Iranian Red Crescent Medical Journal
Year:2014 | Volume:16 | Issue:8|Papers Count:19

Background: Preeclampsia is one of the leading causes of maternal mortality and morbidity. Its prevalence varies between 10-25% among high-risk pregnant patients.Objectives: The aim of this study was to determine whether treatment with acetylsalicylic acid (ASA) reduces the incidence of preeclampsia among pregnant women with abnormal uterine artery flow.Patients and Methods: In this double-blind, placebo controlled trial, 80 high-risk pregnant women with preeclampsia, who had abnormal findings on Doppler ultrasonography at 12-16 weeks of pregnancy (unilateral notch with RI≥0.65 or bilateral notch with RI≥0.55), were randomly divided into two groups; the intervention group was treated with ASA tablet 80 mg, one tablet per day, and the control group was given placebo. Then patients were followed until the end of their pregnancy period, and pregnancy outcomes, including development of preeclampsia, the intrauterine growth retardation (IUGR), prematurity, type of delivery, birth weight, and Apgar score at one and five minutes were assessed. Data were analyzed using the student's t-test, chi-square or Fisher's exact test, and multivariate logistic regression. P values less than 0.05 were considered statistically significant.Results: There were no significant differences between the two groups in terms of baseline characteristics. There was a significant difference between the ASA and placebo groups in the incidence of preeclampsia (2.5% versus 22.5%), adjusting for the neonatal and maternal covariates.Conclusions: ASA prophylaxis can be used for prevention of preeclampsia in high-risk patients with abnormal uterine artery.

Background: Coronary Artery Disease (CAD) is the most common cause of death worldwide. MEF2A directly regulates target genes in the process of muscle development. This gene product is a transcription factor. MEF2A protein in homodimer or heterodimer forms binds to A/T-rich cis elements with conserved sequence in promoter, regulator, and enhancer of many genes, which are determining in evolution and development of skeletal, heart, and smooth muscle cells, especially endothelial cells. In fact, this protein maximizes the activity of these elements.Objectives: The two MEF2A gene polymorphisms that were proposed to have an association with CAD are rs34851361 (A/G) and rs325400 (T/G) SNPs. This study aimed to examine these associations.Patients and Methods: This study was a molecular case-control study. Blood samples were collected from 300 patients with CAD and 150 healthy people from Golestan and Imam Khomeini Hospitals, Ahvaz, Iran. In both groups, angiography had confirmed the presence or lack of stenosis. Association of rs34851361 and rs325400 with CAD was evaluated by PCR and then restriction fragment length polymorphism (RFLP) analysis was performed.Results: Chi square test showed no association between rs34851361 SNP and CAD (X2=3.59, df=2, and P=0.16); however, there was an association between rs325400 SNP and CAD (X2=24.77, df=2, and P<0.001). A/T haplotype showed association with CAD and G/G and G/T showed protective effect against CAD.Conclusions: The results of this study show that rs325400 polymorphism is in association with CAD; meanwhile, none of the rs34851361 genotypes was associated with CAD.

Background: Many of the problems pertaining to old age originate from unhealthy lifestyle and low social support. Overcoming these problems requires precise and proper policy-making and planning.Objectives: The aim of the current research is to investigate the effect of health promoting interventions on healthy lifestyle and social support in elders.Patients and Methods: This study was conducted as a clinical trial lasting for 12 months on 464 elders aged above 60 years who were under the aegis of health homes in Tehran, Iran. Participants were selected through double stage cluster sampling and then divided into intervention and control groups (232 individuals in each). Tools for gathering data were a demographic checklist and two standard questionnaires called Health-Promoting Lifestyle Profile version 2 and personal resource questionnaire part 2. Data were analyzed using descriptive and analytical tests including paired t test, analysis of covariance (ANCOVA) and Pearson correlation coefficient.Results: The average age of elders in this study was 65.9±3.6 years (ranging between 60 and 73 years old). Results showed that the differences between the mean post-test scores of healthy lifestyle and its six dimensions as well as perceived social support and its five dimensions in the control and intervention groups were statistically significant (P value<0.0001).Conclusions: Aging is an inevitable stage of life. However, effective health promoting interventions can procrastinate it, reduce its consequences and problems, and turn it into a pleasant and enjoyable part of life.

Background: Adiponectin is an adipose tissue-derived protein with anti-inflammatory properties. Statins are a class of cholesterol-lowering drugs, widely used for treatment of cardiovascular diseases.Objectives: In the current study, we aimed to assess the effects of simvastatin on serum levels of adiponectin in patients with dyslipidemia, recruited from Ghaem Hospital, Mashhad, Iran.Materials and Methods: A total of 102 patients with dyslipidemia were treated with simvastatin or placebo during a double-blind, cross-over, placebo-controlled trial. The adiponectin levels were measured before and after each treatment period. Seventy seven participants completed the study.Results: There was a significant reduction in serum total cholesterol (approxmately 21%), low density lipoprotein-cholesterol (LDL-C) (approxmately 28%), and triglycerides (approxmately 11%), after four weeks of treatment with simvastatin (P<0.001).Conclusions: No significant change in serum adiponectin concentrations was observed after treatment with simvastatin. This may be because of the relatively short duration of treatment and longer treatment duration may be necessary to investigation in future studies.

Background: Coronary artery disease (CAD) is a major public health problem for developed and developing countries and is the single leading cause of death worldwide.Objectives: There is very few evidence regarding changes of both serum Lectin-like oxidized-low density lipoprotein receptor-1 (LOX-1) and adiponectin in patients with CAD accompanied with metabolic syndrome (MS). Here we aimed to evaluate serum levels of LOX-1 and adiponectin in patients with CAD accompanied with MS.Patients and Methods: Thirty patients with coronary artery disease without metabolic syndrome, 30 patients with coronary artery disease and metabolic syndrome, 30 ones with metabolic syndrome and 30 healthy subjects were enrolled. For all subjects, a questionnaire was filled to collect data, and peripheral blood samples were collected aseptically from the antecubital vein to measure serum Lectin-like oxidized-low density lipoprotein receptor-1 and adiponectin levels by enzyme-linked immunosorbent assay.Results: Serum LOX-1 level was highest in CAD+MS group; the difference between control and disease groups was statistically significant (P<0.001). Adiponectin level had the lowest value in CAD+MS group; the difference between control and disease groups was statistically significant (P<0.05). No significant differences were observed in serum Lectin-like oxidized-low density lipoprotein receptor-1and adiponectin in patients with different ages and gender. Serum LOX-1 level was changed negatively and linearly (R2=0.721) correlated with adiponectin level in different groups.Conclusions: Patient with CAD and MS had higher risk than those with only CAD because of lipid and glucose metabolism abnormalities. Combination measurements of serum LOX-1 and adiponectin levels may be helpful to evaluate the severity of CAD together with MS.

Background: Medical sphincterotomy has gained popularity as a treatment for anal fissure. Calcium channel blockers in topical forms could also be appropriate with low adverse effects.Objectives: This was a prospective randomized controlled trial to compare topical and oral nifedipine in the treatment of chronic anal fissure.Patients and Methods: A prospective randomized controlled trial was conducted at two centers of Shahed University. One hundred and thirty patients with chronic anal fissure aged 18 to 60 years managed in our clinics were included in this study. The patients were randomly divided into two groups. Sixty-five patients received topical nifedipine (TN) and the same number received oral nifedipine (ON).Results: Ulcer healing occurred in 43 (73.33%) of topical nifedipine group compared to 29 (49.5%) patients in oral nifedipine, which was significantly different (P<0.05). Side effects such as headache and flushing in oral nifedipine group were more prevalent than topical nifedipine, which was statistically different. Recurrence rates were the same after six months of follow-up.Conclusions: Although oral nifedipine can reduce symptom and signs of anal fissure, topical nifedipine has a superior role for anal fissure treatment with higher healing rate and lower side effects.

Background: Headache is one of the most prevalent investigated complaints in the neurology clinics and is the most common pain-related complaint worldwide. Stress is a significant factor that causes and triggers headaches. Since healthcare practitioners experience a lot of stress in their careers, they are more prone to headaches.Objectives: This study was designed to evaluate and compares the efficacy of neurofeedback behavioural therapy (NFB) and transcutaneous electrical nerve stimulation (TENS) in the treatment of primary headaches in healthcare providers.Patients and Methods: The current study was a clinical trial, performed in Teheran, IR Iran, with two experimental groups and a control group. Convenient sampling method was used to recruit patients. Independent variables were NFB and TENS and dependent variables were frequency, severity, and duration of headache. Blanchard headache diary was used for assessment. Hence, 45 healthcare providers with primary headache were selected and randomly allocated to one of the NFB, TENS, and control groups by block random assignment method. All three groups completed the headache diary during one week before and after the treatment period as pretest and posttests, respectively. The NFB group was treated in the period between pretest and posttest with fifteen 30-minute treatment sessions three times a week and the TENS group was treated with fifteen 20-minute daily sessions. The control group received none of these treatments.Results: The results from the analysis of covariance showed that treatment with NFB and TENS had caused significant decrease in the frequency, severity, and duration of headache in experimental groups. The results of the LSD post-hoc test indicated that there were significant differences in the frequency, severity, and duration of pain among experimental groups and the control group. Moreover, there were significant differences between pain frequencies in experimental groups.Conclusions: According to the results and given the significant reductions in the frequency, severity, and duration of headaches, it seems that NFB and TENS might have an effective role in reducing primary headaches of healthcare providers. In addition, comparing the two methods, treatment with NFB was more effective in reducing headache frequency and severity.

Background: Disclosure of HIV is important for improving self-care behaviors, psychological well-being, commitment to the treatment, and reducing risk of transmission. One of the major benefits of disclosure is social support, which is an essential resource for effective coping with HIV infection. However, receiving any social support requires disclosing of HIV status.Objectives: This study aimed to determine the disclosure of HIV status and its related factors such as social support in addition to demographic and disease characteristics among people living with HIV in Iran.Patients and Methods: This cross-sectional study, using simple random sampling, was carried out on 175 people with HIV/AIDS who referred to Behavioral Counseling Centers. The self-administrated, Norbeck Social Support Questionnaire was used to measure social support. Disclosure of HIV status was assessed with an investigator-designed questions. Multiple logistic regression analysis with backward Likelihood Ratio method was applied to identify the adjusted odds ratio between disclosure as dependent variable and demographic variables, social support as independent variables.Results: Participants were often disclosed their HIV status to family members. But there were differences about disclosure of HIV status within the context of the family. Family members were perceived as more supportive. Multiple logistic regression analysis demonstrates that the gender (adjusted OR=0.181; 95% CI.068-0.479), CD4 cell count (adjusted OR=0.997; 95% CI 0.994-0.999), route of transmission (injection-drug user [adjusted OR=9.366; 95% CI 3.358-26.123] and other routes [tattooing, mother to child, dental services, etc.], [adjusted OR=3.752; 95% CI 1.157-12.167]), and functional support variable (adjusted OR=1.007; 95% CI 1.001-1.013) remained in the model as significant predictors for disclosure.Conclusions: The results of this study regarding disclosure of HIV status and its relations to social support and some demographic variables can provide an understanding based on the evidence for promotion of knowledge and coping interventions about people living with HIV/AIDS and their perceived social support status.

Background: The involved neurotransmitter pathways in the postoperative shivering (POS) are poorly understood. Recently, 5-hydroxytryptamine 3 (5-HT3) receptor antagonists have been reported to prevent POS. We investigated the effect of ondansetron, a 5-HT3 antagonist that is used to treat postoperative nausea and vomiting, on shivering.Objectives: This study aimed to compare the efficacy of ondansetron and meperidine in the treatment of shivering after general anesthesia.Patients and Methods: In this double-blinded randomized clinical trial, 83 patients (age range, 18-60 years) who had shivering after general anesthesia were randomly allocated to any of these three groups: Group A, (number=27) received 4 mg of intravenous ondansetron, Group B, (number=27) received 8 mg of intravenous ondansetron, and Group C, (number=29) received 0.4 mg/kg of intravenous meperidine at recovery room. The surface temperatures and the incidence as well as intensity of shivering were recorded.Results: Shivering was controlled in 16 patients (59%) in Group A, 22 (81%) in Group B, and 25 (86%) in Group C (P=0.01). Within each group, there were no significant differences among the surface temperature in recovery room. Patients in groups A and B had significantly lower incidence of nausea and vomiting than group C (P=0.01).Conclusions: Ondansetron and meperidine have similar effects on shivering. We concluded that 8 mg of intravenous ondansetron can control shivering and this is the dose of choice, especially in patients with POS with nausea and vomiting.

Background: Primary dysmenorrhea is one of the most common disorders in women and the main cause of absenteeism from work and school.Objectives: Considering the anti-inflammatory properties of wheat germ, the present study examined the effects of wheat germ extract on the severity and systemic symptoms of primary dysmenorrhea.Patients and Methods: This triple-blinded clinical trial was performed on 80 employed women in hospitals affiliated with Hamadan University of Medical Sciences (Hamadan, IR Iran). Subjects were allocated to two groups of 45 patients. Three 400-mg capsules of wheat germ extract or placebo were used daily٫ between the 16th day of the menstrual cycle to the fifth day of the next menstrual cycle for two consecutive months. Pain intensity was measured by a visual analogue scale thrice a day and a four-point verbal rating scale was employed to assess systemic symptoms.Results: Pain severity decreased only in the wheat germ extract group (P<0.001) and there was no statistically significant change in the placebo group. In the wheat germ extract group, the pain severity decreased from 4.701 at baseline to 1.120 at the second cycle. The reduction in total scores of systemic symptoms of dysmenorrhea was statistically significant only in the wheat germ extract group (P<0.001) and there was not a statistically significant change in the placebo group. It revealed statistically significant differences in systemic symptoms associated with dysmenorrhea including fatigue, headache, and mood swings in experimental group.Conclusions: Wheat germ extract seems to be an effective treatment for dysmenorrhea and its systemic symptoms, probably because of its anti-inflammatory effects.

Introduction: Giant fibroadenoma is a rare disease with unknown etiology. During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.Case Presentation: We presented a case of giant fibroadenoma, first detected at the onset of pregnancy, which grew rapidly and was excised surgically two months after the birth. There was no marked deformity in the breast nor a need to reconstruct it, despite the giant mass was excised and the mother was lactating.Discussion: We presented a rare case of giant fibroadenoma in a lactating woman. A progressively growing mass in breast can lead to structural damages. The current management approach for giant fibroadenomas is still surgical excision.

Introduction: Camurati-Engelmann disease (CED) is a rare autosomal dominant disease with various phenotypic expressions. The symptoms usually develop during childhood. The hallmark of the disease is bilateral symmetric diaphyseal hyperostosis of the long bones with progressive involvement of the metaphysis. The epiphysis is strictly spared. The common clinical symptoms are pain of the extremities, muscle wasting, waddling gait, and lethargy. CED is rarely seen in conjunction with hypogonadism. CED-associated hypothyroidism has not been reported yet. Clinical assessment and skeletal survey are important to make the diagnosis.Case Presentation: Hereby we reported a case of CED with concomitant hypogonadism and hypothyroidism. Serial plain radiographs of the patient showed classic and progressive diaphyseal cortical hyperostosis of the long bone.Conclusions: Hyperostosis of the skull was observed in the present case. The characteristic osseous changes of CED were highlighted and the differential diagnoses were discussed.

Background: Substance use in patients with psychiatric disorder is an every-day seen. Detection of this comorbidity can significantly affect the treatment of these disorders, as well as substance use.Objectives: This study has been conducted to determine the prevalence and pattern of substance use in hospitalized psychiatric patients.Patients and Methods: In this cross-sectional study, 210 hospitalized psychiatric patients were selected by simple randomization from all records of hospitalized patients. The instrument of gathering data was a demographic checklist including age, gender, marital status, education, type of disorder and substance abuse and duration of psychiatric disorder. Data were analyzed by SPSS version 16 using Fisher exact and Chi square tests.Results: The mean age of patients was 37.9 years. Most of the patients were male, married and unemployed. The Prevalence of substance use was 36.7%. The most prevalent pattern of substance use was opium, opioid, methamphetamines and other substances (poly substance). The prevalence of substance use in patients with mood disorders was more than the other disorders and the most prevalent substance use in these patients was opium and opioid. Poly substance use was the most prevalent pattern of use (80 %) in psychotic and mood disorders due to substance. Significant difference was seen between genders, marital status, occupation, duration of illness and frequency of substance use (P<0.05), however no significant difference was seen between educational levels, age and substance use.Conclusions: The patients with mood disorders had the highest comorbidity with substance use and concurrent use of poly substance was the most prevalent pattern of use in these patients. Therefore, successful treatment of psychiatric disorders and substance use needs multimodal and more serious interventions. Regarding to the pattern of poly substance use in these patients, careful screening should be performed at admission.

Background: The nursing workload has a close and strong association with the quality of services provided for the patients. Therefore, paying careful attention to the factors affecting nursing workload, especially those working in the intensive care units (ICUs), is very important.Objectives: This study aimed to determine the factors affecting nursing workload in the ICUs of the hospitals affiliated to Tehran University of Medical Sciences.Materials and Methods: This was a cross-sectional and analytical-descriptive study that has done in Iran. All nurses (n=400) who was working in the ICUs of the hospitals affiliated to Tehran University of Medical Sciences in 2014 were selected and studied using census method. The required data were collected using a researcher–made questionnaire which its validity and reliability were confirmed through getting the opinions of experts and using composite reliability and internal consistency (α=0.89). The collected data were analyzed through exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and using SPSS 18.0 and AMOS 18.0.Results: Twenty-five factors were divided into three major categories through EFA, including structure, process, and activity. The following factors among the structure, process and activity components had the greatest importance: lack of clear responsibilities and authorities and performing unnecessary tasks (by a coefficient of 0.709), mismatch between the capacity of wards and the number of patients (by a coefficient of 0.639), and helping the students and newly employed staff (by a coefficient of 0.589).Conclusions: The nursing workload is influenced by many factors. The clear responsibilities and authorities of nurses, patients' admission according to the capacity of wards, use of the new technologies and equipment, and providing basic training for new nurses can decrease the workload of nurses.

Background: A few studies have been carried on preventive drugs for apnea of preterm neonates.Objectives: This study aimed to assess the safety and prophylactic effects of aminophylline on the incidence of apnea in premature neonates.Patients and Methods: This study was a randomized clinical trial (RCT) research. The prophylactic effect of aminophylline on apnea was investigated in premature babies in our NICU (IRAN-Isfahan). In the study group (A), 5 mg/kg aminophylline was initially administered as a loading dose. Then, every 8 hours, 1.5 mg/kg was given as maintenance dose for the next 10 days. In the control group (C), no aminophylline was used during the first ten days of life.Results: Fifty-two neonates were randomized for the study and all of them completed it. Primary outcomes were clearly different between the two groups. Only 2 infants (7.7%) who had been placed in aminophylline group developed apnea, as compared to 16 infants (61.5%) in the control group (P<0.001). Three and four neonates (11.5%, 15.4%) in the aminophylline group developed bradycardia and cyanosis respectively, as compared to 16 infants (61.5%) who did not receive aminophylline (P<0.001). Median time of need to NCPAP (Nasal Continuous Positive Airway Pressure) was 1 (0-4) days and 2.5 (0.5-6.5) days in group A and C, respectively (P=0.03). No side effects were reported in neonates (P>0.999). Median time of hospitalization was shorter in aminophylline group (P=0.04).Conclusions: This study supports the preventative effects of aminophylline on apnea in extreme premature infants. In other words, the more premature an infant, the greater the preventative effect of aminophylline on the incidence of apnea and bradycardia.

Background: Most women taking combined oral contraceptives (COCs) are satisfied with their contraceptive method. However, one of the most common reasons reported for discontinuation of combined oral contraceptives (COCs) is mood deterioration.Objectives: This study aimed to compare effects of the second and third generation oral contraceptive pills on the mood of reproductive women.Materials and Methods: This randomized, double-blind, controlled clinical trial was conducted in reproductive women at health centers in Tehran, Iran. Participants were randomized into the second and third generation oral contraceptive groups. Positive and negative moods were recorded using positive affect, negative affect scale (PANAS) tools at the end the second and fourth months of the study. Data analysis was carried out using ANOVA and P Values<0.05 was considered significant.Results: Statistically significant difference was seen in positive and negative mood changes in women receiving contraceptive pills. The second generation oral contraceptive pills resulted in a decrease in positive mood (95% CI: 43.39 to 38.32 in second month and 43.39 to 26.05 in four month) and increase in negative mood (95% CI: 14.23 to 22.04 in second month and 14.23 to 32.26 in four month - P<0.001), but the third generation led to an increase in positive mood (95% CI: 22.42 to 25.60 in second month and 22.42 to 33.87 in four month) and decrease in negative mood (95% CI: 36.78 to 31.97 in second month and 36.78 to 22.65 in four month-P<0.001).Conclusions: Third generation combined oral contraceptive pills have a better effect on mood in women in reproductive ages than the second generation pills. It can be recommended as a proper combined oral contraceptive in Iran.

Background: The objective structured clinical examination (OSCE) has been introduced as an efficient method for the assessment of medical students.Objectives: The aim of the present study was to determine the satisfaction level of undergraduate medical students of internal medicine department with the OSCE.Materials and Methods: This was a descriptive cross-sectional study, performed on all available undergraduate students at the end of their internal medicine training period in Mashhad University of Medical Sciences. The students responded to 15 multiple-choice questions with confirmed validity and reliability.Results: The majority of the students (94.5%) had a positive attitude toward the OSCE and mentioned that the OSCE format was a more appropriate type of exam than other methods of testing; however, 79.1% thought that the OSCE format was stressful. In addition, the participants’ sex had no effect on their level of satisfaction with the examination. Likewise, there was no significant correlation between their level of satisfaction and their age, marital status, or lack of previous experience with this type of exam.Conclusions: If the exam standards are met and a uniform dispersion of the scientific content is maintained, the OSCE method of assessment can be recommended as an efficient and applicable method for assessing medical students.

Background: There are different and controversial reports about zinc deficiency in patients with major thalassemia.Objectives: The aim of this study was to evaluate zinc status in patients with major thalassemia in Sistan and Baluchistan province, southeastern Iran.Patients and Methods: The study was performed in Ali Asghar Hospital, a specialized governmental hospital located in Zahedan, Iran. In this cross-sectional study, 369 patients with a history of major thalassemia for more than 5 years entered the study using convenience sampling method. Thirty-six subjects were excluded from the study based on our exclusion criteria. Zinc level was measured in all patients after 12 hours fasting using atomic absorption spectrometry method in 2012.Results: Of 369 cases, 333 patients were eligible and evaluated. The mean age was 15.63±7.4 years. One hundred ninety two cases were male and others were female (141 cases). About 27% (90) of the cases were 5-10 years-old, 24% (80) were 10-15 years-old and 49% were older than 15 years old. Iron chelator in 65.46% was Desferrioxamine, in 28.2% was Deferasirox and in 19.5% was combination of Desferrioxamine and Deferiprone. All cases had zinc deficiency, and 98.5% had severe zinc deficiency. Others (1.5%) had mild deficiency.Conclusions: Our study on 333 patients with major thalassemia documented severe zinc deficiency in all cases. We had no cases with normal or increased zinc levels. It was different with other reports in the world.

Background: Anxiety is an important mental health problem in patients with cardiac disease. Anxiety reduces patients’ quality of life and increases the risk of different cardiac complications.Objectives: The aim of this study was to investigate the effects of inhalation aromatherapy on anxiety in patients with myocardial infarction.Patients and Methods: This was a randomized clinical trial conduced on 68 patients with myocardial infarction hospitalized in coronary care units of a large-scale teaching hospital affiliated to Kashan University of Medical Sciences, Kashan, Iran in 2013. By using the block randomization technique, patients were randomly assigned to experimental (33 patients receiving inhalation aromatherapy with lavender aroma twice a day for two subsequent days) and control (35 patients receiving routine care of study setting including no aromatherapy) groups. At the beginning of study and twenty minutes after each aromatherapy session, anxiety state of patients was assessed using the Spielberger’s State Anxiety Inventory. Data was analyzed using SPSS v.16.0. We used Chi-square, Fisher’s exact, independent-samples T-test and repeated measures analysis of variance to analyze the study data.Results: The study groups did not differ significantly regarding baseline anxiety mean and demographic characteristics. However, after the administration of aromatherapy, anxiety mean in the experimental group was significantly lower than the control group.Conclusions: Inhalation aromatherapy with lavender aroma can reduce anxiety in patients with myocardial infarction. Consequently, healthcare providers, particularly nurses, can use this strategy to improve postmyocardial infarction anxiety management.