.. Discussion The main result of this study is that CMT1A patients showed

a lower amount and intensity in some daily living activities with respect to the healthy individuals of the control group. Patients carried out a lower number of both ascending and descending steps and sit to stands, and selected a lower speed of walking and step climbing. Moreover, in CMT1A patients, the number of both ascending and descending steps and sit to stands was correlated with muscle strength. From the analysis of generic physical activity indexes, such as total distance covered and number of steps performed during the whole day, it Inhibitors,research,lifescience,medical has been shown that CMT1A patients did not Inhibitors,research,lifescience,medical differ from healthy individuals of the control group. Moreover, both groups spent a similar

amount of time in resting activities. Although there are no studies in the literature measuring daily living activities in CMT1A patients by means of inertial sensors, our results appear to be in contrast with previous observations of Aitkens and colleagues (Aitkens et al. 2005), based on self-reported levels of physical activity, which were lower in patients with various neuromuscular diseases (CMT, myotonic dystrophy, limb-girdle Inhibitors,research,lifescience,medical syndrome) compared to healthy individuals. This discrepancy could be ascribed not only to the inaccuracy of daily activity logs with respect to inertial sensors, but also to the heterogeneity of the patients’ group, which may have included individuals with higher Inhibitors,research,lifescience,medical impairment in physical Selleckchem GSK126 performances than our patients. Even if CMT1A patients covered the same distance and performed the same number of steps as healthy controls, they carried out a lower number of both ascending and descending steps and performed a lower number of sit-to-stand and stand-to-sit transitions, which is one of the most innovative results of this study due to the inertial sensors’ feature of discriminating specific changes in posture and body motions. It can be speculated that CMT1A patients avoid most Inhibitors,research,lifescience,medical demanding tasks requiring

high-intensity contractions of the lower limbs muscles, both eccentric and concentric, Non-specific serine/threonine protein kinase as a consequence of their functional limits. Moreover, the low number of sit to stands means that CMT1A patients have a more sedentary lifestyle that could be one of the reasons to explain the decline in aerobic capacity reported in literature in patients with neuromuscular diseases (Wright et al. 1996; Fowler 2002; Kilmer 2002; El Mhandi et al. 2008). With regard to physical exercise intensity, mean speed of walking and step climbing during the 24-h sessions was significantly lower in CMT1A patients with respect to healthy controls, which is in line with the results of other researchers who measured speed of walking in a laboratory environment (Kalkman et al. 2005; El Mhandi et al. 2008; Menotti et al. 2011).

Of the 2000 students approached, 717 completed the web-based questionnaire (response = 36%);47 of the students frequently working in student bars responded. Sixty-five selleck percent (n = 496) of the respondents were Libraries female and

the median age was 22 years (range 17–59). Of the 717 respondents in the main cohort, 38 students reported parotitis (5.0%, CI 4.4–7.8%), suggesting that 2000 (95%CI 1662–2378) parotitis cases may have occurred among all 37,742 KU Leuven students in a period of seven months. Eighty-two percent (n = 31) and 71% (n = 27) of the cases reported pain while swallowing and earache, respectively. Other symptoms frequently reported by the cases included headache (n = 26; 68%), fever (n = 22; 58%) and fatigue (n = 20; 53%). Two (8%) of the male cases reported orchitis and two (4%) cases reported meningitis; 34 (72%)

MK-8776 manufacturer cases visited a physician and one case was hospitalized. Mumps cases started to occur from October 2012, peaked at the end of December, decreased during the Christmas holidays and exams and re-increased in February 2013 as classes resumed (Fig 3). The median age of cases was 21.5 years (range 18–26) and 53% (n = 25) were male. No significant differences were found between the main cohort and the student bar-cohort. The gender-specific attack rate was 4% for females and 9% for males (RR: 2.1, 95%CI 1.2–3.7). The duration of mumps symptoms ranged from 1 to 20 days (median: 6.5 days) while absences from classes ranged from 1 to 20 days (median: 4.4 days). The risk of mumps was higher among students working not in student bars (9/47, 19%) than among others (38/717, 5%, RR: 3.6, 95%CI 1.9–7.0). Even after adjustment for documented immunization status the RR differed significantly from one (adjusted RR: 3.4; 95%CI 1.1–11). Of all study participants, 95% (n = 729) reported their vaccination status. Of those, 3% (n = 30) reported that they had not been vaccinated, 37% (n = 290) reported being vaccinated once and 54% (n = 412) reported being vaccinated twice ( Table 1). For 33% (n = 259) of the respondents, documented vaccination

status was available in the medical files of the KU Leuven. Among those with a documented vaccination status, none were unvaccinated, 5% (n = 12) were vaccinated once and 95% (n = 247) twice. The risk of mumps among students who were vaccinated twice (attack rate 5%) was lower than among those who were vaccinated once (attack rate 17%). The two dose vaccine effectiveness, as compared to a single dose, was estimated at 68% (RR: 0.32, 95%CI −24% to 92%). The risk of mumps among those vaccinated with two doses within the last 10 years (attack rate 3%) was lower than among those vaccinated with two doses ≥11 years earlier (attack rate 9%). The difference was not significant (95%CI 0.10–1.02). Between June 2012 and April 2013, the Flemish region of Belgium reported an increased number of mumps cases, mostly among young vaccinated adults and in cities with universities.

A gradient reverse-phase high-performance liquid chromatography (RP-HPLC) method for itraconazole analysis was based off of the European Pharmacopoeia (EP) 5.0 method for the compound [19]. Briefly, the chromatographic procedure is a stability-indicating EP method for itraconazole

in which the detection has been modified for use Inhibitors,research,lifescience,medical with a diode array. This gradient elution method used a Phenomenex Prodigy ODS (3) 100 angstrom, 4.0 × 100mm, 3μm analytical column with mobile phase A containing 27.2g/L tetrabutylammonium hydrogen sulphate in HPLC grade water and mobile phase B containing acetonitrile and used a flow rate of 1.5mL/min with the following gradient conditions: 0 to 20min, 20 to 50% mobile phase B; 20 to 25min, 50% mobile phase B; 25 to 30min, 20% mobile phase B. Itraconazole was detected with a diode array ultraviolet (UV) measurement at 257 +/− 5nm with reference background correction at 375 +/− 25nm and at a retention time of 14.42minutes. A gradient hydrophilic interaction (HILIC)-HPLC method was Inhibitors,research,lifescience,medical used for analysis of zanamivir. Briefly, a Waters Atlantic HILIC Silica 5μm, 4.6 × 100mm analytical column was used with mobile phase A containing 10mM ammonium acetate in 1% methanol and 0.05% Cell Cycle inhibitor phosphoric acid in order to maintain a pH Inhibitors,research,lifescience,medical of 3 to 4 and mobile phase B containing 0.1% phosphoric acid in acetonitrile.

The method used a flow rate of 1.0mL/min with the following gradient conditions: 0 to 2min, 80% mobile phase B; 2 to 7min, 80 to 60% mobile phase B; 7 to 12min, 60% mobile phase B; 12 to 17min, 80% Inhibitors,research,lifescience,medical mobile phase B. Zanamivir was detected by UV measurement at 230nm and at a retention time of 5.52minutes. A gradient super-anionic-exchange-(SAX-) HPLC method was used for analysis of siRNA. Briefly, a Dionex BioLC DNAPac PA 200 4 × 250mm analytical column was used with mobile phase A containing Inhibitors,research,lifescience,medical 25mM NaClO4

and 10mM Tris, 20% ethanol and mobile phase B containing 250mM NaClO4 and 10mM Tris, 20% ethanol, but at a pH of approximately 7.0. The method used a flow rate of 1.0mL/min with a column temperature of 40 degrees C and the following gradient conditions: 0 to 8min, 0–100% mobile phase B; 8 to 10min, 0% mobile phase B. siRNA was detected by UV measurement at 260nm and had a retention time of 6.37 minutes. An isocratic size exclusion chromatography (SEC) method was used for analysis of DNase. Briefly, GE Superdex over 75 5/150 GL column was used with PBS. The method used a flow rate of 0.3mL/min, and the protein was detected by UV measurement at 280nm and at a retention time of 5.14 minutes. In addition to SEC analysis, a DNA-Methyl Green assay was also used to characterize the bioactivity of DNase, as previously performed by others [20]. Briefly, DNA-Methyl Green (Sigma-Aldrich) was solubilized in 0.05M Tris buffer to a concentration of 0.2mg/mL.

clear. This change can be made from one day to the next, (under surveillance for serotonergic syndrome) or after a period without antidepressant (under surveillance for antidepressant withdrawal symptoms). In case of side effects, changing to another antidepressant with a similar pharmacological mode of action entails a high risk of persistence of side effects, except for idiosyncratic conditions such Inhibitors,research,lifescience,medical as allergy. Routine drug monitoring of newer antidepressants in plasma is being

studied, and has very few indications for the present. Obsessive-compulsive disorder stands apart, since improvement can occur progressively over the course of 2 to 4 months of antidepressant prescription. Choosing the second antidepressant Prescribing an antidepressant Inhibitors,research,lifescience,medical for treatment-resistant patients often consists in shifting from one antidepressant to another or in adding a second antidepressant with a different mode of action; this can result in a good therapeutic response. Inhibitors,research,lifescience,medical In cases of severely resistant depressive states, the addition of lithium

or thyroid hormones or atypical antipsychotics constitute the next steps. The prescriptions recommended for antidepressant treatment resistance in case of anxiety disorders are less well established. Deciding on the duration of treatment The duration of newly initiated antidepressant treatment should be at least 6 months, preferably 1 year. This rule prevails for all indications of antidepressants. The risk of relapse is high in cases of dysthymia, panic attacks, and obsessive-compulsive disorder. In case of relapse, Inhibitors,research,lifescience,medical a prescription for 2 to 4 Inhibitors,research,lifescience,medical years can be scheduled. However,

some patients might receive antidepressants for many years, when each attempt at lowering and stopping medication is followed by a relapse. Knowledge about the efficacy of long-term prescriptions is limited, and not founded on DAPT cost evidence-based medicine. Addressing further questions Here, we mention a few questions of clinical relevance. What guides the choice of antidepressant? There is no demonstration that any given class of antidepressants is more efficacious than another for the different categories of depression. Major depression with atypical features was considered to respond next better to MAOIs than to other antidepressants. Also, there is no biological test suggesting the choice of one antidepressant over another for a given patient. It is generally recognized that patients who suffer from insomnia or who have a high degree of anxiety might benefit more from antidepressants that facilitate sleep and do not have the risk of inducing anxiety during the first days of treatment. This is sound clinical practice.

Thus, the higher the surfactant percentage for the same lipid level, the higher the solubility in the ME. Considering TMX water solubility (≈0.4μg/mL) [28–30], these systems represent an improvement of around 150000 fold for vehicle 4, which exhibited a solubility of 60mg/g. 3.5. Physicochemical Characterization A significant lowering effect of approximately 1.5 points in pH values was observed when TMX was added. Conductivity

values obtained for the selected compositions correspond to those of o/w MEs [31, 32]. The low this website viscosity values are representative for MEs (Table 2). The differences observed for viscosity values might be the result of the interaction between ME droplets Inhibitors,research,lifescience,medical in oil/water systems. It is expected that PS 80 Inhibitors,research,lifescience,medical hydrophilic chains are strongly hydrated and connected with hydrogen bonds; this allows the interaction between the droplets, thus raising the viscosity values [33]. It is also to remark that the higher PC concentrations in the compositions, the higher viscosity was observed. Table

2 Physicochemical parameters measured in Inhibitors,research,lifescience,medical the selected microemulsions. Data are expressed as mean ± SD (n = 3). All selected formulations were nonbirefringent when analyzed with the polarized microscope, confirming their isotropy. It was concluded that MEs were not electrically charged (z potential equal to 0mV) due to their ionic characteristics and dipolar attributes. Since ME formation process is generally a random stirring process; the resulting Inhibitors,research,lifescience,medical delivery system may result in a polydispersed system in which different droplet sizes can coexist. This information is extremely valuable in practice because both stability and viscosity depend on the drop size distribution [34]. The later in vivo or in vitro behavior depends on this property as well [35]. Results shown in Table 3 are in the typical range for a ME composition with a narrow range of polydispersion as the polydispersity index (PDI) shown [7]. TEM images also confirmed this size distribution (Figure 7) for blank ME N° 2. The Inhibitors,research,lifescience,medical addition of TMX did not significantly

change droplet size of formulations comparing with empty ones, even at the highest TMX (20mM). This is an interesting advantage for the and selected compositions, because the loading of a lipophilic active compound could result in an increase in the droplet size and, eventually, could compromise the system physical stability [35]. Figure 7 TEM photograph of Formulation 2 (×100000; dilution 1:40). Table 3 Mean droplet size for selected empty and loaded microemulsions. PdI: polydispersity index. A short stability testing was carried out with selected formulations. For this purpose, TMX 10mM was loaded in order to achieve a final concentration of approximately 5.10–4M in the culture media as the higher dose, according to literature data [36].

Our health intent and aim is, for pregnancies complicated by a HDP, to improve short- and long-term maternal, perinatal, and paediatric outcomes, and related cost-effectiveness of interventions. The expected benefit of using this guideline is improved outcomes for mother, baby, and child, through evidence-advised Modulators practice. The target users are multidisciplinary maternity care providers from primary to tertiary levels

of health care. GDC-0941 clinical trial The questions that this guideline seeks to address are: • How, and in what setting, should blood pressure (BP) be measured in pregnancy and what is an abnormal BP? The guideline was developed by a methodologist and maternity care providers (from obstetrics, internal medicine, anaesthesia, and paediatrics) knowledgeable about the HDP and guideline development. The literature reviewed included the previous (2008) SOGC HDP guideline and Smad inhibitor its references [3] covering articles until July 2006, as well as updated literature from January 2006 until March 2012, using a search strategy similar to that for the 2008 guideline (and available upon request); a notable addition was exploration of the perspective and interests of patients with a HDP [4]. Literature reviews were conducted

by librarians of the College of Physicians and Surgeons of British Columbia and University of British Columbia, restricting articles to those published in English and French. We prioritized randomized controlled trials (RCTs) and systematic reviews (if available) for therapies

and evaluated substantive clinical outcomes for mothers (death; serious morbidity, including eclampsia, HELLP syndrome, and other major end-organ complications; severe hypertension; placental abruption; preterm delivery; Caesarean delivery; maternal adverse effects of drug therapies or other interventions; and long-term health) and babies (perinatal death, stillbirth, and neonatal death; small for gestational age infants; NICU care; serious no neonatal morbidity, and long-term paediatric health and neurodevelopment). All authors graded the quality of the evidence and their recommendations, using the Canadian Task Force on Preventive Health Care (Appendix Table A1) [5] and GRADE (Level of evidence/Strength of recommendation, Appendix Table A2) [6]. This document was reviewed by the Executive and Council of the SOGC, and the approved recommendations published on the SOGC website as an Executive Summary (www.sogc.com). 1. BP should be measured with the woman in the sitting position with the arm at the level of the heart (II-2A; Low/Strong). BP measurement in pregnancy should use non-pregnancy standardized technique [7] and [8]. BP may be measured by ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) [9], using auscultatory or automated methods [10]. Most clinics and hospitals use aneroid or automated devices.

Tracheo-esophageal fistula following a fall of 3 m was reported once, and was surgically repaired[16]. This was however an intrathoracic esophageal rupture located just above the carina and thought to be caused

by the esophagus and trachea being crushed between the sternum anteriorly and the vertebral column posteriorly. In our case the trauma-mechanism could not be fully clarified. Because no associated lesions were found in the cervical area, direct blunt trauma is probably not the cause of this rupture. Rupture caused by crush against the cervical spine due to flexion-hyperextension injury has never been described without concomitant cervical spine injury. This leaves Inhibitors,research,lifescience,medical an acute rise in intraluminal esophageal pressure as the most probable cause for this rupture. Another lesson that can be learned from this case is the fact Inhibitors,research,lifescience,medical that the leakage was not detected by CT, even after administering

oral contrast. Although no specific physical complaints of the injury were present during initial evaluation and the injury itself was not detected on CT high clinical suspicion was raised due to massive subcutaneous emphysema and pneumomediastinum without injury to the trachea, bronchus or lungs on CT and bronchoscopy. This was the main reason to suspect the diagnosis of esophageal rupture, perform laryngoscopy and to start prophylactic antibiotics and conduct further diagnostics, as recommended earlier by Goudarzi Inhibitors,research,lifescience,medical et al [10]. Contrast-swallow examination and upper esophageal endoscopy are diagnostic modalities of choice in case of suspicion of esophageal rupture[17]. Inhibitors,research,lifescience,medical Delay in diagnosis was introduced in our case

because other, potentially disabling injuries required treatment first. However, no adverse effects were encountered; antibiotics were already initiated and oral nutrition prohibited. Depending on the cause and site of a rupture, treatment is either conservative or interventional. Interventional treatment options consist of surgical repair, esophageal resection, exclusion and diversion of the esophagus and chest drainage with or without repair. However, interventional treatment Inhibitors,research,lifescience,medical is more frequently required in intrathoracic ruptures. In general, most cervical esophageal perforations unlike intrathoracic Adenosine triphosphate perforations can be treated conservatively, especially if the leak is contained and clinical signs are mild[18]. Conservative treatment consists of fluid resuscitation, antibiotics, gastric decompression and food Anti-cancer Compound Library mw restriction. It is reported that 80% of the conservatively treated high esophageal ruptures will heal successfully[18]. In case of contained leakage it is most unlikely that secondary life-threatening complications like mediastinitis develop, which justifies our policy in this case. This case report presents a high cervical esophageal rupture without associated local injuries after a fall from height. As with any other cervical esophageal perforations, early recognition and treatment are of great importance.

Interventions were provided over 30 minutes twice a week for two consecutive weeks, which

is likely to correspond to typical physiotherapy intervention for acute low back pain. In summary, for non-specific acute low back pain there does not appear to be any short-term or medium-term advantage from the addition of Strain-Counterstrain treatment to appropriate analgesic medication, advice, range of motion exercises, and transversus abdominis exercises. Further studies could examine whether a subgroup of individuals with non-specific acute low back pain are more find more likely to benefit from Strain-Counterstrain treatment. Thanks to Deborah Davis, Administrative Officer, Modulators Stanthorpe Health Services, for assistance in administering self-report outcome questionnaires and randomisation of participants. Thanks to Stephanie Valentin, Physiotherapist, for research assistance at The University Microbiology inhibitor of Queensland. Thanks to Alexandra Newcombe, Senior Physiotherapist Warwick Health Services, for pre-study discussion and input.

Thanks to Dr Asad Khan, Senior Lecturer in Statistics, The University of Queensland, for statistical analysis guidance. Ethics: Ethical approval for the study was given by the Toowoomba and Darling Downs Health Service District Human Research Ethics Committee and The University of Queensland Medical Research Ethics Committee. All participants gave written informed consent before data collection began. Competing interests: None declared. “
“Shoulder pain is a common problem. The incidence is 11.6 per 1000 person-years in Dutch general practice (Bot et al 2005), with reports of the prevalence in various populations ranging from 7% to 67% (Adebajo and Hazleman, 1992, Cunningham and Kelsey, 1984, Meyers et al 1982, Reyes Llerena et al 2000). Abnormal scapular position and movement are associated with shoulder pain and glenohumeral joint impingement syndrome

(Cools et al 2003, Kibler, 1998). Scapular dysfunction may arise from musculoskeletal factors – including sustained abnormal posture (Rempel Florfenicol et al 2007), repetitive movements that deviate from normal movement patterns (Madeleine et al 2008), or glenohumeral and scapulothoracic muscle imbalance (Cools et al 2004, Hallstrom and Karrholm, 2006) – or from neurological abnormalities. Co-ordinated activation of the scapular upward rotators is essential for normal scapulohumeral rhythm. Scapular winging is a specific type of scapular dysfunction that has two common causes. One is the denervation of the long thoracic nerve leading to difficulty flexing the shoulder actively above 120°. The second cause is weakness of the serratus anterior muscle.

We evaluated current physician practice, without the use of the CCR, by noting

the number of cases where patients with cervical spine fractures were discharged from the ED without the fracture having been identified. This occurred 14 times during the study and nine of these cases were SB431542 clinically important cervical spine injuries. All these patients returned due to ongoing pain or were recalled by the radiology department one or more days after the initial ED visit. Fortunately, no patient suffered an adverse outcome. In one of the nine clinically important cervical spine injury cases, no radiography Inhibitors,research,lifescience,medical was ordered during the initial visit. In another seven of the nine cases, physicians misread the radiographs as normal and the radiologists subsequently identified the error. In the ninth clinically important cervical spine injury case, the initial radiograph was actually normal. Results from phase IIIa, which Inhibitors,research,lifescience,medical took place in 12 Canadian EDs from 2004 to 2006 (n = 11,824 patients) were recently published [76]. Phase IIIa was a matched-pair cluster design trial which compared outcomes during 12-month ‘before’ and ‘after’ periods at six ‘intervention’ and six ‘control’ EDs, stratified by teaching or community

hospital status. All alert, stable adults presenting after acute, blunt head or neck trauma were enrolled. Sites were randomly allocated to either intervention or control groups. During the intervention-site Inhibitors,research,lifescience,medical after-period, active strategies were employed to implement the CCR into practice, including education, policy, and ‘on-line’ reminders. Outcomes included cervical spine imaging rates and missed injuries. Inhibitors,research,lifescience,medical From the before to after periods, the cervical spine imaging rate had a relative reduction of 12.8% at the six intervention Inhibitors,research,lifescience,medical sites from 61.7% to 53.3% (P = 0.01) but a relative increase of 12.5% at the six control sites from 52.8% to 58.9% (P = 0.03); this

difference between groups was significant (P < 0.001). There were no missed c-spine injuries at the intervention sites. We concluded that, despite low baseline cervical spine imaging ordering rates, active implementation of the CCR by physicians 17-DMAG (Alvespimycin) HCl led to a significant decrease in use of cervical spine imaging without missed injuries or patient morbidity. Widespread use of the CCR for clinical clearance of the c-spine could lead to reduced health care costs and more efficient patient flow in busy EDs. Validation of the CCR by paramedics The validation of the CCR by paramedics took place between 2002 and 2006 in seven EMS systems distributed in three Canadian provinces [77]. The study population consisted of consecutive alert, stable, and cooperative adults transported by ambulance to the local lead trauma hospital after sustaining acute blunt trauma with potential injury to the neck. These are patients for whom standard basic trauma life support (BTLS) protocols require immobilization.

Resources to manage and act on the transmitted information from these patients are vital to the success of home monitoring. Studies have shown that the amount of information in a controlled, limited-time trial setting already seems overwhelming.

The legal implications of timely follow-up of continuously monitored information and the scope of false positives with health care utilizations is a daunting aspect for handling the information. Moreover, the cost of phone monitoring with no reimbursements might make this modality Inhibitors,research,lifescience,medical less lucrative as opposed to using already available ICD/CRT-D technology. Also, the presence of multiple vendors and proprietary Inhibitors,research,lifescience,medical algorithms of each device company poses a challenge in creating a universally simplified approach to implement a structured algorithm. For those who do not need an implantable device, advancements in wearable monitors and Bluetooth transmission of information seems promising, yet with no strong evidence. Patient compliance issues with these technologies might be overcome by emerging piezo crystal sensors. Recently, Benett et al.30 reported the feasibility of

using the EarlySense’s EverOn® (EarlySense, Waltham, MA) under-the-mattress Inhibitors,research,lifescience,medical sensor system to track physiological information such as respiratory rate, heart rate, and movement rate during sleep in three patients. Also, advancements in implantable Inhibitors,research,lifescience,medical wireless technology seen with the pulmonary capillary pressure monitoring device CardioMEMS® (ATM Kinase Inhibitor in vivo CardioMEMS, Inc., Atlanta, GA) and the left atrial pressure monitor HeartPOD™ System (St. Jude Medical, Inc., St. Paul, MN) or Promote® LAP System (St. Jude Medical, Inc., St. Paul, MN) bring us closer to finding the holy grail of home monitoring systems. Attempts at shifting the burden of self management to patients have not been very effective due to the complexity of the therapies and the advancing age of HF patients in the United Inhibitors,research,lifescience,medical States. Between 27–44%

of Medicare enrollees have marginal or inadequate health literacy,31 making this task more challenging. Powell et al.32 in the HART study found that the addition of self-management counseling to an educational intervention did not make a difference in death Chlormezanone or HF hospitalization in patients with mild to moderate HF. Earlier smaller studies also have not shown any convincing evidence for self-management.33-36 Therefore, a strategy that minimizes patient responsibility in monitoring and care might be more pragmatic. All strategies should still aim at having a patient-centered care plan along with stressing patient education.37 Moreover, there is overwhelming evidence that a multidisciplinary approach to HF care reduces hospital readmissions and improves outcomes in these patients.38 Hence, it is recommended in both U.S. and European guidelines.