Survey of Surgical Management in Intermittent Exotropia

Purpose@#To obtain an overview of the surgical practices for the management of intermittent exotropia among experienced surgeons. @*Methods@#We conducted a survey of members of the Korean Association for Pediatric Ophthalmology and Strabismus, who had experience of > 15 years in strabismus surgery, via e-mail. Surgical methods for basic-type intermittent exotropia, angle of deviation for determining the surgical dose, reasons for surgical dose adjustment, and the postoperative target angle of deviation were analyzed. @*Results@#Bilateral lateral rectus recession was preferred over unilateral recession and resection for basic-type intermittent exotropia with or without a dominant eye. The preoperative maximum angle of deviation was preferred for determining the surgical dose by 56% of the participants. Two-thirds of the participants preferred to reduce the surgical dose in specific circumstances, lateral incomitancy being the most common reason. In case of true divergence excess-type intermittent exotropia, 47.7% of the participants reduced the surgical dose. The most preferred target angle of deviation at 1 day postoperatively was 11-15 prism diopter esodeviation, as reported by 40% of the participants. @*Conclusions@#Although experienced surgeons had different surgical preferences for intermittent exotropia, a general trend was found. This survey may be a useful reference for beginners in strabismus surgery.

Posterior Ischemic Optic Neuropathy after Cervical Spine Surgery

Purpose@#To describe a patient with posterior ischemic optic neuropathy (PION) after cervical spine surgery who recovered after treatment.Case summary: A 51-year-old woman presented with eye pain and decreased visual acuity in the left eye, which had begun 8 hours after cervical spine surgery in the prone position. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye and hand motion in the left eye; a relative afferent pupillary defect was present in the left eye. Ductions and versions were normal with pain in the left eye. The results of slit lamp examination, fundoscopic examination, fluorescein angiography, and optical coherence tomography were unremarkable in both eyes. Brain and orbital magnetic resonance imaging showed no abnormal findings in the visual pathway, such as brain infarction or intracranial artery stenosis. The patient was diagnosed with PION in the left eye. Because postoperative anemia had developed with a rapid decrease in hemoglobin from 14.7 g/dL to 9.9 g/dL, red blood cell (RBC) transfusion was performed together with intravenous high-dose steroid therapy and subcutaneous epoetin alfa injection. After 3 weeks, the patient’s BCVA improved to 20/22 in the left eye. @*Conclusions@#Unilateral PION developed after cervical spine surgery in the prone position. Visual improvement was observed after RBC transfusion, intravenous high-steroid therapy, and subcutaneous epoetin alfa injection.

Preoperative vitamin D level does not affect the short-term functional outcome after total knee arthroplasty in elderly women

Background@#We aimed to evaluate the effect of vitamin D levels on the functional outcome of elderly women who underwent total knee arthroplasty (TKA). @*Methods@#Seven hundred and four patients (1013 knees) who underwent primary TKA were included in our retrospective study. Preoperative vitamin D levels were measured and the relationship analyzed between these and age, weight, height, body mass index, and bone mineral density. Two hundred and twenty patients (220 knees) who received unilateral TKA and were followed up for more than 1 year after operation were divided into two groups: Group 1, serum 25-hydroxyvitamin D3 (25(OH)D3) level < 20 ng/ml; and Group 2, 25(OH)D3 level ≥ 20 ng/ ml. Both groups were evaluated for the relationship between vitamin D levels and postoperative Visual Analogue Scale (VAS) score, Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score. @*Results@#The number of vitamin D-deficient patients (< 20 ng/ml of serum 25(OH)D3 level) was 556 (79.0%). In the correlation analysis, the vitamin D level was negatively correlated with weight only (p

Revision Anterior Cruciate Ligament Reconstruction: Analysis of the Causes of Failure, Associated Injuries and Clinical Results / 대한정형외과학회잡지

PURPOSE: The aim of this study was to analyze the causes of failure after a primary anterior cruciate ligament reconstruction (ACLR), associated injuries, and the clinical results of revision ACLR. MATERIALS AND METHODS: This study evaluated 46 patients (46 knees), who were followed at least two years after revision ACLR. The evaluations included the causes of failure after primary ACLR, associated injuries, 2000 International Knee Documentation Committee (IKDC) subjective knee scores, Lachman test, Pivot shift test, and KT-1000 arthrometer measurement. RESULTS: The most common cause of failure was trauma (27 patients, 58.7%) and 19 failures (19 patients, 41.3%) were caused using an inappropriate surgical technique. The associated injuries were meniscus tears in 29 cases (63.0%) and articular cartilage injuries of Outerbridge grade II to IV in 19 cases (41.3%). The IKDC scores, Lachman test, Pivot shift test, and KT-1000 arthrometer measurements were improved significantly at the final follow-up. CONCLUSION: The most common cause of failure after primary ACLR was trauma. One stage revision ACLR resulted in relatively satisfactory stability but less satisfactory clinical function than the primary reconstruction, as reported previously, which is believed to be due to the more associated injuries.

Bilateral Hypoplasia of the Medial and Lateral Menisci

Hypoplasia of the meniscus is a very rare congenital abnormality, with only a few cases reported to date. A 9-year-old girl visited our hospital due to lateral knee pain following a hyperextension injury to the left knee. Magnetic resonance imaging showed hypoplasia of the medial and lateral menisci, as well as a posterior horn tear of the lateral meniscus, in both knee joints. To our knowledge, this is the first report of a patient with hypoplasia of the medial and lateral menisci in both knee joints.

Comparison of Arthroscopically Guided Suprascapular Nerve Block and Blinded Axillary Nerve Block vs. Blinded Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

BACKGROUND: The purpose of this study was to compare the results of arthroscopically guided suprascapular nerve block (SSNB) and blinded axillary nerve block with those of blinded SSNB in terms of postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. METHODS: Forty patients who underwent arthroscopic rotator cuff repair for medium-sized full thickness rotator cuff tears were included in this study. Among them, 20 patients were randomly assigned to group 1 and preemptively underwent blinded SSNB and axillary nerve block of 10 mL 0.25% ropivacaine and received arthroscopically guided SSNB with 10 mL of 0.25% ropivacaine. The other 20 patients were assigned to group 2 and received blinded SSNB with 10 mL of 0.25% ropivacaine. Visual analog scale (VAS) score for pain and patient satisfaction score were assessed 4, 8, 12, 24, 36, and 48 hours postoperatively. RESULTS: The mean VAS score for pain was significantly lower 4, 8, 12, 24, 36, and 48 hours postoperatively in group 1 (group 1 vs. group 2; 5.2 vs. 7.4, 4.1 vs. 6.1, 3.0 vs. 5.1, 2.1 vs. 4.2, 0.9 vs. 3.9, and 1.3 vs. 3.3, respectively). The mean patient satisfaction score was significantly higher at postoperative 4, 8, 12, 24, 36, and 48 hours in group 1 (group 1 vs. group 2; 6.7 vs. 3.9, 7.4 vs. 5.1, 8.8 vs. 5.9, 9.2 vs. 6.7, 9.5 vs. 6.9, and 9.0 vs. 7.2, respectively). CONCLUSIONS: Arthroscopically guided SSNB and blinded axillary nerve block in arthroscopic rotator cuff repair for medium-sized rotator cuff tears provided more improvement in VAS for pain and greater patient satisfaction in the first 48 postoperative hours than blinded SSNB.

Patterns and Influencing Factors of Medial Meniscus Tears in Varus Knee Osteoarthritis

PURPOSE: To investigate the patterns of medial meniscus (MM) tears in patients with varus knee osteoarthritis who underwent total knee arthroplasty and analyze the factors that could affect MM tears. MATERIALS AND METHODS: The patients (365 knees, 268 patients) were classified into three groups; group I with MM posterior horn (PH) tear only; group II with MM root tear only; and group III with MMPH plus root tear. The following factors were evaluated: age, gender, body mass index, varus deviation of the mechanical axis, medial proximal tibial angle, posterior tibial slope (PTS), and anterior cruciate ligament (ACL) integrity (normal, degeneration, and tear or absence). RESULTS: MM tears were identified in all knees. The patterns of the combined MMPH tears in group III were less complex than those in group I. Varus deviation and PTS were significantly greater in group III than groups I and II. In group III, there were significantly more cases of ACL tear or absence than groups I and II. The others showed no differences among three groups. CONCLUSIONS: Severe varus knee osteoarthritis was always accompanied by MM tears. Risk factors for MMPH plus root tears were severe varus deformity, great PTS, and ACL tear or absence.

Relationship between Mucoid Degeneration of the Anterior Cruciate Ligament and Posterior Tibial Slope in Patients with Total Knee Arthroplasty

PURPOSE: The purpose was to analyze the relationship between posterior tibial slope (PTS) and mucoid degeneration of the anterior cruciate ligament (ACL) in patients with total knee arthroplasty. MATERIALS AND METHODS: Four hundred and twenty-four patients (24 males and 400 females; 636 knees) who received total knee arthroplasty for osteoarthritis were included. Their mean age was 68.9 years (range, 48 to 88 years). The patients were classified into three groups according to the status of ACL; normal ACL group (group I), mucoid degeneration of ACL group (group II) and ruptured or absent ACL group (group III). Plain lateral radiographs were used to measure the PTS and the values were compared among groups. RESULTS: There were no significant differences with regard to gender, age and left-to-right side ratio among groups (p>0.05). The mean PTS was 9.9degrees (range, 0.6degrees to 20.1degrees) in group I (161 knees), 10.8degrees (range, 0.2degrees to 21.8degrees) in group II (342 knees) and 12.3degrees (range, 2degrees to 22.2degrees) in group III (133 knees), which showed significant differences (p<0.001). CONCLUSIONS: The patients with mucoid degeneration of the ACL and those with ruptured or absent ACL had greater PTS than those with normal ACL. These findings suggest that an increased PTS may be one of the causative factors for mucoid degeneration of the ACL.

Morphometric Differences of Distal Femoral Cut Surface between Korean Male and Female in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the morphometric differences of distal femoral cut surface between Korean males and females in total knee arthroplasty. MATERIALS AND METHODS: A total of 696 patients (1,008 knees: male 92, female 916) who underwent TKA using NexGen® legacy posteriorstabilized (LPS) (605 knees: male 41, female 564) and PS ADVANCE® medical pivot knee (MPK) (403 knees: male 51, female 352) implants were analyzed prospectively. After distal femoral resection, the mediolateral width (ML) was measured at four points (anterior [Ant], distal anterior [DA], distal posterior [DP], and posterior [Post]) and compared with the ML width of the implant respectively. The aspect ratio (AR=ML/anteroposterior width) and width ratio (WR=Ant ML/DP ML) were calculated. Differences in AR, WR, and fitness between male and female were analyzed. RESULTS: The AR of males was larger than that of females for both LPS and MPK; however, no differences in the WR were observed between males and females. The WR in MPK was larger than that in LPS. For both LPS and MPK, females showed greater anatomical fitness than males, and males had relatively greater incidence of undersize than females. For MPK, there were relatively more cases of overhang in Ant and DA cut surface. These results were consistent with the fact that the WR of implant in MPK was larger than that in LPS. CONCLUSION: Korean males tend to have larger AR and less anatomical fitness of the femoral component than females because of undersize. No difference in WR was observed between Korean males and females. However, the cut surfaces as well as femoral implant of MPK had larger WR than those of LPS. MPK has more overhang on the anterior cut surface than LPS, due to a wider Ant flange (larger WR) of the implant.

Remote Cerebellar Hemorrhage due to Cerebrospinal Fluid Leakage or Meningitis after Spinal Surgery: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of remote cerebellar hemorrhage (RCH) as a complication of spinal surgery. SUMMARY OF LITERATURE REVIEW: Remote cerebellar hemorrhage is rare but lethal as a complication of spinal surgery. Interestingly, dural tears and cerebrospinal fluid (CSF) leakage are reported in all published cases of RCH. MATERIALS AND METHODS: A 67-year-old man had posterior lumbar decompression and posterolateral fusion for spinal stenosis at L4/5/S1. Intraoperatively, the dura was torn and there was a loss of CSF. The dural tear was sutured immediately in a water-tight manner. After surgery, the patient complained of headache and dizziness. On postoperative day 44, brain magnetic resonance imaging (MRI) showed meningeal enhancement suggesting meningitis. On postoperative day 54, brain computed tomography (CT) showed cerebellar edema and hemorrhage, and external ventricular derivation was performed. RESULTS: The patient died. CONCLUSIONS: Special attention should be paid to prevent dural damage during spinal surgery or minimize CSF leakage in the case of dural damage and tears during spinal surgery, and CT and MRI should be promptly performed for symptomatic patients.

Intradural Extramedullary Epidermoid Cyst: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of epidermoid cyst in the spinal canal. SUMMARY OF LITERATURE REVIEW: Epidermoid cyst in the spinal canal is rare. Idiopathic epidermoid cyst in the spinal canal not associated with a trauma or infection is even rarer. MATERIAL AND METHODS: A 73 year-old female presented with a 1 year history of progressive paresthesia and motor weakness of both lower extremeties. MRI showed a cystic mass on the 7th thoracic canal. We performed total laminectomy at the T6-T8 level. The cystic mass was excised after durotomy using a posterior approach. RESULTS: We confirmed the presence of an epidermoid cyst for histopathology. CONCLUSION: Idiopathic epidermoid cyst in the spine is very rare and requires accurate differential diagnosis. Preoperative MRI scans are necessary to differentiatie epidermoid cysts from other intradural masses. Confirmative diagnosis can be done by histopatholoty.

Total Knee Arthroplasty Using a Posterior Cruciate Ligament Sacrificing Medial Pivot Knee: Minimum 5-year Follow-up Results

PURPOSE: To evaluate minimum 5-year follow-up clinical and radiological results of total knee arthroplasty (TKA) using a posterior cruciate ligament sacrificing (PS), non-substituting Advance Medial Pivot Knee. MATERIALS AND METHODS: One hundred and twenty knees in 80 patients who could be followed up for more than 5 years after TKA using the PS Advance Medial Pivot Knee were evaluated retrospectively. The evaluations included the preoperative and postoperative range of motion (ROM), tibiofemoral angle, Knee Society (KS) knee and function scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score. The Kaplan-Meier method was used for survival analysis. RESULTS: The ROM increased from a preoperative mean flexion contracture of 7.6degrees and further flexion of 115.1degrees to a postoperative mean flexion contracture of 1.5degrees and further flexion of 120.5degrees. The tibiofemoral angle was changed from 4.6degrees varus preoperatively to 5.8degrees valgus postoperatively. The KS knee and function scores as well as WOMAC score significantly improved after surgery (p<0.05). Complications developed in 4 cases (3.3%): 2 cases of periprosthetic patellar fracture (1.7%) and 2 cases of aseptic loosening (1.7%). The seven-year survival rate was 98.1% in the Kaplan-Meier survival analysis. CONCLUSIONS: The minimum 5-year follow-up results of TKA using the PS Medial Pivot Knee were satisfactory.

Mucoid Degeneration of Both ACL and PCL

Unlike meniscal tears and chondral defects, the mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain and there have been no case reports of mucoid degeneration of both the ACL and the posterior cruciate ligament (PCL). A 48-year-old-male patient presented with knee pain and limitation of motion. The patient's magnetic resonance imaging, arthroscopic findings, and pathologic diagnosis confirmed a clinical diagnosis of mucoid degeneration of both the ACL and the PCL. The symptoms disappeared after arthroscopic partial excision of the ACL and PCL.

Relationship between the Synovialization and the Clinical Results after Anterior Cruciate Ligament Reconstruction Using Tibialis Tendon Allograft / 대한스포츠의학회지

The purpose of this study was to evaluate the relationship between the second-look arthroscopic findings of synovialization and the clinical results after the arthroscopic anterior cruciate ligament (ACL) reconstruction with the fresh-frozen tibialis tendon allograft. Fifty-seven patients could be examined with the second-look arthroscopy after the ACL reconstruction with tibialis tendon allograft. The average duration from reconstruction to second-look arthroscopy was 18.4 months (range, 4-48 months). The patients were classified, according to the extent of synovialization, into 3 groups; 37 cases (64.9%) in group A (good), 15 cases (26.3%) in group B (partial), and 5 cases (8.8%) in group C (poor). The clinical results were compared in each group. The 2000 International Knee Documentation Committee (IKDC) subjective knee score was 80 or more in 31 cases (83.8%) in group A, 9 (60%) in group B, and 1 (20%) in group C respectively. All thirty seven cases (100%) in group A had negative or 1+firm end-point Lachman test and negative pivot shift test, however, only 2 cases (40%) in group C. KT-1000 arthrometer measurement was less than 5 mm in 37 (100%) in group A, 14 (93.3%) in group B, and 2 (40%) in group C. According to the 2000 IKDC knee examination form, 37 (100%) in group A, 14 (93.3%) in group B, and 2 (40%) in group C respectively were normal or nearly normal. The synovialization of the graft had positive correlation with the clinical results after the ACL reconstruction with fresh-frozen allograft.

Can We Use the Posterior Condylar Off set as a Predictive Factor for Overhang of the Implant in Total Knee Arthroplasty?

PURPOSE: We tried to demonstrate whether the posterior condylar offset (PCO, the distance from the femoral diaphysis posterior cortex to the posterior condylar margin) and ratio (PCOR, dividing PCO by the maximum antero-posterior diameter of the distal femur) could be used as predictive factors for overhang of the implants or using gender implants in total knee arthroplasty (TKA). MATERIALS AND METHODS: One hundred and one women who underwent TKA using NexGen(R) (LPS) implants, were analyzed prospectively. After distal femoral resection, the mediolateral (ML) width was measured at four points (anterior, distal anterior, distal posterior and posterior) and compared with the ML width of the implant. The aspect ratio (AR, ML/AP ratio) and anterior/distal posterior ML width (Ant/DP) were calculated. Preoperative radiographic PCO and PCOR were measured. Differences of PCO, PCOR, AR and Ant/DP according to the size were analyzed and correlations between PCO, PCOR and AR were also analyzed. The patients were classified into two groups according to the presence of overhang, and differences of each parameter were compared between the two groups. RESULTS: The size of the implant was positively correlated PCO, not significantly correlated with PCOR, and negatively correlated with AR and Ant/DP. PCO and PCOR and AR showed no correlation with each other. PCO and PCOR were not significantly different between the two groups. However, AR and Ant/DP were statistically low in the group with overhang. CONCLUSIONS: Preoperative radiographic PCO or PCOR could not be used as a predictive factor for overhang of the implants or using gender implants in TKA.

A Comparison of the Short-term Results between the PCL Sacrificing Medial Pivot Knee and Nexgen(R) LPS Total Knee Arthroplasty

PURPOSE: We wanted to compare the clinical and radiological results after performing total knee arthroplasty (TKA) with the PCL sacrificing (PS) Medial Pivot Knee (MPK) and the Nexgen(R) LPS. MATERIALS AND METHODS: Seventy knees in 48 patients after TKA with the PS ADVANCE(R) MPK (group I) and 67 knees in 45 patients with the Nexgen(R) LPS (group II) were retrospectively evaluated. All the patients were followed up for more than 2 years. The evaluations included the preoperative and postoperative range of motion (ROM), the Knee Society (KS) scores, the tibiofemoral angle and the postoperative complications. RESULTS: For group I, the ROM increased from a mean flexion contracture of 6.3degrees and further flexion of 116.4degrees to 1.9degrees and 120.5degrees, respectively, and for group II, from 12.6degrees and 117.6degrees to 0.9degrees and 123.0degrees, respectively. For group I, the KS knee and function scores increased from 46 and 37 to 87 and 83, respectively, and for group II, from 50 and 48 to 87 and 83, respectively. For group I, the tibiofemoral angle changed from varus 4.0degrees to valgus 5.5degrees, respectively, and for group II, from varus 4.1degrees to valgus 5.3degrees, respectively. The complications were 2 knees (2.8%) with periprosthetic patellar fractures and 1 knee (1.4%) with a tibial component failure in group I, and 1 knee (1.5%) with early femoral component failure and 1 knee with arthrofibrosis (1.5%) in group II. CONCLUSION: The minimum 2-year follow-up results of PS MPK TKA were comparable to those of Nexgen(R) LPS TKA. However, we think that the MPK system has the advantage of more bony preservation at the femoral intercondylar notch area.

Clinical Value of "The Single Stitch Method" in Intraoperative Assessment of Patellar Tracking in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: We evaluated the lateral release rate and the clinical results according to the intraoperative assessment of patellar tracking in total knee arthroplasty (TKA). MATERIALS AND METHODS: We analyzed 365 primary total knee arthroplasties in 278 patients. The knees showing good patellar tracking without tourniquet deflation were classified into group 1, those showing improved patellar tracking after tourniquet deflation were classified into group 2, those showing improved patellar tracking after the single stitch method were classified into group 3 and those showing persistent patellar maltracking, that resulted in lateral retinacular release, were classified into group 4. The postoperative patellar tilting angle was measured and the clinical results were evaluated for all the groups. RESULTS: We classified 176, 127, 57 and 5 knees into groups 1, 2, 3 and 4 respectively. Only 5 knees (1.4%) showed poor patellar tracking with the single stitch method after tourniquet deflation and this resulted in lateral retinacular release. The postoperative mean patellar tilting angle was 4.1degrees, 3.4degrees, 5.1degrees and 4.3degrees in each group, respectively, and no statistical differences were shown between the groups (p>0.05). Nine knees complained of anterior knee pain and there was no difference between groups. CONCLUSION: Lateral retinacular release in TKA may not be necessary if the patellar tracking is improved with the single stitch method after tourniquet deflation.

Arthroscopic Stabilization Using Remplissage Technique in Recurrent Shoulder Instability with Large Hill-Sachs Lesion / 대한스포츠의학회지

The glenohumeral bone deficiency plays an important role in the failure of arthroscopic shoulder stabilization procedures. Recently, several authors have described more novel approaches to treat the engaging Hill-Sachs lesion. Presented the 'Remplissage' technique that consists of an arthroscopic posterior capsulodesis and infraspinatus tenodesis to fill the Hill-Sachs lesion in addition to an arthroscopic Bankart repair. We report an arthroscopic technique in recurrent shoulder instability with large Hill-Sachs lesion with posterior capsulodesis and infraspinatus tenodesis.

Discal Cyst of Lumbar Spine: A Case Report

STUDY DESIGN: This is a case report. OBJECTIVE: We present here a patient who had a discal cyst of the lumbar spine along with neurological symptoms. SUMMARY OF THE LITERATURE REVIEW: Discal cysts are intraspinal cysts that communicate with an adjacent intervertebral disc, and these are rare lesions that can cause lumbar radiculopathy. Because they are very rare, their natural history and the details of the therapeutic guidelines for the treatment of these cysts are still unknown. MATERIAL AND METHODS: The patient complained of moderate lumbar pain and right lower extremity radiculopathy and he was administered conservative treatment for 5 months. But the radiculopathy became aggravated and he then underwent a hemilaminectomy, cyst decompression and discectomy. RESULTS: The radiculopathy disappeared and any signs of recurrence were not found on the follow up performed at 1 year. CONCLUSION: Discal cyst is rare, but it can be treated successfully.

Fracture of the Fifth Proximal Metatarsal Bone in Soccer Players / 대한스포츠의학회지

The purpose of this study was to evaluate correlation between lower limb varus and fracture of proximal 5th metatarsal bone occurred to soccer players and clinical results of treatment. Twenty soccer players (21 cases) were included and the average age of patients is 20.7 years. The average of follow up is 25 months. Fifteen cases were treated with intramedullary screw and 6 cases by conservative method. Union time, time of returning to exercise, lower extremity varus and complications were evaluated. In surgically treated group, the 14 cases gained radiological union in 7 weeks and the average time of returning to exercise was 3.4 months. In conservatively treated group, the 4 cases gained radiological union in 11 weeks and the average time of returning to exercise was 4.5 months. Radiological lower limb varus was observed in 17 cases. Lower limb varus may be one of predisposing factors to developing the fracture of proximal 5th metatarsal bone. And the surgical treatment was recommended than conservative treatment for better clinical outcomes.