Search Results (40)

Background: Flexible bronchoscopy (FB) is a widely used diagnostic and therapeutic procedure in patients with pulmonary disease, many of whom are at risk of gas exchange impairment. FB may exacerbate hypoxaemia due to increased airway resistance, alveolar derecruitment, and haemodynamic fluctuations. Objectives: To assess the effectiveness of non-invasive respiratory support strategies in preventing oxygen desaturation and respiratory complications during FB. Methods: A systematic review and meta-analysis were conducted using PubMed and Cochrane databases, covering studies from 2000 to 2024. Inclusion criteria focused on adult patients undergoing FB with any form of non-invasive oxygen support. Twelve high-quality studies were selected, including randomised trials and prospective cohorts. Results: High-flow therapy (HFT) was more effective than conventional oxygen therapy (COT) in maintaining oxygenation and reducing procedure interruptions, especially in patients with moderate hypoxaemia or risk factors such as obesity and obstructive sleep apnoea. Continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) offered superior oxygenation and ventilatory support in patients with more severe respiratory or cardiac compromise. Conclusions: Non-invasive respiratory support should be individualised based on patient risk and procedural complexity. HFT benefits mild-to-moderate cases, while CPAP or NIV is preferable in more severe conditions. Further multicentre randomised trials are needed to establish formal guidelines. Full article

Background. Type 2 diabetes mellitus (T2D) and moderate-to-severe obstructive sleep apnea (OSA) commonly coexist and exacerbate poor glycemic control, systemic inflammation, and diminished quality of life (QoL). Although continuous positive airway pressure (CPAP) therapy has demonstrated metabolic and anti-inflammatory benefits, its real-world impact in Bulgarian outpatient settings—where CPAP costs are borne entirely by patients—has not been characterized. Objectives. To evaluate the effects of six months of CPAP therapy on glycemic control (hemoglobin A₁c [HbA₁c]), systemic inflammation (high-sensitivity C-reactive protein [hsCRP]), body mass index (BMI), lipid profile (low-density lipoprotein [LDL]), QoL (Short Form 36 Physical Component Summary [SF-36 PCS] and Mental Component Summary [SF-36 MCS]), and survival among Bulgarian outpatients with T2D and moderate-to-severe OSA. Methods. In this prospective, multicenter cohort study conducted from January 2022 to July 2023, 142 adults with established T2D and OSA (apnea–hypopnea index [AHI] ≥ 15) were enrolled at three outpatient centers in Bulgaria. Fifty-five patients elected to purchase and use home-based CPAP (intervention group), while 87 declined CPAP—either because of cost or personal preference—and continued standard medical care without CPAP (control group). All participants underwent thorough outpatient evaluations at baseline (month 0) and at six months, including measurement of HbA₁c, hsCRP, BMI, fasting lipid profile (LDL), and patient-reported QoL, via the SF-36 Health Survey. Survival was tracked throughout follow-up. Results. After six months, the CPAP group experienced a significant reduction in HbA₁c from a median of 8.2% (IQR 7.5–9.5%) to 7.7% (6.7–8.7%), p < 0.001, whereas the control group’s HbA₁c decreased modestly from a median of 8.6% (IQR 7.9–9.4%) to 8.3% (7.6–9.1%); p < 0.001), with a significant between-group difference at follow-up (p = 0.005). High-sensitivity CRP in the CPAP arm fell from a median of 2.34 mg/L (IQR 1.81–3.41) to 1.45 mg/L (IQR 1.25–2.20), p < 0.001, while remaining unchanged in controls (p = 0.847). BMI in the CPAP group declined significantly from 28.6 kg/m², IQR 26.6–30.6 to 28 kg/m², IQR 25.6–29.2 (p < 0.001), compared to no significant change in controls (median 28.9 kg/m²), p = 0.599. LDL decreased in the CPAP group from a median of 3.60 mmol/L (IQR 3.03–3.89) to 3.22 mmol/L (IQR 2.68–3.48), p < 0.001, with no significant reduction in controls (p = 0.843). Within the CPAP arm, both SF-36 PCS and SF-36 MCS scores improved significantly from baseline (p < 0.001 for each), although between-group differences at six months did not reach statistical significance (PCS: 48 ± 10 vs. 46 ± 9, p = 0.098; MCS: 46, IQR 40–54 vs. 46, IQR 39–53, p = 0.291). All-cause mortality during follow-up included 2 events in the CPAP group and 11 events in the control group (log-rank p = 0.071). Conclusions. In Bulgarian outpatients with T2D and moderate-to-severe OSA, six months of CPAP therapy significantly improved glycemic control, reduced systemic inflammation, lowered BMI and LDL, and enhanced QoL, with a non-significant trend toward reduced mortality. These findings underscore the importance of integrating CPAP into multidisciplinary management despite financial barriers. Full article

Obstructive sleep apnea (OSA) is a prevalent and heterogeneous sleep disorder associated with significant health and societal burdens. While continuous positive airway pressure (CPAP) remains the gold standard treatment, its limitations in adherence and patient tolerance have highlighted the need for alternative therapies. Positional therapy (PT), which targets apneas that occur predominantly in the supine position, has emerged as a promising option for individuals with positional OSA (POSA). This narrative review synthesizes the current literature on PT, examining its clinical indications, typologies, comparative efficacy with CPAP, oral appliances, and hypoglossal nerve stimulation, as well as data on adherence and barriers to long-term use. Traditional methods such as the tennis ball technique have largely been replaced by modern vibrotactile devices, which demonstrate improved comfort, adherence, and comparable short-term outcomes in selected POSA subjects. While PT remains inferior to CPAP in reducing overall AHI and oxygen desaturation, it performs favorably in terms of mean disease alleviation (MDA) and sleep continuity. Importantly, treatment effectiveness is influenced by both anatomical and non-anatomical traits, underscoring the need for accurate phenotyping and individualized care. PT should be considered within a broader patient-centered model that incorporates preferences, lifestyle, and motivational factors. Further research is needed to validate long-term efficacy, optimize selection criteria, and integrate PT into personalized OSA management strategies. Full article

Background/Objectives: Obstructive sleep apnea is a prevalent, yet often underdiagnosed, condition characterized by recurrent upper airway obstruction during sleep, leading to significant perioperative risks in surgical patients. This systematic review aims to evaluate the incidence and impact of objectively diagnosed obstructive sleep apnea on postoperative outcomes across various surgical specialties—including bariatric, orthopedic, cardiac, and otorhinolaryngologic surgeries—and to assess the effectiveness of preoperative screening and perioperative management strategies. Methods: A comprehensive literature search of PubMed was conducted for studies published between January 2013 and December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies involved adult surgical patients with OSA confirmed by polysomnography or respiratory polygraphy. Studies were assessed for methodological quality using the Oxford Centre for Evidence-Based Medicine Levels of Evidence framework. Results: The findings consistently indicated that obstructive sleep apnea significantly increases the risk of postoperative complications, such as respiratory depression, atrial fibrillation, acute kidney injury, delirium, and prolonged hospital stay. Continuous positive airway pressure therapy demonstrated a protective effect in bariatric and cardiac surgeries, though its effectiveness in orthopedic and otorhinolaryngologic contexts was inconsistent, largely due to adherence variability and limited implementation. Preoperative screening tools such as the STOP-BANG questionnaire were widely used, but their utility depended on integration with confirmatory diagnostics. Conclusions: Obstructive sleep apnea represents a significant, modifiable risk factor in surgical populations. Preoperative identification and risk-adapted perioperative management, including CPAP therapy and multimodal analgesia, may substantially reduce postoperative morbidity. However, further randomized trials and cost-effectiveness studies are needed to optimize care pathways and ensure consistent implementation across surgical disciplines. Full article

Introduction: The introduction of the transdiagnostic approach in psychiatry shifts the focus from discrete diagnoses to shared symptoms across various disorders. The Transdiagnostic Global Impression—Psychopathology (TGI-P) scale is a newly developed tool designed to assess psychiatric symptoms across diagnostic boundaries. It evaluates ten core symptom domains—positive, negative, cognitive, manic, depressive, addiction, anxiety, sleep, hostility, and self-harm—regardless of specific diagnoses. Objective: This study aims to evaluate the efficacy of cariprazine across these ten transdiagnostic symptom domains. Methods: A systematic literature review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed on EMBASE and clinicaltrials.gov. Efficacy measures such as the Positive and Negative Syndrome Scale (PANSS), Montgomery–Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), Hamilton Anxiety Rating Scale (HAM-A), and Columbia-Suicide Severity Rating Scale (C-SSRS) were used to assess cariprazine’s effect on the ten transdiagnostic symptoms. Multilevel random-effects meta-analyses were conducted to evaluate the efficacy of cariprazine versus placebo in alleviating depressive and anxiety symptoms across clinical trials. Results: A total of 30 studies were included in the review. Cariprazine showed therapeutic benefits on positive, negative, manic, and depressive symptoms in specifically designed trials. Preliminary positive effects were seen on anxiety, hostility, and cognitive symptoms across disorders. However, specific trials have not been conducted for anxiety disorders or cognitive impairment. Meta-analyses demonstrated that cariprazine significantly reduces both depressive and anxiety symptoms compared to placebo. Cariprazine significantly improved sleep-related symptoms in both mania and depression trials. Suicidality was evaluated in non-suicidal populations, and no increase was observed. Addiction symptoms were part of the exclusion criteria in the RCTs, so they could not be assessed. Previous reports of cariprazine’s anti-craving and anti-abuse effects come from real-world evidence rather than RCT data. Conclusions: Cariprazine appears to be promising in addressing a broad range of symptom domains across psychiatric conditions. Full article

While morningness (a preference for rising earlier in the day) is associated with positive affect and life satisfaction, eveningness is correlated with negative emotionality, poor sleep, less self-control, and more procrastination. The current study investigated inter-relationships between morningness–eveningness; bedtime, academic, and exercise procrastination; mind wandering; sleep quality; self-control; and depressive symptoms. An online survey including questionnaire measures of these variables was completed by 306 university students (aged 18–51 years; mean = 20.36, SD = 4.001; 34 male). Morningness correlated with more self-control and better sleep quality—eveningness correlated with more bedtime, academic, and exercise procrastination; depressive symptoms; and mind wandering. All forms of procrastination negatively correlated with self-control and sleep quality, and positively correlated with depressive symptoms and mind wandering, although more strongly with spontaneous than deliberate mind wandering. Mediation effects were found—bedtime procrastination (BP) between eveningness and spontaneous mind wandering (MW); spontaneous MW between BP and sleep quality; sleep quality between BP and depressive symptoms; self-control between depressive symptoms and academic procrastination. A path model of these inter-relationships was developed. This study adds to a growing body of research indicating that interventions to reduce bedtime procrastination may bring about improvements in wellbeing and academic achievement. Full article

Objectives: This systematic review aimed to evaluate general dentists and dental specialists’ knowledge regarding obstructive sleep apnea (OSA) diagnosis, referral, risk factors, and treatment. Methods: A systematic search of databases, including Web of Science, PubMed, and ProQuest, was conducted for studies published up to 25 September 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included cross-sectional studies that assessed the knowledge of general dentists or dental specialists. A quality assessment was performed using the Newcastle–Ottawa Quality Assessment Scale. Results: The seven included studies demonstrated varied knowledge levels among respondents regarding polysomnography as the gold standard for diagnosing OSA, with percentages ranging from 40.18% to 90%. While recognition of craniofacial structure as a risk factor for OSA was consistently high, knowledge about body weight as a risk factor varied. Additionally, the understanding of continuous positive airway pressure as the standard treatment showed discrepancies across the studies. Conclusions: Given that some of the included articles displayed a moderate to high risk of bias, the results highlight the varying levels of OSA knowledge among dentists and specialists across the studies. This indicates a potential need for targeted educational programs to improve their understanding and management of OSA. Full article

This feasibility study investigates the relationship between functional food consumption and mental well-being, focusing on natural foods traditionally linked to mental health benefits. This research also examines consumer preferences to identify key characteristics that novel functional foods designed to enhance mental well-being should possess. Additionally, this study lays the groundwork for a clinical trial exploring the effects of a novel functional food on mental health and well-being. Data were collected through an online bilingual survey (Greek/English) from 362 participants across Greece and Cyprus, using an adapted Functional Food Frequency Questionnaire (FFFQ) featuring 30 foods with documented effects on cognitive function and mood regulation. The survey included validated scales measuring mental well-being, health-related quality of life (HRQoL), sleep quality, and food choice motives, along with demographic and anthropometric data. Analysis revealed significant associations between functional food consumption and mental health outcomes, particularly in HRQoL, sleep quality, and body mass index (BMI). Most functional foods consumed were natural and aligned with the Mediterranean dietary pattern, such as fruits, vegetables, nuts, herbal infusions, and honey, all demonstrating positive effects on mental and physical health. Consumer preferences showed a strong inclination toward functional foods that balance sensory appeal with health benefits, including milk-based and plant-based beverages, protein bars, and granola bars. Ingredients like St. John’s wort and Greek mountain tea were identified as potentially beneficial for mental well-being, consistent with their established efficacy in psychological health. A significant majority of participants (66.9%) expressed interest in participating in clinical trials, highlighting the need for further research into the efficacy of functional food components. This study provides a foundation for future clinical trials examining the impact of novel functional food formulations on mental and physical health, addressing the growing consumer demand for products that enhance psychological resilience and well-being. Full article

Background/Objectives: Chronotypes significantly influence sleep quality, daily performance, and overall activity levels. Although there is growing evidence indicating that individuals with a late chronotype are more likely to experience cognitive decline, the specific neural mechanisms that contribute to this risk remain unclear. This study aims to explore the relationship between morning and evening preferences and the volumes of subcortical structures in a young, healthy population. Methods: A total of 123 participants (80 females), aged between 18 and 35 years, were recruited. They underwent MRI scans and completed several self-reported assessments, including the morningness–eveningness scale of the Chronotype Questionnaire (ChQ-ME), the amplitude scale of the Chronotype Questionnaire (ChQ-AM), the Epworth Sleepiness Scale (ESS), and the Pittsburgh Sleep Quality Index (PSQI). Participants were classified into early chronotype (EC) and late chronotype (LC) groups based on their ChQ-ME scores. High-resolution T1-weighted imaging was utilized to analyze the volumes of subcortical structures and hippocampal subfields. Results: The volumetric analysis indicated that the LC group showed significant reductions in the right Caudate (p = 0.03) and the left SR-SL-SM (p = 0.03) compared to the EC group. Additionally, a notable leftward hemispheric laterality of the Subiculum (p = 0.048) was observed in the EC group relative to the LC group. Furthermore, the ChQ-AM revealed significant positive (r = 0.23) and negative (r = −0.19) correlations with the volumes of the left thalamus and right amygdala, respectively. The PSQI demonstrated a significant negative correlation (r = −0.21) with the right SR-SL-SM, while the ESS indicated a significant positive correlation (r = 0.24) with the left SR-SL-SM. Multiple regression analysis indicated that variations in daytime sleepiness are linked to the change of the left SR-SL-SM volume. Conclusions: Overall, the findings suggest that chronotype preferences are associated with the changes in the volumes of subcortical structures and hippocampal subfields and highlight the role of chronotypes in the neural mechanisms of these brain structures. Full article

Background: This scoping review investigates the effectiveness of mindfulness meditation in alleviating sleep disturbances among individuals with mild cognitive impairment (MCI) and Alzheimer’s disease (AD). With the rising prevalence of dementia and its profound impact on cognitive function and quality of life, this review aims to synthesize existing research and identify gaps in the literature. Methods: We systematically searched six electronic databases (CINAHL, Embase, Medline, PsycINFO, PubMed, and Scopus) from 2004 to 2024, yielding 462 potentially relevant articles. Screening was conducted using ASReview, an AI ranking tool, which facilitated the selection of studies. Ultimately, seven studies that met our stringent eligibility criteria were included in the review. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines for reporting. Results: Our findings indicate that mindfulness meditation significantly improves sleep quality, reduces insomnia severity, and enhances overall well-being in this at-risk population. Notably, interventions that combine structured, face-to-face sessions with at-home practice emerged as the most effective. Conclusions: Despite these positive outcomes, methodological limitations, including small sample sizes and reliance on self-reported measures, underscore the need for more rigorous long-term studies. This review highlights the potential of mindfulness meditation as a low-cost, scalable intervention to improve sleep and cognitive health in older adults, paving the way for future research and clinical applications. Full article

Obstructive sleep apnea syndrome (OSAS) is a frequently underdiagnosed sleep disorder marked by recurrent episodes of apnea and/or hypopnea during sleep, primarily resulting from the partial or complete collapse of the upper airway. OSAS significantly affects patients’ health and quality of life. Additionally, it is a recognized risk factor for inducing microsleep episodes during daily activities, particularly in occupations such as professional driving, where sustained attention is critical. The aim of our study was to identify an effective screening test for use in outpatient settings, capable of distinguishing patients with a severe form of OSAS. Patients who test positive with this screening tool would subsequently be prioritized for polysomnographic evaluation in a sleep laboratory. A total of 64 patients who underwent polysomnography (PSG) or polygraphy (PG) examination at our clinic were subsequently examined by USG of the tongue with measurements of tongue base thickness (TBT) and the distance between lingual arteries (DLA) during wakefulness and in a relaxed tongue position. The measurements of TBT and DLA were subsequently correlated with the apnea–hypopnea index (AHI) obtained from PSG or PG. In our cohort of patients diagnosed with severe OSAS, a TBT threshold of ≥65 mm served as an effective cutoff value. A TBT value of ≥65 mm reached an AUC value of 78.1%, sensitivity of 74.4%, specificity of 61.9%, positive predictive value of 80%, negative predictive value of 54.2% and overall accuracy of 70.3%. A DLA value of ≥30 mm in our sample of patients with severe OSAS showed an AUC of 76.5%, sensitivity of 69.8%, specificity of 71.1%, positive predictive value of 83.3%, negative predictive value of 53.6%, and overall accuracy of 70.3%. Tongue USG markers, particularly TBT and DLA measurements during wakefulness and in a relaxed tongue position, show potential as effective screening tools for identifying severe OSAS in European populations. These markers demonstrate improved accuracy over traditional screening questionnaires by reducing the likelihood of false-negative results. Patients with a positive screening should preferably be referred for polysomnography. In this way, patients with a serious illness could receive adequate therapy sooner. Full article

Background: Mandibular advancement devices (MADs) are considered a primary alternative treatment for adults with moderate to severe obstructive sleep apnea (OSA) who are unable to tolerate or do not respond to continuous positive airway pressure (CPAP) therapy, supported by substantial scientific evidence. While a range of designs and materials for MADs are commercially available, there is a lack of clear diagnostic guidelines to assist clinicians in selecting the most appropriate device based on a multidisciplinary evaluation of OSA patients. This narrative review seeks to outline the key characteristics of MADs that clinicians should evaluate during both the diagnostic and treatment phases for patients with OSA. Methods: An extensive search of academic databases was conducted to gather relevant studies that address therapeutic and diagnostic recommendations for the design and titration of MADs. The search was carried out across EMBASE, Scopus, PubMed, and Web of Science up to May 2024. From a total of 1445 identified citations, 1103 remained after duplicate removal. Based on the inclusion criteria, the full text of 202 articles was retrieved, and 70 studies were ultimately included in this review. The extracted data were organized to generate clinical insights, aimed at guiding orthodontists in optimizing diagnostic and decision-making processes for treating OSA patients with MADs. Results: The analysis led to the identification of key clinical questions that can assist orthodontists in enhancing their approach and choosing the appropriate appliance basing on the diagnosis and clinical dento-orofacial characteristics. Conclusions: Bibloc appliances could be preferred over mono-bloc devices due to the possibility of arranging the mandibular advancement according to the patient’s clinical condition and orofacial symptoms. Provisional devices could be used as screening tools to verify the patient’s adherence to the therapy. Regardless of the MAD design, type and programmed advancement, it must be under-lined that the rule of the orthodontist/dental specialist is secondary to the other sleep-medicine specialists (ORL, pulmonologist) and must be related to (1) a preliminary assessment of MAD usage (dental anatomical conditions), (2) testing a diagnostic MAD usable during a sleep examination (PSG or DISE), (3) final treatment with a definitive MAD. Full article

Introduction. This study aimed to investigate the relationship between obstructive sleep apnea (OSA), circadian rhythms, and individual sleep–wake preferences, as measured by chronotype, and to assess the association between circadian clock gene expression and subjective sleep-related variables. Methods: A total of 184 individuals were recruited, underwent polysomnography (PSG), and completed questionnaires including a chronotype questionnaire (CQ), insomnia severity index (ISI), and Epworth sleepiness scale (ESS). Blood samples were collected in the evening before and morning after PSG. Gene expression analysis included BMAL1, CLOCK, PER1, CRY1, NPAS2, and NR1D1. Results: In the OSA group, the subjective amplitude (AM score of CQ) positively correlated with all circadian clock genes in the morning (R ≥ 0.230 and p < 0.05 for each one), while the morningness–eveningness (ME score of CQ) was only associated with the evening BMAL1 level (R = 0.192; p = 0.044). In healthy controls, insomnia severity correlated with evening expression of BMAL1, PER1, and CRY1. Conclusions: The findings highlight the complex interplay between OSA, circadian rhythms, and sleep-related variables, suggesting potential determinants of morning chronotype in OSA and implicating disrupted circadian clock function in subjective feelings of energy throughout the day. Further research is warranted to elucidate underlying mechanisms and guide personalized management strategies. Full article

Background and Objectives: Fibromyalgia syndrome (FMS) is a multifaceted disease with a strong preference for the female sex. It is characterised by chronic widespread pain, sleep–wake disorders, fatigue, cognitive disturbances, and several other somatic symptoms. Materials and Methods: In this prospective observational study, we analysed data regarding 302 patients who were referred to our pain centre for a first clinical assessment evaluation and were then inspected for the physician-based 2016 revision of the ACR diagnostic criteria for FMS, regardless of the final diagnosis previously made by the pain therapist. Results: Among the 280 patients who adhered to the 2016 ACR questionnaire, 20.3% displayed positive criteria for FMS diagnosis. The level of agreement between the FMS discharge diagnosis made by the pain clinician and the ACR 2016 criteria-positivity was moderate (kappa = 0.599, with moderate agreement set at a kappa value of 0.6). Only four patients (1.7%) diagnosed as suffering from FMS at discharge did not satisfy the minimal 2016 ACR diagnostic criteria. Conclusions: This prospective observational study confirmed the diagnostic challenge with FMS, as demonstrated by the moderate grade of agreement between the FMS diagnosis at discharge and the positivity for 2016 ACR criteria. In our opinion, the use of widely accepted diagnostic guidelines should be implemented in clinical scenarios and should become a common language among clinicians who evaluate and treat patients reporting widespread pain and FMS-suggestive symptoms. Further methodologically stronger studies will be necessary to validate our observation. Full article

The cross-sectional study aimed to examine the associations of sleep quality and physical activity with diabetes quality of life in Korean Americans with type 2 diabetes. A total of 119 Korean American adults with type 2 diabetes were recruited from Korean communities in Arizona, USA. The Pittsburgh Sleep Quality Index for sleep quality, the International Physical Activity Questionnaire for physical activity, and the Diabetes Quality of Life (DQOL) for quality of life were assessed. Descriptive statistics, bivariate correlations, and multiple linear regressions were conducted. The mean score of the total DQOL was 1.85 (SD = 0.28). Approximately 70% of those had poor sleep quality and a third showed low physical activity. The findings demonstrated that both sleep quality and low physical activity were independent predictors of overall DQOL scores, indicating that poor sleep quality and low physical activity are associated with reduced Diabetes Quality of Life in this demographic. Specifically, the satisfaction subscale of DQOL showed significant associations with low physical activity levels, suggesting that enhancing physical activity could potentially improve satisfaction within DQOL. Furthermore, the impact subscale was positively related to sleep quality, suggesting that better sleep quality might significantly lower the perceived negative impact of diabetes on daily life. No significant associations were found between sleep quality, physical activity, and the worry subscale of DQOL in the adjusted models. The study indicates that addressing sleep quality and promoting physical activity are essential components of diabetes management strategies aimed at improving the quality of life for Korean Americans with type 2 diabetes. This underlines the need for tailored interventions that consider cultural preferences and individual needs to enhance diabetes outcomes and quality of life in this population. Full article