The investigation of Cut-and-cover, top-down construction method for a metro underground station; case study: 'Naghsh-e-Jahan Metro Station, Esfahan, Iran'

Naghsh-e-Jahan subway station is located in Esfahan historical context with 186 meters' distance to the Sheikh Fazlolah mosque – one of the historical cosmopolitan attractions. The subway station is in a shallow depth, soft surrounding soils and with wide span and in a downtown location, have made the situation so critical that precise assessments, not only for the station support but also for compensating the ground settlement, are needed. One of the prerequisite procedures for large underground structures, the cut-and-cover approach, is constructed top-down using the Diaphragm Wall system. This method can be functional in conditions where minimum vertical displacements are essential since roof covering and improvement can be performed even when the excavation operation is not terminated. The embankment process can be done just right after the roof slab is complete and reaches reliable strength. This study uses the Finite Element method to simulate all the construction stages and analyze the ground behavior. It has been observed that the width and the length of diaphragm walls and middle barrettes on the ground settlements. Ground settlement for various stages of excavation at the cross-section and longitudinal section of the station is shown that settlements are spandrel and maximum settlements occur close to the diaphragm walls. As excavation continues, ground surface settlements become concave, and the maximum surface settlements occur at a bit of distance from the diaphragm walls for about 17mm. Furthermore, the diaphragm wall's thickness of 100 cm of diaphragm wall is recommended for optimum values

The investigation of Cut-and-cover, top-down construction method for a metro underground station; case study: 'Naghsh-e-Jahan Metro Station, Esfahan, Iran'

Naghsh-e-Jahan subway station is located in Esfahan historical context with 186 meters' distance to the Sheikh Fazlolah mosque – one of the historical cosmopolitan attractions. The subway station is in a shallow depth, soft surrounding soils and with wide span and in a downtown location, have made the situation so critical that precise assessments, not only for the station support but also for compensating the ground settlement, are needed. One of the prerequisite procedures for large underground structures, the cut-and-cover approach, is constructed top-down using the Diaphragm Wall system. This method can be functional in conditions where minimum vertical displacements are essential since roof covering and improvement can be performed even when the excavation operation is not terminated. The embankment process can be done just right after the roof slab is complete and reaches reliable strength. This study uses the Finite Element method to simulate all the construction stages and analyze the ground behavior. It has been observed that the width and the length of diaphragm walls and middle barrettes on the ground settlements. Ground settlement for various stages of excavation at the cross-section and longitudinal section of the station is shown that settlements are spandrel and maximum settlements occur close to the diaphragm walls. As excavation continues, ground surface settlements become concave, and the maximum surface settlements occur at a bit of distance from the diaphragm walls for about 17mm. Furthermore, the diaphragm wall's thickness of 100 cm of diaphragm wall is recommended for optimum values

بررسی کارایی بیومس قارچ آسپرژیلوس ترئوس در حذف کروم (VI) از محلولهای آبی: مطالعات ایزوترم و سینتیک جذب

Background and Aims: Chromium (VI) is one of the very toxic heavy metals and is known as a carcinogenic, mutagenic and teratogenic agent. In this study, the ability of dead Aspergillus Terreus fungus biomass in the removal of chromium (VI) from aqueous solutions was investigated.Materials and Methods: The suspension of AspergillusTerreus was cultivated in Potato Dextrose Agar and Potato Dextrose Broth mediums. The biomass was then boiled in 0.5 N NaOH solution. The ability of obtained biomass to absorb Chromium (VI) was studied with respect to various variables including time (15 to 120 min), pH (3 to 11), chromium (VI) concentration (20 to 120 mg/L) and absorbent dosage (0.1 to 0.8 g). Chromium concentration was determined using an atomic absorption of. All ethical issues and citations were taken into consideration in conducting the study.Results: Results showed that the maximum removal of chromium (89%) was obtained at contact time 90 min, pH=7, chromium concentration 20 mg/L and adsorbent dosage 0.6 g. The adsorption isotherm was best fitted by Freundlich with a high correlation coefficient (R2=0.952). Furthermore, the adsorption kinetics fitted well to the pseudo-first-order model with a correlation coefficient of 0.9775.Conclusion: The results of present study indicated that the studied variables have an incredible effect on sorption efficiency, as in the optimum condition, the biomass of AspergillusTerreus obtained an acceptable efficiency and adoration capacity compared to other adsorbents. So, this compound can be introduced as a practical natural adsorbent for chromium removal and also other heavy metals form aqueous solutions.زمینه و اهداف: یکی از فلزات بسیار سمی در فاضلابهای صنعتی کروم شش ظرفیتی (VI) میباشد که بعنوان یک عامل کارسینوژن، موتاژن و تراتوژن شناخته میشود. در این مطالعه توانایی بیومس مرده تولید شده از قارچ آسپرژیلوس ترئوس در حذف کروم (VI) از محیطهای آبی مورد بررسی قرار گرفت  مواد و روشها: سوسپانسیون قارچ آسپرژیلوس ترئوس در محیط های کشت پوتیتو دکستروز آگار و پوتیتو دکستروز براث کشت داده و سپس در محلول 0.5نرمال NaOH جوشانده شد. توانایی جذب بیومس حاصل برای متغیرهای زمان 15) تا 120 دقیقه(، 3) pH تا (11، غلظت کروم 20)(VI) تا  (120 mg/L و دوز جاذب 0.1) تا 0.8g) مورد بررسی قرار گرفت. از دستگاه جذب اتمی مدل Varian جهت سنجش کروم(VI) استفاده شد. موازین اخلاقی در انجام این پژوهش و استفاده از منابع رعایت گردید یافته ها : نتایج نشان داد که فرآیند جذب در زمان تماس 90 دقیقه، pH برابر با 7 ، غلظت آلاینده20 mg/L و دوز جاذب 0/6 g، دارای راندمان حذف برابر با 89 درصد میباشد. همچنین فرآیند جذب از ایزوترم فرندلیخ با R2=0.952 و سینتیک شبه درجه اول با R2=0.9775 پیروی می نماید. نتیجه گیری: نتایج نشان داد که متغیرهای مورد مطالعه اثر قابل توجهای در راندمان جذب دارند، بطوریکه در شرایط بهینه، بیومس قارچ آسپرژیلوس ترئوس دارای راندمان و ظرفیت جذب قابل قبولی در حذف کروم (VI) در مقایسه با سایر جاذبها است. در نتیجه میتوان این ترکیب را بعنوان یک جاذب طبیعی جهت حذف کروم (VI ) و سایر فلزات سنگین از محیطهای آبی معرفی کر

Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method

Background : MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized R AND Appropriateness Method (R AM) criteria in 2012. Methods : This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated. Results : Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions. Conclusion : In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement

The global burden of cancer attributable to risk factors, 2010-19 : a systematic analysis for the Global Burden of Disease Study 2019

Background Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings Globally, in 2019, the risk factors included in this analysis accounted for 4.45 million (95% uncertainty interval 4.01-4.94) deaths and 105 million (95.0-116) DALYs for both sexes combined, representing 44.4% (41.3-48.4) of all cancer deaths and 42.0% (39.1-45.6) of all DALYs. There were 2.88 million (2.60-3.18) risk-attributable cancer deaths in males (50.6% [47.8-54.1] of all male cancer deaths) and 1.58 million (1.36-1.84) risk-attributable cancer deaths in females (36.3% [32.5-41.3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20.4% (12.6-28.4) and DALYs by 16.8% (8.8-25.0), with the greatest percentage increase in metabolic risks (34.7% [27.9-42.8] and 33.3% [25.8-42.0]). Interpretation The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.Peer reviewe

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95$7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95$43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and$37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained

THE ROLE OF BIG DATA IN BUSINESS AND DECISION MAKING

Big data has been increasingly considered by experts and company owners due to its direct impact on the development of businesses and companies, so that big data management increases the efficiency of important business decisions. With the increasing use of the Internet and the advancement of information storage technology, there is a vast amount of information that can be used and properly examined. This amount of information is called big data and can be used to make important decisions for the development of a company. All the while, many start-ups and even large corporations are unsure how to use big data. In addition to looking at big data and its role in decision making, this article examines how to properly extract information to support decision making

Global prevalence of drug-resistant tuberculosis: a systematic review and meta-analysis

Abstract Background Tuberculosis is a bacterial infectious disease, which affects different parts of a human body, mainly lungs and can lead to the patient’s death. The aim of this study is to investigate the global prevalence of drug-resistant tuberculosis using a systematic review and meta-analysis. Methods In this study, the PubMed, Scopus, Web of Science, Embase, ScienceDirect and Google Scholar repositories were systematically searched to find studies reporting the global prevalence of drug-resistant tuberculosis. The search did not entail a lower time limit, and articles published up until August 2022 were considered. Random effects model was used to perform the analysis. The heterogeneity of the studies was examined with the I 2 test. Data analysis was conducted within the Comprehensive Meta-Analysis software. Results In the review of 148 studies with a sample size of 318,430 people, the I 2 index showed high heterogeneity (I 2  = 99.6), and accordingly random effects method was used to analyze the results. Publication bias was also examined using the Begg and Mazumdar correlation test which indicated the existence of publication bias in the studies (P = 0.008). According to our meta-analysis, the global pooled prevalence of multi-drug resistant TB is 11.6% (95% CI: 9.1–14.5%). Conclusions The global prevalence of drug-resistant tuberculosis was found to be very high, thus health authorities should consider ways to control and manage the disease to prevent a wider spread of tuberculosis and potentially subsequent deaths

Feasibility of biofilm production capacity by Levilactobacillus brevis isolated from motal cheese and evaluation of biofilm resistance produced in vitro and in yogurt

Traditional dairy products are a unique source which have been considered for the extraction of indigenous probiotic strains in recent years. In this study, biofilm formation power of Levilactobacillus brevis that isolated from Mutal traditional cheese were investigated. Survival was assessed during 21 days of storage time and at the presence of residues antibiotics as well as gastrointestinal conditions. The results showed after 120 min of treatment in high acidic conditions (pH 2.0), the survival rate decreased only 0.75 log CFU/mL in biofilm formed. The antibiotic susceptibility evaluated of probiotic to enrofloxacin, sulfadimidine, tetracycline, and oxytetracycline showed reducing the bacterial population in the biofilm form only 2.6 log. probiotic strain that isolated from indigenous dairy sources showed excellent resistance in the biofilm state. Therefore, extracting strong probiotic strains from indigenous resources, it can significantly improve functional products and fermentory engineering

Health Policy and Management Original Article Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method

Background: MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAND Appropriateness Method (RAM) criteria in 2012. Methods: This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated. Results: Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions. Conclusion: In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement. A B S T R A C T A R T I C L E I N F O Keywords: MRI Prescription Background The ever changing population's needs and increasing costs of treatment are two major challenges facing health systems worldwide (1). A number of studies have shown that large volumes of provided health care may be inappropriate or unnecessary. Some studies show that the quality of and access to health care services are not necessarily related to spending more on health care systems (2,3). RAND (Research AND Development) Appropriateness Method (hereafter RAM) is a transparent approach to assess the appropriateness of health care services. This method was designed in the 1980s by RAND Corporation and University of California, Los Angeles and has been used in a number of studies on appropriateness of health care services (4-6). Radiologic diagnostic methods help physicians in early diagnosis of disorders, and prevent the provision of subsequent aggressive treatments. However, studies show that during the past two decades, the radiologic diagnostic procedures have been progressively more common all over the world. According to statistics of the review conducted by the Board of Radiologic Imaging in the United States, 30% to 40% of diagnostic imaging performed in this country have been unnecessary or have failed to detect the disease (7). As a result, inappropriate order of medical imaging procedures doi: 10.15171/ijhpm.2013.04 Salari et al/International Journal of Health Policy and Management, 2013, 1(1), 17-21 18 by physicians may result in serious problems in terms of economy and quality of health care (8). Low back pain is a prevalent musculoskeletal disorder and has a huge burden to the health care systems of several countries including Iran. Around 80% of people deal with this problem during their lives. In the United States, low back pain is the second most common prevalent disorder after headaches (9-11). Analysing and understanding the pattern of medical imaging technology usage is of great significance for planning health systems, especially in low-and middleincome countries (12). However, based on our literature review, no published paper has ever addressed this issue in Iran. The current study aims to fill this gap by investigating the appropriateness and necessity of lumbar spine MRI prescriptions in hospitals affiliated with Shiraz University of Medical Sciences (SUMS) in 2012. Methods This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. The two phases of study are described in details below. Phase one: developing appropriateness criteria In this study, RAM was used to develop the appropriate scenarios for lumbar spine MRI prescriptions. This phase consisted of two rounds; in the first round, the panel members scored the scenarios independently and there was no interaction among them, while the second round involved interaction among the panel members. According to RAM, the available clinical guidelines on lumbar spine MRI were searched, from which the indications and scenarios were extracted. After that, in order to come to an appropriate consensus on scenarios, two rounds of expert panel were held. Each panel composed of nine specialists: two neurosurgeons, two orthopedists, two radiologists, one neurologist, one rheumatologist, and one physiatrist, all of whom were faculty members working in teaching hospitals. First round was without interaction among panel members. We asked panel members to score the scenarios. Based on the scores of panel members, scenarios were placed into three categories: appropriate, uncertain, and inappropriate. The criteria for this categorization are explained below. For each indication, the panel members rated the benefitto-harm ratio of the procedure on a scale of 1 to 9, where 1 meant that the expected harms greatly outweighed the expected benefits, and 9 meant that the expected benefits greatly outweighed the expected harms. Each indication was considered appropriate if the panel's median rating was 7-9 without disagreement, inappropriate if the value was 1-3 without disagreement, or uncertain if the median rating was 4-6 or if the members of the panel disagreed (4). The panel members further added some indications and scenarios on the list based on their experiences and published papers. In the second round, the members were invited to a meeting. In the meeting, they scientifically discussed the appropriateness of the scenarios and reached a consensus. The process of development of appropriate scenarios and its results are described elsewhere (13). Phase two: identifying the appropriateness of prescription This part of work was a descriptive analytical and crosssectional study performed in hospitals affiliated with SUMS in 2012. It aimed to identify the appropriateness of lumbar spine MRI prescription. Sample size was calculated to be 300 samples and the convenient sampling was used. In the data gathering phase, the first author, accompanied by a trained physician, attended in MRI centers of two hospitals affiliated with SUMS to have the questionnaires filled. They asked the patients some questions and performed physical examinations on the patients. Before selecting the samples, the research aims were explained to patients and if they were willing to participate, they would be recruited. This work continued until a sample size of 300 was reached. A short questionnaire, including 13 questions, designed by the authors, was used as the data gathering instrument. Out of 13 questions, six questions were about the patient demographic information (Additional file 1) and seven were on MRI prescription (Additional file 2). The last question concerned the appropriateness of MRI prescription and was regarded as the key question in the questionnaire. Its response was required for comparing the exact physical examination of patients with the developed scenarios. This sensitive task was performed by a knowledgeable trained physician. The patients' informed written consents were earned prior to the physical examination. SPSS 15 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Frequency tables and chi-square test were selected for statistical analyses. Results Demographic information Of 300 recruited subjects, approximately 51% were male and 49% were female. Most of them were in 20-35 yrs age groups and 35% had primary education. In terms of job status, 53% were housekeeper. In terms of monthly income level, 56% had 2500000-5000000 Rials income per month and 97% had medical insurance (see Prescription information The research results on prescriptions demonstrated that 93% of the patients were outpatient and only 7% were inpatient. In addition, 35% of the patients had only back pain as their symptoms, 17% reported only radicular leg pain, and 44% of the patients had simultaneous back and leg pain as their symptoms. About 18% of patients declared that their prescriptions were administrated without any physical examination, while physical examination had been performed for 82% of the patients. Around 9% of the patients had asked the doctors for MRI prescription. Almost 40% of patients had been referred from public hospitals, 11% from private hospitals, and 49% from private offices. About 31% of patients were referred to the hospital to conduct lumbar spine MRI by neurosurgeon, 15% by physiatrist, 10% by neurologist, 31% by orthopedists, 9% by rheumatologist, and 4% by other specialists. Appropriateness of physicians' orders The research results further revealed that about 56% of prescriptions were inappropriate, 24% were uncertain, and only 20% could be considered appropriate. Financial burden The costs of 167 cases of inappropriate MRIs were considered as a financial burden imposed on both the insurance companies and the patients Related factors The Chi-square test shows a significant relationship between the type of expertise and appropriateness of prescriptions (P>0.001). According to finalized indications, among the physiatrists and neurosurgeons prescriptions, 64% and 60% were inappropriate respectively. Also, 48% of rheumatologists prescriptions were appropriate and 26% of orthopedics prescriptions were uncertain Discussion The results of this study indicate that 56% of lumbar spine MRI prescriptions were inappropriate, about 24% were uncertain and around 20% were appropriate. MRI is a very expensive diagnostic procedure and imposes huge financial and emotional burden on both the society and patients. These unnecessary healthcare procedures could impose high intangible costs on the patients such as wasting time, energy, and money. Therefore, physicians should prescribe them only when necessary. Although in the finalized scenario (the first phase of study), performing an appropriate MRI is recommended after a careful physical examination and six weeks of maintenance therapy, the results of the second phase of the study disclosed that MRI was chosen as the first diagnostic procedure for low back pain. It seems that the inappropriate rate of MRI prescriptions in Iran is higher than that of the US and Canada. According to the study of Lehnert and Bree (14), the inappropriate rate of lumbar spine MRI prescription was 26% in the US; similarly Emery et al. revealed that the inappropriate rate of MRI prescription was 28.50% in Canada The inappropriate prescriptions were 56% (regardless of the uncertain cases). Probably we can generalize our results to the whole country; if 56% of the MRI prescriptions in Iran are considered inappropriate at least half of the reimbursement costs will be wasted. It is claimed that the number of MRI machines installed in Tehran province was enough for the whole population of the country (17). Therefore we can imply that many of imported MRI machines to the country are unnecessary. The authors hypothesize the high availability of MRI machines within the country could be a possible reason for the overuse of MRI procedures. The problem is exacerbated knowing the fact that the price of a MRI machine is about one to three million dollars. In addition, among all imaging diagnostic devices, MRI had a more inappropriate distribution in the country (18). Given that the country is highly dependent on import of this technology (i.e. MRI machines) coupled with the high international sanctions posed on the country, policy makers should adopt proper HTA polices. Palesh and colleagues conducted a qualitative research in order to investigate policy makers' view about diffusion and utilisation of MRI in Iran (17). They found that the process of policy making does not seem to be based on a full understanding of HTA and the country does not follow an official plan for MRI adoption and diffusion. According to this study factors that contribute to the health technology diffusion and utilisation are posed by market forces such as advertisements, and physician and consumer demand. Besides, dual practice can increase the induced demand and also reduce the supervision of the private sector by the Ministry of Health. This study reported another major deficit in HTA process in Iran; a lack of need assessment, where the import of health technologies is not based on need assessment and structured planning (17). The following is a brief discussion of factors related to appropriateness. Firstly, prescriptions without physical examinations were more inappropriate. When a physician makes MRI prescription without any physical examination, it is more probable to be inappropriate. Secondly, those prescriptions, which were performed by rheumatologists, Strengths and limitations The present study enjoys some advantages. First, this was the first published study assessing appropriateness of MRI prescriptions using RAND in Iran. Second, this study, similar to other studies conducted in Iran (1,19), recommends RAM for the healthcare system in Iran, because the evidence is needed for policy making. Third, in order to avoid influence of professional biases in the scoring process, the expert panel members were selected from seven different areas of specialties. Last but not least, in contrast to the majority of RAM studies whose judgment is based on medical records, in this study physical examination was performed for all cases according to standardized clinical indications and scenarios. This process was very time-consuming and costly, but it could obtain more precise results due to the fact that medical records do not always contain a complete set of required data. This study also has several limitations. First, in phase one, although a full-participation of expert panel members was required, this was not perfectly met due to the busy schedule of experts. As such, a great deal of time was devoted to coordinate the expert panel meetings. Second, in data gathering phase, the researchers had to wait a long time for patients with lumbar spine MRI orders in MRI centers. Conclusion This study set out to examine the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAM criteria. This study generated two main outcomes. Firstly, this was the first study which developed a local clinical practice guideline using RAND appropriateness method for lumbar spine MRI for the country. Secondly, it assessed appropriateness of lumbar spine MRI prescriptions. The research findings revealed that the large proportion of lumbar spine MRI prescriptions was unnecessary which result in a financial burden on the insurance companies and the patients alike. The findings provide policy makers with a number of practical recommendations to improve evidence-based policy making. The results also highlight the imperative role of HTA and clinical practice guidelines. Developing local clinical guidelines may create the commitment needed in physicians in performing appropriate prescriptions in the health sector. The Ministry of Health should develop and completely follow the HTA programs. We need a national coordination between HTA policies. Acknowledgments We would like to thank members of expert panel who were Bagher