Search Results (34)

Understanding long-term snow cover dynamics is essential in mountain regions with limited meteorological or in situ observations. This study examines seasonal snow cover evolution across the Romanian Carpathians (2000–2025) using daily MODIS/Terra MOD10A1 Cloud-Gap-Filled data at 500 m resolution. Snow-covered pixels were identified using an NDSI ≥ 40 threshold, and snow cover duration (SCD), snow onset date (SOD), and snow end date (SED) were analyzed in relation to elevation and aspect from the FABDEM, complemented by snow-covered area (SCA) and snowline elevation (SLE) metrics. Across the entire range, the snow season shortens mainly due to later onset (+0.28 days/year) and earlier melt (−0.78 days/year), resulting in an SCD decrease of −1.14 days/year. High-elevation (>2000 m) areas show only small changes (SCD: −0.13 days/year; SOD: +0.46 days/year; SED: +0.32 days/year), while the strongest reductions occur at low and mid elevations, where snow persistence is most sensitive to warming; consistent declines in seasonal SCA and a pronounced monthly SLE cycle further document the spatial expression of this variability. Uncertainty was assessed by comparison with station-based snow cover duration (n = 230 station-years), indicating strong agreement (r = 0.95) with a modest negative bias (median: −8 days) and a mean absolute error (MAE) of 16.7 days. Climate correlations highlight air temperature as the dominant covariate of interannual snow-phenology variability, whereas precipitation associations are weaker. Overall, these shifts in snow phenology highlight increasing instability of the Carpathian snow regime and emphasize the value of long-term MODIS observations for tracking cryospheric change in a warming southeastern European mountain system. Full article

Secchi disk depth (SDD) is a widely critical indicator of water transparency. However, existing retrieval models often suffer from limited transferability and biased predictions when applied to optically diverse waters. Here, we compiled a dataset of 6218 paired in situ SDD and remote sensing reflectance (R_rs) measurements to evaluate model generalization. We benchmarked nine machine learning (ML) models (RF, KNN, SVM, XGB, LGBM, CAT, RealMLP, BNN-MCD, and MDN) under three validation scenarios with progressively decreasing training-test overlap: Random, Waterbody, and Cross-Optical Water Type (Cross-OWT). Furthermore, SHAP analysis was employed to interpret feature contributions and relate model behaviors to optical properties. Results revealed a distinct scenario-dependent generalization gradient. Random splits yielded minimal bias. In contrast, Waterbody transfer consistently shifted predictions toward underestimation (SSPB: −16.9% to −3.8%). Notably, Cross-OWT extrapolation caused significant error inflation and a bias reversal toward overestimation (SSPB: 10.7% to 88.6%). Among all models, the Mixture Density Network (MDN) demonstrated superior robustness with the lowest overestimation (SSPB = 10.7%) under the Cross-OWT scenario. SHAP interpretation indicated that engineered indices, particularly NSMI, functioned as regime separators, with substantial shifts in feature attribution occurring at NSMI values between 0.4 and 0.6. Accordingly, feature sensitivity analysis showed that removing band ratios and indices improved Cross-OWT robustness for several classical ML models. For instance, KNN exhibited a significant reduction in Median Symmetric Accuracy (MdSA) from 96% to 40% after feature reduction. These findings highlight that model applicability must be evaluated under scenario-specific conditions, and feature engineering strategies require rigorous testing against optical regime shifts to ensure generalization. Full article

This paper assesses whether national level digitalization is associated with lower greenhouse gas emissions intensity, and under which conditions the association holds, using an unbalanced panel for twenty-seven European countries from 2014 to 2022. Digitalization is measured through a principal component index constructed from enterprise information technology adoption and fixed broadband subscriptions per capita. The outcome is the logarithm of emissions per unit of gross domestic product. Identification is implemented with two-way fixed effects and Driscoll–Kraay standard errors to exploit within country variation, and dynamic bias and potential endogeneity are probed through parsimonious difference GMM designs. Robustness is assessed through alternative outcomes, country specific linear trends, clustered inference, and leave one out checks. Evidence for an unconditional reduction in emissions intensity associated with digitalization is not found. It is predicted that the relationship between digitalization and e-commerce will be positive and statistically significant, thus meaning that at the median and the upper quartile of e-commerce a one standard deviation increase in digitalization relates to increases in intensity of about 2.4% and 3.3%, respectively. More renewable energy shares come with lower intensity and mitigate the digitalization effect. The contribution here attempts to quantify such conditional associations within a multi-country setting and thereby infer design and energy contexts wherein environmental gains from digital expansion would most likely take place. Full article

Background: Apnea of prematurity affects at least 85% of infants born before 34 weeks’ gestation and represents a significant clinical challenge in neonatal intensive care. Methylxanthines, including caffeine, theophylline, and aminophylline, have emerged as the primary pharmacological intervention for this condition. Objective: To conduct a comprehensive systematic review of the use of methylxanthine in the treatment and prevention of apnea episodes in preterm infants, evaluating efficacy, safety, and long-term outcomes. Methods: We searched multiple databases including PubMed, Embase, Web of Science for randomized controlled trials, retrospective studies, or case–control studies of methylxanthine effects in preterm apnea. Risk of bias was assessed using the Cochrane Risk of Bias tool. Results were summarized narratively and grouped by methylxanthine type, study design, and primary outcomes (reduction in frequency and severity of apnea episodes, success of extubation, risk of bronchopulmonary dysplasia). Results: Twenty-five studies (n = 4599 preterm infants) were included. The landmark Caffeine for Apnea of Prematurity (CAP) trial (n = 2006) demonstrated that caffeine therapy significantly reduced bronchopulmonary dysplasia (36.3% vs. 46.9%, adjusted OR 0.63) and facilitated the earlier discontinuation of positive airway pressure (median 1 week earlier). Studies with a smaller number of cases have consistently demonstrated the efficacy of methylxanthines in reducing the incidence of bronchopulmonary dysplasia and apneic episodes and in supporting successful extubation. Long-term follow-up at 11 years showed improved pulmonary function (FEV₁ z-score −1.00 vs. −1.53). Discussion: Limitations of this review include heterogeneity in outcome definitions, small sample sizes in early studies, and the dominance of evidence from the CAP trial. Methylxanthines, particularly caffeine, are an evidence-based intervention used for apnea of prematurity, with demonstrated benefits that extend beyond reducing the frequency and severity of apnea episodes, including decreasing the risk of bronchopulmonary dysplasia as well as reducing the need for mechanical ventilation. No external funding was received for this review. No registration record exists for this systematic review. Full article

Cat cafés are gaining popularity worldwide, yet little is known about their impact on feline welfare. This study examined a Swedish cat café from an animal perspective by assessing space use, cat–cat interactions, and cat–human interactions. A total of 27 neutered domestic cats (12 males, 15 females), with a median stay of 8 weeks, were directly observed in groups of 8–9 individuals for a total of 227 h over 70 days. Scan sampling and focal observations were conducted without prior knowledge of cat background to minimize bias. Results showed that elevated structures (χ²-goodness-of-fit test, χ² (2) = 1234.2, p < 0.001, post hoc Bonferroni correction p_adj = 0.013) were important, particularly during periods of high customer occupancy, when cats preferred vertical levels or cat-only rooms. Cat–cat interactions were infrequent (0.58 interactions/cat/h) and mostly affiliative (51.9%), consistent with avoidance as a conflict-reduction strategy. Cat–human interactions were absent in 44.4% of the observation time. Cats varied in their responses to human presence, from engaging to avoiding. Findings suggest that cat cafés should provide complex vertical environments, hiding places, and private areas to support natural behaviors, reduce stress, and promote group stability. As cats come into contact with large numbers of visitors prior to adoption, further research should assess its long-term effects on cat–human relationships and optimize café design to balance cat welfare and visitor experience. Full article

Climate change is expected to have significant effects on crop yield in the Canadian Prairies. The objective of this study was to investigate these possible effects on spring wheat, barley and canola production using the Decision Support System for Agrotechnology Transfer (DSSAT) modelling platform. We applied 21 climate change scenarios from high-resolution (0.22°) regional simulations to three modules, DSSAT-CERES-Wheat, DSSAT-CERES-Barley and CSM-CROPGRO-Canola, using a historical baseline period (1985–2014) and three future periods: near (2015–2040), middle (2041–2070), and far (2071–2100). These simulations are part of CMIP6 (Coupled Model Intercomparison Project Phase 6) and have been processed using statistical downscaling and bias correction by the NASA Earth Exchange 26 Global Daily Downscaled Projections project, referred to as NEX-GDDP-CMIP6. The calibration and validation results surpassed the thresholds for a high level of accuracy. Simulated yield changes indicate that climate change has a positive effect on spring wheat and barley yields with median model increases of 7% and 11.6% in the near future, and 5.5% and 9.2% in the middle future, respectively. However, in the far future, barley production shows a modest increase of 4.4%, while spring wheat yields decline significantly by 17%. Conversely, simulated canola yields demonstrate a substantial decrease over time, with reductions of 25.9%, 46.3%, and 62.8% from the near to the far future, respectively. Agroclimatic indices, such as Number of Frost-Free Days (NFFD), Heating Degree-Days (HDD), Length of Growing Season (GSL), Crop Heat Units (CHU), and Effective Growing Degree Days (EGDD), exhibit significant correlations with spring wheat. Conversely, precipitation indices, such as very wet days and annual 5- and 10-day maximum precipitation, have a stronger correlation with canola yield changes when compared with temperature indices. The results provide key guidance for policymakers to design adaptation strategies and sustain regional food security and economic resilience, particularly for canola production, which is at significant risk under projected climate change scenarios across the Canadian Prairies. Full article

Objective: The objective of this study was to assess changes in body composition, with a specific focus on fat mass (FM) and fat-free mass (FFM), in obese adults with type 2 diabetes (T2D) treated with once-weekly (OW) subcutaneous (s.c.) semaglutide. Methods: This was a single-center, 12-month, real-world, ambispective study (6-month prospective and 6-month retrospective). Body composition parameters were assessed via segmental multifrequency bioelectrical impedance analysis (SMF-BIA). Results: A total of 117 patients with DM2, with a median age of 56 years, a median HbA1c level of 9.4%, and a median body weight of 102.5 kg, were included in the study. The median body weight, body fat mass, and visceral fat significantly decreased at 6 months, with values of −9.3, −7.5, and −1.8 kg, respectively. There were further reductions from 6 to 12 months, albeit at a slower rate. The median skeletal muscle mass significantly decreased at 6 months (−1.2 kg), although no further significant reductions were observed at 12 months. Conclusions: OW s.c. semaglutide for 12 months significantly improved body composition parameters, mainly at the expense of fat mass loss, with the preservation of skeletal muscle mass. These changes are clinically meaningful, since they impact general metabolic health and are associated with improvements in metabolic control and clinical parameters associated with renal and CV risks, as well as presumable improvements in quality of life. Full article

Background and Objectives: Postoperative pancreatic fistula and post-hepatectomy liver failure remain significant complications after HPB surgery; however, superficial surgical site infection (SSI) is the most frequent wound-related complication. Closed-incision negative-pressure wound therapy (ciNPWT) has been proposed to reduce superficial contamination, yet no liver-focused quantitative synthesis exists. We aimed to evaluate the effectiveness and safety of prophylactic ciNPWT after hepatopancreatobiliary (HPB) surgery. Methods: MEDLINE, Embase, and PubMed were searched from inception to 30 April 2025. Randomized and comparative observational studies that compared ciNPWT with conventional dressings after elective liver transplantation, hepatectomy, pancreatoduodenectomy, and liver resections were eligible. Two reviewers independently screened, extracted data, and assessed risk of bias (RoB-2/ROBINS-I). A random-effects Mantel–Haenszel model generated pooled risk ratios (RRs) for superficial SSI; secondary outcomes were reported descriptively. Results: Twelve studies (seven RCTs, five cohorts) encompassing 15,212 patients (3561 ciNPWT; 11,651 control) met the inclusion criteria. Device application lasted three to seven days in all trials. The pooled analysis demonstrated a 29% relative reduction in superficial SSI with ciNPWT (RR 0.71, 95% CI 0.63–0.79; p < 0.001) with negligible heterogeneity (I² 0%). Absolute risk reduction ranged from 0% to 13%, correlating positively with the baseline control-group SSI rate. Deep/organ-space SSI (RR 0.93, 95% CI 0.79–1.09) and 90-day mortality (RR 0.94, 95% CI 0.69–1.28) were unaffected. Seven studies documented a 1- to 3-day shorter median length of stay; only two reached statistical significance. Device-related adverse events were rare (one seroma, no skin necrosis). Conclusions: Prophylactic ciNPWT safely reduces superficial SSI after high-risk HPB surgery, with the greatest absolute benefit when baseline SSI risk exceeds ≈10%. Its influence on deep infection and mortality is negligible. Full article

Background: Heart failure (HF) is frequently associated with skeletal muscle wasting, reduced functional capacity, and malnutrition. High-protein diets offer a promising nutritional intervention to improve these outcomes in individuals with HF. Objective: This systematic review evaluated randomized controlled trials of high-protein dietary interventions in HF populations, with emphasis on intervention characteristics, quantitative benefits, and risk of bias. Methods: We conducted a comprehensive search in PubMed, MEDLINE, Embase, and Cochrane CENTRAL from inception to June 2025. Eligible studies enrolled adults (≥18 years) with HF, implemented high-protein regimens (≥1.1 g/kg/day or ~25–30% of energy), and reported on functional capacity, body composition, muscle strength, clinical outcomes, or biochemical markers. Two reviewers independently screened, extracted data, and assessed bias (Cochrane RoB 2). Heterogeneity in dosing, duration, and outcomes precluded meta-analysis; we therefore provide a narrative synthesis. Results: Ten trials (nine randomized controlled trials, one pilot) involving 1080 patients (median n = 38; range 21–652) were included. High-protein interventions yielded mean improvements in six-minute walk distance of +32 ± 14 m, lean body mass gain of +1.6 ± 0.9 kg, and 9 ± 4% enhancement in quality-of-life scores; muscle strength effects varied from −2% to +11%. Two studies reported an 18% reduction in HF readmissions (p < 0.05). The risk-of-bias assessment identified two low-risk, three moderate-risk, and one high-risk study. Key limitations include small sample sizes, varied protein dosing (1.1–1.5 g/kg/day), short follow-up (2–6 months), and outcome heterogeneity. Conclusions: High-protein dietary strategies appear to confer modest, clinically relevant gains in functional capacity, nutritional status, and HF readmission risk. Larger, well-powered trials with standardized dosing and longer follow-up are necessary to establish optimal protein targets, long-term efficacy, and safety. Full article

Background: Sex differences in type 2 diabetes (T2D) are a growing area of diabetes research. No data have been reported on sex differences with oral semaglutide (oSEMA) in a real-world setting. Methods: We included people with T2D who started treatment with oSEMA in routine clinical practice between November 2021 and November 2022, with at least one report of clinical follow-up (FU) data at 3 months. We evaluated in women with T2D (WWT2D) the clinical effectiveness of oSEMA and factors associated with clinical response and persistence. We also analyzed differences in baseline characteristics, clinical effectiveness, persistence rates and safety according to biological sex. Results: Of the 1018 subjects [median age: 63 years, body mass index (BMI): 33.8 kg/m², HbA1c: 7.8%], 469 were WWT2D. In WWT2D, oSEMA reduced HbA1c by 0.7% [−0.1 to −1.3] and 0.9% [−0.2 to −1.5] at the 6- and 12-month FU visits, while weight decreased by 4.6% [2.0 to 7.9] and 7.2% [2.5 to 10.9], respectively. Weight loss was >10% in 29.8% of WWT2D (95% CI 25.8 to 34.1); meanwhile, the combined endpoint (HbA1c decrease ≥ 1% + weight reduction ≥ 5%) was achieved in 23.5% (95% CI 19.8 to 27.5%) of WWT2D at the 12-month FU visit. Achievement of glycaemic targets was similar in women and men (59.3% vs. 61.1%). We found no sex differences in weight loss (6.9% vs. 6.8%), oSEMA maintenance dose, persistence rate (76.3% vs. 77.3%), or adverse events. Conclusions: oSEMA was effective and safe in WWT2D in a real-world setting, with nearly one-third of patients reporting weight loss >10% and more than two-thirds achieving HbA1c < 7%. oSEMA showed no sex bias in terms of effectiveness and safety. Full article

Background: Inclisiran is a novel lipid-lowering agent targeting PCSK9 via small interfering RNA (siRNA) technology. While clinical trials such as the ORION studies have demonstrated significant reductions in low-density lipoprotein cholesterol (c-LDL), real-world data (RWD) often differ due to variations in patient populations and clinical practices. Methods: This systematic review and meta-analysis adhered to PRISMA guidelines. A comprehensive search was conducted in MEDLINE for real-world studies evaluating inclisiran’s efficacy in reducing c-LDL. Articles meeting predefined inclusion criteria were assessed for quality and bias using RTI Item Bank. Data transformations were applied to harmonize median and IQR values to means and standard deviations for meta-analytic synthesis using RevMan 5.4. Results: A total of 3774 articles were identified, of which 7 studies comprising 1454 patients met the inclusion criteria. The meta-analysis revealed an average c-LDL reduction of 42.77% (95% CI: 37.42–48.12%). The subgroup analysis indicated greater reductions in patients receiving inclisiran alongside statins (45.67%; 95% CI: 36.64–54.71%) compared to monotherapy (37.53%; 95% CI: 29.91–45.15%). Discrepancies with clinical trials (e.g., 52% reduction in ORION studies) were attributed to baseline c-LDL differences and real-world adherence. Conclusions: Inclisiran demonstrates robust efficacy in real-world settings, achieving significant c-LDL reductions with a convenient dosing schedule. However, the observed discrepancies with clinical trials highlight the need for further RWD studies to bridge gaps in effectiveness and optimize therapeutic outcomes. Full article

Background: Coronary and carotid artery diseases are manifestations of a systemic atherosclerotic process, often coexisting in patients affected by both conditions. This association emphasizes the importance of evaluating both coronary and carotid atherosclerosis in high-risk individuals. Ultrasound 2D shear-wave elastography (2D-SWE) has shown promise as a noninvasive technique for assessing carotid plaque stiffness. This prospective pilot study aimed to assess carotid plaque stiffness in patients undergoing coronary artery bypass grafting (CABG) and those not scheduled for the procedure as a control group. Methods: 32 patients (17 CABG and 15 controls) were recruited, collectively presenting 43 carotid plaques. Bilateral carotid ultrasound was performed using a high-resolution linear transducer. Plaque stiffness was quantified via 2D-SWE, expressed in shear-wave velocity (SWV, m/s) and Young’s modulus (YM, kPa). Plaque characteristics, including GSM, were quantified. Intra-observer reproducibility was evaluated with intraclass correlation coefficients (ICCs) and Bland–Altman plots. Statistical differences and correlations were assessed using Mann–Whitney U and Spearman’s correlation tests. Results: Carotid plaques in the CABG group exhibited significantly lower stiffness compared to controls (median stiffness SWV: 3.64 m/s vs. 4.91 m/s, p < 0.0001; YM: 20.96 kPa vs. 72.54 kPa, p < 0.0001). ICCs demonstrated excellent reproducibility for stiffness measurements (SWV: ICC = 0.992; YM: ICC = 0.992), with minimal bias in measurements. A positive correlation was observed between 2D-SWE and GSM values (SWV: r = 0.343, p = 0.024; YM: r = 0.340, p = 0.026). Conclusions: Ultrasound 2D-SWE has shown promise as a reliable tool for quantifying carotid plaque stiffness, demonstrating high reproducibility and a significant correlation with GSM. The observed reduction in plaque stiffness among CABG patients highlights its potential as a valuable parameter for identifying high-risk plaques and assessing cerebrovascular risk in patients undergoing CABG. Full article

Background: Healthy lifestyles depend on forming crucial habits through the process of habit formation, emphasising the need to establish positive habits and break negative ones for lasting behaviour changes. This systematic review aims to explore the time required for developing health-related habits. Methods: Six databases (Scopus, PsychINFO, CINAHL, EMBASE, Medline and PubMed) were searched to identify experimental intervention studies assessing self-report habit or automaticity questionnaires (e.g., the self-report habit index (SRHI) or the self-report behavioural automaticity index (SRBAI)), or the duration to reach automaticity in health-related behaviours. Habit formation determinants were also evaluated. Meta-analysis was performed to assess the change in the SRHI or SRBAI habit scores between pre- and post-intervention, and the study quality was assessed using the PEDro scale. Results: A total of 20 studies involving 2601 participants (mean age range: 21.5–73.5 years) were included. Most studies had a high risk of bias rating (n = 11). Health behaviours included physical activity (n = 8), drinking water (n = 2), vitamin consumption (n = 1), flossing (n = 3), healthy diet (n = 8), microwaving a dishcloth (for foodborne disease reduction, n = 2) and sedentary behaviour reduction (n = 1). Four studies reported the median or mean times to reach habit formation, ranging from 59–66 days (median) and 106–154 days (means), with substantial individual variability (4–335 days). The meta-analysis showed significant improvements in habit scores pre- to post-intervention across different habits (standardised mean difference: 0.69, 95% CI: 0.49–0.88). Frequency, timing, type of habit, individual choice, affective judgements, behavioural regulation and preparatory habits significantly influence habit strength, with morning practices and self-selected habits generally exhibiting greater strength. Conclusions: Emerging evidence on health-related habit formation indicates that while habits can start forming within about two months, the time required varies significantly across individuals. A limitation of this meta-analysis is the relatively small number of studies included, with flossing and diet having the most evidence among the behaviours examined. Despite this, improvements in habit strength post-intervention are evident across various behaviours, suggesting that targeted interventions can be effective. Future research should aim to expand the evidence base with well-designed studies to better understand and enhance the process of establishing beneficial health habits. Full article

Background: Many clinical practice guidelines recommend dietary pulses for the prevention and management of cardiovascular disease and diabetes. The impact of extracted pulse proteins remains unclear. We therefore conducted a systematic review and meta-analysis of randomized controlled trials of the effect of extracted pulse proteins on therapeutic lipid targets. Methods and Findings: MEDLINE, Embase, and the Cochrane Library were searched through April 2024 for trials of ≥3-weeks. The primary outcome was low-density lipoprotein-cholesterol (LDL-C). The secondary outcomes were other lipid targets. Independent reviewers extracted data and assessed the risk of bias. Subgroup analyses included by pulse type and the certainty of evidence was assessed using GRADE. Results: Seven included trials (14 trial comparisons, n = 453) with a median of 4-weeks duration and dose of 35 g/day showed that extracted pulse proteins decreased LDL-C by −0.23 mmol/L (95% confidence interval: −0.36 to −0.10 mmol/L, p < 0.001). Similar effects were observed for non-high-density lipoprotein-cholesterol and apolipoprotein B. No interactions were found by pulse type. Subgroup analyses revealed effect modification by sex, with greater proportions of females seeing greater reductions. GRADE was generally moderate. Conclusions: Extracted pulse proteins likely result in moderate reductions in LDL-C and other lipid targets. Future studies on various types of extracted pulse proteins including assessments by sex are warranted. Full article

Emerging evidence in women supports the notion that pregnancy may reset disease resistance, thereby providing protection against subsequent adverse health outcomes, but this hypothesis has not been adequately explored in domestic dogs. Cranial cruciate ligament (CCL) rupture is a degenerative orthopedic disease that frequently affects pet dogs, and its risk has been associated with disruption of the reproductive hormone axis. Our research team is conducting a lifetime cohort study of purebred Rottweilers in North America that have lived 30% longer than breed-average. Detailed medical and reproductive histories of 33 nulliparous and 32 parous Rottweilers were generated from questionnaires and review of medical records. Interviews with owners of bitches in the nulliparous group served to limit selection bias, confirming that in no instance was the reason for nulliparity based upon the owner’s suspicion that a bitch had a heightened risk for CCL rupture. The risk of CCL rupture associated with parity and other exposure variables was estimated using multivariate logistic regression. Overall, CCL rupture was diagnosed in 17 of 65 (26%) bitches. Median age at first litter and CCL rupture were 3.6 and 6.5 years, respectively. Compared to nulliparous, parous bitches had a significant 94% reduction in CCL rupture risk adjusted for duration of ovary exposure, overweight body condition, dietary pattern, habitual physical activity, and work/sport activity [OR_adjusted (95% CI) = 0.06 (0.01–0.46); (p = 0.006)]. The observed parity-associated CCL rupture risk reduction remained robust in sensitivity analysis excluding six nulliparous bitches for which decision not to breed was based on diagnosis of hip or elbow dysplasia, conditions which may be genetically linked to CCL rupture [OR_adjusted (95% CI) = 0.08 (0.01–0.58); (p = 0.01)]. This work sets the stage for replication studies in other canine populations that should begin to explore the mechanistic basis for parity-associated CCL rupture risk reduction and to pursue other non-reproductive health outcomes in bitches whose incidence or severity may be parity-sensitive. Full article