304. Impact of Antibiotic Prophylaxis Prior to Treatment with Steroids and Tocilizumab in COVID-19 Patients

Abstract Background The incidence of bacterial or fungal coinfections in COVID-19 patients is low. The incidence of nosocomial superinfections is higher, especially related to ICU admission. Treating COVID-19 with steroids plus tocilizumab (TCZ) has been associated with superinfections. Therefore, the use of antibiotic prophylaxis prior to infusion of TCZ could be considered to reduce the risk of life-threatening superinfections in critically ill patients. Methods Retrospective, single center cohort study. COVID-19 patients older than 14 years, admitted to Hospital Central de la Defensa (Madrid, Spain) from Mar 5th to Nov 24th, 2020 with a diagnosis of COVID-19 were included. Local protocols suggested antimicrobial prophylaxis before the infusion of TCZ. Medical records, treatments received, and microbiological data of all patients who received TCZ were reviewed. Microbiological isolates were considered in the 14 days following the administration of TCZ. Two ID specialists independently reviewed the medical record and decided to qualify the isolate as superinfection or colonization. Results 2,069 patient records were analyzed. 70 patients received TCZ; all of them were admitted to ID wards and under steroid treatment. 45 (64,5%) patients received antibiotic prophylaxis. The preferred antibiotics were ceftriaxone (N = 18) and ceftobiprole (N = 14). No significant differences were found in age, Charlson index or COVID-19 SEIMC-Score. 24 isolates were detected in 14 patients (18 bacterial, 6 fungal). 17 isolates were considered superinfections; the most frequent isolates were C. albicans (N=5), E. faecalis (N=3) and S. epidermidis (N=2). There were no statistically significant differences between the different prophylaxis strategies in terms of in-hospital mortality or ICU admission. However, patients who received ceftobiprole tended to have fewer isolates and fewer superinfections than those receiving ceftriaxone (ceftobiprole group: 2 isolates in 1 patient, 1 (7,1%) patient with superinfection; ceftriaxone 11 isolates in 5 patients, 4 (22,2%) patients with superinfection) (p= 0,35, Fisher exact test). Table 1. Characteristics of study population. Table 2. Outcomes according to antimicrobial prophylaxis prior to Tocilizumab. Table 3. Description of isolates. Conclusion Antibiotic prophylaxis prior to infusion of TCZ in patients with COVID-19 and receiving steroids could determine the profile of bacterial and fungal superinfections. Disclosures All Authors: No reported disclosures

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Antibiotic Use in Hand Surgery: Surgeon Decision Making and Adherence to Available Evidence

Hand ◽

10.1177/1558944718812161 ◽

2018 ◽

Vol 15 (4) ◽

pp. 534-541 ◽

Cited By ~ 1

Author(s):

John C. Dunn ◽

Kenneth R. Means ◽

Sameer Desale ◽

Aviram M. Giladi

Keyword(s):

Antibiotic Prophylaxis ◽

Hand Surgery ◽

Antibiotic Use ◽

Demographic Variables ◽

Fisher Exact Test ◽

Evidence Based ◽

Supporting Evidence ◽

Exact Test ◽

Preoperative Antibiotic Prophylaxis ◽

Group 1

Background: There are no clearly defined guidelines from hand surgical societies regarding preoperative antibiotic prophylaxis. Many hand surgeons continue to routinely use preoperative prophylaxis with limited supporting evidence. This study aimed to determine for which scenarios surgeons give antibiotics, the reasons for administration, and whether these decisions are evidence-based. Methods: An anonymous 25-question survey was e-mailed to the 921-member American Society for Surgery of the Hand listserv. We collected demographic information; participants were asked whether they would administer antibiotics in a number of surgical scenarios and for what reasons. Respondents were broken into 3 groups based on when they said they would administer antibiotics: Group 1 (40 respondents) would give antibiotics in the case of short cases, healthy patients, without hardware; group 2 (9 respondents) would not give antibiotics in any scenario; and group 3 (129 respondents) would give antibiotics situationally. The Fisher exact test compared demographic variables, frequency of use, and indications of antibiotic prophylaxis. Results: Of the 921 recipients, 178 (19%) responded. Demographic variables did not correlate with the antibiotic use group. Operative case time >60 minutes, medical comorbidity, and pinning each increased antibiotic use. Group 1 respondents were more likely to admit that their practice was not evidence-based (74.4%) and that they gave antibiotics for medical-legal concern (75%). Twenty-two percent of respondents reported seeing a complication from routine prophylaxis, including Clostridium difficile infection. Conclusions: Antibiotics are still given unnecessarily before hand surgery, most often for medical-legal concern. Clear guidelines for preoperative antibiotic use may help reduce excessive and potentially inappropriate treatment and provide medical-legal support.

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173TRANSFER OF VITRIFIED BLASTOCYSTS FROM ONE OR TWO SUPEROVULATED LARGE WHITE HYPERPROLIFIC DONORS TO MEISHAN RECIPIENTS: REPRODUCTIVE PARAMETERS AT DAY 30 OF PREGNANCY

Reproduction Fertility and Development ◽

10.1071/rdv16n1ab173 ◽

2004 ◽

Vol 16 (2) ◽

pp. 208

Author(s):

C. Cuello ◽

F. Berthelot ◽

F. Martinat-Botté ◽

P. Guillouet ◽

V. Furstoss ◽

...

Keyword(s):

Pregnancy Rate ◽

Fisher Exact Test ◽

Corpora Lutea ◽

Large White ◽

Embryo Survival ◽

Exact Test ◽

Group 2 ◽

Fresh Semen ◽

Group 1

The present study was designed to determine the effect of pooling embryos from two donors on the reproductive success of transfer of vitrified/warmed porcine blastocysts. Superovulated Large White hyperprolific gilts (n=24) were used as embryo donors. Gilts were artificially inseminated 12 and 24h after initial detection of estrus using fresh semen, and slaughtered on Days 5.5 to 6 of the estrous cycle (Day 0=Onset of estrus). Embryos were recovered by flushing the uterine horns, and unhatched blastocysts were selected. Vitrification and warming were performed as reported previously (Berthelot et al., 2000 Cryobiology 41, 116–124). Embryo transfers were conducted in asynchronous (−24h) Meishan gilts (n=20). Twenty vitrified/warmed blastocysts were surgically transferred into one uterine horn. Ten recipients received embryos from one donor (group 1) and the other ten transfers were performed with mixed embryos from two donors (group 2). Pregnancy was assessed ultrasonographically at Day 25 after estrus and recipients were slaughtered five days later. The pregnancy rate from the different groups was compared using Fisher exact test. The GLM procedure of SAS was used to determine the effect of the origin of embryos (one or two donors) on the number of developed fetuses and viable fetuses at Day 30 of pregnancy. The ovulation rate was 32.5±11.8 (mean±SD). The total number of embryos collected was 634, of which 57 (9.0%), 36 (5.7%), 513 (80.9%) and 28 (4.4%), were unfertilized oocytes and degenerated embryos, morulae, unhatched blastocysts and hatched blastocysts, respectively. The ratio of collected embryos to the number of corpora lutea was 81.3%. The pregnancy rate for group 1 (70%) was not different (P>0.05) than that for group 2 (90%). No significant differences were detected between group 1 and group 2 for in vivo embryo development (number fetuses/transferred embryos in pregnant recipients; 33.3% v. 40%) or in vivo embryo survival (number viable fetuses/transferred embryos in pregnant recipients; 27.9% v. 33.9%). However, the in vivo efficiency (number viable fetuses/total transferred embryos) was higher (P<0.05) when transfers were performed with embryos from two donors (19.5% v. 30.5%). These results indicate that pooling embryos from two donors increases the in vivo efficiency after transfer of vitrified/warmed porcine blastocysts. This study was supported by grant from SENECA (FPI/99, Spain).

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Study on Maternal and Immediate Fetal outcome of placenta previa

Nepal Journal of Obstetrics and Gynaecology ◽

10.3126/njog.v11i2.17456 ◽

2017 ◽

Vol 11 (2) ◽

pp. 24-27

Author(s):

Sushma Lama ◽

S Ranjit

Keyword(s):

Blood Loss ◽

Medical Records ◽

Placenta Previa ◽

Fetal Outcome ◽

Intrauterine Fetal Death ◽

Dilatation And Curettage ◽

Life Threatening ◽

Study Population ◽

Risks Factors ◽

Caesarean Hysterectomy

Aims: This study aimed to analyze the demographic profile, maternal and fetal outcome of placenta previa.Methods: This was a retrospective study done at Patan Academy of Health Sciences. The study population comprised of all the patients that had caesarean section for placenta previa from April 2012 to October 2015. All patients diagnosed with placenta previa clinically, ultrasonograph or incidentally during caesarean sections were recruited in this study. The data were obtained from medical records and hospital database system. Individual charts were reviewed and data on various parameters were collected.Results: In Patan hospital, there were total 126 placenta previa cases out of 21,552 deliveries during the two and half year period hence the incidence was 0.58 %. We were able to retrieve patient records of only 108 of 126 cases. The incidence of placenta previa was higher with increasing maternal age ≥30 years (41.67%), more common in multigravida (65.74%). We found that associated risks factors included previous CS, multiparity and dilatation and curettage (40.74%). Eleven patients required blood transfusion, seven of them had blood loss of 1000-1400 ml, one had blood loss of 2000 ml. Also, Caesarean hysterectomy were performed in two patients. In term of fetal outcomes, 37.04% were preterm birth and 29.63% of the babies had low birth weight. There was one incident of congenital anomaly, one intrauterine fetal death and six neonatal deaths.Conclusions: Placenta previa is an obstetrics complication that is potentially life threatening to both the mother and the baby.

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Increased risk for abnormalities on perioperative colon screening in patients with microsatellite instability–positive endometrial carcinoma

International Journal of Gynecological Cancer ◽

10.1111/j.1525-1438.2006.00735.x ◽

2006 ◽

Vol 16 (6) ◽

pp. 1980-1986 ◽

Cited By ~ 2

Author(s):

B. M. Buttin ◽

M. A. Powell ◽

P. J. Goodfellow ◽

S. N. Lewin ◽

R. K. Gibb ◽

...

Keyword(s):

Regression Analysis ◽

Microsatellite Instability ◽

Medical Records ◽

Fisher Exact Test ◽

Exact Test ◽

Molecular Stratification ◽

Colon Cancers ◽

Increased Risk ◽

Primary Colon ◽

Endometrial Cancers

Microsatellite instability (MSI) is a feature of certain hereditary and sporadic endometrial and colon cancers. We set out to determine whether molecular stratification of endometrial cancers based on tumor MSI status could help identify patients at increased risk for abnormalities found on perioperative colon screening. From a prospectively accrued series of 413 patients, medical records were reviewed from 94 patients with MSI positive (MSI+) and 94 patients with MSI negative (MSI−) endometrial cancers, matched by year of diagnosis. We reviewed clinicopathologic data and results of perioperative colon screening. Differences were analyzed using Fisher exact test and logistic regression analysis. There were no significant clinicopathologic differences between the two cohorts. Sixty-five percent of patients in each group underwent perioperative colon screening. However, patients with MSI+ cancers had a twofold increase in the frequency of colonic abnormalities (30% versus 14.8%, P= 0.044) over those with MSI− cancers. Furthermore, the only primary colon cancers (N= 2) were found in women with MSI+ endometrial cancers that were unmethylated at the MLH1 promoter. Our data suggest that patients with MSI+ endometrial cancers are at increased risk for abnormalities on perioperative colon screening. Those with MSI+MLH1 unmethylated cancers appear to be at highest risk.

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Knowledge of pregnant women about anemia is related with adherence to iron tablets

Majalah Obstetri & Ginekologi ◽

10.20473/mog.v26i12018.26-28 ◽

2018 ◽

Vol 26 (1) ◽

pp. 26

Author(s):

Baksono Winardi ◽

Elga Caecaria Grahardika Andani

Keyword(s):

Pregnant Women ◽

Cross Sectional Study ◽

P Value ◽

Fisher Exact Test ◽

Chi Square ◽

Cross Sectional ◽

Significance Level ◽

Exact Test ◽

Study Population ◽

Almost All

Objectives: to identify association between knowledge of pregnant women about anemia and the adherence to consume iron tablets in BPM Titik Suharti, Surabaya, IndonesiaMaterials and Methods: Observational analysis cross sectional study. Population consisted of 55 trimester pregnant women in BPM Titik Suharti, Surabaya, in March-April 2017. Samples were recruited using consecutive sampling. The number of sample was 35 respondents. Data were analyzed using chi-square test.Results: This research showed that all of the less knowledgeable women on anemia (100.00%) were non-adherent to consume iron tablets, almost all moderately knowledgeable women (92.9%) were adherent, and all of the fully knowledgeable women (100.00%) were adherent. Fisher exact test in significance level of 0.05 revealed p value equal to 0.0001, indicating association between knowledge about anemia and adherence to consume iron tablets at BPM Titik Suharti, Surabaya, Indonesia.Conclusion: There is an association between knowledge of pregnant women about anemia with adherence to iron tablets.

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Inhibition of rats extramedullary liver erytropoiesis by hyperbaric oxygen therapy

Acta Cirurgica Brasileira ◽

10.1590/s0102-86502007000200011 ◽

2007 ◽

Vol 22 (2) ◽

pp. 137-141 ◽

Cited By ~ 3

Author(s):

Ricardo Costa-Val ◽

Tarcizo Afonso Nunes ◽

Roberto Carlos de Oliveira e Silva ◽

Antônio Francisco de Souza ◽

Irene Edith de Puy e Souza ◽

...

Keyword(s):

Hyperbaric Oxygen ◽

Hyperbaric Oxygen Therapy ◽

Oxygen Therapy ◽

Therapy Group ◽

Control Group ◽

Fisher Exact Test ◽

Exact Test ◽

Significant Difference ◽

Extramedullary Erythropoiesis ◽

Group 2

PURPOSE: To research the hyperbaric oxygen therapy effects on rats' livers and spleens. METHODS: 30 adult male Hotzman rats were used, being randomly distributed, by raffle, into 2 groups of 15 animals each: group 1 - control; group 2 - hyperbaric oxygen therapy. Group-2 animals underwent hyperbaric oxygen therapy for 120 minutes daily, 90 minutes of which were under pressure of 2.5 atmospheres. The first and last 15 minutes were used for gradual compression and decompression, respectively, for 20 days in a row. The livers and spleens of the animals from the two groups were taken out for histologic examination, on the day after the end of hyperbaric oxygen therapy in group 2 animals. Liver and spleen histologic changes of the animals from the two groups were compared by using Fisher exact test. P < 0.05 was regarded as a significant difference. RESULTS: The only change in liver and spleen histology was the significant reduction in hepatic extramedullary erythropoiesis in the animals that underwent hyperbaric oxygen therapy (p < 0.05). CONCLUSION: Hyperbaric oxygen therapy reduces hepatic extramedullary erythropoiesis in rats and doesn't jeopardize the other liver and spleen structures.

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Role of polymorphisms of genes involved in hemostasis in COVID-19 pathogenesis

Infekcionnye bolezni ◽

10.20953/1729-9225-2021-2-16-26 ◽

2021 ◽

Vol 19 (2) ◽

pp. 16-26

Author(s):

V.N. Gorodin ◽

◽

D.L. Moysova ◽

S.V. Zotov ◽

A.A. Vanyukov ◽

...

Keyword(s):

Severe Disease ◽

Protective Role ◽

Categorical Variables ◽

Fisher Exact Test ◽

Homozygous Mutation ◽

Blood Leukocytes ◽

Gene Encoding ◽

Exact Test ◽

Group 2 ◽

Group 1

Objective. To analyze polymorphisms of genes involved in hemostasis among patients with coronavirus disease 2019 (COVID 19) to improve the diagnosis of coagulopathy and prognosis of COVID-19 severity. Patients and methods. We have examined 52 patients with COVID-19 aged 33 to 84 years. Of them, 30 individuals (Group 1) were hospitalized with extremely severe (1A) and severe (1B) disease, whereas 22 patients with mild and asymptomatic disease were treated in outpatient departments (group 2). We assessed allelic variants of genes associated with hemostasis dysfunction (including FGB, FII, FV, FVII, F13A1, PAI-I, Gp1a, and Gp3a) using genomic DNA isolated from peripheral blood leukocytes. Polymorphisms were detected by polymerase chain reaction. Data analysis was performed using the Statistica, version 12 (StatSoft, USA). To compare independent categorical variables, we constructed contingency tables, performed Pearson chisquare test with Yates correction, Fisher exact test, and calculated relative risk (RR) [CI]. Results. COVID-induced coagulopathy (CAC) was diagnosed in 16.7% of patients; risk of CAC was identified in 30% of patients; sepsis-induced coagulopathy (SIC) was observed in 3.3% of patients; none of study participants had disseminated intravascular coagulation (DIC). Hemostasis impairments were more common in group 1A (RR = 2.28 [1.16–4.48]). Only patients from Group 1 had mutations in the gene encoding prothrombin (FII) –6.9% (RR = 1.78 [1.40–2.28]); protective polymorphisms in the FVII gene were more common in patients from Group 2 (χ2 = 3.28, р = 0.046); the rs 5985 polymorphism in the F13A1 gene was more common in patients from Group 1 (RR = 1.73 [1.06–2.82]). Patients with extremely severe COVID- 19 were more likely to have polymorphisms in the Gp1a gene (ITGA2) (RR =1.64 [1.05–2.56]) and F13A1 gene (χ2 = 2.67, р = 0.05), as well as homozygous mutation in the FII gene; they had no polymorphisms in the FVII gene (10976G→A). Thrombophilia, detected in 3 patients from Group 1, was a risk factor for thrombocytopenia (RR = 13.5 [3.56–51.23]), САС (RR = 9.0 [3.1–26.16]), and death (n = 4). The 4G allele (4G/4G, 4G/5G variants) in the PAI-I gene (rs 1799889), causing impaired fibrinolysis, was more frequently registered in patients with mild COVID-19 (91%) than in those with extremely severe COVID-19 (70%). It is possible that patients with extremely severe disease develop transient hyperfibrinolysis, which results in the transformation of local pulmonary COVID-19 into sepsis. Therefore, the 4G/4G and 4G/5G polymorphisms may have a protective role. Key words: hemostasis, COVID-19, polymorphism, genetics, COVID-induced coagulopathy

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Clinical Evaluation of Stress-reducing Direct Composite Restorations in Structurally Compromised Molars: A 2-year Report

Operative Dentistry ◽

10.2341/10-299-c ◽

2012 ◽

Vol 37 (2) ◽

pp. 109-116 ◽

Cited By ~ 7

Author(s):

S Deliperi ◽

DN Bardwell ◽

D Alleman

Keyword(s):

Composite Resin ◽

Clinical Performance ◽

Fisher Exact Test ◽

Exact Test ◽

Composite Restorations ◽

Large Size ◽

Residual Cavity ◽

Molar Teeth ◽

Proximal Extension ◽

Group 2

SUMMARY Objective To evaluate the clinical performance of class II large-size direct composite restorations. Materials and Methods Fifty (50) patients 18 years or older were included in this clinical trial restoring 75 vital molar teeth with large-size cavities. Inclusion Criteria Occlusal extension greater than two-thirds the intercuspal distance and proximal extension greater than half the distance between line angles. Teeth with residual cavity walls less than 1 mm and with one or more cusps involved were excluded. Teeth were randomly divided in three groups. Group 1: Opti-Bond FL; group 2: Scotchbond 1 XT; group 3: PQ1. Total-etching was performed using 35% phosphoric acid followed by the application of 2% chlorhexidine gluconate in the three groups. All teeth were restored using Vit-l-escence microhybrid composite resin. The proximal surface was built up first, followed by dentin and enamel occlusal surface stratification; wedge-shaped increments of composite resin were placed and cured using the UltraLume V curing light through a combination of pulse and progressive curing techniques. Results Restorations were evaluated at six-month intervals during the two-year period using a modified US Public Health Service criteria by two independent evaluators precalibrated at 85% reliability. No failures were reported and α scores were recorded for all parameters. Statistical analysis was performed using a χ2 test and the Fisher exact test (χ2=10.6; p=0.001). No teeth exhibited sensitivity in the three groups both at the two-week recall and two-year follow-up.

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The comparative evaluation of apoptosis produced by leuprolide or orchiectomy on rat prostate tissue

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2015.4.265 ◽

2016 ◽

Vol 87 (4) ◽

pp. 265 ◽

Cited By ~ 1

Author(s):

Basri Cakiroglu ◽

Aydin Ismet Hazar ◽

Seyit Erkan Eyyupoglu ◽

Mustafa Bahadir Can Balci ◽

Orhun Sinanoglu ◽

...

Keyword(s):

Prostate Tissue ◽

Male Rats ◽

Control Group ◽

Fisher Exact Test ◽

Exact Test ◽

Benign Prostate Hypertrophy ◽

Normal Limits ◽

Bilateral Orchiectomy ◽

Glandular Atrophy ◽

Group 2

Introduction: Organisms are constantly in a balance meaning that while new cells are produced, some of the older ones die which takes place in 2 ways: necrosis or apoptosis. Apoptosis is the programmed cellular death triggered by intrinsic or extrinsic stimuli. In this study we have evaluated the apoptosis of prostate tissue generated by surgical or medical orchiectomy. Material and Method: In this experimental study, we used 36 adult male rats that were evaluated in 3 groups. The first group (Group 1) consisted of 12 rats that had bilateral orchiectomy; the second group (Group 2) included 12 rats that were given leuprolide acetate and the third group (Group 3) consisted of 12 control rats. Immunohistochemical staining of the prostate of all rats was performed and the presence of glandular atrophy and apoptosis were evaluated in the three groups. The statistical differences between the two groups were evaluated by the Fisher exact test. Results: Glandular atrophy was not determined in any rat of the control group, and the apoptotic staining was in the normal limits in all the control rats. In Leuprolide group, glandular atrophy was mild in 7 cases, and moderate in 3 rats. In 2 rats of the Leuprolide group, atrophy was not demonstrated. In surgical orchiectomy group, glandular atrophy was present in all cases. Atrophy was observed as cystic atrophy. Statistical analysis with the Fisher exact test revealed that glandular atrophy was statistically significantly more common in surgical orchiectomy group compared with Leuprolide group (p = 0,012). Conclusion: If the aim of treatment in androgen dependent prostatic adenocarcinoma or benign prostate hypertrophy is the construction of a robust apoptosis, bilateral orchiectomy generates a more powerful apoptosis compared with Leuprolide.

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Operative Management of Neonatal Lymphatic Malformations: Lesson Learned From 57 Consecutive Cases

Frontiers in Pediatrics ◽

10.3389/fped.2021.709223 ◽

2021 ◽

Vol 9 ◽

Author(s):

Marianna Scuglia ◽

Andrea Conforti ◽

Laura Valfrè ◽

Giorgia Totonelli ◽

Chiara Iacusso ◽

...

Keyword(s):

Respiratory Distress ◽

Residual Disease ◽

Statistical Significance ◽

Operative Management ◽

Fisher Exact Test ◽

Lymphatic Malformations ◽

Exact Test ◽

Life Threatening ◽

Group A ◽

Group B

Aim of the study: Lymphatic malformations (LMs) are rare entities, sometimes difficult to treat, that may be life-threatening when intricately connected to airway structures. Invasive treatments are occasionally required, with sclerotherapy considered the treatment of choice and surgery as a second-line approach. The aim of the present study was to evaluate our multidisciplinary team experience in treating newborns affected by LMs requiring operative management, while defining early outcomes.Methods: Retrospective review of all consecutive patients admitted for LMs requiring operative management between January 2000 and January 2019. Patients were mainly characterized based on anatomical district of the LM (and further stratified based on the development of respiratory distress), need for tracheostomy, number of sclerotherapies, indication for surgery, and residual disease beyond the 1st year. Morbidity and mortality were also evaluated. Fisher exact test and Mann–Whitney test were used as appropriate. Statistical significance was set at p < 0.05.Results: Fifty-seven patients were included in the study, 36 with cervicofacial and/or mediastinal LMs and 21 with LMs of other anatomical districts. Due to the risk of developing respiratory distress at birth, patients with cervicofacial and/or mediastinal LMs were divided into two groups (8/36 group A vs. 28/36 group B). Group A patients are at higher risk for tracheostomy (7/8 group A vs. 1/28 group B, p = 0.0001) and more often require surgical reduction of the residual lymphatic abnormality (5/8 group A vs. 4/28 group B, p = 0.013). They also require sclerotherapies more often, but the difference is not statistically significant (8/8 group A vs. 19/28 group B, p = 0.15). Patients with cervicofacial/mediastinal LMs frequently suffer from persistent residual disease beyond the 1st year of life, significantly more often in group A (7/8 group A vs. 12/28 group B, p = 0.043).Conclusion: LMs are rare conditions with potential life-threatening behavior. Their intrinsic clinical complexity requires a multidisciplinary approach to the affected patients. Planning a long-term follow-up is essential because of the late-term problems those patients may experience.

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