Characteristics and Mortality Risk Factors of Influenza-Associated Encephalopathy/Encephalitis in Children in a Tertiary Pediatric Hospital in China, 2016-2019

Objective: Seasonal influenza associated neurological complications had high mortality and morbidity rates in children. In this study, we aimed to investigate the clinical characteristics and mortality risk factors in children with influenza-associated encephalopathy. Methods: Retrospectively analyze the clinical data, laboratory tests, and imaging examinations of 68 children diagnosed with influenza-associated encephalopathy from January 2016 to December 2019 at Guangzhou Women and Children’s Medical Center, and the cases were divided into survival and non-survival groups by disease outcome and analyzed between two groups Results: Among the 68 children with influenza-associated encephalopathy, 40 were male, and 28 were female, aged from 3 months to 13 years, of which 66.18% (45/68) were under 5 years old. Pathogenetic tests showed that influenza virus type A accounted for 63.24% (43/68), and influenza virus type B accounted for 36.76% (25/68). Typical brain MRI changes in childhood influenza-associated encephalopathy were bilateral symmetrical lesions of the thalamus, basal ganglia, brainstem, and cerebellum. 68 patients had a mortality rate of 20.59% (14/68), with a significantly higher proportion of fever peak >39°C, Acute Disturbance Of Consciousness (ADOC), and cardiac arrest in the non-survival group than in the survival group (P<0.05). Laboratory tests showed significantly higher Alanine Aminotransferase (ALT), Aspartate Transaminase (AST), Creatinine Kinase (CK), and Lactate Dehydrogenase (LDH), Lactate, C-Reactive Protein (CRP), and CSF protein levels in the non-survival group compared with the survivor (P<0.05), and among them, elevated ALT, AST, LDH, and CSF protein were independent high-risk factors for death from influenzaassociated encephalopathy. Conclusions: Children under 5 years of age with influenza are prone to combine neurological complications and have a higher mortality rate. Significant elevations in ALT, AST, LDH, and CSF proteins predict death from influenzaassociated encephalopathy in children.

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Emphysematous cystitis: mortality, risk factors, and pathogens of a rare disease

Clinics and Practice ◽

10.4081/cp.2017.930 ◽

2017 ◽

Vol 7 (2) ◽

Cited By ~ 10

Author(s):

Andreas Schicho ◽

Christian Stroszczynski ◽

Philipp Wiggermann

Keyword(s):

Risk Factors ◽

Escherichia Coli ◽

Mortality Rate ◽

Mortality Risk ◽

Conservative Management ◽

Mortality Rates ◽

Emphysematous Pyelonephritis ◽

Emphysematous Cystitis ◽

The Mean ◽

High Degree

Although high mortality rates have been reported for emphysematous pyelonephritis (EP), information on emphysematous cystitis (EC), which is less common, is sparse. Here, we report one new case of severe EC and 136 cases of EC that occurred between 2007 and 2016, and review information about the characteristics, diagnosis, treatment and mortality of these patients, and the pathogens found in these patients. The mean age of the 136 patients was 67.9±14.2 years. Concurrent emphysematous infections of other organs were found in 21 patients (15.4%), with emphysematous pyelonephritis being the most common of these infections. The primary pathogen identified was <em>Escherichia coli</em> (54.4%). Patients were mainly treated by conservative management that included antibiotics (n=105; 77.2%). Ten of the 136 patients with EC died, yielding a mortality rate of 7.4%. Despite the relatively low mortality rate of EC compared with that of EP, a high degree of suspicion must be maintained to facilitate successful and conservative management.

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MO850OUTCOMES OF COVID-19 INFECTION IN DIALYSIS PATIENTS IN QATAR: A NATIONWIDE COHORT STUDY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab098.0042 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Tarek Abdellatif ◽

Abdullah Hamad ◽

Mohamad Alkadi ◽

Essa Abuhelaiqa ◽

Muftah Othman ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Critical Care ◽

Mortality Rate ◽

General Population ◽

Hospital Stay ◽

Laboratory Tests ◽

Length Of Hospital Stay ◽

Dialysis Patients ◽

Risk Of Death

Abstract Background and Aims Patients on maintenance dialysis are more susceptible to COVID-19 and its severe complications. We studied outcomes of COVID-19 infection in dialysis patients in the state of Qatar. Our primary outcome was to determine the mortality rate of dialysis patients with COVID-19 infection and associated risk factors. Our secondary outcomes were to assess the severity of COVID-19 in dialysis patients and its related complications such as the incidence of hypoxia, critical care unit admission, need for mechanical ventilation or inotropes, incidence of acute respiratory distress syndrome (ARDS), and length of hospital stay. Method This was an observational, analytical, retrospective, nationwide study. We included all adult patients on dialysis who tested positive for COVID-19 (PCR assay of nasopharyngeal swab) during the period from February 1, 2020 to July 19, 2020. Patient demographics and clinical features were collected from a national electronic medical record. Laboratory tests were evaluated upon diagnosis and on day 7. Results There were 76 out of 1068 dialysis patients who were diagnosed with COVID-19 (age 56±13.6, 56 hemodialysis and 20 peritoneal dialysis, 56 males). Eleven patients (15%) died during study period. Mortality due to COVID-19 among our dialysis cohort was 100 times higher than that in the general population for the same period (15% vs. 0.15%; OR 114.2 [95% CI: 1.53 to 2.44]; p<0.001). Univariate analysis for risk factors associated with COVID-19-related death in dialysis patients showed minor but statistically significant increases in risks with age (OR 1.07), peak WBC peak level (OR 1.189), AST level at day 7 (OR 1.04), fibrinogen level at day 7 (OR 1.4), D-dimer level on day 7 (OR 1.94), and peak CRP level (OR 1.01). A major increase in the risk of death was noted with atrial fibrillation (OR, 8.7; p=0.008) and hypoxia (OR: 28; p=0.001). High severity of COVID-19 illness in dialysis manifested as 25% of patients required admission to the intensive care unit, 18.4% had ARDS, 17.1% required mechanical ventilation, and 14.5% required inotropes for intractable hypotension or shock. The mean length of hospital stay was 19.2±10.4 days. Laboratory tests were remarkable for severely elevated ferritin, fibrinogen, CRP, and peak IL-6 levels and decreased albumin levels on day 7. Conclusion This is the first study to be conducted at a national level in Qatar exploring COVID-19 in a dialysis population. Dialysis patients had a high mortality rate of COVID-19 infection compared to the general population. Dialysis patients had severe COVID-19 course complicated by prolonged hospitalization and high need for critical care, mechanical ventilation and inotropes. Special care should be done to prevent COVID-19 in dialysis patients to avoid severe complications and mortality.

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Mortality Risk Factors in the China Dialysis Outcomes and Practice Patterns Study (DOPPS)

10.21203/rs.3.rs-445338/v1 ◽

2021 ◽

Author(s):

Xinju Zhao ◽

Qingyu Niu ◽

Zhaohui Ni ◽

Xiaonong Chen ◽

Yuqing Chen ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Congestive Heart Failure ◽

Mortality Rate ◽

Mortality Risk ◽

Practice Patterns ◽

Cox Model ◽

Blood Platelets ◽

Cox Proportional Hazards ◽

Dialysis Outcomes

Abstract Background Mortality risk for hemodialysis (HD) patients varies by country and ethnicity. Here, mortality rate and its related risk factors in Chinese HD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS) were investigated.Methods Data from China DOPPS phase 5 (2012–2015) were used. Patients’ demographics, assigned primary causes of end stage Kidney disease (ESKD), comorbidities, dialysis prescription, laboratory values, date and cause for death were analyzed. Cox proportional hazards models were used to assess the association of patient characteristics and treatments with mortality.Results 1427 HD patients were enrolled. The mean age was 59.4 ± 14.9 years. The median follow-up time was 1.9 (1.1–2.1) years. There was total 205 deaths with at least 103 from cardiovascular disease (50.2%). The overall mortality rate was 8.8 per 100 patient-years. In the multivariate COX model, older, serum albumin (Alb < 4g/dl, blood platelets < 100*109/L, pulse pressure (PP) > 63mmHg, and congestive heart failure history were independent risk factors for all-cause mortality.Conclusions Attention should be paid to patients who were older, with lower Alb and blood platelets level, higher PP and congestive heart failure history. Our results highlighted that there might be some modifiable risk factors for patients’ survival, such as Hgb, Alb, blood platelets, and blood pressure management.

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Mortality Risk Factors in the China Dialysis Outcomes and Practice Patterns Study (DOPPS)

10.21203/rs.3.rs-445338/v2 ◽

2021 ◽

Author(s):

Xinju Zhao ◽

Qingyu Niu ◽

Zhaohui Ni ◽

Xiaonong Chen ◽

Yuqing Chen ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Congestive Heart Failure ◽

Mortality Rate ◽

Mortality Risk ◽

Practice Patterns ◽

Cox Model ◽

Blood Platelets ◽

Cox Proportional Hazards ◽

Dialysis Outcomes

Abstract Background Mortality risk for hemodialysis (HD) patients varies by country and ethnicity. Here, mortality rate and its related risk factors in Chinese HD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS) were investigated. Methods Data from China DOPPS phase 5 (2012–2015) were used. Patients’ demographics, assigned primary causes of end stage kidney disease (ESKD), comorbidities, dialysis prescription, laboratory values, date and cause for death were analyzed. Cox proportional hazards models were used to assess the association of patient characteristics and treatments with mortality. Results 1427 HD patients were enrolled. The mean age was 59.4 ± 14.9 years. The median follow-up time was 1.9 (1.1–2.1) years. There was total 205 deaths with at least 103 from cardiovascular disease (50.2%). The overall mortality rate was 8.8 per 100 patient-years. In the multivariate Cox model, older, serum albumin (Alb < 4g/dl, blood platelets < 100*109/L, pulse pressure (PP) > 63mmHg, and congestive heart failure history were independent risk factors for all-cause mortality. Conclusions Attention should be paid to patients who were older, with lower Alb and blood platelets level, higher PP and congestive heart failure history. Our results highlighted that there might be some modifiable risk factors for patients’ survival, such as Hgb, Alb, blood platelets, and blood pressure management.

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On the Analysis of Mortality Risk Factors for Hospitalized COVID-19 Patients: a Data-driven Study Using the Major Brazilian Database

10.1101/2020.09.24.20200766 ◽

2020 ◽

Author(s):

Fernanda Sumika Hojo Souza ◽

Natália Satchiko Hojo-Souza ◽

Ben Dêivide de Oliveira Batista ◽

Cristiano Maciel da Silva ◽

Daniel Ludovico Guidoni

Keyword(s):

Risk Factors ◽

Heart Disease ◽

Mortality Rate ◽

High Mortality ◽

Mortality Risk ◽

Invasive Mechanical Ventilation ◽

Admission Rate ◽

Older Age ◽

Data Driven ◽

Disease Outcome

Background: Brazil became the epicenter of the COVID-19 epidemic in a brief period of a few months after the first officially registered case. The knowledge of the epidemiological/clinical profile and the risk factors of Brazilian COVID-19 patients can assist in the decision making of physicians in the implementation of early and most appropriate measures for poor prognosis patients. However, these reports are missing. Here we present a comprehensive study that addresses this demand. Methods: This data-driven study was based on the Brazilian Ministry of Health Database (SIVEP-Gripe, 2020) regarding notified cases of hospitalized COVID-19 patients during the period from February 26 to August 10, 2020. Demographic data, clinical symptoms, comorbidities and other additional information of patients were analyzed. Results: The hospitalization rate was higher for male gender (56.56%) and for older age patients of both sexes. Overall, the mortality rate was quite high (41.28%) among hospitalized patients, especially those over 60 years of age. Most prevalent symptoms were cough, dyspnoea, fever, low oxygen saturation and respiratory distress. Heart disease, diabetes, obesity, kidney disease, neurological disease, and pneumopathy were the most prevalent comorbidities. A high prevalence of hospitalized COVID-19 patients with heart disease (65.7%) and diabetes (53.55%) and with a high mortality rate of around 50% was observed. The ICU admission rate was 39.37% and of these 62.4% died. 24.4% of patients required invasive mechanical ventilation (IMV), with high mortality among them (82.98%). The main mortality risk predictors were older age and IMV requirement. In addition, socioeconomic conditions have been shown to significantly influence the disease outcome, regardless of age and comorbidities. Conclusion: Our study provides a comprehensive overview of the hospitalized Brazilian COVID-19 patients profile and the mortality risk factors. The analysis also evidenced that the disease outcome is influenced by multiple factors, as unequally affects different segments of population.

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Septic Shock Outcome and Factors Associated with Mortality in the Intensive Care Unit in Vietnam

Journal of the Medical Association of Thailand ◽

10.35755/jmedassocthai.2021.08.11596 ◽

2021 ◽

Vol 104 (8) ◽

pp. 1249-1254

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Septic Shock ◽

Intensive Care ◽

Mortality Rate ◽

Mortality Risk ◽

Cross Sectional Study ◽

Cross Sectional ◽

Old Patients ◽

Shock Outcome

Objective: To evaluate the mortality rate of septic shock patients and to learn about the associated risk factors for death. Materials and Methods: Septic shock is a life-threatening subset of sepsis with profound circulatory, cellular, and metabolic abnormalities. The authors conducted an analytical cross-sectional study on adult patients diagnosed with septic shock using Sepsis-3 criteria between May 2016 and May 2018 at an intensive care unit at a hospital in Vietnam. Data on patients’ outcomes and associated factors were collected through questionnaires and the patient medical records. To measure the association between independent variables and outcomes, odds ratio (OR) and 95% confidence interval (CI) were calculated using logistic regression. Results: One hundred fifty patients with septic shock were enrolled in the present study. Septic shock occurred in 71.3% of the 60-years-old patients and 54% were men. The mean age was 68.5±15.52 years. The mortality rate was 62% and 17.3% of patients died within 24 hours after being diagnosed with septic shock. The median length of ICU stay was four days. The initial mean SOFA and APACHE II scores were significantly higher in the death group. Septic shock patients with comorbidities had a higher mortality risk compared to those without comorbidity (OR 2.9, 95% CI 1.116 to 7.700). Patients who developed septic shock in the hospital were at greater death risk (OR 7.8, 95% CI 3.3 to 18.2). Septic shock due to pneumonia had a higher mortality risk in comparison with those due to the other causes (OR 5.2, 95% CI 2.4 to 11.0). Conclusion: The mortality rate of patients with septic shock in Vietnam was considerably high. Many factors were identified as risks, such as nosocomial infection and respiratory tract diseases. Keywords: Septic shock; Outcome; Risk factors; Vietnam

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Mortality risk factors in premature infants with respiratory distress syndrome treated by mechanical ventilation

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh0502029f ◽

2005 ◽

Vol 133 (1-2) ◽

pp. 29-35 ◽

Cited By ~ 6

Author(s):

Dusko Fidanovski ◽

Vladislav Milev ◽

Aleksandar Sajkovski ◽

Antoni Hristovski ◽

Aspasija Sofijanova ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Developing Countries ◽

Birth Weight ◽

Mortality Rate ◽

Premature Infants ◽

Mortality Risk ◽

Newborn Infants ◽

Risk Of Mortality ◽

Maternity Hospitals

Respiratory distress syndrome (RDS) is the most common cause of respiratory failure and requirement for mechanical ventilation (MV) of newborns. RDS is also common cause of mortality and severe morbidity in premature infants. In developing countries, despite facilities for respiratory care of newborn infants, RDS mortality rate and percentage of complications still remain high in comparison to the developed countries. Survival rates of RDS infants requiring MV ranged from 25% in those newborns with birth weight <1000 grams up to 53% in those with birth weight >2500 grams. There have been limited data about causes of high mortality rate in infants with RDS from developing countries. AIM The objectives of the study were to determine (I) the incidence of severe RDS at Pediatric Intensive Care Unit (PICU), University Children's Hospital Skopje (UCHS) and main characteristics of infants with RDS, as well as (II) the survival rate and mortality risk factors of these infants. MATERIAL AND METHODS The study included 126 premature infants with clinical and radiological signs of RDS requiring mechanical ventilation who were admitted to PICU, UCHS between January 1996 and December 2003. The mean gestational age (GA) of the infants was 31.5+2.5 weeks, and the mean birth weight (BW) was 1663+489 grams. The management of newborns with RDS at PICU, UCHS, follows the standard protocol, with emphasis on minimal manipulation, maintenance of thermo neutral environment, administration of humidified oxygen and non-invasive cardio respiratory monitoring. Pressure-limited time-cycled mechanical ventilation with pediatric/neonatal ventilators was performed in all infants. In those newborn infants with clinical and radiological signs of RDS and need for MV with FiO2>0.4, synthetic (Exosurf) or natural (Survanta) surfactants were administered. Out of all newborns, 43 infants (34%) were not treated with surfactant, because it was not available at that time. RESULTS In the period 1996-2003, out of 1722 consecutive admissions to PICU, 693 hospitalized infants had neonatal RDS (40.2%). A total of 210 (30.3%) infants with RDS required intubation and PPV, and 126 met the inclusion criteria for this study. Surfactant replacement therapy (up to two doses) was given to 83 (65.8%) infants. Most of neonates (80 or 634%) were born at two maternity hospitals in Skopje, and others were transferred from regional maternity hospitals in Macedonia. The relation between perinatal characteristics, disease severity and outcome was illustrated in Table 2. There was higher risk of mortality in infants with lower birth weight, lower Apgar score (minutes 1 and 5), and shorter gestational age. Expected admission values of VI as well as other parameters of illness severity were not significantly associated with higher risk of mortality. The newborns with air-leak sy (any form) and pulmonary hemorrhage had significantly higher risk of dying, while the risk of mortality was significantly lower in infants with sepsis and BPD as complications in studied cohort. The findings of logistic regression analysis for mortality risk factors were presented in Table 3. The minimal model identified a number of factors as independently associated with significantly higher risk of mortality. Infant birth weight ?1500 grams, admission VI ?0.2 mmHg and air leak sy (any form) as complication significantly increased the risk of dying in infants with RDS. BPD was significantly associated with survival in studied cohort. CONCLUSION In spite of the implementation of high technology in Neonatal Intensive Care in our country, the mortality rate of the infants with RDS is high, but is not different from that in developing countries. The improvement of perinatal care and diminution of risk factors, common use of surfactant as well as antenatal steroids could most probably result in better outcome of neonatal RDS.

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Identification of RAGE and OSM as New Prognosis Biomarkers of Severe Pneumonia

Canadian Respiratory Journal ◽

10.1155/2022/3854191 ◽

2022 ◽

Vol 2022 ◽

pp. 1-9

Author(s):

Jing Lei ◽

Li Wang ◽

Qian Li ◽

Lin Gao ◽

Jing Zhang ◽

...

Keyword(s):

Risk Factors ◽

Mortality Rate ◽

Poor Prognosis ◽

Total Bilirubin ◽

Oxygenation Index ◽

Severe Pneumonia ◽

Albumin Level ◽

Significant Decline ◽

Survival Group ◽

Index Level

Objective. To investigate efficiency of RAGE and OSM as new prognosis biomarkers of severe pneumonia. Methods. Eligible patients were classified into hypoxemia and nonhypoxemia groups. Meanwhile, the same cohort was divided into survival and nonsurvival groups after a post-hospital stay of 30 days. We analyzed risk factors for the hypoxia and death among these patients. Results. Compared with nonsurvival group, significant increase was noticed in PH, lymphocyte, albumin and platelet level in survival group, while significant decline was noticed in neutrophils, RBC, hemoglobin, hematocrit, creatinine, total bilirubin, CRP, PCT, OSM, RAGE and neutrophils/lymphocyte level. Oxygenation index level was related to APACHE II, LIS, SOFA, NUTRIC score, WBC, neutrophils, lymphocyte, RAGE, and albumin level ( p < 0.05 ). LIS, SOFA, NUTRIC score, lac, lymphocyte, platelet, BUN, total bilirubin, PCT, and OSM levels were associated with mortality rate ( p < 0.05 ). Conclusions. RAGE and OSM may serve as a new biomarker for poor prognosis in pneumonia patients.

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Frequency and Mortality Risk Factors of Acute Ischemic Stroke in Emergency Department in Burkina Faso

Stroke Research and Treatment ◽

10.1155/2020/9745206 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Alfred Anselme Dabilgou ◽

Alassane Dravé ◽

Julie Marie Adeline Kyelem ◽

Saïdou Ouedraogo ◽

Christian Napon ◽

...

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Ischemic Stroke ◽

Mortality Rate ◽

Acute Ischemic Stroke ◽

Mortality Risk ◽

Average Length ◽

University Teaching ◽

Vascular Risk ◽

The Mean

Objective. To determine the prevalence of ischemic stroke deaths and their predictive factors in the Emergency Department at Yalgado Ouedraogo University Teaching Hospital (YOUTH). Methodology. This was a retrospective study with an analytical and descriptive focus over a period of three years from January 1, 2015, to December 31, 2017. Results. During the study period, 302 acute ischemic stroke patients with a mean age of 62.2±14.26 years were included. Atrial hypertension was the most common vascular risk factor in 52.5%. On admission, 34.8% of patients had loss of consciousness. The mean time to perform brain CT was 1.5 days. The average length of stay was 4 days. Electrocardiogram, echocardiography, and cervical Doppler were not performed during hospitalization in ED. The mortality rate was 39%, respectively, 37.6% in male and 41.6% in female. The mean age of patients who died in ED was 63.6±13.52 years. Hypertension was the most common vascular risk factors in 54.2% of death. After logistic regression, the predictors of death were past history of heart disease, consciousness disorders, hyperthermia, hyperglycemia on admission, poststroke pneumonia, and urinary tract infection. Conclusions. Acute ischemic stroke was frequent in Emergency Department with high mortality rate. The mortality risk factors were the same than those found in literature. This higher mortality can be avoided by early diagnosis and an adequate management.

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The death risk factors of patients undergoing re-exploration for bleeding or tamponade after isolated off-pump coronary artery bypass grafting: a case–control study

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-02017-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Tongxiao Luan ◽

Yingzhu Zhuang ◽

Weihong Nie ◽

Sumin Yang ◽

Yuhui Wu ◽

...

Keyword(s):

Risk Factors ◽

Coronary Artery ◽

Coronary Artery Bypass Grafting ◽

Mortality Rate ◽

Artery Bypass ◽

Bypass Grafting ◽

Survival Group ◽

Off Pump ◽

Pump Coronary Artery Bypass ◽

Death Group

Abstract Background The purpose of the study is to identify off-pump patients who are at higher risk of mortality after re-exploration for bleeding or tamponade. Methods We analyzed the data of 3256 consecutive patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG) in our heart center from 2013 through 2020. Fifty-eight patients underwent re-exploration after OPCABG. The 58 patients were divided into death group and survival group according to their discharge status. Propensity score matching (PSM) was performed to analysis the risk factors of death. 15 pairs of cases of two groups were matched well. Results The mortality rate of patients underwent re-exploration after OPCABG for bleeding or tamponade was 27.59% (16/58). In the raw data, we found the patients in death group had higher body mass index (BMI) (P = 0.030), higher cardiac troponin T (cTnT) (P = 0.028) and higher incidence of heart failure before OPCABG (P = 0.003). After PSM, the levels of lactic acid before and after re-exploration (P = 0.028 and P < 0.001) were higher in death group. And the levels of creatinine (P = 0.002) and cTnT (P = 0.017) were higher in the death group after re-exploration. The death group had longer reoperation time (P = 0.010). In addition, the perioperative utilization rate of intra-aortic ballon pump (IABP) (P = 0.027), continuous renal replacement therapy (CRRT) (P < 0.001) and platelet transfusion (P = 0.017) were higher than survival group. Conclusions The mortality rate of patients undergoing re-exploration for bleeding or tamponade after isolated OPCABG is high. More attention should be paid to patients with above risk factors and appropriate measures should be taken in time.

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