Clinical Triad Research Articles

Kartagener Syndrome: A Case Report

Kartagener syndrome (KS) is a rare autosomal recessive disorder characterized by a clinical triad of situs inversus, chronic sinusitis, and bronchiectasis. Impaired ciliary motility due to abnormal ciliary structure or function is the main pathophysiological problem in KS. A 38-year-old woman presented to our outpatient clinic with a productive cough, fever, and shortness of breath for 1 month. She has had recurrent episodes of respiratory tract infections since childhood. Clinical investigations revealed situs inversus, sinusitis, and bronchiectasis. She was diagnosed with KS and treated with antibiotics, mucolytics, bronchodilators, and chest physiotherapy. Patients with KS present with chronic recurrent respiratory tract infections due to ineffective mucociliary clearance. Early diagnosis is important to improve prognosis. The main goals in the management of KS are to prevent the progression of the disease, preserve pulmonary function, and improve quality of life.

Clinical and Molecular Findings of Autosomal Recessive Spastic Ataxia of Charlevoix Saguenay: an Iranian Case Series Expanding the Genetic and Neuroimaging Spectra.

Autosomal recessive spastic ataxia of Charlevoix Saguenay (ARSACS) is now increasingly identified from all countries over the world, possibly rendering it one of the most common autosomal recessive ataxias. Here, we selected patients harboring SACS variants, the causative gene for ARSACS, in a large cohort of 137 patients with early-onset ataxia recruited from May 2019 to May 2021 and were referred to the ataxia clinic. Genetic studies were performed for 111 out of 137 patients (81%) which led to a diagnostic rate of 72.9% (81 out of 111 cases). Ten patients with the molecular diagnosis of ARSACS were identified. We investigated the phenotypic and imaging spectra of all confirmed patients with ARSACS. We also estimated the frequency of ARSACS in this cohort and described their clinical and genetic findings including seven novel variants as well as novel neuroimaging findings. While the classic clinical triad of ARSACS is progressive cerebellar ataxia, spasticity, and sensorimotor polyneuropathy, it is not a constant feature in all patients. Sensorimotor axonal-demyelinating neuropathy was detected in all of our patients, but spasticity and extensor plantar reflex were absent in 50% (5/10). In all patients, brain magnetic resonance imaging (MRI) showed symmetric linear hypointensities in the pons (pontine stripes) and anterior superior cerebellar atrophy as well as a hyperintense rim around the thalami (thalamic rim). Although infratentorial arachnoid cyst has been reported in ARSACS earlier, we report anterior temporal arachnoid cyst in two patients for the first time, indicating that arachnoid cyst may be an associated imaging feature of ARSACS. We also extended molecular spectrum of ARSACS by presenting 8 pathogenic and one variant of unknown significance (VUS) sequence variants, which 7 of them have not been reported previously. MetaDome server confirmed that the identified VUS variant was in the intolerant regions of sacsin protein encoded by SACS.

Susac's syndrome - the crucial role of imaging tests for proper diagnosis.

Susac's syndrome (SS) is a rare, autoimmune-mediated endoteliopathy characterized by a clinical triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. SS is also characterized by a neuroimaging triad consisting of white matter lesions, grey matter lesions, and leptomeningeal enhancement on magnetic resonance imaging (MRI). Considering the rarity of SS, as well as certain similarity to other, more frequent neurological diseases, such as multiple sclerosis (MS), this syndrome is sometimes incorrectly diagnosed and treated. The aim of the study is to present the current state of knowledge on SS, with particular consideration for the differential diagnostics between SS and MS, using the latest available imaging techniques, such as brain MRI, optical coherence tomography (OCT), OCT angiography (OCTA) and fluorescein angiography (FA). The major electronic databases (PubMed, Google Scholar) were searched manually in order to identify the relevant studies published on SS. Distinguishing SS from MS is a diagnostic challenge. In the majority of cases, patients with SS do not present the complete clinical or neuroimaging triad, and a delay in making the correct diagnosis exposes the patient to the occurrence of complications, resulting from the development of the underlying disease, or/and the application of improper treatment. In the case of SS the results of brain MRI and FA are essential for making the correct diagnosis as they may reveal pathognomonic changes. Imaging examinations, such as brain MRI, FA, and OCT complement each other, due to which the diagnosis of SS may be simpler, irrespective of the stage of the disease.

Undue Influence versus Relational Autonomy in Clinical Decision Making #439.

Undue Influence versus Relational Autonomy in Clinical Decision Making #439.

Identification of New Genetic Determinants in Pediatric Patients with Familial Hypercholesterolemia Using a Custom NGS Panel.

The most common form of inherited lipid disorders is familial hypercholesterolemia (FH). It is characterized primarily by high concentrations of the clinical triad of low-density lipoprotein cholesterol, tendon xanthomas and premature CVD. The well-known genetic background are mutations in LDLR, APOB and PCSK9 gene. Causative mutations can be found in 60–80% of definite FH patients and 20–30% of those with possible FH. Their occurrence could be attributed to the activity of minor candidate genes, whose causal mechanism has not been fully discovered. The aim of the conducted study was to identify disease-causing mutations in FH-related and candidate genes in pediatric patients from Poland using next generation sequencing (NGS). An NGS custom panel was designed to cover 21 causative and candidate genes linked to primary dyslipidemia. Recruitment was performed using Simon Broome diagnostic criteria. Targeted next generation sequencing was performed on a MiniSeq sequencer (Illumina, San Diego, CA, USA) using a 2 × 150 bp paired-end read module. Sequencing data analysis revealed pathogenic and possibly pathogenic variants in 33 out of 57 studied children. The affected genes were LDLR, APOB, ABCG5 and LPL. A novel pathogenic 7bp frameshift deletion c.373_379delCAGTTCG in the exon 4 of the LDLR gene was found. Our findings are the first to identify the c.373_379delCAGTTCG mutation in the LDLR gene. Furthermore, the double heterozygous carrier of frameshift insertion c.2416dupG in the LDLR gene and missense variant c.10708C>T in the APOB gene was identified. The c.2416dupG variant was defined as pathogenic, as confirmed by its cosegregation with hypercholesterolemia in the proband’s family. Although the APOB c.10708C>T variant was previously detected in hypercholesterolemic patients, our data seem to demonstrate no clinical impact. Two missense variants in the LPL gene associated with elevated triglyceride plasma level (c.106G>A and c.953A>G) were also identified. The custom NGS panel proved to be an effective research tool for identifying new causative aberrations in a genetically heterogeneous disease as familial hypercholesterolemia (FH). Our findings expand the spectrum of variants associated with the FH loci and will be of value in genetic counseling among patients with the disease.

Hereditary Hemochromatosis: an Inherited Abnormality of Iron Regulation

Hereditary Hemochromatosis (HH) is an autosomal recessive genetic disease characterized by abnormalities in iron regulation, mostly due to mutations in the HFE gene, leading to increased iron absorption due to hepcidin deficiency. The classification of HH is based on the type of mutated gene, which must be distinguished from non-genetic conditions that cause secondary elevations in serum iron levels such as multiple transfusions and increased iron supplementation. Pathophysiological mechanisms of HH include increased absorption of iron in the upper intestine, decreased expression of the iron regulatory hormone hepcidin, altered function of the HFE protein, and tissue damage and fibrogenesis caused by iron overload. The human body is physiologically unable to excrete excess iron load so excess iron in serum will be deposited in various organs, causing organ dysfunction. The clinical manifestations of hemochromatosis vary widely depending on the location of iron deposition in the organ. The classic clinical triad of hemochromatosis is liver cirrhosis, skin pigmentation, and diabetes mellitus. Hemochromatosis can be screened for and diagnosed by examining serum ferritin levels, transferrin saturation, unsaturated iron-binding capacity, total iron-binding capacity, liver biopsy, magnetic resonance imaging, and genetic testing. The main treatment for hemochromatosis at this time is phlebotomy although other therapeutic methods can also be used to help lower iron levels and improve the patient’s clinical course, such as therapy with chelating agents, erythrocytopharesis, and liver transplantation. If hemochromatosis is not treated, the patient can experience progressive liver damage leading to cirrhosis and hepatocellular carcinoma, and complications due to damage to various tissues and organs.

Phenotypical variability and atypical presentations in a French cohort of Andersen-Tawil syndrome.

Andersen-Tawil syndrome (ATS) is a skeletal muscle channelopathy caused by KCNJ2 mutations, characterized by a clinical triad of periodic paralysis, cardiac arrhythmias and dysmorphism. The muscle phenotype, particularly the atypical forms with prominent permanent weakness or predominantly painful symptoms, remains incompletely characterized. A retrospective clinical, histological, electroneuromyography (ENMG) and genetic analysis of molecularly confirmed ATS patients, diagnosed and followed up at neuromuscular reference centers in France, was conducted. Thirty-five patients from 27 unrelated families carrying 17 different missense KCNJ2 mutations (four novel mutations) and a heterozygous KCNJ2 duplication are reported. The typical triad was observed in 42.9% of patients. Cardiac abnormalities were observed in 65.7%: 56.5% asymptomatic and 39.1% requiring antiarrhythmic drugs. 71.4% of patients exhibited dysmorphic features. Muscle symptoms were reported in 85.7%, amongst whom 13.3% had no cardiopathy and 33.3% no dysmorphic features. Periodic paralysis was present in 80% and was significantly more frequent in men. Common triggers were exercise, immobility and carbohydrate-rich diet. Ictal serum potassium concentrations were low in 53.6%. Of the 35 patients, 45.7% had permanent weakness affecting proximal muscles, which was mild and stable or slowly progressive over several decades. Four patients presented with exercise-induced pain and myalgia attacks. Diagnostic delay was 14.4±9.5years. ENMG long-exercise test performed in 25 patients (71.4%) showed in all a decremental response up to 40%. Muscle biopsy performed in 12 patients revealed tubular aggregates in six patients (associated in two of them with vacuolar lesions), dystrophic features in one patient and non-specific myopathic features in one patient; it was normal in four patients. Recognition of atypical features (exercise-induced pain or myalgia and permanent weakness) along with any of the elements of the triad should arouse suspicion. The ENMG long-exercise test has a high diagnostic yield and should be performed. Early diagnosis is of utmost importance to improve disease prognosis.

A case of new cognitive changes in a patient with seronegative paraneoplastic limbic encephalitis: encephalitis relapse or Wernicke’s encephalopathy?

ABSTRACT Wernicke’s encephalopathy (WE) and paraneoplastic limbic encephalitis (PLE) can both present with acute-to-subacute memory impairment and cognitive dysfunction. Both can lead to significant morbidity and mortality without rapid identification and treatment. Often patients with WE may not have the typical clinical triad of ophthalmoplegia, gait ataxia, and altered mental status. Furthermore, both WE and PLE may share similar MRI findings. Here, we present a case of a patient with a history of seronegative PLE presenting with acute-to-subacute cognitive changes and gait imbalance. Initially, it was felt to be a relapse of PLE but upon further history and testing may potentially have represented WE in the setting of a recent dietary change.

Fever, Chest Pain, and Odynophagia: A Clinical Triad of an Infected Esophageal Duplication Cyst.

Fever, Chest Pain, and Odynophagia: A Clinical Triad of an Infected Esophageal Duplication Cyst.

Highest Resolution MicroCT Scan of the Human Brainstem Reveals Putative Anatomical Basis for Infrequency of Medial Medullary Syndrome

Posterior circulation or brainstem strokes account for approximately 25% of acute strokes, affecting arterial territories in the medial or lateral divisions of the midbrain, pons, or medulla. Out of all brainstem regions, medial medullary strokes are the rarest, making up fewer than 1% of reported posterior circulation cases. Medial Medullary Syndrome (MMS) is a clinical triad of contralateral hemiplegia, loss of fine touch / position sense, and hypoglossal palsy that may result from ischemia or hemorrhage of small perforating branches of the anterior spinal, vertebral, or basilar arteries. The relative infrequency of MMS is surprising given the prevalence of stroke in other perforator artery territories as these vessels are more susceptible to small vessel disease. Indeed, small perforator‐type vessels from other parent arteries contribute to more than 50% of all strokes in a population (e.g. lacunar branches of the middle cerebral artery and paramedian pontine branches of the basilar artery). This disparity in prevalence remains unexplained in part because clinical anatomy has been historically limited by an unfavorable ratio of fine blood vessel size to coarse MRI and CT scan resolution. Here, we capture and digitally dissect the highest‐ever‐resolution diffusible iodine‐based contrast‐enhanced CT (diceCT) scanned images of a cadaveric brainstem to map MMS arteries in never‐before‐captured detail. A cadaveric brain was fixed in formalin and stained using a 3% concentration of Lugol’s iodine (I2KI) for 12.5 weeks (refreshed every 2 weeks), before microCT scanning at 57 microns (a scale twice as fine as any previous scans). The resulting image stack was segmented in Avizo 2020.1. Results show that within the MMS anterior spinal artery territory, there are numerous, small sulcal artery branches perforating the medulla within the anterior median fissure. These branches proceed in parallel through the anteroposterior depth of the medulla as expected; however, we also identify a network of intraparenchymal, rostrocaudal anastomoses between these sulcal perforating branches. This network of intraparenchymal sulcal artery anastomoses has never been described, and may provide a significant collateral supply of oxygenated blood flow throughout the medial medulla. By ramifying deeper tissues, this anastomosis can help explain the infrequency of MMS.

ELECTRONEUROMYOGRAPHIC AND CLINICAL ASPECTS OF BRACHIAL PLEXUS INVOLVEMENT IN PANCOAST-TOBIAS SYNDROME: A CASE REPORT

Pancoast-Tobias syndrome is a rare entity, defined by a clinical triad of cervicobrachial neuralgia in the C8-D1 territory, hand amyotrophy and Claude-Bernard-Horner syndrome, secondary to a tumor of the pulmonary apex. However, there are incomplete or misleading forms that can lead to a wrong diagnosis. The purpose of our observation is to study the clinical and electroneuromyographic patterns of brachial plexus involvement in Pancoast-Tobias syndrome.

Emphysematous pyelonephritis

ABSTRACTUrinary tract infections are commonly encountered and managed worldwide, and emphysematous pyelonephritis (EPN) is among the most serious types of urinary tract infections. EPN is an acute necrotizing infection of the kidney, often associated with high rates of renal loss and mortality. The symptoms of EPN infection can be nonspecific, but the clinical triad of fever, flank pain, and nausea represent the most common presentations. The diagnosis and classification are performed with the assistance of computed tomography (CT). The imaging-based classification system created by Huang and Tseng is widely used in clinical assessments. They defined EPN into four different class (1–4), with the higher number the more severe disease. Optimal EPN treatment is controversial, with emergent nephrectomy suggested during early studies, whereas more recent evidence favors more conservative approaches. Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis are most common pathogens. The initial use of broad-spectrum antibiotics such as Third-or fourth-generation cephalosporins and carbapenems are recommended. Diabetes, obstructive uropathy and hypertension are the most common risk factors and often need treatment together. Emergent drainage is indicated with a larger-sized drainage tube to achieve better drainage function. CT guidance has a better success rate than insertion under the guidance of ultrasonography. Nephrectomy should be reserved as the last resort for those who fail to respond to conservative therapy. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of this life-threatening urological infection.

Episiotomy Scar Endometriosis: A Case Report and Review of Literature.

Abstract
 Background
 Endometriosis is defined as the presence and growth of endometrial tissue implants, outside the uterine cavity. It may be pelvic and extra-pelvic sites. Endometriosis in an episiotomy scar is extremely rare but can lead to significant morbidity in patients due to local infiltration. This condition usually presents with clinical triad of history of episiotomy, tender nodule at the scar site and cyclical pain.
 Case Presentation
 Here we report one such case of episiotomy scar endometriosis in the perineum of a 30 years young female (P1L1) which presented with swelling and pain in perineal region. The clinical examination and Ultrasonography (USG) corroborate with diagnosis of episiotomy scar endometriosis. Excision was done and histopathological examination confirmed the diagnosis.
 Conclusion
 Episiotomy scar endometriosis should always be kept in differential diagnosis when a lady presents with painful perineal swelling which increases during menstruation. This can be diagnosed with clinical and radiological examination. Wide local excision is the treatment of choice. Confirmation of the lesion can be done with histopathological examination.
 Keywords: Episiotomy scar endometriosis, perineal scar endometriosis, scar endometriosis

Pathologically Verified Corticobasal Degeneration Mimicking Richardson's Syndrome Coexisting with Clinically and Radiologically Shunt-Responsive Normal Pressure Hydrocephalus.

ABSTRACTBackgroundNormal pressure hydrocephalus (NPH) manifests as gait instability, cognitive impairment, and urinary incontinence. This clinical triad of NPH sometimes occurs with ventriculomegaly in patients with neurodegenerative disease. Patients with pathologically verified neurodegenerative diseases, such as progressive supranuclear palsy (PSP), have received antemortem diagnoses of NPH.ObjectivesThis study presents clinical and pathological features of a patient with pathologically verified corticobasal degeneration (CBD) coexisting with clinically shunt‐responsive NPH.MethodsWe performed clinical, radiological, and pathological evaluations in a patient with CBD whose antemortem diagnosis was PSP Richardson's syndrome (PSP‐RS) coexisting with shunt‐responsive NPH.ResultsA 59‐year‐old woman developed bradykinesia and gait instability and then frequent falls, urinary incontinence, and supranuclear vertical gaze palsy followed. At 63 years of age, her gait disturbance and urinary incontinence had deteriorated rapidly, and cognitive impairment was disclosed. There were typical findings of NPH with ventriculomegaly and disproportionately enlarged subarachnoid space hydrocephalus as well as a 2‐layer appearance with decreased and increased cerebral blood perfusion. Shunt placement ameliorated gait instability for more than 1 year and improved radiological indicators of NPH. However, atrophy of the midbrain progressed with time after transient increases in size. Although the antemortem diagnosis was probable PSP‐RS, pathological evaluation verified CBD. There were severe discontinuities of the ependymal lining of the lateral ventricles and subependymal rarefaction and gliosis with tau‐positive deposition.ConclusionsShunt surgery could ameliorate NPH symptoms in patients with 4‐repeat tauopathies. Careful assessments of clinical findings are necessary to predict the benefits of shunts as a therapeutic option for patients with neurodegenerative diseases coexisting with NPH.

A new diagnostic paradigm for Erythromelanosis Follicularis Faciei et Colli: Dermoscopic and reflectance confocal microscopic features

Introduction: Erythromelanosis Follicularis Faciei et Colli is a rare variant of Kerastosis pilaris, characterized by a clinical triad of erythema, hyperpigmentation and follicular papules involving bilaterally cheeks, preauricular and maxillary areas of young male or, more rarely, female patients Case presentation: A 21-year-old Caucasian woman presented symmetrical patches of hyperpigmentation, erythema with microscopic telangiectasias and tiny follicular papules involving cheeks, preauricular and maxillary areas, forehead, pinna and neck since childhood. Lesions were asymptomatic but caused profound cosmetic disfigurement and had a negative impact on her social life. The patient underwent a non-invasive diagnostic procedure with epiluminescence and confocal microscopy. Dermoscopic examination revealed prominent yellowwhitish follicular keratotic plugging over a reddish background with short fine telangiectasia in the perifollicular and interfollicular areas. Furthermore, RCM features displayed the presence of enlarged the presence of enlarged follicular openings, absence of demodex mites within the follicles and slight infundibular hyperkeratosis. At the level of the epidermal-dermal junction hyperpigmentation of the epithelial basal cell layer and dilation of dermal capillaries inside dermal papillae were observed, correlating to typical histological features of EFFC. Our patient benefited from the topical use of tretinoin 0.05% cream, with attenuation of the instrumental pictures. Conclusion: Characteristic plugging over a reddish background and morphological features revealed by RCM may be helpful for assessment and monitoring in patients with EFFC. Starting from the observation of this case we would like to underline the importance of a noninvasive diagnostic procedure and an effective therapy for such a rare condition. Keywords: Erythromelanosis Follicularis Faciei et Colli; Erythromelanosis Follicularis Faciei diagnosis; Dermoscopy; In vivo reflectance confocal microscopy.

LENCEPHALOPATHIE DE GAYET-WERNICKE CHEZ UNE PATIENTE SUIVIE POUR PANCREATITE: A PROPOS DUN CAS

Gayet-Wernicke encephalopathy is a serious complication of thiamine deficiency characterized by a clinical triad: confusional state, oculomotor disturbances, and cerebellar ataxia. Alcoholism is the main cause of thiamine deficiency. Severe pancreatitis through prolonged fasting and vomiting may exceptionally give a similar clinical picture which sometimes poses diagnostic difficultiesDiagnosis is based on brain imaging by showing on MRI a T2 or FLAIR hypersignal affecting the peri-aqueductal region, the medial part of the thalamus, the floor of the fourth ventricle, the vermis, the mammillary bodies and, sometimes, the cortex. Treatment consists of rapid intravenous administration of thiamine. We report a case of 66-year-old patient followed for severe pancreatitis whose evolution was marked by the onset of a consciousness disorder whose investigations returned in favor of Gayet-Wernicke encephalopathy.

Myeloid Sarcoma of the Temporal Bone: A Unique Cause of Hearing Loss, Otalgia, and Facial Nerve Weakness.

To characterize a clinical triad of symptoms associated with myeloid sarcomas of the temporal bone via a review of all previously reported cases. Case report and Ovid MEDLINE database literature review. A literature search revealed that a clinical triad of hearing loss, otalgia, and facial nerve weakness are commonly associated with this rare presentation of myeloid sarcoma in the temporal bone. 44% (18/41) of patients presented with all three symptoms, while 76% (31/41) presented with at least two. The presence of t(8;21) was reported in nine patients with myeloid sarcomas of the temporal bone. Although myeloid sarcomas are exceedingly rare, it is necessary to consider them as part of the differential diagnosis for patients who might present with middle ear and mastoid opacification on computed tomography (CT) scan, hearing loss, otalgia, and facial nerve palsy. Physicians should maintain a high degree of suspicion in patients with a history of acute myelogenous leukemia (AML), especially if previous cytogenetic analysis revealed a t(8;21).

Normal-pressure hydrocephalus: A rare cause of reversible dementia.

Normal-pressure hydrocephalus (NPH) is characterized by the clinical triad of dementia, gait instability, and urinary incontinence. The estimated annual incidence is 1.8 cases in 100,000 persons, making NPH a rare diagnosis and uncommon cause of dementia. NPH is a form of communicating hydrocephalus that can easily be missed in older adults with multiple comorbidities, so clinicians must exclude reversible causes of dementia before diagnosing irreversible causes such as Alzheimer disease.

Prevalence Of Acetaminophen Intolerance Among Patients With Aspirin Exacerbated Respiratory Disease At A Tertiary Care Institution

Aspirin Exacerbated Respiratory Disease (AERD) is the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and intolerance to medications that inhibit the cyclooxygenase-1 enzyme. Historically, acetaminophen has been recommended as a safe alternative analgesic but clinically, some AERD patients cannot tolerate acetaminophen. This study examined the prevalence and clinical characteristics associated with acetaminophen intolerance among a cohort of AERD patients.

Effect of multimorbidity and psychosocial factors on posttraumatic stress symptoms among post-9/11 veterans.

Examine the association of multimorbidity and psychosocial functioning with posttraumatic stress disorder (PTSD) symptom severity reported among post-9/11 veterans. This was a secondary analysis of survey data collected from a national sample of post-9/11 veterans with at least 3 years of Department of Veterans Affairs care, stratified by comorbidity trajectory and sex (N = 1,989). Comorbidity trajectories were derived by latent class analysis to develop probabilistic combinations of physical and mental health conditions in a previous effort (Pugh et al., 2016). In this study, linear models analyzed symptom severity reported on the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition by psychosocial factors (i.e., resilience, self-efficacy, and postdeployment social support) while controlling for sociodemographic characteristics and deployment experiences. Veterans in the mental health, pain, and polytrauma clinical triad comorbidity trajectories reported more severe PTSD symptoms than the healthy comorbidity trajectory (p < .01). All psychosocial factors were significantly associated with PTSD symptom severity, accounting for nearly 43% of variability in follow-up analyses. Confidence in self-efficacy demonstrated the strongest association among them (p < .01). Veterans experiencing multimorbidity, particularly mental health distress, reported greater PTSD symptom severity after controlling for psychosocial factors, sociodemographics, and deployment experiences. The salience of psychosocial factors in reported PTSD symptom severity underscores resilience, self-efficacy and social support as potential facilitators of functional reintegration following military service. Our analyses underscore the need to address the systemic barriers in health care access and delivery for minority patient populations in future investigations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).