Assessment of a Personalized Approach to Predicting Postprandial Glycemic Responses to Food Among Individuals Without Diabetes

IMPORTANCE

Emerging evidence suggests that postprandial glycemic responses (PPGRs) to food may be influenced by and predicted according to characteristics unique to each individual, including anthropometric and microbiome variables. Interindividual diversity in PPGRs to food requires a personalized approach for the maintenance of healthy glycemic levels.

OBJECTIVES

To describe and predict the glycemic responses of individuals to a diverse array of foods using a model that considers the physiology and microbiome of the individual in addition to the characteristics of the foods consumed.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study using a personalized predictive model enrolled 327 individuals without diabetes from October 11, 2016, to December 13, 2017, in Minnesota and Florida to be part of a study lasting 6 days. The study measured anthropometric variables, described the gut microbial composition, and assessed blood glucose levels every 5 minutes using a continuous glucose monitor. Participants logged their food and activity information for the duration of the study. A predictive model of individualized PPGRs to a diverse array of foods was trained and applied.

MAIN OUTCOMES AND MEASURES

Glycemic responses to food consumed over 6 days for each participant. The predictive model of personalized PPGRs considered individual features, including the microbiome, in addition to the features of the foods consumed.

RESULTS

Postprandial response to the same foods varied across 327 individuals (mean [SD] age, 45 [12] years; 78.0% female). A model predicting each individual's responses to food that considers several individual factors in addition to food features had better overall performance (R = 0.62) than current standard-of-care approaches using nutritional content alone (R = 0.34 for calories and R = 0.40 for carbohydrates) to control postprandial glycemic levels.

CONCLUSIONS AND RELEVANCE

Across the cohort of adults without diabetes who were examined, a personalized predictive model that considers unique features of the individual, such as clinical characteristics, physiological variables, and the microbiome, in addition to nutrient content was more predictive than current dietary approaches that focus only on the calorie or carbohydrate content of foods. Providing individuals with tools to manage their glycemic responses to food based on personalized predictions of their PPGRs may allow them to maintain their blood glucose levels within limits associated with good health.

Clostridium difficile infection after restorative proctocolectomy and ileal pouch anal anastomosis for ulcerative colitis

AIM

Clostridium difficile infection (CDI) of the ileal pouch following restorative proctocolectomy (RPC) is becoming increasingly recognized. We aimed to understand better (i) the associated risk factors, (ii) treatment practices and (iii) the pouch diversion and failure rate in patients who developed CDI of the pouch after RPC for ulcerative colitis (UC).

METHOD

Patients who tested positive for C. difficile of the pouch between 2007 and 2010 were included in the analysis. Data collected included patient demographics, time from RPC to documented CDI, the treatment of CDI and rate of excision of the pouch.

RESULTS

Of 2785 patients recorded in the hospital CDI database, 15 had had an RPC with ileal pouch anal anastomosis. The median age was 44 years and the median interval from RPC to first documented episode of CDI was 3 years. Thirteen (81%) patients had had multiple episodes of pouchitis before and after CDI infection, and all were symptomatic at the time of testing for CDI. Within 30 days of the diagnosis of CDI, six (40%) patients were taking immunosuppressive medication, seven (47%) were taking a proton pump inhibitor and 12 (80%) had received antibiotics. Five patients required hospitalization for CDI and four had severe infections characterized by a serum creatinine more than 1.5 times baseline (n = 3) and a white cell count above 15 000 (n = 1). Six patients who underwent endoscopy had severe inflammation of the pouch including the presence of a pseudomembrane in one case. Ten patients were treated with metronidazole alone and five with vancomycin. Two patients had recurrent CDI of the pouch during a median follow-up period of 2.9 years and one had CDI refractory to medical management. This patient required diversion of the pouch with an ileostomy for refractory CDI but no patient required excision of the pouch.

CONCLUSION

All 15 patients developing CDI of the pouch were successfully treated with antibiotics and only one required surgery in the form of an ileostomy.

Predictors of palliative treatment in stage IV colorectal cancer

BACKGROUND

Palliative treatment may be associated with prolonged survival and improved quality of life, but remains underutilized in stage IV colorectal (CRC). We examined a national cohort of stage IV CRC patients to determine the factors associated with palliative treatment.

METHODS

Stage IV CRC patients, classified based on their survival length (<6 months, 6-24 months, and 24 + months), were analyzed using the American College of Surgeons National Cancer Data Base (2004-2013). Multivariable analysis was performed to evaluate factors associated with palliative treatment.

RESULTS

Of 85,981 patients analyzed, 10.9% received palliative treatment. For 6-24 months survival, a more recent year of diagnosis, Medicaid, uninsured status, Mountain and Pacific regions were associated with higher odds of palliative treatment. For those who survived < 6months, older patients had lower odds, while academic centers and residence > 20 miles from treating institutions were associated with increased likelihood of palliative treatment.

CONCLUSIONS

Palliative treatment in stage IV CRC is associated with a more recent year of diagnosis, Medicaid, academic centers, Mountain and Pacific regions of the US.

The use of ileal pouch-anal anastomosis in patients with ulcerative colitis from 2009 to 2018

AIM

The existing literature was updated, assessing the use of surgery in patients with ulcerative colitis in more recent years.

METHODS

This was a retrospective observational study identifying all patients with ulcerative colitis within the National Inpatient Sample, years 2009-2018. All patients with International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnostic codes for ulcerative colitis were included. The primary outcome was the trend in total number of total abdominal colectomy, proctocolectomy and simultaneous versus delayed pouch construction.

RESULTS

A total of 1 184 711 ulcerative-colitis-related admissions were identified. An increase of 18.6% in the number of patients was observed, while the number of surgeries decreased. A total of 40 499 patients underwent total colectomy, annually decreasing from 5241 to 3185. The number of proctocolectomies without pouch decreased from 1191 to 530, while the number of patients undergoing pouch construction decreased from 2225 to 1284. The proportion of patients undergoing initial pouch at time of proctocolectomy decreased from 995 (45%) to 265 (21%), while the proportion of patients undergoing delayed pouch construction in 2018 was 79% (n = 1120).

CONCLUSION

Surgery use in ulcerative colitis has decreased in the last decade despite increasing numbers of hospital admissions in patients with this condition. While the overall proportion of patients undergoing pouch construction remained stable, the majority of patients were initially treated with total colectomy and their ileal pouches werre constructed in a delayed fashion.

Intravenous immunoglobulin use in managing severe, perioperative peristomal pyoderma gangrenosum following subtotal colectomy with end ileostomy for medically refractory chronic ulcerative colitis

Peristomal pyoderma gangrenosum (PPG) is a rare subtype of pyoderma gangrenosum that is characterized by painful, necrotic ulcerations occurring in the area surrounding an abdominal stoma. PPG is typically seen in younger patients with active inflammatory bowel disease. The etiology and pathogenesis is largely unknown and risk factors are not well defined. Therapy typically involves a combination of aggressive local wound care and systemic medications. Diagnosis and management of PPG can be difficult and data on treatment are limited. We present a case of severe postoperative peristomal recalcitrant to conventional therapy successfully treated with intravenous immune globulin.

Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study

Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.

Characteristics and outcomes of patients with colorectal cancer and bone metastasis

e15063

Background: Bone metastasis from colorectal cancer is a relatively rare phenomenon. The aim of this study is to identify the risk factors and survival patterns of bone metastasis after colorectal cancer diagnosis. Methods: A total of 23,846 colorectal cancer patients who were diagnosed between 1972 and 2017 at Mayo Clinic were included in the analysis. Freedom from bone metastasis since diagnosis at 5, 10, 15, 25 and 35-years were estimated using Kaplan-Meier method. Multivariable Cox regression models were used to assess the differences in overall survival rate for patients with different cancer sides and cancer locations. All tests were two-sided with alpha level set at 0.05. Results: A total of 798 (3.3%) patients had a diagnosis of bone metastasis after colorectal cancer diagnosis over a median follow up of 3.2 years. Thirty-five year freedom from bone metastasis was 83% (95%CI: 80%-86%) for all patients, and were 87.13%, 82.29% and 77.26% for left colon, right colon and rectal cancer patients. Male gender, recent surgical years, and higher cancer stage were associated with higher risk of developing bone metastasis after colorectal cancer diagnosis. Rectal cancer patients had higher hazard of developing bone metastases compared to left and right colon cancer patients. Conclusions: We were able to identify several patient and tumor-related factors associated with the development of bone metastasis in patients with colorectal cancer. The proportion and factors identified are similar to other studies. Future directions would be to analyze other molecular determinants within this subset of patients.[Table: see text]

BRAF-V600E and microsatellite instability prediction through CA-19-9/CEA ratio in patients with colorectal cancer

e15065

Background: Colorectal cancer (CRC) is a heterogeneous disease. Specifically for patients with BRAF-V600E mutations and/or mismatch repair deficiency or microsatellite instability-high (dMMR/MSI-High), there have been significant advances in terms of treatment options. Early identification of these subsets of patients has both prognostic and predictive value. We wanted to highlight an observation of utilizing 2 simple, rapid and universally available lab tests i.e. carbohydrate cancer antigen 19-9 and carcinoembryonic antigen tumor markers, the ratio (CA-19-9/CEA) of which can distinctly identify these patients. Methods: We included and analyzed the ratio of CA-19-9/CEA levels in patients with metastatic CRC at Mayo Clinic from December 2016 to February 2019, where both the results were available. Non-parametric tests were done to compare and contrast the differences in the median ratio and tumor marker levels. Results: BRAF-V600E mutant CRC patients had a discordantly profound elevation in CA-19-9 levels as opposed to the CEA levels. The median CA-19-9/CEA ratio was 20 (range: 0.3-167.3) in BRAF-V600E MSS patients as opposed to 4.40 (range: 0.003-216.2) in all other patients, p-value of 0.007 (Table). Similarly, the mean CA-19-9/CEA ratio for BRAF V600E MSS tumors was 57.15 (S.D.± 62.76) versus 10.5 (S.D.± 33.90) for all other types. Furthermore, this discordant elevation is not seen in BRAF-mutant MSI-High or any MSI-High patients (median CA-19-9/CEA ratio - 0.46). Conclusions: To date, this is the first report utilizing the ratio of tumor markers CA-19-9/CEA as predictive rather than just prognostic markers. It clearly identifies BRAF-V600E MSS and the MSI-High CRC patients from other subsets.[Table: see text]

Venous thromboembolism and bleeding after hepatectomy: role and impact of risk adjusted prophylaxis

Venous thromboembolism (VTE) occurs in 2-6% of post-hepatectomy patients and is associated with increased mortality and morbidity. The use of VTE risk assessment models in hepatectomy cases remains unclear. Our study aimed to determine the use and impact of Caprini guideline indicated VTE prophylaxis following hepatectomy. Hepatectomy cases performed during 2016-2021 were included. Caprini score and VTE prophylaxis were determined retroactively, and VTE prophylaxis was categorized as appropriate or inappropriate. The primary outcome was the receipt of appropriate prophylaxis, and secondary outcomes were postoperative VTE and bleeding. Statistical analyses included Fisher Exact test, Kruskal-Wallis, Pearson Chi-Square test, and multivariate regression models. R Statistical software was used for analysis. A p-value < 0.05 or 95% Confidence Interval (CI) excluding 1 was considered significant. A total of 1955 hepatectomy cases were analyzed. Patient demographics were similar between study cohorts. Inpatient, 30- and 90-day VTE rates were 1.28%, 0.56%, and 1.24%, respectively. By Caprini guidelines, 59% and 4.3% received appropriate in-hospital and discharged VTE prophylaxis, respectively. Inpatient VTE (4.5-fold) and mortality (9.5-fold) were lower in patients receiving appropriate prophylaxis. All discharged VTE and mortality occurred in patients not receiving appropriate prophylaxis. Inpatient, 30- and 90-day bleeding rates were 8.4%, 0.62%, and 0.68%, respectively. Appropriate prophylaxis did not increase postoperative bleeding. Increasing Caprini score inversely correlated with receiving appropriate prophylaxis (OR 0.38, CI 0.31-0.46) at discharge, and appropriate prophylaxis did not correlate with bleeding risk (OR 0.79, CI 0.57-1.12). Caprini guideline indicated prophylaxis resulted in reduced VTE complications without increasing bleeding risk.

Can preoperative ureteral stent placement help in the intraoperative identification of iatrogenic ureteral injury?

BACKGROUND

The benefits of prophylactic ureteral stent placement during colorectal surgery remain controversial. This study aimed to determine the incidence of ureteral injury in colorectal operations, assess the complications associated with stent usage, and determine whether their use leads to earlier identification and treatment of injury.

METHODS

This was a retrospective study of patients undergoing colorectal abdominal operations between 2015 and 2021. Variables were examined for possible association with ureteral stent placement. The primary study endpoint was ureteral injury identified within 30 days postoperatively.

RESULTS

Of 6481 patients who underwent colorectal surgery, 970 (15%) underwent preoperative ureteral stent placement. The use of stents was significantly associated with a higher American Society of Anesthesiologists classification, wound classification, and longer duration of surgery. A ureteral injury was identified in 28 patients (0.4%). Of these patients, 13 had no stent, and 15 had preoperative stents placed. After propensity matching, stent use was associated with an increased risk of hematuria and urinary tract infection. Ureteral injury was identified intraoperatively in 14 of 28 patients (50.0%) and was not associated with ureteral stent use (P = .45).

CONCLUSION

Iatrogenic ureteral injury was uncommon, whereas preoperative stent placement was relatively frequent. Earlier recognition of iatrogenic ureteral injury is not an expected advantage of preoperative ureteral stent placement.

Mutational profiles and amplifications on circulating tumor DNA testing in patients with young-onset colorectal cancer

e15067

Background: There has been a concerning rise of colorectal cancer (CRC) in young individuals (<50 years). There appears to be a preponderance of left-sided tumors and rectal cancers, however, the etiology and biology is not entirely known. Our aim was to describe the results of circulating tumor DNA based (ctDNA) testing in young-onset CRC. Methods: We studied the results of 186 patients with CRC who had ctDNA testing, of whom 41 (22%) had young-onset CRC from January 2017 to January 2019 at Mayo Clinic, Florida. They were categorized based on their age at diagnosis. Results: The age distribution and the aberrations seen are summarized in the table. 25 (61%) were left sided, 9 (22%) were right sided, 7 (17%) were rectal tumors. ctDNA testing was able to identify mutations in 4 (9.8%) patients with BRAFV600E, 8 (19.5%) with RAS and categorized 29 (70.7%) as RAS/RAF wild-type. Furthermore, amplifications were detected in MYC 6 (14.6%) , MET 3 (7.3%) and ERBB2 1 (2.4%). 3(7.3%) were MSI-High and there were 4 individuals with BRCA1/2 noted on ctDNA testing. Conclusions: ctDNA testing for young onset CRC is feasible and identifies a spectrum of clinically meaningful and actionable aberrations. These can further be of use to evaluate treatment response, progression or help in selection of clinical trials. [Table: see text]

The influence of operating room temperature and humidity on surgical site infection: A multisite ACS-NSQIP analysis

BACKGROUND

Literature evaluating intraoperative temperature/humidity and risk of surgical site infection (SSI) is lacking.

METHODS

All operations at three centers reported to the ACS-NSQIP were reviewed (2016-2020); ambient intraoperative temperature (⁰F) and relative humidity (RH) were recorded in 15-min intervals. The primary endpoint was superficial SSI, which was evaluated with multi-level logistic regression.

RESULTS

14,519 operations were analyzed with 179 SSIs (1.2%). The lower/upper 10th percentiles for temperature and RH were 64.4/71.4 °F and 33.5/55.5% respectively. Low or high temperature carried no significant increased risk for SSI (Low ⁰F OR = 0.95, 95% CI 0.51-1.77, P = 0.86; High ⁰F OR = 1.13, 95% CI = 0.69-1.86, P = 0.63). This was also true for low and high RH (Low RH OR = 0.96, 95% CI 0.58-1.61, p = 0.88; High RH OR = 0.61, 95% CI = 0.33-1.14, P = 0.12). Analysis of combined temperature/humidity showed no increased risk for SSI.

CONCLUSION

Significant deviations in intraoperative temperature/humidity are not associated with increased risk of SSI.

Morbid obesity among Crohn's disease patients is on the rise and is associated with a higher rate of surgical complications after ileocolic resection

AIM

Crohn's disease (CD) is regarded as a wasting disease, yet there is a growing population of CD patients with a body mass index (BMI) of 35 and above. The rate of postoperative complications is relatively high in CD patients but might be even higher in CD with morbid obesity (MO).

METHODS

This was a retrospective study using a prospectively maintained database of all patients undergoing Ileocolic resection for CD between 2014 and 2021 in two referral centres, comparing postoperative complication rates according to BMI.

RESULTS

Three hundred and forty-six patients were identified. Sixty patients (17%) had a BMI over 30 kg/m2, and 28 (8.1%) had a BMI of over 35 kg/m2 (>35 group). The BMI >35 group had more women (78.6% vs. 52%, P < 0.1), a higher rate of patients not receiving an anastomosis (7.1% vs. 2.5%, P = 0.02), a higher rate of any postoperative surgical complication (32.1% vs. 25.2%, P = 0.4), with a higher rate of Clavien-Dindo ≥3 (14.3% vs. 7.2%, P = 0.25), a higher rate of stoma creation on reoperation for complications (7.2% vs. 1.7%, P = 0.04), a higher rate of 30-day readmission due to intra-abdominal abscess (10.7% vs. 4.7%, P = 0.2), but a lower rate of postoperative medical complications (3.6% vs. 15.7%, P < 0.01).

CONCLUSIONS

The rate of MO among CD patients requiring ileocolonic resection is on the rise. MO in this setting is associated with statistically non-significant increases in all surgical complications, severe complications, readmission, and a higher chance for a bailout stoma creation upon reoperation. However, MO seems to be a protective factor for medical postoperative complications, which might suggest better nutritional status.

Mutational burden on circulating cell-free tumor-DNA testing as a surrogate marker of mismatch repair deficiency/microsatellite instability and/or response to immunotherapy in patients with colorectal cancer

e15066

Background: Circulating cell-free tumor-DNA (ctDNA) testing (‘liquid biopsy’) is increasingly being employed both in clinical trials as well as clinical practice. We aimed to contrast and compare the differences in the number of somatic mutations observed on ctDNA testing between mismatch repair deficient/microsatellite instability-high (dMMR/MSI-High) versus mismatch repair proficient/microsatellite stable (pMMR/MSS) colorectal cancers (CRC). Methods: We had 20 patients at Mayo Clinic Florida that were dMMR/MSI-High with testing through the commercially available platform (Guardant360) that uses a 73-gene panel. Median numbers of somatic mutations were compared between the 2 subset of CRC. Results: Patients with dMMR/MSI-High CRC had a median of 8 mutations (range: 2-15) versus a median of 4 mutations (range: 1-22) in pMMR/MSS patients, p-value of 0.001. Similarly, the mean number of somatic mutations were 7.47 (S.D. ± 4.15) versus 5.02 mutations (S.D. ± 3.83) in patients with dMMR/MSI-H and pMMR/MSS, tumors respectively. Though it is simplistic, we could still potentially identify patients who may be candidates for immunotherapy by gauging the mutational burden reported (Table). Furthermore, on serial testing, decline in mutational burden as early as few weeks into therapy was predictive of response later on imaging. Conclusions: Analysis of number of somatic mutations on ctDNA testing can be complementary to MMR/MSI-testing, especially in situations when tissue is not available or safe to obtain. This can also be of value in predicting and/or following response to immunotherapy. The utility of this may go beyond CRC in identifying patients who may benefit from immunotherapy. [Table: see text]

Circulating tumor DNA dynamics, serial testing and evolution on treatment in 322 colorectal cancer patients

3566

Background: According to the American Society of Clinical Oncology and College of American Pathologists (ASCO/CAP) joint review on circulating tumor DNA (ctDNA) issued in March 2018, widespread use of ctDNA assays in most patients with advanced cancer is still an area of ongoing research. However, multiple studies thereafter published and/or presented support its use in patients with metastatic colorectal cancer (CRC). This has led to several institutions adopting it as ‘clinical practice’. The aim of this study is to report on our institution’s adoption of ctDNA testing for every patient at the time of diagnosis and/or time of progression. Methods: We report on results of 322 CRC patients with 607 ctDNA tests at our center from January 2017 to February 2019 using a commercially available platform (Guardant360). Results: Among 322 patients of our cohort, a total of 607 ctDNA tests were done (Table). 127 (39.4%) of these tests were serial analyses. In the CRC patients who had serial testing, at progression, mechanisms of resistance included acquisition of KRAS, NRAS, EGFR mutations; and HER2- and MET-amplifications. The subclonal mutations were noted to disappear when the selective inhibition was stopped. This was seen in patients on targeted therapies/biologics rather than chemotherapy. This was of value in treatment modification, clinical trial selection and/or monitoring of disease progression in these patients. Conclusions: While ctDNA testing may not be ready for primetime in all advanced cancers, it is increasingly being adopted in practice for especially metastatic CRC. Of particular value is the serial ctDNA testing in the RAS/RAF wildtype subset and now BRAF V600E mutant CRC on anti-EGFR based therapies. [Table: see text]

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment

OBJECTIVE

The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients.

METHODS

Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events.

RESULTS

A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding.

CONCLUSION

Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1169-1182, 2024.