885 resultados para Early case detection
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Tutkimuksen tavoitteena oli soveltaa innovaatioprosessiteorioita käytäntöön konteksti huomioonottaen, koska langattoman sähköisen liiketoiminnan nopeat muutokset, metsäteollisuuden erityispiirteet ja ei-kaupallisuus asettavat erityistarpeita innovoinnille. Painopiste on prosessin aikaisissa vaiheissa, koska ne ovat kriittisiä koko innovaatioprosessin menestymisen kannalta. Tähtäimenä oli löytää yrityssektorille uusia langattomia sähköisen liiketoiminnan mahdollisuuksia, jotka hyödyttävät tutkimuksessa mukanaolevaa yritystä. Tutkimuksessa käytettiin konstruktiivista tutkimusotetta ja metodeina sähköistä aivomyrskyä, tarkistuslistaa sekä GDSS- ja postikyselyä.Tutkimuksen tuloksena on esitetty innovaatioprosessin aikaiset vaiheet kirjallisuudesta, metsäteollisuuden erityispiirteet ja innovaatioprosessisovellus. Lisäksi tämä tutkimus tuotti uusia sähköisen liiketoiminnan ideoita, suoritti niille seulonnan ja kävi läpi alustavan tutkimuksen.
The 'Red Flag Instrument' for Early Detection of Crohn's Disease: Is it ready for Clinical Practice?
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Introduction: Tuberous sclerosis complex (TSC) is a neurocutaneous syndrome produced by a number of genetic mutations. The disease is characterized by the development of benign tumors affecting different body systems. The most common oral manifestations of TSC are fibromas, gingival hyperplasia and enamel hypoplasia. Clinical Case: A 35-year-old woman diagnosed with TSC presented with a reactive fibroma of considerable size and rapid growth in the region of the right lower third molar. Discussion: In the present case the association of TSC with dental malpositioning gave rise to a rapidly evolving reactive fibroma of considerable diameter. Few similar cases can be found in the literature. Patients with TSC present mutations of the TSC1 and TSC2 genes, which intervene in cell cycle regulation and are important for avoiding neoplastic processes. No studies have been found associating TSC with an increased risk of oral cancer, though it has been shown that the over-expression of TSC2 could exert an antitumor effect. Careful oral and dental hygiene, together with regular visits to the dentist, are needed for the prevention and early detection of any type of oral lesion. The renal, pulmonary and cardiac alterations often seen in TSC must be taken into account for the correct management of these patients.
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Within the scope of the TECNOLONIAL (HAR2008-02834/HIST) project, an archaeologi- cal and archaeometric research is being conduct- ed in order to clarify and systematize transport jars production in the Iberian peninsula and their distribution abroad, especially to the Americas, from the 15th to the 17th century. The production centre of Seville, in the Crown of Castile, produced large glazed and unglazed transport jars, called botijas, which were mainly devoted to the Atlantic trade network. The pres- ent study accounts for the first results obtained from an initial sample of 34 transport jars dated around the 15th-16th centuries from the produc- tion centre of Seville and the reception site of Santa María de la Antigua del Darién (gulf of Urabá, Colombia). This latter site is especially significant since it was the first Spanish founda- tion (1510) in continental America that obtained the title of town, and was the seat for the Governor of the new region called Castilla de Oro, as well as for the first diocese. All individuals were analyzed by means of x-ray fluorescence and diffraction analyses and then compared with the majolica production database from Seville. The results enabled us to define the first refer- ence groups for such modern transport jars, and to get a first insight into the jars coming to the Americas in the early 16th century whose prove- nance can be linked to Seville, but not Triana.
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Early Detection of Alzheimer's Disease Beta-amyloid Pathology -Applicability of Positron Emission Tomography with the Amyloid Radioligand 11C-PIB Accumulation of beta amyloid (Abeta) in the brain is characteristic for Alzheimer’s disease (AD). Carbon-11 labeled 2-(4’-methylaminophenyl)-6-hydroxybenzothiazole (11C-PIB) is a novel positron emission tomography (PET) amyloid imaging agent that appears to be applicable for in vivo Abeta plaque detection and quantitation. The biodistribution and radiation dosimetry of 11C-PIB were investigated in 16 healthy subjects. The reproducibility of a simplified 11C-PIB quantitation method was evaluated with a test-retest study on 6 AD patients and 4 healthy control subjects. Brain 11C-PIB uptake and its possible association with brain atrophy rates were studied over a two-year follow-up in 14 AD patients and 13 healthy controls. Nine monozygotic and 8 dizygotic twin pairs discordant for cognitive impairment and 9 unrelated controls were examined to determine whether brain Abeta accumulation could be detected with 11C-PIB PET in cognitively intact persons who are at increased genetic risk for AD. The highest absorbed radiation dose was received by the gallbladder wall (41.5 mjuGy/MBq). About 20 % of the injected radioactivity was excreted into urine, and the effective whole-body radiation dose was 4.7 mjuSv/MBq. Such a dose allows repeated scans of individual subjects. The reproducibility of the simplified 11C-PIB quantitation was good or excellent both at the regional level (VAR 0.9-5.5 %) and at the voxel level (VAR 4.2-6.4 %). 11C-PIB uptake did not increase during 24 months’ follow-up of subjects with mild or moderate AD, even though brain atrophy and cognitive decline progressed. Baseline neocortical 11C-PIB uptake predicted subsequent volumetric brain changes in healthy control subjects (r = 0.725, p = 0.005). Cognitively intact monozygotic co-twins – but not dizygotic co-twins – of memory-impaired subjects exhibited increased 11C-PIB uptake (117-121 % of control mean) in their temporal and parietal cortices and the posterior cingulate (p<0.05), when compared with unrelated controls. This increased uptake may be representative of an early AD process, and genetic factors seem to play an important role in the development of AD-like Abeta plaque pathology. 11C-PIB PET may be a useful method for patient selection and follow-up for early-phase intervention trials of novel therapeutic agents. AD might be detectable in high-risk individuals in its presymptomatic stage with 11C-PIB PET, which would have important consequences both for future diagnostics and for research on disease-modifying treatments.
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Alzheimer`s disease (AD) is characterised neuropathologically by the presence of extracellular amyloid plaques, intraneuronal neurofibrillary tangles, and cerebral neuronal loss. The pathological changes in AD are believed to start even decades before clinical symptoms are detectable. AD gradually affects episodic memory, cognition, behaviour and the ability to perform everyday activities. Mild cognitive impairment (MCI) represents a transitional state between normal aging and dementia disorders, especially AD. The predictive accuracy of the current and commonly used MCI criteria devide this disorder into amnestic (aMCI) and non-amnestic (naMCI) MCI. It seems that many individuals with aMCI tend to convert to AD. However many MCI individuals will remain stable and some may even recover. At present, the principal drugs for the treatment of AD provide only symptomatic and palliative benefits. Safe and effective mechanism-based therapies are needed for this devastating neurodegenerative disease of later life. In conjunction with the development of new therapeutic drugs, tools for early detection of AD would be important. In future one of the challenges will be to detect at an early stage these MCI individuals who will convert to AD. Methods which can predict which MCI subjects will convert to AD will be much more important if the new drug candidates prove to have disease-arresting or even disease–slowing effects. These types of drugs are likely to have the best efficacy if administered in the early or even in the presymptomatic phase of the disease when the synaptic and neuronal loss has not become too widespread. There is no clinical method to determine with certainly which MCI individuals will progress to AD. However there are several methods which have been suggested as predictors of conversion to AD, e.g. increased [11C] PIB uptake, hippocampal atrophy in MRI, low CSF A beta 42 level, high CSF tau-protein level, apolipoprotein E (APOE) ε4 allele and impairment in episodic memory and executive functions. In the present study subjects with MCI appear to have significantly higher [11C] PIB uptake vs healthy elderly in several brain areas including frontal cortex, the posterior cingulate, the parietal and lateral temporal cortices, putamen and caudate. Also results from this PET study indicate that over time, MCI subjects who display increased [11C] PIB uptake appear to be significantly more likely to convert to AD than MCI subjects with negative [11C] PIB retention. Also hippocampal atrophy seems to increase in MCI individuals clearly during the conversion to AD. In this study [11C] PIB uptake increases early and changes relatively little during the AD process whereas there is progressive hippocampal atrophy during the disease. In addition to increased [11C] PIB retention and hippocampal atrophy, the status of APOE ε4 allele might contribute to the conversion from MCI to AD.
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This study aims to evaluate the prognostic value of microscopic parameters of asymptomatic leaves of Clusia hilariana Schltdl. subjected to particulate deposition of iron (2.14 mg cm-2 day-1) for 45 consecutive days. Samples of young and expanded leaves without symptoms were collected and subjected to light and scanning electron microscopy techniques. The height of the epidermal cells on both surfaces of the leaf and the thickness of the hypodermis, the chlorophyll parenchyma, and the leaf blade were measured. Micromorphological injury occurred in the abaxial surface of young leaves and on both surfaces of expanded leaves. Erosion of the epicuticular wax and cuticle rupture were frequent on the adaxial surface, while on the abaxial surface of both leaves there was a loss of sinuosity on the anticlinal wall of the epidermal cells, stomatal deformity and obstruction. Micromorphometric alterations were seen in all leaf tissues except in the height of epidermic cells, probably due to the thick cuticle and prominent cuticular flanges. The highest difference in thickness of the leaf blade was seen in young leaves of plants subjected to SPMFe, indicating greater sensibility to particulate iron in comparison to the expanded leaves. The micromorphological and micromorphometric alterations in the leaf blade of Clusia hilariana Schltdl. showed the prognostic potential of these tools on the evaluation of impacts caused by the deposition of particulate matter, especially in the 'Restinga' natural vegetation, where the exposure is increasing due to the presence of iron ore industry in their surroundings.
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Control of the world-wide spread of methicillin-resistant Staphylococcus aureus (MRSA) has been unsuccessful in most developed countries. A few countries have been able to maintain a low MRSA prevalence, plausibly due to their strict MRSA control policies. Such policies require wide-scale screening of patients with suspected MRSA colonization, in order to nurse the MRSA-positive patients in contact isolation. The aim of this study was to develop and introduce a 2-photon excited fluorescence detection (TPX) technique for screening of MRSA directly from clinical samples. The assay principle involves specific online immunometric monitoring of S. aureus growth under selective antibiotic pressure. After the novel TPX approach had been set up, its applicability for the detection of MRSA was evaluated using a large MRSA collection including practically all epidemic MRSA strains identified in Finland between 1991 and 2009. The TPX assay was found both sensitive (97.9%) and specific (94.1%) in this epidemiological setting, illustrating that the method is tolerant to wide biological variation as well as to environments with rapidly emerging MRSA strains. When MRSA was screened directly from colonization samples, all patients positive for MRSA by conventional methods were positive also by the TPX assay. The assay capacity was 48 samples per a test run, and the median time required for confirmation of a true-positive screening test result was 3 h 26 min. Collectively, the findings presented in this thesis suggest that the TPX MRSA screening assay could be applicable for direct screening of MRSA colonization samples without any prior steps of isolation. This can potentially mean that contact isolation of suspected carriers testing negative could be discontinued earlier, thereby reducing the costs and burden associated with the containment of MRSA. In case of infection, a positive test result would ensure an early onset of effective therapy.
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Background: Approximately two percent of Finns have sequels after traumatic brain injury (TBI), and many TBI patients are young or middle-aged. The high rate of unemployment after TBI has major economic consequences for society, and traumatic brain injury often has remarkable personal consequences, as well. Structural imaging is often needed to support the clinical TBI diagnosis. Accurate early diagnosis is essential for successful rehabilition and, thus, may also influence the patient’s outcome. Traumatic axonal injury and cortical contusions constitute the majority of traumatic brain lesions. Several studies have shown magnetic resonance imaging (MRI) to be superior to computed tomography (CT) in the detection of these lesions. However, traumatic brain injury often leads to persistent symptoms even in cases with few or no findings in conventional MRI. Aims and methods: The aim of this prospective study was to clarify the role of conventional MRI in the imaging of traumatic brain injury, and to investigate how to improve the radiologic diagnostics of TBI by using more modern diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) techniques. We estimated, in a longitudinal study, the visibility of the contusions and other intraparenchymal lesions in conventional MRI at one week and one year after TBI. We used DWI-based measurements to look for changes in the diffusivity of the normal-appearing brain in a case-control study. DTI-based tractography was used in a case-control study to evaluate changes in the volume, diffusivity, and anisotropy of the long association tracts in symptomatic TBI patients with no visible signs of intracranial or intraparenchymal abnormalities on routine MRI. We further studied the reproducibility of different tools to identify and measure white-matter tracts by using a DTI sequence suitable for clinical protocols. Results: Both the number and extent of visible traumatic lesions on conventional MRI diminished significantly with time. Slightly increased diffusion in the normal-appearing brain was a common finding at one week after TBI, but it was not significantly associated with the injury severity. Fractional anisotropy values, that represent the integrity of the white-matter tracts, were significantly diminished in several tracts in TBI patients compared to the control subjects. Compared to the cross-sectional ROI method, the tract-based analyses had better reproducibility to identify and measure white-matter tracts of interest by means of DTI tractography. Conclusions: As conventional MRI is still applied in clinical practice, it should be carried out soon after the injury, at least in symptomatic patients with negative CT scan. DWI-related brain diffusivity measurements may be used to improve the documenting of TBI. DTI tractography can be used to improve radiologic diagnostics in a symptomatic TBI sub-population with no findings on conventional MRI. Reproducibility of different tools to quantify fibre tracts vary considerably, which should be taken into consideration in the clinical DTI applications.
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Vaikean sepsiksen varhainen tunnistaminen päivystyspoliklinikalla – merkkiaineiden käyttökelpoisuus aikuispotilaiden arvioinnissa Päivystyspotilaan vakavan yleisinfektion eli sepsiksen varhainen tunnistaminen ja taudin vaikeusasteen arviointi on päivystävälle lääkärille tärkeä haaste. Arvioimme prospektiivisessa kohorttitutkimuksessa eri merkkiaineiden hyödyllisyyttä sepsiksen varhaisessa tunnistamisessa ja vaikeusasteen arvioinnissa. Työssä I ja III oli 539 päivystyspotilasta, joilta kliinikko päätti ottaa veriviljelyn sepsistä epäillen. Tutkimuksessa II oli 525 potilasta ja tutkimuksessa IV 537 potilasta. Tutkimuksessa I plasman C-reaktiivisen proteiinin (CRP) pitoisuuksia verrattiin plasman prokalsitoniinin (PCT) ja interleukiinin (IL-6) pitoisuuksiin. Tutkimuksessa II verrattiin plasman baktersidisen/ permeabiliteettia lisäävän proteiinin (BPI), ryhmän IIA fosfolipaasi A2:n (PLA2GIIA) ja CRP:n pitoisuuksia sekä valkosolujen määriä toisiinsa. Tutkimuksessa III arvioitiin liukoisen urokinaasi-tyyppisen plasminogeenin aktivaattorireseptorin (suPAR) ja tutkimuksessa IV pentraksiini 3:n (PTX3) määrityksen käyttökelpoisuutta. Tutkimuksessa I todettiin päivystystilanteessa mitattujen korkeiden PCT - ja IL-6 - pitoisuuksien ennustavan vaikean sepsiksen kehittymistä paremmin kuin korkean CRP:n. Tutkimuksessa II plasman PLA2GIIA vaikutti hiukan paremmalta vaikean sepsiksen ennustajalta kuin CRP tai veren valkosolutaso, mutta BPI ei ollut hyödyllinen. Tutkimuksessa III korkea plasman suPAR- pitoisuus osoittautui itsenäiseksi kuolleisuuden riskitekijäksi ja se liittyi myös vaikean sepsiksen kehittymiseen. Tutkimuksessa IV korkea PTX3 - pitoisuus toimi samaan tapaan kuin suPAR. Kokonaisuutena PCT osoittautui parhaaksi merkkiaineeksi ennustamaan elinhäiriön kehittymistä ja suPAR kuolleisuutta. PTX3 ei tarjonnut merkittävää lisäetua PCT:iin ja suPAR:iin verrattuna. CRP osoitti suhteellisen hyvin bakteeri-infektion esiintymistä, mutta ennusteellista arvoa sillä ei ollut. suPAR on kiinnostava kuolleisuuden ja elinhäiriön kehittymisen merkkiaine.
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Antikens judiska bibeltolkare hade ett annorlunda sätt att läsa Bibeln än den som moderna läsare är vana vid. Dessa tidiga exegeter tänkte att texten som nu finns i den hebreiska Bibeln, de kristnas Gamla Testamente, är helig ordagrant i den form som den fanns i under deras tid, att den inte innehåller några fel, och att Gud har en övergripande plan gällande helheten, så att man vid behov kan förklara ett Bibelställe med hjälp av ett annat. Dessa antaganden reflekteras i det sätt på vilket antikens exegeter läste och tolkade sin Bibel. Det här ser man då man läser deras texter, från 400-talet före vår tideräknings början till de första århundradena enligt vår tideräkning. Ett verktyg som antikens skrifttolkare ofta använde var den så kallade gezera shava -metoden, där de jämförde identiska ord och fraser i Bibeln för att skänka belysning åt oklara textställen. Hebreiskan, särskilt den ovokaliserade konsonanttexten, innehåller många homonyma ord, alltså ord som ser likadana ut men har olika betydelser. De tidiga exegeterna utnyttjade ofta de möjligheter till alternativa tolkningar som uppstår ur denna tvetydighet. Ibland kunde de dock tvärtom också dra paralleller ur kontextuella likheter, alltid efter behov. I denna avhandling står dessa tidiga anonyma bibeltolkare och deras tolkningar i fokus. Malakis bok, som härstammar från ca år 475 f.v.t., kan ses som ett viktigt tidigt exempel på denna tendens till nytolkning av traditioner. Boken själv har dock också blivit föremål till nytolkningar, redan i de tilläggsverser som finns i dess slut, men särskilt i senare judisk litteratur och i Nya Testamentet. I avhandlingen granskas de fem bibliska gestalter som nämns i Malaki: Jakob, Esau, Levi, Mose och Elia. Hur används de i boken och hur har senare traditioner som anknyter till dem influerats av Malaki? ------------------------------------------------ Antiikin juutalaiset raamatunselittäjät lukivat Raamattua eri tavoin kuin moderni lukija. Heidän näkemyksensä mukaan se teksti, joka nykyään löytyy heprealaisesta Raamatusta eli kristittyjen Vanhasta testamentista, oli pyhä juuri sellaisessa muodossa, jossa se oli heille välittynyt. Se oli virheetön, ja Jumalalla oli siitä kokonaisnäkemys, joka voisi selvitä myös tulkitsijalle, kun tämä vain tutkisi tekstiä riittävän tarkkaan. Nämä perusoletukset näkyvät tavassa, jolla antiikin eksegeetit lukivat ja tulkitsivat Raamattuaan. Se voidaan huomata heidän jälkeensä jättämistään teksteistä, alkaen noin 400-luvulta ennen ajanlaskumme alkua ja jatkuen ajanlaskumme ensimmäisiin vuosisatoihin. Antiikin raamatunselittäjät käyttivät yleisesti muun muassa metodia, joka rabbiinisessa kirjallisuudessa tunnetaan nimellä gezera shava. Raamatussa kahdessa tai useammassa kohtaa esiintyviä samoja sanoja ja ilmauksia verrattiin tällöin toisiinsa ja pyrittiin siten saamaan valaistusta epäselvinä pidettyihin tekstinkohtiin. Heprealle, etenkin sen vokalisoimattomassa muodossa, on tyypillistä homonyymisyys. Samannäköiset sanat voivat eri yhteyksissä tarkoittaa eri asioita. Varhaiset eksegeetit päätyivät usein tästä ilmiöstä nouseviin, keskenään vaihtoehtoisiin tulkintoihin. Toisaalta he saattoivat myös tarvittaessa selittää tekstinkohtaa toisella tekstinkohdalla ainoastaan näiden sisällöllisenkin yhtäläisyyden perusteella. Tässä väitöstutkimuksessa tarkastellaan näitä varhaisia, meille nimettömiksi jääneitä raamatunselittäjiä ja heidän tulkintojaan käyttämällä tutkimuksen lähtökohtana Malakian kirjaa. Malakiaa, joka on peräisin noin vuodelta 475 ennen ajanlaskumme alkua, voidaan pitää yhtenä tärkeimmistä ja varhaisimmista teksteistä, joissa traditioita yhdistellään ja kerrotaan uudelleen edellä mainittuihin perusajatuksiin nojaten ja niihin pohjautuvia menetelmiä käyttäen. Toisaalta Malakian kirjaa on myös tulkittu samojen periaatteiden mukaisesti jo sen myöhemmältä ajalta peräisin olevissa loppujakeissa, ja sittemmin muussa varhaisessa juutalaisessa kirjallisuudessa sekä Uudessa testamentissa. Väitöstutkimuksessa tarkastellaan erityisesti niitä viittä henkilöä, jotka mainitaan Malakian kirjassa: Jaakobia, Esauta, Leeviä, Moosesta ja Eliaa. Kirjoittaja tutkii, miten heidän hahmojaan on käytetty Malakian kirjassa, millaisiin heitä koskeviin traditioihin tämä käyttötapa perustuu, ja missä määrin Malakian kirjan vaikutus on havaittavissa myöhemmässä näihin henkilöihin liitetyssä perinteessä.
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Human localized cutaneous leishmaniasis (LCL), induced by Leishmania braziliensis, ranges from a clinically mild, self-healing disease with localized cutaneous lesions to severe forms which can present secondary metastatic lesions. The T cell-mediated immune response is extremely important to define the outcome of the disease; however, the underlying mechanisms involved are not fully understood. A flow cytometric analysis of incorporation of 7-amino actinomycin D and CD4+ or CD8+ T cell surface phenotyping was used to determine whether different frequencies of early apoptosis or accidental cell death occur at different stages of LCL lesions. When all cells obtained from a biopsy sample were analyzed, larger numbers of early apoptotic and dead cells were observed in lesions from patients with active disease (mean = 39.5 ± 2.7%) as compared with lesions undergoing spontaneous healing (mean = 17.8 ± 2.2%). Cells displaying normal viability patterns obtained from active LCL lesions showed higher numbers of early apoptotic events among CD8+ than among CD4+ T cells (mean = 28.5 ± 3.8 and 15.3 ± 3.0%, respectively). The higher frequency of cell death events in CD8+ T cells from patients with LCL may be associated with an active form of the disease. In addition, low frequencies of early apoptotic events among the CD8+ T cells were observed in two patients with self-healing lesions. Although the number of patients in the latter group was small, it is possible to speculate that, during the immune response, differences in apoptotic events in CD4+ and CD8+ T cell subsets could be responsible for controlling the CD4/CD8 ratio, thus leading to healing or maintenance of disease.
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We analyzed the genetic recombination pattern of the T-cell receptor beta-chain gene (TCR-beta) in order to identify clonal expansion of T-lymphocytes in 17 human T-lymphotropic virus type I (HTLV-I)-positive healthy carriers, 7 of them with abnormal features in the peripheral blood lymphocytes. Monoclonal or oligoclonal expansion of T-cells was detected in 5 of 7 HTLV-I-positive patients with abnormal lymphocytes and unconfirmed diagnosis by using PCR amplification of segments of TCR-beta gene, in a set of reactions that target 102 different variable (V) segments, covering all members of the 24 V families available in the gene bank, including the more recently identified segments of the Vbeta-5 and Vbeta-8 family and the two diversity beta segments. Southern blots, the gold standard method to detect T-lymphocyte clonality, were negative for all of these 7 patients, what highlights the low sensitivity of this method that requires a large amount of very high quality DNA. To evaluate the performance of PCR in the detection of clonality we also analyzed 18 leukemia patients, all of whom tested positive. Clonal expansion was not detected in any of the negative controls or healthy carriers without abnormal lymphocytes. In conclusion, PCR amplification of segments of rearranged TCR-beta is reliable and highly suitable for the detection of small populations of clonal T-cells in asymptomatic HTLV-I carriers who present abnormal peripheral blood lymphocytes providing an additional instrument for following up these patients with potentially higher risk of leukemia.
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Esophageal cancer is a prevalent cancer worldwide. Some studies have reported the possible etiology of human papillomavirus (HPV) in benign and malignant papillomas of the esophagus but the conclusions are controversial. In the present study, we investigated an esophageal papilloma from a 30-year-old male patient presenting aphasia. HPV DNA was detected by generic PCR using MY09/11 primers, and restriction fragment length polymorphism revealed the presence of HPV54, usually associated with benign genital lesions. Hypermethylation of the pINK4A gene was also investigated due to its relation to malignant transformation, but no modification was detected in the host gene. Except for an incipient reflux, no risk factors such as cigarette smoking, alcohol abuse or an infected sexual partner were recorded. Since esophageal lesions may have a malignant potential, HPV detection and typing are useful tools for patient follow-up.