Author Archives: Marie Benz MD FAAD

About Marie Benz MD FAAD

Physician in practice over 30 years. Editor of MedicalResearch.com. All interviews conducted exclusively for MedicalResearch.com by Marie Benz, MD.

Severe Skin Reactions TEN/SJS: Children Generally Do Better Than Adults

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MedicalResearch.com Interview with:
CDC imageJames W. Antoon, MD, PhD
Pediatric Primary Care
University of Illinois Hospital

MedicalResearch.com: What is the background for this study? Would you briefly explain what is meant by Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis?

Response: Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal skin conditions, most commonly caused by medications and infections. Early symptoms include fever, blistering and peeling of the skin and mucus membranes and can affect any organ system including the eyes, lungs, kidneys and intestines. While rare, the conditions often result in life-long effects. The rarity and severity of these diseases have made it a challenge for researchers and clinicians to study, especially in a pediatric population. As a result, much of the information used to drive our care for children is derived from adult studies.

MedicalResearch.com: What are the main findings? 

Response: Using the Pediatric Health Information System, a large pediatric database containing information from 45 U.S. children’s hospitals, we studied the treatment and outcomes of SJS and TEN in children. This is one of the first large-scale to benchmark clinical outcomes the conditions in children. We characterized outcomes such as cost of hospital care, length of hospital stay, mortality, recurrence, hospital readmission as well as short-term complications like kidney failure, respiratory failure and sepsis.

Overall, we found that these outcomes in children were better than in adults. We also found that children with SJS and TEN received different kinds of treatment and that treatment strategies varied by region of the country. Expensive or combination treatments did not necessarily result in better outcomes.

MedicalResearch.com: What should readers take away from your report?

Response: Overall, these findings suggest we can be cautiously optimistic about SJS and TEN outcomes in children. Mortality and short-term morbidity in children with SJS and TEN is lower than in adults. Our results also suggest we can potentially reduce the cost of care for families by selecting lower-cost treatments to achieve the same outcomes. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: We identified a large variation in the treatment kids with SJS and TEN received, yet outcomes did not differ between treatments. This usually indicates an area for improvement in the quality of care doctors provide. Further research focusing on strategies that reduce complications, hospital stays and the cost of care would help provide physicians with better evidence on how to treat these conditions. 

MedicalResearch.com: Is there anything else you would like to add?

Response: The study was performed in collaboration with Drs. Jennifer Goldman and Brian Lee of Children’s Mercy Hospital and Clinic in Kansas City, Missouri, and Dr. Samir Shah of Cincinnati Children’s Hospital Medical Center. Dr. Goldman’s work was supported in part by a grant (KL2TR000119) from the National Center for Advancing Translational Sciences, part of the National Institutes of Health.

Citation:

J Allergy Clin Immunol Pract. 2018 May 30. pii: S2213-2198(18)30346-5. doi: 10.1016/j.jaip.2018.05.024. [Epub ahead of print]
A Retrospective Cohort Study of the Management and Outcomes of Children Hospitalized with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis.
Antoon JW1, Goldman JL2, Shah SS3, Lee B4. 

Jul 16, 2018 @ 8:24 pm

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Study Finds No Link Between Dairy Fats and Heart Disease or Mortality

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MedicalResearch.com Interview with:
“Milk” by Mike Mozart is licensed under CC BY 2.0Marcia C. de Oliveira Otto, PhD, FAHA
Assistant Professor
Division of Epidemiology, Human Genetics and Environmental Sciences
University of Texas
Houston, TX 77030-3900 |

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our research adds to a growing body of evidence showing no harm in relation to heart disease or overall mortality associated with consumption of whole-fat dairy foods.

The findings also indicate that one of three fatty acids present in dairy fat was linked to lower risk of stroke among older adults. To the best of our knowledge, ours was the first large study to use repeated measures of fatty acids over time and evaluate association with mortality in older adults, which allowed us to expand and contribute to this important debate regarding fat intake and health.

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Not All Tomatoes Are Equally Allergenic

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MedicalResearch.com Interview with:
“TOMATOES” by RubyGoes is licensed under CC BY 2.0Prof. Dr. rer. nat. Wilfried Schwab
Technical University of Munich
Center of Life and Food Science Weihenstephan
Biotechnology of Natural Products
Freising, Germany

MedicalResearch.com: What is the background for this study?

Response: The prevalence of food allergy is an increasing health problem. Although tomatoes are one of the most consumed vegetables worldwide and have health beneficial effects lowering the risk of cancer and cardiovascular diseases, patients suffering from birch pollen allergy can develop cross-reactivity after consumption of fresh tomatoes.

The aim of this study was to develop an analytical method for the quantification of the birch-pollen homologous allergen Sola l 4 in various tomatoes cultivars. Furthermore, the effect of conventional or organic cultivation as well as processing techniques on Sola l 4 content was investigated. Continue reading →

Acupuncture For Pain in Breast Cancer Patients on Aromatase Inhibitors

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MedicalResearch.com Interview with:

Dawn Hershman, MD, MS, FASCO Professor of Medicine and Epidemiology Leader, Breast Cancer Program Herbert Irving Comprehensive Cancer Center Columbia University Medical Center

Dr. Hershman

Dawn Hershman, MD, MS, FASCO
Professor of Medicine and Epidemiology
Leader, Breast Cancer Program
Herbert Irving Comprehensive Cancer Center
Columbia University Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Aromatase inhibitors are effective in reducing the risk of recurrence in hormone sensitive breast cancer, however they commonly cause joint pain and stiffness that can lead to early discontinuation of treatment. We know that women who stop early do not get the same benefits as those who continue for the full duration.

Acupuncture has been shown to improve a variety of pain syndromes. We conducted a large multicenter trial among women with joint pain on aromatase inhibitors and randomized patients to true acupuncture, sham acupuncture and a waitlist control arm.

We found that acupuncture resulted in more pain reduction than the other 2 control groups. Measuring pain can be challenging in clinical trials. We now know that a meaningful reduction for a patient is 2 points on a 10 point scale. We found that nearly 60 percent of women in the true acupuncture group experienced at least a 2-point reduction in pain, versus 33 percent of the sham acupuncture group and 31 percent of the controls. These results where highly statistically significant.  Continue reading →

Young Pregnant Women More Likely To Be Depressed Than Their Mothers

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MedicalResearch.com Interview with:

Rebecca Pearson, PhD Lecturer in Psychiatric Epidemiology Centre for Academic Mental Health School of Social & Community Medicine University of Bristol

Dr. Pearson

Rebecca Pearson, PhD
Lecturer in Psychiatric Epidemiology
Centre for Academic Mental Health
School of Social & Community Medicine
University of Bristol

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: We know depression and anxiety are common in young women and during pregnancy when there are also implications for the developing child.

It is therefore important to investigate whether symptoms are rising given the pressures of modern life.

We found that compared to their mothers generation in the 1990s young pregnancy women today are more likely to be depressed. This was driven largely by symptoms of anxiety and feeling overwhelmed rather than feeling down.  Continue reading →

Digestive Organs Have Separate Biologic Clocks From Brain’s Master Clock

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MedicalResearch.com Interview with:

Dr. Hans Van Dongen, PhD Director of the Sleep and Performance Research Center. ELSON S. FLOYD COLLEGE OF MEDICIN Washington State University Spokane, WA

Dr. VAN DONGEN

Dr. Hans Van Dongen, PhD
Director of the Sleep and Performance Research Center.
ELSON S. FLOYD COLLEGE OF MEDICIN
Washington State University
Spokane, WA

MedicalResearch.com: What is the background for this study?

Response: Night shift workers are at increased risk of metabolic disorders, including obesity and type 2 diabetes, as well as cardiovascular disease, chronic kidney disease, and cancer. Although it is believed that the biological clock – the master circadian clock in the brain – plays an important role in these adverse chronic health consequences of night shift work, the underlying mechanisms are not well understood. Continue reading →

Machine Learning Can Help Identify First Episodes of Schizophrenia, As Well As Treatment Response

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MedicalResearch.com Interview with:

Bo Cao, Ph.D. Assistant Professor Department of Psychiatry Faculty of Medicine & Dentistry University of Alberta Edmonton

Dr. Bo Cao

Bo Cao, Ph.D.
Assistant Professor
Department of Psychiatry
Faculty of Medicine & Dentistry
University of Alberta
Edmonton

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Schizophrenia is a severe psychiatric disorder that comes with delusions, hallucinations, poor motivation, cognitive impairments.

The economic burden of schizophrenia was estimated at $155.7 billion in 2013 alone in the United States. Schizophrenia usually emerges early in life and can potentially become a lifetime burden for some patients. Repeated untreated psychotic episodes may be associated with irreversible alterations of the brain. Thus, it is crucial to identify schizophrenia early and provide effective treatment. However, identifying biomarkers in schizophrenia during the first episode without the confounding effects of treatment has been challenging. Limited progress has been made in leveraging these biomarkers to establish diagnosis and make individualized predictions of future treatment responses to antipsychotics.

In a recent study by Dr. Cao and his colleagues, they successfully identified the first-episode drug-naïve schizophrenia patients (accuracy 78.6%) and predict their responses to antipsychotic treatment (accuracy 82.5%) at an individual level by using a machine learning algorithm and the functional connections of a brain region called the superior temporal cortex.  Continue reading →

How Quickly and Accurately Can Ischemic Stroke Be Diagnosed and Treated with tPA?

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MedicalResearch.com Interview with:

Perttu J. Lindsberg, MD, PhD Professor of Neurology Clinical Neurosciences and Molecular Neurology Research Programs Unit, Biomedicum Helsinki University of Helsinki Helsinki, Finland

Dr. Lindsberg

Perttu J. Lindsberg, MD, PhD
Professor of Neurology
Clinical Neurosciences and Molecular Neurology
Research Programs Unit, Biomedicum Helsinki
University of Helsinki Helsinki, Finland

MedicalResearch.com: What is the background for this study?

Response: The past 20 years in shaping the Helsinki model in stroke thrombolysis have proven that we can be very fast in examining the patient, completing the imaging and starting thrombolytic therapy. This is a university hospital center that receives roughly three stroke suspects per day for evaluation of recanalization therapies. Already seven years ago we were able to push the median ’door-to-needle’ time permanently below 20 minutes. What we had not been monitoring was how well we had kept up the accuracy of our emergengy department (ED) diagnostic process. Prehospital emergency medical services (EMS) have been trained to focus on suspecting thrombolysis-eligible stroke and we usually get also pre-notifications of arriving stroke code patients during transportation, but the diagnosis on admission is an independent clinical judgment as the CT findings are largely nondiagnostic for acute changes.

The admission evaluation of suspected acute stroke is therefore a decisive neurologic checkpoint, building the success of acute treatments such as recanalization therapy, but is complicated by differential diagnosis between true manifestations of stroke and numerous mimicking conditions. Although we have invested a lot on training and standardized ED procedures, time pressure and therapy-geared expectations may blur the diagnostic process.

With this background, we embarked on an in-depth-analysis of the admission and final diagnoses of stroke code patients, as well as misdiagnoses, immediate treatment decisions and their consequences.

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To Avoid Leprosy, Stay Away from Armadillos!

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MedicalResearch.com Interview with:

Nine-banded armadillo image credit: Dr. Richard Truman, USPHS, Public Domain (2014)John S. Spencer, Ph.D.
Colorado State University
Fort Collins, Colorado

MedicalResearch.com: What is the background for this study? Where can armadillos be found? What are the main findings? 

Response: The ancient disease leprosy, a disease causing skin lesions, nerve damage, disfigurement and disability, is caused by the bacterium Mycobacterium leprae, and is mainly spread by aerosol infection (coughing and sneezing) from human to human. It is rare in the United States (less than 200 cases on average per year), while it is endemic in Brazil, where over 25,000 new cases were diagnosed last year. In addition, zoonotic transmission of leprosy by nine-banded armadillos (Dasypus novemcintus, pictured at left) has been shown to occur in the southern United States, mainly in Texas, Louisiana and Florida.

Nine-banded armadillos originated from South America, and expanded their range from Mexico into Texas in the 1800’s, eventually spreading north and east throughout the gulf states. People in Brazil, particularly in rural areas, hunt and kill armadillos as a dietary source of protein. In the small town of Belterra in western Pará state in the Brazilian Amazon region, a survey of 146 residents showed that around 65% of people had some contact with armadillos, through hunting, preparing the meat for cooking, or by eating them. A group of individuals who ate armadillos most frequently (more than once per month and up to twice a week) had a significantly higher antibody titer towards the M. leprae-specific antigen PGL-I and an almost two-fold higher risk of being diagnosed with disease, a significant risk.   Continue reading →

It Take More Than Obesity To Shorten Lifespan

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MedicalResearch.com Interview with:

Jennifer L. Kuk, PhD Associate Professor York University School of Kinesiology and Health Science Toronto, Ontario 

Dr. Kuk

Jennifer L. Kuk, PhD
Associate Professor
York University
School of Kinesiology and Health Science
Toronto, Ontario

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Most of the literature on metabolic health obesity has shown that individuals with ‘metabolically healthy obesity’ are still at increased mortality risk.

However, most of these studies have defined healthy as zero or one metabolic risk factor.  This is problematic as hypertension, diabetes or dyslipidemia alone increase your mortality risk and should preclude you from the ‘healthy’ group.

We show that individuals with obesity and no other metabolic risk factors are no more likely to die than normal weight individuals with no metabolic risk factors. 

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Self-Driving Cars Can’t Eliminate All Accidents So How Safe is Safe Enough?

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MedicalResearch.com Interview with:
“Subaru cars waiting for ride” by JackeOb is licensed under CC BY-NC-ND 3.0Dr. Peng Liu, Assistant Professor
Department of Industrial Engineering
College of Management and Economics
Tianjin University, China

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Self-driving vehicles promise to considerably reduce traffic crashes. However, they cannot eliminate all crashes.

On March 18, 2018, a female pedestrian was killed after being struck by an autonomous Uber vehicle in the self-driving mode in Arizona, USA. This fatal crash triggered a widespread public debate over the safety of self-driving vehicles. So, how safe is safe enough for self-driving vehicles?

Our findings show that our participants implicitly think self-driving vehicles should be four to five times as safe as the current human-driven vehicles. 

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Multimodal Imaging Can Personalize and Predict Therapeutic Needs

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MedicalResearch.com Interview with:

Yasser Iturria-Medina, PhD Primary Investigator, Ludmer Centre for Neuroinformatics & Mental Health Assistant Professor, Department of Neurology and Neurosurgery Faculty of Medicine McGill University

Dr. turria-Medina

Yasser Iturria-Medina, PhD
Primary Investigator, Ludmer Centre for Neuroinformatics & Mental Health
Assistant Professor, Department of Neurology and Neurosurgery
Faculty of Medicine
McGill University

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There are millions of patients following therapeutic interventions that will not benefit them. In this study, we aimed to illustrate that it is possible to identify the most beneficial intervention for each patient, in correspondence with the principles of the personalized medicine (PM). Our results show that using multimodal imaging and computational models it is possible to predict individualized therapeutic needs. The predictions are in correspondence with the individual molecular properties, which validate our findings and the used computational techniques.

The results highly also the imprecision of the traditional clinical evaluations and categories for understanding the individual therapeutic needs, evidencing the positive impact that would have to use multimodal data and data-driven techniques in the clinic, in addition to the medical doctor’s criterion/evaluations.   Continue reading →

Disadvantaged Communities More Likely to Have Increase in Greenhouse Gases Under Cap-and-Trade Policies

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MedicalResearch.com Interview with:

Lara Cushing PhD Assistant Professor of Health Education, College of Health and Social Sciences San Francisco State University 1600 Holloway Avenue San Francisco, CA 94132

Dr. Cushing

Lara Cushing PhD
Assistant Professor of Health Education, College of Health and Social Sciences
San Francisco State University
San Francisco, CA 94132

MedicalResearch.com: What is the background for this study?

Response: More and more countries are adopting cap-and-trade programs as a way to reduce emissions of greenhouse gases to address climate change. These efforts can lead to short-term health benefits because when you reduce greenhouse gas emissions, you usually also reduce emissions other harmful air pollutants that can cause cardiovascular disease, asthma and cancer.

However, environmental equity concerns were raised early on about whether cap-and-trade would result in localized differences in emissions reductions that would also result in uneven reductions in harmful co-pollutants, such as particulate matter and air toxics. This is because companies can trade pollution permits under a cap-and-trade system and choose to buy more permits rather than reduce their emissions locally. Prior studies show that low income communities and communities of color are much more likely to live near polluting industries.

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How Fit You Are May Depend On The Bacteria in Your Gut

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MedicalResearch.com Interview with:

James R. Bagley, PhD Assistant Professor of Kinesiology Director, Muscle Physiology Lab Co-Director, Exercise Physiology Lab Research Director, Strength & Conditioning Lab San Francisco State University

Dr. Bagley

James R. Bagley, PhD
Assistant Professor of Kinesiology
Director, Muscle Physiology Lab
Co-Director, Exercise Physiology Lab
Research Director, Strength & Conditioning Lab
San Francisco State University

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The human body contains many billions of bacteria cells, and the type of bacteria in your gastrointestinal tract (termed gut microbiota) has been linked to certain diseases.

Most of your gut microbiota falls into two categories: Firmicutes (F) or Bacteroidetes (B). The relative gut F/B ratio has been used to assess microbiota health. Our study was the first to examine potential relationships among F/B ratio and cardiorespiratory fitness, body composition, and diet in healthy young men and women

We recruited 37 healthy adults to undergo a battery of physiological tests and collected stool samples to analyze their gut F/B ratio using qPCR.

We found that F/B ratio was significantly correlated with cardiorespiratory fitness, but with no other variables. In fact, this correlation was so strong that a person’s fitness level explained ~22% of the variance in their gut bacteria composition. Continue reading →

Nearly a Million People Live with Parkinson’s Disease and Number Expected to Grow

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MedicalResearch.com Interview with:

Dr-James Beck

Dr. Beck

James Beck, Ph.D., Chief Scientific Officer
Adjunct Associate Professor
Department of Neuroscience and Physiology
New York University Langone School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The most frequently cited study for prevalence in the US was based on a door-to-door survey conducted in 1978 in a rural county in Mississippi.  Only 26 cases of Parkinson’s disease (PD) were identified.  That has been extrapolated to our current US population of 330,000,000 people.  To give a sense of how long ago that was, Microsoft was considered a startup company.  Therefore, to provide an improved estimate of who has Parkinson’s disease, the Parkinson’s Foundation lead the Parkinson’s Prevalence study to do just that, using datasets that were from more geographically and ethnically diverse communities that can better reflect the US population as a whole.

The main finding is that we know now that there are nearly 1,000,000 people living with PD – and that number is expected to increase dramatically as our population ages. (The biggest risk factor for Parkinson’s disease is age.)

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Bisexual Adults Have Highest Prevalence of Sleep Problems in NYC Survey

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MedicalResearch.com Interview with:

Dustin T. Duncan, ScD Associate Professor Director, NYU Spatial Epidemiology Lab Department of Population Health NYU School of Medicine NYU Langone Health

Dr. Duncan

Dustin T. Duncan, ScD
Associate Professor
Director, NYU Spatial Epidemiology Lab
Department of Population Health
NYU School of Medicine
NYU Langone Health

MedicalResearch.com: What is the background for this study?

Response: Sleep and sleep hygiene have emerged as one of the major determinants of health and wellbeing (alongside good diet, regular exercise, and not smoking). However, a small number of studies have used population-representative samples to examine sexual orientation disparities in sleep. Our study aimed to fill this gap in knowledge.
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Powerful Men More Inclined to Sexually Harass When They Fear Being Perceived As Incompetent

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MedicalResearch.com Interview with:

Leah Halper, PhD Associate Director Office of Student Life Center for the Study of Student Life Columbus, OH 43210

Dr. Halper

Leah Halper, PhD
Associate Director
Office of Student Life Center for the Study of Student Life
Columbus, OH 43210

MedicalResearch.com: What is the background for this study? What are the main findings?

 Response: We started to run these studies in 2014 given mutual research interests that we shared. We knew that there was much research on sexual harassment that focused on the victim, the victim’s experience and the reporting process for sexual harassment. This work is extremely valuable. We noticed, however, that there was less research on the perpetrator and if there were personality variables related to the likelihood of sexual harassment. In our studies, we demonstrate that a personality variable (Fear of Negative Evaluation, or anxiety that others will see one as incompetent) is related to sexual harassment among men in powerful positions. Our results held up after taking into account other personality variables, such as narcissism and self-esteem. Also, we found that men who felt insecure in their power (i.e., those that were anxious that others would see them as incompetent) were more likely to engage in both quid pro quo harassment – asking for sexual favors in return for something else – and gender harassment – creating a hostile environment for women.

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Is Water Immersion During Labor Safe?

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MedicalResearch.com Interview with:

Dr Elizabeth R Cluett  PhD MSc RM RGN PGCEA PFHEA Senior Lecturer, Faculty of Health Sciences University of Southampton Southampton UK

Dr. Cluett

Dr Elizabeth R Cluett  PhD MSc RM RGN PGCEA PFHEA
Senior Lecturer, Faculty of Health Sciences
University of Southampton
Southampton UK

MedicalResearch.com:What is the background for this study?

Response: Water immersion during labor and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery-led care settings.

Immersion in water during labor and birth facilitates physiological labor and birth, offers women a non-pharmacological pain relief option and facilitates a sense of choice, control and comfort; qualities strongly associated with women’s satisfaction with their birth experience.

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Asthma Linked to Increased Risk of Atrial Fibrillation

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MedicalResearch.com Interview with:

Aivaras Cepelis, MSci Department of Public Health and Nursing, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology Trondheim, Norway

Aivaras Cepelis

Aivaras Cepelis, MSci
Department of Public Health and Nursing, Faculty of Medicine and Health Science
NTNU, Norwegian University of Science and Technology
Trondheim, Norway

MedicalResearch.com: What is the background for this study?

Response: Atrial fibrillation is the most common sustained, irregular and often rapid heart rate with a lifetime risk of 26%. The number of adults with atrial fibrillation is projected to double by 2050. Atrial fibrillation is also linked to adverse cardiovascular outcomes such as doubled risk of stroke and cardiovascular mortality. Therefore, we believe that research into the novel risk factors of the disease is highly warranted.

One of the potential condition that could play a role in the growing prevalence of atrial fibrillation is asthma. Asthma is a chronic inflammatory airway disease, affecting as many as 30 million children and adults in Europe. High levels of systemic inflammation biomarkers have been reported in both uncontrolled asthmatics and patients with atrial fibrillation. Furthermore, beta-agonists, the most common prescribed asthma control medication, has been shown to influence heart rate and increase the risk of irregular heartbeat.

However, research looking at asthma and atrial fibrillation link are lacking and no previous studies have assessed the dose-response relationship between levels of asthma control and atrial fibrillation. We utilized over 54 000 adults from a large well-defined Norwegian population cohort The Nord-Trøndelag Health Study (HUNT) to explore this association.

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How Doctors Communicate Empathy Critical to Family-Physician Partnership

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MedicalResearch.com Interview with:

Dr. Tessie W. October. MD, MPH Critical Care Specialist Children’s National Health System

Dr. October

Dr. Tessie W. October. MD, MPH
Critical Care Specialist
Children’s National Health System 

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: This is a qualitative study that examines the impact of empathetic statements made by doctors on the ensuing conversation with families of critically ill children. We know families are more satisfied when doctors show empathy, but until this study, we did not know how these empathetic statements are received by families. In this study we found that doctors frequently respond to a family’s emotions by responding with empathy, but how the doctor presented that empathetic statement mattered. When doctors made an empathetic statement, then paused to allow time for a family’s response, the family was 18 times more likely to share additional information about their fears, hopes or values. Conversely, when doctors buried the empathetic statement within medical talk or if a second doctor interrupted, the empathetic statement frequently went unheard by the family.

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