Drying beds were used to remove surplus water, and the concentrated ochre was stockpiled on–site. The moisture content of the ochre was 87%. Portland cement (three parts) was added to the raw ochre sludge (seven parts) to produce pellets , 25, 46.The intent of the tested microcosm FTW cell system was to mimic constructed retention systems with floating reed beds under authentic weather conditions on top of a building at The University of Salford (53°29′09.3“N and 2°16’24.8”W). The test was performed between 1st September 2014 and 1st November 2016. The assessment commenced on 1st November 2014. The biofilm growth was unhindered for two months; September and October 2014. About 14–litre plastic buckets  were filled with 10 l of SGW.Phragmites australis (Cav.) Trin. ex Steud. (common reed) plants were supplied by VESI Environmental Ltd. . The corresponding roots and rhizomes (about 1 l) were submerged to a depth of about 30 cm.Washed bare–rooted P. australis were present, to treat greywater. The ability of macrophytes to treat synthetic greywater (SGW) at two different pollutant loadings subject to short (2 days) and long (7 days) HRTs was assessed. The selected retention times are considered typical of floating treatment wetlands [The authors assessed the ability of microcosm FTW cell systems, when cement–ochre pellets and wetlands , 46, 47.P. australis. Cement–ochre pellets (300 g) were designed to treat 10 l of SGW each in microcosms T2, T4, T6, T8, T10, T12, T14 and T16 . The experimental set–up design included four sets of microcosms with two replicates that served as controls (C), which were fed by ten litres of de–chlorinated tap water. All control sets were labelled with the capital letter C followed by the number of the corresponding microcosm, which was either 1, 2, 3 or 4, and a small letter (a or b) allowing for the identification of replicates. The vegetated control microcosm C1 and the non–vegetated control microcosm C2 were linked to 2 days of HRT, while vegetated C3 and non–vegetated C4 benefitted from 7 days of HRT. The simulated greywater in the FTW microcosms (T) was exchanged completely (without disturbing the biofilm) with fresh SGW after the specific time of retention.The set−up design shows 72 FTW microcosms Fig. . The firwww.hach.com) was used for the assessment of parameters such as chemical oxygen demand (COD), ammonia–nitrogen (NH4–N), nitrate–nitrogen (NO3–N), ortho–phosphate–phosphorus (PO4–P), total suspended solids (TSS) and colour. The 5–day biochemical oxygen demand (BOD) was determined with the OxiTop IS 12–6 system according to Wissenschaftlich–Technische Werkstätten (WTW), Weilheim, Germany. Turbidity was determined with a Turbicheck Turbidity Meter . Electric conductivity (EC) was measured by the conductivity meter METTLER TOLEDO FIVE GOTM . Hydrogen ion (pH) and redox potential (Eh) were determined with a sensION+ benchtop multi–parameter meter . Dissolved oxygen (DO) was recorded by a HQ30d Flexi Meter .Water quality examinations were performed according to APHA . The speMinerals and trace elements of inflow and outflow greywater were analysed following the SW–846 Test Method 6010D  by applyP. australis tissues such as roots, rhizomes, stems and leaves. Solid samples were acid−digested following the USEPA Method 3050B [The USEPA Method 200.7 was used to analyse the raw ochre sludge and the cement–ochre pellets . Trace eod 3050B .www.ibm.com) were used to analyse data at a 95% confidence level. The independent sample T–test was used to evaluate sample averages from two independent groups, if their distribution was found to be normal using the normality test of Shapiro–Wilks. The non–parametric test (Mann–Whitney test) was used to match two independent samples when their distributions were not normal. Furthermore, the non–parametric Kruskal–Wallis technique was applied for data that were non–normal distributed. An assessment of the consistency of variances was performed by applying Levene’s test for both parametric and non–parametric techniques. Correlations were assessed with Spearman’s test.Microsoft Excel and the Statistical Package for the Social Sciences (IBM–SPSS) Statistics Version 23 (p < 0.001) with Eh in all treatment systems, which is common in aqueous ecosystems [p = 0.030) between pH and Ca. However, the existence of P. australis in the purification of SGW significantly (p < 0.05) decreased the pH value of the outflow compared to the inflow pH. The drop in pH can be explained by the production of carbon dioxide during rhizome breathing and/or organic acids [The influent water quality was illustrated in Online Resource osystems . The cemic acids , which aic acids , 53.P. australis to cope with the effect of ochre pellets in terms of pH and EC. An increase in HRT when treating SGW in wetland systems using a combination of P. australis and ochre pellets raised the pH values significantly, because of the presence of ochre pellets when comparing T2 and T6 with T10 and T14, respectively  in turbidity, TSS and colour within the outflow compared to the inflow [p = 0.036), TSS  and colour . In comparison, the existence of P. australis in floating systems treating SGW  resulted in a significant drop in turbidity, TSS and colour  by e inflow , 55. TheP. australis and on the vessel walls led to improved biological decomposition enhancing the removal of TSS, turbidity and colour [p = 0.016), and r = 0.767 (p = 0.016), respectively. However, on some occasions, the sloughing–off the heavy biofilms from rhizome surfaces in systems of floating macrophytes may have caused an increase in TSS concentrations [P. australis (T10 and T14) compared with systems a HRT of 2 days   compared with the outflows of systems T3, T7, T11 and T15, respectively , 5–day biochemical oxygen demand (BOD) and chemical oxygen demand (COD) decreased significantly at the presence of Phragmites showed significant decreases in DO and BOD concentrations  and T10 , respectively  and T10 (7–day HRT)), as evident from Online Resource ons Fig. . Similarely Fig. .Fig. 3EfIn addition, the occurrence of pellets alone in treatment of SGW  also resulted in significant decreases in DO, BOD and COD when comparing the inflow equivalents (fills) with the outflow equivalents (draws) of the batch flow systems T3, T7, T11 and T15, respectively  compared with those values in the effluent of system T6 , as shown in Figs. The DO, BOD and COD in this study were not affected by the increase in HRT in system T14  negative correlations were noted between pH and BOD . The strong negative correlation between pH and BOD may occur through elimination of organic substances in settlement and biological degradation processes [Significant  in the treatment of LC–SGW and positive and significant  for HC–SGW. Significant (p < 0.05) and negative correlations between DO and COD and/or BOD were recorded for systems with no limited oxygen supply, where aerobic biodegradation was a function of the amount of organic substances during the chemical oxidation process. For greywater, industrial wastewater and storm water, DO usually correlates negatively with COD. This is due to the lack of provision of dissolved organic matter. Aerobic biodegradation is not restricted by DO provision [p < 0.05) positive correlations between DO and COD, the adequate availability of oxygen to aerobic heterotrophic bacteria will considerably elevate aerobic biochemical oxidation [However, there were considerable correlations between DO and COD, which were negative and significant  decreases of PO4–P values in treatment systems containing only SGW  compared to values of inflow were mainly due to either sedimentation and/or microorganism mechanisms  elevated and PO4–P was significantly (p < 0.05) reduced than those corresponding values of the influent. These observations were similar when comparing inflow with outflow HC–SGW from systems T1  and T4 . Therefore, the significant (p < 0.05) decrease of PO4–P concentration was linked to the effect of the existence of cement−ochre pellets together with P. australis in system T2 compared to system T1.The comparative statistical analysis  and T14 (7–day HRT)), values of NO3–N and PO4–P were significantly (p < 0.05) reduced compared to those of the influent. Nevertheless, no significant (p > 0.05) alterations in concentrations of NH4–N were noted for those systems in comparison to the NH4–N values linked to the inflow  phosphorus removal mechanism in wetland systems [4–P reduction. Nevertheless, this is a seasonal phenomenon, which reverses when the plants are perishing in autumn [p < 0.05) less compared to that for nitrogen [The precipitation of PO systems . The uptn autumn . Plants n autumn . Howevernitrogen .4–P removal into FTWs is the existence of cement−ochre pellets in the treatment process, which is linked to either adsorption processes and/or precipitation mechanisms. This is because of to the relatively high amount of Ca that converts dissolved PO4–P to insoluble forms, if the pH is rather high [4–P concentrations correlated significantly negatively with pH values  and Ca concentrations  in the outflow of treatment systems. Furthermore, the outflow of the treatment systems combining ochre pellets and P. australis showed that TSS correlated significantly negatively (r = −0.717. p = 0.030) with PO4–P and significantly positively  with NO3–N.A significant contribution to POher high , 55, as her high . HoweverP. australis) and T12 (only ochre pellets), NH4–N and PO4–P values decreased significantly (p < 0.05). However, NO3–N increased significantly (p < 0.05) in comparison to those parameters of the influent  showed the same patterns concerning NH4–N and PO4–P. Also, for a HRT of 7 days concerning the purification of HC–SGW, the existence of both cement−ochre pellets and floating P. australis in system T10 significantly (p < 0.05) increased NH4–N and PO4–P concentrations compared with the outflow of system T9 .After 7 days of treating HC–SGW in systems T10  decreased NO3–N and PO4–P within the outflow from systems T6 (2–day) and T14 (7–day) with no significant (p > 0.05) impact on NH4–N values, if compared to those values of outflow from systems with only P. australis; T5 (2–day) and T13 (7–day), respectively  reduced NH4–N and PO4–P values and significantly (p < 0.05) surged the NO3–N concentration in comparison to the system of 2–day HRT. Moreover, a higher HRT for the purification of LC–SGW  decreased NH4–N and significantly (p < 0.05) increased NO3–N. Removal of NO3–N in systems treating LC–SGW with a combination of ochre pellets and P. australis were significantly greater than those reductions in treatment of HC–SGW.Regarding the increases in NOutrients . This hautrients , 13. It utrients . Therefoy p < 0.0 decreasey p < 0.0 decreasey p < 0.0 decrease4–P at the company of cement−ochre pellets , the outflow exhibited significant (p < 0.05) reductions in B, Cd, Cr, Cu, Fe, Mg, Mn, Ni and Zn in comparison to those corresponding concentrations of the inflow (Online Resource p < 0.05) elevation in concentrations of Ca was observed in comparison to the inflow HC–SGW. Similar significant (p < 0.05) changes were observed for the effluent of system T1  with the exception that Al and K showed significant (p < 0.05) decreases. System T4  showed significant (p < 0.5) rises in Ca and Cu, and decreases in B, Mg, Mn and Ni.In the system treating HC–SGW by an arrangement of both cement−ochre pellets and For FTWs, trace elements might be removed by processes such as settlement, sedimentation, biological sorption, precipitation, cation exchange, photo−degradation, biological degradation, microbial processes and uptake by plants. However, the actual reactions cannot easily be determined , 62.p < 0.05) reduced B and Mg, and increased Al, Ca and Fe in the outflows. Those significant increases were linked to high Al, Ca and Fe concentrations within the pellets, which were discharged back into the treated greywater [P. australis, when used in combination with pellets in system T2, significantly (p < 0.05) decreased the concentrations of all considered elements  with a significant rise in Ca concentration compared to those corresponding concentrations of the influent  affected the removal of Al, B, Cd, Cr, Cu, Mg, Ni and Zn compared with those concentrations in the outflow from system T9. While floating P. australis in combination with ochre pellets in system T10 contributed significantly (p < 0.05) to the decrease of Al, Ca, Cd, Cr, Cu, Fe, K, Mg, Mn and Zn values compared with the outflows of system T12. However, system T9  showed significant (p < 0.05) reductions of Cu, K, Mn, Ni and Zn compared to the inflow  in comparison to their inflow concentrations. In Online Resource Concerning the treatment of HC–SGW for a HRT of 7 days when combining ochre pellets and floating ent Fig. . Furtherlow Fig. . System p < 0.05) decreased in comparison to those in the influent. However, there were significant (p < 0.05) increases in Al, Ca, Fe and K in the outflow of system T6 in comparison with those in the influent. Similar significant changes as in system T6 were observed in outflows of systems T5  and T8 , with the exception for significant decreases in Al, Fe and K for system T6, compared to those values of the inflow  impact on the decrease in the B, Cd and Zn values, and the increase in Al, Ca, K, Mn and Ni concentrations compared to the outflow ones of system T5. Furthermore, the presence of floating P. australis contributed significantly to the reduction of B, Ca, Cd, Cr, Cu, Fe, Mn, Ni and Zn compared with the outflow from system T8  reduced concentrations of B, Cd, Cu, Mg, Mn, Ni and Zn and significantly (p < 0.05) increased Ca, Fe and K in comparison to those corresponding values of the influent. The same significant performance as for the outflow of T14 was noted for the outflow of system T13 , but Al, Fe and K were lower, and Mg and Ni were higher than those of the influent. Furthermore, significant (p < 0.05) changes in the outflow of system T16  were noted. These were like those changes in the outflow of system T14, except that a significant elevation in Al was recorded for the effluent of the former system (T16) compared with the inflow  impact on the decrease in B, Mg and Zn, and on the increase in Al, Ca, Fe and K compared with those concentrations of the outflow of system T13. The existence of plants in T14 significantly (p < 0.05) affected the decrease in Al and Zn compared to the outflow of system T16  in comparison with the effluent of system T6 . All wetlands were impacted on by natural forces allowing dust and leaves to enter the systems by coincidence. Therefore, certain elements increased in the effluent of the wetlands without the existence of ochre as well [Concerning the purification of LC–SGW when combining pellets and floating  as well , 32.p < 0.05) elevated except for Ca and Ni. Ca values were significantly (p < 0.05) reduced in pellets. The accumulated Ni concentrations did not increase significantly (p > 0.05) in pellets before  and T8 (only ochre pellets) purifying LC–SGW for HRT of 2 days, the accumulated B, Cd, Cr and Cu also did not increase significantly  increased the Al, B, Ca, Cr, Cu, Fe and Zn concentrations, which accumulated in pellets in comparison to those in system T4 . However, that effect was different for system T10  with a HRT of 7 days, where concentrations of Al, Ca and Cd were significantly (p < 0.05) reduced compared to elements, which accumulated in the pellets of system T12  as shown in Table P. australis and an increase in the accumulation rate of elements in ochre pellets within the same treatment system was noted (Online Resource p < 0.05) lowering of the water pH, converting insoluble metals to their dissolved forms, which could be adsorbed by ochre pellets faster than they could be taken up by P. australis due to chemical reactions  affected the reduction in Ca and increase in Mn that enriched in pellets in comparison to those values in the pellets of system T8 , as shown in Online Resource P. australis significantly (p < 0.05) affected the decrease in Ca and the increase in Cd and Cr in the ochre pellets of system T14 (combined pellets and plants) in comparison to the concentrations in the ochre pellets−based system T16 , as shown in Tables For the treatment of LC–SGW with a HRT of 2 days for system T6 (both pellets and plants), the existence of floating p < 0.05) affected the increase in accumulated Cd and Cr in the ochre pellets of system T14 in comparison with those accumulated in the pellets of system T6 , which accumulated within the ochre pellets of systems treating HC–SGW (T2: 2–day and T10: 7–day), were higher than those values in ochre pellets of systems T6 (2–day) and T14 (7–day), respectively, which were treating LC–SGW. However, the content of Al and Fe (T6: 2–day HRT), and Al and Ca (T14: 7–day HRT), which accumulated in the ochre pellets were higher for the cleaning of LC–SGW compared with the corresponding values in the systems T2 (2–day) and T10 (7–day), respectively, which were treating HC–SGW (Online Resource p < 0.05) correlation with the respective primary element amounts of greywater. High removals of low greywater element amounts suggest a high presence of vacant locations within ochre pellets to endure the adsorbed and absorbed elements [When observing the concentrations of adsorbed elements, there was a significant  to investigate the potentially significant performance of each wetland  lower compared to those in the controls. However, regarding the treatment of SGW in wetlands with a combination of ochre pellets and P. australis at 2–day HRT, Mg accumulated in P. australis tissues of wetlands T2 (HC–SGW) and B, Mg and Zn accrued in wetland T6 (LC–SGW) were significantly (p < 0.05) reduced compared to those values in P. australis of wetland C1 . For 7–day HRT, Cu, Mg, Mn and Zn concentrations accumulated in P. australis tissues of wetland T14 (LC–SGW) were significantly lower compared to those accumulated element concentrations in P. australis of the control wetland C3 , as shown in Table All considered elements had significantly (p < 0.05) elevated accumulations in Elements such as Fe, Mn, Cu, Zn and Ni are recognised as micro−nutrients, which are necessary for physiological and biochemical processes of plant growth . HoweverP. australis tissues with the exception of Ca that increased significantly (p < 0.05), compared to the corresponding amounts accumulated in P. australis tissues in systems purifying both types of SGW with only P. australis at both HRT , and Na accrued in P. australis of wetland T14  were significantly higher than those accumulated amounts in P. australis of wetlands T1  and T13 , respectively  with those of 2–day HRT (C1). However, remarkable increases were observed with increasing HRT in Fe, Mg and Ni accumulation in P. australis of wetland T10 , and Al, Ca and Na in wetland T14  in comparison to those concentrations at 2 days of treatment within wetlands T2 (HC–SGW) and T6 (LC–SGW).Considering the effects of HRT  tolerance for remediation of the elevated concentrations of pollutants such as heavy elements. However, they have a negative impact on the development rates of floating treatment wetlands.This study shows that floating P. australis roots, rhizomes, stems and leaves was investigated (Online Resource p < 0.05) elevated than those concentrations in stems and leaves  elevated in terms of Al, B, Ca, Cd, Cr, Cu, Fe, Mg, Mn and Ni. However, the concentrations of Na and Zn were lower than those concentrations of control wetlands  greater than those values linked to the treatment of LC–SGW, through different locations of the plants, as shown by comparing Online Resource Element accumulation in floating P. australis rhizomes when ochre−based pellets were available.The existence of pellets within the systems had a significant (p < 0.05) effect on the decrease in the build−up of elements in rhizomes except for Ca, which had significantly (p < 0.05) greater accumulations in P. australis significantly (p < 0.05) rose the amount of accumulated trace elements in rhizomes of P. australis in comparison with corresponding values in systems that had only a HRT of 2 days. In contrast, the accumulation in rhizomes of systems comprising only floating macrophytes were significantly (p < 0.05) elevated in systems of 2–day purification time compared with systems of 7–day HRT, as shown by comparing Online Resource Elevated purification HRT using a combination of ochre pellets and Although it has been reported that concentrations of metals in below−ground plant tissues are higher than in plant parts located aboveground, it is necessary to consider the biomass of each plant part to evaluate the total accumulation amount . TransloP. australis acts as a buffer to neutralise the pH of SGWs by producing carbon dioxide through rhizome action and organic acids, which are by–products of biodegradation processes of organic substances. Furthermore, rhizomes and biofilms attached to P. australis mitigate increases in turbidity, TSS and colour values, which occur by using ochre pellets.The performance of floating treatment wetlands can be improved by utilising ochre–cement pellets to increase the pH of greywater and subsequently increase the EC through releasing Ca coupled with Al and Fe, supporting coagulation and flocculation. However, the presence of P. australis have shown significant removals of NH4–N and PO4–P due to nitrification and adsorption mechanisms, respectively, especially with increasing HRT. Due to the presence of ochre pellets, concentrations of Al, Ca and Fe significantly increased in the effluent of treated SGW. A significant improvement in reductions of B, Ca, Cd, Cr, Cu, Fe, Mn, Ni and Zn concentrations in the treatment of SGW was recorded at the presence of P. australis in combination with ochre pellets. However, concentrations of Al, B, and Ni significantly dropped in treated SGW with an increase of the HRT. However, a significant rise in concentrations of Ca, Fe and Mg was noted.Ochre pellets in combination with Floating treatment wetlands have shown significant performance in removal of Al, Ca, Fe and Na from high pollutant strength greywater. Significant removal of Cd, Cu, Mg, Mn, Ni and Zn was recorded from greywater of low pollutant strength.P. australis in remediation of heavy metals and other elements from the SGW has led to significant reductions in the concentrations of accumulated elements in the tissues of P. australis, except for Ca. Higher accumulations of elements (except for Ni) in tissues of plants, which treated high pollutant strength SGW, was noted. Furthermore, considerable concentrations of accumulated elements have been found in P. australis tissues of FTW purifying SGW for 2 days in contrast of control wetlands receiving tap water. Trace element accumulations in rhizomes were significantly higher compared to those in stems and leaves. Al, B, Ca, Cd, Cr, Cu, Fe and Zn have significantly increased in ochre pellets at the presence of P. australis.The competition between ochre pellets and Further research on large–scale floating wetland systems is recommended. Moreover, biochemical and ecological investigations would help to better understand the biological processes.Online resource 1(DOCX 16.8 kb)Online resource 2(DOCX 18 kb)Online resource 3(DOCX 66.1 kb)Online resource 4(DOCX 34 kb)Online resource 5(DOCX 15.5 kb)Online resource 6(DOCX 107 kb)Online resource 7(DOCX 22.6 kb)Online resource 8(DOCX 87.2 kb)Online resource 9(DOCX 21.6 kb)Online resource 10(DOCX 23.8 kb)


Burnout is a syndrome characterized by emotional exhaustion, increased depersonalization, and a diminished sense of personal accomplishment due to chronic emotional stress at work. Burnout impacts job satisfaction, job performance, vulnerability to illnesses, and interpersonal relationships. There is a gap in the systematic data on the burden of burnout among healthcare professionals from different sectors of healthcare in Middle Eastern countries. Our objective was to examine the burden of burnout among healthcare providers in the Middle East, how it was assessed, which sectors were included, and what interventions have been used.Articles were found through a systematic review of search results including PubMed, Web of Science (Thomson Reuters), and PsycINFO (EBSCO) using search terms reflecting burnout in Middle Eastern countries among populations of healthcare providers. Studies were included if they examined a quantitative measure of burnout among healthcare providers in the Middle East.N = 54 articles), nurses (N = 55), combined populations of healthcare workers (N = 22), and medical students (N = 7). The Maslach Burnout Inventory was the most common tool to measure burnout. Burnout is common among physicians, nurses, and other healthcare professionals, with prevalence estimates predominantly ranging between 40 and 60%. Burnout among healthcare providers in the Middle East is associated with characteristics of their work environments, exposure to violence and terror, and emotional distress and low social support.There were 138 articles that met our inclusion criteria for this systematic review. Studies focused on burnout in the Middle East among physicians (Burnout is highly prevalent among healthcare providers across countries in the Middle East. Previous studies examining burnout in this region have limitations in their methodology. More thoroughly developed epidemiologic studies of burnout are necessary. Health system strengthening is needed in a region that has endured years of ongoing conflict, and there is an urgency to design and implement programs that tackle burnout among health professionals. Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a diminished sense of personal achievement . EvidencHealthcare providers experiencing burnout may consequently develop symptoms such as anxiety, irritability, mood swings and depression –17. FurtWhile there are a number of review studies examining the prevalence and determinants of burnout in healthcare workers in developed and/or westernized countries from North America, Europe, and Australasia –30, therThis study aimed to systematically review the literature on the burden of burnout among healthcare providers in the Middle East, including the construct of burnout used, which healthcare subspecialties were included, and any interventions evaluated.This review intends to provide a foundation for future contributions aimed at reducing the burden of burnout in the Middle East.This systematic review was conducted according to Preferred Reporting Items for Systematic.Review and Meta-Analyses (PRISMA) guidelines , and PsychINFO (EBSCO), we identified studies using search terms for burnout and Middle Eastern countries . Studies in populations of healthcare providers (N = 219) were selected for full-text review. In the full-text review, articles were rejected if they were qualitative studies, not available in English, did not include healthcare providers, or were not relevant to the search criteria (N = 83).The original literature search located a total of 722 articles in PubMed, 1167 articles in PsycINFO, and 645 articles in the Web of Science database , nurses (N = 53), combined populations of healthcare workers (N = 22), and medical students (N = 7). Six articles examined burnout among healthcare professionals in Egypt, 46 in Turkey, 18 in Saudi Arabia, 29 in Iran, and 19 in Israel, 1 in United Arab Emirates, 3 in Qatar, 1 in Yemen, 8 in Lebanon, 2 in Palestine, 1 in Bahrain, and 2 in Jordan. Of the 138 eligible articles for inclusion, 130 used versions of the Maslach Burnout Inventory to measure burnout. One study in Saudi Arabia examined burnout among National Guard Physicians using the Oldenburg Burnout Inventory. One Israeli study measured burnout among physicians using the burnout subscale of the Professional Quality of Life Scale (ProQOL). Additionally, three Israeli studies measured burnout using the Shirom-Melamed Burnout Questionnaire among physicians (N = 2 studies) and nurses (N = 1). Lastly, two studies used the Burnout Measure to measure burnout among medical students in Lebanon.A total of 136 articles met our inclusion criteria for this systematic review. Articles examined burnout in the Middle East among physicians , 70% of the participants reported overall burnout, 75.5% reported moderate-to-high emotional exhaustion, 84% had high depersonalization, and 74% experienced a diminished sense of personal accomplishment [N = 96), the prevalence of reported high emotional exhaustion, high depersonalization and reduced personal exhaustion were 68.8, 63.6, and 38.5% respectively [N = 98) met the criteria for all burnout subscales [N = 85), the level of burnout in the three subscales of emotional exhaustion, depersonalization, and perceived low accomplishment was high in 84.5, 48.1, and 80.5% of participants respectively [N = 356), 63.2% were identified as experiencing a high degree of burnout in at least one category of burnout, and those working more than 40 h a week had a 2.8 times higher risk of reporting high levels of burnout compared to those working less than 40 h a week [N = 144) in Qatar, the overall prevalence of burnout according to the MBI was 16.1% [N = 55), 38.2% of them reported high levels of burnout on all three subscales of the MBI [N = 33) [N = 155), 80% of the sample had reported a high level of burnout in at least one domain [N = 230), the reported prevalence of high emotional exhaustion, high depersonalization, and diminished sense of personal accomplishment were 43.1, 70.6, and 11.1% respectively [High levels of burnout were reported among physicians across the Middle Eastern countries. Among physicians undergoing residency training in the United Arab Emirates (lishment . Among dectively . A studyectively . A studyh a week . Among pas 16.1% . A study the MBI . One thi[N = 33) . A studye domain . Among sectively .We found 53 studies that assessed burnout among a total of 10,992 nurses in Palestine, Iran, Turkey, Saudi Arabia, Egypt, Israel, and Jordan (Table N = 152), burnout measures were high on the emotional exhaustion (mean ± standard deviation (SD): 23.48 ± 10.23), depersonalization (5.42 ± 5.61), and personal achievement (34.14 ± 9.44) subscales of the MBI [N = 180) found that 25% of the participants met the criteria for burnout according to the MBI [N = 39) reported that 30.8% of participants reported emotional exhaustion very frequently, 5.1% have a cynical feeling towards their job often, and 15.4% rarely experience professional self-actualization [N = 181), 55% of them reported high level of burnout in the subscale of emotional exhaustion, 50% reported high depersonalization, and 50% reported a reduced sense of personal accomplishment [Nurses reported high levels of burnout Table . For exa the MBI . A study the MBI . A studylization . Among mlishment .N = 256), the prevalence of reported high emotional exhaustion, depersonalization, and reduced sense of personal accomplishment was 54.9, 43.5, and 44.5% respectively [N = 100), burnout scores were high in emotional exhaustion ((mean ± SD): 24.9 ± 6.9), depersonalization (9.3 ± 2.1), and diminished sense of personal accomplishment (35.5 ± 7.0) [N = 90), reported prevalence of emotional exhaustion, depersonalization, and reduced sense of personal achievement was 42, 20, and 35.6% respectively [There were 22 articles that studied burnout among combined populations of healthcare workers Table . Ten stuectively . A study5 ± 7.0) . Among oectively .Table 3N = 662), the prevalence of overall severe burnout was 7.4% as assessed by the MBI [N = 176) were experiencing high levels of overall burnout according to the Burnout Measure [A total of seven articles examined burnout among medical students in Oman, Saudi Arabia, Iran, Turkey, and Lebanon Table . Among m the MBI . Two stu the MBI , 168. A  the MBI . Another Measure . Finally Measure .Table 4N = 155), those who reported working more than 80 h a week were 2.91 times as likely to report burn out compared to residents working less than 80 h a week [N = 246), multivariate regression analysis showed that the number of patients per day (p < 0.001), more paperwork (p < 0.001), unorganized patients flow to clinics (p = 0.021), and patient pressure/violence (p < 0.001) were all statistically significant positive predictors of burnout [p < 0.05) in a study done in Iran [N = 222), those who considered their monthly income level as “poor” differed significantly from those who regarded their monthly income levels as “good” in terms of mean scores in subscales of the MBI, emotional exhaustion, depersonalization, and personal accomplishment (p < 0.05) [N = 170) reported that among nurses with fixed shift schedules, the odds of high risk of emotional exhaustion as measured by the MBI was 10.1 (95%CI: 4.68–21.75) times higher than the odds among nurses with non-fixed shift schedule [Components in the work environment were statistically significantly associated with measures of burnout, including heavy workload, unorganized and difficult working conditions, difficulties balancing professional and private life, and income. For example, among medical residents in Lebanon (h a week . In a Sa burnout . Work ov in Iran . A study < 0.05) . A study < 0.05) . Among 3 < 0.05) . A studyschedule .N = 174), there were significant associations between emotional exhaustion, as reported by the MBI, and overall violence (p = 0.012) and verbal violence (p = 0.016) and depersonalization and total violence (p = 0.021) and verbal violence (p = 0.012) [N = 444) reported that the odds of high risk of burnout among those who had exposure to violence was two times the odds among those who had no exposure to violence [N = 97) reported that higher levels of PTSD symptoms due to war and terror were associated with higher levels of compassion fatigue  [N = 214) reported that nurses’ exposure to national terror and the level of distress they experienced due to ongoing terror attacks were statistically significantly associated with high levels of burnout [Exposure to violence, terror, and conflict were all associated with increased odds of burnout. This suggests there may be an interaction between burnout and secondary traumatic stress in Middle East caregivers. The war trauma primary and secondary exposure as being worsening factors in burnout was specifically mentioned and reported in a study related to Lebanese nurses working in academic centers. The study also linked trauma exposure to higher level of depression in nurses (36.2%) compared to 10% of general population . Moreove= 0.012) . A studyviolence . Additio< 0.001) . Another burnout .N = 270) found that younger age was significantly associated with higher emotional exhaustion and lower personal accomplishment scores [N = 663), mean emotional exhaustion and depersonalization scores were significantly higher and personal accomplishment scores were significantly lower in participants aged under 25 years [N = 141) and (N = 171) younger age was also found to be associated with increased risk of burnout [N = 55), older age was found to be a protective factor for high risk of overall burnout  [N = 90) working in Turkey, being of age less than 35 years was significantly associated with burnout [N = 167) in Turkey, logistic regression confirmed that older age (p = 0.02) was associated with severe burnout [N = 200), greater age and work experience accounted for 30% of the variance in depersonalization [p < 0.001) [Reports examining the association between age, time in career, and burnout were variable. Overall, results suggest that the association between age and burnout is bimodal, in which younger age (i.e. under 25) and old age (i.e. over 55), along with greater work experience are associated with the highest burnout levels. Many studies suggested that younger age was a significant predictor of burnout. For example, a study among physicians in Saudi Arabia  . Among o burnout ; howeverlization . A studylization . In Iran< 0.001) .N = 159) and physicians in Saudi Arabia (N = 348), female gender was significantly associated with greater burnout scores  [N = 132) and nurses in Jordan (N = 407), female gender was also found to be a significant predictor of burnout  [N = 276), female gender was a significant predictor of emotional exhaustion and depersonalization  [p = 0.012, 45). Another study in Turkey among nurses working in dialysis centers (N = 171) found that male sex was associated with higher depersonalization scores (p < 0.05) [N = 548) [The majority of studies that found a significant association between gender and burnout reported that female gender was a significant predictor of increased risk for burnout , 173.. Fctively) , 48. Amo < 0.01) , 125. Am= 0.001) . Only th < 0.05) . Another < 0.05) . Lastly, < 0.05)  and a stN = 548) .p < 0.05) [N = 98) was lack of job support [N = 684), lack of workplace support was also found to be a significant predictor of burnout  [Experiences of stress and lack of job support were additionally found to be predictive of job burnout among healthcare professionals. For example, among trainee anesthesiologists in Turkey, perceived stress, as measured by the Perceived Stress Scale, were significantly associated with increased odds of burnout ( < 0.05) . Among a < 0.05) . Moreove < 0.05) . Further support . Among n–-0.003) .N = 256) burnout outcomes [N = 31) [There were only a few programs aimed at alleviating burnout in the Middle East. Only three studies examined burnout-related interventions in physicians , 68, 83,p = 0.01). A randomized controlled trial was conducted in Turkey by Gunusen and Ustun to evaluate the effects of coping and support group interventions on the reduction of burnout among nurses [In Iran, Darban, Balouchi, Narouipour, Sarfazaei and Shahdahi examined the effect of a communication skills training on the burnout of nurses . The trag nurses . CognitiN = 82) [p < 0.05), and such that nurses in the study group had lower levels of emotional burnout and desensitization and high personal achievement scores at one and three months after the psychological empowerment program compared to nurses in the control/comparison group. Lastly, Sabanciogullari and Dogan evaluated the effects of the Professional Identity Development Program on burnout levels of registered nurses in Turkey [Another study in Turkey was conducted to determine the effect of a “psychodrama-based psychological empowerment program” on the levels of burnout in oncology nurses (N = 82) . They fon Turkey . The proBurnout is prevalent among physicians, nurses, and other medical professionals in the Middle East. Prevalence estimates range between 40 and 60% with reported rates between 13 and 100% (Tables S1–4). The minority of studies that reported lower than average levels of burnout attributed such differences to the quality of their study, sample size, and characteristics of the population studied. Nurses reported the highest levels of burnout among healthcare providers. High levels of burnout were associated with harsh work conditions, stress, and exposure to violence and conflict. Studies in the Middle East maintain previous research among healthcare providers that have demonstrated that risk factors for burnout include female gender, young age, and low support and resources to handle workload. The number of reported interventions aimed at alleviating burnout in the Middle East is scarce. Nevertheless, the interventions that have been attempted are similar to some that have shown benefits in North America and Europe , support groups (180–182), Balint groups ). Mindfulness interventions were mentioned anecdotally in several papers that did not meet inclusion criteria for this review. The duration of these interventions varied from a week  to a yeaWe noted that the MBI was used as the assessment tool for burnout in the majority of studies. Among the studies that used the MBI, we point out that the burnout scores were presorted in multiple manners either listing the percentage of participants with high burnout on each subscale, or the percentage of participants with high burnout on each subscale and the total score, and the percentage of participants with high total burnout. Some listed the percentage of participants with high burnout on emotional subscale only or the total and individual burnout as continuous scores together or separately. Finally, some studies reported individual burnout as continuous score while others reported individual burnout as continuous scores and percentages of participants. In addition, there were three different versions of the MBI used namely: MBI, MBI-HSS, and Abbreviated MBI (or AMI) rendering difficult the direct comparison of burnout rates in different countries and populations of healthcare workers. Additionally, recent work has raised concerns about how the MBI operationalizes burnout . Having In addition, Table In contrast to high-income countries, the Middle East has not given much attention to burnout, despite the many stressors facing its healthcare community. Given the adverse health effects of burnout on patients and providers alike, the ever-increasing burden of caring for major public health threats, amidst ongoing regional conflicts and refugee crises with a paucity of resources and shortage of support, more attention needs to be paid to healthcare provider well-being in the Middle East. Further studies should include longitudinal assessments tackling cognition, performance and quality of life as well as reports on mood, substance use, and safety issues such as suicide, to enhance our understanding of the burnout syndrome and its consequences in the Middle East. Moreover, efforts should be channeled to assessing burnout consistently with a validated instrument or developing new instruments that would perform culturally better in the context of the Middle East. Finally, designing and deploying programs aimed at raising awareness, promoting well-being and burnout prevention, and improving coping with burnout symptoms through evidence-based stress management and resiliency training in the Middle East would be the gold standard for any academic, private or public institution promoting excellence in care for the population they serve.Additional file 1: Table S1. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.Additional file 2: Table S2. Database terms of search.Additional file 3: Table S3. Quality assessment based on modified Newcastle-Ottawa Scale of studies on burnout among physicians in the Middle East (N = 54).Additional file 4: Table S4. Quality assessment based on modified Newcastle-Ottawa Scale of studies on burnout among nurses in the Middle East (N = 53).Additional file 5: Table S5. Quality assessment based on the Newcastle-Ottawa Scale on burnout among healthcare workers in the Middle East (N = 22).Additional file 6: Table S6. Quality assessment based on the Newcastle-Ottawa Scale on burnout among midwives, medical and nursing students in the Middle East(N = 7).