Subjective Appraisal Research Articles

The resilience paradox: flooding experience, coping and climate change mitigation intentions

ABSTRACTClimate change is projected to increase the frequency, intensity and unpredictability of extreme weather events across the globe and these events are likely to have significant mental health implications. The mental health literature broadly characterises negative emotional reactions to extreme weather experiences as undesirable impacts on wellbeing. Yet, other research in psychology suggests that negative emotional responses to extreme weather are an important motivation for personal action on climate change. This article addresses the intersection of mental health and functional perspectives on negative emotions, with a specific focus on the potential that reduced negative emotional responses to extreme weather may also translate to diminished motivation to undertake climate change mitigation actions – which we term the ‘resilience paradox’. Using survey data gathered in the aftermath of severe flooding across the UK in winter 2013/2014, we present new evidence indicating that self-appraised coping ability moderates the link between flooding experience and negative emotions and thereby attenuates the indirect link between flooding experience and climate change mitigation intentions. We conclude that support for flood victims should extend beyond addressing emotional, physical and financial stresses to include acknowledgement of the involvement of climate change and communication of the need for action to combat future climate risks.Key policy insightsPsychological resilience to flooding and other extreme weather events can translate to diminished motivation to mitigate climate changeNegative emotional reactions need to occur at an optimal level to enable people to respond appropriately to climate risks.Flood victims’ subjective appraisal of their ability to cope does not necessarily encompass consideration of the role played by climate change. Therefore, support for victims of extreme weather should include explicit acknowledgement of the involvement of climate change and the need for action to mitigate future climate risks.

What Does “Good Adjustment” Mean for Chinese International Students? A Qualitative Investigation

In this study, we aimed to provide a rich description of Chinese graduate international students’ ways of coping with adjustment challenges and their subjective appraisal of adjustment. Nine Chinese graduate international students (six women, three men) from different institutions and disciplines reported their perceptions of the broad sociopolitical context, cultural adjustment experiences, and subjective evaluation of adjustment. We analyzed the data using consensual qualitative research method. Findings were summarized into three domains: (a) Perceived Sociopolitical Context, (b) Cultural Adjustment Challenges, and (c) Coping and Adjustment. We found frequent long-standing challenges in social and professional domains. Furthermore, interviewees reported an ongoing evaluative process where they negotiated host culture participation expectations in the context of adjustment challenges to achieve a subjective sense of satisfaction. Our findings have implications for professionals working with Chinese international students to help them mitigate internalized oppression and develop purpose and well-being.

Relationship between late objective and subjective outcomes of holistic neurorehabilitation in patients with traumatic brain injury

ABSTRACTObjective: To explore the relation between objectively measured outcomes of neurorehabilitation and subjective self-appraisal of those outcomes in patients with traumatic brain injury (TBI).Methods: Forty-five adults (34 men; age at injury, mean ± SD, 30.1 ± 10.3 years) with chronic moderate-to-severe TBI (9.7 ± 5.5 years from injury; post-traumatic amnesia, 80% over one week) from two rehabilitation centres, in two countries. The subjects have had to resume working at various levels of competence following post-acute comprehensive neuropsychologically oriented neurorehabilitation, and experienced no functionally incapacitating, medical or psychological problems, for a minimum of six months after discharge. Objective outcome measure was the level of work competence attained post-rehabilitation transposed from the descriptions of the types of work attained by each subject into a number along a 10-point scale. Subjective outcome measure was the personal evaluations by ratings in six consequences of rehabilitation (effort during rehabilitation, meaning in life, productivity, acceptance, social life and intimate relationships) along a 10-point scale.Results: The attained work competence was statistically significantly related to the subjective self-appraisal of the ability to establish intimate relationships [odds ratio (OR), 1.79; 95% confidence interval (CI), 1.20–2.68; P = .005]. Otherwise, no association between subjective ratings and the levels of work was found. Of the patients, 67% attained competitive, 22% subsidized, and 11% volunteer or sheltered work. The subjective self-rated outcomes of the patients were relatively good [median, lower quartile (Q1) - upper quartile (Q3): 8 to 9, 7 to 8 – 8 to 9 out of 10]. The lowest ratings were observed for the ability to establish intimate relationships (8, 7–8 out of 10).Conclusions: The results support the need to evaluate rehabilitation outcomes involving both objective measures and subjective appraisals of them. The findings suggest that community functioning and satisfaction with that are distinct aspects of the subjects´ experience that must be considered in the evaluation of rehabilitation. It seems that comprehensive neurorehabilitation improve outcome, and patients with TBI with tailored placements were largely satisfied with the areas of wellness in their life. Additional larger controlled studies are needed to clarify how composition of neurorehabilitation and individualization in outcomes assessment might enhance the outcome of TBI rehabilitation.

Sleep state misperception in psychiatric patients

This study assessed the phenomenon of sleep state misperception with regard to its prevalence and potential causes. For this purpose, 255 Bundeswehr soldiers who were admitted as psychiatric patients with sleep disorders were examined at the Bundeswehr Hospital of Hamburg. The symptoms of sleep state misperception are a consistently negative subjective appraisal of one’s own sleep. Objective measurements using electroencephalography (EEG), however, suggest the opposite, namely that sleep is objectively undisturbed. This discrepancy was seen in 52% of the examined patients in an assessment of eight empirical criteria for objectively healthy sleep. The results of a logistic regression analysis to determine predictors of the symptoms did not allow conclusions to be drawn about possible links between post-traumatic stress disorder (PTSD) or depressive disorders and sleep state misperception. Only the existence of substance use disorders was a significant negative predictor for suffering from sleep state misperception.

Comfort Light Environment under Natural and Combined Lighting Method of Their Characteristics Definition with Subjective Expert Appraisal Using

Light comfort in the room is characterized by the conditions of visual work, which are determined by the levels of illumination of the workplace and the saturation of the entire room with light. The related problems were solved mainly for artificial illumination. The article examines the results of research in our country and abroad by determining the criterion for the comfort of lighting rooms with artificial and natural light. It is pointed out that such studies are obviously insufficient, and suggestions are given on their development.

PMD95 - ECONOMIC EVALUATION OF STRATEGIES WITH/WITHOUT P16 FOR OPPORTUNISTIC CERVICAL CANCER SCREENING

Currently, histological evaluation of cervical biopsy tissue for CIN lesion detection relies on subjective morphological appraisal of H&E stained tissue, which could lead to incorrect diagnoses or inconclusive results. The CINtec p16 Histology test provides objective biomarker data that assists pathologists in their assessment of cervical biopsies. The aim of this study was to access the impact of introducing CINtec p16 Histology into the diagnostic algorithm compared to a scenario with H&E alone as diagnostic method in the screening strategy of HPV 16/18 co-testing genotyping & cytology with reflex to CINtec PLUS, which could deliver the best effectiveness for the opportunistic cervical cancer screenings in urban hospitals as proven by previous research. A Markov cohort model was established to simulate cervical cancer screening in 100,000 volunteer women aged from 30 to 65. The costs and effectiveness of strategies with/without p16 were calculated from the perspective of China’s healthcare system. Over the 10 years (2 screening cycles), compared with H&E alone as diagnostic method, 17.2% more CIN2 and 3.8% more CIN3 were detected with the CINtec p16 Histology test at the increased annual cost of US$35,677(2.32%). Extending to 50 years, the total cost of adding the CINtec p16 Histology test to the diagnostic testing algorithm was 0.95% higher than the current practice. There were however quality of life gains, resulting in an incremental cost effectiveness ratio (ICER) of US$ 2,563 per QALY, which sat well within the WTP threshold of China’s GDP per capita in 2017. In general, compared with H&E alone, the use of CINtec p16 Histology in conjunction with H&E as diagnostic method was very cost effective, which was recommended to be included into the cervical cancer management methods.

At what costs? Student loan debt, debt stress, and racially/ethnically diverse college students' perceived health.

There has been little research on the direct and indirect connections between student loan debt and health. The present study tested a transactional stress model (Lazarus & Folkman, 1984a) of student loan debt in which the appraisal of debt as stressful was proposed to mediate the associations between student loan debt amount and perceived health (i.e., self-rated general health, depressive symptomatology). The present study draws on a racially/ethnically diverse college student sample (N = 1,412) from the National Longitudinal Survey of Freshman (NLSF). Structural equation modeling (SEM) with robust maximum likelihood (MLR) estimation was used to test the fit of the transactional stress model and compare it with an alternative model (that is, Schachter and Singer's (1962) two factor). Multigroup analyses were conducted to test racial/ethnic differences. SEM results indicated good fit of the transactional stress model and suggested its superiority to the alternative two-factor model. Multigroup SEM analyses revealed racial/ethnic differences. Whereas for Black/African Americans, Hispanic/Latino Americans, and White Americans, appraisal of debt as stressful was linked to poorer general health and more depressive symptomatology, these associations were nonsignificant for Asian Americans. Tests of indirect effects indicated that the mediating role of debt stress was most consistently significant for Black/African Americans and Hispanic/Latino Americans compared with Asian and, to a lesser extent, White Americans. Results affirm the potential health impact of both student loan debt amount and the subjective appraisal of stress associated with student loan debt as significant stressors. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Beauty in the eye of the design reviewer: the contested nature of UK design review

ABSTRACTDesign review is an independent expert-led mechanism, employed to evaluate the design quality of proposed developments. It claims an objective and transparent approach, yet has limited guidance on how, or what, reviewers should evaluate. Few studies focus on these reviewers or their attitudes and perceptions to the process. This research, using interviews and Q-Methodology, reveals key differences in how reviewers conceptualize and evaluate design quality within review. The paper argues design review is a contested mechanism, where subjective appraisal plays out alongside more objective approaches. Four competing reviewer priorities on the process are presented: sustainability; people/public; function; and visual aesthetics.

The moderating effect of self-compassion on relationships between performance and subsequent coping and motivation

In this investigation, self-compassion was examined as a potential moderator of relationships between athletes’ subjective appraisals of performance and coping or motivational outcomes after a performance episode. Data were obtained online from competitive swimmers (N = 121, Mage = 15.53, SDage = 2.23). Significant moderation effects were observed in the prediction of post episode task-oriented coping and self-determined motivation. Self-compassion was the only significant predictor of post episode disengagement-oriented coping and trended toward being the only significant predictor of post episode externally-regulated motivation. These findings suggest that there is potential value in developing self-compassion among athletes in performance-based sport.

Mental Health Symptoms and Work-Related Stressors in Hospital Midwives and NICU Nurses: A Mixed Methods Study.

Hospital midwives and neonatal intensive care (NICU) nurses frequently encounter work-related stressors and are therefore vulnerable to developing mental health problems, such as secondary traumatic stress, burnout, anxiety, and depression. However, so far, the exact nature of these work-related stressors (traumatic vs. non-traumatic stressors) has not been investigated. This concurrent triangulation mixed methods cross-sectional study aimed to compare mental health symptoms in hospital midwives and NICU nurses, and to identify and compare work-related traumatic and non-traumatic stressors for both professional groups. 122 midwives and 91 NICU nurses of two Swiss university hospitals completed quantitative measures (Secondary Traumatic Stress Scale, STSS; Hospital Anxiety and Depression Scale, HADS; Maslach Burnout Inventory, MBI) and one qualitative question in an online survey. When controlling for socio-demographic variables, NICU nurses had a higher STSS total score and higher STSS subscales scores and less HADS anxiety subscale scores than hospital midwives. Work-related stressors were classified into five themes: “Working environment,” “Nursing/midwifery care,” “Dealing with death and dying,” “Case management” and “Others.” Forty-six (46.3%) percent of these were classified as traumatic work-related stressors. NICU nurses reported more traumatic stressors in their working environment but no other differences between professional groups regarding the total number of work-related traumatic vs. non-traumatic stressors were found. Measures, such as teaching strategies to amend the subjective appraisal of the traumatic stressors or providing time to recover in-between frequently occurring work-related traumatic stressors might not only improve the mental health of professionals but also decrease sick leave and improve the quality of patient care.

Gender Differences in the Automatic Attention to Romantic Vs Sexually Explicit Stimuli

IntroductionGender differences in sexual responses and cognitive and emotional processing to romantic and sexually explicit stimuli have been reported. However, these differences seem to depend on the automaticity of the task that is being used, thus suggesting that gender differences may be the result of specific mechanisms rather than a generalized effect. AimTo expand previous basic processes research on gender differences to romantic vs sexually explicit stimuli, focusing on potential differentiating mechanisms influencing male and female sexual responses, we aim to investigate gender differences on automatic attention to sexual stimuli, and to test its relationship with sexual excitation proneness. Methods26 women and 30 men (heterosexual) performed an automatic attention task, in which romantic and sexually explicit stimuli were presented as distractors, that is, stimuli to be ignored, while a concurrent letter discrimination task was performed, followed by a self-report task assessing subjective sexual and emotional responses to the stimuli. Main Outcome MeasuresPercentage of accuracy and response times (RTs) to discriminate the target letters were used as markers of automatic attention, with lower accuracy and longer RTs reflecting a higher degree of attentional capture by the distractor stimuli (romantic and sexually explicit). Participants completed self-report ratings on emotional valence, general arousal, and sexual arousal toward romantic and sexually explicit stimuli. They further reported on their sexual excitation proneness. ResultsFindings revealed that sexually explicit pictures yielded more automatic attention capture. However, this effect was superseded by pornography consumption, which likely reflects a habituation mechanism. Also, data revealed gender-x type of picture interaction effects only at the self-report task, with men rating sexually explicit stimuli as more sexually exciting, and women rating these stimuli as less pleasant. No relationship was found between automatic attention proxies and sexual excitation proneness. Clinical TranslationWhile therapeutic strategies are used as tools to improve attention to sexual stimuli (and, hence, increase sexual arousal), the current findings suggest that the specific pathways by which attention influences sexual response are still to be established. Also, gender differences on the subjective appraisal of sex stimuli suggest that therapeutic approaches, consisting on exposure techniques, must recognize gender specificities. Strengths & LimitationsTo our knowledge, this is the first study applying an automatic attention task to the field of sex research, thus adding new inputs to the topic of attention, gender differences, and sexual response. However, there is very limited research in the field of automatic attention, which may limit the interpretation of our findings, at the moment. ConclusionWhereas both genders do not seem to differ in automatic attention toward romantic and sexually explicit stimuli, their responses do differ in their subjective appraisal of the stimuli. Furthermore, despite theoretical assumptions on the relationship between attention and sexual response, automatic attention seemed not to be related to sexual excitation proneness. Carvalho J, Czop O, Rocha M, et al. Gender differences in the automatic attention to romantic vs sexually explicit stimuli. J Sex Med 2018;15:1083–1092.

Changes in caregiving appraisal among family caregivers of persons with dementia: A longitudinal study over 12 months

The main purpose of this study was to identify changes in both caregiver burden and positive caregiving appraisal over time, as well as factors affecting these variables. This analysis included 41 in-home family caregivers who had completed questionnaires at baseline, 6 months, and 12 months. We assessed various caregiver and care recipient characteristics, caregivers' positive appraisal of caregiving, caregiver burden, desire to continue caregiving, severity of care recipients' cognitive impairment, and behavioural and psychological symptoms of dementia. We observed no significant differences in caregiver burden, positive caregiving appraisal, or behavioural and psychological symptoms of dementia across the three measurement times. However, we did find differences in the desire to continue caregiving and in the personal strain and role strain dimensions of caregiver burden. Overall, our study suggests that caregiving service providers should consider support that focuses on improving the subjective caregiving appraisals of caregivers.

003 Effects of age on the subjective sexual response and emotional appraisal of sex pictures in women

Age is expected to influence women’s sexual functioning and behavior, not only due its impact at the organic level, but also given the strong cohort effects that shape women’s beliefs regarding sexuality and relationships. However, most of the current assumptions about the effects of age in women’s sexual response and behavior, relate to the influence of health issues on the propensity for sexual difficulties. Indeed, broader aspects such as sexual and relationship satisfaction, have only recently fallen under the scope of scientific research. Similarly, other aspects relating to the appraisal of sexual contents by older women have been completely dismissed. Accordingly, the aim of the current study was to test the effect of age on the sexual and emotional responses to sex stimuli, as well as to test the adding effects of women’s beliefs regarding sexuality, on the appraisal of these stimuli. Seventy-three heterosexual women, ranging from 18-77 years old, were exposed to a series of romantic, sexually moderate and sexually explicit pictures in a laboratorial context. Women reported on the levels of emotional valence, subjective sexual arousal, and level of sexual content attributed to the pictures in each set. Additionally, women completed a self-report questionnaire aimed at measuring women’s beliefs regarding female sexuality.

Evidential language in Internet forums

AbstractThis article analyses the function of the multiword lexemeya me dirás túas used in Internet forums. We defend the notion thatya me dirás túis a highly polyphonic discourse marker. Its function is evidential as of the moment in which the speaker uses this unit to present a subjective appraisal as a logical truth within the framework of an assertion. We therefore focus on evidentiality from not only a lexical but also a textual-discursive standpoint. Internet forums are the ideal type of text for studying a unit likeya me dirás tú, which is typically used in colloquial language.

P069: Hardened tendencies: persistence of initial appraisals following simulation-based stress training

Introduction: Stress has been shown to impair performance during acute events. The goal of this pilot study was to investigate the effects of two simulation-based training interventions and baseline demographics (gender, age) on stress responses to simulated trauma scenarios. Methods: Sixteen (16) Emergency Medicine and Surgery residents were randomly assigned to one of two groups: Stress Inoculation Training (SIT) or Crisis Resource Management (CRM). Residents served as trauma team leaders in simulated trauma scenarios pre and post intervention. CRM training focused on non-technical skills required for effective teamwork. The SIT group focused on cognitive reappraisal, breathing and mental rehearsal. Training lasted 3 hours, involving brief didactic sessions and practice scenarios with debriefing focused on either CRM or SIT. Stress responses were measured with the State Trait Anxiety Inventory (anxiety), cognitive appraisal (degree to which a person interprets a situation as a threat or challenge) and salivary cortisol levels. Results: Because the pre-intervention stress responses were different between the two groups, the results were analyzed with stepwise regression analyses. The only significant predictor of anxiety and cortisol responses were the residents appraisal responses to that scenario, explaining 31% of the variance in anxiety and cortisol. Appraisals of the post-intervention scenarios were predicted by their appraisals of the pre-intervention scenario and gender, explaining 73% of the variance. Men were more likely than women to appraise the scenarios as threatening. There were no differences in subjective anxiety, cognitive appraisal or salivary cortisol responses as a result of either intervention. Conclusion: Male residents, as well as those who appraised an initial simulated trauma scenario as threatening, were more likely to interpret a subsequent scenario as threatening, and were more likely to have larger subjective (anxiety) and physiological (cortisol) responses a subsequent scenario. Both CRM and SIT training were not effective in overcoming initial appraisals of potentially stressful events.

Effects of opioid- and non-opioid analgesics on responses to psychosocial stress in humans

Both preclinical and clinical evidence suggests that the endogenous opioid system is involved in responses to stress. For example, in animal models opioid agonists reduce isolation distress whereas opioid antagonists increase isolation distress. We recently reported that the mixed mu agonist and kappa antagonist buprenorphine dampened responses to acute psychosocial stress in humans. Now we extend this to study the effects of a pure mu-opioid agonist, hydromorphone, and a non-opioid analgesic, acetaminophen, on response to social stress. We compared the effect of hydromorphone (2 and 4 mg), acetaminophen (1000 mg) to a placebo using a between subject design. Healthy adult volunteers were randomly assigned to receive placebo (N = 13), 2 mg hydromorphone (N = 12), 4 mg hydromorphone (N = 12), or 1000 mg acetaminophen (paracetamol; N = 13) under double-blind conditions before undergoing a stress task or a control task on two separate sessions. The stress task, consisting of a standardized speaking task and the non-stressful control task were presented in counterbalanced order. Dependent measures included mood ratings, subjective appraisal of the stress (or no-stress) task, salivary cortisol, pupil diameter, heart rate, and blood pressure. The stress task produced its expected increase in heart rate, blood pressure, salivary cortisol, pupil diameter, and subjective ratings of anxiety and negative mood. Hydromorphone dose-dependently dampened cortisol responses to stress, and decreased ratings of how “challenging” participants found the task. Acetaminophen did not affect physiological responses, but, like hydromorphone, decreased ratings of how “challenging” the task was. The hydromorphone results support the idea that the mu-opioid system is involved in physiological responses to acute stress in humans, in line with results from preclinical studies. The non-opioid analgesic acetaminophen did not dampen physiological responses, but did reduce some components of psychological stress. It remains to be determined how both opioid and non-opioid systems mediate the complex physiological and psychological responses to social stress.

Psychospołeczne uwarunkowania oceny znaczenia własnej choroby przez osoby przewlekle chore

The literature on the subject identifies chronic disease as a stressor which imposes new adaptive tasks on patients and requires them to change their lifestyle. Therefore, the issues of disease assessment and adaptation to illness, based on individual knowledge of the disease and subjective appraisal of its influence on day-to-day functioning, are becoming increasingly important. In the present article, the appraisal of disease significance is to be understood as a dynamic effect of subjective assessment of one’s own life situation due to chronic disease. The aim of the analysis was validation of the relationship between the basic sociodemographic factors and the appraisal of the significance of a chronic disease among patients with RRMS and diabetes type 2, as well as verification whether these two diseases show any differences in terms of appraisal of their significance in opinion of the patients. In order to verify the hypotheses, The Disease-Related Appraisals Scale, and original scorecard designed to obtain sociodemographic data were used. The analysis was conducted on 118 patients with RRMS and 61 patients with diabetes type 2. The results show a statistically significant relationship between education level and the appraisal of disease significance considered as benefit and injustice among the two groups of patients. Additionally, in the group of patients with diabetes type 2, the aforementioned relationship was also found for appraisal of disease significance considered as a threat. Moreover, it was found that the analysed groups show significant differences in terms of recognition of the disease as an obstacle/loss. Diagnostic assessment of disease significance sets the direction and methods of therapeutic intervention provided, with the primary aim of improving the quality of life of patients suffering from a chronic disease.

A Pilot Study of Metacognitive Training (D-MCT) for Older Adults with Depression

Abstract. Depression remains one of the most common psychological disorders among older adults. Their response to antidepressants: however, is often unsatisfactory, and despite the proven efficacy of psychotherapies, a large treatment gap remains. Metacognitive Training for Depression (D-MCT) is a low-threshold group intervention. This article examines the feasibility, acceptance, and effects of D-MCT as an add-on intervention among a group of older adults (55+ years; N = 116). Participants completed measures of depression and dysfunctional attitudes, and provided subjective appraisals of the training. Per protocol analyses (n = 55) revealed a significant decrease in depressive symptoms (d = 1.06) and cognitive biases (d = 0.33). The findings demonstrate the feasibility and acceptance of D-MCT among older adults with depression.

Patients’ Perspectives on Treatment with Metacognitive Training for OCD

Abstract. There is much room for improvement in the treatment of obsessive-compulsive disorder (OCD). The current study introduces a newly developed version of Metacognitive Training for OCD (MCT-OCD), inspired by the self-help intervention myMCT as well as by MCT group programs for other disorders. The current study examines the acceptability of the training. Forty-four patients with OCD received four sessions of MCT-OCD in addition to inpatient treatment. At post assessment, patients provided a subjective appraisal of the training. Analyses revealed high acceptability and added value of the MCT-OCD. The current, preliminary version of the MCT-OCD is promising in terms of patient acceptance. Results will be used to improve current shortcomings of the training and to develop a more comprehensive MCT-OCD.

Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity.

Even when clubfoot deformity is treated in a timely manner, the consequences observed in adulthood include hypoplasia of the calf muscles, gait impairment, decreases in foot size, and it can also affect the tibial length. These consequences may have negative impacts on the patient's subjective appraisal of long-term outcomes, and can influence the patient's self-esteem in both male and female patients. We present our experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. In total, 72 patients underwent corrective surgery in order to improve undeveloped calves resulting from a congenital clubfoot deformity. We used calf silicone implants in combination with fat grafting in multistaged procedures, in order to decrease complication rates and improve aesthetic outcome. Amongst our patients there were 54 (75%) females and 18 (25%) males. All of the patients, except one, had unilateral calf hypoplasia. The procedures were divided into several groups: (1) medial calf augmentation with silicone implants; (2) medial calf augmentation with silicone implants and fat grafting; and (3) medial and lateral calf augmentation with silicone implants and fat grafting. We had one case of a hyperpigmented scar and one case of partial scar dehiscence. There were no cases of compartment syndrome. The average follow-up period was 9.8 months. Calf enhancement surgery in patients with congenital clubfoot deformity is very gratifying. When combining calf implants with fat grafting in multistaged procedures, we can achieve excellent results with low complication rates.