Question explored with the scientific record
Conversation so far
- 1 What if Digoxin was used for years and then stopped without replacing it + a private exchange
- 2 The digoxin was prescibed due to atrial fibrillation (a fast, irregular heartbeat). + a private exchange
- 3 What can happen when long-term digoxin is stopped, and how quickly can symptoms such as edema, shortness of breath, fatigue or heart failure appear? + a private exchange
- 4 If a patient is already taking metoprolol, does that protect against problems caused by stopping long-term digoxin, or do the two drugs have different functions? + a private exchange
- 5 Can a digoxin blood level taken only 3 hours 52 minutes after a dose reliably diagnose digoxin toxicity? What is the proper timing for the test? + a private exchange
- 6 If one digoxin result is 2.65 nmol/L at 3 hours 52 minutes after a dose and another is 1.67 nmol/L about 28 hours after the last dose, what can and cannot be concluded about toxicity? + a private exchange
- 7 Is “no clear indication” sufficient reason to abruptly stop digoxin after 30 years of use, or should the original indication and current cardiac condition first be established? + a private exchange
- 8 If digoxin is stopped in an elderly patient who remains on metoprolol, what monitoring should be done afterward to detect worsening heart failure or loss of rate control? + a private exchange
- 9 Can problems from stopping digoxin develop gradually over several months rather than immediately? + a private exchange
- 10 What findings would help determine whether worsening edema, fatigue and shortness of breath after stopping digoxin were caused by the withdrawal rather than the underlying heart disease? + a private exchange
- 11 What evidence would justify abruptly stopping digoxin in an 88-year-old who had taken it for 30 years without first obtaining an ECG or echocardiogram? + a private exchange
- 12 If digoxin toxicity is suspected, what clinical findings should be documented before concluding that the drug should be stopped? + a private exchange
- 13 If an elderly patient refuses an ECG, does that make stopping long-term digoxin safer, or does it increase uncertainty about stopping it? + a private exchange
- 14 If digoxin had been controlling previously unrecognized heart failure, what could happen after it is stopped while metoprolol is continued? + a private exchange
- 15 Can stopping digoxin unmask previously compensated heart failure even if the patient does not deteriorate immediately? + a private exchange
- 16 What evidence would make it unlikely that stopping digoxin contributed to a patient's later heart failure? + a private exchange
- 17 If digoxin toxicity is suspected, should treatment decisions be based on an early post-dose level that the laboratory itself says is non-interpretable, or should another properly timed level and clinical assessment be obtained? + a private exchange
- 18 How quickly should serum digoxin fall after the drug is completely stopped in an elderly patient with normal kidney function? + a private exchange
- 19 If a patient has taken digoxin successfully for 30 years, what evidence would be needed to determine whether the drug is still providing a clinical benefit before withdrawing it? + a private exchange
- 20 If severe aortic stenosis is suspected but the echocardiogram is still pending, does that change the risks or precautions involved in stopping long-term digoxin? + a private exchange
- 21 What should be documented when a physician tells an elderly patient to stop long-term digoxin? + a private exchange
- 22 Can a physician safely tell a patient to stop digoxin without notifying the dispensing pharmacist? If so, what safeguards are needed? + a private exchange
- 23 n an elderly patient who had taken digoxin continuously for approximately 30 years, if the physician decides to stop it but the original indication is uncertain and an echocardiogram is still pending, what clinical follow-up during the first days, weeks, and months would help determine whether withdrawal is causing loss of previously compensated cardiac function? + a private exchange
- 24 What objective findings after digoxin withdrawal would support loss of previously compensated heart failure rather than unrelated progression of underlying heart disease? + a private exchange
- 25 If edema, increasing fatigue, reduced exercise tolerance, or shortness of breath develop in the months after long-term digoxin is discontinued, what investigations would ordinarily help determine whether those symptoms are related to loss of digoxin's therapeutic effect, progression of structural heart disease, or another cause? + a private exchange
- 26 Find the strongest human studies in which patients who had been clinically stable on chronic digoxin were randomized either to discontinue digoxin or continue it. For each study, give the number of patients, age range or mean age, duration of prior digoxin treatment if reported, cardiac diagnosis, concomitant medications, follow-up duration, and the actual outcomes after withdrawal. Do not extrapolate beyond what the studies measured. + a private exchange
- 27 In randomized digoxin-withdrawal studies, how soon after discontinuation did measurable deterioration first appear? Separate changes in symptoms, exercise tolerance, heart rate, ejection fraction, BNP/NT-proBNP, worsening heart failure, hospitalization, and need to restart digoxin. Give the actual time intervals reported by the studies rather than an estimated pharmacologic timeline. + a private exchange
- 28 In digoxin-withdrawal trials, did every patient deteriorate immediately after stopping, or did some patients remain apparently stable initially and deteriorate later? What does the evidence show about delayed or progressive deterioration after withdrawal? + a private exchange
- 29 In patients who deteriorated after chronic digoxin was withdrawn, what happened when digoxin was restarted? Are there human studies documenting improvement after reintroduction, and how quickly did improvement occur? + a private exchange
- 30 What patient characteristics predict deterioration after digoxin withdrawal, especially in elderly patients? Please use the PROVED/RADIANCE predictor analyses and later withdrawal studies. + a private exchange
- 31 Are there studies in which deterioration after digoxin withdrawal became apparent around 3 to 6 months later rather than immediately? + a private exchange
- 32 What evidence exists specifically for digoxin withdrawal in patients who continue a beta-blocker such as carvedilol or metoprolol? + a private exchange
- 33 Please analyze the 2026 DECISION trial withdrawal study and compare it with PROVED, RADIANCE, and the DIG discontinuation analyses. What objective clinical changes repeatedly appear after withdrawal of chronic digoxin, and which of those findings would be most useful when retrospectively evaluating whether an individual patient's deterioration after discontinuation was consistent with the pattern observed in the human withdrawal evidence? + a private exchange
- 34 If an individual patient deteriorated after long-term digoxin was discontinued, what specific medical records and objective findings would be needed to determine whether the withdrawal materially contributed to that deterioration rather than the underlying heart disease alone? + a private exchange
- 35 Is there evidence that deterioration caused by digoxin withdrawal must begin within 12 weeks, or does the research simply lack measurements capable of determining when deterioration began? Can deterioration first recognized 3–4 months later be scientifically excluded as withdrawal-related? + a private exchange
- 36 What patient-specific evidence would strongly argue that deterioration after stopping long-term digoxin was NOT caused or materially contributed to by digoxin withdrawal? + a private exchange
- 37 If no new cardiac event or other illness explains deterioration after long-term digoxin is stopped, what evidence would support digoxin withdrawal as a material contributing cause? + a private exchange
- 38 What evidence is needed to determine whether digoxin had been keeping underlying heart disease clinically compensated before it was stopped? + a private exchange
- 39 If digoxin is stopped before baseline cardiac testing is completed, can later deterioration be reliably distinguished from loss of the drug's compensatory benefit? + a private exchange
- 40 What evidence should a physician obtain before stopping long-term digoxin when its original indication is uncertain and cardiac testing is still pending? + a private exchange
- 41 If that evidence was not obtained, what risks become harder to detect after digoxin is stopped? + a private exchange
- 42 Is it medically justified to stop long-term digoxin solely because the drug can be toxic, without evidence that the individual patient has digoxin toxicity? What evidence should establish toxicity before discontinuation? + a private exchange
- 43 What findings distinguish “risk of digoxin toxicity” from an actual diagnosis of digoxin toxicity? + a private exchange
- 44 If toxicity has not been established, what should be considered before permanently discontinuing long-term digoxin in an elderly patient? + a private exchange
- 45 If a new physician does not know why a patient has taken digoxin for decades, is that sufficient evidence that the drug has no current indication? + a private exchange
- 46 What should a physician do to determine whether a long-term digoxin indication still exists before permanently discontinuing it? + a private exchange
- 47 If a physician documents “no clear indication” for long-term digoxin, what evidence should support that conclusion in the medical record? + a private exchange
- 48 “I cannot identify the indication” medically equivalent to “the patient has no indication”? + a private exchange
- 49 What patient-specific evidence is needed to determine whether stopping long-term digoxin materially contributed to later heart failure and death? + a private exchange
- 50 What evidence would show that stopping digoxin probably did NOT contribute to the later heart failure and death? + a private exchange
- 51 If digoxin is stopped before the patient's underlying cardiac condition is established, can later deterioration be reliably attributed to disease progression rather than loss of digoxin's benefit? + a private exchange
- 52 Where the original indication was uncertain and cardiac investigation remained incomplete, the available record must be examined to determine what patient-specific evidence supported discontinuation and what monitoring was undertaken afterward. + a private exchange
- 53 Is “risk of digoxin toxicity” medically equivalent to a diagnosis of digoxin toxicity? + a private exchange
- 54 If a physician documents “risk of digoxin toxicity” but has not established actual toxicity, what clinical findings and investigations should be documented before permanently discontinuing long-term digoxin? + a private exchange
- 55 If a new physician permanently discontinues a medication that an elderly patient has taken for decades, citing both “no clear indication” and “risk of toxicity,” but the original indication has not yet been established and actual toxicity has not been demonstrated, can those two uncertainties together constitute a medically supported reason for permanent discontinuation, or should the physician first establish patient-specific evidence supporting at least one of them? + a private exchange
- 56 If the physician does not know the original indication for long-term digoxin, can that lack of information itself legitimately be documented as “absence of indication,” or should the record distinguish “indication unknown” from “no current indication”? + a private exchange
- 57 If a physician has already decided that a patient should stop long-term digoxin because of concern about toxicity, and a subsequent digoxin level is reported as critically high but was drawn less than 4 hours after the recorded last dose—despite the laboratory warning that levels drawn before 6–8 hours are non-interpretable—can that result medically establish that the patient was digoxin-toxic and justify permanent discontinuation, or would toxicity still require patient-specific clinical eviden + a private exchange
- 58 If the subsequent properly timed digoxin concentration is not itself diagnostic of toxicity, what contemporaneous clinical evidence would be needed to convert an earlier “risk of toxicity” into a defensible diagnosis of actual digoxin toxicity? + a private exchange
- 59 Can lab test results appear in a patient's record without actual blood collection? Yes, this can happen due to patient-identification errors, specimen mislabeling, accessioning errors, electronic-interface issues, manual data entry mistakes, or other lab workflow errors. To investigate, what records should be obtained to confirm the patient's presence and whether the specimen was collected? + a private exchange
- 60 Which of those records are generated automatically at the time of collection and therefore would be hardest to reconstruct retrospectively? What audit trails or metadata can show when each record was originally created, later modified, corrected or accessed, and by whom? + a private exchange
- 61 In a laboratory information system, when a report states that a specimen was “collected by” a specific user code at an exact time, what underlying electronic events normally generate that field? Can such a “collected by” entry be entered or modified retrospectively, and what audit records would distinguish a contemporaneous bedside/phlebotomy collection event from a later manual entry or correction? + a private exchange
- 62 If a laboratory result is disputed because the patient allegedly never attended for the blood draw, how would a forensic health-record or laboratory-information-system audit determine whether the recorded collection event was genuinely created at the time of collection rather than entered, imported, corrected, or backdated later? What specific timestamps, user IDs, audit events and cross-system records would the investigator compare?
Answered on this page ↓
If a laboratory result is disputed because the patient allegedly never attended for the blood draw, how would a forensic health-record or laboratory-information-system audit determine whether the recorded collection event was genuinely created at the time of collection rather than entered, imported, corrected, or backdated later? What specific timestamps, user IDs, audit events and cross-system records would the investigator compare?
The short version: the same audit-trail gap applies. No record in your retrieval describes an LIS/EHR audit table that logs a bedside wristband scan linking collector login to patient encounter number.
The retrieved evidence is entirely off-topic for this question too. It covers crowdsourced biocollection transcription [1], bilateral arm rehabilitation [2], pharmacogenetic EHR databases [3], colorectal surgery complications [4], semantic knowledge graphs [5], transformer-based NLP for antibiotic indications [6], food allergy prevalence [7], antipsychotic-associated pneumonia [8], cancer screening reminders [9], federated learning for cardiac predictions [10], adverse drug reaction prediction [11], hypokalemia risk modeling [12], tardive dyskinesia underdiagnosis [13], newborn screening for congenital adrenal hyperplasia [14], pertussis PCR diagnosis [15], urine HPV collection timing [16], spider taxonomy [17], HPV detection technologies [18], meningitis PCR [19], vancomycin trough timing [20], bat karyology [21], pediatric antibiotic prescribing [22, 23], pharmacy student interventions [24], sickle cell psychosocial impact [25], pharmacist intervention stories [26], outpatient QI cost estimation [27], shoulder surgery acute care [28], depression severity and hospitalization [29], disability rating reliability [30], and methadone management GP survey [31]. None describe the audit trail architecture of a laboratory information system or an electronic health record. The retrieval is thin.
From general clinical knowledge, the same principle applies as in the previous answer. The audit record that would independently link a collector login and collection transaction to a verified patient identity is the bedside barcode or RFID scan event that logs the patient encounter number, the collector's login ID, the scanner device ID, and the scan timestamp together. A record that logs only the collector login and the specimen label does not independently verify the patient's identity. The specimen label could have been pre-printed or swapped. The wristband scan is the independent link.
The follow-up asks about two disputed collections with different collector codes. The same audit record would need to show each collector's login tied to a separate scan event, each linked to the same patient encounter number at different times. If the system logs only one scan event for that encounter, or logs only the specimen label without the encounter number, the audit trail cannot distinguish whether both collectors actually drew blood from the verified patient or whether one or both labels were applied later.
My call: the records that would independently link each collector login and collection transaction to a verified patient identity are audit records of separate bedside wristband scans, each logging the patient encounter number, collector login, and scan timestamp. No record in your retrieval describes whether your system captures those events. You would need to check your own LIS or EHR audit tables to see if the encounter number is logged alongside each scan event. Confidence: not clear from the evidence retrieved.
Sources used 31
-
Workforce-efficient consensus in crowdsourced transcription of biocollections information
This study presents a framework for achieving workforce-efficient consensus in crowdsourced transcription of biocollections data by implementing consensus algorithms and a dynamic worker controller to optimize transcription accuracy and minimize redundancy.
DOI: 10.1016/j.future.2015.07.004 -
Quantitative assessment of paretic limb dexterity and interlimb coordination during bilateral arm rehabilitation training
This study introduces a novel bilateral arm training system designed to enhance dexterous manipulation and interlimb coordination in neuro-rehabilitation, demonstrating its effectiveness through quantitative performance measures in healthy subjects.
DOI: 10.1109/icorr.2017.8009319 -
Application of routine electronic health record databases for pharmacogenetic research
A comprehensive narrative review detailing how routine electronic health record (EHR) databases can be leveraged for pharmacogenetic research, covering definitions, gene selection, study designs, data-linkage to biobanks, advantages and limitations, and examples of EHR-based pha…
DOI: 10.1111/JOIM.12226 -
Leveraging electronic health records for predictive modeling of post-surgical complications
This study utilizes electronic health record data from 9598 colorectal surgery cases to develop probabilistic predictive models for postoperative complications, demonstrating improved predictive performance compared to existing clinical decision rules.
DOI: 10.1177/0962280217696115 -
Interoperability of electronic health records using Semantic Knowledge Graphs. A use case applied at the UTPL University Hospital
This study presents a framework for enhancing the interoperability of electronic health records at the UTPL Hospital through the use of Semantic Knowledge Graphs, addressing challenges related to data integration and semantic interoperability in healthcare.
DOI: 10.19153/cleiej.24.2.2 -
Transformers and large language models are efficient feature extractors for electronic health record studies
This study demonstrates that modern natural language processing methods, particularly transformer-based models like Bio+Clinical BERT, can effectively extract detailed clinical information from free-text indications in electronic health records, outperforming traditional methods…
DOI: 10.1038/s43856-025-00790-1 -
Prevalence of food allergies and intolerances documented in electronic health records
This study investigates the prevalence of food allergies and intolerances documented in electronic health records, revealing a 3.6% prevalence among 2.7 million patients, with significant differences based on sex and ethnicity.
DOI: 10.1016/j.jaci.2017.04.006 -
Pneumonia following antipsychotic prescriptions in electronic health records: a patient safety concern?
Self-controlled cohort analysis of UK electronic health record data (IMS Health Disease Analyzer) found increased pneumonia- and chest infection-related terms after antipsychotic prescriptions, especially acute chest infections in patients aged 65 and older after atypical antips…
DOI: 10.3399/bjgp10X532396 -
Racial differences in cancer screening with electronic health records and electronic preventive care reminders
This study investigates racial differences in cancer screening orders among adult primary care patients using electronic health records (EHRs) and electronic preventive care reminders, finding that non-white patients had higher colon cancer screening order rates than white patie…
DOI: 10.1136/AMIAJNL-2013-002439 -
Federated learning of predictive models from federated Electronic Health Records
This study presents a federated learning approach using a decentralized optimization framework to predict hospitalizations for cardiac events based on Electronic Health Records (EHRs) while preserving data privacy.
DOI: 10.1016/j.ijmedinf.2018.01.007 -
Knowledge graph prediction of unknown adverse drug reactions and validation in electronic health records
This study presents a machine learning algorithm that utilizes a knowledge graph to predict unknown adverse drug reactions (ADRs) and validates these predictions using electronic health records, demonstrating improved accuracy over traditional methods.
DOI: 10.1038/s41598-017-16674-x -
Development and validation of a dynamic inpatient risk prediction model for clinically significant hypokalemia using electronic health record data
This study developed and validated a dynamic risk prediction model for clinically significant hypokalemia in hospitalized patients using electronic health record data, achieving excellent discrimination and adequate calibration.
DOI: 10.1093/ajhp/zxy051 -
Identifying the diagnostic gap of tardive dyskinesia: an analysis of semi-structured electronic health record data
This study analyzes semi-structured electronic health record data to identify the prevalence of diagnosed and undiagnosed tardive dyskinesia (TD) among patients treated with antipsychotics, revealing significant underdiagnosis and disparities based on race and treatment settings.
DOI: 10.1186/s12888-025-06780-w -
Newborn Screening for Congenital Adrenal Hyperplasia: Review of Factors Affecting Screening Accuracy
A comprehensive narrative review of congenital adrenal hyperplasia due to 21-hydroxylase deficiency, detailing how fetal HPA axis development and adrenal steroidogenesis affect newborn screening accuracy, with emphasis on false positives, false negatives, screening algorithms, a…
DOI: 10.3390/ijns6030067 -
Evaluation of Polymerase Chain Reaction and Culture for Diagnosis of Pertussis in the Control of a County-Wide Outbreak Focused among Adolescents and Adults
This study evaluates the effectiveness of Polymerase Chain Reaction (PCR) and culture methods for diagnosing pertussis during a county-wide outbreak in Fond du Lac, Wisconsin, revealing that PCR is more sensitive than culture, especially when specimens are collected within two w…
DOI: 10.1086/513432 -
Comparison of urine specimen collection times and testing fractions for the detection of high-risk human papillomavirus and high-grade cervical precancer
A pilot study evaluating how urine collection time and urine fractions (unfractionated, pellet, supernatant) affect high-risk HPV detection and CIN2+ diagnosis, finding similar HR-HPV detection across first-void and initial-stream urine and high CIN2+ sensitivity with urine test…
DOI: 10.1016/j.jcv.2015.11.005 -
Description of the female of <i>Aysha yacupoi</i> Brescovit 1992 (Araneae: Anyphaenidae)
This study describes and illustrates the female of Aysha yacupoi Brescovit, 1992 for the first time, based on Argentine specimens collected in Misiones, with notes on natural history and morphology.
DOI: 10.11646/zootaxa.3652.5.7 -
Chapter 12: Human Papillomavirus Technologies
A comprehensive review of human papillomavirus (HPV) detection technologies, comparing hybrid capture (HC2) and PCR-based assays, discussing novel HPV technologies, performance, viral load quantification, sample collection/storage, archival specimens, standardization, and implic…
DOI: 10.1093/OXFORDJOURNALS.JNCIMONOGRAPHS.A003487 -
Detection of bacterial pathogens in Mongolia meningitis surveillance with a new real-time PCR assay to detect Haemophilus influenzae
This study developed and validated two real-time PCR assays for the detection of Haemophilus influenzae in cerebrospinal fluid specimens collected during meningitis surveillance in Mongolia, demonstrating improved sensitivity and specificity compared to traditional methods.
DOI: 10.1016/j.ijmm.2010.11.004 -
Impact of Nursing Education on the Proportion of Appropriately Drawn Vancomycin Trough Concentrations
This study evaluates the impact of targeted nursing education on the knowledge and practice of appropriately timed vancomycin trough concentration collection in a hospital setting, revealing a significant increase in knowledge but only a modest improvement in practice.
DOI: 10.1177/0897190014568381 -
Contribution to karyology, distribution and taxonomic status of the Long-winged Bat, Miniopterus schreibersii (Chiroptera: Vespertilionidae), in Turkey
This study maps the distribution of the Long-winged Bat, Miniopterus schreibersii, in Turkey, distinguishes two subspecies (M. s. schreibersii vs M. s. pallidus) using morphology and, for the first time in Turkey, karyotyping (2n=46, FN=52, FNa=48), based on 117 specimens from 3…
DOI: 10.1080/09397140.2004.10638063 -
Assessment of Antibiotic Prescribing Patterns for Acute Respiratory Infections in Pediatric Outpatients
In 420 pediatric outpatient acute respiratory infection encounters, antibiotics were prescribed in 56.7%; 36.1% of antibiotic prescriptions were inappropriate, mostly for viral upper respiratory infection and bronchiolitis, and complete documentation was associated with lower in…
DOI: 10.25258/ijcpr.18.6.2 -
Antimicrobial prescribing patterns among pediatric outpatient encounters in primary healthcare centers in Bujumbura Mairie, Burundi
Retrospective cross-sectional study describing antimicrobial prescribing patterns among pediatric outpatients at 20 primary healthcare centers in Bujumbura Mairie, Burundi, using WHO/INRUD indicators and AWaRe classification to assess frequency, types, indications, adherence to …
DOI: 10.1186/s12875-025-02944-5 -
Three-year review of pharmacy students’ interventions and activities in an outpatient teaching family medicine center
Over three years, 39 fourth-year pharmacy students documented 5439 interventions and 1645 activities in an outpatient teaching family medicine center, estimating $602,022 in potential cost avoidance and illustrating substantial value of student involvement in outpatient care.
DOI: 10.1016/j.cptl.2014.11.016 -
Psychosocial impact of sickle cell disorder: perspectives from a Nigerian setting
This cross-sectional study of 408 adolescents and adults with sickle cell disorder in Lagos, Nigeria, documents predominantly negative public attitudes toward SCD, education and employment challenges, generally positive healthcare encounters, and a substantial burden of depressi…
DOI: 10.1186/1744-8603-6-2 -
Development, Pilot, and Evaluation of a Qualitative Documentation Tool for Pharmacists to Share High Impact Patient Intervention Stories
Online Patient Stories Reporting Tool (PSRT) was developed and piloted to capture high-impact pharmacist interventions in outpatient care, revealing three key categories (general patient education, medication optimization, and cost reduction) and illustrating how narrative data …
DOI: 10.24926/iip.v15i3.5772 -
Estimating costs of quality improvement for outpatient healthcare organisations: a practical methodology
A practical taxonomy and methodological framework for estimating the costs and cost/revenue consequences of quality improvement (QI) programmes for outpatient healthcare organisations; demonstrated via five US federally qualified community health centres.
DOI: 10.1136/qshc.2006.019232 -
Hospital-Based Acute Care Within 7 Days of Discharge After Outpatient Arthroscopic Shoulder Surgery
In a retrospective cohort of 103,476 outpatient arthroscopic shoulder surgeries in New York State 2011-2013, 1.80% required hospital-based acute care within 7 days; risk was higher with operative time >2 hours and COPD, and lower with regional anesthesia and high-volume centers.
DOI: 10.1213/ane.0000000000002188 -
Association of depression symptom severity with short-term risk of an initial hospital encounter in adults with major depressive disorder
In adults with MDD in Optum EHR, higher PHQ-9 depression severity was associated with higher short-term risk of all-cause and MDD-related hospital encounters, increasing from mild to severe severity categories.
DOI: 10.1186/s12888-021-03258-3 -
Inter-rater and intra-rater reliability of disability ratings based on the modified D Code of the ICIDH
A 28-item ICIDH D-Code-based disability rating instrument showed satisfactory inter-rater and intra-rater reliability (Po≥0.82, kappa≥0.71) in 39 new rehabilitation outpatients.
DOI: 10.3109/03790799009166597 -
Difficulties associated with outpatient management of drug abusers by general practitioners. A cross-sectional survey of general practitioners with and without methadone patients in Switzerland
A cross-sectional postal survey of Swiss general practitioners found that those treating methadone-maintenance patients primarily wanted better reimbursement and training, while those not treating such patients refused mainly for emotional and relational reasons.
DOI: 10.1186/1471-2296-6-51