scholarly journals ROLE OF HIGH RESOLUTION ULTRASOUND IN THE DISORDERS OF ACHILLES TENDON.

2021 ◽  
Vol 5 (2) ◽  
Author(s):  
Narayanan Ramakrishna
Keyword(s):  
High Resolution ◽  
Achilles Tendon ◽  
Clinical Examination ◽  
Clinical Presentation ◽  
Plantar Flexion ◽  
Clinical Manifestations ◽  
Clinical History ◽  
Detailed Knowledge ◽  
Common Symptom ◽  
Partial Tears

Background: The Achilles tendon is the most common tendon that can get injured. The tendon can get affected in a wide variety of conditions and present with varied clinical manifestations. A detailed knowledge of the conditions affecting this tendon, their clinical manifestations and their appearance in imaging studies will help narrow down the diagnosis and provide precise treatment. Aim: Aim of the study was to identify the most common pathologies that affect the Achilles tendon and to correlate the clinical presentation with the high resolution ultrasound appearance. Settings and design: This was a prospective study Methods and Material: 52 patients with suspected Achilles tendon pathology were evaluated. After taking a detailed clinical history and performing a clinical examination, HRUS was performed on all the patients. The disorders affecting the patients were characterised based on clinical presentation and ultrasound examination. Correlation was done between the clinical and HRUS presentation of these cases. Results The most common symptom at the time of presentation was pain which was present in 41 patients (78.9%). Other symptoms included loss of plantar flexion seen in 20 patients (38.4%), swelling in 36 patients (69%) and stiffness seen in 12 patients (23%). Tears in the tendon were the most common type of pathology noted in 25 patients (48.07%),18 patients (34.6%) presented with complete tears and 5 patients (13.4%) with partial tears. Complete tears occurred more frequently at a site 3-4 cm from the calcaneal insertion while partial tears were most commonly insertional. 10 (19.2%) patients had findings suggestive of tendinopathy and their most common complaint was chronic pain and swelling. 5 patients (9.62%) had features of enthesitis. Among them 3 had psoriatric arthropathy and 2 had ankylosing spondylitis. Conclusion The spectrum of disorders involving the Achilles tendon are diverse and the clinical examination maybe imprecise, especially in acute conditions. HRUS offers a highly accurate tool that can diagnose these conditions and guide the management. Keywords: Tendoachilles, Achilles tendon, Paratendinopathy, Tendinopathy, Tears, High resolution ultrasound

scholarly journals Avulsion Injuries of the Pelvis and Hip

2020 ◽  
Vol 192 (05) ◽  
pp. 431-440
Author(s):  
Omar M. Albtoush ◽  
Jafar Bani-Issa ◽  
Tanja Zitzelsberger ◽  
Fabian Springer
Keyword(s):  
Clinical Examination ◽  
Correct Diagnosis ◽  
Clinical History ◽  
Special Focus ◽  
Detailed Knowledge ◽  
Imaging Findings ◽  
Radiographic Findings ◽  
Injury Mechanisms ◽  
Chronic Injuries ◽  
Tendon Retraction

Background Avulsion injuries of the pelvis and hip region are typical injuries in adolescent athletes but can be found in adults as well. Typical sites for avulsion injuries include the origin/insertion of tendons and ligaments. Among adolescents, the not yet ossified apophysis is also frequently involved. The pelvis and hip are especially prone to such injuries due to their complex musculotendinous anatomy. Clinical history and physical examination in combination with the recognition of typical imaging findings are essential for correct diagnosis of these mostly acute, but sometimes also chronic injuries. Methods This review article describes typical avulsion injuries of the pelvis and hip and illustrates common radiological findings. Taking current literature into account, there is a special focus on the trauma mechanism, clinical examination, typical imaging findings and clinical management. Results and Conclusion Detailed knowledge of musculotendinous anatomy and typical injury mechanisms allows a correct diagnosis of avulsion injuries often only based on clinical examination and radiographic findings. Further imaging with ultrasound and MRI may be necessary to evaluate tendon retraction in non-osseous avulsion injuries and extent of soft-tissue damage. Knowledge of potential complications of acute/chronic injuries can help to avoid unnecessary examinations or invasive interventions. Conservative management of avulsion injuries usually leads to functionally good results. However, in the case of competitive athletes, relatively wide bone fragment dislocation or marked tendon retraction, operative re-fixation may be considered in order to expedite the rehabilitation process. Key Points: Citation Format

scholarly journals Clinical Manifestations of Symptomatic COVID-19 Patients in Kabul Province, the Capital of Afghanistan

2020 ◽  
Vol 7 ◽  
Author(s):  
Hashmatullah Yousufi ◽  
Ahmad Zia Noori ◽  
Shoaib Naeemi ◽  
Hamidullah Rasekh ◽  
Muzhda Haem Rahimi ◽  
...  
Keyword(s):  
Sore Throat ◽  
Clinical Presentation ◽  
Standard Form ◽  
Clinical Manifestations ◽  
Cross Sectional Study ◽  
Common Symptom ◽  
Young Generation ◽  
Cross Sectional ◽  
Oropharyngeal Swab ◽  
The Mean

Background: SARS-CoV-2 is a novel member of human coronavirus that is newly identified in Wuhan, Hubei, China. The COVID-19 pandemic has spread to over 213 countries and affected more than 33 million individuals and caused 999000 deaths worldwide.Methods: This cross-sectional study conducted on 124 symptomatic COVID-19 patients in Kabul, Afghanistan. Demographic and clinical data collected using a standard form.  Nasopharyngeal/oropharyngeal swab sample collected for viral detection. Data were analyzed using IBM SPSS statistics (version 21) software.Results: Out of 124 patients, 88 (71%) were male and 36 (29%) were female. The mean age of patients was 41.2±17.07 years and the majority of patients 32 (25.8%) were in the age group of 20 – 29 and minority 3 (2.4) was over 79 years. On clinical presentation, most patients had ageusia (71.3%), fever (69.4%), headache (69.4%), sore throat (66.1%), myalgia (66.1%), cough (64.5%), weakness (63.7%), dyspnea (38.7%), and the fewer symptom was diarrhea (31.5%). 19 (15.3%) patients had Hypertension, 16 (12.9%) had cardiovascular disease, 8 (6.5%) had diabetes, 5 (4.0%) had cancer, 4 (3.2%) had chronic pulmonary disease, and 3 (2.4%) had liver disease. The mean duration for the presence of symptoms was 13.3±6.3 days. The fatality rate was 4%.Conclusion: Our study reveals that males are more affected by COVID-19 than females and the young generation is more affected than elders.  The most common symptoms are ageusia, fever, headache, sore throat, and myalgia, and the less common symptom is diarrhea.

High Resolution Transmission Electron Microscopy of an automobile catalytic converter

1990 ◽  
Vol 48 (4) ◽  
pp. 242-243
Author(s):  
Jan-Olle Malm ◽  
Jan-Olov Bovin
Keyword(s):  
Electron Microscopy ◽  
High Resolution ◽  
Catalytic Converter ◽  
Active Material ◽  
Image Intensifier ◽  
High Resolution Electron Microscopy ◽  
Detailed Knowledge ◽  
Transmission Electron ◽  
Resolution Electron ◽  
Atomic Surface

Understanding of catalytic processes requires detailed knowledge of the catalyst. As heterogeneous catalysis is a surface phenomena the understanding of the atomic surface structure of both the active material and the support material is of utmost importance. This work is a high resolution electron microscopy (HREM) study of different phases found in a used automobile catalytic converter.The high resolution micrographs were obtained with a JEM-4000EX working with a structural resolution better than 0.17 nm and equipped with a Gatan 622 TV-camera with an image intensifier. Some work (e.g. EDS-analysis and diffraction) was done with a JEM-2000FX equipped with a Link AN10000 EDX spectrometer. The catalytic converter in this study has been used under normal driving conditions for several years and has also been poisoned by using leaded fuel. To prepare the sample, parts of the monolith were crushed, dispersed in methanol and a drop of the dispersion was placed on the holey carbon grid.

scholarly journals Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon

2021 ◽  
Vol 6 (2) ◽  
pp. 247301142110035
Author(s):  
Keisuke Tsukada ◽  
Youichi Yasui ◽  
Maya Kubo ◽  
Shinya Miki ◽  
Kentaro Matsui ◽  
...  
Keyword(s):  
Achilles Tendon ◽  
Scale Score ◽  
Tendon Rupture ◽  
Plantar Flexion ◽  
Achilles Tendon Rupture ◽  
Case Series ◽  
Semitendinosus Tendon ◽  
Level Of Evidence ◽  
Operative Outcomes

Background: The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture. Methods: A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up. Results: Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up ( P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively ( P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery. Conclusion: The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery. Level of Evidence: Level IV, retrospective case series.

scholarly journals Neuralgic amyotrophy: an underrecognized entity

2021 ◽  
Vol 49 (4) ◽  
pp. 030006052110065
Author(s):  
Tae Uk Kim ◽  
Min Cheol Chang
Keyword(s):  
Clinical Practice ◽  
Magnetic Resonance ◽  
Clinical Manifestations ◽  
Clinical History ◽  
Cervical Radiculopathy ◽  
Sudden Onset ◽  
Clinical Findings ◽  
Magnetic Resonance Neurography ◽  
Essential Information ◽  
Neuralgic Amyotrophy

Neuralgic amyotrophy (NA) is markedly underdiagnosed in clinical practice, and its actual incidence rate is about 1 per 1000 per year. In the current article, we provide an overview of essential information about NA, including the etiology, clinical manifestations, diagnostic investigations, differential diagnosis, treatment, and prognosis. The causes of NA are multifactorial and include immunological, mechanical, or genetic factors. Typical clinical findings are a sudden onset of pain in the shoulder region, followed by patchy flaccid paralysis of muscles in the shoulder and/or arm. A diagnosis of NA is based on a patient’s clinical history and physical examination. Gadolinium-enhanced magnetic resonance imaging and high-resolution magnetic resonance neurography are useful for confirming the diagnosis and choosing the appropriate treatment. However, before a diagnosis of NA is confirmed, other disorders with similar symptoms, such as cervical radiculopathy or rotator cuff tear, need to be ruled out. The prognosis of NA depends on the degree of axonal damage. In conclusion, many patients with motor weakness and pain are encountered in clinical practice, and some of these patients will exhibit NA. It is important that clinicians understand the key features of this disorder to avoid misdiagnosis.

scholarly journals AB0797 ULTRASONOGRAPHIC ASSESSMENT OF ENTHESEAL INVOLVEMENT IN PSORIATIC ARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1698.2-1699
Author(s):  
I. Mahmoud ◽  
S. Rahmouni ◽  
A. Ben Tekaya ◽  
S. Bouden ◽  
R. Tekaya ◽  
...  
Keyword(s):  
Psoriatic Arthritis ◽  
Achilles Tendon ◽  
Patellar Tendon ◽  
Clinical Examination ◽  
Disease Duration ◽  
Plantar Fascia ◽  
Quadriceps Tendon ◽  
The Mean ◽  
Triceps Tendon ◽  
Nail Involvement

Background:Entheseal involvement is a frequent and distinctive feature of psoriatic arthritis (PsA), often under diagnosed. It is especially associated with nail involvement. Because clinical examination is not sensitive enough for the detection of early signs of this involvement, US may be considered as an alternative imaging technique in the diagnosis of enthesopathy.Objectives:The aim of the present study is to evaluate US entheses abnormalities in PsA and their correlation with clinical characteristicsMethods:The study included patients diagnosed with PsA according to the CASPAR criteria. They underwent a thorough clinical examination with special regard to the presence of enthesitis using the Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Index.The US study bilaterally explored entheses at six sites: proximal plantar fascia, distal Achilles tendon, distal and proximal patellar tendon insertion, distal quadriceps tendon and distal brachial triceps tendon. We evaluated the following elemental lesions of enthesis at each site: thickness and structure of the tendon, calcifications, bursae, erosions, power Doppler signal in bursa or enthesis full tendon.Results:Of the 33 patients, 39.4 % were male. The mean age was 51.2±12.5 years. The mean disease duration was 13.5±10.2 years.The mean DAPSA was 22.8± 19.7 [0.1-84.5]: remission(n=9), low activity (n=5),moderate activity (n=11),high activity(n=8).At inclusion, 11 patients (33.4%) patients presented with psoriatic onychopathy (45 fingernails) with a mean mNAPSI of 14.1±16. Out of the 528 entheseal sites, 92 were tender at the palpation (17,4%) with a mean SPARCC at 2.87.A total of 396 entheseal sites were examined by US. In 140 of them (35.35%), US found at least 1 sign indicative of enthesopathy. The most affected tendon was the distal Achilles tendon (42/396), followed by proximal plantar fascia (32/396), distal patellar tendon (20/396), quadriceps tendon (20/396), distal brachial triceps tendon(14/396) and finally proximal patellar tendon (12/396).The most common elemental lesions were enthsophytes (176), erosions (114) and calcifications (50).We found a positive correlation between age and both calcification (r=0,4, p=0.021) and enthesophytes (r=0.479, p=0.005).We found a positive correlation between enthesophyte and the tender and swollen joints count (r= 0.352, p=0.045, r=0.378, p=0.03) and the SPARCC score (r=0.397, p=0.022).Patients with higher BASDAI had thicker tendons (r=0.355, p=0.05).Patients with nail dystrophy had more bursitis and erosions.US scores did not correlate with sexe, disease duration and disease activity measures (ASDAS, DAPSA, DAS28 and PASI). Patients with subclinical entheseal involvement didn’t have higher inflammatory biomarkers (ESR, CRP).Conclusion:US subclinical enthesopthy are not rare in psoriatic arthritis, in particular in patients with active disease.Clinical nail involvement was associated with bursitis and erosions. New studies including larger study groups are required to verify the findings of the present studyDisclosure of Interests:None declared

scholarly journals POS1199 CLINICAL MANIFESTATIONS OF SARS-CoV2 INFECTIONS IN CHILDREN AND ADOLESCENTS WITH RHEUMATIC AND MUSCULUSKELETAL DISEASES – SURVEY DATA FROM GERMANY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 882.1-882
Author(s):  
C. Sengler ◽  
S. Eulert ◽  
M. Niewerth ◽  
T. Kallinich ◽  
H. Wittkowski ◽  
...  
Keyword(s):  
Disease Activity ◽  
Children And Adolescents ◽  
Symptom Onset ◽  
Clinical Manifestations ◽  
Virus Detection ◽  
German Society ◽  
Underlying Disease ◽  
Common Symptom ◽  
Disease Course ◽  
Cardiorespiratory Failure

Background:Although children and adolescents are less likely to develop COVID-19 and generally show milder disease courses, it is unclear what impact the SARS-CoV2 infection has on children and adolescents with rheumatic and musculoskeletal disease (RMD). Due to their underlying disease as well as therapeutic immunosuppression these patients may be at higher risk of being more severely affected by SARS-CoV2. Furthermore, SARS-CoV2 infection might trigger a flare of the underlying disease.Objectives:To evaluate clinical characteristics and disease course of COVID-19 in children and adolescents with RMD and to analyze possible effects of SARS-CoV2 infection on the underlying disease under different therapeutic regimens.Methods:Data from juvenile patients with RMD recorded via the SARS-CoV2 questionnaire within the National Pediatric Rheumatology Database and the registry for hospitalized children and adolescents with COVID-19 of the German Society for Pediatric Infectious Diseases were analyzed. In addition to age, sex and diagnosis, information was collected about the date and method of a positive SARS-CoV2 testing, reason for testing, on clinical manifestations, disease course, treatment and outcome of COVID-19, on drug therapy at the time of virus detection, on disease activity (NRS 0 – 10, 0 = best) of the underlying disease at the last visit before and after the SARS-CoV2 infection.Results:From April 17th 2020 until January 25th 2021, data of 67 patients with RMD and confirmed SARS-CoV2 infection were collected. Mean age was 13.5 ± 3.9 years with equal sex distribution. The majority of patients were diagnosed with juvenile idiopathic arthritis (JIA, 64%), 12 (18%) patients had an autoinflammatory disease (FMF, CAPS, PFAPA, TRAPS) and 5 (7%) a connective tissue disease. Fifty-two patients (78%) were treated with a disease modifying antirheumatic drug (DMARD), 39% with a biological DMARD and 9% systemic glucocorticoids at the time of SARS-CoV-2 infection. Nineteen patients (28%) were tested for SARS-CoV-2 because of typical symptoms, the majority (67%) because of contact to an infected person. PCR was used most often (in 60 %).52 patients (78%) developed symptoms of COVID-19, 15 patients remained asymptomatic. The most common symptom of COVID-19 was rhinitis (42%) and fever (38%), followed by fatigue (34%), taste/smell disorder (33%), sore throat (27%) and cough (23%).Disease severity was graded as mild in 44 of 52 (85%) symptomatic patients, only two patients were hospitalized, one of whom required intensive care and died of cardiorespiratory failure 3 days after symptom onset. In 22 of 26 (85%) SARS-CoV2-positive patients, no relevant increase in disease activity (difference in NRS ≤ 1 before/after infection) of the underlying disease was observed 31 days after symptom onset (median, IQR 17-52 days). One patient, who had paused tocilizumab for 2 doses, experienced a flare of his seronegative polyarthritis 2 months after asymptomatic SARS-CoV-2 infection.Conclusion:In our cohort, the clinical picture of COVID-19 in children and adolescents with RMD was similar to that of healthy peers. The majority of patients showed mild disease course with good outcome under various medications, however, one patient with a severe course of COVID-19 died. In addition, SARS-CoV2 infection does not appear to have a relevant impact on the underlying disease activity, whereas discontinuation of therapy might pose a risk of flare.Disclosure of Interests:None declared.

scholarly journals Biomechanics and Exercise

2015 ◽  
Vol 27 (1) ◽  
pp. 34-38
Author(s):  
Thomas D. O’Brien
Keyword(s):  
Achilles Tendon ◽  
Young’S Modulus ◽  
Young's Modulus ◽  
Plantar Flexion ◽  
Tendon Injury ◽  
Time Curve ◽  
Tendon Stiffness ◽  
Prepubertal Children ◽  
Experimental Group ◽  
Tendon Properties

Children develop lower levels of muscle force, and at slower rates, than adults. While strength training in children is expected to reduce this differential, a synchronous adaptation in the tendon must be achieved to ensure forces continue to be transmitted to the skeleton with efficiency while minimizing the risk of strainrelated tendon injury. We hypothesized that resistance training (RT) would alter tendon mechanical properties in children concomitantly with changes in force production characteristics. Twenty prepubertal children (8.9 ± 0.3 years) were equally divided into control (nontraining) and experimental (training) groups. The training group completed a 10-week RT intervention consisting of 2-3 sets of 8-15 plantar flexion contractions performed twice weekly on a recumbent calf raise machine. Achilles tendon properties (cross-sectional area, elongation, stress, strain, stiffness and Young’s modulus), electromechanical delay (EMD; time between the onset of muscle activity and force), rate of force development (RFD; slope of the force-time curve) and rate of EMG increase (REI; slope of the EMG-time curve) were measured before and after RT. Tendon stiffness and Young’s modulus increased significantly after RT in the experimental group only (~29% and ~25%, respectively); all other tendon properties were not significantly altered, although there were mean decreases in both peak tendon strain and strain at a given force level (14% and 24%, respectively, n.s) which may have implications for tendon injury risk and muscle fiber mechanics. A ~13% decrease in EMD was found after RT for the experimental group which paralleled the increase in tendon stiffness (r = −0.59), however RFD and REI were unchanged. The present data show that the Achilles tendon adapts to RT in prepubertal children and is paralleled by a change in EMD, although the magnitude of this change did not appear to be sufficient to influence RFD. These findings are of potential importance within the context of the efficiency and execution of movement.

Comparison of Functional Ability Following Percutaneous and Open Surgical Repairs of Acutely Ruptured Achilles Tendons

1993 ◽  
Vol 2 (2) ◽  
pp. 115-127 ◽  
Author(s):  
Gregory J. Steele ◽  
Rod A. Harter ◽  
Arthur J. Ting
Keyword(s):  
Achilles Tendon ◽  
Open Repair ◽  
Plantar Flexion ◽  
Secondary Purpose ◽  
Percutaneous Repair ◽  
Study Results ◽  
Male Patients ◽  
Flexion Strength ◽  
Repair Group ◽  
Repair Techniques

The purpose of our study was to evaluate the functional outcomes of two methods of surgical treatment of acute closed raptures of the Achilles tendon, specifically, the primary open repair and the percutaneous repair techniques, utilizing (a) isokinetic plantar flexion strength, (b) midcalf girth, (c) ankle joint proprioception, and (d) ankle range of motion values. As a secondary purpose, the frequency of reruptures and postsurgical complications were compared between techniques. Twenty male patients (mean age, 43.8 ± 9.4 years) who sustained complete, closed ruptures of the Achilles tendon participated in this study. Results of pairedttests revealed significant differences between postsurgical and contralateral normal limbs for 6 of 12 variables. Results of the ANOVAs revealed no significant differences between the open repair group and percutaneous repair group for any of the evaluative parameters. The significant deficits in postoperative isokinetic plantar flexion strength and midcalf girth measurements, irrespective of surgical technique, suggest an incompleteness of rehabilitation or, more likely, the physiological inability to regain these characteristics postoperatively.

Influence of Obesity on Clinical Manifestations and Response to Therapy in Cutaneous Leishmaniasis caused by Leishmania braziliensis

2021 ◽  
Author(s):  
Tainã Lago ◽  
Lucas Carvalho ◽  
Mauricio Nascimento ◽  
Luiz H Guimarães ◽  
Jamile Lago ◽  
...  
Keyword(s):  
Cutaneous Leishmaniasis ◽  
Clinical Presentation ◽  
Clinical Manifestations ◽  
Healing Time ◽  
Response To Therapy ◽  
Leishmania Braziliensis ◽  
Cutaneous Lesions ◽  
Cytokine Levels ◽  
Cure Rates ◽  
The Impact

Abstract Background Cutaneous leishmaniasis (CL) caused by L. braziliensis is characterized by a single ulcer or multiple cutaneous lesions with raised borders. Cure rates below 60% are observed in response to meglumine antimoniate therapy. We investigated the impact of obesity on CL clinical presentation and therapeutic response. Methods A total of 90 age-matched CL patients were included (30 obese, 30 overweight and 30 with normal BMI). CL was diagnosed through documentation of L. braziliensis DNA by PCR or identification of amastigotes in biopsied skin lesion samples. Serum cytokine levels were determined by chemiluminescence. Antimony therapy with Glucantime (20mg/kg/day) was administered for 20 days. Results Obese CL patients may present hypertrophic ulcers rather than typical oval, ulcerated lesions. A direct correlation between BMI and healing time was noted. After one course of Antimony, cure was achieved in 73% of patients with normal BMI, 37% of overweight subjects, yet just 18% of obese CL patients (p&lt;0.01). Obese CL cases additionally presented higher leptin levels than overweight patients or those with normal BMI (p&lt;0.05). Conclusions Obesity modifies the clinical presentation of CL and host immune response, and is associated with greater failure to therapy.

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