Orthopedic Procedures In Patients Research Articles

Pre-Operative Management of the Penicillin Allergic Patient: A Narrative Review

Penicillin is a frequently reported medication allergy. The beta-lactam ring shared between cephalosporins and penicillin often leads to the use of alternative antibiotics for surgical prophylaxis due to concern for cross-reactivity, despite a true IgE-mediated hypersensitivity being very rare. This misconception leads to the use of less effective second line antibiotics, such as clindamycin or vancomycin, for penicillin-allergic patients which has been shown to increase odds of postoperative infection in elective knee arthroplasty, shoulder arthroplasty and spine surgery. Preoperative penicillin allergy testing has been demonstrated to be a cost-effective measure in the prevention of prosthetic joint infection and is suggested for all penicillin-allergic patients in the peri-operative setting. This review highlights and summaries the outcomes of orthopaedic procedures in patients with reported penicillin allergies and discusses potential solutions to the perioperative challenges of patients with reported penicillin allergies.

Comparison of Different Ketofol Procedural Sedation and Analgesic Doses during Orthopedic Procedures in Patients Referred to the Emergency Department: A Double-Blind Randomized Clinical Trial

Background: Orthopedic procedures are one of the most common medical procedures in the emergency department (ED) and are also among the most painful procedures performed on the conscious patient. This study aimed to compare different doses of ketofol in procedural sedation and analgesia (PSA) in patients referred to the EDs. Methods: In this double-blinded clinical trial, 296 patients aged 18 years or over who presented with the need for orthopedic procedures in the three academic EDs in 2020 were studied. After completing the written consent, the patients were randomly assigned to four treatment groups. Demographic information, underlying diseases, patients' physical condition, type of orthopedic injuries requiring intervention, and patients' vital signs were recorded in a checklist for each patient. Results: In this study, the mean age, gender, level of education, addiction, patients' physical condition, type of procedures performed, apnea, hypoventilation, bradycardia, hypotension, and agitation in all four treatment groups were not statistically different, but hallucination and hypoxia in group C (propofol 1 mg/kg plus ketamine 0.33 mg/kg) were much less than other groups; thus, oxygen administration was more common in other groups. Conclusion: By testing different doses of ketamine, we concluded that doses of 1 mg and 0.5 mg were associated with more side effects. A dose of 0.33 mg of ketamine has fewer side effects while causing analgesia and sedation as in the above doses. A dose of 0.25 mg of ketamine increases the likelihood of requiring subsequent doses. Therefore, it seems that 0.33 mg of ketamine is the best dose of choice.

Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases During the COVID-19 Pandemic

Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases During the COVID-19 Pandemic

Immediate and Long-Term Outcomes Following Orthopedic Procedures in Patients with Hemophilia: A Three-Decade Retrospective Review

Introduction: Patients with hemophilia are at risk for developing hemophilic arthropathy and may require orthopedic interventions at a young age. It is unclear whether the advent of routine prophylaxis and comprehensive care have reduced the rates of orthopedic procedures in the past several decades, and whether improved supportive care have reduced perioperative complications. Aim: In this study, we aim to evaluate the overall trends of orthopedic procedures, surgical outcomes and healthcare utilization in patients with hemophilia who underwent orthopedic procedure in the past three decades. Methods: In this single-centre retrospective cohort study, adult patients with all severities of hemophilia who underwent at least one orthopedic procedure from January 1990-August 2018 at the University of Alberta Hospital were included. Demographic data, hemophilia history, details of orthopedic procedure, perioperative factor administration were collected. Temporal changes in the types of procedures, factor utilization, and outcomes were examined using descriptive analyses. Results: In the last 3 decades, 17 patients underwent 50 orthopedic procedures in our institution, including total knee arthroplasty (TKA) (n=18), TKA revision (n=8), total hip arthroplasty (n=5), ankle fusion (n=5), synovectomy (n=4), and others (n=10). Median age at the time of the procedure was 41 years (interquartile range IQR 31-48), and median BMI was 25 (IQR 22-39) (Table 1). Fourteen patients have hemophilia A and 3 have hemophilia B, including severe hemophilia in 13 (76%). Four patients (24%) have active inhibitors at the time of surgery. Ten (59%) patients had active hepatitis C infection at the time of surgery, whereas none had HIV infection. There is a reduction in the number of orthopedic surgeries performed over time (Table 2). There was a significant reduction in the length of stay from 1990-2000 to 2001-2018 (median 20 days vs 6 days, P <0.001). Overall perioperative coagulation factor concentrates were prescribed for a median of 10 days (IQR 7-20), whereas active inhibitor patients received bypassing agent coverage for a longer duration (median 17 days, IQR 10-21). There was a significant reduction in the perioperative factor VIII utilization over time (P=0.02), and a similar trend in factor IX utilization (Table 2). Tranexamic acid was used perioperatively in the majority (68%) of procedures for a median of 10 days. Pharmacologic thromboprophylaxis was prescribed in 15 (30%) procedures for a median of 8 days (IQR 7-13), intermittent pneumatic device was prescribed in 2, the remaining procedures had no documented thromboprophylaxis. Postoperative complications include major bleeding (n=2) and clinically relevant non-major bleeding (n=6), prosthetic joint infection (n=10), aseptic loosening requiring revision (n=2), poor wound healing complicated by skin necrosis (n=2), and deep vein thrombosis (n=1). The 10 infectious complications occurred in 6 patients, including early prosthetic joint infection <4 weeks in 6 cases, despite common use of prophylactic antibiotics in 92% of all cases. Pharmacological thromboprophylaxis was not associated with an increased risk of bleeding. There were no inhibitor development or arterial thromboses perioperatively. All complications occurred in surgeries performed prior to 2011. Conclusions: Over the past three decades, we observe a decline in the number of orthopedic procedures performed in patients with hemophilia, likely reflecting the impact of routine prophylaxis and changes in practice patterns. Orthopedic outcomes have improved over time, in conjunction with a reduction in healthcare utilization including shorter length of stay and reduced factor utilization. Disclosures Sun: Octapharma: Consultancy, Research Funding; Novo Nordisk: Consultancy.

Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample.

The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.

166 Musculoskeletal complications and orthopaedic procedures in patients with X-linked hypophosphataemic rickets

166 Musculoskeletal complications and orthopaedic procedures in patients with X-linked hypophosphataemic rickets

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis.

To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery. We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital's administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery. There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30-59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954-1985 vs 1999-2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time. There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

Red Wine Again? Commentary on an article by Erin L. Hsu, PhD, et al.: "Dioxin Exposure Impairs BMP-2-Mediated Spinal Fusion in a Rat Arthrodesis Model".

In their article, Hsu et al. describe how a specific constituent of cigarette smoke (dioxin) negatively influences bone morphogenetic protein (BMP)-2-mediated spinal fusion in rats. On the basis of their findings, they speculate on potential therapeutic options to improve fusion in spinal arthrodesis and bone-healing in other orthopaedic procedures in patients who continue smoking. Recently, a detailed overview of the adverse effects of smoking on the musculoskeletal system was published in The Journal of Bone & Joint Surgery 1 . These negative effects can be roughly summarized as (1) prothrombotic effects with, among others, an increased risk of osteonecrosis; (2) metabolic effects resulting in decreased bone strength with subsequent increased fracture risk; (3) anti-osteogenic effects with decreased healing capacity of fractures and osteotomy and arthrodesis sites; and (4) other general adverse effects increasing the risk of perioperative complications such as wound-healing disturbances. Although the specific effects of many toxic substances in cigarette smoke, such as carbon monoxide and nicotine, have been established in terms of tissue oxygenation, carcinogenesis, and addiction, it is unclear which toxic substances specifically cause adverse musculoskeletal effects. The role of nicotine, the main addictive substance, is especially controversial regarding the often-reported positive effect …

Orthopedic Procedures in Patients with Congenital Coagulation Disorders: Single Center Experience

Spontaneous intraarticular bleeds in congenital coagulation disorders result in early and extensive damage to the joints and periarticular structures. Total arthroplasty is the only effective method of treating these defects. Interim surgical procedures (arthroscopy, osteotomy, etc.) exist that can postpone arthroplasty, especially considering the fact that the condition affects young people. The aim of this paper is to discuss the range of trauma care and orthopedic procedures performed in patients with congenital coagulation disorders. Also presented are early results of joint arthroplasty in these patients. A total of 168 trauma care and orthopedic procedures were performed in patients with congenital coagulation disorders at the Clinical Department of Orthopedics and Traumatology of the Central Clinical Hospital of the Ministry of Interior in Warsaw in the years 2010-2013. Among them were total arthroplasties (79 arthroplasties of the knee, 30 of the hip, 3 of the ankle and 1 of the elbow), arthroscopies, filling bone cysts with grafts and trauma procedures. The HHS, KSS, AOFAS and MEPS scales were used to evaluate the respective clinical results of hip, knee, ankle and elbow arthroplasty procedures. A VAS was used to evaluate pain intensity. In knee arthroplasty patients, quality of life parameters were evaluated with the WOMAC index. In patients post hip arthroplasty, HHS scores increased by 50.22 points and VAS scores increased by 6.34 points. An increase of 116.41 points in KSS scores and 6.67 points in VAS scores was recorded in patients after knee arthroplasty. Also, WOMAC scores improved by 53.8 points after surgery. Evaluation of early results of ankle arthroplasty in the AOFAS scale showed a mean improvement of 35.5 points and a 5-point improvement in VAS scores. MEPS scores, used for evaluation of elbow arthroplasty results, improved from 15 to 70 points, with an improvement from 6 to 2 points in VAS scores. 1. Orthopedic procedures in patients with congenital coagulation disorders require thorough preparation of the patient and close cooperation between the orthopedic and hematological teams. 2. Early clinical outcomes are promising. 3. Decreased pain intensity, increased joint range of motion and improved quality of life post-surgery are observed.

Risk of Orthopedic Surgical Site Infections in Patients with Rheumatoid Arthritis Treated with Antitumor Necrosis Factor Alfa Therapy

Introduction. International guidelines recommend interruption of anti-TNF medications in the perioperative period, but there are no randomized trials to support such recommendation. Objectives. To study literature evidence assessing the risk of surgical site infections in orthopedic surgery patients with RA using anti-TNF drugs, compared to untreated patients or those using conventional DMARD. Methods. Systematic review of cohort studies is concerning surgical site infections in orthopedic procedures in patients with RA. Results. Three studies were selected. Only one was considered of high-quality, albeit with low statistical power. The review resulted in inconclusive data, since the best quality study showed no significant differences between groups, while others showed increased risk of infections in patients using anti-TNF medications. Conclusion. It is unclear whether patients with RA using anti-TNF medications are at increased risk of surgical site infections. Randomized controlled trials or new high quality observational studies are needed to clarify the issue.

Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system

The maxilla and masseter muscles are components of the stomatognathic system involved in chewing, which is frequently affected by physical forces such as gravity, and by dental, orthodontic and orthopedic procedures. Thyroid hormones (TH) are known to regulate the expression of genes that control bone mass and the oxidative properties of muscles; however, little is known about the effects of TH on the stomatognathic system. This study investigated this issue by evaluating: i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla and ii) myoglobin (Mb) mRNA and protein expression, as well as fiber composition of the masseter. Male Wistar rats (~250 g) were divided into thyroidectomized (Tx) and sham-operated (SO) groups (N = 24/group) treated with T3 or saline (0.9%) for 15 days. Thyroidectomy increased OPG (~40%) and OPN (~75%) mRNA expression, while T3 treatment reduced OPG (~40%) and OPN (~75%) in Tx, and both (~50%) in SO rats. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, Mb content was decreased in Tx rats even after T3 treatment. Since OPG and OPN are key proteins involved in the osteoclastogenesis inhibition and bone mineralization, respectively, and that Mb functions as a muscle store of O2 allowing muscles to be more resistant to fatigue, the present data indicate that TH also interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system, which may require attention during dental, orthodontic and orthopedic procedures in patients with thyroid diseases.

Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system

The maxilla and masseter muscles are components of the stomatognathic system involved in chewing, which is frequently affected by physical forces such as gravity, and by dental, orthodontic and orthopedic procedures. Thyroid hormones (TH) are known to regulate the expression of genes that control bone mass and the oxidative properties of muscles; however, little is known about the effects of TH on the stomatognathic system. This study investigated this issue by evaluating: i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla and ii) myoglobin (Mb) mRNA and protein expression, as well as fiber composition of the masseter. Male Wistar rats (~250 g) were divided into thyroidectomized (Tx) and sham-operated (SO) groups (N = 24/group) treated with T3 or saline (0.9%) for 15 days. Thyroidectomy increased OPG (~40%) and OPN (~75%) mRNA expression, while T3 treatment reduced OPG (~40%) and OPN (~75%) in Tx, and both (~50%) in SO rats. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, Mb content was decreased in Tx rats even after T3 treatment. Since OPG and OPN are key proteins involved in the osteoclastogenesis inhibition and bone mineralization, respectively, and that Mb functions as a muscle store of O2 allowing muscles to be more resistant to fatigue, the present data indicate that TH also interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system, which may require attention during dental, orthodontic and orthopedic procedures in patients with thyroid diseases.

Anaesthesia for total hip replacement in Gaucher's disease

EDITOR: Gaucher's disease, the most common lysosomal storage disorder, is an enzymatic defect with consequent accumulation of undegraded glucocerebroside in cells of the monocyte–macrophage system [1]. Most patients present with enlargement of the spleen and liver resulting in hypersplenism, with thrombocytopaenia generally more significant than anaemia. Skeletal involvement, particularly osteonecrosis of large joints and pathological fractures, invariably is the most significant cause of morbidity and decreased quality of life. In spite of enzyme replacement therapy, osteopaenia and osteonecrosis continue to be clinically important. The need for total hip replacement (THR), and subsequent revision, is relatively common in these patients at a relatively young age. With regard to the anaesthetic management for orthopaedic surgery in patients with Gaucher’s disease, only one case report appears in the literature of an adult with a sub-capital hip fracture who underwent subarachnoid anaesthesia [2]. We wish to report the anaesthetic management of all cases seen in our institution for THR or revision from 1990 to 2005. Patient characteristics and perioperative data are summarized from the clinical records and presented in Table 1.Table 1: Patients with Gaucher’s disease: patient characteristics and perioperative data expressed as mean ± SD (range) or number (%) of patients.There were 14 patients, 10 males and 4 females, who underwent THR. Five of these underwent a revision. Six patients (43%) were homozygous for the mild N370S (1226) mutation; eight patients (57%) had been splenectomized; and six patients (43%) had pulmonary hypertension at the time of surgery. Fifty-three percentage of patients underwent general anaesthesia. Five of the operations (21%) were performed with preoperative platelet counts <80 × 103 mm−3. Perioperative blood product transfusion was required in 68% of the operations. All patients with general anaesthesia were orally intubated utilizing direct laryngoscopy and ventilated with tidal volume 6–8 mL kg−1 and respiratory rate of 10–16 min−1. There were no difficulties in airway management. All patients were given preoperative antibiotic prophylaxis mainly with cefamezine; nonetheless, 37% experienced postoperative wound infections presenting significantly higher rates compared to similar patients in our institution (2%) and the rate reported in medical literature (0.3–2%) [3]. A wound infection was defined as one of the following: wound redness, excessive pain, tissue necrosis, local oedema, purulent discharge from the operation wound and maximal temperature >38.5 and/or white cell count >10 000. Other complications included one inadvertent spinal, one failed spinal and one patient with severe postoperative thrombocytopaenia (21 × 103 mm−3). Joint replacement for patients with Gaucher's disease is an important therapeutic intervention that dramatically reduces pain, improves functionality and increases quality of life. For patients with Gaucher's disease, the preoperative evaluation of haematological status is of primary concern. Many have very low platelet counts with or without abnormal platelet function [4]. Thrombocytopaenia may be sufficiently severe as to preclude regional anaesthesia [5]. In minor procedures (e.g. dental extractions) we have successfully used platelet transfusions immediately prior to and directly after surgery. Coagulation factor deficiencies are also common in this population and may occur independently of platelet abnormalities. A relatively large percentage (44%) in this cohort had pulmonary hypertension at surgery. This complication reflects disease severity but we have also posited a possible connection with enzyme replacement therapy [6], so that a history of enzyme treatment does not preclude abnormal lung function. In these most severe cases, regional anaesthesia may be preferred because of pulmonary hypertension. In conclusion, patients with Gaucher’s disease undergoing THR may have associated medical conditions such as pulmonary hypertension and coagulopathy that complicate their anaesthetic management and postoperative course. Further, they are at high risk for development of postoperative infection. We strongly recommend a multi-disciplinary approach that includes internal medicine, anaesthesiology and orthopaedic surgery when planning of major orthopaedic procedures in patients with Gaucher’s disease.

Elective orthopaedic surgery for inhibitor patients.

We report on a series of 108 elective orthopaedic surgical procedures. It includes 88 radiosynoviortheses and 20 major orthopaedic procedures, performed on 51 patients at nine centres worldwide. The average age of patients was 28.5 years (range 5-40 years), and the average follow-up time was 2 years (range 1-5 years). There were 82 good results, 15 fair and 11 poor. In the synoviorthesis group (41 patients, 88 synoviortheses) the average age was 14.3 years (range 5-40 years) and the average follow-up was 6.5 years (range 1-10 years). There were 66 good results, 14 fair and eight poor. There were no complications. In the group of major orthopaedic procedures, the average age of the 10 patients was 32.5 years (range 27-40 years), and the average follow-up was 2.3 years (range 1-5 years). There were 16 good results, one fair and three poor. Postoperative bleeding complications occurred in three of the 20 major orthopaedic procedures performed (15% complications rate). They occurred in three patients treated with insufficient doses of recombinant activated factor VII. Despite such complications, the study has shown that haemophilic patients with inhibitors requiring elective orthopaedic surgery (EOS) can undergo such procedures with a high expectation of success. In other words, EOS is now possible in haemophilic patients with inhibitors, leading to an improved quality of life for these patients. Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Orthopaedic surgery in haemophilic patients with inhibitors: an overview.

Our experience and a review of the literature on inhibitors have shown that, with the availability of recombinant factor VIIa (rFVIIa), haemophilic patients with high inhibitor titres requiring elective orthopaedic surgery can undergo such surgery with a high expectation of success. The advent of rFVIIa has made major elective orthopaedic surgery possible in haemophilic patients with high-titre inhibitors, resulting in an improved quality of life. Recombinant FVIIa appears to be an efficient haemostatic product for surgery in patients suffering from haemophilia A and B with inhibitors. The series of major elective orthopaedic surgical procedures using rFVIIa (n=53) is the largest ever reported in haemophilic patients with inhibitors, despite the long-standing presence of other treatment modalities, such as high-dose human factor VIII (FVIII), porcine FVIII (n=8), and prothrombin complex concentrates/activated prothrombin complex concentrates (n=9). Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Outcomes after selective dorsal rhizotomy for spastic cerebral palsy.

The purpose of this article was to review the published outcomes after selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy. A literature search identified all articles related to outcomes after SDR. The outcomes were reviewed according to a paradigm developed by the National Center for Medical Rehabilitation Research (NCMRR). The quality of the evidence for each outcome was assessed using Sackett's criteria and the classification system developed by the Brain Trauma Foundation and the American Association of Neurological Surgeons. There is very strong evidence for benefits of SDR in the impairment domain of the NCMRR classification. SDR has been shown conclusively to decrease lower limb spasticity and increase lower limb range of motion. There is strong, but not as conclusive evidence that SDR has a positive impact in the functional limitation dimension, with improvements in motor function, and in particular the Gross Motor Function Assessment (GMFM). There is a moderate degree of certainty that SDR results in improvements in the disability dimension, as evidenced particularly by improvements in the Functional Independence Measure for Children (WeeFIM) and Pediatric Evaluation of Disability Inventory (PEDI). There is a moderate degree of certainty that SDR results in positive suprasegmental effects, especially related to upper limb function and cognition. There is weak evidence that SDR may reduce the need for orthopedic procedures in patients with spastic cerebral palsy, and the impact on hip subluxation relative to the natural history of this problem is unclear. This information could help to define the role of SDR in the management of the child with spastic cerebral palsy, in the light of alternative therapies, such as intrathecal baclofen and botulinum toxin, which have been introduced more recently. It also reveals the need for further studies, particularly dealing with quality of life and economic impact.