Impact of preoperative CEA levels on the prediction of lymphnode (LN) metastasis

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 20070-20070
Author(s):  
K. Danno ◽  
T. Sugimoto ◽  
M. Ikeda ◽  
K. Ikeda ◽  
T. Ohnishi ◽  
...  
Keyword(s):  
Therapy Monitoring ◽  
Random Effect ◽  
The Other ◽  
Statistical Prediction ◽  
P Value ◽  
Positive Trend ◽  
Depth Of Invasion ◽  
Relative Importance ◽  
Bootstrap Sampling ◽  
The Impact

20070 Background: Although CEA is the most commonly used tumor marker for colorectal carcinoma (CRC) and it may correlate with poorer prognosis, data are insufficient to support its use to determine adjuvant therapy. Monitoring preoperative CEA might be useful if it would assist in staging and treatment planning. Methods: This study was a pooled data analysis of 1791 CRC patients (pts) collected prospectively from 25 hospitals participating in the MCSGO. The purpose of this study was to investigate the impact of preoperative CEA on the prediction of the number of LN metastasis (#LN). Data of 1328 pts were completed with preoperative CEA and clinicopathological (CP) data (number of dissected LN, #LN, tumor size, distant metastasis, macroscopic type, depth of invasion, histological type, and lymphatic and vessel invasion). Data of 582 pts with the number of dissected LN 12 were analyzed in this study. #LN was categorized in 5 levels (0, 1, 2, 3, and ≥4), and relationship between #LN and CEA was first investigated via a multivariate analysis based on adjusting for the other CP factors. Discrete logistic regression analysis was used, in which a random effect was incorporated to adjust some bias between hospitals. The linear effects for the factors were evaluated via the regression model. The multivariate adaptive regression spline (MARS), the most powerful tool in the statistical prediction, was employed for the prediction of #LN. Results: The effect of the CEA adjusted by the other CP factors had a positive trend with two-sided P-value of 0.0394 for #LN. The adjusted R-squared measure (R2*) by the MARS fitting, a prediction performance index of #LN, was 0.369, and that averaged based on Bootstrap sampling (Bagging method) was R2* = 0.405. The relative importance of each factor in the prediction of #LN estimated by the decrease rate of R2* on masking each factor is shown in the Table . The relative importance of CEA in the prediction of LN# was ranked second next to lymphatic invasion. Conclusions: Preoperative CEA has a significant impact on the prediction of #LN. [Table: see text] No significant financial relationships to disclose.

scholarly journals Impact of Corporate Governance Attributes on Tax Planning of listed Manufacturing Companies: A Comparative Study between Nigeria and Malaysia

2019 ◽  
Vol 1 (2) ◽  
pp. 105-119
Author(s):  
Sule Ba’aba ◽  
Mahmud Bashiru
Keyword(s):  
Corporate Governance ◽  
Random Effect ◽  
Control Variable ◽  
Tax Planning ◽  
P Value ◽  
Governance Mechanism ◽  
Manufacturing Companies ◽  
Ex Post ◽  
Effect Estimation ◽  
The Impact

The serious decline in the price of crude oil in recent years has led the state government to look for new sources of revenue and becomes strict and aggressive to the assessment and collection of revenue from the existing sources. This study examines the impact of Corporate Governance Attributes on Tax planning of listed manufacturing companies in Nigeria and Malaysia. The corporate governance parameters include board size and CEO tenure while tax planning is proxied by the effective tax rate and firm size as control variable. The objective is to determine if there is a relationship between corporate governance attributes and tax planning which in turn may improve firm performance. The study adopts comparative and ex-post facto research design and will utilise panel data from annual reports and accounts of the listed companies for the period of five years (2014-2018). The Data were analysed using a panel regression technique to assess the effect of the independent variables on the dependent variable. Hausman specification test was conducted to choose between fixed and random effect estimation and the p-value is0.9863 which insignificant. The resultsfrom random effect estimation modelindicates a negative and significant relationship between CEOT, FSIZE and ETR and a positive relationship between BSIZE and ETR.Therefore, the study concludes that corporate governance mechanism plays a significant role in tax planning and Nigerian manufacturing companies pays high tax charges as compare to Malaysian food and beverages companies.

scholarly journals The Impact of Tryptophan Supplementation on Sleep Quality: A Systematic Review, Meta-Analysis and Meta-Regression

2021 ◽  
Vol 5 (Supplement_2) ◽  
pp. 373-373
Author(s):  
Clarinda Sutanto ◽  
Wen Wei Loh ◽  
Jung Eun Kim
Keyword(s):  
Sleep Quality ◽  
Sleep Disturbances ◽  
Meta Analysis ◽  
Random Effect ◽  
Sleep Onset ◽  
Sleep Time ◽  
P Value ◽  
Post Intervention ◽  
Meta Regression ◽  
The Impact

Abstract Objectives Sleep disturbances have been associated with higher risk of developing a range of health conditions such as impaired cognition, type 2 diabetes mellitus and cardiovascular disease. L-tryptophan (Trp) has been documented to aid sleep, but a systematic compilation of its effect on sleep quality is still limited. This study aimed to assess the effect of Trp supplementation on sleep quality via meta-analysis and meta-regression. The effects of Trp dose (<1 g and ≥ 1 g) was also assessed. Methods A database search was done in PubMed, Medline (Ovid), CINAHL and COCHRANE and a total of 18 articles were collected. Sleep outcomes that were observed include total sleep time (TST), sleep latency (SL), wake after sleep onset (WASO) and sleep efficiency (SE). Extracted data from four articles were also analyzed using random-effect meta-analysis and meta-regression. Standardized mean difference (SMD) was used in meta-analysis. To investigate the dose-dependent efficacy of Trp, the post-intervention sleep outcomes from 18 articles were extracted and categorized into two Trp dose groups: <1g and ≥1g. This was then followed by an independent t-test comparison. Results Results from the study suggested that Trp supplementation can shorten WASO [SMD − 1.08 min, 95%CI (−1.89, −0.28); −81.03 min/g, P-value = 0.017]. In addition, the group with ≥ 1g Trp supplementation displayed a shorter WASO than the group with Trp < 1g supplementation (Trp < 1g vs. Trp ≥ 1g: 56.55 mins vs. 29.91 mins; P-value: 0.001). However, Trp supplementation did not affect other sleep components. Conclusions Trp supplementation, especially at ≥ 1g, can aid in improving sleep. Funding Sources National University of Singapore, NUS iHealthtech Microbiome in Health, Disease and Ageing.

Mitigation on Bowel Loops Daily Variations by 1.5-T MR-guided Daily-adaptive SBRT for Abdomino-pelvic Lymph-nodal Oligometastases

2021 ◽  
Author(s):  
Francesco Cuccia ◽  
Michele Rigo ◽  
Davide Gurrera ◽  
Luca Nicosia ◽  
Rosario Mazzola ◽  
...  
Keyword(s):  
Statistical Significance ◽  
Adaptive Strategy ◽  
P Value ◽  
Intestinal Loop ◽  
Target Coverage ◽  
Positive Trend ◽  
Daily Variations ◽  
Dosimetric Data ◽  
Significant Difference ◽  
The Impact

Abstract PurposeWe report preliminary dosimetric data concerning the use of 1.5-T MR-guided daily-adaptive radiotherapy for abdomino-pelvic lymph-nodal oligometastases. We aimed to assess the impact of this technology on mitigating daily variations for both target coverage and organs-at-risk (OARs) sparing. MethodsA total of 150 sessions for 30 oligometastases in 23 patients were analyzed. All patients were treated with MR-guided stereotactic body radiotherapy (SBRT) for a total dose of 35Gy in 5 fractions. For each fraction, a quantitative analysis was performed for PTV volume, V35Gy and Dmean. Similarly, for OARs we assessed daily variations of volume, Dmean, Dmax. Any potential statistically significant change between baseline planning and daily-adaptive sessions was assessed using the Wilcoxon signed-rank test, assuming a p-value< 0.05 as significant.ResultsAverage baseline PTV, bowel, bladder and single intestinal loop volumes were respectively 8.9cc (range, 0.7-41.2cc), 1176cc (119-3654 cc), 95cc (39.7-202.9 cc), 18.3cc (9.1-37.7 cc). No significant volume variations were detected for PTV (p=0.21) bowel (p=0.36), bladder (p=0.47), except for single intestinal loops, which resulted smaller (p=0.026). Average baseline V35Gy and Dmean for PTV were respectively 85.6% (72-98.8%) and 35.6 Gy (34.6-36.1 Gy). We recorded a slightly positive trend in favor of daily-adaptive strategy vs baseline planning for improved target coverage, although not reaching statistical significance. (p=0.11 and p=0.18 for PTV-V35Gy and PTV-Dmean). Concerning OARs, a significant difference was observed in favor of daily-adapted treatments in terms of single intestinal loop Dmax [23.05 Gy (13.2-26.9 Gy) at baseline vs 20.5 Gy (12.1-24 Gy); p-value=0.0377] and Dmean [14.4 Gy (6.5-18 Gy) at baseline vs 13.0 Gy (6.7-17.6 Gy); p-value=0.0003].Specifically for bladder, the average Dmax was 18.6 Gy (0.4-34.3 Gy) at baseline vs 18.3 Gy (0.7-34.3 Gy) for a p-value=0.28; the average Dmean was 7.0 Gy (0.2-16.6 Gy) at baseline vs 6.98 Gy (0.2-16.4 Gy) for a p-value=0.66. Concerning the bowel, no differences in terms of Dmean [4.78 Gy (1.3-10.9 Gy) vs 5.6 Gy (1.4-10.5 Gy); p-value=0.23] were observed between after daily-adapted sessions. A statistically significant difference was observed for bowel Dmax [26.4 Gy (7.7-34 Gy) vs 25.8 Gy (7.8-33.1 Gy); p-value=0.0086].ConclusionsDaily-adaptive MR-guided SBRT reported a significantly improved single intestinal loop sparing for lymph-nodal oligometastases. Also bowel Dmax was significantly reduced with daily-adaptive strategy. A minor advantage was also reported in terms of PTV coverage, although not statistically significant.

scholarly journals Telemedicine applied to offshore medical emergencies: impacts on a Brazilian oil industry

2021 ◽  
Vol 31 (Supplement_2) ◽  
Author(s):  
Douglas de Almeida Martins ◽  
Ana Carolina Braga Menezes ◽  
Vanessa Uchoa de Assis Martins da Silva ◽  
André Santana Costa ◽  
Maria Alzira Pimenta Dinis ◽  
...  
Keyword(s):  
Health Management ◽  
Reference Group ◽  
Operation Time ◽  
The Other ◽  
P Value ◽  
Contributing Factors ◽  
Oil Platforms ◽  
Offshore Oil Platforms ◽  
Medical Emergencies ◽  
The Impact

Abstract Background The study aims to analyse the impact of the use of advanced telemedicine resources in the management of medical emergencies on offshore oil platforms of a major Brazilian operator during the period 2018–2019. Methods 38 maritime platforms were analysed, totalling a sample of 5992 workers. Exploratory data analysis, adherence test to normal distribution (Ryan-Joiner normality test) and linear correlation test (Spearman’s rho) were used to characterize the data. 5 groups were defined, 1 offshore platform with advanced telemedicine resources (reference group) and 4 platforms without this support. Each group had data on the monthly amount of disembarkation due to health reasons, in 2018 and 2019, through common flights (1087 and 1207) and aeromedical evacuations (68 and 126), respectively. Finally, hypothesis testing was carried out for two independent samples, to compare the average landings of the reference group with the other groups. Results The reference group presented average landings for common flights lower than those of the other groups in 2018. In 2019, presented average landings for common flights lower than those of three groups and statistically equal to that of a group. In 2018 and 2019, the reference group presented statistically equal averages (P-value &gt; α = 0.05) of landings due to aeromedical evacuations. Conclusions Despite the possibility of other contributing factors, such as health management of each group and operation time of the platforms, this study allows us to conclude that, in 2018 and 2019, the group of maritime platforms with advanced telemedicine resources obtained, in general, lower average landings due to health reasons.

Modernism, Empiricism, and Rationalism

2016 ◽  
Vol 46 (1) ◽  
pp. 38-47
Author(s):  
Geoffrey Squires
Keyword(s):  
Twentieth Century ◽  
The Other ◽  
Modern Poetry ◽  
Philosophical Perspective ◽  
Irish Poetry ◽  
Dimensional Spectrum ◽  
Culture History ◽  
The World ◽  
The Impact ◽  
Rule Out

Modernism is usually defined historically as the composite movement at the beginning of the twentieth century which led to a radical break with what had gone before in literature and the other arts. Given the problems of the continuing use of the concept to cover subsequent writing, this essay proposes an alternative, philosophical perspective which explores the impact of rationalism (what we bring to the world) on the prevailing empiricism (what we take from the world) of modern poetry, which leads to a concern with consciousness rather than experience. This in turn involves a re-conceptualisation of the lyric or narrative I, of language itself as a phenomenon, and of other poetic themes such as nature, culture, history, and art. Against the background of the dominant empiricism of modern Irish poetry as presented in Crotty's anthology, the essay explores these ideas in terms of a small number of poets who may be considered modernist in various ways. This does not rule out modernist elements in some other poets and the initial distinction between a poetics of experience and one of consciousness is better seen as a multi-dimensional spectrum that requires further, more detailed analysis than is possible here.

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

2020 ◽  
Vol 6 (5) ◽  
pp. 1183-1189
Author(s):  
Dr. Tridibesh Tripathy ◽  
Dr. Umakant Prusty ◽  
Dr. Chintamani Nayak ◽  
Dr. Rakesh Dwivedi ◽  
Dr. Mohini Gautam
Keyword(s):  
Large Scale ◽  
National Level ◽  
Uttar Pradesh ◽  
Life Time ◽  
Structured Interview ◽  
The Other ◽  
Registration System ◽  
Action Group ◽  
Current Article ◽  
The Impact

The current article of Uttar Pradesh (UP) is about the ASHAs who are the daughters-in-law of a family that resides in the same community that they serve as the grassroots health worker since 2005 when the NRHM was introduced in the Empowered Action Group (EAG) states. UP is one such Empowered Action Group (EAG) state. The current study explores the actual responses of Recently Delivered Women (RDW) on their visits during the first month of their recent delivery. From the catchment area of each of the 250 ASHAs, two RDWs were selected who had a child in the age group of 3 to 6 months during the survey. The response profiles of the RDWs on the post- delivery first month visits are dwelled upon to evolve a picture representing the entire state of UP. The relevance of the study assumes significance as detailed data on the modalities of postnatal visits are available but not exclusively for the first month period of their recent delivery. The details of the post-delivery first month period related visits are not available even in large scale surveys like National Family Health Survey 4 done in 2015-16. The current study gives an insight in to these visits with a five-point approach i.e. type of personnel doing the visit, frequency of the visits, visits done in a particular week from among those four weeks separately for the three visits separately. The current study is basically regarding the summary of this Penta approach for the post- delivery one-month period.     The first month period after each delivery deals with 70% of the time of the postnatal period & the entire neonatal period. Therefore, it does impact the Maternal Mortality Rate & Ratio (MMR) & the Neonatal Mortality Rates (NMR) in India and especially in UP through the unsafe Maternal & Neonatal practices in the first month period after delivery. The current MM Rate of UP is 20.1 & MM Ratio is 216 whereas the MM ratio is 122 in India (SRS, 2019). The Sample Registration System (SRS) report also mentions that the Life Time Risk (LTR) of a woman in pregnancy is 0.7% which is the highest in the nation (SRS, 2019). This means it is very risky to give birth in UP in comparison to other regions in the country (SRS, 2019). This risk is at the peak in the first month period after each delivery. Similarly, the current NMR in India is 23 per 1000 livebirths (UNIGME,2018). As NMR data is not available separately for states, the national level data also hold good for the states and that’s how for the state of UP as well. These mortalities are the impact indicators and such indicators can be reduced through long drawn processes that includes effective and timely visits to RDWs especially in the first month period after delivery. This would help in making their post-natal & neonatal stage safe. This is the area of post-delivery first month visit profile detailing that the current article helps in popping out in relation to the recent delivery of the respondents.   A total of four districts of Uttar Pradesh were selected purposively for the study and the data collection was conducted in the villages of the respective districts with the help of a pre-tested structured interview schedule with both close-ended and open-ended questions.  The current article deals with five close ended questions with options, two for the type of personnel & frequency while the other three are for each of the three visits in the first month after the recent delivery of respondents. In addition, in-depth interviews were also conducted amongst the RDWs and a total 500 respondents had participated in the study.   Among the districts related to this article, the results showed that ASHA was the type of personnel who did the majority of visits in all the four districts. On the other hand, 25-40% of RDWs in all the 4 districts replied that they did not receive any visit within the first month of their recent delivery. Regarding frequency, most of the RDWs in all the 4 districts received 1-2 times visits by ASHAs.   Regarding the first visit, it was found that the ASHAs of Barabanki and Gonda visited less percentage of RDWs in the first week after delivery. Similarly, the second visit revealed that about 1.2% RDWs in Banda district could not recall about the visit. Further on the second visit, the RDWs responded that most of them in 3 districts except Gonda district did receive the second postnatal visit in 7-15 days after their recent delivery. Less than half of RDWs in Barabanki district & just more than half of RDWs in Gonda district received the third visit in 15-21 days period after delivery. For the same period, the majority of RDWs in the rest two districts responded that they had been entertained through a home visit.

Wacana Kolonial dalam Novel Max Havelaar: Sebuah Kajian Poskolonial

Metahumaniora ◽  
2017 ◽  
Vol 7 (3) ◽  
pp. 411
Author(s):  
Abu Bakar Ramadhan Muhamad
Keyword(s):  
Point Of View ◽  
The Other ◽  
The Novel ◽  
Colonial Discourse ◽  
The Impact ◽  
The Voice

AbstrakHegemoni kolonialisme dalam budaya poskolonial merupakan alasan penelitian inikemudian mengkaji wacana kolonial dalam novel Max Havellar (MH) khususnya dampakditimbulkannya. Dampak dimaksud adalah posisi keberpihakan pemikiran tersirat darikarya tersebut. Hasil pembahasan menunjukkan, secara temporal maupun permanen MHmenyuarakan ketidakadilan dalam kondisi-kondisi kolonial menyangkut penindasan sangpenjajah terhadap terjajah. Hanya saja, upaya mengatasnamakan atau mewakili suarakaum terjajah terbukti mengimplikasikan ciri ideologis statis kerangka kolonialisme(orientalisme); yakni cara pandang Eropasentris, di mana “Barat” sebagai self adalah superior,dan “Timur” sebagai other adalah inferior. Dalam konteks poskolonialisme, MH dengan sifatkritisnya yang berupaya “menyuarakan” nasib pribumi terjajah, justru menampilkan stigmapenguatan kolonialitas itu sendiri secara hegemonik. Artinya, “menyuarakan” nasib pribumidimaknai sebagai keberpihankan kolonial yang kontradiktif, di mana stigma penguatankolonialitas justru lebih terasa, ujung-ujungnya melanggengkan hegemoni kolonial. Tidakmembela yang terjajah, tetapi memperhalus cara kerja mesin kolonial.AbstractThe hegemony of colonialism in the culture of postcolonial society is the reason this studythen examines the colonial discourse in the novel Max Havellar (MH) in particular the impactit brings. The impact in question is the implied position of thought in the work. The resultsof the discussion show that, temporarily or permanently, MH voiced injustice in the colonialconditions regarding the oppression of the colonist against the colonized. However, the effort toname or represent the voice of the colonized has proven to imply a static ideological characterin the framework of colonialism (orientalism); ie Eropacentric point of view, in which “West” asself is superior, and “East” as the other is the inferior. In the context of postcolonialism, MH withits critical nature that seeks to “voice” the fate of the colonized natives, actually presents thestigma of strengthening coloniality itself hegemonicly. That is, “voicing” the fate of the pribumiis interpreted as a contradictory colonial flare, where the stigma of strengthening colonialityis more pronounced, which ultimately perpetuates the hegemony of colonialism. No longerdefending the colonized, but refining the workings of the colonial machinery.

The effect of brain vitalization activity on dementia incidence in elderly at Budi Luhur Nursing Home of Yogyakarta, Kasongan, Bantul

2020 ◽  
Vol 1 (3) ◽  
pp. 43-50
Author(s):  
Firstyono Miftahul Aziz ◽  
Suratini Suratini
Keyword(s):  
Nursing Home ◽  
The Elderly ◽  
Control Group ◽  
P Value ◽  
Sampling System ◽  
Randomized Sampling ◽  
Care For The Elderly ◽  
Dementia Incidence ◽  
The Family ◽  
The Impact

For some people, dementia is considered as a disease that is common in elderly, regardless the impact of dementia. Taking care for the elderly with dementia brings stress for the family. It can cause and increase the family burden. Brain vitalization gymnastics is one of the methods to improve memory. The study aims to investigate the effect of brain vitalization activity on dementia incidence in elderly at Budi Luhur Nursing Home of Yogyakarta. The study used Quasi Experimental with Pretest-Posttest control group and randomized sampling system. The samples were taken randomly as many as 26 respondents and were divided into two groups namely 13 respondents of experimental group and 13 respondents of control group. The statistical test used Wilcoxon Match Pairs Test. The result showed that Wilcoxon Match pairs test obtained p value 0,003, which is smaller than 0,005. There is an effect of brain vitalization activity on dementia incidence in elderly at Budi Luhur Nursing Home of Yogyakarta

Exploring power in response inhibition tasks using the bootstrap: The impact of number of participants, number of trials, effect magnitude, and study design

2019 ◽  
Author(s):  
Curtis David Von Gunten ◽  
Bruce D Bartholow
Keyword(s):  
Study Design ◽  
Effect Size ◽  
Statistical Power ◽  
Bootstrap Sampling ◽  
Reliable Measure ◽  
Internal Reliability ◽  
The Impact ◽  
Power Analyses ◽  
Effect Magnitude

A primary psychometric concern with laboratory-based inhibition tasks has been their reliability. However, a reliable measure may not be necessary or sufficient for reliably detecting effects (statistical power). The current study used a bootstrap sampling approach to systematically examine how the number of participants, the number of trials, the magnitude of an effect, and study design (between- vs. within-subject) jointly contribute to power in five commonly used inhibition tasks. The results demonstrate the shortcomings of relying solely on measurement reliability when determining the number of trials to use in an inhibition task: high internal reliability can be accompanied with low power and low reliability can be accompanied with high power. For instance, adding additional trials once sufficient reliability has been reached can result in large gains in power. The dissociation between reliability and power was particularly apparent in between-subject designs where the number of participants contributed greatly to power but little to reliability, and where the number of trials contributed greatly to reliability but only modestly (depending on the task) to power. For between-subject designs, the probability of detecting small-to-medium-sized effects with 150 participants (total) was generally less than 55%. However, effect size was positively associated with number of trials. Thus, researchers have some control over effect size and this needs to be considered when conducting power analyses using analytic methods that take such effect sizes as an argument. Results are discussed in the context of recent claims regarding the role of inhibition tasks in experimental and individual difference designs.

Gifted Students' Motivation and its Impact on the Development of their Giftedness

2018 ◽  
Vol 3 (1) ◽  
Author(s):  
Hussein SALEM MUBARAK BARABWD ◽  
Mohammad YUSOFF BIN MOHD NOR ◽  
Noriah Mohd Ishak
Keyword(s):  
Extrinsic Motivation ◽  
Gifted Students ◽  
Qualitative Approach ◽  
The Other ◽  
Phenomenological Method ◽  
Self Confidence ◽  
Verbal Praise ◽  
Intrinsic Motivations ◽  
The Impact ◽  
Intrinsic And Extrinsic Motivations

The aim of the current study is to examine the intrinsic and extrinsic motivations of the gifted students from Hadhramout Gifted Center HGC in Yemen, and to investigate the impact of these intrinsic and extrinsic motivations on their giftedness development. A qualitative approach was adopted; data has been collected through an open- ended questionnaire that was prepared by the researcher and distributed among a sample of gifted students who were chosen purposively from HGC. The interpretative phenomenological method has been used to analyze the data using, Atlas ti. The results indicate that the majority of the participants consider it interesting to explore new things, and experience curiosity and desire to achieve their goals as their intrinsic motivations. Whereas, the minority consider preference to serve the community, competition preference and self-confidence as their intrinsic motivations. On the other hand, half of the participants consider rewards as their extrinsic motivation, whereas 40 % of them consider exams scores, verbal praise, parents and environment as their extrinsic motivations. Regarding the impact of intrinsic and extrinsic motivations on the development of giftedness, the majority of the participants believe that intrinsic and extrinsic motivations affect positively the development of their giftedness development. Finally, based on the findings, some recommendations were provided. 

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