Inflammatory Bowel Disease and Neurodegenerative Diseases

A growing body of evidence has demonstrated an intricate association between inflammatory bowel disease (IBD) and neurodegenerative conditions, expanding beyond previous foci of comorbidities between IBD and mood disorders. These new discoveries stem from an improved understanding of the gut-microbiome-brain axis: specifically, the ability of the intestinal microbiota to modulate inflammation and regulate neuromodulatory compounds. Clinical retrospective studies incorporating large sample sizes and population-based cohorts have demonstrated and confirmed the relevance of IBD and chronic neurodegeneration in clinical medicine. In this review, we expound upon the current knowledge on the gut-microbiome-brain axis, highlighting several plausible mechanisms linking IBD with neurodegeneration. We also summarize the known associations between IBD with Parkinson disease, Alzheimer disease, vascular dementia and ischemic stroke, and multiple sclerosis in a clinical context. Finally, we discuss the implications of an improved understanding of the gut-microbiome-brain axis in preventing, diagnosing, and managing neurodegeneration among IBD and non-IBD patients.

Influences of Workplace Bullying, Social Support and Resilience on Retention Intention among Hospital Nurses: The Mediating Effect of Professional Quality of Life / 임상간호연구

Purpose@#The purpose of this study is to examine the mediating effect of professional quality of life among hospital nurses in the effects of workplace bullying, social support and resilience on retention intention. @*Methods@#A descriptive and cross-sectional study was conducted on 414 hospital nurses who worked for at least two months at a general hospital in the Seoul metropolitan area. The data were analyzed using IBM SPSS 23.0/AMOS 22.0 programs and employed reliability verification, descriptive statistics include frequency analysis, confirmatory factor analysis, structural equation modeling, and bootstrapping. @*Results@#As a result of the study's structural modeling verification, workplace bullying had a negative effect, social support had a positive effect, resilience had a positive effect on professional quality of life, and professional quality of life had a positive effect on retention intention. Also, workplace bullying, social support, and resilience did not directly impact on retention intention. However, the professional quality of life had a complete mediating effect in the relationships between workplace bullying, social support, resilience and retention intention. The study results verified the mediating effect of professional quality of life affecting the retention intention. @*Conclusion@#In order to improve professional quality of life and retention intention, strategies to prevent workplace bullying and promote social support and resilience are needed.

Influences of Workplace Bullying, Social Support and Resilience on Retention Intention among Hospital Nurses: The Mediating Effect of Professional Quality of Life / 임상간호연구

Purpose@#The purpose of this study is to examine the mediating effect of professional quality of life among hospital nurses in the effects of workplace bullying, social support and resilience on retention intention. @*Methods@#A descriptive and cross-sectional study was conducted on 414 hospital nurses who worked for at least two months at a general hospital in the Seoul metropolitan area. The data were analyzed using IBM SPSS 23.0/AMOS 22.0 programs and employed reliability verification, descriptive statistics include frequency analysis, confirmatory factor analysis, structural equation modeling, and bootstrapping. @*Results@#As a result of the study's structural modeling verification, workplace bullying had a negative effect, social support had a positive effect, resilience had a positive effect on professional quality of life, and professional quality of life had a positive effect on retention intention. Also, workplace bullying, social support, and resilience did not directly impact on retention intention. However, the professional quality of life had a complete mediating effect in the relationships between workplace bullying, social support, resilience and retention intention. The study results verified the mediating effect of professional quality of life affecting the retention intention. @*Conclusion@#In order to improve professional quality of life and retention intention, strategies to prevent workplace bullying and promote social support and resilience are needed.

Analysis of perioperative cardiac arrest in a rural hospital in Korea

Background@#Perioperative cardiac arrest has been studied in many countries but few related studies have been conducted in Korea. Previous studies were not applicable to rural hospitals due to differences in the demographics between the regions. In the present study, the incidence, mortality, and related factors of perioperative cardiac arrest in a hospital in Youngdong province were analyzed and compared with previous research. @*Methods@#A retrospective study was conducted from the January 1, 2012, to December 31, 2018, on patients who underwent both anesthesia and surgery in our hospital. Patients who received local anesthesia were not included in the study. The collected data included the patient characteristics, anesthesia methods, the American Society of Anesthesiologists physical status, surgical department, emergency status, traumatic status, pre- and post-cardiac arrest medical records, and patient outcomes. @*Results@#A total of 57,746 patients received anesthesia and underwent surgery during the study period, and 28 patients (4.85 per 10,000 anesthesia cases) received cardiopulmonary cerebral resuscitation (CPCR) during or within 24 hours of surgery. Eight patients survived and twenty patients died (3.46 per 10,000 anesthesia cases). There were three anesthesia-related arrests and all of these patients survived. When limiting the analysis to patients with intraoperative CPCR, the incidence and mortality were 1.56, and 1.39 per 10,000 anesthesia cases, respectively. @*Conclusions@#The incidence and mortality of perioperative cardiac arrest in our hospital were higher than those in a recent study in Seoul, demonstrating a regional gap in Korea.

Transversus abdominis plane block as a sole anesthetic technique for evacuation of rectus abdominis muscle hematoma - A case report -

Background@#Transversus abdominis plane (TAP) blocks have been used for analgesia in various abdominal surgeries. However, a TAP block as the sole anesthetic method for surgery has rarely been reported.Case: A 33-year-old breastfeeding primipara woman was admitted to the hospital due to a rectus abdominis muscle hematoma. Because the patient refused other anesthetic methods, evacuation of the hematoma was performed under an ultrasound-guided bilateral TAP block. A 23-gauge needle was inserted in an in-plane method using a linear ultrasound probe. An injection of 10 ml of 2% lidocaine was made to the right lateral TAP and the left lateral TAP. After confirming the sensory blockade of the T10 to T12 dermatomes, surgery was performed successfully. The patient’s condition stabilized during the surgery. Breastfeeding was performed on the day of surgery. @*Conclusions@#The evacuation of an abdominal wall hematoma in a breastfeeding patient was successfully performed under a bilateral TAP block.

Current use of neuromuscular blocking agents and antagonists in Korea: a 2018 survey

BACKGROUND: Neuromuscular blocking agents (NMBAs) and neuromuscular monitoring in anesthetic management are integral for endotracheal intubation, better visualization of the surgical field, and prevention of residual neuromuscular blockade and pulmonary complications. Sugammadex is a drug that reduces risk of residual neuromuscular blockade, with more rapid recovery compared to anticholinesterase. The purpose of this study was to investigate current usage status of NMBAs and antagonist with neuromuscular monitoring, among anesthesiologists in Korea.METHODS: Anesthesiologists working in Korea were invited to participate in an online survey via email January 2–February 28, 2018. The questionnaire consisted of 45 items, including preferred NMBAs, antagonists, neuromuscular monitoring, and complications related to the use sugammadex. A total of 174 responses were analyzed.RESULTS: Rocuronium was a commonly used NMBA for endotracheal intubation (98%) of hospitals, and maintenance of anesthesia (83.3%) in of hospitals. Sugammadex, pyridostigmine, and neostigmine were used in 89.1%, 87.9%, and 45.4% of hospitals. Neuromuscular monitoring was employed in 79.3% of hospitals; however only 39.7% of hospitals used neuromuscular monitoring before antagonist administration. Usual dosage range of sugammadex was 2.1–4 mg/kg in 35.1% of hospitals, within 2 mg/kg in 34.5% of hospitals, and 1 vial regardless of body weight in 22.4% of hospitals. Sugammadex-related complications were encountered by 14.9% of respondents.CONCLUSIONS: This survey indicates several minor problems associated with the use of antagonists and neuromuscular monitoring. However, most anesthesiologists appear to have appropriate information regarding the usage of NMBAs and sugammadex.

Knowledge of Diaper Dermatitis and Diaper Hygiene Practices among Mothers of Diaper-wearing Children

PURPOSE: The purpose of this study was to investigate the prevalence of diaper dermatitis (DD), knowledge of DD prevention and treatment, and diaper hygiene practices among mothers with diaper-wearing children. METHODS: The participants were 176 mothers who presented to an outpatient clinic at a children's hospital with diaper-wearing children. Data were collected using a structured self-administered questionnaire. RESULTS: The percent of correct answer for knowledge about DD was 59.7%. Almost half of the participants' children had experienced at least 1 episode of DD during the last 6 months. Inappropriate diaper hygiene practices, such as using talcum powder on DD and rubbing with a dry towel after cleansing, were reported. Moreover, only 37% of mothers used the recommended skin barrier to prevent DD. Although many children suffer from DD, levels of educational experience and perceived need for education on this topic were low. Almost 70% of mothers obtained DD-related information through internet sites. CONCLUSION: Educating parents about the etiology of DD and evidence-based diaper hygiene practices is an important aspect of effective DD prevention and treatment. Internet sites or smartphone apps may be effective methods for education on DD prevention and treatment considering parents' preferences for ways to obtain health information.

Comparison between cerebral state index and bispectral index during desflurane anesthesia / 대한마취과학회지

BACKGROUND: Cerebral state index (CSI) is an anesthesia depth monitor alternative to bispectral index (BIS). Published comparative studies have used propofol or sevoflurane. However, studies using desflurane have not been reported yet. Different volatile anesthetics have different electroencephalography signatures. The performance of CSI may be different in desflurane anesthesia. Therefore, the objective of this study was to compare CSI and BIS during desflurane anesthesia. METHODS: Thirty-three patients were recruited. Desflurane and remifentanil were used to maintain general anesthesia. BIS and CSI were recorded simultaneously every minute. End-tidal concentration of desflurane was maintained at 4% from the beginning of surgery for 5 minutes. Pairwise data of CSI and BIS were obtained five times at one-minute intervals. This process was repeated in the order of 6%, 8%, and 10%. RESULTS: BIS and CSI were negatively correlated with the end-tidal concentration of desflurane with a similar degree of correlation (correlation coefficient BIS: –0.847, CSI: –0.844). The relationship between CSI and BIS had a good linearity with a slope close to 1 (R2 = 0.905, slope = 1.01). For the relationship between CSI and BIS at each end-tidal concentration of desflurane, CSI and BIS showed good linearity in 4% and 10% (R2 = 0.559, 0.540). However, the linearity and slope were decreased in 6% and 8% (R2 = 0.163, 0.014). CONCLUSIONS: CSI showed an equivalent degree of overall performance compared to BIS in desflurane anesthesia. Accounting for previous literature, CSI can be used as a good substitute for BIS regardless of the kind of anesthetics used.

An Integrative Review of Korean Nursing Studies on Pediatric Tonsillectomy

PURPOSE: Tonsillectomy is a very common surgical procedure, particularly in children. The purpose of this study was to identify current evidence in nursing research on pediatric tonsillectomy by analyzing and evaluating Korean nursing studies related to pediatric tonsillectomy. METHODS: An integrative literature review of Korean pediatric tonsillectomy research was conducted. Databases were searched to identify research that related to nursing care for pediatric tonsillectomy children. RESULTS: Of the 115 studies identified, 13 studies met the inclusion criteria for this review. All studies were experimental studies and most of those studies had a quasi experimental design. No correlational studies or qualitative studies were found. Providing nursing information and education for children and their mothers at pre, during, and post tonsillectomy by pediatric nurses were found to be effective in reducing children's pain and anxiety and their mother's anxiety and uncertainty, and increasing children's appropriate sick role behaviors and their mother's satisfaction with nursing services provided and knowledge related to tonsillectomy. CONCLUSION: Although most studies reported positive effects in terms of post tonsillectomy outcomes, lack of methodological rigor limits the current evidences for pediatric tonsillectomy nursing interventions. Greater attention to improve methodological rigor for Korean research on pediatric tonsillectomy is needed.

Unilateral sudden sensorineural hearing loss after combined spinal-epidural anesthesia for emergency cesarean section: A case report

A 30-year-old primigravida with gestational age of 25 weeks and 4 days was admitted for emergency cesarean section. She was diagnosed as pre-eclampsia with fetal distress. We anesthetized the patient through the combined spinal-epidural anesthetic technique, and there was no specific event throughout the surgical procedures and in post anesthetic care unit. Subsequently, she complained of unilateral hearing difficulty in the ward and an otolaryngology consultation was obtained. She was diagnosed with left sudden sensorineural hearing loss in full frequency range after an acoustic examination. She received intravenous and local steroid treatments for 4 weeks. She showed 32 dB on pure tone audiometry after 5 months. However, we could not continue follow-up testing on the patient because she stopped visiting the hospital since the last examination. We reported a case of uncommon unilateral sudden sensorineural hearing loss after a combined spinal-epidural anesthesia for emergency cesarean section.

A comparison of oxycodone and fentanyl in the management of early postoperative pain and for patient-controlled analgesia after total abdominal hysterectomy

BACKGROUND: Although oxycodone has been known to be superior to other opioids in postoperative care, few studies have compared its analgesic potency with that of fentanyl. We therefore examined these two drugs in terms of their dose requirements, effects on pain intensity, time needed for relief of pain, and side effects after surgery. METHODS: We enrolled 56 healthy women scheduled for total abdominal hysterectomy and randomly allocated them to either oxycodone or fentanyl. The opioids were administered to the two groups 10 minutes before the end of the operation. In the post-anesthesia care unit (PACU) after surgery, a visual analog scale (VAS) was used to assess the patients' pain every 10 minutes Whenever pain control was required, a bolus of the same dose of the respective drugs was repeated at 10-minute intervals. Patient-controlled analgesia (PCA) was used to manage postoperative pain. After the patient arrived on the ward, pain scores were recorded at once and then 1, 2, 3, and 24 hours thereafter. RESULTS: During the hour spent in the PACU, fewer patients in the oxycodone group required the opioid, and the time needed to achieve pain relief was shorter with oxycodone than with fentanyl. Moreover, postoperative VAS levels were significantly lower in the oxycodone group both in the PACU and on the ward (over a 24-hours period). There were no significant differences in side effects between the patients given oxycodone and those given fentanyl. CONCLUSIONS: Oxycodone was more effective than fentanyl when administered on the basis of the recommended dose ratio (1 : 100). Although further evaluation is needed to investigate the optimal dose ratio, we would recommend a higher conversion factor (1 : 62).

Childhood Fever Management: Current Practice vs Evidence

PURPOSE: The purposes of this review were to address misconceptions of childhood fever and fever management practice among parents and health care providers, and to identify the scientific evidences against such misconceptions and practices. METHODS: Journal databases and clinical guidelines from 2000 to 2015 were searched. The search terms were fever, fever management, misconception, myth, fiction, fact, fever phobia, child, antipyretics, tepid bath, alternating use/combined use of antipyretics, and physical cooling method. RESULTS: There are significant gaps between current concepts and practices, and the scientific evidence. Misconceptions and unrealistic concerns about childhood fever still exist among parents and even health care providers, worldwide. The evidences suggest that antipyretics should be given carefully with the aim of relieving discomfort or pain rather than decreasing the temperature itself. Alternating use of antipyretics should be discouraged due to the risk of confusion and error. Antipyretics do not prevent febrile convulsions. Moreover, the scientific evidence does not support tepid sponge massage. CONCLUSION: Evidence-based childhood fever management interventions should be targeted toward parents and health care providers. By adopting an evidence-based approach to nursing interventions, pediatric nurses can ensure children receive appropriate and safe fever management.

Factors Influencing Pain Management Practice in Pediatric Nurses

PURPOSE: The purposes of this study were to explore knowledge, barriers, and self-efficacy in relation to pain management practice, and to identify factors influencing pain management practice in pediatric nurses. METHODS: A descriptive correlational study was conducted. The participants were 237 pediatric nurses from a metropolitan city. Data were analyzed using t-test or analysis of variance and Pearson correlation and multiple regression analyses. RESULTS: The mean percentage of correct answers on the children's pain management knowledge scale was 58.8%. Child and parent related factors were the main barriers for pain management. Self-efficacy to assess children's pain across developmental stages was particularly low. Pain management practices for assessing pain and non-pharmacological interventions were relatively low. Factors significantly affecting children's pain management practice were current conditions of work department and self-efficacy in pain management, and these factors accounted for 37.5% of the variance in pain management practice. CONCLUSION: The results suggest that an integrative education program needs to be developed to improve self-efficacy in children's pain management practice. Moreover, good communication, building cooperative relationships with children and parents, and a more active role by pediatric nurses are required to carry out more effective pain management.

Factors Affecting Daycare Center Teachers' Management of Childhood Fever

PURPOSE: The purposes of this study were to investigate daycare teachers'knowledge, anxiety and management of childhood fever and to identify factors affecting their management of childhood fever. METHODS: A descriptive correlation study was conducted. Participants were 109 daycare center teachers from G metropolitan city. A self-administered questionnaire was used for data collection. RESULTS: The mean percent of correct answers for knowledge about childhood fever was 42.9%. Levels of anxiety related to children's fever were high among day care teachers in this study. Many daycare center teachers used management practices which were not recommended for childhood fever management. There was a statistically significant difference in participants' knowledge about childhood fever by marital status and having a child. Moreover, there were statistically significant positive correlation between daycare center teachers' knowledge and management and negative correlation between daycare center teachers' anxiety and management of childhood fever. Knowledge and anxiety related to childhood fever accounted for 15.2% of variance for fever management. CONCLUSION: Results show that day care teachers' knowledge and anxiety related to fever are important factors in predicting their fever management. Development and evaluation of educational interventions to improve daycare teachers' childhood fever management are recommended.

Development and Effect of a Global Health Capacity Building Program for Nursing Students

PURPOSE: This study developed a short-term education program aiming to strengthen global health capacity in nursing students, and examined the effects of the program. METHODS: The subjects of this study were 83 students recruited from 29 nursing colleges. Domestic workshops and overseas training in the Philippines were offered. For data collection and analysis, the triangulation method was adopted. RESULTS: Students' critical thinking disposition and global leadership capacity were significantly increased. Thematic content analysis derived fifteen themes: expansion of global health, understanding of cultural diversity, vision of being a global leader, cultivation of communication skills, open mind toward people with different culture, pride and vocation, understanding of nursing in foreign countries, understanding of visiting nurse service, sustainability, understanding of local needs and environments, and education methods with an emphasis on participants, broader view and thinking of the world, reflection on the characteristics of a nurse, development through cooperation, and development through programs. CONCLUSION: The global health capacity building program improved nursing students' view of global health and nursing care. It is needed to develop continuously diverse global health capacity-building programs for nursing students.

Factors Associated with Relative Schoolbag Weight and Musculoskeletal Symptoms Among Elementary School Children

PURPOSE: The purpose of this study was to investigate the use of schoolbags and the prevalence of musculoskeletal symptoms among elementary school children and to identify factors associated with relative schoolbag weight and musculoskeletal symptoms. METHODS: A descriptive correlation study was conducted with 228 elementary school children in grades 4-6. A self-administered questionnaire was used for data collection. Descriptive statistics, t-test, ANOVA, chi2-test or Fisher's exact test, logistic regression analysis were used for data analysis. RESULTS: Mean relative schoolbag weight (RSW) was 6.40%. Among participants, 13.2% carried more than 10% of their RSW. Only 49.6% of participants organized the contents in their school backpack correctly. Musculoskeletal symptoms were reported by 42.5% of participants. Results from logistic regression analysis identified grade was a significant factor predicting RSW, and gender, RSW, and using a locker were significant factors predicting musculoskeletal symptoms among schoolchildren. CONCLUSION: Although RSW of school children in this study was within the currently recommended load limit, a considerable proportion of school children were not following guidelines for safe schoolbag use. An effective schoolbag safety campaign for parents, students, and teachers needs to be developed and evaluated to prevent possible musculoskeletal symptoms related to schoolbag use.

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Comparison of Ocular Biometry Using Low-Coherence Reflectometry with Other Devices for Intraocular Lens Power Calculation

PURPOSE: To compare axial length (AL) and keratometry (K) using optical low-coherence reflectometry (OLCR, Lenstar LS900(R), Haag-Streit, Bern, Switzerland) with current ocular biometry devices and evaluate the accuracy of intraocular lens (IOL) power calculation. METHODS: In this prospective, comparative observational study of eyes with cataracts, AL and K were measured using an OLCR device (Lenstar LS900(R), Haag-Streit), partial coherence interferometry (PCI, IOL Master(R), Carl Zeiss, Jena, Germany), A-scan (Eyecubed) and automated keratometry (KR-7100, Topcon, Tokyo, Japan). IOL power calculation was performed using the Sanders-Retzlaff-Kraff (SRK/T) formula. The IOL prediction error (PE) was calculated by subtracting the predicted IOL power from the postoperative (PO) IOL power (PO 4 weeks, PO 12 weeks). RESULTS: A total of 50 eyes of 39 patients with cataracts (mean age 67.12 +/- 8.51 years) were evaluated in this study. AL and K were not significantly different between the OLCR device and other devices (analysis of variance [ANOVA], p = 0.946, 0.062, respectively). The mean PE in IOL power calculation was -0.22 +/- 0.50D with the OLCR device, 0.08 +/- 0.45D with the PCI device and -0.01 +/- 0.48D with A-scan and automated keratometry (ANOVA, p = 0.006). The highest percentage of eyes with PE smaller than +/- 0.5D was IOL Master(R) followed by Eyecubed and then Lenstar LS900(R). The mean absolute PE was not statistically significant among the 3 devices (ANOVA, p = 0.684). CONCLUSIONS: Ocular biometry measurements were comparable between the OLCR device and the PCI ultrasound device. However, the IOL power prediction showed significant differences among the 3 devices. Therefore, the differences in application of these devices should be considered.

Prevalence and Correlates of DSM-IV Mental Disorders in South Korean Adults: The Korean Epidemiologic Catchment Area Study 2011

OBJECTIVE: The aim of this study was to estimate the prevalence and correlates of mental disorders in Korean adults. METHODS: Door to door household surveys were conducted with community residents aged 18-74 years from July 19, 2011, to November 16, 2011 (n=6,022, response rate 78.7%). The sample was drawn from 12 catchment areas using a multistage cluster method. Each subject was assessed using the Korean version of the World Health Organization Composite International Diagnostic Interview (CIDI) based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). RESULTS: Lifetime and 12-month prevalence estimates were as follows: alcohol use disorders, 13.4% and 4.4%, respectively; nicotine use disorders, 7.2% and 4.0%, respectively; anxiety disorders, 8.7% and 6.8%, respectively; and mood disorders, 7.5% and 3.6%, respectively. The prevalence rates of all types of DSM-IV mental disorders were 27.6% and 16.0%, respectively. Being female; young; divorced, separated, or widowed; and in a low-income group were associated with mood and anxiety disorders after adjustment for various demographic variables, whereas being male and young were associated with alcohol use disorders. Higher income was not correlated with alcohol use disorder as it had been in the 2001 survey. CONCLUSION: The rate of depressive disorders has increased since 2001 (the first national survey), whereas that of anxiety disorders has been relatively stable. The prevalence of nicotine and alcohol use disorders has decreased, and the male-to-female ratio of those with this diagnosis has also decreased.