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Biomedical subjects

Lewis B Morgenstern

Publications and source records attributed to Lewis B Morgenstern.

At least 19 recordsLinked to original sources

Defining cause of death in stroke patients: The Brain Attack Surveillance in Corpus Christi Project.

Stroke mortality is an important national health statistic and represents a frequent endpoint for epidemiologic studies. Several methods have been used to determine cause of death after stroke, but their agreement and reliability are unknown. Two hundred consecutive deaths of transient ischemic attack or ischemic stroke patients were identified (January 2000-September 2001) from an ongoing population-based stroke surveillance study in Texas, The Brain Attack Surveillance in Corpus Christi Project. Two neurologists independently recorded the cause of death based on two methods: 1) determining the underlying cause of death as defined by the World Health Organization, and 2) determining whether the death was stroke related. Kappa statistics with 95% confidence intervals were calculated by comparing agreement between methods within reviewers and between reviewers within methods. Agreement between the two cause-of-death-determination methods for each neurologist was 0.41 (95% confidence interval (CI): 0.31, 0.51) and 0.47 (95% CI: 0.38, 0.58), respectively. Agreement between neurologists for the underlying-cause-of-death method was 0.46 (95% CI: 0.32, 0.60); for the stroke-related method, it was 0.63 (95% CI: 0.52, 0.75). Accurate, reliable determinations of cause of death after stroke/transient ischemic attack are not currently feasible. More research is needed to identify a reliable process for coding cause of death from stroke.

Aged↗

Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study.

BACKGROUND AND PURPOSE: Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study was to determine the "real-world" proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS). METHODS: From a population-based study, patients >44 years of age presenting with DS to the emergency department, or directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms) were assessed. Multivariable logistic regression was used to evaluate the association of age, gender, ethnicity, and isolated DS with stroke/transient ischemic attack (TIA). The association of the presenting symptoms with stroke/TIA was also assessed. RESULTS: Stroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA (69.3+/-11.7 vs 65.3+/-12.9, P=0.02). Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA. CONCLUSIONS: The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA.

Aged↗

Stroke information reported on local television news: a national perspective.

BACKGROUND AND PURPOSE: Local television news commonly reports on health. This study aimed to characterize local TV news stroke reporting in America. METHODS: Content analysis of stroke stories reported on 122 US local television stations. All stroke stories were coded for main focus and discussion of risk factors, stroke signs and symptoms, recombinant tissue plasminogen activator, treatment within 3 hours, or recommendation to call 911. RESULTS: Of the 1799 health stories, only 13 stroke stories aired, and the median story length was 24 seconds (interquartile range 21 to 48). Stroke was the 22nd most common health topic. Few stroke stories discussed useful information about prevention or treatment of stroke. CONCLUSIONS: Stroke stories were nearly nonexistent in our sample, and those reported failed to discuss important messages needed to improve stroke prevention and treatment.

Antioxidants↗

Ethnic differences in stroke recurrence.

OBJECTIVE: To determine whether stroke recurrence and the effect of recurrence on mortality differ by ethnicity. METHODS: Using methods from the Brain Attack Surveillance in Corpus Christi project, we prospectively identified first-ever ischemic strokes from emergency department logs and hospital admissions (January 2000 to December 2004). Recurrent strokes and deaths were identified for the same period. Cumulative probability of stroke recurrence was estimated. Cox proportional hazards models were used to examine ethnic differences in recurrence and to examine the relation among ethnicity, recurrence, and mortality. RESULTS: During the time interval, 1,345 first-ever ischemic strokes were validated. Median age of patients was 72 years; 53% were Mexican American (MA). There were 126 recurrent strokes. Cumulative risk for recurrence at 30 days and 1 year was 2.6 and 7.5%, respectively. MAs had higher risk for stroke recurrence (risk ratio, 1.57; 95% confidence interval, 1.05-2.34) compared with non-Hispanic white patients, adjusted for demographics, stroke risk factors, and stroke severity. Stroke recurrence was related to mortality to a similar extent across ethnic groups (non-Hispanic white patients: risk ratio, 3.32; 95% confidence interval, 2.07-5.32; MAs: risk ratio, 2.35; 95% confidence interval, 1.42-3.88). INTERPRETATION: MAs had higher stroke recurrence risk compared with non-Hispanic white patients. Stroke recurrence had an important impact on mortality. Efforts to reduce stroke recurrence in MAs are needed.

Age Factors↗

Family history and stroke outcome in a bi-ethnic, population-based stroke surveillance study.

BACKGROUND: The genetic epidemiology of ischemic stroke remains relatively unstudied, and information about the genetic epidemiology of ischemic stroke in populations with significant minority representation is currently unavailable. METHODS: The Brain Attack Surveillance in Corpus Christi project (BASIC) is a population-based stroke surveillance study conducted in the bi-ethnic community of Nueces County, Texas, USA. Completed ischemic strokes were identified among patients 45 years or older seen at hospitals in the county between January 1, 2000-December 31, 2002. A random sample of ischemic stroke patients underwent an in-person interview and detailed medical record abstraction (n = 400). Outcomes, including initial stroke severity (NIH stroke scale), age at stroke onset, 90-day mortality and functional outcome (modified Rankin scale > or = 2), were studied for their association with family history of stroke among a first degree relative using multivariable logistic and linear regression. A chi-square test was used to test the association between family history of stroke and ischemic stroke subtype. RESULTS: The study population was 53.0% Mexican American and 58.4% female. Median age was 73.2 years. Forty percent reported a family history of stroke among a first degree relative. Family history of stroke was borderline significantly associated with stroke subtype (p = 0.0563). Family history was associated with poor functional outcome in the multivariable model (OR = 1.87; 95% CI: 1.14-3.09). Family history was not significantly related to initial stroke severity, age at stroke onset, or 90-day mortality. CONCLUSION: Family history of stroke was related to ischemic stroke subtype and to functional status at discharge. More research is needed to understand whether stroke subtype would be a useful selection criterion for genetic association studies and to hypothesize about a possible genetic link to recovery following ischemic stroke.

Aged↗

Gender comparisons of diagnostic evaluation for ischemic stroke patients.

BACKGROUND: Sixty-two percent of all stroke deaths in the United States occur in women. We compared diagnostic evaluations by gender in ischemic stroke patients in a biethnic, population-based study. METHODS: A random sample of patients with ischemic stroke identified between 2000 and 2002 by BASIC (Brain Attack Surveillance in Corpus Christi Project) were selected for this study (n = 381). Gender differences in the use of stroke diagnostic tests were assessed. Separate multivariable logistic regression models predicting diagnostic test use were constructed, adjusted for age, ethnicity, hypertension, atrial fibrillation, diabetes, history of stroke, coronary artery disease, having a primary care provider, discharge disposition, modified Rankin Scale score at discharge, and insurance status. RESULTS: The study population consisted of 161 men and 220 women. Median age was 74.3 years. The respective proportions of males and females receiving any carotid artery evaluation were 71% and 62%; brain MRI, 43% and 41%; echocardiography, 57% and 48%; and EKG, 90% and 86%. Multivariable logistic models found that women were less likely to undergo echocardiography (odds ratio [OR] 0.64, CI: 0.42 to 0.98) and carotid evaluation (OR 0.57, CI: 0.36 to 0.91). There was no association of ischemic stroke subtype and gender to explain these results (p = 0.76). CONCLUSIONS: Despite controlling for explanatory variables, women with stroke were less likely to receive standard diagnostic tests vs men. Intervention is needed to increase access to quality stroke care for women.

Aged↗

Is it time for a large, collaborative study of pediatric stroke?

BACKGROUND AND PURPOSE: A 2002 report from the National Institute of Neurological Disorders and Stroke cited the critical importance of more childhood stroke studies. We present the incidence rate of pediatric stroke from a biethnic community-based project and calculate the population size required for future prospective studies of pediatric stroke. METHODS: This work is part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. The community of 325,000 is located in southeast Texas and is composed of approximately equal numbers of Mexican Americans (MAs) and non-Hispanic whites (NHWs). Discharge diagnosis codes from all hospitals in the county were used to identify cases of childhood stroke (age >1 month and <20 years) in 2002 and 2003, and stroke cases were validated by source document review. On the basis of the incidence rates, the population size required to complete a case-control study to examine risk factors for pediatric stroke was calculated. RESULTS: Eight cases of pediatric stroke were identified, yielding an annual incidence rate of 4.3 per 100,000 (95% CI, 1.9 to 8.5). There were 5 cases of intracerebral hemorrhage, 1 subarachnoid hemorrhage, 1 ischemic stroke, and 1 transient ischemic attack. All of the events occurred in MAs. Depending on the prevalence of the risk factors of interest, future studies of pediatric stroke would have to draw from a population of up to 59 million children to complete a case-control study within 4 years. CONCLUSIONS: Given the rarity of pediatric stroke, future studies will require multicenter efforts and possibly a national surveillance system.

Adolescent↗

Stroke burden in Mexican Americans: the impact of mortality following stroke.

PURPOSE: To estimate ethnic-specific all-cause mortality risk following ischemic stroke and to compare mortality risk by ethnicity. METHODS: DATA from the Brain Attack Surveillance in Corpus Christi Project, a population-based stroke surveillance study, were used. Stroke cases between January 1, 2000 and December 31, 2002 were identified from emergency department (ED) and hospital sources (n = 1,234). Deaths for the same period were identified from the surveillance of stroke cases, the Texas Department of Health, the coroner, and the Social Security Death Index. Ethnic-specific all-cause cumulative mortality risk was estimated at 28 days and 36 months using Kaplan Meier analysis. Cox proportional hazards regression was used to compare mortality risk by ethnicity. RESULTS: Cumulative 28-day all-cause mortality risk for Mexican Americans (MAs) was 7.8% and for non-Hispanic whites (NHWs) was 13.5%. Cumulative 36-month all-cause mortality risk was 31.3% in MAs and 47.2% in NHWs. MAs had lower 28-day (RR = 0.58; 95% CI: 0.41, 0.84) and 36-month all-cause mortality risk (RR = 0.79, 95% CI: 0.64, 0.98) compared with NHWs, adjusted for confounders. CONCLUSIONS: Better survival after stroke in MAs is surprising considering their similar stroke subtype and severity compared with NHWs. Social or psychological factors, which may explain this difference, should be explored.

Aged↗

Major risk factors for intracerebral hemorrhage in the young are modifiable.

BACKGROUND AND PURPOSE: To identify risk factors for intracerebral hemorrhage (ICH), we examined data from the Hemorrhagic Stroke Project (HSP), a case-control study of hemorrhagic stroke among men and women aged 18 to 49 years. METHODS: Case subjects for the HSP were recruited from 44 hospitals in the United States. Eligibility criteria included an ICH within 30 days preceding enrollment, no history of stroke or known brain lesion. For this report, we focused on patients with primary ICH, defined as not associated with an aneurysm, arteriovenous malformation or other structural lesion. Two control subjects were sought for each case subject. A multivariate regression analysis was performed to determine risk factors for primary ICH. RESULTS: A total of 1714 patients with hemorrhagic stroke were identified for participation in the HSP. Of these, 217 cases met the criteria for primary ICH. Cases with primary ICH were matched to 419 controls. Independent risk factors for ICH included hypertension (adjusted odds ratio [OR], 5.71; 95% CI, 3.61 to 9.05), diabetes (adjusted OR, 2.40; 95% CI, 1.15 to 5.01), menopause (adjusted OR, 2.50; 95% CI, 1.06 to 5.88), current cigarette smoking (adjusted OR, 1.58; 95% CI, 1.02 to 2.44), alcoholic drinks> or =2/day (adjusted OR, 2.23; 95% CI, 1.16 to 4.32), caffeinated drinks> or =5/day (adjusted OR, 1.73; 95% CI, 1.08 to 2.79), and caffeine in drugs (adjusted OR, 3.55; 95% CI, 1.24 to 10.20). CONCLUSIONS: Among young men and women, the major risk factors for primary ICH can be modified, suggesting that this type of stroke may be preventable. Our findings for caffeine and menopause warrant further study.

Adolescent↗

Screening for obstructive sleep apnea in stroke patients: a cost-effectiveness analysis.

BACKGROUND AND PURPOSE: Obstructive sleep apnea (OSA) is common after acute ischemic stroke and predicts poor stroke recovery, but whether screening for OSA and treatment by continuous positive airway pressure (CPAP) improves neurological outcome is unknown. We used a cost-effectiveness model to estimate the magnitude of benefit that would be necessary to make polysomnography (PSG) and OSA treatment cost-effective in stroke patients. METHODS: A decision tree modeled 2 alternative strategies: PSG followed by 3 months of CPAP for those found to have OSA versus no screening. The primary outcome was the utility gained through OSA screening and treatment in relation to 2 common willingness-to-pay thresholds of $50,000 and $100,000 per quality-adjusted life year (QALY). RESULTS: Screening resulted in an incremental cost-effectiveness ratio of $49,421 per QALY. Screening is cost-effective as long as the treatment of stroke patients with OSA by CPAP improves patient utilities by >0.2 for a willingness-to-pay of $50,000 per QALY and 0.1 for a willingness-to-pay of $100,000 per QALY. CONCLUSIONS: A clinical trial assessing the effectiveness of CPAP in improving stroke outcome is warranted from a cost-effectiveness standpoint.

Cost-Benefit Analysis↗

Recurrent stroke risk is higher than cardiac event risk after initial stroke/transient ischemic attack.

BACKGROUND AND PURPOSE: Patients with ischemic stroke and transient ischemic attack (TIA) are at risk for recurrent cerebrovascular and cardiac events. Understanding which of these adverse events is more likely to occur next is instructive for preventive therapy planning. METHODS: Subjects (n=1923) were identified from a sample of hospital discharges from administrative claims for the Michigan Medicare population from January 2001 to June 2001 using International Classification of Diseases, 9th Revision codes for ischemic stroke/TIA. Outcomes (cardiac events, myocardial infarction [MI], percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass grafting [CABG] and ischemic strokes) were identified for 2001 to 2003. Comparison between cardiac and stroke as secondary events were made using cumulative incidence estimates. RESULTS: Over the follow-up period, 172 patients had a cardiac event (62.8% MI, 7.6% CABG, 14.5% PTCA, 9.3% MI and PTCA, and 5.8% MI and CABG) and 239 had a stroke as their first event. Cardiac event at 2 years had occurred in 7.7%, and stroke occurred in 11.8%. CONCLUSIONS: The risk of stroke after initial stroke/TIA is higher than the risk of cardiac events. The propensity after stroke/TIA to have the first recurrent ischemic event in the brain, rather than in the heart, has implications for prophylactic therapy selection.

Aged↗

Safety and feasibility of a lower dose intravenous TPA therapy for ischemic stroke beyond the first three hours.

BACKGROUND: The most common reason that patients do not receive intravenous tissue plasminogen activator (TPA) is the inability to meet the strict 3-hour treatment window. The risk/benefit ratio is more unfavorable beyond this time, but some patients might still benefit. We designed a pilot study with the hypothesis that lower dose TPA might be safe in selected patients treated beyond 3 h. SUBJECTS AND METHODS: To determine the range of symptomatic hemorrhage and good outcome, we prospectively gave i.v. TPA 0.6 mg/kg up to 60 mg (15% bolus, 85% infusion over 30 min) to patients with ischemic stroke beyond the first 3 h after last known to be normal. Other eligibility criteria were: NIH Stroke Scale > or =4, normal head CT scan, and clinical suspicion or transcranial Doppler (TCD) evidence of a proximal arterial occlusion. RESULTS: 28 patients were treated, median age 65 (range 24-88) years, median baseline NIHSS score 18 (range 7-34) points. TPA bolus was given 372 +/- 158 min after stroke onset (range 189-720). Symptomatic hemorrhage occurred in 3/28 (11%) patients, including 1 fatal bleed. Overall mortality was 6/28 (21%). Partial or complete recanalization was found in 8/20 (40%) TCD monitored patients within 2 h after TPA bolus. Early major improvement occurred in 4/28 (14%) patients. CONCLUSIONS: Lower dose i.v. TPA in patients presenting beyond 3 h carries a risk of intracerebral hemorrhage. However, recanalization with dramatic recovery can still occur.

Adult↗

Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke.

STUDY OBJECTIVE: The use of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke is controversial among emergency physicians. We survey emergency physicians to determine (1) the proportion of emergency physicians resistant to using rt-PA in the ideal setting because of the risk of symptomatic intracerebral hemorrhage; (2) the proportion of emergency physicians resistant to using rt-PA in the ideal setting because of the perceived lack of benefit; (3) the highest acceptable symptomatic intracerebral hemorrhage risk; and (4) the lowest acceptable accompanying relative improvement in neurologic outcome. METHODS: The American College of Emergency Physicians randomly selected 2,600 of its active members for anonymous Web-based or paper survey. The proportion of ED physicians resistant to rt-PA use because of symptomatic intracerebral hemorrhage risk and perceived lack of benefit, in addition to the mean acceptable symptomatic intracerebral hemorrhage risk and associated benefit, was calculated with 95% confidence intervals (CIs). Multivariable logistic regression was used to identify factors independently associated with willingness to use rt-PA in the ideal setting. RESULTS: The median age of the 1,105 (43%) respondents was 44 years. Overall, the mean upper limit of symptomatic intracerebral hemorrhage tolerable was 3.4% (95% CI 3.2% to 3.5%), with associated lowest acceptable mean relative improvement of 40% (95% CI 39% to 41%). Forty percent (95% CI 37% to 44%) of physicians reported that they were not likely to use rt-PA. Of these, 65% (95% CI 61% to 69%) of physicians reported this was because of the risk of symptomatic intracerebral hemorrhage, 23% (95% CI 19% to 27%) reported the cause was the perceived lack of benefit, and 12% (95% CI 9% to 15%) reported both reasons were the cause. Independently associated with willingness to use rt-PA were female sex (odds ratio 2.30 [1.57, 3.36]) and previous use of rt-PA for stroke (3.13 [2.33, 4.17]). CONCLUSION: Symptomatic intracerebral hemorrhage risk is the factor most likely to preclude rt-PA use by emergency physicians. Of the 40% of physicians who would not use rt-PA, about two thirds reported this was due to symptomatic intracerebral hemorrhage risk, and about a quarter of physicians cited the relative lack of benefit. Treatment trials that aim to reduce symptomatic intracerebral hemorrhage risk to 2% to 3% are likely to stimulate the interest of emergency physicians in the use of thrombolytics for acute ischemic stroke.

Acute Disease↗

Family history of stroke among Mexican-American and non-Hispanic white patients with stroke and TIA: implications for the feasibility and design of stroke genetics research.

Family history of stroke may differ by ethnicity. This study examined the associations of ethnicity and stroke risk factors with family history of stroke using data from the Brain Attack Surveillance in Corpus Christi Project. A random sample of stroke/transient ischemic attack cases was interviewed about family history of stroke (n = 524). Thirty-six percent of the cases reported a family history of stroke, with 26% reporting a parental and 13% a sibling history. Compared to non-Hispanic whites (NHWs), Mexican-Americans (MAs) were two times (OR = 2.07; 95% CI: 1.09-3.95) more likely to have a sibling with stroke. More MAs (8.1%; 95% CI: 4.6-11.6) had living siblings with stroke compared to NHWs (1.9%; 95% CI: 0.1-3.8). Since MAs are more likely to have living siblings with stroke compared with NHWs, MAs may be a more feasible population for family stroke studies than predominantly white populations.

Aged↗

Excess stroke in Mexican Americans compared with non-Hispanic Whites: the Brain Attack Surveillance in Corpus Christi Project.

Mexican Americans are the largest subgroup of Hispanics, the largest minority population in the United States. Stroke is the leading cause of disability and third leading cause of death. The authors compared stroke incidence among Mexican Americans and non-Hispanic Whites in a population-based study. Stroke cases were ascertained in Nueces County, Texas, utilizing concomitant active and passive surveillance. Cases were validated on the basis of source documentation by board-certified neurologists masked to subjects' ethnicity. From January 2000 to December 2002, 2,350 cerebrovascular events occurred. Of the completed strokes, 53% were in Mexican Americans. The crude cumulative incidence was 168/10,000 in Mexican Americans and 136/10,000 in non-Hispanic Whites. Mexican Americans had a higher cumulative incidence for ischemic stroke (ages 45-59 years: risk ratio = 2.04, 95% confidence interval: 1.55, 2.69; ages 60-74 years: risk ratio = 1.58, 95% confidence interval: 1.31, 1.91; ages >or=75 years: risk ratio = 1.12, 95% confidence interval: 0.94, 1.32). Intracerebral hemorrhage was more common in Mexican Americans (age-adjusted risk ratio = 1.63, 95% confidence interval: 1.24, 2.16). The subarachnoid hemorrhage age-adjusted risk ratio was 1.57 (95% confidence interval: 0.86, 2.89). Mexican Americans experience a substantially greater ischemic stroke and intracerebral hemorrhage incidence compared with non-Hispanic Whites. As the Mexican-American population grows and ages, measures to target this population for stroke prevention are critical.

Age Distribution↗

Stroke risk after transient ischemic attack in a population-based setting.

BACKGROUND AND PURPOSE: Stroke risk after transient ischemic attack (TIA) has not been examined in an ethnically diverse population-based community setting. The purpose of this study was to identify stroke risk among TIA patients in a population-based cerebrovascular disease surveillance project. METHODS: The Brain Attack Surveillance in Corpus Christi (BASIC) Project prospectively ascertains stroke and TIA cases in a geographically isolated Southeast Texas County. The community is approximately half Mexican American and half nonHispanic white. Cases are validated by board-certified neurologists using source documentation. Cumulative risk for stroke after TIA was determined using Kaplan-Meier estimates. Cox proportional hazards regression was used to test for associations between stroke risk after TIA and demographics, symptoms, risk factors, and history of stroke/TIA. RESULTS: BASIC identified 612 TIA cases between January 1, 2000, and December 31, 2002; 60.9% were female and 48.0% were Mexican American. Median age was 73.8 years. Stroke risk within 2 days, 7 days, 30 days, 90 days, and 12 months was 1.64%, 1.97%, 3.15%, 4.03%, and 7.27%, respectively. Stroke risk was not influenced by ethnicity, symptoms, or risk factors. CONCLUSIONS: Using a population-based design, we found that early stroke risk after TIA was less than previously reported in this bi-ethnic population of Mexican Americans and nonHispanic whites. Approximately half of the 90-day stroke risk after TIA occurred within 2 days.

Aged↗

Treatment of acute intracerebral hemorrhage with epsilon-aminocaproic acid: a pilot study.

INTRODUCTION: Up to 40% of primary intracerebral hemorrhages (ICHs) expand within the first 24 hours (natural history). The authors aimed to study the safety and preliminary efficacy of epsilon-aminocaproic acid (EACA) in halting ICH enlargement. METHODS: Consecutive patients with hematoma volumes ranging from 5 to 80 mL were recruited within 12 hours of ICH onset. A total of 5 g EACA was infused during 1 hour and then 1 g/hour for 23 hours. Hematoma volume was compared on baseline, and 24-48-hour brain imaging. Consecutive untreated patients underwent the same imaging protocol. RESULTS: Three of the first five patients treated had HE>33% of their baseline volume. HE occurred in two of the nine untreated patients. The 80% confidence interval for HE in the treated patients was 32-88%. No thrombotic or other serious adverse events were attributed to EACA. CONCLUSION: It is unlikely that the rate of HE in patients given EACA within 12 hours of ICH is less than the natural history rate, although this treatment appears to be safe.

Acute Disease↗