Prevalence of asymptomatic or “silent” myocardial ischemia in diabetic patients: Protocol for a systematic review and meta-analysis

Introduction Myocardial ischemia (MI) is a top ranked cause of death among diabetic patients, yet it is mostly asymptomatic or “silent”. There is a need for summary epidemiologic measures on this highly lethal and unnoticeable complication of diabetes. The proposed systematic review and meta-analysis aims to estimate of the global prevalence of silent MI among diabetic patients. Methods and analysis This protocol was prepared according to the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) statement. The systematic review will include all observational studies published until March 23, 2021 and reporting on the prevalence of silent MI in diabetic patients. Electronic sources including MEDLINE(PubMed), Embase, Cochrane Library, and Web of Science will be searched for potentially eligible studies, restricted to only studies published in English. Two investigators will select studies and use a pre-pilot tested form to extract data. Further, they will independently perform a qualitative assessment of the risk of bias and overall quality of the selected studies, followed by a quantitative assessment using funnel plots and Egger’s tests. The heterogeneity between studies will be assessed with the Cochrane’s Q statistic, and the I2 statistic will measure the percentage of variation across studies that is due to their heterogeneity rather than chance; it will decide if a meta-analysis can be conducted. In case a meta-analysis cannot be conducted, a descriptive analysis will be performed. Otherwise, study-specific estimates will be pooled using either a fixed-effects or a random-effects model depending on the value of the I2 statistic. Subgroup and random effects meta-regression analyses will be used to further investigate the potential sources of heterogeneity. Finally, sensitivity analyses will be performed to measure the impact of low-quality studies on the results of the meta-analysis, and power calculations will determine the probability that we will detect a true effect if it does exist. Strengths and limitations of this study The intended review will provide an up-to-date summary of the global prevalence of silent MI in diabetic patients. We will conduct a thorough literature search for eligible studies, and we will use robust meta-analysis tools to provide reliable estimates of the global prevalence of silent MI in diabetic patients. Two major limitations could be: the predominance of clinical trials that might limit the generalizability of the findings, given that the strict inclusion criteria of these studies might have excluded other patients; the risk of type 1 error emanating from the high number of subgroup and sensitivity analyses. PROSPERO registration number CRD42019138136.

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Prevalence of unrecognized or “silent” myocardial ischemia in chronic kidney disease patients: Protocol for a systematic review and meta-analysis

PLoS ONE ◽

10.1371/journal.pone.0256934 ◽

2021 ◽

Vol 16 (9) ◽

pp. e0256934

Author(s):

Christophe Dongmo Fokoua-Maxime ◽

Armel Jackson Seukep ◽

Yahia Bellouche ◽

Takeude Erwan Cheuffa-Karel ◽

Dickson Shey Nsagha ◽

...

Keyword(s):

Systematic Review ◽

Chronic Kidney Disease ◽

Clinical Trials ◽

Kidney Disease ◽

Myocardial Ischemia ◽

Random Effects ◽

Meta Analysis ◽

Sensitivity Analyses ◽

Silent Myocardial Ischemia ◽

Global Prevalence

Introduction Chronic kidney disease (CKD) patients are at an extremely high risk of silent myocardial ischemia (SMI). However, there is a dearth of evidence on the worldwide prevalence of this very lethal and yet unrecognizable complication of CKD. The proposed systematic review and meta-analysis aims to estimate the global prevalence of SMI among CKD patients. Methods and analyses This protocol was conceived according to the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) statement. The systematic review will involve all observational studies and clinical trials published until April 30, 2021, and reporting on the prevalence of SMI in CKD patients. Electronic sources including MEDLINE, Embase, Web of Science, and Cochrane database of systematic reviews will be perused for potentially eligible studies, restricted to only studies published in English or French. Two investigators will independently select studies and use a pre-pilot tested form to extract data. Further, they will independently perform a qualitative assessment of the risk of bias and overall quality of the selected studies, followed by a quantitative assessment using funnel plots and Egger’s tests. The heterogeneity between studies will be assessed with the Cochrane’s Q statistic, and the I2 statistic will measure the percentage of variation across studies that is due to their heterogeneity rather than chance; the I2 will decide if a meta-analysis can be conducted. In case it cannot be conducted, a descriptive analysis will be performed. Otherwise, study-specific estimates will be pooled using either a fixed-effects or a random-effects model, depending on the value of the I2 statistic. Subgroup and random effects meta-regression analyses will further investigate the potential sources of heterogeneity. Finally, sensitivity analyses will be performed to measure the impact of low-quality studies on the results of the meta-analysis, and power calculations will determine the probability that we will detect a true effect if it does exist. PROSPERO registration number CRD42020211929 Strengths and limitations of this study The intended systematic review and meta-analysis will fill the knowledge gap on the global prevalence of silent myocardial ischemia (SMI) in CKD patients. The eligible studies will be identified through a methodic literature search followed by a rigorous screening process; we will then use robust meta-analysis tools to pool the data and provide reliable estimates of the global prevalence of SMI in CKD patients. Two major limitations could be: the predominance of clinical trials that might limit the generalizability of the findings, given that some informative patients might have been sidelined by the strict inclusion criteria of these studies; the high probability of type 1 error originating from the important number of subgroup and sensitivity analyses.

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Effect of garlic intake on inflammatory mediators: a systematic review and meta-analysis of randomised controlled trials

Postgraduate Medical Journal ◽

10.1136/postgradmedj-2019-137267 ◽

2020 ◽

pp. postgradmedj-2019-137267

Author(s):

Mehdi Koushki ◽

Nasrin Amiri-Dashatan ◽

Yasin Pourfarjam ◽

Amir Hossein Doustimotlagh

Keyword(s):

Systematic Review ◽

Inflammatory Mediators ◽

Metabolic Diseases ◽

Meta Analysis ◽

Random Effect ◽

Sensitivity Analyses ◽

Current Evidence ◽

Cochrane Library ◽

Tnf Α ◽

The Impact

BackgroundGarlic is a species in the onion genus, Allium. Data have shown that garlic has anti-inflammatory activity; however, the findings are inconclusive and inconsistent. We aimed to evaluate the impact of garlic intake on inflammatory mediators through systematic review and meta-analysis of existing data.MethodsElectronic databases were completely investigated using databases of ISI Web of Science, Medline, Scopus, Cochrane Library and EMBASE until October 2019. A random effects model and the generic reverse variance procedure were used for quantitative data production. Sensitivity analyses and prespecified subgroup were done to evaluate potential heterogeneity. Random effect meta-regression was conducted to investigate the effects of possible confounders on the assessed effect size.ResultsTen trials with one observational study, including 530 participants, met the eligibility criteria. The findings showed reduction in the tumour necrosis factor alpha (TNF-α) (−0.31 pg/mL, 95% CI −1.07 to 0.46) and C reactive protein (CRP) levels (−0.20 mg/L, 95% CI −1.4 to 1.05) following supplementation with garlic, although it had no marked impact on the interleukin 6 (IL-6) level (0.37 pg/mL, 95% CI −0.58 to 1.33). In the subgroup analysis, we found that garlic supplementation significantly decreased TNF-α, highly sensitive CRP and IL-6 levels in subgroups of >8, >6 and ≥4 weeks of intervention duration, respectively, and dose of garlic consumption between 2 and 2.4 g/day.ConclusionThese findings suggested that current evidence may support garlic as an adjunct to pharmacological management of metabolic diseases.PROSPERO registration numberCRD42018108816.

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Tranexamic acid in non-traumatic intracranial bleeding: a systematic review and meta-analysis

Scientific Reports ◽

10.1038/s41598-021-94727-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Jean-Baptiste Bouillon-Minois ◽

Carolyne Croizier ◽

Julien S. Baker ◽

Bruno Pereira ◽

Farès Moustafa ◽

...

Keyword(s):

Systematic Review ◽

Tranexamic Acid ◽

Meta Analysis ◽

Intracranial Bleeding ◽

Sensitivity Analyses ◽

Health Concern ◽

Cochrane Library ◽

Mortality Data ◽

Meta Regression ◽

The Impact

AbstractNon-traumatic intracranial bleeding (NTIB), comprising subarachnoid hemorrhage (SAH) and intra-cranial bleeding (ICH) is a significant public health concern. Tranexamic acid (TXA) is a promising treatment with benefits yet to be fully demonstrated. We conducted a systematic review and meta-analysis on the impact of TXA on mortality in NTIB. We searched the PubMed, Cochrane Library, Google Scholar and ScienceDirect databases for studies reporting mortality data following the use of TXA in NTIB for comparisons with a control group. We computed random-effect meta-analysis on estimates of risk and sensitivity analyses. We computed meta-regression to examine the putative effects of the severity of NTIB, sociodemographic data (age, sex), and publication date. Among potentially 10,008 articles, we included 15 studies representing a total of 4883 patients: 2455 receiving TXA and 2428 controls; 1110 died (23%) during the follow-up. The meta-analysis demonstrated a potential of 22% decrease in mortality for patients treated by TXA (RR = 0.78, 95%CI 0.58–0.98, p = 0.002). Meta-regression did not demonstrate any influence of the severity of NTIB, age, sex, length of treatment or date of publication. Sensitivity analyses confirmed benefits of TXA on mortality. TXA appears to be a therapeutic option to reduce non-traumatic intracranial bleeding mortality, particularly in patients with SAH.

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Impact of Treatment for Nasal Cavity Disorders on Sleep Quality: Systematic Review and Meta-analysis

Otolaryngology ◽

10.1177/01945998211029527 ◽

2021 ◽

pp. 019459982110295

Author(s):

Jacob Fried ◽

Erick Yuen ◽

Kathy Zhang ◽

Andraia Li ◽

Nicholas R. Rowan ◽

...

Keyword(s):

Systematic Review ◽

Sleep Quality ◽

Nasal Obstruction ◽

Meta Analysis ◽

Mean Difference ◽

Cochrane Library ◽

Life Questionnaire ◽

Subjective Sleep Quality ◽

Subjective Sleep ◽

The Impact

Objective To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality. Data Sources Primary studies were identified though PubMed, Scopus, Cochrane Library, and Web of Science. Review Methods A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI). Results The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was −1.5 (95% CI, –2.4 to –0.5; P = .002) and for the PSQI, –1.7 (95% CI, –2.1 to –1.2; P < .00001). For NSD, the EpSS mean difference was −3.2 (95% CI, –4.2 to –2.2; P < .00001) and for the PSQI, –3.4 (95% CI, –6.1 to –0.6; P = .02). Conclusion Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

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Efficacy of hydrofibre dressing following total joint arthroplasty: a meta-analysis of randomised controlled trials

Hip International ◽

10.1177/11207000211012669 ◽

2021 ◽

pp. 112070002110126

Author(s):

Raman Mundi ◽

Harman Chaudhry ◽

Seper Ekhtiari ◽

Prabjit Ajrawat ◽

Daniel M Tushinski ◽

...

Keyword(s):

Systematic Review ◽

Total Joint Arthroplasty ◽

Meta Analysis ◽

Joint Infection ◽

The United States ◽

Joint Arthroplasty ◽

Cochrane Library ◽

Controlled Trials ◽

Observable Effect ◽

The Impact

Introduction: In the United States, over 1,000,000 total joint arthroplasty (TJA) surgeries are performed annually and has been forecasted that this number will exceed 4,000,000 by the year 2030. Many different types of dressing exist for use in TJA surgery, and it is unclear if any of the newer, hydrofibre dressings are superior to traditional dressings at reducing rates of infections or improving wound healing. Thus, the aim of this systematic review and meta-analysis was to assess the impact of hydrofiber dressings on reducing complications. Methods: A systematic review and meta-analysis was performed using the online databases MEDLINE and the Cochrane Library. Randomized controlled trials (RCTs) comparing hydrofibre dressings to a standard dressing were included. Summary measures are reported as odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). Our primary outcome was prosthetic joint infection (PJI). Secondary outcomes included blisters, dressing changes and wound irritation. Results: 5 RCTs were included. Hydrofibre dressing had no observable effect on PJI or wound irritation (OR 0.53; 95% CI, 0.14–1.98; p = 0.35). Hydrofibre dressings reduced the rate of blisters (OR 0.36; 95% CI, 0.14–0.90; p = 0.03) and number of dressing changes (MD -1.89; 95% CI, -2.68 to -1.11). Conclusions: In conclusion, evidence suggests hydrofibre dressings have no observable effect on PJI and wound irritation. Evidence for reduction in blisters and number of dressings is modest given wide CIs and biased trial methodologies. Use of hydrofibre dressings should be considered inconclusive for mitigating major complications in light of current best evidence.

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The Use of Seton as a Bridge to Definitive Ligation of the Intersphincteric Fistula Tract Procedure for Fistula-in-ano: A Systematic Review and Meta-analysis

Journal of Coloproctology ◽

10.1055/s-0041-1730039 ◽

2021 ◽

Author(s):

Carlos Placer-Galán ◽

Jose Mª Enriquez-Navascués ◽

Tania Pastor-Bonel ◽

Ignacio Aguirre-Allende ◽

Yolanda Saralegui-Ansorena

Keyword(s):

Systematic Review ◽

Anal Fistula ◽

Meta Analysis ◽

Fistula Tract ◽

Cochrane Library ◽

Fistula In Ano ◽

Intersphincteric Fistula ◽

The Impact ◽

Seton Placement ◽

Primary Healing

Abstract Background There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design systematic review and meta-analysis. Data Sources A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results Ten studies met the criteria for systematic review, all retrospective, with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73–1.43: p = 0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27–42.7%), recurrence with the use of seton was 40% (IQR 26.6–51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3–51.3%) Limitations The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement.International prospective register of systematic reviews—PROSPERO registration number: CDR42020149173.

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Risk of nodal disease in patients with MRI-detected extramural vascular invasion in rectal cancer: a systematic review and meta-analysis

Tumori Journal ◽

10.1177/0300891620975867 ◽

2020 ◽

pp. 030089162097586

Author(s):

Pratik Tripathi ◽

Zhen Li ◽

Yaqi Shen ◽

Xuemei Hu ◽

Daoyu Hu

Keyword(s):

Systematic Review ◽

Rectal Cancer ◽

Lymph Node ◽

Vascular Invasion ◽

Literature Search ◽

Meta Analysis ◽

Adjuvant Chemoradiotherapy ◽

Cochrane Library ◽

Nodal Disease ◽

The Impact

Background: The impact of magnetic resonance imaging–detected extramural vascular invasion (mrEMVI) in distant metastasis is well known but its correlation with prevalence of lymph node metastasis is less studied. The aim of this systematic review and meta-analysis was to assess the prevalence of nodal disease in mrEMVI–positive and negative cases in rectal cancer. Methods: Following guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic literature search in PubMed, Web of Science, Cochrane Library, and EMBase was carried out to identify relevant studies published up to May 2019. Results: Our literature search generated 10 studies (863 and 1212 mrEMVI–positive and negative patients, respectively). The two groups (mrEMVI–positive and negative) were significantly different in terms of nodal disease status (odds ratio [OR] 3.15; 95% confidence interval [CI] 2.12–4.67; p < 0.001). The prevalence of nodal disease was 75.90% vs 52.56% in the positive mrEMVI vs negative mrEMVI group, respectively ( p < 0.001). The prevalence of positive lymph node in positive mrEMVI patients treated with neoadjuvant/adjuvant chemoradiotherapy (nCRT/CRT) (OR 2.47; 95% CI 1.65–3.69; p < 0.001) was less compared with the patients who underwent surgery alone (OR 6.25; 95% CI 3.74–10.44; p < 0.001). Conclusion: The probability of positive lymph nodes in cases of positive mrEMVI is distinctly greater compared with negative cases in rectal cancer. Positive mrEMVI indicates risk of nodal disease prevalence increased by threefold in rectal cancer.

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Impact of eating disorders on paid or unpaid work participation and performance: a systematic review and meta-analysis protocol

Journal of Eating Disorders ◽

10.1186/s40337-021-00525-2 ◽

2022 ◽

Vol 10 (1) ◽

Author(s):

Fatima Safi ◽

Anna M. Aniserowicz ◽

Heather Colquhoun ◽

Jill Stier ◽

Behdin Nowrouzi-Kia

Keyword(s):

Systematic Review ◽

Eating Disorders ◽

Meta Analysis ◽

Experimental Studies ◽

Work Participation ◽

Unpaid Work ◽

Cochrane Library ◽

And Performance ◽

The Impact

Abstract Background Eating disorders (ED) can reduce quality of life by limiting participation and performance in social and occupational roles, including paid or unpaid work. The association between ED pathologies and work participation and performance must be well understood to strengthen vocational rehabilitation programmes and prevent occupational disruptions in the ED population. The aims of this study are: (1) to examine the degree of association between ED pathologies and work participation and performance in 15-year-olds and older; (2) to highlight the specific ED symptoms that are most correlated with changes in work performance and participation; (3) to compile the most common metrics and assessments used to measure work participation and performance with ED. Methods Medline, Embase, CINAHL, Web of Science, PsycINFO, and Cochrane Library will be searched for observational and experimental studies that meet the following criteria: (1) a clinical sample of typical or atypical ED; (2) paid or unpaid employment or training; (3) an association between ED pathologies and work participation or performance. Unpublished data will also be examined. Title and abstract, and full-text screening will be conducted in duplicate. Risk of bias and quality of evidence assessments will be completed. A random-effect meta-analysis will be performed. Discussion This synthesis can clarify knowledge and gaps around the impact of ED on work functioning, thereby allowing better evaluation, improvements and development of current workplace assessments, interventions, and policies. Trial registration The registration number for this systematic review on PROSPERO is CRD42021255055.

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Effects of mouth breathing on facial skeletal development and malocclusion in children: A systematic review and meta-analysis.

10.21203/rs.3.rs-28100/v1 ◽

2020 ◽

Author(s):

Ziyi Zhao ◽

Leilei Zheng ◽

Xiaoya Huang ◽

Caiyu Li ◽

Jing Liu ◽

...

Keyword(s):

Systematic Review ◽

Skeletal Development ◽

Meta Analysis ◽

Mouth Breathing ◽

Occlusal Plane ◽

Cochrane Library ◽

Nasal Breathing ◽

Anterior Teeth ◽

Newcastle Ottawa Scale ◽

The Impact

Abstract BACKGROUND: Mouth breathing is closely related to the facial skeletal development and malocclusion. The purpose of this systematic review and meta-analysis was to assess the effect of mouth breathing on facial skeletal development and malocclusion in children. METHODS: An electronic search in PubMed, the Cochrane Library, Medline, Web of Science, EMBASE and Sigle through February 23rd, 2020, was conducted. Methodological quality assessments of the selected articles were performed using the Newcastle-Ottawa Scale. Review Manager 5.3, was used to synthesize various parameters associated with the impact of mouth breathing on facial skeletal development and malocclusion. RESULTS: Following full-text evaluations for eligibility, 7 studies (387 mouth-breathing subjects and 433 nasal-breathing controls) were included in the final quantitative synthesis; they were all high-quality. The included indicators were SNA (p>0.050), ANS-PNS (p>0.050), 1.NB (p>0.050), MP-H (p>0.050), FMA (p>0.050), SNB (MD: -1.99, P <0.0001), ANB (MD: 0.95, P = 0.0005), SN-OP (MD: 3.20, P < 0.0001), SNGoGn (MD: 4.34, P < 0.0001), 1-NA (MD: 0.72, P = 0.004), 1. NA (MD: 1.98, P = 0.020), 1-NB (MD: 1.06, P < 0.0001), SPAS (MD: -5.23, P < 0.0001), PAS (MD: -2.11, P < 0.0001), and C3-H (MD: -1.34, P < 0.0001). CONCLUSIONS: The results showed that mouth breathing can cause underdevelopment of the mandible. The mandible rotated backward and downward, and the occlusal plane was steep. However, there was little effect on the maxilla. In addition, mouth breathing presented a tendency of lip inclination of the upper and lower anterior teeth. Airway stenosis was common in mouth-breathing children. TRIAL REGISTRATION: [email protected]; registration number CRD42019129198 KEYWORDS: Mouth breathing; Facial skeletal development; Children; Systematic review, Meta-analysis.

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"Effectiveness of Robotics Intervention in Education for Children and Healthcare of Elderly People: A Systematic Review and Meta-Analysis Protocol" (Preprint)

10.2196/preprints.32942 ◽

2021 ◽

Author(s):

Ramesh Athe ◽

Vidushi Varma ◽

Shivendra Pandey ◽

Ayush Gupta ◽

Sravanthi Chaitanya

Keyword(s):

Systematic Review ◽

Elder Care ◽

Meta Analysis ◽

Educational Institution ◽

Humanoid Robots ◽

Outcome Data ◽

Population Characteristics ◽

Cochrane Library ◽

Test Procedures ◽

The Impact

UNSTRUCTURED A systematic review will be carried out to examine the use of robots in early childhood and lower-level education, elder care, and learning/teaching in an educational institution(s). Present study to critically review the currently available evidence of studies carried out and look at the impact of humanoid robots on children, elder care, and education. Four major factors will be considered – the type of studies carried on the influence of robots on children’s behavior and growth, elder care, the understanding of stakeholders (parents, children, and educators) on educational robots, and finally, the reactions of the children and elderly population on robot design or presence. This review will reveal the validating of their use of robots including experimental and non-experimental trials. The steps in this process will be conducted according to the PRISMA-P (Preferred Reporting Items for Systematic reviews and Meta-Analysis Protocols) guidelines for meta-analysis. A comprehensive review of the literature search from Medline, the Cochrane Library, Scopus, PubMed, ProQuest, and secondary references will be performed from inception to April 15, 2021. Analyses will be done to calculate summary estimates on awareness indicators and test procedures by using fixed/random-effects models. Meta-regression and covariate analyses will be performed to explore the influence of confounders on the net pooled effect. Titles and abstracts will be assessed by three independent reviewers for potential relevance. Using study-specific data forms, predetermined data will be extracted for each study. Data extracted will include: 1) study characteristics, 2) study design, 3) population characteristics, 4) details of the comparison group(s), 5) awareness indicators, 6) skills development, 7) progressive, 8) outcome data, and 9) Study year. Other classifications to be considered are a type of skill and specific age.

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