Secondary Intention Research Articles

A novel tension relief technique to aid the primary closure of traumatic equine wounds under excessive tension.

To achieve an excellent functional and cosmetic result, primary closure is preferred over leaving wounds to heal by secondary intention. However, traumatic wounds are often under excessive tension during wound closure and incorrect suture technique can compromise microcirculation, leading to skin necrosis and impaired wound healing. To describe an inexpensive and effective tension relief technique that helps the successful primary closure of a variety of equine wounds at high risk of dehiscence. Retrospective case series. All wounds that were managed with the Tension Tile System (TTS) at four Equine Hospitals between March 2017 and May 2021 were evaluated. The wounds were classified according to various criteria including anatomical location, time elapsed prior to surgery, depth of wound and post-surgical use of immobilisation. Outcome criteria were based on the success of primary intention healing. The duration of convalescence (weeks) after surgery was also recorded. During the study period, the TTS was used in 191/860 (22%) wounds repaired under general anaesthesia or standing sedation. Overall, primary intention healing (Group A) was achieved in 132 of 191 cases (69%, CI 62%-75%), with partial dehiscence (Group B) in a further 30/191 cases (16%, CI 11%-22%). Severe dehiscence (Group C) was recorded in 29/191 cases (15%, CI 11%-21%). The median convalescence time was 4 weeks (Range 3-15, interquartile range 4-6) in Group A. Retrospective nature of the study and subjective outcome assessment. The technique was applied to wounds under significant tension; however, this was based on a subjective assessment by the surgeons involved. The Tension Tile System is an economical and effective technique for challenging equine wounds under tension, in a variety of anatomical locations.

Outcomes for 15 cats with bilateral sacroiliac luxation treated with transiliosacral toggle suture repair.

To report a surgical technique and outcomes of transiliosacral toggle suture repair to treat feline bilateral sacroiliac luxation/fracture (SILF). Retrospective study. Fifteen client-owned cats. The medical records of cats with bilateral SILF treated using a transiliosacral toggle suture repair were reviewed. Short- and medium-term outcomes were assessed through standard postoperative clinical evaluation and radiographs, including measurements of angle of deviation (AoD), percentage of reduction (PoR), and pelvic canal width ratio (PCWR). Long-term functional follow up was obtained from a questionnaire derived from the Feline Musculoskeletal Pain Index (FMPI). Fifteen cats were enrolled retrospectively, among which 13 survived to discharge. One minor wound complication, treated by secondary intention healing, was encountered. No major complication was reported. Immediately postoperatively, the mean absolute PoR values were 88.1 ± 11.2% and 91 ± 11.6% on the right and left side, respectively. The mean absolute AoD was 3.1 ± 2.8°, and the mean PCWR was 1.24 ± 0.08. The medium-term radiographic follow up at a median of 205 (71-682) days postsurgery revealed the good stability of the repair. Excellent functional outcomes were identified upon the analysis of 12 long-term questionnaires at a median of 365 (119-798) days postsurgery. Anatomic reduction was satisfactory and comparable with previously described techniques with good implant placement documented. Functional outcomes based on FMPI-derived questionnaires were good to excellent in our population. Transiliosacral toggle suture stabilization of bilateral SILF was associated with good outcomes in cats. Further studies are required to compare biomechanical properties and outcomes between this technique and previously described transiliosacral stabilization.

Practical Review on Delayed Primary Closure: Basic Science and Clinical Applications.

Wound healing complications present a significant burden on both patients and health-care systems, and understanding wound healing principles is crucial across medical and surgical specialties to help mitigate such complications. One of these longstanding principles, specifically delayed primary closure (DPC), described as mechanically closing a wound after several days of secondary intention healing, lacks clear consensus on its definition, indications, and outcomes. This practical review examines wound healing fundamentals, focusing on DPC, its execution, indications, and comparative outcomes. A PubMed literature search was conducted to retrieve studies on DPC. Inclusion criteria included comparative studies assessing outcomes and complications between DPC and other closure techniques, as well as articles investigating DPC's underlying physiology. Twenty-three comparative studies met inclusion criteria. DPC wounds have significantly higher partial pressure of oxygen, higher blood flow, and higher rates of collagen synthesis and remodeling activity, all of which help explain DPC wounds' superior mechanical strength. DPC seems most beneficial in contaminated wounds, such as complicated appendectomies, postcardiac surgery wounds, and complicated abdominal wall reconstructions, where it has been associated with lower rates of surgical site infections. This practical review provides an evidence-based approach to DPC, its physiology, technique, and indications. Based on the existing literature, the authors recommend that DPC wounds should be dressed in saline/betadine soaks, changed and irrigated daily, with delayed closure lasting between 3 and 5 days or until the infection has resolved. The clearest indications for DPC are in the context of contaminated abdominal surgery and sternal wound dehiscence post cardiac surgery.

Do Sex-Specific Factors Influence the Surgical Treatment of Facial Skin Cancer?

Facial skin cancer (FSC) is prone to incomplete excision due to the sophisticated anatomy and the aesthetic importance of the face. In this study, we sought to investigate to what extent sex-specific differences and other operation-, patient-, and cancer-specific factors influence the re-resection rate in FSC surgery, in order to provide personalized treatment strategies to patients. In this retrospective study, patients (>18 years) undergoing surgical excision of an FSC were enrolled. Each patient's demographic data, cancer location, the surgical team, primary and secondary surgeries were analyzed. Overall, 469 patients (819 surgeries) were included. The mean age was 69 ± 15 years. No significant association between sex-specific factors (surgeon's sex (OR: 1.09, 95% CI: 0.76-1.56) or patient's sex (OR: 0.85, 95% CI: 0.62-1.17), surgeon-patient sex concordance and discordance) and the likelihood of secondary surgery were found. However, healing by secondary intention (OR: 4.28; 95% CI: 1.94-9.45) and cancer location showed an increased re-resection rate. In conclusion, FSC surgery is a safe method unaffected by sex-specific factors, which had no impact on the re-resection rate. However, in further analysis, the likelihood of a re-resection was influenced by other factors such as healing by secondary intention and cancer location. This knowledge might be useful to provide an algorithm for personalized treatment strategies in the future.

Comparison of Outcomes of Three Different Modalities for Treatment of Acute Fingertip Injuries

The fingertip has a crucial role in providing tactile and sensory functions to the brain. Anatomically, it refers to the region behind the extensor tendons and point of insertion of the flexor digitorum superficialis at the distal phalanx or interphalangeal joint in the case of the thumb. Objective: To compare the outcomes of three different modalities for managing acute fingertip injuries involving healing by secondary intention, primary closure, and local flap coverage. Methods: A randomized control trial was conducted, employing non-probability consecutive sampling. The inclusion criteria consisted of patients aged 20 to 40 years with fingertip injuries and tissue loss categorized as Allen II, III, or IV injuries. Cold intolerance was assessed using the Cold Intolerance Severity Symptom (CISS) questionnaire, which assigns a score ranging from 0 to 100. The sensibility of the injured and uninjured fingers was evaluated using the Semmes-Weinstein monofilament test (SWF). The chi-square test was used to examine relevant relationships. Results: Statistically significant associations were observed between smoking, comorbidities, and treatment modalities (p < 0.001). Among smokers, 81% received Group A treatment, while only 38% of smoking patients were treated with Group B and 69% with Group C. In the Group A treatment, 54.8% of patients were left-handed, 57.1% had Allen III classification, 54.8% had transverse injuries, and only 8% experienced short-term complications (infection). Conclusions: Based on the study findings, no significant differences were identified among the three treatment modalities.

Identifying and interpreting euphemisms and dysphemisms in RFL classes (the case of political discourse)

This article is devoted to the issue of the need to include in the course of Russian as a foreign language the work on the analysis of Russian-speaking political discourse, the issues of identifying and interpreting euphemisms and dysphemisms in the political discourse, in particular. Euphemisms and dysphemisms are widely used by Russian speakers in a variety of communication situations and speech genres, including political discourse, which makes the research devoted to the systematic description of their functioning in modern Russian-language communication and their place in the Russian language picture of the world urgent. The relevance of the present study is due to the need to integrate the results of cognitive and pragmatic research into the purposeful activities of the teacher of Russian as a foreign language to form the linguistic personality of a foreign student, capable of educational and professional activities in the conditions of multicultural dialogue. The paper deals with the formation of foreign students’ skills and abilities of discursive analysis of the Russian text, identification and interpretation of speech tactics and strategies, the strategy of dominance and resistance, implemented in speech through the use of euphemisms and dysphemisms, in particular. At high levels of proficiency in Russian as a foreign language B2-C1 these skills are a necessary element of the professional competence of humanities professionals. The choice of political texts as the material for the analysis is connected with the fact that for professionals in the humanities, in the field of international relations, in particular, political discourse is a significant sphere of official communication and professional interaction. The aim of the present study is to analyze the theoretical foundations for describing euphemisms and dysphemisms for linguistic and pedagogical purposes, and to develop an approach to creating learning materials aimed at building the skills and abilities of foreign students to recognize hidden meanings and tools of indirect communication in Russian political discourse. The use of the proposed approach helps to develop in foreign students the ability to analyze political discourse and to identify the author’s key and secondary intentions, as well as to improve the skill of operating political terminology and the selection of lexical and verbal means in accordance with the communicative situation and the communicative goals and intentions pursued. The authors relied on the works of domestic and foreign linguists and methodologists in their research. The sociocultural, competence and systemic approaches were used in the research, and the method of complex text analysis and descriptive method were applied.

Correction of Habit along with Laser Assisted Frenectomy in High Frenal Attachment - A Case Report

Digit sucking is the most prevalent oral fixation seen in young toddlers. Digit sucking can be brought on by fatigue, boredom, excitement, hunger, fear, and both mental and physical stress. If these practices persist until the preschool years, when permanent teeth start to erupt, they may operate as a substantial environmental etiological factor in the development of malocclusion. The diode laser can be used to successfully remove pathological frenum. The diode laser can be used in paediatric dentistry due to its application, adequate coagulation, lack of need for sutures, and decreased discomfort and inflammation. In the case study presented in this paper, an 8-year-old female patient who had a high frenal attachment and had thumb-sucked her entire life was treated with fixed appliance therapy and laser labial frenectomy. In addition to resolved malocclusion, acceptable secondary intention wound healing, and beginning functional recovery of a physiological upper lip movement, the clinical evaluation revealed that the malocclusion had been corrected. The surgery was well tolerated, according to the patient. Keywords: Thumb sucking, Fixed appliance therapy, Laser frenectomy

A Case Study of Karanja Tail in the Management of Dushta Vrana

Healing of Vrana is a physiological process of regeneration and repair after injury. Frequency of injury is more common and management of wound is basic surgical skill. The wound is the biggest challenge to medical profession since vedic era . The wound is healed by three way first is primary intention , second is secondary intention third is by tertiary intention .Sushruta Samhita classical text of Ayurveda has elaborately explained Shashthi ( sixty types of procedures) for the management of wounds to achieve good early healing without complication. His techniques are broadly classified as Vrana Shodhana (wound cleaning) and Vrana Ropana (wound healing). Karanja Taila due to its shodhana and ropana properties plays a important role in Dushta vrana . In Dushta vrana vata and kapha dosha has predominant and Karanja Taila has vataghana and kaphagna properties that help in dosha shamana in Dushta vrana.

Ozonated sunflower oil in wound healing in a cat: Case report

Therapies with the use of ozone have been increasingly applied in both human and veterinary medicine due to its high oxygenating and antioxidant power. These factors stimulate the formation of deoxygenating substances within pathogens, which release oxygen into oxyhemoglobins, increasing its migration to epithelial tissues, thus being used in fungal, bacterial, viral and skin lesions. This work aims to report a clinical case of a feline whose veterinary medical clinic’s routine utilized ozone therapy in the primary treatment via ozonized sunflower oil in the tissue repair process. This method can help with the dermal secondary intention healing, having a good acceptance, not causing discomfort or stress to the animal and contributing to its well-being.

Endoscopic Pilonidal Sinus Treatment: Preliminary Results, Learning Curve and Comparison with Standard Open Approach.

Background: Pilonidal sinus (PNS) is a common disease which can lead to complications including infection and abscess formation. Different surgical approaches have been suggested, based on primary or secondary wound closure intention healing or endoscopic treatment (EPSiT). The aim of this study is to verify the superior outcomes of EPSiT, especially in comparison with the traditional open approach, and discuss the operators' learning curve. Methods: A retrospective study was conducted identifying all the patients who underwent surgical treatment for PNS with EPSiT technique between 2019 and 2022 and with open technique between 2002 and 2022. We divided patients in two groups: open procedure (group 1) and EPSiT (group 2). We considered a p value < 0.05 as statistically significant. Results: The mean operative time was 58.6 ± 23.7 min for group 1 and 42.8 ± 17.4 min for group 2 (p < 0.01). The mean hospital stay was 2.6 ± 1.7 days for group 1 patients and of 0.8 ± 0.4 days for group 2 (p < 0.01). Complete healing was obtained in 18.7 ± 5.6 days for group 1 and 38.3 ± 23.5 days for group 2 (p < 0.01). Recurrences were of 23.4% for group 1 and 5.4% for group 2 (p = 0.03). Conclusions: EPSiT is a minimally invasive and effective approach for the treatment of pilonidal cyst that can be safely performed in pediatric patients with promising results concerning aesthetic outcome and pain control, and with a rapid and less complicated recovery compared to traditional open procedures.

Addressing secondary traumatic stress, burnout, resilience and turnover in the child welfare workforce: Results from a 6-month, cluster-randomized control trial of Resilience Alliance

IntroductionUS child welfare agencies have historically struggled with workforce retention and turnover. As part of the Quality Improvement Center for Workforce Development in Child Welfare, we tested an adaptation of the Resilience Alliance (RA) model in a large, midwestern state to address workplace stress, burnout and actual workforce turnover. RA is a 24-week, facilitated program designed to mitigate the impact of secondary traumatic stress among child welfare professionals, and to therefore increase job satisfaction, resilience and optimism and to decrease turnover, stress reactivity and burnout. Methods: Supervisory units of caseworkers and supervisors were randomized to the RA treatment condition (n = 192) or a control condition (no intervention; n = 183). Hypothesis: We hypothesized that participation in the RA adaptation would cause the workforce to experience lower levels of secondary traumatic stress (STS), burnout and intent to search for work or leave their current position. We hypothesized that RA would lead to higher reported levels of resilience and intent to stay. Furthermore, if hypothesized changes were observed due to participation in RA, then such participation would also lead to decreased actual workforce turnover over a 2.5-year period. Results: There were no statistically significant effects of the intervention on changes in STS, burnout or resilience between treatment and control groups over a 6-month period. Participation in RA did cause significant differences in 6-month changes for four turnover intention measures. Finally, RA had no statistically significant effect on turnover. Limitations and implications are described.

Malignant Phyllodes Tumor in the Male: A Case Report

Phyllodes tumors are breast tumors accounting for about 1% of all breast neoplasms in women and are rare in males. Reported here is a case of a 45-year-old male presenting with a rapidly enlarging right breast mass with invasion of the anterior chest wall. Core Needle Biopsy revealed Malignant Phyllodes Tumor. He underwent wide excision and chest wall resection. Reconstruction was performed using polyropelene mesh, a latissimus dorsi flap and split thickness skin grafting. Patient was discharged on the 33rd post-operative day due to delayed expansion of the right lung from splinting and subsequent near-complete loss of the split thickness skin graft over the latissimus muscle flap. On the recommendation of the plastic surgeon, the wound was allowed to heal by secondary intention. This report draws attention to the rarity of malignant phyllodes tumor in males, and the difficulty of recognizing a malignant pathology in males presenting with breast mass. It also highlights a cost-effective treatment option in the management of these tumors. Key words: Malignant Phyllodes tumor, Male Phyllodes tumor, breast

Effect of different visual presentations on the public’s comprehension of prognostic information using acute and chronic condition scenarios: two online randomised controlled trials

ObjectivesTo assess the effectiveness of bar graph, pictograph and line graph compared with text-only, and to each other, for communicating prognosis to the public.DesignTwo online four-arm parallel-group randomised controlled trials....

Tracheocutaneous Fistula After Tracheostomy: Spotlight on a Closure Technique With a High Success Rate.

Tracheostomy is a commonly performed procedure in patients requiring prolonged mechanical ventilation. While it effectively provides a secure airway, tracheostomy can lead to complications, such as tracheal stenosis, tracheomalacia granulation tissue, pneumonia, aspiration tracheovascular fistula, tracheoesophageal fistula, and tracheocutaneous fistula. In this systematic review, we aim to identify the most suitable closure method and compare recurrence outcomes between methods for persistent tracheocutaneous fistula (TCF) in all age groups. We conducted a bibliographic search between January 1st, 2011 and March 10th, 2021 in the PubMed, B-on, Scopus, and Web of Science databases, and also performed a manual search to identify relevant articles. Our inclusion criteria were case series or comparative studies of surgery for persistent TCF and the success rate of TCF closure in patients both below and above 18 years of age. After applying the inclusion criteria to the research results, we included nine studies in our analysis. We found that closure by secondary intention is the most effective method for TCF closure, followed by primary and secondary intention combined. The success rate with most of the techniques was high, regardless of the size of the fistula or associated comorbidities, and its simplicity makes it an appealing treatment option in the care of patients with TCF. In conclusion, this systematic review highlights the importance of selecting an appropriate closure method for persistent TCF and provides valuable insights into the success rate of various techniques.

Appearance-related psychosocial distress after facial non-melanoma skin cancer surgery: A 1-year prospective study.

Patients undergoing Mohs Micrographic Surgery (MMS) for facial non-melanoma skin cancer (NMSC) experience appearance-related psychosocial distress due to its post-surgical esthetic changes. However, little is known about its development over a longer follow-up period. This study prospectively assessed appearance-related psychosocial distress in patients undergoing MMS for facial NMSC over a 1-year follow up period. Patients who had MMS for facial NMSC between September 2020 and October 2021 were invited to answer the FACE-Q Skin Cancer - appearance-related psychosocial distress scale preoperatively, 2weeks, 6months, and 1year after surgery. A total of 217 patients completed the questionnaire at baseline. In addition, 158 (72.8%), 139 (64.1%), and 120 (55.3%) questionnaires were successfully answered 2weeks, 6months, and 1year after surgery, respectively. Patients with a peripheral lesion presented higher appearance-related psychosocial distress scores at baseline than patients with a central lesion (p=0.02). There was a decreasing trend in appearance-related psychosocial distress over time, but without a significant result (baseline-2-week; p=0.73, 2-week-6-month; p=0.80, 6-month-1-year; p=0.17, baseline-1-year; p=0.23). Patients with secondary intention healing and graft reconstruction methods experienced more appearance-related psychosocial distress over time than patients with primary wound closures (p=0.03). Patients still experience appearance-related psychosocial distress 1year after MMS. These patients may benefit from targeted counseling. Additionally, predictors of more appearance-related psychosocial distress, such as secondary intention healing and graft reconstruction methods, may benefit from additional psychological care.

AB154. SOH23ABS_234. A systematic review and meta-analysis of contemporary management of perianal abscess: to pack or not to pack

Background: Traditional management of perianal abscesses involves incising the skin over the abscess to drain the abscess and allow wound irrigation. Following drainage an internal dressing is applied (packing) and is changed regularly until the abscess has healed by secondary intention. More contemporary perianal management strategies such as refraining from regular post-operative packing have shown promising results. The aim of this study was to synthesize the evidence for packing perianal abscesses compared to non-packing.

Ovine Forestomach Matrix in the Surgical Management of Complex Lower-Extremity Soft-Tissue Defects.

Chronic lower-extremity defects may lead to major amputations and have severe consequences on patient quality of life and mortality. Dermal matrices have become part of the reconstructive ladder and are often deployed in these scenarios to quickly build neodermis, especially in volumetric defects over exposed bone and tendon initially, to allow for subsequent closure by means of split-thickness skin grafting (STSG) or secondary intention. Ovine forestomach matrix (OFM) is a decellularized extracellular matrix (ECM) bioscaffold available in both sheet and particulate forms that can be used as a dermal matrix in various soft-tissue reconstruction procedures. This retrospective case series evaluated the use of OFM products in the surgical reconstruction of 50 cases (n = 50) comprised of challenging lower-extremity defects from seven healthcare centers. Patient records were reviewed to identify comorbidities, defect cause, defect size, presence of exposed structures, Centers for Disease Control and Prevention contamination score, Wagner grade, OFM graft use, time to 100% granulation tissue, STSG use, overall time to heal, and postoperative complications. The primary study outcomes were time (days) to 100% granulation tissue formation, with secondary outcomes including overall time to wound closure (weeks), STSG take at 1 week, and complications. The results of this case series demonstrate OFM as a clinically effective treatment in the surgical management of complex lower-extremity soft-tissue defects with exposed structures in patients with multiple comorbidities. One application of OFM products was effective in regenerating well-vascularized neodermis, often in the presence of exposed structures, with a mean time to 100% granulation of 26.0 ± 22.2 days. These data support the use of OFM as a safe, cost-effective, and clinically effective treatment option for coverage in complex soft-tissue wounds, including exposed vital structures, and to shorten the time to definitive wound closure in complicated patient populations.

Factors Affecting Secondary School Teachers' Intention to Use Education 4.0 in UAE: A UTAUT Analysis

The development of education 4.0, driven by information technology, is a crucial aspect of secondary school education in today's fast-paced world. However, limited empirical research exists on how UAE institutions engage with education 4.0, and little attention has been paid to the factors influencing the actual use of technology in this context. Previous studies have tended to focus predominantly on e-learning, students, and universities, rather than on factors driving the intention to use education 4.0. While previous research has identified various important factors affecting users' intention to use technology in developed countries, the factors may differ in the context of developing countries like the UAE. The factors include performance expectancy, effort expectancy, social influence, and facilitating conditions, which were identified through the Unified Theory of Acceptance and Use of Technology (UTAUT) model. To address this literature gap, this study seeks to investigate the factors influencing UAE secondary school teachers' intention to use education 4.0 building on already established antecedents and factors.

PC30. Utilizing Integra for Reconstruction of Facial Defects after Mohs Micrographic Surgery

PURPOSE: We aim to identify how Integra bilayer wound matrix has expanded facial reconstruction options after Mohs surgery due to its reliability in both single- and dual-stage reconstruction. METHODS: A retrospective review of patients undergoing Mohs surgery and alloplastic facial reconstruction with Integra between 2012-2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow up were included. RESULTS: One hundred thirty-two patients (86 males, 46 females) with a mean age of 74 years were included. Basal cell carcinoma was the most common malignancy (39%). One hundred forty-four lesions were treated and reconstructed same-day with Integra. Lesions most commonly involved the nose (34%) and forehead (22%). The mean post-operative defect size was 26.9cm2. 45.5% (n=60) of defect sites underwent single-stage Integra reconstruction with healing by secondary intention, while 54.5% (n=72) underwent dual-stage reconstruction with skin graft. Integra success rate was 90.2%. Average time to completed healing was 169.5 + 14.6 days. The complication rate was 12.8% (n=17), with 12 undergoing debridement, 3 needing placement of a new Integra graft, and 7 needing a new skin graft. The average size for successful healing without complication was 26.6 cm2. Nineteen sites (13.2%) underwent aesthetic improvement procedures with the majority occurring after dual-stage reconstruction (n=13). CONCLUSION: Integra is a reliable outpatient reconstructive option for facial Mohs defects that can increase the threshold for autologous flap harvesting and successfully reconstruct large defects of 26.6cm2 on average with low complication and reoperation rates.

Hyalomatrix coverage in scalp wounds with exposed cranium and dura

The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.