Family medicine

Heart Involvement in Diabetes mellitus Patients

Lyubov Shkala — Fri, 29 Apr 2022 00:00:00 +0300

Diabetes mellitus (DM) is one of the most significant medical and social health problems worldwide. The main cause of death in patients with DM is cardiovascular diseases, which leads to the significant decrease in quality of life and life expectancy.

The aim of this literature review is analyze of the frequency, mechanisms and manifestations of heart disease in diabetes patients.

A significant amount of the modern researches is devoted to the diagnosis and treatment of the diabetes complications, including diabetic cardiomyopathy (DC). According to many authors, heart disease in diabetes is associated with the formation of DC, comorbid coronary heart disease and arterial hypertension. DC occurs in 16.8–54% of patients with diabetes and is an independent factor which increases the death risk by 50–60%.

Numerous scientific studies have been devoted to the diagnosis and treatment of DC, emphasizing that in order to reduce cardiovascular disease and mortality in patients with diabetes, it is necessary, above all, to achieve glycemic control. Diabetic history, age, comorbidities, atherosclerotic lesions, smoking, overweight or obesity also play an important role.

The main aspects of the development and impact of diabetes on the health and life of patients are the untimely diagnosis of this disease, its multifactorial pathogenesis, progressive course and severity of complications. Due to development of the early complications and disability, studies of morphofunctional changes in the myocardium in diabetes are extremely relevant, as cardiomyopathy may increase the risk of myocardial infarction and heart failure.

The rapid increase in the number of patients with diabetes, many of whom die from cardiovascular complications, makes the problem of diabetic heart disease one of the most pressing health problems. Treatment of these patients should include correction of carbohydrate metabolism, control of blood lipid composition, decrease in myocardial ischemia, correction of the myocardial metabolism and the risk of heart failure.

Diagnosis and Treatment of Primary Hypothyroidism in Primary Care

Olha Protsiuk — Fri, 29 Apr 2022 00:00:00 +0300

Decreased thyroid function occurs among 0,2–1% of men and 1,4–5% of women in the general population, and among people over 60 years among 2,5% of men and 6% of women.

Hypothyroidism in 95% of cases is caused by thyroid disfunction (primary hypothyroidism), only 5% of cases are central hypothyroidism, associated with dysfunction of the pituitary gland (insufficient production of thyroid-stimulating hormone) and hypothalamus (impaired thyroliberin synthesis).

Nonspecific clinical manifestations of hypothyroidism are the reason for examining the patient for thyroid hormone levels in primary care.

Primary hypothyroidism screening is a common clinical situation in the general practitioner`s practice. According to Guideline 00514. Hypothyroidism of the Finnish Medical Research Society Duodecim Medical Publications Ltd, the use of which is approved by the Order of the Ministry of Health of Ukraine № 1422 of December 29, 2016, diagnosis of hypothyroidism and treatment of primary hypothyroidism are the tasks of primary care professionals.

Decreased thyroid function may have subclinical and manifest forms, which are detected in the analysis of the results of thyroid hormones and clinical signs of the disease, require different treatment approaches. There are the differences in the use of levothyroxine replacement therapy in patients of different ages and depending on the causes of hypothyroidism.

Patients under 55 years old are prescribed levothyroxine sodium in a daily dose of 1,6–1,8 μg/kg body weight. In patients over 55 years old, the daily requirement of levothyroxine sodium is calculated at 0,9 μg/kg body weight, taking into account existing cardiovascular disease. If patients are obese, the calculation is made on the «ideal» weight.

The calculation of the dose and rules of levothyroxine sodium prescription in primary care are presented on the example of four clinical cases. The algorithm for control levothyroxine replacement therapy in patients with primary hypothyroidism is also presented.

Is Renoprotection Real for Patients with Hyperuricemia?

Fri, 29 Apr 2022 00:00:00 +0300

Number of patients with progressive chronic kidney disease (CKD) is increasing all over the world. One of the risk factors for CKD development and progression is increased serum uric acid (sUA) level. Possibly, control of hyperurcemia with urate lowering therapy drugs can slow the decline in kidney function.

The objective: to determine efficacy and safety of allopurinol and febuxostat in treatment of patients with CKD and hyperurcemia to reduce the sUA level and analyze its influence on glomerular filtration rate (GFR).

Materials and methods. The study included 45 CKD patients (stages 3b-5) without other severe/decompensated diseases and contraindications to the allopurinol/febuxostat. All patients underwent a comprehensive clinical and laboratory examination, and were divided into the study groups: Group I (28 patients, 61.3±3.2 y.o., CKD3b-12, CKD4-10, on hemodialysis-6 patients) received febuxostat, Group II (24 patients, 60.7Ѓ}4.1 y.o., CKD3b-9, CKD4-10, on hemodialysis – 5 patients) took allopurinol.

Results. Achievement of the target level of sUA was significantly often registered in Group I: after 1 month – in 45.5% (in group II – in 15.9%, p<0.001); after 3 months – in 67.5% (in group II – 21.2% p<0.01); after 6 months, these figures were 90% and 37.1%, respectively (p<0.01). sUA level <300 μmol/l was accompanied by significant positive GFR changes in group I patients; in group II there was a gradual progression of GFR deterioration in 31.8% of patients.

Conclusions. In patients with pre-dialysis stages of CKD febuxostat demonstrates renoprotective abilities. Use of febuxostat in patients with CKD stage 3b-4 and in patients on hemodialysis is safe and more effective for target sUA level achievement than the use of allopurinol.

Risks’ Stratification of Metabolic Disorders and Arterial Hypertension Depending on the NOS3 (RS2070744) and GNB3 (RS5443) Genes’ Allelic State

Andriy Sydorchuk — Fri, 29 Apr 2022 00:00:00 +0300

Early diagnosis of essential arterial hypertension (EAH), the search for risk factors for its occurrence and severity, which determine the metabolome and epigenetic structures activity, is an urgent task of modern medicine.

The objective: to assess the risks of metabolic disorders and the EAH occurrence, depending on the NOS3 (rs2070744) and GNB3 (rs5443) genes’ allelic state.

Materials and methods. 100 patients with EAH and 48 practically healthy (control group) were enrolled in the study. All participant underwent clinical and laboratory examinations. Metabolic changes were examined by blood glucose, total cholesterol (TC), triacylglycerol (TG), high and low density lipoprotein cholesterol (HDL-C, LDL-C), Atherogenicity index (AI). The NOS3 (rs2070744) and GNB3 (rs5443) genes were studied by real-time PCR. Risks, prognoses were determined by the clinical epidemiology method.

Results. The risk of metabolic disorders (dyslipidemia and hyperglycemia) in EAH patients does not depend on NOS3 gene polymorphism (rs2070744). However, the mutational T-allele of the GNB3 gene (825C>T) presence in the patients’ genotype increases the risk of hyperlipidemia due to atherogenic LDL-C 8.5 times [OR=8.45; OR 95%CI:0.99–72.70; p=0.05], with the CC-genotype protective role [OR=0.12; OR 95%CI:0.01–1.0; p=0.048].

The overall risk of EAH in the examined population increases with fasting hyperglycemia 9 times [OR 95%CI:2.86–27.08; p<0.001], with hypertriglyceridemia (>1.70 mmol/l) – 3 times [OR 95%CI:1.23–5.56; p=0.009] and with a decrease in HDL-C (<1.2 mmol/l) – more than 3.5 times [OR 95%CI:1.46–8.71; p=0.003], respectively.

Conclusion. The risk of metabolic disorders increases in EAH patients with the T-allele of the GNB3 gene (825C>T) 8.5 times with the lowest probability of such changes in the CC-genotype carriers [OR=0.12; p=0.048].

MRI as an Effective Tool for the Diagnosis and Monitoring of Leffler Endocarditis at the Stages of Longitudinal Observation

Fri, 29 Apr 2022 00:00:00 +0300

Hypereosinophilic syndrome (HES) is an extremely rare disease that is not always diagnosed, and the lack of statistic data does not let to determine its real incidence.

Among patients men predominate, the ratio of men and women is 9: 1, the most vulnerable age is from 20 to 50 years. The familial hypereosinophilia is inherited disease of autosomal dominant type. Two-year mortality was recorded in half of the cases of Leffler’s endocarditis with progressive fibrosis due to heart failure and thromboembolic complications.

Leffler’s endocarditis and endomyocardial fibrosis as components of restrictive cardiomyopathy are accompanied by eosinophilia. The story of the discovery of eosinophils is closely connected to the name of Paul Ehrlich; the further idea of tracing the connection between eosinophilia and the involvement of the heart and other organs belongs to Leffler.

In the presence of Leffler’s syndrome, the probability of thrombosis in the heart cavities and determination of the stage of the disease were analyzed by longitudinal observation using cardiac MRI.

The described clinical case of Leffler syndrome in a young man in real clinical practice clearly demonstrates the difficulties of diagnosis in the outpatient phase, need in interdisciplinary approach in the work of the team “heart team” during the hospital period, the role and importance of long-term cardiac MRI monitoring of the selected optimal therapy.

Leffler’s syndrome in real clinical practice requires from physicians of various specialties, including family physicians, knowledge of etiology, pathogenesis, clinical masks of disease manifestation and tactics of patient management in the outpatient phase.

MRI of the heart remains the “gold standard” for diagnosis and longitudinal monitoring of patients with Leffler syndrome.

COVID-19 in Patients with Psoriatic Arthritis

Fri, 29 Apr 2022 00:00:00 +0300

The COVID-19 pandemic has a negative impact on all aspects of human life and can lead to the exacerbation of chronic diseases. At the same time, it is known that a higher risk of infection and a more severe course of coronavirus infection is found in the elderly, as well as in people with serious comorbidities.

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is often diagnosed in patients with psoriasis. Specific treatment of patients with chronic inflammatory joint disease include nonsteroidal anti-inflammatory drugs, glucocorticosteroids, disease-modifying antirheumatic drugs, new biological agents, including monoclonal antibodies to IL-6, IL-1, TNF-a, target disease modifying drugs. Medications used for PsA treatment can potentially have both negative and positive effects on the course of COVID-19.

The objective: to analyze the features of COVID-19 in patients with PsA and to study the comorbid pathology after coronavirus infection.

Materials and methods. The study involved 174 people with a verified diagnosis of PsA. Patients were divided into two groups. Group I included 112 (64.4%) persons who had COVID-19, and group II - 62 (35.6%) who had not had coronavirus infection at the time of first examination.

Patients in group I significantly differed from group II in age (p <0.001) and duration of PsA (p <0.001), showed a significantly higher degree of psoriatic skin lesions and activity of the underlying disease (p = 0.001) compared to patients from group II. The participants of the study underwent examination characterize the course of the psoriatic disease and skin lesions and risk of cardiovascular disease.

Results. To date, there are no clear scientific data that reveal the specific features of COVID-19 infection and the effect of antirheumatic therapy on the development of dangerous complications associated with coronavirus infection in patients with PsA.

The analysis of comorbid pathology has found cardiovascular pathology in 67 (59.8%) of patients, including arterial hypertension – in 58 (51.8%) people, metabolic syndrome – in 34 (30.4%), diseases of the digestive system – in 32 (28.6%) and respiratory system – in 24 (21.4%) of persons.

Conclusions. Patients with higher activity and duration of the PsA were significantly more likely to get COVID-19 and demonstrated higher total cardiovascular risk for the next 10 years.

Further research is needed to study the impact of specific basic rheumatological drugs on the outcomes of COVID-19 and to analyze the broader effects of the pandemic on the course of psoriatic arthritis.

The Role of Dexmedetomidine in the Structure of Anesthesia for Hip and Knee Arthroplastyс Surgery in Patients with Diabetes

Oleksandr Halushko, Larysa Zenkina — Fri, 29 Apr 2022 00:00:00 +0300

Hip and knee arthroplasty (HKA) is a surgical procedure when damaged parts of the joint are replaced with artificial ones that replicate the shape of a normal joint and restore its function.

Every year more than 1.5 million endoprosthetic operations are performed in the world. Replacement of a damaged joint allows patients to return to the normal life, freeing from pain and limited mobility. However, one of the common diseases that negatively affect the results of these operations is diabetes mellitus (DM).

The aim of the study: to determine the efficacy and safety of the combined multimodal low opioid anesthesia with dexmedetomidine sedation in patients with diabetes undergoing HKA surgery.

Materials and methods. The study included 45 patients who underwent HKA surgery. Patients were divided into three groups according to the scheme of anesthesia. In patients of the 1st group (n = 15) multicomponent low-flow anesthesia with artificial lung ventilation was performed, in the patients of the 2nd group (n = 15) spinal anesthesia was used, in the 3rd group (n = 15) – combined spinal – epidural anesthesia with dexmedetomidine sedation.

The groups of patients were identical in anthropometric and gender characteristics, duration of surgery and anesthesia, baseline somatic status.

Statistical analysis was performed using the IBM SPSS Statistics suite (SPSS v.16.0).

Results. The course of anesthesia in patients in all groups was satisfactory, but patients in group 3 were less likely to experience hyperdynamic reactions (tachycardia and hypotension), postoperative nausea and vomiting (PONV). Only one patient from group 3 required ondansetron for the treatment of PONV against 3 and 2 patients from groups 1 and 2, respectively (p <0.05).

Conclusions. Any of the proposed techniques can be used for anesthesia during hip and knee arthroplasty, but the best results have been obtained with combined spinal-epidural anesthesia with dexmedetomidine sedation. In addition, the use of dexmedetomidine can significantly reduce the use of opioids diring the intraoperative and postoperative period.

Obesity Prevention is the Key to a Nation’s Health

Volodymyr Mykhaylenko — Fri, 29 Apr 2022 00:00:00 +0300

The overweight and obesity is increasing problem for the health care system and for the health of the general population. The number of overweight people with varying degrees of obesity is growing in most countries around the world each year, a third of the world’s population suffers from this condition.

According to scientists, lack of sleep, stress, use of certain pharmacological drugs can lead to obesity. The causes and factors of weight gain are varied, not only in personal life, such as eating habits and physical activity, but also include factors that can not be controlled, such as environmental factors, socio-economic factors, genetic factors and more.

Obesity is a major risk factor for many diseases such as diabetes, cardiovascular disease, stroke and some cancers.

Obesity prevention should be one of the top priorities for the health care system. Preventive measures aimed to prevent the development of overweight and obesity have three levels of intervention: primary, secondary and tertiary. The purpose of the primary prevention is to minimize weight gain and prevent the development of overweight or obesity. Secondary prevention aimes to reduce the impact of the existing disease. Tertiary prevention concentraits on reduction of the complications that have developed as a result of the disease.

To prevent overweight and obesity, doctors advise to limit the caloric content of diet by reducing the consumption of fats and sugars; increase the consumption of fruits and vegetables, as well as whole grains and nuts; perform regular exercise.

Regular weighing by health professionals can help identify patterns and factors that contribute to weight gain. The success of obesity therapy depends on the patient’s trust to his doctor and the knowledge of the clinician in this area.

Stress Management Skills in the Physicians Practice of Primary Care Level

Liudmyla Matviyets — Fri, 29 Apr 2022 00:00:00 +0300

Current approaches to non-specialized help with stress are set out in this article and stress management tools are provided, which are developed by WHO in the stress management handbook “Doing What Matters in Times of Stress: An Illustrated Guide”. This knowledge is especially current in the giving of first aid in emergencies, and in giving psychosocial support to patients as well, by primary care physicians, who must have effective communication skills and mutual understanding, and have experience in supporting people in difficult situations too, as it is specified in numerous WHO recommendations on mental health, in such as : «mhGAP Intervention Guide for mental, neurological and substance use disorders in nonspecialized health settings», «IASC Guidelines for mental health and psychosocial support in emergency settings»,«mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies», «Support for Rehabilitation: Self-Management after COVID-19 Related Illness» and etc.

Aim – to give the information for the distant self-learning of the primary care professionals to use the simple stress-management tools in difficult circumstances.

Distance learning is built on the basis of the evidence based WHO documents and recommendations about low intensity psychological interventions. The WHO Guide has five sections, where five ideas and techniques for reducing stress are descibed, which are designed as the acquisition of five skills. The authors at the end of each section of the Guide developed algorithms of use the skills of such tools as: «Grounding», «Unhooking», «Acting according to own values», «Showing kindness», «Creating space». The psychosocial support provided by the primary care physician / facilitator / assistant lies in helping people to use guidance and apply strategies in their own lives, and it prevents the professional burnout of healthcare professionals as well.

The short information about WHO guide and stress -management methods are described in sufficient details to enhance the awareness level of the primary care personnel about stress-management tools use.

As the result of using the Guide will enhance the capacity of local helth care staff and non medical staff to provide the mental health services and psychosocial support during the current COVID-19 pandemic, and readiness for the future emergencies.

Acute Coronary Syndrome in Patients with Diabetes mellitus: Features of the Course and Manifestations of Pain Syndrome

Oleksandr Halushko, Maryana Bolyuk — Fri, 29 Apr 2022 00:00:00 +0300

Acute coronary syndrome (ACS) remains a common cause of hospitalization for patients with diabetes mellitus (DM). Due to development of diabetic neuropathy, it is believed that this category of patients is characterized by a high frequency of atypical acute coronary syndrome, but data on this are quite contradictory.

The objective: to determine the features of the pain syndrome and its severity in patients with acute coronary syndrome and concomitant diabetes.

Materials and methods. The study involved 36 patients with diabetes (22 men and 14 women) aged 44–86 years, hospitalized urgently for ACS. Pain syndrome was assessed at the time of hospitalization and immediately after coronary artery revascularization according to the following criteria: visual analog scale (VAS), Numerical Rating Scale (NRS), clinical data, and biochemical markers.

Results. The majority of patients (91.67%) at the time of hospitalization complained of chest pain, the rest were not bothered by any pain. During the survey, patients described pain as «burning» (30.56%), «squeezing» (30.56%), «squeezing» (25.0%), «tingling» (5.56%). There were also complaints of difficulty breathing (13.89%), shortness of breath (11.1%), palpitations (41.67%). The appearance of excessive sweating was noticed by 16.67% of patients. There was no statistically significant difference between the results of pain assessment by VAS and NRS (p>0.1). The average value of glycemia at the time of hospitalization was 8.19±3.45 mmol/l (men – 8.17±3.61 mmol/l, women – 8.28±3.13 mmol/l). Glycemia greater than 10.0 mmol/l was detected in 8 patients, which was 22.22% of all patients. This category of patients was dominated by patients with severe pain (62.5%).

Conclusions. In patients with ACS and diabetes, the typical clinical picture of ACS prevailed (91.67% of patients) over the painless form. Prior to revascularization, moderate and severe pain occurred with equal frequency; there is no statistical difference between blood pressure, heart rate and glycemia (p>0.1) in patients with severe and moderate pain. Hyperglycemia (≥10.0 mmol/l) was found in 22.22%, among this category of patients was dominated by patients with severe pain.

Interactive Training as a Method to Change the Attitude to the Vaccination at the Example of COVID-19 Vaccine

Fri, 29 Apr 2022 00:00:00 +0300

The new infectious disease COVID-19 was first registered in late 2019 in Wuhan (China) and has since spread significantly around the world. It is known that 2020 was a year of quarantine measures in most countries around the world, where quarantine was set in attempt to stop or slow the spread of the disease until the vaccine is developed.

The vaccination campaign began in late 2020 in a number of developed countries. To date, several coronavirus vaccines have been registered in Ukraine: Pfizer / BioNTech, Moderna, CoronaVac / Sinovac Biotech and Oxford-AstraZeneca. However, the pace of vaccination in the country is slowing down due to the low readiness of certain segments of the population for vaccination.

The objective: to analyze the changes at family doctors and nurses attitude who had the moderate or low readiness for COVID-19 vaccination before and after the interactive training; development of interactive training using practical and theoretical techniques to increase motivation for vaccination.

Materials and methods. The study was conducted with the participation of 541 nurses (doctors and nurses) of different gander, aged from 19 to 67 years, employees from urban and rural clinics, who participated in interactive training about COVID-19 vaccinatoin. At the time of the training, 265 health workers had been vaccinated. The trainings were scheduled for 6 months (March-September 2021).

Results. A comparison of the ratio of readiness to be vaccinated before and after training was calculated. Statistical analysis showed the link between the profession (doctor or nurse) and the level of readiness for training. The number of health workers who were completely unready to be vaccinated decreased from 9% before training to 1% – after it; the number of those who assessed themselves as unready – decreased from 14% to 5%. The number of people who hesitated – decreased from 57% to 23%. At the same time, the number of those who were ready to be vaccinated increased from 19% to 55%, and those who were absolutely ready - from 1% to 16%.

Conclusions. Interactive trainings or special course in education curriculum with evidence of vaccination efficacy should be used to ensure readiness for immunoprophylaxis among patients and health professionals.

Vaccination remains the most effective strategy for preventing serious illness and death from COVID-19 infection.

Blood Pressure in Patients with Arterial Hypertension and Overweight or Obesity During Office Measurement and Daily Monitoring

Victoriia Potaskalova — Fri, 29 Apr 2022 00:00:00 +0300

Arterial hypertension (AH) is one of the most common chronic diseases in the world. More than 1.5 billion people suffer from hypertension. According to official statistics, in Ukraine in 2021 more than 13 million patients with AH were registered, and annually this disease is detected in 1 million Ukrainians.

The objective: to determine the levels of blood pressure (BP) in overweighted or obese patients with AH who use antihypertensive drugs during office measurement and 24-hours monitoring of BP.

Materials and methods. The study analyzed the results of treatment of 395 overweighted or obese patients (139 women and 236 men) with essential AH. All patients received antihypertensive treatment for at least 3 months before study start. Patients were divided into five groups depending on blood pressure. The control group included 33 age-matched individuals.

During the study BP was measured in physician’s office with use of mechanical tonometer with a shoulder cuff and ambulatory 24-hours blood pressure monitoring (ABPM) was performed for all patients.

Results. The results of office blood pressure measurement and ABPM were analyzed. Normal BP was detected in 34.7% of patients with AH and high BMI. In 10.9% of patients systolic blood pressure (SBP) remains above 139 mm Hg despite of drug use, in 16.3% of patients the grade 1 AH was diagnosed, in 23.2% – grade 2, and in 14.9% – grade 3 AH was deter mined during office blood pressure measurement. It was found that men are 1.7 times more likely had uncontrolled AH comparing to women.

The further analyze of the BP data showed that office BP levels were higher then home. Target blood pressure levels were found in 87% of patients during ABPM, although in the office measurement this figure was 54%, 5% of patients could not withstand the BP monitoring during the day with an automatic device due to pain.

No difference in heart rate was determined in study patients by different types of measurement.

Conclusions. In patients with AH and high body mass index, office measurement reveals insufficient reduction of blood pressure (BP) in 35% of patients despite of antihypertensive drugs use. At the same time ABPM found target BP achievement in 87% of patients. Thus, ABPM should be performed in overweighted or obese patients with AH before making the decision to increase the antihypertensive drug dose to avoid possible undesirable BP decrease.

Quality of Life and Social Functioning of Patients After Cardiosurgical Interventions

Dmytro Mankovskyi — Fri, 29 Apr 2022 00:00:00 +0300

The objective: to study the quality of life (QOL) and social functioning of patients who underwent cardiosurgery intervention (CSI) with the use of artificial circulation (AR) in the postoperative period, to determine and improve the system for further medical, psychological and social rehabilitation.

Materials and methods. 700 patients who underwent CSI with the use of AR were treated at the Heart Institute of the Ministry of Health of Ukraine. 86 patients had cerebral infarction (CI), 217 patients with signs of postoperative encephalopathy, and 504 patients with signs of cognitive dysfunction. The level of QOL and social functioning in patients with this pathology was analyzed.

Statistical analysis of differences in the quantitative values of indicators was performed using the nonparametric Mann-Whitney test.

Results. It was found that patients after CSI had generally low levels of QOL in all fields, namely in the indicators of psychological (emotional) well-being, general perception of life, ability to work, physical well-being, personal realization, selfcare and independence; interpersonal interaction.

The presence of ischemic and neurological complications in patients after CSI significantly reduces the QOL indicators in all areas, with differences in the quantitative values of such patients statistically significant (p<0,01) compared to the groups of patients without such complications.

The most significant deterioration of QOL is found in patients with cerebral infarction in the postoperative period, slightly less significant – in patients with signs of postoperative encephalopathy, and the smallest changes – in patients with signs of cognitive dysfunction.

Conclusions. The main task of modern cardiac surgery is not only to save the patient from death, but also to improve the quality of life (QOL). At the same time, patients after cardiac surgery are at risk of developing ischemic, neurological complications that significantly reduce QOL in all areas of life. That is why it is necessary to take into account the findings of the study in the development of treatment and rehabilitation programs and preventive measures for such patients.