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This study aimed to assess how parent stress and COVID-19 impact on the family are associated with parental pressure to eat during the COVID-19 pandemic. Parents of healthy preschool-aged children completed measures including pressure to eat (Child Feeding Questionnaire), parent perception of their stress (Perceived Stress Scale), household food insecurity (Hunger Vital Sign) and effects of COVID-19 on families (COVID-19 Exposure and Family Impact). Children (N = 228) were racially, ethnically, and socioeconomically diverse (34 % Black, 15 % Hispanic, and 29 % with household income <$20,000). Bivariate analyses showed that parent stress at Year 1 (β 0.02; 95 % CI 0.006, 0.04) was significantly associated with pressure to eat at Year 1 and that COVID-19 impact at Year 1 (β 0.02; 95 % CI 0.001, 0.03) was also significantly associated with pressure to eat. Multivariable linear regression analyses showed that parent stress at Year 1 was significantly associated with pressure to eat at Year 1 (β 0.39; 95 % CI 0.16, 0.61) while COVID-19 impact was not significantly associated with pressure to eat at Year 1. This study, consisting of racially and socioeconomically diverse children, found that while parent stress was significantly associated with increased parental utilization of pressure to eat feeding practice, COVID-19 impact was not significantly associated with pressure to eat in adjusted analyses. This suggests that overall perceived stress by parents could be an important factor in parent pressuring feeding practices. • We surveyed parents of 3–5 year old children annually between February 2020 and December 2021 • Pressuring feeding practices decreased slightly between 2020 and 2021 • In bivariate analyses, higher pressure was associated with concurrent parent stress and COVID-19 impact • In multivariable analysis, increased pressure eat was associated with concurrent parent stress but not COVID-19 impact [ABSTRACT FROM AUTHOR]

Purpose: Low-dose-rate brachytherapy (BT) with permanent iodine-125 radioactive seeds is a highly effective treatment option for low- and favorable intermediate-risk prostate cancer. However, optimal implantation is not always achieved due to edema or seeds loss. One way to improve seed placement is the use of stranded seeds called “intraoperatively built custom-linked seeds (IBCLS)” in an opposition to loose seeds (LS). To date, there are few data comparing toxicity rates between these two techniques. The aim of this study was to compare dosimetric parameters and toxicity rates at 2 years between both procedures in a matched-paired population. Material and methods: Patients were considered for BT according to European guidelines. Among 548 patients treated at our institution, 105 patients in the loose seeds cohort were individually matched to 105 patients in the IBCLS group according to age, prostate volume, pre-operative international prostate symptom score (IPSS), clinical stage, and Gleason score. Erectile function was scored using the five-item international index of erectile function (IIEF-5) score. A multivariable linear mixed-effects model was applied to examine the association between total and individual scores (repeated measures) and covariates. Results: Overall, 61 (29%) patients presented with a favorable intermediate-risk prostate cancer. There were no significant changes in IPSS over time (p = 0.57). During follow-up, the IIEF-5 was similar in the two groups, except at one month, where it was lower in the IBCLS group (10.9 vs. 6.9, p = 0.029). Also, there was no difference in grade ≥ 2 rectal toxicity. At 1 month, D90Gy, V150%, and V100% were higher in the LS group compared to the IBCLS group. Conclusions: Low-dose-rate prostate brachytherapy using IBCLS is a safe technique, with comparable toxicity profiles at 2 years compared to LS brachytherapy. [ABSTRACT FROM AUTHOR]

Background: Education has been highlighted as fundamental in equipping healthcare professionals with essential knowledge and skills to provide good end-of-life care. Multiprofessional educational programmes have a positive influence on knowledge, attitude and confidence but few have sought to understand the longer term impact on care delivery. The European Certificate in Essential Palliative Care is an 8-week home-study-based programme for healthcare professionals and is currently run in nine centres. Successful candidates have undertaken the course from their own countries around the world. This article describes the evaluation of the European Certificate in Essential Palliative Care which has been evolving over 15 years. Aims: To evaluate the impact an educational intervention has on participants' confidence in palliative care, to determine whether this is sustained over time and explore participants' perception of the influence of the course on confidence. Design: A mixed-method longitudinal approach. Setting/participants: A survey using a self-efficacy scale was emailed to 342 candidates who received an educational intervention and semi-structured interviews to a sub-sample of 15 candidates at baseline, 3 and 6 months. Results: At 3 months, candidates had almost 20 times higher odds of being above any given level of confidence than at baseline which was sustained at 6 months. Qualitative analysis identified examples of increased competence and confidence improving palliative care delivery. Conclusion: Findings suggest that the European Certificate in Essential Palliative Care improves confidence in palliative care and that this is sustained over time with evidence of confidence in symptom control, communication and a holistic approach in clinical practice. [ABSTRACT FROM AUTHOR]

Leptospirosis is a globally prevalent zoonosis caused by pathogenic Leptospira spp.; several serologic variants have reservoirs in synanthropic rodents. The capybara is the largest living rodent in the world, and it has a wide geographical distribution in Central and South America. This rodent is a significant source of Leptospira since the agent is shed via urine into the environment and is a potential public health threat. In this study, we isolated and identified by molecular techniques a pathogenic Leptospira from capybara in southern Brazil. The isolated strain was characterized by partial rpoB gene sequencing and variable-number tandem-repeats analysis as L. interrogans, serogroup Icterohaemorrhagiae. In addition, to confirm the expression of virulence factors, the bacterial immunoglobulin-like proteins A and B expression was detected by indirect immunofluorescence using leptospiral specific monoclonal antibodies. This report identifies capybaras as an important source of infection and provides insight into the epidemiology of leptospirosis. [ABSTRACT FROM AUTHOR]

E-technology is increasingly used in oncology to obtain self-reported symptom assessment information from patients, although its potential to provide a clinical monitoring tool in palliative care is relatively unexplored in the UK. This study aimed to evaluate the support provided to lung cancer patients post palliative radiotherapy using a computerized assessment tool and to determine the clinical acceptability of the tool in a palliative care setting. However, of the 17 clinicians identified as managing patients who met the initial eligibility criteria for the study, only one clinician gave approval for their patient to be contacted regarding participation, therefore the benefits of this novel technology could not be assessed. Thirteen key clinicians from the centres involved in the study were subsequently interviewed. They acknowledged potential benefits of incorporating computerized patient assessment from both a patient and practice perspective, but emphasized the importance of clinical intuition over standardized assessment. Although clinicians were positive about palliative care patients participating in research, they felt that this population of patients were normally too old, with too rapidly deteriorating a condition to participate in a study using e-technology. In order to encourage acceptance of e-technology within palliative care, emphasis is needed on actively promoting the contribution of technologies with the potential to improve patient outcomes and the patient experience. [ABSTRACT FROM PUBLISHER]

Conceptus estrogens and prostaglandins have long been considered the primary signals for maternal recognition of pregnancy (MRP) in the pig. However, loss-of-function studies targeting conceptus aromatase genes (CYP19A1 and CYP19A2) and prostaglandin-endoperoxide synthase 2 (PTGS2) indicated that conceptuses can not only signal MRP without estrogens or prostaglandins but can maintain early pregnancy. However, complete loss of estrogen production leads to abortion after day 25 of gestation. Although neither conceptus estrogens nor prostaglandins had a significant effect on early maintenance of corpora lutea (CL) function alone, the two conceptus factors have a biological relationship. To investigate the role that both conceptus estrogens and prostaglandins have on MRP and maintenance of pregnancy, a triple loss-of function model (TKO) was generated for conceptus CYP19A1, CYP19A2, and PTGS2. In addition, a conceptus CYP19A2-/- model (A2KO) was established to determine the role of placental estrogen during later pregnancy. Estrogen and prostaglandin synthesis were greatly reduced in TKO concept uses which resulted in a failure to inhibit luteolysis after day 15 of pregnancy despite the presence of conceptuses in the uterine lumen. However, A2KO placentae not only maintained functional CL but were able to maintain pregnancy to day 32 of gestation. Despite the loss of placental CYP19A2 expression, the allantois fluid content of estrogen was not affected as the placenta compensated by expressing CYP19A1 and CYP19A3, which are normally absent in controls. Results suggest conceptuses can signal MRP through production of conceptus PGE or stimulating PGE synthesis from the endometrium through conceptus estrogen. Failure of conceptuses to produce both factors results in failure of MRP and loss of pregnancy., (© The Author(s) 2024. Published by Oxford University Press on behalf of Society for the Study of Reproduction. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Xenotransplantation has made significant advances recently using pigs genetically engineered to remove carbohydrate antigens, either alone or with addition of various human complement, coagulation, and anti-inflammatory ''transgenes''. Here we evaluated results associated with gene-edited (GE) pig hearts transplanted in baboons using an established costimulation-based immunosuppressive regimen and a cold-perfused graft preservation technique., Methods: Eight baboons received heterotopic abdominal heart transplants from 3-GE (GalKO.β4GalNT2KO.hCD55, n = 3), 9-GE (GalKO.β4GalNT2KO.GHRKO.hCD46.hCD55. TBM.EPCR.hCD47. HO-1, n = 3) or 10-G (9-GE+CMAHKO, n = 2) pigs using Steen's cold continuous perfusion for ischemia minimization. Immunosuppression (IS) included induction with anti-thymocyte globulin and αCD20, ongoing αCD154, MMF, and tapered corticosteroid., Results: All three 3-GE grafts functioned well initially, but failed within 5 days. One 9-GE graft was lost intraoperatively due to a technical issue and another was lost at POD 13 due to antibody mediated rejection (AMR) in a baboon with a strongly positive pre-operative cross-match. One 10-GE heart failed at POD113 with combined cellular and antibody mediated rejection. One 9-GE and one 10-GE hearts had preserved graft function with normal myocardium on protocol biopsies, but exhibited slowly progressive graft hypertrophy until elective necropsy at POD393 and 243 respectively. Elevated levels of IL-6, MCP-1, C-reactive protein, and human thrombomodulin were variably associated with conditioning, the transplant procedure, and clinically significant postoperative events., Conclusion: Relative to reference genetics without thrombo-regulatory and anti-inflammatory gene expression, 9- or 10-GE pig hearts exhibit promising performance in the context of a clinically applicable regimen including ischemia minimization and αCD154-based IS, justifying further evaluation in an orthotopic model., (Copyright © 2024 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Despite increasing prevalence of hypertension in youth and high adult cardiovascular mortality rates, the long-term consequences of youth-onset hypertension remain unknown. This is due to limitations of prior research such as small sample sizes, reliance on manual record review, and limited analytic methods that did not address major biases. The Study of the Epidemiology of Pediatric Hypertension (SUPERHERO) is a multisite retrospective Registry of youth evaluated by subspecialists for hypertension disorders. Sites obtain harmonized electronic health record data using standardized biomedical informatics scripts validated with randomized manual record review. Inclusion criteria are index visit for International Classification of Diseases Diagnostic Codes, 10th Revision (ICD-10 code)-defined hypertension disorder ≥January 1, 2015 and age <19 years. We exclude patients with ICD-10 code-defined pregnancy, kidney failure on dialysis, or kidney transplantation. Data include demographics, anthropomorphics, U.S. Census Bureau tract, histories, blood pressure, ICD-10 codes, medications, laboratory and imaging results, and ambulatory blood pressure. SUPERHERO leverages expertise in epidemiology, statistics, clinical care, and biomedical informatics to create the largest and most diverse registry of youth with newly diagnosed hypertension disorders. SUPERHERO's goals are to (i) reduce CVD burden across the life course and (ii) establish gold-standard biomedical informatics methods for youth with hypertension disorders., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Coral reefs in turbid waters have been hypothesized to be a refuge from climate change. These naturally occurring communities were brought into the spotlight because some of their species exhibited record levels of resistance to marine heatwaves (MHWs) by disturbance-tolerant corals. However, long-term monitoring data on the drivers of coral bleaching in these extreme reef habitats are scarce. Here, we describe the population structure and bleaching rates of a widespread and resilient coral (Siderastrea stellata). We examine the links between environmental factors, namely, rainfall, wind speed, turbidity, solar irradiance, sea surface temperature, MHWs, and coral bleaching status under the worst recorded drought cycle in the Tropical South Atlantic (2013-2015). We examined 2880 colonies, most of which (∼93%) fit in the size group of 2-10 cm, with a small number (∼1%) of larger and older colonies (>20 cm). The results indicated the absence of MHWs and normal sea surface temperature variations (between 26.6 °C and 29.3 °C), however, we detected an extreme rainfall deficit (30-40% less annual volume precipitation). In general, a high proportion (44-84%) of bleached colonies was found throughout the months when turbidity decreased. Siderastrea is the only reef-building coral that comprises this seascape with encrusting and low-relief colonies. During drought periods, cloudiness is reduced, turbidity and wind speed are reduced, and solar irradiance increase, driving coral bleaching in turbid reefs. However, episodic rainfall and higher wind speeds increase turbidity and decrease coral bleaching. Our hypothesis is that turbidity decreases during drought periods which increases bleaching risk to corals even without thermal stress. Our results suggest that turbidity may have related to wind and rainfall to provoke the coral bleaching phenomenon., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

In Brief: Aromatase catalyzes the synthesis of estrogens and has been shown to have an important role during the establishment of pregnancy in the pig. This study confirmed the differential expression of the three aromatase isoforms., Abstract: Although three porcine aromatase isoforms have been identified, their gene expression profiles in reproduction are still poorly understood. Here, we identified by Sanger sequencing unique nucleotide signatures for the three paralogous copies of Cyp19 and analyzed by RT-PCR the occurrence of the Cyp19 and Cyp17a1 transcripts at different tissues and stages of conceptus and fetal-placental development. Cyp19a1 and Cyp19a3 expressions were detected in conceptuses and gonads, respectively. Cyp19a2 transcripts were identified on both the conceptuses and the placenta samples. Transcripts for Cyp17a1 were detected predominantly in conceptus and gonads. In the endometrium of day 21 pregnant females, as well as days 12 and 17 pseudopregnant females, we did not detect the expression of Cyp19a1, Cyp19a2, or Cyp19a3. In our study, we have demonstrated distinct transcriptional regulation for the three functional Cyp19 paralogs and a potential role for Cyp17a1 in controlling the secretion of estrogen from the conceptus and the placenta.

Background: Household food insecurity (HFI) is associated with poor general and mental health. Prior studies assessed parent and child mental health separately and did not assess other social risks., Objective: To assess the relationship between HFI and both parental and child mental health., Methods: Parents of 3-5-year-old children completed validated measures of food insecurity and mental health. Separate linear regression models were used for unadjusted analysis for each mental health outcome (parent depression, anxiety, and stress, and child mental health). Multivariable analysis was performed using hierarchical regression to adjust for relevant covariates., Results: Children (n = 335) were racially and socioeconomically diverse. HFI was reported in 10% of participants. HFI was associated with worse parent depression and stress in unadjusted analyses; however, after adjusting for covariates, the associations became insignificant. HFI was significantly associated with worse child mental health in unadjusted and multivariable analysis (aβ 2.24, 95% CI 0.59-3.88) compared to those without HFI., Conclusion: HFI was not associated with parental mental health outcomes when other social risks were included in the analyses; however, HFI was significantly associated with worse childhood mental health in all analyses. Pediatric providers should screen for and develop interventions to target both HFI and mental health., Impact: Household food insecurity was associated with worse parent depression and stress in unadjusted analyses; however, after adjusting for other social risks, the associations became insignificant. Household food insecurity was significantly associated with worse child mental health, even after adjusting for demographics, other social risks, and parent mental health. Social risks are differentially associated with parent and child mental health. Understanding the complexities of family stressors can help better support parents and children struggling with mental health problems and social risks., (© 2023. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

CRISPR-Cas9 gene editing technology provides a method to generate loss-of-function studies to investigate, in vivo, the specific role of specific genes in regulation of reproduction. With proper design and selection of guide RNAs (gRNA) designed to specifically target genes, CRISPR-Cas9 gene editing allows investigation of factors proposed to regulate biological pathways involved with establishment and maintenance of pregnancy. The advantages and disadvantages of using the current gene editing technology in a large farm species is discussed. CRISPR-Cas9 gene editing of porcine conceptuses has generated new perspectives for the regulation of endometrial function during the establishment of pregnancy. The delicate orchestration of conceptus factors facilitates an endometrial proinflammatory response while regulating maternal immune cell migration and expansion at the implantation site is essential for establishment and maintenance of pregnancy. Recent developments and use of endometrial epithelial "organoids" to study endometrial function in vitro provides a future method to screen and target specific endometrial genes as an alternative to generating a gene edited animal model. With continuing improvements in gene editing technology, future researchers will be able to design studies to enhance our knowledge of mechanisms essential for early development and survival of the conceptus., (© 2022 The Authors. Molecular Reproduction and Development published by Wiley Periodicals LLC.)

Objective: Parents' concerns about their child's feeding may lead parents to pressure their child to eat, which may lead to a greater risk for obesity. We aimed to assess if parental concerns for picky eating and undereating are associated with pressure to eat and increased child BMI z-score (BMIz)., Methods: We performed a cross-sectional study of 328 parents of healthy preschoolers assessing parent concerns about picky eating (Child Eating Behavior Questionnaire) and child undereating ("Are you concerned …doesn't eat enough?"), parent pressure to eat (Child Feeding Questionnaire), and covariates. Dyads' heights and weights were measured. Structural equation modeling (SEM) was performed to examine the relationships between parental concerns, pressure to eat, and child BMIz. Measurement models were tested and refined, and the structural model was tested. Model fit was determined using multiple goodness-of-fit indices., Results: Dyads were racially and socioeconomically diverse. The SEM model demonstrated good goodness-of-fit. Children who were perceived as not eating enough had significantly higher picky eating scores (β 0.756; p < 0.001). Parents had higher pressure to eat scores if children were more picky (β 0.148; p = 0.02) or were perceived as not eating enough (β 0.654; p < 0.001). Parental pressure to eat was not associated with the child's BMIz., Conclusions: In a cohort of diverse preschoolers, parent concerns about eating were associated with increased pressure to eat, but pressure to eat was not associated with BMIz. Identifying these relationships is important to develop effective interventions to improve feeding practices in young children., Competing Interests: Conflicts of interests The authors have no competing interests to disclose., (Copyright © 2022 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Glutamine supplementation to porcine embryo culture medium improves development, increases leucine consumption, and enhances mitochondrial activity. In cancer cells, glutamine has been implicated in the activation of mechanistic target of rapamycin complex 1 (mTORC1) to support rapid proliferation. The objective of this study was to determine if glutamine metabolism, known as glutaminolysis, was involved in mTORC1 activation in porcine embryos. Culture with 3.75 mM GlutaMAX improved development to the blastocyst stage compared to culture with 1 mM GlutaMAX, and culture with 0 mM GlutaMAX decreased development compared to all groups with GlutaMAX. Ratios of phosphorylated to total MTOR were increased when embryos were cultured with 3.75 or 10 mM GlutaMAX, which was enhanced by the absence of leucine, but ratios for RPS6K were unchanged. As another indicator of mTORC1 activation, colocalization of MTOR and a lysosomal marker was increased in embryos cultured with 3.75 or 10 mM GlutaMAX in the absence of leucine. Culturing embryos with glutaminase inhibitors decreased development and the ratio of phosphorylated to total MTOR, indicating reduced activation of the complex. Therefore, glutaminolysis is involved in the activation of mTORC1 in porcine embryos, but further studies are needed to characterize downstream effects on development., (© 2021 The Authors. Molecular Reproduction and Development published by Wiley Periodicals LLC.)

The improvement of in vitro embryo production by culture media supplementation has been a potential tool to increase blastocyst quality and development. Recently, lipid-core nanocapsules (LNC), which were developed for biomedical applications as a drug-delivery system, have demonstrated beneficial effects on in vitro embryo production studies. LNCs have a core composed of sorbitan monostearate dispersed in capric/caprylic triglyceride. Based on that, we firstly investigated if LNCs supplemented during in vitro oocyte maturation had affinity to the mineral oil placed over the top of the IVM media. Also, the effects of LNC supplementation in different concentrations (0; 0.94; 4.71; 23.56; 117.80 and 589.00μg/mL) during the in vitro maturation protocol were evaluated in oocytes and blastocysts by in vitro tests. LNCs seemed not to migrate to the mineral oil overlay during the in vitro oocyte maturation. Interestingly, LNCs did not show toxic effects in the oocyte in vitro maturation rate, cumulus cells expansion and oocyte viability. The highest LNCs concentration tested (589μg/mL) generated the lowest ROS and GSH levels, and reduced apoptosis rate when compared to the control. Additionally, toxic effects in embryo development and quality were not observed. The LNC supramolecular structure demonstrated to be a promising nanocarrier to deliver molecules in oocytes and embryos, aiming the improvement of the embryo in vitro development., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Sudden cardiac death (SCD) is the leading cause of death during exercise in young athletes. Preparticipation physical examinations were developed to maintain the health and safety of athletes, including the prompt identification of those at risk for SCD. The use of medical history and physical examinations, electrocardiography, and echocardiography, or some combination thereof, is the source of continued debate. This article provides an overview of the etiology of SCD and reviews literature relating to preparticipation echocardiography, with a focus on its evolution, utility, and effectiveness. The limited echocardiogram is a potentially viable screening option yet to be thoroughly explored by experts and policymakers in the sports medicine community.

In this work, a promising approach to increase the advantageous properties of melatonin through its encapsulation into lipid-core nanocapsules (LNC) was examined. Oocytes were treated during in vitro maturation with non-encapsulated melatonin (Mel), melatonin-loaded lipid-core nanocapsules (Mel-LNC), and unloaded LNC. Cytotoxicity, meiotic maturation rate, development to the blastocyst stage, reactive oxygen species (ROS) and glutathione levels, mean cell number and apoptotic cell/blastocyst, and mRNA quantification were evaluated. Both Mel and Mel-LNC enhanced in vitro embryo production, however, Mel-LNC proved to be more effective at decreasing ROS levels and the apoptotic cell number/blastocyst, increasing the cleavage and blastocyst rates, up-regulating the GPX1 and SOD2 genes, and down-regulating the CASP3 and BAX genes. Mel-LNC could penetrate into oocytes and remain inside the cells until they reach the blastocyst stage. In conclusion, when melatonin was encapsulated in LNC and applied during in vitro oocyte maturation, some quality aspects of the blastocysts were improved., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In vitro oocyte maturation (IVM) protocols can be improved by adding chemical supplements to the culture media. Tretinoin is considered an important retinoid in embryonic development and its association with lipid-core nanocapsules (TTN-LNC) represents an innovative way of improving its solubility, and chemical stability, and reducing its toxicity. The effects of supplementing IVM medium with TTN-LNC was evaluated by analyzing production of reactive oxygen species (ROS), S36-phosphorilated-p66Shc levels and caspase activity in early embryonic development, and expression of apoptosis and pluripotency genes in blastocysts. The lowest concentration tested (0.25μM) of TTN-LNC generated higher blastocyst rate, lower ROS production and S36-p66Shc amount. Additionally, expression of BAX and SHC1 were lower in both non-encapsulated tretinoin (TTN) and TTN-LNC-treated groups. Nanoencapsulation allowed the use of smaller concentrations of tretinoin to supplement IVM medium thus reducing toxic effects related with its use, decreasing ROS levels and apoptose frequency, and improving the blastocyst rates., (Copyright © 2015 Elsevier Inc. All rights reserved.)

This paper describes three elderly patients who were admitted to hospital with aspiration pneumonia. They were kept nil by mouth (NBM) for a number of days, while being given intravenous hydration initially and enteral feeding subsequently. During that time they deteriorated and appeared to be dying, so the Liverpool Care Pathway (LCP) for the dying was used to support their care. Artificial nutrition and hydration were stopped. They quickly improved and the LCP was discontinued. Two of the patients deteriorated again on reintroduction of enteral feeding and/or intravenous fluids, only to improve a second time following withdrawal of feeding and fluids. Vulnerable elderly patients should not be made NBM except as a last resort. Clinicians should be alert to the possibility of refeeding syndrome and overhydration as reversible causes of clinical deterioration, particularly in frail elderly patients. Use of the LCP in these patients provided a unique opportunity to witness the positive effects of withdrawal of excessive artificial nutrition and hydration.