Is performing hypospadias surgery in early childhood a wise decision? Study sheds light

Germany: Findings from a recent survey revealed satisfaction of 90% of the patients with early hypospadias surgery with average health-related quality of life (HRQOL) and low level of decisional regret in patients and parents.

The findings of the Decision Regret And Quality of Life Assessment (DRAQULA) study, published in the Journal of Pediatric Urology, support the current practice of operating hypospadias in early childhood.

Hypospadias is a common congenital malformation. Mild forms may be corrected by some cosmetic procedures, but correcting moderate and severe forms is important to avoid functional limitations and may have a lifelong impact on quality of life. Currently, a debate is ongoing on whether the current practice of correcting hypospadias during childhood should be continued or waited until the child reaches the age of consent and makes the decision himself.

Ahmed T. Hadidi, Hypospadias Center, Pediatric Surgery Department, Sana Klinikum, Offenbach, Germany, and colleagues evaluate patient satisfaction, DRAQULA among adolescents (older than 15 years) and adults after hypospadias surgery in childhood.

For this purpose, the researchers contacted 234 patients operated on hypospadias as children in the centre and their parents after they reached the age of 15 years to complete a questionnaire survey to evaluate their regret with the operative decision, satisfaction with the operative result, and the health-related quality of life.

The survey was based on the Decision Regret Scale available in the literature; a score of 100 implied maximum dissatisfaction or regret, and on the Kidscreen10 index. Satisfaction was measured on a scale from 1 to 5 with 5 signifying satisfaction.

Following were the key findings from the survey:

  • 34.6 % of patients from 15 to 43 years (mean age 19.7 years) completed the survey. 44 Patients had distal, and 17 proximal hypospadias and the remaining 20 patients could not remember the type of hypospadias they had.
  • The patient’s satisfaction with the operative result was 5 (full satisfaction) in 74.1 %, 4 in 18.5 %, 3 in 6.2 % and 2 in 1.2 % (mean satisfaction score 4.7 of 5).
  • Regarding decision regret among patients, 7.0 % of patients had no decision regret. Only 14.8 % reported mild and 6.2 % moderate decisional regret (mean decisional regret score 4.8).
  • 30.0 % of parents answered the parents’ questionnaire. 81.7 % had no decision regret.
  • 18.3 % of parents had decision regret; 14.1 % of parents reported mild, 2.8 % of parents were moderate, and 1.4 % of parents reported strong decisional regret.
  • The mean HRQOL T-score was 55.9 (SD 10, control Group of adolescent males from 12 to 18 years.) and thus corresponded to the average of the reference normal population.

“Our data and the current literature show high satisfaction with hypospadias surgery, an average quality of life, and low decisional regret after hypospadias surgery in early childhood,” the researchers concluded.

Reference:

Wirmer, J., Fawzy, M., Sennert, M., & Hadidi, A. T. (2023). Should we correct hypospadias during childhood? Decision Regret And QUality of Life Assessment (DRAQULA) study. Journal of Pediatric Urology. https://doi.org/10.1016/j.jpurol.2023.12.005

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Is Montreal Cognitive Assessment for cognitive screening accurate in diverse populations? Study sheds light

USA: A recent study published in the Journal of the American Geriatrics Society has pointed out the inappropriately high current Montreal Cognitive Assessment (MoCA) in a culturally/linguistically diverse urban setting, leading to a high false-positive rate. 

The researchers revealed that lower English and Spanish MoCA cutpoints may improve diagnostic accuracy for identifying cognitive impairment in this group. This highlights the need for the creation and validation of accurate cognitive screeners for linguistically and ethnoculturally diverse older adults.

“A screening tool often used in primary care clinics to detect cognitive impairment has shortcomings when applied to ethnically and linguistically diverse older adults,” the study stated. 

The study looked to see whether currently published English and Spanish cut points for cognitive impairment in the Montreal Cognitive Assessment (MoCA) are appropriate in diverse community-based adults aged 65 years or older with cognitive concerns in the Bronx, New York. There were 231 participants (43% Hispanic, 39% Black/African American); 49% completed testing in English and 51% in Spanish.

Investigators found that the MoCA cut points for indicating mild cognitive impairment or dementia were inappropriately high, as compared with gold standard neuropsychological testing, with a high false-positive rate for detecting cognitive impairment. 

Key findings were as follows:

  • Neuropsychological assessment identified 90 as
    cognitively normal/SCC, average MoCA of 19.9 (SD = 4.1), 133 with MCI, an average
    MoCA of 16.6 (SD = 3.7), and 8 with dementia, with an average MoCA of 10.6 (SD = 3.1).
  • The mean English MoCA average was 18.6 (SD = 4.1)
    versus Spanish 16.7 (SD = 4.3).
  • The published cutpoint ≤23 for MCI yielded a high
    false-positive rate (79%).
  • ROC analyses identified ≤18.5 as the score to
    identify MCI or dementia using the English MoCA (65% sensitivity; 77%
    specificity) and ≤16.5 for the Spanish MoCA (64% sensitivity;73% specificity)
    in this sample of older adults with cognitive concerns.

“These findings underscore the importance of considering cultural factors and social determinants of health when evaluating performances on cognitive screening tools such as the MoCA, particularly in traditionally underserved communities,” said corresponding author Marnina Stimmel, PhD, of the Montefiore Health System and Albert Einstein College of Medicine.

Reference:

Marnina B. Stimmel, Ariela R. Orkaby, Emmeline Ayers, Joe Verghese, Celeste K. Nsubayi, Erica F. Weiss, Is the Montreal cognitive assessment culturally valid in a diverse geriatric primary care setting? Lessons from the Bronx, Journal of the American Geriatrics Society, https://doi.org/10.1111/jgs.18705.

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Statin Use Associated with Lower Pneumonia Risk in Melioidosis Patients: Study

Statins, commonly used to manage cholesterol levels, have been previously linked to a reduced risk of pneumonia and other infections. However, it remains unclear whether statin use specifically lowers the risk of pneumonia compared to other clinical presentations of infection caused by the same pathogen.

A recent study aimed to investigate the association between preadmission statin use and pneumonia risk among hospitalized patients with melioidosis, caused by Burkholderia pseudomallei. This study was published in the journal of Annals of the American Thoracic Society by TD Coston and colleagues.

Melioidosis, caused by the bacterium Burkholderia pseudomallei, is a serious infectious disease prevalent in tropical regions. Pneumonia is a common clinical presentation of melioidosis, but whether statin use affects the risk of pneumonia in these patients has not been extensively studied.

The study conducted a secondary analysis of a prospective multicenter cohort study involving patients hospitalized with culture-confirmed B. pseudomallei infection (melioidosis). A total of 1,121 patients were included in the analysis, of which 141 were statin users and 980 were statin nonusers. Poisson regression with robust standard errors was used to assess the association between statin use and pneumonia risk.

Key Findings:

  • Among the patients analyzed, 33% of statin users presented with pneumonia compared to 44% of statin nonusers.
  • Statin use was associated with a significantly lower risk of pneumonia, with a relative risk of 0.73 (95% CI, 0.57-0.94; P = 0.02) after adjustment for demographic variables, comorbidities, environmental exposures, and symptom duration.
  • Sensitivity analyses, including active comparator analysis and inverse probability of treatment weighting, confirmed the consistent association between statin use and reduced pneumonia risk.

The study suggests that preadmission statin use is associated with a lower risk of pneumonia compared to other clinical presentations of melioidosis in hospitalized patients. This finding highlights a potential lung-specific protective effect of statins in individuals with melioidosis. Further research is warranted to elucidate the mechanisms underlying this association and explore the therapeutic implications of statin use in infectious diseases.

Reference:

Coston, T. D., Wright, S. W., Phunpang, R., Dulsuk, A., Thiansukhon, E., Chaisuksant, S., Tanwisaid, K., Chuananont, S., Morakot, C., Sangsa, N., Chayangsu, S., Silakun, W., Buasi, N., Chetchotisakd, P., Day, N. P. J., Lertmemongkolchai, G., Chantratita, N., & West, T. E. Statin use and reduced risk of pneumonia in patients with melioidosis: A lung-specific statin association. Annals of the American Thoracic Society,2024;21(2):228–234. https://doi.org/10.1513/annalsats.202306-552oc 

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Annual mammography with clinical exam is “likely sufficient” than semiannual after breast-conserving surgery: Study

USA: A recent study found that evidence is insufficient to support semi-annual mammography in the early postoperative period after breast-conserving surgery (BCS) in patients treated with neoadjuvant therapy (NAT), and annual mammography with the clinical exam is likely sufficient.

“Annual mammography with a clinical exam rather than semiannual is likely sufficient for women who have undergone breast-conserving surgery and were treated with NAT,” the researchers wrote in Surgical Oncology Insight. Less than 2% of women developed locoregional recurrence on routine surveillance.

They added, “Semiannual mammography is associated with unnecessary benign biopsies, which may raise health care costs and patient distress.”

Guidelines recommend annual mammography for most women following BCS for invasive breast cancer (IBC). However, for patients treated with BCS after neoadjuvant therapy, the optimal frequency for surveillance has not been established. Therefore, Farin Amersi, Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, CA, USA, and colleagues aimed to assess the efficacy of semi-annual mammography after BCS in patients treated with NAT.

For this purpose, the investigators analyzed an institutional database of patients with IBC (cT1-T4, N0-N3, M0) who received BCS following NAT from 2007-2020. Surveillance imaging, clinicopathologic features, and outcomes were analyzed. Direct costs associated with surveillance were estimated based on Medicare Physician Fees.

The researchers reported the following findings:

· 139 patients received BCS following NAT, of which 42.4% had a pathologic complete response.

· Most patients received semi-annual mammography for 24 months post-operatively (84.2%, 82.0%, 80.0%, and 78.0% of patients received a mammogram at 6, 12, 18, and 24 months, respectively).

· Biopsies were performed due to abnormal imaging findings in 6.5%, 5.3%, 1.5%, and 6.3% of patients at 6, 12, 18, and 24 months, respectively. Overall, 77.8% of biopsies performed were benign.

· At a median follow-up of 65 months, 15.8% of patients developed recurrences, of which 63.6% were distant and 36.4% were locoregional.

· Only 1.4% of patients had a recurrence detected by mammographic surveillance.

· The additional direct costs associated with semi-annual imaging were $373.68 per patient.

The results point to these women being unlikely to benefit from more frequent mammographic surveillance. They added that shifting these women from semi-annual to annual mammography may reduce unnecessary biopsies and follow-up imaging from false-positive cases.

“As more patients receive NAT and pathologic complete response rates continue to improve, it will be vitally important to determine an evidence-based surveillance strategy for detecting locoregional recurrences promptly in women who receive breast-conserving surgery,” they concluded.

Reference:

DOI:https://doi.org/10.1016/j.soi.2024.100037

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Preeclampsia in first trimester linked to higher spontaneous preterm birth risk: AJOG

A recent research published in the American Journal of Obstetrics and Gynecology unveiled a highly effective method for predicting preterm birth risk in the first trimester of pregnancy. This study was conducted by the Fetal Medicine Foundation that indicates a combination of maternal risk factors, mean arterial pressure, uterine artery pulsatility index and placental growth factor which can accurately identify women at risk for preterm preeclampsia.

This study highlights the critical role of early screening in anticipating the complications during pregnancy. Thereby, this screening method offers a valuable tool for clinicians to intervene and reduce the risks by detecting signs of placental dysfunction that often precedes preterm birth.

This secondary analysis of data from the Screening Programme for Pre-eclampsia trial examined over 10,000 cases of spontaneous labor onset in pregnant women. The participants were categorized into low, intermediate and high-risk groups based on their estimated risk for preterm preeclampsia in the first trimester. The outcomes revealed a significant correlation between the level of risk and the gestational age at onset of spontaneous delivery.

The women classified as high-risk faced a fourfold increase in the spontaneous birth risk between 24 to 26 weeks gestation when compared to those in the low-risk group. The risk was three times higher at 28 to 32 weeks and twice as high at 34 to 39 weeks. These results elucidate the critical importance of early identification and proactive management in high-risk pregnancies. Overall, the study emphasized the implications of these outcomes for antepartum counseling, monitoring and interventions by focusing on the personalized care pathways based on early risk assessment.

Reference:

Cavoretto, P. I., Farina, A., Salmeri, N., Syngelaki, A., Tan, M. Y., & Nicolaides, K. H. (2024). First trimester risk of preeclampsia and rate of spontaneous birth in patients without preeclampsia. In American Journal of Obstetrics and Gynecology. Elsevier BV. https://doi.org/10.1016/j.ajog.2024.01.008

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Finerenone and dapagliflozin combo significantly reduced albuminuria in non-diabetic CKD patients: Study

The effectiveness of dapagliflozin and finerenone in reducing albuminuria and slowing the progression of chronic kidney disease (CKD) has been established, but their additive effects have yet to be studied.

According to a study published in the Clinical Kidney Journal, Combining finerenone and dapagliflozin reduced albuminuria safely. Their combined effect was at least equal to each drug’s effect alone, suggesting an additive effect.

The present study aimed to compare these two medications’ individual and combined efficacy and safety in patients with non-diabetic CKD.

In a randomized, open-label clinical trial, researchers enrolled patients aged 18-80. These patients were on the maximum tolerated dose of an ACE inhibitor or angiotensin receptor blocker and had an eGFR of 25-45 mL/min/1,73 m[2] and albuminuria ranging from 150-2000 mg/g. The participants were assigned to receive either finerenone 20 mg/day or dapagliflozin 10 mg/day for a duration of four weeks, followed by a combination therapy for four weeks. Data were collected at the beginning of the study and weeks 4 and 8.

Key results from the study are:

· Twenty patients (10 in each group) were included in this study.

· These patients had a mean mgfr of 34 ml/min/1,73 m[2] and a mean urine albumin creatinine ratio (UACR) of 469 mg/g.

· Patients receiving finerenone alone or in combination with dapagliflozin experienced a -24% and -34% change in UACR, respectively

· Patients taking dapagliflozin alone or combined with finerenone experienced a -8% and -10% uacr change, respectively.

· Uacr change was -36% after eight weeks. Additionally, systolic blood pressure and mGFR decreased by 10 mmHg and 7 ml/min/1,73 m[2].

· Adverse effects were minimal

The administration of finerenone and dapagliflozin was found to be safe and resulted in a marked reduction in albuminuria in this study. The efficacy of combination therapy was comparable to the combined effects of each drug, suggesting an additive impact on albuminuria. More extensive research is necessary to evaluate this approach’s long-term benefits and safety.

Reference:

Mårup, Frederik Husum, et al. “Additive Effects of Dapagliflozin and Finerenone On Albuminuria in Non-diabetic CKD: an Open-label Randomized Clinical Trial.” Clinical Kidney Journal, vol. 17, no. 1, 2024, pp. sfad249.

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Dupilumab safe to continue during vaccine administration in children with AD reveals study

Dupilumab inhibits interleukin (IL)-4 and IL-13 signalling. This monoclonal antibody also acts as an immunomodulator. The current recommendation is to avoid live vaccine administration in dupilumab-treated patients.

A case series involving nine children with severe atopic dermatitis (AD) receiving measles, mumps, and rubella (MMR) vaccine with/without the varicella vaccine in dupilumab clinical trials found no emergence of side effects within four weeks after vaccination. Consequently, the researchers concluded that dupilumab is safe to continue during vaccine administration. This case report is published in Pediatric Dermatology.

In a phase 2/3 clinical trial of dupilumab involving 6-month to 5-year-old children ( subsequently participated in the LIBERTY AD PED-OLE) with moderate-to-severe atopic dermatitis, nine children (protocol deviation) received MMR vaccine with or without varicella vaccine. Five of these children received the vaccine with a ≤12-week gap after dupilumab administration, while four received it >12 weeks after discontinuing dupilumab.

Key findings from the study are:

  • Nine children had severe AD at baseline.
  • Five of the nine children received the MMR or MMR and varicella vaccines within a 1-7 week gap after their dupilumab administration, with treatment resuming for one child as early as two days and three children after 18-43 days.
  • No serious adverse events were reported during a post-vaccination period in any children.

Concluding further, they said, In this case, a series of nine children with severe AD who received the MMR vaccine with or without varicella vaccine while being treated with dupilumab, no adverse events or infection were reported within four weeks of vaccination. Further studies are needed to investigate safety and immune response to live attenuated vaccines in dupilumab-treated patients

Sanofi and Regeneron Pharmaceuticals Inc. sponsored the study.

Reference:

Siegfried et al. A case series of live attenuated vaccine administration in dupilumab‐treated children with atopic dermatitis. Pediatric Dermatology.

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Milk intake may protect against type 2 diabetes in patients with lactose intolerance: Study

USA: A recent study published in Nature Metabolism has shown a protective association between milk intake and type 2 diabetes among lactase non-persistent (LNP) individuals. They also showed a potential involvement of gut microbiota and blood metabolites in this association.

Patients with lactose intolerance are usually advised not to consume milk. However, many still consume dairy products despite experiencing gastrointestinal symptoms. The American study showed that surprisingly, this “unreasonable” strategy may have the benefit of reducing the risk for type 2 diabetes (T2D). 

Lactase non-persistence is an autosomal recessive trait that leads to the down-regulation of lactase activity in the intestinal mucosa and lactose maldigestion. Lactose is present in milk and dairy products; it is a saccharide hydrolysed by the enzyme lactase-phlorizin hydrolase to glucose and galactose in the brush border of the small intestine. 

Cow’s milk is frequently included in the human diet. Nutritional studies have repeatedly studied the effect of milk consumption on diabetes, among other factors, with sometimes heterogeneous results in different countries. The reason for this is presumed to be that in Asia, most people — 60%-100% — are lactose intolerant, whereas in Europe, only as much as 40% of the population has lactose intolerance.

In their paper, the authors led by Kai Luo, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA, did not mention lactose tolerance and intolerance. Instead, they divided the study population into lactase-persistent and non-lactase-persistent participants.

The authors, using data from the Hispanic Community Health Study/Study of Latinos, revealed that in both sexes, higher milk consumption is associated with lower T2D risk in lactase non-persistent individuals (determined by a variant of the lactase LCT gene, single nucleotide polymorphism rs4988235) but not in lactase persistent individuals.

The researchers validated this finding in the UK Biobank. Further analyses showed that among LNP individuals, higher milk consumption is associated with alterations in circulating metabolites (for example, reduced branched-chain amino acid metabolites and increased indole propionate) and gut microbiota (for example, enriched Bifidobacterium and reduced Prevotella).

Many of these metabolites are related to the identified milk-associated bacteria and partially mediate the association between milk intake and type 2 diabetes in LNP individuals.

“Not being lactase-persistent does not necessarily exclude the ability to consume a certain amount of lactose,” said Lonneke Janssen Duijghuijsen, PhD, a nutrition scientist at Wageningen University, Wageningen, the Netherlands.

“Studies have shown that many individuals who lack lactase can still consume up to 12 g of lactose per day — equivalent to the amount in a large glass of milk — without experiencing intolerance symptoms.”

Reference:

Luo, K., Chen, G., Zhang, Y., Moon, J., Xing, J., Peters, B. A., Usyk, M., Wang, Z., Hu, G., Li, J., Selvin, E., Rebholz, C. M., Wang, T., Isasi, C. R., Yu, B., Knight, R., Boerwinkle, E., Burk, R. D., Kaplan, R. C., . . . Qi, Q. (2023). Variant of the lactase LCT gene explains association between milk intake and incident type 2 diabetes. Nature Metabolism, 6(1), 169-186. https://doi.org/10.1038/s42255-023-00961-1

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Psychological Impact of Itchy Dermatoses: Study Highlights Link with Depression, Anxiety, and Stigmatization

A recent study led by Claudia Zeidler, MD, from the University Hospital Münster in Germany, sheds light on the psychological burden experienced by individuals with itchy dermatoses. The research explores the association between itch severity and feelings of depression, anxiety, and stigmatization, emphasizing the importance of addressing both the physical and psychological aspects of skin conditions.

While previous research has touched on the psychological impact of dermatoses, including itch-related stigmatization, this study delves deeper into the specific associations between itch severity and psychological distress. This study was published in the Journal Of The European Academy Of Dermatology and Venerology.

To investigate the relationship between itch severity and psychological variables such as stress, depression, anxiety, and stigmatization among individuals with various types of itchy dermatoses. The study utilized data from the ESDaP-study II, an observational, cross-sectional, multi-center study conducted across 17 European nations. Participants were recruited from dermatological outpatient clinics, and data collection included questionnaires assessing stress, stigmatization perceptions, depression, anxiety, and itch-related quality of life.

Key Findings:

  • Substantial correlations were observed between itch severity and stress perceptions, particularly in individuals with rosacea.

  • Patients with seborrheic dermatitis showed significant associations between itch intensity and reports of stigmatization, depression, and anxiety.

  • Anxiety levels, gender, depression, and perceived stigmatization collectively influenced 9.3% of variation in itch intensity across the cohort.

  • Females and individuals with heightened anxiety, depression, and perceived stigmatization reported stronger itch intensities.

The study underscores the psychological impact of itchy dermatoses, highlighting the need for integrated psychological interventions targeting both itch and related psychological variables. Healthcare providers should consider referring individuals with significant psychological distress for additional evaluation and support. These findings emphasize the importance of comprehensive care for patients with itchy skin conditions, addressing both physical and psychological aspects.

Reference:

Zeidler C, Kupfer J, Dalgard FJ, Bewley A, Evers AWM, Gieler U, et al. Dermatological patients with itch report more stress, stigmatization experience, anxiety and depression compared to patients without itch: Results from a European multi-centre study. J Eur Acad Dermatol Venereol. 2024; 00: 1–13. https://doi.org/10.1111/jdv.19913.

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Noninvasive technique spleen stiffness measurement promising for diagnosing and managing portal hypertension: Study

Researchers have discovered a new noninvasive technique called spleen stiffness measurement for diagnosis of portal hypertension.

Portal hypertension (PHT) is a severe complication of chronic liver disease, like cirrhosis, where increased pressure builds up in the portal vein. This major blood vessel drains blood from the intestines, spleen, and stomach to the liver. This can lead to life-threatening complications such as internal bleeding and liver failure.

Currently, the most accurate way to diagnose PHT is an invasive procedure that measures pressure directly in the liver. However, this procedure is uncomfortable for patients and carries a small risk of complications.

Researchers are excited about a new, noninvasive technique called spleen stiffness measurement (SSM), which uses sound waves to assess the stiffness of the spleen. The spleen is an organ located near the stomach that filters blood and fights infection. When PHT is present, the spleen becomes enlarged and stiffer. SSM uses a painless technique similar to an ultrasound to measure these changes in stiffness.

Several studies have shown that SSM is highly accurate in detecting PHT. SSM may be more accurate in some cases than existing methods, such as measuring liver stiffness with ultrasound. This could be because the spleen is more directly affected by changes in portal pressure than the liver.

The benefits of a non-invasive test like SSM are numerous. First, it would eliminate the need for invasive procedures in many patients, making diagnosis safer and more comfortable. Second, SSM could be used to screen patients with chronic liver disease for PHT at an earlier stage, allowing for earlier intervention and potentially preventing complications. Third, SSM could be a valuable tool for monitoring how well treatments for PHT are working. By tracking changes in spleen stiffness over time, doctors could determine if a patient’s PHT improves or worsens in response to medication or procedures like a transjugular intrahepatic portosystemic shunt (TIPS).

While SSM is promising, further research is needed to confirm its effectiveness in different patient populations and optimise its use in clinical practice. For example, researchers are still determining the best cut-off values for spleen stiffness to diagnose PHT definitively.

Overall, SSM is a promising new tool that could revolutionise the diagnosis and management of portal hypertension. This non-invasive technique can potentially improve patient care, reduce healthcare costs, and ultimately save lives.

Reference:

Xu X, Liu J, Zhu Y, et alSpleen stiffness measurement as a non-invasive assessment in patients with portal hypertensioneGastroenterology 2024;2:e100031. doi: 10.1136/egastro-2023-100031.

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