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Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on “treatment intensity” including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. Conclusions: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.
Background: Clinical practice guidelines for patients with primary biliary cholangitis (PBC) have been recently revised and implemented for well-established response criteria to standard first-line ursodeoxycholic acid (UDCA) therapy at 12 months after treatment initiation for the early identification of high-risk patients with inadequate treatment responses who may require treatment modification. However, there are only very limited data concerning the real-world clinical management of patients with PBC in Germany. Objective: The aim of this retrospective multicenter study was to evaluate response rates to standard first-line UDCA therapy and subsequent Second-line treatment regimens in a large cohort of well-characterized patients with PBC from 10 independent hepatological referral centers in Germany prior to the introduction of obeticholic acid as a licensed second-line treatment option. Methods: Diagnostic confirmation of PBC, standard first-line UDCA treatment regimens and response rates at 12 months according to Paris-I, Paris-II, and Barcelona criteria, the follow-up cut-off alkaline phosphatase (ALP) ≤ 1.67 × upper limit of normal (ULN) and the normalization of bilirubin (bilirubin ≤ 1 × ULN) were retrospectively examined between June 1986 and March 2017. The management and hitherto applied second-line treatment regimens in patients with an inadequate response to UDCA and subsequent response rates at 12 months were also evaluated. Results: Overall, 480 PBC patients were included in this study. The median UDCA dosage was 13.2 mg UDCA/kg bodyweight (BW)/d. Adequate UDCA treatment response rates according to Paris-I, Paris-II, and Barcelona criteria were observed in 91, 71.3, and 61.3% of patients, respectively. In 83.8% of patients, ALP ≤ 1.67 × ULN were achieved. A total of 116 patients (24.2%) showed an inadequate response to UDCA according to at least one criterion. The diverse second-line treatment regimens applied led to significantly higher response rates according to Paris-II (35 vs. 60%, p = 0.005), Barcelona (13 vs. 34%, p = 0.0005), ALP ≤ 1.67 × ULN and bilirubin ≤ 1 × ULN (52.1 vs. 75%, p = 0.002). The addition of bezafibrates appeared to induce the strongest beneficial effect in this cohort (Paris II: 24 vs. 74%, p = 0.004; Barcelona: 50 vs. 84%, p = 0.046; ALP < 1.67 × ULN and bilirubin ≤ 1 × ULN: 33 vs. 86%, p = 0.001). Conclusion: Our large retrospective multicenter study confirms high response rates following UDCA first-line standard treatment in patients with PBC and highlights the need for close monitoring and early treatment modification in high-risk patients with an insufficient response to UDCA since early treatment modification significantly increases subsequent response rates of these patients.
Interactions between proteins and carbohydrates with larger biomacromolecules, e.g., lectins, are usually examined using self-assembled monolayers on target gold surfaces as a simplified model measuring setup. However, most of those measuring setups are either limited to a single substrate or do not allow for control over ligand distance and spacing. Here, we develop a synthetic strategy, consisting of a cascade of a thioesterification, native chemical ligation (NCL) and thiol-ene reaction, in order to create three-component polymer conjugates with a defined double bioactivation at the chain end. The target architecture is the vicinal attachment of two biomolecule residues to the α telechelic end point of a polymer and a thioether group at the ω chain end for fixating the conjugate to a gold sensor chip surface. As proof-of-principle studies for affinity measurements, we demonstrate the interaction between covalently bound mannose and ConA in surface acoustic wave (SAW) and surface plasmon resonance (SPR) experiments.
By 2050, two-third of the world’s population will live in cities. In this study, we develop a framework for analyzing urban growth-related imperviousness in North Rhine-Westphalia (NRW) from the 1980s to date using Landsat data. For the baseline 2017-time step, official geodata was extracted to generate labelled data for ten classes, including three classes representing low, middle, and high level of imperviousness. We used the output of the 2017 classification and information based on radiometric bi-temporal change detection for retrospective classification. Besides spectral bands, we calculated several indices and various temporal composites, which were used as an input for Random Forest classification. The results provide information on three imperviousness classes with accuracies exceeding 75%. According to our results, the imperviousness areas grew continuously from 1985 to 2017, with a high imperviousness area growth of more than 167,000 ha, comprising around 30% increase. The information on the expansion of urban areas was integrated with population dynamics data to estimate the progress towards SDG 11. With the intensity analysis and the integration of population data, the spatial heterogeneity of urban expansion and population growth was analysed, showing that the urban expansion rates considerably excelled population growth rates in some regions in NRW. The study highlights the applicability of earth observation data for accurately quantifying spatio-temporal urban dynamics for sustainable urbanization and targeted planning.
Public safety and socio-economic development of the Jharia coalfield (JCF) in India is critically dependent on precise monitoring and comprehensive understanding of coal fires, which have been burning underneath for more than a century. This study utilizes New-Small BAseline Subset (N-SBAS) technique to compute surface deformation time series for 2017–2020 to characterize the spatiotemporal dynamics of coal fires in JCF. The line-of-sight (LOS) surface deformation estimated from ascending and descending Sentinel-1 SAR data are subsequently decomposed to derive precise vertical subsidence estimates. The most prominent subsidence (~22 cm) is observed in Kusunda colliery. The subsidence regions also correspond well with the Landsat-8 based thermal anomaly map and field evidence. Subsequently, the vertical surface deformation time-series is analyzed to characterize temporal variations within the 9.5 km\(^2\) area of coal fires. Results reveal that nearly 10% of the coal fire area is newly formed, while 73% persisted throughout the study period. Vulnerability analyses performed in terms of the susceptibility of the population to land surface collapse demonstrate that Tisra, Chhatatanr, and Sijua are the most vulnerable towns. Our results provide critical information for developing early warning systems and remediation strategies.
Supraglacial meltwater accumulation on ice sheets can be a main driver for accelerated ice discharge, mass loss, and global sea-level-rise. With further increasing surface air temperatures, meltwater-induced hydrofracturing, basal sliding, or surface thinning will cumulate and most likely trigger unprecedented ice mass loss on the Greenland and Antarctic ice sheets. While the Greenland surface hydrological network as well as its impacts on ice dynamics and mass balance has been studied in much detail, Antarctic supraglacial lakes remain understudied with a circum-Antarctic record of their spatio-temporal development entirely lacking. This study provides the first automated supraglacial lake extent mapping method using Sentinel-1 synthetic aperture radar (SAR) imagery over Antarctica and complements the developed optical Sentinel-2 supraglacial lake detection algorithm presented in our companion paper. In detail, we propose the use of a modified U-Net for semantic segmentation of supraglacial lakes in single-polarized Sentinel-1 imagery. The convolutional neural network (CNN) is implemented with residual connections for optimized performance as well as an Atrous Spatial Pyramid Pooling (ASPP) module for multiscale feature extraction. The algorithm is trained on 21,200 Sentinel-1 image patches and evaluated in ten spatially or temporally independent test acquisitions. In addition, George VI Ice Shelf is analyzed for intra-annual lake dynamics throughout austral summer 2019/2020 and a decision-level fused Sentinel-1 and Sentinel-2 maximum lake extent mapping product is presented for January 2020 revealing a more complete supraglacial lake coverage (~770 km\(^2\)) than the individual single-sensor products. Classification results confirm the reliability of the proposed workflow with an average Kappa coefficient of 0.925 and a F\(_1\)-score of 93.0% for the supraglacial water class across all test regions. Furthermore, the algorithm is applied in an additional test region covering supraglacial lakes on the Greenland ice sheet which further highlights the potential for spatio-temporal transferability. Future work involves the integration of more training data as well as intra-annual analyses of supraglacial lake occurrence across the whole continent and with focus on supraglacial lake development throughout a summer melt season and into Antarctic winter.
Oxidative stress is defined as an imbalance between the antioxidant defense system and the production of reactive oxygen species (ROS). At low levels, ROS are involved in the regulation of redox signaling for cell protection. However, upon chronical increase in oxidative stress, cell damage occurs, due to protein, DNA and lipid oxidation. Here, we investigated the oxidative modifications of myofilament proteins, and their role in modulating cardiomyocyte function in end-stage human failing hearts. We found altered maximum Ca\(^{2+}\)-activated tension and Ca\(^{2+}\) sensitivity of force production of skinned single cardiomyocytes in end-stage human failing hearts compared to non-failing hearts, which was corrected upon treatment with reduced glutathione enzyme. This was accompanied by the increased oxidation of troponin I and myosin binding protein C, and decreased levels of protein kinases A (PKA)- and C (PKC)-mediated phosphorylation of both proteins. The Ca\(^{2+}\) sensitivity and maximal tension correlated strongly with the myofilament oxidation levels, hypo-phosphorylation, and oxidative stress parameters that were measured in all the samples. Furthermore, we detected elevated titin-based myocardial stiffness in HF myocytes, which was reversed by PKA and reduced glutathione enzyme treatment. Finally, many oxidative stress and inflammation parameters were significantly elevated in failing hearts compared to non-failing hearts, and corrected upon treatment with the anti-oxidant GSH enzyme. Here, we provide evidence that the altered mechanical properties of failing human cardiomyocytes are partially due to phosphorylation, S-glutathionylation, and the interplay between the two post-translational modifications, which contribute to the development of heart failure.
Previous research has revealed changes in the perception of objects due to changes of object-oriented actions. In present study, we varied the arm and finger postures in the context of a virtual reaching and grasping task and tested whether this manipulation can simultaneously affect the perceived size and distance of external objects. Participants manually controlled visual cursors, aiming at reaching and enclosing a distant target object, and judged the size and distance of this object. We observed that a visual-proprioceptive discrepancy introduced during the reaching part of the action simultaneously affected the judgments of target distance and of target size (Experiment 1). A related variation applied to the grasping part of the action affected the judgments of size, but not of distance of the target (Experiment 2). These results indicate that perceptual effects observed in the context of actions can directly arise through sensory integration of multimodal redundant signals and indirectly through perceptual constancy mechanisms.
It has been proposed that statistical integration of multisensory cues may be a suitable framework to explain temporal binding, that is, the finding that causally related events such as an action and its effect are perceived to be shifted towards each other in time. A multisensory approach to temporal binding construes actions and effects as individual sensory signals, which are each perceived with a specific temporal precision. When they are integrated into one multimodal event, like an action-effect chain, the extent to which they affect this event's perception depends on their relative reliability. We test whether this assumption holds true in a temporal binding task by manipulating certainty of actions and effects. Two experiments suggest that a relatively uncertain sensory signal in such action-effect sequences is shifted more towards its counterpart than a relatively certain one. This was especially pronounced for temporal binding of the action towards its effect but could also be shown for effect binding. Other conceptual approaches to temporal binding cannot easily explain these results, and the study therefore adds to the growing body of evidence endorsing a multisensory approach to temporal binding.
The present study explored how task instructions mediate the impact of action on perception. Participants saw a target object while performing finger movements. Then either the size of the target or the size of the adopted finger postures was judged. The target judgment was attracted by the adopted finger posture indicating sensory integration of body-related and visual signals. The magnitude of integration, however, depended on how the task was initially described. It was substantially larger when the experimental instructions indicated that finger movements and the target object relate to the same event than when they suggested that they are unrelated. This outcome highlights the role of causal inference processes in the emergence of action specific influences in perception.
The present study explored the origin of perceptual changes repeatedly observed in the context of actions. In Experiment 1, participants tried to hit a circular target with a stylus movement under restricted feedback conditions. We measured the perception of target size during action planning and observed larger estimates for larger movement distances. In Experiment 2, we then tested the hypothesis that this action specific influence on perception is due to changes in the allocation of spatial attention. For this purpose, we replaced the hitting task by conditions of focused and distributed attention and measured the perception of the former target stimulus. The results revealed changes in the perceived stimulus size very similar to those observed in Experiment 1. These results indicate that action's effects on perception root in changes of spatial attention.
Loneliness and lack of social well-being are associated with adverse health outcomes and have increased during the COVID-19 pandemic. Smartphone communication data have been suggested to help monitor loneliness, but this requires further evidence. We investigated the informative value of smartphone communication app data for predicting subjective loneliness and social well-being in a sample of 364 participants ranging from 18 to 78 years of age (52.2% female; mean age = 42.54, SD = 13.22) derived from the CORONA HEALTH APP study from July to December 2020 in Germany. The participants experienced relatively high levels of loneliness and low social well-being during the time period characterized by the COVID-19 pandemic. Apart from positive associations with phone call use times, smartphone communication app use was associated with social well-being and loneliness only when considering the age of participants. Younger participants with higher use times tended to report less social well-being and higher loneliness, while the opposite association was found for older adults. Thus, the informative value of smartphone communication use time was rather small and became evident only in consideration of age. The results highlight the need for further investigations and the need to address several limitations in order to draw conclusions at the population level.
The incidence of differentiated thyroid cancer (DTC) is steadily increasing globally. Epidemiologists usually explain this global upsurge as the result of new diagnostic modalities, screening and overdiagnosis as well as results of lifestyle changes including obesity and comorbidity. However, there is evidence that there is a real increase of DTC incidence worldwide in all age groups. Here, we review studies on pediatric DTC after nuclear accidents in Belarus after Chernobyl and Japan after Fukushima as compared to cohorts without radiation exposure of those two countries. According to the Chernobyl data, radiation-induced DTC may be characterized by a lag time of 4–5 years until detection, a higher incidence in boys, in children of youngest age, extrathyroidal extension and distant metastases. Radiation doses to the thyroid were considerably lower by appr. two orders of magnitude in children and adolescents exposed to Fukushima as compared to Chernobyl. In DTC patients detected after Fukushima by population-based screening, most of those characteristics were not reported, which can be taken as proof against the hypothesis, that radiation is the (main) cause of those tumors. However, roughly 80% of the Fukushima cases presented with tumor stages higher than microcarcinomas pT1a and 80% with lymph node metastases pN1. Mortality rates in pediatric DTC patients are generally very low, even at higher tumor stages. However, those cases considered to be clinically relevant should be followed-up carefully after treatment because of the risk of recurrencies which is expected to be not negligible. Considering that thyroid doses from the Fukushima accident were quite small, it makes sense to assess the role of other environmental and lifestyle-related factors in thyroid carcinogenesis. Well-designed studies with assessment of radiation doses from medical procedures and exposure to confounders/modifiers from the environment as e.g., nitrate are required to quantify their combined effect on thyroid cancer risk.
Health-related quality of life (HRQL) among migrant populations can be associated with acculturation (i.e., the process of adopting, acquiring and adjusting to a new cultural environment). Since there is a lack of longitudinal studies, we aimed to describe HRQL changes among adults of Turkish descent living in Berlin and Essen, Germany, and their association with acculturation. Participants of a population-based study were recruited in 2012–2013 and reinvited six years later to complete a questionnaire. Acculturation was assessed at baseline using the Frankfurt acculturation scale (integration, assimilation, separation and marginalization). HRQL was assessed at baseline (SF-8) and at follow-up (SF-12) resulting in a physical (PCS) and mental (MCS) sum score. Associations with acculturation and HRQL were analyzed with linear regression models using a time-by-acculturation status interaction term. In the study 330 persons were included (65% women, mean age ± standard deviation 43.3 ± 11.8 years). Over the 6 years, MCS decreased, while PCS remained stable. While cross-sectional analyses showed associations of acculturation status with both MCS and PCS, temporal changes including the time interaction term did not reveal associations of baseline acculturation status with HRQL. When investigating HRQL in acculturation, more longitudinal studies are needed to take changes in both HRQL and acculturation status into account.
We describe a system for the analysis of an important unicellular eukaryotic flagellate in a confining and crowded environment. The parasite Trypanosoma brucei is arguably one of the most versatile microswimmers known. It has unique properties as a single microswimmer and shows remarkable adaptations (not only in motility, but prominently so), to its environment during a complex developmental cycle involving two different hosts. Specific life cycle stages show fascinating collective behaviour, as millions of cells can be forced to move together in extreme confinement. Our goal is to examine such motile behaviour directly in the context of the relevant environments. Therefore, for the first time, we analyse the motility behaviour of trypanosomes directly in a widely used assay, which aims to evaluate the parasites behaviour in collectives, in response to as yet unknown parameters. In a step towards understanding whether, or what type of, swarming behaviour of trypanosomes exists, we customised the assay for quantitative tracking analysis of motile behaviour on the single-cell level. We show that the migration speed of cell groups does not directly depend on single-cell velocity and that the system remains to be simplified further, before hypotheses about collective motility can be advanced.
To deliver the best user experience (UX), the human-centered design cycle (HCDC) serves as a well-established guideline to application developers. However, it does not yet cover network-specific requirements, which become increasingly crucial, as most applications deliver experience over the Internet. The missing network-centric view is provided by Quality of Experience (QoE), which could team up with UX towards an improved overall experience. By considering QoE aspects during the development process, it can be achieved that applications become network-aware by design. In this paper, the Quality of Experience Centered Design Cycle (QoE-CDC) is proposed, which provides guidelines on how to design applications with respect to network-specific requirements and QoE. Its practical value is showcased for popular application types and validated by outlining the design of a new smartphone application. We show that combining HCDC and QoE-CDC will result in an application design, which reaches a high UX and avoids QoE degradation.
At present, there is a lack of longitudinal studies on the psychological adjustment of both children and adolescents with 22q11.2 deletion syndrome (22q11.2DS) and their primary caregivers. To fill this gap, we performed a four-year follow-up study. Mothers filled out the Child Behavior Checklist 4–18, the Social Orientation of Parents with Handicapped Children questionnaire to assess maternal stress and coping strategies, and the Freiburger Personality Inventory-Revised — subscales strain and life satisfaction. Fifty-five subjects with 22q11.2DS (26 males and 29 females; age: M = 10.79 years, SD = 3.56 years) and their biological mothers (age: M = 40.84 years, SD = 4.68 years) were included in this study. Significantly higher levels of behavior problems than in the general population and an increase in these problems, especially internalizing ones, over time could be found. In contrast, maternal stress did not change significantly over time, but mothers demonstrated increased levels of strain and reduced life satisfaction at T2. Thus, careful monitoring as well as early and adequate interventions, if indicated, should be offered to families with a child with 22q11.2DS, not only for somatic complaints but also for problems with psychological adjustment.
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that causes progressive autonomy loss and need for care. This does not only affect patients themselves, but also the patients’ informal caregivers (CGs) in their health, personal and professional lives. The big efforts of this multi-center study were not only to evaluate the caregivers' burden and to identify its predictors, but it also should provide a specific understanding of the needs of ALS patients' CGs and fill the gap of knowledge on their personal and work lives. Using standardized questionnaires, primary data from patients and their main informal CGs (n = 249) were collected. Patients' functional status and disease severity were evaluated using the Barthel Index, the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) and the King’s Stages for ALS. The caregivers' burden was recorded by the Zarit Burden Interview (ZBI). Comorbid anxiety and depression of caregivers were assessed by the Hospital Anxiety and Depression Scale. Additionally, the EuroQol Five Dimension Five Level Scale evaluated their health-related quality of life. The caregivers' burden was high (mean ZBI = 26/88, 0 = no burden, ≥24 = highly burdened) and correlated with patients' functional status (r\(_p\) = −0.555, p < 0.001, n = 242). It was influenced by the CGs' own mental health issues due to caregiving (+11.36, 95% CI [6.84; 15.87], p < 0.001), patients' wheelchair dependency (+9.30, 95% CI [5.94; 12.66], p < 0.001) and was interrelated with the CGs' depression (r\(_p\) = 0.627, p < 0.001, n = 234), anxiety (r\(_p\) = 0.550, p < 0.001, n = 234), and poorer physical condition (r\(_p\) = −0.362, p < 0.001, n = 237). Moreover, female CGs showed symptoms of anxiety more often, which also correlated with the patients' impairment in daily routine (r\(_s\) = −0.280, p < 0.001, n = 169). As increasing disease severity, along with decreasing autonomy, was the main predictor of caregiver burden and showed to create relevant (negative) implications on CGs' lives, patient care and supportive therapies should address this issue. Moreover, in order to preserve the mental and physical health of the CGs, new concepts of care have to focus on both, on not only patients but also their CGs and gender-associated specific issues. As caregiving in ALS also significantly influences the socioeconomic status by restrictions in CGs' work lives and income, and the main reported needs being lack of psychological support and a high bureaucracy, the situation of CGs needs more attention. Apart from their own multi-disciplinary medical and psychological care, more support in care and patient management issues is required.
Improving quality of life (QoL) is central to amyotrophic lateral sclerosis (ALS) treatment. This Germany-wide, multicenter cross-sectional study analyses the impact of different symptom-specific treatments and ALS variants on QoL. Health-related QoL (HRQoL) in 325 ALS patients was assessed using the Amyotrophic Lateral Sclerosis Assessment Questionnaire 5 (ALSAQ-5) and EuroQol Five Dimension Five Level Scale (EQ-5D-5L), together with disease severity (captured by the revised ALS Functional Rating Scale (ALSFRS-R)) and the current care and therapies used by our cohort. At inclusion, the mean ALSAQ-5 total score was 56.93 (max. 100, best = 0) with a better QoL associated with a less severe disease status (β = −1.96 per increase of one point in the ALSFRS-R score, p < 0.001). “Limb-onset” ALS (lALS) was associated with a better QoL than “bulbar-onset” ALS (bALS) (mean ALSAQ-5 total score 55.46 versus 60.99, p = 0.040). Moreover, with the ALSFRS-R as a covariate, using a mobility aid (β = −7.60, p = 0.001), being tracheostomized (β = −14.80, p = 0.004) and using non-invasive ventilation (β = −5.71, p = 0.030) were associated with an improved QoL, compared to those at the same disease stage who did not use these aids. In contrast, antidepressant intake (β = 5.95, p = 0.007), and increasing age (β = 0.18, p = 0.023) were predictors of worse QoL. Our results showed that the ALSAQ-5 was better-suited for ALS patients than the EQ-5D-5L. Further, the early and symptom-specific clinical management and supply of assistive devices can significantly improve the individual HRQoL of ALS patients. Appropriate QoL questionnaires are needed to monitor the impact of treatment to provide the best possible and individualized care.
Electroencephalography (EEG) represents a widely established method for assessing altered and typically developing brain function. However, systematic studies on EEG data quality, its correlates, and consequences are scarce. To address this research gap, the current study focused on the percentage of artifact-free segments after standard EEG pre-processing as a data quality index. We analyzed participant-related and methodological influences, and validity by replicating landmark EEG effects. Further, effects of data quality on spectral power analyses beyond participant-related characteristics were explored. EEG data from a multicenter ADHD-cohort (age range 6 to 45 years), and a non-ADHD school-age control group were analyzed (n\(_{total}\) = 305). Resting-state data during eyes open, and eyes closed conditions, and task-related data during a cued Continuous Performance Task (CPT) were collected. After pre-processing, general linear models, and stepwise regression models were fitted to the data. We found that EEG data quality was strongly related to demographic characteristics, but not to methodological factors. We were able to replicate maturational, task, and ADHD effects reported in the EEG literature, establishing a link with EEG-landmark effects. Furthermore, we showed that poor data quality significantly increases spectral power beyond effects of maturation and symptom severity. Taken together, the current results indicate that with a careful design and systematic quality control, informative large-scale multicenter trials characterizing neurophysiological mechanisms in neurodevelopmental disorders across the lifespan are feasible. Nevertheless, results are restricted to the limitations reported. Future work will clarify predictive value.