Adjunct tele-yoga on clinical status at 14 days in hospitalized patients with mild and moderate COVID-19: A randomized control trial.

Background: The initial insights from the studies on COVID-19 had been disappointing, indicating the necessity of an aggravated search for alternative strategies. In this regard, the adjunct potential of yoga has been proposed for enhancing the effectiveness of the standard of care with respect to COVID-19 management. We tested whether a telemodel of yoga intervention could aid in better clinical management for hospitalized patients with mild-to-moderate COVID-19 when complemented with the standard of care. Methods: This was a randomized controlled trial conducted at the Narayana Hrudyalaya, Bengaluru, India, on hospitalized patients with mild-to-moderate COVID-19 infection enrolled between 31 May and 22 July 2021. The patients (n = 225) were randomized in a 1:1 ratio [adjunct tele-yoga (n = 113) or standard of care]. The adjunct yoga group received intervention in tele-mode within 4-h post-randomization until 14 days along with the standard of care. The primary outcome was the clinical status on day 14 post-randomization, assessed with a seven-category ordinal scale. The secondary outcome set included scores on the COVID Outcomes Scale on day 7, follow-up for clinical status and all-cause mortality on day 28, post-randomization, duration of days at the hospital, 5th-day changes post-randomization for viral load expressed as cyclic threshold (Ct), and inflammatory markers and perceived stress scores on day 14. Results: As compared with the standard of care alone, the proportional odds of having a higher score on the 7-point ordinal scale on day 14 were ~1.8 for the adjunct tele-yoga group (OR = 1.83, 95% CI, 1.11-3.03). On day 5, there were significant reductions in CRP (P = 0.001) and LDH levels (P = 0.029) in the adjunct yoga group compared to the standard of care alone. CRP reduction was also observed as a potential mediator for the yoga-induced improvement of clinical outcomes. The Kaplan-Meier estimate of all-cause mortality on day 28 was the adjusted hazard ratio (HR) of 0.26 (95% CI, 0.05-1.30). Conclusion: The observed 1.8-fold improvement in the clinical status on day 14 of patients of COVID-19 with adjunct use of tele-yoga contests its use as a complementary treatment in hospital settings.

Coping Strategy, Life Style and Health Status During Phase 3 of Indian National Lockdown for COVID-19 Pandemic-A Pan-India Survey.

The implementation of timely COVID-19 pan-India lockdown posed challenges to the lifestyle. We looked at the impact of lifestyle on health status during the lockdown in India. A self-rated scale, COVID Health Assessment Scale (CHAS) was circulated to evaluate the physical health or endurance, mental health i.e. anxiety and stress, and coping ability of the individuals under lockdown. This is a pan-India cross-sectional survey study. CHAS was designed by 11 experts in 3 Delphi rounds (CVR = 0.85) and was circulated through various social media platforms, from 9th May to 31st May 2020, across India by snowball circulation method. CHAS forms of 23,760 respondents were downloaded from the Google forms. Logistic regression using R software was used to compare vulnerable (>60 years and with chronic diseases) with non-vulnerable groups. There were 23,317 viable respondents. Majority of respondents included males (58·8%). Graduates/Postgraduates (72·5%), employed (33·0%), businessmen (6·0%), and professionals (9·7%). The vulnerable group had significantly (OR 1.31, p < 0.001) higher representation of overweight individuals as compared to non-vulnerable group. Regular use of tobacco (OR 1.62, p = 0.006) and other addictive substances (OR 1.80, p = 0.039) showed increased vulnerability. Respondents who consume junk food (OR 2.19, p < 0.001) and frequently snack (OR 1.16, p < 0.001) were more likely to be vulnerable. Respondents involved in fitness training (OR 0.57, p < 0.001) or did physical works other than exercise, yoga, walk or household activity (OR 0.88, p = 0.004) before lockdown were less likely to be vulnerable. Majority had a very good lifestyle, 94.4% never smoked or used tobacco, 92.1% were non-alcoholic, 97.5% never used addictive substances, 84.7% had good eating habits, 75.4% were vegetarians, 82.8% had "good" sleep, 71.7% did physical activities. Only 24.7% reported "poor" coping ability. Depression with somewhat low feeling were more likely to be vulnerable (OR 1.26, p < 0.001). A healthy lifestyle that includes healthy eating, proper sleep, physical activeness and non-addictive habits supports better coping ability with lesser psychological distress among Indian population during lockdown.

Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention.

Background: The young Indian population, which constitutes 65% of the country, is fast adapting to a new lifestyle, which was not known earlier. They are at a high risk of the increasing burden of diabetes and associated complications. The new evolving lifestyle is not only affecting people's health but also mounting the monetary burden on a developing country such as India. Aim: We aimed to collect information regarding the prevalence of risk of diabetes in young adults (<35 years) in the 29 most populous states and union territories (7 zones) of India, using a validated questionnaire. Methods: A user-friendly questionnaire-based survey using a mobile application was conducted on all adults in the 29 most populous states/union territories of India, after obtaining ethical clearance for the study. Here, we report the estimation of the prevalence of the risk of diabetes and self-reported diabetes on 58,821 young individuals below the age of 35 years. Risk for diabetes was assessed using a standardized instrument, the Indian diabetes risk score (IDRS), that has 4 factors (age, family history of diabetes, waist circumference, and physical activity). Spearman's correlation coefficient was used to check the correlations. Results: The prevalence of high (IDRS score > 60), moderate (IDRS score 30-50), and low (IDRS < 30) diabetes risk in young adults (<35 years) was 10.2%, 33.1%, and 56.7%, respectively. Those with high-risk scores were highest (14.4%) in the Jammu zone and lowest (4.1%) in the central zone. The prevalence of self-reported diabetes was 1.8% with a small difference between men (1.7%) and women (1.9%), and the highest (8.4%) in those with a parental history of diabetes. The south zone had the highest (2.5%), and the north west zone had the lowest (4.4%) prevalence. Conclusions: Indian youth are at high risk for diabetes, which calls for an urgent action plan through intensive efforts to promote lifestyle behavior modifications during the pandemics of both communicable and noncommunicable diseases.

Erratum: Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India.

[This corrects the article DOI: 10.1055/s-0040-1709369.].

Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India.

Objectives The main purpose of this study is to investigate the prevalence of comorbid conditions in diabetic, prediabetic, and nondiabetic individuals. Additionally, the current study examines the levels of awareness of those comorbidities among North Indian population. Methods As a part of a national study (Niyantrit Madhumeh Bharat [NMB] screening program), different comorbidity parameters were screened in the northern part of India between April and September 2017. There were 1,215 participants recruited in this study. Biochemical analyses of hemoglobin A1c (HbA1c) were conducted on the study subjects. Subsequently, the study subjects were divided into diabetic, prediabetic, and nondiabetic groups based on their HbA1c results. Results The study analysis reveals a higher prevalence of peripheral vascular disease (21.2%), ocular diseases (18%), and hypertension (13.4%) in diabetics with other comorbidities. Furthermore, the study found that a vast majority of the participants were unaware of the presence of hypertension (67.2%), dyslipidemia (84.5%), kidney disease (95.2%), peripheral vascular disease (34.5%), and stroke (95.1%). Conclusion The study concluded that in the northern India, the prevalence of multiple comorbid conditions, such as peripheral vascular disease and hypertension, is higher among diabetic population. Also, the level of awareness of diabetic comorbidities is surprisingly low, which has implications for policymakers, health practitioners, and educators of alternate medicine to increase awareness about diabetes, comorbid conditions, health risk, and possible solution at community and rural level, such as periodic screening programs in this population.

Trends of Hypertension and Neurological Diseases in India: A Nationwide Survey Reporting the Distribution Across Geographical Areas.

BACKGROUND: Hypertension has remained an imperative risk factor for cardiovascular and cerebrovascular diseases, increasing the national burden of premature deaths over the decades. PURPOSE: There is limited data on the prevalence of hypertension and its distribution across all geographic regions in India. This nationwide survey was conducted in 2017 to assess the prevalence of hypertension and prehypertension among the Indian adults. METHODS: A multilevel stratified cluster sampling technique, with a random selection among the urban and rural populations, was adopted to achieve a sample of 70,031 adults from 24 states and 4 union territories. Blood pressure was measured twice using automated oscillometric machines with a minimum of 3-min gap, and the average was recorded. This was later categorized into prehypertension (elevated blood pressure) and hypertension subgroups as defined by the new 2017 American Heart Association guidelines. RESULTS: The prevalence of prehypertension and hypertension in our study population across all ages was found to be 18.2% and 24%, respectively. Prehypertension was common at a younger age, whereas the prevalence of hypertension was higher in the older age groups. The urban population (24.4%) and males (24.7%) were positively associated with prehypertension and hypertension. The western zone had the highest prevalence of hypertension, whereas the eastern population had the lowest. CONCLUSION: Our study revealed an alarmingly high prevalence of hypertension, accounting up to one hypertensive in every four adults in India. There is a need for more robust national strategies for identifying and treating hypertension to reduce the national and the global burden of hypertension by 25% before 2025.

Sleep Disorders in Individuals With High Risk for Diabetes in Indian Population.

BACKGROUND: Sleep restores physiology and neurochemical components of our body and is essential for physical and mental health. Sleep disorders (SDs) are associated with insulin resistance and metabolic disorders. The association between SDs and diabetes needs to be understood in the Indian population. PURPOSE: The purpose was to investigate the association between SD and diabetes in the Indian population. METHODS: As a part of nationwide Niyantrita Madhumeha Bharata Abhiyaan-2017 (NMB-2017), a cross-sectional study was conducted and data was collected from seven zones of India, after screening through the Indian Diabetes Risk Score (IDRS). The sleep quality was assessed on a scale of 1 to 4 (very good = 1, very bad = 4). The time taken to fall asleep (sleep latency) was assessed on a scale of 0 to 5 ("0" = nil and "5" = >1.5 h). Stress was assessed by the perceived stress scale. RESULTS: Bad sleep quality was positively (odds ratio 1.055, CI [1.001, 1.113], and P < .01) associated with self-reported known diabetes. Increased time taken to fall in sleep (sleep latency) was associated significantly with IDRS high risk (odds ratio 1.085, CI [1.008, 1.168], and P = .01), with an average sleep latency /time takes to fall in sleep (maximum range 5 [>1.5 h], mode 2 [10 to 30 min]) minutes. Moderate stress was significantly associated with bad sleep quality (odds ratio 1.659). CONCLUSION: A positive association of bad sleep quality and stress with diabetes, and an increased sleep latency in the IDRS high-risk population point to the role of modifiable risk factors. Behavioral modification and stress reduction by using yoga may be beneficial in the better management of diabetes.

Distribution of glycated haemoglobin and its determinants in Indian young adults.

AIM: The aim of the present study is to understand the distribution of A1c in four different age groups in young adults and its relation to other co-variants. METHODS: The countrywide data was collected in 2017 in Individuals with high risk analysed by Indian Diabetes Risk Score (IDRS) and self-declared diabetics were identified after screening a sample of 240,968 individuals from rural (4 villages of about 500 adults each) and urban (4 census enumeration blocks of about 500 adults each) population spanning 65 districts of 29 states/UTs of Indian subcontinent. Blood tests and other detailed assessments were carried out on this selected group. This study presents the analysis of the A1c values of 2862 young adults (<35 years). RESULTS: In the age group of 31-34 years, the proportion of Diabetes (22.36%) and Prediabetes (9.86%) was higher in comparison with younger age groups. Also, Diabetes (7.3%) and Prediabetes (22%) were highest among those who had parental history of DM in both parents as compared to those with Diabetes history in one parent [Diabetes (7.1%) or Prediabetes (19.0%)] and no Diabetes Parental History (Diabetes (7.3%) and Prediabetes (18.3%) cases. BMI was found to play a significant positive correlation with Diabetes and Prediabetes (p < 0.001) with range of A1c. CONCLUSION: Age, BMI and parental history were found to be correlated with A1c levels in IDRS screened high-risk population. With increasing age, the proportion of Diabetics and Prediabetics also increased with positive correlation of age with A1c levels.

Efficacy of a Validated Yoga Protocol on Dyslipidemia in Diabetes Patients: NMB-2017 India Trial.

Background: Dyslipidemia is considered a risk factor in Type 2 diabetes mellitus (T2DM) resulting in cardio-vascular complications. Yoga practices have shown promising results in alleviating Type 2 Diabetes pathology. Method: In this stratified trial on a Yoga based lifestyle program in cases with Type 2 diabetes, in the rural and urban population from all zones of India, a total of 17,012 adults (>20 years) of both genders were screened for lipid profile and sugar levels. Those who satisfied the selection criteria were taught the Diabetes Yoga Protocol (DYP) for three months and the data were analyzed. Results: Among those with Diabetes, 29.1% had elevated total cholesterol (TC > 200 mg/dL) levels that were higher in urban (69%) than rural (31%) Diabetes patients. There was a positive correlation (p = 0.048) between HbA1c and total cholesterol levels. DYP intervention helped in reducing TC from 232.34 ± 31.48 mg/dL to 189.38 ± 40.23 mg/dL with significant pre post difference (p < 0.001). Conversion rate from high TC (>200 mg/dL) to normal TC (<200 mg/dL) was observed in 60.3% of cases with Type 2 Diabetes Mellitus (T2DM); from high LDL (>130 mg/dL) to normal LDL (<130 mg/dL) in 73.7%; from high triglyceride (>200 mg/dL) to normal triglyceride level (<200 mg/dL) in 63%; from low HDL (<45 mg/dL) to normal HDL (>45 mg/dL) in 43.7% of T2DM patients after three months of DYP. Conclusions: A Yoga lifestyle program designed specifically to manage Diabetes helps in reducing the co-morbidity of dyslipidemia in cases of patients with T2DM.

Partitioning of radiological, stress and biochemical changes in pre-diabetic women subjected to Diabetic Yoga Protocol.

BACKGROUND: Yoga is an ancient system of wellness with Asana and Pranayama as its most popular and propagated modules for management of lifestyle disorders. OBJECTIVES: The aim of the study was to characterise the liver abnormalities, biochemical changes, and stress levels after Yoga intervention in prediabetic females. MATERIALS AND METHODS: 37 females were randomly divided into Yoga practising and non-practising control groups. The Yoga practising group performed Diabetic Yoga Protocol (DYP) for 3 months. Parameters including size of liver, fatty infiltration, and grade of severity were measured using ultrasonography along with biochemical parameters and stress levels at baseline and after Yoga practice. RESULTS: The glycosylated hemoglobin (HbA1c) and glucose levels were found significantly reduced in prediabetic (p = 0.015) women after practising DYP, although cholesterol levels increased in menopausal women. No escalation of fatty liver was noted among women practising DYP. CONCLUSION: DYP reduced the HbA1c and stress levels and therefore, could be a cost-effective tool for preventing prediabetes to diabetes progression.

Effect of a Diet Enriched with Fresh Coconut Saturated Fats on Plasma Lipids and Erythrocyte Fatty Acid Composition in Normal Adults.

OBJECTIVE: The objective of this study was to compare the effects of increased saturated fatty acid (SFA) (provided by fresh coconut) versus monounsaturated fatty acid (MUFA) intake (provided by a combination of groundnuts and groundnut oil) on plasma lipids and erythrocyte fatty acid (EFA) composition in healthy adults. MATERIAL AND METHODS: Fifty-eight healthy volunteers, randomized into 2 groups, were provided standardized diet along with 100 g fresh coconut or groundnuts and groundnut oil combination for 90 days in a Yoga University. Fasting blood samples were collected before and after the intervention period for the measurement of plasma lipids and EFA profile. RESULTS: Coconut diet increased low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels significantly. In contrast, the groundnut diet decreased total cholesterol (TC), mainly due to a decrease in HDL levels. There were no differences in the major SFA of erythrocytes in either group. However, coconut consumption resulted in an increase in C14:0 and C24:0 along with a decrease in levels of C18:1 n9 (oleic acid). There was a significant increase in levels of C20:3 n6 (dihomo-gamma linolenic acid, DGLA). CONCLUSIONS: Consumption of SFA-rich coconut for 3 months had no significant deleterious effect on erythrocytes or lipid-related factors compared to groundnut consumption. On the contrary, there was an increase in the anti-atherogenic HDL levels and anti-inflammatory precursor DGLA in erythrocyte lipids. This suggests that coconut consumption may not have any deleterious effects on cardiovascular risk in normal subjects.

Effect of yoga based techniques on stress and health indices using electro photonic imaging technique in managers.

BACKGROUND: Meditation techniques are known to elicit relaxation response in which moving meditation which combines the practice of yoga postures and guided relaxation is known as Cyclic Meditation reported helpful in reducing the sympathetic arousal and improving health of practitioners. OBJECTIVES: The objective of this study was to investigate the effect of Cyclic Meditation on stress and health indices in managers as measured by Electro Photonic Imaging (EPI) technique. MATERIALS AND METHODS: EPI technique was used to assess participants before and after 35 min of Cyclic Meditation (CM) and equal duration of Supine Rest (SR) session. A total of sixty six male managers, age ranges from 35 to 60 years (mean ± SD 53.97 ± 5.96) were included in the study. EPI parameters, including Activation Coefficient, Integral Area left and right and Integral Entropy, left and right were taken for statistical analyses. RESULTS: Cyclic Meditation has produced a highly significant reduction in stress level, whereas this reduction was not found significant within SR group. There was a significant improvement in health index 'Integral Area' values in both left and right sides within the CM group while only IA right side showed a significant improvement within the CM group. The integral entropy value right side decreased significantly within the CM group, whereas IE left was found deteriorated within the SR group. Moreover, only IE left side has shown a significant difference between the groups. CONCLUSION: The investigations in this study suggest that Cyclic Meditation practice reduces stress and improves psychosomatic health indices more effectively than Supine Rest in managers.

A randomized controlled study on assessment of health status, depression, and anxiety in coal miners with chronic obstructive pulmonary disease following yoga training.

CONTEXT: Psychological comorbidities are prevalent in coal miners with chronic obstructive pulmonary disease (COPD) and contribute to the severity of the disease reducing their health status. Yoga has been shown to alleviate depression and anxiety associated with other chronic diseases but in COPD not been fully investigated. AIM: This study aimed to evaluate the role of yoga on health status, depression, and anxiety in coal miners with COPD. MATERIALS AND METHODS: This was a randomized trial with two study arms (yoga and control), which enrolled 81 coal miners, ranging from 36 to 60 years with stage II and III stable COPD. Both groups were either on conventional treatment or combination of conventional care with yoga program for 12 weeks. RESULTS: Data were collected through standardized questionnaires; COPD Assessment Test, Beck Depression Inventory and State and Trait Anxiety Inventory at the beginning and the end of the intervention. The yoga group showed statistically significant (P < 0.001) improvements on all scales within the group, all significantly different (P < 0.001) from changes observed in the controls. No significant prepost changes were observed in the control group (P > 0.05). CONCLUSION: Yoga program led to greater improvement in physical and mental health status than did conventional care. Yoga seems to be a safe, feasible, and effective treatment for patients with COPD. There is a need to conduct more comprehensive, high-quality, evidence-based studies to shed light on the current understanding of the efficacy of yoga in these chronic conditions and identify unanswered questions.

Effect of integrated Yoga module on positive and negative emotions in Home Guards in Bengaluru: A wait list randomized control trial.

BACKGROUND: The beneficial aspect of positive emotions on the process of learning and the harmful affect of negative emotions on coping with stress and health are well-documented through studies. The Home Guards (HGs) are working in a very stressful situation during election, managing traffic and other crowded places. It is quite essential in present day circumstances that they have to manage their emotions and cope up with different stressful situations. OBJECTIVE: To study the efficacy of integrated Yoga module (IYM) on emotions (positive and negative affect [PA and NA]) of HGs. METHODS: A total of 148 HGs both males and females who qualified the inclusion and exclusion criteria were randomly divided into Yoga group (YG) and control groups (CG). The YG had supervised practice sessions (by trained experts) for 1 h daily, 6 days a week for 8 weeks along with their regular routine work whereas CG performing their routine work. Positive affect negative affect scale (PANAS) was assessed before and after 8 weeks using a modified version of PANAS. RESULTS: PA in YG had significantly increased (P < 0.05) whereas it had decreased significantly (P < 0.05) in CG. Other positive effect in YG had significantly increased (P < 0.001), whereas it had decreased significantly (P < 0.001) in CG. NA in YG had significantly decreased (P < 0.001), whereas it had significantly increased (P < 0.001) in CG. Other NA in YG had significantly decreased (P < 0.001), whereas it had significantly increased (P < 0.01) in CG. CONCLUSIONS: The results suggested that IYM can be useful for HGs to improve the PA and to decrease NA score. Moreover, IYM is cost-effective and helps HGs for coping up with emotions in stressful situations.

Development of normative data of electro photonic imaging technique for healthy population in India: A normative study.

BACKGROUND: Electro photonic imaging (EPI) technique is growing as a novel technique of health assessment and is being utilized in the fields of alternative medicine, conventional practices, psycho-physiology, psychology, and consciousness studies. The existing EPI norms are based mostly on European (EU) population. In order to enhance the practice and research through EPI in India, there is a need for developing norms for the healthy Indian population. OBJECTIVE: The objective of the study was to establish the normative data of EPI for the healthy Indian population, to aid in the accuracy of EPI measurements and interpretations. MATERIALS AND METHODS: A total of 1297 volunteers were assessed once, who represented different parts of India during December 2013 to December 2014. Among them, 880 volunteers were reported to be healthy (age mean ± standard deviation [SD], 33.55 ± 10.92), with 584 males (age mean ± SD, 33.54 ± 10.86) and 296 females (age mean ± SD, 33.56 ± 11.00). In this study activation coefficient (stress level), integral area (IA) (general health), and integral entropy (disorderliness in energy) parameters were analyzed. RESULTS: As the data were not normally distributed, quartile based statistics was used for setting the norms. The 25(th) and 75(th) percentiles were calculated and they were further verified using a bootstrap procedure. Uniquely, the results showed a clear difference in IA parameters under both with filter (physiological) and without filter (psycho-physiological) conditions between the Indian and the EU population. Though other parameters were found almost similar to the EU population, inter quartile ranges were narrower in the Indian population as compared to the EU values. Similar trends were observed in the subgroup analyzes: That is, male versus female genders and age ranges 18-40 versus 40-60. CONCLUSION: As compared to EU population, Indian population had different range of Integral Area values and narrower range for values of other variables. EPI Studies in India should also adjust for factors such as age and gender.

Effects of integrated yoga on quality of life and interpersonal relationship of pregnant women.

PURPOSE: The objective of this study was to investigate the effects of integrated yoga on the quality of life and interpersonal relationships in normal pregnant women. METHODS: One hundred and two pregnant women between 18 and 20 weeks of gestation who met the inclusion criteria were recruited from the obstetric units in Bangalore and were randomly assigned to two groups of yoga (n = 51) and control (n = 51). Women with medical conditions that could potentially lead to pregnancy complications and those with abnormal fetal parameters were excluded. The yoga group received integrated yoga while control group received standard antenatal exercises, both for 1-h three times a week from 20th to 36th week of gestation. Pre and post assessments were done using WHOQOL-100 and FIRO-B questionnaires. RESULTS: Of the six domains of WHOQOL-100, between groups analysis showed significant improvements in the yoga group compared to the control in the physical (P = 0.001), psychological (P < 0.001), social (P = 0.003), and environmental domains (P = 0.001). In FIRO-B, the yoga group showed significant improvements in 'Expressed Inclusion' (P = 0.02) and 'Wanted Control' (P = 0.009) domains compared to the control group. CONCLUSION: The integrated yoga is an efficacious means of improving the quality of life of pregnant women and enhancing certain aspects of their interpersonal relationships.

Investigating paranormal phenomena: Functional brain imaging of telepathy.

AIM: "Telepathy" is defined as "the communication of impressions of any kind from one mind to another, independently of the recognized channels of sense". Meta-analyses of "ganzfield" studies as well as "card-guessing task" studies provide compelling evidence for the existence of telepathic phenomena. The aim of this study was to elucidate the neural basis of telepathy by examining an individual with this special ability. MATERIALS AND METHODS: Using functional MRI, we examined a famous "mentalist" while he was performing a telepathic task in a 1.5 T scanner. A matched control subject without this special ability was also examined under similar conditions. RESULTS: The mentalist demonstrated significant activation of the right parahippocampal gyrus after successful performance of a telepathic task. The comparison subject, who did not show any telepathic ability, demonstrated significant activation of the left inferior frontal gyrus. CONCLUSIONS: The findings of this study are suggestive of a limbic basis for telepathy and warrant further systematic research.