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The effectiveness of this method in chronic gallbladder disease has not been reported to date discount 5mg zebeta overnight delivery hypertension question and answers. This methodology is the only one that has a pro- spective zebeta 5mg without a prescription pulse pressure 25, randomized study that supports its use in patients with chronic acalculous gallbladder disease cheap zebeta 5mg on-line arrhythmia research technology. When patient preparation induces preferential bile flow to the gallbladder (such as in cases of sincalide pretreatment), activity in the small intestine may not be seen during the first hour (or even longer than 2 h) in healthy individuals (91). The hallmark of acute cholecystitis (acalculous as well as calculous) is persistent gallbladder nonvisual- ization after 3–4 h of passive imaging or 30 min after morphine administration. A pericholecystic hepatic band of increased activity (rim sign) is a sign of severe late-stage acute cholecystitis and has been associated with severe phlegmonous or gangrenous acute cholecystitis, a surgical emergency (92). Chronic cholecystitis and clinical settings associated with physiologic failure of the gallbladder to fill with radiotracer (e. In chronic cholecystitis, the gallbladder will usually be seen within 30 min of morphine administration or on 3- to 4-h delayed images, whereas true cystic duct obstruction (acute cholecystitis) will result in persistent gallbladder nonvisualization. A gallbladder that is not visualized until after the time that the bowel is visualized correlates significantly with chronic cholecystitis. Delayed biliary-to-bowel transit beyond 60 min raises suspicion of partial obstruction of the common bile duct, although this may be seen as a normal variant in up to 20% of individuals. With high-grade common bile duct obstruction, there is usually prompt liver uptake but no secretion of the radiotracer into biliary ducts. With partial biliary obstruction, radiotracer fills the biliary system but clears poorly proximal to the obstruction by 60 min or on delayed images at 2–4 h or with sincalide. Severe hepatocellular dysfunction may also demon- strate delayed biliary-to-bowel transit. A bile leak is present when tracer is found in a loca- tion other than the liver, gallbladder, bile ducts, bowel, or urine. Leakage may be seen more easily using a cinematic display or decubitus positioning, as described above. Biliary atresia can be excluded scintigraphically by dem- onstrating transit of radiotracer into the bowel. Failure of tracer to enter the gut is consistent with biliary atresia but can also be caused by hepatocellular disease or immature intrahepatic transport mechanisms. Renal or urinary excretion of the tracer (especially in a diaper) may be confused with bowel activity and is a potential source of erroneous interpretation. During a hepatobiliary scan, activity may reflux from the duodenum into the stomach. Bile reflux that is marked and occurs in a symptomatic patient corre- lates strongly with bile gastritis, a cause of epigastric discomfort. After cholecystectomy, sphincter of Oddi dysfunction has the appearance of partial common bile duct obstruc- tion. Pretreatment with sincalide or morphine may improve the sensitivity for its detection. Various visual, quantitative, and semiquantitative scintigraphic param- eters of bile clearance have been used in conjunction with image analysis. The causes of a false-positive study (gallbladder non- visualization in the absence of acute cholecystitis) include: a. Severe intercurrent illness (despite sincalide pre- treatment and morphine augmentation) f. Rapid biliary-to-bowel transit (insufficient tracer activity remaining in the liver for delayed imaging) h. Previous cholecystectomy The causes of a false-negative study (gallbladder vis- ualization in the presence of acute cholecystitis) are rare but include: a. A bowel loop simulating gallbladder (Drinking 100–200 mL water may remove the radiophar- maceutical from the duodenum and allow differ- entiation of gallbladder from bowel. A right lateral view should be obtained to better distinguish activity in the duodenum from that of the gallbladder. The presence of the dilated-cystic-duct sign simu- lating gallbladder (If this sign is present, morphine should not be given. Description of findings Include the appearance of the liver, intrahepatic ducts, common bile duct, the presence and time of tracer appear- ance in the gallbladder or small bowel, any unusual activity (e. Study limitations (patient reactions to drugs adminis- tered) If there is an allergic or other adverse reaction to the radiopharmaceutical or other administered pharmaceuticals, the reaction must be clearly stated in the findings and impres- sion sections of the report. Gastrointestinal symptoms elicited by sincalide infusion are related to the rapid infusions and are not observed with the recommended slower infusion techni- ques of 45 and 60 min. Gastrointestinal symptoms occurring during the shorter sincalide infusion have no specificity for gallbladder pathology (93) and should not be part of the study report. However, no information about possible pla- cental crossover of hepatobiliary compounds is available. Impression The impression should be concise and as precise as pos- sible, should address the clinical question, should provide a differential diagnosis, and should make recommendations if appropriate. Any urgent or unexpected findings should be directly communicated to the referring physician, and this communication should be documented. Radiation dosimetry in adults, children, and pregnant or potentially pregnant patients is presented in Tables 2–4. The physician must consider the indication for the test, the potential benefit of information it may provide toward improved care of the patient, and the potential risk it may pose to the fetus. The role of sincalide choles- cintigraphy in the evaluation of patients with acalculus gallbladder disease. Cholecystokinin cholescintigraphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease. Acalculous biliary pain: chol- ecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Abnormal gallblad- der nuclear ejection fraction predicts success of cholecystectomy in patients with biliary dyskinesia. Biliary dyskinesia: a study of more than 200 patients and review of the literature. Chronic acalculous biliary disease: cholecystokinin cholescintigraphy is useful in formulating treat- ment strategy and predicting success after cholecystectomy. Gallbladder ejection fraction: an accurate evaluation of symptomatic acalculous gallbladder disease. Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia. Practice Guideline for the Performance of Adult and Pediatric Hepatobiliary Scintigraphy. Biliary dyskinesia: a potentially unrecognized cause of abdominal pain in children. Laparoscopic cholecystectomy for biliary dyskinesia in children: report of 100 cases from a single institution.

Histological changes include reduction of cellular infiltrations and effective 10 mg zebeta heart attack exo, eventually trusted zebeta 10mg blood pressure 50 0, sclerosis of the synovium cheap zebeta 5mg overnight delivery pulse and blood pressure quiz. In the last thirty years, several other radiocolloids have been developed using 90Y, 32P, 165 166 186 Dy, Ho and Re as radionuclides. Indications and contraindications The indications for radiosynovectomy are: —Rheumatoid arthritis (with persistent effusions); —Inflammatory joint diseases other than rheumatoid arthritis; —Pigmental villonodular synovitis; —Haemophilic joint disease; —Chronic pyrophosphate arthropathy; —Persistent effusion after knee prosthesis; —Baker’s cyst; —Activated arthropathy; —Polyarthrosis of finger joints. The absolute contraindications for radiosynovectomy are: —Pregnancy; —Continued breast feeding. The relative contraindications for radiosynovectomy are: —Periarticular sepsis; —Overlying cellulitis; —Bacteraemia; —An unstable joint; —Intra-articular fracture; —A septic joint. Patient selection Patients are eligible if there is inadequate relief after six months of conservative treatment with corticosteroids. Radiosynovectomy has been demon- strated to be successful only if a clear synovitis is indicated by three phase bone scintigraphy, especially in patients with arthrosis (or arthrosis– arthritis). Colloids Because of its deep tissue penetration, 90Y-colloid is suitable for the knee and in joints with greatly thickened synovium. For joints of intermediate size 186 (wrist, elbow, shoulder and hip) Re-colloid has been successfully used and for the smallest joints (phalanges) 169Er-colloid. Yttrium-90 has been bound to silicate, citrate and ferric hydroxide 90 compounds as colloids. Currently, it is most frequently used as Y-citrate, which ranges in particle size from 10 to 100 nm. Leakage estimates for 90Y- citrate range from 5 to 10% after 24 hours and from 15 to 25% after 4 days. Owing to its small particle size, and thus higher leakage, 198Au is no longer recommended. Dysprosium-165 macroaggregates 165 In order to reduce leakage from the synovial space, Dy-ferric hydroxide macroaggregates have been applied for joint therapy. The particle size averages 5 mm and the activity that does leak from the joint quickly decays 165 (with a half-life of Dy of 139 min), thus reducing extraneous organ irradiation. Dose and route of administration It is assumed that intra-articular colloids are uniformly distributed over the joint surfaces. The most apparent problem is leakage from the joint space, primarily by lymphatic clearance, which depends largely on particle size. Leakage is reduced by a flushing injection of a long acting steroid (such as prednisolone acetate) after radiopharmaceutical injection. Biplanar radiographs with the joint positioned at the injection angle are mandatory to correlate palpable bone landmarks as a guide for needle placement. Following injection, the needle position is checked fluoroscopically using a few millilitres of contrast material. The joint is then manipulated through as full an arc as is possible of extension and flexion to distribute the particles throughout the joint space, following which it is splinted to minimize leakage. Early complications Early complications include: —Transient increase in pain; —Radiodermatitis at the injection site (best prevented by flushing with a steroid); —Septic arthritis; —Acute crystal synovitis; —Transient lymphoedaema. Long term complications Long term complications include: —Chromosomal aberrations in circulating lymphocytes; —Chronic myeloid leukaemia (a single case); —No cancers were found in any of the joints treated. If pain increases during the first days after dose administration, local application of ice can be very helpful. Requirements for a therapy ward Therapy is usually carried out on an outpatient basis. Special precautions Leakage through the needle tract and lymphatic clearance are the major mechanisms whereby radiolabelled colloids escape from joint spaces. This cancer is most common in South and South East Asia, although there are other areas with a high incidence including Mongolia and Latin America. The most commonly identified cause is chronic infection with hepatitis B or hepatitis C. Other contributing factors include alcohol abuse or other causes of cirrhotic liver disease. Treatment options ideally include complete surgical resection and, if the tumour is large, liver transplantation. However, once the tumour is greater than 5 cm and if it is multifocal, the probability of a surgical cure is reduced. It is this combination of growing tumour and failure of the remaining liver that tends to kill the patient. Details of one of the easiest, that of Okuda, which dates back to the middle 1980s, are given in Tables 6. Those with grade 2 disease tend to survive only if their liver disease is stable and if they have a complete surgical resection. The outcome for those with grade 3 disease is poor, with many surviving only a few weeks or months. It is clear that patients in stage 1 may be resectable if they have no impairment of liver synthetic function, and those with grade 3 will not survive even with treatment. Therefore most effort in terms of treatment should be concentrated on patients with stage 1 and stage 2 disease. Radionuclide or other treatment should be offered if the patient is unresectable or if there is residual and/or recurrent disease after resection. Tamoxifen was once held to reduce the rate of recurrence after surgery but once it was tested in a placebo controlled trial there was little evidence to support this view. The cannulation does not need to be precise since the origin of the right hepatic artery will feed the right lobe and likewise the left will feed the left lobe. Never- theless, there are significant side effects to the treatment that can last for about 10 days after treatment, namely pain, often requiring infusion of opioids, severe nausea and jaundice. Despite these problems, this remains the only form of treatment that can be offered to a wide range of patients. This approach has not reached clinical practice but may be a possibility in patients with disease outside the liver. The other treatments including 131I-Lipiodol require local delivery of the radiopharmaceutical into the cancer via an angiographic catheter. Clinical trials are under way; 200 patients have received treatment, which is under review. It is also essential to decide who (the first key team member) will deal with the patient after treatment and tackle any potential problems that may arise. These occur most commonly because of the condition of the liver around the tumour; in a patient with poor liver function a significant degree of liver failure, requiring expert supportive therapy, may occur during the treatment. The second key team member is a competent radiologist with experience in identifying and cannulating the right and left hepatic arteries. This should be performed with a catheter of a reasonably wide bore such as a 5 French catheter.

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There may be sexual dysfunction best 5mg zebeta heart attack kid, either impotence or premature ejaculation cheap zebeta 10 mg heart attack demi lovato, which the patient attributes to loss of semen in urine due to excessive masturbation or sexual intercourse cheap zebeta american express blood pressure systolic. An overvalued idea may form that the urine is foul smelling and less viscous than normal. Shenkui (or shen-k’uei) occurs in China and consists of anxiety, panic, and various physical complaints (including tiredness and sexual dysfunction). The author has certainly seen anxious Irish adolescents who imagined that they have semen in the urine due to ‘damage’ induced by masturbation, so the syndrome is more widespread than India. Frigophobia, found in East Asia, involves an excessive fear of the cold (wears far too many clothes). Hwa-byung (wool-hwa-byung; ‘fiery illness’ or ‘illness of anger’) is found in Korea, mainly in women. There are an epigastric mass sensation, anorexia, anxiety, dyspnoea, and epigastric pain. It seems to be reactive to social circumstances (a way to release anger or indignation), although partial improvement with antidepressant therapy has been recorded. There is usually awareness of the attack whilst it is happening and it can be recalled later. It may represent a way of expressing feelings without incurring adverse consequences. Koro (Malaysian for “head of turtle”; rok-joo in Thailand; jinjinia bemar in Assam; also called suk-yeong by Cantonese Chinese: shrinking penis) resembles panic in symptomatology. The victim, who usually has no history of psychopathology, believes that the secondary sexual organs (penis, female genitalia, breasts) are retracting (as does a turtle’s head) into the trunk. He, or she, may take active steps to maintain the externality of breasts, penis, and so on. It is probably a non-specific symptom, especially in the West, having been described in both schizophrenia and bipolar affective disorder. Qi-gong reaction is a transient neurotic or psychotic response to practicing qi-gong177 in China. Shenjing shuairuo (Mandarin Chinese: ‘weakness of the nervous syndrome’) is known to us as neurasthenia. Shinkeishitsu, found in Japan, consists of obsessions, perfectionism, ambivalence, social withdrawal, neurasthenia, and hypochondriasis. Shin-byung is found in Korea where it is attributed to ancestral spirits: initial anxiety and somatic complaints give way to convulsive movements and anorexia. Hsieh-ping in Taiwan is somewhat similar: short-lived trance state whilst possessed by ancestral spirit who may be attempting to communicate with the family through the possessed; auditory or visual hallucinations, delirium, and tremulousness. New Zealand Whakama (shame) is expressed by Maori people when they break social taboos. Whakamomori consists of low mood, sometimes with damage to 174 Person or voice that enters and controls a person (Zulu). It may involve movement, breathing regulation, or focusing on ‘energy centres’ in or around the body. Mate Maori (Maori sickness), which different forms, is due to the spirit world responding to the breaking of rules. Rules may be broken by the patient or by others (alive or deceased) in the whanau (extended family). Early studies of mental disorders shared problems of observer bias, sampling errors, and non-standardised measuring instruments. Initial reports of a lack of depressive guilt in developing countries may not have been entirely accurate, as it has been demonstrated to exist, especially in Uganda. It has been suggested that Afro-Caribbean’s are more likely to be detained as offender patients. Psychologists Li ea (2007) discuss common difficulties in assessing, diagnosing, and treating minorities: flawed approaches to assessment (e. Bhugra & Bhui, 2001) 178 Services for ethnic minorities need to be accessible, provide trained interpreters , employ members of the minority group, and supply patient advocates. Ireland and other countries are experiencing immigration in large numbers and provision remains inadequate. This contains a language identification card, a set of 20 translated phrasebooks and a user manual. The term disorder refers to ‘a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions’. Borderline personality disorder is hesitantly included and hyperkinetic disorder was broadened. Oppositional defiant disorder appears because of its predictiveness for later conduct disorder. In Neurasthenia, or nervous debility/exhaustion, the sufferer complains of tiredness, depression, irritability, 182 poor concentration, and anhedonia (also found in depression and schizophrenia), an inability to derive pleasure from anything. It commonly follows or is associated with exhaustion or an infection like influenza. It has been argued that most cases of neurasthenia are actually cases of anxiety or depression. Shenjing shuairuo, in China, and 183 shinkeishitsu, in Japan, are related concepts. Hedonic tone refers to the ability to experience pleasure, its absence 185 meriting the label anhedonia. Historically, Ernst Kretschmer and William Sheldon tried to associate so-called somatotypes, or body builds, with particular psychiatric conditions. There are three basic types, each one with overdevelopment of one of the primary embryonic layers: the endomorph with large visceral cavities and a tendency to bipolar affective disorder, the mesomorph with antisocial proclivities, and the ectomorph who has a tendency to develop schizophrenia. Dress and address Patients want doctors of both sexes to dress formally, the great majority prefer to address doctors by title, but they like to be called by their own first name or they may be undecided about this (Swift ea, 2000; Gallagher ea, 2008) – when in doubt, ask! In a study by Vinjamuri ea (2009) 91% of adult psychiatric 188 outpatients across all age wished to be greeted with their first name ; most wanted their hand to be shaken 184 A French physician described Briquet’s Syndrome (St Louis Hysteria; now called somatisation disorder), a term rarely applied in Europe, in 1859. Classically, it occurs in women, starts before their thirtieth birthday, the patient persistently complains of a variety of physical symptoms, she will not accept a psychological explanation - even if one is obvious, and it is said to affect at least one in a hundred females. Management and prognosis Preparation of a management plan should include investigations, immediate management strategies and long-term interventions; in each instance one should consider social, psychological and biological interventions, and ask who will intervene, when they will do it, and where will it be carried out. We should consider both short-term (this episode) and long-term (recurrences/maintenance) prognoses; features of both illness and the individual with the disorder should be included in the discussion. This can be useful when highlighting a patient’s care and dealing with a specific problem. Psychiatrists are in a very strong position to view clinical cases as a whole because of their commendable tendency to wade through the thickest charts in liaison settings.

However there is a tendency for them to underestimate the severity of their cognitive defcits order zebeta 5mg visa blood pressure medication how it works. The difference between results on the psychometric meas- ures and self-reports for anxiety and depression may illustrate a possible difference between the presence of a clinical disorder and the subjective daily experience of the patients discount zebeta 5mg with visa pulse pressure 39. The type of injuries sus- tained included: subarachnoid haemorrhage purchase zebeta in india blood pressure medication quinapril, cerebral contusions, skull fractures, intracranial haemorrhage, extradural haematoma J Rehabil Med Suppl 55 Oral Abstracts 13 and diffuse axonal injuries. If not, can we improve it by using simple and inexpensive clinical interventions namely light, melatonin and caffeine? Intervention was consist of melatonin treatment at night and blue light therapy and caffeine treatment in the morning for fve weeks. Detailed visual inspection and micro-structure assessment of sleep recording were performed in order to score sleep stages. With intervention, improvement of sleep stages and/or sleep-wake patterns were detected in 8/10 patients. Cosinor analysis of saliva melatonin results revealed that averaged base- line % rhythmicity was low. Increase in %Melatonin Rhythm following intervention was statistically signifcant (p=0. One of the main limitations to caudal epidural injec- tions is the fairly high failure rate when no imaging guidance is used. Fluoroscopy and ultrasound may help identifying the sacral hiatus and may allow caudal epidural injections to be performed more accurately and safely. Material and Methods: Our purpose was to determine if there are any differences in effcacy and safety of caudal epidural corticoanesthetic injections guided by ultrasound or fuoroscopy in outpatient with subacute or chronic low back pain, refractory to conservative treatment. We conducted a retro- spective study where we evaluated 16 patients in our outpatient clinic, with low back pain related to disk herniation or associated with lumbar spine stenosis, refractory to conservative treatment. A caudal epidural injection (Lidocaine + Depo-medrol) guided by ultrasound or fuoroscopy was performed. We considered injection as successful when: with ultrasound guidance fuid was observed in the sacral canal; with fuoroscopic guidance radio-opaque contrast was observed in the sacral canal. Conclusion: The results showed similar improve- ments in short-term pain relief, function, patient satisfaction and safety with both, ultrasound and fuoroscopic guidance. Con- J Rehabil Med Suppl 55 Oral Abstracts 15 clusion: In Japan, which has a high population aging rate, vertebral low back pain. As part of addressing these matters, the research- body fractures rank high as a cause of interference with a healthy ers came up with the cost-effective lumbar brace and utilizing this life expectancy. The study used the independent 1 t-test to determine the signifcant difference on the functional dis- Marmara University Medical School, Department of Physical ability scores of patients before and after using the cost-effective Medicine and Rehabilitation- Pain Management, Istanbul, Turkey, lumbar brace. The computed t value Introduction/Background: Even though non-surgical treatments of 7. Patients who chose to have surgery and those who chose to have nonsurgical treatments were similar in age, Introduction/Background: A harmonious sagittal spinopelvic align- comorbidity scores and follow-up duration (69. Spinopelvic alignment needs to be included in surgi- culoskeletal symptom that may be either acute or chronic. Breathing exercises, nutrition 1 and psychological interventions do not have consistent evidence P. Centres should Italy consider the addition of other interventions such as inspiratory Introduction/Background: Given the fgures of obesity worldwide, muscle training, self management and integrated disease manage- its impact on disability and on the National Health Systems, it ap- ment which have good evidence. The particular charac- for some interventions such as breathing exercises and psychology. In 2011, the Italian Ministry of Health has acknowledged the need for a multidisciplinar and integrated rehabilitation path- S. Tambunan3 way for severely obese patients with comorbidities including mul- 1Faculty of Medicine, Physical Medicine and Rehabilitation De- tiple rehabilitative settings according to the severity of disability partment of Dr. Cipto Mangunkusumo National General Hospital, and to the phases of instability of the condition. It is important to Jakarta, Indonesia, 2Persahabatan Hospital, Physical Medicine devise pathways of care based on a multidisciplinary approach that and Rehabilitation, Jakarta, Indonesia, 3Dr. Ciptomangunkusumo not only deal with the weight issue in the long term, but, above all, General Hospital, Physical Medicine and Rehabilitation, Jakarta, prevent and treat its complications, improve function and quality Indonesia of life and enhance participation. Treadmill and stationary bicycle training ment on the organizational requisites of rehabilitation units devoted are types of training that involves large muscle groups in the lower to patients affected by severe obesity with comorbidities. In addition, treadmill exercise also involves trunk mus- 2013, the International Society of Physical and Rehabilitation Med- cle. Khan ,1 2 sisted of 10 minutes increase gradually to 30 minutes, 3 sessions 1Royal Melbourne Hospital, Rehabilitation, Melbourne, Australia, per week for 10 sessions. Both groups also received pulmonary 2University of Melbourne, Medicine, Parkville, Australia, 3Royal rehabilitation program. Results: There were 180 low risk cardiac Material and Methods: We have used continuous overnight pulse patients, male (n=137, mean age 56. Our study shows posi- was forwarded to the patient’s community physician for follow-up. Kohzuki Introduction/Background: The health care decision-making system 1Tsukuba University of Technology, Department of Health, Tsuku- requires evidence of the cost-effectiveness of medical therapies. The incremental cost-effectiveness ratio was calculated physical function and greater risk of arteriosclerosis because of based on intervention and health care costs, and the differential in- hypertension, metabolic disturbances, and vascular calcifcation. The Borg scale was used to con- ers charged to decide how limited health care resources should be trol the intensity of training. Therefore, attention and cognition, is a leading complication with detrimental training during hemodialysis session for 12 weeks might improve outcomes during hospitalization among older adults. Cancer rehabilita- Documentation of delirium status at admission improved from 11% tion inpatients have a number of risk factors that could make them to 98%. Material and Methods: Patients presenting requires well-orchestrated effort of multiple disciplines, including to rehabilitation during Apr 2015 and Oct 2015 were identifed referring hospitals beyond the rehabilitation facility. Future studies and as part of their initial physical assessment, calf measurements are needed to tailor the interventions utilizing specifc resources of were taken on both lower extremities. Only 1 patient had a difference in his/her calf measurement to war- Sherrington , S. This presentation re- views the approaches to “treatment” of frailty used in two rand- omized trials to ascertain whether a common approach can be ap- plied both in frailty and pre-frailty. Both applied interdiscipli- nary multifactorial interventions based on phenotypic characteris- 50 tics using Cardiovascular Health Study criteria and comprehensive geriatric assessment. Barrett6 be delivered with coordination from a key staff member (physi- 1Kessler Institute for Rehabilitation, Physical Medicine and Re- cal therapists). Adher- Kessler Institute for Rehabilitation, Occupational Therapy Ser- 4 ence to the interventions was limited in both groups. However, the percentage of obese patients with sarco- ment” programs are feasible and will be associated with beneft if penia has increased. This study aimed to investigate the effect of adequate levels of adherence are achieved. Mate- rial and Methods: A total of 62 patients were randomly assigned 52 to either an experimental group (n=32) or control group (n=30). Results: A statistically signifcant improvement of Specialties and Dentistry, Napoli, Italy, 2Second University of Na- all measures was observed in both the experimental and control ples, Physical and Mental Health and Preventive Medicine, Napoli, groups after intervention (all p<0.