Novel clinical scores for occupational asthma due to exposure to high-molecular-weight agents

OBJECTIVE

Specific inhalation challenge (SIC) as the reference diagnostic test for occupational asthma (OA) is not widely available worldwide. We aimed to develop non-SIC-based models for OA.

METHODS

Of 427 workers who were exposed to high-molecular-weight agents and referred to OA clinic at Montréal Sacré-Cœur Hospital between 1983 and 2016, we analysed 160 workers who completed non-specific bronchial hyper-responsiveness (NSBHR) tests and still worked 1 month before SIC. OA was defined as positive SIC. Logistic regression models were developed. The accuracy of the models was quantified using calibration and discrimination measures. Their internal validity was evaluated with bootstrapping procedures. The final models were translated into clinical scores and stratified into probability groups.

RESULTS

The final model, which included age ≤40 years, rhinoconjunctivitis, inhaled corticosteroid use, agent type, NSBHR, and work-specific sensitisation had a reasonable internal validity. The area under the receiver operating characteristics curve (AUC) was 0.91 (95% CI 0.86 to 0.95), statistically significantly higher than the combination of positive NSBHR and work-specific sensitisation (AUC=0.84). The top 70% of the clinical scores (ie, the high probability group) showed a significantly higher sensitivity (96.4%vs86.9%) and negative predictive value (93.6%vs84.1%) than the combination of positive NSBHR and work-specific sensitisation (p value <0.001).

CONCLUSIONS

We developed novel scores for OA induced by high-molecular-weight agents with excellent discrimination. It could be helpful for secondary-care physicians who have access to pulmonary function test and allergy testing in identifying subjects at a high risk of having OA and in deciding on appropriate referral to a tertiary centre.

Reproducibility of Acoustic Rhinometry in the Investigation of Occupational Rhinitis

Background

To diagnose occupational rhinitis, it is mandatory to conduct an objective assessment of changes in nasal patency during specific inhalation challenge (SIC). The reproducibility of acoustic rhinometry measurements in the setting of occupational challenges has never been examined. This study assessed the reproducibility of acoustic rhinometry during SIC investigation of occupational rhinitis.

Methods

Twenty-four subjects underwent acoustic rhinometry measurements during SIC investigation of occupational rhinitis. Subjects attended 3–6 days of SIC within a week by means of a realistic or closed-circuit apparatus methodology

Results

All of the within-day intraclass correlation coefficients (ICCs) for nasal volume (2–5 cm) and minimum cross-sectional area (MCA) based on a different number of measurements (2–7) were above 0.85; all of the coefficients of variation (CVs) for the same parameters were low (below 10%). The between-day CVs based on different numbers of SIC sessions ranged from 8.0 to 8.8% and from 6.8 to 8.8% for nasal volume and MCA, respectively. The between-day ICCs ranged from 0.80 to 0.88 and from 0.83 to 0.94 for nasal volume and MCA, respectively.

Conclusion

Acoustic rhinometry showed good within- and between-day reproducibility and can be recommended for the objective monitoring of nasal patency during SIC investigating occupational rhinitis.

Diagnostic Accuracy of Inflammatory Markers for Diagnosing Occupational Asthma

BACKGROUND

The assessment of airway responsiveness and inflammation is key to the investigation of occupational asthma (OA).

OBJECTIVE

We sought to assess and compare the diagnostic accuracies of the blood and sputum eosinophil counts and the methacholine challenge for the diagnosis of OA.

METHODS

We conducted a retrospective study assessing 618 patients who underwent specific inhalation challenges (SICs) for symptoms suggestive of OA between 2000 and 2015. A sputum induction and a methacholine challenge were performed before and after SICs. Blood samples were collected in all subjects before the SICs and in 100 subjects before and after SICs. The diagnostic accuracies of blood and sputum eosinophil counts and methacholine challenge were calculated for diagnosing OA.

RESULTS

The change in blood eosinophil count failed to differentiate workers with positive and negative SICs. The change in sputum eosinophil counts induced by the exposure to the offending agent had the highest diagnostic accuracy (receiver operating characteristic area under the curve: 86% [95% confidence interval: 0.8-0.9, P < .001]) for diagnosing OA compared with changes in concentration of methacholine inducing a 20% fall in forced expiratory volume in 1 second (PC₂₀) and blood eosinophils. Combining a 2-fold or greater decrease in PC₂₀ or a 3% or greater increase in sputum eosinophil count achieved a sensitivity of 84% and a specificity of 74% with a negative predictive value of 91% for the diagnosis of OA.

CONCLUSIONS

Blood eosinophil counts do not appear to be an effective aid for diagnosing OA. The performance of both sputum cell count analysis and a methacholine challenge before and after exposure to the offending agent may represent an effective alternative in diagnosing OA when SICs are unavailable.

Occupational rhinitis due to steel welding fumes

Exposure to welding fumes is a recognized respiratory hazard. Occupational asthma but not occupational rhinitis has been documented in workers exposed to steel welding fumes. We report a 26-year-old male with work-related rhinitis symptoms as well as lower airways symptoms suggestive of occupational asthma and metal fume fever associated with exposure to steel welding fumes. The diagnosis of occupational rhinitis was confirmed by specific inhalation challenge.

Matrix metalloproteinase-9 increases in the sputum from allergic occupational asthma patients after specific inhalation challenge

BACKGROUND

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) play a role in the pathogenesis of asthma. MMP-9 increases in the sputum of asthmatic patients after bronchial challenge with common allergens. We sought to assess whether a high-molecular-weight occupational allergen was able to induce changes in MMP-9 as well as in other MMPs and TIMPs in subjects with occupational asthma.

METHODS

Ten patients underwent specific inhalation challenge (SIC) on 2 consecutive days. We monitored changes in lung function by measuring FEV(1) for 7 h. Induced sputum test was performed at 6 h after sham and flour challenge. The total and differential cell counts were analyzed. Levels of MMPs (specifically MMP-2, MMP-7, MMP-9 and MMP-13) were measured using Fluorokine® MultiAnalyte Profiling kits and a Luminex® Bioanalyzer, while levels of TIMP-1 and TIMP-2 were measured by ELISA.

RESULTS

Flour challenge increased the percentage of eosinophils in sputum samples. Asthmatic reactions induced by flour were associated with a significant increase in the sputum level of MMP-9 (p = 0.05), but not in the levels of MMP-2, MMP-7, MMP-13, TIMP-1 and TIMP-2. Sputum levels of MMP-9 measured after flour challenge were nearly significantly correlated (r = 0.67; p = 0.06) with the maximal fall in FEV(1) observed during the asthmatic reaction, but they did not correlate with the number of neutrophils (r = 0.18; p = 0.7) and eosinophils (r = 0.55; p = 0.2).

CONCLUSIONS

This study showed that MMP-9 increases in sputum samples from sensitized occupational asthma patients after SIC with flour.

Upper airway symptoms among workers with work-related respiratory complaints

BACKGROUND

Work-related rhinitis and asthma symptoms frequently co-exist.

AIMS

To determine the prevalence and nature of nasal, pharyngeal, laryngeal and sinus symptoms among individuals with work-related respiratory symptoms.

METHODS

Individuals referred to a tertiary occupational asthma clinic for investigations with specific inhalation challenges were evaluated using the RHINASTHMA quality of life questionnaire and a questionnaire that assessed the nature and frequency of upper airway symptoms, their relationship to the workplace and their temporal relationship with the onset of asthma symptoms.

RESULTS

There were 83 study participants. At least one upper airway symptom was reported by all of these individuals: nasal in 92%; pharyngeal in 82%; laryngeal in 65% and sinus in 53% of participants. Overall, there were no significant differences in the frequencies of nasal, pharyngeal, laryngeal and sinus symptoms when comparing these with occupational asthma (OA), work-exacerbated asthma (WEA) and work-related respiratory symptoms (WRS), except that nasal bleeding was most frequent among those with WRS. The presence of laryngeal symptoms was significantly associated with rhinitis-specific quality of life impairment. Individuals with workplace exposures to high molecular weight agents had greater impaired quality of life than those who were exposed to low molecular weight agents (RHINASTMA Upper Airway sub-scores: 24.0±10.4 versus 19.8±6.8; P < 0.05).

CONCLUSIONS

Individuals who were referred for work-related respiratory symptoms experienced high rates of work-related nasal, pharyngeal, laryngeal and sinus symptoms, regardless of having OA, WEA or WRS.

Occupational rhinitis caused by concurrent sensitization to two different allergens

BACKGROUND

Exposure to wheat flour and guar gum is a well-known cause of occupational respiratory allergies among workers in the food processing industry. To date, there have been no reports of occupational rhinitis (OR) caused concurrently by two different allergens present in the workplace.

AIMS

To report a case of OR likely to be induced concurrently by exposure to wheat flour and guar gum in a mid-40s male employed in the food processing industry.

METHODS

Allergy tests and nasal challenge tests were performed to investigate and confirm the diagnosis of OR. We discuss potential mechanisms involved in the observed dual sensitization.

RESULTS

The patient showed positive responses to wheat and guar gum extracts on skin prick testing. The total IgE was 1680 kU/l (0-100 kU/l). The diagnosis of OR was confirmed by nasal challenge tests with wheat flour and guar gum on different days. In contrast to the control day, the challenge with flour and guar gum induced an immediate clinical reaction associated with a decrease in nasal volume measured by acoustic rhinometry. The patient was advised to avoid exposure to wheat and guar gum, which resulted in a gradual resolution of nasal symptoms.

CONCLUSIONS

Co-sensitization and cross-reactivity are possible mechanisms involved in cases of concurrent sensitization to related and unrelated allergens in patients complaining of work-related rhinitis symptoms.

Matrix metalloproteinases and tissue inhibitors of metalloproteinases in nasal lavage after an inhalation challenge with flour

OBJECTIVES/HYPOTHESIS

The existence of nasal mucosa remodeling in allergic rhinitis is controversial. Few data are available on the dynamics of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in nasal fluid after an allergen challenge. We examined whether an immediate allergic reaction that induces nasal congestion and inflammation is able to also induce changes in remodeling parameters in nasal fluid.

STUDY DESIGN

Controlled experimental study.

METHODS

Ten patients with allergic occupational rhinitis due to flour underwent a control and active inhalation challenge with serial monitoring of nasal congestion and nasal symptoms with acoustic rhinometry and a visual analogue scale. Levels of remodeling markers (MMP-2, MMP-7, MMP-9, MMP-13, TIMP-1, TIMP-2) and inflammatory cells in nasal fluid were measured before the challenge and at 30 minutes, 6 hours, and 24 hours following the challenge.

RESULTS

In contrast to the control challenge, the flour challenge induced nasal symptoms and significant decreases in nasal volume in all subjects. After the flour challenge, a significant increase in nasal levels of TIMP-2 and a nonsignificant increase in TIMP-1 levels were observed, whereas no significant changes in nasal levels of MMPs were documented.

CONCLUSIONS

This study showed that after an inhalation challenge with an occupational allergen, the nasal mucosa displayed an imbalance in favor of TIMPs enzymes activity as compared to MMPs enzymes activity, represented in an increase in nasal levels of TIMP-2 during the course of the early reaction following the allergen challenge.

Polymorphisms in the nitric oxide synthase 1 gene are associated with severe chronic rhinosinusitis

BACKGROUND

Nitric oxide (NO), is a biological messenger molecule and a component of innate immunity, with important roles in the regulation of inflammation and in defense against bacterial biofilms. Polymorphisms in genes regulating NO production have the potential for a role in the development of chronic rhinosinusitis (CRS). The purpose of this study was to determine whether polymorphisms in genes regulating NO synthesis are associated with CRS.

METHODS

An established population of 206 individuals with severe CRS and 196 postal code-matched controls was previously screened using a pooling genome-wide associations study to estimate allelic frequency. Genes regulating NO synthesis with a maximal probability of association were identified. High-probability single nucleotide polymorphisms SNPs from the NO synthase (NOS1) and its ligand NOS1 adaptor protein (NOS1AP) genes were retained for individual genotyping. PLINK software was used to determine association.

RESULTS

Sixteen SNPs were genotyped successfully with a genotype distribution in agreement with Hardy-Weinberg equilibrium. Two SNPs for NOS1 (rs1483757 and rs9658281) were significantly associated with CRS, with a protective effect. The severe subphenotype showed stronger associations. Subgroup analysis for the presence of nasal polyps, origin, and gender did not influence strength of associations.

CONCLUSION

These data suggest that polymorphisms in the NOS1 gene may play a role in the susceptibility to develop CRS. Study findings apply to patients with severe CRS, unresponsive to surgery.

Correlation between acoustic rhinometry and subjective nasal patency during nasal challenge test in subjects with suspected occupational rhinitis; a prospective controlled study

OBJECTIVES

To assess the correlation between acoustic rhinometry and visual analogue scale endpoints in the context of nasal challenge with occupational agents.

DESIGN

Prospective controlled study.

SETTING

University teaching hospital.

PARTICIPANTS

Sixty-seven subjects with a history of work-related rhinitis and asthma symptoms.

MAIN OUTCOMES MEASURES

Subjects underwent nasal challenge with control and specific agent on consecutive days. Nasal congestive response to challenge was monitored by acoustic rhinometry and visual analogue scale.

RESULTS

Results showed no correlation between visual analogue scale and acoustic rhinometry measurements at baseline on the control (r=-0.13, P=0.3) and active (r=0.14, P=0.2) challenge days. No correlation was found between acoustic rhinometry and visual analogue scale when analysing all measurements obtained at all times after challenge with the control and active agent (control: r=0.09, P=0.04; active: r=0.001, P=0.9). The correlation between acoustic rhinometry and visual analogue scale was good and significant (r=-0.62, P=<0.01) when the analysis was restricted to cases showing a decrease in nasal volume>40% from baseline values.

CONCLUSIONS

We showed that the correlation between acoustic rhinometry and subjective nasal patency was poor on steady conditions. However, a significant correlation was observed in those cases showing a greater nasal congestive response after challenge measured by acoustic rhinometry.

Occupational rhinitis and asthma: where do we stand, where do we go?

This review provides an overview of current and emerging issues regarding occupational rhinitis (OR) and occupational asthma (OA), focusing on studies discussing concepts and results that are relevant to both diseases. OA and OR are conditions that affect the upper and lower airways, are characterized by reduced airway caliber and hyperresponsiveness and by inflammation, and are caused by agents present in the workplace. To explain disease expression, research is moving from the T-helper type 1/type 2 cells paradigm to consider the contribution of diverse alternative pathways such as neural inflammation, a dysfunctional epithelial barrier, and autoimmune mechanisms, among others. Objective assessment of OR and OA has been improved and tested for research and, currently, clinical application. Further developments in the field of OR are expected to lead to more generalized clinical applications, following the example of what has been achieved for OA.

Proinflammatory mediators in nasal lavage of subjects with occupational rhinitis

We sought to investigate the type and kinetics of late-phase nasal inflammatory response after nasal challenge with occupational allergens. Participants were 10 subjects experiencing work-related rhinitis symptoms who underwent specific inhalation challenge and tested positive for occupational rhinitis. During challenge, we monitored changes in inflammatory cells, eosinophil cationic protein, myeloperoxidase, and interleukin-8 in nasal lavage samples. The challenge with the active agent induced a significant increase in the percentage of eosinophils at 30 minutes as compared with prechallenge values (P = 0.04). A significant increase in eosinophil cationic protein levels after challenge with the control (P = 0.01) and active agent (P = 0.02) was observed in the late phase after challenge. No significant changes in nasal levels of neutrophils, myeloperoxidase, and interleukin-8 were observed on both control and active challenge days. Our results suggest a predominant nasal eosinophilic inflammatory response after occupational allergen challenge.

c-MET pathway involvement in chronic rhinosinusitis: a genetic association analysis

OBJECTIVE

The c-MET receptor and its ligand hepatocyte growth factor (HGF) has been shown to be overexpressed in tissue from chronic rhinosinusitis (CRS) patients with nasal polyps compared with that from controls. We assessed the genetic association of polymorphisms in the met proto-oncogene (MET) gene with CRS.

STUDY DESIGN

Case-control genetic association study.

SETTING

Tertiary-care university hospital.

SUBJECTS AND METHODS

A total of 206 unrelated Canadian patients with CRS and 196 control subjects were enrolled. Subjects were genotyped for 33 polymorphisms in the MET gene.

RESULTS

The allelic association analysis showed eight single nucleotide polymorphisms in the MET gene (rs38850, rs38855, rs38857, rs2237717, rs2402118, rs193688, rs1621, rs42336) with a statistically significant association with CRS. The rs38850 T allele showed the strongest association and the highest risk for CRS (P = 0.004; odds ratio 1.65, 95% confidence interval 1.18-2.32); the association did not reach statistical significance after adjustment for genomic control (P = 0.06). The haplotype TGG constructed of markers rs38850, rs38855, and rs38857 represented a risk haplotype, resulting in a P value of 0.003 that remained significant after correction for multiple testing (P = 0.018).

CONCLUSION

These data suggest that polymorphisms in the MET gene may play a role in the susceptibility to develop CRS. Study findings apply to patients with severe CRS unresponsive to surgery.

Evidence of Association of Interleukin-1 Receptor-Like 1 Gene Polymorphisms with Chronic Rhinosinusitis

Background

Chronic rhinosinusitis (CRS) is a common complex respiratory disease, with a potential genetic component to its development. The protein encoded by the Interleukin-1 receptor-like 1 (IL1RL1) gene is an important effector molecule of T-helper type 2 responses and may potentially be involved in the persistent inflammatory process observed in CRS. We investigated whether certain polymorphisms in the IL1RL1 gene are differentially present in patients with surgery-unresponsive CRS and in control subjects.

Methods

DNA extracted from an existing population of 206 adult patients with surgery-unresponsive CRS and 196 postal-code-matched controls was used. A set of 15 tagging single nucleotide polymorphisms (SNPs) was selected from the HapMap data set and genotyped. DNA sequencing was performed in a subgroup of 15 CRS patients.

Results

Statistically significant allelic associations with CRS were noted for 5 SNPs (rs10204137, p = 0.04; rs10208293, p = 0.03; rs13431828, p = 0.008; rs2160203, p = 0.03, and rs4988957, p = 0.03). The analysis showed a consistent significant protective effect against CRS for all the SNPs, yielding an odds ratio (OR) ranging from 0.56 to 0.72. The loci rs13431828 showed the highest association with CRS (p = 0.008; OR = 0.56; 95% CI, 0.36–0.86). A subanalysis revealed that the observed associations were stronger among patients with more severe disease. Sequencing identified five additional known nonsynonymous coding SNPs in linkage disequilibrium with genotyped SNPs.

Conclusion

Pending replication of these results, this study suggests that polymorphisms within the IL1RL1 gene may be associated with CRS, conferring a protective effect, particularly among those with severe disease.

EAACI position paper on occupational rhinitis

The present document is the result of a consensus reached by a panel of experts from European and non-European countries on Occupational Rhinitis (OR), a disease of emerging relevance which has received little attention in comparison to occupational asthma. The document covers the main items of OR including epidemiology, diagnosis, management, socio-economic impact, preventive strategies and medicolegal issues. An operational definition and classification of OR tailored on that of occupational asthma, as well as a diagnostic algorithm based on steps allowing for different levels of diagnostic evidence are proposed. The needs for future research are pointed out. Key messages are issued for each item.

Occupational rhinitis

The present document is the result of a consensus reached by a panel of experts from European and nonEuropean countries on Occupational Rhinitis (OR), a disease of emerging relevance, which has received little attention in comparison to occupational asthma. The document covers the main items of OR including epidemiology, diagnosis, management, socio-economic impact, preventive strategies and medicolegal issues. An operational definition and classification of OR tailored to that of occupational asthma, as well as a diagnostic algorithm based on steps allowing different levels of diagnostic evidence, are proposed. The needs for future research are pointed out. Key messages are issued for each item.

Reproducibility of Nasal Lavage in the Context of the Inhalation Challenge Investigation of Occupational Rhinitis

Background

The nasal lavage (NAL) method is increasingly used to assess changes in upper airways inflammation in the investigation of occupational rhinitis (OR). A good reproducibility of the method is fundamental to accurately assess changes in markers of inflammation in nasal secretions before and after inhalation challenges. The main objective of this study was to assess the short-term reproducibility of cells and cellular markers of inflammation in NAL in the setting of specific inhalation challenge (SIC) investigating OR. An ancillary objective was to assess the reproducibility of NAL in the context of two different SIC methodologies.

Methods

Twenty-five subjects attended the laboratory for 2 separate days of NAL performed within the same week. On the first visit subjects underwent NAL before a SIC sham session and on the second visit before a SIC with the active agent. These prechallenge NAL measurements obtained on both days were used to analyze the reproducibility of the NAL method.

Results

The reproducibility for cell differential counts was satisfactory for neutrophils (intraclass correlation coefficient [ICC] = 0.68), for eosinophils (ICC = 0.95), for macrophages (ICC = 0.77), and for epithelial cells (ICC = 0.73). The reproducibility of total cell counting was poor (ICC = 0.12). The reproducibility of ECP concentrations was satisfactory (ICC = 0.67). Eosinophil counts were reproducible in the context of two different challenge methodologies.

Conclusion

The NAL method was shown to be sufficiently reproducible to be considered useful for the monitoring of upper airways inflammation during the investigation of OR by SIC.

Categorizing nasal septal perforations of occupational origin as cases of corrosive rhinitis

BACKGROUND

In clinical practice a perforation of the nasal septum secondary to an occupational exposure to corrosive chemicals is not considered a sequel of rhinitis.

METHODS

Relevant articles published in the last 26 years were searched and retrieved from PubMed.

RESULTS

Patients with nasal septal perforations of occupational origin show a history of rhinitis with a gradual installation of symptoms and damage of the nasal mucosa progressing to ulceration and ultimately to perforation of the nasal septum.

CONCLUSION

Patients with nasal septal perforations of occupational origin exhibit the clinical and histopathological features of rhinitis whereby they should be categorized as rhinitics. This rhinitis should be considered as a type of irritant-induced occupational rhinitis and classified as corrosive rhinitis.

Occupational rhinitis

PURPOSE OF REVIEW

This review updates existing knowledge on occupational rhinitis based on epidemiological and clinical research studies published from 2003 to 2005.

RECENT FINDINGS

The review covers new developments on the pathophysiology, diagnosis, monitoring and management of occupational rhinitis. This article also provides updated information on the prevalence and incidence of both occupational rhinitis and work-related symptoms of rhinitis, as well as on causal agents and personal risk factors associated with this condition.

SUMMARY

Occupational rhinitis is frequently under-diagnosed due to a lack of physician awareness. Diagnosis is suspected when symptoms occur in relation to work. Differentiating between immunological sensitization and irritation may be difficult. Given the high prevalence of rhinitis in the general population from all causes, objective tests confirming the occupational origin are essential. Measures of inflammatory parameters via nasal lavage and objective assessment of nasal congestion both offer practical means of monitoring responses. Growing experience with acoustic rhinometry and peak nasal inspiratory flow suggests that these methods will have an increasingly important role in monitoring and diagnosing in the future. Recent findings indicate that work-related rhinitis is to some extent preventable. Surveillance of sensitized workers may allow early detection of occupational rhinitis.

Defining and classifying occupational rhinitis

Three categories of rhinitis may occur in the workplace: occupational rhinitis, work-aggravated rhinitis and rhinitis-like conditions. In the present paper, we propose a new definition and a new classification of occupational rhinitis that takes into account mechanisms of induction as well as clinical presentation. In parallel with occupational asthma, occupational rhinitis is defined as a type of rhinitis characterized by intermittent or sometimes permanent nasal airflow limitation due to causes and conditions attributable to the work environment. Occupational rhinitis is classified according to its mechanism of induction as immunological or irritant-induced (non-immunological) rhinitis. Occupational rhinitis of the immunological type can itself be episodic or persistent, whereas the non-immunological type is subdivided into acute, chronic and corrosive.

Orthotopic heart transplantation for dilated cardiomyopathy in a patient with persistent left superior vena cava and atresia of the right superior vena cava

OBJECTIVE

To describe the surgical procedure of an orthotopic heart transplantation in a recipient with persistent left superior vena cava and atresia of right superior vena cava.

EXPERIMENTAL DESIGN

Case report.

PATIENT

A 43 year old male with persistent left superior vena cava, atresia of the right superior vena cava and dilated cardiomyopathy.

INTERVENTIONS

Orthotopic heart transplantation with selective cannulation of the left superior vena cava via recipient coronary sinus for cardiopulmonary bypass.

RESULTS

No perioperative complications, satisfactory postoperative course. No rejection episodes at 7 months postoperative with non invasive procedure surveillance.

CONCLUSION

Technique described to preserve left superior vena cava is a useful alternative for this patient with no surgical complications.