搜索结果：Iranian journal of medical sciences

Journal of Women's HealthVol. 29, No. 4 CommentaryFree AccessSex and Gender Disparities in the COVID-19 PandemicJewel Gausman and Ana LangerJewel GausmanWomen & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.Search for more papers by this author and Ana LangerAddress correspondence to: Ana Langer, MD, Women & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 651 Huntington Avenue, FXB Building 6th Floor Office 643B, Boston, MA 02115 E-mail Address: [email protected]Women & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.Search for more papers by this authorPublished Online:17 Apr 2020https://doi.org/10.1089/jwh.2020.8472AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail In the case of the ongoing COVID-19 pandemic, sex-disaggregated data suggest that fewer women are dying from the disease than men.1 However, taking this observation at face value oversimplifies the biological, behavioral, and social and systemic factors that may cause differences to emerge with regard to how women and men experience both the disease and its consequences. As governments react with swift and severe measures in their ongoing fight to control the pandemic's spread, it is important to understand how these actions may disproportionately increase the risks for women both directly and indirectly with regard to sex and gender.Pregnant women are often among the most vulnerable groups during public health emergencies. In some cases, pregnant women face increased biological susceptibility to adverse health outcomes, as in the case of some respiratory infections. With other emergent coronaviruses, such as those responsible for severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS), pregnant women who became infected were found to be more likely than nonpregnant women to experience severe complications.2 It is still too early to tell whether this will be the case with COVID-19.In the ongoing pandemic, other factors may have a ripple effect that put women at increased risk even if the disease itself does not. As made clear during the 2014 Ebola outbreak, the consequences of large-scale infectious disease outbreaks on uninfected pregnant women can be dire. Routine prenatal care appointments, if not interrupted or discontinued, may put women at increased risk of exposure to the virus. Overwhelmed hospitals struggling to function with staff and supply shortages may not be able to provide the high quality of care that all pregnant women and their newborns deserve, let alone respond to emergency obstetric complications. Furthermore, there is also a risk that life-saving treatments or vaccines will be denied to pregnant women over concern for fetal safety or a lack of data.3,4The fear of infection, concern for the well-being of friends and loved ones, uncertainty, disruption, and social isolation that have become part and parcel of daily life for many around the world will undoubtedly have profound effects on mental health on the population at large, but being pregnant during a global pandemic is likely to be even more frightening for many women. Although containment strategies, such as those that require women to deliver without a companion present, including partners and doulas, that have already been put into place in some cities in the United States,5 or those that separate newborns from their mothers immediately after birth if the mother is infected with COVID-196 may be clinically important to reduce transmission, they may also have profound short- and long-term mental health implications for women. Among women who have young children, previous research in Ethiopia, India, and Vietnam found that women who experience family-related stressful life events, such as illness or death within the household and financial uncertainty, are more likely to experience episodes of severe mental distress.7 With the ongoing need to social distance, family and community networks may struggle and pregnant and postpartum women may feel even more vulnerable and isolated over a lack of social support.The adverse effects of the pandemic in relation to women's reproductive health are not limited to pregnancy or motherhood. As movement restrictions are put into place, supply chains are disrupted, and businesses are shuttered, some women may be at increased risk of unintended pregnancy should it become difficult to obtain their regular contraceptive method or emergency contraceptives, if needed. Furthermore, some states within the United States have begun to impose restrictions on certain medical procedures that they deem to be elective, including abortion, suggesting they must be delayed until after the pandemic is over.8 Spikes in domestic violence during times of crisis are another area of grave concern for women's health, and as governments continue to put into place more extreme measures to enforce social distancing, for some women, more time at home may mean more time spent with an abusive partner. Fewer social interactions may also mean less accountability for perpetrators and fewer opportunities for others to intervene.Gender-related factors may also increase the impact of the COVID-19 pandemic on women globally. Women constitute a disproportionately high percentage of caregivers in both the formal and informal sectors.9 A large proportion of frontline health care professionals (nurses, community health workers, health technicians, etc.) is women who face a higher risk of infection, morbidity, and death as a result of their profession.9 At the same time, women more frequently serve as the primary caregivers within a household, which may further increase their risk of exposure. In the United States, 65% of unpaid family caregivers are estimated to be women and 80% of them care for someone aged 50 years or older.10 Outside of their caregiving role, women are overrepresented in the informal employment sector. In low-and middle-income countries, two-thirds of women who work do so as part of the informal economy with limited access to health care for themselves and their families.9 Containment and mitigation policies that limit women's ability to perform their duties without offering effective alternatives, such as closing of daycare facilities for their children or not providing paid sick leave, may result in unnecessary exposure to disease and increased family vulnerability.It is urgent that we adopt a gender lens to study the pandemic and its effects, including the policies and actions that are put into place at the global, country, and local levels. This may be especially important in disadvantaged populations and resource-poor communities, where women are especially vulnerable. The public health community must ensure that existing health and social services meant to support women in the face of their unique needs do not disappear in lieu of the all-encompassing focus on stopping the pandemic. Furthermore, we argue that special attention needs to be paid to ensure that informal caregivers are supported, informed, and protected. To avoid making existing gender disparities larger as a result of the pandemic, a special body at the U.S. Centers of Disease Control and Prevention is urgently needed to track sex disaggregated data and analyze policies related to COVID-19 using a gender lens.Author Disclosure StatementNo competing financial interests exist.Funding InformationNo funding was received for this article.References1. Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med 2020;pii: S2213-2600(20)30117-X. Medline, Google Scholar2. Favre G, Pomar L, Musso D, Baud D. 2019-nCoV epidemic: What about pregnancies? Lancet 2020;395:e40. Crossref, Medline, Google Scholar3. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: What obstetricians need to know. Am J Obstet Gynecol 2020;pii: S0002-9378(20)30197-6. Medline, Google Scholar4. Weigel G. Novel coronavirus "COVID-19": Special considerations for pregnant women. Available at: https://www.kff.org/womens-health-policy/issue-brief/novel-coronavirus-covid-19-special-considerations-for-pregnant-women/?utm_source=Global+Health+NOW+Main+List Accessed March 17, 2020. Google Scholar5. Caron C, Syckle KV. Laboring alone: Some hospitals bar partners because of virus fears. The New York Times. 2020. Google Scholar6. American College of Obstetricians and Gynecologists. Practice advisory: Novel coronavirus 2019 (COVID-19). Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019?IsMobileSet=false Accessed March 13, 2020. Google Scholar7. Gausman J, Austin SB, Subramanian S, Langer A. Adversity, social capital, and mental distress among mothers of small children: A cross-sectional study in three low and middle-income countries. PLoS One 2020;15:e0228435. Crossref, Medline, Google Scholar8. Tavernise S. Texas and Ohio include abortion as medical procedures that must be delayed. The New York Times. 2020. Google Scholar9. Langer A, Meleis A, Knaul FM, et al. Women and health: The key for sustainable development. Lancet 2015;386:1165–1210. Crossref, Medline, Google Scholar10. Feinberg L, Reinhard SC, Houser A, Choula R. Valuing the invaluable: 2011 update, the growing contributions and costs of family caregiving. Washington, DC: AARP Public Policy Institute, 2011:32. Google ScholarFiguresReferencesRelatedDetailsCited byMachine learning-based prediction of COVID-19 mortality using immunological and metabolic biomarkers3 February 2023 | BMC Digital Health, Vol. 1, No. 1No fear: Willingness of smartphone activated first responders to assist with cardiac arrest during the COVID-19 pandemicResuscitation Plus, Vol. 13Overlooked sex and gender aspects of emerging infectious disease outbreaks: Lessons learned from COVID-19 to move towards health equity in pandemic response20 February 2023 | Frontiers in Global Women's Health, Vol. 4Anxiety, depression, and stress in youth during lockdown: differences between clinical and community samples13 February 2023 | CES Psicología, Vol. 16, No. 1Correlates of long-COVID-19: the role of demographics, chronic illness, and psychiatric diagnosis in an urban sample8 February 2023 | Psychology, Health & Medicine, Vol. 11Perception of COVID‐19 pandemic restrictions on dental researchers21 September 2022 | Journal of Dental Education, Vol. 87, No. 2Penicillin Allergy Evaluation and Health Equity: A Call to ActionThe Journal of Allergy and Clinical Immunology: In Practice, Vol. 11, No. 2Covid-19 Effects on Psychological Outcomes: How Do Gender Responses Differ?23 August 2021 | Psychological Reports, Vol. 126, No. 1Gendered Consequences of COVID-19 Among Professional Tennis Players24 August 2022 | Journal of Sports Economics, Vol. 24, No. 2Nursing Students' Perception about Gender Inequalities Presented on Social Networks: A Qualitative Study20 January 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 3Laboring Alone: Perinatal Outcomes during Childbirth without a Birth Partner or Other Companion during the COVID-19 Pandemic1 February 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 3Psychological Adjustment Profiles of LGBTQ+ Young Adults Residing with Their Parents during the COVID-19 Pandemic: An International Study11 February 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 4The Ups and Downs of Feminist Activist Research: Positional Reflections1 March 2023Freiheit und Autonomie von Frauen in Zeiten der Coronakrise3 March 2023COVID-19 Concerns, Perceived Stress, and Increased Alcohol Use Among Adult Women in the United States18 November 2022 | Clinical Nursing Research, Vol. 32, No. 1"Life is hard": How the COVID-19 pandemic affected daily stressors of womenDialogues in Health, Vol. 1Laboratory predictors for COVID-19 Intensive Care Unit admissions in Trinidad and TobagoDialogues in Health, Vol. 1Sex-related disparities in students' disaster responses in the post-COVID-19 eraInternational Journal of Disaster Risk Reduction, Vol. 83Public perceptions during the first wave of the COVID-19 pandemic in Canada: a demographic analysis of self-reported beliefs, behaviors, and information acquisition9 April 2022 | BMC Public Health, Vol. 22, No. 1Implication of single nucleotide polymorphisms in Interleukin-10 gene (rs1800896 and rs1800872) with severity of COVID-191 October 2022 | Egyptian Journal of Medical Human Genetics, Vol. 23, No. 1Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services—Behavioral Insights from the Federation of Bosnia and Herzegovina3 December 2022 | Behavioral Sciences, Vol. 12, No. 12Gender and age structure of mortality caused by COVID-1923 November 2022 | Innovative Medicine of Kuban, No. 4Using trajectory modeling of spatio-temporal trends to illustrate disparities in COVID-19 death in flint and Genesee County, MichiganSpatial and Spatio-temporal Epidemiology, Vol. 43Neonatologist staffing models: urgent change is needed7 October 2022 | Journal of Perinatology, Vol. 42, No. 11The Structure of the Relationship between Physical Activity and Psychosocial Functioning of Women and Men during the COVID-19 Epidemic in Poland20 September 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 19Syndemic aspects between COVID-19 pandemic and social inequalitiesWorld Journal of Methodology, Vol. 12, No. 5Impact of Social and Personal Factors on Psychological Distress in the Spanish Population in the COVID-19 Crisis9 September 2022 | The British Journal of Social Work, Vol. 28(Suppl 1)Levels of Depression and Anxiety Among Informal Caregivers During the COVID-19 Pandemic: A Study Based on the Canadian Longitudinal Study on Aging12 February 2022 | The Journals of Gerontology: Series B, Vol. 77, No. 9Knowledge, attitudes, and practices [KAP] toward COVID-19: A cross-sectional study in the New York Metropolitan Area and California Bay Area10 August 2022 | PLOS ONE, Vol. 17, No. 8Examining the impact of sex differences and the COVID-19 pandemic on health and health care: findings from a national cross-sectional study28 September 2022 | JAMIA Open, Vol. 5, No. 3Combination of cycle threshold time, absolute lymphocyte count and neutrophil:lymphocyte ratio is predictive of hypoxia in patients with SARS-CoV-2 infection11 December 2021 | Transactions of The Royal Society of Tropical Medicine and Hygiene, Vol. 116, No. 7Conflicto trabajo-familia de mujeres en situación de teletrabajo a partir de la contingencia sanitaria por COVID-19 en Chile15 June 2022 | Investigaciones Feministas, Vol. 13, No. 1Impact of COVID-19 restrictions on mental health and physical activity among LGBQAP and heterosexual adults21 December 2021 | Journal of Gay & Lesbian Mental Health, Vol. 26, No. 3Women's Use and Abuse of the News Media during the COVID-19 Pandemic on Mumsnet2 September 2021 | Digital Journalism, Vol. 10, No. 6COVID-19 effects on women's home and work life, family violence and mental health from the Women's Health Expert Panel of the American Academy of NursingNursing Outlook, Vol. 70, No. 4Perceived risk, political polarization, and the willingness to follow COVID-19 mitigation guidelinesSocial Science & Medicine, Vol. 305Racial and Ethnic Disparities in Postpartum Care in the Greater Boston Area During the COVID-19 Pandemic23 June 2022 | JAMA Network Open, Vol. 5, No. 6Access to contraception during the Covid-19 pandemic: barriers and perspectives1 June 2022 | Cadernos Saúde Coletiva, Vol. 30, No. 2Disparities by Sex in COVID-19 Risk and Related Harms Among People with Opioid Use Disorder Caitlin E. Martin, Bhushan Thakkar, DaShaunda D.H. Taylor, and Derek A. Chapman16 May 2022 | Journal of Women's Health, Vol. 31, No. 5Vision 2020: How and for E. A. E. S. and May 2022 | Journal of Women's Health, Vol. 31, No. of women in clinical A for and Clinical Vol. and urban towards pandemic May 2022 | Vol. the The of during a January 2022 | & Psychology, Vol. 32, No. and During the and of the COVID-19 Pandemic in April 2022 | Frontiers in Vol. to Greater With the COVID-19 and to Journal of Health Psychology, Vol. 29, No. of to the of SARS-CoV-2 With Anxiety and A Study of March 2022 | International Journal of Public Health, Vol. in the Impact of COVID-19 Pandemic in in The Gender in Vol. No. 3Women's health and access COVID-19 Outlook, Vol. 70, No. of to COVID-19 Outcomes in a Longitudinal of February 2022 | Vol. No. as March 2022 | Saúde Vol. No. COVID-19 wave in during the of and its with higher February 2022 | PLOS ONE, Vol. 17, No. well-being and during the COVID-19 pandemic in the United A February 2022 | The Social Science Vol. to and February 2022 | Psychology, Vol. women's during the COVID-19 pandemic in June 2021 | and An International Vol. No. an and at the same in work and during the coronavirus April 2021 | International Journal of Psychology, Vol. No. and local A in the time of November 2021 | International Journal of Psychology, Vol. No. and the During June 2021 | & Vol. 26, No. of Medical Care among in the United States during the COVID-19 May 2022 | Journal of Public Health Research, Vol. 11, No. the Gender Disparities in COVID-19 and January 2022 | & Vol. with public health for COVID-19: a study of mothers with young children in the United February 2022 | Journal of in Vol. No. Perspectives on January and Among Adults During the to COVID-191 February in and and during the COVID-19 pandemic health and and Vol. in the COVID‐19 Effects of on December 2021 | British Journal of Vol. No. effects of the on for an emerging January 2022 | & Vol. No. Distress among Dental during the COVID-19 December 2021 | International Journal of Environmental Research and Public Health, Vol. 19, No. physical and social of health during the COVID-19 lockdown: a for of depression, and stress in the population during social isolation to the COVID-19 a cross-sectional study28 April 2021 | BMC Vol. No. and but same mortality of severe disease in March 2021 | BMC Medicine, Vol. No. Factors with and among community October 2021 | and Health, Vol. 17, No. differences in a of COVID-19 patients during the first and pandemic August 2021 | of Sex Vol. 12, No. in December 2021 | Journal of Clinical Medicine, Vol. 10, No. November 2021 | of Coronavirus Anxiety in Women on and Birth One of Coronavirus October 2021 | Journal of and Research, Vol. No. in and among Young Adults During Social to March 2021 | The Journal of Sex Research, Vol. No. of COVID-19 short- and long-term Disparities in and October 2021 | PLOS ONE, Vol. 16, No. analysis of on 2021 | Journal of in Medicine, Vol. No. of and Among COVID-19 by States in Women An September 2021 | and Vol. No. of COVID-19 using Public Gender and COVID-19: a Social Media of 2021 | Journal of Research, Vol. 5, No. for COVID-19 and its impact on in the Research on and Economics, Vol. No. differences in mental health of Canadian during the COVID-19 of and Health, Vol. No. Use and Relationship to Stress, and Perceived During the COVID-19 Pandemic in August 2021 | Frontiers in Public Health, Vol. and Lessons for August 2021 | PLOS ONE, Vol. 16, No. in How women in the United States in of of during the pandemic of March 2021 | Journal of Psychology, Vol. No. of in severe COVID-19 and Vol. No. the gender June 2021 | Journal of Perinatal Medicine, Vol. No. and the Related Factors in for COVID-19 at 2021 | International Journal of Health and Sciences, Vol. No. Gender Disparities and A Vol. No. impact of COVID‐19 on women to A of December | & Vol. No. of the and During the Covid-19 2021 | Frontiers in Psychology, Vol. in a January 2021 | Vol. No. responses to COVID-19 to Abuse & Vol. in and Practice During Social Among Young Adults in the May 2021 | Medicine, Vol. No. SARS-CoV-2 pandemic: A Health, Vol. and and after the pandemic April 2021 | Clinical and Research, Vol. No. on in August | Vol. 13, No. An to COVID-19 February 2022 | Journal of Women and Social Vol. No. in the and Outcomes of With May 2021 | Journal of Medicine, Vol. 16, No. of COVID-19: and May 2021 | Frontiers in Public Health, Vol. in the of February 2022 | Journal of Human Vol. No. and of the COVID-19 pandemic from the of in May 2021 | Journal of Social Work, Vol. No. the Pandemic: December April health disparities in vulnerable populations of psychiatric patients during the COVID-19 Journal of Vol. 11, No. 4The Gender of to in March 2021 | Feminist Economics, Vol. No. in Risk Factors and Mental Health During the of the COVID-19 Pandemic: A of U.S. Women A. E. E. and April 2021 | Journal of Women's Health, Vol. 30, No. and of and in March 2021 | Medicine, Vol. No. impact of COVID-19 on the mental health of and Science & Medicine, Vol. of and with in April 2021 | Vol. 12, No. health and well-being of staff during the coronavirus disease 2019 4 and in an March 2021 | Journal of Vol. of Gender in the and of Coronavirus Disease 2019 An of Health and and March 2021 | Journal of Women's Health, Vol. 30, No. of the COVID-19 pandemic on and Vol. of COVID-19 and of and Public Health, Vol. No. cross-sectional study of the of and with perceptions of to March 2021 | Open, Vol. 11, No. research and social of health: at the of of impact on and of Clinical Medicine, Vol. 17, No. differences in responses to SARS-CoV-2 in patients with January 2021 | Reports, Vol. No. and to COVID-19 in and January 2021 | Policy and Practice, Vol. impact of COVID-19 among and of November | & Health, Vol. 26, No. in case and mortality of coronavirus disease 2019 (COVID-19) among states in the United November | of Medicine, Vol. No. and pandemic risk and fear among September 2021 | Health and Behavioral Medicine, Vol. No. June 2021 | Vol. No. of and with of Coronavirus Related September 2021 | Vol. a January 2021 | Cadernos de Saúde Vol. No. and Among Vol. of Psychological Distress and Factors among During the COVID-19 Pandemic at in March 2021 | Disease and Vol. and on During the COVID-19 Pandemic in of Social Media October 2021 | Journal of Medical Research, Vol. 23, No. and and attitudes, and practices toward COVID-19 among birth of and Health Vol. 10, No. the of in COVID-19 October | Health Vol. No. in the of COVID-19 and political Vol. services in times of in of quality care for pregnant women and their October | Health Care for Women Vol. No. social support in the face of the December | Journal of & Vol. 12, No. with fear and during the COVID-19 pandemic in October | and Health, Vol. 16, No. and of People from by December | Journal of in Health, and Education, Vol. 10, No. is in gender and age for COVID-19 A December | Journal of and Vol. No. of SARS-CoV-2 Among Nursing and in September | Journal of Medicine, Vol. No. role of in the severity of learned from Vol. on gender disparities in the impact of the U.S. COVID-19 Research, Vol. Gender Women's Health and October | Frontiers in Global Women's Health, Vol. and the risk to and women during Journal of Vol. No. With Disparities in COVID-19 Outcomes in an Health Care October | JAMA Network Open, Vol. No. in the time of in August | Vol. 17, No. de la en en por September | Vol. No. de la COVID-19 en la de September | Vol. No. Perspectives to Health Research and Prevention During the COVID-19 | and Health Vol. 24, No. and Disease Disparities in the United in Vol. No. for a to | Global Public Health, Vol. No. and of in September | Vol. 11, No. and What is the Vol. No. we in Covid-19 women and men Vol. in of COVID-19: Insights a Vol. No. will The need to for the research on and the role of and and Vol. Impact and Factors During the of the Coronavirus (COVID-19) Pandemic Among the Population in June | Frontiers in Psychology, Vol. and of and the in SARS-CoV-2 to the in May | International Journal of Sciences, Vol. No. Coronavirus Disease 2019 the of August | Vol. Gender of to in January | Vol. Social of Vol. of of and Digital Vol. this Gausman and Ana and Gender Disparities in the COVID-19 of Women's in April 17,

No AccessHealth, Nutrition, and Population1 Feb 2013Better Health Systems for India's PoorFindings, Analysis, and OptionsAuthors/Editors: David H. Peters, Abdo S. Yazbeck, Rashmi R. Sharma, G. N. V. Ramana, Lant H. Pritchett, Adam WagstaffDavid H. Peters, Abdo S. Yazbeck, Rashmi R. Sharma, G. N. V. Ramana, Lant H. Pritchett, Adam Wagstaffhttps://doi.org/10.1596/0-8213-5029-3SectionsAboutPDF (1.3 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract:This report focuses on four areas of the health system in which reforms, and innovations would make the most difference to the future of the Indian health system: oversight, public health service delivery, ambulatory curative care, and inpatient care (together with health insurance). Part 1 of the report contains four chapters that discuss current conditions, and policy options. Part 2 presents the theory, and evidence to support the policy choices. The general reader may be most interested in the overview chapter, and in the highlights found at the beginning of each of the chapters in part 2. These highlights outline the empirical findings, and the main policy challenges discussed in the chapter. The report does not set out to prescribe detailed answers for India ' s future health system. It does however, have a goal: to support informed debate, and consensus building, and to help shape a health system that continually strives to be more effective, equitable, efficient, and accountable to the Indian people, and particularly to the poor. Previous bookNext book FiguresreferencesRecommendeddetailsCited byWomen's Perceived Barriers to Accessing Post-Abortion Care Services in Selected Districts in KwaZulu Natal Province, South Africa: A Qualitative StudyAnnals of Global Health, Vol.88, No.1Breast reconstruction following mastectomy in Indian women: a neglected entityBMJ Case Reports, Vol.15, No.721 July 2022Bibliometric analysis of scientific publications on health care insurance in India from 2000 to 2021International Journal of Healthcare Management, Vol.3011 June 2022Decrease of glycated hemoglobin based on evaluation of diabetes intervention programs in low-and middle-income countries: A systematic reviewDiabetes Epidemiology and Management, Vol.6Persistent Inequalities in Health-Contextualising the Neglect of Ambedkar's Contribution18 August 2022Measuring Income Elasticity of Healthcare-Seeking Behavior in India: A Conditional Quantile Regression ApproachJournal of Quantitative Economics, Vol.19, No.430 July 2021"Demand Side" Health Insurance in India: The Price of ObfuscationMedical Anthropology, Vol.40, No.528 May 2021Going Granular: Equity of Health Financing at the District and Facility Level in IndiaHealth Systems & Reform, Vol.7, No.217 August 2021Out-of-Pocket Payments for Delivery Care in India: Do Households face Hardship Financing?Journal of Health Management, Vol.23, No.215 June 2021Utilization of health care services in public and private healthcare in India: Causes and determinantsInternational Journal of Healthcare Management, Vol.14, No.211 October 2019Facilities are substantially more influential than care providers in the quality of delivery care received: a variance decomposition and clustering analysis in Kenya, Malawi and IndiaBMJ Global Health, Vol.5, No.819 August 2020Does Credit Utilization Pattern Promote Poverty Alleviation? An Evidence from IndiaGlobal Business Review, Vol.513 May 2020Health Insurance as Social Innovation for Farmers in Cooperatives: Lessons from Yeshasvini in Karnataka, India28 October 2020The price of a woman: Re-examining the use of financial incentives for women's health in IndiaGlobal Public Health, Vol.14, No.1212 June 2019Do poor people in the poorer states pay more for healthcare in India?BMC Public Health, Vol.19, No.130 July 2019Equity in distribution of public subsidy for noncommunicable diseases among the elderly in India: an application of benefit incidence analysisBMC Public Health, Vol.19, No.126 December 2019Understanding public health insurance in India: A design perspectiveThe International Journal of Health Planning and Management, Vol.34, No.423 July 2019Democratizing health insurance services; accelerating social inclusion through technology policy of health insurance firmsBUSINESS STRATEGY & DEVELOPMENT, Vol.2, No.315 April 2019Impoverishment Due to Out-of-pocket Health Expenditures: Measurement and Comparison Across Different Surveys in IndiaIndian Journal of Human Development, Vol.13, No.231 August 2019Catastrophic health expenditure among industrial workers in a large-scale industry in Nepal, 2017: a cross-sectional studyBMJ Open, Vol.8, No.1115 November 2018Uptake of voluntary health insurance and its impact on health care utilization in GhanaHealth Policy and Planning, Vol.33, No.73 August 2018Can Short-term Economic Policies Hurt the Health of the Poor? Demonetization in IndiaInternational Journal of Health Services, Vol.48, No.325 April 2018"When the Government Changes, the Card Will Also Change": Questioning Identity in Biometric Smartcards for National Health Insurance (RSBY) in IndiaAnthropologica, Vol.60, No.1Healthcare for All: A New Multidisciplinary Approach for Designing and Managing Hospital Layouts in India11 January 2018Health-care utilization and expenditure patterns in the rural areas of Punjab, IndiaJournal of Family Medicine and Primary Care, Vol.7, No.1Arriving at a Decision: A Semi-Parametric Approach to Institutional Birth Choice in IndiaSSRN Electronic JournalIncidence and Intensity of the Burden in Paying for Health Care in India: A Rural-Urban AnalysisSSRN Electronic JournalJournal of Quantitative Economics, Vol.16, No.3Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era?BMC Research Notes, Vol.10, No.115 August 2017Public expenditure and healthcare utilization: the case of reproductive health care in IndiaInternational Journal of Health Economics and Management, Vol.17, No.412 July 2017Exposure to Hardship Financing for Healthcare among Rural Poor in Chhattisgarh, IndiaJournal of Health Management, Vol.19, No.313 July 2017The Effectiveness of Public Spending on Education and Health Care in Indian EconomyThe Indian Economic Journal, Vol.65, No.1-417 August 2018Out-of-pocket Payments for Healthcare in IndiaJournal of Health Management, Vol.19, No.18 February 2017Exacerbating Health Risks in India due to Climate ChangeEmerging Themes in Epidemiology, Vol.14, No.1Applied Health Economics and Health Policy, Vol.15, No.6How do parents and pediatricians arrive at the decision to immunize their children in the private sector? Insights from a qualitative study on rotavirus vaccination across select Indian citiesHuman Vaccines & Immunotherapeutics, Vol.12, No.1223 November 2016Role of the private sector in vaccination service delivery in India: evidence from private-sector vaccine sales data, 2009–12Health Policy and Planning, Vol.31, No.714 March 2016Mental health problems among youth in India and its correlatesInternational Journal of Human Rights in Healthcare, Vol.9, No.2The determinants of access to health care and medicines in IndiaApplied Economics, Vol.48, No.1716 November 2015Illness Makes Credit Sick: Can Health Insurance Rescue the Poor from Exploitative Credit?The Geneva Papers on Risk and Insurance - Issues and Practice, Vol.41, No.230 March 2016Health insurance in India: what do we know and why is ethnographic research neededAnthropology & Medicine, Vol.23, No.11 February 2016Mitigating India's health woes: Can health insurance be a remedy to achieve universal health coverage?Archives of Medicine and Health Sciences, Vol.4, No.2Exacerbating Health Risks in India due to Climate ChangeAvailability of medicines in public sector health facilities of two North Indian StatesBMC Pharmacology and Toxicology, Vol.16, No.123 December 2015Expanding availability of safe abortion services through private sector accreditation: a case study of the Yukti Yojana program in Bihar, IndiaReproductive Health, Vol.12, No.110 November 2015Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple rolesHuman Resources for Health, Vol.13, No.19 December 2015Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural AfghanistanHealth Policy and Planning, Vol.30, No.104 December 2014Government Spending on Health in IndiaJournal of Health Management, Vol.17, No.4Economic consequences of ill-health for households in northern rural IndiaBMC Health Services Research, Vol.15, No.126 April 2015Evolving social health scheme for workers in unorganized sector: key evidences from study of cycle rickshaw pullers in Delhi, IndiaThe International Journal of Health Planning and Management, Vol.30, No.427 March 2014Demographic Change and Catastrophic Health Expenditure in IndiaSocial Indicators Research, Vol.122, No.32 August 2014Catastrophic Healthcare Expenditures of Hospitalized Patients in the Hospitals of Shiraz in 2013Shiraz E-Medical Journal, Vol.16, No.510 May 2015Financial catastrophe and poverty impacts of out-of-pocket health payments in TurkeyThe European Journal of Health Economics, Vol.16, No.325 February 2014Effectiveness of micro health insurance on financial protection: Evidence from IndiaInternational Journal of Health Economics and Management, Vol.15, No.124 December 2014Household Costs of Leprosy Reactions (ENL) in Rural IndiaPLOS Neglected Tropical Diseases, Vol.9, No.115 January 2015Health-System Evaluation: A Multi-attribute Decision Making Approach21 January 2015An Empirical Study to Determine the Significant Predictors of Trust in Government Hospitals26 August 2014Effect of Micro Health Insurance on Access and Utilization of Health Services in KarnatakaOpen Medicine Journal, Vol.1, No.1Trends and Differentials in Health Care Utilization Pattern in IndiaJournal of Health Management, Vol.16, No.3Is Public Private Partnership an Effective Alternative to Government in the Provision of Primary Health Care? A Case Study in OdishaJournal of Health Management, Vol.16, No.113 March 2014MOBILE TOBACCO CESSATION CLINIC – A NECESSARY STEP TOWARDS PUBLIC HEALTHJournal of Evolution of Medical and Dental Sciences, Vol.3, No.928 February 2014Information asymmetry minimization system for potential clients of healthcare insurance in Indian context using semantic webCommunity Based Health Insurance in India: Prospects and ChallengesHealth, Vol.06, No.11The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National DataMaternal and Child Health Journal, Vol.17, No.91 November 2012Evaluating medical tourism enablers with interpretive structural modelingBenchmarking: An International Journal, Vol.20, No.6Improving the Method of GDP Estimation of Private Health Care Service in IndiaJournal of Health Management, Vol.15, No.3Dimensions and Determinants of Trust in Health Care in Resource Poor Settings – A Qualitative ExplorationPLoS ONE, Vol.8, No.716 July 2013Refining estimates of catastrophic healthcare expenditure: an application in the Indian contextInternational Journal of Health Care Finance and Economics, Vol.13, No.224 February 2013Burden of direct and indirect costs of illness: Empirical findings from slum settlements in Chennai, South IndiaProgress in Development Studies, Vol.13, No.2Health care services in India: A few questions on equityHealth, Vol.05, No.01Health system capacity: maternal health policy implementation in the state of Gujarat, IndiaGlobal Health Action, Vol.6, No.119 January 2017Catastrophic Spending on Health by Sample Households: Some Results24 April 2013Support for children identified with acute flaccid paralysis under the global polio eradication programme in Uttar Pradesh, India: a qualitative studyBMC Public Health, Vol.12, No.122 March 2012Hardship financing of healthcare among rural poor in Orissa, IndiaBMC Health Services Research, Vol.12, No.127 January 2012Burden of out-of-pocket expenditure for road traffic injuries in urban IndiaBMC Health Services Research, Vol.12, No.128 August 2012Illness Mapping: a time and cost effective method to estimate healthcare data needed to establish community-based health insuranceBMC Medical Research Methodology, Vol.12, No.19 October 2012Can the rural poor in India afford to treat non-communicable diseasesTropical Medicine & International Health, Vol.17, No.114 September 2012Have financial difficulties compromised Christian health services' commitment to the poor?Development in Practice, Vol.22, No.5-65 July 2012Healthcare provision in rural India: does micro health insurance help or hinder?International Journal of Health Care Quality Assurance, Vol.25, No.3Measuring incidence of catastrophic out-of-pocket health expenditure: with application to IndiaInternational Journal of Health Care Finance and Economics, Vol.12, No.118 February 2012Priority Mental Health Disorders of Children and Adolescents in Primary-care Pediatric Setting in India 1: Developing a Child and Adolescent Mental Health Policy, Program, and Service ModelThe Indian Journal of Pediatrics, Vol.79, No.S110 June 2011Universal Health Insurance in India: Ensuring equity, efficiency, and qualityIndian Journal of Community Medicine, Vol.37, No.3Credit from whom and for what? The diversity of borrowing sources and uses in rural southern IndiaJournal of International Development, Vol.245 May 2011Health technology assessment and its role in the future development of the Indian healthcare sectorPerspectives in Clinical Research, Vol.3, No.2Adverse Selection and Private Health Insurance Coverage in India - A Rational Behaviour Model of Insurance Agents Under Asymmetric InformationSSRN Electronic JournalChallenges in the Sustainability of a Targeted Health Care Initiative in IndiaIIM Kozhikode Society & Management Review, Vol.1, No.11 January 2012Appropriation and Dementia in IndiaCulture, Medicine, and Psychiatry, Vol.35, No.412 August 2011HEALTH CARE UTILIZATION, SOCIOECONOMIC FACTORS AND CHILD HEALTH IN INDIAJournal of Biosocial Science, Vol.43, No.69 June 2011Screening for dementia: Fluidity and the Mini Mental State Examination in IndiaTranscultural Psychiatry, Vol.48, No.522 October 2011An evaluation of two health insurance schemes in IndiaBritish Journal of Healthcare Management, Vol.17, No.8Trade in Health Services Implications for People's HealthSocial Change, Vol.41, No.2Whom Do Physicians Work For? An Analysis of Dual Practice in the Health SectorJournal of Health Politics, Policy and Law, Vol.36, No.2Do Health Camps Make People Healthier? Evidence from an RCT of Health Camps on Usage of RSBYSSRN Electronic JournalCoping with Health Care Expenses Among Poor Households: Evidence from a Rural Commune in VietnamSSRN Electronic JournalJob satisfaction and motivation of health workers in public and private sectors: cross-sectional analysis from two Indian statesHuman Resources for Health, Vol.8, No.125 November 2010DETERMINANTS OF INEQUALITY IN CHILD MALNUTRITION IN INDIAAsian Population Studies, Vol.6, No.3Effects of state-level public spending on health on the mortality probability in IndiaHealth Economics, Vol.19, No.1120 November 2009Decentralisation, Governance and Health-System Performance: 'Where You Stand Depends on Where You Sit'Development Policy Review, Vol.28, No.65 October 2010Determinants and implications of new liberal health policies: the case of India, China and LebanonPolitical and economic determinants of health care systems: the case of IndiaImpact evaluation of India's 'Yeshasvini' community-based health insurance programmeHealth Economics, Vol.19, No.S114 December 2010Catastrophic Payments and Impoverishment Due to Out-of-Pocket Health Spending: The Effects of Recent Health Sector Reforms in IndiaSSRN Electronic JournalNon-Hodgkin′s lymphoma: Is India ready to incorporate recent advances in day to day practice?Journal of Cancer Research and Therapeutics, Vol.6, No.1Tobacco and health in IndiaIndian Journal of Cancer, Vol.47, No.5Impact of interpersonal counseling on the blood sugar and lipid profile of type 2 diabetes mellitus subjects (nutrition health education and diabetes mellitus)International Journal of Diabetes in Developing Countries, Vol.30, No.3Saving mothers and newborns through an innovative partnership with private sector obstetricians: Chiranjeevi scheme of Gujarat, IndiaInternational Journal of Gynecology & Obstetrics, Vol.107, No.320 October 2009Healthcare systems: a global comparisonScaling up beyond 'pills and skills': preventing parent-to-child HIV/AIDS transmission and the public/private divide in southern IndiaThe International Journal of Health Planning and Management, Vol.24, No.S12 December 2009Catastrophic payments for health care among households in urban Tamil Nadu, IndiaJournal of International Development, Vol.21, No.2International health policy and stagnating maternal mortality: is there a causal link?Reproductive Health Matters, Vol.17, No.3317 January 2017Support for provision of early medical abortion by mid-level providers in Bihar and Jharkhand, IndiaReproductive Health Matters, Vol.17, No.3317 January 2017Do Spouses Make Claims? Health Seeking and Microfinance In IndiaSSRN Electronic JournalWhy is Access to Basic Services Not Inclusive? A Synthesis with a Special Focus on Developing AsiaSSRN Electronic JournalAids Treatment in South Asia: Equity and Efficiency Arguments for Shouldering the Fiscal Burden When Prevalence Rates are LowSSRN Electronic JournalSaving in Asia: Issues for Rebalancing GrowthSSRN Electronic JournalExploring evidence-policy linkages in health research plans: A case study from six countriesHealth Research Policy and Systems, Vol.6, No.111 March 2008Traditional Indian medicine and homeopathy for HIV/AIDS: a review of the literatureAIDS Research and Therapy, Vol.5, No.122 December 2008Economic evaluation of a surveillance program of hepatocellular carcinoma (HCC) in IndiaHepatology International, Vol.2, No.227 February 2008Poverty and Access to Health Care in Developing CountriesAnnals of the New York Academy of Sciences, Vol.1136, No.125 July 2008Barriers of Mistrust: Public and Private Health Sectors' Perceptions of Each Other in Madhya Pradesh, IndiaQualitative Health Research, Vol.18, No.61 June 2008'Money itself discriminates'Contributions to Indian Sociology, Vol.42, No.11 April 2008Not All Drinks Are Created Equal: Implications for Alcohol Assessment in IndiaAlcohol and Alcoholism, Vol.43, No.61 October 2008Public Financing of Health Services in IndiaJournal of Health Management, Vol.10, No.1Indian community health insurance schemes provide partial protection against catastrophic health expenditureBMC Health Services Research, Vol.7, No.115 March 2007Spending to save? State health expenditure and infant mortality in IndiaHealth Economics, Vol.16, No.91 January 2007Quality improvement and its impact on the use and equality of outpatient health services in IndiaHealth Economics, Vol.16, No.81 January 2007The Dynamics of Gender and Class in Access to Health Care: Evidence from Rural Karnataka, IndiaInternational Journal of Health Services, Vol.37, No.323 June 2016Healthy public policy in poor countries: tackling macro-economic policiesHealth Promotion International, Vol.22, No.213 March 2007The New Evidence on Male Circumcision: An Indian PerspectiveReproductive Health Matters, Vol.15, No.2917 January 2017Can computers improve patient care by primary health care workers in India?International Journal for Quality in Health Care, Vol.18, No.613 October 2006Utilisation of Health Care in North Bengal: A Study of Health Seeking Patterns in an Interdisciplinary FrameworkJournal of Social Sciences, Vol.13, No.19 October 2017Maternity and Child Health Care Services Delivered by Public Health Centers Compared to Health Cooperatives: Iran`s ExperienceJournal of Medical Sciences(Faisalabad), Vol.6, No.3Immunization in india 1993–1999: Wealth, gender, and regional inequalities revisitedSocial Science & Medicine, Vol.62, No.3Journal of Human Ecology, Vol.19, No.4A Case Study of the Yeshasvini Health Insurance Scheme for the Rural Poor in IndiaInternational Journal of Self Help and Self Care, Vol.3, No.3-4Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household surveySocial Science & Medicine, Vol.60, No.4Development and ChoiceThe Millennium Development Goals for India: How Attainable?Private Care and Public Health: Do Vaccination and Prenatal Care Rates Differ between Users of Private versus Public Sector Care in India?Health Services Research, Vol.39, No.6p2Household tobacco and alcohol use, and child health: an exploratory study from IndiaHealth Policy, Vol.70, No.1International health in a globalized development perspectiveJournal of Public Health, Vol.12, No.33 April 2004India mental health country profileInternational Review of Psychiatry, Vol.16, No.1-211 July 2009Factors influencing the care-seeking behaviour of chest symptomatics: a community-based study involving rural and urban population in Tamil Nadu, South IndiaTropical Medicine and International Health, Vol.8, No.4The Role of Oversight in the Health Sector: The Example of Sexual and Reproductive Health Services in IndiaReproductive Health Matters, Vol.10, No.2017 January 2017Exacerbating Health Risks in India due to Climate Change View Published: May 2002ISBN: 978-0-8213-5029-4 Copyright & Permissions Related RegionsSouth AsiaRelated CountriesIndiaRelated TopicsHealth Nutrition and Population KeywordsHEALTH CARE SYSTEMSHEALTH REFORMPUBLIC HEALTH FINANCEPUBLIC HEALTH ADMINISTRATIONSERVICE DELIVERYHEALTH INSURANCEMATERNAL HEALTH SERVICESPRIVATE SECTOR INVESTMENTSAMBULATORY CAREHEALTH CARE RESOURCESTUBERCULOSISHEALTH CAREHEALTH OUTCOMESHEALTH POLICYHEALTH SERVICESHOSPITALSINTERNATIONAL COMPARISONSINTERVENTIONNUTRITIONPATIENTSPUBLIC HEALTH PDF DownloadLoading ...

Abstract Stuxnet, the computer worm which disrupted Iranian nuclear enrichment in 2010, is the first instance of a computer network attack known to cause physical damage across international boundaries. Some have described Stuxnet as the harbinger of a new form of warfare that threatens even the strongest military powers. The influential but largely untested Cyber Revolution thesis holds that the internet gives militarily weaker actors asymmetric advantages, that offense is becoming easier while defense is growing harder, and that the attacker's anonymity undermines deterrence. However, the empirical facts of Stuxnet support an opposite interpretation; cyber capabilities can marginally enhance the power of stronger over weaker actors, the complexity of weaponization makes cyber offense less easy and defense more feasible than generally appreciated, and cyber options are most attractive when deterrence is intact. Stuxnet suggests that considerable social and technical uncertainties associated with cyber operations may significantly blunt their revolutionary potential. This article is part of the following collections: A Decade of Nuclear Scholarship in Security Studies Acknowledgments Jon R. Lindsay is an assistant research scientist with the University of California Institute on Global Conflict and Cooperation (igcc), located at uc San Diego. He holds a PhD in political science from the Massachusetts Institute of Technology, an ms in computer science from Stanford University, and he has served as an officer in the us Navy. He would like to thank Erik Gartzke, Robert Giesler, Brendan Green, Tim Junio, Sean Lawson, Carrie Lee Lindsay, Charles Perrow, Joshua Rovner, and the editors and anonymous reviewers at Security Studies for their valuable comments and advice on previous drafts. Notes The original announcement of “Rootkit.TmpHider” was posted by Sergey Ulasen of VirusBlokAda on an information security forum on 12 July 2010, http://www.anti-virus.by/en/tempo.shtml. For an accessible account of Stuxnet's discovery see Kim Zetter, “How Digital Detectives Deciphered Stuxnet, the Most Menacing Malware in History,” Wired Threat Level Blog, 11 July 2011, http://www.wired.com/threatlevel/2011/07/how-digital-detectives-deciphered-stuxnet. Aleksandr Matrosov, Eugene Rodionov, David Harley, and Juraj Malcho, “Stuxnet under the Microscope,” eset, white paper, 20 January 2011. The dubious honor of “most sophisticated malware” has perhaps passed to a Stuxnet relative named Duqu or to the Flame spyware (which is twenty times the file size of Stuxnet). Mark Clayton, “Stuxnet Malware Is ‘Weapon’ Out to Destroy … Iran's Bushehr Nuclear Plant?” Christian Science Monitor, 21 September 2010. David E. Sanger, “Obama Order Sped Up Wave of Cyberattacks Against Iran,” New York Times, 1 June 2012. William J. Broad, John Markoff, and David E. Sanger, “Israel Tests on Worm Called Crucial in Iran Nuclear Delay,” New York Times, 15 January 2011. Mark Clayton, “The New Cyber Arms Race,” Christian Science Monitor, 7 March 2011, (“cyber equivalent”). In the vein of “a new era of warfare,” the cover of the 3 July 2010 edition of The Economist depicted a digitized mushroom cloud. “Stuxnet: Computer Worm Opens New Era of Warfare,” Transcript, 60 Minutes, CBS News, 4 March 2012. “Russia Says Stuxnet Could Have Caused New Chernobyl,” Reuters, 26 January 2011. Sanger, “Obama Order.” Arguments for the Cyber Revolution thesis by former senior us officials include Mike McConnell, “Cyberwar is the New Atomic Age,” New Perspectives Quarterly 26, no. 3 (Summer 2009): 72–77; Richard A. Clarke and Robert Knake, Cyber War: The Next Threat to National Security and What to Do about It (New York: Harpercollins, 2010); Joel Brenner, America the Vulnerable: Inside the New Threat Matrix of Digital Espionage, Crime, and Warfare (New York: Penguin Press, 2011). On Stuxnet as an rma, see James P. Farwell and Rafal Rohozinski, “Stuxnet and the Future of Cyber War,” Survival 53, no. 1 (February-March 2011): 23–40; Joseph S. Nye Jr., “Nuclear Lessons for Cyber Security?” Strategic Studies Quarterly 5, no. 4 (Winter 2011); Paulo Shakarian, “Stuxnet: Cyberwar Revolution in Military Affairs,” Small Wars Journal (April 2011); Sean Collins and Stephen McCombie, “Stuxnet: The Emergence of a New Cyber Weapon and Its Implications,” Journal of Policing, Intelligence and Counter Terrorism 7, no. 1 (2012): 80–91. Remarks by Secretary Panetta on Cybersecurity to the Business Executives for National Security, us Dept. of Defense, New York City, 11 October 2012, http://www.defense.gov/transcripts/transcript.aspx?transcriptid=5136. Barack Obama, “Taking the Cyberattack Threat Seriously,” Wall Street Journal, 19 July 2012. “Senate Select Intelligence Committee Holds Hearing on Worldwide Threats,” Defense Intelligence Agency, 31 January 2012, http://www.dia.mil/public-affairs/testimonies/2012-01-31.html. Adm. Mike Mullen, quoted in Marcus Weisgerber, “DoD to Release Public Version of Cyber Strategy,” Defense News, 8 July 2011. This is an astonishing claim coming from a man well familiar with the world's nuclear arsenals. James A. Lewis and Katrina Timlin, Cybersecurity and Cyberwarfare: Preliminary Assessment of National Doctrine and Organization (Washington, dc: Center for Strategic and International Studies, United Nations Institute of Disarmament Research, 2011). See inter alia, Nicholas Burns and Jonathon Price, Securing Cyberspace: A New Domain for National Security (Aspen, co: Aspen Institute, 2012); Kristin M. Lord and Travis Sharp, America's Cyber Future: Security and Prosperity in the Information Age (Washington dc: Center for a New American Security, 2011); David J. Betz and Timothy C. Stevens, “Cyberspace and the State: Toward a Strategy for Cyber-Power,” International Institute for Strategic Studies (IISS) Adelphi Paper, no. 424 (2011); Paul Cornish, David Livingstone, Dave Clemente, and Claire Yorke, “On Cyber Warfare,” Royal Institute of International Affairs, Chatham House Report (November 2010); Franklin D. Kramer, Stuart H. Starr, and Larry K. Wentz, eds., Cyberpower and National Security (Washington, dc: National Defense University Press, 2009). Adam P. Liff, “Cyberwar: A New ‘Absolute Weapon’? The Proliferation of Cyberwarfare Capabilities and Interstate War,” Journal of Strategic Studies 35, no. 3 (June 2012); Thomas Rid, “Cyber War Will Not Take Place,” Journal of Strategic Studies 35, no. 1 (February 2011): 5–32; Martin C. Libicki, Cyberdeterrence and Cyberwar (Santa Monica, ca: rand, 2009); Evgeny Morozov, “Cyber-Scare: The Exaggerated Fears over Digital Warfare,” Boston Review (July/August 2009); Myriam Dunn Cavelty, “Cyber-Terror: Looming Threat or Phantom Menace? The Framing of the us Cyber-Threat Debate,” Journal of Information Technology & Politics 4, no. 1 (2007): 19–36; Martin C. Libicki, Conquest in Cyberspace: National Security and Information Warfare (Cambridge University Press, 2007); Gregory J. Rattray, Strategic Warfare in Cyberspace (Cambridge, ma: Massachusetts Institute of Technology (mit) Press, 2001); Bradley A. Thayer, “The Political Effects of Information Warfare: Why New Military Capabilities Cause Old Political Dangers,” Security Studies 10, no. 1 (Autumn 2000): 43–85; Peter D. Feaver, “Blowback: Information Warfare and the Dynamics of Coercion,” Security Studies 7, no. 4 (Summer 1998): 88–120. On the direct technical effects of Stuxnet on Iranian computer systems, I draw on forensic investigation by computer security firms Symantec, eset, and Langner Communications; Nicolas Falliere, Liam O Murchu, and Eric Chien, “W32.Stuxnet Dossier, version 1.4,” Symantec, 4 February 2011, http://www.symantec.com/content/en/us/enterprise/media/security_response/whitepapers/w32_stuxnet_dossier.pdf; Aleksandr Matrosov, Eugene Rodionov, David Harley, and Juraj Malcho, “Stuxnet under the Microscope, version 1.31,” white paper, eset, 20 January 2011, http://go.eset.com/us/resources/white-papers/Stuxnet_Under_the_Microscope.pdf; Ralph Langner, “Stuxnet Attack Code Deep Dive” (presentation at Digital Bond scada Security Scientific Symposium (S4) in Miami, fl, 18–19 January 2012), http://www.digitalbond.com/2012/01/31/langners-stuxnet-deep-dive-s4-video; a synthesis of technical details accessible to lay readers and a detailed interactive timeline can be found in Zetter, “How Digital Detectives Deciphered Stuxnet.” To assess Stuxnet's indirect strategic effects on Natanz, I rely on International Atomic Energy Agency (iaea) inspection reports (http://www.iaea.org/newscenter/focus/iaeairan/iaea_reports.shtml) and Institute for Science and International Security (isis) analyses of Iranian enrichment operations (http://isisnucleariran.org/). I supplement these with contemporary press reporting, particularly the New York Times’ David E. Sanger's path-breaking investigation of Olympic Games. For a detailed history of computerization in the American private and public sector, see James W. Cortada, The Digital Hand, 3 vols. (New York: Oxford University Press, 2004–2008). The “productivity paradox” debate over the relationship between IT inputs and firm performance has been resolved following clarification of the critical role of organizational structure and process; Erik Brynjolfsson, Lorin M. Hitt, and Shinkyu Yang, “Intangible Assets: Computers and Organizational Capital,” Brookings Papers on Economic Activity no. 1 (2002): 137–81. For a textbook introduction to technical cybersecurity, see Ross J. Anderson, Security Engineering: A Guide to Building Dependable Distributed Systems, 2nd ed. (Indianapolis, in: Wiley Publishing, 2008). For a good introduction to offensive cyber operations, including attack/disruption and exploitation/theft, see William A. Owens, Kenneth W. Dam, and Herbert S. Lin, eds., Technology, Policy, Law, and Ethics Regarding u.s. Acquisition and Use of Cyberattack Capabilities (Washington, dc: National Academies Press, 2009). Ross Anderson, Chris Barton, Rainer Bohm, Richard Clayton, Michel J. G. Van Eeten, Michael Levi, Tyler Moore, and Stefan Savage, “Measuring the Cost of Cybercrime,” Proceedings of the Workshop on the Economics of Information Security (June 2012); Kirill Levchenko et. al, “Click Trajectories: End-To-End Analysis of the Spam Value Chain,” Proceedings of the IEEE Symposium and Security and Privacy (May 2011): 431–46; Misha Glenny, DarkMarket: How Hackers Became the New Mafia (New York: Vintage, 2011); Cormac Herley and Dinei Florêncio, “Nobody Sells Gold for the Price of Silver: Dishonesty, Uncertainty and the Underground Economy,” Economics of Information Security and Privacy (2010): 33–53. Bryan Krekel, Patton Adams, and George Bakos, “Occupying the Information High Ground: Chinese Capabilities for Computer Network Operations and Cyber Espionage,” prepared for the us-China Economic and Security Review Commission by Northrop Grumman, 7 March 2012; Office of the National Counterintelligence Executive, “Foreign Spies Stealing us Economic Secrets in Cyberspace,” report to Congress on Foreign Economic Collection and Industrial Espionage 2009–2011, October 2011; Shadows in the Cloud: An Investigation into Cyber Espionage 2.0, joint report of the Information Warfare Monitor and Shadowserver Foundation, 6 April 2010, http://shadows-in-the-cloud.net; “Gauss: Abnormal Distribution,” Kaspersky Lab Global Research and Analysis Team Report, August 2012, http://www.securelist.com/en/analysis/204792238/Gauss_Abnormal_Distribution. Christian Czosseck, Rain Ottis, and Anna-Maria Talihärm, “Estonia after the 2007 Cyber Attacks: Legal, Strategic and Organisational Changes in Cyber Security,” Journal of Cyber Warfare and Terrorism 1, no. 1 (2011); John Bumgarner and Scott Borg, “Overview By the us-ccu of the Cyber Campaign Against Georgia in August of 2008,” us Cyber Consequences Unit Report, August 2009; Ronald Deibert, John Palfrey, Rafal Rohozinski, and Jonathan Zittrain, eds., Access Contested: Security, Identity, and Resistance in Asian Cyberspace (Cambridge, ma: mit Press, 2011); Evgeny Morozov, The Net Delusion: The Dark Side of Internet Freedom (New York: PublicAffairs, 2011). Military doctrine has not stabilized for cyber concepts yet, and debate continues on the distinctions between cyber warfare, computer network operations, information operations, electronic warfare, etc. In this paper I focus on the use of computer hacking to cause mechanical damage in the service of strategic objectives. Cyber warfare clearly encompasses the tactical modalities of cyber attack (degredation of normal hardware or software functionality), exploitation (covert theft or use of data or computational resources), and defense (efforts to prevent adversarial attack or exploitation); my emphasis in this paper is on the primary aggressive move of attack. David A. Fulghum, “Why Syria's Air Defenses Failed to Detect Israelis,” Aviation Week, Ares Blog, 3 October 2007. Some sources dispute whether the Israelis used cyber attack or more traditional forms of electronic jamming; Ellen Nakashima, “u.s. Accelerating Cyberweapon Research,” Washington Post, 18 March 2012. Raphael Satter, “us General: We Hacked the Enemy in Afghanistan,” Associated Press, 24 August 2012. Martin Libicki, Cyberdeterrence and Cyberwar (Santa Monica, ca: rand, 2009) distinguishes “operational cyberwar—cyberattacks to support warfighting” from “strategic cyberwar, cyberattacks to affect state policy”; see Libicki, Cyberdeterrence, 6. The Cyber Revolution thesis treated in this paper emphasizes the latter threat, particularly via ics attack. ics are the industrial plant equivalent of military command and control (C4ISR) systems; they include the embedded controllers that drive machines like generators, valves, production lines, etc.; embedded sensors that monitor their performance; Supervisory Control and Data Acquisition (scada) systems that allow human operators to visualize and manage the process; and the network architecture that connects it all together. For a primer on ics security, see Joseph Weiss, Protecting Industrial Control Systems from Electronic Threats (New York: Momentum Press, 2010). Anna Mulrine, “cia Chief Leon Panetta: The Next Pearl Harbor Could Be a Cyberattack,” Christian Science Monitor, 9 June 2011. According to Scott Berinato, “The Future of Security,” Computerworld, 30 December 2003, the first use of the phrase “digital Pearl Harbor” was in 1991 by then rsa Data Security president D. James Bidzos. rma discourse since the 1990s has focused on the impact of networks on military operational efficiency, but it also has always included a strain of futurism about information warfare as a substitute for traditional operations altogether, e.g., James Adams, The Next World War: The Weapons and Warriors of the New Battlefields of Cyberspace (London: Arrow, 1998); John Arquilla and David F. Ronfeldt, Networks and Netwars: The Future of Terror, Crime, and Militancy (Santa Monica, ca: rand, 2001). Widely cited as an example of supply-chain sabotage is an elaborate 1982 counterintelligence operation in which the cia allegedly tampered with Canadian software that the Soviets planned to steal. Once the Soviets installed it in controllers on the Trans-Siberian oil pipeline, this Trojan horse caused “the most monumental non-nuclear explosion and fire ever seen from space” and “significant damage to the Soviet economy,” according to Thomas C. Reed, At the Abyss: An Insider's History of the Cold War (New York: Random House, 2004), 268–69. However, Rid, “Cyber War Will Not Take Place,” finds little corroborating evidence for Reed's story, which should have had eyewitnesses aplenty; Electrical blackouts in Brazil in 2007 and 2009 have been blamed on hackers, but no supporting evidence has emerged while simpler explanations have been offered in each case: Marcelo Soares, “Brazilian Blackout Traced to Sooty Insulators, Not Hackers,” Wired Threat Level Blog, 9 November 2009, http://www.wired.com/threatlevel/2009/11/brazil_blackout; also, a Wikileaks cable from the American Embassy in Brasilia dated 1 December 2009, 11:27 a.m. gmt, discounts the possibility of a cyber attack in the 2009 blackout. Other examples of physical damage include malicious experiments likely created for hacker bragging rights, like the 1999 Chernobyl or Spacefiller virus, which could overwrite Basic Input Output System (bios) data and effectively turn a computer into a useless brick. On the INL Aurora demonstration, see Jeanne Meserve, “Staged Cyber Attack Reveals Vulnerability in Power Grid,” CNN, 26 September 2007. On the historical absence of cyberwar, see Sean Lawson, “Beyond Cyber-Doom: Assessing the Limits of Hypothetical Scenarios in the Framing of Cyber-Threats,” Journal of Information Technology & Politics 10, no. 1 (December 2012): 86–103; Michael Stohl, “Cyber Terrorism: A Clear and Present Danger, the Sum of All Fears, Breaking Point or Patriot Games?” Crime, Law and Social Change 46, nos. 4–5 (December 2006): 223–38. Bill Gertz, “Computer-Based Attacks Emerge As Threat of Future, General Says,” Washington Times, 13 September 2011. Alexander also cited “the August 2003 electrical power outage in the u.s. that was caused by a power Electrical software that the of to of and all power William J. a New The Foreign no. at Obama, “Taking the Cyberattack Threat and to for cyber attack are described in Kenneth J. and William R. Information Systems Clayton, “The New Cyber Arms On see Scott Borg, IEEE Security and Privacy no. 6 (December A example of is a attack in which the an than the for it by the has to the of the the for the control which to be but can be that of physical than most the to can information from the physical of a as by even the systems can and social as that human for A Price for March 2012, For a of the cyber offense see Kenneth and Peter W. and Brookings February 2012, the of and a has been between offense and defense is in the use on of a phrase known as a to from the can new while the has a more have this not but to to a See Kirill Chris M. and Stefan Savage, from an Economic Proceedings of the Security August 2010. “Senate Select Intelligence Committee Holds Hearing on Worldwide Threats,” Defense Intelligence Agency, 31 January 2012, http://www.dia.mil/public-affairs/testimonies/2012-01-31.html. Ross and Tyler Moore, “The Economics of Information Security,” Science no. 2006): August and Security and Science no. 11 (November 2006): M. and Michel J. G. Van Eeten, and no. and on Power Control 21 and IEEE on Power 26, no. 1 2011): 31 January 2012. On the complexity of see David D. and Proceedings of a Workshop on ed. National Research (Washington, dc: National Academies Press, For of the of cyber cyber or the of cyber attack to See National Research Proceedings of a General Martin at the of July 2012, I to Erik for the between the of and the of in cyber warfare see Gartzke, “The of Cyber War: War on the Internet to at the International Studies San April of the and of Security and in the of Iran,” 18 February 2010. and Assessing Capabilities to Destroy Iranian Nuclear International Security no. 4 Office of the of National Nuclear and November The is described in of the and in David and “The Iranian at from Institute for Science and International Security, March which it from the to in a enrichment plant for and a enrichment plant for industrial have enrichment over at the the has of 20 for and Iran to a to for a a it would have to use the enrichment plant at See David Paul and Iran from Nuclear Its Future Nuclear Institute for Science and International Security, March 2012. The of networks has not been to but can into the from for ics security and of the of by Stuxnet, as in Eric and Joel “How Stuxnet A of in Security white paper, February 2011. The significantly from but the operational of this are as it may have more to or it may have According to the of the would have been the which most of the and that was the “the ics the computer in the control systems and data to in the on the network would have been to by that they from with and to for This network may have had physical from the networks to ics to and not have been an would have of to The network systems, and may have been for each of the in the production of these included the control network that human for the and systems as well as the control network that the the controllers and industrial David Paul and “Stuxnet Malware and of December 2010 Institute for Science and International Security, 15 February 2011, has not the of these data from Stuxnet as it from computer to each instance a of all the machines by the of in or of the worm in the a to internet the of which have not been of these was on was and had at an drive was for a of known are known of Stuxnet, but on inspection data the first version to have damage at The of Stuxnet in June and July 2009, March 2010, and April and 2010. The that about in January 2010, as but in the under when the and and to have had no as the of to after August 2010. of the first Stuxnet's damage from each in a in The between and could have been to the of and the worm to the human would the or to the as I that the that into the on at the is The attack as the associated with a are across the and The between and was the was over and the was twenty have been attractive as as they could have the at or also to in the control while in the network and Stuxnet's could have to with that would and the See “How Stuxnet A of has been to a in that a to as as the is This for the first in the version of Stuxnet, on 1 March 2010. As I most of the damage to Stuxnet to March it not have been the that the that the at The first version of Stuxnet used a less sophisticated to via Falliere, “W32.Stuxnet Sanger, “Obama Order.” William Says It Computer Worm New York Times, October 2010. Iran was likely

BACKGROUND: The purpose of this study was to detect the prevalence of ghost and honorary authors and its determinant factors in bio-medical journals of Iran. METHODS: The study was done in 2009-10 in Tehran, Kerman, and Iran Medical Universities, Iran. We contacted the first or corresponding authors of the papers had published papers in the recent two issues of Iranian Journal of Public Health, Journal of Kerman University of Medical Sciences, and Tehran University Medical Journal. They explored the role of each coauthor and others who had done mouthing for the paper. Then, according to ICMJE criteria, we counted how many of them are real, honorary or ghost author. For the analysis, we utilized two databases. One included articles as the records and the other included authors as the records. RESULTS: From 124 articles, with 536 authors, 301 (56.1%) were honorary authors. Each article had 4.35 authors on average, while 2.4 of them were honorary authors. The percentage of honorary author in basic science articles was about 6% more than the articles of clinical sciences. Moreover, 89% of articles had at least one honorary author. About 20% of all articles had more than three honorary authors. Besides, 25 (21.43%) authors confessed they had colleague(s) omitted from the authors list, while only one (0.81%) of them met the authorship criteria. The percentage of agreement between the corresponding and the remaining authors on the number of honorary of the authors was about 47.4% (Kappa= 0.27, P= 0.01). CONCLUSION: It seems that the present data might assist the authorities to make a decisive decision on amending the process of authorship in Iran.

BACKGROUND: Medical journals are scientific resources where utilization of knowledge is availed and create an environment of competitiveness. To speed up the growth and increase scientific production and in order that the rank of Iranian journals be defined regionally and globally, journal standardization is necessary. This study was done to evaluate the country's medical journals from 2004-2006. METHODS: This is a descriptive/analytical study. Evaluation was based on the following; scientific credibility, registry and year of service, journal management, technical quality and accessibility. The number of journals evaluated during 2004-2006 were 86, 103 and 93, respectively and the process involved 3 phases 1) defining the journal's structural indicators and designing the evaluation form 2) collection, sharing and final confirmation of information with the publication staff 3) data entry, analysis and ranking RESULTS: Improvement and growth of publication depends largely on 5 parameters and its development were based on the following; publication management (61.62 points), scientific credibility (43.80 points), quality of accessing the journals (37.05 points), quality of publication (14.80 points) and registry and year of service (0.02 points). Based on the study, an upward developmental trend of the country's medical journals can be seen and the tools were sufficient in terms of validity and reliability. A revised and more comprehensive checklist that would evaluate all aspects of a publication basing on latest indicators is developed. CONCLUSION: Evaluations of the country's medical journals not only promote compliance to international standards but also led to more indexing of journals in accredited international indices.

Ensuring the long-term retention of healthcare professionals has become a central priority for strengthening the resilience and quality of Iran's health system. A comprehensive understanding of the diverse factors influencing retention, alongside those that may contribute to outward mobility, is essential for informed policymaking. This study adopts a multi-method approach, integrating qualitative inquiry with a scoping review, to explore the determinants shaping healthcare professionals' decisions to remain in or leave the national health system, the implications for workforce stability, and the effectiveness of current policy responses. By examining both individual and systemic dimensions, and by incorporating insights from migrant professionals, domestic policymakers, and existing evidence, this research contributes a nuanced perspective to the broader discourse on human resources for health in developing contexts. The originality of this study lies in combining first-hand qualitative data with a systematic synthesis of literature, allowing for an in-depth understanding of locally grounded drivers of retention and opportunities for strengthening Iran's health workforce. The research employed a qualitative, multi-phase design. In the first phase, semi-structured interviews were conducted with 15 Iranian healthcare professionals residing in countries such as the United States, Germany, Switzerland, Turkey, and Oman to understand their professional trajectories. In the second phase, interviews with 16 Iranian health administrators, policymakers, and senior professionals were undertaken to capture institutional and policy-level perspectives on retention challenges and opportunities. All interviews were transcribed verbatim and analyzed thematically. Complementing this, a scoping review was conducted to synthesize existing evidence, policy documents, and expert assessments related to the retention and mobility of Iran's health workforce. Data sources included PubMed, Scopus, and gray literature obtained through institutional repositories and local websites. Findings highlight several interrelated factors influencing workforce retention. Economic considerations including income stability, purchasing power, and access to research funding remain important determinants of professional commitment. Institutional dynamics such as transparent promotion pathways, supportive management, and opportunities for professional development also play a critical role. Importantly, Iran's integrated system of medical education and service delivery emerged as a key structural strength, providing early clinical exposure, strong professional identity formation, and continuity between training and practice advantages less commonly available in many other health systems. Participants noted that when financial incentives are combined with accessible professional development programs, equitable workload distribution, and recognition of professional contributions, retention outcomes improve substantially. While destination countries may offer expanded career pathways, the sense of belonging, family ties, and cultural identity were identified as influential factors supporting continued service in Iran. Governmental initiatives including compensation adjustments, training reforms, and targeted retention programs have yielded positive outcomes, though further coordination and sustained implementation are needed. Strengthening the retention of healthcare professionals in Iran requires a holistic strategy that integrates economic, organizational, educational, and governance reforms. Enhancing remuneration structures, investing in professional development and research capacity, reinforcing the advantages of Iran's integrated educational service system, and engaging with the healthcare diaspora can collectively support workforce stability. A multi-sectoral, evidence-informed approach has the potential to improve long-term retention, mitigate the need for outward mobility, and promote a more resilient and sustainable health system.

In Iran, the number of published articles has increased significantly in the basic and applied sciences including medicine and its subspecialties during the recent years. The present study reviewed Iranian science production in medicine, focusing on Iranian medical journals and assessing the current status of Iranian medical journals in several information databases. The study revealed that only a few number of Iranian biomedical journals were indexed by Web of Science, Medline, Scopus and Biological abstract, but most of them have been covered by Index Copernicus and Index Medicus for Eastern Mediterranean Region. Observing some important factors such as journal's basic publishing standards may increase the number of Iranian medical journals indexed by reputable information databases and improve Iranian contribution to the world science.

Better evaluation of the contribution of the main diseases, injuries, and risk factors for mortality and life expectancy is crucial for more efficient policy making at the national and subnational levels in Iran. The aim of this study is to assess the effect of emerging causes of mortality on health, specifically COVID-19, which can help policy makers implement preventive measures in similar situations. In this systematic analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we present estimates of cause-specific mortality at the national and subnational levels in Iran from 1990 to 2023. New to this iteration of GBD, we present a decomposition analysis of the contribution of specific causes of death to net gain or loss in life expectancy across 31 provinces of Iran. We used an array of data sources including censuses, vital registration, and surveys for national and subnational estimates. The two leading causes of death in Iran were ischaemic heart disease and stroke in both 1990 and 2019. However, in 2020 and 2021, the COVID-19 pandemic displaced the leading causes of death, ranking first with age-standardised mortality rates of 286·2 deaths (95% uncertainty interval 267·9-310·5) per 100 000 in 2020 and 250·0 deaths (233·2-272·5) per 100 000 in 2021. COVID-19 ranked second and tenth in 2022 and 2023, respectively. Life expectancy at birth for both sexes combined declined from 78·0 years (77·7-78·1) in 2019 to 74·3 years (74·0-74·4) in 2020. It steadily recovered to 78·8 years (78·5-79·2) in 2023. COVID-19 was the main cause of loss in life expectancy, by 4·19 years, between 2019 and 2020. There was a net gain of 12·4 years in life expectancy in Iran from 1990 to 2023. The net gain at the national level can be mostly attributed to reduced mortality from ischaemic heart disease (2·61 years), stroke (1·63 years), neonatal disorders (1·26 years), transport injuries (0·88 years), and neoplasms (0·64 years). The decline in mortality rates of major causes continued to 2023 despite the pandemic. An exception was Alzheimer's disease, which showed a 4·0% increase in rate between 2019 and 2023 and led to a net loss of 0·04 years in life expectancy since 1990. Diabetes led to a net loss of 0·09 years since 1990. There were variations between provinces in terms of age-standardised rates and the net change in life expectancy before and after the COVID-19 pandemic. The COVID-19 pandemic disrupted the rising trend of life expectancy in Iran, varying across provinces. Findings show that the health-care infrastructure and policies in Iran were not efficient in controlling the pandemic in 2020 and 2021, mainly due to inadequate vaccination coverage and timeliness, specifically for vulnerable subgroups. Sanctions may have aggravated the effect of COVID-19 on loss in life expectancy of Iranians. Despite the pandemic, the declining trend in age-standardised rates for top causes of mortality has continued to 2023, leading to a full recovery of life expectancy and underscoring the ultimate resilience of Iran's health system. Gates Foundation.

HomeCirculationVol. 142, No. 1Obesity Is a Risk Factor for Severe COVID-19 Infection Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBObesity Is a Risk Factor for Severe COVID-19 InfectionMultiple Potential Mechanisms Naveed Sattar, Iain B. McInnes and John J.V. McMurray Naveed SattarNaveed Sattar Naveed Sattar, MD, Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, United Kingdom. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1604-2593 Institute of Cardiovascular and Medical Sciences (N.S., J.J.V.M.), University of Glasgow, United Kingdom. , Iain B. McInnesIain B. McInnes Institute of Infection, Immunity and Inflammation (I.B.M.), University of Glasgow, United Kingdom. and John J.V. McMurrayJohn J.V. McMurray Institute of Cardiovascular and Medical Sciences (N.S., J.J.V.M.), University of Glasgow, United Kingdom. Originally published22 Apr 2020https://doi.org/10.1161/CIRCULATIONAHA.120.047659Circulation. 2020;142:4–6Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 22, 2020: Ahead of Print The coronavirus disease 2019 (COVID-19) pandemic has led to worldwide research efforts to identify people at greatest risk of developing critical illness and dying. Initial data pointed toward older individuals being particularly vulnerable, as well as those with diabetes mellitus or cardiovascular (including hypertension), respiratory, or kidney disease. These problems are often concentrated in certain racial groups (eg, African Americans and Asians), which also appear to be more prone to worse COVID-19 outcomes.1 Increasing numbers of reports have linked obesity to more severe COVID-19 illness and death.1–3 In a French study, the risk for invasive mechanical ventilation in patients with COVID-19 infection admitted to the intensive treatment unit was more than 7-fold higher for those with body mass index (BMI) >35 compared with BMI <25 kg/m2.2 Among individuals with COVID-19 who were <60 years of age in New York City, those with a BMI between 30 to 34 kg/m2 and >35 kg/m2 were 1.8 times and 3.6 times more likely to be admitted to critical care, respectively, than individuals with a BMI <30 kg/m2.3We suggest obesity or excess ectopic fat deposition may be a unifying risk factor for severe COVID-19 infection, reducing protective cardiorespiratory reserve as well as potentiating the immune dysregulation that appears, at least in part, to mediate the progression to critical illness and organ failure in a proportion of patients with COVID-19 (Figure). Whether obesity is an independent risk factor for susceptibility to infection requires further research.Download figureDownload PowerPointFigure. Pathways potentially linking obesity or excess ectopic fat to more severe coronavirus disease 2019 (COVID-19) illness. There are multiple pathways by which obesity (or excess ectopic fat) may increase the effect of COVID-19 infection. These include underlying impairments in cardiovascular, respiratory, metabolic, and thrombotic pathways in relation to obesity, all of which reduce reserve and ability to cope with COVID-19 infection and the secondary immune reaction to it. At the same time, there are several reasons why obese individuals may have amplified or dysregulated immune response, linked both to greater viral exposure, as well as the possibility that excess adipose tissue potentiates the immune response. BP indicates blood pressure; COVID-19, coronavirus disease 2019; CV, cardiovascular; FEV1, forced expiratory volume; FVC, forced vital capacity; and SES, socioeconomic status.From a cardiovascular perspective, trial and genetic evidence conclusively show that obesity (and excess fat mass) are causally related to hypertension, diabetes mellitus, coronary heart disease, stroke, atrial fibrillation, renal disease, and heart failure. Obesity potentiates multiple cardiovascular risk factors, the premature development of cardiovascular disease, and adverse cardiorenal outcomes. There is also a metabolic concern. In individuals with diabetes mellitus, or at high risk of diabetes mellitus, obesity and excess ectopic fat lead to impairment of insulin resistance and reduced β-cell function. Both the latter limit ability to evoke an appropriate metabolic response on immunologic challenge, leading some patients with diabetes mellitus to require substantial amounts of insulin during severe infections. Overall, the integrated regulation of metabolism required for the complex cellular interactions, and for effective host defense, is lost, leading to functional immunologic deficit. COVID-19 may also directly disrupt pancreatic β-cell function through an interaction with angiotensin-converting enzyme 2. Furthermore, obesity enhances thrombosis, which is relevant given the association between severe COVID-19 and prothrombotic disseminated intravascular coagulation and high rates of venous thromboembolism.Beyond cardiometabolic and thrombotic consequences, obesity has detrimental effects on lung function, diminishing forced expiratory volume and forced vital capacity (Figure). Higher relative fat mass is also linked to such adverse changes, perhaps relevant to emerging reports of greater critical illness from COVID-19 in certain ethnicities, eg, Asians.1 Asians often display lower cardiorespiratory fitness and carry proportionally more fat tissue at lower BMIs. With extreme obesity (eg, BMI >40 kg/m2), care for individuals admitted to intensive therapy units is often impeded as these patients are more difficult to image, ventilate, nurse, and rehabilitate.With respect to the immune response, there is a clear association between obesity and basal inflammatory status characterized by higher circulating interleukin 6 and C-reactive protein levels. Adipose tissue in obesity is "proinflammatory," with increased expression of cytokines and particularly adipokines. There is also dysregulated tissue leukocyte expression, and inflammatory macrophage (and innate lymphoid) subsets replace tissue regulatory (M2) phenotypic cells. Obesity per se is an independent and causal risk factor for the development of immune-mediated disease, eg, psoriasis,4 suggesting that such adipose state may have systemic immune consequence on additional environmental provocation. In terms of host defense, obesity impairs adaptive immune responses to influenza virus5 and conceivably could do so in COVID-19. Obese individuals may exhibit greater viral shedding, suggesting potential for great viral exposure, especially if several family members are overweight. This may be aggravated in overcrowded multigenerational households, which are more common in the socioeconomically deprived communities in which obesity is prevalent. All these observations point toward a potential for obesity to give rise to a more adverse virus versus host immune response relationship in COVID-19. Poorer nutritional status and hyperglycemia may further aggravate the situation in some obese individuals.Much of the focus of COVID-19 has been on older people. However, it is important to remember that weight and muscle mass start to decline at advanced age but relative fat mass increases, particularly in those with comorbid diseases such as cardiovascular and respiratory conditions. Older age is also associated with more hypertension and diabetes mellitus because of stiffer vessels and impaired metabolic efficiency, respectively. People who are older (eg, >70 years of age), similar to younger obese individuals, have less cardiorespiratory reserve to cope with COVID-19 infection. Immune senescence is well recognized, as is the concept of inflammaging, and both may influence virus–host dynamics in the elderly and infection outcomes.What are the implications of these emerging observations for future research and public health messaging? With respect to research, predictive instruments for those most at risk of severe outcomes should consider BMI. Mechanistic understanding of the relationship between obesity and COVID-19 may suggest therapeutic interventions (eg, proven weight loss drugs, low-calorie diets) to potentially reduce the risk of developing severe COVID-19 illness. With respect to public health, it is important to communicate risks without causing anxiety. People worldwide should be encouraged to improve their lifestyle to lessen risk both in the current and subsequent waves of COVID-19. In addition to increasing activity levels, there should be improved messaging on better diet, focusing on simpler advice to help people adopt sustainable changes. This is particularly challenging with current stay-at-home rules limiting activity levels—the lockdown cost of weight gain. Even more worrying is that the resultant economic downturn may worsen obesity, especially in the most vulnerable individuals, a risk that governments need to address after the current pandemic. Indeed, this pandemic has highlighted that more—not less—must be done to tackle and prevent obesity in societies for the prevention of chronic disease and greater adverse reactions to viral pandemics.AcknowledgmentsThe authors thank Liz Coyle from the University of Glasgow for her excellent technical assistance in the preparation of this article.Sources of FundingThe work in this study is supported by the British Heart Foundation Center of Research Excellence Grant RE/18/6/34217.DisclosuresDr Sattar reports personal fees from Amgen, AstraZeneca, Eli Lilly, Novo Nordisk, Pfizer, and Sanofi and personal fees and research grants from Boehringer Ingelheim outside the submitted work. Drs McInnes and McMurray report no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circNaveed Sattar, MD, Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, United Kingdom. Email naveed.sattar@glasgow.ac.ukReferences1. Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell LF, Chernyak Y, Tobin K, Cerfolio RJ, Francois F, Horwitz LI. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study.BMJ2020; 369:m1966. doi: 10.1136/bmj.m1966CrossrefMedlineGoogle Scholar2. Simonnet A, Chetboun M, Poissy J, Raverdy V, Noulette J, Duhamel A, Labreuche J, Mathieu D, Pattou F, Jourdain M, Lille Intensive Care COVID-19 and Obesity Study Group. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation [published online April 9, 2020].Obesity (Silver Spring). doi: 10.1002/oby.22831. https://onlinelibrary.wiley.com/doi/10.1002/oby.22831Google Scholar3. Lighter J, Phillips M, Hochman S, Sterling S, Johnson D, Francois F, Stachel A. Obesity in patients younger than 60 years is a risk factor for COVID-19 hospital admission [published online April 9, 2020].Clin Infect Dis. 2020. doi:10.1093/cid/ciaa415. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa415/5818333CrossrefGoogle Scholar4. Budu-Aggrey A, Brumpton B, Tyrrell J, Watkins S, Modalsli EH, Celis-Morales C, Ferguson LD, Vie GÅ, Palmer T, Fritsche LG, et al. Evidence of a causal relationship between body mass index and psoriasis: a mendelian randomization study.PLoS Med. 2019; 16:e1002739. doi: 10.1371/journal.pmed.1002739CrossrefMedlineGoogle Scholar5. Green WD, Beck MA. Obesity impairs the adaptive immune response to influenza virus.Ann Am Thorac Soc. 2017; 14(suppl 5):S406–S409. doi: 10.1513/AnnalsATS.201706-447AWCrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited ByMartin S, Aday A, Almarzooq Z, Anderson C, Arora P, Avery C, Baker-Smith C, Barone Gibbs B, Beaton A, Boehme A, Commodore-Mensah Y, Currie M, Elkind M, Evenson K, Generoso G, Heard D, Hiremath S, Johansen M, Kalani R, Kazi D, Ko D, Liu J, Magnani J, Michos E, Mussolino M, Navaneethan S, Parikh N, Perman S, Poudel R, Rezk-Hanna M, Roth G, Shah N, St-Onge M, Thacker E, Tsao C, Urbut S, Van Spall H, Voeks J, Wang N, Wong N, Wong S, Yaffe K and Palaniappan L (2024) 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association, Circulation, 149:8, (e347-e913), Online publication date: 20-Feb-2024. da Costa Ribeiro Quintans I, Pandolfi V, Gaudencio do Rêgo T, Neto J, A.R. Ramos T and Adhikary D (2024) Genome Designing for Nutritional Quality in Amaranthus Compendium of Crop Genome Designing for Nutraceuticals, 10.1007/978-981-19-3627-2_56-2, (1-33), . Aktiz Bıçak E and Oğlak S (2023) Clinical characterisation and management outcome of obstetric patients following intensive care unit admission for COVID-19 pneumonia, Journal of Obstetrics and Gynaecology, 10.1080/01443615.2023.2218915, 43:2, Online publication date: 8-Dec-2023. Nganabashaka J, Niyibizi J, Umwali G, Rulisa S, M. Bavuma C, Byiringiro J, Ntawuyirushintege S, Niyomugabo P, Izerimana L, Tumusiime D and Keetile M (2023) The effects of COVID-19 mitigation measures on physical activity (PA) participation among adults in Rwanda: An online cross-sectional survey, PLOS ONE, 10.1371/journal.pone.0293231, 18:11, (e0293231) Moll-Bernardes R, Ferreira J, Sousa A, Tortelly M, Pimentel A, Figueiredo A, Schaustz E, Secco J, Sales A, Terzi F, Xavier de Brito A, Sarmento R, Noya-Rabelo M, Fortier S, Matos e Silva F, Vera N, Conde L, Cabral-Castro M, Albuquerque D, Rosado de-Castro P, Camargo G, Pinheiro M, Souza O, Bozza F, Luiz R and Medei E (2023) Impact of the immune profiles of hypertensive patients with and without obesity on COVID-19 severity, International Journal of Obesity, 10.1038/s41366-023-01407-0 Onyango T, Zhou F, Bredholt G, Brokstad K, Lartey S, Mohn K, Özgümüs T, Kittang B, Linchausen D, Shafiani S, Elyanow R, Blomberg B, Langeland N and Cox R (2023) SARS-CoV-2 specific immune responses in overweight and obese COVID-19 patients, Frontiers in Immunology, 10.3389/fimmu.2023.1287388, 14 Chenchula S, Sharma S, Tripathi M, Chavan M, Misra A and Rangari G (2023) Prevalence of overweight and obesity and their effect on COVID‐19 severity and hospitalization among younger than 50 years versus older than 50 years population: A systematic review and meta‐analysis, Obesity Reviews, 10.1111/obr.13616, 24:11, Online publication date: 1-Nov-2023. Boutari C, Kokkorakis M, Stefanakis K, Valenzuela-Vallejo L, Axarloglou E, Volčanšek Š, Chakhtoura M and Mantzoros C (2023) Recent research advances in metabolism, clinical and experimental, Metabolism, 10.1016/j.metabol.2023.155722, (155722), Online publication date: 1-Nov-2023. Woodward-Lopez G, Esaryk E, Rauzon S, Hewawitharana S, Thompson H, Cordon I and Whetstone L (2023) Associations between Changes in Food Acquisition Behaviors, Dietary Intake, and Bodyweight during the COVID-19 Pandemic among Low-Income Parents in California, Nutrients, 10.3390/nu15214618, 15:21, (4618) Zhang Y, Li J, Feng L, Luo Y, Pang W, Qiu K, Mao M, Song Y, Cheng D, Rao Y, Wang X, Hu Y, Ying Z, Pu X, Lin S, Huang S, Liu G, Zhang W, Xu W, Zhao Y and Ren J (2023) A Population-Based Outcome-Wide Association Study of the Comorbidities and Sequelae Following COVID-19 Infection, Journal of Epidemiology and Global Health, 10.1007/s44197-023-00161-w Jeong S, Yun S, Park S and Mun S (2023) Understanding cross-data dynamics of individual and social/environmental factors through a public health lens: explainable machine learning approaches, Frontiers in Public Health, 10.3389/fpubh.2023.1257861, 11 Cosentino F, Verma S, Ambery P, Treppendahl M, van Eickels M, Anker S, Cecchini M, Fioretto P, Groop P, Hess D, Khunti K, Lam C, Richard-Lordereau I, Lund L, McGreavy P, Newsome P, Sattar N, Solomon S, Weidinger F, Zannad F and Zeiher A (2023) Cardiometabolic risk management: insights from a European Society of Cardiology Cardiovascular Round Table, European Heart Journal, 10.1093/eurheartj/ehad445, 44:39, (4141-4156), Online publication date: 14-Oct-2023. ATUK KAHRAMAN T and YILMAZ M (2023) Comparison of The Nutritional Habits of Individuals With and Without a COVID-19 Diagnosis: An Online Cross-Sectional Study From TürkiyeCOVID-19 Tanısı Alan ve Almayan Bireylerin Beslenme Alışkanlıklarının Karşılaştırılması: Türkiye'den Çevrimiçi Kesitsel Bir Çalışma, İzmir Katip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi, 10.61399/ikcusbfd.1244702, 8:3, (1009-1017) Sprockel Díaz J, Coral Zuñiga V, Angarita Gonzalez E, Tabares Rodríguez S, Carrillo Ayerbe M, Acuña Cortes I, Montoya Rumpf R, Martínez Arias L, Parra J and Diaztagle Fernández J (2023) Obesity and the obesity paradox in patients with severe COVID-19, Medicina Intensiva (English Edition), 10.1016/j.medine.2023.03.009, 47:10, Online publication date: Sprockel Díaz J, Coral Zuñiga V, Angarita Gonzalez E, Tabares Rodríguez S, Carrillo Ayerbe M, Acuña Cortes I, Montoya Rumpf R, Martínez Arias L, Parra J and Diaztagle Fernández J (2023) Obesity and the obesity paradox in patients with severe COVID-19, Medicina 47:10, Online publication date: T, C and S (2023) The COVID-19, Cardiovascular and a Online publication date: B, K, C, Lin W, Y, T, Lin M and (2023) in the of COVID-19, International Journal of Sciences, van J, J, S, L, van M, M, S, R, van A, A, M, Y, A and (2023) of with SARS-CoV-2 after of H, M, H, M, A, M, M, M, S, W, A, M, I, M, M and (2023) as a Factor in A Infection and E, R, S and related to an Journal of Online publication date: de M, C, D, Silva C, J, T, F, M, I, D, J, T, E, da L, R, F and (2023) The T regulatory with infection and outcome in COVID-19 patients mechanical Scientific A, P, E, G and K (2023) the Risk for Clinical in with A A, M, T, J, S, J, S, Li G, J, N, J, R, G and S (2023) of COVID-19 on Care Online publication date: L, Z, T, A, M, D, M, D and A (2023) as a of COVID-19 of the prospective study, Online publication date: T, K, S, K, H, K, N and J (2023) Impact of body on after infection, PLOS ONE, K, A, T, T, K, M, T, A, and J (2023) Association between obesity and in COVID-19 patients requiring invasive mechanical a study, Scientific M, S, S, A, M, R, and S (2023) Association of body mass index with COVID-19 outcome in a hospital in de Online publication date: P, A, R, R and A Impact of pandemic on development and in and International Journal of Online publication date: C, Y, R, M, R and S status of in a COVID-19 and R (2023) Obesity and of Online publication date: W, E, L, D, M, K, J, J, Figueiredo J, J, A, S, A and M (2023) and Risk of Disease The American Journal of Online publication date: A, V, I, Y, A and A (2023) and immune response coronavirus infection on the of obesity and Obesity and metabolism, A, F, N, A, S, R, M and N (2023) C and inflammatory factors related to COVID-19 consequences, K, O, J, A and (2023) SARS-CoV-2 Infection to and in N, G, H, C, E, G, J, and T (2023) inflammatory syndrome in cohort study of risk factors, S, S and T (2023) The associated with lifestyle risk factors and nutritional status for COVID-19 patients in the Journal of Public in V, N, N, I, M, I, V, T, M, M, A, D and M (2023) and as of in COVID-19 Ko Y, Z, R and S (2023) Association among and Risk Factors with SARS-CoV-2 Infection, and Online publication date: B, T, S and L of a complex to reduce metabolic syndrome in with Online publication date: Y, N, Yang J, C, Zhang A, B, E and C A in the of Online publication date: I, O, I, M, A, R and (2023) is the of adipose tissue in metabolic and future in the Online publication date: G, F, A, R, M, F, Johansen M, F, G, G, N, P, T, I, A, P, G, C and S (2023) and of COVID-19 associated therapeutic Journal of Li C, J, Huang J and (2023) the coronavirus disease New and New Online publication date: A, S, B, Z, A and C (2023) COVID-19 Medical Tsao C, Aday A, Almarzooq Z, Anderson C, Arora P, Avery C, Baker-Smith C, Beaton A, Boehme A, A, Commodore-Mensah Y, Elkind M, Evenson K, C, S, Generoso G, Heard D, Hiremath S, J, Kalani R, Kazi D, Ko D, D, Liu J, J, Magnani J, Michos E, Mussolino M, Navaneethan S, Parikh N, Poudel R, Rezk-Hanna M, Roth G, Shah N, St-Onge M, Thacker E, S, Voeks J, Wang N, Wong N, Wong S, Yaffe K and S (2023) Heart Disease and Stroke A Report From the American Heart Association, Circulation, Online publication date: R, S, A and D of obesity among from and lifestyle perspective, British Food Journal, Online publication date: M, X, H, and J (2023) The of obesity and thrombotic and Frontiers in Cardiovascular A, A, A, S, I, E, N, N, A, H, A, A, R, R, A, M, A, M, M, E, S, S and S (2023) The Impact of and Obesity on the of and Obesity, G, J, A, V, P, K, C, A, F, D, F, M and I (2023) SARS-CoV-2 infection adipose tissue in D, H, M, and M in older the of of the Online publication date: D, B, E, X, M, J, and J (2023) of COVID-19 infection in people with diabetes mellitus or obesity in the care in A cohort study of the Care Online publication date: S, M, M, M, Z, A, A and K (2023) The of and A A, F, A, M, G, X, E, S and G (2023) of D for and H, T, Y, T, M, M, S, K and M (2023) Clinical and the risk of hospitalization of patients with coronavirus disease 2019 in a

Nurses face complex ethical challenges across diverse healthcare settings, making ethical caring competency essential to professional practice. Given that Iranian nurses encounter ethically sensitive situations shaped by sociocultural and religious values and that no validated tool exists to assess this construct the aim of this study was to culturally adapt and psychometrically validate the Ethical&#xa0;Caring&#xa0;Competency&#xa0;Scale&#xa0;(ECCS) for use among Iranian nurses. This methodological, cross&#x2011;sectional study included 697 registered nurses who were recruited through convenience sampling from seven teaching hospitals affiliated with Mazandaran University of Medical Sciences, Iran. Data were collected in person by the researcher through visits to hospital wards, during which nurses completed the instruments at the end of their work shifts. The Ethical Caring Competency Scale (ECCS; 22 items across four dimensions) was culturally adapted for the Iranian context following World Health Organization (WHO) translation protocols, including forward-back translation, expert panel review, and pilot testing with 20 nurses. Construct validity was evaluated using Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), Exploratory Graph Analysis (EGA), and the Random Forest Model (RFM). In addition, internal consistency reliability and measurement invariance across gender were examined. All&#xa0;697&#xa0;nurses&#xa0;fully&#xa0;completed&#xa0;the&#xa0;data&#xa0;collection&#xa0;instruments.&#xa0;Participants&#xa0;had&#xa0;a&#xa0;mean&#xa0;age&#xa0;of&#xa0;35.17&#xa0;&#xb1;&#xa0;8.41&#xa0;years&#xa0;and&#xa0;10.55&#xa0;&#xb1;&#xa0;7.24&#xa0;years&#xa0;of&#xa0;work&#xa0;experience;&#xa0;most&#xa0;were&#xa0;female&#xa0;(80.6%)&#xa0;and&#xa0;held&#xa0;a&#xa0;bachelor's&#xa0;degree&#xa0;(89.4%). EFA identified a four&#x2011;factor structure that explained 52.80% of the total variance. CFA results confirmed an adequate model fit, with all fit indices (PCFI = 0.737, PNFI = 0.713, CMIN/DF = 2.76, RMSEA = 0.071, IFI = 0.934, CFI = 0.933, and GFI = 0.918) meeting acceptable criteria. EGA results also reproduced the four-factor structure in 99.4% of bootstrap samples. Convergent validity (AVE > 0.5) and divergent validity (&#x221a;AVE > inter-construct correlations) were confirmed. All reliability coefficients were above 0.7. The RFM demonstrated that the component 'Acting while thinking about how to provide better care' was the most significant factor (contributing 37.56%) in predicting the total ethical caring competency score. The measurement invariance test indicated that the factor structure was stable across genders. The Persian version of the ECCS demonstrated acceptable psychometric properties, a stable conceptual structure, cultural sensitivity, and good discriminant validity for the components of ethical caring competency. Therefore, it can be considered a valid and reliable instrument for assessing the ethical caring competency of nurses in Iran.

Individuals with abnormal serum lipid levels are at an augmented risk of atherosclerotic cardiovascular diseases (CVDs). The purpose of this study was to evaluate the significance of serum lipid concentrations as determinants for the risk of CVD and all-cause mortality (ACM). This prospective cohort study involved individuals who were part of the Mashhad stroke and heart atherosclerotic disorder (MASHAD) study initiated in 2007. A total of 9704 individuals aged 35- 65 years were involved in the current study. The participants were monitored for about a decade to track mortality and its underlying causes. Multivariable Cox proportional hazards models were applied to estimate hazard ratios (HRs) for serum levels of LDL-C, HDL-C, non-HDL-C, and triglycerides (TG), analyzed both as continuous variables and categorized into tertiles. Three models were developed: Model 1 (unadjusted), Model 2 (adjusted for age and sex), and Model 3 (further adjusted for BMI, smoking status, diabetes, hypertension, CVD, job, marital status, education level, and lipid-lowering drugs use). Kaplan-Meier survival analysis compared outcomes across lipid tertiles. Subgroup analyses were also performed to evaluate and control for confounding variables related to serum lipid levels and mortality. Over a follow-up period of 10 years, there were 429 (4.4%) deaths, including 185 cases due to CVD and 124 cases due to cancer. LDL-C, HDL-C, non-HDL cholesterol, and TG were categorized into three groups based on tertiles. Based on Cox model analysis, after full adjustment, individuals in the second (37.9-45.8 mg/dL) and third (45.8-96.2 mg/dL) tertiles of HDL-C had a significantly lower risk of ACM compared with the lowest tertile (&#x2264;37.9 mg/dL) (HR=0.72, 95% CI: 0.57-0.92; and HR=0.81, 95% CI: 0.64-1.03, respectively). Similarly, the risk of cardiovascular mortality was reduced in the second tertile (HR=0.66, 95% CI: 0.46-0.94). No significant associations were found between LDL-C and mortality after adjustment. Kaplan-Meier analyses confirmed significant survival differences across HDL-C (P value=0.005), TG (P value=0.001), and non-HDL-C (P value<0.001) tertiles for ACM event. Significant differences were also observed in the Kaplan-Meier curves for cardiovascular death between HDL-C (P value=0.003) and TG groups (P value=0.015). The survival curves of HDL-C groups were significantly variable in terms of cancer mortality (P value=0.048). In exploratory subgroup analyses, the inverse correlation between elevated HDL-C levels and mortality was predominantly more pronounced in older people and those with hypertension or diabetes, whereas it was less significant in younger and healthier individuals. Abnormal levels of serum lipids, specifically low HDL-C concentration, are associated with an elevated risk of both non-CVD and CVD mortality. These relationships were widely seen across clinical categories, exhibiting substantially greater patterns in older participants and in persons with hypertension or diabetes. These findings indicate that HDL-C may assist in identifying individuals at increased mortality risk within this population.

Drug-drug interactions (DDIs) are among the most important medical errors that can lead to adverse effects, increased toxicity, or reduced treatment efficacy. The frequency and severity of DDIs vary across specialties. However, studies covering multiple specialties in Iran are few and not up-to-date. This study aims to fill this gap by offering a large-scale, multi-specialty analysis of DDIs in Iran using real-world e-prescription data. This study analyzed pharmacological DDIs in 1,049,769 e-prescription records from Shiraz, Iran, spanning from November 2021 to February 2024. We used Lexicomp&#xae; DDI checker software and Python programming language to identify the most prevalent DDIs overall, the top contributing drug specialties for each of those DDIs, the specialties with the highest rates of potential DDIs, and the most prevalent DDI within each specialty. The analysis revealed that 38.77% of prescriptions contained at least one C, D, or X DDI. Dexamethasone, ketorolac, quetiapine, and aspirin were the drugs most commonly involved. The most frequent DDIs occurred between aprepitant and dexamethasone, ketorolac, and naproxen, aprepitant and doxorubicin, prednisolone, and tacrolimus, and diclofenac sodium and ketorolac. The medical specialties with the highest incidence of D or X level DDIs were rheumatology, endocrinology, orthopedics, oncology, internal medicine, emergency services, and psychiatry. The average counts of D or X DDIs per prescription were 0.53, 0.41, 0.40, 0.40, 0.26, 0.24, and 0.23, respectively. This study underscores the need for provider vigilance and proactive measures, such as training and e-prescription alerts, to ensure patient safety.