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J J Patard

Publications and source records attributed to J J Patard.

At least 19 recordsLinked to original sources
PubMed2003

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder].

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Aged↗
PubMed2002

[Spontaneous subcapsular renal hematoma: diagnosis and treatment. Two case reports].

Spontaneous perirenal haematomas essentially raise the problem of the aetiological diagnosis, but can sometimes be inadequate. Arteriography is useful when CT scan is negative or in the case of vascular disease. The therapeutic attitude, nephrectomy or conservative treatment remains controversial, but in view of the frequency of renal neoplastic lesions, the authors recommend nephrectomy at the slightest doubt concerning renal integrity. When no case be found, the assessment must be completed postoperatively with long-term, close surveillance, due to the risk of an undiagnosed neoplastic lesion. The authors report two recent cases and try to propose a diagnostic and therapeutic strategy based on the aetiology.

Female↗
PubMed2002

Outcome of radical cystectomy for bladder cancer according to the disease type at presentation.

OBJECTIVE: To examine whether the outcome of cystectomy for invasive transitional cell carcinoma (TCC) of the bladder was influenced by the type of disease at initial presentation. PATIENTS AND METHODS: The charts of 76 patients treated for TCC by radical cystectomy from 1987 to 1997 in our unit were reviewed. The patients were divided into three groups: group 1 comprised 43 patients with primary invasive disease; group 2 included 12 patients with progression of an initial superficial bladder tumour after failure of conservative treatment; and group 3 comprised 21 patients who had a radical cystectomy for superficial TCC, with a high risk of progression after attempts at conservative treatment. The pathological findings on transurethral resection and cystectomy specimens, cancer-specific survival and the time to progression were compared among the three groups. RESULTS: The rate of pT0 in cystectomy specimens was 16%, 41% and 24% in groups 1, 2 and 3, respectively. Under-staging occurred in 24% of cases in group 3. The 10-year cancer-specific survival rates were 48%, 47% and 82% in groups 1, 2 and 3, respectively. The cancer-specific survival rate and progression rate were not significantly different between groups 1 and 2, but were significantly lower/higher in these patients than in group 3 (P < 0.01). CONCLUSIONS: These data suggest that the prognosis of superficial TCC which progresses despite conservative management is no better than that of invasive TCC at initial presentation, despite the closer follow-up received by the former patients. Early identification of this group of patients may improve the cancer-specific survival, as early cystectomy for high-risk superficial TCC yields better results.

Aged↗
PubMed2002

Real indications for adrenalectomy in renal cell carcinoma.

OBJECTIVES: We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy. PATIENTS AND METHODS: From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. RESULTS: Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC. CONCLUSIONS: Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Adolescent↗
PubMed2001

Early endoscopic realignment of post-traumatic posterior urethral disruption.

OBJECTIVES: The management of complete or partial urethral disruption is controversial, and much debate continues regarding immediate versus delayed definitive therapy. We further analyze our experience and long-term results using early endoscopic realignment. METHODS: Between April 1987 and January 1999, 29 men with posterior urethral disruption (23 complete and 6 partial) underwent primary urethral realignment 0 to 8 days after injury. Pelvic fractures were present in 23 patients. In all patients, the actual operating time for realignment was 75 minutes or less. All patients were evaluated postoperatively for incontinence, impotence, and strictures. RESULTS: After a mean follow-up of 68 months (range 18 to 155), all patients were continent. Four patients (13.7%) required conversion to an open perineal urethroplasty. At the last follow-up visit, 25 (86%) of the 29 patients were potent and 4 achieved adequate erections for intercourse using intracorporeal injections (prostaglandin E(1)). Twelve patients (41%) developed short secondary strictures and were successfully treated with internal urethrotomy. The mean follow-up of these 12 patients was 83 months (range 34 to 120). Urinary flow rate measurement at the last follow-up visit revealed satisfactory voiding parameters in all patients. CONCLUSIONS: Primary endoscopic realignment offers an effective method for treating traumatic urethral injuries. Our long-term follow-up provides additional support for the use of this technique by demonstrating that urethral continuity can be established without an increased incidence of impotence, stricture formation, or incontinence. In case of failure, endoscopic realignment does not compromise the result of secondary urethroplasty.

Adolescent↗
PubMed2001

Tolerability of bacille Calmette-Guérin maintenance therapy for superficial bladder cancer.

OBJECTIVES: To study the influence of adverse reactions on adherence to an immunotherapy maintenance schedule and the recurrence rate of bladder cancer. Bacille Calmette-Guérin immunotherapy has documented efficacy in the management of high-risk superficial bladder cancer. However, the optimal duration of intravesical bacille Calmette-Guérin therapy and the risk/benefit ratio of maintenance therapy are controversial. METHODS: From April 1996 to April 2000, 72 patients with superficial bladder cancer were treated with Immucyst (six consecutive weekly instillations of 81 mg) and then received maintenance therapy consisting of three consecutive weekly instillations 3, 6, 12, 18, 24, 30, and 36 months later. Adverse reactions, studied during 518 instillations, were classified in four categories using a scale based on the World Health Organization recommendations, and their impact on the adherence to therapy was analyzed. RESULTS: After an average follow-up of 24 months, a durable disease-free response was observed in 84.9% of the patients; 12.5% of patients had a relapse and 2.6% had disease progression. The response rate was similar in patients with and without adverse reactions. Only 14 patients (19%) received all the scheduled maintenance instillations. The dose was reduced in 41 patients (57%), and treatment was stopped in 28 patients (39%). In multivariate analysis, an adverse event score of 1.5 or greater during induction therapy was significantly associated with cessation or modification of maintenance therapy (P = 0.01). CONCLUSIONS: The scale developed in this study to monitor the adverse reactions to bacille Calmette-Guérin and their impact on the adherence to maintenance therapy may be helpful for tailoring maintenance regimens or implementing protective measures (dose reduction or treatment postponement).

Adjuvants, Immunologic↗
PubMed2001

Leukocyturia as a predictor of tolerance and efficacy of intravesical BCG maintenance therapy for superficial bladder cancer.

OBJECTIVES: To examine leukocyturia as a predictor of tumor recurrence and occurrence of adverse events after bacille Calmette-Guérin (BCG) immunotherapy. The use of BCG immunotherapy, a very major advance in the management of superficial bladder cancer, is limited by the frequency of adverse events. As yet, we have no way of predicting the efficacy and tolerability of BCG instillation in clinical practice. This problem is even more acute during BCG maintenance therapy. METHODS: Adverse events in 72 patients who received 518 instillations were prospectively assessed using a four-class scale based on severity and duration. Urinary leukocytes were counted 3 days after each instillation, using the KOVA-Slide 10 method. RESULTS: High leukocyturia during BCG treatment (cutoff value 1.65 x 10(5)/mL urine) correlated with recurrence-free status (P = 0.009). The degree of leukocyturia correlated with the severity/duration of adverse events (P <0.0001); the median leukocyturia values associated with class I, II, and III adverse events were 4 x 10(4)/mL, 1.5 x 10(5)/mL, and 3.5 x 10(5)/mL, respectively. No class IV events occurred. The cutoff point indicating treatment cessation for adverse events was leukocyturia of 8.6 x 10(4)/mL. CONCLUSIONS: These results suggest a link between adverse events and efficacy during BCG maintenance therapy. Leukocyturia appears to correlate with both efficacy and tolerability in this setting. Prospective randomized studies are required to evaluate leukocyturia as a basis on which to adapt the BCG instillation schedule to individual patient susceptibility.

Administration, Intravesical↗
PubMed2001

A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments.

OBJECTIVES: To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments. PATIENTS AND METHODS: All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging. RESULTS: Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P < 0.08) and the need for delayed surgical intervention (nine vs two, P < 0.01) between patients with and with no devitalized segments, respectively. Urinary extravasation spontaneously resolved in two of 11 patients with and in seven of nine with no devitalized segment, respectively (P < 0.05) CONCLUSIONS: Urinary extravasation will resolve spontaneously in most patients with blunt renal trauma, and expectant treatment does not adversely affect the outcome or prolong hospitalization. In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. However, the physician must be especially aware of the probable complications within this subset of patients.

Adolescent↗
PubMed2001

Evaluation of cellular tumour rejection mechanisms in the peritumoral bladder wall after bacillus Calmette-Guérin treatment.

OBJECTIVE: To compare the immunological status of normal and peritumoral bladder walls, and to characterize immunocompetent cells before and during intravesical instillations of bacillus Calmette-Guérin (BCG). PATIENTS AND METHODS: Twenty-three patients with superficial urothelial bladder carcinoma (stages pTa to pT1, grades 1-3) were treated with six weekly instillations of 150 mg of BCG (Pasteur strain). Biopsies of cystoscopically normal bladder wall were taken before, 3 weeks and 3 months after BCG instillation. The controls comprised bladder biopsy specimens from 13 brain-dead ventilated kidney donors. Local infiltrating cell types, i.e. lymphocyte infiltrates (CD4, CD8, CD20, CD3, interleukin-2-receptor-positive, natural killer, gammadelta), macrophages and dendritic cells, adhesion and costimulatory molecules (ICAM-1 and B7-BB1) and major histocompatibility complex (MHC) class I and class II antigens were assessed using semi-quantitative immunohistochemical analysis. RESULTS: Before BCG the peritumoral bladder wall had fewer macrophages than control bladder wall. BCG treatment restored normal numbers of macrophages and enhanced T helper lymphocytes, B lymphocytes, natural killer cells, activated lymphocytes, dendritic cells, normal MHC class I, adhesion (ICAM-1) and costimulatory (B7-BB1) expression. The enhancement of these immunological variables was transient, with a return to baseline 3 months after BCG instillation. CONCLUSIONS: These results support the concept that there is a host-immune escape associated with bladder cancer. BCG therapy may temporarily restore impaired tumour rejection mechanisms in the peritumoral bladder wall, suggesting a need for maintenance therapy after the first course of BCG.

Adult↗
PubMed2001

Clinical significance of cell proliferation, microvessel density, and CD44 adhesion molecule expression in renal cell carcinoma.

Renal cell carcinoma (RCC) is known to have a wide variation in clinical outcome despite the use of conventional prognostic factors, such as staging or grading. A better knowledge of the biologic aggressiveness of RCC could facilitate the selection of patients at high risk of tumor progression. The aim of this study was to determine if use of measurements of vascular density, cell proliferation, and cell adhesion could better predict the biologic behavior of RCC. We immunohistochemically analyzed CD34, Ki-67, and CD44H expression on formalin-fixed, paraffin-embedded tissues from 73 RCCs for quantifying microvessel density (MVD), Ki-67 labeling index (LI), and CD44H LI, respectively. Univariate cancer-specific survival analysis showed that tumor stage (P < .01), tumor size (P < .001), nuclear grade (P < .01), metastasis (P < .001), MVD (P < .03), Ki-67 LI (P < .001), and CD44H LI (P < .0001) were predictors of tumor-related death. There was a statistical correlation between CD44H LI and both Ki-67 LI (r' = .3) and MVD (r' = -44). Ki-67 LI (P < .04) and CD44H LI (P < .02), as well as metastasis (P < .008), emerged as independent predictors of cancer-specific survival in multivariate analysis in patients with metastases (P < .04 and P < .02, respectively) and in patients without metastases (P < .006 and P < .00001, respectively). Our study suggests that vascular density, cell proliferation, and cell adhesion represent a complex tumor-host interaction that may favor progression of RCC. Cell proliferation and CD44H expression appear to be powerful markers to identify patients with an adverse prognosis.

Adult↗
PubMed2001

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE: To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms. PATIENTS AND METHODS: From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years). RESULTS: There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01). CONCLUSION: Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.

Acute Disease↗
PubMed2001

Management of major blunt renal lacerations: is a nonoperative approach indicated?

OBJECTIVES: The aim of the study was to determine whether a nonoperative approach is able to reduce renal parenchymal loss after renal trauma. METHODS: Sixty-four consecutive patients with major blunt renal lacerations were treated from 1988 to 1999. Initial management was conservative. In group 1 (35 patients) delayed hemorrhage, persistent urinoma or hemodynamic instability were dealt with by open surgery. In group 2 (29 patients), most complications were dealt with using endoscopic procedures; open surgery was reserved exclusively for major complications. RESULTS: In group 1, 7 patients were not operated and 28 patients were managed surgically. Twenty (57%) patients underwent total (8) or partial (12) nephrectomy. In 8 patients the surgical intervention was open drainage of perinephric collection (6) and/or renorrhaphies (2). Four patients in this group developed urinary fistulae treated successfully with ureteral stents. Length of hospital stay was 9.6 days (3-25 days). In group 2, persistent hemodynamic instability led to nephrectomy in 1 case. The remaining 28 patients were managed conservatively, with endoscopic ureteric stenting in 5 cases. A persistent urinary extravasation with hyperthermia led to open drainage of perinephric urinoma (5) and renorrhaphy (2). No delayed nephrectomy was necessary. Average hospital stay was 12 days (5-21 days). Only 1 patient in this group developed hypertension. CONCLUSION: For most patients and with close follow-up available, conservative treatment represents a real alternative to open surgery in major blunt renal lacerations. In our experience, open surgery usually results in loss of renal parenchyma.

Adolescent↗
PubMed2001

[Natural history of vascular ports for hemodialysis after renal transplantation].

INTRODUCTION: The objective of this study was to assess the long-term outcome of AV shunts in renal transplant recipients, to discuss mechanisms affecting their functioning and the surgical strategy designed to optimally preserve the venous capital in the hypothesis of a return to dialysis. MATERIALS AND METHODS: 160 renal transplant recipients, with a mean age of 47 years, were reviewed. AV shunts were performed at the wrist in 95% of cases and in the cubital fossa in 13% of cases. The AV shunt had been performed an average of 29 months before renal transplantation. RESULTS: 62% of AV shunts were considered to be functional with a mean follow-up of 69 months after transplantation and 95 months after creation. The intraoperative and early and late postoperative thrombosis rates were 6%, 7.5% and 17%, respectively. The AV shunt was subsequently closed in 12 patients (7.5%). CONCLUSION: Native distal AV shunts, although not used after renal transplantation, have a prolonged survival. The main risk is thrombosis which can be prevented intraoperative and perioperatively. These results encourage a conservative attitude to all well tolerated AV shunts.

Adolescent↗
PubMed2001

[Arterial embolization in hemorrhagic renal angiomyolipoma].

OBJECTIVE: Renal angiomyolipoma (AML) is a rare benign tumour (2-3%) comprising variable proportions of an adipose component, which is often the most abundant, a smooth muscle contingent and a vascular contingent. The objective of this study is to demonstrate the value of embolization of bleeding angiomyolipomas. MATERIAL AND METHODS: 2 patient, aged 22 and 62 years, presented with perirenal haematoma secondary to bleeding angiomyolipoma and were treated by selective arterial embolization. RESULTS: In one case, partial nephrectomy was subsequently performed because of the size of the angiomyolipoma (10 cm). In the other case, attempted partial nephrectomy at 3 months failed due to the proximity of the renal hilum and nephrectomy was performed. CONCLUSION: Beyond a diameter of 4 cm, the risk of perirenal haemorrhage is proportional to the size of the tumour. When surgery is required, selective arterial embolization is the first stage of treatment allowing partial nephrectomy in the majority of cases.

Adult↗
PubMed2001

Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures.

PURPOSE: We assessed the feasibility, reproducibility and morbidity of retroperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. MATERIALS AND METHODS: A total of 55 retroperitoneal laparoscopic pyeloplasties were performed at 3 institutions between September 1996 and May 2000 in 33 women and 21 men. Results were analyzed in regard to radiological assessment by excretory urography at 3 months, complications and hospital stay. RESULTS: We performed dismembered pyeloplasty in 48 cases and Fenger plasty in 7 cases. Crossing vessels were noted in 23 patients. The conversion rate was 5.4%. Mean operative time was 185 minutes (range 100 to 260), mean hospital stay was 4.5 days (range 1 to 14) and mean followup was 14.4 months (range 6 to 43.6). The overall complication rate was 12.7%. Complications in 7 patients included hematoma in 3, urinoma in 1, severe pyelonephritis in 1 and anastomotic stricture in 2 requiring open pyeloplasty at 3 weeks and delayed balloon incision at 13 months, respectively. Excretory urography in 50 patients and ultrasound in 4 showed decreased hydronephrosis in 88.9% at 3 months. Normal physical activity and absent pain were reported by 47 patients (87%) 1 month after surgery. CONCLUSIONS: Retroperitoneal laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for ureteropelvic junction obstruction. The long-term outcome must be assessed before this procedure may be definitively validated.

Adolescent↗
PubMed2001

T helper 1/2 lymphocyte urinary cytokine profiles in responding and nonresponding patients after 1 and 2 courses of bacillus Calmette-Guerin for superficial bladder cancer.

PURPOSE: Interleukin (IL)-2 and interferon-gamma are released during T helper 1 lymphocyte responses and IL-10 is released during T helper 2 lymphocyte responses. We have previously reported that a T helper 1 lymphocyte urinary cytokine profile is associated with a favorable prognosis after bacillus Calmette-Guerin (BCG) treatment. We evaluated the T helper 1/2 lymphocyte cytokine profiles during courses 1 and 2 of 6 weekly BCG instillations. MATERIALS AND METHODS: Urinary interferon-gamma, IL-2 and IL-10 were measured by enzyme-linked immunosorbent assay after each of 6 weekly instillations of 150 mg. BCG, Pasteur strain, in 19 patients with superficial stages Ta and T1 bladder cancer, and carcinoma in situ. The 11 patients who did not respond to course 1 were re-treated according to the same schedule and reevaluated. RESULTS: During course 1 interferon-gamma was higher than during course 2 (p <0.001), which was associated with nonrecurrence (p <0.001). In contrast, IL-2 cytokine was higher after course 2 (p <0.01), which was associated with a BCG response (p = 0.01). Interferon-gamma and IL-10 correlated during courses 1 and 2 (p = 0.04 and 0.0004, respectively). We distinguished groups 1-immediate T helper 1 lymphocyte profile consisting of responders to course 1 with high interferon-gamma, IL-2 and IL-10, 2-delayed T helper 1 lymphocyte profile consisting of responders to course 2 with early high IL-2 and 3-consisting of nonresponders to the 2 courses with low interferon-gamma, IL-2 and IL-10. CONCLUSIONS: A T helper 1 lymphocyte urinary cytokine profile was associated with a clinical response to BCG. A repeat BCG course induces a favorable immune response in a subset of patients, suggesting that maintenance therapy may be beneficial.

Adjuvants, Immunologic↗
PubMed2001

[Urologic management of ureteral iatrogenic lesions].

INTRODUCTION: Iatrogenic trauma of the ureter can occur following pelvic, abdominal or retroperitoneal surgery and during laparoscopy or ureteroscopy. MATERIAL AND METHODS: From 1988 to 1998, 30 patients with 34 iatrogenic ureteric injuries were treated in our department. RESULTS: Patients were referred after a mean of 13 days. Endourological treatment was performed as first-line management in 76% of cases of ureteric trauma, with a 71% immediate success rate. In the case of failure, surgery was performed in 78% of cases, with an 83% success rate. Seven patients required nephrectomy and one patient died. CONCLUSION: First-line endourological treatment gives good results. An early diagnosis remains an essential prerequisite to avoid serious complications.

Humans↗