Cost of bladder cancer in Lebanon before and after the economic collapse: a probabilistic modeling study.

BACKGROUND AND OBJECTIVES: Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon's economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs. METHODS: This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category. RESULTS: Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs. CONCLUSION: Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments.

Characterizing Persons With HIV/HCV Coinfection Who Remain Untreated for Hepatitis C at Four HIV Clinics in Connecticut (CT): Role of Multiple Overlapping Barriers at the Individual and Clinic System Levels.

Introduction. Direct-acting antiviral medications have made hepatitis C virus (HCV) cure possible for >95% of persons with chronic HCV infection, including those coinfected with HIV. Achieving strategic HCV elimination targets requires an understanding of system, provider, and patient-level barriers to treatment. We explored such barriers among persons with HIV/HCV coinfection who remained untreated for HCV. Methods. Among four primary care HIV clinics in CT with high rates of HCV cure, 25 patients with HIV/HCV coinfection were eligible (no HCV treatment as of March 31, 2021). We conducted retrospective chart reviews of demographics, clinical practice patterns, patient-specific issues such as housing, transportation, food security, and presence of mental health and substance use problems. Results. Among untreated patients, 13 (51%) were female; 17 (68%) were Black; median age was 62 years old. The majority (84%) had injecting drug use (IDU) as HIV transmission risk factor; 14 (56%) were prescribed medication-assisted treatment. Median time since HIV and HCV diagnosis was 25 and 19 years, respectively. Clinic-level barriers were noted in 19 (76%) and included lack of evaluation, treatment not recommended or implemented. Concomitant structural barriers included unstable housing for 11 (44%) and lack of transportation for eight (32%). Most patients had history of illicit substance use (84%) and mental health issues (68%). Many (76%) had multiple potential barriers. Conclusions. Multiple overlapping barriers spanning clinic and patient level domains including social determinants of health were the norm in persons with long-standing HIV/HCV coinfection who have not received HCV treatment. Interventions will require innovative, multi-disciplinary and personalized approaches.

Cost of illness of chronic kidney disease in Lebanon: from the societal and third-party payer perspectives.

BACKGROUND: Chronic kidney disease (CKD) is the 12th leading cause of death worldwide. Cost-of-illness studies of CKD are scarce in developing countries. This study aims to estimate the cost of illness of all stages of CKD in Lebanon, from early stages until dialysis and kidney transplantation. The secondary objective is to identify factors related to the highest financial burden. METHODS: This is a cross-sectional study of CKD patients who presented to two nephrology clinics during November 2020. Their medical and administrative records were reviewed for collection of demographics, CKD characteristics, direct medical costs (medications, diagnostic tests, hospitalizations, inpatient care, outpatient care), direct non-medical costs (transportation) and indirect costs (productivity losses) for one year. Kruskal Wallis test was used to compare the costs between different CKD stages and categories. Logistic regression analysis was used to evaluate risk factors associated with costs. RESULTS: The sample included 102 non-dialysis CKD patients, 40 hemodialysis, 8 peritoneal dialysis and 10 transplant patients. Their mean age was 66.74 ± 15.36 years, 57.5% were males and 42.5% diabetics. The total median cost per year of CKD across all categories was assessed to be 7,217,500 Lebanese Pounds (3,750,000-35,535,250; 1 $USD = 1515 LBP in 2019) from the societal perspective and 5,685,500 LBP (2,281,750- 32,386,500) from the third-party payer perspective. Statistical analysis showed a higher total cost in hemodialysis (p < 0.001), higher cost of medications in transplant (p < 0.001) and higher cost in technique modality in peritoneal dialysis (p < 0.001). In a sub-analysis of hemodialysis patients, dialysis vintage negatively correlated with total societal cost (r = -0.391, p = 0.013); the regression analysis found diabetes as a risk factor for higher cost (OR = 2.3; 95%CI: 0.638,8.538; p = 0.201). In the subcategory of CKD-ND patients, age correlated with total societal cost (r = 0.323, p = 0.001); diabetes and coronary artery disease were significantly associated with higher total cost (OR = 2.4; 95%CI: 1.083,5.396; p = 0.031; OR = 3.7; 95%CI: 1.535,8.938; p = 0.004). CONCLUSIONS: This cost of illness study showed a high burden of hemodialysis and peritoneal dialysis cost compared to transplant and non-dialysis CKD patients. It revealed a significantly higher cost of medications in transplant patients. Health policies should target interventions that prevent end-stage kidney disease and encourage kidney transplantation.

Automatic Classification of Screen Gaze and Dialogue in Doctor-Patient-Computer Interactions: Computational Ethnography Algorithm Development and Validation.

BACKGROUND: The study of doctor-patient-computer interactions is a key research area for examining doctor-patient relationships; however, studying these interactions is costly and obtrusive as researchers usually set up complex mechanisms or intrude on consultations to collect, then manually analyze the data. OBJECTIVE: We aimed to facilitate human-computer and human-human interaction research in clinics by providing a computational ethnography tool: an unobtrusive automatic classifier of screen gaze and dialogue combinations in doctor-patient-computer interactions. METHODS: The classifier's input is video taken by doctors using their computers' internal camera and microphone. By estimating the key points of the doctor's face and the presence of voice activity, we estimate the type of interaction that is taking place. The classification output of each video segment is 1 of 4 interaction classes: (1) screen gaze and dialogue, wherein the doctor is gazing at the computer screen while conversing with the patient; (2) dialogue, wherein the doctor is gazing away from the computer screen while conversing with the patient; (3) screen gaze, wherein the doctor is gazing at the computer screen without conversing with the patient; and (4) other, wherein no screen gaze or dialogue are detected. We evaluated the classifier using 30 minutes of video provided by 5 doctors simulating consultations in their clinics both in semi- and fully inclusive layouts. RESULTS: The classifier achieved an overall accuracy of 0.83, a performance similar to that of a human coder. Similar to the human coder, the classifier was more accurate in fully inclusive layouts than in semi-inclusive layouts. CONCLUSIONS: The proposed classifier can be used by researchers, care providers, designers, medical educators, and others who are interested in exploring and answering questions related to screen gaze and dialogue in doctor-patient-computer interactions.

The use of mirabegron in neurogenic bladder: a systematic review.

PURPOSE: To evaluate the use of mirabegron in patients with neurogenic bladder. METHODS: A systematic review of the literature was conducted using four databases (Medline via PubMed, Scopus, Cochrane, and EMBASE). Articles evaluating mirabegron in neurogenic bladder patients were collected, and assessment of the drug's efficacy was reviewed according to clinical and urodynamic parameters. RESULTS: Seven studies were selected and a total of 302 patients with NB were evaluated, ranging from 15 to 66 patients per study. All of the patients had received antimuscarinics as a previous treatment modality. Mirabegron was used as a second-line treatment after antimuscarinics lacked efficacy or caused adverse effects. The duration of the treatments ranged from 4 to 12 weeks. Reported in two studies each, bladder compliance and maximal cystometric capacity were the most commonly improved urodynamic parameters. In the majority of the studies, positive outcomes were reported for clinical scores. Additionally, analysis of the IPSS subscores revealed an improvement of storage symptoms as opposed to voiding symptoms. In all of the studies, mirabegron was well tolerated. CONCLUSION: Mirabegron appears to be an effective treatment in the management of neurogenic bladder unresponsive to antimuscarinics, particularly in patients presenting with storage symptoms. There is still no evidence concerning the use of mirabegron as a first-line therapy for neurogenic bladder.

Fatal case of cutaneous-sparing orolaryngeal zoster in a renal transplant recipient.

Herpesvirus infections in solid organ transplant (SOT) recipients are a significant cause of morbidity and mortality. We report a case of herpes zoster (HZ) in a kidney transplant recipient while receiving belatacept, a CTLA-4 inhibitor that prevents acute rejection. The patient presented with oropharyngolaryngeal mucosal lesions that subsequently disseminated resulting in pneumonitis and meningo-encephalitis. Very late-onset HZ can occur and can present atypically in SOT recipients. Delayed recognition and treatment may result in poor outcomes, as illustrated by this case.

Data protection and information security in biomedical research: A sequential explanatory mixed study.

PURPOSE: Biomedical research is a pillar of every medical student's career. When collecting data, several regulations are established to ensure the protection of individuals. Most medical students are not compliant with the guidelines, and this is probably due to a lack of knowledge. The aim of our research is to evaluate the knowledge and behavior of medical students regarding these rules, then attempt to explain the results obtained. METHODS: This is a sequential explanatory mixed study including an initial quantitative section followed by an explanatory qualitative section. For the quantitative part, we administered a questionnaire based on the information security regulation and the GDPR to third- and fourth-year medical students. We evaluated their knowledge and behaviors and their correlation. For the qualitative part, we conducted semi-structured interviews with eight students followed by thematic analysis to explain the results. RESULTS: Most students have a lack of knowledge. A correlation was found between the non-compliant behavior of keeping the laptop unattended in a public place and a low level of knowledge. For the qualitative section, the thematic analysis represents three groups to explain non-compliant behavior: lack of knowledge, work overload, and consideration of the hospital as a safe place. CONCLUSION: Data collection and information security rules are rarely followed by medical students. This is mainly due to lack of knowledge, work overload and assuming the hospital as a safe place. Future awareness interventions would be necessary to improve non-compliant behavior and subsequently ensure a more secure environment during medical research.

Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique.

OBJECTIVE: To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches. PATIENTS AND METHODS: Between 2009 and 2012, 15 patients underwent laparoscopic (n = 11) or robot-assisted (n = 4) construction of vesicostomy by a single surgeon (D.R.): Mitrofanoff appendicovesicostomy (n = 11) or double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty. Indications for surgery included neurogenic bladder (n = 11) and urethral dysfunction (n = 4). The patients were evaluated postoperatively using cystography. Quality of life (QoL) was evaluated using an internally developed questionnaire. RESULTS: All surgeries were successfully completed with no conversions. Operating time was always <5 h. The mean estimated blood loss was 150 mL and the mean follow-up was 22 months. Early postoperative complications included deep retrovesical abscess (n = 2) and upper urinary tract infections (n = 4), and one patient had peri-operative cardiac failure. Late postoperative complications included stomal stenosis (n = 2), persistent low-pressure bladder incontinence (n = 1) and recurrent infections (n = 1). Surgical excision of the conduit was necessary in one patient. Postoperatively, patients showed complete bladder emptying and no leak on follow-up cystography. According to our QoL questionnaire, 13/15 patients did not regret the surgery. CONCLUSIONS: While a longer follow-up is needed to assess the durability of our results, this series shows that the laparoscopic and robot-assisted approaches for the construction of continent urinary diversions are feasible and safe in an adult population.

Virtual reality for healthcare: A scoping review of commercially available applications for head-mounted displays.

Objective: This scoping review aimed to describe the scope of commercially available virtual reality (VR) healthcare applications for mainstream head-mounted displays (HMD)s. Methods: A search was conducted during late April and early May 2022 over five major VR app stores using "health," "healthcare," "medicine," and "medical" as keywords. Apps were screened based on their title and description sections. Metadata collected included: title, description, release date, price (free or paid), multilingual support, VR app store availability, and HMD support. Results: The search yielded 1995 apps, out of which 60 met the inclusion criteria. The analysis showed that the number of healthcare VR apps has been steadily increasing since 2016, but no developer has released more than two apps so far. Most of the reviewed apps can run on HTC Vive, Oculus Quest, and Valve Index. Thirty-four (56.7%) apps had a free version, and 12 (20%) apps were multilingual, i.e., supported languages other than English. The reviewed apps fell into eight major themes: life science education (3D anatomy, physiology and pathology, biochemistry, and genetics); rehabilitation (physical, mental, and phobia therapy); public health training (safety, life-saving skills, and management); medical training (surgical and patient simulators); role-playing as a patient; 3D medical imagery viewing; children's health; and online health communities. Conclusions: Although commercial healthcare VR is still in its early phases, end-users can already access a broad range of healthcare VR apps on mainstream HMDs. Further research is needed to assess the usefulness and usability of existing apps.

Laparoscopic repair of acquired rectourethral fistula by vesical peritoneal flap.

INTRODUCTION: A rectourethral fistula (RUF) is an infrequent complication that can be iatrogenic in most cases. Multiple surgical interventions were described for RUF repair including transsphincteric, transanal, transperineal, and transabdominal approaches. To this day, there is no consensus on a standardized surgery of choice for acquired RUF. MATERIALS AND SURGICAL TECHNIQUE: Our patient was diagnosed with RUF 4 weeks after undergoing laparoscopic low anterior resection for midrectum adenocarcinoma, with failure of conservative treatment. A three-port transabdominal approach was used to dissect the rectoprostatic space and close the fistula orifice on the anterior rectal wall. With the technical impossibility to develop an omental flap, the peritoneum on the posterior vesical wall was carefully dissected to form a rectangular flap pedicled by its inferior aspect. The harvested peritoneal flap was then anchored between the prostate and the rectum. Follow-up imaging showed the absence of RUF, concurrently with total remission of RUF symptomatology. DISCUSSION: Management of acquired RUF can be challenging, especially after failure of conservative treatment. Laparoscopic repair of acquired RUF by vesical peritoneal flap is a valid option for a minimally invasive approach for the treatment of RUF.

Physician Communication Skills in Telemedicine: The Role of Eye Contact.

Gaze is an important non-verbal behavior in patient-physician communication. We examine the effect of the physician's gaze direction in video consultations on their communication and interpersonal skills ratings. 51 subjects watched videos of a physician providing the same teleconsultations while (a) looking directly at the camera and (b) looking at the computer screen. After each video, the participants rated the physician's skills. The results showed that looking at the camera is perceived as making eye contact and is associated with higher ratings on two communication skill items: (1) using empathy to communicate appreciation of the patient's feelings, and (2) providing support by expressing concern, understanding, and willingness to help. The effect of eye contact depended on the content of the consultation and on the general attitude of the physician. These results highlight the role of eye contact in video consultations and its dependency on other verbal and non-verbal behaviors.

Data Protection in Healthcare Research: Medical Students' Knowledge and Behavior.

Healthcare research involves handling personal health information. Information security policies are implemented in research institutions to ensure data subjects' rights but are not always respected due to researchers' neglect or unawareness. This paper is part of an action research project at Saint Joseph University in Lebanon aiming to increase researchers' compliance with the university's information security policy. An anonymous online questionnaire was administered to medical students to evaluate their knowledge and behavior regarding patient data handling in research projects. 38 responses were collected. Results show that most students collect patient data for research, and are frequently not aware of, and do not comply with, the existing information security policy. We also found correlations between low knowledge and non-compliant behaviors including clicking on links from unknown senders, leaving computers unattended, and sharing data insecurely. To address these issues, we plan to implement various Information Security Awareness interventions and compare their effectiveness.

Bladder instillation for urinary tract infection prevention in neurogenic bladder patients practicing clean intermittent catheterization: A systematic review.

OBJECTIVE: To assess the efficacy and safety of different modalities of bladder instillation in patients with neurogenic bladder practicing intermittent catheterization. METHODS: A systematic review of the literature were conducted using two databases: Medline via PubMed and Scopus. Articles evaluating bladder instillation in patients with neurogenic bladder, who are practicing intermittent catheterization, were collected and assessed for the efficacy and safety of the studied agent by two different reviewers. RESULTS: Among the 1896 studies, eight involving 346 patients with neurogenic bladder, were included in this systematic review according to the PRISMA protocols. Gentamicin, Hyaluronic acid, and Lactobacillus rhamnosus was found to decrease the incidence of urinary tract infections, the former reduced multidrug-resistant organisms. Kanamycin-colistin, showed a drop in the mean incidence of bacteriuria in males only. Trisdine, the only studied antiseptic, significantly reduced bacteriuria. Neomycin, however, showed no efficacy in term of bacteriuria. Regarding safety, when evaluated, no major adverse events were reported with any of the studied modalities. CONCLUSION: Bladder instillations of either antibiotics, antiseptics, hyaluronic acid, or Lactobacillus rhamnosus GG are efficient and safe in patients having neurogenic bladder, with recurrent urinary tract infections and practicing clean intermittent catheterization, with gentamicin being the most recommended product among the different studied agents.

Ensuring Care Continuity in Extreme Crises: A Participatory Action Research Approach.

The Lebanese healthcare system has been facing major challenges due to an unprecedented financial crisis, socio-political instability, and the COVID-19 pandemic. This study aims to examine the impact of overlapping major crises on care continuity and to propose IT-based solutions to address current challenges and build future resilience. To this end, we adopted a participatory action research approach and conducted a two-phase qualitative study - six semi-structured interviews followed by three future workshops with local stakeholders including physicians and interns practicing in Lebanon. Through the interviews, we identified the primary consequences of the crises and the ways they impacted the continuity of care. We also identified adaptation mechanisms used by physicians and patients to ensure continuity of care. Through the future workshops, we identified various IT-based solutions that could be implemented to tackle existing challenges and support local adaptation attempts.

Physician eye contact in telemedicine video consultations: A cross-cultural experiment.

INTRODUCTION: Eye contact is generally considered a beneficial non-verbal behavior in patient-physician communication. Physicians are advised to simulate eye contact during video consultations by gazing at the camera, although we lack evidence that doing so is beneficial. This work is a cross-cultural experiment that aims to answer: "Are physicians who gaze at the camera during video consultations perceived as making eye contact, and are their communication skills rated higher?" METHODS: 43 Japanese and 61 Lebanese participants watched videos of physicians providing the same video consultations while gazing at the camera and screen. After watching each video, they rated the physicians' communication skills using six items from the GCRS and the MAAS-G scales. They also picked and justified their preferred physician gaze direction. RESULTS: When physicians gazed at the camera, they were perceived as making more eye contact and received higher communication and interpersonal skills ratings, both in Japan and Lebanon. The effect of gazing at the camera was consistently positive but varied by country and consultation content. In Japan, simulating eye contact improved the ratings of the attentive and caring physician, whereas in Lebanon, it improved the ratings of the tired and inattentive physician. When asked to choose their preferred gaze direction, 88.4% of Japanese and 90.2% of Lebanese participants chose camera gaze over screen gaze due to its positive effect on patient feelings and physician perception. Participants who chose screen gaze noted the unnaturalness of gazing at the camera and its potential negative impact on care quality. CONCLUSION: Physicians providing video consultations can simulate eye contact by gazing at the camera. Doing so improves their communication and interpersonal skills ratings and could potentially enhance their communication with their patients. Mainstream video conferencing platforms could implement gaze correction methods to simulate eye contact without affecting the physicians' experience and capacity to provide quality care.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis.

BACKGROUND: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. OBJECTIVE: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. METHODS: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. RESULTS: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. CONCLUSION: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Factors Related to Personal Health Data Sharing: Data Usefulness, Sensitivity and Anonymity.

Using an online survey, we examined the relationships between the perceived usefulness, sensitivity, and anonymity of personal health data and people's willingness to share it with researchers. An analysis of 112 responses showed that people's willingness and perceptions are related to the type of the data, their trust in the data's anonymity, and their personal sociodemographic characteristics. In general, we found that people do not completely trust that their identities remain anonymous when sharing data anonymously with researchers. We also found that they are more willing to share personal health data with researchers if they perceive it as useful for public health research, not sensitive, and if they trust that their identity will remain anonymous after sharing it. We also found that people's age, gender, occupation, and region of residence may be related to their perceptions regarding the sharing of personal health data.

Mobile sonouroflowmetry using voiding sound and volume.

Uroflowmetry (UF) is a common clinic-based non-invasive test to diagnose Lower Urinary Tract Dysfunction (LUTD). Accurate home-based uroflowmetry methods are needed to conveniently conduct repeated uroflowmetries when patients are physiologically ready to urinate. To this end, we propose and evaluate a novel mobile sonouroflowmetry (SUF) method that estimates the urinary flow rate from a sound signal recorded using a mobile phone. By linearly mapping the total sound energy to the total voided volume, the sound energy curve is transformed to a flow rate curve allowing the estimation of the flow rate over time. An evaluation using data from 44 healthy young men showed high similarity between the UF and SUF flow rates with a mixed-effects model correlation coefficient of 0.993 and a mean root mean square error of 2.37 ml/s. Maximum flow rates were estimated with an average absolute error of 2.41 ml/s. Future work on mobile uroflowmetry can use these results as an initial benchmark for flow rate estimation accuracy.

The place of 5-aminolaevulinic acid-photodynamic therapy in the treatment landscape of urethral warts: A systematic review.

BACKGROUND: Human papilloma virus (HPV) infection is the most common sexually transmitted disease worldwide and the main cause of genital warts. Clear recommendations for the management of urethral warts, which are often hard to detect and difficult to treat, are still lacking. OBJECTIVE: To summarize all available data describing treatment modalities of urethral warts, compare their efficacy and side effects, and provide physicians a treatment strategy outline. MATERIAL AND METHODS: Till June 2020, we conducted a systematic review of articles studying the different treatment modalities of urethral condylomas. A chi-square test was used to compare the recurrence rates between treatment modalities, the complete clearance rates at first follow-up and the rates of adverse events. RESULTS: A total of 26 articles with 1730 patients were included in our review. 61 % of patients were deemed completely cured on the first follow-up while 21 % recurred. 5-aminolevulinic acid (ALA) mediated photodynamic therapy (PDT) was the most common treatment and yielded the lowest recurrence rate (7.5 %) followed by laser therapy (24 %) and topical therapy (31 %) (p < 0.01). ALA-PDT resulted in a higher rate of clearance on follow up (96 %) compared to laser therapy (69 %) and topical therapy (14 %) (p < 0.01). Adverse events were more frequent in the ALA-PDT group (69 %) compared to laser therapy (28 %) and topical treatment (30 %) (p < 0.01). CONCLUSION: ALA-PDT appears to be the most effective treatment of urethral condylomas in term of clearance and recurrence rate, but with a higher risk of adverse events. Management should be tailored to the type of lesion found at presentation.