Definitive Assessment Research Articles

P1315PREDICTABILITY OF SONOGRAPHICALLY DETERMINED IMMEDIATE POST-OPERATIVE BLOODFLOW AND VEIN DIAMETER ON PRIMARY RADIOCEPHALIC FISTULA SHORT AND LONGTERM OUTCOMES

Abstract Background and Aims Vascular access (VA) guidelines recommend radio-cephalic (RC) over upper arm autogenous arteriovenous fistulas (AVF) as first line VA for hemodialysis in end stage renal disease (ESRD) patients. RCAVFs generally have inferior maturation and patency rates predicated on a lower feeding arterial blood flow (BF) and outflow vein calibre (VC). However studies on postoperative BF and VC as predictors of AVF outcomes, so far are confounded by their focus on early outcomes only, heterogeneity of AVFs studied, variable timing of assessment and use of non-standardised outcome definitions. Our aim was therefore to assess the accuracy and influence of immediate post-operative BF and VC on both early and longterm outcomes in a homogenous cohort of primary RCAVFs using standardised definitions and outcome measures as mandated by VA guidelines. Method This was a prospective study conducted in multi-ethnic Asian ESRD patients who had their primary RCAVFs created between October 2013 and October 2014 under regional anesthesia at Khoo Teck Puat hospital Singapore. All AVFs were assessed immediately after surgery for brachial artery BF and outflow VC using doppler ultrasound. A 10MHz linear probe and GE Logic e R7 machine were used exclusively by a single operator. Receiver operating characteristic (ROC) curves were generated to determine the optimal BF and VC cut-off for AVF maturation. Maturation was defined as BF>600mL/min, VC>6mm and vein depth <6mm at 6 weeks post-op. An area under the curve (AUC)> 0.7 was considered clinically significant. Kaplan–Meier analysis was used to evaluate the AVF primary and secondary patency based on best BF and VC cut-offs. Cox regression statistics was used to determine AVF hazard factors. Results Fifty-seven primary RCAVFs were created and included in the study. The baseline characteristics are shown in Table 1. Sonography- based non-assisted maturation at 6 weeks was 56%. ROC identified 410 mL/min and 42mm as the best BF and VC cut-off respectively to most accurately predict 6-week maturation. The sensitivity, specificity, positive predictive value and negative predictive value were 75%, 61%, 44% and 86% for BF at 410 mL/min and 69%, 61%, 41% and 83% for VC at 42mm respectively. Survival analysis (Fig. 1 and 2) showed that AVFs with VC≥42 mm compared to <42mm had significantly greater 6 months, 1-year, 2-year and 4-year primary and secondary patency rates. There was no significant difference in patency rates between AVFs with BF≥410 and <410mL/min. Cox proportional regression hazard analysis showed that diabetes (HR 2.26, CI 1.02-4.99, p= 0.04) and maturation (HR 0.47, 95% CJ 0.24-0.89, p=0.02) as significant contributed to the variability of primary patency. Only VC (HR 0.28, 95% CI 0.13-0.063, p=0.002) impacted significantly towards secondary patency. Conclusion An immediate post-op BF≥410mL/min and VC≥42mm can predict early RCAVF outcome in the form of nonassisted maturation, but only VC accurately impact on longterm AVF survival. VA surveillance efforts should therefore target RCAVFs with post-op VC <42mm for timely intervention and maintenance of longterm patency.

Prégabaline et risque d’addiction : une nouvelle demande de soin ?

PurposePregabalin (PRG) is a gamma-aminobutyric acid (GABA) analogue used for treatment of epilepsy, neuropathic pain, generalised anxiety disorder and currently being studied for other indications. Supported by the results of case studies and a limited number of studies, there is an ongoing debate about the addictive potential of PRG. However, evidence is scarce and no definitive assessment on the potential for abuse and dependence to PRG is available. The objective of our study was to identify the number of cases of abuse or dependence to PRG published and to study potential risk factors of addiction to PRG. MethodsWe have identified on PubMed and ScienceDirect published case studies of PRG abuse or dependence and analysed these cases on the basis of several clinical parameters. ResultsA total of 118 cases of PRG abuse or dependence were identified, including 21 isolated cases (mean age 33 years, 67 % men). The mean daily dose of PRG was 2,9 g. Current or past polydrug abuse was present in the majority of cases. Psychiatric diagnoses, other than substance-related disorders, were reported in as many patients, and almost all patients experienced withdrawal symptoms when PRG was discontinued. ConclusionCurrent literature suggests an important and growing concern for the abuse of PRG. Male sex, psychiatric and/or addiction history, including opioid addiction, may be potential risk factors for the development of addictive behaviours associated with PRG.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico

BackgroundIn rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018.MethodsFocusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent.ResultsThe programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4–15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262–588) at purchasing power parity.ConclusionsThese numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting.Trial registrationThis study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

Vexed questions of legal definition of unfair competition

The subject of this research is the legal definition of the concept of “unfair competition” established by the Federal Law “On Protection of Competition”. The goal of this research is to analyze the content of this legal definition, determine its elements, as well as assess the legal definition from the perspective of its unambiguousness and correspondence to the goal of regulation of relations pertaining to protection from unfair competition, including through the analysis of the existing views within the doctrine. The novelty of this research consists in the critical analysis of the existing within legal science approaches towards assessment of legal definition of unfair competition formulated in Russian legislation, as well as postulation of a previously undiscussed problem pertaining to establishment of such sign of unfair competition as possibility of causing losses. The conclusion is made on correspondence of the legal definition of unfair competition in the current legislation to the goals of efficient protection of competition contrary to critical assessments that are prevalent within the doctrine, as well as on the necessity to form a uniform approach of the practice towards proving the possibility of inflicting losses as a sign of unfair competition.

Assessment of a demonstrator repository for individual clinical trial data built upon DSpace.

Background: Given the increasing number and heterogeneity of data repositories, an improvement and harmonisation of practice within repositories for clinical trial data is urgently needed. The objective of the study was to develop and evaluate a demonstrator repository, using a widely used repository system (DSpace), and then explore its suitability for providing access to individual participant data (IPD) from clinical research. Methods: After a study of the available options, DSpace (version 6.3) was selected as the software for developing a demonstrator implementation of a repository for clinical trial data. In total, 19 quality criteria were defined, using previous work assessing clinical data repositories as a guide, and the demonstrator implementation was then assessed with respect to those criteria. Results: Generally, the performance of the DSpace demonstrator repository in supporting sensitive personal data such as that from clinical trials was strong, with 14 requirements demonstrated (74%), including the necessary support for metadata and identifiers. Two requirements could not be demonstrated (inability to incorporate de-identification tools in the submission workflow, lack of a self-attestation system) and three requirements were only partially demonstrated (ability to provide links to de-identification tools and requirements, incorporation of a data transfer agreement in system workflow, and capability to offer managed access through application on a case by case basis). Conclusions: Technically, the system was able to support most of the pre-defined requirements, though there are areas where support could be improved. Of course, in a productive repository, appropriate policies and procedures would be needed to direct the use of the available technical features. A technical evaluation should therefore be seen as indicating a system's potential, rather than being a definite assessment of its suitability. DSpace clearly has considerable potential in this context and appears a suitable base for further exploration of the issues around storing sensitive data.

Assessment of Target Volume Definition for Radiosurgery of Atypical Meningiomas with Multimodality Imaging

Objective Meningiomas are most common intracranial benign tumors comprising around one third of all intracranial neoplasms, and typically have benign and indolent nature with slow-growing behaviour. Benign meningiomas are slow growing tumors typically following an indolent disease course. Nevertheless, atypical or anaplastic meningiomas may follow a more aggressive disease course with invasion of critical structures and recurrences. In the current study, we evaluate the incorporation of magnetic resonance imaging (MRI) for radiosurgery treatment planning of atypical meningiomas. Materials and Methods Atypical meningioma radiosurgery target volume determination with and without incorporation of MRI has been evaluated. Ground truth target volume used as the reference has been outlined by the board-certified group of radiation oncologists after comprehensive assessment, thorough collaboration and consensus. Results Target volume definition by use of Computed Tomography (CT)-only imaging and by CT-MR fusion based imaging has been comparatively evaluated in this study for linear accelerator (LINAC)-based radiosurgical management of atypical meningioma. Ground truth target volume defined by the board-certified radiation oncologists after detailed evaluation, collaboration, colleague peer review and consensus has been found to be identical to target determination by use of CT-MR fusion based imaging. Conclusion Despite significant progress in neurosurgical techniques over the years, complete surgical resection may not be feasible in the presence of meningiomas located at eloquent brain areas in close association with important neurovascular structures. RT may have a role in multidisciplinary management of meningiomas. Incorporation of MRI into treatment planning for radiosurgery of atypical meningiomas may improve target definition despite the need for further supporting evidence.

Bailout subclavian artery stenting in a sick child with iatrogenic subclavian artery perforation: a case report

BackgroundSubclavian artery injury during internal jugular vein catheterization is a rare yet potentially life-threatening complication leading to hemothorax and exsanguination. The percutaneous endovascular approach offers a less invasive and effective alternative to the high-risk surgical repair in emergent situations.Case presentationWe present a case of a 6-year-old child suffering from hemolytic uremic syndrome requiring urgent hemodialysis, for which IJV (internal jugular vein) cannulation was attempted. This procedure led to iatrogenic subclavian arterial perforation causing massive hemothorax with hemodynamic compromise. CT angiogram showed a through and through perforation in the first part of right subclavian artery between common carotid and vertebral artery. A definitive assessment of the extent of ongoing leak was made through an invasive angiogram in the catheterization laboratory. The perforation was successfully closed percutaneously with a covered stent without compromising any branch vessels.ConclusionArterial injury although rare is a potentially life-threatening complication of IJV cannulation which warrants immediate attention and corrective measures. Ultrasound guidance can reduce the risk of such life-threatening complications. Percutaneous management offers a less invasive, less time consuming, and effective alternative in critically ill patients in emergency situations.

Emergence, viability and competitive leverages of CouchSurfing in the national capital region of the Philippines: basis for a propose strategic brand awareness program

CouchSurfing is a travel-related mobile application that focuses on helping its users find free-of-charge accommodation and also engage in cultural exchange . This study aimed to determine its emergence, viability and competitive leverages in the National Capital Region of the Philippines . A mixed-method approach was utilized wherein survey questionnaires which were distributed online to 37 respondent-CouchSurfers and structured interview guide questions were constructed to be answered by the founder of CouchSurfing and selected active CouchSurfers. The result found there was definitive list of factors that affected the emergence and competitive leverages of CouchSurfing as mobile application. In additions, there was an established definitive assessment of CouchSurfing in the tourism and hospitalaity service based on the respondent-CouchSurfers’ satisfaction level. Therefore, a strategic brand awareness program is being proposed through utilization of gathered data.

Managing risks or generating uncertainties? Ambiguous ontologies of testing in Australian healthcare.

Medical testing promises to establish certainty by providing a definitive assessment of risk or diagnosis. But can those who rely on tests to offer advice or make clinical decisions be assured of this certainty? This article examines how Australian health professionals, namely clinicians, microbiologists, specialist physicians and health policymakers, delineate the boundary between certainty and uncertainty in their accounts of medical testing. Applying concepts from science and technology studies, and drawing on qualitative data from a sociological study of testing in Australian healthcare, we consider how professionals ascribe meaning to testing and test results. As we argue, for these health professionals, the 'evidence' that testing generates has ambiguous ontological significance: while it promises to provide diagnostic certainty and clear direction for advice or treatment, it also generates uncertainties that may lead to yet further tests. Our analysis leads us to question a key premise of testing, namely that it is possible to establish certainty in medical practice via the measurement of individual health risks and disease markers. Against this dominant view, the responses of the health professionals in our study suggest that uncertainty is intrinsic to testing due to the constantly changing, unstable character of 'evidence'. We conclude by considering the implications of our analysis in light of healthcare's increasing reliance on sophisticated technologies of 'personalised' testing using genetic information and data analytics.

Regulations of Digital Platform Markets Under the Japanese Antimonopoly Act: Does the Regulation of Unfair Trade Practices Solve the Gordian Knot of Digital Markets?

When it comes to digital platform markets, the competition authorities of Japan, the EU, and the United States share a similar approach toward the regulation of mergers. Additionally, they share a common approach with respect to exclusive dealings but apply slightly different rules concerning a refusal to deal in the regulation of monopolization. However, the regulation of Unfair Trade Practices (UTPs) in Japan is unique in that it is possible to regulate a vertical nonprice restraint imposed by a company with a market share between 20% and 50%. The author explores the regulation in the digital platform markets by the UTPs under the Japanese Antimonopoly Act and examines the possibility of the regulations by the UTPs as an alternative method. This article argues that it is desirable, especially in the case of private suits, that the assessment of market definition and the burden of proof be simplified.

AVALIAÇÃO DO CICLO DE VIDA E CONSTRUÇÃO CIVIL: UMA REVISÃO DA LITERATURA ACERCA DA AVALIAÇÃO DE RESIDÊNCIAS UNIFAMILIARES

Faz alguns anos que as questões ambientais vêm ocupando espaço de destaque em conferências sobre o desenvolvimento sustentável. Identificar os possíveis impactos ambientais e atuar de modo a minimizá-los, tornou-se uma das prioridades em organizações de diversos segmentos. O mesmo ocorre para a indústria da construção civil que, devido ao consumo de recursos e energia, torna-se responsável por impactos ambientais ao longo do ciclo de vida dos seus produtos. À vista disso, esse trabalho teve o objetivo de destacar os principais itens das fases da Avaliação do Ciclo de Vida (ACV) (definição do objetivo e escopo, inventário e avaliação do impacto) e identificar os métodos de AICV (Avaliação do Impacto do Ciclo de Vida) aplicados à avaliação de residências unifamiliares. Por meio de uma revisão sistemática da literatura, verificou-se que as categorias de impacto que mais se destacaram foram a depleção da camada de ozônio, eutrofização, acidificação, mudanças climáticas, esgotamento de recursos e toxicidade humana. Além disso, métodos como ReCiPe, Eco-indicator 99, IMPACT 2002+ e o CML foram identificados como os mais adequados para a avaliação de edificações.

Meta-analysis: Supplementary artificial light and goose reproduction

Photoperiod affects poultry reproduction, and in birds, photoperiod regulation is a complex physiological process. In modern poultry production, lighting management has become an important and effective management approach for increasing egg production. Geese are domesticated fowl and in many goose production enterprises animals are allowed to roam in outside pens during the day and are housed indoors at night, so the animals can be exposed to artificial lighting during the night periods. Supplementary artificial lighting resulted in improved reproduction in some studies, but reports have been inconsistent. To evaluate the results from previous studies of supplementary lighting on goose egg production, a meta-analysis was conducted to determine optimal supplementary artificial lighting regimens for geese egg production. Results indicated supplementary artificial light increases mean egg production, the length of the period of egg production before there is cessation of egg production capacity, and fertility. In summary, there were evaluations of data from five studies focused on White Roman geese in the meta-analysis conducted in the present study, however, examination of more breeds is necessary to make more definitive assessments of the findings from this meta-analysis.

Порівняльна оцінка санітарно-бактеріологічних показників коров'ячого і козиного молока

The aim of the article is to present the results of researches about comparative assessment's definition of the sanitary and bacteriological indicators of cow and goat milk. To determine the bacterial contamination of goat's milk, was used the classic method, which is also an arbitration, cup method and a modern method  with by means of using of “Petri-film” plates. To obtain more accurate results by means of applying the last method, we have improved the formula for calculating the number of microorganisms in the analyzed sample. The higher economic efficiency of the method of determining the ячеmicrobiological purity of milk and dairy products is established  by means of using plates "Petri-film”, compared with the using of Petri plates. The number of microorganisms determined by the two methods did not differ significantly - the correlation coefficient for mesophilic aerobic and facultatively anaerobic microorganisms (MAFAnM) is 0.89, and for coli - 0.88. The discrepancies between the indicators were within the confidence interval at a confidence level of P ≥ 95%. Goat milk is less contaminated (contaminated) by extraneous microbiota than cow milk, which is due to  different diet, way of keeping goats, milking characteristics and the actual biology of animals, or a higher content of bactericidal substances in goat milk compared with cow's milk. The number of somatic cells in the samples of cow and goat milk was determined with folowiing the rules of milking culture. According to this doctrine, the obligatory technological operation during milking is the removal of the first portions of milk with a high probability of contamination of the udder with somatic cells and extraneous microflora, which affects the change in the physiochemical milk's composition. It was found that goat milk contains a smaller amount of extraneous (MAFAnM, coliforms and Escherichia coli) microflora, as well as the number of somatic cells, which indicates its higher food safety compared with cow's milk. Therefore, it is recognized as suitable for industrial processing as drinking milk and fermented dairy products.

Assessment of Treatment Volume Definition for Irradiation of Spinal Ependymomas: an Original Article

Assessment of Treatment Volume Definition for Irradiation of Spinal Ependymomas: an Original Article

Lessons Learned from Reinforcing Epidemiologic Surveillance During the 2017 Ebola Outbreak in the Likati District, Democratic Republic of the Congo.

On May 12, 2017, the Democratic Republic of Congo (DRC) publicly declared an outbreak of Ebola virus disease (EVD) in the Likati District of the Bas-Uélé Province, 46 days after the index case became symptomatic. The delayed EVD case detection and reporting highlights the importance of establishing real-time surveillance, consistent with the Global Health Security Agenda. We describe lessons learned from implementing improved EVD case detection and reporting strategies at the outbreak epicenter and make recommendations for future response efforts. The strategies included daily coordination meetings to enhance effective and efficient outbreak response activities, assessment and adaptation of case definitions and reporting tools, establishment of a community alert system using context-appropriate technology, training facility and community health workers on adapted case definitions and reporting procedures, development of context-specific plans for outbreak data management, and strengthened operational support for communications and information-sharing networks. Post-outbreak, surveillance officials should preemptively plan for the next outbreak by developing emergency response plans, evaluating the case definitions and reporting tools used, retraining on revised case definitions, and developing responsive strategies for overcoming telecommunications and technology challenges. The ongoing EVD outbreak in the North Kivu and Ituri provinces of DRC, currently the second largest EVD outbreak in history, demonstrates that documentation of successful context-specific strategies and tools are needed to combat the next outbreak. The lessons learned from the rapid containment of the EVD outbreak in Likati can be applied to the DRC and other rural low-resource settings to ensure readiness for future zoonotic disease outbreaks.

Editorial

Editorial

A new drepanosauromorph, <em>Ancistronychus paradoxus</em> n. gen. et sp., from the Chinle Formation of Petrified Forest National Park, Arizona, USA

Author(s): Goncalves, Gabriel S.; Sidor, Christian A. | Abstract: Drepanosauromorpha is an extinct group of reptiles known from the Middle Triassic to Late Triassic (237–212 Ma). The clade currently includes seven genera (Avicranium, Dolabrosaurus, Drepanosaurus, Hypuronector, Kyrgzsaurus, Megalancosaurus, and Vallesaurus) that are known from fossils collected in Europe, North America, and Asia. These discoveries have helped shape our understanding of the biology and diversity of drepanosauromorphs. Here we describe Ancistronychus paradoxus n. gen. et sp. from the Chinle Formation in Petrified Forest National Park, Arizona based on the ungual phalanx of the second digit of the manus. A characteristic that this taxon shares with Drepanosaurus unguicaudatus is the pronounced size of the ungual relative to the penultimate element. It differs significantly from D. unguicaudatus and the Hayden Quarry Drepanosaurus in the shortened proximal dorsoventral height of the claw, its great transverse breath, the presence of both a furrow on the midline of the extensor surface and a cleft on the apex, and a broad and flattened terminus. We suggest that A. paradoxus is likely closely related to D. unguicaudatus and the Hayden Quarry Drepanosaurus, but missing phylogenetic data precludes a more definitive assessment at this point. Ancistronychus paradoxus highlights unsuspected morphological variation within Drepanosauromorpha and suggests that different drepanosauromorphs used their enlarged second manual unguals for distinct functions enabling them to fill different ecological niches.

Assessment of Target definition based on Multimodality Imaging for Radiosurgical Management of Glomus Jugulare Tumors (gjts)

Assessment of Target definition based on Multimodality Imaging for Radiosurgical Management of Glomus Jugulare Tumors (gjts)

Statin-induced LDL cholesterol response and type 2 diabetes: a bidirectional two-sample Mendelian randomization study.

It remains unclear whether the increased risk of new-onset type 2 diabetes (T2D) seen in statin users is due to low LDL-C concentrations, or due to the statin-induced proportional change in LDL-C. In addition, genetic instruments have not been proposed before to examine whether liability to T2D might cause greater proportional statin-induced LDL-C lowering. Using summary level statistics from the Genomic Investigation of Statin Therapy (GIST, nmax=40,914) and DIAGRAM (nmax=159,208) consortia, we found a positive genetic correlation between LDL-C statin response and T2D using LD score regression (rgenetic=0.36, s.e.=0.13). However, mendelian randomization analyses did not provide support for statin response having a causal effect on T2D risk (OR 1.00 (95%CI: 0.97, 1.03) per 10% increase in statin response), nor that liability to T2D has a causal effect on statin-induced LDL-C response (0.20% increase in response (95%CI: −0.40, 0.80) per doubling of odds of liability to T2D). Although we found no evidence to suggest that proportional statin response influences T2D risk, a definitive assessment should be made in populations comprised exclusively of statin-users, as the presence of non-statin users in the DIAGRAM dataset may have substantially diluted our effect estimate.

Assessment and Validation of Syndromic Case Definitions for Respiratory Syncytial Virus Infections in Young Infants: A Latent Class Analysis.

Respiratory syncytial virus (RSV) is a major cause of pediatric morbidity and mortality worldwide. Standardized case definitions that are applicable to variety of populations are critical for robust surveillance systems to guide decision-making regarding RSV control strategies including vaccine evaluation. Limited data exist on performance of RSV syndromic case definitions among young infants or in high-resource settings. The purpose of this study was to evaluate existing and potential syndromic case definitions for RSV among young infants in an urban, high-income setting using latent class analyses (LCA). We used data collected on infants <6 months of age tested for RSV as part of routine clinical care at Children's Healthcare of Atlanta between January 2010 and December 2015. We computed the sensitivity, specificity, positive and negative predictive values of clinical features, existing syndromic case definitions used by the World Health Organization (WHO) and alternative definitions we constructed using LCA to detect RSV infection. Among 565 infants tested for RSV, 161 (28.5%) had laboratory-confirmed RSV infection. Among all case definitions evaluated, the definition developed through LCA (cough plus shortness of breath plus coryza plus wheeze plus poor feeding plus chest in-drawing) was the most specific (95.8%, 95% CI 93.8-97.8) and had the highest positive predictive value (51.4%, 95% CI, 34.9-68.0). WHO-acute respiratory infection (cough or sore throat or shortness of breath or coryza, plus a clinician's judgment that illness is due to infection) was the most sensitive (98.1%, 95% CI, 96.1-100.0; negative predictive value 96.3%, 95% CI 92.2-100.0). The WHO acute respiratory infection definition could be useful for initial screening for RSV among infants <6 months, whereas our alternative syndromic case definition may serve as the strongest confirmatory case definition in the same population. Appropriate case definitions will vary depending on the content and setting in which they are utilized.