Sexual Dysfunctions, Psychological

性功能障碍,心理
  • 文章类型: Journal Article
    为了确定育龄妇女的性功能障碍,并考察其与压力应对方式的关系。
    方法:横截面,描述性研究于2019年2月至6月在安卡拉Gulhane培训研究医院的妇产科门诊进行,Turkiye.样本包括年龄在18-49岁之间的已婚妇女,她们在前一个月有活跃的性生活,既没有怀孕也没有产后阶段。数据是使用女性性功能指数收集的,和应力应对样式比例。数据采用SPSS22进行分析。
    结果:共有216名女性,平均年龄33.58±6.77岁。女性性功能指数平均得分为22.29±6.08。平均压力应对方式量表子量表得分为:自信20.71±3.53,无助18.07±4.27,顺从12.13±3.00,乐观13.70±2.35,寻求社会支持11.89±2.01。女性性功能指数总分为阳性,与自信心(r=0.15;p=0.03)和寻求社会支持分量表(r=0.18;p=0.01)显着相关,与压力应对方式量表的顺从子量表(r=-0.17;p=0.02)显着相关。
    结论:在女性中建立对性功能障碍的认识并改善有效的应对方式可能有助于改善女性的性健康。
    UNASSIGNED: To identify sexual dysfunction in married women of reproductive age, and to examine its relationship with stress coping styles.
    METHODS: The cross-sectional, descriptive study was conducted between February and June 2019 at the obstetrics and gynaecology outpatient clinic of Gulhane Training and Research Hospital in Ankara, Turkiye. The sample comprised married women aged 18-49 years who had an active sexual life over the preceding month, and were neither pregnant nor in the postpartum phase. Data was collected using the Female Sexual Function Index, and the Stress Coping Styles Scale. Data was analysed using SPSS 22.
    RESULTS: There were 216 women with mean age 33.58±6.77 years. The mean Female Sexual Function Index score was 22.29±6.08. The mean Stress Coping Styles Scale subscale scores were: self-confident 20.71±3.53, helpless 18.07±4.27, submissive 12.13±3.00, optimistic 13.70±2.35, and seeking social support 11.89±2.01. The total Female Sexual Function Index score had a positive, significant correlation with self-confidence (r=0.15; p=0.03) and seeking social support subscales (r=0.18; p=0.01) and a negative, significant correlation with submissive subscale (r=-0.17; p=0.02) of the Stress Coping Styles Scale.
    CONCLUSIONS: Establishing awareness among women about sexual dysfunction and improving effective coping styles may contribute to improved sexual health among women.
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  • 文章类型: Journal Article
    背景:虽然一些证据表明L-精氨酸可以改善性功能和缓解抑郁症,尚未在患有抑郁症的女性中进行调查,以同时评估其对抑郁症和性功能的影响。
    方法:被诊断为重度抑郁症的患者,根据预定的纳入和排除标准确定,参加了这项三盲临床试验。患者分为两组:A组,每天两次服用L-精氨酸1克,B组,服用安慰剂4周。他们在基线时进行了评估,在使用汉密尔顿抑郁量表(HDRS)进行四周和八周后,和罗森的问卷或女性性功能指数(FSFI)。
    结果:在所有患者中观察到抑郁症的严重程度有所下降,这是根据汉密尔顿的问卷确定的(P值<0.001)。在A组的时间里,FSFI增加。根据FSFI问卷,他们在某些领域有所改善,包括润滑指数和性高潮指数,与基线相比,第8周显着变化(P值<0.05)。然而,与安慰剂组相比,这两项指标无统计学差异.
    结论:补充L-精氨酸可以改善性功能,特别是润滑和性高潮,抑郁症女性的情绪,观察到最小的副作用。额外的研究是必要的,以验证这些结果,通过检查更高的剂量的影响,延长的持续时间,和更多的抑郁症患者。
    背景:伊朗临床试验注册:IRCT20100127003210N26。
    BACKGROUND: While some evidence suggests that l-arginine may improve sexual function and alleviate depression, it has not been investigated in women with depression to assess both its effects on the depression and sexual function concurrently.
    METHODS: Patients who had received a diagnosis of major depressive disorder, as determined by predetermined inclusion and exclusion criteria, were enrolled in this triple-blind clinical trial. Patients were divided into two groups: group A, received L-arginine 1 gram twice daily, and group B, received a placebo for four weeks. They were evaluated at baseline, after four and eight weeks with the Hamilton Depression Rating Scale (HDRS), and Rosen\'s questionnaire or Female Sexual Function Index (FSFI).
    RESULTS: A decrease in the severity of depression was observed in all patients, which was determined due to Hamilton\'s questionnaire (P-value < 0.001). During the time in group A, FSFI increased. Based on the FSFI questionnaire, they had improvement in some domains, including the lubrication index and orgasm index, which significantly changed in the eighth week compared to the baseline (P-value < 0.05). However, these two indicators did not change statistically significantly compared to the placebo group.
    CONCLUSIONS: L-arginine supplementation can improve sexual function, particularly lubrication and orgasm, and mood in women with depression, with minimal side effects observed. Additional research is necessary to validate these results by examining the effects of higher dosages, extended durations, and larger populations of depressed patients.
    BACKGROUND: Iranian Registry of Clinical Trial: IRCT20100127003210N26.
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  • 文章类型: Journal Article
    背景:女性糖尿病并发症对她们的自我形象有不良影响,生活质量,健康,和其他社会关系,从而导致性功能障碍。产妇护士护理可以在评估性健康需求知识方面发挥关键作用。
    目的:本研究旨在评估咨询模式对女性糖尿病患者性功能障碍的影响。
    方法:在2家医院的糖尿病和产科门诊诊所(AlSalamPortSaidGeneralHospital,Elzohor总医院),在塞得港市的五个中心(El-KuwaitCenter,奥斯曼·伊布纳凡中心,阿拉伯一号中心,El-manakh中心,El-arab2中心)。该研究包括178名女性糖尿病患者的目的样本。使用了两种工具收集数据,包括:(1份访谈问卷),包括个人特征,病史,并提出了被研究的女性患者的性问题,(和2个女性性功能指数(FSFI)。
    结果:当前的研究表明,与教育前干预措施的平均值±SD(19.5±3.7)相比,女性性功能在平均±SD(23.3±4.1)之间存在很大的统计学差异。而在女性性功能指数方面,程序前和程序后应用之间存在高度统计学上的显着差异(p>0.001)。
    结论:咨询模式对改善女性糖尿病患者性功能有积极作用。
    研究方案由护理学院研究伦理委员会批准,塞得港大学(代码:NUR12/9/2021-6)。
    BACKGROUND: Complications of diabetes in women have adverse effects on their self-image, quality of life, health, and other social relationships, thereby leading to sexual dysfunction. maternity nurse care can play a critical role in assessing the knowledge about needs for sexual health.
    OBJECTIVE: The present study aims to evaluate the effect of the counseling model on female patients with diabetes regarding sexual dysfunction.
    METHODS: A quasi-experimental research design was used to conduct the study at the diabetic and obstetric outpatient clinic in 2 hospitals (Al Salam Port Said General Hospital, Elzohor General Hospital), and in five centers in Port Said City (El-Kuwait Center, Othman Ibnafan Center, El-arab 1 center, El-manakh center, El-arab2 center). A purposive sample of 178 female diabetic patients was included in the study. Two tools were used for collecting data consisted of; (1 interview questionnaire sheet) including personal characteristics, medical history, and present sexual problem of the studied female patients, (and 2 female sexual function index (FSFI).
    RESULTS: the current study revealed that there was a high statistical difference between female sexual function in post with mean ± SD (23.3 ± 4.1) compared to pre-educational intervention with mean ± SD (19.5 ± 3.7), while there was a high statistically significant difference among pre- & post-program application regarding female sexual function index (p > 0.001).
    CONCLUSIONS: the counseling model had a positive effect in improving the sexual function among female patients with diabetes.
    UNASSIGNED: The study protocol was approved by the Research Ethics Committee of the Faculty of Nursing, Port Said University (code number: NUR 12/9/2021-6).
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  • 文章类型: Journal Article
    随着人们对开发用于治疗性功能障碍的数字健康工具的兴趣日益浓厚,这项初步研究旨在确定社区样本(N=57)中针对女性低性欲的自我主导的在线正念干预与在线心理教育干预的可行性,并收集初步疗效数据.经过四周的干预,参与者表现出性功能的整体改善,性高潮,性自我愉悦,性自我形象,和性困扰,在两个治疗臂中。大多数人完成了分配的作业,并认为干预可以增强他们的性生活。这项研究支持自我引导的在线正念干预的可行性,该干预可以帮助为未来的计划提供信息。
    With growing interest in developing digital health tools for treating sexual dysfunction, this pilot study aimed to determine feasibility and gather preliminary efficacy data of a self-led online mindfulness intervention in comparison to an online psychoeducational intervention for women\'s low sexual desire in a community sample (N = 57). After a four-week intervention, participants showed overall improvements on sexual functioning, orgasm, sexual self-pleasure, sexual self-image, and sexual distress, in both treatment arms. Majority completed assigned homework and felt the intervention enhanced their sexual well-being. This study supports the feasibility of a self-led online mindfulness intervention that could help inform future programs.
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  • 文章类型: Journal Article
    目的:确定糖尿病预防计划(DPP)结果研究(DPPOS)中糖尿病前期(PreD)和2型糖尿病(T2D)女性性功能障碍(FSD)的负担和相关性。
    方法:DPPOS访视包括女性性功能指数(FSFI)以确定性功能。在1464名参与者中,1320(90%)完成了(FSFI),426人有性活跃。反向选择多变量逻辑回归模型估计了社会人口统计学的FSD几率,临床,和糖尿病相关协变量。
    结果:一百八十五(43%)的得分为≤26.55,符合FSD的标准。在调整DPP治疗和年龄后,尿失禁(UI)(比值比[OR]=1.91,95%可信区间[CI]=1.15~3.17)和子宫切除术(OR=1.89,95%CI=1.01~3.53)与FSD的比值增加相关.体重指数增加对FSD具有保护作用(OR=0.93/kg/m2,95%CI=0.89-0.96)。密歇根神经病筛查基于仪器的周围神经病变(平均值±SD评分1.1±1.3vs.0.9±1.1,p<0.0001)和基于心电图(ECG)的自主神经功能障碍测量(平均±SD心率水平64.3±6.8vs.65.6±10.2,p=0.008)与FSD相关。有糖尿病(66.5%)和没有(66%)的女性之间的糖尿病发生率没有差异(p=0.7)。
    结论:FSD在患有PreD和T2D的女性中普遍存在。我们的发现表明,FSD与PreD和T2D中常见的神经病性并发症有关。
    OBJECTIVE: To determine the burden and identify correlates of female sexual dysfunction (FSD) among women with prediabetes (PreD) and type 2 diabetes (T2D) enrolled in the Diabetes Prevention Program (DPP) Outcomes Study (DPPOS).
    METHODS: The DPPOS visit included the Female Sexual Function Index (FSFI) to determine sexual function. Of 1464 participants, 1320 (90%) completed the (FSFI) and 426 were sexually active. A backward selection multivariable logistic regression model estimated the odds of FSD for sociodemographic, clinical, and diabetes-related covariates.
    RESULTS: One hundred and eighty-five (43%) had a score of ≤26.55 and met the criteria for FSD. After adjustment for DPP treatment and age, urinary incontinence (UI) (odds ratio [OR] = 1.91, 95% confidence interval [CI] = 1.15-3.17) and hysterectomy (OR = 1.89, 95% CI = 1.01-3.53) were associated with increased odds of FSD. Increased body mass index was protective for FSD (OR = 0.93 per kg/m2, 95% CI = 0.89-0.96). Michigan Neuropathy Screening Instrument-based peripheral neuropathy (mean±SD scores 1.1±1.3 vs. 0.9±1.1, p < 0.0001) and Electrocardiogram (ECG)-based autonomic dysfunction measures (mean ± SD heart rate levels 64.3 ± 6.8 vs. 65.6 ± 10.2, p = 0.008) were associated with FSD. There were no differences in diabetes rates between women who did (66.5%) and did not (66%) have (p = 0.7).
    CONCLUSIONS: FSD is prevalent in women with PreD and T2D. Our findings suggest that FSD is associated with neuropathic complications commonly observed in PreD and T2D.
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  • 文章类型: Journal Article
    泰国女性性功能指数歧视使用新的精神疾病诊断和统计手册,第五版,尚未调查文本修订标准。这项研究旨在评估女性性功能指数作为评估性症状的工具,并使用新的《精神障碍诊断和统计手册》确定泰国女性性功能障碍的患病率,第五版,文本修订标准。这项前瞻性横断面诊断研究包括年龄≥18岁的性活跃女性,2023年1月至6月接受采访。参与者完成了泰语版的女性性功能指数综合问卷,包括一般信息和自我报告的女性性功能评估,随后是痛苦症状严重程度的半结构化访谈。女性性功能是通过筛查女性性功能指数总分来确定的,而女性性功能障碍是使用精神疾病诊断和统计手册进行评估的,第五版,文本修订标准。使用接收器工作特性曲线,女性性功能指数评分23.1的临床截止值被确定为识别女性性功能障碍(曲线下面积,0.76;95%置信区间,0.71-0.80;灵敏度,75.6%;特异性,67.7%;阳性预测值,77.7%;阴性预测值,65%)。在研究人群中观察到女性性功能障碍的患病率为40.2%。本研究结果可作为今后泰国女性性功能障碍女性筛查的实践指导。
    Thai Female Sexual Function Index discrimination using the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria has not been investigated. This study aimed to evaluate the Female Sexual Function Index as a tool for assessing sexual symptoms and to determine the prevalence of female sexual dysfunction in Thai women using the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria. This prospective cross-sectional diagnostic study included sexually active women aged ≥18 years, interviewed from January to June 2023. The participants completed the Thai version of a comprehensive of the Female Sexual Function Index questionnaire encompassing general information and self-reported assessments of female sexual function, followed by a semi-structured interview of distress symptom severity. Female sexual function was determined by screening of the total Female Sexual Function Index score, whereas female sexual dysfunction was evaluated using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria. Using receiver operating characteristic curves, a clinical cutoff for the Female Sexual Function Index score of 23.1 was determined to identify female sexual dysfunction (area under the curve, 0.76; 95% confidence interval, 0.71-0.80; sensitivity, 75.6%; specificity, 67.7%; positive predictive value, 77.7%; negative predictive value, 65%). A prevalence of 40.2% for female sexual dysfunction was observed in the study population. The results of this study could be used as practical guidance for the screening of women affected by female sexual dysfunction in Thailand in the future.
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  • 文章类型: Journal Article
    背景:在临床实践中经常观察到痴呆的心理和行为症状,那些与性有关的问题尤其具有挑战性。然而,很少有研究评估痴呆患者性欲亢进的患病率或相关因素.
    目的:本研究旨在确定痴呆患者性欲亢进的患病率,描述相关因素,定性报告最常见的介绍和治疗。
    方法:这项回顾性横断面研究收集了2015年至2019年在二级护理参考中心随访的痴呆症患者的半结构化图表数据。结果:552例患者中,52(9.3%)性欲过高,与男性相关(P<.000;OR2.95,95%CI1.73-5.01),额颞叶痴呆(P<.007),酒精使用(P<.015;OR2.35,95%CI1.16-4.73)和烟草使用(P<.000;OR2.88,95%CI1.61-5.13)。
    结论:尽管我们的发现与文献相似,它们的显著可变性反映了现有证据的有限和低质量,以及缺乏关于术语的标准化,定义,和性欲亢进的诊断标准。
    BACKGROUND: The psychological and behavioral symptoms of dementia are frequently observed in clinical practice, and those related to sexuality are particularly challenging. However, few studies have evaluated the prevalence or factors associated with hypersexuality in patients with dementia.
    OBJECTIVE: This study aims to determine the prevalence of hypersexuality in patients with dementia, describe associated factors, and qualitatively report the most common presentations and treatments.
    METHODS: This retrospective cross-sectional study collected data from semi-structured charts of dementia patients who were followed up at a secondary care reference center between 2015 and 2019. Results: Of 552 total patients, 52 (9.3%) were hypersexual, which was associated with male sex (P < .000; OR 2.95, 95% CI 1.73-5.01), frontotemporal dementia (P < .007), alcohol use (P < .015; OR 2.35, 95% CI 1.16-4.73) and tobacco use (P < .000; OR 2.88, 95% CI 1.61-5.13).
    CONCLUSIONS: Although our findings were similar to the literature, their significant variability reflects the limited and low quality of the available evidence and a lack of standardization regarding terminology, definitions, and diagnostic criteria for hypersexuality.
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  • 文章类型: Journal Article
    乳腺癌治疗导致身体和心理变化。这项研究的目的是分析诊断为乳腺癌的女性中性功能障碍的发生率及其危险因素。这项回顾性队列研究包括诊断和治疗乳腺癌的女性(暴露组,n=90)和健康女性(非暴露组,n=93)。数据是从2019年2月到2021年10月在北里奥格兰德州(巴西东北部)收集的,从医疗记录和使用女性性功能指数(FSFI)问卷。数据来自医疗记录,并使用女性性功能指数(FSFI)问卷。使用二元逻辑回归分析主要结果。Mann-Whitney检验用于分析组间的FSFI结构域。与非暴露组相比,暴露组的性功能障碍发生率为74%,发生性功能障碍的几率增加了3.9倍(OR3.9,CI1.8至8.2,p<0.001)。合并症的存在使性功能障碍的机会增加了2.5倍(OR2.5,CI1.2至4.9,p=0.009)。诊断和治疗乳腺癌的女性性功能障碍的发生率高于健康女性。此外,无论是否接触乳腺癌,合并症也会增加性功能障碍的机会。
    Breast cancer treatment leads to physical and psychological changes. The aim of this study was to analyze the incidence of sexual dysfunction and its risk factors in women diagnosed with breast cancer. This retrospective cohort study included women diagnosed and treated for breast cancer (exposed group, n = 90) and healthy women (non-exposed group, n = 93). Data were collected from February 2019 to October 2021 in the state of Rio Grande do Norte (Northeast Brazil), from medical records and using the Female Sexual Function Index (FSFI) questionnaire. Data were collected from medical records and using the Female Sexual Function Index (FSFI) questionnaire. Primary outcomes were analyzed using binary logistic regression. The Mann-Whitney test was used to analyze FSFI domains between groups. The exposed group had a 74% incidence of sexual dysfunction and 3.9 times increased chances of having sexual dysfunction compared with the non-exposed group (OR 3.9, CI 1.8 to 8.2, p < 0.001). Presence of comorbidities increased the chances of sexual dysfunction by 2.5 times (OR 2.5, CI 1.2 to 4.9, p = 0.009). Women diagnosed and treated for breast cancer had a higher incidence of sexual dysfunction than healthy women. Furthermore, comorbidities also increased the chances of sexual dysfunction regardless of exposure to breast cancer.
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  • 文章类型: Journal Article
    进行了一项混合方法研究,以调查首次接受药物辅助生殖的不育患者的性功能。这项研究采用了访谈和内容分析的方法,涉及45名不育患者在接受医学辅助生育程序之前。研究结果表明,不育患者是存在性困扰风险的群体。此外,性功能障碍患者的性活动水平较低,可能会降低他们怀孕的机会。参与者在公开讨论他们的性问题时面临挑战,并且对性功能的了解有限。在有性功能障碍的不育女性中,最常报告的问题是性兴趣/唤起障碍,大多数人在性活动期间也经历疼痛和相关的生殖器盆腔疼痛疾病。相比之下,延迟射精和勃起障碍似乎在不育男性中更常见,而性欲和兴奋障碍和早泄障碍似乎与普通人群一样普遍。虽然不育和性行为之间的关系很复杂,我们的研究表明,性功能障碍或缺乏性活动可能解释不孕症。因此,临床医生必须评估接受医学辅助生殖治疗的男性和女性的性功能,增加他们生育的机会,并在需要时为他们提供性支持。未来的研究应扩大其范围,以包括更大的样本量,并深入研究与性功能障碍相关的潜在病因。
    A mixed-methods study was conducted to investigate sexual function among infertile patients undergoing medically assisted procreation for the first time. The study employed an interview and content analysis approach, involving 45 infertile patients prior to their medically assisted procreation procedures. The findings revealed that infertile patients are a group at risk for sexual distress. Furthermore, patients with sexual dysfunctions exhibited lower levels of sexual activity, potentially diminishing their chances of achieving pregnancy. Participants faced challenges in openly discussing their sexual problems and demonstrated limited knowledge of sexual functioning. Among infertile women with sexual dysfunctions, the most frequently reported issues were sexual interest/arousal disorders, with a majority also experiencing pain during sexual activity and associated genital-pelvic pain disorders. In contrast, delayed ejaculation and erectile disorder seem to be more common in infertile men, while sexual desire and excitement disorders and premature ejaculation disorders appeared to be as common as in the general population. While the relationship between infertility and sexuality is complex, our study suggests that sexual dysfunctions or the absence of sexual activity may explain infertility. Therefore, it is imperative for clinicians to evaluate the sexual functioning of both men and women undergoing medically assisted procreation treatment, to increase their chances of procreation and offer them sexological support if needed. Future studies should expand their scope to include a larger sample size and delve into the potential etiological factors associated with sexual dysfunctions.
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  • 文章类型: Journal Article
    背景:中风后疾病综合征(POIS)是一种罕见的综合征,患者在射精后会出现各种身体和认知症状,其病理生理学仍然未知。
    目的:本研究的目的是表征临床表现,病程,和门诊患者的治疗结果,以及检查POIS的初步标准和症状群的有效性。
    方法:这项回顾性单中心研究是在神经内科进行的,患者包括2010年至2023年。诊断标准和症状群描述基于先前的研究。
    结果:该研究集中于POIS的临床特征,进行的补充测试,尝试的治疗方法,和他们的有效性。
    结果:37名男性被纳入研究,症状发生在平均±SD年龄23.6±7.4岁。从射精到症状发作的平均时间为1小时22分钟±3小时42分钟。症状的平均持续时间为4.7±3.4天。17名患者(46%)主要出现症状,而在20(54%)中,它们是次要出现的。19例患者(51%)符合所有初步标准。在所有37例患者中,最常见的症状群是“一般”(100%;例如,虚弱和注意力不集中)和35例患者的“头”(95%;主要是头痛和雾状)。在治疗方面,我们尝试了抗组胺药和非甾体类抗炎药,部分改善了部分患者的症状.
    结论:这项研究有助于通过指定最常见的症状并将其与初始标准进行比较来进一步表征POIS。
    据我们所知,这是咨询提示POIS症状的最大患者队列之一.由于数据收集的回顾性性质,存在局限性,如数据缺失和治疗效果不精确。
    结论:大多数参与者至少符合3项初步诊断标准,大多数症状在一般和头部集群。然而,根据疾病的类型确定治疗反应的预测因素仍有待确定。
    Postorgasmic illness syndrome (POIS) is a rare syndrome in which patients experience various physical and cognitive symptoms after ejaculation, and its pathophysiology remains unknown.
    The aim of this study was to characterize the clinical presentations, disease course, and treatment outcomes in outpatients, as well as to examine the validity of the preliminary criteria and symptom clusters of POIS.
    This retrospective monocentric study was conducted in a neurourology department, with patients included from 2010 to 2023. The diagnostic criteria and symptom cluster descriptions were based on previous studies.
    The study focused on the clinical features of POIS, the complementary tests performed, the treatments tried, and their effectiveness.
    Thirty-seven men were included in the study, with symptom onset occurring at a mean ± SD age of 23.6 ± 7.4 years. The mean time from ejaculation to symptom onset was 1 hour 22 minutes ± 3 hours 42 minutes. The mean duration of symptoms was 4.7 ± 3.4 days. Seventeen patients (46%) developed the symptoms primarily, whereas in 20 (54%) they appeared secondarily. All preliminary criteria were met in 19 patients (51%). The most common symptom clusters were \"general\" in all 37 patients (100%; eg, asthenia and concentration difficulties) and \"head\" in 35 patients (95%; mostly headache and a foggy feeling). In terms of treatments, antihistamines and nonsteroidal anti-inflammatory drugs were tried and partially improved symptoms for some patients.
    This study helps to further characterize POIS by specifying the most frequent symptoms and comparing them with the initial criteria.
    To our knowledge, this is one of the largest cohorts of patients consulting for symptoms suggestive of POIS. There are limitations due to the retrospective nature of the data collection, such as missing data and imprecision of treatment efficacy.
    The majority of participants met at least 3 of the preliminary diagnostic criteria, with a majority of symptoms in the general and head clusters. However, the determination of predictive factors for treatment response based on the typology of the disorders remains to be established.
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