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The role of acceptance in chronic fatigue syndrome. J Psychosom Res 2011; 71:411-5. [PMID: 22118384 DOI: 10.1016/j.jpsychores.2011.08.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 08/04/2011] [Accepted: 08/12/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In this paper we consider the role that acceptance plays in fatigue and physical and social functioning. We predicted that lack of acceptance would be positively correlated with fatigue and impairment in functioning; that there would be a significant relationship between perfectionism and acceptance; and cognitive behavioural therapy (CBT) would increase acceptance. METHODS Two hundred and fifty nine patients with chronic fatigue syndrome (CFS) completed questionnaires measuring fatigue, physical functioning, work and social adjustment, lack of acceptance, perfectionism and depression. Ninety consecutive attenders received a course of CBT and completed further questionnaires at discharge and 3months post-treatment. Correlations and multiple hierarchical regressions were used to determine relationships between acceptance, perfectionism and clinical outcome variables. RESULTS At baseline, lack of acceptance was the key factor associated with impaired physical functioning and work and social adjustment. Lack of acceptance and doubts about actions were associated with fatigue in a multiple regression analysis. At discharge and follow-up patients showed significantly increased acceptance, as well as reduced Concern over Mistakes, less fatigue and impairment of physical functioning, and improved work and social adjustment. CONCLUSION This is the first study to our knowledge which shows a change in acceptance after CBT and a relationship between acceptance and perfectionism. Acceptance may be an important factor to consider within treatments for CFS.
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Poppe C, Crombez G, Hanoulle I, Vogelaers D, Petrovic M. Mental quality of life in chronic fatigue is associated with an accommodative coping style and neuroticism: a path analysis. Qual Life Res 2011; 21:1337-45. [DOI: 10.1007/s11136-011-0048-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2011] [Indexed: 10/15/2022]
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Rimes KA, Wingrove J. Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study. Clin Psychol Psychother 2011; 20:107-17. [PMID: 21983916 DOI: 10.1002/cpp.793] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 09/15/2011] [Accepted: 09/23/2011] [Indexed: 11/11/2022]
Abstract
UNLABELLED Cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS; sometimes known as myalgic encephalomyelitis). However, only a minority of patients fully recover after CBT; thus, methods for improving treatment outcomes are required. This pilot study concerned a mindfulness-based cognitive therapy (MBCT) intervention adapted for people with CFS who were still experiencing excessive fatigue after CBT. The study aimed to investigate the acceptability of this new intervention and the feasibility of conducting a larger-scale randomized trial in the future. Preliminary efficacy analyses were also undertaken. Participants were randomly allocated to MBCT or waiting list. Sixteen MBCT participants and 19 waiting-list participants completed the study, with the intervention being delivered in two separate groups. Acceptability, engagement and participant-rated helpfulness of the intervention were high. Analysis of covariance controlling for pre-treatment scores indicated that, at post-treatment, MBCT participants reported lower levels of fatigue (the primary clinical outcome) than the waiting-list group. Similarly, there were significant group differences in fatigue at 2-month follow-up, and when the MBCT group was followed up to 6 months post-treatment, these improvements were maintained. The MBCT group also had superior outcomes on measures of impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioural responses, unhelpful beliefs about emotions, mindfulness and self-compassion. In conclusion, MBCT is a promising and acceptable additional intervention for people still experiencing excessive fatigue after CBT for CFS, which should be investigated in a larger randomized controlled trial. KEY PRACTITIONER MESSAGE Only about 30% of people with chronic fatigue syndrome (CFS) recover after cognitive behaviour therapy (CBT); thus, methods for improving treatment outcomes are needed. This is the first pilot randomized study to demonstrate that a mindfulness-based intervention was associated with reduced fatigue and other benefits for people with CFS who were still experiencing excessive fatigue after a course of CBT. Levels of acceptability, engagement in the intervention and rated helpfulness were high. A larger-scale randomized controlled trial is required.
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Affiliation(s)
- Katharine A Rimes
- University of Bath, Department of Psychology, Claverton Down, Bath, UK.
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Eccles FJR, Murray C, Simpson J. Perceptions of cause and control in people with Parkinson's disease. Disabil Rehabil 2011; 33:1409-20. [DOI: 10.3109/09638288.2010.533241] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Eglinton R, Chung MC. The relationship between posttraumatic stress disorder, illness cognitions, defence styles, fatigue severity and psychological well-being in chronic fatigue syndrome. Psychiatry Res 2011; 188:245-52. [PMID: 21600664 DOI: 10.1016/j.psychres.2011.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 04/11/2011] [Accepted: 04/12/2011] [Indexed: 11/19/2022]
Abstract
This study investigated, firstly, the rate of posttraumatic stress disorder (PTSD) and the level of psychological well-being amongst people with chronic fatigue syndrome (CFS); and secondly, the extent to which illness cognitions, defence styles and PTSD symptom severity related to fatigue severity and psychological well-being. Seventy-eight participants with a diagnosis of CFS completed the Chalder Fatigue Scale, the General Health Questionnaire-28, the Posttraumatic Stress Diagnostic Scale, the Illness Cognition Questionnaire and the Defence Style Questionnaire. Fifty-nine participants were recruited from the general public to form the non-fatigued control group. CFS participants had significantly higher levels of PTSD symptoms, lower levels of psychological well-being and more traumatic life events compared to the non-fatigued controls. Trauma exposure and PTSD severity both predicted CFS status. However, regression analyses demonstrated no significant relationship between PTSD symptoms and fatigue severity or the degree of psychological well-being. 'Helplessness' predicted both physical and mental fatigue and psychological well-being, whilst the 'mature' defence styles predicted fatigue severity only. The results offer support to previous research showing that the rate of traumatic life events and PTSD are significantly higher amongst the CFS population. The lack of relationship between PTSD symptoms and fatigue severity or psychological well-being indicates that these processes may operate independently of one another, via different appraisal processes. This study focused on fatigue severity, but it may be that the role of pain in CFS is a key element in the previously reported association between PTSD and CFS.
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Affiliation(s)
- Rebekah Eglinton
- Independent Medical and Psychological Services, Taunton, United Kingdom
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Casier A, Goubert L, Theunis M, Huse D, De Baets F, Matthys D, Crombez G. Acceptance and well-being in adolescents and young adults with cystic fibrosis: a prospective study. J Pediatr Psychol 2011; 36:476-87. [PMID: 21208979 DOI: 10.1093/jpepsy/jsq111] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To prospectively investigate the role of acceptance in well-being in adolescents and young adults with cystic fibrosis (CF). METHOD A total of 40 adolescents and young adults with CF (ages 14-22 years) completed questionnaires assessing acceptance, anxiety and depressive symptoms, physical functioning, role functioning, emotional functioning, and social functioning. After 6 months, 28 of them completed the questionnaires on anxiety and depressive symptoms, physical functioning, role functioning, emotional functioning, and social functioning a second time. RESULTS More acceptance (Time 1) was related to less depressive symptoms (Time 1 and 2), and to better role, emotional, and social functioning (Time 1). CONCLUSIONS Results indicate that accepting the limitations imposed by chronic disease and readjusting life goals may have a positive effect upon well-being in adolescents and young adults with CF. Further research is needed to clarify whether acceptance-based interventions are useful in promoting well-being in adolescents and young adults with CF.
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Affiliation(s)
- Annabelle Casier
- Department of Experimental-Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium.
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Pain, Spirituality, and Meaning Making: What Can We Learn from the Literature? RELIGIONS 2010. [DOI: 10.3390/rel2010001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bossema ER, Seuntiëns MWM, Marijnen CAM, Baas-Thijssen MCM, van de Velde CJH, Stiggelbout AM. The relation between illness cognitions and quality of life in people with and without a stoma following rectal cancer treatment. Psychooncology 2010; 20:428-34. [PMID: 20878851 DOI: 10.1002/pon.1758] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 03/15/2010] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To compare health-related quality of life, emotional functioning and illness cognitions between people with and without a stoma after rectal cancer treatment about 8 years ago and to examine the relation between illness cognitions and health-related quality of life and emotional functioning. METHODS Sixty-two people who had undergone abdominoperineal resection with a permanent stoma and 60 people who had undergone low anterior resection without a permanent stoma participated. Questionnaires included the European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30, the Hospital Anxiety and Depression Scale, and the Illness Cognition Questionnaire. RESULTS There were no significant differences between people with and without a stoma in health-related quality of life, emotional functioning and illness cognitions. There were moderate and significant relations between the illness cognitions helplessness (negative) and disease acceptance (positive) on the one hand and health-related quality of life and emotional functioning on the other. For helplessness this relation barely differed between people with and without a stoma, but for disease acceptance this relation was stronger for people without a stoma than for people with a stoma. CONCLUSIONS The study showed no differences in health-related quality of life, but a stronger relation between disease acceptance and health-related quality of life for people without a stoma than for people with a stoma. If this relation is causal, people with negative illness cognitions after rectal cancer treatment might be identified and offered help.
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Affiliation(s)
- Ercolie R Bossema
- Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands.
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Verschuren JEA, Enzlin P, Dijkstra PU, Geertzen JHB, Dekker R. Chronic disease and sexuality: a generic conceptual framework. JOURNAL OF SEX RESEARCH 2010; 47:153-70. [PMID: 20358458 DOI: 10.1080/00224491003658227] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Although sexual dysfunctions are frequently comorbid with many chronic diseases and their treatments, until recently, these dysfunctions have been neglected in both research and clinical practice. Fortunately, sexual functioning in the context of chronic disease has now begun to receive more scientific attention. Studies in the field are, however, quite diverse in terms of topics and methodology, not only making comparisons across studies on a single disease difficult, but also making comparisons across different diseases impossible. In an attempt to inspire researchers, this article presents a "generic" conceptual framework regarding the impact of chronic diseases (and their treatments) on sexual function. The major goals of this conceptual framework are to provide an in-depth analysis of, and insight into, the process by which disease-related psychological and relational factors impact the sexual functioning and well-being of patients, their partners, and their relationships. Some of the associations within the conceptual framework have already been supported by the results of empirical studies on various diseases. This review ends with an overview of the limitations of previous research, proposes a research agenda for the field, and presents a research tool that may be helpful in developing new studies investigating the association between chronic diseases and sexuality.
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Affiliation(s)
- Jesse E A Verschuren
- Department of Rehabilitation Medicine, Center for Rehabilitation, University Medical Center Groningen, University of Groningen
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Karademas EC, Tsagaraki A, Lambrou N. Illness acceptance, hospitalization stress and subjective health in a sample of chronic patients admitted to hospital. J Health Psychol 2010; 14:1243-50. [PMID: 19858343 DOI: 10.1177/1359105309345169] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim of this study was to examine the effects of illness acceptance on the subjective health of hospitalized chronic medical patients. Participants were 128 patients with a previous diagnosis of chronic coronary artery disease, cancer, or chronic renal disease, who were admitted to a public hospital. Illness acceptance was associated with higher levels of subjective health. It was negatively related to psychological symptoms and positively to self-rated health, even after controlling for demographic variables, type of disease, years since diagnosis, health-related quality of life and hospitalization stress. Furthermore, acceptance mediated the effects of hospitalization stress on subjective health measures.
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Van Houdenhove B, Luyten P, Tiber Egle U. Stress as a Key Concept in Chronic Widespread Pain and Fatigue Disorders. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/10582450903284745] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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The Construct Validity of the Illness Cognition Questionnaire: The Robustness of the Three-factor Structure Across Patients with Chronic Pain and Chronic Fatigue. Int J Behav Med 2009; 17:90-6. [DOI: 10.1007/s12529-009-9059-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Van Houdenhove B, Luyten P. Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of perpetuating factors. PSYCHOSOMATICS 2009; 49:470-7. [PMID: 19122123 DOI: 10.1176/appi.psy.49.6.470] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Syndromes characterized by chronic, medically unexplained fatigue, effort- and stress-intolerance, and widespread pain are highly prevalent in medicine. RESULTS In chronic fatigue syndrome (CFS) and fibromyalgia (FM), various perpetuating factors may impair patients' quality of life and functioning and impede recovery. Although cognitive-behavioral and graded-exercise therapy are evidence-based treatments, the effectiveness and acceptability of therapeutic interventions in CFS/FM may largely depend on a customized approach taking the heterogeneity of perpetuating factors into account. CONCLUSION Further research should clarify the aim and outcome of different treatment strategies in CFS/FM, as well as the underlying mechanisms of change, including those facilitating neurobiological recovery.
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Abstract
BACKGROUND Conditions with chronic, non-life-threatening pain and fatigue remain a challenge to treat, and are associated with high health care use. Understanding psychological and psychosocial contributing and coping factors, and working with patients to modify them, is one goal of management. An individual's spirituality and/or religion may be one such factor that can influence the experience of chronic pain or fatigue. METHODS The Canadian Community Health Survey (2002) obtained data from 37,000 individuals 15 years of age or older. From these data, four conditions with chronic pain and fatigue were analyzed together -- fibromyalgia, back pain, migraine headaches and chronic fatigue syndrome. Additional data from the survey were used to determine how religion and spirituality affect psychological well-being, as well as the use of various coping methods. RESULTS Religious persons were less likely to have chronic pain and fatigue, while those who were spiritual but not affiliated with regular worship attendance were more likely to have those conditions. Individuals with chronic pain and fatigue were more likely to use prayer and seek spiritual support as a coping method than the general population. Furthermore, chronic pain and fatigue sufferers who were both religious and spiritual were more likely to have better psychological well-being and use positive coping strategies. INTERPRETATION Consideration of an individual's spirituality and/or religion, and how it may be used in coping may be an additional component to the overall management of chronic pain and fatigue.
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Does hypothalamic-pituitary-adrenal axis hypofunction in chronic fatigue syndrome reflect a 'crash' in the stress system? Med Hypotheses 2009; 72:701-5. [PMID: 19237251 DOI: 10.1016/j.mehy.2008.11.044] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 11/18/2008] [Accepted: 11/21/2008] [Indexed: 11/22/2022]
Abstract
The etiopathogenesis of chronic fatigue syndrome (CFS) remains poorly understood. Although neuroendocrine disturbances - and hypothalamic-pituitary-adrenal (HPA) axis hypofunction in particular - have been found in a large proportion of CFS patients, it is not clear whether these disturbances are cause or consequence of the illness. After a review of the available evidence we hypothesize that that HPA axis hypofunction in CFS, conceptualized within a system-biological perspective, primarily reflects a fundamental and persistent dysregulation of the neurobiological stress system. As a result, a disturbed balance between glucocorticoid and inflammatory signaling pathways may give rise to a pathological cytokine-induced sickness response that may be the final common pathway underlying central CFS symptoms, i.e. effort/stress intolerance and pain hypersensitivity. This comprehensive hypothesis on HPA axis hypofunction in CFS may stimulate diagnostic refinement of the illness, inform treatment approaches and suggest directions for future research, particularly focusing on the neuroendocrine-immune interface and possible links between CFS, early and recent life stress, and depression.
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Luyten P, Van Houdenhove B, Pae CU, Kempke S, Van Wambeke P. Treatment of chronic fatigue syndrome: findings, principles and strategies. Psychiatry Investig 2008; 5:209-12. [PMID: 20046339 PMCID: PMC2796012 DOI: 10.4306/pi.2008.5.4.209] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Chronic fatigue syndrome (CFS) is a debilitating condition characterized by serious medically unexplained mental and physical fatigue. The high prevalence and both direct and indirect health costs of CFS patients represent a huge problem for contemporary health care. Moreover, the prognosis of CFS, even when treated, is often poor. In this paper, we first critically review current evidence based treatments of CFS. Second, we discuss the growing insights into the etiopathogenesis of CFS, and the need to translate and integrate these insights into future treatments. In particular, we formulate a pragmatic and empirically testable treatment approach, tailored to the individual needs of patients, which aims at restoring the mental and physical equilibrium of CFS patients by trying to bring about sustained life style changes.
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Affiliation(s)
- Patrick Luyten
- Department of Psychology, University of Leuven, Leuven, Belgium
| | | | - Chi-Un Pae
- Department of Psychiatry, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Psychiatry and Behavioral Sciences, Duke University Medical University, Durham, NC, USA
| | - Stefan Kempke
- Department of Psychology, University of Leuven, Leuven, Belgium
| | - Peter Van Wambeke
- University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Casier A, Goubert L, Huse D, Theunis M, Franckx H, Robberecht E, Matthys D, Crombez G. The role of acceptance in psychological functioning in adolescents with cystic fibrosis: A preliminary study. Psychol Health 2008; 23:629-38. [DOI: 10.1080/08870440802040269] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Travers MK, Lawler J. Self within a climate of contention: Experiences of chronic fatigue syndrome. Soc Sci Med 2007; 66:315-26. [PMID: 17961894 DOI: 10.1016/j.socscimed.2007.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Indexed: 11/26/2022]
Abstract
Chronic fatigue syndrome (CFS) is a contested condition associated with scepticism and dispute. This qualitative project examines the illness experiences, and specifically the experiences of self, for people affected with CFS living in Australia. Using grounded theory methods, theory related to the process of self-renewal and adaptation associated with CFS is explicated. Narratives were derived from semi-structured interviews with 19 adults, including 3 people recovered from CFS. Analysis generated the narrative of the struggling self seeking renewal that defined the illness experience of CFS. The struggling self articulated the negative effects to self and personhood associated with CFS, defined as the violation of self, and the consequent efforts of participants to manage symptoms and decrease their violation by use of what was termed the Guardian Response and the Reconstructing Response. The Guardian Response provided protection and self-reclamation. The Reconstructing Response fostered self-renewal and meaning. The struggling self occurred within a climate of threats, and it was these threats which provided the catalyst for violation and the responses. Under different conditions the relative strengths of violation, guardianship or reconstruction fluctuated, and it was these fluctuations that presented the participants with the ongoing struggle of CFS.
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Bogaerts K, Hubin M, Van Diest I, De Peuter S, Van Houdenhove B, Van Wambeke P, Crombez G, Van den Bergh O. Hyperventilation in patients with chronic fatigue syndrome: the role of coping strategies. Behav Res Ther 2007; 45:2679-90. [PMID: 17719001 DOI: 10.1016/j.brat.2007.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 07/08/2007] [Accepted: 07/16/2007] [Indexed: 11/15/2022]
Abstract
Hyperventilation has been suggested as a concomitant and possible maintaining factor that may contribute to the symptom pattern of chronic fatigue syndrome (CFS). Because patients accepting the illness and trying to live with it seem to have a better prognosis than patients chronically fighting it, we investigated breathing behavior during different coping response sets towards the illness in patients with CFS (N=30, CDC criteria). Patients imagined a relaxation script (baseline), a script describing a coping response of hostile resistance, and a script depicting acceptance of the illness and its (future) consequences. During each imagery trial, end-tidal PCO2 (Handheld Capnograph, Oridion) was measured. After each trial, patients filled out a symptom checklist. Results showed low resting values of PetCO2 overall, while only imagery of hostile resistance triggered a decrease and deficient recovery of PetCO2. Also, more hyperventilation complaints and complaints of other origin were reported during hostile resistance imagery compared with acceptance and relaxation. In conclusion, hostile resistance seems to trigger both physiological and symptom perception processes contributing to the clinical picture of CFS.
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Affiliation(s)
- Katleen Bogaerts
- Research Group on Health Psychology, Department of Psychology, University of Leuven, Tiensestraat 102, 3000 Leuven, Belgium
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Logie H, Crombez G, Evers AWM. De Ziekte Cognitie Lijst bij chronische onverklaarde lichamelijke klachten. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/bf03071769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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