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Background/Introduction: WHO recommended ‘ready to use therapeutic food’ (RUTF) for community-based management (CMAM) of severely malnourished children (SMC). This is often rejected by children. The objective is to identify and map the locally produced and socio-culturally acceptable food items to treat SMC. Methods: Through community participation, eight varieties of MAHAN Local therapeutic foods (LTFs) were prepared by tribal females at our center as per WHO norms with a shelf life of 4 weeks. LTFs with micronutrients were given at the feeding centers in the villages under supervision 3 - 4 times a day. Results: Multiple, palatable, culturally acceptable, safe, feasible with local womanpower, and cost-effective recipes were developed. Hence, our LTFs are qualitatively superior to other therapeutic foods. This mapping exercise provides a ready reference to other government or non-government organizations for CMAM. Conclusion: MAHAN-LTF is a multiple, palatable, generalizable, and sustainable therapeutic food and are being used in other tribal blocks of India.

The COVID-19 pandemic resulted in public health measures and fewer viral infections, which trigger the nephrotic syndrome. Our objectives were to characterize the effect of the COVID-19 pandemic on children with nephrotic syndrome. This single-center retrospective chart review compared children with nephrotic syndrome one year before the pandemic with the first wave of the pandemic. Epidemiologic events, clinical characteristics, and health care utilization were compared using paired t-tests, Fisher’s exact tests and Wilcoxon Rank Sum tests. Among 96 children the mean age was 10.7 ± 5.28 years. The distribution was minimal change disease (16.7%), focal segmental glomerulosclerosis (12.5%), membranous nephropathy (1%) and not biopsied (69.8%). Medication responsiveness was steroid-sensitive (25%), frequently relapsed (54%) and steroid-resistant (20.8%). There were 14 new diagnoses of nephrotic syndrome pre-pandemic and 18 during the pandemic. Fewer relapses during the pandemic were likely due to fewer viral illnesses from public health measures during the pandemic.

Background: Hepatitis B is a major public health issue worldwide. Immunization of infants against this disease has been effective in Morocco since 1999. However, evaluation of post-vaccination response is rarely performed in our setting. The purpose of this study was to evaluate immunity against HBV in fully vaccinated children in the city of Marrakech in Morocco and to investigate the factors influencing the level of post-vaccination immunity. Methods: A descriptive cross-sectional study was conducted on fully vaccinated children who have medical and vaccination records, from three primary healthcare centers in Marrakech. Children with anti-HBs antibody levels between 10 and 100 IU/L were considered moderately immune, and those with antibody levels above 100 IU/L as highly immune, while those with antibody levels below 10 IU/L were considered non-immune. Results: Of the 123 children recruited, 114 (92.7%) had protective anti-HBs antibody titers, of which 37 (30%) were moderately immunized and 77 (62.7%) were highly immunized, and nine (7.3%) were non-immune. Age, birth weight, vaccine type, and time since the previous dose have all been significantly associated with the degree of post-vaccination immunity. Anti-HBs antibody levels were not significantly related to factors potentially linked to post-vaccination non-response, such as chronic disease, immunosuppressive medication and others.Conclusion: Our findings denote that the HBV vaccine used in The Moroccan Expanded Program on Immunization (EPI) is effective against HBV. Nevertheless, in non-responders, corrective actions such as re-vaccination and monitoring of post-vaccination anti-HBs antibody levels should be implemented.

Background: Pediatric nurses are in a unique position to provide oral health care to hospitalized children and help in the prevention and management of oral diseases. The objectives of this study were to determine pediatric nurses’ level of oral health knowledge and to evaluate their attitude towards the prevention of oral diseases and willingness to obtain more oral health education and training.Methods: A cross-sectional study was conducted at 6 randomly selected hospitals in Riyadh city, Saudi Arabia. A self-administrated questionnaire with items including demographic data, dental knowledge, attitude, and willingness to obtain more information and training was completed by 240 pediatric nurses working in different pediatric medical wards.Results: On average, 64% of surveyed pediatric nurses had acceptable dental knowledge. Only 79% of nurses assess patients’ mouths on admission. About 77% of nurses claimed to receive instructions regarding oral care before qualification and 72% after qualification. However, 91% showed great attitudes and interest in providing oral care to hospitalized children and were willing to obtain more information about oral health care for children.Conclusion: Pediatric nurses working in Riyadh hospitals had limited oral health knowledge, however, they showed good awareness and a positive attitude toward promoting oral health care to hospitalized children.

Introduction: Oral habit is common in childhood and it is proven to cause multiple adverse effects on oral and general health, while oral habits in the adult population are under looked. The prevalence of oral habits varied among different societies. The extent of these effects varies depending on a wide range of variables including the actual habit, the duration, and the intensity of the oral habit. Objectives: The primary objective is to determine the prevalence of oral habits in adults in Riyadh, Saudi Arabia, and the secondary objective is awareness of different types of oral habits and their adverse effects.Methods: Descriptive cross-sectional study using questionnaire through google form which will address the prevalence of 5 Oral habits in the adult population, Riyadh, Saudi Arabia such as nail biting, chewing on pens/pencils/Miswak, using the teeth as a tool, chewing ice, and teeth clenching/grinding and bruxism. Also, it will address the awareness of these 5 oral habits and their adverse effects on oral health and prevention modalities. Results: There were 220 participants. The majority were Saudi (52.7%), females (83.2%) with bachelor’s degrees (63.6%) and around fifty percent with age below 30 years old. The most prevalent pattern was using teeth as a tool (46.8%), followed by chewing ice (43.6%) and nail-biting (39.1%). All five habits were mainly started in childhood; however, a respectable percentage of beginning is still reported during adulthood, particularly for clenching/grinding/ bruxism and chewing ice, with a ratio of 36.4% and 25%, respectively. Most participants who reported clenching/grinding/ bruxism and nail-biting were related to stress (75.3%, 48.8%, respectively). The majority reported that oral habits could harm teeth (82.3%) and could be preventable (78.6%).Discussion: Most of the studies concentrate on oral habits in children while few studies had concentrated on oral habits in adults. Oral habit is not uncommon in adults, they have either to continue childhood bad habits or practice new oral habit. The adverse effect varies widely on oral and general health. Although the adult population is aware of these side effects few only seek medical advice.Conclusion: In Saudi Arabia, oral habit is not uncommon in adults. So the recommendation for the prevention of oral habits is to embed it in all public services, at strategic and operational levels.

Human osteosarcoma is the most common malignant bone tumor with an annual incidence of two cases per 1 million population. Osteosarcoma account for 60% of all malignant bone tumors occurring in childhood, followed by Ewing’s sarcoma [1-3]

Viruses becoming day by day dominate over humans, as a covid-19 pandemic is not jet over, new monkeypox virus infection cases emerged in the month of May 2020. On 13th May 2020 WHO reported monkeypox virus cases from 12 member states that are epidemic for this virus. In the past monkeypox virus are rarely seen outside of west and central Africa. Investigations are going to establish a travel link between reported cases and epidemic areas. There are very little data regarding viral mechanism or time of shading and still, we have no licensed treatment. Two smallpox-approved drugs brincidofovir and tecovirimat have efficacy against monkeypox shown in animals. Now two smallpox-recommended vaccinations JYNNEOS and ACAM2000 are also available and are efficient to prevent the monkeypox virus. Two second- and third-generation Vaccinations are recommended by WHO for people that are immunocompromised and children’s MVA-BN, LC16. This article aims to raise awareness of virus spread, providing information regarding virus detail, severity, precautions, and detection.

Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood and is very rare in the neonatal period. At this age, the alveolar type is a remarkably uncommon variety.We report a 56 days old female with alveolar RMS of the right eye noted since the age of 7 days with fast progression and unfavorable prognosis. Congenital alveolar RMS is an important cause of neonatal onset rapidly progressive proptosis. Early onset, alveolar type, and late diagnosis were poor prognostic factor.

SARS-CoV-2 is the virus associated with the disease called COVID-19 and become a global pandemic. The only way to prevent its severe scenarios is through timely and rapid testing. In comparison to more time taking gold-standard RT-PCR testing, rapid diagnostic kits are used. For better prevention and diagnosis of SARS-CoV-2, the analysis of rapid diagnostic kits' accuracy and specificity is necessary. This study is meant to assess and examine the viability, responsiveness, and explicitness of quick antigen distinguishing nasopharyngeal swabs (NPS), and saliva-based units. The study was conducted on 200 suspected COVID-19 patients from Islamabad, 100 of which were RT-PCR positive while 100 were RT-PCR negative. For the analysis of Rapid diagnostic COVID-19 kits (RDT), nasopharyngeal swabs (NPS) and saliva samples were taken from the RT-PCR positive and negative patients. Among 100 RT-PCR positive patients, 62% were males (19 - 91 years), 34% were females (20 - 78 years) and 4% were children (6 - 17 years). False-negative results were significantly more observed in saliva-based RDTs of the sample (49%) as compared to nasopharyngeal swab RDT (38%). There were 2% invalid results in saliva-based RDT and 3% invalid results in Nasopharyngeal swab RDT. While among 100 RT-PCR negative patients 69% were males (19 - 80 yrs), 27% were females (18 - 77 yrs) and 4% were children (12 - 16 yrs.). False positive results were significantly more in saliva-based RDT (22%) as compared to Nasopharyngeal swab RDT (13%). The sensitivity and specificity of saliva-based RDT were 67% and 87% respectively while that of Nasopharyngeal swab (NPS) was 72% and 82% respectively, both of which were less than the gold standard RT-PCR sensitivity demanding the introduction of more sensitive RDT kits in Pakistan for accurate detection of COVID-19.

The birth of a high-risk infant such as an extremely premature infant can represent an important traumatic experience for mothers. Perinatal Post Traumatic Stress Disorder Questionnaire (PPTSDQ) explores retrospectively maternal post-traumatic stress reaction. This shelf-rating questionnaire explores the potential for experiencing posttraumatic symptoms related to childbirth and the ensuing post-natal period. The PTSD questionnaire was originally developed by DeMier and Hynan and their colleagues at the University of Wisconsin and has been widely used in research and in clinical practice for identifying mothers experiencing significant emotional distress during the post-natal period, so they may be referred for mental health services. The present study aims to introduce this tool in perinatal settings as an early intervention. It has been widely used with other measures of post-traumatic stress and depression, such as the Openness Scale from the NEO-PR, the self-report measure of depression BDI-II, the IES (Impact Event Scale) and the EPDS (Edinburgh Postnatal Depression Scale). Although already a useful clinical instrument the current study used the revised version. This modification refines the response options from dichotomous choices to a Likert scale format by Callahan Borja and Hynan. Numerous qualitative and quantitative studies state that premature delivery is a highly stressful event and document the full range of post-traumatic sequelae, such as intrusive recollections, behavioral avoidance, and hyperarousal, as well as attachment difficulties following childbirth. Furthermore, the severity of neonatal complications and gestational age have been found to be predictive of PTSD symptomatology in parents as measured by the PPQ. For this reason, the current study aims to give increased focus to mothers having a premature birth and often expecting their children to die. The sample comprises 25 mothers of prematurely born infants hospitalized in the NICU and 25 mothers of full-term infants born in the maternity ward of the same Greek hospital who responded to the Perinatal PTSD Questionnaire and equally the PERI a postnatal complication rating inventory and the clinical interview for parents CLIP.Mothers of high-risk infants present post-traumatic stress reactions related to prematurity. The Perinatal PTSD Questionnaire identifies postnatal maternal distress but should not substitute a clinical interview, yet findings indicate that equally identifies pre-existing distress symptoms associated with maternal personality traits that emerged with the traumatic event of the unexpected birth.Due to the consistency of the population of the experimental group, who come mostly from the provinces, the possibility of a follow- up of the cases is quite limited.

The flat foot can be defined as a syndrome with multiple etiopathogenesis, characterized by an altered structure of the longitudinal arch of the plantar vault with its reduction in height. The plantar arch collapse can be counteracted by strengthening the muscles involved; for many years, specific physical exercises have been proposed for this purpose in physical and rehabilitation medicine. Our work aimed to improve the plantar arch muscles’ tone using high focal vibration therapy (300 Hz). Methods: 49 children with a 3rd degree flat foot (age: 8,7,6) underwent 10 sessions, 2 days/wk, of 30 min of focused high vibratory therapy at a frequency of 300 Hz (Vissman, Italy). Before and after treatment stabilometry (StT), static and dynamic baropodometry tests were performed. Results: Evaluation of StT showed an improvement in stability and a decrease in the sway area and ellipse area. Baropodometry tests showed a decrease in foot surface. Also, dynamic tests showed a decrease in both foot surfaces. Discussion: The results lead us to consider this method as a method of the first choice for a conservative approach in the rehabilitation of flat foot syndrome and also for 3rd grade children [1,2].

Studies in children with eosinophilic esophagitis (EoE) have reported esophageal strictures but none have examined risk factors associated with strictures. Aim: To assess risk factors associated with strictures in children with EoE. Methods: In this retrospective study, children with EoE seen over 20 years were separated into two groups; with and without strictures. Physical features, CBC, endoscopic findings, and biopsy of the distal and mid-esophagus were captured. Statistical significance with p - value and multivariate logistic regression was done. Results: Total patients 222 and 20 (9.1%) had strictures. Mean age of stricture patients 12.7 years (range 7-18) and non-stricture 9.3 years (range 1-17) (p = 0.006). Among stricture patients following were prevalent and significant; dysphagia (stricture 100% vs. non-stricture 41.6%, p = 0.0005) and food impaction (70.04% vs. 4%, p = 0.0005); EGD: rings and exudates were strongly associated with stricture, 45.0% vs. 4.5%, p = 0.0005 and 60% vs. 30.7%, p = 0.008, respectively. Abdominal pain was lower in the stricture group (5% vs. 31.2%, p = 0.017). Eosinophil counts were numerically more in the stricture group but not significant. Multivariate logistic regression confirmed that strictures are likely to occur among patients with dysphagia (p = 0.02, OR = 11.7, 95% LCL 2.0) and food impaction (p = 0.0001, OR = 80.9, 95% LCL 15.4), respectively, adjusted for age and gender. Conclusion: EoE children with dysphagia or food impaction have a higher chance of having an esophageal stricture. These EoE children 12 years or over with exudates or rings on endoscopy, should be treated and carefully monitored, to reduce the risk of stricture formation.

Many advances have been made in recent years in the development of hearing and cochlear implants. These use acoustic and electrical stimulation technologies to improve speech intelligibility for the hearing impaired. However, for cochlear prostheses, the results are not very promising and vary from one patient to another. Certain technical and sometimes physiological problems have limited the expected performances of these devices, especially for children and the elderly. These problems include cochlear malformation and ossification of the auditory channels. This led us to reduce the number of electrodes in order to allow quality deep insertion while preserving the low-frequency acoustic bands of the operated patient.

Congenital cystic adenomatoid malformation of the lung (CCAM) is characterized by an adenomatoid proliferation of bronchiole-like structures and cysts formation. The condition is most commonly found in newborns and children and may be associated with other malformations; rarely, the presentation is delayed until adulthood. We herein report two cases of CCAM in adult patients. 22 years old healthy female with pre-employment health screening chest x-Ray showed a lesion in the upper lobe of the right lung. In another case, a computed tomographic scan of the thorax (CT) confirmed a mass in the upper right lung. A 28-year-old male presented with recurrent respiratory tract infection resistant to antimicrobial therapy. CT scan of the thorax showed a mass in the left lung upper zone. Surgical resection was performed in both cases, and histopathology of the resected specimen showed both cases were consistent with the CCAM.

Background: A large body of evidence suggests that child abuse and neglect by a caregiver is a recurrent event linked to increased psychopathology symptoms. The Childhood Trauma Questionnaire (CTQ) is commonly used to assess abuse/neglect during childhood. However, even though the Minimization-Denial (MD) subscale was originally designed to assess response bias (i.e., underreporting of childhood maltreatment), it is possible that the scale may reflect coping strategies that play an effective role in the relationship between childhood trauma and their negative outcomes. Also, even though MD has been associated with decreased psychopathology symptoms, it is also strongly associated with other scales of the CTQ. Method: This study (n = 133) examined whether (1) the MD-scale is negatively associated with alexithymia, emotion dysregulation and psychopathology, if (2) these associations will hold when adjusting for different subtypes of abuse and neglect and (3) and the role of MD as a possible moderator in these relationships. Results: The analyses showed that, although MD scores have relatively strong and (mostly) significant (negative) associations with the CTQ, emotion dysregulation strategies and psychopathology symptoms, these associations were weak and failed to remain significant when adjusting for the effect of CTQ. Conclusion: Our findings suggest that the MD scores should be viewed as an accurate reflection of the absence (or little) of exposure to childhood abuse/neglect. 

Introduction: Sonographic scan tests are real-time procedures but the female reproductive systems are subject to continued changes beyond the mid-menstrual period. Therefore a second test may be useful after mid-menstrual ultrasound tests among women with infertility who first had normal ultrasound tests during the mid-menstrual period. Aim: The aim of this study is to find out whether physiological changes beyond the mid-menstrual period in the female reproductive system could develop into findings that could be missed at the first ultrasound test among women with infertility during mid menstrual period. Method: One hundred and forty (140) women participated in this study, over a period of 12 months. The inter-observer correlations were carried out. The ultrasound test measured the diameters of the endometrium and ovarian follicle. The study was carried out during the mid-menstrual cycle when normal changes are optimal. The subjects were women of childbearing age (18 years - 40 years) with 28 days cycles who were referred from the fertility clinic. Women who had previous pelvic surgery, women on fertility therapy, and women who were unsure of the date were excluded from the study. Only women who met the inclusion criteria were selected for the study. The selection was by convenience sampling method. The women underwent the first phase of the ultrasound test during the mid-menstrual cycle. Those who had ultrasonographic-positive infertility reports were returned to the referral clinic. Only women who had normal ultrasonographic fertility reports were included in the second phase of further ultrasonographic tests. The scans were carried out further for four days for this second phase study and the result was again compared with normal values. (Endometrium Normal range 7.4 mm - 13.5 mm and ovarian follicles normal range 17.4 mm to 23.5 mm). Results: The first phase of the scan showed 108 (77%) of the women had positive infertility results for endometrium and ovarian follicles, while 32 (23%) of the women had a normal ultrasonographic result and were rescanned over days. The findings of the second phase scan showed that 10 subjects (7.30%) showed new abnormalities, Findings were distributed in three sub-groups in this second phase of the study. Sub-group A, 4 (2.67%) had enlarged unruptured follicles, sub-group B, 6 (4.30%) had an endometrial cavity filled with fluid, sub-group C, 22 (15.70%) subjects still had normal scans who may be referred for other studies. Conclusion: Women with infertility who had a normal scan at the mid-menstrual cycle should be followed up with a second-phase ultrasound scan before other tests.

Background: Parapneumonic pleural effusion is a relatively common entity and continues to be a major cause of morbidity in children. However, managing this disease is still a matter of controversy between surgical and non-surgical options. With the advancement of mini-invasive surgery, video-assisted thoracoscopic surgery (VATS) has become a mainstay in the treatment of parapneumonic effusion in children. This study aimed to evaluate the clinical characteristics and pathological features of parapneumonic pleural effusion in children and to explore the feasibility and safety of the thoracoscopic approach in the pediatric population.Methods: The clinical data of all patients who underwent VATS for parapneumonic effusion between 2007 and 2021 were analyzed retrospectively. Factors that were documented included demographic criteria, clinical manifestations, preoperative examinations, therapeutic procedures, intraoperative findings, postoperative complications, and outcomes.Results: Totally, 35 patients with a mean age of 5.14 ± 3.9 years were operated on thoracoscopically. The mean duration of evolution before VATS was 9 days ± 4. All children were hospitalized in a Pediatric Continuing Care Unit. Antibiotic therapy was administrated in combination in all cases. Corticosteroid therapy was used in 2 patients. Thoracentesis was performed in 6 patients. Thoracostomy tube drainage was placed before surgery in 11 patients. The average duration of drainage before VATS was 6 days ± 4. VATS decortication and/or debridement was indicated as second-line in 23 patients. The average duration of the surgery was 51 minutes (20 min - 115 min). There is no conversion to open surgery and no intraoperative procedure-dependent complication. 4 children have early complications after the VATS and one patient had a late postoperative complication. There were no deaths during the hospital stay or follow-up. Conclusion: In skilled hands, VATS is safe, feasible, and effective in the management of parapneumonic pleural effusion in children with excellent outcomes.

Aim: The current paper presents a subjective symptom survey regarding postpartum discomfort (Study 1) and a case study on postpartum care using the program developed based on the survey results (Study 2). Thereafter, health care during the postpartum period is discussed.Methods: Study 1 analyzed 1638 postpartum women who completed the Subjective Fatigue Symptom Scale (SFSS) over the period from June 2012 to December 2019. Study 2 detailed the case of a 33-year-old primiparous woman who answered questions regarding the rehabilitation care program.Results: The 1638 subjects included in Study 1 had a mean age of 32.4 ± 8.2 years and a mean postpartum duration of 4.3 ± 2.3 months. Subjective symptoms included lower back pain, shoulder stiffness, sleepiness, wanting to lie down, yawing, and eye strain. The case included in Study 2 showed certain psychological and physical changes following the exercise program. The results of Study 1 showed that motor system discomfort, such as stiff shoulders and lower back pain, occurred in women across all postpartum stages. Our results demonstrated that care and exercise geared toward improving motor system function are imperative after childbirth. Meanwhile, the results of Study 2 imply that our rehabilitation program based on postpartum physical conditions had positive psychological and physical effects.Conclusion: Taken together, our results suggest that continuing rehabilitative care based on the physical condition during each postpartum stage facilitates improvement in mothers’ physical and psychological discomfort.

Introduction: Percutaneous kidney biopsy is a necessary tool to diagnose many kidney diseases. However, major complications were reported in adults, including bleeding in the kidney or around it, creation of arteriovenous fistula, wound infection, damage to adjacent organs, or even loss of the kidney. Such complications can rapidly develop serious consequences. Exploring risk factors might help in preventing them.Objective: The current study aims to evaluate and explore the complications that happened after percutaneous kidney biopsy in children and associated risk factors.Methodology: A retrospective record-based study was conducted by reviewing the medical records of children with post-ultrasound-guided percutaneous kidney biopsy complications at King Saud Medical City, a tertiary hospital in Riyadh, Saudi Arabia during the period from May 2014 to June 2021. Data were extracted using pre-structured data collection sheet. Data collected included children’s age, gender, primary disease, laboratory findings, and kidney complications with needed management. Results: The study identified 76 children who had undergone 86 ultrasound-guided percutaneous kidney biopsies in the study period and fulfil the inclusion criteria. Children’s ages ranged from 1 years to 15 years with a mean age of 7.3 ± 4.0 years old. Most of the study children had nephrotic syndrome (61.6%; 53), followed by glomerulonephritis (25.6%; 22). Thirty-five (40.7%) children developed at least one of the complications. The most-reported complication was microscopic haematuria (32.6%; 28), followed by gross haematuria (3.5%; 3), Flank pain was reported among 3 (3.5%) children also and hematoma (1 child), only 2 children (3.9%) among those who had no complications recorded Haemoglobin drop > 2 g/dl compared to 3 of those who had complications with no statistical significance (p = .365). Prothrombin time was significantly higher among children who had renal complications than others who had not (11.7 ± 1.8 vs. 10.8 ± 1.2 seconds; p = .022).Conclusion: Suggestive by the low need to intervene in complications, ultrasound-guided percutaneous kidney biopsy is a relatively safe procedure in children. Even in the most commonly observed complication, i.e. hemorrhagic ones, blood transfusion is rarely needed.

Background: Among the different forms of ectopic pregnancy, cesarean scar pregnancy is one of the most uncommon with an estimated incidence of 1/1800 pregnancies. A major risk of massive hemorrhage, it requires active management as soon as it is diagnosed because it can affect the functional prognosis of the patient (hysterectomy) but can also be life-threatening. Different surgical techniques are generally proposed in first intention to patients who no longer wish to have children, who are hemodynamically unstable and/or in case of failure of medical treatment.Case presentation: We hereby report the case of a young 19-year-old patient with no particular medical history, gravida 2 para 1 with a live child born after a cesarean section for fetal heart rhythm abnormalities during labor 5 months earlier and who presented to the emergency room of our structure for the management of a cesarean pregnancy scar diagnosed at 6 weeks of amenorrhea. She was successfully managed with an intramuscular injection of methotrexate. The follow-up was uneventful.Conclusion: The implantation of a pregnancy on a cesarean section scar is becoming more and more frequent. With consequences that can be dramatic, ranging from hysterectomy to life-threatening hemorrhage, clinicians must be familiar with this pathological entity and be prepared for its management. The latter must be rapid and allow, if necessary, the preservation of the patient's fertility. In this sense, conservative medical treatment with methotrexate injections should be proposed as a first-line treatment in the absence of contraindication.