Breast Cancer Prevention Practices and Knowledge in Italian and Chinese Women in Italy: Clinical Checkups, Free NHS Screening Adherence, and Breast Self-Examination (BSE).

Breast cancer remains a significant global concern, underscoring the critical need for early detection and prevention strategies. Primary and secondary preventive measures, such as routine screenings and behaviors like breast self-examination (BSE), play a crucial role in facilitating early diagnosis. While the National Health System (NHS) in Italy offers free regular screenings for women aged 50-69, there is a lack of clarity regarding the participation of both Italian and Chinese women residing in Italy in these screening programs. This study aims to bridge this knowledge gap by thoroughly assessing the involvement in regular clinical check-ups and the types of screening employed, the adherence to free screenings offered by the NHS, and the practice of BSE among women aged 50-69 of these two groups. Furthermore, it investigates their knowledge and perceptions regarding breast cancer and BSE. Results reveal disparities in breast cancer control practice between Italian and Chinese women in Italy: the former demonstrates higher adherence to clinical checkups (53% vs. 3%, p < 0.001), while both groups show low participation in free NHS screenings (70% vs. 4%, p < 0.001). Additionally, Chinese women reported significantly lower frequency of mammography (96% vs. 33%, p < 0.001) and ultrasound (69% vs. 16%, p < 0.001). The frequency of BSE also differed substantially, with 47% of Chinese women never performing BSE compared to 12% of Italian women (p < 0.001). This comprehensive exploration provides valuable insights, attitudes, and knowledge into the disparities and potential areas for improvement in breast cancer prevention, thus contributing to the overall well-being of these communities. The findings highlight the necessity for educational initiatives aimed at improving awareness and participation in screenings, particularly among the Chinese population. These initiatives could have profound implications for patient education by equipping women with the knowledge and skills necessary to engage in proactive health behaviors.

Clinical Features of Takotsubo Syndrome and Its Differential Diagnostic Criteria in Clinical Nursing Practice: A Review of the Literature.

PURPOSE OF REVIEW: Takotsubo cardiomyopathy (TCM) is a heart disease that mimics the symptoms of a myocardial infarction (MI). The exact cause of TCM is unknown, but the main theory is that the syndrome is triggered by an excessive release of catecholamines, a consequence of factors related to stress or severe emotional distress. The aim of this review is to summarize the various scientific journal articles on the nursing differential diagnosis of TCM, on the specific nurse training (particularly the role of the Advanced Practice Nurse, APN), and on the nursing educational support for the patient after hospital discharge. RECENT FINDINGS: A literature review was conducted on Medline (via PubMed), Web of Science (WoS), Scopus, and Google Scholar databases. Relevant indexed articles that investigated the elements characterizing TCM in nursing differential diagnosis and the role of the APN were identified. RESULTS: Sixteen studies were included in the review; they highlighted the role of the nurse in identifying and educating patients with TCM. Nurses must have a thorough understanding of the syndrome, the onset symptoms, the unusual characteristics, and the probable etiology of TCM in order to recognize and promptly treat patients affected by this syndrome and have the opportunity to educate them after hospital discharge to reduce the possibility of recurrence.

Gambling and internet addiction: a pilot study among a Population of Italian Healthcare : Gambling and Internet Addition in a Healthcare Group.

AIM: Measuring the phenomenon of gambling and Internet addiction, with analysis of attitudes and psychophysical consequences among nurses working in different care settings. METHODS: An observational, cross sectional, multicenter study was conducted from April to September 2020. Participants' socio-demographic information, the "Internet Addiction Test" (IAT) scale, and the "South Oaks Gambling Screen" (SOGS) were collected in order to assess the overuse of and whether an individual has a problematic relationship with gambling, respectively. RESULTS: 502 nurses were enrolled in the study. Significant correlations were found (p < .001) between the IAT score and gender, number of years of work experience, job role, educational qualification; and between the SOGS and gender, number of years of work experience, job role and regions of Italy. CONCLUSIONS: The study highlighted an emerging social problem, and the results may be just the tip of the iceberg. Given the lack of knowledge of these phenomena and a high percentage of people who suffer from them but are afraid to admit it and get help, this study could also be useful in expanding knowledge and allow more professionals to get help and learn about possible treatments and cures for the resolution of these addictions.

Breast Cancer Prevention: The Key Role of Population Screening, Breast Self-Examination (BSE) and Technological Tools. Survey of Italian Women.

Breast cancer is the most common tumor among women worldwide and still remains the leading cause of death in women in Italy. Although survival from this pathology has increased, this disease and its treatment can have lasting or delayed effects that can greatly affect a woman's quality of life. Primary and secondary prevention are currently the best strategies to combat this cancer: improved lifestyle, early adherence to screening, Breast Self-Examination (BSE), and even now the use of technology, have become among the most important tools to ensure increasingly early diagnosis of this disease, which is a major cause of suffering and premature mortality in women. Indeed, early diagnosis of the disease can lead to a good prognosis and a high survival rate. This study investigates the attitude of Italian women to perform clinical checkups aimed at cancer prevention, particularly adherence to free screening programs offered by the National Health Service (NHS) for women in the 50-69 age group. The knowledge, use and emotional approach toward BSE as a screening tool and the use of dedicated apps for this purpose are also investigated. Low adherence to screening programs, lack of BSE practice, and nonuse of dedicated apps are just some of the results observed in this study. Therefore, it becomes essential to spread the culture of prevention, cancer awareness and the importance of screening throughout life.

Communicating bad news: attitudes and modes of communication of the health professions.

SUMMARY: TBackground. Information regarding ominous prognoses, which may cause concern and distress, should be provided carefully and cautiously, using non-traumatizing terminology, accommodating the patient's fears, and not excluding elements of hope. Goal. To analyze the difficulties of health care providers in the process of communicating bad news. Materials and Methods. An observational, cross-sectional, multicenter study was conducted from March to August 2021 among Italian Physicians and Nurses. Results. The results of the study indicate a greater participation of Nurse practitioners than Physicians, a fact that may indicate how necessary it is, to overcome the belief that the communication of bad news is of exclusive medical relevance. Among the participants in the study, about half, equal to 46.7% stated that they had no specific training, while the remainder claimed to have attended master's or higher education courses in 8.5% of cases, 23% attended conferences, while 21.8% acquired their skills through work experience. Conclusions. The communication of bad news, needs to be recognized in the same way as those procedures that characterize care itself, and for which the highest possible quality is sought.

Physical assessment techniques performed by Italian registered nurses: a quantitative survey.

AIMS AND OBJECTIVES: The aims of the study were to describe which of the core techniques of the physical assessment are regularly performed by a sample of Italian nurses, and to investigate the potential predictors of a more complete examination. BACKGROUND: Physical examination is among the essential tasks of nursing professionals, who are requested to perform a correct and complete physical assessment. DESIGN: Cross-sectional survey. METHODS: The study was performed between August 2013 and January 2014 in 17 Italian regions. A total of 1182 questionnaires were collected. RESULTS: Most participants were females (age range 41-50 years), and worked in Internal Medicine, Intensive Care and Surgical hospital units. Of the 30 core techniques that are currently taught and performed according to the Italian Baccalaureate degree requirements, 20 were routinely performed, 6 were seldom used and 4 were learnt but almost never performed (auscultation of lung, heart and bowel sounds and spine inspection). Graduate and postgraduate nurses, working in Intensive Care Units and Nursing Homes, were more prone than the others to carry out a more complete physical assessment. CONCLUSIONS: The skills to perform a physical assessment are suboptimal among this sample of Italian nurses. Health and educational providers should pose more attention and efforts to provide nurses with an acceptable training in physical examination practice. RELEVANCE TO CLINICAL PRACTICE: This study describes the specific physical techniques performed by nurses in real practice and provides information on which skills require more attention in nursing educational programmes.

Effects of Long COVID on Psycho-Physical Conditions in the Italian Population: A Statistical and Large Language Model Combined Description.

BACKGROUND: Long COVID refers to the persistence or development of signs and symptoms well after the acute phase of COVID-19. OBJECTIVE OF THE STUDY: To investigate the long-term outcomes of the SARS-CoV-2 infection in terms of psychological, social, and relational consequences within the Italian population. MATERIALS AND METHODS: We conducted an observational, cross-sectional, and multicenter study using an online questionnaire distributed to a sample of the Italian population. By utilizing the Short Form 12 Health Survey (SF-12) and the Hikikomori scale, we assessed perceived quality of life and social isolation, respectively. The questionnaire also included an open-answer question: "What will you remember about the pandemic period?". We used generative artificial intelligence to analyze and summarize the corresponding answers. RESULTS: A total of 1097 people participated in this study. A total of 79.3% (n = 870) of participants declared that they had been hospitalized and 62.8% (n = 689) received home care. Physical symptoms included headaches (43%, n = 472) and asthma (30.4%, n = 334). Additionally, 29.2% (n = 320) developed an addiction during the pandemic and, among these, 224 claimed internet addiction while 73 declared an emotional addiction. Furthermore, 51.8% (n = 568) experienced limitations in carrying out daily life activities. According to the Hikikomori scale, participants with positive SARS-CoV-2 infection exhibited higher levels of isolation compared to the others (p < 0.001). Participants without COVID-19 showed higher levels of emotional support (p < 0.001). Our semiautomatic analysis of the open-ended responses, obtained by a procedure based on a free large language model, allowed us to deduce and summarize the main feelings expressed by the interviewees regarding the pandemic. CONCLUSIONS: The data collected emphasize the urgent need to investigate the consequences of long COVID in order to implement interventions to support psychological well-being.

Can Music Reduce Stress and Anxiety in the Operating Room Team? Insights from a Cross-Sectional Study in Northern Italy Healthcare Services.

BACKGROUND: Music evokes positive emotions and reduces stress and anxiety. Operating room (OR) staff face various challenges which can lead to high levels of stress. The aim of the study is to assess whether listening to music during intraoperative phases improves the work environment by reducing anxiety and stress in the entire surgical team. METHODS: A prospective observational study was conducted from February to September 2023, involving medical personnel, nursing staff, and nursing students. They were divided into two groups: Group 1 with music during surgical procedures, and Group 2 without music. Participants were administered two validated instruments: the Zung Anxiety Self-Assessment Scale (SAS) to measure anxiety, and the Positive and Negative Affect Schedule to assess emotions generating stress. Additional items were included for demographics, job satisfaction, and the organization method. RESULTS: Music did not impact anxiety, but increased positive emotions while reducing negative ones. Music had an ancillary effect, highlighting the need for significant organizational interventions aimed at increasing operator satisfaction, including offering voluntary instead of mandatory assignments to nursing staff. CONCLUSIONS: Music appears to reduce stress in the intraoperative team when supported by a positive work environment in which assigned operators have chosen to work in the OR.

Exploring the Landscape of Breast Cancer Prevention among Chinese Residents in Italy: An In-Depth Analysis of Screening Adherence, Breast Self-Examination (BSE) Practices, the Role of Technological Tools, and Misconceptions Surrounding Risk Factors and Symptoms.

BACKGROUND: Breast cancer remains a significant health concern among women globally. Despite advancements in awareness and diagnostic techniques, it persists as a leading cause of death, with profound impacts on affected individuals' quality of life. Primary and secondary prevention, including regular screenings and practices like breast self-examination (BSE), are pivotal in ensuring early diagnosis. The national health system (NHS) in Italy offers screenings for women aged 50-69 every two years, managed by the local health authority. However, the participation rates, especially among the Chinese female population residing in Italy, are not well understood. METHODS: Using a snowball method, we electronically disseminated a survey to investigate how Chinese women living in Italy engage with available NHS screening programs. The survey also explores their practice of BSE and the use and impact of technological tools on prevention. Furthermore, the study aims to understand the subjects' depth of knowledge and misconceptions about breast cancer. RESULTS: The data reveal a significant gap in breast cancer screening adherence and knowledge among Chinese women in Italy, with a notable discrepancy between the general population and those who have previously encountered cancer. CONCLUSIONS: The results highlight the urgent need for interventions that are culturally sensitive, stressing that these actions are not only desirable but essential.

Work-family conflict in a cohort of Italian nurses. An observational, multicenter, cross-sectional study.

BACKGROUND AND AIM OF THE WORK: Work-family and family-work conflict can be defined as the degree to which participation in one role, in this case as a worker, interferes with the ability to cope with the responsibilities of another role, namely that of a member of a household. The aim of the study is to investigate the presence of indicators of work- family and/or family-work conflict in a cohort of Italian nurses and possible correlations with social and work variables. RESEARCH DESIGN AND METHODS: An observational, quantitative, multicenter survey was conducted for the study through the computerized administration of a validated questionnaire (Work-Family and Family-Work Conflict, CLF), with the implementation of sociographic variables. The cooperation of 15 Orders of Nursing Professions throughout the country was sought for sample collection. Data collection was bimonthly. RESULTS: Among the participating nurses, there is a statistically significant predominance of conflict in the family-work direction. In particular, the phenomenon seems to be related to age and the presence of children and/or elderly at home to care for. Some work variables seem to positively affect the prevention of potential work-life conflict, such as rostering and work articulation. CONCLUSIONS: These findings place emphasis on the need for healthcare organizations to address the work-family balance of their employees.

Acute myocardium infarction: difficulties and interventions perceived by Italian nurses and physicians.

BACKGROUND: Among cardiovascular diseases, acute coronary syndrome is the main cause of mortality and morbidity in the Western industrialized countries. Evidence suggested how continuous updating in cardiovascular area both for nurses and physicians was essential to improve patient outcomes in clinical process, welfare and rehabilitation, since physicians and nurses could play a key role in empowering the care of patients affected by the acute myocardium infarction (AMI). Although the correlation between continuous training and improvement of nursing care was therefore clear, the difficulties that nurses encountered in AMI patients' management remained unexplored. The present study aimed to identify any difficulties that both nurses and physicians in emergency/urgent departments encountered in the AMI patient care. METHODS: An observational, cross sectional, multicenter online study was conducted, in online mode. An ad hoc questionnaire was created and publicized through social networks, collecting only nurses and physicians. RESULTS: A total of 401 nurses and physicians were recruited. Significant association was assessed between the importance of the re-training participation and the item regarding: "To implement strategies to avoid excessive patient stress," since healthcare workers who constantly re-trained their competences encountered less difficulties than the others (P=0.002). By considering associations between the re-training condition and any interventions implemented by the interviewer to prevent or reduce the psycho-physical stress in AMI patients, a significant association (P=0.017) was assessed between the re-training condition and the improvement of the sleep-rest model (item no. 20), since healthcare professionals who re-trained their competences in the AMI care promoted regular rest condition in the AMI patients. CONCLUSIONS: The study highlighted the importance of basic and advanced training both for physicians and nurses in the AMI patient care, by demonstrating how health promotion and therapeutic education and information could be important to the AMI patient care.

Transcultural Nursing in Italy: An Explorative Study.

The health profile of foreigners in Italy is affected by multiple factors and events, including environmental, microbiological, cultural, and behavioral. To explore nurses' basic cross-cultural knowledge, and their perceptions of problems that arise in encounters with clients from outside the country, and to suggest solution strategies, we enrolled 327 nurses in an observational, cross-sectional, multicenter study. The findings suggested a need to improve sociocultural skills related to working in a multiethnic society, as early as the first level courses and possibly continue with appropriate master's degrees and research projects.

The role of the nursing coordinator and the leadership style in the Italian healthcare organizations.

BACKGROUND AND AIM: The leadership of the Nursing Coordinator is essential to ensure quality care and to empower the nursing staff. To identify the leadership style used by the coordinator as nurses and the support staff perceive the leadership behaviors of the coordinator. METHODS: Data were collected through an online questionnaire including the Empowering Leadership Questionnaire. RESULTS: Positive associations were recorded between participants' satisfaction levels and high standards of job performance (p<0.001), being a good example for the whole group (p=0.004) and to encourage sharing ideas and suggestions (p=0.003), hearing ideas and suggestions (p=0.013), giving the opportunity to express their opinions (p=0.046); in the "Coaching" dimension, according to attitudes to help the group to become aware (p<0.001), among all group members (p=0.044); by focusing on their goals (p<0.001); in the "Informing" dimension according to levels and attitudes to explain decisions (p<0.017) and rules and expectations (p=0.046); in the "Showing Concern/Interacting with the Team" dimension according to attitude in personal problems (p<0.028); to discuss concerns (p=0.033); to show interest (p<0.040) and to chat with members (p=0.003). Negative association was registered between the ability to make decisions based solely on the coordinator's ideas (p=0.010), ability to pay attention to the group's efforts (p<0.015). CONCLUSIONS: The role of the Nursing Coordinator within the work setting is very fundamental. The latter must be able to guarantee, through good leadership, a serene work environment so that professionals can provide optimal care to patients and safeguard their profession.

How knowledge time influenced anxiety, depression, stress and quality of life levels in patients suffering from Crohn disease: a cross-sectional multicenter study.

BACKGROUND AND AIM OF THE WORK: The diagnosis of Crohn Disease (CD) represents a turning point in the life of patients, which inevitably marks them. The present study represents a direct "feed-back" from patients suffering from Crohn disease, in order to reveal how the diagnosis of CD changed lifestyles and psychological conditions in their patients. METHODS: An observational, cross sectional, online, snowball sampling study was conducted through participants suffered from CD and belonged to social networks and Facebook groups. For each participant, sampling characteristics, a series of lifestyle habits Before to After the diagnosis of CD and anxiety, depression, and stress conditions were investigated. RESULTS: A total of 785 participants agreed to participate. As Participants underwent significant challenges in their lifestyles after the CD diagnosis (p<0.001), specifically their reduced their smoking habits, alcohol and drugs intakes and also their diets both in high sugar and fatty compositions. Anxiety and stress levels were not statistical different among participants according to years of the knowledge of their CDs. Meanwhile, as regards depression condition, significantly higher levels were recorded among participants who knew their CD until 5 and 25 years, respectively (p=0.031). CONCLUSIONS: From the study emerges several aspects of quality of life compromised, a fact supported by the analysis of psychophysical sequelae, which allowed to lay the groundwork for further studies, studying the comorbidity of this disease with other factors. Future randomized controlled trials should deepen the correlation between eating disorders and CD, a link little explored in the literature.

The Social and Professional Image of the Nurse: Results of an Online Snowball Sampling Survey among the General Population in the Post-Pandemic Period.

Background. The COVID-19 pandemic has transformed people's lifestyles by imposing social, economic, and labor changes. Health professionals have been in the spotlight, occasionally even elevated to the status of "heroes", as they have been at the forefront of the health emergency. Media exposure has undoubtedly played a pivotal role in the evolution and perception of the public's image of nurses, especially within the Italian context. Currently, there is only one study conducted in Italy during the pandemic period. For this reason, we have opted to delve further into this subject during the post-pandemic period, with the ultimate goal of identifying this perceptual evolution. Methods. An online snowball sampling survey was conducted among the Italian population using social networks between August 2022 and January 2023. The survey utilized the Nursing Attitude Questionnaire (NAQ) to collect data. Results. The sample consisted of 564 individuals. Among the respondents, 63.8% (n = 360) were familiar with the nursing pathway, and the level of agreement regarding the training of nurses was 81.5% (n = 260). In terms of recognizing the professional role of nurses, variations emerged in certain domains of the NAQ. Specifically, professional values of nurses were more pronounced in northern and central Italy (M = 26.27). Moreover, stereotypes were more prevalent in the north (23.73 ± 3.538) and the center (23.13 ± 4.104) (p = 0.001). Conclusions. The sample acknowledged a unique competence inherent to nurses that cannot be replaced by other professionals. The study population perceives the nursing profession as pivotal within the IHS (Integrated Health System). However, the attractiveness of the profession remains exceedingly low. This study was not registered on a publicly available registry.

A New Berlin Questionnaire Simplified by Machine Learning Techniques in a Population of Italian Healthcare Workers to Highlight the Suspicion of Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) syndrome is a condition characterized by the presence of repeated complete or partial collapse of the upper airways during sleep associated with episodes of intermittent hypoxia, leading to fragmentation of sleep, sympathetic nervous system activation, and oxidative stress. To date, one of the major aims of research is to find out a simplified non-invasive screening system for this still underdiagnosed disease. The Berlin questionnaire (BQ) is the most widely used questionnaire for OSA and is a beneficial screening tool devised to select subjects with a high likelihood of having OSA. We administered the original ten-question Berlin questionnaire, enriched with a set of questions purposely prepared by our team and completing the socio-demographic, clinical, and anamnestic picture, to a sample of Italian professional nurses in order to investigate the possible impact of OSA disease on healthcare systems. According to the Berlin questionnaire, respondents were categorized as high-risk and low-risk of having OSA. For both risk groups, baseline characteristics, work information, clinical factors, and symptoms were assessed. Anthropometric data, work information, health status, and symptoms were significantly different between OSA high-risk and low-risk groups. Through supervised feature selection and Machine Learning, we also reduced the original BQ to a very limited set of items which seem capable of reproducing the outcome of the full BQ: this reduced group of questions may be useful to determine the risk of sleep apnea in screening cases where questionnaire compilation time must be kept as short as possible.

Autism Spectrum Disorders and inclusion attitudes in the Italian school environments: teachers' knowledge, attitudes, perceptions and their necessity to consult a healthcare multidisciplinary team.

BACKGROUND: Schools play a key role in detecting early signs of autism and creating a targeted pathway of study and inclusion. This becomes complicated when faced with unknown situations, such as managing a student with Autism Spectrum Disorders (ASD). MATERIALS AND METHODS: A nationwide study involving teachers (n=235) was conducted from March to August 2021. The survey instrument consisted of a questionnaire administered online through social networks containing socio-demographic data, attitudes, knowledge and inclusion plans from school teachers towards students with ASD. RESULTS: Statistical significant differences were registered for the item no.13: among the main deficits caused by ADS are reduced social cognition, language abnormalities, and impaired sensory functioning. (p=.025); the item no.8 (p=.011): if an intervention works for one child with ASD, it is certain to work on another child with ASD; the item no.3(p=.002): genetic factors play an important role in the causes of ASD. By also considering teacher's attitudes towards ASD according to the presence of a healthcare worker in the school environment, significant differences were registered for the item no.1 (p=.032): the interpretation that the diagnostic criteria for Asperger's syndrome are the same as for high-functioning autism; the item no.6 (p=.025): children with ADS are very similar to each other, and the item no.7(p=.015): early intervention does not lead to additional benefits for children with ASD. CONCLUSIONS: The presence of professionals with advanced skills could be a benefit and represent a strong point in the application of measures of prevention and containment of community pathologies.

The satisfaction level perceived by Italians during the first phase of the Covid-19 pandemic phase.

Aim of the work.  To survey the degree of satisfaction of the Italian population in reference to the health care provided throughout the national territory in the period of emergency COVID-19. METHODS: Observational, cross sectional, multicenter study conducted during the first phase of the pandemic (May-June 2020) involving the national population (n=889) subjects, through an online survey. RESULTS: 889 people participated in the study. Among the perceptions regarding the level of satisfaction with the care received during the first pandemic wave, significant differences were found in the level of satisfaction with the health care received in general (p=.049), the degree of satisfaction toward the health care to people admitted to the hospital (p=. 046), to the treatment received for the COVID-19 test (p=.002), to the difficulty of contacting the general practitioner (.032), to the treatment received by their own health care company (p=.006), to the treatment received by the toll-free number (p<.001) and the 1500 number (p<.001) and the treatment received for one's own relative (p<.001). The greatest difficulty for all detected was finding surgical masks to protect themselves from infection. CONCLUSIONS: The COVID-19 pandemic seems not to have created new problems, rather it has shown - in a violent way - many of the challenges that have been looming for some time in the health services (and not only the Italian one) and, for these reasons, it is necessary to start from what has been learned in the last few months and draw new guidelines for the future.

Nurse's knowledge and perceptions on communicative hypnosis: an observational study.

Background Much evidence shows that hypnotic communication can have a pain-relieving effect and reduce complications such as anxiety, insomnia and depression. Whenever this technique was applied, the use of pharmaceuticals was reduced, there were less side effects, shorter hospitalization timesframes and lower treatment costs. Aim of the study Evaluate the knowledge and perceptions of nurses about hypnotic communication and the causes for which this technique is not frequently used. A secondary objective pointed to measuring the effectiveness of an educational event on hypnosis. Method The evaluation was done by administering an anonymous and voluntary survey, in a pre-test and post-test modality to nurses subscribed to a formative event on hypnotic communication organized by the Nursing Order, Province of Ravenna. Results 78 nurses participated in the study. The analysis of the pre-test results show a gap of knowledge regarding hypnotic communication. The main causes were found regarding the lack of use for hypnotic communication: stereotypes and prejudices related to this technique and insufficient university education. Conclusions The implementation of this technique, effective and efficient under various aspects, requires a preliminary creation of culture regarding this theme, capable of surpassing the stereotypes and resistances brought by a lack of theoretical elements.