• 13-Valent vaccine serotype pneumococcal community acquired pneumonia in adults in high clinical risk groups.

      Bewick, Tom; Greenwood, S (2018-02)
      There is debate regarding the value of vaccinating adults with the 13-valent pneumococcal conjugate vaccine (PCV-13). This analysis was conducted to investigate the risk of PCV-13 serotype community acquired pneumonia (CAP) in hospitalised adults with co-morbid disease and risk factors for pneumococcal disease in the UK. Consecutive adults hospitalised (2008-2013) with a primary diagnosis of CAP, were recruited. Pneumococcal aetiology disease was identified by use of pneumococcal urinary antigen detection and serotype identification using a validated multiplex immunoassay or serum latex agglutination. Adults with PCV-13 serotype CAP were compared to those with non-PCV-13 serotype CAP. Of 2224 patients, PCV-13 serotype CAP was identified in 337 (15.2%) and non-PCV-13 serotype CAP in 250 (11.2%) individuals. Adults aged ≥65 years with one or more clinical risk factors had a significantly lower risk of PCV-13 serotype CAP compared to those aged 16-64 years without clinical risk factors (aOR 0.61, 95%CI 0.41-0.92, p = .018). In a stacked-risk analysis, the presence of incremental clinical risk factors was associated with lower odds of PCV-13 disease (p for trend = .029) Adults with underlying chronic respiratory disease (aOR) 0.56, 95% CI 0.36-0.85, p = .007) and chronic kidney disease (aOR 0.48, 95% CI 0.25-0.92, p = .028) had significantly lower adjusted odds of PCV-13 compared to non-PCV-13 serotype CAP. This analysis suggests that in the UK, the burden of PCV13 disease is greater in adults outside the traditional 'at-risk' groups compared to adults in 'at-risk' groups.
    • A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy.

      Fluck, Richard (2017-04)
      BACKGROUND: Patients who start renal replacement therapy (RRT) for End-Stage Kidney Disease (ESKD) without having had timely access to specialist renal services have poor outcomes. At one NHS Trust in England, a community-wide CKD management system has led to a decline in the incident rate of RRT and the lowest percentage of patients presenting within 90 days of starting RRT in the UK. We describe the protocol for a quality improvement project to scale up and evaluate this innovation. METHODS: The intervention is based upon an off-line database that integrates laboratory results from blood samples taken in all settings stored under different identifying labels relating to the same patient. Graphs of estimated glomerular filtration rate (eGFR) over time are generated for patients <65 years with an incoming eGFR <50 ml/min/1.73 m(2) and patients >65 years with an incoming eGFR <40 ml/min/1.73 m(2). Graphs where kidney function is deteriorating are flagged by a laboratory scientist and details sent to the primary care doctor (GP) with a prompt that further action may be needed. We will evaluate the impact of implementing this intervention across a large population served by a number of UK renal centres using a mixed methods approach. We are following a stepped-wedge design. The order of implementation among participating centres will be randomly allocated. Implementation will proceed with unidirectional steps from control group to intervention group until all centres are generating graphs of eGFR over time. The primary outcome for the quantitative evaluation is the proportion of patients referred to specialist renal services within 90 days of commencing RRT, using data collected routinely by the UK Renal Registry. The qualitative evaluation will investigate facilitators and barriers to adoption and spread of the intervention. It will include: semi-structured interviews with laboratory staff, renal centre staff and service commissioners; an online survey of GPs receiving the intervention; and focus groups of primary care staff. DISCUSSION: Late presentation to nephrology for patients with ESKD is a source of potentially avoidable harm. This protocol describes a robust quantitative and qualitative evaluation of a quality improvement intervention to reduce late presentation and improve the outcomes for patients with ESKD.
    • A randomised controlled study of mouth swab testing versus same day blood tests for HIV infection in young people attending a community drug service.

      Apoola, Ade (2011-01)
      INTRODUCTION AND AIMS: This study was designed to determine whether providing an oral swab test in the community for blood borne virus testing leads to an increase in subsequent attendance for sexually transmitted infection (STI) screening at the STI clinic compared with making appointments for young people to attend the clinic for same day HIV testing and STI screening. DESIGN AND METHODS: Participants were randomised into either the oral swab test group or the blood test group of the trial if eligible. RESULTS: All the 27 participants in the oral swab test group were tested for HIV and hepatitis C compared with five for HIV and two for hepatitis C in the blood test group (P < 0.001). Only two of the 27 participants in the blood test group were tested for hepatitis B compared with 25 in the oral swab test group (P < 0.001). Nine participants in the oral swab test group attended the STI clinic for STI screening compared with three in the blood test group (P = 0.09). DISCUSSION AND CONCLUSIONS: An oral swab test in the community for blood borne virus testing leads to an increase in the number of young high-risk people tested for blood borne infections and is associated with a trend towards higher rates of subsequent attendance for STI screening.
    • A simple care bundle for use in acute kidney injury: a propensity score matched cohort study.

      Kolhe, Nitin; Taal, Maarten; Selby, Nicholas; Fluck, Richard; Leung, Janson; Reilly, Timothy; Swinscoe, Kirsty (2016-05)
      BACKGROUND: Consensus guidelines for acute kidney injury (AKI) have recommended prompt treatment including attention to fluid balance, drug dosing and avoidance of nephrotoxins. These simple measures can be incorporated in a care bundle to facilitate early implementation. The objective of this study was to assess the effect of compliance with the AKI care bundle (AKI-CB) on in-hospital case-fatality and AKI progression. METHODS: In this larger, propensity score-matched cohort of multifactorial AKI, we examined the impact of compliance with an AKI-CB in 3717 consecutive episodes of AKI in 3518 patients between 1 August 2013 and 31 January 2015. Propensity score matching was performed to match 939 AKI events where the AKI-CB was completed with 1823 AKI events where AKI-CB was not completed. RESULTS: The AKI-CB was completed in 25.6% of patients within 24 h. The unadjusted case-fatality was higher when the AKI-CB was not completed versus when the AKI-CB was completed (24.4 versus 20.4%, P = 0.017). In multivariable analysis, AKI-CB completion within 24 h was associated with lower odds for in-hospital death [odds ratio (OR): 0.76; 95% confidence interval (95% CI): 0.62-0.92]. Increasing age (OR: 1.04; 95% CI: 1.03-1.05), hospital-acquired AKI (OR: 1.28; 95% CI: 1.04-1.58), AKI stage 2 (OR: 1.91; 95% CI: 1.53-2.39) and increasing Charlson's comorbidity index (CCI) [OR: 3.31 (95% CI: 2.37-4.64) for CCI of more than 5 compared with zero] had higher odds for death, whereas AKI during elective admission was associated with lower odds for death (OR: 0.29; 95% CI: 0.16-0.52). Progression to higher AKI stages was lower when the AKI-CB was completed (4.2 versus 6.7%, P = 0.02). CONCLUSIONS: Compliance with an AKI-CB was associated with lower mortality and reduced progression of AKI to higher stages. The AKI-CB is simple and inexpensive, and could therefore be applied in all healthcare settings to improve outcomes.
    • Accidental finding of a toothpick in the porta hepatis during laparoscopic cholecystectomy: a case report.

      Al-Khyatt, Waleed; Rashid, Farhan; Iftikhar, Syed (2011-08)
      INTRODUCTION: Unintentional ingestion of a toothpick is not an uncommon event. Often the ingested toothpicks spontaneously pass through the gut without sequelae. However, serious complications can happen when these sharp objects migrate through the gastrointestinal wall. CASE PRESENTATION: In the current report, we describe the case of a 37-year-old Caucasian woman with an incidental finding of a toothpick in the porta hepatis during laparoscopic cholecystectomy for symptomatic gall stones. CONCLUSION: Toothpick ingestion is not an uncommon event and can predispose patients to serious complications. In this particular case, the toothpick was only discovered at the time of unrelated surgery. Therefore, it was important during surgery to exclude any related or missed injury to the adjacent structures by this sharp object.
    • Achieving Thoracic Oncology data collection in Europe: a precursor study in 35 Countries.

      Beckett, Paul (2018-11)
      BACKGROUND: A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire. METHODS: Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months. RESULTS: Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses. CONCLUSION: Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a well-designed dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.
    • Acid Reflux Is Common in Patients With Gastroesophageal Reflux Disease After One-Anastomosis Gastric Bypass.

      Krivan, Sylvia
      INTRODUCTION: Patients with one-anastomosis gastric bypass (OAGB) can develop gastroesophageal reflux disease (GERD). The nature of this GERD (acid or biliary) remains unclear. OBJECTIVE: To assess the nature of GERD via impedance pH testing in patients presenting with reflux post OAGB. METHODS: Retrospective analysis of a prospectively collected database of 43 patients with OAGB backgrounds who developed postoperative GERD and were investigated with impedance pH monitoring between 2006 and 2019. RESULTS: Mean age was 52.48 ± 9 years. Mean body mass index (BMI) prior to OAGB was 46.82 kg/m2. None of these patients had clinical GERD before surgery. The median time interval between surgery and investigation with 24-h impedance pH monitoring was 64 (56) months. The mean BMI at the time of investigations was 32.67 ± 6.9 kg/m2. The type of reflux was acid in 13 (30.2%), non-acid (biliary) in 12 (27.9%), and mixed (acid and biliary) in 5 (11.6%) patients. However, it remained not confirmed in 13 (30.2%). Median DeMeester score was 48.95 (27.67) in patients with acid, 2.8 (7.4) in patients with biliary, and 28.7 (5.6) in patients with mixed reflux. Median percent of time spent with pH < 4 was 9.65 (8) in patients with acid, 0.6 (1.75) in patients with biliary, and 7.7 (3.9) in patients with mixed reflux. CONCLUSION: Acid reflux seems to be as common as bile reflux in patients presenting with GERD after OAGB. In case of revisional surgery for severe GERD post OAGB, 24-h impedance pH monitoring could be essential to determine the surgical procedure of choice.
    • Acute intestinal obstruction secondary to left paraduodenal hernia: a case report and literature review.

      Al-Khyatt, Waleed; Aggarwal, Smeer; Birchall, James; Rowlands, Timothy (2013-01)
      INTRODUCTION: An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias. METHODS: A literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH). RESULTS: In Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 – 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH. CONCLUSION: Intestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome.
    • Acute kidney injury associated with COVID-19: A retrospective cohort study

      Kolhe, Nitin; Fluck, Richard; Selby, Nicholas; Taal, Maarten (2020-10)
      Background: Initial reports indicate a high incidence of acute kidney injury (AKI) in Coronavirus Disease 2019 (COVID-19), but more data are required to clarify if COVID-19 is an independent risk factor for AKI and how COVID-19–associated AKI may differ from AKI due to other causes. We therefore sought to study the relationship between COVID-19, AKI, and outcomes in a retrospective cohort of patients admitted to 2 acute hospitals in Derby, United Kingdom. Methods and findings: We extracted electronic data from 4,759 hospitalised patients who were tested for COVID-19 between 5 March 2020 and 12 May 2020. The data were linked to electronic patient records and laboratory information management systems. The primary outcome was AKI, and secondary outcomes included in-hospital mortality, need for ventilatory support, intensive care unit (ICU) admission, and length of stay. As compared to the COVID-19–negative group (n = 3,374), COVID-19 patients (n = 1,161) were older (72.1 ± 16.1 versus 65.3 ± 20.4 years, p < 0.001), had a greater proportion of men (56.6% versus 44.9%, p < 0.001), greater proportion of Asian ethnicity (8.3% versus 4.0%, p < 0.001), and lower proportion of white ethnicity (75.5% versus 82.5%, p < 0.001). AKI developed in 304 (26.2%) COVID-19–positive patients (COVID-19 AKI) and 420 (12.4%) COVID-19–negative patients (AKI controls). COVID-19 patients aged 65 to 84 years (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.11 to 2.50), needing mechanical ventilation (OR 8.74, 95% CI 5.27 to 14.77), having congestive cardiac failure (OR 1.72, 95% CI 1.18 to 2.50), chronic liver disease (OR 3.43, 95% CI 1.17 to 10.00), and chronic kidney disease (CKD) (OR 2.81, 95% CI 1.97 to 4.01) had higher odds for developing AKI. Mortality was higher in COVID-19 AKI versus COVID-19 patients without AKI (60.5% versus 27.4%, p < 0.001), and AKI was an independent predictor of mortality (OR 3.27, 95% CI 2.39 to 4.48). Compared with AKI controls, COVID-19 AKI was observed in a higher proportion of men (58.9% versus 51%, p = 0.04) and lower proportion with white ethnicity (74.7% versus 86.9%, p = 0.003); was more frequently associated with cerebrovascular disease (11.8% versus 6.0%, p = 0.006), chronic lung disease (28.0% versus 19.3%, p = 0.007), diabetes (24.7% versus 17.9%, p = 0.03), and CKD (34.2% versus 20.0%, p < 0.001); and was more likely to be hospital acquired (61.2% versus 46.4%, p < 0.001). Mortality was higher in the COVID-19 AKI as compared to the control AKI group (60.5% versus 27.6%, p < 0.001). In multivariable analysis, AKI patients aged 65 to 84 years, (OR 3.08, 95% CI 1.77 to 5.35) and ≥85 years of age (OR 3.54, 95% CI 1.87 to 6.70), peak AKI stage 2 (OR 1.74, 95% CI 1.05 to 2.90), AKI stage 3 (OR 2.01, 95% CI 1.13 to 3.57), and COVID-19 (OR 3.80, 95% CI 2.62 to 5.51) had higher odds of death. Limitations of the study include retrospective design, lack of urinalysis data, and low ethnic diversity of the region. Conclusions: We observed a high incidence of AKI in patients with COVID-19 that was associated with a 3-fold higher odds of death than COVID-19 without AKI and a 4-fold higher odds of death than AKI due to other causes. These data indicate that patients with COVID-19 should be monitored for the development of AKI and measures taken to prevent this. Trial registration: ClinicalTrials.gov NCT04407156
    • Acute kidney injury in urology patients: incidence, causes and outcomes.

      Caddeo, Giacomo; Williams, Simon; McIntyre, Christopher; Selby, Nicholas (2013-11)
      BACKGROUND: Acute kidney injury (AKI) is common in hospitalised patients and is associated with high mortality rates. However, the epidemiology of AKI in urology patients may differ due to a higher proportion of post-renal causes and surgical procedures that result in the intentional removal of renal parenchyma. OBJECTIVES: We performed a study to examine the incidence, aetiology and outcomes of AKI in a urological population. PATIENTS AND METHODS: We performed a single-centre observational study including all hospitalised patients who sustained AKI within the Urology Department over an 18 month period. Patients with AKI were prospectively identified by a hospital-wide, electronic AKI reporting system that also allows demographic, hospital admission and co-morbidity data collection. Data regarding aetiology of AKI and details of surgical procedures were added retrospectively by manual case-note search. RESULTS: 587 episodes of AKI occurred in 410 urology patients, giving an overall incidence of 6.7%. 137 (33.4%) were elective cases of whom 58 had undergone nephrectomy (radical and partial). Urinary obstruction and sepsis were the predominant causes of AKI in the 273 patients (66.6%) admitted as an emergency. Overall 30-day mortality was 7.8%; increasing severity of AKI was associated with mortality (4.8% in stage 1, 9.1% in stage 2, 14.9% in stage 3, P = 0.007). At time of discharge, only 57.7% of patients had recovered pre-morbid renal function. The observational nature of this study is a limitation, preventing determination of causality of associations. CONCLUSIONS: AKI is common in urology patients. The underlying aetiologies of AKI in this group may explain a lower overall mortality, although increasing AKI severity remains a marker of patients at higher risk of poor outcomes. The low rate of renal recovery suggests that urology patients who sustain AKI are exposed to a significant risk of CKD and its attendant consequences for long term health.
    • Acute kidney injury is independently associated with death in patients with cirrhosis

      Scott, Robert; Austin, Andrew; Kolhe, Nitin; McIntyre, Christopher; Selby, Nicholas (2013-07)
      BACKGROUND AND AIMS: Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes. METHODS: We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI. RESULTS: 162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child-Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0-8.75) versus 16.0 days (IQR 6.0-27.5), p<0.001. Multivariate analysis identified AKI and Child-Pugh classes B and C as independent factors associated with mortality. CONCLUSIONS: The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.
    • Acute kidney: improving the pathway of care for patients and across healthcare.

      Fluck, Richard (2015-11)
      PURPOSE OF REVIEW: Acute kidney injury (AKI) is common, harmful and of global concern. There is a need to understand the pathway of the management of AKI in order to identify potential areas where care can be improved, for the individual and for healthcare systems. RECENT FINDINGS: There has been considerable focus on risk assessment and earlier detection using changes in serum creatinine. There is less understanding of optimal management, enhanced and long-term recovery, and education to support better care. Using Kidney Disease Improving Global Outcomes-based criteria to improve the detection of AKI improves its detection, but requires supportive training and education to deliver better outcomes.Policy makers need to understand the personal and economic burden that results from AKI. There is a need to provide commissioning support, improvement methodologies, and registry initiatives with research investment to sustain progress in overall management. SUMMARY: There is clear evidence of harm related to AKI and a need to improve the reliability of care. The prevalence is high, with the potential to significantly improve short-term and long-term care by addressing all the elements in the pathway, at both patient and system level, assessing risk, detection, treatment, and recovery.
    • Alteration of Lymphocytes Subpopulations and Immunoglobulins Levels in Patients with Diabetic Foot Ulcers Infected Particularly by Resistant Pathogens

      Game, Frances (2016-12)
      The aim of our study was to analyse immune abnormalities in patients with chronic infected diabetic foot ulcers (DFUs) especially those infected by resistant microorganisms. Methods. 68 patients treated in our foot clinic for infected chronic DFUs with 34 matched diabetic controls were studied. Patients with infected DFUs were subdivided into two subgroups according to the antibiotic sensitivity of causal pathogen: subgroup S infected by sensitive (n = 50) and subgroup R by resistant pathogens (n = 18). Selected immunological markers were compared between the study groups and subgroups. Results. Patients with infected chronic DFUs had, in comparison with diabetic controls, significantly reduced percentages (p < 0.01) and total numbers of lymphocytes (p < 0.001) involving B lymphocytes (p < 0.01), CD4+ (p < 0.01), and CD8+ T cells (p < 0.01) and their naive and memory effector cells. Higher levels of IgG (p < 0.05) including IgG1 (p < 0.001) and IgG3 (p < 0.05) were found in patients with DFUs compared to diabetic controls. Serum levels of immunoglobulin subclasses IgG2 and IgG3 correlated negatively with metabolic control (p < 0.05). A trend towards an increased frequency of IgG2 deficiency was found in patients with DFUs compared to diabetic controls (22% versus 15%; NS). Subgroup R revealed lower levels of immunoglobulins, especially of IgG4 (p < 0.01) in contrast to patients infected by sensitive bacteria. The innate immunity did not differ significantly between the study groups. Conclusion. Our study showed changes mainly in the adaptive immune system represented by low levels of lymphocyte subpopulations and their memory effector cells, and also changes in humoral immunity in patients with DFUs, even those infected by resistant pathogens, in comparison with diabetic controls.
    • An unusual case of severe high anion gap metabolic acidosis

      Bavakunji, Riaz; Turner, Jake; Jujjavarapu, Sagar; Taal, Maarten; Fluck, Richard; Leung, Janson; Kolhe, Nitin; Selby, Nicholas (2011-04)
      We present a case of high anion gap metabolic acidosis with an unusual aetiology in a 75-year-old lady with hypoglycaemia, encephalopathy and relatively preserved renal function. Full toxicology and biochemical analysis suggested that she had an inborn error of metabolism, riboflavin-responsive multiple acyl-CoA dehydrogenase deficiency that can predispose to severe acidosis in situations where calorific intake is reduced. We believe this to be one of the few published cases and is remarkable for the presentation in late adulthood in addition to the requirement for emergency haemodialysis due to the severity of the metabolic disturbance.
    • An unusual cause of a mediastinal mass.

      Mohammed, Abdul; Rea, Rustram (2010-08)
      Primary hyperparathyroidism (PHPT) is a disorder resulting in hypercalcaemia due to autonomous over secretion of parathyroid hormone. Mediastinal parathyroid adenoma is a rare disorder which can present with a widened mediastinum on a plain film. Its always important to check calcium level in patients who present with a mediastinal mass to rule out PHPT. Recognition of this disorder is crucial to prevent long-term sequelae. The authors report an interesting case and discuss further about it, which would be of help both to a specialist and a general physician.
    • An unusual cause of a sellar mass.

      Mohammed, Abdul; Amin, Peshraw (2010-12)
      A 57-year-old man presented with features suggestive of a non-functioning pituitary tumour. He underwent trans-sphenoidal resection of the tumour which was found to be a chordoma and not a pituitary adenoma. This case demonstrates that a chordoma may directly involve the sellar region and mimic a pituitary adenoma. We also discuss the aetiology, areas of involvement, management and prognosis of this unusual tumour.
    • Anesthesia Clinical Services Accreditation by Royal College of Anaesthetists UK: An example to follow

      Zahid, Sheikh (2018-07)
      There has been an increasing awareness about the need of a system of quality assurance in the healthcare services throughout the world. Many of the advanced countries have developed meticulous guidelines and checklists to assure quality and safety, and prevent medical errors at every step of the healthcare and minimise the iatrogenic mortality and morbidity, and have introduced accreditation systems to offer incentives to the best of the institutions. A system of awarding a certificate of Anesthesia Clinical Services Accreditation’ (ACSA) has been evolved by Royal College of Anaesthetists UK (RCoA) to be awarded to the suitable healthcare institutions. This editorial offers an outline of this system to introduce the need of such a system in every country with the aim of enhancing quality of the care being provided by the healthcare institutions.