Sometimes WHO representatives may also participate in the working

groups. After assessing all available data, the committee will reach consensus and recommendations will be made. If consensus proves impossible, the matter will be sent to the MoH, to make the final decision. Agreed Selleck EX-527 recommendations are forwarded to the ultimate decision-makers within the MoH and then widely circulated via circulars and newsletters. It should be noted that to date the committee has always followed official WHO recommendations for vaccine use. Formal contact between the committee members and similar NITAGs in the Gulf Cooperation Council (GCC) countries is facilitated through an annual inter-country Selleckchem Natural Product Library meeting on communicable diseases that includes all the countries of the GCC. This comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab

Emirates and Yemen. Half of the meeting each year is devoted to discussing issues concerning the Expanded Programme on Immunization (EPI), including the introduction of new vaccines and immunization issues. In 2007, it was recommended that GCC countries would have a common EPI schedule, a decision validated by all NITAGs in GCC countries and then approved by the relevant Ministers. As of 1 January 2008, the decision was implemented. The cost of vaccines, as well as that of the overall immunization program, is considered when the committee decides on its recommendations. Formal economic evaluations are made (cost-effectiveness, cost-benefit and cost-utility) and both affordability and sustainability are assessed. Subcommittees, with the assistance of health economic experts from within the MoH, assist in making these evaluations—for example, an economic evaluation of rotavirus vaccine disease burden was undertaken. They are currently assessing the human papillomavirus (HPV) disease burden from an economic

perspective. Additionally, assessments made regionally are taken into account, particularly when provided by WHO’s Eastern Mediterranean Regional Office (EMRO) or from other GCC countries, such as in the case of cost-effectiveness studies on HPV. Recommendations are circulated to all members to receive their comments, after which they are sent below to decision-makers for final approval. The Government is obliged to implement committee recommendations. The Ministry of Finance and other government departments play no part in decision-making. A good example of how decisions are made can be found in the case of the introduction of PCV-7 into the EPI schedule in Oman. At the time, there was very strong demand from the vaccine committee members and paediatricians to introduce the vaccine. As a result, the committee recommended forming a task force to study the disease burden and the vaccine’s cost-effectiveness.

69 (d, J = 8.4 Hz, 2H, H-2′ & H-6′), 7.52 (d, J = 2.4 Hz, 1H, H-6), 7.42 (d, J = 8.4 Hz, 2H, H-3′

& H-5′), 6.96 (dd, J = 8.8, 2.4 Hz, 1H, H-4), 6.63 (d, J = 8.8 Hz, 1H, H-3), 3.62 buy Quisinostat (s, 3H, CH3O-2), 1.28 (s, 9H, (CH3)3C-4′); EI-MS: m/z 355 [M + 2]+, 353 [M]+, 338 [M-CH3]+, 322 [M-OCH3]+, 289 [M-SO2]+, 197 [C10H13SO2]+, 156 [C7H7ClNO]+. 146–148 °C; Molecular formula: C16H18ClNO3S; Molecular weight: 339; IR (KBr, ѵmax/cm−1): 3208 (N H stretching), 3079 (Ar C H stretching), 1609 (Ar C C stretching), 1363 (S O stretching);1H NMR (400 MHz, CDCl3, ppm): δ 7.27 (d, J = 2.8 Hz, 1H, H-6), 6.91 (dd, J = 8.8, 2.4 Hz, 1H, H-4), 6.89 (s, 2H, H-3′ & H-5′), 6.66 (d, J = 8.4 Hz, 1H, H-3), 3.72 (s, 3H, CH3O-2), 2.62 (s, 6H, CH3-2′ & CH3-6′), 2.24 (s, 3H, CH3-4′); EI-MS: m/z 341 [M + 2]+, 339 [M]+, 324 [M-CH3]+, 308 [M-OCH3]+, 275 [M-SO2]+, 183 [C9H11SO2]+, 156 [C7H7ClNO]+. Light purple amorphous

solid; Yield: 65%; M.P. 136–138 °C; Molecular formula: C14H14ClNO4S; Molecular weight: 327; IR (KBr, ѵmax/cm−1): 3190 (N H stretching), 3057 (Ar C H stretching), 1601 (Ar C C stretching), 1359 (S O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.64 (d, J = 8.8 Hz, 2H, H-2′ & H-6′), 7.12 (dd, J = 8.8, 2.8 Hz, 1H, H-4), 7.04 (d, J = 2.4 Hz, 1H, H-6), 6.92 (d, J = 8.8 Hz, 2H, H-3′ & H-5′), 6.63 (d, J = 8.8 Hz, 1H, H-3), 3.85 (s, 3H, CH3O-4′), 3.40 (s, 3H, CH3O-2); EI-MS: m/z 329 [M + 2]+, 327 [M]+, 312 [M-CH3]+, 296 [M-OCH3]+, 263 [M-SO2]+, 171 [C7H7OSO2]+,

GW-572016 chemical structure 156 [C7H7ClNO]+. Grey amorphous solid; Yield: 71%; M.P. 156–158 °C; Molecular formula: C15H14ClNO4S; Molecular also weight: 339; IR (KBr, ѵmax/cm−1): 3218 (N H stretching), 3081 (Ar C H stretching), 1612 (Ar C C stretching), 1356 (S O stretching), 1720 (C=O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.97 (d, J = 8.0 Hz, 2H, H-2′ & H-6′), 7.86 (d, J = 8.4 Hz, 2H, H-3′ & H-5′), 7.54 (d, J = 2.0 Hz, 1H, H-6), 6.99 (dd, J = 8.4, 2.4 Hz, 1H, H-4), 6.63 (d, J = 8.8 Hz, 1H, H-3), 3.63 (s, 3H, CH3O-2), 2.59 (s, 3H, CH3CO); EI-MS: m/z 341 [M + 2]+, 339 [M]+, 324 [M-CH3]+, 208 [M-OCH3]+, 275 [M-SO2]+, 183 [C8H7OSO2]+, 156 [C7H7ClNO]+. Cream grey amorphous solid; Yield: 69%; M.P. 156–158 °C; Molecular formula: C17H14ClNO3S; Molecular weight: 347; IR (KBr, ѵmax/cm−1): 3215 (N H stretching), 3085 (Ar C H stretching), 1615 (Ar C C stretching), 1365 (S O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 8.36 (brd s, 1H, H-7′), 7.90 (d, J = 7.6 Hz, 1H, H-4′), 7.86 (d, J = 8.8 Hz, 1H, H-3′), 7.84 (d, J = 2.4 Hz, 1H, H-8′), 7.73 (dd, J = 8.4, 2.0 Hz, 1H, H-2′), 7.60 (ddd, J = 9.6, 1.2 Hz, 1H, H-6′), 7.58 (ddd, J = 9.6, 2.4 Hz, 1H, H-5′), 7.09 (br.

An overview of evidence

for a variety of interventions for frozen shoulder is then presented, including: advice and education, exercise therapy, manual mobilisations, electrotherapy, medications, injections, accupuncture, and operative treatments. This is followed by a systematic review Selleck Pazopanib with meta-analyses of evidence relating to the physiotherapy management of frozen shoulder. Summaries of all papers included are also presented. Six pages of general recommendations are then made for the diagnosis, assessment, and management of contracted frozen shoulder, followed by a brief section on recommendations for future research. “
“Latest update: March 2012. Next update: Not indicated. Patient group: Adults with symptoms suggestive of Amyotrophic Lateral Sclerosis (ALS). Intended audience: Health professionals involved in the diagnosis and management of patients with ALS. Additional versions: This version is an update of the 2005 European Federation of Neurological Societies (EFNS) guidelines: Andersen PM, et al (2005) EFNS task force on management of amyotrophic lateral

sclerosis. Guidelines for diagnosing and clinical care of patients and relatives. An evidencebased review with Good Practice Points. Eur J Neurol 12: 921–938. Expert working group: This was a 15-member task force of members from European Neurological Societies and nine European countries. Funded by: This guideline development received no funding support. Veliparib mw Consultation with: Not indicated. Approved by: The European Federation of Neurological Societies (EFNS). L-NAME HCl Location: Andersen PM et al (2012) Amyotrophic lateral sclerosis: EFNS guidelines on the clinical management of amyotrophic lateral sclerosis – revised report of an EFNS task

force. Eur J Neurol 19: 360–375. http://www.efns.org/ Guideline-Archive-by-topic.389.0.html Description: This practice guideline is presented as a review paper that provides evidence for the diagnosis and clinical management of patients with amyotrophic lateral sclerosis. It begins by presenting the diagnostic criteria for ALS, discusses and recommends investigations, outlines possible alternative diagnoses, and provides recommendations for communication with patients. Multidisciplinary clinical management is recommended including physiotherapy. Timelines for review and recommendations to support caregivers are suggested. Evidence for clinical management constitutes the main section of the guideline. This includes neuroprotective or disease-modifying treatments (medication) and interventions to provide symptomatic relief and improve quality of life, such as management of respiratory complications, cramps, spasticity, and fatigue. All 186 supportive references are included.

Intervention context has been reported as a key component of evaluations relating to obesity prevention (Waters et al., 2011) and further exploration

of this construct through qualitative case studies will provide critical evidence to help interpret the observed outcomes across schools and improve policy and practice in Nova Scotia (Hawe and Potvin, 2009 and Wang and Stewart, 2012). Strengths of our study include the relatively high response rates and reduction of nonresponse bias through the use of weighting. Furthermore, we adjusted for a number of potential confounders, measured participants’ height and weight, and applied consistent protocols to survey administration. We also used a validated FFQ which enables consideration of a number of important dietary factors and we have LY2835219 mw considerable experience with the use of this tool for population level analyses of the type reported here (e.g., Veugelers and Fitzgerald, 2005a and Veugelers and Fitzgerald, 2005b). Most of the questions included were validated, although self-reported responses, including selleckchem those in the YAQ, remain subjective and hence may be prone to error. Unfortunately, this remains a limitation

of population-based dietary surveys, but has been mitigated by the steps taken above to ensure consistency in data capture. The YAQ may not fully capture newer foods, e.g., energy drinks. FFQs may also overestimate intake (Burrows et al., 2010) although this is less of an issue in our study which uses the same tool over two time points. We also observed that, relative to 2003, parents in 2011 reportedly had higher levels of education and higher incomes. These changes paralleled not only economic growth but also differences in participation rates, and underline the importance that temporal comparisons are adjusted for ADAMTS5 these socioeconomic differences, as was done in the present study. In summary, population health approaches that include a focus on healthy school policies are critical in the prevention of childhood obesity. The implementation of the NSNP provides an important

opportunity to explore the relative effect of student population trends in nutritional habits and weight status observed before and after policy implementation. Although this study reports improvements in diet quality, energy intake and healthy beverage consumption, no significant effects on overweight or obesity were observed over time. It is clear that more action is needed to curb the increases in the prevalence of childhood obesity. This includes more consistent messaging and support for parents and the community to reinforce healthy school food practices. The authors declare that there are no conflicts of interest. This research was funded by an operating grant from the Canadian Institutes of Health Research (CIHR). Dr. Paul J.

The standardised mean differences were calculated BIBW2992 chemical structure by dividing the raw result by the standard deviation of the post-test score for the 14 trials for which this value was available. For the remaining three trials, the post-test standard deviation was estimated from the standard deviation of the change between initial and final assessment scores assuming a 0.6 correlation between pre and post scores. Meta-regression was also undertaken to assess whether there was a bigger effect on strength outcomes

of programs that specifically challenged strength. Meta-regression was not possible for any other outcomes due to the relatively small number of trials for those outcomes (ie, six) (Sterne et al 2001). The search strategy

identified 2198 studies (excluding duplicates). After screening, 23 eligible randomised trials were included in this review (Asikainen et al 2006, Bemben et al 2000, Bergstrom CT99021 solubility dmso et al 2007, Bravo et al 1996, de Jong et al 2006, Fu et al 2009, Garcia-Lopez et al 2007, Heinonen et al 1998, Janzen et al 2006, King et al 1991, Klentrou et al 2007, Levinger et al 2007, Lindheim et al 1994, Maiorana et al 2001, Mitchell et al 1998, Pereira et al 1998, Sallinen et al 2007, Shirazi et al 2007, Sillanpaa et al 2009, Singh et al 2009, Stefanick et al 1998, Teoman et al 2004, Uusi-Rasi et al 2003). Figure 1 presents the flow of studies through the review. The 23 included trials

involved a total of 2550 participants. Table 1 summarises the features of the included trials. Table 2 presents the characteristics of participants, interventions, and adherence to the intervention. Quality: Three trials performed concealed allocation ( de Jong et al 2006, Fu et al 2009, King et al 1991) and two trials used blinded assessment of outcomes ( Fu et al 2009, from Uusi-Rasi et al 2003). This information is also presented in Table 2. Participants: The majority of trials recruited postmenopausal women. The mean age of participants in the included studies ranged from 41 to 60 years of age. Intervention: Most trials included a strength component, followed by a combination of the strength and endurance components. Three trials included a combination of all three physical activity components (ie, strength, balance, and endurance). Included trials were heterogeneous regarding the total prescribed physical activity hours and adherence. Outcome measures: Lower limb strength was measured in 13 trials, endurance was measured in 7 trials, and balance in 6 trials. No studies reported effects of physical activity on falls soon after receiving the intervention program. One study reported longer-term (15 year) effects of physical activity on falls. We were able to pool data from 17 of the included trials in the meta-analyses. The data used in the meta-analyses are shown in Table 3.

Four studies reported compliance of at least 80% ( Barnard et al 2000, Feiereisen et al 2007, Pu et al 2001, Tyni-Lenné et al 2001), and one study reported’excellent’ compliance ( Beckers et al 2008). Two studies reported compliance with means of 75% and 78% respectively ( Cider et al 1997, Mandic et

al 2009) and one study did not report compliance ( Selig et al 2004). Among all of the studies, only one sudden death was reported, which occurred at home three days after Epigenetics Compound Library the most recent resistance training session. One drop-out was reported in the resistance training group due to noncompliance ( Table 3). One study reported that four patients had intermittent mild musculoskeletal symptoms during resistance training with minor modification of their training protocol afterwards ( Pu et al 2001). No safety issues were reported selleck products by either the resistance training alone or combined aerobic training studies. Interventions: Four studies ( Cider et al 1997, Pu et al 2001, Selig et al 2004, Tyni-Lenné et al 2001) compared resistance training alone with usual activity, usual care, or sham exercise. The other four studies ( Barnard et al 2000, Beckers et al 2008, Feiereisen et al 2007, Mandic et al 2009) studied combined (resistance and aerobic) training versus aerobic training groups. All the training programs

were supervised. The length of training ranged from 2 to 6 months. The intensity for resistance training was Parvulin moderate or about 50–75% of one repetition maximum

(1RM), while aerobic training on a treadmill or cycle ergometer was moderate to vigorous intensity. Two studies used high intensity exercise at 80% of 1RM, with no exercise-induced cardiac events reported (Barnard et al 2000, Pu et al 2001). The resistance training usually consisted of 2 sets of 8–12 repetitions for 5–6 exercises targeting the large muscle groups of upper limbs, trunk, and lower limbs. The exercise duration was around 30–60 minutes and exercise frequency was 2–3 times per week. One study included respiratory muscle training as one of the nine exercises (Beckers et al 2008). This was the largest number of exercises among the eight studies. We examined by separate analyses the effect of resistance training alone or in combination with aerobic training. Four studies reported cardiac function, seven reported exercise capacity, and five reported quality of life. All reported whether there were adverse events. Cardiac function: The effect of resistance training alone on cardiac function was examined in one trial ( Pu et al 2001), with no significant difference in left ventricular ejection fraction compared to control (MD 1.8%, 95% CI –5.7 to 9.3).

Despite evidence that exercise therapy is of limited value for patients

with acute low back pain (pain of less than 6 weeks) (Hayden et al 2005, Chou et al 2007), many physiotherapists continue to use treatment approaches that incorporate exercise. This trial investigated whether short-term pain outcomes were improved by adding McKenzie treatment to recommended first-line care for patients with buy I-BET-762 acute low back pain. The trial has many merits, including the attention to working with highly trained McKenzie therapists to deliver the intervention, the blinded outcome assessments, the high follow-up rates, the attention to the measurement of adherence to the McKenzie exercise program, and recruitment of patients consulting their family doctor about their low back pain. The results show small but statistically significant differences in pain at 1 and 3 weeks, the clinical importance of which the research team quite appropriately question. Their pre-set level of difference between groups was a difference of 1 (on a 0 to 10 scale of pain) and the differences they saw (0.4 and 0.7 at 1 and 3 weeks respectively) were smaller than this. Overall, the trial concludes that a treatment program based on the McKenzie method does not produce clinically important short-term

improvements in pain but it did seem to reduce health care use in the follow-up period through to 3 months. Given that we know the course of low back pain tends to follow a recurrent pattern (Dunn et al 2006), it is a pity that this trial stopped follow-up at only 3

months. It could be hypothesised that many of the 148 patients recruited ATM inhibitor will proceed to future recurrences and, for some, long term persistence. One might argue that patients treated with the McKenzie approach to self-management isothipendyl might be equipped to manage their own low back pain. This is partially supported by the short-term data on lower health care use in the group receiving the McKenzie intervention in this trial. Future trials of the McKenzie approach could usefully incorporate longer-term data collection with robust health economic analyses. This trial encourages us to think about which patients with back pain we target with which treatments. The results suggest there seems little point in providing McKenzie treatment to all patients with acute low back pain seeking primary care, and thus there is a need to better identify those patients who would benefit most from treatment options. “
“Latest update: July 2009. Next update: Within five years. Patient group: Patients with hip and knee osteoarthritis. Intended audience: General practitioners and other primary care health professionals involved in the management of patients with hip and knee osteoarthritis. Additional versions: A guide for referral for joint replacement mentioned in the care algorithm of this guideline is also available. Expert working group: 14 health care professionals including rheumatologists, GPs, physiotherapists, and nurses.

The results showed that both exercise programs were associated with reductions in depressive symptoms and increased physical

activity participation. Neither exercise program impacted body composition or fitness. The authors concluded that both clinic-based and home-based exercise programs can benefit women with depressive symptoms. During pregnancy, symptoms are an important contributor to poor health status, while in the postpartum period a lack of social support is the most consistent predictor of poor health outcomes (Hueston and Kasik-Miller, 1998). The recommended levels of physical activity were positively associated with reduced depressive symptoms. In particular, social functioning, and mental health are critically affected by the recommended Apoptosis Compound Library level

of physical activity (Brown et al 2003). Our estimate of the effect of aerobic exercise on depression is likely to be valid because the study design incorporated features such as concealed allocation and intention-to-treat analysis in order to minimise the potential for bias in the results. Only one outcome was measured so the risk of Type I error was low. The required sample Galunisertib mouse size was calculated a priori and was attained, with little attrition from the study cohort during the trial period. Nevertheless, our findings should be considered within the context of the limitations of the study design. One limitation was that the therapists and participants were not blinded. Further studies may be needed to explore the relationships aminophylline among psychological status, physical function, and quality of life during pregnancy with depressive symptoms ( Brown et al 2000, Ramírez-Vélez et al 2011a, Montoya Arizabaleta et al 2010). Investigation of other intervention components, such as behaviour therapy, is also needed ( Field et al 2009, Rethorst et al 2009). In addition, future randomised controlled trials should

study the effects of exercise in pregnancy among women with low pre-pregnancy physical activity. Physiotherapists should advise pregnant women that aerobic exercise training during pregnancy reduces the severity of symptoms of depression. It is unclear whether the effect on depression alone is large enough for pregnant women to feel it justifies the time, effort and cost of the exercise regimen. However, the effect on depression is supplemented by preventive effects on maternal hypertension and gestational diabetes, as well as improved well-being and quality of life. eAddenda: Table 3 available at http://jop.physiotherapy.asn.au Ethics: The University of Valle Research Ethics Committee approved this study (Res-021/010-UV). Informed consent was gained from all participants before data collection began. Support: COLCIENCIAS (Grant No 1106-45921540). Competing interests: The authors declare that they have no competing interests.

The WHO vaccine position papers, available in English, French, Arabic, Chinese, Russian

and Spanish, summarize the recommendations of SAGE and serve as key reference documents. [6] Comments from vaccine manufacturers to the position papers are sought through e-consultations, while aware of potential conflicts of interest and equity. SAGE has also provided guidance to vaccination in humanitarian emergencies, based on assessment of the epidemiological risk, vaccine characteristics, and prioritization in the context of other urgent public health needs and security, financial, and political realities. New SAGE working groups will be formed to review evidence leading to updating recommendations on the use of Japanese EPZ5676 encephalitis,

pertussis, varicella, hepatitis E, and malaria vaccines among others. N. Dellepiane gave updated information on WHO Prequalification (PQ) procedures, focusing on the strategic priorities, including securing the supply base for priority vaccines for developing countries, facilitating access to quality products, improving efficiency of the prequalification procedure and to expanding portfolio for vaccine introduction. Related activities were conducted including the amendment of several WHO guidance documents [7], [8], [9], [10], [11], [12], [13], [14] and [15], the implementation of expedited/facilitated registration procedure for prequalified vaccines in receiving countries, Gefitinib in vitro and two WHO workshops in China and India targeting at manufacturers with potential for PQ of priority vaccines. In 2013, already an Internet based tool has been developed and hosted on WHO-server

for online submission, processing and monitoring of registration applications. She introduced the features of the revised procedure, notably, the Programmatic Suitability of Product Characteristics (PSPQ) committee, the streamlined prequalification procedure of 6 months for manufacturers in countries with eligible authorities, and the establishment of annual reporting systems (PQVARs). Finally, a customers’ survey was made of PQ service design (PQ process) and service delivery. Still, there are concerns about overall time required for prequalification and process time inefficiencies (e.g. overall elapsed time, knowing when to expect a response). Manufacturers would like to see samples tested in parallel to the review of the file, while this may not be feasible to implement. In addition, there is a need for harmonization of expectations between different GMP auditors, categorization of deviations and of GMP code applied. This year the first open Chief Executive Officers (CEOs) Panel Discussion held at an annual general meeting was moderated by H. Dabas, from the Clinton Health Access Initiative (CHAI). CEOs from 9 DCVMN member companies discussed how to turning challenges into opportunities. A.

“
“Placenta percreta (PP) is a condition in which the placenta abnormally penetrates entirely through the myometrium and into the uterine serosa. This might be complicated by attachment selleck inhibitor of the placenta to surrounding structures or organs, such as the urinary bladder or rectum. PP is a potentially fatal condition,

and mortality rate is correlated to the extent of involvement of surrounding structures. When PP is complicated by bladder invasion, mortality rates have been estimated as high as 9.5% and 24% for mother and child, respectively.1 Knowledge of this condition and expectant management are especially important, as the incidence is on the rise—an estimated 50-fold increase in the last 50 years—attributed to the increased frequency of Caesarean deliveries.2 A 38-year-old woman (G6P3023) at 24 weeks gestation presented with vaginal bleeding. She reported that 1 week before she awoke in a “puddle of fluid.” She denied gross hematuria. She had a history of 3 Caesarean sections.

Fetal ultrasound showed complete placenta previa with placental vessels invading the bladder confirming PP (Fig 1). She was admitted for expectant management. Maternal fetal medicine, anesthesia, neonatal intensive care, and urology were all consulted. Magnesium sulfate, antibiotics, and steroids were administered prophylactically. On hospital day #2, the patient had an increased oxygen requirement and tachycardia. A computed tomographic scan Forskolin research buy of the chest revealed extensive bilateral pulmonary emboli. She underwent inferior vena cava filter placement, was transferred to the surgical intensive care unit, and continuous heparin infusion was initiated. On hospital day #6, the patient went into labor and was taken to the operating room for a multidisciplinary procedure. She underwent exploratory laparotomy and repeat Caesarean section through a fundal uterine incision by the obstetrics team. A viable female neonate was delivered with Apgar scores of 9 and 9. A total abdominal hysterectomy and lysis

of adhesions were then performed by the gynecologic oncology service. The anterior uterine wall was then recognized to be affixed to the bladder. Dissection of the anterior uterine wall from the posterior bladder was accompanied by large posterior cystotomy. On routine inspection, decreased efflux was noted from the nearly right ureteral orifice, and the right ureter was markedly dilated. At this point, intraoperative urology consultation was requested. The right ureter was secured, and a suture was identified that appeared to be constricting it. This was released with immediate return of urine from the ureteral orifice. A double-J ureteral stent was placed, and cystorrhaphy was performed. No leak was identified on bladder irrigation, and an omental flap was placed between the bladder and the vaginal cuff. A Jackson-Pratt drain and a Foley catheter were placed.