News Article | May 5, 2017
(PR NewsChannel) / May 5, 2017 / Nesconset, New York Syeda Hossain, MD, Gastroenterologist at Mount Sinai Doctors, and affiliated with the Saint Catherine of Siena Medical Center and Mercy Medical Center, has been named a 2017 Top Doctor in Nesconset, New York. Top Doctor Awards is dedicated to selecting and honoring those healthcare practitioners who have demonstrated clinical excellence while delivering the highest standards of patient care. Dr. Syeda Hossain has been in practice for more than 11 years, and has already become renowned as one of the top gastroenterologists in New York. Her medical career began in 2005, when she graduated from New York Medical College. After an internship and residency at the prestigious Harvard Medical School, she completed a fellowship at the New York University College of Medicine. Dr. Hossain is dual board certified, in Internal Medicine and in Gastroenterology. It is in this latter field that she has become known as a specialist, treating conditions including Crohn’s Disease, enteritis, ulcerative colitis, anemia, celiac disease, and inflammatory bowel disease. Expert procedures undertaken by Dr. Hossain include colonoscopy, sigmoidoscopy, and video capsule endoscopy. Dr. Hossain uses the latest cutting edge techniques in her work, bringing excellent results for her patients. She currently serves as Medical Director of the Mount Sinai Physician Endoscopy Center-Nesconset. Her dedication and commitment makes Dr. Syeda Hossain a very worthy winner of a 2017 Top Doctor Award. About Top Doctor Awards Top Doctor Awards specializes in recognizing and commemorating the achievements of today’s most influential and respected doctors in medicine. Our selection process considers education, research contributions, patient reviews, and other quality measures to identify top doctors.
News Article | May 9, 2017
Two Studies Presented at DDW 2017 Showed Clinically Meaningful Reduction in Symptoms and Withdrawal or Reduction in Proton Pump Inhibitor Use by Two-Thirds of Patients Following Treatment with MUSE™ System Separate Presentation Supports HOF Criteria as a Potential Endoscopic Selection Criteria to Predict Amount of Reflux and Improve Treatment Outcomes OMER, ISRAEL--(Marketwired - May 9, 2017) - Medigus Ltd. ( : MDGS) ( : MDGS), a medical device company developing minimally invasive endosurgical tools and a leader in direct visualization technology, today announced results from three clinical studies involving the company's MUSE™ System, a minimally invasive solution for gastroesophageal reflux disease (GERD). The data were presented in three posters at Digestive Disease Week® (DDW), taking place in Chicago from May 6-9, 2017. The MUSE system is a single-use flexible transoral stapler that merges the latest advancements in microvisual, ultrasonic and surgical stapling. The device comes equipped with an ultrasonic sight and range finder and a micro ScoutCam™ CMOS camera, which enables a single physician to perform an incisionless transoral fundoplication -- the procedure is intended to treat the anatomical cause of gastroesophageal reflux disease (GERD), commonly known as acid reflux. Giorgia Mazzoleni, fellow at the San Raffaele Scientific Institute at the San Raffaele Hospital in Milan, Italy, presented a poster entitled, "Transoral Anterior Fundoplication (TAF) with Medigus Ultrasound Surgical Endostapler (MUSE™) for the Treatment of Gastroesophageal Reflux Disease (GERD); 6-Month Results from a Single-Center Prospective Study," which enrolled 24 GERD patients to assess the six-month safety and efficacy of TAF with MUSE. GERD quality of life questionnaires (HRQL) improved from a baseline of 43 to 18 six months after TAF with MUSE (p < 0.003). The study also highlighted an improvement in Reflux Symptom Index (RSI), from 21 to 10 (p < 0.009). A 79% reduction or withdrawal in PPI therapy was observed six-months after treatment, with 50% of patients stopping PPI use, 28.6% of patients halving PPI use, and 21.4% remaining on the same dose prior to treatment with TAF with MUSE. Dr. Ali Lankarani, board member of the Advanced Therapeutic Endoscopy Center (ATEC) at the Broland-Groover Clinic in Jacksonville, FL, presented a poster titled, "Interim Results From A Multi-Center Post-Marketing Surveillance Registry Study for Endoscopic Anterior Fundoplication," reported data from an ongoing post-market registry study of 68 GERD patients who underwent Endoscopic Anterior Fundoplication (EAF) in 13 international centers. GERD-HRQL improved from 24.0 to 6.0 following treatment with MUSE (CI, 13.4 - 20.8, p < 0.00001), demonstrating patients experienced a clinically meaningful reduction in GERD-related symptoms. In addition, baseline patient satisfaction was reported at 0%, but improved to 70% (26/37) at 6 months and 90% (9/10) at 1 year. Of note, 76% (28/37; p < 0.00001) of patients have eliminated or reduced their use of proton pump inhibitors (PPI), with 96% of patients that responded favorably to treatment with the MUSE System stopping daily PPI therapy. Dr. Lankarani remarked, "These interim results, in conjunction with the data from the single-center study presented by Mazzoleni, highlight how the MUSE System can be a revolutionary, minimally-invasive treatment option for patients with GERD who are unsatisfied with PPI therapeutics and hesitant to pursue surgical intervention. In addition to the impressive findings, in another study we were able to access the value of the HOF criteria over the Hill classification, which we believe will play a pivotal role alongside the MUSE System in improving overall treatment outcomes in GERD." In addition, Dr. Lankarani presented a second poster, entitled, "Endoscopic Predictors of Decreased Reflux After Endoscopic Anterior Fundoplasty," which evaluated the HOF criteria as an endoscopic grading system of gastroesophageal junction (GEJ) geometry, as well as selection criteria to guide treatment decisions and predict treatment outcomes. Currently, Hill classification is the most commonly used criteria for antireflux procedures, however it has limited utility and still results in one-third of EAF-treated patients to continue experiencing reflux. HOF criteria categorizes GEJ geometry based on measurement of axial length of hiatal hernia (H), hiatus opening dimension (O) and flap valve size (F), with H and O openings less than 1cm considered normal (N) and 1cm or larger categorized as abnormal (A). GEJ is categorized as AAA if all three HOF landmarks are abnormal, NAA if one HOF landmark is normal and two are abnormal, and NNN if all three HOF landmarks are normal. Using the HOF criteria, the researchers identified and successfully treated 18 GERD patients, with Total Present of Time spent in Reflux (TPTR) showing a reduction in all patients with NAA configuration, and 75% and 71% TPTR reduction in individuals that had a 1 and 2 cm hiatal hernia, respectively. Average TPTR improvement was 53% for the NAA configuration patients, while average TPTR improvement in patients with 1 and 2 cm hiatal hernia was 56% and 46%, respectively. Chris Rowland, Chief Executive Officer of Medigus, commented, "As the developers of a completely new, minimally invasive solution for the treatment of GERD, we are extremely motivated by data presented this year at DDW. We are pleased with the results reported from the single center study, and look forward to continuing the ongoing post-market multi-center study, which have shown promising reductions in PPI reliance, as well as increases in patient quality of life and satisfaction. These studies continue to support the use of our MUSE System, which can reduce the need for pharmaceuticals and invasive surgical procedures." To learn more about MUSE, visit: www.medigus.com Medigus is a medical device company specializing in developing minimally invasive endosurgical tools and highly innovative imaging solutions. They are the pioneer developer of the MUSE™ system, an FDA cleared and CE marked endoscopic device to perform Transoral Fundoplication (TF) for the treatment of GERD (gastroesophageal reflux disease), one of the most common chronic conditions in the world. In 2016, the CMS established the Category I CPT® Code of 43210 for TF procedures, such as the ones performed with MUSE, which establishes reimbursement values for physicians and hospitals. MUSE is gaining adoption in key markets around the world -- it is available in world-leading healthcare institutions in the U.S., Europe and Israel. Medigus is also in the process of obtaining regulatory clearance in China. Medigus is traded on the Nasdaq Capital Market and the TASE (Tel-Aviv Stock Exchange). To learn more about the company's advanced technology, please visit www.medigus.com or www.RefluxHelp.com. This press release may contain statements that are "Forward-Looking Statements," which are based upon the current estimates, assumptions and expectations of the company's management and its knowledge of the relevant market. The company has tried, where possible, to identify such information and statements by using words such as "anticipate," "believe," "envision," "estimate," "expect," "intend," "may," "plan," "predict," "project," "target," "potential," "will," "would," "could," "should," "continue," "contemplate" and other similar expressions and derivations thereof in connection with any discussion of future events, trends or prospects or future operating or financial performance, although not all forward-looking statements contain these identifying words. These forward-looking statements represent Medigus' expectations or beliefs concerning future events, and it is possible that the results described in this news release will not be achieved. By their nature, Forward-Looking Statements involve known and unknown risks, uncertainties and other factors which may cause future results of the company's activity to differ significantly from the content and implications of such statements. Other risk factors affecting the company are discussed in detail in the Company's filings with the Securities and Exchange Commission. Forward-Looking Statements are pertinent only as of the date on which they are made, and the company undertakes no obligation to update or revise any Forward-Looking Statements, whether as a result of new information, future developments or otherwise. Neither the company nor its shareholders, officers and employees, shall be liable for any action and the results of any action taken by any person based on the information contained herein, including without limitation the purchase or sale of company securities. Nothing in this press release should be deemed to be medical or other advice of any kind.
News Article | May 9, 2017
Southern California medical group Allied Anesthesia today announced the addition of eight board certified physicians in Orange and Fullerton, Calif. Several of the doctors are fellowship trained in pediatric anesthesia, or regional anesthesia and acute pain management. Dr. Edward Lee, lead physician recruiter for Allied Anesthesia, said, “The addition of these incredible physicians signifies another step in our constant effort to give our patients in Southern California access to the absolute best possible care. Today, Allied is more than 100 doctors strong. And each of these doctors, including our eight new anesthesiologists, has passed through one of the most rigorous vetting processes in America—a process designed to filter out all but the top one percent. We couldn’t be prouder to welcome these fine doctors to the Allied Anesthesia team.” Dr. Abisola Ayodeji earned her medical doctorate at Medical College of Virginia, completed her first residency at Maimonides Medical Center, Brooklyn and pediatric residency at Stephen and Alexandra Cohen Children's Medical Center, New Hyde Park, N.Y. Dr. Ayodeji was also a pediatric anesthesia fellow at Loma Linda University Medical Center, Loma Linda, Calif. She is based in Orange, Calif., and practices at St. Joseph Hospital of Orange and CHOC Children’s Hospital. Dr. Andrew Chen graduated from Arizona College of Osteopathic Medicine, Glendale, and completed his residency at University of Arizona, Tucson. He was a fellow in regional anesthesia at The University of Pittsburgh Medical Center. Dr. Chen is based in Fullerton and practices at St. Jude Medical Center, St. Jude Plaza Surgery Center and the Knott Family Endoscopy Center, all in Fullerton. Dr. James Cheon earned a medical doctorate at the University of Illinois College of Medicine, Chicago, and completed his residency at the University of Chicago. He was a pediatric anesthesia fellow at Children’s Hospital Los Angeles. Dr. Cheon practices at CHOC Children’s Hospital, St. Joseph Hospital and the Orthopaedic Institute for Children in Los Angeles. He is based in Orange. Dr. Hao Ho graduated from Jefferson Medical College of Thomas Jefferson University, Philadelphia. He completed a residency at Rush University Medical Center, Chicago, and was a regional anesthesia and acute pain fellow at University of California, Irvine. Dr. Ho is based in Orange and practices at St. Joseph and St. Jude Medical Centers. Dr. Vincent Lin earned his medical doctorate at St. Louis University and completed his residency at University of California, Irvine. Dr. Lin practices St. Joseph Hospital and Newport Center Surgical, Newport Beach, Calif. He is based in Orange. Dr. Sherif Meckael earned his medical degree at Rutgers University New Jersey Medical School and completed his residency at Montefiore Medical Center Albert Einstein College of Medicine, the Bronx, N.Y. Dr. Meckael served two fellowship at Albert Einstein College of Medicine—the first in pediatric anesthesiology and the second in congenital pediatric cardiac anesthesiology. He is based in Irvine and practices at Children’s Hospital of Orange County and St. Joseph Medical Center. Dr. Rebekah Nam earned a medical doctorate from New York University School of Medicine and completed her residency there. Dr. Nam regularly practices at St Joseph Hospital of Orange. She is based in Orange. Dr. Christopher Nguyen earned his medical doctorate at the University of Michigan Medical School. He completed his first residency at University of California, San Diego, and an additional residency in pediatric anesthesiology at Seattle Children’s Hospital. Dr. Nguyen regularly practices at CHOC Children’s Hospital and St. Joseph Hospital of Orange, both in Orange. About Allied Anesthesia: With over 100 highly qualified physician anesthesiologists on staff, Allied Anesthesia provides adult and pediatric anesthesia services to St. Joseph Hospital of Orange, CHOC Children’s Hospital, St. Jude Medical Center in Fullerton, Calif., San Antonio Community Hospital in Upland, St. Mary’s Hospital in Apple Valley and many other Southern California health care facilities. In 2014, Allied Anesthesia joined with Fullerton Anesthesia Associates and Upland Anesthesia Medical Group to consolidate best practices in more than six hospitals and more than a dozen ambulatory surgery centers. The expanded medical practice is dedicated to offering the highest comprehensive quality of care and the most cost-effective procedures in all facilities they serve. All Allied physician anesthesiologists are board certified in anesthesiology and staff and manage the most efficient operating rooms in Southern California. Allied is a member of the California Society of Anesthesiologists, the American Society of Anesthesiologists, and the Anesthesia Quality Institute.
Mizukami T.,Endoscopy Center |
Suzuki H.,Keio University
Intestinal Research | Year: 2017
Background/Aims: Colonoscopy and computed tomography (CT) are used primarily to exclude organic diseases in patients with irritable bowel syndrome (IBS), rather than to assess the pathophysiology of IBS. We aimed to evaluate colonic dysmotility and morphology in Japanese patients with IBS. Methods: One hundred eighty-four patients with IBS and 49 asymptomatic controls who underwent colonoscopy in combination with CT colonography or barium enema were retrospectively reviewed between 2008 and 2012. Water-aided colonoscopy was performed without sedation by a single endoscopist. The duration and pattern of colonic movement and cecal intubation time were recorded. To assess colonic morphology, barium enema or CT colonography were performed immediately after colonoscopy. Results: Colonic dysmotility was more frequent in the IBS group (28.8% vs. 2.0% in controls, P <0.001), especially in cases of IBS with diarrhea (IBS-D) (IBS with constipation [IBS-C] 28.8% vs. IBS-D 60.0% vs. mixed IBS [IBS-M] 5.1%, P <0.001). Colonic morphological abnormality was more frequent in the IBS group than in the control group (77.7% vs. 24.5%, P <0.001), especially in IBS-M and IBS-C groups (IBS-C 77.5% vs. IBS-D 48.9% vs. IBS-M 100%, P <0.001). Most patients with IBS with colonic dysmotility had experienced stress related to their symptoms. Cecal intubation time was significantly longer in the IBS group than in the control group (12.1±6.9 minutes vs. 4.6±1.9 minutes, P <0.001). Conclusions: Unsedated colonoscopy, combined with radiographic findings, can detect colonic dysmotility and morphological abnormality. Technical difficulties observed during cecal intubation may partially explain the pathophysiology of IBS. © 2017. Korean Association for the Study of Intestinal Diseases.
News Article | November 3, 2016
HERSHEY, Pa., Nov. 03, 2016 (GLOBE NEWSWIRE) -- Penn State Health has selected Cerner Millennium Revenue Cycle™, a patient-centric financial management platform designed to optimize provider and user workflow. The new platform will be integrated with the existing Cerner electronic health record (EHR) at the Milton S. Hershey Medical Center, resulting in a Clinically Driven Revenue Cycle™ across the health system, including more than 60 clinics. As part of the expanded relationship, Cerner will also extend the clinical and financial health information technology system to Penn State Health St. Joseph, previously St. Joseph Regional Health Network. “Having one integrated platform will support our efforts to create seamless coordination and collaboration among our departments and venues of care,” said Stephen Massini, chief financial officer, Penn State Health. “Incorporating clinical data into our revenue cycle processes will enable a better experience for our patients and providers and enhance our ability to holistically manage our patient’s financial responsibility.” Cerner’s Clinically Driven Revenue Cycle is designed to support clinicians and staff to update the billing process throughout the patient’s visit, enhance clinical documentation to help improve reimbursement and limit claims errors. Patients will benefit by having direct access to their clinical results and a streamlined financial experience, including visibility of their financial liability from a single source. “This expanded relationship makes Penn State Health a robust academic client with an integrated health IT system that supports the delivery of high quality care across the continuum,” said Dick Flanigan, president of Cerner HS. “We look forward to providing Penn State Health with a platform that works for the organization versus the organization working around a disrupted and disparate system.” About Penn State Health Penn State Health is a not-for-profit, tax-exempt corporation, established by Penn State for oversight of its health care enterprises and jointly owned health care organizations, to help meet the health needs of people and communities across Pennsylvania. Penn State Health includes several hospitals, including St. Joseph Medical Center in Reading, Pa., and the Milton S. Hershey Medical Center in Hershey, Pa., as well as their respective outpatient medical group practices. The system also includes Penn State Children’s Hospital and Penn State Cancer Institute, and jointly owned health care providers, including Hershey Outpatient Surgery Center, Hershey Endoscopy Center, Horizon Home Healthcare and the Pennsylvania Psychiatric Institute. Penn State Health shares an integrated strategic plan and operations with Penn State College of Medicine, the University’s medical school. About Cerner Cerner’s health information technologies connect people, information and systems at more than 25,000 provider facilities worldwide. Recognized for innovation, Cerner solutions assist clinicians in making care decisions and enable organizations to manage the health of populations. The company also offers an integrated clinical and financial system to help health care organizations manage revenue, as well as a wide range of services to support clients’ clinical, financial and operational needs. Cerner’s mission is to contribute to the systemic improvement of health care delivery and the health of communities. Nasdaq: CERN. For more information about Cerner, visit cerner.com, read our blog at blogs.cerner.com, connect with us on Twitter at twitter.com/cerner and on Facebook at facebook.com/cerner. Our website, blog, Twitter account and Facebook page contain a significant amount of information about Cerner, including financial and other information for investors.
Leung W.K.,University of Hong Kong |
Leung W.K.,Endoscopy Center |
Tang V.,University of Hong Kong |
Tang V.,Endoscopy Center |
Lui P.C.W.,Union Hospital
Journal of Digestive Diseases | Year: 2012
Objective: The aim was to determine the detection rates and characteristics of large or proximal serrated polyps in Chinese patients undergoing screening colonoscopy. Methods: Consecutive screening colonoscopies performed between 2008 and 2011 were analyzed. Serrated polyps consisted of all hyperplastic polyps, sessile serrated adenomas and traditional serrated adenomas. Large serrated polyps were defined as serrated polyps with a diameter≥10mm. Lesions proximal to the descending colon were considered as proximal lesions. Advanced neoplasia included invasive adenocarcinomas, adenomas with high grade dysplasia, adenomas with any villous histology and tubular adenomas≥10mm. Results: In total, 1282 colonoscopies were included. The detection rates for adenoma, advanced neoplasia, proximal serrated polyps and large serrated polyps were 26.1%, 10.5%, 7.2% and 2.3%, respectively. There was a significant association between synchronous advanced neoplasia and large serrated polyps (P=0.002) or proximal serrated polyps (P=0.013). Age ≥55 years (OR 1.9, 95% CI 1.2-2.8) and the presence of advanced neoplasia (OR 1.8, 95% CI 1.0-3.1) were significantly associated with the presence of large or proximal serrated polyps. Males had more advanced neoplasia (OR 2.0, 95% CI 1.4-2.9), but not more large or proximal serrated polyps, than females. Conclusions: Large and proximal serrated polyps were detected in 2.3% and 7.2% of Chinese patients undergoing screening colonoscopies, respectively. Individuals with large or proximal serrated polyps have a higher risk of synchronous advanced neoplasia. © 2012 The Authors. Journal of Digestive Diseases. © 2012 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.
Sugimoto S.,Yokohama Municipal Citizens Hospital |
Sugimoto S.,Keio University |
Hosoe N.,Keio University |
Mizukami T.,Endoscopy Center |
And 11 more authors.
Digestive Endoscopy | Year: 2014
Background and Aim Although intestinal obstruction as a result of sigmoid volvulus (SV) may be successfully resolved using endoscopic detorsion, surgical treatment remains the main therapeutic strategy. We evaluated the endoscopic detorsion procedure using unsedated water-immersion colonoscopy for the treatment of SV. Methods A retrospective chart review was conducted on the clinical background and prognosis of 21 SV patients who underwent 71 endoscopic detorsion procedures using unsedated, water-immersion colonoscopy. Results In all, 14 (67%) male and seven (33%) female patients, with a mean age of 73 years (range, 54-95 years) were enrolled; 86% were >70 years of age. Among these patients, 90% had a background of key predisposing factors. In the 21 patients, endoscopic detorsion was successfully done using unsedated water-immersion colonoscopy. SV recurred in 10 patients at a median of 180 days. Endoscopic detorsion for recurrent SV was successfully achieved in all cases, and none of the secondary cases became severe. Only male patients were observed to experience three or more recurrent episodes of SV. Conclusions SV occurred most commonly in elderly patients with a surgical risk. Our experience suggests that conservative endoscopic treatment using unsedated water-immersion colonoscopy is a safe, reasonable, conservative endoscopic approach for elderly patients in the absence of necrotic findings. We currently use this procedure in most of our cases. © 2014 The Authors. Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society.
Sugimoto S.,Keio University |
Mizukami T.,Endoscopy Center
World Journal of Gastroenterology | Year: 2015
Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications. © The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
Mizukami T.,Endoscopy Center |
Ogata H.,Keio University |
Hibi T.,Keio University
World Journal of Gastroenterology | Year: 2012
Colonoscopy sometimes causes pain during insertion, especially in difficult cases. Over-insufflation of air causes elongation or acute angulations of the colon, making passage of the scope difficult and causing pain. We previously reported a sedative-risk-free colonoscopy insertion technique, namely, "Water Navigation Colonoscopy". Complete air suction after water infusion not only improves the vision, but also makes water flow down to the descending colon, while the sigmoid colon collapses and shortens. While non-sedative colonoscopy can be carried out without pain in most cases, some patients do complain of pain. Most of these patients have abnormal colon morphology, and the pain is caused while negotiating the "hairpin" bends of the colon. The "hairpin" bends of the colon should be negotiated by gently pushing the full-angled colonoscope. The proximal 10-20 cm from the angulated part of the conventional colonoscope is stiff, with a wide turning radius, therefore, a conventional colonoscope cannot be negotiated through the "hairpin" bends of the colon without stretching them and causing pain. The "passive-bending colonoscope" has a flexible tip with a narrow turning radius, so that the scope can be negotiated through the "hairpin" bends of the colon with a minimum turning radius and minimal discomfort. Therefore, the intubation and pain-reducing performance of the "passive-bending colonoscope" was assessed in difficult cases. © 2012 Baishideng.
PubMed | Wonkwang University and Endoscopy Center
Type: Journal Article | Journal: Clinical endoscopy | Year: 2015
Drainage of pancreatic abscesses is required for effective control of sepsis. Endoscopic ultrasound (EUS)-guided endoscopic drainage is less invasive than surgery and prevents local complications related to percutaneous drainage. Endoscopic drainage with stent placement in the uncinate process of the pancreas is a technically difficult procedure. We report a case of pancreatic abscess treated by repeated EUS-guided aspiration and intravenous antibiotics without an indwelling drainage catheter or surgical intervention.