Complete hydatidiform mole with concurrent fetus: Two cases of live, term birth coupled with spontaneous resolution of molar tissue.

Pregnancies with a complete hydatidiform mole and co-existing fetus (CMCF) are rare, but increasingly common due to the rising prevalence of assisted reproductive technology. They are frequently associated with adverse obstetric outcomes, providing women with the challenge of pregnancy termination or continuing the pregnancy at the risk of maternal-fetal morbidity and fetal mortality. This report demonstrates two cases of CMCF pregnancy with excellent maternal-fetal outcomes, including spontaneous resolution of the molar tissue antenatally. It is helpful in counselling women who are diagnosed with this rare and frequently morbid condition in considering how to proceed with their pregnancy.

Modeling the air pollution process using a novel multi-site and multi-scale method with adaptive utilization of spatio-temporal information.

This study focuses on modeling air quality with an adaptive utilization of spatio-temporal information from multiple air quality monitoring stations under a multi-scale framework. To this end, it is necessary to consider different strategies to combine different methods to decompose the given series and to fuse multi-site information. Based on a systematic comparative analysis, we propose a novel multi-scale and multi-site modeling method named the multivariate empirical mode decomposition and spatial cosine-attention-based long short-term memory (MEMD-SCA-LSTM). The MEMD-SCA-LSTM first employs MEMD to decompose the multi-site air quality series into the scale-aligned components and then models the components at different scales. The high-frequency components are modeled by a novel SCA-LSTM, which employs LSTM with residual blocks to extract the temporal information and utilizes an attention mechanism based on the cosine similarity to adaptively extract interactions among different sites. Other relatively regular components are modeled by the LSTM. Empirical study on PM2.5 in Hong Kong has demonstrated the effectiveness of fusing multi-site information using the spatial attention (SA) mechanism under the multi-scale framework with MEMD. The proposed MEMD-SCA-LSTM can improve the one-day ahead modeling performance with the mean absolute error and the root mean square error reduced over 10%, compared to the baseline modeling methods. For the two-day and three-day ahead performance, the MEMD-SCA-LSTM is still the best one. Furthermore, by visualizing the attention weights, we illustrate that our proposed SCA-LSTM can overcome some limitations of the traditional attention mechanisms and that the attention weights exhibit more informative patterns which could be used to analysis the transport of air pollutant between sites. The proposed modeling method is a general method, which is feasible and applicable to other pollutants in other cities or regions.

Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis.

BACKGROUND: Balance impairments are common in cerebellar ataxia. Exercises are beneficial in this population. OBJECTIVE: Explore the benefits of therapeutic exercises on disease severity, balance and functional independence in cerebellar ataxia. METHODS: Databases were searched from inception until July 2021. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Newcastle-Ottawa Scale (NOS); and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. RESULTS: Twenty-six studies were included and eight studies of low to high PEDro methodological quality were meta-analyzed. 'Low' to 'moderate' GRADE quality evidence supports the use of therapeutic exercises to reduce disease severity, assessed using the Scale for the Assessment and Rating of Ataxia [weighted mean difference (WMD): -3.3; 95% confidence interval (95%CI): -3.7, -2.8; p < .01]; and improve balance, assessed using the Berg Balance Scale (WMD: 2.6; 95%CI: 1.1, 4.2; p < .01). The effect of therapeutic exercises on functional independence was insignificant (WMD: 1.6; 95%CI: -1.5, 4.6; p = .31). CONCLUSION: Low to moderate evidence from studies of low to high methodological quality provides some support for therapeutic exercises for reducing disease severity among non-hereditary degenerative cerebellar ataxia and improving balance among acquired cerebellar ataxia. Exercises did not benefit functional independence. Additional studies of large sample size and high methodological quality are necessary to substantiate these findings.

Lynch syndrome associated endometrial carcinomas in Western Australia: an analysis of universal screening by mismatch repair protein immunohistochemistry.

BACKGROUND: In 2016 universal screening with mismatch repair protein immunohistochemistry in all newly diagnosed endometrial carcinomas was introduced in Western Australia. OBJECTIVE: To compare the prevalence of Lynch syndrome associated endometrial carcinomas between 2016 and 2019 with a historical control (2015). Additionally, to compare the number of cases appropriately referred for genetic assessment. METHODS: A cross-sectional study of cases presented at the Western Australia gynecologic oncology tumor board was carried out. The primary outcome was the prevalence of Lynch syndrome associated endometrial carcinomas. A secondary outcome was the number of cases appropriately referred for genetic assessment. The following variables were extracted: date of birth; age at diagnosis; vital status; tumor mismatch repair protein expression status (retained or lost) and if lost, the specific mismatch repair protein deficiency; patients who were referred to a genetic clinic; and family history, if recorded. Data were collected from the clinical databases of the Familial Cancer Program at Genetic Services of Western Australia and WOMEN Center, to determine whether patients were appropriately referred for genetic evaluation and to ascertain the results of genetic testing. RESULTS: Between 2016 and 2019, there were 1040 new endometrial carcinomas. Tumors of 883 (85%) patients underwent mismatch repair protein immunohistochemistry compared with 117 of 199 patients (59%) in 2015 (χ2 73.14, p<0.001). Of 883 tumors tested, 242 (27%) showed loss of mismatch repair protein expression. In 2015, 30 (26%) tumors of 117 tested showed loss of mismatch repair protein expression. During the 4 years of universal screening, 13 (1.5%) of 883 patients screened were diagnosed with Lynch syndrome compared with 2 (1.7%) of 117 in 2015 (Fisher's exact test 0.04, p=0.69). In 2015, 11 (37%) of 30 patients with loss of mismatch repair protein expression were not referred for genetic assessment compared with 36 (17%) of 209 patients in the universal screening group (χ2 6.28, p=0.02). No cases of Lynch syndrome were diagnosed in patients aged over 70 years. CONCLUSIONS: Universal immunohistochemical screening did not increase the proportion of Lynch syndrome associated endometrial carcinomas identified, although the study was underpowered to detect small differences. There was an improvement in appropriate referrals for genetic assessment.

Validating the Team Emergency Assessment Measure (TEAM) in obstetric and gynaecologic resuscitation teams.

BACKGROUND: Simulation-based training is an effective method of enhancing the knowledge, skill, and technical abilities of individuals and teams encountering obstetric and gynaecologic emergencies. Simulation may also enhance the non-technical performance of teams resulting in improved patient outcomes. Although simulation-based training is widely recognised as an effective educational approach, issues around feasibility - the lack of simulation experts and malleable outcome measures of team performance - remain critical barriers to their implementation. AIM: To evaluate the psychometric properties of the Team Emergency Assessment Measure (TEAM) when used by medical professionals in simulated obstetric and gynaecological emergencies. METHODS: There were 151 participants (63% female; 60% consultants; 69% no previous simulation-based training) who observed three live high-fidelity obstetric and gynaecological resuscitation simulations and completed the TEAM. RESULTS: Confirmatory factor analysis evaluated the construct validity of the TEAM, yielding a second-order structure identified by 'leadership', 'teamwork', and 'team management'. Convergent validity was supported by the average item-to-scale total correlation which was 0.75, P < 0.001 and the average analysis of variance extracted (AVE) 0.88. The individual factors also yielded high factor-to-scale total correlations (mean [M] = 0.87), and AVE (M = 0.89). The internal reliability was high for the whole scale (average alpha = 0.92) and across the sub-factors (average alpha = 0.80). The inter-rater reliability was excellent (inter-class correlation coefficient 1 = 0.98). Participants with differing levels of simulation training experience did not significantly differ. CONCLUSION: The TEAM is a viable instrument for the assessment of non-technical performance during simulated obstetric and gynaecologic emergencies, thus enhancing the feasibility of simulation-based training.

Complete pathological response following levonorgestrel intrauterine device in clinically stage 1 endometrial adenocarcinoma: Results of a randomized clinical trial.

PURPOSE: Intrauterine levonorgestrel (LNG-IUD) is used to treat patients with endometrial adenocarcinoma (EAC) and endometrial hyperplasia with atypia (EHA) but limited evidence is available on its effectiveness. The study determined the extent to which LNG-IUD with or without metformin (M) or weight loss (WL) achieves a pathological complete response (pCR) in patients with EAC or EHA. PATIENTS AND METHODS: This phase II randomized controlled clinical trial enrolled patients with histologically confirmed, clinically stage 1 FIGO grade 1 EAC or EHA; a body mass index > 30 kg/m2; a depth of myometrial invasion of less than 50% on MRI; a serum CA125 ≤ 30 U/mL. All patients received LNG-IUD and were randomized to observation (OBS), M (500 mg orally twice daily), or WL (pooled analysis). The primary outcome measure was the proportion of patients developing a pCR (defined as absence of any evidence of EAC or EHA) after 6 months. RESULTS: From December 2012 to October 2019, 165 patients were enrolled and 154 completed the 6-months follow up. Women had a mean age of 53 years, and a mean BMI of 48 kg/m2. Ninety-six patients were diagnosed with EAC (58%) and 69 patients with EHA (42%). Thirty-five participants were randomized to OBS, 36 to WL and 47 to M (10 patients were withdrawn). After 6 months the rate of pCR was 61% (95% CI 42% to 77%) for OBS, 67% (95% CI 48% to 82%) for WL and 57% (95% CI 41% to 72%) for M. Across the three treatment groups, the pCR was 82% and 43% for EHA and EAC, respectively. CONCLUSION: Complete response rates at 6 months were encouraging for patients with EAC and EHA across the three groups. TRIAL REGISTRATION: U.S. National Library of Medicine, NCT01686126.

Development of a surgical competency assessment tool for sentinel lymph node dissection by minimally invasive surgery for endometrial cancer.

INTRODUCTION: Sentinel lymph node dissection is widely used in the staging of endometrial cancer. Variation in surgical techniques potentially impacts diagnostic accuracy and oncologic outcomes, and poses barriers to the comparison of outcomes across institutions or clinical trial sites. Standardization of surgical technique and surgical quality assessment tools are critical to the conduct of clinical trials. By identifying mandatory and prohibited steps of sentinel lymph node (SLN) dissection in endometrial cancer, the purpose of this study was to develop and validate a competency assessment tool for use in surgical quality assurance. METHODS: A Delphi methodology was applied, included 35 expert gynecological oncology surgeons from 16 countries. Interviews identified key steps and tasks which were rated mandatory, optional, or prohibited using questionnaires. Using the surgical steps for which consensus was achieved, a competency assessment tool was developed and subjected to assessments of validity and reliability. RESULTS: Seventy percent consensus agreement standardized the specific mandatory, optional, and prohibited steps of SLN dissection for endometrial cancer and informed the development of a competency assessment tool. Consensus agreement identified 21 mandatory and three prohibited steps to complete a SLN dissection. The competency assessment tool was used to rate surgical quality in three preselected videos, demonstrating clear separation in the rating of the skill level displayed with mean skills summary scores differing significantly between the three videos (F score=89.4; P<0.001). Internal consistency of the items was high (Cronbach α=0.88). CONCLUSION: Specific mandatory and prohibited steps of SLN dissection in endometrial cancer have been identified and validated based on consensus among a large number of international experts. A competency assessment tool is now available and can be used for surgeon selection in clinical trials and for ongoing, prospective quality assurance in routine clinical care.

Predictors of endometrial carcinoma in patients with atypical endometrial hyperplasia at a tertiary gynaecological cancer centre in Western Australia.

AIM: Our objective was to assess clinical and pathological factors associated with a final diagnosis of endometrial carcinoma in patients with atypical endometrial hyperplasia with a particular emphasis on the grading of atypia. MATERIALS AND METHODS: A retrospective review over five years on patients (N = 97) who underwent hysterectomy for a diagnosis of atypical endometrial hyperplasia at a statewide public tertiary gynaecologic oncology centre. Clinical and pathological characteristics were obtained. RESULTS: The rate of concurrent endometrial carcinoma was 34% (n = 33) with most being stage 1A endometrioid. A significant group difference was reported for age at diagnosis (t = -2.20 P = 0.031 d = 0.43) with carcinoma patients on average older (Mage  = 60.2 (8.9) years) than patients without carcinoma (Mage  = 55.5 (12.3) years). No significant group differences were found for body mass index, endometrial thickness or time between diagnosis and treatment. Significantly higher rates of carcinoma were reported in patients with moderate atypical hyperplasia (27.6%) and severe atypical hyperplasia (66.7%), compared to mild atypical hyperplasia (7.1%). Only severe atypical hyperplasia (odds ratio (OR) = 21.5, 95% CI 2.8-163.1, P = 0.003) and postmenopausal status (OR = 13.2, 95% CI 1.3-139.0, P = 0.032) significantly increased the risk of carcinoma in a multivariate model. CONCLUSION: Severe atypical hyperplasia and postmenopausal status were significant predictors of concurrent endometrial carcinoma in patients with atypical endometrial hyperplasia. The grading of atypical hyperplasia may be utilised by gynaecologic oncologists in the triage and referral process of managing these patients; however, the grading system requires external validation in larger prospective studies.

A novel method for identifying hotspots and forecasting air quality through an adaptive utilization of spatio-temporal information of multiple factors.

Air pollution exerts serious impacts on human health and sustainable development. The accurate forecasting of air quality can guide the formulation of mitigation strategies and reduce exposure to air pollution. It is beneficial to explicitly consider both spatial and temporal information of multiple factors, e.g., the meteorological data, in the forecasting of air pollutant concentrations. The temporal information of relevant factors collected at a location should be considered for forecasting. In addition, these factors recorded at other locations may also provide useful information. Existing methods utilizing the spatio-temporal information of these relevant factors are usually based on some very complicated frameworks. In this study, we propose a novel and simple spatial attention-based long short-term memory (SA-LSTM) that combines LSTM and a spatial attention mechanism to adaptively utilize the spatio-temporal information of multiple factors for forecasting air pollutant concentrations. Specifically, the SA-LSTM employs gated recurrent connections to extract temporal information of multiple factors at individual locations, and the spatial attention mechanism to spatially fuse the temporal information extracted at these locations. This method is effective and applicable to forecast any air pollutant concentrations when spatio-temporal information of relevant factors has to be utilized. To validate the effectiveness of the proposed SA-LSTM, we apply it to forecast the daily air quality in Hong Kong, a high density city with peculiar cityscapes, by using the air quality and meteorological data. Empirical results demonstrate that the proposed SA-LSTM outperforms the conventional models with respect to one-day forecast accuracy, especially for extreme values. Moreover, the attention weights learned by the SA-LSTM can identify hotspots of the air pollution process for reducing computational complexity of forecasting and provide a better understanding of the underlying mechanism of air pollution.

Fractal analysis of recurrence networks constructed from the two-dimensional fractional Brownian motions.

In this study, we focus on the fractal property of recurrence networks constructed from the two-dimensional fractional Brownian motion (2D fBm), i.e., the inter-system recurrence network, the joint recurrence network, the cross-joint recurrence network, and the multidimensional recurrence network, which are the variants of classic recurrence networks extended for multiple time series. Generally, the fractal dimension of these recurrence networks can only be estimated numerically. The numerical analysis identifies the existence of fractality in these constructed recurrence networks. Furthermore, it is found that the numerically estimated fractal dimension of these networks can be connected to the theoretical fractal dimension of the 2D fBm graphs, because both fractal dimensions are piecewisely associated with the Hurst exponent H in a highly similar pattern, i.e., a linear decrease (if H varies from 0 to 0.5) followed by an inversely proportional-like decay (if H changes from 0.5 to 1). Although their fractal dimensions are not exactly identical, their difference can actually be deciphered by one single parameter with the value around 1. Therefore, it can be concluded that these recurrence networks constructed from the 2D fBms must inherit some fractal properties of its associated 2D fBms with respect to the fBm graphs.

Excisional treatment comparison for in situ endocervical adenocarcinoma (EXCISE): A phase 2 pilot randomized controlled trial to compare histopathological margin status, specimen size and fragmentation after loop electrosurgical excision procedure and cold knife cone biopsy.

OBJECTIVE: Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. We aimed to compare margins status, specimen size and fragmentation after loop electrosurgical excision procedure (LEEP) and 'cold knife cone biopsy' (CKC). METHODS: The EXCISE Trial was an investigator-initiated, multicenter, open-label, parallel-group, phase 2, randomized study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. RESULTS: Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p = 1·00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p = ·00). There were no differences in grade three complications (p = ·65). CONCLUSIONS: LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardized protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted.

Exploring Attitudes to Conception in Partners and Young Women with Gynecologic Cancers Treated by Fertility Sparing Surgery.

BACKGROUND: Approximately 20% of women with gynecologic cancers are under age 40 and with delayed childbearing, women may be diagnosed before their first pregnancy. Although fertility preservation is a priority for many women, attitudes to conception have not previously been investigated in these patients or their partners. We explored attitudes to conception in partners and young women, following fertility preserving treatment for gynecologic cancers. METHODS: A total of 16 telephone interviews were conducted with a purposive sample of patients who had had an early stage gynecologic cancer or borderline ovarian tumor treated by fertility sparing surgery in Western Australia between January 1st, 2005 to December 31st, 2016. The interviews were audio recorded, transcribed and thematic analysis was conducted. RESULTS: Four main themes were identified: (i) Emotions at diagnosis and perception of information given; (ii) Discussions of fertility and factors affecting childbearing; (iii) Role of partners in decision making and relationship pressures; (iv) Decision for treatment and postoperative regrets. CONCLUSIONS: Regret and relationship breakdown were commonly reported. Women need appropriate support including inviting their partners to attend clinic appointments and may need several appointments before treatment. Regret was commonly reported by women who opted for completion surgery.
.

Evaluation of Optimized Procedures for High-Precision Lead Isotope Analyses of Seawater by Multiple Collector Inductively Coupled Plasma Mass Spectrometry.

The application of Pb isotopes to marine geochemistry is currently hindered by challenges associated with the analysis of Pb isotopes in seawater. The current study evaluates the performance of multiple collector inductively coupled plasma mass spectrometry (MC-ICP-MS) measurements of seawater Pb isotope compositions following Pb separation by either solid-phase extraction with Nobias Chelate PA-1 resin or coprecipitation with Mg(OH)2 and using either a Pb double spike or external normalization to Tl for mass bias correction. The four analytical combinations achieve results of similar quality when measuring 1-7 ng of seawater Pb, with reproducibilities (two standard deviations, 2SD) of 100-1200 ppm for 206Pb/207Pb and 208Pb/207Pb and 300-1700 ppm for ratios involving the minor 204Pb isotope. All four procedures enable significantly improved sample throughput compared to an established thermal ionization mass spectrometry (TIMS) double-spike method and produce unbiased seawater Pb isotope compositions with similar or improved precision. Nobias extraction is preferable to coprecipitation due to its greater analytical throughput and suitability for analyses of large seawater samples with high Si(OH)4 contents. The most accurate Pb isotope data are produced following Nobias extraction and double-spike correction as such analyses are least susceptible to matrix effects. However, Nobias extraction with Tl normalization constitutes an attractive alternative as, unlike the double-spike procedure, only a single mass spectrometric measurement is required, which improves analytical throughput and optimizes Pb consumption for analysis. Despite the advantages of solid-phase extraction, coprecipitation represents a useful Pb separation technique for samples with low to moderate Si contents as it is inexpensive, simple to implement, and the data are only marginally less accurate, especially when combined with a Pb double spike for mass bias correction.

Developing an Australian multi-module clinical quality registry for gynaecological cancers: a protocol paper.

INTRODUCTION: Gynaecological cancers collectively account for almost 10% of cancer diagnoses made in Australian women. The extent of variation in gynaecological cancer survival rates and treatment outcomes across Australia is not well documented. The purpose of the clinical quality registry described in this paper is to systematically monitor and improve quality of care provided to these women, and facilitate clinical process improvements to ensure better patient outcomes and greater adherence to best practice care. The registry infrastructure has been developed in conjunction alongside the inaugural ovarian, tubal and peritoneal (OTP) module, allowing for concurrent piloting of the methodology and one module. Additional tumour modules will be developed in time to cover the other gynaecological tumour types. METHOD AND ANALYSIS: The National Gynae-Oncology Registry (NGOR) aims to capture clinical data on all newly diagnosed cancers of the uterus, ovary, fallopian tubes, peritoneum, cervix, vulva and vagina in Australia with a view to using these data to support improved clinical care and increased adherence to 'best practice'. Data are sourced from existing clinical databases maintained by clinicians and/or hospital gynaecological cancer units. A pilot phase incorporating only OTP cancers has recently been conducted to assess the feasibility of the registry methodology and assess the support of a quality initiative of this nature among clinicians and other key stakeholders. ETHICS AND DISSEMINATION: The NGOR has received National Mutual Acceptance (NMA) ethics approval from Monash Health Human Research Ethics Committee (HREC), NMA HREC Reference Number: HREC/17/MonH/198. We also have approval from Mercy Health HREC and University of Tasmania HREC. Data will be routinely reported back to participating sites illustrating their performance against measures of agreed best practice. It is through this feedback system that the registry will support changes to quality of care and improved patient outcomes.

Perceived barriers to multiprofessional team briefings in operating theatres: a qualitative study.

OBJECTIVES: This study investigates perceived barriers towards the implementation of multiprofessional team briefings (MPTB) in operating theatres, as well as ways to overcome these perceived barriers. Previous research shows that MPTB can enhance teamwork and communication, but are underused in operating theatres. By adopting a multilevel systems perspective, this study examines perceived barriers and solutions for MPTB implementation. DESIGN: Participants completed open-ended survey questions. Responses were coded via qualitative content analysis. The analysis focused on themes in the responses and the systems level at which each barrier and solution operates. SETTING: Four tertiary hospitals in Australia. PARTICIPANTS: 103 operating theatre staff, including nurses, surgeons, anaesthetists, technicians and administrators. RESULTS: Participants identified barriers and solutions at the organisational (15.81% of barriers; 74.10% of solutions), work group (61.39% of barriers; 25.09% of solutions) and individual level (22.33% of barriers; 0% of solutions). Of all the perceived barriers to MPTB occurrence, a key one is getting everyone into the room at the same time . Matching of perceived barriers and solutions shows that higher systems-level solutions can address lower level barriers, thereby showing the relevance of implementing such wider reaching solutions to MPTB occurrence (including work practices at occupational level and above) as well as addressing more local issues. CONCLUSIONS: Successful MPTB implementation requires changes at various systems levels. Practitioners can strategically prepare and plan for systems-based strategies to overcome barriers to MPTB implementation. Future research can build on this study's findings by directly examining higher systems-level barriers and solutions via detailed case analyses.

Designing meditation for doctor well-being: can 'Om' help obstetrics and gynaecology doctors?

OBJECTIVE: The study aimed to measure the impact of meditation on participants' ability to regulate brain wave activity in high-stress situations, control physiological stress responses and improve subjective wellbeing. METHODS: Twelve obstetrics and gynaecology (O&G) doctors meditated for 20 minutes daily for 21 days utilising a portable EEG (electroencephalogram) providing instantaneous audio feedback. Their brain activity levels and salivary cortisol were measured before and after performing three surgical procedures. Participants were interviewed about their experiences and completed self-ratings of distress (e.g. DASS-21, Depression, Anxiety and Depression Scale). Data were analysed statistically and thematically. RESULTS: (a) Measures of pre- and post-operative brain activity showed no significantly higher levels of alpha waves. (b) Pre- and post-operative salivary cortisol levels did not significantly decrease. (c) DASS-21 scores showed significant decreases in levels of anxiety and stress. CONCLUSION: Results suggest that, with biofeedback meditation, O&G doctors can learn to reduce situational stress and improve mood overall through a focussed intervention.