Do functionality, strength, vascularization, inflammatory and biopsychosocial status improve by biopsychosocial model-based exercise in SSc?

OBJECTIVES: This study aimed to investigation of the effects of the Cognitive Exercise Therapy Approach (Bilissel Egzersiz Terapi Yaklasimi-BETY), a supervised biopsychosocial model-based exercise intervention, on functionality, muscle strength, vascularization, anti-inflammatory and biopsychosocial status in Systemic Sclerosis (SSc) patients. METHODS: Thirty-seven SSc patients were included. Twenty of them were recruited into the study group (SG) undergoing BETY group exercise sessions three times a week for three months and 17 were in the control group (CG) following a home exercise program. Assessments tools were the Modified Rodnan Skin Score (mRSS), Scleroderma Health Assessment Questionnaire (SHAQ), Modified Hand Mobility in Scleroderma (mHAMIS), Duruoz Hand Index (DHI), Six Minute Walk Test (6MWT), skeletal muscle strength measurements using an isokinetic dynamometer (Biodex System 3 Pro), Shear Wave Elastography (SWE), ELISA kits (for tumor necrosis factor-alpha, Interleukin-6, IL-10, serum irisin level), BETY-Biopsychosocial Questionnaire (BETY-BQ), Hospital Anxiety and Depression Scale (HADS), and Short Form-36 (SF-36). RESULTS: The SG demonstrated improvements in SHAQ, mHAMIS, 6MWT, BETY-BQ, HADS, and SF-36 values, excluding the DHI scores (p < 0.05). In contrast, CG showed worsening in SHAQ-general scleroderma symptoms and HADS scores compared to SG (p < 0.05). IL-10 and TNF-alpha increased in both groups, also various vascular parameters were significantly different changed in SG than CG (p < 0.05). Muscle strength values improved in the SG but decreased in the CG however this was statistically not significant (p > 0.05). CONCLUSIONS: BETY can be recommended as a nonpharmacologic approach to the disease management of SSc patients.

The Effects of Various Approaches to Lobectomies on Respiratory Muscle Strength, Diaphragm Thickness, and Exercise Capacity in Lung Cancer.

BACKGROUND: The most common surgery for non-small cell lung cancer is lobectomy, which can be performed through either thoracotomy or video-assisted thoracic surgery (VATS). Insufficient research has examined respiratory muscle function and exercise capacity in lobectomy performed using conventional thoracotomy (CT), muscle-sparing thoracotomy (MST), or VATS. This study aimed to assess and compare respiratory muscle strength, diaphragm thickness, and exercise capacity in lobectomy using CT, MST, and VATS. METHODS: The primary outcomes were changes in respiratory muscle strength, diaphragm thickness, and exercise capacity. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were recorded for respiratory muscle strength. The 6-min walk test (6MWT) was used to assess functional exercise capacity. Diaphragm thickness was measured using B-mode ultrasound. RESULTS: The study included 42 individuals with lung cancer who underwent lobectomy via CT (n = 14), MST (n = 14), or VATS (n = 14). Assessments were performed on the day before surgery and on postoperative day 20 (range 17-25 days). The decrease in MIP (p < 0.001), MEP (p = 0.003), 6MWT (p < 0.001) values were lower in the VATS group than in the CT group. The decrease in 6MWT distance was lower in the MST group than in the CT group (p = 0.012). No significant differences were found among the groups in terms of diaphragmatic muscle thickness (p > 0.05). CONCLUSION: The VATS technique appears superior to the CT technique in terms of preserving respiratory muscle strength and functional exercise capacity. Thoracic surgeons should refer patients to physiotherapists before lobectomy, especially patients undergoing CT. If lobectomy with VATS will be technically difficult, MST may be an option preferable to CT because of its impact on exercise capacity.

Albumin-myosteatosis gauge as a prognostic factor in patients with advanced pancreatic cancer undergoing first-line chemotherapy.

BACKGROUND: Sarcopenia and myosteatosis have been associated with a poor prognosis for several cancers. The albumin-myosteatosis gauge (AMG) is a novel integrated measure proposed to assess myosteatosis along with serum albumin level as a surrogate of systemic inflammation and malnutrition. The aim of this study was to investigate the prognostic value of AMG in patients with advanced pancreatic ductal adenocarcinoma (PDAC). METHODS: Patients with advanced PDAC treated with chemotherapy between 2013 and 2022 were evaluated. Skeletal muscle radiodensity (SMD) and skeletal muscle index (SMI) were calculated using computed tomography at the level of the L3 vertebra. The AMG was defined as albumin x SMD and expressed as an arbitrary unit (AU). Patients were first categorized by sex-specific quartiles and then dichotomized at the sex-specific median value of the AMG. RESULTS: A total of 196 patients were included. The median age (interquartile range) was 62 (54-67), and 128 (65.3%) were male. With regard to AMG, 142.86 and 114.15 AU were identified as cutoff values for males and females, respectively. In multivariable analyses, lower AMG values (G1-G2 vs. G3-G4) (HR: 1.61, 95% CI 1.17-2.21, p = 0.003), higher ECOG performance score (> 0 vs. 0) (HR: 1.51, 95% CI 1.10-2.06, p = 0.009) and metastatic disease (vs. locally advanced) (HR: 1.88, 95% CI 1.27-2.79, p = 0.001) were associated with OS. CONCLUSION: The study findings suggest the prognostic value of AMG in patients with advanced PDAC undergoing first-line chemotherapy. Further studies are warranted to validate these findings and assess potential predictive role of AMG in guiding treatment selection.

Role of sarcopenia on survival and treatment-related toxicity in head and neck cancer: a narrative review of current evidence and future perspectives.

PURPOSE: The purpose of this article is to provide an up-to-date summary of sarcopenia and its clinical implications for patients with head and neck cancer (HNC). METHODS: We conducted a literature review of recent studies investigating the prevalence of sarcopenia in HNC patients, its detection using MRI or CT scans, and its association with clinical outcomes such as disease-free and overall survival time, radiotherapy-related side effects, cisplatin toxicity, and surgical complications. RESULTS: Sarcopenia, characterized by low skeletal muscle mass (SMM), is a prevalent condition in HNC patients and can be effectively detected using routine MRI or CT scans. Low SMM in HNC patients is associated with increased risks of shorter disease-free and overall survival times, as well as radiotherapy-related side effects such as mucositis, dysphagia, and xerostomia. In addition, cisplatin toxicity is more severe in HNC patients with low SMM, leading to higher dose-limiting toxicity and treatment interruptions. Low SMM may also predict higher risks of surgical complications in head and neck surgery. Identifying sarcopenic patients can aid physicians in better riskstratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes. CONCLUSIONS: Sarcopenia is a significant concern for HNC patients and can impact their clinical outcomes. Routine MRI or CT scans can effectively detect low SMM in HNC patients. Identifying sarcopenic patients can aid physicians in better risk-stratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes. Further research is needed to explore the potential of interventions to mitigate the negative effects of sarcopenia in HNC patients.

Radiological management and challenges of the twin earthquakes of February 6th.

Two major earthquakes measuring 7.8 and 7.7 on the Richter scale struck Turkey and Northern Syria on February 6, claiming more than 50,000 lives. In such an unprecedented disaster, radiologists were confronted with very critical tasks of stepping out of the routine reporting process, performing radiological triage, managing acute adverse events, and optimizing imaging protocols. In our experience, radiologists can take three different positions in such disasters: (1) in the scene of the disaster, (2) serving in teleradiology, and (3) working in tertiary hospital for transported patients. With this article, we aimed to describe the challenges radiologists face on the three main fronts and how we manage these challenges.

Imaging in crush injury: a spectrum of findings in survivors of the twin earthquakes on February 6, 2023.

On February 6, two major earthquakes with magnitudes of 7.8 and 7.7 on the Richter scale hit Turkey and Northern Syria causing more than 50,000 deaths. In the immediate aftermath of the earthquakes, our major tertiary medical referral center received dozens of cases of crush syndrome, presenting with a variety of imaging findings. Crush syndrome is characterized by hypovolemia, hyperkalemia, and myoglobinuria that can lead to rapid death of victims, despite their survival of staying under wreckage for days. The typical triad of crush syndrome consists of the acute tubular necrosis, paralytic ileus, and third-space edema. In this article, we focus primarily on characteristic imaging findings of earthquake-related crush syndrome and divided them into two distinct subsections: myonecrosis, rapid hypovolemia, excessive third-space edema, acute tubular necrosis, and paralytic ileus, which are directly related to crush syndrome, and typical accompanying findings of earthquake-related crush syndrome. Lower extremity compression in earthquake survivors results in the typical third-space edema. In addition to the lower extremities, other skeletal muscle regions are also affected, especially rotator muscles, trapezius, and pectoral muscles. Although it may be relatively easy to better detect myonecrosis with contrast-enhanced CT scans, changing the windowing of the images may be helpful.

Primary renal sarcomas: imaging features and discrimination from non-sarcoma renal tumors.

OBJECTIVES: To assess imaging features of primary renal sarcomas in order to better discriminate them from non-sarcoma renal tumors. METHODS: Adult patients diagnosed with renal sarcomas from 1995 to 2018 were included from 11 European tertiary referral centers (Germany, Belgium, Turkey). Renal sarcomas were 1:4 compared to patients with non-sarcoma renal tumors. CT/MRI findings were assessed using 21 predefined imaging features. A random forest model was trained to predict "renal sarcoma vs. non-sarcoma renal tumors" based on demographics and imaging features. RESULTS: n = 34 renal sarcomas were included and compared to n = 136 non-sarcoma renal tumors. Renal sarcomas manifested in younger patients (median 55 vs. 67 years, p < 0.01) and were more complex (high RENAL score complexity 79.4% vs. 25.7%, p < 0.01). Renal sarcomas were larger (median diameter 108 vs. 43 mm, p < 0.01) with irregular shape and ill-defined margins, and more frequently demonstrated invasion of the renal vein or inferior vena cava, tumor necrosis, direct invasion of adjacent organs, and contact to renal artery or vein, compared to non-sarcoma renal tumors (p < 0.05, each). The random forest algorithm yielded a median AUC = 93.8% to predict renal sarcoma histology, with sensitivity, specificity, and positive predictive value of 90.4%, 76.5%, and 93.9%, respectively. Tumor diameter and RENAL score were the most relevant imaging features for renal sarcoma identification. CONCLUSION: Renal sarcomas are rare tumors commonly manifesting as large masses in young patients. A random forest model using demographics and imaging features shows good diagnostic accuracy for discrimination of renal sarcomas from non-sarcoma renal tumors, which might aid in clinical decision-making. KEY POINTS: • Renal sarcomas commonly manifest in younger patients as large, complex renal masses. • Compared to non-sarcoma renal tumors, renal sarcomas more frequently demonstrated invasion of the renal vein or inferior vena cava, tumor necrosis, direct invasion of adjacent organs, and contact to renal artery or vein. • Using demographics and standardized imaging features, a random forest showed excellent diagnostic performance for discrimination of sarcoma vs. non-sarcoma renal tumors (AUC = 93.8%, sensitivity = 90.4%, specificity = 76.5%, and PPV = 93.9%).

Radiation dose levels of thoracic-lumbar spine CT in pediatric trauma patients and assessment of scan parameters for dose optimization.

BACKGROUND: CT is frequently used for assessing spinal trauma in children. OBJECTIVE: To establish the local diagnostic reference levels of spine CT examinations in pediatric spinal trauma patients and analyze scan parameters to enable dose optimization. MATERIALS AND METHODS: In this retrospective study, we included 192 pediatric spinal trauma patients who underwent spine CT. Children were divided into two age groups: 0-10 years (group 1) and 11-17 years (group 2). Each group was subdivided into thoracic, thoracolumbar and lumbar CT groups. CT acquisition parameters (tube potential, in kilovoltage [kV]; mean tube current-time product, in milliamperes [mAs]; reference mAs; collimated slice width; tube rotation time; pitch; scan length) and radiation dose descriptors (volume CT dose index [CTDIvol] and dose-length product [DLP]) were recorded. The CTDIvol and DLP values of spine CTs obtained with different tube potential and collimated slice width values were compared for each group. RESULTS: CTDIvol and DLP values of thoracolumbar spine CTs in group 1 and lumbar spine CTs in group 2 were significantly lower in CTs acquired with low tube potential levels (P<0.05). CTDIvol and DLP values of thoracolumbar spine CTs in both groups and lumbar spine CTs in group 2 acquired with high collimated slice width values were significantly lower than in corresponding CTs acquired with low collimated slice width values (P<0.05). CONCLUSION: Pediatric spine CT radiation doses can be notably reduced from the manufacturers' default protocols while preserving image quality.

Excessive z-axis scan coverage in body CT: frequency and causes.

OBJECTIVES: The aim of this study was to determine the frequency and causing factors of excessive z-axis coverage in body CT examinations. METHODS: A total of 2032 body CT examinations performed between 1 March and 1 April 2018 in 1531 patients were included in this study. The over-scanned length values in the z-axis for each CT examination on each patient were determined by calculating the difference between the actual scanned length and optimal scan length in the z-axis. Over-scanning and over-scanning ratios were interrogated in terms of potential underlying factors that can be affected by patient demography, time, the throughput of CT, and the experience of technologists. RESULTS: Over-scanned CTs in z-axis were 66% of all CTs performed. CT scans were over-scanned in the cranial side in 18.4% and caudal side in 48.5% of patients. Over-scanning was found to be more frequent in 55-64-year-old age group (74%), thorax CTs (89.2%), patients with consciousness change (88.9%), patients with misleading findings related to lung apex or diaphragm on the scout images (76.6%), CTs performed in day shift (66.8 %), in CT with low daily scan (72.4%), and CT scans performed by less-experienced technologists (75.9%). CONCLUSIONS: Over-scanning in z-axis in body CT examinations is not infrequently encountered in routine practice. Awareness of causes of over-scanning in z-axis can be helpful to prevent over-scanning in CT and unnecessary ionizing radiation exposure in patients. KEY POINTS: • Over-scanning in z-axis frequently occurs in body CT. • The frequency of over-scanning in caudal side is higher than cranial side. • Chest CT and any CT performed in following situation were more prone to over-scanning: older patients, patients with consciousness change, presence of misleading findings on the scout images related to lung apex or diaphragm, day shift, CT with low daily scan, less-experienced technologist.

Primary retroperitoneal fasciitis; A rare cause of acute abdominal pain.

The retroperitoneal fascial planes can be affected by various clinical disorders. In most of the cases retroperitoneal involvement occurs secondary to spread of a distinct underlying etiology. Herein we report two cases of primary retroperitoneal fasciitis diagnosed with imaging findings. The diagnosis of retroperitoneal fasciitis should be made by exclusion since various and more frequently encountered disorders including acute pancreatitis, duodenitis, pyelonephritis, and appendicitis may present with similar imaging findings.

Shear Wave Elastography Is a Reliable and Repeatable Method for Measuring the Elastic Modulus of the Rectus Femoris Muscle and Patellar Tendon.

OBJECTIVES: The purpose of this study was to determine intraobserver, interobserver, and inter-day reliability levels for stiffness measurements of the patellar tendon and rectus femoris muscle using shear wave elastography (SWE). METHODS: This study was conducted on 12 healthy male individuals. Two examiners measured mean shear wave velocity values of the patellar tendons and rectus femoris muscles of both extremities using a 9L4 (4-9 MHz) transducer and an Acuson S3000 ultrasound system (Siemens Medical Solutions, Mountain View, CA). The elasticity images were acquired by the Virtual Touch tissue imaging quantification technique (Siemens Medical Solutions). Measurements were repeated 20 minutes and 1 week after the first measurements. The reliability of SWE measurements was assessed by means of the intraclass correlation coefficient (ICC). RESULTS: The 12 participants ranged in age from 19 to 33 years (mean age ± SD, 25.33 ± 4.56 years). For the patellar tendon stiffness measurements with SWE, it was found that intraobserver reliability (ICC, 0.91-0.92) and interday reliability (ICC, 0.81-0.83) were excellent, and interobserver reliability (ICC, 0.71) was good. For the rectus femoris muscle stiffness measurements with SWE, it was found that the intraobserver reliability (ICC, 0.93-0.94), interday reliability (ICC, 0.81-0.91), and interobserver reliability (ICC, 0.95) were perfect. CONCLUSIONS: Shear wave elastography using the Virtual Touch tissue imaging quantification technique is a reliable and repeatable technique for patellar tendon and rectus femoris stiffness measurements according to intraobserver, interday, and interobserver ICC values.

Hepatobiliary Tuberculosis: Imaging Findings.

OBJECTIVE: Tuberculosis (TB) may present with highly variable imaging findings. The findings may vary from nonspecific hepatomegaly to abscesses or solid focal lesions, mimicking liver tumors. Biliary tract involvement may also be detected, which may manifest with ductal dilatations from underlying strictures. CONCLUSION: All cross-sectional imaging modalities, including sonography, CT, and MRI, may be used in the evaluation of patients with TB. Imaging findings may be perplexing to radiologists, particularly ones who practice in areas where TB is not endemic; thus, histopathologic diagnosis may be required.

CT and MRI of aortic coarctation: pre- and postsurgical findings.

OBJECTIVE. The purpose of this article is to summarize the roles of CT and MRI in the diagnosis and follow-up of patients with aortic coarctation. CONCLUSION. Aortic coarctation is a common congenital heart disease accounting for approximately 6-8% of congenital heart defects. Despite its deceptively simple anatomic presentation, it is a complex medical problem with several associated anatomic and physiologic abnormalities. CT and MRI may provide very accurate information of the coarctation anatomy and other associated cardiac abnormalities.

Imaging of hepatobiliary involvement in sarcoidosis.

Sarcoidosis is mainly a disease of the respiratory system; however, several other organ systems may be affected in the course of the disease. Liver is one of the most frequently affected organs in the setting of sarcoidosis after lungs and lymph nodes. Microscopic hepatic involvement is common in these patients but is mostly clinically silent. However, in a significant portion of these patients, macroscopic findings can be detected in the course of the disease, and these findings may easily be confused with other benign and malignant conditions of the liver. The purposes of this article are to briefly summarize the clinical findings and the underlying pathophysiology of sarcoidosis and detailed presentation of the radiologic findings of hepatic involvement in this disease. We subgrouped the imaging findings based on the location and the radiologic appearance of the hepatic involvement. We tried to provide images that would enable the readers to link the imaging findings with the underlying pathology and clinical symptoms.

Utility of semiquantitative strain elastography for differentiation between benign and malignant solid renal masses.

OBJECTIVES: The aim of this study was to determine the role of semiquantitative strain elastography for differentiation of benign and malignant solid renal masses. METHODS: Seventy-one patients with solid renal masses were prospectively examined with ultrasound elastography after grayscale sonography. Strain elastography was used to compare the stiffness of the renal masses and renal parenchyma. The ratio of strain in a renal mass and nearby renal parenchyma was defined as the strain index value. Mean strain index values for benign masses (n = 29; 24 angiomyolipomas and 5 oncocytomas) and malignant masses (n = 42; 34 renal cell carcinomas, 4 transitional cell carcinomas, 3 metastases, and 1 lymphoma) and mean strain index values for angiomyolipomas and renal cell carcinomas were compared. RESULTS: There were no significant differences in the mean age of the patients, mean diameter of the masses, and mean probe-mass distance between benign and malignant groups. The mean strain index value ± SD for malignant masses (4.05 ± 2.17) was significantly higher than the value for benign masses (1.43 ± 0.94; P < .05). The mean strain index value for renal cell carcinomas (4.30 ± 2.27) was significantly higher than the value for angiomyolipomas (1.28 ± 1.01; P < .0001). CONCLUSIONS: Strain elastography may be a useful imaging technique for differentiation between benign and malignant solid renal masses.

Sacrococcygeal sinus angle: as a new anatomic landmark for the posterior approach of presacral lesions.

PURPOSE: We have discussed the importance of sacrococcygeal sinus angle (SSA), which is a new anatomical landmark in the surgery of presacral lesions. Because of its anatomical structure, the sacrum limits the surgical exposure like a compact barrier for the posterior surgical approach. The main aim of this paper is to explain the anatomical description and clinical importance of SSA in the surgery of presacral lesions. METHODS: Three groups were designated, consisting of ten patients in each group, as early childhood (group 1), late childhood (group 2) and adulthood (group 3). Patients were selected randomly. The degree of SSA measurement was performed between the line tangent to the anterior margin of the first sacral vertebra and the line from the promontorium to the tip of the coccyx. The measurement of SSA was performed on patients' lumbosacral magnetic resonance images. When the SSA forms a triangle via a parallel line starting from the inferior tip of the sacrum and running parallel to the ground, the area of the triangle also covers the field of view of the presacral region. In addition, the sacral region needed to be resected for maximum exposure is also within this area. RESULTS: The mean SSA was measured to be 53.9 ± 11.4° in group 1, 77.8 ± 11.2° in group 2 and 74.5 ± 12.5° in group 3. Intergroup comparisons revealed a significant difference between group 1 and the other two groups statistically. It was found that the SSA was 20° less in group 1 as compared to the other age groups (p = 0.0005). The area of a triangle is calculated using the sine area formula, and according to this formula the area of a triangle increases when the degree of the angle increases, thus comprising larger part of the sacrum. This condition requires more and wide sacral resection to obtain maximum exposure in the presacral zone. CONCLUSIONS: We have observed that the SSA is significantly smaller during early childhood compared with the other age groups. This feature provides an anatomical superiority in this age group for the posterior approach in the surgical treatment of presacral masses.

Introducing AEM-RADS: A novel reporting and data system for abdominal emergencies.

PURPOSE: The Reporting and Data System (RADS) has proven successful in various medical settings, but a standardized reporting system for abdominal emergencies is lacking. In this study, the Abdominal Emergency Reporting and Data System (AEM-RADS) for urgent findings on abdominal CT scans is introduced to address the need for consistency in emergency radiology. METHODS: In this prospective observational study, conducted over a six-month period, the urgency of abdominal CT scans was assessed using the proposed AEM-RADS scoring system. The committee developed a scale ranging from AEM-RADS 1 (normal) to AEM-RADS 5 (urgent disease). Interobserver agreement between two observers with different experience was evaluated, and robust AEM-RADS reference values were established by radiologists who were not observers. Statistical analysis used mean, standard deviations and Kendall's tau analysis for interobserver agreement. RESULTS: Among 2656 patients who underwent CT for abdominal emergencies, the AEM-RADS distribution was 17.50% AEM-RADS 1, 28.57% AEM-RADS 2, 7.22% AEM-RADS 3, 35.61% AEM-RADS 4, and 11.06% AEM-RADS 5. Interobserver agreement was high, especially for urgent and emergent cases (p < 0.0001). Notable discrepancies were observed in AEM-RADS categories 2C-D and 3B-C, emphasizing the influence of radiologists' experience on interpretation. However, the interobserver agreement for both AEM-RADS 2C-D and 3B-C were statistically significant (p < 0.001). CONCLUSIONS: AEM-RADS showed promising reliability, particularly in identifying urgent and emergent cases. Despite some inter-observer discrepancies, the system showed potential for standardized emergency workups. AEM-RADS could significantly enhance diagnostic accuracy in abdominal emergencies and provide a structured framework for shared decision-making between clinicians and radiologists.0.

Sonographic Measurements of Rectus Femoris Muscle Thickness Strongly Predict Neutropenia in Cancer Patients Receiving Chemotherapy.

The objective of this study was to explore the possible association between low skeletal muscle mass (SMM)-assessed by computed tomography (CT) and ultrasound (US)-and hematologic toxicity in cancer patients. A prospective cohort study was conducted in cancer patients who received anthracycline-based chemotherapy between 2018 and 2020 and who had baseline abdominal CT including L3 level for measuring SMM. Regional muscle measurements were carried out using US. A total of 65 patients (14 males, 51 females) were included. ROC (receiver operating characteristic) analysis identified threshold values of 18.0 mm [AUC (area under the curve) = 0.765] for females and 20.0 mm (AUC = 0.813) for males, predicting severe neutropenia. Using these cut-offs, females with low rectus femoris (RF) thickness (<18.0 mm) had a significantly higher incidence of grade ≥3 neutropenia (50.0% vs. 10.8%, p = 0.005), and males with low RF values (<20.0 mm) had a higher incidence (80.0% vs. 22.2%, p = 0.063). A regression analysis, irrespective of age, gender, and body mass index, revealed that only low RF muscle thickness increased the risk of grade 3-4 neutropenia by 9.210 times (95% CI = 2.401-35.326, p = 0.001). Utilizing US to measure RF muscle thickness aids in identifying cancer patients at an elevated risk of developing neutropenia. Needless to say, US can serve as a convenient and easily accessible tool for assessing low SMM, providing repeat point-of-care evaluations in clinical practice.