Enhanced global carbon cycle sensitivity to tropical temperature linked to internal climate variability.

The sensitivity of atmospheric CO2 growth rate to tropical temperature (γT) has almost doubled between 1959 and 2011, a trend that has been linked to increasing drought in the tropics. However, γT has declined since then. Understanding whether these variations in γT reflect forced changes or internal climate variability in the carbon cycle is crucial for future climate projections. We show that doubling sensitivity events can arise in simulations by Earth system models with perturbed initial conditions but are likely explained by internal climate variability. We show that the doubling sensitivity event is associated with the occurrence of a few, but very strong, El Niño events, such as 1982/83 and 1997/98. Such extreme events result in concurrent carbon release by tropical and extratropical ecosystems, increasing the variance of the global land carbon sink and its apparent sensitivity to tropical temperature. Our results imply that the doubling sensitivity does not necessarily indicate a change in carbon cycle response to climate change.

Carbon system state determines warming potential of emissions.

Current strategies to hold surface warming below a certain level, e. g., 1.5 or 2°C, advocate limiting total anthropogenic cumulative carbon emissions to ∼0.9 or ∼1.25 Eg C (1018 grams carbon), respectively. These allowable emission budgets are based on a near-linear relationship between cumulative emissions and warming identified in various modeling efforts. The IPCC assesses this near-linear relationship with high confidence in its Summary for Policymakers (§D1.1 and Figure SPM.10). Here we test this proportionality in specially designed simulations with a latest-generation Earth system model (ESM) that includes an interactive carbon cycle with updated terrestrial ecosystem processes, and a suite of CMIP simulations (ZecMIP, ScenarioMIP). We find that atmospheric CO2 concentrations can differ by ∼100 ppmv and surface warming by ∼0.31°C (0.46°C over land) for the same cumulated emissions (≈1.2 Eg C, approximate carbon budget for 2°C target). CO2 concentration and warming per 1 Eg of emitted carbon (Transient Climate Response to Cumulative Carbon Emissions; TCRE) depend not just on total emissions, but also on the timing of emissions, which heretofore have been mainly overlooked. A decomposition of TCRE reveals that oceanic heat uptake is compensating for some, but not all, of the pathway dependence induced by the carbon cycle response. The time dependency clearly arises due to lagged carbon sequestration processes in the oceans and specifically on land, viz., ecological succession, land-cover, and demographic changes, etc., which are still poorly represented in most ESMs. This implies a temporally evolving state of the carbon system, but one which surprisingly apportions carbon into land and ocean sinks in a manner that is independent of the emission pathway. Therefore, even though TCRE differs for different pathways with the same total emissions, it is roughly constant when related to the state of the carbon system, i. e., the amount of carbon stored in surface sinks. While this study does not fundamentally invalidate the established TCRE concept, it does uncover additional uncertainties tied to the carbon system state. Thus, efforts to better understand this state dependency with observations and refined models are needed to accurately project the impact of future emissions.

Tracking movements of meagre (Argyrosomus regius) during the spawning season: Preliminary indications of off estuary spawning.

Understanding the spawning behavior of meagre (Argyrosomus regius) is crucial for fisheries management and conservation. Meagre forms large spawning aggregations in estuaries, yet details of its spawning grounds remain elusive. We tagged 41 individuals and monitored their movements throughout several spawning seasons. Detections inside estuaries were limited. Fish detected inside the Tejo estuary during the spawning season performed regular movements toward coastal areas, suggesting potential spawning outside estuaries. Our findings underscore the significance of understanding meagre's migratory patterns for effective fisheries management and conservation strategies, supporting the establishment of spatial and seasonal closures during the spawning season.

Working with patients' treatment expectations - what we can learn from homeopathy.

The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.

Long-distance migrations and seasonal movements of meagre (Argyrosomus regius), a large coastal predator, along the Iberian Peninsula coast.

BACKGROUND: The meagre, Argyrosomus regius, is a large coastal predatory fish inhabiting waters from the north-eastern Atlantic and Mediterranean Sea, where it is targeted by commercial and recreational fisheries. Previous genetic studies have found an unexpectedly high population differentiation not only between the Atlantic and the Mediterranean, but also along the Atlantic coast. However, the reasons underpinning this genetic barrier remained unclear. Likewise, even though the species is amongst the world's largest marine teleosts, knowledge about its movement ecology and migratory behaviour remains notably scarce, and primarily reliant on fisheries-dependent data. METHODS: In this study, we used a combination of acoustic telemetry and pop-up satellite archival tags to investigate the movements of 22 adult meagre (70-143 cm total length) along the Southwestern coast of the Iberian Peninsula. RESULTS: Our results strongly suggest that the previously reported genetic differentiation is not maintained by limited adult dispersal/movement, as hypothesized. On the contrary, we documented some of the longest individual annual migrations ever recorded for a coastal teleost, up to > 2000 km, with frequent back-and-forth movements between the West and Southern Iberian coasts. Moreover, their detected regional movement patterns support the existence of a marked seasonal behavioural shift, with individuals being less active and moving to deeper waters during winter, and are consistent with spawning philopatry associated to their summer reproductive movements. Finally, we identified putative aggregation areas that may harbour important feeding/overwintering grounds. CONCLUSIONS: These findings shed new light on the movement and behaviour patterns of meagre that may be of particular importance for the conservation and spatial management of this species throughout its range, and open the door to further research on functional connectivity.

Tagging mortality in acoustic telemetry studies: Insights from a multispecies analysis.

The widespread adoption of acoustic telemetry has transformed our understanding of marine species' behavior and movement ecology. However, accurately interpreting telemetry data, especially concerning tagging mortality, is essential for drawing valid conclusions. In this study, we scrutinized tagging mortality in 223 individuals across 14 species and evaluated the impact of tagging methodologies, including capture method and size effects. Results reveal high tagging survival rates overall, attributable to the resiliency of the studied species and the rigorous animal welfare protocols followed during tagging procedures. Our results highlight the importance of tailoring array designs to the specific mobility patterns of the studied species for accurate survival assessments. This research contributes to generalizing mortality assessments and clearing the path for more precise and reliable telemetry studies in the future.

Depth and temperature preferences of meagre, Argyrosomus regius, as revealed by satellite telemetry.

Argyrosomus regius (commonly referred to as meagre), is one of Europe's largest coastal bony fish species and supports important recreational and commercial fisheries in the Atlantic and Mediterranean coasts. Demand for this species, and more recently for their swim bladders, has led to regional population declines and growing importance as an aquaculture species. Despite intense research in captivity, little is known about the spatial ecology of A. regius's wild population, including basic information such as vertical migrations and depth/temperature preferences. Previous research based on indirect data suggests a seasonal habitat shift from shallow to deeper waters, but this has never been validated through direct high-resolution movement data. In this study, we tagged 13 adult A. regius with pop-up satellite archival tags in the South of Portugal, which successfully returned data from 11 individuals including high-resolution data from six recovered tags (mean, range: 167 days, 28-301 days). We found that adults of this population spend 95.2% of their time between 5 and 75 m depth (mean ± SD, 30.9m ± 18.3m) and do not venture beyond 125 m. Across seasons, A. regius move across water temperatures between 13.3 and 24.8°C with a preferred thermal range between 14 and 18°C where they spent 75.4% of their time. The inferential modelling using this electronic data validated previous hypotheses by showing significant differences between a shallower and warmer summer habitat vs. a deeper and cooler winter habitat. Visual investigation of the diel effects on depth preferences suggests subtle changes in depth use between day and night during the warmer months of the year. We speculate that these patterns are in response to the species' behavioural ecology and physiology, reflecting the seasonal changes in water stratification and presence of prey, as well as on the species reproduction, which results in summer spawning aggregations in shallower areas.

Endodontic Outcome of Root Canal Treatment Using Different Obturation Techniques: A Clinical Study.

OBJECTIVE: To evaluate the clinical outcome of root canal treatment by obturation technique, root canal filling quality, and tooth- and patient-related variables. METHODS: This clinical study investigated the endodontic outcome of 114 teeth treated between the years 2009 and 2012. Three different obturation methods were used: (1) adhesive obturation using the continuous wave of condensation technique with Resilon® (CWR), (2) matching-taper single-cone technique with gutta-percha and AH Plus® (SCGP), and (3) matching-taper single-cone technique with gutta-percha and GuttaFlow® (SCGF). Pre- and postoperative periapical radiographs were performed to detect the presence of endodontic lesions (PAI classification) and to assess the quality of both the obturation and the restoration. Tooth- and patient-related data were collected. RESULTS: The overall endodontic success rate was 75.4% after a mean observation period of 6.3 years. There were no significant correlations between the type or overall quality of obturation and the treatment outcome. Teeth with preoperative lesions had the highest odds ratio (factor of 4.98) for endodontic failure. Tooth- and patient-related variables had no significant effect on endodontic outcome. CONCLUSIONS: The preoperative periapical status of teeth requiring endodontic treatment was a substantial prognostic factor for endodontic outcome, whereas the type of obturation material or technique did not affect it.

Methodological challenges and new perspectives of shifting vegetation phenology in eddy covariance data.

While numerous studies report shifts in vegetation phenology, in this regard eddy covariance (EC) data, despite its continuous high-frequency observations, still requires further exploration. Furthermore, there is no general consensus on optimal methodologies for data smoothing and extracting phenological transition dates (PTDs). Here, we revisit existing methodologies and present new prospects to investigate phenological changes in gross primary productivity (GPP) from EC measurements. First, we present a smoothing technique of GPP time series through the derivative of its smoothed annual cumulative sum. Second, we calculate PTDs and their trends from a commonly used threshold method that identifies days with a fixed percentage of the annual maximum GPP. A systematic analysis is performed for various thresholds ranging from 0.1 to 0.7. Lastly, we examine the relation of PTDs trends to trends in GPP across the years on a weekly basis. Results from 47 EC sites with long time series (> 10 years) show that advancing trends in start of season (SOS) are strongest at lower thresholds but for the end of season (EOS) at higher thresholds. Moreover, the trends are variable at different thresholds for individual vegetation types and individual sites, outlining reasonable concerns on using a single threshold value. Relationship of trends in PTDs and weekly GPP reveal association of advanced SOS and delayed EOS to increase in immediate primary productivity, but not to the trends in overall seasonal productivity. Drawing on these analyses, we emphasise on abstaining from subjective choices and investigating relationship of PTDs trend to finer temporal trends of GPP. Our study examines existing methodological challenges and presents approaches that optimize the use of EC data in identifying vegetation phenological changes and their relation to carbon uptake.

AR visualizations in laparoscopy: surgeon preferences and depth assessment of vascular anatomy.

Introduction: This study compares five augmented reality (AR) vasculature visualization techniques in a mixed-reality laparoscopy simulator with 50 medical professionals and analyzes their impact on the surgeon. Material and methods: ​​The different visualization techniques' abilities to convey depth were measured using the participant's accuracy in an objective depth sorting task. Demographic data and subjective measures, such as the preference of each AR visualization technique and potential application areas, were collected with questionnaires. Results: Despite measuring differences in objective measurements across the visualization techniques, they were not statistically significant. In the subjective measures, however, 55% of the participants rated visualization technique II, 'Opaque with single-color Fresnel highlights', as their favorite. Participants felt that AR could be useful for various surgeries, especially complex surgeries (100%). Almost all participants agreed that AR could potentially improve surgical parameters, such as patient safety (88%), complication rate (84%), and identifying risk structures (96%). Conclusions: More studies are needed on the effect of different visualizations on task performance, as well as more sophisticated and effective visualization techniques for the operating room. With the findings of this study, we encourage the development of new study setups to advance surgical AR.

Ocean warming favours a northern Argyrosomus species over its southern congener, whereas preliminary metabolic evidence suggests that hybridization may promote their adaptation.

Anthropogenic-induced climate change is having profound impacts on aquatic ecosystems, and the resilience of fish populations will be determined by their response to these impacts. The northern Namibian coast is an ocean warming hotspot, with temperatures rising faster than the global average. The rapid warming in Namibia has had considerable impacts on marine fauna, such as the southern extension of the distribution of Argyrosomus coronus from southern Angola into northern Namibian waters, where it now overlaps and hybridizes with the closely related Namibian species, A. inodorus. Understanding how these species (and their hybrids) perform at current and future temperatures is vital to optimize adaptive management for Argyrosomus species. Intermittent flow-through respirometry was used to quantify standard and maximum metabolic rates for Argyrosomus individuals across a range of temperatures. The modelled aerobic scope (AS) of A. inodorus was notably higher at cooler temperatures (12, 15, 18 and 21°C) compared with that of A. coronus, whereas the AS was similar at 24°C. Although only five hybrids were detected and three modelled, their AS was in the upper bounds of the models at 15, 18 and 24°C. These findings suggest that the warming conditions in northern Namibia may increasingly favour A. coronus and promote the poleward movement of the leading edge of their southern distribution. In contrast, the poor aerobic performance of both species at cold temperatures (12°C) suggests that the cold water associated with the permanent Lüderitz Upwelling Cell in the south may constrain both species to central Namibia. This is most concerning for A. inodorus because it may be subjected to a considerable coastal squeeze.

The impact of pharmaceutical form and simulated side effects in an open-label-placebo RCT for improving psychological distress in highly stressed students.

Open-label placebo (OLP) may be utilized to reduce psychological distress. Yet, potential contextual effects have not been explored. We investigated the impact of pharmaceutical form and the simulation of side effects in a parallel group RCT (DRKS00030987). A sample of 177 highly stressed university students at risk of depression were randomly assigned by computer generated tables to a 1-week intervention with active or passive OLP nasal spray or passive OLP capsule or a no-treatment control group. After the intervention, groups differed significantly in depressive symptoms but not regarding other outcomes of psychological distress (stress, anxiety, sleep quality, somatization), well-being or treatment expectation. OLP groups benefitted significantly more compared to the no-treatment control group (d = .40), OLP nasal spray groups significantly more than the OLP capsule group (d = .40) and the active OLP group significantly more than the passive OLP groups (d = .42). Interestingly, before intervention, most participants, regardless of group assignment, believed that the OLP capsule would be most beneficial. The effectiveness of OLP treatments seems to be highly influenced by the symptom focus conveyed by the OLP rationale. Moreover, pharmaceutical form and simulation of side effects may modulate efficacy, while explicit treatment expectation seems to play a minor role.

Tracking and evaluating motion skills in laparoscopy with inertial sensors.

BACKGROUND: Analysis of surgical instrument motion is applicable in surgical skill assessment and monitoring of the learning progress in laparoscopy. Current commercial instrument tracking technology (optical or electromagnetic) has specific limitations and is expensive. Therefore, in this study, we apply inexpensive, off-the-shelf inertial sensors to track laparoscopic instruments in a training scenario. METHODS: We calibrated two laparoscopic instruments to the inertial sensor and investigated its accuracy on a 3D-printed phantom. In a user study during a one-week laparoscopy training course with medical students and physicians, we then documented and compared the training effect in laparoscopic tasks on a commercially available laparoscopy trainer (Laparo Analytic, Laparo Medical Simulators, Wilcza, Poland) and the newly developed tracking setup. RESULTS: Eighteen participants (twelve medical students and six physicians) participated in the study. The student subgroup showed significantly poorer results for the count of swings (CS) and count of rotations (CR) at the beginning of the training compared to the physician subgroup (p = 0.012 and p = 0.042). After training, the student subgroup showed significant improvements in the rotatory angle sum, CS, and CR (p = 0.025, p = 0.004 and p = 0.024). After training, there were no significant differences between medical students and physicians. There was a strong correlation between the measured learning success (LS) from the data of our inertial measurement unit system (LSIMU) and the Laparo Analytic (LSLap) (Pearson's r = 0.79). CONCLUSION: In the current study, we observed a good and valid performance of inertial measurement units as a possible tool for instrument tracking and surgical skill assessment. Moreover, we conclude that the sensor can meaningfully examine the learning progress of medical students in an ex-vivo setting.

Root Maturation of an Immature Dens Invaginatus Despite Unsuccessful Revitalization Procedure: A Case Report and Recommendations for Educational Purposes.

BACKGROUND: The clinical management of teeth with complex dens invaginatus (DI) malformations and apical periodontitis may be challenging due to the lack of routine. The aim of this case report is to describe the endodontic treatment of an immature tooth with DI and to discuss strategies for preclinical training for teeth with such malformations. CASE REPORT: A 9-year-old male presented with an immature maxillary incisor with DI (Oehlers Type II) and apical periodontitis which was diagnosed by cone beam computed tomography (CBCT). Revitalization was initially attempted but then abandoned after failure to generate a stable blood clot. Nevertheless, considerable increase in both root length and thickness could be detected after medication with calcium hydroxide followed by root canal filling with MTA as an apical plug. CONCLUSIONS: The endodontic management of teeth with DI requires thorough treatment planning. In immature teeth, under certain conditions, root maturation may occur even with conventional apexification procedures. From an educational perspective, different strategies including CBCT and 3D-printed transparent tooth models for visualization of the complex internal morphology and redesigned 3D-printed replica with various degrees of difficulty for endodontic training, can be used to overcome the challenges associated with endodontic treatment of such teeth.

The Hand-Withdrawal-Method - An Adapted and Simplified Method of Limits for Behavioral Heat Pain Assessment.

The method-of-limits (MLI) is an established psychophysical procedure, for example for determining thermal thresholds. The standard MLI relies on fixating the thermode at the stimulation site by means of a strap and requires the participant to terminate the increase in heat by pressing a button. This, however, raises concerns regarding safety and task complexity in specific populations, such as cognitively impaired individuals, people with high fear of pain or young children (< 6 years). In this study, we aimed at developing a simplified version of the commonly used MLI for testing heat pain threshold (HPT) and tolerance (HPTol), and at validating it as a first step in healthy adults. Heating is terminated by withdrawing the hand from the heat probe, thereby ensuring maximum control and safety. For validation, HPTs and HPTols were assessed with the novel "hand-withdrawal-method" (HWM) and compared to the standard MLI, using a within-subject design. Additionally, as one potential research area in which the HWM may be used, we explored expectancy-induced placebo hypoalgesic effects by comparing results of standard MLI with those of HWM. Our data confirm good concordance between the 2 methods. For none of the outcomes significant differences between the 2 methods were found. PERSPECTIVE: In the present study in healthy adults, an adapted simplified and safe method of limits was demonstrated to be equivalent to the standard method-of-limits. This novel behavioral "hand-withdrawal-method" seems promising for future investigations of pain sensitivity and placebo effects, especially for specific populations such as young children.

Phantom study on surgical performance in augmented reality laparoscopy.

PURPOSE: Only a few studies have evaluated Augmented Reality (AR) in in vivo simulations compared to traditional laparoscopy; further research is especially needed regarding the most effective AR visualization technique. This pilot study aims to determine, under controlled conditions on a 3D-printed phantom, whether an AR laparoscope improves surgical outcomes over conventional laparoscopy without augmentation. METHODS: We selected six surgical residents at a similar level of training and had them perform a laparoscopic task. The participants repeated the experiment three times, using different 3D phantoms and visualizations: Floating AR, Occlusion AR, and without any AR visualization (Control). Surgical performance was determined using objective measurements. Subjective measures, such as task load and potential application areas, were collected with questionnaires. RESULTS: Differences in operative time, total touching time, and SurgTLX scores showed no statistical significance ([Formula: see text]). However, when assessing the invasiveness of the simulated intervention, the comparison revealed a statistically significant difference ([Formula: see text]). Participants felt AR could be useful for various surgeries, especially for liver, sigmoid, and pancreatic resections (100%). Almost all participants agreed that AR could potentially lead to improved surgical parameters, such as operative time (83%), complication rate (83%), and identifying risk structures (83%). CONCLUSION: According to our results, AR may have great potential in visceral surgery and based on the objective measures of the study, may improve surgeons' performance in terms of an atraumatic approach. In this pilot study, participants consistently took more time to complete the task, had more contact with the vascular tree, were significantly more invasive, and scored higher on the SurgTLX survey than with AR.

Local Shape Preserving Deformations for Augmented Reality Assisted Laparoscopic Surgery.

Image registration is a commonly required task in computer assisted surgical procedures. Existing registration methods in laparoscopic navigation systems suffer from several constraints, such as lack of deformation compensation. The proposed algorithm aims to provide the surgeons with updated navigational information about the deep-seated anatomy, which considers the continuous deformations in the operating environment. We extended an initial rigid registration to a shape-preserving deformable registration pathway by incorporating user interaction and an iterative mesh editing scheme which preserves local details. The proposed deformable registration workflow was tested with phantom and animal trial datasets. A qualitative evaluation based on expert feedback demonstrated satisfactory outcome, and an commensurate execution efficiency was achieved. The improvements offered by the method, couples with its relatively easy implementation, makes it an attractive method for adoption in future pre-clinical and clinical applications of augmented reality assisted surgeries.

Emergence of the physiological effects of elevated CO2 on land-atmosphere exchange of carbon and water.

Elevated atmospheric CO2 (eCO2 ) influences the carbon assimilation rate and stomatal conductance of plants, thereby affecting the global cycles of carbon and water. Yet, the detection of these physiological effects of eCO2 in observational data remains challenging, because natural variations and confounding factors (e.g., warming) can overshadow the eCO2 effects in observational data of real-world ecosystems. In this study, we aim at developing a method to detect the emergence of the physiological CO2 effects on various variables related to carbon and water fluxes. We mimic the observational setting in ecosystems using a comprehensive process-based land surface model QUINCY to simulate the leaf-level effects of increasing atmospheric CO2 concentrations and their century-long propagation through the terrestrial carbon and water cycles across different climate regimes and biomes. We then develop a statistical method based on the signal-to-noise ratio to detect the emergence of the eCO2 effects. The eCO2 effect on gross primary productivity (GPP) emerges at relatively low CO2 increase (∆[CO2 ] ~ 20 ppm) where the leaf area index is relatively high. Compared to GPP, the eCO2 effect causing reduced transpiration water flux (normalized to leaf area) emerges only at relatively high CO2 increase (∆[CO2 ] >> 40 ppm), due to the high sensitivity to climate variability and thus lower signal-to-noise ratio. In general, the response to eCO2 is detectable earlier for variables related to the carbon cycle than the water cycle, when plant productivity is not limited by climatic constraints, and stronger in forest-dominated rather than in grass-dominated ecosystems. Our results provide a step toward when and where we expect to detect physiological CO2 effects in in-situ flux measurements, how to detect them and encourage future efforts to improve the understanding and quantification of these effects in observations of terrestrial carbon and water dynamics.

No open-label placebo effect in insomnia? Lessons learned from an experimental trial.

BACKGROUND: Open-label placebo (OLP) treatment seems to be effective in several medical conditions but has not yet been investigated in insomnia. Furthermore, it needs to be evaluated whether providing a plausible treatment rationale is essential to obtain OLP effects. METHODS: In two consecutive nights, the sleep of patients with primary insomnia (n = 45) was assessed via subjective and objective measures. Before the second night, they received a single OLP pill that was randomly provided either with a treatment rationale (OLP+) or without (OLP-). When (M)ANOVAs did not reveal differential effects between the two OLP groups, the OLP+ group was compared post-hoc to a formerly assessed no pill control sample (NPC; n = 23). RESULTS: Neither the MANOVAs nor the ANOVAs revealed significant interaction effects of treatment group and assessment night. The OLP+ condition was superior neither to OLP- nor to NPC in improving the patients' sleep. DISCUSSION: Our findings do neither confirm the general efficacy of OLP in primary insomnia nor differential effects depending on the treatment rationale. Possible explanations lie in the dosing scheme (i.e., single OLP application), the provision of the OLP rationale by video and the experimental instead of therapeutic character of our investigation. Trials with larger samples and longer-term OLP treatment in insomnia are needed. Providing the rationale face-to-face and in a clinical setting might be additionally beneficial.