[Candida endocarditis: retrospective study in 12 patients]. / Endocardites à Candida: étude rétrospective de 12 patients.

PURPOSE: Candida endocarditis are rare, with a poor prognosis. Actually, the principal problem concerns the growing incidence of nosocomial fungal infections. The objective of the present investigation is to assess a disease which risks becoming more pronounced in the future. METHODS: We have collected observations of Candida sp. endocarditis between 1985 to 1997 from three French university hospitals. RESULTS: Twelve of the observations fit the Duke criteria of acute endocarditis. Patients were eight men and four women, with a mean age of 46 years. An immunodepression was found in seven cases, and four patients were active drug addicts. Six had an underlying heart disease at risk to acute endocarditis. Candidemia risk factors were found in nine cases, with an average of 2.7 risk factors per patient. The fungal agents detected were Candida albicans (eight cases), C. tropicalis (one case), C. parapsilosis (two cases), and C. glabrata (one case). These vegetations were on aortic (seven cases), mitral (three cases), tricuspid valves (two cases) or in other areas (three cases), with multiple localizations (two cases). In three observations, vegetations were associated with myocardium abscesses. Eight patients had embolic complications, two had a cardiac insufficiency leading to death. The treatment was medical in all of the cases and combined with a surgical treatment in ten cases. The surgery was performed, on an average, 17 days after diagnosis, allowing seven surviving patients. Among them, five received a secondary prophylaxis and no recurrence was recorded. CONCLUSIONS: Prognosis remains severe because of the voluminous, friable and necrotic vegetations, which favor embolic migrations and which are not easily accessible to antifungals, which penetrate poorly into these vegetations. Therapy is based on a medical treatment combined with a valve replacement which needs to be done early on, and is followed by a relapse prevention which can occur several years after the initial episode.

Echocardiographic features of Candida species endocarditis: 12 cases and a review of published reports.

OBJECTIVE: To describe the specific echocardiographic features of Candida species endocarditis. DESIGN: Retrospective review of the case records of patients with confirmed candida endocarditis. SETTING: Cases referred to three French university centres over an eight year period were studied. DESIGN: 12 patients with confirmed Candida species endocarditis infection were identified. The transthoracic (n = 12) and transoesophageal (n = 12) echocardiographic appearances were compared with the surgical findings (n = 10). RESULTS: Large dense heterogeneous vegetations were found in 11/12 cases. A hyperechogenic heterogeneous myocardial texture, observed in seven of the 12 patients, was associated with extensive myocardial damage at surgery. While it was possible to diagnose candidal cardiac infection in all patients by transthoracic echocardiography, transoesophageal echocardiography was useful for optimal assessment of the valvar and paravalvar structures. CONCLUSIONS: In the setting of endocarditis, the detection of myocardial involvement, which is characterised by a heterogeneous myocardial texture, is an argument in favour of Candida species endocarditis and may warrant early surgical intervention.

Assessment of hemodynamic and gastric mucosal acidosis with modified fluid versus 6% hydroxyethyl starch: a prospective, randomized study.

OBJECTIVE: To investigate the effect of 4 % succinylated modified fluid gelatin (MFG) versus mean weight, highly substituted 6% hydroxyethyl starch (HES) on hemodynamic and gastric mucosal acidosis variables, in septic hypovolemic patients. DESIGN: Prospective, randomized, clinical investigation. SETTING: University hospital intensive care unit. PATIENTS: Thirty-four septic hypovolemic ventilated and hemodynamically controlled patients. INTERVENTIONS: Invasive hemodynamic and gastric tonometric measurements. MEASUREMENTS AND RESULTS: Hemodynamic and tonometric parameters were recorded at baseline and 60 min after infusion of 500 ml of each colloid. In all patients central venous pressure, pulmonary artery occlusion pressure, cardiac index and mean arterial pressure increased significantly with both colloids, and hemoglobin concentration decreased by the same amount while oxygen delivery remained stable. Gastric intramucosal pH increased from 7.27 +/- 0.08 to 7.31 +/- 0.07 (p < 0.001) with MFG and decreased non-significantly from 7.26 +/- 0.11 to 7.22 +/- 0.08 (ns) with HES. Carbon dioxide gastric mucosal arterial gradient decreased from 18 +/- 9 to 13 +/- 9 mmHg (p < 0.0005) in the MFG group and rose non-significantly from 18 +/- 11 to 21 +/- 11 mmHg with HES. CONCLUSIONS: Although MFG and 6% HES have the same hemodynamic effects, their physicochemical properties induce different responses on gastric mucosal acidosis in septic, hypovolemic and ventilated patients. These effects of MFG and HES on gastric mucosa need to be considered in patient management.

Nosocomial endocarditis in the intensive care unit: an analysis of 22 cases.

OBJECTIVES: To review the intensive care unit experience of patients with admitted or acquired nosocomial endocarditis (NE) defined according to the Duke criteria. DESIGN: Prospective, cohort study. SETTING: University teaching hospital. PATIENTS: We reviewed the records of 22 patients documented with NE during a 6-yr period from 1992 to 1997. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients (9 women/13 men) aged 38-83 yrs (mean 65+/-9 yrs) had a NE (prevalence of 5 per 1,000 admissions). For six patients, NE was the reason for the admission to the intensive care unit. For 17 patients, the time elapsed between admission and diagnosis of NE was 39+/-25 days. Sixteen patients were predisposed to infection and seven had underlying heart conditions that put them at risk for acute endocarditis: three prosthetic valves, two valvular diseases, and two cardiac pacemakers. In 21 cases (one unknown portal of entry), NE was the consequence of bacteremia related to a medical or surgical procedure: 11 intravascular devices, eight surgical wounds, one tracheal procedure, and one leg ulceration. The bacteriologic agents detected in blood cultures were: staphylococci (n = 17), Streptococcus (n = 2), Pseudomonas aeruginosa (n = 2), and Candida (n = 2). Fourteen patients underwent echocardiography according to cardiac signs (cardiac failure, new cardiac murmur, or embolic event). For the eight remainders, echocardiography was performed systematically because of fever and positive blood cultures. The lesions detected by 21 transthoracic and 17 transesophageal echocardiographs were the following: vegetations (n = 19), myocardial abscesses (n = 5), and valvular perforation (n = 1). On 16 surgical indications, only five patients underwent surgery because the others were in too poor of a condition. The overall mortality was 68% (n = 15) and was directly associated with NE in 36% of cases (n = 8). Seven patients (28%) were discharged 34 days after the diagnosis of endocarditis. CONCLUSIONS: NE is a frequent nosocomial infection that occurs late during hospitalization. Persistent fever with positive blood cultures is sufficient symptomology to promptly perform an echocardiogram. The poor prognosis is related to the poor condition of those patients who cannot be referred for surgical treatment.

Severe lactic acidosis induced by nucleoside analogues in an HIV-infected man.

Nucleoside analogues can induce myopathy or hepatitis by means of mitochondrial dysfunction. We report the case of a 31-year-old man infected with HIV who had a severe lactic acidosis without muscle or liver symptoms. He improved after hemodialysis and withdrawal of antiviral drugs. Muscle and liver evaluation allowed us to ascribe lactic acidosis to a mitochondriopathy induced by zidovudine and didanosine.

[The role of hyperbaric oxygen therapy in radiation-induced digestive disorders. 36 cases]. / Intérêt de l'oxygènothérapie hyperbare dans la pathologie digestive post-radique. 36 observations.

OBJECTIVES: Study the effect of hyperbaric oxygen on chronic irradiation induced digestive disorders. PATIENTS AND METHODS: A retrospective study was conducted in 36 patients (mean age 66 +/- 11 years) with chronic digestive tract necrosis which had developed a mean 42 months after irradiation therapy. Hyperbaric oxygen therapy was given a mean 17 months after symptom onset: failing healing (n = 9), rectal bleeding (n = 19), profuse diarrhea (n = 9), recurrent anal abscess (n = 1). The severity of the digestive tract radionecrosis was quantified using the Soma-Lent scale. Hyperbaric oxygen therapy was grade 1 (n = 1), grade 2 (n = 11), grade 3 (n = 16), grade 4 (n = 8). RESULTS: Thirty-six patients underwent a mean 67 hyperbaric sessions (100% O2, 2.5 atm, 90 min). Three patients died within one month of the first session due to radiation enteritis, a neoplastic process or another concomitant cause. Immediate outcome after hyperbaric oxygen therapy was cure (n = 3) or improvement (n = 16) in 19 patients (53%) and failure in 17 (47%). Long-term results evaluated in 32 subjects with a mean 52 months follow-up were: cure (n = 9) or improvement (n = 12) in 21 patients (66%) and failure in 11 (34%). Nine patients died within a mean 25 months after the end of the hyperbaric sessions. Death was related to digestive tract radionecrosis in 1 case and neoplasia in 5. CONCLUSION: Hyperbaric oxygen therapy provides clinical relief in 2 out of 3 patients and can be a useful alternative to conventional treatment in patients with chronic radiation-induced necrosis of the digestive tract.

Necrobiosis lipoidica: treatment by hyperbaric oxygen and local corticosteroids.

Necrobiosis lipoidica (NL) is closely associated with diabetes mellitus. Two-thirds to three-fourths of patients with NL have diabetes, although NL occurs in only 0.3% of diabetic patients. Typical lesions are found on pretibial skin, usually in young female diabetic patients whose disease is inadequately controlled. The cause of this dermopathy remains unknown. Multiple treatments have been described but have not led to consistent results. We report the case of a 28-year-old insulin-dependent diabetic woman with a disease duration of 23 years who spontaneously developed ulcerated NL on pretibial skin. NL progressively improved during 113 sessions of hyperbaric oxygen therapy and local corticosteroids.

Gastric intramucosal pH: an indicator of weaning outcome from mechanical ventilation in COPD patients.

The aim of this study was to determine whether gastric intramucosal pH (pHim) and/or gastric intramucosal carbon dioxide tension (PCO2,im) measured by tonometry can be used to predict the success of weaning in chronic obstructive pulmonary disease (COPD) patients. Twenty six consecutive COPD patients, undergoing mechanical ventilation for acute respiratory failure and satisfying the criteria of weaning from mechanical ventilation with nasogastric tonometer in place, were studied. Arterial blood gas values and PCO2,im were measured 24 h before (H-24), just before (H0), and after 20 min of a weaning trial on T-piece (H20min). Weaning failure was defined as the development of respiratory distress and/or arterial blood gas impairments during the first 2 h of spontaneous breathing on T-piece, or reintubation within 24 h after extubation. Between the weaning failure (n = 6) and weaning success (n = 20) groups, there were no differences in blood gas analysis readings at H-24 and H0 before the weaning period, age, Simplified Acute Physiology Score (SAPS) on admission, SAPS on the day of weaning trial, and duration of ventilation. Clinical status, tonometric and arterial gasometric data were similar at H-24 and H0 in all patients. During mechanical ventilation, pHim was < or = 7.30 in patients who failed weaning and > 7.30 in patients who were successfully weaned (p < 0.001; 100% sensitivity and specificity). The threshold value for PCO2,im of 8.0 kPa (60 mmHg) represents a clear demarcation with respect to outcome before the weaning trial. PCO2,im values during mechanical ventilation are significantly different (p < 0.001) between patients who were successfully weaned and those who were not (6.9 +/- 0.9 vs 9.9 +/- 1.1 kPa (51.9 +/- 6.7 vs 74.3 +/- 8.0 mmHg, respectively)). At H20min, pHim and PCO2,im were still statistically different between the weaning failure and the weaning success group. We conclude that measurement of gastric intramucosal pH (or gastric intramucosal carbon dioxide tension) represents a simple and accurate index to predict weaning outcome in chronic obstructive pulmonary disease patients before attempting weaning.

Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial.

Hyperbaric Oxygen (HBO) therapy is advocated for the treatment of severe trauma of the limbs in association with surgery because of its effects on peripheral oxygen transport, muscular ischemic necrosis, compartment syndrome, and infection prevention. However, no controlled human trial had been performed until now to specify the role of HBO in the management of crush injuries. Thirty-six patients with crush injuries were assigned in a blinded randomized fashion, within 24 hours after surgery, to treatment with HBO (session of 100% O2 at 2.5 atmosphere absolute (ata) for 90 minutes, twice daily, over 6 days) or placebo (session of 21% O2 at 1.1 ata for 90 minutes, twice daily, over 6 days). All the patients received the same standard therapies (anticoagulant, antibiotics, wound dressings). Transcutaneous oxygen pressure (PtCO2) measurements were done before (patient breathing normal air) and during treatment (HBO or placebo) at the first, fourth, eighth, and twelfth sessions. The two groups (HBO group, n = 18; placebo group, n = 18) were similar in terms of age; risk factors; number, type or location of vascular injuries, neurologic injuries, or fractures; and type, location, or timing of surgical procedures. Complete healing was obtained for 17 patients in the HBO group vs. 10 patients in the placebo group (p < 0.01). New surgical procedures (such as skin flaps and grafts, vascular surgery, or even amputation) were performed on one patient in the HBO group vs. six patients in the placebo group (p < 0.05). Analysis of groups of patients matched for age and severity of injury showed that in the subgroup of patients older than 40 with grade III soft-tissue injury, wound healing was obtained for seven patients (87.5%) in the HBO group vs. three patients (30%) in the placebo group (p < 0.05). No significant differences were found in the length of hospital stay and number of wound dressings between groups. For the patients with complete healing, the PtCO2 values of the traumatized limb, measured in normal air, rose significantly between the first and the twelfth sessions (p < 0.001). No significant change in PtCO2 value was found for the patients whose healing failed. The Bilateral Perfusion Index (BPI = PtCO2 of the injured limb/PtCO2 of the uninjured limb) at the first session increased significantly from 1 ata air to 2.5 ata O2 (p < 0.05). In patients with complete healing, the BPI was constantly greater than 0.9 to 2.5 ata O2 during the following sessions, whereas the BPI in air progressively rose between the first and the twelfth sessions (p < 0.05), reaching normal values at the end of the treatment. In conclusion, this study shows the effectiveness of HBO in improving wound healing and reducing repetitive surgery. We believe that HBO is a useful adjunct in the management of severe (grade III) crush injuries of the limbs in patients more than 40 years old.

[Prognosis of systemic diseases diagnosed in intensive care units]. / Pronostic des maladies systémiques diagnostiquées en réanimation.

OBJECTIVES: The aims of this study were to evaluate the prognosis of patients with systemic rheumatic disease diagnosed in medical intensive care unit (MICU) and to determine whether the outcome is different for patients with systemic rheumatic disease previously known hospitalized in MICU. METHODS: Retrospective evaluation, over a ten-year period, of 88 cases of systemic rheumatic disease selected in two groups: group I: diagnosed in MICU, group II: previously known and treated. RESULTS: Group I: 18 patients with necrotizing vasculitis (n = 6), extra-intestinal manifestations of inflammatory bowel disease (n = 4), systemic lupus erythematosus (n = 3), miscellaneous (n = 5). Group II: 70 patients with rheumatoid arthritis (n = 31), necrotizing vasculitis (n = 12), systemic lupus erythematosus (n = 12), polymyositis (n = 4), extra-intestinal manifestations of inflammatory bowel disease (n = 5), miscellaneous (n = 6). The main admission diagnoses were infectious diseases (p < 0.005) or iatrogenic complications in the group II (p < 0.01) and acute exacerbation of systemic rheumatic disease in the group I (p < 0.0001). Age; simplified acute physiologic score (SAPS); number of acute organ system failure; number of patients requiring mechanical ventilation, haemodialysis or right heart catheterization were not different between the two groups. The durations of mechanical ventilation and stay in the MICU were shorter in the group II (p < 0.005). MICU mortality rate was higher in the group II (p < 0.05), with a five years cumulative proportion of surviving statistically lower (p < 0.05). Mortality rate of the entire population (37.5%) was similar to that of a non-selected population with comparable SAPS. Multivariate analysis showed that SAPS, number of acute organ system failure and iatrogenic complications were the main prognostic factors (p = 0.05). CONCLUSIONS: The prognosis was better for patients with systemic rheumatic disease diagnosed in MICU. Infectious diseases were the main cause of death, probably in relation with immunosuppressive treatments.

[Acute cervical necrotizing fasciitis of pharyngeal origin: possible role of steroidal and non-steroidal anti-inflammatory agents. Apropos of 5 cases]. / Cellulites cervicales nécrosantes aiguës à porte d'entrée pharyngée: rôle possible des anti-inflammatoires stéroïdiens et non stéroïdiens. A propos de 5 observations.

Within 20 cases of cervical acute necrotizing fasciitis treated in the intensive care unit and hyperbaric oxygen therapy department between 1986 and 1995, the authors report five cases of pharyngeal origin. 4 have been initially treated with anti-inflammatory drugs: non steroidal (1 case), steroidal (2 cases), non steroidal and steroidal (1 case). The five patients have been operated. They needed at least 30 days of endotracheal intubation and hyperbaric oxygen therapy. No death outcome but a important morbidity is reported. The immunosuppressive features of the two type of anti inflammatory drugs are exposed. Different publications suggesting the possible association between non steroidal anti inflammatory drugs and non cervical necrotizing fasciitis are reported. It is not possible to prove a direct link because of the number of our cases, because of the wide number of pharyngitis treated in the area, and because the absence of precise data about the use of anti inflammatory drugs in the initial treatment of this pharyngitis. Existence of other type of antalgic and non immunosuppressive drugs make the use of anti inflammatory drugs not justify.

[Electrophysiological study for the diagnosis and prognosis of syncope of unknown origin]. / Exploration électrophysiologique pour le diagnostic et le pronostic des syncopes de cause indéterminée.

OBJECTIVE: To evaluate, on the basis of long-term outcome, the value of electrophysiologic exploration for determining the cause of syncope of unknown origin after clinical examination and standard laboratory tests. METHODS: In 1985 and 1986, 109 consecutive patients with syncope of unknown origin underwent electrophysiologic exploration. The patients were divided into two groups. Baseline electrocardiogram was abnormal in 59 patients: cardiopathy (32%), ischemia (17%). In 44 of these patients, electrophysiologic exploration revealed major abnormalities requiring treatment (Group 1). No aetiology could be defined in 65 patients (Group 2). Patients were followed for 37 +/- 11 months. Three were lost to follow-up and 106 were retained for analysis. RESULTS: Morbidity and mortality were 25% and 16% respectively at the end of follow-up. Two sudden deaths were recorded, both in Group 1. Total mortality was greater in Group 1 (10 vs 6) so electrophysiologic exploration had defined a population at lower risk of sudden death and overall mortality. Relapse of syncope was observed in 27 patients (25% and 26% in Groups 1 and 2 respectively) due to rhythm disorders in 8, vasodepression in 1 and unknown origin in 18. CONCLUSION: The rate of recurrent syncope suggests these patients should have a second work-up in order to diagnose initially false negatives. Relapse raises the problem of electrophysiologic abnormalities and multifactorial mechanisms causing syncope of unknown origin.

Adrenocortical function during septic shock.

OBJECTIVE: To investigate, in patients with severe septic shock, the adrenocortical function assessed by daily plasma cortisol determinations during the first 72 h and by the short synthetic ACTH stimulation test performed within 24 h of the onset of shock. DESIGN: Prospective clinical investigation. SETTING: Medical intensive care unit in a university teaching hospital. PATIENTS: 40 consecutive patients with documented septic shock requiring at least hemodynamic resuscitation and respiratory support. INTERVENTIONS: There were no interventions. MEASUREMENTS AND RESULTS: Basal cortisol concentrations were increased with a mean value of 36.8 micrograms/dl (range 7.9-113). Of the overall cortisol determinations 92% were above 15 micrograms/dl. No statistically significant differences in basal cortisol concentrations were found when survival, type of infection, and positive blood cultures were considered. Patients with hepatic disease had significantly higher cortisol (50.1 (+/- 6.2) micrograms/dl versus 35.9(+/- 3.3) micrograms/dl, p = 0.035) levels compared to other patients. No correlations were found between basal plasma cortisol concentrations and factors such as SAPS, OSF, hemodynamic measurements, duration of shock, and amount of vasopressor and/or inotropic agents. Cortisol concentrations had significant but weak correlation with ACTH levels in survivors (r = 0.4; p = 0.03; n = 28) but not in non-survivors (r = 0.03; p = 0.85; n = 52). Cortisol levels in non-survivors increased significantly from enrollment time to the 72nd hour of the survey (day 1: 38.9(+/- 3.8) micrograms/dl versus day 3: 66.7(+/- 17.1) micrograms/dl; p = 0.046) and were significantly higher than those recorded in survivors. Responses to the short ACTH stimulation test were not significantly different between survivors and non-survivors. According to the different criteria used to interpret the response to the ACTH stimulation test, incidence of adrenocortical insufficiency was highly variable ranging from 6.25-75% in patients with septic shock. Only one patient had absolute adrenocortical insufficiency (basal cortisol level below 10 micrograms/dl; response to the ACTH stimulation test below 18 micrograms/dl). CONCLUSION: Our data suggest that in a selected population of patients with severe septic shock single plasma cortisol determination has no predictive value. The short ACTH stimulation test performed within the first 24 h of onset shock can neither predict outcome nor estimate impairment in adrenocortical function in patients with high basal cortisol level. Adrenal insufficiency is rare in septic shock and should be suspected when cortisol level is below 15 micrograms/dl and then confirmed by a peak cortisol level lower than 18 micrograms/dl during the short ACTH stimulation test.

[Detection of left cardiopathy using echocardiography during acute respiratory failure in chronic respiratory insufficiency]. / Dépistage des cardiopathies gauches par échocardiographie au cours de l'insuffisance respiratoire aiguë des insuffisances respiratoires chroniques.

Echocardiography was performed in a systematic fashion in 58 patients suffering from on-chronic respiratory failure (IRC) who were admitted to the intensive care unit. The prevalence of left ventricular disease in patients with IRC who were admitted to the intensive care unit was 31%, there were 18 cases of cardiac disease: nine had hypertrophic cardiac disease (two with intraventricular gradients), three had dilated cardiomyopathies, and there were six cases of ischaemic cardiac disease. Among these cases, six had not previously been diagnosed as having cardiac disease (10%). In cases with poor echogenicity by the transthoracic root, oesophageal echocardiography was performed and this improved the feasibility of a good examination with only a five per cent failure rate. Left ventricular disease was implicated in the clinical assessment eleven times (19%), either on admission (nine times) or during the course of the in-patient treatment (twice). In directing the initial assessment and the aetiological treatment, echocardiography directly contributed to better management in six cases (10%). As regards the number of cases of cardiac disease which were detected, the study confirms the value of this technique at the bedside of the patient. The use of the transoesophageal route improves the diagnostic value including those patients who were intubated and ventilated.

Hemodynamic changes in acute adrenal insufficiency.

OBJECTIVE: Acute adrenocortical insufficiency is an unusual cause of isolated shock. The purpose of this study is to describe the cardiovascular changes in 6 patients with acute adrenal insufficiency presenting with hemodynamic instability. DESIGN: Retrospective and prospective study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: 6 patients studied by right cardiac catheterization. MEASUREMENTS AND RESULTS: Results before glucocorticoid treatment show two possible hemodynamic states: 1) myocardial depression with hypovolemia in 3 patients, and 2) hyperdynamic shock with high cardiac output and diminished systemic arterial resistance in 3 other patients. The 3 patients presenting hyperdynamic shock were all given intravenous fluid therapy of over 20 ml/kg before the first hemodynamic measurement. For 2 other patients with low cardiac index and high systemic arterial resistance studied prospectively, 20 ml/kg intravenous fluid therapy transformed the hemodynamic state to hyperdynamic shock. The cardiovascular effect of glucocorticoid treatment studied in 4 patients was resulted in an improvement in the left ventricular systolic work index. CONCLUSIONS: Diagnosis of acute adrenocortical insufficiency must be considered if clinical manifestations are present suggesting septic shock without any obvious infectious cause in patients having undergone considerable intravenous fluid therapy as an initial course of treatment.

[Thrombocytopenia caused by digitoxin overdose]. / Thrombopénie induite par un surdosage en digitoxine.

The authors report a new case of digitoxin-related thrombocytopenia. It involved a patient hospitalised for torsades de pointe in whom blood digitoxin was 85 micromols/l on admission. This rare complication progressed to a satisfactory conclusion in seven days. The mechanism is immuno-allergic and/or toxic since thrombocytopenia occurs only following therapeutic overdose. The prognosis is determined by the cardiac arrhythmia rather than the hemostasis abnormality. Treatment is symptomatic and should include the withdrawal of digitoxin which can be replaced by digoxin. Oral activated charcoal decreases the plasma half-life by blocking the enterohepatic cycle and is hence recommended in this situation.