Statistical significance: p value, 0.05 threshold, and applications to radiomics-reasons for a conservative approach

Service Needs of Clients Before and After Short Term Community Mental Health Case Management

This study evaluated level of service need before and after a short-term community mental health case management intervention from the perspective of both clients and case managers. Ontario Common Assessment of Need data were used to describe client needs. McNemar's test was applied to assess differences in pre- and post- need scores. Psychological distress, company, daytime activities, and physical health were most commonly rated by clients as unmet needs at enrolment. At discharge, there was a significant change in psychological distress from the perspective of clients, and in psychological distress and daytime activities from the perspective of case managers. Statistically significant changes were observed for Total Need, Total Unmet Need and Met Need scores from the perspective of case managers. While both clients and case managers reported changes in total service needs between admission and discharge from short-term case management, clients were less likely to report a difference in needs.

Information literacy at journalists’ workplace in Pakistan

This research investigated the development of information literacy skills and their self-perceived assessment among journalists in Pakistan. A cross-sectional survey using an online questionnaire was conducted in four Provinces and the Federal Capital of Pakistan with the consent of relevant authorities for data collection. A total of 1089 responses were received. The data were analyzed in SPSS by applying descriptive as well as inferential statistics. A large majority of the surveyed respondents received information literacy instruction of short duration during their careers while being mainly in practice. The most covered topics included research literacy, communication skills, information discovery, critical literacy, tools literacy, and information handling. These participants perceived information literacy as invaluable in their practical work context. The survey participants perceived themselves as information literate not only for basic levels of information literacy but also for advanced levels. In addition, journalists’ gender, age, academic qualification, job experience, information literacy instructions received, nature of work, and region predicted their levels of information literacy. The results generated pragmatic insight for educators and information professionals in designing a need-based information literacy instruction program for existing as well as prospective journalists. This research would make a worthy contribution to the existing information literacy research in the context of the workplace as no such comprehensive study on journalists’ workplace had appeared so far.

Marital dissolution and associated factors in Hosanna, Southwest Ethiopia: a community-based cross-sectional study

BACKGROUND

Marriage dissolution, divorce, or separation from a spouse or common-law partner is a serious public health concern due to its increasing prevalence and devastating health and socio-economic consequences. Evidence suggests an increased risk of marital instability in Ethiopia. In addition, the extent of marital dissolution and other related factors have increased in the study area. Despite these, the prevalence of marital dissolution and the influence of associated factors (main reason for marriage, and parental history of marital dissolution) on marital dissolution has not been assessed in the study area. Therefore, the aim of this study was to investigate the prevalence of marital dissolution and its associated factors among residents of Hosanna town in southwestern Ethiopia in 2022.

METHODS

We conducted a community-based cross-sectional study among 459 randomly selected Hosanna Township residents. We used structured questionnaires to collect data. Descriptive statistics and logistic regression were performed to describe the data and test-associated factors, respectively. A p-value less than 0.05 was used to define statistical significance. We used STATA 14 and IBM SPSS 25.0 computer packages to process data.

RESULTS

Out of the 459 potentially eligible individuals, 450 participants properly responded to the questionnaires yielding a response rate of 98.04%. Of these, 218 (52.9%) were female. The commonly reported reason for marriage was to have children 150 (36.9%). The prevalence rate of marital dissolution was 26.0% (95% CI: (21.7%, 30.3%)). The participant's level of education and the primary reasons (motives) why they get married were statistically significantly associated with marital dissolution. The odds of marital dissolution was higher among participants who completed secondary education (AOR = 3.2, 95% CI = 1.26-8.17) compared to those having no formal education. The participants who married for companionship reasons (AOR = 0.31, 95% CI = 0.11-0.83) had significantly lower odds of marriage dissolution compared with those who married for financial security.

CONCLUSIONS

In this study, the prevalence of marital dissolution was high. The participant's level of education and the primary reasons (motives) why they getting married were significantly associated with marital dissolution. Therefore, an integrated, community-based approach should be developed to prevent marital dissolution.

Analysis of comorbidity in rheumatoid arthritis-associated interstitial lung disease: a nested case-cohort study

OBJECTIVES

To describe comorbid conditions in patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and to analyze factors associated with multimorbidity.

METHODS

Nested case-cohort study of 2 prospective cohorts: one with RA-ILD (cases) and another with RA but not ILD (controls). The cohorts were matched for age, sex, and time since diagnosis. Multimorbidity was defined as the co-occurrence of 2 or more chronic diseases, in addition to RA and ILD. We evaluated the comorbid conditions included in the Charlson Comorbidity Index, cardiovascular risk factors, neuropsychiatric conditions, and other frequent conditions in RA. We also recorded clinical-laboratory variables, inflammatory activity according to the 28-joint Disease Activity Score, C-reactive protein (CRP), physical function, and pulmonary function. We performed 2 multivariate analyses to identify factors associated with multimorbidity in RA and RA-ILD.

RESULTS

The final study population comprised 110 cases and 104 controls. Multimorbidity was more frequent among cases than controls (80 [72.7] vs 60 [57.7]; p = 0.021). In both groups, multimorbidity was associated with ILD (OR [95% CI] 1.92 [1.03-3.59]; p = 0.039), age (OR [95% CI] 1.05 [1.01-1.08]; p = 0.004), CRP (OR [95% CI] 1.16 [1.05-1.29]; p = 0.003), and erosions (OR [95% CI] 1.05 [1.01-1.08]; p = 0.004); in the cases, it was associated with CRP (OR [95% CI] 1.17 [1.01-1.35]; p = 0.027), anti-citrullinated peptide antibody (OR [95% CI] 1.23 [1.14-13.02]; p = 0.049), and forced vital capacity (OR [95% CI] 0.79 [0.96-0.99]; p = 0.036).

CONCLUSION

In patients with RA, multimorbidity was associated with ILD, systemic inflammation, and advanced age.

Understanding consumers' continuance intention to watch streams: A value-based continuance intention model

Introduction

Live stream-watching has become increasingly popular worldwide. Consumers are found to watch streams in a continuous manner. Despite its popularity, there has been limited research investigating why consumers continue to watch streams. Previously, the expectation-confirmation theory (ECT) has been widely adopted to explain users' continuance intention. However, most current ECT-based models are theoretically incomplete, since they only consider the importance of perceived benefits without considering users' costs and sacrifices. In this paper, we propose a value-based continuance intention model (called V-ECM), and use it to investigate factors influencing consumers' continuance intention to watch streams.

Methods

Our hypotheses were tested using an online survey of 1,220 consumers with continuance stream-watching experiences.

Results

Results indicate that perceived value, a process of an overall assessment between users' perceived benefits and perceived sacrifices, is proved to be a better variable than perceived benefits in determining consumers' continuance watching intention. Also, compared with other ECT-based models, V-ECM is a more comprehensive model to explain and predict consumers' continuance intention.

Discussion

V-ECM theoretically extends ECT-based studies, and it has potential to explain and predict other continuance intentions in online or technology-related contexts. In addition, this paper also discusses practical implications for live streaming platforms with regards to their design, functions and marketing.

Pattern and perceived changes in quality of life of Vietnamese medical and nursing students during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and governments' response lead to dramatical change in quality of life worldwide. However, the extent of this change in Vietnamese medical and nursing students has not been documented.

OBJECTIVES

The study aims to describe the quality of life and changes in quality of life of medical and nursing students during the COVID-19 pandemic and examine the association of quality of life and changes in quality of life with fear of COVID-19 and other socio-economic and demographic factors.

METHODS

The study was a cross-sectional study on all students of Hanoi Medical University from 3 majors: General Medicine, Preventive Medicine, Nursing (3672 invited students); from 7th to 29th of April 2020; using an online questionnaire that included demographic and academic information, the Vietnamese version of the SF-36 Quality of Life questionnaire and the Fear of COVID-19 Scale (FCV-19S). Linear and modified Poisson regression was used to examine the association between quality of life, changes in quality of life and other factors.

RESULTS

The number of participants was 1583 (response rate 43%). Among 8 dimensions of the SF-36 (ranged 0-100), Vitality had the lowest score with a median score of 46. The median physical composite score (PCS) of the sample was 40.6 (IQR:20.8-53.2), 33.5% of the sample had an above-population average PCS score. The median mental composite score (MCS) of the sample was 20.3 (IQR:3.8-31.7), and 98.2% had an MCS score below average. 9.9% (95%CI:8.5%-11.4%) of the population reported a significant negative change in the quality of life. Fear of COVID-19 was not associated with significant changes in quality of life, nor MCS while having some association with PCS (Coef:-5.39;95%CI:-3to-7.8). Perceived reduction in quality of life was also associated with: being on clinical rotation COVID-19 (PR:1.5;95%CI:1.05-2.2), difficulties affording health services (PR:1.4;95%CI:1.02-1.95), obesity (PR:2.38;95%CI:1.08-5.25) and chronic disease (PR:1.92;95%CI:1.23-3), typical symptoms (PR:1.85; 95%CI:1.23-2.78) and atypical symptoms of COVID-19 (PR:2.32;95%CI:1.41-3.81).

CONCLUSION

The majority of medical and nursing students had below average quality of life, with lower vitality and mental composite health score in the settings of COVID-19. Perceived decrease in quality of life was associated with clinical rotation, difficulties affording healthcare services and was not associated with Fear of COVID-19.

Safe Follow-Up after Endovascular Aortic Repair with Unenhanced MRI: The SAFEVAR Study

We aimed to investigate whether unenhanced magnetic resonance imaging (MRI) could represent a safe and highly sensitive tool for endoleak screening in patients treated with endovascular aneurysm repair (EVAR) using computed tomography angiography (CTA) as a reference standard. Patients who underwent CTA for EVAR follow-up at our institution were prospectively enrolled. All MRI examinations were performed with a 1.5 T unit. The true-FISP and HASTE sequences of the MRI scans were assessed for the presence of hyperintensity within the aneurysm sac outside the graft, whereas phase-contrast through-plane sequences were used for blood flow quantification. We included 45 patients, 5 (11%) of whom were female. The median age was 73 years (IQR 68−78 years). Among our patients, 19 (42%) were positive for endoleaks at CTA, of whom 13 (68%) had type II endoleaks and 6 (32%) had type I endoleaks. There were no significant differences in age, sex, aneurysm type, prosthesis type, or contrast-to-noise ratio between hyperintensity and thrombus between patients with and without endoleaks (p > 0.300). The combined evaluation of true-FISP and HASTE yielded 100% sensitivity (95% CI: 79−100%) and 19% specificity (95% CI: 7−40%). Patients with a positive CTA had a median thrombus flow of 0.06 L/min (IQR 0.03−0.23 L/min), significantly greater than that of patients with a negative CTA (p = 0.007). Setting a threshold at 0.01 L/min, our MRI protocol yielded 100% sensitivity, 56% specificity, and an AUC of 0.76 (95% CI 0.60−0.91). In conclusion, unenhanced MRI has perfect sensitivity for endoleak detection, although with subpar specificity that could be improved with phase-contrast flow analysis.

Identifying the areas of low self-reported confidence of internal medicine residents in geriatrics: a descriptive study of findings from a structured geriatrics skills assessment survey

BACKGROUND

Currently, no standardized methods exist to assess the geriatric skills and training needs of internal medicine trainees to enable them to become confident in caring for older patients. This study aimed to describe the self-reported confidence and training requirements in core geriatric skills amongst internal medicine residents in Toronto, Ontario using a standardized assessment tool.

METHODS

This study used a novel self-rating instrument, known as the Geriatric Skills Assessment Tool (GSAT), among incoming and current internal medicine residents at the University of Toronto, to describe self-reported confidence in performing, teaching and interest in further training with regard to 15 core geriatric skills previously identified by the American Board of Internal Medicine.

RESULTS

190 (75.1%) out of 253 eligible incoming (Year 0) and current internal medicine residents (Years 1-3) completed the GSAT. Year 1-3 internal medicine residents who had completed a geriatric rotation reported being significantly more confident in performing 13/15 (P < 0.001 to P = 0.04) and in teaching 9/15 GSAT skills (P < 0.001 to P = 0.04). Overall, the residents surveyed identified their highest confidence in administering the Mini-Mental Status Examination and lowest confidence in assessing fall risk using a gait and balance tool, and in evaluating and managing chronic pain.

CONCLUSION

A structured needs assessment like the GSAT can be valuable in identifying the geriatric training needs of internal medicine trainees based on their reported levels of self-confidence. Residents in internal medicine could further benefit from completing a mandatory geriatric rotation early in their training, since this may improve their overall confidence in providing care for the mostly older patients they will work with during their residency and beyond.

A Critical Appraisal of the Quality of Vertigo Practice Guidelines Using the AGREE II Tool: A EuroAIM Initiative

OBJECTIVES

The aim of this review is to assess the methodological quality of guidelines for the management of vertigo and dizziness and to compare their recommendations, with specific focus on neuroimaging.

DATABASES REVIEWED

MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence database.

METHODS

In March 2022, a systematic search was performed to find practice guidelines of management of vertigo and dizziness. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool. We excluded from the results those guidelines that were not primarily focused on vertigo and dizziness, such as national/international guidelines in which vertigo and dizziness were only briefly mentioned.

RESULTS

Our strategy of literature search identified 161 studies, and 18 guidelines were selected for the appraisal. Only five guidelines reached the acceptance level in the overall result (at least 60%), with three of them reaching the highest scores (at least 80%). The highest scores were found in Domain 6 "Editorial Independence," Domain 1 "Scope and purpose," and Domain 4 "Clarity of presentation" (median value = 66%, 62%, and 61%, respectively). The remaining domains showed a low level of quality: Domain 2 "Stakeholder Involvement," Domain 3 "Rigor of development," and Domain 5 "Applicability" had median values of 27%, 27%, and 22%, respectively. The quality of these guidelines was very low, because of low involvement of multidisciplinary teams in writing guidelines recommendations.

CONCLUSION

Considering all guidelines, only three had a "high" overall score, whereas 13 of 18 (72%) of them were rated as of "low" quality. Future guidelines might take this into account to improve clinical applicability.

A Marked Low-Grade Inflammation and a Significant Deterioration in Metabolic Status in First-Episode Schizophrenia: A Five-Year Follow-Up Study

The objective of this study was to evaluate how schizophrenia spectrum disorders and applied long-term (5.1 years) antipsychotic (AP) treatment affect the serum level of acylcarnitines (ACs), cytokines and metabolic biomarkers and to characterize the dynamics of inflammatory and metabolic changes in the early course of the disorder. A total of 112 adults participated in the study (54 patients with first-episode psychosis (FEP) and 58 control subjects). Biomolecule profiles were measured at the onset of first-episode psychosis and 0.6 years and 5.1 years after the initiation of APs. The results of the present study confirmed that specific metabolic-inflammatory imbalance characterizes AP-naïve patients. Short-term (0.6-years) AP treatment has a favourable effect on psychotic symptoms, as well as the recovery of metabolic flexibility and resolution of low-level inflammation. However, 5.1 years of AP treatment resulted in weight gain and increased serum levels of interleukin (IL)-2, IL-4, IL-6, IL-10, interferon-γ, hexoses, acetylcarnitine, short-chain ACs (C3, C4) and long-chain ACs (C16:2, C18:1, C18:2). In conclusion, despite the improvement in psychotic symptoms, 5.1 years of AP treatment was accompanied by a pronounced metabolic-inflammatory imbalance, which was confirmed by the presence of enhanced pro-inflammatory activity and increased obesity with changes in the metabolism of carbohydrates, lipids, and their metabolites.

Improvement of large copy number variant detection by whole genome nanopore sequencing

INTRODUCTION

Whole-genome sequencing using nanopore technologies can uncover structural variants, which are DNA rearrangements larger than 50 base pairs. Nanopore technologies can also characterize their boundaries with single-base accuracy, owing to the kilobase-long reads that encompass either full variants or their junctions. Other methods, such as next-generation short read sequencing or PCR assays, are limited in their capabilities to detect or characterize structural variants. However, the existing software for nanopore sequencing data analysis still reports incomplete variant sets, which also contain erroneous calls, a considerable obstacle for the molecular diagnosis or accurate genotyping of populations.

METHODS

We compared multiple factors affecting variant calling, such as reference genome version, aligner (minimap2, NGMLR, and lra) choice, and variant caller combinations (Sniffles, CuteSV, SVIM, and NanoVar), to find the optimal group of tools for calling large (>50 kb) deletions and duplications, using data from seven patients exhibiting gross gene defects on SERPINC1 and from a reference variant set as the control. The goal was to obtain the most complete, yet reasonably specific group of large variants using a single cell of PromethION sequencing, which yielded lower depth coverage than short-read sequencing. We also used a custom method for the statistical analysis of the coverage value to refine the resulting datasets.

RESULTS

We found that for large deletions and duplications (>50 kb), the existing software performed worse than for smaller ones, in terms of both sensitivity and specificity, and newer tools had not improved this. Our novel software, disCoverage, could polish variant callers' results, improving specificity by up to 62% and sensitivity by 15%, the latter requiring other data or samples.

CONCLUSION

We analyzed the current situation of >50-kb copy number variants with nanopore sequencing, which could be improved. The methods presented in this work could help to identify the known deletions and duplications in a set of patients, while also helping to filter out erroneous calls for these variants, which might aid the efforts to characterize a not-yet well-known fraction of genetic variability in the human genome.

Cryptococcus neoformans- and Cryptococcus gattii-specific IgG, IgA and IgM differ among children and adults with and without cryptococcosis from Colombia

Cryptococcus neoformans (Cn) and Cryptococcus gattii (Cg) cause cryptococcosis, a life-threatening systemic mycosis of global distribution affecting mainly immunocompromised adults. Although a humoral response occurs during cryptococcosis, the role of antibody production against this mycosis is not fully understood. We aimed to determine total and specific antibodies against cryptococcal protein antigens in sera from people with and without diagnosis of cryptococcosis from Colombia. Using ELISA, total and specific levels of immunoglobulin (Ig)G, IgA and IgM were determined in sera from children and adults with (n = 109) and without (n = 119) cryptococcosis. Specific antibodies were those binding Cn- and Cg-protein antigens. In general, the mean of the total IgG production was higher in cryptococcosis patients than in controls (13 942.32 vs. 6459.91 µg/ml), while levels of IgA (488.13 vs. 1564.53 µg/ml) and IgM (775.69 vs. 1014.72 µg/ml) were higher in controls than in cryptococcosis patients (p ≤ 0.05). In patients with cryptococcosis, total IgG, IgA and IgM levels were higher in HIV + compared with HIV- (p ≤ 0.05). Specific antibodies tended to be higher in cryptococcosis patients than in controls and in adults than in children, with a positive correlation between antibody reactivity and age. All immunoglobulins were more reactive against Cn-proteins than Cg-proteins. Overall, a positive weak correlation between total and specific antibodies was found, although not always statistically significant. In patients with cryptococcosis from Colombia, the levels of immunoglobulins, total and specific, differ with respect to people without cryptococcosis. Variations in antibody production among adults and children with cryptococcosis and between Cn- and Cg-protein antigens were as well established. Our findings encourage further studies to determine the role of humoral immunity for host defence against cryptococcosis.

A behavioural study of hydrothermally derived novel alumina/magnesia/hydroxyapatite (Al2O3/MgO/HA) bioceramic nanocomposite

Regeneration and regrowth of human bones is a gradual and time-consuming process. Therefore scaffolds are required to hold the bones in position and give them time to heal well. Though hydroxyapatite (HA) is a potential candidate, its weak mechanical nature has made it undesirable. To overcome this hurdle, a novel nanocomposite of HA with alumina (Al₂O₃) and magnesia (MgO) was prepared by hydrothermal method in this study. The constitution, composition and conformation of the Al₂O₃/MgO/HA nanocomposite were affirmed via X-ray Diffraction (XRD), Fourier-Transform Infra-Red (FTIR) and imaging tests. Vicker's hardness test evinces the mechanical calibre of the nanocomposite. A perspective load-displacement analysis was done by means of Onitsch and Kick's power laws. The nanocomposite excelled above par with a hardness of 5.19 GPa and fracture toughness of 1.27 MPam^1/2. This holistic progress makes this nanocomposite a very desirable bone implant material.

Cerium oxide-doped PEDOT nanocomposite for label-free electrochemical immunosensing of anti-p53 autoantibodies

A label-free nanoimmunosensor is reported based on p53/CeO₂/PEDOT nanobiocomposite-decorated screen-printed gold electrodes (SPAuE) for the electrochemical detection of anti-p53 autoantibodies. CeO₂ nanoparticles (NPs) were synthesized and stabilized with cyanopropyltriethoxysilane by a soft chemistry method. The nanoimmunosensing architecture was prepared by in situ electropolymerization of 3,4-ethylenedioxythiophene (EDOT) on SPAuE in the presence of CeO₂ NPs. The CeO₂ NPs and Ce/PEDOT/SPAuE were characterized by scanning and transmission electron microscopy, dynamic and electrophoretic light scattering, ultraviolet-visible spectrophotometry, X-ray diffraction, Fourier-transform infrared spectroscopy, cyclic voltammetry, and electrochemical impedance spectroscopy. Ce/PEDOT/SPAuE was biofunctionalized with p53 antigen by covalent bonding for the label-free determination of anti-p53 autoantibodies by differential pulse voltammetry. The nanobiocomposite-based nanoimmunosensor detected anti-p53 autoantibodies in a linear range from 10 to 1000 pg mL^-1, with a limit of detection (LOD) of 3.2 pg mL^-1. The nanoimmunosensor offered high specificity, selectivity, and long-term storage stability with great potential to detect anti-p53 autoantibodies in serum samples. Overall, incorporating organo-functional nanoparticles into polymeric matrices can provide a simple-to-assemble, rapid, and ultrasensitive approach for on-site screening of anti-p53 autoantibodies and other disease-related biomarkers with low sample volumes.

Quantification of epicardial adipose tissue in obese patients using an open-bore MR scanner

Background

Our aim was to evaluate the reproducibility of epicardial adipose tissue (EAT) volume, measured on scans performed using an open-bore magnetic resonance scanner.

Methods

Consecutive patients referred for bariatric surgery, aged between 18 and 65 years who agreed to undergo cardiac imaging (MRI), were prospectively enrolled. All those with cardiac pathology or contraindications to MRI were excluded. MRI was performed on a 1.0-T open-bore scanner, and EAT was segmented on all scans at both systolic and diastolic phase by two independent readers (R1 with four years of experience and R2 with one year). Data were reported as median and interquartile range; agreement and differences were appraised with Bland-Altman analyses and Wilcoxon tests, respectively.

Results

Fourteen patients, 11 females (79%) aged 44 (41–50) years, underwent cardiac MRI. For the first and second readings, respectively, EAT volume was 86 (78–95) cm³ and 85 (79–91) cm³ at systole and 82 (74–95) cm³ and 81 (75–94) cm³ at diastole for R1, and 89 (79–99) cm³ and 93 (84–98) cm³ at systole and 92 (85–103) cm³ and 93 (82–94) cm³ at diastole for R2. R1 had the best reproducibility at diastole (bias 0.3 cm³, standard deviation of the differences (SD) 3.3 cm³). R2 had the worst reproducibility at diastole (bias 3.9 cm³, SD 12.1 cm³). The only significant difference between systole and diastole was at the first reading by R1 (p = 0.016). The greatest bias was that of inter-reader reproducibility at diastole (-9.4 cm³).

Conclusions

Reproducibility was within clinically acceptable limits in most instances.

The Impacts of Value-Added Tax Audit on Tax Revenue Performance: The Mediating Role of Electronics Tax System, Evidence from the Amhara Region, Ethiopia

Governments worldwide cannot collect the required tax revenue for their planned activities. This study aims to assess how inefficient VAT audit function and related factors affect tax revenue performance in Amhara Region, Ethiopia. The study used primary data sources from 377 VAT registered taxpayers in Amhara Region. It also used the Ability to Pay theory of taxation, structural equation model, path diagram, and multiple regression with SPSS/AMOS software for data analysis to identify the relationship between VAT audit and tax revenue performance. Even though the Amhara Region has revenue potential to cover its expenditures, because of inefficient VAT audit functions, poor system of tax education, lack of tax resources, and long time served tax rate, the tax revenue performance is inefficient. The study assured that VAT audit and tax education significantly affect tax revenue performance. The scarcity of resources for the VAT audit function is a critical problem. Even if the existed technology networked up to woreda levels, tax auditors did not use this system appropriately. Long-time-served tax rates also greatly influence tax revenue performance. The study recommended that there should be a chain mentor relationship between experienced auditors to new and ineffective auditors. The government should supply appropriate technology that is simple to use and quickly detect tax evasion. The existed tax rate and the system of tax education should be revised. The above findings are essential for taxpayers, policymakers, and tax authorities to understand, analyze, and use the main causes of VAT audit problems on tax revenue performance.

Future Climate Change Conditions May Compromise Metabolic Performance in Juveniles of the Mud Crab Scylla serrata

Research characterising the effects of future climate change on the marine environment remains heavily focussed on that of temperate regions and organisms. Furthermore, little is known of these effects on the early life stages of many marine species. Tropical regions are already experiencing an increase in sea surface temperature and decrease in sea surface salinity, conditions favoured by pathogenic bacteria such as Vibrio spp. The early life stages of crabs are known to be particularly vulnerable to both the direct physiological effects of climate change and exposure to harmful microorganisms, yet there are limited data on these effects on juveniles of many tropical crustacean species. This study assessed the metabolic responses of mud crab (Scylla serrata) juveniles to warming and/or freshening in the presence or absence of pathogenic bacteria in southwest India. Juvenile crabs were exposed to either ambient (28 °C/30 PSU) or one of three projected climate change regimes (28 °C/20 PSU (freshening), 32 °C/30 PSU (warming), 32 °C/20 PSU (warming + freshening)) for 10 days, in either the presence or absence of the pathogenic bacteria Vibrio parahaemolyticus. Results show that simulated climate change conditions, especially freshening, caused a significant increase in oxygen consumption rates (MO2), and that these were further increased when juveniles were exposed to V. parahaemolyticus. These results suggest that the effects of future climate change conditions could have significant implications for the conservation of wild stocks and commercial farming of this species in South Asia.

Combined Vitamin D, Omega-3 Fatty Acids, and a Simple Home Exercise Program May Reduce Cancer Risk Among Active Adults Aged 70 and Older: A Randomized Clinical Trial

Objective: The aim of this study was to test the individual and combined benefit of vitamin D, omega-3, and a simple home strength exercise program on the risk of any invasive cancer. Design: The DO-HEALTH trial is a three-year, multicenter, 2 × 2 × 2 factorial design double-blind, randomized-controlled trial to test the individual and combined benefit of three public health interventions. Setting: The trial was conducted between December 2012 and December 2017 in five European countries. Participants: Generally healthy community-dwelling adults ≥70 years were recruited. Interventions: Supplemental 2000 IU/day of vitamin D3, and/or 1 g/day of marine omega-3s, and/or a simple home strength exercise (SHEP) programme compared to placebo and control exercise. Main outcome: In this pre-defined exploratory analysis, time-to-development of any verified invasive cancer was the primary outcome in an adjusted, intent-to-treat analysis. Results: In total, 2,157 participants (mean age 74.9 years; 61.7% women; 40.7% with 25-OH vitamin D below 20 /ml, 83% at least moderately physically active) were randomized. Over a median follow-up of 2.99 years, 81 invasive cancer cases were diagnosed and verified. For the three individual treatments, the adjusted hazard ratios (HRs, 95% CI, cases intervention versus control) were 0.76 (0.49-1.18; 36 vs. 45) for vitamin D3, 0.70 (0.44-1.09, 32 vs. 49) for omega-3s, and 0.74 (0.48-1.15, 35 vs. 46) for SHEP. For combinations of two treatments, adjusted HRs were 0.53 (0.28-1.00; 15 vs. 28 cases) for omega-3s plus vitamin D3; 0.56 (0.30-1.04; 11 vs. 21) for vitamin D3 plus SHEP; and 0.52 (0.28-0.97; 12 vs. 26 cases) for omega-3s plus SHEP. For all three treatments combined, the adjusted HR was 0.39 (0.18-0.85; 4 vs. 12 cases). Conclusion: Supplementation with daily high-dose vitamin D3 plus omega-3s, combined with SHEP, showed cumulative reduction in the cancer risk in generally healthy and active and largely vitamin D-replete adults ≥70 years. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT01745263.

Genetic Associations and Differential mRNA Expression Levels of Host Genes Suggest a Viral Trigger for Endemic Pemphigus Foliaceus

The long search for the environmental trigger of the endemic pemphigus foliaceus (EPF, fogo selvagem) has not yet resulted in any tangible findings. Here, we searched for genetic associations and the differential expression of host genes involved in early viral infections and innate antiviral defense. Genetic variants could alter the structure, expression sites, or levels of the gene products, impacting their functions. By analyzing 3063 variants of 166 candidate genes in 227 EPF patients and 194 controls, we found 12 variants within 11 genes associated with differential susceptibility (p < 0.005) to EPF. The products of genes TRIM5, TPCN2, EIF4E, EIF4E3, NUP37, NUP50, NUP88, TPR, USP15, IRF8, and JAK1 are involved in different mechanisms of viral control, for example, the regulation of viral entry into the host cell or recognition of viral nucleic acids and proteins. Only two of nine variants were also associated in an independent German cohort of sporadic PF (75 patients, 150 controls), aligning with our hypothesis that antiviral host genes play a major role in EPF due to a specific virus−human interaction in the endemic region. Moreover, CCL5, P4HB, and APOBEC3G mRNA levels were increased (p < 0.001) in CD4+ T lymphocytes of EPF patients. Because there is limited or no evidence that these genes are involved in autoimmunity, their crucial role in antiviral responses and the associations that we observed support the hypothesis of a viral trigger for EPF, presumably a still unnoticed flavivirus. This work opens new frontiers in searching for the trigger of EPF, with the potential to advance translational research that aims for disease prevention and treatment.

Role of Knowledge Management on the Sustainable Environment: Assessing the Moderating Effect of Innovative Culture

Environmental sustainability has become the need of the hour and has been emphasized immensely because of the increased environmental awareness and resulting problems caused due to negligence. This study has intended to determine the role of knowledge management (KM) practices in achieving a sustainable environment with the mediating role of environmental awareness and green technological use. The study further examined the moderating role of green innovative culture between the relationship of KM practices and a sustainable environment. The data were acquired from 378 managerial level personnel of the construction industry in China through questionnaires. Smart-PLS 3.3.3 was used to determine the study's hypothesis through the structural equation modeling (SEM) technique. The study found that KM practice has a significant relationship with a sustainable environment, environmental awareness, and green technological use. Also, environmental awareness has a significant effect on a sustainable environment. Moreover, it was found in the study that environmental awareness significantly mediated the relationship between KM practices and sustainable environment, but green technological use did not find any mediating effect on the relationship between KM practices and sustainable environment. Furthermore, green innovative culture considerably moderated the relationship between KM practices and a sustainable environment. Theoretically, this study contributes to the existing literature by incorporating and investigating the role of KM practices in a sustainable environment. Practically, this article presented some implications for the management concerning promoting KM practices and environmental awareness within the organization and developing a green innovative culture.

Impact of a Clinical Decision Support System for Addressing Physical Activity and/or Healthy Eating during Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial (Preprint)

Background

People who smoke have other risk factors for chronic diseases, such as low levels of physical activity and poor diet. Clinical decision support systems (CDSSs) might help health care practitioners integrate interventions for diet and physical activity into their smoking cessation programming but could worsen quit rates.

Objective

The aims of this study are to assess the effects of the addition of a CDSS for physical activity and diet on smoking cessation outcomes and to assess the implementation of the study.

Methods

We conducted a pragmatic hybrid type I effectiveness-implementation trial with 232 team-based primary care practices in Ontario, Canada, from November 2019 to May 2021. We used a 2-arm randomized controlled trial comparing a CDSS addressing physical activity and diet to treatment as usual and used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to measure implementation outcomes. The primary outcome was self-reported 7-day tobacco abstinence at 6 months.

Results

We enrolled 5331 participants in the study. Of these, 2732 (51.2%) were randomized to the intervention group and 2599 (48.8%) to the control group. At the 6-month follow-up, 29.7% (634/2137) of respondents in the intervention arm and 27.3% (552/2020) in the control arm reported abstinence from tobacco. After multiple imputation, the absolute group difference was 2.1% (95% CI −0.5 to 4.6; F_1,1000.42=2.43; P=.12). Mean exercise minutes changed from 32 (SD 44.7) to 110 (SD 196.1) in the intervention arm and from 32 (SD 45.1) to 113 (SD 195.1) in the control arm (group effect: B=−3.7 minutes; 95% CI −17.8 to 10.4; P=.61). Servings of fruit and vegetables changed from 2.64 servings to 2.42 servings in the intervention group and from 2.52 servings to 2.45 servings in the control group (incidence rate ratio for intervention group=0.98; 95% CI 0.93-1.02; P=.35).

Conclusions

A CDSS for physical activity and diet may be added to a smoking cessation program without affecting the outcomes. Further research is needed to improve the impact of integrated health promotion interventions in primary care smoking cessation programs.

Trial Registration

ClinicalTrials.gov NCT04223336 https://www.clinicaltrials.gov/ct2/show/NCT04223336

International Registered Report Identifier (IRRID)

RR2-10.2196/19157

Impact of Social Media News Overload on Social Media News Avoidance and Filtering: Moderating Effect of Media Literacy

In the present era of information technology, people tend to seek out news to enhance their current knowledge and awareness and to gain literacy. The reliance on seeking out news and relevant information has become very necessary to accomplish personal and organizational objectives. The present study has undertaken an inquiry to investigate the impact of social media news overload on news avoidance and news filtering with the mediating and moderating mechanisms of the need for news and media literacy, respectively. For this purpose, data were obtained from 358 Chinese social media users through the aid of survey forms. The data obtained were then analyzed through Smart-PLS software. The statistical technique used for analysis is structural equation modeling (SEM) to determine the validity of the proposed hypotheses. The results of the study indicated that social media news overload has a significant effect on news avoidance, the need for news, and news filtering behavior. It was also observed that the need for news had a significant impact on news avoidance. In addition to this, it was also revealed that the need for news significantly mediated the relationship between social media news overload and news avoidance; however, it did not mediate the relationship between social media news overload and news filtering. Lastly, it was identified that media literacy significantly moderated the relationship between the need for news and news avoidance and it did not moderate the relationship between the need for news and news filtering behavior. This study has made important theoretical contributions by advancing the current literature in terms of the empirical evidence that indicates a significant relationship between social media news overload, news avoidance, and news filtering. Practically, this study contributed by emphasizing the need to encourage and train people to use strategies to seek relevant news in a vast repository of information available through information technology.

Adults with tetralogy of Fallot show specific features of cerebral small vessel disease: the BACH San Donato study

Life expectancy in adults with congenital heart disease (ACHD) has increased. As these patients grow older, they experience aging-related diseases more than their healthy peers. To better characterize this field, we launched the multi-disciplinary BACH (Brain Aging in Congenital Heart disease) San Donato study, that aimed at investigating signs of brain injury in ACHD. Twenty-three adults with repaired tetralogy of Fallot and 23 age- and sex-matched healthy controls were prospectively recruited and underwent brain magnetic resonance imaging. White matter hyperintensities (WMHs) were segmented using a machine-learning approach and automatically split into periventricular and deep. Cerebral microbleeds were manually counted. A subset of 14 patients were also assessed with an extensive neuropsychological battery. Age was 41.78 ± 10.33 years (mean ± standard deviation) for patients and 41.48 ± 10.28 years for controls (p = 0.921). Albeit not significantly, total brain (p = 0.282) and brain tissue volumes (p = 0.539 for cerebrospinal fluid, p = 0.661 for grey matter, p = 0.793 for white matter) were lower in ACHD, while total volume (p = 0.283) and sub-classes of WMHs (p = 0.386 for periventricular WMHs and p = 0.138 for deep WMHs) were higher in ACHD than in controls. Deep WMHs were associated with poorer performance at the frontal assessment battery (r = -0.650, p = 0.012). Also, patients had a much larger number of microbleeds than controls (median and interquartile range 5 [3–11] and 0 [0–0] respectively; p < 0.001). In this study, adults with tetralogy of Fallot showed specific signs of brain injury, with some clinical implications. Eventually, accurate characterization of brain health using neuroimaging and neuropsychological data would aid in the identification of ACHD patients at risk of cognitive deterioration.

The optimal period for oocyte retrieval after the administration of recombinant human chorionic gonadotropin in in vitro fertilization

Background

Our objective was to investigate the existence of an optimal period for oocyte retrieval in regards to the clinical pregnancy occurrence after the administration of recombinant human chorionic gonadotropin (rhCG) (Ovitrelle®).

Methods

We studied the digital records of 3362 middle eastern couples who underwent in vitro fertilization (IVF) treatment between 2019 and 2021.

Results

Through statistical testing, we found that there is a significant positive correlation between the oocyte retrieval period and the clinical pregnancy occurrence up to the 37th hour, where retrieval at the 37th hour was found to provide the most optimal outcome, especially in the case of gonadotropin-releasing hormone agonist (GnRHa) long protocol.

Conclusions

This cohort study recommends retrieval at hour 37 after ovulation triggering under the described conditions.

Retrospective Study of the Association Between Platelet-to-Lymphocyte Ratio in Patients with Acute Coronary Syndrome on Admission to a Rural Referral Center in East Java, Indonesia, and the Incidence of New Symptomatic Heart Failure at 6 Months

BACKGROUND This was a retrospective study conducted at a rural referral center in East Java, Indonesia, to evaluate the association between the platelet-to-lymphocyte ratio (PLR) on hospital admission and the incidence of new symptomatic heart failure (HF) within 6 months in patients with acute coronary syndrome (ACS). MATERIAL AND METHODS The study population consisted of all ACS patients who were hospitalized between 1 January and 31 December 2018 at a non-percutaneous coronary intervention-capable secondary referral hospital and came for a routine follow-up until 6 months afterwards. The diagnosis of new symptomatic HF was based on International Classification of Diseases 10th revision code I50.9. RESULTS From 126 hospitalized patients, 92 patients were included in the analysis. The incidence rate of new symptomatic HF at 6 months was 70.65%. High PLR upon initial admission was significantly associated with new symptomatic HF incidence (odds ratio=1.70, P<0.001). PLR was also able to discriminate new symptomatic HF incidence at 6 months with area under the curve of 0.83 (P=0.001). Multivariate Cox regression analysis showed that PLR was an independent predictor for new symptomatic HF incidence (hazard ratio=4.5, P=0.001). CONCLUSIONS In a rural center in Indonesia, the PLR was independently correlated with the onset of new symptomatic HF in patients with ACS 6 months after hospital admission. The PLR may be a supplementary biomarker for clinical outcomes in patients with ACS for use in resource-limited regions.

Evaluating the Performance of a Convolutional Neural Network Algorithm for Measuring Thoracic Aortic Diameters in a Heterogeneous Population

The purpose of this work was to assess the performance of a convolutional neural network (CNN) for automatic thoracic aortic measurements in a heterogeneous population. From June 2018 to May 2019, this study retrospectively analyzed 250 chest CT scans with or without contrast enhancement and electrocardiographic gating from a heterogeneous population with or without aortic pathologic findings. Aortic diameters at nine locations and maximum aortic diameter were measured manually and with an algorithm (Artificial Intelligence Rad Companion Chest CT prototype, Siemens Healthineers) by using a CNN. A total of 233 examinations performed with 15 scanners from three vendors in 233 patients (median age, 65 years [IQR, 54-72 years]; 144 men) were analyzed: 68 (29%) without pathologic findings, 72 (31%) with aneurysm, 51 (22%) with dissection, and 42 (18%) with repair. No evidence of a difference was observed in maximum aortic diameter between manual and automatic measurements (P = .48). Overall measurements displayed a bias of -1.5 mm and a coefficient of repeatability of 8.0 mm at Bland-Altman analyses. Contrast enhancement, location, pathologic finding, and positioning inaccuracy negatively influenced reproducibility (P < .003). Sites with dissection or repair showed lower agreement than did sites without. The CNN performed well in measuring thoracic aortic diameters in a heterogeneous multivendor CT dataset. Keywords: CT, Vascular, Aorta © RSNA, 2022.

A Combined Deep Learning System for Automatic Detection of “Bovine” Aortic Arch on Computed Tomography Scans

The “bovine” aortic arch is an anatomic variant consisting in a common origin of the innominate and left carotid artery (CILCA), associated with a greater risk of thoracic aortic diseases (aneurysms and dissections), stroke, and complications after endovascular procedures. CILCA can be detected by visual assessment of computed tomography (CT) chest scans, but it is rarely reported. We developed a deep learning (DL) segmentation-plus-classification system to automatically detect CILCA based on 302 CT studies acquired at 2 centers. One model (3D U-Net) was trained from scratch (supervised by manual segmentation), validated, and tested for the automatic segmentation of the aortic arch and supra-aortic vessels. Three DL architectures (ResNet50, DenseNet-201, and SqueezeNet), pre-trained over millions of common images, were trained, validated, and tested for the automatic classification of CILCA versus non-CILCA, supervised by radiologist’s classification. The 3D U-Net-plus-DenseNet-201 was found to be the best system (Dice index 0.912); its classification performance obtained from internal, independent testing on 126 patients gave a receiver operating characteristic area under the curve of 87.0%, sensitivity 66.7%, specificity 90.5%, positive predictive value 87.5%, negative predictive value 73.1%, positive likelihood ratio 7.0, and negative likelihood ratio 0.4. In conclusion, a combined DL system applied to chest CT scans was developed and proven to be an effective tool to detect individuals with “bovine” aortic arch with a low rate of false-positive findings.

Evaluating workplace safety in the oil and gas industry during the COVID-19 pandemic using occupational health and safety Vulnerability Measure and partial least square Structural Equation Modelling

The study aims to apply the Partial Least Squares Structural Equation Modeling (PLS-SEM) to model workplace safety in the Oil and Gas Industry (OGI) during the COVID-19 pandemic. The five areas of the Occupational Health and Safety (OHS) Vulnerability Measure (e.g., Exposure to Workplace Hazards, Policies and Procedures in the Workplace, Perception on Health & Safety Culture in the Workplace, Self-Awareness in Health & Safety Procedures and Responsibilities, and Preventive Measure for Prevention of the Transmission of COVID-19 at Workplace) were considered as the constructs to be evaluated. Fifty workers from the oil and gas industry worldwide participated in the online survey, and the data were analyzed using the SmartPLS software. The results revealed that only Perception on Health & Safety Culture was a significant factor influencing the perceived workplace safety in the OGI during the COVID-19 pandemic (β = 0.603; t-value = 3.323; p-value = 0.001). The study suggested that the oil and gas companies should maintain a positive perception of health and safety culture to improve workplace safety even during the pandemic.

The Expanded Endocannabinoid System Contributes to Metabolic and Body Mass Shifts in First-Episode Schizophrenia: A 5-Year Follow-Up Study

Alterations in the expanded endocannabinoid system (eECS) and cell membrane composition have been implicated in the pathophysiology of schizophrenia spectrum disorders. We enrolled 54 antipsychotic (AP)-naïve first-episode psychosis (FEP) patients and 58 controls and applied a targeted metabolomics approach followed by multivariate data analysis to investigate the profile changes in the serum levels of endocannabinoids: 2-arachidonoylglycerol (2-AG) and anandamide, endocannabinoids-like N-acylethanolamines (NAEs: linoleoylethanolamide, oleoylethanolamide, and palmitoylethanolamide), and their dominating lipid precursor’s phosphatidylcholines. Biomolecule profiles were measured at the onset of first-episode psychosis (FEP) and 0.6 years and 5.1 years after the initiation of AP treatment. The results indicated that FEP might be characterized by elevated concentrations of NAEs and by decreased 2-AG levels. At this stage of the disease, the NAE-mediated upregulation of peroxisome proliferator-activated receptors (PPARs) manifested themselves in energy expenditure. A 5-year disease progression and AP treatment adverse effects led to a robust increase in 2-AG levels, which contributed to strengthened cannabinoid (CB1) receptor-mediated effects, which manifested in obesity. Dynamic 2-AG, NAEs, and their precursors in terms of phosphatidylcholines are relevant to the description of the metabolic shifts resulting from the altered eECS function during and after FEP.

How Psychological Wellbeing and Digital Mental Health Services Intervene the Role of Self-Efficacy and Affective Commitment of University Students in Their Performance?

Student performance is a critical factor in academic achievement. Other factors like the students' self-efficacy, affective commitment, and psychological wellbeing play a significant role in shaping their performance. The present study aims to understand the role of self-efficacy, affective commitment, and psychological wellbeing in the students' performance. To carry out the study, the data were collected from the 308 students currently enrolled in the public sector universities of China. Smart-PLS is used to check the validation of the proposed hypotheses. Partial least square structural equation modeling is used for hypothesis testing. Results of the study show that self-efficacy does not play a role in the student performance in public sector universities; however, the affective commitment of the students plays a significant role in their performance. The psychological wellbeing of the students has a substantial influence on their performance. Furthermore, the results have also indicated that psychological wellbeing is an important indicator of student performance. It has also been revealed that psychological wellbeing significantly mediates the relationship between self-efficacy, affective commitment, and student performance. The students who availed of the digital mental health services were found to have a low relationship between their self-efficacy and performance.

Different timing in allograft and autograft maturation after primary anterior cruciate ligament reconstruction does not influence the clinical outcome at mid-long-term follow-up

PURPOSE

The use of allografts in primary anterior cruciate ligament reconstruction (ACLR) is increasing although they are still supposed to be associated to greater risk of re-rupture due to a slower and less efficient graft maturation. The aim of this prospective randomized controlled study was to compare the graft maturation after ACLR with allograft and autograft by MRI at 6- and 12-month follow-up and integrate these data with the functional and clinical results observed at 6-, 12- and 60-month follow-up.

METHODS

Fifty patients with indication to primary ACLR were randomly and equally divided into hamstring autograft or allograft tendon groups. The graft maturation was measured at 6- and 12-month follow-up by the SNQ score and other radiological parameters on MRI scans. Clinical and functional recovery was evaluated by Lysholm score, Visual Analogues Scale, Tegner activity scale and modified Cincinnati knee rating system at 6, 12 and 60 months after surgery to estimate the predictive value of the radiological parameters for clinical outcomes. Return-to-sport (ACL-RSI) was measured 60 months after surgery.

RESULTS

Three patients had retear of the neo-ligament (two from Auto group and one from Allo group). All the clinical/functional parameters significantly improved over time, with no statistically significant difference between the groups. At 6 months, the SNQ value was significantly higher in the Auto than in the Allo group (12.9 vs 7.9, p = 0.038), but at 12 months they were comparable (9.8 vs 10.4). The 6-month SNQ values did not correlate with the clinical scores, whereas the 12-month SNQ values significantly correlated with the Cincinnati score, Lysholm score and Tegner activity scale collected at 60-month follow-up.

CONCLUSION

No clinical or functional differences have been found between the two treatment groups, supporting the suitability of using allograft in primary ACLR, when available. The results at MRI scans showed a different graft maturation trend in the two groups, with allografts being more reactive in the first 6 months. MRI together with the subjective evaluation allows to evaluate objectively the status of the neo-ligamentization process and therefore helps the surgeon to dictate the individual time for return-to-sport.

LEVEL OF EVIDENCE

Level I.

Design and Testing of Two Haptic Devices Based on Reconfigurable 2R Joints

This paper presents the design and testing of two haptic devices, based on reconfigurable 2R joints: an active 2R spherical mechanism-based joint and a differential gear-based joint. Based on our previous works, in which the design and kinematic analysis of both reconfigurable joints were developed, the experimental setup and the various tasks intended to test the reconfigurability, precision, force feedback system and general performance, are presented herein. Two control modes for the haptic device operation are proposed and studied. The statistical analysis tools and their selection principles are described. The mechanical design of two experimental setups and the main elements are considered in detail. The Robot Operating System nodes and the topics that are used in the software component of the experimental setup are presented and explained. The experimental testing was carried out with a number of participants and the corresponding results were analyzed with the selected statistical tools. A detailed interpretation and discussion on of the results is provided.

Predictive Machine Learning Models and Survival Analysis for COVID-19 Prognosis Based on Hematochemical Parameters

The coronavirus disease 2019 (COVID-19) pandemic has affected hundreds of millions of individuals and caused millions of deaths worldwide. Predicting the clinical course of the disease is of pivotal importance to manage patients. Several studies have found hematochemical alterations in COVID-19 patients, such as inflammatory markers. We retrospectively analyzed the anamnestic data and laboratory parameters of 303 patients diagnosed with COVID-19 who were admitted to the Polyclinic Hospital of Bari during the first phase of the COVID-19 global pandemic. After the pre-processing phase, we performed a survival analysis with Kaplan–Meier curves and Cox Regression, with the aim to discover the most unfavorable predictors. The target outcomes were mortality or admission to the intensive care unit (ICU). Different machine learning models were also compared to realize a robust classifier relying on a low number of strongly significant factors to estimate the risk of death or admission to ICU. From the survival analysis, it emerged that the most significant laboratory parameters for both outcomes was C-reactive protein min; HR=17.963 (95% CI 6.548–49.277, p < 0.001) for death, HR=1.789 (95% CI 1.000–3.200, p = 0.050) for admission to ICU. The second most important parameter was Erythrocytes max; HR=1.765 (95% CI 1.141–2.729, p < 0.05) for death, HR=1.481 (95% CI 0.895–2.452, p = 0.127) for admission to ICU. The best model for predicting the risk of death was the decision tree, which resulted in ROC-AUC of 89.66%, whereas the best model for predicting the admission to ICU was support vector machine, which had ROC-AUC of 95.07%. The hematochemical predictors identified in this study can be utilized as a strong prognostic signature to characterize the severity of the disease in COVID-19 patients.

Identification of the Potential Prognosis Biomarkers in Hepatocellular Carcinoma: An Analysis Based on WGCNA and PPI

Aim

This study was done to determine biomarkers for the prognostic prediction of hepatocellular carcinoma (HCC).

Materials and Methods

In the Gene Expression Omnibus, the gene expression profiles of HCC were downloaded. Biomarkers were identified by weighted gene co-expression network analysis and protein–protein interaction network analysis.

Results

There were 24 modules, which were characterized by the high correlation with HCC. Meanwhile, through enrichment analysis, differentially expressed genes were largely participated in the ubiquitination and autophagy processes. Moreover, PRC1, TOP2A and CKAP2L may be the hub genes involved in HCC tumorigenesis, and their biomarker roles were further demonstrated via Gene Expression Profiling Interactive Analysis (GEPIA) and Oncomine databases. In addition, the levels of PRC1, TOP2A and CKAP2L were obviously up-regulated in the sera of HCC patients.

Conclusion

PRC1, TOP2A and CKAP2L may serve as biomarkers for the prognostic prediction of HCC patients.

A Report on Multi-Target Anti-Inflammatory Properties of Phytoconstituents from Monochoria hastata (Family: Pontederiaceae)

This study aims to investigate the potential analgesic properties of the crude extract of Monochoria hastata (MH) leaves using in vivo experiments and in silico analysis. The extract, in a dose-dependent manner, exhibited a moderate analgesic property (~54% pain inhibition in acetic acid-induced writhing test), which is significant (** p < 0.001) as compared to the control group. The complex inflammatory mechanism involves diverse pathways and they are inter-connected. Therefore, multiple inflammatory modulator proteins were selected as the target for in silico analysis. Computational analysis suggests that all the selected targets had different degrees of interaction with the phytochemicals from the extract. Rutin (RU), protocatechuic acid (PA), vanillic acid (VA), and ferulic acid (FA) could regulate multiple targets with a robust efficiency. None of the compounds showed selectivity to Cyclooxygenase-2 (COX-2). However, regulation of COX and lipoxygenase (LOX) cascade by PA can reduce non-steroidal analgesic drugs (NSAIDs)-related side effects, including asthma. RU showed robust regulation of cytokine-mediated pathways like RAS/MAPK and PI3K/NF-kB by inhibition of EGFR and IKBα (IKK), which may prevent multi-organ failure due to cytokine storm in several microbial infections, for example, SARS-CoV-2. Further investigation, using in vivo and in vitro experiments, can be conducted to develop multi-target anti-inflammatory drugs using the isolated compounds from the extract.

Occupational burnout among radiation therapy technologists in Italy before and during COVID-19 pandemic

Introduction

Radiation therapy technologists (RTTs) are exposed to high stress levels which may lead to burnout, which could be further increased by the current pandemic. The aim of our study was to assess burnout and stress among Italian RTTs before and during the pandemic.

Methods

The Italian Association of Radiation Therapy and Medical Physics Technologists (AITRO) and the Italian Federation of Scientific Radiographers Societies (FASTeR) proposed a national online survey, including the Maslach Burnout Inventory assessing emotional exhaustion (EE), depersonalisation (DP), and personal accomplishment (PA) to RTTs before and during the pandemic. Multivariate regression analyses and χ² tests were used for data analysis.

Results

We obtained 367 answers, 246 before and 121 during the pandemic. RTTs before and during the pandemic showed high EE and DP, intermediate PA. Median EE was 37 (interquartile range [IQR] 31–46] before and 37 (IQR 30–43) during the pandemic, median DP was 16 (IQR 13–21) and 15 (IQR 12–20), respectively. PA was 31 (IQR 28–34) and 32 (IQR 28–34), respectively. Through multivariate analysis, being female and having children led to higher EE scores before and during the pandemic (p≤0.026). Only the presence of workplace stress management courses was related to lower DP before and being female was related to higher DP during the pandemic (p<0.001). Being female, having children, and working with paediatric patients were related to lower PA before and during the pandemic (p≤0.015).

Conclusion

Our study highlighted high burnout levels for RTTs regardless of the pandemic. Future interventions aimed at preventing burnout should be implemented in their work environment, independently of the impact of exceptional events.

Genome-Wide Association Studies of Soybean Yield-Related Hyperspectral Reflectance Bands Using Machine Learning-Mediated Data Integration Methods

In conjunction with big data analysis methods, plant omics technologies have provided scientists with cost-effective and promising tools for discovering genetic architectures of complex agronomic traits using large breeding populations. In recent years, there has been significant progress in plant phenomics and genomics approaches for generating reliable large datasets. However, selecting an appropriate data integration and analysis method to improve the efficiency of phenome-phenome and phenome-genome association studies is still a bottleneck. This study proposes a hyperspectral wide association study (HypWAS) approach as a phenome-phenome association analysis through a hierarchical data integration strategy to estimate the prediction power of hyperspectral reflectance bands in predicting soybean seed yield. Using HypWAS, five important hyperspectral reflectance bands in visible, red-edge, and near-infrared regions were identified significantly associated with seed yield. The phenome-genome association analysis of each tested hyperspectral reflectance band was performed using two conventional genome-wide association studies (GWAS) methods and a machine learning mediated GWAS based on the support vector regression (SVR) method. Using SVR-mediated GWAS, more relevant QTL with the physiological background of the tested hyperspectral reflectance bands were detected, supported by the functional annotation of candidate gene analyses. The results of this study have indicated the advantages of using hierarchical data integration strategy and advanced mathematical methods coupled with phenome-phenome and phenome-genome association analyses for a better understanding of the biology and genetic backgrounds of hyperspectral reflectance bands affecting soybean yield formation. The identified yield-related hyperspectral reflectance bands using HypWAS can be used as indirect selection criteria for selecting superior genotypes with improved yield genetic gains in large breeding populations.

Reprocessing 16S rRNA Gene Amplicon Sequencing Studies: (Meta)Data Issues, Robustness, and Reproducibility

High-throughput sequencing technology provides an efficient method for evaluating microbial ecology. Different bioinformatics pipelines can be used to convert 16S ribosomal RNA gene amplicon sequencing data into an operational taxonomic unit (OTU) table that is used to analyze microbial communities. It is important to assess the robustness of these pipelines, each with specific algorithms and/or parameters, and their influence on the outcome of statistical tests. Articles with publicly available datasets on the oral microbiome were searched for, and five datasets were retrieved. These were from studies on changes in microbiota related to smoking, oral cancer, caries, diabetes, or periodontitis. Next, the data was processed with four pipelines based on VSEARCH, USEARCH, mothur, and UNOISE3. OTU tables were rarefied, and differences in α-diversity and β-diversity were tested for different groups in a dataset. Finally, these results were checked for consistency among these example pipelines. Of articles that deposited data, only 57% made all sequencing and metadata available. When processing the datasets, issues were encountered, caused by read characteristics and differences between tools and their defaults in combination with a lack of detail in the methodology of the articles. In general, the four mainstream pipelines provided similar results, but importantly, P-values sometimes differed between pipelines beyond the significance threshold. Our results indicated that for published articles, the description of bioinformatics methods and data deposition should be improved, and regarding reproducibility, that analysis of multiple subsamples is required when using rarefying as library-size normalization method.

Image-guided thermal ablation in autonomously functioning thyroid nodules. A retrospective multicenter three-year follow-up study from the Italian Minimally Invasive Treatment of the Thyroid (MITT) Group

OBJECTIVES

To report the results of a multicenter retrospective evaluation of the clinical outcomes of thermal ablation (TA) in a large series of autonomously functioning thyroid nodules (AFTN) with a follow-up protracted up to 3 years.

METHODS

Patients treated with single TA for an AFTN in Italy were included. Changes in nodule volume, TSH values, and ongoing anti-thyroid therapy were assessed at the 2-, 6-, 12-, 24-, and 36-month follow-up controls. Complications and need of any additional therapy after TA were also registered.

RESULTS

A total of 361 patients (244 females, 117 males, median age 58 years, IQR 46-70 years) were included. Nodule volume was significantly reduced at all time points (p < 0.001) (median volume reduction 58% at 6-month and 60% at 12-month). Serum TSH values increased significantly at all time points. After TA, anti-thyroid therapy was withdrawn in 32.5% of patients at 2 months, in 38.9% at 6 months, and in 41.3% at 12 months. A significant difference in the rate of patients who withdrawn medical therapy at 12 months was registered between small (< 10 mL) (74%), medium (49%), or large (> 30 mL) nodules (19%). A single major complication occurred (0.25%). Additional treatments were needed in 34/361 (9.4%) of cases including 4 (1.1%) surgical treatment.

CONCLUSIONS

Image-guided thermal ablation offers a further safe and effective therapeutic option in patients with AFTN. Clinical outcomes are significantly more favorable in small than in large size AFTN.

KEY POINTS

• Thermal ablations (TA) can be safely and effectively used in patients with autonomously functioning thyroid nodules (AFTN). • TA results in a clinically significant nodule volume reduction that is paralleled by TSH level normalization and anti-thyroid drug therapy discontinuation (after TA anti-thyroid therapy was withdrawn in 41.3% at 12 months). • Clinical outcomes after TA are more favorable in small nodules, and when a large amount of thyroid nodule tissue is ablated.

Potential role of epicardial adipose tissue as a biomarker of anthracycline cardiotoxicity

Background

We investigated the radiodensity of epicardial (EAT), subcutaneous (SAT), and visceral adipose tissue (VAT) before and after treatment with anthracyclines in a population of breast cancer (BC) patients, and in controls not treated with anthracyclines, to detect a potential role of EAT density as a biomarker of changes related to chemotherapy cardiotoxicity.

Methods

We reviewed BC patients treated with anthracyclines who underwent CT before (CT-t₀) and after (CT-t₁) chemotherapy, and age- and sex-matched controls who underwent two CT examinations at comparable intervals. On non-contrast scans, EAT was segmented contouring the pericardium and thresholding between -190 and -30 Hounsfield units (HU), and SAT and VAT were segmented with two 15-mm diameter regions of interest thresholded between -195 and -45 HU.

Results

Thirty-two female patients and 32 controls were included. There were no differences in age (p = 0.439) and follow-up duration (p = 0.162) between patients and controls. Between CT-t₀ and CT-t₁, EAT density decreased in BC patients (-66 HU, interquartile range [IQR] -71 to -63 HU, to -71 HU, IQR -75 to -66 HU, p = 0.003), while it did not vary in controls (p = 0.955). SAT density increased from CT-t₀ to CT-t₁ in BC patients (-107 HU, IQR -111 to -105 HU, to -105 HU, IQR -110 to -100 HU, p = 0.014), whereas it did not change in controls (p = 0.477). VAT density did not vary in either BC patients (p = 0.911) or controls (p = 0.627).

Conclusions

EAT density appears to be influenced by anthracycline treatment for BC, well known for its cardiotoxicity, shifting towards lower values indicative of a less active metabolism.

Evaluation of the Influence of the Combination of pH, Chloride, and Sulfate on the Corrosion Behavior of Pipeline Steel in Soil Using Response Surface Methodology

External damage to buried pipelines is mainly caused by corrosive components in soil solution. The reality that numerous agents are present in the corrosive environment simultaneously makes it troublesome to study. To solve that issue, this study aims to determine the influence of the combination of pH, chloride, and sulfate by using a statistical method according to the design of experiment (DOE). Response surface methodology (RSM) using the Box–Behnken design (BBD) was selected and applied to the design matrix for those three factors. The input corrosion current density was evaluated by electrochemical tests under variable conditions given in the design matrix. The output of this method is an equation that calculates the corrosion current density as a function of pH, chloride, and sulfate concentration. The level of influence of each factor on the corrosion current density was investigated and response surface plots, contour plots of each factor were created in this study.

PFKFB4 is overexpressed in clear-cell renal cell carcinoma promoting pentose phosphate pathway that mediates Sunitinib resistance

BACKGROUND

Kinases play critical role in clear-cell renal cell carcinoma (ccRCC). We aim to exploit novel kinase that is both protumorigenic and drugable in ccRCC.

METHODS

Reproduction of public datasets with validation using microarray was performed to identify candidate gene. Functionality was studied using multi-omics with validation in vitro and in vivo.

RESULTS

6-Phosphofructo-2-Kinase/Fructose-2,6-Biphosphatase 4 (PFKFB4) was differentially expressed showing significantly higher expression in tumor than in normal kidney. PFKFB4 overexpression was associated with advanced tumor grade, stage and worsened prognosis. PFKFB4-knockdown significantly impaired fitness in cell proliferation, migration and wound healing. Despite being recurrently deleted on 3p, PFKFN4 mRNA remained actively transcribed by HIF1α. Metabolomics showed overexpressed PFKFB4 showed enriched metabolites in pentose phosphate pathway (PPP). Phosphoproteomics and immunoprecipitation showed PFKFB4 also phosphorylated NCOA3 which interacted with FBP1 to counteract overactive PPP flux, forming a regulatory loop. PFKFB4-knockdown overcame resistance to Sunitinib in vitro and in vivo both in xenograft and tail-vein injection murine models.

CONCLUSION

We concluded PFKFB4 was associated with PPP activity and the fine-tuning of which was mediated by its phosphorylation of NCOA3. Targeting PFKFB4 held promise to combat resistance to Sunitinib.

CT-derived epicardial adipose tissue density: Systematic review and meta-analysis

PURPOSE

The aim of our work was to systematically review and meta-analyze epicardial adipose tissue (EAT) density values reported in literature, assessing potential correlations of EAT density with segmentation thresholds and other technical and clinical variables.

METHOD

A systematic search was performed, aiming for papers reporting global EAT density values in Hounsfield Units (HU) in patients undergoing chest CT for any clinical indication. After screening titles, abstract and full text of each retrieved work, studies reporting mean and standard deviation for EAT density were ultimately included. Technical, clinical and EAT data were extracted, and divided into subgroups according to clinical conditions of reported subjects. Pooled density analyses were performed both overall and for subgroups according to clinical conditions. Metaregression analyses were done to appraise the impact of clinical and technical variables on EAT volume.

RESULTS

Out of 152 initially retrieved works, 13 were ultimately included, totaling for 7683 subjects. EAT density showed an overall pooled value of -85.86 HU (95% confidence interval [95% CI] -91.84, -79.89 HU), being -86.40 HU (95% CI -112.69, -60.12 HU) in healthy subjects and -80.71 HU (95% CI -87.43, -73.99 HU) in patients with coronary artery disease. EAT volume and lower and higher segmentation thresholds were found to be significantly correlated with EAT density (p = 0.044, p < 0.001 and p< 0.001 respectively).

CONCLUSIONS

Patients with coronary artery disease appear to present with higher EAT density values, while the correlations observed at metaregression highlight the need for well-established, shared thresholds for EAT segmentation.

Effects of Interobserver Variability on 2D and 3D CT- and MRI-Based Texture Feature Reproducibility of Cartilaginous Bone Tumors

This study aims to investigate the influence of interobserver manual segmentation variability on the reproducibility of 2D and 3D unenhanced computed tomography (CT)- and magnetic resonance imaging (MRI)-based texture analysis. Thirty patients with cartilaginous bone tumors (10 enchondromas, 10 atypical cartilaginous tumors, 10 chondrosarcomas) were retrospectively included. Three radiologists independently performed manual contour-focused segmentation on unenhanced CT and T1-weighted and T2-weighted MRI by drawing both a 2D region of interest (ROI) on the slice showing the largest tumor area and a 3D ROI including the whole tumor volume. Additionally, a marginal erosion was applied to both 2D and 3D segmentations to evaluate the influence of segmentation margins. A total of 783 and 1132 features were extracted from original and filtered 2D and 3D images, respectively. Intraclass correlation coefficient ≥ 0.75 defined feature stability. In 2D vs. 3D contour-focused segmentation, the rates of stable features were 74.71% vs. 86.57% (p < 0.001), 77.14% vs. 80.04% (p = 0.142), and 95.66% vs. 94.97% (p = 0.554) for CT and T1-weighted and T2-weighted images, respectively. Margin shrinkage did not improve 2D (p = 0.343) and performed worse than 3D (p < 0.001) contour-focused segmentation in terms of feature stability. In 2D vs. 3D contour-focused segmentation, matching stable features derived from CT and MRI were 65.8% vs. 68.7% (p = 0.191), and those derived from T1-weighted and T2-weighted images were 76.0% vs. 78.2% (p = 0.285). 2D and 3D radiomic features of cartilaginous bone tumors extracted from unenhanced CT and MRI are reproducible, although some degree of interobserver segmentation variability highlights the need for reliability analysis in future studies.

Anxiety, stress, and binge eating tendencies in adolescence: a prospective approach

BACKGROUND

Recent years have witnessed an increasing prevalence of binge eating tendencies in adolescence-warranting a clearer understanding of their underlying predisposing and precipitating factors. The current study investigated whether the interaction between high levels of anxiety and stress predicted increased levels of binge eating tendencies in a prospective cohort of adolescents (N = 324).

METHODS

Measurements were taken over three waves (M ages: 13.33, 14.48, 15.65) as part of the CogBIAS Longitudinal Study. Longitudinal associations between levels of anxiety and stress with binge eating tendencies were estimated using a random intercept cross-lagged panel model (RI-CLPM), which calculates within-person fluctuations over time while accounting for individual trait-like stability and between-person variations. Binge eating tendencies were measured by the Cognitive Restraint, Uncontrolled Eating, and Emotional Eating styles from the Three-Factor Eating Questionnaire-R18. Two models were created for each binge eating tendencies variable: (1) a basic model with anxiety and stress as independent variables; (2) an interaction model with an additional anxiety*stress interaction term. Model fit was assessed by SEM fit indices: X², CFI, NFI, TLI, RMSEA, SRMR. Superior model fit was ascertained by a chi-square difference test (p < .05).

RESULTS

For Cognitive Restraint, the interaction model demonstrated superior fit to the data (p < .05). The anxiety*stress interaction at Waves 1 and 2 was significantly negatively associated with Cognitive Restraint at Waves 2 (β = -0.18, p = .002) and 3 (β = -0.14, p = .002)-suggesting that anxiety and stress interacted to predict increased binge eating tendencies linked with cognitive restraint over and above their independent effects. In contrast, the interaction term between anxiety*stress did not predict levels of Uncontrolled Eating or Emotional Eating over time.

CONCLUSIONS

The results highlight the importance of increasing awareness of the interaction between concurrently high anxiety and stress as a potential risk factor for binge eating tendencies in young people.

TRIAL REGISTRATION

Not applicable.

The effect of decongestion on nasal airway patency and airflow

Nasal decongestant reduces blood flow to the nasal turbinates, reducing tissue volume and increasing nasal airway patency. This study maps the changes in nasal anatomy and measures how these changes affect nasal resistance, flow partitioning between superior and inferior cavity, flow patterns and wall shear stress. High-resolution MRI was applied to capture nasal anatomy in 10 healthy subjects before and after application of a topical decongestant. Computational fluid dynamics simulated nasal airflow at steady inspiratory flow rates of 15 L.min[Formula: see text] and 30 L.min[Formula: see text]. The results show decongestion mainly increases the cross-sectional area in the turbinate region and SAVR is reduced (median approximately 40[Formula: see text] reduction) in middle and lower parts of the cavity. Decongestion reduces nasal resistance by 50[Formula: see text] on average, while in the posterior cavity, nasal resistance decreases by a median factor of approximately 3 after decongestion. We also find decongestant regularises nasal airflow and alters the partitioning of flow, significantly decreasing flow through the superior portions of the nasal cavity. By comparing nasal anatomies and airflow in their normal state with that when pharmacologically decongested, this study provides data for a broad range of anatomy and airflow conditions, which may help characterize the extent of nasal variability.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses

PURPOSE

No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses.

METHODS

Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes.

RESULTS

Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters.

CONCLUSION

Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

A policy construction for sustainable rice food sovereignty in Indonesia

As an agricultural country with large natural resources, Indonesia still has considerable problems in managing food security. This is evidenced by the lack of agricultural land and human resources that can support people's food needs so that the government still imports food from other countries. These issues as; it are feared that population growth and high food consumption power, social exclusion (marginalization of agricultural laborers and agricultural land) will cause food security vulnerability in the future. This Mixed method quantitative and qualitative method by statistical and in-depth interview study involving 169 respondents from many stakeholders such as politicians, academicians, farmers, and students to determine policy construction for sustainable rice food sovereignty in Indonesia. The statistical study shows the rice consumption in Indonesia is correlated to education than the age and gender of the respondents. The study indicating problems such as; the welfare of farmers, the application of price limits for staple goods, and improving the quality of agriculture both natural resources, human resources and the provision of agricultural equipment assistance have not been resolved properly. To build food security, it should be balanced with the application of the concept of food sovereignty which is realized by aligning and maximizing competence between political resources, environmental resources capacity, and environmental diplomacy.

Using Computational Methods to Improve Integrated Disease Management for Asthma and Chronic Obstructive Pulmonary Disease: Protocol for a Secondary Analysis

Background

Asthma and chronic obstructive pulmonary disease (COPD) impose a heavy burden on health care. Approximately one-fourth of patients with asthma and patients with COPD are prone to exacerbations, which can be greatly reduced by preventive care via integrated disease management that has a limited service capacity. To do this well, a predictive model for proneness to exacerbation is required, but no such model exists. It would be suboptimal to build such models using the current model building approach for asthma and COPD, which has 2 gaps due to rarely factoring in temporal features showing early health changes and general directions. First, existing models for other asthma and COPD outcomes rarely use more advanced temporal features, such as the slope of the number of days to albuterol refill, and are inaccurate. Second, existing models seldom show the reason a patient is deemed high risk and the potential interventions to reduce the risk, making already occupied clinicians expend more time on chart review and overlook suitable interventions. Regular automatic explanation methods cannot deal with temporal data and address this issue well.

Objective

To enable more patients with asthma and patients with COPD to obtain suitable and timely care to avoid exacerbations, we aim to implement comprehensible computational methods to accurately predict proneness to exacerbation and recommend customized interventions.

Methods

We will use temporal features to accurately predict proneness to exacerbation, automatically find modifiable temporal risk factors for every high-risk patient, and assess the impact of actionable warnings on clinicians’ decisions to use integrated disease management to prevent proneness to exacerbation.

Results

We have obtained most of the clinical and administrative data of patients with asthma from 3 prominent American health care systems. We are retrieving other clinical and administrative data, mostly of patients with COPD, needed for the study. We intend to complete the study in 6 years.

Conclusions

Our results will help make asthma and COPD care more proactive, effective, and efficient, improving outcomes and saving resources.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27065