Search Results (23,994)

Background/Objectives: Cardiovascular diseases (CVDs) frequently limit the feasibility and effectiveness of cancer treatment. However, CVD burden has not been comprehensively described in pancreatic cancer. In our systematic review and meta-analysis, we evaluated the prevalence and incidence of CVDs in pancreatic ductal adenocarcinoma (PDAC). Methods: We conducted the systematic search in PubMed, EMBASE, and CENTRAL on 5 February 2024. Studies reporting the prevalence or incidence of CVDs in PDAC were included. Subgroup analyses were performed based on cancer stage and treatment type. Pooled proportions with the 95% confidence interval (CI) were calculated using a random-effects model. (PROSPERO: CRD42023482295). Results: We included 197 articles. At PDAC diagnosis, non-thrombotic cardiovascular diseases (NT-CVDs) were as prevalent as in the general population: hypertension in 33% (CI: 27–40%), ischemic heart disease in 6% (CI: 3–12%), and heart failure, arrhythmia, and stroke each in 2–3%. Their incidence during treatment remained low (1–10%). Thrombotic events, excluding pulmonary embolism, were present in 11% (CI: 7–15%) at diagnosis, with an incidence of 8–10% regardless of stage or treatment. Pulmonary embolism affected 3% at diagnosis and occurred at a similar rate during treatment. Conclusions: Thromboembolic events are common in PDAC and occur both at diagnosis and during follow-up. Their incidence remains stable across treatment modalities and disease stages, suggesting that the tumor itself is the primary driver of thrombotic risk. The prevalence of NT-CVDs in PDAC is comparable to that in the general population and shows minimal variation across cancer stages or treatment modalities. Full article

Modern healthcare remains structurally and conceptually fragmented, with profound clinical and policy implications. At its root lies an ontological fracture: the prevailing biomedical model reduces patients to discrete biological systems (organs, biomarkers, and symptoms) detached from the psychological, social, and ecological contexts in which health and illness are experienced. This is compounded by epistemological fragmentation, where medical knowledge is compartmentalized into increasingly narrow specialties, limiting holistic understanding. These philosophical divisions manifest in downstream operational, informational, financial, and policy dysfunctions duplicative testing, misaligned incentives, disconnected care pathways, and population health failures. To address these multilevel fractures, we propose a unified architecture grounded in three interlocking components. First, the Precision and Personalized Population Health (P3H) framework offers a principle-based realignment toward care that is integrated, personalized, proactive, and population wide. P3H addresses the conceptual shortcomings of fragmented care by focusing on the full human trajectory across time, systems, and determinants. Second, General Purpose Technologies including artificial intelligence, biosensors, mobile diagnostics, and multimodal data systems enable the operationalization of whole-person care at scale, especially in low-resource settings. Third, the AI-WHOLE policy framework (Alignment, Integration, Workflow, Holism, Outcomes, Learning, and Equity) provides governance principles to guide ethical, equitable, and context-specific implementation. We argue that this triadic blueprint is particularly critical for Global South nations, where the lack of legacy infrastructure offers an opportunity for leapfrogging toward integrated, intelligent systems of care. Early models illustrate how policy-aligned, technology-enabled care rooted in whole-person principles can yield improvements in continuity, cost-efficiency, and chronic disease outcomes. This manuscript offers a systems-level strategy to overcome fragmentation and reimagine healthcare delivery, not only by refining clinical tools, but by redefining what it means to care for the human being in full. Full article

The two-spotted spider mite, Tetranychus urticae Koch, is a major arthropod pest that causes substantial economic losses in strawberry and other crops worldwide. Its management often relies on intensive acaricide applications, which may negatively affect human health, the environment, and beneficial organisms. Biological control using predatory mites has been widely adopted under greenhouse conditions, and its success is influenced by several factors, particularly temperature, T. urticae population density, and predator release methods. During the 2023–2024 season, this study evaluated the effects of ambient greenhouse temperature on the population dynamics of T. urticae and on the efficacy of two phytoseiid predators, Phytoseiulus persimilis (Athias-Henriot) and Amblyseius swirskii (Athias-Henriot). The predators were released individually and in combination on strawberry plants. The efficacy of single and combined releases was assessed under three temperature ranges: 25–27 °C, 28–30 °C, and 30–32 °C. The results showed that the mean number of motile T. urticae per plant increased from 21.7 to 95.66, while the mean number per leaf increased from 2.33 to 6.05 during the experimental period. The mean greenhouse temperature ranged from 23.83 °C to 31.88 °C. Temperature was strongly and positively correlated with T. urticae population density, with higher temperatures generally accelerating development and population growth. Both predator species, whether released individually or in combination, significantly reduced T. urticae populations compared with untreated control plants. Amblyseius swirskii demonstrated greater efficacy than P. persimilis at temperatures above 28 °C. However, the combined release consistently achieved the highest level of mite suppression across all temperature ranges. Significantly greater population reduction was observed at approximately 25–26 °C compared with single-species releases, while maximum effectiveness occurred at temperatures above 28 °C. These findings indicate that the combined use of P. persimilis and A. swirskii represents an effective biological control strategy for managing T. urticae in greenhouse-grown strawberries, particularly under elevated and fluctuating temperature conditions. Full article

Background/Objectives: High-grade endometrial cancer (EC) is associated with poor outcomes, particularly in populations with a high burden of aggressive histologies. There is a critical need for accessible biomarkers to improve prognostic assessment and guide clinical management. Methods: In this study, we evaluated the feasibility and clinical relevance of monitoring circulating tumor DNA (ctDNA) by tracking somatic TP53 mutations using a routine next-generation sequencing (NGS) assay already implemented in diagnostic practice. Results: Among 21 patients with high-grade EC carrying TP53 mutations in the primary tumor, ctDNA was detectable in over 75% during follow-up. Baseline ctDNA detection strongly correlated with advanced disease: none of the FIGO I tumors were ctDNA-positive at diagnosis, whereas 73% of FIGO > I tumors showed detectable ctDNA. Patients with ctDNA detected at baseline had significantly poorer outcomes, with a 2-year recurrence-free survival (RFS) of 18% versus 60% and a 2-year overall survival (OS) of 40% versus 78%. Longitudinal monitoring revealed that postoperative persistence or reappearance of ctDNA was consistently associated with disease progression, often preceding radiological relapse. Conversely, early ctDNA clearance (at M4–M8) was associated with more favorable clinical trajectories. Conclusions: These findings highlight the potential role of ctDNA as a real-time molecular marker of minimal residual disease and tumor dynamics. Our results demonstrate that TP53-based ctDNA tracking using a standard NGS panel is feasible, sensitive, and clinically informative in high-grade EC. This approach may contribute to improving prognostic stratification and enabling more personalized, responsive clinical management, particularly in high-risk populations. Full article

Background/Objectives: Retinoblastoma represents the most common intraocular malignancy in childhood; however, the clinical applicability of mitomycin C (MMC) is restricted by dose-dependent ocular toxicity. Consequently, the development of pharmacological strategies that sensitize tumor cells to MMC while allowing dose reduction remains an unmet therapeutic objective. In this context, quercetin, a bioactive flavonoid with pleiotropic anticancer properties, has emerged as a potential chemosensitizing agent. Methods: Human retinoblastoma cell lines Y79 and WERI-Rb1 were exposed to MMC and quercetin, administered either individually or in fixed-ratio combinations. Cytotoxic responses were quantified through dose–response modeling and IC₅₀ determination following 24 and 48 h of treatment. Drug–drug interactions were quantitatively characterized using the Chou–Talalay combination index (CI) approach and isobologram analysis. Cell cycle distribution was assessed by propidium iodide (PI)-based flow cytometric analysis to evaluate treatment-associated alterations in cell cycle progression. Apoptotic cell death was assessed by Annexin V-FITC/PI flow cytometry, while transcriptional modulation of genes associated with apoptosis, cell cycle regulation, and oxidative stress (BAX, BCL-2, TP53, CASP3, CDKN1A, and HMOX1) was evaluated by qRT-PCR. Modulation of tumor-supportive signaling was examined by measuring VEGF and IL-6 secretion. Translational relevance was further investigated using a three-dimensional (3D) tumor spheroid model, and the functional contribution of reactive oxygen species (ROS) was interrogated through N-acetyl-L-cysteine (NAC) rescue experiments. Results: Quercetin significantly enhanced the cytotoxic activity of MMC in both retinoblastoma cell lines, with CI values below 1 across IC₅₀–IC₉₀ effect levels, indicating a synergistic pharmacological interaction. PI–FACS analysis revealed that combined MMC and quercetin treatment induced a pronounced accumulation of cells in the G2/M phase, consistent with cell cycle arrest, with a more marked effect observed in Y79 cells compared with WERI-Rb1 cells. Combination treatment resulted in a pronounced increase in apoptotic cell populations compared with single-agent exposure and triggered a coordinated pro-apoptotic transcriptional response, characterized by increased expression of BAX, TP53, CASP3, CDKN1A, and HMOX1, alongside suppression of BCL-2 and a marked shift in the BAX/BCL-2 ratio. Concurrently, VEGF and IL-6 secretion were significantly reduced, reflecting attenuation of pro-angiogenic and pro-inflammatory signaling. Notably, synergistic cytotoxicity was maintained in 3D tumor spheroids, where combined treatment induced spheroid shrinkage, architectural disruption, and reduced viability. NAC pretreatment diminished ROS accumulation and partially restored cell viability, indicating that oxidative stress contributes to, but does not solely account for, the observed synergistic cytotoxic effect. Conclusions: Collectively, these findings indicate that quercetin appears to function as an effective chemosensitizing adjuvant to MMC in retinoblastoma models, through transcriptional changes consistent with p53-associated apoptotic signaling at the transcriptional level, G2/M cell cycle arrest, and partial involvement of ROS-related cellular stress responses, along with suppression of tumor-supportive signaling pathways. The preservation of synergistic activity in 3D tumor spheroids supports the potential preclinical relevance of this combination. However, these findings are based on transcriptional and phenotypic analyses and should be interpreted as hypothesis-generating, requiring further validation through protein-level and in vivo studies before translational application. Full article

Background/Objectives: Secondary prevention after a first acute myocardial infarction (AMI) is crucial to reduce complications and improve long-term outcomes. Persistent gender inequalities in cardiovascular care suggest differences in post-AMI healthcare pathways between men and women. Understanding these trajectories could guide post-discharge clinical management, secondary prevention, and follow-up after acute myocardial infarction. This study aimed to describe healthcare pathways following a first AMI and explore gender inequalities within these trajectories. Methods: We conducted an observational, population-based study using real-world data (RWD) from the CARhES cohort. A total of 4298 individuals discharged alive after a first AMI between 2017 and 2022 were included. Healthcare trajectories during the 90 days following discharge were reconstructed across primary and specialised care, emergency services, and hospital admissions, and stratified by sex and the occurrence of clinical outcomes. Results: Post-AMI care pathways were highly heterogeneous. Although general practitioners often served as the first point of contact, most trajectories began in emergency departments. Patients with clinical outcomes showed higher healthcare utilisation. Women accessed primary care more frequently, whereas men showed greater use of specialised services and higher readmission rates, patterns that may reflect differences in follow-up strategies and clinical management during the early post-discharge period. Despite this variability, overall trajectories showed no significant sex-based differences. Conclusions: Post-AMI care pathways are complex and variable, with gender differences in patterns of service use. Women more often accessed scheduled care, while men relied more on emergency services. These findings highlight the need for gender-sensitive post-discharge follow-up to guide clinicians in secondary prevention strategies for AMI. Full article

Postural balance is a foundational component of human motor behavior, yet it remains conceptually ambiguous and methodologically heterogeneous across the clinical, educational, and sport sciences. This narrative review aims to provide an integrative framework that clarifies key concepts (postural control vs. postural balance), synthesizes the main sensorimotor and biomechanical mechanisms underpinning balance, and organizes current assessment approaches and functional implications across populations. Narrative literature synthesis was conducted to integrate evidence covering multisensory integration and sensory reweighting, central neural control (spinal, brainstem, cerebellar, and cortical contributions), neuromuscular and biomechanical strategies (e.g., ankle/hip/stepping), and cognitive influences (e.g., dual-task effects). We further summarize commonly used instrumental outcomes derived from force-platform center-of-pressure metrics and widely adopted clinical and functional balance tests, highlighting their typical applications and limitations across the lifespan including pediatric, general adults, older adults, and athletic populations. This review proposes a closed-loop, systems-based model in which postural balance is conceptualized as an emergent functional outcome arising from distributed postural control processes shaped by task, environmental, and individual constraints. In conclusion, integrating mechanistic understanding with population-specific assessment enhances interpretability and supports more precise, context-sensitive balance evaluation and intervention in both health and performance settings. Full article

Background/Objectives: We aimed to identify eating habits associated with hepatic fat fraction (HFF) and assess effect modification by an established genetic variant for fatty liver disease, PNPLA3 rs738409, among 381 general-risk adolescents. Methods: Dietary intake was assessed using the Block Kids Food Frequency Questionnaire and HFF was measured via magnetic resonance imaging (MRI) at age ~16 years. We first characterized naturally occurring dietary patterns using principal component analysis followed by reduced-rank regression with HFF as the response variable to identify a dietary pattern that is both relevant to the population and associated with HFF. Next, we investigated associations of the dietary pattern with HFF using linear regression models that accounted for maternal gestational diabetes, education, and prenatal smoking and child sex, age, Tanner stage, and BMI. Finally, we tested for a dietary pattern and PNPLA3 rs738409 interaction and stratified by genotype if P-interaction < 0.05. Results: The participants were 16.7 ± 1.2 years (range: 12.6–19.6 years). Half were female (50.4%) and 52.0% identified as non-Hispanic White. The dietary pattern of interest was composed of vegetables, fruit, nuts and seeds, oatmeal, sports bars, crackers and sandwiches, and beef, and was inversely associated with HFF (−0.48 [95% CI: −0.81, −0.16]). Stratified analyses revealed the strongest inverse association observed between the diet pattern score and HFF in the high-risk-variant (GG) group (−2.19 [−4.35, −0.03]), followed by the intermediate-risk (CG) group (−0.43 [−0.77, −0.10]), but not the low-risk (CC) group (−0.32 [−0.77, 0.13]). Conclusions: A diet high in vegetables, fruit, nuts and seeds, oatmeal, sports bars, crackers and sandwiches, and beef—potentially capturing an active, on-the-go lifestyle—is associated with lower HFF during adolescence, especially among individuals at genetic risk. Full article

Perilla frutescens(L.) Britt. (P. frutescens) is an important medicinal and aromatic plant, whose leaf color and chemotype strongly influence its medicinal quality and economic value. All the previously discovered perillene (PL)-type P. frutescens are double-sided green, and whether the PL-type trait is tightly linked with the green-leaf trait in genetics remains to be clarified. This study aimed to address this question and attempt to create purple-leaf PL-type germplasm through perillaldehyde (PA) × PL hybridization. Three parallel experiments were conducted using purple-leaf PA-type P. frutescens as male parents and green-leaf PL-type P. frutescens as female parents. Chemotypes were identified by gas chromatography (GC). Association analyses between leaf color and chemotype were performed in segregating F₂ populations. Genes involved in leaf color formation and PL biosynthesis were mapped onto the published Hoko-3 reference genome to provide genomic evidence for the genetic relationship between the two traits. All F₁ individuals were uniformly PA-type. The three F₂ populations exhibited distinct leaf color–chemotype association patterns: Z01 (n = 118) showed a strong association (Fisher’s exact p = 9.13 × 10⁻¹⁰; φ = 0.564), Z02 (n = 117) showed no detectable association (p = 0.9; φ = 0.012), and Z03 (n = 88) showed a moderate association (p = 0.00669; φ = 0.289). Importantly, purple-leaf PL-type recombinants were obtained in F₂ populations and stably maintained through subsequent generations (F₃–F₅), demonstrating that the PL-type trait is not tightly linked with the green-leaf trait in P. frutescens. Genomic mapping genes related to leaf color and PL biosynthesis are distributed across multiple chromosomes and usually present as multiple loci, which is consistent with the pattern of incomplete linkage. The PL-type trait is recessive and not genetically tightly linked to the green-leaf traits in P. frutescens. The successful creation of a purple-leaf PL-type germplasm breaks the historical phenotypic constraint and provides a novel material for further dissection of the molecular mechanisms regulating secondary metabolism and organ coloration in P. frutescens. Full article

Background: Since sedentary habits have become a growing global public health concern, the promotion of physical activity (PA) from early childhood could help children live healthy lifestyles. The aim of this systematic review was to analyze the level of compliance with PA in preschoolers in relation to the reference guidelines. Method: A systematic review of relevant articles was carried out using four databases (PubMed, ProQuest, SCOPUS, and FECYT (Web of Sciences, CCC, CIDW, KJD, MEDLINE, RSCI, and SCIELO)) until 14 May 2025. The methodological assessment process was performed by using an adapted version of the MINORS assessment criteria. Results: A total of 623 studies were initially found and 23 were included in the qualitative synthesis. Conclusions: The results revealed that the average in most contexts usually ranges between 30% and 65% of the child population. Due to different operational criteria, compliance was generally higher when PA was assessed separately using single-behavior guidelines as opposed to when integrated 24 h movement frameworks were used. However, these results should be considered with caution because establishing the level of adherence to PA guidelines is difficult due to the different outcomes and guidelines used to compare the level of children’s PA. In future research, it is important to establish common baseline criteria (specifying more specific ages, common questionnaires, and criteria for calculating PA quantity and intensity) to facilitate more objective and reliable comparisons between studies. This systematic review is important because it highlights the need for healthy educational habits from the first years of a person’s life. Full article

Growth differentiation factor 15 (GDF15) is a stress-responsive cytokine strongly associated with aging, multimorbidity, and cardiovascular disease. Although prior studies have established its prognostic value in high-risk populations, its role in the general population remains less defined. The aim of this study was to determine if there is an association between plasma GDF15 levels, heart disease and mortality in a representative population-based cohort. We analyzed 1532 participants (mean age 55 years; 54.6% women) with available baseline plasma GDF15 concentrations. Participants were stratified according to an optimal cutoff of 1081 pg/mL, derived from ROC curve analysis for mortality. Associations with prevalent heart disease were assessed using multivariable logistic regression models adjusted for cardiovascular risk factors and NT-proBNP. Mortality was analyzed using Cox proportional hazards models, with model performance evaluated by C-index and time-dependent ROC curves. Individuals with GDF15 > 1081 pg/mL were older and exhibited a more adverse cardiometabolic profile with higher prevalence of comorbidities. Elevated GDF15 was independently associated with ischemic cardiomyopathy (OR 3.34, 95% CI: 1.38–8.11), particularly in men (OR 4.26, 95% CI: 1.40–12.96), but not in women. No independent associations were observed with arrhythmias, valvulopathy, or heart failure after adjustment for NT-proBNP. During a median follow-up of 6.2 years, 51 deaths occurred. Elevated GDF15 independently predicted all-cause mortality (HR 2.47, 95% CI: 1.19–5.13), though the effect was attenuated after adjustment for NT-proBNP. GDF15 improved model discrimination (ΔC-index = +0.01; LRT p = 0.011) and showed robust time-dependent predictive ability, with AUCs of 0.76, 0.82, and 0.85 at 2, 4, and 6 years, respectively. In this population-based cohort, elevated GDF15 identified individuals with an adverse health profile, was independently associated with ischemic cardiomyopathy in men, and predicted mortality. Although its incremental predictive value over NT-proBNP was modest, GDF15 could provide complementary biological information and may enhance multimarker strategies for cardiovascular risk stratification in the general population. Full article

Metaheuristic algorithms have become indispensable for solving high-dimensional, non-convex, and constrained optimization problems arising in science and engineering. However, no single method can simultaneously provide strong global exploration, accurate local exploitation, and robust performance across diverse problem classes. This paper proposes JADEFLO, a new hybrid nature-inspired metaheuristic that couples Adaptive Differential Evolution with Optional External Archive (JADE) and Frilled Lizard Optimization (FLO) in a two-stage search framework. In the first stage, JADE drives global exploration using p-best mutation, an external archive, and adaptive control of the mutation factor and crossover rate to maintain population diversity. In the second stage, FLO performs intensive local refinement by mimicking the hunting and tree-climbing behaviors of frilled lizards through dedicated exploration and exploitation moves. The resulting algorithm has linear time complexity with respect to the population size, dimensionality, and number of iterations. JADEFLO is evaluated on the IEEE CEC 2022 single-objective benchmark suite (F1–F12) and three constrained engineering design problems (Pressure Vessel, tension/compression spring, and speed reducer), using 30 independent runs and comparisons against more than thirty state-of-the-art metaheuristics, including GA, PSO, DE variants, GWO, WOA, MFO, and FLO. The results show that JADEFLO attains the best overall rank on the CEC functions, delivers faster convergence and higher accuracy on most test cases, and matches or improves the best-known designs with markedly reduced variance. These findings indicate that JADEFLO is a promising general-purpose optimizer and a flexible foundation for future extensions to multi-objective and large-scale optimization. Full article

Background/Objectives: Poincaré plot analysis represents a nonlinear approach to heart rate variability (HRV) assessment, but the physiological meaning of several derived parameters remains unclear. This study aimed to evaluate associations between selected Poincaré plot-derived parameters, conventional HRV indices, and cardiovascular autonomic reflex tests in a real-world clinical population. Methods: This observational study included 269 adult patients referred for evaluation of suspected autonomic dysfunction. All participants underwent short-term resting ECG, cardiovascular autonomic reflex testing, and 24 h Holter ECG monitoring. Poincaré plot-derived parameters were analyzed in relation to short- and long-term HRV measures using the Spearman correlation with false discovery rate correction, and group comparisons were performed based on reflex test results. Results: Several Poincaré plot-derived parameters showed strong correlations with long-term HRV indices. VLI and LA were primarily associated with global and long-term autonomic variability, whereas VAI and SA were more closely related to parasympathetic modulation. Associations with short-term HRV were generally weak. Lower values of selected parameters were observed in patients with abnormal parasympathetic reflex tests, while no significant differences were found in relation to orthostatic hypotension. Conclusions: Poincaré plot-derived parameters capture complementary aspects of autonomic regulation beyond conventional HRV indices and may enhance autonomic phenotyping in clinical settings. Full article

Background: The construct of psychopathy encompasses the manifestation of psychopathic traits in subclinical populations related to sensation seeking. This study aims to examine the relationship between these two constructs and to determine whether differences exist as a function of age and gender. Method: A total of 345 participants aged between 18 and 40 years (M = 24.72, SD = 5.60) were recruited and completed the Levenson Self-Report Psychopathy Scale (LSRP) and the Brief Sensation Seeking Scale (BSS). Results: Positive and significant correlations were found between the three psychopathy factors and the disinhibition subscale. Specifically, the interpersonal and behavioural factors were positively associated with disinhibition, whereas the affective factor showed a negative association. Gender differences were observed, with men scoring higher on the behavioural factor of psychopathy, disinhibition and sensation seeking. Conclusions: The findings confirm the relationship between psychopathy and sensation seeking in a subclinical population and contribute to a better understanding of their potential implications. Full article

Introduction: Acute gallstone pancreatitis is a potentially severe disease associated with morbidity and mortality. Cholecystectomy is recommended to prevent recurrence. During pregnancy, surgical management is challenging, and in the post-partum period small gallstones may spontaneously disappear. Ursodeoxycholic acid (UDCA) is safe during the last 6 months of pregnancy and effective in dissolving small gallstones, although recurrence after discontinuation is common in the general population. The optimal strategy to prevent recurrent acute pancreatitis during and after pregnancy remains unclear. Methods: Between 2002 and 2017 we prospectively treated women with acute pancreatitis related to small gallstones (≤1 cm in diameter) during the last six months of pregnancy or within the first post-partum year who declined surgery. Patients received UDCA until stone dissolution. A patent cystic duct was confirmed by ultrasonography; after delivery, a non-contrast CT scan was performed to exclude calcified stones. Patients were followed for at least 6 years or until recurrence, with serial clinical and ultrasonographic examinations. Results: UDCA was associated with complete dissolution in 13/14 women within a mean ± SD of 7.77 + 3.1 months. One patient experienced gallstone recurrence 75 months after treatment discontinuation. Two patients developed recurrent pancreatitis (at 1 and 88 months respectively). Twelve women remained free of recurrence over a mean ± SD follow-up of 79.5 + 9.4 months. Discussion: This is an observational study in which we document that UDCA may facilitate the spontaneous dissolution of small gallstones after delivery and can be considered a bridge strategy during pregnancy when surgery is not feasible. However, this study cannot determine the additional benefit of UDCA over the spontaneous disappearance of stones observed after delivery because we had no control group. Cholecystectomy remains the standard of care post-partum. Medical therapy should be reserved for women who refuse surgery and it requires close ultrasonographic surveillance. The main strength of this study is the prospective long-term follow-up of a consecutive cohort with a rare condition. Limitations include the small sample size, missing control group and single-center design. Full article