English Studies Research Articles

The effect of non-pharmacological prenatal interventions on fear of childbirth: an overview of systematic reviews and meta-analysis

BackgroundDuring pregnancy and childbirth, alongside positive feelings, women undergo feelings such as fear of childbirth (FoC) and worry about its consequences, which could leave negative effects on the mother and her child during pregnancy, delivery, and postpartum. The study was carried out to determine the effectiveness of prenatal non-pharmacological interventions on reducing the FoC.MethodsThe protocol of the study was registered in PROSPERO (ID: CRD42023468547). PubMed, Web of Science, Cochrane, Scopus, SID (Scientific Information Database) and Google Scholar search engine databases were systematically searched until July 27, 2023 with no limitation of time and limited to Persian and English studies in order to perform this overview. Certainty of evidence was assessed using GRADE, methodological quality using AMSTAR 2 and reporting quality using PRISMA score. Meta-analysis was performed on the data extracted from the original trials to evaluate the effect of different interventions on reducing the FoC. Sub-group analysis and meta-regression models were used to examine high heterogeneity, and sensitivity analysis was used to eliminate the effect of high risk of bias studies on the study findings.ResultsOverall, 15 systematic reviews (SRs) were included in the overview, among which meta-analysis was performed in 9 studies. Considering methodological quality, these SRs were in low to critically low status and had relatively complete reports regarding reporting quality. Meta-analysis findings indicated that psychological interventions (SMD -2.02, 95% CI -2.69 to -1.36, 16 trials, 1057 participants, I2 = 95%) and prenatal educations (SMD -0.88, 95% CI -1.16 to -0.61, 4 trials, 432 participants, I2 = 72.8%) cause a significant reduction in FoC relative to prenatal usual cares with low certainty of evidence. Distraction techniques lead to a significant reduction in FoC relative to prenatal usual care with high certainty of evidence (SMD -0.75, 95% CI -1.18 to -0.33, 4 trials, 329 participants, I2 = 69%), but enhanced cares do not result in a significant decrease FoC relative to prenatal usual care with very low certainty of evidence (SMD -1.14, 95% CI -2.85 to 0.58, 3 trials, 232 participants, I2 = 97%).ConclusionsDistraction techniques are effective in reducing FoC. Regarding the effect of psychological interventions and prenatal educations on the reduction of FoC, the findings indicated that the interventions may result in the reduction of FoC. Very uncertain evidence showed that enhanced cares are not effective in reducing the FoC.

English language learning anxiety and academic burnout in Chinese freshmen: a chain mediating approach.

The university stage is critical for cultivating and enhancing students' practical English proficiency, encompassing listening, speaking, reading, writing, and translation skills. Losing interest in English studies at this stage not only hampers the development of practical English competence but also has a negative impact on future employment and personal growth. This study aimed to explore to how English language learning anxiety (ELLA) affects academic burnout (AB) of freshman in China and explores the role of academic peer support (APS) and academic self-efficacy (ASE) in the relationship between the two. The study involved 1,355 college students who completed English Language Learning Anxiety Scale, the English Academic burnout Scale, Academic Peer Relationship Scale, the Academic Self-efficacy Scale. AB was significantly impacted by ELLA. ELLA and AB were mediated by ASE. Another factor that acted as a mediator between ELLA and AB was APS. ELLA and AB were mediated by a chain reaction involving ASE and APS. The chain mediation model validated in this study, providing valuable insights into the effects of freshmen's ELLA on AB in China, as well as practical insights into the prevention and intervention of ELLA and AB in other current college students.

A systematic review of the mechanisms influencing engagement in diabetes prevention programmes for people with pre-diabetes.

To identify barriers and enablers that influence engagement in and acceptability of diabetes prevention programmes for people with pre-diabetes. The results will provide insights for developing strategies and recommendations to improve design and delivery of diabetes prevention programmes with enhanced engagement and acceptability for people with pre-diabetes. This review used a critical realist approach to examine context and mechanisms of diabetes prevention programmes. Medline, Embase, PsycInfo, Cinahl, Web of Science, Scopus and Pre-Medline were searched for English language studies published between 2000 and 2023. A quality assessment was conducted using Joanna Briggs Institute critical appraisal tools. A total of 90 papers met inclusion criteria. The included studies used a variety of quantitative and qualitative methodologies. Data extracted focused on barriers and enablers to engagement in and acceptability of diabetes prevention programmes, with seven key mechanisms identified. These included financial, environmental, personal, healthcare, social and cultural, demographic and programme mechanisms. Findings highlighted diverse factors that influenced engagement in preventive programmes and the importance of considering these factors when planning, developing and implementing future diabetes prevention programmes. Mechanisms identified in this review can inform design and development of diabetes prevention programmes for people with pre-diabetes and provide guidance for healthcare professionals and policymakers. This will facilitate increased participation and engagement in preventive programmes, potentially reducing progression and/or incidence of pre-diabetes to type 2 diabetes and improving health outcomes.

The Influence of Genetic Markers on the Development of Mental Disorders: A Systematic Review of Studies

Introduction: The etiology of mental disorders is largely influenced by genetic elements. Several studies have shown that genetic elements influence major mental disorders (MDs). However, the quantity and type of the genetic input remain unknown and require further research. Objective: In this review, we aim to investigate the impact of genetic markers on the development of mental disorders. Methodology: In our study, we included English studies from online databases such as Web of Science, Scopus, Google Scholar, PubMed, and the Cochrane Library using the following keywords “genetic factors”, “genetic markers”, “mental disorders”, “anxiety”, “depression”, and “schizophrenia” till March 2024. Results: The result of the search utilizing the strategy of our search was 2107 studies. We selected the articles that were relevant to our topic by screening these articles. After eliminating the remaining papers based on title and abstract screening, we conducted a full-text screening of 318 publications. In the end, we consulted 68 articles to learn more about our subject and compose this evaluation. Scientific Novelty: Most of the previous studies discovered that genetic elements contribute to major MDs. However, the nature and extent of the genetic contribution have not been determined. In our review, we discussed the genetic contribution to the occurrence of MDs. Practical Significance of the Results Obtained: The influence of genetic research on individuals with MDs and their families was one of our review's main concerns. Understanding the extent of genetic elements' contribution to MDs may have implications for society, research, patient outcomes, and quality of life. Conclusion: This comprehensive study demonstrates that the development and onset of MDs are affected by several elements, which can be genetic polymorphisms and genetic mutations. The potentiality of genetics studies to detect the occurrence of MDs may help in the early recognition of these conditions. It could assist in identifying people who are more susceptible to developing specific disorders according to their genetic profile.

Social relationships in adults who were adopted following institutional deprivation

Research examining the effects of severe, prolonged early deprivation has shown elevated rates of neurodevelopmental symptoms, which frequently persist into adulthood and are associated with functional and social relationship difficulties, as well as elevated rates of mental health problems. The behavioural manifestations of these symptoms closely resemble those of ADHD and also ASD. Here, we used qualitative methods to explore and characterise the social experiences and difficulties encountered by young adults exposed to profound early deprivation, in part to highlight any apparent parallels between the experiences in this group and those identified in typically developing samples with ADHD or ASD. To do so, we interviewed young adults and their adoptive parents ( N = 18) from the English and Romanian Adoptees study, about their social lives. Participants were keen to describe not only the challenges they faced but also adaptive responses. A semantic/descriptive thematic analysis revealed that the young adults strongly desired social relationships but struggled to navigate social norms, resulting in frustration and frequent loss of relationships. This was accompanied by strong feelings of loss and rejection, all of which were perceived to have a negative impact upon self-esteem and mental health. Adaptive strategies included the fostering of casual friendships with older individuals and seeking employment with strong social components. Similarities and differences between our findings and the social difficulties experienced by typically developing groups with neurodevelopmental problems, and adopted individuals more generally, are discussed.

Philippine English and commodity formation

AbstractThis article aims to expand the scope of Philippine English studies by investigating the viability of Philippine English as a resource for the contestation of the global–local interface, a perspective that remains understudied in Philippine English studies. We do this by analysing the language of t‐shirts that creatively reappropriate global brands into the local domain, demonstrating the dynamics of t‐shirt production and consumption in the Philippines. Our analysis shows that the use of Philippine English in these products can be viewed as a commodified resource for the expression of local sensibilities amidst the dominance of global consumerism. However, while this reappropriation can be viewed as a form of local expression, it is not devoid of ideological complexities. Although the linguistic market of pop culture provides people with opportunities to contest the global–local dichotomy, it may still tacitly reflect or reinforce structures of linguistic inequality.

Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs.

The objective of this review was to explore parents' experiences and information needs regarding management of their child with an intellectual and/or developmental disability (IDD) in the emergency department (ED). We searched six electronic databases and grey literature to identify primary studies in English published since 2000. We synthesized quantitative and qualitative outcome data simultaneously using a convergent integrated approach and used a Mixed Methods Appraisal Tool (MMAT) to assess methodological quality of the included studies. Nine articles derived from seven studies were included (3 qualitative, 3 quantitative, 1 mixed method). Four main themes related to parents' self-reported experiences were identified: 1) appropriateness of the ED to manage and support their child; 2) acknowledgement/recognition of their child's IDD and incorporation of those considerations into overall care and management; 3) managing and navigating the ED environment; and 4) decision to disclose their child's condition when visiting the ED. Two articles provided data relevant to information needs, highlighting parents' desire to have resources supporting ED orientation and access to services within and outside of the ED setting. From the limited number of studies, it was evident that parents wanted better communication with healthcare providers and a greater understanding by ED staff around physical space settings needed to support their child. Resources supporting ED staff and parents to communicate effectively and work together can ensure that children with IDDs care needs are met. Further research into understanding parents' experiences and information needs related to managing a child with an IDD in the ED is needed to guide the development of effective resources.

Time, Non-Tenure-Track Labor, and the Academic Knowledge Economy in English Studies: Let’s Break the Scholarship Machine

This mixed-methods study reveals the underrepresentation of non-tenure-track (NTT) scholars in academic publications in English, even while they teach the majority of courses. Interviews with NTT scholars and editors reveal time, in several dimensions, as a significant barrier to publication. An analysis of interviews with editors and journal websites suggests models for change.

The Role of Letter-Speech Sound Integration in Native and Second Language Reading: A Study in Native Japanese Readers Learning English.

The automatic activation of letter-speech sound (L-SS) associations is a vital step in typical reading acquisition. However, the contribution of L-SS integration during nonalphabetic native and alphabetic second language (L2) reading remains unclear. This study explored whether L-SS integration plays a similar role in a nonalphabetic language as in alphabetic languages and its contribution to L2 reading among native Japanese-speaking adults with varying English proficiency. A priming paradigm in Japanese and English was performed by presenting visual letters or symbols, followed by auditory sounds. We compared behavioral and event-related responses elicited by congruent letter-sound pairs, incongruent pairs, and baseline condition (symbol-sound pairs). The behavioral experiment revealed shorter RTs in the congruent condition for Japanese and English tasks, suggesting a facilitation effect of congruency. The ERP experiment results showed an increased early N1 response to Japanese congruent pairs compared to corresponding incongruent stimuli at the left frontotemporal electrodes. Interestingly, advanced English learners exhibited greater activities in bilateral but predominantly right-lateralized frontotemporal regions for the congruent condition within the N1 time window. Moreover, the enhancement of P2 response to congruent pairs was observed in intermediate English learners. These findings indicate that, despite deviations from native language processing, advanced speakers may successfully integrate letters and sounds during English reading, whereas intermediate learners may encounter difficulty in achieving L-SS integration when reading L2. Furthermore, our results suggest that L2 proficiency may affect the level of automaticity in L-SS integration, with the right P2 congruency effect playing a compensatory role for intermediate learners.

A Field in Transition: A Scoping Review and Thematic Network Map of Qualitative Health Research in Liver Transplantation

BACKGROUNDIn liver transplantation, qualitative methodologies can offer important insights from a range of perspectives into the meaning and impact of health experiences. This review aims to characterize the existing qualitative research in liver transplantation to understand how this work has evolved over time, its contribution to understanding clinical issues, and to conceptualize under-developed areas for future research. METHODSStudies from MEDLINE, Embase, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, and Web of Science were searched from database inception to January 2024. All English language studies focused on a liver transplant population with qualitative methodological components were included. Using VOSviewer network mapping software we constructed a visualization of the thematic networks within included studies. RESULTSOur initial search yielded 9092 studies from which 229 were included in the final review. Data extraction revealed significant increases in the publication of qualitative studies since 2015, predominantly utilizing interviews and focus groups. The thematic network map we constructed placed “social support” as a dominant and central concept across many different studies, with related themes tending to cluster within four domains of research: Care of the Organ & Patienthood; Identity, Embodiment, Adjustment; Relational & Ethical Issues; Existential Themes. Medicalized subject such as “self-management” were less well-networked with identity-related, ethical, and existential topics. DISCUSSIONThere is a growing body of rich qualitative research in liver transplantation. Future research would benefit from more longitudinal approaches as well as increased attention to the interrelation between “clinical” issues (adherence, quality of life) and ethical, relational, and existential ones.

Integrating evidence and causal mapping of help-seeking behaviour of migrant women with postpartum depression in Shanghai, China: a scoping review protocol

IntroductionThe estimated prevalence of postpartum depression (PPD) worldwide, in China, and Shanghai is 17.2%, 18.0% and 23.2%, respectively. In 2021, Shanghai housed a population of 3.2 million childbearing-age migrant women,...

Validation of a polygenic risk score for frailty in the Lothian Birth Cohort 1936 and English longitudinal study of ageing

Frailty is a complex trait. Twin studies and high-powered Genome Wide Association Studies conducted in the UK Biobank have demonstrated a strong genetic basis of frailty. The present study utilized summary statistics from a Genome Wide Association Study on the Frailty Index to create and test the predictive power of frailty polygenic risk scores (PRS) in two independent samples – the Lothian Birth Cohort 1936 (LBC1936) and the English Longitudinal Study of Ageing (ELSA) aged 67–84 years. Multiple regression models were built to test the predictive power of frailty PRS at five time points. Frailty PRS significantly predicted frailty, measured via the FI, at all-time points in LBC1936 and ELSA, explaining 2.1% (β = 0.15, 95%CI, 0.085–0.21) and 1.8% (β = 0.14, 95%CI, 0.10–0.17) of the variance, respectively, at age ~ 68/ ~ 70 years (p < 0.001). This work demonstrates that frailty PRS can predict frailty in two independent cohorts, particularly at early ages (~ 68/ ~ 70). PRS have the potential to be valuable instruments for identifying those at risk for frailty and could be important for controlling for genetic confounders in epidemiological studies.

A comparative study of English and Japanese ChatGPT responses to anaesthesia-related medical questions

PurposeThe expansion of artificial intelligence (AI) within large language models (LLMs) has the potential to streamline healthcare delivery. Despite the increased use of LLMs, disparities in their performance particularly in different languages, remain underexplored. This study examines the quality of ChatGPT responses in English and Japanese, specifically to questions related to anaesthesiology. MethodAnaesthesiologists proficient in both languages were recruited as experts in this study. Ten Frequently asked Questions (FAQs) in anaesthesia were selected and translated for evaluation. Three non-sequential responses from ChatGPT were assessed for content quality (accuracy, comprehensiveness, and safety) and communication quality (understanding, empathy/tone, and ethics) by expert evaluators. ResultEight anaesthesiologists evaluated English and Japanese LLMs responses. The overall quality for all questions combined, was higher in the English responses compared to Japanese responses. Content and communication quality were significantly higher in the English compared to Japanese LLMs responses (both p<0.001) in all three responses. Comprehensiveness, safety and understanding were higher scores in English LLMs responses. In all 3 responses, more than half of evaluators marked overall English responses were better than Japanese response. ConclusionEnglish LLMs responses to anaesthesia related FAQs were superior in quality to Japanese responses when assessed by bilingual anaesthesia experts in this report. This study highlights the potential for language-related disparities in healthcare information and the need to improve the quality of AI responses in underrepresented languages. Future studies are needed to explore these disparities in other commonly spoken languages and to compare the performance of different LLMs.

Long-term outcomes of converting fused hips to total hip arthroplasty are satisfactory: a systematic review and meta-analysis

Background: Although conversion arthroplasty of fused hips can relieve pain and provide patient satisfaction, long-term outcomes of total hip arthroplasty (THA) after hip fusion remain a subject of debate. This meta-analysis aimed to assess the effectiveness of THA for fused hips over a long period with concerns over potential complications. Methods: A systematic search of five databases from 2000 until 2023 identified English studies evaluating THA for fused hips with at least 100 months of follow-up. Meta-analyses were conducted using random-effect models via the comprehensive meta-analysis software. Sensitivity analysis, in-depth meta-regression, Egger's test, and the trim-and-fill method were performed appropriately Results: The meta-analysis assessed 790 patients and 889 hips with a mean follow-up of 11 years. At the final follow-up, the mean Harris Hip Score (HHS) and leg length discrepancy (LLD) improved by 34.755 and 2.3 cm from the baseline, respectively. Regarding survival of hip fusion conversion to THA, most studies (88.8%) reported a 5-year implant survival rate of at least 90%, and the 15-year and 20-year implant survival rates, ranged between 80–90% and 70–90%, respectively. Subjective dissatisfaction with the conversion of hip fusion to THA was only 5.3%. Composite rates of revision, instability, and aseptic loosening were 13.6%, 3.8%, and 8.8%, respectively. Conclusions: Conversion of fused hips to THA results in favourable long-term outcomes regarding HHS, LLD, survival rates, and subjective satisfaction, leading to improved quality of life in properly selected patients. However, the presence of complications should be considered when evaluating the overall success of the procedure.

Effectiveness of exercise-based sports injury prevention programmes in reducing injury rates in adolescents and their implementation in the community: a mixed-methods systematic review

ObjectiveDespite evidence supporting the efficacy of sport injury prevention programmes (SIPPs) in adolescents, implementation of SIPPs in community settings is low. This review aims to synthesise and integrate evidence on...

Short-term (1-3 months) versus standard (12 months) dual antiplatelet therapy following new-generation drug-eluting stent implantation: A meta-analysis of randomized controlled trials.

Patients undergoing percutaneous coronary intervention mainly receive antiplatelet therapy. However, limited data are available regarding the optimal dual antiplatelet therapy (DAPT) following the implantation of new-generation drug-eluting stent (DES). This study aimed to compare the clinical outcomes of short-term (1-3 months) DAPT and standard (12 months) DAPT after the implantation of a new-generation of DES. We systematically searched PubMed, The Cochrane Library Database, Embase for trials that compared short-term (1-3 months) and standard DAPT after the implantation of next-generation DES were retrieved from all published studies in English until December 31, 2021. The primary endpoint was major bleeding. The secondary endpoints included all-cause mortality, cardiac death, myocardial infarction, stroke, stent thrombosis, and all bleeding. This study included a total of 7 randomized controlled trials, comprising 28,344 subjects. Regarding primary endpoints, short-term DAPT exhibited a significantly lower incidence of major bleeding compared with standard DAPT [relative risk (RR): 0.66, 95% confidence interval (CI): (0.54, 0.81), P < .0001]. For secondary endpoints, there were significant differences between short-term and standard DAPT in all bleeding [RR: 0.59, 95% CI: (0.50, 0.69), P < .00001]. However, no significant differences were identified in all-cause mortality [RR: 0.96, 95% CI: (0.77, 1.18), P = .27], myocardial infarction [RR: 0.98, 95% CI: (0.82, 1.18), P = .86], cardiac death [RR: 0.83, 95% CI: (0.63, 1.10), P = .20], stroke [RR: 1.08, 95% CI: (0.79, 1.47), P = .63], cerebrovascular [RR: 1.08, 95% CI: (0.79, 1.47), P = .63], and stent thrombosis [RR: 1.13, 95% CI: (0.80, 1.57), P = .49] between the 2 groups. In patients undergoing implantation of a new-generation of DES, short-term (1-3 months) DAPT exhibited no inferiority compared with standard (12 months) DAPT in terms of all-cause mortality, cardiac death, myocardial infarction, stroke, and definite or probable stent thrombosis compared with standard (12 months) DAPT. However, short-term DAPT appeared superior to standard DAPT in terms of major bleeding and all bleeding.

Reviewer Acknowledgements for English Language and Literature Studies, Vol. 14, No. 2

Reviewer Acknowledgements for English Language and Literature Studies, Vol. 14, No. 2

Methods, Indicators, and End-User Involvement in the Evaluation of Digital Health Interventions for the Public: Scoping Review.

Digital health interventions (DHIs) have the potential to enable public end users, such as citizens and patients, to manage and improve their health. Although the number of available DHIs is increasing, examples of successfully established DHIs in public health systems are limited. To counteract the nonuse of DHIs, they should be comprehensively evaluated while integrating end users. Unfortunately, there is a wide variability and heterogeneity according to the approaches of evaluation, which creates a methodological challenge. This scoping review aims to provide an overview of the current established processes for evaluating DHIs, including methods, indicators, and end-user involvement. The review is not limited to a specific medical field or type of DHI but offers a holistic overview. This scoping review was conducted following the JBI methodology for scoping reviews based on the framework by Arksey & O'Malley and complies with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Three scientific databases (PubMed, Scopus, and Science Direct) were searched in April 2023. English and German studies between 2008 and 2023 were considered when evaluating DHIs that explicitly address public end users. The process of study selection was carried out by several researchers to avoid reviewer bias. The search strategy identified 9618 publications, of which 160 were included. Among these included articles, 200 evaluations were derived and analyzed. The results showed that there is neither a consensus on the methods to evaluate DHIs nor a commonly agreed definition or usage of the evaluated indicators, which results in a broad variety of evaluation practices. This aligns with observations of the existing literature. It was found that there is a lack of references to existing frameworks for the evaluation of DHIs. The majority of the included studies referred to user-centered approaches and involved end users in the evaluation process. As assistance for people developing and evaluating DHIs and as a basis for thinking about appropriate ways to evaluate DHIs, a results matrix was created where the findings were combined per DHI cluster. Additionally, general recommendations for the evaluators of DHIs were formulated. The findings of this scoping review offer a holistic overview of the variety and heterogeneity according to the approaches of evaluation of DHIs for public end users. Evaluators of these DHIs should be encouraged to reference established frameworks or measurements for justification. This would ease the transferability of the results among similar evaluation studies within the digital health sector, thereby enhancing the coherence and comparability of research in this area.

Non-pharmacological methods to reduce pain in preterm infants: A systematic review

Objective: To systematically review the literature to determine whether non-pharmacological interventions reduce preterm infants' pain during invasive procedures in the neonatal intensive care unit. Methods: A systematic search was conducted according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for conducting and reporting systematic reviews. The search was performed in PubMed and Scopus from 2013 to 2023. Only studies in English were included. Results: In total, forty-four studies were included. Kangaroo Mother Care, massage, Yakson Touch, Gentle Human Touch, music therapy, mother’s voice, white noise, maternal heartbeat sounds, facilitated tucking, sucrose administration, olfactory stimulation, the use of "Calmer," environment modification, expressed breast milk, the mother scented simulated hand, and the combination of these methods proved to be effective in reducing pain in preterm infants undergoing various medical procedures. Conclusion: Healthcare professionals should consider using non-pharmacological methods for pain relief during minor invasive procedures.

New Insights on Molecular Autopsy in Sudden Death: A Systematic Review.

Sudden unexpected deaths often remain unresolved despite forensic examination, posing challenges for pathologists. Molecular autopsy, through genetic testing, can reveal hidden causes undetectable by standard methods. This review assesses the role of molecular autopsy in clarifying SUD cases, examining its methodology, utility, and effectiveness in autopsy practice. This systematic review followed PRISMA guidelines and was registered with PROSPERO (registration number: CRD42024499832). Searches on PubMed, Scopus, and Web of Science identified English studies (2018-2023) on molecular autopsy in sudden death cases. Data from selected studies were recorded and filtered based on inclusion/exclusion criteria. Descriptive statistics analyzed the study scope, tissue usage, publication countries, and journals. A total of 1759 publications from the past 5 years were found, with 30 duplicates excluded. After detailed consideration, 1645 publications were also excluded, leaving 84 full-text articles for selection. Out of these, 37 full-text articles were chosen for analysis. Different study types were analyzed. Mutations were identified in 17 studies, totaling 47 mutations. Molecular investigations are essential when standard exams fall short in determining sudden death causes. Expertise in molecular biology is crucial due to diverse genetic conditions. Discrepancies in post-mortem protocols affect the validity of results, making standardization necessary. Multidisciplinary approaches and the analysis of different tissue types are vital.