Validation of Glasgow-Blatchford Score in Predicting Management of Upper Gastrointestinal Bleeding

Background : Upper Gastrointestinal Bleeding is a common emergency with varying degrees of severity. Haemorrhage is managed by Therapeutic Endoscopy, Radiological Intervention or Surgery and Blood Transfusion which are available only in Tertiary Care Centre. So, when patient presents in primary healthcare setting, it is important to recognize the patients who need this treatment. Glasgow-Blatchford Score is a score which is used for this purpose. The purpose of this research was to validate its reliability in identifying such high-risk patients. Materials and Methods : This study was prospective and observational, conducted in Medical College and Hospital, from December, 2017 to May, 2019. All adult patients presenting to Emergency Department with sudden onset Upper Gastrointestinal Bleeding were included. Glasgow-Blatchford Score was computed. Patients were followed up till their discharge (or death) from the hospital. The therapeutic management needed and its relationship with the score and treatment modalities were noted. Area under Receiver Operating Characteristic (ROC) Curve was calculated. Results : Total 100 patients were included in study. 85% were male and 15% were female. Glasgow-Blatchford Score was found as a good predictor in discriminating patients. Patients with score 14. Interventional radiology or surgery was never used. The area under ROC Curve was 0.738 suggesting fair reliability. Conclusion : Glasgow-Blatchford Score is good predicting tool in cases of Upper Gastrointestinal bleeding and patients with score >7 should be transferred to speciality centres

Study of Orthopedic Morbidities among Postmenopausal Women in a Medical College Hospital in Rural Area of Western Maharashtra, India

Introduction: It is estimated that a total of 130 million Indian women are expected to live beyond menopause by 2015. Health of postmenopausal women is of growing concern because of increased longevity and various morbidities associated with old age. Objectives: 1) To assess various orthopedic problems among postmenopausal women in rural area. 2) To estimate magnitude of common orthopedic problems and associated sociodemographic factors. Methodology: A cross-sectional study was conducted at the medical college hospital in rural area of Western Maharashtra on 500 postmenopausal women availing healthcare in a medical college hospital. Data was collected with the help of predesigned questionnaire by interview technique and with the help of case records available from orthopedic department. Results: Backache (62%) and osteoarthritis (51.6%) were common orthopedic problems. Osteoarthritis was significantly associated with obesity.

Hemorrhagic PRES: A Rare Neurological Manifestation of COVID -19 Infection

As of August 2021, the COVID -19 pandemic has affected approximately 200 million cases worldwide. Most of the reported medical literature about the COVID-19 infection discusses its respiratory and haematological manifestations, with limited information about its neurological complications. Encephalitis, meningitis, acute disseminated encephalomyelitis, stroke and encephalopathy have been reported in patients with COVID-19 infection. Symptomatology of CNS involvement includes dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizures. Encephalopathy is encountered commonly in patients with severe disease, multi-organ dysfunction and elevated inflammatory markers. Acute cerebrovascular disease is another major manifestation of COVID -19 infection and is mainly due to occlusion of large vessels, hypercoagulability and a pro-inflammatory state. In this report, we discuss the diagnosis and outcome of a 30-year-old patient detected with Posterior Reversible Encephalopathy Syndrome (PRES) as a complication of COVID-19 infection. We hope this report will provide physicians with a useful framework for understanding pathophysiology and imaging findings of PRES in COVID-19 infection.

To Study Adverse Effect following Immunization (AEFI) and COVID-19 Infection amongst COVID-19 Vaccine Benefeciaries

Introduction: Coronavirus disease associated mucormycosis (CAM), perturbed a lot by reaching to epidemic proportions particularly during the second wave of the pandemic. Material and Methods: This was a retrospective, observational study of patients with COVID-19-associated mucomycosis admitted in April-May 2021 at a tertiary care teaching hospital. Demographic profile, clinical and laboratory parameters were recorded Multidisciplinary treatment including antifungals and surgical interventions were noted. Results: This study included 98patients of mucormycosis, diagnosed on the basis of clinical and radiological findings and later were confirmed by microbiological investigations. Out of 98 patients, 72 had rhino orbital, 24 had rhino-orbital- cerebral and 2 had pulmonary mucormycosis. Twelve had coinfection of covid 19 while 86 had developed mucormycosis within 3 weeks. Conclusion: CAM has posed as a continuum of challenges faced during the pandemic of covid 19. This rare and life threatening complication requires high index of suspicion for early diagnosis. Multidisciplinary involvement and timely interventions including antifungal pharmacotherapy, stringent glycemic control and surgical debridement can reduce the mortality. Mucormycosis is uniformly associated with low iron levels but role of zinc needs to be further studied

A Rare Cause of Breathlessness in a Patient on Hemodialysis

Background: The possibility of recurrence in COVID-19 is very rare and hence mostly underdiagnosed. In the face of pandemic, this can lead to circulation of the virus like a hidden iceberg. Better understanding about this topic can improve our knowledge of the COVID-19 pathogenesis and ways to control the transmission. Case presentation: A 41 year old male with no known comorbidities was admitted five times during a period of 7 months each time after being detected RTPCR positive for SARS-CoV-2 and more symptomatic than previously. He had no contact with other COVID-19 patients and was asymptomatic in between admissions. Despite this, he did not develop antibodies against SARS- CoV-2. Later on, he was diagnosed with thymoma on biopsy of the anterior mediastinal mass. Patient’s condition deteriorated on last hospitalization and he died, despite the treatment. Here we present an interesting report on multiple times recurrent COVID-19 infection, probably a case of reactivation and different plausible explanations on the role of thymoma. Conclusion: Acknowledging the potential of SARS-CoV-2 to cause recurrence is very important during the pandemic as a part of the long term transmission mitigation. The case report shows that previous infection does not guarantee complete immunity from COVID-19, especially in immuno-compromised patients. Hence, despite the status of prior infection, vulnerable individuals who recovered from COVID-19 should be under surveillance.

Development and Validation of Perceived Oral Health Benefits on Yoga Scale (POBYS) / Desenvolvimento e validação da Escala de Benefícios da Saúde Oral Percebidos no Yoga (POHBYS)

Objective: Sustained practice of Yoga leads to self-awareness, physical strength and high sense of energy. Yoga stimulates antioxidant levels in the body and reduces likelihood of dental disorders. No research has been undertaken connecting perception on yoga and oral health behaviors. The present study is an attempt to develop a psychometric scale entitled Perceived Benefits on Yoga Scale (PBYS) to measure individuals' perception on Yoga in relation to oral health behaviors. Material and methods: The psychometric tool was developed based on the concepts of Health Benefit Model (HBM). Among the four components of the model, the present study considered "perceived benefits" component. A total of 206 individuals participated in the study. To analyze the scale theoretically, face and content validity were assessed. Reliability of the scale was tested using Cronbach's alpha and Spearman-Brown coefficient. Using exploratory and confirmatory factor analysis, construct validity was tested. Cronbach alpha and Spearman- Brown coefficient were applied to test the reliability of scale. Results: There were six items in the final scale, with a Spearman- Brown coefficient of 0.92 and Cronbach's alpha of 0.91. Statistically significant (p < 0.001) positive correlation was found between POBYS scores and Yoga Self-Efficacy Scale (YSES). Validity of scale is within accepted range as indicated by Goodness of Fit indices. Conclusion: POBYS is a reliable and valid measure of perception on yoga outcomes with specific reference to oral health behavior. (AU)

Objetivo: A prática continua de Yoga leva ao autoconhecimento, força física e a sensação de energia elevada. O yoga estimula os níveis de antioxidantes no corpo e reduz a probabilidade de desordens dentais. Nenhuma pesquisa foi realizada conectando a percepção sobre o yoga e os comportamentos da saúde bucal. O presente estudo é uma tentativa de desenvolver uma escala psicométrica intitulada Escala de Benefícios Percebidos no Yoga (PBYS) para medir a percepção dos indivíduos sobre o Yoga em relação aos comportamentos da saúde bucal. Material e Métodos: A ferramenta psicométrica foi desenvolvida com base nos conceitos do Modelo de Benefícios à Saúde (HBM). Dentre os quatro componentes do modelo, o presente estudo considerou o componente "benefícios percebidos". Participaram do estudo 206 indivíduos. Para analisar teoricamente a escala, foram avaliadas a validade de face e de conteúdo. A confiabilidade da escala foi testada usando o alfa de Cronbach e o coeficiente de Spearman-Brown. Usando análise fatorial exploratória e confirmatória, a validade do construto foi testada. O alfa de Cronbach e o coeficiente de Spearman-Brown foram aplicados para testar a confiabilidade da escala. Resultados: Havia seis itens na escala final, com coeficiente de Spearman-Brown de 0,92 e alfa de Cronbach de 0,91. Estatisticamente significativo (p <0,001) foi encontrada correlação positiva entre os escores do PBYS e a Escala de Autoeficácia do Yoga (YSES). A validade da escala está dentro da faixa de aceitabilidade conforme indicado pelos índices de Goodness of Fit. Conclusão: PBYS é uma medida confiável e válida de percepção sobre os resultados do yoga com referência específica ao comportamento de saúde bucal. (AU)

Prevalence of anaemia and visual impairment among primary school children of South Gujarat region of India: a cross sectional study

Background: Nutritional Anemia and visual impairment among school age children are recognized as major public health problem in India. Authors objective was to study prevalence of anemia and visual impairment among school going adolescents of Vadodara and Surat city of Gujarat, India.Methods: This cross sectional study was carried during period from April 2015 to March 2016. Total 8 schools were selected from Vadodara and Surat city by purposive sampling. After taking the permission of principals of schools and informed written consent of the parents of children, 859 children from these schools were examined for anaemia and visual impairment. The data was collected by predesign, pretested proforma and analysed using SPSS version 17 (Trial version).Results: Out of total 859 children 421(49.1%) were female. Mean age of the study children was 8.95'1.52 years. The prevalence of anemia in children in present study was 61.6 % (529 children). The prevalence of anemia in female (274, 65.1%) was higher than males (255, 58.2%). Moderate visual impairment and blindness was 5.9% in girls and 8.2% in boys respectively. Severe visual impairment and blindness was 2.1% in girls and 2.7% in boys respectively and the gender difference was not statistically significant. Though 61(7.1%) children had moderate to severe visual impairment to blindness only 21 (2.4%) children were wearing spectacles.Conclusions: High prevalence of anaemia and visual impairment among these children needs great attention and health education.

Tobacco and betel nut use among school going adolescents of South Gujarat region, India: a cross sectional study

Background: Adolescence period is very crucial in the life of an individual, when major physical, psychological and behavioral changes take place. Tobacco and Areca nut use among school going adolescent is becoming a major public health problem. Objective of this study was to determine the prevalence and pattern of smokeless tobacco and betel nut use among school going adolescents.Methods: The study was a cross sectional study. After taking the permission of principal of Government high schools of Vadodara and Surat city of Gujarat and consent of the parents of adolescents, 1107 adolescents were interviewed during March-April 2017. A self-administered questionnaire was used for data collection. Thus collected data was analyzed using SPSS 17 (Trial Version).Results: Age of the study students (total 1107) ranged from 10-19 years. (Mean age=14.61'2.85 years). Out of 1107 children 389 (35.1%) children had addiction. Prevalence of any type of addiction in girls and boys was 14.3% and 20.7% respectively. Tobacco prevalence was 13.4% and betel nut prevalence was 21.6%. Type of addiction and its association with gender was highly significant. All children addicted to tobacco using chewing form (gutkha) of tobacco. The mean age group of children who consume tobacco and betel nut was 16.13'1.32 years and 16.01'1.21 years respectively. Most common reasons among adolescents for starting addiction of tobacco and betel nut was to look mature (93.8%) followed by to look good (63.2%) and to refresh breathe (48.6%).Conclusions: High prevalence of tobacco and betel nut use among adolescents needs attention of parents, teachers and health officials.

Importance of HAS-Bled Score in Patients on Warfarin Therapy for Atrial Fibrillation

Introduction: Bleeding is a significant complication whenpatients are on anticoagulant therapy. The risk of bleedingoverall when anticoagulant therapy is used is 3.8%. A numberof risk factors are associated with increased bleeding whenpatients are on anticoagulants. A practical risk score HASBLED score was developed to estimate 1year risk for majorbleeding in patients with atrial fibrillation. This study aimedto understand to assess the relevance of HAS-BLED scorein predicting bleeding in patients coming to AJ institute ofmedical sciences.Material and methods: We conducted a case control studyin patients on Warfarin therapy for Atrial fibrillation whopresented with major bleeding manifestations betweenSeptember2017-2018 in a tertiary care centre in AJ InstituteOf Medical Sciences in South India. Patients or their medicalpower of attorneys provided written informed consent. Atotal no of 100 patients were enrolled based on the inclusioncriteria patients aged more than 18 years. They were groupedinto cases who had bleeding and controls who did not havebleeding. HAS BLED score was calculated. The data wasentered in Microsoft Excel and was analysed with SPSSResults: Total of 100patients (50cases and 50controls) werestudied. On analysing the HAS-BLED score the P valueshowed significant difference between the case and controlgroups. The sensitivity was 80% and specificity was 68%. Thepositive and negative predictive value of HAS-BLED valueswere 71.4% and 77.27% respectively.Conclusion: Our study emphasises the need for making betteruse of HAS-BLED score in predicting bleeding and the needfor monitoring the INR regularly and educating patients onWarfarin therapy about frequent monitoring, the risks ofbleeding and to seek early medical attention on developingbleeding.

Effect of long term high altitude exposure on cardiovascular autonomic adjustment during rest and post-exercise recovery

BACKGROUND: Despite the successful adaptation to high altitude, some differences do occur due to long term exposure to the hypoxic environment. The effect of long term high altitude exposure on cardiac autonomic adjustment during basal and post-exercise recovery is less known. Thus we aimed to study the differences in basal cardiac autonomic adjustment and its response to exercise in highlanders and to compare it with lowlanders. METHODS: The study was conducted on 29 healthy highlander males who were born and brought up at altitude of 3000 m and above from the sea level, their cardiac autonomic adjustment was compared with age, sex, physical activity and ethnicity-matched 29 healthy lowlanders using Heart Rate Variability (HRV) during rest and recovery from sub-maximal exercise (3 m step test). Intergroup comparison between the highlanders and lowlanders and intragroup comparison between the rest and the postexercise recovery conditions were done. RESULTS: Resting heart rate and HRV during rest was comparable between the groups. However, heart rate recovery after 3 min step test was faster in highlanders (p < 0.05) along with significantly higher LF power and total power during the recovery phase. Intragroup comparison of highlanders showed higher SDNN (p < 0.05) and lower LF/HF ratio (p < 0.05) during recovery phase compared to rest which was not significantly different in two phases in lowlanders. Further highlander showed complete recovery of RMSSD, NN50, pNN50 and HF power back to resting level within five minutes, whereas, these parameters failed to return back to resting level in lowlanders within the same time frame. CONCLUSION: Highlanders completely recovered back to their resting state within five minutes from cessation of step test with parasympathetic reactivation; however, recovery in lowlanders was delayed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s40557-018-0240-1) contains supplementary material, which is available to authorized users.

Low lymphatic vessel density correlates with lymph node metastasis in oral squamous cell carcinoma

Statement of the Problem: Regional lymph nodes are the nodes draining lymph from region around the tumor and presence of metastatic tumor in regional lymph nodes is the most important prognostic factor for malignant tumors of epithelial origin. Lymphangiogenesis is associated with an increased incidence of regional lymph nodes metastasis and is possibly an essential step for metastasis. Tumor cells secrete lymphangiogenic cytokines, which results in formation of lymphatic vessels within and around the tumor and act as portals for tumor spread

Purpose: The present study aims to investigate and quantify lymphatic vessel density [LVD] in oral squamous cell carcinoma [OSCC] and determine whether LVD can predict the risk of sentinel lymph node metastasis

Material and Method: 50 specimens of OSCC, without and with lymph node metastasis [25 each] along with 25 specimens of normal oral mucosa were assessed and LVD was quantified by D2-40 immunostaining. Discrete hotspots of intratumoral lymphatics were identified in superficial and deep areas in all carcinomas to calculate LVD

Results: When compared to normal mucosa, LVD decreased in the superficial intratumoral areas and decreased further in deep areas. In addition, LVD in the superficial and deep areas of OSCC without nodal metastasis was significantly higher than that in OSCC with nodal metastasis

Conclusion: Our study provides evidence that lymphangiogenesis varies within the tumor. Lymphatic vessels are either compressed, collapsed, destroyed or absent in deep intratumoral region. Decrease in LVD predicts cervical lymph node metastasis both in superficial and deep areas. Lymphatics in superficial areas are probably major conduit for nodal metastasis in OSCCs

Characterization of coal fly ash nanoparticles and their induced in vitro cellular toxicity and oxidative DNA damage in different cell lines.

Coal combustion generates considerable amount of ultrafine particles and exposure to such particulate matter is a major health concern in the developing countries. In this study, we collected nano sized coal fly ash (CFA) and characterized them by scanning electron microscope-energy dispersive X-ray analysis (SEM-EDX), particle size analyzer (PSA) and transmission electron microscope (TEM), and investigated its toxicity in vitro using different cell lines. The imaging techniques showed that the coal fly ash nanoparticles (CFA-NPs) are predominately spherical shaped. The analyses have revealed that the CFA-NPs are 7-50 nm in diameter and contain several heavy metals associated with CFA particles. The studies showed significant amount of toxicity in all cell lines on treatment with CFA-NPs. The cytotoxicity and oxidative DNA damage caused by CFA-NPs were determined by inhibition of cellular metabolism (MTT), total intracellular glutathione (GSH), reactive oxygen species (ROS) and DNA fragmentation in cultured cell lines (Chang liver, HS294T and LL29). The cellular metabolism was inhibited in a dose-dependent manner in CFA-NPs treated cell lines. The CFA-NPs induced ROS and decreased the total intracellular glutathione with increased dose. Further, the CFA-NPs treated cells showed severe DNA laddering as a result of DNA fragmentation.

Unusual immunophenotype of T-cell large granular lymphocytic leukemia: Report of two cases.

Large granular lymphocytes (LGL) leukemias are commonly of the T-cell or NKcell type. T-cell LGL leukemia is typically a disorder of mature CD3, CD8 and T-cell receptor TCR (TCR — T cell receptor)-αβ positive cytotoxic T-cells. Rare variants include TCRγδ+ variants and CD4+ TCRαβ+ cases. We report a case of each of these rare variants. An 83-year-old female presented with anemia and lymphocytosis with LGLs on peripheral smear. Six-color multiparametric fl owcytometric analysis showed expression of CD3, heterogeneous CD7, dim CD2 and TCRγδ and lacked expression of CD5, TCRαβ, CD56, CD4 and CD8. A fi nal diagnosis of TCRγδ+ T-cell LGL leukemia was made. Differentiation between TCRγδ+ T-cell LGL leukemia and other γδ+ T-cell malignancies is of utmost importance due to the indolent nature of the former as compared to the highly aggressive behavior of the latter. An 85-year-old male diagnosed with liposarcoma was identifi ed to have lymphocytosis during preoperative evaluation. Peripheral smear showed presence of LGLs. Flowcytometric immunophenotyping showed expression of TCRαβ, CD3, CD2, CD5, CD4, dim CD8, CD56 with aberrant loss of CD7 expression. Vβ repertoire analysis by fl owcytometry showed 97% cells with Vβ14 clonality. A fi nal diagnosis of TCRαβ+ CD4+ T-cell LGL leukemia was made. CD4+ T-cell large granular lymphocytic leukemias have an indolent, less aggressive course when compared to their CD8+ counterparts and are not necessarily associated with cytopenias. However, their association with secondary neoplasia (29% of the cases) warrants a high degree of suspicion in the diagnosis as also noted in the index case. Use of a wide panel of antibodies and newer modalities such as Vβ repertoire analysis helps in accurate subtyping of LGL leukemia

Agenesis of right lobe of liver; a rare anomaly: a case report.

Agenesis of right lobe of liver is a rare finding and was defined as the absence of liver tissue on the right side with preservation of the middle hepatic vein without previous disease or surgery. Congenital agenesis of right hepatic lobe is a rare anomaly which is found incidentally in radiologic examination. Here we present a case of 22 year old female who came with abdominal distension suspecting liver cirrhosis she was investigated and on imaging studies incidentally it was revealed that there is absence of right lobe of liver.

Immediate changes in muscle strength and motor speed following yoga breathing.

The present study was conducted to assess the immediate effect of high-frequency yoga breathing on muscle strength and motor speed. Bilateral handgrip strength, leg and back strength, finger tapping and arm tapping speed were assessed in fifty male participants (group mean age±SD, 26.9±6.2 years) before and after (a) high frequency yoga breathing for 15 minutes and (b) breath awareness for the same duration. Sessions (a) and (b) were on two different days but at the same time of the day. The schedule was alternated for different participants. There was a significant increase (P<0.05) in right hand grip strength after high frequency yoga breathing. Both finger and arm tapping improved after both practices. The results suggest a role for high frequency yoga breathing in improving the hand grip strength as an immediate effect.

3D QSAR and Pharmacophore Modelling on Chalcones as Antileishmanial Agents potential Trypanothione reductase Inhibitors.

Chalcones is an important auxiliary having various important clinical applications. A series of Chalcones as antileishmanial agents by were reported. Three dimensional quantitative structure-activity relationship (3DQSAR), including, were performed to elucidate the 3D structural features which are important for the antileishmanial activity. The results of 3D QSAR model (q2 = 0.8100, r2 = 0.9355,) exhibited the highly degree of statistical significance and good predictive ability. The results generated 3D QSAR can provide important information about the structural characteristics which are contributors of the inhibitory potency of chalcones. In addition, docking analysis and pharmacophore mapping was applied to identify the binding modes between the ligands and the Trypanothione reductase and structural features of the ligands which are important for the biological activity of the molecules. The information obtained from this study could provide vital information for future development of potent instructions for the further development of potent antileishmanial agents as trypanothione reductase inhibitors.

Study of Orthopedic Morbidities Among Postmenopausal Women in a Medical College Hospital in Rural Area of Western Maharashtra, India.

Introduction: It is estimated that a total of 130 million Indian women are expected to live beyond menopause by 2015. Health of postmenopausal women is of growing concern because of increased longevity and various morbidities associated with old age. Objectives: 1) To assess various orthopedic problems among postmenopausal women in rural area. 2) To estimate magnitude of common orthopedic problems and associated sociodemographic factors. Methodology: A cross-sectional study was conducted at the medical college hospital in rural area of Western Maharashtra on 500 postmenopausal women availing healthcare in a medical college hospital. Data was collected with the help of predesigned questionnaire by interview technique and with the help of case records available from orthopedic department. Results: Backache (62%) and osteoarthritis (51.6%) were common orthopedic problems. Osteoarthritis was significantly associated with obesity.

Preformulations studies and preperation of dithranol loaded solid lipid nanoparticles.

Dithranol belongs to the keratolytic category, which is widely used drug in the treatment of psoriasis. The drug is practically insoluble in water. Many conventional dosage forms for psoriasis treatment have been have been formulated earlier, but they did not show good results. Hence in the present study, it was attempted to formulate dithranol in the form of solid lipid nanoparticle. Solid lipid nanoparticles of dithranol were obtained by adaption of lipid dispersion method. Preformulation studies were performed to check the compatibility of drug and excepient for the preparation of formulation by DSC and no interaction was found. Solubility study, partition coefficient determination, UV analysis, HPLC study, FTIR study were also performed. After the preformulation studies Dithranol loaded solid lipid nanoparticles was also prepared. Hence it was concluded that solid lipid nanoparticle of dithranol could be formulated.

Effect of yoga on different aspects of mental health.

State anxiety, somatization of stress, quality of life, self-rated quality of sleep, and discomfort due to over-breathing which occurs when stressed were studied. Out of a total of 140 participants, seventy participants self-selected to be in a yoga group for stress relief (group mean age±SD, 33.0±6.5 years; 37 males). Seventy age and gender matched participants were in a control group. State anxiety, somatization of stress, quality of life, discomfort and self-rated quality of sleep were assessed using the State-Trait Anxiety Inventory, Symptom Checklist-90-R, SF-12, Nijmegen Discomfort Evaluation Scale and a Sleep Rating Questionnaire respectively. Assessments were made at the beginning and end of the week. Repeated measures ANOVAs with Bonferroni adjusted post-hoc analyses showed a significant decrease in state anxiety (P<0.001), somatization of stress (P<0.01), improved health-related quality of life (P<0.01), self-rated quality of sleep (P<0.01), and decrease in discomfort due to over-breathing (P<0.001). No changes (except decreased discomfort due to over-breathing; P<0.01) occurred in the control group. This study suggests that a brief yoga program may be beneficial in decreasing anxiety, somatization of stress and discomfort, improving health-related quality of life and self-rated sleep quality.