Vascular Causes Research Articles

Demographic and epidemiological risk factors in patients with acute vestibular neuritis

Vestibular neuritis (VN) is one of the most common peripheral vestibular balance disorder. Demographic and other risk factors associated with VN are insufficiently published. Therefore, the aim of this study is to identify associated risk factors in patients with acute VN. This study evaluated all hospitalized VN cases between 2017-2019. Inclusion criteria was an otoneurologically confirmed diagnosis of acute VN. Patient data was compared with data of the German normal population (Robert Koch Institute, "Gesundheit in Deutschland aktuell"). 168 patients (Ø 59.8 years) were included. Compared with the normal German population, the study population was significantly more likely to have preexisting cardiovascular diseases, and the male patients were significantly more likely to have arterial hypertension. No significant differences were measurable between the study population and the normal population for other secondary diseases. Leukocytosis was present in 23% on admission, and 9% of patients reported a history of VZV or HSV-1 disease. Etiology and pathogenesis of VN are poorly understood. Inflammatory and vascular causes are discussed. In this study, patients had increased prevalence of cardiovascular disease compared with the normal population, but the study population had a higher average age. Currently, it is unclear what significance nonspecific elevated leukocyte values could have as a possible sign of VN triggered by an infection. Since the number of inpatient cases with VN is rising, prospective studies should be performed to get a better understanding of the pathogenesis of the disease.

The Relationship Between Periodontal Disease (PD) and Recurrent Vascular Events in Ischemic Stroke/Transient Ischemic Attack (TIA) Patients: A Hospital-Based Cohort Study

Background In this cohort study, the association between periodontal disease (PD) andrecurrent vascular events was determined among the subjectswithischemic stroke/transient ischemic attack (TIA), and the extent and severity of periodontal disease were estimated among these subjects. Methods This prospective, longitudinal, hospital-based cohort study included 153 individuals who had a stroke or TIA. They were divided into two groups: high periodontal disease (HPD) (N=55, mean age: 59.40±12.21) and low periodontal disease (LPD) (N=98, mean age: 53.03±12.82). Clinical attachment loss (CAL) and probing pocket depth (PPD) were used to measure the severity of the periodontal disease. TOAST criteria were used to determine the ischemic stroke etiology, and the NIH Stroke Scale (NIHSS) was used to determine theischemic stroke severity. A follow-up survey found that vascular incidents recurred. Results HPD individualsexhibited a higher median NIHSS (eight) than LPD patients (seven) in a subset of stroke population (N=23). Thirty-eight cardiovascular events occurred in the first three months after enrollment, including 23 strokes and seven TIAs, and five myocardial infarctions(MIs). There were three deaths from vascular causes. There was a non-significant association between PD and composite vascular events (HR 1.06, 95% CI, 1.03 to 1.09, p=0.71). Compound vascular events were not related to severe HPD (HR 1.31, 95 % CI 0.54 to 3.16, p=0.07). Conclusion In stroke/TIA patients, there is no link between high periodontal disease and recurrent vascular episodes. The proportions of stroke subtypes were not substantially differentbetween HPDand LPD.

Dexmedetomidine infusion in the management of acute ischemic stroke undergoing endovascular recanalization: a retrospective observational study

Background and purposeStroke is defined as a sudden onset of a neurological deficit caused by an acute focal injury to the central nervous system due to a vascular cause. It represents the second leading cause of death, the third leading cause of disability worldwide and the primary cause of disability in the elderly. Ischemic strokes are the most common (≈85%), the rest (≈15%) are hemorrhagic strokes, that include cerebral and subarachnoid. One of the commonly procedure used in patients with large-vessel occlusion is intra-arterial (IA) recanalization. Moderate conscious sedation (CS) and general anesthesia (GA) with intubation are the most used anesthesia techniques for patients with acute ischemic stroke undergoing endovascular recanalization.MethodsIn this retrospective observational study, we analyzed data of registry before and after we have changed our sedation protocol from remifentanil/propofol (P/R group) infusion in total intravenous anesthesia (TIVA) to intravenous infusion of dexmedetomidine alone (D group). The primary endpoint was to determine the rate of conversion from CS to GA for each group. The secondary outcomes were the incidence of complications (bradycardia, hypotension, tachycardia, hypertension).Results and conclusion12 patients in P/R group need the conversion from CS to GA while only 5 patients in D group. There weren't significant differences between the 2 groups respect to heart rate (HR), peripheral oxygen saturation (SpO2) during the procedure, for the good neurological outcome (mRS score < 3, p > .05) and NIHSS score after 48 h (p > .05). There were several organizational and economic advantages with the conscious sedation procedure, such as reduction of occupation time in the operating room and reduction of postoperative Intensive Care Unit (ICU) stay.

Vertebral Artery Dissection Following Anterior Cervical Decompression and Artificial Disc Replacement

Vertebral artery dissection (VAD) is a rare vascular cause of acute stroke. Although VAD may be classified as spontaneous or traumatic, it is increasingly recognized that trivial mechanical stress typically precipitates this potentially dangerous condition. Herein, we report a rare case of VAD and acute stroke following anterior cervical decompression and artificial disc replacement (ADR). To our knowledge, there have been no other cases of acute vertebrobasilar stroke caused by VAD following anterior cervical decompression and ADR. This case highlights that, although rare, acute vertebrobasilar stroke may occur after the anterior cervical approach.

INVICTUS: Vitamin K antagonists remain the standard of care for rheumatic heart disease-associated atrial fibrillation.

Rheumatic heart disease (RHD) remains a major healthcare problem. Atrial fibrillation (AF) is the commonest sustained arrhythmia in RHD, leading to major complications and morbidity in a young population. Currently, anticoagulation with vitamin K antagonists (VKA) is the mainstay of therapy for the prevention of thromboembolic adverse events. However, effective use of VKA remains challenging, especially in developing countries, showing a need for alternatives. Novel oral anticoagulants (NOACs), including rivaroxaban, could form a safe and effective alternative to fulfil a major unmet need in RHD patients with AF. However, until recently, no data was available for the use rivaroxaban in patients with rheumatic heart disease associated AF. Study and Results: The INVICTUS trial was conducted to assess efficacy and safety of once-daily rivaroxaban compared with a dose-adjusted VKA for the prevention of cardiovascular events in patients with RHD-associated AF. A total of 4531 patients (age: 50.5±14.6years) were followed for 3.1±1.2years in which 560/2292 patients in the rivaroxaban group and 446/2273 in the VKA group had a primary-outcome adverse event. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the VKA group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P <0.001). A higher incidence of death occurred in the rivaroxaban group than in the VKA group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted. The INVICTUS trial shows that Rivaroxaban is inferior to Vitamin K-antagonists in patients with RHD associated AF as VKA therapy led to a lower rate of ischemic and lower mortality due to vascular causes, without significantly increasing the rate of major bleeding. The results support current guidelines, which recommend vitamin K antagonist therapy for the prevention of stroke in patients with RHD associated AF.

Vertigo from a neurological point of view

Vertigo has many different causal disorders, ranging from general dizziness and orthostatic regulation disorders to attacks of rotary vertigo. A targeted anamnesis and clinical examination can be used to narrow down the differential diagnosis. Questions about the type of dizziness, the duration and accompanying symptoms must be clarified. Various methods are used for differentiation in clinical examinations: the head impulse test, testing of the vertical divergence of the eyes, positioning maneuvers and the ability to stand and walk. But diagnostic imaging is also important. MRI can be used to confirm or rule out vascular causes (cerebral infarction or minor bleeding) and inflammatory lesions. Because the most serious misdiagnosis of dizziness is overlooking a stroke.

Status Epilepticus in an Internal Medicine Ward: Different Patients Therefore Distinct Approaches.

Background Status epilepticus (SE) is a medical condition that bestows substantial morbidity and mortality. Literature is scarce regarding SE in elderly patients, particularly in the context of internal medicine wards. Aim To characterize SE patients admitted to an internal medicine ward, identify potential outcome predictors and differences between young and elderly, as well asconvulsive (CSE) and non-convulsive SE (NCSE) patients. Methods We enrolled 135 consecutive patients in an observational, retrospective cohort study. We established elderly patients as more than 64 years old and defined worse prognosis as a modified Rankin Scale (mRS)>4. Results The SE population was 73% elderly, and 75% presented with NCSE, mainly metabolic, idiopathic, or vascular SE. The intra-hospital mortality was 51%, and 62% had an mRS>4 at discharge. NCSE and electroencephalogram (EEG) with paroxysmal activity at discharge were predictive of a worse prognosis. Elderly patients had increased disability at admission, most had NCSE (81%), and the SE etiology differed with more idiopathic and vascular causes. In the elderly, mortality was increased, as was the number of patients with mRS>4 at discharge. NCSE patients had the more neurodegenerative disease (30%) and presented predominantly with vascular and anoxic causes. Morbidity and mortality were also increased in the NCSE group. There was no difference in the antiepileptic drugs used or in the percentage of patients achieving an EEG with no paroxysmal activity between the subpopulations. Conclusion SE in elderly patients should be addressed distinctly. Current approaches based on the strategies used for standard CSE have shown little or no efficacy overall.

Can Assessment of Rheological Properties of Whole Blood and Plasma Be Useful in the Diagnosis of Tinnitus? A Pilot Study.

Tinnitus is a sensation of ringing in the ears in the absence of any physical source in the environment. Between 9-35% of adults experience some form of tinnitus. Common causes of tinnitus include noise, head injury, ototoxic substances, as well as disorders of blood and blood vessels. Vascular causes include: head-neck tumours, turbulent blood flow, problems with blood supply and inner ear cell damage. The aspect of rheology in terms of tinnitus has not been described yet. In the present study, which comprised 12 patients aged 30 to 74 years presenting with tinnitus, rheological properties of whole blood and plasma were assessed. All the subjects underwent audiological and neurological evaluation. The Quemada model was used to describe the variability of red blood cell shape, as well as their tendency to form aggregates. On the basis of the experimental study, statistically different results of haemorheological measurements were observed in the evaluated group in comparison to a reference group.

Single internal carotid cavernous sinus aneurysm presented as bilateral painful ophthalmoplegia: a case report

BackgroundIntracranial aneurysms are the most common vascular cause of painful ophthalmoplegia. Symptoms include retro-orbital pain, diplopia, ophthalmoplegia, trigeminal neuropathy, or a combination of these. Most single aneurysms cause ipsilateral, painful ophthalmoplegia. Here, we report the first, to our knowledge, case of bilateral painful ophthalmoplegia possibly caused by an aneurysm of the cavernous segment of the left internal carotid artery.Case presentationA 62-year-old male patient presented with headache and bilateral ptosis. Laboratory tests revealed hypopituitary function. Computerized tomography angiography showed a large aneurysm in the cavernous sinus segment of the left internal carotid artery. Aneurysm embolization was performed in the Nerve Interventional Department. Four months after surgery, the patient's symptoms returned to normal.ConclusionsThis case suggests that patients with bilateral painful ophthalmoplegia should be screened for aneurysms using computed tomography angiography or magnetic resonance angiography immediately.

Magnetic resonance imaging of disorders with white matter changes in children and adolescents: a pictorial essay.

White matter changes are seen in a spectrum of disorders in children and adolescents. Understanding their distribution and appearance helps to reach diagnoses in daily radiologic practice. This pictorial essay will outline the magnetic resonance imaging (MRI) appearances of diseases with white matter changes including demyelinating diseases, dysmyelinating disorders/leukodystrophies, infections, autoimmune diseases, vascular causes, mitochondrial disorders and neurocutaneous syndromes, along with a brief overview of clinical aspects of the diseases such as typical age of presentation, etiology, symptoms and signs and treatment options. This article highlights important features in common white matter diseases in children and adolescents.

Trimethoprim-sulfamethoxazole induced aseptic meningitis case report

Drug-induced aseptic meningitis (DIAM) is an uncommon meningitis and trimethoprim with or without sulfamethoxazole is the most involved antibiotic. Although DIAM is easily treated with the discontinuation of the causative drug, the diagnosis is a big challenge for physicians, as it remains a diagnosis of exclusion. Here, we present a case report of trimethoprim-sulfamethoxazole induced aseptic meningitis in a woman with acute osteomyelitis. A 52-year-old woman was admitted to the hospital for septic shock and acute osteomyelitis of the right homerus. She was started on antibiotic therapy with oxacillin and daptomycin, then oxacillin was replaced with cotrimoxazole, due to its excellent tissue penetration, including bone tissue. During cotrimoxazole therapy, the patient developed a fluent aphasia with ideomotor apraxia and muscle hypertonus. Having excluded infectious, epileptic and vascular causes of the acute neurologic syndrome of our patient, given the improvement and full recovery after discontinuation of cotrimoxazole, we hypothesized a DIAM. After discontinuation of cotrimoxazole, in 48 hours the patient had a full recovery. Although DIAM can be easily managed with the withdrawal of the causative drug, it can be difficult to recognize if it is not included in the differential diagnosis. An antimicrobial stewardship program with a strict monitoring of patients by infectious disease specialists is essential, not only to optimize the appropriate use of antimicrobials, but also to improve patient outcomes and reduce the likelihood of adverse events.

Association between hypertension and neurovascular inflammation in both normal-appearing white matter and white matter hyperintensities

The major vascular cause of dementia is cerebral small vessel disease (SVD), including white matter hyperintensities (WMH) amongst others. While the underlying pathology of SVD remains unclear, chronic hypertension and neuroinflammation are recognized as important risk factors for SVD and for the conversion of normal-appearing white matter (NAWM) to WMH. Unfortunately, most studies investigating the role of neuroinflammation in WMH relied on peripheral blood markers, e.g., markers for systemic or vascular inflammation, as a proxy for inflammation in the brain itself. However, it is unknown whether such markers accurately capture inflammatory changes within the cerebral white matter. Therefore, we aimed to comprehensively investigate the impact of hypertension on perivascular- and neuroinflammation in both WMH and NAWM. We conducted high field brain magnetic resonance imaging (MRI), followed by (immuno-)histopathological staining of neuroinflammatory markers on human post-mortem brains of elderly people with a history of hypertension (n = 17) and age-matched normotensive individuals (n = 5). MRI images were co-registered to (immuno-)histopathological data including stainings for microglia and astroglia to assess changes in MRI-based WMH at microscopic resolution. Perivascular inflammation was carefully assessed based on the severity of perivascular astrogliosis of the smallest vessels throughout white matter regions. Hypertension was associated with a larger inflammatory response in both WMH and NAWM. Notably, the presence of close-range perivascular inflammation was twice as common among those with hypertension than in controls both in WMH and NAWM, suggesting that neurovascular inflammation is critical in the etiology of WMH. Moreover, a higher degree of microglial activation was related to a higher burden of WMH. Our results indicate that neuro(vascular)inflammation at the level of the brain itself is involved in the etiology of WMH. Future therapeutic strategies focusing on multitarget interventions including antihypertensive treatment as well as neuroinflammation may ameliorate WMH progression.

A curious case of confusion

A curious case of confusion

OBSERVATIONAL STUDY ON ROLE OF NEUROSONOGRAM IN INTRACRANIAL PATHOLOGIES IN NEONATES AT A TERTIARY CARE CENTER.

ABSTRACT BACKGROUND AND OBJECTIVES: Neonates face a lot of challenges especially based on their gestational age, maternal factors, birth weight at the time of delivery, immediate cry following birth. H ypoxic ischemic encephalopathy and Germinal matrix haemorrhage constitutes major portion of those challenges. To identify varied conditions, we can take help of imaging in form of neurosonogram. METHODS : Neurosonogram was carried out on all n tool including followeonates both as screening and diagnostic up scans. A total of 100 preterm babies with positive findings were included in the study. An analysis was performed over different pathologies including grading of specific condition in requir ed areas. RESULTS: Our study comprising of 100 neonates with brain pathologies showed following results. In our study of 100 neonates, most of the disease burden is by vascular causes (56%), then followed by infective (19%), congenit al (14%), trauma (8%), metabolic (2%) and miscellaneous (2%). 52% of PVL showed associated risk factors. CONCLUSION: In our study 100 preterm babies with suspected brain injuries were studied with ultrasound through anterior fontanelle and mastoid sutures. Neurosonogram can detect various intracranial pathologies on par with CT scan . Transcranial doppler can reflect the cerebral blood volume and perfusion status through RESISTIVE INDEX and abnormal values according to literature are &gt;0.8 and &lt;0.4 and can be noticed in severe HIE and conditions which increases intracranial pressure . Any measure that decreases the vasospasm which decreases RI can eventually prevent the neonate having progression of ischemia and further new infarct. 1

Epidemiology of patients revascularized for peripheral artery disease in France (2016–2019): A retrospective observational cohort study using the French hospital discharge database (PMSI)

There is a lack of up-to-date epidemiological data regarding patients with lower extremity peripheral artery disease (PAD) who underwent lower limb revascularization in France. It appears interesting to provide an estimation of the subset of patients who could benefit from the dual pathway inhibition (DPI: low-dose rivaroxaban 2.5 mg b.i.d and aspirin 100 mg o.d.) indicated for the prevention of atherothrombotic events (AE) after revascularization for PAD, following the results of the VOYAGER-PAD trial. To quantify the number of patients with PAD who annually undergo lower limb revascularization (PAD revascularized population) in France, to identify the proportion of those who could benefit from DPI and to assess the onset of AE in those two populations. Using the French Hospital Discharge Database (PMSI), patients hospitalized for revascularization for PAD (index date) were followed from January 1, 2016 to December 31, 2019. AE (a composite of: acute limb ischemia, major amputation for vascular cause, myocardial infarction, ischemic stroke/TIA, and in-hospital death) as well as comorbidities were identified using ICD-10 codes, medical procedure code, or medication dispensing. Patients eligible to DPI were defined by transposing the inclusion/exclusion criteria of the VOYAGER-PAD trial to the French PAD revascularized population. The unadjusted incidence rate of AE was assessed both populations. During the 4-year study period, a total of 191,758 patients (47,340 patients/y on average) underwent revascularization for PAD. Patients had a mean age of 72 ± 12.2 years at index date and were mainly men (69.3%). The three most frequent comorbidities were diabetes mellitus (35.7%), chronic coronary disease (30.3%), and renal failure (15.8%). A share ranging from 46.6 to 49.5% would have been eligible for DPI after revascularization. In those patients, age, gender and comorbidities distribution were similar to the PAD revascularized population. Cumulative incidence of the first AE at 12, 24 and 36 months were at 33.8%, 43.2% and 50.1% respectively in the overall population, and 25.5%, 32.8%, and 37.7% for the DPI-eligible population. This study provides a comprehensive and contemporary overview of patients treated by revascularization for PAD in our country in the recent years. Adjusted comparative results will allow to compare these occurrences between the different groups of interest.

STUDY ON PREVALENCE OF DIABETES MELLITUS AND ITS RELATION WITH CLINICAL OUTCOME IN ACUTE ISCHEMIC STROKE PATIENTS OF ADULT AGE GROUP IN A TERTIARY CARE HOSPITAL

Introduction:Astroke, or cerebrovascular accident, is dened as an abrupt onset of a neurologic decit that is attributable to a focal vascular cause. Thus, the denition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. Cerebral ischemia is caused by a reduction in the blood ow that lasts longer than several seconds. Aims: To compare the clinical outcome of acute ischemic stroke among non-diabetic and diabetic (well controlled and poorly controlled) patients of adult age group Materials and Methods: The present study was a prospective study. This Study was conducted from March 2019 to August 2020 at Department of NRS Medical College &amp; Hospital, Kolkata. Result: In our study, 100 patients in the study Atrial Fibrillation (risk factor) is absent in 88 and present in are 12 cases comprising 88.0 % and 12.0 % respectively. Conclusion: We found that chronic hyperglycemia is associated with an increased risk for cardiovascular outcomes and all-cause mortality among patients with type 2 diabetes, likely independently from other conventional risk factors.

Facial palsy: diagnostic traps

Peripheral facial palsy is a common, often idiopathic and self-limiting mononeuropathy. However, secondary facial palsies require specific management: they are most often of infectious, vascular or dysimmune causes. The presence of red flags in the history, clinical examination or medical follow-up should alert clinicians. Because of the high incidence of Lyme disease in our region, this etiology deserves special attention. The management is based on general measures (eye protection, rehabilitation) and corticosteroid therapy; antivirals may provide additional benefit.

Exudative Retinal Detachment in Nigerians: Demographics and Causes.

Exudative retinal detachment (ERD) is a rare type of retinal detachment (RD), and information on its causes and presentation in Nigerians and Black Africans is scarce. To report the prevalence, vision at presentation, and causes of ERD in a cohort of RD patients. A prospective, multicentre, hospital-based study. We examined consecutive eyes diagnosed with ERD in ophthalmic patients seen within 1 year in four ophthalmic hospitals in Nigeria. The patients had a complete eye examination, including visual acuity, intraocular pressure measurement, slit lamp examination of the anterior segment, dilated fundus examination, and other ancillary investigations. Statistical analysis was done using SPSS version 22.0. Nine out of 237 patients were diagnosed with ERD, giving a hospital-based prevalence of 3.8% of RDs. The mean age of patients was 45.8 ± 21.6 years (6 months-80 years), male:female = 2:1. ERD was bilateral in one patient and unilateral in eight patients. There was no gender association (P = 0.84), but systemic disease was associated with a risk of ERD (P = 0.001). Five out of 9 (55.6%) patients had an associated systemic disease. The systemic diseases include two patients (40%) who had chronic renal failure, two patients (40%) who had systemic hypertension, and one patient (10%) who had lung cancer. Other ocular causes of ERD include post endophthalmitis, coats disease, and age-related macular degeneration in one eye each. 80 % of eyes were blind at presentation. ERD is a rare form of RD in Nigerians and is associated with systemic diseases. There are inflammatory, neoplastic, vascular, and degenerative causes of ERD. At presentation, most eyes are blind. Early presentation will be beneficial in salvaging vision. Also, awareness of the occurrence and causes of ERD should be created amongst eye care practitioners.

Essentials of Computed Tomography Imaging of Hematuria

Hematuria is defined usually as the presence of blood in the urine, either on voiding or in a catheterized specimen. Hematuria is broadly divided into microscopic and gross hematuria and may be symptomatic or asymptomatic. The causes of hematuria include a very wide spectrum of conditions. However, here, we have filtered the causes causing gross hematuria, including calculus, trauma, tumors, vascular, and miscellaneous causes. Plain X-rays of the kidney, ureter, and bladder; ultrasound; intravenous urography; computed tomography (CT); magnetic resonance imaging; retrograde ureterography and pyelography (RGP); cystoscopy; and ureteroscopy are techniques that are useful for diagnosis. In the past, one or a combination of several techniques was used to evaluate hematuria but recently, advances in CT urography mean that it can be used alone for this task. This article briefly reviews the common causes of gross hematuria in adults and their evaluation by CT-based urography. Gross hematuria is evaluated well with CT scan urography which includes an unenhanced scan, the nephrographic phase, and the excretory phase. Unenhanced scans are routinely performed to evaluate the basic parameters such as the size, shape, position, and outline of the kidneys and calculus disease, which is the most common cause of hematuria. Renal parenchymal diseases including masses are best visualized in the nephrographic phase along with other abdominal organs. Delayed excretory phases including the kidneys, ureters, and bladder are useful for detecting urothelial diseases. CT urography's protocol permits evaluations of hematuria through a single examination.

Efficacy of semaglutide: an evidence-based review

Type 2 diabetes mellitus (T2DM) dominates the chronic non-communicable disease pandemics by its exceptionally rapid expansion into communities all over the world. In many countries diabetes is a socially significant disease. According to the data over the past decade, the number of people with T2DM has more than doubled globally. Equally disturbing is the fact that there are more than 250 million people with undiagnosed T2DM and more than 300 million with prediabetes. For 2045, it was estimated by the International Diabetes Federation that 693 million people will have diabetes. T2DM is a disorder of complex nature that urges further dedicated studies and ingenuity in the search for novel therapeutic approaches and on the pathogenetic links of disease. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in people with T2DM, and diabetes itself confers a substantial independent risk of coronary heart disease, stroke, and death from other vascular causes. The article discusses an urgent challenge of modern healthcare – the role of new class of sugar-lowering drugs (exogenously administered glucagon-like peptide-1 receptor agonists (arGLP-1)) semaglutide in reducing the risk of developing cardiovascular complications. The authors paid attention to the main results of SUSTAIN clinical program and use as initial treatment for patients with T2DM with very high risk indicated in the new European guidelines with a view to get additional advantages in terms of life prognosis.