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Background: Omics approaches are widely applied in the field of biology for the discovery of potential CAZymes including whole genome sequencing. The aim of this study was to identify protein encoding genes including CAZymes in order to understand glycans-degrading machinery in the thermophilic Caldicoprobacter algeriensis TH7C1 T strain., Results: Caldicoprobacter algeriensis TH7C1 T is a thermophilic anaerobic bacterium belonging to the Firmicutes phylum, which grows between the temperatures of 55 °C and 75 °C. Next generation sequencing using Illumina technology was performed on the C. algeriensis strain resulting in 45 contigs with an average GC content of 44.9% and a total length of 2,535,023 bp. Genome annotation reveals 2425 protein-coding genes with 97 ORFs coding CAZymes. Many glycoside hydrolases, carbohydrate esterases and glycosyltransferases genes were found linked to genes encoding oligosaccharide transporters and transcriptional regulators; suggesting that CAZyme encoding genes are organized in clusters involved in polysaccharides degradation and transport. In depth analysis of CAZomes content in C. algeriensis genome unveiled 33 CAZyme gene clusters uncovering new enzyme combinations targeting specific substrates., Conclusions: This study is the first targeting CAZymes repertoire of C. algeriensis, it provides insight to the high potential of identified enzymes for plant biomass degradation and their biotechnological applications., (© 2022. The Author(s).)

Background: Treatment with opioid agonists is effective for opioid use disorder, but early discontinuation of treatment is a major obstacle to success. Intensive longitudinal methods - which take many repeated measurements over time, usually in the field- have provided unique insight into the effects of stress, mood and craving on drug use while people are being treated; these methods might also be useful for studying the processes that lead people to drop out of treatment., Methods: Ecological momentary assessment (EMA) was conducted for up to 17 weeks by obtaining multiple electronic diary entries per day from 238 participants being treated with methadone or buprenorphine-naloxone. Survival analysis was used to study two outcomes: dropping out of treatment and noncompliance with EMA self-report requirements. Self-reports of stress, craving, and mood were used as time-varying predictors. Demographic and psychosocial variables measured with the Addiction Severity Index at the start of treatment were used as time-invariant predictors., Results: Dropping out of treatment was more likely in participants with more reported hassles (a measure of stress), higher levels of cocaine craving, lower levels of positive mood, a recent history of emotional abuse, a recent history of being bothered frequently by psychological problems, and with buprenorphine rather than methadone as their medication. In contrast, study noncompliance was not significantly associated with any of the variables analyzed., Conclusions: Assessment of stress, craving and mood during treatment might identify people who are at greater risk of dropping out, and therapeutic interventions targeting these processes might increase retention., (Published by Elsevier B.V.)

Introduction: Acute Heart Failure (AHF) is a specific syndromic disorder grouping several heterogeneous clinical conditions frequently seen in the emergency department. This study aimed to describe the epidemiological, clinical, therapeutic and prognostic features of patients with AHF admitted to the emergency department., Methods: We conducted a prospective, descriptive study in the emergency department. It included all patients admitted with AHF. We studied the epidemiological, clinical, therapeutic and prognostic features of these patients., Results: The study enrolled 180 patients with AHF admitted to the emergency department. Sex ratio was 1.27. The average age of patients was 66±12 years. Eighty-two percent of patients were hypertensive and 69% were known diabetic patients. The causes of decompensation included primarily hypertensive crisis (61.7% of patients), acute coronary syndrome (24% of patients). Respiratory support was mainly provided by CPAP (Continuous Positive Airway Pressure) in 73.3% of cases. Pharmacological treatment was based on nitrate derivatives (70% of cases) and diuretic (40.5% of cases). Acute heart failure incidence at one month was 21.7% (n=39 patients) and mortality rate at 3 months was 13.3%., Conclusion: Patients with AHF treated in the emergency department mainly had hypertensive crisis. Treatment is primarily based on CPAP, vasodilators and diuretics. Recurrence rate and mortality rate were high., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts., (© Sarra Jouini et al.)

Background and Aims: Stress can be validly assessed "live" or by a summary evaluation of the very recent past. Using smartphone-based ecological momentary assessment (EMA) combined with end-of-day (EOD) entries, we assessed the association between daily hassles, stressful events and use of opioids and cocaine, in opioid- and cocaine-using men and women., Methods: For up to 16 weeks, 161 outpatients in opioid-agonist treatment who reported cigarette smoking carried smartphones on which they reported stressful events (SEs) and drug use (DU) and completed an EOD questionnaire to report hassles encountered throughout the day, current perceived stress, cigarettes/day, and current mood. We compared EOD responses on days with and without SE and DU reports and on days when thrice-weekly urine drug screens indicated opioid or cocaine use or abstinence., Results: Participants (N = 161) made 11,544 EOD entries; EMA SEs were reported on 861 (7.5%) days, and DUs on 1685 (14.6%) days. The most frequently reported hassles in EOD entries were "not enough money" (31.4% of daily reports) and maintaining abstinence (18.7%). Total EOD hassles showed small but statistically significant associations [odds ratios (95% CIs)] with EMA SEs [1.09 (1.06-1.13)], DUs [1.08 (1.06-1.10)], and urine-positive opioid [1.06 (1.04-1.09)] and cocaine [1.03 (1.00-1.06)] results. Men and women had similar rates (mean/day (SD)) of hassles: men 2.25 (3.55); women 2.55 (3.76) (F 1,159  = 0.53, p = 0.47)., Conclusions: Daily hassles, reported at the end of the day, are associated with both same-day stressful events and drug use. Monitoring hassles and devising specific coping strategies might be useful therapeutic targets., (Published by Elsevier B.V.)

Rationale: Ecological momentary assessment (EMA) of specific events usually focuses more on antecedents and concomitants than on aftermaths., Objectives: To examine mental state both before and after discrete episodes of stress and drug use., Methods: For up to 16 weeks, outpatients on opioid-agonist treatment carried smartphones on which they initiated entries for stressful events (SEs) or lapses to drug use (DUs), and thrice daily when randomly prompted (RPs). Participants rated their stress, opioid craving, cocaine craving, and moods. RP entries within 5 h of an event were analyzed and compared to other RPs., Results: Stress, negative mood, and craving were generally higher before and after DUs and SEs compared to background levels in participants with at least one DU (n = 149) or SE (n = 158). Before DUs, there were increases in negative mood, opioid craving, and cocaine craving, but not background stress. Before SEs, there were increases in background stress, opioid craving, and cocaine craving, but not negative mood. These changes were more variable after events than before. Neither DUs nor SEs were significantly related to positive mood., Conclusions: Stress increased before stressful-event entries, but was less evident before drug use. Craving increased in the hours before drug use and stressful events-and remained elevated in the hours after either event. These results suggest a stronger link between drug use and craving than between drug use and stress. Lapses to drug use did not improve mood or reduce stress, at least not at our 1-h-bin time resolution, suggesting that if such benefits exist, they are brief.

In addiction, risk factors for craving and use include stress and drug-related cues. Stress and cues have additive or more-than-additive effects on drug seeking in laboratory animals, but, surprisingly, seem to compete with one another (ie, exert less-than-additive effects) in human laboratory studies of craving. We sought heretofore elusive evidence that human drug users could show additive (or more-than-additive) effects of stress and cues on craving, using ecological momentary assessment (EMA). Outpatients (N=182) maintained on daily buprenorphine or methadone provided self-reports of stress, craving, mood, and behavior on electronic diaries for up to 16 weeks. In three randomly prompted entries (RPs) per day, participants reported the severity of stress and craving and whether they had seen or been offered opioids, cocaine, cannabis, methamphetamine, alcohol, or tobacco. In random-effects models controlling for between-person differences, we tested effects of momentary drug-cue exposure and stress (and their interaction) on momentary ratings of cocaine and heroin craving. For cocaine craving, the Stress × Cue interaction term had a positive mean effect across participants (M=0.019; CL95 0.001-0.036), denoting a more-than-additive effect. For heroin, the mean was not significantly greater than 0, but the confidence interval was predominantly positive (M=0.019; CL95 -0.007-0.044), suggesting at least an additive effect. Heterogeneity was substantial; qualitatively, the Stress × Cue effect appeared additive for most participants, more than additive for a sizeable minority, and competitive in very few. In the field, unlike in human laboratory studies to date, craving for cocaine and heroin is greater with the combination of drug cues and stress than with either alone. For a substantial minority of users, the combined effect may be more than additive.

Background: Responses to stress and drug craving differ between men and women. Differences in the momentary experience of stress in relation to craving are less well-understood., Objectives: Using ecological momentary assessment (EMA), we examined sex differences in real-time in two areas: (1) causes and contexts associated with stress, and (2) the extent to which stress and drug cues are associated with craving., Methods: Outpatients on opioid-agonist treatment (135 males, 47 females) reported stress, craving, and behavior on smartphones for 16 weeks. They initiated an entry each time they felt more stressed than usual (stress event) and made randomly prompted entries 3 times/day. In stress-event entries, they identified the causes and context (location, activity, companions), and rated stress and craving severity., Results: The causes reported for stress events did not differ significantly by sex. Women reported arguing and being in a store more often during stress events, and men reported working more often during stress events, compared to base rates (assessed via random prompts). Women showed a greater increase in opioid craving as a function of stress (p < 0.0001) and had higher stress ratings in the presence of both stress and drug cues relative to men (p < 0.01). Similar effects were found for cocaine craving in men (p < 0.0001)., Conclusion: EMA methods provide evidence based on real-time activities and moods that opioid-dependent men and women experience similar contexts and causes for stress but differ in stress- and cue-induced craving. These findings support sex-based tailoring of treatment, but because not all participants conformed to the overall pattern of sex differences, any such tailoring should also consider person-level differences.

Rationale: Knowing how stress manifests in the lives of people with substance-use disorders could help inform mobile "just in time" treatment., Objectives: The purpose of this paper is to examine discrete episodes of stress, as distinct from the fluctuations in background stress assessed in most EMA studies., Methods: For up to 16 weeks, outpatients on opioid-agonist treatment carried smartphones on which they initiated an entry whenever they experienced a stressful event (SE) and when randomly prompted (RP) three times daily. Participants reported the severity of stress and craving and the context of the report (location, activities, companions). Decomposition of covariance was used to separate within-person from between-person effects; r effect sizes below are within-person., Results: Participants (158 of 182; 87%) made 1787 stress-event entries. Craving for opioids increased with stress severity (r effect  = 0.50). Stress events tended to occur in social company (with acquaintances, 0.63, friends, 0.17, or on the phone, 0.41) rather than with family (spouse, -0.14; child, -0.18), and in places with more overall activity (bars, 0.32; outside, 0.28; walking, 0.28) and more likelihood of unexpected experiences (with strangers, 0.17). Being on the internet was slightly protective (-0.22). Our prior finding that being at the workplace protects against background stress in our participants was partly supported in these stressful-event data., Conclusions: The contexts of specific stressful events differ from those we have seen in prior studies of ongoing background stress. However, both are associated with drug craving.

Objective: The objective of this study was to assess craving and mood related to opioid and cocaine use among asymptomatic hepatitis C virus (HCV)+ and HCV- methadone patients who have not started antiviral treatment., Methods: In this 28-week prospective ecological momentary assessment (EMA) study, 114 methadone-maintained, heroin- and cocaine-abusing individuals reported from the field in real time on their mood, craving, exposure to drug-use triggers, and drug use via handheld computers., Results: Sixty-one percent were HCV+; none were overtly symptomatic or receiving HCV treatment. HCV status was not associated with age, sex, race, or past-30-day or lifetime heroin or cocaine use. In event-contingent EMA entries, HCV+ individuals more often attributed use to having been bored, worried, or sad; feeling uncomfortable; or others being critical of them compared with HCV- participants. In randomly prompted EMA entries, HCV+ participants reported significantly more exposure to drug-use triggers, including handling ≥$10, seeing cocaine or heroin, seeing someone being offered/use cocaine or heroin, being tempted to use cocaine, and wanting to see what would happen if they used just a little cocaine or heroin., Conclusions: HCV+ individuals experienced more negative moods and more often cited these negative moods as causes for drug use. HCV+ individuals reported greater exposure to environmental drug-use triggers, but they did not more frequently cite these as causes for drug use. The EMA data reported here suggest that HCV+ intravenous drug users may experience more labile mood and more reactivity to mood than HCV- intravenous drug users. The reason for the difference is not clear, but HCV status may be relevant to tailoring of treatment.

Background: Maladaptive behaviors may be more fully understood and efficiently prevented by ambulatory tools that assess people's ongoing experience in the context of their environment., Methods: To demonstrate new field-deployable methods for assessing mood and behavior as a function of neighborhood surroundings (geographical momentary assessment; GMA), we collected time-stamped GPS data and ecological momentary assessment (EMA) ratings of mood, stress, and drug craving over 16 weeks at randomly prompted times during the waking hours of opioid-dependent polydrug users receiving methadone maintenance. Locations of EMA entries and participants' travel tracks calculated for the 12 before each EMA entry were mapped. Associations between subjective ratings and objective environmental ratings were evaluated at the whole neighborhood and 12-h track levels., Results: Participants (N=27) were compliant with GMA data collection; 3711 randomly prompted EMA entries were matched to specific locations. At the neighborhood level, physical disorder was negatively correlated with negative mood, stress, and heroin and cocaine craving (ps<.0001-.0335); drug activity was negatively correlated with stress, heroin and cocaine craving (ps .0009-.0134). Similar relationships were found for the environments around respondents' tracks in the 12h preceding EMA entries., Conclusions: The results support the feasibility of GMA. The relationships between neighborhood characteristics and participants' reports were counterintuitive and counter-hypothesized, and challenge some assumptions about how ostensibly stressful environments are associated with lived experience and how such environments ultimately impair health. GMA methodology may have applications for development of individual- or neighborhood-level interventions., (Published by Elsevier Ireland Ltd.)

We sought to develop and deploy a video-based smartphone-delivered mobile HIV Risk Reduction (mHIVRR) intervention to individuals in an addiction treatment clinic. We developed 3 video modules that consisted of a 10-minute HIVRR video, 11 acceptability questions, and 3 knowledge questions and deployed them as a secondary study within a larger study of ecological momentary and geographical momentary assessments. All 24 individuals who remained in the main study long enough completed the mHIVRR secondary study. All 3 videos met our a priori criteria for acceptability "as is" in the population: they achieved median scores of ≤2.5 on a 5-point Likert scale; ≤20% of the individuals gave them the most negative rating on the scale; a majority of the individuals stated that they would not prefer other formats over video-based smartphone-delivered one (all P < 0.05). Additionally, all of our video modules met our a priori criteria for feasibility: ≤20% of data were missing due to participant noncompliance and ≤20% were missing due to technical failure. We concluded that video-based mHIVRR education delivered via smartphone is acceptable, feasible and may increase HIV/STD risk reduction knowledge. Future studies, with pre-intervention assessments of knowledge and random assignment, are needed to confirm these findings.

Context: In ecological momentary assessment (EMA), participants electronically report their activities and moods in their daily environments in real time, enabling a truly prospective approach to the study of acute precipitants of behavioral events. Ecological momentary assessment has greatly enhanced the study of tobacco addiction, but its use has rarely been attempted in individuals with cocaine or heroin addiction., Objective: To prospectively monitor the acute daily life precipitants of craving for and use of cocaine and heroin., Design: Cohort study., Participants: A volunteer sample of 114 cocaine- and heroin-abusing outpatients who were being treated with methadone provided EMA data on handheld electronic devices for 14 918 person-days (mean, 130.9; range, 6-189 days per participant). Of these outpatients, a total of 102 (63 men, 39 women) provided acute precraving and/or preuse data and were thus included in the present analyses., Main Outcome Measures: Changes in reports of mood and exposure to 12 putative drug-use triggers at random intervals during the 5 hours preceding each self-reported episode of drug craving or use, analyzed via repeated-measures logistic regression (generalized linear mixed models)., Results: During the 5 hours preceding cocaine use or heroin craving, most of the 12 putative triggers showed linear increases. Cocaine use was most robustly associated with increases in participants reporting that they "saw [the] drug" (P < .001), were "tempted to use out of the blue" (P < .001), "wanted to see what would happen if I used" (P < .001), and were in a good mood (P < .001). Heroin craving was most robustly associated with increases in reports of feeling sad (P < .001) or angry (P = .01). Cocaine craving and heroin use showed few reliable associations with any of the putative triggers assessed., Conclusions: These findings confirm that polydrug-abusing individuals can provide behavioral data in their daily environments using handheld electronic devices and that those data can reveal orderly patterns, including prospectively detectable harbingers of craving and use, which may differ across drugs.

Introduction and Aims: A challenge in treatment research is the necessity of adhering to protocol and regulatory strictures while maintaining flexibility to meet patients' treatment needs and to accommodate variations among protocols. Another challenge is the acquisition of large amounts of data in an occasionally hectic environment, along with the provision of seamless methods for exporting, mining and querying the data., Design and Methods: We have automated several major functions of our outpatient treatment research clinic for studies in drug abuse and dependence. Here we describe three such specialised applications: the Automated Contingency Management (ACM) system for the delivery of behavioural interventions, the transactional electronic diary (TED) system for the management of behavioural assessments and the Protocol Workflow System (PWS) for computerised workflow automation and guidance of each participant's daily clinic activities. These modules are integrated into our larger information system to enable data sharing in real time among authorised staff., Results: ACM and the TED have each permitted us to conduct research that was not previously possible. In addition, the time to data analysis at the end of each study is substantially shorter. With the implementation of the PWS, we have been able to manage a research clinic with an 80 patient capacity, having an annual average of 18,000 patient visits and 7300 urine collections with a research staff of five. Finally, automated data management has considerably enhanced our ability to monitor and summarise participant safety data for research oversight., Discussion and Conclusions: When developed in consultation with end users, automation in treatment research clinics can enable more efficient operations, better communication among staff and expansions in research methods.

Objectives: To describe the epidemiological and clinical features of patients with primitive adhesive capsulitis of the shoulder treated by capsular distension and then rehabilitation; to evaluate the short-, mid- and long-term efficiency of this therapeutic protocol and compare it with rehabilitation alone., Materials and Methods: This was a two-year prospective study. Sixty patients were included and divided into populations P1 (capsular distension and rehabilitation) and P2 (rehabilitation only). Assessment of the treatments' efficacy was based on the following parameters: pain on a visual analogue scale (VAS), joint motion in several axes, a simplified Constant score (functional ability) and the SF-36 quality of life score., Results: Thirty patients (mean age: 56) underwent capsular distension. The Constant score was judged to be poor in over half of the patients. All the quality of life parameters were modified. When compared with P2, the P1 group showed a statistically significant improvement in terms of the pain score (p=0.005), anterior elevation (p=0.001), lateral elevation (p=0.005), external rotation (p=0.006) and the Constant score (p<0.001) one week after capsular distension. One year after capsular distension, this gain persisted in a statistically significant manner for all functional parameters and all SF-36 dimensions (p<0.001 for PF, RP, BP, SF and RE; p=0.01 for GH and VT and p=0.002 for MH)., Conclusion: Our results show that capsular distension and subsequent intensive rehabilitation have a beneficial effect. This combination enables rapid, significant improvement from the first week onwards. The improvement phase lasts for one month and may hold steady for up to 12 months.

Pharmacies have become essential components in support of clinical research. Their operations become highly complex when preponderance of prescriptions is composed of controlled substances. Application of informatics will result in more efficient operations. We present the Pharmacy Information Management System (PIMS) that includes a set of decision support systems to address the pharmacy challenges and is integrated into our electronic health record system.

Objectives: To study the prevalence of knee osteoarthritis in a group of former top-level football players and to assess the condition's impact on joint function and structure, compared with a control group., Materials and Methods: A cross-sectional, descriptive study was performed on a group of male former top-level football players (group G1), aged over 45 and with no history of knee trauma, arthritis, arthropathy or surgery. A second group of otherwise matched nonsporting subjects (group G2) was compared with the first group. For each subject, we specified age, weight, height, body mass index (BMI), dominant foot, the presence of knee axis deviation, the presence of pain and functional impairment. The pain level was assessed using a visual analogue scale (VAS). The functional assessment was performed using the Arabic version of the Lequesne index. Moreover, for each former player, we specified a number of sporting parameters, including those related to their playing career. The diagnosis of knee osteoarthritis was made using standard radiological and clinical criteria. The radiological severity of knee osteoarthritis was assessed using the Kellgren and Lawrence classification. We compared the two groups in terms of the frequency of knee osteoarthritis, the severity of pain and disability and the severity of structural impairment., Results: Our study included two groups of patients: a group of 50 former football players (G1) with a mean age of 49.2. Overweight was noted in 40 subjects. The mean number of training hours a week was 14+/-3.5 during their professional career and 2.5 during their retirement. Half of the sportsmen had taken part in more than 200 matches. Knee axis deviation was observed in 29 former players (i.e. 58% of the cases) and 27 displayed genuvarum. A group of 50 nonsporting volunteers (G2) was matched to the G1 group in terms of age, BMI and frequency of axis deviation. Knee osteoarthritis was more common in the football players than in the nonsporting subjects (80% versus 68%), although the difference was not statistically significant. Whereas pain was noted in only six footballers (with an average VAS score of 25.4+/-6.3mm) and was observed in 50% of controls (with a mean VAS score of 39.2mm+/-7.3) (P=0.001). Disability was recorded in six sportsmen, with a mean Lequesne score of 0.38+/-1.27. Disability was more frequent (23 subjects) and more intense (with a mean Lequesne score of 1.71+/-3.2) in the nonsportsmen (P=0.001). The Kellgreen and Lawrence radiological classification revealed that 57.5% of the sportsmen had scores of III or IV, compared with just 29.4% in the control group., Conclusion: Knee osteoarthritis is common in male football players. However, our study shows that the condition is less painful and less likely to cause functional disability (but paradoxically more destructive) than in nonsportsmen.

A clinical recruiting management system with qualification decision support systems was developed to increase the efficiency of screening and evaluation of participants during a recruiting process whereby recruiting for various protocols are conducted at multiple sites by different groups with process interdependencies. This system is seamlessly integrated into our enterprise-scale Human Research Information System (HuRIS), encompassing research participants' electronic health records (EHR), with real-time access to the clinical trial data.

In psychological research, efforts to capture day-to-day human experience traditionally relied on pen-and-paper diaries and questionnaires. Some current studies, however, incorporate handheld computers, which provide researchers with many options and advantages in addition to providing more reliable data. One advantage of using handheld computers is the programmability of the electronic diary, which, compared to old-fashioned paper diaries, affords the researchers with a wealth of possibilities. An important possibility is to construct a built-in mechanism in the computer-administered questionnaires that would allow transparent branching, in which question presentation is contingent on participants' answers to previous questions. The major hurdle in implementing such an approach is the limitations of the platform used for such assessments: inexpensive "low-end" handheld devices. We propose a high-level specification which enables non-programming researchers to "branch" their questionnaires without modifications to the source code in a highly user-friendly fashion, with backtracking capability and very modest hardware requirements. A finite state automaton approach was implemented, we believe for the first time, to create an auto-trigger mechanism for the real-time evaluation of the conditions. This solution provides our investigators with the capacity to administer efficient assessments that are dynamically customized to reflect participants' behaviors without the need for any post-production programming.

Objectives: To study shoulder impairment and disability caused by obstetrical brachial plexus palsy, their evolution under physical and surgical treatments, and the place of complementary explorations in persistent sequels., Methods: From 1991 to 2000, 129 patients (66 M, 63 F) were included in a retrospective study. Impairment was assessed by muscle recovery (deltoid, biceps, external rotators) and shoulder passive motion. Disability was assessed by Mallet functional test., Results: Full spontaneous recovery was noted in 20% of patients before the age of 3 months. Repair of the nerve lesion was undertaken in four children between the 18th and 24th months. Full recovery of deltoid and biceps was noted in three-fourth of whole cases before the 12th month, and of the external rotation in only 45% at this same age. Seventy-seven percent of patients showed stage >or= III of Mallet test (VI: 20%, IV: 32%; III: 25%) at a middle age of 3.5 years. A long-term follow-up showed an external rotation limited less than 20 degrees in 15 children. Investigation by RMN or Arthroscanner was realized for five patients, this reveals a deformation with subluxation of the humeral head in two cases. Ten children were operated (liberation of sub-scapula in nine cases associated to a tendinous transfer six times; humeral osteotomie in one case). This surgery has allowed the improvement of the functional state in all cases., Conclusion: After-effects in shoulder are frequent especially the limitation of external rotation, which can lead to a deformation, and subluxation of the humeral head. The authors insist on the importance to push investigations in case of limitation of the passive external rotation to improve the therapeutic choice.

The authors report 5 cases of strangulation of the penis with hair in children. This affection, more seen frequently within socially disadvantaged children, needs early diagnosis and treatment because it may be responsible for glans amputation. A better knowledge of this accident by parents and physicians might prevent this barbaric aggression.