Digital Commons Network^™

The Relationship Between The Effects Of Rape, Posttraumatic Stress Disorder, Complex Trauma, And Post-Attack Victim-Perpetrator Interaction In Female College Students, Stephanie Christine Bell

Electronic Theses and Dissertations

The purpose of this study was to assess for effects of rape that are specific to women attending college and for relationships between the effects of rape, Posttraumatic Stress Disorder, previous trauma, complex trauma, and post-attack victim-perpetrator interaction to fill gaps in the literature around these issues. The survey was distributed to all female undergraduates at the main campus of a large, public university in the south (N ≈ 8,400). The sample consisted of 463 women (response rate = 5.5%). The majority of participants were between the ages of 18-22, Caucasian, lived off-campus, and with roommates. Participants received an e-mail …

Stratification Of The Impact Of Inappropriate Empirical Antimicrobial Therapy For Gram-Negative Bloodstream Infections By Predicted Prognosis, Sarah E. Cain, Joseph Kohn, P. Brandon Bookstaver, Helmut Albrecht, Majdi N. Al-Hasan

Faculty Publications

The bloodstream infection mortality risk score (BSIMRS) predicts the outcome of patients with Gram-negative bloodstream infections (BSI) with high discrimination. This retrospective cohort study examined the impact of inappropriate antimicrobial therapy on mortality in adult patients with Gram-negative BSI admitted to Palmetto Health Hospitals in Columbia, SC, USA, from 1 January 2011 to 31 December 2012 after stratification by predicted prognosis at initial presentation using BSIMRS. A multivariate Cox regression model was used to identify independent risk factors for 28-day mortality overall and within each predefined BSIMRS category (<5, 5 to 9, and ≥10). Relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to treat (NNT) were calculated from a predictive logistic regression model of mortality. Overall, 390 unique patients with first episodes of Gram-negative BSI were identified. The median age was 66 years, and 229 (59%) were women. There was significant association between inappropriate antimicrobial therapy and mortality in patients with BSIMRS of 5 to 9 (adjusted hazard ratio [aHR], 3.55; 95% confidence intervals [CI], 1.22 to 8.31; P = 0.02) and BSIMRS of ≥10 (aHR, 4.99; 95% CI, 1.09 to 22.87; P = 0.04) but not in those with BSIMRS of <5 (aHR, 3.34; 95% CI, 0.17 to 22.77; P = 0.34). RRR, ARR, and NNT were 0.25, 0.02, and 63 for BSIMRS of <5; 0.56, 0.32, and 3 for BSIMRS of 5 to 9; and 0.39, 0.39, and 3 for BSIMRS of ≥10, respectively. There is a significant benefit from appropriate antimicrobial therapy in patients with Gram-negative BSI with guarded (BSIMRS of 5 to 9) and poor (BSIMRS of ≥10) predicted prognosis. Survival difference remains unclear among those with good predicted prognosis (BSIMRS of <5) at initial presentation.

A Coding Variant In Tmc8 (Ever2) Is Associated With High Risk Hpv Infection And Head And Neck Cancer Risk, Caihua Liang, Karl T. Kelsey, Michael D. Mcclean, Brock C. Christensen, Carmen J. Marsit

Dartmouth Scholarship

HPV infection is a causal agent in many epithelial cancers, yet our understanding of genetic susceptibility to HPV infection and resultant cancer risk is limited. Epidermodysplasia Verruciformis is a rare condition of extreme susceptibility to cutaneous HPV infection primarily attributable to mutations in TMC6 and TMC8. Genetic variation in the TMC6/TMC8 region has been linked to beta-type HPV infection and squamous cell carcinoma of the skin, cervical cancer, HPV persistence and progression to cervical cancer. Here, we have tested the hypothesis that the common TMC8 SNP rs7208422 is associated with high-risk HPV infection and risk of head and neck …

Anti-Cancer Activity Of Withaferin A In B-Cell Lymphoma., M K Mckenna, B W Gachuki, S S Alhakeem, K N Oben, V M Rangnekar, R C Gupta, Subbarao Bondada

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Withaferin A (WA), a withanolide from the plant, Ashwagandha (Withania somnifera) used in Ayurvedic medicine, has been found to be valuable in the treatment of several medical ailments. WA has been found to have anticancer activity against various solid tumors, but its effects on hematological malignancies have not been studied in detail. WA strongly inhibited the survival of several human and murine B cell lymphoma cell lines. Additionally, in vivo studies with syngeneic-graft lymphoma cells suggest that WA inhibits the growth of tumor but does not affect other proliferative tissues. We demonstrate that WA inhibits the efficiency of NF-κB nuclear …

Differences In Breast-Feeding Initiation And Continuation By Maternal Diabetes Status, Reena Oza-Frank, Ilana Chertok, Adam Bartley

Faculty & Staff Scholarship

To examine (i) the prevalence of and associations between breast-feeding initiation and continuation by maternal diabetes status and (ii) the reasons for not initiating and/or continuing breast-feeding by maternal diabetes status. Secondary data analyses of a population-based cross-sectional study were conducting using data from the US Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS), 2009-2011. Multivariable logistic regression was used to investigate the associations between breast-feeding initiation and continuation by diabetes status. Thirty states and New York City, USA. Mothers of recently live-born infants, selected by birth certificate sampling. Among 72755 women, 8.8 % had gestational …

Acute Kidney Injury Risk Prediction In Patients Undergoing Coronary Angiography In A National Veterans Health Administration Cohort With External Validation, Jeremiah R. Brown, Todd A. Mackenzie, Thomas M. Maddox, James Fly, Thomas T. Tsai, Mary E. Plomondon, Christopher D. Nielson, Edward D. Siew, Frederic S. Resnic, Clifton R. Baker, John S. Rumsfeld, Michael E. Matheny

Dartmouth Scholarship

Background:

Acute kidney injury (AKI) occurs frequently after cardiac catheterization and percutaneous coronary intervention. Although a clinical risk model exists for percutaneous coronary intervention, no models exist for both procedures, nor do existing models account for risk factors prior to the index admission. We aimed to develop such a model for use in prospective automated surveillance programs in the Veterans Health Administration.

Methods and Results:

We collected data on all patients undergoing cardiac catheterization or percutaneous coronary intervention in the Veterans Health Administration from January 01, 2009 to September 30, 2013, excluding patients with chronic dialysis, end‐stage renal disease, renal …

Does Self-Care Moderate The Relation Of Stress To Quality Of Life Of Female Doctoral Students In Professional Psychology?, Erin Elizabeth Ayala

Legacy Theses & Dissertations (2009 - 2024)

Increasing numbers of women are pursuing doctoral degrees in psychology, and the stress of being a female doctoral student can create a risk for aversive consequences (e.g., ineffective clinical work, impaired competence). Psychologists lack an understanding of the extent to which women can protect themselves from undue stress in professional psychology programs by engaging in self-care. The lack of a comprehensive framework for this phenomenon calls for the need to apply and test the Health Promotion Model to the experience of women in professional psychology programs. The current investigation assessed the extent to which self-care activities would moderate the negative …

The Feasibility, Acceptability, And Effectiveness Of A School-Based Motivational Interviewing Intervention For Adolescent Females, Vanessa Durand

Electronic Theses and Dissertations

Motivational Interviewing (MI) is an evidence-based therapeutic approach shown to elicit behavior change in adolescents engaged in risky behavior. MI is used to increase the individuals feeling of self-efficacy and outcome expectancy. Female adolescents engaged in substance use, sexual activity and identified as academically disengaged were provided an MI intervention in their alternative education setting. According to the Social Cognitive Theory, MI is well suited toward supporting individual behavior change. Results showed that MI is an acceptable intervention to at-risk adolescent females. However, feasibility considerations highlighted the implementation barriers present in this alternative high school as well as those in …

Age-Related Factors Influencing The Occurrence Of Undernutrition In Northeastern Ethiopia, Abraham Degarege, Elifaged Hailemeskel, Berhanu Erko

Journal Articles: Epidemiology

BACKGROUND: Undernutrition is a major public health problem on the globe particularly in the developing regions. The objective of the current study was to assess the prevalence of undernutrition in different age groups and examine the relationship of the disease to parasitic and socioeconomic factors among communities in Harbu Town, northeastern Ethiopia.

METHODS: Stool samples of the study participants were examined for intestinal helminth infections using the Kato-Katz method. Blood specimens were diagnosed for Plasmodium infection using CareStartTM Malaria Pf/Pv Combo test. The blood type was determined from blood samples using antisera A and antisera B. In addition, the height …

A New Ethical Model For The Analysis Of Care For Refugee Women Who Experience Female Genital Cutting, Sharon R. Higginbothan

Electronic Theses and Dissertations

The United States is rapidly becoming a location for refugee women who are migrating from countries that embrace different and distinctive practices. One such practice is Female Genital Cutting/ mutilation (FGC/m). FGC is a medical procedure that alters the natural structure and functioning of the female body. It is also a cultural tradition and custom. Until recently, worldwide studies estimated that approximately 80 to 140 million women have undergone FGC and that 228, 000 of those women live in the U.S. However, the estimate of women and girls in the U.S. living with or at risk from FGC has grown …

A Time-Efficient Web-Based Teaching Tool To Improve Medical Knowledge And Decrease Abim Failure Rate In Select Residents, Sean Drake, Waqas Qureshi, William Morse, Kimberly Baker-Genaw

Internal Medicine Articles

AIM: The American Board of Internal Medicine (ABIM) exam's pass rate is considered a quality measure of a residency program, yet few interventions have shown benefit in reducing the failure rate. We developed a web-based Directed Reading (DR) program with an aim to increase medical knowledge and reduce ABIM exam failure rate.

METHODS: Internal medicine residents at our academic medical center with In-Training Examination (ITE) scores ≤ 35 th percentile from 2007 to 2013 were enrolled in DR. The program matches residents to reading assignments based on their own ITE-failed educational objectives and provides direct electronic feedback from their teaching …

Concordance Of Self-Report And Measured Height And Weight Of College Students, Virginia Quick, Carol Byrd-Bredbenner, Suzanne Shoff, Adrienne A. White, Barbara Lohse, Tanya Horacek, Kendra Kattelmann, Beatrice Phillips, Sharon L Hoerr, Geoffrey Greene

Health and Nutritional Sciences Faculty Publications

OBJECTIVE: This study examined associations between college students' self-report and measured height and weight.

METHODS: Participants (N = 1,686) were 77% white, 62% female, aged 18-24 years (mean ± SD, 19.1 ± 1.1 years), and enrolled at 8 US universities. Body mass index (BMI) was calculated for self-report (via online survey); trained researchers measured height and weight and categorized them as normal (18.5 to < 25), overweight (25 to < 30), obese (30 to < 35), and morbidly obese (≥ 35).

RESULTS: Concordance of self-report vs objectively measured BMI groups using chi-square revealed that 93% were accurate, 4% were underestimated, and 2.7% were overestimated. Pearson correlations and adjusted linear regression revealed significant associations between self-report and measured …

Joint Impact Of Clinical And Behavioral Variables On The Risk Of Unplanned Readmission And Death After A Heart Failure Hospitalization, Badri Padhukasahasram, Chandan K. Reddy, Yan Li, David Lanfear

Cardiology Articles

Most current methods for modeling rehospitalization events in heart failure patients make use of only clinical and medications data that is available in the electronic health records. However, information about patient-reported functional limitations, behavioral variables and socio-economic background of patients may also play an important role in predicting the risk of readmission in heart failure patients. We developed methods for predicting the risk of rehospitalization in heart failure patients using models that integrate clinical characteristics with patient-reported functional limitations, behavioral and socio-economic characteristics. Our goal was to estimate the predictive accuracy of the joint model and compare it with models …

Methodological Considerations In Estimation Of Phenotype Heritability Using Genome-Wide Snp Data, Illustrated By An Analysis Of The Heritability Of Height In A Large Sample Of African Ancestry Adults, Fang Chen, Jing He, Jianqi Zhang, Gary K. Chen, Venetta Thomas, Christine B. Ambrosone, Elisa V. Bandera, Sonja I. Berndt, Leslie Bernstein, William J. Blot, Qiuyin Cai, John Carpten, Graham Casey, Stephen J. Chanock, Iona Cheng, Lisa Chu, Sandra L. Deming, W. Ryan Driver, Phyllis Goodman, Richard B. Hayes, Anselm J. M. Hennis, Ann W. Hsing, Jennifer J. Hu, Sue A. Ingles, Esther M. John, Rick A. Kittles, Suzanne Kolb, M. Cristina Leske, Robert C. Millikan, Kristine R. Monroe, Adam Murphy, Barbara Nemesure, Christine Neslund-Dudas, Sarah Nyante, Elaine A. Ostrander, Michael F. Press, Jorge L. Rodriguez-Gil, Benjamin A. Rybicki, Fredrick Schumacher, Janet L. Stanford, Lisa B. Signorello, Sara S. Strom, Victoria Stevens, David Van Den Berg, Zhaoming Wang, John S. Witte, Suh-Yuh Wu, Yuko Yamamura, Wei Zheng, Regina G. Ziegler, Alexander H. Stram, Laurence N. Kolonel, Loïc Le Marchand, Brian E. Henderson, Christopher A. Haiman, Daniel O. Stram

Public Health Sciences Articles

Height has an extremely polygenic pattern of inheritance. Genome-wide association studies (GWAS) have revealed hundreds of common variants that are associated with human height at genome-wide levels of significance. However, only a small fraction of phenotypic variation can be explained by the aggregate of these common variants. In a large study of African-American men and women (n = 14,419), we genotyped and analyzed 966,578 autosomal SNPs across the entire genome using a linear mixed model variance components approach implemented in the program GCTA (Yang et al Nat Genet 2010), and estimated an additive heritability of 44.7% (se: 3.7%) for this …

Targeted Mutational Profiling Of Peripheral T-Cell Lymphoma Not Otherwise Specified Highlights New Mechanisms In A Heterogeneous Pathogenesis., J. H. Schatz, S. M. Horwitz, J. Teruya-Feldstein, Matthew A. Lunning, A. Viale, K. Huberman, N. D. Socci, N. Lailler, A. Heguy, I. Dolgalev, J. C. Migliacci, M. Pirun, M. L. Palomba, D. M. Weinstock, H-G Wendel

Journal Articles: Oncology and Hematology

No abstract provided.

Evaluation Of Common Risk Factors For Breast Carcinoma In Females: A Hospital Based Study In Karachi, Pakistan, Saira Naz, Imrana Masroor, Waseem Mirza, Sehrish Abrar, Shaista Afzal Saeed, Zafar Sajjad

Department of Radiology

Background: Breast malignancies are one of the leading causes of deaths in females worldwide. There are a number of risk factors associated with breast cancer but in Karachi Pakistan there are insufficient data available.
Materials and methods: A case control study was conducted on females in age group between 30-80 years. This study was accomplished by retrospective data collection in Aga Khan University Hospital Karachi, Pakistan. A total of 108 females with primary malignancy of breast were included along with 108 matched controls. Relationship of various factors with disease was studied using logistic regression to calculate odds ratios with 95 …

Sulforaphane Reverses The Expression Of Various Tumor Suppressor Genes By Targeting Dnmt3b And Hdac1 In Human Cervical Cancer Cells, Munawwar Ali Khan, Madhumitha Kedhari Sundaram, Amina Hamza, Uzma Quraishi, Dian Gunasekera, Laveena Ramesh, Payal Goala, Usama Al Alami, Mohammad Zeeshan Ansari, Tahir A. Rizvi, Chhavi Sharma, Arif Hussain

All Works

© 2015 Munawwar Ali Khan et al. Sulforaphane (SFN) may hinder carcinogenesis by altering epigenetic events in the cells; however, its molecular mechanisms are unclear. The present study investigates the role of SFN in modifying epigenetic events in human cervical cancer cells, HeLa. HeLa cells were treated with SFN (2.5 μM) for a period of 0, 24, 48, and 72 hours for all experiments. After treatment, expressions of DNMT3B, HDAC1, RARβ, CDH1, DAPK1, and GSTP1 were studied using RT-PCR while promoter DNA methylation of tumor suppressor genes (TSGs) was studied using MS-PCR. Inhibition assays of DNA methyl transferases (DNMTs) and …

Outcome Predictability Biases Learning., Oren Griffiths, Chris J. Mitchell, Anna Bethmont, Peter F. Lovibond

School of Psychology

Much of contemporary associative learning research is focused on understanding how and when the associative history of cues affects later learning about those cues. Very little work has investigated the effects of the associative history of outcomes on human learning. Three experiments extended the "learned irrelevance" paradigm from the animal conditioning literature to examine the influence of an outcome's prior predictability on subsequent learning of relationships between cues and that outcome. All 3 experiments found evidence for the idea that learning is biased by the prior predictability of the outcome. Previously predictable outcomes were readily associated with novel predictive cues, …

Safety And Effectiveness Of A New Toric Presbyopia-Correcting Posterior Chamber Silicone Intraocular Lens., Jay S. Pepose, Jon Hayashida, John Hovanesian, James Davies, Phillips Kirk Labor, Jeffrey Whitman, Harvey Carter, Michael Colvard, Phillip J. Buckhurst, Omid Khodai, David Mittleman, Gregg Feinerman

School of Health Professions

PURPOSE: To evaluate the safety and effectiveness of the Trulign toric intraocular lens (IOL) in adults with cataract. SETTING: Eight private practices in the United States and 1 in Canada. DESIGN: Prospective randomized single-masked multicenter study. METHODS: A toric IOL (1.25 D, 2.00 D, or 2.75 D, determined by a toric calculator) was implanted in eligible patients with age-related cataract requiring a 16.00 to 27.00 diopter (D) spherical IOL power and with a predicted postoperative astigmatism of 0.83 to 2.50 D. Eyes within the lowest cylinder range (predicted postoperative astigmatism 0.83 to 1.32 D) were randomized in a 1:1 ratio …

Effective, Clinically Feasible And Sustainable: Key Design Features Of Psycho-Educational And Supportive Care Interventions To Promote Individualised Self-Management In Cancer Care, P. Schofield, Suzanne Chambers

Research outputs 2014 to 2021

As the global burden of cancer increases healthcare services will face increasing challenges in meet the complex needs of these patients, their families and the communities in which they live. This raises the question of how to meet patient need where direct clinical contact may be constrained or not readily available. Patients and families require resources and skills to manage their illness outside of the hospital setting within their own communities. Aim. To propose a framework for the development and delivery of psycho-educational and supportive care interventions drawing on theoretical principles of behaviour change and evidence-based interventions, and based on …

The (Re)Naturalization Of Margaret Cavendish: Making Active The Relationship Between Nature And Female Subjectivity In Blazing World, Daniel P. Richards, Julie Chappell (Ed.), Kamille Stone Stanton (Ed.)

English Faculty Publications

No abstract provided.

More Than A Woman: Insights Into Corporate Governance After The French Sex Quota, Darren Rosenblum, Daria Roithmayr

Faculty Publications

In 2011, France enacted a Corporate Board Quota to establish a forty percent floor for either sex on corporate boards. Existing literature presumes that women will change the way firms function and that their presence in upper management will improve both governance and financial returns. To assess the potential impact of the quota, we interviewed twenty-four current and former corporate board members. Our analysis of these interviews generates two findings. First, our results indicate that, at least in the view of board members, the sex quota has had an impact on the process of board decision-making, but adding women has …

Effects Of Supplemental Energy On Beef Female Performance, Sara Ann Mccullough

Open Access Theses

ABSTRACT

Women's Fitness Week, Claire T. Lucas, Tiffany M. Finch

Williams Honors College, Honors Research Projects

This project addressed women’s wellness. Many women experience physical and mental health issues related to a lack of physical activity or psychological support. Women’s Fitness Week was offered to women of the University of Akron and the outside community, providing opportunities to learn more about and improve upon the various dimensions of wellness – emotional, environmental, financial, intellectual, occupational, physical, social/cultural, and spiritual. Events were held at the University’s Student Recreation and Wellness Center and encompassed topics such as nutrition, weight training, and self-defense. The goals of this project were to: increase knowledge levels of fitness, health, and wellness, increase …

Functional Local Renin-Angiotensin System In Human And Rat Periodontal Tissue, Carlos Ferreira Santos, Ana Carolina Morandini, Thiago José Dionísio, Flávio A. Faria, Marta C. Lima, Caio M. Figueiredo, Bella L. Colombini-Ishikiriama, Carla Renata Sipert, Rubens P. Maciel, Ana P. Akashi, Gabriela P. Souza, Gustavo P. Garlet, Camila O. Rodini, Sandra L. Amaral, Christiane Becari, Maria C. Salgado, Eduardo B. Oliveira, Isaac Matus, Daniela N. Didier, Andrew S. Greene

All Dugoni School of Dentistry Faculty Articles

The initiation or progression of periodontitis might involve a local renin-angiotensin system (RAS) in periodontal tissue. The aim of this study was to further characterize the local RAS in human and rat periodontal tissues between healthy and periodontally-affected tissue. Components of the RAS were investigated using in vitro, ex vivo and in vivo experiments involving both human and Wistar rat periodontium. Although not upregulated when challenged with P. gingivalis-lipopolysaccharide, human gingival and periodontal ligament fibroblasts expressed RAS components. Likewise, healthy and inflamed human gingiva expressed RAS components, some of which were shown to be functional, yet no differences in expression …

Content Analysis Of Archetypal Portrayal Of Females In Picture Books Read In Preschool Classrooms, Karen Lynn Ellefsen

Walden Dissertations and Doctoral Studies

Literature that depicts females in restrictive roles may limit girls' aspirations and success. Previous studies of award-winning books for young children have found gender-stereotypical role portrayal to be common. The purpose of this qualitative content analysis was to identify the archetypal roles assigned to female characters in picture books read aloud by teachers in the preschool classroom. The conceptual framework for this study was derived from feminist theory and Jungian archetypes. Data were collected in the form of teachers' logs of books they read aloud over a 2-week period. Data were analyzed by employing the 3-read method developed by Madsen, …

Does Motor Competence Affect Self-Perceptions Differently For Adolescent Males And Females?, Elizabeth Rose, Dawne Larkin, Helen Parker, Beth Hands

Health Sciences Papers and Journal Articles

Little is understood about the impact of level of motor competence on self-perceptions in adolescence, in particular how this may differentially affect girls and boys. A sample of 1,568 14-year-old participants (766 girls and 802 boys) were grouped into four motor competence levels (very low to high) based on the McCarron Assessment of Neuromuscular Development (MAND). Self-perceptions were assessed using the Self-Perception Profile for Adolescents. Boys had higher self-perceptions of global self-worth, athletic competence, and physical appearance, whereas girls had higher scores for close friendships and behavioral conduct. Main effects in the predicted direction were found for motor competence for …

Three-Dimensional Age-Related Changes Of The Adult Face; African American Female Population, Christina Theresa Sutherland

All ETDs from UAB

Objectives: Treatment of older adults is one of the fastest growing areas in orthodontic practice. The objectives of this study are to: 1. Investigate the aging of the female African American face using three-dimensional surface imaging to understand how the soft tissue of the face matures in relation to the teeth and 2.) Compare the effects of aging on African American female faces to aging of Caucasian female faces. Methods: This is a cross-sectional study of 100 African American females with balanced faces. Five age groups (in years) were included: [20-30], [31-40], [41-50], [51-60], [61-70]. Three-dimensional (3D) surface images of …

Gene Expression Changes Reflect Clinical Response In A Placebo-Controlled Randomized Trial Of Abatacept In Patients With Diffuse Cutaneous Systemic Sclerosis, Eliza F. Chakravarty, Viktor Martyanov, David Fiorentino, Tammara A. Wood, David J. Haddon, Justin A. Jarrell, Paul Utz, Mark Genovese, Michael Whitfield, Lorinda Chung

Dartmouth Scholarship

Systemic sclerosis is an autoimmune disease characterized by inflammation and fibrosis of the skin and internal organs. We sought to assess the clinical and molecular effects associated with response to intravenous abatacept in patients with diffuse cutaneous systemic.

Medical Versus Surgical Methods Of Early Abortion: Protocol For A Systematic Review And Environmental Scan Of Patient Decision Aids, Kyla Z. Donnelly, Rachel Thompson

Dartmouth Scholarship

Introduction: Currently, we lack understanding of the content, quality and impact of patient decision aids to support decision-making between medical and surgical methods of early abortion. We plan to undertake a systematic review of peer-reviewed literature to identify, appraise and describe the impact of early abortion method decision aids evaluated quantitatively (Part I), and an environmental scan to identify and appraise other early abortion method decision aids developed in the US (Part II).

Methods and analysis: For the systematic review, we will search PubMed, Cochrane Library, CINAHL, EMBASE and PsycINFO databases for articles describing experimental and observational studies evaluating …