[Effect of Aphrodit capsule on somatic symptoms of postmenopausal women]

Background and Objective: Somatic and psychological altrations during menopause have negative impact on quality of life. This study was done to evaluate the effect of Aphrodit on somatic symptoms in postmenopausal women

Methods: In this clinical trial study 63 menopausal women were randomly divided into intervention and control groups. Subjects in interventional group were received Aphrodit capsule [40 mg of Tribulus terrestris fruits, 12.27 mg ginger, 33 mg saffron and 11 mg of cinnamon] for four weeks. Somatic symptoms of menopause [including hot flashes, night sweats and tachycardia] and sleep disorder and muscluskeletal disorder were evaluated using Menopause Rating Scale

Results: After intervention, the mean of hot flash score in interventional and control groups was 1.29 +/- 0.1 and 3.1 +/- 0.6 [P<0.05].The mean of sleep disorder score in interventional group and controls was 1.82 +/- 0.2 and 2.82 +/- 3.1 [P<0.05]. The mean of muscluskeletal disorder score in interventional group and controls was 1.03 +/- 0.1 and 2.81 +/- 1.2 [P<0.05].There was no difference in the heart problem score between interventional and control groups

Conclusion: Consumption of Aphrodit capsule reduces hot flash, sleep disorder and muscluskeletal disorder in postmenopausal women

[Requirements of information security in a telemedicine network: review of IT managers' opinion]

The requirements of information security in a telemedicine network can be categorized in four areas, namely; data storage and data accessibility, data transfer, human resources, and equipment for medical diagnosis. The purpose of this study was to determine the importance of each of the above areas from the perspective of information technology [IT] managers in teaching hospitals affiliated to Tehran and Shahid Beheshti Universities of Medical Sciences, and the experts in the field who worked in the Ministry of Health. This was a survey study conducted in 2013. The participants of the study included 41 information technology [IT] managers in teaching hospitals and seven experts who worked in the Ministry of Health. Data were collected using a five-point Likert scale questionnaire and were analyzed using descriptive statistics. The content and face validity of the questionnaire were confirmed by the experts in the field. The reliability of the questionnaire was calculated using Cronbach's coefficient alpha [alpha= 0/75]. The results of the present study showed that among the requirements of information security in a telemedicine network, human resources were of high importance [mean = 87.50]. The requirements related to the medical diagnostic equipment and those related to data storage and data accessibility were in the second [mean=87.04] and the third place [mean=85.97] of importance respectively. The requirements of information security in the area of data transfer were in the fourth place of importance. Considering the degree of importance that human resources gained compared to the importance of other requirements of information security in a telemedicine network, it seems that employing experts in the field of information security and training health care professionals in the application of telemedicine technology, may facilitate efficient deployment of this technology in the healthcare settings

[Comparison of the effect of two types of short message service [interactive and non-interactive] on anticoagulant adherence of patients with prosthetic heart valves]

Introduction: One of the major complications of valve replacement, is valve dysfunction which occurs in thrombolytic complication and systemic embolism. Therefore, these patients should take anticoagulant with warfarin. Incorrect use of anticoagulant is the cause of thrombotic complications and bleeding in patients with mechanical valves due to very low levels of adherence to the medication. This research was done with the purpose of comparison of the effect of two types of short message service [interactive and non-interactive] on patient compliance with anticoagulant regimens in patients with prosthetic heart valves

Method: This study is a clinical trial performed on 90 eligible patients referred to Imam Khomeini hospital in Tehran, Iran for a period of three months. The patients were divided into three groups of 30 patients, control, interactive and noninteractive. Self-report questionnaires were completed and International Normalized Ratio [INR] levels were recorded. Educational leaflets were given to all of the patients, their phone numbers were taken and they were instructed about using short message service. The control group did not receive SMS. Four educational messages were sent to the non-interactive group every week for a period of three months. In the interactive group, in addition to sending educational messages, patients were able to communicate with the researcher and ask their questions. After three months, all three groups completed the self-report questionnaires again. Then anticoagulant adherence was evaluated using questionnaire and INR levels. Data were analysed using fisher exact test, Chi-Square, paired T test, and analysis of variance

Results: Before the intervention all three groups did not have a significant difference in the mean of drug [P=0.43] and diet [P=0.84] adherence. But three months after intervention, three groups had significant difference in the mean of the anticoagulant adherence [P

[Nursing students' perceptions regarding actual and expected Iran university of medical sciences clinical learning environment]

Introduction: Clinical learning environment have an important role in clinical learning of nursing students. Any differences between expected and actual clinical learning environment of nursing student result in reduce the interest of nursing students to clinical environment and decrease their clinical performance. The aim was to comparison the perception of nursing students regarding expected and actual clinical learning environment in medical-surgical wards

Method: This study was a descriptive cross-sectional and conducted in first semester of 2009-2010 educational years. In this study 217 baccalaureate nursing student from Iran nursing and midwifery faculty participated. The researcher appeared in the student's clinical learning placement at last day, and after produce necessary information about purpose of study, both of versions of questionnaire give to students contemporaneously, and collected after completion. For data collection, clinical learning environment inventory was used that contain 42 item in six areas. Data was analyzed by SPSS software using descriptive and inferential statistic

Results: The paired t test showed that there were statistical differences between actual and expected perception on nursing students regarding clinical learning environment

Conclusion: The results of this study showed, nursing students haven't positive perception of the clinical learning environment and their perception of actual clinical learning environment to differ from expected clinical learning environment

[Assessment level of physical activity and its associated beliefs]

Introduction: Improvement in technology has resulted in sedentary lifestyle with increasing risk of non communicable diseases. Identifying physical activity level and its associated beliefs in adolescent girls can facilitate the planning of programs for improving health promotion

Method: This study is a cross-sectional descriptive analytical research that was conducted through multistep randomized sampling in 636 student from 7 public middle school of Rafsanjan city. Data were collected via a 3 part questionnaire [demographic, level of physical activity over the last 7 days and beliefs regarding exercise]. Data analysis was performed using SPSS software [version 16] and including descriptive statistics [mean, standard deviation, …] and deductive statistics [t-test, ANONA]

Results: About 52% of students had inadequate physical activity. Only 4.2% had adequate physical activity. This study found that there was a significant relationship between physical activity level and the level of parents' education [P=0.019 and P=0.044]. There were no significant relationship between physical activity and age, BMI, economic status of family and employment status of parents [P>0.05]. In addition results showed that majority of students were strongly agree with the encourage role of teacher of physical educations [71.1%] parent [61%] and athletes [59.7%]

Conclusion: Given the importance of physical activity in adolescent girls, health policy makers should make appropriate measures through education and counseling to encouraging this vulnerable group and their parents to do appropriate physical activity and having active life style to promote community health

[Patients' perceptions of caring behaviors in oncology settings]

Introduction: Cancer patients need a comprehensive nursing care. Knowing nurse caring behaviors as perceived by patients helps to facilitate quality nursing care based on priorities identified by patients. Purpose of this study is identifying nurses caring behaviors as was perceived by cancer patients

Method: This is a cross- sectional study conducted on 200 patients who had been admitted to hospital's medical oncology setting, in Tehran between 2012-2013. These patients were selected by proportional allocation sampling. Data was collected via Caring Behaviors Inventory [CBI]. All of the samples completed the inventory. Reliability and validity were assessed in 2007 by Rafii et all. Cronbach's alpha was %92. Data analysis was done by SPSS v.16

Results: According to the findings order of scoring subscale was: Professional knowledge and skill [5.5], Attentiveness to other's experience [5.13], Assurance of human presence [5.11] Respectful to the others [4.94], Positive connectedness [4.93]

Conclusion: Since from the patients point of view the nurses' Professional knowledge and skill is seen more and Positive connectedness is seen less, it seems that nurses as well as maintaining their knowledge and skill should attempt to consider emotional and relational aspect of their caring behaviors for patients. This important aspect of caring, should be mentioned by nursing managers in during educational planning and nurses evaluation as well as staff distribution, Particularly in oncology wards. The lack of adequate personnel may not only cause unwanted neglect of the emotional aspect of nursing care, but also decreasing the quality of nursing care in all aspects

[Health related quality of life among patients with hypertension in teaching hospitals of Tehran university of medical sciences]

Like other chronic diseases, hypertension is closely related with lifestyle, mental health and quality of life. The goal of this study was Determination of health related quality of life in hypertensive patients. The study was Descriptive, samples were chosen by using convenience sampling and according to characteristics of samples and Their willingness to participate in the study. The data gathering tools in this study were Social and personal information [demographic] forms, and health-related quality of life questionnaire. [SF-36]. Clinical research environment at selected hospitals affiliated to Tehran University of Medical Sciences consist of Hazrat Rasoul Akram Hospital, Imam Khomeini Hospital, and Shahid Rajai. To determine the relationship between. The main variable and demographic variables and use ANOVA and T-Test, we entered variables that were significant in our regression model. 264 patients with hypertension take part in this study. Most of Participants were male and their age was in range of 40-60 years old. Mean of quality of life among hypertensive patients was 55.33. There was a statistically significant relationship between quality of life and job, information about the disease, other chronic diseases and medication groups. The study shows that there health related quality of life is low in hypertensive patients

[ survey on barriers to the development and adoption of electronic health records in Iran]

The development and the adoption of electronic health records may face a number of bathers. These barriers can be classified as technical, organizational, individual, financial and ethico-legal. This study aimed at determining the importance of each of the mentioned barriers in the development and adoption of the electronic health records from the perspectives of the experts in the Ministry of Health. This was a descriptive applied research completed in 2011. The study population were constituted the faculty members working in of the departments of health information technology, health information management, and medical informatics, and as well as those who were in charge of the development and adoption of the electronic health records in the Ministry of Health and Medical Education. In this study, no No sampling method was used due to the limited number of the study population. Data were collected using a Likert scale questionnaire and were analysed by means of descriptive statistics. The content and face validity of the questionnaire were established and the reliability was calculated using Cronbach's alpha. In total, 32 participants [51.6%] completed the questionnaire. The participants' perspectives showed that the most important barriers in the development and adoption of electronic health records were the technical barriers [mean=71.00]. The financial barriers and the ethico-legal barriers with the mean values of 70.05 and 68.16 were in the second and third place, respectively. The individual and organisational barriers with the mean values of 64.84 and 62.67 were in the fourth and fifth places. It seems that employing a team of experts in different areas related to the development and adoption of EHR, training users, and addressing technical concerns along with allocating financial resources can help overcome barriers to the adoption of EHR

[Comparison of creativity skill between the first year and fourth year undergraduate nursing students]

Introduction: Nursing education is responsible for providing an environment to facilitate students learning and acquiring cognitive, affective and psychomotor skills. Nurses are now required to provide skilled, multidimensional care in multiple, often unfamiliar environments or settings. Consequently, nurses should be prepared to function as safe, competent, intuitive and innovative clinicians in an environment where new information and clinical situations are constantly changing. In the midst of a knowledge explosion in health care, students need to be provided with the tools and experiences that teach them how to think that promotes an understanding and an embracement of lifelong learning. This study was developed to determine and compare the nursing student's creativeness

Methods: This was a cross-sectional study. The study was carried out in Faculty of Nursing and Midwifery Iran University of Medical Sciences. Study population was all of students enrolled in nursing four-year program 2009-2010 curriculum. Three hundred and twenty two students participated in this study by using the Abebi's creativity Test. The data was coded and analyzed using the SPSS. Mean creativity scores between students' responses in different years were compared by ANOVA

Results: It was found that the mean score of the students' creativity was 136.19 +/- 13.31. When compared to a normative sample of Iran, the subjects were above or similar for overall creativity totally and four subscales. When the mean score and number of years of education were considered, no statistically significant difference was found for overall creativity, fluency and originality [P>0.05]. However the difference for mean scores of elaboration [F=3.35, P=0.019] and flexibility [F=2.82, P=0.039] was statistically significant

Conclusion: Nursing schools should establish proper, accepting, and trustable atmosphere in order to develop nursing student's thinking, creativity, Self-centered learning abilities. This Atmosphere facilitates inquiry and questioning skills and improves unpredictable solutions in students and after that this critical skill will be improved. Revision the undergraduate educational program frequently according Nursing students' creativity seems to be necessary

[Sleep and health related quality of life in patients with chronic heart failure]

Introduction: Heart failure is one of the most common cardiovascular disorders. In this disease heart is disable to perfusion, insufficient perfusion lead to many symptoms in this patients. Each of these symptoms in some patients is deprived from the suitable sleep. Sleep is a vital and effective element in the health and quality of life in these patients. The purpose of this study is to assess of relationship between sleep quality and quality of life in patients with chronic heart failure

Methods: In this cross-correlation study, 200 patients with chronic heart failure in two teaching university hospital of Tehran university of medical sciences was selected using sampling with proportional allocation. Data were collected using from demographic questioner, Pittsburgh sleep quality index and Kansas City Cardiomyopathy Questionnaire and then were analyzed using the SPSS software and statistical tests

Results: Sleep quality, with some aspects of health related quality of life including physical limitations [P<0.000], symptoms [P<0.001], social functioning [P<0.000], quality of life, [P<0.011] as well as general health related quality of life [P<0.000] has a significant relationship

Conclusion: Considering that sleep quality are associated with health-related quality of life. Community health care providers especially nurses had to more than before attention to sleep quality in these patients

[Nursing student's attitude and motivation towards work in cancer settings]

Introduction: One of the main goals of bachelor's degree program in nursing produce graduates to meet the needs of the community and employment in various settings of health and medical care while after graduation in Iran recruitment of nurses in cancer nursing is difficult. It is important to understand why working in cancer areas is not popular. The aim of this study identifies Iranian undergraduate nursing students' attitude and motivation toward employment in cancer settings after graduation

Method: A cross sectional study 2010 was carried out in three nursing schools. The participants were 469 nursing student who were in third and fourth year of their nursing education. Data was collected using self-completed questionnaires that their validity was substantiated by the results of the research from the perspective of experts in nursing and the reliability was measured through Cronbach Alpha Coefficient, the alpha coefficient of which was equal to 81% and then was analyzed by SPSS and by means of descriptive and inferential statistical methods

Results: Statistically significant difference was detected between gender, academic year, and clinical experience with cancer patient, and passing theory credit of cancer before practice. The independent Test also showed significant differences between the two academic years [P<0.05]. The fourth year students had higher grades in the parts of emotion, feeling, behavior, and total score of attitude and motivation questionnaires than the other. Students who had not passed the cancer theory credit had higher grades in parts of behavior, attitude and motivational factors which with use of the independent t-test a statistically significant difference was seen [P<0.05]

Conclusion: The results of this study indicated that nursing students have negative attitude towards working in cancer wards. The highest rank among motivational factors was the unusable theory trainings and the lowest rank was the disproportionate cancer theoretical course content with the real needs in the cancer ward. Changing these attitudes presents a significant challenge. Curricula need to be reviewed, and revise the content. Nursing schools and nursing educators must reconsider their performance and hospital managers must improve environment and working conditions of cancer settings

[Effect of sedamin capsule on sleep disorder among menopausal women]

Sleep disurbance is considered to be one of the most common problems in menopausal women. Herbal supplements are being used as herbal supplemental medication to solve the problem. The aim of this study was to determine the effect of Sedamin capsule on sleep disorder among menopausal women. This randomized controlled trial study was done on 100 Menopausal women aged 50-60 with sleep disorder. Women randomly divided into intervention and contol groups. Subjects intervention group were received Sedamin capsule [530 mg Valerian root] twice a day for 30 days. Women in control group were received capsule [50 mg of carbohydrate] twice a day for 30 days. Demographic data form and Pittsburg sleep quality index was instrumented for the evaluation of disorder. Data analyzed with using independent T and ANOVA tests. Mean score of sleep disorder peior and after intervention was 9.8 +/- 3.6 and 6.02 +/- 2.6 [P<0.05] in interventional group and 11.14 +/- 4 and 9.4 +/- 3.9 in controls, respectively. Also, 40% of the participants in the intervention group and 12% in the control group showed an improvement in the quality of sleep [P<0.05]. This study showed that consumption of Sedamin capsule improves the quality of sleep in menopausal women with sleep disorder

[ effect of valerian on sleep component among menopausal women]

About 50 percent of menopausal women have sleep problems that can lead to reduced quality of life; according to the population growth in postmenopausal women today, raising the level of their health issues are deemed important. The aim of this study was to investigate the effect of valerian on sleep component among 60-50 year women. In this study, a randomized controlled trial design was employed. Participants consisted of 100 women with menopause aged 50-60, who suffered from insomnia. Instruments included demographic data form and Pittsburg sleep quality index. Descriptive and inferential statistics were used to analyze the data. Prevalence of sleep disorders by Pittsburg sleep quality index in this group was 70%. A statistically significant change was reported in the six component of sleep disturbance in intervention group in comparison to the placebo group [p=0.000]. But the sixth component [the mount of drugs] was not statistically different. The results show that valerian improves the component of sleep in women with insomnia. So, it is essential that health providers would be familiar with these herb supplements

[Desired attributes of outpatient services from the perspective of patients: using a choice- based conjoint analysis technique]

Patients' perception of various aspects of health services could provide useful insights to improve health services. In the present study the technique of Choice- Based Conjoint Analysis [CBCA] was used to elicit patients' views on desired attributes of outpatient services. Five attributes related to outpatient services provided by hospital clinics, were surveyed. They included appointment making, waiting time, forming medical records, and presence of medical students and other patients in the examination room. There were 200 patients selected through convenient sampling method. Data were gathered via structured interviews and analyzed by logit regression model. The three main attributes preferred by respondents were: no presence of other patients [57%], appointment making [17%], and forming medical records [15%]. The scenario with maximum utility consisted of the following: telephone appointments, having medical records, no presence of medical students and other patients in the examination room, and the maximum waiting time of half an hour. The sequence of the priorities preferred by the outpatients was found to be firstly, examination by consultants in private, secondly, telephone appointments, and finally, formation of medical records. CBCA could be a potentially useful technique for eliciting the preferences of health service users

[ effect of honey mouthwash on the prevention mucositis due to head and neck radiotherapy]

Mouthwash helps prevent and treat mucositis. The aim of this study was to investigate the effect of honey mouthwash in the prevention mucositis due to head and neck radiotherapy. In this clinical trial, single blind study, 80 patients with head and neck radiotherapy who attended in radiotherapy ward in Shafa Hospital, Kerman, 1389, was investigated. Applying simple sampling technique, the cases were selected and randomly divided into two groups of control and experiment. The experiment group [N=40] would gurgle 5 spoons of honey mouthwash after tooth brushing, and control group [40] used water as mouthwash. In this 14-day study, subjects' mouths were examined regarding mucositis, based on WHO grading scale on the 1st, 7th, and 14th days. Data were then analyzed applying SPSS, v.16 and employing Fisher exact test, and Mann-Whitney test. In the experiment group, in the units under study the severity of mucositis was mild in the first day [42.94] and lacking mucositis in both the 7th [62.84] and 14th [68.6%] days. In the control group, the severity was mild in the 1st day [29.5%] in the most units under study, and was mild and moderate in the 7th [29.4%] and 14th [32.4%] days, respectively. There was a significant difference between 2 groups regarding mucositis intensity in the first, seventh and fourteenth days [P<0.000]. Since mucositis can be easily prevented by using mouthwash, honey mouthwash can be applied to prevent mucositis and reduce its intensity in head and neck-radiotherapy units.

[Factors associated with quality of life in people with lower limb amputations]

Amputation of a body part is a "life-changing event". Amputation affects almost all aspects of an individual's life. Many issues arise following the loss of all or part of a person's limb[s]. Disability as a consequence of amputation has a devastating effect on the quality of life of the disabled people. The aim of this study was to investigate the factors associated with quality of life in people with lower limb amputations. It was a descriptive, cross-sectional study. The study population consisited of all above 18 years refferd to the rehabilitation center of Tehran during 2008 who had lost part or all of their lower limb due to disease or accident. Data was collected by the Short Form 36 Item Health Survey Questionner [SF36], and a researcher made tool, and analyzed using SPSS-PC [v.12]. The score of the quality of life of most study sample [%59/2] was 34-46. The mean and standard deviation of total quality of life was 55.02 +/- 17.226. there were a significant relationship between the quality of life and the samol's age, marital status, number of children, education, job status [before and after amputation], financial status, residence, the status of residence, type of insurance, type of home, the amputated limb, the level of amputation, the time after amputation, using prosthesis, use of assistive devices, and the reson for amputation [P<0/05]. The regression analysis revealed that the factors associated with quality of life in order of importance were using prosthesis, financial status, the reson for amputation, and the number of children. Identification of these factors for consultation, planning and implementing appropriate health policies to improve quality of life of these individuals is recommended

[ survey of the effects of olive oil and saj cream on striae gravidarum in the second trimester of pregnancy]

Striae gravidarum appears in many pregnant women and it creates aesthetic concerns among them. This study was done with the aim of determination of the effects of olive oil and Saj cream on the occurrence of striae gravidarum in the second trimester of pregnancy. This study was a randomized trial. The study sample included 105 nulliparous women in their second trimester of pregnancy. All the women were in their 18th -20th week of pregnancy and refered to health centers of Tehran. Two intervention groups applied Saj cream [n=30] or olive oil [n=30] and control group [n=30] did not apply any creams. Data was collected by interview and observation and analyzed using SPSS-PC [v.13]. Striae manifested among 40% of those taking olive oil, 16.7% of those using Saj cream and 56% of those in the control group. There was a significant difference between the two intervention groups and the control group [P<.006]. The findings of this study indicated that application of Saj cream during the beginning of pregnancy to the end of the second trimester had been effective in reduction of striae gravidarum. Studies investigating the effect of other herbal oils on prevention of striae are recommended

[Related factors of acute Leukemia in children and the role of breast feeding]

In this study we aimed to determine factors related to the etiology of cancer in children. We investigated this issue in a case control study of 300 patients, aged 2 +/- 14 years, with acute leukemia, and 300 controls, individually matched to cases for age and sex, and place of residence. Children were enrolled after selection by a continuous sampling method. Information regarding breast-feeding was obtained through face to face interviews with mothers. Breastfeeding for durations less than one month increased the risk for childhood acute leukemia. Also, results showed that children 18-13 months and 24-19 months were breast fed, respectively, 2.45 and 3.54 times less than had been breastfed children under 1 year were diagnosed with acute leukemia. [P<0.05]. Higher number of children [OR=1.42, CI 1.03-1.96] and low family income [OR=0.6, CI 0.38-1.01] increased the risk for childhood acute leukemia [p<0.05]. Results of this study indicate that childhood acute leukemia may be associated with breast-feeding, economic status, and number of children. Further cohort studies on factors causing acute Leukemia in children are recommended

[ relationship between organizational health and performance indicators of health care in teaching hospitals affiliated to Tehran university of medical sciences: 2011]

Organizational health, influenced by various factors, can affect the effectiveness, efficiency, and profitability of the organization. This study investigated the relationship between organizational healths [and its seven-fold dimensions] and the performance indicators at teaching hospitals affiliated to Tehran University of Medical Sciences [TUMS]. This descriptive, analytical and applied study was conducted in winter 2011. There were 300 employees randomly selected from among the research population who were the staff of teaching hospitals affiliated to TUMS. The instruments were the checklist of performance indicators and a standard questionnaire of organizational health the validity of which was obtained through opinion analysis of seven experts and its reliability was measured by Cronbach's alpha [88%]. Data analysis was carried out using SPSS software and descriptive statistics including absolute frequency, relative frequency, mean, standard deviation, and Spearman correlation test. No significant relationship was found between any of performance indicators and either of the dimensions of morality, scientific emphasis, consideration, and support of resources. Significant relationship was, however, observed between construction of organizational health and indicators of the total number of occupied bed days, total number of those admitted the performance of the rotating beds, and the crude mortality rate [P

[Self-efficacy and the related factors in ostomates]

Stoma surgery is one of the events that strongly influences individual life and causes major changes in life style. Self-efficacy as a personal coping resource can facilitate adaptation with these changes. So the aim of this study was to assess self-efficacy and the related factors in ostomates. It was a cross-sectional study. Eighty four patients with ostomy who were referred to selected educational centers of Tehran University of Medical Sciences and Iranian Ostomy Association [IOA] were selected through convenience sampling. The data were collected using personal information form and Stoma Self-Efficacy Scale [Stoma SE Scale]. Data was analyzed by SPSS 15 using descriptive statistics, independent t-test, ANOVA and regression analysis. Half of the participants gained at least half of the overall self-efficacy scores. The mean score of social self-efficacy was lower than the mean score of stoma care self-efficacy. Self-efficacy was associated with marital status, stoma status and stoma duration [P<0.05] but the relationship between self-efficacy and age, gender, educational level, type of stoma and reason of stoma was not statistically significant. The Present study provided useful information about self-efficacy and its related factors in stoma patients. This information can be used for designing and performing appropriate nursing interventions to promote these patients' self-efficacy, especially in the social dimension which is weaker in most ostomates