Disparities among Black and Hispanic colorectal cancer patients: Findings from the California Cancer Registry.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in California and second among Hispanic/Latinx (H/L) males. Data from the California Cancer Registry were utilized to investigate the differential impact on CRC outcomes from demographic and clinical characteristics among non-Hispanic white (NHW), non-Hispanic Black (NHB), U.S. born (USB), and non-U.S. born (NUSB) H/L patients diagnosed during 1995-2020. METHODS: We identified 248,238 NHW, 28,433 NHB, and 62,747 H/L cases (32,402 NUSB and 30,345 USB). Disparities across groups were evaluated through case frequencies, odds ratios (OR) from logistic regression, and hazard ratios (HR) from Cox regression models. All statistical tests were two-sided. RESULTS: NHB patients showed a higher proportion of colon tumors (75.8%) than NHW (71.5%), whereas both NUSB (65.9%) and USB (66.9%) H/L cases had less (p < 0.001). In multivariate models, NUSB H/L cases were 15% more likely than NHW to have rectal cancer. Compared to NHW, NHB cases had the greatest proportion of Stage IV diagnoses (26.0%) and were more likely to die of CRC (multivariate HR = 1.12; 95% CI = 1.10-1.15). Instead, NUSB H/L patients were less likely to die of CRC (multivariate HR = 0.87; 95% CI = 0.85-0.89) whereas USB H/L did not differ from NHW. CONCLUSIONS: NHB and H/L cases have more adverse characteristics at diagnosis compared to NHW cases, with NHB cases being more likely to die from CRC. However, NUSB H/Ls cases showed better survival than NHW and US born H/L patients. These findings highlight the importance of considering nativity among H/L populations to understand cancer disparities.

Estimation of disease burden and clinical severity of COVID-19 caused by Omicron BA.2 in Shanghai, February-June 2022.

An outbreak of COVID-19 caused by the SARS-CoV-2 Omicron BA.2 sublineage occurred in Shanghai, China from February 26 to June 30, 2022. We use official reported data retrieved from Shanghai municipal Health Commissions to estimate the incidence of infections, severe/critical infections, and deaths to assess the disease burden. By adjusting for right censoring and RT-PCR sensitivity, we provide estimates of clinical severity, including the infection fatality ratio, symptomatic case fatality ratio, and risk of developing severe/critical disease upon infection. The overall infection rate, severe/critical infection rate, and mortality rate were 2.74 (95% CI: 2.73-2.74) per 100 individuals, 6.34 (95% CI: 6.02-6.66) per 100,000 individuals and 2.42 (95% CI: 2.23-2.62) per 100,000 individuals, respectively. The severe/critical infection rate and mortality rate increased with age, noted in individuals aged 80 years or older. The overall fatality ratio and risk of developing severe/critical disease upon infection were 0.09% (95% CI: 0.09-0.10%) and 0.27% (95% CI: 0.24-0.29%), respectively. Having received at least one vaccine dose led to a 10-fold reduction in the risk of death for infected individuals aged 80 years or older. Under the repeated population-based screenings and strict intervention policies implemented in Shanghai, our results found a lower disease burden and mortality of the outbreak compared to other settings and countries, showing the impact of the successful outbreak containment in Shanghai. The estimated low clinical severity of this Omicron BA.2 epidemic in Shanghai highlight the key contribution of vaccination and availability of hospital beds to reduce the risk of death.

Struvite crystallization by using active serpentine: An innovative application for the economical and efficient recovery of phosphorus from black water.

Recovery of phosphorus from wastewater through struvite crystallization is one of the most attractive methods. However, the cost of chemical consumption makes this technology is unattractive to some extent. In this work, highly active serpentine was prepared by one-step mechanical activation and then used to recover phosphate as struvite from the black water containing 132.8 mg/L phosphorus and 3144 mg/L ammonia nitrogen. The results indicated that the prepared active serpentine can release magnesium ions and hydroxide ions simultaneously into an aqueous solution and is an ideal raw material for struvite crystallization. The factors for phosphorus recovery in this process mainly include mechanical activation intensity, serpentine dosage, and contact time. For the actual black water, a high recovery rate of phosphorus (>98%) is achieved by using active serpentine as the magnesium and alkali source for struvite precipitation. The recovery product was identified as struvite with a median particle size of 32.96 µm. It was confirmed that the mechanical activation damaged the crystal structure of the raw serpentine, improving the activity of Mg2+ and OH-. The undissolved Si-containing particles act as crystal seeds, accelerating the struvite crystallization process. Furthermore, a pilot-scale test was conducted with a rural public toilet in Xiong'an New District, Hebei Province. The results showed that an acceptable phosphorus recovery (98%) could be achieved using active serpentine. Additionally, it was demonstrated that the serpentine process to recover phosphate as struvite reduced the cost by 54.4% in compared with an ordinary chemical process. The active serpentine is a promising dual source of magnesium and alkali for the phosphorus recovery by the struvite method. It has a potential prospect for the large-scale application in phosphorus recovery and struvite fertilizer production.

Rapid and cost-effective screening of CRISPR/Cas9-induced mutants by DNA-guided Argonaute nuclease.

OBJECTIVE: With the widespread application of CRISPR/Cas9 gene editing technology, new methods are needed to screen mutants quickly and effectively. Here, we aimed to develop a simple and cost-effective method to screen CRISPR/Cas9-induced mutants. RESULT: We report a novel method to identify CRISPR/Cas9-induced mutants through a DNA-guided Argonaute nuclease derived from the archaeon Pyrococcus furiosus. We demonstrated that the Pyrococcus furiosus Argonaute (PfAgo)-based method could distinguish among biallelic mutants, monoallelic mutants and wild type (WT). Furthermore, this method was able to identify 1 bp indel mutations. CONCLUSION: The PfAgo-based method is simple to implement and can be applied to screen biallelic mutants and mosaic mutants generated by CRISPR-Cas9 or other kinds of gene editing tools.

Time-varying optimization of COVID-19 vaccine prioritization in the context of limited vaccination capacity.

Dynamically adapting the allocation of COVID-19 vaccines to the evolving epidemiological situation could be key to reduce COVID-19 burden. Here we developed a data-driven mechanistic model of SARS-CoV-2 transmission to explore optimal vaccine prioritization strategies in China. We found that a time-varying vaccination program (i.e., allocating vaccines to different target groups as the epidemic evolves) can be highly beneficial as it is capable of simultaneously achieving different objectives (e.g., minimizing the number of deaths and of infections). Our findings suggest that boosting the vaccination capacity up to 2.5 million first doses per day (0.17% rollout speed) or higher could greatly reduce COVID-19 burden, should a new wave start to unfold in China with reproduction number ≤1.5. The highest priority categories are consistent under a broad range of assumptions. Finally, a high vaccination capacity in the early phase of the vaccination campaign is key to achieve large gains of strategic prioritizations.

Selection of Muscle-Activity-Based Cost Function in Human-in-the-Loop Optimization of Multi-Gait Ankle Exoskeleton Assistance.

Using "human-in-the-loop" (HIL) optimization can obtain suitable exoskeleton assistance patterns to improve walking economy. However, there are differences in these patterns under different gait conditions, and currently most HIL optimizations use metabolic cost, which requires long periods to be estimated for each control law, as the physiological objective to minimize. We aimed to construct a muscle-activity-based cost function and to find the appropriate initial assistance patterns in HIL optimization of multi-gait ankle exoskeleton assistance. One healthy subject walked assisted by an ankle exoskeleton under nine gait conditions and each condition was the combination of different walking speeds, ground slopes and load weights. Ten assistance patterns were provided for the subject under each gait condition. Then we constructed a cost function based on surface electromyography signals of four lower leg muscles and select the muscle weight combination by using particle swarm optimization algorithm to compose the cost function with maximum differences between different assistance patterns. The mean weights of medial gastrocnemius, lateral gastrocnemius, soleus and tibialis anterior activity under all gait conditions are 0.153, 0.104, 0.953 and 0.145, respectively. Then we verified the effectiveness of this cost function by optimization and validation experiments conducted on four subjects. Our results are expected to guide the selection of muscle-activity-based cost functions and improve the time efficiency of HIL optimization.

Evidence for racial/ethnic disparities in emergency department visits following breast cancer surgery among women in California: a population-based study.

PURPOSE: Racial/ethnic disparities in breast cancer outcomes may be related to quality of care and reflected in emergency department (ED) visits following primary treatment. We examined racial/ethnic variation in ED visits following breast cancer surgery. METHODS: Using linked data from the California Cancer Registry and California Office of Statewide Health Planning and Development, we identified 151,229 women diagnosed with stage 0-III breast cancer between 2005 and 2013 who received surgical treatment. Differences in odds of having at least one breast cancer-related ED visit within 90 days post-surgery were estimated with logistic regression controlling for clinical and sociodemographic variables. Secondary analyses examined health care-related moderators of disparities. RESULTS: Hispanics and non-Hispanic (NH) Blacks had an increased likelihood of having an ED visit within 90 days of surgery compared to NH Whites [OR = 1.11 (1.04-1.18), p = 0.0016; OR = 1.38 (1.27-1.50), p < 0.0001, respectively]; the likelihood was reduced in Asian/Pacific Islanders [aOR = 0.77 (0.71-0.84), p < 0.0001]. Medicaid and Medicare (vs. commercial insurance) increased the likelihood of ED visit for NH Whites, and to a lesser degree for Hispanics and NH Blacks (p < 0.0001 for interaction). Receipt of surgery at an NCI-designated Comprehensive Cancer Center or at a for-profit (vs. non-profit) hospital was associated with reduced likelihood of ED visits for all groups. CONCLUSION: Racial/ethnic disparities in ED visits following breast cancer surgery persist after controlling for clinical and sociodemographic variables. Improving quality of care following breast cancer surgery could improve outcomes for all groups.

Improving Walking Economy With an Ankle Exoskeleton Prior to Human-in-the-Loop Optimization.

Lower limb robotic exoskeletons have shown the capability to enhance human locomotion for healthy individuals or to assist motion rehabilitation and daily activities for patients. Recent advances in human-in-the-loop optimization that allowed for assistance customization have demonstrated great potential for performance improvement of exoskeletons. In the optimization process, subjects need to experience multiple types of assistance patterns, thus, leading to a long evaluation time. Besides, some patterns may be uncomfortable for the wearers, thereby resulting in unpleasant optimization experiences and inaccurate outcomes. In this study, we investigated the effectiveness of a series of ankle exoskeleton assistance patterns on improving walking economy prior to optimization. We conducted experiments to systematically evaluate the wearers' biomechanical and physiological responses to different assistance patterns on a lightweight cable-driven ankle exoskeleton during walking. We designed nine patterns in the optimization parameters range which varied peak torque magnitude and peak torque timing independently. Results showed that metabolic cost of walking was reduced by 17.1 ± 7.6% under one assistance pattern. Meanwhile, soleus (SOL) muscle activity was reduced by 40.9 ± 19.8% with that pattern. Exoskeleton assistance changed maximum ankle dorsiflexion and plantarflexion angle and reduced biological ankle moment. Assistance pattern with 48% peak torque timing and 0.75 N·m·kg -1 peak torque magnitude was effective in improving walking economy and can be selected as an initial pattern in the optimization procedure. Our results provided a preliminary understanding of how humans respond to different assistances and can be used to guide the initial assistance pattern selection in the optimization.

Calculating the Electrical Conductivity of Graphene Nanoplatelet Polymer Composites by a Monte Carlo Method.

Electrical conductivity is one of several outstanding features of graphene-polymer nanocomposites, but calculations of this property require the intricate features of the underlying conduction processes to be accounted for. To this end, a novel Monte Carlo method was developed. We first established a randomly distributed graphene nanoplatelet (GNP) network. Then, based on the tunneling effect, the contact conductance between the GNPs was calculated. Coated surfaces (CSs) were next set up to calculate the current flow from the GNPs to the polymer. Using the equipotential approximation, the potentials of the GNPs and CSs met Kirchhoff's current law, and, based on Laplace equation, the potential of the CSs was obtained from the potential of the GNP by the walk-on-spheres (WoS) method. As such, the potentials of all GNPs were obtained, and the electrical conductivity of the GNP polymer composites was calculated. The barrier heights, polymer conductivity, diameter and thickness of the GNP determining the electrical conductivity of composites were studied in this model. The calculated conductivity and percolation threshold were shown to agree with experimental data.

Burden of influenza-associated outpatient influenza-like illness consultations in China, 2006-2015: A population-based study.

BACKGROUND: Human influenza virus infections cause a considerable burden of morbidity and mortality worldwide each year. Understanding regional influenza-associated outpatient burden is crucial for formulating control strategies against influenza viruses. METHODS: We extracted the national sentinel surveillance data on outpatient visits due to influenza-like-illness (ILI) and virological confirmation of sentinel specimens from 30 provinces of China from 2006 to 2015. Generalized additive regression models were fitted to estimate influenza-associated excess ILI outpatient burden for each individual province, accounting for seasonal baselines and meteorological factors. RESULTS: Influenza was associated with an average of 2.5 excess ILI consultations per 1000 person-years (py) in 30 provinces of China each year from 2006 to 2015. Influenza A(H1N1)pdm09 led to a higher number of influenza-associated ILI consultations in 2009 across all provinces compared with other years. The excess ILI burden was 4.5 per 1000 py among children aged below 15 years old, substantially higher than that in adults. CONCLUSIONS: Human influenza viruses caused considerable impact on population morbidity, with a consequent healthcare and economic burden. This study provided the evidence for planning of vaccination programs in China and a framework to estimate burden of influenza-associated outpatient consultations.

Influenza-associated excess respiratory mortality in China, 2010-15: a population-based study.

BACKGROUND: The estimation of influenza-associated excess mortality in countries can help to improve estimates of the global mortality burden attributable to influenza virus infections. We did a study to estimate the influenza-associated excess respiratory mortality in mainland China for the 2010-11 through 2014-15 seasons. METHODS: We obtained provincial weekly influenza surveillance data and population mortality data for 161 disease surveillance points in 31 provinces in mainland China from the Chinese Center for Disease Control and Prevention for the years 2005-15. Disease surveillance points with an annual average mortality rate of less than 0·4% between 2005 and 2015 or an annual mortality rate of less than 0·3% in any given years were excluded. We extracted data for respiratory deaths based on codes J00-J99 under the tenth edition of the International Classification of Diseases. Data on respiratory mortality and population were stratified by age group (age <60 years and ≥60 years) and aggregated by province. The overall annual population data of each province and national annual respiratory mortality data were compiled from the China Statistical Yearbook. Influenza surveillance data on weekly proportion of samples testing positive for influenza virus by type or subtype for 31 provinces were extracted from the National Sentinel Hospital-based Influenza Surveillance Network. We estimated influenza-associated excess respiratory mortality rates between the 2010-11 and 2014-15 seasons for 22 provinces with valid data in the country using linear regression models. Extrapolation of excess respiratory mortality rates was done using random-effect meta-regression models for nine provinces without valid data for a direct estimation of the rates. FINDINGS: We fitted the linear regression model with the data from 22 of 31 provinces in mainland China, representing 83·0% of the total population. We estimated that an annual mean of 88 100 (95% CI 84 200-92 000) influenza-associated excess respiratory deaths occurred in China in the 5 years studied, corresponding to 8·2% (95% CI 7·9-8·6) of respiratory deaths. The mean excess respiratory mortality rates per 100 000 person-seasons for influenza A(H1N1)pdm09, A(H3N2), and B viruses were 1·6 (95% CI 1·5-1·7), 2·6 (2·4-2·8), and 2·3 (2·1-2·5), respectively. Estimated excess respiratory mortality rates per 100 000 person-seasons were 1·5 (95% CI 1·1-1·9) for individuals younger than 60 years and 38·5 (36·8-40·2) for individuals aged 60 years or older. Approximately 71 000 (95% CI 67 800-74 100) influenza-associated excess respiratory deaths occurred in individuals aged 60 years or older, corresponding to 80% of such deaths. INTERPRETATION: Influenza was associated with substantial excess respiratory mortality in China between 2010-11 and 2014-15 seasons, especially in older adults aged at least 60 years. Continuous and high-quality surveillance data across China are needed to improve the estimation of the disease burden attributable to influenza and the best public health interventions are needed to curb this burden. FUNDING: National Science Fund for Distinguished Young Scholars, National Science and Technology Major Project of China, National Institute of Health Research, the Harvard Center for Communicable Disease Dynamics from the National Institute of General Medical Sciences, and the China-US Collaborative Program on Emerging and Re-emerging Infectious Disease.

Assessment of Human-to-Human Transmissibility of Avian Influenza A(H7N9) Virus Across 5 Waves by Analyzing Clusters of Case Patients in Mainland China, 2013-2017.

Background: The 2016-17 epidemic of human infections with avian influenza A(H7N9) virus was alarming, due to the surge in reported cases across a wide geographic area and the emergence of highly-pathogenic A(H7N9) viruses. Our study aimed to assess whether the human-to-human transmission risk of A(H7N9) virus has changed across the 5 waves since 2013. Methods: Data on human cases and clusters of A(H7N9) virus infection were collected from the World Health Organization, open access national and provincial reports, informal online sources, and published literature. We compared the epidemiological characteristics of sporadic and cluster cases, estimated the relative risk (RR) of infection in blood relatives and non-blood relatives, and estimated the bounds on the effective reproductive number (Re) across waves from 2013 through September 2017. Results: We identified 40 human clusters of A(H7N9) virus infection, with a median cluster size of 2 (range 2-3). The overall RR of infection in blood relatives versus non-blood relatives was 1.65 (95% confidence interval [CI]: 0.88, 3.09), and was not significantly different across waves (χ2 = 2.66, P = .617). The upper limit of Re for A(H7N9) virus was 0.12 (95% CI: 0.10, 0.14) and was not significantly different across waves (χ2 = 1.52, P = .822). Conclusions: The small cluster size and low Re suggest that human-to-human transmissibility of A(H7N9) virus has not changed over time and remains limited to date. Continuous assessment of A(H7N9) virus infections and human case clusters is of crucial importance for public health.

Comprehensive assessment of T-cell repertoire following autologous hematopoietic stem cell transplantation for treatment of type 1 diabetes using high-throughput sequencing.

OBJECTIVE: We aimed to investigate T-cell receptor (TCR) repertoires in type 1 diabetes (T1D) patients receiving autologous hematopoietic stem cell transplantation (AHSCT) treatment. METHODS: High-throughput deep TCR beta (TCRB) chain sequencing was performed to assess millions of individual TCRs in five T1D patients receiving AHSCT treatment and another five patients receiving insulin treatment during 12 months of follow-up. RESULTS: No significant changes in TCRB sequence reads, complementarity-determining region 3 (CDR3) sequences, or the usage of TCRB VJ gene-segments were observed at 12 months after AHSCT. Compared with the baseline, the usage of TCRB VJ gene-segments at 12 months decreased in the insulin treatment group (1836.4 ± 437.7 vs 2763.6 ± 390.6, P = 0.015), and the change rates were larger than those undergoing AHSCT (-0.62 ± 0.16 vs 0.06 ± 0.45, P = 0.002). Changes in the TCR repertoire were smaller after AHSCT than those with insulin treatment (P = 2.2*10-32 ). TCRBV 7-7/TCRBJ 2-5 was depleted after AHSCT while expanded with insulin treatment. TCRBV 12-4, TCRBV 10-3, TCRBV 12-3/TCRBJ 1-2 were expanded after AHSCT while ablated with insulin treatment. CONCLUSIONS: We found that AHSCT is safe without reduction in the diversity of TCR repertoires and TCR repertoires tend to be more stable after AHSCT. Furthermore, these four candidate TCRBV/TCRBJ gene usages on CDR3 regions may act as therapeutic targets and biomarkers.

Striking Racial/Ethnic Disparities in Liver Cancer Incidence Rates and Temporal Trends in California, 1988-2012.

Background: Hepatocellular carcinoma (HCC) is characterized by disparate risk patterns by race/ethnicity. We examined HCC incidence patterns and temporal trends among detailed racial/ethnic populations, including disaggregated Asian-American subgroups. Methods: Using data from the population-based California Cancer Registry, we identified 41 929 invasive HCC cases diagnosed during 1988-2012. Patients were grouped into mutually exclusive racial/ethnic groups of non-Hispanic (NH) white, NH black, Hispanic, and NH Asian/Pacific Islander (API), as well as Asian subgroups of Chinese, Filipino, Japanese, Korean, Vietnamese, Cambodian, Laotian, and South Asian. Age-adjusted and age-specific incidence rates by sex, race/ethnicity, and time period were calculated. The average annual percent change (AAPC) in incidence rates was estimated using joinpoint regression. All estimates were provided with the 95% confidence intervals (CIs). Results: Aggregated NH API had higher HCC risk than NH whites, NH blacks, and Hispanics. When disaggregated, Southeast Asians (Vietnamese, Cambodians, and Laotians) had overall HCC incidence rates eight to nine times higher than NH whites and more than twice that of other ethnic Asians. Statistically significant rising temporal trends of HCC were found in NH whites, NH blacks, and Hispanics, especially those older than age 50 years. Overall HCC risk declined in Chinese males (AAPC = -1.3%, 95% CI = -2.0 to -0.6), but rose in Filipino (AAPC = +1.2%, 95% CI = 0.3 to 2.1) and Japanese males (AAPC = +3.0%, 95% CI = 0.4 to 5.6) and Vietnamese (AAPC = +4.5%, 95% CI = 0.7 to 8.5) and Laotian (+3.4%, 95% CI = 0.1 to 6.8) females. Conclusions: Our findings provide valuable information for the identification of at-risk ethnic subgroups of Asian Americans while underscoring the importance of disaggregating ethnic populations in cancer research.

Stomach Cancer Disparity among Korean Americans by Tumor Characteristics: Comparison with Non-Hispanic Whites, Japanese Americans, South Koreans, and Japanese.

Background: Stomach cancer incidence shows substantial racial-ethnic disparity in the United States, with Korean Americans experiencing by far the highest incidence. We examined stomach cancer incidence trends in Korean Americans by tumor subsite, histology, and stage and compared them with incidence rates in racial-ethnic groups with the second highest rate (Japanese Americans) and the lowest rate (non-Hispanic whites; NHWs) as well as populations in South Korea and Japan.Methods: We calculated age-adjusted incidence rates by racial-ethnic groups, sex, and tumor characteristics, using the 1988-2012 California Cancer Registry data. Data on South Korea and Japan were obtained from the literature and other resources.Results: Between 1988 and 2012 in California, Korean Americans had about five times greater incidence than NHWs and twice that of Japanese Americans. Tumor characteristics differed by ethnic group and gender. The incidence in Korean Americans has declined during recent years, for both cardia and noncardia sites and for both intestinal- and diffuse-type histology. Although Korean Americans were diagnosed at an earlier stage than other Californians, the proportion with localized disease (43%) was much smaller than in South Korea (57%), where population-based screening is available.Conclusions: Stomach cancer incidence declined in the highest risk ethnic groups. However, the persistent disparity between Korean Americans and other racial-ethnic groups warrants additional strategies for prevention and earlier diagnosis.Impact: Analysis of California Cancer Registry data identified a racial-ethnic subgroup with stomach cancer disparity that may benefit from targeted prevention and screening efforts. Cancer Epidemiol Biomarkers Prev; 26(4); 587-96. ©2016 AACR.

Disparities in colorectal cancer incidence among Latino subpopulations in California defined by country of origin.

PURPOSE: In California, colorectal cancer (CRC) is the second most common cancer in Latinos. Using data from the California Cancer Registry, we investigated demographic and clinical characteristics of 36,133 Latinos with CRC living in California during 1995-2011 taking into account subpopulations defined by country of origin. METHODS: Cases were defined as Latino according to the North American Association of Central Cancer Registries Hispanic Identification Algorithm, which was also used to group cases by country of origin: Mexico (9,678, 27 %), Central or South America (2,636, 7 %), Cuban (558, 2 %), Puerto Rico (295, 1 %), and other or unknown origin (22,966, 64 %; Other/NOS). 174,710 non-Hispanic white (NHW) CRC cases were included for comparison purposes. Annual age-adjusted incidence rates (AAIR) and proportional incidence ratios (PIRs) were calculated. RESULTS: Differences were observed for age at diagnosis, sex distribution, socioeconomic status (SES), nativity (US born vs. foreign born), stage, and tumor localization across Latino subpopulations and compared to NHW. Mexican Latinos had the lowest AAIR and Cuban Latinos had the highest. PIRs adjusted for age, SES, and nativity showed an excess of CRC males and female cases from Cuba, female cases from Puerto Rico and reduced number of female cases from Mexico. CONCLUSIONS: Differences in cancer incidence patterns and tumor characteristics were observed among Latino subpopulations in California. These disparities may reflect differences in cancer determinants among Latinos; therefore, given that country of origin information is unavailable for a large proportion of these patients, greater efforts to collect these data are warranted.