Introduction: Inappropriate and excess vitamin supplementation, particularly for vitamin A, is increasingly recognized as a public health problem in developed countries. On the other hand, blind supplementation of vit...Introduction: Inappropriate and excess vitamin supplementation, particularly for vitamin A, is increasingly recognized as a public health problem in developed countries. On the other hand, blind supplementation of vitamin A, for children in developing countries is a subject of controversy in the literature. The crucial role of vitamin A in the process of spermatogenesis in adult rodents is well established, but only a few publications are consecrated to the long-term effect of vitamin A intake at a young age on testicular development and differentiation. Objectives: Our study aimed to evaluate the long-term effects of acute supplementation at an early age, in the post-natal period, on spermatogenesis and testicular trophicity at adult age. Material and Methods: Young Wistar Albinos rats of 22 days received an acute high dose of supplementation of vitamin A (retinyl palmitate). The control group, group 1, received only extra virgin olive oil, Group 2 a dose of 7000 IU/kg of retinyl palmitate, group 3, 14,000 IU/kg, and Group 4 a dose of 28,000 IU/kg. At 10 weeks of age, the testes’ testosterone levels were measured by ELISA. For histological assessment, sections were stained with Hematoxylin eosin, and the Johnsen score was used to evaluate spermatogenesis in the seminiferous tubules. Results: The average testicular weights of rats were significantly lower in group 4 (p < 0.05), and so was the testosterone level in the testis compared to the control group (p .01). Most of the seminiferous tubules were concerned by an arrest of spermatogenesis and the Johnsen score was decreased with a mean score of 5.96 ± 1.60 (p .001) in that Group. In Group 3, Johnsen’s score was significantly better than the one obtained with the control. Conclusion: We observed a negative effect in the long term with a high acute dose of supplementation of retinyl palmitate at a young age, on testicular development and differentiation. Despite a return to normal diet after that supplementation, during childhood, impaired spermatogenesis was identified at the adult age with an arrest of spermatogenesis. The reversibility of that lack of differentiation by a return to a normal diet is questionable and would need more investigation.展开更多
Background: In disorders of sexual differentiation, sexual development may not conform to the chromosomal structure, thus forming different types of abnormalities. Among these abnormalities is syndrome 46, XX DSD wher...Background: In disorders of sexual differentiation, sexual development may not conform to the chromosomal structure, thus forming different types of abnormalities. Among these abnormalities is syndrome 46, XX DSD where most patients are female phenotype with clitoral hypertrophy that can go to complete masculinization especially in the presence of the SRY gene. Objective: The goal of this work is to demonstrate a relationship between the genotype and the phenotype in five patients karyotype 46, XX with the presence of the SRY gene. Methodology: The study involves five patients referred to the laboratory under suspicion of sexual development anomalies. The diagnosis took place through hormonal and echography examinations, a classic cytogenetic study (Barr chromatin and karyotype) and an amplification of the SRY gene located on the Y chromosome. The resulting PCR products were sent for sequencing. Results: Based on the results of clinical and paraclinical tests carried out it was found clitoral hypertrophy, the presence of clitoris penis for some, presence of normal penis for others. In addition, echography revealed a lack of female internal genitalia (P2, P3), and a presence of testicles (P3, P4, P5). Genetic analysis (chromosomal and molecular) showed a karyotype 46, XX SRY (+) for all patients. New mutations were found c.246 T > A, p.82 Asn82Lys and c.171 G > C, p.57 Gln57His. Conclusion: In our study, we were able to correlate each DSD with karyotype 46, XX to a pathology such as 46, XX DSD testicular, 46, XX DSD with clitoral hypertrophy and ovotestis 46, XX. The next step will undoubtedly be the integration of other molecular techniques (genotyping, FISH, CGH or even the CGH array) to further genetic exploration.展开更多
Dear Editor,Monkeypox is an infectious disease that is endemic in a dozen of African countries.Some imported cases have been also reported outside of Africa in the past[1].Since early May 2022,monkeypox infections inc...Dear Editor,Monkeypox is an infectious disease that is endemic in a dozen of African countries.Some imported cases have been also reported outside of Africa in the past[1].Since early May 2022,monkeypox infections including human-to-human transmission,were reported in a multi-country outbreak in non-endemic countries and declared Public Health Emergency of International Concern(PHEIC)by the World Health Organization(WHO)in July 2022[2].As of 20 September 2022,a total of at least 62,798 human cases of monkeypox with 20 deaths have been confirmed in 115 countries in five WHO regions[3].展开更多
Varicocele is the first etiology of infertility in men worldwide and affects almost half of the men dealing with infertility in Senegal. Varicocele is associated with a high rate of sperm DNA fragmentation so this tes...Varicocele is the first etiology of infertility in men worldwide and affects almost half of the men dealing with infertility in Senegal. Varicocele is associated with a high rate of sperm DNA fragmentation so this test is being more and more recommended especially when patients have to benefit from an ART (Assisted Reproductive Technology) procedure. The aim of our study was to assess if our patients with varicocele are concerned by higher DNA fragmentation rate in spermatozoon. Sperm samples were collected (95 cases of varicocele and 30 controls) and analyzed between January 2013 and June 2016 in a prospective study. Sperm DNA damage, characterized by the rate of DNA fragmentation was evaluated by TUNEL assay using fluorescence microscopy. There was a significant higher percentage of DNA fragmentation in patients with varicocele (p < 0.001), compared to controls. We plan to study a bigger cohort to assess this tendency and study the benefits of surgery in varicocele by evaluating DNA fragmentation after the procedure.展开更多
The presence of DNA fragmentation in semen is associated with poor results in ART (Assisted Re-productive Technology). This has led to the introduction of sperm DNA integrity testing in the clinical assessment of male...The presence of DNA fragmentation in semen is associated with poor results in ART (Assisted Re-productive Technology). This has led to the introduction of sperm DNA integrity testing in the clinical assessment of male infertility. The TUNEL assay is one of the most commonly used tests to measure DNA fragmentation in research studies, but it is now being optimized for routine clinical use. So, the objectives of our study were to install the TUNEL assay in our laboratory and to use it to assess the degree of DNA fragmentation in our patients dealing with couple infertility. Forty seven (47) and 25 samples from patients followed up for infertility and known fertile men were analyzed between August 2013 and July 2015 respectively. The sperm samples were evaluated according to the World Health Organization Guidelines. Sperm DNA damage was assessed by the TUNEL assay, with a standardized protocol that we adapted for reading using fluorescence microscopy instead of flow cytometry. The Sperm DNA Fragmentation Index was significantly higher in patients with infertility compared to the controls (22.2% ± 5.6% vs. 16.7% ± 0.7%) with a p < 0.05. This Index was also high in patients with varicocele compared to the control group (22.8% ± 9.2 vs. 16.7% ± 0.7%) (p < 0.01). After establishing the ROC curve (Receiver Operating Characteristics curve), we found a 15% threshold of DNA fragmentation, separating the patients with infertility from the control group. In our study, a 15% threshold positivity of DNA fragmentation using the TUNEL assay was highly associated with infertility. The results indicate that high level DNA fragmentation is associated with infertility.展开更多
Introduction: Inter individual variation for semen on analysis is well known. Therefore, Semen profile is not the same in individuals from different geographic locations, environments, ways of life, and populations. I...Introduction: Inter individual variation for semen on analysis is well known. Therefore, Semen profile is not the same in individuals from different geographic locations, environments, ways of life, and populations. It is important for a laboratory to have an idea of the semen profile of its population, especially for those who present with infertility. The aim of this study was to draw the pattern of semen abnormalities in male partner of infertile couple in Dakar, Senegal. Materials and Methods: A retrospective study of all the semen samples of male partners of infertile couples submitted for analysis in the laboratory of Cytogenetic and Reproductive Biology of Dakar at the University Teaching hospital from January 2013 to June 2014. Results: A total of 262 male semen analyses were reported. Analysis was performed according to WHO, 2010 manual for examination of human semen. Our study reveals that 80.9% of men in infertile couples present an abnormality in sperm pattern. The main one is oligo-astheno-terato-necrozoospermia (20.2%), followed by azoospermia, (14.1%), astheno-necrospermia (10.3%) and astheno-terato-necro-zoospermia (10.3%). Leucocytospermia was found in 57.8%. Teratozoospermia (80.9%) was the most associated abnormality, followed by necrozoospermia (76.2%). Low sperm count under 5 million per ml concerned 27.7% of the patients, and 11.2% patients had low ejaculate volume. Nearly 42.1% of the male partners are potential candidates for Assisted Reproductive Technology for male infertility. Conclusion: The high rate of semen abnormality in patients of infertile couples and consequently the high rate of potential candidates to Assisted Reproductive Technology for male infertility are important reasons for taking into account rigorously the male subject if we want to improve fertility rate in our context. The pattern of the specific abnormalities found is precious clues to guide management of these patients.展开更多
Introduction: the roots of Leptadenia hastata, (L hastata) are remedies from the Senegalese pharmacopoeia and are as widely used as the leaves. However, few researchers have devoted themselves to their toxicity, unlik...Introduction: the roots of Leptadenia hastata, (L hastata) are remedies from the Senegalese pharmacopoeia and are as widely used as the leaves. However, few researchers have devoted themselves to their toxicity, unlike the leaves. However, in the traditional pharmacopoeia, the indications for use are very different. The aim of our study was to study the effect of the administration of methanolic extracts of roots of L hastata on renal tissue, using an animal model. Materials and Methods: a cohort of 18 rats was studied with a random distribution of the animals in 3 groups (n = 6). The first group was the control group. The treated groups (Group II and III) received the methanolic extract of L. hastata with an administration of 500 mg / kg / day and 1000 mg / kg / day respectively, for 28 days. Results: The dose of 1000 mg / kg / day was lethal in group III, from the first week in females. Serum creatinine was significantly higher in rats given the root extract. There was kidney damage with vacuolar degeneration starting at 500 mg / kg / day. The lesions were more severe in group III with glomerular involvement characterized by retraction in the renal corpuscles. Conclusion: If the leaves of L hastata seem to be safe for consumption according to the majority of authors in the literature, the roots of this same plant could be harmful. In addition to the lethality observed at the doses tested, the lesions in the renal parenchyma would be dose-dependent.展开更多
Background: Mainly for economic reasons, histopathologic analysis is not a systematic practice in medical structures in Senegal, and the utility of this exam is being questioned by many authors. The purpose of this pa...Background: Mainly for economic reasons, histopathologic analysis is not a systematic practice in medical structures in Senegal, and the utility of this exam is being questioned by many authors. The purpose of this paper is to report the results of this exam, in our medical practice and try to determine if this exam should be systematic of kept only for individualized cases. Material and Methods: It was a retrospective study from January 2010 to December 2018, carried out in the Laboratory of Pathology of the Teaching Hospital of Grand Yoff in Dakar. The data were collected from the register of pathologic examinations of the laboratory. Results: We registered 543 results of histopathologic examination of products of conception from the first trimester abortion. The women mean age was 22.4 years ± 6.2 with extremes of 17 and 46 years. The routine histopathologic assessment of products of first- trimester miscarriages highlighted in our study three pathologies: hydatidiform mole (24.7%), infection (4.6%) and ectopic pregnancy (0.09%). Only 11.7% of cases of Hydatidiform mole (HM) were suspected before the histopathologic assessment. In our sample, molar pregnancy seems to be higher in anembryonic conception with a prevalence of 45%. The prevalence of Complete Hydatidiform Mole (CHM) was higher than the one of Partial Hydatidiform Mole (PHM) (14.8% vs. 9.9% of miscarriages). Indeed, both require follow up to prevent or manage at time the occurrence of choriocarcinoma. Conclusion: The results of the histologic analysis after abortion in the first trimester of pregnancy show that this exam should be practiced systematically in routine in our context because of high prevalence of hydatidiform mole.展开更多
Introduction: Ventriculomegaly is one of the most common abnormalities detected by prenatal ultrasound. This entity can be associated with brain abnormalities and other malformations. In order to perform a good prenat...Introduction: Ventriculomegaly is one of the most common abnormalities detected by prenatal ultrasound. This entity can be associated with brain abnormalities and other malformations. In order to perform a good prenatal counseling, the diagnosis is essential. Objective: Our purpose was to report the management of 3 cases of ventriculomegaly in our practice and underline the benefits of the neuropathologic exam. Methods: We analyzed retrospectively 3 medical files concerning fetus that were diagnosed as having one or two ventricles of >10 mm and a follow up for prenatal diagnosis. Results: All cases were diagnosed between 22 and 27 weeks of gestation by an ultrasound. In a case, the ventriculomegaly evolved rapidly to a hydrocephalus. In two cases, the pregnancy was terminated with medical interruption by the parent’s request. Amniocentesis confirmed the diagnosis of congenital toxoplasmosis in case 2 there were no chromosomal abnormalities after karyotyping. Causes included holoprosencephaly, congenital toxoplasmosis and mesencephalosynapsis. Conclusion: Ultrasonography may detect ventriculomegaly nerverthless in the cases presented, pathology exam was essential to assess the diagnostic. Causes are numerous and prognosis variable. We recommand MRI that is more and more accessible in our regions in the follow up of this entity and neuropathology exam in case of termination of the pregnancy. The establishment of main causes of ventriculomegaly in our regions (infectious causes for example) could help to prevent this outcome in our practice.展开更多
文摘Introduction: Inappropriate and excess vitamin supplementation, particularly for vitamin A, is increasingly recognized as a public health problem in developed countries. On the other hand, blind supplementation of vitamin A, for children in developing countries is a subject of controversy in the literature. The crucial role of vitamin A in the process of spermatogenesis in adult rodents is well established, but only a few publications are consecrated to the long-term effect of vitamin A intake at a young age on testicular development and differentiation. Objectives: Our study aimed to evaluate the long-term effects of acute supplementation at an early age, in the post-natal period, on spermatogenesis and testicular trophicity at adult age. Material and Methods: Young Wistar Albinos rats of 22 days received an acute high dose of supplementation of vitamin A (retinyl palmitate). The control group, group 1, received only extra virgin olive oil, Group 2 a dose of 7000 IU/kg of retinyl palmitate, group 3, 14,000 IU/kg, and Group 4 a dose of 28,000 IU/kg. At 10 weeks of age, the testes’ testosterone levels were measured by ELISA. For histological assessment, sections were stained with Hematoxylin eosin, and the Johnsen score was used to evaluate spermatogenesis in the seminiferous tubules. Results: The average testicular weights of rats were significantly lower in group 4 (p < 0.05), and so was the testosterone level in the testis compared to the control group (p .01). Most of the seminiferous tubules were concerned by an arrest of spermatogenesis and the Johnsen score was decreased with a mean score of 5.96 ± 1.60 (p .001) in that Group. In Group 3, Johnsen’s score was significantly better than the one obtained with the control. Conclusion: We observed a negative effect in the long term with a high acute dose of supplementation of retinyl palmitate at a young age, on testicular development and differentiation. Despite a return to normal diet after that supplementation, during childhood, impaired spermatogenesis was identified at the adult age with an arrest of spermatogenesis. The reversibility of that lack of differentiation by a return to a normal diet is questionable and would need more investigation.
文摘Background: In disorders of sexual differentiation, sexual development may not conform to the chromosomal structure, thus forming different types of abnormalities. Among these abnormalities is syndrome 46, XX DSD where most patients are female phenotype with clitoral hypertrophy that can go to complete masculinization especially in the presence of the SRY gene. Objective: The goal of this work is to demonstrate a relationship between the genotype and the phenotype in five patients karyotype 46, XX with the presence of the SRY gene. Methodology: The study involves five patients referred to the laboratory under suspicion of sexual development anomalies. The diagnosis took place through hormonal and echography examinations, a classic cytogenetic study (Barr chromatin and karyotype) and an amplification of the SRY gene located on the Y chromosome. The resulting PCR products were sent for sequencing. Results: Based on the results of clinical and paraclinical tests carried out it was found clitoral hypertrophy, the presence of clitoris penis for some, presence of normal penis for others. In addition, echography revealed a lack of female internal genitalia (P2, P3), and a presence of testicles (P3, P4, P5). Genetic analysis (chromosomal and molecular) showed a karyotype 46, XX SRY (+) for all patients. New mutations were found c.246 T > A, p.82 Asn82Lys and c.171 G > C, p.57 Gln57His. Conclusion: In our study, we were able to correlate each DSD with karyotype 46, XX to a pathology such as 46, XX DSD testicular, 46, XX DSD with clitoral hypertrophy and ovotestis 46, XX. The next step will undoubtedly be the integration of other molecular techniques (genotyping, FISH, CGH or even the CGH array) to further genetic exploration.
基金supported by the Benin Ministry of Health and the Institut Pasteur de Dakar Internal Funds for Research.·。
文摘Dear Editor,Monkeypox is an infectious disease that is endemic in a dozen of African countries.Some imported cases have been also reported outside of Africa in the past[1].Since early May 2022,monkeypox infections including human-to-human transmission,were reported in a multi-country outbreak in non-endemic countries and declared Public Health Emergency of International Concern(PHEIC)by the World Health Organization(WHO)in July 2022[2].As of 20 September 2022,a total of at least 62,798 human cases of monkeypox with 20 deaths have been confirmed in 115 countries in five WHO regions[3].
文摘Varicocele is the first etiology of infertility in men worldwide and affects almost half of the men dealing with infertility in Senegal. Varicocele is associated with a high rate of sperm DNA fragmentation so this test is being more and more recommended especially when patients have to benefit from an ART (Assisted Reproductive Technology) procedure. The aim of our study was to assess if our patients with varicocele are concerned by higher DNA fragmentation rate in spermatozoon. Sperm samples were collected (95 cases of varicocele and 30 controls) and analyzed between January 2013 and June 2016 in a prospective study. Sperm DNA damage, characterized by the rate of DNA fragmentation was evaluated by TUNEL assay using fluorescence microscopy. There was a significant higher percentage of DNA fragmentation in patients with varicocele (p < 0.001), compared to controls. We plan to study a bigger cohort to assess this tendency and study the benefits of surgery in varicocele by evaluating DNA fragmentation after the procedure.
文摘The presence of DNA fragmentation in semen is associated with poor results in ART (Assisted Re-productive Technology). This has led to the introduction of sperm DNA integrity testing in the clinical assessment of male infertility. The TUNEL assay is one of the most commonly used tests to measure DNA fragmentation in research studies, but it is now being optimized for routine clinical use. So, the objectives of our study were to install the TUNEL assay in our laboratory and to use it to assess the degree of DNA fragmentation in our patients dealing with couple infertility. Forty seven (47) and 25 samples from patients followed up for infertility and known fertile men were analyzed between August 2013 and July 2015 respectively. The sperm samples were evaluated according to the World Health Organization Guidelines. Sperm DNA damage was assessed by the TUNEL assay, with a standardized protocol that we adapted for reading using fluorescence microscopy instead of flow cytometry. The Sperm DNA Fragmentation Index was significantly higher in patients with infertility compared to the controls (22.2% ± 5.6% vs. 16.7% ± 0.7%) with a p < 0.05. This Index was also high in patients with varicocele compared to the control group (22.8% ± 9.2 vs. 16.7% ± 0.7%) (p < 0.01). After establishing the ROC curve (Receiver Operating Characteristics curve), we found a 15% threshold of DNA fragmentation, separating the patients with infertility from the control group. In our study, a 15% threshold positivity of DNA fragmentation using the TUNEL assay was highly associated with infertility. The results indicate that high level DNA fragmentation is associated with infertility.
文摘Introduction: Inter individual variation for semen on analysis is well known. Therefore, Semen profile is not the same in individuals from different geographic locations, environments, ways of life, and populations. It is important for a laboratory to have an idea of the semen profile of its population, especially for those who present with infertility. The aim of this study was to draw the pattern of semen abnormalities in male partner of infertile couple in Dakar, Senegal. Materials and Methods: A retrospective study of all the semen samples of male partners of infertile couples submitted for analysis in the laboratory of Cytogenetic and Reproductive Biology of Dakar at the University Teaching hospital from January 2013 to June 2014. Results: A total of 262 male semen analyses were reported. Analysis was performed according to WHO, 2010 manual for examination of human semen. Our study reveals that 80.9% of men in infertile couples present an abnormality in sperm pattern. The main one is oligo-astheno-terato-necrozoospermia (20.2%), followed by azoospermia, (14.1%), astheno-necrospermia (10.3%) and astheno-terato-necro-zoospermia (10.3%). Leucocytospermia was found in 57.8%. Teratozoospermia (80.9%) was the most associated abnormality, followed by necrozoospermia (76.2%). Low sperm count under 5 million per ml concerned 27.7% of the patients, and 11.2% patients had low ejaculate volume. Nearly 42.1% of the male partners are potential candidates for Assisted Reproductive Technology for male infertility. Conclusion: The high rate of semen abnormality in patients of infertile couples and consequently the high rate of potential candidates to Assisted Reproductive Technology for male infertility are important reasons for taking into account rigorously the male subject if we want to improve fertility rate in our context. The pattern of the specific abnormalities found is precious clues to guide management of these patients.
文摘Introduction: the roots of Leptadenia hastata, (L hastata) are remedies from the Senegalese pharmacopoeia and are as widely used as the leaves. However, few researchers have devoted themselves to their toxicity, unlike the leaves. However, in the traditional pharmacopoeia, the indications for use are very different. The aim of our study was to study the effect of the administration of methanolic extracts of roots of L hastata on renal tissue, using an animal model. Materials and Methods: a cohort of 18 rats was studied with a random distribution of the animals in 3 groups (n = 6). The first group was the control group. The treated groups (Group II and III) received the methanolic extract of L. hastata with an administration of 500 mg / kg / day and 1000 mg / kg / day respectively, for 28 days. Results: The dose of 1000 mg / kg / day was lethal in group III, from the first week in females. Serum creatinine was significantly higher in rats given the root extract. There was kidney damage with vacuolar degeneration starting at 500 mg / kg / day. The lesions were more severe in group III with glomerular involvement characterized by retraction in the renal corpuscles. Conclusion: If the leaves of L hastata seem to be safe for consumption according to the majority of authors in the literature, the roots of this same plant could be harmful. In addition to the lethality observed at the doses tested, the lesions in the renal parenchyma would be dose-dependent.
文摘Background: Mainly for economic reasons, histopathologic analysis is not a systematic practice in medical structures in Senegal, and the utility of this exam is being questioned by many authors. The purpose of this paper is to report the results of this exam, in our medical practice and try to determine if this exam should be systematic of kept only for individualized cases. Material and Methods: It was a retrospective study from January 2010 to December 2018, carried out in the Laboratory of Pathology of the Teaching Hospital of Grand Yoff in Dakar. The data were collected from the register of pathologic examinations of the laboratory. Results: We registered 543 results of histopathologic examination of products of conception from the first trimester abortion. The women mean age was 22.4 years ± 6.2 with extremes of 17 and 46 years. The routine histopathologic assessment of products of first- trimester miscarriages highlighted in our study three pathologies: hydatidiform mole (24.7%), infection (4.6%) and ectopic pregnancy (0.09%). Only 11.7% of cases of Hydatidiform mole (HM) were suspected before the histopathologic assessment. In our sample, molar pregnancy seems to be higher in anembryonic conception with a prevalence of 45%. The prevalence of Complete Hydatidiform Mole (CHM) was higher than the one of Partial Hydatidiform Mole (PHM) (14.8% vs. 9.9% of miscarriages). Indeed, both require follow up to prevent or manage at time the occurrence of choriocarcinoma. Conclusion: The results of the histologic analysis after abortion in the first trimester of pregnancy show that this exam should be practiced systematically in routine in our context because of high prevalence of hydatidiform mole.
文摘Introduction: Ventriculomegaly is one of the most common abnormalities detected by prenatal ultrasound. This entity can be associated with brain abnormalities and other malformations. In order to perform a good prenatal counseling, the diagnosis is essential. Objective: Our purpose was to report the management of 3 cases of ventriculomegaly in our practice and underline the benefits of the neuropathologic exam. Methods: We analyzed retrospectively 3 medical files concerning fetus that were diagnosed as having one or two ventricles of >10 mm and a follow up for prenatal diagnosis. Results: All cases were diagnosed between 22 and 27 weeks of gestation by an ultrasound. In a case, the ventriculomegaly evolved rapidly to a hydrocephalus. In two cases, the pregnancy was terminated with medical interruption by the parent’s request. Amniocentesis confirmed the diagnosis of congenital toxoplasmosis in case 2 there were no chromosomal abnormalities after karyotyping. Causes included holoprosencephaly, congenital toxoplasmosis and mesencephalosynapsis. Conclusion: Ultrasonography may detect ventriculomegaly nerverthless in the cases presented, pathology exam was essential to assess the diagnostic. Causes are numerous and prognosis variable. We recommand MRI that is more and more accessible in our regions in the follow up of this entity and neuropathology exam in case of termination of the pregnancy. The establishment of main causes of ventriculomegaly in our regions (infectious causes for example) could help to prevent this outcome in our practice.
