High Incidence Of Injuries Research Articles

Patterns of orthopedic injuries associated with increasing e-scooter-related trauma: A retrospective observational study with a 4-year evaluation from a tertiary center in Istanbul, Turkey.

The increasing use of electric scooters (e-scooters) has been accompanied by an increase in the number of traumas. Noncompliance with regulations and the effectiveness of legal measures remain subjects of ongoing debate. This study aimed to investigate the demographic characteristics of patients with e-scooter-related orthopedic injuries, temporal distribution of trauma, and patterns of these injuries. We retrospectively evaluated 534 patients with e-scooter-related injuries who were referred to the Department of Orthopedics and Traumatology between January 2020 and October 2023. Variables such as patient sex, age, time of trauma, type of hospital transfer, mechanism of trauma, injury location and type, accompanying head trauma in extremity injuries, and treatment approach were recorded. Temporal analysis was performed by hour, day, month, season, and weekday versus weekend. The majority of patients were male (80.0%), with injuries most common in the 25 to 39 age group (33.7%). Trauma was frequent in the summer (45.7%), especially in July (16.5%), with most hospital visits occurring on Fridays (18.2%) and weekends (32.2%). Blunt soft tissue injuries (47.3%) and fractures (42.4%) were prevalent, particularly in the elbow (18.4%), wrist (16.9%), and knees (14.3%). A total of 247 fractures were identified, with the radial head (17.0%) and distal radius (10.9%) being the most common fractures. Fracture rates have increased in 2022 and 2023 compared to those in previous years. While 86.0% of patients received nonsurgical treatment, 14.0% underwent surgery, with a rise in surgical cases in 2022 and 2023. Elbow (19.0%), knee (16.7%), and wrist (16.7%) were the most frequent surgical sites. The increasing use of e-scooters among young people has increased trauma cases, with a growing proportion of fractures over time. The higher incidence of injuries, particularly in the elbow and knee joints, underscores the importance of protective equipment. Therefore, additional legal regulations can help to prevent such injuries.

Incidence of injury among male Varsity Cup Young Guns rugby players in South Africa.

The physical nature of the sport of rugby results in a high incidence of injury, even in university rugby, compared to other contact sport codes. Rugby Union lacks injury data focusing on university student-athletes, specifically in South Africa. The aim of the study was to determine the incidence of injury among male rugby players participating in the Varsity Cup Young Guns national rugby tournament. The study used a quantitative, cross-sectional, and correlational research design. A total of 252 rugby players, males aged 18 to 20 years, who played for their university rugby team in the 2022 Varsity Cup Young Guns national tournament were conveniently recruited to determine the incidence of overall, match, and training injuries (number of injuries/1000 hours) for the 2022 tournament. The overall injury incidence for all players was 9.5 injuries/1000 player-hours. The injury incidence for all players during matches was 136.5 injuries/1000 match-hours, whereas during training it was 0.6 injuries/1000 training-hours. The injury incidence was greater for backs than forwards (150.6 injuries/1000 match-hours vs. 124.1 injuries/1000 match-hours, respectively). The lower limb was the most commonly injured anatomical site with 36.6% (95% CI: 27.7-48.3%), while the common types of injuries were the joints (41.6%, 95% CI: 29.9-49.9%) and muscles (28.7%, 95% CI: 20.8-38.0%). A statistically significant association was found between the playing position and the phase of play in which injury occurred (χ2<inf>(1)</inf>=160.2; P=0.021). This study reported a high injury incidence, especially during matches, in the Varsity Cup Young Guns tournament. It is recommended that prospective, incidence-based studies be used to precisely determine the incidence, nature, severity and mechanisms of injury. An injury surveillance system should be implemented, specifically within Varsity Cup rugby to inform, support, and improve current injury prevention strategies.

The Characteristics of Sports Injuries in Adolescent Athletes according to Sports Specialization: A Preliminary Study

OBJECTIVES The purpose of this study is to investigate the characteristics of sports injuries in adolescent athletes according to sports specialization.METHODS One hundred and seventeen adolescent athletes including soccer, swimming, artery, weightlifting, modern pentathlon, and softball were recruited for this study, and a 12 questionnaire related to sports injuries was surveyed and analyzed.RESULTS The longer the period of sports specialization, the more frequent the number of sports injuries. Most sports injuries occur in the afternoon, but some adolescent athletes with long careers have had injuries in the early morning. Adolescent athletes with less than 3 years of careers had the highest incidence of sports injuries during match(52%), while those with 3 to 5 years (55%) of careers and more than 5 years (73%) of careers had the highest incidence of injuries during training. The main causes of sports injuries for athletes with less than 3 years of careers were poor skill (27%), overuse (25%), and lack of warm-up (23%). For adolescent athletes with 3 to 5 years of careers, the main causes were poor skill (31%), lack of warm-up (19%), and overuse(16%). 5 years or more of careers, the main causes were poor skill (35%), overuse (24%), and lack of warm-up (19%).CONCLUSIONS Adolescent athletes who are exposed to sports specialization early may be exposed to sports injuries due to intensive training, overuse, and poor skill according to the characteristics of the sport. Therefore, managers such as coaches and athletic trainers need to create a training environment to prevent sports injuries due to sports specialization of adolescent athletes.

High Incidence of Injuries Among Adolescent Elite Skiers-A 5-Year Cohort Study.

Competitive skiing has gained increasing popularity among adolescent, yet it comes with injury risks. The aim was to determine injury incidence, type and time of injury, localization, and diagnosis, among adolescent competitive skiers (alpine, cross-country, ski-cross, mogul), and to compare between skiing discipline, sex, and high school year. All students (n = 190) enrolled in a ski high school from August 2013 to June 2018 were included. All injuries during the study period were prospectively registered by the physiotherapist at the high school. Demographic and injury data were registered. Absolute injury incidence (injuries/100 skiers) was calculated. In total, 166 (87%) skiers reported 502 injuries, which corresponds to an absolute injury incidence of 264.2 injuries/100 skiers during the 5-year follow-up. A higher injury incidence was shown in school year 1 compared with year 2-4 (131.3 vs. 79.5-98.4; p < 0.05). No differences in injury incidence were found between sex or skiing discipline. Females were more prone of having a gradual-onset injury compared with males (179.3 vs. 96.3; p < 0.001). Mogul skiers had higher incidence of acute injuries compared with the other disciplines (220.0 vs. 71.4-160.0; p < 0.001). The knee was the most common localization across all skiing disciplines, except for cross-country (lower leg). Low back pain was the predominant diagnosis, except in ski-cross (concussion). Skiers attending specialized ski high schools exhibited a significantly high injury incidence, with first-year students being the most susceptible to injuries, across all skiing disciplines and both sexes. While the knee was the most common injury location, concussion was remarkably frequent, particularly among ski-cross skiers.

The frequency of injuries of Iranian male professional soccer players: a cross-sectional study.

Soccer is known to be a sport that carries a high risk of injuries due to its physical nature, involving intense contact and rapid movements like acceleration, deceleration, jumping, and sudden changes in direction. Compared to other sports, soccer is considered a contact sport with a heightened injury risk. The primary objective of this study was to assess the prevalence of sports injuries among professional soccer players. In this cross-sectional study, 56 male professional footballers participated to assess their injuries. The Pre-Competition Medical Assessment (PCMA) was utilized as the standard protocol for evaluating the athletes. The study examined variables such as injury type, player position on the field, and body mass index (BMI) in accordance with the FIFA-recommended PCMA guidelines. Student t-test was used to compare demographic characteristics injured and healthy athlete. Chi square and fisher exact tests were used to assess the association between player position, injury type and BMI classification. In this study, the mean age of the soccer players was 19.38 ± 1.30 years, with a history of participating in 3 to 60 matches. The highest incidence of injuries was recorded in the knee (48.21%) and ankle (30.36%), respectively. A significant relationship was found between the players' positions on the field and knee pain, with strikers experiencing more knee pain compared to players in other positions (p less than 0.04). However, no significant association was observed between the players' BMI and the occurrence of sports injuries (p greater than 0.05). Given the widespread occurrence of knee injuries among footballers, particularly in attacking players, proper planning and appropriate training protocols would be useful to prevent knee injuries and reduce treatment costs.

Physical Therapy in Neurorehabilitation with an Emphasis on Sports: A Bibliometric Analysis and Narrative Review.

The increasing interest in physical therapy in sports neurorehabilitation stems from the high incidence of neurological injuries among athletes and the crucial role of rehabilitation in facilitating their safe return to sports. This study aims to provide a comprehensive analysis of research trends in physical therapy and neurorehabilitation in athletes. This study presents a bibliometric analysis of 103 documents from the Scopus database, followed by a narrative review of the identified thematic areas. Together, these approaches offer a comprehensive overview of the international literature on the application of physical therapy in sports neurorehabilitation, highlighting key trends and contributors. The software VOSviewer and Power BI (2.136.1202.0) were used for the bibliometric analysis and the visualization of the results. Techniques such as performance analysis (documents per year, top sources and countries in documents, and top authors in citations) and science mapping (co-authorship, bibliographic coupling, co-citation, and co-occurrence) were conducted. The results revealed the journals and the authors with the greatest impact in the field and collaborations between various countries. From the co-occurrence analysis of the keywords, three key thematic clusters were identified, Clinical Approaches and Outcomes in Neurorehabilitation, Athlete-Centered Neurorehabilitation Techniques, and Specialized Interventions in Sports Medicine and Neurorehabilitation, which were used to conduct the narrative review. These findings provide a solid foundation for future research and clinical practice aimed at enhancing recovery times and overall performance in athletes with neurological injuries.

Mechanisms and Prevention Strategies of Anterior Cruciate Ligament Injuries in Alpine Skiers

Alpine skiing is a sport enjoyed by more than 50 million people across the world every year. However, despite advancements in safety practices and technology, anterior cruciate ligament (ACL) injuries remain a significant concern. This narrative review investigates the prevalence and mechanisms of ACL injuries in alpine skiing and differentiates between intrinsic (e.g., age, sex, and skill level) and extrinsic factors (e.g., equipment design and environmental conditions) that contribute to the risk of ACL injuries. This article outlines 4 primary mechanisms through which ACL injuries occur, highlighting the complex physical demands of skiing and the role of skier behavior and environmental interactions in injury occurrence. Based on these findings, this article advocates for neuromuscular training (NMT) as a possible effective prevention strategy. NMT enhances muscular coordination and strength, balance, and agility through exercises that mimic skiing movements, potentially lowering the risk of ACL injuries. By providing a detailed analysis of ACL injury risk factors and prevention strategies in the sport, this review offers valuable insights for reducing injury rates and underscores the importance of NMT to mitigate the high incidence of ACL injuries in alpine skiing.

Athlete Health Implications of Match Injuries in Portuguese Rugby Union.

Our aim was to report time-loss match injuries in Portugal's "Divisão de Honra" (Portuguese first tier) in the 2022/2023 season, focusing on injury incidence, burden, anatomical region, and type, to assess their impact on athletes' health and availability to play. A prospective cohort study was conducted monitoring injuries via an online form filled in by each team's medical department, categorizing player position, as well as injury type, location, and severity. Incidence and burden were calculated per 1000 player-match-hours. The overall injury incidence was 54.4 injuries per 1000 player-match-hours (95% CI 30.3-96.2). Forwards had higher injury incidence than backs. Lower limbs were the most affected locations-29 injuries/1000 h of exposure (95% CI 13.7-52.0). Sprain/ligaments injuries were the most common type of injury (14.4 injuries/1000 h (95% CI 3.7-30.0), followed by muscle injuries (8.1 injuries/1000 h 95% CI 4.9-11.5). Injury incidence was higher than what is reported in amateur competitions and lower than for professionals. Injury severity was similar to that in other studies. Our study suggests a lower injury burden than in other semi-professional and elite leagues. These findings highlight the need for targeted injury prevention strategies in the Portuguese Rugby Union to increase athletes' availability by decreasing injury incidence and/or burden. Further research with broader participation and training injury data is needed.

Prospective cohort study identifying risk factors for sports injuries in adolescent athletes: the Healthy Injury-Free Adolescent Athletes (HIFAA) study

A high incidence of injuries has been reported in young athletes. Several factors have been associated with athletes’ sports injuries. However, scientific evidence is lacking, particularly for adolescent athletes. Hence,...

The impact of neuromuscular warm-up on the level of dynamic stability of lower limbs in female football players in the context of injury prevention

Background: In female football, there’s a high incidence of injuries, with insufficient dynamic stability a significant risk for lower limb injuries. Consequently, diagnosing and compensating for dynamic stability in female footballers is crucial. Objective: The aim of the study was to verify the impact of neuromuscular warm-up on the level of dynamic stability as a method of preventing lower limb injuries in female football players. Methods: The research sample consisted of 36 players, who were divided into an experimental group (EG, n = 20) and a control group (CG, n = 16) based on their club affiliation. The average age of the EG was 17.45 ± 2.63 years, with a height of 168.31 ± 6.13 cm and a weight of 60.21 ± 8.87 kg. The CG consisted of players with an average age of 16.24 ± 1.09 years, a height of 163.84 ± 5.58 cm, and a weight of 55.91 ± 6.87 kg. The assessment of dynamic stability of the lower limbs was conducted using the Y Balance Test, which is considered a reliable test for assessing dynamic stability and identifying deficits in this area. The experimental factor of the research was neuromuscular warm-up, implemented during the warm-up phase of the players’ training sessions, with a frequency of 2-3 times per week for a duration of 12 weeks. Results: No statistically significant difference was found in the impact of neuromuscular warm-up in any tested direction or in the composite score of the female football players. Conclusion: We conclude that in our study, neuromuscular warm-up did not have an impact on the dynamic stability of female football players. More regular monitoring and higher frequency of neuromuscular warm-up may have beneficial effects on female football players.

Myocardial Injury by COVID-19 Infection Assessed by Cardiovascular Magnetic Resonance Imaging - A Prospective Multicenter Study.

This prospective multicenter study assessed the prevalence of myocardial injury in patients with COVID-19 using cardiac magnetic resonance imaging (CMR). We prospectively screened 505 patients with moderate to severe COVID-19 disease from 7 hospitals in Japan. Of these patients, 31 (mean [±SD] age 63.5±10.4 years, 23 [74%] male) suspected of myocardial injury, based on elevated serum troponin or B-type natriuretic peptide concentrations either upon admission or 3 months after discharge, underwent CMR 3 months after discharge. The primary endpoint was the presence of myocardial injury, defined by any of the following: (1) contrast enhancement in the left or right ventricle myocardium on late gadolinium enhancement CMR; (2) left or right ventricular dysfunction (defined as <50% and <45%, respectively); and (3) pericardial thickening on contrast enhancement. The mean (±SD) duration between diagnosis and CMR was 117±16 days. The primary endpoint was observed in 13 of 31 individuals (42%), with 8 (26%) satisfying the modified Lake Louise Criteria for the diagnosis of acute myocarditis. This study revealed a high incidence of myocardial injury identified by CMR in patients with moderate to severe COVID-19 and abnormal findings for cardiac biomarkers.

Injury rates and mechanisms of starting and replacement players

ABSTRACT To examine injury rates, injury mechanisms and injury inciting tackle characteristics of both starting and replacement players. A prospective, cohort study of four male professional Welsh Rugby Union (WRU) teams. Injury surveillance and Global Positioning System (GPS) data were collected from league matches between the 1st of July 2017 to the 31st of August 2020. Video analysis included league matches from the 1st of July 2017 to the 31st of March 2021. Player-specific GPS exposure was used to calculate injury incidence. Generalised linear mixed models were used to analyse the effect of replacement players on injuries. Tackle injury propensity (injuries/100 tackle events) and descriptive characteristics for the tackle event were reported. A total of 290 injuries were sustained by 105 players. Starting players had a higher injury incidence than replacement players (80.8 vs 57.2 injuries/1000 match hours; rate ratio: 1.41 (95% CI 1.00 – 1.98)). For every replacement used there was a 12% increase in the number of injuries (p = 0.037). However, there was no increase in the number of injuries accounting for the replacement time-in-game (p = 0.099). The injury propensity was highest for starting versus opposition replacement players (RR: 4.08, 95% CI: 2.28 – 7.29). Injury inciting tackles for starting players showed higher body positions, whereas replacement players maintained a lower body position. Match injuries were influenced by the number of replacement players, but this was mitigated when accounting for the replacement player time-in-game. Starting and replacement players have differing injury inciting tackle characteristics, suggesting that injury risk mitigation associated with the tackle should be incorporated at a player-specific level.

Match Injury Incidence for a New Zealand Amateur Domestic Female Soccer Team over Two Consecutive Seasons.

To determine the match injury incidence for a New Zealand amateur domestic female soccer team over two consecutive seasons. A descriptive, epidemiological observational study was conducted to determine match injury incidence for 49 players over two domestic seasons. Match exposure and injury burden were calculated. A total of 84 match-related injuries resulted in a match injury incidence of 145.5 (95% confidence interval (CI): 117.4 to 180.1) per 1000 match h. Attackers had a higher incidence of injuries for total (200.0 per 1000 match h) and missed matches (152.4 per 1000 match h). The lower limbs had the highest injury incidence (105.6 per 1000 match h), with ankle injury being the most reported (43.3 per 1000 match h) lower limb injury. Over three quarters (75.3%) of the injuries recorded were missed match injuries. Sprains/strains were the most recorded total (86.6 per 1000 match h) injury type. Fractures were recorded as having the highest mean injury burden (68.7 ± 70.4 days). Historically, there was a paucity of injury burden data for female football; however, the data presented within this study can be utilised to support the identification of injury patterns and areas to be included within injury reduction programmes.

Between-Session Reliability of Athletic Performance and Injury Mitigation Measures in Female Adolescent Athletes in the United States.

Adolescence is a fundamental period for female athletes to develop athletic performance, mitigate injury risk, and gain collegiate sport scholarships, but there is also a high incidence of sport-related injuries. Physical profiling and athlete screening can support the individualisation of training programmes; however, there is a lack of data pertaining to the reliability of athletic performance and injury surrogate measures in adolescent female athletes. The aim of this study was to quantify the between-session reliability of an athletic performance and injury mitigation testing battery in female adolescent athletes. A total of 31 post-peak height velocity (PHV) (3.00 ± 0.82 years) female athletes (age: 16.20 ± 1.20 years; standing height: 166.00 ± 6.00 cm; mass: 65.5 ± 10.70 kg) from various sports (track and field = 1; lacrosse = 2; basketball = 2; soccer = 3; softball = 11; volleyball = 12) completed two sessions of a multicomponent testing battery 48 h to 1 week apart including the assessment of 33 measures addressing lower-limb isometric strength, eccentric strength, reactive strength, linear sprint and change of direction speed, and lower limb control. Of the 33 measures, between sessions, 29 had a high to nearly perfect intraclass correlation coefficient (ICC) (0.508-0.979), and 26 measures were not statistically significantly different between sessions (p ≤ 0.05). All measures demonstrated low to acceptable coefficient variation (CV%) (0.61-14.70%). The testing battery used can be utilised for recruitment and longitudinal monitoring within sports organisations for female adolescent athletes.

The Most Common Injuries in Soccer: An Analytical Review

Soccer, also known as football in many parts of the world, is a sport with a high incidence of injuries due to its physically demanding nature. This paper reviews the most common injuries sustained by soccer players, their causes, prevention strategies, and rehabilitation processes. Understanding these injuries can help in developing better training programs and safety measures to protect athletes.

Time to level the playing field between men and women — Given similar injury incidence: A two-season analysis of match injuries in elite men and women's (Super League) rugby league

ObjectivesTo compare match injury incidence, severity and burden in men's and women's elite rugby league. DesignA prospective cohort epidemiological study. MethodsTime loss match injury data were collected from all men's (11,301 exposure hours) and women's (5,244 exposure hours) Super League clubs. ResultsInjury incidence and burden were not different between men and women (mean [95 % CI]; 54 [45 to 65] vs. 60 [49 to 74] per 1000 match-hours; p = 0.39, and 2332 [1844 to 2951] vs. 1951 [1560 to 2440] days lost per 1000 match-hours; p = 0.26). However, injury severity was greater for men than women (42 [35–50] vs. 35 [29 to 42]; p = 0.01). Lower limbs accounted for 54 % and 52 % of injuries for men and women, with the head/face the most frequently injured location due to concussion (12 [10 to 15] and 10 [8 to 14] per 1000 match-hours for men and women). Injuries to the knee had the greatest burden for men and women (708 [268–1868] and 863 [320–2328] days lost per 1000 match-hours). Being tackled was the most common injury mechanism for men and women (28 % and 38 %) with greater burden (p < 0.01) than other injury mechanisms. ConclusionsMale and female rugby league players have similar injury incidence and burden; however, injury severity was higher in men. Head/face injuries have the highest injury incidence and knee injuries have the highest burden. These injuries should be the focus for prevention initiatives at a league (via laws), player, and coach level, with equal and specific focus for both men's and women's rugby league players.

Tennis Injuries Among German League Players: Investigating Patterns and Epidemiology of Acute and Chronic Injuries.

While injuries among elite tennis athletes are extensively documented, a notable research gap exists regarding tennis injuries among club-level players. This study examines tennis injuries in German league players, with a particular emphasis on the impact of racquet properties and court surfaces, distinguishing between chronic and acute injuries. Retrospectively analyzing data from 600 tennis players over a 1.5-year period, a standardized questionnaire covered anthropometrics, injury characteristics, equipment usage, and court surface conditions. The study identified 1012 tennis-related injuries, averaging 1.7 per player. Acute injuries predominantly affected the lower extremity (56%), with ankle injuries being the most prevalent, and ligaments were the most commonly affected structures (36.4%). Chronic complaints (reported by 364 athletes) focused on the upper extremity (63.2%), primarily tendon injuries (56.8%). Racket properties exhibited no significant impact on chronic upper extremity injuries. This study highlights a high incidence of acute lower extremity injuries, especially ankle ligament injuries, among German league tennis players. It offers crucial insights for devising targeted injury prevention strategies applicable to amateur, semi-professional, and professional tennis players, despite finding no significant link between racquet material and chronic upper extremity injuries.

Perspectives on reasons why football and handball players sustain acute and severe knee injuries: a mixed-methods concept mapping study

BackgroundThe high incidence of knee injuries in football/handball challenges effective prevention. Identifying tangible and modifiable factors associated with a knee injury may innovate preventive actions. Engaging key stakeholders can reveal...

Drug-induced liver injury in HIV-infected patients with active tuberculosis

High prevalence, variability of clinical manifestations, limited knowledge about mechanisms of toxicity, and difficulty in diagnosis make drug-induced liver injury one of the unsolved problems in clinical medicine. Drug-induced liver injury during antiretroviral and antituberculosis therapy is a serious complication, which can reach a severe degree, leading to acute liver failure. Studies to identify the frequency, type, and severity of drug-induced liver injury in HIV-infected patients with active tuberculosis are essential. The article summarizes the current data of scientific publications on the frequency, type, and severity of drug-induced liver injury in patients treated with antiretroviral and antituberculosis drugs. A search and subsequent analysis of scientific publications in MedLine, the Cochrane Library, PubMed, and Scopus was performed. Available data indicate a high incidence of drug-induced liver injury and variation in types and severity among TB/HIV patients. This necessitates the need to examine patients taking ART and anti-TB drugs for the occurrence of liver damage, especially those with high-risk conditions such as viral hepatitis and alcohol use. It should remain a key component of TB/ HIV treatment.

A CASE SERIES AND LITERATURE REVIEW: MANAGEMENT STRATEGIES FOR RADIATION-INDUCED ULCERS OF THE CHEST

Highlights: Radiotherapy leads to a high occurrence of skin alterations and can advance to different levels of tissue damage, presenting challenges in treatment. Management can be effective employing diverse wound treatment methods, although severe cases may necessitate surgical intervention. Surgery takes into several key considerations to increase chances of success and tackle specific issues of chest wall instability and breast reconstruction. Abstract: Introduction: Radiotherapy as an adjunct to cancer treatment causes a high incidence of radiation-induced tissue injury, ranging from radiation dermatitis to severe osteoradionecrosis. Currently, no gold standard exists in the management of radiation injury. Various strategies ranging from modern wound treatment to surgical management have been studied. Case Illustration: Three women presented with varying degrees of ulceration in the chest during or shortly following radiotherapy. Each case followed different approaches to management. One case solely received wound treatment, another received wound treatment and a sequestrectomy, and the third required surgical reconstruction of the chest wall and defect. Discussion: Methods of wound treatment range from topical agents, barrier films and dressings, hydrogel and hydrocolloid dressings, miscellaneous treatments, and biodressings. Surgery is required in severe cases, particularly with osteoradionecrosis. This may include wound debridement, biopsy, chest wall stabilization, closure using various flaps, and potential breast reconstruction. Conclusion: Radiation-induced ulcers of the chest pose a complex issue. Understanding effective treatment methods and key surgical principles is important for ensuring better outcomes. Further studies are needed to provide a complete guide to treatment.