title
stringlengths 1
1.19k
| keywords
stringlengths 0
668
| concept
stringlengths 0
909
| paragraph
stringlengths 0
61.8k
| PMID
stringlengths 10
11
|
|---|---|---|---|---|
Conclusion
|
gallstone
|
GALLSTONE
|
UDCA treatment leads to a higher, but clinically irrelevant increase in ALP level in patients 6 months after bariatric surgery. No other changes in metabolic or inflammatory markers were observed. Except for the reduction of gallstone formation, UDCA has no effects after bariatric surgery.
|
PMC10234851
|
Graphical Abstract
|
PMC10234851
|
|||
Supplementary Information
|
The online version contains supplementary material available at 10.1007/s11695-023-06581-8.
|
PMC10234851
|
||
Keywords
|
PMC10234851
|
|||
Introduction
|
non-alcoholic fatty liver disease, gallstones, Gallstone disease, nausea, NAFLD, diarrhea, skin rash, PBC, gallstone disease
|
GALLSTONES, PBC, MORBID OBESITY, INFLAMMATION, COMPLICATION, NON-ALCOHOLIC FATTY LIVER DISEASE, GALLSTONE DISEASE, PRIMARY BILIARY CIRRHOSIS
|
Gallstone disease is a common complication after bariatric surgery, the most effective long-term treatment for morbid obesity. Recently, the UPGRADE trial demonstrated that in patients without gallstones before bariatric surgery the prophylactic use of ursodeoxycholic acid (UDCA) for 6 months after surgery reduces the occurrence of symptomatic gallstone disease [UDCA is a naturally occurring bile acid, which is orally prescribed. The most common side effects include diarrhea, nausea, and skin rash. On the other hand, beneficial effects of UDCA treatment such as a reduction in liver enzymes and total cholesterol were reported in patients with primary biliary cirrhosis (PBC) [Furthermore, the exact functions and exerting mechanisms of several bile acids are still not fully understood, but influences on lipids, glucose metabolism, and non-alcoholic fatty liver disease (NAFLD) have been described previously [The UPGRADE trial, in which patients were randomized to receive either UDCA or placebo, provides us with the possibility to investigate the effects of a high dose of UDCA on liver enzymes, glucose and lipid metabolism, and inflammation. The present study aimed to explore these effects in blood samples of patients before and six months after bariatric surgery.
|
PMC10234851
|
Methods
|
PMC10234851
|
|||
Study Design and Population
|
gallstone disease
|
GALLSTONE DISEASE
|
The source population for this cohort study comprised the patients of the UPGRADE trial (Netherlands Trial Register, NL5954), a randomized, multicenter, placebo-controlled, double-blind trial assessing the effect of UDCA on the prevention of symptomatic gallstone disease after bariatric surgery. The protocol, statistical analysis plan, and results of this trial have been published previously [
|
PMC10234851
|
Trial Medication
|
Patients were randomly assigned to either commercially available UDCA 900 mg daily for 6 months (Ursochol 450 mg tablet; two pills once daily) or matching placebo pills. Patients were instructed to start preferably within 2 weeks, but no later than 8 weeks after surgery. An uninterrupted break of up to 4 weeks was allowed during the treatment course. Patients were allowed to take one pill twice a day or break the pills. Patients, investigators, and treating physicians were all blinded for treatment allocation.
|
PMC10234851
|
||
Data Collection and Procedures
|
high-density lipoprotein
|
PARATHYROID, BLOOD
|
Clinical data including age, gender, weight, body mass index (BMI) before surgery, comorbidities, and medication use were obtained during hospitalization. Blood tests comprising total bilirubin, alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, leukocytes count, C-reactive protein (CRP), hemoglobin A1c (HbA1c), hemoglobin (Hb), platelet count, prothrombin time (PT), total protein, albumin, and calcium were performed as part of regular care at the outpatient clinic before and 6 months after surgery. Parathyroid hormone (PTH) and vitamin D were only measured after surgery. Preoperative blood values were included when obtained up to a maximum of 1 year before bariatric surgery. For postoperative blood values, a window of 4 to 9 months after surgery was applied.
|
PMC10234851
|
Outcomes and Definitions
|
hypertension, DM2
|
HYPERTENSION, DIABETES MELLITUS TYPE 2, DYSLIPIDEMIA
|
The primary outcomes were liver enzymes (total bilirubin, ALP, GGT, AST, ALT), lipid spectrum (total cholesterol, LDL, HDL, triglycerides), leukocytes, CRP, and HbA1c levels. Secondary outcomes were blood serum levels and counts of Hb, platelets, PT, total protein, albumin, calcium, PTH, and vitamin D. The definitions of diabetes mellitus type 2 (DM2), dyslipidemia, and hypertension were described previously [
|
PMC10234851
|
Statistical Methods
|
diabetes mellitus, DM2, dyslipidemia
|
REGRESSION, DIABETES MELLITUS, DYSLIPIDEMIA
|
Descriptive statistics were used to summarize patient characteristics. First, we calculated the change in blood values (Δ) between 6 months postoperative and preoperative blood values, i.e., the change after bariatric surgery. To investigate the clinical effect of UDCA, we used the unpaired t-test in the main analysis to compare the change in blood values between the group with UDCA treatment and the group with placebo treatment. In order to investigate the actual biochemical effect of UDCA which is not influenced by poor adherence, the second analysis comparing changes in blood values was performed in adherent patients only.In addition, sensitivity analyses were performed. The first sensitivity analysis was a cross-sectional comparison of blood values at 6 months after bariatric surgery in order to exclude preoperative factors that could influence the outcomes of UDCA treatment. This analysis was repeated in adherent patients only. The second sensitivity analysis was performed in patients without diabetes mellitus to explore the effect of DM2, which was present more often in the placebo group at baseline.We repeated the analyses in a subgroup with preoperatively elevated liver enzymes and in a subgroup with preoperative dyslipidemia to examine the influences of UDCA use in these specific subgroups. Patients were included in the first subgroup if any of the liver enzymes were elevated (total bilirubin, ALP, GGT, AST, or ALAT). Patients in the second subgroup were included if diagnosed with dyslipidemia but not requiring lipid-lowering drugs before and after bariatric surgery. All additional analyses were also performed using the unpaired t-test.Finally, regression analysis was used to evaluate whether increased ALP levels were associated with ASAT, ALAT, bilirubin, GGT, calcium, vitamin D, or PTH levels. IBM SPSS statistics (version 26, Armonk, New York) was used and two-sided
|
PMC10234851
|
Changes in Blood Values After Surgery
|
The changes in blood values after bariatric surgery are shown in Table Changes in laboratory results 6 months after bariatric surgery for 513 patients treated with trial medicationData are shown as mean ± standard deviationAbbreviations: Changes in laboratory results 6 months after bariatric surgery for 316 patients adherent to trial medicationData are shown as mean ± standard deviationAbbreviations:
|
PMC10234851
|
||
Blood Values After Surgery: Cross-Sectional Comparison
|
In Table
|
PMC10234851
|
||
Influence of DM2 and Abnormal Preoperative Blood Values
|
DM2
|
Subsequently, we performed a second sensitivity analysis in patients without DM2. As can be seen in Table Last, we analyzed two subgroups. In adherent patients with preoperative elevated liver enzymes, the same responses were observed after surgery in any of the evaluated blood measurements in 64 patients in the UDCA group and 61 patients in the placebo group. However, a cross-sectional comparison at 6 months after surgery revealed higher ALP levels (mean difference 14.48 U/l; 95% CI 3.16–25,80;
|
PMC10234851
|
|
ALP in Relation to Calcium Metabolism
|
REGRESSION
|
Regression analysis showed that the increase in ALP levels in the total population was correlated with an increase in GGT levels (At 6 months after surgery, ALP levels in the total population were not correlated to vitamin D, PTH, or calcium levels either. A significant correlation was observed between ALP levels and GT (
|
PMC10234851
|
|
Discussion
|
non-alcoholic fatty liver disease, NAFLD, metabolic alterations, overdose, gallstone, inflammation, PBC, weight loss, steatohepatitis
|
PBC, GALLSTONE, INFLAMMATION, MINOR, NON-ALCOHOLIC FATTY LIVER DISEASE, STEATOHEPATITIS
|
In this study, we evaluated the effects of UDCA treatment for six months on liver enzymes, lipid profile, glucose level, and inflammatory markers in patients after bariatric surgery. We found a higher increase in mean ALP level in patients who used UDCA compared to patients receiving placebo treatment. No other significant changes in blood values were observed. Cross-sectional analysis of postoperative blood values did also reveal lower AST and ALT levels, and a slightly higher level of cholesterol in patients who were adherent to UDCA treatment. However, the observed effects of UDCA treatment on liver enzymes, metabolism, and inflammation are minor or absent, and the clinical consequences are negligible. In view of these results, it is confirmed that UDCA treatment in patients after bariatric surgery is safe, but the role in metabolic alterations after surgery seems limited.To our knowledge, only one study has previously examined the effects of UDCA treatment on clinical blood values in patients after bariatric surgery [In contrast to these previous studies, we were not able to detect clinically relevant effects of UDCA use on blood values in this study. Cross-sectional analyses did reveal slightly lower levels of ALT and AST and a marginally higher level of total cholesterol in the UDCA group. Also, the main analysis in which changes in values were compared, showed a greater decrease of AST and ALT and less decrease of total cholesterol in the UDCA group, but these differences did not reach statistical significance. This might be explained by the different populations in our study with substantial changes occurring in the body composition and metabolism after bariatric surgery, especially in the first 6 months. For instance, studies focusing on the underlying mechanisms of action of UDCA showed that a changed bile acid profile and microbiome remodeling might be involved [The strengths of this study include the randomized controlled study design (as part of the UPGRADE trial) and the relatively large sample size. Although power calculations were not performed for the endpoints of the present study, we were not able to detect any additional effects of UDCA. Even if these effects on laboratory markers could be detected in larger study populations, they are probably too small and therefore nog clinically relevant. Furthermore, adherence was assessed in a structured manner, providing the possibility to assess both clinical effects in the entire population and biological effects in patients who actually used UDCA according to prescriptions. However, several limitations should be addressed. First, laboratory measurements were not included in the UPGRADE trial design but were part of regular clinical assessment in the largest participating center, which resulted in missing values and exclusion of results on blood drawn more than 4 weeks after the last dose of trial medication. Second, patients allocated to prophylactic UDCA use were prescribed 900 mg of UDCA daily. This was independent of their body weight before or in the first 6 months after bariatric surgery, whereas UDCA in other conditions such as PBC is prescribed based on body weight. Hence, for some patients, 900 mg might be below the recommended dose at first and might have changed to an appropriate dose or overdose during weight loss. On the other hand, the recommended dose is higher for PBC than for gallstone dissolution. Third, the number of patients known with non-alcoholic fatty liver disease or steatohepatitis in our study population was limited, most probably because these conditions were not structurally recorded in patient’s records. Therefore, we cannot make any statements about the effects of UDCA treatment in this subgroup of patients. However, the analysis in the subgroup of the patient with any of the liver enzymes elevated before surgery did not result in clinically relevant changes either. This is in line with previous studies in patients with NAFLD showing ambivalent effects of UDCA treatment [In conclusion, UDCA treatment after bariatric surgery does not seem to affect liver function, lipid, glucose, and inflammatory metabolism in a clinically relevant way. Only a limited effect on ALP was noted, which could not be explained by an altered calcium metabolism either. The mechanisms leading to protection against gallstone formation have yet to be identified. Future studies in patients after bariatric surgery should focus on the underlying mechanisms of action in humans and also investigate the effects of treatment with other bile acids, for example, chenodeoxycholic acid, which might be more beneficial to human metabolism.
|
PMC10234851
|
Declarations
|
PMC10234851
|
|||
Ethical Approval
|
The conduction of the UPGRADE trial was approved by the institutional review board of the Slotervaart Hospital and Reade (Amsterdam, the Netherlands). All procedures performed in the UPGRADE trial were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
|
PMC10234851
|
||
Informed Consent
|
Written informed consent was obtained from all individual participants included in the study.
|
PMC10234851
|
||
Conflict of Interest
|
NNF
|
Max Nieuwdorp is supported by a ZONMW VICI grant 2020 [number 09150182010020]. Max Nieuwdorp and Victor Gerdes are supported by the NNF GUTMMM grant 2016 NNF15OC0016798. All other authors do not have any conflict of interest.
|
PMC10234851
|
|
References
|
PMC10234851
|
|||
Introduction
|
anxiety, inflammation, psychiatric, depression, T2DM, Infection
|
INFLAMMATION, DISEASE, TYPE 2 DIABETES MELLITUS, INSULIN SENSITIVITY, INFECTION
|
Edited by: Jun Wang, Institute of Microbiology (CAS), ChinaReviewed by: Lin Jin, Kunming Institute of Zoology (CAS), China; Yipeng Wang, Soochow University, China; Xueqing Xu, Southern Medical University, ChinaThis article was submitted to Microbiome in Health and Disease, a section of the journal Frontiers in Cellular and Infection MicrobiologyPrevious studies have demonstrated that patients with type 2 diabetes mellitus (T2DM) often had the problems of fecal microbiota dysbiosis, and were usually accompanied with psychiatric comorbidities (such as depression and anxiety). Here, we conducted a randomized clinical study to analyze the changes in gut microbiota, serum metabolism and emotional mood of patients with T2DM after consumption of a high-fiber diet. The glucose homeostasis of participants with T2DM was improved by the high-fiber diet, and the serum metabolome, systemic inflammation and psychiatric comorbidities were also altered. The increased abundances of Accumulating studies have demonstrated that there were intimate correlations between type 2 diabetes mellitus (T2DM) and gut microbiota. By modulating the structure of gut microbiota, a specially designed high-fiber diet was proved to be able to provide obvious beneficial effects for patients with T2DM (The clinical symptoms of anxiety and depression were often observed in patients with T2DM, and the reason might lie in that the diabetic nutrient restrictions and the imbalanced gut microbiota influence the patient’s emotional state (Nowadays, personalized nutritional interventions based on transcriptomics, proteomics, and metabolomics techniques could provide additional benefits for patients with T2DM. Consumptions of functional foods and bioactive ingredients could enhance the anti-oxidant properties, the anti-inflammatory activities, the anti-cholesterol activities, and the insulin sensitivity of patients with T2DM (In this study, the profiles of fecal microbiota samples from patients with T2DM altered by a high-fiber diet were studied, and the relations between the microbial communities and the host’s clinical features were also determined and analyzed.
|
PMC9922700
|
Materials and methods
|
PMC9922700
|
|||
Subject recruitment
|
cerebral apoplexy, mental illness, cancer, coronary heart disease, organic diseases, hepatic diseases, T2DM
|
HEPATIC DISEASE, TYPE 1 DIABETES, ORGANIC DISEASE
|
This study was a randomized, open-label, parallel-group clinical trial in T2DM patients with a 4-week treatment period. The study was performed according to the principles of the Declaration of Helsinki (2008), and the study protocol was approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine (ID: SNPH2017-026). All the participants signed the informed consent forms.During the initial screening period, patients with plasma HbA1c levels (6.5%-12.0%) were recruited. Patients who had taken antibiotics, probiotics and prebiotics during the previous 3 months were excluded. Other exclusive criteria included type 1 diabetes, severe hepatic diseases, gastrointestinal surgery and severe mental illness. Patients were also excluded if they had severe organic diseases, including cancer, coronary heart disease, and cerebral apoplexy.
|
PMC9922700
|
Study design
|
T2DM, Diabetes
|
DIABETES
|
After a 2-week washout period, 17 patients clinically diagnosed with T2DM enrolled in the clinical trial and were randomly assigned into two groups using the SAS software. As an open-label, parallel-group study, the control group (n = 8 patients) received usual care, including patient education and dietary recommendations based on the 2013 Chinese Diabetes Society guidelines for T2DM; the treatment group (n = 9 patients) received whole grains, prebiotics, and traditional Chinese medicinal foods composed high-fiber diet. The high-fiber diet for the treatment group consisted of several whole grains and traditional Chinese medicinal food (shown in The components of the high fiber diet.The recruited participants received either acarbose (100 mg; 3 times/day) plus common diet for T2DM (control group) or acarbose (100 mg; 3 times/day) plus the high fiber diet (treatment group) for 8 weeks, while all the patients received the same total caloric and macronutrients prescriptions and followed the exercises advice according to the Chinese Diabetes Society.
|
PMC9922700
|
Anthropometric measurement and evaluation
|
HAMD, fasting blood glucose, tumor necrosis, anxiety, Anxiety, depression, Depression, TG
|
TUMOR NECROSIS
|
The assessments of fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), serum insulin, C-peptides, triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) were detected before and after the treatment. The serum levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), and tumor necrosis factor-α (TNF-α) were quantified by enzyme-linked immunosorbent assays (ELISAs), respectively. The depression and anxiety symptoms of all participants were evaluated by the validated questionnaires of Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD).
|
PMC9922700
|
Fecal DNA extraction and high-throughput sequencing
|
The fecal samples were collected for gut microbiota analysis before and after the treatments. Microbial genomic DNA was extracted using an InviMagH Stool DNA kit referred to the previous study (
|
PMC9922700
|
||
Bioinformatics and statistical analysis
|
The quality control and sequence filtering of raw reads was performed according to the barcode matching and sequence overlapping using QIIME (version 1.9.1). The filtered high-quality reads were clustered into operational taxonomic units (OTUs) with a similarity level of 97%, then the obtained OTUs were used for taxonomical assignments by RDP classifier (
|
PMC9922700
|
||
Statistical analysis
|
The data statistical analyses were compared using a one-way analysis of variance (ANOVA) by the SPSS Data Analysis Program (version 17.0; SPSS Inc., Chicago, IL, USA) at the end of each bioassay. All mean comparison was performed using Fisher’s least significant difference test (LSD) with a significance level of
|
PMC9922700
|
||
Results
|
PMC9922700
|
|||
The glucose homeostasis of participants with T2DM was improved by the high-fiber diet
|
T2DM
|
After 8 weeks of intervention, the glucose homeostasis of the treatment group was significantly improved by the high-fiber diet. Compared with the control group, the HbA1c levels and FBG levels of the treatment group decreased significantly, while the levels of serum insulin and C-peptides of the treatment group increased significantly (A high-fiber diet improved the glucose homeostasis in participants with T2DM. Changes in fasting blood glucose
|
PMC9922700
|
|
Changes in the serum lipid metabolism profiles
|
TG, T2DM
|
To observe the blood lipid profiles influenced by the high-fiber diet, the serum levels of TC, TG, LDL-C and HDL-C were measured and analyzed. Compared with the control group, the serum concentrations of TC, TG and LDL-C in the treatment group were decreased, while the serum levels of HDL-C in the treatment group were increased (shown in Changes of the serum lipid metabolism parameters.The data are shown as the mean ± S.E.M, **P <0.01 and ***P<0.001 vs start period of the same group.These data indicated that the lipid metabolism of the participants with T2DM was improved by the high-fiber diet, which revealed that the added fermentable carbohydrates could produce clinically lipid metabolic improvements in the treatment group.
|
PMC9922700
|
|
Measurements of serum inflammatory chemokines levels
|
T2DM
|
INFLAMMATION
|
Serum levels of inflammatory chemokine can be used as indicators of systemic inflammation, in this study, four kinds of serum inflammatory chemokines (IL-1β, IL-6, MCP-1 and TNF-α) in the two groups were measured by ELISA detecting methods. Compared with the control group, the serum levels of inflammatory chemokines in the treatment group were significantly decreased (The serum levels of inflammatory chemokines in participants with T2DM altered by the high-fiber diet intake. Expressions of serum levels of IL-1β
|
PMC9922700
|
Evaluations of the depression and anxiety symptom severities
|
depression, HAMD, anxiety
|
The depression and anxiety symptom severities were evaluated by HAMA and HAMD questionnaires. The scores of HAMA and HAMD were significantly decreased in patients of the treatment group (Analysis of the mood symptoms. HAMA scores
|
PMC9922700
|
|
Microbial compositional alterations of the gut microbiota
|
TYPE 2 DIABETES
|
The raw data obtained from the Illumina MiSeq platform were quality-filtered and demultiplexed to remove invalid and low-quality sequences. A total of 2170797 quality-filtered and chimera-checked sequences were obtained from the 34 samples. The rarefaction curves demonstrated that the sequencing depth was enough for the microbial diversity analysis in the current study (The diversities of gut microbiota before and after the high-fiber diet consumption were analyzed, and the CS and CE groups revealed the start and end phases in the control group, while the TS and TE groups revealed the start and end phases in the treatment group. The rarefaction curves To assign taxonomic compositions of gut microbiota, the RDP classifier was used to compare the bacterial community structure shifts at the phylum level and genus level, respectively. Taxonomic analysis revealed that a total of 15 phyla, 25 classes, 63 orders, 119 families, 307 genera, and 603 species were identified. At the phylum level, Firmicutes and Bacteroidota account for 79.96% percentages of the total bacterial communities (The bacterial communities at the phylum levels Heatmap of hierarchy cluster results for the abundance of genus in control group and treatment group. The color of the spots corresponded to the normalized and log-transformed relative abundance of the OTUs. The genus names of the OTUs are shown on the right.PICRUSt functional prediction was performed using EggNOG database, pathways related to type 2 diabetes were identified and compared.
|
PMC9922700
|
|
Discussion
|
inflammation, diabetic, T2DM
|
INFLAMMATION, OBESE, OTHER METABOLIC DISORDERS
|
Previous studies had already proved that the gut microbiota was a critical environmental factor for treating T2DM and other metabolic disorders (Zhao et al. had revealed that the gut microbiota could bring additional health benefits for patients with T2DM through carbohydrate fermentation and SCFA production (Manipulation of the gut microbiota by prebiotic administration could improve the glucose and lipid metabolism in obese and diabetic mice, and the low-grade inflammation were also decreased (The hippocampal neuronal apoptosis and synaptic structural damage were proved to be associated with the overexpression of proinflammatory cytokines and overactivation of microglia and astrocytes, therefore alterations of intestinal flora could inhibit the immune-inflammatory response and signaling by producing SCFAs (The microbial communities of patients with T2DM were obviously changed after the high-fiber diet administration. The richness and diversity of the bacterial community in the treatment group were both enhanced (
|
PMC9922700
|
Conclusions
|
T2DM
|
In the present study, clinical data indicated that the increased availability of fermentable carbohydrates was sufficient to induce metabolic improvements in patients with T2DM. The dietary source of fibers demonstrated protective impacts on the gut ecosystem, and the alteration of the gut microbiota composition improved the glucose homeostasis in patients with T2DM.
|
PMC9922700
|
|
Data availability statement
|
The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below:
|
PMC9922700
|
||
Ethics statement
|
The studies involving human participants were reviewed and approved by Ethics Committee of Shanghai Jiao Tong University School of Medicine. The patients/participants provided their written informed consent to participate in this study.
|
PMC9922700
|
||
Author contributions
|
Investigation, LC and LR; software, BoL; methodology, HD, CF, CQ, BiL, and RZ; writing—original draft preparation, ZL; review and editing, HL; supervision, ZM. All authors contributed to the article and approved the submitted version.
|
PMC9922700
|
||
Conflict of interest
|
HL
|
Author HL is employed by Sino-science Yikang Beijing Biotech Co., Ltd.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.
|
PMC9922700
|
|
Publisher’s note
|
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.
|
PMC9922700
|
||
References
|
PMC9922700
|
|||
Introduction
|
LMSs
|
To stem the spread of COVID-19, public health measures have resulted in the closure of schools and universities. Globally, education systems face unprecedented challenges. Government agencies are collaborating with international organizations, private sector partners, and members of civil society to deliver distance education using a variety of technologies. In this way, the educational process is maintained and all students learn. To achieve student engagement and curriculum goals, the development and implementation of distance learning strategies must be urgently explored and expanded to avoid exacerbating existing educational and social disparities [During the COVID-19 pandemic, learning management systems (LMSs) were the only solution for continuing education. Foreman [Blackboard includes asynchronous tools such as course descriptions, course content, assignments, course messages, discussion boards, blogs and wikis, pools, tests, etc. A full-grade center is also included. Moreover, the company has developed Blackboard apps for both teachers and students which can be used on Android and IOS mobile devices [With the COVID-19 pandemic, social distancing has become a necessity. This has had an effect on people’s social and academic lives. Even in the classroom, cooperative learning has become nearly impossible, even though students must work with their peers and support one another. It is clear from all of the literature that student collaboration benefits learning [Stephen [According to the foregoing, there is a gap between the functionality of webinar tools and the results achieved in increasing student participation and efficiency in distance education. Also, despite the importance of active learning strategies, particularly collaborative learning, it is imperative to provide mechanisms that enable them to be used when teaching online. Accordingly, the significance of the current study lies in the ability to design learning to incorporate collaborative learning techniques into online teaching. This is done by utilizing the breakout groups feature in Blackboard Collaborate Ultra.Therefore, the current study aimed to investigate the effectiveness of a Blackboard collaborative breakout group on the cognitive achievement of physical education teaching styles. The spectrum of teaching styles in physical education theory by Mosston and Ashworth [
|
PMC9821457
|
|
Theoretical framework
|
PMC9821457
|
|||
Active learning
|
Active learning is any learning strategy in which students are actively involved. During active learning, students engage in meaningful learning activities and reflect on their experiences [
|
PMC9821457
|
||
Cooperative learning theory
|
A cooperative learning environment occurs when students work together as part of a group to complete a task [And from the above, It is possible to engage in cooperative learning in three different ways: formally, informally, or in a cooperative base group [
|
PMC9821457
|
||
Cognitive load Theory (CLT)
|
According to the CLT, working memory capacity is one of the most important indicators of effective learning outcomes in a classroom setting. Working memory has a limited capacity. Consequently, complex material, which consists of numerous interconnected elements of information, will be difficult to comprehend. The reason for this is that working memory is limited. Therefore, learners should maintain these elements in working memory and link them to understanding the material. As a result of this cognitive load, working memory capacity is frequently exceeded (i.e., it is overloaded). Thus, successful learning requires a working memory that can handle what is required. Hence, learning success depends on cognitive processes during learning, which put cognitive demands on working memory [Sweller [
|
PMC9821457
|
||
Instructional Design (ID) models
|
Educators and designers can incorporate technology into education using a variety of models. In order to create an effective learning design process, developers can use these models as a framework to guide their work, enabling them to produce an effective learning program which focuses on the student rather than the teacher. Koper [Among the most widely used and well-known models of ID are ADDIE, DDD-E, ASSURE, Morrison, Ross, and Kemp, as well as Smith and Ragan. An ADDIE model was used in the current study as shown in (
|
PMC9821457
|
||
ADDIE model [
|
The ADDIE model is a popular ID model for creating instructional materials. These five steps are outlined as follows, as seen in
|
PMC9821457
|
||
The significant differences between the two groups.
|
PMC9821457
|
|||
Materials and methods
|
PMC9821457
|
|||
Ethics statement
|
The study was conducted in accordance with the ethical standards of the Scientific Research Committee at the Department of Physical Education and Kinesiology, College of Education, Qassim University (Approval No. 11444182022). To obtain informed consent from study participants, the author developed an online Google form based on the COVID-19 pandemic. Several aspects of the study were addressed in the online form, including voluntary participation, withdrawal rights, objectives, importance, procedures, and confidentiality. The author ends the form by asking the participants, "Would you like to participate in the study?". In response to this question, you will select Agree or Disagree to indicate whether or not you agree to participate.
|
PMC9821457
|
||
Design
|
The quasi-experimental method involved creating two groups: one experimental and one control, with the experimental group using Blackboard collaborative breakout groups and the control group relying exclusively on online lectures and continuing with the same method without breakout groups. To determine the extent of the continuity of the impact of Blackboard collaborative breakout groups, the post-test was administered to the two groups immediately following the completion of the teaching and learning processes, while the follow-up test was administered after no further teaching and learning processes had taken place for a month.
|
PMC9821457
|
||
Study population and sample
|
The participants were randomly selected from seventh-level students who were enrolled in the Physical Education and Kinesiology Program for men at Qassim University in the second semester of the 2020/2021 academic year and who were registered for the Physical Education Teaching Methods course. There were 69 students in total. The study sample consisted of 40 students who were randomly assigned and divided equally into two groups: control and experimental. Based on the research sample, homogeneity within the group and equivalence between groups in terms of age, Grade Point Average (GPA), and high intelligence test (IQ) [According to
|
PMC9821457
|
||
Descriptive statistics of the control group (
|
According to
|
PMC9821457
|
||
Independent samples compare means.
|
According to an independent samples t-test, it is clear that there are no statistically significant differences between the experimental and control groups in the variables of age and IQ level, where the value of According to the Mann-Whitney U test, there were no statistically significant differences between the two groups in the University GPA, where the value of
|
PMC9821457
|
||
Data collection tools and equipment
|
PMC9821457
|
|||
The high IQ test
|
The IQ of university students was evaluated in Arabic [
|
PMC9821457
|
||
Students’ cognitive achievement test
|
BLOOM
|
To achieve the research aim, the researcher designed a cognitive achievement test for students in the teaching physical education styles topic as follows:1- Prepare a table of specification (TOS)Frequently, Bloom’s taxonomy is used to describe behavior goals students should be able to accomplish upon completing their education. These are categorized into three domains: cognitive, psychomotor, and affective [
The cognitive achievement test specification is shown in
|
PMC9821457
|
|
Difficulty and discrimination index of test items.
|
5- ReliabilityCronbach’s alpha was used to calculate the reliability of the test; the result was 0.78, which indicates a high-reliability index. (Scores greater than 0.7 indicate good reliability [
|
PMC9821457
|
||
The educational program using blackboard collaborate breakout groups
|
BLOOM
|
Through the following steps, ADDIE learning design was used to design learning on the Blackboard collaborate breakout groups platform:1- Analysis: This stage involved determining the general objectives of the program, the characteristics of the students, and the educational activities.
The general objective is to improve students’ cognitive achievement of "the spectrum of physical education teaching styles".Student characteristics: This study sample ranged in age from 21 to 23 years old. According to Spano [There are two types of educational activities: those performed by the teacher and those performed by the student. During the teacher’s instruction, students learn how to use Blackboard Collaborate (joining the class, using breakout groups, submitting assignments and tests, and communicating with other students and the teacher). In the control group, students interact with the Blackboard collaborative platform, communicate with their teacher and colleagues through audio and video, and follow the teacher’s presentation. For the experimental group, task sheets explain the formation and use of subgroups, as well as how to interact with each other. After the collaborative work groups have completed their tasks, the tasks are sent to the teacher on time and displayed in the main room.2- Design: In this stage, behavioral objectives are set, a teaching strategy is defined, an assessment strategy is formed, and task sheets are designed for experimental groups to collaborate on.
The formulation of learning outcomes: In accordance with Bloom [Teaching strategy: With the control group, an online lecture was conducted using the Blackboard platform. Experiment groups used breakout-group tools in the Blackboard collaborative system and task sheets to reinforce collaborative learning.Assessment strategy: As specified in the TOS for the test, an online cognitive test was designed to measure the topics under study and the cognitive levels.Developing task sheets for the experimental group to use during breakout groups, containing instructions, learning outcomes, tasks, and performance times. As Mosston and Ashworth [Time framework: According to the Physical Education Teaching Methods course credit hours (CR), one lecture was given per week to each experimental and control group, with two theoretical CRs for each lecture; one CR equaled 50 contact minutes. Over a five-week period, each experimental and control group received five lectures on the topics.3- Development: Blackboard Collaborate Ultra was selected as one of the webinar tools because it is an official app approved by Qassim University and integrated with the university’s academic system. The educational resources (e-books, presentations) were downloaded using the Blackboard Collaborate platform and were presented to the students, allowing them to ask and discuss questions through the platform, in addition to the breakout groups’ tool that was unique to the experimental group.4- Implementation: Over a five-week period, between 31/1/2021 and 3/3/2021, the main experiment was conducted on Sundays for the control group and Wednesdays for the experimental group. In the experimental group, the Blackboard Collaborate system was utilized with breakout groups for collaborative activities, while in the control group, the system was utilized in a traditional way without any collaborative activities. To assess cognitive achievement, each group took a post-test on 7/3/2021. One month after the discontinuation of the teaching and learning processes, a follow-up measurement was performed.
|
PMC9821457
|
|
Statistical analysis
|
IBM SPSS Statistics for Windows (2017; version 25; IBM Corp, Armonk, NY, USA) was used for the following statistical analyses: frequencies, percentage (%), mean (
|
PMC9821457
|
||
Results
|
PMC9821457
|
|||
Significant differences between the two groups using independent sample T-tests regarding their level of cognitive achievement (n1 = n2 = 20).
|
PMC9821457
|
|||
The significant differences between the post-measurement and the follow-up measurement for the experimental group.
|
PMC9821457
|
|||
Significant differences, statistically, using paired samples T-tests between the post-measurement and the follow-up measurement for the experimental group in the level of cognitive achievement of teaching physical education styles (n = 20).
|
PMC9821457
|
|||
The significant differences between the post-measurement and the follow-up measurement for the control group.
|
PMC9821457
|
|||
Significant differences, statistically, using paired samples T-tests between the post-measurement and the follow-up measurement for the control group in the level of cognitive achievement of teaching physical education styles (n = 20).
|
PMC9821457
|
|||
Discussion
|
mistakes
|
According to the results of the first hypothesis, the experimental group outperformed the control group on cognitive achievement of physical education teaching style scores. Because of the experimental group students collaborated with and helped one another, they were more likely to learn physical education teaching styles that require high levels of thinking and problem-solving. This is consistent with the findings of Kitchen and McDougall [Also, the researcher notes that breakout rooms in the Blackboard Collaborate system provide privacy, which makes students feel comfortable in their groups, without feeling embarrassed about making mistakes in front of the teacher. In addition, they share solutions to any problems they face on their worksheets. This is in line with the results of the studies by Oraif and Elyas [Moreover, by using breakout groups, students can better collaborate and comment on each other’s work, thus increasing productivity and achieving certain learning objectives, especially because worksheets have already been created that direct students to academic goals, assignments, and time for group work, especially when the teacher is absent; they can also distribute roles among them, such as presenter, dialogue leader, and participant, with an exchange of roles among students. As Read et al. [In addition, the researcher suggests that the ease of using the breakout groups allowed the students of the experimental group to save their interactions and send them to the teacher, then present them to colleagues in the main room after the time allotted for the workshops in the breakout groups ended. Furthermore, the breakout groups created a competitive environment between the groups, with each group wanting to display the best work in the main room. The results of Wenzel [The results also showed that there were no statistically significant differences between the post-test and follow-up test of the experimental group in the level of cognitive achievement after the cessation of any teaching and learning processes for a month. This result consistent with the theory of cognitive load that was explained by Sweller [
|
PMC9821457
|
|
Conclusions
|
This study explored the effectiveness of Blackboard collaborative breakout groups on physical education teaching styles. According to the results, the experimental group achieved greater cognitive achievement than the control group, which received only online lectures through a Blackboard collaborative ultra. In contrast, in the experimental group, breakout groups were formed using collaborative strategies and worksheets. Furthermore, the results showed that the experimental group maintained its cognitive achievement despite the suspension period, compared to the control group, for which their follow-up measurements decreased due to reliance on online lectures. Due to this, it is essential that the online learning process promotes collaboration, engagement, and reinforcement among students. The use of technologies in the classroom must be planned and complemented by teaching strategies with a positive reputation in learning that supports active learning strategies.
|
PMC9821457
|
||
Limitations
|
Due to the fact that the Physical Education and Kinesiology program at Qassim University is exclusively for males, all participants in this study were male. It would be possible to explore breakout groups in other online courses with female students.
|
PMC9821457
|
||
Implications
|
The development of more active learning strategies is a very imperative thing that needs to be done to increase students’ engagement and the efficiency of online teaching, so that students will be motivated towards online learning in the future.
|
PMC9821457
|
||
Supporting information
|
PMC9821457
|
|||
The cognitive achievement test of the spectrum of physical education teaching styles.
|
(DOCX)Click here for additional data file.
|
PMC9821457
|
||
An example task sheet for organizing experimental breakout groups.
|
(DOCX)Click here for additional data file.My sincere thanks go out to all the students who participated in the study.
|
PMC9821457
|
||
References
|
PMC9821457
|
|||
2. Materials and Methods
|
PMC10458832
|
|||
2.1. Study Design, Population, and Products
|
A multicentre, randomized, double-blind, controlled clinical study was carried out in Italy, in compliance with the Helsinki Declaration (1964) and its amendment. This study’s protocol was approved by the “Independent Ethical Committee for Non-Pharmacological Clinical Studies” (Genova, Italy). Written informed consent was obtained from all subjects before enrolment. This study was registered at the ISRCTN registry (registration number: ISRCTN99047904). Subject enrolment was carried out between July 2020 and July 2021. Two hundred healthy Italian (Caucasian) pregnant women, aged between 18 and 50 years old, were enrolled according to the inclusion and exclusion criteria reported in Subjects were randomly assigned to 2 groups according to a randomization list previously generated using the statistical algorithm “Wey’s urn”. The two groups (95 subjects each) were provided with two different products as follows: one group used the probiotic plus multivitamin food supplement (active treatment), while the other group used the multivitamin food supplement only (control treatment). The active product contained two probiotic strains, named
|
PMC10458832
|
||
2.2. Outcome Measures
|
depression, Depression
|
The evaluation of depression-related symptoms was carried out by using the Edinburgh Postnatal Depression Scale (EPDS) [The evaluation of breastfeeding quality was performed using the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF) reported by Rashid et al. [The questionnaires were completed at T1 and T2. At T0, no questionnaire was filled since, generally, depression symptoms appear within 30–40 days from delivery [
|
PMC10458832
|
|
2.3. Statistical Analysis
|
Statistical analysis was performed using NCSS 10 Statistical Software (version 10.0.7 for Windows; NCSS, Kaysville, UT, USA) running on Windows Server 2008 R2 Standard SP1 64-bit edition (Microsoft, Redmond, WA, USA). The data normality was checked using the Shapiro–Wilk W normality test and data shape. Intergroup (active vs. control) comparisons were carried out using the Mann–Whitney U test. The data were expressed as mean ± standard deviation (SD). A
|
PMC10458832
|
||
3. Results
|
PMC10458832
|
|||
3.1. Depression Symptom Evaluation
|
depression, Depression
|
MINOR
|
The evaluation of depression symptoms was conducted using the Edinburgh Postnatal Depression Scale, after 45 and 90 days of active/control treatment (T1 and T2, respectively). At T1, the active treatment group reached a total score that was underneath the limit of minor depression (i.e., 10 points) with an average score of 9.0 ± 4.8, while the control group reached a mean value of 12.1 ± 5.9 points. The result obtained for the active treatment was significantly lower than that for the control (
|
PMC10458832
|
3.2. Breastfeeding Quality Assessment
|
The breastfeeding quality was determined using the BSES-SF questionnaire filled by subjects after 45 and 90 days of treatment. The active product showed a significant improvement in the average score obtained with respect to control already at T1 (51.46 ± 9.1 vs. 42.80 ± 10.7, respectively, with
|
PMC10458832
|
||
3.3. Baby’s Crying/Fussing Events
|
EVENTS
|
Regarding the daily improvement in crying/fussing events, a positive effect was observed in the group treated with probiotics. At T1, considering the positive answer to item 15 the of the BSES-SF questionnaire (assessing the crying/fussing events during the treatment), 81% of the active group reported an improvement in comparison to 42% in the control group (
|
PMC10458832
|
|
4. Discussion
|
anxiety, allergy, ’ mood, weakness, mastitis, depression, allergic diseases
|
ALLERGY, ALLERGY, SECONDARY, MASTITIS, EVENTS
|
According to the World Health Organization, stress has been defined as the “Health Epidemic of the 21st Century”. Indeed, the physical and psychological burden caused by long stress periods is increasing [Nowadays, it is well known that probiotic supplementation in women during the last trimester of gestation and breastfeeding shapes newborns’ immune systems. According to the 2015 World Allergy Organization guidelines, pregnant women whose infants are at high risk for allergy should assume probiotics as a preventive treatment. Indeed, probiotic integration positively stimulates the children’s immune system, decreasing the onset of allergic diseases [The majority of scientific studies available in the literature evaluate the immune system response and the GM composition of newborn babies in women taking probiotic supplements during the perinatal period [The aim of our study was to assess whether a supplement containing The evidence that women supplemented with probiotics had fewer symptoms of postnatal anxiety and depression caused by stress is consistent with two previous clinical studies evaluating the effect of probiotics on stress-related parameters in different target populations. The first study is a proof-of-concept trial of 30 students enrolled during an exam session and treated with a probiotic supplement containing the same strains According to this preliminary evidence, our study was designed to assess the effect of probiotics on mood and mental state in the period in which the first PPD symptoms emerge. It is worth noticing that the clinical protocol could not include evaluation questionnaires at T0 since they are not relevant before the occurrence of different and opposite emotional events (e.g., from excitement and joy to weakness and fright due to motherhood). However, this study demonstrated a significant improvement in mothers’ mood in the first trimester when supplemented with Remarkably, this study showed a significant daily improvement in baby crying/fussing events (To the best of our knowledge, only one other published study assessed PPD neurological parameters as a result of the effect of probiotics in new mothers. This study investigated the effect of In our study, the questionnaires used for the assessment of the mothers’ mood state and breastfeeding confidence lacked a basal score, as the selected questionnaires only referred to the postnatal period; indeed, they could not be properly filled at T0 since the mothers had just undergone delivery, without experiencing the wide range of emotional events linked to motherhood yet. For this reason, no evaluation was performed at T0 in order to avoid any alteration of the EPDS and BSES-EF questionnaires.As secondary outcome, mastitis incidence was taken into consideration to further characterize the lactation performance. However, since the two items of the BSES-SF questionnaire related to mastitis did not record any episodes, this outcome was not considered.
|
PMC10458832
|
5. Conclusions
|
The mechanism by which probiotics modulate the mood is still to be clarified; however, growing evidence suggests that probiotics influence the gut–brain axis.The aim of the present study was to further investigate the efficacy of the two probiotics strains in a transitory stress condition, i.e., the postpartum period. In this case, early PPD could be considered as a novel condition to explore, considering its high prevalence in developed countries. Our study provides evidence that the administration of a probiotic supplement containing
|
PMC10458832
|
||
Author Contributions
|
Conceptualization, F.V. and V.D.L.; investigation, M.T. and V.D.L.; data curation, M.T. and V.D.L.; writing—original draft preparation, F.V., P.M., M.T. and V.D.L.; writing—review and editing, F.V., P.M., M.T., G.C., L.L. and V.D.L.; supervision, F.V. All authors have read and agreed to the published version of the manuscript.
|
PMC10458832
|
||
Institutional Review Board Statement
|
This study was conducted in accordance with the Declaration of Helsinki and approved by the Independent Ethical Committee for Non-Pharmacological Clinical Studies, Genova, Italy (protocol code K.E.HU.NN.NGN00.000.00.00_2019/FV, approved on 13 November 2019). This study was registered at the ISRCTN registry with the following registration number: ISRCTN99047904.
|
PMC10458832
|
||
Informed Consent Statement
|
Informed consent was obtained from all subjects involved in this study.
|
PMC10458832
|
||
Data Availability Statement
|
The data presented in this study are available on request from the corresponding author.
|
PMC10458832
|
||
Conflicts of Interest
|
Patrizia Malfa is a Synbalance srl employee. She had no role in the design of this study; the collection, analyses or interpretation of data; she contributed to the writing of this manuscript.
|
PMC10458832
|
||
References
|
Depression, crying/fussing
|
EVENTS, SECONDARY, POSITIVE
|
Flowchart of this study.Study timeline.Score obtained from the Edinburgh Postnatal Depression Scale questionnaire. Comparison between the active and control products at T1 (Score obtained from the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF) questionnaire. Comparison between active and control at (Average number of crying/fussing events. Comparison between the active and control product at T1 (Inclusion and exclusion criteria of this study.* If the woman after delivery was not able to breastfeed, she still remained in the panel since maternal breastfeeding was a secondary outcome.Study schedule.Positive and negative answers to question number 15 of the Breastfeeding Self-Efficacy Scale—Short Form (BSES-SF). The question was related to the improvement recorded in the crying/fussing events during the treatment.
|
PMC10458832
|
Introduction
|
Our recollections tend to become more similar to the correct information when we recollect an initial response using the correct information, known as the hindsight bias [Studies usually investigate hindsight bias in experiments comparing participants’ initial responses with recollection values after providing the correct information [The causes of hindsight bias have been explained in several ways, such as assimilation, recollection, reconstruction, and adoption [The reconstruction theory posits that individuals attempt to repeat the judgment process of initial responses [Considering the recollection and reconstruction theories in the hindsight bias, the memory load of information encoded (MLOIE) should also increase hindsight bias because a high load for memory encoded may contribute to forgetting initial responses and facilitate reconstruction. It makes the source memory weaken and the reconstruction process confused, which may facilitate the assimilation of correct information into initial responses. Also, it is possible that the memory traces of correct information themselves also would weaken under a high MLOIE condition (i.e., the more items of correct information to be memorized). In this case, the weak memory traces of correct information may The aim of the present study was to provide pilot data to clarify whether hindsight bias is affected by the number of items to be remembered, i.e., MLOIE. We tentatively stood on the recollection and reconstruction theories and hypothesized that the hindsight bias is more substantial in high MLOIE conditions than in low MLOIE conditions.
|
PMC10085031
|
||
Materials and methods
|
PMC10085031
|
|||
Participants and protocol
|
Participants (N = 63) were assigned to two conditions for the hindsight bias test (HBT); 32 participants (Mean age 22.6 years, SD = 2.93, 20 women) were assigned to the HIGH list (HIGH) and 31 (Mean age 22.8 years, SD = 2.33, 20 women) to the LOW list (LOW) condition. The desired power level was 0.80, and the minimum effect size calculated by G*Power was 0.71. The HIGH and LOW conditions consisted of 50 and 20 questions, respectively. The HIGH condition consisted of 20 identical questions to the LOW condition and an additional 30 unique questions. The authors developed these HBT questions based on preliminary discussions and pilot trials. The HBT items used in the two conditions were included in supporting information (The LOW and HIGH conditions differed only in the number of correct answers to be remembered (i.e., 20 versus 50), which we defined as MLOIE. Therefore, we used the data of the 20 questions in the HIGH condition that was identical to the LOW condition to compare the MLOIE effect on hindsight bias between the two conditions after eliminating the potential effect of different questions on hindsight bias. Two indices were developed and compared between the LOW and HIGH conditions to test the hypothesis. First, the hindsight bias index (%) was calculated as defined (initial responses—recollection values) / (initial responses—correct information). Second, the distorted items (%) were calculated as the number of distorted items divided by the number of all the items. All the questions were made available to answer in numbers, given that the amount of hindsight bias can also be estimated as numerical values.
|
PMC10085031
|
||
Experimental schedule
|
Participants arrived at the laboratory between 9 and 10 a.m. and responded to the verbally presented HBT questions in a sound-attenuated room, which were considered their Initial responses. The participants were
|
PMC10085031
|
||
Compliance with ethical standards
|
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. The study was reviewed and approved by the ethical review board at the National Institute of Advanced Industrial Science and Technology (AIST).
|
PMC10085031
|
||
Data analysis
|
We defined hindsight bias as the difference between initial responses and recollection values after memorizing the correct information. The percentage of items showing hindsight bias was calculated as the number of biased items divided by all the items, including unbiased items. We defined the two directions of hindsight bias, which are ‘toward’ and ‘reversed’ with the recollection values getting closer to or farther from the correct information, respectively. The hindsight biases in the direction of ‘toward’ and ‘reversed’ the correct answer were calculated separately to clarify the direction of memory bias and conditional differences.The percentage of hindsight was defined as 100 (initial responses–recollection values) / (initial responses–correct information), following the definition by Hell et al. (1988) [
|
PMC10085031
|
||
Statistics
|
We omitted absolute values greater than ± 100% from the data analysis as outliers because some data showed extremely large deviance that disturbed parametric analysis. We performed the non-parametric tests in which the full sample set produced similar results to the omitted sample set. The number of omitted data is described in the Results section. Parametric (unpaired
|
PMC10085031
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.