[Association of serumomentin levels in women with polycystic ovarian syndrome]

Adipokines, compounds secreted from adipose tissue, are involved in metabolism control. Omentin is one of the adipokines with different biological roles. Serum levels of Omentin were found to be associated with BMI, insulin resistance, metabolic syndrome, diabetes, and cardiovascular disease in several studies. The aim of this study was to assess the association between omentin level and the PolyCystic Ovarian Syndrome. This case-control study was performed on 45 patients with Poly Cystic Ovarian Syndrome and 45 normal individuals as controls. BMI and fasting omentin and insulin serum levels were measured by Enzyme-Linked Immunosorbent Assay [ELIZA] method, fasting glucose serum level was measured by enzyme-calorimetric method and insulin resistance index [HOMA-IR] was measured using the relevant equation. Data was analyzed using the independent t-test, Pearson correlation coefficient and by SPSS 16 software. Omentin serum levels in the patient PCOS group were significantly lower in patients with polycystic ovarian syndrome than in controls. Insulin and glucose serum levels in the PCOS group were significantly higher than in controls, indicating these patients had insulin resistance. There was no significant correlation between serum levels of omentin and HOMA-IR between cases and controls. This study shows that serum omentin level decreased in PCOS patient in comparison with BMI-matched controls. The findings of this study suggest that changes in omentin serum level may be considered as a criterion of PCOS

Safety and adequacy of percutaneous biopsies in pediatric orthotopic kidney transplantation

The gold standard for investigating the cause of renal graft dysfunction is renal biopsy. However, as this procedure is invasive and has inherent risks, its safety must be established. To determine the safety of percutaneous renal biopsy in pediatric orthotopic renal transplantation. Percutaneous renal biopsies performed on pediatric orthotopic renal transplants in a single center between 1987 and 2010 were studied. Biopsy specimen adequacy and post-procedure complications were reviewed by prospectively collected data. A total of 54 ultrasound [real-time] guided biopsies in 25 patients were performed. Minimum specimen adequacy was achieved in 98% of biopsy specimens. No major complications were identified; 6% of patients developed minor complications-e.g., grade 3 macroscopic hematuria that did not require intervention. Percutaneous renal biopsies using [real-time] ultrasound guidance on pediatric orthotopic kidney transplants is safe

Molecular epidemiology of zoonotic streptococcosis/lactococcosis in rainbow trout [Oncorhynchus mykiss] aquaculture in Iran

Streptococcosis/lactococcosis is a hyperacute systemic disease that can occur in marine and fresh waters of many species of fish. The aim of this work was to study the disease outbreak in the major rainbow trout [Oncorhynchus mykiss] production of Iran. 108 Gram positive cocci isolates were obtained from diseased trout in seven provinces with major trout production during 2008 till 2009. These bacterial isolates were characterized using phenotypic and molecular studies. The isolates were also analysed phylogeneticaly and compared with the available data. 49 samples [45.37%] were identified as Streptococcus iniae, 37 samples [35.2%] matched with Lactococcus garvieae; and 22 samples [19.43%] were identified as members of Streptooccus genus by culture-based and biochemical tests of API 50 CH, API 20 STREP and rapid 32 STREP systems. Using universal primers for differentiation of Streptococcus sp. and Enterococcus sp, all 108 samples were identified as Streptococcus sp. with a target region of 500 bp. Single specific PCR resulted in identification of 64 [59.2%] isolates as S. iniae and 44 [40.8%] isolates as L. garvieae. The phylogenetic analysis of the S. iniae isolates resulted in maximal similarity to some strains reported from Taiwan and to all Brazilian strains. Also, one strain showed less sequence similarity values with other tested strains although this strain has high similarity with ATCC 29178 strain, all reported Chinese, and some Taiwanian strains. Also, analysis of S. iniae LctO gene sequence showed that this isolate clustered within the S. iniae group. The sequence analysis of L. garvieae strains also showed that they have maximum similarity to all Japanese and Chinese strains, but one strain has lower sequence similarity values with all other recorded strains. The results of this study clearly show that trout farming in Iran is severely affected by both species of S. iniae and L. garvieae and requires serious preventive criteria

Effects of all-trans retinoic acid on the pancreas development in rat Embryo

Recent data shows that retinoic acid [RA] signaling is required for early pancreatic development in animals, whereas the effects of exogenous All-trans Retinoic Acid [ATRA] on gestation day [GD] 10 in later development have not been well documented. In this experimental interventional study, female rats, were randomly divided into two groups [experimental and control, n=5 each]. Animals in the experimental group received single dose [100 mg /kg] of ATRA orally on GD 10 and fetuses were observed on GD 18.The fetus pancreas [from both the experimental and control groups; each n=24] were processed for staining and followed by measuring the accumulation of pancreatic acinus and pancreatic ductile associated with the islets of langerhans. In addition, the mean diameter of pancreatic acinus, acinar cells and related nucleus were measured. Statistical analysis was done by student t-test, P value<0.05 being considered significant. In the experimental embryos on GD 18, the mean accumulation of pancreatic acinus [23.5%], and pancreatic ductile, associated with the islets of langerhans [76%] per field were increased. There was a significant difference in accumulation of pancreatic acinus [P< 0.0001] and pancreatic ductile, associated with the islets of langerhans [P< 0.0001], between the groups in this regard. The mean diameter of pancreatic acinus and the related nucleus were compared in the two groups, and results showed significant [P< 0.0001] decrease of this parameter in the experimental group. Results suggest that ATRA may have positive effects on proliferation, differentiation and maturation of pancreatic acinus and pancreatic ductile associated with the islets of langerhans

[Anxiolytic effects of the aqueous extracts of spinach leaves in mice]

Previous studies have shown the effect of antioxidant properties of spinach on delaying the aging process of CNS and age related cognitive function and some neurodegenerative diseases. This study was designed to evaluate the anxiolytic effects of different doses of aqueous extracts of spinach leaves. This study included fifty male mice [Wt: 25-30 g] which were divided into three experimental and two control groups. Different doses of the spinach extract powder [0.05, 0.10 and 0.15 g/mice] were given to the experimental groups for one month. Also, one of the control groups received water and the other one sucrose 3% [w/v] for one month. In order to increase the activity and curiosity of the mice, they were put inside a box with black walls for five minutes. Then the animals were transferred to the elevated plus maze in regular time intervals and evaluated for standard indexes of anxiety reaction for five minutes. The results of this study showed that percentage of open time was significantly increased in doses of 0.10 and 0.15, and the number of open arm entries was more with a dose of 0.15 g of spinach extract in comparison to the control group [P<0.05]. Furthermore, no significant differences were found in the total number of arm entries between the groups. In comparison to the control group, the number of SAP was significantly reduced with doses of 0.10 and 0.15 g of spinach extract in the experimental group [P<0.05]. It is concluded that higher doses of aqueous extract of spinach can decrease anxiety

Surveying the efficacy of hypercvad regimen in acute lymphoblastic leukemia patients

Acute lymphoblastic leukemia [ALL] is a malignant disorder with the origin of B or T lymphocyte progenitor. This malignancy presents with anemia, thrombocytopenia and neutropenia due to suppression of hematopoiesis by increasing blast cells in bone marrow. With regard to many reports on effectiveness of HyperCVAD regimen in ALL patients and inadequate data from Iranian patients, the present study was conducted to assess the efficacy of this regimen in Iranian patients. This comparative before-after study included 36 adults with newly diagnosed ALL referred to Taleghani hospital between September 2004 and September 2007. Treatment consisted of four cycles of HyperCVAD alternating with four cycles of high dose methotrexate [MTX] and cytarabine with intrathecal prophylaxis and supportive care with antibiotic prophylaxis and G-CSF. Maintenance included 2 years of treatment with mercaptopurine, MTX, vincristine and prednisolone. Results of treatment on complete remission and survival were evaluated. Mean age of patients was 21 +/- 11.3 years. Mature B-cell disease [Burkitt-type] was present in 2.7%, T-cell disease in 25%, and leukocytosis of more than 30_10[9]/L, Philadelphia chromosome, and mediastinal mass were found in 27.8%, 8%, and 8% of patients, respectively.The complete response and mortality during induction were 91.6% and 2.7%, respectively, while estimated median survival time and estimated median CR duration were 13 and 8.3 months, respectively. Our results revealed that efficacy of HyperCVAD regimen in our patients were inferior to other studies. We recommend another study with larger sample size to compare the efficacy of this regimen with other standard regimens

[ association between nurses' communication skills and nurse-physician relationship and collaboration in Alborz hospital of Karaj in 2008]

The ability of physicians and nurses to work together as a unified team is essential to improve outcomes, error and risk reduction, and optimum care. The purpose of this study was to determine the association between nurses' communication skills and nurse-physician relationship and collaboration in Alborz hospital of Karaj in 2008. In this descriptive-correlative study, 100 nurses entered the study by convenience sampling. Data were collected by self-report questionnaire. The instruments for gathering data were included sample selection and demographic data form, communication skills questionnaire, nurse-doctor relationship questionnaire and nurse-physician collaboration questionnaire. There was significant positive correlation between communication skills and nurse-physician relationship [P<0.001], but significant correlation was not found between communication skills and nurse-physician collaboration. Staff shortage [72%], government policies [52%] and failure of communication skills [67%] were the most effective factors on nurse-physician relationship. This study showed that appropriate communication skills increases nurse-physician relationship, but it doesn't affect on nurse-physician collaboration in the management of patients. Interventions for increasing nurses' communication skills can improve nurse-physician relationship

Thyroid autoantibodies in women with and without thyroid disorders in an iodine-replete area

To compare the prevalence of positive autoantibodies in patients with thyroid disorders and healthy subjects in an iodine-replete area of the Islamic Republic of Iran, we studied 930 women in a clinic-based study: 698 patients [286 hypothyroid, 140 hyperthyroid, 272 with simple goitre] and 232 healthy women. Serum thyroxine [T4], triiodothyronine [T3], thyroid stimulating hormone, and antithyroid antibodies were measured. Positive autoantibodies were detected in 75.5% of patients with hypothyroidism, 73.6% of those with hyperthyroidism, 48.9% of those with simple goitre and 35.8% of the control group [P < 0.001]. Autoimmunity may have a role in the genesis of common thyroid disorders

[ prevalence of thyroid pathological lesions of in 202 autopsic samples obtained at Isfahan forensic medicine center]

Considering the influence of geographical, genetic and ethnic factors on the prevalence of thyroid pathological lesions, this study was performed to assess the prevalence of pathological lesions in thyroid autopsic samples obtained from adult cadavers of Isfahan Forensic Medical Center. In this study, 202 thyroid glands from cadavers with no evidence of thyroid diseases, removed during autopsies at Isfahan Forensic Medicine Center, were analyzed. After gross studies, thyroid glands were fixed in 5% formalin for 72 hrs, and then 3-6 sections were obtained from each gland. Tissue sections were microscopically studied by two pathologists for histopathological lesions. Among 202 thyroid glands [removed from 159 males and 43 females], 131[64.85%] were histopathologically normal, and goiter [nodular, and diffuse], Hashimoto's thyroiditis, lymphocytic thyroiditis, follicular adenoma and papillary carcinoma were observed in 41 [20.3%], 10 [4.95%], 12 [5.94%], 2 [1.49%] and 12 [5.94%] of the thyroid glands, respectively. Twenty-six glands [12.23%] had nodules sized

[ relationship between stressful life events and prevalence of metabolic syndrome in family members of type 2 diabetics]

Some evidences suggest a possible relationship between enviromental stresses and the prevalence of metabolic syndrome [MS]. To investigate the association between major stressful life events and the prevalence of MS. In this Cross-sectional study, the 35-55 years old first-degree relatives of type 2 diabetics were included. The questionairs of stressful life events, physical activity and basic characteristics were completed. Also, the waist circumference, blood pressure, FBS, TG, Chol, and HDL were measured. MS was defined according to ATP III criteria and the number of stresses was compared between two groups of participants with and without MS. Among 439 participants, the prevalence of MS was 26.8%. The mean number of stresses in MS and non-MS groups were [3.82 +/- 2.67] and [3.14 +/- 2.35], respectively. The difference was found to be significant, statistically [P=0.036]. Comparing the prevalence of MS in subjects with 8 or more stressful life events [46%] with those who experienced less than 8 stresses [23.4%] was indicative of a higher prevalence among the former [P=0.017]. Cosidering the possible association between stresses and the prevalence of MS, which in turn increases the risk of heart diseases, educating high risk people on how to cope with stresses may be of benefit in CVD prevention

[Comparison between the effect of dexamethasone luntophoresis and drug therapy on 60 cases with carpal tunnel syndrome]

Carpal tunnel syndrome [CTS] is the most common entrapment neuropathy in all peripheral nervous system e of it is one of the most important causes of disability in patients. This study was designed to compare the efficacy of luontophoresis and medical treatment for idiopathic CTS. 60 consecutive patients with CTS confirmed by electromyography participated randomly in two experimental groups [drug therapy], and luontophoresis. lntervention in each group include 20 daily treatment luontophoresis [4ma, positive electrode, 15 mm/session] applied to the area over the carpal tunnel of the wrist region. Measurement were performed before and after treatment and included pain assessment, electromyo and neurography measurement [motor and sensory latency, motor and sensory nerve conduction velocity], grip strength. Improvement was significantly more pronounced in Iuntophoresis group than drug therapy group for variables, motor latency [P<0/000], sensory latency [P< 0/005], hand grip [P<0/000], and pain relief [P<0/000]. In clinical findings atrophy was not observed. Nocturnal pain and paresthesia were reduced 80% in luntophoresis group but 46/6% in control group. Results indicate both luntophoresis and drugs were effective, but luntophoresis was better than drugs. Further investigation is needed to investigate the effects of combination of these treatments in patients with mild to sever CTS

[Relation between the number of major negative stressful life events and undiagnosed glucose metabolism disorders [IGT, diabetes] in first-degree relatives of type 2 diabetics]

Current evidence suggests that stressful experiences may affect both onset and exacerbation of type 1 or type 2 diabetes. The aim of this study was to assess the relation between the number of stressful life events and prevalence of glucose metabolism disorders [IGT, Diabetes] In this cross sectional study, 35-55 year old first degree relatives of type 2 diabetics without history of diabetes were included. Questionaires of stressful life events, physical activity and basic chacteristics were completed. Waist and hip circumference was also measured and OGTT was performed in all patients. Of 477 participants, 288, 146 and 43 were normal, IGT and diabetics respectively; the mean number of stressful events for these groups was 3.15, 3.55, 3.91 [P=0.016], respectively. The prevalence of glucose metabolism disorders was 26.8 in those who reported no stress and 41.5% in participants with stressful events [p=0.03]. The prevalence of diabetes was 25.6% vs. 3.2% in subjects with 8 or more stressful events in comparison to subjects with less than 8 stressful events. Considering the probable contribution of stress in the development of diabetes, it is suggested to evaluate the relationship between stress and diabetes as well as the role of education on coping with stress in diabetes prevention, specially in high risk groups, in a more precise manner

Is iron deficiency responsible for endemic goiter in semirom?

In spite of iodine fortification programs, goiter is still hyperendemic in Semirom, a mountainous region in the central part of Iran. This study was conducted to assess whether iron deficiency could be responsible for the high prevalence of goiter in this region. A total of 1828 schoolchildren, aged 7-13 years, were evaluated for presence of goiter, and 220 cases were randomly selected. Urine and serum samples were collected from these children and assayed for urinary iodine concentraton [UIC] and serum ferritin, iron, thyroxine [T4] and thyroid stimulating hormone [TSH] concentrations. In the 1828 children evaluated, 670 cases [36.7%] were goitrous, with goiters of grade 1 or 2. The mean UIC in children was 19.3 +/- 9.1 micro g/dl. Mild [UIC <10 micro g/dl] and moderate [UIC <5 micro g/dl] iodine deficiency was detected in 6.4% and 3.2% of cases, respectively. Only 1.8% of children were severly iodine deficient [UIC <2 micro g/dl]. The median serum ferritin concentration was 26.6 ng/ml [95% CI: 24.2-28.9], and 11 cases [5%] had serum ferritin concentrations less than 20 ng/ml. Goiter rate was 48.3% and 50.3% in children with low and normal serum ferritin levels, respectively [P = NS]. It seems that factors other than iodine and iron deficiency may, at least partly, be responsible for the high prevalence of goiter in the area studied. Further investigations for evaluating other micronutrient deficiencies and autoimmunity in goitrous children would contribute to the planning more effective goiter control programs

[Prevalence and risk factors for gestational diabetes mellitus in pregnant women of Isfahan, Iran]

There are limited studies concerning the prevalence of gestational diabetes [GDM] in Iran. This study was performed to investigate the prevalence and risk factors for GDM in Isfahan, and to compare the results of selective and universal GDM screening methods. In a cross - sectional study conducted between June 2003 and March 2005, GDM universal screening [based on the Carpenter and Coustan criteria] was done for pregnant women between 24 and 28 weeks of gestation, referred to the Isfahan Endocrine and Metabolism Research Center; 1112 pregnant women with no history of diabetes underwent 50 gr glucose challenge test [GCT]. Cases with blood sugar >/= 130 mg/dL were considered positive and underwent a 3-hour, 100 gr glucose tolerance test [OGTT]; this was also done randomly in some of negative GCT cases. OGTT was performed in 245 GCT - positive cases and 130 women with negative G.C.T, GDM was diagnosed in 67 and 6 women respectively, showing a total prevalence of 6.76% for GDM. Of all pregnant women, 23.2% were classified as a low-risk group, including only 2 diagnosed cases of GDM [2.7% of all GDM cases]. Among risk factors, only age, pre-pregnancy BMI and gravidity were significantly correlated with GDM. There is a moderate prevalence of GDM in Isfahan; a selective GDM screening method seems to be more appropriate for this community

[ comparative study on iron intake in first degree relatives of type 2 diabetic patients with impaired or normal glucose tolerance]

Studies have reported a relationship between serum ferritin and some components of insulin resistance, as well as an increased risk for type 2 diabetes. Therefore, it is probable for the dietary content of iron to have an influence on the development of diabetes. In this study, the iron intake in first degree relatives of type2 diabetic patients with normal or impaired glucose tolerance was investigated. Based on the results of OGTT, 210 first degree relatives of type 2 diabetic patients were divided into 2 groups with normal and impaired [diabetic, IGT] glucose tolerance. Using a 3-day food questionnaire, the daily intake of energy, red meat, fish and poultry meat, magnesium, iron, zinc and chromium was calculated and compared between the 2 groups. The mean age and BMI were 48.9 +/- 5.2 years and 43.7 +/- 6.7 years [P=0.373] and 29.3 +/- 0.7 kg/m[2] and 28.7 +/- 0.8 kg/m[2] [P=0.654] in impaired and normal groups, respectively. Iron intake was significantly higher in impaired group in comparison with normal subjects. [P=0.015], however, no significant differences were observed between the two groups concerning the intake of other nutrients. Keeping the role of other risk factors in mind, the higher iron intake observed among subjects of the impaired group shows a probable relationship between an increased intake of iron and a higher risk in developing type2 diabetes

[Prevalence of hypertension in Iranian urban and rural populations aged over 20 years in 2004]

Several studies have shown differences in HTN prevalence between urban and rural populations. The aim of this study was to compare the prevalence of HTN and the status of HTN awareness, treatment and control between Iranian urban and rural populations aged over 20 years. As a part of a nation-wide survey in 2004 on risk factors of non-communicable diseases, a cross-sectional study was performed on 75.132 adults aged over 20 years. In all participants, blood pressure was measured for twice in a standard method, followed by a collection of data on patients' awareness, treatment and control of HTN. The data were compared between urban and rural populations. The crude prevalences of HTN were 30.5% [CI 95%: 30.496- 30.50], 29.2% [CI 95%: 29.19-29.21], and age-adjusted prevalences were 26.09% [CI 95%: 26.086-26.094] and 26.03% [CI 95%: 26.015-26.025] for urban and rural populations, respectively. Rural residents were significantly less aware of HTN, its treatment and control than urban people. Considering the similarity of age-adjusted HTN prevalence between Iranian rural and urban communities, there is the same burden on our health system. With respect to the lower degree of HTN awareness and control in rural residents, and the integral role of rural health system in diminishing the mentioned difference, further developments are recommended for system

[Evaluation the effects of extracts ofzataria, carum and geranium on different stages haemonchus contortus [nematode] invitro and invivo condition]

In Iran different species from Zataria, Carom and Geranium are present and in some areas are endemic. There is no report about effect of this herbal extracts on helminth parasites. This study aims at investigating the effect of three herbal extracts of Zataria, Carom and Geranium on different stages including egg, larvae and mature of Haemonchus contortus, parasitic nematode of sheep. After experimental infection of the lambs was determinated the number of egg per gram [EPG] of feces and its cultured. Evaluating the effect of the extracts breeding, a plant synthesis along with the control group were added to the feces samples separately and after placing the sample in the incubator for its culture and then examined light microscope to evaluate of hatching status. Furthermore, in order to evaluate the effect of extracts on larvae stage, three different volume of herbal extracts were added to the larvae and the percentage of lost larvae was counted through in different period [0, 5, 10, 15, 20, 30, 40 and 60 min]. Infected lambs were fed by hand during their maintenance and a month after contamination the volume of 20 cm3 of each extract was fed to each lamb. The results showed that three extracts of, Zataria, Carom and Geranium have the effect of 89.9%, 21.6% and 6.6% on egg stage of Haemonchus contortus, respectively. Besides, with direct contact of the larvae, the Zataria extract caused 95.7% 97.7% and 100% loss in volume of 0.01, 0.02 and 0.03 cm3 after 10 min and the extracts of Carom and Geranium caused 83.2%, 87.5%, 86% and 65.8%, 77.6% and 78.5% respectively. The field condition and necropsy results showed the lack of extracts effects on the adult stage of Haemonchus contortus

[ rare variation in branches of abdominal aorta]

Although there are many reports about variation of the branches of abdominal aorta, the present report is a very rare case that it has not been reported so far. The coeliac trunk is a wide ventral branch of abdominal aorta with 2.25cm long. The coeliac trunk divided into three branches: left gastric, common hepatic and splenic branch. Normally, the trunk has not any branches for small intestine after duodenum. In cudavr of a man with 65 years old who was dissected with grants method, the following variations were observed: a common trunk which is raised from common hepatic artery and divided to following branches: branches for pancreas near the neck and body of pancreas, a branch for head of pancreas, branches for duodenum, a huge branch for jejunum and ileum from right side, a huge branch for large intestine from left side, a communication branch between right gasteroepiploic and coeliac, arise cystic artery from common hepatic artery. Since the current report is a rare case, which has not been reported in any anatomical and clinical literatures so far, it may be an interesting and important case

[ Prevalence of clinical goiter and urinary iodine concentration in 8-12 years old students of Semirom in 2004 [15 years after execution of national program for elimination of iodine deficiency disorders]]

With respect to the high prevalence of goiter in Semirom before the initiation of National Program for Elimination of Iodine Deficiency Disorders [NPEIDD], the impact of the program on the prevalence of goiter in 8-12 years old students of Semirom was investigated in this study, after 15 years of sucessful execution of NPEIDD. After excluding students with any clinical evidence of hyper- or hypo-thyroidism, 1817 students aged 8-12 years were recruited based on a cluster sampling method. The participants were examined for the presence of goiter by experiencd endocrinologists. Urinary iodine was measured in 182 examined students, too. Chi- Square statistical method was used to analyze the data. Goiter was detected in 36.7% of the students [grade 1: 30.4%, grade 2: 6.3%]. The median urinary iodine was 18.5 and mean was 19.37 +/- 9.22 ?g/dl in collected specimens. The adequacy of urinary iodine in students of Semirom confirms the success of NPEIDD, however, the higher than expected prevalence of goiter in the region suggests the probable role of other goitrogenous or autoimmune factors. Further studies should be performed to investigate the possible causes

Hypertension and pre-hypertension: prevalence, awareness and management among Iranian adults older than 20 years

Hypertension [HTN] is an important worldwide challenge. The 7th report of the Joint National Committee [JNC7] provided the last classification of blood pressure levels and introduced the new category of prehypertension. The aim of this study was to estimate the national prevalence of HTN and prehypertension according to the JNC7 guideline and to determine the status of HTN awareness, treatment and control in Iranian adults aged older than 20 years. This cross-sectional study was a part of a nationwide survey on the risk factors for non-communicable diseases, which was conducted in 2004. In 75112 over 20 year old adults, two blood pressure measurements were obtained by a standard method and blood pressure levels were classified according to the JNC7 criteria. Data on patients' awareness, management and treatment of HTN were also collected. The age-adjusted prevalence of HTN and prehypertension was 25.3% and 49.7% in men, and 26% and 38% in women, respectively. Only 35% of hypertensive subjects were aware of their disease, and effective control was observed in 21.4% of them. Considering the high prevalence of HTN and prehypertension and the low awareness and effective control of HTN, our country is facing a serious health problem