Understanding the benefits of universal plasma and cryoprecipitate in hospitals in England.

BACKGROUND: Group AB plasma does not contain anti-A or anti-B antibodies and is therefore considered universal but is in limited supply (4% of the population). There is currently no licensed universal plasma available, and therefore current clinical guidelines for transfusion require the donor and recipient to be blood group compatible. We sought to understand the benefits of universal plasma to hospitals in England, to inform R&D priorities going forward. STUDY DESIGN AND METHODS: To understand the benefits of universal plasma (cryoprecipitate included), we distributed two surveys to hospitals (267 in total) in England. RESULTS: Safety was the perceived top benefit of universal plasma (95%), with cost identified as the main barrier to adoption (82%), although the majority of respondents were willing to pay more for universal components. Ninety-five respondents felt they would replace all or part of their stock holding with universal plasma, with 91% anticipating that their overall stock holding of plasma would reduce as well as there will be a reduction in their plasma wastage (by up to 25%). Hospitals (56%) thought that the availability of universal plasma would support more rapid provision of plasma for transfusion, particularly in emergency situations, with the emergency/trauma department deemed to be the area that would see the greatest benefit from these universal blood components. DISCUSSION: The response to both the potential clinical and operational benefits of a universal plasma and cryoprecipitate was positive.

A Scoping Review of Economic Evaluations to Inform the Reorientation of Preventive Health Services in Australia.

The Australian National Preventive Health Strategy 2021-2030 recommended the establishment of evidence-based frameworks to enable local public health services to identify strategies and interventions that deliver value for money. This study aimed to review the cost-effectiveness of preventive health strategies to inform the reorientation of local public health services towards preventive health interventions that are financially sustainable. Four electronic databases were searched for reviews published between 2005 and February 2022. Reviews that met the following criteria were included: population: human studies, any age or sex; concept 1: primary and/or secondary prevention interventions; concept 2: full economic evaluation; context: local public health services as the provider of concept 1. The search identified 472 articles; 26 were included. Focus health areas included mental health (n = 3 reviews), obesity (n = 1), type 2 diabetes (n = 3), dental caries (n = 2), public health (n = 4), chronic disease (n = 5), sexual health (n = 1), immunisation (n = 1), smoking cessation (n = 3), reducing alcohol (n = 1), and fractures (n = 2). Interventions that targeted obesity, type 2 diabetes, smoking cessation, and fractures were deemed cost-effective, however, more studies are needed, especially those that consider equity in priority populations.

What are health professionals' perceptions of conducting routine growth assessments and lifestyle interventions? A qualitative study involving allied health professionals, nurses and doctors in rural and regional New South Wales.

BACKGROUND: Allied health professionals, nurses and doctors within the New South Wales (NSW) public health system provide trusted health information to a large proportion of families across the state. This means they are well positioned to opportunistically assess and discuss child weight status with families. Prior to 2016, weight status was not routinely addressed in most NSW public health settings, however recent policy changes promote quarterly growth assessments for all children aged under 16years who attend these facilities. The Ministry of Health recommend health professionals use the 5 As framework, a consultation approach to encourage behaviour change, to identify and manage children with overweight or obesity. This study aimed to explore allied health professionals', nurses' and doctors' perceptions of conducting routine growth assessments and providing lifestyle support to families in a local health district in rural and regional NSW, Australia. METHODS: This descriptive, qualitative study involved online focus groups and semi-structured interviews with health professionals. Audio recordings were transcribed and coded for thematic analysis, with rounds of data consolidation between research team members. RESULTS: Allied health professionals, nurses and doctors who work in a variety of settings within a local health district of NSW participated in one of four focus groups (n =18 participants) or semi-structured interviews (n =4). The predominant themes related to: (1) health professionals' professional identity and their perceived scope of practice; (2) interpersonal qualities of health professionals; (3) the service delivery ecosystem in which health professionals worked. Diversity in attitudes and beliefs about routine growth assessments were not necessarily specific to discipline or setting. CONCLUSIONS: Allied health professionals, nurses and doctors recognise the complexities involved in conducting routine growth assessments and providing lifestyle support to families. The 5 As framework used in NSW public health facilities to encourage behaviour change may not allow clinicians to address these complexities in a patient centred way. The findings of this research will be used to inform future strategies aimed at embedding preventive health discussions into routine clinical practice, and to support health professionals to identify and manage children with overweight or obesity.

Diet suppresses glioblastoma initiation in mice by maintaining quiescence of mutation-bearing neural stem cells.

Glioblastoma is thought to originate from neural stem cells (NSCs) of the subventricular zone that acquire genetic alterations. In the adult brain, NSCs are largely quiescent, suggesting that deregulation of quiescence maintenance may be a prerequisite for tumor initiation. Although inactivation of the tumor suppressor p53 is a frequent event in gliomagenesis, whether or how it affects quiescent NSCs (qNSCs) remains unclear. Here, we show that p53 maintains quiescence by inducing fatty-acid oxidation (FAO) and that acute p53 deletion in qNSCs results in their premature activation to a proliferative state. Mechanistically, this occurs through direct transcriptional induction of PPARGC1a, which in turn activates PPARα to upregulate FAO genes. Dietary supplementation with fish oil containing omega-3 fatty acids, natural PPARα ligands, fully restores quiescence of p53-deficient NSCs and delays tumor initiation in a glioblastoma mouse model. Thus, diet can silence glioblastoma driver mutations, with important implications for cancer prevention.

Start small and let it build; a mixed-method evaluation of a school-based physical activity program, Kilometre Club.

BACKGROUND: Despite the benefits of physical activity, there is minimal research focusing on factors that influence real-world school-based physical activity programs. Kilometre (KM) Club is an Australian grassroots program which aims to increase physical activity in students through the completion of an outside walk or run at school. This small-scale pilot evaluation aimed to examine families, teachers and principals' perceptions of the benefits, enablers and barriers of KM Club. It also aimed to examine the effects of KM Club on student's physical activity levels during the school day. METHODS: Four regional New South Wales (NSW) primary schools participated in this study. 26 families, four teachers, and two principals from School A, C, B and D completed semi-structured interviews to understand their perceptions of KM Club. 21 students completed emotional state-scales to understand their emotions when participating in KM Club. 141 students from Schools B, C and D participated in step-count measures using accelerometers. RESULTS: Families, teachers and principals reported a range of benefits such as improved social connectedness, wellbeing, home and classroom behaviours, participation in sport and fitness levels. Enablers consisted of champion engagement, incentives, versatile facilities and integration with other school activities. Identified barriers included the weather and environment, program timing and health issues. Most students reported that participating in KM Club made them feel proud, confident and fantastic. School B reported a significant increase in students' daily step counts on KM Club days compared to non-KM Club days (+ 15%; p = 0.001), while School C reported no significant changes (-5%; p = 0.26). School D reported a significant increase in the number of daily steps taken by KM Club participants compared with non-KM club participants (+ 10%; p = 0.024). CONCLUSION: There is no one-size-fits-all approach to implementing school-based physical activity initiatives. However, it appears that flexible and adaptable factors are important to the successful implementation of school-based programs, such as KM Club. This study revealed a variety of self-reported health, wellbeing and educational benefits for students, as well as an increase in student's physical activity levels at 2 of the 3 schools participating in the quantitative data collection. This pilot evaluation may help to inform future design, implementation and scale-up of KM Club and school-based health promotion programs, potentially improving child health, wellbeing and educational outcomes. TRIAL REGISTRATION: (LNR223 - LNR/19/NCC/45).

Clinimetric Properties of Outcome Measures in Bronchiectasis.

Rationale: There is a lack of outcome measures with robust clinimetric properties in bronchiectasis. Objectives: To determine the clinimetric properties (reliability over 1 year during clinical stability and responsiveness over the course of antibiotics for pulmonary exacerbation) of objective and patient-reported outcome measures. Methods: This multicenter cohort study included adults with bronchiectasis from seven hospitals in the United Kingdom. Participants attended four visits, 4 months apart over 1 year while clinically stable and at the beginning and end of exacerbation and completed lung function (spirometry and multiple breath washout), provided a blood sample for C-reactive protein (CRP) measurement, and completed health-related quality of life (HRQoL) questionnaires (Quality of Life-Bronchiectasis, St. George's Respiratory Questionnaire, and EuroQoL 5-Dimensions 5-Levels). Results: Participants (n = 132) had a mean (standard deviation) age of 66 (11) years, and 64% were female. Lung function parameters (forced expiratory volume in one second [FEV1], standard lung clearance index [LCI2.5]) were reliable over time [coefficient of variation (CV): <10%]). Regarding responsiveness, FEV1 demonstrated better properties than LCI2.5; therefore, a clear justification for the use of LCI2.5 in future trials is needed. CRP was less reliable (CV > 20%) over time than FEV1 and LCI2.5, and whereas CRP had a large mean change between the start and end of an exacerbation, this may have been driven by a small number of patients having a large change in CRP. Reliability of HRQoL questionnaires and questionnaire domains ranged from acceptable (CV: 20-30%) to good (CV: 10-20%), and HRQoL were responsive to treatment of exacerbations. Considering the specific questionnaire domain relevant to the intervention and its associated clinimetric properties is important. Additional statistics will support future power and/or sample size analysis. Conclusions: This information on the clinimetric properties of lung function parameters, CRP, and HRQoL parameters should be used to inform the choice of outcome measures used in future bronchiectasis trials.

Walking and Sitting Outdoors: Which Is Better for Cognitive Performance and Mental States?

Myriad research indicates that physical activity and natural environments enhance cognitive performance and mental health. Much of this research is cross-sectional or involves physical activity in outdoor environments, rendering it difficult to ascribe the results to a particular condition. This study utilized electroencephalography (EEG) and established cognitive performance tasks to determine the impact of a short intervention including either walking or sitting in an outdoor environment. In this experiment, a total of 50 participants were randomized into walking and sitting groups, with cognitive performance measured before, after, and 10 min post intervention. Both groups demonstrated improvements in cognitive performance, with no significant difference between groups. Elevated levels of relaxation during the intervention were the best predictor of post-test performance. Participants reporting a higher connection to nature, as well as state-based mindfulness during the outdoor intervention, also reported lower levels of frontal theta (i.e., rumination) during the interaction, while the walking group demonstrated higher relaxation. These findings provide a direct connection to neural mechanisms influenced by physical activity and the natural environment, and their impact on cognitive performance. This supports Attention Restoration Theory and the effectiveness of short outdoor interventions incorporating physical activity as a method of restoring mental attention.

Concerted modification of nucleotides at functional centers of the ribosome revealed by single-molecule RNA modification profiling.

Nucleotides in RNA and DNA are chemically modified by numerous enzymes that alter their function. Eukaryotic ribosomal RNA (rRNA) is modified at more than 100 locations, particularly at highly conserved and functionally important nucleotides. During ribosome biogenesis, modifications are added at various stages of assembly. The existence of differently modified classes of ribosomes in normal cells is unknown because no method exists to simultaneously evaluate the modification status at all sites within a single rRNA molecule. Using a combination of yeast genetics and nanopore direct RNA sequencing, we developed a reliable method to track the modification status of single rRNA molecules at 37 sites in 18 S rRNA and 73 sites in 25 S rRNA. We use our method to characterize patterns of modification heterogeneity and identify concerted modification of nucleotides found near functional centers of the ribosome. Distinct, undermodified subpopulations of rRNAs accumulate upon loss of Dbp3 or Prp43 RNA helicases, suggesting overlapping roles in ribosome biogenesis. Modification profiles are surprisingly resistant to change in response to many genetic and acute environmental conditions that affect translation, ribosome biogenesis, and pre-mRNA splicing. The ability to capture single-molecule RNA modification profiles provides new insights into the roles of nucleotide modifications in RNA function.

Cladobotric Acids: Metabolites from Cultures of Cladobotryum sp., Semisynthetic Analogues and Antibacterial Activity.

Three new polyketide-derived natural products, cladobotric acids G-I (1-3), and six known metabolites (4, 5, 8-11) were isolated from fermentation of the fungus Cladobotryum sp. grown on rice. Their structures were elucidated by extensive spectroscopic methods. Two metabolites, cladobotric acid A (4) and pyrenulic acid A (10), were converted to a series of new products (12-20) by semisynthesis. The antibacterial activities of all these compounds were investigated against the Gram-positive pathogen Staphylococcus aureus including methicillin-susceptible (MSSA), methicillin-resistant and vancomycin-intermediate (MRSA/VISA), and heterogeneous vancomycin-intermediate (hVISA) strains. Results of these antibacterial assays revealed structural features of the unsaturated decalins important for biological activity.

In silico analyses of maleidride biosynthetic gene clusters.

Maleidrides are a family of structurally related fungal natural products, many of which possess diverse, potent bioactivities. Previous identification of several maleidride biosynthetic gene clusters, and subsequent experimental work, has determined the 'core' set of genes required to construct the characteristic medium-sized alicyclic ring with maleic anhydride moieties. Through genome mining, this work has used these core genes to discover ten entirely novel putative maleidride biosynthetic gene clusters, amongst both publicly available genomes, and encoded within the genome of the previously un-sequenced epiheveadride producer Wicklowia aquatica CBS 125634. We have undertaken phylogenetic analyses and comparative bioinformatics on all known and putative maleidride biosynthetic gene clusters to gain further insights regarding these unique biosynthetic pathways.

Endoscopic transsphenoidal surgery for biochemically and clinically non-functioning adenohypophyseal tumours in the elderly: experience from a single UK centre.

PURPOSE: To assess and compare outcome of surgical management of non-functioning pituitary adenohypophyseal tumours in patients under 65-years, and 65-years and older at tertiary neurosurgical referral centre. METHODS: Data was retrospectively analysed from pituitary database. Forty-four patients aged 65 or older (Group 1) and 93 patients under 65 (Group 2) underwent endoscopic trans-sphenoidal surgery (ETSS) between January 2017 and July 2019. The surgical, endocrinological, ophthalmological and radiological outcomes were compared. RESULTS: 6.8% of Group 1 patients had peri-operative surgical complications compared to 12.9% in Group 2 (p = 0.29). Improved visual fields and acuity were seen in 65.2% and 82.8% of Group 1 and Group 2 respectively (p = 0.124), although there were pre-existing ocular problems in 15.9% of Group 1. New hormone deficiencies were observed in 31.8% of Group 1 patients, and 24.7% of Group 2 (p = 0.555). Tumour regrowth/recurrence was seen in 2.3% of Group 1 (p = 0.553). The rate of repeat surgery was 6.8% in the Group 1 and 12.9% in Group 2 (p = 0.28). There was no significant relationship between extent of resection, complications or hormonal deficiency. The mean duration of follow-up was 10.5 ± 13.0 months for Group 1 patients and 13.0 ± 16.0 months for Group 2 patients (p = 0.526). CONCLUSIONS: ETSS for non-functioning pituitary adenohypophyseal tumours is safe and well tolerated in the patients aged 65 and older. Advanced age by itself should not be a contra-indication for ETSS. It is however highly recommended that the care of such patients to be offered at a high volume, dedicated pituitary surgical units.

A survey of teaching undergraduate neuroanatomy in the United Kingdom and Ireland.

BACKGROUND: Medical students' perception of neuroanatomy as a challenging topic has implications for referrals and interaction with specialists in the clinical neurosciences. Given plans to introduce a standardised Medical Licensing Assessment by 2023, it is important to understand the current framework of neuroanatomy education. This study aims to describe how neuroanatomy is taught and assessed in the UK and Ireland. METHODS: A structured questionnaire capturing data about the timing, methods, materials, assessment and content of the 2019/2020 neuroanatomy curriculum in the UK and Ireland medical schools. RESULTS: We received 24/34 responses. Lectures (96%) were the most widely used teaching method, followed by prosection (80%), e-learning (75%), tutorials/seminars (67%), problem-based learning (50%), case-based learning (38%), and dissection (30%). The mean amount of core neuroanatomy teaching was 29.3 hours. The most common formats of assessing neuroanatomical knowledge were multiple-choice exams, spot tests, and objective structured clinical exams. Only 37.5% schools required demonstration of core clinical competency relating to neuroanatomy. CONCLUSIONS: Our survey demonstrates variability in how undergraduate neuroanatomy is taught and assessed across the UK and Ireland. There is a role for development and standardisation of national undergraduate neuroanatomy curricula in order to improve confidence and attainment.

Towards inferring nanopore sequencing ionic currents from nucleotide chemical structures.

The characteristic ionic currents of nucleotide kmers are commonly used in analyzing nanopore sequencing readouts. We present a graph convolutional network-based deep learning framework for predicting kmer characteristic ionic currents from corresponding chemical structures. We show such a framework can generalize the chemical information of the 5-methyl group from thymine to cytosine by correctly predicting 5-methylcytosine-containing DNA 6mers, thus shedding light on the de novo detection of nucleotide modifications.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 24-month implementation and cost outcomes from a cluster randomised controlled trial.

BACKGROUND: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. METHODS: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. RESULTS: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). CONCLUSIONS: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

Core Steps to the Azaphilone Family of Fungal Natural Products.

Azaphilones are a family of polyketide-based fungal natural products that exhibit interesting and useful bioactivities. This minireview explores the literature on various characterised azaphilone biosynthetic pathways, which allows for a proposed consensus scheme for the production of the core azaphilone structure, as well as identifying early diversification steps during azaphilone biosynthesis. A consensus understanding of the core enzymatic steps towards a particular family of fungal natural products can aid in genome-mining experiments. Genome mining for novel fungal natural products is a powerful technique for both exploring chemical space and providing new insights into fungal natural product pathways.

Adipose triglyceride lipase protects renal cell endocytosis in a Drosophila dietary model of chronic kidney disease.

Obesity-related renal lipotoxicity and chronic kidney disease (CKD) are prevalent pathologies with complex aetiologies. One hallmark of renal lipotoxicity is the ectopic accumulation of lipid droplets in kidney podocytes and in proximal tubule cells. Renal lipid droplets are observed in human CKD patients and in high-fat diet (HFD) rodent models, but their precise role remains unclear. Here, we establish a HFD model in Drosophila that recapitulates renal lipid droplets and several other aspects of mammalian CKD. Cell type-specific genetic manipulations show that lipid can overflow from adipose tissue and is taken up by renal cells called nephrocytes. A HFD drives nephrocyte lipid uptake via the multiligand receptor Cubilin (Cubn), leading to the ectopic accumulation of lipid droplets. These nephrocyte lipid droplets correlate with endoplasmic reticulum (ER) and mitochondrial deficits, as well as with impaired macromolecular endocytosis, a key conserved function of renal cells. Nephrocyte knockdown of diglyceride acyltransferase 1 (DGAT1), overexpression of adipose triglyceride lipase (ATGL), and epistasis tests together reveal that fatty acid flux through the lipid droplet triglyceride compartment protects the ER, mitochondria, and endocytosis of renal cells. Strikingly, boosting nephrocyte expression of the lipid droplet resident enzyme ATGL is sufficient to rescue HFD-induced defects in renal endocytosis. Moreover, endocytic rescue requires a conserved mitochondrial regulator, peroxisome proliferator-activated receptor-gamma coactivator 1α (PGC1α). This study demonstrates that lipid droplet lipolysis counteracts the harmful effects of a HFD via a mitochondrial pathway that protects renal endocytosis. It also provides a genetic strategy for determining whether lipid droplets in different biological contexts function primarily to release beneficial or to sequester toxic lipids.

A microfluidic impedance-based extended infectivity assay: combining retroviral amplification and cytopathic effect monitoring on a single lab-on-a-chip platform.

Detection, quantification and monitoring of virus - host cell interactions are of great importance when evaluating the safety of pharmaceutical products. With the wide usage of viral based vector systems in combination with mammalian cell lines for the production of biopharmaceuticals, the presence of replication competent viral particles needs to be avoided and potential hazards carefully assessed. Consequently, regulatory agencies recommend viral clearance studies using plaque assays or TCID50 assays to evaluate the efficiency of the production process in removing viruses. While plaque assays provide reliable information on the presence of viral contaminations, they are still tedious to perform and can take up to two weeks to finish. To overcome some of these limitations, we have automated, miniaturized and integrated the dual cell culture bioassay into a common lab-on-a-chip platform containing embedded electrical sensor arrays to enrich and detect infectious viruses. Results of our microfluidic single step assay show that a significant reduction in assay time down to 3 to 4 days can be achieved using simultaneous cell-based viral amplification, release and detection of cytopathic effects in a target cell line. We further demonstrate the enhancing effect of continuous fluid flow on infection of PG-4 reporter cells by newly formed and highly active virions by M. dunni cells, thus pointing to the importance of physical relevant viral-cell interactions.

Cleaning the Cellular Factory-Deletion of McrA in Aspergillus oryzae NSAR1 and the Generation of a Novel Kojic Acid Deficient Strain for Cleaner Heterologous Production of Secondary Metabolites.

The use of filamentous fungi as cellular factories, where natural product pathways can be refactored and expressed in a host strain, continues to aid the field of natural product discovery. Much work has been done to develop host strains which are genetically tractable, and for which there are multiple selectable markers and controllable expression systems. To fully exploit these strains, it is beneficial to understand their natural metabolic capabilities, as such knowledge can rule out host metabolites from analysis of transgenic lines and highlight any potential interplay between endogenous and exogenous pathways. Additionally, once identified, the deletion of secondary metabolite pathways from host strains can simplify the detection and purification of heterologous compounds. To this end, secondary metabolite production in Aspergillus oryzae strain NSAR1 has been investigated via the deletion of the newly discovered negative regulator of secondary metabolism, mcrA (multicluster regulator A). In all ascomycetes previously studied mcrA deletion led to an increase in secondary metabolite production. Surprisingly, the only detectable phenotypic change in NSAR1 was a doubling in the yields of kojic acid, with no novel secondary metabolites produced. This supports the previous claim that secondary metabolite production has been repressed in A. oryzae and demonstrates that such repression is not McrA-mediated. Strain NSAR1 was then modified by employing CRISPR-Cas9 technology to disrupt the production of kojic acid, generating the novel strain NSARΔK, which combines the various beneficial traits of NSAR1 with a uniquely clean secondary metabolite background.

Engaging New Parents in the Development of a Peer Nutrition Education Model Using Participatory Action Research.

This study investigated the implementation model and research methods of a peer education program for new parents focused on infant feeding and nutrition. Two hundred and sixty-nine parents with an infant aged birth to two years old were invited to become co-researchers in a Participatory Action Research (PAR) study over three years. Data included focus group and online participant meeting transcripts, social media data, correspondence between the implementation team and peer educators, and field notes. All data were consolidated regularly and discussed by project participants and the research team. After each PAR cycle, structured content analysis was conducted, informing the next iteration of the implementation model and research methods. Participating parents were highly engaged in child feeding peer-to-peer education, but felt more effective and comfortable being considered as a child-feeding information resource sharer or 'champion' rather than a formal peer educator. Similarly, quantitative data collection was only effective when it was integrated seamlessly into the implementation model. PAR methodology suited the diversity and dynamic real-life study setting, facilitating substantial improvements to the peer nutrition intervention model and data collection methods. Our study demonstrated that a genuine collaboration between health professionals and participants to implement research in practice can achieve both intervention outcomes and research aims.