Journal of Medicine

Comparison of Serum C-Reactive Protein (CRP) Level Between Non-Alcoholic Fatty Liver Disease (NAFLD) Cases and Healthy Adults: A Cross-sectional Analytical Study.

Md Mohi Uddin — 2024-01-04

Background: Non-alcoholic fatty liver disease (NAFLD) encompasses the simple steatosis to more progressive steatosis with associated hepatitis, fibrosis and cirrhosis. Though accurate diagnosis of simple fatty liver (SFL) and non-alcoholic steatohepatitis (NASH) can be made by liver biopsy, it is not feasible to be done in all NAFLD patients. Relationship of C-reactive protein (CRP) with NAFLD was well documented in many populations, but comprehensive data is lacking in Bangladeshi people.

Method: This case-control study was conducted at the Medicine, Gastroenterology and Hepatology departments in Dhaka Medical College Hospital from March to August 2018 involving 30 patients with NAFLD as case and apparently healthy 30 individuals as control. Abdominal ultrasound to detect fatty liver and serum CRP level estimation by nephelometry were performed for each subject to compare between two groups.

Result: Majority of the NAFLD cases and healthy controls were female (70% and 60% respectively). Mean age was 47.53±9.69 year in NAFLD group and 46.03±8.44 year in healthy controls. NAFLD cases had significantly higher mean serum CRP concentration (6.27±1.80) mg/dl than that of healthy controls (3.94±2.16) mg/dl (p<0.001). Overweight/obesity and dyslipidaemia were found as significant risk factors for NAFLD compared to the healthy control group (p<0.05).

Conclusion: NAFLD cases had significantly higher CRP than the control group. But, to find out the association of increasing CRP level with the severity of NAFLD and to establish it as a diagnostic tool, further extensive studies are recommended.

J MEDICINE 2024; 25: 5-10

Electrophysiological variations of Guillain-Barre syndrome in Bangladesh- Hospital based study

Shinjini Sarker — 2024-01-04

Introduction: Guillain-Barre syndrome (GBS) is an immune mediated disorder of peripheral nerves which usually presents by rapidly evolving ascending weakness & mild sensory loss and hypo- or areflexia. Electrodiagnostic study (EDS) is the basis for classification of different subtypes of the disease. EDS also has a crucial role in diagnosis, ruling out of some differential diagnosis like myopathic and motor neuron disorders and confirming the neuropathic nature of GBS. The benefit of immunotherapy is greatest when introduced early. In addition, electrophysiological characteristic can predict the prognosis of patients with GBS. This study was conducted to determine the predominant subtype and electrophysiological pattern of GBS in the context of Bangladesh.

Objectives: Objective of this study was to compare the electrophysiological variations among different electrophysiological subtypes of GBS.

Methods: It is an observational cross sectional study conducted in Department of Medicine and Neurology, Sir Salimullah Medical College & Mitford Hospital and National Institute of Neuroscience (NINS), Dhaka, over a period of one year & four months. Total 30 patients were selected by purposive sampling technique. Demographic data were collected from the patients and recorded in structured case report form. Clinical examination and relevant investigations were done meticulously. Collected questionnaire were checked to identify any error in data. Data was analyzed with SPSS version 21 software.

Result: In this study, maximum numbers of patients 53% were between 21-30 years of age group with mean value 27.47±8.1 years. Male to female ratio was 1.7:1. Frequency of Guillain-Barre syndrome is predominance at middle age group. Commonest presentation was limb weakness (parapledgia or quadripledgia) in 60% patients, paresthesias & numbness (40%), pain (100%) and deviation of mouth (63%) of GBS patients. Cerebrospinal fluid shows a mild pleocytosis (5 to 50 cells/µl) in majority of cases was found in 76% of patients. Whereas elevated CSF Protein (>45 mg/dl) was seen in all GBS patient. Increased distal motor latency (DML) was found in 93% patients, whereas 7% patients had normal DML. In the case of the lower limbs, increased distal motor latency was predominant. Decreased amplitude of sensory nerve action potential (SNAP) was seen in 83% patients while 16% patients had normal. Slowing of motor conduction velocities, decreased amplitude as well as increase in distal motor latencies were observed, being more pronounced in the lower limbs. F-wave was completely absent in 20.0% patients while 20% patients showed decreased conduction velocity with prolonged latency. Sensory nerve action potential revealed that decreased sensory conduction velocity (SCV) was seen in 26%, absent SCV in 10% and normal SCV in 63% patients. Present study demonstrated that Acute inflammatory demyelinating polyneuropathy (AIDP) was the commonest type of Guillain-Barré syndrome, present in 56% of patient. Around 30% of the patients belonged to acute motor axonal polyneuropathy (AMAN) and 13% were acute motor sensory axonal polyneuropathy (AMSAN).

Conclusion: In this study AIDP was the most frequent subtype. The characteristic findings supportive of AIDP include prolonged distal motor latencies, reduced conduction velocities, conduction blocks at non-entrapment sites, temporal dispersion and prolonged F wave latencies.

J MEDICINE 2024; 25: 11-16

Role of Home Blood Pressure Monitoring in Treatment Follow-up by Hypertensive Patients Cohort

Farjana Pervin Nupur — 2024-01-04

Background: The main benefit of home-based blood pressure monitoring (HBPM) is the potential approach to reduce the risk of white-coat hypertension (HTN) and to encourage patients to take ownership of their condition. This study was conducted to assess the role of HBPM in treatment follow-up in a cohort of hypertensive patients.

Materials and methods: This was a prospective observational study conducted from December 2017 to May 2018. A total of 100 patients fulfilling the inclusion and exclusion criteria were selected by purposive sampling from Medicine Outdoor of Dhaka Medical College Hospital (DMCH). In total, 100 hypertensive patients were enrolled, and informed consent was obtained. Subsequently, the study subjects received information and training on BP self-management and performed 2 resting measurements per day for 4 days per week for 3 months. All measurements were performed using validated BP monitors.The study endpoints included patient awareness, attainment of BP goals, adherence to antihypertensive treatment, lifestyle modification, assessment of discrepancy between office and HBPM, and white coat HTN or masked HTN at 3 months. SPSS version 22.0 was used for data analysis and reporting.

Results: Overall, the mean age was 57.76 ±12.60 years with a range of 34 – 80 years. Males were more prevalent than females, and the ratio was 1.17:1. The majority of cases (76.0%) had established HTN with a history of taking medication, whereas others were non-compliant with medications. Among them 47% had obesity, and 24% had diabetes mellitus. Of the patients, 91% adherence to HBP monitoring, 84.0% adherence to medication, and 75.0% achieved their target BP. The achievement of target blood pressure was significantly higher among the study subjects who adhered to HBP monitoring, and the p-value was < 0.04 (Fisher’s Exact test).

Conclusion: In a cohort of patients with arterial hypertension, information, and training on BP self-measurement and direct involvement of patients using HBPM led to improvement in BP control and could be an effective method by incorporating it into the usual care of hypertensive patients in the hypertension management center of the community.

J MEDICINE 2024; 25: 17-23

Clinical Presentation of Ischaemic and Haemorrhagic Stroke and Its Relation to Lipid Profile

Rahatun Nayeem — 2024-01-04

Introduction: Stroke is a major health hazard in both developed and developing countries. Dyslipidaemia is one of the important risk factors for stroke. The purpose of the present study was to identify clinical presentations of both ischaemic and haemorrhagic stroke, and to find out correlation between stroke and lipid profile.

Methods: The observational study was conducted in the Department of Medicine at Sher-e-Bangla Medical College Hospital, Barishal from April to September 2013 for a period of 6 months. All the stroke patients over 20 years of age of both sexes were selected as study population. After admission at the hospital, history was taken from the patients or the attendants. The clinical presentation was recorded in a pre designed data collection sheet. Fasting lipid profile was measured in every stroke patient.

Results: Total 100 stroke patients were enrolled for this study, of them 36 were haemorrhagic and 64 were ischaemic stroke patients. The mean ± SD of age were 63.945 ± 8.84 and 62.26 ± 14.40 in haemorrhagic and ischaemic stroke patients respectively (p>0.05). Among both haemorrhagic and ischaemic stroke patients maximum 61.1% and 60.9% used to have sedentary work. Impaired level of consciousness was more common among the haemorrhagic stroke patients (91.7%) than ischaemic stroke patients (57.8%) group and the association is statistically significant (p=0.001). Limb weakness was the commonest presentation in both haemorrhagic (91.7%) and ischaemic (87.5%) stroke patients. The mean ± SD of total cholesterol was 173.47 ± 61.96 and 178.22 ± 54.79 in haemorrhagic stroke and ischaemic stroke patients respectively (p<0.05).

Conclusion: Older age, male sex, sedentary work and dyslipidaemia were susceptible to be affected in stroke. Among lipoproteins, elevated total cholesterols, triglycerides and LDL showed strong correlation with both ischaemic and haemorrhagic strokes.

J MEDICINE 2024; 25: 24-28

Nutritional Status and Quality of Life among Geriatric Patients in a Tertiary Care Hospital

Suzana Malek Tinu — 2024-01-04

Background: Wellbeing of the elderly population in terms of their health and nutritional status are often ignored and unidentified in the community. This study aimed at assessing the nutritional status of the geriatric patients and their quality of life (QOL) attending OPD of Mugda Medical College Hospital.

Method: This survey was conducted in the OPD of Mugda Medical College Hospital from June to December 2022 through a cross-sectional analytical method. The study tools were the Mini-Nutritional Assessment tool and WHOQOL-BREF questionnaires which were used to observe the level of nutrition and quality of life among geriatric population respectively.

Result: Of all the respondents, about half (46%) were at risk for malnutrition and about 28% were malnourished while 26% respondents’ level of nutrition was normal. About 62% respondents had poor QOL, whereas, 31% had fair QOL and only 7% had good QOL. Also, nutritional status and quality of life of the elderly had significant relationship.

Conclusion: The impact of poor nutrition on the quality of life and physical ability of geriatric population is remarkably worthy of attention. The ageing process is challenging and raises public health concerns. Reduction of the observed prevalence of malnutrition and thereby upgrading the quality of life of elderly population should be more focused on and proper attention to this issue is crucial in the community as well as national level.

J MEDICINE 2024; 25: 29-34

Prevalence of Psoriatic Arthritis among Patients with Arthritis: Insights from a Tertiary Rheumatology Clinic in Bangladesh

Sayeef Hossain Khan Mark — 2024-01-04

Background: Psoriatic Arthritis (PsA) is a complex seronegative inflammatory arthritis associated with psoriasis, characterized by a wide range of clinical manifestations. This study aimed to explore the prevalence of PsA in arthritic patients along with associated demographic and clinical characteristics in a tertiary care setting in Bangladesh.

Methods: This cross-sectional study was conducted at the Rheumatology Clinic of Dhaka Medical College Hospital over a period of 6 months from March 2018 to August 2018. A total of 600 arthritis patients underwent screening for PsA, with subsequent evaluations of confirmed cases based on the CASPAR criteria. Demographic and clinical characteristics were documented through face-to-face interviews and physical examination. For data collection, a pre-structured questionnaire was used. Disease activity was assessed using the DAPSA score. The study was conducted according to the ‘Declaration of Helsinki’. The statistical analysis was done with SPSS v-21.

Results: The prevalence of PsA in arthritis patients was 5%. Age distribution of PsA showed a majority in between 30-39 years age group with a mean of 36.33±11.86 (SD). Slight female predominance was reported with a percentage of 53.3%. Almost three-fourths of study patients presented with a current diagnosis of psoriasis while the rest had a personal history or family history. A higher incidence (67.7%) of plaque psoriasis was observed followed by sebopsoriasis (20%) and for the rest of the patients, the type of psoriasis was unknown. The disease mostly involved multiple joints (90%), with ankle and metacarpal joints being the most commonly affected at 43.3% and 33.3%, respectively. Disease activity was high in the majority of the patients according to the DAPSA score, representing 53.34% of the patients, with the remainder exhibiting moderate to low disease activity.

Conclusion: The study revealed a significant incidence of PsA among the arthritic population which indicates a pressing need for further extensive research on PsA across diverse populations.

J MEDICINE 2024; 25: 35-40

Study on Red Cell Indices in Chronic Liver Disease in Tertiary Level Hospital

Rafiya Afroz — 2024-01-04

Background: Chronic liver disease (CLD) in the clinical context is a disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Liver diseases are frequently associated with hematological abnormalities. Bleeding and defective blood coagulation contributes to the anemia in CLD patients. Other mechanisms of anemia include aplastic anemia secondary to previous hepatitis, or side effects of treatment of hepatitis with chemotherapeutic agent. Other different factors, such as malabsorption, malnutrition or direct toxic effect also contribute to hematological abnormalities. The examination of complete blood count is common, economically cheap and readily available laboratory procedure. Red cell indices are valuable in the evaluation of morphologic characteristic of anaemias or hematological abnormalities in CLD patients.

Objectives: To assess the red cell indices in chronic liver disease patients.

Materials & method: This descriptive type of cross-sectional study was conducted in Department of Medicine, Dhaka Medical College Hospital, Dhaka, among 75 cases of Chronic liver disease patients. Samples were selected by purposive sampling technique. Detail demographic data were collected from the patients and recorded in structured case report form. Clinical examination and relevant investigation were done meticulously. Data was processed and analysed with the help of computer program SPSS and Microsoft excel. Quantitative data expressed as mean and standard deviation and qualitative data as frequency and percentage. Results was presented by tabulation and graphical presentation in the form of tables, pie chart, graphs, bar diagrams, histogram & charts etc.

Result: Maximum number of patients, 37(49.3%) were between 31-40 years of age with mean age of the patient was 37.58 ± 8.23 years. Out of 75 cases 58(77.0%) patients were male and 17(23.0%) were female. Male-female ratio was 3.34:1. Majority of patients belonged to Child Pugh score B. Prevalence of anaemia was 54(72%) in CLD patients. Microcytic anaemia was predominant and Normocytic anaemia was second most common. Hb concentration & MCV decreases with the severity of Child Pugh score. Abnormalities of red cell indices were positively associated with severity of CLD.

Conclusion: Present study concluded that chronic liver diseases are associated with hematological abnormalities. Patients with severe hepatocellular disease develop defects of blood coagulation as a consequence of endothelial dysfunction, thrombocytopenia, deficiencies of coagulation factors and various associated disorders. In overall patients, Child Pugh class C cases had significant low hemoglobin in comparison to rest of group. Assessing the severity and type of anaemia by red cell indices is a useful tool for proper treatment, prognosis in patients of CLD for reducing the mortality and morbidity.

J MEDICINE 2024; 25: 41-45

CT severity Radiological phenotypes (CTS) assessment in COVID-19 pneumonia as ‘inconsistent predictor of disease severity’: A large tertiary care center study in India

Shital Patil — 2024-01-04

Introduction: Radiological phenotypes are radiological patterns or observable characteristics of COVID-19 pneumonia. Various phenotypic classifications have been reported in literature. CT severity radiological phenotypes are widely used and universally accepted radiological phenotypic methods. Robust data is available regarding role of HRCT in COVID-19 pneumonia and we have evaluated role of CT severity in assessing natural course of COVID-19 illness during its evolution sand follow-up.

Methods: Prospective, Observational study, included 3000 COVID-19 RT-PCR confirmed cases with lung involvement documented and radiological severity phenotypes categorized on HRCT thorax as mild, moderate and severe as per lung segment involvement bilaterally (scoring tool 0-25 score, mild 1-7, moderate 8-15 and severe 16-25). Radiological CT severity phenotypes were evaluated in correlation with interventions such as oxygen support and oxygen plus ventilatory support requirement during hospitalization. Age, gender, Comorbidity, laboratory parameters and use of BIPAP/NIV in COVID-19 cases and outcome as with or without lung fibrosis were key observations. Final radiological outcome documented in follow up CT thorax imaging done at six months of discharge from hospital. Statistical analysis is done by using Chi square test.

Results: In study of 3000 cases, ‘mild, moderate and severe’ radiological CT severity phenotypes were documented as 13.33%, 48.33% & 38.34 % respectively. CT severity has documented significant association with duration of illness at entry point [p<0.00001] Duration of illness (<7 days, 7-14 days and >14 days) plays a crucial role in predicting radiological CT severity phenotypes. CT severity has documented significant association with laboratory parameters at entry point (d-dimer, CRP, IL-6) [p<0.00001] and interventions required in indoor unit. [p<0.00001] Post COVID-19 lung fibrosis or sequelae has significant association with radiological CT severity phenotypes. [p<0.00001] Covariates such as age, gender, diabetes mellitus, IHD, Hypertension, COPD, Obesity has significant association with radiological CT severity phenotypes. [p<0.00001]

Conclusion: Radiological CT severity phenotypic differentiation has documented very crucial role in initial assessment and during triaging of these cases in indoor and outdoor setting. Although CT severity is best predictor of severity it has showed ‘inconstancy’ in predicting disease severity, targeting interventions and predicting early and long-term outcomes in COVID-19 pneumonia.

J MEDICINE 2024; 25: 46-57

A Young Adult with Crohn’s Arthritis Necessitating Upper Gastrointestinal Tract Surgery - A Case Report

Tasmina Chowdhury — 2024-01-04

Upper gastrointestinal tract predominant Crohn’s Disease (CD) remains an uncommon clinical entity, manifesting limited or vague symptomatology, thus delaying clinical suspicion and subsequent diagnostic evaluation. For that reason, it has not been widely described and there is a lack of clear recommendations for diagnosis or management. Standard Inflammatory Bowel Disease (IBD) evaluation including serologic testing, imaging, and endoscopy may initially not be fruitful. Furthermore, endoscopic evaluation may be inconclusive even in patients with long standing-disease. We describe a 30-year-old male who suffered long with persistent iron-deficiency anemia (IDA) and occasional melaena along with predominant axial arthropathy. Extensive in-patient testing including multiple endoscopic evaluation with standard biopsy were unfruitful. Ultimately, long standing recurrent gastric and duodenal ulcer, suggestive colonoscopy finding, and positive fecal calprotectin in a patient along with spondyloarthropathy drove us toward the diagnosis of Crohn’s disease. We started steroid, PPI, sulfasalazine and the patient is on follow up.

J MEDICINE 2024; 25: 83-86

Idiopathic Pericarditis Leading to Hemorrhagic Pericardial Effusion- A Case Report and Review

Forest Riekhof BS — 2024-01-04

Pericardial effusion presentation is a large spectrum that can vary from asymptomatic to cardiac tamponade. It is a relatively common syndrome and has a diverse set of etiologies including infections, malignancy, radiation/iatrogenic, pericardial injury, metabolic disturbances, endocrine disease, connective tissue disease, autoimmune disorders, trauma, or idiopathic. Pericardial drainage is recommended in most large pericardial effusions or those causing cardiac tamponade. Pericardial fluid can be either purulent, serous, serosanguinous, or hemorrhagic. In the case of hemorrhagic effusion, the common etiologies include malignancy, iatrogenic, and tuberculosis (in endemic regions). Large hemorrhagic pericardial effusions resulting from idiopathic (presumed viral) pericarditis are rare but possible. We present an interesting case of a woman with a large hemorrhagic pericardial effusion presenting as subacute cardiac tamponade caused by idiopathic pericarditis in the setting of known malignancy. This report aims to increase awareness about pericarditis as a potential cause of significant hemorrhagic pericardial effusions, rather than solely attributing them to malignancy.

J MEDICINE 2024; 25: 87-89

Arsenic intoxication causing Megaloblastic Anaemia- lesson learnt

Ishrat Binte Reza — 2024-01-04

Megaloblastic anaemia is a common hematological abnormality encountered in clinical practice. We here report a case of 40-year-old male who presented to us with feature of anaemia and typical dermatological manifestation of arsenic intoxication. Complete blood count of patient showed pancytopenia with no circulating atypical cells. Bone marrow examination performed and showed megaloblastic change. Arsenic level in the hair was done and came out very high a. A very few case reports of arsenic causing megablastic anaemia were done in past. Aim of this case report is to create awareness among the physician.

J MEDICINE 2024; 25: 90-93

Rare Case of Primary Hypereosinophilic Syndrome

Ayesha Mohan BS — 2024-01-04

Hypereosinophilia is a rare collection of syndromes of various etiologies that can present incidentally or in some cases, in a life-threatening manner. This is a unique case of a 38-year-old male who presented with acute encephalopathy following a cerebrovascular event and was later found to have elevated eosinophil counts. It is crucial to have high clinical suspicion to diagnose this rare disease when a patient presents with multi-organ dysfunction with no clear etiology, especially when involving a presentation of acute onset in a relatively young patient.

J MEDICINE 2024; 25: 94-97

Cutaneous Leishmaniasis in Bangladeshi Adult Male: A Case Report

Farjana Sultana — 2024-01-04

Abstract not available

J MEDICINE 2024; 25: 98-99

A case of unusual hemorrhage as a complication of dengue fever in a tertiary hospital in Dhaka

Tahmid Bhuiyan — 2024-01-04

Common bleeding complications of dengue hemorrhagic fever are epistaxis, gum bleeding, gastrointestinal bleeding, menorrhagia, hematuria.¹ Major hemorrhage like intracranial hemorrhage have been documented but rare. We present here a case of a 24 year old man with complaints of high grade intermittent fever for 5 days, upper abdominal discomfort for 3 days and swelling of right upper limb for same duration. Laboratory investigations revealed a positive dengue serology, thrombocytopenia and elevated transaminases. USG of the hand revealed a hematoma involving the right upper arm. The patient was managed conservatively with elevation and immobilization of the upper limb and recovered gradually.

J MEDICINE 2024; 25: 100-101

The Dengue Outbreak of 2023: A Wake-Up Call for Healthcare Professionals and Policymakers for Effective Prevention and Control Strategies

Quazi Tarikul Islam — 2024-01-04

Abstract not available

J MEDICINE 2024; 25: 1-3

Dengue: The Enduring Endemic Challenge in Bangladesh

Goutam Saha — 2024-01-04

Abstract not available

J MEDICINE 2024; 25: 78-82

The Quest for an Effective Dengue Vaccine: Hope or Hype

Fazle Rabbi Chowdhury — 2024-01-04

Several trials are ongoing to develop a safe and effective vaccine to prevent dengue virus (DENV) infections, especially avoiding the risk of antibody-dependent enhancement. Only three of them (Dengvaxia/CYTTDV, Takeda TAK-003, and NIH TV-003/TV-005) have shown promising results. The issue of ‘hyperendemicity’ and ‘quasi-species the major challenge behind developing a successful vaccine. The overall efficacy of first successful vaccine ‘Dengvaxia’ showed 30.2%–60.8% efficacy with limited protection against DEN 1 and DEN 2. In Bangladesh, since 2019, outbreaks have mostly been caused by DEN 2 and DEN 3, and the trend is predicted to continue for the coming years. TAK-003 gives almost no protection against DEN 3, which is the most notorious serotype encircling Bangladesh. The overall efficacy of this vaccine is 62%, with limited protection against DEN 4. NIH TV-003/TV-005 currently shows more promise with an overall efficacy of 80%. However, we have to wait until June 2024 for the final results. All of these vaccines are safe and effective for travelers. However, for mass vaccination, a country should make a decision based on their prevalent serotypes and the potential serotypes that might cause the next epidemic. To gather these data, a robust serotype- and genotype-based surveillance system and warning system should be in place.

J MEDICINE 2024; 25: 58-67

Metabolic dysfunctions in polycystic ovary syndrome

Mehrin Rahman — 2024-01-04

Polycystic Ovary Syndrome (PCOS) is a condition that involves various metabolic dysfunctions such as insulin resistance (IR), hyperandrogenemia, obesity, dyslipidemia, and steroid hormone irregularities. Although the exact cause of PCOS is still unknown, it is known to cause several hormonal disturbances, including hyperandrogenemia, IR, and hyperinsulinemia. Insulin appears to disrupt all components of the hypothalamic-pituitary-ovarian (HPO) axis, and ovarian tissue insulin resistance results in impaired metabolic signaling. This causes hyperandrogenemia, which is one of the primary causes of the symptoms of PCOS. Androgens may also lead to IR by modifying muscle tissue composition and functionality and increasing levels of free fatty acids, perpetuating the IR-hyperinsulinemia-hyperandrogenemia cycle. Obesity exacerbates hormonal imbalances, and in combination with dyslipidemia, amplifies cardiovascular and cerebrovascular risks. This review discusses the complex risk factors of PCOS, including genetic, epigenetic, and environmental factors. It also discusses the interconnected etiologies of metabolic dysfunctions of PCOS, its effective management, and metabolic consequences such as cardiovascular and cerebrovascular diseases.

J MEDICINE 2024; 25: 68-77

Fundamentals in Clinical Neurology- 1st Edition by Aminur Rahman

Rubina Yasmin — 2024-01-04

Abstract not available

J MEDICINE 2024; 25: 102