United States

Abstract

Objective: To analyze differences in impulsivity, emotional regulation, symptom severity, cognitive perofrmance, and presence of comorbid psychiatric conditions between focused and automatic subtypes of SPD.

Methods: 83 adults aged 18-65 with skin-picking disorder were enrolled at the University of Chicago and separated into four skin-picking subtype groups based on levels of focused/automatic picking scores on the Milwaukee Inventory for the Dimension of Adult Skini Picking . Each group completed the same assessments and ANOVA or Chi-Squared tests were used to analyze differences in clinical and neurocognitive outcomes. 

Results: Higher focused-picking scores were significantly associated with greater symptom severity, impairment, and presence of comorbid depression and ADHD. Differences in levels of automatic/focused picking did not seem to be associated with impulsivity, emotional/behavior regulations, or neurocognitive outcomes. 

Conclusion: The findings suggest that focused and automatic picking may not be particularly useful in subtyping SPD. Future research should examine whether classifying SPD subtypes based on focused/automatic pulling have statistical or clinical utility.

AMA Research Challenge 2024 

Picking Apart the Disorder: A Comparative Study of Focused and Automatic Skin Picking Disorder Subtypes

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Background 

Transcranial Magnetic Stimulation (TMS) has consistently demonstrated safety and effectiveness in adults, particularly for treatment-resistant depression (TRD) and its potential application in generalized anxiety disorder (GAD). Although this FDA-approved method has been in use for over a decade, studies on TMS efficacy in geriatric and pediatric populations remain inconclusive. Our research explores TMS efficacy across different age groups to determine if certain populations respond more favorably. 

Methods 

Data was extracted from the Olympia Center for TMS & Psychiatry Electronic Health Record. 288 patients with TRD who completed 36 standard repetitive TMS or theta burst stimulation treatments between 2020 and 2023 were selected. The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores were used to assess depression and anxiety severity before and after treatments. Patients were categorized into three age groups: ≤21 years (pediatrics), 22–64 years (adults), and ≥65 years (geriatrics). 

In a clinical setting, treatment response was defined as a 50% reduction in PHQ-9 or GAD-7 scores. The percentage of responders in each age group was calculated, and a Chi-square analysis was performed. Treatment efficacy was measured by averaging the initial and final PHQ-9 or GAD-7 scores and conducting a paired t-test for each age group. 

Results 

Out of 288 patients with TRD, 39 were pediatrics, 192 were adults, and 57 were geriatrics. Overall, 74% of participants responded to treatment: 51% of pediatrics, 77% of adults, and 81% of geriatrics (p-value 0.002). Improvement in mean PHQ-9 scores was observed overall and in each age group (p-values < 0.001). Among the 288 patients, 204 had initial GAD-7 scores ≥10, indicating co-existing moderate to severe anxiety. Of these, 26 were pediatrics, 151 were adults, and 27 were geriatrics. Overall, 54% responded to treatment for anxiety: 31% of pediatrics, 58% of adults, and 56% of geriatrics (p-value 0.03). Improvement in mean GAD-7 scores was observed overall and in each age group (p-values < 0.001). 

Conclusion 

TMS treatment produced clinically meaningful changes in depressive and anxiety symptom severity across all age groups. The evidence supports the potential of incorporating TMS as a routine adjunct to pharmacotherapy in treating depression and anxiety. This result is notable given the adverse effects associated with pharmacotherapy, including increased suicide risk with SSRI use in adolescents and polypharmacy among geriatric patients. Limitations of this study include the absence of sham groups for comparison and relatively small sample sizes for certain age demographics, which warrant consideration.

Pulses of Potential: Assessing the Efficacy of Transcranial Magnetic Stimulation Across Age Groups

Eating disorders (ED) are a group of psychiatric conditions that impair both physical health and psychosocial functioning. Anorexia nervosa (AN) is an ED characterized by an inability to maintain an adequate, healthy body weight, along with persistent disturbances in eating behavior and body image. AN is a disorder with considerable morbidity and mortality, with a weighted annual mortality rate of 5 per 1,000 person-years. Although AN can resolve acutely, many patients relapse soon after weight-restoring treatment and more than half of patients with AN show signs of the disorder for years. We believe that aberrant processing of social information is a key component that contributes to the development and maintenance of the disease. We hypothesized that a more negative view of both self and social environment in adolescent AN patients and increased sensitivity to negative social interaction contribute to the pathology of AN. The project followed a cohort of adolescents receiving treatment for AN as well as matched healthy controls (HC) recruited from two clinical sites: Children’s Medical Center Plano and Children’s Hospital of Pennsylvania. Clinical status assessments at baseline, 3 months, and 6 months were assessed through percent expected body weight (%EBW), responses on the 13-point abbreviated eating disorder examination questionnaire (EDEQ-13) and the 25-point abbreviated Revised Child Anxiety and Depression Scale (RCADS-25). Social self-report questionnaires at the three timepoints included an abbreviated 14-point Internal Personal Situational Attribution Questionnaire (IPSAQ), the Rosenberg Trait Self-Esteem Scale (RSES), and the Social Reward Questionnaire (SRQ). AN adolescents had significantly lower %EBW compared to HC (M = 80.28, M = 101.77, p <0.0001). Total EDEQ-13 scores at baseline were also significantly higher in the AN group compared to HC (M = 2.95, M = 1.40, p = 0.0003). The RSES score was significantly lower in the AN group compared to HC (M = 22.22, M = 30.62, p = 0.0038) and of the five subscale scores of the SRQ, the AN group had significantly higher scores for prosocial interactions compared to HC (M = 28.67, M = 26.39, p = 0.0362). Responses to these selected social questionnaires suggest that AN adolescents have lower global self-esteem and a tendency towards self-blame in negative social scenarios compared to their HC. Additionally, the AN group had a significantly higher SRQ prosocial interactions sub-scale score when compared to their healthy counterparts, reflecting a value of fairness and equality in social interactions.

Self-concept and Social Processing in Adolescents with Eating Disorders

Objectives: To assess if adolescent suicide in the United States changed with the onset of the COVID-19 pandemic, and if there are significant differences between demographics.
Hypothesis: Adolescent suicides in the US increased during the COVID-19 pandemic.
Methods: We analyzed national mortality data from the Centers for Disease Control and Prevention, National Center for Health Statistics, public database for adolescents (age 10-19) from January 2018 until December 2022. Monthly numbers of suicides (per 100,000 individuals) were extracted and stratified based on sex, race, and region of residency in the United States. Data were analyzed using fisher's exact test, Chi square test, Z-test, and correlation analysis to look for associations between groups.
Results:
Of the 14139 adolescent suicides per 100,000 individuals, in the 60 months analyzed, there were no significant differences in the total rate of suicides prior to and during COVID (z = 0.358, p = 0.358). However, suicide of Black adolescents increased (z = 4.157, p = 0), which correlated with Black adolescent all-cause mortality (r (59) = 0.41, p = 0.001), and with suicide of all Black individuals (r (59) = 0.43, p = 0.001). In contrast, suicide rates for White adolescents (z = -2.23, p = 0.025) and adolescents living in the Midwest (z = -2.21, p = 0.027) decreased.
Conclusions:
Although the rate of adolescent suicides did not change significantly during the COVID pandemic, suicides of White teens and Midwestern adolescents decreased, whereas Black adolescent suicides increased over the same period. This increase in suicide rate among Black teens was associated with increased all-cause mortality of Black adolescents and suicide rates of all Black individuals during the pandemic. While there has been an increase in access to and acceptance of mental health care recently, we need more tailored anti-suicide strategies to address the disparities faced by communities of color and specifically Black adolescents. 
Limitations:
Study limitations include data obtained, which are per 100,000 individuals, likely underestimating the true numbers of suicides and deaths. Moreover, as there have been multiple events and unmeasured factors that occurred during the COVID-19 pandemic, the study cannot identify specific causes resulting in the suicide and death rates.

White and Midwestern Adolescents Show Fewer Suicides than Black Adolescents During the COVID19 Pandemic When Compared to PrePandemic Numbers

Diffuse Alveolar Hemorrhage: Importance of Early Recognition and Treatment

Granulomatosis with Polyangiitis (GPA) is a small-vessel vasculitis classically associated with focal necrotizing vasculitis, necrotizing glomerulonephritis, and necrotizing granulomas in the lungs and upper airway. GPA can be classified as limited or severe. Those with severe disease were older at disease onset, had a higher likelihood of diffuse alveolar hemorrhage (DAH), and had a higher probability of previous thyroid disease. Common presentations of this disease are chronic sinusitis and perforation of the nasal septum, hematuria with red cell casts, cough, hemoptysis, and dyspnea. Renal involvement occurs in 77-85% throughout the disease course, while DAH occurs in 5-45% of patients. DAH is characterized by bleeding into the alveoli. It has a high mortality rate and requires supportive treatment and aggressive treatment of GPA.

We present the case of a 69-year-old male, who presented to the emergency department with generalized weakness and hematuria. The weakness progressed over several months to the point where the patient was fatigued and dyspneic with minimal exertion. The patient was found to have atrial fibrillation and renal insufficiency (creatinine of 3.6 with unknown baseline) and was admitted for further workup. Over the next few days, his renal function deteriorated (creatinine maximum: 8.2). The patient developed progressive dyspnea associated with hemoptysis and acute hypoxic respiratory failure. Chest x-ray (CXR) demonstrated pulmonary vascular congestion. The patient was started on broad-spectrum antibiotics on 1/1/24 and transferred to the ICU and hemodialysis was initiated. Repeat CXR showed no improvement after dialysis. The patient’s status deteriorated requiring intubation, vasopressors, and amiodarone. Workup revealed c-ANCA positivity and he was transferred to a referral center. Bronchoalveolar lavage revealed DAH secondary to GPA. The patient was treated with high-dose pulsed steroids (1 g Solumedrol, 5-day course) and transitioned to 80 mg prednisone. He was also started on cyclophosphamide. After 9 days the patient was extubated. Hemoglobin counts rebounded to 8.4-9 from previous levels of 6.9.

DAH is a rare but serious consequence of GPA associated with a mortality rate of 35-50%. Nearly two-thirds of patients require mechanical ventilation, and kidney involvement was not predictive of respiratory failure. Treatment focuses on supportive measures as well as treating the GPA. Current treatment includes high-dose pulsed steroids and rituximab or cyclophosphamide. Plasma exchange may be necessary. Long-term rituximab has also been shown to achieve higher remission rates than cyclophosphamide. Early recognition and initiation of treatment provide the best chances for survival.

Diffuse Alveolar Hemorrhage: Importance of Early Recognition and Treatment

Abstract Title
Effect of Metformin on N3 and REM Sleep of Medicare Patients Compared to Non-Medicare Patients

Background
During N3, or slow-wave sleep, the body repairs itself, while REM sleep is associated with memory consolidation and brain health. Metformin, a first line treatment for type 2 diabetes mellitus (T2DM), has been reported to cause insomnia and sleep disturbances. In the US, Medicare and Medicaid are forms of public health insurance available to patients who are elderly, disabled, or financially limited. Our study examines the impact of Metformin on sleep architecture in patients with public and private health insurance.

Methods
Overnight polysomnography was performed on 27 diabetic patients taking Metformin. Patients underwent six channel EEG, Electrooculogram, Electromyogram EKG, pulse oximetry, respiratory and flow monitoring. Sleep staging was performed using AASM guidelines, verified by a physician. Age, gender, BMI, insurance, and medication data were collected. N1, N2, N3 and REM sleep stage data were analyzed, and total sleep time (TST) was calculated as the sum duration of N1, N2, N3, and REM sleep. 22% of patients on Metformin had Medicare (Medicare), 22% had Medicaid (Medicaid), and 56% had private insurance (PI).

Results
Among Medicare, the mean duration of N3 was 6.28% of TST (+ 0.362% SD) and the mean duration of REM sleep was 1.57% of TST (+ 0.134% SD). Among PI and Medicaid, the N3 sleep duration was 17.5% of TST (+ 1.35% SD), and REM sleep duration was 8.84% of TST (+ 0.417% SD). Both N3 (p<0.00201) and REM (p<0.00081) sleep duration were significantly longer in non-Medicare patients.
Among Medicare and Medicaid, the duration of N3 was 10.6% of TST (+ 0.698% SD), and the duration of REM sleep was 6.42% of TST (+ 0.528% SD). Among PI, N3 sleep duration was 18.4% of TST (+ 1.64% SD), and REM sleep duration was 7.87% of TST (+ 0.394% SD). N3 (p<0.0343) sleep duration was significantly longer in PI.

Conclusion
Medicare diabetic patients taking Metformin exhibit significant declines in both REM and N3 duration when compared to non-Medicare diabetic patients on Metformin. When comparing sleep quality of Medicare and Medicaid patients taking Metformin with that of patients on private insurance on Metformin, the significant decrease in N3 duration persists. Our study is limited by sample size as well as patient demographics in Southern California. Nevertheless, our results suggest a link between Metformin usage, sleep quality, and healthcare accessibility, prompting future research.

Effect of Metformin on N3 and REM Sleep of Medicare Patients Compared to Non-Medicare Patients

Background
β-Blockers are used widely in outpatient care for chronic disease, but little is known about therapy changes with septic shock. We sought to characterize the epidemiology of β-blocker therapy during and after septic shock among patients administered chronic β-blocker therapy in the year prior to hospitalization.

Methods
We studied electronic health records of patients who received outpatient b-blocker therapy in the 12 months prior to hospitalization at 12 UPMC hospitals from 2010 to 2014. Eligible patients were adults (age ≥ 18 years) with septic shock, defined using modified Sepsis-3 criteria. Demographics, biomarkers, β-blocker and vasopressor administration were abstracted for 14 admission days. Patients were stratified as those who, during the hospital stay, were administered β-blockers daily (“continued”), had chronic therapy stopped for more than 24 hours with or without restart (“held”), or never received β-blockers (“discontinued”). Descriptive data were compared using the Kruskal-Wallis test or c2 test, as appropriate.

Results
Of 22,208 patients, 3,748 were hospitalized with septic shock and received chronic β-blockers (mean age 67 ± 14 years, 56% male, 87% White), of which 405 (11%) continued therapy, 2,025 (54%) held therapy, and 1,317 (35%) discontinued therapy during their hospital stay.
Patients in whom β-blockers were discontinued had greater SOFA score (continued, median SOFA 8.0 (IQR: 6.0-11.0); held, median SOFA 8.0 (IQR: 6.0-11.0); discontinued, median SOFA 10.0 (IQR: 7.0-12.0); p<0.001), while first-measured biomarkers, such as serum lactate, troponin, and platelets, were similar across groups.
Among patients with β-blockers held, 50% of patient-days were on β-blockers alone, 22% on vasopressors alone, 7% on both, and 22% on neither. 92% of patients restarted β-blocker therapy with a median time of 4 days from admission (IQR: 2-6 days).
In-hospital mortality was 17% if β-blockers were continued, 16% if held, and 41% if discontinued (p<0.001). Among 1,908 patients who survived 6 months after septic shock, 89% received outpatient β-blockers--most often those with inpatient β-blockers continued (95%) or held (94%) versus those discontinued (74%; p<0.001).

Conclusion
In a multicenter cohort study of septic shock patients who received chronic β-blocker therapy, most patients had therapy discontinued or held during hospitalization. Among those with β-blockers held, inpatient prescribing was variable, overlapped with vasopressor use, and resumed, on average, four days after admission; nearly all patients restarted β-blocker therapy in the 6 months post-hospitalization. With increasing use of β-blockade for chronic disease, variable inpatient prescribing for septic shock necessitates optimizing adrenergy to improve resuscitation outcomes.

Epidemiology of β-Blocker Use Among Critically Ill Patients During and After Septic Shock

Background: Painful inspiration due to rib fractures impairs one’s ability to cough and deep-breathe thus diminishing their ability to clear respiratory secretions and debris resulting in the development of pneumonia and atelectasis. Pneumonia remains a common complication of rib fractures in those aged 65 and older with a 22% mortality rate. This study aims to define the risk factors, onset, and duration of pulmonary decline in trauma patients with isolated rib fractures.

Methods: This was a single center retrospective research study done at a Level I tertiary care Trauma center. The study had 483 patients aged 18 and older who sustained rib fractures between January 2017 and September 2022. 171 (35.4%) were escalated to a critical care unit; intensive care unit (ICU) or Step-down-unit, while the remaining 312 (64.6%) did not. Descriptive statistics were presented in the form of median and interquartile range (BMI) or frequencies and percentages (all other variables). Unadjusted associations between each potential predictor and service escalation were assessed using the Wilcoxon-Mann-Whitney test (BMI) and chi-square tests. A logistic regression was fit with service escalation as the dependent variable and nearly all the demographics, comorbidities, and medications as independent variables.

Results: A history of chronic obstructive pulmonary disease was more common in the escalated group 21.1% (n = 36), versus in the non-escalated group 12.8% (n = 40) at p = 0.025. Also, 25.7% (n = 44) of those in the escalated group were taking an anticoagulant, compared to 14.7% (n = 46) of those in the non-escalated group (p = 0.004). Most (90.1%, n = 154) were transferred to the ICU within the first 20 hours. An additional 4.1% (n = 7) were transferred within the first 30 hours, while less than 6% (n = 10) took longer to be transferred. Having an incentive spirometry above 1,000 significantly reduced the odds of escalation by nearly 95%, OR = 0.054 [0.029, 0.097], p < 0.001. Having a history of chronic obstructive pulmonary disease more than doubled the odds of transfer to the intensive care unit, OR = 2.447 [1.286, 4.688], p = 0.007.

Conclusion: Pulmonary decline following rib fractures can last for 20 to 36 hours after injury, for which the biggest risk factors are an admission incentive spirometry of less than 1,000 mL and a history of chronic obstructive pulmonary disease.

Predictors of Pulmonary Decline in Patients with Isolated Rib Fractures

Background
Preserved ratio impaired spirometry (PRISm) and abnormal serum insulin-like growth factor 1 (IGF-1) levels are both associated with cardiopulmonary disease, diabetes, and mortality. However, the relationship between PRISm and serum IGF-1 levels is unclear and investigated in this study.

Methods
Wave 4 (2008/2009) of the English Longitudinal Study of Ageing (ELSA), a large representative sample of adults 50 years and older in England, was analyzed. Participants were categorized into three pulmonary function groups: normal spirometry (NS) (FEV1/FVC≥0.7 and FEV1≥80% predicted), PRISm (FEV1/FVC≥0.7 and FEV1<80% predicted), and airflow obstruction (AO) based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (FEV1/FVC<0.7). Serum IGF-1 levels were first collected in Wave 4. Multivariable linear and logistic regression were used to examine the association between the pulmonary function groups and serum IGF-1 levels. Models adjusted for age, sex, body mass index, race/ethnicity, education, occupation, smoking status, alcohol use, pulmonary medications, respiratory infection, asthma, heart disease, diabetes, hypertension, hypercholesterolemia, stroke, cancer, and physical activity level.

Results
5390 participants were included: 3246 (60.2%) NS, 667 (12.4%) PRISm, and 1477 (27.4%) AO. The mean serum IGF-1 level was 15.9 nmol/L overall, and 16.1 nmol/L, 15.2 nmol/L, and 15.8 nmol/L in the NS, PRISm, and AO groups, respectively. In multivariable linear regression, compared with NS, PRISm was associated with lower serum IGF-1 levels (-0.64 [95% CI -1.12 to -0.16], p=0.009). In multivariable logistic regression, PRISm was associated with higher odds of membership in the lowest serum IGF-1 quartile (OR 1.36 [95% CI 1.13, 1.64], p=0.001). The association was stronger in men compared with women.

Conclusions
PRISm was significantly associated with lower serum IGF-1 levels after adjusting for various potential confounders. More studies are needed to explore this association, elucidate mechanistic pathways, and understand the potential clinical significance of this finding.

Serum insulin-like growth factor 1 (IGF-1) levels in preserved ratio impaired spirometry (PRISm)

Abstract Title
The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background
Altered Mental Status (AMS) ranges from confusion to coma and is frequently encountered in patients admitted to the Intensive Care Unit (ICU). Etiologies include metabolic disturbances, neurological insults, and systemic illnesses. The precise impact of AMS on in-ICU mortality remains an area of ongoing research, necessitating comprehensive evaluation and elucidation. The objective of our study was to identify significant patterns and outcomes associated with the presence of AMS upon initial Emergency Department (ED) presentation to better inform ICU management and enhance patient care.

Methods
A retrospective cohort study was conducted using patient data from the Northwell Health network, focusing on adult ICU admissions between July 1, 2022, and July 1, 2023. The study included 21,900 unique patients. The primary variables were AMS presence and in-ICU mortality, both recorded as binary outcomes. Descriptive statistics were analyzed for patient demographics and clinical characteristics, including gender distribution and racial composition. The association between AMS and in-ICU mortality was tested using a Chi-square test of independence, with statistical significance set at p < 0.05. The impact of AMS on ICU and hospital stays, treatments (steroids and vasopressors), and acute renal failure incidence was further assessed using Chi-square tests with relative risks and 95% confidence intervals calculated.

Results
Patients with AMS experienced longer ICU and hospital stays, averaging 144.3 hours in the ICU and 13.6 days in the hospital compared to 111.3 hours and 10.1 days for those without AMS, respectively. Patients with AMS were more likely to receive steroids, χ2(1, N = 21,900) = 40.0, p < .001, RR = 1.13, 95% CI [1.08, 1.18]. They were also more likely to be on vasopressors, χ2(1, N = 21,900) = 98.2, p < .001, RR = 1.24, 95% CI [1.18, 1.31], and to develop acute renal failure, χ2(1, N = 21,900) = 53.1, p < .001, RR = 1.15, 95% CI [1.10, 1.20]. The Chi-square test demonstrated a significant association between AMS and in-ICU mortality, χ2(1, N = 21,900) = 111, p < .001, RR = 1.13, 95% CI [1.10, 1.17]. 

Conclusion 
AMS presence was significantly associated with longer ICU and hospital length of stay, more frequent need for vasopressors and steroids, a higher occurrence of acute renal failure, and increased in-ICU mortality rates. These findings underline the importance of AMS as a prognostic indicator in ICU settings and stress the need for increased awareness and proactive management of AMS to potentially improve patient outcomes in the ICU.

The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background
Multiple studies have demonstrated the predictive value of machine learning-based radiomic approaches to CT imaging in colorectal cancer microsatellite instability (MSI) status diagnosis. This study aimed to identify and formulate potential CT-based imaging characteristics available to the general radiologist without access to radiomics, to differentiate MSI status amongst colorectal cancer tumors.


Methods
109 patients with an average age of 61 years (58 male, 51 female) who were diagnosed with MSI-positive colorectal adenocarcinomas between 2011 and 2018 and received imaging at Banner MD Anderson Cancer Center. This was a retrospective analysis where various imaging features of the primary mass and metastasis were analyzed, including location, size, attenuation (compared to the liver and metastases, if present), growth pattern, tumor margin, primary mass area, and mesenteric infiltration. This data was compared with tumor biopsy MSI staging to identify correlations. Patient information (age, sex, tumor staging) was obtained from medical records. Statistical analysis was performed using chi-square, t-test, and Mann-Whitney U tests.

Results
Five tumor characteristics showed a statistically significant relationship with MSI status. Clinical staging differed significantly between MSI groups (p=0.012). CRC tumors with distant metastasis are more likely to be MSI-L, and those with regional metastasis are more likely to be MSI-H (p<0.001). Primary mass area was larger in the MSI-H group compared to the MSI-L group (p<0.001). CRC tumors in the left colon are more likely to be MSI-L, while those in the right colon are more likely to be MSI-H (p<0.001). MSI-H samples had a lower primary tumor Hounsfield Units standard deviation (SD) than MSI-L samples (p=0.002).
Mesenteric infiltration showed no significant difference (p=0.189). Both MSI-L and MSI-H were likely to be well-defined, with no statistical difference in definition (p=1.000). They were also likely to be homogenous, with no statistical difference in homogeneity (p=0.498). Both MSI groups were more likely to exhibit mucosal rather than mass-like growth, with no statistical difference in growth type (p=0.127). The distribution of Mean Primary Tumor Hounsfield Unit: hyperdense region and mean Liver Hounsfield Unit was the same across MSI categories (p=0.162 and p=0.105, respectively). Both MSI-L and MSI-H were more likely to be hypoattenuating, with no significant relationship between tumor enhancement and MSI status (p=0.376).

Conclusion
Multiple CT imaging characteristics were relevant in predicting the classification of MSI in CRC tumors, holding potential clinical relevance in guiding individualized therapy. While these results were statistically significant, more research must be done to validate these findings.

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