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J Sváb

Publications and source records attributed to J Sváb.

At least 37 records · Page 2Linked to original sources
PubMed2005

[Intestinal ischaemia--consequence of intestinal malrotation].

The subsets of acute intestinal ischaemia include mesenterica arterial occlusion, venous thrombosis and non-occlusive mesenteric ischaemia. Advances in pathophysiology, diagnosis and treatment, prognostic problems are associated still in mortality rates of more than 60%. Early diagnosis is the first in possibility for better prognosis. In our article is case one young man with acute non-occlusive intestinal ischaemia described, diagnosis and treatment. Mucosal surface necrosis and hemorrhage was supposed, sepsis was expected, mucosal regeneration after ten days surprising. While changes on the bowel were hard to decide to resection, there are bioptic picture of mucosal layer in the time described (Fig. 5-9). We have written about similar case of young man with Waldayer hernia in 1999.

Adult↗
PubMed2004

[Pancreatic carcinoma and diabetes mellitus].

BACKGROUND: The aim of the present study was to evaluate the relationship between Pancreatic Cancer and Type 2 Diabetes Mellitus, which represents a higher risk of many human tumors. In patients with Pancreatic Cancer, Type 2 Diabetes Mellitus occurs approximately in 30%. METHOD AND RESULTS: Fifty patients with newly diagnosed Pancreatic Cancer were analysed in a retrospective pilot study where the staging of the tumor and the case history of the patients were studied. This data were compared in three groups of patients: the control group without diabetes, one with Impaired Fasting Glucose, and patients with Diabetes Mellitus. Incidence of Diabetes Mellitus and that of Impaired Fasting Glucose were also followed in patients with Pancreatic Cancer and Colorectal Cancer. The retrospective study confirmed the late diagnosis of Pancreatic Cancer. The tumors were actually in clinical stage IV in 50% of the patients. Diabetes Mellitus was present in 34% of patients with Pancreatic Cancer; in 44% of these patients the Impaired Fasting Glucose was also diagnosed while the normal glucose status was seen in 22% of patients. Incidence of Impaired Fasting Glucose and that of Diabetes Mellitus in groups of patients with Pancreatic Cancer and Colorectal Cancer was studied. Diabetes Mellitus was present in 12.5% patients with Colorectal Cancer. CONCLUSIONS: In spite of modern diagnostic methods, the early diagnosis of Pancreatic Cancer remains a great problem. Incidence of Diabetes Mellitus in patients with Pancreatic Cancer was significantly higher in comparison with the Colorectal Cancer group (P0.01). A significant number of patients with Impaired Fasting Glucose were also present in the group with Pancreatic Cancer. Analysis of the relationships between Pancreatic Cancer and Impaired Glucose Metabolism could contribute to the early diagnosis of this serious malignant disease.

Adult↗
PubMed2004

[Jejunal perforation by a plastic biliary stent after injury].

The authors present case of patient with biliary stent dislocation after chest injury and fracture of VIII. rib. Polymorbid patient with cirrhosis, chronic pancreatitis, portal hypertension (Child Plugh B) and biliary stent insertion came with acute abdominal pain and inflammatory signs. Progressive signs of acute abdomen have led to laparotomy. Perforation of duodeno-jejunal-loop due to dislocated biliary stent, small loop adhesions and thickened intestine wall were found. Postsurgical period was complicated with obstructive ileus, cholecystitis and cholangiolitis and the second biliary stent was inserted. Present-day status of the patient is satisfactory.

Bile Ducts↗
PubMed2004

[Results of the large intestine resection in elderly patients].

The colorectal carcinoma incidence increases with age. The radical resection procedure significantly extends the survival period, when compared with other therapeutic approaches. The tissue damage may exceed the organ reserve capacity in cases of the elderly patients and may result in higher postoperative morbidity and mortality rates. The aim of this study was to compare the results and the surgical risks of the large intestine carcinoma resection procedure in elderly patients, compared to younger patients with the same diagnosis. THE PATIENT GROUP AND METHODOLOGY: The retrospective study summons up the clinical results of 3778 patients from all over the Czech Republic, who underwent primeoperations for the following diagnoses: C18--a malignant neoplasm of the large intestine, and C19--a malignant neoplasm of the rectosigmoideal junction, in 2001. The results are compared with our own patient group in the same time-period. The results were assessed according to the following age-group criteria: 21-59 yrs., 60-69 yrs. and over 70 yrs. of age. We assessed the following factors: age, diagnosis, incidence of early postoperative complications and duration of patients hospitalization. RESULTS: The patients in the 21-59 year-group and in the group over 70 years of age, had significantly different rates of early postoperative complications (12.3% vs 17.6%, p < 0.001). The rate of complications was twice as high in urgent procedures compared to planned procedures in all age groups (p < 0.001). The average hospitalization lasted 14.8 +/- 10.9 days. We discovered statistically significant differences in the duration of hospitalization among all three age groups respectively (p < 0.01). CONCLUSION: Based on our results, we believe the age itself not be an indication-limiting factor for the radical resection procedure for the large intestine carcinoma. The elderly patients benefit from its oncological radicality with acceptable rates of the postoperative complications risks. We believe even extensive surgical procedures to be feasible in cases of appropriately indicated elderly patients, and their surgical risks to be acceptable considering the expected benefits for the respective patient.

Adult↗
PubMed2003

Surgical treatment of haemorrhoids according to Longo and Milligan Morgan: an evaluation of postoperative tissue response.

OBJECTIVES: To compare by prospective randomised trial the postoperative tissue reaction of stapled vs. conventional haemorrhoidectomy. PATIENTS AND METHODS: Fifty patients with stage III haemorrhoids underwent surgery for haemorrhoids. Group 1 (n = 25) had the Milligan-Morgan procedure; Group 2 (n = 25) had a stapled haemorrhoidectomy. All patients underwent measurements of endothelial dysfunction markers including E-selectin, P-selectin and intercellular adhesion molecule (ICAM). Acute-phase proteins including C-reactive protein, orosomucoid and fibrinogen were also measured. Estimations were made prior to surgery, immediately afterward surgery and on the first and fifth postoperative days. Assessment of clinical outcome was made one month after the surgery. RESULTS: There was a postoperative increase of acute-phase reactants in both groups. The patterns of the cures of the monitored parameters appeared similar in both groups. Lower values were found in Group 1, but the difference was not statistically significant except the level of fibrinogen on day 5, which was significantly higher in Group 2. E-selectin, P-selectin and ICAM showed similar time curves. Statistical analysis found the differences to be significant only when individual days were compared and not for the types of surgery. Raised ICAM and P-selectin on the fifth postoperative day was found in both groups. In Group 1, pain assessment by patients remained in the lower part of the pain rating scale, while in Group 2 it did not start declining until one week after surgery and became normal in the third to fourth weeks. In Group 1, the duration of hospitalization and the duration of incapacity for work were 50% of the values in Group 2. CONCLUSION: Patients having stapled haemorrhoidectomy have less pain and experience more rapid recovery when compared to classical haemorroidectomy. This was mirrored by the acute-phase protein CRP and fibrinogen levels postoperatively. There was no significant difference in other acute-phase reactants monitored, nor was there any difference in parameters of endothelial dysfunction. The techniques differ in extent of pain and duration of hospital stay and incapacity for work.

E-Selectin↗
PubMed2002

[The age of formation of Czech clinical medicine].

Era of Emperor Francis Joseph I is said to be a golden age for the Czech nation. It can be found in numerous panegyric articles to any jubilee of the emperor's rule. What was formally dictated by respect brought by education and by the system of the Greek and Roman tradition adopted in Austria in Middle Ages, seams to be valid today as most of the contemporary technical and economical progress roots within those days. The Czech cultures namely music and art reached international acknowledgement. Though with difficulties, Czech achieved in education and in science as a full-fledged language. After the year 1848 an average citizen was entitled to such freedom as never before. Technical, economical and cultural progress enabled real ascent of the Czech society and its social differentiation. In sixties, after the Austria-Hungary Alignment, Hapsburg government undertook no serious restrains. Such development was nothing unusual. Similar one underwent after the period of storms all European societies from south to north and form west to east. They brought ideas of the French revolution and years 1848/1849 are therefore called "the spring of European nations". In all countries where revolutionary ideas were represented and various countermeasures were accepted, governments were forced to accept temporary arrangements (in Austrian monarchy it was the promise of constitution, language compromise etc.). Nevertheless, in the second half of the 19th century the most important condition for further revival was the long period of peace and stability of international relations. The internal stability of the Austrian monarchy was achieved for long time by the Austria-Hungary Alignment in 1867. After the lost battle at Hradec Kralove in summer 1866 it became clear that contemporary centralistic organization of the state, balancing between absolutism and constitutionalism is not further tenable. Years long pressure of patriotic forces in the parliament brought about division of the Charles-Ferdinand University. Important role in the partition of the Czech Medical Faculty from the German one had the foundation of the Czech Medical Society and the Czech Medical Journal in 1862 patronaged by professors Purkynĕ, Eiselt, Grégr and others. That was the platform for the conception of the Czech medical terminology. Partition of faculties was decided by the law, which was accepted at February 28, 1882. The Czech Medical Faculty was opened only at 1883 because Emperor resolved that professors themselves had to decide to either faculty their clinics would belong. Only professor Eiselt with the First clinic of internal medicine, Weiss with the clinic of surgery and Streng with clinic of obstetrics were assigned to the Czech faculty. Till the official opening on October 15, 1882 all other departments and clinics had to be organized. Though Professor Vilem Weiss as the head of the department and dean of the faculty had his opening Czech lecture already on April 28, 1882, due to material and personal reasons the Czech Medical Faculty was opened only one year later than Faculties of law and philosophy. Most of the eminent members of the Medical faculty remained at the German faculty. However, having higher number of students the Czech faculty became larger and was attended by students from the whole Slavonic world.

Austria↗
PubMed2002

[Organ torsion and abdominal symptoms--case reports].

Torsions are rare acute abdominal conditions and are mistaken for other more frequent diseases. The present work draws attention to the most frequent diagnostic errors. The authors present three cases of torsions of intraabdominal organs and two cases of testicular torsion. All patients attended their doctor because of abdominal pain. In four of five cases the patients were first treated for an erroneous diagnosis of acute abdomen. In the first case the torsion of the omentum was mistaken for diverticulitis of the sigmoid, later for an intraperitoneal lipoma, in he second case for cholecystitis, in the third case a patient with torsion of a myoma was indicated for surgery on account of acute appendicitis. In the fourth case incomplete torsion of the testis was mistaken for irritation of the appendix. In the fifth case where abdominal symptomatology dominated the correct diagnosis of testicular torsion was made and atypically spontaneous detorsion of the testis occurred.

Abdomen, Acute↗
PubMed2002

[The plug system and laparoscopic hernioplasty in recurrent inguinal hernia].

A total of 1511 patients were operated on at the 1st Department of Surgery Charles University in Prague during 1996 through 2000. Of this number, 81.3% underwent surgery for primary and 18.7% for recurrent inguinal hernia. Among the patients with recurrences, 81% had the first, 15% patients the second, and 4% at least the third episode of recurrent hernia. A total of 604 patients were operated on during 1999-2000, when a plug system (Bard Mesh Perfix Plug) was introduced into surgery protocols. Of this number, 113 patients had a recurrent hernia with an identical ratio of recurrences. The following plastic surgery interventions were carried out during the latter period: McVay-Lotheissen (54.2%), TAPP (26.5%), PHS (13.2%), Plug (3.3%), and Lichtenstein (2.6%). The following interventions were used when operating recurrences: McVay-Lotheissen (20.3%), TAPP (31%), PHS (21.2%), Plug (16.8%), and Lichtenstein (9.7%). During the 1-24-month follow-up period, recurrences occurred 1x after the TAPP procedure, 1x after McVay-Lotheissen, and 1x after the Lichtenstein procedure (95% and 88% patients who underwent plug and Lichtenstein procedures, respectively, were included in the follow-up). Comparison of plug vs. TAPP in patients with recurrent hernia (Plug/TAPP): mean age of patients: 62/45 years, length of operation: 66/48 minutes, overall post-operative morbidity: 9.4%/3.6%, hospitalization: 4.3/1.8 days, return to the working process 28 days (range 9-38 days) vs. 7.2 days (range 2-15 days). Both procedures can be considered safe and reliable interventions for treatment of recurrent inguinal hernia. They meet the requirements for elastic strength (more the plug procedure), closure, and bridging of defects even in several layers. The plug system can be implanted under local anaesthesia, it is capable of bridging large defects in a firm and elastic manner, and appears to be a very suitable solution for large defects in patients with advanced biological age. In these indications, the plug system brings many benefits but also the risk of more open access and greater "quantity" of materials. TAPP appears to be more suitable in younger patients with recurrences and large defects. We evaluate favourably in particular, all aspects of the postoperative period. An experienced team of surgeons is needed to achieve good results in both procedures.

Hernia, Inguinal↗
PubMed2002

[AESOP 3000--computer-assisted surgery, personal experience].

At present the most widely used system of CAS is a vocally controlled manipulator of the laparoscope AESOP 3000 (Automated Endoscopic System for Optimal Positioning) which makes it possible to implement some operations without the assistance of another surgeon ("Solo-surgery"). Because of financial costs the so far little used equipment ZEUS or DA VINCI are already "master-slave" systems with several robot arms where the surgeon operates by means of manipulators in the controlling unit without direct contact with the patient. At the First Surgical Clinic, General Faculty Hospital and First Medical Faculty Charles Universitx the authors use the robot system AESOP 3000 since March 2000, in particular in laparoscopic gastric banding on account of obesity, in laparoscopic cholecystectomies, laparoscopic gastroenteroanastomoses and operations in the area if the hiatus. This system made it possible to reduce the number of assisting physicians. E.g. in gastric banding one assistant is sufficient, in laparoscopic cholecystectomy it is possible to operate only with a suture nurse. The application of AESOP is particularly useful in laparoscopic appendectomies and inguinal hernioplasties where it makes possible so-called "solo-surgery" or "one man surgery". No doubt, it is however necessary to have the possibility to call immediately another doctor to the operation theatre in case of necessary conversion of laparoscopy of laparotomy. The authors did not record any case of unwanted movement of the robot arm or another serious technical problem. As compared with a manually guided laparoscope during the use of AESOP the number of unwanted or inadequate shifts of the optical equipment or its angular rotation decreased considerably.

Humans↗
PubMed2002

["Nonsurgical" pneumoperitoneum].

The authors submit case-histories of patients with an X-ray finding of pneumoperitoneum on a native X-ray of the abdomen. Air in the abdominal cavity was proved in the majority of cases also on laparotomy, however, the source of air was not found. The authors mention four cases from their own department. In the first female patient with a generalized gynaecological tumour pneumoperitoneum was diagnosed repeatedly before surgery. In the second case a female patient was involved with an inoperable pancreatic tumour; obstruction of the biliary pathways was resolved by an endoscopically inserted stent. In that case too the pneumoperitoneum was repeatedly detected before surgery. The third patient with a generalized ovarian tumour, acute abdominal pain and pneumoperitoneum died on the second day after operation. Similarly as patient 2 on necropsy thrombosis of the portal vein was found. In the 4th case the finding of pneumoperitoneum was made after diagnostic technically difficult gastroscopy. This patient was not operated. Patients 1-3 were operated without evidence of perforation of the digestive tract. For illustration cases described in the literature are quoted. The causes of non-surgical pneumoperitoneum are classified according to the anatomical site of development. The author describes the assumed mechanisms of development of non-surgical pneumoperitoneum. In the discussion aspects are mentioned which decide on conservative or surgical treatment of pneumoperitoneum.

Aged↗
PubMed2002

[Laparoscopic splenectomy--personal experience].

The authors present an account on their own experience with laparoscopic splenectomy which is used at the First Surgical Clinic, First Medical Faculty and General Faculty Hospital in Prague since 1996. In 1996 to 2002 the authors performed at the Surgical Clinic a total of 66 splenectomies. This number included on account of injury of the spleen, tumour or cyst 12 splenectomies by the open route. The remaining ones were indicated for haematological reasons in collaboration with the haematological department of the First Medical Clinic of the First Medical Faculty and General Faculty Hospital in Prague and the Institute of Haematology and Blood Transfusion in Prague. 23 splenectomies for haematological reasons were made by the classical open route. In 31 patients the splenectomy was performed by the laparoscopic route. In all haematological reasons were involved. In the group operated at the First Surgical Clinic LSE was indicated because of ITP 15x, for spherocytosis 8x, for haemolytic anaemia 7x, for eliptocytosis 1x. In eight patients at the same time laparoscopic cholecystectomy was performed. In the group subjected to classical splenectomy infection in the surgical wound was recorded in 11%, re-operations on account of a suppurative complications in the abdominal cavity were made in 13% and on account of haemorrhage in 11%. In the group of laparoscopic splenectomies the authors did not record infection at the site of the inserted trocars, there were no suppurative complications in the abdominal cavity. In four laparoscopic operations the authors converted the operation on account of haemorrhage four times (11%), once on account of major adiposity of the omentum, in five postoperative revision on account of haemorrhage was necessary (16%), incl. one case of profuse haemorrhage. Therefore the authors sought a way how to prevent haemorrhage. Based on their own experience they recommend to apply clamps to the trunk of the lienal artery. The time of operation was reduced by the application of clamps to the lienal artery to 60-80 mins. and the peroperative blood losses dropped to 20-30 ml. The morbidity declined and the patients are discharged into domiciliary care on the 4th day after operation, to be on the safe side. No late complications of the operation were recorded.

Humans↗
PubMed2002

[P.H.S. (Prolene Hernia System) mesh--initial experience].

In 197 among plastic operations of the groin without tension, using a mesh and new method was added: P.H.S.--Prolene Hernia System--mesh. At the Surgical Clinic of the General Faculty Hospital and First Medical Faculty Charles University in Prague this method is used for plastic operations of the inguinal canal since October 1999. Every year some 300 patients with inguinal hernia are operated, incl. 18.7% operations or multiple relapses. 91% of the group are men and the mean period of hospitalization is 4.9 +/- 3 days. The method "under tension" (McVay, Lotheissen) is used on average in 56.2% patients, in the remainder we use methods "without tension": laparoscopic hernioplasty (TAPP) in 26.7%, Lichtenstein's method in 2.4% and hernioplasty by means of PHS in 14.7% of the patients. Since October 1999 we used it so far in 88 male patients, mean age 55.3 years (2-90 years) with 97 primary or recurrent inguinal hernias. In these patients in 36 instances an indirect hernia was involved (37.1%), a direct hernia was present in 59 patients (60.8%). In two patients we found a saddle hernia (2.1%) and 11 patients (11.4%) had a bilateral hernia. In 12 (12.4%) patients we observed haematoma in the subcutaneous layer in the area of the wound and on the scrotum. In 4 (4.1%) patients there was a seroma in the wound, and subfebrile temperatures up to 38 degrees C were recorded in 9 (9.3%), in 4 patients (4.1%) pain or oedema of the testis developed but receded very rapidly. Postoperative hospitalization lasted on average 2.4 days (1-6 days) and the period before return to normal physical activity was 9.9 days (7-16 days). The patients are checked after regular intervals: 2 weeks, 6 weeks, 6 months, 1 and 2 years. Between October 1999 and February 2002 in the group only one relapse occurred after 6 months.

Adolescent↗
PubMed2002

[History of surgery in the Czech Republic and evolution of Czech surgery clinics].

The author presents a brief of the position of the surgery during centuries in Czech. He mentions the conditions for university education of the surgery since 1848. In 1860 the Czech Medical Society was founded and in 1862 the first issue of the Czech Medical Journal (Casopis lékarů ceských) was published. The first Czech lecture was made on 28th April 1882 on the Czech surgery clinic. The climax of Czech desires of revival was the separation of Czech and German clinics in 1882. The development of some medical disciplines, incl. surgical disciplines, made the surgeons abandon the Czech Medical Society and after the establishment of the committee of the Czechoslovak Republic they founded in 1920 the committee of the Czechoslovak Society for Surgery and Gynaecology. There is explained origin of title MUDr., so typical for graduated students on Prague Medical Faculty. The First Surgery Clinic (founded in 1920) of the Charles University and General Hospital in Prague is continuator of the Czech surgery clinic.

Czech Republic↗
PubMed2002

[Treatment of metastatic liver tumors].

We had operated 72 patients for hepatic metastatic malignancies from 1991 to 2000. In 66 cases were colorectal metastases. Extend of operations were from no anatomical resections, segmentectomies to hemihepatectomies. Operating lethality was 5.5% and long time survival only 10%. In the same period we took arterial port for 22 patients for regional chemotherapy. Response rate was 20% patients. The first experience with radiofrequency ablation (we had 12 ablation procedure) show, that minimal invasive treatment (RFA) is good procedure for high-risk patients. If the patient is able to hepatic resection it will be still standard for treatment.

Humans↗
PubMed2002

[Choice of surgical procedure in operations for chronic pancreatitis--personal experience].

The First Surgical Clinic of the First Medical Faculty of Charles University and General Faculty Hospital in Prague made operations of the pancreas ever since 1971. In the work sooner or later all approaches to surgical treatment pancreatitis were reflected. The authors present a brief review of results and their own experience since 1994 when duodenum-sparing operations were introduced. Indications for surgical treatment were based on the diagnosis by US, CT and ERCP, in exceptional case MR, after evaluation by a pancreatologist, roentgenologist and surgeon. The group of patients with chronic pancreatitis was extended by 21 patients from a group operated because of preoperative suspicion of a malignant pancreatic tumour not confirmed during and after surgery. In those Whipple's operation was preformed. The same operation was performed in three patients with chronic pancreatitis with serious changes in the area of the head of the pancreas. In 123 patients a drainage and duodenum sparing operation was preformed, of these in 57 according to Beger, 19 according to Frey, 37 Partington-Rochelle's procedure. The authors record two sepsis postoperative complications after the classical Beger operation and the hospital stay was on average by five days shorter as compared with the classical method of Whipple. When evaluating postoperative complaints and problems (pain, malnutrition, physical constitution and social position) the authors recorded equally favourable results as after non-complicated duodenopancreatectomy. They varied, depending on the patients co-operation round 84-87% while authors consider Beger's operation logical because of the removal of the main tissue mass of the head of the pancreas, responsible for pain, complications caused by fibrosis in the area round the bile duct and duodenum, responsible for the deteriation of the compartment syndrome in the left half of the gland. Its result is destruction of the remainder of exocrine and endocrine tissue. Of 187 operated patients one patient with decompensated diabetes died postoperatively. Based on their own experience the authors do not consider repeated re-operations an absolute contraindication of Beger's operation when conditions permit. A problem is, in their opinion, fibrosis in the vicinity of the pancreas and portal overpressure.

Chronic Disease↗
PubMed2002

[Laparoscopic fundoplication in the treatment of Barrett esophagus].

UNLABELLED: Barrett's esophagus (BE) the serious complication of gastroesophageal reflux disease (GERD) is discussed. BE has been defined as the complete intestinal metaplasia of distal esophagus. The most serious complication of BE is esophageal adenocarcinoma. We present our results with the group of patients with GERD from the years 1998-2000. We prospectively followed 67 patients with GERD (group A) and 8 patients with GERD/BE (group B). All patients underwent laparoscopic fundoplication. The average length of the Barrett's segment was 4.3 cm. Average time of the surgery was 75 min. Nissen fundoplication was used in seven cases in group B, in one case we used Rossetti laparoscopic fundoplication. The postoperative endoscopic controls were performed at two months after surgery and then every one-year. RESULTS: In one case we observed the complete reepithelization with the mixed spinocelullar and columnar components. We didn't observe any one case of histological deterioration. There was on any difference between two groups regarding the subjective complains. Six patients form group B reported complete disappearing of pyrosis. Two patients reported significant improvement, with very rare pyrosis or dysphagia. Our experience (together with the literature) proved the surgical antireflux therapy is very safe, very effective and with very long lasting effect. The effectivity of surgical therapy is increased by the laparoscopy. Described laparoscopic approaches can lead to the reepithelization of Barrett's metaplasia or, at least, they can diminish the symptoms without any long-term medication. Surveillance endoscopy and biopsy are strictly recommended in all patients with BE and also in the patients with BE after antireflux surgery. The intervals depend on the grade of dysplasia in metaplastic epithelium.

Barrett Esophagus↗
PubMed2002

[Results of rectal resection procedures at the First Surgical Clinic of the First Medical Faculty of Charles University].

Conventional surgical techniques play an important role in rectal cancer. Dehiscence of the anastomosis after low anterior resection of the rectum is a serious complication. The incidence of dehiscences can be reduced when known principles of preoperative care are respected but in particular by correct surgical technique. In 92 patients operated for rectal cancer at First Surgical Clinic of Charles University we had six patients (6.5%) with dehiscences of anastomosis. The serious character of this surgical complication can be reduced by a primary derivative stomy. Authors recommend implementing a preventive ileostomy in low resection of the rectum in high-risk patients.

Aged↗