<div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1053476767" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{10}"><span data-contrast="auto" xml:lang="EN-US" lang="EN-US" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Myocardial bridging<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">(MB)<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">is independently associated with epicardial spasm during standardized<span> </span></span></span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">acetylcholine</span><span class="NormalTextRun SCXW261131747 BCX0">-base</span><span class="NormalTextRun SCXW261131747 BCX0">d</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>vasomotor function</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>testing</span><span class="NormalTextRun SCXW261131747 BCX0">, according to a new database study.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1460187422" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{12}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">“</span><span class="NormalTextRun SCXW261131747 BCX0">The present data from the largest database available investigating hemodynamic changes following acetylcholine support routine consideration of provocation testing when myocardial bridging is identified and may help refine invasive<span> </span></span><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">endotyping</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>pathways and personalised therapy</span><span class="NormalTextRun SCXW261131747 BCX0">,”<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">wrote</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>the researchers, led by<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">Robert Sykes</span><span class="NormalTextRun SCXW261131747 BCX0">,</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>MBChB,</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>from the University of Glasgow, UK, and</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>Meriam El-Hirch</span><span> </span><span class="NormalTextRun SCXW261131747 BCX0">MD,</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>from<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">the<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">University Medical<span> </span></span><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">Center</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>Mainz</span><span class="NormalTextRun SCXW261131747 BCX0">, Germany.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="602817924" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{14}"><span class="NormalTextRun SCXW261131747 BCX0">The findings were published Tuesday online ahead of print in<span> </span></span><em><span class="NormalTextRun SCXW261131747 BCX0">JACC: Cardiovascular Interventions</span></em><span class="NormalTextRun SCXW261131747 BCX0">.</span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1910673624" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{16}"><span class="NormalTextRun SCXW261131747 BCX0">MB is a condition whereby part of the epicardial coronary artery runs through heart muscle instead of over it, most commonly the mid-left anterior descending artery, the researchers noted. This results in systolic compression and dynamic luminal narrowing.</span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="51851955" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{18}"><span class="NormalTextRun SCXW261131747 BCX0">The condition promotes<span> </span></span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">endothelial injury, smooth muscle hyperreactivity, and accelerated atherosclerosis in adjacent segment</span><span class="NormalTextRun SCXW261131747 BCX0">, they added, highlighting a “plausible link” between MB and abnormal vasoreactivity</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>“which is<span> </span></span></span><a class="Hyperlink SCXW261131747 BCX0" href="https://academic.oup.com/eurheartj/article/45/36/3415/7743115" target="_blank" rel="noreferrer noopener"><span class="NormalTextRun SCXW261131747 BCX0" data-ccp-charstyle="Hyperlink">increasingly recognised</span></a><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>as [a] major cause of angina</span><span class="NormalTextRun SCXW261131747 BCX0">.”</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="2016759192" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{20}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">The current study therefore set out to define whether<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">epicardial spasm triggered during<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">a</span><span class="NormalTextRun SCXW261131747 BCX0">cetylcholine<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">provocation</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>testing of vasomotor function</span><span> </span><span class="NormalTextRun SCXW261131747 BCX0">of patients in</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>the</span><span> </span></span><a class="Hyperlink SCXW261131747 BCX0" href="https://clinicaltrials.gov/study/NCT06125392" target="_blank" rel="noreferrer noopener"><span class="NormalTextRun SCXW261131747 BCX0" data-ccp-charstyle="Hyperlink">Micro-SNAPE</span></a><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span> </span><span class="NormalTextRun SCXW261131747 BCX0">registry<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">was</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>associated with MB.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1389860531" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{22}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">A total 1,</span><span class="NormalTextRun SCXW261131747 BCX0">088 evaluable</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>participants who underwent vasomotor testing in the<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">in the left anterior descending coronary artery</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>as part of the Micro-SNAPE<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">registry</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>were included in the current analysis. </span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="2079600352" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{24}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">The</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>patients</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>were dosed<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">across Germany, Italy</span><span class="NormalTextRun SCXW261131747 BCX0">,</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>the UK,<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">Spain</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>and Canada</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>with<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">a standardized protocol of<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">intravenous</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>adenosine of</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>140</span></span><span class="NormalTextRun SCXW261131747 BCX0">m</span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">g/kg/min or intracoronary</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>adenosine of</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>140-200</span></span><span class="NormalTextRun SCXW261131747 BCX0">m</span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">g bolus</span><span class="NormalTextRun SCXW261131747 BCX0">, followed by<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">intracoronary bolus doses of acetylcholine 2</span></span><span class="NormalTextRun SCXW261131747 BCX0">m</span><span class="NormalTextRun SCXW261131747 BCX0">g, 20</span><span class="NormalTextRun SCXW261131747 BCX0">m</span><span class="NormalTextRun SCXW261131747 BCX0">g, 100</span><span class="NormalTextRun SCXW261131747 BCX0">m</span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">g</span><span class="NormalTextRun SCXW261131747 BCX0">.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1034022589" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{26}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Epicardial coronary spasm was defined as a Pd/Pa</span><span> </span><span class="NormalTextRun SCXW261131747 BCX0">90% coronary diameter reduction with</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>electrocardiogram (ECG) changes and angina during<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">acetylcholine</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>and MB was recorded in 124 (11.3%) patients before the coronary function test when there was a<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">visually appreciable systolic compression of the lumen (>50%) and a consistent diastolic recoil in the same segment on orthogonal projections at physiological heart rates.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="2024196509" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{28}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Those with MB tended to have lower body mass indices (BMI;<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">27±5 vs 28±5, P=0.017</span><span class="NormalTextRun SCXW261131747 BCX0">), were less likely to have heart failure with preserved ejection fraction (EF,<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">2% vs 6%, P=0.022), prior<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">percutaneous coronary intervention (</span><span class="NormalTextRun SCXW261131747 BCX0">PCI</span><span class="NormalTextRun SCXW261131747 BCX0">,<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">8.9% vs 21.8%, P=0.001), hypertension (50% vs 66%, P=0.001) and peripheral vascular disease (1% vs 5%, P=0.036).</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>There was also a slightly higher prevalence of Chinese ethnicity patients in the MB group.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1910941211" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{30}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">The researchers found that MB patients also had lower aortic (P=0.008), distal coronary pressure (P=0.001), Pd/Pa (P<0.001</span><span class="NormalTextRun SCXW261131747 BCX0">)</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>and fractional flow reserve during the adenosine stage of dosing (</span><span class="NormalTextRun SCXW261131747 BCX0">P<0.001).</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1005125953" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{32}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">In response to<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">acetylcholine</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>provocation, a total 189 (17.4%) of the total 1,088 evaluable patients experienced epicardial spasm, more commonly in those with MB (31.1% vs 15.2%; P<0.001). In these cases, it was mostly localized at the MB, the<span> </span></span><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">researchers</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>noted.<span> </span></span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="521824012" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{34}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Conversely, m</span><span class="NormalTextRun SCXW261131747 BCX0">icrovascular spasm during acetylcholine testing was<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">observed</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>in 192</span><span> </span><span class="NormalTextRun SCXW261131747 BCX0">(20.6%)<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">of the overall cohort and was</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>less common in patients with bridging (18.6% vs 21.0%; P=0.009).</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="2013396050" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{36}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">“</span><span class="NormalTextRun SCXW261131747 BCX0">Of the 8 previously<span> </span></span></span><a class="Hyperlink SCXW261131747 BCX0" href="https://academic.oup.com/eurheartj/article/47/5/594/8320199" target="_blank" rel="noreferrer noopener"><span class="NormalTextRun SCXW261131747 BCX0" data-ccp-charstyle="Hyperlink">identified forms</span></a><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>of vasomotor dysfunction, myocardial bridging was more frequent only in the epicardial spasm endotype</span><span class="NormalTextRun SCXW261131747 BCX0">,” the researchers said.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1967013275" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{38}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">A multivariable<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">logistics</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>model analysis in 939 completed cases found that MB remained independently associated with epicardial spasm (odds ratio: 2.59; 95% confidence interval [CI]: 1.62 to 4.16; P<0.001). </span><span class="NormalTextRun SCXW261131747 BCX0">“</span><span class="NormalTextRun SCXW261131747 BCX0">The magnitude of the association between MB and coronary artery spasm was clinically relevant, with myocardial bridging conferring ~13% absolute increase in the probability of spasm after adjustment for cardiovascular risk factors and prior cardiovascular events</span><span class="NormalTextRun SCXW261131747 BCX0">,” the authors wrote.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="45149771" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{44}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">“T</span><span class="NormalTextRun SCXW261131747 BCX0">his evidence supports a mechanistic link between anatomical systolic compression and dynamic vasomotor hyper-reactivity, consistent with prior experimental observations of disturbed shear stress and endothelial dysfunction within bridged s</span><span class="NormalTextRun SCXW261131747 BCX0">egments</span><span class="NormalTextRun SCXW261131747 BCX0">.”</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1916735606" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{47}"><span class="NormalTextRun SCXW261131747 BCX0">The findings support prior smaller<span> </span></span><a class="Hyperlink SCXW261131747 BCX0" href="https://pubmed.ncbi.nlm.nih.gov/40630252/" target="_blank" rel="noreferrer noopener"><span class="NormalTextRun SCXW261131747 BCX0" data-ccp-charstyle="Hyperlink">cohort studies</span></a><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>suggesting an association between MB and epicardial vasospasm, they added. </span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="611533832" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{49}"><strong><span class="NormalTextRun SCXW261131747 BCX0">Sources:</span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></strong></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" paraid="1577010177" paraeid="{ef041cca-8a36-47a4-b2e8-a0b57b0d23b3}{53}"><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Sykes R, El-Hirch M,<span> </span></span><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">Biscaglia</span><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>S, et a</span><span class="NormalTextRun SCXW261131747 BCX0">l.<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">Myocardial Bridging Independently Associates with Coronary Artery Spasm</span><span class="NormalTextRun SCXW261131747 BCX0">.<span> </span></span></span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><em><span class="NormalTextRun SCXW261131747 BCX0">JACC: Cardiovasc </span><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">Interv</span></em><span class="NormalTextRun SpellingErrorV2Themed SCXW261131747 BCX0">.</span></span><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0"><span> </span>2026; DOI:<span> </span></span><span class="NormalTextRun SCXW261131747 BCX0">10.1016/j.jcin.2026.03.026</span><span class="NormalTextRun SCXW261131747 BCX0">.</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></p> </div> <div class="OutlineElement Ltr SCXW261131747 BCX0"> <p class="Paragraph SCXW261131747 BCX0" lang="EN-US" paraid="1792583983" paraeid="{7382a3a7-b11e-4b48-a5a1-7df64f68500c}{78}"><strong><span data-contrast="auto" xml:lang="EN-GB" lang="EN-GB" class="TextRun MacChromeBold SCXW261131747 BCX0"><span class="NormalTextRun SCXW261131747 BCX0">Image Credit: </span><span class="NormalTextRun SCXW261131747 BCX0">Nadezhda Buravleva</span><span class="NormalTextRun SCXW261131747 BCX0"> – stock.adobe.com</span></span><span class="EOP SCXW261131747 BCX0" data-ccp-props="{}"> </span></strong></p> </div>