Medicine and Health Sciences Commons^™

A National Multi-Institutional Analysis Of Predictors Of Surgical Site Complications And Unplanned Reoperation After Paramedian Forehead Flap Reconstruction, Garrett Ni, Rohan Brebion, Pablo A. Baltodano, Michael C. Coronado, Nicholas Elmer, Theresa K. Webster, Huaqing Zhao, Xiaoning Lu, Sthefano Araya, Sameer Patel

Student Papers, Posters & Projects

Background: Although postoperative complications of paramedian forehead flap (PMFF) are generally low, surgical site complications and unplanned reoperation can still occur. Recent literature suggests infection to be the most common complication following PMFF reconstruction. This study sought to determine the patient and preoperative factors associated with surgical site complications and unplanned reoperations at a national level.

Methods: Patients who underwent PMFF reconstruction from the ACS-NSQIP 2007 - 2019 database were analyzed to determine composite surgical site morbidity and unplanned return to the operating room. Patient and operative factors were also analyzed to assess independent risk factors for surgical site morbidity …

Indirect Comparison Of Lenadogene Nolparvovec Gene Therapy Versus Natural History In Patients With Leber Hereditary Optic Neuropathy Carrying The M.11778g>A Mt-Nd4 Mutation, Valerio Carelli, Nancy J. Newman, Patrick Yu-Wai-Man, Valerie Biousse, Mark L. Moster, Prem S. Subramanian, Catherine Vignal-Clermont, An-Guor Wang, Sean P. Donahue, Bart P. Leroy, Robert C. Sergott, Thomas Klopstock, Alfredo A. Sadun, Gema Rebolleda Fernández, Bart K. Chwalisz, Rudrani Banik, Jean François Girmens, Chiara La Morgia, Adam A. Debusk, Neringa Jurkute, Claudia Priglinger, Rustum Karanjia, Constant Josse, Julie Salzmann, François Montestruc, Michel Roux, Magali Taiel, José-Alain Sahel

Wills Eye Hospital Papers

INTRODUCTION: Lenadogene nolparvovec is a promising novel gene therapy for patients with Leber hereditary optic neuropathy (LHON) carrying the m.11778G>A ND4 mutation (MT-ND4). A previous pooled analysis of phase 3 studies showed an improvement in visual acuity of patients injected with lenadogene nolparvovec compared to natural history. Here, we report updated results by incorporating data from the latest phase 3 trial REFLECT in the pool, increasing the number of treated patients from 76 to 174.

METHODS: The visual acuity of 174 MT-ND4-carrying patients with LHON injected in one or both eyes with lenadogene nolparvovec from four pooled phase 3 …

Characterizing Pulmonary Function Test Changes For Patients With Lung Cancer Treated On A 2-Institution, 4-Dimensional Computed Tomography-Ventilation Functional Avoidance Prospective Clinical Trial, Ryan C. Miller, Richard Castillo, Edward Castillo, Bernard L Jones, Moyed Miften, Brian Kavanagh, Bo Lu, Maria Werner-Wasik, Nader Ghassemi, Joseph Lombardo, Julie Barta, Inga Grills, Chad G Rusthoven, Thomas Guerrero, Yevgeniy Vinogradskiy

Department of Radiation Oncology Faculty Papers

Purpose: Four-dimensional computed tomography (4DCT)-ventilation-based functional avoidance uses 4DCT images to generate plans that avoid functional regions of the lung with the goal of reducing pulmonary toxic effects. A phase 2, multicenter, prospective study was completed to evaluate 4DCT-ventilation functional avoidance radiation therapy. The purpose of this study was to report the results for pretreatment to posttreatment pulmonary function test (PFT) changes for patients treated with functional avoidance radiation therapy.

Methods and materials: Patients with locally advanced lung cancer receiving chemoradiation were accrued. Functional avoidance plans based on 4DCT-ventilation images were generated. PFTs were obtained at baseline and 3 months …

Biomarkers In The Development Of Individualized Treatment Regimens For Colorectal Cancer, Madison Crutcher, Scott A Waldman

Department of Surgery Faculty Papers

Introduction: Colorectal cancer (CRC) is the third most common and second most deadly malignancy in the world with an estimated 1. 9 million cases and 0.9 million deaths in 2020. The 5-year overall survival for stage I disease is 92% compared to a dismal 11% in stage IV disease. At initial presentation, up to 35% of patients have metastatic colorectal cancer (mCRC), and 20-50% of stage II and III patients eventually progress to mCRC. These statistics imply both that there is a proportion of early stage patients who are not receiving adequate treatment and that we are not adequately treating …

Synaptic Development In Diverse Olfactory Neuron Classes Uses Distinct Temporal And Activity-Related Programs, Michael A. Aimino, Alison T. Depew, Lucas Restrepo, Timothy J. Mosca

Farber Institute for Neuroscience Faculty Papers

Developing neurons must meet core molecular, cellular, and temporal requirements to ensure the correct formation of synapses, resulting in functional circuits. However, because of the vast diversity in neuronal class and function, it is unclear whether or not all neurons use the same organizational mechanisms to form synaptic connections and achieve functional and morphologic maturation. Moreover, it remains unknown whether neurons united in a common goal and comprising the same sensory circuit develop on similar timescales and use identical molecular approaches to ensure the formation of the correct number of synapses. To begin to answer these questions, we took advantage …

Anna Magee’S Vision 100 Years Past 1923-2023!, Christopher Formal, John F. Ditunno Jr.

Department of Rehabilitation Medicine Faculty Papers

Anna Magee's vision of Magee Rehabilitation Hospital has been realized in three phases. The first spanned the writing of her will until groundbreaking of the new hospital. This was followed by the early years as an entirely independent institution. The third phase began with its association with Thomas Jefferson University, and continues to this day with integration into a complete system of patient care, education, and research. Magee owes its existence to the philanthropy of Anna Magee and it continues to fortify her legacy and fulfill her vision of an institution where patients whose acute illness has passed can receive …

Choosing Not To Look: Not A Solution, Rosemary Frasso

College of Population Health Faculty Papers

No abstract provided.

The Associations Between Central Serous Chorioretinopathy And Muscle Relaxants: A Case-Control Study, Manish Jain, Sunir J. Garg, Mohammad Khan, Varun Chaudhary, Dena Zeraatkar, Dhanya Kurian, Sarath Lal

Wills Eye Hospital Papers

PURPOSE: To evaluate the role of muscle-relaxants as risk factors for the development of central serous chorioretinopathy (CSC) - the second most common retinopathy in our settings; despite multiple risk factors seen in our patients, 21% were initially labelled as idiopathic.

MATERIALS AND METHODS: Retrospective case-control study at a tertiary hospital in the United Arab Emirates, where we reviewed the medical records of 273 patients with CSC examined between 2010 and 2019 for use of muscle-relaxants including tolperisone/eperisone, carisoprodol and gabapentin/pregabalin within a year of onset/recurrence of the disease. Intake of drugs with known association with CSC (including corticosteroids/sympathomimetics) was …

Comprehensive Review Of Cardiovascular Disease Risk In Nonalcoholic Fatty Liver Disease, Kevan Josloff, Jacob Beiriger, Adnan Khan, Richard J. Gawel, Richard S. Kirby, Aaron Kendrick, Abhinav K. Rao, Roy Wang, Michelle Schafer, Margaret Pearce, Kashyap Chauhan, Yash B. Shah, Gregary D. Marhefka, Dina Halegoua-De Marzio

Department of Medicine Faculty Papers

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising …

Using Genomic Variation To Distinguish Ovarian High-Grade Serous Carcinoma From Benign Fallopian Tubes, Jesus Gonzalez-Bosquet, Nicholas D Cardillo, Henry D Reyes, Brian J Smith, Kimberly K Leslie, David P Bender, Michael J Goodheart, Eric J Devor

Department of Obstetrics and Gynecology Faculty Papers

The preoperative diagnosis of pelvic masses has been elusive to date. Methods for characterization such as CA-125 have had limited specificity. We hypothesize that genomic variation can be used to create prediction models which accurately distinguish high grade serous ovarian cancer (HGSC) from benign tissue.

Methods: In this retrospective, pilot study, we extracted DNA and RNA from HGSC specimens and from benign fallopian tubes. Then, we performed whole exome sequencing and RNA sequencing, and identified single nucleotide variants (SNV), copy number variants (CNV) and structural variants (SV). We used these variants to create prediction models to distinguish cancer from benign …

Piperine Attenuates Cigarette Smoke-Induced Oxidative Stress, Lung Inflammation, And Epithelial-Mesenchymal Transition By Modulating The Sirt1/Nrf2 Axis, Pritam Saha, Sneha Durugkar, Siddhi Jain, P A Shantanu, Samir R Panda, Aishwarya Jala, Sharad Gokhale, Pawan Sharma, V G M Naidu

Center for Translational Medicine Faculty Papers

Piperine (PIP) is a major phytoconstituent in black pepper which is responsible for various pharmacological actions such as anti-inflammatory, antioxidant, and antitumor activity. To investigate the effects and mechanisms of PIP on cigarette smoke (CS)-induced lung pathology using both in-vitro and in-vivo models. BEAS-2B and A549 cells were exposed to CS extract (CSE) for 48 h; BALB/c mice were exposed to CS (9 cigarettes/day, 4 days) to induce features of airway disease. PIP at doses of (0.25, 1.25, and 6.25 µM, in vitro; 1 and 10 mg/kg, in vivo, i.n) and DEX (1 µM, in vitro; 1 mg/kg, in vivo, …

Developing Guiding Principles For Technology-Based Rehabilitation Program By Engaging People With Motor Incomplete Tetraplegia, Alison Bell, Namrata Grampurohit, Gabrielle Kains, Ralph J. Marino

Department of Rehabilitation Medicine Faculty Papers

Background: Technology-aided rehabilitation is well established in the field of neurologic rehabilitation. Despite the widespread availability, the development of technology-based interventions that incorporate perspectives of the people who will use them is lacking.

Objectives: This qualitative study aims to understand how people with chronic motor incomplete cervical spinal cord injury view rehabilitation technology to improve upper extremity function and neuromuscular recovery to inform future intervention development.

Methods: Seven participants with chronic upper extremity impairment due to spinal cord injury/dysfunction trialed five rehabilitation technology devices. After a 30-45 min trial for each device, participants engaged in a semi-structured interview. Interviews were …

Altered Expression Of Glycobiology-Related Genes In Parkinson’S Disease Brain, Jay S Schneider, Garima Singh

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

The precise mechanisms initiating and perpetuating the cellular degeneration in Parkinson's disease (PD) remain unclear. There is decreased expression of the main brain gangliosides, and GM1 ganglioside in particular, in the PD brain along with decreased expression of the genes coding for the glycosyltranferase and the sialyltransferase responsible for the synthesis of these brain gangliosides. However, potentially important pathogenic mechanisms contributing to the neurodegeneration in PD may also include altered levels of expression of genes involved in glycosylation, sialylation and sphingolipid synthesis and metabolism. Although various studies have described pathological lipid and glycolipid changes in PD brain, there have been …

Molecular Insights And Clinical Outcomes Of Drugs Of Abuse Adulteration: New Trends And New Psychoactive Substances, Annagiulia Di Trana, Diletta Berardinelli, Eva Montanari, Paolo Berretta, Giuseppe Basile, Marilyn A. Huestis, Francesco Paolo Busardò

Institute of Emerging Health Professions Faculty Papers

Adulteration is a well-known practice of drug manufacturers at different stages of drug production. The intentional addition of active ingredients to adulterate the primary drug may enhance or mask pharmacological effects or may produce more potent drugs to increase the number of available doses and the dealer's profit. Adulterants found in different drugs change over time in response to different factors. A systematic literature search in PubMed and Scopus databases and official international organizations' websites according to PRISMA guidelines was performed. A total of 724 studies were initially screened, with 145 articles from PubMed and 462 from Scopus excluded according …

Methylone And Mdma Pharmacokinetics Following Controlled Administration In Humans, Lourdes Poyatos, Alfredo Fabrizio Lo Faro, Diletta Berardinelli, Giorgia Sprega, Sara Malaca, Simona Pichini, Marilyn A. Huestis, Esther Papaseit, Clara Pérez-Mañá, Francesco Paolo Busardò, Magí Farré

Institute of Emerging Health Professions Faculty Papers

The aim of this study is to define, for the first time, human methylone and HMMC plasma pharmacokinetics following controlled administration of 50–200 mg methylone to 12 male volunteers. A new LC-MS/MS method was validated to quantify methylone, MDMA, and their metabolites in plasma. The study was a randomized, cross-over, double-blinded and placebo-controlled study, with a total of 468 plasma samples collected. First, 10 µL of MDMA-d5, MDA-d5 and methylone-d3 internal standards were added to 100 µL of plasma. Two mL of chloroform and ethyl acetate 9:1 (v/v) were then added, mixed well and centrifuged. The supernatant was fortified with …

Epigenetic Regulation In Chromium-, Nickel- And Cadmium-Induced Carcinogenesis, Lei Zhao, Ranakul Islam, Yifang Wang, Xiujuan Zhang, Ling-Zhi Liu

Department of Medical Oncology Faculty Papers

Environmental and occupational exposure to heavy metals, such as hexavalent chromium, nickel, and cadmium, are major health concerns worldwide. Some heavy metals are well-documented human carcinogens. Multiple mechanisms, including DNA damage, dysregulated gene expression, and aberrant cancer-related signaling, have been shown to contribute to metal-induced carcinogenesis. However, the molecular mechanisms accounting for heavy metal-induced carcinogenesis and angiogenesis are still not fully understood. In recent years, an increasing number of studies have indicated that in addition to genotoxicity and genetic mutations, epigenetic mechanisms play critical roles in metal-induced cancers. Epigenetics refers to the reversible modification of genomes without changing DNA sequences; …

Transradial-Transfistula Access For Cardiac Catheterization In Patients With Abandoned Hemodialysis Fistulas, Noah Q. Haroian, Michael P. Savage, David L. Fischman

Department of Medicine Faculty Papers

Guidelines consider radial access a relative contraindication in patients with end-stage renal disease as part of a vessel preservation strategy. Radial access distal to a hemodialysis fistula, what we term transradial-transfistula access, offers a solution to radially access this population without affecting their vessel preservation plan. (Level of Difficulty: Advanced.)

Strategies For Expanding Iohexol Supply During A Shortage, Anupam Sinha, Theodore Conliffe

Rothman Institute Papers

No abstract provided.

Interferon Partly Dictates A Divergent Transcriptional Response In Poxvirus-Infected And Bystander Inflammatory Monocytes, Carolina R Melo-Silva, Marisa I Roman, Cory J Knudson, Lingjuan Tang, Ren-Huan Xu, Michel Tassetto, Patrick Dolan, Raul Andino, Luis J. Sigal

Department of Microbiology and Immunology Faculty Papers

Inflammatory monocytes (iMOs) and B cells are the main targets of the poxvirus ectromelia virus (ECTV) in the lymph nodes of mice and play distinct roles in surviving the infection. Infected and bystander iMOs control ECTV's systemic spread, preventing early death, while B cells make antibodies that eliminate ECTV. Our work demonstrates that within an infected animal that survives ECTV infection, intrinsic and bystander infection of iMOs and B cells differentially control the transcription of genes important for immune cell function and, perhaps, cell identity. Bystander cells upregulate metabolism, antigen presentation, and interferon-stimulated genes. Infected cells downregulate many cell-type-specific genes …

Using A Human-Centered, Mixed Methods Approach To Understand The Patient Waiting Experience And Its Impact On Medically Underserved Populations, Elizabeth N. Liao, Lara Z. Chehab, Kathryn Neville, Jennifer Liao, Devika Patel, Amanda Sammann

Department of Emergency Medicine Faculty Papers

Purpose: To use a mixed methods approach to investigate the patient waiting experience for a medically underserved population at an outpatient surgical clinic.

Methods: We used lean methodology to perform 96 time-tracked observations of the patient journey in clinic, documenting the duration of activities from arrival to departure. We also used human-centered design (HCD) to perform and analyze 43 semi-structured interviews to understand patients’ unmet needs.

Results: Patients spent an average of 68.5% of their total clinic visit waiting to be seen. While the average visit was 95.8minutes, over a quarter of visits (27%) were over 2hours. Patients waited an …

Association Between Sacubitril/Valsartan Initiation And Mitral Regurgitation Severity In Heart Failure With Reduced Ejection Fraction: The Prove-Hf Study, James L Januzzi, Alaa Mabrouk Salem Omar, Yuxi Liu, Sean Murphy, Javed Butler, G Michael Felker, Iliana L Piña, Jonathan Ward, Scott Solomon, Johanna Contreras

Division of Cardiology Faculty Papers

No abstract provided.

Emergency Medicine Clinician Experiences Addressing Uncertainty In First-Trimester Bleeding., Garrison Nord, Amanda Doty, Andrew J Monick, Danielle M Mccarthy, Robin J Casten, Amer Z Aldeen, Philip S Nawrocki, Kristin L. Rising

Department of Emergency Medicine Faculty Papers

The purpose of this work is to understand Emergency Department (ED) clinicians' experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians' frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the …

Genome-Scale Metabolic Modeling Reveals Sequential Dysregulation Of Glutathione Metabolism In Livers From Patients With Alcoholic Hepatitis, Alexandra Manchel, Radhakrishnan Mahadevan, Ramon Bataller, Jan B. Hoek, Rajanikanth Vadigepalli

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

Alcoholic hepatitis (AH) is the most severe form of alcoholic liver disease for which there is no efficacious treatment aiding most patients. AH manifests differently in individuals, with some patients showing debilitating symptoms more so than others. Previous studies showed significant metabolic dysregulation associated with AH. Therefore, we sought to analyze how the activity of metabolic pathways differed in the liver of patients with varying degrees of AH severity. We utilized a genome-scale metabolic modeling approach that allowed for integration of a generic human cellular metabolic model with specific RNA-seq data corresponding to healthy and multiple liver disease states to …

Pathogenicity And Impact Of Hla Class I Alleles In Aplastic Anemia Patients Of Different Ethnicities, Timothy S Olson, Benjamin F Frost, Jamie L Duke, Marian Dribus, Hongbo M Xie, Zachary D Prudowsky, Elissa Furutani, Jonas Gudera, Yash B Shah, Deborah Ferriola, Amalia Dinou, Ioanna Pagkrati, Soyoung Kim, Yixi Xu, Meilun He, Shannon Zheng, Sally Nijim, Ping Lin, Chong Xu, Taizo A Nakano, Joseph H Oved, Beatriz M Carreno, Yung-Tsi Bolon, Shahinaz M Gadalla, Steven Ge Marsh, Sophie Paczesny, Stephanie J Lee, Dimitrios S Monos, Akiko Shimamura, Alison A Bertuch, Loren Gragert, Stephen R Spellman, Daria V Babushok

Department of Medicine Faculty Papers

Acquired aplastic anemia (AA) is caused by autoreactive T cell-mediated destruction of early hematopoietic cells. Somatic loss of human leukocyte antigen (HLA) class I alleles was identified as a mechanism of immune escape in surviving hematopoietic cells of some patients with AA. However, pathogenicity, structural characteristics, and clinical impact of specific HLA alleles in AA remain poorly understood. Here, we evaluated somatic HLA loss in 505 patients with AA from 2 multi-institutional cohorts. Using a combination of HLA mutation frequencies, peptide-binding structures, and association with AA in an independent cohort of 6,323 patients from the National Marrow Donor Program, we …

A Consensus List Of Ultrasound Competencies For Graduating Emergency Medicine Residents, David A Haidar, William J Peterson, Patrick G Minges, Jennifer Carnell, Jason T Nomura, John Bailitz, Jeremy S Boyd, Megan M Leo, E Liang Liu, Youyou Duanmu, Josie Acuña, Ross Kessler, Marco F Elegante, Mathew Nelson, Rachel B Liu, Resa E. Lewiss, Arun Nagdev, Rob D Huang

Department of Emergency Medicine Faculty Papers

Objectives: Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method.

Methods: We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional …

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique, Alexander J. Rondon, Dominic M. Farronato, Joshua D. Pezzulo, Joseph A. Abboud

Rothman Institute Papers

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement.

Maternal Healthcare Utilization Among Pregnant Women Experiencing Intimate Partner Violence: A Rapid Systematic Review, Gabrielle Harb

Master of Public Health Capstone Presentations

Intimate Partner Violence (IPV) impacts millions of pregnant women every year, and IPV is associated with adverse maternal and infant health outcomes. Previous studies have suggested that women experiencing IPV during pregnancy are less likely to access maternal healthcare services. Still, no consensus has been found, particularly within understudied low-and middle-income countries. This rapid systematic review identifies and examines evidence related to maternal healthcare utilization among women experiencing IPV in studies from 2015 to the present. A literature search was conducted in PubMed and Scopus, and 1797 unique records were identified. After reviewing abstracts and full texts, 28 studies were …

Process Mapping: The "One Best Way" To Improve Public Health Interventions, Adam T. Thompson

Master of Public Health Capstone Presentations

Process mapping (PM) is a quality improvement (QI) systems-level intervention used to analyze workflows in a variety of industries. PM is a robust improvement strategy but there is poor evidence for its effectiveness within healthcare QI projects. Evidence also suggests that there is variation in the implementation of PM likely affecting the value derived from the practice. In 2021, Antonacci, et al., proposed an empirical framework to guide the implementation, reporting, and evaluating of PM within healthcare QI projects. Informed by the empirical framework for process mapping (EFPM), the aim of this capstone was to enhance the value derived from …

The Impact Of Doulas On Birth Outcomes: A Rapid Systematic Review, Heather Higgins

Master of Public Health Capstone Presentations

Although most pregnancies in the United States are uncomplicated, adverse birth outcomes are more common in the U.S. than any other developed country (CDC, n.d.). The use of doula care during labor and delivery has shown to be effective in reducing adverse birth outcomes. A rapid systematic review was conducted to consolidate information on the effectiveness doulas have on certain adverse birth outcomes. These adverse birth outcomes included, low-birth weight, preterm birth, caesarean sections, shorter laboring time, and epidural use. The review of the literature was conducted using PubMed and search terms. PRISMA guidelines were followed and out of the …

A Rapid Systemic Review Of The Significance Of Parental Awareness Of Children’S Oral Health On The Prevalence Of Dental Caries In Saudi Arabia, Nasser Albishi

Master of Public Health Capstone Presentations

Dental caries in children has been identified as a public health challenge in the Kingdom of Saudi Arabia (KSA). Among those factors associated with their presence is the role that parents play in their children’s oral hygiene practices and how much it affects their development. The knowledge and awareness levels of the parents when it comes to maintaining proper oral hygiene in their children are still limited in the KSA, and a well-rounded characterization of these levels is needed for the problem to be addressed. Hence, a rapid systematic review was conducted to synthesize the evidence from published articles and …