| Young Ho Yun | 19 Articles |
Background
Although, its efficacy is unclear, the application of complementary and alternative medicine (CAM) is increasing among patients worldwide. The physician's role is very important to help patients understand and use CAM properly. The aim of this study is to examine the perceptions, attitudes and physician-patient communication of about CAM in two distinguished specialty physicians. Methods: A web-based survey was performed to list oncologists and family physicians in Korea between May 2007 and July 2007. E-mails were sent to total of 5,429 physicians and 547 physicians replied on survey (response rate: 10.1%). Of them, 500 participants comprising 174 clinical oncologists and 326 family physicians were involved in this study. The study questionnaire consisted of 26 questions including questions about general characteristics of CAM and intentions of introduction and education to their patients. Results: Of 500 physicians, males were 73.4%, and 82.0% were middle-aged 30-49. Family physicians had more interest than oncologists about CAM (79.5% and 57.5%, respectively). In addition to, family physicians preferred introducing CAM to their patients than oncologists (34.1% and 18.4%, respectively). Almost 85% of the oncologists and family physicians thought that it was necessary to introduce CAM to their patients. However, 60.2% of them had hesitated their practice because 70.3% of them did not have suffi cient knowledge in CAM. Both specialty physicians responded that usefulness of CAM information when regarding practice, should contain evidence-based evaluation (59.2%) and consensus guideline(37.0%). Conclusion: The results of this study showed that most physicians did not have sufficient information regarding CAM(87.2%). The result implies that evidence based information on complementaryand alternative medicine should be offered in the national level to improve communication between physicians and patients. Citations Citations to this article as recorded by
Background
: Two representative groups of family physicians and oncologists were surveyed concerning their knowledge and attitudes toward cancer pain management (CPM). Methods : A questionnaire, designed to assess knowledge (13 items) and attitudes (6 items) toward CPM, was sent to 2,200 members of Korean Association of Family Medicine and 800 members of Korean Cancer Association. Results : Three hundred and eighty eight family physicians (17.6%) and one hundred and forty seven oncologists (18.4%) responded and completed the questionnaire. They had inadequate knowledge toward CPM, especially, chance of respiratory depression, tolerance to adverse effect, ceiling effect, risk of addiction, and use of adjuvants. Most of the physicians had positive attitude toward importance of CPM, best judge of pain severity, and priority of CPM but had negative attitude toward concerns about potential problem of addiction and earlier prescription of maximum dose of opioid. Family physicians displayed more lack of knowledge about CPM in 9 of 13 items and more negative attitudes toward 4 of 6 items. Adjustment for demographic characteristics and experiences in cancer patients with pain showed that while family physicians had poor knowledge of tolerance to confusion, they had more adequate knowledge on the effect of antidepressant and had positive attitude towards best judge of pain severity and priority of CPM. Poor knowledge about CPM was rated by 66.3% of physicians as the most important barrier to adequate CPM. Conclusion : These findings that most of the physicians had poor knowledge and negative view toward CPM suggest a continuous need for comprehensive education program focused on CPM for physicians.
Background
: We conducted this study to investigate the financial burden of terminal cancer patients' family and to identify factors influencing their economic burden. Methods : We approached 187 family members supporting their famly member with terminal cancer who was enrolled in four hospice and palliative care program. We constructed a questionnaire examining the impact of illness on their family. With multiple logistic analysis, we examined the patients' and family members' demographic and the patients' clinical factors associated with the burden caused by terminal cancer. Results : The majority of families reported the loss of savings (54%), the need to make major life changes in order to care for the patient (50%), the loss of incomes (34%), the inability to function normally because of the stress of the illness (27%). Many families had to move to a less expensive home (18%), delay medical care for other family members (12%), or change educational plans for other family members (13%). Families that cared for patients who wanted to be cared for at institution (odds ratio: 2.72, 95% confidence interval: 1.19∼6.19), patients with liver cancer (3.61, 1.53∼8.57), and families who were poor caregivers (2.97, 1.24∼7.10), or primary caregiver was a spouse (3.57, 1.47∼8.68) were more likely to lose savings. Families that were in 'new couple' in family life cycle stages (3.91, 1.04∼14.63), 'birth of the first child' (8.34, 2.74∼25.32), and 'the adolescent family or the launching family' (10.56, 4.07∼27.33), were more likely to lose savings than 'the empty family or the aging family'. Conclusion : families with predictors of high economic burdens.
Background
: Because of a continuous increase in elderly population with functional disabilities and diseases including cancer in Korea, the need for measuring the quality of life in the elderly with cancer is growing. The purpose of this study was to examine the factors associated with the quality of life in the elderly with cancer. Methods : The instruments of this study were European Organization for Research and Treatment of Cancer (EORTC0 QLQ-C30, Beck Depression Inventory (BDI), and Brief Pain Inventory (BPI). We conducted the stepwise multiple regression to analyze predictors of global QOL in the elderly and the younger cancer patient groups. Results : The main findings were as follows: The regression analysis of the elderly group revealed some items as significant predictors; sadness, insomnia, fatigability of depression subscales, and work of pain interference item. The regression analysis of the younger group revealed cognitive functioning and activity of pain interference item as significant variables. Conclusion : The findings support the conclusion that depression items were the most important factors in QOL of elderly patients with cancer. Therefore, we need to take more interest concerning depression in elderly cancer patients.
Background
: CRC is an ideal target for population screening because it is a prevalent disease with an identifiable precursor lesion. This study was performed for the purpose of comparing cost-effectiveness of CRC screening strategies. Methods : The natural history of a simulated cohort of 50- year-old Koreans in the general population was modeled with and without CRC screening until age 80 years. We evaluated 16 different screening strategies with Markov model. Cases of positive screening test results were worked up with a colonoscopy. After polypectomy, colonoscopy was repeated every 3 years. Our main outcome measurements were discounted lifetime costs, life expectancy and incremental cost-effectiveness (CE) ratio, comparing 16 different CRC screening strategies. Results : In base-case analysis, compliance was assumed to be 60% with the initial screen and 80% with follow-up or surveillance colonoscopy. The non-dominated strategies were colonoscopy every 10 years (COL10), colonoscopy every 5 years (COL5) and colonoscopy every 3 years (COL3). Strategies that only included sigmoidoscopy were generally not regarded as non-dominated strategies, but sigmoidoscopy every 5 years (SIG5) showed similar cost and effects as COL10 while sigmoidoscopy every 3 years (SIG3) had similar results as COL5. Other strategies recommended by the expert panel, such as sigmoidocopy plus colon study every 5 years were less cost-effective than the alternatives. Conclusion : Colonoscopy is the most cost-effective strategy in Korea for colorectal cancer screening. Unfortunately, the number of physicians skilled enough to perform colonoscopy is not enough to meet the demands of screening for colorectal cancer in average-risk adults. Therefore, we consider alternative strategies such as SIG5 or SIG3.
Background
: For cancer patients, pain is the most common symptom and the most important factor that seriously affects their treatment and quality of life. The purpose of the research was to determine the controllable factors for pain management in order to increase patients' satisfaction for pain management. Method: This study was based on the survey answers and medical records of 464 cancer patients, in 8 hospitals in Korea from March until September 2000.
Background
: Many terminal cancer patients and families are affected with physical, emotional, and social problems. Many people claim that a type of medical services is needed to manage them such as hospice·palliative care. There have not been many studies of cancer patients and families with respect to their opinions and attitudes on hospice·palliative care for terminal cancer patients, although their views on it is important. Methods : We surveyed 687 in-patients, out-patients and their families with cancer in 8 hospitals. The self-administered questionnaires included the following; 1) socio-demographic and clinical variables; 2) opinions on hospice·palliative care; 3) attitudes on ethical issues associated with hospice·palliative care; 4) factors associated with withholding futile care at the end-of-life. The data were analyzed with x2-test, Mantel-Haenszel x2-test, and multiple logistic regression. Results : Almost 90% of the subjects agreed to the need of obtaining hospice·palliative care with health care insurances and reaching a social consensus on the contents of its programs. Five hundred and seventy six (83.8%) subjects agreed to the need of using advanced directives. Two hundred and eighty five (72.2%) cancer patients and 200 (68.5%) families agreed to the need of withholding futile care at the end-of-life and of people accepting their cancer diagnosis with insight and living in the metropolis as they were more likely to do. In the multivariate analysis, the attitudes on withholding futile care at the end-of-life was significantly different only by insight of cancer diagnosis (OR; 1.09∼3.15). Conclusion : This study showed that hospice·palliative care should be established through social consensus on the issues related to ethics and insurances, and that cancer patients and families must have a right to choose such services with informed decision-making.
Background
: According to different characteristics of health dimensions and its consisting item contents, valid and useful health status assessment tool for the elderly is rare. Because of the continuous increase in elderly population with functional disability in Korea, the need for a valid Korean health status assessment tool for the elderly is growing. Therefore, we have attempted to develop a Korean Health Status Measure for the Elderly in this study. Methods : We gathered important health related items from 671 individuals aged 60 years and over to form item pool with interview. Then we classified all items into representative items according to its meaning with the experts in geriatrics. With these representative items we constructed a preliminary questionnaire. After wards we performed a pilot study for evaluating understandability, accessibility, item analysis, reliability and for detecting other modifiable limitations. After completing the pilot study we finally developed the Korean Health Status Measure for the Elderly (KoHSME V1.0) Results : The number of collected health related items were 2,500 in the item pool. After classification of items in the pool, 40 representative items were selected for constructing preliminary version of the KoHSME. And we added 3 items of ‘general health perception’ dimension to 40 common representative items to construct a preliminary version of the KoHSME. It took an average of 18.8 minutes to complete the preliminary questionnaire by the elderly in the pilot study. Most responders (90.9%) thought the questionnaire was not difficult to understand. After the pilot study we added 2 items (wearing clothes, pain frequency) and omitted 1 item (eating). Finally, the KoHSME V1.0 questionnaire consisted of 44 items and 6 domains such as physical function, emotional function, social function, pain, sexual function, and general health perception. All items were Likert scale except pain intensity item, which was visual analogue scale. Conclusion : The KoHSME V1.0 to assess health status and quality of life for the Korean elderly was developed. We think the KoHSME V1.0 is a reliable instrument for assessing health related to quality of life in the elderly. After documenting the validity, the KoHSME V1.0 can be a useful tool for comprehensive assessment of health status in the eelderly and for the medical outcome study.
Background
: In western countries the proportion of deaths in the hospital has somewhat decreased. While that of Korea has continuously increased, it is interesting things that the hospital death rate in Korea is less than that in western countries. Therefore we tried to find the factors associated with the place of death in Korea. Methods : We obtained the data from the National Statistical Office. They are composed of classified by ICD-10. Univariate and Mutivariate analysis were done to find the effect of each variable for the place of death. Results : Total number of the study population was 242,362 (male:136,063, female:106,299). Female died more in the hospital. The younger are more likely to die in the hospital. People having lived in metropolitan, having educated to higher level and professionals died more in the hospital. And the people having had ischemic heart disease and cancer death were more likely to die in the hospital. The single (unmarried, divorced) died more in the hospital. In multivariate analysis, the place of death was significantly different by sex, age, address, occupation, cause of death, and level of education Conclusion : In Korea sex, age, address, occupation, cause of death, and level of education are helpful in predicting the palce of death.
Background
: There are a few studies on the effects of job-strain on the prevalence of sleep problems in the foreign countries. In Korea, it has not been studied till now. In this article, the combined effects of job strain, shift work and some life-style on the prevalence of sleep proplems were studied among workers in middle-aged men. Methods : 998 cases were chosen from 1109 men who visited health screening certer form October to November, 1999. Sleep problems were categorized to insomnia, sleep deprivation, daytime sleepiness and snoring on the base of result of factor analysis of 11 questions. Job strain was measured by 11 questions which developed by Karasek by and Theorell. All data set were analyzed using Chi-square test and multiple logistic regression analysis. Results : The 4 sleep problems were analyzed by multiple logistic regression analysis in relation to job strain, shift work, occupation, obesity, sedentary life-style, smoking, drinking. Insomnia was increased significantly from highest job-strain group (Odds ratio (OR:2.02)) and non-exercise group(OR:2.05). In these groups, daytime sleepiness was increased significantly(OR=1.92 in the highest job-strain group, OR=1.72 in non-exercise group). Sleep deprivation was increased in the highest job-strain group(OR=2.18), managers & clerks(OR:1.67) and non-exercise group(OR:1.78). Snoring was increased from BMI(Body mass index) ≥25(OR=1.77), BMI ≥27(OR=2.80) and non-exercise group(OR:1.87). Conclusion : In the highest job strain group, insomnia, sleep deprivation and daytime sleepiness was increased significantly. And sedentary life-style increased all sleep problems.
Background
: Early detection and treatment for depression are very important. But because of several factors such as practice time etc, primary care physician missed potential depression patients. The Korean version Beck Depression Inventory (BDI) is useful for the detection of depression but the validation study of this tool is not confirmed yet. And so we conducted the validation study of BDI. Methods : From July 1999 to October 1999, 259 patients who visited five family practice center in tertiary or secondary hospital were the study subjects. They have experienced depressive symptoms or had past history of depression during recent one year. The subjects were responded to the questionnaire including BDI, and diagnosed with depression or nondepression according to DSM-IV-PC(interview). The depression patients were retested with BDI. Cronbach α were estimated for internal consistency, and factor analysis were done for validation. Kappa statistics were estimated according to the consistency between BDI and DSM-IV-PC(interview). Using ROC curve, optimal cut-off point were estimated. Results : Depression ad nondepression patients were 205(79.2%), 54(20.8%) each. Cronbach α (total items of BDI) was 0.87. Factor analysis resulted that two factors explained 90.7% of total variance. BDI score of depression, mild depression and nondepression groups were 22.29(±9.68), 14.43(±8.44), 11.68(±6.42) each (F=29.77, df=2, P=0.001). At 13 BDI score on ROC curve, we have known the results of sensitivity 78.3%, specificity 76.5% and positive predictive value 94.2%. Conclusion : We concluded BDI was very useful and convenient easy screening tool for depression in primary care.
No Abstract Available.
Background
: Although family physicians are performing an increasing number of esophagogastoduodenoscopies(EGDs), there is little research conducted in Korea. Thus, the purpose of this research is to assess the ability of family physicians in performing EGD. Methods : All EGDs performed by family physicians in the department of family medicine of one general hospital from January 1995 to December 1996 were reviewed retrospectively through medical records. The including physicians a family physician and nine family residents, performed EGDs five times per week. Results : 4,468 EGDs were performed on 4,313 persons during the two years. No major complications were noted and all of the procedures were completely investigated to the second portion of the duodenum. Normal findings were 1,268 cases(28.4%) and abnormal findings were 3,200 cases(71.6%). Among the abnormal findings, gastritis was the most common finding(73.7%). The most common pathologic diagnosis was peptic ulcer 37.7%(177/470cases). Positive rate of CLO test was 89.4%. Family physicians, endoscopic diagnosis agreed with pathologic reports in 86.6%. The number of EGDs performed by each family physician ranged from 2 to 1,503 cases. Data of six physicians who performed more than 200 EGDs for their diagnostic were comparatively analyzed ability. Diagnosis of normal, gastritis or gastric ulcer was significantly different(P<0.05) according to each physicians but the diagnosis of duodenal ulcer was not statistically different(P<0.05). There was little difference among physicians in the biopsy rate. The agreement ratio between endoscopic diagnoses and pathologic reports among those physicians who performed more than 200 procedures were 79.7-93.3% and were not statistically different(P<0.05). Conclusion : This study is the first report of EGDs performed by family physician in Korea. Some family physicians performed more than 4,000 EGDs without major complications in primary care. These data confirm the ability of some family physicians to perform EGD. Biopsy analysis indicates the diagnostic accuracy is high. Further study on performance of EGD by family physicians and its standardization concerning description of endoscopic are needed.( J Korean Acad Fam Med 1999;20:1027-1039)
Background
: Hypothyroidism may be involved in a significant portion of the causes of hypercholesterolemia in Korea. In this study, we determined the frequency of suspected hypothyroidism in hypercholesterolemic patients and compared the frequency of elevated thyrotropin levels among the groups with various total cholesterol levels. Methods : The study subjects were healthy, asymptomatic people who visited Health Promotion Center of Seoul National University Hospital. We excluded subjects with history of hypertension, DM and hypothyroidism. The study subjects underwent physical examination and filled out a questionnaire on health risk factors. Also blood chemistry and thyroid function test were done. Results : Among 6479 subjects, 194(2.99%) had elevated(>4.1μIU/ml) thyrotropin levels. Among the hypercholesterolemic(≥240mg/dl) patients(n=868), 40(4.60%) had elevated thyrotropin levels. And there was statistically significant difference between normal cholesterolemic and hypercholesterolemic subjects(P<0.05). Among the patients with total cholesterol above 280mg/dl (n=180), 15(8.33%) had elevated thyrotropin levels. As amount of the total cholesterol increased, the frequency of elevated thyrotropin levels increased(P=0.001). And this result was consistent following adjustment for age, sex, BMI, smoking and drinking status(P<0.01). Conclusion : Practicing physicians should be aware of the possibility of secondary hypercholesterolemia due to hypothyroidism and keep in mind the importance of evaluating TSH level.
Background
: In order to improve the quality of life of dying patients so that they may die with dignity, they need to receive not only the physical, psychological, social, and spiritual care, but also systematic and continuous care. However, there is no adequate medical service at present. We studied terminal cancer patients' behavior patterns of health care utilization, the problems of caring for the patient, and medical services that bereaved families suggested for terminal cancer patients and their families. Methods : From 271 patients' families who participated in our hospice program from March 1991 to February 1996, 108 bereaved families whom we could have contacted were interviewed by three student nurses with a structured questionnaire. Results : The terminal cancer patients received their medical care through admission to hospital(45.4%), outpatient clinic(22.2%), emergency room(16.7%), and oriental medicine(12.0%). But during their terminal phase of the illness, 32.4% of patients never received medical care including oriental medicine, and 28.7% received alternative medicine care such as intake of mushroom and elm tree. 26 bereaved families(24.1%) pointed out the indifference of the medical team as a problem receiving proper hospital care, and 22 bereaved families(20.4%) emphasized emotional strain of their helplessness with the patient's suffering as a problem of caring for the patient at home. Over 90% of bereaved families from their experience suggested needs of continuous care, hospice care, home care, and 24hr telephone service. Conclusion : There were inappropriate behavior patterns of health care utilization which resulted in large proportion of terminal cancer patients received alternative medicine never receiving proper medical care. Therefore, there is a need to develop the continuous and comprehensive care for terminal cancer patients and their family, such as hospice.
Background
: Previously, a large epidemiological study has found that an increase in the serum triglyceride level is an independent risk factor of coronary artery disease and by treating it, the mortality due to coronary artery disease could be decreased. Our study is designed to analyze the serum triglyceride level in healthy adults and to study various factors influencing the serum triglyceride level. Methods : Study involved all patients who visited Seoul National University Hospital Health Promotion Center from May 1995 to Feb 1997. After a complete history and a physical examination, each participant answered a questionnaire involving sociodemographics, tobacco, alcohol, exercise, menstrual cycle and daily dietary contents. A blood chemistry was also drawn after 12 hours of fasting. We used analysis of covariance and multiple regression analysis to correlate triglyceride level with forementioned variables. Results : Healthy 3,332 men and 2,986 women were statistically analyzed. The average triglyceride level was 110.7mg/dl(geometric mean). Men at 50's had the highest level of triglyceride. As women aged, their triglyceride level increased. The proportion of participants in their 40's in men and 70's and over in women with triglyceride >220mg/dl, a value of clinical importance, was 19.0% and 18.4%, respectively. The triglyceride level changed significantly according to BMI, exercise, physical fitness, alcohol, tobacco, blood pressure, uric acid and glucose. However, no statistically significant difference was found among diet, thyroid function, income and region. For men, a multiple regression analysis revealed that the factors influencing triglyceride level in decreasing order, were BMI, uric acid, tobacco, diastolic blood pressure, ALT and maximal oxygen uptake. However, for women, a similar analysis showed that BMI, systolic blood pressure, exercise, tobacco and age played a significant role(p<0.001). Conclusion : Serum triglyceride level was associated with correctable behavioral factors such as obesity, smoking, alcohol, exercise, and physical fitness. Among these factors obesity was the most related factor with triglyceride level.
Background
: Recently, cancer have become the major cause of death in Korea. But the diagnosis of the terminal cancer have been made, patients have been left alone without any discharge plan or have been admitted to a university hospital. In order to offer useful medical care to terminal cancer patients and to increase the efficiency of the sickbeds, it is needed to study the reasons for terminal cancer patients’ admission to a university hospital and problems associated with the admission. Methods : Two groups of each 60 and 25 terminal cancer patients were randomly selected as subjects of. The patients were admitted to one university hospital located in Seoul and one university hospital located in a country city from Sep. 1, 1995 to Nov. 30, 1995. Their medical problems and treatment were reviewed. And through interviewing with patients’ chief doctor and families, we surveyed 69 patients’ reasons for admission, problems of home care, and the type of medical service needed by patients and familes. Result: The most common medical problem precipitating the terminal care patient’s admission was pain(25.9%). 61.2% of chief doctors and 44.9% of family stated that the reason for admission to the hospital was symptom control including pain. Of 69 families who stated the place for patient’s death, 28(40.6%) chose the hospital. Concerning the worrying aspects of home care, 13(18.8%) families stated difficulty of admission, 10(14.5%) said inability to leave patient attended, 10 did inability to call medical personnel, 9 did no medical team for consultation. About 90% of the families wanted 24hr telephone service, readmission and continuous care of their hospital. Also, many families(about 70%) wanted admission to other hospital and care by other medical team. There was no significant difference between two university hospitals. Conclusion : The main problems of care for terminal cancer patients were insufficiency of medical institutions and home care services for terminal cancer patients, and inappropriate symptom control. The refore, through introduction of home care service, establishment of palliative care centers and construction of strong connection with acute care institutions, we should be able to offer efficient and good medical service.
Background
: Informing patients of their cancer diagnosis is a difficult task for most physicians and is a traumatic event from the patient's point of view. With the remarkable development of medical science, prolongation of life is possible and some cancers are curable. Also, expanding medical technology has enabled nonsurgical physicians to sample tissues for pathologic examination. The doctor's office may become the primary place where the patients are told their cancer diagnosis in the future. Because there is little empirical literature to guide the clinician an how to inform the patients, and in what context to present cancer diagnosis, analysis of the experience of groups of cancer patients may be valuable in gaining a wider view of this issue. Methods : Forty patients with knowledge on their cancer, undergoing chemotherapy were interviewed to learn how patients were told, their feelings how and where they were told, and the patient's opinion on how other patients should be told in the future. Results : 45% of forty patients were told by physicians, 30% by family and 25% by accident. 57.5% of patients were told in the hospital room. 30% in the doctor's office and 12.5% in the home. When asked whether they should be told about cancer diagnosis 87.5% of all respondents answered "yes", 12.5% answered "dependent on situation" and none answered "no". When asked who should tell the diagnosis, 80% answered "doctor", and 20% answered "family". When asked who should be informed of the cancer diagnosis first, 62.5% of respondents answered "the family", 22.5% "the patient", 15% "simultaneously". Conclusion : This study showed that cancer patient should be told the diagnosis and the informant should be the physician. This study also showed that in contrast to western society, the family should be considered in the presentation of cancer diagnosis. In order to achieve active participation of the patient in the treatment of their cancer, the doctor should inform the patients their cancer diagnosis in a hopeful and caring environment with the support of their family.
Background
The association between sleep duration and obesity risk among risky drinkers remains controversial. This study aims to investigate the relationship between adequate sleep duration and both central and overall obesity among risky drinkers in Korea, with a focus on identifying potential interventions to reduce obesity rates. Methods We analyzed data from 978 individuals, selected from 1,356 risky drinkers—as defined by the World Health Organization criteria—who participated in the 2019–2020 Korea National Health and Nutrition Examination Survey. Participants had no missing values and were engaged in economic activities. Demographic characteristics and key variables by obesity status were examined using frequency analysis and chi-square tests. Multivariable logistic regression analysis was performed to explore the association between sleep duration and obesity. To account for the stratified sampling design, we utilized complex sample analysis with weighted values. Results Risky drinkers with adequate sleep duration (7–9 hours) were less likely to be obese based on waist circumference (≥90 cm in males; ≥85 cm in females) (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.48–0.86) and body mass index (≥25 kg/m2) (OR, 0.56; 95% CI, 0.41–0.76). Trend analysis revealed a significant inverse relationship between sleep duration and obesity likelihood (P for trend <0.05). Gender-stratified analysis demonstrated that the association was significant among males and more pronounced in risky drinkers compared to the general population. Conclusion This study suggests that adequate sleep duration may play a key role in reducing obesity rates among Korean male risky drinkers. Further longitudinal studies are recommended to strengthen this finding.
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