scholarly journals The Isocaloric Substitution of Plant-Based and Animal-Based Protein in Relation to Aging-Related Health Outcomes: A Systematic Review

Nutrients ◽  
2022 ◽  
Vol 14 (2) ◽  
pp. 272
Author(s):  
Jiali Zheng ◽  
Tianren Zhu ◽  
Guanghuan Yang ◽  
Longgang Zhao ◽  
Fangyu Li ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health Outcomes ◽  
Health Effect ◽  
Plant Protein ◽  
Current Evidence ◽  
Processed Meat ◽  
Inverse Association ◽  
Cross Sectional ◽  
Meat Protein ◽  
Cvd Mortality

Plant-based and animal-based protein intake have differential effects on various aging-related health outcomes, but less is known about the health effect of isocaloric substitution of plant-based and animal-based protein. This systematic review summarized current evidence of the isocaloric substitutional effect of plant-based and animal-based protein on aging-related health outcomes. PubMed and Embase databases were searched for epidemiologic observational studies published in English up to 15 March 2021. Studies that included adults ≥18 years old; use of a nutritional substitution model to define isocaloric substitution of plant protein and animal protein; health outcomes covering mortality, aging-related diseases or indices; and reported association estimates with corresponding 95% confidence intervals were included. Nine cohort studies and 3 cross-sectional studies were identified, with a total of 1,450,178 subjects included in this review. Consistent and significant inverse association of substituting plant protein for various animal proteins on all-cause mortality was observed among 4 out of 5 studies with relative risks (RRs) from 0.54 to 0.95 and on cardiovascular disease (CVD) mortality among all 4 studies with RRs from 0.58 to 0.91. Among specific animal proteins, the strongest inverse association on all-cause and CVD mortality was identified when substituting plant protein for red and/or processed meat protein, with the effect mainly limited to bread, cereal, and pasta protein when replacing red meat protein. Isocaloric substitution of plant-based protein for animal-based protein might prevent all-cause and CVD-specific mortality. More studies are needed on this topic, particularly for cancer incidence and other specific aging-related diseases.

scholarly journals Green Space Quality and Health: A Systematic Review

2021 ◽  
Vol 18 (21) ◽  
pp. 11028
Author(s):  
Phi-Yen Nguyen ◽  
Thomas Astell-Burt ◽  
Hania Rahimi-Ardabili ◽  
Xiaoqi Feng
Keyword(s):  
Systematic Review ◽  
Health Outcomes ◽  
Cohort Studies ◽  
Green Space ◽  
Health Benefits ◽  
Experimental Studies ◽  
Tree Canopy ◽  
Current Evidence ◽  
Cross Sectional ◽  
Wide Range

(1) Background: As cities densify, researcher and policy focus is intensifying on which green space types and qualities are important for health. We conducted a systematic review to examine whether particular green space types and qualities have been shown to provide health benefits and if so, which specific types and qualities, and which health outcomes. (2) Methods: We searched five databases from inception up to June 30, 2021. We included all studies examining a wide range of green space characteristics on various health outcomes. (3) Results: 68 articles from 59 studies were found, with a high degree of heterogeneity in study designs, definitions of quality and outcomes. Most studies were cross-sectional, ecological or cohort studies. Environment types, vegetation types, and the size and connectivity of green spaces were associated with improved health outcomes, though with contingencies by age and gender. Health benefits were more consistently observed in areas with greater tree canopy, but not grassland. The main outcomes with evidence of health benefits included allergic respiratory conditions, cardiovascular conditions and psychological wellbeing. Both objectively and subjectively measured qualities demonstrated associations with health outcomes. (4) Conclusion: Experimental studies and longitudinal cohort studies will strengthen current evidence. Evidence was lacking for needs-specific or culturally-appropriate amenities and soundscape characteristics. Qualities that need more in-depth investigation include indices that account for forms, patterns, and networks of objectively and subjectively measured green space qualities.

scholarly journals Association between body weight misperception and dietary patterns in Brazilian adolescents: Cross-sectional study using ERICA data

PLoS ONE ◽  
2021 ◽  
Vol 16 (9) ◽  
pp. e0257603
Author(s):  
Simoni Urbano da Silva ◽  
Mariane de Almeida Alves ◽  
Francisco de Assis Guedes de Vasconcelos ◽  
Vivian Siqueira Santos Gonçalves ◽  
Laura Augusta Barufaldi ◽  
...  
Keyword(s):  
Dietary Patterns ◽  
Cross Sectional Study ◽  
Processed Meat ◽  
Principal Component Factor Analysis ◽  
Inverse Association ◽  
Sectional Study ◽  
Cross Sectional ◽  
Weight Misperception ◽  
Direct Association ◽  
Sweet Foods

The association between body image and eating behaviors or weight control strategies has been demonstrated in the scientific literature, but there is a lack of evidence on the association between weight misperception and food consumption indicators in adolescents. This study aimed to evaluate the association between weight misperception and dietary patterns (DPs) in the Brazilian Study of Cardiovascular Risks in Adolescents (ERICA). It was a national school-based cross-sectional study conducted among students aged 12–17 years. Data were collected in the form of anthropometric measurements, responses in self-answered questionnaires, and 24-h dietary recall. The following variables were assessed: weight underestimation and overestimation (independent variables), which were defined as the presence of a disagreement between nutritional status and self-perceived weight; dietary patterns (dependent variables), defined by a posteriori method using principal component factor analysis; and individual and demographic variables (covariates). Data analysis was performed using the Poisson regression models method, stratified by sex. A total of 52,038 adolescents with normal weights were evaluated. The weight misperception prevalence was 34.0% (95% confidence interval [CI]: 33.0, 35.0). Three DPs were identified: “Traditional Brazilian,” “Processed meat sandwiches and coffee,” and “Ultra-processed and sweet foods.” In girls, weight underestimation was directly associated with the “Traditional Brazilian” (1.24; 95% CI: 1.08, 1.43) and “Ultra-processed and sweet foods” DPs (1.29; 95% CI: 1.09, 1.54), and overestimation was inversely associated with all the DPs. In boys, a direct association between underestimation and the “Ultra-processed and sweet foods” DP (1.29; 95% CI: 1.10, 1.51) was found. Overestimation was inversely associated with the “Traditional Brazilian” DP (0.79; 95% CI: 0.63, 0.99). The inverse association between overestimation and the “Traditional Brazilian” DP, and the direct association between underestimation and the “Ultra-processed and sweet foods” DP indicated that weight misperception was related to unhealthy eating habits in Brazilian adolescents.

scholarly journals Post-COVID-19 Syndrome: The Persistent Symptoms at the Post-viral Stage of the Disease. A Systematic Review of the Current Data

2021 ◽  
Vol 8 ◽  
Author(s):  
Francesca Salamanna ◽  
Francesca Veronesi ◽  
Lucia Martini ◽  
Maria Paola Landini ◽  
Milena Fini
Keyword(s):  
Systematic Review ◽  
Chronic Fatigue ◽  
Current Data ◽  
Assessment Tools ◽  
Current Evidence ◽  
Case Control Studies ◽  
Cross Sectional ◽  
Persistent Symptoms ◽  
Collection Form

Whilst the entire world is battling the second wave of COVID-19, a substantial proportion of patients who have suffered from the condition in the past months are reporting symptoms that last for months after recovery, i. e., long-term COVID-19 symptoms. We aimed to assess the current evidence on the long-term symptoms in COVID-19 patients. We did a systematic review on PubMed, Web of Science, EMBASE, and Google Scholar from database inception to February 15, 2021, for studies on long-term COVID-19 symptoms. We included all type of papers that reported at least one long-term COVID-19 symptom. We screened studies using a standardized data collection form and pooled data from published studies. Cohort cross-sectional, case-report, cases-series, case-control studies, and review were graded using specific quality assessment tools. Of 11,361 publications found following our initial search we assessed 218 full-text articles, of which 145 met all selection criteria. We found that 20.70% of reports on long-term COVID-19 symptoms were on abnormal lung functions, 24.13% on neurologic complaints and olfactory dysfunctions, and 55.17% on specific widespread symptoms, mainly chronic fatigue, and pain. Despite the relatively high heterogeneity of the reviewed studies, our findings highlighted that a noteworthy proportion of patients who have suffered from SARS-CoV-2 infection present a “post-COVID syndrome.” The multifaceted understanding of all aspects of the COVID-19 pandemic, including these long-term symptoms, will allow us to respond to all the global health challenges, thus paving the way to a stronger public health.

scholarly journals Is Non-Chlamydial Non-Gonococcal Urethritis Associated with Significant Clinical Complications in Men? A Systematic Review

2020 ◽  
Vol 14 (1) ◽  
pp. 1-13 ◽  
Author(s):  
Cassandra E.L. Fairhead ◽  
Alexander Hampson ◽  
Louis Dwyer-Hemmings ◽  
Nikhil Vasdev
Keyword(s):  
Systematic Review ◽  
Reactive Arthritis ◽  
Case Reports ◽  
Case Series ◽  
Current Evidence ◽  
Future Research ◽  
Qualitative Synthesis ◽  
Cross Sectional ◽  
Gonococcal Urethritis ◽  
Clinical Complications

Background: It is estimated that between 50 and 89% of non-gonococcal urethritis is not caused by Chlamydia trachomatis. Associations between non-chlamydial non-gonococcal urethritis (NCNGU) with balanoposthitis, epididymo-orchitis and reactive arthritis have been suggested, but evidence to support these often-theoretical relationships is sparse and further investigation is called for. Concerns over increasing antimicrobial resistance has rendered the need for clarity over this question ever more pressing in recent years. A review of the current evidence on the complications of NCNGU in men is therefore urgently warranted. Objective: This systematic review summarizes and evaluates the available evidence that NCNGU, whether symptomatic or asymptomatic, causes the significant complications that are already well-recognized to be associated with non-gonococcal urethritis. These significant complications are epididymo-orchitis, balanoposthitis, and sexually-acquired reactive arthritis (Reiter's syndrome) including arthritis or conjunctivitis. Summary: We conducted a systematic review and qualitative synthesis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. Five databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and British Nursing Index) were searched. We included studies that measured clinical outcome after diagnosis of NCNGU in men. Bias was assessed using variations of the Newcastle-Ottawa scale. Data were extracted and entered into a pre-written data abstraction proforma. Seven peer-review studies were included. This included 2 retrospective cohort studies, 1 case series, 2 case reports and 2 cross-sectional studies. The studies described and analyzed 3 types of complication: balanitis, posthitis and/or meatitis; reactive arthritis and/or conjunctivitis; and epididymitis. All studies reported one or more complications. Key Messages: This review identifies an important avenue for future research: while the available evidence suggests that NCNGU has the potential to cause significant complications in men, with the strongest evidence existing for balanitis, posthitis and/or meatitis, the nature and significance of these relationships is far from clear. The findings of this review suggest that prospective, adequately powered research into whether there is a causal link between NCNGU and significant clinical complications in men would be highly worthwhile. The findings of this review raise important questions about the utility of the term NCNGU in research and clinical practice.

scholarly journals Prevalence of Diabetes Mellitus and Its Associated Unfavorable Outcomes in Patients With Acute Respiratory Syndromes Due to Coronaviruses Infection: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 13 ◽  
pp. 117955142096249
Author(s):  
Isabel Pinedo-Torres ◽  
Magaly Flores-Fernández ◽  
Marlon Yovera-Aldana ◽  
Claudia Gutierrez-Ortiz ◽  
Paolo Zegarra-Lizana ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Systematic Review ◽  
Health Outcomes ◽  
Meta Analysis ◽  
Population Based ◽  
Pooled Analysis ◽  
Sensitivity Analyses ◽  
Cross Sectional ◽  
Treatment Regimens ◽  
Prevalence Of Diabetes Mellitus

Introduction: Only 3 types of coronavirus cause aggressive respiratory disease in humans (MERS-Cov, SARS-Cov-1, and SARS-Cov-2). It has been reported higher infection rates and severe manifestations (ICU admission, need for mechanical ventilation, and death) in patients with comorbidities such as diabetes mellitus (DM). For this reason, this study aimed to determine the prevalence of diabetes comorbidity and its associated unfavorable health outcomes in patients with acute respiratory syndromes for coronavirus disease according to virus types. Methods: Systematic review of literature in Pubmed/Medline, Scopus, Web of Science, Cochrane, and Scielo until April of 2020. We included cohort and cross-sectional studies with no restriction by language or geographical zone. The selection and extraction were undertaken by 2 reviewers, independently. The study quality was evaluated with Loney’s instrument and data were synthesized by random effects model meta-analysis. The heterogeneity was quantified using an I2 statistic. Funnel plot, Egger, and Begg tests were used to evaluate publication biases, and subgroups and sensitivity analyses were performed. Finally, we used the GRADE approach to assess the evidence certainty (PROSPERO: CRD42020178049). Results: We conducted the pooled analysis of 28 studies (n = 5960). The prevalence analysis according to virus type were 451.9 diabetes cases per 1000 infected patients (95% CI: 356.74-548.78; I2 = 89.71%) in MERS-Cov; 90.38 per 1000 (95% CI: 67.17-118.38) in SARS-Cov-1; and 100.42 per 1000 (95% CI: 77.85, 125.26 I2 = 67.94%) in SARS-Cov-2. The mortality rate were 36%, 6%, 10% and for MERS-Cov, SARS-Cov-1, and SARS-Cov-2, respectively. Due to the high risk of bias (75% of studies had very low quality), high heterogeneity ( I2 higher than 60%), and publication bias (for MERS-Cov studies), we down rate the certainty to very low. Conclusion: The prevalence of DM in patients with acute respiratory syndrome due to coronaviruses is high, predominantly with MERS-Cov infection. The unfavorable health outcomes are frequent in this subset of patients. Well-powered and population-based studies are needed, including detailed DM clinical profile (such as glycemic control, DM complications, and treatment regimens), comorbidities, and SARS-Cov-2 evolution to reevaluate the worldwide prevalence of this comorbidity and to typify clinical phenotypes with differential risk within the subpopulation of DM patients.

Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis

Pain Medicine ◽  
2019 ◽  
Author(s):  
Kelsey L Corcoran ◽  
Lori A Bastian ◽  
Craig G Gunderson ◽  
Catherine Steffens ◽  
Alexandria Brackett ◽  
...  
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Spinal Pain ◽  
Chiropractic Care ◽  
Current Evidence ◽  
Inverse Association ◽  
Case Control Studies ◽  
Opioid Prescription

Abstract Objective To investigate the current evidence to determine if there is an association between chiropractic use and opioid receipt. Design Systematic review and meta-analysis. Methods The protocol for this review was registered on PROSPERO (CRD42018095128). The MEDLINE, PubMed, EMBASE, AMED, CINAHL, and Web of Science databases were searched for relevant articles from database inception through April 18, 2018. Controlled studies, cohort studies, and case–control studies including adults with noncancer pain were eligible for inclusion. Studies reporting opioid receipt for both subjects who used chiropractic care and nonusers were included. Data extraction and risk of bias assessment were completed independently by pairs of reviewers. Meta-analysis was performed and presented as an odds ratio with 95% confidence interval. Results In all, 874 articles were identified. After detailed selection, 26 articles were reviewed in full, and six met the inclusion criteria. Five studies focused on back pain and one on neck pain. The prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users (range = 12.3–57.6%) than nonusers (range = 31.2–65.9%). In a random-effects analysis, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers (odds ratio = 0.36, 95% confidence interval = 0.30–0.43, P < 0.001, I2 = 92.8%). Conclusions This review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.

scholarly journals Dynapaenic obesity and its association with health outcomes in older adult populations: protocol for a systematic review

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e027728 ◽  
Author(s):  
Siobhan Leahy ◽  
Marica Cassarino ◽  
Matthew DL O' Connell ◽  
Liam Glynn ◽  
Rose Galvin
Keyword(s):  
Systematic Review ◽  
Older Adults ◽  
Health Outcomes ◽  
Older Adult ◽  
Observational Studies ◽  
Functional Disability ◽  
Age Groups ◽  
Ageing Population ◽  
Cross Sectional ◽  
Age Related

IntroductionTwo major global health challenges are the rapidly ageing population and the high prevalence of obesity in all age groups. Older adults are also susceptible to age-related loss of muscle strength, termed dynapaenia. The co-occurrence of both obesity and dynapaenia, termed dynapaenic obesity (DO), has been associated with poorer health outcomes and increased healthcare usage compared with either state alone. The purpose of this systematic review is to quantify the prevalence and incidence of DO in older adult populations, and to explore the association between DO and health outcomes, specifically chronic disease and multimorbidity, functional disability and healthcare usage.Methods and analysisUsing the Meta-analyses Of Observational Studies in Epidemiology guidelines, we will conduct a systematic review of cross-sectional and longitudinal observational studies of older adults, which include measures of DO and specified outcomes. Detailed literature searches of will be conducted using six electronic databases: Excerpta Medica dataBASE (EMBASE), PubMed, MEDLINE, SCOPUS, ScienceDirect and Cumulative Index of Nursing and Allied Health Complete (CINAHL), including articles published from database inception until Febuary 2019. The reference lists of included articles will also be searched. Two independent reviewers will undertake a three-step screening and review process using the Population, Risk Factor, Outcome framework to define eligibility. The Newcastle Ottawa Scale for non-randomised studies will be used to assess risk of bias and to rate study quality. The findings will be synthesised in a narrative summary, and a meta-analysis will be conducted where appropriate.Ethics and disseminationEthical approval is not required for this systematic review. Findings from this research will be submitted for peer-reviewed publication in academic journals, and presented at relevant academic conferences.PROSPERO registration numberCRD42018112471.

scholarly journals A systematic review of the knowledge, attitudes, and practices of physicians, health workers, and the general population about Coronavirus disease 2019 (COVID-19)

2020 ◽  
Author(s):  
Saeede Saadatjoo ◽  
Maryam Miri ◽  
Soheil Hassanipour ◽  
Hosein Ameri ◽  
Morteza Arab-Zozani
Keyword(s):  
Systematic Review ◽  
Positive Attitude ◽  
Health Workers ◽  
International System ◽  
Good Practice ◽  
Negative Attitude ◽  
Current Evidence ◽  
Cross Sectional ◽  
Attitudes And Practices ◽  
Good Level

AbstractBackgroundUnderstanding people, physicians, and healthcare workers’ knowledge, attitude, and practices (KAPs) can help to achieve the outcomes of planned behavior. The aim of this study was to investigate and synthesize the current evidence on KAPs regarding COVID-19.MethodsWe conducted a systematic search on PubMed/LitCovid, Scopus, and Web of Sciences databases for papers in the English language only, up to 1 Jul 2020. We used the Joanna Briggs Institute (JBI) checklist developed for cross-sectional studies to appraise the quality of the included studies. All stages of the review conducted by two independent reviewers and potential discrepancies solved with a consultation with a third reviewer. We reported the result as number and percentage. PROSPERO registration code: (CRD42020186755).ResultsFifty-two studies encompassing 49786 participants were included in this review. 45.76% of the participants were male. The mean age of the participants was 32.6 years. 44.2% of the included studies were scored as good quality, 46.2% as fair quality, and remaining (9.6%) as low quality. 30.76% examined all three components of the KAPs model. The knowledge component was reported as good, fair, and poor in 59%, 34%, and 7%, respectively. Of the studies that examined the attitude component, 82% reported a positive attitude, 11% a fairly positive attitude, and 7% a negative attitude. For the practice component, 52% reported good practice, 44% fair practice, and 4% poor practice.ConclusionThis systematic review showed that the overall KAP components in the included studies were at an acceptable level. In general, knowledge was at a good level, the attitude was positive and practice was at a fairly good level. Using an integrated international system can help better evaluate these components and compare them between countries.

Association between intra-hospital uncontrolled glycemia and health outcomes in patients with diabetes: A systematic review of observational studies

2020 ◽  
Vol 16 ◽  
Author(s):  
Renata Cunha Carvalho ◽  
Fernanda Ayache Nishi ◽  
Tatiane Bomfim Ribeiro ◽  
Gustavo Galvão França ◽  
Patricia Melo Aguiar
Keyword(s):  
Systematic Review ◽  
Adverse Events ◽  
Health Outcomes ◽  
Descriptive Analysis ◽  
Length Of Hospital Stay ◽  
Severe Hypoglycemia ◽  
Glycemic Variability ◽  
Current Evidence ◽  
Analysis Method ◽  
Patients With Diabetes

Background: Many people are still affected by uncontrolled glycemic events during hospital admission, what encompasses hypoglycemia, hyperglycemia, and high glycemic variability. Introduction: Primary studies have shown association of glycemic dysregulation with increased length of hospital stay and with mortality among overall patients, however, there is no systematic review of current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes. This study aimed to systematic review the current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes. Methods: The association between glycemic dysregulation and health outcomes for inpatients with diabetes was systematically reviewed. PubMed, Embase, and LILACS databases were searched. Two independent reviewers were involved in each of the following steps: screening titles, abstracts, and full-texts; assessing the methodological quality; and extracting data from included reviews. Descriptive analysis method was used. Results: Seven cohort studies were included, and only two had a prospective design, consisting of 7,174 hospitalized patients with diabetes. In-hospital occurrence of hypoglycemia, hyperglycemia, and glycemic variability were assessed, and outcomes were mortality, infections, renal complications, and adverse events. Among the exposure and outcomes, an association was observed between severe hypoglycemia and mortality, hyperglycemia and infection, and hyperglycemia and adverse events. Conclusion: In-hospital uncontrolled glycemia in patients with diabetes is associated with poor health outcomes. More studies should be conducted for better investigation because diabetes is a complex condition. Effects of glycemic dysregulation should be investigated according to overall health instead of the organ target perspective, which makes the investigation difficult.

scholarly journals Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review

2015 ◽  
Vol 7 (2) ◽  
pp. 174-180 ◽  
Author(s):  
Joshua Davis ◽  
Lee Ann Riesenberg ◽  
Matthew Mardis ◽  
John Donnelly ◽  
Branden Benningfield ◽  
...  
Keyword(s):  
Systematic Review ◽  
Patient Outcomes ◽  
English Language ◽  
Self Report ◽  
Current Evidence ◽  
Cross Sectional ◽  
Electronic Tool ◽  
Process And Outcome ◽  
Randomized Crossover Study

Abstract Background Multiple organizations have recognized that handoffs are prone to errors, and there has been an increase in the use of electronic health records and computerized tools in health care. Objective This systematic review evaluates the current evidence on the effectiveness of electronic solutions used to support shift-to-shift handoffs. Methods We searched the English-language literature for research studies published between January 1, 2008, and September 19, 2014, using National Library of Medicine PubMed, EBSCO CINAHL, OvidSP All Journals, and ProQuest PsycINFO. Included studies focused on the evaluation of physician shift-to-shift handoffs and an electronic solution designed to support handoffs. We assessed articles using a quality scoring system, conducted a review of barriers and strategies, and categorized study outcomes into self-report, process, and outcome measures. Results Thirty-seven articles met inclusion criteria, including 20 single group pre- and posttest studies; 8 posttest only or cross-sectional studies; 4 nonrandomized controlled trials; 1 cohort study; 1 randomized crossover study; and 3 qualitative studies. Quality scores ranged from 3.5 to 14 of a possible 16. Most articles documented some positive outcomes, with 2 of the 3 studies evaluating patient outcomes yielding statistically significant improvements. The only other study that analyzed patient outcomes showed that interventions other than the electronic tool were responsible for most of the significant improvements. Conclusions The majority of studies supported using an electronic tool, yet few measured patient outcomes, and numerous studies suffered from methodology issues. Future studies should evaluate patient outcomes, improve study design, assess the role of faculty oversight, and broaden the focus to recognize the role of human factors.

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