The endoscopic management of pancreatic fistulas.

BACKGROUND: Interest in the use of therapeutic endoscopy for the treatment of pancreatic diseases has been on the increase for several years. Our aim was to assess the efficacy of endoscopic retrograde cholangiopancreaticography (ERCP) in the treatment of pancreatic fistulas. METHODS: We evaluated the results of therapeutic ERCP in 50 patients with pancreatic fistula treated at the Helsinki University Central Hospital from 1998 to 2003. RESULTS: The success rate of fistula closure after therapeutic ERCP was 82%. Five patients required operative treatment when ERCP was unsuccessful. There was little morbidity and no procedure-related mortality. Four patients died because severe illnesses made them unfit for any further procedures. CONCLUSION: ERCP is a safe and effective modality and should be considered as first-line therapy in the management of pancreatic fistula.

Clinical value of severity markers in acute pancreatitis.

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.

Bactericidal/permeability-increasing protein and group I and II phospholipase A2 during the induction phase of human acute pancreatitis.

Activated endogenous mediators of inflammation have important roles in the pathogenesis and complications of acute pancreatitis (AP). These mediators include bactericidal/ permeability-increasing protein (BPI) and phospholipase A2 (PLA2). The time course of their activation during human AP is not known. The aim of this study was to evaluate the kinetics of BPI, group I (pancreatic) and group II (synovial type) PLA2 during human AP with temporally defined onset, as being induced by endoscopic retrograde cholangiopancreatography (ERCP). Serum samples of 273 consecutive patients undergoing ERCP were collected before and at 3, 6, and 24 h after ERCP. Twenty-four (8.7%) patients developed ERCP-induced pancreatitis. Seven of them were graded to have a severe disease. Forty randomly selected patients undergoing ERCP without evidence of pancreatitis served as controls. The serum concentrations of BPI and groups I and II PLA2 were measured by specific immunoassays. The mean concentration of BPI increased from 14 to 26 microg/L at 24 h after ERCP in patients with AP. In the control group, BPI values remained unchanged, and the difference was statistically significant (p<0.001). The increase of BPI was seen in 22 of 28 patients with AP at 3 h after the onset of the disease. BPI values were higher in severe post-ERCP pancreatitis than in mild disease (p = 0.07; NS). The serum concentrations of group II PLA2 before ERCP were consistently higher in the control patients than in the patients with pancreatitis, 65.8 and 14.2 microg/L, respectively. High baseline values in the control group were associated with preexisting infectious diseases. Thereafter, the mean concentration decreased in the control group to 44 microg/L and increased in the pancreatitis group up to 27.5 microg/L. The difference was statistically significant (p = 0.007). Increased group II PLA2 values were seen in 10 of 17 patients with mild AP and in five of seven patients with severe disease. There were no significant differences in group I or II PLA2 values in patients with mild or severe AP. The serum concentration of group I PLA2 increased in the patients with post-ERCP pancreatitis from 5.4 to 37.5 microg/L at 24 h. The difference was statistically significant, (p< 0.001) as compared with controls. In conclusion, in acute pancreatitis, the increase of BPI in serum starts at 3 h after the onset of the disease, and the concentration seems to correlate with the severity of the disease. Increased group II PLA2 concentrations also were seen in patients with mild AP. The kinetics of group I PLA2 resembles that of other pancreatic enzymes.

Extracellular phospholipases A2 in relation to systemic inflammatory response syndrome (SIRS) and systemic complications in severe acute pancreatitis.

The pathophysiology of severe acute pancreatitis (AP) resembles other conditions with systemic inflammatory response syndrome (SIRS) such as sepsis predisposing to remote organ failure. Because extracellular phospholipases A2 (PLA2) have been implicated in AP, their serum concentrations were analyzed with respect to SIRS and systemic complications in patients with severe AP. The serum samples were collected daily for 12 days in 57 patients with severe AP. SIRS, early organ complications, local complications, and outcome of AP were recorded. Time-resolved fluoroimmunoassays were used for group I and group II PLA2 measurements. Thirty-nine (68.4%) patients fulfilled the criteria of SIRS within 12 days from admission. Pancreatic necrosis was detected in 43 (75.4%) patients. Infected necrosis was found preoperatively or at operation in five (8.8%) patients. Twenty-six (45.6%) and eight (14.0%) patients had respiratory or renal failure, respectively. Seven (12.3%) patients died of their disease. All patients with systemic complications fulfilled the criteria of SIRS. The increasing number of positive SIRS criteria was associated with increased frequency of systemic complications. Pancreatic necrosis was not significantly associated with SIRS. The serum concentration of group II PLA2 was significantly higher in patients with SIRS (p < 0.05) compared with patients without from day 7 onward. The concentration of group II PLA2 increased (p < 0.01) in patients with SIRS but decreased in patients without. The serum concentration of group II PLA2 did not differ significantly with respect to systemic complications. The concentration of group I PLA2 decreased (p < 0.05) similarly in patients with and without SIRS or systemic complications during follow-up, respectively. Early systemic complications of severe AP are associated with SIRS with increasing frequency as the number of positive SIRS criteria increases. Group II PLA2 but not group I PLA2 may have pathophysiologic importance in severe AP-associated SIRS. Increasing serum concentration of group II PLA2 seems to reflect the ongoing systemic inflammation in severe AP-associated SIRS.

Severe acute pancreatitis: prognostic factors in 270 consecutive patients.

Acute pancreatitis (AP) is a common abdominal disorder with severity varying from mild to fatal disease. Predicting a patient's outcome remains problematic. The aim of this study was to analyze a large consecutive series of patients with severe AP and to identify prognostic factors for hospital mortality. Between 1989 and 1997, a consecutive series of 270 patients with severe AP were included in the study. All patients fulfilled the criteria of Atlanta classification for severe AP. Retrospectively and prospectively collected data included age, gender, etiology, number of previous episodes of pancreatitis, medication history, type of admission, body-mass index (BMI), respiratory failure, renal failure, need for pressor support, and abdominal surgery performed during hospitalization. The overall mortality rate was 24.4%. In univariate survival analysis advanced age, history of continuous medication, patient transferred from other hospital, high BMI, respiratory or renal failure, need for pressor support, and need for abdominal surgery were significant prognostic factors for hospital mortality. In a multivariate stepwise logistic regression analysis, the need of pressor support, renal failure requiring dialysis, advanced age, history of continuous medication and need for abdominal surgery were identified as independent prognostic factors for mortality. A logistic regression analysis of variables available on admission (the first seven above mentioned variables) showed that transferral admission, advanced age, and history of continuous medication were independent prognostic factors for mortality. In patients with severe AP, advanced age, history of continuous medication, and need for dialysis, mechanical ventilator support, and pressor support predict fatal outcome and thus should be taken into account in clinical evaluation.

Comparison of urine trypsinogen-2 test strip with serum lipase in the diagnosis of acute pancreatitis.

BACKGROUND/AIMS: The accuracy of a new rapid urinary trypsinogen-2 test strip (actim Pancreatitis) was compared with that of serum lipase for detection of acute pancreatitis in patients with acute abdominal pain. METHODOLOGY: A prospective study was conducted which consisted of 237 consecutive patients with acute abdominal pain admitted to the emergency unit at Helsinki University Central Hospital. The patients were tested on admission with the actim Pancreatitis test strip. Serum amylase, serum lipase, and urine trypsinogen-2 concentrations were also determined quantitatively. RESULTS: The actim Pancreatitis test strip result was positive in 27 out of 29 patients with acute pancreatitis (sensitivity 93%) and in 16 of 208 patients with non-pancreatic abdominal pain (specificity 92%). This was superior to that of serum lipase (sensitivity 79% and specificity 88%). With a cut-off > 3x the upper reference limit, the sensitivity of serum lipase was only 55% while the specificity was 99%. The high sensitivity for the actim Pancreatitis test strip resulted in a very high negative predictive value of 99%. All six patients with severe acute pancreatitis were detected by the dipstick. With a higher cut-off value (> 3x upper reference limit) for lipase, two patients with severe acute pancreatitis remained undetected. Combining the actim Pancreatitis dipstick with serum lipase a positive predictive value of 94% was obtained. CONCLUSIONS: Acute pancreatitis can be excluded with a higher probability with the actim Pancreatitis strip than with serum lipase determination, and therefore appears to be more suitable for screening of acute pancreatitis. With its high specificity with a cut-off > 3x the upper reference limit, serum lipase is suitable as a confirmatory test for pancreatitis when a positive dipstick result is obtained.

The implementation of security in distributed infant and maternity care.

According to the Finnish National Fund for Research and Development in the information society, knowledge is the basis of education and culture and the most important production factor. ICT significantly promotes interaction and exchange between individuals, business enterprises and other organisations, utilisation of information, and provision of services and access to them. Our project is one of approximately 300 projects which are developing seamless social and health care ICT services in Finland [P. Ruotsalainen, Asiakaslähtöinen palveluketju ja tietote-knologia, Kirjassa: Nouko-S. Juvonen, P. Ruotsalainen, I. Kiikkala (toim), Hyvinvointivaltion palveluketjut. Hygieia. Kustannusosakeyhtiö Tammi, Tammer-Paino Oy, Tampere, 2000]. The principal aim is both to research and create a new model for social and health care services and to disseminate the know-how brought about for the benefit of software enterprises and educational institutes. A product called Maternity Clinic on the Net is developed in the project, and it can be applied to the national and international social and health care services.

Serum complex of trypsin 2 and alpha 1 antitrypsin as diagnostic and prognostic marker of acute pancreatitis: clinical study in consecutive patients.

OBJECTIVE: To estimate the usefulness of serum concentrations of the complex of trypsin 2 and alpha 1 antitrypsin in diagnosing and assessing the severity of acute pancreatitis in comparison with serum C reactive protein, amylase, and trypsinogen 2 concentrations (reference markers). DESIGN: Markers were measured in consecutive patients admitted with acute abdominal pain that was either due to pancreatitis or to other disease unrelated to the pancreas (controls). SETTING: Department of surgery of a teaching hospital in Helsinki. SUBJECTS: 110 patients with acute pancreatitis and 66 with acute abdominal diseases of extrapancreatic origin. On the basis of the clinical course, acute pancreatitis was classified as mild (82 patients) or severe (28 patients). MAIN OUTCOME MEASURES: Clinical diagnosis of acute pancreatitis and severity of the disease. RESULTS: At admission all patients with acute pancreatitis had clearly raised concentrations of trypsin 2-alpha 1 antitrypsin complex (32 micrograms/l), whereas only three of the controls had such values. Of the markers studied, trypsin 2-alpha 1 antitrypsin complex had the largest area under the receiver operating curve, both in differentiating acute pancreatitis from extrapancreatic disease and in differentiating mild from severe disease. CONCLUSIONS: Of the markers studied, trypsin 2-alpha 1 antitrypsin complex was the most accurate in differentiating between acute pancreatitis and extrapancreatic disease and in predicting a severe course for acute pancreatitis.

Fear conditioning is impaired in systemic kainic acid and amygdala-stimulation models of epilepsy.

PURPOSE: The lateral nucleus of the amygdala is critical for fear conditioning, a paradigm of emotional learning, which requires recognition of an unconditioned stimulus as aversive and association of conditioned stimuli with an unconditioned stimulus. Some patients with temporal lobe epilepsy have amygdaloid damage associated with impaired emotional learning. Fear conditioning also is impaired at least in some animal models of epilepsy. We studied whether contextual or tone-cued fear conditioning is impaired in two status epilepticus models of epilepsy and whether impairment correlates with the extent of damage in the lateral nucleus of the amygdala. METHODS: We induced epilepsy in rats by either systemic kainic acid administration or electrical amygdala stimulation. Behavioral reactions in all phases of fear conditioning were analyzed from videotapes. Damage to the lateral nucleus of the amygdala was analyzed from thionin-stained sections both histologically and by volumetry. RESULTS: Immediate reflexive responses to unconditioned and conditioned stimuli were preserved, whereas the freezing response to an unconditioned stimulus was reduced. Contextual conditioning was severely impaired, whereas tone-cued conditioning was better preserved. The lateral nucleus pathology did not correlate with impaired fear conditioning. CONCLUSIONS: These data suggest that processing of complex contextual stimuli is severely affected in experimental epilepsy, whereas conditioning to simple cues is better preserved.

Intra-abdominal abscess in a patient with tumour necrosis factor receptor-associated periodic syndrome.

Tumour necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS) is an autoinflammatory disorder characterized by periodic attacks of fever and inflammation, due to mutations in the gene coding for the TNF type I receptor (TNFRSF1A). A 16-year-old patient with the diagnosis of TRAPS was admitted to hospital because of fever and abdominal pain. Initially, the symptoms were interpreted as manifestations of another TRAPS attack, but the patient's condition worsened, despite treatment with corticosteroids and antibiotics. A repeated computer tomography revealed an intra-abdominal abscess, which necessitated urgent surgical intervention. This case stresses the importance of differential diagnostic vigilance when dealing with patients with rare genetic diseases.

Vasodilatory shock in severe acute pancreatitis without sepsis: is there any place for hydrocortisone treatment?

BACKGROUND: Hydrocortisone (HC) has been reported to rapidly improve hemodynamics and reduce the time to vasopressor cessation in septic shock, but none has focused on this effect in acute pancreatitis. We therefore performed a study to assess the effects of hydrocortisone on catecholamine-dependent shock among patients with severe acute pancreatitis. METHODS: A retrospective, case-controlled study among 10 patients with severe acute pancreatitis and HC treatment for catecholamine-dependent shock was performed. The control group comprised 11 conventionally treated patients with the same severity of pancreatitis and circulatory shock according to the norepinephrine support required. In focus were the first 48 h from the start of HC administration in the HC group and from the reference point in the control group, respectively. The reference point for the control group was the time point at which doses of norepinephrine exceeded 0.3 microg kg(-1) min(-1). RESULTS: Patients in the HC group were weaned off norepinephrine in a significantly shorter time (61 h in HC group vs. 141 h, P = 0.016). The HC group received significantly less norepinephrine (area under curve of norepinephrine dose, P = 0.041). The reduction in norepinephrine dose was comparable at 24 h, being -0.051 (-0.208-0.022) microg kg(-1) min(-1) in the HC group vs. -0.026 (-0.150-0.030) microg kg(-1) min(-1) in the controls (P = 0.307), and at 48 h with respective figures of -0.206 (-0.317 to -0.102) microg kg(-1) min(-1) and -0.103 (-0.178-0.029) microg kg(-1) min(-1) (P = 0.072), from the start of HC administration. CONCLUSION: According to our data it seems reasonable to formulate a hypothesis that low doses of HC shorten the time to vasopressor cessation and rapidly reduce the need for norepinephrine support in patients with shock associated with severe acute pancreatitis without sepsis.

Early prediction of organ failure by combined markers in patients with acute pancreatitis.

BACKGROUND: Several biological markers and clinical scoring systems have been used to predict the course of acute pancreatitis. Because organ failure is the most severe complication of the disease, prognostic markers and their combinations that would predict organ failure on hospital admission were sought. METHODS: Some 351 consecutive patients with acute pancreatitis were studied. Blood samples were taken within 12 h of admission. This case-control study included all 33 patients with organ failure and 99 matched controls without organ failure. Measurements included 19 prognostic markers and Acute Physiology And Chronic Health Evaluation (APACHE) II score. RESULTS: Plasma interleukin 10, serum glucose and serum calcium were identified as independent predictors of organ failure by logistic regression analysis. Calcium level correlated with clinical onset of organ failure. The combination of interleukin 10 (more than 50 pg/ml) or calcium (less than 1.65 mmol/l) was a significantly better predictor than any single marker or APACHE II score, with a sensitivity of 88 per cent, specificity 93 per cent and diagnostic odds ratio 94. CONCLUSION: Organ failure in acute pancreatitis can be predicted with high accuracy at hospital admission using a combination of plasma interleukin 10 and serum calcium measurements.

Fatal cardiac tamponade after emergency tension-free repair of a large paraesophageal hernia.

Paraesophageal hernia is an unusual disorder of the esophageal hiatus that may be associated with life-threatening mechanical problems. We report a case of a large paraesophageal hernia that presented with acute thoracic herniation and incarceration of the stomach. The patient underwent laparoscopic operation, including reduction of an intrathoracic stomach, hernial sac removal, and tension-free repair of the hiatus with polytetrafluoroethylene (PTFE) mesh. The mesh was fixed with a straight hernia stapler. Postoperatively the patient developed a fatal cardiac tamponade secondary to a coronary vein laceration due to fixation of the mesh with the stapler. Different operative techniques and possibilities for prevention of the complication are discussed.

Jejunal diverticulosis: a potentially dangerous entity.

Although jejunal diverticulosis is a rare entity and usually asymptomatic, it may cause chronic symptoms and acute complications. Because of the rarity of the entity, diagnosis is often delayed, resulting in unnecessary morbidity and mortality. The purpose of this study was to draw attention to jejunal diverticula and their complications. The medical records of 8 consecutive patients with complications due to small-bowel diverticula treated at our department during the past 4 years were reviewed. All diverticula were located in the jejunum. Seven patients had acute complications, 3 patients had an intra-abdominal abscess, 2 had free perforation with diffuse peritonitis, 1 had a bowel occlusion and 1 patient had concomitant bleeding and occlusion. One patient presented with chronic symptoms. A preoperative diagnosis of jejunal diverticula, before explorative laparotomy, was not reached in any of the 7 patients with acute symptoms. In the patient with chronic symptoms, multiple jejunal diverticula complicated by a jejuno-colic fistula and foreign body were found at laparotomy. On patient died of multiorgan failure. Small-bowel diverticulosis is a rare entity, but it should not be regarded as a clinically insignificant finding. It may be difficult to make a preoperative diagnosis. Patients with incidentally detected proximal jejunal diverticula, at imaging studies or at laparotomy, warrant close observation and awareness that the diverticula may cause serious complications.

One dose cefuroxime prophylaxis in hip fracture surgery.

One 3 g intravenous dose of cefuroxime during the induction of anaesthesia was administered randomly in a series of 162 consecutive hip fractures. The overall infection rate was 8.0%, and 2.4% for deep infections. The number of infections was seven in the prophylaxis group and six in the control group. The percentage of deep infections was 3.9 and 1.4, correspondingly. Antibiotic prophylaxis given did not seem to have an effect on the infection rate.

Superior mesenteric and portal vein thrombosis following laparoscopic nissen fundoplication.

This case report describes superior mesenteric and portal vein thrombosis after laparoscopic Nissen fundoplication. As a thromboembolic prophylaxis, 2,500 IU of dalteparin was given preoperatively. After postoperative day 19, the patient experienced gradually increasing abdominal pain, mostly related to meals. Physical examination and laboratory tests were normal. CT scan revealed a portal and superior mesenteric vein thrombosis. Dalteparin and warfarin treatment was started, and symptoms relieved rapidly. In a control Doppler ultrasound 1 month after the onset of the treatment, a good flow in the portal and superior mesenteric vein was seen. Possible mechanisms are discussed.

Expression of group II phospholipase A2 in the liver in acute pancreatitis.

BACKGROUND: A number of distinct secretory phospholipases A2 (PLA2) have been characterized in the human. Elevated group II PLA2 serum levels are associated with inflammatory diseases such as infections, septic shock, rheumatoid arthritis, multiple organ failure and acute pancreatitis. The cellular source of circulating group II PLA2 has not been defined unequivocally. The possible role of the liver as a source of circulating group II PLA2 in acute pancreatitis was studied using liver biopsies from five patients operated on for necrotizing acute pancreatitis and from two control liver samples. METHODS: Reverse transcription polymerase chain reaction (RT PCR), northern hybridization and in situ hybridization were used to study the expression of group II PLA2. Immunohistochemistry was used to study the localization of the group II PLA2 protein in liver cells and time-resolved fluoroimmunoassay to measure the plasma group II PLA2 content. RESULTS: Expression of group II PLA2 was found in the livers of patients with acute pancreatitis by RT PCR and confirmed by northern hybridization. Group II PLA2 mRNA was localized in hepatocytes by in situ hybridization. Faint immunopositivity was found in Kupffer cells. Time-resolved fluoroimmunoassay revealed elevated concentration of group II PLA2 in plasma samples. Only low levels of expression were found in the control livers. CONCLUSIONS: Group II PLA2 is expressed in the livers of patients suffering from acute pancreatitis but not in the livers of patients without pancreatic disease. The current results support the idea that hepatocytes are an important source of circulating group II PLA2 in inflammatory diseases.

Time course profile of serum trypsinogen-2 and trypsin-2-alpha1-antitrypsin in patients with acute pancreatitis.

BACKGROUND: Trypsinogen-2 and the trypsin-2-alpha1-antitrypsin complex are recently introduced new laboratory markers for acute pancreatitis. They show high sensitivity and specificity for acute pancreatitis on admission, but little is known on their time course profiles. METHODS: The serum concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin were monitored in 92 patients with verified acute pancreatitis. The follow-up period was 42 days in patients with severe acute pancreatitis (N = 73) and 9 days in mild disease (N = 19). RESULTS: On admission the mean serum concentration of trypsinogen-2 was 2880 microg/l in severe and 920 microg/l in mild acute pancreatitis. These values were 32- and 10-fold the upper reference limit, respectively. Trypsin-2-alpha1-antitrypsin concentrations were 1250 microg/l (100-fold the upper reference limit) and 635 microg/l (52-fold), respectively. The differences were statistically significant (P = 0.026-0.001). The concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin decreased gradually during the follow-up period, but they remained elevated for the entire study period in patients with severe and mild disease. CONCLUSIONS: The time course profile of trypsinogen-2 and trypsin-2-alpha1-antitrypsin is favorable for diagnosing acute pancreatitis. The elevation starts within hours after the onset of the disease and it is very steep. Both markers remain elevated longer than amylase and the magnitude of the elevation correlates with the severity of the disease. This is further evidence to support the use of trypsinogen-2 and trypsin-2-alpha1-antitrypsin for the evaluation of patients suspected of having acute pancreatitis.

Cholecystokinin in acute alcoholic and biliary pancreatitis.

BACKGROUND: Recent studies have shown that cholecystokinin (CCK) agonist, cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated plasma CCK levels in alcoholic and biliary pancreatitis on admission and during the episode of acute pancreatitis. METHODS: Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden) in 35 patients with acute alcoholic pancreatitis, in 27 patients with acute biliary pancreatitis, in 34 patients with nonpancreatic acute abdominal pain, and in 43 healthy subjects. The mean time from the first symptoms to the plasma sample was 31 (+/- 3.7) h in alcoholic pancreatitis patients and 25 (+/- 5.1) h in biliary pancreatitis patients. We also determined CCK levels in 20 patients during the episode of acute pancreatitis. Normal fasting level of CCK is < or = 1.12 pmol/L according to manufacturer. RESULTS: Basal plasma CCK concentrations were significantly lower both in alcoholic pancreatitis (mean +/- SEM, 0.04 +/- 0.03 pmol/L, p < 0.0001) and biliary pancreatitis patients (0.17 +/- 0.13 pmol/L, p < 0.0001) than in nonpancreatic acute abdominal pain patients (1.23 +/- 0.32 pmol/L) or healthy subjects (1.18 +/- 0.20 pmol/L). Plasma CCK levels also remained low until the patient was well-recovering and had started oral diet. CONCLUSION: Basal plasma CCK concentrations are significantly decreased in acute alcoholic and biliary pancreatitis after the first day from the beginning of the symptoms until the patient was well-recovering.