Aquagenic wrinkling of the palms in a cohort of Greek children diagnosed with cystic fibrosis: Associated clinical parameters

BACKGROUND

Aquagenic wrinkling of the palms (AWP) is an excessive and early palmar wrinkling occurring after brief immersion to water (BIW), and has been reported as a frequent finding among Cystic Fibrosis (CF) patients.

OBJECTIVES

To investigate any associations of CF patients presenting AWP with other disease characteristics and explore the pathomechanism of AWP phenomenon.

METHODS

We evaluated AWP in CF patients and assessed the AWP parameters of palmar wrinkling, oedema, papules, pruritus and pain at 3, 7 and 11 min after a BIW test with other disease characteristics. Statistical analyses explored the associations of AWP with genotype, lung function, pancreatic insufficiency, hyperhidrosis, personal and family history of atopy and sweat chloride levels.

RESULTS

One hundred CF patients (mean age 10.4 years) were included in the analysis. The genotypic distribution was ΔF508/ΔF508: 47%, ΔF508/other: 41% and other/other: 12%. Statistically significant associations of Kaplan-Meier curves of the AWP parameters with various disease characteristics and personal/family history were detected. Wrinkling was associated with history of atopy, hyperhidrosis and levels of sweat chloride test. The time to presentation of oedema and the appearance of papules were associated with history of hyperhidrosis and age at diagnosis. Finally, time to appearance of pruritus was related to history of atopy and of hyperhidrosis. Regarding TEWL regression analysis showed significant associations with age at diagnosis (p = 0.024), sweat chloride test levels (p = 0.005), history of hyperhidrosis (p = 0.033), history of atopy (p = 0.002) and hepatic-pancreatic involvement (p = 0.027).

CONCLUSIONS

The existence of a statistically significant association between AWP and the history of hyperhidrosis, atopy, sweat chloride levels and hepatic-pancreatic function in CF patients was detected. A strong association between AWP and CF was detected. AWP after BIW could be elicited easily and possibly can be used as an initial screening tool to diagnose an individual with symptoms and signs that raise the likelihood of CF.

Glycemic Control Predicts Severity of Hepatocyte Ballooning and Hepatic Fibrosis in Nonalcoholic Fatty Liver Disease

BACKGROUND AND AIMS

Whether glycemic control, as opposed to diabetes status, is associated with the severity of NAFLD is open for study. We aimed to evaluate whether degree of glycemic control in the years preceding liver biopsy predicts the histological severity of NASH.

APPROACH AND RESULTS

Using the Duke NAFLD Clinical Database, we examined patients with biopsy-proven NAFLD/NASH (n = 713) and the association of liver injury with glycemic control as measured by hemoglobin A1c (HbA1c). The study cohort was predominantly female (59%) and White (84%) with median (interquartile range) age of 50 (42, 58) years; 49% had diabetes (n = 348). Generalized linear regression models adjusted for age, sex, race, diabetes, body mass index, and hyperlipidemia were used to assess the association between mean HbA1c over the year preceding liver biopsy and severity of histological features of NAFLD/NASH. Histological features were graded and staged according to the NASH Clinical Research Network system. Group-based trajectory analysis was used to examine patients with at least three HbA1c (n = 298) measures over 5 years preceding clinically indicated liver biopsy. Higher mean HbA1c was associated with higher grade of steatosis and ballooned hepatocytes, but not lobular inflammation. Every 1% increase in mean HbA1c was associated with 15% higher odds of increased fibrosis stage (OR, 1.15; 95% CI, 1.01, 1.31). As compared with good glycemic control, moderate control was significantly associated with increased severity of ballooned hepatocytes (OR, 1.74; 95% CI, 1.01, 3.01; P = 0.048) and hepatic fibrosis (HF; OR, 4.59; 95% CI, 2.33, 9.06; P < 0.01).

CONCLUSIONS

Glycemic control predicts severity of ballooned hepatocytes and HF in NAFLD/NASH, and thus optimizing glycemic control may be a means of modifying risk of NASH-related fibrosis progression.

Duration of type 2 diabetes does not appear to moderate hypoglycaemia rate with insulin degludec versus insulin glargine U100

In the DEVOTE and SWITCH 2 trials, insulin degludec 100 units/mL (degludec) was superior to insulin glargine 100 units/mL (glargine U100) with respect to the rates of severe (DEVOTE; across trial) and overall symptomatic (SWITCH 2; during the maintenance period of the trial) hypoglycaemia in individuals with type 2 diabetes. In this post hoc analysis, data from 7635 individuals from DEVOTE and 720 individuals from SWITCH 2 were analysed by subgroups of diabetes duration at baseline (<10, ≥10-<15, ≥15-<20 and ≥20 years) using prespecified models from both trials. There was a trend towards lower rates of hypoglycaemia with degludec versus glargine U100 across all diabetes duration subgroups in both trials, with the difference being statistically significant in some subgroups in DEVOTE and SWITCH 2. Overall, however, no significant interaction was observed between diabetes duration and treatment (DEVOTE interaction, P = .496; SWITCH 2 interaction, P = .144). Therefore, in this post hoc analysis of DEVOTE and SWITCH 2, diabetes duration did not appear to affect the reduction in rates of hypoglycaemia observed with degludec compared with glargine U100.

Aquagenic wrinkling of the palms after brief immersion to water test as a screening tool for cystic fibrosis diagnosis

BACKGROUND

Aquagenic wrinkling of the palms (AWP) is an excessive and early palmar wrinkling occurring after Brief Immersion to Water (BIW), and has been reported as a frequent finding among cystic fibrosis (CF) patients.

OBJECTIVES

To evaluate and assess the diagnostic performance of BIW test as an initial screening tool for CF diagnosis.

METHODS

We measured AWP in CF patients, CF-heterozygotes (CF-het) and normal controls. The AWP parameters of palmar wrinkling, oedema, papules, pruritus and pain were assessed at 3, 7 and 11 min after a BIW test was performed for all the participants. Statistical analyses explored the progression of AWP in time for the three groups and assessed the diagnostic performance of BIW test as a diagnostic screening tool for CF.

RESULTS

A total of 250 individuals (100 CF patients, their 50 CF-het parents, 100 healthy controls) were included in the analysis. The average age in years (mean ± SD) was 10.4 ± 4.0 for CF, 35.9 ± 6.1 for CF-het and 10.5 ± 4.0 for controls. The rate of positives for AWP at 3 min among CF patients, CF-het and controls was 68%, 8% and 0%, respectively (P < 0.01). Kaplan-Meier analysis showed a clear trend towards earlier appearance of all five parameters in the direction controls < hetCF < CF (P values <0.01). The best diagnostic performance in detecting between CF patients and non-CF was achieved by the presence of papules and wrinkling at 7 min (sensitivity/specificity: 94.0%/98.3% and 100.0%/92.0%, respectively).

CONCLUSIONS

A strong association between AWP and CF was detected. AWP after BIW could be elicited easily and possibly can be used as an initial screening tool to assess if an individual with symptoms and signs that raise the likelihood of CF is a CF patient.

ABREAST: a prospective, real-world study on the effect of nab-paclitaxel treatment on clinical outcomes and quality of life of patients with metastatic breast cancer

PURPOSE

The efficacy of nab-paclitaxel in patients with metastatic breast cancer (MBC) has been demonstrated in randomized clinical trials. However, real-world evidence on effectiveness remains limited.

PATIENTS AND METHODS

The primary objective of this multicenter prospective study was to assess the overall response rate (ORR) of patients with MBC treated with nab-paclitaxel. Secondary objectives included progression-free survival (PFS), overall survival (OS) and quality of life, assessed with the Functional Assessment of Cancer Therapy-Breast (FACT-B) instrument.

RESULTS

Eligible patients (N = 150; 36% with de novo MBC presentation) with a median age of 64.5 years were enrolled (86% were ER+, 33.3% (50/150) were ≥ 70 years of age and 53% were treated in the third or later line of treatment). A median of 6 cycles were administered but 26% of patients required dose reduction due to toxicity. The ORR was 26.7% [95% confidence interval (CI) 19.6-33.7], the median PFS was 6.2 months (95% CI 5.2-7.3), and the median OS 21.1 months (95% CI 17.2-not estimable). There was no statistical significant difference in the median PFS of patients < and ≥ 70 years of age. The patients' baseline FACT-B total score remained unchanged. The serious and non-serious adverse event incidence rates were 13% and 48%, respectively.

CONCLUSIONS

This prospective study provides further evidence on quality of life, efficacy, and safety of nab-paclitaxel in patients with MBC and sheds more light in special subpopulations such as the elderly and those treated beyond the second line.

Validation of the dermatology-specific proxy instrument the Infants and Toddlers Dermatology Quality of Life

BACKGROUND

The first dermatology-specific proxy health-related quality of life (HRQoL) instrument for children 0-4 years old with skin diseases, the Infants and Toddlers Dermatology Quality of Life (InToDermQoL), was recently developed. In order to avoid the problem of cross-cultural inequivalence focus groups work and pilot tests were organized simultaneously in all national centres of the project. The InToDermQoL showed good comprehensibility, clarity and acceptance.

OBJECTIVE

To validate the InToDermQoL questionnaire during international field tests.

METHODS

Internal consistency, test-retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire were checked during international field tests.

RESULTS

Parents of 473 children with skin diseases filled in the national language versions of the InToDermQoL questionnaire. All three age-specific versions of the InToDermQoL questionnaire with 10, 12 and 15 items, respectively, showed high internal consistency (Cronbach's α 0.90-0.93), good test-retest reliability (correlation coefficients > 0.9), significant correlations with the most widely used atopic dermatitis-specific proxy instrument, the Infants Dermatitis Quality of Life Index (correlation coefficients 0.68-0.79). The InToDermQoL versions for children <3 years old well correlated with the atopic dermatis severity measure Scoring of Atopic Dermatitis (correlation coefficients 0.66 and 0.86 for 10 and 12 items versions, respectively). The InToDermQoL questionnaire discriminated well among different diagnoses and disease severity levels.

CONCLUSION

Our field tests confirmed internal consistency, test-retest reliability, convergent and discriminant validity of the InToDermQoL questionnaire. Development and validation of the InToDermQoL questionnaire make it possible to assess dermatology-specific aspects of HRQoL in youngest children with skin diseases. There are many reasons to assess HRQoL in dermatologic clinical practice, and we hope that our new instrument will be used internationally in paediatric dermatology for research and practical needs.

Voxel-based morphometric magnetic resonance imaging postprocessing in non-lesional pediatric epilepsy patients using pediatric normal databases

BACKGROUND AND PURPOSE

Pre-surgical evaluation of pediatric patients with drug-resistant focal epilepsy and negative (non-lesional) magnetic resonance imaging (MRI) is particularly challenging. Focal cortical dysplasia (FCD), a frequent pathological substrate in such setting, may be subtle on MRI and evade detection. The aim of this study was to use voxel-based MRI postprocessing to improve the detection of subtle FCD in pediatric surgical candidates.

METHODS

A consecutive cohort of pediatric patients undergoing pre-surgical evaluation with a negative MRI by visual analysis was included. MRI postprocessing was performed using a voxel-based morphometric analysis program (MAP) on T1-weighted volumetric MRI, with comparison to an age-specific normal pediatric database. The pertinence of MAP-positive areas was confirmed by surgical outcome and pathology.

RESULTS

A total of 78 patients were included. Forty-four patients (56%) had positive MAP regions. Complete resection of the MAP-positive regions was positively associated with seizure-free outcome compared with the no/partial resection group (P < 0.001). Patients with no/partial resection of the MAP-positive regions had worse seizure outcomes than the MAP-negative group (P = 0.002). The MAP-positive rate was 100%, 77%, 63% and 40% in the 3-5, 5-10, 10-15 and 15-21 year age groups, respectively. MAP-positive rates were 45% in patients with temporal resection and 63% in patients with extratemporal resection. Complete resection of the MAP-positive regions was positively associated with seizure-free outcome in the extratemporal group (P = 0.001) but not in the temporal group (P = 0.070).

CONCLUSION

Our data suggest the importance of using MRI postprocessing in the pre-surgical evaluation process of pediatric epilepsy patients with apparently normal MRI.

Experimental effect of ozone upon the microbial flora of commercially produced dairy fermented products

Ozone was used to control spoilage microorganisms during the manufacturing of dairy products. Ozone stream was applied onto the surface of freshly filled yoghurt cups just before storage for curd development in order to prevent cross contamination from spoilage airborne microorganisms. Accordingly, brine solution was bubbled with ozone for various periods of time and used for ripening of white (feta type) cheese. Both products were subjected to a continuous monitoring of microbial load and also tested for their sensorial properties. In ozonated yoghurt samples there was a reduction in mould counts of approximately 0.6Logcfu/g (25.1%) by the end of the monitoring period in relation to the control samples. In white cheese ripened with ozonated brine (1.3mg/L O₃, NaCl 5%) it seems that ozone treatment during the two months of observation reduced some of the mould load but without offering any advantages over the use of traditional brine (NaCl 7%). However, some sensorial alterations were observed, probably due to the organic load in the brine which deactivates ozone in early stages of application. It is concluded that, if the factors of time and concentration of ozone are configured properly, ozonation could be a promising approach safeguarding the production of some dairy products.

Study of kefir grains application in sourdough bread regarding rope spoilage caused by Bacillus spp

Sourdough breads prepared with kefir grains resulted in appearance of rope spoilage at the 15th day of bread storage, while the control samples (sourdough breads prepared with wild microflora) were spoiled approximately at the 7th day. Denaturing Gradient Gel Electrophoresis (DGGE) analysis confirmed the above macroscopic observation since Bacillus spp. were detected on sourdough breads prepared with kefir grains at the 15th day of bread storage. The content of organic acids that play synergistic role regarding the enhancement of bread self life was also determined. Lactic acid concentration of sourdough breads prepared with kefir grains were approximately 41-82% higher than the control samples, while acetic acid concentration was about 0.5-1-fold higher respectively. The concentration of some other organic acids studied was also found in higher levels (up to 0.06μg/g) than the control samples. These findings could probably explain the stability of breads prepared with kefir grains against rope spoilage.

Role of cortisol in mood and memory in patients with intractable temporal lobe epilepsy

OBJECTIVE

This study prospectively examined the relationships among late night salivary cortisol (NSC) levels and depressive symptoms, memory performance, and hippocampal volumes in patients with medically intractable temporal lobe epilepsy (TLE) and the potential mediating effects of cortisol in the relationships between these variables.

METHODS

Participants included 24 adults with well-characterized medically refractory TLE (right = 11; left = 12; bitemporal = 1). All patients provided saliva samples and completed measures of mood, anxiety, and memory (objective and subjective). MRI-based volumetric analyses of the hippocampi were also conducted.

RESULTS

As hypothesized, cortisol was found to be negatively related to several memory measures such that patients with higher cortisol levels demonstrated lower memory performance. However, unexpectedly, cortisol was not related to current symptoms of depression or anxiety, subjective memory ratings, or hippocampal volumes. Consistent with previous findings in the literature, a number of other relationships among the study variables were observed (objective memory and hippocampal volume; subjective memory and mood/anxiety). Results of mediator analyses suggested that cortisol does not mediate the relationship between depression and memory dysfunction or the relationship between depression and hippocampal atrophy.

CONCLUSIONS

While cortisol may play a role in memory performance in patients with TLE, it does not fully explain the relationship between depression and mesial temporal dysfunction, likely reflecting the complex and multifactorial relationships among these variables. Results confirm the relationship between memory performance and structural brain integrity and provide further support for a role of depression in subjective memory complaints.

Chemical and microbiological characterization of artisan inoculants used for the fermentation of traditional dairy products in Epirus area (Greece)

The artisan production of a variety of dairy products is a historical tradition since antiquity, which is still practiced nowadays, in the area of Epirus, (northwestern Greece). The common denominator of these products, regardless of the final form of the end product, is the fermentation of raw milk by the use of dried artisan inoculants made of the dehydrated rumen of small ruminants, mainly lambs. The aim of this research project is to study the microbiological parameters as well as certain technological parameters (chymosin activity and lipolytic activity) of these inoculants. The results revealed a wide biodiversity of microorganisms such as Lactobacilli, Lactococci, Leuconostoc, Pediococci, Streptococci, Bifidobacteria, Enterococci, Clostridia and coliforms. Chymosin activity and lipolytic activity were found to be higher in artisan inoculants than in the commercial ones.

Hygienic quality and antibiotic resistance profile of sliced butchery

In order to investigate the microbiological quality of different meat products on the Greek market, 200 samples were collected from the following preparations: boiled turkey (n=50), boiled pork ham (n=50), smoked turkey (n=50) and smoked pork ham (n=50). In all cold meat preparations Clostridium perfringens vegetative and spore forms, Staphylococcus aureus, Escherichia coli and other Clostridium sp lec(-), as well as Lactobacillus, Bacillus sp. and Salmonella sp. were recovered. For instance Bacillus cereus was present in 6% of the samples. L. monocytogenes, Campylobacter jejuni and Campylobacter coli were rarely present (1-4%) while Yersinia enterocolitica and Campylobacter lari were absent. Differences in the occurrence of S. aureus, Salmonella sp., E. coli and spore forms of C. perfringens in boiled and smoked samples, reflects either the differences in the processing of the foods or could be associated to the extensive handling by the personnel during the purchasing (storage, slicing, wrapping). Antibiotic resistance on specific antibiotics for each pathogen was also studied. A multiresistance antibiotic profile was effective for most bacterial strains, and pronounced resistance profiles were observed for the commonly used antibiotics as ampicillin, penicillin, cephalothin, streptomycin followed by ceftriaxone and gentamycin. Albeit this high observed resistance profile, the tested strains generally conserved their susceptibility to amikacin, aztreonam, chloramphenicol and tylosin conserved an almost absent resistance. Antibiotics commonly used for therapeutic purposes, as well as antibiotics added to feed stuff of animals for increasing animal flesh production should contribute to the extensive spreading of antibiotic resistance in food and the environment. Systematically monitoring of the microbiological quality of cold butchery preparations must be done, in order to preserve food quality, optimizing the processing and elaboration methods of the product and safeguard the public health.

Microbial ecology of the watery ecosystems of Evros river in North Eastern Greece and its influence upon the cultivated soil ecosystem

The aim of the present study was to evaluate the microbial ecosystem of cultivated soils along the Evros river in NE Greece. Evros river together with its derivative rivers constitute the capital source of life and sustainable development of the area. Along this riverside watery ecosystem systematic agro-cultures were developed such as wheat, corn and vegetable cultures. The evaluation of the ecosystem microbial charge was conducted in both axes which are the watery ecosystem and the riverside cultivated soil area. Considerable discrimination of water quality was observed when considering chemical and microbiological parameters of the Evros river ecosystem. Ardas river possesses a better water quality than Evros and Erythropotamos, which is mainly due to the higher quantities that these two rivers accumulate from industrial, farming and urban residues leading to higher degree of pollution. An increased microbial pollution was recorded in two of the three rivers monitored and a direct relation in microbial and chemical charging between water and cultivated-soil ecosystems was observed. The protection of these ecosystems with appropriate cultivated practices and control of human and animal activities will define the homeostasis of the environmental area.

Occurrence of Clostridium perfringens from different cultivated soils

The occurrence of Clostridium perfringens was estimated in 750 samples originated from a variety of soils bearing various bulb crops: Brawnica oderacea (vegetable), Olea europaea, Daucus carota (carote), Solanum tuberosum (potato), Phaseolus vulgaris (green haricot), Beta vulgaris var. rapaceum (beetroot), Cucurbita pepo (squash), Allium cepa (onion), Cucumis sativus (cucumber) and Capsicum annum (pepper). All isolated strains were tested for their antimicrobial activities to amoxicillin, penicillin G, kanamycin, tetracycline, streptomycin, erythromycin, chloramphenicol and metronidazole. When considering the type of the bulb production, it was observed increased number of C. perfringens spore densities in the most undersurface bulb soils. Moreover, C. perfringens spore are likely to occur in particularly large numbers in soil contaminated by fecal matter. Additionally, there is a close relationship between the spore amount and nature of organic content. Presence of C. perfringens was associated with acidic soil. Most of our strains showed resistance to the studied antibiotics applied usually for human and veterinary care. A systematic monitoring of the cultivated soil ecosystems must include bacteriological parameters together with chemical indices of organic pollution in order to obtain information adequate for assessing their overall quality.

Scattering and cloaking of binary hyper-particles in metamaterials

We derive the d-dimensional scattering cross section for homogeneous and composite hyper-particles inside a metamaterial. The polarizability of the hyper-particles is expressed in multi-dimensional form and is used in order to examine various scattering characteristics. We introduce scattering bounds that display interesting results when d --> ∞ and in particular consider the special limit of hyper-particle cloaking in some detail. We demonstrate cloaking via resonance for homogeneous particles and show that composite hyper-particles can be used in order to obtain electromagnetic cloaking with either negative or all positive constitutive parameters respectively. Our approach not only considers cloaking of particles of integer dimension but also particles with non-integer dimension such as fractals. Theoretical results are compared to full-wave numerical simulations for two interacting hyper-particles in a medium.

Effective-medium theory of surfaces and metasurfaces containing two-dimensional binary inclusions

The paper extends one-body effective-medium theory to incorporate the correct second-order interactions in a two-dimensional Maxwell-Garnett theory. The two-body inclusion problem is solved using the averaged dipole moments that are induced by the scattering electromagnetic field on the medium/inclusion system. By incorporating the appropriate polarizability factor in the solutions, conventional right-handed media with binary embeddings are analyzed while a different form for the polarizability term allows the study of the effective properties of a metasurface. In both cases, it is shown that the two-body coefficient to second order in the low area fraction of inclusions is exact, while the corresponding results of the Maxwell-Garnett and Bruggeman theories are incorrect. This is especially true in the superconducting and holes limits, respectively. In the study of metasurfaces, the requirement for electromagnetic screening of the inclusions as well as the requirement needed to achieve the Fröhlich condition are stated. Negative permittivity and permeability are presented for strong-scattering showing negative resonances for a given frequency spectrum. It is shown that these resonances disappear when we derive the weak-scattering limit. The possibility of obtaining doubly negative effective permittivity and permeability is discussed by using an appropriate polarization for the applied electromagnetic field propagating in the metasurface. Finally, the potential difference and hence voltage and capacitance between binary inclusions is determined for surfaces/metasurfaces which allows, in the case of metasurfaces, the behavior of split-ring-type resonators to be investigated.

Aerobic and Anaerobic Microbiology of the Immersion Chilling Procedure During Poultry Processing

The development of treatments to reduce bacterial numbers on poultry carcasses is important for the overall hygienic quality of birds. The important washing effect of the immersion chilling procedure is discussed. Systematic monitoring of fecal bacterial indicators as well as some classic pathogens was performed at selected critical points in a water chiller ecosystem. Clostridium perfringens, fecal coliforms, Enterococcus sp., and Streptococcus sp. were found in all water chiller samples. The temperature of the chiller ecosystem varied according to location: Escherichia coli and Salmonella sp. were found at 16 degrees C, compared with the 4 degrees C location, where these species were found in lower numbers. Moreover, the psychrotrophic bacterium Pseudomonas was found only at this last location. The temperature of the water during the immersion chilling procedure was unfavorable for the growth of Campylobacter sp., whose presence was always strictly associated with a pH close to 6. Spore forms of C. perfringens were persistent in all locations and seemed to be a reliable indicator of contamination of the water chiller ecosystem.

Rainwater harvesting, quality assessment and utilization in Kefalonia Island, Greece

The quality of harvested rainwater which is used for domestic and drinking purposes in the northern area of Kefalonia Island in SW Greece and the factors affecting it were assessed through 3-year surveillance. In 12 seasonal samplings, 156 rainwater and 144 ground- or mixed water samples were collected from ferroconcrete storage tanks (300-1000 m3 capacity), which are adjacent to cement-paved catchment areas (600-3000 m2). Common anions and major cations as well as the metals Fe, Mn, Cd, Pb, Cu, Cr, Ni and Zn were tested. The presence of three major groups of organic compounds, polycyclic aromatic hydrocarbons (PAHs), organochloride pesticides (OCPs) and volatile organic compounds (VOCs), was screened by common analytical techniques. All of the rainwater samples were within the guidelines for chemical parameters established by the 98/93/EU directive. As far as microbiological quality is concerned, total coliforms, Escherichia coli and enterococci were detected in 80.3%, 40.9% and 28.8% of the rainwater samples, respectively, although they were found in low concentrations. Chemical and microbiological parameters showed seasonal fluctuations. Principal component analysis revealed that microbiological parameters were affected mainly by the cleanness level of catchment areas, while chemical parameters were influenced by the sea proximity and human activities. Disinfection should be applied into the tanker trucks which distribute the water to the consumers and not into the big storage tanks in order to avoid by-products formation. Due to the lack of fluoride in rainwater samples, the consumers must become aware of the fact that the supplementation of this element is needed.