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Dyslipidemia is a major contributor to the development of atherosclerotic cardiovascular disease. Despite high level of physical activity, athletes are not immune from dyslipidemia, but longitudinal data on the variation of lipids are currently lacking. We sought to assess lipid profile changes over time in Olympic athletes practicing different sports disciplines (power, skills, endurance, and mixed). We enrolled 957 consecutive athletes evaluated from London 2012 to Beijing 2022 Olympic Games. Dyslipidemia was defined as low-density lipoprotein (LDL) ≥115 mg/dl, high-density lipoprotein (HDL) <40 mg/dl for males, or HDL <50 mg/dl for females. Hypertriglyceridemia was defined as triglycerides >150 mg/dl. At the follow-up, a variation of ±40 mg/dl for LDL, ±6 mg/dl for HDL, and ±50 mg/dl for triglycerides was considered relevant. Athletes with follow-up <10 months or taking lower lipid agents were excluded. Follow-up was completed in 717 athletes (74.9%), with a mean duration of 55.6 months. Mean age was 27.2 ± 4.8 years old, 54.6% were male (n = 392). Overall, 19.8% (n = 142) athletes were dyslipidemic at both blood tests, being older, practicing nonendurance sports, and predominantly male. In 69.3% (n = 129) of those with elevated LDL at t0, altered values were confirmed at follow-up, while the same occurred in 36.5% (n = 15) with hypo-HDL and 5.3% (n = 1) in those with elevated triglycerides. Weight and fat mass percentage modifications did not affect lipid profile variation. LDL hypercholesterolemia tends to persist over time especially among male, older, and nonendurance athletes. LDL hypercholesterolemia detection in athletes should prompt early preventive intervention to reduce the risk of future development of atherosclerotic disease. [ABSTRACT FROM AUTHOR]

Background: Osteoporosis with pathological fractures is a significant public health issue, contributing to morbidity, disability, diminished quality of life, and increased mortality. Understanding mortality trends related to this condition is crucial for developing effective interventions to reduce mortality and improve healthcare outcomes. This study aimed to analyze trends and causes of death associated with osteoporosis and pathological fractures in the United States using a multi-cause approach. Methods: Annual death and age-standardized mortality rate (ASMR) data from 1999 to 2020 were obtained from the Centers for Disease Control and Prevention (CDC) mortality database. Death certificates listing ICD-10 M82 (osteoporosis with pathological fracture) as an underlying or related cause of death were analyzed. Epidemiological data were analyzed, and the ASMR data were calculated for each year, and trends were assessed using the Cochran-Armitage trend test. Results: From 1999 to 2020, there were 40,441 deaths related to osteoporosis with pathological fractures in the United States, with a female-to-male ratio of 5.6:1. Among these, 12,820 deaths (31.7%) listed osteoporosis with pathological fractures as the underlying cause of death (UCD), yielding a female-to-male ASMR ratio of approximately 5.0-7.7:1. When classified as a non-UCD, the ASMR ratio was approximately 4.8–6.2:1. At the same time, we found that the total number of deaths classified as UCD and multiple causes of death (MCD), but the trend ratio of the two groups in different years did not change statistically significant (P > 0.05), and the ASMR of both groups showed a downward trend. The UCD-to-MCD ratio increased between 1999 and 2007, then decreased from 2007 to 2020. As MCD, the number of female deaths was more than that of male, and both showed a decreasing trend, but there was no statistical significance in the change of trend ratio in different years (P > 0.05). Deaths were predominantly concentrated in individuals over 75 years of age, with those over 84 years being the most affected. The number of deaths in different age groups showed a decreasing trend, and the change of trend ratio in different years was statistically significant (P < 0.05). White individuals had the highest number of deaths. The leading causes of death were heart diseases, chronic lower respiratory diseases, and alzheimer's disease. In addition, the number of deaths of patients with prostate cancer and breast cancer showed a significant downward trend, and the change of trend ratio between the two groups in different years was statistically significant (P < 0.05). Conclusions: Although mortality from osteoporosis with pathological fractures is decreasing, anti-osteoporosis therapy remains essential for elderly patients. Healthcare providers should remain vigilant for potential complications, including malignant neoplasms, and ensure timely diagnosis and treatment to further reduce mortality in this population. [ABSTRACT FROM AUTHOR]

Intestinal parasitic infections (IPIs) remain a significant contributor to morbidity and mortality globally, particularly in developing countries such as Ethiopia. Periodic assessments of IPI prevalence are essential prerequisite for effective control measures. Therefore, this cross‐sectional study is aimed at determining the prevalence of gastrointestinal parasitic infections and associated risk factors among schoolchildren at Wonji Shoa Secondary School, East Shoa Zone, Adama district, Oromia region, Ethiopia, between January and June 2022. A simple random stratified sampling technique was employed to select participants. Sociodemographic and risk factor data were collected using a structured questionnaire. Stool samples were examined to identify parasites. Data were analyzed using SPSS version 20. Descriptive statistics, chi‐square tests, and logistic regression were conducted to assess associations between variables and then the strength of the association. A p value < 0.05 was considered statistically significant. Of the 403 selected students, 330 completed the study that makes 81.89% response success. The overall IPI prevalence was 16.66% (55/330), with a higher prevalence among males (60%, 33/55) than females (40%, 22/55). Five parasite species were identified: two protozoa (Entamoeba histolytica and Giardia lamblia) with a combined prevalence of 9.70% (32/330) and three helminths (Ascaris lumbricoides, Hymenolepis nana, and Taenia spp.) with a combined prevalence of 6.97% (23/330). Cysts were detected in 62.5% of E. histolytica cases (15/24), and eggs were detected in 76.92% of A. lumbricoides cases (10/13). The study revealed a substantial IPI prevalence (16.66%) among the students. This finding underscores the need for effective prevention and control strategies. The predominance of parasitic infections among males is notable requiring further investigation of the factors. The identification of multiple parasite species indicates a complex epidemiological scenario. The presence of protozoan cysts and helminthic eggs highlights the potential for fecal‐oral transmission and the importance of improved sanitation and hygiene practices. [ABSTRACT FROM AUTHOR]

Background: External Jugular Thrombophlebitis (EJT) is a rare clinical phenomenon with few reports in the literature, especially in the pediatric population. This is a report of an unusual case of right-sided EJT in a pediatric patient secondary to acute pharyngitis with sinusitis most prominent on the left side. Case presentation: A 13-year-old presented to the emergency department with worsening upper respiratory infectious (URI) symptoms and facial swelling, cough, throat pain, and emesis. The patient had traveled to Switzerland and received amoxicillin for strep throat 6 weeks before this hospitalization. Physical examination revealed nasal purulence, allodynia over the right side of the face without overlying erythema, and oropharyngeal exudate. CT scan revealed left-sided predominate sinusitis and right external jugular vein thrombosis. Blood cultures confirmed the presence of group A streptococcus infection. Treatment included IV antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), IV steroids, and anticoagulation. Follow-up imaging demonstrated improvement in thrombosis, cellulitis, and sinus disease. The patient was discharged on antibiotics for 6 weeks and anticoagulation for 10 weeks. Follow-up imaging at 6 months revealed no EJT, and medications were discontinued. Conclusions: EJT is a rare condition, and to our knowledge, no reports of EJT with sinusitis most pronounced on the contralateral side have been published. Physicians will benefit from noting clinical signs of EJT such as facial edema, headache, erythema, and palpable neck mass, especially if these symptoms occur with URI symptoms refractory to treatment. The use of anticoagulation is controversial for internal jugular vein thrombosis, and while no guidelines for EJT exist, anticoagulation is likely not necessary save for severe complications. [ABSTRACT FROM AUTHOR]

Background: Despite the worldwide increasing incidence of Group A Streptococcus (GAS) infections reported since December 2022, data on noninvasive GAS (nGAS) infections in the post COVID-19 era are limited. By a self-reported survey performed in an outpatient setting, we investigated the number and clinical features of GAS infections, the diagnostic work-up and the type of treatment utilized. In addition, the rate of influenza vaccination was evaluated. Methods: In June 2023 family pediatricians involved in the study sent the survey to parents of patients aged 0–16 years. The survey included questions on GAS infections that occurred from January 1 to May 31, 2023. Results: Among 3580 children, 20.3% had a GAS infection (0,8% < 1 year, 16,4% 1–3 years, 42,3% 3–6 years, 26,5% 6–9 years, 11,4%, 9–12 years, and 2,6% 12–16 years). Symptoms reported were sore throat (76.9%), fever (75.2%), tonsillar exudate (25.2%), lymphadenopathy (21.8%), and scarlet fever (14.7%). A single patient was hospitalized due to GAS meningitis. Twenty four percent of children had more than one GAS infection. In this group, frequencies of symptoms reported in the first and in the following infection were similar, except for fever and scarlet fever which were less frequent during relapses. GAS was identified by rapid antigen detection test in 81.0% of children. Eighty-nine per cent of children were treated with antibiotics, mostly amoxicillin/clavulanate (40.4%) and amoxicillin (39.4%). Thirty four percent of children received influenza vaccine. No difference was observed among immunized and not immunized regarding the number and characteristics of GAS infection. Conclusions: We reported a certain prevalence of nGAS infections in children, mainly those aged 3–6 years age, who were mostly characterized by a low score of symptoms, and in most of the cases diagnosed and treated using a microbiological test as confirmatory tool. In this new clinical setting, a national study would be useful to reach more significant data for the definition of a correct diagnosis and clinical management of nGAS infections in children. Moreover, it is important to improve flu vaccination campaign and coverage to protect children from coinfections that could worsen the disease and misdiagnose the etiology of pharyngitis. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. Methods: 100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients. Results: After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I. Conclusion: ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients. Implications for Rehabilitation: Extracorporeal shock wave therapy represents a useful non-invasive, additional modality for reduction of foot spasticity and equinus deformity in chronic stroke patients. The application of such a modality improves limb posture, range of motion, and muscle extensibility. Early extracorporeal shock wave rehabilitative intervention in stroke patients reduces fat infiltration and fibrosis replacement of spastic muscle. [ABSTRACT FROM AUTHOR]

Purpose: This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members. Materials and Methods: A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice. Results: Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information. Conclusions: This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration. IMPLICATIONS FOR REHABILITATION: Families reported the hospital environment, inexperienced and inconsistent staffing, and difficulty identifying triggers were challenges in effectively managing challenging behaviours after traumatic brain injury (TBI) in the acute setting. Clinicians can support family involvement in preventative strategies with patients with TBI. Clinicians can enable quality of care by building rapport and providing compassionate care to patients with TBI. Families need more support and information during the acute stage of TBI in hospital settings. [ABSTRACT FROM AUTHOR]

Purpose: Cognitive fatigue is commonly reported and described as disabling by patients recovering from neurological conditions including stroke. However, cognitive fatigue is usually underdiagnosed among stroke survivors which leads to a lack of specific treatments for this condition. Therefore, the aim of this study was to explore post-stroke cognitive fatigue as it is experienced by stroke survivors. Methods: This qualitative research followed the principles of descriptive phenomenology within a constructivist paradigm. Individual semi-structured interviews were conducted with stroke survivors experiencing post-stroke cognitive fatigue recruited through the Heart and Stroke Foundation, the Canadian Partnership for Stroke Recovery, and social media posts. Data were analyzed through inductive content analysis. Results: Eleven stroke survivors participated. The analysis revealed five themes illustrating the experience and descriptions of post-stroke cognitive fatigue: (1) characteristics, (2) aggravating factors, (3) management, (4) effect of cognitive fatigue on daily life, and (5) social awareness and support. Conclusion: This study highlights the complexity of post-stroke cognitive fatigue. Cognitive fatigue becomes more evident after discharge; therefore, clinicians should consistently screen for it and provide proper education to the patients and their carers. IMPLICATIONS FOR REHABILITATION: Cognitive fatigue is a complex phenomenon that can negatively affect the daily life of stroke survivors. Sensory-overloaded environments, emotional distress, poor sleep, and engaging in complex cognitive tasks can trigger post-stroke cognitive fatigue. More education on the concept of cognitive fatigue should be provided to healthcare providers to be able to identify and manage this symptom properly. [ABSTRACT FROM AUTHOR]

Purpose: This focus group study aimed to explore experiences and perceptions on post-stroke fatigue guidance in Dutch rehabilitation and follow-up care among people/patients with stroke and health professionals. Methods: Ten persons with stroke and twelve health professionals with different professions within stroke rehabilitation or follow-up care in the Netherlands were purposively sampled and included. Eight online focus group interviews were conducted. We analysed the data using reflexive thematic analysis. Results: Three themes were identified. Guidance in fatigue management did not always match the needs of people/patients with stroke. Professionals were positive about the provided fatigue guidance (e.g. advice on activity pacing), but found it could be better tailored to the situation of people/patients with stroke. Professionals believe the right time for post-stroke fatigue guidance is when people/patients with stroke are motivated to change physical activity behaviour to manage fatigue – mostly several months after stroke – while people/patients with stroke preferred information on post-stroke fatigue well before discharge. Follow-up care and suggestions for improvement described that follow-up support after rehabilitation by a stroke coach is not implemented nationwide, while people/patients with stroke and professionals expressed a need for it. Conclusions: The study findings will help guide improvement of fatigue guidance in stroke rehabilitation programmes and stroke follow-up care aiming to improve physical activity, functioning, participation, and health. IMPLICATIONS FOR REHABILITATION: We recommend fatigue guidance, including peer support, to be accessible to all people after stroke and for health professionals to pay attention to acceptance of the stroke. To improve fatigue guidance, we suggest providing information on post-stroke fatigue to people after stroke and their relatives well before discharge from stroke rehabilitation. Tailored advice on activity pacing during and after stroke rehabilitation is important to fill the current unmet need of people after stroke to manage fatigue and to gradually improve participation, physical activity behaviour and health. We recommend to health professionals working in stroke rehabilitation to tailor the rehabilitation schedule to their patients' energy level and perception of fatigue levels. [ABSTRACT FROM AUTHOR]

Objective Gastroschisis is the most common congenital abdominal wall defect, with an increasing incidence. It results in extrusion of abdominal contents with associated delayed intestinal motility. Abnormal heart rate characteristics (HRCs) such as decreased variability occur due to the inflammatory response to sepsis in preterm infants. This study aimed to test the hypothesis that infants with gastroschisis have decreased heart rate variability (HRV) after birth and that this physiomarker may predict outcomes. Study Design We analyzed heart rate data from and clinical variables for all infants admitted with gastroschisis from 2009 to 2020. Results Forty-seven infants were admitted during the study period and had available data. Complex gastroschisis infants had reduced HRV after birth. For those with sepsis and necrotizing enterocolitis, abnormal HRCs occurred early in the course of illness. Conclusion Decreased HRV was associated with complex gastroschisis. Infants in this group experienced complications that prolonged time to full enteral feeding and time on total parenteral nutrition. Key Points Infants with gastroschisis can be classified into two subcategories, simple and complex disease. Those with complex disease often require prolonged stays in the neonatal intensive care unit and costly hospitalizations. We hypothesized that infants with complex gastroschisis are more likely to have abnormal HRC due to intestinal inflammation. In this study, we identified associations between abnormal HRV, heart rate characteristicHRC, and the development of gastroschisis complications. Additionally, we described differences in clinical characteristics between infants with complex versus simple gastroschisis. [ABSTRACT FROM AUTHOR]

Objective. Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, represents the most prevalent autoimmune thyroid disorder globally. The potential influence of HT on the clinical and pathological attributes, as well as the clinical outcomes of differentiated thyroid carcinoma (DTC), remains a point of ongoing debate within the medical community. The central focus of this study was to analyze the influence of HT on clinico‐pathological characteristics and its prognostic impact in a large cohort of DTC from Middle Eastern ethnicity. Design, Patients, Measurements. An extensive analysis involving 1822 DTC patients was conducted to determine the association with clinico‐pathological characteristics as well as prognosis, using Chi‐square tests and Kaplan‐Meier curves. Results. 23.9% (435/1822) of DTC patients were diagnosed with HT. Univariate analysis revealed a positive correlation between presence of HT and clinico‐pathological factors such as female gender, younger age, and early stage tumor. In contrast, HT demonstrated a negative association with several aggressive clinical features, including extrathyroidal extension, distant metastasis, recurrent/persistent disease and high‐risk categorization by the American Thyroid Association (ATA) guidelines. Despite HT being associated with favorable clinico‐pathological features in Middle Eastern DTC patient, our study found no significant influence on overall survival or recurrence‐free survival. Conclusion. The finding of an association between HT and favorable clinico‐pathological characteristics, but lack of impact on prognosis, underscores the complexity of HT‐DTC relationship, necessitating further comprehensive research to fully understand these interactions. [ABSTRACT FROM AUTHOR]

Background: Our previous research showed that Porphyromonas gingivalis (P. gingivalis) infection can activate the inflammatory signaling pathway and promotes the malignancy development of esophageal squamous cell carcinoma (ESCC). However, the prognostic significance of inflammatory response-related genes (IRRGs) in P. gingivalis -infected ESCC requires further elucidation. Hence, our study constructed a prognostic signature based on P. gingivalis and IRRGs to forecast the survival of patients with ESCC, which may provide insight into new treatment options for ESCC patients. Methods: Differentially expressed genes (DEGs) were identified in P.gingivalis -infected and P.gingivalis -uninfected ESCC cell by RNA sequencing. A risk model was constructed and validated using the The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) database by using univariate Cox regression analysis, LASSO, and the multivariate Cox regression analysis. Kaplan-Meier analysis was carried out to compare the overall survival (OS) between high-risk and low-risk groups. Single-sample gene set enrichment analysis was used to analyze the immune cell infiltration. The Genomics of Drug Sensitivity in Cancer database was used to predict drug sensitivity. Results: There were 365 DEGs between the P.gingivalis -infected and P.gingivalis -uninfected groups. Four genes including DKK1, ESRRB, EREG, and RELN were identified to construct the prognostic risk model (P =.012, C-index = 0.73). In both the training and validation sets, patients had a considerably shorter OS in the high-risk group than those in the low-risk group (P <.05). A nomogram was established using the risk score, gender, and N stage which could effectively forecast the prognosis of patients (P =.016, C-index = 0.66). The high-risk group displayed lower immune infiltrating cells, such as activated dendritic cells, type 2 T helper cells, and neutrophils (P <.05). A total of 41 drugs, including dactinomycin, luminespib, and sepantronium bromide, had a significant difference in IC50 between the 2 subgroups. Conclusion: We demonstrated the potential of a novel signature constructed from 4 P. gingivalis -related IRRGs for prognostic prediction in ESCC patients. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusions To conduct a systematic review in order to better understand the association of glycaemic risk factors and diabetes duration with risk of heart failure (HF) in individuals with type 2 diabetes (T2D).We identified longitudinal studies investigating the association of glycaemic factors (glycated haemoglobin [HbA1c], HbA1c variability, and hypoglycaemia) and diabetes duration with HF in individuals with T2D. Hazard ratios and odds ratios were extracted and meta‐analysed using a random‐effects model where appropriate. Risk of bias assessment was carried out using a modified Newcastle–Ottawa Scale. Egger's test along with the trim‐and‐fill method were used to assess and account for publication bias.Forty studies representing 4 102 589 people met the inclusion criteria. The risk of developing HF significantly increased by 15% for each percentage point increase in HbA1c, by 2% for each additional year of diabetes duration, and by 43% for having a history of severe hypoglycaemia. Additionally, variability in HbA1c levels was associated with a 20%–26% increased risk of HF for each unit increase in the metrics of variability (HbA1c standard deviation, coefficient of variation, and average successive variability). All included studies scored high in the risk of bias assessment. Egger's test suggested publication bias, with trim‐and‐fill analyses revealing a significant 14% increased risk of HF per percentage point increase in HbA1c.Glycaemic risk factors and diabetes duration significantly contribute to the heightened risk of HF among individuals with T2D. A reduction in risk of HF is anticipated with better management of glycaemic risk factors. [ABSTRACT FROM AUTHOR]

Fibrosis is an abnormal tissue healing process characterized by the excessive accumulation of ECM components, such as COL I and COL III, in response to tissue injury or chronic inflammation. Recent advances in epitranscriptomics have underscored the importance of m6A modification in fibrosis. m6A, the most prevalent modification in eukaryotic RNA, is catalyzed by methyltransferases (e.g., METTL3), removed by demethylases (e.g., FTO), and recognized by reader proteins (e.g., YTHDF1/2). These modifications are crucial in regulating collagen metabolism and associated diseases. Understanding the role of m6A modification in fibrosis and other collagen-related conditions holds promise for developing targeted therapies. This review highlights the latest progress in this area. [ABSTRACT FROM AUTHOR]

Fibrosis is an abnormal tissue healing process characterized by the excessive accumulation of ECM components, such as COL I and COL III, in response to tissue injury or chronic inflammation. Recent advances in epitranscriptomics have underscored the importance of m6A modification in fibrosis. m6A, the most prevalent modification in eukaryotic RNA, is catalyzed by methyltransferases (e.g., METTL3), removed by demethylases (e.g., FTO), and recognized by reader proteins (e.g., YTHDF1/2). These modifications are crucial in regulating collagen metabolism and associated diseases. Understanding the role of m6A modification in fibrosis and other collagen-related conditions holds promise for developing targeted therapies. This review highlights the latest progress in this area. [ABSTRACT FROM AUTHOR]

Background: Transient synovitis of the hip is the most common cause of limping in paediatric emergency departments. There is no consensus regarding routine follow-up after hip synovitis among children, and there are no standardized criteria for selecting cases that warrant follow-up due to persistent or recurring symptoms to rule out the possibility of Legg-Calvé-Perthes disease. Delayed treatment of Legg-Calvé-Perthes disease may increase the risk of developing early secondary coxarthrosis. Understanding the prevalence of Legg-Calvé-Perthes disease among paediatric patients with transient synovitis of the hip is of paramount importance and could empower both parents and paediatricians to make well-informed decisions when selecting follow-up care for children, thus ensuring that no cases of Legg-Calvé-Perthes disease are missed among diagnosis paediatric patients with transient synovitis of the hip. The aim of this review was to estimate the prevalence of Legg-Calvé-Perthes disease among paediatric patients with transient synovitis of the hip. Methods: This study was conducted in strict accordance with the PRISMA guidelines and was registered with PROSPERO. The PubMed, Embase, and Cochrane Library databases were comprehensively searched up to July 2024 to identify relevant studies. The inclusion criteria were as follows: patients diagnosed with transient synovitis of the hip; patients aged up to 18 years; and studies with a minimum of 10 cases of paediatric transient synovitis of the hip. To pool the prevalence rates from individual studies, we utilized a random-effects meta-analysis. To assess the quality of the included studies in detail, we employed the Joanna Briggs Institute's quality assessment checklist. Results: A total of 19 studies were ultimately included for the final analysis, with 2,617 paediatric cases of transient synovitis of the hip. The results of meta-analysis revealed that the pooled prevalence estimate of Legg-Calvé-Perthes disease among all paediatric patients with transient synovitis of the hip was 2.7% (95% CI 1.4–5.1). Significant heterogeneity was observed across the studies included in this analysis (I2 = 79.990%; P = 0.000). The pooled prevalence estimate of Legg-Calvé-Perthes disease among paediatric patients with recurrent or persistent transient synovitis of the hip was 36.3% (95% CI 21.6–54.2). Significant heterogeneity was also observed across the studies included in this analysis (I2 = 51.519%; P = 0.036). Furthermore, the follow-up period varied from 6 weeks to 24 months. The primary diagnostic imaging modality utilized for identifying Perthes disease was X-ray. Conclusion: Our study revealed that among paediatric patients with transient synovitis of the hip, routine X-ray follow-up of the hips after 6 weeks to rule out Legg-Calvé-Perthes disease is warranted only in patients who exhibit persistent or recurrent symptoms. [ABSTRACT FROM AUTHOR]

Background: The perioperative management of patients with chronic cough or cough hypersensitivity syndrome and its sometimes severe effects is currently under-researched and under-reported. Case presentation: A 46-year-old female patient with a history of chronic cough and Cough Hypersensitivity Syndrome. After laparoscopic hiatoplasty and anterior fundoplication under general anesthesia, experienced a pronounced exacerbation of coughing symptoms. Despite prompt and extensive treatment involving antitussives, inhalants, anxiolytics, and sedatives, the symptoms remained uncontrollable. Within a few hours, the patient developed a respiratory alkalosis with severe and life-threatening electrolyte shift (pH 7.705, pCO2 1.72 kPa, K+ 2.1 mmol/l). Lactatemia lasted for more than 12 hours with values up to 6.6 mmol/l. Acute bleeding, pneumothorax, and an acute cardiac event were ruled out. Deep analgosedation and inhalation of high-percentage local anesthetics were necessary to manage the clinical symptoms. Conclusions: This case highlights the challenging nature of chronic cough and hypersensitivity syndrome perioperatively. A tailored anesthesiologic approach, exclusion of other provoking medical problems, and knowledge of possible management and treatment options are key. [ABSTRACT FROM AUTHOR]

Background: Patients with atrial fibrillation (AF) often have concomitant long-term conditions that negatively impact their quality of life and the clinical management they receive. The AFFIRMO study aimed to identify the needs, quality performance indicators (QPIs), and outcomes relevant to patients, caregivers and healthcare professionals (HCPs) to improve the care of patients with AF. Methods: An on-line survey to collect the key needs, QPIs, and outcomes relevant to patients with AF, their caregivers and HCPs, was distributed between May 2022 and January 2023 in five countries (UK, Italy, Denmark, Romania and Spain). Results from the on-line survey were discussed in a three-round Delphi process with international representatives of patients with AF, caregivers, and HCPs to determine the key needs, QPIs and outcomes for the management of patients with AF and multimorbidity. Results: 659 patients (47.2% males, mean (SD) age 70.9 (10.2) years), 201 caregivers (26.9% males, mean (SD) age: 58.3 (SD 15.2) years), and 445 HCPs (57.8% males, mean (SD) age 47.4 (10.6) years) participated in the survey. An initial list of 27 needs, 9 QPIs, and 17 outcomes were identified. Eight patients, two caregivers, and 11 HCPs participated in the Delphi process. Nineteen (70%) needs, 8 (89%) QPIs, and 13 (76%) outcomes reached "consensus in", and were included in the final list. Conclusions: The final key needs, QPIs and outcomes obtained from the Delphi process will inform the AFFIRMO clinical trial, which aims to test the iABC app which incorporates an empowerment toolbox for patients and their caregivers, providing information to improve patient engagement and empowerment to help improve the clinical and self-management of patients with AF in the context of multimorbidity. [ABSTRACT FROM AUTHOR]

Background: Pulmonary hypertension (PH) is a pulmonary vascular disease characterized by elevated pulmonary vascular pressure. Long-term PH, irrespective of its etiology, leads to increased right ventricular (RV) pressure, RV hypertrophy, and ultimately, RV failure. Main body: Research indicates that RV failure secondary to hypertrophy remains the primary cause of mortality in pulmonary arterial hypertension (PAH). However, the impact of PH on RV structure and function under increased overload remains incompletely understood. Several mechanisms have been proposed, including extracellular remodeling, RV hypertrophy, metabolic disturbances, inflammation, apoptosis, autophagy, endothelial-to-mesenchymal transition, neurohormonal dysregulation, capillary rarefaction, and ischemia. Conclusions: Studies have demonstrated the significant role of oxidative stress in the development of RV failure. Understanding the interplay among these mechanisms is crucial for the prevention and management of RV failure in patients with PH. [ABSTRACT FROM AUTHOR]

Background: The potential link between alopecia areata (AA) and eosinophilia is unclear, as well as its clinical manifestations in these patients' subsets. Methods: This is a monocentric retrospective observational study in which clinical and laboratory data were summarized and evaluated the AA subset with concurrent eosinophilia. Results: In a sample of 205 AA patients, 38 (18.5%) were classified as AA with eosinophilia. Interestingly, this subset of patients had a statistically higher prevalence of atopia and nail abnormalities (p < 0.05) than AA without eosinophilia. AA patients with eosinophilia had a 3.70 higher odds of more severe hair loss versus age‐ and gender‐matched AA without eosinophilia. Conclusions: AA patients with eosinophilia had distinctive clinical and laboratory characteristics, so future studies may potentially explore the use of IL‐5 inhibitors. [ABSTRACT FROM AUTHOR]

Background. Limited knowledge exists about genital psoriasis in Thai individuals. Objectives. This study aimed to assess the clinical features of genital psoriasis and its effects on quality of life and sexual health in Thai patients. Materials and Methods. A cross‐sectional, self‐administered question‐based study was conducted at Siriraj Hospital. Participants were psoriasis patients older than 18 years of age with past or current genital involvement. The study assessed quality of life and sexual health. Results. Among the 50 patients, 33 (66%) were female. The mean (standard deviation) age was 45.4 (±13.4) years. Genital psoriasis was active in 34% of the participants. The mons pubis (48.5%) and labia majora (18.2%) were the most frequently affected sites in females, while in males, the penile shaft (52.9%) and glans (47.1%) were the most common sites. Itch‐related symptoms predominated, affecting 82% of patients. The median dermatology life quality index score was 6.5 for females and 10 for males. A sexual health survey revealed that 54% of participants had low self‐esteem. This issue was more pronounced in males, with 76.5% reporting lower self‐esteem compared to 42.4% of females (P = 0.022). Males were also more inclined to postpone or avoid marriage (47.1% vs. 15.6%, P = 0.038) and more embarrassed about sexual activities (63.6% vs. 14.3%, P = 0.017). In addition, males were more inclined to avoid sexual encounters due to their genital condition. Notably, 42.9% of all patients had never disclosed to a doctor that they had genital psoriasis. Conclusions. Genital psoriasis impacts quality of life and sexual function, with male patients being particularly impacted. Improved awareness of these issues among health professionals might increase patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: COPD patients show higher mortality and worse prognosis in the acute phase of COVID-19, and survivors may suffer persistent symptoms that could make them more vulnerable to exacerbations. Objectives: We aimed to evaluate the impact of COVID-19 on the exacerbations, symptoms, quality of life, and mental health of a cohort of COPD patients. Methods: Retrospective case-control single-centre study including all COPD patients from the pulmonary consultation of University Hospital Santa Maria (Lleida, Spain) surviving COVID-19 between March 2020 and September 2021, and similar propensity-score-matched (1:2) COPD patients. Differences in COPD exacerbations, COPD clinical evolution (lung function, dyspnoea, CAT and symptoms), long COVID-19 symptoms, quality of life, and mental health, were assessed at the end of 2021. Results: We included 39 COVID-19 COPD patients and 78 similar non-COVID-19. No differences were found on exacerbations (46(59%) vs. 27(69.2%), p = 0.380), dyspnoea (2 [1; 3] vs. 2 [1; 3], p = 0.921) CAT (14.5 [10.0; 18.8] vs. 13.0 [10.0; 16.0], p = 0.432). Only the prevalence of smell or taste disorders, hair loss and tingling was higher in COVID-19 patients. No differences were found in quality of life or mental health. Conclusions: COPD patients surviving COVID-19 were not at a higher risk of COPD exacerbations nor showed significant changes in COPD clinical evolution, and only showed differences in a few very specific COVID-19 symptoms. These unexpected results suggest that the conditions triggered by the pandemic and its management could have affected COPD patients as much as actually having had COVID-19. [ABSTRACT FROM AUTHOR]

Background: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal hemorrhage. Despite diagnostic and therapeutic advances, the mortality rate in AEF patients remains high because of its fulminant course, even with maximal intensive care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation technique to control life-threatening bleeding. It has become an important modality in the management of life-threatening, traumatic or non-traumatic, arterial bleeding. However, it's use in hemorrhagic shock caused by cancer has rarely been reported. Case presentation: A 51-year-old woman with a history of esophageal cancer presented to our emergency department with hematemesis. Computed tomography was performed because of a strong suspicion of hemorrhagic shock. With a diagnosis of AEF due to esophageal cancer, emergency thoracic endovascular aortic repair was performed while the bleeding was controlled using REBOA. Staged elective esophageal reconstruction was successfully performed. Conclusions: Hemostasis is crucial in patients who present with suspected hemorrhagic shock attributable to AEF. The timely implementation of REBOA has shown promise and potential effectiveness in such cases. [ABSTRACT FROM AUTHOR]

Background: Cervical epidural hematoma (CEH) is a rare but potentially devastating condition, characterized by the accumulation of blood within the epidural space of the cervical spine, leading to spinal cord compression (Perron AD, Huff JS. Spinal cord disorders. In: Marx JA, et al. editors. Rosen's emergency medicine: concepts and clinical practice. 8th ed. Philadelphia: Saunders; 2013. pp. 1419–27.); (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Ryo Yamamoto M, Ito H, Shimuzu K, Wakabayashi H, Oyama. Two cases of cervical epidural hematoma presenting with left-sided hemiplegia and requiring surgical drainage. Cureus. 2022;14(4):e23915. https://doi.org/10.7759/cureus.23915.). While trauma and iatrogenic causes are well-documented, cases attributed to neck strain and acupuncture are uncommon. (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of an acupuncture. Neurology. 1979;29(8):1188–90. https://doi.org/10.1212/wnl.29.8.1188.) Here, we present two cases of CEH secondary to these unusual aetiologies. Both cases highlight the importance of considering uncommon causes of CEH to ensure early recognition and prompt treatment. Case presentations: Case 1 is an 81-year-old lady who presented with left hemiparesis and paraesthesia following a fall with neck strain. Magnetic resonance imaging (MRI) of cervical spine revealed left C3-C7 epidural haematoma with severe cord compression. In Case 2, a 35-year-old gentleman experienced sudden onset numbness and weakness in all limbs just 10 minutes after receiving acupuncture. MRI showed an epidural hematoma at the C2-C4 levels. Both patients underwent immediate surgical decompression and had significant recovery. Conclusion: Although CEH is a rare occurrence, it can potentially be a neurosurgical emergency. Physicians must remain cognizant of the diverse aetiologies associated with CEH and the necessity for early recognition and immediate treatment. [ABSTRACT FROM AUTHOR]

Background: End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores. Methods: Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents. Results: Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05). Conclusions: The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted. [ABSTRACT FROM AUTHOR]

Background: The prevalence of type 2 diabetes (T2D) in the French overseas department of French Guiana, South America, nearly doubles that in its European counterpart, Metropolitan France. This region is demographically diverse and includes several populations of Indigenous Peoples. Although such populations are at particular risk of developing T2D across the Americas, very little is known about their health status in French Guiana, and accurate numbers of diabetic patients do not exist. Methods: In light of a potential public health crisis, an ethnomedicinal study of diabetes experienced by Indigenous Parikweneh was conducted to provide better insight into the knowledge, attitudes and practices (KAP) related to this quickly emerging disease in French Guiana. Altogether, 75 interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikweneh population of Macouria and Saint-Georges de l'Oyapock. Results: Interviews suggest a high incidence of T2D in this population, with cases that have risen quickly since the mid-twentieth century. Parikweneh participants linked the development of the illness to dietary changes, notably through the introduction of new and sweet foods. Recognizing the complexity of diabetes and its symptoms, diabetic patients highlighted the importance of biomedical treatments and follow-ups, though they frequently alternated or used them concomitantly with Parikweneh medicines. With the help of biomedical tools (i.e. glucometer), local medicinal practices mirrored biomedical approaches through dietary adaptation and the use of medicinal animals and plants for glycaemic control and the treatment of complications from the disease. Conclusion: Parikweneh are appropriating T2D into their knowledge system and adapting their health system in response to this relatively new health concern. A greater understanding of local practices and perceptions relating to T2D among medical staff may therefore be beneficial for meeting patients' needs, providing greater autonomy in their health path, and improving treatment outcomes. [ABSTRACT FROM AUTHOR]

Objectives To describe the clinical features and treatment outcomes of children with juvenile psoriatic arthritis (JPsA) and compare the distinct patterns of the disease between early-onset and late-onset age groups. Methods Patients with JPsA followed regularly for at least 6 months between 2010 and 2020 in seven paediatric rheumatology centres in Turkey were included in the study. The demographic features, clinical manifestations, treatment strategies and outcomes of the patients were evaluated retrospectively. Results A total of 87 (46 male/41 female) patients were included in the study. The mean age at diagnosis was 11.9 years (s. d. 4.5). Fifty-seven (65.5%) patients had psoriasis at the time of diagnosis and arthritis preceded psoriasis in 10 (11.5%) patients. Thirty (34.5%) patients had dactylitis, 28 (32.2%) had nail pitting, 36 (41.4%) had involvement of the small joints and 20 (23%) had enthesitis. Sacroiliitis was detected in 11 (12.6%) patients by MRI. ANA was positive in 35 (40.2%) patients. Twelve children (13.8%) were in the early-onset (<5 years) group. Uveitis and ANA positivity were more common in the early-onset group. Active joint counts and activity scores of our patients showed significant improvement at month 6 and at the last control compared with baseline. Conclusion About one-third of patients with JPsA do not have psoriasis at the time of diagnosis. In some patients, no skin lesion is seen during the course of the disease. Children with PsA seem to display two different phenotypes. Younger children have a female predominance, ANA positivity and uveitis, while older children have more axial involvement. [ABSTRACT FROM AUTHOR]

Background: While home is frequently expressed as the favorite place of death (PoD) among terminally ill cancer patients, various factors affect the fulfillment of this wish. The determinants of the PoD of cancer patients in countries without healthcare system-integrated palliative and supportive care have not been studied before. This study aimed at identifying the predictors of the PoD of patients who suffer from advanced cancer by developing a reliable predictive model among who received home-based palliative care in Iran as a representative of the countries with isolated provision of palliative care services. Methods: In a cross-sectional study, electronic records of 4083 advanced cancer patients enrolled in the Iranian Cancer Control Center (MACSA) palliative homecare program, who died between February 2018 and February 2020 were retrieved. Multivariable binary logistic regression analysis as well as subgroup analyses (location, sex, marital status, and tumor topography) was performed to identify the predictors of PoD. Results: Of the 2398 cases included (mean age (SD) = 64.17 (14.45) year, 1269 (%52.9) male), 1216 (50.7%) patients died at home. Older age, presence and intensity of medical homecare in the last two weeks and registration in the Tehran site of the program were associated with dying at home (P < 0.05). Gynecological or hematological cancers, presence and intensity of the calls received from the remote palliative care unit in the last two weeks were predictors of death at the hospital (p < 0.05). The model was internally and externally validated (AUC = 0.723 (95% CI = 0.702–0.745; P < 0.001) and AUC = 0.697 (95% CI = 0.631–0.763; P < 0.001) respectively). Conclusion: Our model highlights the demographic, illness-related and environmental determinants of the PoD in communities with patchy provision of palliative care. It also urges policymakers and service providers to identify and take the local determinant of the place of death into account to match the goals of palliative and supportive services with the patient preferences. [ABSTRACT FROM AUTHOR]

Introduction: Myocardial ischemia can occur due to several causes, which result in an imbalance between the supply and demand of oxygen to cardiac muscles. One potential reason for this condition is the overwork of the heart due to hyperstimulated thyroid function. Case presentation: The patient was a 36-year-old woman who presented with left-sided chest pain, dyspnea, palpitation, and tremor. The initial evaluation showed evidence of myocardial ischemia (positive high-sensitivity troponin) caused by a hyperactive thyroid gland. The treatment for myocardial infarction, along with anti-thyroid medications, improved the patient's condition and subsided the symptoms. The coronary angiography revealed no pathologic finding, and the hypokinetic left ventricle, observed in the first echocardiogram, was resolved. The patient was discharged with an excellent clinical condition, and after the 4-month taking of a calcium channel blocker and tapering carbimazole, the thyroid function became normal, and her symptoms resolved completely. Conclusion: Patients without evident risk factors for ischemic heart disease, such as non-diabetic, nonsmoker, and young individuals who presented with acute coronary syndrome, should be evaluated for a potential background reason for the imbalance between the oxygen demand and supply of the myocardium. The presence of palpitation, weight loss, tremors, insomnia, and anxiousness, along with ischemic signs, should make the physician think about the probability of the hyperthyroid-induced cardiovascular disorder. Clinical key point: The initial presentation of hyperthyroidism might be accompanied by severe cardiac symptoms. When the demographic features are not aligned with usual ischemic heart disease, other probable symptoms and signs should be investigated, and thyroid function should be checked. The control of thyroid hyperactivity would result in the resolution of both cardiac and non-cardiac symptoms. [ABSTRACT FROM AUTHOR]

Objective: There are very few reports on the prevalence of diabetic retinopathy (DR) in children and youth with type-1 diabetes (T1D). Studies have also found very low rates of referral for DR screening in children and youth with T1D. We conducted this study to determine the prevalence of DR, to study the reliability of ISPAD screening recommendations and to identify predictors of DR, its progression and regression in Indian children and youth with T1D. Methods: This study included 882 children and youth with T1D. Demographic data, anthropometry, blood pressure, sexual maturity rating, ophthalmological examination (slit lamp for cataract) and biochemical measurements were performed using standard protocols. Fundus images were captured using the Forus Health 3netra classic digital non-mydriatic fundus camera by the same experienced operator. De-identified images were assessed by a senior grader and ophthalmologist (Belfast Ophthalmic Reading Center). Severity of DR was graded as per the UK National Health Service (NHS) DR classification scale. Result: We report 6.4% and 0.2% prevalence of DR and cataract in Indian children and youth with T1D, respectively. All the subjects with DR had early non-proliferative DR. We report that amongst subjects with DR, only 2 subjects were aged less than 11 years and had duration of illness less than 2 years. Presence of hypertension and older age were significant predictors of DR (P <.05). Subjects with DR had significantly higher triglyceride concentrations (P <.05), of these, 6.9% had progression and 2.9% had regression at 1 year follow up; the change in glycaemic control was a significant positive predictor of progression of DR (P <.05). None of the participants included in the study progressed to develop sight-threatening DR. Conclusion: DR is not uncommon in Indian children and youth with T1D, thus screening for DR needs to be initiated early, particularly in older individuals with higher disease duration. Controlling blood pressure and triglyceride concentrations may prevent occurrence of DR. Improving glycaemic control may prevent progression of DR in Indian children and youth with T1D. Plain Language Summary: Diabetic retinopathy in Indian children with Type 1 Diabetes We found that 6.4% and 0.2% Indian children and youth with type-1 diabetes had diabetic retinopathy and cataract respectively. We report that amongst subjects with DR, only 2 subjects were aged less than 11 years and had duration of illness less than 2 years. Thus, International Society for Paediatric and Adolescent Diabetes (ISPAD) screening criteria must be implemented by all centres to avoid missing cases. Presence of high blood pressure, high triglyceride levels and older age were significant predictors of DR. Of the subjects with DR, 6.9% had progression and 2.9% had regression at 1 year follow up; the change in glycaemic control was a significant positive predictor of progression of DR. None of the participants included in the study progressed to develop sight-threatening DR. DR is not uncommon in Indian children and youth with T1D, hence, screening for DR needs to be initiated early, particularly in older individuals with higher disease duration. Controlling blood pressure and triglyceride concentrations may prevent occurrence of DR. Improving glycaemic control may prevent progression of DR in Indian children and youth with T1D. [ABSTRACT FROM AUTHOR]

Background: Severe kyphosis is a common condition in patients with advanced ankylosing spondylitis (AS). Although two-level osteotomy may serve as a potential alternative, it is often associated with increased blood loss and elevated surgical risks. To date, the optimal treatment for the challenging condition remains unclear. This study aims to introduce an effective strategy for the treatment of severe kyphosis secondary to AS, using one-level modified osteotomy combined with shoulders lifting correction method. Methods: Seventy AS kyphosis who were treated with the strategy from 2012 to 2022, were reviewed retrospectively. All patients were followed up for a minimum duration of 2 years. Spinal and pelvic parameters were measured, including pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumber lordosis (LL), PI and LL mismatch (PI-LL), thoracic kyphosis, global kyphosis (GK), T1 pelvic angle (TPA), sagittal vertical axis (SVA), osteotomized vertebral angle (OVA), and chin-brow vertical angle (CBVA). Parameters of local osteotomized complex were measured and calculated, including the height of osteotomized complex and the length of spinal cord shortening. Clinical outcome was evaluated using Scoliosis Research Society-22 and Oswestry Disability Index scores. Results: Seventy patients with average age of 39.8 years were followed-up for 29.3 months. Average operation time was 373.5 min, and average blood loss was 751.0 ml. Postoperatively, sagittal balance was successfully restored. GK decreased from 90.6° to 35.6°, LL decreased from 8.0° to -35.1°, TPA decreased from 56.8° to 27.8°, and SVA decreased from 24.4 cm to 8.7 cm (P < 0.05). A harmonious and matched spinopelvic alignment was achieved. PT decreased from 37.2° to 26.3°, PI-LL decreased from 54.1° to 10.2°, and SS increased from 9.2° to 19.7°(P < 0.05). Horizontal vision was obtained with postoperative CBVA of 8.8°. Average OVA correction was up to 47.3°, and the spinal cord was shortened by 24.3 mm, with a shortening rate of 36.0%. All patients demonstrated a favorable clinical outcome. No permanent nerve damage, screw loosening, rod breakage and main vascular injury were observed. One case required revision surgery due to screw cap loosening and delayed union. Solid bone fusion was achieved in all other patients. Conclusions: One-level modified osteotomy combined with shoulders lifting correction method is a safe and effective strategy for the treatment of severe AS kyphosis. This strategy offers a promising alternative for managing severe AS kyphosis, and may be particularly well-suited for individuals with concurrent osteoporosis. Level of evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Carboxylesterase 1(CES1) is expressed mainly in the liver and adipose tissue and is highly hypothesized to play an essential role in metabolism. Our study aimed to investigate the association between CES1 and metabolic syndrome (MetS) and metabolic dysfunction associated steatotic liver disease (MASLD) in children with obesity in China. Methods: This study included 72 children with obesity aged 6-13years (including 25(35%) diagnosed as MetS and 36(50%) diagnosed as MASLD). All subjects were measured in anthropometry, serum level of biochemical parameters related to obesity, circumstance levels of insulin-like growth factor1, adipokines (adiponectin, leptin and growth differentiation factor 15) and CES1. Results: Higher serum CES1 level were found in the MetS group (P = 0.004) and the MASLD group (P < 0.001) of children with obesity. Serum CES1 levels were positively correlated with alanine aminotransferase, aspartate aminotransferase, triglyceride, cholesterol, low-density lipoprotein cholesterol, GDF15, Leptin and negatively correlated with high-density lipoprotein cholesterol, adiponectin and IGF1. We also found a multivariable logistic regression analysis of MASLD and MetS predicted by CES1 significantly (MASLD P < 0.01, MetS P < 0.05). The combination of CES1, sex, age and BMI Z-score showed a sensitivity and specificity of 92.7% for the identification of MASLD and 78.6% for the identification of MetS. The cutoff for CES1 of MASLD is 56.30 ng/mL and of MetS is 97.79 ng/mL. Conclusions: CES1 is associated with an increasing risk of MetS and MASLD and can be established as a biomarker for metabolic syndrome and MASLD of children with obesity. [ABSTRACT FROM AUTHOR]

Background: Systemic Lupus Erythematosus (SLE) patients are more likely than the general population to suffer from thyroid illness. The major goal was to assess the thyroid dysfunctions due to immunological factors in Egyptian SLE children and how they are related to the course and severity of the illness. Methods: Fifty children and adolescents with SLE are included in this cross-sectional observational study. Every patient underwent a thorough physical examination and a comprehensive history taking. An enzyme-linked immunosorbent assay (ELISA) approach was used to evaluate the thyroid profile, anti-thyroglobulin (Anti-TG), and anti-thyroid peroxidase (anti-TPO) antibodies. Results: Of the 50 patients, the female: male ratio (F: M = 7:1) was 44 females and 6 males (12%). They were between the ages of 5 and 17. Out of the patients, thirty-two (64%) had thyroid dysfunctions, 19 (38%) had euthyroid sick syndrome, ten (20%) had overt hypothyroidism, three (6%) had subclinical hypothyroidism, and none had hyperthyroidism. Of the 50 patients, one (2%) had increased anti-TPO, whereas all other patients had normal anti-TG levels. A statistically significant negative correlation (p-value 0.007) was seen between the disease duration and free thyroxine (FT4). Furthermore, a significant negative correlation (p-values 0.015 and 0.028) was found when comparing the disease duration with thyroid antibodies (anti-TG and anti-TPO). Conclusion: In Juvenile Systemic Lupus Erythematosus (JSLE), thyroid dysfunctions can be identified. The disease duration but not its activity was significantly correlated with thyroid antibodies. For children with JSLE, thyroid function testing should be done on a regular basis. It is preferable to carry out additional thyroid antibody tests when necessary. [ABSTRACT FROM AUTHOR]

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening skin lesion triggered by hypersensitive drug reaction. They are characterized by extensive epidermal necrosis and skin exfoliation. Fulminant type 1 diabetes mellitus (FT1DM) is featured by a rapid-onset of hyperglycemia with ketoacidosis due to severely destroyed β-cell function. Fulminant type 1 diabetes mellitus as a sequela of SJS/TEN has rarely been reported. Case presentation: We present a 73-year-old female patient who developed SJS/TEN skin allergic reaction after taking carbamazepine and phenytoin for 35 days. Then, hyperglycemia and diabetic ketoacidosis occurred 20 days after discontinuation of antiepileptic drugs. A very low serum C-peptide level (8.79 pmol/l) and a near-normal glycosylated hemoglobin level met the diagnostic criteria for fulminant T1DM. Intravenous immunoglobulin (IVIG) and insulin were promptly administered, and the patient recovered finally. Conclusions: This rare case indicates that monitoring blood glucose is necessary in SJS/TEN drug reaction, and comprehensive therapy with rehydration, insulin, antibiotics, and IVIG may improve the prognosis. [ABSTRACT FROM AUTHOR]

Background and Objective: Prospective sequential analyses after a new drug approval allow proactive surveillance of new drugs. In the current study, we demonstrate feasibility of frailty-specific sequential analyses for dabigatran, rivaroxaban, and apixaban versus warfarin. Methods: We partitioned Medicare data from 2011 to 2020 into datasets based on calendar year following the date of drug approval. Each calendar year of data was added sequentially for analysis. We used a new-user, active comparative design by comparing the initiators of dabigatran versus warfarin, rivaroxaban versus warfarin, and apixaban versus warfarin. Patients aged ≥ 65 years with atrial fibrillation without contraindication to the anticoagulants were included. Claims-based frailty index ≥ 0.25 was used to define frailty. The initiators of each direct oral anticoagulant were propensity-score matched to the initiators of warfarin within each frailty status. The effectiveness outcome was ischemic stroke or systemic thromboembolism, and the safety outcome was major bleeding. For each calendar year, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) from Cox proportional hazards models using all data available up to that year. Results: As an example of the results, in the 2020 dataset, compared with warfarin, apixaban was associated with a reduced risk of ischemic stroke or systemic thromboembolism (frail: HR 0.73, 95% CI 0.63–0.85; non-frail: HR 0.65, 95% CI 0.59–0.72) and major bleeding (frail: HR 0.63, 95% CI 0.57–0.69; non-frail: HR 0.59, 95% CI 0.56–0.63) in both frail and non-frail patients. We found evidence for apixaban's effectiveness and safety within 1–2 years after the drug approval in frail older patients. Conclusion: Our frailty-specific sequential analyses can be applied to future near-real-time monitoring of newly approved drugs. [ABSTRACT FROM AUTHOR]

Still's disease (SD) is a rare systemic inflammatory disease that is characterized by high fever, polyarthritis, and an evanescent rash as its main symptoms but that may also be complicated by pleuritis and macrophage activation syndrome (MAS). There has been a recent increase in studies on older-onset SD, which presents with less-typical clinical features, such as sore throat, skin lesions, and splenomegaly, but more complications including pleuritis and disseminated intravascular coagulation. Several reports have shown higher levels of inflammatory markers, including serum ferritin, and poorer outcomes in terms of survival and drug-free remission in older patients. In addition, caution is needed when diagnosing SD in older patients because of the increased incidence of differential diagnoses such as infectious diseases, malignancies, and inflammatory diseases. Prognosis is poor in older patients, and treatment-associated infections and severe complications such as MAS are the main cause of mortality. The use of biologics and treatment response may not differ greatly between older and younger patients. Although the data are limited, anti-IL-1 and anti-IL-6 agents may control SD in these patients with careful use and adequate infection prevention. Recent studies that classified adult-onset SD by cluster analysis or latent class analysis showed that older patients form a unique cluster of SD, indicating the need for clinicians to pay more attention to the diagnosis and management of SD in older patients. [ABSTRACT FROM AUTHOR]

Background: An intricate physiological and pathophysiological connection exists between the heart and lungs, which is especially important in individuals with spinal cord injury (SCI). While an exercise intervention may seem the best approach to leverage this relationship, the prior work has shown that, despite numerous health benefits, regular exercise training does not improve cardiorespiratory control in individuals with SCI. Breath training presents an alternative intervention that is uniquely accessible, with yogic breathing directly engaging linked fluctuations in respiration and cardiovascular control. In addition, there is evidence across a range of populations that regular yogic breathing reduces cardiovascular disease risk. It is possible that the chronic decrease in breathing frequency associated with regular yogic breathing, rather than the specific yogic breathing techniques themselves, is the primary contributor to the observed risk reduction. Methods: Therefore, in 12 individuals with traumatic SCI from C4 to T8, the authors compared Unpaced and conventional 0.083 Hz (Slow) paced breathing with various yogic breathing techniques including: (1) inspiratory–expiratory breath holds (i.e., Kumbhaka or "Box Breathing"), (2) extended exhalation (1:2 duty cycle), and (3) expiratory resistance via throat constriction (i.e., Ujjayi). Beat-to-beat heart rate and blood pressure were measured as well as end-tidal CO2 and O2 saturation were measured. Statistical analysis was performed using a one-way repeated-measures analysis of variance with post hoc pairwise t tests corrected for multiple comparisons. Results: As expected, all slow breathing patterns markedly increased respiratory sinus arrhythmia (RSA) compared with Unpaced in all (n = 12) individuals. More importantly, Ujjayi breathing appeared to improve ventilatory efficiency over Unpaced breathing in individuals with SCI by increasing O2 saturation (97.6% vs. 96.1%; p = 0.042) and tended to decrease end-tidal CO2 (32 mmHg vs. 35 mmHg; p = 0.08). While other slow breathing patterns demonstrated similar effects, only Ujjayi improved RSA while increasing heart rate and improving ventilatory efficiency. Conclusions: Hence, slow breathing per se can result in important cardiorespiratory changes, but the yogic breathing practice of Ujjayi, with glottic throat resistance, may hold the greatest promise for improving cardiorespiratory control in individuals with SCI (CTR ID No. NCT05480618). [ABSTRACT FROM AUTHOR]

This series of three articles will explore the fundamentals related to anatomy, physiology and pathophysiology in relation to three important topics: the cardiac system, the respiratory system and the endocrine system. The series is intended to provide an informative and evidence-based summary of each topic for both students and clinicians. This first article explores the maternal cardiovascular system, outlining its anatomy and the key physiological adaptations of pregnancy, and summarising pathophysiological conditions that may occur. [ABSTRACT FROM AUTHOR]

Approximately 8% of patients with Cushing syndrome can develop psychosis. Current knowledge on the effective management of psychosis in the course of Cushing syndrome is based mostly on case reports. Treatment is considered difficult and patients' responses vary. In only one of the analyzed cases, administration of atypical antipsychotic drugs was sufficient to control the psychosis. In none of the cases were typical antipsychotics effective. Some authors reported cessation of psychotic symptoms after treatment with steroidogenesis inhibitors, glucocorticoid receptor antagonists or dopamine receptor agonists; however, in others, surgical removal of the underlying cause of Cushing syndrome was necessary. There are also reports of patients who required additional psychotropic medications after successful surgery. Additional studies are required to define the most effective therapeutic approach. [ABSTRACT FROM AUTHOR]

Objectives: Our study aimed to investigate the association between shift work and stroke and determinewhether this association varies depending on the presence of insomnia. Methods: Utilizing the KoGES prospective cohort data, our primary exposure variables were shift work and insomnia. The occurrence of strokewas themain outcome of interest. Hazards ratios and 95%confidence intervals were estimated using Cox regression analysis. An interaction analysis was conducted to assess the interaction of shift work and insomnia on stroke incidence. Results: In the interaction analysis, shift work was significantly associated with stroke incidence only in groupswith insomnia and a hazards ratio of 2.49 (95% confidence interval, 1.02-6.11). Conclusions: Our study demonstrated that shift work was associated with a higher risk of stroke among the population with insomnia. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to examine the influence of socioeconomic deprivation on language and developmental outcomes in toddlers with cleft palate with or without cleft lip (CP ± L). Other factors known to influence language outcomes were also considered, including home language history, history of hearing problems, syndromic diagnoses, and sex. Method: A multicenter, cross-sectional study design was conducted. Data for 566 16-month-old toddlers with CP ± L were collected from 17 outpatient cleft palate clinics located throughout the United States. Outcome measures included the MacArthur-Bates Communicative Development Inventories, LENA Developmental Snapshot, age at first word as reported by the caregiver, and the Ages and Stages Questionnaires-Third Edition (ASQ-3). Multivariable linear or logistic regression was used to determine the influence of socioeconomic deprivation, as measured by the Area Deprivation Index, on language and developmental outcomes. Results: Greater socioeconomic deprivation significantly predicted poorer language outcomes in toddlers with CP ± L, including receptive vocabulary words (p = .02), expressive vocabulary words (p = .02), and late-developing gestures (p = .02). Additionally, toddlers from less affluent neighborhoods produced their first words significantly later than their counterparts living in more affluent areas (p < .01). Lower maternal education levels predicted significantly increased risk for problem solving delays (p < .01), and patients with subsidized insurance were at significantly increased risk for personal-social delays on the ASQ-3 (p < .01). Conclusions: Children with CP ± L are susceptible to developmental delays associated with socioeconomic deprivation. These findings have implications for identifying a child's individual risk factors for developmental language disorders when conducting speech-language assessments. Future study should examine how inequities in care can be mitigated and addressed. [ABSTRACT FROM AUTHOR]

Purpose: Parkinson's disease (PD) results in hypokinetic dysarthria in as many as 90% of cases. Among the most distinctive features of hypokinetic dysarthria are atypical timing and articulatory imprecision in speech production. Here, we examined the contributions of perceived speech timing typicality and articulatory precision, both on their own and while controlling for the other, on intelligibility and naturalness in speakers with PD. Method: Twenty speakers with PD and four healthy older adults read aloud the first paragraph of the Rainbow Passage. Twenty inexperienced listeners with typical hearing listened to these recordings and rated intelligibility, naturalness, timing typicality, and articulatory precision using separate visual analog scales. Ratings were averaged across listeners and entered into linear regression models with intelligibility and naturalness as dependent variables and timing typicality and articulatory precision as independent variables in each. Results: Articulatory precision, but not timing typicality, was positively correlated with intelligibility on its own, but neither was associated with intelligibility after accounting for the other. Both timing typicality and articulatory precision were positively correlated with naturalness on their own as well as after controlling for the other variable. Conclusion: These results contribute to the overall understanding of speech factors associated with intelligibility and naturalness in speakers with PD and indicate that considering the unique contributions of related perceptual constructs may provide more information than bivariate relationships alone. [ABSTRACT FROM AUTHOR]

Purpose: Ten years after Miller and Lowit's (2014) groundbreaking book providing a cross-linguistic perspective on motor speech disorders, we ask where we are regarding dysarthria treatment across languages in two specific populations: adults with Parkinson's disease (PD) and children with cerebral palsy (CP). Method: In this commentary, we consider preliminary evidence for both languageindependent and language-specific approaches to treatment and propose a hybrid approach to speech treatment across languages, centered on the individual with dysarthria who speaks any given language. Conclusions: Treatment research on individuals with dysarthria secondary to PD and CP is advancing, but several areas remain to be explored. Next steps are suggested for addressing the paucity and complexity of cross-linguistic speech treatment research. [ABSTRACT FROM AUTHOR]

Purpose: Reduced speech intelligibility is often a hallmark of children with dysarthria secondary to cerebral palsy (CP), but effects of speech strategies for increasing intelligibility are understudied, especially in children who speak languages other than English. This study examined the effects of (the Korean translation of) two cues, "speak with your big mouth" and "speak with your strong voice," on speech acoustics and intelligibility of Korean-speaking children with CP. Method: Fifteen Korean-speaking children with CP repeated words and sentences in habitual, big mouth, and strong voice conditions. Acoustic analyses were performed and intelligibility was assessed by means of 90 blinded listeners' ease-of-understanding (EoU) ratings and percentage of words correctly transcribed (PWC). Results: In response to both cues, children's vocal intensity and utterance duration increased significantly and differentially, whereas their vowel space area gains did not reach statistical significance. EoU increased significantly in the big mouth condition at word, but not sentence, level, whereas in the strong voice condition, EoU increased significantly at both levels. PWC increases were not statistically significant. Considerable variability in children's responses to cues was noted overall. Conclusions: Korean-speaking children with CP modify their speech styles differentially when provided with cues aimed to increase their articulatory working space and vocal intensity. The results provide preliminary support for the use of the strong voice cue, in particular, to increase EoU. While the findings do not offer conclusive evidence of the intelligibility benefits of these cues, investigation with a larger sample size should provide further insight into optimal cueing strategies for increasing intelligibility in this population. Implications for language-specific versus language-independent treatment approaches are discussed. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this article is to raise awareness about the importance of diverting from English-centric approaches in the management of dysarthria associated with Parkinson's disease (PD) in the United States, and embracing a language- and culture-specific perspective when working with linguistically and culturally diverse populations within the context of culturally responsive, precision medicine. Method: This tutorial is divided into two primary components: a critical review of language universal and language-specific characteristics of dysarthria associated with PD and their relationship with speech intelligibility, and a practical guide to culturally responsive evidence-based practice for speech-language pathologists. Conclusions: We offer a framework for linguistically and culturally appropriate considerations when working with clients with dysarthria associated with PD. While "universal" representations of dysarthria may be part of the big picture, language-specific contributions to speakers' intelligibility should be carefully examined to maximize treatment outcomes. Additionally, an evidence-based model that fully embraces clients' wishes and values within the context of culturally responsive, precision medicine should be prioritized, a practice that may include the use of interpreters. [ABSTRACT FROM AUTHOR]

Background: Oropharyngeal cancer (OPC) survivorship is a nursing priority because patients are living longer while significant short-term and long-term treatment complications that require nursing care are increasing. Hospital readmission is costly and reflects the quality of care patients receive. Objectives: This secondary analysis aimed to determine the prevalence of treatment complications resulting in hospital admissions among persons with OPC and examine the relationship between treatment complications resulting in hospital admission among persons with OPC and all other persons with head and neck cancer. Methods: Using the National Inpatient Survey 2008-2019 database, we identified persons with relevant head and neck cancer diagnoses using specific International Classification of Disease ICD-9 and ICD-10 codes. Complications were operationalized by diagnosis-related codes; persons with codes for major elective surgery were excluded as our focus was posttreatment symptoms requiring hospitalization. Descriptive statistics were used to characterize persons with OPC hospitalized between 2008 and 2019. Binary logistic regression was used to assess complications using crude comparisons. The Elixhauser Comorbidity Index was used for controlling for comorbidities. Results: The final analysis samples included 751,533: 164,770 persons with OPC and 586,763 with other head and cancers. Themost prevalent diagnoses observed in those with OPC were esophagitis, nutrition disorder, hematological disorder, and renal failure; the least common diagnoses were sepsis, respiratory tract infection, and pneumonia. Binary regression revealed that persons with OPC experienced significantly more esophagitis, nutrition disorders, hematological disorders, and renal failure compared to persons with other head and neck cancers. Discussion: Treatment of survivors of OPC requires more intensive monitoring for early symptoms associated with treatment, including esophagitis, nutrition disorders, bleeding disorders, and renal failure, than persons with other head and neck cancers. Monitoring laboratory values and clinical manifestations of these conditions is imperative. Nurses may encounter persons with OPC in emergency departments, outpatient radiology, or inpatient general medicine floors to manage swallowing difficulties, dehydration, malnutrition, and bleeding. Delayed or ineffective treatment of these conditions contributes to readmission, financial burden, and impairment of patient's quality of life. Future research should investigate the relationship between targeted treatment for expected complications and readmission rates in persons with OPC. [ABSTRACT FROM AUTHOR]

Better mechanistic understanding of desmosome disruption and acantholysis in Grover's disease (GD) may improve management of this disease. Recent molecular studies highlighted promising pathways to be explored by directly comparing GD and selected features of associated skin diseases. The association between GD and cutaneous keratinocyte carcinomas, the most prevalent non-melanoma skin cancers (NMSC), is not completely characterized. To review the medical literature regarding GD-associated cutaneous keratinocyte cancers, focusing on molecular features, pathophysiological mechanisms, and disease associations, to help guide future research and patient management. GD has been associated with a variety of skin conditions, but its association with skin cancers has been rarely reported. Between 1983 and 2024, only nine scientific papers presented data supporting this association. Interestingly, we found that GD may mimic multiple NMSCs, as few authors reported GD cases misdiagnosed as multiple cutaneous squamous cell carcinomas for more than 4 years or the presence of superficial basal cell carcinoma-like areas associated with focal acantholysis. In conclusion: (a) GD may be an imitator of multiple NMSCs, and (b) the relationship between GD and NMSCs may reveal promising pathways for the mechanistic understanding of desmosome disruption and acantholysis in GD and may even lead to its reclassification as a distinctive syndrome. [ABSTRACT FROM AUTHOR]

Neutrophil extracellular traps (NETs) are three-dimensional reticular structures that release chromatin and cellular contents extracellularly upon neutrophil activation. As a novel effector mechanism of neutrophils, NETs possess the capacity to amplify localized inflammation and have been demonstrated to contribute to the exacerbation of various inflammatory diseases, including cardiovascular diseases and tumors. It is suggested that lysophosphatidylcholine (LPC), as the primary active component of oxidized low-density lipoprotein, represents a significant risk factor for various inflammatory diseases, such as cardiovascular diseases and neurodegenerative diseases. However, the specific mechanism of NETs formation induced by LPC remains unclear. Quercetin has garnered considerable attention due to its anti-inflammatory properties, serving as a prevalent flavonoid in daily diet. However, little is currently known about the underlying mechanisms by which quercetin inhibits NETs formation and alleviates associated diseases. In our study, we utilized LPC-treated primary rat neutrophils to establish an in vitro model of NETs formation, which was subsequently subjected to treatment with a combination of quercetin or relevant inhibitors/activators. Compared to the control group, the markers of NETs and the expression of P2X7R/P38MAPK/NOX2 pathway-associated proteins were significantly increased in cells treated with LPC alone. Quercetin intervention decreased the LPC-induced upregulation of the P2X7R/P38MAPK/NOX2 pathway and effectively reduced the expression of NETs markers. The results obtained using a P2X7R antagonist/activator and P38MAPK inhibitor/activator support these findings. In summary, quercetin reversed the upregulation of the LPC-induced P2X7R/P38MAPK/NOX2 pathway, further mitigating NETs formation. Our study investigated the potential mechanism of LPC-induced NETs formation, elucidated the inhibitory effect of quercetin on NETs formation, and offered new insights into the anti-inflammatory properties of quercetin. [ABSTRACT FROM AUTHOR]

Preclinical research on diabetes and obesity has been carried out in various animal models over the years. These animal models are developed from genetic manipulation that affects their body metabolism, chemical-induced procedures, diet alteration/modifications, or combinations of the aforementioned approaches. The diabetic and obesity animal models have allowed researchers to not only study the pathological aspect of the diseases but also enable them to screen and explore potential therapeutic compounds. Besides several widely known complications such as macrovascular diseases, diabetic neuropathy, nephropathy and retinopathy, type 2 diabetes mellitus is also known to affect bone health. There is also evidence to suggest obesity affects bone health. Therefore, continuous research needs to be conducted to find a remedy or solution to this matter. Previous literature reported evidence of bone loss in animal models of diabetes and obesity. These findings, as highlighted in this review, further augment the suggestion of an inter-relationship between diabetes, obesity and bone loss. [ABSTRACT FROM AUTHOR]

Regardless of the cause, hypothyroidism should be treated with levothyroxine. The objectives of management are the normalization of TSH levels and the relief of symptoms. In general, the vast majority of patients who achieve normalization of TSH levels show a resolution of symptoms; however, for a small number of individuals, symptoms persist (despite adequate control of TSH). This scenario generates a dilemma in the therapeutic approach to these patients, because even when excluding other causes or concomitant diseases that can explain the persistence of symptoms, pharmacological management strategies are scarce. Consequently, the efficacy of some less conventional approaches to therapy, such as the use of LT3 monotherapy, desiccated thyroid extracts, and LT4/LT3 combinations, in addressing persistent hypothyroid symptoms have been evaluated in multiple studies. The majority of these studies did not observe a significant benefit from these "nonconventional" therapies in comparison to results with LT4 monotherapy alone. Nevertheless, some studies report that a significant proportion of patients prefer an alternative to monotherapy with LT4. The most common approach has been to prescribe a combination of LT4 and LT3, and this review describes and analyzes the current evidence of the efficacy of LT4/LT3 combination therapy vs. LT4 monotherapy in addressing persistent hypothyroidism symptoms to provide suggested guidelines for clinicians in the management of these patients. [ABSTRACT FROM AUTHOR]