SUPRACONDYLAR FRACTURES IN CHILDREN: A SYSTEMATIC REVIEW OF TREATMENT OPTIONS.

OBJECTIVE: To compare the outcomes of surgical stabilization of pediatric supracondylar humeral fractures with the use of crossed Kirschner wires versus divergent lateral pinning wires. METHODS: This is a systematic review with meta-analysis carried out by searching the MEDLINE/PubMed, Science Direct and Scielo databases. In these, the search for journals was carried out between January and August 2023, where 695 studies were found. To assess the quality of the studies, the Jadad and the MINORS scales were used.. The selection and reading of relevant articles were carried out by the researchers and 11 studies met the selection criteria. RESULTS: From the 11 selected studies, 963 patients who met the criteria for the surgical treatment of these fractures were grouped. After the statistical analysis, we found that the ulnar nerve injury had a higher incidence when the crossed-K wire technique was used; and the lateral fixation is safer for the ulnar nerve. CONCLUSION: Both fixation techniques determine good functional results. However, fixation with lateral Kirschner wires proves to be safer considering the risk of iatrogenic injury to the ulnar nerve. Crossed-K wire fixation is more effective in terms of stability and maintenance of fracture reduction. Level of Evidence II, Systematic Review of Level II or Level I Studies with discrepant results.

Objetivo: Comparar os desfechos da estabilização cirúrgica das fraturas supracondilianas do úmero pediátricas com o uso de fios de Kirschner cruzados versus fios laterais divergentes. Métodos: Trata-se de uma Revisão Sistemática com metanálise realizada pela pesquisa nas bases de dados MEDLINE/PubMed, Science Direct e Scielo. Nessas, a busca dos periódicos foi realizada entre janeiro e agosto de 2023, e foram encontrados 695 estudos. Para a avaliação da sua qualidade, foram utilizadas a escala de Jadad e a escala MINORS. A seleção e a leitura dos artigos pertinentes foram realizadas pelos pesquisadores e 11 estudos preencheram os critérios de escolha. Resultados: Dos estudos selecionados, agrupamos 963 pacientes que preenchiam os critérios para o tratamento cirúrgico das fraturas. Após a análise estatística, observamos que maior incidência de lesão do nervo ulnar quando foi utilizada a técnica de pinagem cruzada; e a fixação lateral demonstrou ser mais segura para tal. Conclusão: Ambas as técnicas de fixação determinam bons resultados funcionais. Entretanto, a fixação com fios de Kirschner laterais demonstra ser mais segura, considerando o risco de lesão iatrogênica do nervo ulnar. A fixação com fios cruzados é mais eficaz, levando em conta a estabilidade e a manutenção da redução das fraturas. Nível de evidência II, Revisão sistemática de Estudos de Nível II ou Nível I com resultados discrepantes.

Dorsal Preservation Rhinoplasty Using a Ferreira-Nakamura Spare Roof Technique B Highlighting the Low Septal Cartilage Strip.

Dorsal preservation rhinoplasty techniques can be surface or foundation techniques and respect the philosophy of preserving the osteocartilaginous nasal vault. A spare roof technique (SRT) aims to preserve the upper lateral cartilages through surface techniques. In tension noses with considerable caudal septum deviations, the septal can be repositioned after a low strip of septal cartilage is removed, and the SRT-B is used to reduce the osteocartilaginous hump. This inclusion of the low septal cartilage strip in the SRT-B rhinoplasty is termed as SRT-B3 and builds upon the previously reported philosophy advocated in SRT-A and SRT-B. Correction of moderate deviations of the nasal axis and/or the caudal septum can be addressed with this modification.

Biochemical characterization of an esterase from Thermobifida fusca YX with acetyl xylan esterase activity.

BACKGROUND: Esterases (EC 3.1.1.X) are enzymes that catalyze the hydrolysis ester bonds. These enzymes have large potential for diverse applications in fine industries, particularly in pharmaceuticals, cosmetics, and bioethanol production. METHODS AND RESULTS: In this study, a gene encoding an esterase from Thermobifida fusca YX (TfEst) was successfully cloned, and its product was overexpressed in Escherichia coli and purified using affinity chromatography. The TfEst kinetic assay revealed catalytic efficiencies of 0.58 s-1 mM-1, 1.09 s-1 mM-1, and 0.062 s-1 mM-1 against p-Nitrophenyl acetate, p-Nitrophenyl butyrate, and 1-naphthyl acetate substrates, respectively. Furthermore, TfEst also exhibited activity in a pH range from 6.0 to 10.0, with maximum activity at pH 8.0. The enzyme demonstrated a half-life of 20 min at 70 °C. Notably, TfEst displayed acetyl xylan esterase activity as evidenced by the acetylated xylan assay. The structural prediction of TfEst using AlphaFold indicated that has an α/ß-hydrolase fold, which is consistent with other esterases. CONCLUSIONS: The enzyme stability over a broad pH range and its activity at elevated temperatures make it an appealing candidate for industrial processes. Overall, TfEst emerges as a promising enzymatic tool with significant implications for the advancement of biotechnology and biofuels industries.

Healthcare Students' Perceptions About Approaching Spirituality in Their Training and Patient Care: Online, Cross-Sectional Survey.

Objective: Recent scientific literature points out that religiosity and spirituality play a relevant role in many aspects of life, including health issues. We aimed to evaluate the healthcare students' perceptions about approaching spirituality in their training and patient care in Brazilian universities. Methods: A cross-sectional observational study was conducted following the STROBE guidelines. Through an anonymous online survey, adult healthcare students from two universities in the city of Pelotas (Brazil) answered a questionnaire about their perceptions on approaching spirituality in their training and patient care. Chi-squared tests were performed, and P ≤ .05 was considered statistically significant. Results: A total of 163 students were included in the analysis. Most believed that spirituality is important for their training (74.8%) and patient care (84%). However, a minority had had contact with the theme of spirituality during their training (48.5%) or had experienced a situation in which the spiritual aspects of a patient were addressed (47.2%). The students from the private university had more contact with the theme of spirituality in healthcare during their training. Nursing students had significantly more contact with the theme of spirituality in healthcare (P = .008) and had experienced more situations in which the spiritual aspects of a patient were addressed (P = .031) than other students. Conclusion: Most students believed that the theme of spirituality in healthcare is important for their training and patient care. However, they still had insufficient contact with it during their education. More studies with greater statistical power are needed to better understand this situation globally.

Medial Patellofemoral Ligament Reconstruction Using the Medial Third of the Patellar Tendon: Camanho's Technique.

The reconstruction of the medial patellofemoral ligament (MPFL) is an essential procedure in the surgical treatment of patellar instability. The medial third of the patellar tendon is a good graft option for this reconstruction, maintaining the insertion of the graft in the patella, with no need for hardware for patellar fixation. The objective of this article is to describe the MPFL reconstruction technique with the patellar tendon graft.

Influence of the Different Maturation Conditions of Cocoa Beans on the Chemical Profile of Craft Chocolates.

Cocoa beans (Theobroma cacao L.) can be used for craft chocolate production, which arouses consumer interest due to their perceived better quality. This study aimed to evaluate the chemical profile of 80% artisanal chocolate samples produced with cocoa beans subjected to different maturation conditions. In the first maturation process, beans were matured under no-oxygen conditions, and in the second, the toasted beans were matured in oak barrels. The volatile compounds of the chocolate samples were extracted by the solid-phase microextraction method in headspace mode and analyzed by gas chromatography/mass spectrometer. The non-volatile compounds were extracted with methanol and analyzed through paper spray mass spectrometry. Overall, 35 volatile compounds belonging to different chemical classes (acids, alcohols, aldehydes, ketones, esters, and pyrazines) were identified, such as propanoic acid and butane-2,3-diol. In addition, 37 non-volatile compounds, such as procyanidin A pentoside and soyasaponin B, were listed. Tannins, flavonoids, and phenylpropanoids were the main chemical classes observed, varying between the two samples analyzed. Therefore, it was possible to verify that maturation conditions affected the metabolomic profile of the 80% artisanal chocolate samples, being able to influence the sensory characteristics and bioactive compounds profile. Given these results, the sensory evaluation of these chocolates is suggested as the next step.

Self-help mobile messaging intervention for depression among older adults in resource-limited settings: a randomized controlled trial.

Scalable solutions to treat depression in older adults in low-resourced settings are urgently needed. The PRODIGITAL-D pragmatic, single-blind, two-arm, individually randomized controlled trial assessed the effectiveness of a mobile messaging psychosocial intervention in improving depressive symptomatology among older adults in socioeconomically deprived areas of Guarulhos, Brazil. Older adults (aged 60+ years) registered with 24 primary care clinics and identified with depressive symptomatology (9-item Patient Health Questionnaire (PHQ-9) scores ≥ 10) received the 6-week Viva Vida intervention based on psychoeducation and behavioral activation (n = 298) or a single message (n = 305). No health professional support was offered. The primary outcome was improvement from depressive symptomatology (PHQ-9 < 10) at 3 months. Of the 603 participants enrolled (mean age = 65.1 years; 451 (74.8%) women), 527 (87.4%) completed the follow-up assessment. In the intervention arm, 109 of 257 (42.4%) participants had an improved depressive symptomatology, compared with 87 of 270 (32.2%) participants in the control arm (adjusted odds ratio = 1.57; 95% confidence interval = 1.07-2.29; P = 0.019). No severe adverse events related to trial participation were observed. These results demonstrate the usefulness of a digital messaging psychosocial intervention in the short-term improvement from depressive symptomatology that can potentially be integrated into primary care programs for treating older adults with depression. Brazilian Registry of Clinical Trials registration: ReBEC ( RBR-4c94dtn ).

ß-1,3-Glucan recognition by Acanthamoeba castellanii as a putative mechanism of amoeba-fungal interactions.

In this study, we conducted an in-depth analysis to characterize potential Acanthamoeba castellanii (Ac) proteins capable of recognizing fungal ß-1,3-glucans. Ac specifically anchors curdlan or laminarin, indicating the presence of surface ß-1,3-glucan-binding molecules. Using optical tweezers, strong adhesion of laminarin- or curdlan-coated beads to Ac was observed, highlighting their adhesive properties compared to controls (characteristic time τ of 46.9 and 43.9 s, respectively). Furthermore, Histoplasma capsulatum (Hc) G217B, possessing a ß-1,3-glucan outer layer, showed significant adhesion to Ac compared to a Hc G186 strain with an α-1,3-glucan outer layer (τ of 5.3 s vs τ 83.6 s). The addition of soluble ß-1,3-glucan substantially inhibited this adhesion, indicating the involvement of ß-1,3-glucan recognition. Biotinylated ß-1,3-glucan-binding proteins from Ac exhibited higher binding to Hc G217B, suggesting distinct recognition mechanisms for laminarin and curdlan, akin to macrophages. These observations hinted at the ß-1,3-glucan recognition pathway's role in fungal entrance and survival within phagocytes, supported by decreased fungal viability upon laminarin or curdlan addition in both phagocytes. Proteomic analysis identified several Ac proteins capable of binding ß-1,3-glucans, including those with lectin/glucanase superfamily domains, carbohydrate-binding domains, and glycosyl transferase and glycosyl hydrolase domains. Notably, some identified proteins were overexpressed upon curdlan/laminarin challenge and also demonstrated high affinity to ß-1,3-glucans. These findings underscore the complexity of binding via ß-1,3-glucan and suggest the existence of alternative fungal recognition pathways in Ac.IMPORTANCEAcanthamoeba castellanii (Ac) and macrophages both exhibit the remarkable ability to phagocytose various extracellular microorganisms in their respective environments. While substantial knowledge exists on this phenomenon for macrophages, the understanding of Ac's phagocytic mechanisms remains elusive. Recently, our group identified mannose-binding receptors on the surface of Ac that exhibit the capacity to bind/recognize fungi. However, the process was not entirely inhibited by soluble mannose, suggesting the possibility of other interactions. Herein, we describe the mechanism of ß-1,3-glucan binding by A. castellanii and its role in fungal phagocytosis and survival within trophozoites, also using macrophages as a model for comparison, as they possess a well-established mechanism involving the Dectin-1 receptor for ß-1,3-glucan recognition. These shed light on a potential parallel evolution of pathways involved in the recognition of fungal surface polysaccharides.

Plant-based diets benefit aerobic performance and do not compromise strength/power performance: a systematic review and meta-analysis.

Plant-based diets have emerged as athletic performance enhancers for various types of exercise. Therefore, the present study evaluated the effectiveness of plant-based diets on aerobic and strength/power performances, as well as on BMI of physically active individuals. This systematic review and meta-analysis was conducted and reported according to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. A systematic search of electronic databases, including PubMed, Web of Science and SPORTDiscus, was performed. On the basis of the search and inclusion criteria, four and six studies evaluating the effects of plant-based diets on aerobic and strength/power performances in humans were, respectively, included in the systematic review and meta-analysis. Plant-based diets had a moderate but positive effect on aerobic performance (0·55; 95 % CI 0·29, 0·81) and no effect on strength/power performance (-0·30; 95 % CI -0·67, 0·07). The altogether analyses of both aerobic and strength/power exercises revealed that athletic performance was unchanged (0·01; 95 % CI -0·21, 0·22) in athletes who adopted plant-based diets. However, a small negative effect on BMI (-0·27; 95 % CI -0·40, -0·15) was induced by these diets. The results indicate that plant-based diets have the potential to exclusively assist aerobic performance. On the other hand, these diets do not jeopardise strength/power performance. Overall, the predicted effects of plant-based diets on physical performance are impactless, even though the BMI of their adherents is reduced.

Vascular Growth Factor Inhibition with Bevacizumab Improves Cardiac Electrical Alterations and Fibrosis in Experimental Acute Chagas Disease.

Chagas disease (CD) caused by Trypanosoma cruzi is a neglected illness and a major reason for cardiomyopathy in endemic areas. The existing therapy generally involves trypanocidal agents and therapies that control cardiac alterations. However, there is no treatment for the progressive cardiac remodeling that is characterized by inflammation, microvasculopathy and extensive fibrosis. Thus, the search for new therapeutic strategies aiming to inhibit the progression of cardiac injury and failure is necessary. Vascular Endothelial Growth Factor A (VEGF-A) is the most potent regulator of vasculogenesis and angiogenesis and has been implicated in inducing exacerbated angiogenesis and fibrosis in chronic inflammatory diseases. Since cardiac microvasculopathy in CD is also characterized by exacerbated angiogenesis, we investigated the effect of inhibition of the VEGF signaling pathway using a monoclonal antibody (bevacizumab) on cardiac remodeling and function. Swiss Webster mice were infected with Y strain, and cardiac morphological and molecular analyses were performed. We found that bevacizumab significantly increased survival, reduced inflammation, improved cardiac electrical function, diminished angiogenesis, decreased myofibroblasts in cardiac tissue and restored collagen levels. This work shows that VEGF is involved in cardiac microvasculopathy and fibrosis in CD and the inhibition of this factor could be a potential therapeutic strategy for CD.

The prevalence of risk for hearing impairment in newborns with congenital syphilis in a newborn hearing screening program (NHS).

Objective: To study the prevalence of risk for hearing impairment in neonates with congenital syphilis in a newborn hearing screening program. Study design: The study design is retrospective, documentary, and is cross-sectional. The sample consisted of newborns who were born between January 2019 and December 2021 and who underwent neonatal hearing screening in a public maternity hospital. Demographic data and the presence and specification of risk indicators for hearing impairment (RIHL) were collected. In retest cases, the results and the final score were also collected. For data analysis, the Kruskal-Wallis and Conover-Iman post-hoc tests were used, comparing the groups that passed and failed the hearing screening that had RIHL, using a significance level of p of <0.5. Results: Among the RIHL observed in the sample, prematurity was more frequent in newborns who passed the screening (55.26%) than in those who failed the test (45.67%). Congenital syphilis was the ninth most frequent RIHL (8.04%) among the newborns who passed the test and the 15th factor (3.03%), with the highest occurrence in those who failed the hearing screening. When comparing the two groups (pass and fail), we found significant differences (p < 0.05) between them. Conclusion: Congenital syphilis was the ninth risk indicator for the most common hearing impairment and, in isolation, did not present a risk for failure in neonatal hearing screening. Notably, congenital syphilis can cause late hearing loss during child development. Thus, there is an indication of audiological monitoring of these neonates.

A conservative full-mouth ceramic rehabilitation for a severely worn dentition.

There is a constantly growing prevalence of tooth wear in dentistry. The present case report describes a rehabilitation through ceramic restorations of a severely worn dentition based on a conservative intervention, adequate restorative material selection, and adhesive bonding strategies. A 36-year-old patient with a mainly esthetic complaint presented with signs of tooth wear caused by erosion and attrition. Preparations were performed guided by the diagnostic planning. The full-mouth rehabilitation, combined with the correction of the vertical dimension of occlusion, was split into quadrants, and lithium disilicate partial restorations were fabricated. The proposed rehabilitation was based on the maximal preservation of the remaining tooth structure and the adequate selection of restorative materials and adhesive bonding strategies.

Fractal analysis is a useful tool for evaluating prostate tissue remodeling caused by ethanol consumption and androgen therapy.

Alcohol has been widely consumed for centuries and is linked to the aggravation of diseases. Several studies have shown that excessive consumption of ethanol results in morphophysiological changes in the male reproductive system. One of the effects of ethanol is the decrease in testosterone concentration and hormonal therapies are an alternative to minimize the changes resulting from chronic alcoholism. Qualitative studies were commonly carried out to evaluate the male histopathological alterations resulting from ethanol consumption, being necessary quantitative and non-subjective techniques. This study analyzes the importance of fractal analysis as a useful tool to identify and quantify tissue remodeling in rats submitted to ethanol consumption and hormone therapy with testosterone. Prostate of animals submitted to chronic ethanol consumption showed tissue disorganization, which was confirmed by an increasing of fractal dimension. Regarding the prostatic stroma, collagen fractal dimension and quantification revealed lower values in animals that were only submitted to androgen therapy. Thus, we can conclude that the fractal analysis was a useful tool to quantify tissue changes caused by ethanol consumption and androgen therapy.

WEDGE FRAGMENT VARIATIONS OF TIBIAL SHAFT FRACTURES WITH INTRAMEDULLARY NAILING.

Introduction: Tibial shaft fracture is the most common long-bone fracture, and the standard treatment is intramedullary (IM) nail fixation. Regardless of the development of this technique pseudoarthrosis remains prevalent. Objectives: Evaluate the correlation between wedge fragment size and displacement, displacement of the main fragments of the 42B2 type, and pseudoarthrosis incidence. Methods: We retrospectively assessed all patients with 42B2 type fracture treated with IM nailing between January, 2015 and December, 2019. Six radiographic parameters were defined for preoperative radiographs in the anteroposterior (AP) and lateral views. Another six parameters were defined for postoperative radiographs at three, six, and 12 months. The Radiographic Union Score for Tibial Fractures score was used to assess bone healing. Results: Of 355 patients with tibial shaft fractures, 51 were included in the study. There were 41 (82.0%) male patients, with a mean age of 36.7 years, 37 (72.5%) had open fractures, and 28 (54.9%) had associated injuries. After statistical analysis, the factors that correlated significantly with nonunion were wedge height > 18 mm, preoperative translational displacement of the fracture in the AP view > 18 mm, and final distance of the wedge in relation to its original anatomical position after IM nailing > 5 mm. Conclusion: Risk factors for nonunion related to the wedge and42B2 fracture are wedge height > 18 mm, initial translation in the AP view of the fracture > 18 mm, and distance > 5 mm of the wedge from its anatomical position after IM nailing. Evidence level III; Retrospective comparative study .

Introdução: A fratura da diáfise da tíbia é a fratura mais comum dentre os ossos longos, sendo o tratamento padrão a fixação com haste intramedular (HIM). Independentemente do desenvolvimento da técnica cirúrgica, a pseudoartrose continua prevalente. Objetivo: Avaliar a associação entre o tamanho e o desvio da cunha, os desvios dos fragmentos principais do tipo 42B2 e a incidência de pseudoartrose. Métodos: Avaliamos, retrospectivamente, todos os pacientes com fraturas tipo 42B2 tratados com hastes intramedulares entre janeiro de 2015 e dezembro de 2019. Seis parâmetros radiográficos foram definidos para as radiografias pré-operatórias nas incidências anteroposterior (AP) e perfil. Outros seis parâmetros foram definidos para as radiografias pós-operatórias em 3, 6 e 12 meses de acompanhamento pós-operatório. O Escore Radiográfico de União para as Fraturas da Tíbia (RUST) foi o instrumento usado para avaliar a consolidação óssea. Resultados: Dos 355 pacientes com fraturas da diáfise da tíbia, 51 foram incluídos no estudo. Os pacientes incluídos foram 41 (82,0%) do sexo masculino, com idade média de 36,7 anos, 37 (72,5%) com fraturas expostas e 28 (54,9%) com lesões associadas. Após análise estatística, os fatores que se correlacionaram significativamente com a não consolidação foram a altura da cunha > 18 mm, o deslocamento translacional pré-operatório da fratura na incidência AP > 18 mm e a distância final da cunha em relação à sua posição anatômica original após a cravação do MI > 5 mm. Conclusão: Os fatores de risco para a pseudartrose relacionada com a fratura em cunha e42B2 são a altura da cunha > 18 mm, a translação inicial na vista AP da fratura > 18 mm e a distância > 5 mm da cunha em relação à sua posição anatómica após a fixação IM. Nível de evidência III; estudo comparativo retrospectivo. Nível de evidência III; Estudo retrospectivo comparativo .

Relationship between sleep problems and headaches among adolescents: Pelotas 2004 Birth cohort.

Objective: To investigate the cross-sectional association between sleep problems (the exposure) and headaches (the outcome) among 15-year-olds from the Pelotas 2004 Birth Cohort, a population-based study in the south of Brazil. Method: The occurrence of headaches was obtained through the question: "Do you usually suffer headaches?" and the ICHD-3 criteria were used to classify as: tension-type headache, headache with characteristics of migraine with or without aura, or other. Regarding sleep, the weekly frequency in the last month of insomnia and bad dreams/nightmares, and self-reported sleep quality were investigated. Unadjusted and adjusted prevalence ratios (PR) with 95% confidence intervals were calculated using Poisson regression with robust variance. Results: A total of 1916 adolescents were analyzed. The prevalence of headaches was 51.6% (69.0% in females and 34.8% in males): 31.8% (39.7% vs. 24.1%) reported tension-type headache; 14.7% (21.9% vs. 7.8%), headaches with characteristics of migraines without aura; 3.6%, headaches with characteristics of migraines with aura; and 1.5% (5.1% vs. 2.3%), other types. Adolescents with insomnia ≥3 times/week presented higher probability of headaches (PR = 1.54; 95%CI 1.23-1.93), compared with those with no problems falling asleep or maintaining sleep. Among those who classified their sleep as poor/very poor, the probability of headaches was 33% higher (PR = 1.33; 95%CI 1.13-1.57) than among those who classified their sleep as very good. Conclusions: Headaches were highly prevalent among the adolescents and were related to sleep problems even after allowing for several confounders.

Is physical performance affected by non-steroidal anti-inflammatory drugs use? A systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis aim to analyze the effects of ingesting non-steroidal anti-inflammatory drugs (NSAIDs) on physical performance, muscle strength, and muscle damage in three different moments: immediately, 24 and 48 h after resistance exercise practice. METHODS: Relevant studies were researched in three databases (PubMed, Web of Science and SPORTDiscus) in April 2023. After excluding duplicates, the decision to include or exclude studies was made by two independent investigators in the following steps: (I) the study title; (II) the study abstract; and (III) the complete study manuscript. The following characteristics were recorded: (I) first author, (II) year of publication, (III) sample size, (IV) method of NSAIDs administration, (V) exercise protocol, and (VI) analyzed variable results. The studies selected were divided into trials that evaluated the effects of NSAIDs ingestion on performance indices of resistance exercise, endurance exercise and resistance training. RESULTS: The meta-analysis, based only on resistance exercises, revealed that both performance and muscle strength were similar between placebo or NSAID treatment immediately and 24 h after resistance exercise practice. An ergolytic effect was found 48 hours after resistance exercise (mean effect size (ES) = -0.42; 95% CI: -0.71, -0.12; p = 0.132), as well as reduced muscle strength (ES = -0.50; 95% CI: -0.83, -0.16; p = 0.072). Additionally, NSAID use did not prevent muscle waste as seen by the unchanged CK plasma concentration at all timetables. CONCLUSION: The data of the present meta-analysis indicate that NSAID use is ineffective in improving resistance performance and muscle strength, as well as exercise recovery. When considering the practical application of using NSAIDs to improve exercise capacity and strength gains, the present data supports that consumption of analgesic drugs as an endurance performance enhancer or as a muscle anabolic must not be recommended.