Complaints Of Pain Research Articles

Revision of The Total Hip Artroplasty Previously Placed False Acetabulum

A 43-year-old female patient underwent total hip arthroplasty as a result of coxarthrosis in an external center, and it was observed that the acetabular cup was placed in the false acetabulum. Later, as a result of the examination and examination performed on the patient who applied to the outpatient clinic with the complaint of hip pain, loosening of the acetabular cup was found and revision total hip arthroplasty was performed approximately 26 months after the first surgery. The acetabular cup, which was previously placed in the false acetabulum, was left in place to act as a bone stock in the superior acetabulum. There were no complications in the patient's follow-up and clinical improvement was observed in the patient.

Adult ileal duplication cyst acting as lead point of ileo-caecal intussusception a rare case of complete bowel obstruction in adults

Enteric duplication cyst presenting as intussusception in adult and causing complete small bowel obstruction is a rare phenomenon. A 19 year old female presented with complaints of abdominal pain, bilious vomiting, abdomen distension and constipation for 2 days. Patient had similar episodes in the past. Computed tomography of abdomen showed dilated small bowels with “Target Sign” suggestive of Ileo caecal intussusception. Patients was taken for surgery and intraoperatively it was noted to have thick walled cystic swelling in the terminall ileum. Segmental resection done along with cyst and primary anastamosis was done. Histopathological confirmation was done as Duplication cyst.

Sheehan’s syndrome of a 50 years old female with bipolar disorder: a case report

Empty Sella syndrome (ESS) pertains to a phenomenon in which the Turkish sale seems through radiography to be larger and perhaps partially or entirely filled with brain fluids. It can be major illness/ develop as a result of pituitary medical procedures, radiation therapy cerebral infarction/bleeding process. A 50 years old female patient was admitted in emergency medicine ward with chief complaint of pain in abdomen, weakness and vomiting. MRI scan of pituitary cerebrospinal fluid (CSF) signal intensity is seen in Sella with no visible anterior pituitary gland tissue noted-likely suggestive of secondary empty Sella (SES). Long-term steroid use is principal therapy for adrenocorticotropic hormone deficiency (IAD). In this instance, ESS, which can be primary/secondary, also noticed.

Analysis of the effectiveness and efficiency of the Indonesian metastatic bone disease of unknown origin algorithm (INA-MBD): time to diagnosis and cost to diagnosis : Quasi-experimental study

Background Patients with Metastatic Bone Disease (MBD) often presenting with complaints of pain and multiple osteolytic lesions findings. Remarkably, 30% of these cases exhibit an undetected primary lesion. Hence, categorizing them as MBD of unknown origin. The diagnostic processes of patients with MBD of unknown origin typically takes up to four months, rendering it as a catastrophic disease with the second-highest financial burden. Given its urgency, it is necessary to develop a systematic and evidence-based consensus for managing cases of MBD with an unknown origin. Purpose This study aimed to enhance the effectiveness and efficiency of treating patients with MBD of unknown origin through the application of the INA-MBD algorithm. Research method A quasi-experimental study with a pretest and post-test design was conducted with a total of 128 patients who met the inclusion and exclusion criteria. The patients were consecutively enrolled and categorized into two groups: the intervention group with the INA-MBD algorithm and the non-intervention group without the INA-MBD algorithm. The primary outcomes were the cost and time to diagnose MBD of unknown origin. The proposed measuring tool was the INA-MBD algorithm. Furthermore, for the cost-to-diagnosis variable, an extra measurement tool was used, which were summaries of the patient’s medical bill including hospital stays and medical procedures. The analysis of data related to the time-to-diagnosis variable was conducted using the Log Rank regression test, and cost-to-diagnosis variable was carried out using co-variance test.

Spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma: a rare case

BackgroundGastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma.Case presentationA 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma.ConclusionA gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

Poorly differentiated mucinous carcinoma of the ascending colon complicated by bilateral ovarian mature cystic teratomas in a 17-year-old female patient: a case report

BackgroundColorectal cancer (CRC) is one of the most common cancers worldwide, and screening colonoscopy has led to a decreasing incidence rate. However, the incidence of CRC is increasing among young people, especially adolescents and young adults (AYAs) who are not routinely screened. Although CRC is the fourth most common cancer among AYAs, it is extremely rare. In younger patients, CRC is often diagnosed later, and the proportion of patients with advanced CRC is higher than that in older patients. We herein present a case of poorly differentiated mucinous carcinoma of the ascending colon complicated by bilateral ovarian mature cystic teratomas (MCTs) in an AYA.Case presentationA 17-year-old female patient presented with a chief complaint of abdominal pain and diarrhea that had persisted for more than 3 years. Colonoscopy revealed circumferential wall thickening of the ascending colon, and colonic biopsy revealed a mucous mass and findings of adenocarcinoma, predominantly signet ring cell carcinoma. Abdominal computed tomography (CT) and pelvic magnetic resonance imaging (MRI) showed bilateral ovarian tumors. Laparoscopic right hemicolectomy and enucleation of bilateral ovarian tumors were performed. Although the ascending colon cancer formed a large mass, there were no signs of peritoneal dissemination or direct invasion to the surrounding organs. Microscopically, the ascending colon was a poorly differentiated mucinous carcinoma with signet ring cell carcinoma and lymph node metastasis (9/42). The ovarian tumors were diagnosed as MCTs without any malignant components. The pathological diagnosis was ascending colon cancer (pT4aN2bM0, pStage IIIC) and bilateral ovarian MCTs. Microsatellite instability (MSI) testing was negative, and there were no gene mutations in either RAS or BRAF. Postoperative adjuvant chemotherapy with oxaliplatin and 5-FU was started.ConclusionsWe presented a case of locally advanced ascending colon cancer in a 17-year-old female patient. CRC rarely occurs in AYAs. However, the incidence has gradually increased in recent years. It should be considered as a differential diagnosis for young patients with long-term abdominal symptoms of unknown cause.

Utilization of Biopsy-Guided CT Scan in Diagnosing Liver Cancer: A Case Study

Introduction: Liver cancer is one of the most common types of cancer in Indonesia and has a high mortality rate. Early diagnosis of liver cancer is very important to increase the patient's chances of recovery. Biopsy-guided CT scan is an effective method for diagnosing liver cancer.
 Case presentation: We report the case of a 55 year old man with a history of chronic hepatitis B who presented with complaints of right upper abdominal pain and weight loss. Physical examination revealed hepatomegaly and ascites. Investigations, including abdominal ultrasound and liver function tests, showed a mass in the liver. CT scan of the abdomen with contrast showed a hypodense mass in the right hepatic lobe. A CT-guided liver biopsy was performed and the histopathological diagnosis was hepatocellular carcinoma (HCC). The patient then underwent partial resection hepatectomy and chemotherapy.
 Conclusion: Biopsy-guided CT scan is a valuable tool for the diagnosis of HCC in patients with chronic hepatitis B.

COMBINATION OF REGENERATIVE THERAPY AND FREE GINGIVAL GRAFT IN STAGE IV PERIODONTITIS: CASE REPORT

Introduction: Periodontal regenerative therapy can be used to repair damaged periodontal tissues caused by periodontitis. The combination of regenerative periodontal surgery and FGG (Free Gingival Graft) is expected to accelerate the regeneration of periodontal tissue. Case : A 37-year-old woman came with complaints of loose lower front teeth, frequent bleeding and pain when eating and drinking. The complaint was felt since 1 year ago. Clinical examination obtained an average pocket depth of 6 mm and an average second degree of tooth mobility. On radiographic examination found bone damage horizontally. Case Management: The patient received root planing scaling and occlusion adjustment, followed by dental periodontal surgery 42,41,31,32. Stage II surgery for recession closure therapy with FGG was carried out three months after stage 1 surgery was performed. Discussion: Regenerative periodontal surgery is performed to produce new periodontal tissue growth and restore connective tissue attachment to the teeth. Free Gingival Graft is performed to increase gingival keratinization and improve patient esthetics. Conclusion and Suggestions: The combination of regenerative periodontal surgery and FGG for the treatment of periodontitis cases involving severe bone destruction gives good results of periodontal tissue healing by alveolar bone healing and regeneration and quite good aesthetics.

FIXED DOSE COMBINATION OF MECOBALAMIN AND PREGABALIN IN THE TREATMENT OF OROFACIAL NEUROPATHIC PAIN

Introduction: orofacial neuropathic pain is extraordinary disease in character with its complicated management. Mecobalamin has been used to provide regeneration of traumatized nerves. Pregabalin with its analgesic activities relieves the clinical signs of neuropathic pain. The aim of this case report is to explain fixed dose combination of Mecobalamin and Pregabalin as the treatment of neuropathic pain caused by inferior alveolar nerve and facial nerve neuropathy. Case: First case was an inferior alveolar nerve neuropathy experienced by 63 years old female with complaints of persistent pain and numbness around the left chin and left lower lip the day following the procedure of surgery for the treatment of dentoalveolar abscess on left second premolar of mandibula. Second case was facial nerve neuropathy experienced by 54 years old female had persistent pain and numbness of the anterior two-thirds of the tongue after total thyroidectomy and 1,100 MBq (30 mCi) activity of Radioactive iodine (RAI) therapy, followed with two 131I whole body scans. Case Management: Mecobalamin 500 µg and Pregabalin 75 mg twice daily for 5 weeks were given with tolerable side effects and improvement symptoms. Discussion: Pregabalin combined with Mecobalamin can reduce orofacial neuropathic pain. Pregabalin possess analgesic property and reduce neuropathy-related pain symptoms while Mecobalamin facilitates myelinogenesis and nerve regeneration. Conclusion: Fixed Dose Combination of Mecobalamin and Pregabalin has the potential analgesic effect, reduced neuropathic orofacial pain at a below than determined dosage in case of inferior alveolar and facial nerve neuropathic pain.

0998 Sleeping It Off: Alcohol, Cannabis, and Alterations in Bedtime and Waketime in Women with Sleep and Pain Complaints

0998 Sleeping It Off: Alcohol, Cannabis, and Alterations in Bedtime and Waketime in Women with Sleep and Pain Complaints

Chilaiditi Syndrome - A Case Report of Pseudopneumoperitoneum

Pneumoperitoneum presents a crucial diagnostic indicator, dictating the immediacy of patient management within an emergency department. Chilaiditi's sign denotes an uncommon radiological discovery characterized by the transposition of the large intestines between the diaphragm and the liver. Should symptoms arise in the patient, this condition is referred to as Chilaiditi syndrome. We report a unique instance involving a 77-year-old female who visited our emergency department with complaints of chest and abdominal pain. Upon radiological evaluation through chest radiograph and computed tomography scan, she was diagnosed with Chilaiditi syndrome. Instead of opting for invasive and potentially unnecessary diagnostic and therapeutic procedures, she was managed conservatively. This approach was chosen to mitigate the risk of heightened morbidity associated with unwarranted interventions. This case report delves into Chilaiditi syndrome, aiming to enhance the understanding of healthcare practitioners regarding this condition. Emphasizing the significance of thorough physical examinations in assessing patients presenting with apparent signs of air under the diaphragm is a key focus of this review. Keywords: Pneumoperitoneum, Chilaiditi, Pseudopneumoperitoneum.

The role of Radiotherapy in relieving pain caused by calcaneal spur

The pain caused by the calcaneal spur and the decreased quality of life are the hallmark features of this condition. Radiotherapy has been the subject of increasing evolution in recent decades for pain relief in both benign and malignant pathologies. The aim is to evaluate the efficacy in pain relief and the toxicity associated with the treatment. A retrospective review of a group of patients with painful complaints due to calcaneal spur who underwent Radiotherapy. Between 2012 and 2023, twelve patients, seven men, and five women, with a median age of 61 years (40-82) underwent palliative radiotherapy for calcaneal spur. Five patients had calcaneal spur on the right, five on the left, and two with bilateral spurs. All had complaints of pain in the calcaneus. One patient had undergone previous surgery and one radiofrequency and corticosteroid infiltration without resolution of the painful condition. The treatment regimens varied, with the majority (n=7) receiving 15Gy in 3 fractions of 5Gy on alternate days. 100% of the patients reported complete pain relief after treatment. One patient required re-irradiation after 4 months, with a complete response in pain control. No patient experienced toxicity related to radiotherapy. Radiotherapy plays an important role in pain control for this pathological condition, as demonstrated in this analysis. Classical studies have shown that a minimum total dose of 5Gy would be necessary for better pain control. There is a need to raise awareness among healthcare professionals about the important role of radiotherapy in pain management in this pathology.

Rapid pulmonary fistulization complicating a psoas abscess with intraoperative hypoxemia: a rare case report

Introduction and importance: Psoas abscess is a relatively uncommon condition that can present with vague clinical features. Patients with this condition often present in different ways to different specialties leading to delays in diagnosis and management. Case presentation: We present a 47-year-old woman with complaint of vague abdominal pain, fever and raised inflammatory markers who underwent CT examination. On CT, a collection was noted in the right iliac fossa that extended along the right retroperitoneum through the retrocrural space in the right lung base communicating with a cavitary pulmonary lesion with air-fluid level. The psoas abscess was drained. Clinical discussion: Our case presents a number of rare and intriguing features. Notably, the patient, who was immunocompetent, experienced a primary Staphylococcus infection that swiftly progressed to a sizable pulmonary abscess, a phenomenon uncommon in such hosts. The rarity further extends to the source of infection, originating abdominally but culminating in thoracic complications through contiguous spread from a retroperitoneal site. Despite the potential severity, the patient’s outcome was remarkably positive Conclusion: This case underscores the potential rapidity of pulmonary involvement in psoas abscesses, emphasizing the need for heightened awareness and consideration of respiratory signs during preoperative assessments

Changing Nature of Endoleak in a Patient of Superior Mesenteric Artery Aneurysm Treated with Endovascular Stent Graft

AbstractA man in his early thirties with complaints of abdominal pain for 1 week was diagnosed with a fusiform, partially thrombosed aneurysm of the superior mesenteric artery (SMA), which was treated with an endovascular stent graft. Three months later, when the patient again presented with abdominal pain, there was an endoleak of type III as detected by computed tomography and digital subtraction angiography. This was treated by in-stent balloon angioplasty with complete resolution of the endoleak. The patient again presented 1 month later with abdominal pain, with a residual sac posterior to the stent, detected on digital subtraction angiography, which was confirmed to be type II endoleak as it was getting filled by one of the jejunal branches of SMA. This was treated by glue embolization of the patent component of the aneurysm after selectively cannulating the branch vessel. This case highlights changing nature of endoleak as a complication of SMA stenting.

Preoperative diagnosis and safe surgical approach in gallbladder amyloidosis: a case report

BackgroundPreoperative diagnosis of gallbladder amyloidosis is usually difficult. In our case, the patient exhibited gallbladder dyskinesia, which led us to suspect cholecystic amyloidosis. We were able to safely perform surgery before cholecystitis onset.Case presentationA 59-year-old male patient with a history of multiple myeloma and cardiac amyloidosis presented to our hospital with a chief complaint of epicardial pain. Abdominal ultrasonography and computed tomography revealed an enlarged gallbladder and biliary sludge without any specific imaging findings of cholecystitis. After percutaneous transhepatic gallbladder aspiration (PTGBA), the patient experienced recurrent bile retention and right upper quadrant pain. Flopropione was effective in relieving these symptoms. Based on his symptoms and laboratory findings, we diagnosed the patient with dyskinesia of the gallbladder. Considering his medical history, we suspected that it was caused by amyloidosis of the gallbladder. A laparoscopic cholecystectomy was performed. The histopathological examination showed amyloid deposits in the gallbladder mucosa, from the intrinsic layer to the submucosa, and in the peripheral nerves of the gallbladder neck. The patient was discharged on postoperative day 5 and has had no recurrence of abdominal pain since then.ConclusionIn our case, gallbladder dyskinesia symptoms led us to suspect gallbladder amyloidosis. We safely surgically treated the patient before cholecystitis onset.

Cracked tooth and endodontic-periodontal lesion: 2-years follow up of a conservative treatment

This study report diagnosis and management of an endodontic-periodontal lesion in a cracked mandibular tooth after a cyclist’s fall. A 34-year-old female patient with a chief complaint of pain and edema in the region of the mandibular right first molar was evaluated and treated. Patient presented excellent oral health. After clinical, radiographical and tomographic exams, it was diagnosed an acute periapical abscess in stage II combined with tooth cracks and a periodontal involvement (endodontic-periodontal lesion). After emergency dental care it was performed subgingival scaling and root planing, definitive endodontic treatment, indirect definitive restoration (overlay) combined with a reinforcement of the tooth structure with a high-resistance polyethylene tape. Patient was periodically followed up until 24 months and treatment was successful. It can be concluded that a correct diagnosis and a conservative and well-planned and -executed treatment of a compromised tooth by cracks can have good results even endodontic-periodontal lesion is present.

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BackgroundThe majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.Case presentationCase 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.ConclusionAlthough strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

The Impact of Bone Marrow Venting Augmentation on Knee Functions in the Repair of Vertical/Longitudinal Meniscus Tears: A Triple Comparison.

Preserving and restoring meniscus function is crucial for maintaining knee biomechanics and overall functionality. To enhance the healing process after meniscus repair, various biological techniques have been introduced. In this study, three treatment approaches examined were bone marrow venting with stem cells (BMVP), anterior cruciate ligament reconstruction (ACLR) with meniscus repair, and isolated meniscus repair. From 2015 to 2019, we retrospectively analyzed data from 83 patients who presented with complaints of knee pain or pain in addition to instability, were diagnosed with vertical/longitudinal meniscus tears, and underwent arthroscopic repair (30 with isolated repair, 28 with ACLR repair, and 25 with BMVP) at our University Hospital. Among the 28 patients with anterior cruciate ligament rupture, pain and instability were the predominant complaints, whereas 55 patients with meniscus tear primarily complained pain. Clinical and functional conditions were assessed using Lysholm, WOMAC, IKDC, and VAS scores before and 18months after surgery. Surgical success was evaluated based on Barrett's criteria. Causes of failure were analyzed considering demographic data, smoking status, injury time, tear location, shape, zone, and suture type and number. Of the participants, 58 were male, 25 were female, 61 had medial meniscus lesions, and 22 had lateral meniscus lesions. The tear types included 51 simple longitudinal tears, 18 bucket handle tears, and 14 complex tears. A significant improvement was observed in the postoperative 18month Lysholm, WOMAC, and IKDC values in all three groups (p: 0.001). At the 18month mark, clinical and functional outcomes were comparable between BMVP and ACLR repair groups (Lysholm p: 0.951, WOMAC p: 0.241, IKDC p: 0.984). Both of these procedures yielded better results compared to isolated meniscus repair (Lysholm p: 0.001, WOMAC p: 0.027, IKDC p: 0.001). The superior clinical and functional outcomes observed after meniscus repair with BMVP and ACLR, compared to isolated meniscus repair, indicate positive effects of bone marrow stem cells, blood components, and tissue healing factors on meniscus repair and knee function.

Normal Functional Local Alignment and Segmental Motion at the Thoracolumbar Junction: A Cross-Sectional Study of Healthy Subjects

Several studies have investigated the mechanical behavior of the thoracolumbar spine. However, finding an accurate reference for the normal functional local alignment and segmental motion (SM) at the thoracolumbar junction (TLJ) is challenging. Therefore, this study aimed to assess age- and sex-related changes and differences in local alignment and SM at the TLJ. The study recruited healthy subjects aged 20 to 79 without complaints of back pain. Healthy subjects (60 males and 60 females) with appropriate imaging results were enrolled in the study. The subjects were divided into age groups (20-29, 30-39, 40-49, 50-59, 60-69, and 70-79years); each group included 10 subjects of each sex. The SM at the TLJ was small but noticeable, and the motion gradually increased toward the lower level of the TLJ, closer to the lumbar region. No significant differences were observed between male and female subjects in any SM measurements at the TLJ. The SM at the TLJ gradually decreased with age, while local kyphosis of TLJ progressed. The results also showed that the thoracolumbar slope value did not change with age and remained at a mean of-12.8±7.2° (P=0.893). This study's results provide valuable guidance for appropriate surgical planning and rehabilitation of patients with spinal diseases or trauma. Furthermore, the results can be the basis for categorizing accurate criteria to evaluate the degree of disability after treatment.

Disseminated Cryptococcus neoformans infection involving multiple bones and lung in an immunocompetent patient: a case report

BackgroundCryptococcal osteomyelitis is a rare and potentially serious condition, typically encountered in individuals with compromised immune systems. This case underscores the unusual occurrence of disseminated Cryptococcosis in an immunocompetent person, involving multiple bones and lungs, with Cryptococcus neoformans identified as the causative agent.Case presentationAn Indonesian man, previously in good health, presented with a chief complaint of successive multiple bone pain lasting for more one month, without any prior history of trauma. Additionally, he reported a recent onset of fever. On physical examination, tenderness was observed in the left lateral chest wall and right iliac crest. Laboratory findings indicated mildly elevated inflammatory markers. A computed tomography (CT) scan of the chest revealed an ovoid solid nodule in the right lower lung and multifocal osteolytic lesions in the sternum, ribs, and humeral head. A magnetic resonance imaging (MRI) study of the sacrum showed multiple lesions in the bilateral iliac bone and the lower L4 vertebral body. Confirmation of Cryptococcal osteomyelitis involved a fine-needle biopsy and culture, identifying Cryptococcus neoformans in the aspirate. The patient responded positively to targeted antifungal treatments, leading to a gradual improvement in his condition.ConclusionsThis case emphasizes the need to consider Cryptococcus neoformans osteomyelitis in immunocompetent patients with bone pain. A definitive diagnosis involves a fine-needle biopsy for pathology and culture, and prompt initiation of appropriate antifungal treatment has proven effective in preventing mortality.