• Title/Summary/Keyword: 연령효과

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Usefulness of LIFE in diagnosis of bronchogenic carcinoma (기관지 암의 진단에서 형광기관지 내시경검사의 유용성)

  • Lee, Sang Hwa;Shim, Jae Jeong;Lee, So Ra;Lee, Sang Youb;Suh, Jung Kyung;Cho, Jae Yun;Kim, Han Gyum;In, Kwang Ho;Choi, Young Ho;Kim, Hark Jei;Yoo, Se Hwa;Kang, Kyung Ho
    • Tuberculosis and Respiratory Diseases
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    • v.44 no.1
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    • pp.69-84
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    • 1997
  • Background : Although the overall prognosis of patients with lung cancer is poor, highly effective treatment exists for the small subset of patients with early lung cancer(carcinoma in situ/micro- invasive cancer). But very few patients have benefit from them because these lesions are difficult to detect and localize with conventional white-light bronchoscopy. To overcome this problem, a Lung Imaging Fluorescence Endoscopic device(LIFE) was developed to detect and clearly delineate the exact location and extent of premalignant and early lung cancer lesions using differences in tissue autofluorescence. Purpose : The purpose of this study was to determine the difference of sensitivity and specificity in detecting dysplasia and carcinoma between fluorescence imaging and conventional white light bronchoscopy. Material and Methods : 35 patients (16 with abnormal chest X-ray, 2 with positive sputum study, 2 with undiagnosed pleural effusion, 15 with respiratory symptom) have been examined by LIFE imaging system. After a white light bronchoscopy, the patients were submitted to fluorescence bronchoscopy and the findings of both examinations have been classified in 3 categories(class I, II, III). From of all class n and III sites, 79 biopsy specimens have been collected for histologic examination: a comparison between histologic results and white light or fluorescence bronchoscopy has been performed for assessing sensitivity and specificity of the two methods. Results : 1) Total 79 sires in 35 patients were examined. Histology demonstrated 8 normal mucosa, 21 hyperplasia, 23 dysplasia, and 27 microinvasive and invasive carcinoma. 2) The sensitivity of white light or fluorescence bronchoscopy in detecting dysplasia was 60.9% and 82.6%, respectively. 3) The results of this study showed 70.3 % sensitivity for microinvasive or invasive carcinoma with LIFE system, versus 100% sensitivity for white light in 27 cases of carcinoma. The false negative study of LIFE system was 8 cases(3 adenocarcinoma and 5 small cell carcinoma), which were infiltrated in submucosal area and had normal epithelium. Conclusion : To improve the ability 10 diagnose and stage more accurately, fluorescence imaging may become an important adjunct to conventional bronchoscopic examination because of its high detection rate of premalignant and malignant epithelial lesion. But. it has limitation to detect in submucosal infiltrating carcinoma.

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Evaluation of Sodium Intake and Relationship between Sodium Intake and the Bone Mineral Density of Female University Students (중부 지역 여대생에서 음식섭취빈도조사지를 이용한 나트륨 섭취량 평가 및 나트륨 섭취와 골밀도와의 관련성 조사)

  • Bae, Yun-Jung;Yeon, Jee-Young
    • Journal of the East Asian Society of Dietary Life
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    • v.21 no.5
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    • pp.625-636
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    • 2011
  • The purpose of this study was to evaluate the relationship between bone health and sodium intake in female university students using a dish frequency questionnaire (DFQ 125), anthropometric checkups, food records for 3 days, and ultrasound measurement of calcaneus bone mineral density. Subjects were divided into two groups: normal (n=196) and osteopenia (n=52). There were no significant differences in age or height between the two groups. The average weight, body mass index, and body fat in the normal group were significantly higher than in the osteopenia group. The sodium intake of DFQ was positively correlated with the sodium intake of 3 days of dietary records (p=0.0003). There were no significant differences in the sodium intake between the two groups from DFQ. The dishes were ranked by sodium intake: kimchies were 17.68%, noodles and mandu were 16.36%, stews were 13.69%, main dishes such as meat, egg, and beans were 11.47%, and fish and shellfish were 11.07%. The frequency of eating noodles and mandu (p=0.0116), stews (p=0.0008), kimchies (p=0.0482), fish and shellfish (p=0.0362), vegetables (p=0.0064) and seasoning (p=0.0347) were negatively associated with bone mineral density. Bone health was not significantly different with increasing quartiles of sodium intake. As excessive sodium intakes may indirectly affect bone mineral density, these results suggest that to prevent osteoporosis, university students needed to be more educated about diets containing less sodium through nutrition education programs.

LINAC-based Stereotactic Radiosurgery for Meningiomas (수막종에 대한 선형가속기형 정위방사선수술)

  • Shin Seong Soo;Kim Dae Yong;Ahn Yong Chan;Lee Jung Il;Nam Do-Hyun;Lim Do Hoon;Huh Seung Jae;Yeo Inhwan J;Shin Hyung Jin;Park Kwan;Kim BoKyoung;Kim Jong Hyun
    • Radiation Oncology Journal
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    • v.19 no.2
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    • pp.87-94
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    • 2001
  • Purpose : To evaluate the role of LINAC-based stereotactic radiosurgery (SRS) in the management of meningiomas, we reviewed clinical response, image response, neurological deficits for patients treated at our institution. Methods and materials : Between February 1995 and December 1999, twenty-six patients were treated with SRS. Seven patients had undergone prior resection. Nineteen patients received SRS as the initial treatment. There were 7 male and 19 female patients. The median age was 51 years (range, $14\~67\;years$). At least one clinical symptom presented at the time of SRS in 17 patients and cranial neuropathy was seen in 7 patients. The median tumor volume was $4.7\;cm^3\;(range,\;0.7\~16.5\;m^3)$. The mean marginal dose was 15 Gy (range, $10\~20\;Gy$), delivered to the $80\%$ isodose surface (range, $46\~90\%$). The median clinical and imaging follow-up periods were 27 months (range, 1-71 months) and 25 months (range, $1\~52\;months$), respectively. Results : Of 14 patients who had clinical follow-up of one year or longer, thirteen patients $(93\%)$ were improved clinically at follow-up examination. Clinical symptom worsened in one patient at 4 months after SRS as a result of intratumoral edema, who underwent surgical resection at 7 months. OF 14 patients who had radiologic follow-up of one year or longer, tumor volume decreased in 7 patients $(50\%)$ at a median of 11 months (range, $6\~25\;months$), remained stable in 6 patients $(43\%)$, and increased in one patient $(7\%)$, who underwent surgical resection at 44 months. New radiation-induced neurological deficits developed in six patients $(23\%)$. Five patients $(19\%)$ had transient neurological deficits, completely resolved by conservative treatment including steroid therapy. Radiation-induced brain necrosis developed in one patient $(3.8\%)$ at 9 months after SRS who followed by surgical resection of tumor and necrotic tissue. Conclusions : LINAC-based SRS proves to be an effective and safe management strategy for small to moderate sized meningiomas, inoperable, residual, and recurrent, but long-term follow-up will be necessary to fully evaluate its efficacy. To reduce the radiation-induced neurological deficit for large size meningioma and/or in the proximity of critical and neural structure, more delicate treatment planning and optimal decision of radiation dose will be necessary.

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Study on Acknowledge and State of Clinical Experience for 3-years Dental Technology Department (3년제 치기공과 임상실습에 대한 인식 및 실태조사 - 일부 치과기공소 소장을 중심으로 -)

  • Park, Myung-Ja
    • Journal of Technologic Dentistry
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    • v.17 no.1
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    • pp.41-57
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    • 1995
  • This study was conducted to collect and analyze previous information in order to manage efficience, improve experience effect and promote employment rate. The questionnaire interview with 27 chief of dental Laboratory refered clinical experience in technology department about clinical experience in 14 Jumior colleges were also investigated. The results were summarried as follows : The portion of age of 35-39 among chief of dental Laboratory was 40.7% which was the highest, that of male was 96.3%, that of junior college graduate was 97.5%, that of 10years experience was 92.6% and that of ceramic technician was 85.2%, 63.0% dental laboratory for clinical experience was a bore space of 30pyong. Aspect of dental laboratory management, manufacturing all part of prosthetic restoration was 29.6%, othodontic appliance and ceramic restoration was 7.4%, 3.8%, each. The percentage of 40.7 was having connection with 30-3a dental clinics and referring case per day was 10-19 cases(40.7%), manufacturing time of referred prosthetic restoration was 3-4 days(77.8%), places preparing seminar room for education was 29.6%, above a place of 40pyong was 11.1% 30-34 pyong and 35-39 pyong was 7.4% each. During training of 2 years education course student, 18.5% was rack of thorough occupational career. While 44.4% will want the more salary among 3years education course student, 74.1% will expect the more dental techmicians would engaged in their field, 51.9% will hope improve of their theory and practice, 29.6% be expected better skill and 14.8% be expected better theory. Attitude of clinical experience places was distributed by 59.3% of offering only experience chance, 25.9% of wasting time and 29.0% of annoying. The big emphasis of climical experience was thorough occupational career(44.4%). The clinical experience places of our college were selected after direct visiting, so their condition of management was not that bad but most of dental laboratory were poor in management state and working environment. Therefore it is difficult to choose appropriate places and dental Laboratory are also limited manpower and time as suppliers. So that it recommended to induce flexible management of experience period by interval and rotation of experience places among college and to applicate intern-system for employment ant industry-college cooperation aspect.

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Smoking-Induced Dopamine Release Studied with $[^{11}C]Raclopride$ PET ($[^{11}C]Raclopride$ PET을 이용한 흡연에 의한 도파민 유리 영상 연구)

  • Kim, Yu-Kyeong;Cho, Sang-Soo;Lee, Do-Hoon;Ryu, Hye-Jung;Lee, Eun-Ju;Ryu, Chang-Hung;Jeong, In-Soon;Hong, Soo-Kyung;Lee, Jae-Sung;Seo, Hong-Gwan;Jeong, Jae-Min;Lee, Won-Woo;Kim, Sang-Eun
    • The Korean Journal of Nuclear Medicine
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    • v.39 no.6
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    • pp.421-429
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    • 2005
  • Purpose: It has been postulated that dopamine release in the striatum underlies the reinforcing properties of nicotine. Substantial evidence in the animal studies demonstrates that nicotine interacts with dopaminergic neuron and regulates the activation of the dopaminergic system. The aim of this study was to visualize the dopamine release by smoking in human brain using PET scan with $[^{11}C]raclopride$. Materials and Methods: Five male non-smokers or ex-smokers with an abstinence period longer than 1 year (mean age of $24.4{\pm}1.7$ years) were enrolled in this study $[^{11}C]raclopride$, a dopamine D2 receptor radioligand, was administrated with bolus-plus-constant infusion. Dynamic PET was performed during 120 minutes ($3{\times}20s,\;2{\times}60s,\;2{\times}120s,\;1{\times}180s\;and\;22{\times}300s$). following the 50 minute-scanning, subjects smoked a cigarette containing 1 mg of nicotine while in the scanner. Blood samples for the measurement of plasma nicotine level were collected at 0, 5, 10, 15, 20, 25, 30, 45, 60, and 90 minute after smoking. Regions for striatal structures were drawn on the coronal summed PET images guided with co-registered MRI. Binding potential, calculated as (striatal-cerebellar)/cerebellar activity, was measured under equilibrium condition at baseline and smoking session. Results: The mean decrease in binding potential of $[^{11}C]raclopride$ between the baseline and smoking in caudate head, anterior putamen and ventral striatum was 4.7%, 4.0% and 7.8%, respectively. This indicated the striatal dopamine release by smoking. Of these, the reduction in binding potential in the ventral striatum was significantly correlated with the cumulated plasma level of the nicotine (Spearman's rho=0.9, p=0.04). Conclusion: These data demonstrate that in vivo imaging with $[^{11}C]raclopride$ PET could measure nicotine-induced dopamine release in the human brain, which has a significant positive correlation with the amount or nicotine administered bt smoking.

A Basic Study on the Establishment of Preservation and Management for Natural Monument(No.374) Pyeongdae-ri Torreya nucifera forest of Jeju (천연기념물 제374호 제주 평대리 비자나무 숲의 보존·관리방향 설정을 위한 기초연구)

  • Lee, Won-Ho;Kim, Dong-Hyun;Kim, Jae-Ung;Oh, Hae-Sung;Choi, Byung-Ki;Lee, Jong-Sung
    • Journal of the Korean Institute of Traditional Landscape Architecture
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    • v.32 no.1
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    • pp.93-106
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    • 2014
  • In this study, Analyze environment of location, investigation into vegetation resources, survey management status and establish to classify the management area for Natural monument No.374 Pyengdae-ri Torreya nucifera forest. The results were as follows: First, Torreya nucifera forest is concerned about influence of development caused by utilization of land changes to agricultural region. Thus, establish to preservation management plan for preservation of prototypical and should be excluded development activity to cause the change of terrain that Gotjawal in the Torreya nucifera forest is factor of base for generating species diversity. Secondly, Torreya nucifera forest summarized as 402 taxa composed 91 familly 263 genus, 353 species, 41 varieties and 8 forms. The distribution of plants for the first grade & second grade appear of endangered plant to Ministry of Environment specify. But, critically endangered in forest by changes in habitat, diseases and illegal overcatching. Therefore, when establishing forest management plan should be considered for put priority on protection. Thirdly, Torreya nucifera representing the upper layer of the vegetation structure. But, old tree oriented management and conservation strategy result in poor age structure. Furthermore, desiccation of forest on artificial management and decline in Torreya nucifera habitat on ecological succession can indicate a problem in forest. Therefore, establish plan such as regulation of population density and sapling tree proliferation for sustainable characteristics of the Torreya nucifera forest. Fourth, Appear to damaged of trails caused by use. Especially, Scoria way occurs a lot of damaged and higher than the share ratio of each section. Therefore, share ratio reduction Plan should be considered through the additional development of tourism routes rather than the replacement of Scoria. Fifth, Representing high preference of the Torreya nucifera forest tourist factor confirmed the plant elements. It is sensitive to usage pressure. And requires continuous monitoring by characteristic of Non-permanent. In addition, need an additional plan such as additional development of tourism elements and active utilizing an element of high preference. Sixth, Strength of protected should be differently accordance with importance. First grade area have to maintenance of plant population and natural habitats. Set the direction of the management. Second grade areas focus on annual regeneration of the forest. Third grade area should be utilized demonstration forest or set to the area for proliferate sapling. Fourth grade areas require the introduced of partial rest system that disturbance are often found in proper vegetation. Fifth grade area appropriate to the service area for promoting tourism by utilizing natural resources in Torreya nucifera forest. Furthermore, installation of a buffer zone in relatively low ratings area and periodic monitoring to the improvement of edge effect that adjacent areas of different class.

Results of Radiation Therapy and Extrafascial Hysterectomy in Bulky Stage IB, IIA-B Carcinoma of the Uterine Cervix (종괴가 큰 병기 IB, IIA-B 자궁경부암에서 방사선치료와 Extrafascial Hysterectomy의 결과)

  • Kim Jin Hee;Lee Ho Jun;Choi Tae Jin;Do Cha Soon;Lee Tae Sung;Kim Ok Bae
    • Radiation Oncology Journal
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    • v.17 no.1
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    • pp.23-29
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    • 1999
  • Purpose : To evaluate the efficacy of radiation therapy and extrafascial hysterectomy in bulky stage IB, IIA-B uterine cervix cancers. Methods and Materials : Twenty four patients with bulky stage IB and IIA-B carcinoma of the uterine cervix were treated with extrafascial hysterectomy following radiation therapy due to doubts of residual disease at Department of therapeutic radiology, Keimyung University, Dongsan Hospital, from April 1986 to December 1997 According to FIGO staging system, there were 7 patients with stage IB, 9 patients with IIA and 8 patients with IIB stage whose median age was 45. Pathologic distribution showed 16 patients with squamous cell carcinoma and 8 patients with adenocarcinoma. Seven patients had tumors that are less than 5cm in size and 17 patients had tumors with larger than 5cm. The mean interval between radiation therapy and extrafascial hysterectomy was 57 days. The radiation therapy consisted of external irradition to the whole pelvis (180 cGy/fraction, mean 4100 cGy) and parametrial boost (for a mean total dose of 5000 cGy) with midline shield (4H 10 cm), followed by intracavitary irradiation up to 7500 cGy to point A (maximum 8500 cGy). The maximum follow up duration was 107 months and mean follow up duration was 42 months. Results :Ten out of 24 patients (41.7%) had residual disease found at the time of extrafascial hysterectomies. Five year overall survival rate (5Y OSR) and five year disease free survival rate (5Y DFSR) were 63.6% and 62.5% respectively. Five year overall survival rate for stage IB and IIA was 71.4% and 50% for stage IIB. There was a significant difference in 5Y OSR and 5Y DFSR between patients with and those without residual disease (negative vs positive, 83.3% vs. 40% (P=0.01), 83.3% vs 36% (P=0.01) respectively). There was a notable tendency of better survival with adenocarcinoma than with squamous cell carcinoma (adenocarcinoma vs squamous cell carcinoma, 85.7% vs. 53.3% (P=0.1), 85.7% vs. 50.9% (P=0.1) of 5Y OSR and 5Y DFS respectivey). Total dose to A point did not make a significant difference in survival rate or the existence of residual lesion (< 7500 cGy, ${\geq}$ 7500 cOy). It was also noted that significantly more frequent local failures have occurred in patients with positive residual disease compared with negative residual disease (5/10 vs. 0/14, p=0.003), There was no death related to the treatment. Conclusion : There was no improvement of residual disease and to the overall survival rate in spite of increased total dose to point A. We conclude that there is a possible beneficial effect of radiation therapy followed by extrafaseial hysterectomy in survival for adenocarcinoma of bulky stage IB and IIA-B uterine cervix. We need to confirm this with longer follow up and with large number of patients.

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Actual Conditions and Perception of Safety Accidents by School Foodservice Employees in Chungbuk (충북지역 학교급식 조리종사원의 안전사고 실태 및 인식)

  • Cho, Hyun A;Lee, Young Eun;Park, Eun Hye
    • Journal of the Korean Society of Food Science and Nutrition
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    • v.43 no.10
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    • pp.1594-1606
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    • 2014
  • The purpose of this study was to examine safety accidents related to school foodservice, working and operating environments of school foodservice, status and awareness of safety education, educational needs, and information on qualitative improvement of school foodservice. The subjects in this study were 234 cooks in charge of cooking at elementary and secondary schools in Chungbuk. A survey was conducted from July 30 to August 8, 2012, and among 202 questionnaires gathered, 194 completed questionnaires were analyzed. Statistical analyses were performed on data utilizing the SPSS version 19.0. The main results of this study were as follows: 44.3% of workers experienced safety accidents. The most frequent safety accident was 'once' (60.5%), and most safety accidents took place between June and August (31.4%). The time at which most safety accidents happened was between 8 and 11 am. Most safety accidents happened during cooking (52.3%) and while using a soup pot or frying pot (52.4%). The most common accidents were 'burns', 'wrist and arm pain', and 'slips and falls'. Respondents who experienced safety accidents replied that 57.6% of employees dealt with injuries at their own expense, and only 35.3% utilized industrial accident insurance. In terms of the operating environment, the score for 'offering information and application' was highest (3.76 points), whereas that for 'security of budget' was lowest (1.77 points). As for accident education, employees received safety education approximately 3.45 times and 5.10 hours per year. Improving the working environment of school foodservice cooks requires administrative and financial support. Furthermore, educational materials and guidelines based on the working environment and safety accident status of school foodservice cooks are required in order to minimize potential risk factors and control safety accidents in school foodservice.

The Effect of Active Senior's Career Orientation and Educational Entrepreneurship Satisfaction on Entrepreneurship Intention and Entrepreneurship Preparation Behavior (액티브 시니어의 경력지향성과 창업교육 만족이 창업의지와 창업준비행동에 미치는 영향)

  • Park, Joungbum;Yang, Youngseok;Kim, Myungseuk
    • Asia-Pacific Journal of Business Venturing and Entrepreneurship
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    • v.15 no.1
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    • pp.285-301
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    • 2020
  • Looking at the problem of aging in the nation from a demographic perspective, it is not a problem of the overall population, but of the structure of the population. It is the baby boomer and post-baby boomers, the largest population in the country. Baby boomers were born between 1955 and 1963, and currently have a population of 7001,333, which is 13.6 percent (as of 2015). The Post-Baby Boomer generation was born between 1964 and 1974, with a total population of 9,567,171, accounting for 18.8 percent of the total population. In particular, baby boomers and post-baby boomers (32.4% of the total population) have begun to retire or will retire soon. The average life expectancy continues to increase due to the development of medical technology, and the falling birth rate of newborns and the declining population of the production population are darkening the domestic economy. In a policy proposal aimed at easing the nation's falling economic growth rate, women's participation rate is as high as Sweden and men's efforts to increase it as high as Japan's, while the elderly rate is desirable to maintain Korea's high level. This is because the expansion of the elderly generation's participation in economic activities could ease a sharp drop in economic growth and reduce the burden of supporting the elderly population. The study, based on this social problem awareness and problem solving plan, looks at the relationship between career orientation and satisfaction in start-up education based on the diverse career base of active seniors, and also suggests the importance of customized start-up education on the diversity of active seniors by clarifying the relationship between them, and suggests the desirable direction of senior start-up policy design, funding, and start-up education. Based on the theoretical background, the concept of five factors was defined: active senior, career-oriented, satisfaction level of start-up education, willingness to start a business, and the concept definition of an active senior, which is particularly key to the baby boomers in their 50s and 60s, is generally regarded as a source of consumption or welfare benefits, but in this study, the concept of active start-up is reflected in the domestic start-up market by young people in their 40s, 50s and 60s. As a result of a hypothesis test. Hypothesis 1 and Hypothesis 5: Career orientation has been verified to affect the willingness to start a business and the behavior of preparation for a start-up. Hypothesis 3: The willingness to start a business has been verified as having an effect between startup preparation actions. Hypothesis 4: The satisfaction level of start-up education has been verified to affect start-up preparation behavior. However, hypothesis 2: The satisfaction level of education for start-ups does not affect the willingness to start a business. Such results can be inferred that satisfaction in start-up education does not have a direct effect on the will to start a business and increases the will to start a business through the influence of personal career orientation.

Clinical Efficacy of Clomiphene Citrate and Letrozole Combined with Gonadotropins for Superovulation in Patients with Clomiphene-Induced Thin Endometrium (클로미펜에 얇은 자궁내막을 보이는 환자에서 성선자극호르몬 병합 과배란유도시 클로미펜과 레트로졸의 임상적 효용성)

  • Lee, Eun-Joo;Park, Hyun-Jong;Yang, Hyo-In;Lee, Kyung-Eun;Seo, Seok-Kyo;Kim, Hye-Yeon;Cho, Si-Hyun;Choi, Young-Sik;Lee, Byung-Seok;Park, Ki-Hyun;Cho, Dong-Jae
    • Clinical and Experimental Reproductive Medicine
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    • v.36 no.2
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    • pp.111-119
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    • 2009
  • Objective: The aim of this study was to compare the clinical efficacy of clomiphene citrate (CC) and letrozole combined with gonadotropins for controlled ovarian stimulation (COS) in patients with CC-induced thin endometrium Methods: Fifty-one intrauterine insemination cycles performed in patients who previously had a thin endometrium (<8 mm) to ovulation induction using CC were included in this study. A CC 100 mg/day (CC+gonadotropin group, n=26) or letrozole 2.5 or 5 mg/day (letrozole+gonadotropin group, n=25) was administered on day 3~7 of the menstrual cycle, combined with gonadotropins at dose 75~150 IU every other day starting on day 5~7. We compared total dose of gonadotropin used, endometrial thickness, endometrial pattern, number of follicles ${\geq}14\;mm$ on hCG day, pregnancy rate and multiple pregnancy rate between the two groups, which were statistically analyzed using Mann-Whitney U test or Fisher's exact test, where appropriate. Results: There were no significant differences in clinical characteristics such as age, duration of infertility, number of previous IUI cycles, basal serum hormone levels and cause of infertility between the two groups. In both groups, the endometrium was significantly thicker than that of previous ovulation induction cycles using CC. No significant differences were found in the total dose of gonadotropin used, day of hCG administration, the rate of triple endometrium and pregnancy rate. The number of follicles ${\geq}14\;mm$ was significantly lower ($3.7{\pm}1.7$ vs. $2.8{\pm}1.7$, p=0.03) and the endometrium on hCG day was significantly thicker ($7.7{\pm}1.5$ vs. $9.1{\pm}1.7$, p=0.001) in letrozole+gonadotropin group compared to CC+gonadotropin group. Conclusion: The clomiphene citrate and letrozole combined with gonadotropins appear to avoid the undesirable effects on the endometrium frequently seen with CC for ovulation induction. However, in terms of adequate endometrial development or optimal follicular growth, letrozole may be more beneficial than CC for gonadotropin-combined COS in patients with CC-induced thin endometrium. Further prospective randomized controlled studies in a larger scale will be necessary to confirm our findings.