Iranian Journal of Public Health
Volume:50 Issue: 8, Aug 2021

COVID-19 has resulted in an emerging respiratory infection with a pandemical diffusion since December 2019. We aimed to elucidate whether the presence of thyroid disease might increase the risk of severe COVID-19 infection.

Studies reporting seriously ill in COVID-19 patients with and without thyroid disease combined were searched and 11 relevant studies were subjected to our analysis, and pooled odds ratios (ORs) together with 95% confidence intervals (CIs) were calculated by using STATA and Review Manager Software.

In total, 2,995 COVID-19 patients were included in this study. The pooled ORs were calculated using a fixed-effects model according to the heterogeneity. The pooled results revealed that thyroid disease was associated with severe COVID-19 infection in patients (OR = 2.14, 95 % CI: 1.23–3.72, P = 0.007). In the subgroup analysis by type of thyroid disease, hypothyroidism was positively associated with risks of severe COVID-19 infection (OR = 4.78, 95 % CI: 1.59–14.36, P = 0.005), however, no obvious difference was found in the risk regarding the severe COVID-19 infection amongst hyperthyroidism or unclassified thyroid disease. In addition, subgroup analysis stratified by ethnic groups demonstrated that thyroid disease was linked to the risks of severe COVID-19 infection in Asian patients (OR = 2.41, 95 % CI: 1.30–4.48, P = 0.005) rather than non-Asian (OR = 1.31, 95 % CI: 0.35–4.87, P = 0.684).

This study indicates a correlation between thyroid disease and severe COVID-19 infection.

The delirium in Intensive Care Untints (ICU) patients is a major cause of unplanned extubation, increased length of hospital day. This study aimed to review systematically risk factors associated with the occurrence of delirium among ICU patients in South Korea.

Data collection was done with domestic literature search databases including KMbase, KoreaMed, KISS, and KisTi and also with hand searching, from February 17 to May 19, 2019. Two researchers independently selected research literatures, and three researchers summarized and identified related variables based on data extraction methods.

Overall, 140 articles identified, 18 articles met the inclusion criteria for review. According to the results of the methodological quality, one article was found to have a high level of quality, while the remaining 17 articles belonged to the medium level. Those factors found to be highly associated with delirium by more than 9 out of the 18 selected studies were listed as follows; age, the application of ventilator, APACHE II score, comorbidity, the application of restraint, and educational level. In addition, catheter insertion and the application of artificial airway were also found to have significant relevance with the occurrence of delirium.

For management of delirium among ICU patients, it is necessary to eliminate and prevent delirium-associated risk factors, and also to detect and treat the delirium early through regular monitoring using an appropriate screening tool for delirium.

The tectonic activities at the meeting points of three large plates make Indonesia a high-risk disaster-prone area. Nevertheless, disaster risk reduction efforts in various regions of Indonesia are still lacking, in terms of both knowledge and the ability to analyze disaster risks. This study examines the implementation of disaster preparedness and mitigation in Indonesia.

The method used in this study was narrative review. The authors collected the articles through searching for 3 data sources from 2016–2019 using Google Scholar, iSeek, and Microsoft Academic. Content analysis of all information to obtain the thematic phenomena of this study completed the methodological approach.

After applying the exclusion criteria and removing duplicates, six studies remained that focused on disaster mitigation in remote areas of Indonesia. Implementation of regulation and policy framework in disaster management is not yet optimal. Disaster preparedness and mitigation is characterized by the low utilization of technology and information related to the disaster, and various obstacles in the process of evacuation and transportation. Promoting local wisdom and enhancing it through integrating science can increase disaster resilience.

The existence of a disaster-resilient village is very influential in community preparedness in dealing with disasters and other emergencies. This study provides some recommendations for disaster risk reduction: a) strengthening policies related to evacuation procedures in the health sector by local government, b) integrating transportation modes in remote areas, c) enhancing all parties with education and training, d) establishing community-based information systems; and e) strengthening the disaster resilience of villages.

COVID-19 was first declared as an international public health emergency and then a pandemic by the WHO. In this systematic review, the importance of isolation and contact tracing has been explained, and what kinds of practices exist in different countries are mentioned.

A systematic review was conducted in accordance with the PRISMA and Cochrane guidelines by searching articles from major medical databases such as Google Scholar, PubMed/MEDLINE, Cochrane Library, EMBASE, CINAHL between Jan 1, 2020 and Apr 1, 2021. Observational and modeling studies written on contact tracing, screening, quarantine and isolation were included.

27 observational and modeling studies were included. It was seen that rapid contact tracing to reduce the basic reproduction number (R0) from 3.11 to 0.21. Additionally, each new case requires an average of 36 people to be monitored. Since screening programs missed 75% of cases, high-level contact tracing should also be done simultaneously. Wide quarantine would prevent 79.27% deaths and 87.08% infections.

Effective, rapid contact tracing is the cornerstone of an effective public health response in outbreaks. Its success depends on quickly identifying cases, gathering information from them about their last contacts, and tracing and isolating those contacts.

End-Stage Renal Disease (ESRD) is an irreversible impairment of kidney function that leads to permanently dependent on alternative therapies such as hemodialysis, peritoneal dialysis, and renal transplantation. This study aimed to systematically investigate the survival rate of patients with renal transplantation, graft, and its related factors in Iran.

This systematic review and meta-analysis drew on articles indexed in six international and one internal databases (Medline/PubMed, ProQuest, Scopus, Embase, SID, and Web of knowledge) until Nov 2020. The reporting of the present study was performed in terms of PRISMA statement. All analyzes were performed using the STATA software.

Overall, 367 titles from 6 databases were evaluated of which 86 articles met the inclusion criteria. According to the random model, the graft survival rate at one, three, five, and 10 years were 92.48%, 85.08%, 79.96% and 68.15% respectively. Additionally, the patient survival rates at one, three, five, and 10 years were 91.27%, 86.46%, 81.17% and 78.15% respectively. There was a significant relationship between the age recipient and three-year graft survival rate (P=0.021). Additionally, there was an inverse and significant relationship between the donor age and 10-year patient survival rate (P=0.011).

The patient and graft survival in transplanted kidney patients is comparable with most developed countries.

Breast cancer is responsible for up to 25% of all cancers in Iran. The age at diagnosis of Iranian breast cancer patients starts a decade earlier than most of developed countries. This study aimed to evaluate the mean age at diagnosis of Iranian breast cancer patients.

In this systematic review and meta-analysis, the mean age at diagnosis of Iranian breast cancer patients and its pattern between 2008 and 2017, were evaluated. All papers with age at diagnosis of histopathological verified breast cancer patients were considered eligible to enter to the analysis. We used databases including Medline/PubMed, Scopus, Embase, Cochrane Library, Iranmedex and SID for the search process. The meta-analysis was performed only on studies with separate data for female patients, using random-effects model, Mantel and Haenszel method and the Comprehensive Meta-analysis software.

Finally, 92 studies with 19,784 patients (both-genders) were included. The mean age at diagnosis had increased from 47.93 (2008) to 49.91 (2016) years. The meta-analysis was done on 78 studies containing of 15,071 female patients and the mean age at diagnosis was 46.76±1.19. There was a wide range of age at diagnosis within different provinces. The mean age at Hamadan and Khuzestan provinces were the lowest and highest, respectively (42.48±7.96 vs. 51.00±11.47). The heterogeneity of studies was statistically significant (I2=99.744).

Mean age at diagnosis of Iranian women with breast cancer was 46.76±1.19. There was an increasing pattern in mean age of diagnosis at breast cancer patients within the past 10 years.

Nowadays, statistical methods are used frequently in research articles. This review study aimed to determine the statistical methods used in original articles published in Iranian journal of public health (IJPH).

Original articles in the period 2015 to 2019 from volumes 44 to 48 and numbers 1 to 12 were reviewed by a 3-member committee consisting of a statistician and two health researchers. The statistical methods, sample size, study design and population, type of used software were investigated. Multiple response analysis (MRA), Kruskal–Wallis test and Spearman correlation coefficient were used to data analysis. All analyzes were performed in SPSS21 software. Significant level was set at 0.05.

Statistical population in most of the articles were related to human samples at the field level (36% and 297 articles). 66.6% (549 articles) had the sample size less than 500 cases. Study design in most of them were analytical observational 56.2% (464 cases). Acceptance period was 115.5 ± 52.27 days. All the mentioned variables had no significant relationship with the acceptance period (P>0.05). Both among the total tests and the articles, the highest rate of use of statistical methods was related to descriptive statistical method (34.4%, 75.8% and 532 articles), also, the highest use of tests was related to chi square test  and t-test( (29%(450 articles)).

Study design in most of the articles were analytical, to increase thematic diversity, accepting different articles seems necessary. The statistical tests, which used in most articles, were simple, so accepting articles with advanced statistical methods is recommended.

To evaluate the condition of antiviral therapy (ART) for individuals infected HIV-1 in Suqian district of Jiangsu Province, China.

Altogether, 561 HIV-positive patients who received antiviral therapy in Suqian district in 2019 were recruited. EDTA anticoagulated blood was collected and separated to obtain the plasma samples. Viral load (VL) were tested for evaluating the outcome of ART. Then samples with VL beyond 1000IU/mL were used to conduct the molecular test in order to master the characters of HIV-1 and the prevalence of resistance strains.

VL results showed that the virus in 91.1% of the patients who received continuous antiviral treatment for more than 6 months were effectively inhibited (VL ≤ 1000 IU / ml). Among the 50 patients who failed in the treatment, 46 HIV-1 pol gene sequences were obtained, and the positive rate was 92.0%. The most prevalent strain was CRF_ 07bc (32.6%), and new epidemic strains, such as 67_01B、79_0107、87_cpx, were popular in this district. Drug resistance test results showed that 56.5% of the patients failed in antiviral treatment due to drug resistance, mainly resistant to the national first-line antiviral drug 3TC. Drug-resistant strains were not found in 43.5% of the patients.

ART achieved a satisfied result in Suqian district, but the main cause resulting in ART-failure was resistant, so it is very necessary to enhance the education of adherence prior to the initiation of ART.

The relationship between cadmium (Cd) exposure and depression remains unclear. This nationwide study aimed to compare the levels of blood Cd with the presence of depressive mood in Korean adults.

From the 2008–2013 Korea National Health and Nutrition Examination Survey, 10,968 individuals over 20 yr old were identified. Data on demographics, health behaviors, depressive mood, and blood Cd (B-Cd) levels were used in the analysis. Estimated levels of B-Cd were drawn from multivariate regression models.

Higher age-adjusted B-Cd levels were noted among women, rural residents, people who have a low economic or educational status, smoke currently, drink frequently, or have depressive mood than the counterpart groups. In fully adjusted models, men with depressive mood exhibited significantly higher B-Cd levels than those without depressive mood, and these levels were strongly mediated by smoking status.

Our results suggest a need for Cd accumulation screening among individuals with depressive mood.

The efficacy of color Doppler ultrasound, multislice spiral CT combined with serum alpha-fetoprotein (AFP) and alpha-fetoprotein heterogeneity (AFP-L3) in the diagnosis of primary hepatic carcinoma was evaluated.

Seventy-nine patients with primary hepatic carcinoma (PHC group) and 50 patients with benign liver lesions (benign control group) admitted in Yantaishan Hospital (Yantai, China) from January 2016 to December 2018 were selected. The liver was scanned by color Doppler ultrasound and multiple multislice spiral CT. The serum AFP and AFP-L3 levels were detected by electrochemiluminescence. The value of color Doppler ultrasound, multislice spiral CT combined with serum AFP and AFP-L3 in diagnosis of primary liver cancer was retrospectively analyzed.

The color Doppler flow imaging (CDFI) showed a high-speed and high-resistance spectrum. The serum AFP and AFP-L3 levels of patients with primary hepatic carcinoma were significantly higher than those of the benign control group were (U=138.000 and 155.500, P=0.000 and 0.000), P<0.01. The sensitivity, accuracy and negative predictive value of color Doppler ultrasound, multislice spiral CT combined with serum AFP and AFP-L3 examinations for diagnosis of primary hepatic carcinoma were 96.20, 90.70 and 93.18%, which was significantly improved compared with each single examination (X2=27.888, 17.511 and 16.202, P=0.000, 0.002 and 0.003), P<0.01.

Color Doppler ultrasound, multislice spiral CT combined with AFP and AFP-L3 examination could significantly improve the diagnosis efficiency of primary hepatic carcinoma, which was beneficial to early clinical diagnosis and early treatment.

Hierarchical medical system (HMS) is a good policy to promote the fairness of medical services for residents. Given the importance of HMS, it is necessary to know the implementation effect of the policy. Therefore, we aimed to analyze the efficiency of medical service resources in China under the background of hierarchical medical policy.

Based on the panel data of China's medical resources in 2015-2019, we used DEA model to calculate the technical efficiency (TE), pure technical efficiency (PTE) and scale efficiency (SE) of medical resources from both lateral and longitudinal aspects. We used Malmquist index to evaluate the change trend of efficiency, and further we compared the efficiency differences of regions and medical institutions.

In lateral evaluation results, TE was relatively stable, while total factor productivity (TFP) was on the rise. In longitudinal evaluation results, TE and TFP showed a downward trend.

The government should consider the differences in development between regions and make health plans by regions. Medical institutions should strive to break down the constraints and make use of their advantages, which is conducive to improving efficiency.

We investigated the human risk due to radon and heavy metals (HM) in soil.

Samples were collected in 2017 from 10 representative geographical locations at Jazan region of southwestern Saudi Arabia and analyzed for elements (Al, Ca, Cu, Ni, Sr Fe, Mg, B, Co, Cr, V, Zn, Mn, Ba, Cd, and Pb). Elements were measured using inductively coupled plasma optical emission spectrometer (ICP-OES). Radon (Rn) was measured using solid-state nuclear detector (SSNTDs).

The maximum human risk was due to Al, which had the highest concentration, where the lowest human risk was due to Cd. The maximum radon concentration was obtained at El-Mazab area with value of 381.05 Bq/m3which leads to 6.55 mSv/y and 78.94 Bq/m2d annual effective doses and radon exhalant rate respectively. Average equivalent and effective dose to different organs due to radon concentration was estimated. Hazard Index due to both carcinogenic and non-cancer hazards were calculated it exceeds permissible level for child due to Nickel and Chromium hence there is a significant risk on children in the study area.

HM concentrations were over limits in some places according to the human activities, municipal waste disposal, fertilizers and pesticides in agriculture. In addition, soil is porous permit dispersion of radon to the atmosphere.

Some patients discharged automatically are classified as terminal discharge, while their clinical outcome is survival, disrupting the results of clinical research.

The data of this study were taken from inpatients admitted to the ICU of the First Medical Center of the People's Liberation Army General Hospital, Beijing, China from 2008-2017. We collected the data regarding medications used over the three days before discharge from the group of patients who survived and the group of patients who died, and the outcomes of all patients were recalculated by three classification algorithms (AdaBoosting, Pearson correlation coefficient, observed to expected ratio-weighted cosine similarity). Our basic assumption is that if the classification result is death but the actual in-hospital outcome is survival, the associated patient was likely terminally discharged.

The coincidence rate of the outcomes calculated by the AdaBoosting algorithm was 98.1%, the coincidence rate calculated by the Pearson correlation coefficient was 61.1%, and the coincidence rate calculated by the observed to expected ratio-weighted cosine similarity was 93.4%. When the three classification methods were combined, the accuracy reached 98.56%.

The combination of clinical rules and classification methods has a synergistic effect on judgments of patients’ discharge outcomes, greatly saving time on manual retrieval and reducing the negative influence of statistics or rules.

The upregulation of miRNA-155 (miR-155) has been associated with oncogenesis of many human tumors, including nasopharyngeal carcinoma (NPC). However, the profile of miR-155 in Vietnamese NPC patients has not been investigated. The current study aimed to evaluate the miR-155 expression and assess whether miR-155 is a potential biomarker for diagnosis of NPC in Vietnamese patients.

In current case-control study, total of RNA was isolated from 60 biopsy NPC samples and 60 non-cancerous swab samples were analyzed by Reverse-transcription PCR, qualitative Real-time PCR.

The frequency of miR-155 detection were 78.33%, 15.0% in NPC and non-cancerous samples (P<0.05), respectively. The miR-155 expression level was 4.92 times higher in tumor samples than non-cancerous sample.

Taken together, miR-155 in NPC was upregulated. It may serve as a potential biomarker for NPC in the Vietnamese population.

To promote the treatment effects and self-management behaviors of the patients with type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic, this study empirically investigated the relationship among family support (FMS), mental resilience (MR) and diabetic distress (DD) in patients with T2DM.

Overall, 256 patients with T2DM from the Department of Endocrinology, Jinhua People’s Hospital, ZheJiang, China were selected and measured for their perceptions of FMS, MR and DD from 2019-2020. Based on the measurements, the difference and correlation matrix under different background variables were studied by one-way variance and correlation analysis. A structural equation was used to analyze the causal path among the measurements.

Patients that differ in marital status, annual family income, medical insurance level, number of complications, and with/without insulin injection therapy were significantly different in their perception of FMS, MR and DD. FMS and MR had a significant negative correlation with DD. FMS used MR as an intermediary variable that affected DD.

Diabetes education, improved medical insurance levels, and targeted psychological consultation for patients could effectively improve their MR and alleviate DD.

The emergence of COVID-19 in 2020 has brought dramatic impacts to the global economy. The resulting health crisis and widespread fear have triggered labor shortage problems such as high job vacancy rate and low labor participation rate. Thus, how to increase the labor supply has become a hotspot among scholars. We aimed to analyze the influences of public medical insurance system on labor health status and supply.

Using the China Health and Nutrition Survey five-phase panel data, the new rural cooperative medical system was taken as an example to empirically analyze the influences of public medical insurance system on the individual health status and labor supply via the panel Tobit model and panel binary Logit model. The analysis revealed the mediating effect of health status.

First, Public medical insurance system could significantly improve individual health status. Second, public medical insurance system will lengthen the labor supply time and elevate the labor supply rate by improving individual health status. Third, the influences of public medical insurance system on labor health status and supply vary with gender and age.

Public medical insurance system will generate positive influences on labor health status and labor supply. Hence, perfecting the public medical insurance system is able to mitigate the negative impacts of population aging and pandemic on the labor supply.

Mosquito species are highly considering as disease transmission as well as nuisance insects. One of the principal strategy to protect human from the mosquito bites is repellent agents. This study aimed to assess repellency of two organic essential oils, Eucalyptus globulus and Syzygium aromaticum from bites of malaria vector, Anopheles stephensi.

The study was conducted in 2019-2020. The components of essential oils of E. globulus and S. aromaticum was determined using gas chromatography/mass spectrometry. The unfed female mosquitoes aged 2-5 d old were used in all experiments. In vivo Klun and Debboun module bioassays were utilized on human-volunteer skin. The essential oils at serial concentrations were used to find repellent efficacy against Anopheles landings and bites. To find the synergistic effect, four combinations of the essential oils were tested.

The main composition of E. globulus essential oil was 1,8-Cineol (78.20%), whereas that of S. aromaticum essential oil was 2-methoxy-3-(2-propenyl) (77.04%). Based on minimum effective dose (≤1% biting), 10% (v/v) of E. globulus showed high landing repellency (77.78%), whereas minimum effective dose of S. aromaticum at concentration of 1% had high landing repellency (88.89%). Among four combinations, the ratio of 1:1 of E. globulus (10%):S. aromaticum (1%) showed the most landing repellency (94.44%).

The combinations of two essential oils had the most potential repellency effect against landing of mosquitoes. As essential oils are eco-friendly with less irritation for human skin, E. globulus and S. aromaticum essential oils are recommended as effective and safe mosquito repellents.

People are still not prepared for earthquakes in vulnerable areas although preparedness considered an effective way of reducing the disastrous consequences. A proper tool was needed to assess the predicting factors of mitigation behaviors in a large vulnerable community who speak Persian. This study aimed to introduce the valid and reliable Persian version of public intention to prepare against earthquakes.

Translation, validation and reliability checking articulated according to the standard methodology for Forward-Backward translation and psychometric evaluation. Totally, 369 Tehran households were selected through stratified random sampling from Oct 2016 to Jun 2017. Exploratory Factor Analysis used to check the construct validity of all scales.

Face, content and construct validity of all scales confirmed (S-CVR: .65) and (S-CVI/Universal: .98). The finalized Persian version (69 items in 8 scales) showed good reliability over time in test-retest (ICC: .92) and high internal consistency both in the pilot (α: .94) and main studies (α: .94). No significant floor and ceiling effects were found in any of scales.

Persian version of Earthquake Public Intention to Prepare is applicable as a valid and reliable instrument for research regarding disaster preparedness in Persian speaking communities.

We aimed at estimating the burden of cancer in Kurdistan Province, western Iran during 2011-2017.

In this cross-sectional study, incidence data extracted from the cancer registry system and death data were extracted from the system of registration and classification of causes of death of Kurdistan Province. We applied the WHO’ methods to calculate the disability-adjusted life year (DALYs).

The burden of cancer increased from a DALYs of 12309 in 2011 to 13969 in 2017, the YLL from 11644 in 2011 to 12951 in 2017 and the YLD from 665 in 2011 to 1018 in 2017. The top five cancers, according to DALYs (%) in both sex during 2011-2017 were: stomach (25%), lung (14%), liver (9%), esophagus (6%), and colon (6%). The most burden of cancer related to gastrointestinal tract (54% vs. 45%). Totally, more than 25% of DALYs were related to stomach cancer.

The increasing DALYs of cancer in Kurdistan Province is one of the major public health concerns as in most developed countries. More than half of the burden of cancer in the Kurdistan Province is related to gastrointestinal tract. Stomach cancer, is accounting for more than 25% of the burden in both sexes. Urgent policy, management and public health measures such as general education, screening, early detection and effective treatment are recommended to reduce the burden of cancers and especially gastrointestinal tract malignancies.

The purpose of present study was to investigate mitochondrial DNA copy number (mtDNAcn) and mtDNA damage in peripheral blood of patients with Hashimoto's thyroiditis (HT) and healthy controls (HC).

The relative mtDNAcn and oxidative DNA damage in this case-control study were measured in peripheral blood of 50 patients with Hashimoto’s thyroiditis and 50 healthy controls using quantitative real-time PCR. The study was conducted in Tehran University of Medical Sciences hospital, Tehran, Iran in 2018.

HT patients had significantly higher mitochondrial DNA copy number and mitochondrial oxidative damage than the comparison group.

These data suggest the possible involvement of mitochondria and oxidative stress in the pathophysiology of HT.

Cancer is one of the most important causes of death in the world and has an increasing trend globally. We aimed at investigating the five leading cancers in Iranian women based on a 10-year history of cancer registry reports and illustrating the trends in all cancer sites and breast cancer as the top leading one from 2003 to 2015.

Data were obtained from national cancer registry study. Age-Specific Incidence Rate (ASR) data were obtained from Iran’s annual national cancer registry reports between 2003 to 2010 and 2014 to 2015. Using Joinpoint regression, we analyzed incidence trends over time for all cancer sites and the top leading cancer from 2003 to 2015.

Breast cancer was ranked first in Iranian women. Its ASR raised from 15.96 in 2003 to 32.63 in 2015. Results of trend analysis based on Annual Percent Change (APC) index showed 5.6 (95%CI: 2.9 to 8.3) and 4.6 (95%CI: 2.0 to 7.2) annual increase in the incidence of all cancer sites and breast cancer from 2003 to 2015, respectively.

This study indicates significant increasing trends in all cancer sites and breast cancer incidence in Iran. Despite the national coverage of cancer registry over the past decade, more considerations should be taken into account, especially in Breast cancer.

The prevalence of cardiovascular disease is dramatically increasing particularly in developing countries. Among the different factors, diet has an important role in the pathogenesis of these diseases. This study aimed to assess the relationship between dietary quality index-international (DQI-I) and cardiovascular risk factors in adult Iranian women.

This was a cross-sectional study of 371 participants, aged 20-50 yr, and recruited from 10 health centers from health centers affiliated with Tehran University of Medical Sciences (TUMS), Tehran, Iran in 2018. Usual dietary intake was evaluated by a validated and reliable 168-items food frequency questionnaire (FFQ). To assess overall quality of diet, the Dietary Quality Index-International (DQI) was used. Anthropometric measurements, blood pressure, and fasting blood of samples were taken to assess biochemical parameters related to cardiovascular disease.

The results of linear regression showed that DQI-I score was inversely and directly associated with serum level of total cholesterol (TC) (0.27, confidence interval (CI): 0.13-0.58; P<0.001) and high-density lipoprotein cholesterol (HDL-C) (2.53, CI: 1.42-4.52; P=0.001), respectively. However, there was no significant association between DQI-I and other cardiovascular risk factors.

A greater DQI-I score was associated with preferable lipid profile including TC and HDL-C. Future large-scale, prospective cohort or clinical studies are required to confirm these findings.