Photostability of sennosides and their aglycones in solution.

INTRODUCTION: Sennosides are the main active constituents of the dried leaves and/or pods of Senna alexandrina Mill. that are used as laxatives. A hypothesis is that aglycones are formed during the degradation of sennosides. However, it is unknown, whether this happens under visible light exposure and how photosensitive sennosides behave in solution. OBJECTIVES: Pure anthraquinone glycosides were tested on their behaviour during sample preparation in the lab under visible light exposure in dependence on the instability of the solvent. MATERIALS AND METHODS: Samples before and after exposure were analysed using UHPLC with UV/Vis and MS detection. RESULTS: Under visible light protection, the solutions were stable for 14 days at room temperature whereas a loss of 20%-60% was measured after 1 day of light exposure. The loss of sennosides due to degradation can be as fast as up to 2%-2.5% per hour, which might have a tremendous impact on phytochemical analysis results during the course of an analysis. The formation of aglycones was not observed in the degradation of sennosides and rhein-8-O-glucoside. CONCLUSION: Aglycones could not be found as a result of the forced degradation. The solutions of sennosides clearly need to be protected from light to obtain reliable analytical results, and light protection is a major point for the stability of liquid preparations.

How has COVID-19 changed healthcare professionals' attitudes to self-care? A mixed methods research study.

BACKGROUND: The COVID-19 pandemic fundamentally changed the way services are delivered. Self-care, including good hygiene practices and avoidance of risk was emphasised as the key measure to tackle the pandemic in the early stages. OBJECTIVE: To understand how self-reported professional attitudes, perceptions and practices of self-care have changed as a result of the COVID-19 pandemic. DESIGN: Cross-sectional online survey and semi-structured qualitative interview. SETTING: Health care. PARTICIPANTS: 304 healthcare professionals (HCPs). METHODS: A wide range of HCPs, including pharmacists, nurses, doctors, social prescribers and other designations took part in a 27-item anonymous online survey. Semi-structured qualitative interviews with nine healthcare professionals explored attitudes to and practices of self-care before and during the pandemic. Views were sought on the permanence and implications of changes. Data were analysed using routine statistics and thematic analysis to identify major themes. RESULTS: A total of 304 HCPs responded to the survey fully. Nine participated in a semi-structured interview. There was agreement that the importance of self-care has increased markedly during the pandemic. The percentage of respondents who felt that self-care was 'very' important to their clients increased from 54.3% to 86.6% since the pandemic. Personal empowerment and capacity of service users to self-care increased significantly during the pandemic. Willingness of patients to engage (74%) and poor understanding of self-care (71%) were cited as the two main barriers to self-care. A close third was digital exclusion (71%), though 86% of respondents recommended online resources and 77% the use of smartphone apps. Survey respondents believed the changes to be permanent and positive. Interviewees reported a major, and positive move to self-care with the pandemic seen as an opportunity to be grasped, but professional education would have to be aligned to make the most of it. They raised concerns as to whether the shift to self-care was perceived by users as 'abandonment' rather than 'empowerment' and whether problems had been stored rather than dealt with through self-care and therefore whether the positive changes would continue after the pandemic. CONCLUSION: Reporting their views before the pandemic, barely more than half of the professionals surveyed saw self-care as fundamentally important to the individuals they served. This changed to 86% as a result of the pandemic. Patient/client engagement with and understanding of self-care were reported as major barriers, as was digital exclusion, though increased technological solutions were used by all respondents. Concerns were raised that the permanence of the changes depended upon continued encouragement and empowerment of individuals to self-care and on its inclusion in professional education as a substantive subject.

Effect of cognitive-behavioral techniques for problem gambling and gambling disorder: A systematic review and meta-analysis.

AIMS: To measure the effect of cognitive-behavioral techniques (CBTs) on gambling disorder severity and gambling behavior at post-treatment and follow-up. METHOD: Seven databases and two clinical trial registries were searched to identify peer-reviewed studies and unpublished studies of randomized controlled trials. The Cochrane Risk of Bias tool assessed risk of bias in the included studies. A random effect meta-analysis with robust variance estimation was conducted to measure the effect of CBTs relative to minimally treated or no treatment control groups. RESULTS: Twenty-nine studies representing 3991 participants were identified. CBTs significantly reduced gambling disorder severity (g = -1.14, 95% CI = -1.68, -0.60, 95% prediction interval [PI] = -2.97, 0.69), gambling frequency (g = -0.54, 95% CI = -0.80, -0.27, 95% PI = -1.48, 0.40) and gambling intensity (g = -0.32, 95% CI = -0.51, -0.13, 95% PI = -0.76, 0.12) at post-treatment relative to control. CBTs had no significant effect on follow-up outcomes. Analyses supported the presence of publication bias and high heterogeneity in effect size estimates. CONCLUSIONS: Cognitive-behavioral techniques are a promising treatment for reducing gambling disorder and gambling behavior; however, the effect of cognitive-behavioral techniques on gambling disorder severity and gambling frequency and intensity at post-treatment is overestimated, and cognitive-behavioral techniques may not be reliably efficacious for all individuals seeking treatment for problem gambling and gambling disorder.

Use of a sequential multiple assignment randomized trial to test contingency management and an integrated behavioral economic and mindfulness intervention for buprenorphine-naloxone medication adherence for opioid use disorder.

BACKGROUND: Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment. METHODS: The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization. CONCLUSIONS: This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04080180.

Effects of cognitive behavioral techniques for gambling on recovery defined by gambling, psychological functioning, and quality of life: A systematic review and meta-analysis.

OBJECTIVE: Individuals who experience gambling harms report that sustained recovery involves changing both gambling behaviors and psychological symptoms, as well as building a meaningful life. However, there is limited understanding about the effect of cognitive behavioral (CB) techniques on psychological symptoms and quality of life. The purpose of the present study was to examine the effect of CB techniques for gambling-related harms on broader recovery outcomes such as psychological symptoms and quality of life. METHOD: A systematic article search was conducted to identify randomized controlled trials of CB techniques with nonactive and minimal treatment control groups that assessed psychological symptoms or quality of life as outcomes. Random-effects meta-analysis was used to examine the effect of CB techniques relative to nonactive and minimal treatment control groups. RESULTS: A total of nine studies representing 658 participants were included. Eight studies reported outcomes on depression and anxiety, three on substance use, and six on quality of life. CB techniques significantly reduced anxiety (g = -0.44) and depression (g = -0.35) at posttreatment, but not substance use. CB techniques also significantly increased quality of life at posttreatment (g = 0.40). There was a large amount of heterogeneity suggesting the magnitude of effects could vary significantly in future randomized trials. CONCLUSIONS: Future studies should examine the longitudinal associations between gambling harms, psychological symptoms, and quality of life and to assess whether changes in gambling harms throughout treatment precede or are a consequence of changes in psychological symptoms and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clinical outcomes of ankle fractures in sub-Saharan Africa: a systematic review.

PURPOSE: Ankle fractures may cause disability and socioeconomic challenges, even when managed in a high-resource setting. The outcomes of ankle fractures in sub-Saharan Africa are not widely reported. We present a systematic review of the patient-reported outcomes and complications of patients treated for ankle fractures in sub-Saharan Africa. METHODS: Medline, Embase, Google Scholar and the Cochrane Central Register of Controlled Trials were searched, utilising MeSH headings and Boolean search strategies. Ten papers were included. Data included patient demographics, surgical and non-surgical management, patient-reported outcome measures and evidence of complications. RESULTS: A total of 555 patients with ankle fractures were included, 471 of whom were followed up (range 6 weeks-73 months). A heterogenous mix of low-quality observational studies and two methodologically poor-quality randomised trials demonstrated mixed outcomes. A preference for surgical management was found within the published studies with 87% of closed fractures being treated operatively. A total of five different outcome scoring systems were used. Most studies included in this review were published by well-resourced organisations and as such are not representative of the actual clinical practice taking place. CONCLUSION: The literature surrounding the clinical outcomes of ankle fractures in sub-Saharan Africa is sparse. There appears to be a preference for surgical fixation in the published literature and considering the limitations in surgical resources across sub-Saharan Africa this may not be representative of real-life care in the region.

The Veterans Health Administration's integrated model of care increases accessibility and delivery of mental health services.

Depression and posttraumatic stress disorder (PTSD) are two of the most common mental health conditions experienced by veterans. It is unclear what individual and system level factors are associated with receiving mental health treatment for these concerns. Using a national sample of Gulf War Era veterans who endorsed lifetime diagnoses of either depression or PTSD (N = 425), regression analyses were used to predict past-year treatment utilization. Predictor variables were those indicated in the behavioral model of health care utilization, including predisposing demographic variables (e.g., age, race), enabling variables (e.g., service connection, enrollment in Veterans Health Administration [VHA]), and need-based variables (e.g., current symptom severity). VHA enrollment was associated with a three- and five-times higher odds of being treated for depression or PTSD, respectively. Income and symptom severity were also positively associated with treatment utilization. Among individuals with diagnoses of depression and/or PTSD, VHA enrollment was the strongest predictor of receiving mental health treatment for these diagnoses, controlling for all other variables in the model including recent contact with the health care system, current symptom severity, and the presence of other enabling resources. Results suggest that the VHA's integrated model of care increases accessibility and delivery of effective mental health services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are each common among Unites States (U.S.) military veterans and frequently co-occur (i.e., PTSD+AUD). Although comorbid PTSD+AUD is generally associated with worse outcomes relative to either diagnosis alone, some studies suggest the added burden of comorbid PTSD+AUD is greater relative to AUD-alone than to PTSD-alone. Furthermore, nonsuicidal self-injury (NSSI) is more common among veterans than previously thought but rarely measured as a veteran psychiatric health outcome. This study sought to replicate and extend previous work by comparing psychosocial functioning, suicide risk, and NSSI among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder. METHODS: This study analyzed data from a national sample of N = 1046 U.S. veterans who had served during the Gulf War. Participants self-reported sociodemographic, functioning, and clinical information through a mailed survey. RESULTS: Veterans with probable PTSD+AUD reported worse psychosocial functioning across multiple domains compared to veterans with probable AUD, but only worse functioning related to controlling violent behavior when compared to veterans with probable PTSD. Veterans with probable PTSD+AUD reported greater suicidal ideation and NSSI than veterans with probable AUD, but fewer prior suicide attempts than veterans with probable PTSD. LIMITATIONS: This study was cross-sectional, relied on self-report, did not verify clinical diagnoses, and may not generalize to veterans of other military conflicts. CONCLUSIONS: Findings underscore the adverse psychiatric and functional outcomes associated with PTSD and comorbid PTSD+AUD, such as NSSI, and highlight the importance of delivering evidence-based treatment to this veteran population.

Text Comprehension Analyses to Improve Assessment Accuracy: Demonstration Using Gambling Disorder Screening.

Many individuals diagnosed with an addictive disorder are members of disadvantaged groups and obtain a high school education or less, yet self-report questionnaires widely used to identify symptoms of addictive disorders do not use best practices to ensure item clarity and comprehension. In the present study, we explore how advanced text-analysis technology can be used to guide the development of a diagnostic questionnaire with an emphasis on maximizing its readability and then test the accuracy of this questionnaire. In Study 1, a self-report questionnaire for symptoms of gambling disorder was created using best practices for item clarity and comprehension. In study 2 an experimental design was used to test whether the measure with enhanced readability, compared to a commonly used screening instrument, improved diagnostic symptom accuracy among samples of high school and college educated individuals. Subsequent analyses revealed that education was positively related to item comprehension, and participants who completed the maximized readability questionnaire correctly identified more symptoms of gambling disorder than participants who completed the comparison questionnaire, regardless of educational attainment. These studies indicate that the rate at which individuals accurately identify symptoms of psychopathology is strongly related to their educational attainment and the readability of the questionnaire items themselves.

Total knee replacement in a transtibial amputee.

We present the case of a man in his 60s with a transtibial amputation (TTA) undergoing total knee replacement (TKR) for symptomatic osteoarthritis (OA). It is unusual to develop OA in the ipsilateral knee to TTA; and while it is postulated that this is because patients preferentially load their unaffected limb to protect the TTA-sided knee, there is also the ability to offload specific knee compartments through prosthetic adjustment. When planning TKR in such patients, it is important to consider several technical challenges in order to prevent a poor outcome. The literature is sparse with evidence to guide decision-making, and this case report and literature review aims to summarise our preoperative planning and intraoperative technique, which ultimately resulted in a good outcome.

Saphenous vein harvesting techniques for coronary artery bypass grafting: a systematic review and meta-analysis.

The great saphenous vein (GSV) graft remains a frequently used conduit for coronary artery bypass graft (CABG) surgery. The optimal technique for GSV harvesting has been the subject of on-going controversy. We therefore sought to conduct a systematic review and meta-analysis of all available GSV harvesting techniques in CABG. A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any GSV harvesting technique, including conventional vein harvesting (CVH), no-touch, standard bridging technique (SBT) and endoscopic vein harvesting (EVH) techniques. We investigated safety and long-term efficacy outcomes. All outcomes were analyzed using the frequentist network meta-analysis. A total of 6480 patients from 34 RCTs were included. For safety outcomes, EVH reduced 91% and 77% risk of wound infection compared to no-touch and CVH, respectively. EVH and SBT also significantly reduced the risk of sensibility disorder and postoperative pain. The techniques were not significantly different regarding long-term efficacy outcomes, including mortality, myocardial infarction and graft patency. For GSV harvesting for CABG, EVH techniques are the most favorable, but in case of using an open technique, no-touch is more recommended than CVH. More effective and safer procedures should be investigated for GSV harvesting in CABG.

Nonstigmatizing and Precise Terminology to Describe Processes and Outcomes in Addiction Medicine.

ABSTRACT: Scholarly journals and professional organizations in addiction medicine have recently discussed the importance of adopting nonstigmatizing and precise terminology. The present commentary expands that ongoing discussion to terms related to treatment processes and outcomes. Four implicit assumptions of stigmatizing and imprecise terms related to treatment processes and outcomes are overviewed, and research evidence against these assumptions is presented. The commentary ends with recommendations for the use of positive behavioral indicators of processes and outcomes and, more importantly, accompanying them with nonevaluative, objective descriptors of patients' behaviors.

Dropout from face-to-face, multi-session psychological treatments for problem and disordered gambling: A systematic review and meta-analysis.

OBJECTIVE: The aims of this systematic review and meta-analysis were to examine the overall prevalence of dropout from psychological treatments for problem gambling and gambling disorder and to examine how study, client, and treatment variables influenced dropout rates. METHOD: A systematic search was conducted to identify studies of cognitive and/or behavioral therapies and motivational interventions for problem gambling and gambling disorder. Meta-analysis was used to calculate an overall weighted dropout rate. Random effect meta-regressions were used to examine covariates of dropout rates. Mixed-effect subgroup analyses were used to examine moderators of dropout rates. RESULTS: The systematic search identified 24 studies (31 dropout rates) comprising 2,791 participants. Using a random-effects model, the overall weighted dropout rate was 39.1%, 95% CI [33.0%, 45.6%]. Increases in the percentage of married participants were significantly associated with lower dropout rates. Dropout rates were significantly higher when dropout was defined as attending all sessions of a treatment protocol compared to when defined as attending a prespecified number of sessions different from the total in the protocol and when defined as study therapists judging participants to be dropouts. Insufficient reporting of some gambling-related variables and other psychological symptom variables prevented a thorough examination of covariates and moderators. CONCLUSIONS: A large proportion of individuals drop out of treatment for problem gambling and gambling disorder. Future research should examine the reasons for dropout across marital statuses and should adopt dropout definitions that consider session-by-session symptom change. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

HPTLC Fingerprint Authentication of Selected Sideritis spp. Using a Pharmacognostic Approach.

The genus Sideritis (Lamiaceae) comprises around 150 species, of which many are popular herbal remedies in Mediterranean folk medicine. Already mentioned by Dioscorides and Theophrastus, the "ironwort" or "Greek mountain tea" has been receiving increased attention in recent years. A European Union herbal monograph and assessment report (HMPC) has been issued, covering the species Sideritis scardica, S. clandestina, S. raeseri, and S. syriaca. This study presents results of a first pharmacognostic examination of the botanical and phytochemical differences among and between these emerging commercial species, and other, less studied species. An HPTLC method is proposed for normal phase separation of the species; this means applying two mobile phases on silica plates and subsequent derivatization with natural product reagent (NP/PEG) for visualization of phenolic compounds and anisaldehyde for a broader detection. With the help of selected reference compounds, a system suitability test was established for proper chromatographic separation. The method was applied to specimens from botanical gardens and commercial raw material in order to test its suitability for differentiation and authentication. The HPTLC analysis also includes, for the first time, S. hyssopifolia and other less used Sideritis species. The results might enable the development of a validated phytochemical fingerprint authentication procedure for quality assurance of Sideritis herba.

Increased Demographic Representation in Randomized Control Trials for Gambling Disorder in the United States is Needed: A Systematic Review.

Participants in randomized control trials (RCTs) should be representative of those most likely to experience the disorder of focus, yet reviews of psychology research studies consistently find certain demographic groups are overrepresented at the price of others being unincluded. The present review aimed to characterize the demographic representation of US-based RCTs for gambling disorder and compare findings to the population of individuals most likely to experience the disorder. Thirteen US-based RCTs comprising a total of 2,343 participants were reviewed. We found that although gambling disorder is most prevalent among low SES racial minorities, RCTs are mostly conducted among populations who are white, employed, and have some level of college education. Demographic variables that are related to the likelihood of experiencing gambling disorder are not consistently reported, and there are many groups of individuals who experience gambling disorder that have been virtually left out of all treatment study samples to date. We conclude with recommendations for future gambling focused treatment studies, which are geared towards increasing the convergence between characteristics of participants in RCTs and those who experience gambling disorder in the United States.

Voice Rehabilitation by Voice Prostheses After Total Laryngectomy: A Systematic Review and Network Meta-Analysis for 11,918 Patients.

Purpose Our aim was to assess the different voice prostheses (VPs) to identify the most efficient, safest, patient-tailored, longest lifetime, and inexpensive VPs and assess the different factors affecting their quality. Method In September 2017, 15 databases were searched to include all randomized controlled trials. A new search was done in May 2019 to include all other study design articles, which include all the new-era VPs subtypes. Network meta-analysis (NMA) was applied to all 27 outcomes, besides NMA overall and partial order setting was done by using Hasse scatter plots. p values were used in NMA, where the best VPs are approaching one and the least approaches zero. Meta-analysis was done for the rest of the outcomes. Results Two hundred one articles were eligible for inclusion in our study (N = 11,918). Provox-2 was significantly the most efficient and safest device concerning the most patient preference (odds ratio [OR] = 33.88 [0.65, 1762.24]; p = .92), the least dislodgement (risk ratio [RR] = 0.27 [0.13, 0.57]; p = .79), the least airflow resistance (RR = 0.42 [0.08, 2.11]; p = .84), the least granulation formation (RR = 0.73 [0.02, 26.32]; p = .60), and the least VPs' inaccurate size (RR = 0.77 (0.23, 2.61); p = .66). Heat and moisture exchanger addition showed a significant increase in maximum phonation time and breathing experience, with p values (1 and .59), respectively. While heat and moisture exchanger addition showed a significant decline in stoma cleaning frequency, coughing frequency, forced expectoration, sputum production, sleeping problems, and loosening of adhesive, with p values (.99, .72, .69, .96, 1, and 0.96), respectively, Groningen low resistance and Nijdam were considered the worst devices with both overall mean p value of .44. Conclusions Provox-2 is considered the best choice as being the most preferable for patients, with the least airflow resistance, dislodgment, granulation formation, and prosthesis inaccurate size. Groningen low resistance and Nijdam were considered the worst devices according to our analysis. Supplemental Material https://doi.org/10.23641/asha.14802903.

Frequent Gamblers' Reasons for and Against Completing a Problem Gambling Screener.

Problem gambling screeners are easily accessible and potentially reduce harm for those individuals who engage in risky levels of gambling behavior. However, a recent study found that when frequent gamblers were offered the chance to complete a screener and receive feedback, most chose not to do so. In this paper, secondary analysis was completed on frequent gamblers' open-ended responses to questions regarding reasons for and against completing a problem gambling screener. Participants (N = 262) were individuals who gambled at least once per week and were not currently being treated for gambling problems. A qualitative open-coding procedure independently completed by multiple researchers revealed that the most common reasons for completing the screener were individuals having a desire to check in on their behavior, because they were curious about the screener, because they were experiencing gambling-related harm, or that they were already considering making changes to their gambling. The most common reasons against completing the screener were that they were either avoidant of the experience because they thought it might cause psychological distress, or because they believed that they did not have a problem. This study provides insight into why many individuals who engage in risky levels of gambling behavior do not seek out helping resources. In addition to creating practically accessible helping resources, researchers should focus on techniques that can make help-seeking a less distressing and more acceptable experience.

Glycothermal synthesis and photoluminescence of Mg-Si modified Ce:YAG nanophosphors.

The absorption spectrum of Ce in a YAG based host grown using the glycothermal method was modified using the addition of Mg-Si pairs. Photoluminescence intensity was dramatically improved by increasing the reaction temperature to 315 °C instead of the conventionally used 300 °C. It was found that Mg acetate and tetraethylorthosilicate (TEOS) are suitable as precursors for the glycothermal process, as EDS elemental mapping showed their homogeneous inclusion in the final product. Their addition only slightly modified the emission spectrum of Ce:YAG. It was found that increasing the reaction temperature to 315 °C yielded nanoparticles 56 ± 16 nm in size with a 3.3× enhancement in absorption and 3.7× enhancement in emission intensities compared to samples synthesized at 300 °C, and an increase in photoluminescence quantum yield from 32% to 48%. Reaction kinetics of the precursors and a proposed route for post-synthesis surface functionalization are discussed.

Can motivational messages engage individuals at-risk for gambling disorder in an online assessment?

There is a need to better understand how to motivate individuals experiencing addiction-related concerns, such as gambling problems, to engage in help-seeking behaviors. This experiment tested whether online messages based on principles of motivational interviewing (MI) could be used to encourage individuals to complete a problem gambling screener. Participants (N = 805) who gambled at least weekly and were not receiving treatment for gambling problems were recruited via Amazon Mechanical Turk. Participants were randomly assigned to 1 of 3 message conditions that all offered participants the choice to complete either a problem gambling screener or an alternative questionnaire focused on gambling-related attitudes. The first condition was an MI-based interactive message, the second was similar in content but was presented in a noninteractive manner, and the third was a control message that did not include motivational elements. We found that the interactive motivational message yielded significantly higher rates of screener completion (39%) than the noninteractive message (28%) or control message (29%), χ² (2, N = 805) = 8.28, p = .016, Φ = .29. This remained significant after controlling for other study variables. Controlling for message condition, participants were more likely to complete the screener if they gambled more frequently, with more money, were more psychologically distressed and interested in receiving help for gambling problems, or had ever received treatment for gambling problems. These findings provide support for the use of interactive MI-based messages to encourage individuals at-risk for experiencing problems to use helping resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).