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1.
Can Commun Dis Rep ; 50(7-8): 260-273, 2024.
Article in English | MEDLINE | ID: mdl-39170590

ABSTRACT

Background: Social capital can be used as a conceptual framework to include social context as a predictor of human papillomavirus (HPV) vaccination and cervical cancer screening behaviours. However, the effectiveness of interventions that use social capital as a mechanism to improve uptake of immunization and screening remains elusive. Objective: To synthesize empirical evidence on the impact of social capital interventions on HPV immunization and cervical cancer screening and describe key characteristics of such interventions. Methods: Using a rapid review methodology, a search of literature published between 2012 and 2022 was conducted in four databases. Two researchers assessed the studies according to inclusion criteria in a three-step screening process. Studies were assessed for quality and data concerning social capital and equity components and intervention impact were extracted and analyzed using narrative synthesis. Results: Seven studies met the inclusion criteria. Studies found improved knowledge, beliefs and intentions regarding HPV immunization and cervical cancer screening. None of the studies improved uptake of immunization; however, three studies found post-intervention improvements in uptake of cervical cancer screening. All studies either tailored their interventions to meet the needs of specific groups or described results for specific disadvantaged groups. Conclusion: Limited evidence suggests that interventions that consider and reflect local context through social capital may be more likely to increase the uptake of HPV immunization and cervical cancer screening. However, further research must be done to bridge the gap in translating improvements in knowledge and intention into HPV immunization and cervical cancer screening behaviours.

2.
World J Gastrointest Oncol ; 16(8): 3521-3528, 2024 Aug 15.
Article in English | MEDLINE | ID: mdl-39171162

ABSTRACT

BACKGROUND: Bevacizumab, an anti-vascular endothelial growth factor (VEGF) monoclonal antibody, inhibits angiogenesis and reduces tumor growth. Serum VEGF-C, lactate dehydrogenase, and inflammatory markers have been reported as predictive markers related to bevacizumab treatment. Programmed cell death ligand 1 (PD-L1) could act upon VEGF receptor 2 to induce cancer cell angiogenesis and metastasis. AIM: To investigate the efficacy of bevacizumab-containing chemotherapy in patients with metastatic colorectal cancer (CRC) according to the expression of PD-L1. METHODS: This analysis included CRC patients who received bevacizumab plus FOLFOX or FOLFIRI as first-line therapy between June 24, 2014 and February 28, 2022, at Samsung Medical Center (Seoul, South Korea). Analysis of patient data included evaluation of PD-L1 expression by the combined positive score (CPS). We analyzed the efficacy of bevacizumab according to PD-L1 expression status in patients with CRC. RESULTS: A total of 124 patients was included in this analysis. Almost all patients were treated with bevacizumab plus FOLFIRI or FOLFOX as the first-line chemotherapy. While 77% of patients received FOLFOX, 23% received FOLFIRI as backbone first-line chemotherapy. The numbers of patients with a PD-L1 CPS of 1 or more, 5 or more, or 10 or more were 105 (85%), 64 (52%), and 32 (26%), respectively. The results showed no significant difference in progression-free survival (PFS) and overall survival (OS) with bevacizumab treatment between patients with PD-L1 CPS less than 1 and those with PD-L1 CPS of 1 or more (PD-L1 < 1% vs PD-L1 ≥ 1%; PFS: P = 0.93, OS: P = 0.33), between patients with PD-L1 CPS less than 5 and of 5 or more (PD-L1 < 5% vs PD-L1 ≥ 5%; PFS: P = 0.409, OS: P = 0.746), and between patients with PD-L1 CPS less than 10 and of 10 or more (PD-L1 < 10% vs PD-L1 ≥ 10%; PFS: P = 0.529, OS: P = 0.568). CONCLUSION: Chemotherapy containing bevacizumab can be considered as first-line therapy in metastatic CRC irrespective of PD-L1 expression.

3.
ACS Omega ; 9(32): 34259-34267, 2024 Aug 13.
Article in English | MEDLINE | ID: mdl-39157099

ABSTRACT

Ruegeria atlantica and Pseudoalteromonas neustonica are fish gut bacteria that have been isolated from the guts of Pagrus major and Acanthopagrus schlegelii, respectively. A total of 22 compounds (1-22) were isolated from these two bacteria; 16 compounds (1-16) from R. atalantica and 6 compounds (17-22) from P. neustonica. Their chemical structures were elucidated by spectroscopic and spectrometric data analysis and chemical synthesis. Compounds 11 and 13 showed strong collagenase inhibitory activity, with 31.91% and 36.43% at 20 µM, respectively, comparable to or surpassing that of the positive control epigallocatechin gallate (EGCG, 34.66%). Also, compounds 11 and 14 exhibited a mild tyrosinase inhibitory effect of 6.73% and 13.68%, respectively. All of the tested compounds displayed no significant antibacterial activity against Escherichia coli and Bacillus subtilis up to 100 µM. The collagenase- and tyrosinase-inhibitory compound 11, cyclo(l-Pro-d-Leu), was found to be stable under heat (50 °C) and UV light (254 and 365 nm) for up to 6 days. These results indicate that compound 11 could be developed into a cosmeceutical with antiaging effects.

4.
Org Lett ; 2024 Aug 19.
Article in English | MEDLINE | ID: mdl-39159400

ABSTRACT

Chemical synthesis plays a crucial role in confirming and revising the structures of natural products. Through meticulous synthetic efforts, NMR spectroscopic and single-crystal X-ray diffraction analyses, DFT calculations, and mass spectrometric investigations, we revised the structure of securingine E. The revised structure of securingine E was unambiguously confirmed by its chemical synthesis.

5.
Eur J Pharm Sci ; : 106878, 2024 Aug 17.
Article in English | MEDLINE | ID: mdl-39159789

ABSTRACT

The aim of this study was to investigate the impact of genetic polymorphisms on methotrexate (MTX) metabolism in Korean children and young adults with acute lymphoblastic leukemia, specifically focusing on MTX polyglutamates (MTX-PGs) in erythrocytes, which have been rarely studied. Korean children and young adult patients undergoing maintenance therapy for acute lymphoblastic leukemia, who were receiving weekly oral MTX doses of 20 mg/m²/week, were prospectively included. We investigated erythrocyte MTX-PG (PG1 to PG5) levels, MTX-PG/MTX dose ratios, and 222 genetic polymorphisms spanning 78 genes and three intergenic areas related to MTX transport, folate cycle metabolism, purine/pyrimidine pathways, and non-pathway genes (including TPMT and NUDT15 genotypes) to explore their association with MTX metabolism. MTX-PG levels were associated with MTX dose (p < 0.05), and MTX-PG3 comprised the majority of the total MTX-PGs, with a median of 39.3%. Various polymorphisms within the same gene demonstrated differing associations with each type of MTX-PG, underscoring the complexity of MTX pharmacogenetics. Among the polymorphisms examined, 14 across 13 genes showed significant associations with MTX-PG2-5 levels, even after adjusting for the false discovery rate (ABCC5, ATG16L1, CEP72, FSTL5, GMPS, HTR3A, IMPDH1, NT5C2, SLC28A3, SLCO1B3, SUCLA2, TPMT, and TYMS). This study enhances our understanding of genetic polymorphisms in MTX metabolism and therapeutic monitoring for MTX maintenance, promoting personalized medicine in acute lymphoblastic leukemia patients.

8.
Transl Vis Sci Technol ; 13(8): 2, 2024 Aug 01.
Article in English | MEDLINE | ID: mdl-39087930

ABSTRACT

Purpose: Homozygous hypomorphic variants of the RP1 gene, including c.5797C>T, p.Arg1933Ter, have traditionally been considered non-pathogenic. This study aimed to elucidate the clinical manifestations of late-onset, slowly progressive cone/macular dystrophy in patients homozygous for p.Arg1933Ter in the RP1 gene. Methods: Five patients with biallelic p.Arg1933Ter in RP1 were retrospectively recruited, and their clinical profiles were analyzed. Copy number variation analysis and Alu insertion assessment of genes associated with inherited retinal diseases were conducted. The results of comprehensive ophthalmological examinations, multimodal imaging, and full-field electroretinogram tests were analyzed. Results: No specific sequencing errors or structural variations associated with the clinical phenotypes were identified. Alu element insertion in RP1 was not detected. The mean ± SD age at the first visit was 62.2 ± 9.8 years, with symptoms typically starting between 45 and 50 years of age. Two patients exhibited a mild form of cone/macular dystrophy, characterized by a relatively preserved fundus appearance and blurring of the ellipsoid zone on optical coherence tomography. Three patients had late-onset cone/macular dystrophy with significant atrophy. Conclusions: To our knowledge, this study is the first to report that a homozygous hypomorphic variant of RP1, previously considered non-pathogenic, leads to cone/macular dystrophy. Translational Relevance: The study introduces novel possibilities suggesting that the homozygous hypomorphic variant of RP1 may be linked to variant pathogenicity.


Subject(s)
Electroretinography , Eye Proteins , Tomography, Optical Coherence , Humans , Male , Female , Middle Aged , Retrospective Studies , Aged , Eye Proteins/genetics , Visual Acuity , DNA Copy Number Variations/genetics , Disease Progression , Cone Dystrophy/genetics , Cone Dystrophy/diagnostic imaging , Macular Degeneration/genetics , Macular Degeneration/pathology , Macular Degeneration/diagnostic imaging , Macular Degeneration/congenital , Pedigree , Homozygote , Phenotype , Mutation , Adult , Age of Onset , Microtubule-Associated Proteins
9.
iScience ; 27(8): 110495, 2024 Aug 16.
Article in English | MEDLINE | ID: mdl-39148712

ABSTRACT

The isolation of a natural product conventionally precedes its chemical synthesis. Often, the isolation and structure determination of a natural product present in minute quantities in its natural source pose formidable challenges, akin to finding "a needle in a haystack." On the other hand, leveraging plausible biosynthetic insights and biomimetic synthetic expertise would allow for the prior synthesis of presumed natural products, followed by their verification in natural sources. In this study, we unveil two novel securinega alkaloids, securingines H and I, employing the natural product anticipation through synthesis approach. Structural analysis of securingines H and I suggests that they are biosynthetic derivatives of secu'amamine E and securinol A, respectively. We posit that this "synthesis first" strategy represents a valuable approach to the discovery of new natural products.

10.
Ann Surg Oncol ; 2024 Aug 01.
Article in English | MEDLINE | ID: mdl-39090496

ABSTRACT

BACKGROUND: The role that preoperative Satisfaction with Breast plays in a patient's postoperative course after postmastectomy breast reconstruction (PMBR) is not understood. The aim of this study is to understand the impact of the preoperative score on postoperative outcome as an independent variable. METHODS: We examined patients who underwent PMBR between 2017 and 2021 and who completed the BREAST-Q Satisfaction with Breasts at 1 year postoperatively. Two multiple linear regression models (Model 1 with the preoperative Satisfaction with Breasts score and Model 2 without the preoperative score), likelihood ratio tests, simple t-statistics, and sample patient dataset to predict the 1 year score were performed. Multiple imputation was used to account for missing preoperative scores. RESULTS: Overall, 2324 patients were included. Model 1 showed that the preoperative score is significantly associated with the postoperative score (ß = 0.09, 95% confidence interval 0.04-0.14; p < 0.001). Comparing Model 1 and Model 2 demonstrated that including preoperative Satisfaction with Breasts in a regression significantly improves model fit (test statistic = 10.04; p = 0.0021). Using the absolute value of the t-statistics as a measure of variable importance in linear regression, the importance of the preoperative score was quantified as 3.39-more important than neoadjuvant radiation, mastectomy weight, body mass index, bilateral prophylactic mastectomy, and race, but less than adjuvant radiation, reconstruction type, and psychiatric diagnoses. CONCLUSION: Preoperative Satisfaction with Breasts scores are an important independent predictor of postoperative satisfaction after PMBR. Just as vital sign and work-up are carefully documented before surgery, preoperative scores should be collected to pre-emptively gauge patients' satisfaction and optimize postoperative outcomes.

11.
J Med Food ; 2024 Aug 08.
Article in English | MEDLINE | ID: mdl-39116888

ABSTRACT

Menopausal depression, often associated with hormonal fluctuations such as decreased estrogen levels, imposes significant mental health burdens. Despite the antidepressant biological properties of standardized rice bran supplement (RBS), its impact on menopausal depression and underlying mechanisms remains largely unexplored. In this study, we investigated the antidepressant effects of RBS in a mouse model of estrogen deficiency-induced depression. Ovariectomized (OVX) mice received oral doses of RBS (250 and 1000 mg/kg) and 17ß estradiol over a 20-week period. RBS administration resulted in decreased immobility time in the tail suspension and forced swim tests, along with increased locomotor activity in the open field test. Furthermore, RBS enhanced nitric oxide production and neuronal nitric oxide synthase (nNOS) expression in the hippocampi of OVX mice. Additionally, RBS administration phosphorylated extracellular signal-regulated kinase (ERK), cAMP response element-binding protein (CREB), and tropomyosin receptor kinase B and increased the protein expression of brain-derived neurotrophic factor (BDNF) in the hippocampus. These findings suggest that RBS alleviated depressive behaviors in OVX mice by augmenting hippocampal nNOS expression and activating the ERK-CREB-BDNF signaling pathway. Therefore, based on these results, we propose that RBS is a promising agent to treat menopausal depression, a challenging condition.

13.
Sci Total Environ ; 946: 174497, 2024 Oct 10.
Article in English | MEDLINE | ID: mdl-38969131

ABSTRACT

Partial nitrification (PN) is crucial for anaerobic ammonium oxidation (ANAMMOX), but faces challenges such as high energy demands and process control. Recent research has highlighted additives like magnetite as potential alternatives to conventional electron acceptors (O2 and NO2-) for enhancing ammonium (NH4+) oxidation with lower energy consumption. This study investigated the effect of adding 50 mg/L of magnetite to ANAMMOX reactors, resulting in improved nitrogen (N) removal efficiency. The magnetite-added ANAMMOX (M-ANA) reactor yielded N removal efficiencies of 71 %, 66 %, and 57 % for NH4+:NO2- molar ratios of 1:1.3, 1:0.8, and 1:0.5, respectively. The M-ANA reactor operated under a 0.5 mol lower NO2- concentration achieved similar performance to the control ANAMMOX (C-ANA) reactor operated with a theoretical amount of NO2-. Moreover, the M-ANA reactor showed the potential to remove NH4+ by 56 % without any NO2- supplementation. Metagenomic analysis showed that the addition of magnetite significantly improved the relative abundance of microorganisms involved in the FEAMMOX reaction, such as Fimbriimonas ginsengisoli and Pseudomonas stutzeri. It also facilitated positive mutualism between ANAMMOX and FEAMMOX reactions. In addition, M-ANA granules exhibited a dense and compact structure compared with C-ANA, and the presence of magnetite facilitated the formation of resilient granules. Notably, the useful protein (Heme C) concentration and specific microbial activity in the M-ANA reactor were 1.3 and 2.2 times higher than those in the C-ANA reactor. Overall, the results demonstrate that an appropriate amount of magnetite can enhance the N removal efficiency while reducing the energy input requirements and associated carbon emissions. These findings can guide the future development of carbon- and energy-neutral N removal processes.


Subject(s)
Ammonium Compounds , Bioreactors , Ferrosoferric Oxide , Nitrites , Oxidation-Reduction , Waste Disposal, Fluid , Bioreactors/microbiology , Anaerobiosis , Waste Disposal, Fluid/methods , Nitrites/metabolism , Ammonium Compounds/metabolism , Nitrification , Bacteria/metabolism
15.
J Craniofac Surg ; 2024 Jul 12.
Article in English | MEDLINE | ID: mdl-38994844

ABSTRACT

Sagittal mandibular fractures are challenging to manage using traditional open reduction and internal fixation techniques due to the difficulty in manually reducing mandibular fragments and performing osteosynthesis on the lingual side. In addition, there is a risk of damaging dental roots with screws during fixation. In this case, the authors employed the lag screw technique combined with digitally guided surgery to effectively perform osteosynthesis on the fragments and avoid iatrogenic tooth and nerve injury.

16.
J Korean Med Sci ; 39(26): e199, 2024 Jul 08.
Article in English | MEDLINE | ID: mdl-38978486

ABSTRACT

BACKGROUND: The relationship between aspirin usage and the risk of colorectal cancer (CRC) among individuals with both hypertension (HTN) and diabetes mellitus (DM) remains unclear. This study aims to explore the impact of aspirin use on the site-specific CRC risk in patients with metabolic comorbidity. METHODS: A case-control study was conducted among 1,331 CRC patients and 2,771 controls recruited from the Nation Cancer Center in Korea. Multinomial logistic regression analyses were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between aspirin use, metabolic disease status, and site-specific CRC risk. RESULTS: Among the 4,102 participants, 1,191 individuals had neither HTN nor DM, 2,044 were diagnosed with HTN, 203 with DM, and 664 presented with HTN and DM comorbidity. An increasing number of HTN and DM was associated with an increased risk of overall CRC (HTN or DM: OR, 1.70; 95% CI, 1.39-2.07; HTN and DM: OR, 8.43; 95% CI, 6.37-11.16), while aspirin use was associated with a decreased risk of overall CRC (OR, 0.31; 95% CI, 0.21-0.46). These results remained consistent across anatomical sites. Among individuals with HTN and DM comorbidity, aspirin use notably associated with lower risk of overall CRC (OR, 0.39; 95% CI, 0.21-0.72), proximal colon (OR, 0.32; 95% CI, 0.13-0.71) and rectal cancer (OR, 0.27; 95% CI, 0.08-0.97), but not distal colon cancer (OR, 0.58; 95% CI, 0.27-1.24). CONCLUSION: This study showed that aspirin use is negatively associated with overall and site-specific CRC, even among individuals with HTN and DM comorbidity.


Subject(s)
Aspirin , Colorectal Neoplasms , Comorbidity , Hypertension , Humans , Aspirin/therapeutic use , Male , Female , Middle Aged , Case-Control Studies , Colorectal Neoplasms/epidemiology , Aged , Odds Ratio , Hypertension/epidemiology , Hypertension/complications , Risk Factors , Logistic Models , Diabetes Mellitus/epidemiology , Republic of Korea/epidemiology , Adult
17.
Plants (Basel) ; 13(14)2024 Jul 11.
Article in English | MEDLINE | ID: mdl-39065442

ABSTRACT

Phedimus aizoon has been utilized as a medicinal plant in Asia. However, the production of phytochemical-rich extracts from P. aizoon and the evaluation of their bioactivity are limited. Herein, phytochemical-rich extracts were prepared by ultrasound-assisted extraction of P. aizoon, with a high extraction yield of 16.56%. The extracts contained about 126 mg of phenolics and 31 mg of flavonoids per g of the extracts. The chromatographic analysis (GC-MS and HPLC analyses) identified 19 notable phytochemicals of the extracts from P. aizoon, including pentacosane, hexadecanoic acid, gallic acid, vanillic acid, and quercetin. The gallic acid content of the extracts was relatively high at 2.75 mg/g. The identified compounds are known to have various bioactivities, such as antioxidant, antibacterial, and antifungal activities. In fact, the prepared extracts exhibited antioxidant activity at 24-28% of that of ascorbic acid. In addition, it showed antibacterial activity against both Escherichia coli (Gram-negative bacteria) and Staphylococcus aureus (Gram-positive bacteria). This study highlights that P. aizoon deserves attention as a natural bioactive substance and emphasizes the need for applications of the extracts from P. aizoon.

18.
Article in English | MEDLINE | ID: mdl-39003647

ABSTRACT

BACKGROUND: Wheat allergy is one of the most prevalent allergens in Korea, decreasing quality of life and causing nutritional repercussions. OBJECTIVE: We aimed to investigate the efficacy and safety of the home-based wheat oral immunotherapy (OIT) using wheat noodles in children with a wheat allergy. METHODS: We conducted a retrospective study involving 72 children aged 3 to 17 years diagnosed with a wheat allergy. Patients received wheat OIT using wheat noodles (n = 50) and were compared with a historical control group (n = 22). Baseline characteristics, adverse events, and immunological changes were assessed. Predictors of successful desensitization were identified using logistic regression analysis. RESULTS: Among 50 patients completing the up-dosing phase, 82.0% achieved desensitization to 2,400 mg of wheat protein, compared to 4.5% in the control group (p < 0.001). During the up-dosing period, the median number of adverse reactions per person was 2, and anaphylaxis occurred in 30.0% (15/50). However, there were no life-threatening adverse events. In multivariable analysis, the presence of asthma (adjusted odds ratio [aOR], 8.88; 95% confidence interval [CI], 1.10-71.97; p = 0.041) and a higher ratio of specific IgE (sIgE) to ω-5-gliadin and total IgE (aOR 19.09, 95%CI 1.21-300.80, p = 0.036) were significantly associated with treatment outcomes of wheat OIT. CONCLUSION: Our study showed the safety and efficacy of home-based wheat OIT using boiled noodles in Korean children with wheat allergies. Careful consideration is warranted for patients with elevated baseline sIgE to ω-5-gliadin to total IgE ratio and a history of asthma.

19.
JMIR Public Health Surveill ; 10: e51891, 2024 Jul 30.
Article in English | MEDLINE | ID: mdl-39078683

ABSTRACT

BACKGROUND: Understanding the association between hypertension prevalence and socioeconomic and behavioral variables during a pandemic is essential, and this analysis should extend beyond short-term trends. OBJECTIVE: This study aims to examine long-term trends in the prevalence of participants diagnosed with and receiving treatment for hypertension, using data collected by a nationally representative survey from 2009 to 2022, which includes the COVID-19 pandemic era. METHODS: A nationwide, population-based, cross-sectional study used data collected from the South Korea Community Health Survey between 2009 and 2022. The study sample comprised 3,208,710 Korean adults over a period of 14 years. We aimed to assess trends in the prevalence of participants diagnosed with and receiving treatment for hypertension in the national population from 2009 to 2022, with a specific focus on the COVID-19 pandemic, using weighted linear regression models. RESULTS: Among the included 3,072,546 Korean adults, 794,239 (25.85%) were aged 19-39 years, 1,179,388 (38.38%) were aged 40-59 years; 948,097 (30.86%) were aged 60-79 years, and 150,822 (4.91%) were aged 80 years or older. A total of 1,426,379 (46.42%) were men; 761,896 (24.80%) and 712,264 (23.18%) were diagnosed with and received treatment for hypertension, respectively. Although the overall prevalence over the 14-year period increased, the upward trends of patients diagnosed with and receiving treatment for hypertension decreased during the COVID-19 pandemic era compared with the prepandemic era (ß difference for trend during vs before the pandemic -.101, 95% CI -0.107 to -0.094 vs -.133, 95% CI -0.140 to -0.127). Notably, the trends in prevalence during the pandemic were less pronounced in subgroups of older adults (≥60 years old) and individuals with higher alcohol consumption (≥5 days/month). CONCLUSIONS: This nationwide representative study found that the national prevalence of participants diagnosed with and receiving treatment for hypertension increased during the prepandemic era. However, there was a marked decrease in these trends during the prepandemic era, compared with the pandemic era, particularly among specific subgroups at increased risk of negative outcomes. Future studies are needed to evaluate the factors associated with changes in the prevalence of hypertension during the COVID-19 pandemic.


Subject(s)
COVID-19 , Hypertension , Humans , Republic of Korea/epidemiology , Hypertension/epidemiology , COVID-19/epidemiology , Prevalence , Middle Aged , Adult , Female , Male , Cross-Sectional Studies , Aged , Young Adult , Pandemics , Health Surveys
20.
Vascular ; : 17085381241263190, 2024 Jul 19.
Article in English | MEDLINE | ID: mdl-39027947

ABSTRACT

BACKGROUND: Although renal artery aneurysms (RAAs) are rare and often asymptomatic with slow growth, their natural progression and optimal management are not well understood. Treatment recommendations for RAAs do exist; however, they are supported by limited data. METHODS: A retrospective cohort study was conducted to explore the management of patients diagnosed with an RAA at our institution from January 1st, 2013, to December 31st, 2020. Patients were identified through a search of our radiological database, followed by a comprehensive chart review for further assessment. Data collection encompassed patient and aneurysm characteristics, the rationale for initial imaging, treatment, surveillance, and all-cause mortality. RESULTS: One hundred eighty-five patients were diagnosed with or treated for RAAs at our center during this timeframe, with most aneurysms having been discovered incidentally. Average aneurysm size was 1.40 cm (±0.05). Of those treated, the mean size was 2.38 cm (±0.24). Among aneurysms larger than 3 cm in size, comprising 3.24% of the total cases, 83.3% underwent treatment procedures. Only 20% of women of childbearing age received treatment for their aneurysms. There was one instance of aneurysm rupture, with no associated mortality or significant morbidity. CONCLUSIONS: Our institution's management of RAAs over the period of the study generally aligned with guidelines. One potential area of improvement is more proactive intervention for women of childbearing age.

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