Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review.

INTRODUCTION: There are no generally accepted criteria for when and how to fixate osteoporotic pelvic ring fractures in elderly. This systemic review aims to summarize the currently available literature regarding the indications and methods for surgical fixation of fragility fractures of the pelvic ring in elderly patients after low-energy trauma. MATERIALS AND METHODS: The Pubmed and Embase databases were searched using the key words pelvic fractures, geriatric, fragility, osteoporosis, and surgical fixation, and their synonyms. Extracted data including the indication, method of operative fixation, and post-operative outcomes (pain levels, mobility, complications and mortality) were analyzed using descriptive statistics. The studies were too heterogeneous to perform a meta-analysis. RESULTS: Eleven cohort studies (3 comparative and 8 noncomparative) were included. The methodological quality was poor to moderate; the studies were heterogeneous regarding study design and reported outcomes. In all included studies operative treatment for all fracture types was preceded by a period of conservative treatment comprising physiotherapy-guided full weight-bearing. Time to surgery differed widely. For posterior ring fixation, the majority of the included studies used minimally invasive surgery with trans-iliosacral screws. Five studies described a form of additional fixation of the anterior pelvic ring but did not report the indications. CONCLUSIONS: Fixation of low-energy pelvic ring fractures in elderly is commonly performed after a period of conservative treatment, with persistent pain as the most frequent indication for fixation. Fracture classification based on stability seems to be of secondary importance. Timing for surgical fixation of the pelvic ring fracture in elderly patients remains diverse. Large well-designed comparative prospective studies and randomized controlled trials are needed to provide clearly substantiated guidelines.

Rates and risk factors of complications associated with operative treatment of pelvic fractures.

PURPOSE: Post-operative complications following fixation of pelvic fractures can lead to mortality and increased morbidity. Available literature regarding complications is heterogeneous and knowledge on risk factors is limited. This study aims to identify the most common post-operative complications and their possible risk factors following pelvic fracture surgery. METHODS: A retrospective cohort study was performed in two level-1 trauma centers in the Netherlands between January 2015 and January 2021. Included patients were all adult patients (≥ 18 years) with an operatively treated pelvic fracture (pelvic ring and/or acetabular fractures). Post-operative complications included surgical site infections (SSI), material-related complications, neurological complications, malunion/non-union and performed reoperations. A forward stepwise multivariable logistic regression analysis was used to identify any risk factors associated with these complications. RESULTS: Complications occurred in 55 (24%) of the 233 included patients. SSI's were most common, occurring in 34 (15%) patients. Duration of surgery (odds ratio 1.01 per minute, 95% confidence interval 1.00-1.01) and obesity (odds ratio 1.10 per BMI point, 95% confidence interval 1.29-7.52) were independent risk factors for development of SSI. Less common post-operative complications were material-related complications (8%) and neurological damage (5%). CONCLUSION: Limiting operation time by using less invasive and less time-consuming surgical approaches may reduce the risk of SSI. More awareness and post-operative screening for early signs of SSI is mandatory, especially in obese patients. Future research should include large prospective patient cohorts to determine risk factors for other post-operative complications associated with pelvic fracture surgery.

Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer.

INTRODUCTION: In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS: A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS: 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS: For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER: Dutch Trial Registry (NTR3142).

Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up.

BACKGROUND: Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS: The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS: A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION: The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.

The predictive value of proteinuria in acute pancreatitis.

BACKGROUND/OBJECTIVES: Acute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP). METHODS: This is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality. RESULTS: Proteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03). CONCLUSION: Proteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.

Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review.

BACKGROUND: It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis. METHODS: MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists. RESULTS: Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%). CONCLUSION: Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.

Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients.

OBJECTIVES: Historically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients. METHODS: A prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2-4 weeks, and 3, 6 and 12 months after fracture. RESULTS: 102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2-4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0-8) vs. 5 (0-10), p = 0.19) and ADL scores (85 (25-100) vs. 78.6 (5-100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%. CONCLUSIONS: The vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.

Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction.

BACKGROUND AND STUDY AIMS: Colonoscopy is increasingly performed by nurse endoscopists. We aimed to assess the endoscopic quality and patient experience of these procedures. PATIENTS AND METHODS: This prospective multicenter study analyzed 100 consecutive colonoscopies each for 10 trained nurse endoscopists with respect to endoscopic quality and patient experience. Colonoscopies were performed under the supervision of a gastroenterologist, using the techniques and protocols of the participating hospitals. Patient experience was assessed using a questionnaire. RESULTS: Most nurse endoscopists were female (90 %; median age 43 [range 35 - 49]). Before the start of the study, they had performed a median of 528 colonoscopies (range 208 - 2103). For the 1000 patients, mean age was 56 ± 15 years; 55 % were women; and 96 % were in class I or II according to the American Society of Anesthesiologists' physical status classification system. Colonoscopies were performed for screening or surveillance in 42 %; for symptomatic indications in 58 % of patients. The unassisted cecal intubation rate was 94 %; the mean withdrawal time was 10 ±â€Š5 minutes. The adenoma detection rate was 26.7 %. In 229 of the colonoscopies (23 %), the nurse endoscopists required assistance from the supervising gastroenterologist. The complication rate was 0.2 %: one perforation and one cardiopulmonary complication. The questionnaire was completed by 734 /1000 patients (73 %) and of these 694 /734 (95 %) were satisfied with the endoscopic procedure. Among the respondents 530 /734 (72 %) had no specific preference for a physician or nurse endoscopist, whereas 113 /734 (15 %) preferred a physician endoscopist, and 91 /734 (12 %) preferred a nurse endoscopist. CONCLUSION: The nurse endoscopists performed colonoscopies according to the internationally recognized quality standards and with high patient satisfaction.

Vibrational Förster transfer in ice Ih.

We have studied Förster energy transfer between O-H vibrations in H(2)O/D(2)O ice Ih using femtosecond, two-color, mid-infrared pump-probe spectroscopy. We found that as a result of couplings to nearby O-H stretch modes, the vibrational relaxation time decreases from 480 fs for dilute HDO in D(2)O down to 300 fs for pure H(2)O ice. The anisotropy shows an initial 140 fs decay down to a concentration-dependent end level. This end level for low concentrations can be explained from the limited rotational freedom ( approximately 20 degrees ) of a water molecule in the ice lattice over time scales > 15 ps. The decreasing end levels for higher concentrations of H(2)O result from Forster energy transfer to the next-nearest six O-H groups. No Förster transfer beyond these neighbors is observed. Variation of the ice temperature between 200 and 270 K was found to have negligible effect on the dynamics.

Direct observation of proton transfer in ice Ih using femtosecond spectroscopy.

We studied proton transfer in ice samples containing the photoacid 8-hydroxypyrene-1,3,6-trisulfonic acid and the base sodium formate using femtosecond pump-probe spectroscopy. Pump pulses, centered at a wavelength of 400 nm, electronically excited the photoacid molecules which released their protons. These protons subsequently traveled from the photoacid through the ice lattice to the base and were observed as they arrived at the base using the transient absorption of an infrared probe pulse. Both the temperature and concentration dependence of the proton transfer dynamics were modeled using a discrete set of two intrinsic transfer rates, associated with short and long-range proton transfer, respectively. Proton transfer in configurations where the acid and base were separated by up to about two water molecules, was found to occur on a approximately 1 ps time scale for all temperatures (240-270 K). Long range direct proton transfer through water wires of about four water molecules in length was found to occur on a approximately 300 ps time scale at 270 K. This latter process was observed to slow down significantly with decreasing temperature, with an activation energy of approximately 80 kJ/mol.

Vibrational Förster transfer to hydrated protons.

We have studied the influence of excess protons on the vibrational energy relaxation of the O-H and O-D stretching modes in water using femtosecond pump-probe spectroscopy. Without excess protons, we observe exponential decays with time constants of 1.7 and 4.3 ps for the bulk and anion bound O-D stretch vibrations. The addition of protons introduces a new energy relaxation pathway, which leads to an increasingly nonexponential decay of the O-D stretch vibration. This new pathway is attributed to a distance-dependent long range dipole-dipole (Forster) interaction between the O-D stretching vibration and modes associated with dissolved protons. The high efficiency of hydrated protons as receptors of vibrational energy follows from the very large absorption cross section and broad bandwidth of protons in water. For a proton concentration of 1M we find that Forster energy transfer occurs over an average distance of 4.5 A, which corresponds to a separation of about two water molecules.

Hydrogen bond fluctuations of the hydration shell of the bromide anion.

We study the hydrogen bond dynamics of solutions of LiBr and NaBr in isotopically diluted water (2% HDO:D2O) with femtosecond spectral hole-burning spectroscopy. We study the frequency fluctuations of the O-H stretch vibrations of the HDO molecules and observe spectral dynamics with time constants of 0.8 +/- 0.1 ps and 4.3 +/- 0.3 ps. The slow process we assign to the hydrogen bond fluctuations of the O-H...Br- hydrogen bonds of the hydration shell of the Br- anion. We find that the time scale of the hydrogen bond fluctuations of the hydration shell of Br- is independent of the nature of the cation and the concentration.

Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer.

BACKGROUND AND STUDY AIMS: The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction. PATIENTS AND METHODS: Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1). RESULTS: A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy. CONCLUSIONS: The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention.

Molecular reorientation of liquid water studied with femtosecond midinfrared spectroscopy.

The molecular reorientation of liquid water is key to the hydration and stabilization of molecules and ions in aqueous solution. A powerful technique to study this reorientation is to measure the time-dependent anisotropy of the excitation of the O-H/O-D stretch vibration of HDO dissolved in D2O/H2O using femtosecond midinfrared laser pulses. In this paper, we present and discuss experiments in which this technique is used to study the correlation between the molecular reorientation of the water molecules and the strength of the hydrogen-bond interactions. On short time scales (<200 fs), it was found that the anisotropy shows a partial decay due to librational motions of the water molecules that keep the hydrogen bond intact. On longer time scale (>200 fs), the anisotropy shows a complete decay with an average time constant of 2.5 ps. From the frequency dependence of the anisotropy dynamics, it follows that a subensemble of the water molecules shows a fast reorientation that is accompanied by a large change of the vibrational frequency. This finding agrees with the molecular jumping mechanism for the reorientation of liquid water that has recently been proposed by Laage and Hynes.

Effect of laparoscopic gastric banding on esophageal motility.

BACKGROUND: Alterations in esophageal motility may occur after placement of an adjustable gastric band as treatment for morbid obesity, near the gastro-esophageal junction. It causes an outlet obstruction, especially during follow-up after the band is filled. METHODS: 29 morbidly obese patients underwent conventional manometry preoperatively, 6 weeks postoperatively before and after filling the band and at 6 months postoperatively. A questionnaire was used to assess upper gastrointestinal symptoms during follow-up. RESULTS: After band placement, there was a significant increase in lower esophageal sphincter (LES) end-expiratory pressure at 6 weeks with an empty band: 1.3 (0.9-1.9) kPa (median (interquartile range) (P=0.003), 6 weeks with a filled band: 2.1 (1.5-2.8) kPa (P=0.0001), and at 6 months: 1.5 (1.3-1.9) kPa (P=0.001), compared to the preoperative pressure: 0.8 (0.6-1.3) kPa. Also after band placement, the high pressure zone length increased (preop 5.0 (4.3-6.0) cm vs 6 weeks 6.0 (5.0-6.5) cm (P=0.003). The propagation of peristaltic contractions was not significantly altered after band placement. Heartburn decreased 6 weeks postoperatively (P=0.04) but increased at 6 months. Heartburn at 6 months was correlated with pouch formation (0.667; P<0.01). CONCLUSION: Adjustable gastric band placement causes an increase in LES pressure and length of the high pressure zone. It decreases reflux symptoms in the short-term, but this effect appears not to be related to an effect on LES pressure or length. Pouch formation increases reflux symptoms without having any relationship to LES pressure and length. Band placement in the short-term does not disturb propagation of esophageal contractions.

Gastro-oesophageal reflux of liquids and gas during transient lower oesophageal sphincter relaxations.

Some transient lower oesophageal sphincter relaxations (TLOSRs) are accompanied by gastro-oesophageal reflux and others are not. We aimed to investigate what factors determine the occurrence and type of reflux during TLOSRs. In 12 healthy subjects prolonged high-resolution manometry was performed. Reflux was detected using pH-impedance monitoring. A total of 219 TLOSRs were detected; no differences were observed between the duration of TLOSRs with liquid-containing reflux (20.2 +/- 1.0 s), gas reflux (17.0 +/- 1.0 s) and no reflux (19.0 +/- 1.0 s). Trans-sphincteric pressure gradient was similar in TLOSRs with liquid reflux (1.6 +/- 0.1 kPa), gas reflux (1.5 +/- 0.1 kPa) and no reflux (1.7 +/- 0.3 kPa). Prevalence, duration and amplitude of oesophageal pre-contractions and sphincteric after-contractions were not different for TLOSRs with and without reflux. The total number of TLOSRs decreased significantly from 8.2 +/- 0.8 in the first to 5.7 +/- 0.5 in the second and 4.4 +/- 0.6 in the third 70-min recording period. The number of TLOSRs accompanied by liquid-containing reflux decreased from 4.7 +/- 0.9 to 3.0 +/- 0.4 to 1.6 +/- 0.4, while the numbers of TLOSRs with gas reflux remained unchanged (2.1 +/- 0.6-2.1 +/- 0.7-2.2 +/- 0.6). Besides, time after the meal, no differences were observed in the characteristics of TLOSRs with and without gastro-oesophageal reflux. We conclude that factors, other than TLOSR characteristics, are important of whether or not a TLOSR is reflux-related.

[Oesophageal endoscopic ultrasound with fine-needle aspiration biopsy in the staging of non-small-cell lung carcinoma; results from 43 patients]. / Slokdarmendo-echografie met dunnenaaldaspiratie ter stadiëring bij niet-kleincellig longcarcinoom; resultaten bij 43 patiënten.

OBJECTIVE: To calculate the number of cervical mediastinoscopies that need not be carried out ifoesophageal endoscopic ultrasound and fine-needle aspiration biopsy (EUS-FNA) are included in the staging of patients with non-small-cell lung carcinoma (NSCLC). DESIGN: Retrospective, descriptive. METHOD: Patients referred to the St. Antonius Hospital in Nieuwegein, the Netherlands, with NSCLC from January to December 2003 routinely underwent EUS-FNA during the staging process. If mediastinal or distant metastases were found to be present then cervical mediastinoscopy was not carried out as the patient was not eligible for operation. If no metastases were demonstrated then cervical mediastinoscopy was carried out. The value of EUS-FNA was calculated. RESULTS: A total of 43 patients underwent EUS-FNA: 32 men and 11 women with an average age of 64 (range: 45-77). In 22 (51%) of them, cervical mediastinoscopy was not performed as EUS-FNA demonstrated malignant cells in the lymph nodes of the mediastinum or abdomen, in the left adrenal gland or in the primary tumour which had grown into the mediastinum. In 2 of the 21 other patients malignant cells were found on mediastinoscopy showing the EUS-FNA results in 2 of 43 patients (5%) to be false-negative. No complications occurred. CONCLUSION: Based on the findings from EUS-FNA, cervical mediastinoscopy was not performed in 51% of the patient group.

[Belching (ructus)]. / Boeren (ructus).

Accumulation of air in the stomach increases the gastric volume, which activates receptors in the gastric wall. This results in a reflex that relaxes the lower oesophageal sphincter, whereby the intragastric air can escape through the oesophagus. Ventilation of the stomach via the oesophagus is known as belching (ructus). Belching often occurs in combination with reflux symptoms and dyspepsia. In these cases, other symptoms are often more predominant, and it is advisable to treat these first. In patients with aerophagia, belching is the most common reason for medical consultation. These patients belch frequently, up to 20 times per minute, and often during consultation. Aerophagia results from air being sucked into the oesophagus or injected by pharyngeal contraction, after which it is expelled immediately. In contrast to the described gastric belching, aerophagia is therefore a form of supragastric belching. Aerophagia is a behavioural disorder, and behavioural therapy or logopedics appears to be most common therapeutic approach.