TY - JOUR
AU - Vassar, Matt
AB - Introduction Superlatives—‘exaggerated or hyperbolical expression[s] of praise’1—are tactics used by journalists to inflate the benefit of drugs and medical devices. News articles using these exaggerations could distort the perceptions of a drug’s effectiveness on health care providers and consumers. Superlative use is of particular importance when readers look beyond medical literature and use news articles to seek medical information. The current extent of superlative use in news articles of cardiac drugs is not currently known. The primary objectives of this study were to explore the use of superlatives in news articles covering cardiac drugs and to evaluate the characteristics of the articles that may be associated with superlative use. Our secondary objectives were to evaluate whether superlative use was more common in news articles of novel compounds or drugs in later phases of development and whether the news websites that posted articles were committed to factual accuracy, as determined by certification from the Health on the Net Foundation Code of Conduct (HONcode). Methods Our methodology was modelled after Abola and Prasad2 with modifications. From 5 September 2019 to 20 January 2020, we searched Google News for 10 prespecified superlative terms, ‘breakthrough’, ‘cure’, ‘game changer’, ‘groundbreaking’, ‘home run’, ‘life saving’, ‘marvel’, ‘miracle’, ‘revolutionary’, and ‘transformative’ along with the search term ‘heart drug’. Articles were screened and data were extracted by two investigators (D.J. and A.D.) in a duplicate, blinded fashion. Articles were excluded if they were not related to a cardiac drug or if the superlative was not used in reference to the drug. We extracted the following data elements from each news article: superlative term (cure, miracle, game changer, breakthrough, life saving, revolutionary, groundbreaking, transformative, home run, and marvel), article URL, news outlet, frequency of superlative(s) used, drug name(s) covered by the article, class of drug, whether the drug is FDA approved, whether clinical data were provided in the article, and the authors’ background (journalist, medical writer, physician, unsure, and not listed). Following data extraction, the two investigators met and resolved discrepancies. If a discrepancy could not be resolved, a third investigator (M.V.) was available for adjudication. For purposes of this study, we defined a novel compound as one in the initial phases of drug discovery, either research and development or preclinical studies (including in vitro, in vivo, or animal studies). Concerning factual accuracy, two methods were used to investigate the presence of HONcode certification. First, we searched the websites of the news outlets for the HONcode logo and then validated our work by searching the Health on the Net database of certified websites.3 Results We included 53 news articles from 47 different news outlets. Eighty-seven superlative terms were used to describe 25 unique cardiac drugs (Table 1). The most common drug associated with superlative use was Inclisiran, a siRNA PCSK9 inhibitor, with 42 instances in 21 news articles (Table 1). PCSK9 inhibitors as a drug class had the most instances of superlative use (45/87, 51.7%). Over one-third of the drugs are not FDA approved (10/25, 40.0%) and nearly half of the news articles did not provide clinical data (26/53, 49.0%). The majority of the authors were journalists (44/53, 83.0%), seven articles did not mention the author (7/53, 13.2%) and only two articles were written by a physician (2/53 3.8%). Of the 25 drugs in our sample, 14 were FDA approved (14/25, 56.0%), 7 drugs were in clinical trial (7/25, 28.0%), 3 drugs were not FDA approved or discontinued (3/25, 12.0%), and 1 drug was a novel compound (1/25, 4.0%) (Table 2). When comparing news articles and superlative frequencies with the phase of drug development, over half of the news articles (27/53, 50.9%) and superlatives (50/87, 57.5%) were associated with drugs in clinical trials. Of the 47 news outlets, only four of the news outlet websites were registered through the HONcode (4/47, 8.5%). Table 1 Characteristics and frequencies of cardiovascular drugs associated with superlative use Drugs/treatments . News articles with superlative(s) used (n = 53), N (%) . Superlative(s) used (n = 87), N (%) . Superlative(s) used . Drug class . FDA approved? . News articles that provided clinical data, N (%) . Repatha/Praluent 2 (3.8) 3 (3.4) Life-saving (2), breakthrough (1) PCSK9 inhibitor Yes 1 (33.0) Dapagliflozin (FARXIGA) 8 (15.1) 10 (11.5) Breakthrough (4), game changer (3), groundbreaking (1), transformative (1), game changer (1) SGLT-2 Yes 6 (75.0) Empagliflozin 1 (1.9) 2 (2.3) Game changer (2) SGLT-2 Yes 0 (0.0) Inclisiran 21 (39.6) 42 (48.3) Game changer (22), groundbreaking (7), transformative (4), breakthrough (3), revolutionary (2), home run (2), life-saving (2) PCSK9 inhibitor In clinical trial 10 (47.6) Selatogrel 1 (1.9) 1 (1.1) Game changer (1) P2Y12 receptor antagonist In clinical trial 1 (100.0) Rivaroxaban 1 (1.9) 1 (1.1) Game changer (1) Factor Xa inhibitors Yes 1 (100.0) 4F-PCC 1 (1.9) 1 (1.1) Life-saving (1) Haemostatic agent Yes 1 (100.0) CSL112 1 (1.9) 3 (3.4) Game changer (2), transformative (1) Apolipoprotein A-I In clinical trial 0 (0.0) Tenecteplase 1 (1.9) 1 (1.1) Life-saving (1) Tissue plasminogen activator (tPA) Yes 0 (0.0) KAND567 1 (1.9) 1 (1.1) Life-saving (1) Fractalkine receptor antagonist In clinical trial 0 (0.0) VASCEPA® (icosapent ethyl) 1 (1.9) 1 (1.1) Life-saving (1) Omega-3 fatty acid Yes 1 (100.0) Bretylol 1 (1.9) 1 (1.1) Life-saving (1) Antiarrhythmic agent Discontinued 0 (0.0) Aspirin 1 (1.9) 1 (1.1) Life-saving (1) Non-steroidal anti-inflammatory drug Yes 1 (100.0) Vazalore 1 (1.9) 3 (3.4) Revolutionary (1), life-saving (1), miracle (1), Non-steroidal anti-inflammatory drug Yes 1 (100.0) TT-00920 1 (1.9) 1 (1.1) Transformative (1) PDE9 inhibitor In clinical trial 0 (0.0) Dobutamine 1 (1.9) 1 (1.1) Revolutionary (1) Inotrope Yes 0 (0.0) Heart Plaster 1 (1.9) 6 (6.9) Revolutionary (4), transformative (1), game changer (1) Stem cell therapy No 0 (0.0) CaPre 1 (1.9) 1 (1.1) Miracle (1) Omega-3 fatty acid In clinical trial 1 (100.0) Tafamidis 1 (1.9) 1 (1.1) Breakthrough (1) Transthyretin stabilizers Yes 0 (0.0) Sacubitril/Valsartan (ENTRESTO) 1 (1.9) 1 (1.1) Breakthrough (1) Angiotensin receptor-neprilysin inhibitors Yes 1 (100.0) SR9009 1 (1.9) 1 (1.1) Breakthrough (1) Rev-Erb modulator No 0 (0.0) Vitamin E 1 (1.9) 1 (1.1) Game changer (1) Supplement No 0 (0.0) PolyPilla 2 (3.8) 2 (2.3) Life-saving (1) breakthrough (1) ACEi, statin, betablocker, NSAID Yes 1 (50.0) Unknown 1 (1.9) 1 (1.1) Breakthrough (1) Kinase inhibitor In clinical trial 0 (0.0) Drugs/treatments . News articles with superlative(s) used (n = 53), N (%) . Superlative(s) used (n = 87), N (%) . Superlative(s) used . Drug class . FDA approved? . News articles that provided clinical data, N (%) . Repatha/Praluent 2 (3.8) 3 (3.4) Life-saving (2), breakthrough (1) PCSK9 inhibitor Yes 1 (33.0) Dapagliflozin (FARXIGA) 8 (15.1) 10 (11.5) Breakthrough (4), game changer (3), groundbreaking (1), transformative (1), game changer (1) SGLT-2 Yes 6 (75.0) Empagliflozin 1 (1.9) 2 (2.3) Game changer (2) SGLT-2 Yes 0 (0.0) Inclisiran 21 (39.6) 42 (48.3) Game changer (22), groundbreaking (7), transformative (4), breakthrough (3), revolutionary (2), home run (2), life-saving (2) PCSK9 inhibitor In clinical trial 10 (47.6) Selatogrel 1 (1.9) 1 (1.1) Game changer (1) P2Y12 receptor antagonist In clinical trial 1 (100.0) Rivaroxaban 1 (1.9) 1 (1.1) Game changer (1) Factor Xa inhibitors Yes 1 (100.0) 4F-PCC 1 (1.9) 1 (1.1) Life-saving (1) Haemostatic agent Yes 1 (100.0) CSL112 1 (1.9) 3 (3.4) Game changer (2), transformative (1) Apolipoprotein A-I In clinical trial 0 (0.0) Tenecteplase 1 (1.9) 1 (1.1) Life-saving (1) Tissue plasminogen activator (tPA) Yes 0 (0.0) KAND567 1 (1.9) 1 (1.1) Life-saving (1) Fractalkine receptor antagonist In clinical trial 0 (0.0) VASCEPA® (icosapent ethyl) 1 (1.9) 1 (1.1) Life-saving (1) Omega-3 fatty acid Yes 1 (100.0) Bretylol 1 (1.9) 1 (1.1) Life-saving (1) Antiarrhythmic agent Discontinued 0 (0.0) Aspirin 1 (1.9) 1 (1.1) Life-saving (1) Non-steroidal anti-inflammatory drug Yes 1 (100.0) Vazalore 1 (1.9) 3 (3.4) Revolutionary (1), life-saving (1), miracle (1), Non-steroidal anti-inflammatory drug Yes 1 (100.0) TT-00920 1 (1.9) 1 (1.1) Transformative (1) PDE9 inhibitor In clinical trial 0 (0.0) Dobutamine 1 (1.9) 1 (1.1) Revolutionary (1) Inotrope Yes 0 (0.0) Heart Plaster 1 (1.9) 6 (6.9) Revolutionary (4), transformative (1), game changer (1) Stem cell therapy No 0 (0.0) CaPre 1 (1.9) 1 (1.1) Miracle (1) Omega-3 fatty acid In clinical trial 1 (100.0) Tafamidis 1 (1.9) 1 (1.1) Breakthrough (1) Transthyretin stabilizers Yes 0 (0.0) Sacubitril/Valsartan (ENTRESTO) 1 (1.9) 1 (1.1) Breakthrough (1) Angiotensin receptor-neprilysin inhibitors Yes 1 (100.0) SR9009 1 (1.9) 1 (1.1) Breakthrough (1) Rev-Erb modulator No 0 (0.0) Vitamin E 1 (1.9) 1 (1.1) Game changer (1) Supplement No 0 (0.0) PolyPilla 2 (3.8) 2 (2.3) Life-saving (1) breakthrough (1) ACEi, statin, betablocker, NSAID Yes 1 (50.0) Unknown 1 (1.9) 1 (1.1) Breakthrough (1) Kinase inhibitor In clinical trial 0 (0.0) a Polypill consists of Aspirin, Lisinopril, Simvastatin, and Atenolol. Open in new tab Table 1 Characteristics and frequencies of cardiovascular drugs associated with superlative use Drugs/treatments . News articles with superlative(s) used (n = 53), N (%) . Superlative(s) used (n = 87), N (%) . Superlative(s) used . Drug class . FDA approved? . News articles that provided clinical data, N (%) . Repatha/Praluent 2 (3.8) 3 (3.4) Life-saving (2), breakthrough (1) PCSK9 inhibitor Yes 1 (33.0) Dapagliflozin (FARXIGA) 8 (15.1) 10 (11.5) Breakthrough (4), game changer (3), groundbreaking (1), transformative (1), game changer (1) SGLT-2 Yes 6 (75.0) Empagliflozin 1 (1.9) 2 (2.3) Game changer (2) SGLT-2 Yes 0 (0.0) Inclisiran 21 (39.6) 42 (48.3) Game changer (22), groundbreaking (7), transformative (4), breakthrough (3), revolutionary (2), home run (2), life-saving (2) PCSK9 inhibitor In clinical trial 10 (47.6) Selatogrel 1 (1.9) 1 (1.1) Game changer (1) P2Y12 receptor antagonist In clinical trial 1 (100.0) Rivaroxaban 1 (1.9) 1 (1.1) Game changer (1) Factor Xa inhibitors Yes 1 (100.0) 4F-PCC 1 (1.9) 1 (1.1) Life-saving (1) Haemostatic agent Yes 1 (100.0) CSL112 1 (1.9) 3 (3.4) Game changer (2), transformative (1) Apolipoprotein A-I In clinical trial 0 (0.0) Tenecteplase 1 (1.9) 1 (1.1) Life-saving (1) Tissue plasminogen activator (tPA) Yes 0 (0.0) KAND567 1 (1.9) 1 (1.1) Life-saving (1) Fractalkine receptor antagonist In clinical trial 0 (0.0) VASCEPA® (icosapent ethyl) 1 (1.9) 1 (1.1) Life-saving (1) Omega-3 fatty acid Yes 1 (100.0) Bretylol 1 (1.9) 1 (1.1) Life-saving (1) Antiarrhythmic agent Discontinued 0 (0.0) Aspirin 1 (1.9) 1 (1.1) Life-saving (1) Non-steroidal anti-inflammatory drug Yes 1 (100.0) Vazalore 1 (1.9) 3 (3.4) Revolutionary (1), life-saving (1), miracle (1), Non-steroidal anti-inflammatory drug Yes 1 (100.0) TT-00920 1 (1.9) 1 (1.1) Transformative (1) PDE9 inhibitor In clinical trial 0 (0.0) Dobutamine 1 (1.9) 1 (1.1) Revolutionary (1) Inotrope Yes 0 (0.0) Heart Plaster 1 (1.9) 6 (6.9) Revolutionary (4), transformative (1), game changer (1) Stem cell therapy No 0 (0.0) CaPre 1 (1.9) 1 (1.1) Miracle (1) Omega-3 fatty acid In clinical trial 1 (100.0) Tafamidis 1 (1.9) 1 (1.1) Breakthrough (1) Transthyretin stabilizers Yes 0 (0.0) Sacubitril/Valsartan (ENTRESTO) 1 (1.9) 1 (1.1) Breakthrough (1) Angiotensin receptor-neprilysin inhibitors Yes 1 (100.0) SR9009 1 (1.9) 1 (1.1) Breakthrough (1) Rev-Erb modulator No 0 (0.0) Vitamin E 1 (1.9) 1 (1.1) Game changer (1) Supplement No 0 (0.0) PolyPilla 2 (3.8) 2 (2.3) Life-saving (1) breakthrough (1) ACEi, statin, betablocker, NSAID Yes 1 (50.0) Unknown 1 (1.9) 1 (1.1) Breakthrough (1) Kinase inhibitor In clinical trial 0 (0.0) Drugs/treatments . News articles with superlative(s) used (n = 53), N (%) . Superlative(s) used (n = 87), N (%) . Superlative(s) used . Drug class . FDA approved? . News articles that provided clinical data, N (%) . Repatha/Praluent 2 (3.8) 3 (3.4) Life-saving (2), breakthrough (1) PCSK9 inhibitor Yes 1 (33.0) Dapagliflozin (FARXIGA) 8 (15.1) 10 (11.5) Breakthrough (4), game changer (3), groundbreaking (1), transformative (1), game changer (1) SGLT-2 Yes 6 (75.0) Empagliflozin 1 (1.9) 2 (2.3) Game changer (2) SGLT-2 Yes 0 (0.0) Inclisiran 21 (39.6) 42 (48.3) Game changer (22), groundbreaking (7), transformative (4), breakthrough (3), revolutionary (2), home run (2), life-saving (2) PCSK9 inhibitor In clinical trial 10 (47.6) Selatogrel 1 (1.9) 1 (1.1) Game changer (1) P2Y12 receptor antagonist In clinical trial 1 (100.0) Rivaroxaban 1 (1.9) 1 (1.1) Game changer (1) Factor Xa inhibitors Yes 1 (100.0) 4F-PCC 1 (1.9) 1 (1.1) Life-saving (1) Haemostatic agent Yes 1 (100.0) CSL112 1 (1.9) 3 (3.4) Game changer (2), transformative (1) Apolipoprotein A-I In clinical trial 0 (0.0) Tenecteplase 1 (1.9) 1 (1.1) Life-saving (1) Tissue plasminogen activator (tPA) Yes 0 (0.0) KAND567 1 (1.9) 1 (1.1) Life-saving (1) Fractalkine receptor antagonist In clinical trial 0 (0.0) VASCEPA® (icosapent ethyl) 1 (1.9) 1 (1.1) Life-saving (1) Omega-3 fatty acid Yes 1 (100.0) Bretylol 1 (1.9) 1 (1.1) Life-saving (1) Antiarrhythmic agent Discontinued 0 (0.0) Aspirin 1 (1.9) 1 (1.1) Life-saving (1) Non-steroidal anti-inflammatory drug Yes 1 (100.0) Vazalore 1 (1.9) 3 (3.4) Revolutionary (1), life-saving (1), miracle (1), Non-steroidal anti-inflammatory drug Yes 1 (100.0) TT-00920 1 (1.9) 1 (1.1) Transformative (1) PDE9 inhibitor In clinical trial 0 (0.0) Dobutamine 1 (1.9) 1 (1.1) Revolutionary (1) Inotrope Yes 0 (0.0) Heart Plaster 1 (1.9) 6 (6.9) Revolutionary (4), transformative (1), game changer (1) Stem cell therapy No 0 (0.0) CaPre 1 (1.9) 1 (1.1) Miracle (1) Omega-3 fatty acid In clinical trial 1 (100.0) Tafamidis 1 (1.9) 1 (1.1) Breakthrough (1) Transthyretin stabilizers Yes 0 (0.0) Sacubitril/Valsartan (ENTRESTO) 1 (1.9) 1 (1.1) Breakthrough (1) Angiotensin receptor-neprilysin inhibitors Yes 1 (100.0) SR9009 1 (1.9) 1 (1.1) Breakthrough (1) Rev-Erb modulator No 0 (0.0) Vitamin E 1 (1.9) 1 (1.1) Game changer (1) Supplement No 0 (0.0) PolyPilla 2 (3.8) 2 (2.3) Life-saving (1) breakthrough (1) ACEi, statin, betablocker, NSAID Yes 1 (50.0) Unknown 1 (1.9) 1 (1.1) Breakthrough (1) Kinase inhibitor In clinical trial 0 (0.0) a Polypill consists of Aspirin, Lisinopril, Simvastatin, and Atenolol. Open in new tab Table 2 N (%) of news articles and superlative frequencies by phase of drug development Phase of drug development . Drugs (n = 25), N (%) . News articles (n = 53), N (%) . Superlatives (n = 87), N (%) . Novel compounda 1 (4.0) 1 (1.9) 6 (6.9) In clinical trial 7 (28.0) 27 (50.9) 50 (57.5) FDA approved 14 (56.0) 22 (41.5) 28 (32.2) Not FDA approved or discontinued 3 (12.0) 3 (5.7) 3 (3.4) Phase of drug development . Drugs (n = 25), N (%) . News articles (n = 53), N (%) . Superlatives (n = 87), N (%) . Novel compounda 1 (4.0) 1 (1.9) 6 (6.9) In clinical trial 7 (28.0) 27 (50.9) 50 (57.5) FDA approved 14 (56.0) 22 (41.5) 28 (32.2) Not FDA approved or discontinued 3 (12.0) 3 (5.7) 3 (3.4) a Compound in the initial phases of drug discovery, either research and development or preclinical studies (including in vitro, in vivo, or animal studies). Open in new tab Table 2 N (%) of news articles and superlative frequencies by phase of drug development Phase of drug development . Drugs (n = 25), N (%) . News articles (n = 53), N (%) . Superlatives (n = 87), N (%) . Novel compounda 1 (4.0) 1 (1.9) 6 (6.9) In clinical trial 7 (28.0) 27 (50.9) 50 (57.5) FDA approved 14 (56.0) 22 (41.5) 28 (32.2) Not FDA approved or discontinued 3 (12.0) 3 (5.7) 3 (3.4) Phase of drug development . Drugs (n = 25), N (%) . News articles (n = 53), N (%) . Superlatives (n = 87), N (%) . Novel compounda 1 (4.0) 1 (1.9) 6 (6.9) In clinical trial 7 (28.0) 27 (50.9) 50 (57.5) FDA approved 14 (56.0) 22 (41.5) 28 (32.2) Not FDA approved or discontinued 3 (12.0) 3 (5.7) 3 (3.4) a Compound in the initial phases of drug discovery, either research and development or preclinical studies (including in vitro, in vivo, or animal studies). Open in new tab Discussion We demonstrated that superlatives are common in news articles about a variety of cardiovascular drugs. Superlatives are more often than not used in conjunction with drugs in clinical trials; however, superlatives use is not exclusively related to drugs in earlier phases of development, as we found that the majority of drugs in our sample were previously FDA approved. Other studies have demonstrated the use of superlatives in oncology news articles, though this study is the first of its kind exploring superlative use in cardiology news articles. We agree with Abola and Prasad2 that news journalists may not correctly understand the magnitude of clinical benefit of particular drugs and may thus use superlatives unjustifiably. The HONcode is a third-party foundation designed to help readers identify reliable and accurate health information by providing registered websites with a HONcode logo.3,4 To date, the HONcode registration is the most successful third-party certification initiative and the presence of its logo is a reliable indicator of website quality and accuracy of health information.4–9 With roughly 70% of the US population using the internet to search for health information, it is vital that information be accurate.10 Only four news websites were HONcode certified; thus, we recommend that physicians and patients check the news outlet website for HONcode certification.3 Limitations of our study include using only a single search engine, Google News, for news articles, and this single source may not accurately represent all news articles on the topic of cardiovascular drugs. Further research exploring superlative use in cardiology is warranted. Superlatives may influence consumers and health care providers’ perceptions of a specific drug and its relation to current medical care. We found that superlative use was common in news articles covering cardiovascular pharmacotherapy and more often than not these sources were not HONcode accredited; thus, we recommend readers exercise caution that their opinion not be clouded by these exaggerative terms. Conflict of interest: none declared. References 1 Superlative | Definition of Superlative by Lexico. Lexico Dictionaries | English. https://www.lexico.com/en/definition/superlative (25 January 2020 ). 2 Abola MV , Prasad V. The use of superlatives in cancer research . JAMA Oncol 2016 ; 2 : 139 – 141 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Health On the Net (HON): Health On the Net Code of Conduct (HONcode). https://www.hon.ch/HONcode/ (23 January 2020 ). 4 Boyer C , Dolamic L, Ranasinghe M, Baujard V. An automated HONcode detection system informs internet users of HONcode compliance . Swiss Med Informatics 2015 ; 17 : 369 – 378 . Google Scholar OpenURL Placeholder Text WorldCat 5 Bruce-Brand RA , Baker JF, Byrne DP, Hogan NA, McCarthy T. Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet . Arthroscopy 2013 ; 29 : 1095 – 1100 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Tavare AN , Alsafi A, Hamady MS. Analysis of the quality of information obtained about uterine artery embolization from the internet . Cardiovasc Intervent Radiol 2012 ; 35 : 1355 – 1362 . Google Scholar Crossref Search ADS PubMed WorldCat 7 IOS Press Ebooks. Improving the Transparency of Health Information Found on the Internet through the Honcode: A Comparative Study. doi:10.3233/978-1-60750-806-9-654. 8 Fallis D , Frické M. Indicators of accuracy of consumer health information on the Internet: a study of indicators relating to information for managing fever in children in the home . J Am Med Inform Assoc 2002 ; 9 : 73 – 79 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Advances in Member States. Safety and Security on the Internet. https://www.who.int/goe/publications/goe_security_web.pdf (23 January 2020). 10 Health Online 2013. Pew Research Center: Internet, Science & Tech. Published 15 January 2013 . https://www.pewresearch.org/internet/2013/01/15/health-online-2013/ (31 January 2020). Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - The use of superlatives in news articles covering cardiovascular drugs
JF - European Heart Journal – Cardiovascular Pharmacotherapy
DO - 10.1093/ehjcvp/pvaa012
DA - 2020-02-17
UR - https://www.deepdyve.com/lp/oxford-university-press/the-use-of-superlatives-in-news-articles-covering-cardiovascular-drugs-cvE2ORlAFm
SP - 405
EP - 407
VL - 6
IS - 6
DP - DeepDyve
ER -