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Introduction: Medical culture can make trainees feel like there is neither room for mistakes, nor space for personal shortcomings in the makeup of physicians. A dearth of role models who can exemplify that it is acceptable to need support compounds barriers to help-seeking once students struggle. We conducted a mixed-methods study to assess the impact of physicians sharing their living experiences with medical students. Methods: Second-year medical students participated, through synchronized videoconferencing, in an intervention consisting of 3 physicians who shared personal histories of vulnerability (e.g. failure on high-stakes exams; immigration and acculturation stress; and personal psychopathology, including treatment and recovery), followed by facilitated, small-group discussions. For the quantitative component, students completed the Opening Minds to Stigma Scale for Health Care Providers (OMS-HC) before and after the intervention. For the qualitative component, we conducted focus groups to explore the study intervention. We analyzed anonymized transcripts using thematic analysis aided by NVivo software. Results: We invited all students in the class (n = 61, 46% women) to participate in the research component. Among the 53 participants (87% of the class), OMS-HC scores improved after the intervention ( P = .002), driven by the Attitudes ( P = .003) and Disclosure ( P

BackgroundAtrial fibrillation (AF) is a common arrhythmia that adversely affects health-related quality of life (HRQoL). We conducted a pilot trial of individuals with AF using a smartphone to provide a relational agent as well as rhythm monitoring. We employed our pilot to measure acceptability and adherence and to assess its effectiveness in improving HRQoL and adherence. ObjectiveThis study aims to measure acceptability and adherence and to assess its effectiveness to improve HRQoL and adherence. MethodsParticipants were recruited from ambulatory clinics and randomized to a 30-day intervention or usual care. We collected baseline characteristics and conducted baseline and 30-day assessments of HRQoL using the Atrial Fibrillation Effect on Quality of Life (AFEQT) measure and self-reported adherence to anticoagulation. The intervention consisted of a smartphone-based relational agent, which simulates face-to-face counseling and delivered content on AF education, adherence, and symptom monitoring with prompted rhythm monitoring. We compared differences in AFEQT and adherence at 30 days, adjusted for baseline values. We quantified participants’ use and acceptability of the intervention. ResultsA total of 120 participants were recruited and randomized (59 to control and 61 to intervention) to the pilot trial (mean age 72.1 years, SD 9.10; 62/120, 51.7% women). The control group had a 95% follow-up, and the intervention group had a 93% follow-up. The intervention group demonstrated significantly higher improvement in total AFEQT scores (adjusted mean difference 4.5; 95% CI 0.6-8.3; P=.03) and in daily activity (adjusted mean difference 7.1; 95% CI 1.8-12.4; P=.009) compared with the control between baseline and 30 days. The intervention group showed significantly improved self-reported adherence to anticoagulation therapy at 30 days (intervention 3.5%; control 23.2%; adjusted difference 16.6%; 95% CI 2.8%-30.4%; P

Spesialsamlingene ved Universitetsbiblioteket i Bergen tok i en workshop opp problemstillingen «Hvilke utfordringer vil bibliotekene møte i framtiden, og hvordan forholder vi oss til disse?». Fokuset var bibliotekenes spesialsamlinger og deres møte med den digitale fremtiden. Det er «digitalisering», dvs. lagring av kopier av materialet og metadata i et digitalt format, som er nøkkelen til den digitale fremtiden. Hvordan den digitale fremtiden påvirker bibliotekenes samlingsforvaltning var derfor temaet for workshopen. Fokuset var rettet mot de norske bibliotekenes spesialsamlinger som har ansvar for et stort mangfold av materiale og materialtyper. Workshopen inneholdt tre deler: Hvordan velge hva som skal digitaliseres? Formidling av det digitaliserte materialet. Forholdet mellom det digitale og det fysiske materialet. Hvert innlegg ble etterfulgt av spørsmål og diskusjoner blant deltagerne. Dette åpnet for at workshopen gav et nyttig innblikk i hva slags behov som eksisterer hos bibliotek med spesialsamlinger i hele landet. Det første innlegget redegjorde for mengdeproblematikken ved digitalisering: Ofte har bibliotekene så store samlinger at prioriteringer må gjøres før digitalisering, både av prinsipielle og praktiske årsaker. Det må etableres prinsipielle kriterier som legges til grunn for digitalieringsutvalget og -strategien, samt at det må foretas en prioritering i forhold til hvilket materiale som er forskningsrelevant. Samlinger kan nærmest være en godt bevart hemmelighet før man får formidlet dem på nett, og det var et mål og et ønske hos deltagerne på workshopen å tilgjengeliggjøre samlingene på nett, enten på samlingsnivå, men aller helst på dokumentnivå. Det andre innlegget presenterte løsningene som Spesialsamlingene ved Universitetsbiblioteket i Bergen har valgt når det gjelder problemkomplekset: «Digital samlingsforvaltning». I dag legger mange av biblioteksinstitusjonene sitt digitale materiale i egne «lukkede» baser og datasett, uten at basene har muligheten til å kommunisere med andre nasjonale og internasjonale baser. Hva er fremtiden her? Universitetsbiblioteket i Bergens digitale portal Marcus bruker en løsning basert på Linked Data. Dette gir muligheter for samhandling og lenking til andre baser. Andre institusjoner kan ha valgt andre løsninger, men mulighetene for en felles samarbeidsstrategi for fremgangsmåte og system med andre norske institusjoner bør utredes. Det var et gjennomgående tema blant deltagerne at alle har et udekket behov for tekniske løsninger hvor man kan digitalt formidle materialet til brukerne. Mange spesialsamlinger har også materiale som ikke lar seg digitalisere på tradisjonell måte, spesielt i tilfeller hvor det klassiske bokformatet overskrides, for eksempel lange skriftruller eller kunstbøker. Mindre bibliotek har ofte ikke tilgang på tekniske løsninger, og ved et velfungerende nasjonalt nettverk kan man legge til rette for at større institusjoner kan være støttespillere for de mindre institusjonene med hensyn til digital formidling. Digital formidling er mer enn «digitalisering». Gjenfinnbarhet fordrer også at det er tilstrekkelig med ressurser til å kunne bygge opp gode metadata. I tillegg ble det fremhevet blant deltagerne viktigheten av å samarbeide med ulike fagmiljøer for å kunne produsere metadata og øke tilgjengeligheten. Det tredje innlegget så nærmere på forholdet mellom det digitale og det fysiske materiale. Hvis man ser bort fra de digitalt skapte gjenstandene finnes det bak hver digitale kopi et originalt objekt med en fysisk form og tilstedeværelse. Det fysiske objektet vil alltid kunne tilby forskningen ny innsikt, fordi det stadig finnes opp nyere teknologi og analysemetoder for å studere gjenstandene som forvaltes av spesialsamlingene. Forholdet med de digitale kopiene ble da problematisert: Hva skal skje med det fysiske materialet etter at det er digitalisert? Skal det gjemmes bort i depotmagasin, eller kasseres? Denne utfordringen er viktig for ulike spesialsamlinger som forvalter unike manuskripter og sjeldne bøker, men den er også relevant for bibliotekene generelt. Gjennom workshopen kom det frem at det også er ulik praksis rundt materialhåndtering. Noen har egne konservatorer, andre ikke. Rutinene for hvordan materialet gjøres tilgjengelig for brukerne varierer også nasjonalt. Det kan være nyttig å også her utveksle ytterligere erfaringer i tiden fremover. I samtalen ble det lagt vekt på at den digitale versjonen og den materielle gjenstanden ikke må settes opp mot hverandre, for begge er viktige. Det er viktig å digitalisere for å kunne formidle objektet uavhengig av brukerens lokasjon, uavhengig om dokumenter som står i en relasjon til hverandre ligger plassert ulike steder, samt for å bevare en digital kopi som dokumentasjon og for digital preservering. Digitaliseringen vil også kunne skåne originalen og dermed fremme fysisk preservering. Det kom frem at mange ønsket å ha et faglig nasjonalt nettverk hvor spesialsamlinger kan utveksle erfaringer. Spesialsamlingene ved Universitetsbiblioteket i Bergen inviterte deltagerne til videre diskusjon på konferansen «Spesialsamlinger i bibliotekene» avholdt i desember 2019 i Bergen. I workshopen ble det diskutert digitaliseringsstrategier og utvalgskriterier, og utforskning av felles plattformer for å optimalisere den digitale samlingsforvaltning, og det ble lagt frem scenarioer og lagt vekt på mulighetene for sameksistens mellom de fysiske og de digitale samlingene. Workshop-formatet i en VIRAK-kontekst gir unike muligheter for å utveksle idéer og ulike innspill som kan lage synergier på tvers av spesialsamlinger og biblioteker i Norge.

Lake sediments can retain imprints of past floods, enabling reconstructions that span well-beyond instrumental time series. Time series covering thousands of years can document the natural range of flood variability, which is critical for understanding the potential causality between changing flood patterns and climate. Here, we analyzed sediments from Lake Sandvinvatnet in southwest Norway. Detailed environmental magnetic analyses of an 830 cm-long sediment core covering the last 6,500 years captured decadal scale trends in local flood frequency. Magnetic susceptibility (MS) assessments were carried out both on split cores and individual samples to track variability in sedimentary influx; the ratios of MS measured at 77 and 293 K (MS ratios) provided information on potential changes in source regions. The results suggested that sediments from the Buerdalen valley dominate the signal in the core, and the amount of ferromagnetic (high MS) carriers increases during flood events. These carriers were assumed to be transported from slope deposits in Buerdalen during rainstorm-triggered flood events. The reconstructed flood frequency, based on sediment layers with ferromagnetic carriers, showed high variability over the past 6,500 years, and the finding was validated by overlapping with known historical floods in the area. We observed periods with a high frequency of extreme floods (4,100–3,140 cal. yr BP) compared with intervals with a few or no extreme floods (6,050–4,100 cal. yr BP). Floods in this region are commonly a result of intense rain events during fall and snow and glacial melt during late spring and summer. The systematic frequency changes during the past 6,500 years suggest a certain persistency in the processes that cause floods, where mean trends in summer temperature and precipitation may have played a role.

Introduction Advance care planning (ACP) is associated with improved health outcomes for patients with cancer, and its absence is associated with unfavourable outcomes for patients and their caregivers. However, older adults do not complete ACP at expected rates due to patient and clinician barriers. We present the original design, methods and rationale for a trial aimed at improving ACP for older patients with advanced cancer and the modified protocol in response to changes brought by the COVID-19 pandemic.Methods and analysis The Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly study is a pragmatic, stepped-wedge cluster randomised trial examining a Comprehensive ACP Program. The programme combines two complementary evidence-based interventions: clinician communication skills training (VitalTalk) and patient video decision aids (ACP Decisions). We will implement the programme at 36 oncology clinics across three unique US health systems. Our primary outcome is the proportion of eligible patients with ACP documentation completed in the electronic health record. Our secondary outcomes include resuscitation preferences, palliative care consultations, death, hospice use and final cancer-directed therapy. From a subset of our patient population, we will collect surveys and video-based declarations of goals and preferences. We estimate 11 000 patients from the three sites will be enrolled in the study.Ethics and dissemination Regulatory and ethical aspects of this trial include Institutional Review Board (IRB) approval via single IRB of record mechanism at Dana-Farber Cancer Institute, Data Use Agreements among partners and a Data Safety and Monitoring Board. We plan to present findings at national meetings and publish the results.Trial registration number NCT03609177; Pre-results.

Atrial fibrillation (AF) is an arrhythmia associated with an increased stroke risk and mortality rate. Current treatment options leave unmet needs in AF therapy. Recently, doxapram has been introduced as a possible new option for AF treatment in a porcine animal model. To better understand its pharmacokinetics, three German Landrace pigs were treated with intravenous doxapram (1 mg/kg). Plasma and brain tissue samples were collected. For the analysis of these samples, an ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) assay for the simultaneous measurement of doxapram and its active metabolite 2-ketodoxapram was developed and validated. The assay had a lower limit of quantification (LLOQ) of 10 pg/mL for plasma and 1 pg/sample for brain tissue. In pigs, doxapram pharmacokinetics were biphasic with a terminal elimination half-life (t1/2) of 1.38 ± 0.22 h and a maximal plasma concentration (cmax) of 1780 ± 275 ng/mL. Its active metabolite 2-ketodoxapram had a t1/2 of 2.42 ± 0.04 h and cmax of 32.3 ± 5.5 h after administration of doxapram. Protein binding was 95.5 ± 0.9% for doxapram and 98.4 ± 0.3% for 2-ketodoxapram with a brain-to-plasma ratio of 0.58 ± 0.24 for doxapram and 0.12 ± 0.02 for 2-ketodoxapram. In conclusion, the developed assay was successfully applied to the creation of pharmacokinetic data for doxapram, possibly improving the safety of its usage.

The presented three different balloon dilation devices for treating Eustachian tube dysfunction were compared regarding their geometries and designs. The balloon dilation behaviour was investigated by an in vitro test setup consisting of a test chamber with 37 °C water, a 2-axis laser scanner and a pressure controller. All balloons could be properly dilated up to the given nominal pressure (NP) or to rated burst pressure (RBP). The balloons reached their expected balloon diameter and length. The compliance data were 1.07 %/atm (TubaVent short), 1.16 %/atm (Acclarent Aera) and 1.28 %/atm (XprESS LoProfile). The measured profile and compliance data can be used for development of new devices for balloon dilation Eustachian tuboplasty.

Inkjet printing has become essential for pharmaceutical research as well as biomedical applications. It is a promising tool to meet future challenges in patientindividual designed pharmaceuticals and implants. In this context, the main areas of use are high-throughput screening (HTS), drug-loaded microparticles, drug formulation and oral dose development, 3D-printing/bioprinting as well as coating of implants. This study deals with the latter. In view of promising applications for localized coating and functionalization of implant surfaces this work shows preliminary results on inkjet printing of the polymer poly(2- ethyl-2-oxazoline) (PetOx), a protein repellent polymer (PRP). To deposit single droplets with small volumes (~500 pl) of aqueous PetOx solution (50 g/l), printing parameters were determined for the piezo-driven drop-ondemand inkjet printhead NanoTip J, operating in a Nanoplotter 2.1 (both from GeSiM mbH, Germany). Different printing strategies are demonstrated by varying droplet spacing and drying time while printing on hydrophilic glass substrate. Printing and stacking of almost uniform polymer lines (width ~ 200 μm) is demonstrated.

To provide an effective and safe therapy for chronic Eustachian tube dysfunction (ETD), biodegradable stents should be developed to restore important functions, e.g. middle ear ventilation and drainage. After defining general requirements specifications, stent designs of cardiovascular polymeric stents were modified according to dimensions and conditions of the Eustachian tube. Finite element simulations demonstrated the crimping capacity of the developed stent design and the ability of expansion in the specific geometry of the target location. Subsequent in vitro tests of stent prototypes showed satisfying properties concerning crimpability, expansion behavior and elastic recoil to demonstrate general feasibility. Further developments and additional testing will advance the implementation of a new treatment option of ETD.

Abstract Background Untreated chronic otitis media severely impairs quality of life in affected individuals. Local destruction of the middle ear and subsequent loss of hearing are common sequelae, and currently available treatments provide limited relief. Therefore, the objectives of this study were to evaluate the feasibility of the insertion of a coronary stent from the nasopharynx into the Eustachian tube in-vivo in sheep and to make an initial assessment of its positional stability, tolerance by the animal, and possible tissue reactions. Methods Bilateral implantation of bare metal cobalt-chrome coronary stents of two sizes was performed endoscopically in three healthy blackface sheep using a nasopharyngeal approach. The postoperative observation period was three months. Results Stent implantation into the Eustachian tube was feasible with no intra- or post-operative complications. Health status of the sheep was unaffected. All stents preserved their cylindrical shape. All shorter stents remained in position and ventilated the middle ear even when partially filled with secretion or tissue. One of the long stents became dislocated toward the nasopharynx. Both of the others remained fixed at the isthmus but appeared to be blocked by tissue or secretion. Tissue overgrowth on top of the struts of all stents resulted in closure of the tissue-lumen interface. Conclusion Stenting of the Eustachian tube was successfully transferred from cadaver studies to an in-vivo application without complications. The stent was well tolerated, the middle ears were ventilated, and clearance of the auditory tube appeared possible. For fixation, it seems to be sufficient to place it only in the cartilaginous part of the Eustachian tube.

Abstract Background Acute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences. Method This is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates. Results Over 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value

Insertion of a cochlear implant (CI) into the scala tympani evokes electrode insertion trauma that can result in mechanical damage of the lateral and medial wall and causes ingrowth of fibrous tissue on the implant surface. In consequence, it is of great clinical interest to modify the silicone surface of CI electrodes in order to inhibit and minimize the overgrowth by connective tissue. In this case, the covalent coupling of bifunctional polymers on common CI silicone surfaces is a versatile method to influence the implant cell interaction, but is still a challenge due to the chemically unreactive properties of silicone. We present a sophisticated method to apply a biodegradable polymer coating, such as polylactide or polyhydroxybutyrate, on silicone surfaces to generate a drug delivery system using a covalently bound intermediate layer. The adhesive coatings were applied via spincoating processes with different adherence to the intermediate layer. Changes in surface morphology were investigated by comparison of pure silicone and coated silicone. Specific polymer bands of the infrared spectra were detected by IR spectroscopy. Results indicate a complete coating with polylactide or polyhydroxybutyrate. The presented method is a versatile tool for the coating of silicone CI electrodes with degradable polymer layers.

Cochlear implants, like other active implants, rely on precise and effective electrical stimulation of the target tissue but become encapsulated by different amounts of fibrous tissue. The current study aimed at the development of a dual drug release from a PLLA coating and from the bulk material to address short-term and long-lasting release of anti-inflammatory drugs. Inner-ear cytocompatibility of drugs was studied in vitro. A PLLA coating (containing diclofenac) of medical-grade silicone (containing 5% dexamethasone) was developed and release profiles were determined. The influence of different coating thicknesses (2.5, 5 and 10 µm) and loadings (10% and 20% diclofenac) on impedances of electrical contacts were measured with and without pulsatile electrical stimulation. Diclofenac can be applied to the inner ear at concentrations of or below 4 × 10−5 mol/L. Release of dexamethasone from the silicone is diminished by surface coating but not blocked. Addition of 20% diclofenac enhances the dexamethasone release again. All PLLA coatings serve as insulator. This can be overcome by using removable masking on the contacts during the coating process. Dual drug release with different kinetics can be realized by adding drug-loaded coatings to drug-loaded silicone arrays without compromising electrical stimulation.

Background: Electrocardiographic (ECG) features of left bundle branch (LBB) block (LBBB) can be observed in up to 20%-30% of patients suffering from heart failure with reduced ejection fraction. However, predicting which LBBB patients will benefit from cardiac resynchronization therapy (CRT) or conduction system pacing remains challenging. This study aimed to establish a translational model of LBBB to enhance our understanding of its pathophysiology and improve therapeutic approaches. Methods: Fourteen male pigs underwent radiofrequency catheter ablation of the proximal LBB under fluoroscopy and ECG guidance. Comprehensive clinical assessments (12-lead ECG, bloodsampling, echocardiography, electroanatomical mapping) were conducted before LBBB induction, after 7, and 21 days. Three pigs received CRT pacemakers 7 days after LBB ablation to assess resynchronization feasibility. Results: Following proximal LBB ablation, ECGs displayed characteristic LBBB features, including QRS widening, slurring in left lateral leads, and QRS axis changes. QRS duration increased from 64.2 ± 4.2 ms to 86.6 ± 12.1 ms, and R wave peak time in V6 extended from 21.3 ± 3.6 ms to 45.7 ± 12.6 ms. Echocardiography confirmed cardiac electromechanical dyssynchrony, with septal flash appearance, prolonged septal-to-posterior-wall motion delay, and extended ventricular electromechanical delays. Electroanatomical mapping revealed a left ventricular breakthrough site shift and significantly prolonged left ventricular activation times. RF-induced LBBB persisted for 3 weeks. CRT reduced QRS duration to 75.9 ± 8.6 ms, demonstrating successful resynchronization. Conclusion: This porcine model accurately replicates the electrical and electromechanical characteristics of LBBB observed in patients. It provides a practical, cost-effective, and reproducible platform to investigate molecular and translational aspects of cardiac electromechanical dyssynchrony in a controlled and clinically relevant setting. [ABSTRACT FROM AUTHOR]

Background: Cancer patients are at a high risk of complications in cases of infection, and head and neck cancers (HNC) are no exception. Since late 2019, SARS-CoV-2 has caused a global health crisis, with high rates and severe forms of the disease in cancer patients. Hospitalization, surgery and radiotherapy were rapidly described as increasing the risk of infection. Since March 2020, the Amiens University Hospital (France) has been taking care of COVID-19 patients while its maxillofacial surgery department managed HNC patients without interruption, even during lockdown periods. However, many questions concerning the impact on patient care were still pending. The aim of this study is to describe HNC management in our center during the first epidemic peak and to evaluate the impact of containment measures on patient treatment. Methods: We retrospectively included 44 HNC patients treated in our department between 1 March and 31 August 2020. Two groups were defined according to the period of care: lockdown (March to May) and lighter restrictions (June to August). Results: The results show typical epidemiological characteristics, maintained management times and non-downgraded procedures. Conclusions: Thus, during the first epidemic peak, continuity of care and patients' safety could be ensured thanks to adequate means, adapted procedures and an experienced surgical team. [ABSTRACT FROM AUTHOR]

Introduction: Increased BMI has been identified as a risk factor for most pregnancy complications, but the underlying metabolic factors mediating the detrimental effects of BMI are largely unknown. We aimed to compare metabolic profiles in overweight/obese women (body mass index [BMI] ≥ 25 kg/m2) and normal weight/underweight women (BMI < 25 kg/m2) across gestation. We also explored how gestational weight gain (GWG) affected maternal metabolic profiles. Material and methods: Exploratory nested case–control study based on a prospective longitudinal cohort of women who were healthy prior to pregnancy and gave birth at Oslo University Hospital from 2002 to 2008. The sample consisted of 48 women who were overweight/obese and 59 normal‐weight/underweight women. Plasma samples from four time points in pregnancy (weeks 14–16, 22–24, 30–32 and 36–38) were analyzed by nuclear magnetic resonance spectroscopy and 91 metabolites were measured. Linear regression models were fitted for each of the metabolites at each time point. Results: Overweight or obese women had higher levels of lipids in very‐low‐density lipoprotein (VLDL), total triglycerides, triglycerides in VLDL, total fatty acids, monounsaturated fatty acids, saturated fatty acids, leucine, valine, and total branched‐chain amino acids in pregnancy weeks 14–16 compared to underweight and normal‐weight women. Docosahexaenoic acid and degree of unsaturation were significantly lower in overweight/obese women in pregnancy weeks 36–38. In addition, overweight or obese women had higher particle concentration of XXL‐VLDL and glycoprotein acetyls (GlycA) at weeks 14–16 and 30–32. GWG did not seem to affect the metabolic profile, regardless of BMI group when BMI was treated as a dichotomous variable, ≥25 kg/m2 (yes/no). Conclusions: Overweight or obese women had smaller pregnancy‐related metabolic alterations than normal‐weight/underweight women. There was a trend toward higher triglyceride and VLDL particle concentration in overweight/obese women. As this was a hypothesis‐generating study, the similarities with late‐onset pre‐eclampsia warrant further investigation. The unfavorable development of fatty acid composition in overweight/obese women, with possible implication for the offspring, should also be studied further in the future. [ABSTRACT FROM AUTHOR]