Dysfunctional Elimination Syndrome Research Articles

Elimination disorders and associated factors among children and adolescents age 5–14 year-old attending paediatric outpatient clinic at Wolaita Sodo University comprehensive specialized hospital, South Ethiopia

BackgroundElimination disorder occurs in children over the age of normal toileting who continue to have an inability to control urination or feces, either during the day, at night, or both. Paediatric elimination disorders are not well understood by parents, teachers, medical professionals, mental health practitioners, and researchers. Hence, this study aimed to assess the magnitude of elimination disorder and associated factors among children and Adolescents aged 5–14 years old at Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia, in 2022.MethodA hospital-based cross-sectional study was conducted from September 22 to November 22, 2022, at Wolaita Sodo University Comprehensive Specialized Hospital. A systematic random sampling technique was employed to select 423 study subjects. The data were gathered using a structured, face-to-face interviewer-administered questionnaire. The development of the symptom score for dysfunctional elimination syndrome of Vancouver questionnaires was used to screen for elimination disorders. Logistic regression model was used to determine the association between the outcome and independent variables. A 95% CI and Odds ratio with corresponding p-value < 0.05 were used to determine the predictors of the outcome variable.ResultThe overall magnitude of elimination disorder among children and Adolescents age 5–14 in this study was (n 70, 16.8%); in boys (n 47, 17.3%) and girls (n 23, 15.75%). The prevalence of enuresis was (n 64, 15.3%), encopresis (n 15, 3.6%), both enuresis and encopresis, or combined elimination disorder (n 9, 2.2%). Age 9–11 years (AOR = 3.2, 95%CI:1.09, 9.43), family size four and above (AOR = 3.4, 95%CI:1.78, 6.56), family history of elimination disorder (AOR = 3.9, 95%CI:2.12, 7.45), emotional problem (AOR = 2.2, 95%CI:1.18, 4.05), hyperactive problem (AOR = 3.8, 95%CI:1.83, 7.83), low toilet training skills (AOR = 5.9, 95%CI:2.61, 13.33), bad parenting practices, were poor supervision (AOR = 4.4, 95%CI 1.29, 14.69) were significantly associated with elimination disorder.Conclusion and recommendationIn this study, approximately one in five children and adolescents had an elimination disorder. Younger age, family size four and above, positive family history of elimination disorder, presence of emotional and hyperactive problems, bad parenting practices, and low toilet training skills were factors associated with elimination disorders. Therefore, preventative, etiological, and therapeutic measure, early toilet training, supportive parenting practices, screening for children’s and adolescents’ behavioral problems, and elimination disorders need attention to reduce the effect of the problem.

S2534 Medical Myopia: Dysfunctional Elimination Syndrome in Stricturing Crohn's Disease

S2534 Medical Myopia: Dysfunctional Elimination Syndrome in Stricturing Crohn's Disease

Vancouver Symptom Score for Dysfunctional Elimination Syndrome: Hindi translation and validation.

Bladder and bowel dysfunction (BBD) is a common problem in school-aged children and is evaluated using questionnaires. Among available questionnaires, "Vancouver Symptom Score for Dysfunctional Elimination Syndrome" (VSSDES) is considered superior in validity and reliability. We translated VSSDES into Hindi and performed validity and reliability testing of Hindi-VSSDES in children aged 4-16 years with lower urinary tract dysfunction (LUTD). In this cross-sectional study, we followedConsensus-based Standards for the selection of health Measurement Instruments recommendation to develop Hindi-VSSDES. Forward-translation-harmonization-back-translation-expert committee review-prefinal version sequence of translation was followed by cognitive debriefing. One hundred and sixteen children with symptoms suggestive of LUTD and 106 healthy controls were recruited. Construct validity of Hindi-VSSDES was assessed via structural validity (factor analysis) and hypotheses testing. In addition, test-retest reliability and internal-consistency reliability were assessed. Hindi-VSSDES had acceptable face validity. Factor analysis identified four factors representing three domains. All a priori hypotheses were met. The questionnaire displayed excellent convergent validity and discriminative ability (area under receiver operating characteristic curve 0.83). The cutoff scores for screening and diagnosis were 7 and 11, respectively. Scores were comparable whether children self-filled the questionnaire or parents were proxy. Scores in girls were significantly higher. It had an excellent test-retest reliability (intraclass correlation coefficient = 0.96) and Cronbach's ɑ was 0.62. The smallest detectable change was 4.1 points. Median time to complete the questionnaire was 7 min and majority (91%) rated it as easy. Hindi-VSSDES is the first validated and reliable Hindi questionnaire for children with BBD. Clinimetric properties of responsiveness and interpretability are yet to be tested.

Dysfunctional elimination syndrome: a short review of the literature.

The combination of the functional disorders of urination and defecation constitutes the Dysfunctional Elimination Syndrome (DES). DES refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding, with no underlying anatomic or neurologic abnormalities. Essential precondition for a child to be subsumed under this entity is the exclusion of either anatomical or neurological causative factors. In the present review study the individual entities of dysfunctional filling, such as the unstable or lazy bladder, or dysfunctional urination, such as the detrusor sphincter dyssynergia and the functional constipation are being described comprehensively. Subsequently, the analysis of the pathophysiological effects of the dysfunctional elimination syndrome such as incontinence, urinary tract infections and the conservation or the deterioration of vesicoureteric reflux, is being accentuated. With the documentation of DES, the therapeutic strategy should aim at treating both the functional disorder of the vesicourethral unit and the functional constipation. The first part does not specify depending on the type of this disorder. Rarely, surgical treatment of functional urinary disorders may be required.

Successful Conservative Management of Dysfunctional Elimination Syndrome Associated with Micronutrient Deficiencies, Recurrent Juvenile Allergic Urethritis and Penoscrotal Edema

Dysfunctional elimination syndrome is a constellation of symptoms related to the urinary, genital and colorectal dysfunction of the psycho-neuro-endocrine-target organs axis origin secondary to congenital and acquired disorders

Improvement in bladder function in children with functional constipation after a bowel management program.

PurposeWe sought to determine if children with functional constipation (FC) would have an improvement in bladder function with treatment of constipation with a bowel management program (BMP).MethodsA single-institution review was performed in children aged 3–18 with FC who underwent a BMP from 2014 to 2020. Clinical characteristics, bowel management details, and the Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSS), Baylor Continence Scale (BCS), and Cleveland Clinic Constipation Score (CCCS) were collected. Data were analyzed using linear mixed effect modeling with random intercept.Results241 patients were included with a median age of 9 years. Most were White 81 and 47% were female. Univariate tests showed improvement in VSS (− 3.6, P < 0.0001), BCS (− 11.96, P < 0.0001), and CCCS (− 1.9, P < 0.0001) among patients having undergone one BMP. Improvement was noted in VSS and CCCS among those with more than one BMP (VSS: − 1.66, P = 0.023; CCCS: − 2.69, P < 0.0001). Multivariate tests indicated undergoing a BMP does result in significant improvement in VSS, BCS, and CCCS (P < 0.0001).ConclusionsThere is significant improvement in bladder function in children with FC who undergo a BMP. For patients with bowel and bladder dysfunction and FC, a BMP is a reasonable treatment strategy for lower urinary tract symptoms.

Is Urinary Retention Following Extravesical Ureteral Reimplantation Still a Concern?

Transient urinary retention is a known complication of bilateral extravesical ureteral reimplantations. Recent studies have shown that the robotic-assisted bilateral extravesical reimplantation may have lower transient urinary retention rates than previously reported for the open approach. The purpose of this review is to compare urinary retention incidence in patients undergoing open versus robotic-assisted extravesical reimplantations. In some of the larger series, open bilateral extravesical ureteral reimplantation was noted to have a temporary urinary retention rate of 4–15%. In our recent experience with the open approach, we have noted a 2% incidence of transient urinary retention. In recent series of robotic-assisted bilateral extravesical reimplantations, transient retention was seen in 0–22%, with larger series favoring lower urinary retention rates. The incidence of transient urinary retention following open or robotic-assisted approaches in recent series is 0–2%, which is almost negligible. Dysfunctional elimination syndrome symptoms and constipation need to be aggressively treated preoperatively. Families of patients who undergo bilateral extravesical ureteral reimplantations, regardless of whether it is performed via the open or robotic-assisted approach, should not only be counseled of the small risk of transient urinary retention but should also be told that this can also be seen with any other surgical approach for the repair of primary vesicoureteral reflux.

The effects of antimuscarinic agents on the activity of the cardiac autonomic nervous system in children with functional overactive bladder

Functional overactive bladder disorder is one of the most prevalent presentations of bladder and bowel dysfunction in children, and it is associated with lower overall cardiac autonomic and parasympathetic activity. Antimuscarinics are the most frequently used pharmacological agents for treatment of children with functional overactive bladder disorder; however, there is a gap in the literature in describing the effect of antimuscarinics on the autonomic profile of this population. The aim of the study was to assess the cardiac parasympathetic activity before and after 12 weeks of oxybutynin treatment in children with overactive bladder. This was a single-institution prospective cohort study. Cardiac autonomic activity was assessed during storage and voiding phases of the bladder function via spectral analysis of heart rate variability and impedance cardiography. The primary outcome measure was high frequency, a proxy for parasympathetic nervous system activity. Parameters of uroflow study, severity of symptoms, and quality of life outcomes were also assessed. Ten children (7 females) diagnosed with overactive bladder with a median age of 10 years (range = 6-14) were followed up for a median treatment duration of 11.8 weeks (range = 6-19.4). After treatment, there was a significant reduction in high frequency during the storage phase (median change=-24.17%, p=0.047). No change was observed in the other outcome measures except for the overall Symptom Score for Dysfunctional Elimination Syndrome after treatment (5-point decrease, p=0.034) (Summary Table). The findings of the present follow-up study suggest that the use of oxybutynin in children with overactive bladder is associated with a significant reduction in the activity of the parasympathetic nervous system. The clinical implications of this finding are important because similar autonomic profiles (as markers of chronic stress) have been shown to be associated with increased inflammation and are found in major chronic diseases. The authors caution making a clinical connection between the heart rate variability profile of the patients in this study and patients with chronic diseases because oxybutynin is usually not administered as long-term treatment for overactive bladder. Use of oxybutynin was associated with reduction in cardiac parasympathetic activity of children with functional overactive bladder. Further investigation into the role of the autonomic nervous system as a treatment target in the management of these children is warranted.

Management of constipation in preventing urinary tract infections in children: a concise review

Objectives: Constipation is a common problem in children. Chronic functional constipation (CFC) has been a claimed conditions that may increase the risk for urinary tract infections (UTIs). Dysfunctional voiding (DV) and lower urinary tract dysfunctions (LUTD) with chronic constipation are referred to dysfunctional elimination syndromes (DES). The aim of the present review is to look at the management of constipation in children with CFC or DES in reducing the risk of recurrent UTIs. Methods: We performed a literature search on electronic databases (Pubmed and Scopus) for relevant clinical trials investigating the results of one or more treatments for children’s constipation in the term of UTIs recurrence. Results: The search strategy identified 20 valuable clinical trials. The studies are not homogenous but showed an improvement in UTIs occurrences in children managed for bowel dysfunction. Conclusion: In conclusion, children referred to a pediatric nephrologist for UTIs should include an inquiry bowel habits and those with a positive assessment for bowel dysfunction needs the collaboration with a pediatric gastroenterologist with a multidisciplinary approach.

Urinary Outcomes in Patients with Down's Syndrome and Hirschsprung's Disease.

Previous research in children with Hirschsprung's disease (HD) and Down's syndrome (DS) has focused on colorectal outcomes. We set out to review urinary outcomes in this patient group. The medical records of all patients aged five years and older with HD were reviewed, and patients and caregivers filled out the Vancouver Symptom Score at intake, which is designed and validated to diagnose dysfunctional elimination syndrome. A total of 104 patients with HD were included in this study. Of these, 16 (15%) patients had DS. There were no significant differences in the prevalence of enterocolitis or colorectal symptoms between patients with or without DS. Five of 88 (6%) patients without DS and 7 of 16 (44%) (p = 0.00001) with DS reported having urinary accidents. Patients with HD and DS scored higher on the Vancouver score (9 vs. 17.5; p = 0.007), indicating more severe urinary symptoms. Patients who also reported fecal accidents scored significantly higher on the Vancouver (12 vs. 9; n = 61; p = 0.016), indicating more problems. Patients with DS appear to be a unique subset of HD patients who have a higher prevalence of urinary symptoms after surgery. In the postoperative care of patients with HD and DS, a strong focus should be placed on postoperative urinary care in addition to their bowel care. This could significantly ease care and contribute to the quality of life of the parents and the patient.

Urinary Infection Recurrence and Its Related Factors in Urinary Tract Infection

Background: Recurrent urinary tract infection (UTI) is one of the major health problems in children because of its high rate of occurrence. This study aimed at evaluating the frequency of recurrent urinary tract infection and related factors in children aged two months to 15 years old, refereed to the pediatric nephrology clinic of Zahedan city. Methods: In this descriptive study, 270 children with urinary tract infection were studied. The sampling method was convenient. Information was gathered from patients and their files. Data was analyzed by the SPSS version 18 software, using Chi Square and T-test. Results: The mean age of the children was 4.3 ± 3.7 years old. Thirty-four children (12.6%) were male and 236 (87.4%) female (P > 0.05). Overall, 109 children (73.6%) with recurrent UTI and 53 children (44.2%) without recurrent UTI had abnormal ultrasonography (P = 0.001). Furthermore, 115 children (76.7%) with recurrent UTI and 100 children (83.3%) with first UTI had positive results for E. coli culture (P = 0.177). Seventy-nine children (54.5%) with recurrent UTI and 61 children (39%) with first UTI were diagnosed to have elimination syndrome (P = 0.067). Abnormal VCUG was found in 39 children (47.6%) of 82 children with recurrent UTI yet children with first UTI had normal VCUG (P = 0.001). Conclusions: There was no difference regarding age, gender, dysfunctional elimination syndrome, and urine culture in children with recurrent UTI compared to those with first UTI, yet abnormal VCUG, kidney, and urinary tract ultrasonography were much more common in children with recurrent UTI.

Urotherapy in children with dysfunctional voiding and the responsiveness of two condition-specific questionnaires.

We sought to establish the responsiveness of the Dutch Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSSDES) and Pediatric urinary incontinence Quality of life (PinQ) questionnaires. Secondary, we evaluated the outcome of urotherapy extended for children with dysfunctional voiding (DV). This cross-sectional multicenter study was done in one tertiary and two community hospitals. Children with DV were included, also when refractory to previous urotherapeutic treatment. The questionnaires were completed before and after urotherapy. The primary outcome measure was the responsiveness of the Dutch VSDESS and PinQ. Secondary outcome was the initial success (defined by the International Children's Continence Society) of extended urotherapy. Between June 2014 and May 2016, 64 children (median age 7 years, IQR 6-10) received urotherapy (median 18 weeks, IQR 11-28). In contrast to the VSSDES, the PinQ showed good responsiveness. For children and parents, respectively, the area under the ROC-curve was 0.79 (P = 0.01) and 0.72 (P = 0.03) for the PinQ and 0.50 (P = 0.98) and 0.55 (P = 0.62) for the VSSDES. Fifty children received extended urotherapy, 27 had complete, and 14 had partial response. Sixteen children had been refractory to previous treatment; four showed complete, and six showed partial response. The PinQ is able to detect clinically important changes in continence-specific quality of life after treatment. We support the use of the VSSDES questionnaire in addition to the current diagnostics for the diagnosis of DV. Extended urotherapy showed to be a successful treatment for children with DV, also for those who had received previous unsuccessful treatment.

A study to identify prevalence and effectiveness of sensory integration on toilet skill problems among sensory processing disorder

Background: Toilet skill problems have been reported among children with sensory processing disorders (SPD) in recent literatures. Pollock concluded that children with dysfunctional elimination syndrome (53%) had SPD than was reported for the general population. Occupational therapists from India experience similar observations in their clinical practice. However, there is limited evidence within the Indian context. Objectives: The objectives of the study are to find the prevalence of problems in toilet skills in children with SPD and the effectiveness of sensory integration therapy (SIT) for the improvement of toilet skills in children with SPD. And also to compare the effectiveness of SIT with behavior modification for developing age-appropriate toileting habits in children with SPD. Study Design: A cross-sectional survey and quasi-experimental pre-posttest design were adopted for the study. Methods: The study consisted of 2 phases. In Phase 1, 96 children with SPD were screened to find out the prevalence of toilet skill problems among them. In Phase 2, the study effectiveness of SIT on toilet skill development was investigated on 22 children. The baseline and posttest measurement were done using sensory profile (SP), Canadian Occupational Performance Measure and modified diet schedule. The control group underwent behavior modification therapy, and experimental group, in addition, underwent SIT for 4 months. Both groups also underwent conventional occupational therapy. Results: This study found out among 96 SPD children, 68.75% had toilet skill problems. There was the difference in sections, factors, and quadrants in SP for children with and without toilet skill problems. In Phase 2, the result shows a significant difference (P

A percepção dos educadores acerca da disfunção eliminatória

A Residência Pediátrica (RP) é uma revista eletrônica trimestral, em publicação contínua, da Sociedade Brasileira de Pediatria (SBP), disponível em português e inglês, destinada aos médicos residentes de nossa especialidade, áreas afins e aos pediatras. O conteúdo da revista pode ser acessado livremente. A missão da RP é contribuir para a formação acadêmica dos residentes e incentivá-los a uma participação ativa na produção científica sobre temas pediátricos e relacionados à adolescência.

Quality of life outcomes in children with Hirschsprung disease

BackgroundMorbidity following repair of Hirschsprung disease (HD) is common. However, quality of life (QoL) results focused on HD children are contradictory. We aimed to measure QoL outcomes in HD children using validated questionnaires. MethodsPatients with HD, managed at a large tertiary pediatric institution between 2004 and 2013, were identified. Parents completed validated questionnaires. Results were compared with published healthy population controls. QoL outcomes were measured using Pediatric Quality of Life (PedsQL) and Fecal Incontinence and Constipation Quality of Life (FIC QOL). Functional outcomes were assessed using Baylor Continence Scale, Cleveland Clinic Constipation Scoring System, and Vancouver Dysfunctional Elimination Syndrome Survey. ResultsParents of 60 HD patients [M:F 49:11; median age 6.4years (2.3–10.9)] were interviewed (59% participation). The majority (47/60, 78%) had rectosigmoid disease. There was significant reduction in psychosocial (social and emotional) QoL compared with healthy children (p=0.03). Psychosocial functioning was affected by increasing age (r=−2.72, p<0.001), fecal incontinence (r=−0.475, p=0.007), constipation (r=−1.58, p=0.006), and dysfunctional elimination (r=−2.94, p=0.004). Fecal incontinence also reduced physical functioning QoL (r=−0.306, p=0.007). Children with HD had significantly higher levels of fecal incontinence (p<0.01). ConclusionsWe have demonstrated that HD children have significant reductions in psychosocial QoL and functional outcomes. Level of evidencePrognosis Study – Level II (Prospective cohort study).

Enema Regimen in Pediatric Bladder Dysfunction

In this review, we will describe the techniques which we have developed to properly diagnose the constipation component of pediatric bowel and bladder disorders (BBD) in children and the treatment techniques that most rapidly and effectively resolve these issues. Constipation is commonly understood to be a major component of dysfunctional elimination syndrome in children. All methodologies described for the treatment of overactive bladder dysfunction in the pediatric population include the treatment of constipation as a critical component. Diagnostic techniques that remain inconclusive are best used to diagnose constipation and the treatment modalities most ideally suited to address bowel dysfunction in these patients.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation

BackgroundSacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. MethodsUsing a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. ResultsTwenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. ConclusionsIn children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. Level of evidenceIV.

The relationship of enuresis nocturna and adenoid hypertrophy.

This study was organized to assess the relationship of enuresis nocturna (EN) and upper airway obstruction (UAO) in children. This study was multi-centrically and prospectively designed including 79 children who presented to a urology clinic with symptoms of EN between January 2013 and February 2014. Sixty-four age-matched children with no history of urological complaints were randomly recruited from children admitted to a pediatric clinic as a control group. All children and parents were asked to fill out a dysfunctional elimination syndrome (DES) questionnaire and children were examined by an ear, nose and throat (ENT) specialist to evaluate the UAO. Descriptive statistics, chisquare and Mann-Whitney-U tests were used to compare variables. The mean ages of the 79 children (48 male, 31 female) in the study group and the 64 children (41 male, 23 female) in the control group were 10.14+/-3.38 and 9.17+/- 2.85, respectively. Family history of the study showed that 19% of the children's mothers, 10% of the children's fathers and 37% of the children's siblings had experienced EN. There was a significant difference between the study and the control groups in terms of urge to urinate, bladder emptying, bowel symptoms and psychological stress. There was also a significant difference between rates of tonsillar hypertrophy and nasopharynx obstruction in the EN group (p = 0.009). In this study we found that half of the children with EN had tonsillar hypertrophy, which was significantly higher than in the control group. Further studies are needed to clarify the exact relationship between UAO and EN.

Modified O’Regan Protocol for Overactive Bladder

We have demonstrated in previous publications the consistent association of the dilated rectum and overactive bladder in children. The pioneering work on this topic, first published by Sean O’Regan, described an enema regimen ideally suited to resolve megaretcum and voiding compliants in these children. As our experience has grown with this population, we have gained more insight into the function of the dilated rectum, its role in dysfunctional elimination syndrome, and the methods required for its most effective resolution. In this review, we will describe the Modified O’Regan protocol, which we have developed to treat patients resistant to Dr. O’Regan’s originally described regimen, and we will introduce the concept of “rectal failure,” which we feel fully describes the onset and progression of dysfunctional elimination syndrome.

Vancouver Symptom Score for Dysfunctional Elimination Syndrome: Reliability and Validity of the Dutch Version

We sought to establish the reliability and validity of the Dutch version of the Vancouver Symptom Score for Dysfunctional Elimination Syndrome for children with dysfunctional voiding and their parents. For this cross-sectional multicenter study the Vancouver Symptom Score for Dysfunctional Elimination Syndrome was translated andcross-culturally adapted to Dutch following a standardized process. Patients 16 years or younger with dysfunctional voiding and their parents were recruited at pediatric, pediatric urology and pelvic floor physical therapy outpatient clinics. The reference group consisted of children 6 to 16 years old without dysfunctional voiding and their parents. All groups completed questionnaires. The evaluated measurement properties included discriminative ability, internal consistency, test-retest reliability, interrater agreement, criterion validity using the Pediatric Incontinence Questionnaire and construct validity. A cutoff value for diagnosis of dysfunctional voiding was determined. A total of 50 patients and 60 references and their parents were included in the study. The Vancouver Symptom Score for Dysfunctional Elimination Syndrome showed good discriminative ability. A moderate internal consistency was found (Cronbach alpha 0.37-0.55). Test-retest reliability was moderate to good, and interrater agreement demonstrated good correlation between children and parents (ICC 0.85, 95% CI 0.79-0.89). A weak correlation with the Pediatric Incontinence Questionnaire was found in patients and construct validity was confirmed. Cutoff scores for dysfunctional voiding were 11 and 9 for patients and parents, respectively. The Dutch Vancouver Symptom Score for Dysfunctional Elimination Syndrome displayed moderate to good reliability and validity properties for the patient and parent versions. Use of this instrument in clinical practice will support the assessment of dysfunctional voiding and facilitate international reporting of research results.