Objective: De Quervain tenosynovitis is the most common cause of lateral wrist pain. The diagnosis can be made with the Finkelstein test when pain is provoked with wrist ulnar deviation. Conservative treatment including rest, non-steroidal anti-inflammatory medication and physical therapy is applied first, then there may be a need for corticosteroid injections, and in resistant cases, surgery. The aim of this study was to evaluate the effectiveness of neural therapy (NT) on pain and hand functions in patients with De Quervain tenosynovitis. Methods: A total of 36 patients admitted between May 2019 and March 2020 were randomly assigned to neural therapy (NT) and control groups. Hand rest and thumb spica splint were applied to all the patients, and NT interventions to the NT group only. A visual analog scale (VAS) and the Duruöz Hand index (DHI) were used to measure pain and functionality at baseline, then at 1 and 12 months after the end of the treatment. Results: The NT and control groups both showed improvements in VAS and DHI scores at 1 and 12 months compared to baseline. The VAS scores were significantly lower at both 1 and 12 months compared to baseline in the NT group. The DHI scores were lower in the NT group at 1 month, and at 12 months there was no significant difference between the two groups. No adverse effects were seen in any patient. Conclusion: NT seems to be effective in reducing pain and improving hand functions in patients with De Quervain tenosynovitis.
Background: Obesity is a global issue. Energy density (ED) can influence on body compositions (BCs). Consumption of HED (high energy density) foods can increase body fat mass (BFM) and inflammatory markers. Methods: This study was a cross-sectional research among 391 women. Body composition analyzer (BIA) and food frequency questionnaire (FFQ) was used to assess BCs and food intake of individuals. Blood samples and serum level of high-sensitive C-reactive protein (hs-CRP), plasminogen activator inhibitor- 1 (PAI-1) and transforming growth factor-β (TGF-beta) were collected. ED per one gram of foods were calculated and divided to quartiles. Linear logistic regression tests were used to investigate the association between BCs across quartiles of ED intake. Results: Results demonstrate skeletal muscle mass (SMM), total body water (TBW), intracellular water (ICW), fat free mass (FFM), visceral fat area (VFA) and fat free mass index (FFMI) was seem to be under the effect of hs-CRP among ED intakes. TBW, extracellular water (ECW), FFM with PAI-1, bone mineral content (BMC) with PAI-1 and TGF-beta, and Skeletal lean mass (SLM) with hs-CRP were inversely associated. Fat right arm (FRA), fat right arm (FLA), fat right and left leg (FRL,FLL), fat trunk, TBW, ICW, ECW, BFM, FFM, SMM, SLM, waist circumference (WC), FFMI and FMI were positively under the influence of TGF-beta after following higher ED food intakes. FRA, FLA, FRL, FLL, fat trunk, ICW, BFM, SMM, SLM, WC, FFMI and FMI were positively under the influence of PAI-1. Conclusion: All adipose tissue content of subcategories of BC were strongly associated with ED intake in the mediatory role of PAI-1 and TGF-beta.
Background: Injury represents 260,000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among ED presentations between countries and providers but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation. Methods: We conducted a retrospective multicenter cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years). Results: The prevalence of low-value injury admissions was 16% (n=19,163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12,345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value pediatric injury admissions; n=922), superficial injuries (14%, n=660) or minor spinal injuries (14%, n=634) in adults aged 16-64, and superficial injuries in adults aged 65+ (22%, n=2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC=37%). Conclusion: One out of six hospital admissions following injury may be of low-value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce health care services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.
ABSTRACT Introduction: Sjögren syndrome is a chronic, systemic, inflammatory disease characterized with lymphocytic infiltration of the exocrine glands, frequently manifested by dryness in the region affected. Although the most common extraglandular involvement in SS is pulmonary involvement. Early diagnosis and treatment is considered to be important. It was aimed to evaluate the frequency of early lung involvement, high resolution computed tomography (HRCT) findings and data of pulmonary function test (PFT) in SS in this study. Material-Method: Thirty five patients diagnosed with SS and referred by the Department of Rheumatology to determine potential lung involvement to the 8th chest diseases outpatient clinic of our hospital between September 2015 and December 2018 were included in this study. Respiratory signs, demographic features, length of disease and treatment regimens, PFT, data of 6-minute walk test (MWT) and findings of HRCT of the patients were retrospectively obtained from hospital information system and patient files. Results: The mean age of the patients was 54.4 ± 9.2. The majority of the patients were women (94.3%). When the HRCT findings were evaluated, 28 (80%) patients had CT findings, while 7 (20%) patients had no CT findings. The most common HRCT findings found in patients were peribronchial thickening (48.6 %), ground glass appearance (28.6%) and prominence in interstitial scars. Conclusion: We think that the evaluation of HRCT and PFTs in patients diagnosed with SS for assessing early pulmonary involvement will be guiding in terms of follow-up and treatment.
Objective:After radical prostatectomy,prostate-specific antigen(PSA) value measuring ≥0.1ng/ml is defined as persistent PSA(pPSA) and in many studies,it was found to be associated with aggressive disease and poor prognosis.Our aim in this study is to point out the pathological and clinical factors affecting pPSA among the patients who underwent robot-assisted radical prostatectomy(RARP) in an experienced academic center and to make a nomogram,predicting pPSA value based on operative data,useful. Methods:We examined records of 1273 patients who underwent RARP retrospectively. Preoperative,operative,and postoperative data were collected.Based on the PSA values (ng/ml) measured after 4-to-8 weeks of RARP,patients were divided into 2 groups as pPSA group (Group1)(n=97) with PSA values ≥0.1ng/ml and undetectable PSA group (Group2)(n=778) with PSA values <0.1ng/ml.Later on,Group1 was further divided into Group1a (PSA:0.1-0.2ng/ml) and Group 1b (PSA≥0.2ng/ml) to evaluate biochemical recurrence(BCR). Results:Multivariate logistic regression analyses of the collected data revealed that PSA>20ng/ml,operation time,a postoperative international society of urological pathology (ISUP) grade of ≥4, pT 3-4, and pN were independently associated with pPSA.According to the results, a nomogram predicting pPSA was developed(Table 4).By looking at the nomogram pPSA was found in 98.9% of the cases with a PSA value of ≥20ng/ml, an operation time of 150 minutes, a postoperative ISUP grade of 4-5, a positive lymphovascular invasion (LVI) status, pT3-T4, and pN+; while pPSA was found in 25.5% of the cases with a PSA value of <20 ng/ml, an operation time of 100 minutes, a postoperative ISUP grade of <4-5, a negative LVI status, pT<3-4, and pN-.The estimated BCR-free survival time was 16.3 months in Group 1a and 57.0 months in Group2 (p<0.001).Adjuvant treatment ratio was 64.9% in Group1 and 7.1% in Group2 (p<0.001). Conclusion:For the patients who underwent RARP,factors associated with aggressive disease can predict the PSA persistence.To plan our treatment modalities accurately,an applicable nomogram in daily practice would be useful.
Objective: Abdominal hernia repair is a common surgery, with 15% of patients presenting as incarcerated hernias. In these cases, early diagnosis of intestinal ischemia and necrosis is crucial for mortality and morbidity. Biomarkers that can predict ischemia or necrosis status are vital. In this study, we aimed to reveal the roles of basic blood parameters in determining ischemia or necrosis status. Methods: The patients were divided into three groups as normal bowels (Group I: 24 patients), intestinal ischemia without necrosis (Group II: 31 patients), and Group III who underwent bowel resection because of necrosis (10 patients). Patients’ demographic characteristics and blood parameters were retrospectively analyzed. Results: 65 patients operated for incarcerated abdominal hernias. There was no significant difference between the groups in terms of age, sex, comorbidity, or complications (p>0.05). The highest length of stay was observed in Group III (p<0.001). There were significant differences between the groups in terms of serum white blood cell (WBC), neutrophil, lymphocyte (LYM), neutrophil-lymphocyte ratio (NLR), urea, creatinine, total bilirubin, indirect bilirubin, lipase, C-reactive protein (CRP), and CRP/LYM levels (p<0.05). Conclusion: Preoperative WBC, neutrophil, NLR, urea, creatinine, and total bilirubin levels can be used to predict the onset of intestinal ischemia. Serum creatinine, total bilirubin, indirect bilirubin, phosphorus, lactate dehydrogenase (LDH), and lipase levels can be used for bowel resection.
Abstract Objective The aim of this study is to examine the effectiveness of a single physician-led weight loss program in a primary care. Methods This is a retrospective analysis of 300 patients with a BMI >30 kg/m2 in an outpatient weight loss program. Weight loss interventions included lifestyle counseling and pharmacotherapy. Outcomes were assessed based on percentage weight change during a time period of two consecutive visits less than 90 days. Results We found that 57.7%, 43.3% and 16.1% patients who attended the clinic 5 or more times, 4-5 times, 2-3 times respectively achieved 5% weight loss (p < 0.0001). In regard to achieving 10% weight loss, 42.3%, 8.7% and 4.3% patients who attended the clinic 5 or more times, 4-5 times and 2-3 times did it respectively (p<0.0001). Moreover 60% of patients achieved 5% of weight loss in about 200 days, and 40% achieved 10% weight loss in 350 days. Patients who achieved 5% weight loss, their average A1c was reduced to 5.8 at their last visit from 6.4 at the first visit. Conclusions A single physician-led weight loss program is effective and can be created within a primary care setting to achieve 5-10% weight loss.
Background: To evaluate the efficiency and safety of medium power (MP) holmium laser devices in the enucleation of the enlarged prostate (HoLEP) adenomas compared to high power (HP) laser devices. Methods: Based on the device power used, a total of 120 patients were divided randomly into two groups. While patients in Group 1 were treated with a MP device (50 W) at 39.6-W (2.2J / 18Hz ), patients in Group 2 were treated with HP (100W) device at 42W (1.2J / 35Hz). Peri- and postoperative parameters were well evaluated in both groups with an emphasis on enucleation efficiency and hemoglobin decrease in a comparative manner. Results: Peri- and postoperative parameters as well as functional results were similar in the two groups. The median enucleation efficiency (EE) values in Group 1 and Group 2 were 1.15 (IQR: 0.33-2.2) and 1.11 (IQR: 0.4-2.8), respectively (p=0.775). Hemoglobin decrease values in Group 1 and Group 2 were 1.3 (IQR: 0.1-4) and 1.4 (IQR: 0.4-3.1), respectively (p=0.736). Significant improve in the postoperative functional parameters were noted again in both groups. Conclusion: Our results indicate well that similar to the HP laser devices, effective and safe removal of the enlarged prostate adenomas with MP laser devices (50W) is possible without any technical difficulties, even in patients receiving antithrombotic therapy.
Abstract Aims: Recurrent pregnancy loss (RPL) is usually defined by two or more consecutive clinical miscarriages, which causes psychological trauma for couples. In this study, we aimed to investigate the predictive role of Fibrinogen to albumin ratio (FAR) in patients with RPL. Methods: Pregnant women in their first trimester of pregnancy were included in the study and divided in to two groups as RPL patients (n:44) and patients with no previous recurrent miscarriage (n:60) as control group. Demographical parameters and routine blood parameters (fibrinogen, D-dimer, fibrinogen to albumin ratio (FAR), neutrophil to lymphocyte ratio (NLR), platelet count, main platelet volume (MPV), and red cell distribution width (RDW) values) were compared between the RPL group and the control group. Results: The groups were determined to be statistically different in regards to gravidity and parity (p<0.05). The difference between the groups was statistically different in regards to fibrinogen (mg/dl), albumin (g/dl), FAR (%), NLR (%), RDW-coefficient of variation (CV) (%), RDW-standard deviation (SD) (fL), and platelet counts (10-3/ uL). However, MPV (fL) and D-dimer (ug/L) levels were similar in both groups. The receiver operating characteristic (ROC) curve analysis revealed that the NLR levels were 84.1% sensitive and 75% specific with a cut-off value of 4.27 and the FAR levels were 79.5% sensitive and 88.3% specific with a cut-off value of 105.69 for predicting RPL. Conclusion: Our results indicate that the FAR and NLR levels seem to be effective parameters for predicting RPL with high sensitivity and specificity.
Context: Multisystem Inflammatory Syndrome in Children (MISC) is a newly and rising condition, particularly in SARS-CoV-2 high transmission communities. Objective: Analyze current literature and reported cases of MISC, concerning its clinical spectrum, complications associated, therapeutic strategies and distinguishing features of other clinical syndromes. Data Sources: Extensive literature research was performed in MEDLINE (trough PubMed), Scopus and Web of Science from December 2019 to December 2020.Study Selection: First analysis included all article titles and abstracts screening to identify relevant studies and second analysis included a full text screening of previous selected studies. Eligibility was assessed independently by two authors and disagreements were resolved by discussion and consensus. Data Extraction: Data were extracted on MISC definition, demographic data, clinical features, diagnostic tests, laboratory analysis andimaging, therapeutical approach and outcomes. Results: Common symptoms included: gastrointestinal (70%), rash (57%) and cardiovascular (52% with shock). Notable differences with Kawasaki Disease were identified including age, clinical presentation and cardiac involvement. 30% presented positive SARS-CoV-2 2 reverse transcription polymerase chain reaction and 51% positive serologies. 62% received intravenous immunoglobulin and 42% glucocorticoids. 62% required intensive care, 21 children died (<2%). Severe presentations were associated with neurological symptoms, hepatitis and acute kidney injury. Limitations: As a recently documented disease, there was limited prospective and follow-up studies, therefore disregarding long-term sequelae and prognosis. Conclusions: MISC raises concern on its severe cardiac involvement at presentation, with frequent intensive care and immunomodulatory therapy need. Short term outcomes seem to be favorable, with cardiac disfunction recovery and low mortality rates.
Introduction: The covid-19 disease is a pandemic threat for humanity’s healthcare system, social, economic, and psychological well-being for both developed and developing nations. In the case of developing nations such as the resource of Ethiopia, however, the key obstacle is to buy the vaccine and administer it to their people.. In the study area, however, the degree of adherence to the covid-19 preventive measure was not well established. The aim of this study is to determine adherence to covid-19 prevention measures in Hossana town. Methods: From 3 to 29 January 2021, a community-based cross-sectional study was conducted among individuals living in the Hosanna town. We used a sample size of 384. The sample size was distributed to all 8 kebeles in proportion to the size of the households contained in each kebele in the town of Hossana. Systematic sampling methods were used and both descriptive and advanced analysis, data was entered into Epi-data and exported to SPSS. Binary logistic regression was used to identify variables associated with adherence to preventive measures for covid-19. Result: 50.4% of the study participants had good adherence with the COVID-19 preventive measures. 145 (38.5%) of all respondents had poor knowledge on COVID-19 preventive measures and 40.3 % had poor COVID-19 transmission methods knowledge. Age [AOR: 0.34; 95 % CI (0.131-0.912)], educational status [AOR: 0.32; 95% CI (0.165-0.632)], marital status [AOR: 2; % CI (1.191-3.803)], family size [AOR: 2.4; % CI (1.322-4.366)]] and covid-19 complication [AOR: 0.49: 95% CI (0.242-0.979)]] were significantly associated with covid-19 prevention measurement adherence in multivariate analysis. Conclusion: This study found that approximately half of the participants had poor adherence to COVID-19 preventive measures. Factors associated with covid-19 preventive measures were age, educational age, marital status, family size, and heard about complication of COVID-19 were associated with preventive measures.
Aims: In our study,we aimed to investigate whether end-expiratory vena cava inferior (expVCI) diameter and vena cava inferior collapsibility index predicted post-spinal hypotension in geriatric patients undergoing spinal anesthesia, the correlation between them and other parameters. Material and methods: Our prospective study included ASA I-4,73 patients over 65 years of age, who were scheduled for operation using spinal anesthesia. According to the expVCI diameter displayed with USG before spinal anesthesia, patients; those with an expVCI diameter less than 1.8 cm previously determined as the threshold value are grouped as 1.(Small-VCI) Group,those greater than 1.8cm as 2.(Large-VCI) Group. Demographic characteristics of the patients, comorbidities, duration and type of operation, basal (preoperative) heart rate, systolic, diastolic, mean blood pressure, peripheral oxygen saturation values before spinal anesthesia and after spinal anesthesia in supine position (0 min) and 5th, 10th, 15th, 20th, 25th, 30th min and preoperative arterial blood gas parameters, amount of peroperative urine and bleeding, inotropic and fluid requirement, complications were recorded. Results: Hypotension developed in 28(38.4%) patients and bradycardia in 14 (19.2%) of patients. The patients who developed hypotension had more ASA 2 and ASA 3 (p=0.01), shorter height (p=0.02), and smaller expVCI diameter (p=0.004).It was observed that they had higher lactate (p=0.03), lower pH (p=0.006) values, and more inotropic agents were administered (p<0.001). While the rate of developing hypotension was 51.1% (n=23) in the patients in the Small-VCI group, this rate was 17.9% (n=5) in the patients in the Large-VCI group (p=0.004). Conclusion: It was concluded that the expVCI diameter value measured by USG before spinal anesthesia in elderly patients is effective in predicting post-spinal hypotension with lactate and pH values, which are among the blood gas parameters, and expVCI can be preferred to invasive methods due to its noninvasive, easy and fast application.
Objective: To evaluate the accuracy of radiological staging, especially renal venous and perirenal fat invasion, in renal cell carcinoma (RCC). Material & Methods: Data of 4823 renal tumor patients from Renal Tumor Database of Association of Uro-oncology in Turkey were evaluated. Of 4823 patients, 3309 RCC patients had complete radiological and histopathological data were included to this study. The Pearson Chi-squared test (χ2) was used to compare radiological and histopathological stages. Results: The mean (SD) age of 3309 patients was 58 (12.3). Preoperative radiological imaging was performed using computed tomography (CT) (n=2510, 75.8%) or magnetic resonance imaging (MRI) (n=799, 24.2%). There was a substantial concordance between radiological and pathological staging (к=0.52, p<0.001). Sensitivities of radiological staging in stage I, II, III and IV were 90.7%, 67.3%, 27.7% and 64.2%, respectively. The sensitivity in stage III was lower than the other stages. Sub-analysis of stage IIIa cases revealed that, for perirenal fat invasion and renal vein invasion, sensitivity values were 15.4% and 11.3%, respectively. Conclusions: There was a substantial concordance between radiological (CT and/or MRI) and pathological T staging in RCC. However, this is not true for T3 cases. Sensitivity of preoperative radiological imaging in patients with pT3a tumors is insufficient and lower than the other stages. Consequently, preoperative imaging in patients with T3 RCC has to be improved, in order to better inform the patients regarding prognosis of their disease.
Background: CRC incidence is increasing in our region. There is no specific CRC control program or national cancer registry in Pakistan. Previously no data has been published on presentation and diagnosis delay of CRC in our region. This study is conducted to determine the factor affecting delay in presentation and diagnosis and to provide baseline information to launch a CRC control program. Primary objective is to determine factor causing delay in diagnosis of CRC. Secondary objective is to evaluate relationship between tumor site and stage of CRC with presenting symptoms and symptom duration. Methods: This project is a prospective cross-sectional study on 113 biopsy-proven CRC patients admitted to the surgical ward of civil hospital Karachi. Results: A total number of participants was 113. Presentation delay was observed in 83.2% of patients. The main reasons for a reported delay in the presentation were lack of patients’ knowledge that these symptoms may be cancer (60.4%), the wrong diagnosis by the primary physician (34.6%), or the patient didn’t want to visit the doctor (0.04%). Most tumors (95%) originated from the sigmoid and rectum. 38.9% and 44.2% of the patients diagnosed at Stage 4 and 3 respectively. Conclusions: This study revealed that CRC patients in Pakistan are facing delays in presentation and diagnosis. This is the reason behind diagnosis at the advanced stage with a poor prognosis. Based on this study findings CRC control program should be introduced to detect CRC at an early stage. Keywords: Colorectal cancer, Colon, Rectum, Cancer, Presentation delay, Diagnosis delay.
Aim: Urinary incontinence is an important problem that can arise due to neurogenic or functional reasons and can negatively affect the psychological, social and personality development of children. This study was conducted in Eskişehir province, on secondary school students in order to determine the prevalence and nature of urinary incontinence at night and/or daytime. Methods: The study universe included all secondary school students attending state elementary schools in the city center of Eskişehir (N=34.000). Ethics Committee and Provincial Directorate of National Education approval was obtained before conducting the study, which was supported by Eskişehir Osmangazi University Scientific Research Projects Commission (2017-1876) . A data collection form prepared by the researchers, and a consent form were delivered in sealed envelope to the parents via the students. The study data were collected between 09.05.2018-30.05.2018. Only volunteers were included in the study. 6957 questionnaires which have been fully completed from the 7370 surveys have been taken into consideration. The statistical analysis was carried out using the SPSS soft ware package. Results: The number of children found to have urinary incontinence was determined to be 215 (3.1%). It has been determined that 33 children (0.5%) have urinary incontinence only at daytime, 61 children (0.9%) have urinary incontinence both at night and daytime, and 121 children (1.7%) have urinary incontinence only at night. It was observed that 56% of the children suffering from urinary incontinence had not applied to any health institution for treatment before. Conclusions: Children and families with urinary incontinence need medical information and support to cover the cause of the problem and suggestions for solutions. Accompanying pathologies in cases to be detected can be determined in the early period by means of school screenings and medical evaluation and support can prevent the psychosocial and personality development of children from being adversely affected.
Objective Although it may have been criticized and questioned by numerous authors, external fixation holds its place in modern orthopaedics and traumatology. The aim of this paper is to show the applicability of the unilateral 3D external fixation in everyday practice. Methods For external fixation of the bones, we used unilateral 3D external fixators according to Mitkovic. Results In the Republic of Serbia, the Mitkovic unilateral 3D external fixation system has been used in over 30,000 cases. The indication field of applicability of this method is wide. External fixation method was mostly used for the treatment of open and closed tibial fractures at all levels, in open femoral fractures as a part of the “staging” protocol and in fractures of the upper limbs. We used external fixation for the treatment of nonunions, malunions, in the treatment of osteitis, septic pseudoarthrosis, angular knee deformities, post-traumatic deformities, for limb lengthening and in replantation surgery. Conclusion The unilateral external fixator enables 3D biomechanical stability and is suitable for use in everyday traumatology and orthopaedics practice.
Objectives: To evaluate clinical characteristics and prognosis of patients presented with ventricular tachyarrhythmia (VTA) during the course of acute coronary syndrome (ACS) and to analyze it according to period of presentation. Background: VTA is an infrequent yet serious complication of ACS. There is limited data regarding the incidence and prognostic implications of VTA in the last decade as compared with the previous decade. Methods: We evaluated clinical characteristics, major adverse cardiovascular events, short and long- term mortality of patients hospitalized with ACS who were enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) during the years 2000-2016. Patients were classified into three groups: no VTA, early VTA (≤48h of onset) and late VTA (>48h of onset). Data were analyzed according to decades of presentation (current decade vs. previous decade). Results: The study population comprised 15,200 patients. VTA occurred in 487 (3.2%) of patients. Early VTA presented in 373/487 (77%) patients and late VTA in 114/487 (23%) patients. VTA’s, occurring in ACS patients were associated with increased risk of in-hospital, 30-days, 1-year and 5-year mortality rates during both early and late periods in compared with no VTA. Moreover, late VTA was associated with the highest mortality rate with up to 65% in 5-year follow up (p<0.001). Nevertheless, late VTA was associated with lower mortality rate in the current decade (2008-2016) compared with last decade (2000-2006). Conclusions: Any VTA following ACS was associated with high short and long-term mortality rate. However, over the past decade there has been a significant improvement in survival rates, especially in patients with late VTA. This may be attributed to early and invasive reperfusion therapy, implantable cardioverter defibrillator implantation and better medical treatment.