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1.
《Contact lens & anterior eye》2023,46(2):101811
PurposeTo determine the effects of a thermo-mechanical action-based peri-orbital fractional skin treatment (Tixel®) on dry eye disease.MethodsThis prospective, controlled, open labelled study was conducted at two study centres: Midland Eye, Solihull, UK, and Vallmedic Vision, Andorra. Participants were screened at the baseline visit (visit-1), received three Tixel® treatments at 2-weeks intervals including further assessment (visits 2, 3 and 4). Participants were followed up for three months post-treatment (visit 5). Vision, intraocular pressure (IOP), dry eye symptomatology were assessed, including the Ocular Surface Disease Index (OSDI) questionnaire, non-invasive tear break-up time (NIBUT) and tear osmolarity as well as detailed ophthalmic assessments.ResultsSeventy-four participants (41 in Birmingham and 33 in Andorra) with periorbital wrinkles and moderate to severe dry eye disease (DED) were enrolled. The mean age was 59.3 ± 13.3 years and 57 were females. No adverse events, no change in vision (p = 0.310) or IOP (p = 0.419) were observed. Tixel treatment was associated with clinically and statistically significant improvement in the DED symptoms, which was supported by a reduction of 21.40 ± 15.08 (P < 0.001) of the OSDI index. Non-invasive tear break-up time improved by 2.10 ± 0.91 s (p < 0.001) in the Birmingham cohort and 6.60 ± 2.13 s (p < 0.001) in the Andorra cohort. Tear osmolarity reduced from 299.8 ± 13.3 mOsm/L to 298.8 ± 15.6 mOsm/L following the Tixel treatment (p = 0.271).ConclusionsThermo-mechanical action-based peri-orbital fractional skin treatment Tixel® could be an attractive, safe and effective treatment for DED. This treatment is associated with high clinical and statistically significant improvement in DED signs and symptoms with no adverse events. 相似文献
2.
《Contact lens & anterior eye》2022,45(5):101539
ObjectivesTo assess systemic, environmental and lifestyle risk factors for dry eye disease (DED) in a Mediterranean Caucasian population.MethodsA cross-sectional study was performed on 120 Caucasian participants aged between 18 and 89 years (47.0 ± 22.8 years). Medical history, information regarding environmental conditions and lifestyle, Ocular Surface Disease Index, Dry Eye Questionnaire-5, non-Invasive (Oculus Keratograph 5 M) breakup time, tear film osmolarity and ocular surface staining parameters were assessed in a single clinical session to allow DED diagnosis based on the guidelines of the Tear Film and Ocular Surface Society Dry Eye Workshop II Diagnostic Methodology Report. A multivariate logistic regression model was constructed including those variables with a p-value less than 0.15 in the univariate analysis.ResultsA prevalence of 57.7 % for DED was found. No age differences were found between those with and without DED (U = 1886.5, p = 0.243). Nevertheless, the DED group had more females (X2 = 7.033, p = 0.008). The univariate logistic regression identified as potential risk factors for DED the following: female sex, sleep hours per day, menopause, anxiety, systemic rheumatologic disease, use of anxiolytics, daily medication, ocular surgery, poor diet quality, more ultra-processed food in diet, not drinking caffeine and hours of exposure to air conditioning per day. Multivariate logistic regression revealed that hours of sleep per day, menopause and use of anxiolytics were independently associated with DED (p ≤ 0.026 for all).ConclusionsDED is associated with systemic, environmental and lifestyle risk factors. These findings are useful to identify potentially modifiable risk factors, in addition to conventional treatments for DED. 相似文献
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《Contact lens & anterior eye》2019,42(5):497-501
PurposeTo evaluate the discriminative ability of a rapid non-invasive dry eye assessment algorithm (global evaluation component: SANDE questionnaire, and non-invasive tear film breakup time; subtype classification testing component: tear film lipid layer grade, and tear meniscus height) in detecting dry eye disease, as defined by the TFOS DEWS II diagnostic criteria.MethodsTwo hundred and thirty-five participants (77 male, 158 female), with a mean ± SD age of 43 ± 17 years, were recruited into a prospective diagnostic accuracy study. OSDI, DEQ-5, and SANDE dry eye symptomology scores; non-invasive tear film breakup time; absolute and inter-ocular differences in tear osmolarity; corneal, conjunctival, and lid margin staining scores; tear film lipid layer, meibum expressibility, meibomian gland orifice plugging, and eyelid margin telangiectasia grades; and tear meniscus height were evaluated in a single clinical session.ResultsThe areas under the ROC curves exceeded 0.80 for all individual components of the rapid non-invasive dry eye assessment algorithm, and the discriminative abilities were significantly greater than chance (all p < 0.001). At the Youden optimal diagnostic thresholds for the global evaluation component of the rapid non-invasive assessment algorithm (SANDE score ≥30, non-invasive tear film break-up time <10 s), the overall sensitivity was 86%, specificity 94%, positive likelihood ratio 15.0, and negative likelihood ratio 0.15.ConclusionsThe abridged non-invasive dry eye assessment algorithm may be a useful rapid screening instrument for the full TFOS DEWS II diagnostic test battery, of particular benefit in resource or time-constrained settings. 相似文献
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《Contact lens & anterior eye》2019,42(6):640-645
PurposeTo compare the effects of virtual reality headset wear and conventional desktop computer display use on ocular surface and tear film parameters.MethodsTwenty computer operators were enrolled in a prospective, investigator-masked, randomised crossover study. On separate days, participants were randomised to 40 min of continuous virtual reality headset wear or conventional desktop computer display use. Outer eyelid and corneal temperatures, tear film lipid layer grade, and non-invasive tear film breakup time were measured at baseline and immediately following the 40-minute exposure period.ResultsVirtual reality headset wear resulted in increases in outer eyelid (mean difference +0.5 ± 0.6 °C; p < 0.001) and corneal temperatures (mean difference, +0.4 ± 0.6 °C; p = 0.004), relative to conventional desktop computer display use. These increases were associated with significant improvements in tear film lipid layer grade (median difference, +1 grade; interquartile range, 0 to +2 grades; p < 0.001) and non-invasive tear film breakup time (mean difference, +7.2 ± 12.4 s; p = 0.02).ConclusionsClinically significant improvements in lipid layer thickness and tear film stability were observed with virtual reality headset wear, despite producing only modest increases in ocular temperatures relative to conventional desktop computer display use. These findings would suggest that virtual reality headset wear demonstrates potential for dry eye relief for computer operators in the modern workplace environment. 相似文献
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《Contact lens & anterior eye》2023,46(3):101799
ObjectivesTo assess the effects of different condition-induced changes on current and novel ocular surface metrics.MethodsEighty-four healthy volunteers (22.4 ± 2.6 years) participated in this study. The ocular surface and tear film response to (1) computer use, (2) contact lens insertion and (3) tear film instillation during computer use with contact lenses were assessed. Current metrics included the ocular surface disease (OSDI) questionnaire, 5-item dry eye questionnaire (DEQ-5), bulbar redness, tear meniscus height (TMH) and non-invasive keratograph break-up time (NIKBUT). Novel metrics included the lipid layer thickness obtained from the intensity of the reflected Placido disk and the speed of tear film particles post-blink.ResultsHigher dry eye symptoms, TMH and bulbar redness, and lower values in metrics related to the intensity of the Placido disk pattern and to particle speed were found after the computer reading task (p < 0.036). When a contact lens was fitted, lower TMH, NIKBUT and particle speed metrics were obtained (p < 0.044). Mixed ANOVA revealed that artificial tears significantly ameliorated the effect of computer reading on OSDI, DEQ-5, NIKBUT, metrics related to the intensity of the Placido disk pattern and metrics related to particle speed (p < 0.033).ConclusionsComputer use and contact lens wear worsened dry eye signs and symptoms, but artificial tears ameliorated this effect. Newly developed methods can serve as a tool to detect changes in the tear film triggered by different ocular surface-disturbing conditions. 相似文献
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《Contact lens & anterior eye》2019,42(6):620-624
PurposeTo compare the single application and two week treatment effects of device-applied (Eyepeace) and manually-applied eyelid massage techniques, as an adjunct to warm compress therapy, on ocular surface and tear film parameters.MethodsTwenty participants (11 females, 9 males; mean age, 27 ± 11 years) with dry eye symptoms were recruited in a two week, investigator-masked, randomised, contralateral-eye trial. Following 10 min of warm compress therapy application (MGDRx EyeBag®) on both eyes, eyelid massage therapy was applied to one eye (randomised) by device, and to the fellow eye by manual eyelid massage, once daily for 14 days. Ocular surface and tear film measurements were conducted at baseline, and 15 min post-application by a clinician, then again after 14 days of self-administered daily treatment at home.ResultsBaseline clinical measurements did not differ between the treatment groups (all p > 0.05). Following two weeks of treatment, tear film lipid layer grade improved significantly with device massage (p = 0.008), and was marginally greater than manual massage by less than 1 grade (p = 0.03). Although immediate post-treatment improvements in tear film stability were observed in both groups (both p < 0.05), no significant long-term cumulative effects or inter-treatment differences in stability measures were detected (all p > 0.05). Visual acuity, tear meniscus height, conjunctival hyperaemia, ocular surface staining, and meibomian gland dropout did not change during the treatment period (all p > 0.05).ConclusionsTwo weeks of treatment with the eyelid massage device, as an adjunct to warm compress therapy, effected marginally greater improvements in tear film lipid layer thickness than the conventional manual technique, which were statistically but not clinically significant. Future parallel group trials with longer treatment periods and a greater range of disease severity are required. 相似文献
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《Contact lens & anterior eye》2021,44(1):24-29
PurposeTo investigate whether standard clinical measures of tear film stability, meniscus height and symptomology reflect changes in evaporation rate induced by ocular surface provocations.MethodsForty participants (23.8 ± 4.5 years, 53 % female) with healthy to mild dry eyes underwent two tear film provocations in random sequence on separate occasions: playing a tablet computer high concentration game (http://slither.io/) for 30 min; and receiving treatment with humidity goggles for 10 min followed by liposomal spray application. Measures at baseline and 30 min later were: Symptom Assessment iN Dry Eye (SANDE) questionnaire, tear film lipid layer thickness (LLT), non-invasive tear film break-up time (NIBUT), tear meniscus height (TMH), dynamic tear film lipid layer pattern (DLP) and tear film evaporation (TFE).ResultsThere were no differences in the baseline measurements before each provocation (p > 0.05). Dry eye symptoms significantly worsened with concentration task (p < 0.001) and improved with treatment (p < 0.001). DLP and LLT significantly increased with treatment (p < 0.05), but was unaffected with the concentration task (p > 0.05). NIBUT declined with the concentration task (p = 0.015), but was not enhanced with treatment (p = 0.142). TMH increased after treatment (p = 0.001) and decreased with the concentration task (p = 0.006). While evaporation decreased with the concentration task (p < 0.001), treatment had no effect (p = 0.333). LLT was associated with evaporation (p = 0.036) and additionally with symptom severity (p = 0.002) and tear volume (p = 0.017).ConclusionsSub-classifying dry eye based on an ‘evaporative’ component to inform treatment seems over-simplistic. However objective TMH, NIBUT and LLT seem to be the key clinical metrics that drive ocular comfort. 相似文献
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《Contact lens & anterior eye》2019,42(2):147-154
The symptom severity of patients with dry eye disease (DED) varies over a 24-hour period. It is typically worse upon waking than later in the morning and deteriorates towards the evening. Substantial differences in the characteristics and physical properties of the tear film, such as levels of inflammation, pH, osmolarity, volume and stability, also exist between night (sleeping) and day (waking), and over the course of the day itself. Data on diurnal variation in symptom severity and tear film characteristics have been reviewed to recommend a management strategy that supports the various needs of patients with DED over a full 24-hour period.Treatment strategies for DED must be matched to the variations in the severity of DED and to the environments that eyes are subjected to over a 24-hour period. While artificial tears are used to moisturise the ocular surface and reduce damage to the corneal epithelium during the day, gels are used at night-time; they are more viscous and have a longer ocular surface retention time than artificial tears. Several combinations of these products are currently available in tandem to support the 24-hour variation in tear film characteristics. The present review of published literature provides evidence that the approach of the daytime use of artificial tears to protect the eye from aggravating environmental factors in combination with the night-time use of gels to relieve more severe symptomatology. This, in turn, should provide optimal ‘around-the-clock’ DED management. 相似文献
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《Contact lens & anterior eye》2020,43(3):261-267
PurposeTo estimate the astigmatic power and axis of the tear film over the central optical zone of the cornea by vector analysis of topographic data, in ocular surface disease (OSD) and controls, during blink suppression.MethodsVideo-keratoscopic images were captured on opening the eyes after a single blink 5, 10 & 15 s later during blink suppression in OSD patients (mixed aetiology, group 1 age 20 50 years, n = 12, group 2 > 50 years, n = 38) and controls (group 3, n = 19). The SimK and axis values were used to calculate the astigmatism (power and axis) that formed in the precorneal tear film during each period. Data were aggregated into 3 periods; T0-T5 (between 0 & 5 s after the blink), T5-T10 (5 & 10 s later, T10-T15 (between 10 & 15 s later).ResultsMean (± SD, 95%CI) astigmatic power (DC) formed in the tear film over each period was respectively : Group 1, −0.81 DC (0.99, −1.44 to −0.17), −2.65 DC(1.36, −3.52 to −1.79), −1.37 DC (2.15, −2.73 to −0.01). Group 2, −0.33 DC (0.38, −0.45 to −0.20), −0.57 DC (0.97, −0.91 to −0.24) −0.96 DC (2.10, −1.68 to −0.24), Group 3, −0.57 DC (0.55 −0.76 to −0.38), −0.56 DC (0.57, −0.76 to -0.37), −0.31 DC (0.44, −0.46 to −0.16). Changes were significant in groups 1 (p = 0.013) & 3 (p = 0.033) but not in 2 (p = 0.078). Intergroup differences were significant at all periods (p < 0.05). Significant correlations were detected following vector analysis, e.g Group2 between the astigmatism formed during T5-T10 (y) and ocular surface astigmatism at 5 s was y = 0.281x - 0.834 (r = 0.328, n = 38, p < 0.05). In all three groups apparent changes in the axes of astigmatism were not significant (p > 0.05).ConclusionsChanges in the precorneal tear film after blinking are predominately astigmatic indicating that changes in the central region of the tear film following the natural blink are quasi-orthogonal. 相似文献
11.
《Contact lens & anterior eye》2022,45(2):101468
PurposeTo evaluate the 5-item dry eye questionnaire (DEQ-5) for measurement precision and unidimensionality, and assess the ability of Ocular Surface Disease Index (OSDI), McMonnies Dry Eye Questionnaire (MQ), Ocular Comfort Index questionnaires (OCI), and DEQ to predict clinical measures of DED in an African population.MethodParticipants (n = 113; mean age 24.7 ± 5.4 years) completed all four questionnaires administered in a randomized order. Internal consistency and test-retest reliability of the instruments were assessed. A masked examiner performed clinical dry eye tests in both eyes of participants and the results used to classify into either “dry” or “non-dry” groups. The diagnostic criteria for dry eye disease were tear break up time (TBUT) < 10 s plus at least one of Schirmer <15 mm in 5 min., > 5 corneal staining spot, or > 9 conjunctival staining spots. Rasch analysis was performed to assess the DEQ for unidimensionality and measurement precision, and receiver operating characteristic curve (AUC) analysis was used to assess the ability of the four questionnaires to predict clinical measures of DED.ResultsThe responses from the DEQ-5 met the Rasch analysis criterion of unidimensionality with infit and outfit values of between 0.74–1.43 mean-square and 0.69–1.49 mean-square, respectively, and measurement precision of 2.33. Internal consistency and test-retest reliability of each test was high, with Cronbach alpha >0.70 for the questionnaire and their respective subscales but internal consistency reliability of the MQ was poor (Cronbach’s alpha = 0 .29?0 0.52). Each test segregated the “dry” and “non-dry” groups with moderate (all AUC 0.70?0.80) and similar accuracy (P > .05).ConclusionThe DEQ -5 demonstrated adequate measurement precision and unidimensionality. Each of the four questionnaires showed psychometric validity for clinical use in the African population, and modest and similar accuracy when screening for dry eye signs but the performance of the McMonnies questionnaire was limited in terms of internal consistency reliability. 相似文献
12.
《Contact lens & anterior eye》2023,46(2):101809
Tear evaporation is a normal physiological phenomenon that has an important role in regulating blink activity and tear production. An altered tear evaporation rate (TER) is a defining characteristic of evaporative dry eye disease (DED), and the measurement of tear evaporation is a useful clinical test for diagnosis. Reported values for a normal TER cover a broad range, which may be due to the influence of ocular, environmental, and systemic factors. For improved disease diagnosis, a fuller understanding of the normal TER range is essential. This paper reports on a literature review of the current knowledge of these normal influences on TER. 相似文献
13.
《Contact lens & anterior eye》2014,37(2):81-91
Ocular comfort agents are molecules that relieve ocular discomfort by augmenting characteristics of the tear film to stabilize and retain tear volume and lubricate the ocular surface. While a number of clinical comparisons between ocular comfort agent solutions are available, very little work has been done correlating the properties of specific comfort agents (species, molecular weight, and water retention) and solution properties (concentration, viscosity, zero shear viscosity, and surface tension) to the performance and effectiveness of comfort agent solutions. In this work, comfort-promoting properties related strongly to comfort agent concentration and molecular weight, the first objective demonstration of this relationship across diverse comfort agent species and molecular weights. The comfort agents with the greatest comfort property contributions (independent of specific molecular weight and concentration considerations) were hyaluronic acid (HA), hydroxypropyl methylcellulose (HPMC), and carboxymethylcellulose (CMC), respectively. The observed, empirical relationships between comfort property contribution and comfort agent species, solution properties, comfort agent molecular weight, and solution concentration was used to develop novel comfort agent index values. The comfort agent index values provided much insight and understanding into the results of experimental studies and/or clinical trials and offer potential resolution to numerous conflicting reports within the literature by accounting for the difference in comfort agent performance due to molecular weight and concentration of comfort agents. The index values provide the first objective, experimental validation and explanation of numerous general trends suggested by clinical data. 相似文献
14.
《Contact lens & anterior eye》2022,45(6):101724
IntroductionThe diagnosis of dry eye is challenging for eye health practitioners (EHP) and recently, a variety of new diagnostic tests have emerged. This study assesses the attitudes of EHP to dry eye and testing and compares these with attitudes in 2003.MethodsAn electronic questionnaire was disseminated to EHP in Australasia between December 2020 to March 2021. Participants rated the likelihood that presenting symptoms/signs were associated with dry eye, the utility of diagnostic tests, the value of test characteristics, and their satisfaction with dry eye diagnostics. Qualitative responses were categorised into positive, negative, or neutral themes.Results144 responses were received, with 117 (81.3%) from Australia and 27 (18.7%) from New Zealand. Posterior blepharitis was significantly more likely to be associated with dry eye than other factors (p < 0.01). Clinical history, fluorescein staining and FBUT were judged significantly more useful in diagnosing dry eye compared to other tests (p < 0.01). Test validity was judged significantly more important in choosing a test than other qualities. Qualitative attitudes towards dry eye presentations and diagnostic tests were positive in 42.2% and 24.3%, negative in 32.4% and 41.9%, and neutral in 25.5% and 33.8% respectively.ConclusionsThe opinions of EHP regarding dry eye tests were variable, but most favour history and corneal staining for diagnosis. Patterns of responses were similar to that reported by Turner et al 16-years ago, however, there is a higher satisfaction with available tests and therapeutic options. There is a need to develop a consensus amongst real-world clinicians regarding an optimum diagnostic pathway for dry eye, particularly in relation to newer diagnostic tests. 相似文献
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Michael T.M. Wang Irene Cho Soo Hee Jung Jennifer P. Craig 《Contact lens & anterior eye》2017,40(4):236-241
Purpose
To compare the effects on tear film parameters and contamination in cosmetic eyeliner wearers, after single application of two lipid-based dry eye treatments: a lipid-containing lubricant eye drop and a phospholipid liposomal spray.Methods
Fifty participants were enrolled in a prospective, randomised, paired-eye, investigator-masked trial. Pencil eyeliner (Body Shop® Crayon Eye Definer) was applied to the upper eyelid periocular skin of both eyes, anterior to the lash line. Baseline tear film quality was assessed fifteen minutes after eyeliner application. A lubricant drop (Systane® Balance) was then applied to one eye (randomised), and liposomal spray (Tears Again®) to the contralateral eye. Tear film contamination, lipid layer grade, non-invasive tear film break-up time and tear evaporation rate were evaluated fifteen minutes post-treatment and compared to pre-treatment values.Results
Pre-treatment measurements did not differ between eyes assigned to lubricant drop and liposomal spray. Tear film contamination was observed in a greater proportion of eyes following both treatments (both p < 0.05), with no significant difference between treatments (p = 0.41). Both treatments improved lipid layer thickness (both p ≤ 0.01), but effected no significant change in non-invasive tear film break-up time or tear evaporation rate (all p > 0.05). Changes in tear film parameters did not differ between treatments (all p > 0.05).Conclusions
Both the lipid-containing lubricant eye drop and phospholipid liposomal spray result in clinically apparent tear film contamination in eyeliner cosmetic wearers. Although both treatments effected an increase in lipid layer thickness, neither displayed clinical efficacy in improving tear film stability. 相似文献17.
Purpose
To compare the prophylactic efficacy of single application of lipid and non-lipid containing tear supplements, prior to exposure of symptomatic dry eye subjects to a simulated adverse environment.Methods
Thirty subjects with mild-to-moderate dry eye symptoms participated in the prospective, randomised, double-masked, paired-eye trial. A lipomimetic drop (Systane® Balance) was applied to one eye (randomised), and a non-lipid containing drop (Systane® Ultra) applied simultaneously to the contralateral eye. Subjects were subsequently exposed to a validated simulated adverse environment model created by a standing fan directed towards the eye, at a distance of 1 m, for 2.5 min. Low contrast glare acuity, lipid layer grade (LLG), non-invasive tear break-up time (NIBUT), temperature variation factor (TVF), and tear meniscus height (TMH) were evaluated at baseline, following eye drop instillation and following simulated adverse environment exposure.Results
Both therapies resulted in increased NIBUT (both p < 0.001), and prevented its decline below baseline with simulated adverse environment exposure (both p > 0.05). However, only the lipomimetic drop increased LLG (p < 0.001) and precluded its fall below baseline post-adverse environment exposure (p = 0.15). Furthermore, post-instillation and post-exposure LLGs and NIBUT were significantly higher in the lipomimetic group (all p < 0.05). No significant changes were observed in glare acuity, TVF and TMH (all p > 0.05). More subjects (67%) reported greater ocular comfort in the eye receiving the lipomimetic.Conclusions
Single application of both lipid and non-lipid containing eye drops conferred protective effects against exposure to adverse environmental conditions in subjects with mild-to-moderate dry eye, although the lipomimetic demonstrated superior prophylactic efficacy. 相似文献18.
《Contact lens & anterior eye》2021,44(5):101407
Scleral lenses can affect a range of anterior segment structures including the eyelids and the tears. The eyelids, consisting of the outer skin layer, the middle tarsal plate, and the posterior palpebral conjunctiva, provide physical protection and house the meibomian glands and cilia which have important and unique functions. Tears consist of a mix of aqueous, mucus, and lipidomic components that serve vital functions of lubricity, protection, and nourishment to the ocular surface. Both the eyelids and the tear film interact directly with scleral lenses on the eye and can affect but also be impacted by scleral lens wear. The purpose of this paper is to review the anatomy and physiology of the eyelids and tear film, discuss the effects and impacts of the scleral lenses on these structures, and identify areas that require further research. 相似文献
19.
《Contact lens & anterior eye》2020,43(4):355-358
PurposeTo estimate the prevalence of symptomatic dry eye disease (DED) and investigate its associated risk factors in the Lebanese population.MethodsPopulation-based cross-sectional study of 602 participants from Lebanon aged 18 years and older. Ocular Surface Disease Index (OSDI) questionnaire on dry eye symptoms was used to evaluate the prevalence of symptomatic DED. Chi-square test was used to investigate the association between DED status and risk factors such as age, gender and smoking tobacco.ResultsThe percentage of DED among the study population (271 males and 331 females) was 36.4% with OSDI score ≥ 13 (mild to moderate and severe OSDI status). The most reported DED symptom in the population was sensitivity to light. Smokers reported higher DED symptoms than non-smokers. Older and smoker populations were more likely to report significantly higher OSDI scores (p < 0.05). Moreover, gender was not statistically associated with DED (p > 0.05).ConclusionSymptomatic DED is substantial in Lebanon. It is statistically associated with the age of population and their tobacco exposure. 相似文献
20.
Chih-Huang Yang Julie Albietz Damien G. Harkin Michael G. Kimlin Katrina L. Schmid 《Contact lens & anterior eye》2018,41(1):69-76