Brain network properties were measured and between-group differences evaluated using graph theory. We also calculated and explored asymmetry indices for the cerebral hemispheres in the four groups, to explore whether differences between the two hemispheres were characteristic of each group. Our study revealed significant differences in the network properties of the HC and AD groups . In addition, differing hub regions were identified in the different dementias. We also identified rightward asymmetry in the hemispheric brain networks of patients with AD and DLB, and leftward asymmetry in the hemispheric brain networks of patients with PDD, which were attributable to aberrant topological properties in the corresponding hemispheres.Facilitating accurate diagnosis and ensuring appropriate treatment of dementia subtypes, including Alzheimer's disease (AD), Parkinson's disease dementia (PDD), and Lewy body dementia (DLB), is clinically important. However, the differences in glucose metabolic distribution among these three dementia subtypes are minor, which can result in difficulties in diagnosis by visual assessment or traditional quantification methods. Here, we explored this issue using novel approaches, including brain network and abnormal hemispheric asymmetry analyses. We generated 18F-labeled fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) images from patients with AD, PDD, and DLB, and healthy control (HC) subjects ( Dementia is progressive cognitive deterioration caused by brain injury or disease. The deterioration is much more rapid than that associated with normal aging, and affects memory, attention, language, and problem-solving skills , 2. The The technique, 18F-labeled fluorodeoxyglucose (18F-FDG) positron emission tomography (PET), which reveals glucose metabolic distribution across the whole brain, is the most commonly used, accurate and effective, gold-standard method for diagnosis of early-stage dementia. Based on quantitative analysis of FDG-PET scans, scholars have explored the clinically significant differences between healthy controls and patients with different dementia subtypes, including AD , PDD 4)4), and DRecently, analyses of brain networks and abnormal hemispheric asymmetry have been considered as alternative neuroimaging approaches for exploration of marginal differences in patients with dementia –10. In bFurthermore, analyses of abnormal hemispheric asymmetry, based on brain network parameters that have long been measured and compared, have also been used to study dementia. For example, cortical volume , 13, corThis study therefore recruited patients with AD, PDD, and DLB, in comparison with HC, with two main objectives: (1) exploration of the disrupted glucose metabolism network topology (brain network) and comparison of related parameters, and (2) exploration of hemispheric asymmetry.Metabolic brain images were acquired using 18F-labeled fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) from four groups, including 22 healthy subjects, and 22, 18, and 22 patients with AD, PDD, and DLB, respectively. Subjects were recruited from the PET Center of Huashan Hospital, Shanghai, China. All participants were right-handed. Three days before and after PET image acquisition, we obtained basic information about these subjects, including their age, sex, and Mini-Mental State Examination (MMSE) scores . All aspWhole brain PET images were acquired from 84 participants using a Siemens Biograph 64 PET/CT machine in the PET Center of Huashan Hospital in Shanghai, China. The spatial resolution of the PET scanner was 5.9 mm full-width at half-maximum (FWHM) in the transaxial plane and 5.5 mm FWHM in the axial plane. All subjects were intravenously injected with 185 MBq FDG in a dimly-lit, quiet room. They were asked to keep their eyes closed for 1 h to reduce possible activities which could obscure the results. Thereafter, static emission scans were conducted for 10 min. Using a Shepp–Logan filter, we implemented a filtered back projection algorithm to reconstruct transaxial images with the following dimensions: 168 × 168 × 148 matrices and a size of 2.0 × 2.0 × 1.5 mm.https://www.nitrc.org/projects/dcm2nii/). For pre-processing of converted images, Statistical Parametric Mapping 12 software  was implemented in MATLAB (2016)3 FWHM. Finally, images were converted to grayscale, with 256 gray levels.All original images were obtained in Digital Imaging and Communications in Medicine format and converted to NIfTI format using DCM2NII software  template . Secondly, the value of each network node was calculated. The globally normalization was obtained by averaging the intensity values of the ROI in each patient, calculating the correlation matrix between the nodes in the group to obtain the correlation matrix. Partial correlation coefficients were used here to exclude age and sex interference. Finally, the sparsity threshold (n) method was used to determine whether the connection is taken into account. The connection strength which is higher than top n% in the matrix was counted as 1, and vice versa. In this way, the aforementioned correlation coefficient matrix can be converted into a set of binarization matrices with a threshold of 6–40% –22.https://sites.google.com/site/bctnet/).After network construction, brain function networks were calculated for the HC, AD, PDD, and DLB groups, using a graph theory approach. The following network parameters were calculated: clustering coefficient (C), characteristic path length (L), gamma, lambda, small-world coefficient (sigma), local efficiency , global efficiency , and node betweenness centrality (BC). In graph theory, the C of a network is as a measure of the degree to which nodes in a graph tend to cluster together, while L is as a measure of the efficiency of the information, or the mass transport, of a network. A small-world network should meet the following criteria: gamma >> 1, lambda ≈ 1, and sigma > 1. GlobalE and localE are measures of the efficiency of information exchange in an entire network and a local network, respectively. BC is typically used to determine the number of candidate hubs in a network. According to previous studies, nodes with high bi (BC/averaged BC) values (bi > 1.5) were considered candidate hubs. We further differentiated the AAL template according to the left and right hemispheres, and constructed brain networks for both hemispheres (including 45 brain regions), to further evaluate the efficiencies of the hemispheres. In this study, network characteristic parameters were calculated using the open source graph analysis software, graph theoretical network analysis (GRETNA)  and The To determine the statistical significance of differences in network parameters in the AD, PDD, DLB, and HC groups, we used a non-parametric permutation test with 1,000 repetitions.After determining hubs in the four groups, brain areas that were significantly changed, or isolated, among different groups were subjected to further analysis. Seed-based correlation analysis was used to further explore the details of the connectivity between other brain regions and those that were significantly altered.First, the Pearson correlation coefficient was calculated for each voxel across the whole brain in a designated altered brain region, and the obtained correlation coefficients converted to z-values using Fisher's r-to-z transformation, to ensure that they obeyed an approximate Gaussian distribution, using the following formula:ri refers to the correlation coefficients, and zi the transformed z-values. Finally, these z-values were compared among groups using Z statistics with the formula:where 1 and n2 refer to the samples of two groups . Compared with the HC group, all network parameters in the DLB group were significantly different at specific sparsity values. LocalE was significantly higher in the AD group than the HC group at sparsity values of 30–31%; C was significantly higher in the PDD group than the HC group sparsity values of 18–33% and 37–40%; localE was significantly higher in the PDD group than the HC group at sparsity values of 21–32%; while lambda was significantly higher in the PDD group than the HC group at sparsity values of 11–19% and 22–27%.A non-parametric permutation test was applied to test the statistical significance of between-group differences among the AD, PDD, DLB, and HC groups  is a very useful indicator in graph-based theory because it reflects the relative importance of nodes in the network, helping us to identify the hub nodes. Before determining the candidate hubs in the four network, we first chose a reasonable sparsity. This sparsity should ensure that all four networks can be fully connected, without missing any brain region, biologically reasonable, and should be as small as possible to reflect the differences between the four groups. In this experiment, we chose 28%.In the HC, AD, PDD and DLB groups, 15, 19, 23, and 20 hub nodes appeared respectively on the principle of bi>1.5. We showed its distribution and importance in an axial view in To further investigate the detailed connectivity associated with the hubs in the four groups, the right middle temporal gyrus (MTG.R) was selected as a seed. This region was selected for two primary reasons: first, the MTG.R was a hub node in the HC, PDD, and DLB groups (bi > 1.5) and also relatively important in the AD group (bi = 1.48); second, in various previous studies, the MTG.R has been identified as having a very important role in dementia pathogenesis –31.P < 0.05). To represent the results more clearly, we plotted the average Z-scores of the significant connections in the enhanced ITG.R brain region in the four groups. The ITG.R region in the DLB group clearly had the strongest metabolic activity connection, relative to the HC group.Next, all patient data were used as a reference for further analysis. Z-statistical mapping was performed for the MTG.R regions of the four groups. The same analysis was also performed for the AD and PDD groups. For the AD group, connection enhancements were relatively scattered, mainly in the right middle occipital gyrus (MOG.R) and right inferior parietal, but also in the supramarginal and angular gyri (IPL.R), and the right precuneus (PCUN.R). These brain regions overlap with the brain default mode network (DMN) to a large extent. For the PDD group, connection enhancements were mainly located in the parietal region, including the bilateral postcentral gyrus (PoCG.L and PoCG.R); brain regions with weakened connections were mainly the left precentral gyrus (PreCG.L) and the left gyrus rectus (REC.L).P < 0.0001); significant rightward asymmetry  in global network efficiency was observed in all three groups.The within-group asymmetries of global and local network efficiencies for each group are illustrated in P < 0.0001), respectively, without either rightward or leftward asymmetry. Analysis of local network asymmetry indicated significant rightward asymmetry in both the AD  and DLB  groups, while significant leftward asymmetry was observed in the PDD group .The left and right brain local efficiency values for the HC group were 0.6816 and 0.6744 (P < 0.05)  . For thepost-hoc comparisons of the AI values revealed significant differences between those of the HC and patient groups. Compared with the HC group, the PDD and DLB groups exhibited significantly increased asymmetry in global network efficiency . Further, there were significant differences in the global network hemispheric topological properties for each hemisphere in the PDD and DLB groups. The AI_global value of the AD group was 0.0011, which was similar to that of the HC group, indicating no obvious asymmetry.p < 0.0001).Similarly, the AI_local values of the AD, PD, and DLB groups  deviated substantially from that of the HC group (1.10) and indicated clear asymmetry. Hence all the dementia groups exhibited results significantly different from those of the HC group  and tau . Hence, The results of our analyses of brains from patients with PDD indicated that hubs were mainly concentrated in middle temporal gyrus, middle occipital gyrus, inferior occipital gyrus, and fusiform gyrus. Structural and pathological changes occur in middle occipital gyrus and inferior occipital gyrus in PDD. Voxel-based analysis of FA, using DTI, found that it was significantly reduced in patients with this condition . FurtherAlthough there is no literature to support significant changes in the middle temporal gyrus of patients with PDD, numerous studies have concluded that this key brain region is closely related to Parkinson's disease (PD) and related disorders. For example, Howlett et al. demonstrated that a combined pathology  is a major determining factor in the development of dementia, particularly in the middle temporal gyrus, which contributes to the deterioration of PD to related disorders .In the DLB group, we detected higher betweenness centrality in the right thalamus, consistent with a previous study suggesting that both thalamic nodes have higher node degrees in DLB compared with controls, possibly reflecting compensatory responses . NotablyThe DLB hubs in the anterior cingulate and paracingulate gyri were first discovered in this investigation. The anterior cingulate cortex (ACC) is part of the brain limbic system and is widely recognized as a structure involved in control-related functions . NeuroimThe results of seed correlation analysis in this study also provide physicians with new insights into means of discriminating among the three dementia subtypes included. Comparisons with the literature also verify the effectiveness of our seed correlation analysis, or provide physiological and/or pathological explanations for our findings.For example, the results of our seed correlation analysis indicated that, compared with the HC group, regions of strengthened connection in the AD group were primarily located in the brain DMN. These findings can be explained by DMN atrophy, which is generally acknowledged in the context of glucose metabolism . FurtherIn addition, strengthened connections between the bilateral postcentral gyrus and the MTG.R were detected in the PDD group. The postcentral gyrus is the somatic sensory center, and its abnormal function is closely associated with PD, and diffuse glucose anomalies in the postcentral gyrus are correlated with dementia in patients with PD –31.In the DLB group, the connection with the right inferior temporal gyrus was strengthened, consistent with a previous study suggesting that this area is significantly different in patients with DLB relative to controls on medical imaging, and potentially represents either an alternative or adjunctive biomarker, which may reflect compensatory responses .The results of within-Group asymmetry analyses provide further evidence of the feasibility of using brain network analysis to discriminate dementia subtypes in the clinic. Through analysis of network parameters , we found that the phenomenon of abnormal hemisphere asymmetry was present in all three groups of patients with dementia. These results support the findings of previous investigations using non-brain network analysis methods. For example, we found that HC subjects exhibited no significant differences between their two hemispheric brain networks, suggesting that the two hemispheres have similar intra-connected pathways in HC. Scholars previously identified rightward asymmetry in AD hemispheric brain networks , 47, 48.Similar to the AD group, we also discovered that the DLB group exhibited rightward asymmetry, whereas the PDD group had leftward asymmetry in local efficiency. This may be explained by the fact that PDD progression is accompanied by a decrease in brain motor zone function, since the motor zone is on the left side and the memory area on the right .Although the findings of this study indicate that the methods we employed are effective, there are several issues that require further consideration. First, we constructed unweighted and binary networks. During the study, we discarded the direction in which the nodes were connected, and this variable may contain a lot of unknown information, including brain cooperation mode, information transmission, and biological transmitter diffusion mode. Also, partial correlation matrices were used to calculate network parameters and identify altered ROIs. Subsequently, Pearson correlation was applied in this study for ROI-based correlation analysis, which may have introduced bias.Second, it can be the case that the use of brain templates with better symmetry generate AI values closer to zero; therefore, the development of a symmetrical brain template, with corresponding biological information may facilitate improved exploration of the symmetry of brain function.Third, the data set included in this study was insufficient. The number of patients included in this study was limited, which may mean that the experimental results are not entirely representative. In future, we plan to collect more disease cases. In addition, the sex of patients in the different groups was not symmetrical, particularly in the DLB group, which is a mental illness more common in men, making it more difficult to collect a sex-balanced sample set for this condition. In future, we plan to further investigate DLB brain network differences between the sexes, to determine whether this characteristic significantly impacts the results.Finally, in this experiment, the MMSE scale values of the three disease groups did not match exactly, which may have impacted the cognitive function results; however, given the different pathogenesis of the types of dementia studied, it may be difficult to identify perfectly matched subjects.This study was carried out in accordance with the recommendations of the institutional review board of Huashan Hospital with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the institutional review board of Huashan Hospital.DC, JL, and HZ made specific experiments. JJ and PW had unique insights in characterization and analysis. DC wrote articles, CZ guided, reviewed and examined the experiments. KS participated in the discussion and gave unique insights.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background and objective: Sclerosing pneumocytoma is a rare, benign tumor of the lung that represents a diagnostic challenge due to the diversity of pathohistological findings. The aim of this study was to present a 10-year experience with sclerosing pneumocytoma of a large center for the diagnosis and treatment of pulmonary diseases, and to emphasize differential diagnostic dilemmas as a potential source of errors. Material and Methods: This represents a retrospective study of six patients diagnosed and treated with sclerosing pneumocytoma in the 10-year period. The study analyzed various parameters, which are: Sex, age, symptoms, size and localization of the tumor, and its gross and histological features. Results: Sclerosing pneumocytoma was more frequently diagnosed in females (83.34%). The patients ranged in age from 38 to 61. Most of the patients (66.66%) were asymptomatic. Two patients underwent a video-assisted thoracoscopic surgery, two patients had a video-assisted minithoracotomy, and two patients underwent a thoracotomy in order to remove the tumor. The tumor was localized in the left lower lobe, in the right upper lobe, and in the right lower lobe in 50%, 33.34%, and 16.66% of patients, respectively. The tumor size ranged from 1 to 2.5 cm. A pathohistological examination of all six cases reported that all four major histological patterns were found in tissue sections: solid, papillary, sclerosing, and hemorrhagic. In all six cases, an immunohistochemical analysis showed positive expression of TTF-1 and panCK in surface epithelial cells, and TTF-1 positivity and panCK negativity in round stromal cells. Conclusions: Sclerosing pneumocytoma is a strictly histological diagnosis supported by clinical and radiological findings and corresponding immunohistochemical methods. Lung pathologists should always keep this tumor in mind, since its spectrum of differential diagnosis is wide, and therefore it can be an important diagnostic pitfall. One of the rare, benign tumors of the lung is sclerosing pneumocytoma (SP), which represents a pulmonary neoplasm with a complicated and an undefined histogenesis. This tumor was first described by Liebow and Hubbell over 60 years ago as an uncommon lesion with an uncertain origin. The original description by these two authors implied that this tumor originates from vascular endothelial cells; so, initially, this lesion was named sclerosing hemangioma . AlthougThe aim of this study was to present a 10-year experience with sclerosing pneumocytoma of a large center for the diagnosis and treatment of pulmonary diseases, and to emphasize differential diagnostic dilemmas as a potential source of errors.A retrospective, 10-year-period study included six patients diagnosed with sclerosing pneumocytoma. The study protocol was approved by the Ethics Committee of Institute for Pulmonary Diseases of Vojvodina . All clinical data referring to age, symptoms, smoking status, surgical procedures, localization of the tumor, and diameter of the tumor were obtained from patients’ medical charts. The video-assisted thoracoscopic surgery (VATS), minithoracotomy, and thoracotomy were the surgical procedures performed in order to remove the tumor and to confirm the final diagnosis by histology. During surgery, a pathohistological examination on a frozen section specimen was performed in all six cases. The surgical specimen was embedded in a gel-like medium consisting of polyethilene glycol and polyvinyl alcohol  and placed on a metal tissue disc that was then frozen rapidly to about −20 to −30 °C. Afterwards, it was cut with the microtome of the cryostat on a histology 4-μm-thick slice. The section was picked up on a glass slide and stained with hematoxylin and eosin (H & E) stain. The preparation of the sample is much more rapid than a traditional histology technique. It takes about 10 min for whole procedure to be done; in comparison, the standard protocol for formalin-fixed, paraffin-embedded (FFPE) tissue takes much longer, since tissue should be fixed in formalin usually for at least for 12 h. However, the technical quality of the frozen sections is much lower, so a final pathohistological diagnosis should always be made on FFPE tissue. After taking a specimen for a frozen section analysis, more specimens from the tumor were taken for a standardized pathohistological analysis on FFPE tissue. All tissue sections were fixed by 10% neutral formalin, paraffin-embedded, sliced into 4-μm-thick sections, and stained with hematoxylin and eosin. The immunohistochemical analysis was performed by using TTF-1 and CK7 antibodies , as well as additional staining for estrogen receptors (ER) and progesterone receptors (PR) . All of the patients have been followed up for at least 5 years.During a 10-year period, we found six patients with SP: five females (88.34%) and one male (16.66%), Most of the patients (66.66%) were asymptomatic with changes discovered accidentally during routine medical examinations or while performing follow-up examinations of existing respiratory diseases. Within two patients (33.34%), the tumor presented with clinical symptoms. From data regarding medical charts, we discovered that two patients (33.34%) were smokers; one had a history of 25 pack/years, and the other a history of 10 pack/years. For the pathological examination of verified radiological masses, all patients underwent surgical procedures .In all six patients, during surgery, a pathohistological examination on frozen section specimens was performed. In three cases, pathologists set a diagnosis of SP; in one case, a diagnosis of clear cell tumor  was made; and, in two cases, pathologists could not set an appropriate diagnosis on the frozen section specimen, so a final diagnosis was made on FFPE tissue. A pathohistological examination of all six cases on FFPE tissue revealed that this tumor was typically composed of two cellular components: surface epithelial cells that resemble type II alveolar pneumocytes, and round stromal cells. These cells were typically arranged in four major histological patterns: papillary, sclerosing, solid, and hemorrhagic. The papillary pattern was composed of complex papillae without a typical fibrovascular core. The papillae were lined with surface cells covering stroma with round cells a. The scIn all six cases, an immunohistochemical analysis showed positive expression of TTF-1 and panCK in surface epithelial cells, and TTF-1 positivity and panCK negativity in round stromal cells . AdditioPatients were discharged from hospital 4–6 days after surgery. The presence of lymph node metastasis was not detected within these six cases, nor were any death outcomes reported during the 5-year follow-up period.Pulmonary sclerosing pneumocytoma is considered to be a rare benign neoplasm originating from type II pneumocytes.Current studies have reported that the female population is affected more frequently, with the tumor generally occurring in the middle-aged population, with peak age incidence between the 4th and 7th decade . This waThe majority of patients are asymptomatic, with the tumor being incidentally revealed as a soft-tissue mass on routine chest radiographs . In our Two of the six patients in our research were smokers. In other available reports, the incidence of smokers and nonsmokers with diagnosed pulmonary SP was variable; however, none of these studies defined smoking as a risk factor or its influence on the development of this neoplasm .Rare studies have reported that SP can be bilateral, which can be important in differential diagnosis from metastatic lung tumors ,13. In rSurgical resection is currently widely used for treating SP. Xu and colleagues have suggested that surgical resection is curative for this tumor, and that no additional treatment after the surgery and no evidence of recurrence define the excellent prognosis of the disease . Among tSclerosing pneumocytoma has no predilection for a particular lobe of the lung, which was confirmed by a study analyzing 28 cases with a definitive diagnosis. Among the peripheral lesions, five were located in the right upper lobe, four in the right middle lobe, six in the right lower lobe, nine in the left lower lobe, and three in the left upper lobe of the lung . Our resThe maximum diameters of SP in our patients varied from 1 to 2.5 cm. According to other studies, lesions range from 0.3 to 7 cm in greatest dimension ,6. Some Cytological findings of SP have not been helpful in the diagnosis of this tumor. Aspiration or imprint cytology may show polygonal cells, erythrocytes, and foamy macrophages, but the components of solid, papillary, sclerosing, and hemorrhagic patterns can also be occasionally found . The cytThe diversity of pathohistological findings results in a wide range of differential diagnoses, which includes various benign conditions and benign and malignant tumors . Among tA pathohistological examination is usually combined with an immunohistochemical analysis for the definitive diagnosis of SP. Previous studies have reported that both surface and round cells show a positive immunohistochemical reaction on certain antibodies, which facilitates the diagnosis of the tumor. A positive nuclear reaction on TTF-1 has been observed in both cellular components, while panCK has been expressed only in the cytoplasm of surface epithelial cells . The facThe patients with SP have an excellent prognosis with no need for additional treatment after surgical resection. This tumor is generally considered to be a benign lesion, although potential malignant behavior is expressed through lymph node metastasis that was first reported in 1986 by Tanaka and colleagues . Adachi Sclerosing pneumocytoma is a histological diagnosis supported by clinical and radiological findings and corresponding immunohistochemical methods. Lung pathologists should always keep this tumor in mind, since the spectrum of differential diagnoses is wide, and therefore it can be an important diagnostic pitfall.


Depression, which is the most common comorbidity in breast cancer (BC) patients, has adverse effects on patients’ quality of life, disease progress, and survival.The protocol of this study was registered in PROSPERO (registration No. CRD42019121494). We electronically searched published studies through January 2019 with the aim of finding articles that investigated the prevalence of depression among BC survivors. Web of Science, Scopus, PubMed/MEDLINE, Science Direct, and Google Scholar were searched to obtain relevant published studies. This review included 14 cross-sectional and 4 cohort studies published from 2000 to 2018. We used a random-effects model to conduct the meta-analysis and generated a summary estimate for the pooled prevalence with 95% confidence intervals (CIs). A subgroup analysis was also conducted based on the depression assessment tool used and the study design.2 =98.5%; p<0.001). The prevalence of depression ranged from 14.00%  to 95.90% . The results of the subgroup analyses suggested that the depression assessment tool, year of publication, and study design were sources of heterogeneity.The total sample size of the studies contained 2,799 women with BC, including 1,228 women who were diagnosed with depression. The pooled prevalence of depression among Iranian women with BC was 46.83%  with significant heterogeneity (IOur findings indicate a high prevalence of depression among BC patients, underscoring the urgent need for clinicians and health authorities to provide well-defined social and psychological supportive care programs for these patients. It is estimated that about 2.1 million newly diagnosed cases of breast cancer (BC) occurred in 2018 worldwide, accounting for almost 1 in 4 of all cases of cancer among women. BC is the most frequently diagnosed cancer in most countries 154 of 185), and is the leading cause of death due to cancer in over 100 countries ,4. As a 4 of 185,When diagnosed with cancer, patients are exposed to an instigator of many fears, including fears of death, separation, and isolation from their loved ones, as well as fear of deterioration and pain. The most common psychological disorders among cancer patients are mood disorders, anxiety, depression, and sexual dysfunction. For example, the period from the diagnosis of BC to months following primary therapy is long and highly stressful, which causes psychological instability and depression . DepressHelping patients with cancer achieve the best possible QoL is a shared goal among medical and healthcare communities . Hence, The present systematic review and meta-analysis was prepared according to the PRISMA  statement .The purpose of the present study was to determine the prevalence of depression among women with BC in Iran. The study protocol was registered in PROSPERO, an international prospective register of systematic reviews, under the registration No. CRD42019121494.A comprehensive search was performed with the aim of finding any cross-sectional or cohort studies that investigated the prevalence of depression among patients with BC in Iran. Accordingly, the following sources were searched: Web of Science, Scopus, PubMed/MEDLINE, Science Direct, Google Scholar, Magiran, Scientific Information Database, IranMedex, and Medlib. Four sets of related MeSH and non-MeSH terms in titles, abstracts, or keywords were used: (1) “breast cancer” OR “breast carcinoma” OR “breast neoplasm”, (2) “depression” and (3) “prevalence” OR “occurrence” and (4) “Iran” were searched for articles published from February 2000 until January 2019.The search strategy was performed using Boolean operators . Two authors independently reviewed the articles (HAG and SMK) and discrepancies were resolved by discussing with the third author (MD). We also manually reviewed the reference lists of related articles for other possibly relevant articles that were not found through the electronic search strategy.Prospective cohort studies and cross-sectional studies that investigated the prevalence of depression among Iranian BC patients were included, encompassing both studies on newly diagnosed BC cases (incident cases) and prevalent cases of BC.Prospective cohort studies and cross-sectional studies that did not report the prevalence of depression among Iranian BC patients, reported the prevalence of depression among patients with other types of cancer (not relevant or modified data), reported the prevalence of depression among other comorbidities of BC patients, or focused on BC recurrence were not included in our systematic review and meta-analysis. Studies in review design or letter to the editors (not a research article) were also excluded.Two authors (HAG and SMK) independently extracted the following data for each study: authors’ name, publication year, setting, sample size, numbers of patients who suffered from depression, prevalence of depression, age, the tool used, marital status, and study design. If the full text of any article was unavailable or if key information was missing from the reported data, up to 2 attempts to contact the authors were made at 1-week intervals, and we also sent an email to the publishers .An 8-item checklist for the critical appraisal of studies of the prevalence/incidence of health problems  was used2 test was used to evaluate the heterogeneity of studies [A random-effects model was used to investigate the pooled prevalence of depression with 95% CIs among women with BC. The I studies . Subgrou studies  and funn studies  were use studies .Ethical approval was obtained from Tehran University of Medical Sciences. This was a review study, so consent to participate was unnecessary.As described in Overall, the included studies contained 2,799 women with histologically confirmed BC . Of those patients, 1,228 (43.87%) were diagnosed with depression, and the mean age of the patients was 47.94 years .Six different methods were used to diagnose depression in the included studies. Seven studies used the Beck Depression Inventory (BDI) -25,29-31According to the critical appraisal of studies of prevalence/incidence of a health problem checklist , 2 studi2=98.5%; p<0.001).The highest prevalence of depression among women with BC was 95.90%  which was reported by Shakeri et al.  in KermaMeta-regression was conducted according to study design, the measurement method, participants’ age, the article’s publication year, sample size, and studies’ quality score . HeterogThe Egger test and funnel plot method were used to measure publication bias. As presented in The pooled depression prevalence measured by the BDI, HADS, and other methods was 66.18% , 28.92% , and 40.19% , respectively . MoreoveDepression is a common condition among BC patients, but it is often unrecognized and therefore untreated. The condition intensifies physical symptoms, resulting in additive functional impairment and poor adherence to treatment. As a result, depression in BC patients is responsible for significant deterioration in QoL .The current systematic review and meta-analysis was conducted to investigate the prevalence of depression among Iranian women diagnosed with BC. The high prevalence 46.8%) of depression observed in this study among BC survivors is worrying, and it calls for immediate attention. We found that the lowest and highest reported prevalence rates were 14.0% in Tehran  and 95.9.8% of deThe results of this study showed that the prevalence of depression increased from 2000 to 2017; the prevalence of depression in 2000-2004 years was 31.4%, and after 2015 it was around 57.7%. Many factors may have an effect on the prevalence of depression among BC patients, including increases in the prevalence and incidence of BC, increases in the survival rate of patients, improvements in diagnostic methods, and the launch of a cancer registration system.It seems that in Iranian society, for cultural reasons, women are placed under additional pressure following the diagnosis and treatment of BC. As a result, while suffering from physical complications of the disease and its treatment, BC patients suffer from stress and emotional problems . The higThe opinion of relatives, especially the husband’s relatives, about the patient is another source of stress. Emotional support from their husbands is therefore fundamentally important for patients during the treatment of BC. It has been shown that society’s and relatives’ attitude toward women who have lost their feminine organs have significant effects on their feelings, potentially resulting in depression and anxiety . This isAnother important factor that may have a significant effect on depression among patients with BC is the late diagnosis of BC, as around 70% of Iranian patients with BC are diagnosed at an advanced stage , which iAlong with the previously discussed issues, the observed difference in the prevalence of depression reported by previous studies can also be explained in terms of the studies’ design. In this review study, the prevalence of depression reported in cross-sectional studies was much higher 55.3%) than that reported in prospective studies (17.5%). In line with this result, another review article reported that the prevalence of depression in cross-sectional studies was higher than in prospective studies . A possi.3% than The results of the current study revealed a high prevalence of depression among women with BC. Suffering from depression can exacerbate the prognosis of the disease and reduce patients’ survival . AccordiThe present study has some limitations that must be pointed out. Firstly, data on some important factors, including the stage of BC and the years since diagnosis, were not available, making it impossible to conduct a subgroup analysis of whether the prevalence of depression differed according to those factors. Secondly, Iran is a country with considerable ethnic diversity, which may affect the prevalence of depression in different areas of the country. However, it was not possible for us to determine the possible role of ethnicity in these findings. In contrast, strengths of this study include the fact that national and international databases were searched in both Farsi (Persian) and English to obtain comprehensive results, and that we excluded studies on BC recurrence because this may be a source of bias.The results of this systematic review revealed a remarkably high prevalence of depression among women with BC. Early diagnosis, social support, and emotional support from family members can help in the management of depression, with positive impacts on QoL. These results should be carefully considered by physicians, healthcare providers, and the patient’s family when a woman is diagnosed with BC.


Impairments in the ability to understand others and the self in terms of internal mental states  are thought to play a key role in the development of borderline personality disorder (BPD). The first aim of this study was to validate the Italian version of the Reflective Functioning Questionnaire (RFQ), a brief self-report measure of RF, by examining its factor structure with Principal Component Analyses (PCA), and correlations with constructs that should be theoretically related to RF. In addition, we investigated whether the RFQ could empirically distinguish between healthy controls and carefully diagnosed BPD patients using Research Operating Curve methods, and was related to severity of borderline pathology as measured with the Shedler–Westen Assessment Procedure (SWAP), an observer-rated measure of BPD pathology.An Italian translation of the RFQ was administered to a sample of 154 healthy controls and a clinical sample of 59 BPD patients diagnosed with the Structured Clinical Interview for DSM-IV Axis II disorders. Clinical severity of BPD was assessed with the SWAP. Normal controls completed self-report inventories of constructs related to RF .p < 0.05). ROC analyses showed that the uncertainty subscale discriminated BPD patients from healthy individuals . Within the patient group, regression analyses showed uncertainty about mental states to have a significant unique contribution in predicting BPD severity (p < 0.05), explaining 12% of the variance.PCA confirmed the a priori factor structure in the Italian translation of the RFQ, showing two subscales that measure certainty and uncertainty about mental states, with satisfactory reliability and construct validity. These dimensions also distinguished BPD patients from healthy controls (Results largely supported the reliability and validity of the Italian version of the RFQ. These findings also provide further evidence for the role of impairments in mentalizing and reinforce the rationale for offering mentalization-based interventions to individuals with this disorder. Borderline personality disorder (BPD) is a psychiatric disorder characterized by instability in self-image and interpersonal relationships, impairments in emotion regulation, and impulsivity, which may lead to disruptive and self-harming behaviors . The preThe mentalizing approach to BPD –9 highliRF has historically been measured with the Reflective Functioning Scale (RFS) , an instTo overcome these limitations, Fonagy and colleagues recently validated the first self-report measure of RF, the Reflective Functioning Questionnaire (RFQ) . The RFQThe aims of the present study are the validation of the Italian version of the RFQ and the investigation of its ability to distinguish between healthy individuals and BPD patients. Indeed, translation and transcultural validation into Italian are urgently needed to facilitate research in the mentalization field among Italian-speaking populations. In line with previous work , 28 we ePositive associations between the degree of certainty about mental states (RFQ_C) and mindfulness, empathy, and Theory of Mind capacity were expected; however, correlations with Theory of Mind were expected to be relatively lower, in that this construct refers to mentalizing based on external features, while the RFQ is primarily designed to test individuals’ ability to focus on internal mental states rather than external physical cues. Negative correlations between RFQ_C and alexithymia and autistic traits were expected, in that these dimensions indicate poor awareness of emotions or feelings and “mind-blindness”. Correlations between the degree of uncertainty about mental states (RFQ_U) and the constructs listed above were hypothesized to show the opposite pattern. The discriminant validity of the RFQ was established by testing its ability to differentiate between healthy and BPD participants.Further, having established the validity of the Italian version of the RFQ, on the basis of the literature about mentalizing, we hypothesized that impairments in RF measured with the RFQ would be related to the severity of borderline pathology in BPD patients.RFQ data were collected in samples of BPD patients and healthy individuals. Inclusion criteria for all participants were age between 18 and 50 years and being a native Italian speaker. Participants were considered eligible for the analyses provided there were not too many missing values (more than 5% of missing data); outliers were removed from the analyses if the error checking was not successful.Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [For the clinical BPD sample, 62 patients fulfilling criteria for BPD based on the fourth edition of the (DSM-IV)  were rec(DSM-IV) . Patient(DSM-IV) , 31 and (DSM-IV) , 33. BPD(DSM-IV) , 35. Mea(DSM-IV) , 37 and (DSM-IV) , 39, res(DSM-IV) .Of the 62 BPD patients, 2 were excluded because of missing values (response rate: 96.7%); 1 was excluded as outlier. Between the remaining 59 patients, 42 had one or more current comorbid Axis I or Axis II diagnosis . Twenty-nine patients were medicated; 18 were on antidepressants ; 9 on mood stabilizers ; 12 were on atypical antipsychotics .As a comparison group, 158 healthy participants were recruited via advertisements at the University of Pavia; these individuals comprised students and service staff. 4 of them were excluded because of missing values (response rate: 97.5%). See All participants gave written informed consent in accordance with the requirements of the ethics committee of the Department of Applied and Behavioral Sciences of Psychiatry, University of Pavia, Pavia, Italy, which approved this study.The RFQ and the self-report measures of constructs related to RF were individually administered to the healthy participants. Participants were supervised by a trained psychiatrist while completing the measures to ensure appropriate understanding of items.As first step of the validation process, the RFQ was translated into Italian by a native Italian speaker; to maintain sentences’ meaning between English and Italian, the Italian version of the RFQ underwent a back-translation . To thisThe RFQ comprises two subscales, each containing 6 items, measuring the degrees of uncertainty (RFQ_U) and certainty (RFQ_C) about mental states. The RFQ_U subscale consists of 6 items focusing on the level of participant agreement, with statements such as “Sometimes I do things without really knowing why”. Items are scored by the participant on a 7-point Likert scale (ranging from “completely disagree” to “completely agree”). To capture extreme levels of uncertainty, items are rescored to 0, 0, 0, 0, 1, 2, 3, so that very high agreement on this scale reflects hypomentalizing , while some disagreement reflects adaptive acknowledgement of the opaqueness of one’s own mental states, typical of genuine mentalizing. The RFQ_C subscale consists of 6 items, such as “I don’t always know why I do what I do”, and is scored on the same 7-point Likert scale as the RFQ_U, then rescored to capture extreme levels of certainty; to this end, these items are recoded to 3, 2, 1, 0, 0, 0, 0. As a result, low agreement reflects hypermentalizing, while some agreement reflects adaptive levels of certainty about mental states.The Reading the Mind in the Eyes Test (RMET) , 44 was The Empathy Quotient (EQ) , 46 was The Kentucky Inventory of Mindfulness Skills (KIMS)  was admiThe Toronto Alexithymia Scale (TAS-20) , 49 compThe Autism Spectrum Quotient (AQ) , 51 was The SWAP 200  is an asIn the present study, to optimize the power of clinical observations, SWAP scores were performed by the psychiatrist that clinically assessed each BPD patient.Principal component analysis (PCA) was performed to study the factor loading of both subscales of the RFQ.n = 30) of healthy participants, in order to demonstrate temporal stability.The reliability of the subscales was estimated by calculating Cronbach’s alpha coefficients and mean inter-item correlation. Test–retest correlation after an interval of 2 weeks was calculated in a subsample  in the whole sample, with the RFQ subscale scores entered as dependent variables, with diagnosis as a factor and age as a covariate. Receiver Operating Curve (ROC) analysis was performed to investigate the ability of the RFQ_C and RFQ_U subscales to identify clinical cases, and to determine a cut-off score.Hierarchical multiple regressions were conducted in the clinical sample with the SWAP-200 borderline score as dependent variable, and age, depression and RFQ_U scores as independent variables. An inverse relationship between age and BPD severity  and a poSPSS 17.0  was used for analysis of demographics and the psychological and psychopathological measures.p < 0.05) for both RFQ_U and RFQ_C, supporting the factorability of the data.The RFQ_C and RFQ_U subscale items were subjected to PCA using data from the sample of healthy participants. First, the suitability of the data for factor analysis was assessed. The Kaiser-Meyer-Olkin value was 0.8 for RFQ_U and 0.76 for RFQ_C; Bartlett’s test of sphericity reached statistical significance .The Italian RFQ subscales had good internal consistency, with Cronbach’s alpha coefficient of 0.77 for RFQ_U and 0.75 for RFQ_C. Mean inter-item correlations were 0.36 and 0.35, respectively. The test–retest reliability was good, with Consistent with expectations, RFQ_C was positively correlated with measures of mentalizing-related abilities—the KIMSac, the EQ, and the RMET see . The corF1,210 = 7.1, p < 0.01, partial eta squared = 0.12; RFQ_U: F1,210 = 55.6, p < 0.001, partial eta squared = 0.32).The ANCOVAs showed a significant effect of diagnosis (BPD vs. controls) on RFQ_C and RFQ_U scores  .F3,39 = 3.3, p < 0.05). This indicated that uncertainty about mental states explained an additional 8.8% of the variance in BPD severity as measured with SWAP-200, after controlling for age and depressive symptoms  = 4.3, p < 0.05). In the final model, only RFQ_U was statistically significant .RFQ_U scores were correlated with severity of BPD see . RegressThis study first aimed to validate the factor structure of the Italian version of the RFQ by factor analysis and by examining its correlations with related constructs and clinical variables in a sample of healthy individuals. Furthermore, this study also investigated the ability of the RFQ to distinguish between healthy controls and BPD patients. A final aim was to investigate the relationship between impairments in RF as measured with the RFQ and the severity of BPD psychopathology in a sample of BPD patients.PCA resulted in the extraction of single factors for both the RFQ_U and RFQ_C subscales, reflecting the conceptualization of the original version of the RFQ . Both suThe RFQ subscales were also in theoretically expected ways related to constructs that are closely related to RF, such as empathy and aspects of mindfulness. These results are consistent with mentalizing theory, in that empathy and mindfulness, like RF, imply the capacity for internally-based mentalizing. The construct of empathy, although broad and complex, involves the ability to detect other people’s mental states and predict their future behavior , and theNegative correlations were found between the RFQ_C subscale and the constructs of alexithymia and symptoms of autistic spectrum disorder; conversely, positive relations were found between the RFQ_U subscale and these same constructs. Indeed, alexithymia, that is, the inability to experience, identify and express emotions, reveals uncertainty about the emotional states of others and the self, and, as such, poor RF. Likewise, the presence of autistic traits implies poor imaginative, communication and social skills—skills that are required attributes of a good reflective capacity.Both the RFQ_C and RFQ_U were able to differentiate healthy participants from carefully diagnosed BPD patients. The ROC analysis indicated that the RFQ_U subscale was able to discriminate BPD patients from healthy controls, allowing identification of a cut-off, with relatively good sensitivity and specificity for such a brief measure, although of course improvement is possible. The same was not found for the RFQ_C subscale in the ROC analysis, although BPD patients differed significantly from healthy controls on this subscale.With regard to the relationship between RF and severity of borderline psychopathology, uncertainty about mental states was found to have a unique contribution to the severity of BPD as independently assessed by trained observers using the SWAP. These results are consistent with mentalizing approaches to BPD , 9, 11, A strength of this study is that all participants BPD were recruited directly from a clinical population drawn from a clinical setting specialized in the treatment of BPD. However, some methodological limitations must be mentioned. First, our analyses and conclusions are largely based on self-report questionnaires, with the exception of the SWAP. A further weakness is the lack of an appropriate criterion for measuring mentalizing; therefore, our conclusion that the RFQ actually measures RF can be only provisional. A further limitation is the fact that participants’ emotional state at the time of assessment may have had an impact on the results. Indeed, Fonagy et al.  point ouIn conclusion, this study provides preliminary evidence for the reliability and validity of the Italian version of RFQ as a self-report tool for measuring RF. The RFQ_U subscale in particular had good discriminative capacity, but further research is needed to determine whether this instrument can be used as a screening tool for the diagnosis of BPD. However, the RFQ provides a measure of individuals’ reflective abilities and as such it can be used to enhance the clinical assessment of BPD patients, as well as to measure the response to clinical intervention, for example, mentalization-based treatment , 28. UseS1 Dataset(XLSX)Click here for additional data file.


Purpose: This study aimed to analyze the differences in physical activity, mental health, and quality of life between the elderly without activity-limiting disabilities and in elderly with activity-limiting disabilities, stratified by medical category. Methods: A total of 1504 elders aged 65–80 who responded to the 2016 Korea National Health and Nutrition Examination Survey were the participants in this study. They were divided into two groups, 303 elders with disabilities who responded to the survey saying they have active limiting disabilities, and 1201 elders without disabilities. The questionnaire reflected the criteria of a survey developed by the American College of Sports Medicine (ACSM) to measure the physical activity of elders. Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 Dimension (EQ-5D) were used to measure participants’ mental health and quality of life, respectively. Analysis of covariance (ANCOVA) adjusted for age, sex, marital status, notional basic livelihood, recipient status, and personal income was conducted for data analysis after the normal distribution was confirmed. Results: Significant differences between elders with disabilities and those without disabilities were seen in terms of physical activity levels (p < 0.01), stress, and depression (p < 0.001), and in all five domains measuring the quality of life (p < 0.05). The ANCOVA revealed significant differences in motor ability (p < 0.01) and pain/discomfort (p < 0.05) relating to the quality of life among the elders with activity-limiting disability depending on the medical category. Conclusions: The results could provide basic data regarding the degree of physical activity, mental health, and quality of life according to activity-limitation disability status and medical category. From the findings, elders with disabilities are clearly more exposed to risk in the areas of physical activity, mental health, and quality of life. Differences in quality of life among elderly with disabilities were also seen based on medical category. Our findings suggest that research into elders with disabilities should consider the implications of these results. The 2015 Korean National Statistics Office Survey found that 14.5% of the Korean population was over 65 years. It has been predicted that post-2025, more than 20% of the elderly will come under the category of the super-aged .Elderly with disabilities can be divided into two groups: aging with disability and disability with aging. These two groups are commonly called “elders with disabilities.” They experience limitations in their daily lives regardless of the reason for or type of disability ,5. ElderPhysical activity behavior is related to risk reduction of chronic disease conditions, functional limitations of the elderly, and quality of life ,11. DisaTo help them maintain their physical health behaviors and to prepare a program to enhance the quality of their lives, it is important to consider the physical activity, mental health, and quality of life of elders with disabilities ,15,16. PThis study provides the basic data needed for promoting the health of elders with disabilities by understanding their degrees of physical activity, mental health, and quality-of-life status, and comparing and analyzing the differences between the different disabilities according to the medical category to which they belong. The aim of the study is, therefore, to compare and analyze these differences based on activity-limiting disability and medical category. We hypothesized that the physical activity, mental health, and quality-of-life status of elders with activity-limiting disabilities would be different from that of elders without disabilities. Furthermore, we hypothesized that for elders with disabilities, these areas would vary depending on disability status and medical category.This is a descriptive survey study based on the 2016 Korea National Health and Nutrition Examination Survey (KNHANES) aimed at analyzing the differences in the physical activity, mental health, and quality of life of the elderly based on the activity limitation of the disability  , the disThe 2016 KNHANES survey was conducted on 4416 families in 192 survey districts, and 1534 elders aged 65 to 80  participated. Activity-limitation disability status was defined as the difficulty encountered by an individual in executing a task or action. Exclusion criteria were: (1) under 65 years old; (2) unclear status regarding the activity-limitation disability; (3) no submission of medical condition; (4) unreliable results from the survey. Elderly with cognitive deficits such as dementia or mental retardation were not excluded. Questionnaires were to be completed with help from family members if participants had difficulty filling out the survey. Of the total 1534 participants, 30  were excluded because they had not completed some or any sections of the questionnaire. Thus, data from 1504 elders aged 65 to 80 years  were included for the analysis. The KNHANES team also evaluates the health level and health behavior of Koreans every three years. The general characteristics of participants such as age, gender, marital status, marital condition, national basic livelihood recipient status, and personal income were derived from this survey see .The data for this study were drawn from the 2016 KNHANES survey. We evaluated three domains: physical activity, mental health, and quality of life. To evaluate physical activity, participants completed the survey reflecting the ACSM-recommended physical activity criteria. Aerobic physical activity was evaluated by whether or not they participated in such activity for more than 150 min per week, and also by the number of days they walked for at least 10 min per day. Strength exercise was defined as physical activity that forces muscles to work by using resistance, like a dumbbell or one’s own body weight. Strength exercise was evaluated by days participating in strength exercises per week. To evaluate mental health, participants assessed their stress and depression levels using Patient Health Questionnaire-9 (PHQ-9) . Qualityn = 1) had to be eliminated because it is impossible to run a Bonferroni test if a group has only one case. Statistical significance was set at p < 0.05 for all analyses.Means and standard deviations were calculated for all data and were analyzed using SPSS 21.0 . Frequency analysis was conducted to assess the participants’ characteristics. After normal distribution was confirmed, analysis of covariance (ANCOVA) was conducted to control several confounders  to examine the differences in physical activity, mental health, and quality of life based on activity limitations corresponding to the disability status of the elders. After a homogeneity of variance test was completed to evaluate normal distribution, ANCOVA with a post-hoc test (Bonferroni) was conducted to control several confounders  to analyze the differences in physical activity, mental health, and quality of life. The case of an elder with mental retardation (p < 0.01). In the mental health domain, the sum of the responses from the survey represents increased severity of stress as the number gets closer to 1. Elders with disabilities showed a significant level of stress (2.79 ± 0.94) compared to elders without disabilities (3.20 ± 0.86) (p < 0.001). Depression levels based on the PHQ-9 test also showed that elders with disabilities showed a significant difference  compared to elders without disabilities (p < 0.001). Finally, among the quality-of-life variables, significant differences were seen between the two groups in terms of motor ability (p = 0.007), self-management (p = 0.013), daily life (p = 0.018), pain/discomfort (p < 0.001), and anxiety/depression  who completed the physical activity survey, 73 elders with disabilities (24.09%), and 432 elders without disabilities (35.97%) participated in aerobic physical activity (over 150 min a week). In the section on strength exercises per week, 31 elders with disabilities (10.23%) and 215 elders without disabilities (17.90%) reported participating in resistance exercises more than once a week. For the number of days they walked per week (more than 10 min per day), elders with disabilities reported walking on 2.66 ± 1.78 days, and elders without disabilities walked on 3.51 ± 1.82 days. There were significant differences between the two groups of elders in terms of their participation in all three physical activities (p = 0.004) and pain/discomfort  showed significant differences in the quality-of-life domain. Nevertheless, a post-hoc test (Bonferroni) revealed that the difference in the quality-of-life domain was not statistically significant among medical categories.The percentage of activity limitation for each disability type is shown in The present study aimed to analyze physical activity, mental health, and quality of life among elderly Koreans with and without activity-limiting disabilities, including analysis of those with disabilities by medical category. Data on these areas were obtained from 1504 elders aged 65 to 80 who participated in the 2016 KNHANES.A decline in physical activity, strength, and ambulatory ability among elders is a general characteristic of frailty. Physical activity participation and fitness maintenance are important factors for the prevention and management of frailty ,28. EldeElders experience depression and stress, which is expressed as worry, gloom, helplessness, and worthlessness. Some of the most frequent mental health problems experienced in old age occur due to physical changes, along with changes in social roles and support systems . Among eAn active lifestyle is associated with health-related fitness and functionality of independence as well as the quality of life among individuals with disabilities . HoweverThis study used the KNHANES medical categorization of activity-limiting disabilities into 24 categories to investigate the association of a specific medical category with physical activity, mental health, and quality of life among elders with disabilities. Based on these categories, no significant differences were seen in the physical activity and mental health domains. However, there were significant differences in the quality-of-life domain of motor ability and pain/discomfort. This was consistent with a study on patients with chronic diseases, such as those with hypertension and arthritis, whose quality of life was poor . While sThis study has several limitations. First, physical activity was not measured objectively, but rather using a self-reported questionnaire. However, the questionnaire’s reliability and validity have been verified as it was used according to national standards . Second,Comparing the physical activity, mental health, and quality of life of 1504 elders with and without activity-limiting disabilities showed significant differences in (a) aerobic physical activity participation rates and number of days of doing strength exercises in the physical activity domains; (b) stress and depression in the mental health domains; and (c) all variables  in the quality-of-life domains between the elderly with and without disabilities. In terms of medical category, there were no differences in the physical activity and mental health domains, but there were differences in motor ability and pain/discomfort in the quality-of-life domain. From these results, it is possible to grasp the levels of physical activity, mental health, and quality-of-life status of the elderly with an activity-limiting disability status. This can serve as basic data for further studies on activity limitations among the elderly.


To investigate the association between tonsillitis and the risk of newly diagnosed ankylosing spondylitis (AS).We used 2003–2012 data from Taiwan’s National Health Insurance Research Database to conduct this nationwide, population-based, case-control study. We identified AS patients newly diagnosed between 2005 to 2012 as the study group and selected age, sex and index-year matched (1:6) non-AS individuals as controls. The association between tonsillitis and risk of newly diagnosed AS was determined by calculating odds ratios (ORs) with 95% confidence intervals (CIs) using conditional logistic regression analysis.We identified 37,002 newly diagnosed AS cases and 222,012 matched non-AS controls. Patients with AS were more likely to have tonsillitis , appendicitis  and periodontitis  than non-AS control subjects. The association between tonsillitis and AS was consistent using varying definitions for tonsillitis, and we further found that a high frequency of visits for tonsillitis, a high medical cost for tonsillitis and a long interval between diagnosis were associated with newly diagnosed AS in a dose-response manner. Furthermore, the association between tonsillitis and AS appeared to be stronger in females  than those in males .The present study revealed an association between AS risk and prior tonsillitis and indicates the need for vigilance of AS-associated symptoms in patients who had been diagnosed with tonsillitis, particularly in females. Ankylosing spondylitis (AS), an autoimmune arthritis, is characterized by a dysregulated inflammation involving mainly the sacroiliac joints, axial structure, and enthesis . AS deveThis study was approved by the Institutional Review Board of Taichung Veterans General Hospital, Taiwan (IRB number: CE16251A-1). All the personal data obtained were anonymized before analysis, and informed consent was thus waived.In Taiwan, a single-payer National Health Insurance (NHI) program was launched on March 1, 1995. As of 2015, up to 99.6% of Taiwan’s population was enrolled in the NHI program . We usedth Revision, Clinical Modification (ICD-9-CM) code 720 or 720.00) during 2003–2012, and those who had AS diagnosis before 2005 were excluded given that we aimed to identify those with newly diagnosed AS. To ensure diagnostic validity, we only included those who had received medications, including corticosteroid, non-steroidal anti-inflammatory drugs, sulfasalazine, methotrexate, and biological agents including adalimumab, etanercept, and golimumab. The first date of a visit with an AS diagnosis was selected as the index date, and the index year was the year of the index date.In this study, AS patients were defined as having at least three ambulatory visits or one hospital admission with a diagnosis of AS  for age, gender, and the index year after exclusion of individuals who ever had ICD-9 codes for AS. The index date used for non-AS controls was the day of the first ambulatory visit for any reason in the index year.We used both inpatient and outpatient databases in this study and defined tonsillitis by one ambulatory visit or hospital admission with the tonsillitis-associated diagnosis. The codes of tonsillitis-associated diagnoses and procedures included acute tonsillitis (ICD-9-CM code 463), chronic tonsillitis (ICD-9-CM code 474.0), and tonsillectomy .et al. [Potential confounders used for adjustment in the conditional logistic regression included age, gender, Charlson comorbidity index (CCI), history of periodontitis, and history of appendicitis. The presence of comorbidity was defined as having at least three ambulatory visits or one inpatient visit with a corresponding ICD-9CM code within 1 year before the index date. The CCI, as adapted by Deyo et al. . was utiet al. –16. To met al. . In the t-test for continuous variables and Pearson’s χ2 test for categorical variables. A conditional logistical regression model was conducted to estimate the odds ratio (OR) and 95% confidence interval (CI) of newly diagnosed AS after adjustment for age, gender, CCI, history of periodontitis, and history of appendicitis. All the data were analyzed using SAS statistical software version 9.3 . A P value <0.05 was considered statistically significant.Data were presented as the mean ± standard deviation (SD) for continuous variables and as number (percentages) for categorical variables. The differences were analyzed using Student’s A total of 37,002 newly diagnosed AS patients were identified and 222,012 matched non-AS control subjects were assessed see . The intWe investigated the association between the risk of AS and infectious diseases including tonsillitis, appendicitis, and periodontitis. A conditional logistic regression model that was adjusted for potential confounders revealed that AS case subjects were more likely to have tonsillitis , appendicitis  and periodontitis  than non-AS control subjects . Next, wWe then stratified the frequency of visit for tonsillitis and medical cost of tonsillitis to explore whether the strength of correlation between tonsillitis and AS was associated with the severity of tonsillitis. AS risk was strongest in those with the highest number of visits for tonsillitis (>4 visits)  followed by risks in those with 3–4 visits , those with 2 visits , and those with 1 visit . With regard to the medical cost, a similar pattern was found between newly diagnosed AS and the four quartiles categorized by medical cost for tonsillitis. The strongest risk for AS was observed in those with the highest number of medical cost for tonsillitis (Q4)  followed by risks in Q3 , Q2 , and Q1 . Furthermore, we stratified the interval (years) between diagnosis-date of tonsillitis and AS into four quartiles and identified that a longer interval was associated with a stronger association between tonsillitis and newly diagnosed AS. In detail, AS risk was the strongest among those with the longest interval between tonsillitis and AS (Q4)  followed by risks in Q3 , Q2 , and Q1  . AdditioIn this population-based study, we investigated the correlation between tonsillitis and newly diagnosed AS. We found that tonsillitis, appendicitis and periodontitis were independently associated with newly diagnosed AS. Additionally, we demonstrated that the severity of tonsillitis and interval between diagnosis of tonsillitis and AS correlated with the strength of association between tonsillitis and newly diagnosed AS. Furthermore, the association between tonsillitis and AS appeared to be stronger in females than in males. These findings highlight the correlation between tonsillitis and AS and indicate the need for vigilance of AS-associated symptoms in patients who had been diagnosed with tonsillitis, particularly in females.et al. recently demonstrated that tonsils were involved in the tolerance to allergens through the generation of allergen-specific FOXP3+ regulatory T cells, indicating that tonsils are crucial in the development of immune-tolerance [The underlying mechanisms of development or exacerbation of autoimmunity in AS are complex, involving genetic predisposition including HLA-B27, gut dysbiosis, and environmental triggers including infectious diseases. The tonsils are secondary lymphoid tissue in humans, and tonsillitis, including acute tonsillitis and chronic tonsillitis, is a leading disease in otolaryngology . Indeed,olerance . We thuset al. demonstrated a correlation between alteration of gut microbiota, i.e., gut dysbiosis, and systemic inflammation through IL-22/23 signaling in patients with AS [Increasing evidence suggests that gut microbiota plays a pathogenic role in autoimmune arthritis including RA and AS . Mouse s with AS , 22. Mor with AS , 23. Not with AS . Taken t with AS . Therefoet al. conducted a nationwide case-control study in Sweden and found a decreased risk of AS in patients underwent an appendectomy in the childhood [In the present study, we also found that periodontitis and appendicitis were independent risk factors for AS. The positive correlation between AS and periodontitis as we shown in this study was consistent with the results of a previous study which included 6,821 patients with AS obtained from a database of 1,000,000 randomly selected individuals in Taiwan (LHID200 of NHIRD) , while thildhood . Childrehildhood , 29, whihildhood , 31, andhildhood . In the et al. conducted a nationwide case-control study in Sweden and reported that childhood hospitalization for tonsillitis was associated with the development of AS in the adulthood  [et al. included patients with tonsillitis that developed before the age of 17 years in their research and suggested that tonsillitis may be implicated in the development of AS. Given that the alteration of immune balance resulting from tonsillitis may lead to either the initiation of autoimmunity or dysregulated inflammation in individuals with existed spondylitis, we thought that both remote and recent tonsillitis should be taken into account to address the association between tonsillitis and AS. In the present study, we enrolled patients with tonsillitis prior to the diagnosis of AS and both recent and remote tonsillitis were hence included in our study. Additionally, Lindström et al. used an inpatient database in their study, while in the present study we used both inpatient and outpatient data which are available in the NHIRD. Therefore, and it is thus reasonable that the strength of correlation in our study  was slightly higher than that reported in the study by Lindström et al.Lindström 03–1.67) . To specThis study has limitations. First, owing to the nature of the study design, it was not possible to demonstrate a causal link between tonsillitis and newly diagnosed AS; however, increasing evidence support the essential role of the gut microbiome in the linkage between infectious diseases and autoimmunity , 10. SecIn conclusion, we identified an increased risk for AS in patients with tonsillitis using a population-based claim database. There was a stronger correlation between tonsillitis and AS in patients with a higher severity of tonsillitis or a longer interval between diagnosis of tonsillitis and AS. These findings indicate that tonsillitis may trigger a gradual exacerbation of inflammation among patients with AS. More studies are warranted to explore the underlying mechanisms linking tonsillitis with AS and to investigate the roles of tonsillitis in other autoimmune diseases.S1 Dataset(CSV)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


To study the effects of customer self-audit on the service quality (SQ) and customer quality (CQ) of maternity care.A community-based cluster-randomized controlled trial.Twenty-one health centres and health posts in Tabriz, Iran.Of 21 health centres/health posts, 10 were randomly assigned to the intervention group and 11 randomly assigned to the control group. Participants were 185 pregnant women selected from health centre/post registration lists .® model of prenatal group care. The intervention group attended group support sessions focused on participants’ opinions, questions, and self-management concerns. They also received sessions on experiential learning, coping, problem-solving, and goal-setting by a family health expert, a midwife, and a doctor. Control group participants continued to receive individual care.The intervention was a customer self-audit based on the CenteringPregnancySQ and CQ were assessed using questionnaires. Patients rated the importance and performance of non-health quality dimensions. SQ was calculated as: SQ = 10 − (Importance × Performance).Total mean SQ scores were 7.63 (0.91) and 8.91 (0.76) for the control and intervention groups, respectively, a statistically significant difference (p<0.001). Compared with the control group, the intervention group scored higher on the SQ aspects confidentiality, communication, autonomy, availability of support group, dignity, safety, prevention, and accessibility. Total mean CQ scores for the control and intervention groups were 82.63(7.21) and 87.47 (6.75), respectively, a statistically significant difference (p<0.001). After intervention, 82.6% of intervention group participants and 50.5% of control group participants reached the highest stage of self-management, showing an ability to take care of themselves under stress and financial constraints.The group prenatal care customer self-audit improved the SQ and CQ of maternity care by increased involvement of participants and giving them active roles in the care process. Maternity care, a set of services to improve the health of both pregnant women and neonates, is essential in obtaining the desirable outcomes of prevention, detection, and treatment of complications , 2. SuchQuality of maternity care is defined as a pregnancy and childbirth care in which the physical infrastructure, supplies and qualified human resources are available and delivery of care is performed within a normal physiological, social, and cultural processes. Quality of maternity care is a multidimensional concept  and hereFocusing only on clinical or technical aspects of service fails to produce a comprehensive picture of quality of care. Therefore, understanding the customer’s perception of SQ and CQ can help providers to determine what their customers are seeking . AssessmThe SQ concept originated in Parasuraman’s (1988) work on service organizations. In 1991, SQ was redefined as a ‘multi-dimensional scale to capture customer perceptions and expectations of SQ which involves the calculation of the differences between expectations and perceptions on a number of specified criteria’ . DiffereCQ is related to aspects of the customer, including knowledge, skills, and confidence. These qualities are essential for active participation in health care processes and decision making, performing appropriate activities, and changing the environment and health-related behaviours . Most prTabrizi et al. have shown that the quality of non-clinical aspects of prenatal care in Tabriz is low. Pregnant women do not participate in decisions made about their care process, feel that they lack group support, and feel that there is little coordination with health care providers . A low pA community-based cluster-randomized controlled trial was conducted to assess the effects of customer's self-audit in GPC on SQ and CQ of maternity care. The perspectives of pregnant women in Tabriz, Iran, were considered. The study was conducted in health centres and health posts in urban areas in Tabriz between September 2012 and May 2013. Primary health care in urban areas in Iran is provided in health centres and health posts. Health centres are the principal sources of care and provide care from physicians and health experts. Health posts provide care only from health experts and customers are referred to health centre physicians if necessary. Participants were recruited between September 14, 2012, and November 14, 2012. A follow-up was conducted between March 14, 2013, and May 14, 2013. The study design and procedure were approved by the Ethics Committee of Tabriz University of Medical Sciences before the study began. At the time of research proposal approval, clinical trial registration was generally not required for educational and non-medical clinical trials in Tabriz University of Medical Sciences, and the trial received approval by the local ethics committee. However, we registered the trial in 2013 when we prepared the research papers (registration number: IRCT2013020612378N1) to meet international guidelines. The authors confirm that all on-going and related trials for this drug/intervention were registered. Study participants were informed about the trial. After the briefing, participants gave written permission for their involvement.All 81 health centres/posts in the Tabriz urban area were stratified into three categories based on the socioeconomic status of the regions in which the centres/posts were located. Experts at the Family and Population Health Department of Tabriz University of Medical Sciences selected 21 health centres and health posts from registration lists of pregnant women. For this study, 6–8 centres in each category were randomly assigned to either an intervention or a control group; in total, 10 centres were allocated to the intervention group and 11 were allocated to the control group . Family An 80% statistical power level and a 95% confidence level were used. G*Power version 3.1.2  , a statiThe customer self-audit was the intervention of interest and was based on an alternative model of prenatal group care termed the CenteringPregnancy® program, which includes group support and health education. The intervention group comprised 8–12 women who were all in the third month of pregnancy and who were randomly selected based on registration lists. Participants in the intervention group not only received national guideline-based care at individual visits, but also took part in self-care activities and attended group support sessions. Intervention group participants attended six sessions during pregnancy; each session lasted 1.5 h. The meetings focused on women’s opinions, questions, and concerns about self-management and their co-experiences of pregnancy challenges. In the sessions, women received educational tips about experiential learning, coping, problem-solving, and goal-setting from a family health expert, a midwife, and a doctor. At the beginning of each session, experts would address these issues and then participants would describe their experiences and discuss their problems, and the health experts would respond to them. At such sessions, participants not only received the education they needed, but also shared their experiences with each other. In addition, maternity books developed according to the maternity care protocols issued by the Iranian Ministry of Health  were proParticipants in the control group received only individual care in a treatment room from a midwife or doctor. Each visit lasted approximately 10 min. During each visit, participants received a routine check-up and examinations according to the national guideline. If participants had a particular problem, they discussed it with their midwife/doctor. A participant receiving only individual care could not share her experiences with other pregnant women and she received only the care recommended for her own situation. Control group participants did not receive information about service standards during pregnancy or pregnancy educational material. Control group participants were able to voluntarily attend one educational session, which was a lecture about breastfeeding, infant care, and delivery types .SQ data were collected using a structured questionnaire, which was based on the work of Van Der Eijk and modified to a maternity care setting , 37. TheChoice of Care Provider, choice of health centre, physician, and other providers (three questions); Communication, close relationship with physician/other provider and information sharing (five questions); Autonomy, participation in decision making about care procedures (four questions); Support Groups, support from other women, sharing information and experiences among women and professionals (four questions); Continuity (three questions); Basic Amenities, personnel and centre cleanliness and adequate amenities (four questions); Dignity, empathy, respect for beliefs and cultures, privacy, and providing accurate information to the patient’s family (five questions); Timeliness, (five questions); Safety, information about side effects of procedures and avoidance of harm to the patient (three questions); Prevention, information about high-risk pregnancy and self-care education (three questions); Accessibility, geographical and financial access (three questions), and Confidentiality (two questions). The fourth part of the questionnaire measured four stages of CQ related to maternity care: 1) Belief that the patient’s role is important, 2) Having the confidence and knowledge necessary to take action, 3) Actually taking action to maintain and improve one’s health, and 4) Continuing the self-management activities even under stressful conditions.The study questionnaire had four main parts. The first part assessed demographic characteristics, the second part related to pregnancy condition, and the third part consisted of questions related to SQ. Twelve aspects of SQ were measured: Participants were asked to evaluate the performance of each aspect of SQ according to either their understanding of the quality of care or their experience of receiving care that pertained to that aspect during the pregnancy. The importance of SQ was scored on a four-point Likert scale that ranged from 0 to 10: 0 = not important, 3 = may be important, 6 = important, and 10 = very important. Perceived quality of care received (performance) was assessed on a four-point Likert scale with the following categories: poor, fair, good, and excellent. Scores on this scale were dichotomized as 0 = good/excellent and 1 = poor/fair. A score was calculated for each SQ aspect by combining the importance and performance scores, based on the Quality of Care Through the Patient’s Eyes (QUOTE) scoring system instructions . An overData on the CQ of maternity care were collected using a structured questionnaire based on a study by Tabrizi et al. . Raw CQ Primary outcomes measures were the SQ and CQ of maternity care. SQ and CQ were assessed using questionnaires. Patients rated the importance and performance of non-health quality dimensions.Frequencies and percentages were used to summarize demographic information; means and standard deviations were used to summarize SQ and CQ scores. Chi-square and Fisher’s exact tests were used to analyse differences in categorical variables between groups. Independent samples t-tests were conducted to compare SQ scores between groups. To assess the effect of the intervention adjusted for planned pregnancy and education in CQ model and occupation, seeing midwife and effective maternity care in SQ model, a mixed model analysis was used, with the restricted maximum likelihood estimation method and first order autoregressive (RA (1)) covariance structure (taking into account the effect of sampling design). The P-values for entry and removal variables in the stepwise regression model were 0.05 and 0.10, respectively. P-values ≤0.05 were considered statistically significant. Data were analysed using the Statistical Package for the Social Sciences (SPSS) software for Windows, version 17 .Of 210 pregnant women who were contacted in health centres or health posts (105 participants in each group), 92 participants in the intervention group and 93 participants in the control group completed the study (86% response rate). Of the 25 non-responders, 11 (44%) people (5 in the intervention group and 6 in the control group) were excluded from the study because they had moved away from Tabriz, 7 (28%) were excluded owing to inability to answer the questionnaires, and 7 (28%) were excluded because they did not fill in the consent forms. The trial period ended after participants had delivered their babies.Study participants in both groups were mostly aged between 20–30 years old (68%) and almost one-third (32%) had elementary and secondary education. Most participants (56.6% in the intervention and 53.8% in the control groups) were experiencing their first pregnancy; 73.9% of participants in the intervention group and 75.3% of participants in the control group had planned their pregnancy. Most of the participants in both groups (90.2% in the intervention and 87.1% in the control groups) were covered by health insurance .Of the different aspects of SQ, confidentiality and communication showed the highest score for both groups. The total SQ score was 8.91 (0.76) for the intervention group and 7.63 (0.91) for the control group (P<0.001). Compared with the control group, the intervention group scored higher on the SQ aspects of communication (P<0.001), autonomy (P = 0.023), availability of support group (P<0.001), dignity (P<0.001), safety (P<0.001), prevention (P<0.001), and accessibility (P = 0.038) .Generalized linear model analysis showed a statistically significant between-group difference in total SQ score: women in the intervention group had higher SQ scores (b = 1.24) (P<0.001) than those in the control group by adjusting for occupation, seeing midwife, and effective maternity care. Also, women who rated their received maternity care good and excellent had higher SQ scores (b = 1.07) (P = 0.007) than those who rated their received maternity care poor and weak .Analysis of the self-reported CQ scores showed that 50.5% of the participants in the control group achieved the highest score related to the self-management stages, but none of them believed in the importance of the patient role or rated themselves as having the confidence and knowledge necessary to take action. The results showed that 82.6% of participants in the intervention group continued their self-management activities, even under stressful conditions and financial constraints. The between-group difference in the distribution of participants in the self-management stages was statistically significant (P<0.001) .A univariate regression analysis of CQ scores showed that women who had planned their pregnancy had statistically higher CQ scores (P = 0.015). Study group (intervention or control) was significantly related to CQ score (P<0.001). Additionally, participants with higher educational status reported better CQ scores .Generalized linear model analysis of total CQ scores showed a statistically significant between-group difference in total CQ score: women in the intervention group reported higher CQ scores (b = 4.81) (P<0.001) than those in the control group, by adjusting for education and planned pregnancy .As an educational–informational intervention, the customer self-audit (based on GPC) had positive effects on the SQ and CQ of maternity care by increased involvement of participants through involving them in maternity care. Use of a customer self-audit in maternity care can help to improve perception of maternity care SQ, particularly the autonomy and communication aspects. Because of the nature of the intervention, we expected most improvement in the availability of the support group, safety, and prevention features, which are the SQ aspects most influenced by mothers’ knowledge of pregnancy care. However, the post-intervention improvement also encompassed other aspects of SQ, including autonomy, communication, dignity, confidentiality, and accessibility. The intervention group also showed higher scores on CQ of maternity care compared with the control group. Therefore, it can be concluded that customer self-audit can improve the CQ of maternity care from the perspective of pregnant women. Our findings support the recommendation of the World Health Organization that quality maternity care should be available to all pregnant women to assure a positive pregnancy experience . GPC-basThe intervention group had significantly higher scores on the SQ aspects of safety and prevention during pregnancy. These findings support those of Mehdizadeh and colleagues (2003), who found that pregnant women who received health education and consultations, as well as training in neuromuscular exercises, were less tired and experienced less lumbar and pelvic pain during pregnancy compared with controls; they also were more physically active during the day than mothers who had not received such education and training . Our finConfidentiality  showed the highest SQ score in both intervention and control groups. This indicates that pregnant women consider this aspect of SQ important. The maintenance of confidentiality could also indicate whether health centres have reached optimal performance. In summary, the intervention had positive and significant effects on most aspects of SQ; however, there was no significant between-group difference for care provider, basic amenities, service continuity, and timeliness. This was partly predictable, because these areas are affected by organizational and infrastructural issues, and empowerment of providers and customers cannot influence these aspects.The CQ scores demonstrated that all participants in both intervention and control groups passed self-management stages one and two. Moreover, all participants accepted that their role is important and that they have the necessary confidence and knowledge to take action, when it was needed, during the care process. Compared with the control group, significantly more women in the intervention group reached the highest stage of self-management. This indicates that, in addition to having the knowledge and ability to take action during the care process (because of the increased involvement), they could continue self-management activities even under stressful conditions and financial constraints. Our findings support those of several previous studies indicating that GPC has positive results. For instance, a study by Patil et al. (2017) showed that GPC was strongly associated with higher pregnancy-related empowerment in Malawi . KennedyThe present findings revealed that having a planned pregnancy and higher education are predictors of higher CQ. This indicates the need for greater focus on women with lower educational status and unwanted and unplanned pregnancies. Joshi et al. and Neupane et al. found that less educated women from socioeconomically disadvantaged households require more attention and greater help , 52. In Although several studies have evaluated whether GPC can improve the quality of care, few studies have used self-audit as a model. Participants in an Australian CenteringPregnancy® study reported supportive relationships between women and their peers or midwives as one of the strengths of GPC. Participants in this study recorded increased satisfaction from the care they received . In two The present findings have some generalizability, because the health centres were selected randomly and the features of these centres are similar to others in both Tabriz and other public health centres in Iran. As GPC is feasible to implement and produced positive results from the customer self-audit, we suggest that this intervention should be provided to all pregnant women in Iran. A focus on improving CQ as an indicator of customer capabilities may be an effective strategy to improve other dimensions of care quality, such as SQ and TQ. Such improvements may positively affect the health of mothers and their babies, and have other health consequences. The current study showed that pregnant mothers not only require traditional individual care from health care services, but also need to share their experiences with other pregnant women, feel that they are not alone, be involved in their care process, and audit their received services. However, there is a pressing need to widen this research to rural areas. More researchers are needed to evaluate the cost-effectiveness of customer self-audit in GPC and its effects on clinical outcomes.This study had some limitations. The first is that only urban health centres were included. Therefore, the generalizability of results to rural areas is limited, as the socioeconomic characteristics of individuals in urban areas are different from those in rural areas. The second limitation is lack of blinding. Because of the nature of the intervention, it was not possible to blind participants. However, blinding was used in the data gathering and data evaluation, as these processes were conducted by an individual not involved in the implementation of the intervention. The last limitation relates to lack of health centre facilities to fully implement the intervention; to carry out GPC adequately, health centres must be able to host meetings.Some of the strengths of our study were the high validity of the results owing to the study design, the use of valid and reliable questionnaire to assess maternity care SQ and CQ, and the low-cost intervention design.An intervention in response to the low quality of maternity care in Tabriz, the customer self-audit, was effective in improving the quality of non-health aspects of maternity care. The intervention increased involvement of pregnant women by providing active roles for them in the care process and increasing their awareness of their rights. Increasing mothers’ awareness of their rights and involving them in monitoring the care process had a positive effect on their perceptions and expectations of the quality of services. In addition, women who were involved in the customer self-audit were more likely than women in the control group to be able to take care of themselves under stressful conditions and financial constraints. The finding that educational status and planned pregnancy had a positive effect on CQ indicate the importance of focusing on improving care for less educated women and increasing the access to, and utilization of, family planning and pre-pregnancy services in the health system. The results of this study will be used either in national level by policymakers or in local level by healthcare providers to revise the way in which maternity care is provided for pregnant women in Iran. In developing countries like Iran, where the maternity care is delivered in a traditional manner  a shift to a more participatory method that involves pregnant women in their care process will result in more satisfaction regarding nonclinical aspects of care. This study introduces such a low-cost alternative for traditional maternity care.S1 File(RAR)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(JPG)Click here for additional data file.S4 File(PDF)Click here for additional data file.S5 File(PDF)Click here for additional data file.S6 File(PDF)Click here for additional data file.S7 File(PDF)Click here for additional data file.S8 File(PDF)Click here for additional data file.S9 File(PDF)Click here for additional data file.