Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis.

BACKGROUND: Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis. METHODS: In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272. FINDINGS: After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only. INTERPRETATION: Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm. FUNDING: None.

Survey and Interview Findings of an Environmental Scan of Perioperative Geriatric Models of Care in Canada.

Background: Best practice recommendations support the implementation of perioperative geriatric care models that tailor to the specific needs of older adults undergoing surgery. The objective of this study was to describe the current proactive perioperative geriatric programs and pathways in Canadian hospitals. Methods: A survey of geriatricians, surgeons, and anesthesiologists practicing in Canada combined with phone interviews of a subset of participants were used to determine characteristics of perioperative geriatric pathways or programs including eligibility, team composition, and intervention elements. Results: Analysis of 132 survey respondents and 24 interviews showed 47% (40 out of 85) of hospitals described had elements of a perioperative geriatrics program and 20% had two or more elements. Eleven themes emerged including: how perioperative geriatric care programs built geriatric competencies in other health-care providers; geriatric assessment identified risks not captured in standard perioperative risk assessment; perceived value for patients and the health-care team; delirium prevention was addressed; most programs were reactive; most programs were informal; virtual care may be used to meet demand; successful implementation required system buy-in with collaboration across subspecialties; mechanisms to drive improvement were accountability and data evaluation; few clinicians with geriatric expertise; and other priorities limited program implementation. Conclusions: There were few hospitals in Canada with perioperative geriatric care models and even fewer with elements spanning the entire perioperative pathway. Strengths, weaknesses, opportunities, and threats to inform the implementation and sustainability of perioperative geriatric care in the Canadian context were identified in this national environmental scan.

Hope for the best, but prepare for the worst: Social media posted by participants in stem cell clinical trials.

This article examines the influence of social media posts on clinical trials involving stem cell-based interventions. Based on the literature review, we identified three potential risks associated with social media posts regarding clinical trials that involve stem cell-based interventions: (1) threats to scientific validity, (2) amplification of excessive expectations, and (3) breaches of confidentiality. Additionally, preliminary recommendations are provided to safeguard the value of stem cell clinical trials for future patients in the age of social media. Our approach aims to safeguard the well-being of forthcoming participants and ensure the scientific validity of stem cell research, as well as possibly aid in the further development of shared guidelines for posting stem cell clinical trial information on social media platforms.

Transoral Laser Resection of the Tongue Base in the Workup of Unknown Primary Head and Neck Squamous Cell Carcinoma.

Objective Failure to localize the primary tumor site in head and neck carcinoma of unknown origin after imaging and endoscopic evaluation leads to increased treatment-related morbidity. The use of transoral laser microsurgery to improve the detection of unknown primary carcinoma site identification is described in this article. Methods A retrospective cohort of 71 consecutive cases of cervical carcinoma of an unknown primary source from 2006 until 2012 from a single academic institution was analyzed. Of these, 10 patients were excluded based on our exclusion criteria. All patients underwent endoscopy with biopsies performed by fellowship-trained head and neck cancer surgeons.  Results The primary detection rate was 76% for patients who underwent laser tongue base resection versus 34% for traditional operative examination. There were no complications or prolonged recovery times in either group. Operative time was increased by the addition of the transoral base of tongue resection by 30 minutes. Conclusions Laser tongue base excision offers improved sensitivity in primary site detection without a significant increase in morbidity and only a modest increase in operative time.

Assessing Autism Knowledge Across the Global Landscape Using the ASK-Q.

Substantial variability exists with regard to autism service provision around the world. Service disparities observed in many low- and middle-income countries may be driven, in part, by limited autism knowledge; however, measurement limitations have made it difficult to quantify autism knowledge across countries. The current study uses the autism stigma and knowledge questionnaire (ASK-Q) to quantify autism knowledge and stigma between different countries and demographics. The current study compiled data from 6830 participants collected using adapted versions of the ASK-Q administered in 13 different countries, representing four different continents. Structural equation modeling was used to examine how autism knowledge varied across country and individual factors. Results reveal cross country variability with a large, 17-point difference between the countries with the highest knowledge (Canada) and the lowest knowledge (Lebanon). As expected, countries with higher economies had higher levels of knowledge. We also documented differences based on country worldview, participant occupation, gender, age, and education level. These results help to identify specific regions and populations that might most need greater information about autism.

Applying motivational framework in medical education: a self-determination theory perspectives.

BACKGROUND: The application of self-determination theory in explaining student achievement has been well-established in various contexts. However, its application to medical education, particularly in interprofessional education (IPE) remains underexplored. Understanding how students' motivation plays a role in students' engagement and achievement is essential to optimize efforts to improve learning and instruction. OBJECTIVE: This two-stage study aims to contextualize the SDT framework to IPE through the adaptation of the Basic Psychological Need Satisfaction to IPE (Study 1) and to demonstrate how SDT can be applied in IPE by examining a model of SDT constructs (Study 2) in predicting outcomes (behavioral engagement, team effectiveness, collective dedication, goal achievement). DESIGN: In Study 1 (n=996), we adapted and validated BPNS-IPE using confirmatory factor analysis and multiple linear regression using data from 996 IPE students (Chinese Medicine, Medicine, Nursing, and Pharmacy). In Study 2 (n=271), we implemented an IPE program where we integrated SDT approaches and examined the relationship of SDT constructs with IPE outcomes using multiple linear regression. RESULTS: Our data supported the three-factor structure (autonomy, competence, and relatedness) of BPNS-IPE, meeting the required model fit. Autonomy predicted team effectiveness (F=51.290, p<.05, R2=.580); competence predicted behavioral engagement (F=55.181, p<.05, R2=.598); while relatedness predicted significantly four IPE outcomes: behavioral engagement (F=55.181, p<.01, R2=.598), team effectiveness (F=51.290, p<.01, R2=.580), collective dedication (F=49.858, p<.01, R2=.573), goal achievement (F=68.713, p<.01, R2=.649). CONCLUSIONS: The SDT motivational framework can be adapted and applied in the IPE context to understand and enhance student motivation in medical education. Potential studies with the use of the scale are provided to guide researchers.

The Effect of Mobilization at 6 Months after Critical Illness - Meta-Analysis.

Mobilization at 6 Months After Critical IllnessThis report was a systemic review and meta-analysis of early mobilization in the intensive care unit. The authors found no significant effect on days alive and out of hospital; however, they report the possibility that it might increase mortality and adverse events.

The experiences of children with a cardiac transplant, their families and health care providers in the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had deleterious impacts on pediatric patients and families, as well as the healthcare providers who have attended to their care needs. METHODS: In this qualitative study, children with a cardiac transplant, as well as their families and healthcare providers were interviewed to explore the impact of the COVID-19 pandemic on pediatric care, as well as on patients' and their families' daily lives. Participants were recruited from a children's hospital in western Canada. Fifteen caregiving parents of transplanted children, 2 young patients, and 8 healthcare providers participated in interviews. RESULTS: Findings highlighted how families and their healthcare providers experienced pandemic-related shifts. Themes highlighted experiences, which entailed (1) initially hearing about the COVID-19 pandemic; (2) learning about their new reality; (3) adjusting to the pandemic; (4) adjusting to shifts in pediatric services; (5) evolving a view on the future, and (6) offering recommendations for cardiac care in a pandemic. CONCLUSIONS: Study implications emphasize the need to critically reflect on, and advance, methods of helping young patients and their families in pandemic circumstances, and supporting healthcare providers.

Reimbursement Savings Associated With Tissue Versus Mechanical Surgical Aortic Valve Replacement in Thailand.

OBJECTIVES: Surgical aortic valve replacement (SAVR) is an indicated treatment for severe aortic stenosis. Although mechanical valves are typically more durable, tissue SAVR valves do not require lifetime anticoagulation monitoring and may have lower rates of expensive sequelae. This economic evaluation estimates payer costs to the 3 largest Thai health insurance mechanisms for tissue versus mechanical SAVR. METHODS: A deterministic and Monte Carlo simulation model based on literature and expert opinion estimated total payer costs for tissue and mechanical valves over a 25-year duration for 3 separate age cohorts (45, 55, and 65 years). Reimbursements levels for hospitalization services were from the Thai Diagnosis Related Groups. Separate models are generated for the 3 main Thai health insurance mechanisms. RESULTS: The discounted expected 25-year reduction in payer savings associated with tissue SAVR are $2540, $2529, and $2311 per surgery for patients aged 45, 55, and 65 years, respectively, for the largest Thai insurer. Expected cost reductions associated with tissue SAVR are larger for each of the other schemes and generally decrease with patient age. Most savings accrue within 10 years of surgery. Reoperation costs are larger with tissue valves, but reductions in complications and anticoagulation monitoring more than offset these expenditures. Results are robust to multiple sensitivity and scenario analyses. CONCLUSIONS: Coverage and reimbursement of tissue valves can financially benefit Thai insurers and reduce expenditures in the Thai health system compared with mechanical valves. As tissue valve technology evolves and reoperation rates decline, the financial benefit associated with tissue valves will increase.

A systematic scoping review moral distress amongst medical students.

BACKGROUND: Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students. METHODS: The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion. RESULTS: Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD. CONCLUSIONS: MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

What factors facilitate interprofessional collaboration outcomes in interprofessional education? A multi-level perspective.

OBJECTIVES: Interprofessional education (IPE) harnesses the power of teams to facilitate collaborative learning across disciplines. However, prior research has not paid sufficient attention to the role of team-level factors on IPE outcomes, posing a major theoretical and methodological limitation. In response to this, using social interdependence theory (SIT), this study aimed to delineate the independent contributions of both team-level and student-level interprofessional attitudes (teamwork, roles, and responsibilities; patient-centeredness; and community-centeredness) in predicting IPE collaboration outcomes (goal achievement, team effectiveness, and team performance) employing multi-level analysis. METHODS: To test whether interprofessional attitudes at the team and student levels predict IPE collaboration outcomes, conducted multilevel modeling. We used the pretest and posttest data from 323 healthcare students in Hong Kong from Chinese medicine, medicine, nursing, pharmacy, and social work programmes enrolled in the IPE Cancer module. RESULTS: Among the interprofessional attitudes, "teamwork, roles, and responsibilities" was found to be the best predictor of IPE outcomes, both at the student and team levels. Students who recognized the benefits of shared learning had better goal achievement and team effectiveness. Furthermore, teams that emphasized shared learning also had better overall team performance. CONCLUSIONS: Students' attitudes towards teamwork, roles, and responsibilities in interprofessional collaborative practice, both at the student and team levels, are important to attaining positive student- and team-level outcomes. The study contributes to the expansion of existing knowledge in medical education, theoretically, by adopting SIT as a lens through which collaborative learning in healthcare teams can be understood, and methodologically, by applying multi-level approaches and delineating important student- and team-level predictors of IPE outcomes.

Advances in tests for colorectal cancer screening and diagnosis.

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths globally. Nonetheless, with early detection of CRC or its precancerous lesions, mortality, and CRC incidence can be reduced. Although colonoscopy is currently the gold standard for CRC screening and diagnosis, its invasive nature, and troublesome bowel preparation deter patient participation. Therefore, there is a need to expand the use of noninvasive or minimally invasive methods to increase patient compliance. AREAS COVERED: This review summarizes advances in different methods for CRC screening, including stool bacterial and metagenomic markers, fecal proteins, genetic and epigenetic markers in blood and stools, and imaging modalities. The cost-effectiveness of these methods is also discussed. FIT is more cost-effective compared to virtual colonoscopy, mSEPT9 test, and Multitarget Stool DNA test, while the cost-effectiveness of other noninvasive methods requires further evaluation. EXPERT OPINION: Recent evidence has well demonstrated the usefulness of gut microbiome and certain fecal bacterial markers in the noninvasive diagnosis of CRC and its precancerous lesions. Many of the fecal biomarkers, from host cells or the gut environment, show better diagnostic sensitivity than FIT. New screening tests based on these fecal biomarkers can be expected to replace FIT with higher cost-effectiveness in the near future.

Identifying and articulating the student experience in the Intercalated Enrichment Year.

BACKGROUND: Benefits of intercalation during an undergraduate medical degree are well-recognized. The University of Hong Kong implemented a compulsory Enrichment Year (EY) in its Bachelor of Medicine and Bachelor of Surgery degree programme (MBBS) in 2016. In their third year of study, students could work on an area of interest in any of three programme categories (i) intercalation/ university exchange (IC); (ii) research (RA); (iii) service/ humanitarian work (SH). This study aimed to explore the barriers, enablers, and overall student learning experiences from the first cohort of EY students in order to inform future development of the EY. METHODS: An exploratory sequential mixed-method study in 2019-20. Twenty students were purposively selected to attend three semi-structured focus group interviews. Conventional thematic analysis was employed and results assisted the design of a cross-sectional questionnaire. Sixty-three students completed the questionnaire. ANOVA or chi-square test was used to compare the difference in student's characteristics, barriers, enablers and perspectives on EY between programme categories. Adjusting student's characteristics, logistic regressions were conducted to identify the effect of programme categories on the EY experience. RESULTS: Most students (95% in the questionnaire) agreed that EY was worthwhile and more rewarding than expected. EY was positively regarded for enhancing personal growth and interpersonal relationships. The main barriers were financial difficulties, scholarship issues and insufficient information beforehand. A few students had practical (i.e. accommodation, cultural adaptation) problems. Potential enablers included better financial support, more efficient information exchange and fewer assignments and preparation tasks. Similar barriers were encountered by students across all three categories of EY activities. CONCLUSIONS: Personal growth was the most important benefit of the EY. Barriers were consistent with those identified in the literature except for cultural adaptation, which could be related to Hong Kong's unique historical context. Financial limitation was the most concerning barrier, as it could result in unequal access to educational opportunities. Better and timely access to scholarships and other funding sources need to be considered. TRIAL REGISTRATION: Ethics approval was obtained from the local Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 19-585 ).

An anti-PD-1-GITR-L bispecific agonist induces GITR clustering-mediated T cell activation for cancer immunotherapy.

Costimulatory receptors such as glucocorticoid-induced tumor necrosis factor receptor-related protein (GITR) play key roles in regulating the effector functions of T cells. In human clinical trials, however, GITR agonist antibodies have shown limited therapeutic effect, which may be due to suboptimal receptor clustering-mediated signaling. To overcome this potential limitation, a rational protein engineering approach is needed to optimize GITR agonist-based immunotherapies. Here we show a bispecific molecule consisting of an anti-PD-1 antibody fused with a multimeric GITR ligand (GITR-L) that induces PD-1-dependent and FcγR-independent GITR clustering, resulting in enhanced activation, proliferation and memory differentiation of primed antigen-specific GITR+PD-1+ T cells. The anti-PD-1-GITR-L bispecific is a PD-1-directed GITR-L construct that demonstrated dose-dependent, immunologically driven tumor growth inhibition in syngeneic, genetically engineered and xenograft humanized mouse tumor models, with a dose-dependent correlation between target saturation and Ki67 and TIGIT upregulation on memory T cells. Anti-PD-1-GITR-L thus represents a bispecific approach to directing GITR agonism for cancer immunotherapy.

Diagnosis and management of pulmonary hypertension in infants with bronchopulmonary dysplasia: a guide for paediatric respiratory specialists.

Pulmonary hypertension (PH) can develop in babies with bronchopulmonary dysplasia (BPD). PH is common in those with severe BPD and is associated with a high mortality rate. However, in babies surviving beyond 6 months, resolution of PH is likely. There is currently no standardised screening protocol for PH in BPD patients. Diagnosis in this group relies heavily on transthoracic echocardiography. Management of BPD-PH should be led by a multidisciplinary team and focus on optimal medical management of the BPD and associated conditions that may contribute to PH. PH-targeted pharmacotherapies have been used in BPD-PH. To date, these have not been investigated in clinical trials and evidence of their efficacy and safety is absent. Educational aims: To identify those BPD patients most at risk of developing PH.To be aware of detection, multidisciplinary management, pharmacological treatment and monitoring strategies for BPD-PH patients.To understand the potential clinical course for patients with BPD-PH and that evidence on efficacy and safety of PH-targeted pharmacotherapy in BPD-PH is limited.

Systematic scoping review on moral distress among physicians.

BACKGROUND: Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians. METHODS: A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows. RESULTS: A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions. CONCLUSIONS: Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

Nature in virtual reality improves mood and reduces stress: evidence from young adults and senior citizens.

Large populations worldwide have been deprived from nature experiences due to mass quarantines and lockdowns during the COVID-19 pandemic, and face a looming mental health crisis. Virtual reality offers a safe and practical solution to increase nature exposure. This research examined the effects of virtual nature using a within-subject design with young adults (Study 1) and senior citizens (Study 2). Results from the young adult sample showed that walking in a virtual forest reduced negative affect due to enhanced nature connectedness, and reduced stress measured by heart rate. Consistently, the senior citizen sample reported improved positive affect due to enhanced nature connectedness after the virtual nature walk. Our findings unveil the underlying mechanism of how virtual nature may improve psychological well-being and demonstrated how virtual nature can be used as an intervention to promote mental health. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10055-021-00604-4.

What makes AI 'intelligent' and 'caring'? Exploring affect and relationality across three sites of intelligence and care.

This paper scrutinises how AI and robotic technologies are transforming the relationships between people and machines in new affective, embodied and relational ways. Through investigating what it means to exist as human 'in relation' to AI across health and care contexts, we aim to make three main contributions. (1) We start by highlighting the complexities of philosophical issues surrounding the concepts of "artificial intelligence" and "ethical machines." (2) We outline some potential challenges and opportunities that the creation of such technologies may bring in the health and care settings. We focus on AI applications that interface with health and care via examples where AI is explicitly designed as an 'augmenting' technology that can overcome human bodily and cognitive as well as socio-economic constraints. We focus on three dimensions of 'intelligence' - physical, interpretive, and emotional - using the examples of robotic surgery, digital pathology, and robot caregivers, respectively. Through investigating these areas, we interrogate the social context and implications of human-technology interaction in the interrelational sphere of care practice. (3) We argue, in conclusion, that there is a need for an interdisciplinary mode of theorising 'intelligence' as relational and affective in ways that can accommodate the fragmentation of both conceptual and material boundaries between human and AI, and human and machine. Our aim in investigating these sociological, philosophical and ethical questions is primarily to explore the relationship between affect, relationality and 'intelligence,' the intersection and integration of 'human' and 'artificial' intelligence, through an examination of how AI is used across different dimensions of intelligence. This allows us to scrutinise how 'intelligence' is ultimately conveyed, understood and (technologically or algorithmically) configured in practice through emerging relationships that go beyond the conceptual divisions between humans and machines, and humans vis-à-vis artificial intelligence-based technologies.