Epidemiologia da anafilaxia no Brasil: Registro Brasileiro de Anafilaxia (RBA) da Associação Brasileira de Alergia e Imunologia (ASBAI) / Epidemiology of anaphylaxis in Brazil: The Brazilian Registry of Anaphylaxis (RBA) of the Brazilian Association of Allergy and Immunology (ASBAI)

INTRODUÇÃO: A anafilaxia é uma reação alérgica multissistêmica grave, de início agudo e potencialmente fatal. Poucos são os dados sobre sua epidemiologia no Brasil. O Registro Brasileiro de Anafilaxia da Associação Brasileira de Alergia e Imunologia (RBAASBAI) teve como objetivo ampliar o conhecimento sobre anafilaxia em indivíduos brasileiros. MÉTODOS: Estudo observacional transversal com questionário online sobre dados demográficos, desencadeantes suspeitos, manifestações clínicas, atendimento durante a reação, investigação diagnóstica e aconselhamento após a reação de pacientes que experimentaram uma reação anafilática. RESULTADOS: Entre junho/2021 e abril/2023, foram incluídos 237 pacientes (131 femininos): 99 crianças/adolescentes; 127 adultos e 11 idosos. Houve predomínio de meninos entre crianças/adolescentes (55,5%), e de mulheres entre os adultos (64,5%), e mediana de idade de 22 anos (< 1 a 77 anos). As manifestações cutâneas (92,8%) foram as mais frequentes, seguidas pelas respiratórias (70,1%), gastrointestinais (52,3%), neurológicas (36,3%) e cardiovasculares (35,3%). Os principais desencadeantes foram: alimentos (43,0%), medicamentos (26,2%), himenópteros (21,6%) e látex (2,5%); os alimentos entre crianças (leite, ovo, amendoim/castanhas), e os fármacos (anti-inflamatórios e antibióticos) entre os adultos. Quanto ao tratamento, 61,1% recebeu adrenalina (52,7% por profissional e 8,4% via autoinjetor de adrenalina -AIA). Uma adolescente (12 anos) faleceu após picada de abelha. A maioria recebeu plano escrito de emergência (78,1%) e foi ensinada a usar o AIA (70%). CONCLUSÃO: Os alimentos foram os desencadeantes mais comuns entre crianças/adolescentes, e os fármacos entre adultos brasileiros. A adrenalina continua sendo subutilizada, reforçando a necessidade de maior disseminação do tratamento adequado da anafilaxia.

INTRODUCTION: Anaphylaxis is a life-threatening, acute, severe multisystem allergic reaction.There is little data on its epidemiology in Brazil. The Brazilian Anaphylaxis Registry of the Brazilian Association of Allergy and Immunology (RBA-ASBAI) was devised to expand knowledge about anaphylaxis in Brazilian individuals. METHODS: Cross-sectional observational study using an online questionnaire to collect data on demographics, suspected triggers, clinical manifestations, treatment during the reaction, diagnostic workup, and post-reaction counseling in patients who have experienced an anaphylactic reaction. RESULTS: Between June 2021 and April 2023, 237 patients were included (131 female): 99 children/adolescents (<18yo), 127 adults (18-64yo), and 11 older adults (65-77yo). There was a male predominance in the pediatric group (55.5%), while females were predominant among adults (64.5%). The median age was 22 years (range, <1 to 77). The most frequent clinical manifestations were cutaneous (92.8%), followed by respiratory (70.1%), gastrointestinal (52.3%), neurological (36.3%), and cardiovascular (35.3%). The most common triggers were foods (43.0%), drugs (26.2%), venoms (21.6%), and latex (2.5%). Foods (milk, egg, peanuts/tree nuts) predominated among children, versus drugs (mostly nonsteroidal anti-inflammatory drugs and antibiotics) among adults. Regarding treatment, 61.1% received epinephrine (52.7% by a healthcare professional and 8.4% via epinephrine auto-injector [EAI]). One teenager (12yo) died due to a bee sting. Most patients received a written emergency plan (78.1%) and were taught how to use the EAI (70%). CONCLUSION: Foods were the most common triggers of anaphylaxis among Brazilian children and adolescents, while drugs predominated among adults. Epinephrine continues to be underused, highlighting the need for greater awareness of proper treatment of anaphylaxis.

Local allergic rhinitis in children: identification and characterization in a specialty outpatient clinic.

Summary: Background. Local Allergic Rhinitis (LAR) is a phenotype defined by rhinitis symptoms with negative responses to systemic sensitization tests but with an exclusively nasal allergic inflammatory response. Data on the pediatric age group is scarce, and no Latin American data has been published so far. Methods. Nasal Allergen Challenge (NAC) was performed with Dermatophagoides pteronyssinus and Blomia tropicalis in six- to 18-year-old patients diagnosed with rhinitis and no systemic sensitization. NAC was monitored using subjective parameters and acoustic rhinometry. The study aimed to identify LAR in child and adolescent subjects previously diagnosed with non-allergic rhinitis (NAR) in a Brazilian specialty outpatient clinic (Allergy and Immunology). Results. During the study period, we analyzed 758 skin prick tests (SPT). Of those, 517 (68.2%) were diagnosed with rhinitis. Among those, 18.4% (95/517) had a negative SPT, meeting the criteria for inclusion in the study. Twenty-five patients underwent NAC, and 40% (10/25) of them, previously considered to have NAR, had a positive test and were reclassified as having LAR. Based on the analyzed characteristics, clinically differentiating LAR from NAR was impossible. Conclusions. This study represents the first investigation of LAR in child and adolescent subjects in Latin America, contributing significantly to the understanding of its prevalence and characteristics in this geographic area. Among a subgroup of patients lacking systemic sensitization submitted to NAC, 40% (10/25) demonstrated a positive NAC with Dermatophagoides pteronyssinus and Blomia tropicalis, warranting their reclassification to LAR. NAC with multiple allergens has been proven safe and viable in pediatric populations, affirming its critical role in the accurate diagnosis of LAR.

The molecular epidemiology of SARS-CoV-2 in the Pityusic Islands shows multiple introductions and fast replacements of variants in a touristic worldwide hot spot.

The public health emergency caused by the Covid-19 outbreak in March 2020 encouraged worldwide initiatives to monitor the genetic diversity and features of the SARS-CoV-2 circulating variants, mainly based on the genomic surveillance. However, due to the impossibility to carry out extensive sequencing in resource-limited hospitals, other PCR-based strategies could be applied to efficiently monitor the circulating variants without the need to greatly expand the sequencing capacity. In our case, overpassing the technical limitations inherent to a second level hospital, we were able to characterize the weekly distribution of SARS-CoV-2 by the RT-qPCR amplification patterns visualization, single nucleotide polymorphism genotyping, and sequencing of randomly selected samples. All these molecular approaches allowed us to trace the epidemiology of SARS-CoV-2 viruses circulating in Ibiza and Formentera (Balearic Islands, Spain) during the third to the sixth pandemic waves (January 2021-July 2022), in which three major lineages that were considered as VOCs (Alpha, Delta, and Omicron), and many other non-VOC variants were detected and tracked.

[Omental infarction, unusual cause of abdominal pain]. / Infarto omental, causa poco común de dolor adbominal.

INTRODUCTION: Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain. CLINICAL CASE: An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours. CONCLUSION: Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

COVID-19 and air pollution: A dangerous association?

In late 2019, a new infectious disease (COVID-19) was identified in Wuhan, China, which has now turned into a global pandemic. Countries around the world have implemented some type of blockade to lessen their infection and mitigate it. The blockade due to COVID-19 has drastic effects on the social and economic fronts. However, recent data released by the National Aeronautics and Space Administration (NASA), European Space Agency (ESA), Copernicus Sentinel-5P Tropomi Instrument and Center for Research on Energy and Clean Air (CREA) indicate that the pollution in some of the epicenters of COVID-19, such as Wuhan, Italy, Spain, USA, and Brazil, reduced by up to 30%. This study compiled the environmental data released by these centers and discussed the impact of the COVID-19 pandemic on environmental pollution

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COVID-19 and air pollution: A dangerous association?

In late 2019, a new infectious disease (COVID-19) was identified in Wuhan, China, which has now turned into a global pandemic. Countries around the world have implemented some type of blockade to lessen their infection and mitigate it. The blockade due to COVID-19 has drastic effects on the social and economic fronts. However, recent data released by the National Aeronautics and Space Administration (NASA), European Space Agency (ESA), Copernicus Sentinel-5P Tropomi Instrument and Center for Research on Energy and Clean Air (CREA) indicate that the pollution in some of the epicenters of COVID-19, such as Wuhan, Italy, Spain, USA, and Brazil, reduced by up to 30%. This study compiled the environmental data released by these centers and discussed the impact of the COVID-19 pandemic on environmental pollution.

The relationship between second-hand smoke and wheezing in infants from Córdoba, Argentina

Background: Wheezing constitutes a common respiratory symptom in children, and several risk factors have been associated with the prevalence of recurrent wheezing (RW) and its severity, especially viral respiratory infections and second-hand smoke (SHS) exposure. Objective: To analyze the relationship between smoking patterns in the home and wheezing, in infants from the city of Córdoba, Argentina, during their first year of life. Methods: Parents of infants were invited to complete a standardized questionnaire voluntarily and anonymously (WQ-P1-EISL). Wheezing in the first 12 months of life was classified as occasional wheezing (OW) when having one or two episodes during the first 12 months of life; recurrent wheezing (RW) if having three or more, and more frequent wheezing (MFW) ≥ 6 episodes. Results: 409 infants (39.0%) had one or more episodes of wheezing in the first 12 months. Of these, 214 infants (52.3%) presented occasional wheezing (OW), 135 (33%) had recurrent wheezing (RW), and 60 (14.7%) more frequent wheezing (MFW). SHS was significantly related to MFW, especially if the mother smoked (OR = 2.7; IC 95%: 1.4-5.18; p = 0.0009) or if she smoked during pregnancy (OR = 4; IC 95%: 1.8-8.5; p = 0.0001). This group of MFW was also associated with SHS as well as having been to the emergency room for wheezing (40.87%, p = 0.0056). Conclusion: The results indicate that second-hand tobacco smoke is a significant risk factor for the presence of wheezing in infants, and for its severity. Our findings have significant implications for public health, as smoking is a modifiable behavior

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The relationship between second-hand smoke and wheezing in infants from Córdoba, Argentina.

BACKGROUND: Wheezing constitutes a common respiratory symptom in children, and several risk factors have been associated with the prevalence of recurrent wheezing (RW) and its severity, especially viral respiratory infections and second-hand smoke (SHS) exposure. OBJECTIVE: To analyze the relationship between smoking patterns in the home and wheezing, in infants from the city of Córdoba, Argentina, during their first year of life. METHODS: Parents of infants were invited to complete a standardized questionnaire voluntarily and anonymously (WQ-P1-EISL). Wheezing in the first 12 months of life was classified as occasional wheezing (OW) when having one or two episodes during the first 12 months of life; recurrent wheezing (RW) if having three or more, and more frequent wheezing (MFW) ≥6 episodes. RESULTS: 409 infants (39.0%) had one or more episodes of wheezing in the first 12 months. Of these, 214 infants (52.3%) presented occasional wheezing (OW), 135 (33%) had recurrent wheezing (RW), and 60 (14.7%) more frequent wheezing (MFW). SHS was significantly related to MFW, especially if the mother smoked (OR=2.7; IC 95%: 1.4-5.18; p=0.0009) or if she smoked during pregnancy (OR=4; IC 95%: 1.8-8.5; p=0.0001). This group of MFW was also associated with SHS as well as having been to the emergency room for wheezing (40.87%, p=0.0056). CONCLUSION: The results indicate that second-hand tobacco smoke is a significant risk factor for the presence of wheezing in infants, and for its severity. Our findings have significant implications for public health, as smoking is a modifiable behavior.

Effectiveness and safety of Omalizumab in the treatment of chronic spontaneous urticaria: Systematic review and meta-analysis

Introduction: Chronic spontaneous urticaria (CSU) affects approximately 1% of the population, affecting both children and adults. Omalizumab (Oma) is a therapeutic option for patients with refractory forms of CSU. Objectives: To determine the effectiveness and safety of Oma in the treatment of CSU. Methods: Systematic review (Cochrane Collaboration methodology) of randomized clinical trials comparing Oma to placebo in refractory CSU treatment. The search is based on MEDLINE; EMBASE, Central Cochrane Library, and LILACS. The outcomes evaluated were: control of the illness, adverse events, and quality of life. Results: Of the 848 identified studies 13 were selected for further review and six were included in the meta-analysis. For all outcomes, high-quality evidence has confirmed that Oma is effective in the treatment of CSU. The dosage of 300mg/month achieved better results; namely a significant reduction in pruritus, papules, and urticaria activity, as well as an increase in the number of patients with a controlled condition, improvement in the quality of life and no differences in adverse events compared to the placebo. Conclusions: High-quality evidence demonstrates that Oma is effective and safe in the treatment of CSU refractory to therapy with H1 antihistamines

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Why despite the lower prevalence, is asthma more severe in the semiarid region?

Introduction and objectives: Asthma is a chronic inflammatory disease which is very prevalent throughout the world, and climatic factors, especially air humidity, have been considered fundamental to its development. This study aims to evaluate the relationship between the climate factor and the severity of asthma episodes in the semiarid region, comparing it to the coast and an intermediate climate region, considering the use of medication as an intervening factor. Materials and methods: Ecological study in cities with different climatic conditions (semiarid, intermediate region and Coast). Prevailing data was obtained from the International Study of Asthma and Allergies in Childhood (ISAAC) protocol. We evaluated the temperature, humidity and use of drugs for asthma/100,000 inhabitants. Results: The prevalence of asthma was lower in the semiarid (14%; 95% CI = 12.1-15.7) than the intermediate region (19.1%; 95% CI = 17.7-20.6) and coast (17.9%; 95% CI = 16.6-19.2). Episodes of severe asthma attacks were surprisingly higher in semiarid (10.4%; 95% CI=8.9-11.9) when compared to coast (4.1%; 95% CI = 3.4-4.9) and intermediate region (5.0%; 95% CI = 4.3-5.8). In the semiarid region, the humidity was lower and the temperature higher than the other cities evaluated. The dispensing of medications was lower in the semiarid region. Conclusions: Temperature and humidity may have contributed to a lower prevalence and greater severity of asthma in the semiarid region. The dispensing of medications was lower in the semiarid region, indicating that access to both relief and control drugs was lower in this city. The possibility of lack of health care in the semiarid region can also be another explanatory factor associated

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Effectiveness and safety of Omalizumab in the treatment of chronic spontaneous urticaria: Systematic review and meta-analysis.

INTRODUCTION: Chronic spontaneous urticaria (CSU) affects approximately 1% of the population, affecting both children and adults. Omalizumab (Oma) is a therapeutic option for patients with refractory forms of CSU. OBJECTIVES: To determine the effectiveness and safety of Oma in the treatment of CSU. METHODS: Systematic review (Cochrane Collaboration methodology) of randomized clinical trials comparing Oma to placebo in refractory CSU treatment. The search is based on MEDLINE; EMBASE, Central Cochrane Library, and LILACS. The outcomes evaluated were: control of the illness, adverse events, and quality of life. RESULTS: Of the 848 identified studies 13 were selected for further review and six were included in the meta-analysis. For all outcomes, high-quality evidence has confirmed that Oma is effective in the treatment of CSU. The dosage of 300mg/month achieved better results; namely a significant reduction in pruritus, papules, and urticaria activity, as well as an increase in the number of patients with a controlled condition, improvement in the quality of life and no differences in adverse events compared to the placebo. CONCLUSIONS: High-quality evidence demonstrates that Oma is effective and safe in the treatment of CSU refractory to therapy with H1 antihistamines.

Youth tobacco use in Latin America: What is the real extent of the problem?

Introduction: Cigarette consumption among teenagers is one of the most critical health-related risk behaviors. Method: Prospective study carried out in seven sites of five Latin American countries (Argentina [Cordoba, N = 958, Corrientes, N = 1013], Brazil [Curitiba, N = 650; Uruguaiana, N = 997], Cuba [Havana, N = 1004], Mexico [Veracruz, N = 991] and Paraguay [Ciudad del Este, N = 868]) with public-school adolescents (aged 12-19 years). Respondents were asked to answer the California Student Tobacco Survey. Results: 6550 adolescents took part in the survey (average age: 14 years). 38.5% (N = 2517) "tried smoking" and 37.5% started smoking before the age of 12. Sixty-one percent of adolescents think that cigarettes are easily accessible; 41.7% considered that smokers have more friends; 88% indicated knowledge of the harms of smoking one to five cigarettes per day; 58.9% would smoke new cigarette types with less harmful substances; 27.8% have already used e-cigarettes; 28% have smoked hookah. Fifty-seven point five percent have been, in the past seven days, in the same room with someone who was smoking a cigarette; and 30.5% indicated that there were not any no-smoking rules inside their homes. Identifiable risk factors were (logistic regression analysis): smoking cigarettes offered by friends, smoking cigarettes with less harmful substances, knowing what a hookah is, being in the same room with a smoker in the past week. Identifiable protective factors against tobacco use were: knowing the health risks caused by smoking hookah and to have their own room. Conclusion: Youth tobacco use in Latin America is a major public health concern, and tobacco control measures are highly needed

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Why despite the lower prevalence, is asthma more severe in the semiarid region?

INTRODUCTION AND OBJECTIVES: Asthma is a chronic inflammatory disease which is very prevalent throughout the world, and climatic factors, especially air humidity, have been considered fundamental to its development. This study aims to evaluate the relationship between the climate factor and the severity of asthma episodes in the semiarid region, comparing it to the coast and an intermediate climate region, considering the use of medication as an intervening factor. MATERIALS AND METHODS: Ecological study in cities with different climatic conditions (semiarid, intermediate region and Coast). Prevailing data was obtained from the International Study of Asthma and Allergies in Childhood (ISAAC) protocol. We evaluated the temperature, humidity and use of drugs for asthma/100,000 inhabitants. RESULTS: The prevalence of asthma was lower in the semiarid (14%; 95%CI=12.1-15.7) than the intermediate region (19.1%; 95%CI=17.7-20.6) and coast (17.9%; 95%CI=16.6-19.2). Episodes of severe asthma attacks were surprisingly higher in semiarid (10.4%; 95%CI=8.9-11.9) when compared to coast (4.1%; 95%CI=3.4-4.9) and intermediate region (5.0%; 95%CI=4.3-5.8). In the semiarid region, the humidity was lower and the temperature higher than the other cities evaluated. The dispensing of medications was lower in the semiarid region. CONCLUSIONS: Temperature and humidity may have contributed to a lower prevalence and greater severity of asthma in the semiarid region. The dispensing of medications was lower in the semiarid region, indicating that access to both relief and control drugs was lower in this city. The possibility of lack of health care in the semiarid region can also be another explanatory factor associated.

Impulse oscillometry in the assessment of children's lung function

Purpose: To review available evidence in the literature on impulse oscillometry in the assessment of lung function in children with respiratory diseases, especially asthma. Data collection: Research in the Medline, PubMed, and Lilacs databases, with the keywords forced oscillation, impulse oscillometry, asthma and impulse oscillometry. Results: The Impulse Oscillometry System (IOS) allows the measurement of resistance and reactance of airways and is used as a diagnostic resource. A significant association between the findings of the IOS and those of spirometry is observed. In asthma, the IOS has already been used to assess the bronchodilator response and the therapeutic response to different drugs and has shown to be a sensitive technique to evaluate disease control. There are limitations to this assessment, such as children with attention deficit and in some cases it is difficult to interpret the results from a clinical point of view. Conclusion: The IOS is a useful tool for the measurement of the lung function of children. It is an easy test, although its interpretation is not straightforward

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Youth tobacco use in Latin America: What is the real extent of the problem?

INTRODUCTION: Cigarette consumption among teenagers is one of the most critical health-related risk behaviors. METHOD: Prospective study carried out in seven sites of five Latin American countries (Argentina [Cordoba, N=958, Corrientes, N=1013], Brazil [Curitiba, N=650; Uruguaiana, N=997], Cuba [Havana, N=1004], Mexico [Veracruz, N=991] and Paraguay [Ciudad del Este, N=868]) with public-school adolescents (aged 12-19 years). Respondents were asked to answer the California Student Tobacco Survey. RESULTS: 6550 adolescents took part in the survey (average age: 14 years). 38.5% (N=2517) "tried smoking" and 37.5% started smoking before the age of 12. Sixty-one percent of adolescents think that cigarettes are easily accessible; 41.7% considered that smokers have more friends; 88% indicated knowledge of the harms of smoking one to five cigarettes per day; 58.9% would smoke new cigarette types with less harmful substances; 27.8% have already used e-cigarettes; 28% have smoked hookah. Fifty-seven point five percent have been, in the past seven days, in the same room with someone who was smoking a cigarette; and 30.5% indicated that there were not any no-smoking rules inside their homes. Identifiable risk factors were (logistic regression analysis): smoking cigarettes offered by friends, smoking cigarettes with less harmful substances, knowing what a hookah is, being in the same room with a smoker in the past week. Identifiable protective factors against tobacco use were: knowing the health risks caused by smoking hookah and to have their own room. CONCLUSION: Youth tobacco use in Latin America is a major public health concern, and tobacco control measures are highly needed.

Impulse oscillometry in the assessment of children's lung function.

PURPOSE: To review available evidence in the literature on impulse oscillometry in the assessment of lung function in children with respiratory diseases, especially asthma. DATA COLLECTION: Research in the Medline, PubMed, and Lilacs databases, with the keywords forced oscillation, impulse oscillometry, asthma and impulse oscillometry. RESULTS: The Impulse Oscillometry System (IOS) allows the measurement of resistance and reactance of airways and is used as a diagnostic resource. A significant association between the findings of the IOS and those of spirometry is observed. In asthma, the IOS has already been used to assess the bronchodilator response and the therapeutic response to different drugs and has shown to be a sensitive technique to evaluate disease control. There are limitations to this assessment, such as children with attention deficit and in some cases it is difficult to interpret the results from a clinical point of view. CONCLUSION: The IOS is a useful tool for the measurement of the lung function of children. It is an easy test, although its interpretation is not straightforward.

Knowledge on asthma, food allergies, and anaphylaxis: Assessment of elementary school teachers, parents/caregivers of asthmatic children, and university students in Uruguaiana, in the state of Rio Grande do Sul, Brazil

INTRODUCTION: Allergic diseases have become an increasingly common reality in the last years, extending beyond the family context. OBJECTIVE: Assessing the level of knowledge on asthma, food allergies and anaphylaxis of asthmatic children's parents/caregivers (PC), elementary school teachers (EST) and university students (US) in Uruguaiana, RS, Brazil. METHOD: 577 individuals (PC - N = 111; EST - N = 177; US - N = 299) took part in the study, answering the Newcastle Asthma Knowledge Questionnaire (validated for Portuguese) and another questionnaire on Food Allergy (FA) and anaphylaxis. RESULTS: Although PC have asthmatic children, their asthma knowledge level was average, slightly above that of EST and EU. The lack of knowledge on passive smoking, use of medications and their side effects should be highlighted. US have shown to be better informed about FA and anaphylaxis. However, even though a significant proportion of respondents know the most common symptoms of FA and anaphylaxis, few named subcutaneous adrenaline as the drug of choice for treating anaphylaxis. Although a significant number of respondents know about the possibility of anaphylactic reactions happening at school or in activities outside the school, we were surprised by the absence of conditions in schools to provide emergency care to such students. CONCLUSION: Despite the high prevalence of allergic diseases in childhood, asthmatic children's parents/caregivers, elementary school teachers and university students have inadequate levels of knowledge to monitor these patients

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