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Objective To investigate the diagnostic efficiency of artificial intelligence(AI)in rib frac-ture under the computed tomography(CT)images with different reconstruction slice thickness.Methods The first CT images of 100 patients with rib fractures were selected,and the interval-free recon-struction was carried out with the thickness of 0.625 mm,1.250 mm,2.500 mm and 5.000 mm,respectively.The rib fracture screening function of AI was used to automatically detect the CT images of four groups,and the diagnostic efficiency of AI for rib fracture under different reconstruction thickness conditions was com-pared.Results The sensitivity of AI in the diagnosis of rib fracture at 0.625 mm,1.250 mm,2.500 mm and 5.000 mm thickness was 99.32%(436/439),98.41%(432/439),89.52%(393/439)and 83.60%(367/439),respectively.The false positive rate was 4.80%(22/458),0.92%(4/436),0.76%(3/396)and 0.27%(1/368).The diagnostic sensitivity of AI in 0.625 mm and 1.250 mm thickness was higher than that in 2.500 mm and 5.000 mm,and the difference was statistically significant(P<0.05),while there was no significant difference in the thickness of 0.625 mm and 1.250 mm.The false positive rate of AI in the diagnosis of 0.625 mm slice thickness was higher than that of 1.250 mm,2.500 mm and 5.000 mm,and the difference was sta-tistically significant(P<0.05),while there was no significant difference in the thickness of 1.250 mm,2.500 mm and 5.000 mm(P>0.05).Conclusion The diagnostic efficiency of AI in 1.250 mm CT images is better than that in 0.625 mm,2.500 mm and 5.000 mm CT images.
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Objective@#To investigate the expression pattern,underlying function and clinical significance of Guanylate-binding protein 1 ( GBP1) in pulmonary tuberculosis ( pTB) .@*Methods@#Immunohistochemical staining was applied to detect the expression of GBP1 in pTB specimensand control samples. Combined with Gene Expression Omnibus ( GEO) datasets ,including GSE83456 and GSE34608,receiver operating characteristic ( ROC) curve was depicted to assess the diagnostic value of GBP1 in pTB.Then,the correlation between GBP1 and related regulatory factors was analyzed by protein-protein interaction network ( PPI) ; Finally,the potential molecular mechanism of GBP1 in pTB was probed by Gene Set Enrichment Analysis( GSEA) . @*Results@# Compared with the control group,GBP1 was significantly overexpressed in human pTB samples,including lung tissue and blood.The positive rate of GBP1 protein in pTB was 73. 9% . ROC curve analysis revealed that GBP1 might have important value in early diagnosis of pTB.GSEA analysis suggested that the hyper-expression of GBP1 was closely related to the host inflammatory response,IFN-γ/ α signaling pathway and TNF-α/ IL-6 signal transduction.@*Conclusion@# GBP1 is highly expressed in pTB tissues and is involved in the process of inflammatory response and host anti-tuberculosis infection ; GBP1 may be used as an early diagnostic marker or therapeutic target for pTB.
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In order to improve the professional level and service ability of general practitioners, this study is guided by the needs of community medical institutions in the county medical communities. Two small-class training of 15 modules were carried out for a week, taking "2+5" training mode, including 2 days of theoretical teaching and case discussion, and 5 days of bedside teaching. After the training, the theoretical examination, case report and objective clinical structured examination were carried out. Those who passed the examination were issued a certificate of qualification and given corresponding rewards. The results showed that the post-test scores of trainees after training were significantly improved compared with the pre-test scores, and the qualification rate increased from 18.4% to 85.9%. This training mode can be promoted in a wider range, but it should be adjusted appropriately according to the actual situation in various places, and the relevant departments and hospitals should give full support.
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Contemporary college students have low levels of health literacy, facing problems such as weak awareness of health care, unhealthy diet habits, insufficient physical activity, and inadequate emergency response to public health emergencies. The reasons may be related to weak personal awareness of health literacy, imperfect health education system, shortage of health literacy education talents, lack of family health literacy education, and the insufficient social investment in health literacy cultivation. Faced with this current situation, the government, universities, families, individuals, and society should respond to the call of "Healthy China 2030" Plan Outline, regard improving college students’ health literacy level as their own responsibility, help them eliminate or reduce the risk factors affecting health, improve their health literacy level and quality of life, and contribute to the Healthy China strategy.
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BACKGROUND@#Previous studies have revealed that the number of cancer survivors developing a second primary malignancy is increasing, especially among thyroid cancer patients, and lung cancer is still the main cause of cancer death. Therefore, we aimed to investigate the risk of second primary lung cancer (SPLC) in patients with thyroid cancer.@*METHODS@#We searched the PubMed, Web of Science, Embase, and Scopus databases up to November 24, 2021, for relevant research and merged the standardized incidence ratios (SIRs) and 95% confidence intervals (95% CIs) to evaluate the risk of developing SPLC in patients with thyroid cancer.@*RESULTS@#Fourteen studies involving 1,480,816 cases were included in our meta-analysis. The pooled result demonstrated that thyroid cancer patients may have a higher risk of SPLC than the general population (SIR = 1.21, 95% CI: 1.07-1.36, P < 0.01, I2 = 81%, P < 0.01). Subgroup analysis stratified by sex indicated that female patients may have a markedly higher risk of SPLC than male patients (SIR = 1.65, 95% CI: 1.40-1.94, P < 0.01, I2 = 75%, P < 0.01).@*CONCLUSIONS@#Thyroid cancer patients are more likely to develop SPLC than the general population, especially women. However, other risk factors must be investigated, and more prospective studies are needed to confirm our results.@*REGISTRATION@#International Prospective Register of Systematic Reviews: No. CRD42021285399.
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Humanos , Masculino , Femenino , Neoplasias Primarias Secundarias/patología , Revisiones Sistemáticas como Asunto , Neoplasias Pulmonares/patología , Factores de Riesgo , Neoplasias de la Tiroides/complicaciones , IncidenciaRESUMEN
BACKGROUND@#Lung cancer prevails and induces high mortality around the world. This study provided real-world information on the evolution of clinicopathological profiles and survival outcomes of lung cancer, and provided survival information within stage I subtypes.@*METHODS@#Patients pathologically confirmed with lung cancer between January 2009 and December 2018 were identified with complete clinicopathological information, molecular testing results, and follow-up data. Shifts in clinical characteristics were evaluated using χ2 tests. Overall survival (OS) was calculated through the Kaplan-Meier method.@*RESULTS@#A total of 26,226 eligible lung cancer patients were included, among whom 62.55% were male and 52.89% were smokers. Non-smokers and elderly patients took increasingly larger proportions in the whole patient population. The proportion of adenocarcinoma increased from 51.63% to 71.80%, while that of squamous carcinoma decreased from 28.43% to 17.60%. Gene mutations including EGFR (52.14%), KRAS (12.14%), and ALK (8.12%) were observed. Female, younger, non-smoking, adenocarcinoma patients and those with mutated EGFR had better survival prognoses. Importantly, this study validated that early detection of early-stage lung cancer patients had contributed to pronounced survival benefits during the decade. Patients with stage I lung cancer, accounted for an increasingly considerable proportion, increasing from 15.28% to 40.25%, coinciding with the surgery rate increasing from 38.14% to 54.25%. Overall, period survival analyses found that 42.69% of patients survived 5 years, and stage I patients had a 5-year OS of 84.20%. Compared with that in 2009-2013, the prognosis of stage I patients in 2014-2018 was dramatically better, with 5-year OS increasing from 73.26% to 87.68%. Regarding the specific survival benefits among stage I patients, the 5-year survival rates were 95.28%, 93.25%, 82.08%, and 74.50% for stage IA1, IA2, IA3, and IB, respectively, far more promising than previous reports.@*CONCLUSIONS@#Crucial clinical and pathological changes have been observed in the past decade. Notably, the increased incidence of stage I lung cancer coincided with an improved prognosis, indicating actual benefits of early detection and management of lung cancer.
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Humanos , Masculino , Femenino , Anciano , Neoplasias Pulmonares/genética , Adenocarcinoma/patología , Pronóstico , Tasa de Supervivencia , Mutación , Receptores ErbB/genética , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
Lung cancer is the malignancy with the highest mortality rate worldwide. Malignant pleural effusion (MPE) caused by advanced lung cancer severely affects the quality of life and prognosis of patients. Tumor-associated genetic testing is the basis for making precise treatment decisions. There are some risks of tissue biopsy, and it is difficult to sample repeatedly. Due to its non-invasive and can reflect the full profile of tumor gene characteristics, liquid biopsy is increasingly used in the diagnosis and treatment of lung cancer. Because of the extremely low DNA level of circulating tumor, the sensitivity and specificity of liquid biopsy based on blood samples are limited. Tumor cells is enriched in MPE. The detection of cell-free DNA, extracellular vesicles and microRNA in MPE will be helpful to the diagnose, treatment and assess prognosis of patients with lung cancer. This review aims to discuss the research progress of liquid biopsy based on MPE in the diagnosis and treatment of lung cancer patients. .
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Objective:Our study aims to predict acute kidney injury (AKI) in acute myocardial infarction (AMI) by establishing a random forest model.Methods:By using the clinical database from affiliated Dongyang Hospital of Wenzhou Medical University, a total of 1 363 AMI cases were included. Then, 75% of participants were analyzed as training subsets and the remaining 25% were testing subsets. The CARET package in R was used to filter variables and build random forest. The prediction ability of established model was evaluated by specificity, sensitivity, accuracy, relative operating characteristic curve (ROC curve) in testing subsets. In addition, the performance of random forest was compared with other 3 commonly used machine learning algorithms (Artificial Neural Network, Naive Bayes, and Support Vector Machine).Results:In this study, 30 variables including the demographic information, risk factors of cardiovascular disease, vital signs at admission, laboratory tests were identified and used to establish our random forest prediction model. The area under the curve of the testing subsets ROC was 0.893. The specificity and sensitivity of prediction model was 0.791 and 0.866, respectively. And the first creatinine, first blood urea nitrogen, and D-dimer after admission, age, mechanical ventilation were the top-five factors in this model. After comparing various machine learning algorithms, random forest model had a better performance.Conclusion:The random forest model would be used to predict the occurrence of AMI with AKI.
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In response to the major national strategic needs of "Healthy China" and "Innovation-Driven Development", Sichuan University, as a pilot university of "Excellent Doctor Education and Training Plan-Top Innovative Medical Personnel Training", has been exploring the training strategies since 2012. On the basis of the international theory of "The Third Generation of Medical Education based on Health System", we have innovatively put forward the new era of "Med+" education theory based on research-oriented hospitals (with medical/research/translational facility) and the two-level training paradigm from "cultivating professionalism" to "notch up to top" by planting three cultures. We have also developed a competency training system of "Five Integrated Curricula and Five Teaching & Learning Strategies". We have shifted from "didactic teaching" to "formative learning", edifying excellent doctors with "professionalism culture". We have initiated two kinds of top-notch plans, constructed a "1+2+3" innovation and entrepreneurship education system, explored "transformative learning" to incubate compound top-notch personnel with "innovative culture", opened up a "school-hospital unified" administrative system, built a PDCA closed-loop of quality control supported by mobile technology, and recast the "quality culture" to ensure shifting from "cultivating professionalism" to "notch up to top".
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BACKGROUND@#Mortality of lung cancer can be decreased by early screening effectively. However, consistent and proficient standards & methods have not been established in China. This study was based on pulmonary nodules/lung cancer comprehensive management platform established by West China Hospital, Sichuan University. Early screening of pulmonary nodules was integrated into standard healthcare of lung cancer system, aiming to improve survivals of lung cancer patients.@*METHODS@#Three cohorts were established: healthy populations, pulmonary nodules cohort and lung cancer patients cohort, and related clinical data will be collected and analyzed. Preliminary plan includes verifying effect of pulmonary nodules screening module.@*RESULTS@#Pulmonary nodules screening was performed in 2,836 employers (>40 years old) of West China Hospital. Lung cancers were diagnosed in 66 participants, all receiving surgery to remove the lesions. 65 of them were with early stage diseases, 1 with lung cancer and brain metastasis.@*CONCLUSIONS@#Proficient screening, follow-up and healthcare can be achieved via pulmonary nodules/lung cancer comprehensive management mode, which will be extended all over west China region in future.
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Non-alcoholic fatty liver disease (NAFLD) is characterized by increased fat depositions in the liver while the patients do not have drinking history.NAFLD has a prevalence of 10% ~40% in global,25% ~26% in Western populations.From 2004 to 2013,the numbers of new patients on the waitlist who had NASH increased by 170% in America.The prevalence of NAFLD in China is 20%.With the decrease of HBV and HCV and the increase of diabetes mellitus type 2 and obesity,NAFLD will become the most common chronic liver disease in China over the next 20 years.NAFLD related end-stage liver disease will become the most common indication of liver transplantation.In this paper,the epidemiological features,pathogenesis,indication and prognosis of liver transplantation are reviewed.
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Objective:To analyze the expression and clinical significance of human papillomavirus (HPV) 16/18E6 in lung adenocarcinoma tissues and adjacent specimens.Methods:Sixty patients with pathologically confirmed lung adenocarcinoma treated with surgical resection were included in the study. To determine the expression of HPV16/18 E6, carcinoma specimens and adjacent tissues were collected and detected using immunohistochemistry. The χ 2 test was used to analyze the relationship between HPV16/18 E6 expression and the clinical features of lung adenocarcinoma. Using the cell transfection technique, the A549 lung adenocarcinoma cell line with high HPV16/18E6 expression was established, and the differences in cisplatin resistance between the E6, control (Ctl), and A549 groups were compared using the MTT assay. Results:Of the 60 cases, 29 (48%) were male and 31 (52%) were female, with an average age of (55.5±2.4) years. In lung adenocarcinoma specimens, the positive expression rate of HPV16/18 E6 was 48% (29/60), which was higher than that observed in adjacent tissues (18%; 11/60), demonstrating a statistically significant difference (P<0.05 ); the differences between the positive expression rate of HPV16/18E6 and TNM stage, age, gender, smoking, and tumor size were not statistically significant. In the E6 A549 lung adenocarcinoma group, cisplatin resistance was higher than that in the Ctl and A549 groups, demonstrating a statistically significant difference (P<0.05 ). Finally, the half-maximal inhibitory concentration (IC 50) of cisplatin in E6 (111 mg/L)was higher than that in Ctl(75 mg/L) and A549(79 mg/L) groups, demonstrating a statistically significant difference (P<0.05 ).Conclusions:High-risk HPV16/18E6 has a higher positive expression rate in lung adenocarcinoma, independent of TNM stage, age, gender, smoking, and tumor size, and may influence resistance to chemotherapy drugs.
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Objective To evaluate the effect of dexmedetomidine on renal fibrosis in a mouse model of renal ischemia-reperfusion (I/R) and the role of serine-threonine kinase (Akt).Methods Sixty male C57BL/6 mice,aged 8 weeks,weighing 20-25 g,were divided into 5 groups (n=12 each) using a random number table method:sham operation group (S group),renal I/R group (I/R group),renal I/R plus dexmedetomidine group (I/R + D group),renal I/R plus dexmedetomidine plus Akt agonist SC79 group (I/R + D + SC group),and renal I/R plus dexmedetomidine plus normal saline group (I/R+D+NS group).Renal I/R injury model was established by clamping the bilateral renal pedicle for 30 min followed by reperfusion.Dexmedetomidine was intraperitoneally injected at 30 rmin before surgery in I/R+D,I/R+D+SC and I/R+D+NS groups.SC79 was intraperitoneally injected as a bolus of 0.04 mg/kg at 1 min of reperfusion,followed by an intraperitoneal injection of the same dose every 24 h until day 7.The serum blood urea nitrogen (BUN) and Scr concentrations were detected at 24 h of reperfusion.Renal tissues were taken,and the damage to the renal tubules was scored.Renal tissues were removed at 14 days of reperfusion to detect the degree of renal fibrosis and expression of collagen 1 (COL1),fibronectin (FN),and α-smooth actin (α-SMA) (by immunofluorescence and Western blot).The expression of phosphorylated Akt (p-Akt) in renal tissues was determined by Western blot at 24 h and 14 day of reperfusion.Results Compared with group S,the serum BUN and Scr concentrations,renal tubule damage score and degree of renal fibrosis were significantly increased,and the expression of COL1,FN,α-SMA and p-Akt was up-regulated in group I/R (P<0.05).Compared with I/R group,the serum BUN and Scr concentrations,renal tubular damage score and degree of renal fibrosis were significantly decreased,and the expression of COL1,FN,α-SMA and pAkt was down-regulated in I/R+D and I/R+D+NS groups (P<0.05).Compared with I/R+D group,the serum BUN and Scr concentrations,renal tubule damage score and degree of renal fibrosis were significantly increased,and the expression of COL1,FN,α-SMA and p-Akt was up-regulated in I/R+D+SC group (P<0.05).Conclusion Dexmedetomidine can reduce the degree of renal fibrosis in a mouse model of renal I/R and the mechanism is related to inhibiting activation of Akt.
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Ischemia-reperfusion injury is one of the main causes of complications related to liver transplantation, hepatectomy, trauma and hemorrhagic shock. The cells of ischemia and hypoxic injury release of injury-related molecular patterns, lead to the activation of immune cells and cytokine, which further aggravates the inflammatory response and enlarges the injury. It ' s indicated that injury-related molecular patterns, liver resident immune cells and cytokines play a key role in promoting inflammation and liver ischemia-reperfusion injury. However, recent studies suggested that the ischemia cells and cytokines played acomplex role in this process. Relevant progresses were reviewed in this article.
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Ischemia-reperfusion injury is one of the main causes of complications related to liver transplantation, hepatectomy, trauma and hemorrhagic shock. The cells of ischemia and hypoxic injury release of injury-related molecular patterns, lead to the activation of immune cells and cytokine, which further aggravates the inflammatory response and enlarges the injury. It’s indicated that injury-related molecular patterns, liver resident immune cells and cytokines play a key role in promoting inflammation and liver ischemia-reperfusion injury. However, recent studies suggested that the ischemia cells and cytokines played acomplex role in this process. Relevant progresses were reviewed in this article.
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Objective@#To evaluate the effect of dexmedetomidine on renal fibrosis in a mouse model of renal ischemia-reperfusion (I/R) and the role of serine-threonine kinase (Akt).@*Methods@#Sixty male C57BL/6 mice, aged 8 weeks, weighing 20-25 g, were divided into 5 groups (n=12 each) using a random number table method: sham operation group (S group), renal I/R group (I/R group), renal I/R plus dexmedetomidine group (I/R + D group), renal I/R plus dexmedetomidine plus Akt agonist SC79 group (I/R + D + SC group), and renal I/R plus dexmedetomidine plus normal saline group (I/R+ D+ NS group). Renal I/R injury model was established by clamping the bilateral renal pedicle for 30 min followed by reperfusion.Dexmedetomidine was intraperitoneally injected at 30 min before surgery in I/R+ D, I/R+ D+ SC and I/R+ D+ NS groups.SC79 was intraperitoneally injected as a bolus of 0.04 mg/kg at 1 min of reperfusion, followed by an intraperitoneal injection of the same dose every 24 h until day 7.The serum blood urea nitrogen (BUN) and Scr concentrations were detected at 24 h of reperfusion.Renal tissues were taken, and the damage to the renal tubules was scored.Renal tissues were removed at 14 days of reperfusion to detect the degree of renal fibrosis and expression of collagen 1 (COL1), fibronectin (FN), and α-smooth actin (α-SMA) (by immunofluorescence and Western blot). The expression of phosphorylated Akt (p-Akt) in renal tissues was determined by Western blot at 24 h and 14 day of reperfusion.@*Results@#Compared with group S, the serum BUN and Scr concentrations, renal tubule damage score and degree of renal fibrosis were significantly increased, and the expression of COL1, FN, α-SMA and p-Akt was up-regulated in group I/R (P<0.05). Compared with I/R group, the serum BUN and Scr concentrations, renal tubular damage score and degree of renal fibrosis were significantly decreased, and the expression of COL1, FN, α-SMA and p-Akt was down-regulated in I/R+ D and I/R+ D+ NS groups (P<0.05). Compared with I/R+ D group, the serum BUN and Scr concentrations, renal tubule damage score and degree of renal fibrosis were significantly increased , and the expression of COL1, FN, α-SMA and p-Akt was up-regulated in I/R+ D+ SC group (P<0.05).@*Conclusion@#Dexmedetomidine can reduce the degree of renal fibrosis in a mouse model of renal I/R and the mechanism is related to inhibiting activation of Akt.
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With the continuous development of endovascular surgery, thoracic endovascular aortic repair (TEVAR) has gradually replaced traditional open surgery and has become the preferred treatment strategy for Stanford type B aortic dissection. However, the disadvantage of the short proximal landing zone greatly limited the indication of TEVAR surgery and affected the prognosis. In recent years, many strategies such as hybrid surgery, in vitro fenestrated and branched aortic endo-graft, chimney technique, in-situ fenestration technique, etc., have been developed, which greatly broadens the TEVAR indication and improved the prognosis.
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Objective: To analyze the effect of air quality index (AQI) on the incidence of tuberculosis (TB) in Beijing, and to provide evidence for setting up a better program regarding prevention and control of tuberculosis. Methods: Generalized additive model (GAM) was used to analyze the association between AQI and the incidence of tuberculosis in Beijing, from January 1, 2014 to November 9, 2016. Confounding factors as meteorological conditions and time trends were under control. Results: In Beijing, a total of 14 533 TB cases with definite dates of onset were collected during the study period, with 36 children excluded from the study. Finally, 14 497 cases were included in the study, including 9 513 men and 4 984 women, with 11 290 adults (15-59 years old) and 3 207 elderly (≥60 years old). Data from the optimal single-day lag effect of GAM showed that,with every 10 increase of AQI, the percent of increase on the onsets of overall, male, female and adult; tuberculosis cases were 0.85% (95%CI: 0.26%-1.44%), 0.83% (95%CI: 0.24%-1.42%), 0.93% (95%CI: 0.24%-1.62%) and 0.88% (95%CI: 0.29%-1.46%), respectively. The optimal lag time of the single-day effects were 15 days (lag15), but 16 days (lag16) for male. The optimal cumulative lag effect showed that with every 10 AQI increase, the percent of increase on the onsets of overall, male, female and adult tuberculosis cases were 1.92% (95%CI: 0.23%-3.16%), 1.94% (95%CI:0.15%-3.72%), 2.04% (95%CI: 0.10%-3.97%) and 2.00% (95%CI: 0.30%-3.69%), respectively, with the optimal lag time of cumulative delayed effects as 17 days (lag0_17), 18 days (lag0_18), 16 days (lag0_16) and 17 days (lag0_17), respectively. However, there were no statistical significances noticed in the elderly cases. Conclusion: There was a positive correlation between AQI and the number of TB cases in Beijing, and the effects of AQI on the number of TB cases in different genders and age groups were different.
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Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Contaminantes Atmosféricos/efectos adversos , Contaminación del Aire , Beijing , Incidencia , Material Particulado/efectos adversos , Tuberculosis/epidemiologíaRESUMEN
With an increasing proportion of sedentary lifestyle related chronic diseases, an efficient way to help fight the growing world epidemic of non-communicable diseases (NCDs) and promote public health in a fast-changing world is urgently needed. Exercise and medicine science have played an important role in prevention and control of NCDs. However, the current status and future development directions regarding the integration of exercise science and medicine (IESM) in China have not been well discussed. During 2017 Belt and Road Initiative Global Health International Congress & 2017 Chinese Preventive Medicine Association-Chinese Society on Global Health Annual Meeting, Xi'an Jiaotong University Global Health Institute, and the Integration of Sport and Medicine Innovation Research Center, China Institute of Sport Science organized the IESM Forum on September 27. Six leaders and experts from China and abroad presented excellent research reports in the IESM Forum from several aspects. Experts reached a consensus at the end of their discussions that, in the near future, the IESM will be a key part of a sustainable health care system and as such should contribute to prosperity in China and around the world. However, Abstract compared with European, American and Japanese universities, the development of the IESM in China is in its early stages with huge development potential.
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In order to strengthen the cultivation of core competence of undergraduate clinical medi-cine interns and improve the quality and efficiency of practice, Dongyang People's Hospital has constructed an integrated training system of practice teaching with objectives, contents, methods and assessment. The system is guided by "actual nursing capacity" and "medical professional knowledge and skills". By setting goals, improving teaching content, improving teaching methods, and strengthening assessment and evalua-tion, the quality of interns' practice has been improved, and the excellent rate of interns' medical history collection and assessment and skill operation assessment has also been improved. According to assessment tests of theory and technical operation, and the passing rate of examination of doctor qualification of the new employees in the past 2 years, the results shows that the scores of new employees who used to practice in the hospital are significantly higher than those in other hospitals.