Search Results (4,489)

Background/Objectives: Impaired angiogenesis and vascular dysfunction are central features of chronic diseases such as cardiovascular disorders, neurodegeneration, and metabolic syndrome. Vascular endothelial growth factor (VEGF) plays a pivotal role in vascular repair and metabolic regulation, yet its responses to exercise remain inconsistently reported. This study aimed to systematically compare the effects of different exercise modalities and doses on VEGF levels across diverse populations. Methods: This review was registered in PROSPERO (CRD42025643709) and followed PRISMA guidelines. PubMed, Web of Science, Embase, and Cochrane Library were searched until 16 January 2025. Eligible studies were randomized or quasi-experimental trials reporting exercise-induced changes in serum/plasma VEGF. Data were extracted and assessed independently using JBI tools. Exercise types were categorized and doses standardized as metabolic equivalents (METs). Network meta-analysis was performed in Stata17.0 (SMD as effect size), with SUCRA used for ranking. Dose–response relationships were examined by meta-regression (remr package), and publication bias was assessed via funnel plots. Results: Twenty-eight studies (N = 1138) were included. In healthy adults, lower-limb resistance training produced the greatest VEGF increase, with benefits observed above ~600 METs-min/week and peaking near 1950 METs-min/week. Among obese individuals, combined aerobic and resistance training under hypoxic conditions showed the highest VEGF response, though dose-specific effects were not significant. In patients with chronic conditions, upper-limb resistance training within 756–950 METs-min/week was most effective, displaying a U-shaped dose–response relationship. No substantial publication bias was detected. Conclusions: The VEGF response to exercise appears to be influenced by both population characteristics and training dosage. High-intensity lower-limb resistance training may provide greater benefits for healthy adults, while obese individuals might experience enhanced responses with combined training under hypoxic conditions. For clinical populations, moderate-dose upper-limb resistance training may be particularly beneficial. Large-scale, long-term trials are needed to further clarify and refine exercise prescriptions targeting VEGF-mediated vascular adaptations. Full article

Background/Objectives: Gamification and game-based learning (GBL) have recently emerged as fresh and appealing ways of health education, and they have been shown to perform better in knowledge acquisition than traditional teaching approaches. Digital serious games are developing as innovative tools for cancer education and behaviour change, yet no review has systematically synthesized their use across key populations. This scoping review aimed to map evidence on serious games for cancer prevention, care, and survivorship among the public, patients, and healthcare professionals, framed through the Capability, Opportunity, Motivation-Behaviour (COM-B) model. Methods: Following Joanna Briggs Institute methodology, we searched Web of Science, MEDLINE, CINAHL, and PsycINFO. Eligible studies evaluated a serious game with a cancer focus and reported outcomes on knowledge, awareness, engagement, education, or behaviour. Data extraction and synthesis followed the PRISMA-ScR checklist. Results: Thirty-five studies met the inclusion criteria, covering diverse cancers, populations, and platforms. Most reported improvements in knowledge, engagement, self-efficacy, and communication. However, heterogeneity in study design and limited assessment of long-term behaviour change constrained comparability. Conclusions: Digital serious games show promise for enhancing cancer literacy and supporting behavioural outcomes across patients, professionals, and the public. By integrating multiple perspectives, this review highlights opportunities for theory-driven design, robust evaluation, and implementation strategies to maximize their impact in cancer education and awareness. Full article

Background: Metabolic syndrome (MetS) is a set of cardiometabolic abnormalities, including central obesity, dyslipidemia, hypertension, and hyperglycemia, that substantially increases the risk of cardiovascular disease and type 2 diabetes. Marine-derived omega-3 polyunsaturated fatty acids (n-3 PUFAs), especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), may improve MetS components through triglyceride-lowering, anti-inflammatory, and insulin-sensitizing effects; however, randomized controlled trial (RCT) results remain inconsistent, and the influence of dose and intervention duration is unclear. Methods: Following PRISMA guidelines, PubMed, Embase, Scopus, and Web of Science were searched to June 2024 for RCTs in adults with MetS or its components. Eligible trials assessed marine-derived omega-3 supplementation (EPA/DHA) versus placebo or control and reported at least one MetS diagnostic criterion (triglycerides, HDL cholesterol, fasting plasma glucose, blood pressure, or waist circumference) or related parameter (LDL cholesterol, HOMA-IR, or HbA1c). Data were extracted in duplicate and quality assessed using the Cochrane Risk-of-Bias Tool. Trials were categorized by dose—low (<1000 mg/day), medium (1000–2000 mg/day), and high (>2000 mg/day)—and duration: short-term (ST; ≤8 weeks), medium-term (MT; >8–12 weeks), and long-term (LT; >12 weeks). Meta-regression using ordinary least squares estimated dose–duration effects. Publication bias was assessed with funnel plots and Egger’s test for outcomes with ≥3 studies. Results: Twenty-one RCTs (n ≈ 1950) were included. For triglycerides, the largest reductions occurred in the high-dose LT (−56.78 mg/dL ± 3.44) and ST (−50.873 mg/dL ± 3.04) groups, and MT duration (−41.536 mg/dL ± 4.12), showing that in high doses of omega-3, the beneficial effect of reducing TGs was more prominent in long-term and short-term treatment other than with medium-term duration of treatment. In comparison, the result for medium-dose with MT duration was (−24.93 mg/dL ± 0.464) and for LT duration was (−31.843 mg/dL ± 0.46), all p < 0.001. In LDL cholesterol, an increase in the low-dose ST group (+7.04 mg/dL ± 4, p < 0.001) and low-dose LT group (+35.525 mg/dL ± 4.33, p < 0.001) was observed. In other subgroups, either there were no data available or the number of studies was limited and could not be considered as statistically significant in meta-analysis due to low power. As for HDL cholesterol, FBS, SBP, DBP, waist circumference, BMI, and HOMA-IR, the data extracted from the included studies were not sufficient to be eligible for the meta-analysis. Conclusions: Marine-derived omega-3 supplementation produces substantial triglyceride reductions, especially at doses >2000 mg/day for ≥8 weeks. HDL cholesterol and blood pressure benefits are not consistent, fasting glycemia is largely unaffected, and LDL cholesterol may increase, especially in low doses. High-dose marine omega-3s can be considered as part of dietary strategies for MetS management, with monitoring for LDL changes. Standardized intervention protocols and long-term RCTs are needed to clarify dose and duration–response relationships. Full article

Background/Objectives: Estimating the sex from unknown individuals is a critical step when constructing their biological profile. The distal humerus is a useful sex discriminator as shown through metric, morphoscopic, and geometric morphometric approaches. A recently developed web application using geometric morphometric techniques has provided an accessible tool for estimating sex from the shape of the olecranon fossa. The aims of this study were to examine the accuracy of the Ammer–Coelho web application on Scottish individuals, as well as test its repeatability and reproducibility among seven different observers. Methods: The right humerus was obtained from 52 Scottish individuals, and the Ammer–Coelho web application was used to estimate sex. Total accuracy rates and sex-specific rates were calculated, and an analysis of Cohen’s and Fleiss’ kappa was performed. Results: The results demonstrate an overall accuracy of 69.23% with a sex bias of −5.33%, with 55.56% of the sample being accurately estimated with probabilities equal to or higher than 0.95. Substantial agreement was reported for intra-observer error, and an overall low agreement was reported for inter-observer error Conclusions: This is the first study that evaluates the Ammer–Coelho web application. A tendency to perceive more triangular shapes (male appearance) rather than oval shapes (female appearance) resulted in a high level of observer errors, with only 6% of females correctly estimated across the seven observers. The low accuracy rates obtained could also indicate inter-population variation, as shown by other studies. Due to the results obtained, research considering different levels of observers’ experience and diverse population samples is needed to confirm our findings. Full article

Background/Objectives: The COVID-19 pandemic highlighted how infodemics—an excessive amount of both accurate and misleading information—undermine health responses. Artificial intelligence (AI) and digital tools have been increasingly applied to monitor, detect, and counter health misinformation online. This scoping review aims to systematically map digital and AI-based interventions, describing their applications, outcomes, ethical and equity implications, and policy frameworks. Methods: This review followed the Joanna Briggs Institute methodology and was reported according to PRISMA-ScR. The protocol was preregistered on the Open Science Framework . Searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, and CINAHL (January 2017–March 2025). Two reviewers independently screened titles/abstracts and full texts; disagreements were resolved by a third reviewer. Data extraction included study characteristics, populations, technologies, outcomes, thematic areas, and domains. Quantitative synthesis used descriptive statistics with 95% confidence intervals. Results: A total of 63 studies were included, most published between 2020 and 2024. The majority originated from the Americas (41.3%), followed by Europe (15.9%), the Western Pacific (9.5%), and other regions; 22.2% had a global scope. The most frequent thematic areas were monitoring/surveillance (54.0%) and health communication (42.9%), followed by education/training, AI/ML model development, and digital engagement tools. The domains most often addressed were applications (63.5%), responsiveness, policies/strategies, ethical concerns, and equity/accessibility. Conclusions: AI and digital tools provide significant contributions in detecting misinformation, strengthening surveillance, and promoting health literacy. However, evidence remains heterogeneous, with geographic imbalances, reliance on proxy outcomes, and limited focus on vulnerable groups. Scaling these interventions requires transparent governance, multilingual datasets, ethical safeguards, and integration into public health infrastructures. Full article

Background: Movement is crucial for human development, particularly during childhood. Fundamental movement skills (FMSs) are essential movement patterns that support physical, cognitive, and social development. Recent studies indicate an alarming worldwide decline in FMS acquisition, potentially impacting children’s long-term physical fitness and health. This scoping review explored FMSs, their relationship to motor competence and physical literacy, associations with physical activity and fitness, assessment methods, and effective interventions. Methods: A comprehensive literature review was conducted using the PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases. The search utilized key phrases related to FMSs, motor competence, and physical literacy. Initially, 2251 publications were identified. Results: After rigorous screening, 95 English-language literature reviews and meta-analyses focusing on FMSs in healthy children were selected for detailed analysis. The accepted publications were categorized into five thematic areas: FMSs and motor development (11 publications), conceptual terms in FMS context (8 publications), relationships between FMSs and other parameters (15 publications), FMS assessment tools (14 publications), and intervention effects on FMSs (47 publications). Conclusions: Effective FMS acquisition requires collaborative interventions involving teachers, parents, sports professionals, and healthcare providers. Future research should focus on developing standardized assessment tools, interpreting FMSs as part of physical literacy to understand their association with PA level and design efficient intervention strategies. Full article

Listeria monocytogenes is a ubiquitous foodborne pathogen whose occurrence in food and food-processing environments raises public-health concerns, particularly when isolates carry antimicrobial-resistance determinants. Next-generation sequencing (NGS) is increasingly used to detect resistance genes and to predict phenotypic resistance. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, PubMed, Web of Science, and Scopus were searched for original articles (2015–2024) that used second- and/or third-generation sequencing to characterize antibiotic resistance in L. monocytogenes from food and food-processing environments. After deduplication and screening, 58 studies were included from an initial 418 records. NGS reliably detected a set of recurrent resistance determinants across diverse sample types and geographies. The fosX locus (intrinsic fosfomycin-related marker) was effectively ubiquitous across studies, while acquired determinants were variably distributed: lin (35/58 studies, 60.34%), norB (33/58, 56.90%), and tetracycline genes overall in 20/58 (34.48%) with tetM as the most common (11/58, 18.97%). Reported concordance between the genotypes and phenotypes for acquired resistance was very high (>99% for most agents), with notable exceptions (e.g., ciprofloxacin and some fosfomycin cases). Common analysis pipelines and databases included ResFinder, CARD, BIGSdb-Lm, ABRicate, and ARIBA; most sequencing used Illumina short reads, with an increasing use of long-read or hybrid approaches. NGS is a powerful surveillance tool for detecting resistance determinants and for source-tracking, but its predictive value depends on integration with phenotypic testing, standardized reporting, and comprehensive, curated databases. Key gaps include inconsistent phenotype reporting, variable database coverage, and limited assessment of gene expression/regulatory effects. Full article

This review presents a synthesis of global research on precision forestry, a field that integrates advanced technologies to enhance—rather than replace—established tools and methods used in the operational forest management and the wood products industry. By evaluating 210 peer-reviewed publications indexed in Web of Science (up to 2025), the study identifies six main categories and eight components of precision forestry. The findings indicate that “forest management and planning” is the most common category, with nearly half of the studies focusing on this topic. “Remote sensing platforms and sensors” emerged as the most frequently used component, with unmanned aerial vehicle (UAV) and light detection and ranging (LiDAR) systems being the most widely adopted tools. The analysis also reveals a notable increase in precision forestry research since the early 2010s, coinciding with rapid developments in small UAVs and mobile sensor technologies. Despite growing interest, robotics and real-time process control systems remain underutilized, mainly due to challenging forest conditions and high implementation costs. The research highlights geographical disparities, with Europe, Asia, and North America hosting the majority of studies. Italy, China, Finland, and the United States stand out as the most active countries in terms of research output. Notably, the review emphasizes the need to integrate precision forestry into academic curricula and support industry adoption through dedicated information and technology specialists. As the forestry workforce ages and technology advances rapidly, a growing skills gap exists between industry needs and traditional forestry education. Equipping the next generation with hands-on experience in big data analysis, geospatial technologies, automation, and Artificial Intelligence (AI) is critical for ensuring the effective adoption and application of precision forestry. Full article

Background: Gingival recession (GR) is defined as the exposure of the root surface due to the gingival margin shifting apically from the cemento-enamel junction. Current effective management of defects related to GR relies on root coverage periodontal plastic surgery (RCPPS), using the Modified Coronally Advanced Flap (mCAF) with an envelope design. Recent literature also reported the association of different biomaterials to the mCAF procedure. In light of these considerations, a systematic review (SR) was conducted to determine and compare the efficacy of all mCAF adjunctive techniques for the treatment of multiple adjacent GR-type (MAGR) defects. Methods: An electronic search was conducted in 2025 on studies published between 2013 and 2025, using PubMed, Scopus, Web of Science, and Cinahl Complete, to address the focused question: “which is the efficacy of different mCAF adjunctive techniques for the treatment of multiple adjacent GR-type defects, in terms of root coverage (RC), esthetic outcomes, and keratinized tissue (KT) augmentation?”. Randomized controlled trials with a minimum follow-up of 6 months with ≥ 5 patients treated for coverage of MAGR were included. Risk of bias was assessed with RoB 2 Tool. A meta-analysis was performed using RevMan5.4 software and the level of evidence of included studies was analyzed with GRADEPro GDT. Results: A total of 17 studies were included in the SR, 9 of which evaluating mCAF + sCTG (subepithelial connective tissue graft) vs. mCAF adjunctive techniques [Collagen Matrix (CM), xenogeneic acellular dermal matrix (XADM), Platelet-Rich Fibrin (PRF), Enamel Matrix Derivatives (EMD), sCTG harvested double blade scalpel] were then included in the meta-analysis. The primary outcomes of complete root coverage (CRC) and keratinized tissue width variation (ΔKTW) were statistically significant ([CRC: Odds Ratio (OR) 1.70; 95% CI (confidence interval) 1.18, 2.44; p = 0.004]; [ΔKTW: SMD (standardized mean difference) 0.37; 95% CI 0.11, 0.63; p = 0.005]) in favor of mCAF + CTG. Meanwhile, no statistically significant difference was observed in terms of RES. The certainty assessment highlighted relevant results: despite the lack of evidence in the long-term, a high level of evidence showed that sCTG was more effective than XADM in terms of CRC (p = 0.002) and ΔKTW (p = 0.0001). A low level of evidence revealed that sCTG achieved a greater ΔKTW compared to CM (p = 0.0006). Although no significant differences were observed, a low level of evidence suggested that mCAF + EMD and mCAF + sCTG (DBS) may provide good results. To date, only one RCT showed long-term stable results of CTG in terms of RC. Conclusions: The association of sCTG to mCAF demonstrated better results in terms of RC and KTW augmentation in short- and medium-term follow-ups. Long-term studies are needed to confirm the efficacy of the other mCAF adjunctive techniques, considering limitations due to heterogeneity in follow-ups, distribution of techniques analyzed, and different study designs. Registration in PROSPERO (International prospective register of systematic reviews) was performed with ID CRD420251085823. Full article

Introduction: Three-dimensional (3D) printing technology has rapidly evolved across various fields of medicine and dentistry, particularly in orthodontics. One key application in orthodontics is the fabrication of dental models. Numerous parameters throughout the dental cast fabrication workflow can influence the accuracy of 3D-printed models. This review aims to evaluate the influence of post-processing procedures, specifically post-curing and post-rinsing, on the dimensional accuracy of 3D-printed dental casts. Materials and Methods: An initial data search was conducted using specific keywords across four databases (PubMed, Scopus, Web of Science, and Google Scholar). A secondary search of references and citations was also performed. This systematic review ultimately identified five studies that met the inclusion criteria (in vitro studies and studies referred to post-processing only of 3D-printed models) for further evaluation and analysis, whereas reviews, opinion studies, and papers in languages other than English were excluded. Based on the QUIN tool, all studies were assessed for their risk of bias. Because of the studies’ heterogeneity, a qualitative descriptive synthesis was conducted. Results: All five included studies were in vitro investigations. One study examined the influence of the post-curing process on dimensional accuracy, while the remaining four explored the impact of post-rinsing procedures on both dimensional accuracy and other surface characteristics of 3D-printed dental casts. Conclusions: According to the findings of the included studies, both post-curing and post-rinsing procedures had statistically significant effects on the dimensional accuracy of 3D-printed dental models. Nevertheless, all five studies concluded that the observed deviations remained within clinically acceptable limits, rendering the casts suitable for diagnostic orthodontic purposes or device fabrication. However, further research is needed to reinforce current findings and to enhance our understanding of the optimal post-processing protocols of additively manufactured dental casts. Full article

Adolescents living with HIV face unique challenges when transitioning from pediatric to adult care—including stigma, disclosure concerns, and loss of support—that undermine continuity. We systematically searched PubMed, Embase, and Web of Science through August 2025 in accordance with PRISMA 2020. Two reviewers independently screened records and appraised risk of bias using Joanna Briggs Institute (JBI) tools by study design; appraisals informed interpretation but did not determine inclusion. Thirty-two studies met criteria; given heterogeneity, findings were narratively synthesized. Post-transition outcomes were suboptimal: retention often declined to ~70% by two years and viral suppression to roughly two-thirds, below global targets. Older transfer age and minimal gaps between pediatric discharge and adult enrollment were associated with better retention. Structured programs combining early preparation, coordinated handoffs, psychosocial/peer support, and youth-friendly adult services consistently improved engagement (often >90% 12-month retention), though improvements in viral suppression were less uniform. JBI appraisal indicated mostly moderate methodological quality with common risks from confounding and incomplete follow-up, tempering certainty. Purposeful, well-supported transition models are essential to sustain treatment success into adulthood; future work should evaluate scalable delivery and long-term outcomes across diverse settings. Full article

Background: Older adults are highly vulnerable to infectious diseases due to immunosenescence, multimorbidity, and atypical presentations. Artificial intelligence (AI) offers promising opportunities to improve diagnosis, prognosis, treatment, and continuity of care in this population. This review summarizes current applications of AI in the management of infections in older adults across diagnostic, prognostic, therapeutic, and preventive domains. Methods: We conducted a narrative review of peer-reviewed studies retrieved from PubMed, Scopus, and Web of Science, focusing on AI-based tools for infection diagnosis, risk prediction, antimicrobial stewardship, prevention of healthcare-associated infections, and post-discharge care in individuals aged ≥65 years. Results: AI models, including machine learning, deep learning, and natural language processing techniques, have demonstrated high performance in detecting infections such as sepsis, pneumonia, and healthcare-associated infections (Area Under the Curve AUC up to 0.98). Prognostic algorithms integrating frailty and functional status enhance the prediction of mortality, complications, and readmission. AI-driven clinical decision support systems contribute to optimized antimicrobial therapy and timely interventions, while remote monitoring and telemedicine applications support safer hospital-to-home transitions and reduced 30-day readmissions. However, the implementation of these technologies is limited by the underrepresentation of frail older adults in training datasets, lack of real-world validation in geriatric settings, and the insufficient explainability of many models. Additional barriers include system interoperability issues and variable digital infrastructure, particularly in long-term care and community settings. Conclusions: AI has strong potential to support predictive and personalized infection management in older adults. Future research should focus on developing geriatric-specific, interpretable models, improving system integration, and fostering interdisciplinary collaboration to ensure safe and equitable implementation. Full article

Background: Artificial sweeteners, widely used as non-nutritive sugar substitutes, are increasingly prevalent in ultra-processed products. Although promoted for weight management due to their minimal caloric content, their impact on systemic inflammation remains uncertain. This systematic review of animal studies aims to evaluate the association between artificial sweetener consumption and inflammatory biomarkers. Methods: A systematic literature search was conducted up to May 2025 across PubMed, Web of Science, and Scopus, following PRISMA guidelines and registered in PROSPERO (CRD420251084004). Risk of bias was assessed using the ARRIVE guidelines and SCYRCLE’s risk of bias tool. Results: Thirty-seven animal studies were included: aspartame (n = 17), sucralose (n = 16), acesulfame potassium (n = 5), and saccharin (n = 4). Protocols varied in terms of dosage, exposure duration, animal models, and assessment of inflammatory outcomes, including C-reactive protein, interleukins (IL-6 and IL-1β), and tumor necrosis factor alpha. Aspartame and sucralose could elevate inflammatory markers, with sucralose also disrupting gut integrity and microbiota. Acesulfame K and saccharin showed variable, dose-dependent effects. Conclusions: This systematic review of animal studies suggests a possible mechanistic association between the consumption of certain artificial sweeteners and systemic inflammation. However, this relationship remains to be clarified and warrants exploration through well-designed, large-scale randomized controlled trials. Full article

Breast cancer is a globally prevalent oncological disease whose treatments, while improving survival rates, often lead to adverse cognitive effects. Brain-derived neurotrophic factor (BDNF) and cytokines, key mediators of the inflammatory response, may play a significant role in these cognitive alterations. This systematic review (osf.io/vk37x) addresses the use of BDNF and cytokines as biomarkers of cognitive impairment in breast cancer animal models. A comprehensive literature search was conducted across the following databases: Web of Science, Scopus, ScienceDirect, PubMed, and Medline. Keywords used were: (“breast cancer” AND “cognitive impairment” AND (“brain derived neurotrophic factor” OR “cytokines”). A total of 9876 articles were identified, of which 17 studies met the inclusion criteria. For quality assessment the SYRCLE’s tool for assessing Risk of Bias was used. Neuroinflammatory and systemic inflammatory responses, particularly increases in pro-inflammatory cytokines (IL-6, IL-1β, TNF-α) and reductions in hippocampal BDNF, are consistently linked to breast cancer and chemotherapy-induced cognitive impairment in animal models. Several interventions normalized these biomarkers and improved cognitive performance after chemotherapy. Anti-inflammatory cytokines (IL-10 or IL-4) were measured in fewer studies and recent research suggests that they could serve as potential protective biomarkers. BDNF, pro- and anti-inflammatory cytokines may represent candidate biomarkers for cancer-related cognitive impairment. Full article

Objectives: This systematic review aimed to examine hip rotator range of motion (ROM) and strength values across athletic, injured, and non-active populations, and to determine how these values differ when measured at different hip flexion angles. Methods: A systematic literature search was conducted in accordance with PRISMA guidelines across six electronic databases (PubMed, Scopus, Web of Science, SPORTDiscus, CINAHL, and Medline) from inception to June 2025. Eligible studies included observational, cross-sectional, case-control, or randomized controlled trial (RCT) studies that quantitatively assessed hip IR/ER ROM and/or strength in defined population groups (athletic, injured, or non-active). Two reviewers independently screened titles, abstracts, and full texts, extracted data on study design, population characteristics, measurement methods, and outcome variables, and assessed risk of bias using an established tool. Discrepancies were resolved by a third reviewer. Results: 11 studies met the inclusion criteria, including 1276 participants across athletic, injured, and non-active populations. Hip rotator ROM was measured in nine studies and strength in three, with varying testing angles (0° and/or 90° hip flexion). Overall, athletes showed greater ROM at 0° compared to injured and non-active groups, but had reduced ROM at 90° relative to non-active participants. Non-active individuals had the lowest ROM at 0°. Strength findings, though limited, indicated higher values at 90° than at 0°. Conclusions: Hip rotator ROM and strength vary across populations and testing angles, with ROM generally lower and strength higher at 90° of hip flexion. Due to methodological inconsistencies, findings should be interpreted as directional evidence, reinforcing the need for standardized assessment protocols in future research. Full article