Phytochemical composition, biological activity and anti-inflammatory potential of acetone extract from the lichen Platismatia glauca (L.) W.L. Culb. & C.F. Culb.

This investigation examined the antioxidant, antimicrobial, cytotoxic, and anti-inflammatory activities of the acetone extract of the lichen Platismatia glauca (L.) W.L. Culb. & C.F. Culb. (PGAE). The phytochemical study of PGAE showed presence of seven compounds: salazinic acid, ß-orcinol carboxylic acid, 3-hydroxyphysodalic acid, physodalic acid, physodic acid, atranorin, and chloroatranorin. The antimicrobial potential was determined by microdilution which showed that S. aureus was most sensitive to the effect of PGAE with MIC value 0.312 mg/ml. Antioxidant activity was evaluated by using DPPH method. The obtained IC50 value for PGAE was 194.30 ± 3.32 µg/ml. The cytotoxic effect of the extract was evaluated by MTT test and the strongest activity was towards human epithelial carcinoma cells with IC50 value of 59.10 ± 0.46 µg/ml. The findings revealed that the application of lichen extracts decreased the paw edoema in a dose-dependent manner at 1, 2, 3, and 4 h following carrageenan administration.

Topical Application of Siberian Pine Essential Oil Formulations Enhance Diabetic Wound Healing.

This study aimed to develop novel topical formulations based on a natural component (0.5% of Siberian pine essential oil) and to assess its wound-healing capacity through macroscopic, histopathological, and biochemical examination. The phytochemical profile of Pinus sibirica essential oil (PSEO) and rheological analysis and safety potential of formulations were determined. The wound-healing effect was evaluated on an excision wound model in diabetic Wistar albino rats randomly divided into the following groups topically treated with (1) untreated, (2) 1% silver sulfadiazine, (3) ointment base, (4) gel base, (5) PSEO ointment, and (6) PSEO gel. Formulations containing PSEO were stable and safe for skin application. Three weeks of treatment with both PSEO formulations (ointment and gel) led to a significant reduction in wound size (98.14% and 96.28%, respectively) and a remarkably higher level of total hydroxyproline content (9.69 µg/mg and 7.26 µg/mg dry tissue, respectively) relative to the control group (65.97%; 1.81 µg/mg dry tissue). These findings were in correlation with histopathological results. Topically applied PSEO formulations were associated with a significant reduction in most of the measured pro-oxidants and enhanced activity of the antioxidant defense system enzymes (p < 0.05). Our findings showed that gel and ointment with PSEO demonstrated significant wound-repairing capabilities in the excision wound model.

Lady's Bedstraw as a Powerful Antioxidant for Attenuation of Doxorubicin-Induced Cardiotoxicity.

This study aimed to examine the effects of a 14-day treatment with lady's bedstraw methanol extract on doxorubicin-induced cardiotoxicity through functional, biochemical and histological examinations. We used 24 male Wistar albino rats divided into the following groups: control (CTRL), doxorubicin (DOX), and DOX + GVE (Galium verum extract). GVE was administered orally at a dose of 50 mg/kg per day for 14 days, while a single dose of doxorubicin was injected into the DOX groups. After accomplishing treatment with GVE, cardiac function was assessed, which determined the redox state. During the autoregulation protocol on the Langendorff apparatus, ex vivo cardiodynamic parameters were measured. Our results demonstrated that the consumption of GVE effectively suppressed the disturbed response of the heart to changes in perfusion pressures caused by administration of DOX. Intake of GVE was associated with a reduction in most of the measured prooxidants in comparison to the DOX group. Moreover, this extract was capable of increasing the activity of the antioxidant defense system. Morphometric analyses showed that rat hearts treated with DOX showed more pronounced degenerative changes and necrosis compared to the CTRL group. However, GVE pretreatment seems to be able to prevent the pathological injuries caused by DOX injection via decrease in oxidative stress and apoptosis.

Synthesis and Investigation of Anti-Inflammatory Activity of New Thiourea Derivatives of Naproxen.

The aim of the study was a synthesis and investigation of the dose-dependent anti-inflammatory effect of new thiourea derivatives of naproxen with selected aromatic amines and esters of aromatic amino acids. The results of the in vivo study indicate that derivatives of m-anisidine (4) and N-methyl tryptophan methyl ester (7) showed the most potent anti-inflammatory activity four hours after injection of carrageenan, with the percentage of inhibition of 54.01% and 54.12%, respectively. In vitro assays of COX-2 inhibition demonstrated that none of the tested compounds achieved 50% inhibition at concentrations lower than 100 µM. On the other hand, the aromatic amine derivatives (1-5) accomplished significant inhibition of 5-LOX, and the lowest IC50 value was observed for compound 4 (0.30 µM). High anti-edematous activity of compound 4 in the rat paw edema model, together with potent inhibition of 5-LOX, highlight this compound as a promising anti-inflammatory agent.

The impact of the COVID-19 pandemic on the trend of prescribing long-acting injections of paliperidone and risperidone in Central Serbia.

Since the end of 2019, the global spread of COVID-19 has represented a historic event that changed our way of treating patients globally. The use of long-acting injections (LAI) antipsychotics was emphasized. Our goal was to investigate the impact of COVID-19 on the frequency of prescribing LAI and compare it with a period before. All patients (198) who started LAI-risperidone or LAI-paliperidone for the period 2017-2022, in Kragujevac, the city in Central Serbia, were considered. The frequency of prescribing LAI before and during COVID-19 and the total number of prescribed LAI per year were compared. Separately, the frequency of prescribing LAI-R and the frequency of prescribing LAI-P were compared. The significant (p < 0,05) increase in the use of LAI risperidone and paliperidone was in 2020 and 2021 [per year 2017(3), 2018(6), 2019(26), 2020(75), 2021(55), and 2022(33)]. The significant (p < 0,05) increase in monthly and quarterly preparations of LAI paliperidone was in 2020 and 2021 relative to the years before the pandemic. As the pandemic weakened, the inclusion of LAI paliperidone therapy weakened during 2022. A significant increase in usage of LAI risperidone was in 2022, and in 2020 and 2021 was as it was in the period 2017-2019. During COVID-19, especially in years when COVID-19 restriction measures were stricter, there was a significant change in the application method of antipsychotic therapy in favor of LAI. Regardless of the increase in treatment costs, patients' interests and protection were prioritized in the treatment process.

Synthesis, Characterization, and Investigation of Anti-Inflammatory and Cytotoxic Activities of Novel Thiourea Derivatives of Naproxen.

The objective of this study was to synthesize seven novel thiourea derivatives of naproxen (8-14), examine the anti-inflammatory activity of the newly synthesized compounds, investigate the cytotoxic potential of both sets of synthesized compounds (1-7 and 8-14), and select the most promising anti-inflammatory and antitumor drug candidates. The results of the in vivo anti-inflammatory study clearly showed that compounds 8 and 9 were capable of decreasing paw edema, as evident from a high percentage of inhibition (44.83% and 49.29%, respectively). In addition, the results of in vitro enzyme inhibition assays demonstrated that neither of the newly synthesized compounds reached 50% inhibition of 5-LOX at concentrations lower than 100 µM. In terms of antitumor potential, derivatives 3 and 8 exhibited strong cytotoxic effects on the HeLa cell line, suggesting the involvement of the extrinsic pathway of apoptosis. According to the overall results obtained for both sets of synthesized molecules, derivatives 4 and 8 can be underlined as molecules with the strongest anti-inflammatory activity, while derivatives 3 and 8 are the most promising cytotoxic agents.

Anti-inflammatory and Antioxidant Effects of Melissa officinalis Extracts: A Comparative Study.

Melissa officinalis L. (MO), traditionally referred to as lemon balm, is one of the lemon-scent aromatic herbs widely used in traditional medicine due to its calming, sedative, and anti-arrhythmic effects. Furthermore, several studies have linked its therapeutic potential with its antioxidant properties. Here, we aimed to evaluate and compare the content of active components, antioxidant, and anti-inflammatory potential of three different MO extracts (MOEs), ethanolic macerate (E1), aqueous (E2), and ethanolic (E3), obtained under reflux and their effects on systemic redox status after acute per os administration in vivo post-carrageenan application. The HPLC analysis revealed that the most abundant constituent in all the three extracts was rosmarinic acid (RA), with higher content in E1 and E3 than in E2 (P < 0.05). The highest flavonoid content was found in the aqueous extract, especially quercetin (P < 0.05). For the carrageenan-induced paw edema model, dark agouti rats were used and divided into the groups: Control, indomethacin, E1, E2, and E3 subgrouped according to applied doses: 50, 100, and 200 mg/kg. Ethanolic macerate (E1200) and aqueous (E2100) MOE were shown to be anti-inflammatory agents in the carrageenan paw edema model, with the most prominent edema inhibition in the sixth hour post-carrageenan (63.89% and 69.44%, respectively, vs. 76.67% in the indomethacin group). All the three extracts reduced the production of pro-oxidants H2O2 and TBARS post-carrageenan and increased GSH levels compared to control (P < 0.05). These data imply the possible future usage of MOEs to prevent inflammatory and oxidative stress-related diseases.

The Evaluation of Healing Properties of Galium verum-Based Oral Gel in Aphthous Stomatitis in Rats.

Although oral ulcers represent one of the most frequent oral mucosal diseases, the available treatment is not sufficient to provide complete ulcer recovery without side-effects. Therefore, the aim of our study was to prepare a mucoadhesive oral gel based on Galium verum ethanol extract (GVL gel) and reveal its healing effects in the model of aphthous stomatitis in rats. Rats with oral ulcers were divided into the following groups: control (untreated), gel base (ulcer was treated with the gel base, three times per day for 10 days), and GVL gel group (the ulcer was treated with GVL gel in the same way as the gel base). Animals from each group were sacrificed on days 0, 3, 6, and 10 for collecting blood and ulcer tissue samples. Healing properties of oral gel were determined by clinical evaluation, as well as biochemical and histopathological examinations. Our findings suggest a significant decrease in the ulcer size in GVL gel group, with healing effects achieved through the alleviation of oxidative stress, reduction in COX-2 immunopositivity, and increase in collagen content in buccal tissue. Significant ulcer repairing potential of GVL gel highlights this oral mucoadhesive gel as a promising tool for prevention and treatment of RAS.

Phytochemical Analysis, Antioxidant, Antimicrobial, and Cytotoxic Activity of Different Extracts of Xanthoparmelia stenophylla Lichen from Stara Planina, Serbia.

The aim of this study was to identify some of the secondary metabolites present in acetonic, methanolic, and hexanic extracts of lichen Xanthoparmelia stenophylla and to examine their antioxidant, antimicrobial, and cytotoxic activity. Compounds of the depsid structure of lecanoric acid, obtusic acid, and atranorin as well as usnic acid with a dibenzofuran structure were identified in the extracts by HPLC. The acetone extract was shown to have the highest total phenolic (167.03 ± 1.12 mg GAE/g) and total flavonoid content (178.84 ± 0.93 mg QE/g) as well as the best antioxidant activity (DPPH IC50 = 81.22 ± 0.54). However, the antimicrobial and antibiofilm tests showed the best activity of hexanic extract, especially against strains of B. cereus, B. subtilis, and S. aureus (MIC < 0.08, and 0.3125 mg/mL, respectively). Additionally, by using the MTT method, the acetonic extract was reported to exhibit a strong cytotoxic effect on the HeLa and HCT-116 cell lines, especially after 72 h (IC50 = 21.17 ± 1.85 and IC50 = 21.48 ± 3.55, respectively). The promising antioxidant, antimicrobial, and cytotoxic effects of Xanthoparmelia stenophylla extracts shown in the current study should be further investigated in vivo and under clinical conditions.

Short-Term Administration of Lemon Balm Extract Ameliorates Myocardial Ischemia/Reperfusion Injury: Focus on Oxidative Stress.

We aimed to investigate the cardioprotective effects of ethanolic Melissa officinalis L. extract (ME) in the rat model of myocardial ischemia/reperfusion (I/R) injury. Thirty-two Wistar rats were randomly divided into a CTRL non-treated control group with myocardial I/R injury and three experimental groups of rats treated with 50, 100, or 200 mg/kg of ME for 7 days per os. Afterward, hearts were isolated, and cardiodynamic function was assessed via the Langendorff model of global 20 min ischemia and 30 min reperfusion. Oxidative stress parameters were determined spectrophotometrically from the samples of coronary venous effluent (O2-, H2O2, TBARS, and NO2-,) and heart tissue homogenate (TBARS, NO2-, SOD, and CAT). H/E and Picrosirius red staining were used to examine cardiac architecture and cardiac collagen content. ME improved cardiodynamic parameters and achieved to preserve cardiac architecture after I/R injury and to decrease fibrosis, especially in the ME200 group compared to CTRL. ME200 and ME100 markedly decreased prooxidants TBARS, O2-, and H2O2 while increasing NO2-. Hereby, we confirmed the ME`s ability to save the heart from I/R induced damage, even after short-term preconditioning in terms of preserving cardiodynamic alterations, cardiac architecture, fibrosis, and suppressing oxidative stress, especially in dose of 200 mg/kg.

Application of the Kvaal Method in Age Estimation of the Serbian Population Based on Dental Radiographs.

This study aimed to evaluate the applicability of the Kvaal method in determining the age of a Serbian population. In this retrospective descriptive study, 170 dental patients (age range 16-77 years) were included. The measurements of six types of teeth were performed on digital orthopantomography radiographs according to the Kvaal method. Statistical inter-observer and intra-observer reliabilities were calculated to evaluate the reproducibility of the measurements, as well as to examine the correlation between chronological age and measured values. The evaluation revealed a substantial difference (over 12 years) between chronological and estimated age. The P ratio had the strongest correlation with chronological age for the maxillary central (r = ±0.293) and lateral incisors (r = ±0.240), whereas the pulp/root width ratio at level A had the strongest correlation for the mandibular first premolars (r = ±0.270). The lowest SD values, for measurements on teeth 15/25 (SD = 125,787), had the most accurate correlation with age. Thus, we can conclude that the original Kvaal method is not applicable in the age estimation of the Serbian population. For future research, we suggest using cone beam computer tomography as a precise technology to evaluate the applicability of Kvaal and other methods for age estimation.

Immortelle essential oil-based ointment improves wound healing in a diabetic rat model.

The phytochemical analysis of the investigated Immortelle essential oil revealed the presence of monoterpenes and sesquiterpenes as major components that might be efficient as a wound healing potential agent. The present study aimed to develop an ointment based on the Immortelle essential oil and investigate its wound healing effects on excision wounds in diabetic rats. The topical formulated Immortelle ointment was subjected to pharmaco-technical characterization. Thirty-two diabetic rats with the induced excision wound were used to evaluate in vivo wound healing effects of ointment. The animals were randomly divided into four groups untreated or topically treated with either a 1% silver sulfadiazine, the ointment base, or Immortelle ointment. The response to the treatment was assessed by macroscopic, biochemical and histopathological analysis. The ointment, compatible with the skin remained stable for 6 months. Topical application of the Immortelle ointment showed the highest wound contraction with the highest content of hydroxyproline in comparison to the all examined groups. The Immortelle ointment showed significant wound contraction from day 7 to day 21 as compared to other groups. On the day 21, there was an average of 99.32% wound contraction in the Immortelle group, whereas the mean wound contraction in the negative control and ointment base group was 71.36% and 81.26% respectively. The histopathological results validated the potential wound healing effect of Immortelle ointment with evident post-excision scar maturation and increased collagen fibers density. Our findings revealed that the Immortelle ointment approach might serve as a promising and innovative tool for wound healing.

Lifestyle, Physical Activity, Eating and Hygiene Habits: A Comparative Analysis Before and During the COVID-19 Pandemic in Student Population.

Background: Changing daily habits such as diet, hygiene and physical activity may be some of the consequences of the COVID-19 pandemic. The aim of the study was to analyze the effect of this pandemic on lifestyle, physical activity, eating and hygiene habits among students. Methods: This cross-sectional study involved 171 students from the Faculty of Medical Sciences, University of Kragujevac, Serbia. Data were statistically analyzed using Wilcoxon Signed-Rank test, Marginal homogeneity test and Chi-square test. The differences were considered statistically significant when p ≤ 0.05. Results: In this study, it was observed that the most common physical activity before the pandemic was walking, while during the pandemic was home exercising. Compared to the period before the pandemic, there was no difference in the time spent engaging in daily physical activity (p = 0.334). However, there was a significant increase in sitting time during the pandemic (p = 0.005). Difference was noticed in the use of breakfast, the number of meals, and the type of fat in the diet before and during the pandemic (p = 0.000). During the pandemic, there was an increase in the use of fruits (p = 0.000), vegetables, and nuts (p = 0.001), while the use of fast food and alcohol have decreased. During the COVID-19 pandemic, a significant increase in the use of dietary supplements was observed (40.2%), (p = 0.008). Conclusions: Given that the COVID-19 pandemic is ongoing, certain changes in lifestyle observed in this study should be confirmed in more extensive population studies.

Newly synthesized palladium(II) complexes with aminothiazole derivatives: in vitro study of antimicrobial activity and antitumor activity on the human prostate cancer cell line.

Five new complexes of the palladium(II) ion (C1-C5) having the general formula [(PdL2)]Cl2 with some 2-aminothiazoles (L1-L5), where L1 = 2-amino-4-(3,4-difluorophenyl)thiazole, L2 = 2-amino-5-methyl-4-phenylthiazole, L3 = 2-amino-4-phenylthiazole, L4 = 2-amino-4-(4-chlorophenyl)thiazole, and L5 = 2-amino-4-(2,4-difluorophenyl)thiazole, have been synthesized and characterized by elemental microanalysis and infrared, 1H NMR and 13C NMR spectroscopy. The in vitro antimicrobial activity of the five ligands and the corresponding Pd(II) complexes is investigated. Testing is performed by the microdilution method and the minimum inhibitory concentration (MIC) and minimum microbicidal concentration (MMC) have been determined. Testing is conducted against 11 microorganisms (nine strains of pathogenic bacteria and two yeast species). The tested ligands and palladium(II) complexes show selective, high and moderate activity. There is a difference in antimicrobial activity between the ligands and the corresponding palladium(II) complexes. The complexes have significant anti-staphylococcal activity and activity on Pseudomonas aeruginosa which is better than the positive control. The interactions of newly synthesized palladium(II) complexes with calf thymus DNA (CT-DNA) were investigated using UV-Vis absorption and fluorescence spectroscopy. Analysis of UV-absorption and fluorescence spectra indicates the formation of a complex between the palladium(II) complexes and DNA. The high values of intrinsic binding constants, Kb, of the order 104 M-1 and Stern-Volmer quenching constants, KSV, of the order 105 M-1 indicated very good binding of all complexes to CT-DNA. Also, the new Pd(II) complexes show high cytotoxic activity towards the human prostate cancer cell line and insignificant activity towards non-cancerous human fibroblasts. Future research could additionally explore the biological activity of Pd(II) complexes presented in this paper and investigate the possibility of their implementation in clinical practice.

Formulation and Evaluation of Helichrysum italicum Essential Oil-Based Topical Formulations for Wound Healing in Diabetic Rats.

As proper wound management is crucial to reducing morbidity and improving quality of life, this study evaluated for the first time the wound healing potential of H. italicum essential oil (HIEO) prepared in the form of ointment and gel in streptozotocin-induced diabetic wound models in rats. After creating full-thickness cutaneous wounds, forty-eight diabetic rats were divided into six groups: (1) negative control; (2) positive control; (3) ointment base; (4) gel base; (5) 0.5% HIEO ointment (6) 0.5% HIEO gel. Wound healing potential was determined by the percentage of wound contraction, hydroxyproline content, redox status, and histological observation. A significant decrease in the wound size was observed in animals treated with HIEO formulations compared with other groups. The HIEO groups also showed a higher level of total hydroxyproline content, and more pronounced restitution of adnexal structures with only the underlying muscle defect indicating the incision site. Hence, our results legitimate the traditional data of the pro-healing effect of HIEO because HIEO in both formulations such as gel and ointment exhibited the significant wound repairing effect in the incision wound model.

Can early hyperglycemia affect the morbidity/mortality of very low birth weight premature infants?

BACKGROUND: The study aimed to examine the effect of early hyperglycemia on the morbidity/mortality of very low birth weight premature infants. METHODS: This retrospective study included all premature infants with gestational age ≤32 gestational weeks, hospitalized at the Department of Intensive Neonatal Care, Clinical Center Kragujevac, during the period 2017-2019. Hyperglycemia was defined as glycemia of ≥12 mmol/l in one measurement, or > 10 mmol/l in two measurements, at repeated intervals of 2-4 hours. Glycemia was determined from capillary blood, using a gas analyzer of Gem Premier 3000, during the first 7 days of life. Continuous intravenous insulin infusion was administered after ineffective glucose restriction at glycemic values of > 14 mmol/l. RESULTS: Patients with normoglycemia (41/72 (56.94%)) and hyperglycemia (31/72 (43.06%)) did not differ in gender, gestational age, mode of delivery and antenatal administration of steroids, while birth weight had a tendency to be lower in the hyperglycemic group (p=0.052). Hyperglycemia was significantly associated with a low APGAR score at the fifth minute (p=0.048), necrotizing enterocolitis (p=0.011), and shorter duration of mechanical ventilation (p=0.006). Hyperglycemia was associated with significantly more frequent fatal outcomes (35.5%) when compared with the normoglycemic group (4.9%). Accordingly, these patients required inotropic (r=0.036) and insulin therapy (r < 0.001) more often. Retinopathy of prematurity, bronchopulmonary dysplasia and sepsis did not correlate with hyperglycemia in our study. Intraventricular hemorrhage of the first degree was more often associated with normoglycemia in premature infants on prolonged mechanical ventilation while more severe intracranial hemorrhage was more common in the hyperglycemic group but did not result in statistical significance due to the small number of patients. CONCLUSIONS: Monitoring glucose levels in the blood of very low birth weight premature infants is clinically important because abnormalities in glucose homeostasis can have serious short-term and long-term consequences.

Antimicrobial treatment of Corynebacterium striatum invasive infections: a systematic review.

The aim of this study was to establish an evidence-based guideline for the antibiotic treatment of Corynebacterium striatum infections. Several electronic databases were systematically searched for clinical trials, observational studies or individual cases on patients of any age and gender with systemic inflammatory response syndrome, harboring C. striatum isolated from body fluids or tissues in which it is not normally present. C. striatum had to be identified as the only causative agent of the invasive infection, and its isolation from blood, body fluids or tissues had to be confirmed by one of the more advanced diagnostic methods (biochemical methods, mass spectrometry and/or gene sequencing). This systematic review included 42 studies that analyzed 85 individual cases with various invasive infections caused by C. striatum. More than one isolate of C. striatum exhibited 100% susceptibility to vancomycin, linezolid, teicoplanin, piperacillin-tazobactam, amoxicillin-clavulanate and cefuroxime. On the other hand, some strains of this bacterium showed a high degree of resistance to fluoroquinolones, to the majority majority of ß-lactams, aminoglycosides, macrolides, lincosamides and cotrimoxazole. Despite the antibiotic treatment, fatal outcomes were reported in almost 20% of the patients included in this study. Gene sequencing methods should be the gold standard for the identification of C. striatum, while MALDI-TOF and the Vitek system can be used as alternative methods. Vancomycin should be used as the antibiotic of choice for the treatment of C. striatum infections, in monotherapy or in combination with piperacillin-tazobactam. Alternatively, linezolid, teicoplanin or daptomycin may be used in severe infections, while amoxicillin-clavulanate may be used to treat mild infections caused by C. striatum.

Assessment of Quality of Life, Anxiety and Depressive Symptoms in Serbian Children with Celiac Disease and their Parents.

OBJECTIVES: To evaluate the level of health-related quality of life (QoL) and presence of anxiety and depressive symptoms in Serbian children with celiac disease from the perspective of patients and their parents. METHODS: This cross-sectional study investigated the group of children and adolescents with celiac disease aged 5-18 y, and at least one parent of each patient with celiac disease. The patients and their parents were recruited at the Institute of Mother and Child Health of Serbia and the University Children's Hospital in Belgrade. The instruments used in this study were child-self and parent-proxy versions of the Pediatric Quality of Life Inventory (PedsQL), Screen for Child Anxiety Related Emotional Disorder (SCARED) and Short Mood and Feelings Questionnaire (MFQ). Additional information was collected from the medical records of each patient. RESULTS: According to the PedsQL questionnaire, the quality of life was similarly assessed by both parents and their children (p > 0.05), as well as the presence of depressive symptoms according to MFQ questionnaire. However, a statistically significant difference was observed in the total score of the SCARED questionnaire for children and parents [total score (p < 0.05), panic-somatic disturbance (p < 0.01) and social anxiety (p < 0.01)]. CONCLUSIONS: The patients and their parents in Serbia have similarly assessed the quality of life of children with celiac disease, but the differences in the scores of SCARED questionnaire indicate that it is necessary to include both children and parents in the assessment of QOL.