What's trending? Reach and content of the Society for Maternal-Fetal Medicine on social media

BACKGROUND

The Society for Maternal-Fetal Medicine uses social media to increase awareness of the Society and its key programs and to foster community and discussion around perinatal health, especially on Twitter. The influence and role of the Society for Maternal-Fetal Medicine Twitter account in public discourse around issues relevant to pregnancy have not been studied.

OBJECTIVE

This study aimed to evaluate the trends in engagement with the Society for Maternal-Fetal Medicine on Twitter by analyzing Society for Maternal-Fetal Medicine follower growth and discussion topics on Twitter compared with Facebook and by quantifying public engagement during the Society for Maternal-Fetal Medicine Annual Pregnancy Meeting.

STUDY DESIGN

This retrospective study analyzed follower growth data from August 2019 to July 2022 for the Society for Maternal-Fetal Medicine Twitter (@MySMFM) and Society for Maternal-Fetal Medicine Facebook (@SocietyforMaternalFetalMedicine) accounts. We identified the top 10 tweets and Facebook posts during the study period using Twitter Analytics and Facebook data. The popularity of tweets and Facebook posts was determined by "impressions" and "reach," respectively; these metrics reflect the number of times a post was viewed. To evaluate annual trends in Society for Maternal-Fetal Medicine Twitter engagement, we analyzed data associated with the Society for Maternal-Fetal Medicine Annual Pregnancy Meeting, including the number of tweets using the hashtag (#SMFM(Year)) and overall impressions for the Society for Maternal-Fetal Medicine Twitter account for each meeting from 2016 to 2023.

RESULTS

The absolute number of new followers for the Society for Maternal-Fetal Medicine Twitter and Facebook accounts was similar, but the relative increase and rate of follower growth was higher for Twitter than for Facebook. The Twitter account consistently gained followers, whereas the Facebook account experienced intermittent periods of stagnancy or follower loss. More than half of the top-ranked posts on Twitter and Facebook mentioned the COVID-19 vaccine; other popular topics included COVID-19 and abortion. During the Society for Maternal-Fetal Medicine Annual Pregnancy Meeting, the number of tweets using the meeting hashtag consistently peaked on meeting day 4, coincident with the opening plenary session (mean 1270±499). An upward trend in annual pregnancy meeting tweets was observed each year until 2021-the first virtual Society for Maternal-Fetal Medicine meeting.

CONCLUSION

The trends in Society for Maternal-Fetal Medicine Twitter engagement suggest increasing use and popularity of the platform for timely dissemination of pregnancy-related news, guidelines, and research. The reduction in annual pregnancy meeting tweets and impressions in 2021 and 2022 suggests the potential negative effect of virtual meetings on Society for Maternal-Fetal Medicine member engagement around annual meeting content.

MC3R links nutritional state to childhood growth and the timing of puberty

The state of somatic energy stores in metazoans is communicated to the brain, which regulates key aspects of behaviour, growth, nutrient partitioning and development1. The central melanocortin system acts through melanocortin 4 receptor (MC4R) to control appetite, food intake and energy expenditure2. Here we present evidence that MC3R regulates the timing of sexual maturation, the rate of linear growth and the accrual of lean mass, which are all energy-sensitive processes. We found that humans who carry loss-of-function mutations in MC3R, including a rare homozygote individual, have a later onset of puberty. Consistent with previous findings in mice, they also had reduced linear growth, lean mass and circulating levels of IGF1. Mice lacking Mc3r had delayed sexual maturation and an insensitivity of reproductive cycle length to nutritional perturbation. The expression of Mc3r is enriched in hypothalamic neurons that control reproduction and growth, and expression increases during postnatal development in a manner that is consistent with a role in the regulation of sexual maturation. These findings suggest a bifurcating model of nutrient sensing by the central melanocortin pathway with signalling through MC4R controlling the acquisition and retention of calories, whereas signalling through MC3R primarily regulates the disposition of calories into growth, lean mass and the timing of sexual maturation.

Disc wall structural abnormalities can act as initiation sites for herniation

Both posture and loading rate are key factors in the herniation process and can determine the failure mechanism of the disc. The influence of disc structure on the herniation process has yet to be directly observed, thus the aim of this study was to test the hypothesis that discs containing greater levels of pre-existing disruption would be more vulnerable to herniation when subjected to severe levels of posture and loading. 30 ovine lumbar motion segments were subjected to combinations of 4 loading conditions (0 - 12° flexion,0 - 9° lateral bending, 0 - 4° axial rotation, 0-1500 N axial compression) for 1000 loading cycles at 2 Hz in a dynamic disc loading simulator. The discs were scanned in an ultra-high field MRI (magnetic resonance imaging, 11.7 T) prior to and following testing. 4 discs herniated and 7 discs suffered nucleus displacement. These discs contained pre-existing defects in the central dorsal annulus. Generally, following testing, discs contained more dorsal annulus disruption, including 7 discs which developed similar characteristic defects although these did not herniate. Overall, more severe complex postures produced more disruption. While more severe postures such as twisting and bending increased disc damage, these results are probably the first directly showing that naturally occurring defects in the disc can act as initiation sites for herniation. The clinical significance of these findings is that, in principle at least, MRI based techniques could be capable of identifying vulnerable discs, with the obvious caveat that further correlation with clinical techniques is required.

Persistence of self-injury, aggression and property destruction in children and adults with tuberous sclerosis complex

BACKGROUND

Individuals with tuberous sclerosis complex (TSC) are at increased risk of developing self-injurious behaviour. The persistence of this deleterious behaviour over years is reported in aetiologically heterogeneous samples to be between 60% and 80% but is unknown for TSC.

METHOD

In this study, we determined the 3-year persistence of self-injury in a sample (n = 52) of children (with and without ID) and adults (with ID) with TSC and examined characteristics associated with persistence.

RESULTS

Findings for self-injury were contrasted to those for aggression and property destruction to examine the specificity of results to this behaviour. Self-injury was persistent in 84.6% of those with TSC who showed this behaviour, in contrast to 66.7% both for aggression and destruction. Persistent self-injury was associated with poor self-help skills, greater overactivity/impulsivity and more behavioural indicators of pain. These latter two characteristics were also associated with persistent aggression. No characteristics were associated with persistence of property destruction.

CONCLUSION

These findings suggest that self-injurious behaviours in individuals with TSC, together with aggressive and destructive behaviours, are highly persistent and would benefit from targeted intervention. Poor adaptive skills, overactivity/impulsivity and painful health conditions may differentiate those at most risk for persistent self-injury or aggression.

Implementing 12345 Fit-Tastic: A Tool for Combating Childhood Obesity

Childhood obesity is epidemic in the United States. School nurses are in a unique position to address weight with the students they serve. This article provides tools for school nurses to be able to conduct an obesity screening, demonstrate the basic skills of motivational interviewing in treatment of obesity in a school age child, and utilize the 12345 Fit-Tastic program in their practice. This article is the seventh and final article in a series on the topic of childhood obesity and the accompanying comorbidities.

Growth modeling of dairy heifers in Québec based on random regression

Cue, R. I., Pietersma, D., Lefebvre, D., Lacroix, R., Wade, K., Pellerin, D., de Passillé, A-M. and Rushen, J. 2012. Growth modeling of dairy heifers in Québec based on random regression. Can. J. Anim. Sci. 92: 33–47. A total of 144 006 weight (calculated from tape girth measurements) and height data records from Québec dairy heifers were analyzed using random regression to estimate growth curve parameters of Ayrshires, Brown Swiss and Holstein animals to permit prediction of individual heifer growth from 0 to 32 mo. There were, on average, 5.15 records per heifer (minimum 3 records, maximum 25 records). The body weight data were analyzed using linear and quadratic fixed and random regressions, with a power-of-the-mean (POM) function to model the residual variance. The POM was 1.2 for Holstein and Ayrshire and slightly less than 1 for Brown Swiss. Estimated body weight at 24 mo was 507, 564, 624 kg, for Ayrshires, Brown Swiss and Holstein, respectively. The height data were analyzed with a Brody, monomolecular non-linear growth curve model. Mature height was estimated to be 148 cm in both Holstein and Ayrshires, and 150 cm in Brown Swiss. Random regression models were shown to be able to predict individual growth, and can be incorporated in decision-support tools to help producers reducing the average age at first calving.

Catch ‘Em Being Good:” An Extension Service and State School System Team Up to Promote Positive Outcomes for Youth

This feature article describes a collaboration between the West Virginia University Extension Service and the West Virginia Department of Education to implement the “Responsible Students through School Wide Positive Behavior Supports” program (RS-SWPBS) throughout the state. A case study of Grandview Elementary School in Kanawha County illustrates the benefits that the collaboration brought to local youth. West Virginia Department of Education established the program and brought local schools onboard, while educators from the West Virginia University Extension Service became coaches and led the effort to collect and analyze data. Results included the development of positive behaviors, a decrease in negative behaviors, and the creation of a positive school climate.

Tissue- and bone cell-specific expression of bone sialoprotein is directed by a 9.0 kb promoter in transgenic mice

Bone sialoprotein (BSP) is a phosphorylated glycoprotein that is expressed almost exclusively in mineralizing connective tissues. In bone, expression of BSP correlates with the differentiation of osteoblasts and the onset of mineralization. To determine how the tissue- and differentiation-specific transcription of BSP is regulated, various lengths of promoter sequence were ligated to a luciferase reporter and stably transfected into a rat stromal bone marrow cell line, RBMC-D8 and undifferentiated C3H10T1/2 cells. Luciferase transcription of reporter constructs including 5.4 kb (mBSP5.4Luc) and 9.0 kb (mBSP9.0Luc) of the BSP promoter was strongly up-regulated in parallel with endogenous BSP mRNA in differentiating SBMCs, but not in C3H10T1/2 cells. In contrast, 0.1 kb and 1.4 kb BSP promoter constructs did not show selective expression. To determine tissue-specific expression in vivo, transgenic mice expressing reporter constructs for the 9.0 kb promoter and a 4.8 kb promoter lacking two upstream Cbfa1/Runx2 elements (mBSP9.0Luc and mBSP4.8Luc, respectively) were generated. Analysis of various tissues collected from 1-, 4-, 7-, 14-, and 42-day-old mice revealed extremely high levels of luciferase activity in calvaria, mandible, and tibia of the mBSP9.0Luc mice. In contrast, soft tissues showed negligible luciferase expression. Mice harboring the 4.8 kb transgene also showed selective luciferase expression but displayed a significantly lower activity in mineralized tissues. Northern hybridization of endogenous BSP mRNA and immunostaining of BSP in mBSP9.0Luc mice showed a temporo-spatial expression pattern consistent with the luciferase activity. These results indicate that regulatory elements within the 9.0 kb region of the promoter are required for strong, tissue- and differentiation-specific expression of BSP.

How mothers respond to their crying infant

INTRODUCTION

The purpose of this study was to allow mothers who are at high risk for abusing their child to describe how they manage when their infant cries.

METHOD

This phenomenologic qualitative study used a focus group design and semi-structured interview format. Participants were seven low-income women with a child enrolled in an urban day care facility, which provided the setting for data collection.

RESULTS

Analyses of the data revealed three themes: (a) activities done to pacify the infant, (b) coping mechanism, and (c) social support available.

DISCUSSION

The results of this study indicate that activities (a) may include the infant, such as holding and singing, or (b) may be directed toward the mother, such as using headphones or leaving the room. These activities follow the guidelines of the American Academy of Pediatrics and are not unique. Social support primarily was provided at the day care facility, supplemented with personal relationships that are tentative. Valued informal and formal interactions with supportive persons provide the emotional and psychosocial support for this at-risk population.

Minimally invasive bar repair for 'redo' correction of pectus excavatum

BACKGROUND/PURPOSE

A small percentage of patients who have undergone traditional, "Ravitch-type" pectus excavatum repair present with unsatisfactory results and require a second procedure for correction. Reoperative open surgery for pectus excavatum has been associated with extensive dissection and substantial blood loss. The minimally invasive (MIS) bar repair for the correction of pectus excavatum has been gaining acceptance. This study evaluates the authors results with patients who have undergone the MIS bar repair for redo correction of their pectus excavatum.

METHODS

A retrospective chart review of all patients undergoing MIS bar repair between December 1997 and August 2001 was performed. Information about demographics, deformity, operative course, complications, and early outcome was recorded.

RESULTS

Ninety-two patients underwent MIS repair during this period. Ten patients had redo MIS bar repair for unsatisfactory prior open correction. Operating time was 52 minutes for standard patients and 70 minutes for the redo patients (P <.001). Blood loss and postoperative hospitalization were similar between groups.

CONCLUSION

The minimally invasive pectus repair can be performed safely with minimal blood loss and short operating time in patients who have undergone prior unsatisfactory open repair of pectus excavatum and can be an alternative approach to reoperative open repair in these patients.

Minimally invasive repair of pectus excavatum: a single institution's experience

BACKGROUND

The Nuss repair of pectus excavatum is a relatively new, minimally invasive surgical (MIS) alternative to the traditional open "Ravitch-type" operation. We have one of the larger single-center experiences to date, and we conducted this clinical study to evaluate our early experience, emphasizing initial outcome and technical modifications designed to minimize complications.

METHODS

A retrospective chart review was performed on 112 patients who underwent 116 pectus excavatum repairs between January 1995 and January 2001. The Nuss procedure was performed in 80 patients, and open repair was performed in 32 patients. Information about demographics, deformity, operative course, complications, and early outcome was recorded.

RESULTS

Operative duration was 143 minutes for the open group and 53 minutes for the Nuss MIS group (P <.001). Blood loss was 6 mL/kg for the open group and 0.5 mL/kg for the MIS group (P <.001). Postoperative hospitalization was 3.2 days for the open group versus 3.7 days for the MIS group (P<.05).

CONCLUSIONS

The MIS pectus repair can be performed safely with minimal blood loss and reduced operative time. Short-term analysis of the quality of repair, including absence of preoperative symptoms, patient satisfaction, and cosmetic appearance are encouraging.

Raspberry leaf in pregnancy: its safety and efficacy in labor

OBJECTIVE

Many women consume the raspberry leaf herb during their pregnancies in the belief that it shortens labor and makes labor "easier."

METHODOLOGY

Because of the paucity of research regarding this herb, particularly in relation to pregnancy and birth, the authors undertook a double-blind, randomized, placebo-controlled trial. The sample consisted of 192 low-risk, nulliparous women who birthed their babies between May 1999 and February 2000 at a large tertiary-level hospital in Sydney, Australia. The aim of the study was to identify the effect and safety of raspberry leaf tablets (2 x 1.2 g per day), consumed from 32 weeks' gestation until labor, on labor and birth outcomes.

RESULTS

Raspberry leaf, consumed in tablet form, was found to cause no adverse effects for mother or baby, but contrary to popular belief, did not shorten the first stage of labor. The only clinically significant findings were a shortening of the second stage of labor (mean difference = 9.59 minutes) and a lower rate of forceps deliveries between the treatment group and the control group (19.3% vs. 30.4%). No significant relationship was found between tablet consumption and birth outcomes.

CONCLUSION

The lack of significant differences between the groups on measures expected to demonstrate the effect of raspberry leaf ingestion during pregnancy on labor prompted consideration of the issue of effectiveness of dosage level. Suggestions for further research are offered.

Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria

BACKGROUND

Clinically abnormal retinal vessels unique to cerebral malaria have previously been shown to be associated with a poor outcome in African children. There have been no studies of the histopathological correlates of these vessels.

DESIGN

This is a descriptive study of the clinical-histopathological correlates of the retinal vessels of 11 children who died with cerebral malaria.

RESULTS

The retinal vessels in children with cerebral malaria contained many parasitized red blood cells; these cells tended to cluster at the periphery of vessels or, in the case of capillaries, to fill the vessel. Those with late-stage parasites had markedly reduced amounts of hemoglobin. The pattern of dehemoglobinization corresponds to the pattern of clinically abnormal vessels.

CONCLUSIONS

The sequestration of late-stage parasitized red blood cells with reduced amounts of hemoglobin accounts for the unique white and pale orange retinal vessels seen in cerebral malaria. Clinical examination of these "marked" vessels offers a method to monitor a basic pathophysiological process of cerebral malaria in vivo. Arch Ophthalmol. 2000;118:924-928

Inhibition of 5-lipoxygenase-activating protein (FLAP) reduces pulmonary vascular reactivity and pulmonary hypertension in hypoxic rats

Chronically elevated shear stress and inflammation are important in hypertensive lung vessel remodeling. We postulate that 5-lipoxygenase (5-LO) is a molecular determinant of these processes. Immunohistology localized the 5-LO to macrophages of normal and chronically hypoxic rat lungs and also to vascular endothelial cells in chronically hypoxic lungs only. In situ hybridization of normal and chronically hypoxic lungs demonstrated that 5-LO mRNA is expressed in macrophages. Rats hypoxic for 4 wk-developed pulmonary hypertension increased translocation of the lung 5-LO from the cytosol to the membrane fraction and increased levels of lung tissue 5-lipoxygenase-activating protein (FLAP). A FLAP ligand, 3-[l-(4-chlorobenzyl)-3-t-butyl-thio-t-isopropylindol-2-yl]-2,2- dimethylpropanoic acid (MK-886), inhibited the acute angiotensin II and hypoxia-induced pulmonary vasoconstriction in vitro and the development of chronic hypoxic pulmonary hypertension in rats in vivo. Mice bred with the deletion of the 5-LO enzyme (5-LO knockout) developed less right heart hypertrophy than age-matched 5-LO competent mice. Our results support the hypothesis that the 5-LO is involved in lung vascular tone regulation and in the development of chronic pulmonary hypertension in hypoxic rodent models.

An economic analysis of two models of hospital care for AIDS patients: implications for hospital discharge planning

The development of cost effective models of hospital care and discharge planning for people with HIV is a vital policy issue. However, almost no data exist evaluating cost and quality differences in alternate hospital models of care. This empirical study retrospectively evaluates social work discharge planning for patients with HIV disease in two hospital care models: a cluster AIDS unit and general inpatient site beds. The independent effect of each hospital model of care on length of stay is assessed in a multivariate analysis, controlling for level of care needs and other social and clinical factors. Results reveal that the cluster AIDS unit, where a specialized AIDS social work staff works in collaboration with the interdisciplinary AIDS team, is associated with a significant reduction in hospital length of stay for persons with HIV disease and complex discharge planning needs. These results support the hypothesis that discharge planning services, performed by specialized social workers, are a cost effective investment for hospitals treating patients with complex chronic conditions, such as AIDS. Further research should be developed to systematically evaluate the cost effectiveness of hospital-based social workers, using prospective experimental designs, in order to establish the net impact of social work discharge planning services on patient and family outcomes and institutional and social costs.

Bryostatin 1, a novel antineoplastic agent and protein kinase C activator, induces human myalgia and muscle metabolic defects: a 31P magnetic resonance spectroscopic study

Bryostatin 1, a novel antineoplastic agent and protein kinase C (PKC) activator, has been found to induce myalgia (muscle pain) 48 h after administration in clinical trials. This is the dose-limiting toxicity and has restricted the duration of therapy in phase I trials. To investigate the mechanisms and try to increase toleration of the drug, we studied calf muscle metabolism of 14 patients at rest and during exercise and subsequent recovery using 31P magnetic resonance spectroscopy (MRS) before and 4 h, 48-72 h and 1-2 weeks following bryostatin therapy. In resting muscle there was a significant (P < 0.001) increase in the phosphodiester/adenosine 5'-triphosphate (PDE/ATP) ratio 48 h post bryostatin and in patients with myalgia compared with pre-bryostatin control studies. Following exercise, patients with myalgia showed significantly slower phosphocreatine (PCr) and ADP recovery half-time (P < or = 0.05) suggesting impaired mitochondrial (oxidative) energy production, possibly due to a direct effect on the mitochondria or secondary to reduced blood flow. The apparent proton efflux rate following exercise was significantly reduced 4 h after bryostatin (P < or = 0.05), suggesting reduced blood flow. The rate of post-exercise reoxygenation was studied in four patients by near-infrared spectroscopy 4 h post bryostatin. In three of these the rate was reduced, consistent with reduced muscle blood flow. Bryostatin 1 appeared to cause a long-lasting impairment of oxidative metabolism and proton washout from muscle, consistent with a vasoconstrictive action. Thus these studies provide evidence for two mechanisms of the dose-limiting toxicity for bryostatin. Prospective studies on the use of vasodilators to improve the tolerance of the drug should be carried out.

Tuberculosis and AIDS: the impact on the hospital social worker

The second decade of the AIDS epidemic is marked by increasing numbers of people being diagnosed with HIV infection as well as mycobacterium infection (pulmonary tuberculosis). The convergence of these two epidemics presents new challenges for social workers. Serious threat of HIV infection from occupational exposure was diminished by the knowledge of roots of disease transmission. TB, on the other hand, is an airborne infectious disease. Social workers working with patients over long periods of time in confined spaces can be at risk for contracting TB. Hospital social workers must struggle and advocate for full information regarding the incidence of risk and risk precaution. They must find ways of coping with their own emotional responses to the resurgence of TB and their own fear of exposure to avoid physical and emotional withdrawal from their HIV infected patients. This paper will address the unique impact on the worker's personal safety, the impact on the therapeutic relationship with the patient, and provide action steps for workers facing these challenges.

The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications

It is well accepted that breastfeeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own efficacious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate breastfeeding practices to prolong lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.

Survival bonding: a response to stress and work with AIDS

There is ample literature describing the ongoing stressors and tremendous emotional impact on health care professionals caring for patients with AIDS. This paper is a report of a research study which explored collegial relationships and staff retention to determine factors that reduced staff burnout. The study explored an observed phenomenon of pairing among staff members of various disciplines, working with patients with AIDS, in a tertiary care hospital. The authors called this phenomenon "survival bonding." These informal but intense relationships offered staff a mutually supportive environment which reduced their anxiety, stress, and helped prevent burnout. Given the growing volume of HIV infected persons, and the increased work load of many health care professionals in the aids field, it is important to understand the complex emotional and social support needs of staff to prevent burnout and to improve staff recruitment and retention.

Release of cholecystokinin from rat midbrain slices and modulatory effect of D2DA receptor stimulation

Cholecystokinin octapeptide (CCK-8) is colocalized within a majority of dopamine (DA)-containing neurons of the rat midbrain. Exogenous CCK-8 can modulate the electrophysiological activity of DA neurons, at least in part, by direct actions on the somatodendritic region of these cells. If CCK-8 is somatodendritically released from DA neurons, it may influence DA cell function as has been shown for DA itself. In the present study, radioimmunoassay was used to determine if CCK-8 is released in vitro from slices of rat midbrain under basal and depolarizing (30 mM potassium) conditions. Low levels of CCK-8 were detected in the basal incubation medium. Thirty mM potassium caused about a 3-fold increase in the release of CCK-8. This stimulated release was abolished in calcium-free medium. The D2 receptor agonist quinpirole, but not the D1 agonist SKF 38393, attenuated the potassium-stimulated release of CCK-8 but did not affect basal release. These results show that CCK-8, like DA, can be released from midbrain slices, presumably from DA/CCK-8-containing neurons. This finding is in accordance with the possibility that CCK-8 plays a role in the regulation of DA neuronal function at the level of the cell body, where it might influence the excitability of the DA cell membrane.

Uterine sarcoma: steroid receptors and response to hormonal therapy

Seventy-three patients with uterine sarcomas were treated between 1976 and 1987. Steroid receptors were analyzed in 60 cases; 48% were estrogen receptor (ER) positive, and 30% progesterone receptor (PR) positive. Only 1 of 28 patients with residual or recurrent disease showed a response to hormonal therapy. Neither receptor status of the primary tumor nor use of adjuvant hormonal therapy affected survival.