Objectives: The prospective audit aims to evaluate how blood pressure is managed in patients with acute ICH against NICE NG128 standards, alongside exploring staff awareness and barriers to compliance. Methods: This prospective audit included 39 patients with CT-confirmed ICH who presented between February and May 2021. Data were collected retrospectively from electronic records. A structured questionnaire was distributed to multidisciplinary staff involved in ICH care to assess guideline awareness and implementation challenges. Results: Out of 34 patients eligible for rapid BP lowering, only 9 (26%) received antihypertensive treatment within one hour. Neurosurgical referrals were made for all patients, but only one was accepted. Staff survey (n=40) revealed that 47.5% were unaware of the correct NICE target for BP, and only 25% knew the appropriate BP monitoring duration. Moreover, 77% of staff reported difficulty-achieving target BP in clinical practice. Conclusion: There is suboptimal adherence to NICE guidance for BP management in acute ICH at EDGH, compounded by low staff awareness and inconsistent practices. Targeted education, a standardized BP-lowering protocol, and re-auditing following implementation are recommended to improve care quality and patient outcomes.
Objective: determine the prevalence and types of thyroid dysfunction among adults with T2DM in Sulaymaniyah, Kurdistan Region, Iraq, and identify associated risk factors. Methods: Between November 2024 and July 2025, a descriptive cross-sectional study was conducted among 1,000 adults with T2DM attending private clinics in Sulaymaniyah. Thyroid status was based on documented diagnoses or abnormal thyroid function tests. Given its cross-sectional design, causal relationships could not be established. Results: The mean age was 54.3 ± 8.2 years, and 54.4% were female. Thyroid dysfunction was present in 5.5% (95% CI: 4.2–7.1%), including hypothyroidism in 3.7% and hyperthyroidism in 1.8%. Women accounted for 83.6% of affected cases. Female sex predicted both hypothyroidism (OR 2.95, 95% CI: 1.13–7.74) and hyperthyroidism (OR 5.34, 95% CI: 1.12–25.49). A positive family history was a strong predictor (OR > 80, p < 0.001). Meanwhile, Age, diabetes duration, and glycemic control were not influential factors. Conclusion: Thyroid dysfunction was relatively uncommon among T2DM patients, with hypothyroidism being predominant. Female sex and family history were the strongest predictors, supporting targeted screening of high-risk groups. Longitudinal studies are recommended to clarify causal relationships.
Objective: This study measures the quality of recovery for patients scheduled for elective surgery and compares general and spinal anesthesia on the QoR-15 score. Method: prospective, parallel, cross sectional study in which 160 patients with class I, II ASA status were scheduled for elective abdominal surgeries. 80 patients received general anesthesia, while 80 patients received spinal anesthesia. After acquiring informed written consents, the Kurdish version of the QoR-15 score questionnaire was filled out preoperatively and 24 hr postoperatively. Result: In 160 patients, Spinal anesthesia is better than general anesthesia regarding a 24-hour postoperative total QoR-15 score median (124 versus 114.5), respectively, with a p-value of 0.008. Males had a significantly better postoperative quality of recovery, and obesity had a negligibly opposite effect. Conclusion: Spinal anesthesia is better than general anesthesia for abdominal surgeries in terms of early quality of recovery as tested by the QoR-15.
Objectives: This study aimed to assess the level of knowledge about anemia and its associated factors among Palestinian students in medical and allied health fields, and to evaluate the impact of a course on anemia-related topics. Methods: Data were collected through an electronic questionnaire assessing students' knowledge of anemia, sociodemographic characteristics, nutritional status, and whether they had completed a course covering anemia. An anemia knowledge score and a socioeconomic status (SES) score were calculated. The data were analyzed using SPSS. Results: A total of 117 students from medicine, nursing, pharmacy, and other health-related disciplines participated. The average age was 19.9 ± 2.24 years, and the mean anemia knowledge score (out of 26) was 19.4 ± 3.6. Males comprised only 29.9% of the sample. Age, SES (based on income), and father's education level were significant predictors of anemia knowledge. Taking a nutrition course was associated with higher anemia knowledge scores (p = 0.09), while the specific field of study was not a significant predictor. Conclusion: Students in medical and allied health professions may benefit from including targeted nutrition courses on anemia in their academic curriculum.
Objectives: This study aimed to enhance the outcomes of surgical treatment for patients with gallstone disease by utilizing a minilaparotomy approach. Methods: A prospective clinical analysis was conducted involving 259 patients diagnosed with acute or chronic calculous cholecystitis. All patients were treated in the Department of Abdominal Surgery at the Khorezm Regional Multidisciplinary Medical Center, affiliated with the Department of General Surgery at the Urgench branch of the Tashkent Medical Academy. Preoperative assessments included standard laboratory tests (complete blood count, urinalysis, biochemical profile, coagulation tests, serologic screening for RW, HBsAg, and HBVg), electrocardiography, chest radiography, abdominal and pelvic ultrasound, and upper gastrointestinal endoscopy to identify coexisting conditions and assess the major duodenal papilla. Results: Cholecystectomy was performed through a minilaparotomy approach, using either a right-sided transrectal or pararectal incision. Both techniques involved partial disruption of motor and sensory nerve fibers of the right abdominal wall, which manifested postoperatively as restricted movement and increased pain levels. However, the use of a small oblique Kocher-type incision in the right hypochondrium, avoiding muscle and nerve injury, significantly reduced these adverse effects. Conclusion: A minimally invasive Kocher incision for cholecystectomy offers a safer alternative by preserving muscular and neural structures, thereby reducing postoperative pain and complications. This approach appears to improve patient recovery and surgical outcomes in the management of gallstone disease.
Objectives: This study aimed to assess the effectiveness of ultrasound therapy in preventing complications associated with ventral hernias and to enhance the quality of clinical data collected at participating research centers. Methods: An open-label, retrospective-prospective study design was used, with retrospective data forming the comparison group and prospectively collected data used for the intervention group. Patients were randomized based on hernia location, size, and the type of surgical repair (allohernoplasty) performed. The study included 219 patients with both primary and recurrent abdominal wall hernias who were treated between 2018 and 2023 at two healthcare facilities in the Khorezm region. Results: In the comparison group, a dormant encapsulated abscess developed in one patient. In contrast, no cases of dormant occluded abscesses were observed in the intervention group, where ultrasound therapy was applied postoperatively. Conclusion: To effectively reduce the risk of early postoperative complications following allohernia repair, a multimodal prevention strategy is recommended. This includes the local application of low-frequency ultrasound therapy and continuous use of an abdominal binder for the first 48 hours to ensure immobilization of the subcutaneous tissue.
Objective: To evaluate the effectiveness of full-house revision functional endoscopic sinus surgery (FESS) in patients with recurrent chronic rhinosinusitis (CRS) who had previously undergone sinus surgeries. Methods: This prospective study was carried out at the Otorhinolaryngology – Head & Neck Surgery Center in Sulaymaniyah Teaching Hospital and Zhian Private Hospital between January 2019 and March 2020. A total of 21 patients with recurrent CRS, each having undergone at least one previous sinus surgery, were enrolled to undergo revision full-house FESS. The effectiveness of the surgery was assessed using both subjective and objective outcome measures. Subjective evaluations included the Sino-Nasal Outcome Test (SNOT-22) and the Smell Identification Test (SIT) utilizing 16 Sniffin’ Sticks. Objective assessments included the Modified Lund-Kennedy (LK) endoscopic scoring system and the Lund-Mackay (LM) scoring system based on computed tomography scans. Evaluations were conducted preoperatively and postoperatively at 1, 3, and 6 months, with LM scores recorded at baseline and again at the 6-month follow-up. Results: The study cohort consisted of 21 patients, including 11 females and 10 males, with a mean age of 41.67 ± 11.93 years. Preoperative mean scores were as follows: SNOT-22 (48.10 ± 4.40), LK (4.10 ± 0.26), LM (10.48 ± 1.62), and SIT (8.00 ± 4.06). Statistically significant improvements were observed postoperatively across all parameters (P = 0.001). However, no significant differences in outcomes were identified based on the duration of follow-up or the number of previous sinus surgeries, specifically for the SNOT-22, LK, and LM scores. Conclusion: Revision full-house FESS resulted in significant improvement in both subjective and objective outcome measures over a 6-month follow-up period. These findings suggest that this surgical approach is an effective and reliable option for managing patients with recurrent CRS, offering notable enhancement in quality of life.
Objectives: This quality improvement study aimed to evaluate the impact of implementing restrictions on procalcitonin (PCT) testing to enhance antibiotic stewardship in a hospital setting. Methods: A retrospective, single-phase analysis was conducted over a five-month period at Eastbourne District General Hospital, involving 66 patients admitted to acute medical wards who underwent PCT testing. Data were extracted from electronic hospital records, including e-search, PACS, Evolve, and microbiology department databases. The study examined the correlation between PCT levels and other clinical and inflammatory markers, including C-reactive protein (CRP), white cell count (WCC), neutrophils, National Early Warning Score 2 (NEWS2), and temperature. Results: Restricting PCT testing resulted in a 40% reduction in inappropriate test requests. The use of PCT-guided decision-making was associated with a shortened duration of antibiotic therapy for lower respiratory tract infections (3–5 days compared to the standard 7–10 days). Strong positive correlations were observed between PCT and CRP (r = 0.985), WCC (r = 0.993), neutrophils (r = 0.986), NEWS2 (r = 0.958), and temperature (r = 0.960), all statistically significant (p < 0.0001). Conclusions: Selective use of PCT testing can optimize antibiotic prescribing practices and support effective antimicrobial stewardship. Long-term success relies on guideline adherence, clinician education, and seamless integration of PCT protocols into electronic health systems.
ObjectivesThis study aimed to investigate the factors contributing to the low thrombolysis rates for acute ischemic stroke at Eastbourne District General Hospital and to formulate evidence-based recommendations to improve timely access to thrombolytic treatment. MethodsA retrospective audit was conducted on stroke admissions during April–May 2019 and 2020. Patient records were analyzed to assess eligibility for thrombolysis, time of presentation, imaging timelines, and treatment decisions. Comparisons were drawn between in-hours and out-of-hours presentations using descriptive and inferential statistics. ResultsAmong 395 suspected stroke cases, 185 thrombolysis alerts were initiated, yet only 21 patients (7.3%) received Alteplase. The majority of these treatments occurred outside of regular hours. Key barriers included delayed door-to-needle times and incomplete pre-alert notifications. Median door-to-needle times frequently exceeded 60 minutes, indicating systemic inefficiencies. ConclusionTo enhance thrombolysis rates, comprehensive improvements across the stroke care pathway are necessary. These include raising public awareness, streamlining in-hospital procedures, ensuring consistent medical staffing, and exploring the use of faster-acting thrombolytic agents such as Tenecteplase.
ObjectivesThis study aimed to investigate the potential role of Enterococcus faecalis in the development of atherosclerosis, focusing on two primary mechanisms: the induction of vegetative endocarditis and the promotion of oxidative stress. By examining systemic effects following dissemination of E. faecalis, commonly associated with dental infections, the study sought to explore its possible contribution to cardiovascular pathology. MethodsE. faecalis was isolated from dental caries lesions and identified as gram-positive cocci using selective and differential culture media. Twenty adult albino rats were randomly divided into two groups (n=10 per group). Group 1 served as the control, while Group 2 received an intraperitoneal injection of E. faecalis suspension (1 mL, 7.8 × 10⁷ CFU/mL). After 90 days, oxidative stress biomarkers—GSH, SOD, TAC, MDA, NO, IL-6, and TNF-α—were measured in cardiac and aortic tissues. Serum CRP levels were assessed to evaluate systemic inflammation. Histopathological examinations of the aorta and heart were conducted to assess structural and inflammatory changes. ResultsInfected rats exhibited significant histopathological alterations in the aorta, including lipid vacuole accumulation, foam cell infiltration in intima and media layers, and fragmentation of elastic fibers. Cardiac examination revealed vegetative endocarditis with bacterial colonies, mononuclear cell infiltration, myocardial fatty degeneration, and mural valve thrombi. Coronary arteries displayed wall thickening, thrombus formation, and periarteritis. Biochemical assays showed elevated oxidative stress markers and significantly increased CRP levels in Group 2 compared to controls. ConclusionThe findings suggest that systemic E. faecalis infection can contribute to atherosclerosis by promoting both vegetative endocarditis and oxidative stress. This supports a mechanistic link between oral bacterial infections and cardiovascular disease, underscoring the importance of oral health in systemic disease prevention.
ObjectivesThis study aimed to analyze the patterns and surgical management strategies of combined esophageal and gastric chemical burns, with a focus on the types of gastric involvement and appropriate surgical interventions based on the stage of injury. MethodsA retrospective analysis was conducted based on clinical experience from the Department of Esophagus and Stomach Surgery at the Republican Specialized Scientific and Practical Medical Center for Surgery named after Academician V. Vakhidov. A total of 247 patients with post-burn cicatricial strictures of the esophagus and stomach (PBCSES) were examined and treated between 1990 and 2022. The extent and location of gastric injuries were categorized, and surgical approaches were evaluated based on the timing and severity of the burns. ResultsAmong the 247 patients, the distribution of combined gastric lesions was as follows: isolated pylorus involvement in 24 cases (9.7%), antrum in 51 cases (20.6%), both pylorus and antrum in 143 cases (57.9%), body of the stomach in 7 cases (2.8%), antrum and body in 11 cases (4.5%), subtotal gastric involvement in 4 cases (1.6%), and total gastric involvement in 7 cases (2.8%). Combined damage to the esophagus and stomach, with predominance of one organ, was observed in approximately 50% of cases. Conclusion Surgical intervention for early-stage chemical burns is generally limited to symptomatic and supportive treatments due to incomplete scarring. In contrast, late-stage burns may be amenable to radical surgical procedures, provided that the patient's nutritional (alimentary) status is adequately maintained. In cases of compromised nutritional status, symptomatic surgical approaches remain the primary option.
ObjectivesKlebsiella pneumoniae is a Gram-negative pathogen responsible for a range of hospital-acquired infections and is increasingly resistant to antibiotics. This study aimed to evaluate the immunogenic potential of a 65.5 kDa pili protein from K. pneumoniae by assessing its ability to induce Interleukin-5 (IL-5) production in the spleen of BALB/c mice, thereby exploring its suitability as a vaccine candidate. MethodsTwenty-one BALB/c mice were randomly assigned to three groups: control (PBS), adjuvant only, and pili protein. The animals received three intraperitoneal injections at 14-day intervals. The first dose was given with Complete Freund's Adjuvant (CFA), followed by two doses with Incomplete Freund's Adjuvant (IFA). Fourteen days after the final injection, spleens were collected, and IL-5 levels were measured using enzyme-linked immunosorbent assay (ELISA). ResultsThe group immunized with the 65.5 kDa pili protein showed a statistically significant increase in IL-5 levels compared to both the control and adjuvant groups (p < 0.001). This indicates that the pili protein effectively stimulates IL-5 production, a key cytokine in the Th2 immune response pathway. ConclusionThe 65.5 kDa pili protein of Klebsiella pneumoniae demonstrated the ability to enhance IL-5 production and elicit a Th2-type immune response in BALB/c mice. These findings support its potential as a promising vaccine candidate for preventing K. pneumoniae infections through stimulation of humoral immunity.
ObjectivesBaker’s cyst is the most common cystic lesion around the knee joint, particularly prevalent in individuals with knee osteoarthritis, with an incidence rate reported between 10% and 41%. This study aimed to evaluate the clinical effectiveness of intralesional Ozonated Platelet-Rich Plasma (PRP) injections combined with exercise in managing Baker’s cyst associated with knee osteoarthritis. MethodsThis retrospective study included 24 patients (17 females and 7 males) treated at a private clinic in Kirkuk over an 18-month period (July 1, 2018 – December 31, 2019). All patients received a comprehensive clinical, radiological, and ultrasound assessment. PRP was prepared from autologous blood using a two-step centrifugation process and activated with ozone using a Longevity Resources EXT50 Ozone Generator. Following cyst aspiration, the first Ozonated PRP injection was administered under ultrasound guidance. Subsequent intra-cystic and intra-articular PRP injections were given every 4 weeks for four more sessions. Each intra-articular injection was accompanied by periarticular subcutaneous ozone infiltration. Patients also performed quadriceps-strengthening and calf-stretching exercises beginning three days after the first injection. ResultsThe mean patient age was 59 ± 8 years, with the majority aged between 50–59 years (n = 12, 50%) and 60–69 years (n = 7, 29%). A total of 21 patients (87.5%) demonstrated good to excellent clinical improvement in terms of pain relief and functional recovery following the treatment regimen. ConclusionIntralesional and intra-articular Ozonated PRP injections, combined with a structured exercise program and adjunctive ozone therapy, appear to be a safe and effective approach for managing Baker’s cyst associated with knee osteoarthritis.
Objective:To investigate the efficacy of nitric oxide nanoparticles (NO-np) and β-sitosterol, delivered via aloe vera hydrogel, as a topical treatment for burn wounds, leveraging nitric oxide's antibacterial, anti-inflammatory, and wound-healing properties. Methods:Using a rat burn model, the study evaluated the antibacterial effect of NO against Pseudomonas aeruginosa, Klebsiella pneumoniae, and Staphylococcus aureus in vitro. Burn healing was assessed by applying a combination of NO-np, β-sitosterol, and aloe vera gel to the wounds, comparing treated samples to control groups. Histological analysis was performed to assess tissue regeneration and angiogenesis in the treated areas. Results:The NO-np exhibited significant antibacterial activity by inhibiting the growth of the tested bacteria. Additionally, the combination of NO-np, β-sitosterol, and aloe vera gel accelerated wound healing in burn injuries, with significant improvement in healing speed (P<0.05) and enhanced angiogenesis compared to controls. Conclusion:This study suggests that nitric oxide-loaded silica nanoparticles, especially when combined with β-sitosterol and delivered via aloe vera hydrogel, hold promise as an effective topical treatment for cutaneous burns. This combination therapy enhances wound healing, reduces burned tissue, and promotes angiogenesis, indicating potential for clinical application in burn management.
Objectives: By studying hydrogen peroxide induced apoptosis, this study aims to provide an understanding for the mechanism of various liver diseases and thus drug development. Methods: Oxidative stress was experimentally induced in rats through daily oral administration of 1% hydrogen peroxide (H2O2) for 15 and 30 days, leading to liver injury characterized by cell death of hepatocytes, particularly in the centrilobular region. Results: This study aimed to investigate the role of apoptosis in the pathogenesis of H2O2-induced hepatic injury. Apoptotic hepatocytes and Kupffer cells were identified and quantified using light microcopy. Liver sections revealed characteristic apoptotic changes, including a honeycomb appearance, cellular shrinkage, nuclear condensation and fragmentation, apoptotic body formation and phagocytosis of apoptotic cells by neighboring cells. The number of apoptotic cells was positively correlated with the duration of H2O2 exposure (15 and 30 days). Ultrastructural analysis showed liver injury marked by mitochondrial swelling, cristae lysis, fragmentation of the endoplasmic reticulum and disruption of cytoplasmic structures. Additionally, rats treated with H2O2 exhibited a significant reduction in hepatic glutathione (GSH) levels compared to control. Conclusion: The findings of this study suggest that apoptosis plays a significant role in the pathological process underlying liver injury induced by oxidative stress mediated by H2O2.
Objective: Healthcare workers (HCWs) experience more individual and occupational health problem than other professional groups, the most common being low back pain (LBP). Furthermore, nurses are the majority of victims who worked in different aspects at hospital which have experience with LBP. The aim of this study is to find out the prevalence of low back pain related to health cost and its associated risk factors among healthcare workers at hospitals. Methods: Cross sectional study, a convenience sampling technique was used comprising of 302 of hardcopy questionnaires that were distributed to healthcare workers in two tertiary hospitals in Erbil, Kurdistan Region of Iraq between March 2021 to June 2021. The data were analyzed by using descriptive analytical method and Chi-square. Results: The result showed that most of the respondents (59.3%) had experienced low back pain, with (47%) reporting LBP in present and (55.3%) revealed LBP in past 12 months. The highest prevalence was reported by nurses and the lowest amongst physiotherapist. Prolonged bad posture and lifting heavy weights were the most contributing factors of LBP. Furthermore, cost of treatment (direct cost) was significantly association with LBP. Conclusions: Preventive and control measures should be taken to reduce the risk of lower back pain, and also taking forward steps to diminish the incidence of occupational hazards. Therefore, our findings can help to establish policies, strategies, and appropriate interventions aimed to reduce the risk onset of LBP among health care professionals.
Objective: The goal of this study is the detection of the P. aeruginosa isolate for production the protease, the optimal conditions for produce, extraction, purification and characterization of the enzyme and study the synergistic effect of protease with antibiotics on P. aeruginosa. Method: Among (110) isolates from clinical sources, only (74) isolates identified as P. aeruginosa isolated from Baghdad hospitals. Detection of the optimal isolate for production the protease enzyme and the optimal conditions its produce, purification of enzyme by using ammonium sulfate, ion exchange chromatography and gel filtration, enzyme characterization of PH and temperature activity and stability, the study of synergistic effect of protease with antibiotics on P. aeruginosa. Result: The optimal conditions to produce protease is pH (8), (37) ºC, (BHI) broth, and during (48 hrs.). The precipitation saturation ratio (80%). Ion- exchanges (DEAE and CM) Cellulose and Gel filtration have specific activity ((121.25), (161.6), (660.53)) units/ mg)) respectively. The characterization done by pH and temperature activity purified protease was active in (138.51units/ ml) at pH (8), and stable in pH (8), the temperature for protease activity is (158.21 units/ ml) at (37) ºC. The synergistic effect of purified protease with antibiotics on P. aeruginosa in- vitro, was detected using the agar diffusion method, the effectiveness of the prepared hydrogel types, the results showed P. aeruginosa was sensitive isolate to prepare (Gel & Protease & Ceftriaxone) the diameter of the inhibition zone reached (42 mm), the synergistic effect we noticed when using a (Gel & Ceftriaxone & Protease) healing was observed in time (7-10 days) with wound healing without effect. Conclusion: In this study, it was discovered that mixing (protease + hydrogel + Ceftriaxone) accelerates the wound healing without leaving traces.
Objective:To evaluate the impact of protein supplementation on kidney health among athletes, focusing on the relationship between protein supplements and kidney biomarkers. Methods:The study analyzed kidney biomarkers—creatinine, urea, and uric acid levels—in serum and urine samples, as well as the albumin-to-creatinine ratio (ACR) in urine. Participants included adult male athletes from Sulaymaniyah City, Iraq, divided into two groups: those who did not consume protein supplements (-ve protein supplementation) and those who did (+ve protein supplementation). Results:Statistical analysis showed no significant difference (P < 0.05) in kidney biomarker levels between the -ve and +ve protein supplementation groups, indicating no adverse effects of protein supplements on kidney health. Conclusion:The study concludes that protein supplementation does not appear to have detrimental effects on kidney biomarkers in athletes. Excluding other lifestyle factors, such as smoking and alcohol consumption, is important to prevent additional alterations in kidney function.
Objective: To evaluate the efficacy of localized hypothermia as a tissue-protection strategy in mitigating ischemic and inflammatory damage during colon strangulation. Specifically, this study aimed to assess the impact of hypothermia on colon wall thickness, inflammatory cell infiltration, and pro-inflammatory cytokine levels in a controlled experimental model using white rats. By comparing outcomes between hypothermia-treated and untreated groups, the research sought to provide insights into the potential of hypothermia as an adjunctive therapy to enhance surgical outcomes and reduce complications associated with strangulated hernias. Methods: This experimental study involved 40 white rats with induced colon strangulation, divided into control (n=20) and hypothermia (n=20) groups. Local hypothermia was applied to the abdominal region at 13°C for 3–6 hours. The study evaluated colon wall thickness, inflammatory infiltrate area, macrophage counts, and levels of pro-inflammatory cytokines (IL-1β, IL-6, TNF-α) using histological, morphometric, and biochemical methods. Statistical significance was determined using Student’s t-test (p < 0.05). Results: Hypothermia significantly reduced colon wall thickness (0.5 ± 0.2 mm vs. 1.2 ± 0.3 mm in the control, p < 0.01), inflammatory infiltrate area (5,000 ± 1,500 µm² vs. 12,000 ± 3,000 µm², p < 0.05), and macrophage counts (50 ± 10 cells vs. 100 ± 20 cells, p < 0.05). Pro-inflammatory cytokine levels (IL-1β, IL-6, TNF-α) decreased by 45.8%, 47.4%, and 56.3%, respectively, in the hypothermia group compared to the control group (p < 0.01 for all). These findings confirm hypothermia's anti-inflammatory and tissue-protective properties. Conclusions: Hypothermia demonstrates significant potential in minimizing ischemic and inflammatory damage in cases of colon strangulation, reducing tissue edema and inflammatory cell infiltration. This approach may improve surgical outcomes and warrants further exploration for integration into clinical practice.
