This document provides information on rapid sequence intubation (RSI) in adults. It defines RSI as the virtually simultaneous administration of a sedative and neuromuscular blocking agent to facilitate endotracheal intubation while minimizing aspiration risk. The principles of RSI are described, including preparation, preoxygenation, pretreatment, paralysis with induction, protection/positioning, tube placement confirmation, and post-intubation management. Contraindications and advantages of RSI are also outlined.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Differences between Paediatric and Adult airway gourav_singh
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Just a brief discussion.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Differences between Paediatric and Adult airway gourav_singh
These slides contain a brief discussion about what all common differences between pediatric and adult airway can be found if you are in an ENT OPD or during Anesthesia.
Just a brief discussion.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Rapid sequence intubation (RSI) is a technique that is used when rapid control of the airway is needed as a precaution for patients that may have a 'full stomach' or other risks of pulmonary aspiration. A short description about RSI procedure according to IQARUS guideline.
Dr. Ummay Sumaiya
ICU DOCTOR
| IQARUS | Medical Treatment Facility / IQARUS - Cox’s Bazar - Bangladesh |
Mail: Ummay.Sumaiya@iqarus.com
SEMS 2014: Ang Shiang Hu - Life threatening asthma Rahul Goswami
The Critical Care track of the Society for Emergency Medicine in Singapore Annual Scientific Meeting 2014.
For more information and conference videos, go to singem.blogspot.sg
Rapid Sequence Intubation
RSI describes a coordinated, sequential process of preparation, sedation, and paralysis to facilitate safe, emergency tracheal intubation.
Pharmacologic sedation and paralysis are induced in rapid succession to quickly and effectively perform laryngoscopy and tracheal intubation.
The goal of RSI is to intubate patients quickly and safely using sedation and paralysis.
Airway management is the cornerstone of resuscitation and is a defining skill for the specialty of emergency medicine. The emergency clinician has primary airway management responsibility, and all airway techniques lie within the domain of emergency medicine. Although rapid sequence intubation (RSI) is the most commonly used method for emergent tracheal intubation, emergency airway management includes various intubation techniques and devices, approaches to the difficult airway, and rescue tech- niques when intubation fails.
The decision to intubate should be based on careful patient assessment and appraisal of the clinical presentation with respect to three essential criteria: (1) failure to maintain or protect the airway; (2) failure of ventilation or oxygenation; and (3) the patient’s anticipated clinical course and likelihood of deterioration.
In most patients, intubation is technically easy and straightfor- ward. Although early ED-based observational registries reported cricothyrotomy rates of about 1% for all intubations, more recent studies have shown a lower rate, less than 0.5%.3 As would be expected with an unselected, unscheduled patient population, the ED cricothyrotomy rate is greater than in the operating room, which occurs in approximately 1 in 200 to 2000 elective general anesthesia cases.4 Bag-mask ventilation (BMV) is difficult in approximately 1 in 50 general anesthesia patients and impossible in approximately 1 in 600. BMV is difficult, however, in up to one-third of patients in whom intubation failure occurs, and dif- ficult BMV makes the likelihood of difficult intubation four times higher and the likelihood of impossible intubation 12 times higher. The combination of failure of intubation, BMV, and oxy- genation in elective anesthesia practice is estimated to be exceed- ingly rare, roughly 1 in 30,000 elective anesthesia patients.4 These numbers cannot be extrapolated to populations of ED patients who are acutely ill or injured and for whom intubation is urgent and unavoidable. Although patient selection cannot occur, as with a preanesthetic visit, a preintubation analysis of factors predicting difficult intubation gives the provider the information necessary to formulate a safe and effective plan for intubation.
Preintubation assessment should evaluate the patient for potential difficult intubation and difficult BMV, placement of and ventilation with an extraglottic device (EGD; and cricothyrotomy. Knowledge of all four domains is crucial to successful planning. A patient who exhibits obvious difficult airway characteristics is highly predictive of a challenging intuba- tion, although the emergency clinician should always be ready for a difficult to manage airway, because some difficult airways may not be identified by a bedside assessment.
Airway difficulty exists on a spectrum and is contextual to the provider’s experience, environment, and armamentarium of devices.
Please share your valuable opinions.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
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3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
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Study Resources:
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2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
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The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Rapid sequence intubation
1. B Y
M U R T A Z A R A S H I D M . D
D E P A R T M E N T O F E M E R G E N C Y M E D I C I N E
R O Y A L C O M M I S S I O N H O S P I T A L , J U B A I L
Rapid Sequence Intubation In
Adults
2. DEFINITION
Rapid sequence intubation (RSI) is the virtually
simultaneous administration of a sedative and a
neuromuscular blocking (paralytic) agent to render a
patient rapidly unconscious and flaccid in order to
facilitate emergent endotracheal intubation and to
minimize the risk of aspiration.
4. WHY RSI
CASE (1) AMITRYPTILLINE TIPPER
27 year old overdose benzodiazepines + TCAs 1 hour PTA.
Decreasing LOC, HR 140, wide complex regular, BP 90/50, RR 24,O2 sat
99% on O2.
CASE (2) STAB WOUNDS
22 yr old multiple abdominal stab wounds 6” knife.
Evisceration, agitation and uncooperative.
HR 140, BP 90/50, RR 22,
O2 sat 99% on O2.
6. ORAL INTUBATION WITHOUT DRUGS
THE CRASH AIRWAY
ARREST SITUATIONS ONLY
PATIENT IS COMPLETELY UNCONSCIOUS,
PULSELESS, UNRESPONSIVE AND APNIC
7. PRINCIPLES OF RSI
RSI is the standard of care in emergency airway
management for intubations not anticipated to be difficult.
Multiple large prospective observational studies confirm
that the implementation of RSI has led to improved success
and decreased complication rates for emergency
intubations
• Emergency intubation is indicated
• The patient has a “full” stomach
• Intubation is predicted to be successful
• If intubation fails, ventilation is predicted to be successful
8. DO NOT INTUBATE
DYSARTHRIC ANTI IPSILATERAL HORNERS SYNDROME
DUE TO LATERAL CORTICOMEDULLARY STROKE WITH
BLA BLA BLASTEROSIS
C
A
U
T
I
O
N
10. ADVANTAGES OF RSI
Facilitates and expedites endotracheal intubation
increased success rate
decreased time to intubation
Minimizes trauma during laryngoscopy
Minimizes hypoxia and hypercapnia
Minimizes risk of aspiration
Minimizes hemodynamic effects of intubation
11. SEVEN “P” OF RSI
Preparation
Pre oxygenation
Pretreatment
Paralysis with induction
Protection and positioning
Placement with proof
Post intubation management
12. PREPARATION (10 mins before intubation)
• ETT, stylet, blades, suction, BVM
• Cardiac monitor, pulse oximeter, ETCO2
• One ( preferably two ) iv lines
• Drugs
• Difficult airway kit including cricothyrodotomy kit
• Patient positioning
13. PREOXYGENATION (5 mins before intubation)
Facemask with oxygen reservoir (non rebreather)
Manual ventilation prior to intubation should be
reserved for patients who are hypoxic (saturation
<91 percent). Slow rate 8 b/m to avoid over inflation
of lungs and stomach.
It allows 3-5 mins of apnea.
14. PRETREATMENT (3 mins before intubation)
Laryongoscopy can activate coughing and gagging.
Infants: Bradycardia
Adults: High B.P, Bronchospasm, Increase ICP and
Heart Rate
In highly emergent cases it is not worth to wait for
pretreatment and can be judiciously omitted.
Drugs vary according to the condition.
15. PRETREATMENT MNEMONIC “ABC”
ASTHMA
BRAIN AND BABIES
CARDIOVASCULAR
Atropine: Used in infants and sometimes after
second dosage of succinylcholine in adults with
profound bradycardia.
16. PRETREATMENT
Lidocaine (1.5 mg/kg i.v): Reduces airway
resistance and decreases ICP. Contraindicated in
Mobitz II or Third degree heart block.
17. PRETREATMENT
Fentanyl ( 3 mcg/kg i.v): Decreases ICP, B.P, Heart
rate. Given in ACS, Aortic dissection.
Fentanyl can cause respiratory collapse and
hypotension. If given only low dosage of 1 mcg/kg.
Fentanyl should be the last pretreatment drug to be
used.
19. PARALYSIS WITH INDUCTION
Head injury or Stroke: Goal is to maintain
adequate cerebral perfusion and maintain arterial
pressure.
Etomidate (0.3mg/kg): Excellent sedation and
dosent cause hypotension. No change in B.P. Causes
adrenal insufficiency.
Ketamine (1-2mg/kg): Use in Septic shock,
Bronchospasm and hypotensive patients with head
injury. Avoid in cerebral hemorrhage.
Midazolam, barbiturates and propofol can be used in
head injury but risk of hypotension must be
considered
20. PARALYSIS WITH INDUCTION
Status Epilepticus:
Midazolam (0.2-0.3mg/kg): Can cause hypotension,
use etomidate if patient has hemodynamic
compromise.
Do not use Ketamine due to stimulant effect.
• Severe Bronchospasm:
Hemodynamically stable: Ketamine, Propofol,
Etomidate, Midazolam.
Hemodynamically unstable: Ketamine or Etomidate
21. PARALYSIS WITH INDUCTION
Cardiovascular : Etomidate preferred in CAD and
Aortic dissection. Use fentanyl as pretreatment.
Shock: Etomidate or Ketamine. If refractory septic
shock, with etomidate give Hydrocortisone
In patient in which we need “awake” look, use
ketamine. Provides analgesia, amnesia and
sedation without respiratory concern.
22. NEUROMUSCULAR BLOCKING AGENTS
PRODUCE PARALYSIS. NOT PROVIDE
SEDATION OR ANALGESIA. USED IMMEDIATELY
AFTER INDUCTION AGENTS.
DEPOLARIZING: Succinylcholine (Sch), binds to
Ach receptors produces fasciculation's and paralysis.
NON DEPOLARIZING: Rocuronium, Vecuronium,
and Pancuronium. Competitively inhibit the post-
synaptic Ach receptor and produce paralysis.
23. DEPOLARIZING PARALYTICS
SUCCINYLCHOLINE (1.5 mg/kg): Mostly preferred
agent due to rapid onset (45-60 sec) and offset (6-10
mins). Better to overdose than under dose.
Absolute Contraindications:
SIGNIFICANT HYPERKALEMIA DEMONSTRATED BY EKG
FINDING.
MALIGNANT HYPERTHERMIA (FAMILY OR PERSONAL Hx.)
RHABDOMYOLYSIS
STROKE OR BURN 72 HOUR OLD, DUE TO UPREGULATION OF
Ach RECEPTORS
SIGNIFICANT NEUROMUSCULAR Dx OR MUSCULAR DYSTROPHY
25. NONDEPOLARIZING NEUROMUSCULAR
BLOCKING AGENTS (NMBAS)
USED WHEN DEPOLARIZING AGENTS ARE
CONTRAINDICATED OR PROLONGED BLOCKADE IS
WARRANTED.
ROCURONIUM (1 mg/kg): Short onset (45-60 sec), duration upto 45
mins. Effect comparable to Succinylcholine.
VECURONIUM (0.15 mg/kg): onset about 90 sec.
A predicted difficult airway is the most common relative
contraindication to the use of nondepolarizing NMBAs for RSI
26. REVERSAL OF NONDEPOLARIZING AGENTS
COMPETITIVELY BIND Ach RECEPTORS
NEOSTIGMINE: Acetyl cholinesterase inhibitor which allows ACh to
continue to stimulate the neuromuscular junction and cause muscular
stimulation.
SUGAMMADEX: is a novel agent that encapsulates and binds with
molecules of rocuronium or vecuronium, thereby rapidly reversing
their neuromuscular blocking effects. Still pending for FDA.
In Myasthenia Gravis dose of Depolarizing agent should be increased
while dose of non-depolarizing should be decreased.
27. PROTECTION (CRICOID PRESSURE) AND
POSITIONING
This phase of RSI refers to protecting the airway against
aspiration prior to placement of the endotracheal tube by
avoiding bag-mask ventilation and applying cricoid
pressure (Sellick's maneuver). Bag-mask ventilation is
unnecessary if the patient has been successfully
preoxygenated.
Provided oxygen saturation remains above 90 percent, bag-
mask ventilation is unnecessary, even between
laryngoscopy attempts
A common error is to apply pressure to the thyroid cartilage
(Adam's apple).
29. PLACEMENT WITH PROOF
After paralysis has been achieved finally the tube is
placed through glottis and cuff is inflated.
The most accurate means of confirming ETT
placement is End-tidal CO2 (EtCO2) determination.
A single-view chest radiograph is only useful to determine
depth of placement (eg, tracheal versus right mainstem).
31. POSTINTUBATION MANAGEMENT
RSI remains incomplete until the properly placed
endotracheal tube is secured. Several techniques are
commonly used to secure the tube, including taping, tying
etc.
Hypotension can occur due to decreased venous return
from increased intrathoracic pressure due to mechanical
ventilation or due to sedatives.
32. GENERAL TECHNIQUE
VARIATIONS OF TECHNIQUE — The general
approach described above is a commonly accepted
way of performing rapid sequence intubation (RSI).
There are, however, a number of variations,
depending on clinical circumstance.