Do Mesocarnivores Respond to the Seasonality in Management Practices in an Agroforestry Landscape?

In the Mediterranean, we find a mosaic of natural and cultural landscapes, where a variety of forest management practices created intermediate disturbance regimes that potentially increased biodiversity values. Nonetheless, it is essential to understand the species' long-term response to the dynamic management in agroecosystems, since the species tolerance to disturbance can change throughout the life cycle. Mammalian carnivores can be sensitive to human disturbance and are an essential part of ecosystems due to their regulatory and community structuring effects. We investigated the spatial response of five mesocarnivores species to spatially- and temporally- varying management practices in an agroforestry landscape. More specifically, we assessed the mesocarnivores' temporal changes in space use by implementing multi-season occupancy models in a Bayesian framework, using seasonal camera-trapping surveys for a 2-year period. All species had a weak response of local extinction to forestry management and livestock grazing pressure. For forest-dwelling species, occupancy was higher where productivity of perennial vegetation was high, while colonization between seasons was positively associated with vegetation cover. For habitat generalist species, we found that occupancy in the wet season increased with the distance to cattle exclusion plots. Most of these plots are pine stands which are subject to forestry interventions during winter. During the 2-year period we found seasonal fluctuations in occupancy for all species, with an overall slight decrease for three mesocarnivore species, while for the two forest-dwelling species there was an increase in occupancy between years. The weak species response to management practices supports the importance of traditional management for upholding a diverse mesocarnivore community in agroforestry systems but could also reflect these species' ecological plasticity and resilience to disturbance.

In-Hospital Management and Long-term Clinical Outcomes and Adherence in Patients With Acute Decompensated Heart Failure: Primary Results of the First Brazilian Registry of Heart Failure (BREATHE).

BACKGROUND: Heart failure (HF), a common cause of hospitalization, is associated with poor short-term clinical outcomes. Little is known about the long-term prognoses of patients with HF in Latin America. METHODS: BREATHE was the first nationwide prospective observational study in Brazil that included patients hospitalized due to acute heart failure (HF). Patients were included during 2 time periods: February 2011-December 2012 and June 2016-July 2018 SUGGESTION FOR REPHRASING: In-hospital management, 12-month clinical outcomes and adherence to evidence-based therapies were evaluated. RESULTS: A total of 3013 patients were enrolled at 71 centers in Brazil. At hospital admission, 83.8% had clear signs of pulmonary congestion. The main cause of decompensation was poor adherence to HF medications (27.8%). Among patients with reduced ejection fraction, concomitant use of beta-blockers, renin-angiotensin-aldosterone inhibitors and spironolactone decreased from 44.5% at hospital discharge to 35.2% at 3 months. The cumulative incidence of mortality at 12 months was 27.7%, with 24.3% readmission at 90 days and 44.4% at 12 months. CONCLUSIONS: In this large national prospective registry of patients hospitalized with acute HF, rates of mortality and readmission were higher than those reported globally. Poor adherence to evidence-based therapies was common at hospital discharge and at 12 months of follow-up.

Magic mushroom: all is not as it seems.

BACKGROUND: The late adverse effects of radiotherapy are caused by microvascular injury or depletion of differentiated cells. METHODS: Here we describe a clinical case of a late and unusual complication related to radiotherapy, in a patient with a history of squamous cell carcinoma of the anal canal. RESULTS: The patient presented with a large perianal vegetating lesion suspicious of local recurrence, however the biopsy of the lesion did not show malignancy. CONCLUSION: Fortunately, all is not as it seems, and what appeared as a suspected relapse turned out to be a benign reactive lesion, consequence of radiotherapy.

Chagas Cardiomyopathy in Latin America Review.

PURPOSE OF REVIEW: Chagas cardiomyopathy is a major public health disease in Latin America and, due to migration, is becoming a worldwide health and economic burden. This review sought to present the clinical and epidemiological aspects of Chagas cardiomyopathy, as well as some specific features and principles of treatment. We also retrospectively assessed our institutional experience with mechanical circulatory support in refractory heart failure due to Chagas cardiomyopathy over a 10-year period. RECENT FINDINGS: The role of antiparasitic treatment in patients with heart failure due to Chagas cardiomyopathy is controversial. Heart transplantation, although formerly contraindicated, is currently established as an important therapeutic option. Also, the favorable characteristics of Chagas patients, such as younger age, little comorbidity, and no reoperations or severe pulmonary hypertension, could be an advantage for a mechanical circulatory support indication in advanced heart failure due to Chagas cardiomyopathy. Despite the absence of large evidence-based data, much has been accomplished since Carlos Chagas' discovery one century ago. Our institutional experience shows that mechanical circulatory support in Chagas patients is associated with more successful bridging to heart transplantation when compared to non-Chagas patients.

Circulating miRNAs as Potential Biomarkers Associated with Cardiac Remodeling and Fibrosis in Chagas Disease Cardiomyopathy.

Chagas disease (CD) affects approximately 6-7 million people worldwide, from which 30% develop chronic Chagas cardiomyopathy (CCC), usually after being asymptomatic for years. Currently available diagnostic methods are capable of adequately identifying infected patients, but do not provide information regarding the individual risk of developing the most severe form of the disease. The identification of biomarkers that predict the progression from asymptomatic or indeterminate form to CCC, may guide early implementation of pharmacological therapy. Here, six circulating microRNAs (miR-19a-3p, miR-21-5p, miR-29b-3p, miR-30a-5p, miR-199b-5p and miR-208a-3p) were evaluated and compared among patients with CCC (n = 28), CD indeterminate form (n = 10) and healthy controls (n = 10). MiR-19a-3p, miR-21-5p, and miR-29b-3p were differentially expressed in CCC patients when compared to indeterminate form, showing a positive correlation with cardiac dysfunction, functional class, and fibrosis, and a negative correlation with ejection fraction and left ventricular strain. Cardiac tissue analysis confirmed increased expression of microRNAs in CCC patients. In vitro studies using human cells indicated the involvement of these microRNAs in the processes of cardiac hypertrophy and fibrosis. Our study suggests that miRNAs are involved in the process of cardiac fibrosis and remodeling presented in CD and indicate a group of miRNAs as potential biomarkers of disease progression in CCC.

Association of Cardiac Galectin-3 Expression, Myocarditis, and Fibrosis in Chronic Chagas Disease Cardiomyopathy.

Chronic Chagas disease cardiomyopathy, caused by Trypanosoma cruzi infection, is a major cause of heart failure in Latin America. Galectin-3 (Gal-3) has been linked to cardiac remodeling and poor prognosis in heart failure of different etiologies. Herein, we investigated the involvement of Gal-3 in the disease pathogenesis and its role as a target for disease intervention. Gal-3 expression in mouse hearts was evaluated during T. cruzi infection by confocal microscopy and flow cytometry analysis, showing a high expression in macrophages, T cells, and fibroblasts. In vitro studies using Gal-3 knockdown in cardiac fibroblasts demonstrated that Gal-3 regulates cell survival, proliferation, and type I collagen synthesis. In vivo blockade of Gal-3 with N-acetyl-d-lactosamine in T. cruzi-infected mice led to a significant reduction of cardiac fibrosis and inflammation in the heart. Moreover, a modulation in the expression of proinflammatory genes in the heart was observed. Finally, histological analysis in human heart samples obtained from subjects with Chagas disease who underwent heart transplantation showed the expression of Gal-3 in areas of inflammation, similar to the mouse model. Our results indicate that Gal-3 plays a role in the pathogenesis of experimental chronic Chagas disease, favoring inflammation and fibrogenesis. Moreover, by demonstrating Gal-3 expression in human hearts, our finding reinforces that this protein could be a novel target for drug development for Chagas cardiomyopathy.

A Rare Lesion in the Anterior Region of the Third Ventricle: Rosette-Forming Glioneuronal Tumor.

Rosette-forming glioneuronal tumor (RGNT) is a rare and indolent mixed glioneuronal tumor involving primarily the fourth ventricular region and occurring predominantly in young adults. We present a case of a 44-year-old woman presented with progressive headaches, vomiting, and a sudden decreasing level of consciousness. The magnetic resonance imaging showed a regular lesion within the anterior portion of the third ventricle and the patient underwent an endoscopic approach to remove the tumor that was exclusively within the anterior portion of the third ventricle. Histopathology showed an RGNT that was totally removed. We also report some unusual complications that are described in the literature and are related to ventricular endoscopy such as seizures and hydroelectrolyte disorders. With two years of follow-up, the patient had no complaints and no tumor progression was observed.

Remarks on Eimeria spp. (Apicomplexa: Eimeriidae) from Kobus spp. (Bovidae: Reduncini), with supplementary morphological data of Eimeria congolensis Ricci-Bitti et al., 1973 from a new host subspecies, the common waterbuck Kobus ellipsiprymnus ellipsiprymnus (Ogilbyi, 1833).

Reduncin bovids of Kobus spp. (Bovidae: Reduncini) are natively distributed in sub-Saharan Africa, although some populations have been introduced into parks and zoos around the world. The majority of the species has declining populations, being categorized as threatened by the International Union for Conservation of Nature and Natural Resources; therefore, protective measures for the conservation of Kobus spp. are necessary, including the study of their parasites, such as the eimeriid coccidians (Apicomplexa: Eimeriidae). In this context, the aim of the current study was to brings together the taxonomic data from the descriptions and reports of Eimeria spp. from reduncin bovids, based on the detailed morphological identification of Eimeria congolensis Ricci-Bitti, Pampiglione & Kabala, 1973 from a new host subspecies, the common waterbuck Kobus ellipsiprymnus ellipsiprymnus (Ogilbyi, 1833), in a safari park of Portugal. Five Eimeria spp. are recorded from reduncin bovids, in addition to six more reports identified generically as Eimeria sp., which were compared and taxonomically rearranged. The oocysts identified as E. congolensis in the current study were compatible with the original description and were supplemented for some taxonomic characters not originally included, such as: Stieda body flattened to nipplelike, sub-Stieda body rounded to trapezoidal, sporocyst residuum granular and membrane-bound, in addition to greater details of the micropyle, among others. Finally, the current study highlights the importance of studying the coccidians of reduncin bovids for the conservation of Kobus spp. due to the possibility of these Eimeria spp. are extra-intestinal parasites, which can potentially cause severe coccidiosis associated with increased morbidity and mortality in certain threatened populations of Kobus spp.

Short tandem repeat analysis: a practical tool to identify specimen mix-ups in the pathology laboratory.

Despite all precautions in pathology laboratories, contaminations and specimen mix-ups still occur and can negatively impact both patients and institutions. We present two cases in which short tandem repeat (STR) analysis was used to assert the correct identity of specimens. The first patient had a biopsy diagnosis of triple negative invasive carcinoma of no special type of the breast. Sample mix-up with another biopsy was suspected, because in her post-chemotherapy mastectomy specimen, a hormone receptor-positive lobular carcinoma was diagnosed. STR analysis displayed a complete common loci profile of the patient's biopsy and mastectomy, supporting that no mix-up occurred. The second patient underwent hysterectomy due to cervix squamous cell carcinoma. A fragment of adenocarcinoma was identified and confirmed by STR profile to be a contaminant. STR analysis is a fast, easy-to-perform, and widely available technique which can clarify contaminations and specimen mix-ups in pathology laboratories.

Vitrectomy and tumor endoresection for the diagnosis and treatment of focal nodular retinal gliosis.

We report the case of a 60-year-old woman who presented with metamorphopsia and progressive vision loss in the right eye. Fundus examination revealed an elevated, white-yellow mass in the peripheral inferotemporal retina, with massive retinal exudation, proliferative vitreoretinopathy, and retinal detachment. Pars plana vitrectomy with tumor endoresection was performed, and a complete excisional biopsy of the lesion was obtained by removing the tumor through the anterior chamber. Histopathological analysis of the specimen confirmed a diagnosis of peripheral, focal, nodular retinal gliosis. Postoperatively, visual function improved greatly, with no recurrence of the disease at 12 months' follow-up. Focal nodular retinal gliosis is a rare, non-neoplastic proliferation of retinal glial cells, with a vascular component. In our case, surgical treatment with pars plana vitrectomy facilitated accurate diagnosis and resulted in effective management of the retinal tumor and associated complications.

Not all Nodules Are Cancer and not all Fungal Infections Are Aspergillus.

Pithomyces, a dematiaceous fungus, is a common colonizer of dead leaves and stems of many different plants and is associated with facial eczema in some animals. We report a case of invasive fungal pulmonary disease by Pithomyces chartarum in a healthy, nonimmunocompromised patient. We aim to demonstrate our diagnostic and therapeutic approach and focus on the major challenges arising from the lack of scientific evidence regarding infection by this fungus in humans.

Pithomyces, um fungo demáceo, é um colonizador comum de folhas e caules de diferentes plantas e está associado a eczema facial em alguns animais. Neste trabalho, descrevemos um caso de infeção fúngica invasiva pelo fungo Pithomyces chartarum, numa mulher não imunocomprometida. O nosso objetivo é descrever a abordagem diagnóstica e terapêutica deste caso, realçando os principais desafios que surgem devido à falta de evidência científica relativamente à infeção deste fungo em humanos.

Antioxidant Capacity and Phenolics Profile of Portuguese Traditional Cultivars of Apples and Pears and Their By-Products: On the Way to Newer Applications.

Pears (Pyrus communis L.) and apples (Malus domestica Borkh.) are two of the most popular fruits worldwide. The phenolic compounds they offer are associated with human health benefits due to their antioxidant properties. Since these fruits' by-products are not yet fully exploited, it is important to characterize them, especially in terms of their antioxidant properties. The aim of this study was to determine the antioxidant properties of old traditional cultivars, six regional pear cultivars and five regional apple cultivars grown in the Alcobaça region (Portugal). Antioxidant capacity assays were used to evaluate the antioxidant properties. Generally, the antioxidant capacity, total phenolics content (TPC), and total flavonoids content (TFC) of fruit byproducts (both seeds and peels) were higher than the corresponding mesocarp, indicating their potential as sources of beneficial antioxidant compounds. Moreover, a UHPLC-ToF-MS method was optimized and validated in order to quantify 21 distinct phenolics in these fruit samples. The analytical method's suitability for quantifying phenolic compounds was demonstrated by an evaluation of linearity, limit of detection, limit of quantification, precision and accuracy. This method was used to determine the phenolic composition of samples of regional (local) cultivars. The phenolics in the fruit samples with the highest concentrations were phlorizin and chlorogenic acid. Principal component analysis (PCA) was used to separate distinct fruit species while emphasizing their similarities and differences.

Importance of anemia in the chronic Cardiorenal syndrome: effects on renal function after heart transplantation.

BACKGROUND: Cardiorenal syndrome has been recently divided into 5 categories, according to acute or chronic evolution and primary organ dysfunction. Anemia can also accompany this disorder, leading to a more complex situation. This study aims to analyze the renal outcomes of patients, specifically patients with chronic Cardiorenal syndrome, with or without anemia, long-term after heart transplantation. MATERIAL/METHODS: This was a retrospective cohort study on chronic Cardiorenal syndrome patients submitted to heart transplantation. Patients were divided according to presence of anemia and renal dysfunction before heart transplantation. RESULTS: A total of 108 patients (92 males) with the mean age of 45±12 years were included. The etiologies of the heart failure were hypertensive dilated myocardiopathy (66%), ischemic (14%) and Chagasic (12%). Before the heart transplantation, 51 patients had an eGFR less than 60 mL/min. From these, 24 had concomitant anemia. One year after the transplantation, patients with previous isolated renal dysfunction ameliorates eGFR (45±11 vs. 65±26 mL/min, p<0.001), while those patients with previous renal dysfunction and anemia presented no improvement (eGFR 44±14 vs. 47±13 mL/min, p=0.619) 1 year after heart transplantation. Moreover, higher hemoglobin was an independent predictor of eGFR improvement after heart transplantation when associated with previous renal dysfunction (OR 1.8; CI 1.2-3.6, p<0.01 for each hemoglobin increment of 1 g/dL). CONCLUSIONS: Patients with isolated Cardiorenal syndrome presented partial renal function recovery after heart transplantation, while the presence of cardiorenal anemia was a marker of renal function non-recovery 1 year after heart transplantation.

Xanthogranulomatous salpingo-oophoritis presenting as an ovarian tumour.

Xanthogranulomatous salpingo-oophoritis (XGSO) is an exceptionally rare entity. Its clinical manifestations and imaging modalities can mimic benign and malignant adnexal diseases, making it difficult to diagnose. Here we report a case of XGSO in a young woman who was operated with suspicion of a borderline ovarian tumour. Preoperative diagnosis of XGSO should be considered to avoid radical surgical treatment, especially in young patients.

Metaplastic Breast Carcinoma in a 37-Year-Old Female: A Case Report.

Metaplastic breast carcinoma (MBC) is a rare and aggressive histologic subtype of cancer. Because of its rarity and heterogeneity, the management of these patients is challenging. Here, we present the case of a rapidly progressive MBC with mesenchymal differentiation in a 37-year-old female, treated with trimodal therapy consisting of neoadjuvant chemotherapy with paclitaxel and carboplatin, followed by dose-dense cyclophosphamide and doxorubicin (ddAC), modified radical left mastectomy, and adjuvant radiotherapy. Despite the need to anticipate the surgery after the first cycle of ddAC, because of a life-treating adverse event, there was a pathologic complete response. Nevertheless, 6.2 months after completing adjuvant radiotherapy, the patient had a recurrence on the central nervous system (CNS) (two lesions), which was managed with excisional biopsy and stereotactic body radiation therapy. The patient also started "complementary" chemotherapy with capecitabine. Still, 18 months after being diagnosed, she died due to CNS disease progression.

Spatial Distribution of Mortality for Heart Failure in Brazil, 1996 - 2017. / Distribuição Espacial de Mortalidade por Insuficiência Cardíaca no Brasil, 1996-2017.

BACKGROUND: Heart failure (HF) is a leading cause of mortality and morbidity worldwide, and is associated with the high use of resources and healthcare costs. In Brazil, the HF prevalence is around 2 million patients, and its incidence is of approximately 240,000 new cases per year. OBJECTIVE: The present investigation aimed to analyze the spatiotemporal trend of mortality caused by HF in Brazil, from 1996 to 2017. METHODS: This is an ecological study developed with secondary data on HF mortality in Brazil. During the period, 1,242,014 cases of death caused by heart failure were analyzed. The existence of spatial autocorrelation of cases was calculated using the Global Moran Index (GMI) and, when significant, the Local Moran Index, considering p<0.05. The relative risk of the clusters was calculated. RESULTS: The mortality rate due to HF was diversified in all Brazilian regions, with an emphasis in the South, Southeast, and Northeast. The GMI indicated positive spatial autocorrelation (p=0.01) in all periods. Municipalities located in the South, Southeast, Northeast, and Midwest showed a higher Relative Risk for mortality from HF, and most municipalities in the North were classified as a protective factor against this cause of death. CONCLUSIONS: The study showed a decline in mortality rates across the national territory. The highest concentration of mortality rates is in the North and Northeast regions, highlighting priority vulnerable areas in the planning and controlling strategies of health services.

FUNDAMENTO: Insuficiência cardíaca (IC) é uma das principais causas de mortalidade e morbidade no mundo, e está associada ao alto uso de recursos e custos com saúde. No Brasil, a prevalência de IC é de aproximadamente 2 milhões de pacientes, e sua incidência é de aproximadamente 240.000 novos casos por ano. OBJETIVO: A investigação objetivou analisar a tendência espaço-temporal da mortalidade causada por IC no Brasil, de 1996 a 2017. MÉTODOS: Este é um estudo ecológico desenvolvido com dados secundários sobre mortalidade por IC no Brasil. Durante o período, 1.242.014 casos de morte causada por IC foram analisados. A existência da autocorrelação espacial de casos foi calculada utilizando o Índice de Moran Global (IMG) e, quando significativo, o Índice de Moran Local, considerando p <0,05. O risco relativo dos grupos foi calculado. RESULTADOS: A taxa de mortalidade causada por IC foi diversificada em regiões brasileiras, com ênfase no sul, sudeste e nordeste. O IMG indicou autocorrelação espacial positiva (p=0,01) em todos os períodos. Cidades localizadas no sul, sudeste, nordeste e centro-oeste mostraram maior risco relativo para mortalidade causada por IC, e a maioria das cidades do norte foi classificada como um fator protetivo contra esta causa de morte. CONCLUSÕES: O estudo demonstrou declínio nas taxas de mortalidade no território nacional. A maior concentração de taxas de mortalidade está nas regiões norte e nordeste, enfatizando as áreas prioritárias de vulnerabilidade no planejamento e estratégias de controle de serviços de saúde.

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis.

BACKGROUND: Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other ß-lactams. METHODS: We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS: We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2  = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2  = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS: In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.