Arthroscopic Ankle Arthrodesis

2007 ◽  
Vol 28 (6) ◽  
pp. 695-706 ◽  
Author(s):  
Nikolaos E. Gougoulias ◽  
Filon G. Agathangelidis ◽  
Stephen W. Parsons
Keyword(s):  
Sagittal Plane ◽  
Deformity Correction ◽  
Frontal Plane ◽  
Ankle Arthrodesis ◽  
Valgus Deformity ◽  
Postoperative Treatment ◽  
Average Hospital ◽  
Superficial Wound ◽  
Group A ◽  
Group B

Background: Arthroscopic arthrodesis has been used mainly for in situ fusion of arthritic ankles without deformity. This paper presents the application of arthroscopic arthrodesis of ankles with marked deformity. Methods: The results of 78 consecutive cases of arthroscopic ankle arthrodeses, performed in 74 patients, were retrospectively evaluated. Forty-eight ankles had minor deformity (group A), whereas 30 ankles had a varus or valgus deformity of more than 15 degrees (maximum 45 degrees) (group B). The average hospital stay was 3.8 and 3.4 days in groups A and B, respectively ( p = 0.74). Postoperative treatment included ankle immobilization for 3 months. Progressive weightbearing was initiated at 2 weeks. Mean followup was 21.1 months. Results: Fusion occurred in 47 of 48 (97.9%) ankles in group A at an average time of 13.1 ± 5.8 weeks and in 29 of 30 (96.7%) ankles at 11.6 ± 2.4 weeks in group B ( p = 0.19). Unplanned operative procedures were required in 11 ankles (14.1%). One superficial wound infection occurred. Symptomatic arthritis from the adjacent joints developed in six ankles (7.7%). Postoperative ankle alignment in the frontal plane averaged 0.7 and 0.4 degrees of valgus ( p = 0.41), whereas the sagittal plane angle averaged 106 ± 4 degrees and 104.5 ± 7 degrees in groups A and B, respectively ( p = 0.22). The outcome was graded as very good in 79.2% (38 feet) in group A and 80% (24 feet) in group B, fair in 18.8% (9 feet) in group A and 16.7% (5 feet) in group B and poor in one ankle in each group ( p = 0.68). Conclusions: The arthroscopic technique offered high fusion rates and low morbidity. Deformity correction was achieved with good results.

Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation

2020 ◽  
Vol 102-B (4) ◽  
pp. 470-477 ◽  
Author(s):  
Yaser Alammar ◽  
Anatoliy Sudnitsyn ◽  
Andrey Neretin ◽  
Sergey Leonchuk ◽  
Nikolay Mikhailovich Kliushin
Keyword(s):  
Operating Time ◽  
Deformity Correction ◽  
Ankle Arthrodesis ◽  
Ilizarov Method ◽  
Foot And Ankle ◽  
Ring Fixator ◽  
Ilizarov Ring Fixator ◽  
Group A ◽  
American Orthopaedic ◽  
Group B

Aims Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. Methods We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. Results The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. Conclusion We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470–477.

scholarly journals Comparison of Preventive and Therapeutic Transplantations of Allogeneic Mesenchymal Stem Cells in Healing of the Distal Femoral Growth Plate Cartilage Defects in Miniature Pigs

2009 ◽  
Vol 78 (2) ◽  
pp. 293-302 ◽  
Author(s):  
Ladislav Plánka ◽  
David Starý ◽  
Jana Hlučilová ◽  
Jiří Klíma ◽  
Josef Jančář ◽  
...  
Keyword(s):  
Valgus Deformity ◽  
Control Group ◽  
Left Femur ◽  
Bone Bridge ◽  
Allogeneic Mscs ◽  
Growth Cartilage ◽  
Group A ◽  
Therapeutic Transplantation ◽  
Group B ◽  
Iatrogenic Defect

The aim of the study was to verify whether there is a difference in the lengthwise growth of the femurs and in their angular deformity when comparing preventive vs. therapeutic transplantation of allogeneic mesenchymal stem cells (MSCs) to an iatrogenic defect in the distal physis of femur. Modified composite chitosan/collagen type I scaffold with MSCs was transplanted to an iatrogenically created defect of the growth cartilage in the lateral condyle of the left femur in 20 miniature male pigs. In Group A of animals (n = 10) allogeneic MSCs were transplanted immediately after creating the defect in the distal physis of femur (preventive transplantation). In Group B of animals (n = 10) the same defect of the growth cartilage was treated by transplantation of allogeneic MSCs four weeks after its creation (therapeutic transplantation), after the excision of the bone bridge that had formed in it. On average, left femurs with a damaged distal physis and preventively transplanted allogeneic MSCs (Group A) grew during 4 months from transplantation by 0.56 ± 0.44 cm more than right femurs without the transplantation of MSCs, whereas left femurs with physeal defects treated with a therapeutic transplantation of allogeneic MSCs (Group B) by 0.14 ± 0.72 cm only, compared to right femurs without transplanted MSCs. Four months after preventive transplantation of MSCs (Group A), valgus deformity of the distal part of left femur with the defect was 0.78 ± 0.82°; in the control group (right femur in the same animal without MSCs transplantation) it was 3.7 ± 0.82°. After therapeutic transplantation of MSCs (Group B) 0.6 ± 3.4°, in the control group (right femur in the same animal without MSCs transplantation) it was 2.1 ± 2.9°. In all the animals of Groups A and B, the presence of newly formed hyaline cartilage was confirmed histologically and immunohistochemically. In the distal physis of right femurs with an iatrogenic defect of the growth cartilage without the transplantation of MSCs (control) bone bridge was formed. Preventive transplantation of allogeneic MSCs into the defect of the distal growth zone of femur appears more suitable compared to the therapeutic transplantation, with regard to the more pronounced lengthwise bone growth. Differences found in the extent of valgus deformity were non-significant comparing preventive and therapeutic transplantations of MSCs.

scholarly journals Comparison of central venous oxygen saturation and serum lactate clearance as predictors of outcome in septic shock patients: a prospective control trial

2018 ◽  
Vol 6 (2) ◽  
pp. 653
Author(s):  
Gagan Kumar Narula ◽  
Ajit Kumar Singh ◽  
Anish Adya
Keyword(s):  
Early Recognition ◽  
Serum Lactate ◽  
Therapeutic Interventions ◽  
Average Hospital ◽  
Mortality And Morbidity ◽  
Prospective Control Trial ◽  
Icu Stay ◽  
Significant Difference ◽  
Group A ◽  
Group B

Background: Sepsis is the leading causes of mortality and morbidity in ICU. Early recognition and intervention ensures speedy recovery and early discharge. It’s possible only if good predicting parameters indicating optimum resuscitation are available. Lactate level reduction and ScvO2 level in the jugular vein can be utilized as predictors.Methods: In this prospective study after applying exclusion inclusion criteria, 99 patients were selected and randomized into 2 groups. In one group reduction in lactate levels and in other ScVo2 levels were used as a predictor of resuscitation. Therapeutic interventions, Hospital stay, ICU Stay and 28-day mortality were compared in both groups. Statistical analysis was carried out by SPSS software.Results: On comparison of demographic profile, morbidity, SOFA score and hemodynamic parameters, there was insignificant difference (P >0.05). No significant difference in the number of vasopressors, Average Hospital or ICU Stay (Group A is 10.68±21.46 while Group B is 9.49±17.22) and 28-day mortality rate (in Gp A 60% vs group B 57.1) was observed. Mean crystalloids administered in group A was 4.93±1.11 liters, significantly more than group B i. e. 4.19±1.17 liters. (P<0.05) which was statistically significant.Conclusions: Although both parameters of resuscitation are used widely and sometimes simultaneously, in this study lactate and ScvO2 both used and compared in a similar set of patients, appeared to be equivocal in term of 28-day mortality, except the volume of crystalloids required was more in ScvO2 Group.

scholarly journals Extended Distal Chevron Osteotomy

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0002 ◽  
Author(s):  
Chan Kang ◽  
Jaehwang Song ◽  
Donghun Kang ◽  
Chang-Kyun Noh ◽  
Ahn Ki Jun
Keyword(s):  
Hallux Valgus ◽  
Valgus Deformity ◽  
Plantar Surface ◽  
Chevron Osteotomy ◽  
Hallux Valgus Deformity ◽  
Radiographic Measurements ◽  
Valgus Angle ◽  
Group A ◽  
Group B

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Numerous corrective osteotomies have been performed for surgical treatment of hallux valgus(HV). One of these procedures is distal chevron osteotomy, traditionally indicated for correction of mild to moderate HV. We proposed a new modification of the chevron osteotomy, extended distal chevron osteotomy, to provide even greater stability by extend the contact surface, as well as more effective and accurate correction of the angulation and rotational profile than conventional osteotomy. Methods: Between July 2013 and June 2014, the extended distal chevron osteotomy (DCO) was performed for the treatment of mild-to-moderate hallux valgus deformity in 63 feet (Group A) by the same surgeon. For the extended chevron, the first osteotomy was performed to cut 5-10 mm from the head of metatarsal to the proximal upper 1/3 of the neck. The second osteotomy was performed to cut 2.5~3.0 cm from the upper 1/3 of the neck toward horizontal plane of the plantar surface with an angle of 45~50 degree. Standard foot radiographic measurements, hallux valgus angle(HVA) and intermetatarsal angle(IMA), were recorded to compare with the values of 37 patients (Group B) who were treated by the traditional DCO technique. Results: Mean patient age was 45.3 (range 15–78) years, and 54 patients were available for follow-up at both one and two years postoperatively. Mean follow-up duration was 13.7 (range 4–26) months. In group A, mean HVA decreased from 32.3° preoperatively to 8.4° at final follow-up, while the angle of group B decreased from 32.4° to 11.4°. Mean IMA decreased from 15.1° preoperatively to 7.3° at final follow-up in group A, while the IMA decreased from 15.1° to 8.9° in group B. That way we could verify that the extended chevron osteotomy is more effective for stability and correcting of the angulation and rotational profile than traditional DCO. Conclusion: The extended chevron osteotomy achieved even greater stability and accurate correction of the deformity. Furthermore, it was more effective than traditional chevron osteotomy in terms of correction of the angulation and rotational profile.

Cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation

2008 ◽  
Vol 24 (03) ◽  
pp. 312-317 ◽  
Author(s):  
Jean-Blaise Wasserfallen ◽  
Mira Kast-Brückner ◽  
Oriol Manuel ◽  
Jean-Pierre Venetz ◽  
Pascal R. A. Meylan ◽  
...  
Keyword(s):  
Kidney Transplantation ◽  
Cost Effectiveness ◽  
Infectious Complications ◽  
Treatment Costs ◽  
Accounting System ◽  
Average Hospital ◽  
Outpatient Visits ◽  
Group A ◽  
Group B ◽  
Cmv Prophylaxis

Objectives:The aims of this study were to assess the 1-year cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation to prevent both rejection and infectious complications.Methods:Patients (pts) transplanted from January 2000 to March 2003 (Group A) and treated with a conventional protocol were compared with pts submitted to a combined regimen including universal cytomegalovirus (CMV) prophylaxis between April 2003 and July 2005 (Group B). Costs were computed from the hospital accounting system for hospital stays, and official tariffs for outpatient visits. Patients with incomplete costs data were excluded from analysis.Results:Fifty-three patients were analyzed in Group A, and 60 in Group B. Baseline characteristics including CMV serostatus were not significantly different between the two groups. Over 12 months after transplantation, acute rejections decreased from 41.5 percent in Group A to 6.7 percent in Group B (p&lt; .001), and CMV infections from 47 percent to 15 percent (p&lt; .001). Overall, readmissions decreased from 68 percent to 55 percent (p= .160), and average hospital days from 28 ± 19 to 20 ± 11 days (p&lt; .007). The average number of outpatient visits decreased from 49 ± 10 to 39 ± 8 (p&lt; .001). Average 1-year immunosuppressive and CMV prophylaxis costs (per patient) increased from CHF20,402 ± 7,273 to 27,375 ± 6,063 (p&lt; .001), graft rejection costs decreased from CHF4,595 ± 10,182 to 650 ± 3,167 (p= .005), CMV treatment costs from CHF2,270 ± 6,161 to 101 ± 326 (p= .008), and outpatient visits costs from CHF8,466 ± 1’721 to 6,749 ± 1,159 (p&lt; .001). Altogether, 1-year treatment costs decreased from CHF39’957 ± 16,573 to 36,204 ± 6,901 (p= .115).Conclusions: The new combined regimen administered in Group B was significantly more effective, and its additional costs were more than offset by savings associated with complications avoidance.

The Rationale of Osteotomy around the Knee

2017 ◽  
Vol 30 (05) ◽  
pp. 386-392 ◽  
Author(s):  
Philipp Lobenhoffer
Keyword(s):  
Sagittal Plane ◽  
Weight Bearing ◽  
Cartilage Damage ◽  
Frontal Plane ◽  
Varus Deformity ◽  
Valgus Deformity ◽  
Wedge Osteotomy ◽  
Early Weight Bearing ◽  
Plate Fixator ◽  
Closed Wedge

AbstractFrontal plane varus or valgus deformity causes overload in the ipsilateral compartment and may induce and accelerate cartilage damage. Osteotomy around the knee should be considered in symptomatic constitutional and posttraumatic metaphyseal deformities of more than 3-degree deviation. Age, grade of osteoarthritis, obesity, and nicotine consumption are no exclusion criteria for osteotomy. For correction of varus deformity, biplanar open wedge osteotomy of the tibia with fixation by a plate fixator has proven to be a safe and stable construct allowing for early weight-bearing. Valgus deformities of the tibia can be treated by biplanar closed wedge osteotomy of the proximal tibia. For femur deformities closed wedge biplanar osteotomy and fixation with a specific plate fixator is an attractive solution reducing implant-related morbidity. Osteotomy around the knee may also be used to protect cartilage reconstruction and meniscus transplantation. Corrections in the sagittal plane may improve the anteroposterior stability of the knee significantly and can be combined with frontal plane corrections.

scholarly journals Mono-segment Fixation Method Versus Short-segment Fixation Methods, In Treatment Of Mono-segmental Lumbar Tuberculosis; Using Titanium Mesh Cage With Interbody Fusion: Retrospective Cohort Study.

2019 ◽  
Author(s):  
Hongqi Zhang ◽  
Daudi Romani Manini ◽  
Yuxiang Wang
Keyword(s):  
Interbody Fusion ◽  
Deformity Correction ◽  
Operation Time ◽  
Fixation Method ◽  
Short Segment ◽  
Fixation Methods ◽  
Mesh Cage ◽  
Group A ◽  
Group B ◽  
Short Segment Fixation

Abstract Background ： 1/3rd-2/3rd of the remaining vertebral height can hold and withstand the standard pedicle screws; some surgeons have adopted affected vertebral fixation to avoid the complications of both long and short segment fixation during surgical correction of lumbar tuberculosis (TB).This study aimed to compare efficacy of mono-segment-fixation versus the short-segment fixation methods with the use of titanium mesh-cage (TMCs) and interbody fusion in the treatment of mono-segmental lumbar spinal TB via single stage posterior-only approach. Methods ： A retrospective review was done among 34 lumbar spinal TB patients. These patients underwent debridement, interbody fusion with (TMCs) by either Mono-segment fixation or short-segment fixation methods. Eighteen patients underwent mono-segment fixation method, group (A). While 16 patients underwent short-segment fixation method, group (B). Fusion, deformity correction, and decompression were done within the affected segment in group (A), while for group (B) fusion extended one level above and below the affected vertebrae . Operation time, intra-operative blood loss, degree of deformity correction and neurological functions were analyzed. Results: Comparing group (A) vs (B), average operation time in minutes (mins) for group A was 144.2±16.5, group B was 170.3 ± 25.0 (P=0.001). Average intraoperative blood loss in milliliter (mls) was 502.8±151.9 for group (A) and 742.5±143.2 for group (B) (p ˂0.05). The mean cobb’s angle between group A versus group B; preoperative was 23.8 ± 6.5 0 vs 22.2±9.2 0 (p=0.6), immediate post operatively was 8.0±3.5 0 vs 8.3±5.7 0 (p=0.847) and at final follow-up was 8.9±3.1 0 vs 9.2 ± 5.9 0 (p=0.866) respectively. Correction rate between group (A) vs group (B) was 15.7±3.8 0 vs 13.9±5.5 0 (p=0.285) and loss of correction was 1.2±0.7 0 vs 1.1±0.7 (p=0.817) respectively. No significant differences in neurological recovery between the two groups were founds. Conclusion: Under precise conditions: mono-segment fixation method, debridement, interbody fusion with TMCs, and posterior instrumentation can effectively reconstruct the spine, maintain stability and correct kyphosis deformity similar to short-segment fixation method. Also, it can relieve pain and improve neurological symptoms. When used in combination with anti-TB chemotherapy in the treatment of mono-segmental lumbar TB via a single-stage posterior-only approach.

scholarly journals Surgical management of consecutive multisegment thoracic and lumbar tuberculosis: anterior-only approach vs. posterior-only approach.

2020 ◽  
Author(s):  
Chen Zhao ◽  
Lei Luo ◽  
Liehua Liu ◽  
Pei Li ◽  
Lichuan Liang ◽  
...  
Keyword(s):  
Loss Rate ◽  
Deformity Correction ◽  
Operation Time ◽  
Clinical Results ◽  
Surgery Group ◽  
Significant Difference ◽  
Functional Scores ◽  
Group A ◽  
Group B

Abstract Purpose: To compare the efficacy, safety, and technical characteristics of anterior-only and posterior-only approach surgeries for the treatment of consecutive multisegment thoracic and lumbar tuberculosis.Methods: Thirty-five patients who developed consecutive multisegment thoracic and lumbar tuberculosis from September 2012 to May 2016 were retrospectively analyzed. Group A was the posterior-only surgery group, and group B was the anterior-only surgery group. The data on the surgery, deformity correction, functional scores and complications were compared between the two groups.Results: There was no significant difference in the operation time or blood loss between groups A and B (P>0.05). The preoperative average Cobb angle of kyphosis in groups A and B were 36.2±15.2° and 27.9±7.7°, respectively, which significantly decreased to 4.9±11.8° and 10.4±5.6° after the operation, respectively (P<0.05). At the final follow-up, the angles were 7.1±10.5° and 14.6±8.0°, respectively. The correction angle and correction rate in group A (31.3±16.6°, 88.6±43.6%) were greater than those in group B (17.5±4.4°, 64.9±14.0%) (P<0.05). There was no significant difference in the loss angle between groups A and B (P>0.05), but the loss rate in group B (24.0±27.8%) was higher than that in group A (9.6±10.2%) (P<0.05). There was no significant difference in the incidence of complications between the two groups (P>0.05). Conclusion: The posterior-only and anterior-only approaches can lead to satisfactory clinical results in the treatment of patients with consecutive multisegment thoracic and lumbar tuberculosis. With posterior-only surgery, kyphosis can be better corrected, and the correction can be better maintained than with anterior-only surgery.

scholarly journals HEMORRHOIDECTOMY VS RUBBER BAND

2011 ◽  
Vol 18 (04) ◽  
pp. 571-574
Author(s):  
MUHAMMAD DILAWAIZ ◽  
ABID RASHID ◽  
MUHAMMAD ABID BASHIR
Keyword(s):  
Hospital Stay ◽  
Rubber Band Ligation ◽  
Rubber Band ◽  
University Hospital ◽  
Severe Bleeding ◽  
Average Hospital ◽  
Band Ligation ◽  
Open Hemorrhoidectomy ◽  
Group A ◽  
Group B

Objectives: To compare open hemorrhoidectomy and Rubber Band Ligation (RBL) in the management of 2nd and 3rd degree hemorrhoids in terms post operative and hospital stay. Design: Experiential Randomized Control Trial. Setting: Department of surgery, Allied Hospital and Independent University Hospital Faisalabad. Period: Dec 2008 to May 2009. Patients & Methods: 100 consecutive patients with second and third degree hemorrhoids were randomly divided into two groups. Group A (50 patients) were operated by open hemorrhoidectomy (Milligan morgan technique) while in group B (50 patients) rubber band ligations was performed. Open hemorrhoidectomy was performed under spinal anesthesia while rubber bands were applied with local xylocaine gel using Barron’s rubber band ligator. All the three hemorrhoids were ligated in single session. Results: Average hospital stay was 24 hours in patient operated by open hemorrhoidectomy as compared to one hour in rubber band ligation. 60% patients in group A developed moderate to severe pain requiring I/V morphine derivatives while 40% developed mild pain and treated with NSAIDS. In group B only 20% patients developed moderate pain and were dealt with I/M diclofenac sodium. Eightyeight percent patients in group A and 60% patients in group B developed mild to moderate bleeding in first postoperative week, which was self limiting. 6 patients developed severe bleeding after hemorrhoidectomy requiring blood transfusion. During six month follow up, two patients (4%) of open hemorrhoidectomy and 3 patients (6%) of RBL presented with recurrence and respective procedures were repeated. Conclusions: Rubber band ligation is safe, quick, economical and effective method for the treatment of 2nd and 3rd degree hemorrhoids. 

scholarly journals SUPRACONDYLAR FRACTURES

2006 ◽  
Vol 13 (02) ◽  
pp. 244-252
Author(s):  
MUKHTAR AHMAD TARIQ ◽  
MUHAMMAD ShAFI ◽  
ASGHAR ALI
Keyword(s):  
Sampling Technique ◽  
Supracondylar Fractures ◽  
Superficial Wound ◽  
Quasi Experimental ◽  
Experimental Type ◽  
Group A ◽  
Carrying Angle ◽  
Pin Tract Infection ◽  
Group B ◽  
Condylar Fractures

Objective:- To determine the surgical approach most suited in our setup and evaluate the results based on the functional and cosmetic outcome especially in the range of motion,the subsequent defromity, if any, and the carrying angle. Setting Orthopaedic surgery, Nishtar Hospital, Multan. Duration Two years, Study design Quasi experimental type of study. Material & Methods Thirty patients. Sampling technique Non-probability technique. Results The age of the patients included in our study ranged from 4-10 years with a mean age of 5.93 years in group A and 6.66 years in group B. Out of 30 patients in group-A and 11 (73.3%) males and 4(26.6%) in group B had fracture on right side where as 12(80%) in group-A and 11(73.3%) in group-B got injured due to fall from height. One (6.66%) patients from group-A and B had superficial wound infection. Pin tract infection was found in 1(6.66%) in group A and 2(13.33%) patients in group-B. Conclusion: This technique was easy to perform and proved to be safe, although hospitalization time was minimum in both groups. So we recommend medial approach for open reduction and internal fixation of all displaced supra-condylar fractures of humerus in children with appropriate indications.

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