Background/Aim Anethum graveolens L. (dill) (Apiaceae) is one of the most popular culinary herbs in the world. Dill has been cultivated since ancient times, and the use of this plant for medicinal and consumption purposes has been recorded dating back to the Greek and Egyptian civilizations. Dill is widely used to give flavor to food. The aim of this work was to assess the chemical composition of the volatile compounds in dill as well as their hepatoprotective and nephroprotective activity against free radicals generated by paracetamol. Materials and methods The chemical composition of the volatile compounds of dill was assessed by gas chromatography and gas chromatography-mass spectrometry. Four groups of rats were used (the normal control group, the A. graveolens-supplemented group, the paracetamol-intoxicated group, and the A. graveolens-protected group) for studying the effect of plant infusion on panadol (paracetamol)-induced free radicals and hepatotoxicity. Plasma total antioxidant capacity, plasma catalase, cellular glutathione peroxidase, plasma total protein, albumin, alanine amino transferase, aspartate amino transferase, alkaline phosphate, γ-glutamyl transferase, total bilirubin, and direct bilirubin levels were determined. In addition, kidney functions (plasma urea and creatinine) and histopathological and histochemical changes in the liver were investigated. Results The phytochemical results identified volatile components 7-α-hydroxy manool (24.43%), l-carvone (14.28%), limonene (13.9%), epi-α-bisabolol (6.81%), α-terpinene (5.44%), and α-phellandrene (4.63%) as the main constituents. p-Cymene (2.13%), sabinene (1.98), and α-pinene (1.43%) were determined as the minor constituents. The biochemical results showed that a mega dose of paracetamol induced the production of free radicals, which caused damage to hepatocytes and nephrocytes in rats. The aqueous extract of dill revealed high antioxidant properties and acted as an extracellular neutralizer of free radicals. Histopathological and histochemical observations showed severe damage in the liver. Supplementation with dill in paracetamol-intoxicated rats attenuated the damage to the liver. Conclusion The present study revealed that A. graveolens has antihepatotoxic properties that could minimize the deleterious effects generated by hepatotoxin paracetamol, and therefore it can be used as a potent antihepatotoxic agent.

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Background/aim Children with epilepsy are at an increased risk of poor health-related quality of life even in the absence of active seizures. The study was undertaken to assess the health-related quality of life and its predictors in children with epilepsy, comparing the relationship between different types of seizures and health-related quality of life in Egypt. Patients/methods This cross sectional case control study included 50 epileptic children aged 8-12 years, with a mean age of 9.35 ± 1.59 years and a male to female ratio of 1.8 : 1. They were divided into two subgroups according to the types of seizures: 26 patients with generalized seizures in subgroup I and 24 patients with partial seizures in subgroup II, and 50 apparently healthy children of matched age, sex, and social class were included as the control group. The Arabic version of the 23-item Pediatric quality of life Generic Core Scale (Parents' scale) was applied to evaluate the health-related quality of life of both patients and healthy controls. Results Diminished health-related quality of life is a common feature of epilepsy. Highly significant lower overall quality of life scores of all functioning domains of health-related quality of life were present between patients' subgroups (P < 0.001), and between total patients versus control groups (P < 0.001). Univariate analysis was performed to identify significant predictors of poorer quality of life in children with epilepsy. On analyzing the risk factors using odds ratio, epilepsy-related risk factors such as age at onset of seizures, types of seizures, duration of the illness, number and duration of antiepileptic drugs as well as children's clinical variables such as learning problems, developmental delay in milestones, limitation in child hobbies, urine incontinence, and prolonged sleep, and some family-related variables such as marital disharmony and parental anxiety were found to be significantly strong predictors of poorer health-related quality of life in children with epilepsy, with prediction of 95%. Conclusion Epileptic patients were found to be at a higher risk of developing impaired quality of life with lower mean scores of all domains of quality of life, especially patients with generalized, frequent fits, those on polytherapy, and patients with a younger age of seizure onset and a longer duration of illness. The scope of management of epilepsy should include optimal seizure control and improvement of the health-related quality of life of the affected children.

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Background/aim Cape gooseberry is golden-colored spherical fruit commercially produced in Egypt. It is primarily used in folk medicine for treating some diseases. To identify the aroma compounds in Cape gooseberry and to evaluate its antioxidant activities as well as its anticancer (for colon and breast cancers) effects in human cell lines. Materials and methods The volatile compounds were identified using gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS). Polyphenols (phenolics and flavonoids) were also determined. Antioxidant activity was determined by three different methods: 2,2΄-diphenyl-1-picrylhydrazyl (DPPH), 2,2-azinobis(3-ethyl-benzothiazoline-6-sulfonic acid) (ABTS), and ferric reducing antioxidant power (FRAP) assays. Anticancer (for colon or breast cancer) activity was determined in cancer cell lines using 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay. Results A total of 34 components of the essential oil were identified by GC and GC-MS. The volatile compounds were grouped in classes of substances, including 11 terpene compounds (six monoterpenoids and five sesquiterpene), 11 esters, five alcohols, two phenolic compounds, two aldehydes, two ketones, and one lactone. Terpenes (monoterpenes and sesquiterpenes) were the most abundant volatile constituents, accounting for the largest portion of the total volatiles (36.09%). The next most abundant compounds were esters, comprising 17.17% of the total volatile components identified. Phenolic compounds were the next most abundant compounds, comprising 16.04% of the total volatiles. Alcohols and aldehydes represented 6.37 and 1.88% of the total volatile compounds, respectively. Ketones and lactones are less abundant in the profile of volatile compounds in Cape gooseberry. Ethanol extract had higher phenolic and flavonoid contents than did hexane extract. As ethanol extract of Cape gooseberry achieved higher antioxidant activity than did hexane extract, it tested as an anticancer (for colon or breast cancer) agent. Cape gooseberry extract was more potent in inhibiting colon cell lines (IC ₅₀ : 142 μg/ml) compared with breast cell line (IC ₅₀ : 371 μg/ml). Conclusion Egyptian Cape gooseberry fruits may be suggested as a potential source of natural antioxidants and anticancer agents.

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Background/aim Although it is recommended that healthcare professionals should comply with the standard precautions to prevent acquiring blood-borne diseases (AIDS, hepatitis B and C), yet, they frequently do not comply with this recommendation. Understanding the reasons for compliance and noncompliance will help in designing educational programs for hospital staff and in determining a strategy for improving health behavior. The present study aimed to assess surgeons' compliance to standard precautions and determine surgeons' perceived beliefs affecting their compliance using the Health Belief Model. Participants and methods A cross-sectional study was carried out at surgical departments in Zagazig University Hospitals from December 2012 to May 2013. A questionnaire on various aspects of infection control and standard precautions practices was provided to 307 surgeons, with a response rate of 70%. Results Our findings indicated that 57.5% of the surgeons sampled in Zagazig University Hospitals were compliant with standard precautions. 59.8% of compliant surgeons had been exposed to at least one needle-stick injury in the previous 3 months, whereas slightly less than half of compliant surgeons (48.4%) had been exposed to splashes, with a highly significant difference compared with nonexposed surgeons. All Health Belief Model subscales were correlated directly with the surgeons' compliance, except perceived barriers. Conclusion There is adequate compliance with standard precautions among surgeons in Zagazig University Hospitals, especially female surgeons, with a high level of knowledge among compliant compared with noncompliant surgeons. All Health Belief Model subscales were correlated directly with the surgeons' compliance, except perceived barriers. Adequate training of surgeons, provision of infection prevention equipment, regular reporting, follow-up, and assessment of occupational exposures need to be introduced.

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Background/aim Worldwide, more than half of all unintended pregnancies end in abortion, indicating the preference for increasingly smaller families. The present work aimed to assess the determinants of unintended pregnancy and its impact on women's health in El Fayoum and Benisuef governorates. Participants and methods A community-based cross-sectional household survey was conducted among 827 married women of reproductive age. The study was conducted in two governorates, El Fayoum and Benisuef, for a period of 6 months. Results The current study revealed that 15.9% of women who participated in the study had an unmet need for family planning, with subsequent unintended pregnancy. Higher age of women and her age at the time of marriage, illiteracy, short interpregnancy spacing, exceeding the desired number of children, negative attitude of husbands toward the use of family planning methods, and absence of discussion between partners on the use of means to postpone pregnancy increased the number of unintended pregnancies. Also, women with unintended pregnancy were at a higher risk of experiencing health problems during her pregnancy. Conclusion Despite the efforts taken by family planners, the problem of unintended pregnancy continues to increase in Egypt, with its adverse effect on pregnancy and maternal outcomes. Therefore, the strategy for maternal mortality reduction in Egypt should focus on addressing the unmet needs of high-parity, uneducated, nonworking women.

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Objective The aim of this study was to evaluate the total phenolic content (TPC) and antioxidant potential of Althaea rosea Cav., family Malvaceae, as well as to isolate and identify the flavonoid content of the methanolic extract of the aerial parts. In addition, a comparison between the TPC and antioxidant capacity of the methanolic extract of both aerial parts and flowers was carried out to discover new active constituents that can be utilized in drug industry. Materials and methods The extraction of the flavonoid compounds was carried out by percolation of the dried aerial parts of the plant under investigation with 70% methanol until exhaustion. The combined extract was then concentrated and defatted with petroleum ether (60-80°C). After separation of the lipoidal matter, the remaining extract was purified from mucilage and subjected to several column chromatographic techniques for isolation of the flavonoids. The identification of flavonoid compounds was carried out using physical, chemical, and spectral methods such as ultraviolet, ¹ H NMR, and ¹³ C NMR. The antioxidant potential of the methanolic extracts of both aerial parts and flowers was determined using the s[table 2], 2-diphenyl-1-picrylhydrazyl free radical scavenging activity method. Furthermore, their TPC was also determined using the Folin-Ciocalteu method. Results Five flavonoid compounds were isolated from the aerial parts of A. rosea Cav., which were identified as quercetin 3-O-β-d-glucuronopyranoside-8-C-β-d-glucopyranoside, kaempherol-3-O-β-d-rutinoside, kaempherol-4΄-O-β-d-glucoside, kaempherol-3-O-β-d-glucoside, and kaempherol. The antioxidant activity was measured in terms of their IC ₅₀ . The IC ₅₀ values of the methanolic extracts of the aerial parts and flowers were 11 and 1 mg/ml, respectively, whereas the TPCs were 48 and 73 μg/ml, respectively. Conclusion The methanolic extracts of both aerial parts and flowers of A. rosea Cav. are rich in phenolic compounds and have a prominent antioxidant activity. The antioxidant activity of both extracts may be attributed to their phenolic content.

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Background/aim Pollens from different plants contain unsaturated fatty acid esters (USFAEs) and flavonoids that play a very important role as bioactive compounds. Therefore, the present study was designed to improve the production of volatile USFAEs and flavonoids from date palm pollen (DPP) in a culture of Trichoderma koningii and test its activities as an anti-breast-cancer and antiviral agent. Materials and methods The volatile esters of fermented and nonfermented date palm pollens (FDPPs) were identified using gas chromatographic-mass spectrometric (GC-MS) analysis. Antioxidant activities were determined using three different methods: the 2,2′-diphenyl-1-picrylhydrazyl (DPPH) assay, the ferric reducing antioxidant power assay, and the 2,2-azinobis(3-ethyl-benzothiazoline-6-sulfonic acid) (ABTS) assay. Polyphenols (phenolics and flavonoids) were also determined. Anti-breast-cancer and antiviral activities were determined using the 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay. Results GC-MS analysis showed an improvement in the level of USFAE in FDPP (47.99%) almost double that of the DPP results (24.11%) extract concentration. Flavonoids content of the FDPP extract (93.4 ± 6.3 mg/ml) was higher than that obtained by the DPP extract (45.4 ± 2.1 mg/ml), which was more than double the value. Antioxidant activity of the FDPP extract increased 3.16, 3.42, and 2.14 times that of the DPP extract as determined by the ABTS, ferric reducing antioxidant power (FRAP), and DPPH assays, respectively. The extract of FDPP showed strong anticancer activity against the MCF-7 cell line (IC ₅₀ : 9.52 μg/ml) compared with the DPP extract (IC ₅₀ : 96.22 μg/ml). Also, the FDPP extract had strong antiviral activity (CC ₅₀ : 16.5 μg/ml) compared with DPP (CC ₅₀ : 38.8 μg/ml). This is the first report in which the FDPP extract is used in biological studies as anti-breast-cancer and antiviral agents. Conclusion Fermentation of DPP by T. koningii improves many bioactive volatile USFAE and flavonoid contents; these have anti-breast-cancer and antiviral activity.

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Background/aim Water pollution not only damages the environment but also kills wildlife. The present study aimed to investigate the effect of Escherichia coli, Salmonella typhi, and Staphylococcus aureus, which were isolated from drainage water at El-Rahawey area, Giza, Egypt, on experimental rats. Materials and methods Water samples were collected from the subsurface layer for bacteriological examination, stored in an ice box, and delivered to the laboratory and analyzed to count the total viable bacterial counts/ml using the most probable number technique. The isolated bacteria were given to rats for 21 days at a dose equal to 10³/ml and the liver and kidney were dissected for histopathological and histochcemical studies. Results Results showed that the average counts at 22 and 37°C were 10⁵ and 10⁶ CFU/ml, respectively, whereas the average counts by using the most probable number technique/100 ml were 10⁵, 10⁴, 10³, 10³, and 10² for total coliforms, fecal coliforms, E. coli, Salmonellae group, and total staphylococci, respectively. Isolation of pathogens from water sources were identified by using membrane filter technique on specific media. The histopathological examination of the liver of treated rats with E. coli, S. typhi, and S. aureus revealed swollen hepatocytes with decreased sinusoidal spaces and widely distributed necrotic foci. In the kidney, renal tubules showed extensive epithelial swelling with decreased lumen space and generalized necrotic changes with interstitial hemorrhage in renal cortex. The histochemical study indicated the depletion of staining of protein and polysaccharides. Conclusion E. coli, S. typhi, and S. aureus that are isolated from polluted drainage water cause histological and histochemical changes in the liver and kidney of rats.

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Background and aim The role of T helper-17 lymphocytes in the regulation of the immune response against Schistosoma soluble egg antigens is still controversial. In this study, the in-vitro effects of T helper-17 cytokines [interleukin (IL)-17 and IL-22] on granulocyte functions isolated from Schistosoma-infected patients or healthy individuals were examined. Patients and methods Twenty-seven Schistosoma mansoni-infected patients and 13 healthy individuals from Kasr Al-Aini Viral Hepatitis Center were enrolled in the present study. Granulocytes were isolated from whole blood of patients and controls by Ficoll–Paque density gradient for removal of the mononuclear layer and then lysis of red blood cells. Granulocytes were stimulated in vitro with soluble egg antigen in the presence of IL-17, IL-22, or both. After 24 h, the supernatants were collected for the measurement of tumor necrosis factor (TNF)-α, hydrogen peroxide (H₂O₂), myeloperoxidase (MPO), and nitric oxide (NO) using enzyme-linked immunosorbent assay as surrogate markers for granulocyte functions. Results The results indicated that the presence of IL-17 significantly decreased (P<0.05) TNF-α, H₂O₂, MPO, and NO production by granulocytes isolated from Schistosoma-infected patients. In contrast, in the presence of IL-22 or both IL-17 and IL-22, there were significant increases in the production of H₂O₂ and TNF-α by granulocytes isolated from Schistosoma-infected patients. Moreover, in the presence of both IL-17 and IL-22, nonsignificant changes were observed in MPO or NO levels compared with those in the control participants. Conclusion IL-17, in contrast to IL-22, inhibited the functional activity of granulocytes isolated from S. mansoni-infected patients. Therefore, neutralization of IL-17 may work as a therapeutic strategy for these patients.

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Background/aim There is an imperative, yet unmet need for the development of a biomarker panel for progression of rheumatoid arthritis (RA). This study aimed to investigate the reliability of B-cell differentiation factor (BCDF) and macrophage colony-stimulating factor (MCSF) as diagnostic and prognostic biomarkers of RA. Patients and methods A total of 25 RA patients were enrolled and divided into three subgroups according to the disease activity score, remission/minimal, moderate, and severe, in addition to 20 healthy controls. Enzyme-linked immunosorbent assay was used to measure serum BCDF, MCSF, and interleukin (IL)-2, and the calorimetric method was used to measure immunoglobulin G (IgG). In addition, the erythrocyte sedimentation rate was measured at 1 h in the RA patients. Results BCDF, MCSF, and IgG were significantly higher in the RA patients compared with the controls. BCDF was significantly higher in the severe disease group compared with the remission/mild and the moderate disease groups, whereas IgG was significantly higher among the moderate disease group compared with the remission/mild disease group, and among the severe disease group compared with the remission/mild disease group, whereas the erythrocyte sedimentation rate did not show any significant difference between the three subgroups of the disease group. BCDF delineates RA from controls at a cut-off value of 102 pg/ml, whereas at a cut-off value of 37.5 ng/l MCSF delineates RA from controls. Conclusion Serum BCDF and MCSF can be used as RA diagnostic biomarkers, whereas BCDF can be used additionally as a prognostic biomarker.

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Background/Aim Measurement of carotid artery intima–media thickness (CIMT) is reliable for early detection of atherosclerosis, one of obesity’s complications, which is a leading cause of mortality among patients with end-stage renal disease. The study aimed to evaluate CIMT in relation to obesity, chronic renal failure (CRF) and both, for the early prevention of cardiovascular problems. Patients and methods This cross-sectional study included 118 adult individuals of both sexes, aged 30–60 years. Patients with CRF were gathered from the renal dialysis unit of King Fahd Hospital-Kasr El Einy Hospital, and the obese without CRF from the ‘Management of Visceral obesity Unit’, in ‘Medical Excellence Research Center (MERC)’, National Research Centre, during the period spanning from June 2015 to April 2016.They were grouped into three groups: a case group, which included 45 obese individuals with CRF, and two control groups: one comprised 39 nonobese patients with CRF and the other group comprised 34 obese patients without CRF. Anthropometric assessment, lipid profile, and ultrasound measurement of CIMT were performed for each patient. Results CIMT was greater in all groups than the normal range (0.06–0.08 cm), particularly in the obese group without renal failure. CIMT had a highly significant correlation with waist circumference and insignificant correlation with BMI and lipid profile in different groups. Conclusion The increase in CIMT was related to obesity and renal failure, but it was more prominent with obesity. CIMT had highly significant correlation with central obesity in cases wherein obesity and renal failure were coexisting together and insignificant correlation with lipid profile.

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Background/Aim This study was designed to assess the relationship between the serum level of 25-hydroxyvitamin D and the clinical, functional severity and the level of asthma control among Egyptian asthmatic children. Patients and methods This case-control cross-sectional study was conducted on 50 asthmatic patients from those regularly attending the Pediatric Chest Clinic, Children's Hospital, Ain Shams University. Twenty healthy children of matched age and sex were recruited as the control group. Results Pulmonary function tests were significantly decreased in the asthmatic cases compared with the control (P < 0.01). The serum vitamin D level was found to be significantly decreased in asthmatic children compared with the control group (P < 0.001). Out of the 50 asthmatic children, 20 had a serum vitamin D level of less than 25 ng/ml, and were considered to be 'vitamin D deficient', whereas the remaining 30 children had a level ranging between >25 ng/ml and ≤30 ng/ml and were considered to be 'vitamin D insufficient'. The asthmatic children had a highly significant increase in the total leukocytic count, the eosinophilic count, serum immunoglobulin E, and serum alkaline phosphatase (P < 0.001 in all). There was also a significant increase in the serum phosphorus level in the asthmatic children group compared with the control group (P < 0.01). The serum vitamin D level was 24.1 ng/ml ± 2.9 in the asthmatic patients on inhaled corticosteroid therapy and 28 ng/ml ± 1.4 in those not on inhaled corticosteroid therapy. Significant positive correlations were found between the serum vitamin D level and the predicted percentage of forced expiratory volume in 1 s (r = 0.871, P < 0.001). A highly significant negative correlation was found between the serum vitamin D level and serum immunoglobulin E (marker of allergy; r = −0.589, P < 0.001). Moreover, serum vitamin D showed an inverse correlation with the clinical severity of bronchial asthma (r = 0.903, P < 0.001) and the level of control of asthma (r = 0.923, P < 0.001), classified according to the Global Initiative for Asthma (GINA) classification. The accuracy of vitamin D as a predictor of asthma was found to be 88% by automatic linear modeling. Conclusion Our results revealed an important support for the association between bronchial asthma in children and vitamin D deficiency, with a direct relationship between its serum level and pulmonary function test measures and the increased asthma severity. Vitamin D deficiency can be considered as a strong predictor of asthma. Improving the vitamin D status can help in the primary prevention of asthma and in decreasing exacerbations of attacks. Clinical trials of vitamin D supplementation to prevent asthma exacerbation are recommended.

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Background/aim Apiaceae is a large plant family; it comprises about 60 annual and biannual species mostly distributed in Europe, Africa, West Asia, and Australia. The Daucus genus is one of the most common genera of this family in which Daucus syrticus (DS) is a common member, growing mainly in the Sirt region (Libya). It is locally known as wild carrot. This study aims to investigate volatile oils, lipid constitutes, and the antimicrobial activity of DS extracts. Materials and methods The herb of DS was collected from Wadi Telal, Sirt region (Libya), during January and April 2011. About 250 g of different parts from fresh plant material (aerial parts, roots, and seeds) of DS were subjected to hydrodistillation. Extraction of lipid constituents was carried out as follows: About 1500 g of dried powdered plant material of DS were extracted with petroleum ether in a soxhlet. The antimicrobial activity was determined using the disk diffusion method, and the inhibition zone (IZ) was measured for each extract under study against Escherichia coli, Bacillus subtilis, Aspergillus niger, and Candida albicans. Results Results of Gas chromatography/Mass spectrometry GC/MS analyses of the volatile oils of the aerial parts (January and April collections) proved that they contain a mixture of 47 and 33 compounds, respectively, whereas the roots (April and July) were found to contain a mixture of 32 and 20 compounds, respectively. In addition, the seeds (July) were found to contain 18 compounds, with β-asarone (26.23%) as the main compound. Investigation of the lipid fraction of the herb revealed the presence of a mixture of fatty alcohols; the major contents of the unsaponifiable fraction were identified as a series of n-alkanes C ₈ -C ₂₈ (84.85%), four steroidal compounds, triterpene, and a mixture of fatty acid methyl esters consisting of eight different acids. The antimicrobial evaluation of DS extracts exhibited different IZ values against the tested microorganisms. Conclusion The main constituents of the different volatile oils of the aerial parts, the roots, and the seeds were identified. The fraction of total fatty acid had the highest activity against E. coli (IZ = 2.7, minimum inhibitory concentration = 250 mg/ml).

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Background/aim Acute or chronic liver failure is associated with numerous complications that may occur in combination, and patients may require ICU treatment. Therefore, it seems necessary to identify prognostic clinical parameters and risk factors at the time of ICU admission. The present study aims to estimate the frequency of mortality and evaluate morbidity from cirrhosis in patients with end-stage liver disease (ESLD) admitted to the ICU and evaluate the relationship between the demographic, clinical, and laboratory data (potential risk factors) of those patients and mortality. Patients and methods A total of 120 patients with ESLD were enrolled [102 (85%) male and 18 (15%) female patients]. History taking, clinical examination, and other laboratory investigations were carried out, and patients were classified according to the Child-Turcotte-Pugh (CTP) and the model for end-stage liver disease (MELD) scores. Results Regarding the clinical presentation, hepatic encephalopathy (HE) was found in 87.5% of patients, jaundice in 60%, hematemesis in 41.7%, hepatorenal syndrome (HRS) in 35.8%, and spontaneous bacterial peritonitis in 20.8% of patients. The mortality rate was 57.5%; the main causes of death were HRS (40.8%), HE (21.7%), aspiration pneumonia (10%), septic shock (2.5%), and irreversible shock (1.7%). There was a significant relationship between mortality and old age, CTP and MELD scores, and a longer stay at the ICU. Increased white blood cell count, increased hemoglobin and decreased prothrombin concentration, and elevated creatinine were independent risk factors of mortality in ESLD patients in the ICU. Mortality rates were higher in patients with 5-6 risk factors (86.2%) than in those with 1-2 risk factors (21.7%). Conclusion Mortality rate in ESLD patients admitted to the ICU was 57.5% and the most common cause of death was HRS. CTP, MELD score, HE, HRS, and jaundice were significant predictors of mortality in ESLD patients. Mortality increased with increased number of risk factors. Creatinine level, white blood cell count, hemoglobin, and prothrombin concentration were independent risk factors of mortality in ESLD patients.

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