Iranian Red Crescent Medical Journal
Year:2014 | Volume:16 | Issue:6|Papers Count:20

Background: Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that leads to a progressive ankylosis of vertebras and ossification of paravertebral ligaments. Bone loss and osteoporosis are amongst the important complications of AS, treatment of which is a challenging issue.Objectives: This study aimed to clarify the effect of alendronate on the prevention of bone loss in patients with early AS.Patients and Methods: In a randomized, double-blind, placebo-controlled study, 24 patients with early stages of AS were recruited in Emam Reza Hospital, Tabriz University of Medical Sciences. The diagnostic criteria of early AS were Schober’s index ³ 5, normal hip joint in pelvic radiography, and absence or rarity of syndesmophytes in spine radiography (Taylor index £ 1). The participants were randomly allocated to the treatment and control groups and received 70 mg/week of alendronate and the same dose of placebo, respectively, for 12 months. Before and 12 months after the intervention, bone densitometry was performed from lumbar and pelvic region using the dual-energy X-ray absorptiometry (DEXA) method with Hologic QDR model instrument. Patients, physicians who prescribed the medications and those who interpreted the outcomes, and densitometry technicians were unaware of the assigned medication to each patient. Both groups received supplemental calcium (1000 mg/day) and vitamin D (400 mg/day).Results: After 12 months of treatment, hip and lumbar bone mineral density differences were not statistically significant between study groups (P=0.061 and P=0.112, respectively). No case of clinically apparent vertebral and nonvertebral fracture were observed in the treatment and control groups. Conclusions: Our results suggested that applying alendronate was ineffective in preventing bone loss in patients with early stages of AS.

Background: Cervical spondylotic myelopathy (CSM) is a common cause of significant clinical morbidity. The Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) is a measure of health-related quality of life in these patients.Objectives: This study aimed to cross-culturally translate and validate the JOACMEQ in Iran.Patients and Methods: This study was a prospective clinical validation one. Forward-backward procedure was applied to translate the questionnaire from English into Persian. The translation and cross-cultural adaptation were performed in accordance with the published guidelines. A sample of patients with CSM was asked to respond to the questionnaire at two times: providing preoperative and postoperative assessments (6 months follow-up). To test the reliability, the internal consistency was assessed by Cronbach α coefficient and the validity was assessed by convergent validity. Responsiveness to change was also assessed comparing patients’ preoperative and postoperative scores.Results: All 87 patients completed the questionnaire. The Cronbach α coefficient for the JOACMEQ at preoperative and postoperative assessments ranged from 0.71 to 0.82 indicating a good internal consistency for the questionnaire. In addition, the correlation of each item with its hypothesized subscale of the JOACMEQ showed satisfactory results suggesting that the items had a substantial association with their own subscales. Further analysis also indicated that the questionnaire was responsive to change (P<0.001).Conclusions: In general, the findings suggest that the Persian version of the JOACMEQ is a reliable and valid measure of functionality and quality of life evaluation among Iranian patients suffered from CSM.

Background: Cardiovascular diseases are the leading causes of death around the world. The coronary artery disease (CAD) is one of the most common diseases in this category, which can be the trigger to various psychosocial complications. We believe that inadequate attention has been paid to this issue.Objectives: The purpose of the present study was to explore the psychosocial complications of CAD from the Iranian patients’ perspective.Patients and Methods: A qualitative design based on the content analysis approach was used to collect the data and analyze the perspective of 18 Iranian patients suffered from CAD, chosen by a purposeful sampling strategy. Semi-structured interviews were held in order to collect the data. Sampling was continued until the data saturation. The data were analyzed using qualitative content analysis approach by MAXQUDA 2010 software.Results: This study revealed the theme of the patients’ challenges with CAD. This theme consisted of: "primary challenges, "including doubting early diagnosis and treatment, and feeling being different from others; "psychological issues, " including preoccupation, fear of death and surgical intervention, recurrence stress, anxiety and depression; "problems of life, " including financial problems, work-related problems, and family-related problems; and "sociocultural issues, " including change in perspective of people towards the patient, and cultural issues. Conclusions: Although the management of physical problems in patients with CAD is important, psychosocial effects of this disease is more important. Thus, health care personnel should pay ample attention to identify and resolve psychosocial problems of these patients.Results of this study can be used to empower these patients.

Background: Vitiligo is one of the autoimmune skin diseases that destroy the melanocytes of the skin. Moreover, its prevalence varies in different countries and regions.Objectives: The aim of this study was to compare the effect of Nigella sativa and fish oil on vitiligo lesions of the patients referred to a dermatology clinic.Materials and Methods: This randomized, double blind clinical trial was conducted in the dermatology clinic of the Imam Khomeini Hospital Ahvaz, Iran, from June to December 2011. We used a randomized simple sampling. From 96 patients with vitiligo, 52 eligible patients were selected and allocated to two groups with equal size. The study medications were applied twice a day by patients on their lesions. After six months, the improvement rate of lesions was assessed by the Vitiligo Area Scoring Index (VASI). Data were analyzed using SPSS v. 15; P value<0.05 was considered as statistically significant.Results: After six months, a mean score of VASI decreased from 4.98 to 3.75 in patients applying topical Nigella sativa and from 4.98 to 4.62 in those using topical fish oil. Most of the percent improvement observed in upper extremities, trunk, head, and neck of those who received Nigella sativa and head, neck, trunk, and feet of those who received fish oil. No adverse effect was reported by the patients.Conclusions: Nigella sativa oil and fish oil were effective in reduction the size of patient’s lesions; however, Nigella sativa was more effective in comparison to the fish oil. Therefore, using Nigella sativa with the major drugs in the treatment of vitiligo is recommended.

Introduction: Hirsutism is a common disorder of excess growth of terminal hair in an androgen-dependent male distribution in women, including the chin, upper lip, breasts, back, and abdomen. It is very important to identify the etiology of hirsutism and adequate treat is prior to any cosmetic therapy.Case Presentation: The case was a 17-year-old female with severe hirsutism, oligomenorrhea, and obesity. She was evaluated to identify the etiology and diagnosed as a case of polycystic ovarian syndrome (PCOS), nonclassic congenital adrenal hyperplasia (NC-CAH), and hyper androgenic insulin-resistant acanthosis nigricans (HAIR-AN) syndrome, which is a rare combination of hirsutism etiology. She was successfully treated according to the underlying pathology, and laser photo epilation was used as the preferred hair removal method.Discussion: Establishing the etiology, using the evidence–based strategies to improve hirsutism, and treating the underlying disorder, are essential for proper management of women with hirsutism.

Background: Responsiveness assessment of health system with the quality information is the key in effective evidence-based management of the health system.Objectives: This qualitative study defines the necessary components required for the health system responsiveness assessment information system (HS-RAIS).Materials and Methods: This study was conducted based on mixed-methods approach and by using Delphi technique (29 participants in first round and 25 participants in second round) and semi-structured interviews in Iran 2013. The participant selection strikes a balance between being able to provide valid data, and increasing representative’s leverage. The final framework for HS-RAIS was extracted from in-depth interviews with ten key informants.Results: We followed these recommendations and developed a framework in 10 components including: minimum datasets, data sources, data gathering, data analysis, feedback and dissemination, legislative needs, objectives of health system responsiveness assessment, repetition period, executive committee and stewardship.Conclusions: This framework provides useful information for decision-making at all levels about assessment of health system.

Context: Helicobacter pylori is the most common infecting organism affecting humans, being almost half the population infected. The aim of this study was to find out the epidemiological features and the sensitivity of diagnostic methods of Helicobacter pylori infection in Iran, which can provide the logic of developing preventive approaches to control Helicobacter pylori infections and the associated diseases.Evidence Acquisition: By reviewing the databases of SID, MAGIRAN, SCOPUS, MEDLIB, Google, ISI and PUBMED, a total of 30 papers, published from 1994 to 2011, were extracted. Summary prevalence and 95% confidence intervals (95% CI) were calculated using random-effects model. Statistical analyses were performed using STATA Ver.11.Results: Among the 30 studies evaluated, the prevalence rate of Helicobacter pylori infections in Iran was estimated as 50.7 % (95% CI: 44.4-56.9%). When the sensitivity of diagnostic methods was evaluated, ELISA, with an accuracy rate of 52.3% (95% CI: 43.8 to 60.8%) was found the most accurate diagnostic method available. The highest and the least Helicobacter pylori prevalence were 19.2% in Tehran and 74.27% in Mazandran respectively.Conclusions: About half the population in Iran is infected with Helicobacter pylori, the pollution in different areas and preventive strategies should be carried out to control this infection. The prevalence rate of Helicobacter pylori infections in Iran showed only little changes during the years 1994 to 2011.

Introduction: Tumors which originate from the Bartholin’s glands (BGs) are very rare. Many solid masses that arise from the BGs are carcinoma, though these benign solid lesions are rare.Case Presentation: To the best of the reporter’s knowledge, about 35 cases have been reported in the English literature so far, most of which accompanied with signs or symptoms of Bartholin’s duct cyst. In this paper we report a 43-year-old woman with bilateral solid masses in the BGs, incidentally detected during anterior-posterior colpoperineoplasty. The masses were then excised.Discussion: The histopathological examination showed increased number of acini with preserved duct-acinar connection, consistent with nodular hyperplasia. The patient had used oral contraceptive pill for four years.

Background: Multiple Sclerosis (MS) is a demyelinating disease of the nervous system which has numerous disabling effects on patients. Objectives: This study aimed at investigating the short- and long-term effects of a period of combination exercise therapy on walking distance, balance, fatigue and quality of life in multiple sclerosis patients referred to the physiotherapy clinic of Iran's Multiple Sclerosis Society in 2013.Patients and Methods: This study was a randomized controlled clinical trial on 59 patients divided into the intervention (n=39) and control groups (n=20). The intervention group received 10 weeks of combination therapy including aerobic, strengthening, balancing and stretching exercises. A week before, a week later and a year after the beginning of the exercises, both groups of patients received BBSS, six minute walking, Family Support Services (FSS), Expanded Disability Status Scale (EDSS) and quality of life tests. The scores of two groups were then compared using statistical tests such as repeated measures ANOVA test.Results: The results indicated significant changes in the intervention group in comparison to the control group in the second phase of the study comparing to the first one for all tests except EDSS (Mean difference scores of EDSS: -0.13), P-value=0.60; FSS: -6.9, P-value = 0.02, Mental Quality of Life (QOL): 16.36, P-value = 0.001; Physical QOL: 12.17, P-value=0.001, six minute walking: 137.2, P-value<0.0001; and Berg: 3.34, P-value<0.0001. These changes were not significant in the second phase of the study comparing to the third one; however, they were again significant in the third phase comparing to the first phase of the study (P<0.05).Conclusions: Exercise has significant effect on improving symptoms of multiple sclerosis, and cessation of exercise may cause recurrence of symptoms in the intervention group with a slope similar to that of the control group. Therefore, continuous rather than short period exercises have valuable symptomatic and supportive relief effects in patients.

Background: Endotheline-1 (ET-1), an endothelial mediator, influences on mineral metabolism; especially vascular calcification in uremic patients.Objectives: The aim of the present study was to evaluate of ET-1, high-sensitivity C-reactive protein (hs-CRP) and mineral metabolites as the main factors for vascular calcification and inflammation in hemodialysis (HD) patients.Patients and Methods: In this cross-sectional study, 46 chronic stable HD patients were selected from nephrology departments of Tabriz University of Medical Sciences affiliated hospitals and classified based on phosphorus (P), Ca-P product (Ca × P) and intact Parathyroid Hormone (iPTH) levels. We evaluated fasting serum ET-1and hs-CRP levels by the standard methods and compared with 46 healthy control subjects.Results: The levels of serum hs-CRP and ET-1 were significantly higher in the patient’s group compared with controls (4.40±1.26 vs. 1.38±1.61, P<0.0001, and 2.31±0.87 vs. 0.75±0.48, P<0.0001, respectively) and with regard to Ca × P product cut-off point (3.99±0.78 vs. 5.33±1.64, P<0.0001, and 2±0.73 vs. 3.04±0.73, P<0.0001 respectively). ET-1 was correlated significantly with hs-CRP level (r=0.776, P<0.0001). Serum P, Ca × P and iPTH levels directly and Ca indirectly were correlated with serum ET-1 in HD patients (r=0.932, P<0.0001, r=0.766, P<0.0001, r=0.514, P<0.0001, r=-0.538, P<0.0001 respectively). Multiple regression analysis demonstrated that serum P were independently associated with ET-1 levels (b=0.932, P<0.0001).Conclusions: Serum P and iPTH levels were independently associated with ET-1 and those may play a role in development of endothelial dysfunction in chronic kidney disease.

Background: The manner in which healthcare professionals deliver bad news affects the way it is received, interpreted, understood, and dealt with. Despite the fact that clinicians are responsible for breaking bad news, it has been shown that they lack skills necessary to perform this task.Objectives: The purpose of this study was to explore Iranian mothers’ experiences to receive bad news about their children cancer and to summarize suggestions for improving delivering bad news by healthcare providers.Materials and Methods: A qualitative approach using content analysis was adopted. Semi-structured interviews were conducted with 14 mothers from two pediatric hospitals in Iran.Results: Five major categories emerged from the data analysis, including dumping information, shock and upset, emotional work, burden of delivering bad news to the family members, and a room for multidisciplinary approach. Conclusions: Effective communication of healthcare team with mothers is required during breaking bad news. Using multidisciplinary approaches to prevent harmful reactions and providing appropriate support are recommended.

Background: Sociodemographic factors are important determinants of weight disorders. National representative studies provide a view on this health problem at national and regional levels.Objectives: This study aimed to assess the distribution of growth disorders in terms of body mass index (BMI) and height in 6-year-old Iranian children using geographical information system (GIS).Materials and Methods: In this cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were examined in a mandatory national screening program in 2009. Descriptive analysis was used to calculate the prevalence of underweight, overweight, obesity, and short stature. Then, ArcGIS software was used to draw the figures.Results: The study population consisted of 955388 children (48.5% girls and 76.5% urban). Overall, 20% of children were underweight, and 14.3% had high BMI, consisted of 10.9% overweight and 3.4% obese. The corresponding figure for short stature was 6.6%; however, these growth disorders were not equally distributed across various provinces.Conclusions: Our results confirmed unequal distribution of BMI and height of 6-year-old children in Iran generally and in most of its provinces particularly. The differences among provinces cannot be fully explained by the socioeconomic pattern. These findings necessitate a comprehensive national policy with provincial evidence-based programs.

Background: Maternal health improvement is one of the eight goals of the third millennium development, set in 2000. Pregnancy complications are the most important causes of maternal mortality worldwide. Proper and qualified health care access is one the most important factors for reducing maternal and neonatal mortality rates.Objectives: This study aimed to determine quality of peripartum care in Lorestan province in 2013.Materials and Methods: This was a descriptive cross-sectional study, in which quality of peripartum care was assessed among 200 women (sample size was determined according to other studies), referred to Lorestan province public hospitals. Quality assessment according to the WHO was used for the framework of structure, process and outcome. Data was collected by a researcher-made checklist, developed based on the administered instructions by Iran Health Ministry. The checklists were filled by observation. The calculated quality scores were expressed as percentage. SPSS version 18 was used for data analysis.Results: The mean percentages of compatibility with desirable situation were 54%, 57% and 66% in first, second and third stage of labor, respectively. The lowest scores were related to: Leopold maneuvers in the first stage, hand washing in the second stage and pulse control in the third stage of labor.Conclusions: Quality of peripartum care is moderate in Lorestan province, therefore, continuous evaluation of quality of care by administrators and hospital staff is essential to improve this quality and will ultimately result in maternal and neonatal health improvement.

Background: Anxiety is the most common psychological response of women to labor. Aromatherapy, i.e. the use of fragrant essential oils to stimulate the olfactory system, can create a state of calmness and help to alleviate anxiety.Objectives: The present study tried to determine the efficacy of aromatherapy with Citrus aurantium oil in reducing anxiety during the first stage of labor.Patients and Methods: This randomized clinical trial was conducted on two groups of pregnant women, referred to Vali-Asr Hospital (Tuyserkan, Iran) between June and September 2013. The sample size was comprised of 63 subjects in each group. Gauzes impregnated with 4 mL of C. aurantium distillate and normal saline were attached to the collar of subjects in the aromatherapy and control groups, respectively. The gauzes were changed every 30 minutes. The levels of anxiety in both groups were measured at baseline and after the intervention at dilations of 3-4 and 6-8 cm. The participants were followed up until delivery and the first- and fifth-minute Apgar scores were recorded. Data were collected using a demographic and obstetric characteristics questionnaire, an examination and observation checklist, and Spielberger state-trait anxiety questionnaire. Data analysis was performed with independent-t, Mann-Whitney, and chi-square tests in SPSS-22. P values less than 0.05 were considered significant.Results: Before the intervention, both groups had same levels of anxiety. However, the levels of anxiety at dilations of 3-4 and 6-8 cm were significantly lower in the aromatherapy group compared with the control group.Conclusions: The results of this study confirmed aromatherapy with C. aurantium blossom oil as a simple, inexpensive, noninvasive, and effective intervention to reduce anxiety during labor.

Background: During lactation, especially the first few days after birth, some breast problems can cause pain and inadequate milk emptying.Objectives: This study aimed to investigate the risk factors of breast problems and their effect on neonatal complications.Patients and Methods: This case-control study was conducted on 566 infants referred to Mashhad Ghaem Hospital clinic (from 2008 to 2012) in Iran. Researchers filled out the questionnaire with the relevant neonatal and maternal information. They also recorded the mothers' breasts problems after examination. Then the infants were divided into two groups: Infants whose mothers complained from breast problems (case group), and the infants whose mothers did not have any breast problems (control group). Finally, two groups were compared with respect to the maternal and neonatal risk factors.Results: The two groups were matched on these variables: parity (P=0.861), maternal weight (P=0.577), education level (P=0.807), pregnancy complications (P=0.383), gestational age (P=0.161), Apgar score (P=0.530), birth weight (P=0.090), infant gender (P=0.439), and infant age (P=0.152). Case group vs. control group showed significant differences regarding prenatal care, mode of delivery, lactation status and the letdown reflex, serum sodium, frequency of urination and defecation, new weight and supplementation (P<0.05). Conclusions: According to our study, breast problems were fewer in mothers who had prenatal care, normal vaginal delivery, proper breastfeeding position, and let down reflex. Neonatal complications of breast problems include pathologic weight loss and decrease in the frequency of urination. Therefore, special attention to mother's breasts during pregnancy and in the early days of delivery, and their appropriate treatment may reduce breast problems and related neonatal complications.

Background: Revealing data on the role of vitamin D and calcium supplementation in bone health has led some to suggest that vitamin D and calcium treatment could also play a role in protecting bone against microgravity-induced mineral loss.Objectives: The aim of the present study was to investigate the effects of vitamin D and calcium administration on microscopic and densitometric changes of rat femur in a Microgravity Simulator Model.Materials and Methods: After designing a Microgravity Simulator Model, 14 rats were placed in the cages as follows: seven rats as osteoporosis group and seven rats received oral supplement of calcium/vitamin D as the treatment group. Animals were sacrificed after eight weeks and then both femurs were removed. Bone mineral density was measured for one femur from each animal, and morphologic studies were evaluated for the contralateral femur.Results: Bone mineral density of the whole femur in the treatment group was significantly higher than the osteoporosis group (0.168±0.005 vs. 0.153±0.006, P=0.003). Also, bone mineral content of the whole femur was significantly higher in treatment group (0.415±0.016 vs. 0.372±0.019, P=0.003). However, resorption eroded surface percentage was higher in the osteoporosis group (18.86±3.71% vs. 9.71±1.61%, P=0.002).Conclusions: According to the results of this study, vitamin D and calcium administration might have protective effects against microgravity-induced mineral loss in a Rat Microgravity Simulator Model.

Background: Adolescents have particular health and developmental needs that suggest they should neither be treated as older children nor younger adults.Objectives: The aim of this paper is to report the protocol for a mixed methods study that set out to investigate the health concerns of Iranian adolescents and their sources of health information with the goal of identifying suitable strategies to address their health concerns.Materials and Methods: This mixed methods study consists of an explanatory sequential design to be conducted in two phases. The first phase was a population-based cross-sectional survey of 915, 14-18 year old adolescents who were selected by stratified cluster random sampling method from the 22 main municipal sectors of Tehran, Iran. They completed a series of self-administered questionnaires which were analyzed using quantitative approaches. The second phase was a qualitative study in which adolescents were selected using purposeful sampling for individual in-depth semi-structured interviews on the basis of the quantitative findings from the first phase. These data, together with a literature review and data obtained through nominal group technique, would then be used to in the development of strategies to reduce adolescents’ health concerns.Results: The findings of this mixed methods sequential explanatory study are expected to provide unique information about the health concerns of Iranian adolescents and their sources of information, which to date have received little attention.Conclusions: These data will provide a rich source of information that can be used by intervention programs, health professionals and policy makers in addressing the health concerns of adolescents, with the goal of facilitating a successful passage to adult life.

Background: Neural tube defects (NTDs) including spina bifida and anencephaly are the second most common birth defects with 2.8 per 1000 births in northern Iran.Objectives: This study was conducted to determine the risk factors of neural tube defects in Gorgan, north of Iran.Patients and Methods: This hospital-based, case-control study was carried out on all NTD-affected pregnancies (n=59) during February 2007 - August 2010, and 160 healthy pregnancies were selected via convenient sampling method in three hospitals in Gorgan, north of Iran. Risk factors including maternal body mass index (BMI), season of birth, gender of the newborn, mother’s age, ethnicity, consanguineous marriage, folic acid consumption, nutrition, habitat, and education, were assessed through interviews with mothers. Univariate and multivariate logistic regression analyses were used to estimate the risks by odds ratios (ORs) and 95% confidence intervals.Results: The multivariate analysis showed that maternal BMI (normal/underweight OR: 0.23, overweight/underweight OR: 0.15, obese/underweight OR: 0.13) and maternal ethnicity (Fars/Sistani OR: 3.49) and maternal nutrition (good/poor OR: 0.46) were significantly correlated with NTDs in the newborns.Conclusions: This study showed that maternal ethnicity, insufficient nutrition, and BMI, were the main risk factors of NTDs in northern Iran.

Context: All over the the world, preterm birth is a major cause of death and important neurodevelopmental disorders. Approximately 9.6% (12.9 million) births worldwide are preterm.Evidence Acquisition: In this review, databases such as PubMed, EMBASE, ISI, Scopus, Google Scholar and Iranian databases including Iranmedex, and SID were researched to review relevant literature. A comprehensive search was performed using combinations of various keywords.Results: Cerebral palsy especially spastic diplegia, intellectual disability, visual (retinopathy of prematurity) and hearing impairments are the main neurodevelopmental disorders associated with prematurity.Conclusions: The increased survival of preterm infants was not associated with lower complications. There is now increasing evidence of sustained adverse outcomes into school age and adolescence, for preterm infants.

Background: Myocardial infarction is one of the important causes of death during old ages. Gallic acid as an antioxidant or cyclosporine A (CsA) as inhibitor of mitochondrial permeability transition pore (mPTP) alone could prevent these complications to some extent, but their combination effect has not been investigated.Objectives: The aim of this study was to determine the combined effect of gallic acid and CsA on antioxidant capacity of isolated heart tissues during ischemia reperfusion. Materials and Methods: Eighty male Wistar rats were randomly assigned to different groups: sham, control (Ca, received saline, 1 mL/kg); 3 groups were pretreated with gallic acid (G1a: 7.5, G2a: 15, G3a: 30 mg/kg) for 10 days, and the other 3 groups were pretreated with gallic acid and received CsA (0.2 mM) for 10 minutes before induction of ischemia and during the first 10 minutes of reperfusion (G1b, G2b and G3b) and the last group received CsA alone (Cb). After 10 days of pretreatment, the heart was isolated and transferred to the Langendorff apparatus and exposed to 30 minutes ischemia followed by 60 minutes of reperfusion. After that cardiac markers and antioxidant enzymes were assessed in cardiac tissues.Results: Lactate dehydrogenase (LDH), Superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPX) activity increased and malondialdehyde (MDA) decreased in animals pretreated with gallic acid significantly. However, pretreatment with gallic acid followed by CsA during reperfusion improved the antioxidant capacity and cardiac marker enzymes and restored the lipid peroxidation more effective than gallic acid or CsA alone. Nevertheless, CsA did not change the cardiac marker enzymes significantly.Conclusions: Gallic acid and CsA combination improved antioxidant capacity and cell membrane integrity more than each one alone. Therefore, it can be a therapeutic approach to reduce the I/R injury.