Objective To investigate the association between intestinal permeability and severity of nonalcoholic fatty liver disease (NAFLD), and the value of intestinal permeability in predicting the efficacy of metabolic therapy for NAFLD. Methods Disease severity was compared between patients with normal and elevated intestinal permeability; correlations between D-lactate and different NAFLD parameters were analyzed; and the effects of metabolic therapy on NAFLD patients with normal and elevated intestinal permeability were evaluated. Results A total of 190 patients with NAFLD were enrolled. NAFLD patients with elevated intestinal permeability had significantly higher levels of liver test parameters, liver ultrasonographic fat attenuation parameter, triglyceride, homeostasis model assessment of insulin resistance value and diamine oxidase (all P˂0.05) than NAFLD patients with normal intestinal permeability. Further, serum D-lactate levels were positively correlated with alanine transaminase, aspartate transaminase, gamma-glutamyl transpeptidase, total bilirubin, indirect bilirubin, fat attenuation parameter, triglyceride, and diamine oxidase (all P˂0.05). Moreover, NAFLD patients with elevated intestinal permeability showed less improvement in TG levels (P=0.014) after metabolic therapy. Conclusion Intestinal permeability correlates with the disease severity in patients with NAFLD. Moreover, intestinal permeability may have value for predicting the efficacy of metabolic therapy for NAFLD patients.

Background: Little is known about the efficacy and safety of single balloon enteroscopy (SBE) in patients with Peutz-Jeghers syndrome (PJS). The aim of this study was to assess the efficacy and safety of SBE for treatment of small bowel polyps in patients with PJS. Methods: We conducted a single center observational study, which included all patients diagnosed with PJS who underwent SBE for polypectomy between January 2018 and March 2021. Complete treatment was defined as the absence of polyps≥20mm after SBE resection. The clinical records were retrospectively reviewed. Results: 102 patients (including 40 men and 62 women) with a mean age of 28.7 years (range 13-55y), were enrolled in our study. The intubation depth via oral approach of patients with history of laparotomy was significantly shorter than that of the patients without history of laparotomy ([241.6±64.2] cm vs [280.9±40.2] cm, P = 0.008). The maximum size of the resected polyps via anus during the second hospitalization was significantly smaller than that during the first hospitalization ([2.25±1.29] cm vs [4.26±3.51] cm, P = 0.032). Complications occurred in 10/129 of hospitalizations (4 delayed bleeding, 3 perforation, and 3 acute pancreatitis). Conclusions: SBE is effective and safe for resection of small bowel polyps in patients with PJS.

Aims It is unclear whether thyroid hormones are associated with functional outcome after ischemic stroke. We aimed to investigate the impact of thyroid hormones at admission on functional outcome at 3 months after acute ischemic stroke. Methods A total of 480 consecutive patients for ischemic stroke within 48 hours of onset were enrolled in this study. Thyroid hormones including thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were measured at admission and functional outcomes were assessed at 3 months with the modified Rankin Scale (mRS) ranging from 0 to 6. Poor outcome was defined as mRS≥3. Results FT3 levels at admission were considerably lower in poor outcome patients than those with good outcome at 3 months (3.53±0.70pmol/L vs 4.04±0.68pmol/L, respectively; P＜0.001). Lower levels of FT3 were observed with higher mRS scores. Multivariable logistic regression analysis revealed that FT3 levels were significantly associated with risk of poor outcome at 3 months independent of conventional risk factors such as age, NIHSS score and recanalized therapy. In addition, patients in the bottom quartile of FT3 levels had a 2.56-fold higher risk of developing poor outcome compared with patients in the top quartile (OR=2.56; 95%CI 1.15-5.69, p =0.021). The sensitivity and specificity of FT3 (≤3.69pmol/L) predicting poor outcome were 62.70% and 72.03% respectively. Conclusion Our study suggests that FT3 levels at admission are significantly and independently associated with risk of poor outcome after ischemic stroke and lower FT3 levels can be regarded as a prognostic biomarker for poor outcome at 3 months.

OBJECTIVE The aim of this study was to access the influence of active warming after epidural anesthesia (EDA) and before general anesthesia in prevention of perioperative hypothermia. METHOD This randomized controlled trial was conducted in the department of anesthesiology in university medical center of Ho Chi Minh city, Vietnam from December 2019 until April 2020. This trial included 60 adult patients who were scheduled for major abdominal surgery with a duration of at least 120 minutes and under combined general anesthesia and EDA. Patients were excluded if age was below 18 years, American Society Anesthesiologists’ physical status classification of IV or higher, or refusal of EDA. Written informed consent was obtained for all patients. Patients were divided randomly into two groups. The first group received 10 minutes of active air-forced warming after EDA before the induction of general anesthesia. The second group was covered with a blanket 10 minutes after EDA and before general anesthesia. Core temperatures were recorded throughout the study. The primary outcome measures were the incidence of perioperative hypothermia and the degree of hypothermia. The secondary outcome measures were rate and time for body temperature to return to normal and incidence of postoperative body shivering. RESULTS Without active warming (n = 21), 70% of patients became hypothermic (<36°C) postoperatively. Active air-forced warming for 10 minutes after EDA and before induction of general anesthesia decreased the incidence of postoperative hypothermia to 26.7% (n = 8). CONCLUSION Active air-forced warming for 10 minutes after EDA and before induction of general anesthesia is efficient in reducing the incidence of perioperative hypothermia.

Objective: The aim of this study was to evaluate the diagnosis of sarcopenia by abdominal tomography, prevelance and prognosis in critical patient admitted to intensive care unit(ICU). Methods: It was planned as a retrospective observational study. Patients older than 40 years of age with abdominal tomography who needed to be in the ICU were included. Muscle mass was measured by abdominal tomography. All patients were divided into two groups as sarcopenic and non-sarcopenic according to the measurement results. We compared the prognosis and clinical features of patients with and without sarcopenia. Results: Fifty five(59%) of all patients were found as sarcopenic and 70.8% over 70 years of age. The length of stay in ICU and in hospital were 27.8 ± 29.7 and 33.0 ± 31.2 days in sarcopenic patients, 15.1±17 and 23.8±21.3 days in nonsarcopenic patients respectively(p <0.05). Thirty day mortality was found 49.1% in patients sarcopenic(<0.05). SMI was found lower over aged 70 years(p <0.05). Conclusions: Sarcopenia was associated with the increasing of 30 day mortality, a prolongation in the lenght of stay in ICU and hospital. Therefore, we believe that awareness about sarcopenia will be important in order to shorten the mortality and lenght of stay in ICU.

Background and aims: The type 2 diabetes mellitus (T2DM) is a common comorbidity of chronic hepatitis C (CHC). This study intended to investigate the impact of direct-acting antiviral agents (DAAs)-induced sustained virological response (SVR) on glycometabolism in CHC patients with T2DM. Methods: We searched PubMed, Scopus, Web of Science, and Embase up to July 7th, 2021. Studies reporting the association between DAA-induced SVR and glycometabolism in diabetic patients were retained. Changes in glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels before DAA treatment and after SVR were conducted meta-analyses with random-effects models. Results: 1371 potentially relevant articles were screened. Our analysis included 16 studies with data for 5024 patients. A significant improvement was noted in glycemic control in SVR group, with a mean HbA1c reduction of 0.57% (95% CI: 0.46–0.69%; I2=72.8%) and FPG reduction of 22.28mg/dL (95% CI: 13.35–31.21mg/dL; I2=96.18%). Conversely, changes of HbA1c in non-SVR group were a mean increase of 0.03% (95% CI: -0.15–0.22%; I2=68.75%). Subgroup analyses about HbA1c and FPG classified by study type both showed decline of the two indicators after SVR, and especially a reduction of HbA1c, 0.52% (95% CI: 0.39–0.65%; I2=73.5%) in retrospective study subgroup and 0.70% (95% CI: 0.54–0.87%; I2=36.15%) in prospective study subgroup, indicating lower heterogeneity in prospective studies. Egger’s test suggested publication bias in impact of DAAs on FPG, and no publication bias in impact on HbA1c. Sensitivity analyses confirmed robustness of the results. Conclusion: The glyco-metabolic control improved in terms of HbA1c and FPG level after DAA-induced SVR. However, further large and well-designed prospective cohort studies are still warranted and a prolonged follow-up is needed.

Background: This study aimed to investigate the risk factors for smoking and negative perinatal outcomes among Jordanian women about smoking status. Methods: A case-control study was conducted among singleton full-term pregnant women who gave birth at the main hospital in Jordan in June 2020. They were divided into three groups according to their smoking status (active, passive and non-smokers) and were interviewed using a semi-structured questionnaire, including demographic information, current pregnancy history, perinatal and neonatal outcomes. The study investigated the effect of smoking status on both independent and dependent variables. Results: Our study revealed that low-level maternal education (OR=25.38), unemployed maternal status (OR=2.67), the absence of following up during pregnancy (OR=5.8), smoking husband were risk factors for smoke exposure among pregnant women. The risk for cesarean section was increased in nulliparous smoking women (OR=9.0), those with low family monthly income (OR=7.8), and those who did not get any information about the hazard effect of smoking (OR=4.38), as well as in unemployed passive smoking women (OR=6.25). Parity of more than one has raised the risk of NICU admission inactive smoking women (OR=10.38). This risk was also increased in active and passive women with a lower level of education (OR=186.33 and OR=17.5), respectively, as well as inactive smoking women with low family monthly income (OR=4.11). Conclusions: Appropriate preventive strategies should focus on modifiable risk factors for smoking during pregnancy.

We studied COVID-19 hospitalisation rates in elderly Maltese residents, aged 80 years and older, after national attainment of 70% first-dose coverage of COVID-19 vaccine in this age cohort. The milestone resulted in almost 50% reduction of hospital admissions, as confirmed by time series modelling using national SARS-CoV-2 infection rates as the comparator. The reduction was not seen in younger, as yet unvaccinated, age groups, where hospital admissions actually increased during the same period following a third wave of infections.

Background: Information regarding the effect of a multidisciplinary team (MDT) to improve cardiometabolic risk factors (CMRF) in routine clinical settings is lacking. Methods: In this one-year retrospective chart review (2018), 598 adults (African American 59%, Hispanic 35%, Caucasian 6%) with a mean age of 43.8 ± 14.0 were included. Qualifying patients (≥ 1 CMRF of overweight/obesity, prediabetes/diabetes, or hypertension) who were treated under an MDT protocol were compared to patients who qualified for MDT but were treated solely by a primary care provider (PCP). The MDT protocol included endocrinology-oriented visits, lifestyle counseling, care coordination, and shared medical appointments. Linear and binary regression were performed to identify the factors associated with CMRF changes. Results: Patients treated by MDT had a greater reduction (β, 95% CI) in weight (- 4.29 kg, -7.62, -0.97), BMI (-1.43 kg/m2, -2.68, -0.18), SBP (- 2.18 mmHg, -4.09, -0.26), and DBP (- 1.97 mmHg, -3.34, -0.60). They also had 77% higher odds of reducing ≥ 5% their initial weight, 83% higher odds of reducing 1 point of BMI, and 59% higher odds of reducing ≥2 mmHg DBP. No association was observed for MDT intervention and A1c changes. Conclusion: Compared to PCP, MDT-protocolized intervention improves CMRF in a multi-ethnic adult cohort in a routine clinical setting. Patient’s activation to access the best care and overcoming barriers from patients (weight perception, social determinants increasing no-shows to visits), providers (obesity stigma, clinical inertia), and health system (time constraints and high paperwork imposed by payers) is a priority.

Background: Diabetes mellitus has been associated with many different musculoskeletal system problems. Objective: This study aims to show the prevalence of musculoskeletal disorders in patients with diabetes and to reveal their relationship to the metabolic parameters and microvascular complications. Methods: Seven hundred two diabetic patients who consecutively applied to our clinic between March 2017 and February 2018 were included in this prospective cross-sectional study. The relationship of the musculoskeletal disorders including carpal tunnel syndrome, Dupuytren’s contracture, adhesive capsulitis, flexor tenosynovitis, limited joint mobility syndrome, Charcot arthropathy, diabetic foot and gout to the patients’ age, gender, type of diabetes, duration of diabetes, metabolic parameters, and microvascular complications were evaluated. Results: Musculoskeletal system disorders were detected in 45.9% (n = 322) of the 702 diabetic patients evaluated in our study. The most common disorders were carpal tunnel syndrome 17.7% (n = 124), Dupuytren’s contracture 14.4% (n = 101), and adhesive capsulitis 13.8% (n = 97). A statistically significant relationship of the HbA1c level with Dupuytren’s contracture, carpal tunnel syndrome, and adhesive capsulitis was detected (p<0.05). Conclusions: Patients’ age, duration of diabetes, HbA1c level, and presence of microvascular complications are associated with musculoskeletal disorders in this population.

Objective: Chemotherapy and radiotherapy, used to treat childhood hematological malignancies (HM), can negatively impact oral tissues and organs. This study aimed to evaluate oral health-related quality of life in children with HM. Material and Methods: A total of 99 children, including 49 undergoing HM (41 for acute lymphocytic leukemia, 8 for acute myelocytic leukemia,) and 50 healthy volunteers, were included in this cross-sectional study. The mean age of the entire study group was 78.63 ± 34.41 months. The mean age of the HM and control groups was 87.12 ± 35.04 and 70.95 ± 34.85 months, respectively. The Simplified Oral Hygiene Index (SOHI), Decayed, Missing, and Filled Teeth (DMFT/dmft) index, and Turkish version of the Early Childhood Oral Health Impact Scale (ECOHIS-T) were administered to all children. The data were analyzed using SPSS software (version 22.0). Results: The age and gender distributions of the two groups were similar. The SOHI was significantly higher in the HM group, whereas the DMFT/dmft score was similar between the groups. No significant difference in the total ECOHIS-T score was observed between the two groups, but there was a group difference in the responses to questions on pain and psychological processes. Conclusions: Oral health and self-care were negatively affected by childhood HM and the treatment thereof. Close clinical dental follow-up of such patients is required.

Aim: The aim of this study was to evaluate the efficacy and side effects of silymarin in the treatment of CIPN. Methods: Patients who referred to outpatient oncology department of a referral educational hospital affiliated to Mazandaran University of Medical Sciences and experienced CIPN were randomized to receive silymarin or placebo. Intervention group received 140 mg of the Silymarin twice daily accompanied and 300 mg/day Gabapentin, whereas control group received 300 mg/day of Gabapentin and placebo twice daily for 3 months. The grade of neuropathy was determined according to the CTCAE criterion. The improvement of neuropathy was defined as the reduction of at least one neuropathic score. The visual analogue scale (VAS) was used to assess the severity of patients’ pain and the EORTC-QLQ-C30 criterion was used to assess the quality of life. Patients were evaluated initially and at the follow up visit 3 months after the enrollment. Results: A total of 80 patients were enrolled in the study. There was no significant difference between the groups in terms of severity of neuropathy at baseline. At the end of the study, the number of people with improved neuropathy in the silymarin group was 82.8% patients, which was significantly higher than 48.4% observed in the patients received placebo (P= 0.005). The silymarin-treated group showed a significant reduction in pain compared with those receiving placebo. Despite the improvement in quality of life in the intervention group compared to the comparison group, this difference was not statistically significant. Gastrointestinal symptoms were the only reported side effects with a similar incidence in two groups. Conclusion: The present data demonstrate the potential clinical use of silymarin as an adjuvant therapy to reduce CIPN symptoms.

Background: Pneumonia is one of the leading causes of mortality and morbidity worldwide. Microbiology tests play a critical role in the diagnosis of pneumonia. Our study aimed to determine microbiology result reporting times and evaluate its association with outcomes of adult patients (≥18 years) hospitalized with pneumonia. Methods: A 3-year (2016-2018) retrospective cohort study in six hospitals in New South Wales, Australia. Study data were obtained by linking hospital and laboratory system databases. Result reporting times including time from admission to the first and the last microbiology test results were determined. The outcome measures were hospital length of stay (LOS) and in-hospital mortality. We fit median and logistic regression to evaluate the association of time-to-first microbiological result with hospital LOS and in-hospital mortality respectively. Results: A total of 6,298 patients met the inclusion criteria. Of these, 85.3% (n=5,375) ordered at least one microbiology test. The top 5 microbiology tests were blood culture, urine culture, respiratory polymerase chain reaction (PCR), urine antigen and sputum culture. The median time-to-first microbiology result was 26 hrs while the median time-to last test result was 144 hrs. The rate of in-hospital mortality was 5.9% (n=371). After adjusting for confounders, every 5 hrs increase in the time to-first microbiology test was associated with an increase of 3.9 hrs in the median hospital LOS [95% Confidence Interval (CI), 3.5 to 4.3; P<0.001]. There was no association between time-to-first microbiology result and in-hospital mortality (OR 1.01; 95% CI 1.00-1.02; P=0.122). Conclusion: Time-to-first microbiology result reporting was significantly associated with hospital LOS but not with in-hospital mortality. Further research should be conducted to understand if improving result reporting times can reduce the length of hospital stay of patients. Key words: Microbiology diagnostics; Test result reporting; Pneumonia; Diagnostic informatics

Introduction: Raynaud phenomenon (RP) is a multifactorial disorder. If any underlying disease cannot be detected responsible for RP then it considered as primary RP (pRP). We aimed to investigate the differences between laboratory markers and impaired endothelial function in pRP. Material and Methods: Forty-two pRP patients included as study and control groups were created from 30 healthy individuals. The endothelial function was evaluated with flow-mediated dilatation (FMD) of the brachial artery. The blood samples were obtained both groups and white blood cell [WBC], hemoglobin, platelet, mean platelet volume [MPV], creatinine, alanine aminotransferase [ALT], aspartate aminotransferase[AST], D-dimer, fibrinogen, albumin, fibrinogen to albumin ratio [FAR], Neutrophil to Lymphocyte ratio [NLR], D-dimer to albumin ratio [DDAR] and monocyte chemo-attractant protein-1 [MCP-1]. Obtained blood parameters and FMD values were compared between groups. Results: The groups were found as similar in regards to age, gender, smoking history (p<0.05). There was no difference between the two groups in regards to hemoglobin, platelet, MPV, creatinine, ALT, D-dimer, albumin, FAR, NLR, DDAR levels (p<0.05). AST levels were slightly higher in pRP group (p=0.027). Markedly increased WBC, fibrinogen, MPV and MCP-1 values were detected in pRP group (p=0.000). Additionally, higher abnormal FMD responses were detected in pRP group (p=0.000). There was a direct correlation between abnormal FMD response and serum MCP-1 values in patients with pRP (R: 0.308, R2: 0.095, p: 0.044). Conclusion: It seems to be that MCP-1 levels are higher in patients with pRP and increased values of MCP-1 levels seem to be related to impaired endothelial functions

Background: The evaluation of solitary lung nodules via FDG PET/CT has high sensitivity for nodules larger than 8 mm and is utilized to exclude lung cancer. Aim: This study aimed to retrospectively explore whether the lesions in patients who underwent F18 fluorodeoxyglucose-positron emission tomography/computed tomography imaging with the staging of the solitary pulmonary nodule and lung mass were within the local imaging area. It also investigated whether a relationship existed between the size of the lung lesion and extrathoracic spread. Materials and Method: Three hundred eight patients histopathologically diagnosed lung cancer were included in this study. All patients lung lesions were measured and patients were classified as four groups according to the size of the lung lesion. In all groups, the F18 FDG PET/CT examination was used to detect liver, adrenal, bone and supraclavicular lymph node metastasis, besides extrathoracic metastasis. Results: Liver, bone and extrathoracic metastasis of group-1 was statistically lower than group-2 (P < 0.001, p<0.01 and P = 0.03, respectively). Liver, extrathoracic, adrenal and bone metastasis of group-3 was statistically lower than the group-4 (P<0.001, P = 0.01, and P = 0.04, p<0.01 respectively). Extrathoracic extension was observed in only one patient in the group-3. In addition liver, adrenal, and bone metastases were not observed in any group-3 patients. Conclusions: PET/CT may be a more appropriate approach to be aplied in cases with nodule diameter ≤20mm. Performing local imaging in patients with a nodule diameter of ≤20 mm could not only reduce radiation exposure but also save radiopharmaceuticals used in PET/CT imaging. Keywords: lung cancer, solitary pulmonary nodule, PET/CT, fluorodeoxyglucos

Abstract: Background: Pneumocystis pneumonia (PCP) incidence in acute myeloid leukemia (AML) patients have not been well described and some studies have shown the risk of this infection in these groups of patients. In this systematic review, we reviewed the published studies about PCP in AML to evaluate the PCP incidence and outcomes in these patients and then focuses on its immunological mechanism. Method: All articles reviewed in this collection are from recruited sites: PubMed and Embase databases. No time limit was considered for article searching. The following keywords were used: (“Pneumonia, Pneumocystis” OR Pneumocystis Pneumonia” OR “Pneumocystis jirovecii”), AND (“leukemia, myeloid, acute OR acute myeloid leukemia”). Our search strategy yielded 356 articles. After implementing the exclusion and inclusion criteria, the final papers were selected and reviewed. Result: By our search, 356 articles were found (316 in PubMed and 40 in Embase). After the implementation of inclusion and exclusion criteria, seven papers remained. A total of seven articles with a total number of 41 patients were included. Conclusion: Affected patients appear to have a clear resistance to PCP infection despite chemotherapy and bone marrow suppression due to the preservation of a specific immunological milieu in the lung. In fact, may be due to immunological stability of the lungs that remains intact. Further studies are needed.

Aims: The COVID-19 pandemic led to hospitals in the United Kingdom substituting face-to-face (FtF) clinics with virtual clinic (VC) appointments. We evaluated the impact of virtual two-week wait (2-ww) lower gastrointestinal (LGI) consultations on stakeholders at a district general hospital in England. Methods: Patients undergoing index outpatient 2-ww LGI clinic assessment between 01/06/2019-31/10/2019 (FtF group) and 01/06/2020-31/10/2020 (VC group) were identified. Relevant data were obtained using electronic patient records. Compliance with national cancer waiting time targets (WTT) was assessed. Environmental and financial impact analyses were performed. Results: In total, 1531 patients were analysed (median age=70, male=852, 55.6%). Of these, 757 (49.4%) were assessed virtually via telephone; the remainder were seen FtF (n=774, 50.6%). Ninety two (6%, VC=44, FtF=48) patients had malignant pathology and 64 (4.2%) had colorectal cancer (CRC); of these, 46 (71.9%, VC=26, FtF=20) underwent treatment with curative intent. The median waiting times to index appointment, investigation and diagnosis were significantly lower following VC assessment (p<0.001). The cancer detection rates (p=0.749), treatments received (p=0.785) and median time to index treatment for CRC patients (p=0.156) were similar. A significantly higher proportion of patients were seen within two weeks of referral in the VC group (p<0.001). VC appointments saved patients a total of 9288 miles, 0.7 metric tonnes of CO2 emissions and £7482.97. Taxpayers saved £80,242.00 from VCs. No adverse events or complaints were reported in the VC group. Conclusion: Virtual 2-ww LGI clinics were effective, safe and were associated with tangible environmental and financial benefits for stakeholders.

Aim- To describe the pattern of clinical presentation of patients with neurofibromatosis in a homogeneous black African population with emphasis on ophthalmological presentation in a multidisciplinary management setting. Methods- Ophthalmology clinic records from the Department of Ophthalmology and database of the Department of Pathology, both of University College Hopsital, Ibadan, Nigeria were reviewed for cases of neurofibromatosis over a 10-year period (Jan 2010 and Dec 2019). Relevant demographic, clinical information, management, complications and patient follow up were extracted from the records and entered into a spreadsheet and analysed. Results - The 34 cases included in this study comprised 19 males (55.9%) and age ranged from 18 months – 60 years, with a median age of 15 years. The male to female ratio was 1.3:1 with approximately 35.3% (12 patients) in the paediatric age group. The most frequent reason for consultation was unilateral progressive painless lid swelling (plexiform neurofibroma) often associated with ptosis. There was a positive family history of neurofibromatosis in 9 out of 32 cases (28.1%). Café au laît macules were observed in 22 out of 25 (88%) of cases. Typical neurofibromas were present in 84.8% of the patients. There was no significant difference in prevalence of plexiform neurofibromas with age (p= 0.05) or sex (p= 0.79). Bone and joint abnormalities was present in 17.6% of the patients. Ophthalmic examination showed conjunctiva changes in 3 cases, prominent cornea nerves in 2 cases. Iris lisch nodules was present in 75.9% of cases that had documentation, cataract in 2 cases and optic atrophy in 6cases.Three patients had ophthalmic pathway gliomas. Patients were managed by multidisciplinary teams depending on their needs. Conclusion- Multidisciplinary team management is advocated because of the multi-system disorders these patient have and the need for holistic, patient centred care that is of good quality, and sustainable.