Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial.

BACKGROUND: Preterm newborns admitted to the Neonatal Intensive Care Unit are deprived of sensory stimulation. Tactile/kinaesthetic stimulation results in weight gain. Studies involving the cutaneous application of vegetable oils have shown improvement in somatic growth and on skin barrier function. OBJECTIVE: To assess the neurodevelopmental and biological benefits of the simultaneous use of multimodal stimulation (SMS) and the cutaneous application of vegetable oils. Setting Tertiary referral centre serving the Poitou-Charentes region of France. METHODS: Randomized controlled trial of 49 low-risk preterm infants, born at 31- to 34-week gestation. Each infant was randomly assigned to one of three treatment groups, Sensori-Tonico-Motor (STM) touch for 10 days with either: sweet almond oil, ISIO4 blended oil, or placebo - normal saline, or to a control group who did not receive any intervention. The primary outcome was weight gain. Secondary outcomes were linear growth, neurological maturation, psychomotor development and number of days of admission. Analysis was by intention-to-treat. RESULTS: The group who received STM with ISIO4 oil demonstrated enhanced weight gain (+57%, 95% CI 37-76) compared with controls (P = 0.030). All STM groups showed shorter admission times (mean reduction 15 days, 95% CI 23-50 days hospitalised, P = 0.005), and an increase in body length (P = 0.030). Both groups of oil massaged babies (almond and ISIO4) showed an increased neurological score (P = 0.001) compared to controls. The infants receiving ISIO4 oil had an associated increase in psychomotor scores (P = 0.028), time spent in quiet wakefulness (P = 0.036), improved orientation (P = 0.036), and enhanced development of the oculomotor (P = 0.012) and sensorimotor (P = 0.003) systems. An additional benefit seen was improved moisturization (P = 0.001), and quicker recovery of dermatological conditions. No adverse dermatological events were observed. CONCLUSIONS: The combination of STM and cutaneous application of oils to healthy preterm babies resulted in enhanced weight gain and neurological development, and a shorter stay in hospital.

[A case of atypical pericarditis]. / Une péricardite atypique.

INTRODUCTION: An acute viral pericarditis may reveal a congenital pericardial abnormality. CASE HISTORY: We report the case of a young man of 29 years in whom the development of rapidly progressive dyspnoea and fever led to the echocardiographic diagnosis of a pericardial tumour. The thoracic CT scan showed a mass arising in the superior mediastinum with no evidence of spread. Surgical exploration allowed the excision of a soft mutilobular mass adherent only to the aorta. Histological examination revealed an intrapericardial bronchogenic cyst. CONCLUSION: After a review of bronchogenic cysts we point out the properties of this rare intra-pericardial localisation, one of which is the frequently observed secretion of CA 19-9.

Early angiography cannot predict postthrombolytic coronary reocclusion: observations from the GUSTO angiographic study. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries.

OBJECTIVES: The purpose of this study was to determine whether early qualitative or quantitative angiographic features can predict reocclusion after initially successful coronary thrombolysis. BACKGROUND: Although both the benefits of early reperfusion and the consequences of subsequent reocclusion after thrombolysis for acute myocardial infarction have been well described, efforts to describe angiographic markers of lesions at high risk for reocclusion have produced conflicting results. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient cohort studied to date. METHODS: We studied 559 patients undergoing follow-up angiography at 90 min and 5 to 7 days after thrombolysis in the GUSTO trial. Patients received one of four thrombolytic regimens: 1) streptokinase with intravenous heparin; 2) streptokinase with subcutaneous heparin; 3) accelerated-dose recombinant tissue-type plasminogen activator (rt-PA) with intravenous heparin; or 4) a combination of streptokinase and conventionally dosed rt-PA with intravenous heparin. Qualitative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) flow grade, visible thrombus and lesion morphology. Quantitative variables included percent diameter stenosis, percent area stenosis, minimal lumen diameter and lesion length. The study contained a power > 0.85 to detect clinically important differences in percent diameter stenosis, percent area stenosis and minimal lumen diameter between the groups with subsequent reocclusion and sustained patency at the p = 0.05 level. RESULTS: At follow-up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group with reocclusion was compared with the group with continued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, percent area stenosis, minimal lumen diameter or lesion length. CONCLUSIONS: Our findings demonstrate that neither qualitative nor quantitative angiographic variables at 90 min after initiation of thrombolytic therapy can be used to predict subsequent coronary reocclusion.

One-week and six-month angiographic controls of stent implantation after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction.

We prospectively assessed in 124 consecutive patients by means of 1-week and 6-month follow-up angiograms the rate of reocclusion and restenosis of coronary stenting with Palmaz-Schatz stents after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction (AMI). Patients were further evaluated clinically at 1 year. Stenting was performed on large (>3.2 mm) coronary arteries for suboptimal results (47%), occlusive (8%), or nonocclusive dissections (45%) after balloon angioplasty. Stents were delivered using the bare stent technique and high pressure inflations (>12 atm). All patients received ticlopidine 250 mg (500 mg if weight was >80 kg) and aspirin 100 mg for 1 month. No patient received warfarin. At 1 week, 6 patients died of cardiogenic shock and 2 of right ventricular infarction. One subacute occlusion occurred at day 14. At 6 months, in 95 patients, the angiographic restenosis rate (>50% diameter stenosis) was 19%. One-year clinical follow-up, available in 55 patients, indicated cardiac death in 5, and repeat revascularization in 3. Thus, coronary stenting on large (>3.2 mm) coronary arteries after occlusive and nonocclusive dissection during primary balloon angioplasty for AMI using bare Palmaz-Schatz stents, high pressures, ticlopidine, and aspirin is safe. Our reocclusion and restenosis rates are similar to those of trials on elective stenting in stable patients.

[Left pulmonary artery originating from the ascending aorta in tetralogy of Fallot. Therapeutic strategy]. / Artère pulmonaire gauche naissant de l'aorte ascendante dans une tétralogie de Fallot. Stratégie thérapeutique.

The authors report the rare case of a 12 year old child with an anomalous origin of the left pulmonary artery from the ascending aorta associated with Tetralogy of Fallot. This complex congenital malformation was treated surgically by a Deleval anastanosis between the right subclavian and right pulmonary arteries. The result was good with a 9 year follow-up, the patient having only Grade II effort duspnoea and cyanosis. The authors discuss the advantages and drawbacks of the different possible surgical approaches to this problem in the light of the outcome of this case and a review of the literature.

[Doppler echocardiographic evaluation of left ventricular wall stress in aortic stenosis]. / Evaluation en échocardiographie doppler des contraintes pariétales du ventricule gauche dans le rétrécissement aortique.

The measurement of wall stress allows study of morphological adaptation of the left ventricle, especially in conditions associated with symmetric hypertrophy (hypertension, aortic stenosis). The calculation is performed in hypertensive heart disease but not in aortic stenosis because of the ventriculo-aortic pressure gradient. In a preliminary study, the authors validated the peak systolic left ventricular pressure calculated by adding the systolic brachial artery pressure to the maximal transvalvular pressure gradient by comparing the value with that obtained by catheterization in 21 patients with aortic stenosis. The second phase of the study was to measure meridian and circumferential wall stress prospectively in 35 patients with aortic stenosis (29 symptomatic, 6 asymptomatic) and to compare the results with those observed in 21 normal subjects. In the latter group, the values were 151 +/- 22 and 311 +/- 37 10(3) dynes/cm2 respectively, whereas in asymptomatic aortic stenosis the stresses were 136 +/- 28 and 303 +/- 41 10(3) dynes/cm2 respectively (NS) and in symptomatic aortic stenosis 210 +/- 55 and 437 +/- 94 10(3) dynes/cm2 respectively (p < 0.0001). None of the cases of asymptomatic aortic stenosis had raised wall stress values whereas only 6 symptomatic aortic stenosis patients had normal wall stress. The values of wall stress obtained using the method proposed were comparable to those reported by other authors with invasive investigations. Non-invasive measurement of wall stress by Doppler echocardiography may be proposed as a method of evaluation of left ventricular adaptation, especially in severe stenosis and in patients with a patent geometric abnormality (abnormal dilatation or even an inadequately hypertrophied wall).

[Coronary angiography by left radial approach. A bi-center prospective pilot study]. / Coronarographie par voie radiale gauche. Une étude pilote prospective bicentrique.

The aim of this study was to assess prospectively the feasibility, safety and quality of coronary angiography performed by a left radial arterial approach. The investigation was performed under local anesthesia with a Lidocaine gel using Judkins 5f catheter. A bolus of heparin was injected intravenously at the start of the procedure (no heparin in phase 0.2 to 3.000 IU during phase 1 and 5.000 IU in phase 2). Between March 1994 and January 1996, after exclusion of 108 patients (15.1%) mainly because of an abnormal Allen test, coronary angiography was carried out in 540 patients aged 58.4 +/- 11.7 years, 85% of whom were men. The failure rate was 8%. The quality of opacification of the left coronary artery (scale 1 to 3) was 2.91 +/- 0.27 and of the right coronary artery was 2.96 +/- 0.18. There were no complications during the procedure. Analysis of the learning curve showed a failure rate decreasing to less than 5% after 60 procedures/operator. In the last 100 procedures, the failure rate fell to 3%, the canulation time was 2.2 +/- 2.5 min, the duration of fluoroscopy was 6.5 +/- 3.9 min and the duration of the procedure was 17.5 +/- 4.7 min (14.7 +/- 3.8 min, p < 0.01, by the femoral approach). Clinical and Doppler ultrasonographic follow-up revealed one in-hospital complication (a spontaneously regressive compressive haematoma). No clinical complications were observed at 3 months. Doppler ultrasonography showed the radial artery occlusion rate to be 71% in phase 0.32% in phase 1 and 3.2% in phase 2 (p < 0.0001). These results show that the left radial arterial approach for coronary angiography is safe and effective but requires a period of training. A 5.000 IU dose of heparin limits the risk of radial artery occlusion to 3%. The absence of complications in this large series which included the training period and the patient comfort suggest that this technique may be an excellent alternative to the femoral approach and especially the brachial approach when the Allen test is normal.

[The use of laser fluorometry of NADH in cardiology]. / Applications de la fluorimétrie laser du NADH en cardiologie.

In this paper the first results of experimental studies of myocardial energy metabolism conducted in situ by laser fluorimetry are described. With this method the myocardial oxygen uptake is determined by measuring the fluorescence of NADH (reduced nicotinamide adenine dinucleotide). The equipment required consists of pulsed laser beams in the ultraviolet (337 nm) and visible (586 nm) spectra, very thin catheters with a single optic fibre, and an original digital data processing technique. The first applications envisaged concern: 1. pharmacological studies, notably evaluation of the protective effect of drugs against ischaemia; 2. evaluation of revascularization procedures in emergency surgery, notably assessment of reversibility of the ischaemic lesions; 3. monitoring of myocardial protection during cardiac surgery.

[Transluminal coronary angioplasty in the acute phase of myocardial infarction]. / Place de l'angioplastie transluminale des coronaires dans le traitement de l'infarctus du myocarde à la phase aiguë.

The objective of the treatment of myocardial infarction is to reestablish patency of the occluded artery as soon as possible. Two methods have been validated: intravenous thrombolysis which is easy to perform, and transluminal coronary angioplasty requiring expensive infrastructures and a skilled medical team but which has a higher success rate of restoring arterial patency. Angioplasty is indicated in cardiogenic shock and cases in which there is diagnostic uncertainty or a contraindication to thrombolysis. In addition, its superiority over thrombolysis has been clearly demonstrated in the following indications: 1) primary angioplasty if proper facilities with an experienced team are available in less than 45 minutes and 2) after failed thrombolysis (rescue angioplasty). The use of stents improves the results of primary angioplasty. Angioplasty and thrombolysis are not rival techniques: the choice depends on local conditions (proximity to a catheterization laboratory with a trained medical team) and the clinical context (presence of "high-risk" criteria). Their association (prehospital thrombolysis followed by immediate angioplasty) is the object of prospective clinical trials.

[Treatment of stable angina. Coronary angioplasty versus medical treatment]. / Traitement de l'angor stable. Angioplastie coronaire versus traitement médical.

Stable angina is a common clinical condition in everyday practice. Several studies (ACME, MASS, RITA 2) compared the efficacy of angioplasty with medical management in this context with concordant results: significant reduction in the frequency of angina and improved exercise capacity, without reduction in the number of serious events (death, infarction). Even though developments in the field of angioplasty have provided better clinical results, especially with the use of stents, the indication of dilatation should be clearly defined by a series of clinical and angiographic parameters. Although resistance to well conducted medical treatment is an indication for revascularisation when possible, the indications should be reconsidered if persistent ischaemia with medical therapy has not been proved.

[Doppler evaluation of blood flow of the lower limb]. / Evaluation du débit sanguin de membre inférieur par méthode doppler.

UNLABELLED: Regional blood flow measurement in the limbs (BFLL) is of special interest in order to evaluate the consequences of hypertension. The purpose of this study is to assess the interest of the Doppler ultrasound method in the BFLL measurement among normotensive or borderline hypertensives young male adults. BFLL reproducibility was evaluated among 23 healthy subjects aged 21 +/- 2 y, height 177 +/- 8 cm, weight 75 +/- 13 kg at day one (D1) and three day later (D3). Measurements were made basically after 20 minutes lying at rest and after cold pressor test (CPT). BFLL estimation depends on common femoral artery diameter (FAD) echographic measurement at the thigh root and on velocity time interval (VTI) calculation with pulsed wave doppler using controlled incident angle and sample volume. The following parameters were measured: mean arterial pressure (MAP) using Dinamap, heart rate (HR), FAD, common femoral artery cross sectorial area (A), VTI and peripheral arteriolar resistances (PAR). Basic and CPT results at D1 and D3 were compared using paired "t" test. RESULTS: [table: see text] Comparisons between basic state and CPT demonstrate a significant decrease of VTI and BFLL, a significant increase of PAR. D remained unchanged. Doppler ultrasound method is easy to use. Systolic femoral volume measurement is relatively insensitive to small transducer positioning variations so that the method reproducibility is satisfactory.

[Demonstration of muscular activity in the human aorta. Effects of trinitrin]. / Mise en évidence d'une activité musculaire au niveau de l'aorte humaine. Effet de la trinitrine.

The human thoracic aorta is usually considered to be a purely elastic vessel. Transoesophageal echo-cardiography (TEE) provides a new approach to study the mechanical properties of the descending aorta. The aim of the study was to evaluate the reproducibility and accuracy of M mode recordings of the human descending thoracic aorta and to appreciate the changes produced by an infusion of glyceryl trinitrate (GTN). The reproducibility of M mode recordings was studied in vitro on plexiglass tubes of different calibre, and also in vivo, the inter and intra-observer error was estimated to 0.6% in vitro and 1% in vivo. The accuracy of the method was evaluated in vitro by comparing the measured values (MV) with the actual diameters of the plexiglass tubes (T): MV = 1.012T + 0.9; r = 0.99; SE = 0.8 mm. The systolic and diastolic diameters of the descending thoracic aorta were measured in 8 healthy volunteers by TEE, before and during continuous intravenous infusion of GTN at a rate of 0.9 mg/hr and then 1.35 mg/hr after a 10 minutes interval. Systolic and diastolic blood pressures were recorded automatically every minute. The results showed a very significant increase in the systolic (from 20.3 +/- 0.7 to 20.9 +/- 1.3 and 22.1 +/- 2.2 mm) and diastolic diameters of the aorta (from 18.3 +/- 0.7 to 19.1 +/- 1.4 and 20.1 +/- 2.4 mm) despite a fall in systolic blood pressure (from 121.3 +/- 7.7 to 114.5 +/- 6.6 and 108.4 +/- 5.4 mmHg). This study shows that TEE is a reliable and reproducible method of measuring the diameter of the human descending thoracic aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arrhythmia and syndrome of obstructive sleep apnea in adults]. / Arythmies et syndrome d'apnées obstructives du sommeil de l'adulte.

Many nocturnal cardiac arrhythmias and conduction defects have been reported in the adult sleep apnoea syndrome. The most original is the great variability of the heart rate which is cyclical and related to the apnoeic episodes, and easily differentiated from simple respiratory sinus arrhythmia. It is characterised by an initial bradycardia followed by rebound tachycardia. The bradycardia is vagally dependent (inhibited by atropine) probably secondary to carotid chemoreceptor stimulation by the hypoxaemia. The tachycardia is mainly attributed to the cessation of vagal hypertonicity although catecholamine stimulation has been suggested. The origin of these changes is purely functional, regressing with treatment of apnoea (waking, tracheotomy), the maintenance of arterial oxygen concentrations with oxygen therapy and parasympathetic blockade (atropine). The intensity of the phenomenon is related to the degree of arterial desaturation, which is itself related to basal arterial saturation (SaO2) and the duration of the apnoeas. Prolonged systole due to paroxysmal sino-atrial or atrioventricular block may be observed at night in these patients. The influence of vagal overactivity is confirmed (suppression of vagotomy) with no organic pathology (diurnal absence, tracheotomy, normal electrophysiological testing) in favour of a relationship with apnoea. Though less common than conduction abnormalities, atrial arrhythmias (extrasystoles, flutter, fibrillation) are also possible complications of sleep apnoea. The absence of an organic substrate is indicated by their regression post-tracheotomy and the efficacy of atropine (again in favour of a vagally-induced mechanism). Finally, nocturnal ventricular hyper-excitabilty is sometimes observed, the probable mechanism being the association of severe hypoxaemias (SaO2 < 60%) and the increased sympathetic tone at the end of the apnoea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value and indication of the use of 2 internal mammary arteries in repeated coronary surgery]. / Intérêt et indication de l'utilisation des 2 artères mammaires internes dans la chirurgie coronaire redux.

Forty-nine patients who had coronary artery reoperations were divided into two groups: the 29 patients of the first group were operated conventionally with use of one internal mammary artery or a saphenous vein; the 20 patients of the second group were reoperated using both internal mammary arteries. Three patients (6%) died prematurely: two in the first and one in the second group. The rates of peri-operative infarction were 7% and 15% respectively. The average postoperative bleeding was 472 +/- 385 ml in the first group and 700 +/- 628 ml in the second group (NS). All patients are pauci-symptomatic and have a negative exercise stress test. The mortality and morbidity of coronary reoperation does not seem to be greater with double internal mammary artery bypass grafting. However, this technique should be reserved for patients who can derive long-term benefit from reoperation with arterial grafts, that is to say in patients in good clinical condition, less than 65 years of age with good left ventricular function. In these patients, double internal mammary artery bypass grafting may avoid a third operation for myocardial revascularisation.

[Angioplasty with stent of the common trunk of the left coronary artery with abnormal origin at the level of the right anterior sinus and with a retro-aortic trajectory]. / Angioplastie avec stent d'un tronc commun de la coronaire gauche à naissance anormale au niveau du sinus antéro-droit et à trajet rétro-aortique.

The authors report a case of angioplasty with implantation of a stent in an anomalous left main coronary artery arising from the right anterior sinus of Valsalva with a retro-aortic trajectory. The introduction of stenting has made angioplasty of anomalous coronary arteries a possible alternative to surgery with the reserve of a high risk of restenosis when the lesion is distal and situated at a bifurcation.

[In coronary surgery can both internal mammary arteries be used systematically? Apropos of 560 patients]. / En chirurgie coronaire l'utilisation des deux artères mammaires internes peut-elle être systématique? A propos de 560 patients.

The grafts commonly used in coronary bypass surgery are the left internal mammary artery and the saphenous veins of the legs: the use of both internal mammary arteries, with potential long-term benefits, is only justified if the operative risk is not increased. Since 1987, the authors use both internal mammary arteries systematically in patients under 70 years of age and in good general condition. The retrospective analysis of 560 patients having undergone this surgery from 1987 to 1994 was undertaken to determine if this surgical option is justified without increased operative risk. The dissection of the mammary arteries is performed in a special manner by skeletonization technique. The total hospital complication rate was 12% with 9 deaths in the first 30 postoperative days (1.6%). Mediastinitis was observed in 6 patients (1.1%) Early angiographic controls showed a patent mammary graft rate of 98%. The use of both internal mammary arteries does not therefore increase postoperative morbidity or mortality. It may be proposed systematically in patients in good general condition and may provide long-term benefits in graft patency rates.

[Management during the first hours following myocardial infarction. Round table]. / Prise en charge dans les premières heures de l'infarctus du myocarde. Table ronde.

Myocardial infarction, due to complete occlusion of a coronary artery, is a frequent disease which must be diagnosed as rapidly as possible on the basis of clinical and electrocardiographic arguments in order to allow rapid medicalized management; medical ambulance, followed by admission to the intensive care unit. Treatment is designed to disobstruct the coronary occlusion as rapidly as possible, either by intravenous fibrinolysis or by percutaneous transluminal coronary angioplasty in a specialized centre. The subsequent assessment (stress test, coronary angiography) guides the indications for secondary revascularization.

[Isolated atrial fibrillation. The risk of embolism and its prevention]. / Fibrillation auriculaire isolée. Le risque embolique et sa prévention.

Whether or not atrial fibrillation is alone, if not idiopathic, is difficult to determine. The risk of embolization in lone atrial fibrillation is distinctly higher in healthy subjects over 60 years of age when the left atrium is dilated. In chronic atrial fibrillation this risk is higher than in paroxysmal fibrillation, especially within the year following the onset of the arrhythmia. In most patients anticoagulant therapy is effective in the primary or secondary prevention of embolic accidents. In subjects older than 75 aspirin given in daily doses of 325 mg seems to give similar results. The risk of antithrombosis therapy must not be underevaluated. The alternative is to maintain or restore the sinus rhythm, even at an advanced age, if the arrhythmia is recent and the left atrium is moderately dilated.

[Coronary embolism revealing mitral valve stenosis]. / Embolie coronaire révélatrice d'un rétrécissement mitral.

We report a case of myocardial infarction with normal coronary arteriography in a 39-year-old woman presenting with tight mitral stenosis complicated by atrial extrasystoles and spontaneous atrial contrast at echocardiography. The diagnosis of coronary embolism was most probable. Coronary embolism is a rare disease, usually due to a blood clot or, less frequently, to a vegetation of endocarditis starting in a heart valve. The left network is usually involved, with typical myocardial necrosis. Coronary arteriography is sufficient to make the diagnosis. Preventive treatment is essential.