Medicine and Health Sciences Commons^™

Exploring Music As A Therapeutic Tool For Patients, Andrew Rosario, Josh Robinson

Phase 1

Introduction: Music is a remarkably powerful art form that has the potential to impact people in innumerable ways. This project seeks to explore the many ways patients think about and use music in their lives, whether it be as a source of healing, a reminder of their past memories, an outlet to express emotions, or a companion through whatever challenges they may face.

Methods: This project partnered with an existing workshop run by Josh Robinson for patients in the Headache Unit at Jefferson Methodist Hospital. The first part of these sessions involved a “Soundtrack to My Life” activity where …

Patient Perceptions Of Medicare Annual Wellness Visits: Findings From A Pilot Survey, Payton Mccready, Amy Cunningham, Susan Parks

Phase 1

Purpose

Medicare Annual Wellness Visits (AWVs) were introduced in 2011 to promote preventive care among Medicare beneficiaries, yet patient satisfaction remains understudied. Participating in the  Age-Friendly Health Systems Initiative, Jefferson Health’s Center for Healthy Aging (CHA) is redesigning its AWVs to align with Age-Friendly principles. This study aimed to obtain baseline data on Medicare patients’ familiarity, experience, and satisfaction with AWVs in a geriatrics practice before implementing the redesigned model.

Methods

This cross-sectional survey was conducted in July 2025 at Jefferson Health’s CHA, a geriatrics practice serving about 2,000 Medicare patients. Eligible participants were Medicare-enrolled CHA patients. An eight-item survey …

The Effect Of Prior Work And Educational Experience On Medical School Small Group Case-Based Learning, Alexandra Kelleher, Alisa Losasso, Md

Phase 1

Purpose

Medical students have varied academic and professional backgrounds, many taking gap years in healthcare or research before matriculation. Prior studies suggest these experiences may reduce burnout, enhance patient skills, and improve teamwork capabilities, but their impact on early case-based learning (CBL) performance and perceived comfort level is unclear. This study explores how prior healthcare and research experience influence perceived preparedness and participation for first-year medical students in CBL at SKMC.

Methods

This mixed-methods study was conducted among 66 rising second-year JeffMD students. Participants completed an online 15-item survey assessing undergraduate background and self-reported confidence in CBL. Ten students were …

Understanding The Benefits Of Sustainable Ir Fellowship To A Large Public Hospital In Kenya, Abigael Gebremariam, Kevin Anton

Phase 1

In 2021, Kenya had 10 interventional radiologists for a population of about 54 million. RAD-AID, a non-profit organization improving global radiology, partnered with the University of Nairobi and Kenyatta National Hospital to establish the first IR fellowship program in Kenya in 2021. Through the program, the number of practicing IRs in Kenya has nearly doubled; however, their practice is limited by capital and supply resources. This study will demonstrate the benefit of the program to the hospital system and the patient population in Kenya.

The project employed a retrospective and comparative analysis of IR services at a large public hospital …

Patient Characteristics Associated With Telehealth Use In A Large Federally Qualified Health Center, Priyanka Gautom, Cara L. Eckhardt, Lisa K. Marriott, Cirila Estela Vasquez Guzman, Gloria D. Coronado

OHSU-PSU School of Public Health Faculty Publications and Presentations

The COVID-19 pandemic rapidly expanded telehealth services when in-person care was limited. Using primary care data from a large federally qualified health center in Washington state, this study aimed to: 1) describe trends in telehealth use among adult patients, and 2) provide disaggregated patient characteristic data associated with telehealth use, with a focus on patients speaking Asian Indian languages.

Association Between Environmental Exposures To Perfluoroalkyl And Polyfluoroalkyl Substances And Military Veterans Cancer Determination, Stephen A. Pereira Jr

Walden Dissertations and Doctoral Studies

This study involved evaluating whether cumulative exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS) was associated with kidney cancer, bladder cancer, and adult leukemia among U.S. veterans. Pooled National Health and Nutrition Examination Survey (NHANES) data from 2005–2015 were analyzed for sample of 2,500 veterans with available serum PFAS measurements and physician-diagnosed cancer histories. This study employed a cross-sectional, correlational design grounded in a post-positivist paradigm. Inclusion required complete data for (a) serum PFAS concentrations, (b) kidney cancer, bladder cancer, and adult leukemia, and (c) covariates age, sex, race/ethnicity, smoking status, and body mass index. Cumulative PFAS was modeled as a …

Staff Education To Improve Knowledge On Early Recognition Of Staff Burnout In Nurses Working In Long-Term Care, Geraldine Ndeng Akonwah

Walden Dissertations and Doctoral Studies

This doctoral project was a practice-based staff education project aimed at educating nurses concerning early burnout recognition. The educational intervention was chosen to promote awareness and knowledge related to the concept of burnout and self-care among nurses employed in a long-term care facility. The practice problem addressed was the high prevalence of nurse burnout and the limited ability of nurses to recognize early signs of burnout. The problem is significant in nursing practice as burnout is detrimental to the clinical judgment, patient safety, job satisfaction and staff retention. The guiding question of the project was as follows: Does a staff …

Emergency Nurses’ Perspectives On Workload, Stress, And Violence In The Context Of The U.S. Nursing Shortage, Wanda Marie Haynes

Walden Dissertations and Doctoral Studies

The nursing shortage is a critical global issue that significantly impacts emergency nurses (ER), leading to increased workloads, psychological stress, and heightened exposure to workplace violence (WPV). This phenomenon raises concerns among healthcare administrators and nurse leaders who seek strategies to improve retention and ensure quality patient care. The purpose of this qualitative study was to explore the meaning of workload, stress, and WPV among ER nurses during the U.S. nursing shortage. Guided by Herzberg’s two-factor theory, the study employed a phenomenological approach to capture nurses’ lived experiences. Data were collected through semi-structured interviews with eight ER nurses from diverse …

Group Antenatal Care Model As An Innovative And Sustainable Maternal And Child Health Service Delivery In A Northern Nigerian State, Pius I. Christopher-Izere, Abiola Ajibola, Abimbola Phillips, Dorcas Magbadelo, Ibidun Jolaoso, Obioma Azurunwa, Francis Ogirima, Collins Imarhiagbe, Anthony Onwuegbusi, David Udanwojo, Emmanuel Udeh, Victor Obagunlu, Adebola Adekogbe, Sunday Joseph, Hamza Abubakar, Neyu Iiyasu, Adetosoye Adebanjo, Barlarbe Gaya, Olayiwola Jaiyeola, Damilola Olaniyan, Bankole Olatosi Ph.D., Deborah Lynn Billings Ph.D., Et. Al.

Faculty Publications

The maternal and child health situation in developing countries remains critical and deeply concerning, These regions account for 99% of global maternal and under-five deaths. In Nigeria, uptake of critical life-saving maternal, neonatal and child health (MNCH) services, delivered through antenatal care (ANC), are sub-optimal, leading to poor outcomes. Group antenatal care (G-ANC) is an evolving antenatal care delivery model in low and medium-income countries. G-ANC models can improve quality and uptake of maternal health services.G-ANC model was implemented across 255 primary health facilities (PHFs) to ensure pregnant women receive components of a well-defined package of MNCH services at regular …

Sexual And Gender Minority Nurses’ Minority Stress In The Workplace: A Scoping Review, Justin Chavis, Robin Dawson Phd, Rn, Cpnp-Pc, Faan, Liam C. Hein

Faculty Publications

Background

Purpose

Methods

“My Heart Was In My Stomach”: Texas-Based Obstetricians’ And Gynecologists’ Experiences Post Anti-Abortion Legislation, Chelsey Kanipe, Precious Chiamaka Anunobi, Anupria D Davenport, Sheryl A Mccurdy, Marie A Brault

Faculty, Staff and Student Publications

Background

The purpose of this study is to investigate the downstream effects of anti-abortion legislation on the practice of obstetrics and gynecology in urban Texas.

Methods

We conducted semi-structured interviews until saturation with eleven obstetricians/gynecologists (OBGYNs) to explore the effects of Texas’s abortion laws. Analysis consisted of inductive and deductive approaches.

Results

We identified three main themes regarding the downstream effects of Texas abortion laws: the conflicting role of colleagues as a support system and a source of frustration and distrust for OBGYNs, the lowered standard of care for those with a desired pregnancy, and concerns that anti-abortion legislation will …

Leveraging Ancestral Recombination Graphs For Scalable Mixed-Model Analysis Of Complex Traits, Jiazheng Zhu, Georgios Kalantzis, Ali Pazokitoroudi, Árni Freyr Gunnarsson, Hrushikesh Loya, Han Chen, Sriram Sankararaman, Pier Francesco Palamara

Faculty, Staff and Student Publications

Recent algorithmic advances have enabled the inference of genome-wide ancestral recombination graphs (ARGs) from large genomic cohorts, providing detailed models of genealogical relatedness along the genome. These inferred ARGs can complement genotype imputation by capturing the effects of unobserved variants, but their use in large-scale linear mixed-model analyses has been computationally prohibitive. Here, we develop methods that leverage the ARG to perform genotype-matrix multiplications in sublinear time and implement scalable randomized algorithms for mixed-model analyses. We introduce ARG-RHE, a randomized Haseman-Elston approach for estimating narrow-sense heritability and performing region-based association testing using ARGs, enabling parallel analysis of multiple quantitative traits. …

Correction: The Hsp90-Myc-Cdk9 Network Drives Therapeutic Resistance In Mantle Cell Lymphoma, Fangfang Yan, Vivian Jiang, Alexa Jordan, Yuxuan Che, Yang Liu, Qingsong Cai, Yu Xue, Yijing Li, Joseph Mcintosh, Zhihong Chen, Jovanny Vargas, Lei Nie, Yixin Yao, Heng-Huan Lee, Wei Wang, Johnnelson R Bigcal, Maria Badillo, Jitendra Meena, Christopher Flowers, Jia Zhou, Zhongming Zhao, Lukas M Simon, Michael Wang

Faculty, Staff and Student Publications

No abstract provided.

Identifying Alzheimer's Disease Progression Subphenotypes Via A Graph-Based Framework Using Electronic Health Records, Yu Huang, Jie Xu, Zhengkang Fan, Yu Hu, Xing He, Aokun Chen, Yuxi Liu, Rui Yin, Jingchuan Guo, Steven T Dekosky, Michael Jaffee, Manqi Zhou, Chang Su, Fei Wang, Yi Guo, Jiang Bian

Faculty, Staff and Student Publications

Understanding the heterogeneity of neurodegeneration in Alzheimer's disease (AD) and identifying distinct progression pathways is critical for improving diagnosis, treatment, prognosis, and prevention. Motivated by this need, this study aimed to identify disease progression subphenotypes among patients with mild cognitive impairment (MCI) and AD using electronic health records (EHRs). We developed a novel approach that combines a graph neural network (GNN)-based framework with time series clustering to characterize progression subphenotypes from MCI to AD. We applied the proposed framework to a real-world cohort of 2,525 patients (61.66% female; mean age 76 years), of whom 64.83% were Non-Hispanic White, 16.48% Non-Hispanic …

Third-Party Effects On Intergroup Trust: The Role Of Punishment/Compensation And Group Regulatory Focus, Xiaowei Geng, Jie Cui, Jie Wang, Feng Zhang, Wei Wang

Faculty, Staff and Student Publications

Intergroup trust refers to a collective prediction and belief among members of one group regarding those of another in intergroup interactions. It plays an important role in avoiding intergroup conflicts, and thereby sustaining social development. This study was designed to investigate the effects of third-party punishment and compensation, as well as group regulatory focus, on intergroup trust. The findings revealed that, at both individual and group levels, prevention-focused groups exhibited higher levels of intergroup trust than promotion-focused groups under third-party compensation conditions. In contrast, under the third-party punishment conditions, promotion-focused groups displayed greater trust than prevention-focused groups, although this difference …

Identification Of Gene Signatures Of Metabolic Dysfunction-Associated Steatotic Liver Disease In Patients With Pancreatic Ductal Adenocarcinoma Via Whole Transcriptome Sequencing, Chaitanya Karimanasseri Bse, Pongsakorn Choochuen Md, Phd, Yotsawat Pomyen Phd, Hien Dang Phd

Phase 1

Introduction
Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related mortality worldwide. While the only curative treatment for PDAC is surgical excision of the tumor, often surgery is ineffective due to early metastasis to other organs. A better understanding of PDAC’s risk factors would contribute to earlier PDAC diagnoses and thus more effective surgical resections before metastasis occurs.

One pathology related to PDAC is metabolic dysfunction-associated steatotic liver disease (MASLD), a metabolic disease leading to triglyceride accumulation in the liver. MASLD is known to cause worse PDAC outcomes versus non-MASLD PDAC. Further elucidating the mechanism through which MASLD increases …

Mapping The Pathology Competencies For Medical Education (Pcme) To The Sidney Kimmel Medical College’S Jeffmd Gi Curriculum, Emma Sanders, Alexander Macnow, Md, Mhpe

Phase 1

Introduction/Purpose: Sidney Kimmel Medical College’s competency-based curriculum, JeffMD, is structured around SMART objectives. However, evaluation of the alignment of these objectives against the PCME, a collection of graduation competencies published by the Association for Academic Pathology, has not yet been performed. This study investigated how comprehensively the GI/Liver block of the JeffMD curriculum addresses the corresponding PCME learning objectives, thereby piloting a pathology curriculum map and allowing evaluation of this curriculum.

Methods: In this study, a curriculum map was created of all learning events covered within the JeffMD GI/Liver block. Each learning event was cross-matched with competencies within the gastrointestinal …

Interviewing Rural Primary Care Physicians To Inform Learning Objectives For A Rural Health Curriculum, Luke May, Caleb Gayman, Robert J. Motley, Md, Mhcds

Phase 1

Introduction/Purpose: Pennsylvania has a large rural population with too few physicians to meet medical needs. The Physician Shortage Area Program (PSAP) at SKMC works to address the shortage of primary care physicians in rural Pennsylvania. To adequately prepare future rural physicians, this project sought to obtain input from practicing PSAP graduates to inform learning objectives for a future curriculum intervention for preclinical PSAP students.

Methods: The target learner population is preclinical PSAP students at SKMC. A codebook was generated based on SKMC Graduation Competencies. Semi-structured interviews with PSAP graduates were conducted via video call, focused on those graduates practicing primary …

Interviewing Rural Primary Care Physicians To Inform Learning Objectives For A Rural Health Curriculum, Caleb Gayman, Luke May, Robert J. Motley, Md, Mhcds

Phase 1

Introduction/Purpose: There is a significant shortage of physicians in rural Pennsylvania. Programs like the Physician Shortage Area Program (PSAP) at SKMC aim to address this gap by providing support and guidance for medical students who grew up in rural areas and hope to return to practice in a rural area. This project focuses on identifying rural health topics and modes of delivery recommended by practicing primary care physicians to inform new learning objectives (LOs) for a future curriculum intervention for first and second-year medical students.

Methods: SKMC PSAP graduates practicing in rural areas were interviewed using semi-structured interviews that included …

Artificial Intelligence In Case-Based Learning: A Survey Of Student Current Practices In Small Group Self-Directed Learning Pedagogy, Clarice Pamplona, Joshua Kim

Phase 1

Introduction: Although Artificial Intelligence (AI) is expected to become an essential clinical tool, its incorporation into the undergraduate medical curricula is disproportionately lacking. Notably, limited research remains on medical student use and perspective on AI, specifically within small-group learning settings. This study explores AI use and perspectives among medical students within Case-Based Learning (CBL) groups at Sidney Kimmel Medical College (SKMC) with the aim to establish a formal AI curriculum.

Methods: The population studied includes the Class of 2028 at SKMC. An anonymous Qualtrics survey was distributed within the class Group Me between April and May 2025, exploring student demographics, …

Agent-Based Modeling Of Cellular Dynamics In Adoptive Cell Therapy, Yujia Wang, Stefano Casarin, May Daher, Vakul Mohanty, Merve Dede, Mayra Shanley, Eleonora Dondossola, Ludovica La Posta, Rafet Başar, Katayoun Rezvani, Ken Chen

Faculty, Staff and Student Publications

Adoptive cell therapies (ACT) leverage tumor-immune interactions to cure cancer. Despite promising phase I/II clinical trials of chimeric-antigen-receptor natural killer (CAR-NK) cell therapies, molecular mechanisms and cellular properties required to achieve clinical benefits in broad cancer spectra remain underexplored. While in vitro and in vivo experiments are essential, they are expensive, laborious, and limited to targeted investigations. Here, we present ABMACT (Agent-Based Model for Adoptive Cell Therapy), an in silico approach employing agent-based models (ABM) to simulate the continuous course and dynamics of an evolving tumor-immune ecosystem, consisting of heterogeneous "virtual cells" created based on knowledge and omics data observed …

Precision Chemotherapy In Biliary Tract Cancer Moving From Empiric Intensification To Biomarker-Guided Treatment: Editorial On "Molecular Determinants Of Outcome To Gemcitabine, Cisplatin, And Nab-Paclitaxel In Patients With Advanced Btc", Sung Hwan Lee, Ahmed O Kaseb, Ju-Seog Lee

Faculty, Staff and Student Publications

No abstract provided.

Three-Dimensional Versus Two-Dimensional Echocardiographic Assessment Of Left Atrial Volume And Deformation In Children, Alexander J Kiener, James Croft, Krista N Harris, Ankona Banerjee, Aura A Sanchez, Xander H T Wehrens, Anitha Parthiban, Xiaotian Gao, Tam T Doan, Minh B Nguyen

Faculty, Staff and Students Publications

Background: Left atrial (LA) volume and function are important for assessing pediatric diastolic dysfunction (DD). Three-dimensional echocardiographic (3DE) LA assessment may overcome limitations and assumptions inherent in two-dimensional echocardiographic (2DE).

Methods: We conducted a cross-sectional study of children under 18 years of age with structurally normal hearts, using transthoracic 3DE apical volume datasets. LA volumetric function and phasic deformation analyses were performed using 3DE (GE, EchoPAC 4DLAQ v206, near fully-automated) and 2DE (TomTec, TTA2.51, CPA, manual) was performed by three operators and processing time was collected. Agreement and reproducibility was assessment for each modality.

Results: Fifty patients (median age 12.8 …

Community Participatory Co-Design And Development Of A Digital Diabetes Prevention Education Program For Hispanic Families With Obesity: Mixed Methods Study, Sandra Mihail, Marbelly Partida, Lizette Villanueva, Debbe Thompson, Teresia M O'Connor, Salma M Musaad, Maria J Redondo, Erica G Soltero

Children’s Nutrition Research Center Staff Publications

Background: Digital health interventions (DHIs) can extend the reach of disease prevention interventions; however, few are evidence-based, theoretically grounded, or developed for high-risk youth and families. Co-design approaches engage end users in the design and development of the DHI, which can lead to increased accessibility and engagement.

Objective: This study aimed to describe the adaptation of an evidence-based diabetes prevention program for remote, digital delivery.

Methods: The adaptation of the in-person intervention was guided by a modified Inclusive Digital Health Intervention Design to Promote Health Equity framework and conducted in collaboration with Hispanic adolescents (n=23) with obesity (BMI ≥95th percentile) …

Prevalence Of Premenstrual Syndrome, Premenstrual Dysphoric Disorder, And Dysmenorrhea In Nursing Students: A Systematic Review, Meta-Analysis, And Evidence-Based Recommendations, Sabyasachi Maity, Bharathi Gadad, Hansapani Rodrigo, Seham Noorani, Ayesha Usman, Chloe Lark, Mona Attarpour, Ivy Mageto, Lucas Schwartz, Nikhilesh Anand

School of Medicine Publications

Introduction: Menstrual disorders—including premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and dysmenorrhea—are highly prevalent among women of reproductive age and are associated with impaired academic performance, psychological distress, and reduced social functioning. Nursing students are particularly vulnerable due to the combined demands of intensive academic schedules and clinical training, yet prevalence estimates and institutional responses remain inconsistent.

Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD420251109363). PubMed, Scopus, Web of Science, CINAHL Ultimate, and APA PsycINFO were searched for studies published between 2016 and 2025. Eligible studies reported prevalence or …

Sand Fly Endosymbionts In Kenya: Rickettsia And Wolbachia Associations With Leishmania And Detection Of Rickettsia Africae, Steve Kiplagat, Damaris Matoke-Muhia, Barrack O. Owino, David P. Tchouassi, Daniel K. Masiga, Gregory D. Hurst, Jandouwe Villinger

All Peer-Reviewed Publications

BACKGROUND: Sand flies are small hematophagous insects known as leishmaniasis vectors. Similar to most arthropods, they harbor nonobligate endosymbionts that may influence host adaptation and pathogen transmission, but these symbiont communities remain poorly characterized in Leishmania-endemic African sand flies. METHODS: We screened 1700 wild-caught phlebotomine sand flies (1266 females, 434 males) from Kenya's Baringo, Nakuru, and Kajiado counties, and 253 colony Phlebotomus duboscqi, for Rickettsia, Wolbachia, Spiroplasma, Cardinium, Arsenophonus, Microsporidia, and Leishmania by high-resolution melting analysis and sequencing of PCR products. RESULTS: In wild sand flies (Phlebotomus and Sergentomyia spp.), Wolbachia spp. were most common (8.5%, 145/1700), with particularly high …

Emotional Intelligence : The Road To Professionalism Development, Wuttipat Iammeechai, Tanapat Prakairungtong

Chulalongkorn Medical Journal

Abstract

Medical professionalism development is a significant challenge of medical education, even though it is essential for medical practitioners. The Dynamics and ambiguity of medical professionalism cause difficulty in setting specific learning objectives, creating validated assessment methods, and designing effective teaching methodologies. Meanwhile, emotional intelligence is a growing area of study in medical education. There is a significant connection between medical professionalism and emotional intelligence. Certain attributes of emotional intelligence contribute to developing professionalism. Numerous pieces of literature illustrated emotional intelligence development and assessment in health professions education. Emotional intelligence is potentially the path to developing medical professionalism.

Bioprinting: Revolutionizing Biology With 3d Innovation, Gopalarethinam Janani Ms, Naven Kumar Rk, Agnishwar Girigoswami Prof, Koyeli Girigoswami Prof

Chulalongkorn Medical Journal

3D bioprinting is an innovative technology that enables the creation of bioengineered structures through computer-guided processes. This technique has been in use for more than 35 years and has made a huge contribution in the biomedical field. Utilizing biomaterials with regenerative properties has significantly impacted tissue engineering, regenerative medicine, and pharmaceutical research. Various bioprinting techniques, including inkjet, extrusion, laser-assisted, and stereolithography, offer unique advantages for precise tissue construction. Bioinks used for printing, can be derived from natural and synthetic sources. It ensures biocompatibility, mechanical integrity, and controlled degradation. Advanced bioinks—such as nanoengineered, biomolecular, multimaterial, self-assembling, and stimuli-responsive variants—enhance applications in …

A Rare Case Of Hirayama Disease With Ulnar Nerve Palsy: Expanding The Clinical Spectrum, Chaitanya Kulkarni, Medhavi Joshi, Sakshi Mhase, Manasi Metkar

Chulalongkorn Medical Journal

ABSTRACT

Hirayama disease, or monomelic amyotrophy, is a rare, self-limiting cervical myelopathy that primarily affects young males. It leads to muscle atrophy and weakness, especially in the hands and forearms, often due to cervical spinal cord compression during neck flexion. We report a case of a 41-year-old female from rural India who presented with progressive weakness in her left hand, resulting from ulnar nerve compression. The patient was unable to actively extend the metacarpophalangeal joint of her left hand, significantly impairing her hand function. Notably, she did not exhibit autonomic symptoms, which are commonly seen in cervical myelopathies. This case …

Etiologies, Management, And Outcomes Of Pediatric Stroke In A Tertiary Care Center, Supinya Naruphanthawart, Tanitnun Paprad, Tanai Trongmonthum, Tunchanok Paprad, Krisanachai Chomtho

Chulalongkorn Medical Journal

Background

Recent developments in neuroimaging and treatments, such as thrombolysis and endovascular thrombectomy, have improved across pediatric stroke diagnosis and management. However, no contemporary data exist on stroke characteristics related to clinical outcomes among Thai children.

Objectives

To study clinical characteristics, investigations, and treatments associated with outcomes in Thai pediatric stroke patients.

Methods

Methods: We enrolled children aged 28 days to 18 years with "cerebrovascular disease" recorded as ICD 10 and inpatient records from January 2011 to September 2022. Outcomes included disability at discharge (mRS grade 4-5), in-hospital mortality, and two-year recurrent stroke rate.

Results

Of 206 patients, 53.4% had …