Medical Journal of Mashhad University of Medical Sciences
Year:2022 | Volume:65 | Issue:5|Papers Count:44

Introduction: With the increasing use of cyberspace, communication between people occurs easily, which can be associated with problems. The aim of this study was to investigate the mediating role of alexithymia in the relationship between childhood maltreatment and cyberbullying in adolescents. Methods: The method of the present study was descriptive-correlational through structural equation modeling. The statistical population included all adolescents aged 15 to 17 in the second and third grades of high school in Mashhad who were studying in the academic year 1399-1400. For this purpose, 471 people were selected by cluster random sampling method. Data were collected through an online questionnaire in schools in the second district of Mashhad. The research instruments included Patchin and Hindoja (2016) cyberbullying questionnaire, Bagbi et al. (1994) alexithymia questionnaire and child maltreatment of Mohammad Khani et al. (2013). Data analysis was performed using structural equations in Spss26 and Smart PLS3 software. Results: The results of structural equations showed that the direct paths of child maltreatment-alexithymia, alexithymia-cyberbullying were significant, but the indirect path from childhood maltreatment to cyberbullying mediated by alexithymia was not significant and the model fits well did not have. Conclusion: The results of the findings emphasized the need to pay attention to alexithymia in reducing cyberbullying.

Introduction: Physiological chronic diseases such as multiple sclerosis can reduce the resilience and mental coherence of patients. According to this the present study was conducted to investigate the effectiveness of psychological capital training on psychological resilience and sense of coherence of people with multiple sclerosis. Methods: The research method was semi experimental with a pre-test and post-test design with a control group and a 3 month follow-up phase. The statistical population of the study included people with multiple sclerosis who referred to health centers and clinics in Isfahan city in the first six months of 2022. 35 patients with multiple sclerosis were selected through purposive sampling method and randomly accommodated into experimental (18 people) and control groups (17 people). The experimental group received ten ninty-minute sessions of psychological capital training during ten weeks. The applied questionnaires included Psychological Resilience Questionnaire (PRQ) and Sense of Coherence Questionnaire (SCQ). The data from the study were analyzed through mixed ANOVA method via SPSS23 software. Result: The results showed that psychological capital training has significant effect on the psychological resilience (F=42. 59,Eta=0. 56,P<0001) and sense of coherence (F=56. 83,Eta=0. 63,P<0001) of people with multiple sclerosis. Conclusion: According to the findings of the present study it can be concluded that psychological capital training can be used as an efficient method to improve psychological resilience and sense of coherence of people with multiple sclerosis through applying the mechanisms such as optimism, self-efficacy, resilience and hope.

Introduction: The physical and psychological health of people in society is of fundamental importance,In this regard, the aim of this research is to investigate the social mechanisms of young athletes in terms of physical and psychological health. Methods: In this research, in order to determine the sample size, Cochran's formula of 381 samples was used as a multi-stage cluster sampling for an unlimited population. Ajmon independent t and Yeoman-Whitney statistics were used for data analysis and SPSS version 25 software was used at the level of 0. 05. Conclusion: The research results show that there is a significant relationship between social mechanisms and physical and psychological health (P<0. 05). Conclusion: It seems that planning on social mechanisms can play an essential role in the physical and psychological health of young athletes. (P <0. 05).

Introduction: Due to the fact that dyslexic children have more difficulty in reading and executive functions than children who are average or above average readers, so the purpose of this study is Effectiveness of Direct Instruction of Phonolical Awareness on Fluency and Executive Functions on Students with Dyslexia disorder. Material and Method: In this applied research, a single-subject research design and a multi-baseline design with different subjects were used. The statistical population studied in this study included all students with reading disorders in the second grade of elementary school who referred to Tonekabon Health Learning Disorders Center in the academic year of 2009-2010. The sample includes 3 students with reading disabilities who are selected by available means who were studying in different schools. First, WISC-IV children’, s Wechsler test, reading and dyslexia test (faç, ade), Strop test, Researcher-made comprehension test were completed. The sessions were conducted by the researcher, after the end of the fifteenth session, and 1 month later (in order to evaluate the sustainability of the effectiveness of the educational program) The questionnaires were completed again by the children of both groups. Results: The results of the research showed that the phonological awareness direct training program increased the subjects' reading skills, but it did not have a significant effect on the executive functions. Conclusion: The phonological awareness direct training program is a suitable intervention method to improve fluency and executive functions, so this program can be used to improve the health of dyslexic students.

Introduction Low back pain is physically debilitating and leads to reduced quality of life. Because traditional therapies (such as physiotherapy and medications) are not always effective, people with low back pain often seek complementary and alternative therapies. The aim of this study was to evaluate the effectiveness of the selected Swedish massage therapy protocol on pain in women aged 40 to 45 years with chronic non-specific low back pain in Bandar Abbas. Material and Method The current research is prospective and applied, which was carried out with a semi-experimental research design with a pre-test and post-test with a control group. The statistical population of this research is all women aged 40 to 45 in Bandar Abbas city who referred to the orthopedist's office due to nonspecific chronic back pain. The research samples were selected from among the clients with the coordination of the responsible doctor and according to the entry criteria checklist. Among the 45 people who qualified for the study, 24 people (people with body mass index less than 25) were selected as the research sample and randomly divided into two massage and control groups. A visual pain scale questionnaire was used to measure pain. Results Mean and standard deviation of age was 42. 64 1 1. 8 years, height was 162. 58 4 4. 2 cm, weight was 62. 25 4 4. 5 kg and body mass index was 25. 25. It was 23. 53 kg / m2. The results of independent t-test showed that there was no significant difference between the mean of age, height, weight and body mass index in massage and control groups. Statistical analysis of the data showed that there was a significant difference between the mean pain after the intervention in the two groups of massage therapy and control (t-11. 03, P = 0. 01). Conclusion The results of the present study showed that massage is effective on pain and can help reduce pain in these people.

Introduction Intensive care units (ICU) still face a high risk of primary and nosocomial infection. Pathogens in ICU are generally becoming more resistant to antimicrobial drugs, but there are differences between countries, possibly moving to different antibiotic usage patterns. It seems necessary to have adequate knowledge about local microbes and their sensitivity patterns in order to prepare an effective experimental treatment protocol in the ICU. In this study, the bacteriological profile and antibiogram of cultures performed in the ICU are investigated. Material and Method The cross-sectional study examined all culture samples obtained from patients in four intensive care units at Imam Reza Hospital, Mashhad, Iran, during 2016 to 2019. Culture and antibiogram information was extracted from the HIS system and compared with patient files whenever necessary. In order to analyze the data, SPSS software was used along with the Chi Square test. Results In total, 1569 samples were examined, and 674 (42. 95%) were positive for microbial culture. As the most commonly isolated bacteria, Acinetobacter accounted for 32. 9% of the cases in 222 cases. Candida accounted for 85 cases (12. 6%), Staphylococcus aureus 81 cases (12%), and Klebsiella 59 cases (7. 8%). Colistin, the most effective antibiotic against Acinetobacter, showed a resistance rate of 0. 9%, whereas carbapenems were not effective against over 95% of these bacteria. Conclusion Acinetobacter was the most common Gram-negative bacillus in intensive care units, accounting for more than half of infections. In addition, most of the tested antibiotics, except colistin, were resistant to these strains. Since these microorganisms are multidrug resistant, it is crucial that infection control processes in intensive care units are reviewed and standard antibiotics are prescribed.

Introduction: Exercise may activate important biochemical processes and change the phenotype of adipose tissue. The aim of the present study was to investigated the comparison effects of eight weeks of continuous and high intensity interval swimming on irisin tissue levels and insulin sensitivity in male rats with metabolic syndrome. Materials and Methods: 48 male Wistar rats with six weeks of age and a weight range of 150-180 gr were randomly divided into four groups of eight including: standard control, metabolic syndrome control, moderate continuous swimming + metabolic syndrome (CT + MetS) and high-intensity interval swimming + metabolic syndrome (HIIT + MetS). The training program was carriedout for eight weeks and five days a week, equivalent to 65 and almost 100 percent of the maximum oxygen consumption, respectively, for the program of CT and HIIT swimming. Measurement of blood and tissue variables (visceral fat and liver) was done by ELISA method and statistical analysis was done using one-way ANOVA analysis of variance at a significance level of p<0. 05. Results: The results showed that CT and HIIT swimming after induction of metabolic syndrome increased level of irisin in the liver tissue and visceral fat of rats (p=0. 002 and p=0. 0001, respectively),so the changes were higher after HIIT. The glucose levels in the CT and HIIT swimming group were significantly lower than the standard and the metabolic syndrome control (p=0. 0001) groups. No significant difference was observed in the insulin sensitivity (p=0. 67) between the training groups and the metabolic syndrome control group. Conclusion: It is possible that moderate and high intensity intermittent swimming induce protective effects on metabolic syndrome by increasing irisin and reducing blood glucose.

Introduction Amygdalin is a cyanogenic compound naturally present in apricot, peach, bitter almond, plum and apple seeds. The aim of this study was to evaluate the effect of amygdalin on cell survival and Malondialdehyde (MDA) level in the SK-BR-3 breast cancer cell line and to compare these effects on the healthy MRC-5 cell line. Material and Method Breast cancer cell line SK-BR-3 and healthy cell line MRC-5 were used in this study. To study the effect of amygdalin on the survival of these two cell lines and on the surface of MDA, concentrations of 2. 5, 5, 10, 20, 40 and 80 mg/ml of amygdalin were used. Cell survival was assessed by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyl-2H-tetrazolium bromide (MTT) assay and MDA level was assessed by thiobarbituric acid and spectrophotometric method. Statistical comparison of the mean between the groups was performed using a one-way analysis of variance (ANOVA) followed by a post hoc Tukey's test. Results Based on the results of the present study, amygdalin in a dose-dependent manner significantly reduced SK-BR-3 tumor cell survival and also significantly increased MDA levels in this cell line (P <0. 05), but it there were no statistically significant effect on the normal survival of MRC-5 cells and MDA levels (P >0. 05). Conclusion Amygdalin kills SK-BR-3 breast cancer cells by increasing the level of MDA in these cells.

Introduction The aim of this study was to determine the effectiveness of cognitive behavioral therapy on emotional processes in students with social anxiety disorder. Material and Method The present study was a quasi-experimental study with a pretest-posttest design and follow-up with a control group. The statistical population of the present study included all 26 to 18 year old female undergraduate students of Guilan University (11271 people) in the academic year 1397-98. At this stage, the Social Panic Questionnaire (SPIN) of Connor et al. (2000) was administered to all undergraduate female students of Guilan University who were selected using random sampling method. Cognitive behavioral therapy sessions for social anxiety disorder (Hayes, 2004) were conducted in 10 2-hour group sessions, but the control group remained on the waiting list. Analysis of variance with repeated measures and SPSS software were used to analyze the data. Results The results showed that cognitive behavioral therapy on the improvement of repression (F=10. 80, P=0. 003), unpleasant emotional experience (F=12. 86, P<0. 001), emotional symptoms Processing (F=16. 95, P<0. 001), avoidance (F=19. 65, P<0. 001) and emotional control (F= 21. 23, P<0. 001) of the experimental group subjects It was effective. Conclusion It can be concluded that cognitive behavioral therapy was effective on emotional processes in girls with social anxiety disorder.

Introduction Purpose of this study was to investigate of prevalence, phylogenetic groups and antibiotic resistance pattern EAEC isolated from diarrheic children in Mashhad city. Material and Method This cross-sectional study conducted for one year. In total, 450 diarrhea samples of children under 10 years of age were collected from children's specialized hospital in Mashhad. After isolation of Escherichia coli, EAEC isolates were identified by PCR molcular method. Phylogenetic groups of EAEC isolates were determined using the original and updated 2019 method. Antimicrobial susceptibility test was performed using disc diffusion methods(Kirby-Bauer method) against 12 antibiotics. Results 44(9. 8%) EAEC isolates were identified from 422(93. 8%) Escherichia coli isolates by PCR. Seven phylogroups including D(40. 9%), unknown(27. 3%), G(11. 4%), B1(9. 1%), F(4. 5%), B2(4. 5%) and A(2. 3%) were detected among EAEC isolates. The highest diversity of antibiotic resistance patterns was related to Phylogroup D. EAEC isolates showed the highest resistance to amoxicillin and erythromycin 100%. Overall, 97. 7% of EAEC isolates were with multiple drug resistance(MDR). Conclusion The present study showed a significant presence of EAEC strains. Considering the role of EAEC in chronic diarrhea and growth retardation syndrome in children, it is suggested that the identification of EAEC strains to be considered in diagnostic laboratories in cases of children’, s diarrhea. on the other hand, due to the high prevalence of multiple resistances, antibiogram test is required to treat diarrhea in children.

Introduction Sexual addiction is a psychiatric disorder with unpleasant personal, interpersonal, legal, social, and physical outcomes. Sexual addiction is mainly rooted in unpleasant experiences within family and during childhood. The purpose of this study was to investigate comparison of self-concept and childhood traumas of people with sexual addiction disorder with healthy people. Material and Method This study was a causal-comparative investigation and using purposive sampling method, was carried out on 50 people with sexual addiction disorder and 50 healthy people in the control group matching with age and academic. The study made use of the sexual addiction screening test-revised (SAST-R) of Carnes and et al, self-concept questionnaire (SCQ) of Rogers and short form of the childhood trauma questionnaire (CTQ-SF) of Bernstein and et al. In this study, Multivariate analysis of variance (MANOVA) was used for data analysis. Results The results of multivariate analysis of variance showed that there is a difference between self-concept and childhood traumas of people with sexual addiction disorder with healthy people,in this way, the people with sexual addiction disorder have lower scores in negative self-concept and childhood traumas than the healthy people. Conclusion These results have important implications of the role of unpleasant experiences in the family on the sexual behaviors of people in the later years of life. So that those who have negative self-concept and more childhood trauma are more to sexual addiction disorder.

Introduction Various studies have demonstrated that different rest Intervals has a significant effect on hormonal, metabolic and cardiovascular responses. This factors can lead to different muscle damage responses. Material and Method 20 untrained subjects (25. 4 ±,0. 068 years, height 1. 74 ±,0. 97 cm and weight 30. 8 ±,8. 48 kg) in three sessions of eccentric resistance exercise with 24 hours rest between each session Participated in this study. Subjects were divided into 2 groups of 10 subjects who performed 50 eccentric contractions with number of 5 sets, 10 repetitions, and the interset rest interval 1 and 3 minutes with 85% of one repetition maximum (1RM). Alpha necrosis tumor factor, were measured immediately before, immediately after each session and 24 hours after the last training session. Variance analysis with repeated measurment and Bonferroni post-hoc test were used to statistical analysis of data. Results Alpha necrosis tumor factor in the immediately after each training session and 24 hours after the last training session in 2 groups significantly increased (P <0. 05), but no significant difference in All dependent variable was found in 2 groups at different time points. Conclusion The repetition of eccentric exercise for three consecutive days causes muscle damage that can be a factor influencing the immune system and causing inflammatory responses in untrained individuals independent of manipulating the interset rest intervals.

Introduction A positive attitude towards drugs is an important factor in drug-seeking behavior, the occurrence of dependence and the continuation of drug abuse. The aim of this study was to determine the mediating role of ego capacity in the relationship between attachment styles and attitude towards addiction of clients who are quitting. Material and Method The method of this present study was descriptive-correlational. The statistical population of this research included all addicts who referred to addiction treatment centers in one district of Tehran for addiction treatment from July to October 2019. 214 samples were selected using random cluster sampling method. The data collection tools were Hazan and Shaver's Adult Attachment Questionnaire (1987), Markströ, m et al. 's (1997) Psycho-Social Ego Strength Inventory, and Theoretical Addiction Attitude Questionnaire (1379). Results Data analysis using structural equation modeling showed that secure attachment style had a negative effect on positive attitude towards addiction (β,=-0. 317,p < 0. 01) and anxious insecure attachment style (p < 0. 01) β, ,p<0. 01) and insecure avoidant (β, =0. 375,p<0. 01) have a positive effect on positive attitude towards addiction. Also, secure attachment style has a positive effect on negative attitude towards addiction (β, =0. 364,p<0. 01) and anxious insecure attachment styles (β, =0. 315,p<0. 01) and insecure avoidant (341) β,=-0. 01,p < 0. 01) have a negative effect on the negative attitude towards addiction. Ego capacity has a positive effect on the negative attitude towards addiction (β, =0. 512,p<0. 01) and has a negative effect on the positive attitude towards addiction (β, =0. 744,p<0. 01). Secure attachment style has a positive effect on ego capacity (β, =0. 743,p<0. 01) and anxious insecure attachment styles (β, =0. 732,p<0. 01) and insecure avoidant attachment styles (β, =0. 01,p<0. 01) β, ,p<0. 01) have a negative effect on ego capacity. Conclusion According to the findings of this study, it seems that supportive treatments can be appropriate in managing and reducing the intensity of consumption and modifying the attitude towards addiction, and in general, treating addiction and preventing relapse, and it is one of the costs imposed on families, society and the system. Reduce healthcare.

Introduction Diabetes is one of the most common metabolic diseases that has macrovascular and microvascular complications including nephropathy, retinopathy and neuropathy. Electrolyte and vitamin D disorders have also been seen in diabetic patients. The aim of this study was to investigate the relationship between serum levels of vitamin D, sodium and potassium with nephropathy in patients with type 2 diabetes. Material and Method This case-control study was performed on 83 patients with type 2 diabetes referred to Shahrivar Hospital in Mashhad in 2019 who were divided into two groups with nephropathy and no nephropathy. Fat, creatinine, FBS, HbA1c, GFR profiles were evaluated along with other demographic information. Serum level of vitamin D was measured by ELISA method and serum level of sodium and potassium was measured by atomic absorption spectrophotometry in all patients. IBM-SPSS v. 20 software was used to analyze the findings and the significance level of the tests was less than 0. 05. Results The mean age was 59. 27±, 10. 62 years which included 45 men and 38 women. Body mass index (P-value=0. 009), Smoking (P-value=0. 005), Duration of Diabetes, Systolic and Diastolic Blood Pressure, Potassium, FBS, HbA1c, Creatinine, GFR were significantly different between the two groups. (P-value=0. 0001 for each). Also, there was a significant relationship between serum vitamin D level (P-value=0. 004) with the incidence and serum potassium level with the severity of nephropathy (P-value=0. 001). Conclusion Control of serum levels of vitamin D and potassium can affect the incidence and severity of diabetic nephropathy, so control of these variables is recommended in these patients.

Introduction Obsessive-compulsive disorder is one of the most frequent mental disorders. On the one hand, various theoretical models emphasize different structures,on the other hand, OCD psychotherapies result in inadequate therapeutic outputs. Therefore, it is essential to look into this subject. This study extracted OCD diagnostic components based on lived experiences. Material and Method This study is qualitative and phenomenological. The information was gathered through the use of semi-structured interviews and criterion-based sampling. Accordingly, six participants with OCD were interviewed. The themes were extracted through performing interviews and obtaining lived experiences. Results In this research, four organizing themes were extracted. The organizing themes include Cognition (catastrophizing, should, excessive responsibility, and labeling), emotions (anger, fear, and sense of guilt), behavior (inspection, excessive washing, and avoidance), and lifestyle (interactions, excretion, work/education, and leisure activities). These organizing themes were the main components that can facilitate diagnosing and understanding OCD. Conclusion OCD is related to two major cognitive perceptions: 1. Excessive damage (risk) phobia, 2. Taking on excessive responsibility for damages (risks).

Introduction Various studies agree on the benefits of breast milk for mother and infant. Breast milk, which is the main food of the baby, is a complete diet in the first 6 months of life and alone is able to meet all the needs for the growth and development of the baby and leads to meeting all the growth and developmental needs of the first year of life. Therefore, interventions that can support breastfeeding and increase breastfeeding are important. So far, various educational interventions have been performed to continue breastfeeding, therefore, it is necessary to review the studies conducted to determine the quantity and quality and effectiveness of educational interventions in promoting breastfeeding behavior. In this systematic review, our aim is to evaluate the effectiveness of educational interventions in increasing the continuity of exclusive breastfeeding. Material and Method Literature search was performed using four databases of Scientific Jihad Scientific Information Center (SID), Iran Scientific Information and Documentation Research Institute (Irandoc), Database of Iranian Publications (Magiran) and Google Scholar. The present study includes studies from 5/24/2010 to 7/12/2020. Results A total of 11 studies, including data from 1275 participants, met the inclusion criteria. Eleven studies measured the amount of exclusive breastfeeding before and after the intervention, and 4 articles used the model and theories of health education for the intervention. The planned behavior pattern has been used in 3 studies and the health belief model once to improve breastfeeding. Conclusion We found that the design and implementation of educational intervention to continue breastfeeding significantly improves the awareness of the need for breastfeeding. Education can be effective in improving performance, awareness and attitudes among parents about how to breastfeed the baby, and since breastfeeding has many benefits for the infant, so use educational programs to teach breastfeeding. Mothers with fathers can be more likely to continue breastfeeding.

Introduction Dimensional stability of removable dentures in various disinfecting agents is considered an important and necessary property. The purpose of this study is to evaluate the dimensional stability of two types of heat-cured acrylic after immersion in distilled water, ozonated water and sodium hypochlorite solution. Material and Method In this in-vitro study, 60 disk-shaped samples were made, including 30 samples of Acropars heat cure acrylic resin and 30 samples of Pro Base heat cure acrylic resin. 30 samples of each acrylic were divided into three subgroups (n=10): 1) Immersion for 8 hours in distilled water (control group). 2) immersion for 8 hours in 1% sodium hypochlorite and 3) immersion for 8 hours in ozonized water. After every 8 hours, the solutions were changed and all samples were placed in disinfectant solutions for 16 weeks. Before and after immersion in each of the environments, the diameter of the samples was measured with an accurate micrometer with an accuracy of 1 micron. Finally, the obtained data were analyzed through appropriate statistical tests. Results Results showed that the dimensional changes of Pro Base heat cure acrylic resin by immersion in any of the 1% sodium hypochlorite solutions, ozonated water and, distilled water are not significant, and the dimensional changes of Acropars (Iranian) acrylic resin are not also significant in each of these solutions. Therefore, both disinfectant solutions are suitable for disinfection of dentures. Conclusion After 16 weeks of immersion, the change in dimensions of heat cure acrylic resins in ozonated water is clinically acceptable, and according to the confirmation of the appropriate disinfection property of ozonated water in previous research and further studies, it can be suggested to the patients as a suitable disinfectant for disinfection of dentures.

Introduction the age when menarche started as a reproductive trait has undergone a significant decline over the twentieth century which is widely attributed to environmental factors. The current study aims to investigate the environmental factors impacting menarche in the girl’, s school in Kermanshah, Iran. Material and Method in this case-control study, 400 participants of age 12 and over were recruited based on a cluster sampling strategy from three neighborhoods in Kermanshah, Iran. The questionnaires were measured based on demography, and physical and socio-economical status items. Logistic regression, Independent sample T test, Mann-Whitney, and chi-square were used for statistical calculations. Results It was observed that the girls with early menarche were significantly taller (p<0. 001) and heavier (p < 0. 001) than non-menarcheal. The obese and overweight girls had respectively 3. 36 and 2. 55 higher chance of early age at menarche in comparison with normal BMI ones. The mean birth weight of early menarche girls was 0. 18 kg lower than that of healthy girls. However, there was no significant difference in the age of complementary feeding and the breastfeeding period between the two groups. The girls who had low physical activity(OR=0/56, 95% CI 0/32-0/98), medium (OR=0/52, 95% CI 0/32-0/92), and high (OR=0/41, 95% CI 0/23-0/72), had respectively 44%, 48% and 59% lower risk of early menarche compared to inactive students. The statistical findings approved a correlation between the family income and premature menarche, whereas there was no correlation between parental education, occupational status, and early menarche. Finally, girls whose mothers had also early menarche tended to have the same experience compared to the control group. Conclusion the findings show that early menarche is associated with many environmental factors.

Introduction Candida albicans is a yeast-like part of the normal flora of the mucosal surfaces of the oral cavity, digestive tract, and vagina. This study aimed to determine the prevalence of candidiasis and its relation with predisposing factors such as age, sex, smoking and disease type (gastrointestinal problems, diabetes, and Alzheimer's disease). Material and Method In this cross-sectional study, lesions of 183 patients suspected of candidiasis(vaginal discharge, anal swab and oral)were sampled in2018. Candida species were identified using morphological, biochemical tests and culture on the CHROMagar Candida medium and the PCR-RFLP method was used for definitive identification of the candida species. Sampling was done with the consent of the subjects and the required data were recorded in the relevant questionnaire. The necessary data were recorded in the relevant data sheets and analyzed by Fisher and Chi-square test(P. value=0. 05). Results Of the 183 samples studied, Candida albicans with 98 cases(53. 55%)had the highest contribution. Results showed that 78. 12% of people with gastrointestinal candidiasis aged 55 to 80 years were suffering from Alzheimer's disease(P. value<0. 05). Also among the 56 diabetic patients, 36 (64. 28%) had oral candidiasis, most of which were in the age group of 18-30 years(P. value<0. 05). The distribution of vaginal candidiasis was significantly associated with gastrointestinal infections and age. There was no significant relationship between the distribution of candidiasis and smoking and sex(P. value>0. 05). Conclusion This study showed that candidiasis is highly prevalent in people with predisposing conditions, especially diabetes, Alzheimer's and people with digestive problems. Candida albicans and Candida tropicalis are the major contributing factors.

Introduction Chronic kidney failure is one of the diseases that affect the quality of life of people today. Peritoneal dialysis is one of the treatments for chronic kidney failure. Education is an important part of the care program that helps the patient to play an important role in the treatment process. The aim of this study was to evaluate the needs of patients undergoing peritoneal dialysis, which is based on nursing diagnoses, nursing interventions and the results obtained during the nursing process. Then, according to the needs of patients, a self-care educational program was developed. Material and Method The present study is a descriptive study that was performed on 74 patients referred to peritoneal dialysis wards of 5 medical centers. Demographic-clinical information was collected through patients' medical records and educational needs through face-to-face and telephone interviews with patients undergoing peritoneal dialysis. The training needs were determined based on the nursing diagnoses of the International Association of North America, and finally the self-care program was developed through nursing interventions related to common diagnoses and their expected outcomes. Data were analyzed by SPSS software version 26. Results and Conclusion Among the 20 nursing diagnoses presented in NANDA in patients undergoing peritoneal dialysis, 5 diagnoses including: water and electrolyte disorders, infection, constipation, sleep disorders, and skin integrity disorders are the most common. Self-care was developed to meet these needs.

Introduction Lactoferrin is a glycoprotein and one of the most important bioactives of milk, which has antibacterial, antiviral, antifungal and antiparasitic activity. Antimicrobial peptides have been receiving a lot of attention in recent decades due to having suitable properties such as fast killing, wide spectrum of activity and also their effectiveness in relation to drug resistance. Material and Method The purpose of this study is to investigate the antibacterial effect of silver lactoferrin nanocomplex on Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter baumannii and Streptococcus pyogenes. For this purpose, silver nanoparticles were first loaded on lactoferrin. Then, to confirm the loading of silver nanoparticles on lactoferrin, the zeta potential was measured by the zeta potential determination device. Also, with the help of Raman spectroscopy, FTIR and scanning electron microscope, the properties of this nanocomplex were investigated. Then the effect of lactoferrin + silver nanocomplex on cells was investigated to determine the toxicity of this compound on cells. The antibacterial properties of lactoferrin + silver nanocomplex on Pseudomonas aeruginosa bacteria, Staphylococcus aureus bacteria, Streptococcus pyogenes bacteria and Acinetobacter baumannii bacteria were investigated by MTT test, MIC, MBC tests and diffusion in agar hole Results The results show that lactoferrin + silver nanocomplex had the most lethal effect on Streptococcus pyogenes bacteria and the least effect on Acintobacter baumannii bacteria Conclusion Synthesis of silver-lactoferrin nanoparticle complex can be used as an innovative, economic antimicrobial agent in the field of medicine and food industry.

Introduction Research has shown that positivist psychotherapy leads to marital adjustment in couples. On the other hand, acceptance and commitment therapy has been effective in reducing issues such as conflict and conflict, adaptation and commitment meaning a rich and meaningful life, but there is a research gap in comparing the two approaches. The purpose of this study is to compare the effectiveness of couples. Positive therapy and therapy was based on acceptance and commitment to increase marital adjustment in couples. Material and Method The method of the present study was quasi-experimental with a pretest-posttest design with a control group. The statistical population included all couples seeking divorce who had referred to family counseling centers in Iranshahr in 1399 for couple therapy. 45 couples were selected by convenience sampling method and then randomly divided into two groups of 30 experimental and one group of 30 controls. Participants responded to the Lock and Wallace Marital Adjustment Questionnaire (1995). Couples therapy, positive therapy Seligman and Sequent Mihali (2000) and therapy based on acceptance and commitment Hayes, Strosahel and Wilson (2012) performed in 8 sessions of 90 minutes on the experimental groups and after the post-test sessions. Done. Finally, after the post-test, the results were analyzed by analysis of covariance. Results The results showed that couples therapy, positive therapy and acceptance and commitment based therapy were effective in increasing marital adjustment in couples (P <0. 01). Also, positive couple therapy training had a more significant effect than acceptance and commitment therapy (P <0. 01). Conclusion Considering that both interventions had a strong effect on increasing marital adjustment, but positive couple therapy was more effective in increasing marital adjustment and negligence, so the combination of these two methods in couples therapy interventions will probably lead to more effective results.

Introduction and purpose: The birth of a child with a disability causes mothers to face various psychological, emotional and social injuries. according to this the present study was conducted to investigate the effectiveness of self-compassion training on hoping for constructive relationships of mothers with exceptional children. Methodology: The present study was quasi-experimental with pretest, posttest, control group design. The statistical population of the research included mothers with exceptional children whose children were studying in one of the exceptional schools of Rafsanjan city in the academic year of 2019-2019, and their number was 320 in total. 37 mothers with exceptional children were selected through voluntary sampling method and were randomly accommodated into experimental and control groups. The experimental group received self-compassion training during twelve sessions. The applied questionnaires included Hope Questionnaire (Snyder et al, 1991). The data from the study were analyzed through Covariance using SPSS statistical software version 23. Findings: The results showed that self-compassion training has significant effect on the hoping for constructive relationships (F=47. 57,Eta=0. 58,P<0001) in mothers with exceptional children. Conclusion: According to the findings of the present study, self-compassion training can be used as an efficient method to improve hoping for constructive relationships of mothers with exceptional children through focusing on the method of Visualizing compassion for self and others, using creative helplessness, articulating worthwhile goals, fostering compassionate behaviors, and developing intelligent behaviors.

Introduction: The purpose of the research was to investigate the effectiveness of cognitive therapy based on mindfulness on sleep disorder, ataxia and rumination in patients with irritable bowel syndrome. Methods: In order to select the participants, 30 patients were selected from the women with irritable bowel syndrome who referred to the public health center in Kerman in 1400 based on the study entry and exit criteria and were divided into two cognitive therapy groups based on mindfulness. (15 people) and control (15 people) were placed. Cognitive therapy based on mindfulness was performed during 12 weekly sessions based on Segal and Tizdel's guidelines, and the control group did not receive any treatment. Questionnaires of sleep disorder, alexithymia and rumination were completed in three stages: pre-test, post-test and follow-up. Results: The results of mixed analysis of variance showed that cognitive therapy based on mindfulness had a significant effect in improving sleep disorder and rumination in the post-test and follow-up phase (P≥, 0. 001), but it did not have a significant effect on the emotional ataxia variable (P≤, 0. 001). Conclusion: It seems that cognitive therapy based on mindfulness is effective in improving the sleep disorder and rumination of female patients with irritable bowel syndrome, but it is necessary to investigate this treatment method in men to confirm this result.

Introduction The present study was conducted with the aim of predicting death obsession based on anxiety sensitivity, mindfulness and psychological toughness in people with type 2 diabetes. Material and Method The current descriptive-correlation study and the statistical population included men and women with type 2 diabetes in Tehran between May and November 2022, from which 134 people were selected by convenience sampling. The data were obtained using the death obsession scale of Abdul Khaliq (1998), the anxiety sensitivity questionnaire (ASI) of Reiss and Patterson (1985), the FFMQ mindfulness questionnaire of Bayer et al. (2006) and the psychological toughness scale of Ahvaz Kiamarthi et al. Came. The data obtained from the implementation of the research were analyzed using the methods of descriptive statistics and inferential statistics (correlation matrix) as well as the analysis of the raw data obtained from the research in the software (SPSS). Results The results showed that the variable of anxiety sensitivity has a direct effect on death anxiety (0. 735), the variable of psychological toughness has an inverse effect on the variable of death anxiety (-0. 251), and the variable of mindfulness has an inverse effect on the anxiety variable. Death has an effect (-0. 219). Conclusion It can be concluded that death anxiety can be predicted based on anxiety sensitivity, psychological toughness, and mindfulness, and anxiety sensitivity, psychological toughness, and mindfulness variables are predictors for death anxiety.

Introduction: The link between sciences, including disciplines such as psychology and social sciences, can bring practical and useful results for the society. In this regard, the current research examines the social and psychological structures of women in Tehran. Methods: The descriptive research method is a survey. The statistical population of the research by age group (14-50) in Niavaran and Molavi areas of Tehran is 370626 people and 384 people were selected as the research sample according to Cochran's formula. Independent t, Yeoman-Whitney and Wilcoxon tests and SPSS version 25 software at the level of 0. 05 were used to analyze the data. Results: The results showed that social structures and its components predict the psychological level of people in that society (P<0. 05). Conclusion: It seems that paying attention to the psychological status of people according to different levels of society is one of the important points that can be considered in planning.

Introduction Marriage is one of the most important events in life. A successful marriage and starting a marital relationship will satisfy many physical and psychological needs in a safe environment. This study was conducted with the aim of the effectiveness of the marital satisfaction model on increasing the sexual quality of couples. Material and Method In terms of the research method, the present study is the analysis of structural relations for developing a correlation type model. The research population included all married men and women who referred to the laboratory of the family clinic and the specialized clinic of Quds Hospital in Sanandaj. To determine the sample size in this research, 500 subjects were selected using available sampling method and research tools were implemented on them. The research tools in this study are the questionnaires of Nathan H. 's Marital Satisfaction Questionnaire. Azrin, Barry T. Naster and Robert Jones (1973), the questionnaire of the quality of sexual life of women by Simmonds et al. (2005) and the quality of sexual life of men by Pakpour et al. Results The obtained results show that there is a significant difference between the average scores of the post-test of the quality of sexual life of women in the control and experimental groups, and there is also a significant difference between the average scores of the post-test of the quality of sexual life of men in the two groups of the control and the experiment (p< 0. 05). Conclusion To improve marital quality, it is necessary to focus more on "marital satisfaction".

Introduction This study aimed to investigate the effect of organizational bullying on turnover intention with the mediating role of burnout and moderating role of Compulsory citizenship behavior. Material and Method this is Quantitative research and applied descriptive-survey study in which the statistical population includes 1132 registered and contract registered nurses of ImamReza Hospital in Mashhad. Cochran's formula was used to determine the sample size, based on this, 287 of them were selected as statistical sample with the random sampling method. To collect data, the Inarsen et al. 's (2009) organizational bullying questionnaire, Memon et al. 's turnover intention (2014), Copenhagen burnout (2005), and Vigoda-gadot (2007) Compulsory citizenship behavior questionnaires and For analyzing them, Structural equation modeling with partial least squares approach and smart-PLS software were used. Results Data analysis using structural equation modeling showed that the direct effect of organizational bullying on turnover intention is 0. 524 and significant (p<0. 05). The direct effect of organizational bullying on burnout is 0. 752 and significant (p<0. 05). The direct effect of burnout on organizational bullying is 0. 492 and significant (p<0. 05). Also, burnout mediates the relationship between organizational bullying and turnover intention (t=3. 863 and β,=0. 371). In addition, Compulsory citizenship behavior moderates the relationship between organizational bullying and turnover intention. Conclusion The result of this research showed that burnout plays a mediating role in the relationship between organizational bullying and nurses' turnover intention. Based on this, it is suggested to through identifying the causes of nurses' burnout and reducing it's occurrence, The rate of their turnover intention should also be reduced. This result can also be achieved by reducing Compulsory citizenship behavior in nurses.

Introduction Marital infidelity causes serious psychological and emotional damage to women. According to this the aim of this study was to develop a attachment-based mindfulness therapy was prepared and its efficacy was evaluated on the self-compassion and emotional experience with spouse in the women with the experience of marital infidelity. Material and Method The research method of the present study was comparative analysis according to Breddy’, s comparative method in the qualitative part and it was quasi-experimental with pretest, posttest and control group with two-month follow-up test in the quantitative part. The statistical population of included the women with marital experience who referred to consultation centers in the city of Tehran in the autumn 2020 in the quantitative part. 25 women with marital experience were selected through purposive sampling method and were randomly accommodated into experimental and control groups in order to do the study. The experimental group received eight sessions of attachment-based mindfulness therapy during two months. The applied questionnaires in this study included self-compassion questionnaire (Neff, 2003) and emotional experience with spouse scale (O’, Leary et al, 1975). The data from the study were analyzed through Mixed analysis of variance and Bonferney post hoc test via SPSS23 statistical software. Results The results showed that the attachment-based mindfulness therapy enjoys acceptable content validity. Moreover, this therapy has influenced on the self-compassion (P<0. 001, Eta=0. 61, F=36. 08) and emotional experience with spouse (P<0001, Eta=0. 53, F=26. 72) in the women with marital infidelity. Conclusion According to the findings of the study, attachment-based mindfulness therapy can be used as an efficient method to improve self-compassion and emotional experience with spouse in the women with the experience of marital infidelity through employing theoretical concepts of mindfulness therapy and attachment.

Introduction The most common type of cancer is skin cancer, especially in men. Lacticin 3147 is a bacteriocin from the lantibiotic family. Since it is similar to nisin, Lacticin was considered for its anticancer properties’,investigation. The aim was to investigate the effect of Lacticin 3147. The MTT Assay helped assess A431 cell survival and cytotoxicity following treatment with Lacticin 3147 after 24 and 48 hours. The cell apoptosis amounts were investigated by measuring the activity of caspases 8 and 9 in A431 cancer cells treated with the IC50 concentration of Lacticin 3147 after 24, 48, and 72 hours. The Boyden Chamber method evaluated the invasion ability of A431 cancer cells treated with a sublethal dose of Lacticin 3147. Specific primers were designed for proapoptotic genes bax, antiapoptotic bcl-2, and the reference gene ꞵ,-actin. The expression level in A431 cells treated with IC50 concentration of Lacticin 3147 was investigated using the quantitative Real-Time PCR method. Data were analyzed by SPSS 16 software and ANOVA statistical test (P<0. 05). Statistical analysis of the data obtained from the MTT test showed that the growth of cells treated with different concentrations of Lacticin 3147 decreased significantly (p<0. 001). The inhibitory effect of Lacticin 3147 on the viability of A431 cells depends on the concentration and treatment time. As a result, a 0. 3 μ, M concentration and 72-hour duration were the most consequential effects. Lacticin IC50 concentration was equal to 0. 8 μ, M. The activity of caspases 8 and 9 in the treated A431 cancer cells increased in a time-dependent manner, and after 72 hours, it was 2. 36 and 2. 72 times compared to the control, respectively (p<0. 001). The invasion activity of A431 cancer cells treated with the sublethal dose of Lacticin 3147 decreased in a dose-dependent manner. The lowest invasion activity was at concentration of 0. 5 μ, M with minimal lethal effect (p<0. 001). The expression of the bax proapoptotic gene in A431 cells treated with IC50 concentration of Lacticin 3147 increased significantly (p<0. 001). Also, the antiapoptotic bcl-2 gene expression reduction was significant in the same conditions. As a result, the use of Lacticin 3147 in the future may lead to a new strategy for the treatment of skin cancer.

Introduction: Marital forgiveness is one of the factors related to intimacy, commitment and reduction of marital conflicts and in general is one of the most important effective factors in marital satisfaction,Therefore, the main purpose of this study was to determine the effectiveness of the protocol extracted from the causal model of marital forgiveness on marital intimacy, marital commitment and marital conflicts. Methods: The present research is experimental of pre-test and post-test type with a control group, which 40 people were selected by the available sampling method, based on the research entry criteria, from among all the women who referred to the counseling centers of Hamedan city in 1400. who were randomly replaced in two experimental and control groups (20 people in each group) and the experimental group received the designed forgiveness intervention extracted from the causal model in a group manner in 8 sessions of 120 minutes. Collected data through Asoudeh and Timuri's Perceived Intimacy Questionnaires (1387), Sanai Zakir and Barati's Marital Conflict Questionnaire (2008), Adams and Jones's Marital Commitment (1997), the research units before and after the intervention using SPSS22 statistical software was analyzed. Results: The findings showed that the protocol derived from the causal model of forgiveness was effective on increasing women's commitment and intimacy in life by (0. 18, 0. 16) and reducing marital conflicts (0. 56). Conclusion: According to the obtained results, it can be said that the forgiveness protocol group training approach has been effective in reducing marital conflicts and increasing the commitment and intimacy of women in life.

Introduction The family is the first founder of human personality, values and attitudes, and its emergence in the current style is one of the valuable characteristics of human beings compared to other creatures. The purpose of this research is to qualitatively investigate the causes of conflict between couples. Material and Method The method of the current research is a qualitative method of the grounded theory type, which collects information through an inductive and exploratory research method. the statistical population of the research is all couples with marital conflict referring to counseling centers in Tehran in 1400-1999, who at least 1 year has passed since their marriage. The data collection tool was an in-depth interview. In the qualitative part, interviews were conducted with the interviewees who were selected purposefully and the statistical sample of the research reached saturation with 15 couples. Results Based on the qualitative analysis of this research, the causes of conflict between couples are categorized into six categories: the interference of significant others (spousal discrimination), past and present unresolved disorders and injuries, economic and financial issues, individual components of couples, crises and Milestones of life, virtual shelter. Conclusion Based on this, it is necessary to pay attention to the role of other people's interference (differentiation of marital incompatibility), past and present unresolved disorders and injuries, economic and financial issues, individual components of couples, crises and milestones in life in order to reduce marital conflicts. It reduced the marital conflicts of couples.

Introduction The purpose of this study was to develop a model for students' academic achievement through executive functions, psychological capital and academic engagement. The present study by correlation method and in the group of nonexperimental causal designs by path analysis which examines nonexperimental causal relationships through correlations between them. The statistical population of the study included all girl elementary students in the sixth grade of public schools in District 4 of Tehran in the academic year 2021-2022. Sample size Based on Morgan table, 240 students were selected by cluster random sampling. The Research tools were included the Executive Functional Behavior Rating Questionnaire (BRIEF), the Lutans and Olivier (2007) Psychological Capital Questionnaire, the Academic Conflict Questionnaire, and the Pham and Taylor (1994) Academic Achievement Questionnaire. the results obtained using structural equation modeling showed that in the whole sample, all path coefficients between variables were statistically significant. In this model, the effect of executive functions, psychological capital and variable (external) academic engagement on academic achievement (endogenous variable) was positive and significant.

Introduction The purpose of this research is to investigate the effect of academic vitality on students' self-efficacy with the mediating role of peer support and academic resilience. Material and Method The method of the present research is practical in terms of purpose, and in terms of the method of data collection, it is descriptive of the correlation type. The statistical population of this research is all male students of the first secondary level of Qain city, based on stratified random sampling, 214 of them were selected as a sample. SPSS and Smart-PLS software were used for data analysis. To measure the research variables, Martin and Marsh (2013), Liang (2000), Martin and Marsh (2006) and Jiang (1999) questionnaires were used, and their reliability was confirmed by Cronbach's alpha. Academic vitality has a positive and significant effect on students' self-efficacy both directly and indirectly through the mediation of peer support and academic resilience. Results The results of the present research have brought innovations in the field of self-efficacy and personal development of students and help the officials and policy makers of the country's education in understanding the effectiveness of academic vitality, peer support and resilience in promoting self-efficacy.

Introduction: In addition to attention deficit hyperactivity disorder and impulsivity, children with attention deficit hyperactivity disorder also have major problems with sensory processing. The aim of this study was to determine the effect of family-based sensory diet on Attention Deficit Hyperactivity Disorder. Methods: The research method was quasi-experimental with pre-test-posttest design with control group and one-month follow-up test. From the statistical population of children with attention deficit hyperactivity disorder aged 6 to 12 years referring to Hasti, Bahar and Masir Sabz treatment clinics in 1399 in Tehran, 30 people were selected by available sampling method and randomly assigned to intervention and control groups. They underwent 12 sessions of family-based sensory diet program intervention, which was derived from Wilburger's sensory protocol and were tailored to each child's sensory status, 3 days a week and each session lasted 45 minutes. To measure the variables, Wechsler Children's Intelligence Scale and Conners Parent Form Scale were used and to assess the sensory status of children, a sensory profile questionnaire was used. Statistical tests included repeated measures analysis of variance and Bonferroni post hoc test. Results: The findings showed that the mean scores of post-test and follow-up test for attention deficit, hyperactivity and impulsivity in the experimental group decreased and the results of repeated measures analysis of variance showed that this decrease was significant and stable. Conclusion: Sensory diet intervention is a new and effective intervention in children with attention deficit hyperactivity disorder and improves the symptoms of these children and their performance in various social situations and can be used in Iran as a new method. Functional and free to use.

Introduction: The impact of cancer patients on various biological, psychological and social aspects of the disease requires the need for psychological interventions. This research was conducted with the aim of determining the effectiveness of compassion therapy on body image, post-traumatic growth and death anxiety of breast cancer patients. Method: In the form of a semi-experimental design, pre-test, post-test and follow-up test with a control group, 30 people were randomly selected from the patients with breast cancer in district 1 of Tehran by available sampling method and randomly divided into test and control groups. They were replaced. The required findings were collected by using body image, post-traumatic growth and death anxiety questionnaires in three pre-tests, post-test and follow-up tests, and by using variance analysis with repeated measurements. and Bonferroni's post hoc test was analyzed. Results: Descriptive findings and analysis of variance with repeated measurements showed that compassion therapy intervention is effective in improving body image, post-traumatic growth and death anxiety of breast cancer patients (p<0. 001) and Bonferroni post hoc test. also showed that this effect is permanent due to the passage of time. Conclusion: Compassion therapy intervention can be used to increase body image and growth after the accident and reduce death anxiety in breast cancer patients.

Introduction: Research has shown that lifestyle components can be associated with human health and osteoporosis can endanger health, especially in women,Therefore, the aim of this study was to investigate the relationship between lifestyle and osteoporosis in women. Methods: The research method is survey and the data collection tool is a questionnaire. The statistical population of the present study in the 17th and 4th districts of Tehran is 253, 360, of which 382 samples were selected based on random sampling. Independent t-test, Human Whitney, Wilcoxon were used to analyze the data. Results: The results showed that there is a significant relationship between lifestyle and osteoporosis. Conclusion: It seems that lifestyle should be given more importance during adolescence, especially female adolescents, because lifestyle changes in adolescence play an important preventive role in the development of osteoporosis in adulthood.

Introduction: Considering that the prevalence of paranoid thoughts increases with age and the person suffering from it becomes resistant to treatment,Therefore, this research was conducted in order to compare the effectiveness of life skills training and group relaxation on the paranoid thinking of Imam Khomeini nurses in Arak city. Methods: The statistical population of the research was all the nurses of Imam Khomeini Hospital in Arak, 45 of whom were selected as available and were randomly divided into three experimental groups 1, 2 and control. Experimental group 1 underwent life skills training and experimental group 2 underwent relaxation training. The executive protocol consisted of 10 sessions of 45 minutes and twice a week. Paranoid thinking scale (Green, 2008) was the instrument used. Single factor covariance test, multivariate covariance test and Ben Feroni post hoc test were used to analyze the data using SPSS version 25 software. Results: The findings showed that both approaches of life skills and group relaxation have a significant effect on the paranoid thinking of Imam Khomeini Hospital nurses in Arak city (p<0. 001). Also, the approach of life skills is more effective on paranoid thinking than group relaxation. There is no statistically significant difference between the mean scores of the post-test and the mean scores of the follow-up test, which indicates the stability of the results affected by the therapeutic interventions over time. Conclusion: According to the results, it can be said that teaching life skills can be more effective on paranoid thinking.

Introduction: Health tourism is one of the growing industries in the world. The main goal of this research was discovering the background model of word of mouth advertising in the development of health tourism. Methods: In this research, the researcher has used a mixed approach. For this purpose, in the first study, in order to know the components of the background model of word of mouth advertising in the development of health tourism from the foundation data approach, and in the second study, the model was tested using a quantitative method. In the first study, the required data collection tool was the protocol and in-depth interview with eighteen hospital managers, and in the next step, the required data was distributed among 384 patients and the results were analyzed by AMOS software. Results: The researcher has conducted eighteen interviews to theoretical saturation and finally extracted 250 open codes and based on Strauss and Corbin's point of view, the analysis and results have been presented in the form of six main dimensions and thirty sub-dimensions. Conclusion: The researcher presented his research in the form of a model including six dimensions, health tourism, brand equity of the health center brand, word of mouth advertising, quality of medical services, halal tourism, loyalty to the therapy center brand, and thirty sub-dimensions. Also, the results of the research have shown that the satisfaction with the treatment and medical staff and the accommodation of the patient and companion has a positive and significant effect on the increase of word of mouth advertising from the hospital and medical centers.