Digital Commons Network^™

Association Between The Dietary Index For Gut Microbiota (Di-Gm) And Colorectal Cancer In The Plco Cohort, Bezawit E. Kase, Angela D. Liese, Jiajia Zhang, Elizabeth Angela Murphy, Susan E. Steck

Faculty Publications

Objectives: The study aimed to examine the association between a dietary index for gut microbiota (DI-GM) and the risk of incident colorectal cancer (CRC). Clarifying the role of diet-induced alterations in the composition and function of gut microbiota on the development of CRC can contribute to prevention efforts. Methods: Participants from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening trial enrolled in the intervention arm and who completed baseline assessments were included in the analysis (n = 55,685). The DI-GM is a literature-derived index used to score diet quality in terms of maintaining healthy gut microbiota. A time-dependent Cox model …

An Atlas Of Genetic Effects On The Monocyte Methylome Across European And African Populations, Wanheng Zhang, Chuan Qiu, Xiao Zhang, Zichen Zhang, Kuan-Jui Su, Zhe Luo, Minghui Liu, Bingxin Zhao, Lang Wu, Qing Tian, Hui Shen, Chong Wu, Hong-Wen Deng

Faculty, Staff and Student Publications

No abstract provided.

Letter To The Editor: Evidence For A Two-Step Species-Level Pulmonary Nocardiosis Diagnostic Approach, John Halphen, Mohadese Ahmadzade, Babith Mankidy, Ashkan Berenji, Mohammad Ghasemi-Rad

Faculty, Staff and Students Publications

Pulmonary nocardiosis, a rare and diagnostically challenging infection, usually presents with heterogeneous radiographic findings, compounded by the low sensitivity of traditional confirmatory cultures. In their most recent work, Wang et al analyzed 102 patients with pulmonary nocardiosis to address these concerns, investigating species-characteristic imaging patterns, pathological associations, and the role of metagenomic next-generation sequencing (mNGS) in the diagnostic approach. High-resolution computed tomography (CT) in adult patients with pulmonary infections caused by Nocardia wallacei was demonstrated to have a sensitive (85.71%) and specific (83.34%) presentation of bronchopneumonia in relation to the five Nocardia species in the sample with CT data. The …

Influenza Infection Has Higher Risk Of Postoperative Complications Than Covid-19 In Shoulder Arthroplasty Patients, Jad J Lawand, Umar Ghilzai, Caleb Witsken, Dion Birhiray, Abdullah Ghali, Youssef M Khalafallah, Rohan G Reddy, Sameer R Khawaja, Adil Shahzad Ahmed

Faculty, Staff and Students Publications

INTRODUCTION: The COVID-19 pandemic has captured the attention of healthcare systems worldwide, and testing remains a mainstay of preoperative testing before all surgical procedures, including shoulder arthroplasty. Other viral illnesses, specifically influenza, while still having severe complications, are either overshadowed by testing for COVID-19 or not tested at all.

METHODS: A multi-institutional cohort study using the TriNetX network examined patients undergoing total or hemi shoulder arthroplasty from January 2020 to March 2024. Matched cohorts were created: one with influenza and one with COVID-19 infection, 14 days before surgery.

RESULTS: A total of 3233 and 18,209 patients were included in the …

Perinatal Obsessive-Compulsive Symptoms And Maternal-Infant Bonding: A Longitudinal Examination Of Depression And Relationship Quality, Journa Njoh, Jonathan S Abramowitz, Rashelle Musci, Mary C Kimmel, Lauren M Osborne, Jack Samuels, Paul Nestadt, Gerald Nestadt, Eric A Storch

Faculty, Staff and Students Publications

Background

Perinatal obsessive–compulsive (OC) symptoms are common and distressing, yet their impact on early parenting outcomes such as maternal-infant bonding remains poorly understood. Although prior research links maternal depression and anxiety to bonding difficulties, less is known about how perinatal OC symptoms relate to maternal-infant bonding over time, or the extent to which maternal-partner relationship quality is associated with these outcomes, and whether depressive symptoms explain observed associations.

Methods

Data were drawn from a longitudinal study of 256 pregnant women recruited from two U.S. sites between 2020 and 2023. Participants completed self-report and clinician-administered assessments at 20 weeks (PGWK20), 34 …

The Hexosamine Biosynthetic Pathway Alters The Cytoskeleton To Modulate Cell Proliferation And Migration In Aggressive Prostate Cancer, Rajina Shakya, Praveen Suraneni, Amit Rahi, Michael Y Young, Emily Cousino, Christine B Magdongon, Raju Gajjela, Basil B Mattamana, Alexander Zaslavsky, Ganesh S Palapattu, Arun Sreekumar, Dileep Varma

Faculty, Staff and Students Publications

Castration-resistant prostate cancer (CRPC) progresses despite androgen deprivation therapy, as cancer cells adapt to grow without testosterone, becoming more aggressive and prone to metastasis. CRPC biology complicates the development of effective therapies, posing challenges for patient care. Recent gene-expression and metabolomics studies highlight the Hexosamine Biosynthetic Pathway (HBP) as a critical player, with key components like GNPNAT1 (Glucosamine-phosphate N-acetyltransferase 1) being downregulated in CRPC. GNPNAT1 knockdown in pre-clinical models has been shown to increase growth and metastasis in CRPC tumors, though the mechanisms remain unclear.To investigate the cellular basis of these CRPC phenotypes, we generated a CRISPR-Cas9 knockout model of …

Structural Barriers And Clinical Outcomes: A Literature Review On The Role Of Social Determinants In Hiv Care Engagement And Viral Suppression, Vonda M. Mckeithan

Knowledge and Creativity Expo

This project explores how social and structural challenges, including unstable housing, poverty, and stigma, impact the ability of people living with HIV to stay in care and achieve viral suppression. It reviews recent research and argues that health interventions must go beyond the clinic and address broader social barriers to improve equity in HIV outcomes.

Maternal Respiratory Syncytial Virus Vaccination And Preterm Birth A Utah Statewide Retrospective Cohort Study, Amy Solsman, Torri Metz, Josh Benton, Shana Godfred-Cato

Knowledge and Creativity Expo

We conducted a statewide, retrospective cohort study to evaluate the association between maternal receipt of the respiratory syncytial virus (RSV) vaccine and preterm birth. All individuals who delivered a singleton neonate in Utah and were between 32 0/7 and 36 6/7 weeks of gestation from September 2023 to February 2024 were included and followed up until delivery. Overall, 2,733 of 24,213 individuals (11.3%) received the vaccine. Vaccine receipt was associated with lower odds of preterm birth (5.5% vaccinated group vs 6.8% unvaccinated group, adjusted odds ratio 0.80, 95% CI, 0.67–0.95). Receipt of the RSV vaccine was not associated with any …

Mendeley: Cite Smarter Not Harder, Jennifer Stockton

Library Class: Lunch & Learn

Tired of manually formatting bibliographies and struggling to keep your research organized? This class introduces you to Mendeley, the free, powerful reference manager that will revolutionize how you handle citations. Learn how to quickly capture and organize references, generate bibliographies in various citation styles (e.g., APA, MLA, Chicago), and deduplicate your results. Join us to save time, reduce errors, and focus on your research, not your formatting!

Epidemiologic Evaluation Of Canine Urate Urolithiasis In Thailand: A Comparative Cross-Sectional Study Between 2016-2023, Nattaporn Chaysakul, Jody P. Lulich, Vachira Hunprasit

The Thai Journal of Veterinary Medicine

A comparative cross-sectional study aimed to describe the epidemiological data of canine urate urolithiasis in Thailand by evaluating the change in proportion over the year and identifying risk-associated factors, including age, breed, sex, and neutered status, through comparisons with multiple comparison groups. The urate and non-urate group was dogs whose uroliths were submitted from Thailand to the Minnesota Urolith Center between 2016 and 2023, and the hospital group was dogs that were visited at the Small Animal Hospital, Chulalongkorn University, between 2020 and 2023. Of 6,171 canine urolith submissions, 210 samples (3.4%) were urate-containing uroliths submitted from twenty-eight canine breeds. …

Evaluation Of Serum Microrna-375 Concentration In Dogs With Diabetes Mellitus: A Pilot Study, Hyeongyeong Lee, Dohee Lee, Jayeon Park, Yeon Chae, Byeong-Teck Kang, Taesik Yun, Hakhyun Kim

The Thai Journal of Veterinary Medicine

Serum microRNAs (miRNAs) serve as diagnostic and prognostic biomarkers for various diseases. The serum concentration of miRNA-375 (miR-375), which is abundantly expressed in pancreatic islet cells, is increased in dogs with experimentally induced pancreatic injury and naturally occurring acute pancreatitis. However, this has not been reported in dogs with diabetes mellitus (DM). This study aimed to compare the expression of serum cfa-miR-375 between dogs with DM and healthy dogs and examine changes in serum cfa-miR-375 levels after insulin administration in dogs with DM. Twenty dogs with DM and 18 healthy dogs were included. The relative expression of serum cfa-miR-375 using …

Incidence Of High Volume Residual Gastric Content In Perioperative Patients Taking Glucagon-Like Peptide-1 Receptor Agonists, And Its Dependence On The Duration Of Preoperative Fasting And Drug Holding: A Prospective Observational Study, Marissa Huggins, Ion Hobai

Cumberland Medica

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs), including semaglutide and dulaglutide, are increasingly prescribed for type 2 diabetes mellitus and obesity. These agents delay gastric emptying and have been associated with a higher incidence of unexpected full stomachs in procedural patients. To prevent pulmonary aspiration, current recommendations include extending preoperative fasting (e.g., 24 hours instead of the standard 8 hours) and/or withholding the GLP-1RA medication before surgery (≥1 drug half-lives). However, the efficacy of these strategies have remained unclear and are evaluated in this study.

Hypothesis: GLP-1RA use in surgical patients is associated with increased incidence and volume of residual gastric …

Nest Project: A Community Partnership Based Solution For Supportive Cancer Care, Manav M. Patel, Sophie Callaway-Young, Sandhya Mudumbi

Cumberland Medica

Breast and prostate cancer patients in rural Tennessee often face significant barriers to accessing supportive oncology services such as palliative care, psychological counseling, and integrative oncology. These barriers include geographic isolation, limited broadband access, long wait times, and a lack of culturally attuned care. The NEST (Navigated, Embedded, Supportive Care via Telehealth) Project is a community-based participatory research (CBPR) initiative designed to co-develop telehealth-based supportive care interventions for rural patients in seven counties across three regions of Tennessee. This abstract focuses on preliminary findings from Region 1 (Dickson and Robertson Counties) Breast Cancer focus groups.

Four breast cancer focus group …

Service Dogs As An Intervention To Improve Sleep: A Systematic Review, Yvonne Monti, Sara Kuiken, Anna Owens, Rachel Madden, Skyler Roote

People and Animals: The International Journal of Research and Practice

Purpose: The use of service dogs as a holistic intervention has grown significantly in the past 10 years. Studies report positive impacts of service dogs on primary and secondary symptoms associated with various disabilities. Dysfunctional sleep is a common symptom among individuals receiving service dog assistance. This study investigates the efficacy of service dogs in improving co-occurring sleep dysfunction in handlers with various conditions.

Methods: A comprehensive search of Science Direct, ProQuest Psychology Journals, PubMed, MEDLINE, PsycINFO, and CINAHL was conducted in accordance with PRISMA guidelines, and 11 studies met inclusion criteria. Data extraction and quality assessment were conducted by …

Early Sepsis-Recognition Simulation Training: An Evidence-Based Initiative, Blanca A. Zavala

SACAD: Scholarly Activities

Sepsis is a life-threatening condition that requires rapid recognition and intervention to prevent poor patient outcomes. Delays in identification remain a significant concern for patient safety, particularly among nurses and nursing students who may lack confidence and clinical judgment in early sepsis recognition (Marsack et al., 2022). This evidence-based practice project aimed to examine the existing evidence on sepsis education and evaluate the effectiveness of simulation-based learning in improving clinical judgment and sepsis recognition, with the goal of informing a potential sepsis training initiative for nursing students.

A literature review of six peer-reviewed studies (2022–2026) was conducted using the PubMed …

Enhancing Staff Education For Remote Blood Pressure Monitoring In Rural Clinics, Judi Brown Brown

Walden Dissertations and Doctoral Studies

This is an educational intervention project targeted was developed to fill a knowledge gap in the treatment of hypertension in a rural primary care clinic. The project focused on enhancing staff education for Remote Blood Pressure Monitoring (RBPM) to enhance the desired patient outcomes regarding continuous monitoring and early interventional actions. The practice problem focuses on the lack of effective methods in managing hypertension that can facilitate the identification of hypertensive crisis and in rural areas. This project's primary research question is: "How can staff education on RBPM enhance knowledge and skills about hypertension management in rural clinics?" The project …

Assessment Of Routine, On-Demand Electroencephalograms For Seizure Detection In The Intensive Care Unit Of A Major Saudi Tertiary Center, Abdulrahman Yousef Aldayel, Homoud Alsahli, Rawabi Alhathlool, Afag Osman, Sonia Khan, Mohammed T. Alshahrani

Neurosciences

Objectives: To investigate the occurrence and characteristics of seizures using routine electroencephalograms (EEGs) in intensive care unit (ICU) patients.

Methods: We conducted a retrospective analysis on routine, portable EEGs of 188 adult ICU patients (53% male) in a large tertiary hospital in Riyadh, Kingdom of Saudi Arabia. We compared variables of interest using a t-test and chi-squared analyses and explored significant associations using binary logistic regression analysis.

Results: We found significant associations between the occurrence of seizures on EEGs and several variables, including patient age, ICU admission due to status epilepticus, history of epilepsy or previous neurosurgical procedure, coma state, …

Nurse Educators’ Understanding Of Social Justice As A Core Professional Value, Julie Larson, Msn, Rn

College of Nursing Posters

Background

• Health disparities persist along socially constructed lines
• Equity and social justice are prioritized as core values in The Essentials¹ and The Future of Nursing², yet social justice in nursing remains “abstractly defined and poorly operationalized”³ 
• Growing social determinants of health (SDoH) focus in nursing education with limited attention to structural causes

Key literature findings:

• Limited curricular inclusion of social justice; unclear understanding of student learning ^4,5,6
• Faculty hesitancy; lack of preparation to teach equity/social justice content ^7,8
• Predominance of Whiteness in nursing education ^9,10

Increasing Utilization Trends Of Robotic Assistance In Orthopaedic Surgery, Anish K. Ponna, Alec Giakas, Anthony A. Khoudary, Spencer N. Uggla, Sina Ramtin, Yousef A. Soliman, Asif M. Ilyas

Department of Orthopaedic Surgery Faculty Papers

INTRODUCTION: Robotic-assisted surgeries in orthopaedics have increased, particularly in hip and knee arthroplasty and spine surgeries. This study evaluates national utilization trends of robotic-assisted orthopaedic surgeries and demographic and geographic distribution of patients undergoing these surgeries.

METHODS: A retrospective cohort study was conducted on patients who underwent total hip arthroplasty, total and partial knee arthroplasty, or spine arthrodesis from 2017 to 2023 using the TriNetX database. Relevant International Classification of Diseases, 10th Revision, and Current Procedural Terminology codes identified patients who underwent a primary surgery with a corresponding robot-assisted code on the same day. Temporal trends in procedural volume were …

Strain Gauge Analysis And Deformation Detection Of Maxillary Denture Bases Reinforced By Cad/Cam Milled Zirconia And Cobalt Chromium (Co-Cr) Frameworks: An In-Vitro Study, Maha Nagy Kamal, Marwa Ezzat Sabet, Ghada Mahmoud Elgindy, Hebatallah Tarek Mohamed

Dentistry

Background A lot of studies have demonstrated the increased hardness of the reinforced maxillary dentures. However, the amount of stress induced by different reinforcement materials under the reinforcement dentures and their effect on the underlying supporting tissues and on the deformation of the denture bases were questionable. This study was conducted to compare the stresses induced within the supporting oral tissues from maxillary denture bases reinforced with computer-aided designing/computer-aided manufacturing CAD/CAM zirconia framework or cobalt chrome (Co-Cr) framework, and to detect the deformation that occurred to these bases. Materials and methods Twenty-six maxillary complete dentures were fabricated and divided into …

Impact Of Burnout And Sleep Deprivation On The Clinical Performance Of Neurology Residents: A Cross-Sectional Country Wide Study, Bandar N. Aljafen, Walaa S. Alkhamis, Rahmah M. Alsawad, Israa B. Alhamoud, Zahra B. Alamer, Waad A. Alshanqiti, Rawan M. Alenez

Neurosciences

Objective: To assess burnout (BU) and sleep deprivation (SD) among neurology residents and their impact on clinical performance (CP). This study is based on a neurology residents from Saudi Arabia.

Methods: This multi-centric, cross-sectional study invited 214 registered neurology residents in the country; 179 participated in the study. The Maslach Burnout Inventory (MBI), the Pittsburgh Sleep Quality Index (PSQI), and the Medical Council of Canada’s Physicians’ Self-Assessment Questionnaire (PSAQ) were used to evaluate burnout (BU) and sleep deprivation (SD) among neurology residents and their impact on clinical performance (CP).

Results: Of the total 214 registered neurology residents, 179 participated in …

Predictors Of Long-Term Outcome And Recurrence Of Intramedullary Spinal Ependymomas: A Multicenter Study, Reem Albuhairan, Laila Alqahtani, Ahmed Gamal Sayed, Ali Alkhaibary, Sami Khairy, Faisal Farash, Ali H. Alassiri, Ahmed Alkhani

Neurosciences

Objectives: To define prognostic factors that affect clinical outcome of patients after surgical resection of spinal intramedullary ependymoma.

Methods: A retrospective multi-center study, including all cases operated on from 2007 through 2024 at 3 institutes. Data on surgical factors included: resection extent, intraoperative neurophysiology monitoring methods, and intraoperative/postoperative complications.

Results: A total of 19 patients were included with a mean age of 37.8 years (SD = 13.2, range 8–57 years). The majority of ependymomas (n = 14, 73.7%) were in the cervical region. The most common presenting symptoms included pain in 14 patients (73.7%), sensory deficits in 11 patients (57.8%), …

Identifying Risk Factors For The Rising Prevalence Of Multiple Sclerosis In Saudi Arabia: A Case-Control Analysis, Omar Babateen, Jamil Adnan Samkari, Rewaa Abdulaziz Alkaki, Sadin Ayman Alamri, Manal Mutlaq Alzahrani, Mussaed Saleh Alharbi, Ali Abdulrazaq Alghamdi, Amwaj Sultan Aljurays, Amjad Faleh Aldosari, Seraj Makkawi

Neurosciences

Objective: This study aims to identify risk factors linked to the increasing prevalence of multiple sclerosis (MS) in Saudi Arabia. Multiple sclerosis is a chronic autoimmune condition affecting the central nervous system, marked by inflammation and damage to nerves and the myelin sheath.

Method: A case-control study conducted from September 2022 to January 2024 included 832 participants—263 diagnosed with MS and 569 controls. Controls were matched by age, gender, residence, and employment status. Data was collected using a validated questionnaire, with written consent obtained from participants aged 18 and older. Logistic regression analysis was used to ascertain risk factors.

Results: …

Efficacy Of Erenumab In Patients With Treatment-Resistant Chronic Migraine And Medication Overuse Headache, Mohamed F. Binfalah, Anwar A. Alrayyes, Hussein H. Alhafnawi, Moiz O. Bakhiet

Neurosciences

Objective: To evaluate the efficacy and safety of erenumab, a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor, in patients with treatment-resistant chronic migraine and medication overuse headache.

Methods: A single-center, retrospective observational study conducted at University Medical Center on 73 patients with both medication-overuse headache and treatment-resistant chronic migraine who failed at least three oral preventive medications and/or botulinum toxin injections. Clinical data were extracted from the medical records and patient interviews. The patients received monthly erenumab injections 70 mg. Key outcomes included monthly migraine days, headache severity (visual analog scale [VAS]), headache impact test (HIT-6), acute …

Association Between Extracranial Artery Stenosis And Cerebral Small-Vessel Disease In Patients With Ischemic Stroke, Ahmad Ghoochani-Khorasani, Seyed Hadi Aghili, Seyed Zakaria Hosseini, Seyed Amir Hasan Habibi, Mehri Farhangranjbar, Mahdi Abdi

Neurosciences

Objective: To review the relationship between extracranial artery stenosis (ECAS) severity and total cerebral small-vessel disease (CSVD) burden and evaluated 5-year mortality, disability, and stroke recurrence in ischemic stroke patients. Cerebral small-vessel disease and ECAS often share risk factors such as hypertension and atherosclerosis and coexist in ischemic stroke. Although ECAS affects large-artery disease, its impact on total CSVD burden on MRI and subsequent clinical outcomes is not well defined.

Methods: We retrospectively reviewed the medical records of 348 patients older than 35 who had suffered acute ischemic stroke and were admitted to selected hospitals in Tehran, Iran from March …

Vagal Nerve Stimulation As Therapy For Drug-Resistant Epilepsy: A Tertiary Hospital Experience Of Outcomes And Efficacy In King Abdullah Medical City, Bassam G. Sef, Abeer S. Albalawi, Ahmed M. Alhajji, Muhammed M. Irfan, Hanadi M. Abu Alela

Neurosciences

Objective: To determine the efficacy and safety of vagus nerve stimulation (VNS) for reducing the frequency of seizures and complications in drug-resistant epilepsy.

Methods: This was a retrospective case series study conducted in King Abdullah Medical City from January 2015 to December 2021 hospital record. All patients undergoing VNS were enrolled according to inclusion and exclusion criteria. Patients were followed up for 12 months, and the seizure frequency and number of epileptic drugs used were evaluated. A paired sample t-test was applied to compare the outcome variables considering p-value < 0.05 as significant.

Results: Among 9 enrolled patients, four were females, and five …

Insights Into Stroke Risk And Prediction For Underweight Individuals, Saeed Awad M. Alqahtani, Moutasem S. Aboonq

Neurosciences

This review explores the relationship between underweight status and stroke risk and outcomes. Although the impact of obesity on stroke is well-documented, the harmful effects of being underweight are often overlooked. Drawing on evidence from observational studies, case-control studies, and meta-analyses, this review highlights that underweight individuals face increased mortality, poorer functional recovery, and higher rates of major adverse cardiovascular events and recurrent strokes post-stroke. Challenges in stroke prediction for this population are examined, including the limited research focus, shortcomings of existing risk assessment tools such as the CHA₂DS₂-VASc score, and population-specific factors affecting underweight prevalence …

Key Attributes Of An Ideal Neurology Residency Candidate: Program Directors’ Perspectives, Bandar N. Aljafen, Ruwa A. Alneseyan, Rahmah M. Alsawad, Mohamed Bahr

Neurosciences

Objectives: To guide medical students and interns interested in neurology by identifying the key attributes of an ideal neurology candidate from the perspectives of neurology program directors (PDs).

Methods: In this cross-sectional study, former and current neurology PDs were contacted across Saudi Arabia to complete a self-administered survey sent via email or text. The survey included seven questions: six on PD demographics and a seventh with 51 items evaluating candidate attributes on a 7-point Likert scale from disadvantage to advantage.

Results: Thirty-two neurology PDs filled out the questionnaire. Among the key attributes PDs prioritized in a candidate is their letter …

Novel Enpp1 Gene Mutation Causing Generalized Arterial Calcification Of Infancy: A Case Report, Haifa M. Alturki, Haya S. Alfaris, Mohammed A. Al-Owain, Musaad F. Abukhalid

Neurosciences

Generalized Arterial Calcification of Infancy (GACI), a complex disorder affecting multiple systems, stems from an autosomal recessive mutation in the ENPP1 gene. This condition is marked by arterial stenosis and usually manifests prenatally or in the initial months following birth. High mortality rates characterize the first few months, a phase often termed the ``critical period.'' The report presents a case study of a four-year-old female with a new mutation in the ENPP1 gene, which broadens our understanding of this rare genetic disorder.

Associations Between Caregiver-Provider Communication Quality And Unmet Care Needs Among Older Adults, Jiaming Liang, Rafael Samper-Ternent, Brian Downer, Zhigang Xie

Faculty, Staff and Student Publications

BACKGROUND: Unmet care needs (lack of assistance with daily activities) among older adults are common and linked to adverse health outcomes, greater healthcare utilization, and caregiver burden. While effective patient-provider communication is known to improve care quality, less is understood about the role of caregiver-provider communication, particularly across sociodemographic, health, and caregiving contexts. METHODS: We conducted a cross-sectional secondary analysis of pooled 2021–2023 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC) data, restricted to community-dwelling older adults (65 + years) who received assistance from caregivers due to difficulty with daily activities, and had at least …