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Background Graft versus host disease (GVHD) most often occurs 100-365 days after hematopoietic stem cell transplant (HSCT). Manifestations most often are dermatologic, hepatic or pulmonic, and are rarely cardiac. We present a unique case of GVHD inducing cardiogenic shock necessitating advanced heart failure therapies. Case This is a 34 year-old male with a history of acute lymphoblastic leukemia who completed chemoradiation and HSCT from an HLA perfect sibling in 1992. In May 2020, he presented with dyspnea for 6 weeks. An echocardiogram at that time showed an EF of 10% and severe biventricular dilatation. He was originally hospitalized at an outside institution for hypoxia where a left heart catheterization showed normal coronaries and goal directed therapy was initiated. After 2 negative COVID tests, he was discharged with a LifeVest. One month later, despite medication compliance, he returned in cardiogenic shock after his LifeVest was activated for ventricular tachycardia (VT). Decision-making He was started on inotropic therapy and an intra-aortic balloon pump (IABP) was placed 1:1 prior to transfer to our tertiary center. After support was started, a right heart catheterization showed a right atrial pressure of 13 mmHg, a wedge of 17, and a cardiac index of 2.6. His course was complicated by VT storm. Differentials for his non-ischemic cardiomyopathy (NICMO) included myocarditis (viral vs. giant cell) with a possible component of chemotherapy/radiation induced NICMO. Immediate AHFT work-up was started. He was unable to be weaned off his IABP or inotropic support. The decision was made to pursue emergent left ventricular assist device placement (LVAD) and achieve a definitive diagnosis with a core biopsy. Pathology resulted with myocyte hypertrophy, chronic inflammation with eosinophils concerning for chronic GVHD. Conclusion There have only been a handful of case reports describing cardiac manifestations of GVHD, and none with NICMO and cardiogenic shock requiring an LVAD. Despite this, suspicion should remain present for GVHD in HSCT patients regardless of time frame from oncologic therapies or specificity of HLA match when presenting in cardiogenic shock.Copyright © 2023 American College of Cardiology Foundation
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Donor specific antibodies (DSA) are known to be associated with increased mortality following heart transplant (HT). Despite the high overall burden of disease from novel coronavirus (COVID-19) among HT recipients, little is known about the subsequent development of de novo or increased DSA (diDSA) in COVID-19 survivors. We performed a retrospective analysis at 8 large centers of HT recipients diagnosed with COVID-19 between 3/1/2020 and 3/31/2021. Acting on anecdotal reports, we began checking DSA approximately 3, 6, and 12 months after acute COVID-19 as standard of care. Incidence of diDSA, defined as an increase in MFI by >2500, was determined. Treatment of acute cellular rejection (ACR) and antibody mediated rejection was recorded. Of 380 HT patients who developed COVID-19, 191 (70% male) had DSA data available by study end-date. A total of 5% developed diDSA by 3 months (11/191), 10% by 6 months (17/172) and 18% by 12 months (24/131). The median time for development of diDSA was 144 days. Patients with pre-existing DSA had a significantly increased incidence of diDSA compared to those without pre-existing DSA (15/32 vs 9/159, p<0.001). There was no difference in diDSA between patients who had immunosuppression reduced during acute COVID-19 and those who did not (6/47 vs 17/107, p=0.890). Compared to those without diDSA, there was a significant increase in the incidence of ACR (ISHLT grade ≥2R) in the year following infection in those with diDSA (3/165 vs 4/24, p=0.006). This study demonstrates a high incidence of diDSA (18%) at 12 months among HT recipients after COVID-19. In addition, diDSA was more common among those with pre-existing DSA, and diDSA was associated with higher incidence of ACR. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
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The whole world is going through a revolutionary change but this time it is not because of changes in technology or government policies. The entire world has changed in order to adapt to the unwarranted pandemic situation created by COVID-19 virus. The economic growth is negative across the world and the Indian economy is no exception. The worst affected is the micro, small and medium scale sector of India, which faced some major challenges. The paper explores the problems these MSMEs (Micro, Small & Medium scale Enterprises) faced during this pandemic and the crisis management that the government can do for the revival of this sector. The paper analyses the government reforms and the changes that Indian MSMEs need to bring to survive such hard times.
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P157 Figure 1DiscussionOf those who attended, the LTBI rate was 20%, highlighting the importance of targeted population screening. Early identification prevents some cases developing active TB. 7 active TB cases were identified early, with improved patient outcomes and reduced contacts. Limitations are the poor uptake, partly due the COVID-19 pandemic (service suspension). Barriers include language (non-English speakers);lack of understanding about latent TB;stigma associated with TB;financial constraints;and temporary accommodation of this population, hence difficulty arranging appointments. Leaflets in different languages and work with community and religious leaders would help to raise awareness.ReferencesTuberculosis in England 2021 report – UK Health Security Agencyhttps://www.england.nhs.uk/tuberculosis-programme/area-for-action-8-national-latent-tb-infection-testing-and-treatment-programme/
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In 2015, a resolution known as Agenda 2030 was passed by United Nations General Assembly in which seventeen goals for Sustainable Development were laid down for global dignity, peace and prosperity. The post- pandemic era became full of uncertainties in pursuing those Sustainable Development Goals (SDGs) and its implementation became a challenge especially for the developing economies like India. The country is facing a tremendous gap in arranging for resources to meet the climatic changes and attaining the SDGs. India requires 170 billion dollars per year from 2015-2030 to fulfill the Sustainable Development Goals as per the estimation done by National Determined Contribution, a body setup after Paris agreement 2015 to monitor the efforts of the country towards reducing national emissions and adapting to climate change. There is a huge concern amongst the various agencies on exploring the ways to fill this financing gap especially after the economic slowdown seen in the post pandemic era. This research paper analyses the challenges imposed by the COVID 19 pandemic on financing for SDGs and also explores the options to mitigate them. The articles and research papers related to SDG financing are reviewed by the researchers to arrive at the above mentioned statements. This paper is an attempt to draw the attention of worldwide authorities towards this grim situation as sustainable finance is far from reality in India and requires immediate up scaling. © The Electrochemical Society
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A novel coronavirus commonly known as COVID-19 has resulted in an ongoing outbreak of viral pneumonia. This pandemic started from Wuhan City, China and has spread throughout most parts of the world (210 countries). COVID-19 is a large sized, enveloped, positive stranded RNA virus. Out of the four known genera, alpha and beta corona viruses are the most commonly recognized viruses infecting human beings. COVID-19 is a new virus that is highly contagious. It spreads through infected persons in its prodromal stage which suggest its transmission is not likely through air. COVID-19 can affect people of all age groups and mostly results in the death of people with weak immune systems. Its most common reported symptoms are fever, fatigue, dry cough, lymphopenia, raised levels of lactate de-hydrogenase and, bilateral patchy shadows or ground glass opacity in the lungs (opacities may be mild damage of one lobe or all five lobes). This virus has the potential to affect pregnant women, however, its prevalence was not noticed in new-borns. Time to recovery is generally two weeks. To reduce the spread of COVID-19, observing hygienic practices like frequent hand washing, social distancing and drinking warm water and chloroquine phosphate are some of the measures to mitigate the effect of cronavirus. Copyright 2022 by the authors.
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Background. We conducted a follow up study on patients previously diagnosed with COVID-19 one year ago in an urban community in Paterson, New Jersey. The purpose of the study was to evaluate the socioeconomic impact of COVID-19 as well as assess for receptiveness towards COVID-19 vaccination amongst various ethnic groups. Methods. This was a prospective cohort study consisting of patients who had COVID-19 in the months of March and April of 2020. This was a single institutional study conducted at St. Joseph's Hospital in Paterson, NJ from March to April of 2021. Patients included were either male or female aged 18 years or older. Patients were contacted by telephone to participate to completed the survey. Chi-square testing and multivariable logistic regression analysis were utilized for statistical analysis. Results. Of the 170 patients enrolled in the study, the most common ethnicity was Hispanic (79/170 [46.47%]), followed by African American (46/170 [27.05%]). 83 patients were male (83/170 [48.82%]). Caucasians were the most willing to receive a COVID-19 vaccine (28/30 [93.3%]), followed by Asians (13/14 [92.8%]), Hispanics (63/78 [80.7%]) and African Americans (29/46 [63.0%]). Hispanics had the highest rate of job loss (31/79 [39.24%]), followed by African Americans (16/46 [34.7%]). Hispanics were found to be in the most financial distress (31/79 [39.2%]), followed by African Americans (17/46 [36.9%]). Hispanics and African Americans were more likely to refuse COVID-19 vaccination (p: 0.02). Hispanics were more likely to lose their jobs compared to Caucasians (odds ratio,4.456;95% CI, 1.387 to 14.312;p: 0.0121). African Americans were also more likely to lose their jobs when compared to Caucasians (odds ratio, 4.465;95% CI, 1.266 to 15.747;p: 0.0200). Conclusion. Hispanics reported the most financial distress and with nearly 40% losing their jobs, the highest in our study group. 37% of African Americans experienced job loss and financial distress following their diagnosis with COVID-19. Only 63% of African Americans and 80.7% of Hispanics were willing to get vaccinated, mostly due to lack of trust in the vaccine. Statistical analysis showed Hispanics and African Americans were more likely to lose their jobs and refuse COVID-19 vaccination following diagnosis with COVID-19.
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: Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses which belong to family Coronaviridae. These viruses are responsible for mild to severe respiratory ailments such as common cold to SARS, MERS and COVID-19. Pandemic COVID-19 is an ongoing issue of 2020. It starts from Wuhan city of China that later extended to the whole world (203 countries). However, according to another report of World Health Organization (WHO) the virus may start from some other part of the world rather than Wuhan city of China. The major structural components of COVID-19 are spike, envelope and nucleocapsid proteins. It enters the cell via cellular receptors angiotensin-converting enzyme 2 (ACE-2). Its symptoms are high fever, dry cough, fatigue, dyspnea, tiredness, headache, body-aches, pneumonia, and difficult breathing. Its man to man transmission is extraordinarily high and has ability to infect all age groups however, morbidity cases are noticed higher in elderly group of people. It can be transferred by the carriers via cough, sneeze or when they touched the surfaces or any object. It is concluded that there are more chances for the spread of disease in casual and workplaces. To control pandemic COVID-19 there is need to spread awareness about its structure, way of transmission and prevention. The present review discusses structure, mechanism of action, incubation period, most affected age groups, symptoms, transmission, and precautions to stop its progress.
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Many patients diagnosed with COVID-19 develop a post-viral syndrome commonly known as Long COVID-19. Long COVID is described as when a patient experiences persistent symptoms for more than 12 weeks after their initial infection. Recent studies have shown that patients may experience long covid for as many as 6 months after initial infection. We conducted a follow up study on patients diagnosed with COVID-19 one year ago at one of the worst affected tertiary hospitals in the state of New Jersey. METHODS: This was a prospective cohort study consisting of patients with a confirmed positive COVID-19 test by PCR in the months of March and April of 2020 in the St. Joseph’s University Hospital network. Individuals who were either admitted to the hospital or tested positive in the outpatient setting with Sars- CoV2 were included in the study. Patients under 18 years of age or those with cognitive impairment or inability to complete the survey were excluded. Informed consent was taken over the telephone. The participants completed a comprehensive questionnaire including sociodemographic information and a review of systems to evaluate for persistent symptoms they have experienced over the past year directly due to COVID-19. All patient identifying information was de-identified in compliance with HIPAA rules and regulations. RESULTS: There were 91 inpatients ( 91/173 [52.6%]) and 82 outpatients (82/173 [47.4%]) with a mean age of 51.5. The most common ethnicities were Hispanic (80/173 [46.24%]) African American (48/173 [27.74%]), Caucasian (32/173 [18.49%]) and the most common comorbidities were hypertension (68/173 [39.5%]), obesity (45/173 [26.9%]) and diabetes (33/173 [19.1%]). There were 91 inpatients ( 91/173 [52.6%]) and 82 outpatients (82/173 [47.4%]), of which 85 were male (85/173 [49.42%]). Overall 83 patients (47.9%) still experienced at least one persistent symptom after initial infection. The most commonly reported symptoms were shortness of breath (44/173 [25.4%]), fatigue (43/173 [21%]), anxiety (36/173 [20.8%]), difficulty focusing/brain fog (32/173 [18.5%]), body aches (32/173 [18.5%]), headaches (29/173 [16.8%]), memory loss (25/173 [14.5%]), cough (23/173 [13.3%]), depression (22/173 [12.7%]), chest pain (19/173 [11%]), palpitations (15/173 [8.7%]), lightheadedness (15/173 [8.7%]), runny nose (12/173 [6.9%]) and loss of taste (11/173 [6.4%]). CONCLUSIONS: In our patient population nearly half of all patients (47.9%) still experienced at least one symptom 12 months after their initial infection. In both patient populations the most common persistent symptoms were shortness of breath, fatigue, anxiety and difficulty focusing/brain fog. The risk factors and pathophysiology of long covid remain unknown, highlighting the importance of further research into the topics. CLINICAL IMPLICATIONS: Nearly half of our patient population still experienced at least one symptom from their COVID-19 infection after one year. This further suggests that infection with COVID-19 may carry a risk of developing long term and possibly permanent sequelae from the virus. As more patients continue to be infected with COVID-19 and subsequently develop long covid, a public health crisis may be looming in the future. This highlights the need for continued public education on COVID-19 as well as the critical importance of widespread vaccination across the world to end the pandemic. DISCLOSURES: No relevant relationships by Polina Aron, source=Web Response No relevant relationships by Hamdallah Ashkar, source=Web Response No relevant relationships by Sohail Chaudhry, source=Web Response No relevant relationships by Arslan Chaudhry, source=Web Response No relevant relationships by Beenish Faheem, source=Web Response No relevant relationships by Alisa Farokhian, source=Web Response No relevant relationships by George Horani, source=Web Response No relevant relationships by Humberto Jimenez, source=Web Response No relevant relationships by Christina Kmiecik, source=Web Response No relevant relationships by Patrick Michael, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Spandana Narvaneni, source=Web Response No relevant relationships by Sherif Roman, source=Web Response No relevant relationships by Fady Shafeek, source=Web Response No relevant relationships by Yezin Shamoon, source=Web Response No relevant relationships by Jin Suh, source=Web Response
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Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods. Background: The COVID-19 pandemic led to widespread repercussions on the delivery of health care worldwide. Design/Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by ICD-10 codes and/or classifications in stroke center databases. Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI,-11.7 to-11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI,-13.8 to-12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI,-13.7 to-10.3, p=0.001). There were greater declines in primary compared to comprehensive stroke centers (CSC) for stroke hospitalizations (-17.3% vs-10.3%, p<0.0001) and IVT (-15.5% vs-12.6%, p=0.0001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) months of the pandemic, with greater recovery in hospitals with lower COVID-19 hospitalization volume, high volume stroke center, and CSC. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months, with greater recovery in hospitals with lower COVID-19 hospitalizations, high volume stroke centers, and CSCs.
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The prevailing pandemic (COVID-19) has increased socioeconomic problems and caused psychological distress due to work uncertainty, specifically in emerging economies. Small and medium enterprises (SMEs) in emerging economies have been severely affected. Particularly, work uncertainty is becoming a hindrance towards proactive work behaviour (PWB) that can be improved by an effective entrepreneurial leadership role and proactive personality attribute. Based on fortifying self-determination theory, this research answered the question to what extent proactive personality moderates the relationship between work uncertainty and PWB and strengthens the relationship between entrepreneurial leadership and PWB. To empirically examine the study’s underlying theoretical framework, respondents were selected from SMEs working in Pakistan from the high-tech industry. Multisource data were accumulated from 420 workers and their leaders utilizing a two-wave, time-lagged research design. Conclusions revealed that entrepreneurial leadership first reduced individuals’ work uncertainty, which in turn, led to enhanced proactive work behaviour of employees. Furthermore, the results revealed that work uncertainty mediates the relationship between entrepreneurial leadership and proactive work behaviour. Moreover, proactive personality moderates the link concerning work uncertainty and proactive work behaviour, such that this association is significant only when proactive personality is low. Additionally, the moderated mediation analysis indicated that less proactive people, compared with their extraordinarily proactive colleagues, trusted entrepreneurial leadership to be more proactive in the workplace. These findings have important implications to induce PWB among employees. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
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Purpose: Guided by resource-based theory, this investigation examines the extent to which knowledge sharing as part of interfirm collaboration serves as a performance-enhancing strategy;that is, in the context of assisting ethnic minority-owned urban restaurants to survive during a major market disruption. Specifically, the study features owner-managers' perceptions concerning the evolving environmental circumstances associated with the novel coronavirus (COVID-19) pandemic. Design/methodology/approach: Data collection took place among owner-managers of urban restaurants in a Canadian city during the COVID-19 pandemic in late 2020. This featured semi-structured interviews with restaurants' owner-managers originating from various ethnic origins together with secondary data where possible. Data analysis followed an adapted Gioia approach. Findings: Examples of interfirm collaboration include restaurants' owner-managers leveraging social capital and sharing knowledge about the effects of legislation and health guidelines on operating procedures, together with good and bad practices where firms have pivoted their business models via take-outs, patio dining and in-room dining. Irrespective of the strength of network ties (within and across ethnic communities), owner-managers were motivated to share information to facilitate their survival. Nevertheless, this study raises questions over the extent that certain decision-makers exhibit strategic flexibility responding to environmental conditions together with their respective ability to engage/retain customers plus service-oriented employees. In addition, a question is whether some owner-managers will continue to collaborate with their competitors after COVID-19 ends, and if so, with whom and the magnitude of activities. In particular, “trust” via psychological contracts and “complementary strategies” among partners across coethnic and different ethnic origins are key considerations. Originality/value: A body of knowledge exists addressing the notions of both interfirm collaboration and market disruptions in the broader cross-disciplinary literature. However, the interfirm collaborative practices of small firms with ethnic minority ownership that are otherwise rivals remain under-researched. More specifically, interfirm collaboration as a survival strategy for owner-managers during the market disruption arising from a crisis situation features as an original contribution. © 2021, Emerald Publishing Limited.
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Information and Communications Technology (ICT) has revolutionized the healthcare leading to provision of eHealth facilities remotely. During the peak time of COVID-19, as the long queues at health care facilities can result in spread of the virus. ICT can play an effective role especially for reducing the extended waiting time of patients to consult a medical practitioner which is considered as a source of hazard during the pandemic. However, in developing countries where majority population is semiliterate so find difficulty when come into contact with appointment systems which are not particularly designed keeping in consideration the requirements of semiliterate users. It is extremely important to better understand how to design user interface which allow semiliterate users to effectively perform the tasks. So there is a dire need to develop a simple, effective, easy to learn user interface (UI) of an online appointment system for the productive doctor-patient consultation. Therefore, this study aimed to providing an effective user interface of web based online appointment system to semi-literate users through User-Centered Design (UCD) methodology. To achieve this, a prototype was designed to overcome issues in the existing appointment systems gathered through a field study. The needs and expectation for semiliterate users were fulfilled by incorporating the requirements of UI development for the target users. A sample of forty-two semiliterate users was used to evaluate the prototype. The evaluation results showed that semiliterate users’ performance measured using— effectiveness, efficiency and satisfaction significantly improved while interacting with the prototype as compared to existing interfaces. The effectiveness is measured through number of errors and tasks accomplished in UI, efficiency by the time required to complete the task and satisfaction by System Usability Scale (SUS). The SUS score improved from 50.8 to 77.6 for the prototype. © 2021, Tech Science Press. All rights reserved.
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Aim: To detect the early HRCT chest findings and clinical course in patients diagnosed as COVID-19 positive but are asymptomatic. Study design: A prospective study. Setting: All the confirmed COVID-19 patients encountered at Sir Ganga Ram Hospital Lahore corona desk, from 1st April 2020 to 30th April 2020 were studied in this survey. Methods: In our survey, we selected those asymptomatic patients who had positive contact history, diagnosed as COVID-19 positive by RT-PCR. Characteristic CT findings of each enrolled patient were collected and then interpreted. Results: 53 asymptomatic exposed patients with COVID-19 lung disease were enrolled and underwent HRCT Chest. All patients who had a contact history of COVID-19 patients were tested positive by RT-PCR. These patients had a history of contact with COVID-19 patients. 58.49% of patients had normal HRCT Chest while 41.5% patients had abnormal CT findings. The predominant feature on HRCT Chest was GGO in (100%) with peripheral distribution (72.2%), diffuse (27.27%), unilateral distribution (45.4%), and bilateral distribution (54.5%). After a short-term follow-up, 20 patients (37.7%) developed symptoms mainly including fever, SOB, cough, and lethargy. Follow-up HRCT showed progression of disease in (9.09%) patients. Conclusion: HRCT chest of patients having COVID-19 pneumonia that are asymptomatic has specific characteristics. As asymptomatic patients are silent carriers and some patients can worsen in a very short period. It is important to consider the importance of the detection and surveillance regarding asymptomatic patients having COVID-19. HRCT chest also has great value in screening and diagnosing patients with COVID-19 pneumonia, specifically in those who have a high suspicion, asymptomatic patients with negative PCR. © 2021 Lahore Medical And Dental College. All rights reserved.
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Background/Objective: To evaluate the impact of the COVID-19 pandemic on hospital admissions and outcomes in patients admitted with acute ischemic stroke. Methods: Single-center retrospective analysis of patients admitted to the hospital with acute ischemic stroke, between December 1st, 2019 and June 30th, 2020. Outcomes were classified as none-to-minimal disability, moderate-to-severe disability, and death based on discharge disposition, and compared between two time periods: pre-COVID-19 era (December 1st, 2019 to March 11th, 2020) and COVID19 era (March 12th to June 30th, 2020). We also performed a comparative trend analysis for the equivalent period between 2019 and 2020. Results: Five hundred and seventy-five patients with a mean age (years +/- SD) of 68 +/- 16 were admitted from December 1st, 2019 to June 30th, 2020, with a clinical diagnosis of acute ischemic stroke. Of these, 255 (44.3%) patients were admitted during the COVID-19 era. We observed a 22.1% and 39.5% decline in admission for acute ischemic stroke in April and May 2020, respectively. A significantly higher percentage of patients with acute ischemic stroke received intravenous thrombolysis during the COVID-1 9 era (p = 0.020). In patients with confirmed COVID-19, we found a higher percentage of older men with preexisting comorbidities such as hyperlipidemia, coronary artery disease, and diabetes mellitus but a lower rate of atrial fibrillation. In addition, we found a treatment delay in both intravenous thrombolysis (median 94.5 min versus 38 min) and mechanical thrombectomy (median 244 min versus 86 min) in patients with confirmed COVID-19 infection. There were no differences in patients' disposition including home, short-term, and long-term facility (p = 0.60). Conclusions: We observed a reduction of hospital admissions in acute ischemic strokes and some delay in reperfusion therapy during the COVID-1 9 pandemic. Prospective studies and a larger dataset analysis are warranted.