Adopting online problem-based learning (OPBL) to internship educational programs is an effective teaching method to stimulate self-directed and collaborative learning and knowledge-sharing behavior (KSB) of students. However, the OPBL collaboration experience is different from the traditional lecture-based learning experience for students. Integrating social identity theory and commitment-trust theory develops a formative research model that explains the KSB of students when using social media tools for the OPBL process. This process encourages social interaction and communication of students, in turn, facilitating the integration of collective intelligence or the creation, sharing, and exchange of knowledge. Data collected from 425 nursing students who studied at seven nursing colleges or medical universities in Taiwan were analyzed using the partial least squares (PLSs) technique. The results indicate that social identification is a crucial antecedent of KSB. Relationship quality plays a vital role in shaping the effects of interpersonal trust and relationship commitment (RC) on KSB during internship periods. The findings can contribute to theoretical discussions and enhance the effectiveness of KSB in the literature of internship and non-internship in the higher education field. On the other hand, OPBL is an effective self-directed and collaborative learning strategy that offers flexibility and opportunities for participation and discussion of students, encourages active learning, and promotes critical reasoning skills in various collaborative learning activities  approach in various educational contexts e.g., . Howevertivities . In genetivities .In the OPBL context, social media tools are often used as supportive learning tools to obtain the required knowledge and new information to promote collaborative learning, communication, or sharing of knowledge . ResearcPrevious studies that compare the effectiveness of OPBL with that of face-to-face PBL have revealed that the learning efficiency or outcome of students is inconsistent in different PBL contexts . Some stAccording to commitment-trust theory , maintaiTo conclude, individuals can utilize social media tools to share knowledge when participating in discussions or training sessions/activities . It is tRQ: How does social identification of students influence the levels of relationship commitment and interpersonal trust in small group discussions using OPBL groups, which, in turn, affects their KSB?via educational programs. The development of this capability is highly dependent on the level of the effectiveness of knowledge acquisition anytime and anywhere. Prior studies on the adoption of the OPBL approach in various educational contexts have identified and examined a number of important factors, such as active learning and improving knowledge  rather than knowledge dimension . In this study, the nature of the problem is more related to knowledge acquisition through the cognitive process  of students rather than through instructions  of teachers . AdditioPrior studies have widely applied social identity theory to research behaviors of computer-mediated communication . From thSome studies on virtual group identification have suggested that individuals who have a strong sense of belonging with their groups are likely to regard their goals as individual goals . Based oCommitment-trust theory  emphasizSince individuals are somehow unpredictable and uncontrollable by other people, collaborating with peers to solve problems tends to be a challenge in an OPBL group. In this study, interpersonal trust is defined as the extent to which students believe their peers will act in their interest. In addition, an interpersonal trust includes ability, integrity, and benevolence. Ability is viewed as an evaluation of the skills of OPBL members and competency in a learning group, which is related to captivating the professional knowledge of one; integrity refers to the reputation of honesty and truthfulness of the OPBL members; and lastly, benevolence is defined as the notion of reciprocal loyalty between an individual and an OPBL group, which would satisfy the expectations of behavior.This study mainly focuses on the KSB of students in OPBL activities using the LINE app to support collaborative learning in nursing internship educational programs. KSB refers to the degree to which nursing students share their experiences, professional knowledge, ideas, and answers to OPBL group questions. Identities of individuals with a particular objective in a group are characterized by a strong belief in accepting the values and goals of the group. As a result, they are willing to put extra effort into their group . FurtherH1a: Social identification of students is positively related to their interpersonal trust.A high level of social identification leads individuals to perceive greater homogeneity with others, display their adherence to the norms of a group, and strengthen their loyalty to the members in an OPBL group . Social H1b: Social identification of students is positively related to their relationship commitment.Previous studies have indicated that both social identification and KSB or the quality of knowledge-sharing depict a strong linkage between an individual and members based on interaction frequency, friendship, and group task . TherefoH1c: Social identification is positively related to their KSB.via relationship commitment mediation  to increase the validity of the research. Seven instructors accepted the interviews of the authors and shared their experiences concerning OPBL information in more detail. Finally, we integrated the two theories and examined the effects of critical factors on KSB performing rigorous statistical procedures to aggregate the questionnaire survey results.Based on the responses of the interviewees in nursing internship educational programs (6 months or longer), each student has to achieve at least six skill-based clinical courses in order to be eligible to take the licensing examination for nursing practitioners. Students are assigned to multiple small groups; each group has less than eight students. In this study, the qualification of those nursing students who enrolled in various clinical courses is consistent with the sample selection purpose of this study. It can be inferred that they have sufficient experience or knowledge to answer the questions.Additionally, the participants of this study, as members of learning groups, have to collaborate with one another in order to accomplish a shared learning goal. They did not receive any additional rewards except for getting good grades in the internship programs. Since students who belonged to the same learning group were assigned to the same hospital to do their internships, it was highly necessary for them to collaborate with one another in order to jointly resolve the problems that they encountered at work as an effective team. Since the healthcare problems of some patients were urgent, these students had to work together effectively to resolve the problems in a timely manner in order to deliver high-quality nursing services.Furthermore, even though the students are in a learning environment in which they competed with one another to get the recognition of their instructors in order to acquire good grades, they were likely to cooperate with peers to ensure that they would pass the evaluation of the internship programs. To be more specific, because all the students in the internship programs needed to pass these courses to get the qualification to take the national nurse practitioner certification examination, they were willing to put significant efforts into collaboration with fellow students as a team in order to make sure that everyone could make it to the national nurse practitioner certification examination. This would lead to their benevolent KSB with the members of the OPBL groups, regardless of the possibility of reciprocated KSB from peers, although they might hope for the best. Therefore, to better explain such selfless KSB, this study identified the construct of social identification as one of the key antecedents of KSB in the proposed research model see .The data of this study were collected from students in nursing internship education programs. We invited nursing students to participate in the survey based on their experience in internship educational programs. These procedures have been undertaken with the consent of the instructors of the internship programs appropriately. If the participants preferred to complete the questionnaires online, they could fill out our survey questions on the website by clicking a hyperlink. We provided a short description on the first page before asking related questions. All the participants were voluntary in response to the questions, and they could withdraw their participation in this survey at any time. Additionally, all the respondents remained anonymous in this survey.We eventually received 467 replies from students who studied at seven nursing colleges or medical universities, yielding a response rate of approximately 90.5%. Because of the reason that respondents offered systematic answers or failed to pass the examination of reverse questions that they were purposely included in the survey, 42 problematic questionnaires were excluded. A total of 425 valid responses were used for subsequent data analysis procedures, yielding an effective response rate of 82.36%.The instruments of this study were obtained from different studies, and the wording of all questions has been slightly modified to fit the unique research context. Social identification was measured using six items (three items for cognitive and three items for affective), adopted from The overall sample population was 86.35% female. Of the students, 91.76% experienced LINE app for more than 2 years. During the progress of the internship programs, 84.48% spent more than 2 hours per day using the Internet for their homework. Additionally, 81.18% of the students reported using the LINE app, 80% used e-Library, and 73.65% used Google Scholar to support their learning activities. We can, thus, consider these students to be active users of computer-mediated technology and networks. Moreover, the students who completed the clinical courses, 88.94% completed fundamental nursing, 70.12% completed medical-surgical nursing, 68% completed psychiatric mental health nursing, 66.82% completed maternal and neonatal nursing, 65.41% completed community health nursing, 64.94% completed pediatric nursing, and 37.88% completed additional clinical nursing practices .Partial least square (PLS), a component-based structured equation modeling technique, was used in this study. PLS has not required the normality of data distribution. It is appropriate to predict critical drivers of KSB because the research model of this study includes four constructs  that are complicated . We usedFirst-order reflective constructs were used in the measurement model for testing its reliability and validity, which was assessed in terms of convergent and discriminant validity . Additiop < 0.01) while all of the indicators’ coefficients were significant. These results indicate that their first-order indicators well-described social identification and interpersonal trust , relationship commitment , and KSB , respectively. Hypotheses H2a and H2b are both supported, indicating that interpersonal trust has a direct positive effect on relationship commitment  and KSB , respectively. Hypothesis H3 is supported, indicating that relationship commitment has a direct positive effect on KSB . The results indicate that social identification accounts for 60% of the variance of interpersonal trust. Additionally, social identification and interpersonal trust account for 49% of the variance of relationship commitment. Overall, all of the constructs that directly or indirectly influence KSB account for 59% of its variance.Using a bootstrapping technique by SmartPLS 3.0, we evaluated the hypotheses of the structural model. We used explained variances (R2) for the endogenous constructs to assess the structural model. The hypotheses of the proposed model are depicted in The results of this study are as predicted. Social identification is positively related to relationship commitment (H1a), interpersonal trust (H1b), and KSB (H1c), consistent with prior research on social identification . When thFurthermore, interpersonal trust is positively associated with relationship commitment (H2a) and KSB (H2b), consistent with the results obtained in previous studies . InterpeFinally, relationship commitment is positively associated with KSB (H3), consistent with a previous study . Relatiovia the social media support. In the literature of online communities in the area of electronic commerce, relationship quality is recognized as a crucial mediator of the KSB of individuals  and their degrees of relationship commitment to and interpersonal trust in other group members, as suggested in prior studies e.g., . TherefoDuring the progress of internship programs, students believe that the information/knowledge is credible and may gradually motivate their willingness to share their ideas or opinions and their commitment to other peers when they obtain useful and prompt feedback from their fellow peers in an OPBL group. In contrast, students who have a low interest in participating in OPBL activities may be encouraged to use the traditional learning method of rote memory to complete the clinical course that does not benefit the critical thinking and reasoning skills of students. The instructor can play an active role in collaborative learning to disseminate information while encouraging students to participate in professional communication in the OPBL context. Active participation in discussions may help students clarify false information, explain their ideas, and provide appropriate and accurate information to their peers. Additionally, instructors would need to respond to knowledge contributions (such as simple appreciations by posting a sticker) of students when students share their ideas, information, and opinions. Instructors are also required to regularly give comments for group discussions , coach communication skills of students , and encourage their exploration and collaboration. Finally, instructors may need to revise the traditional curriculum and combine various other materials, issues, and social media tools for designing content-laden curricula that are more appropriate for the needs of students of internship programs.In an OPBL group, students with relationship commitment can readily connect and quickly exchange knowledge or information with peers beneficial to their communication and interaction expertise . An OPBLThis study obtains meaningful results; similarly, several limitations also are considered in this study. First, the environment of OPBL is different from that of general PBL teaching designs. This study focuses only on internship OPBL courses of nursing students who have to encounter real-world professional situations and deal with complicated and dynamic problems during the progress of their internship educational programs. Therefore, future studies can extend the contribution of this study by focusing on the examination of the research model of its extensions in various higher educational programs in other professional fields. Second, this study only considers the perspective of nursing students in the internship programs of the environment of OPBL communities. Factors related to the academic cultures, characteristics or styles of students, and perceptions of an instructor were not addressed in this study. We suggest that future research extends the proposed model by considering the factors mentioned above and use data collected from students in different professional areas or regions to investigate further how OPBL-based practices are used in an internship or non-internship educational programs. Third, because this study did not intend to investigate the differences in online and offline KSB of students, we did not collect data that would allow us to examine whether the effects of key factors identified on the KSB of students would be the same in online and offline situations. Future studies that focus on this issue may be conducted. Finally, most students lack critical thinking and communicative skills when they encounter real-world problems or patients. Therefore, the instructors should create an online collaborative learning environment to foster active participation and frequency of group interaction for filling in the knowledge gaps of students. Future research can investigate the role of instructors in sustaining the sense of belongingness of students in virtual communities that strengthen their interactions in OPBL activities.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The authors’ University Governance Framework approved this study for Human Research Ethics . The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: Allergic reactions to Hymenoptera stings can have varying levels of severity, according to the Müller grading system. Methods: By an epidemiological concept, this is a retrospective cohort study. The observed cohort was represented by patients referred to the University Clinic Golnik due to Hymenoptera allergic reaction in the period from 1997 to 2015. From the immunological database of the University Clinic Golnik, we obtained laboratory data . The clinical characteristics of patients were obtained from BIRPIS. With the help of a questionnaire, which was sent to each patient in the period from May 2019 to April 2021, we obtained epidemiological data. For the assessment of the association between the severity of allergic reaction for the observed outcome, the severity of the first allergic reaction after Hymenoptera sting was used. Other variables were grouped according to risk factors. Discussion: We will identify the risk factors that could play an important role in a severe systemic reaction: the aetiology of the Hymenoptera sting, sex, age, history and severity of previous systemic reactions, being re-stung in an interval of two months, the frequency of re-stings, atopy, genetic predisposition, preventive medication use, other medication use, beekeeping or living next to beehives and why immunotherapy was not taken. Laboratory data will also be analysed to determine if there is any association with laboratory tests and the severity of the allergic reactions after Hymenoptera stings. Conclusions: Several new approaches are introduced in the study design. The most important is that the protocol covers epidemiological data gained from the questionnaire, as well as clinical data gained from the Immunological database and BIRPIS database. We expect to obtain significant results that will explain the risk factors for the natural history of Hymenoptera sting allergic reactions and will help allergologists, as well as general doctors, when facing those patients allergic to Hymenoptera venom without immunotherapy. Apis mellifera), wasps (Vespula vulgaris) and hornets (Vespa crabro) living in colonies) has noticeably increased. Epidemiological studies of Hymenoptera stings in the general adult population show a sting prevalence of 56.6–94.5%, depending on the climate [In the previous five decades, interest in hypersensitivity reactions caused by stings of Hymenoptera  to bee and wasp venom is frequently detected when measuring levels of specific IgE (sIgE) to Hymenoptera venom and is reported to be present in 27.2–40.7% of the general population . FurtherAllergic reactions to Hymenoptera stings have varying levels of severity, which is not only true for the comparison between different individuals, as the stage of severity can also vary in each patient. According to the results of several studies, various risk factors may facilitate the development of Hymenoptera venom allergy and increase the severity of SSRs to Hymenoptera stings. A short interval between two stings is often followed by SSR to the second sting . HoweverThe eventual goals of the epidemiological studies concerning Hymenoptera allergy are to elucidate the risk factors for severe/mild SSRs and the need for treatment with Hymenoptera venom immunotherapy to achieve a better quality of life or to prevent death by preventing anaphylaxis in affected patients. The current paper aims to describe a wide epidemiological approach for evidence-based new knowledge about the natural history of Hymenoptera venom sensitivity in adults.This is a retrospective cohort epidemiological study design based on data from the Immunological database of the University Clinic of Respiratory and Allergic Diseases Golnik in Slovenia , clinical data from the BIRPIS database of the University Clinic of Respiratory and Allergic Diseases Golnik in Slovenia and data collected by a questionnaire sent to patients from May 2019 to October 2020. For the study, we collected all data retrospectively: laboratory data ); clinical characteristics of the patients and data about the past characteristics after repeated stings  from the time patients were examined in the hospital. The University Clinic Golnik immunological database covers patients referred due to SSRs and LLRs after Hymenoptera sting  from 1997 to 2015. In our study, we included only patients without Hymenoptera venom immunotherapy. Patients were divided into two periods: those admitted to hospital from 1997 to 2004 and those admitted to hospital from 2005 to 2015, since the BAT (basophil activation test) was performed during the second period for some of them. There was no specific risk associated with participating in this study for the patients. The National Medical Ethics Committee of Slovenia approved this study (Academic research 0120-188/2017/4).The Republic of Slovenia is a nation-state in Southern Central Europe. It covers 20,273 square kilometres (7827 sq. mi) and had a population of 2,062,874 in 2015 . There aBefore we started our research, the immunological database had to be prepared. The whole database, which contains 5657 patients admitted to the University Clinic Golnik, who were allergic to Hymenoptera sting  during the two observed periods (those without Hymenoptera venom immunotherapy and those with Hymenoptera venom immunotherapy) was sent to the Republic of Slovenia Statistical Office in May 2019 to exclude patients who had died and to update the addresses of the participating patients. Excluded due to death were exactly 251 patients. One thousand, nine hundred and sixty-eight patients in the Immunological database were excluded from the study due to venom immunotherapy. Those patients with venom immunotherapy in our study were only unintentionally included in the recruitment, as the Immunological database is not perfect. We deliberately excluded those with Hymenoptera venom immunotherapy from our study, as we are currently interested only in the natural history of Hymenoptera venom sensitivity reactions. The allergic reactions after Hymenoptera stings for those with venom immunotherapy are expected to be different, and we intend to discover these kinds of allergic reactions in the following study. In our study, we included 3689 patients without immunotherapy. In the first period from 1997 to 2004, 1468 patients were included, and in the second period from 2005 to 2015, 2221 patients were included.The first contact with the patients was a questionnaire about their history of bee, wasp or hornet stings sent to all included patients. In the envelope sent to the patient’s home address were (i) an invitation letter with a brief explanation of the study, (ii) a two-sided questionnaire and (iii) informed consent for agreement to participate in the study. Patients were asked to return the completed questionnaire and signed informed consent. From May to the end of June 2019, 2221 patients received the post. By the end of October 2019, 586 completed questionnaires with consent to participate were returned to us. In 56 cases, we received only the questionnaire without the signed informed consent. For these 56 patients, another invitation letter with informed consent was sent to be signed, and 18 patients returned the signed agreement. For the first period, the number of participants ready for analysis was 604. During March 2020, another 1430 envelopes were sent to the patients from the first period in the same manner as previously done. By the end of May 2020, 301 completed questionnaires with informed consent to participate were returned to us.Since the response rate was not as high as we had expected, we decided to contact the patients again. We developed an internet questionnaire, which was identical to those sent previously to patients. To nonrespondents after the first round, we sent another invitation. It was a short letter inviting an individual patient to contact us through an e-mail specifically created for this study. After their contact, we promised to re-email them a link to the internet questionnaire. An informed consent form was included in the questionnaire. Nonrespondents aged more than 75 years were now excluded from the research. We also provided our telephone number for them to contact us for any explanation or information about the study. At the beginning of September 2020, 1350 invitation letters were sent to nonrespondents from the 2005–2015 period. After four weeks, we received 154 completed questionnaires. We received about 40 phone calls, of which 21 were from patients who did not have a computer but were interested in participating in the study. We sent them a questionnaire with an informed consent form to their home addresses, and 18 of them responded. For the first period from 1997–2004, the second round (invitation letter and internet questionnaire) was carried out in April 2021, when we sent 1003 invitation letters to nonrespondents. This time, we received 20 phone calls requesting information about the research. After three weeks, we received 72 completed questionnaires.We had to remove some of the respondents from our database. Some of the respondents were already treated with immunotherapy; for some, there were no available data in the BIRPIS database, and some of the respondents expressed a wish not to participate in the research. Due to these facts, we withdrew 73 of the respondent patients .At the end of this process, 1076 patients were enrolled in theanalysis.From the immunological database, we obtained a list of all patients admitted to University Clinic Golnik due to Hymenoptera venom allergy  who did not have venom immunotherapy for the two observed periods; we obtained the age, sex, geographic position of the patient and aetiology of the sting. In this database, information on laboratory tests was also available. Each patient had at least one of the laboratory tests: sIgE for bee venom and/or wasp venom and/or hornet venom, skin test and BAT.BIRPIS is a database covering all clinical data of the patients admitted to University Clinic Golnik. It also includes the history of each patient. For each patient, from the list of our participants, we examined the following characteristics: (i) aetiology of the first sting/stings, which was/were the cause for the allergy and admission to hospital, (ii) severity of the first allergic SSR or LLR (Mueller grading system), (iii) history of asthma, (iv) history of cardiovascular diseases, (v) atopic constitution  and (vi) other medical therapy. When considering the assessment of the severity of the systemic allergic reactions at the Golnik Clinic, the Mueller grading system was used. The severity ranged from grade I to grade IV: grade I systemic reaction is characterised by generalised urticaria or erythema, itching, malaise or anxiety; grade II reactions may include symptoms associated with grade I reactions, as well as generalised oedema, tightness in the chest, wheezing, abdominal pain, nausea and vomiting and dizziness; grade III reactions may include symptoms associated with grade I or II reactions, as well as symptoms of dyspnoea, dysarthria, hoarseness, weakness, confusion and a feeling of impending doom and grade IV reactions may include symptoms associated with grade I, II or III reactions, as well as loss of consciousness, incontinence of urine or faeces or cyanosis. LLRs are characterised by oedema, erythema and pruritus, cover more than 10 cm in diameter and peak at between 24 and 48 h after the sting .We created a questionnaire on the basis of published scientific literature (The questions were the following: (i) Have you ever had another sting (honeybee and/or wasp and/or hornet) after visiting our clinic, and how many of them? (ii) What were the signs of the allergic reaction (a table explaining the signs was included in the questionnaire)? (iii) Was the allergic reaction more severe, less severe or similar to the first allergic reaction? (iv) How long was the time from visiting our hospital to the next sting? (v) how many stings have you experienced since visiting the hospital? (vi) Do you have prescribed/take medicines/injection of adrenalin after you have been stung? (vii) Which medicine do you take? (viii) Does anybody in your family suffer from allergic reactions after bee and/or wasp and/or hornet stings? (ix) Do you live in an urban or rural area? (x) Are you a beekeeper, or do you live near a beehive? (xi) Do you often work in the garden? (xii) Why did you not treat your allergy with venom immunotherapy (if a doctor suggested it to you)?The questionnaire was validated in terms of its content validity and face validity. Content validation aims to assess the relevance and representativeness of each item to a specific domain by the panel of experts. In this context, it will assess the relevance of all 15 items in the questionnaire to represent the usability domain. Content validation was conducted by 6 experts  who were asked to give a score of 0 (item not relevant) or 1 (item very relevant). The Content Validity Index (CVI) was computed by calculating the scale average . This waAll the data were prepared using Microsoft Excel, version 2010 . Most data were converted into codes; those that were descriptive  remained uncoded. Finally, 46 variables were created. After all the data were prepared in Microsoft Excel, they were imported to IBM SPSS Statistic 27 and ready for statistical analysis.In the analysis, we used univariate and multivariate analytical approaches to elucidate the risk factors associated with an increased risk of a severe systemic allergic reaction after Hymenoptera sting.In the analysis, we included the following variables:Observed outcome: First Hymenoptera sting  and the severity of the allergic reaction according to the Müller grading system.skin prick test .sIgE (continuous variable).BAT (continuous variable).Other potential confounding factors:Factors that increase the risk for repeated Hymenoptera stings:Sex .Rural and urban area .Beekeeping .Farming .Explanatory variables: History of repeated Hymenoptera sting and the severity of the allergic reaction according to the Müller grading system:Age .Genetic predisposition .Cardiovascular diseases .Atopic constitution .Asthma .The time from visiting our hospital to the next sting .The frequency of Hymenoptera stings (continuous variable).Preventive medication use ((1) antihistaminic and (2) corticosteroids; noncontinuous variable; only antihistaminic = 1, only corticosteroids = 2, both = 3 and none = 0).Injection of adrenalin .Use of other medications .Factors that increase the risk for severity of repeated Hymenoptera stings:To the best of our knowledge, this is the first extended retrospective study on the natural history of Hymenoptera venom sensitivity in adults. Previous studies on this topic were retrospective epidemiological observational studies ,25,26,27Bee and wasp venom sensitisation frequently occurs when measuring elevated levels of specific IgE (sIgE) to Hymenoptera venom and is reported to be 27.2–40.7% of the general population . Many epThe prevalence of LLR varies widely in the populations studied and ranges from 2.4% to 26.4% . In beekThe prevalence of Hymenoptera SSRs in the general population has been the subject of various studies, which estimate it to be from 0.15% to 3.3% ,33. The A total of 17% of the general population have been reported to have positive venom skin test responses . The stuAs we have already stated, the prevalence of Hymenoptera sting is higher for wasps than honeybees in our country. In another study, it was demonstrated that patients sensitive to honeybees may react repetitively with grade III and IV reactions more often than those sensitive to wasps . This isStudies about sex differences when reacting with SSRs after Hymenoptera stings usually focus on the role of sex hormones. Androgen receptors have been demonstrated on human mast cells, and oestrogens have been shown to enhance IgE-dependent mast cell activation. Being female is a risk factor for other immediate-type hypersensitivity disorders . HoweverAdults are more likely to have re-sting SSRs than children are; this is partially explained by different immunological responses not fully elucidated yet . Those aThe most important factor for the recurrence of SSR is the severity of the previous one. The disease tends towards spontaneous self-limitation, and the tendency to relapse varies from 21% to 73%, but the more severe the symptoms of the first sting, the more likely the reaction is to recur ,39. In sA specific risk factor for the occurrence of the first SSR is a well-tolerated sting in the previous two months .A large number of simultaneous stings (>50) in one year may sensitise a person and then be followed by single-sting anaphylaxis, which was indicated in a study of beekeepers in Finland by Anilla and colleagues. The risk of SSRs was greatest during the first years of beekeeping, suggesting that spontaneous desensitisation occurs later . FurtherAtopy is a risk factor for severe SSRs in beekeepers . MoreoveIn Slovenia, prescribing prophylactic antihistamines and glucocorticoids is an example of good practice to prevent serious SSR. If a patient has had an experience of an SSR range of III or IV, according to the Müller grading, in the past and he/she has not taken immunotherapy, an injection of adrenalin is prophylactically prescribed. We will assess the prevalence of taking antihistamines and glucocorticoids after Hymenoptera re-stings and the prevalence of carrying/using adrenalin for auto-injection.It is well-known that some medications worsen the allergic response after Hymenoptera stings. In particular, these include medications for cardiovascular diseases (beta-blockers and angiotensin-converting enzyme inhibitors) . We willBeekeepers and their family members are heavily exposed to honeybee stings and are thus at an especially high risk of becoming allergic; therefore, they are an interesting population for the study of the epidemiology of venom allergy. We will assess how they are affected and what the differences from the general population are.We will assess which regions in Slovenia are where patients more commonly refuse to take immunotherapy. This is partially connected with the distance to the University Clinic Golnik, job engagement, not having time for any other reasons, poverty and not trusting the results of immunotherapy treatment.The study protocol introduced several new approaches addressing the problem of identification of the risk factors associated with the severity of systemic allergic reactions after Hymenoptera stings. First, the protocol addresses multiple variables in one unique study, which is not usual for the retrospective studies already conducted in this field. It covers epidemiological data gained from the questionnaire, as well as clinical data gained from the Immunological database and BIRPIS database. Second, we analysed all Hymenoptera, not only allergies to individual insects such as honeybees, wasps and hornets. Third, the study population covered all Slovenian patients admitted to the hospital due to allergic reaction after Hymenoptera stings from 1997 to 2015, as the University Clinic Golnik is the only one in Slovenia that covers diagnostic procedures and the treatment of this kind of allergy. Fourth, until now, no retrospective study in this field has included so many patients in the analysis. Fifth, this study was a very long-lasting retrospective study, so we expected to gain significant results. Further research is called for to discover and explore the potential of those novel approaches.As far as data collection is concerned, the most used tool is the questionnaire. This approach has some limits. The problem is that different patients subjectively answered the same question differently even though they had had similar SSRs after re-stings. Greater control over the questionnaire results can be achieved with the supervision of an allergologist and by measuring the skin test and/or sIgE to confirm patients’ histories and thereby yield a picture of the data that is close to reality. For these reasons, the database of individual histories (BIRPIS) was extremely important in our study, as we had access to everyone’s history concerning the characteristics of individual health status and of the first sting.Despite increasing interest in the natural history of Hymenoptera venom sensitivity in adults and studies being done, many facts still must be elucidated. Some risk factors are already known , which should be discussed in the general population in preventing allergic reactions following a wasp, bee or hornet sting. The several new approaches of this study design compared to the already published studies in this field are that this kind of study design may provide more prediction information for patients allergic to Hymenoptera venom and improve their quality of life. The information from this study could also be used to guide medical attention and to properly shape interventions for allergic patients to Hymenoptera venom. The information regarding the problem of early diagnosis, treatment and improvement of prognosis among Hymenoptera allergic patients is particularly useful, as there are still many gaps that must be elucidated in the natural history of Hymenoptera allergic reactions. Promoting the importance of health in the natural course of the disease and on the effects of immunotherapy based on the scientific findings will undoubtedly improve the quality of life of patients suffering from such problems.


Many studies have examined the effects of caregiving burden and many others have focused on the effects of having a caregiver . However, there is little data on the experience of role reversal, once responsible for caring for others and now being cared for while living with cancer. This project aims to identify ways in which women living with cancer cope with the internal struggles of receiving care. The current project is a case study of two females, one age 67, NHW, with a breast cancer diagnosis and one age 60, Black, with an ovarian cancer diagnosis, who once were caregivers and are now being cared for by family. Two semi-structured interviews were conducted that were approximately 60 minutes each. The study data are from a larger project focused on the self-perception of older women with late-stage cancer. Four independent researchers used thematic analysis to uncover common themes of coping between the two women receiving care. The themes uncovered were acceptance of the loss of autonomy, positive death attitudes, good relationships with their caregivers, and religiosity were identified and coded as coping strategies. The qualitative data showed that the use of these coping strategies helped the women be more accepting to care with less internal conflict. Future research should focus on generalizing these findings on a larger sample and use the data to help cancer patients better accept care from others.


IntroductionLimited data is available on which interventions are likely to improve compliance to hand hygiene, especially in underdeveloped countries. The objective of this study is to explore whether the introduction of a particular bundle of strategies to improve hand hygiene is effective.Material and methodsIn this pre-post study, a multimodal strategy comprised of educating healthcare staff, using reminders, providing feedback and increasing the availability of soap and alcohol, was implemented over a period of one year from 2019 to 2020. Trained observers assessed compliance to hand hygiene before and after the intervention.ResultsA total of 143 hand hygiene opportunities were observed. Hand hygiene compliance rate did not improve despite the introduction of multiple measures.ConclusionsOther approaches should be considered to promote hand hygiene. The choice of which strategies to use should be adapted to the local setting. For instance, in some healthcare facilities, emphasis should be placed on leadership support and on the training of hand hygiene champions. Acinetobacter spp., 30% of Enterobacteriaceae and 80% of Pseudomonas spp. were carbapenem resistant [Compliance rate to hand hygiene (HH) in developing countries is known to be poor. This can be a risk factor for the spread of multi-drug resistant organisms. A study conducted at an intensive care unit in Mauritius found a high prevalence of antibiotic resistance: 86% of esistant . Since tesistant . Hence, In May 2019, healthcare workers (HCW) at a 600-bed tertiary hospital in Mauritius were observed for one month to assess their compliance to HH. The targeted population included physicians, nurses, and healthcare assistants. All hospital departments including the emergency, intensive care, surgical and internal medicine wards, were involved except for operating theaters, laboratories, and administrative units.From July 2019 to July 2020, the following steps were introduced: posters on how to perform HH were displayed at each sink, several educational sessions were organized by nursing officers and doctors, alcohol dispensers were made more accessible, feedback regarding the performance on HH was provided and soap was made available in a larger proportion of toilets. Due to the COVID-19 pandemic, hygiene was emphasized throughout 2020. Training consisted of one-hour PowerPoint presentations; at least 20 participants were invited to attend per session.In October 2020, for a period of one month, direct observation based on the HH steps described by the World Health Organization (WHO) was once again carried out to determine whether any improvement in HH occurred. WHO’s hand hygiene observation tool was filled in by trained staff .A checklist was used to systematically review any barriers that could hinder the implementation of HH. Along with several other items, this checklist assessed the availability of alcohol-based hand rub, the functionality of washbasins, the presence of HH posters and the accessibility of hand towels for single use.Data were analyzed using IBM SPSS Statistics version 20 and a p-value of less than 0.05 was considered to be statistically significant.This study was approved by the Ethics Committee of the Ministry of Health and Wellness of Mauritius.Before the intervention, out of 43 HH opportunities, staff used alcohol or washed their hands only 5 times, which constituted a compliance rate of 12%. These opportunities included but were not limited to performing a physical examination, taking vital signs, inserting Foley catheters, placing IV cannulas, and taking glucose readings.After the intervention, out of 100 HH opportunities, HCW were compliant only once .Of note, during that period, the proportion of alcohol dispensers that were functional increased from 64% to 85%, the number of sinks with a washing agent increased from 34% to 42% and the percentage of toilets with soaps increased from 21% to 29%. Yet, the amount of alcohol used per 1,000 patient days dropped by 18%.Table This is the first study to report the implementation of a multifaceted hand hygiene improvement strategy in the Mauritian healthcare setting.HCW were asked to provide an explanation regarding their lack of compliance. Out of the 11 staff that were interviewed, 8 persons (73%) thought that the lack of functional sanitizers at points of care were one of the main reasons for the failure to adhere to HH and 3 persons (27%) believed there was insufficient institutional emphasis, inadequate training and a lack of guidelines on the topic.During the period of intervention, despite constant advocacy to provide adequate resources to improve HH, the number of alcohol dispensers within 1 meter of a patient bed dropped by 5 times, mostly because the dispensers were preferentially hoarded next to the nursing station. Moreover, disposable paper towel remained unavailable at the washing basins and in toilets. Furthermore, attendance during training sessions was often modest, mostly because of a lack of interest on the topic and a general paucity of awareness on the importance of HH.The negative results of this study can be explained by a lack of accountability of staff, insufficient oversight by the administration over the issue of hygiene, inadequate hospital leadership, a high ratio of patients to nurses and the absence of a full-time, functional Infection Prevention and Control (IPC) team. In addition, due to the mental toll of the COVID-19 pandemic on the HCW and the absence of local cases of SARS-CoV-2 in the community of Mauritius in October 2020, it is possible that staff let their guard down because of alert fatigue. Moreover, the wearing of gloves could have reduced HH compliance, a behavior that has been reported elsewhere in the literature .Table This is not the first study to demonstrate a drop in IPC standards during the COVID-19 pandemic. Hess et al. reported a decrease in the use of HH monitoring badges from 2019 to 2020 while Patel et al. described an increase in the standardized infection ratio of central line-associated bloodstream infections by 28% when comparing data of 2020 to those of 2019 ,12. In FThe spread of multi-drug resistant organisms within certain hospitals in Mauritius can be explained by poor HH. Also, the elevated rate of COVID-19 among HCW  may be linked to deficient IPC standards . FurtherOne main advantage of this study is the long duration of the study of over a year which aimed at assessing the sustainability of the interventions. In addition to this, it is easily reproducible in most settings. Several studies examined the effects of these strategies over a period of only a few weeks but this fails to account for long term effects. The Hawthorne bias was unlikely to be present given that HCW were unaware when they were being observed. The weaknesses include the fact that this study was carried out at a single center, a control group was absent and its sample size was small. However, the author believes the negative results of this study can help to inform subsequent strategies to improve HH, not only to reduce the prevalence of drug resistant microbes but also to stop the spread of harmful organisms in the community, especially during outbreaks .In the future, multimodal strategies to tackle deficiencies in HH should take a different approach from the one taken in this study. For instance, dispensers should be placed at points of care, health behavior change theory should be used to engage staff to help sustain long-term improvement, administrative support must be present and HH champions should be trained. Other strategies that may improve HH and require further investigation include the organization of HH competitions and simulation exercises, and the use of automated electronic hand hygiene compliance monitoring systems. Following this study and through noteworthy support from the WHO, the Ministry of Health and Wellness of Mauritius agreed to set up a National IPC Committee in 2021 in order to further scrutinize IPC practices and to ensure that safe practices are followed judiciously in the country.


Among 1–7 years old children the worldwide prevalence of mental disorders is ~20%. Without treatment, the prognosis of such disorders in children is poor. Early intervention is estimated to result in a positive return. However, traditional screening to detect children at need is particularly challenging due to the concerns by false positives. The aim of the current study was to develop a more acceptable though effective method using the existing annual evaluation meetings between parents and teachers in a more systematic and goal directed way. The method should build on the teacher's and parents' complementary knowledge and perception of the child, and fit into the everyday routines in daycare centers.During a period of 6 years, a developmental process aiming for a novel screening method was carried out in cooperation with eight Norwegian daycare centers. After conception of the idea, the framework of the Dialogue Based Early Detection including the first version of the Early Worry Questionnaire (EWQ) was constructed. An iterative process involving parents and teachers completing workshops and subsequent testing facilitated a re-modeling of the method.In the resulting Dialogue Based Early Detection a 36-item version of EWQ was completed by both parents and teachers ahead of the annual parent-teacher meeting. During that meeting the participants should try to reach a consensus whether there was a concern, some uncertainty, or no worry for the child, and which appropriate actions should be taken for a possible follow up. Both parents and teachers reported that the EWQ supported them in verbalizing already existing worries for the child. Teachers reported that parents were better prepared and participated more actively in the evaluation meetings. However, some parents complained that there was too much focus on possible worries. During the testing, challenges of language development, conduct, emotional reactions, toileting, attention, and eating were detected among the children.The Dialogue Based Early Detection method was endorsed by both teachers and parents and holds promise as a tool for improving early awareness and identification of developmental and mental health problems of preschool children in daycare centers. Mental disorders among children and adolescents represent a major public health challenge, with a worldwide prevalence of 13.4% . The impIt has been suggested that childhood mental health is the strongest predictor of adult wellbeing . Early dHowever, only a minority of children suffering from a mental disorder is detected and offered appropriate interventions, and younger children less often than older ones –17.For the individual child there may be years delay from the appearance of symptoms and difficulties to referral and intervention for these challenges. This aligns with clinical experience from Child and Adolescent Mental Health Service (CAMHS) where recurrently parents report that they were concerned for their child as early as 3–4 years of age. In 2015, the average age of referral to CAMHS in the catchment area of Haukeland University Hospital was far above school age for both suspected ADHD (9.7 years), for anxiety disorders (12.0 years), and higher for girls than for boys . This deIdeally, all children with significant emotional or behavioral difficulties should be detected and offered adequate developmental support to promote healthy emotional, social, and intellectual development and achieve optimal educational and social gains. For minor difficulties, preschool teachers or child health clinics may offer sufficient adaption and advice. For moderate difficulties, various services at the municipality level, such as special educationists, community psychologists, general practitioners, or physiotherapists, may offer a brief assessment and more specialized advice to preschool educators and parents. However, if the offered help at these levels fails or the difficulties are of a major kind, such as a suspected mental disorder, referral to CAMHS should be made.According to our clinical experience, parents often report that their early concerns for their child were not taken seriously enough by the daycare center staff or the community nurse, who advised a “wait and see” approach. In Norway a daycare center , is an all-day educational institution. The educational context is not school-like with classrooms and desks, but an environment facilitating ordinary play and other daily activities, nourishing normal physical, cognitive, emotional, and social development.During their training, Norwegian preschool teachers learn much about normal development in children and how to promote it in their daily interaction with children. Together with the parents, as the closest caregivers, they have a fundamental impact on building resilience fostering good mental health in the individual child. In the daycare centers, children will meet different challenges in the social interactions with both other children and the staff. The teacher can guide the child to find a good balance between a positive self-representation and social respect to others. However, in general, preschool teachers show insecurity as to understanding and management of mental health challenges of the children when they appear. In Norway, as in most other countries, the health and educational sectors are separated, all from the governmental down to the elementary level. In their curriculum, preschool teacher students have minimal teaching about mental health, as this is considered a health matter. Further, in Norwegian municipalities systematic interaction and collaboration between these two sectors is uncommon.While screening of mental health problems could be a way to improve access to help for young children, it is particularly challenging to screen for such problems in this age group. What is considered normality, covers a wide range of behavioral and emotional expressions. Moreover, symptoms of mental disorders are less specific than among older children. Many parents and preschool teachers dislike the objectifying approach of symptom assessment, as opposed to seeing, understanding and appreciating the child as a unique individual. Furthermore, traditional screening programs for behavioral or emotional problems in general populations of children are problematic, as such screening carries the downside of producing large numbers of false positive cases. They have thus been rightfully criticized by the users, i.e., preschool teachers and the parents of the children; claiming it pathologizes natural variation in behavior and in emotional reactions and generates unnecessary worry for healthy children.Therefore, there is a clear need for better and more user-acceptable methods to identify children with a concerning development, ideally well in advance of starting school . After dHence, the aim of the current study was to develop a method to detect and manage possible worries for the individual child using the existing annual evaluation meetings between parents and teachers in daycare centers in a systematic and goal directed way. The method should build on the teacher's and parents' complementary knowledge and perception of the child and fit into the everyday routines. Such a method might have the potential to solve three major obstacles to develop efficient screening for child mental health problems—(i) the ethical problem of causing worry in healthy children, (ii) the time-consuming process of detailed symptomatic assessment, and (iii) being both sensitive and specific enough to fulfill the requirements as screening tool.(ABLE)   develope(ABLE) . The aim(ABLE) . This apIn Norwegian daycare centers, the parents have individual annual  parent-teacher meeting to evaluate the child's wellbeing and development. We considered this meeting the optimal arena for screening, and outlined a two-step procedure for the purpose: To help the appropriate focus on the child's mental health, both parents and teachers should complete the EWQ as a preparation before the meeting. Parents should then participate actively in the meeting by giving their view of possible concerns for their child aiming for a common understanding of the child in the dialogue with the teacher. The method was named Dialogue Based Early Detection (DBED). To our knowledge, the use of such an approach has not been employed for screening purposes.The further development was based on user involvement and consisted of an iterative process involving managers, teachers, and parents from eight daycare centers .First, we presented and discussed the proposed model for teachers and managers of four different daycare centers in separate meetings.Second, we arranged three workshops with teachers and parents of children from the same four daycare centers for a more thorough review of the procedures in DBED. In the first workshop, every item of the EWQ was critically assessed as to both content and wording. In the second workshop, we discussed how to present the method and invite parents to participate in the coming testing. Further, we reflected on how to use the results from the completed EWQs in the parent-teacher meetings, included different challenges that might arise during the dialogue. Not least important, we shared ideas on how to conclude and follow up the outcome of the meeting. In the third workshop, the participants role played parent-teacher meetings and shared experiences of disagreement with parents as to reason for worry or not. Next, we went through possible supportive efforts relevant for the different kind of concerns, such as adaption and advice for minor concerns by preschool teachers or child health clinics, referral to special educationists, community psychologists, general practitioners, or physiotherapists for moderate concerns, or referral to child and adolescent mental health service where there is a major concern as to suspected mental disorder. In addition, we received feedback on how to evaluate user satisfaction of the method.Third, we trained the teachers of eight daycare centers by theory, role play, and following discussions in advance of testing the method. The method was then tested in these centers repeatedly during 2018 and 2019 for children aged 3–6 years. Four centers participated in all three testing rounds, and four additional centers that had not participated in the preceding workshops, participated in the third and final round. During all rounds altogether 24 teachers participated and ~300 parent-teacher meetings were accomplished. After each round both parents and teachers were asked to complete a user satisfaction questionnaire, that ended with an open field for free text comments. The teachers were also interviewed by the first author (IB) in separate groups, one group for each center. They were asked by open questions to share their experiences with the method. The interviewer followed up by elaborative questions. Notes from the interviews were summarized by the first author. Every daycare center contributed with valuable suggestions for improvements of both wordings of the EWQ and details of the other procedures.The four additional day care centers in the final round accomplished 153 parent-teacher meetings, from which data on user satisfaction and conclusions from the parent-teacher meetings were collected. The data protection official of Bergen municipality was consulted before this final testing, who concluded that a full ethical review at that stage of the project was not necessary. However, as a premise, all participating parents signed an informed consent and all information about the children (conclusions from the parent-teacher meetings) was delivered to us as aggregated data. Information about the individual child was stored safely in their respective day care center. All written feedback from teachers was voluntary and anonymous.After the first presentation of the model teachers and managers of the four daycare centers responded overall positively. In their oral feedback they expressed a clear need for a more systematic approach and naming of specific mental health challenges among the children. In addition, they suggested more appropriate wordings or specifications of single items. For example, “language development” was differentiated to “pronunciation,” “vocabulary,” “use of language,” and “ability to understand what is said.” During the subsequent workshops suggestions for new items, such as “lack of eye contact,” came up spontaneously. In sum, 13 new items were added.The main element of DBED was the prepared and focused dialogue in the regular  parent-teacher meeting. Both the parents and the teacher were expected to prepare for the dialogue by completing the EWQ prior to the meeting. The participants should try to reach a consensus whether there is a concern, some uncertainty, or no worry for the child, and which appropriate actions should be taken for a possible follow up . The DBEEWQ was finally presented as “About the child's wellbeing and development” see  and a seCompleted user satisfaction questionnaires from the final testing round were received from 11 teachers (65% response rate) and parents of 110 children (72% response rate). The results showed that in general the method was well-accepted , 3. Durin = 31, 20.3%) was the matter of concern, then “conduct” , “emotional reactions” , “peeing and pooping” , “attention” , and “eating” . External services involved were special educationalists, speech therapist, physiotherapist, GP, child, and adolescent mental health service, pediatrics, and child welfare. As a child and adolescent psychiatrist the first author offered consultations for single case guidance, which, however, was not necessary.In the final testing, conclusions were reported from all 153 parent-teacher meetings. In 61 (39.9%) of these cases the dialogue concluded with “A bit uncertain” or “Concerned” in at least one item. Most often “language”  is a novel method for early detection of mental health challenges among children in daycare centers. The method consists of (1) the Early Worry Questionnaire (EWQ) to be completed by parents and teachers before (2) the discussion at the regular parent-teacher conference. During testing of the method under everyday conditions, the DBED has been well-accepted by parents and teachers, and also seems to function well as a screen for mental health and developmental problems. Preparation before the parent-teacher meetings by the EWQ seemed to facilitate a more active involvement of the parents in the dialogue, which next challenged the teachers to play a more counseling role in the meeting.The DBED fills a void in providing parents and preschool teachers with a tool to focus on behavior and symptoms that may be early signs of mental health challenges. To this aim, the DBED contains more novel elements: First, the utilization of the regular teacher-parent meetings to focus on the child's wellbeing and mental health. Second, the systematic and multi-domain Early Worry Questionnaire developed in cooperation with parents and teachers taking into account what items and formulations are suitable in the context of daycare centers. Third, active involvement of the parents in the assessment of their child by completing the same questionnaire (EWQ) as the teacher, thereby empowering their role in the dialogue concerning the development and wellbeing of their child. With the two-step process, focusing on concerns and the consensus decision reached through the dialogue, the DBED holds promise as a sensitive yet specific screening tool. This is essential for the next step, i.e., offering the right help to the right children at the right time. Our experience from the present developmental project is that the daycare centers is a virginal field for early promotion of mental health. However, here is a need for more mental health competence among teachers and a more systematic approach for early detection and intervention. This development is hampered by the barriers between the health sector and the educational sector at all levels. Many teachers express a need for more knowledge of mental health problems and how to adapt the education for vulnerable children. The health sector on the other hand, may be too focused on pathology and deviances, as was clear from teachers' and parents' reactions to the initial wordings in the EWQ. The pathology approach is not adequate in a general population setting such as a daycare center, where most children are healthy.The focus on pathology and problems was the main objection to the method from both parents and teachers. This lead to rephrasing of many of the items to better fit an educational setting. The inconvenience of extra time and effort spent using the DBED was viewed by the teachers as worth the investment.Some teachers were concerned that the DBED approach might overlook causes of distress and poor development of children. However, in EWQ the respondents are invited to suggest possible causes for the reported concern, given examples such as serious events or situations at home or otherwise in the family  and difficulties in relation to the daycare center . Nevertheless, very few respondents made such suggestions. A possible improvement of the EWQ might be to introduce a few check boxes with some broad “cause categories” supplemented with space for free text.In ~40% of the parent-teacher meetings the conclusion was that there was one or more areas of worry for the child, with language problems being the most frequent worry. This indicates the method is sensitive to identify developmental concerns. The most salient question is, however, whether the implementation of the DBED really detects the right children, providing earlier access to support and intervention for them, and, ultimately, have a positive effect on the individual child's future mental health. Future studies will examine the DBED in terms of (1) its feasibility more thoroughly in everyday life in ordinary daycare centers, (2) its case-finding properties, (3) how it influences early interventions in the ordinary public services, and (4) whether it will have a positive influence on the children's future mental health.The novel Dialogue Based Early Detection (DBED) method was endorsed by both teachers and parents and holds promise as a tool for improving early identification of mental health problems of preschool children in daycare centers. It differs from traditional screening methods due to its two-stage procedure, its focus on the concern for the child rather than symptoms, and finally in the questionnaire prepared dialogue between teacher and parents before a consensus conclusion is reached. However, further evaluation of the method is imperative.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.IB created the idea of the Dialogue Based Early Detection and initiated and led the development process described in the present paper and wrote the first outline of the draft, and led the following writing process. GW and M-BP have contributed with intellectual input during the development of the present method and participated in the writing process of the paper. All authors contributed to the article and approved the submitted version.GW reports receiving consulting fees and lecture fees from Medice. M-BP reports receiving no fees as a member of the scientific advisory board of Takeda/Neurim for Slenyto. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.