Next generation antibacterial strategies for regenerative endodontic procedures: A scoping review.

BACKGROUND: The clinical results following regenerative endodontic procedures (REPs) vary according to numerous parameters, including the presence of bacteria. This limitation reduces the indications for REPs and calls for the development of next generation antibacterial strategies (NGAS) providing alternatives to current antibacterial strategies (CAS) such as double or triple antibiotic paste (DAP/TAP) and (Ca(OH)2). OBJECTIVES: The present scoping review aims to describe the current trends regarding the use of such strategies and highlight future perspectives. METHODS: Four databases (PUBMed, Cochrane, ClinicalTrials and Science Direct) were searched until 1st May 2023. RESULTS: A total of 918 records were identified, 133 were screened and assessed for eligibility, and 87 articles were included. The findings show that (1) clinical studies are only available for CAS, (2) although next generation strategies are the most studied approach since 2017, they are all at the pre-clinical stage, (3) most of the next generation strategies use galenic forms which offer cell support and colonization and which simultaneously contain antibacterial molecules as alternatives to CAS and to antibiotics in general, (4) standardization is required for future research, specifically regarding the bacterial strains studied, the use of biofilm studies and the cellular behaviour assessments. CONCLUSION: Although NGAS are promising strategies to improve REPs in the context of infection, the current evidence is mostly limited to pre-clinical studies. Further methodological improvement is required to allow relevant comparisons between studies and to reduce the time from bench to bedside.

A clinical decision rule to rule out bloodstream infection in the emergency department: retrospective multicentric observational cohort study.

BACKGROUND: We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED. METHODS: We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy. RESULTS: We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6). CONCLUSION: The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.

Cerebral epidural empyema due to Bartonella henselae: a case report.

BACKGROUND: Cat scratch disease frequently involves a benign, self-limited disease. Neurological forms associated with Bartonella henselae are uncommon, consisting mostly in neuroretinitis, encephalitis and meningitis. Cerebral epidural empyema has never described. CASE PRESENTATION: An adult patient was hospitalized for isolated headaches. Magnetic Resonance Imaging (MRI) identified typical features of cerebral epidural empyema. The diagnosis of B. henselae was performed incidentally by 16S rDNA gene sequencing on the abscess fluid, and confirmed by specific qPCR. We report here the first case, to our knowledge, of cerebral epidural empyema associated with B. henselae. Further follow-up visits allowed identifying frequent cat scratches on the scalp as the presumptive source of infection. CONCLUSIONS: This case report alerts about such atypical clinical presentation, which requires an extensive clinical investigation. It also emphasizes on the usefulness of additional molecular diagnosis techniques in such CNS infection cases.

[Applying active learning in pharmaceutical studies by the way of team-based learning]. / Mobilisation des pédagogies actives dans les études pharmaceutiques à travers les travaux de groupes.

Currently, the most used pedagogical approach in pharmaceutical studies is transmissive teaching, in which students usually adopt a passive attitude. The aim of this article is to present the main characteristics of active learning, and to point how it can be integrated in pharmaceutical studies by the way of team-based learning. According to its different characteristics, team-based learning is an authentic method of active learning. This pedagogical method includes a preparation time, usually individually performed, and followed by the group work itself, in which the case method is the most frequently used. Team-based learning also allows students to work in interdisciplinarity and facilitates interactions between peers. The wide majority of the studies demonstrate that students acclaim this pedagogical approach as compared to more conventional teaching methods, and that their satisfaction increases their commitment in the tasks proposed in the course. Even though the results of studies concerning the impact of team-based learning on student retention and scores in tests are somewhat discordant, this pedagogical approach allows the acquisition or the reinforcement of skills that will be useful to students in their future professional life, like collaborative work and confidence in their ability to complete a task.

Performance of penicillinase detection tests in Staphylococcus epidermidis: comparison of different phenotypic methods.

BACKGROUND: Staphylococcus epidermidis is the leading coagulase negative staphylococci (CoNS) species associated with healthcare associated infections. In order to de-escalate antimicrobial therapy, isolates of S. epidermidis lacking the blaZ gene should be eligible for targeted antimicrobial therapy. However, testing the susceptibility of coagulase negative staphylococci (CoNS) to penicillin G is no longer recommended by EUCAST, given the low performances for penicillinase detection in CoNS. The objective of this work was to determine a phenotypic method with high performance for detecting penicillinase production in S. epidermidis. RESULTS: Four techniques for the detection of penicillinase production (disk diffusion, zone edge test, nitrocefin test, Minimal Inhibitory Concentration (MIC) by automated system Vitek2®) were evaluated on 182 S. epidermidis isolates, using identification of blaZ gene by PCR as the reference method. The performance of the methods for penicillinase detection was compared by the sensitivity, the specificity, the negative predictive value and the positive predictive value, and with Cohen's kappa statistical test. Among the 182 S. epidermidis included in this study, 55 carried the blaZ gene. The nitrocefin test, characterized by a poor sensitivity (91%), was therefore excluded from S. epidermidis penicillinase detection. The algorithm proposed here for the penicillinase detection in S. epidermidis involved two common antimicrobial susceptibility techniques: disk diffusion method and MIC by Vitek2® system. Disk diffusion method, interpreted with a 26 mm breakpoint for penicillin G, was associated with a high sensitivity (98%) and specificity (100%). This method was completed with zone edge test for S. epidermidis with penicillin G diameter from 26 to 35 mm (sensitivity of 98%). The Vitek2® system is associated with a low sensitivity (93%) and a high specificity (99%) This low sensitivity is associated with false negative results, in isolates with 0.12 mg/L Penicillin G MIC values and blaZ positive. Thus for penicillin G MIC of 0.06 mg/L or 0.12 mg/L, a second step with disc diffusion method is suggested. CONCLUSIONS: According to our results, the strategy proposed here allows the interpretation of penicillin G susceptibility in S. epidermidis isolates, with an efficient detection of penicillin G resistance.

Pneumonia-Specific Escherichia coli with Distinct Phylogenetic and Virulence Profiles, France, 2012-2014.

In a prospective, nationwide study in France of Escherichia coli responsible for pneumonia in patients receiving mechanical ventilation, we determined E. coli antimicrobial susceptibility, phylotype, O-type, and virulence factor gene content. We compared 260 isolates with those of 2 published collections containing commensal and bacteremia isolates. The preponderant phylogenetic group was B2 (59.6%), and the predominant sequence type complex (STc) was STc73. STc127 and STc141 were overrepresented and STc95 underrepresented in pneumonia isolates compared with bacteremia isolates. Pneumonia isolates carried higher proportions of virulence genes sfa/foc, papGIII, hlyC, cnf1, and iroN compared with bacteremia isolates. Virulence factor gene content and antimicrobial drug resistance were higher in pneumonia than in commensal isolates. Genomic and phylogenetic characteristics of E. coli pneumonia isolates from critically ill patients indicate that they belong to the extraintestinal pathogenic E. coli pathovar but have distinguishable lung-specific traits.

Performance of the extended use of the FilmArray® BCID panel kit for bronchoalveolar lavage analysis.

Ventilator-associated pneumonia (VAP) are responsible for an increase in morbidity, mortality, and prolonged hospital stay. A multiplex PCR kit such as the FilmArray® BCID panel could allow early adaptation of antimicrobial therapy, which is crucial for clinical outcomes. The purpose of this study was to test the performances of FilmArray® BCID panel for the detection of bacteria producing VAP. We tested the FilmArray® BCID panel on 50 bronchoalveolar lavages (BALs), from patients hospitalized in two intensive care units at the Angers university hospital, compared to the conventional culture-based method. The sensitivity and the specificity of the FilmArray® BCID panel were 67.2% and 98.9% respectively. They were 88.6% and 98.3% respectively when considering BALs with a positive culture > 104 CFU/mL, and 94.7% and 99.6% respectively if considering BALs with a positive direct examination. This study underlines the good performance of the FilmArray® BCID panel for BAL fluid analysis. In case of positive direct examination, this test allows reliable results that can be obtained at an early stage, facilitating the early adaptation of antimicrobial therapy.

Extrahuman epidemiology of Acinetobacter baumannii in Lebanon.

The presence of Acinetobacter baumannii outside hospitals is still a controversial issue. The objective of our study was to explore the extrahospital epidemiology of A. baumannii in Lebanon. From February 2012 to October 2013, a total of 73 water samples, 51 soil samples, 37 raw cow milk samples, 50 cow meat samples, 7 raw cheese samples, and 379 animal samples were analyzed by cultural methods for the presence of A. baumannii. Species identification was performed by rpoB gene sequencing. Antibiotic susceptibility was investigated, and the A. baumannii population was studied by two genotyping approaches: multilocus sequence typing (MLST) and blaOXA-51 sequence-based typing (SBT). A. baumannii was detected in 6.9% of water samples, 2.7% of milk samples, 8.0% of meat samples, 14.3% of cheese samples, and 7.7% of animal samples. All isolates showed a susceptible phenotype against most of the antibiotics tested and lacked carbapenemase-encoding genes, except one that harbored a blaOXA-143 gene. MLST analysis revealed the presence of 36 sequence types (STs), among which 24 were novel STs reported for the first time in this study. blaOXA-51 SBT showed the presence of 34 variants, among which 21 were novel and all were isolated from animal origins. Finally, 30 isolates had new partial rpoB sequences and were considered putative new Acinetobacter species. In conclusion, animals can be a potential reservoir for A. baumannii and the dissemination of new emerging carbapenemases. The roles of the novel animal clones identified in community-acquired infections should be investigated.

Molecular epidemiology of Acinetobacter baumannii in different hospitals in Tripoli, Lebanon using bla(OXA-51-like) sequence based typing.

BACKGROUND: A. baumannii has emerged as an important nosocomial pathogen with an outstanding ability to acquire multidrug resistant mechanisms. In this study, we investigate the molecular epidemiology and carbapenem resistance mechanisms of A. baumannii in Tripoli, Northern Lebanon. METHODS: One hundred sixteen non-duplicate isolates isolated between 2011 and 2013 in different hospitals in Tripoli, Lebanon from Lebanese patients and wounded Syrian patients during Syrian war were studied. Antibiotic susceptibility testing was determined by agar disc diffusion and Etest. Carbapenemase-encoding genes were investigated by PCR. All isolates were typed by bla OXA-51-like sequence based typing (SBT) and 57 isolates were also analysed by MLST using Pasteur's scheme followed by eBURST analysis. RESULTS: Of the 116 isolates, 70 (60 %) showed a carbapenem resistance phenotype. The bla OXA-23 with an upstream insertion of ISAba1 was the major carbapenem resistance mechanism and detected in 65 isolates. Five isolates, including four from wounded Syrian patients and one from a Lebanese patient, were positive for bla NDM-1. bla OXA-51-like SBT revealed the presence of 14 variants, where bla OXA-66 was the most common and present in 73 isolates, followed by bla OXA-69 in 20 isolates. MLST analysis identified 17 sequence types (ST) and showed a concordance with bla OXA-51-like SBT. Each clonal complex (CC) had a specific bla OXA-51-like sequence such as CC2, which harboured bla OXA-66 variant, and CC1 harbouring bla OXA-69 variant. NDM-1 producing isolates belonged to ST85 (4 Syrian isolates) and ST25 (1 Lebanese isolate). CONCLUSIONS: Our results showed a successful predominance of international clone 2 with a widespread occurrence of OXA-23 carbapenemase in Lebanese hospitals. These findings emphasise the urgent need of effective measures to control the spread of A. baumannii in this country.

First report of endocarditis caused by a Pseudoclavibacter species.

We describe the first case of Pseudoclavibacter species endocarditis in a 44-year-old patient. This genus, rarely isolated from humans, confirms here its role as a human pathogen.

An experience of multidisciplinary tutorials sessions about antibiotics in the third year of pharmacy studies in Angers, France: learning assessment and evaluation of students' feelings by a mixed approach.

For undergraduate pharmacy students, the first step of antimicrobial stewardship learning objectives is to integrate antimicrobial knowledge from the foundational sciences. We hypothesised that using a multidisciplinary approach including two sessions of tutorials could be relevant in term of students' interest, satisfaction and learning retention time. The evaluation of students' feelings was based on a questionnaire including different dimensions and three focus groups with four students. Quantitative data were analysed with the EPI-INFO 7.2 software and a thematic analysis was implemented for qualitative data by using NVivo 12 software. The evaluation of students' learning concerned both short-time learning retention (STLR) and medium-time learning retention (MTLR), six months after the last session. Overall, 63 students responded to the questionnaire. Most of them appreciated the tutorials according to the different dimensions envisaged. Focus groups confirmed the interest of students for the multidisciplinary approach, interactions with teachers and opportunities of learning transfers. Concurrently, a lack of self-efficacy, low confidence towards the other students, external regulation of motivation and poor autonomy were recorded for some participants. Finally, there was no significant decrease between the scores of the STLR assessment and those of the MTLR assessment (58.5 ± 12.1/100 and 54.4 ± 8.9/100, respectively).

Emergence and spread of Mycobacterium ulcerans at different geographic scales.

The classical lineage of Mycobacterium ulcerans is the most prevalent clonal group associated with Buruli ulcer in humans. Its reservoir is strongly associated with the environment. We analyzed together 1,045 isolates collected from 13 countries on two continents to define the evolutionary history and population dynamics of this lineage. We confirm that this lineage spread over 7,000 years from Australia to Africa with the emergence of outbreaks in distinct waves in the 18th and 19th centuries. In sharp contrast with its global spread over the last century, transmission chains are now mostly local, with little or no dissemination between endemic areas. This study provides new insights into the phylogeography and population dynamics of M. ulcerans, highlighting the importance of comparative genomic analyses to improve our understanding of pathogen transmission. IMPORTANCE: Mycobacterium ulcerans is an environmental mycobacterial pathogen that can cause Buruli ulcer, a severe cutaneous infection, mostly spread in Africa and Australia. We conducted a large genomic study of M. ulcerans, combining genomic and evolutionary approaches to decipher its evolutionary history and pattern of spread at different geographic scales. At the scale of villages in an endemic area of Benin, the circulating genotypes have been introduced in recent decades and are not randomly distributed along the river. On a global scale, M. ulcerans has been spreading for much longer, resulting in distinct and compartmentalized endemic foci across Africa and Australia.

Wound colonization with methicillin-resistant Staphylococcus aureus and hypotheses about acquisition routes in rural health care settings in Sub-Saharan Africa: Perspective from a center devoted to the treatment of cutaneous neglected tropical diseases.

We identified a high prevalence (46.4%) of wound colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized in a center devoted to the treatment of cutaneous tropical diseases in Benin. The proportion of MRSA among S aureus isolates was 54.3%. Thirty percent of these MRSA were identified in outpatients. The analysis of pulsed-field gel electrophoresis demonstrated an important diversity of strains but also identified 8 small clusters containing between 2 and 4 isolates suggesting cross-transmission.

BIOFIRE® Blood Culture IDentification 2 (BCID2) panel for early adaptation of antimicrobial therapy in adult patients with bloodstream infections: a real-life experience.

Our objective was to assess the effectiveness of a multiplex PCR panel for blood culture identification (BCID2) on the implementation of appropriate antimicrobial therapy. We conducted a monocentric pre/post study comparing the time to result from direct microscopic examination (DE) to bacterial identification (BI) in positive blood cultures between 2 different periods: P1 without BCID2 and P2 with BCID2. Appropriate treatments prescribed before DE and after DE / BCID2 and after BI / BCID2 were compared using direct proportion comparison and survival analysis. For mono-microbial bloodstream infections, the proportion of appropriate antimicrobial treatment after DE was 50% in P1 vs. 87.5% after BCID2 in P2 (P < 0.001) for Gram-negative bacteria and 33.0% in P1 vs. 64.4% in P2 (P < 0.01) for Gram-positive bacteria. A significant difference (P = 0.04) was recorded with survival curves for Gram positive bacteria. BCID2 seems effective in reducing the time for prescribing appropriate antimicrobials.

Impact of a strategy based on unique blood culture sampling on contamination rate and detection of bloodstream infections in critically ill patients.

BACKGROUND: Unique blood culture (UBC) has been proposed to limit the number of venipuncture and to decrease the risk of BC contaminations (BCC) without affecting their yield. We hypothesized that a multi-faceted program based on UBC in the ICU may reduce the rate of contaminants with a similar performance for bloodstream infections (BSI) identification. METHODS: In a before and after design, we compared the proportion of BSI and BCC. A first 3-year period with multi-sampling (MS) strategy followed by a 4-month washout period, where staff received education and training for using UBC, and a 32-month period, where UBC was routinely used, while education and feedback were maintained. During the UBC period, a large volume of blood (40 mL) was sampled through a unique venipuncture with additional BC collections discouraged for 48 h. RESULTS: Of the 4,491 patients included (35% female patients, mean age 62 years) 17,466 BC were collected. The mean volume of blood per bottle collected increased from 2.8 ± 1.8 mL to 8.2 ± 3.9 mL between the MS and UBC periods, P < 0.01. A 59.6% reduction (95% CI 56.7-62.3; P < 0.001) of BC bottles collected per week was observed between the MS and UBC periods. The rate of BCC per patient decreased between the two periods from 11.2% to 3.8% (73.4% reduction; P < 0.001) for the MS and UBC periods, P < 0.001. Meanwhile, the rate of BSI per patient remained stable at 13.2% and 13.2% for the MS and UBC periods, P = 0.98. CONCLUSIONS: In ICU patients, a strategy based on UBC reduces the contamination rate of cultures without affecting their yield.

Cell surface properties of two differently virulent strains of Acinetobacter baumannii isolated from a patient.

The aim of this study was to unravel, by focusing on cell surface properties, the underlying virulence factors contributing to the difference in the pathogenicity observed in two Acinetobacter baumannii strains isolated from the same patient. The two strains were phenotypically different: (i) a mucoid strain (AB-M), highly virulent in a mouse model of pneumonia, and (ii) a nonmucoid strain (AB-NM), moderately virulent in the same model. The study of the cell surface properties included the microbial adhesion to solvents method, the measurement of the electrophoretic mobility of bacteria, the analysis of biofilm formation by calcofluor white staining, the adherence to silicone catheters, and scanning electron microscopy. The AB-NM strain was more hydrophobic, more adherent to silicone catheters, and produced more biofilm than the AB-M strain. Scanning electron microscopy showed bacterial cells with a rough surface and the formation of large cell clusters for AB-NM whereas the AB-M strain had a smooth surface and formed only a few cell clusters. Contrary to the results of most previous studies, cell surface properties were not correlated to the virulence described in our experimental model, indicating that mechanisms other than adherence may be involved in the expression of A. baumannii virulence.

Machine-learning approaches prevent post-treatment resistance-gaining bacterial recurrences.

Despite susceptibility testing, recurrent infections are common and are associated with resistance. Using whole-genome sequencing, Stracy et al. demonstrated that recurrence is often driven by a different strain than the original infection. By machine-learning analysis, they developed an algorithm for patient-specific recommendations to minimize antimicrobial resistance (AMR) at the individual-patient level.

A combined field study of Buruli ulcer disease in southeast Benin proposing preventive strategies based on epidemiological, geographic, behavioural and environmental analyses.

Buruli ulcer is a neglected tropical disease caused by M. ulcerans, an environmental mycobacterium. This cutaneous infectious disease affects populations with poor access to sanitation, safe water and healthcare living in rural areas of West and Central Africa. Stagnant open bodies of surface water and slow-running streams are the only risk factor identified in Africa, and there is no human-to-human transmission. Appropriate and effective prevention strategies are required for populations living in endemic areas. Based on a multidisciplinary approach in an area in which Buruli ulcer is endemic in South Benin, we investigated the link between all human-environment interactions relating to unprotected water and behaviors associated with Buruli ulcer risk likely to affect incidence rates. We characterised the sources of water as well as water bodies and streams used by communities, by conducting a prospective case-control study directly coupled with geographic field observations, spatial analysis, and the detection of M. ulcerans in the environment. A full list of the free surface waters used for domestic activities was generated for a set of 34 villages, and several types of human behaviour associated with a higher risk of transmission were identified: (i) prolonged walking in water to reach cultivated fields, (ii) collecting water, (iii) and swimming. Combining the results of the different analyses identified the risk factor most strongly associated with Buruli ulcer was the frequency of contact with unprotected and natural water, particularly in regularly flooded or irrigated lowlands. We confirm that the use of clean water from drilled wells confers protection against Buruli ulcer. These specific and refined results provide a broader scope for the design of an appropriate preventive strategy including certain practices or infrastructures observed during our field investigations. This strategy could be improved by the addition of knowledge about irrigation practices and agricultural work in low-lying areas.

Impact of a multi-faceted training intervention on the improvement of hand hygiene and gloving practices in four healthcare settings including nursing homes, acute-care geriatric wards and physical rehabilitation units.

AIMS: To assess the impact of a multi-faceted training program on the compliance with hand hygiene and gloving practices. BACKGROUND: Hand hygiene is considered as the cornerstone of the prevention of hospital-acquired infections. Several studies have enhanced the poor effectiveness of training programs in improving hand hygiene compliance. DESIGN: A before-after evaluation study. METHODS: The study was conducted in four healthcare settings before and after an intervention program which included the performance feedback of the first evaluation phase, three six-h training sessions, the assessment of hand hygiene performance with teaching boxes and the organisation of one full-day session devoted to institutional communication around hand hygiene in each setting. Hand hygiene compliance and quality of hand rubbing were evaluated. Hand hygiene opportunities were differentiated into extra-series opportunities (before or after a single contact and before the first contact or after the last contact of a series of consecutive contacts) and intra-series opportunities (from the opportunity following the first contact to the opportunity preceding the last in the same series). RESULTS: Overall, 969 contacts corresponding to 1,470 hand hygiene opportunities (760 during the first phase and 710 during the second) were observed. A significant improvement of observed practices was recorded for the hand hygiene compliance in intra-series opportunities (39·0% vs. 19·0%; p < 10(-5) ), the proportion of gloves worn if indicated (71·4% vs. 52·0%; p < 0·001) and the quality of hand rubbing (85·0% vs. 71·9%; p < 10(-5) ). CONCLUSIONS: Some of the performances measured for both hand hygiene and gloving practices were improved. We plan to extend this investigation by performing a qualitative study with experts in behavioural sciences to try improving practices for which adherence was still weak after the training program such as hand hygiene in intra-series opportunities. RELEVANCE TO CLINICAL PRACTICE: This study underscored the usefulness of implementing contextualised training programs, while more traditional courses have shown little impact.

Teaching bacterial infections in pharmaceutical studies: why not 'with students' instead of 'to students'?

In pharmaceutical studies, a course of bacteriology based on case studies provided by the teacher was transformed in a course based on a combination of student/teacher co-creation of cases and peer reviewing. Our objectives were to describe the perception of students about the new format and to assess the impact of changing on the learning outcomes. For teaching evaluation, we used a questionnaire and focus groups. The assessment of learning outcome was performed by comparing the students' scores in final tests with the previous and the revised course formats. The students embraced the creation of cases in small groups with the teacher. In addition, they reported a perception of weakened hierarchy between the teacher and themselves, an increase of their self-confidence and a better ability to transfer their learning to their professional activities in community pharmacies. Lastly, their opinion about the transferability of this format in other disciplines were divided.