Latin-American guidelines of recommendations at discharge from an acute coronary syndrome.

The diagnostic criteria, treatments at the time of admission, and drugs used in patients with acute coronary syndrome are well defined in countless guidelines. However, there is uncertainty about the measures to recommend during patient discharge planning. This document brings together the most recent evidence and the standardized and optimal treatment for patients at the time of discharge from hospitalization for an acute coronary syndrome, for comprehensive and safe care in the patient's transition between care from the acute event to the outpatient care, with the aim of optimizing the recovery of viable myocardium, guaranteeing the most appropriate secondary prevention, reducing the risk of a new coronary event and mortality, as well as the adequate reintegration of patients into daily life.

Los criterios diagnósticos, los tratamientos en el momento de la admisión y los fármacos utilizados en pacientes con síndrome coronario agudo están bien definidos en innumerables guías. Sin embargo, existe incertidumbre acerca de las medidas para recomendar durante la planificación del egreso de los pacientes. Este documento reúne las evidencias más recientes y el tratamiento estandarizado y óptimo para los pacientes al momento del egreso de una hospitalización por un síndrome coronario agudo, para un cuidado integral y seguro en la transición del paciente entre la atención del evento agudo y el cuidado ambulatorio, con el objetivo de optimizar la recuperación de miocardio viable, garantizar la prevención secundaria más adecuada, reducir el riesgo de un nuevo evento coronario y la mortalidad, así como la adecuada reinserción de los pacientes en la vida cotidiana.

Exploring the genetics of lithium response in bipolar disorders.

BACKGROUND: Lithium (Li) remains the treatment of choice for bipolar disorders (BP). Its mood-stabilizing effects help reduce the long-term burden of mania, depression and suicide risk in patients with BP. It also has been shown to have beneficial effects on disease-associated conditions, including sleep and cardiovascular disorders. However, the individual responses to Li treatment vary within and between diagnostic subtypes of BP (e.g. BP-I and BP-II) according to the clinical presentation. Moreover, long-term Li treatment has been linked to adverse side-effects that are a cause of concern and non-adherence, including the risk of developing chronic medical conditions such as thyroid and renal disease. In recent years, studies by the Consortium on Lithium Genetics (ConLiGen) have uncovered a number of genetic factors that contribute to the variability in Li treatment response in patients with BP. Here, we leveraged the ConLiGen cohort (N = 2064) to investigate the genetic basis of Li effects in BP. For this, we studied how Li response and linked genes associate with the psychiatric symptoms and polygenic load for medical comorbidities, placing particular emphasis on identifying differences between BP-I and BP-II. RESULTS: We found that clinical response to Li treatment, measured with the Alda scale, was associated with a diminished burden of mania, depression, substance and alcohol abuse, psychosis and suicidal ideation in patients with BP-I and, in patients with BP-II, of depression only. Our genetic analyses showed that a stronger clinical response to Li was modestly related to lower polygenic load for diabetes and hypertension in BP-I but not BP-II. Moreover, our results suggested that a number of genes that have been previously linked to Li response variability in BP differentially relate to the psychiatric symptomatology, particularly to the numbers of manic and depressive episodes, and to the polygenic load for comorbid conditions, including diabetes, hypertension and hypothyroidism. CONCLUSIONS: Taken together, our findings suggest that the effects of Li on symptomatology and comorbidity in BP are partially modulated by common genetic factors, with differential effects between BP-I and BP-II.

Nutritional value and kinetics of in vitro fermentation of spineless cactus of the genus Nopalea in different phenological phases.

The objective was to evaluate the chemical composition and in vitro fermentation of spineless cactus of the genus Nopalea, F-21 (Nopalea cochenillifera Dyck), IPA-Sertânia (Nopalea cochenillifera Dyck) and Miúda (Nopalea cochenillifera Salm Dyck), in different phenophases. There was no effect (P < 0.05) of the phenological phases of spineless cactus on DM, ash, OM, EE, and CP. Varieties F-21 and Miúda presented higher values of DM and OM, whereas the CP was higher for IPA-Sertânia. The contents of NDF, ADF, and ADL, as well as the fractions of carbohydrates B2 and C were higher in the mature stage, irrespective of the variety. The Miúda variety showed higher levels of NFC and fractions A + B1 and the lower levels of pectin compared to the F-21 and IPA-Sertânia varieties, but not differ of TC to F-21. The volume of gas produced via the degradation of NFC was higher for young phenological phases. The young and intermediate stages showed a higher in vitro digestibility of DM. Based on the results, varieties IPA-Sertânia and Miúda have a high potential for use in animal feed because of their high nutritional quality. Mature cladodes showed a higher fibrous fraction and lower digestibility in all varieties.

Artificial intelligence for ventricular arrhythmia capability using ambulatory electrocardiograms.

Aims: European and American clinical guidelines for implantable cardioverter defibrillators are insufficiently accurate for ventricular arrhythmia (VA) risk stratification, leading to significant morbidity and mortality. Artificial intelligence offers a novel risk stratification lens through which VA capability can be determined from the electrocardiogram (ECG) in normal cardiac rhythm. The aim of this study was to develop and test a deep neural network for VA risk stratification using routinely collected ambulatory ECGs. Methods and results: A multicentre case-control study was undertaken to assess VA-ResNet-50, our open source ResNet-50-based deep neural network. VA-ResNet-50 was designed to read pyramid samples of three-lead 24 h ambulatory ECGs to decide whether a heart is capable of VA based on the ECG alone. Consecutive adults with VA from East Midlands, UK, who had ambulatory ECGs as part of their NHS care between 2014 and 2022 were recruited and compared with all comer ambulatory electrograms without VA. Of 270 patients, 159 heterogeneous patients had a composite VA outcome. The mean time difference between the ECG and VA was 1.6 years (⅓ ambulatory ECG before VA). The deep neural network was able to classify ECGs for VA capability with an accuracy of 0.76 (95% confidence interval 0.66-0.87), F1 score of 0.79 (0.67-0.90), area under the receiver operator curve of 0.8 (0.67-0.91), and relative risk of 2.87 (1.41-5.81). Conclusion: Ambulatory ECGs confer risk signals for VA risk stratification when analysed using VA-ResNet-50. Pyramid sampling from the ambulatory ECGs is hypothesized to capture autonomic activity. We encourage groups to build on this open-source model. Question: Can artificial intelligence (AI) be used to predict whether a person is at risk of a lethal heart rhythm, based solely on an electrocardiogram (an electrical heart tracing)? Findings: In a study of 270 adults (of which 159 had lethal arrhythmias), the AI was correct in 4 out of every 5 cases. If the AI said a person was at risk, the risk of lethal event was three times higher than normal adults. Meaning: In this study, the AI performed better than current medical guidelines. The AI was able to accurately determine the risk of lethal arrhythmia from standard heart tracings for 80% of cases over a year away-a conceptual shift in what an AI model can see and predict. This method shows promise in better allocating implantable shock box pacemakers (implantable cardioverter defibrillators) that save lives.

Patentometric analysis of the technological development of biotechnology for health in higher education institutions in Rio Grande do Sul.

Biotechnology offers solutions and opportunities to meet various societal demands, thereby contributing to significant scientific advancements. This study aimed to characterize the technological development of biotechnology in the healthcare sector in the state of Rio Grande do Sul, Brazil, from 2016 to 2022 by analyzing patents filed by and granted to public and private Higher Education institutions. For data collection, a quantitative exploratory approach was employed using statistical methods and a patent analysis of institutions in the patent database of the Brazilian National Institute of Industrial Property (INPI), focusing on patents related to the healthcare field. Data were collected in October, November, and December. A total of 580 patent records were collected from the INPI, belonging to Sections A and C of the International Patent Classification (IPC) related to educational institutions. Furthermore, this study highlighted that higher education institutions have a higher number of patents in the healthcare field. These results provide an understanding of the strategic areas for technological development in biotechnology in Rio Grande do Sul, Brazil.

Change in neurocognitive functioning in patients with treatment-resistant depression with serial intravenous ketamine infusions: The Bio-K multicenter trial.

This nonrandomized, multicenter, open-label clinical trial explored the impact of intravenous (IV) ketamine on cognitive function in adults (n = 74) with treatment-resistant depression (TRD). Patients received three IV ketamine infusions during the acute phase and, if remitted, four additional infusions in the continuation phase (Mayo site). Cognitive assessments using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) were conducted at baseline, end of the acute phase, and end of the continuation phase (Mayo site). Results showed a significant 53 % (39/74) remission rate in depression symptoms after the acute phase. In adjusted models, baseline language domain score was associated with a higher odd of remission (Odds Ratio, 1.09, 95 % CI = 1.03-1.17, p = 0.004) and greater improvement in MADRS at the end of the acute phase (ß =-0.97; 95 % CI, -1.74 to -0.20; P = 0.02). The likelihood of remission was not significantly associated with baseline immediate or delayed memory, visuospatial/constructional, or attention scores. In the continuation phase, improvements in immediate and delayed memory and attention persisted, with additional gains in visuospatial and language domains. Limitations included an open-label design, potential practice effects, and ongoing psychotropic medication use. Overall, the study suggests cognitive improvement, not deterioration, associated with serial IV ketamine administrations for TRD. These findings encourage future studies with larger sample sizes and longer follow-up periods to examine any potential for deleterious effect with recurrent ketamine use for TRD. Trial Registration: ClinicalTrials.gov: NCT03156504.

New hard tick (Acari: Ixodidae) reports and detection of Rickettsia in ticks from Sierra Nevada de Santa Marta, Colombia.

The Sierra Nevada de Santa Marta (SNSM), located in northern Colombia, is considered a geographical island with high levels of biodiversity and endemism. However, little is known about tick species and their associated microorganisms at the SNSM. In this study we sampled host-seeking ticks in areas of the town of Minca within the SNSM. We collected 47 ticks identified as Amblyomma pacae, Amblyomma longirostre, Amblyomma ovale, Amblyomma mixtum, Haemaphysalis juxtakochi, Ixodes sp. cf. Ixodes affinis and Ixodes sp. Of these ticks, we tested for Rickettsia spp. by amplifying the gltA, SCA1, and 16S rRNA genes via PCR. Rickettsia amblyommatis was detected in one pool of 3 larvae and in a female of A. pacae. Additonally, we isolated Rickettsia sp. belonging to the group of spotted fevers in larvae of A. longirostre. This study reports new findings of six species of ticks and two species of Rickettsia within the SNSM.

Clinical Characteristics and Neuroimaging Correlations in Autoimmune Encephalitis: A Report of Two Cases.

Autoimmune encephalitis is an infrequent pathological occurrence documented within our local context. When clinical suspicion arises, employing electroencephalogram and brain magnetic resonance imaging (MRI) proves valuable. However, for conclusive diagnosis confirmation, lumbar puncture for cerebrospinal fluid (CSF) analysis is indispensable. Managing this condition involves a combination of immunosuppression and, when necessary, tumor resection. We document the initial cases reported in our city, featuring two young patients without significant pre-existing conditions. Patients initially displayed behavioral alterations progressing to altered consciousness, febrile peaks, and challenging epileptic status, requiring intensive care and mechanical ventilation. The diagnosis was made based on MRI and anti-N-methyl-D-aspartate (anti-NMDA) antibodies. Treatment involved intravenous (IV) immunoglobulins, plasmapheresis, and corticosteroids. After discharge, both had cognitive sequelae. Autoimmune encephalitis is a pathological condition that still lacks thorough exploration and reporting. It predominantly affects young patients without a history of acute psychiatric symptoms, necessitating consideration when behavioral alterations emerge. The challenges faced by small cities, including a shortage of technical resources, further impede the timely and precise diagnosis of this intricate condition.

RapidpulseTM cyclic aspiration system for acute ischemic stroke due to large vessel occlusions.

BACKGROUND: The best strategy to achieve optimal reperfusion outcomes during mechanical thrombectomy remains to be defined. The RapidPulseTM Cyclic Aspiration System is a novel technology, delivering high-frequency pulsed vacuum forces to increase the efficiency of aspiration thrombectomy. METHODS: Prospective, multicenter, open-label, core lab-adjudicated, two-arm study comparing safety and efficacy of a feasibility version of the RapidPulseTM system compared with contemporary controls. Primary endpoint was the rate of mTICI ≥ 2c after first-pass effect (FPE). Additional efficacy endpoints were the rates of mTICI ≥ 2b after first pass (modified FPE (mFPE)), last pass with study device defined as frontline technical success, and after all passes including rescue therapy. The primary safety endpoints included symptomatic ICH (sICH) within 24 h post-procedure. RESULTS: Between February 2022 to December 2022, 80 subjects were consented and enrolled in the study (n = 40 treatment arm, n = 40 control arm). In the intent to treat (ITT) population, mean age was 67.8 ± 11.5 years; 19 (47.5%) were male. Median NIHSS score was 16 (IQR: 13-22). Median ASPECTS score was 9 (IQR: 8-10). The rate of mTICI ≥ 2c after first pass was 53.9% in ITT population (60.0% in per-protocol population) versus 38.5% in the corresponding control population. Functional independence (mRS 0-2) at 90 days was achieved in 61.1% (22/36) in the RapidPulseTM arm and 52.8% (19/36) in the control arm. In the RapidPulseTM arm, no sICH within 24 h and no device-related morbidity or mortality occurred. CONCLUSION: Preliminary data suggests RapidPulseTM Aspiration System is highly effective and safe for recanalization of large vessel occlusions.

Identifying genetic differences between bipolar disorder and major depression through multiple GWAS.

Background: Accurate diagnosis of bipolar disorder (BD) is difficult in clinical practice, with an average delay between symptom onset and diagnosis of about 7 years. A key reason is that the first manic episode is often preceded by a depressive one, making it difficult to distinguish BD from unipolar major depressive disorder (MDD). Aims: Here, we use genome-wide association analyses (GWAS) to identify differential genetic factors and to develop predictors based on polygenic risk scores that may aid early differential diagnosis. Methods: Based on individual genotypes from case-control cohorts of BD and MDD shared through the Psychiatric Genomics Consortium, we compile case-case-control cohorts, applying a careful merging and quality control procedure. In a resulting cohort of 51,149 individuals (15,532 BD cases, 12,920 MDD cases and 22,697 controls), we perform a variety of GWAS and polygenic risk scores (PRS) analyses. Results: While our GWAS is not well-powered to identify genome-wide significant loci, we find significant SNP-heritability and demonstrate the ability of the resulting PRS to distinguish BD from MDD, including BD cases with depressive onset. We replicate our PRS findings, but not signals of individual loci in an independent Danish cohort (iPSYCH 2015 case-cohort study, N=25,966). We observe strong genetic correlation between our case-case GWAS and that of case-control BD. Conclusions: We find that MDD and BD, including BD with a depressive onset, are genetically distinct. Further, our findings support the hypothesis that Controls - MDD - BD primarily lie on a continuum of genetic risk. Future studies with larger and richer samples will likely yield a better understanding of these findings and enable the development of better genetic predictors distinguishing BD and, importantly, BD with depressive onset from MDD.

Identification of genomic regions and pathways associated with traits related to rumen acidosis in feedlot Nellore cattle.

There may be an increased risk of metabolic disorders, such as rumen acidosis, in cattle fed high-concentrate diets, particularly those from Bos taurus indicus genotypes, which have shown to be more sensitive to ruminal acidification. Therefore, this study aimed to estimate (co)variance components and identify genomic regions and pathways associated with ruminal acidosis in feedlot Nellore cattle fed high-concentrate diets. It was utilized a dataset containing a total of 642 Nellore bulls that were genotyped from seven feedlot nutrition studies. The GGP Indicus 35k panel was used with the single step genome-wide association study methodology in which the effects of the markers were obtained from the genomic values estimated by the GBLUP model. A bivariate model to estimate genetic correlations between the economically important traits and indicator traits for acidosis was used. The traits evaluated in this study that were nutritionally related to rumen acidosis included average daily gain (ADG), final body weight, time spent eating (TSE), time spent ruminating, rumenitis score (RUM), rumen absorptive surface area (ASA), rumen keratinized layer thickness (KER) and hot carcass weight (HCW). The identified candidate genes were mainly involved in the negative or non-regulation of the apoptotic process, salivary secretion, and transmembrane transport. The genetic correlation between HCW and ASA was low positive (0.27 ± 0.23), and between ADG and ASA was high moderate (0.58 ± 0.59). A positive genetic correlation between RUM and all performance traits was observed, and TSE correlated negatively with HCW (-0.33 ± 0.21), ASA (-0.75 ± 0.48), and KER (-0.40 ± 0.27). The genetic association between economically important traits and indicator traits for acidosis suggested that Nellore cattle may be more sensitive to acidosis in feedlot systems.

Exploring potooxidative degradation pathways of harmol and harmalol alkaloids in water: effects of pH, excitation sources and atmospheric conditions.

This work explores the photochemical degradation of cationic species of 7-hydroxy-1-methyl-2H-pyrido[3,4-b]indole or harmol (1C) and the corresponding partially hydrogenated derivative 7-hydroxy-1-methyl-3,4-dihydro-2H-pyrido[3,4-b]indole or harmalol (2C) in aqueous solution. UV-visible absorption and fluorescence emission spectroscopy coupled with multivariate data analysis (MCR-ALS and PARAFAC), HPLC and HRESI-MS techniques were used for both quantitative and qualitative analysis. The formation of hydrogen peroxide reactive oxygen species (ROS) was quantified, and the influence of pH, oxygen partial pressure and photoexcitation source on the photochemical degradation of both compounds was assessed. The potential implications on the biosynthesis of ßCs and their biological role in living systems are discussed.

Adaptive exponential integrate-and-fire model with fractal extension.

The description of neuronal activity has been of great importance in neuroscience. In this field, mathematical models are useful to describe the electrophysical behavior of neurons. One successful model used for this purpose is the Adaptive Exponential Integrate-and-Fire (Adex), which is composed of two ordinary differential equations. Usually, this model is considered in the standard formulation, i.e., with integer order derivatives. In this work, we propose and study the fractal extension of Adex model, which in simple terms corresponds to replacing the integer derivative by non-integer. As non-integer operators, we choose the fractal derivatives. We explore the effects of equal and different orders of fractal derivatives in the firing patterns and mean frequency of the neuron described by the Adex model. Previous results suggest that fractal derivatives can provide a more realistic representation due to the fact that the standard operators are generalized. Our findings show that the fractal order influences the inter-spike intervals and changes the mean firing frequency. In addition, the firing patterns depend not only on the neuronal parameters but also on the order of respective fractal operators. As our main conclusion, the fractal order below the unit value increases the influence of the adaptation mechanism in the spike firing patterns.

Lithium response in bipolar disorder is associated with focal adhesion and PI3K-Akt networks: a multi-omics replication study.

Lithium is the gold standard treatment for bipolar disorder (BD). However, its mechanism of action is incompletely understood, and prediction of treatment outcomes is limited. In our previous multi-omics study of the Pharmacogenomics of Bipolar Disorder (PGBD) sample combining transcriptomic and genomic data, we found that focal adhesion, the extracellular matrix (ECM), and PI3K-Akt signaling networks were associated with response to lithium. In this study, we replicated the results of our previous study using network propagation methods in a genome-wide association study of an independent sample of 2039 patients from the International Consortium on Lithium Genetics (ConLiGen) study. We identified functional enrichment in focal adhesion and PI3K-Akt pathways, but we did not find an association with the ECM pathway. Our results suggest that deficits in the neuronal growth cone and PI3K-Akt signaling, but not in ECM proteins, may influence response to lithium in BD.

ECGVEDNET: A Variational Encoder-Decoder Network for ECG Delineation in Morphology Variant ECGs.

Electrocardiogram (ECG) delineation to identify the fiducial points of ECG segments, plays an important role in cardiovascular diagnosis and care. Whilst deep delineation frameworks have been deployed within the literature, several factors still hinder their development: (a) data availability: the capacity of deep learning models to generalise is limited by the amount of available data; (b) morphology variations: ECG complexes vary, even within the same person, which degrades the performance of conventional deep learning models. To address these concerns, we present a large-scale 12-leads ECG dataset, ICDIRS, to train and evaluate a novel deep delineation model-ECGVEDNET. ICDIRS is a large-scale ECG dataset with 156,145 QRS onset annotations and 156,145 T peak annotations. ECGVEDNET is a novel variational encoder-decoder network designed to address morphology variations. In ECGVEDNET, we construct a well-regularized latent space, in which the latent features of ECG follow a regular distribution and present smaller morphology variations than in the raw data space. Finally, a transfer learning framework is proposed to transfer the knowledge learned on ICDIRS to smaller datasets. On ICDIRS, ECGVEDNET achieves accuracy of 86.28%/88.31% within 5/10 ms tolerance for QRS onset and accuracy of 89.94%/91.16% within 5/10 ms tolerance for T peak. On QTDB, the average time errors computed for QRS onset and T peak are -1.86 ± 8.02 ms and -0.50 ± 12.96 ms, respectively, achieving state-of-the-art performances on both large and small-scale datasets. We will release the source code and the pre-trained model on ICDIRS once accepted.

Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce.

Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.

Satellite mapping reveals extensive industrial activity at sea.

The world's population increasingly relies on the ocean for food, energy production and global trade1-3, yet human activities at sea are not well quantified4,5. We combine satellite imagery, vessel GPS data and deep-learning models to map industrial vessel activities and offshore energy infrastructure across the world's coastal waters from 2017 to 2021. We find that 72-76% of the world's industrial fishing vessels are not publicly tracked, with much of that fishing taking place around South Asia, Southeast Asia and Africa. We also find that 21-30% of transport and energy vessel activity is missing from public tracking systems. Globally, fishing decreased by 12 ± 1% at the onset of the COVID-19 pandemic in 2020 and had not recovered to pre-pandemic levels by 2021. By contrast, transport and energy vessel activities were relatively unaffected during the same period. Offshore wind is growing rapidly, with most wind turbines confined to small areas of the ocean but surpassing the number of oil structures in 2021. Our map of ocean industrialization reveals changes in some of the most extensive and economically important human activities at sea.

Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals.

BACKGROUND AND AIMS: Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be re-evaluated. We tested 3 outreach approaches for transitioning patients to the 10-year interval recommendation. METHODS: This was a 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. The setting was Kaiser Permanente Northern California, a large integrated healthcare system. Participants were patients 54-70 years of age with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all 3 outreach modalities. Patients were randomly assigned to the outreach arm (telephone [n = 200], secure message [n = 203], and mailed letter [n = 201]) stratified by age, sex, and race/ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval. RESULTS: Sixty-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) vs mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared with mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% confidence interval: 8.3%-27.9%) and secure message outreach (13.1%; 97.5% confidence interval: 3.5%-22.7%) vs mailed letter outreach. CONCLUSIONS: Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting. (ClinicalTrials.gov, Number: NCT05389397).