Uric acid-lowering effects of sodium-glucose cotransporter 2 inhibitors for preventing cardiovascular events and mortality: A systematic review and meta-analysis.

BACKGROUND: To evaluate the effect of a 1 mg/dl reduction in uric acid (UA) on cardiovascular events and mortality in patients treated with sodium-glucose cotransporter 2 (SGLT2) inhibitors. RESEARCH DESIGN AND METHODS: We performed a systematic review of the MEDLINE and EMBASE databases searched up to 30 June 2023 (PROSPERO, CRD42022355479) to identify large-scale SGLT2 inhibitor trials. Random-effects meta-analyses were used to pool the estimates. RESULTS: In total, five SGLT2 inhibitor trials (31 535 patients, 54% with heart failure) were analysed. Over a median follow-up of 2.2 years, the mean reduction in UA was -0.79 mg/dl (95% confidence interval (CI), -1.03 to -0.54). Every 1 mg/dl reduction in UA was associated with a significantly lower risk of a composite of cardiovascular death and hospitalization for heart failure [hazard ratio, 0.64 (95% CI, 0.46-0.88)] and hospitalization for heart failure (0.68; 95% CI, 0.62-0.74), with a similar risk of mortality. CONCLUSIONS: SGLT2 inhibitors reduced UA levels and cardiovascular events independently of heart failure status.

[Gunshot wounds of low urinary tract in period of security crisis at the Sominé Dolo Hospital of Mopti (Mali): Epidemiological and diagnostic aspects]. / Blessures par arme à feu du bas appareil urinaire en période de crise sécuritaire à l'hôpital Sominé Dolo de Mopti (Mali) : aspects épidémiologiques et diagnostiques.

INTRODUCTION: Firearm injuries to the lower urinary tract are injuries resulting from an energy transfer from a projectile fired by a firearm or a blast from a firearm, to the bladder, prostate, urethra and terminal ureter. Our objective was to describe the epidemiological and diagnostic aspects in the context of a security crisis. PATIENTS AND METHOD: This was a descriptive cross-sectional study of lower urinary tract firearm injuries at Sominé Dolo Hospital in Mopti from January 2017 to December 2021. RESULTS: In five years, 29 traumas of the lower urinary tract have been collected, about 6 cases per year. The mean age of patients was 27.48 years, the sex ratio was 13.5/1. The main circumstances of occurrence were intercommunal violence 51.72 %, war wounds 31.03 %. Injuries were inflicted by rifles in 62.1 % and improvised explosive devices in 37.9 %. The main modes of discovery were acute urine retention, hematuria and penoscrotal wounds respectively in 31.03 %, 20.69 %, 17.24 %. The organs affected were the urethra in 58.62 %, the bladder, 37.93 %, the prostate 3.45 %. Associated non-urological lesions present in 68.96 % (n=20) were dominated by intestinal lesions and pelvic fractures. CONCLUSION: Firearm injuries to the lower urinary tract are rare despite the context of the security crisis. They affect young men, are mostly linked to intercommunal violence, and are dominated by urethral and bladder injuries.

EPILEPTIC SEIZURES REVEALING STURGE WEBER'S DISEASE IN A TROPICAL ENVIRONMENT: STUDY OF EIGHT CASES.

In sub-Saharan Africa (SSA), the etiological factors of epilepsy are multiple and phacomatoses, in particular Sturge weber's disease, are rarely reported due to under-medicalization and insufficient multidisciplinary care. We carried out a retrospective study of 216 patients hospitalized for recurrent epileptic seizures between 2015 and 2022 in the neurology and pediatrics department of the University Hospital Center of Conakry, among whom eight (8) patients were identified for Sturge Weber's disease in order to reassess this pathology from a clinical and paraclinical point of view in a tropical environment. Sturge Weber's disease was retained in eight (8) on the presence of symptomatic partial epileptic seizures (age 6 months to 14 years) with frequency of status epilepticus, homonymous lateral hemiparesis linked to occipital involvement, piriform calcifications on imaging and ocular disorders. The delay in consultation and medical care revealed severe mental deterioration in our patients. This study shows a stereotyped clinical picture in a context of aggravation of signs related to a delay in multidisciplinary management. These results are important for the diagnostic, therapeutic and prognostic discussion.

GAYET WERNICKE'S ENCEPHALOPATHY AFTER COVID-19 IN ELDERLY SUBJECTS IN TROPICAL ENVIRONMENTS: STUDY OF SIX (6) OBSERVATIONS IN CONAKRY.

In sub-Saharan Africa, the COVID-19 pandemic has caused severe malnutrition in elderly populations with the appearance of vitamin deficiencies, in particular thiamine responsible for Gayet Wernicke's encephalopathy (EGW). We present a series of six (6) patients hospitalized in the Neurology Department of the CHU Ignace Deen for the management of a brain syndrome with vigilance disorders after recovery from COVID-19, including oculomotor disorders, motor incoordination on a course of severe weight loss. The six patients underwent an evaluation of malnutrition by determining the WHO body mass index, the Detsky index, the serum albumin assay, the thiamine assay and a neuroradiological assessment (MRI) and an electroencephalogram (EEG) examination although this does not seem necessary for diagnosis. Study of nutritional status: weight loss greater than 5%, patients in Desky group B and C, plasma albumin<30 g/l, lowered thiamine and MRI neuroradiological data: by the existence of hypersignals in certain regions of the neocortex, certain gray nuclei, the mammillary bodies the thalamic nuclei close to the wall of the 3rd ventricle and the regions bordering the 4th ventricle sign Gayet Wernicke's encephalopathy syndrome. This study shows a stereotyped clinical, biological, neuroradiological and evolutionary profile of Gayet Wernicke's encephalopathy in elderly subjects recovered from Covid-19 with proven malnutrition. These results are useful for the therapeutic and prognostic discussion.

In-plane InGaAs/Ga(As)Sb nanowire based tunnel junctions grown by selective area molecular beam epitaxy.

In-plane InGaAs/Ga(As)Sb heterojunction tunnel diodes are fabricated by selective area molecular beam epitaxy with two different architectures: either radial InGaAs core/Ga(As)Sb shell nanowires or axial InGaAs/GaSb heterojunctions. In the former case, we unveil the impact of strain relaxation and alloy composition fluctuations at the nanoscale on the tunneling properties of the diodes, whereas in the latter case we demonstrate that template assisted molecular beam epitaxy can be used to achieve a very precise control of tunnel diodes dimensions at the nanoscale with a scalable process. In both cases, negative differential resistances with large peak current densities are achieved.

A rare localisation of intra-abdominal focal fat infarction: The falciform ligament. Contribution of imagery.

Pathological conditions of the falciform ligament are rare, one of which is the twisting of a fatty fringe that can lead to fatty infarction of the peritoneal fat. To our knowledge, only 21 cases with radiological documentation have been published in the literature. Ultrasound and computed tomography facilitated prompt diagnosis of this rare finding. The condition is best managed conservatively, but sometimes, a surgical intervention is necessary. We report herein a case of torsion of fatty falciform ligament appendage in a 73-year old female.

Enhanced biodegradation of crude oil in soil by a developed bacterial consortium and indigenous plant growth promoting bacteria.

AIMS: This study aimed to develop an efficient, cost-effective and eco-friendly bacterial consortium to degrade petroleum sludge. METHODS AND RESULTS: Four bacterial strains belonging to genera Acinetobacter and Pseudomonas were selected to constitute three different consortia based on their initial concentration. The highest degradation rate (78%) of 1% (v/v) crude oil after 4 weeks of incubation was recorded when the concentration of biosurfactant (BS) producing isolate was high. Genes, such as alkB, almA, cyp153, pah-rhdGN, nah, phnAC and cat23 were detected using the polymerase chain reaction method and their induction levels were optimal at pH 7·0. A crude oil sludge was artificially constituted, and its bacterial composition was investigated using 16S rRNA gene amplicon sequencing. The results showed that the soil bacterial community was dominated by plant growth-promoting bacteria (PGPB) after crude oil treatment. CONCLUSIONS: Our findings indicate the decontamination of the crude oil contaminated soil was more effective in the presence of both the constituted consortium and PGPB compared to the presence of PGPB alone. SIGNIFICANCE AND IMPACT OF THE STUDY: This study showed that the PGPB (Taibaiella) present in petroleum uncontaminated soil can promote the soil decontamination. The addition of both efficient hydrocarbon-degrading and BS producing bacteria is also necessary to improve the decontamination.

[Mycoses and antifungals: What is the situation in Senegal in the current context?] / Mycoses et antifongiques : quelle est la situation du Sénégal dans le contexte actuel ?

In the context of increasing incidence of fungal infections worldwide, the availability of antifungal drugs was studied in Senegal, a country with limited resources where diagnosis of invasive fungal infections is not often established by lack of specialists and/or diagnostic tools. After a background on the country's situation with regard to fungal infections and the drug distribution network in Senegal, a compilation of the various available antifungals was presented before concluding with recommendations to prepare for a situation that could allow to treat appropriately invasive mycoses.

Signatures of aestivation and migration in Sahelian malaria mosquito populations.

During the long Sahelian dry season, mosquito vectors of malaria are expected to perish when no larval sites are available; yet, days after the first rains, mosquitoes reappear in large numbers. How these vectors persist over the 3-6-month long dry season has not been resolved, despite extensive research for over a century. Hypotheses for vector persistence include dry-season diapause (aestivation) and long-distance migration (LDM); both are facets of vector biology that have been highly controversial owing to lack of concrete evidence. Here we show that certain species persist by a form of aestivation, while others engage in LDM. Using time-series analyses, the seasonal cycles of Anopheles coluzzii, Anopheles gambiae sensu stricto (s.s.), and Anopheles arabiensis were estimated, and their effects were found to be significant, stable and highly species-specific. Contrary to all expectations, the most complex dynamics occurred during the dry season, when the density of A. coluzzii fluctuated markedly, peaking when migration would seem highly unlikely, whereas A. gambiae s.s. was undetected. The population growth of A. coluzzii followed the first rains closely, consistent with aestivation, whereas the growth phase of both A. gambiae s.s. and A. arabiensis lagged by two months. Such a delay is incompatible with local persistence, but fits LDM. Surviving the long dry season in situ allows A. coluzzii to predominate and form the primary force of malaria transmission. Our results reveal profound ecological divergence between A. coluzzii and A. gambiae s.s., whose standing as distinct species has been challenged, and suggest that climate is one of the selective pressures that led to their speciation. Incorporating vector dormancy and LDM is key to predicting shifts in the range of malaria due to global climate change, and to the elimination of malaria from Africa.

[Epidemiological, clinical and etiological profile of tinea capitis in adult patients in Dakar, Senegal]. / Profil épidémio-clinique et étiologique des teignes du cuir chevelu chez l'adulte à Dakar (Sénégal).

OBJECTIVE: To determine the epidemiological and etiological profile of tinea capitis in adults in Dakar (Senegal). PATIENTS AND METHODS: A 9-month prospective, multicenter, descriptive and analytic study. Patients included were aged over 18 years. Mycological tests were used to confirm the diagnosis. RESULTS: 121 patients were included with a mean age of 36.1 years and a hospitalisation frequency of 0.8%. The age range of 64.4% of patients was between19 and 38 years. 51% of patients were housewives. A low socioeconomic level was found in 72.8% of cases. In 3.3% of patients, the disease began in childhood. 31.4% of patients had already consulted a traditional healer. Similar familial cases were noted in 60.3% of patients. Contact with a sheep was noted in 32.2% of cases, deliberate skin lightening in 64% of women, hair salon attendance in 46.7% of women, and immunosuppression in 17.3% of patients, while itching was present in 95.5%. Dermatologic examination showed scaled plaques and a diffuse form, with 92.6% and 64% (n=75) respectively. Wood's light examination was positive in 40.2% of patients. A positive culture test was found in 71%. The most frequently encountered species were: T. soudanense (65%), M. audouinii (21%), T. rubrum (4.7%), M. gypseum (3.5%), T. violaceum (2.3%), T. verrucosum (2.3%) and M. canis (1 case). The clinical course was favorable under treatment with griseofulvin or terbinafine. CONCLUSION: Tinea capitis in adults mainly affects young women. The diffuse form is the most common. The most frequently encountered species was T. soudanense.

[Targeted newborn screening for sickle-cell anemia: Sickling test (Emmel test) boundaries in the prenatal assessment in West African area]. / Dépistage néonatal ciblé de la drépanocytose : limites du test de falciformation (test d'Emmel) dans le bilan prénatal en zone ouest africaine.

BACKGROUND: Newborn screening for sickle cell anemia is necessary in Africa where the disease is more frequent. Hemoglobin electrophoresis is used for screening, but is limited by a high cost and difficult access. Sickling test (Emmel test), which is more affordable and technically more accessible, is often requested for prenatal assessment of pregnant women in West African areas to reserve screening for newborns from mothers in whom the positive sickling test attests the presence of hemoglobin S. This study aims to evaluate the number of undetected sickle cell anemia newborns by a screening policy targeting only newborns from mothers in whom a sickling test would have been positive. METHODS: From 2010 to 2012, in Bamako, Mali, West Africa, 2489 newborns were routinely screened for sickle cell anemia at the umbilical cord or heel by isoelectrofocusing and, if necessary, by high-performance liquid chromatography. These newborns were born from 2420 mothers whose hemoglobin was studied by isoelectrofocusing. The data was recorded and processed using Excel software version 14.0.0. We calculated the frequency of the sickle cell gene in mothers and newborns as well as the number of SCA newborns from heterozygous or C homozygous mothers. RESULTS: Of the 2489 newborns, 16 had sickle cell anemia (6 SS and 10 SC); 198 had the sickle cell trait; 139 were AC and 1 was CC. Of the 10 newborns with SC profile, 3 were born from mothers not carrying the S gene but the C gene of hemoglobin and in which an Emmel test would have been negative. CONCLUSION: Targeted newborn screening, based on the results of sickling test in pregnant women, would misdiagnose more than one of six sickle cell anemia newborns who would not benefit from early care. Cost-effectiveness studies of routine newborn screening for sickle cell anemia should lead to a better screening strategy in contexts where hemoglobin S and other hemoglobin defect genes coexist.

[Factors associated to loss of follow-up in patients underwent antiretroviral therapy in an ambulatory HIV treatment center at Conakry]. / Facteurs associés aux perdus de vue des patients sous traitement antirétroviral dans un centre de traitement ambulatoire du VIH à Conakry, Guinée.

BACKGROUND: Late or inadequate therapeutic management increases the risk of mortality associated with HIV/AIDS. The aim of this study was to analyze the proportion and factors associated with loss of follow-up in HIV patients who receiving antiretroviral therapy at Conakry. METHODS: A retrospective cohort study was conducted in HIV patients aged over 15 years and who receiving antiretroviral therapy. Between August 1, 2008 and July 31, 2015, all patients managed by the ambulatory treatment center of the Guinean Women Association against AIDS and sexually and transmissible infection were included. Loss of follow-up was defined as no follow-up visit within 3 months. Kaplan-Meier curves and multivariate Cox regression models were used to analyze factors associated with loss of follow-up. Analyses were performed by using Stata 13 software. RESULTS: 614 patients aged 36.3±11.2 years, mainly females (68.4%) and living in Conakry (80.5%) were included. Among them, 104 were loss to follow-up, corresponding to a proportion rate of 16.9% (95% CI: 14.2-19.7%) or 5.79/100 person-years. The results of multivariate analyses showed that factors independently associated with loss of follow-up were malnutrition (AHR=7.05; 95% CI: 2.05-24.27; P=0.002) and CD4 cells account at the initiation of AHR (2.35; 95% CI: 1.61-6.39; P=0.016) in patients with 201-350 CD4/µL and 5.83 (95% CI: 2.85-11.90; P<0.001) in patients with less than 150CD4/µL. CONCLUSION: Despite efforts of health care workers and free antiretroviral therapy, many patients were loss to follow-up. Multivariate analysis showed that malnutrition and low CD4 account were independently associated with loss to follow-up.

Cutaneous squamous cell carcinomas (SCC) associated with cosmetic skin whitening: 8 cases reported in Senegal.

BACKGROUND: The cosmetic use of bleaching products is common among women from sub-Saharan Africa. The most frequently used products are highly potent corticosteroids (clobetasol propionate) and hydroquinone. Herein, we report 8 cases of SCC in women using skin bleaching products for cosmetic purposes. Our aim is to describe the epidemiological, clinical and pathological aspects of the carcinomas observed during the course of skin lightening. METHODS: We conducted a descriptive multicentre study from August 2005 to January 2016 in three dermatology units in Senegal. We included all patients consulting for cutaneous squamous cell carcinoma associated with skin bleaching. Sociodemographic, clinical, paraclinical and therapeutic data were recorded. RESULTS: A total of 8 female patients were included. The mean age was 48.1 years (37-63 years). Topical hydroquinone and highly potent corticosteroids were the main products used over the whole body, for an average duration of 20.3 years. No pre-neoplastic skin disease was found in our patients. The clinical aspects of tumours were as follows: cauliflower-like (n=4), ulcerated (n=3) and nodular (n=1). The average development time before consultation was 6.75 months. All the cutaneous squamous cell carcinomas were localized to lichenoid lesions or exogenous ochronotic lesions on photo-exposed areas: face (n=1), neck (n=3) or upper back (n=4). The most common histopathological type was the infiltrating form and there was one case of in situ carcinoma. The outcome was favourable in six of eight patients after surgical resection. Two deaths occurred: one through tumour recurrence and the other through haemorrhagic shock. CONCLUSIONS: From 2005 to 2016, eight cases of cutaneous squamous cell carcinomas associated with cosmetic use of bleaching products were reported in Senegal. The mechanism was not fully elucidated and further studies are necessary. These observations provide an additional argument for combating this practice and including skin bleaching among known risk factors for squamous cell carcinoma.

Genetic structure and invasion history of the house mouse (Mus musculus domesticus) in Senegal, West Africa: a legacy of colonial and contemporary times.

Knowledge of the genetic make-up and demographic history of invasive populations is critical to understand invasion mechanisms. Commensal rodents are ideal models to study whether complex invasion histories are typical of introductions involving human activities. The house mouse Mus musculus domesticus is a major invasive synanthropic rodent originating from South-West Asia. It has been largely studied in Europe and on several remote islands, but the genetic structure and invasion history of this taxon have been little investigated in several continental areas, including West Africa. In this study, we focussed on invasive populations of M. m. domesticus in Senegal. In this focal area for European settlers, the distribution area and invasion spread of the house mouse is documented by decades of data on commensal rodent communities. Genetic variation at one mitochondrial locus and 16 nuclear microsatellite markers was analysed from individuals sampled in 36 sites distributed across the country. A combination of phylogeographic and population genetics methods showed that there was a single introduction event on the northern coast of Senegal, from an exogenous (probably West European) source, followed by a secondary introduction from northern Senegal into a coastal site further south. The geographic locations of these introduction sites were consistent with the colonial history of Senegal. Overall, the marked microsatellite genetic structure observed in Senegal, even between sites located close together, revealed a complex interplay of different demographic processes occurring during house mouse spatial expansion, including sequential founder effects and stratified dispersal due to human transport along major roads.

The predictor of mortality outcome in adult patients with Ebola virus disease during the 2014-2015 outbreak in Guinea.

The purpose of this study was to examine the association of any demographic and clinical factors with mortality outcome among adult patients with Ebola virus disease (EVD) in Guinea. This retrospective observational study analyzed medical records of laboratory confirmed EVD adult patients during the 2014-2015 EVD outbreak in Guinea. The associations between any demographic or clinical variables and mortality outcome of EVD were assessed using univariate and multivariate logistic regression analyses. Of 2,310 EVD adult patients included for analysis, the overall case fatality rate was 68.1%. Univariate analyses identified factors possibly associated with mortality outcome, including patient age (p < 0.001), history of visiting or close contact with a suspected or confirmed EVD patient (p = 0.035), and seven clinical symptoms on admission, i.e., fever (p = 0.003), hiccups (p < 0.001), vomiting (p = 0.003), diarrhea (p < 0.001), cough (p = 0.001), sore throat (p = 0.016), and unexplained bleeding (p = 0.021). The multivariate analysis showed that patient age was independently associated with mortality outcome of EVD (OR = 1.06; 95%CI = 1.03-1.09; p < 0.001), while none the of clinical symptoms on admission were significantly associated with the mortality outcome. Our analysis indicates that older age was the only independent factor associated with death among EVD adult patients in Guinea. This suggests that older EVD patients should receive intensive medical care and be carefully monitored.

Comparison of expression of key sporulation, solventogenic and acetogenic genes in C. beijerinckii NRRL B-598 and its mutant strain overexpressing spo0A.

The production of acetone, butanol and ethanol by fermentation of renewable biomass has potential to become a valuable industrial process. Mechanisms of solvent production and sporulation involve some common regulators in some ABE-producing clostridia, although details of the links between the pathways are not clear. In this study, we compare a wild-type (WT) Clostridium beijerinckii NRRL B-598 with its mutant strain OESpo0A, in which the gene encoding Spo0A, an important regulator of both sporulation and solventogenesis, is overexpressed in terms of solvent and acid production. We also compare morphologies during growth on two different media: TYA broth, where the WT culture sporulates, and RCM, where the WT culture does not. In addition, RT-qPCR-based analysis of expression profiles of spo0A, spoIIE, sigG, spoVD, ald and buk1 genes involved in sporulation or solvent production in these strains, were compared. The OESpo0A mutant did not produce spores and butanol titre was lower compared to the WT, but increased amounts of butyric acid and ethanol were produced. The gene spo0A had high levels of expression in the WT under non-sporulating culture conditions while other selected genes for sporulation factors were downregulated significantly. Similar observations were obtained for OESpo0A where spo0A overexpression and downregulation of other sporulation genes were demonstrated. Higher expression of spo0A led to higher expression of buk1 and ald, which could confirm the role of spo0A in activation of the solventogenic pathway, although solvent production was not affected significantly in the WT and was weakened in the OESpo0A mutant.

[Treatment outcome, survival and their risk factors among new tuberculosis patients co-infected with HIV during the Ebola outbreak in Conakry]. / L'issue du traitement, la survie et ses facteurs de risque chez les nouveaux tuberculeux co-infectés par le VIH pendant l'épidémie d'Ebola à Conakry.

BACKGROUND: Mortality among TB/HIV co-infected patients remains high in Africa. The study aimed to estimate survival and associated factors in a cohort of TB/HIV co-infected patients who started tuberculosis treatment during the Ebola outbreak in Conakry, Guinea. METHODS: A prospective cohort study was conducted from April 2014 to December 2015. TB patients with HIV co-infection were enrolled at the University Hospital of Conakry. Survival and risk factors were analyzed according to Kaplan-Meier's method, log-rank test and Cox's regression. RESULTS: Data from 573 patients were analyzed. From these, 86 (15.0%) died before the end of treatment, 52% occurring within eight weeks of treatment onset. Survival at 4, 12 and 24 weeks after the beginning of the TB treatment was 92%, 86% and 83%, respectively. Independent risk factors associated with death were in the cell CD4 <200 cells/mm3 [adjusted hazard ratio (AHR): 2.25; 95% CI (confidence intervals): 1.16-4.37], opportunistic infections other than TB [AHR: 2.89; 95% CI: 1.39-6.02], and comorbidities [AHR: 4.12; 95% CI: 2.10-8.10]. An increase of one unit in hemoglobin [AHR: 0.81; 95% CI: 0.75-0.91] was protective of death. CONCLUSION: TB/HIV co-infected patients had a higher fatality rate during treatment of tuberculosis. Prevention of opportunistic infections, anemia and proper management of tuberculosis treatment in early comorbidities may improve survival for TB/HIV co-infected patients in restoring immune function.

The "pouch" of the Douglas's pouch.

Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a peritoneal or mesentery defect, a normal or abnormal compartment of the peritoneal cavity. Hernias occurring in the pelvis cavity are usually classified according to the fascial margins breached and include sciatic, obturator and those through the rectouterin pouch: elytrocele and enterocele. Those hernias are defined by the protrusion of a viscus through the wall of the pelvis due to weakness of the pelvic fascia and/or muscles. Pelvic hernia through the pouch of Douglas (PD) involves the genital tract in female (elytrocele and enterocele). Sometimes described in the literature as Douglas hernia, this type of hernia must be distinguished from the conventional IH. As defined before, the borders to be considered for IH is the peritoneal membrane, which is not a real solid wall but delimitates the peritoneal cavity; and there is no peritoneal defect in elytrocele or enterocele. A PubMed search for IH through a defect in the peritoneal PD revealed only five female cases, making this an extremely rare condition. To our knowledge, we have presented here the only published case in a male. This probably congenital and morphologic anomaly (defect) of pouch of Sir Douglas must be distinguished as the real "Douglas IH". Authors discuss the concept of a new and more detailed classification of IH.