Frailty, Quality of Life, and Loneliness of Aging in Native and Diasporic Chinese Adults.

BACKGROUND: Global migration has increased in the past century, and aging in a foreign country is relevant to the Chinese diaspora. OBJECTIVE: With regard to migration, this study focuses on the places of aging as the context of older Chinese adults. This study aimed to describe the general health and wellbeing of this population with respect to their location. DESIGN: This study has a cross sectional design. SETTING AND PARTICIPANTS: Participants were recruited who were "aging in place" from Tianjin, China (199 participants), and "aging out of place" from the Netherlands (134 participants). Data from April to May 2019 in China and November 2018 to March 2019 in the Netherlands were aggregated. MEASUREMENTS: frailty, QoL and loneliness were used in both samples. RESULTS: T-tests and regression analyses demonstrated that social domains of frailty and QoL, as well as loneliness and frailty prevalence characterized the major differences between both places of aging. A correlation analysis and visual correlation network revealed that frailty, quality of life (QoL), and loneliness were more closely related in the aging out of place sample. Social domains of frailty and QoL, as well as the prevalence of loneliness and frailty, characterized the major differences between both places of aging. CONCLUSIONS: The findings indicate that frailty, QoL, and loneliness have a complex relationship, confirming that loneliness is a major detriment to the general wellbeing of older Chinese adults aging out of place. This study examined the places of aging of the larger Chinese population and allows a comprehensive understanding of health and wellbeing. The social components, especially loneliness, among the aging out of place Chinese community should receive more attention practice and clinical wise. On the other hand, frailty as well as its prevention is of more importance for the Chinese community aging in place.

Towards criteria and symptoms of constipation in people with severe or profound intellectual and multiple disabilities: A Delphi study.

Background: Chronic constipation is common in people with intellectual disabilities, and seems to be highly prevalent in people with severe or profound intellectual and multiple disabilities (SPIMD). However, there is no current widely accepted definition for the constipation experienced by these individuals. Aim: This Delphi study aims to compile a list of operationalized criteria and symptoms of constipation in people with SPIMD based on practical experiences of and consensus between experts supporting them. Methods: A two-round Delphi study with an intermediate evaluation and analyses was conducted. Parents and relatives of persons with SPIMD and support professionals were included. The panel answered statements and open questions about symptoms and criteria of constipation. They were also requested to provide their opinion about classifying criteria and symptoms into domains. Answers to statements were analysed separately after both rounds with regard to consensus rate and displayed qualitatively; answers to open questions were analysed deductively. Results: In the first Delphi round (n = 47), consensus was achieved on criteria within the domains 'Defecation' and 'Physical features', that were assigned to broader categories. Symptoms retrieved within the domain 'Behavioural/Emotional' were brought back to the panel as statements. After the second Delphi round (n = 38), consensus was reached on questions about domains, and for eight criteria (domain 'Defecation' n = 5; domain 'Physical features n = 3). Within the domain 'Behavioural/Emotional', consensus was achieved for five symptoms. Criteria and symptoms with consensus >70% were considered 'generic' and <70% as 'personal'. Symptoms mentioned in the text boxes were used to operationalize categories. Discussion and conclusion: It was possible to compile a list of generic criteria related to the domains 'Defecation' (n = 5) and 'Physical features' (n = 3) supplemented with generic symptoms related to the domain 'Behavioural/Emotional' (n = 5). We propose using both generic as well as personal criteria and symptoms resulting in a personal profile for an individual with SPIMD. Based on the current results, we recommend follow-up research to develop a screening tool to be used by relatives and professional caregivers, and a definition of constipation. This may support reciprocal collaboration and lead to timely identification of constipation in people with SPIMD.

Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey.

BACKGROUND: Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM. METHODS: A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists). RESULTS: Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained. CONCLUSION: Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.

Implementation of a program to support direct support professionals to promote a healthy lifestyle for people with moderate to profound intellectual disabilities.

BACKGROUND: There is a lack of theory-based interventions for direct support professionals (DSPs) to support a healthy lifestyle for people with moderate to profound intellectual disabilities (ID) despite their major role in this. This study aims to evaluate the preparation, implementation, and preliminary outcomes of a theory-based training and education program for DSPs to learn how to support these individuals. METHODS: The program consisting of e-learning, three in-person sessions, and three assignments was implemented. The implementation process was evaluated with a mixed method design with the following components: preparation phase, implementation phase, and the outcomes. These components were measured with project notes, questionnaires, interviews, reflections, assignments, food diaries, Actigraph/Actiwatch, and an inventory of daily activities. RESULTS: Regarding the preparation phase, enough potential participants met the inclusion criteria and the time to recruit the participants was 9 months. The program was implemented in four (residential) facilities and involved individuals with moderate to profound ID (n = 24) and DSPs (n = 32). The e-learning was completed by 81% of the DSPs, 72-88% attended the in-person sessions, and 34-47% completed the assignments. Overall, the fidelity of the program was good. DSPs would recommend the program, although they were either negative or positive about the time investment. Mutual agreement on expectations were important for the acceptability and suitability of the program. For the outcomes, the goals of the program were achieved, and the attitudes of DSPs towards a healthy lifestyle were improved after 3 months of the program (nutrition: p = < 0.01; physical activity: p = 0.04). A statistically significant improvement was found for food intake of people with ID (p = 0.047); for physical activity, no statistically significant differences were determined. CONCLUSIONS: The theory-based program consisting of a training and education section for DSPs to support a healthy lifestyle for people with moderate to profound ID was feasible to implement and, despite some barriers regarding time capacity and mutual expectations, it delivered positive changes in both persons with moderate to profound ID and DSPs. Thus, the program is a promising intervention to support DSPs.

The degree of joint range of motion limitations after burn injuries during recovery.

INTRODUCTION: The aim of this study was to determine the degree of ROM limitations of extremities, joints and planes of motion after burns and its prevalence over time. METHOD: The database of a longitudinal multicenter cohort study in the Netherlands (2011-2012) was used. From patients with acute burns involving the neck, shoulder, elbow, wrist, hip, knee and ankle joints that had surgery, ROM of 17 planes of motion was assessed by goniometry at 3, 6 weeks, 3-6-9 and 12 months after burns and at discharge. RESULTS: At 12 months after injury, 12 out of 17 planes of motion demonstrated persistent joint limitations. The five unlimited planes of motion were all of the lower extremity. The most severely limited joints at 12 months were the neck, ankle, wrist and shoulder. The lower extremity was more severely limited in the early phase of recovery whereas at 12 months the upper extremity was more severely limited. CONCLUSION: The degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. This study showed which joints and planes of motion should be watched specifically concerning the development of scar contracture.

Items analysis of the Frailty Index (FI-35): Insight in the contribution of each item to the level of frailty.

BACKGROUND: The FI-35 is a valid multidimensional Chinese frailty assessment instrument. Like other scales, functional measures rely on the information the total score provides. Our research aimed to analyze the contribution of each item. METHODS: Descriptive statistics were used to summarize the sample characteristics. The expected item score (EIS) was used to determine how the items contribute to the generic measure of frailty. RESULTS: This study showed that most of the EIS curves increased across the entire range of frailty levels, and most of the items discriminate relatively well over the entire frailty range. Items differentially contributed to the total frailty score and differentially discriminated between frailty levels. CONCLUSIONS: Although nearly all items monotonically increased with frailty levels, there were large differences between items in their ability to differentiate between persons being either weakly, moderately or highly frail.

Variables related to the quality of life of families that have a child with severe to profound intellectual disabilities: A systematic review.

BACKGROUND: Family quality of life (FQoL) of families that have a child with severe to profound intellectual disabilities (SPID) is an important and emerging concept, however, related variables are inconclusive. AIM: To gain a better understanding of variables related to the FQoL of families that have a child with SPID, variables related to the FQoL of families that have a child with intellectual disabilities (ID) were systematically reviewed. METHODS AND PROCEDURES: A search strategy was performed in five databases. Critical appraisal tools were employed to evaluate the quality of both quantitative and qualitative studies. Data extraction and synthesis occurred to establish general study characteristics, variables, and theoretical concepts. Variables were categorised into four key concepts of the FQoL: systemic concepts, performance concepts, family-unit concepts and individual-member concepts. OUTCOMES AND RESULTS: A total of 40 studies were retrieved with 98 variables. Quality scores ranged from 7 to 13 (quantitative) and 5 to 13 (qualitative) out of 13 and 14 points, respectively. Five out of the 40 studies (13%) focused on individuals with SPID. Variables related positively or negatively to the FQoL, and were categorised within systemic concepts (n = 3); performance concepts (n = 11); family-unit concepts (n = 26); and individual-member concepts (n = 58). CONCLUSIONS AND IMPLICATIONS: Several variables were found to be (inter)related to the FQoL of families that have a child with ID. A contrasting picture emerged regarding the impact of a disability in relation to transitional phases. However, studies which include families of children with SPID were minimal, therefore, it remained ambiguous to what extent the identified variables apply to these families.

Frailty among older people in a community setting in China.

Frailty is the most common manifestation of serious health issues in the world, and it is becoming more prevalent worldwide as the aging population grows. Changes that occur in an individual during the aging process have physical, psychological, social, and environmental aspects that make an individual more frail. In China, older people may live in communities for aging individuals. This study aimed to describe the presence and severity of frailty and to analyze influencing factors among this population in China. The Frailty Index 35 (FI-35) scale, which includes 35 items in physical, psychological, social, and environmental domains, was used to investigate frailty. The FI-35 score ranges from zero to one, with a score closer to one indicating greater frailty. Biographical, socioeconomic, and lifestyle factors were measured as potential determinants of frailty. We relied on the November 2017-February 2018 waves of the Chinese cross-sectional study survey that comprised a sample of 513 adults, aged 60 or older, who were living in China. Linear regression was performed to identify factors associated with FI-35 scores. We categorized the determinants of frailty into three models: Model 1: biographical variables; Model 2: biographical and socioeconomic variables; and Model 3: biographical, economic, and lifestyle variables. Frailty scores ranged from 0.00 to 0.89, with a median of 0.31, and the prevalence of frailty was 67.6%. The final model obtained after variable selection included age, minority status, marriage status, income, diet, and exercise. The adjusted R-squared indicated that the analysis explained 13.8% of the variance in frailty scores. Adding household, marriage status, education level, medical insurance, and income as elements in Model 2 explained 25.7%. Adding diet, smoking, drinking, exercise, and hobbies in Model 3 explained 27.9%. The degree of frailty varies considerably among Chinese community-dwelling older people and is partly determined by biographical, socioeconomic, and lifestyle factors.

Coexistence of malnutrition, frailty, physical frailty and disability in patients with COPD starting a pulmonary rehabilitation program.

BACKGROUND & AIMS: Malnutrition, frailty, physical frailty, and disability are common conditions in patients with chronic obstructive pulmonary disease (COPD). Insight in the coexistence and relations between these conditions may provide information on the nature of the relationship between malnutrition and frailty. Such information may help to identify required interventions to improve the patient's health status. We therefore aimed to explore whether malnutrition, frailty, physical frailty, and disability coexist in patients with COPD at the start of pulmonary rehabilitation. METHODS: For this cross-sectional study, from March 2015 to May 2017, patients with COPD were assessed at the start of a pulmonary rehabilitation program. Nutritional status was assessed with the Scored Patient-Generated Subjective Global Assessment (PG-SGA) based Pt-Global app. Frailty was assessed by the Evaluative Frailty Index for Physical activity (EFIP), physical frailty by Fried's criteria, and disability by the Dutch version of World Health Organization Disability Assessment Schedule 2.0 (WHODAS). These variables were dichotomized to determine coexistence of malnutrition, frailty, physical frailty, and disability. Associations between PG-SGA score and respectively EFIP score, Fried's criteria, and WHODAS score were analyzed by Pearson's correlation coefficient. Two tailed P-values were used, and significance was set at P < 0.05. RESULTS: Of the 57 participants included (age 61.2 ± 8.7 years), malnutrition and frailty coexisted in 40%. Malnutrition and physical frailty coexisted in 18%, and malnutrition and disability in 21%. EFIP score and PG-SGA score were significantly correlated (r = 0.43, P = 0.001), as well as Fried's criteria and PG-SGA score (r = 0.37, P = 0.005). CONCLUSIONS: In this population, malnutrition substantially (40%) coexists with frailty. Although the prevalence of each of the four conditions is quite high, the coexistence of all four conditions is limited (11%). The results of our study indicate that nutritional interventions should be delivered by health care professionals across multiple disciplines.

Joint flexibility problems and the impact of its operationalisation.

BACKGROUND: Dissatisfaction is being voiced with the generally used way joint flexibility problems are defined (operationalised), i.e. as a range of motion (ROM) one or more degrees lower than normative ROM of healthy subjects. Other, specifically more function-related operationalisations have been proposed. The current study evaluated the effect of applying different operationalisations of joint flexibility problems on its prevalence. METHOD: ROM data of 95 joints affected by burns of 23 children were used, and data on 18 functional activities (Burn Outcome Questionnaire (BOQ)). Five methods were used to operationalise joint flexibility problems: (1) ROM below normative ROM, (2) ROM below normative ROM minus 1SD, (3) ROM below normative ROM minus 2SD, (4) ROM below functional ROM, and (5) a score of 2 or more on the Likert Scale (BOQ). RESULTS: Prevalence of joint flexibility problems on a group level ranged from 13 to 100% depending on the operationalisation used. Per joint and movement direction, prevalence ranged from 40% to 100% (Method 1) and 0% to 80% (Methods 2-4). 18% of the children received '2' on the Likert Scale (Method 5). CONCLUSION: The operationalisation of joint flexibility problems substantially influences prevalence, both on group and joint level. Changing to a function-related operationalisation seems valuable; however, international consensus is required regarding its adoption. TRIAL REGISTRATION: The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).

Anabolic competence: Assessment and integration of the multimodality interventional approach in disease-related malnutrition.

Disease-related malnutrition (DRM) is a frequent clinical problem, characterized by loss of lean body mass and decreased function, including muscle function and immunocompetence. In DRM, nutritional intervention is necessary, but it has not consistently been shown to be sufficient. Other factors, for example, physical activity and hormonal or metabolic influencers of the internal milieu, are also important in the treatment of DRM. A prerequisite for successful treatment of DRM is the positive balance between anabolism and catabolism. The aim of this review was to approach DRM using this paradigm of anabolic competence, for conceptual and practical reasons. Anabolic competence is defined as "that state which optimally supports protein synthesis and lean body mass, global aspects of muscle and organ function, and immune response." Anabolic competence and interdisciplinary, multimodality interventions create a practical foundation to approach DRM in a proactive comprehensive way. Here, we describe the paradigm of anabolic competence, and its operationalization by measuring factors related to anabolic competence and suited for clinical management of patients with DRM.

The prevalence and development of burn scar contractures: A prospective multicenter cohort study.

OBJECTIVE: The objective of this study was to identify the prevalence and development of after burn joint limitation by scar contracture. METHODS: In 2011-2012, consecutive patients were enrolled in this prospective multi center cohort study. Eligible were all patients admitted to the 2 participating Dutch Burn Centers with acute burns across or adjacent to the neck, shoulder, elbow, wrist, hip, knee and ankle. Passive range of motion was measured in week 3 and subsequently every 3 weeks until discharge, on discharge from the hospital and during follow-up at the outpatient clinic at 3-6-9-12 months after burn. RESULTS: Limited range of motion of non-operated burned joints (N = 195) was restored back to normal within 6-9 months. From the operated burned joints (N = 353), 58.6% demonstrated a limited range of motion at 3-6 weeks declining to 20.9% at 12 months. The upper part of the body was affected more often by scar contracture than the lower part. At 12 months, the shoulder was limited most often (51.3%) and the hip least often (0%). Reconstructive surgery was performed in 13.3% of the operated burned joints. CONCLUSIONS: Persistent joint limitations at 12 months were exclusively present in joints that needed skin grafting for rapid wound closure. The upper part of the body was more prone to contracture formation than the lower part, from which the shoulder was most often involved. More than half of the limited range of motion seen in the acute phase, resolved in the long term. The need for reconstructive surgery was less than expected.

Trajectories of Physical Work Capacity in Early Symptomatic Osteoarthritis of Hip and Knee: Results from the Cohort Hip and Cohort Knee (CHECK) Study.

Purpose To evaluate the 5-year course of physical work capacity of participants with early symptomatic osteoarthritis (OA) of the hip and/or the knee; to identify trajectories and explore the relationship between trajectories and covariates. Methods In a prospective cohort study, physical work capacity was measured at baseline, using a test protocol (functional capacity evaluation) consisting of work-related physical activities. Participants were invited to participate in 1, 2 and 5 year follow-up measurements. Multilevel analysis and latent classes analysis were performed, in models with test performances as dependent variables and age, sex, work status, self-reported function (Western Ontario McMasters Arthritis Scale-WOMAC), body mass index (BMI) and time as independent variables. Multiple imputation was used to control for the influence of missing data. Results At baseline and after 1, 2 and 5 years there were 96, 64, 61 and 35 participants. Mean (SD) age at baseline was 56 (4.9) years, 84% were females. There was no statistically significant change in test performances (lifting low and high, carrying, static overhead work, repetitive bending, repetitive rotations) between the 4 measurements. Male sex, younger age and better self-reported function were statistically significant (p < 0.05) determinants of higher performance on most of the tests; having a paid job, BMI and progression of time were not. Three trajectories were identified: 'weak giving way', 'stable and able', and 'strong with decline'. Discussion In subgroups of participants with early symptomatic OA, determined by age, sex and self-reported function, physical work capacity seems to be a stable characteristic over 5 years.

Shoulder and elbow range of motion for the performance of activities of daily living: A systematic review.

The loss of range of motion (ROM) in the upper extremities can interfere with activities of daily living (ADL) and, therefore, many interventions focus on improving impaired ROM. The question, however, is what joint angles are needed to naturally perform ADL. The present review aimed to compile and synthesize data from literature on shoulder and elbow angles that unimpaired participants used when performing ADL tasks. A search was conducted in PubMed, Cochrane, Scopus, CINAHL, and PEDro. Studies were eligible when shoulder (flexion, extension, abduction, adduction) and/or elbow (flexion, extension) angles were measured in unimpaired participants who were naturally performing ADL tasks, and angles were provided per task. Thirty-six studies involving a total of 66 ADL tasks were included. Results demonstrated that unimpaired participants used up to full elbow flexion (150°) in personal care, eating, and drinking tasks. For shoulder flexion and abduction approximately 130° was necessary. Specific ADL tasks were measured often, however, almost never for tasks such as dressing. The synthesized information can be used to interpret impairments on the individual level and to establish rehabilitation goals in terms of function and prevention of secondary conditions due to excessive use of compensatory movements.

Translation and Psychometric Evaluation of the Dutch Families Importance in Nursing Care: Nurses' Attitudes Scale Based on the Generalized Partial Credit Model.

The instrument called Families Importance in Nursing Care-Nurses' Attitudes (FINC-NA) is used to measure nurses' attitudes toward involving families in their nursing care. The aim of this study is to evaluate the FINC-NA scale in a population of Dutch nurses and add new psychometric information to existing knowledge about this instrument. Using a cross-sectional design, 1,211 nurses received an online application in 2015. Psychometric properties were based on polychoric correlations and the Generalized Partial Credit Model. A total of 597 (49%) nurses responded to the online application. Results confirmed a four-subscale structure. All response categories were utilized, although some ceiling effects occurred. Most items increase monotonically, and the majority of items discriminate well between different latent trait scores of nurses with some items providing more information than others. This study reports the psychometric properties of the Dutch language FINC-NA instrument. New insights into the construct and content of items enable the possibility of a more generic instrument that could be valid across several cultures.

Evaluation of change in dietitians' perceived comprehensibility and difficulty of the Patient-Generated Subjective Global Assessment (PG-SGA) after a single training in the use of the instrument.

BACKGROUND: The Patient-Generated Subjective Global Assessment (PG-SGA) is an instrument used to assess malnutrition and its risk factors. Some items of the PG-SGA may be perceived as hard to comprehend or as difficult by healthcare professionals. The present study aimed to determine whether and how dietitians' perceptions of comprehensibility and difficulty of the PG-SGA change after a single training in PG-SGA use. METHODS: In this prospective evaluation study, Dutch PG-SGA-naïve dietitians completed a questionnaire regarding perceived comprehensibility and difficulty of the PG-SGA before (T0) and after (T1) receiving a single training in the use of the instrument. Perceived comprehensibility and difficulty were operationalised by calculating item and scale indices for comprehensibility (I-CI, S-CI) and difficulty (I-DI, S-DI) at T0 and T1. An item index of 0.78 was considered acceptable, a scale index of 0.80 was considered acceptable and a scale index of 0.90 was considered excellent. RESULTS: A total of 35 participants completed the questionnaire both at T0 and T1. All item indices related to comprehensibility and difficulty improved, although I-DI for the items regarding food intake and physical examination remained below 0.78. Scale indices for difficulty and comprehensibility of the PG-SGA changed significantly (P < 0.001) from not acceptable at T0 (S-CI = 0.69; S-DI = 0.57) to excellent for comprehensibility (S-CI = 0.95) and acceptable for difficulty (S-DI = 0.86) at T1. CONCLUSIONS: The findings of the present study suggest that significant improvement in PG-SGA-naïve dietitians' perception of comprehensibility and difficulty of the PG-SGA can be achieved quickly by providing a 1 day of training in the use of the PG-SGA.

Social frailty in older adults: a scoping review.

Social frailty is a rather unexplored concept. In this paper, the concept of social frailty among older people is explored utilizing a scoping review. In the first stage, 42 studies related to social frailty of older people were compiled from scientific databases and analyzed. In the second stage, the findings of this literature were structured using the social needs concept of Social Production Function theory. As a result, it was concluded that social frailty can be defined as a continuum of being at risk of losing, or having lost, resources that are important for fulfilling one or more basic social needs during the life span. Moreover, the results of this scoping review indicate that not only the (threat of) absence of social resources to fulfill basic social needs should be a component of the concept of social frailty, but also the (threat of) absence of social behaviors and social activities, as well as (threat of) the absence of self-management abilities. This conception of social frailty provides opportunities for future research, and guidelines for practice and policy.

Patterns of multimorbidity in people with severe or profound intellectual and motor disabilities.

BACKGROUND: People with severe or profound intellectual and motor disabilities (SPIMD) experience multimorbidity and have complex health needs. Multimorbidity increases mortality, decreases functioning, and negatively influences quality of life. Information regarding patterns of multimorbidity in people with SPIMD may lead to proactive prevention, specifically detection and treatment of physical health problems at an early stage and prevention of secondary complications. AIM: The aim of this study was to explore patterns of multimorbidity in individuals with SPIMD. METHODS AND PROCEDURES: Data from medical records and care plans on reported physical health problems of 99 adults with SPIMD were analysed. To explore the co-occurrence of physical health problems, cross tabulations and a 5-set Venn Diagram were used. OUTCOMES AND RESULTS: The most common combination of two physical health problems comprise the most prevalent physical health problems, which included visual impairment, constipation, epilepsy, spasticity, and scoliosis. These five issues occurred as a multimorbidity combination in 37% of the participants. In 56% of the participants a multimorbidity combination of four health problems emerged, namely constipation, visual impairment, epilepsy, and spasticity. CONCLUSIONS AND IMPLICATIONS: People experiencing SPIMD have interrelated health problems. As a consequence, a broad variety of potential interactions between physical health problems and their treatments may occur. Identifying multimorbidity patterns can provide guidance for accurate monitoring of persistent health problems and, early detection of secondary complications. However, the results require confirmation with larger samples in further studies.