Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity

to identify quality improvement practices that could be disseminated among hospitals.”
“Photoluminescent diamino-substituted dinaphthopentalenes were synthesized successfully by the treatment of in situ prepared dinaphthocyclooctadiyne with lithium amide. This reaction involves a series of transformations including the nucleophilic addition of the lithium amide to a triple bond of the cyclooctadiyne moiety, transannulation, protonation of the resulting pentalene anion, and the nucleophilic substitution of the pentalene core with the lithium amide. In this procedure, a novel double

amination step plays a key role. Apoptosis Compound Library cell line When GDC-0973 inhibitor the diamino-substituted dinaphthopentalenes were irradiated with UV light in toluene, fluorescence was observed at around 580 nm (Phi(F) smaller than 0.03).”
“Nucleoside-derived anticancer agents must be transported across the plasma membrane as a preliminary step to their conversion into active drugs. Hence, modulation of a specific nucleoside transporter may affect bioavailability and contribute significantly to sensitizing tumor cells to these anticancer agents. We have generated and functionally characterized a new recombinant adenovirus (Ad-hENT1) that has allowed us to overexpress the equilibrative nucleoside transporter hENT1 and to analyze its effects in human pancreatic tumor cells. Overexpression of hENT1 is associated

with changes in cell cycle profile, in a variable manner depending on the particular cell Pitavastatin concentration type, thus suggesting a metabolic link between hENT1-mediated transport processes and the enzymatic machinery responsible for intracellular nucleoside metabolism. When assayed in vivo in a human pancreatic adenocarcinoma xenograft, intratumoral Ad-hENT1 injection improved the therapeutic response to gemcitabine. In summary, hENT1 overexpression is associated with alterations in nucleoside enzymatic machinery and cell cycle progression in cultured cells and enhances gemcitabine action in vivo. (C) 2008 Elsevier Inc. All rights reserved.”
“The role of CD4(+) helper T cells in modulating the acquired immune response to herpes simplex virus type 1 (HSV-1) remains ill defined; in particular, it is unclear whether CD4(+) T cells are needed for the generation of the protective HSV-1-specific CD8(+)-T-cell response. This study examined the contribution of CD4(+) T cells in the generation of the primary CD8(+)-T-cell responses following acute infection with HSV-1. The results demonstrate that the CD8(+)-T-cell response generated in the draining lymph nodes of CD4(+)-T-cell-depleted C57BL/6 mice and B6-MHC-II-/- mice is quantitatively and qualitatively distinct from the CD8(+) T cells generated in normal C57BL/6 mice.

High-level overexpression is also possible, facilitating biochemical and structural studies

of mycobacterial proteins produced in their native host. (C) 2008 Elsevier Ltd. All rights reserved”
“A total of 37 street vended food samples were examined for bacterial Tipifarnib and the colony forming units counts ranged from 4.5 x 10(5) to 1.12 x 10(6). The isolates were identified as Escherichia coli (37.5%), Pseudomonas aeruginosa (3.57%), Staphylococcus aureus (14.20%), Salmonella sp. (5.36%), Klebsiella sp. (10.71%), Shigella sp. (19.64%) and Enterobacter sp. (8.93%) respectively. All the 56 isolates were susceptible to ciprofloxacin while their susceptibility to the other drugs varied. These findings demonstrated that the ready-to-eat foods vended in Silchar city constitute an important potential hazard to human health and provision

of health education to the vendors would improve quality of street foods.”
“Objective: To present a case of hepatic hydatid cyst with a biliary click here communication that was not suitable for surgery and hence necessitated sclerotherapy with absolute alcohol after occluding the biliary communication with a balloon catheter. Clinical Presentation and Intervention: A 50-year-old Asian man presented to the surgical emergency department with a 1-year history of repeated attacks of obstructive jaundice and right hypochondrial pain. Ultrasound and contrast 4 computed tomography revealed a cyst, and endoscopic retrograde cholangiopancreatography and cystography revealed a biliocystic communication. An indirect hemagglutination test for echinococcosis showed the presence of antibodies to Echinococcus species at a titer of 8 establishing the diagnosis of hydatid cyst. Although surgery is the accepted modality of treatment in these cases, the patient was deemed unfit for surgery due to his underlying cardiac problem. MEK162 chemical structure While percutaneous treatment with absolute alcohol is contraindicated in his case, it was successfully attempted after balloon occlusion of the biliocystic communication. Conclusion: This

case showed that in this patient with hepatic hydatid disease and biliocystic communication, who was not fit for surgery, percutaneous sclerotherapy with absolute alcohol after balloon occlusion was successfully performed by an interventional radiologist. Copyright (C) 2011 S. Karger AG, Basel”
“Objective: The aim of this study was to determine the success of limited neck exploration (LE) for primary hyperparathyroidism (1 degrees HPT).\n\nMethods: Between 1999 and 2007, 1407 patients with hyperparathyroidism underwent bilateral neck exploration (BE). Of these, 1158 patients with first-time sporadic P HPT were analyzed prospectively. Based on surgeon-performed ultrasound (US) and sestamibi scan (MIBI), LE was initially performed. Regardless of results, BE followed to identify the presence of additional parathyroid pathology.

“
“Monoamine oxidase (MAO) inhibitors were the first antidepressant drugs to be prescribed and are still used today with great success, especially in patients resistant to other antidepressants. In this study, we evaluated the MAO inhibitory properties and the potential

antidepressant action of 2-(3,4-dimethoxy-phenyl)-4,5-dihydro-1H-imidazole (2-DMPI) in mice. We found that 2-DMPI 432 inhibited both MAO isoforms (K-i values were 1.53 (1.3-1.8) mu M and 46.67 (31.8-68.4) mu M for MAO-A and MAO-B, respectively) with 30-fold higher selectivity toward MAO-A. In relation to the nature of MAO-A inhibition, 2-DMPI showed ARS-1620 concentration to be a mixed and reversible inhibitor. The treatment with 2-DMPI (100-1000 mu mol/kg, s.c.) caused a significant decrease in immobility

time in the tail suspension test (TST) without affecting locomotor activity, motor coordination or anxiety-related activities. Conversely, moclobemide (1000 mu mol/kg, s.c.) caused a significant increase in immobility time in the TST, which appeared to be mediated by a nonspecific effect on motor coordination function. 2-DMPI (300 mu mol/kg, s.c.) decreased serotonin turnover in the cerebral cortex, hippocampus and striatum, whereas WH-4-023 dopamine turnover was diminished only in the striatum, and norepinephrine turnover was not changed. The antidepressant-like effect of 2-DMPI was inhibited by the pretreatment of mice with methysergide (2 mg/kg, s.c., a non-selective serotonin receptor antagonist), WAY100635 (0.1 mg/kg, s.c., a selective 5-HT1A receptor antagonist) or haloperidol (0.05 mg/kg, i.p., a non-selective dopamine receptor antagonist). These results suggest that 2-DMPI is a prototype reversible and preferential MAO-A inhibitor with potential antidepressant activity, due to its modulatory effect on serotonergic and dopaminergic systems. (c) 2012 Elsevier Inc. All rights reserved.”
“The operational and analytical performance of two automated triplex Selleckchem CHIR98014 hepatitis

B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) nucleic acid test (NAT) systems were compared in four screening laboratories of the French Blood Service.\n\nTwo laboratories evaluated the Procleix Tigris system (Chiron/Gen-Probe) in individual donation (ID) format and two sites used the cobas s 201 system (Roche Molecular Systems) on minipools (MPs) of six donations. The analytical sensitivity, the specificity, and operational performance were compared.\n\nThe ID to MP-NAT relative sensitivity factors in standard dilution panels of different genotypes varied between 8.7 and 21.9 for HCV RNA, 6.7 and 14.8 for HIV RNA, and 0.71 and 11.6 for HBV DNA. Tigris was 800-fold more sensitive than cobas s 201 (1:6) for a HIV group O sample, but did not detect the HIV-2 sample picked up by cobas s 201 with equal sensitivity as the HIV-1 group M samples. The specificity of both NAT systems after initial screening of 10,520 donations with Tigris and 1444 test pools on s 201 was 99.

\n\nMethods: Hundred consecutive patients with trauma admitted to a surgical intensive care unit at a level I trauma center were prospectively analyzed. Demographies, acid-base data and diagnoses, and interventions were collected. Patients were cared for by one physician using a PC approach, or four using conventional (CONV) acid-base balance techniques. The diagnoses and interventions made by CONV physicians were reviewed by the PC ACY-738 solubility dmso physician for accuracy and appropriateness using PC techniques. Data are mean +/- SD or percents; p values reflect PC evaluation of CONV analysis.\n\nResults: There were 50 PC

patients and 50 CONV. There were no differences in age (p = 0.13), injury severity score (p = 0.21), number of operations (p = 0.87), transfusions (p = 0.87), or survival (p = 0.15). CONV missed 12 diagnoses of metabolic acidosis (p = 0.03), 10 of hyperchloremic metabolic acidosis (p = 0.003), 11 metabolic alkalosis (p = 0.02), and 19 tertiary disorders (p < 0.001). CONV missed 38 diagnoses of increased unmeasured ions (p < 0.001). PC normalized their acid-base balance sooner than CONV (3.3 days +/- 3.4 days vs. 8.3 days +/- 7.4 days, p < 0.01).\n\nConclusions:

A PC approach imp roves acid-base diagnosis accuracy. selleck CONV often miss acidosis (particularly those because of hyperchloremia), alkalosis, and tertiary disorders. Inappropriate volume loading follows in the wake of misinterpretation selleck chemical of increased base 3 deficit using CONV and is avoided using PC. PC-directed therapy normalizes acid-base balance more rapidly than CONV.”
“Postoperative diplopia and strabismus may result from a variety of ocular surgical procedures. Common underlying mechanisms include sensory disturbance,

scarring, direct extraocular muscle injury, myotoxicity from injections of local anesthesia or antibiotics, and malpositioning of extraocular muscles by implant materials. The most common patterns are vertical and horizontal motility disturbance. Treatment options include prisms, botulinum, occlusion, or surgery. (Surv Ophthalmol 55:335-358, 2010. (C) 2010 Elsevier Inc. All rights reserved.)”
“Aim: The study aims to investigate affect recognition in young people at different stages of psychotic illness.\n\nMethods: Seventy-nine ultra-high risk patients, 30 first-episode schizophrenia patients and 30 healthy control subjects completed a facial affect labelling test and an affective prosody recognition test. Psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS).\n\nResults: We observed significant impairments in facial and vocal emotion recognition in both of the clinical groups compared with the control group. These group differences remained significant when age, sex and education were taken into account.

Placental and peripheral blood was collected for diagnosis of malaria by microscopy and rapid diagnostic tests (RDTs). Gestational age was estimated based on last menstrual period or Ballard score. Infant birth weights were recorded within 24 hours of delivery. Results: check details Of 431 participants, 167 (38.75%), 134 (31.09%), 104 (24.23%),

and 26 (6.03%) reported taking none, one, two, and bigger than = three doses of SP during pregnancy, respectively. The uptake of bigger than = three doses of IPTp-SP among delivering women at Geita hospital and Katoro health centre was 9.06% and 1.2%, respectively. The overall prevalence of malaria in pregnancy by RDT, peripheral and placental smears was 19.5%, 29.7% and 37.6% respectively. The prevalence of placental parasitaemia was higher for women who delivered at Katoro Health Centre (41.57%) than those

who delivered at Geita hospital (35.09%). The uptake of bigger than = three doses of SP was associated with reduced odds of having placental malaria (adjusted odds ratio (AOR) = 0.31, p = 0.039) compared to smaller than three doses. Women with placental parasitaemia were five times more likely to have delivered pre-term (AOR = 4.67, p = 0.002) and had lower mean birth weight infants than their uninfected counterparts (mean difference = 82 g, p = 0.039). Conclusions: The uptake of bigger than = three doses of IPTp-SP is low in the present study area. Placental parasitaemia eFT-508 chemical structure is prevalent and is associated with adverse birth outcomes. Receipt of bigger than = three doses of IPTp-SP reduced the odds of placental parasitaemia. Thus, increased efforts towards scale-up and continuous evaluation of IPTp-SP efficacy is recommended.”
“The

C-aryl glucoside 6 (dapagliflozin) was identified as a potent and selective hSGLT2 inhibitor which reduced blood glucose levels in a dose-dependent manner by as much as 55% in hyperglycemic streptozotocin (STZ) rats. These findings, combined with a favorable ADME profile, have prompted clinical learn more evaluation of dapagliflozin for the treatment of type 2 diabetes.”
“A binuclear copper complex, [Cu-2(BPMP) (OAc)(2)][ClO4]center dot H2O, has been prepared using the binucleating ligand 2,6-bis[bis(pyridin-2-ylmethylamino)methyl]-4-methylphenol (H-BPMP). The X-ray crystal structure reveals the copper centers to have a five-coordinate square pyramidal geometry, with the acetate ligands bound terminally. The bridging phenolate occupies the apical position of the square-based pyramids and magnetic susceptibility, electron paramagnetic resonance (EPR) and variable-temperature variable-field magnetic circular dichroism (MCD) measurements indicate that the two centers are very weakly antiferromagnetically coupled (J = -0.6 cm(-1)).

Chronic progressive headaches often indicate a serious underlying pathology such as a brain tumor and warrant a detailed neurological examination for signs of raised intracranial pressure (ICP) and focal deficits. Children with abnormal neurological findings require a neuroimaging. CT scan

usually detects most of the abnormalities. Initial stabilization and management of raised ICP takes precedence in sick children. While simple analgesics like paracetamol and ibuprofen are used for symptomatic therapy, identification and appropriate treatment of underlying conditions is necessary for complete resolution of headache.”
“Localized-surface-plasmon (LSP)-enhancement effect on one-photon buy AZD8186 photochromic ring-opening reaction of two diarylethene (DE) derivatives was studied using absorption https://www.selleckchem.com/products/jq-ez-05-jqez5.html spectroscopy.

DEs were doped in polymer films and those were coated onto Au-nanoparticles-integrated substrates. Acceleration of the one-photon photochromic reactions was observed in the presence of Au nanoparticles. The origin of the behavior was attributed to an enhancement effect of incident electromagnetic field by LSP. An alternative mechanism, i.e., photothermal effect was also experimentally examined and discussed. Crown Copyright (C) 2011 Published by Elsevier B.V. All rights reserved.”
“Spin Hall effect in a superconductor is theoretically studied. The spin injection from a ferromagnet into a superconductor creates quasiparticle spin and charge currents in SC, which generate charge

and spin currents in the transverse direction to accumulate spin and charge imbalance near the side edges of a superconductor. A giant enhancement of spin and charge accumulation signals in the side jump and skew scattering mechanisms of the spin Hall effect is predicted to occur at low temperatures in the superconducting state. (C) 2012 The Japan Society of Applied Physics”
“Aim Fire is a key agent in savanna systems, yet the capacity to predict fine-grained population phenomena Sapitinib datasheet under variable fire regime conditions at landscape scales is a daunting challenge. Given mounting evidence for significant impacts of fire on vulnerable biodiversity elements in north Australian savannas over recent decades, we assess: (1) the trajectory of fire-sensitive vegetation elements within a particularly biodiverse savanna mosaic based on long-term monitoring and spatial modelling; (2) the broader implications for northern Australia; and (3) the applicability of the methodological approach to other fire-prone settings. Location Arnhem Plateau, northern Australia. Methods We apply data from long-term vegetation monitoring plots included within Kakadu National Park to derive statistical models describing the responses of structure and floristic attributes to 15 years of ambient (non-experimental) fire regime treatments.

We investigate the choice of the underlying parametric distribution function and find that the two-sided power distribution function is well suited both from a computational and mathematical

point of view. The model is motivated by traditional nonlinear models for dose-response analysis, and provides possibilities to elicitate informative prior distributions on different aspects of the curve. The method is compared with other recent approaches to monotone nonparametric regression in a simulation study and is illustrated on a data set from dose-response analysis.”
“Bleeding from the anastomotic site is a frequent complication of surgery for acute aortic dissection. Many methods have been devised in order to avoid this problem. We report a simple, easy Fedratinib datasheet technique to reinforce the anastomotic sites. One small 4-mm-high ring is cut from the same prosthesis and click here placed circumferentially inside the aorta edge. Another ring of the same width is opened in a “C” shape, and placed outside the aorta. The conduit was eventually sutured to the aorta in a standard fashion using a running 3-0 polypropylene suture. The final result appeared good with no bleeding, and the rim lines appear clearer and the edges easier to suture because the Dacron is thinner than other used materials (that is, Teflon). In our opinion, this technique

is a simple method to reinforce the anastomosis for both proximal and distal aorta.\n\n(J Card Surg 2009;24:173-174).”
“Scope: Cell defenses regulating homeostatic control of postprandial stress are influenced by interindividual variation, food composition and health status. This study investigates effects of Baf-A1 food composition on individual postprandial responses and associations with health. Methods and results: Volunteers (n = 16) consumed four food formulations (50% unsaturated/saturated

fat, with/without beetroot extract 10 g/100 g) on separate occasions. GeXP assay measured whole blood postprandial gene expression profiles of 28 cell defense markers at baseline and postprandial time points 1, 2, 4, 6, 24 h. Plasma markers of metabolic lipids, hormones, inflammatory cytokines, oxidative stress, and DNA damage/repair were also assessed. SIRT 1, UCP2, HO1, GSS, PTGS2, TP53, CDKN2A, PPIA, SOCS3, and APE1 expression profiles revealed distinct stratified subgroups associated with plasma HDLs, TNF-alpha and postprandial responses of SOCS3, and PPIA. Leptin, IL6, and DNA strand breaks revealed differing responses to fat type consumed. Conclusion: This study demonstrates postprandial immune, inflammatory, redox, metabolic, and DNA repair responses that are largely independent of fat type consumed (unsaturated/saturated) or addition of beetroot extract, in apparently healthy individuals.

Magnetic susceptibility studies indicate antiferromagnetic coupling between the Cu+2 ions with a singlet ground-state and triplet excited-state separated by |2J = 319(1) cm(-1)|.”
“Optimal carbon allocation to growth, defense, or storage is a critical trait in determining the shade tolerance of tree

species. Thus, examining interspecific differences in carbon allocation patterns is useful when evaluating niche partitioning in forest communities. We hypothesized that shade-tolerant species allocate more carbon to defense and storage and less to growth compared to shade-intolerant species. In gaps and Selleck Trichostatin A forest understory, we measured relative growth rates (RGR), carbon-based defensive compounds (condensed tannin, total phenolics), and storage compounds (total non-structural carbohydrate; TNC) in seedlings of two tree species differing selleck in shade tolerance. RGR was greater in the shade-intolerant species, Castanea crenata, than in the shade-tolerant species, Quercus mongolica var. grosseserrata, in gaps, but did not differ between the species in the forest understory. In contrast, concentrations

of condensed tannin and total phenolics were greater in Quercus than in Castanea at both sites. TNC pool sizes did not differ between the species. Condensed tannin concentrations increased with increasing growth rate of structural biomass (GRstr) in Quercus but not in Castanea. TNC pool sizes increased with increasing GRstr in both species, but the rate of increase did not differ between the species. Accordingly, the amount of condensed tannin against TNC pool sizes was usually higher in Quercus than in Castanea. www.selleckchem.com/products/cl-amidine.html Hence, Quercus preferentially invested more carbon in defense than in storage. Such a large allocation of carbon to defense would be advantageous for a shade-tolerant species, allowing Quercus to persist in the forest understory where damage from herbivores and pathogens is costly. In contrast, the shade-intolerant Castanea preferentially invested more carbon in growth rather

than defense (and similar amounts in storage as Quercus), ensuring establishment success in gaps, where severe competition occurs for light among neighboring plants. These contrasting carbon allocation patterns are closely associated with strategies for persistence in these species’ respective habitats.”
“Convolvulus arvensis L. causes special problems because of its ability to reproduce both through seeds but particularly through vegetative propagation, and also because it’s relative tolerance to numerous herbicides. Extending new tillage systems, conservative systems specific to conservative sustainable agriculture, is a difficult task to accomplish under the circumstances of strong dicotyledonous perennial weed infestation. C. arvensis is one of the most dangerous perennial dicotyledonous weeds when applying minimum tillage systems.

Air drying slightly reduced the oxygen transmission rate (OTR) of the amnion and the value significantly dropped after 15 kGy (p smaller than 0.05). Glycerol preservation significantly reduced (p

smaller than 0.05) the OTR indicating less oxygen transmitted through the well structured cells of the amnion. Increase in the OTR with the increasing radiation doses up to 35 kGy possibly due to direct effects of radiation that resulted in large intercellular gaps. Both preservation methods significantly increased (p smaller than 0.05) the water vapour transmission rate (WVTR). IPI 145 However, the low WVTR in the air dried amnion at 15 and 25 kGy was postulated due to cross-linking of collagen. Changes in the biophysical properties can be linked to direct and indirect effects of radiation on collagen 3 bundles. The radiation dose of 25 kGy caused no adverse effect on biophysical properties hence GSK2126458 inhibitor it is still acceptable to sterilize both the air dried and the glycerol preserved amnions.”
“Patients with HIV/AIDS on antiretroviral therapy (ART) live longer and now require surgery for indications similar to those described for the general population. They have been previously

reported to carry higher mortality and complication rates, especially septic complications. The aim of this study was to compare the outcome of major abdominal surgery in three groups of patients with different CD4 counts. This is a prospective study comparing HIV-negative patients and two groups

of HIV-infected patients on ART with different CD4 counts. The primary outcomes considered were mortality and complication rates after abdominal surgery. We emphasised on the value of CD4 as a predictor of outcome and the impact of the indication for surgery (septic versus non-septic). We included 63 patients (21 per group). The majority of patients (71 %) were operated on as an emergency and the indications were similar in all groups. The overall and the septic complication PCI-34051 ic50 rates were both higher in the group with a low CD4 count. This resulted in a significantly longer admission period but did not result in a higher mortality rate. The duration of ART and the World Health Organisation stage of the disease did not significantly influence surgical outcomes. HIV-infected patients on ART can now safely undergo major abdominal surgery with encouraging results though still relatively poorer than those of HIV-negative subjects. CD4 count remains a significant predictor of outcome and patients with a low CD4 count, however, still require closer pre- and post-operative monitoring.”
“Background aims. Mucopolysaccharidosis type I (MPS I) is characterized by deficiency of the enzyme alpha-L-iduronidase (IDUA) and storage of glycosaminoglycans (GAG) in several tissues. Current available treatments present limitations, thus the search for new therapies.

\n\nOccupational diesel exhaust exposure was assessed previously using an algorithm and a single rater for all 14 983 jobs reported by 2631 study participants during personal

interviews conducted from 2001 to 2004. Two additional raters independently assessed a random subset of 324 jobs that were selected based on strata defined by the cross-tabulations of the algorithm and the first raters probability assessments for each job, oversampling buy AG-014699 their disagreements. The algorithm and each rater assessed the probability, intensity and frequency of occupational diesel exhaust exposure, as well as a confidence rating for each metric. Agreement among the raters, their aggregate rating (average of the three raters ratings) and the algorithm were evaluated using proportion of agreement, kappa and weighted kappa ((w)). Agreement

analyses on the subset used inverse probability weighting to extrapolate the subset to estimate agreement for all jobs. Classification and Regression Tree (CART) models were used to identify patterns in questionnaire responses that predicted disparities in exposure status (i.e., 123 unexposed versus LY2835219 chemical structure exposed) between the first rater and the algorithm-based estimates.\n\nFor the probability, intensity and frequency exposure metrics, moderate to moderately high agreement was observed among raters ((w) 0.500.76) and between the algorithm and the individual raters ((w) 0.580.81). For these metrics, the algorithm estimates had consistently higher agreement with the aggregate rating ((w) 0.82) than with the individual raters. For all metrics, the agreement between the algorithm and the aggregate ratings was highest for the unexposed category (9093%) and was poor to moderate for the exposed categories (964%). Lower agreement was observed for jobs with a start year < 1965 versus 1965. For the confidence metrics, the agreement was poor to moderate among raters ((w) 0.170.45)

and between the algorithm and the individual raters ((w) 0.240.61). CART models identified patterns in the questionnaire responses SB203580 in vivo that predicted a fair-to-moderate (3389%) proportion of the disagreements between the raters and the algorithm estimates.\n\nThe agreement between any two raters was similar to the agreement between an algorithm-based approach and individual raters, providing additional support for using the more efficient and transparent algorithm-based approach. CART models identified some patterns in disagreements between the first rater and the algorithm. Given the absence of a gold standard for estimating exposure, these patterns can be reviewed by a team of exposure assessors to determine whether the algorithm should be revised for future studies.