United States

Background: Vaginal Birth After Cesarean (VBAC) plays an essential role in current strategies to lower cesarean rates. Despite the American College of Obstetrics and Gynecology (ACOG) endorsement, Trial of Labor after Cesarean (TOLAC) attempt rates remain low. The Zavanelli maneuver is considered a last resort procedure used in the management of severe shoulder dystocia unable to be relieved by other techniques. It is the cephalic replacement of the fetal head back into the pelvis immediately followed by cesarean delivery. We discuss a case of a woman determined to have a vaginal birth after her prior birth required this heroic measure to facilitate delivery.

Case Presentation: A 34-year-old G4P1021 presented seeking care with a history of a complicated delivery requiring Zavanelli maneuver of a 4.4kg female infant. She was determined to avoid a repeat cesarean delivery and desired to pursue a trial of labor after cesarean section (TOLAC) this pregnancy. She addressed her modifiable risk factors and decreased her pre-pregnancy body mass index (BMI) to 26 from 39 kg/m2. She avoided excess weight gain during pregnancy (with a 25 pound gain versus 50 in her prior pregnancy). Her lifestyle changes influenced improvement in fetal growth with a current estimated fetal weight in the 50th percentile, compared to 95th percentile in her prior and her avoidance of gestational diabetes; whereas she was previously diagnosed. Consultation with three different perinatologists, all agreed her pursuit of TOLAC was reasonable. Nonetheless, she had to travel across state lines to find a provider willing to permit a trial of labor. She then presented in spontaneous active labor at 41 weeks gestation and went on to deliver a 3350g female infant in an uncomplicated vaginal delivery. She described this birth experience as euphoric.

Discussion: Practitioner fear was demonstrated as a barrier to this patient’s autonomy in delivery route decision. Risk factors for shoulder dystocia may vary in each pregnancy. Improvement in the overall risk profile should not be ignored when counseling patients and deciding on the best delivery route for that and future pregnancies. Decisions must be based on a thorough analysis of risk factors, past and present, and individualized to meet the goals of a woman&#39;s reproductive career.


AMA Research Challenge 2023

Vaginal Birth After Cesarean after Zavanelli Maneuver: 
A Woman’s Right to Choose

Background: Vaginal Birth After Cesarean (VBAC) plays an essential role in current strategies to lower cesarean rates. Despite the American College of Obstetrics and Gynecology (ACOG) endorsement, Trial of Labor after Cesarean (TOLAC) attempt rates remain low. The Zavanelli maneuver is considered a last resort procedure used in the management of severe shoulder dystocia unable to be relieved by other techniques. It is the cephalic replacement of the fetal head back into the pelvis immediately followed by cesarean delivery. We discuss a case of a woman determined to have a vaginal birth after her prior birth required this heroic measure to facilitate delivery.

Case Presentation: A 34-year-old G4P1021 presented seeking care with a history of a complicated delivery requiring Zavanelli maneuver of a 4.4kg female infant. She was determined to avoid a repeat cesarean delivery and desired to pursue a trial of labor after cesarean section (TOLAC) this pregnancy. She addressed her modifiable risk factors and decreased her pre-pregnancy body mass index (BMI) to 26 from 39 kg/m2. She avoided excess weight gain during pregnancy (with a 25 pound gain versus 50 in her prior pregnancy). Her lifestyle changes influenced improvement in fetal growth with a current estimated fetal weight in the 50th percentile, compared to 95th percentile in her prior and her avoidance of gestational diabetes; whereas she was previously diagnosed. Consultation with three different perinatologists, all agreed her pursuit of TOLAC was reasonable. Nonetheless, she had to travel across state lines to find a provider willing to permit a trial of labor. She then presented in spontaneous active labor at 41 weeks gestation and went on to deliver a 3350g female infant in an uncomplicated vaginal delivery. She described this birth experience as euphoric.

Discussion: Practitioner fear was demonstrated as a barrier to this patient’s autonomy in delivery route decision. Risk factors for shoulder dystocia may vary in each pregnancy. Improvement in the overall risk profile should not be ignored when counseling patients and deciding on the best delivery route for that and future pregnancies. Decisions must be based on a thorough analysis of risk factors, past and present, and individualized to meet the goals of a woman's reproductive career.


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Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) is a rare congenital anomaly that is characterized by the triad of uterus didelphys, obstructed hemivagina, and ipsilateral renal dysplasia. It is also known as Herlyn-Werner-Wunderlich syndrome. 

OHVIRA is typically diagnosed after menarche and is often associated with recurrent severe dysmenorrhea and vague lower abdominal pain, although the presentation can be variable. Due to the normal onset of menarche from the non-obstructed side, diagnosis of OHVIRA can easily be missed, which can lead to complications such as infection, pelvic inflammatory disease, and endometriosis. 

In this report, we present a case of OHVIRA syndrome in a 16-year-old girl who presented with lower abdominal pain and constipation. This case underscores the importance of maintaining a high index of suspicion for OHVIRA syndrome in adolescents with non-specific abdominal or pelvic symptoms.



When Constipation is More than Just Constipation: A Rare Case of OHVIRA Syndrome

Introduction : Glaucoma, a leading cause of irreversible blindness, presents a significant challenge in ophthalmology. While numerous treatment modalities exist, management becomes complex when patients exhibit intolerance to conventional treatments. This case highlights a patient with open angled glaucoma(AOG) who is unable to tolerate common glaucoma medications. 
Patient’s Main Concerns and Important Clinical Findings: A 79-year-old woman presents with a longstanding history of AOG, strongly influenced by her family history. The patient underwent significant obstacles due to intolerance to standard glaucoma eyedrops, including those that increase outflow (ie. Latanoprost) and aqueous suppressants for reduced inflow. 
Primary Diagnoses, Interventions, and Outcomes: The patient’s management involved multiple surgical interventions: two trabeculectomies were performed in the left eye (OS) in 1995 and 2006, with adjunctive 5-fluorouracil and mitomycin to inhibit fibroblast proliferation and increase the success rate of the surgery. Additionally, postoperative argon laser suture lysis was employed after both trabeculectomies to prevent hypotony. In the right eye (OD), the patient underwent argon laser trabeculoplasty in 2004, repeated as selective laser trabeculoplasty in 2007, and finally micropulse laser trabeculoplasty in 2009 and 2018. This series of procedures aimed to improve aqueous outflow through the trabecular meshwork. A trabeculectomy was also performed OD in 2018. As of the patient’s last examination on April 5, 2023, the patient’s vision was 20/80 OD and 20/500 OS, with intraocular pressures of 12 OD and 10 OS. Her visual fields showed stable superior and inferior loss, greater in OD than OS. 
Conclusion: This case illustrates the complexity of managing advanced glaucoma in patient’s intolerant to traditional medications. It highlights the necessity for personalized treatment strategies and the importance of building a supportive, ongoing relationship with patients dealing with lifelong diseases. Multiple surgeries may be required to control the disease, emphasizing the necessity for careful follow-up and dynamic treatment plans to preserve visual function. The case underscores the essence of ophthalmology - not just managing a disease, but guiding patients along a lifelong journey. 


Management Challenges in Advanced Open-Angle Glaucoma: A Case Report

Background
Guillotine amputations involve amputating an extremity with the wound left open, and are indicated in the setting of contamination. With lower extremity amputation, surgical options include below-knee amputation (BKA), through-knee amputation or knee disarticulation (KD), and above-knee amputation (AKA). BKAs preserve the knee joint and have been shown to have fewer complications and improved rehabilitation compared to KDs and AKAs. When BKAs are not feasible for a traumatic injury, an AKA is often chosen, due to difficulty or lack of understanding of KD surgery. While few RCTs have compared KDs to AKAs, they may be a viable alternative to AKAs.
Case Presentation
A 28-year-old male presented to the ED after being hit by a truck while on a motorcycle. Physical exam revealed severe injuries to the left lower extremity (LLE), including open tibia and fibula fractures, degloving of the associated soft tissue, obliteration of the anterior compartment of muscles, and a cool foot with no identifiable pulse. Radiographs revealed open, comminuted fractures of the left tibia and fibula. CTA of the LLE revealed abrupt cut-off of contrast at the level of the distal trifurcation of the popliteal artery, proximally in the tibia. 
The patient was urgently taken to the OR, where a guillotine amputation was performed through the knee joint (KD), due to the proximal nature of the fractures and level of vessel tear. KD was chosen over AKA in order to preserve the thigh musculature and therefore maximal function in this young, healthy patient. Three days later, he underwent irrigation and debridement of the LLE with wound closure. The patient was discharged home five days after wound closure, or eight days after admission. Three months out of surgery, the patient has done well with physical therapy and prosthetic usage; he will continue to be followed closely for rehabilitation and recovery. 
Discussion
Factors to be considered in the level of amputation include soft tissue viability for bone coverage, blood vessel viability, and wound contamination. When BKA is not possible, KD can offer an alternative to AKA. KDs present concerns of poor wound healing and stump breakdown, as well as increased risk of revision surgery. However, compared to ambulating on a normal leg, patients undergoing AKAs require 70% more energy expenditure. As compared to AKA, KD preserves the adductor muscles, leading to improved stability and reduced metabolic expenditure with ambulation. Therefore, KDs may result in improved rehabilitation and increased long-term functionality.


A Case of Traumatic Guillotine Knee Disarticulation

Background
Antiphospholipid syndrome (APS), a thrombo-inflammatory systemic autoimmune disease, refers to the presence of persistent procoagulatory antiphospholipid antibodies (APLA) in the setting of arterial/venous thrombosis and/or recurrent obstetric morbidity. Primary APS refers to disease manifestation in the absence of clinical or laboratory evidence of another disease. Secondary APS occurs in the presence of another autoimmune disorder, infection, drugs, or malignancy. APS is known to induce a hypercoagulable state which, in rare circumstances following surgical procedures, could present as acute upper limb ischemia. Successful limb salvage and revascularization requires a timely diagnosis and localization of the arterial occlusion.
Case Presentation
We present a case of a 40-year-old female, 10 days post breast implant surgery and reduction abdominoplasty, who developed arterial thrombosis of the right upper extremity and subsequently the right lower extremity. The patient has a 25-pack year smoking history. On her physical exam she had a cold, mottled, cyanotic right hand, thenar area, and thumb. The patient underwent multiple surgical procedures, including a thrombectomy with thrombolytic therapy for a right subclavian clot, subsequent arteriotomy for radial artery occlusion, a femoral and popliteal thrombectomy, and eventually multiple digital amputations, secondary to digital necrosis, with application of a groin flap. Following this procedure, she fell dehiscing the groin flap requiring three additional debridement procedures. Additional testing revealed positive ANA and lupus anticoagulants. She was subsequently diagnosed with antiphospholipid syndrome, explaining the cascade of thrombotic events.
Discussion
Taking into account patients' risk factors is essential in considering the diagnosis of APS. Timely recognition and diagnosis of APS is not only important to guide treatment and management, but also contributes to physicians’ understanding of the psychosocial impact of APS. The patient’s complications were not limited to physical manifestations, as there is a demonstrated psychosocial impact to the diagnosis of APS. This sequence of events contributed to her feelings of depression, which led to her pursuing psychiatric treatment. The large delay in finding the underlying cause of her symptoms certainly added to her anxiety and stress. Further demonstrating the need for consideration and further research investigating the psychiatric manifestations of APS, with an emphasis on depression. Additional considerations should be made regarding the timely diagnosis of APS in order to more aptly care for patients and limit the patients’ psychological toll.

A Case of Digital Gangrene in a Patient with Antiphospholipid Syndrome

Background: Wound dehiscence is a known postoperative complication but, in cervical spine surgery, it is rare and there is a lack of documented literature. This clinical vignette reports novel complications of wound dehiscence in a patient treated with spinous process ostectomies after posterior cervical surgeries.

Case Presentation
A 41-year-old male initially presented to the emergency department (ED) with a chief complaint of middle thoracic back pain, numbness and tingling in the T4 dermatome and bilateral lower extremity motor deficits. MRI showed T2-T3 discitis, osteomyelitis and a thoracic epidural abscess, central cord remodeling, and a paraspinal soft tissue abscess that measured 2.2 x 1.2 x 2.3 cm. The patient ultimately underwent a T2-T3 decompression with left pedicle subtraction, irrigation, and debridement (I&D) of the T2-T3 disc space, and C7-T5 posterior spinal fusion.
Following an uneventful postoperative course, at five months postoperatively the patient felt a tear over the incision and was found to have a full thickness wound dehiscence with protrusion of the spinous processes. 
The patient underwent operative intervention for resection of the spinous process, I&D, and approximation of the muscle tissue and fascia. The spinous processes of T4 and T5 that were visible were removed. Flaps were raised to allow for adequate coverage of scar and fascia. At the two-week follow-up, the incision showed positive signs of healing overall, although there was some blistering noted; the sutures remained in place for another week. The spinous process at the level above the incision (C6, C7, and T1) was more prominent postoperatively which were not prominent prior to surgery. One week later, sutures were removed, and the wound looked well healed overall despite some erythema.
Six weeks following the second surgery, the spinous process at C6, C7, and T1 had eroded through the skin. The patient was scheduled for resection of those spinous processes and a large paraspinal flap for wound coverage. At the two-week, one-month, and six-month follow-up visits, the incision looked well healed with no signs of dehiscence

Discussion
This clinical vignette documents the successful treatment of cervical wound dehiscence which is a rare postoperative complication of cervical spinal surgery. We believe that this clinical vignette demonstrates successful treatment of cervical wound dehiscence with notable prominence of spinous processes, a topic that is not well documented in the literature. This information is valuable as treatment strategies and research into cervical wound dehiscence are limited to a single case report.




Cervicothoracic Wound Dehiscence Following Internal Fixation of the Cervical and Thoracic Spine

Background: Stress fractures are a type of bone injury resulting from repetitive microtrauma and abnormal bone stress. There are two main types of stress fractures: fatigue fractures (repetitive stress on normal bones) and insufficiency fractures (any injury to weakened bones). This case report highlights a rare and challenging diagnosis of bilateral synchronous fatigue fractures of the proximal tibial metaphysis, accompanied by sprains of the medial menisci and anterior cruciate ligaments.

Case presentation: A 36-year-old male with a BMI of 33 and a sedentary lifestyle for over a decade started jogging and playing cricket matches. He developed pain and swelling in both knees within a week of becoming physically active. There was no history of trauma. Weight-bearing increased the pain. Point tenderness was present along the medial side of the knee joint lines. Tibial traction tests, varus, and valgus stress tests were negative on both legs. McMurray test was negative on the left side and positive on valgus stress with external rotation on the right leg, suggesting a tear on the medial meniscus on the right side. 

He was clinically diagnosed as having a medial meniscal tear on the right knee and left infrapatellar bursitis on the left knee. X-rays of both knees were normal. Initial management with the RICE algorithm (Rest, Ice, Compression, and elevation) and NSAIDs did not improve clinical status. MRI taken after two weeks showed bilateral stress fractures of the proximal tibial metaphysis, bilateral partial tears of the medial menisci, and anterior cruciate ligaments. Lab tests showed elevated ESR, normal Vitamin D and calcium levels, and negative for autoantibodies. Bone densitometry was normal. With the new diagnosis, he was treated with partial immobilization by knee splints with bathroom privileges for three weeks and physiotherapy for 12 weeks. He started walking with support after three months and total weight bearing after six months of initial diagnosis.

Discussion: The diagnosis was initially missed, leading to mistreatment and significant physical, mental, and financial consequences to the patient. This case emphasizes the importance of considering stress fractures and ligament injuries in individuals with recent intense exercise history, particularly in obese patients and obtaining imaging studies earlier. It also underscores the need for evidence-based practices and encourages healthcare professionals to stay updated with current research to improve patient care.

Bilateral Synchronous Proximal Tibial Metaphyseal Stress Fractures with Sprains of Anterior Cruciate Ligaments and Medial Menisci – A Case Report

Background

Parotitis presents in many forms, and the symptoms vary from modest to debilitating. It may
present a diagnostic challenge because of its extensive etiologies: bacterial, pure viral,
autoimmune or a combination of these. Before the development of the mumps vaccine, parotitis
caused by the mumps virus was extremely common, particularly in school-aged children.
However, in recent years, the influenza (type A most commonly) virus has emerged as another
viral etiology associated with parotitis. Given this emerging clinical knowledge, healthcare
workers should start considering influenza as a cause of parotitis, especially during flu seasons.
We present a case of a pediatric patient with a recent positive influenza test who returned to the
Emergency Room with swollen bilateral parotid glands. The patient was diagnosed with parotitis
clinically and it was associated with the influenza virus.

Case presentation

A three-year-old boy with prior medical history of hypoparathyroidism presented to the ER with
swollen bilateral facial edema a day after presenting shortness of breath, runny nose, fever and
cough consistent with influenza. Patient vaccination status was up-to-date, except for the annual
influenza one. Physical examination revealed a well developed and nourished child with nasal
secretions and bilateral facial swelling. He had clear lungs, normal breath sounds and no
respiratory distress. Pertinent labs revealed leukocytosis (12.65), increased CRP (1.8) and
increased amylase levels (241), suggesting inflammation of the parotid glands. Patient underwent
CT of facial bones with IV contrast, which revealed bilateral parotid glands swelling. Given his
upper respiratory symptoms, the patient was diagnosed with bilateral parotitis secondary to
influenza virus infection. He was treated with supportive care, acetaminophen and catch-up
influenza vaccine.

Discussion

It can be challenging to determine whether the temporal association between influenza and rare
complications indicates that the virus is causally associated with the syndrome. However,
physicians should consider the possibility of influenza infection when a patient presents with
parotitis, especially if a temporal relation exists. Patients may benefit because widespread
epidemics of influenza occur in the United States each year and such a public health response
would generally be unnecessary if a case of parotitis were found to be due to influenza rather
than mumps, the most common cause of parotitis.

Is there a link between parotitis and influenza? Physicians should consider influenza virus as an etiology for patients​

Background: 
Total hip arthroplasty (THA) is an effective procedure to improve pain, range of motion, and function for a variety of conditions, including osteoarthritis and post-traumatic arthritis. In the absence of surgical complications, some patients have unexplained persistent pain or weakness at the operative joint. It has been shown that up to 28% of patients had persistent pain at the surgical site 12 to 18 months following THA. Importantly, more than 12% of patients had pain that limited their activities of daily living to a moderate or severe degree. Currently, there are no widely accepted non-pharmacological treatments for persistent postoperative pain for THA. The purpose of this case report is to detail a successful reduction of chronic postoperative pain and weakness with implanted peripheral nerve stimulation (PNS) and physical therapy (PT) in a patient with post-traumatic THA. 

Case Presentation: 
The patient is a 53-year-old white male pilot who presented to our pain management clinic in May 2022. In February 2021 he was ejected from an airplane and had polytrauma with multiple facial fractures, an L4 vertebral compression fracture, and a right hip fracture. He had an immediate uncomplicated THA surgery followed by standard physical therapy treatment. Approximately five months following THA, he developed right-sided thigh pain, numbness, and tingling in the femoral nerve distribution, which was recalcitrant to medication and standard physical therapy. 
SPR Therapeutics single-lead percutaneous peripheral nerve stimulator was implanted near the right femoral nerve on 3/10/23. During four months of treatment, the patient attended 11 visits of physical therapy. 

Discussion: 
This case report demonstrates the effectiveness of implanted PNS in a patient with chronic pain and weakness following post-traumatic THA. This treatment improved his hip flexion strength, measured by handheld dynamometer, from 22.83lb to 50.8lb in three weeks. Limb symmetry index improved from 58.19% to 91.87%. His Lower Extremity Functional Scale improved from 35/80 (43.75%) to 54/80 (67.5%) within five weeks. 

Although peripheral nerve field stimulation has been used previously for this indication, single lead implanted PNS has not been studied. This case’s success demonstrates PNS may help eliminate post-operative persistent pain and weakness in many patients, including those with post-traumatic arthroplasty. Future randomized control trials using implanted single-lead PNS are warranted to provide robust results to guide physician clinical practice.

Implanted Peripheral Nerve Stimulation Improves Chronic Pain and Weakness Following Total Hip Arthroplasty

Background
Delirium, defined as a disturbance in attention and awareness that cannot be better explained by a medical condition1, is a serious complication of hospitalization for the elderly population, impacting 8-17% of older adults in the emergency room and up to 40% of nursing home residents. Development of delirium is associated with long term poor health outcomes, including dementia, institutionalization, and death. While the presentation of delirium can sometimes mimic a catatonic state with psychomotor retardation, echolalia, the inappropriate repetition of words spoken by others, is not common. More frequently, echolalia is cited as a symptom of catatonia. This case report describes a patient with minimal psychiatric history who experienced oxycodone-induced delirium, with unique primary presenting symptoms of echolalia and narration. A thorough search of existing literature has found no similar examples.

Case Presentation
We present a case report of an 80-year-old female who presented with altered mental status and mental status exam significant for overproduction of speech and echolalia. The patient was found to have a recent history of spinal surgery performed at an outside hospital and was discharged to home on baclofen and oxycodone four days prior to admission. Extensive diagnostic work-up that included routine blood work, blood and CSF cultures, EEG, and neuroradiological studies were all within normal limits. The patient’s echolalia and narration extinguished and her mental status improved by day three of admission after discontinuing oxycodone and empiric treatment with acyclovir and thiamine.

Discussion
Narcotic analgesics have long been explained as a cause of delirium in elderly patients. This patient showed acute emergence of symptoms following onset of treatment with opioid analgesic, oxycodone. Although this presentation is complicated by the patient’s recent operation, lack of symptoms post-op and the disappearance of symptoms following cessation of the drug suggest that oxycodone was the cause of her delirium. Notably, this patient presented to the hospital exhibiting echolalia, the inappropriate repetition of words spoken by others. These behaviors are more commonly associated with catatonia, and have yet to be described as a primary presenting feature of delirium.

In conclusion, physicians should be aware of the possible deliriogenic properties of all narcotic substances, including oxycodone. Furthermore, atypical presenting symptoms of delirium including echolalia and narration should be considered when establishing a diagnosis. Additional research is warranted to examine whether such symptoms are more commonly associated with delirium in general or that associated with narcotics than is currently suspected. 



Echolalia as the Presenting Symptom of Opioid-Induced Delirium: A Case Report

Background
A paucity of literature delineates psychiatric symptoms in osmotic demyelination syndrome (ODS). Though clinical manifestations of ODS are canonically limited to the neurologic, some existing literature has identified psychiatric sequelae of ODS including: psychosis, catatonia, mania, behavioral changes, and cognitive disturbances. This case report discusses psychiatric sequelae of ODS, specifically manic-like symptoms, and the importance of judicious medical work-up for new onset psychiatric symptoms. This neuropsychiatric case highlights interdisciplinary collaboration between inpatient psychiatry and neurology in promptly recognizing and treating a neurologic emergency. 
Case Introduction
A 37-year-old female with a past psychiatric history of generalized anxiety disorder, no history of inpatient psychiatric admissions, initially presented to inpatient psychiatry with new onset: lack of sleep, disorganization, distractibility, behavioral disinhibition, destruction of property, complaint of foot tremor and drooling. On initial inpatient psychiatric exam, the patient presented with seemingly manic symptoms and notable cranial nerve deficits including: drooling, diplopia, dysphagia, dysdiadochokinesia, dystonic posturing of bilateral lower extremities, postural and action tremor of bilateral upper extremities, gait instability. It was noted that 8 days prior to psychiatric presentation, the patient had been admitted to the intensive care unit for severe hyponatremia and prolonged QTc following elective submental liposuction. This constellation of symptoms was concerning for ODS, prompting immediate MRI and neurology consult. 
Results
MRI brain demonstrated marked symmetric T2 FLAIR hyperintense signal in the bilateral putamen, bilateral caudate heads, and the cortex of the bilateral hand knobs, without associated reduced diffusion. Within the central pons, there was focal T2 hyperintense signal. Findings were consistent with acute/subacute osmotic demyelination and extrapontine osmotic demyelination, in the setting of recently overcorrected hyponatremia. 
The patient was immediately transferred to the neurointensive care unit for stabilization with IVIG and Decadron taper. Behavioral disinhibition resolved with short-course valproic acid. Upon neuropsychiatric stabilization, the patient was discharged home with outpatient physical rehab, occupational rehab, neurology, psychiatry, plastic surgery, and primary care follow-up. 
Discussion
Medical etiologies of seemingly manic presentations must be judiciously worked-up prior to diagnosing primary psychiatric etiology. ODS can present with psychiatric symptomatology in addition to neurologic. This case demonstrates mania-like symptoms secondary to general medical condition. Interdisciplinary collaboration was critical in pursuing timely medical work-up and treatment of ODS, thus preventing serious adverse outcomes such as progression to locked-in syndrome. Inpatient psychiatry promptly recognized a neurologic emergency through its psychiatric manifestation, allowing for immediate neurointensive treatment and stabilization.

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