Medicine and Health Sciences Commons^™

Recovery Time Of Diabetic Patients Undergoing Arthroplasties: A Literature Review, Joshua Nwose, Yolanda V. Gutierrez, Blake Martin, Robert H. Ablove

Research Colloquium

Introduction: Arthroplasties, especially on the hip and knee are one of the most common procedures undergone as people age. There are many different comorbidities that affect the success of a surgical intervention. We sought to review current literature to determine if diabetes had a significant impact on the outcome of a procedure compared to other comorbidities.

Methods: A survey across several databases including but not limited to Pubmed, NIH, Mayo Clinic, was performed. Each article was reviewed and assessed whether diabetes had a significant impact on the efficacy of arthroplasties.

Results: We identified 10 articles regarding the post-operative outcome …

Identifying Key Predictors Of Academic Achievement In A Longitudinal Medical Research Module., Anesu Karen Murambadoro, Juan C. Lopez-Alvarenga, Kevin Garcia Valdez, Kory Deshawn Punch, Natasha N. Quailes, Nina Mourao, Elias Arellano Villanueva, Tyler Torres, Nikhilesh Anand, Bharathi Shrikanth Gadad

Research Colloquium

Background: Research engagement among medical students is often hindered by perceived time constraints, lack of motivation, inadequate facilities, and insufficient supervisory guidance. Only 7% have published research papers. Project-based programs enhance research skills but frequently lack alignment between objectives, teaching methods, and evaluation. In the Rio Grande Valley, there is limited research on these issues. This study aims to analyze the performance of pre-clerkship students in a two-year longitudinal research course.

Aim: We hypothesize that core independent variables (InVar) such as attitudes toward research (R-ATR), cognition (BCRS), self-efficacy, and competency scores will improve throughout the longitudinal Research Module. These …

Evaluating Ai Language Models For Patient Queries On Total Knee Replacement (Tkr), Brianna Guillen, Anesu Karen Murambadoro, Victoria Elizondo, Matthew Hnatow, Michael Sander

Research Colloquium

Introduction: Within the past few years, large language models (LLMs) (ChatGPT, LLaMa 3, Microsoft Copilot) have increasingly become a resource that patients engage with to learn about health care procedures, including total knee replacement (TKR). Previous studies have analyzed the efficacy of large language models in providing accurate and relevant responses to questions about various procedures. Our study aims to evaluate the clarity, validity, and understandability of LLMs to patient questions about total knee replacement and assess the consistency of these models and their effectiveness in providing accurate, valid, and guideline-adherent information to patients.

Methods: We selected 30 frequently asked …

Euglycemic Diabetic Ketoacidosis Induced By Jardiance In A 37-Year-Old Female: A Case Report, Ivan Mogollon, Juan Gomez, Rodrigo Lema, Juan Calero, Juan Ortiz, Catherine Matos, Renzo Aller, Francisco Arias, Luis Salcedo

Research Colloquium

Background: Diabetic ketoacidosis (DKA) is a complication of diabetes, very common throughout the Rio Grande Valley region, can be life threatening and is characterized by hyperglycemia, ketonemia and metabolic acidosis. Nevertheless, euglycemic diabetic ketoacidosis (euglycemic DKA) is an atypical presentation in which patients show the classic signs of DKA but with normal or near-normal blood glucose levels. The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as Jardiance (empagliflozin), has been associated with an increased risk of euglycemic DKA. This case report describes a case of euglycemic DKA in a 37- year-old woman with type 2 diabetes mellitus who …

Unique Considerations In The Management Of Healthcare Among Fertile Women A Case Report On Chronic Myeloid Leukemia And Pregnancy, Hermione Yamyo Monie, Taha Al Hassan, Salomon Pardo Roca, Uchechi Ehiemua, Ramiro Leal

Research Colloquium

Background: With the overturning of Roe v. Wade, the management of women who are family planning has become more complex, highlighting the necessity for comprehensive and informed healthcare. This case report underscores the importance of holistic, interdisciplinary care for women with chronic conditions like Chronic Myeloid Leukemia (CML) who are planning for pregnancy. The novelty lies in the interplay between oncological treatment and reproductive health under current legal constraints.

Case Presentation: We present the case of a 32-year-old woman, G2P0010, with a history of CML and a previous spontaneous abortion. Initially believed to be in remission, she was started …

Multifactorial Pancreatitis In A Patient With Dyslipidemia And Diabetes, Potential Role Of Glyxambi: Case Report, Ivan Mogollon, Catherine Matos, Michelle Lopez, Juan Gomez, Juan Ortiz, Juan Calero, Rodrigo Lema

Research Colloquium

Background: Acute pancreatitis is an inflammatory condition of the pancreas that can arise from various etiologies such as alcohol consumption, gallstones, hypertriglyceridemia, and use of certain medications. Hypertriglyceridemia is a significant risk factor for pancreatitis, especially in patients with uncontrolled diabetes mellitus. Medications like dipeptidyl peptidase-4 (DPP-4) inhibitors have also been implicated in rare cases of pancreatitis. This report presents a complex case of multifactorial acute pancreatitis in a patient with diabetes mellitus and dyslipidemia suspected to be induced by the medication Glyxambi and hypertriglyceridemia.

Case Presentation: A 48-year-old male with known history of diabetes mellitus and dyslipidemia presented …

New Insights Into The Mechanisms Of Skeletal Muscle Atrophy In Copd, Justin D. Mills, Hiram L. Garcia, Alex Zuo

Research Colloquium

Background: In 2020, it was estimated that there were over 480 million cases of chronic obstructive pulmonary disease (COPD) worldwide. Up to 40% of COPD patients suffer from certain degrees of muscle atrophy. The severity of this muscle atrophy is normally correlated with an increased mortality rate among these patients. The goal of this study is to underline the causes of muscle atrophy/dysfunction in the COPD population and to investigate treatment options.

Methods: We conducted an extensive literature review using the PubMed database, mainly focusing on publications from 2013 to 2024. Our objective was to identify the biological mechanisms underlying …

Tc-Ptp-Mediated Epidermal Differentiation Protects Skin From Ultraviolet B Radiation, Smaran Marupudi, Jared Hensley, Lindsey Shim, Bilal B. B. Hafeez, Dae Joon Kim

Research Colloquium

Background: The fine balance of the inverse relationship between keratinocyte proliferation and differentiation is critical in maintaining epidermal homeostasis. The disruption of this balance is one of the characteristic features of skin cancer. Exposure to ultraviolet B (UVB) radiation disrupts signaling pathways involved in the maintenance of epidermal cell homeostasis, resulting in hyperplasia and skin cancer formation. One implicated signaling pathway involved in epidermal homeostasis is tyrosine phosphorylation signaling. T-cell protein tyrosine phosphatase (TC-PTP) is a tyrosine-specific intracellular non-receptor PTP and is ubiquitously expressed in embryonic and adult tissues including skin. Our previous studies showed that TC-PTP has been shown …

Recurrent Atrial Myxoma And Transient Ischemic Atack, Abdel Martinez Borrego, Benito Moran Herrera, Eduardo Flores

Research Colloquium

Background: Myxomas are the most common primary cardiac neoplasms and are predominantly located in the left atrium, accounting for approximately 80% of cases. Clinical manifestations can vary widely, ranging from asymptomatic to severe, with potential embolic or obstructive symptoms. Diagnosis is typically made through echocardiography, although CT and MRI can also be useful diagnostic tools. The primary treatment is surgical resection; however, long-term follow-up is essential due to the risk of recurrence, which may occur up to 10 years after the initial surgery.

Case presentation: A 54-year-old female patient with a history of a 5x3x2 cm left atrial …

Integrating Artificial Intelligence With Electrocardiograms: A New Era In Cardiac Care, Abdel Martinez Borrego, Eduardo Flores

Research Colloquium

Background: The integration of artificial intelligence with electrocardiography has significantly transformed contemporary medical practice, representing a major advancement in cardiac care. These algorithms have enhanced the detection of subtle ECG patterns, improving the diagnosis of conditions such as arrhythmias and providing a more accurate diagnostic environment. However, challenges such as data privacy, algorithm transparency, and clinical integration remain. AI holds substantial potential for improving diagnostic accuracy, with several FDA-approved devices now available in the market aimed at enhancing patient outcomes. Future efforts should focus on further validation, implementation, and research to fully realize AI's capabilities in this field.

Methods: This …

The Impact Of Electronic Messaging On Hiv In A Medically Underserved Population, Blake Martin, Smaran Marupudi, Justin Heckman, Russell Wiggins

Research Colloquium

Introduction: HIV in the United States has affected all types of demographics and has been growing by 50,000 new infections each year. Healthy people 2030 states that their objectives of both reducing new HIV cases and increasing knowledge of the disease has had little to no change. We intend to decrease both short-term incidence of HIV contracture and long-term incidence of disease progression to AIDS via utilization of an electronic health messaging and outreach system.

Methods: Individuals will be registered for text alerts at their next AHEC medical appointment. The practitioner, utilizing an HIV Risk Assessment Tool would ask high-risk …

Systematic Review And Meta-Analysis Of Total Elbow Arthroplasty In Outpatient Versus Inpatient Settings, Blake Martin, Yolanda V. Gutierrez, Joshua Nwose, Robert H. Ablove, Juan Lopez-Alvarenga

Research Colloquium

Introduction: Total joint arthroplasties (TJA), including total elbow arthroplasty (TEA), are growing in number, shifting towards a younger age group, and moving more towards the outpatient setting. We are conducting this study to summarize the current knowledge about the outcomes of TEA in outpatient versus inpatient settings to allow for the best possible care when performing this procedure. We believe that outpatient TEA will have better outcomes with lower complication rates compared to inpatient TEA.

Methods: We conducted a systematic review and meta-analysis using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) framework. Electronic database searches were performed …

Clearance Of Recalcitrant Prosthetic Fungal Infection Utilizing Administration Of Voriconazole Through Intra-Articular Catheters Of The Knee, Blake Martin, Matthew Hnatow, Emma Herrera

Research Colloquium

Background: Prosthetic joint infection is a high cost and high morbidity complication of total joint arthroplasty accounting for about 1-2% of all joint replacements. Rarely fungal infections may complicate treatment and lower the rate of clearance of infection with rates as low as 50% or less in the literature. Intra-articular antibiotics have drawn more interest recently and may be a promising intervention for challenging prosthetic joint infections. We present a novel case utilizing voriconazole via intra-articular catheters with successful clearance of a recalcitrant fungal prosthetic joint infection with 2 year follow up.

Case Presentation: A case study is presented in …

Ormeloxifene Suppresses Emt In Hepatocellular Carcinoma By Targeting Β-Catenin Signaling Pathway, Shabnam Malik, Mohammed Sikander, Daniel Zubieta, Anyssa Rodriguez, Murali Yallapu, Meena Jaggi, Subhash C. Chauhan

Research Colloquium

Background: Hepatocellular carcinoma (HCC) is one of the deadliest cancers, with a five-year survival rate. While Sorafenib (SRB) is the standard therapy, it is only effective in prolonging survival for some patients, emphasizing the urgent need for alternative treatment options. Resistance to apoptosis is a defining characteristic of cancer cells and a crucial factor in cancer recurrence and relapse. Although, anticancer potential of the FDA-approved compound Ormeloxifene (ORM), which has well-defined pharmacokinetic and pharmacodynamic properties, has been explored in a variety of cancers, its efficacy in HCC has remained unknown. Therefore, the purpose of this study was to investigate the …

Investigating The Determinants Of Frailty: The Intersection Of Genetics And Environment In Mexican Americans From South Texas, Natasha Garcia-Rodriguez, Vincent P. Diego, Marcio Almeida, Jacob Galan, Sandra Laston, Joanne E. Curran, Tom Howard, Eron Manusov, John Blangero, Sarah Williams-Blangero

Research Colloquium

Background: The projected worldwide population of people aged 65 and over is anticipated to hit 1.6 billion by 2050. Frailty, marked by increased susceptibility to adverse health outcomes, mortality, and decreased health-related quality of life (HrQoL), poses significant challenges to an aging population. The Frailty Index (FI), is the ratio of the number of accumulated health deficits to the total number of deficits considered, is used to predict frailty.

Methods: Utilizing data from the Mexican American Family Study, we investigated the heritability and gene-environment (GxE) interactions influencing frailty in 1,029 Mexican American participants. We calculated the FI using 34 variables, …

Inflammatory Breast Carcinoma In The Rio Grande Valley: A Case Report, Miguel A. Lopez, Maria Villegas, Thomas Davis

Research Colloquium

Inflammatory breast carcinoma (IBC) is a rare and aggressive subtype of invasive breast cancer found in a small percentage of patients in the United States.The Rio Grande Valley is a region of Texas with pockets of low socioeconomic status and increased rates of obesity, a large risk factor for IBC. The cutaneous presentation of IBC is a tender, erythematous patch or plaque that surrounds hair follicles (referred to as peau d’orange) and is frequently edematous. Diagnosis requires a high clinical index of suspicion supported by a thorough patient history and pathology consistent with invasive carcinoma. This case study discusses a …

Successful Typical And Atypical Atrial Flutter Ablation In A Patient With Systolic-Diastolic Heart Failure And A Recent Implantable Cardioverter Defibrillator: A Case Report, Jose J. Loayza Pintado, Michelle Lopez

Research Colloquium

Background: The prevalence of atrial fibrillation/flutter (AF) increases with the severity of chronic heart failure (HF) and is linked to worsened outcomes and higher mortality. Implantable cardiac devices, such as the implantable cardioverter-defibrillator (ICD), reduce mortality from ventricular arrhythmias in HF patients. Conversely, AF, which occurs in up to 20% of ICD patients, can limit the clinical effectiveness of ICDs. The impact of AF on prognosis, including inappropriate ICD therapy, remains debated. This case report aims to illustrate this sporadic occurrence and discuss the controversy surrounding AF's impact on the prognosis of ICD patients.

Case Presentation: A 63-year-old male …

Yb1 Modulates Sorafenib Sensitivity In Hepatocellular Carcinoma Cell Lines, Dennis Kwabiah, Yamile Abuchard Anaya, Ricardo Bracho Pequeno, Mohammed Shabir Hussain, Manish K. Tripathi

Research Colloquium

Background: Drug resistance is a leading cause of mortality in cancer, responsible for up to 90% of cancer-related deaths. Understanding the mechanisms behind drug resistance is crucial for enhancing the efficacy of cancer therapies. Hepatocellular carcinoma (HCC) is the most prevalent form of liver cancer and a major contributor to liver cancer-related fatalities. While early-stage HCC can often be cured with surgical interventions like liver transplantation or hepatectomy, advanced stages are challenging due to drug resistance. Sorafenib, an FDA-approved multi-tyrosine kinase inhibitor for treatment of advanced HCC, has shown limited effectiveness in prolonging overall survival in advanced HCC patients. …

Characterization Of Alzheimer's Disease In South Asians: Analysis Of Cardiovascular Disease Prevalence As A Risk Factor, Ramya Kunta, Luis A. Pena Marquez, Maria Sophia Z. Malbas, Astrid-Ines Foamkom, Ney Alliey Rodriguez

Research Colloquium

Background: Alzheimer’s Disease (AD), a growing public health issue affecting an estimated 6.7 million Americans, is characterized by a slow progressive decline in cognition. While there is extensive research focused on Non-Hispanic European populations, data is limited on underrepresented minorities, particularly South Asians. This study aims to analyze cardiovascular disease prevalence as a risk factor in relation to AD in South Asians.

Methods: The National Alzheimer’s Coordinating Center (NACC) Uniform Data Set was utilized for this study. The study sample consists of 47,165 participants, including 66 South Asian individuals, which represents 0.1% of the total population selected for the study. …

The Hidden Dangers Of Cocaine: A Rare Case Of Necrotic Penile Ulcer, Roy Kondapavuluru, Khairiya Haj-Yahya, Elimar Gonzalez, Victor Tran, Roque Mifuji, Luis Rosas

Research Colloquium

Introduction: Cocaine is a strong central nervous system stimulant that is highly addictive with a wide potential for abuse as a recreational drug. The use of cocaine in an estimated 3 million Texans and 560 million Americans, has led to a growing health care hazard with many detrimental effects. Physiologically, cocaine causes significant vasoconstriction often leading to venous occlusion with subsequent ulceration and necrosis of mucosal membranes. Although cocaine is typically abused by inhalation or intravenous routes, few cases of injection into the genital region have been reported as means of abuse, leading to priapism, vasculitis, and in some cases …

Elevated Troponin Levels And Seizures Associated With Synthetic Cannabinoid Use: A Case Report, William Reckley, Kennedy Olson, Roy Kondapavuluru, Elimar Gonzalez, Victor Tran, Anthony Alanis, Andres Suarez Parraga

Research Colloquium

Introduction: Marijuana is the most commonly used illicit drug in the U.S. and the third leading cause of drug-related emergency room visits. It is known to have potential long-term negative effects on health, particularly impacting the neurological and cardiovascular systems. The most common associated issues include strokes and myocardial infarctions; however, there have been very few documented cases of seizures and coronary vasospasms following synthetic cannabinoid use in adolescents and young adults. In this case, we describe a young woman who came to the emergency room with altered mental status and seizures, along with elevated troponin levels and subtle EKG …

Pulmonary Fibrosis As A Presentation Of Short Telomere Syndrome: Case Report, Roy Kondapavuluru, Jian Garcia Cruz, Sreejith Pillai, Andres Suarez Parraga

Research Colloquium

Introduction: Short telomere syndrome (STS), also known as accelerated aging syndrome, is an inheritable gene mutation resulting in decreased telomere length causing high cell turnover of organ systems such as skin, bone marrow, liver, hair, lungs, and immune system. Due to diverse clinical manifestations, STS poses a diagnostic challenge, with bone marrow failure and idiopathic pulmonary fibrosis being frequent manifestations. The inherited form of STS demonstrates genetic anticipation occurring at an earlier age with more severe manifestations in the affected progeny. We present a rare case of inherited STS in a young patient with severe pulmonary fibrosis.

Case Presentation: A …

Tc-Ptp Overexpression In Mouse Skin Is Linked To Enhanced Epidermal Differentiation In Response To Tumor Promoter Tpa Exposure, Jared Hensley, Smaran Marupudi, Lindsey Shim, Bilal Hafeez, Dae Joon Kim

Research Colloquium

Background: Maintaining a balance between keratinocyte proliferation and differentiation is essential for epidermal homeostasis. Disruption of this balance can lead to hyperplasia and cancer. Epidermal homeostasis is regulated by various signaling pathways, including those mediated by reciprocal regulation between protein tyrosine kinases and protein tyrosine phosphatases. T-cell protein tyrosine phosphatase (TC-PTP), encoded by the PTPN2 gene, is one such phosphatase known to inhibit epidermal cell proliferation through the direct dephosphorylation of STAT3, a key transcription factor involved in cell survival and proliferation following exposure to chemical toxicants. Our previous studies have demonstrated the crucial role of TC-PTP in the prevention …

Vegf In Diabetic Retinopathy And Age-Related Macular Degeneration, Justin Z. Heckman, Andrew Tsin, Sophia Villa

Research Colloquium

Vascular Endothelial Growth Factor is a growth factor that plays a significant role in angiogenesis and vascular permeability. This paper dives into the development of diabetic retinopathy and age-related macular disease and focuses on the molecular pathway that VEGF goes through as the diseases progress. Diabetic retinopathy can progress from non-proliferative diabetic retinopathy into the more aggressive proliferative diabetic retinopathy through a series of molecular changes. In non-proliferative diabetic retinopathy hyperglycemia damages microvasculature and can lead leads to retinal vascular permeability, pericyte loss, microaneurysms, and acellular capillary formation. As the disease progresses, hypoxia leads to the production of VEGF which …

Medicinally Privileged Natural Chalcones: Abundance, Mechanisms Of Action, And Clinical Trials, Sophia M. Villa, Justin Z. Heckman, Debasish Bandyopadhyay

Research Colloquium

Chalcones have been utilized for centuries as foods and medicines across various cultures and traditions worldwide. This paper concisely overviews their biosynthesis as specialized metabolites in plants and their significance, potential, efficacy, and possibility as future medicines. This is followed by a more in-depth exploration of naturally occurring chalcones and their corresponding mechanisms of action in human bodies. Based on their mechanisms of action, chalcones exhibit many pharmacological properties, including antioxidant, anti-inflammatory, anticancer, antimalarial, antiviral, and antibacterial properties. Novel naturally occurring chalcones are also recognized as potential antidiabetic drugs, and their effect on the GLUT-4 transporter is investigated. In addition, …

Literature Review: Exploring The Efficacy Of Minimally Invasive Surgery (Mis) Techniques In Spinal Fusion For Degenerative Spondylolisthesis, Yolanda V. Gutierrez, Blake Martin, Joshua Nwose, Robert H. Ablove

Research Colloquium

Introduction: Spine diseases and degeneration of the spine are common causes of back pain. One common cause of back pain is spondylolisthesis which is the slipping of a vertebral body disc. A subtype of spondylolisthesis is degenerative spondylolisthesis which commonly occurs due to wasting of the intervertebral disc leading to an unstable spine. In patients with a lack of neurological issues, conservative treatment is recommended. If conservative treatment is ineffective, surgery is deemed the next step, involving decompression of and fusion of the vertebrae. Minimally invasive surgery (MIS) techniques have emerged in the last decade. This systematic literature review aims …

The Impact Of Diabetes Mellitus On The Severity Of Alzheimer’S Disease In Hispanics In The Rio Grande Valley, Maria Camila Gonzalez Tovar, Kelsey Baker

Research Colloquium

Alzheimer’s disease is becoming more prevalent worldwide, leading to a growing demand to understand its risk factors and their impact on disease progression. Notably, Diabetes Mellitus has emerged as a significant risk factor to the development of Alzheimer’s disease, given its association with cognitive impairment. Due to its pathophysiology, Diabetes Mellitus could potentially contribute to the progression of Alzheimer’s disease. This study involved a detailed chart review of Hispanic patients diagnosed with Alzheimer’s disease within the past five years, some of whom also had a preexisting diagnosis of Diabetes Mellitus. This study formed two cohorts: Alzheimer patients without Diabetes Mellitus …

Deciphering Tumorigenesis: Pathophysiological Roles Of Reactive Oxygen Species In Glioblastoma, Maria Camila Gonzalez Tovar, Alex Zuo

Research Colloquium

Background. Reactive oxygen species (ROS) play a significant role in activating multiple signaling pathways for cellular proliferation but can be influential in tumorigenesis. We explore how ROS can be used to aid the advances of therapeutic interventions for glioblastoma, a highly aggressive and reoccurring brain cancer.

Methods. Over 30 of the most recent and relevant studies were extensively reviewed to determine the significance and implications of ROS in the pathophysiology of glioblastoma.

Results. ROS are essential for cell signaling. At low levels, ROS have been seen to promote tumorigenesis by inducing cell proliferation, which indirectly causes the tumor microenvironment to …

Utrgv Som Stroke Prevention Education Program, Briana Gonzalez Digrazia, Mia Rose Schmolze, Chantal Uzoma, Paul Digrazia, Maria Camila Gonzalez Tovar

Research Colloquium

Purpose: The UTRGV SOM Stroke Prevention Education Program is a patient education initiative for uninsured patients in Hidalgo County, where the prevalence of the five major risk factors for strokes, like diabetes and hypertension, are especially high. Texas Medical Association student members collaborated with the UTRGV SOM Area Health Education (AHEC) Scholars program, which aims to help reduce the significant shortage of primary health care providers in rural and medically underserved communities in the Rio Grande Valley.

TMA and AHEC students from multiple disciplines like medicine, dietetics, nutrition, and exercise studies offered specific techniques (i.e. home workout programs and culturally …

Use Of Digital Cadaveric Digital Atlases To Improve Student Performance In Neuroanatomy, Kevin A. Garcia Valdez, Anesu Karen Murambadoro, Kory Deshawn Punch, Megan W. Szobody, Tori Sayers, Nina Mourao, Blake Martin, Tyler Torres, Juan Torres, Natasha N. Quailes, Neharika Penmetcha, Sriya Gullapalli, Lois F. Baldado, Isabella Rodriguez, Arjun Bellamkonda, Sridhar Srinivasan, Xiaoqian Fang, Bharathi Shrikanth Gadad, Ricardo Belmares

Research Colloquium

Background: The use of digital platforms to teach various subjects in the pre-clerkship curriculum is a fast-developing field, but their utility compared to traditional in-person didactics is unclear. Partly fueled by the recent demand for remote learning materials and ever-burgeoning access to artificial intelligence, the drive has been to develop materials to meet the demands of the digital age. Our goal is to evaluate the efficacy of the use of a digital atlas to improve learning outcomes in the field of neuroanatomy, namely developing skills in interpreting imaging studies featured on summative examinations. Literature has shown that the implementation of …