Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 53 61 Onesimo CUAMEA Facultad de Turismo y Mercadotecnia, Universidad Autonoma de Baja California, Tijuana, Mexico Karen RAMOS Facultad de Contaduria y Administracion. Universidad Autonoma de Baja California, Tijuana, Mexico 2019 01 16 Background: The problem consists in the lack of knowledge of the factors that tourists choose the clinics of a foreign city for their aesthetics treatments, especially at a frontier where a developed and developing country coexist and interact. Methods: The information was obtained on 2016, by applying an exit pool survey to a selected sample of 385 visitors- patients from clinics in the Tijuana, Mexico. Sixteen items were included in the exploratory factor analysis. Results: Four key factors influenced the decision: Quality & Prestige of Clinic and Surgeon, Integration with Tourism Sector, Destination Image and Border Interaction. All the elements had a load factor greater than 0.56 which proved the actual fit in the factor analysis and none of the included variables is trivial. Conclusion: Allow maintaining or increasing the attractiveness of a border city for aesthetic tourism, the administrators of the clinics establish cooperation agreements with entrepreneurs of the tourism sector to benefit their patients.     https://ijph.tums.ac.ir/index.php/ijph/article/view/15938 https://ijph.tums.ac.ir/index.php/ijph/article/download/15938/6253

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 1 8 Rui ZHANG School of Public Health and Management, Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing, 400016, China AND Collaborative Innovation Center of Social Risk Governance in Health, Chongqing Medical University, Chongqing, 400016, China Ling CHEN The Center of Experimental Teaching Management, Chongqing Medical University, Chongqing, 401331, China Ya-Deng CUI School of Public Health and Management, Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing, 400016, China AND Collaborative Innovation Center of Social Risk Governance in Health, Chongqing Medical University, Chongqing, 400016, China Ge LI The Center of Experimental Teaching Management, Chongqing Medical University, Chongqing, 401331, China 2019 01 16 Background: The aim of our study was to identify the association between Human papillomavirus (HPV) positive rate and smoking in lung cancer (LC) patients. Meanwhile, to analyze differences among gender, age differences on HPV infection rate in LC patients. Methods: We performed a systematic literature search through PubMed, Wan Fang, China National Knowledge Infrastructure (CNKI), MEDLINE, EMBASE (OVID), and Web of Science databases from 1991-2017, and we searched these keywords such as “lung cancer”, “HPV”, “smoking”, and “human papillomavirus”. Review Manager 5.3 software was used to analyze. An estimate of the odds ratio (OR) with 95% confidence intervals (CI) was calculated. Results: In China, a statistical significance was observed between HPV positive rate and smoking in LC patients (OR=2.34, 95%CI: 1.76–3.09, P<0.001; I2 =25%). However, after stratified by region, no significance was observed in other regions, gender, and age. Conclusion: HPV infections are associated with smoking in LC patients. The association between HPV infection and smoking in LC patients may relate to different regions. There were no differences between gender and age among HPV infection rates in LC patients. To identify the etiology of smoking, HPV, and LC, a further experimental research needs to be conducted.   https://ijph.tums.ac.ir/index.php/ijph/article/view/15933 https://ijph.tums.ac.ir/index.php/ijph/article/download/15933/6248

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 171 172 Sungyung CHUN Department of Football Science, School of Health Science, Honam University, Gwangju, Republic of Korea Kyoungkyu JEON Division of Sport Science, College of Arts and Physical Education, Incheon National University, Incheon, Republic of Korea and Sport Science Institute, Incheon National University, Incheon, Republic of Korea 2019 01 16 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/15953 https://ijph.tums.ac.ir/index.php/ijph/article/download/15953/6268

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 62 68 Feng GUO Department of Rheumatism, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210029, China Jianmei CHEN Department of Rheumatism, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210029, China Yu XIE Department of Rheumatism, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210029, China Xueping ZHOU Nanjing University of Chinese Medicine, Nanjing 210023, P.R. China 2019 01 16 Background: This study aimed to explore the clinical characteristics of noninfectious fever in patients with systemic lupus erythematosus (SLE) and the underlying causes through multivariate analysis. Methods: Clinical data of 128 patients with SLE who were admitted to Affiliated Hospital of Nanjing University of TCM, Nanjing 210029, P.R. China from January 2015 to December 2017 were retrospectively analyzed. Results: The following factors were closely associated with fever: patient age, treatment history, SLEDAI score, enlarged liver, spleen and lymph nodes, low hemoglobin, leukopenia, CRP, complement C3, albumin, anti-dsDNA antibody, glucocorticoids, and cyclophosphamide. Multivariate logistic regression analysis showed that factors, such as enlarged liver, spleen and lymph nodes, digestive system involvement, low hemoglobin, leukopenia, CRP, decreased albumin, anti-dsDNA antibody, glucocorticoids and cyclophosphamide, were closely associated with noninfectious fever in SLE. Conclusion: Noninfectious fever is a common clinical manifestation of SLE. Factors, such as enlarged liver, spleen and lymph nodes, digestive system involvement, low hemoglobin, leukopenia, CRP, decreased albumin, anti-dsDNA antibody, glucocorticoids, and cyclophosphamide, were independent risk factors for noninfectious fever in SLE.     https://ijph.tums.ac.ir/index.php/ijph/article/view/15939 https://ijph.tums.ac.ir/index.php/ijph/article/download/15939/6254

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 9 19 Mohamed H. ELSHAHIDI Faculty of Medicine, Mansoura University, Mansoura, Dakahliya, Egypt 2019 01 16 Background: During the past 20 years, the prevalence of gestational diabetes mellitus (GDM) has increased by ∼10%-100% in several race/ethnicity groups. There is an association between ambient air pollution (AAP) and GDM. This study aimed to summarize the evidence about the association between AAP and GDM. Methods: PubMed, Embase, Scopus, Web of Science and Cochrane Library were searched from inception till Oct 2017. Studies about the association between ambient air pollutants levels and GDM were included. Pooled effect estimates and their 95% confidence interval (CI) were calculated using R. Results: Eight studies met the inclusion criteria. The odds of developing GDM upon exposure to CO (per 1 ppm), NO (per 1 ppb), NO2 (per 10 µg/m3), NOx (per 1 ppb), O3 (per 10 ppb), SO2 (per 10 ppb), PM10 (per 10 µg/m3) and PM2.5 (per 10 µg/m3) were 1.47 (95% CI 0.88-2.06), 1.04 (95% CI 1.03-1.06), 1 (95% CI 0.93-1.08), 1.02 (95% CI 1-1.04), 1.05 (95% CI 0.94-1.16), 1.39 (95% CI 1.04-1.73), 0.97 (95% CI 0.94-0.99) and 1.12 (95% CI 0.93-1.31), respectively. Conclusion: The current literature showed evidence for an association between AAP and GDM. However, further well-designed studies are needed.   https://ijph.tums.ac.ir/index.php/ijph/article/view/15934 https://ijph.tums.ac.ir/index.php/ijph/article/download/15934/6249

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 173 175 Tigran PETROSYAN Department of Speech Therapy and Rehabilitation, Armenian State Pedagogical University after Khachatur Abovyan, Yerevan, Armenia Hasmik MKRTCHYAN Department of Speech Therapy and Rehabilitation, Armenian State Pedagogical University after Khachatur Abovyan, Yerevan, Armenia Zvart HARUTYUNYAN Department of Speech Therapy and Rehabilitation, Armenian State Pedagogical University after Khachatur Abovyan, Yerevan, Armenia Armenuhi AVAGYAN Department of Speech Therapy and Rehabilitation, Armenian State Pedagogical University after Khachatur Abovyan, Yerevan, Armenia 2019 01 16 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/15954 https://ijph.tums.ac.ir/index.php/ijph/article/download/15954/6269

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 69 76 Saejong PARK Department of Sports Sciences, Korea Institute of Sport Science, Seoul, Korea Dong-Sik CHUNG Department of Sports Sciences, Korea Institute of Sport Science, Seoul, Korea Byoung-Goo KO Department of Sports Sciences, Korea Institute of Sport Science, Seoul, Korea Hong-Sun SONG Department of Sports Sciences, Korea Institute of Sport Science, Seoul, Korea Kwang Jun KIM Department of Sports Sciences, Korea Institute of Sport Science, Seoul, Korea Jin-Wook CHUNG Department of Sports Culture, Dongguk University, Seoul, Korea Seunghee LEE Department of Physical Education, Korea University, Seoul, Korea Chul-Hyun KIM Department of Sports Medicine, Soonchunhyang University, Asan, Korea Younshin NAM Department of Sports for All, Duksung Women's University, Seoul, Korea Seungyun SHIN Department of Martial Arts, Yongin University, Yongin, Korea Hyo LEE Department of Sport and Health Sciences, Sangmyung University, Seoul, Korea Sochung CHUNG Department of Pediatrics, Konkuk University Medical Center, Research Institute of Medical Science, Konkuk University, School of Medicine, Seoul, Korea Hong-Yup AHN Department of Statistics, Dongguk University, Seoul, Korea Jeong Hun OH Seoul Physical Education Middle School, Seoul, Korea Wi-Young SO Sports and Health Care Major, College of Humanities and Arts, Korea National University of Transportation, Chungju-si, Korea 2019 01 16 Background: This study aimed to identify percent body fat cut-off points related to metabolic syndrome in a large sample of Korean adolescents. Methods: The subjects (n=2120; boys=1107, girls=1013) were middle and high school students aged 12–17 yr who participated in the Korean National Fitness Award Project in 2013. Percent body fat was estimated via eight-polar bioelectrical impedance analysis. Metabolic syndrome was classified using established standards based on the National Cholesterol Education Program with the definition modified for age. Age- and sex-specific percent body fat z-scores were calculated for every adolescent using skewness, median, and coefficient of variation curves to account for growth and development. Receiver operating characteristic curve analysis was used to identify the percent body fat cut-off points using percent body fat z-scores from skewness, median, and coefficient of variation curves as the test and metabolic syndrome as the criterion. Results: Based on the modified National Cholesterol Education Program criteria for metabolic syndrome, the areas under the receiver operating characteristic curve for percent body fat were 0.882 and 0.893 for boys and girls, respectively. The percent body fat percentiles were 82.2 and 87.3 for boys and girls, respectively. According to the skewness, median, and coefficient of variation curves, the percent body fat cut-off points based on the modified National Cholesterol Education Program criteria were 23.6%-25.7% for boys and 32.8%-37.3% for girls, both aged 12-17 yr. Age- and sex-specific percent body fat cut-off points were identified in relation to the metabolic syndrome status of Korean adolescents. Conclusion: These percent body fat cut-offs might be useful for identifying metabolic abnormality due to obesity in Korean adolescents.     https://ijph.tums.ac.ir/index.php/ijph/article/view/15940 https://ijph.tums.ac.ir/index.php/ijph/article/download/15940/6255

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 1 2019 01 16 20 31 Farshid NOORBAKHSH Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Kamal ABDOLMOHAMMADI Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran AND Department of Immunology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran AND Department of Stem Cell Biology, Stem Cell Technology Research Center, Tehran, Iran Yousef FATAHI Department of Pharmaceutical Nanotechnology, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran AND Nanotechnology Research Center, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Hossein DALILI Department of Pediatrics, Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran Mehrnaz RASOOLINEJAD Alexandr FURSOV JSC 'Astana Medical University', Astana, Kazakhstan Bagdat IMASHEVA JSC 'Astana Medical University', Astana, Kazakhstan Roman FURSOV JSC 'Astana Medical University', Astana, Kazakhstan Yerzhan KUSPAEV JSC 'Astana Medical University', Astana, Kazakhstan Timofei KOVALENKO JSC 'Astana Medical University', Astana, Kazakhstan Alishan ISMAILOV JSC 'Astana Medical University', Astana, Kazakhstan Aigul ABDULDAYEVA JSC 'Astana Medical University', Astana, Kazakhstan Irina VOLCHKOVA JSC 'Astana Medical University', Astana, Kazakhstan 2019 10 04 Background: The prevalence of bleeding and perforation against the diabetes mellitus, obesity and metabolic syndrome (MetS) is studied not sufficiently. Methods: The period of collecting the material was 15 years (2003-2017). The observation analysis was conducted for the patients at polyclinics observations, by the doctors of first-aid, in the surgical departments of the Astana City, Kazakhstan. The number of first-aid visits to patients, the medical cards of the patients with gastroduodenal perforation (GDP) and gastroduodenal bleeding (GDB) were analyzed. Results: The rate of annual growth of indices of overall morbidity Rgm=1.0%, obesity in combination with diabetes was Ro=1.7%; and morbidity with metabolic syndrome was Rm=3.1%. The diagnosis of GDP was revealed in 0.63 men with MetS for every 100000 urban people. The diagnosis of GDB was registered in 2.12 men for 100000 urban people. The index of the annual growth in patients with MetS had the tendency to the growth (Rms=3.1%). Conclusion: The high medical and social significance of diseases of the digestive system among the adult population in Kazakhstan is determined by the annual increase in the incidence rate and a clear decrease in the quality of life of such patients, which necessitates the search for scientifically based ways to improve medical care for this population. https://ijph.tums.ac.ir/index.php/ijph/article/view/18533 https://ijph.tums.ac.ir/index.php/ijph/article/download/18533/6530

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 10 2019 10 05 1924 1926 Jeong-Hyun LEE Department of Beauty Art, Youngsan University, Busan, Republic of Korea Yeona KIM Department of Beauty Art, Youngsan University, Busan, Republic of Korea Wi-Young SO Sports and Health Care Major, Korea National University of Transportation, Chungju-si, Republic of Korea 2019 10 05 Abstracts Abstracts  Abstracts  Abstracts https://ijph.tums.ac.ir/index.php/ijph/article/view/18560 https://ijph.tums.ac.ir/index.php/ijph/article/download/18560/6550

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 10 2019 10 05 1794 1801 Dariusz BOGUSZEWSKI Department of Rehabilitation, Physiotherapy Division, 2nd Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland Jakub Grzegorz ADAMCZYK Department of Theory of Sport, Józef Pilsudski University of Physical Education in Warsaw, Warsaw, Poland Dariusz BIALOSZEWSKI Department of Rehabilitation, Physiotherapy Division, 2nd Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland 2019 10 05 Background: Physical activeness is one of the main elements of lifestyle in terms of preventing civilization diseases. The main purpose of this study was to assess the selected health behaviors of men practicing combat sports and martial arts and to find out what features or variables may have an influence one’s lifestyle. Methods: Overall, 561 men aged 17-35 yr were enrolled and divided into three groups. Studies were conducted from March 2011 to June 2015 in Warsaw, Poland. The main research tool was Juczyński’s Health Behaviour Inventory. The questionnaire includes 24 statements – descriptions of various health-related attitudes and behaviours – divided into four categories: proper eating habits, preventive behaviours, positive psychical attitude, and health practices. Results: The persons practicing combat sports and martial arts presented the highest level of health behaviours. The result of Group 1 was significantly higher than the result of Group 2 (P=0.05) and Group 3 (P<0.001). The sportsmen from Group 1 obtained the highest result in the category of psychical attitude (3.5), which was similar to the result of the non-active group (3.29). The men belonging to Group 2 rated highest their eating habits (3.37). All groups obtained the lowest results in the category of preventive behaviours. Conclusion: The men practicing combat sports and martial arts showed high general level of health behaviours. It may give evidence to the intellectualization of sport and health training process, as well as to the fact of adopting the desired behaviours in everyday life.     https://ijph.tums.ac.ir/index.php/ijph/article/view/18536 https://ijph.tums.ac.ir/index.php/ijph/article/download/18536/6531

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 10 2019 10 05 1927 1929 Jinkui LU School of Sport, Shangrao Normal University, Jiangxi Shangrao, 334000, P.R. China Yongsheng XU School of Sport, Shangrao Normal University, Jiangxi Shangrao, 334000, P.R. China Jianming XIANG School of Sport, Shangrao Normal University, Jiangxi Shangrao, 334000, P.R. China 2019 10 05 No Abstract No Abstract No Abstract https://ijph.tums.ac.ir/index.php/ijph/article/view/18561 https://ijph.tums.ac.ir/index.php/ijph/article/download/18561/6551

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 10 2019 10 05 1802 1809 Lili ZHUANG Reproductive Department, Yantai Yuhuangding Hospital, Yantai 264000, P.R. China Wei CUI Obstetrics Department, Yantai Yuhuangding Hospital, Yantai 264000, P.R. China Jianxiang CONG Reproductive Department, Yantai Yuhuangding Hospital, Yantai 264000, P.R. China Yinghong ZHANG Obstetrics Department, Yantai Yuhuangding Hospital, Yantai 264000, P.R. China 2019 10 05 Background: We aimed to explore the clinical efficacy of vitamin D combined with metformin and clomiphene in the treatment of patients with polycystic ovary syndrome combined with infertility. Methods: Overall, 396 cases of polycystic ovarian syndrome combined with infertility in Yantai Yuhuangding Hospital, Yantai, China were prospectively analyzed. Among them, 204 cases treated with vitamin D combined with metformin and clomiphene were set as the study group; 192 cases treated with only metformin and clomiphene were set as the control group. The ovarian volume and thickness of uterine wall before and after treatment were recorded. Levels of fasting insulin (FINS), luteinizing hormone (LH), testosterone (T), follicle-stimulating hormone (FSH), and estradiol (E2) before and after treatment were recorded. Results: There was no difference in body weight, BMI, ovarian volume, thickness of ovarian wall, FINS, LH, T, FSH and E2 between the study group and the control group; there was no significant difference in FSH, E2 and the thickness of uterine wall between the two groups. After treatment, the BMI, FINS, LH, and T in the study group were significantly lower than those in the control group (P<0.05); the incidence rates of oligomenorrhea, facial acne and hairy symptoms in the study group were significantly lower than those in the control group (P<0.05); after treatment, the ovulation rate and pregnancy rate in 36 cycles in the observation group were significantly higher than those of the control group (P<0.05). Conclusion: Our challenge could significantly improve clinical symptoms and endocrine conditions, and greatly enhance the ovulation rate and pregnancy rate.  https://ijph.tums.ac.ir/index.php/ijph/article/view/18537 https://ijph.tums.ac.ir/index.php/ijph/article/download/18537/6532

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 10 2019 10 05 1930 1932 Min ZHANG Department of Neurosurgery, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, 161041, P.R. China Yang YU Department of Neurology, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, 161041, P.R. China Yujun CHEN Department of Neurosurgery, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, 161041, P.R. China Guihong FAN Department of Nursing, The First Affiliated Hospital of Qiqihar Medical University, Qiqihar, 161041, P.R. China 2019 10 05 Abstract Abstract Abstract Abstract Abstract https://ijph.tums.ac.ir/index.php/ijph/article/view/18563 https://ijph.tums.ac.ir/index.php/ijph/article/download/18563/6552

48 2 2019 02 01 270 277 Jinting WU Second Affiliated Hospital of Wannan Medical College, Wuhu, 241002, China Hairong LIU Department of Public Administration, Wannan Medical College, Wuhu, 241001, China 2019 02 05 Background: This study investigated the nonsuicidal self-injury (NSSI) presentation and the features of coping methods among college students, in addition to analyzing the factors that influence self-injury behavior. Methods: From April to November 2016, 2,520 undergraduate students who were studying in some colleges in Anhui Province in China were surveyed using the Self-Injury Behavioral Survey Questionnaire and the Coping Styles Questionnaire (CSQ). Results: The detection rate of self-injury behavior among college students was 13.73%. Frequent Internet use and smoking were associated with self-injury behavior (P < 0.05). There were statistically significant differences between the self-injury group and the non-self-injury group in terms of the coping methods of problem-solving, self-reproach, help-seeking, and illusions (P < 0.01). According to the logistic regression analysis of the students, their place of origin, mother’s education, family finances, family type, family relationships, gender, frequent Internet use, and smoking were associated with self-injury behavior (P< 0.01). Self-reproach and withdrawal were risk factors for self-injury behavior while problem-solving and rationalization were protective factors for self-injury behavior. Conclusion: Students who frequently use the Internet and smoke are more prone to self-injury. College students’ choices of problem-solving and rational coping styles in the face of pressure are conducive to preventing nonsuicidal self-injury.     https://ijph.tums.ac.ir/index.php/ijph/article/view/16147 https://ijph.tums.ac.ir/index.php/ijph/article/download/16147/6284

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 227 237 Homayoun SADEGHI-BAZARGANI Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Hamid ALLAHVERDIPOUR Clinical Psychiatry Research Center, Department of Health Education & Promotion, Tabriz University of Medical Sciences, Tabriz, Iran; AND Research Center of Psychiatry and Behavioral Sciences, Department of Health Education & Promotion, Tabriz University of Medical Sciences, Tabriz, Iran Mohammad ASGHARI JAFARABADI Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran Saber AZAMI-AGHDASH Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran 2019 02 05 Background: One of the most important effects of many drying lakes in the world is increasing the emergence and outbreak of different diseases. For this sake, the present study aimed to systematically review the effects of lakes drying on human health. Methods: The present systematic review was designed and conducted in 2017. Data were gathered by searching the Science Direct, Cochrane Library, Google Scholar, Scopus, PubMed, and Web of Knowledge databases, along with hand search of key journals and unpublished resources and contact with experts. There was no specific time span for the search. Results: Overall, 22 articles were selected with 20 articles about Aral Lake drying. Almost all studies were cross-sectional and retrospective. In 8 studies, the participants were children. Seventeen articles lakes drying have adverse effects on human health. Based on the type of effect, the studies were classified into 7 categories (respiratory problems, reproductive system problems, kidney and urological diseases, cancers, anemia, and diarrhea). Conclusion: Most studies depicted the harmful effects of lakes draught on human health; they had low level of evidence as they were mostly retrospective and cross-sectional. There is not enough evidence to accept or reject with high level of certainty the very effects of lakes drying on human health. To provide such evidence we suggest conducting middle and long term cohort and observational studies with scientific bases.     https://ijph.tums.ac.ir/index.php/ijph/article/view/16141 https://ijph.tums.ac.ir/index.php/ijph/article/download/16141/6279

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 355 356 Ardalan SHARIAT Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Noureddin Nakhostin ANSARI Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran AND Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran Joshua A. CLELAND Franklin Pierce University, Manchester, New Hampshire, USA Azadeh HAKAKZADEH Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Ramin KORDI Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Mehdi KARGARFARD Department of Exercise Physiology, Faculty of Sports Sciences, University of Isfahan, Isfahan, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16172 https://ijph.tums.ac.ir/index.php/ijph/article/download/16172/6298

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 278 288 Waldemar W. KOCZKODAJ Computer Sciences, Laurentian University, Sudbury, Canada Jolanta MASIAK Independent Neurophysiological Unit, Department of Psychiatry, Medical University of Lublin, Lublin, Poland Mirosław MAZUREK Faculty of Electrical and Computer Engineering, Rzeszów University of Technology, Al. Powstańców Warszawy 12, 35-959 Rzeszów, Poland Dominik STRZAŁKA Faculty of Electrical and Computer Engineering, Rzeszów University of Technology, Al. Powstańców Warszawy 12, 35-959 Rzeszów, Poland Pavel F. ZABRODSKII Saratov Medical University "REAVIZ", Saratov, Russia 2019 02 05 Background: Using data collected by the Office for Civil Rights, Department of Health and Human Services (HHS), over half of the population in the USA might have been affected by security breaches since Oct 2009. This study provided analysis of the data, presenting the numbers of individuals affected in one breach and the number of breaches. Methods: Statistical analysis has been conducted with visualizations. Visualizations include categorized histograms and tables. Histograms are presented as bar charts with categories: location and breach type. Tables show case counts (across top 10 breaches and those with more than one million stolen records) in successive years and covered entity types. All statistics were calculated with the use of package R. Analyzed data were collected from Oct 2009 till Jun 2017. Results: This study presents evidence of health data breaches taking place at an unprecedented level. Medical records of at least 173 million of people, gathered since Oct 2009, have been breached and might have adversely influenced over half of the population in the USA. Conclusion: Results of this study are expected to motivate public care authorities to develop similar laws and regulations as the USA while striving for better law enforcement. It takes a considerable amount of time to educate public and it takes substantial financial resources to prevent data breaches.     https://ijph.tums.ac.ir/index.php/ijph/article/view/16148 https://ijph.tums.ac.ir/index.php/ijph/article/download/16148/6285

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 357 358 Salman KHAZAEI Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran Ensiyeh JENABI Pediatric Developmental Disorders Research Center, Hamadan University of Medical Sciences, Hamadan, Iran Shahab REZAEIAN Research Center for Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16173 https://ijph.tums.ac.ir/index.php/ijph/article/download/16173/6299

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 289 298 Haemi JEE Department of Sports and Health Care, Namseoul University, Cheonan-si, Korea Jaehyun PARK Department of Information and Communication, Inha University, Incheon, Korea 2019 02 05 Background: The clinical gender-dependent characteristics of visuospatial neglect between men and women have not been elucidated in Korean patients with cognitive impairment. The goal of this study was to observe the asymmetric lateralization in patients using a novel e-pen based cognitive assessment system. Methods: A total of 31 patients, 16 men and 15 women, with early stage hemispheric cerebral dysfunction were recruited for the assessment of unilateral neglect suing a novice paper-and-pencil based electronic evaluation system from a rehabilitation center of Inha University hospital in 2016. Results were assessed for degrees of deviations, and numbers of neglected lines. Degree of deviation was assessed using the positions and distances from the horizontal line centers. Effect sizes were calculated to assess proximities between the assessed results. Results: Comparatively greater left and rightward biasness for the right-sided and left-sided horizontal lines were observed for the male patients, respectively. Moreover, greater degree of left to rightward biasness was observed as the horizontal lines shortened in both groups. However, the magnitude of biasness in female patients showed comparatively less directional bias, indicating greater prevalence for the center of mass effect in male patients. Conclusion: Gender difference in visuospatial neglect seems to exist with less accuracy in recognition for the bisecting center for the female and asymmetrical lateralization and magnitude of deviation for the male patients.   https://ijph.tums.ac.ir/index.php/ijph/article/view/16150 https://ijph.tums.ac.ir/index.php/ijph/article/download/16150/6286

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 359 361 Zohreh RAHIMI Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran AND Department of Clinical Biochemistry, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran Sozan NAJAFI Student Research Committee, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran Lila MOGHOFEHIE Student Research Committee, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran Ebrahim AMIRI Central Lab, Kermanshah University of Medical Sciences, Kermanshah, Iran Asad VAISI-RAYGANI Department of Clinical Biochemistry, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran Ziba RAHIMI Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16174 https://ijph.tums.ac.ir/index.php/ijph/article/download/16174/6300

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 299 304 Meihong ZHOU Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, P.R. China Zhaojun HUANG Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang 330000, P.R. China 2019 02 05 Background: We aimed to explore the effect of comprehensive cerebral protection on cerebral oxygen metabolism and vascular endothelial function in elderly patients with acute cerebral infarction. Methods: A total of 168 elderly patients with acute cerebral infarction treated in The First Affiliated Hospital of Nanchang University, China from January 2016 to January 2018 were selected. The patients were divided into a control group and an observation group using random number method, n=84. Patients in the observation group were given comprehensive cerebral protection treatment, and patients in the control group were treated with conventional standardized treatments. The changes of cerebral oxygen metabolism, hemorheology and vascular endothelial function before and after treatment were compared between the two groups. Results: After treatment, oxygen content in arteries and internal jugular veins (Da-vO2), ofoxygen uptake fraction (OEF), Oxygen saturation (SpO2), nitric oxide (NO) were increased in both groups in comparison to before treatment, jugular venous oxygen saturation (SjvO2), brain oxygen uptake rate (ERO2), endothelin (ET), intracranial pressure (ICP), whole blood viscosity, plasma viscosity, reduced viscosity of whole blood, and hematocrit were decreased. However, the changes in the observation group were larger than those in the control group, the difference was statistically significant (P<0.05). Conclusion: The treatment of cerebral infarction in elderly patients with acute cerebral infarction can effectively improve the cerebral oxygen metabolism and vascular endothelial function and improve the blood rheology, which has important clinical value.   https://ijph.tums.ac.ir/index.php/ijph/article/view/16151 https://ijph.tums.ac.ir/index.php/ijph/article/download/16151/6287

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 362 364 Maryam MORADNIA Student Research Committee, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran Mohsen POURSADEGHIYAN Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Amir Hossein MAHVI Center for Solid Waste Research, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran Masoud PANAHI FARD Department of Environmental Health Engineering, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16175 https://ijph.tums.ac.ir/index.php/ijph/article/download/16175/6301

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 305 313 Cuma UZ Physical Medicine and Rehabilitation Clinic, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, University of Health Science, Ankara, Turkey Ebru UMAY Physical Medicine and Rehabilitation Clinic, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, University of Health Science, Ankara, Turkey Ibrahim GUNDOGDU Physical Medicine and Rehabilitation Clinic, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, University of Health Science, Ankara, Turkey Aytul CAKCI Physical Medicine and Rehabilitation Clinic, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, University of Health Science, Ankara, Turkey 2019 02 05 Background: Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy in the upper limb. Although more objective methods for assessment have been reported in literature, there is a lack of evidence concerning the best methods for assessment of CTS. This study aimed to investigate whether there was a difference in the first web space in patients with different severities of CTS in relation to healthy controls as easy screen method. Methods: This prospective controlled trial was conducted on 126 patients at the Physical Medicine and Rehabilitation Clinic, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, University of Health Science, Ankara, Turkey, from January 2016 to January 2018. Hand grip and pinch strength of patients were determined. Also, first web angle were measured by goniometer. Patients were divided into 3 CTS groups as electrophysiologically: "mild: group 1", "moderate: group 2" and "severe: group 3". Patient and healthy groups were compared in terms of the evaluation parameters. Comparisons were also made between these groups. Results: There was significant reduction in hand strengths and first web angle in patient groups compared to healthy groups (P<0.05). Moreover, the first web angle was significantly different between the CTS groups (P= 0.001). The cut-off value for CTS was <38.5º. Conclusion: The possibility of CTS can be evaluated by measuring the first web space angle with a simple goniometer as a easy and in-expensive method in outpatient clinics.   https://ijph.tums.ac.ir/index.php/ijph/article/view/16152 https://ijph.tums.ac.ir/index.php/ijph/article/download/16152/6288

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 365 366 Ali SEYFZADEH Department of Sociology, Dehaghan Branch, Islamic Azad University, Dehaghan, Iran Mansoor HAGHIGHATIAN Department of Sociology, Dehaghan Branch, Islamic Azad University, Dehaghan, Iran Aliasghar MOHAJERANI Department of Sociology, Dehaghan Branch, Islamic Azad University, Dehaghan, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16176 https://ijph.tums.ac.ir/index.php/ijph/article/download/16176/6302

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 314 322 Muhammad Ibrahim Alhadi EDOO Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Vikram Kumar Chutturghoon Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Gyabaah Kwabena WUSU-ANSAH Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Hai ZHU Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Tao Yang ZHEN Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Hai Yang XIE Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China Shu-Sen ZHENG Division of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China AND Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou 310003, China 2019 02 05 Background: We aimed to evaluate the whether AFP levels alone is an adequate screening indicator, or a combination of Generally, alpha-fetoprotein (AFP), CA19-9 and CEA could provide a better diagnostic tool in detecting and screening asymptomatic patients with primary hepatic cancer (PHC), and also evaluate the correlation of degree of differentiation with serum biomarker levels. Methods: We retrospectively reviewed the medical records of 1362 patients form 2014-2018 who visited the first Affiliated Hospital of Zhejiang University, Hangzhou, China for health check-ups or were diagnosed with cancer or cirrhosis. We then analyzed preoperative tumor markers level of AFP, CA19-9, and CEA. The standard reference values (AFP ≤20 ng/L CEA ≤ 5 ng/L, and CA19-9  ≤ 37 U/mL) were as positive or negative cut off values. Further, the histological sections of patients were categorized and correlated them with the three serum biomarkers. Results: Serum AFP, CEA, and CA19-9 levels in the PHC group were significantly higher compared to those with liver cirrhosis and healthy control groups (P < 0.03). With AFP as a single tumor marker for PHC diagnosis, it had a sensitivity of 63.3% with a specificity of 80.8%. AFP combined with CA19-9 and CEA showed specificity of 100%, a sensitivity 2.5% with the positive and negative predictive values of 100% and 22% respectively. Furthermore, histological evaluation revealed the highest AFP level of 9366.14±23902.61 ng/L associated with poorly differentiated HCC, while well-differentiated HCC, had the lowest mean AFP level of 45.19±181.27 ng/L. Conclusion: Combined serum levels of AFP, CA19-9  and CEA does not provide a superior advantage over AFP alone as a screening and diagnostic tool for HCC detection.   https://ijph.tums.ac.ir/index.php/ijph/article/view/16153 https://ijph.tums.ac.ir/index.php/ijph/article/download/16153/6289

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 367 368 Ali PEDRAMI Department of Oral Medicine, Zahedan University of Medical Sciences, Zahedan, Iran Fateme ARBABI-KALATI Department of Oral Medicine, Oral and Dental Disease Research Center, Zahedan University of Medical Sciences, Zahedan, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16177 https://ijph.tums.ac.ir/index.php/ijph/article/download/16177/6303

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 323 330 Yingjin WANG Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Xiaoyuan CHEN Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Shujuan ZHONG Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Rong ZHANG Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Yanyan PAN Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Peili AN Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China Xinru GAO Medical Ultrasound Centre, Northwest Women’s and Children’s Hospital, Xian 710061, P.R. China 2019 02 05 Background: To assess the clinical value of two-dimensional (2D) plus four-dimensional (4D) ultrasonography in diagnosis of fetal craniocerebral anomalies. Methods: Retrospective analysis was performed on the sonographic features of 83 maternity patients admitted to Northwest Women’s and Children’s Hospital, Xian China from January 2013 to December 2017 diagnosed with suspected fetal anomalies of the brain and skull through 2D and 4D ultrasonography. Results: Fifty six patients were diagnosed with the anomalies by 2D ultrasonography only, 65 patients by 4D ultrasonography only, and 74 patients by 2D plus 4D ultrasonography.76 patients were confirmed to have fetal craniocerebral anomalies after birth or induced labor. Diagnostic accuracies of 2D ultrasound only, 4D ultrasound only, and 2D plus 4D ultrasound were 68.67%, 81.93% and 95.18%, respectively (P<0.05). The accuracy of 2D plus 4D ultrasound was greater than those of 2D ultrasound only and 4D ultrasound only, and the accuracy of 4D ultrasound only was higher than that of 2D ultrasound only (P<0.05). The sensitivity of 2D plus 4D ultrasound was greater than those of 2D ultrasound only and 4D ultrasound only (P<0.05). The specificity of 2D plus 4D ultrasound was greater than those of 2D ultrasound only and 4D ultrasound only (P<0.05). Conclusion: Combined ultrasonography can better differentiate fetal craniocerebral anomalies, providing early and more accurate information for clinicians as well as maternity patients to make a decision. This clinical practice would be valuable for improving the quality of the newborn population.   Keywords:      https://ijph.tums.ac.ir/index.php/ijph/article/view/16154 https://ijph.tums.ac.ir/index.php/ijph/article/download/16154/6290

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 369 370 Amir BAIRAMI Department of Medical Laboratory Sciences, School of Allied Medicine, Alborz University of Medical Sciences, Karaj, Iran Enayatollah KALANTAR Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran Mohammad Hossein DEHGHAN Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran Monireh SEZAVAR Department of Medical Laboratory Sciences, School of Allied Medicine, Alborz University of Medical Sciences, Karaj, Iran Parviz FALLAH Rajaei Hospital, Alborz University of Medical Sciences, Karaj, Iran Aliehsan HEIDARI Department of Medical Parasitology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran 2019 02 06 No Abstract### https://ijph.tums.ac.ir/index.php/ijph/article/view/16179 https://ijph.tums.ac.ir/index.php/ijph/article/download/16179/6304

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 331 337 Hasti KAMALI SARWESTANI Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Roshanak DAIE GHAZVINI Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Seyed Jamal HASHEMI Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Sassan REZAIE Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Mohsen GERAMI SHOAR Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Shahram MAHMOUDI Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran AND Department of Medical Parasitology and Mycology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran Miad ELAHI Department of Head and Neck Surgery, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran Ardavan TAJDINI Department of Head and Neck Surgery, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 02 05 Background: Otomycosis is a superficial infection of the ear caused by a spectrum of various fungal agents and its epidemiology depends on geographical region and climatic condition. The aim of this study was to investigate the causal agents and clinical manifestations of otomycosis at a tertiary referral center in Tehran, Iran. Methods: From Apr 2016 to Jan 2017 a set of 412 subjects with suspicion of external otitis were included. Clinical examination and specimen collection were performed by an otorhinolaryngologist. Subsequently, direct examination and culture were performed on specimens and isolated molds were identified morphologically. Yeast isolates were identified using CHROMagar Candida medium and PCR-RFLP of ribosomal DNA whenever needed. Data were analyzed using SPSS. Results: Otomycosis was confirmed in 117 cases (28.39%) including 64 (54.7%) males and 53 (45.3%) females. Patients were within the age range of 10-75 yr and the highest prevalence was found in the age group of 46-55 yr (30.77%). Pruritus (89.74%) and auditory manipulation and trauma (83.76%) were the predominant symptom and predisposing factor, respectively. Among 133 isolates from 117 patients, Aspergillus niger (n=50, 37.59%) was the most common etiologic agent and Candida glabrata (n=25, 18.8%) was the predominantly isolated yeast. Furthermore, 16 cases of mixed infection were identified and coinfection due to A. niger and C. glabrata (seven cases) was the predominant pattern. Conclusion: Our results revealed the high prevalence of C. glabrata and mixed infections in otomycosis patients. Therefore, mycological examinations should be considered for proper treatment.   https://ijph.tums.ac.ir/index.php/ijph/article/view/16155 https://ijph.tums.ac.ir/index.php/ijph/article/download/16155/6291

Tehran University of Medical Sciences Iranian Journal of Public Health 2251-6085 48 2 2019 02 01 338 344 Mohammad Esmaeil MOTLAGH Department of Pediatrics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Seiyed Davoud NASROLLAHPOUR SHIRVANI Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran Farahnaz TORKESTANI Department of Obstetrics and Gynecology, School of Medicine, Shahed University, Tehran, Iran Zahra HASSANZADEH-ROSTAMI Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran Seyed-Mozaffar RABIEE Department of Anesthesiology and Intensive Care, Babol University of Medical Sciences, Babol, Iran Hassan ASHRAFIAN AMIRI Internal Medicine, Babol University of Medical Sciences, Babol, Iran Laleh RADPOOYAN Department of Health, Ministry of Health, Tehran, Iran 2019 02 05 Background: Anemia is a common nutritional disorder that is more prevalent in pregnant women than other population groups. This study aimed to assess the frequency of anemia and its association with health care determinants among Iranian pregnant women from provinces with different Maternal Mortality Rate (MMR). Methods: This cross-sectional survey was carried out on 2737 pregnant women referred to public health centers in Iran, 2015. The participants were randomly selected by multistage sampling from six provinces with low, moderate or high MMR. The level of hemoglobin lower than 11 g/dl were defined as