Quality Of Life In Patients Research Articles

Clinical Care of Acne Vulgaris for Transgender and Gender Diverse Youth

Abstract Primary care providers have reported feeling ill-equipped to care for transgender and gender diverse (TGD) patients because of lack of training, and their treatment of acne has been shown to be variable and not standardized. This is an important practice gap, as TGD youth represent a historically underserved population in medicine, despite data suggesting that up to 9.2% of high school–age adolescents identify as TGD. Although needs and expectations for quality health-care in TGD youth do not necessarily differ from their cisgender peers, TGD adolescents have unique considerations in their care and are at risk for negative social and emotional outcomes secondary to minority stress, discrimination, and rejection by peers and family. Acne is estimated to affect approximately 85% of adolescents and is associated with negative mental health outcomes, including suicidal ideation, low self-esteem, and depression. As such, knowledgeable and culturally informed care of acne in TGD adolescents has important implications for quality of life for patients who desire effective treatment. This review article addresses these practice gaps by summarizing an approach to acne evaluation and management with an emphasis on appropriate regimens for TGD youth, and the unique psychosocial and medical considerations for this population.

Depressive symptoms and quality of life in patients with benign essential blepharospasm under long-term therapy with botulinum toxin.

Regular and long-term injections of botulinum toxin (BoNT) are considered the first line therapy for essential blepharospasm (BEB), but no data exists on the long-term effect of this therapy on depressive symptoms and quality of life. This study aims to prospectively evaluate the long-term effects of BoNT therapy on depressive symptoms as well as on daily activities, emotional well-being and quality of life using validated questionnaires (BEB-scale, Beck`s Depression Inventory (BDI)). 86 patients diagnosed with BEB were followed up for a median of 4 years. Clinical symptoms improved significantly after BoNT-injections. Everyday activities and subjective assessment of the overall situation improved gradually under long-term BoNT therapy. Significant correlations (p < 0.0001; r-values between 0.498 and 0.706) were found between the BDI and items of the BEB-scale. No significant antidepressive effect of long-term BoNT therapy was found with a low median BDI total score (5/max. 63), but up to 31.3% of BEB patients had a BDI score ≥ 11, indicating clinically relevant depressive symptoms. Of these, 65.4% had no known history of depression. Although, several studies reported an antidepressant effect of botulinum toxin injections in patients with major depression, this effect does not seem to be present in patients with BEB despite clinical improvement of symptoms. A high prevalence of previously undetected depressive symptoms was found in BEB patients. As this may influence BoNT therapy success, identifying potential depressive symptoms at the time of BEB diagnosis and initiating appropriate treatment seems important.

Correlations between blood vessel distribution, lung function and structural change in idiopathic pulmonary fibrosis.

Correlations between the image analysis of CT scan, lung function and quality of life in patients with idiopathic pulmonary fibrosis (IPF) remain unclear. This study aimed to investigate the impacts of pulmonary blood-vessel distribution and the extent of fibrosis on the lung function and quality of life of patients with IPF. Patients were enrolled in an IPF registry and had completed pulmonary function tests, chest HRCT, St. George Respiratory Questionnaire (SGRQ) and echocardiography. Pulmonary blood-vessel distribution, specific image-derived airway volume (siVaw) and fibrosis extent (siVfib) were quantitatively calculated by functional respiratory imaging on HRCT. The study subjects were categorized into DLco <40% pred. (n = 40) and DLco ≥40% pred. (n = 19) groups. Patients with DLco <40% pred. had significantly higher scores of SGRQ, composite physiologic index (CPI), exercise oxygen desaturation (∆SpO2), siVaw, lower FVC% pred. and 6-minute walking distance% pred. The proportion of small blood vessels in the upper lobes (BV5PR-UL) was significantly correlated with CPI, DLco % Pred., FVC% pred., SGRQ and ∆SpO2. Only BV5PR-UL had a significant impact on all indices but not BV5PR in the lower lobes (BV5PR-LL). siVfib was significantly negatively correlated with BV5PR-UL, DLco% pred. and FVC% pred., as well as positively correlated with CPI, ∆SpO2 and siVaw. BV5PR-UL and siVfib had significant correlations with lung function and may become important indicators to assess the severity of IPF and the impact on quality of life.

BP09 Presentation Time: 5:12 PM: Doubly Accelerated Partial Breast Irradiation after Breast-Conserving Surgery: High Five (HiFi) APBI Study - Preliminary Report on Patients Quality of Life

BP09 Presentation Time: 5:12 PM: Doubly Accelerated Partial Breast Irradiation after Breast-Conserving Surgery: High Five (HiFi) APBI Study - Preliminary Report on Patients Quality of Life

Electro-capacitive cancer therapy using wearable electric field detector: a review

Electro-capacitive cancer therapy (ECCT), a less invasive and more targeted approach using wearable electric field detectors, is revolutionizing cancer therapy, a complex process involving traditional methods like surgery, chemotherapy, and radiation. The review aims to investigate the safety and efficacy of electric field exposure in vital organs, particularly in cancer therapy, to improve medical advancements. It will investigate the impact on cytokines and insulation integrity, as well as contribute to improving diagnostic techniques and safety measures in medical and engineering fields. Wearable electric field detectors have revolutionized cancer therapy by offering a non-invasive and personalized approach to treatment. These devices, such as smart caps or patches, measure changes in electric fields by detecting capacitance alterations. Their lightweight, comfortable, and easy to-wear nature allows for real-time monitoring, providing valuable data for personalized treatment plans. The portability of wearable detectors allows for long-term surveillance outside clinical settings, increasing therapy efficacy. The ability to collect data over extended periods provides a comprehensive view of electric field dynamics, aiding researchers in understanding tumor growth and progression. Technology advancements in electro-capacitive therapy, including wearable devices, have revolutionized cancer treatment by adjusting electric field intensity in real-time, enhancing personalized medicine, and improving treatment outcomes and patient quality of life.

The Landscape of microRNAs in Bone Tumor: A Comprehensive Review in Recent Studies.

Cancer, the second greatest cause of mortality worldwide, frequently causes bone me-tastases in patients with advanced-stage carcinomas such as prostate, breast, and lung cancer. The existence of these metastases contributes to the occurrence of skeletal-related events (SREs), which are defined by excessive pain, pathological fractures, hypercalcemia, and spinal cord com-pression. These injurious incidents leave uncomfortably large holes in each of the cancer patient's life quality. Primary bone cancers, including osteosarcoma (OS), chondrosarcoma (CS), and Ewing's sarcoma (ES), have unclear origins. MicroRNA (miRNA) expression patterns have been changed in primary bone cancers such as OS, CS, and ES, indicating a role in tumor development, invasion, metastasis, and treatment response. These miRNAs are persistent in circulation and ex-hibit distinct patterns in many forms of bone tumors, making them potential biomarkers for early detection and treatment of such diseases. Given their crucial regulatory functions in various bio-logical processes and conditions, including cancer, this study aims to look at miRNAs' activities and possible contributions to bone malignancies, focusing on OS, CS, and ES. In conclusion, miRNAs are valuable tools for diagnosing, monitoring, and predicting OS, CS, and ES outcomes. Further research is required to fully comprehend the intricate involvement of miRNAs in these bone cancers and to develop effective miRNA-based treatments.

Transitional care interventions improve quality of life in both surgical and non-surgical lung cancer patients: Insights from asubgroup analysis.

Transitional care interventions improve quality of life in both surgical and non-surgical lung cancer patients: Insights from asubgroup analysis.

Severe Uncontrolled Asthma: A Longitudinal Retrospective Study Illustrating the Experience of the Pulmonology Clinic of Târgu-Mureș, Romania

Introduction: Severe uncontrolled asthma (SUA) affects approximately 5% of asthma patients, leading to frequent exacerbations, reduced lung function, and lower quality of life. Recent biologic therapies target specific inflammatory pathways, offering new options for SUA. Objective: This study aimed to evaluate clinical characteristics, treatment outcomes, and biomarkers in patients with SUA treated with biologics (Omalizumab, Benralizumab, and Dupilumab) at our clinic. Material and Methods: A six-month retrospective longitudinal study was conducted on 28 patients aged 36–83 years with SUA. Patients were divided into three groups: Omalizumab (n = 4), Benralizumab (n = 18), and Dupilumab (n = 6). Lung function tests and biomarkers such as eosinophil and IgE levels were measured over 3-month periods (T0, T1, and T2). Asthma control was assessed using asthma control tests (ACT), and non-parametric statistical methods were applied. Results: The median patient age was 64 years, with 75% showing elevated eosinophil counts (&gt;300 cells/µL). Benralizumab significantly improved lung function (p &lt; 0.05) and ACT scores (p &lt; 0.001), reducing eosinophil counts to zero (p &lt; 0.001). Patients on Dupilumab and Omalizumab showed improved asthma control (p &lt; 0.05) and reduced exacerbations, albeit to a lesser extent (p &gt; 0.05). Conclusions: Biologics, particularly Benralizumab and Dupilumab, improved asthma control, lung function, and quality of life in SUA patients, with improved ACT scores and spirometry values. Some patients remained poorly controlled, emphasizing the need for personalized treatment and regular biomarker monitoring. Multidisciplinary management and lifestyle changes are critical for better outcomes in SUA.

Factors associated with quality of life and functional capacity in patients with diabetic foot in the Dominican Republic

Factors associated with quality of life and functional capacity in patients with diabetic foot in the Dominican Republic

The quality of life among women with breast cancer: a qualitative study in the environment of healthcare in Morocco

ABSTRACT Breast cancer is a real Moroccan public health problem, deeply affecting the quality of life of patients. This qualitative study aimed to explore the quality of life among breast cancer patients in Morocco. Twenty-three patients were interviewed during November-December 2023. The data was analysed using Interpretative Phenomenological Analysis. The results showed that patients confirmed the feeling of great depression and anxiety after the announcement of the diagnosis. Side effects of treatment are the most difficult challenge for patients. Married participants reported alteration of sex life and salaried patients abandon their professions. Yet, the patients maintained good self-esteem. These results indicate the need for multidisciplinary interventions to maintain a good quality of life in breast cancer patients.

Parallel Mediating Roles of Social Support and Self-Efficacy in the Relationship Between Frailty and Depression in Elderly Patients After Percutaneous Coronary Intervention.

To examine chain mediating roles of social support and self-efficacy between quality of frailty and depression in elderly people after percutaneous coronary intervention (PCI). Frailty is a cause of depression among elderly patients after PCI. Although previous studies have shown that frailty, social support, self-efficacy and depression are significantly related, the interaction mechanism remains unclear. Employing a cross-sectional research design and convenience sampling methodology, data were collected at a tertiary hospital in China. Participants completed the FRAIL Scale, Social Support Rate Scale, General Self-Efficacy Scale and the Hospital Anxiety and Depression Scale. We utilised the PROCESS macro in SPSS to ascertain the mediating roles of social support and self-efficacy between frailty and depression. The study used the STROBE checklist for reporting. A total of 241 elderly patients were included in the study, with an average age of 68.05 (6.04) years. Among them, 63.1% of the participants had experienced depression. Elderly patients after PCI's frailty score was negatively correlated with social support and self-efficacy, and positively correlated with depression. Social support was significantly positively correlated with self-efficacy, significantly negatively correlated with depression. Finally, self-efficacy was significantly negatively correlated with depression. Social support and self-efficacy mediated 11.61% and 29.46% of the total depressive role in elderly after frailty and PCI, respectively. Frailty in elderly PCI patients is directly associated with depression and indirectly related through social support or self-efficacy. To enhance the quality of life for elderly patients following PCI, healthcare providers should address the impact of frailty on depression and develop intervention strategies based on the levels of social support and self-efficacy. Questionnaires filled out by patients were used to understand the relationship between frailty, social support, self-efficacy and depression.

Quality of life and survivorship in patients with low-grade ovarian cancer

ObjectiveHigh-grade (HGOC) and low-grade ovarian carcinoma (LGOC) are distinct malignancies with different biological features, treatment paradigms, and life expectancies. However, differences in quality of life (QOL), sleep, and depressive symptoms have not been examined by grade, and neither have inflammatory profiles associated with these symptoms. We aim to characterize QOL and biomarkers by OC grade. MethodsParticipants included patients with HGOC (N = 578) or LGOC (N = 85). Participants completed baseline assessments of psychosocial factors prior to primary surgery or neoadjuvant chemotherapy and contributed saliva for cortisol and blood for interleukin-6 (IL-6) quantification. Samples were collected intraoperatively to quantify tumor cortisol. General linear models were used to examine differences in biological and psychological variables by grade. ResultsAt baseline, patients with LGOC reported less depression (p = 0.018) and sleep disturbances (p = 0.014), but no significant difference in depressive mood (p = 0.11) or QOL (p = 0.51) compared to patients with HGOC, adjusting for age and disease stage. There were trends towards lower tumor cortisol levels (p = 0.078) in LGOC compared to HGOC. One-year post-diagnosis, we found a significant improvement in QOL and fatigue, and a decrease in vegetative depression and IL-6 levels irrespective of grade. ConclusionsWe present the first characterization of psychosocial experiences of patients with LGOC. Despite having a better disease prognosis, patients with LGOC were just as likely to have mood disturbances as those with HGOC. There was a trend towards differences in tumor cortisol by grade. Our findings highlight the need to address well-being in patients with both low- and high-grade ovarian malignancies.

Effect of increased systemic oxygen delivery on postoperative outcomes and quality of life in elderly undergoing major abdominal surgery: A randomised controlled trial.

Studies comparing the intentional increase in oxygen delivery and normal oxygen delivery during general anaesthesia in elderly patients undergoing major abdominal surgery are limited and have reported contradictory findings. Therefore, the study aimed to evaluate the effect of intraoperative increase in systemic oxygen delivery on postoperative outcomes and quality of life in elderly patients undergoing major abdominal surgery. This randomised, blinded, parallel-arm, pragmatic clinical trial included elderly patients of >60 years of age undergoing major abdominal surgery. The patients in the intervention arm received noradrenaline or increased fractional inspiration of oxygen to augment central venous oxygen saturation ⩾75%. The primary outcome measure was composite of in-hospital mortality and major organ complications. The secondary outcome measure included comparison of quality of life. A total of 160 patients were assessed for eligibility, and 146 were randomised in the study groups. The mean arterial and central venous oxygen saturation increased and were significantly higher in the intervention arm. The composite primary outcome occurred in 49.31% in the intervention arm and 57.53% in the usual care arm (relative risk; 95% confidence interval: 0.85; 0.63-1.16; absolute risk reduction; 8.22%; p = 0.32). Furthermore, quality of life at the end of three months was similar (0.658 ± 0.19 versus 0.647 ± 0.19; p = 0.771). In conclusion, central venous oxygen saturation-guided increase in systemic oxygen delivery during the intraoperative period of major abdominal surgery in elderly patients did not reduce predefined composite outcome of in-hospital mortality or organ-specific complications.

Playing sport as a central-line carrier: a survey to collect the European pediatric intestinal failure centers' view.

The administration of home parenteral nutrition improves quality of life for patients with intestinal failure, thus fostering their will to actively participate to social activities. Nevertheless, sports participation can be risky for patients with a central venous catheter (CVC). Despite literature thoroughly proving the positive impact of sports on motor-psychosocial development, no consistent evidence assessing its role on central-line complications is available. This study aimed to report the European centers' approach to children with intestinal failure on home parenteral nutrition and interested in playing sports, further assessing complications and how to prevent them. A questionnaire focusing on children with intestinal failure regarding physical activity was circulated to 20 centers. Questions assessed the centers' policy for CVC management, the sports-related recommendations for patients on home parenteral nutrition and complication rates. Sixteen (80%) centers filled in the questionnaire. Twelve centers reported not to have a standardized formal protocol for catheter care during sports. All centers encouraged patients to perform mild/moderate exercise, whereas high-contact sports were allowed by one center only. Specific dressings were suggested to protect the vascular access device, especially for water sports. Only one sports-related complication (rupture) was reported. This survey emphasizes that sports should not be restricted in patients with intestinal failure and represents a blueprint for sports-related recommendations for these patients. Prospective studies assessing complication rates are advisable to ensure an improved access to sports for these patients.

A Systematic Review of Comparative Effectiveness of Interventions for Low Anterior Resection Syndrome: Impacts on Bowel Function and Quality of Life.

Low anterior resection syndrome (LARS) is a common complication following sphincter-preserving surgical resection for rectal cancer, characterized by symptoms such as fecal incontinence, urgency, and altered bowel habits, which significantly affect patients' quality of life. This cluster of symptoms not only limits their day-to-day physical activity but also has a debilitating effect on their emotional and mental well-being, undermining their integration and overall psychological health. This systematic review aimed to evaluate the effectiveness of invasive and non-invasive interventions for LARS, including pelvic floor rehabilitation, transanal irrigation, and various surgical options such as sacral neuromodulation and stoma formation, either as part of primary surgery or as a definitive treatment option for refractory cases. We systematically searched relevant databases for studies published in the last decade, focusing on adult patients diagnosed with LARS post-low anterior resection (LAR), with outcomes assessed through bowel function and quality of life metrics. The review identified six studies that met our eligibility criteria; a pooled cohort of 794 patients was identified, with sample sizes ranging from 37 to 430 participants. Our analysis revealed that pelvic floor rehabilitation significantly improves bowel function and quality of life in patients with LARS; yet, the optimal management approach remains unclear due to variability in patient responses. These findings highlight the inherent complexity and heterogeneity of LARS management, underscoring the necessity for multifaceted and individualized treatment strategies. Although pelvic floor rehabilitation shows promise, especially among motivated patients, its long-term sustainability remains uncertain. Surgical options are typically reserved for severe cases and carry significant risks and psychological impacts. For patients identified as being at high risk for LARS, treatment options must be considered and discussed at an earlier phase of their care. Our review concludes with the need for a tailored, patient-centered approach to managing LARS, highlighting the importance of ongoing research to fill existing evidence gaps. There is a need for translational research across various treatment modalities, comparing their effects, cost-effectiveness, implementation strategies, and the consequent effects on patients' quality of life and mental health.

Optic Neuritis and its Prevalence in Immunocompromised Patients: A Review Article

Optic neuritis is an inflammation that affects the optic nerve, causing vision loss, eye pain, and changes in color perception. The condition can be associated with autoimmune diseases such as multiple sclerosis (MS) or infections, especially in immunocompromised individuals such as HIV/AIDS patients or those undergoing chemotherapy. In these individuals, optic neuritis usually results from opportunistic infections like toxoplasmosis and syphilis, complicating diagnosis and treatment. In immunocompetent patients, optic neuritis may indicate autoimmune diseases like MS or neuromyelitis optica (NMO), with better prognoses when treated early with corticosteroids. However, in immunocompromised individuals, the prognosis tends to be worse due to underlying infections and a limited response to immunosuppressive treatment. The management of optic neuritis involves anti-inflammatory therapies and, in cases of infections, specific antimicrobials. Continuous clinical and visual follow-up is also crucial. Studies suggest that clinical outcomes vary depending on the etiology and the patient's immune status, highlighting the need for personalized therapeutic strategies. Early diagnosis is critical to improving vision and quality of life for patients.

Restorative Treatments for Cervical Spinal Cord Injury, a Narrative Review.

A narrative review. To summarize relevant data from representative studies investigating upper limb restorative therapies for cervical spinal cord injury. Cervical spinal cord injury (SCI) is a debilitating condition resulting in tetraplegia, lifelong disability, and reduced quality of life. Given the dependence of all activities on hand function, patients with tetraplegia rank regaining hand function as one of their highest priorities. Recovery from cervical SCI is heterogeneous and often incomplete; currently, various novel therapies are under investigation to improve neurological function and eventually better quality of life in patients with tetraplegia. In this article, a narrative literature review was performed to identify treatment options targeting the restoration of function in patients with cervical SCI. Studies were included from available literature based on the availability of clinical data and whether they are applicable to restoration of arm and hand function in patients with cervical SCI. We describe relevant studies including indications and outcomes with a focus on arm and hand function. Different treatment modalities described include nerve transfers, tendon transfers, spinal cord stimulation, functional electrical stimulation, non-invasive brain stimulation, brain-machine interfaces and neuroprosthetics, stem cell therapy, and immunotherapy. As the authors' institution leads one of the largest clinical trials on nerve transfers for cervical SCI, we also describe how patients undergoing nerve transfers are managed and followed at our center. While complete recovery from cervical spinal cord injury may not be possible, novel therapies aimed at the restoration of upper limb motor function have made significant progress toward the realization of complete recovery.

Cost-effectiveness of an online supervised group physical and mental health rehabilitation programme for adults with post-COVID-19 condition after hospitalisation for COVID-19: the REGAIN RCT

BackgroundFollowing the COVID-19 pandemic, millions of people continue to experience ongoing physical and mental health sequelae after recovery from acute infection. There is currently no specific treatment for the diverse symptoms associated with post-COVID-19 condition. Physical and mental health rehabilitation may help improve quality of life in such patients. This study reports the cost-effectiveness of a programme of physical and mental health rehabilitation compared to best practice usual care in people with post-COVID-19 condition who were previously hospitalised.MethodsWe conducted an economic evaluation within a randomised controlled trial from the perspective of the UK national health service (NHS) and personnel social services perspective (PSS). Resource used and health-related quality of life were collected using bespoke questionnaire and the EQ-5D-5 L questionnaire at three, six, and 12 months. Incremental costs and quality adjusted life years accrued over the follow-up period were estimated and reported as the incremental cost-effectiveness ratio. Estimate uncertainty was managed by multiple imputation and bootstrapping cost-effectiveness estimates; and displayed graphically on the cost-effectiveness plane.ResultsOver a 12-month time horizon, incremental costs and QALYs were £305 (95% CI: -123 to 732) and 0.026 (95% CI: -0.005 to 0.052) respectively. The ICER was £11,941 per QALY indicating cost-effective care. Sensitivity analyses supported the base case findings. The probability of the intervention being cost-effective at a £30,000 per QALY willingness-to-pay threshold was 84%.ConclusionThe within-trial economic evaluation suggested that people with post-COVID-19 condition after hospitalisation should be offered a programme of physical and mental health rehabilitation as it likely reflects a cost-effective use of NHS resources. Hospitalisation for COVID-19 has become less commonplace: further evaluation in non-hospitalised patients may be worthwhile.Trial registrationISRCTN registry ISRCTN11466448 23rd November 2020.

Spinal cord stimulation combined with exercise in patients diagnosed with persistent spinal pain syndrome. Study protocol for a randomized control trial.

Administration of spinal cord stimulation to individuals with PSPS-T1/2 may induce supraspinal descending activation. Similarly, exercise is recognized as a fundamental aspect of spinal pain management. Studies have demonstrated its impact on neurophysiological factors, including the release of spinal and supraspinal beta-endorphins, which activate μ-opioid receptors. Therefore, the purpose of this study will be to examine the effect of SCS in combination with lumbo-pelvic stability core training on perceived low back pain, quality of life and disability in PSPS-T2 patients. A double-blind randomized clinical trial (RCT) has been designed. All participants will be randomized from a pre-set sequence. The intervention design has been elaborated from the CONSORT guidelines. This study has been registered at Clinicaltrial.gov (NCT06272539). Sample size was calculated using G Power® Sample size software (University of Düsseldorf). The calculation was based on a moderate effect size of 0.7 (partial η2 = 0.70, α = .05, power = 0.95), resulting in a total of 40 patients. Assuming a 30% dropout rate, 52 participants will be recruited in total. Two sessions per week will be scheduled for 8 weeks with a total of 16 sessions. Each work session will have a duration of 60 minutes. The exercise will be adapted according to the phases based on the results already published, limiting in each phase the degrees of flexion and extension of the spine to avoid the risk of electrode migration. Primary outcomes will be functionality, satisfaction, strength, psychosocial variables, quality of life and pain perception.

A study of oral health and quality of life in patients with dyslipidemia

Objectives: This study analyzed factors influencing oral health and quality of life in patients with dyslipidemia using raw data from the first year (2019) and third year (2021), where the quality of life was assessed using the HINT-8 tool from the 8th National Health and Nutrition Survey data. Methods: Frequency analysis, descriptive statistics, general linear model analysis, and linear regression analysis were performed on the collected data using SPSS program 26.0, and the data of 1,926 participants were analyzed. Results: The mean quality of life (HINT-8) score was 0.78 out of 1.00. Quality of life according to general characteristics, showed significant differences according to gender, age, household income, education level, lifetime smoking status, and lifetime alcohol consumption. In terms of oral health, it significantly differed according to chewing discomfort, speaking discomfort, oral examination history, toothbrushing frequency, toothache history, untreated dental care needs, subjective oral health status and use of oral care products. The predictors of quality of life were gender, household income, education level, lifetime alcohol consumption, chewing discomfort, speaking discomfort, toothache history, and untreated dental care needs. Conclusions: These results confirm that oral health influences the quality of life of patients with dyslipidemia and are expected to provide basic data for research on improving oral health and quality of life in these patients.