Combined Impact of Irrigation, Potassium Fertilizer, and Thinning Treatments on Yield, Skin Separation, and Physicochemical Properties of Date Palm Fruits.

Orchard cultural practices, i.e., irrigation, fertilizer, and fruit thinning, are crucially encompassed to enhance fruit yield and quality. Appropriate irrigation and fertilizer inputs improve plant growth and fruit quality, but their overuse leads to the degradation of the ecosystem and water quality, and other biological concerns. Potassium fertilizer improves fruit sugar and flavor and accelerates fruit ripening. Bunch thinning also significantly reduces the crop burden and improves the physicochemical characteristics of the fruit. Therefore, the present study aims to appraise the combined impact of irrigation, sulfate of potash (SOP) fertilizer, and fruit bunch thinning practices on fruit yield and quality of date palm cv. Sukary under the agro-climatic condition of the Al-Qassim (Buraydah) region, Kingdom of Saudi Arabia. To achieve these objectives, four irrigation levels (80, 100, 120, and 140% of crop evapotranspiration (ETc), three SOP fertilizer doses (2.5, 5, and 7.5 kg palm-1), and three fruit bunch thinning levels (8, 10, and 12 bunches palm-1) were applied. The effects of these factors were determined on fruit bunch traits, physicochemical fruit characteristics, fruit texture profile, fruit color parameters, fruit skin separation disorder, fruit grading, and yield attributes. The findings of the present study showed that the lowest (80% ETc) and highest (140% ETc) irrigation water levels, lowest SOP fertilizer dose (2.5 kg palm-1), and retaining the highest number of fruit bunch per tree (12 bunches) had a negative effect on most yield and quality attributes of date palm cv. Sukary. However, maintaining the date palm water requirement at 100 and 120% ETc, applying SOP fertilizer doses at 5 and 7.5 kg palm-1, and retaining 8-10 fruit bunches per palm had significantly positive effects on the fruit yield and quality characteristics. Therefore, it is concluded that applying 100% ETc irrigation water combined with a 5 kg palm-1 SOP fertilizer dose and maintaining 8-10 fruit bunches per palm is more equitable than other treatment combinations.

Effectiveness of radiographs and computed tomography in evaluating primary elbow osteoarthritis.

BACKGROUND: Preoperative radiographic assessment of osteophyte and loose body locations is critical in planning an arthroscopic débridement for primary elbow osteoarthritis. The purpose of this study was to evaluate the effectiveness of radiographs and computed tomography (CT) in localizing osteophytes and loose bodies. METHODS: A consecutive series of 36 patients with primary elbow osteoarthritis was investigated with radiographs and multiaxial 2-dimensional CT prior to elbow arthroscopy. The location of osteophytes and loose bodies was assessed in 9 anatomic locations by 2 fellowship-trained upper extremity surgeons. The diagnostic effectiveness of both imaging modalities was evaluated by calculating the sensitivity and specificity and compared to the gold standard of elbow arthroscopy. Inter- and intrarater percentage agreement between the observations was calculated using Kappa score. RESULTS: The mean sensitivity for detecting osteophytes in the 9 different anatomic locations was 46% with radiographs and 98% with CT, whereas the mean specificity was 66% and 21% for radiographs and CT, respectively. The mean sensitivity and specificity for loose body detection with radiography were 49% and 89%, respectively, whereas CT had a mean sensitivity of 98% and specificity of 47%. The overall inter-rater percentage agreement between the surgeons in detecting osteophytes and loose bodies on radiographs was 80% and 85%, respectively, whereas on CT it was 95% for detecting osteophytes and 91% for loose bodies. CONCLUSION: CT has greater sensitivity than radiographs for the detection of osteophytes and loose bodies in primary elbow osteoarthritis. The lower specificity of CT may be due to this imaging modality's ability to detect small osteophytes and loose bodies that may not be readily identified during elbow arthroscopy. Radiographs have an inferior inter-rater percentage agreement compared with CT. CT is a valuable preoperative investigation to assist surgeons in identifying the location of osteophytes and loose bodies in patients undergoing surgery for primary elbow osteoarthritis.

Assessment of the current knowledge and willingness to conduct medical research work of future healthcare providers: A cross-sectional study in Jeddah, Saudi Arabia.

BACKGROUND AND OBJECTIVES: Healthcare research work contributes significantly to the advancement and development of medical education. Numerous studies have demonstrated the efficiency and productivity of student participation in medical research work, which has a positive impact on the health system. In this study, we intended to examine medical students' knowledge and attitudes regarding, and actual participation in, medical research work. METHODS: This cross-sectional study was conducted on 184 medical students of Batterjee Medical College. The students received a paper-based survey questionnaire, containing multiple parts that related to their knowledge and attitudes regarding, and actual participation in, research work. One-way analysis of variance was utilized for the comparison of the average scores of the academic specialization groups. RESULTS: One hundred and forty-three participants completed the questionnaire, with a response rate of 78%. The overall average scores for the students' knowledge and attitudes regarding, and actual participation in, research work were 57.2%, 76%, and 31.5%, respectively. Medicine students obtained significantly higher average scores than the students of other specializations in terms of the scale of knowledge and attitudes regarding, and actual participation in, research work. The principal barriers that deterred the students from undertaking research work were poor time management (68.5%), inadequate feedback (64.3%), and a lack of research skills (54.5%). CONCLUSION: Medical students showed a low level of knowledge relating to research work and infrequently participated in them, but they reported a positive attitude toward research work activity. Extensive work is needed to overcome several barriers, such as poor time management and insufficient research skills.

Actualización en abuso de drogas por vía nasal / Update on drug abuse by nasal route

La vía nasal, ya sea mediante la inhalación o aspiración, se ha convertido en una ruta atractiva para quienes abusan de sustancias, principalmente por la fácil accesibilidad y la rápida absorción sistémica, además de evitar las consecuencias asociadas al uso de drogas intravenosas (enfermedades de transmisión). El objetivo de esta revisión es presentar una actualización de diversas sustancias que son utilizadas por esta vía, enfocándose en aquellas en las que se ha documentado daños en la anatomía nasal.

The nasal route, either by inhalation or aspiration, has become an attractive route for substances abusers, mainly because of its easy accessibility, rapid systemic absorption and also to avoid the consequences associated with intravenous drug use (transmitted diseases). The objective of this review is to present an update of various substances that are used by this route, focusing on those in which damage to the nasal anatomy has been documented.

Reference range of flaccid and stretched penile lengths of adult males in Baghdad: A cross-sectional study.

OBJECTIVES: To establish a baseline reference range for flaccid (FPL) and stretched penile lengths (SPL) in adult males and to compare with reports from different nationalities, as concerns over penile size are common among men and currently the number of men seeking help for the perceived problem of a 'short' penis is increasing. SUBJECTS AND METHODS: Over a 1-year period, FPL and SPL measurements were taken from males undergoing medical examination in the outpatient clinic of the Al-Karama Teaching Hospital, using a rigid centimetre ruler. The correlation between penile length and age was investigated. RESULTS: In all, 223 apparently healthy males were included in this study with a mean (SD; range) age of 41.3 (15.0; 20-77) years. The mean (SD; range) FPL was 9.8 (2.0; 5-17) cm and the SPL was 12.6 (1.9; 7.5-19.5) cm. Statistical analysis showed that penile length is increased in older age (>55 years). A penile length nomogram was constructed, showing that the 50th percentiles of FPL and SPL were 9.0 and 12.5 cm, respectively. CONCLUSION: Our data establish a baseline reference range for adult male penile lengths in the Capital of Iraq (Baghdad), which should be useful for urologists when counselling patients.

Impact of self-watching double j stent insertion on pain experience of male patients: a randomized control study using visual analog scale.

Objective. To confirm safety and feasibility of double J stent insertion under local anesthesia and to assess the effect of detailed explanation and observing double J stent insertion on pain experience of male patients. Material and Methods. Eighty consenting males, randomized and divided prospectively into group A, who were allowed to observe DJ stent insertion, and group B, were not observed. All DJ stent insertions were done by senior urologist in operating urology room with or without fluoroscopy guidance. At the end of the procedure the vital signs and duration of the procedure were documented and patients were asked to fill unmarked 100 mm visual analogue pain scale (VAS) as soon as the surgeon leaves operating room. Results. Mean age of entire study group was 38.8 years; the majority of the patients had DJ stent insertion for obstructed ureteric stone, with uneventful outcomes. Postprocedural systolic blood pressure and mean pain using VAS showed statistically significant difference between groups A and B. Conclusion. DJ stent insertion under local anesthesia is a safe and feasible procedure. We recommended self-watching and detailed explanation to patients who underwent DJ stent insertion to reduce the pain and anxiety associated with the procedure.

Cosmetic and functional outcomes of two-stage hypospadias repair: an objective scoring evaluation and uroflowmetry.

OBJECTIVE: The functional outcome following hypospadias repair is as important as the cosmetic outcome. Currently, structured scoring systems, patient questionnaires and evaluations of photographs and uroflowmetry are used to assess the results of hypospadias repair. In the present study, we assessed the outcomes of two-stage hypospadias repair using Hypospadias Objective Scoring Evaluation-HOSE and measures of uroflowmetry. MATERIAL AND METHODS: Over a period of eight years, from January 1997 to December 2004, 126 hypospadias patients were treated, 90 of these patients received two-stage repairs and 36 patients received single-stage repairs. HOSE questionnaire and uroflowmetry data were obtained to evaluate the long-term outcome of the two-stage hypospadias repairs. RESULTS: The age at the time of assessment ranged from 8 to 23 years-old, with a mean follow-up time of 39.78 months. Thirty-five patients had proximal hypospadias, and 20 had distal hypospadias. Of the 55 patients who received complete two-stage hypospadias repair and agreed to participate in the study, nineteen patients had acceptable HOSE scores and 36 patients had non-acceptable scores. The uroflow rates of 43 of the subjects were below the fifth percentile in three patients, equivocal (between the 5(th) and 25(th) percentile) in four patients and above the 25(th) percentile in 36 patients. CONCLUSION: Two-stage repair is a suitable technique for all types of hypospadias with varying outcomes. HOSE and uroflowmetry are simple, easy, non-invasive and non-expensive tools for objectively assessing the long-term outcomes of hypospadias repair.

Premedication intake behavior--does it predict behavior during dental treatment?

OBJECTIVES: To investigate whether behavior during hydroxyzine administration predicts children's behavior during dental treatment and whether behavior during treatment is affected by the complexity of treatment. MATERIALS AND METHOD: 118 children aged 2 to 6.5 years old were treated under conscious sedation with oral premedication (3.7 mg/kg of hydroxyzine in a concentration of 50 mg/5 cc. hydroxyzine) and 50% nitrous oxide/oxygen sedation. Children were divided in two age groups: aged 2 to < or = 4 years old, and aged 4 > to 6 years old. Behavior during first examination; cooperation during premedication administration, cooperation during nitrous oxide nose-mask placement, behavior during dental treatment, treatment duration and complexity of treatment were recorded. RESULTS: More children in the older group took the premedication willingly (p = 0.026). Significant correlation (p = 0.002) between behavior during examination and nitrous oxide mask acceptance was found in the older age group. No correlation was found regarding the cooperation during premedication intake and behavior during treatment within and between age groups. No statistical differences within the groups and between the groups were found between complexity of treatment and behavior during treatment. CONCLUSIONS: Premedication intake is not a reliable predictive tool for behavior during treatment in children aged 2-6.5 years. Complexity of treatment does not influence behavior during treatment in children aged 2-6.5 years.

Asthma knowledge and behaviours among mothers of asthmatic children in Aseer, south-west Saudi Arabia.

Mothers of children with bronchial asthma consecutively admitted to Aseer central hospital, Saudi Arabia (n = 171), were interviewed using a questionnaire based on the Chicago Community Asthma Survey to study their knowledge and behaviours concerning bronchial asthma. The least known information among mothers was the complications of bronchial asthma. Breathing exercises during asthma attacks were the least practised behaviour. In a multivariate analysis, significant risk factors for poor knowledge and behaviours among mothers were female sex of the child, illiterate mother and young age of mother (< 30 years). More education is needed to help the mothers of asthmatic children to acquire the necessary knowledge and practices to care for their children.

Identification of lactic acid bacteria in Moroccan raw milk and traditionally fermented skimmed milk 'lben'.

AIMS: To identify lactic acid bacteria (LAB) present in Moroccan dairy products to establish and preserve their microbial species diversity. METHODS AND RESULTS: Thirty-seven samples were collected from different farms. A total of 146 LAB were isolated and subjected to (GTG)(5)-PCR analysis. Comparison of the profiles with data available at the Moroccan Coordinated Collections of Micro-organisms allowed identification of 85 isolates. The remaining 61 were subjected to SDS-PAGE analysis of whole cell proteins. Comparison of the profiles with data available at the Belgian Coordinated Collections of Micro-organisms allowed identification of 43 isolates. Several of the remaining 18 isolates exhibited identical protein electrophoretic fingerprints. Therefore, eight representatives of them were subjected to partial pheS gene sequencing which allowed identification of all remaining isolates. In raw milk, six genera were found while in 'lben', three were found. This is the first report of Leuconostoc kimchii in dairy products. CONCLUSIONS: LAB diversity was established using a stepwise polyphasic identification approach. It used the expertise of both research bodies involved in this study and proved to be cost-effective for the identification of all isolates. SIGNIFICANCE AND IMPACT OF THE STUDY: To establish LAB diversity in Moroccan dairy products which could be a source of strains with specific properties.

A rare complication of a common operation: hepatic artery pseudo aneurysm following cholecystectomy report of a case.

BACKGROUND: Vascular injuries following cholecystectomy are a known entity though the incidence is low. More frequently we are seeing cases of right hepatic artery pseudo aneurysm post cholecystectomy after the advent of the laparoscopic approach. METHODS: We report a case of multiple right hepatic artery aneurysms as a complication of cholecystectomy in a 71-year-old patient. RESULTS: The diagnosis was confirmed by angiogram, and the patient was treated successfully with coil embolisation. CONCLUSION: Though it is a rare complication, early diagnosis and treatment of postoperative pseudo aneurysm is essential to prevent life threatening bleeding.

Hospital outbreak of vancomycin-resistant enterococci caused by a single clone of Enterococcus raffinosus and several clones of Enterococcus faecium.

A mixed outbreak caused by vancomycin-resistant Enterococcus raffinosus and Enterococcus faecium carrying the vanA gene was analysed. The outbreak occurred in a large hospital in Poland and affected 27 patients, most of whom were colonised, in three wards, including the haematology unit. The E. raffinosus isolates had a high-level multiresistant phenotype and were initially misidentified as Enterococcus avium; their unambiguous identification was provided by multilocus sequence analysis. The molecular investigation demonstrated the clonal character of the E. raffinosus outbreak and the polyclonal structure of the E. faecium isolates. All of the isolates carried the same Tn1546-like element containing an IS1251-like insertion sequence, located on a c. 50-kb conjugative plasmid. One of the E. faecium clones, found previously to be endemic in the hospital, was probably the source of the plasmid. The results of the study suggest that difficulties in identification may have led to an underestimate of the importance of E. raffinosus in vancomycin-resistant enterococci (VRE) control strategies.

A novel fluorescence imaging technique combining deconvolution microscopy and spectral analysis for quantitative detection of opportunistic pathogens.

A novel fluorescence imaging technique based on deconvolution microscopy and spectral analysis is presented here as an alternative to confocal laser scanning microscopy. It allowed rapid, specific and simultaneous identification of five major opportunistic pathogens, relevant for public health, in suspension and provided quantitative results.

Phylogeny and molecular identification of vibrios on the basis of multilocus sequence analysis.

We analyzed the usefulness of rpoA, recA, and pyrH gene sequences for the identification of vibrios. We sequenced fragments of these loci from a collection of 208 representative strains, including 192 well-documented Vibrionaceae strains and 16 presumptive Vibrio isolates associated with coral bleaching. In order to determine the intraspecies variation among the three loci, we included several representative strains per species. The phylogenetic trees constructed with the different genetic loci were roughly in agreement with former polyphasic taxonomic studies, including the 16S rRNA-based phylogeny of vibrios. The families Vibrionaceae, Photobacteriaceae, Enterovibrionaceae, and Salinivibrionaceae were all differentiated on the basis of each genetic locus. Each species clearly formed separated clusters with at least 98, 94, and 94% rpoA, recA, and pyrH gene sequence similarity, respectively. The genus Vibrio was heterogeneous and polyphyletic, with Vibrio fischeri, V. logei, and V. wodanis grouping closer to the Photobacterium genus. V. halioticoli-, V. harveyi-, V. splendidus-, and V. tubiashii-related species formed groups within the genus Vibrio. Overall, the three genetic loci were more discriminatory among species than were 16S rRNA sequences. In some cases, e.g., within the V. splendidus and V. tubiashii group, rpoA gene sequences were slightly less discriminatory than recA and pyrH sequences. In these cases, the combination of several loci will yield the most robust identification. We can conclude that strains of the same species will have at least 98, 94, and 94% rpoA, recA, and pyrH gene sequence similarity, respectively.

Phylogeny and identification of Enterococci by atpA gene sequence analysis.

The relatedness among 91 Enterococcus strains representing all validly described species was investigated by comparing a 1,102-bp fragment of atpA, the gene encoding the alpha subunit of ATP synthase. The relationships observed were in agreement with the phylogeny inferred from 16S rRNA gene sequence analysis. However, atpA gene sequences were much more discriminatory than 16S rRNA for species differentiation. All species were differentiated on the basis of atpA sequences with, at a maximum, 92% similarity. Six members of the Enterococcus faecium species group (E. faecium, E. hirae, E. durans, E. villorum, E. mundtii, and E. ratti) showed > 99% 16S rRNA gene sequence similarity, but the highest value of atpA gene sequence similarity was only 89.9%. The intraspecies atpA sequence similarities for all species except E. faecium strains varied from 98.6 to 100%; the E. faecium strains had a lower atpA sequence similarity of 96.3%. Our data clearly show that atpA provides an alternative tool for the phylogenetic study and identification of enterococci.

Photobacterium rosenbergii sp. nov. and Enterovibrio coralii sp. nov., vibrios associated with coral bleaching.

Six new Vibrio-like isolates originating from different species of bleached and healthy corals around Magnetic Island (Australia) were investigated using a polyphasic approach. Phylogenetic analyses based on 16S rRNA, recA and rpoA gene sequences split the isolates in two new groups. Strains LMG 22223(T), LMG 22224, LMG 22225, LMG 22226 and LMG 22227 were phylogenetic neighbours of Photobacterium leiognathi LMG 4228(T) (95.6 % 16S rRNA gene sequence similarity), whereas strain LMG 22228(T) was related to Enterovibrio norvegicus LMG 19839(T) (95.5 % 16S rRNA gene sequence similarity). The two new groups can be distinguished from closely related species on the basis of several phenotypic features, including fermentation of d-mannitol, melibiose and sucrose, and utilization of different compounds as carbon sources, arginine dihydrolase activity, nitrate reduction, resistance to the vibriostatic agent O/129 and the presence of fatty acids 15 : 0 iso and 17 : 0 iso. The names Photobacterium rosenbergii sp. nov. (type strain LMG 22223(T)=CBMAI 622(T)=CC1(T)) and Enterovibrio coralii sp. nov. (type strain LMG 22228(T)=CBMAI 623(T)=CC17(T)) are proposed to accommodate these new isolates. The G+C contents of the DNA of the two type strains are respectively 47.6 and 48.2 mol%.

Epidemiology of the human immunodeficiency virus in Saudi Arabia; 18-year surveillance results and prevention from an Islamic perspective.

BACKGROUND: data on HIV epidemiology and preventive measures in Islamic countries is limited. This study describes the results of 18-year of HIV surveillance in Saudi Arabia (SA) and the preventive measures implemented from an Islamic perspective. METHODS: surveillance for HIV has been underway in SA since 1984. Indications for HIV testing include clinical suspicion, screening of contacts of HIV-infected patients, and routine screening of blood and organ donors, prisoners, intravenous drug users, patients with other sexually transmitted infections, and expatriates pre-employment. This is a case series descriptive study of all confirmed HIV infections diagnosed in SA from 1984 through 2001. RESULTS: a total of 6046 HIV infections were diagnosed, of which 1285 (21.3%) cases were Saudi citizens. Over the 18-year surveillance period the number of HIV infections diagnosed annually among Saudi citizens gradually increased and, over the period 1997-2001, it reached to 84 to 142 cases per year. The number of cases per 100,000 population varied widely between regions with a maximum of 74 cases and a minimum of 2 cases. The infection was most common in the age group 20-40 years (74.6%) and predominantly affected men (71.6%). The modes of transmission among Saudi citizens and expatriates, respectively, were as follows: heterosexual contact, 487 (37.9%) and 1352 (28.4%) cases; blood transfusion, 322 (25.0%) and 186 (3.9%) cases; perinatal transmission, 83 (6.5%) and 19 (0.4%) cases; homosexual contact, 32 (2.5%) and 38 (0.8%) cases; intravenous drug use, 17 (1.3%) and 33 (0.7%) cases; bisexual contact, 10 (0.8%) and 14 (0.3%) cases; unknown, 334 (26.0%) and 3119 (65.5%) cases. The number of HIV infections transmitted by blood or blood products transfusion declined to zero by year 2001 and all such infections occurred due to transfusions administered before 1986. At HIV diagnosis, 4502/6046 (74.5%) patients had no symptoms, 787 (13.0%) patients had non-AIDS defining manifestations, and 757 (12.5%) patients had AIDS. A total of 514/1285 (40%) Saudi patients died by year 2001. CONCLUSIONS: the number of HIV cases in SA is limited with heterosexual contact being the main mode of transmission. From an Islamic perspective, preventive strategies include prevention of non-marital sex and intravenous drug use with encouragement of "safe sex" through legal marriage.

In situ identification of mycobacteria in Crohn's disease patient tissue using confocal scanning laser microscopy.

The diversity in the methodology employed to investigate Crohn's disease (CD) etiology has added significantly to the controversy of the mycobacterial role in this chronic inflammatory bowel disease. Mycobacterium avium subsp paratuberculosis (MAP), a proposed and suspected agent in many CD patients, is a fastidious and very slow grower bacillus, which causes Johne's disease (JD) in cattle. The methodology that has been widely and successfully used for isolation and identification of MAP from and in JD animals is not reliable and has proven to be unsuccessful in achieving the same objectives for CD diagnosis. In this study, a Confocal Scanning Laser Microscopy (CSLM) system has been employed in an attempt to detect MAP in CD patient. In situ hybridization was performed on full thickness tissue using rabbit anti-MAP polyclonal antibody that was adsorbed with E. coli protein extracts. Consequently, MAP was detected in the microvilli region in tissue specimens from CD patient and not in the controls. In the same CD tissue specimen, MAP was not detected when isotype normal rabbit sera was employed. The polyclonal antibody marker may be replaced with monoclonal antibodies, if available, or with MAP-specific-DNA or RNA probes. This technique adds an additional approach to investigate MAP role in CD etiology especially when the culture approach is long and inconsistent.

Open clinical trial of rifabutin and clarithromycin therapy in Crohn's disease.

BACKGROUND: Crohn's disease, an inflammatory bowel disease in humans, has a suspected aetiology of Mycobacterium avium subsp. Paratuberculosis. AIMS: To evaluate the role of rifabutin and clarithromycin anti-Mycobacterium avium subsp. Paratuberculosis treatment in Crohn's disease patients using an open clinical trial. METHODS: . A total of 36 patients with acute presentations of Crohn's disease, whose sera tested positive against p35 and p36 antigens (two recombinant proteins of Mycobacterium avium subsp. Paratuberculosis), were selected for treatment with rifabutin and macrolide antibiotic therapy Rifabutin and macrolide antibiotic therapy medications included 250 mg 1 po bid clarithromycin and 150 mg 1 po bid Ri-fabutin accompanied with a probiotic. Crohn's disease patients' response to rifabutin and macrolide antibiotic therapy was monitored over a period ranging from 4 to 17 months. RESULTS: Seven patients (19.4%) withdrew from the study since they were unable to tolerate medications. Of the remaining 29 patients, 21 (58.3%) reached a sustained state of improvement, traditionally defined as a decrease of 70 points between their entrance and exit Crohn's disease activity index scores together with the absence of the need of all other Crohn's medications, such as immunosuppressants and corticosteroids. Three Crohn's disease patients [8. 3%) noticed significant improvements, but required other Crohn's medications, concurrently with rifabutin and macrolide antibiotic therapy, to achieve and sustain improvement. Only 5 Crohn's disease patients (13.8%) were non-responders, noticing no marked improvement while on rifabutin and macrolide antibiotic therapy. CONCLUSION: The data add further evidence to support the role of rifabutin and macrolide antibiotic therapy in the treatment of Crohn's disease specifically in those patients with evidence of Mycobacterium avium subsp. Paratuberculosis infection. A large multi-centre clinical trial is needed to further explore these findings.