Impact of Ramadan fasting on lipid profile, uric acid, and HbA1c in CKD: A systematic review and meta-analysis.

Studies have shown that fasting during Ramadan has different effects on circulating levels of several biochemical markers. This study aims to conduct a comprehensive evaluation of studies related to the effect of fasting in the holy month of Ramadan on lipid profile, uric acid, and HbA1c in CKD patients. Studies were systematically searched and collected from three databases (PubMed, Scopus, and Web of Science). After screening, the quality and risk of bias assessment of the selected articles were evaluated. Study heterogeneity was assessed using the Cochrane test and I² statistic. In case of any heterogeneity random effects model with the inverse-variance method was applied. All analyses were performed using STATA software version 16. Four observational studies were included in this study. The results of this meta-analysis were that cholesterol (Weighted mean differences (WMD):0.21 with 95% CI:-0.09-0.51 (P-value=:0.18)), LDL (WMD:0.06 with 95% CI -0.24-0.36 (P-value:0.69)), triglyceride (WMD:0.05 with 95% CI:-0.25-0.35 (P-value:0.73)) had not-significant increase. Uric acid (WMD: -0.11 with 95% CI: -0.42-0.21 (P-value:0.51)) and HbA1c (WMD: -0.22 with 95% CI: -0.79-0.36 (P-value: 0.46)) show a non-significant decrease. The results of the analyses did not report significant changes in the lipid profile, uric acid, and HbA1c in CKD patients after Ramadan fasting.

A New Approach to Eliminate Hymenoptera Venom Grading Sensitization Test in the North Iran: Cross-Sectional Study.

Background: Anaphylaxis is an allergic reaction which occurs with or without the stimulation of the immune system. Hymenoptera stings are common causes of anaphylaxis in the world. Skin tests are the first-line diagnostic measure for Hymenoptera anaphylaxis. The present study aimed to evaluate the safety of a single-step approach in sensitization testing for Hymenoptera venom. Methods: This cross-sectional study was conducted in 2019 in Golestan province the north of Iran. The sample population consisted of 140,000 individuals covered by 84 rural healthcare centers in the vicinity of Gorgan, Iran. Thirty-three patients agreed to receive the diagnostic test. In this research, in contrast to the 2011 ACAAI guideline, the extracts of venom of three types of Hymenoptera were injected intra-dermally without any dilution at the concentration of 1 µg/ml. Results: The results of the skin test in the patients bitten by honey bee, yellow jacket, and paper wasp were negative in 15.2%, 15.2%, and 21.2% of the cases, respectively. After the test, no allergic reaction was observed, with the exception of a minor skin reaction, which improved within a short time. These preventive measures were taken during the test for the following four hours when the patient was present at the test site and up to 48 hours afterward via follow-up from the healthcare center to the home of the patient. Conclusion: The results of our study showed that the non-diluted single injection of the Hymenoptera sting was accompanied by no side effects.

Effective factors of severity of traffic accident traumas based on the Haddon matrix: a systematic review and meta-analysis.

Objective: This study aims to investigate the factors affecting the severity of trauma caused by traffic accidents based on martrix Haddon; a systematic review and meta-analysis. Methods: In this study searched five international databases in this study, including Medline/PubMed, ProQuest, Scopus, Web of Knowledge, and Google Scholar, for published articles by the end of 2022. Data were entered into the statistical program and analyses were performed using STATA 17.0 software. Odds ratio (OR) values were computed for severity accidents. Results: Results of study showed that among the risk factors related to the host, not using helmet increased the risk of injury severity by 3.44 times compared to people who have used helmets (OR Not using helmet/Using helmet = 3.44, 95% CI: 2.27-5.00, P=0.001, I2=0.00%). Also, crossing over a centre divider has a protective role for the risk of injury severity compared to undertaking (OR crossing over a centre divider/undertaking=0.39, 95% CI: 0.20-0.75, P=0.01, I2=25.79%). in terms of the type of accident, accident of car-car reduces the risk of injury severity by 23% compared to accident of car-pedestrian (OR accident of car-car/accident of car-pedestrian=0.77, 95% CI: 0.61-0.96, P=0.02, I2=0.00%). Conclusions: It is necessary to pay attention to the intersection of human, vehicle and environmental risks and their contribution and how they interact. Based on the Haddon matrix approach, special strategies can be designed to prevent road damage. Safety standards for vehicles should also be addressed through stricter legal requirements and inspections.

PERCHING syndrome caused by variant gene KLHL7 in the first Iranian patient: a case report study.

Introduction and importance: PERCHING syndrome is a condition that affects many parts of the body and is caused by genes passed down from both parents. People with this syndrome have delays in their development, unusual facial features, trouble eating and breathing, slow overall growth, weak muscles, and stiff joints. Case presentation: The child at the age of 6 months suffered from developmental delay, delayed walking, speech delay, and hypotonia and was referred to the Neurologist. Also, he has an abnormal phenotype. Whole-exome sequencing (WES) revealed a missense variant in the KLHL7 gene at a highly conserved genomic Chr7: 23124718T>G; NM_018846:exon3:c.110T>G:p.Val37Gly. Clinical discussion: One way to explain the difference in physical characteristics caused by recessive KLHL7 mutations might be related to the person's genetic makeup. However, the genes someone has do not always accurately determine their physical traits. Conclusion: This report will help us learn more about the different traits and characteristics of Perching syndrome. The authors need to do more research on how proteins work and study more about patients with different characteristics to fully understand this.

Role of diabetes health literacy, psychological status, self-care behaviors, and life satisfaction in predicting quality of life in type 2 diabetes.

One of the factors that can affect the quality of life is the psychological status of people. Also, the psychological status of individuals can be affected by other variables. Therefore, this study was aimed to determine the role of diabetes health literacy, psychological status, self-care behaviors, and life satisfaction in predicting the quality of life in Iranian patients with type 2 diabetes. This cross-sectional study was conducted in Iran in 2021 among 300 patients with type 2 diabetes. The method of selecting the participants in this study was the proportional stratified sampling method. Data collection instruments included six questionnaires of demographic questionnaire and diabetes status, DASS-21 questionnaire (depression, anxiety, and stress), diabetes health literacy scale, self-care behavior questionnaire, satisfaction with life scale (SWLS), and quality of life questionnaire. Statistical methods such as independent sample t test, one-way analysis of variance, linear regression test, and Pearson correlation were used to analyze the data. Based on the results of Pearson correlation test, there was a positive and significant correlation between diabetes health literacy (r = 0.438, p < 0.001), depression (r = - 0.380, p < 0.001), anxiety (r = - 0.355, p < 0.001), stress (r = - 0.423, p < 0.001), and SWLS (r = 0.265, p < 0.001) with quality of life. Based on the results of linear regression, variables of diabetes health literacy, life satisfaction, self -care behaviors, depression, stress, anxiety, age of onset of diabetes and diabetes duration were able to predict 31% of the quality of life (p < 0.001). The results of this study indicated that diabetes health literacy, life satisfaction, stress and the duration of diabetes are able to predict the quality of life of patients with diabetes. Therefore, it is necessary to pay more attention to these effective variables training programs, especially health literacy, the effect of which is very obvious in this study.

Survival rate of vaginal cancer in Asian countries: a systematic review and meta-analysis.

Introduction: Vaginal cancer is one of the major causes of mortality in women, which mostly takes place in low- and middle-income countries. Assessing the survival rate of vaginal cancer is essential to investigate the success rate of current treatments and screening tools. This study aims to determine the survival rate of vaginal cancer in Asia. Methods: This systematic review was carried out using four international databases, including Medline/Pubmed, ProQuest, Scopus, Web of Knowledge, and also Google Scholar. Articles were investigated up to the end of August 2021. The authors utilized the Newcastle-Ottawa Scale to evaluate the quality of the articles. Evaluating the papers for heterogeneity was performed using the Cochrane test and I² statistic. Meta-regression analysis was also applied based on the year of the study. Results: Three articles (13 records) fulfilled the inclusion criteria. Based on the random model, the overall 5-year survival rate was 74.63%. Also, the rates of survival in relation to the type of treatment including chemotherapy, radiotherapy, or other modalities, were 78.53, 78.44, and 68.54%, respectively. According to meta-regression analysis, no correlation was found between the survival rate and the year of the study. Conclusion: The vaginal cancer survival rate is lower in Asian countries compared to that of developed countries. Increasing patient survival rates in such countries is crucial by implementing newer diagnostic tools, advanced surgical techniques, and goal-oriented treatments. Early diagnosis in lower stages and educating the populations about risk factors and preventative measures are also necessary for raising the rate of survival.

Leukoencephalopathy with vanishing white matter disease: a case report study.

Vanishing white matter (VWM) is a neurological disorder that has an autosomal recessive mode of inheritance. VWM is caused due to a mutation in in any of the five genes of eukaryotic translation initiation factor 2B (eIF2B). The etiology is unknown. Case presentation: The authors report two cases of VWM disease. In the first case, an 8-month-old female child, brought to the pediatric clinic with seizure and loss of consciousness. The second case was a 24-month-old girl, presented with weakness, a disability to walk and swallow, and poor feeding. Her brain MRI demonstrated cystic changes (white matter rarefaction) in supratentorial peri-ventricular white matter and genetic testing result showed an EIF2B3 gene mutation. Clinical discussion: Leukoencephalopathy with VWM, also known as Cree encephalopathy is caused by mutations in the EIF2B gene. The disease is inherited in an autosomal recessive fashion. There are various agents leading to symptoms and signs of VWM disease. Physical stress like head trauma even in a mild degree, infections, and febrile diseases can be mentioned as causes of VWM. The eIF2B complex, plays a role as an important factor in the regulation of protein synthesis in cells under different conditions. Conclusion: As a conclusion, genetic counseling could be recommended to all individuals with VWM disease and their family members for next pregnancies and possible precautions for consanguineous marriages.

Psychometric properties of multidimensional health locus of control scale, form C among Iranian type 2 diabetes.

Objective: This study aimed at examining the psychometric properties of Persian version of Multidimensional Health Locus of Control scale, form C (MHLC-C) among Iranian type 2 diabetes. Method: This cross sectional study was conducted on 557 type 2 diabetes in eastern city of Iran in 2022. Participants were selected by proportional stratified sampling. The validity of MHLC-C was tested by face validity, content validity, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA).Reliability of MHLC-C was assessed by McDonald omega coefficient, Cronbach's alpha coefficient, and Intraclass Correlation Coefficient. Results: Based on the results of EFA, 4 factors with eigenvalues greater than 1 were extracted, which explained 61.66% of the variance. In EFA, a question was removed. In CFA, the factor loading of all questions was more than 0.4 and the indexes of the goodness-of-fit were acceptable (for example: X2/df = 4.457, RMSEA: 0.079, CFI = 0.904, and PGFI = 0.663). McDonald omega coefficient and Cronbach's alpha coefficient of MHLC-C were 0.869 and 0.866. The Intraclass Correlation Coefficient of MHLC-C was 0.817. Finally, the MHLC-C with 17 questions and 4 factors of chance (6 items), internal (5 items), other powerful people (3 items), and doctors (3 items) was approved. Conclusions: The Persian version of the MHLC-C questionnaire, with 17 questions and four factors, is a valid and reliable scale for Iranian type 2 diabetes to assess their health locus of control status.

Mutation in PYCR2 gene and hypomyelinating leukodystrophy in children: a case report study.

Hypomyelinating leukodystrophies are a heterogeneous group of inherited white matter disorders characterized by a predominant absence of myelin deposits in the central nervous system. Case presentation: The patient was a one-year-old girl child. She at the age of 6 months was hospitalized due to loose, muscle weakness, and an upward gaze for 7-8 min with complaints of fever and convulsions. Clinical discussion: Using the test of whole exome sequencing, a nonsense homozygous mutation was found in the PYCR2 gene, which a mutation in the PYCR2 gene causes hypomyelinating leukodystrophy type 10 disease. Conclusion: Advances in the field of genetics, increased awareness, and the increasing availability of genetic testing in small cities in developing countries are helping to better assess complex neurological disorders and establish a complete diagnosis.

Detection of FLAD1 mutations and lipid storage myopathy in a 5-year-old boy: a case report study.

Lipid storage myopathy due to flavin adenine dinucleotide synthetase 1 (FLAD1) deficiency is an autosomal recessive error of metabolism that causes variable mitochondrial dysfunction. Case presentation: At the age of 3, the patient was found to have movement problems, such as difficulty rising from a chair (Gower's sign) and climbing stairs, which led to hospital admission and diagnosis. At the age of 4, carrier detection for spinal muscular atrophy was normal; however, at the age of 5, whole-exome sequencing revealed a pathogenic variant of Chr1: 154960762: A>T c.A554T:p.D185V in exon-2 of FLAD1 gene was identified as homozygous. Clinical discussion: In general, it is expected that the treatment of type 2 FLAD1 gene mutation with riboflavin has a better prognosis, but these interventions may not be sufficient for the survival of the patient. Treatment with riboflavin has increased various functions, including skeletal-muscular, and cardiovascular function. As a result, like the patient in our study, the mutation in exon-2 is more severe and less responsive to riboflavin treatment. Conclusion: Checking the FLAD1 gene is recommended in all people with multiple acyl-CoA dehydrogenase deficiency.

Short-term exposure to some heavy metals carried with PM10 and cardiovascular system biomarkers during dust storm.

This study aimed to evaluate the effect of short-term exposure to heavy metals (HM) extracted from PM10 on CB in workers' population in an outdoor space located in southern Iran during a dust storm. At first, 44 healthy and non-smoking workers were selected. Then PM10 and Blood samples were collected before and after the dust storm. Finally, HMs associated with PM10 measured by ICP-MS and its effect on the CB, including fibrinogen, CRP, TNF-α, and BP were estimated by ANOVA, Pearson correlation, and Odd Ratio (OR) in SPSS23. Based on the results, the concentration of PM10 and extracted HM such as Cr, As, and Cd was higher than the WHO/EPA standards in dust storms they increased the CB and BP remarkably. Moreover, the level of fibrinogen, blood pressure (BP) and TNF-α in dust storms were higher than in normal conditions (p < 0.05, OR > 3). In addition, As and Cd decreased fibrinogen concentration and systolic BP, respectively. Whereas, TNF-α was associated with concentration of Pb (R = - 0.85) on normal days. Consequently, the HM on PM10 such as As, interferes with the level of investigated CB. These results considered a potential risk for the residents in the southern regions of Iran.

Correlation Between Diabetes and COVID-19 Indices: A Global Level Ecological Study.

Introduction: Coronavirus is threatening the global public health as a new and widespread crisis. The researchers must keep in mind that one of the most vulnerable groups to COVID-19 are the people with underlying diseases, especially diabetes. Objective: This ecological study aimed to investigate the correlation between diabetes and the epidemiological indices of COVID-19. Methods: This ecological study included 144 countries. Their available data consists of the cumulative incidence rate of cases, cumulative incidence rate of death, recovery rate, case fatality rate, and performed tests of COVID-19, and diabetes. To collect the variables, a data set was provided which included the information of 144 countries based on diabetes and COVID-19 indices. Spearman coefficients were used for assess correlation between diabetes and COVID-19 indices. Also, Scatter plots of diabetes for the studied countries were drawn based on cumulative incidence rate of cases, cumulative incidence rate of death, tests, recovery rate, and case fatality rate of COVID-19. Results: The results of this ecological study showed in total countries, there was a weak positive correlation between diabetes and cumulative incidence rate of cases and also cumulative incidence rate of death. Correlation between diabetes with test of COVID-19 was very weak. Scatter plots showed a weak liner correlation between diabetes and cumulative incidence rate of cases, cumulative incidence rate of death and test of COVID-19. Conclusions: In this study, there was a weak positive correlation between diabetes and cumulative incidence rate of cases, cumulative incidence rate of death, and performed test of COVID-19. This disease is an enormous challenge for health policymakers; therefore, it is necessary to develop strategies and practical guidelines specific to each region to take the necessary care, especially for diabetic patients.

Neoadjuvant VS adjuvant chemotherapy in patients with locally advanced breast cancer; a retrospective cohort study.

Background: Breast cancer is one of the most common challenges for women's health. Until now, neoadjuvant chemotherapy is a standard approach in locally advanced breast cancer (LABC), as it increases the probability of breast-conserving surgery (BCS). This study aimed to compare the survival rate in neoadjuvant and adjuvant groups to suggest a better treatment strategy for locally advanced breast cancer. Methods: The study was conducted between 2009 and 2019 on 845 LABC patients at the Cancer Research Center of Shahid Beheshti University of Medical Sciences in Iran. All patients with LABC at stages 3A, 3B, and two were evaluated for treatment with adjuvants (n = 520 female patients) and neoadjuvant (n = 320 female patients) treatment strategies. Patients were followed up for at least 120 months. The Kaplan-Meier method calculated the survival rate using SPSS version 23 software. Result: The 5 and 10 years survival rates of neoadjuvant and adjuvant groups were 87 ± 0.04, 80 ± 0.07% and 87 ± 0.02, 83 ± 0.03%, respectively. Statistical analysis results with the mentioned treatment strategies did not show any significant difference in overall survival. Conclusion: The result of this study on LABC patients demonstrated that compared to surgery first following adjuvant chemotherapy, the neoadjuvant chemotherapy has several benefits, including downstaging and more BCS, with no statistically significant difference in the overall survival rate of the patients.

The prevalence of electronic cigarettes vaping globally: a systematic review and meta-analysis.

BACKGROUND: The purpose of this systematic review study was to determine the national, regional, and global prevalence of electronic cigarettes (e-cigarettes) vaping. METHOD: The articles were searched in July 2020 without a time limit in Web of Science (ISI), Scopus, PubMed, and Ovid-MEDLINE. At first, the titles and abstracts of the articles were reviewed, and if they were appropriate, they entered the second stage of screening. In the second stage, the whole articles were reviewed and articles that met the inclusion criteria were selected. In this study, search, selection of studies, qualitative evaluation, and data extraction were performed by two authors independently, and any disagreement between the two authors was reviewed and corrected by a third author. RESULTS: In this study, the lifetime and current prevalence of e-cigarettes vaping globally were 23% and 11%, respectively. Lifetime and current prevalence of e-cigarettes vaping in women were 16% and 8%, respectively. Also, lifetime and current prevalence of e-cigarettes vaping in men were 22% and 12%, respectively. In this study, the current prevalence of e-cigarettes vaping in who had lifetime smoked conventional cigarette was 39%, and in current smokers was 43%. The lifetime prevalence of e-cigarettes vaping in the Continents of America, Europe, Asia, and Oceania were 24%, 26%, 16%, and 25%, respectively. The current prevalence of e-cigarettes vaping in the Continents of America, Europe, Asia, and Oceania were 10%, 14%, 11%, and 6%, respectively. CONCLUSIONS: Based on the results of this study, it can be concluded that the popularity of e-cigarettes is increasing globally. Therefore, it is necessary for countries to have more control over the consumption and distribution of e-cigarettes, as well as to formulate the laws prohibiting about the e-cigarettes vaping in public places. There is also a need to design and conduct information campaigns to increase community awareness about e-cigarettes vaping.

Survival Rate of Liver Transplantation in Asia: A Systematic Review and Meta-Analysis.

Background: Liver transplantation is one of the most effective treatments for acute liver failure, chronic liver cirrhosis, and hepatocellular carcinoma. This study was implemented to evaluate the survival rate of liver transplant in Asia. Methods: Studies that investigated the survival rate of liver transplant were selected using a systematic search strategy in the following databases: Medline, Embase, Scopus, ProQuest, ISI Web of Science, and Cochrane to Nov 30th, 2020. Pooled survival rate and 95% confidence intervals were calculated using Der-Simonian and Laird method. Stata 16.0 (Stata Corp, College Station, TX, USA) was used for analysis. Results: One, 2, 3, 5, and 10-year survival rates of liver transplant were estimated to be 85%, 80%, 75%, 73%, and 71%, respectively. The results of the univariate meta-regression for defining the sources of heterogeneity for one-Year survival rate (SR) showed significant effects of bias (ß high risk/moderate risk =0.059, 95% CI: 0.002, 0.115, P-Value=0.04) and follow up time (ß= -0.0002, 95% CI: -0.0003, -0.00, P-Value=0.02) on heterogeneity. Conclusion: The survival rate of liver transplant in Asia is comparable with the corresponding rate reported in the United States and Europe. This study provides a better view of the efficiency of medical cares, regarding liver transplantation. Medical care be enhanced to increase the survival of liver transplant patients.

Prevalence of Syphilis Infections among the Iranian Population: A Systematic Review and Meta-Analysis.

Background: Syphilis is one of the most important sexually transmitted infections (STI) and a public health problem, but the literature describing the true burden of syphilis is limited. In Iran, there are no accurate results on the prevalence of syphilis. This study aimed to conduct a systematic review and meta-analysis of syphilis in Iran. Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies published on the prevalence of Syphilis in Iran. We systematically reviewed the literature to identify eligible studies as of Sep 13, 2020, in international and national databases. The results are presented in the form of forest plots and tables. Pooled prevalence and 95% confidence intervals were calculated using Der Simonian and Laird method. Perform subgroup analysis through population, gender, city, and diagnostic tests to assess the source of heterogeneity. Results: We reviewed 1,229 papers and reports, and extracted data from 15 eligible records. The prevalence of combined syphilis in Iran is 0.1% (95% confidence interval [95% CI] 0.1-0.1%). The prevalence of syphilis was 0.4% in men (95% confidence interval [95% CI] -0.3, 1%) and 0.6% in women (95% confidence interval [95% CI] (0.1, 1%)). The cumulative meta-analysis showed a decline in the prevalence of syphilis between the years 1999 and 2015. Conclusion: The prevalence of syphilis in Iran is low. In the past few decades, the prevalence of syphilis across the country has declined. Syphilis infection is a small burden that needs to be revised in the implementation of high-cost screening programs.

Psychometric properties of Persian version of diabetes health literacy scale (DHLS) in patients with type 2 diabetes.

BACKGROUND: The purpose of this study was to investigate the psychometric properties of the Persian version of Diabetes Health Literacy Scale in type 2 diabetic patients. METHOD: This cross-sectional study was conducted in 2021 in 1040 patients with type 2 diabetes in eastern Iran. Participants was selected by proportional stratified sampling method. The validity of DHLS was investigated through qualitative face validity, qualitative content validity, and structural validity (exploratory factor analysis and confirmatory factor analysis). The reliability of DHLS was checked by Cronbach's alpha coefficient, McDonald omega coefficient, and test-retest. RESULTS: In exploratory factor analysis, 3 factors with eigenvalues greater than 1 were extracted, explaining 68.57% of the variance. These factors entered the confirmatory factor analysis, none of the questions were removed, and all questions had factor loading above 0.4. Cronbach's alpha coefficient and McDonald omega coefficient of DHLS were 0.919 and 0.922. Also, the Intraclass correlation coefficient of DHLS was 0.957. Finally, the DHLS was approved with 14 questions and the three subscales of Informational Health Literacy (6 items), Numerate Health Literacy (5 items), and Communicative Health Literacy (3 items). CONCLUSIONS: DHLS with 14 questions and the three subscales is a valid and reliable tool for examining diabetes health literacy in people with type 2 diabetes.

Comparison the Ability of Quantitative Trauma Severity Assessment Methods Based On GAP, RTS, and ISS Criteria in Determining the Prognosis of Accidental Patients.

Objective: To compare the ability of quantitative trauma severity assessment methods based on Glasgow coma scale, age, and arterial pressure (GAP), revised trauma score (RTS), and injury severity score (ISS) criteria in determining the prognosis of accidental patients. Methods: This cross-sectional study was performed on random patients referred to Imam Khomeini Hospital in Urmia from March 20, 2020 to September 21, 2020. The data were obtained by using a checklist includes items such as age, sex, respiration rate, oxygen saturation level, pulse rate, primary blood pressure, initial Glascow coma scale (GCS), patient outcome and injury to different parts of body. After collecting the data, it was entered into SPSS 18 and analyzed with the descriptive and analytical statistics include an independent t-test and receiver operating characteristic curve (ROC) curves. Results: Out of 1930 studied patients, 365 (18.9%) were women and 1565 (81.1%) were men. The mean age of patients was 37.05±17.11 years and women were significantly older than men. The mortality rate was 4.8% and was significantly more in men compared to women. The mean blood pressure, GCS and oxygen saturation level were lower in deceased patients. The mean GAP, ISS and RTS values were 23.13±2.69, 4.07±3.82, 7.72±0.52, respectively. The mean values of GAP and RTS were significantly low in deceased patients whereas the mean ISS value was significantly high in the deceased patients. The Area under the curve (AUS) for ISS was greater than the other two scoring systems. Conclusion: The findings of the current study showed that all three systems were adequately efficient to prognoses the final outcome in multi-trauma patients but the ISS measure was better than the other two criteria.