ABSTRACT This case involves a woman with a perforated intrauterine contraceptive device (IUCD) that has silently migrated to the bladder–abdominal wall interface. The perforation was unrecognized for nearly 14 years, during which the patient conceived and delivered vaginally due to contraceptive failure. Over the following years, she underwent a few pelvic ultrasounds, experienced three miscarriages, and ultimately presented with secondary infertility attributed to tubal blockage. This case highlights the importance of investigating contraceptive failure and missing IUCD with appropriate follow-up and patient counselling to prevent the long-term complications of silent migration of IUCD. This case underscores the importance of interdisciplinary management involving gynecology, radiology, and urology to safely localize and remove the migrated device and prevent injury to adjacent organs like the bladder or bowel.
ABSTRACT Background : Hemophilia is a hereditary disease identified by compromised blood coagulation as a result of inadequate levels of particular clotting factors. The nutritional status of children with hemophilia is an essential indicator of their overall health and well-being. Research has revealed malnutrition as a major cause of several adverse effects, including reduced treatment tolerance, raised morbidity rates, adverse prognosis, decreased quality of life, and increased healthcare costs. The study objective was to assess the nutritional status of children with hemophilia and to find any association between malnutrition and socio-demographic factors. Methods : A case-control study was conducted in the child welfare teaching hospital in Baghdad city for 4 months. The study sample included 194 children (97 cases and 97 controls) aged 5 to 14 years, using simple random sampling and a special questionnaire design, and measuring anthropometric measures. Results : The results revealed that the highest percentage of patients was in the age group >10 years (30.9%), the highest percentage (81.4%) of patients live in urban areas, and the highest percentage (50.5%) of patients have low socio-economic status. The association between malnutrition and demographic variables showed a significant association ( p -value <0.005) with age group 5 to 6 years, who have a low educational level of the mother, a birth interval of less than 1 year, and who have low socioeconomic status. Conclusion : Patients with hemophilia have a higher percentage of malnutrition, with other factors that increase the risk of developing malnutrition, including the age of the child, the low educational level of the mother, who has a birth interval of less than 1 year, and low socio-economic status.
ABSTRACT Objective : The current study was conducted to assess domestic violence against married men, determine the causes, and identify its impacts on their health. Material : A descriptive study was conducted, and the assessment approach was applied to the convenience sample, the total number was 120 persons, and it was distributed as follows: 40 lawyers, 40 married men, and 40 women. The study was carried out from September 1, 2019, to February 1, 2021, in Baghdad city. Data are collected by using a structured interview technique. The questionnaire was constructed through a review of related literature and previous experience. Validity of the questionnaire was established by showing the questionnaire to three specialists, and the internal consistency reliability of the questionnaire was determined by application of the split-half technique and computation of Cronbach’s alpha correlation coefficient. Data are analyzed through the application of descriptive statistics of frequencies, percentages, and mean scores. Results : The results showed that the married men between 25 and 35 years of age, among them, more than half were at secondary school 24 (60%), and the majority of them, 34 (85%), were employed. In most forms of violence, they were exposed to psychological abuse and neglect of the husband’s needs as a result of family causes 38 (95%) and social matters 35 (87.5%). While the health problems of the men 32 (80 %) and social issues started to increase 31 (77.5 %). Conclusion : The study concludes that the wife’s domestic violence against men is considered a community-oriented health problem due to some family and psychosocial factors that affect the personal health of men and their families.
Background: The relationship between clinical indicators and illness severity in hospitalized patients with both diabetes mellitus (DM) and COVID-19 remains incompletely understood, particularly with respect to endocrine markers. Aim: This study aimed to identify clinical predictors of critical illness in hospitalized adults with DM and COVID-19 and to develop a predictive nomogram for individualized risk assessment. Method: This retrospective cross-sectional study enrolled 393 hospitalized patients with confirmed DM and COVID-19, who were categorized into non-critical (n = 309) and critical (n = 84) groups. We evaluated a comprehensive panel of candidate predictors, including demographic characteristics, vital signs, and laboratory markers such as C-reactive protein (CRP), fasting C-peptide (FCP), and free triiodothyronine (FT3). Multivariable logistic regression was used to develop the prediction model. Results: Multivariate logistic regression identified several independent predictors of critical illness. Elevated levels of blood urea nitrogen (BUN) (OR: 1.100, 95% CI: 1.026-1.183), serum creatinine (SCr) (OR: 1.027, 95% CI: 1.011-1.043), and CRP (OR: 1.011, 95% CI: 1.005-1.019), along with advanced age (OR: 1.073, 95% CI: 1.039-1.112), were significant risk factors. Conversely, lower levels of FCP (OR: 0.483, 95% CI: 0.305-0.737), FT3 (OR: 0.519, 95% CI: 0.313-0.835), and serum sodium (OR: 0.911, 95% CI: 0.860-0.962) were independent protective factors. The resulting nomogram showed excellent discrimination (C-index = 0.964). Conclusion: A combination of clinical and laboratory parameters, including age, renal function, inflammatory markers, and endocrine indicators (FCP and FT3), can effectively predict COVID-19 severity in patients with DM. The developed nomogram provides a practical tool for early risk stratification in this high-risk population.
Aim: To examine the state of menstrual hygiene management (MHM) among female university students in Gaza, with a particular focus on access to menstrual materials and water, sanitation, and hygiene (WASH) facilities. Method: This study employed an exploratory cross-sectional survey design targeting female university students, usinga structured online questionnaire. Items related to MHM were adapted from the Arabic MHM Toolkit Mini Guide. The survey was distributed through social media, university listservs and networks, and online student group platforms. Data were collected between November 2024 and December 2024. Participants were eligible for inclusion if they were identified as female, enrolled in a university, and residents of Gaza. Results: Our sample comprised 214 participants. Most respondents (95.3%) reported using sanitary pads during menstruation. Almost half of the participants (46.7%) were able to change their pads only once or twice per day, closely aligning with the 48.6% who perceived their frequency of pad changes as inadequate. Approximately 17% of participants lacked access to a safe and private space to change menstrual materials, while nearly 40% lacked access to a safe and private space for bathing during menstruation. Additionally, 22.4% of participants were unable to regularly clean their external genitalia with water and soap during menstruation, and 14.5% reported a lack of trash bins for the disposal of pads or cloth materials. Conclusion: Our findings highlight the distressing realities of the ongoing genocide in Gaza and its impact on women and girls of reproductive age. There is an acute shortage of menstrual materials- particularly menstrual pads-along with other hygiene items (e.g. soap) and WASH facilities to support proper menstrual hygiene practices. We call on the international community and governments to act jointly to establish an immediate, permanent ceasefire and to facilitate the timely entry of humanitarian aid into Gaza.
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that can lead to cerebral edema, organ failure, and even death. Traditional diagnosis depends on clinical assessment and laboratory tests, which may delay recognition and overlap with other conditions. Recent advances in artificial intelligence (AI), particularly machine learning (ML), present opportunities to improve early diagnosis, risk stratification, and management of DKA. Various ML models—such as Random Forest, K-Nearest Neighbors, XGBoost, and Long Short-Term Memory networks—have demonstrated high predictive accuracy for assessing DKA severity, prognosis, and mortality. However, many of these studies are limited by small, single-center cohorts and lack external validation. Although AI shows strong potential to transform DKA care, further standardization, validation across diverse populations, and integration into clinical workflows are required before routine adoption.
Background: Diabetic nephropathy (DN) represents one of the most severe complications associated with type 2 diabetes (T2D), often leading to kidney failure and significantly affecting patients' quality of life. Early detection and monitoring of DN are essential to prevent its progression. Midkine and copeptin, two biomarkers associated with inflammatory and metabolic processes, have shown promise in reflecting the underlying changes associated with DN, thus offering hope for improved diagnosis and management. The objective of this study was to investigate the clinical relevance of midkine and copeptin levels in T2D patients and their associations with insulin resistance and albuminuria status, evaluating their potential as predictive tools to detect the progression of DN. Methods: A case-control study was carried out with 360 participants, grouped into 90 healthy controls and T2D patients categorized by different stages of albuminuria (normoalbuminuric, microalbuminuric, and macroalbuminuric, with 90 individuals in each category). Serum levels of midkine, copeptin, fasting insulin, and other biochemical analytes were measured. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR), while renal function was evaluated using the albumin-creatinine ratio (ACR) and the estimated glomerular filtration rate (eGFR). Results: Elevated levels of midkine and copeptin were found in T2D patients, with the highest levels observed in the macroalbuminuric group (p < 0.001). Both biomarkers were positively correlated with glycemic parameters (fasting glucose, HbA1c), insulin resistance (HOMA-IR), and markers of DN (ACR, eGFR) (p < 0.001). ROC (receiver operating characteristic) analysis showed strong diagnostic performance for both biomarkers, with midkine yielding an area under the curve (AUC) of 0.96 (95% CI: 0.94-0.99, sensitivity: 96.7%, specificity: 91.1%) and copeptin yielding an AUC of 0.98 (95% CI: 0.97-1.0, sensitivity: 97.8%, specificity: 88.9%). Multivariate linear regression analysis identified midkine (p = 0.039) and copeptin (p = 0.027) as significant predictors of albuminuria. Conclusion: Serum levels of midkine and copeptin are elevated in T2D patients, with a strong association with the onset and progression of DN. These biomarkers may serve as early indicators for diabetic kidney disease, facilitating timely detection and management of renal complications. Their role in predicting insulin resistance and cardiovascular risk further underscores their potential as clinical tools for managing DN.
Introduction: The COVID-19 pandemic has posed significant challenges to healthcare systems, underscoring the need for effective triage tools to predict disease severity and guide clinical decision-making. Several prognostic scoring systems have been developed for this purpose, yet their relative effectiveness remains unclear. This study evaluates the performance of five commonly used scoring systems-CRB65, modified PRIEST (mPRIEST), NEWS2, Modified Early Warning Score (MEWS), and Quick COVID-19 Severity Index (qCSI)-in predicting in-hospital mortality and intensive care unit (ICU) admissions among COVID-19 patients. Methods: A retrospective prognostic accuracy study was performed involving 7,674 adult patients diagnosed with COVID-19 at Hamad General Hospital, Qatar. Data were extracted from electronic medical records, and severity scores were calculated based on patients' initial clinical presentation. The predictive accuracy of each score for mortality and ICU admission was assessed using the area under the receiver operating characteristic curve (ROC AUC), along with sensitivity, specificity, and Youden's index. Results: In the study cohort, the overall mortality rate was 1.1%, with an ICU admission rate of 5.2%. Among the various scoring systems evaluated, mPRIEST demonstrated the highest AUC for predicting mortality (0.899) and ICU admission (0.888), followed by qCSI (0.870 for mortality, 0.865 for ICU admission) and NEWS2 (0.858 and 0.866, respectively). In contrast, CRB65 and MEWS showed lower predictive accuracy, with AUC values of 0.776 and 0.672 for mortality and 0.692 and 0.670 for ICU admission, respectively. Conclusion: The findings indicate that mPRIEST and qCSI are the most accurate prognostic scores among those evaluated for predicting mortality and ICU admission, thus serving as valuable tools for COVID-19 triage in emergency settings. NEWS2 also demonstrated strong predictive performance, whereas CRB65 and MEWS were comparatively less effective. These insights help optimize early risk stratification and resource allocation in clinical practice.
Introduction: Low back pain (LBP) is a prevalent problem that affects at least 80% of all individuals at some point in their lifetime. LBP was ranked sixth in terms of global disease burden and causes more disability globally than any other condition. Therefore, this study aims to assess the prevalence of LBP and associated risk factors among medical students in Egypt. Methods: A previously validated questionnaire was adopted in our study. Quantitative data were summarized as mean and standard deviation, and the qualitative data were summarized as frequency and percentage. We used the chi-square test to detect an association between different variables and LBP at the point of data collection, 6 and 12 months. Results: The questionnaire was filled out by 576 medical students. The total prevalence of participants who reported LBP at least once was (481/576, 83.5%). The point prevalence of LBP was 52.4%, while the 6- and 12-month prevalence was 70.1% and 71.5%, respectively. LBP prevalence was significantly associated with sex, with higher prevalence in females than males at point prevalence (57.6% vs. 47%, p = 0.011) and 6-month prevalence (75.8% vs. 64.2%, p = 0.002). Furthermore, body mass index was significantly associated with LBP during the last 6 months (p = 0.01). Also, LBP was significantly associated with physical activity frequency, chair characteristics, including sitting surface and back support, rest time, and type of daily activity. Conclusion: There was a high prevalence of LBP among medical students in Egypt. The point, 6= and 12-month prevalence rates underscore the persistent nature of this condition. There is a need for targeted interventions focusing on ergonomics, physical activity, and lifestyle modifications to reduce the burden of LBP and improve overall well-being. Due to the limitations of study design, future longitudinal studies are still required.
Introduction: It has been determined that type A behavior patterns and coronary artery disease incidence are related. According to recent research, having type A personality traits raises the coronary disease. Although type D personality has not been thoroughly studied, some research suggests that it may also be a risk factor for those diseases. Our study aimed at examining the link between personality patterns and coronary disease. Methods: At the Mohamed Tahar Ma & acirc;mouri University Hospital in Nabeul, we conducted a crosssectional study. One hundred individuals with coronary artery disease from the cardiology department were recruited. They were either hospitalized or outpatients. We also included 100 controls. Personality types A and D were screened using the Bortner questionnaire and the "DS-14" scale, respectively. Results: Compared to 13% of controls, 45% of patients with coronary artery disease had a behavioral type D personality. The prevalence of type A was 35% in controls and 25% in patients with coronary artery disease. Type D personality was linked to coronary artery disease with an odds ratio = 4.8 (95% CI, 2.4-9.2) and a p = 0.002 after adjusting using binary logistic regression and accounting for confoundingvariables. We found that individuals with type D personalities were five times more likely to have coronary artery disease. There was no statistically significant correlation between coronary artery disease and type A personality (p = 0.123). Conclusion: The study emphasizes the necessity of encouraging type D personality early detection to contribute to averting coronary artery disease.
Background: Anatomy is a cornerstone of medical education, yet delivering effective instruction in resource-limited settings presents significant challenges. This study evaluates medical students' perceptions of three prominent anatomy learning modalities, including educational videos, threedimensional (3D) digital atlases, and plastic models, while examining differences in preference by gender and academic year. The study also explores key institutional barriers impacting anatomy education at Ibb University, Yemen. Methods: A cross-sectional survey was conducted between April and December 2024 involving 171 undergraduate medical students from the first to third years at Ibb University. A rigorously validated 81-item questionnaire, distributed electronically via Google Forms, assessed perceived modality effectiveness, institutional challenges, and curricular preferences. Data analysis included descriptive statistics, chi-square tests for group comparisons, and multivariate logistic regression to identify predictors of learning modality preferences. Results: Among respondents (58% female, 42% male; mean age, 21.2 +/- 1.5 years), 3D digital atlases were most strongly endorsed for improving spatial visualization skills, with agreement decreasing from 88% in first-year year to 71% in third-year students (p = 0.01). Educational videos consistently facilitated conceptual understanding, with positive perceptions ranging from 79% to 72% across academic years (p = 0.21). Plastic models were viewed as less effective by senior students, particularly regarding exam recall (62% in early years vs. 48% in third-year; p = 0.02). Institutional challenges prominently included cadaver unavailability (89%) and insufficient teaching staff (78%), both highly significant (p < 0.001). Students favored blended learning formats (63%) and mixed assessment methods (70%). Logistic regression showed first-year students had over twice the odds of valuing 3D atlases (OR, 2.12 [95% CI, 1.45-3.10]) and were 24% less likely to endorse plastic models (OR, 0.76 [95% CI, 0.62-0.93]) compared to third-year counterparts. Female students had significantly higher odds of reporting laboratory overcrowding than males (OR, 1.37 [95% CI, 1.03-1.82]). Conclusions: Medical students at Ibb University demonstrate clear preferences for multimodal anatomy learning approaches, shaped by gender and academic progression. Addressing institutional limitations such as resource scarcity and staffing deficiencies, alongside tailoring instructional methods to students' educational stages, may significantly enhance anatomy education effectiveness in resource-constrained settings.
Background: The concept of food addiction (FA) represents a significant shift in our understanding of the etiology of obesity and has the potential to optimize and streamline its management. The multifactorial etiology of FA requires a deeper investigation into various psychological correlates beyond genetic predispositions and the obesogenic environment. Aim: The study aimed to identify psychological predictors of FA and investigate the relationships between FA and psychopathological symptoms in the context of adverse childhood experiences (ACEs). Materials and Methods: A correlational, quantitative, non-experimental design was employed. A self-report assessment battery included the Yale Food Addiction Scale, the Adverse Childhood Experiences Questionnaire, and the Symptom Checklist-90. The research sample consisted of 188 participants. Results: We identified psychoticism, depression, and ACEs as significant predictors of FA. Psychoticism and depression explained 24% of the variance of FA, while ACEs explained 10% of this variance. ACEs significantly mediated the relationship between psychopathological symptom prevalence and FA. Conclusions: By investigating the psychological correlates of FA, this study aimed to gain a deeper understanding of how different risk factors may contribute to specific eating behaviors. These insights can inform the development of more effective personalized therapeutic interventions.
This study investigates the concentrations of gross alpha and beta activities in tap water samples collected from Kumbotso local government, reporting values ranging from 0.04 +/- 0.01 BqL-1 to 0.9 +/- 0.28 BqL-1 for gross alpha activities, and 0.7 +/- 0.8 BqL-1 to 85.1 +/- 11.7 BqL-1 for gross beta activities. The findings reveal that gross beta activities exceed their alpha counterparts across all tap water samples, with both surpassing the World Health Organization (WHO)-recommended thresholds of 0.1 BqL-1 for gross alpha and 1.0 BqL-1 for gross beta activities. This indicates an annual effective dose exceeding WHO's reference level of 0.1 mSvy-1, highlighting a significant radiological risk to residents. The most vulnerable areas identified are Dorayi-1 and Gasau-2, where the annual effective dose rates are markedly higher than the recommended limits for adults and children. This work provides baseline radiometric data for tap and drinking water in the region, emphasizing the need for public awareness and immediate mitigation efforts to address these potential health hazards. Moreover, the findings underscore the importance of further research to confirm and expand upon these results, aiming to safeguard public health through informed policy and infrastructure improvements.
Background: Video gaming has become a primary form of entertainment worldwide, offering recreational benefits while simultaneously raising concerns about its physical and psychosocial impacts on children. These concerns include mental health, academic performance, and social interactions. The aim of this study was to evaluate parental awareness of these effects in order to identify knowledge gaps and support the development of targeted interventions. Methods: A descriptive cross-sectional hospital-based study included 411 students aged 13–28 years and their parents at Punjab and the ICT (Islamabad Capital Territory) region from July to September 2022. The study design enables concurrent data collection, providing a comprehensive overview of parents’ knowledge, perceptions, and concerns about the effects of video games on their children’s mental health, social behavior, academic performance, and overall well-being. The collected data were subsequently analyzed and interpreted using both descriptive and inferential statistics. Data were analyzed using SPSS version 20. Results: Among the 411 participants, a majority, 251 (61.8%), of students reported that they did not feel themselves addicted to video games, while 233 (56.7%) parents believed that their children were addicted and observed signs of depression, anger, and social phobia. Of the 98 (23.8%) students who admitted to being addicted, many indicated that it started during the COVID-19 quarantine. Conclusion: The study suggests that, although students spend long periods playing video games, they do not perceive any symptoms of addiction. In contrast, parents generally find video games unbeneficial, noting a decline in interactive time with their children. They observed behavioral changes, although there were no signs of loss in academic performance. Notably, the results indicate that COVID-19 may have played a role in the onset of video game addiction. It is essential to implement educational initiatives focused on responsible gaming in schools. Parents require assistance in setting healthy gaming boundaries and monitoring screen usage. Policymakers should consider enforcing stricter regulations on child-oriented gaming advertisements. Further research is necessary to evaluate the long-term behavioral effects and intervention techniques.
Background: Autonomic dysfunction, characterized by heightened sympathetic and diminished parasympathetic activity, is increasingly recognized as a significant factor in the pathophysiology and therapeutic management of bipolar disorder (BD). The aim of this study is to investigate the changes in sympathetic skin response (SSR) among BD type 1 patients during the manic phase compared to their state after clinical remission. Methods: This retrospective cross-sectional study enrolled 17 patients who were newly diagnosed with BD type 1 in the manic phase, adhering to DSM V criteria, over 4 years from January 2018 to December 2022. All subjects received treatment with sodium valproate, and SSR testing was performed during both the manic phase and following a washout period. The latency and amplitude of bilateral palmar and plantar SSRs were examined using electrical stimulation of the median and tibial nerves. Statistical analyses were conducted using paired T -tests and Mann–Whitney U tests to assess the mean differences in SSR latency and amplitude pre- and post-treatment. Results: The treatment led to a statistically significant reduction in SSR latency for the right tibial nerve (from 2.380 ± 0.370 to 2.126 ± 0.241 seconds, p = 0.014) and the left median nerve (from 1.829 ± 0.410 to 1.600 ± 0.217 seconds, p = 0.033), indicating moderate effect sizes. In contrast, SSR amplitude demonstrated minimal variation across all examined nerves, with no statistically significant increase observed following treatment (all p -values = 0.05). Limitations: The small number of participants in the study could affect the reliability of the results. Conclusion: The results of the study indicate that SSR latency may serve as a promising biomarker for evaluating autonomic function in patients experiencing manic and euthymic phases of BD following mood stabilizer treatment. Nonetheless, further validation through larger cohort studies with long-term follow-up is essential to corroborate these preliminary findings and better understand the implications for clinical practice.
Background: In 2022, 4.9 million children died worldwide before the age of five years. The UN General Assembly has set the target to reduce under-five child mortality rate (U5MR) to 25 deaths per 1,000 live births by 2030. However, the UN Inter-Agency Group for Child Mortality Estimation highlights that, without rapid action, many low and lower middle-income countries may fall short of this target, resulting in the loss of 35 million children under five years of age before 2030. In such a scenario, it is crucial to understand the determinants that contribute to the reduction of preventable child deaths. Design: Anonymized and publicly accessible data from the Indian National Family Health Survey (NFHS-5) were used. The sample consisted of 724,115 women aged 15–49 years, categorized into urban and rural groups. Data on the number of community daycare centers, or Anganwadi centers, per state were obtained from the Ministry of Women and Child Development. For better analysis of data, the country was divided into regions, with union territories classified according to their geographical locations. Various statistical methods such as descriptive statistical analysis, correlation coefficient, and linear regression analysis were used. Results: Descriptive analysis showed that Central India had the highest U5MR (49.8%), despite having the second highest number of community daycare centers (74,510) in the country. The Spearman rank correlation analysis showed a significantly large positive relationship between community daycare centers (%) and U5MR ( r = 0.521, p < 0. 001). Conversely, there was a significantly large negative relationship between women with internet access (%) and U5MR ( r = -0.6908, p < 0. 001). The results from multiple linear regression showed b 0 = 53.6807, b 1 = -0.58788, and b 2 = 0.77266, with an R 2 value of 0.5616 ( p = 0). Additionally, simple linear regression analysis for the percentage of community daycare centers along with U5MR in children showed a beta coefficient ( b ) of 2.5767 ( p < 0. 001), with an R 2 value of 0.2938. For the data on internet access to women (%) and U5MR, the beta coefficient ( b ) was -0.6759, the p value was 0, and the R 2 value was 0.5444. Conclusion: In comparison to the data from NFHS-4 (2015–16), there was a notable decrease in the U5MR in almost all states in the country. The study showed that urban women had greater access to the Internet than rural women. Furthermore, child mortality rates were higher in rural areas than in urban areas in every state. The enhanced access to health information through the Internet for urban women may have contributed to the lower child mortality rates observed in urban settings. Internet access for women at the individual level is significantly more effective in reducing the U5MR than the community-level approach of daycare centers.
The aim of our cross-sectional study was to evaluate the reliability of videos uploaded on YouTube demonstrating the Heimlich maneuver. We searched for the terms “Heimlich maneuver”, “abdominal thrust”, “abdominal thrust maneuver”, “foreign body airway obstruction”, or “subdiaphragmatic abdominal thrusts” to find videos uploaded on YouTube from 2020 to 2023. We analyzed the source of the upload, the time duration, the viewership, and the use of mannequins or performance on humans or neither. Of the 1,008 videos uploaded, 106 videos met the inclusion criteria. The median score for the included videos was 2.5. There was no statistical difference in the scores between the professional videos compared to non-professional videos. However, videos uploaded by professionals had a higher viewership and median score than those uploaded by non-medical sources (median scores 3 and 2, respectively). The results of our study indicate that the videos uploaded by medical professionals were viewed more frequently than unidentified sources, although they were not comparatively more reliable.
