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Extracorporeal shock wave therapy (ESWT) may improve pain and function in patients with calcaneal spur; however, outcomes may vary according to patient characteristics. This study aimed to identify clinical, functional, radiological, and physical activity-related predictors of treatment response in individuals with calcaneal spur who received ESWT and to assess the extent of improvement after treatment. Retrospective observational study using a single-assessment retrospective pretest-posttest design. A total of 120 patients who underwent ESWT for heel pain/plantar fasciitis associated with calcaneal spur and who had complete study data were included. Participants completed a single post-treatment telephone interview, reporting their current status and retrospectively recalling their pre-treatment status. Assessments included Numerical Rating Scale scores for first-step pain and total heel pain, Roles and Maudsley Scale scores, Foot Function Index scores, International Physical Activity Questionnaire-Short Form scores, analgesic consumption, calcaneal spur size, and radiological stage. Significant improvements were observed in pain and foot-related functional measures following ESWT. The percentage of patients utilizing analgesics decreased from 64.2% to 31.7%. IPAQ-SF (International Physical Activity Questionnaire-Short Form)/MET (Metabolic Equivalent of Task)-based scores for walking, moderate-intensity activity, vigorous activity, and total physical activity increased significantly after ESWT. ESWT may reduce pain and analgesic use while improving function and physical activity in patients with calcaneal spur. Patient-related, radiological, functional, and physical activity-related factors were associated with the degree of treatment benefit. Level IV, retrospective observational study.

Background and objective Extra-articular fractures of the proximal third of the tibia are technically demanding injuries due to the complex deforming muscular forces and frequently compromised soft tissue envelope. The optimal treatment strategy for this fracture subtype remains unsettled, particularly regarding the choice between minimally invasive percutaneous plate osteosynthesis (MIPPO) and intramedullary interlocking nailing (IMILN). This study was undertaken to compare these two treatment modalities and determine their relative effectiveness. Methods A single-center, prospective, comparative study employing alternating allocation was conducted at IMS and SUM Hospital, Bhubaneswar, with patient recruitment carried out from September 2024 to February 2025, and final clinical and functional follow-up at 12 months completed by March 2026. Fifty-two adults aged 20-60 years with AO/OTA 41A2 fractures, including Gustilo-Anderson grade I and II open injuries, were sequentially allocated to either MIPPO (n = 26) or IMILN (n = 26). The primary outcomes included time to radiological union and 12-month functional assessment using the Knee Society Score (KSS), Lower Extremity Functional Scale (LEFS), and Johner and Wruhs grading scale. Continuous variables were compared using the independent-samples t-test, while categorical variables were analyzed using the chi-square or Fisher's exact test as appropriate. Statistical analyses were performed using IBM SPSS Statistics version 21.0 (IBM Corp., Armonk, NY). Results Forty-six patients completed the one-year follow-up (MIPPO, n = 24; IMILN, n = 22). Mean radiological union time was 16.1 weeks (MIPPO) versus 16.9 weeks (IMILN) (mean difference: -0.8 weeks, 95% CI: -4.0 to 2.4; p = 0.62). Final union rates were 23/24 (95.8%) and 21/22 (95.5%), respectively. Malreduction > 5&#xb0; occurred in 4/26 (15.4%, MIPPO) and 5/26 (19.2%, IMILN) (p = 0.71). Mean KSS was 80.2 versus 80.8 (mean difference: -0.6, 95% CI: -7.0 to 5.8; p = 0.85), and mean LEFS was 65.2 versus 67.3 (mean difference: -2.1, 95% CI: -6.6 to 2.4; p = 0.35). Excellent or good Johner and Wruhs grades were achieved in 18/24 (75.0%, MIPPO) and 18/22 (81.8%, IMILN). Partial weight-bearing was initiated earlier in the IMILN group (two to three postoperative days vs. three to four weeks; p < 0.001). Intraoperative adjuncts were required in 13/26 (50.0%) of IMILN versus 3/26 (11.5%) of MIPPO procedures (p = 0.005). Conclusions Within the limitations of this small, single-center cohort study, MIPPO and IMILN demonstrated comparable union rates and one-year functional outcomes for AO/OTA 41A2 fractures. IMILN facilitated earlier mobilization but necessitated adjunct procedures more frequently and was associated with anterior knee pain. MIPPO was associated with minimal knee-related morbidity, albeit with a more gradual rehabilitation timeline. Implant selection should therefore be guided by fracture morphology, soft-tissue condition, and locally available instrumentation rather than an absolute preference for either construct.

This study aims to investigate whether arthroscopy-assisted minimally invasive percutaneous plate osteosynthesis (MIPPO) provided more favorable early functional recovery and reduced surgical trauma compared to traditional open reduction and internal fixation (ORIF). A total of 84 patients with Schatzker type I-IV tibial plateau fractures treated between January 2021 and January 2024 were retrospectively analyzed. The MIPPO group (n = 41) underwent arthroscopy-assisted reduction plus MIPPO, while the ORIF group (n = 43) received conventional ORIF. Allocation was chronological, with ORIF predominant in the first two years and MIPPO in the latter two years. Operative parameters, postoperative drainage, radiographic outcomes (Rasmussen radiological score), functional recovery (Hospital for Special Surgery [HSS] score), range of motion (ROM), fracture healing time, hospital stay, and complications were compared. Of a total of 84 patients, 28 were male and 56 were female of 49.4 &#xb1; 9.0 (range, 27 to 69) years. The arthroscopy-assisted MIPPO group had significantly longer operative time (96.0 &#xb1; 18.2 vs. 84.0 &#xb1; 13.9 min, p = 0.001) but shorter incision length (3.9 &#xb1; 0.7 vs. 6.2 &#xb1; 0.9 cm, p < 0.001), less intraoperative blood loss (56.5 &#xb1; 9.6 vs. 72.6 &#xb1; 10.1 mL, p < 0.001), and lower postoperative drainage volume (47.1 &#xb1; 7.5 vs. 59.0 &#xb1; 7.0 mL, p < 0.001) than the ORIF group. The arthroscopy-assisted MIPPO group also achieved higher Rasmussen radiological scores (15.4 &#xb1; 1.4 vs. 14.0 &#xb1; 1.6, p < 0.001) and better HSS scores at one, three, and six months postoperatively (all p < 0.001). At six months postoperatively, the MIPPO group also demonstrated significantly improved knee ROM (118.5&#xb0; &#xb1; 8.2&#xb0; vs. 107.3&#xb0; &#xb1; 9.1&#xb0;, p < 0.001), a difference exceeding the clinically meaningful threshold for activities of daily living. However, no significant differences were found in hospital stay (p = 0.051), fracture healing time (11.4 &#xb1; 1.3 vs. 11.1 &#xb1; 1.3 weeks, p = 0.340), or the excellent-and-good rate of HSS score at final follow-up (95.1% vs. 97.7%, p = 0.746). Complication rates were similar between the groups (p = 1.000). For Schatzker type I-IV tibial plateau fractures, arthroscopy-assisted MIPPO provides more favorable early functional recovery and radiological reduction quality compared to conventional ORIF, with less surgical trauma and comparable early functional recovery and similar complication rates during follow-up. Although operative time is longer, this minimally invasive approach is a safe and effective option for managing these complex fractures. Its principal advantage is accelerated early recovery, particularly in knee ROM, enabling patients to reach clinically meaningful thresholds for activities of daily living sooner.

AIM: To analyze the safety and effectiveness of the minimally invasive endoscopic approach in the treatment of large intraventricular tumors. MATERIAL and METHODS: We retrospectively reviewed the demographic, radiological, and surgical data of 8 patients who were operated on using the endoscope-plus-port technique for large (>5 cm) intraventricular tumors at our clinic between 2015 and 2020. All procedures were performed using the minimally invasive endoscopic approach. RESULTS: The cohort comprised 3 females and 5 males, with a mean age of 40.88 years. All tumors were located in the lateral ventricle; near-total resection was achieved in 3 patients and subtotal resection in 5 patients. External ventricular drainage was inserted in all patients postoperatively. The histological diagnosis was neurocytoma in 3 patients, glioblastoma in 2 patients, metastasis in 2 patients, and a grade II meningioma in 1 patient. No complications or mortality were reported in the 31-month follow- up period. CONCLUSION: Safe and effective tumor resection of intraventricular tumors is possible using the endoscope-plus-port, even in tumors >5 cm. This technique permits dynamic mobilization and facilitates bimanual operation, increasing resection rates and improving outcomes for these tumors.

Stereotactic radiosurgery (SRS) is an established treatment for vestibular schwannoma, offering high tumor control rates and a favorable safety profile. SRS-induced facial palsy is typically a late-onset complication, with acute-onset cases being exceedingly rare. We report the case of a 42-year-old man with a left-sided Koos grade I vestibular schwannoma who underwent single-fraction Gamma Knife radiosurgery with a prescription dose of 11 Gy to the 50% isodose line. Baseline facial nerve function was intact. Seventy-two hours post-treatment, the patient developed House-Brackmann (HB) grade V peripheral facial palsy, accompanied by severe vestibular symptoms. Magnetic resonance imaging obtained on post-treatment day 6 demonstrated reduced contrast enhancement, partial capsular breakdown, and central hypointensity within the tumor, suggestive of acute necrotic change. Vestibular symptoms improved rapidly following corticosteroid therapy; however, facial palsy recovery was gradual, improving to HB grade II at 12 months, with persistence at final follow-up (20 months). The tumor remained radiologically stable. Acute-onset facial palsy following SRS for vestibular schwannoma is extremely rare, with only four previous cases reported in the literature. This is the first reported case to occur following a relatively low margin dose-11 Gy-in contrast to the 13-14 Gy doses prescribed in earlier reports.

Primary bone lymphoma (PBL) is a rare extranodal lymphoma accounting for approximately 7% of malignant primary bone tumors. It typically presents with nonspecific features, frequently resulting in diagnostic delay and inappropriate initial management. We retrospectively analyzed the characteristics of 72 patients diagnosed with PBL between 1966 and 2025 at a tertiary referral center in Spain. Diffuse large B-cell lymphoma (DLBCL) was the predominant histological subtype. The most frequent presentations included persistent bone pain, pathological fractures, and palpable masses, often associated with elevated LDH levels or underlying immunosuppressive conditions. Imaging findings were heterogeneous, ranging from permeative lytic patterns to sclerotic lesions, occasionally resembling osteomyelitis or other aggressive neoplasms. MRI proved essential for early detection, accurate assessment of bone marrow infiltration, and soft tissue extension, while CT played a key role in biopsy guidance. FDG PET/CT was critical for staging, restaging, and treatment response evaluation. Diagnostic precision depended heavily on close clinico-radiological-pathological correlation, particularly in cases with atypical or misleading imaging patterns. Most patients were treated with combined chemotherapy and radiotherapy, which was associated with high response rates and favorable survival outcomes. PBL is an uncommon but potentially curable malignancy. Early diagnosis requires a high index of suspicion and systematic integration of clinical data, laboratory findings, and multimodal imaging. PBL should be systematically considered in patients presenting with aggressive-appearing bone lesions, pathological fractures, or unexplained marrow replacement, especially in the presence of elevated LDH levels or immunosuppression, in order to prevent diagnostic delay and optimize outcomes.

Rothia spp. are commensal organisms involved in serious infections such as infective endocarditis (IE). There is a significant lack of information regarding de clinical course and management of Rothia spp. IE in immunocompetent patients. This study describes 11 cases of Rothia spp. bacteremia over a 10-year period in a secondary hospital, analyzing clinical, demographic, and microbiological data. True infection was defined based on clinical signs, microbiological criteria, and radiological evidence. Three cases (27.3%) were confirmed as true infections, all presenting as infective endocarditis. All three infections were caused by Rothia mucilaginosa in non-immunocompromised patients. Identified risk factors included type 2 diabetes, pre-existing valvular disease, prosthetic implants, and odontogenic foci. 100% of cases developed severe central nervous system complications. Total bacterial eradication without recurrence was achieved, and no acute valve surgery was required. Rothia spp. can cause true bacteremia and IE in non-immunocompromised patients. Time to positivity (TTP) and clinical correlation are fundamental to distinguish between true infection and contamination. Individualized shorter antibiotic regimens might be explored in selected cases, although conventional durations remain the standard due to the severity of complications.

AIM: To investigate the preoperative, early and late postoperative differences in the anterior callosal angle, lateral and third ventricle shapes of patients with pituitary macroadenoma operated via the transsphenoidal approach. MATERIAL and METHODS: Shape data of the third and lateral ventricles were collected from the two-dimensional digital images. The generalised Procteus analysis was used to obtain mean shapes in the preoperative, early and late postoperative phases. The shape deformation of the ventricles from pre-to postoperative phases was evaluated using the thin plate spline method. Anterior callosal angle (ACA) was measured pre-to postoperative images and was analyzed statistically. RESULTS: There was no significant lateral ventricle shape and ACA measurement difference in the pre and postoperative phases. The high-level deformations from the pre- to postoperative phase were seen in thin plate spline graphs. The highest deformation was observed at the third ventricle. Third ventricle deformation continued from the early to the late postoperative period, but this deformation is more limited than in preoperative comparisons. CONCLUSION: We demonstrated that shape changes in the third ventricle of patients with pituitary macroadenoma persisted during the postoperative period through statistical geometric morphometric shape analysis. This phenomenon may result from dysfunction of the ventricular surface cilia due to chronic tumor compression and surgery-related neurotrauma. Additionally, we identified the diagnostic limitations of ACA in patients without radiological signs of hydrocephalus.

Dose optimization in radiation-based imaging is pivotal in enhancing patient safety and minimizing unnecessary exposure. DRLs are useful guides in dose management in clinical settings. This study assesses the level of awareness, practices, and barriers of DRLs among radiological professionals in the UAE, trying to highlight the main issues affecting their involvement. To meet the aims of the study, a cross-sectional survey was conducted among 101 radiology professionals, using an online questionnaire. Demographic data and assessment of the knowledge, practice behaviors, awareness, and perceived barriers of DRLs were collected. Descriptive statistics and nonparametric tests, including the Mann-Whitney U and Kruskal-Wallis H tests, were performed for differences in demographic groups. Participants demonstrated a high level of DRL knowledge (mean score: 73.4 &#xb1; 14.29), and most routinely applied dose-optimization techniques (87.1%). Awareness was more variable: although 88.1% reported familiarity with DRL guidelines, 33.6% mistakenly believed DRLs were legally binding. Key barriers included limited institutional audits (28.7%), insufficient training, and uncertainty regarding national regulatory responsibilities. Significant differences in practice and awareness were associated with age and qualification (p < 0.001), with more experienced and highly qualified professionals showing greater engagement with DRL principles. The findings highlight strong foundational knowledge and positive practice patterns but reveal gaps in awareness and institutional support for DRL implementation. Targeted educational initiatives, structured professional development, and strengthened institutional policies are needed to improve DRL understanding and promote consistent, effective dose-optimization practices within the surveyed cohorts and similar clinical settings. Medical scans that use radiation need careful dose control to keep people safe. This study asked radiology staff about their use and understanding of dose guidelines that help manage radiation levels. This study found that most had good knowledge and used dose reduction methods, but some lacked clear understanding and support. This matters because better training and guidance can help ensure safer scans for patients.

Renal pelvis epidermoid cysts are extremely rare and often misdiagnosed as stones or tumors. Only one previous case has been treated via the percutaneous approach (PCN). A 67-year-old diabetic female on Empagliflozin presented with imaging suggestive of a staghorn calculus. During Percutaneous Nephrolithotomy (PCNL), whitish keratinous material was found in the renal pelvis along with a small obstructing stone. All material was evacuated through the Amplatz sheath. Urine culture was negative. Histopathology confirmed an epidermoid cyst. Postoperative CT scan at one month showed complete resolution. Epidermoid cysts can mimic staghorn calculi radiologically. A Fungal ball was initially suspected due to diabetes and SGLT2 inhibitor therapy, but radiopacity, negative culture, and histology ruled this out. PCNL served as both a diagnostic and therapeutic procedure, preserving renal function. Renal pelvis epidermoid cysts should be considered in the differential diagnosis of opaque pelvic lesions. PCNL is a minimally invasive, kidney-preserving treatment that can be performed as a renal-sparing procedure.

Intravascular large B-cell lymphoma (IVLBCL) is a rare extranodal neoplasm in which malignant B cells proliferate predominantly within small blood vessels. Because lymphadenopathy, mass lesions, circulating malignant cells, and specific radiological findings may be absent, IVLBCL can closely mimic other medical conditions, resulting in delayed diagnosis. This case is notable for a prolonged culture-negative sepsis-like presentation with persistent unexplained hypoxemia due to predominant pulmonary microvascular involvement, further obscured by lupus-like autoimmune features and subsequent COVID-19 infection. An older woman in her early 70s presented with fever, lethargy, weight loss, back pain, hypotension, raised inflammatory markers, cytopenia, markedly elevated lactate dehydrogenase (LDH), and progressive hypoxemia. She was initially treated for presumed sepsis, but repeated microbiological investigations and serial imaging did not identify an infectious source, and clinical improvement was not sustained. A transient malar rash and a positive antinuclear antibody raised concern for a lupus-like autoimmune disease; however, testing for anti-double-stranded DNA and extractable nuclear antigen was negative, and the broader autoimmune workup did not support systemic lupus erythematosus as the unifying diagnosis. Subsequent severe acute respiratory syndrome coronavirus 2 infection further complicated the interpretation of hypoxemia and deterioration. Despite antimicrobial therapy, corticosteroids, antiviral treatment, and supportive care, she developed progressive multiorgan failure and died approximately six weeks after admission. Postmortem examination revealed widespread multiorgan IVLBCL involving the lungs, heart, kidneys, liver, spleen, and multiple additional extranodal sites. Pulmonary capillary involvement provided a clinicopathological explanation for persistent unexplained hypoxemia. This case demonstrates how IVLBCL may remain concealed when several plausible diagnoses coexist. Persistent culture-negative fever, constitutional decline, cytopenia, high LDH, nondiagnostic imaging, treatment nonresponse, and unexplained hypoxemia should prompt consideration of IVLBCL and early tissue-based investigation.

In this study, we aimed to compare the clinical and radiological outcomes of patients undergoing arthrodesis and trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI) for thumb carpometacarpal (CMC) osteoarthritis and to investigate whether patient-specific decision-making could offer advantages over LRTI or arthrodesis as a surgical approach. Between August 2014 and January 2025, a total of 40 patients who underwent surgical treatment for thumb CMC osteoarthritis were retrospectively analyzed. The patients were divided into two groups as the T + LRTI group (n = 22) and arthrodesis group (n = 18). Clinical outcomes were assessed using the Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), grip strength (kg), and pinch strength (kg) measurements. Of the patients, 7 were male and 33 were female with a mean age of 62.9 &#xb1; 6.5 years in T + LRTI group, 60.1 &#xb1; 7.4 years in arthrodesis group (range, 40 to 75 years). Both groups demonstrated significant improvement in VAS and QuickDASH scores postoperatively (p < 0.001). The mean postoperative VAS scores were 2.7 &#xb1; 2.0 in the T + LRTI group and 1.9 &#xb1; 0.9 in the arthrodesis group (p = 0.267), while QuickDASH scores were 26.4 &#xb1; 17.3 and 19.1 &#xb1; 3.2, respectively (p = 0.085). No significant differences were observed in grip strength (p = 0.358), palmar pinch (p = 0.104) and key pinch strength (p = 0.097) between the groups. The overall complication rate was 12.5% in both groups, indicating no statistically significant difference (p = 0.642). Our study results suggest that both T + LRTI and arthrodesis provide effective and comparable pain relief and functional outcomes in the surgical management of thumb CMC osteoarthritis and can be considered reliable surgical options.

AIM: To analyze the efficacy and safety of Gamma Knife radiosurgery (GKRS) in the management of thyroid cancer brain metastases (TCBM). MATERIAL and METHODS: This retrospective study analyzed patients who underwent GKRS for TCBM at two centers between September 2005 and February 2025. Patients' clinical and radiological outcomes, including local tumor control and overall follow-up, were investigated. RESULTS: Among the 3,834 patients who underwent GKRS for brain metastases at two centers, only 0.26% had primary thyroid cancer. A total of 10 patients with 40 TCBM were treated by GKRS, with a median of two metastases per patient. The most common metastasis site was the frontal lobe (47.5%), and 60% of patients had multiple metastases. Papillary carcinoma was the most frequent histological subtype (57.1%). The median latency from thyroid cancer diagnosis to the development of brain metastases was 22 months. The median GKRS dose was 23 Gy, and local failure occurred in 5% of treated metastases. Radiation-induced necrosis was observed in one case and resolved without clinical impact. Intracranial distant metastases developed in two patients. The median follow-up was 8 months, and 80% of patients died during follow-up, with one death attributed to brain metastasis. CONCLUSION: The limited number of patients and the short follow-up period, partly reflecting the aggressive nature of TCBM, may have influenced the study results. Nevertheless, despite the short follow-up, GKRS provided favorable local control without significant adverse effects, suggesting that it may be an effective treatment option for TCBM.

Disseminated fungal infection (DFI) is the presence of a fungal pathogen in the blood and/or any other deep-seated site due to vascular spread. It represents a rare but life-threatening infectious complication in immunocompromised patients. In this case report, we present a 19-year-old male with weakness of the limbs, headache, and slurred speech. He was a known case of endobronchial fungal infection with worsening neurological symptoms. Motor examination revealed reduced tone and strength, while respiratory examination revealed bilaterally decreased air entry. Fundoscopic examination revealed papilledema. Immunological evaluation demonstrated elevated IgE and IgG levels and a reduced CD16/56 natural killer cell count, indicating defective innate immunity. Radiological examination, including computed tomography (CT), positron emission tomography-computed tomography (PET-CT), and magnetic resonance imaging (MRI), demonstrated nodules with opacities and mediastinal and cervical lymphadenopathy in the chest, as well as multiple supratentorial and infratentorial lesions, extensive edema, and nodular leptomeningeal thickening on neuroimaging. The patient is hypothesized to have dysfunctional ryanodine receptors (RyR) rather than typical CGD. The patient was managed with antifungal therapy along with antiepileptic and antiedema drugs.

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Lung adenocarcinoma (LUAD) is marked by significant tumor heterogeneity and immune interactions that influence therapeutic response, while radiation-induced fibrosis poses a critical clinical challenge by compromising pulmonary function and complicating post-treatment surveillance. A prognostic risk signature for lung adenocarcinoma was established by integrating transcriptomic data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) repositories. The methodology involved initial screening for differentially expressed radiotherapy-related fibrosis genes, followed by least absolute shrinkage and selection operator (LASSO) regression coupled with multivariate Cox analysis to derive a compact risk model. Rigorous validation-encompassing survival analysis, receiver operating characteristic (ROS) evaluation, and external cohort testing-confirmed its predictive accuracy. Subsequent analyses delved into functional enrichment pathways, the tumor immune microenvironment, mutational characteristics, and potential chemotherapeutic responsiveness. Following construction and validation, a model based on six genes demonstrated high accuracy in predicting patient outcomes. Low-risk patients exhibited "hot" immune phenotypes with favorable immunotherapy responses, while high-risk patients showed elevated tumor mutational burden (TMB) and differential drug sensitivity. Three molecular subtypes were identified, with Group 3 representing a "cold" tumor phenotype associated with poorest prognosis. This study developed and validated a six-gene-fibrosis-based prognostic model for LUAD. The model stratifies survival risk and correlates with immune features and drug sensitivity, but provides a preliminary framework requiring prospective clinical validation.

Delayed re-occlusion after successful mechanical thrombectomy (MT) is uncommon and often underrecognized. Iatrogenic intracranial arterial dissection represents a rare but potentially devastating mechanism requiring rapid salvage intervention with or without a stent. A 63-year-old woman with a wake-up stroke underwent thrombolysis and MT with complete reperfusion (Thrombolysis in Cerebral Infarction (TICI) grade 3) and full neurological recovery. Three days later, she developed acute neurological deterioration. Angiography demonstrated a right M1 re-occlusion caused by a flow-limiting dissection. Following failed aspiration, emergent rescue stenting with a self-expanding Low-profile Visualized Intraluminal Support (LVIS) EVO stent achieved immediate reperfusion. A tirofiban-based bridging strategy with dual antiplatelet therapy was initiated without hemorrhagic complications. Follow-up imaging showed a small infarct. At 12 months, the patient remained functionally independent, with a modified Rankin Scale (mRS) score of 1 and a National Institutes of Health Stroke Scale (NIHSS) score of 0. Delayed iatrogenic dissection should be suspected in post-thrombectomy deterioration. Rescue intracranial stenting is a definitive and effective salvage strategy, provided that antithrombotic therapy is carefully individualized.