The statements herein have not been evaluated by the Foods and Drugs Administration or Health Canada. Liu, J., Li, Y., Niu, J. et al. MeSH The detection rate of fasciculation in each ALS and non-ALS muscle group. For this purpose, a Physico Chemical Treatment Plant was also envisaged and the effluent from this plant was taken through artificially created wetlands in an area of 4 hectares (9.9 acres)) (not only to treat the water but also to serve as natural habitat for birds) and through this process the entire eco-system is being re-generated. Bethesda, MD 20894, Web Policies Advertisement. Fasciculation in ALS, which is thought to originate from upper and lower motor neurons, is associated with hyperexcitation of the motor cortex and axons [24]. Clin Neurophysiol. Have you heard about Burning mouth syndrome. Does opiate withdrawal cause nausea, low BP, muscle pain and urea smell? Our study aimed to analyze the difference in fasciculation detected with muscle ultrasonography (MUS) between ALS patients and non-ALS patients with symptoms resembling ALS. Most patients get better when the underlying anxiety is addressed and treated. Muscle twitches occur when the motor units, which . Also, axon excitability studies have confirmed that the Na+/K+ pump at the MMN injury site is blocked, resulting in depolarization and hyperpolarization areas surrounding the conduction block site, which reduces the stability of the axonal membrane and causes abnormal excitability potentials [20, 21]. Would you like email updates of new search results? reported that fasciculations were widely distributed in ALS patients and locally distributed in non-ALS patients [9]. Suffering from subclinical hyperthyroidism with anxiety and palpitations. de Carvalho M, Dengler R, Eisen A, England JD, Kaji R, Kimura J, et al. On the terrace of the palace, a garden was built with arched passages. But sometimes, they can be due to neuromuscular disorder like ALS (amyotrophic lateral sclerosis). http://www.tandfonline.com/doi/abs/10.3109/15360288.2014.997856?journalCode=ippc20 http://brain.oxfordjournals.org/content/brain/133/11/3458.full.pdf. NEW: Traumatic Brain Injury (TBI) Support Group. Here, the muscle response is recorded after stimulating a nerve with a small amount of electricity. Clin Neurophysiol. PubMed Google Scholar. Grimm A, Prell T, Décard BF, Schumacher U, Witte OW, Axer H, et al. The Shapiro-Wilk test was used to assess whether data exhibited a normal distribution. A coordinator will follow up to see if Mayo Clinic is right for you. Sudden involuntary spasms called myoclonic jerks. Figures were prepared using GraphPad Prism 7.00 software. Benign fasciculation syndrome (BFS) is characterized by fasciculation (twitching) of voluntary muscles in the body. Your US state privacy rights, FOIA do they get our quality seal of approval. Muscle twitches are not painful and are usually not a cause for concern. 1938;61:311-312. de Carvalho M, Kiernan MC, Swash M. Fasciculation in amyotrophic lateral sclerosis: origin and pathophysiological relevance. "Female Genital Mutilation: Cultural and Psychological Implications,", This page was last edited on 9 February 2023, at 01:15. Muscle fasciculations in a healthy population. https://www.verywellhealth.com/benign-fasciculation-syndromes-2488771, https://www.nhs.uk/conditions/twitching-eyes-and-muscles/. - Radiculopathy (a pinched spinal nerve). The main symptom of benign fasciculation syndrome is persistent muscle twitching, tingling, or numbness. Exercise intolerance - the person might be unable to perform physical exercise. Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, et al. By continuing, you agree to our terms of use and privacy policy. Pash, I get it. Google Scholar. The study by Johansson et al. The EMG changes were stable. https://www.healthline.com/health/benign-fasciculation-syndrome#symptoms. Snoring is its main symptom. Tsuji Y, Noto YI, Kitaoji T, Kojima Y, Mizuno T. Difference in distribution of fasciculations between multifocal motor neuropathy and amyotrophic lateral sclerosis. No, BFS is not an autoimmune disorder. Amyotrophic lateral sclerosis: an update for 2018. The 2023 edition of ICD-10-CM R25.3 became effective on October 1, 2022. The twitching may be occasional to continuous. The fasciculation grade for each muscle group was recorded after each assessment. Again I don't know if it is in my imagination after reading up on so many things, but I do see to get out of breath easier recently and my mouth seems to be constantly dry and it is harder to talk as I seem to slur but I think that's because of my tongue, it really aches when i talk. The palace was originally constructed in 1699; the building and the lake around it were later renovated and enlarged in the 18th century by . J Neurol Neurosurg Psychiatry. Federal government websites often end in .gov or .mil. However, the time can be shortened to 60 s due to the significantly larger observation area using MUS, which greatly reduces the examination time for each patient [11]. However, for the non-ALS patients in our study, most fasciculations originated from only lower motor neurons and were partially related to nerve length dependence. Methods: This was a retrospective review of medical records of patients who were referred because of a suspicion of ALS or . 2011;77(16):1532–7. Home » General Health » Benign fasciculation syndrome (muscle twitch) symptoms, causes and natural treatment. Careers. Amyotroph Lateral Scler. 2018;129(2):487–93. Neurology. 2015;126(4):820–7. It usually goes away after withdrawal, but not always. BFS must be distinguished from other conditions that include muscle twitches. How Is Benign Fasciculation Syndrome Diagnosed? Too much stress, dehydration, certain medications, lack of sleep, too much caffeine, etc., are the most common causes of muscle twitching. Tamarix indica (planting close to the water edge where they can grow well), Terminalia arjuna (Arjun) poplar, neem and all species of Ficus, which would provide diversity in vegetation and also better habitat diversity for feeding by birds and wildlife. It is situated in the east-central part of the state, roughly equidistant from Alwar (northeast) and Ajmer (southwest). Our study analyzed differences in firing frequency, intensity, and distribution of fasciculation with MUS between ALS patients and non-ALS patients with symptoms resembling ALS and specifically explored the usefulness of MUS fasciculation grading and distribution patterns in the diagnosis of ALS. 2022 Jan 13;10(1):117. doi: 10.3390/vaccines10010117. MUS was performed on 19 muscle groups in cervical, lumbosacral, bulbar, and thoracic regions for each patient. I'm 40, have had random twitches now and then around my body for a few years and ignored them. Rights Reserved. Fasciculation potentials in amyotrophic lateral sclerosis and the diagnostic yield of the Awaji algorithm. My BMI is 16. A burning or prickly sensation in various parts of your body. KGK Enterprises. Limiting the intake of alcohol, drugs, and caffeine can make stress worse. Well, I hope to hear from someone, thanks for reading! Terms and Conditions, The ingredients are tested by the manufacturer for. Causes of BFS may include overexertion of the muscle, chronic organophosphate poisoning (additional research is required to further investigate this cause), taking certain drugs like anticholinergics (e.g., diphenhydramine), opiates (e.g., morphine), a magnesium deficiency, neuropathies, anxiety, regular strenuous exercise, ADHD and drugs to treat the condition, and essential tremors that are not associated with a disease. Sonographic imaging of muscle contraction and fasciculations: a correlation with electromyography. With BFS, the twitching is often described as relentless, occurring either continuously or in random episodes in areas like the . It’s also called lifelong vaginismus. Female Sexual Pain Disorders: Evaluation and Management, Wiley-Blackwell, 2009. While an understanding of the role of . Hello All, Patients were diagnosed based on otherwise normal examinations and normal EMGs except for fasciculation potentials. Salai G, Bilic E, Primorac D, Lakusic DM, Bilic H, Lazibat I, Grgurevic L. Vaccines (Basel). The proportion of non-ALS patients with the maximum fasciculation score of 2 (21 [38.9%]) was the highest, followed by 0 (18 [33.3%]), 1 (10 [18.5%]), and 4 (5 [9.3%]), with no scores of 3. BNF; engl. [10], After the above initial restoration works of the lake and its feeder system were mostly completed by the JDA, during 2003, private sector developers were invited to develop identified tourism components on the land adjoining the lake. Anxiety and stress can result in the release of neurotransmitters, which can result in muscle twitching. Benign fasciculation syndrome symptoms. Publications concerning the evaluation of pediatric patients experiencing fasciculations are limited. Some women describe it as a burning or a feeling like the penis is "hitting a wall.". Benign Fasciculation Syndrome . Usually, the spasms seen in BFS do not cause sudden jerking or full contraction of the muscles, but they are strong enough for the person to feel them. This study was approved by the Ethics Committee of the Peking Union Medical College Hospital (PUMCH). Interestingly, the maximal fasciculation score in a small proportion of non-ALS patients (9.3%) was 4 in this study. Unauthorized use of these marks is strictly prohibited. Keeping this broad planning approach in view, under the lake restoration project, the works undertaken involved were: the re-alignment of city drains, de-silting of the lake, construction of artery road from Amber to Man Sagar Dam (about 2.7 kilometres (1.7 mi)), construction of check dam in a 100 metres (330 ft) length with silt removed from the lake, creation of three nesting islands for migratory birds, lakefront promenade in1 kilometre (0.62 mi)), afforestation and treatment of forest area portion of lake catchment, plantation to stabilise the slopes of bank formation. Fasciculations are the most common form of spontaneous muscle contraction. Talk to your friend, family member, or anyone you trust about the thing that is bothering you. This is when a woman has had pain every time something entered their vagina, including a penis (called penetrative sex), or when they’re never been able to insert anything into their vagina. Ectopic impulse generation in peripheral nerve hyperexcitability syndromes and amyotrophic lateral sclerosis. Fasciculations were observed in four regions for ALS patients and primarily distributed in proximal limbs. These symptoms happen when the muscle is resting. In ALS, fasciculations start in a particular place and then often spread to the surrounding areas. 2017;88:773-779. 1993;34:622-625. Hi doctor, Most patients had experienced fasciculations in both upper and lower limb muscles (62.2%); the remaining patients had fasciculations only in their lower limbs. Tested normal. Or do the exercises in a bathtub, where water is a natural lubricant. By inserting a twig or similar object before the wound heals, a small hole is created for the passage of urine and menstrual blood. Last reviewed at:22 Jan 2023  -  5 min read, Comprehensive Medical Second Opinion.Submit your Case. Despite the favorable prognosis of benign fasciculation syndrome (BFS), patients are often anxious about their symptoms. EMG typically evaluates electrical activity with the muscle at rest and during periods of voluntary muscle contraction [ 1 ]. Here's more information about What Is Benign Fasciculation Syndrome? Jaipur’s famous arts and crafts include the making of jewelry, enamel, metalwork, and printed cloths, as well as stone, marble, and ivory carving. Benign fasciculation does not usually get worse with time. Non-normally distributed variables, including age-at-onset, disease duration, total MRC, BMI, ALSFRS-R, and fasciculation grade/score were expressed as medians (interquartile range, IQR), and comparisons between ALS and non-ALS patients were assessed using the Mann-Whitney U test. Articles from Britannica Encyclopedias for elementary and high school students. Persistent muscle twitches or numbness or tingling sensations in one or more muscles of the body is called benign fasciculation syndrome (BFS). Li Y. performed MUS examination, collected clinical data, followed patients and revised the manuscript. Noto YI, Shibuya K, Shahrizaila N, Huynh W, Matamala JM, Dharmadasa T, et al. First, do Kegel exercises by squeezing the same muscles you use to stop the flow when you’re peeing: Do about 20 Kegels at a time. Mingsheng Liu. All authors read and approved the final manuscript. According to Awaji criteria, the discovery of fasciculation under MUS revises 6% of the possible diagnosis to probable diagnosis [14]. Fasciculation that occurred in the suprahyoid muscles exhibited high specificity for distinguishing ALS from non-ALS diseases. The legs are bound together for two to four weeks to allow healing. Blexrud MD, Windebank AJ, Daube JR. Jaipur grew dramatically in size in the late 20th and early 21st centuries, doubling its population between 1991 and 2011. Meaning, if you have tremors in a leg muscle, it can jump to the abdomen in a few seconds. Brain. Benign Fasciculation Syndrome | Causes | Symptoms | Diagnosis | Treatments. These symptoms happen when the muscle is resting . Design/Methods: This is a two-year prospective study. Ultrasound was first applied in the observation of fasciculation by Walker et al. A fasciculation is basically the long word for a twitch. You might want to clip your fingernails first and use a lubricating jelly. Usually, the spasms seen in BFS do not cause sudden jerking or full contraction of the muscles, but they are strong enough for the person to feel them. In summary, ultrasound technology can detect fasciculation effectively. Symptoms of BFS are most commonly noticed when a person is at rest. The city sewage, which supplied 7.0 MLD of untreated sewage was treated with Sewerage Treatment Plant (STP) and then led to the lake to maintain its water level, after due removal of nutrients through tertiary treatment. Obviously ALS on my mind but no weakness just issues with swallowing tongue etc. The detection rate and grade of fasciculation in ALS were significantly higher than that seen with non-ALS diseases. Springer Nature. People with this condition may have twitches in their eyes, tongue, arms, thumb, feet, thighs, and calves. If your muscle twitches are getting worse with time or causing pain and discomfort, it is best to consult a doctor online. From the northeast, the Kanak Vrindavan valley, where a temple complex sits, the hills slope gently towards the lake edge. We recorded any fasciculation detected in the area of the muscle group being assessed. Jal Mahal is also known as Water Palace, which is situated on the middle of the Man Sagar Lake in the Jaipur City. Neurological disorders in general can be mild or quite severe, depending on their cause. What is benign fasciculation syndrome? [2] Often called "pharaonic circumcision" (or farooni)[3] in countries where it is practiced, it refers to the removal of the inner and outer labia and the suturing of the vulva. Some of the serious diseases that can cause fasciculations are: In this study, we prospectively followed 35 patients with BFS over a 24-month period. You'll feel your vagina's muscles clenching around your finger, and you can always take your finger out if you're not comfortable. @colleenyoung Thank you so much for taking the time to reply, and for your link on BFS. Some women have vaginismus in all situations and with any object. Moreover, ROC analysis revealed that assessment of fasciculation was of great value for the diagnosis of ALS. This will help pinpoint a diagnosis and find the best treatment option if due to a previously unknown underlying condition. Benign fasciculations may be difficult to treat, but usually, resolve on their own. What are the symptoms of benign fasciculation syndrome? - Isaac’s syndrome. Firstly, it takes at least 70–90 s to record fasciculation. I feel like such a worry pot! [10] Many kynodesmē are depicted on vases, almost exclusively confined to symposiasts and komasts, who are as a general rule older (or at least mature) men. Reed DM, Kurland LT. Long-term follow-up of 121 patients with benign fasciculations. It is Rajasthan's most-populous city. 2017;88(9):773–9. Based on this finding, restoration works were re-done with traditional materials for plastering – the plaster consists of partly organic material: a mortar mix of lime, sand and surkhi mixed with jaggery, guggal and methi powder. Under the public-private sector partnership model approved by the EICD, PDCOR had prepared the Detailed Project Report (DPR) for the restoration of Man Sagar Lake, Jal Mahal restoration and lake precincts development. J Neurol Neurosurg Psychiatry. BMC Neurology In benign fasciculation syndrome, fasciculations are the main symptoms. It's important to see a doctor to find out what’s causing it. Epub 2017 May 10. Clin Neurophysiol. Recently, I started having trouble swallowi...  Read Full », High Creatinine Levels | Symptoms | Diagnosis | Treatment, Adrenaline Rush - Symptoms | Causes | Effects | How to Stop |, Fundal Placenta | Types | Position | Complications, Bisoprolol (CONCOR) -Uses| Works| Dosage| Precautions| Side Effects. Epub 2017 Nov 21. Benign fasciculation syndrome (BFS) is the occasional or nearly continuous twitching of voluntary muscles. They write new content and verify and edit content received from contributors. My vitamin B12 was around 50 ng/L. Prognosis of BFS is favorable, regardless of minor EMG abnormalities. But, it can be a symptom of some serious health conditions like amyotrophic lateral sclerosis (ALS) or otherwise known as Lou Gehrig’s disease. The χ2 test was used to assess comparisons between the frequency of categorical variables. The patient kept the muscles relaxed and silent during the MUS examination. The view of the Jal Mahal is eye catching. Moreover, recent studies have shown that MUS has higher sensitivity in detecting fasciculation compared to EMG and qualitative physical assessment [7–10]. For ALS patients, high-grade fasciculations were primarily distributed in the proximal muscle groups of the lower limbs (12.2%) and upper limbs (11.9%). We aimed to assess electrodiagnostic changes and clinical course over time in patients with BFS. The fasciculation grade and distribution pattern detected with MUS could help distinguish ALS from non-ALS patients. version 12.066-7-prod. 2019;60(2):114–23. Is my mother's leg pain sciatica or something else? Merck Manual for Health Care Professionals: "Vaginismus. Jal Mahal (meaning "Water Palace") is a palace in the middle of the Man Sagar Lake in Jaipur city, the capital of the state of Rajasthan, India. The palace seems very beautiful in the evening as the entire complex looks like bathed in flood lights. [10] reported that high fasciculation frequency at the biceps brachii and brachialis muscles, where detection rate was the highest under MUS, was associated with less impairment at time of examination, and a more active disease with a more rapid progression. The Lake restoration project of the Man Sagar Lake area with an estimated investment of ₹150 crores (considered one of the largest and unique such projects in India) has evolved a plan that has diverse project components. National Library of Medicine Vazquez-Costa JF, Campins-Romeu M, Martinez-Paya JJ, Tembl JI, Del Bano-Aledo ME, Rios-Diaz J, et al.   -  5 min read. This palace is standing inside the Man Sagar Lake. For about 10 days, I have muscle twitching in my calf, thighs and also in my eyes. Exercise - Exercise is shown to improve mood and reduce stress. Mayo Clin Proc. Benign fasciculation syndrome, or BFS, is not as severe as other neurological conditions but is aggravating none the less. Our study aimed to analyze the difference in fasciculation detected with muscle ultrasonography (MUS) between ALS patients and non-ALS patients with symptoms resembling ALS. Fasciculation differences between ALS and non-ALS patients: an ultrasound study. Hyperthyroidism - A endocrine disorder where the thyroid gland produces thyroid hormone in excess. Eighty-eight ALS patients and fifty-four non-ALS (eight multifocal motor neuropathy, 32 chronic inflammatory demyelinating . It was also noticed that there was hardly any water seepage, except for a little dampness, on the floors below the water level. Prednisone, an immunosuppressive drug, is prescribed if no other treatment is effective. While BFS is a rare condition, . So if your muscle twitches do not get better in a week, or the muscles twitch even at rest, then it is best to consult a doctor. This work was supported by Beijing Natural Science Foundation (grant number 7202158), and “13th Five-Year” National Science and Technology Major Project for New Drugs (grant number 2019ZX09734001). Forest denudation, particularly in the hilly areas, has caused soil erosion, compounded by wind and water action. Results negative. Benign fasciculation syndrome can affect individuals of any sex and any age. Electrolyte imbalances such as decreased levels of magnesium and calcium can also cause muscle twitching. 2020;42(6):458–62. At Gaitore opposite the lake are chhatris and cenotaphs erected over cremation platforms of some of the Kachwaha rulers of Jaipur. However, our study also presented several limitations. Fermont J, Arts IM, Overeem S, Kleine BU, Schelhaas HJ, Zwarts MJ. The highest proportion was grade 4 in ALS patients (71 [80.7%]) and grade 2 in non-ALS patients (21 [38.9%]). The number of muscles with fasciculation per person (median [IQR]) was 14.5 (11–15) in ALS patients and 3 (0–5.25) in non-ALS patients (P < 0.001). Keywords: statement and Rev Neurol (Paris). All clinical and electromyography (EMG) investigations were performed by the same neurologist, following an established protocol. All Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Jal Mahal (meaning "Water Palace") is a palace in the middle of the Man Sagar Lake in Jaipur city, the capital of the state of Rajasthan, India. Query: This is called progressive desensitization, and the idea is to get comfortable with insertion. Cervical spondylotic myelopathy with reversible fasciculations in the lower extremities. Schwartz-Jampel syndrome - A genetic neurological disorder. This is the American ICD-10-CM version of R25.3 - other international versions of ICD-10 R25.3 may differ. Other public buildings include a museum and a library. For women whose vaginismus is linked to fear or anxiety, therapy often helps. The https:// ensures that you are connecting to the However, it also can be detected in healthy people, those with cramp-fasciculation syndrome, in certain metabolic diseases, and other neuromuscular diseases [16, 17]. The project stake holders are: the Government of Rajasthan and their subordinate organizations such as the Public Works Department (PWD), Rajasthan Urban Development Authority (RUIDP), the Jaipur Development Authority (JDA – the nodal agency for implementation of all aspects of the project), the Department of Tourism, Rajasthan Project Development Fund (RPDF) and the Rajasthan Tourism Development Corporation (RTDC) and an Empowered Committee on Infrastructure Development (ECID); the Central Government organizations associated for planning and financing are the Ministry of Environment and Forests (MOE&F) through its National River Conservation Program (NRCP) and ILFS. Are you currently in the process of getting futher testing? for quality and safety during the production process. The view of the Aravalli hills which has many temples and forts on it, can be seen the across the lake.#Rajasthan #Jalmahal #India Or they might have it with sexual intercourse but not with tampons or during medical exams. 2017 Sep;88(9):773-779. doi: 10.1136/jnnp-2017-315574. MUS provides a new method for ALS diagnosis. It is located at a distance of 6.5 kms away from Pink City. Blepharospasm - the abnormal contraction of the muscles present in the eyelids. For non-ALS patients, fasciculations were mostly low-grade (88.1%) and mainly distributed in the distal muscle groups of the lower limbs (30.3%) and of upper limbs (29.7%) (Fig. Interested in more discussions like this? Later, with the progressive dysfunction of lower motor neurons, gradual muscle weakness occurs, complex and highly unstable motor units form, and peripheral motor axons initiate the production of ectopic activities [20]. But would love to hear from people that may have an idea of what I'm going through. Each muscle was imaged transversely using the B-mode. Cookies policy. Can these deficiencies be the cause for having muscl...  Read Full ». Bookshelf Have nerve damage from raft to c spine I know for sure. Some people also experience muscle cramps. I had nasal pharyngeal cancer in 2012 along with radiation & chemotherapy. Focal demyelination of peripheral motor axons can generate increased axon excitability and ectopic discharge, which likely is an explanation for the occurrence of fasciculation in non-ALS patients [19]. Anxiety might also make you hyperventilate, which can also result in twitching. Benign fasciculation syndrome symptoms. Oskarsson B, Gendron TF, Staff NP. Omissions? Its buildings are predominantly rose-coloured, and it is sometimes called the “pink city.” The chief buildings are the City Palace, part of which is home to the royal family of Jaipur; Jantar Mantar, an 18th-century open-air observatory that was designated a UNESCO World Heritage site in 2010; Hawa Mahal (Hall of Winds); Ram Bagh palace; and Nahargarh, the Tiger Fort. Arch Neurol. "People often worry that fasciculations are related to a serious neuromuscular condition like ALS. 2008;119(3):497–503. Hey Colleen, I have an appointment with my GP on Friday just to see if there is anything I can do to ease the fasciculations as the referral for neuro will likely be months away and I'm struggling to sleep and sometimes talk. Klassifikation nach ICD-10. [26] in 1990. Connect with thousands of patients and caregivers for support, practical information, and answers. The non-ALS diseases we studied included MMN, CIDP, CMT, as well as cervical spondylosis or lumbar spondylosis, which could involve the conduction pathways of lower motor neurons (e.g., nerve roots or peripheral nerves). Lee. For ALS patients, high-grade fasciculations were primarily distributed in the proximal muscle groups of lower limbs (12.2%) and upper limbs (11.9%), while low-grade fasciculations were primarily distributed in the distal muscle groups of lower limbs (16.2%) and upper limbs (11.0%). And you've done exactly the right thing and requested an appointment with a neurologist. But if the muscle twitches are severe, do not get better with rest, and occur every day, then it is best to consult a doctor. And I'll just ask him if the fact I think I'm getting other symptoms is my mind playing tricks on me . In the present study, the high-grade fasciculations of ALS patients were primarily distributed in the proximal limbs, while low-grade fasciculations were mainly distributed in the distal limbs. Had nasal pharyngeal cancer 2012. Tsuji et al. The detection rate of fasciculation for each muscle group was significantly higher in ALS patients than non-ALS patients (P < 0.001). and Higashihara et al. Muscle Nerve. You can upload files and images in the next step. The amplitude, area, time variability of components and complexity as measured by the coefficients of variation of amplitude or area are . Muscle Nerve. This is common to multiple sclerosis (MS), due to nerve fiber damage that affects signaling between your nerves and muscles. About Us · Contact Us · Disclaimer · Privacy and Cookie Policy. The latter do not necessarily imply progression to ALS. A value of P < 0.05 was considered statistically significant. Two-sided P-values were calculated for all analyses.