International Journal of Pediatrics
Volume:9 Issue: 91, Jul 2021

Background :

Arterial ischemic stroke (AIS) is an important cause of neurological disabilities, such as hemiparesis, epilepsy, and cognitive dysfunction in children. This study aimed to describe the clinical presentation, risk factors, and neuroimages of pediatric patients with AIS.

In a cross sectional study all of 73 patients admitted to Tabriz children’s hospital with the diagnosis of Ischemic stroke between 2014 and 2019 were enrolled in the study and follow up for at least one year after discharge. Stroke was diagnosed based on clinical presentation and compatible Brain CT scan and MRI, or MRV/MRA and then Para clinical assessment were done.

Male predominance in the present have been observed with male/female ratio of 1.28. AIS was common in younger age (79.4% 0.05).

Conclusion :

With careful investigation, in most of the children underlying risk factors could be found. Based on the results, acute illness and cardiac disorders were the most frequent risk factors in pediatric stroke. However, some of these risk factors (such as anemia, infection, and dehydration) which are relatively common in the pediatric population were preventable.

Background :

The World Health Organization (WHO) has announced that severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) outbreak is a public health emergency requiring international concern. Thalassemia syndromes are the most prevalent monogenic hemoglobin disorder in world and Iran is located on thalassemia belt, so this type of hemoglobinopathy has a critical importance in our country.

In this overview, the research was conducted by screening the relevant articles evaluating the COVID-19 in patients with thalassemia. An electronic search was performed in online data bases of Scopus, Sid.ir, EMBASE, Cochrane, Web of Science and Medline (via PubMed) with English and Persian language from December 2019 up to November 2020.

Results:

 Overall, 59 articles could be originally identified, 43 of which were excluded and 16 articles have been investigated. Thalassemic patients had a higher risk for severe clinical events due to 2019 novel corona virus. Presence of comorbidities could aggravate the course of COVID-19 in these patients. In thalassemic patients, the protocol of transfusion should not be altered. Also in asymptomatic thalassemic cases, iron chelation should not be stopped but in thalassemic patients with confirmed COVID-19 infection, iron chelation must be discontinued.

Conclusion :

According to low number of reported cases of infected thalassemic patient with confirmed COVID19, there are many unanswered question in management of these vulnerable patients. In this setting treatment decision need to be individualized on a case-by-case basis. In order to deliver an appropriate treatment for these patients, a teamwork between attending clinicians is of utmost importance.

Background

 Studies on colonic motor function in pediatric patients with constipation have revealed some dysfunctional patterns of colonic transit. The aim of this study was to evaluate the times and patterns of colon transit time to diagnose and categorize of colon abnormalities.

This descriptive, cross-sectional study was performed at Dr. Sheikh Pediatrics Hospital of Mashhad University of Medical Sciences, Mashhad, Iran during 2013-2019. Sixty-four children with chronic constipation that were referred to the radiology department were enrolled in the study. Segmental and total colon transit times (CTT) were calculated by using plastic markers and Metcalf Protocol. Data were analyzed using SPSS software (version 22.0).

Among 64 children with constipation (aged between 2 and 18 years), about half (51.5%) of patients had normal segmental and total CTT. Of 43 patients with a normal total CTT, 10 (23%) had a prolonged segmental CTT. the normal upper limits of CTT were considered for the right colon, left colon, rectosigmoid, and total colon at 20, 20, 30, and 60 hours, respectively. These times had a 97% specificity with AUC = 0.74 to 0.93 to differentiate the normal from the abnormal transit time. The transit abnormalities were included rectosigmoid retention (22%), colon inertia (17.2%), left colon retention (6.2%), and right colon retention (3.1%).

Both segmental and total CCT were found normal in half of our constipated patients and Rectosigmoid retention and colon inertia were the most common abnormalities. The normal upper limits for colon transit time in the northeast of Iran were less than those found in Western countries.

According to education experts, learning the concepts and topics of the information technology age is influenced by the five minds introduced by Gardner, therefore, it is necessary to pay attention to these five minds in educational centers and identify the factors affecting it. The aim of the present study was to investigate the relationship between individual, educational, social and cultural factors with five minds among student teachers.

This was a descriptive-analytical research and its statistical population included all student teachers of Farhangian University of Kerman, Iran, in 2020. A total of 400 people were selected by stratified random sampling. The data collection tool included two researcher-made questionnaires. Data were analyzed using Pearson correlation coefficient and multiple linear regression in SPSS ver. 25.

The results showed a positive and significant relationship between individual, educational, social and cultural factors with Gardner's five minds, so that these four factors simultaneously (R2adj = 422) explain the variance of the five minds. Moreover, the most important predictors of the five minds of student teachers are individual factors (β = 0.266, p = 0.001), social factors (β = 0.229, p = 0.001), and educational factors (β = 0.20, p =0.001), and cultural factors (β= 0.166, p = 0.001), respectively.

Based on the research results, individual, educational, social factors and cultural factors were the predictors of five minds among the student teachers.

Background:

 The researchers do not prove the effect of birth weight on childhood obesity, so far. This study aimed at providing evidence on the effect of birth weight on obesity and overweight among primary school pupils.

This case-control study was conducted on 508 primary school pupils. Multistage sampling technique was applied to increase the accuracy of risk calculation. Pupils were divided into the two groups of case (170 pupils with a Z-score  ≥ 1 as overweight and obese)  and control (338 pupils with a Z-score between -2 to 1 as not being obese or overweight) based on WHO reference data, For each case, two controls were matched and selected based on age, gender, and type of school. Demographic, physical activity as well as 24-hour dietary program and amount of energy expenditure data were collected. All data analyses were performed using SPSS. Odds ratio with 95% confidence interval was estimated.

The risk of obesity and overweight among girls who had a birth weight > 3,500g, was 2.51 times higher than that in girls with a birth weight ≤ 3,500g (OR=2.51, 95% Cl: 1.2-5.25). However, not only this risk among boys was not higher than unity, but also it was less than one showing a reveres not-significant association (OR=0.715, 95% CI: 0. 369-1.39).

Birth weight was an independent risk factor for obesity and overweight during childhood only among girls. Gender had a moderating effect on the relation between birth weight and obesity during childhood.

The present study aimed to evaluate the accuracy of enzyme-linked immunosorbent assay (ELISA) compared to the real-time reverse transcription-polymerase chain reaction (rRT-PCR) in the diagnosis of coronavirus disease 2019 (COVID-19) in Iranian children. 

Materials and Methods:

In this cross-sectional study, 90 children under 15 years of age were randomly selected from suspects of COVID-19 referred to the Tabriz Children Hospital, the main pediatric COVID-19 diagnostic center of Tabriz, from May 21, 2020 to June 21, 2020. Blood and nasopharyngeal samples were taken simultaneously at the referring time. The diagnostic accuracy of ELISA-based IgM and IgG antibody tests for COVID-19 were compared with the rRT-PCR.

The calculated sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, overall diagnostic accuracy, and diagnostic odds ratio were 0.5745, 0.9767, 0.9643, 0.6774, 24.66, 0.4357, 0.7667, and 56.60 for IgM; and 0.6170, 0.9302, 0.9355, 0.6897, 8.84, 0.4117, 0.7667, and 21.47 for IgG, respectively.

Due to the lower sensitivity of antibody detection-based serological tests compared to rRT-PCR, they cannot be considered as initial and reliable tests for the diagnosis of COVID-19. It can be suggested that the serological tests be only used as complementary tests to rRT-PCR or for monitoring the immune response of children with COVID-19.

The purpose of this study was to investigate the effects of chlorhexidine, fluoride and green tea gel on salivary S. mutans and Lactobacillus in children.

The present single-blinded clinical trial was conducted on 60 children aged 4- 6 years in pediatric dental clinic of Kerman University of Medical Sciences, Kerman, Iran, in 2019. Children randomly were divided into three groups of 20. In each group, one of green tea 5% gel, chlorhexidine 2% gel or fluoride 0.2% gel was applied to teeth of children for five minutes before spitting out. Unstimulated saliva samples were taken from children before intervention, 30 minutes and one week after gel applications. Real-time quantitative Polymerase Chain Reaction method was used for counting bacteria. Flavor acceptability of each gel was also recorded using the Visual Analogue Scale. Data were analyzed using SPSS software version 21.0.

Participants were equally distributed in terms of gender and the mean DMFT score was not different between three groups. Green tea 5%, chlorhexidine 2% and fluoride 0.2% gel reduced the count of salivary S. mutans and Lactobacillus at 30 minutes and one week after intervention (P=0.000). Bacterial count increased one week after the application of chlorhexidine gel. However, a week after the application of green tea gel, the bacterial count was still less than what it was 30 minutes post application. The flavor acceptability of green tea was higher than chlorhexidine (P=0.007).

The gel form of green tea, fluoride and chlorhexidine reduced salivary S. mutans count. However, the durability and flavor acceptance of green tea was more than chlorhexidine and fluoride gel.

The main objective of the present study was to investigate the prevalence of the polycystic ovary syndrome (PCOS) among girls’ students of Kerman University of Medical Sciences and its relationship with anthropometric indices and the secondary purpose included a meta-analysis of the prevalence of PCOS in Iranian adolescent girls.   In the first part, the cross-sectional descriptive study was carried out on 636 students residing in dormitories of Kerman University of Medical Sciences. Cluster sampling was used and stepwise logistic regression was used to evaluate the factors affecting the prevalence of PCOS. In the second part of the study, online databases were searched in Scopus, PubMed, Web of Science, EMABSE and Persian Magiran, SID, and Iran Doc databases basis of inclusion-exclusion criteria until January 2020. STROBE checklist was used to measure for evaluating of study quality.   At firs part, 636 girl's students participant in this study. A total of 73 patients (11.5%) had PCOS. There was a significant relationship only between waist circumference with the prevalence of PCOS. For every one centimeter increase in waist circumference, the odds ratio of developing PCOS increases by 7%. According to the findings of six studies in the present meta-analysis, the prevalence of PCOS is 5.2% (95% CI: 3-8%). Heterogeneity cross studies was highly significant (p <0.01; I2=94%).   The prevalence of PCOS in adolescents and childbearing age group is not high in Iran. The results of the present study showed a significant relationship between waist circumferences (WC) with the prevalence of PCOS, so that for one-centimeter increase in WC, the odds ratio of developing PCOS increases by 7%.

Adult-onset Still’s disease (AOSD) is an uncommon inflammatory condition presenting with high grade fever, arthralgia, skin rash, and leukocytosis. Autoimmune thyroid disease (AITD) is commonly seen in females in their third to fifth decade and usually missed to screen in other autoimmune diseases. In this study, the case of a 17-year-old female patient from Pune is reported who presented to Bharati hospital in November 2020, with a six-month history of high-grade fever, arthritis, and elevated acute phase reactants along with hypothyroidism. She was diagnosed with AOSD (based on Yamaguchi criteria) and AITD with positive anti-thyroid peroxidase (anti-TPO) antibodies. She responded well to oral steroids and thyroid supplements. This case draws attention to the rare association between AOSD and AITD.

Background :

Quality of school life is defined as the overall student satisfaction with their experiences of school activities. The purpose of this study was to investigate the structural relationships between perfectionism and quality of school life with respect to the mediating role of emotional regulation difficulty.

This is a descriptive correlation study using structural equations. A sample of 353 female high school students in Kerman, Iran, was selected through Cochran's formula using random cluster sampling. To collect data, Ainley and Bourke's Quality of School Life (QSL) scale, Terry-Short's Positive and Negative Perfectionism (PAPS) scale, and Gratz & Roemer's Difficulties in Emotion Regulation Scale (DERS) were used. The validity of the questionnaires was measured and confirmed using factor analysis and reliability through Cronbach's alpha. Data were analyzed using descriptive and inferential statistical indicators including structural equation modeling and confirmatory factor analysis using SPSS (version 16.0), and AMOS software (version 24.0).

Results showed that positive and negative perfectionism have a significant effect on the quality of school life with respect to the mediating role of emotional regulation difficulty. The impact of positive perfectionism on the quality of school life was direct and significant, while its effect on the difficulty of emotional regulation was significant but inverse; emotional regulation difficulty showed a significant inverse effect on the quality of school life.

Conclusion :

Perfectionism and emotional regulation difficulty are threats to the quality of school life, so adopting a comprehensive perspective to understand and solve these issues is necessary.

Fetal growth restriction is one of the main causes of perinatal mortality that can be predicted by ferritin. We aimed to evaluate the role of ferritin in prediction of mothers with Appropriate-for-gestational-age (AGA), Small-for-gestational age (SGA) and intrauterine growth restriction (IUGR).

In this cohort study, we screened 73 mothers with gestational ages of 32-34 weeks. If amniotic fluid index (AFI) was normal and there was no circulation defect, the fetuses were classified in SGA group and in case of presence of oligohydramnios or circulation defect; they were classified in IUGR group. Also, fetuses with normal growth were classified in AGA group. We evaluated the serum ferritin, hemoglobin, and iron of the mothers. Moreover, we evaluated the levels of placenta ferritin, Hb, and hematocrit in the delivery room.

In this study, 28 patients were categorized in AGA group, 15 patients in SGA group and 30 patients in IUGR group. Mean weight of all infants was 2210.60 ± 932.77 grams. Also, the mean AFI of all infants was 9.81 ± 3.59. The mean ferritin level of all mothers was 30.29 ± 10.80 and IUGR group had the highest and AGA group had the lowest ferritin levels (P=0.015). Maternal ferritin (µg/l) (Sen: 67.9%, Sp: 61.9%), maternal hematocrit (%) (Sen: 70%; Sp: 62.8%,) and maternal Hb (Sen: 70%, Sp: 65.1%,) could predict IUGR.

Increased (>34 µg/l) and decreased.

Background:

 Learning is a multi-directional process involving many factors, such as teachers, students, characteristics of the learning environment, to attain desired objectives. This study aimed to investigate the color preference of the educational space by teachers and students and its effect on the attitude and learning productivity in primary school students.

The research method was a combination of documentary and library studies along with survey research. After the classification of data obtained by the library research, the images of 60 cases were presented to 31 experts, and 15 cases were finally selected and distributed among 212 subjects in Noorabad Delfan, Iran. The samples were selected among 10 classes using the un-purposeful non-probability sampling. The teachers and students answered a researcher-made questionnaire.

There were 106 (50%) male students in this study. Blue and green colors had the highest priority among male and female teachers. Results showed that the preference for red decreased while that for green increased with age.The results of examining the opinions of experts and audiences showed that the color of the classroom also affected the physical and mental health of users of that space, in addition to being a factor of vitality.

The findings indicate that the color priority of the educational space was different in teachers and students, as well as by their gender. Given that the space color affects the mood of the users and the productivity of learning, this issue should be considered besides the connection between indoor and outdoor spaces and the use of educational spaces with a color spectrum that conforms to the users' desires and needs.

Background:

 The internal position of health control is related to positive awareness and attitude, cognition status, hygienic behaviors, and health. We aimed to investigate psychological issues related to the first childbirth and its relationship with favorite of the kind of next childbirths in women referring Ghamar-e Bani Hashem Hospital, Khoy, Iran.

The present study was a descriptive-analytical cross-sectional study. The study participants were postpartum women admitted to the postpartum ward of Qamar Bani Hashem Khoi Hospital in 2014-2015. Data collection tools included a questionnaire of preference for the next type of delivery and its causes, individual-social questionnaires, Edinburgh Postnatal Depression Scale (EPDS), Spielberger state-trait anxiety inventory, Wake-Forest, Multi-Scale Health Control Scale. Finally, the data were analyzed using SPSS software (version 13.0).

The sample size of this study was 380 pregnant mothers. There was no significant statistical relationship between psychological variables and preference for delivery (P>0.05). The variables that were obtained statistically significant in the analysis of one variable with a preference for the type of delivery were entered into the regression test. Between these data, age, spouse's education, and income as a determinant of postpartum depression, anxiety and internal health scores, were among the predictors of preference for delivery (p <0.05).

Based on the results, there was no relationship between depression, anxiety, and post-partum health beliefs, with women preferring the next type of delivery. There was a relationship between individual and social factors and preference for the next type of women's delivery.

Social interaction is an inevitable technique and resource of children's mental development, and children learn how to interact with others. The purpose of this study was to determine the effectiveness of social skills training on aggression among preschool children in the kindergarten of Tehran, Iran.

The study was a quasi-experimental design with a pre-test and post-test were selected by simple random sampling to compare a group of experiments (n= 7) with control (n = 7) groups. In this study, the statistical population in Tehran kindergartens in 2017-18 consisted of all children aged 4 to 6 years.  The intervention was conducted 10 sessions in 60-minute after pre-test and then the results were evaluated in two stages of pre-test and post-test by Matson's Social Skills Questionnaire and finally, after one month of intervention, the data were collected. Data were analyzed by using SPSS software (version 22.0).

According to the descriptive results, the study group consisted of 7 children aged 4 to 6 years, while the control group consisted of 7 children aged 4.7 to 5.5 years. The findings showed that the mean and SD of aggression and impulsive behaviors in the experimental group decreased in the post-test 26.71±6.47 and 170± 11, respectively (p < 0.05).

The study was conducted 10 sessions in 60-minute by Matson's Social Skills intervention for children aged 4 to 6 years. Therefore, this psychotherapeutic intervention reduced aggression and impulsive behaviors among kindergartens children.

Pragmatic skills of language are important for everyday life interactions. It has been proven that cochlear implantation age should be considered, as an important predictor of language skills in children with cochlear implantation (CI), but information about the benefits of early cochlear implantation on pragmatic language development in these children are very few. Thus, this study intends to compare pragmatic skills as well as speech intelligibility in prelingual deaf children who received cochlear implants before the age of 6 years and those who received cochlear implants after the age of 6 years with an 8-year follow-up.

This Retrospective 8-year longitudinal study was conducted in a cochlear implant center in the city of Tehran, Iran, in 2021. Forty-five children were included in two groups: early cochlear implant (n = 17), and early cochlear implant (n = 28). The Persian version of the children's communication checklist (CCC) was used to assess the participants 'pragmatic skills and the Persian version of the Intelligibility Context Scale (ICS) was used to assess the participants' speech intelligibility.

The two study groups did not show a significant difference in terms of pragmatic scores (P>0.05) but had a significant difference in terms of ISC scores (p <0.001). Speech intelligibility had a significant negative relationship with the age of cochlear implantation (r = -0.5, p <0.001) but had no significant correlation with pragmatic skills (P>0.05).

The long-term results of early and late cochlear implants were similar in terms of the development of pragmatic skills but very different in terms of speech intelligibility. The age of cochlear implantation had no effect on the pragmatic of language.

The aim of this study was to determine the suitable maintenance fluid that sustains normal plasma sodium levels in children that are 5 years and below in the perioperative period by comparing 4.3% dextrose in 0.18% saline with Ringer’s lactate when either is administered as maintenance fluid. This comparative prospective study was carried out at the pediatric surgery unit of the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria between September 2014 and October 2015.50 patients were enrolled, 25 in each group. One group received 4.3% dextrose in 0.18% saline, while the other group received Ringer’s lactate as maintenance fluid in the perioperative period. Serial blood and urine samples were collected before, during and after the surgery up till the first 24 hours after surgery. These samples were analyzed for concentration of sodium and creatinine. Fractional excretion of sodium was calculated. Data were analyzed using SPSS software (version 22.0). The mean age of the study population was 30.6+19.33 months. The mean age of the patients on dextrose saline and Ringer’s lactate was 28.72+20.3 32.52+18.53 months, respectively (p=0.49). The proportion of patients that developed hyponatraemia in the group that received hypotonic fluid was 32% (8/25), while it was 8% (2/25) in the group that received isotonic fluid (p=0.034). The patients who received Ringer’s lactate as maintenance fluid also had a higher mean plasma sodium concentration during the study. Ringer’s lactate was found to be a better fluid in terms of preventing hyponatraemia in children who are five years and below during the perioperative period compared to 4.3% dextrose in 0.18% normal saline.

Background:

 An importance issue for pediatric health is to understand how to enhance the level of physical activity of children and adolescents. The purpose of the present study was to investigate the effects of a physical education-based intervention on promoting physical activity and well-being of primary school’s students.  

The present causal-comparative field study was conducted on 300 primary school girls (mean age: 10.72±0.73 years) of Urmia city, West Azerbaijan province, Iran, in 2019. The participants were randomly allocated into two groups including intervention (n=150), and control groups (n=150). Participants of intervention group were exposed to a six months’ intervention and 2 sessions per week based on social cognitive and social-ecological theories within the physical education classes, while those in control group followed their regular school tasks. Physical activity behavior and physical and psychological well-being were measured as dependent variables. Data were analyzed using SPSS software (version 16.0).

Age of participants in intervention and control group was not significantly different. Results of pretest showed that the participants of both group had similar physical activity behavior and well-being at baseline. However, the participants in the intervention group reported higher physical activity level (F = 17.11, P < 0.001) and physical (F = 30.76, P < 0.001), and psychological (F = 36.03, P < 0.001) well-being in comparison to those in control group in the posttest.

These results highlight the importance of developing physical education-based interventions for improving physical activity level and well-being of primary school-aged children.

The aim of this study was to investigate the density and type of bacterial and fungal bioaerosols in the air of the pediatric burn ward.

In this cross-sectional study, two active and passive sampling methods were used simultaneously to evaluate the density and type of bacterial and fungal bioaerosols. In 2019, sampling was performed once every six days, according to the sampling guideline developed by the 2019 United States Environmental Protection Agency (EPA). Data were analyzed using SPSS software (version 22.0).

According to the EU GMP standard, in the active method, bacterial and fungal contaminations in the indoor air of the burn ward were in grades C and D, respectively. According to this standard, in the active method, bacterial and fungal contaminations in the outdoor air of the burn ward were in grade C. According to the EU GMP standard, in the passive method, bacterial and fungal contaminations in the indoor air of the pediatric burn ward were in grade C. According to this standard, in the passive method, bacterial and fungal contaminations in the outdoor air of the burn ward were in grade C.

Given the importance of preventing infection in patients with burns and preventing deaths caused by infections in these patients, especially in children with burns, it is necessary to pay attention to the role of bioaerosols in developing nosocomial infections in burn patients.

There is little evidence of the efficacy of acetaminophen prophylaxis in preventing PDA in premature infants. Regarding the effects of acetaminophen in these cases and also safety of this drug in preterm infants, as well as the high prevalence of arterial duct in our population, we aimed to determine the preventive effects of this drug on PDA in preterm infants.

Materials and Methods :

In this clinical trial, 64 premature infants with gestational age less than 31 weeks were randomly divided into two groups including intervention group receiving acetaminophen prophylaxis (10 mg/kg) every 6 hours for 5 days and the control group did not receive any intervention. After 10 days, both groups were assessed by echocardiography regarding the PDA condition. Serum levels of ALT and AST enzymes were also measured 10 days later and simultaneously with doing echoes.

Results :

There was a significant different in the rate of PDA closure across the two intervention and control groups (84.4% versus 50.0%, p = 0.007). After the intervention, open PDA was found in 50% of neonates in control group and 15.6% in intervention group that were treated with ibuprofen and echocardiography was performed again after 1 month. PDA was closed in the remaining 87.5% in the control group and remaining 100% of patients in the intervention group indicating no difference (p = 0.632). The changes in liver enzymes slightly changed after intervention.

Conclusion:

 Preventive treatment with acetaminophen can effectively lead to PDA closure in premature infants.

Parents of children with autism spectrum disorder (ASD) showed significant fatigue and loss in their quality of life. The study aims to investigate the effectiveness of the strategic solution oriented therapy on fatigue and quality of life among mothers of children with autism spectrum disorder. This experimental study was performed among 28 mothers of children with autism spectrum disorder using purposeful sampling. The participants were divided in two groups, namely, experimental (n=14), and control (n=14) groups. The experimental group held 7 sessions of 1.5-hour while the control group was not offered any therapy from the second half of October until the second half of December 2019.   The questionnaire Fatigue (SPIN) and Life Quality (RCSQ) were completed before and after any type of (experimental and control) education. In addition to descriptive statistics, the study of variance estimation (MANOVA) was used to interpret the findings using the SPSS software version 25. In this study, the majority of mothers (32.1%) were between 25 and 30 years of age and the higher education degree of mothers (44.6%) was a diploma. The Mean and SD for mental fatigue (3.02±0.103), and quality of Life (2.03±0.127) in pre-test and post-test mental fatigue (1.10±0.699), and quality of Life (3.31±0.220) has been shown respectively (p <0.05). The strategic solution-oriented counseling intervention for mothers with children with autism was administered in seven 90-minute sessions. As a result of this strategic solution-oriented intervention, mothers with children with autism experienced less emotional fatigue and had a higher quality of life.