Role of ultrasound in the diagnosis of primary and recurrent dermatofibrosarcoma protuberans

Immune checkpoint inhibitors (ICIs) activate the immune system by blocking PD-1, CTLA-4, and PD-L1, thereby inducing autoimmune-mediated adverse reactions known as immune-related adverse events (irAEs). When two or more organs are involved, this condition is defined as multi-organ immune-related adverse events (multi-organ irAEs). Patients with multi-organ irAEs account for approximately 20%-30% of all irAE cases; however, clinical research focusing on this subset remains limited. The purpose of this study is to analyze the clinical characteristics, optimal therapeutic approaches, and mortality-related risk factors of multi-organ irAEs. We searched all case reports of irAEs associated with ICIs in the PubMed, Web of Science, Cochrane Library, and Embase databases from their inception to January 2022. Search terms included "Immune Checkpoint Inhibitors", "Checkpoint Inhibitors, Immune", "Immune Checkpoint Blockers", "PD-L1", "CTLA-4 Inhibitor", "PD-1", and "Case report". After removing duplicate literature and applying strict inclusion/exclusion criteria, a total of 2,740 articles were included, encompassing 2,964 patients (782 with multi-organ irAEs and 2,182 with single-organ irAEs). Patients were stratified by the number of affected organs to compare clinical characteristics between multi-organ and single-organ irAE groups. For patients with multi-organ irAEs, subgroup analyzes were performed based on glucocorticoid dosage to identify optimal treatment strategies, and further stratified by survival status to explore potential mortality risk factors. No statistically significant differences in age or sex were observed between patients with multi-organ irAEs and those with single-organ irAEs (P > 0.05). However, the multi-organ irAE group exhibited significantly higher proportions of cardiovascular toxicity, thyroid toxicity, skin toxicity, and severe adverse reactions (P < 0.05), as well as a significantly elevated mortality rate (P < 0.05). Among patients with severe multi-organ irAEs, there were no significant differences in sex or age between high-dose and low-dose glucocorticoid subgroups (P > 0.05); notably, the high-dose glucocorticoid group had a significantly higher mortality rate (P < 0.05). For patients with non-severe multi-organ irAEs, no statistically significant differences in sex, age, mortality, or prognosis were detected between high-dose and low-dose glucocorticoid groups (P > 0.05). Multivariate logistic regression analysis revealed that cardiovascular toxicity, pulmonary toxicity, hepatotoxicity, and myositis were positively correlated with mortality in patients with multi-organ irAEs (OR > 1, P < 0.05). The most common organ combinations in multi-organ irAEs are "cardiac + neurological, cardiac + pulmonary, thyroid + pituitary, cardiac + hepatic, and gastrointestinal + skin". Multi-organ irAEs are generally more severe and associated with poorer outcomes compared to single-organ irAEs. High-dose glucocorticoids did not demonstrate superior prognostic outcomes and may be associated with an increased mortality risk in severe irAEs.clinical decisions regarding glucocorticoid dosing should be individualized based on the severity of irAEs and the specific organs involved.Cardiovascular toxicity, pulmonary toxicity, hepatotoxicity, and myositis are potential mortality risk factors for multi-organ irAEs induced by ICIs.

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous mesenchymal locally aggressive sarcoma with high recurrence. We report a case of recurrent vulvar DFSP, and a literature review was performed with a PubMed search using the terms "Dermatofibrosarcoma protuberans" and "vulva." Total 85 cases with vulvar DFSP were analyzed for their clinicopathological features among fibrosarcomatous DFSP (FS-DFSP) and non-FS-DFSP. Listless asymptomatic growth had resulted in delay in presentation of 2.3 years. Tumor size was significantly more in FS-DFSP ( P 0.005). Higher mitotic rate is found to have strong association with FS-DFSP ( P 0.0001). FS-DFSP has more recurrences compared with non-FS-DFSP ( P 0.0001). DFSP with FS transformation was more aggressive as there was significant difference in metastasis ( P 0.073, OR 0.18) and mortality ( P 0.210, OR 0.19). To investigate the risk of outcome, 59 cases were included following the exclusion of <6 months follow-up. Age (>50 years) was found to be a risk for metastasis and death from the disease. Tumor size (>5 cm) and mitosis (≥5/10-HPF among non-FS-DFSP) were found to be the risk for the LR. Different histological diagnosis was made initially in 32%, and local excision was performed without margins in 65% of vulvar DFSP because of initial incorrect diagnosis. Therefore, pre-treatment biopsy or re-biopsy should be performed with immunohistochemistry for definitive diagnosis to exclude histologic mimics. The optimal treatment is wide local excision with 3-cm margin or with margin assessment for both primary and recurrent DFSP. As most recurrences occur within the first three years of wide excision in DFSP, regular follow-up visits are advocated.

The aim of this research was to investigate the clinical and ultrasonographic features of papillary thyroid carcinoma (PTC) in the isthmus. A total of 823 patients with 823 PTCs including 133 in the isthmus and 690 in the lateral lobe were included in our study. All patients were confirmed by postoperative pathology. The clinical and ultrasonographic characteristics were retrospectively analyzed and compared. Univariate analysis and multivariate logistic regression analysis were performed. Multifactor analyses showed that PTC in the isthmus was significantly different from PTC originating from the lateral lobe in aspect ratio, microcalcification, extrathyroid extension, lymph node metastases, and lymph node density ( P < 0.05, for all). There were no significant differences in age, sex, tumor size, margin, halo, echogenicity, and homogeneity ( P > 0.05, for all). The results indicated that the sonographic appearances of PTC in the isthmus were relatively atypical; however, it had a higher incidence of extrathyroidal extension, central lymph node metastasis, and a tendency of higher lymph node density. Therefore, more careful ultrasound evaluation should be performed for these nodules.

Objectives:In cases of patellar dislocation, surgical intervention is typically reserved for patients with recurrent instability, unless a chondral or osteochondral fragment is identified following the initial dislocation. There is concern that multiple dislocation events may result in a higher incidence of articular cartilage injury. The purpose of this study is to compare the incidence of articular cartilage damage in patients with a single patellar dislocation to those with multiple patellar dislocations, and secondarily to compare the location and severity of chondral injury between the groups.Methods:Patients diagnosed with patellar dislocation were retrospectively identified by ICD-9 & ICD-10 codes from 2017-2021. Inclusion criteria were patients with a documented history of patellar dislocation with an MRI of the affected knee available for review. Patients with articular cartilage injury prior to dislocation event were excluded. Medical records were reviewed to determine the number of previous patellar dislocations. Articular cartilage injury was graded using a validated system, AMADEUS (mean total Area Measurement And DEpth & Underlying Structures, a scale from 0 to 100; 100 = no injury).Parametric continuous data was calculated by performing t tests. Nonparametric continuous data was calculated by performing Mann-Whitney tests. Chi-Square or Fisher’s Exact tests were used to calculate p values for categorical data.Results:After chart and imaging review, 233 patients were included: 117 with a primary dislocation and 116 with recurrent dislocations. Fifty-one (43.6%) of the primary dislocations and 68 (58.6%) of the recurrent dislocations were found to have articular cartilage injuries (p=0.068). When comparing the primary and recurrent groups, there was no difference in age, BMI, race, or laterality, but the recurrent group contained a significantly larger proportion of females (46.2% vs. 65.5%, P=0.004). There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between groups (p=0.231). Subgroup analysis revealed that when cartilage damage is present, patients from the primary group had significantly more full-thickness lesions (p<0.001) and lower AMADEUS scores (p=0.016). The primary group had an increased proportion of medial facet and lateral femoral condyle lesions (p=0.026).Conclusions:There is a high percentage of cartilage injury in patients with a history of primary and recurrent patellar instability, with 43.6% and 58.6% of patients respectively, showing articular cartilage injury on MRI. Chondral injury primarily affected the medial and lateral patellar facets, and the lateral femoral condyle in both the primary and recurrent dislocation groups. However, the primary group demonstrated an increased number of full thickness lesions and subchondral bone defects. There was no difference in lesion size, presence of bone edema, or total AMADEUS score between the primary and recurrent groups.

Objective: This study aimed to compare ultrasonography (US) features and the Korean-Thyroid Imaging Reporting and Data System (K-TIRADS) categories for diagnosing isthmic and lobar papillary thyroid carcinomas (PTC).Methods: From January 2009 to December 2012, 163 patients who underwent thyroid surgery and were confirmed with a post-operative histopathological diagnosis of isthmic PTC were retrospectively included. Fifty-nine patients were excluded because their tumor size was <0.5 cm or because of other reasons. The control group comprised of 145 patients who underwent thyroid surgery from January to April 2013 for a classic type of PTC, with the largest diameter being ≥ 0.5 cm and located in the thyroid lobe. A single radiologist retrospectively reviewed the US features and K-TIRADS categories of each nodule using a picture archiving and communication system.Results: Among 104 patients with isthmic PTC, 95 and 9 had primary and secondary cancers, respectively. On the other hand, all 145 patients with lobar PTC had primary cancers. Isthmic PTC showed a lower prevalence of non-parallel orientation than lobar PTC (23.1 and 71%). Nodule orientation was the only US feature statistically different between the two groups (p < 0.0001). However, there was no significant difference in patient age, sex, nodule size, composition, echogenicity, microcalcification, spiculated/microlobulated margin, and K-TIRADS category between the two groups (p > 0.05).Conclusions: K-TIRADS may be useful in the diagnosis of both isthmic and lobar PTC.

The extent of local invasion in dermatofibrosarcoma protuberans (DFSP) is often clinically difficult to appreciate, and this leads to inadequate resections. We examined the effect of inadequate initial treatment and the efficacy of wide resection. We performed a retrospective analysis of the records of 35 patients with DFSP treated at our institution (1985 and 2001). Data were analyzed with Wilcoxon's ranked sum test and Fisher's exact test. Of the 24 patients eligible for analysis, 11 had definitive wide resection after diagnostic excisions elsewhere (primary group), and 13 had recurrent tumors after previous surgical treatment elsewhere (recurrent group). Twenty-three patients were treated with wide resection only, and adjuvant radiation was administered to one patient who had a fibrosarcoma. At a median follow-up of 54 months, patients definitively treated at our institution had a 100% local recurrence-free survival. In comparison to the primary group, recurrent DFSPs were significantly larger and deeper and occurred in the head and neck region. Five cases had bone involvement, and of these, 80% occurred in the recurrent group. Inadequate initial treatment results in larger, deeper recurrent lesions, but these can be managed by appropriate wide excision. Wide resection of DFSP (whether recurrent or primary) with negative histological margins predicts a superior local recurrence-free survival.

Objective: To investigate the nasal microbial diversity in patients with chronic sinusitis with nasal polyps (CRSwNP), as well as the nasal microbiome characteristics, inflammatory cells and factors in postoperative relapses, in order to understand the effects of microbiome factors on the postoperative prognosis of CRSwNP. Methods: The nasal secretions and nasal polyp tissues from 77 patients with CRSwNP were collected in Department of Otorhinolaryngology Head and Neck Surgery, West China Hospital, Sichuan University from December 2017 to December 2018. The cohort consisted of 34 males and 43 females, aged from 29 to 76 years. Microbial DNA was extracted from cotton swabs for high-throughput sequencing based on 16SrRNA to detect bacterial community composition, and Luminex was used to analyze cytokines such as IL-5, IL-8, IL-17a, IL-17e, IL-18, IL-27, and IFN-γ in polyp tissue. Eosinophils and neutrophils in peripheral blood and polyp tissue were counted. Patients with CRSwNP were followed up for 1 year after surgery, and the recurrence of nasal polyps was recorded. The correlation between the recurrence of nasal polyps and inflammatory cytokines, inflammatory cell counts and nasal microbial diversity was analyzed. Chi-square test was used for bicategorical variables, Mann-Whitney U test was used for continuous variables, and Wilcoxon rank sum test was used to compare the difference in average relative abundance between the two groups. Results: At the one year follow-up, 12 patients experienced a recurrence, including 5 males and 7 females. There was no significant difference in age, sex, asthma, allergic rhinitis and eczema between the relapsing group and the non-relapsing group. The total nasal symptoms score (TNSS) in the recurrent group [42.3 (30.2, 67.1), M (Q1, Q3)] was significantly higher than that in the non-recurrent group [37.8 (29.4, 50.3)]. In nasal polyp tissue, the number of eosinophils [40.83 (22.33, 102.00)/HP] and neutrophils [30.83 (20.33, 56.44)/HP] in the recurrent group were significantly higher than those in the non-recurrent group [13.72 (13.50, 48.33)/HP] and [18.50 (12.00, 26.08)/HP], Z-values were -6.997 and -8.243, respectively, all P<0.001. The expression levels of IFN-γ, IL-17A, IL-17E and IL-18 in relapsed group were significantly higher than those in non-relapsed group, but there was no significant difference in positive rates. At the generic level, the mean relative abundance of Corynebacterium in the nasal passage of CRSwNP patients in the non-relapses group was (11.90±20.31)%, higher than that in the relapses group (0.15±0.20)%, but the difference was not statistically significant after correction (FDR P=0.638). The mean relative abundance of staphylococcus in the non-relapsed group was (8.17±27.70)%, significantly lower than that in the relapsed group (8.99±15.89)%, but the difference was not statistically significant (FDR P=0.638). Conclusions: Neutrophil-mediated inflammatory responses are associated with recurrent nasal polyps. The recurrence of nasal polyps after endoscopic surgery may be related to the decrease in the abundance of protective microorganisms and the increase in the number of pathogenic microorganisms.

Objective:The objective of the following study is to compare the conjunctival graft thickness measured with anterior segment optical coherence tomography (OCT) after primary and recurrent pterygium excision.Design:Prospective, interventional and comparative study.Participants:A total of 20 eyes of 20 patients with primary pterygium (primary group) and 20 eyes of 20 patients with recurrent pterygium (recurrent group) were enrolled.Materials and Methods:All patients underwent pterygium excision with conjunctival autograft transplantation. Conjunctival graft thickness was measured at 1 week, 1 month and 3 months after surgery using the Visante-OCT (Carl-Zeiss Meditec, Dublin, CA, USA). Main outcome measure was the mean conjunctival thickness determined as the mean of three measurements at 1, 2 and 3 mm posterior to the scleral spur.Results:There were no statistically significant differences in age, sex, or laterality between the groups. Mean thickness of the graft in primary and recurrent groups, respectively, was 430 ± 127 μm and 461 ± 178 μm at 1 week after surgery (P = 0.587), 114 ± 19 μm and 162 ± 48 μm at 1 month after surgery (P = 0.001) and 109 ± 15 μm and 107 ± 18 μm at 3 months after surgery (P = 0.726).Conclusion:The findings revealed that conjunctival thickness after primary or recurrent pterygium excision was greatest at 1 week after surgery and continued to decrease for up to 3 months. Mean graft thickness differed significantly between the two groups only at 1 month after surgery.

ObjectiveTo explore and analyze the risk factors for recurrence in patients with lower extremity arteriosclerosis obliterans (ASO) after surgical intervention and to construct and validate a nomogram prediction model.MethodsA total of 270 patients with ASO treated at our hospital were retrospectively selected as study subjects and divided into a training cohort (189 cases) and a validation cohort (81 cases) based on a 7:3 ratio. Patients in the training cohort were further divided into recurrence and non-recurrence groups based on whether they experienced recurrence within two years post-surgery. Univariate and multivariate logistic regression analyses were employed to identify independent risk factors for postoperative recurrence, which were then used to construct a predictive model and generate a nomogram.ResultsOf the 270 patients with ASO included in the study, the training cohort consisted of 189 patients, with 76 (40.21%) in the recurrence group and 113 (59.79%) in the non-recurrence group. The validation cohort consisted of 81 patients, with 32 (39.51%) in the recurrence group and 49 (60.49%) in the non-recurrence group. Univariate analysis in the training cohort revealed significant differences in age, body mass index (BMI), diabetes, hypertension, lesion location classification, use of antiplatelet drugs, triglycerides, fibrinogen (FIB), and di-dimer (D-D) (P < 0.05, respectively). Multivariate logistic regression analysis indicated that age ≥ 60 years, BMI ≥ 24 kg/m², diabetes, hypertension, discontinuation of antiplatelet therapy, FIB, and D-D were independent risk factors for recurrence after surgical intervention in patients with lower extremity ASO (OR = 2.471, 1.625, 4.568, 2.678, 5.974, 2.073 and 3.067; P < 0.05, respectively). When the training and validation cohorts were tested in the established nomogram model, the area under the curve (AUC) of the model was 0.832 (95% CI: 0.765–0.919) in the training cohort and 0.858 (95% CI: 0.745–0.964) in the validation cohort. Calibration curves indicated high consistency between the predicted and actual outcomes in both groups, suggesting good predictive accuracy of the model. Decision curve analysis showed that using this model significantly increased net clinical benefit for patients.ConclusionThe nomogram model constructed for predicting the risk of recurrence in patients with lower extremity ASO after surgical intervention demonstrates good predictive and discriminative abilities, offering valuable guidance for clinical screening of high-risk populations.

ObjectiveTo understand the situation and risk factors of skin lesions following the eruption of shingles.MethodsWe selected 275 patients with shingles who had been diagnosed and treated in the Dermatology Department of Changshu No. 1 People’s Hospital between July 2017 and March 2022. Age, gender, skin lesion site, skin lesion type, prodromal pain, history of diabetes, history of hypertension, history of other immune diseases, as well as other pertinent clinical data, were collected. The severity and pain of patients with severe shingles were evaluated, and their fasting blood sugar and plasma albumin were measured for routine antiviral treatment. They were followed up 6 months—the types of skin lesions and pertinent clinical data were compared, and the risk factors for skin lesions were analyzed.ResultsThere were no statistically significant differences in gender, age, or site among the different types of skin lesions (P > 0.05). The severity of skin lesions, acute pain, history of diabetes, history of scars, low immune function, combined with hypoproteinemia, squeezing and stripping behavior, and post-herpetic neuralgia (PHN) were significantly associated with skin lesions (P < 0.05). The results of multivariate analysis showed that: age ≥60 years old, severe skin injury combined with diabetes, low immune function, scar history, squeezing and stripping were independent risk factors for the development of skin lesions due to shingles.ConclusionThere is no significant difference in age, gender, site, or other characteristics between the types of skin lesions due to shingles. The independent risk factors of skin lesions due to shingles are old age, severe rash, history of scars, diabetes, low immunity, squeezing, and peeling.

This study aimed to identify the predictive value of the extent of metastatic lymph nodes in the central and lateral neck compartment for recurrence in papillary thyroid cancer (PTC) patients with pathologically lateral lymph node metastasis (pN1b). This study enrolled 252 patients with pN1b from PTC. During a mean follow-up of 17.6 years, 55 (21.8%) patients experienced recurrence. Patients with palpable lymph nodes were more likely to have a recurrence than those with nonpalpable lymph nodes (30.1% vs. 17.8%, relative risk 1.7, 95%CI: 1.1-2.7). For patients with palpable metastatic lymph nodes, lymph node ratio of lateral lymph nodes ≥0.5 (aHR=2.906, 95%CI: 1.29-6.54) and age ≥55 years (aHR=2.508, 95%CI: 1.12-5.63) were independent prognostic factors. For those without palpable nodes, age ≥55 years (aHR=2.224, 95%CI: 1.08-4.60) and tumor size >4cm (aHR=2.168, 95%CI: 1.01-4.66) were independently predictive of worse RFS. Palpable lymph nodes were approximately twice as likely to recur as nonpalpable nodes. Metastatic lateral lymph node ratio predicts recurrence in pN1b PTC patients with palpable lymph nodes, but not those without ones.

Purpose: This study examines and compares the differences between self-esteem and health promotion behavior of health department and non-health department college students. Method: The research instruments were as follows : The first one is RSES developed by Rosenberg and translated into Korean by Jeon. The second one is HPLP developed by Walker et al, and including six subareas by Lee and modified to be suitable to Korean culture by Suh. Data were statistically analyzed with SPSS PC/12.0. Results : 1. Comparison of self-esteem had no significant difference(p=.190) and health promotion behaviors had significant differences(p=.000) between the two groups. 2. According to general characteristics and health-related characteristics, the differences of self-esteem in health department showed significant differences in grade(p=.020), sex(p=.000), age(p=.000), parents' economic conditions(p=.048), and smoking(p=.030) while non-health departments revealed significant differences in grade(p=.003), sex(p=.000), age(p=.000) and smoking(p=.001). 3. According to general characteristics and health-related characteristics, the differences of health promotion behaviors in health department showed significant differences in grade(p=.008), sex(p=.021), age(p=.000) and parents' economic conditions(p=.017) while non-health department revealed significant differences in sex(p=.000) and age(p=.000). 4. There were positive correlations between self-esteem, health promotion behaviors and subareas in health department (r=.422) and non-health department (r=.383). Conclusion: There were significant positive correlations between self-esteem and health promotion behaviors in health and non-health department college students. Therefore, health related programs should be developed to enhance self-esteem and health management by college students can influence themselves on self-esteem and health promotion behaviors.

Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans: Results of a multiinstitutional series with an analysis of the extent of microscopic spread

BackgroundLiver transplantation has adverse effects from life-long immunosuppression that limit the improvement of long-term outcomes. Achieving clinical operational tolerance is a major goal in organ transplantation.MethodsThis study analyzed liver transplantation patients at a single institution from 1998 to 2020, excluding those who died within 1-year posttransplant. Operational tolerance was defined as normal liver function even after immunosuppressive drugs were discontinued. Propensity score matching was implemented at a 12 ratio for the tolerant group (TG) and the nontolerant group (NTG).ResultsOut of 2,300 recipients, 99 achieved operational tolerance without rejection. No significant differences in sex or body mass index (BMI) were found between the TG and NTG. There was a significantly higher percentage of children in the TG (24.0%) than in the NTG (10.1%). The NTG had more living donor liver transplants. Among 2,054 adult recipients, no significant differences in age, sex, or BMI were found between the TG and the NTG. However, the rate of living donor liver transplantation was 40.3% (29/75) in the TG and 84.8% in the NTG (P<0.001). The propensity score-matched analysis showed higher chronic renal failure rates and a higher graft recipient weight ratio in the TG, along with shorter warm ischemic times during surgery. After immunosuppressant withdrawal, a significant increase in the ratio of CD4+CD25+ T cells to total CD4+ T cells was observed in the TG.ConclusionsThese findings suggest that larger, healthier grafts are more conducive to inducing tolerance, and regulatory T cells are crucial in achieving tolerance.

In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs. To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital. This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching. In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching. Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population. This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.