Background: Data published by task groups of the Ministry of Health of the Russian Federation, the European Society of Cardiology, and other medical associations and institutions show that chemotherapy-induced cardiomyopathy is still a challenging issue that requires further research.

Objective: To compare the cardioprotective potential of trimetazidine and dapagliflozin in a rat model of doxorubicin-cyclophospha-mide cardiomyopathy.

Materials and methods: Our randomized in vivo experimental study included 80 Wistar female rats. Doxorubicin and cyclophosphamide were administered at a dose of 15 mg/kg and 150 mg/kg, respectively. Trimetazidine (42 mg/kg) and dapagliflozin (14 mg/kg) were additionally administered to groups 3 and 4, respectively. The total duration of the experiment was 14 days.

Results: Doxorubicin+cyclophosphamide mode of chemotherapy induces the development of toxic-ischemic cardiomyopathy. The trimetazidine and dapagliflozin administration was accompanied by stabilization of cardiovascular parameters. Comparison of both drugs’ cardioprotective properties revealed a clear advantage of dapagliflozin over trimetazidine, especially in terms of such an important indicator as N-terminal pro-B-type natriuretic peptide.

Conclusions: Further research aimed at exploring the cardioprotective potential of dapagliflozin against cardiovascular complications of chemotherapy is justified from a pathogenetic point of view.

Objective: To assess the risks of no/slow-­reflow phenomena and treatment outcomes in patients with ST­-segment elevation myocardial infarction (STEMI) from different age groups.

Materials and methods: We analyzed treatment outcomes of 535 STEMI patients who were divided into 4 groups based on their age: 33 patients younger than 44 years (group 1), 209 patients aged 45 to 59 years (group 2), 247 patients aged 60 to 74 years (group 3), and 46 patients aged 75 to 80 years (group 4).

Results: Our study revealed that among the young people STEMI is more often found in men, whereas in the older population the number of women increases accounting for 37% (compare with 3% among the young patients). It was also shown that with age, statistically significantly more coronary stents (P = .009, Kruskal­Wallis test) are needed to repair an infarct-­related coronary artery lesion. The time required to perform a percutaneous coronary intervention was statistically significantly higher in the older adults than in the young patients (P = .022, Kruskal­-Wallis test).

Conclusions: Our study found that the frequency of deaths was higher in STEMI patients from the older age groups (9.30% and 10.90%), whereas in the young patients, no deaths were registered during the 30­-day follow­up. In the middle­aged patients, mortality accounted for 3.3%. The reported differences were statistically significant (P = .016, Pearson’s χ²). The analysis of overall survival based on the age group revealed statistically significant differences (likelihood ratio test, P = .006).

Objective: To reduce the complication rate in patients with multiple trauma (including bone fractures) by objectifying criteria that allow conversion from the external fixator to the definitive osteosynthesis.

Materials and methods: The study was based on a retrospective analysis of the treatment outcomes in 308 patients (18­60 years, males and females) with multiple trauma and no apparent comorbidity.

All patients were divided into 3 groups depending on the treatment outcomes. The therapeutic and diagnostic approaches in both groups were equal and compliant with the current standards and guidelines. Surgical treatment was performed according to the damage control principles in orthopedics.

As the groups were statistically comparable, their data could be used for an accurate comparative statistical analysis.

Results: The statistical analysis of the treatment outcomes in patients from all the groups demonstrated the possibility of using the SOFA scale to determine the conversion time. In patients who underwent conversion osteosynthesis, with comparable severity of injuries according to the NISS scale, a SOFA score >10 points right prior to the surgery was associated with the maximum number of complications including mortality. A SOFA score <6 points right prior to the surgery was associated with significantly lower number of complications and no mortality.

Conclusions: Objective tools for assessing the severity of the condition, such as the SOFA scale, will allow to customize the approach to the time of conversion osteosynthesis in patients with multiple trauma and improve the treatment outcomes in general.

Objective: To evaluate results of surgical treatment in patients with bradyarrhythmia and risk factors for pacemaker (PM) malfunctions using improved preventive measures.

Materials and methods: Our study consisted of two stages. At stage I, we retrospectively analyzed histories and outpatient medical records of 948 patients with various forms of bradiarrhythmias who underwent surgery in the clinic between 2006 and 2021 to identify PM malfunctions that occurred both in the early and late postoperative  periods. Based on the data on the most common types of PM malfunctions and possible risk factors for their development, preventive measures were improved in this cohort of patients and were further used at stage II (pilot) to select patients for surgery.

During stage II (pilot), 188 patients were operated on between 2019 and 2021: risk factors for malfunctions were identified in 72 (38.3%) cases at the preoperative stage. All the patients underwent surgery with the proposed and improved preventive measures. Follow­up was during the hospital stay and in 6 and 12 months.

Results: At stage I (retrospective analysis), 78 (8.23%) patients had signs of PM malfunction. The most common malfunctions were endocardial electrode displacement (30.8%), increased stimulation threshold (25.6%), a change in the endocardial electrode impedance (17.9%), and impaired sensitivity (10.3%). In addition, premature battery depletion and PM syndrome were present in 9% and 6.4% of the patients, respectively.

The correlation analysis revealed that the most common findings associated with malfunctions were enlarged right chambers of the heart due to valvular defects and dilated cardiomyopathy, myocardial remodeling caused by chemotherapy and radiation therapy, postinfarction cardiosclerosis in the electrode implantation area, untimely and inadequate PM programming, as well as increased levels of blood uric acid, urea, and creatinine, and prolonged and uncontrolled use of steroid drugs and bronchodilators.

At stage II, there were no PM malfunctions requiring changes in the pacing parameters during the hospitalization period. Six months postsurgery, 1 (1.4%) patient had an increase in impedance (to 2843 ohms) caused by the uncontrolled intake of high doses of corticosteroids due to decompensation of chronic obstructive pulmonary disease. After correction of the corticosteroids dose, the ventricular electrode impedance returned to the normal level. Twelve months postsurgery, 2 (2.8%) patients had a decrease in impedance to 215 and 143 ohms, respectively, caused by the ventricular electrode displacement. After correcting the electrode position, normal pacing parameters were restored. No cardiac complications due to malfunctions were observed. Morphofunctional parameters of the heart did not significantly differ when compared with preoperative ones.

Conclusions: Surgical treatment of patients with bradyarrhythmia and risk factors for PM malfunctions who underwent surgery with the proposed preventive measures demonstrated high efficiency in reducing the number of malfunctions and cardiac complications associated with inadequate stimulation in the long­term follow­up.

Background: The PD-­L1 level is mainly used to predict the effect of drug treatment in patients with melanoma. Despite the radical nature of surgery in these patients, the rate of disease progression remains high. Therefore, it is important to study the relation between the PD-­L1 level in the tumor and surgical treatment options for cutaneous melanoma and patient survival.

Objective: To analyze the effect of the PD-­L1 level in patients with primary cutaneous melanoma at different levels of tumor excision and options for closing the surgical defect.

Materials and methods: We used data of 143 patients with stage 0­IIIC primary cutaneous melanoma who were randomized into 2 groups: the main group (wide excision of the tumor and plastic repair of the tissue defect) and the comparison group (standard tumor removal) with different PD-­L1 levels (IC [immune cells] %). The 5­-year survival of patients was estimated.

Results: We found the mutual dependence of the PD­-L1 level and the survival of patients with stage 0-­IIC melanoma on the extent of the tissues removed and the option for closing the defect.

Conclusions: The 5­year progression­free survival in patients with stage 0­IIA primary cutaneous melanoma was higher than that of those with stage IIB-­IIC melanoma regardless of the PD-­L1 level. In patients with stage 0-­IIA primary cutaneous melanoma and the low PD-­L1 level (˂5), progression­free survival was 26.3% higher (P = .013) than that of those with the high PD-­L1 level (≥5). In patients from the main group with stage 0-­IIA melanoma and the low PD­L1 level (˂5), progression­free survival was 25% higher (P = .017) and overall survival was 16.7% higher (P = .045) compared with patients from the control group with the same PD-­L1 level. In patients from the main group with stage 0­-IIC melanoma and the high PD­-L1 level (≥5), the 5-­year progression­free survival was 21.2% higher (P = .033) compared with patients from the comparison group.

Introduction: Due to the high incidence of congenital heart diseases (CHD) it is important to identify risk factors for abnormal organogenesis. There is a crucial medical need to understand cardiogenesis and possible markers of abnormalities in fetuses.

Objective: To determine risk factors for CHD in pregnant women and their partners and assess CHD markers on the first ultrasound screening.

Materials and methods: We analyzed 221 medical records of pregnant women with prenatally diagnosed fetal CHD and divided the patients into 2 groups: group I (n = 177) with CHD compatible with postnatal development and group II (n = 44) with CHD incompatible with postanatal development. We evaluated physical findings and somatic and reproductive history in both groups. We retrospectively analyzed 2272 ultrasound scans and first screening markers: nuchal translucency (NT) thickness and ductus venosus pulsatility index (DVPI).

Results: We identified possible risk factors for fetal CHD: body mass index, P = .000; age of menarche, P = .037; chronic tonsillitis, Р = .046; cervical erosion, Р = .045; vulvovaginal candidiasis, Р = .005; vaginitis, Р = .027; cervicitis, Р = .027; chronic hepatitis B and C viruses, Р = .005; respiratory tract infection with fever during the current pregnancy, Р = .012. We built 500 networks with the highest performance for a predictive model and found that the model’s predictors did not fully represent the risk factors for CHD. CHD with increased NT thickness (≥2.5 mm) was detected in 2.24% of cases. NT thickness and DVPI were 3.37 ± 0.92 mm and 1.098 ± 0.158, respectively. According to our correlation analysis, increased DVPI and NT thickness were associated with CHD (R = 0.510).

Conclusions: It is not possible to identify risk factors for CHD in fetuses by medical history, reproductive history and physical status of pregnant women, and unhealthy habits of their sexual partners. Increased NT thickness and DVPI moderately correlate with CHD incidence.

Introduction: Predicting various events based on influencing factors is important for statistical analysis in medical research. Unfortunately, mathematical models are rarely built on the identified factors.

Objective: To develop a model to predict the risk of bronchopleural fistula after pneumonectomy for destructive pulmonary tuberculosis.

Materials and methods: We analyzed medical records of 198 patients who underwent pneumonectomy. Of them 6 patients (3%) developed a bronchopleural fistula. We used machine learning algorithms such as ridge regression, support vector machine, random forest, and CatBoost, the Jupyter open­source development environment, and Python 3.6 to build prediction models. ROC analysis was used to evaluate the quality of the binary classification.

Results: We built 4 models to predict the risk of bronchopleural fistula. Their ROC AUC were as follows: ridge regression – 0.88, support vector machine – 0.87, CatBoost – 0.75, and random forest – 0.74. The model based on the ridge regression showed the best ROC AUC. Based on the coordinates of the ROC curve, the threshold value of 1.9% provides the maximum total sensitivity and specificity (100% and 68.8%, respectively).

Conclusions: The developed model has a high predictive ability, which allows focusing on the patient group with an increased risk of bronchopleural fistula and justifying the need for preventive measures.

Globally, tuberculosis remains an important public health problem and a major leading cause of mortality and morbidity. The term posttuberculosis lung disorder (PTLD) encompasses various manifestations after successful treatment of tuberculosis, such as respiratory symptoms, decline in respiratory function, residual radiological lesions, exercise intolerance, and reduced health­related quality of life (HRQOL). We aimed to assess the HRQOL in PTLD patients by 36­Item Short Form Health Survey. Our study was conducted on PTLD patients who completed their antituberculosis treatment and presented to the outpatient department with diagnosed PTLD or post pulmonary tuberculosis. A total of 92 patients aged 18­-81 years participated in the study after giving written informed consent. Biomass exposure was statistically significant for mental health components (P < .05). Post pulmonary tuberculosis patients with obstructive airway disease showed decreased HRQOL in both physical and mental health components. Our findings revealed a high prevalence of comorbidities, and no significant association was found between physical and mental health components of HRQOL. Thus, we emphasize the need for psychological counselling, pulmonary rehabilitation, and follow­up as holistic management even after microbiological cure for post pulmonary tuberculosis and suggest early screening of HRQOL to improve people’s standard of living.

Introduction: Lung cancer is one of the most common cancers in the world. Approximately 40% of all metastases make up brain metastases that occur in 3% of patients at early stages of lung cancer. Early diagnosis of brain metastases directly affects patients’ survival and quality of life.

Objective: To study the role of contrast-­enhanced magnetic resonance imaging (MRI) in detecting brain metastases at the outpatient stage in patients with newly diagnosed and histologically confirmed lung cancer and to compare the findings to that of computed tomography (CT).

Materials and methods: Our study was conducted at the premises of the Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) between November 2022 and January 2023. Seventy­five patients with histologically confirmed lung cancer underwent brain MRI on a Philips Panorama 1.0T MRI scanner and intravenous administration of Clariscan to detect metastatic lesions. As a diagnostic method, we used a “short” scanning protocol in T1­-WI (TR: 450, TE: 15, slice thickness 5 mm), T2­-WI (TR: 4533, TE: 100, slice thickness 5 mm) and DWI (TR: 3712, TE: 97, slice thickness 5 mm) modes in the axial plane, then the Clariscan contrast agent was injected intravenously at the rate of 0.2 ml per 1 kg of the patient's weight, after which the scan was repeated using 3D T1 (TR: 450, TE: 15, slice thickness 1 mm).

Results: The average age of the patients was 60 years. The majority of the participants were male. Of all the patients, the majority had central lung cancer (57.3%). During contrast-­enhanced brain MRI, brain metastases that accumulated a contrast agent in 100% of cases were detected in 30 patients (40%) of the total number of patients. In 7% of the patients, there were non-­metastatic findings undetected by prior contrast­-enhanced CT, such as pontine cavernoma and venous malformations. After MRI for brain metastases, management strategies changed in 30 (40%) patients.

Discussion: Contrast-­enhanced MRI is one of the most effective methods for diagnosing metastatic lesions. It allows to localize brain metastases and helps the clinician choose the most effective management strategy. The introduction of contrast­-enhanced brain MRI into routine medical practice could improve the accuracy and quality of brain metastasis detection in patients with lung cancer.

Introduction: In recent years, there has been a significant increase in the incidence of tricuspid valve infective endocarditis (IE), which is associated with both the increased number of invasive examinations and procedures and the high rates of intravenous drug use. The initial treatment for tricuspid valve IE was surgical removal of the focus of infection and restoration of intracardiac hemodynamics.

Reconstructive surgery aimed at preserving the valve is the preferred method of surgical treatment. If a valve-­preserving operation is not possible due to significant valvular apparatus destruction, implantation of artificial heart valves (both mechanical and biological) is the method of choice.

Objective: To analyze the results of reconstructive valve-­preserving surgery and tricuspid valve replacement for tricuspid valve IE treatment.

Materials and methods: In the Scientific Research Institute – Specialized Cardiac Surgery Clinical Hospital named after Academician B.A. Korolev (Nizhny Novgorod, Russian Federation) 110 patients underwent surgery for tricuspid valve IE. Primary surgery was performed in 97 patients, and 13 patients underwent repeated surgery. The patients were divided into 2 groups based on the chosen surgical method for correcting tricuspid valve disease. Group 1 included 62 patients who successfully underwent tricuspid valve replacement: mechanical prostheses in 10 patients and biological prostheses in 52 patients. Group 2 included 38 patients who underwent reconstructive valve­preserving surgery. All patients underwent De Vega annuloplasty. In 10 patients it was directly associated with bicuspidalization of the tricuspid valve and plastic surgery of intact leaflets. Two patients had suture annuloplasty of the tricuspid valve based on the modified technique. In 2 of 3 patients, an infected right atrial thrombus was removed. Three patients underwent removal of the left ventricular wall abscess and aortic valve replacement for critical stenosis. After translocation of the chords, triangular resection of the anterior leaflet was performed to separate the chord of the left side of the chest and the myxoma of the right and left chest.

Results: In the early postoperative period, no valve­related complications were observed in group 1. The most common nonlethal complication was a third­-degree atrioventricular block. Multiple organ dysfunction syndrome occurred in 3 patients; cardiac tamponade was reported in 2 patients, and 1 patient had postoperative bleeding that required resternotomy for serous mediastinitis in the mid­term period and reosteosynthesis. At the hospital stage, 1 patient from group 1 died, whereas there were no deaths in group 2. In­-hospital mortality in the groups of operated patients was 0.9%.

Functional ultrasound imaging findings in the postoperative period show that patients from group 1 had the peak gradient across the prosthetic tricuspid valve of 9.4 ± 1.8 mm Hg, while the mean gradient was 5.8 ± 1.75 mm Hg. There was a significant decrease in the estimated right ventricle pressure from 54.0 ± 16.2 to 35.0 ± 5.5 mm Hg. In group 2 tricuspid valve regurgitation was not observed in 27 patients, while mild and moderate regurgitation was reported in 8 and 3 patients, respectively. The peak gradient during the tricuspid valve reconstruction was 6.2 ± 1.7 mm Hg, while the mean gradient was 2.8 ± 0.75 mm Hg. The annulus fibrosus size during tricuspid valve annuloplasty averaged 30.8 ± 2.5 (28­33) mm. There was a decrease in the right ventricle pressure from 44.0 ± 18.4 to 32.0 ± 7.3 mm Hg. In the mid-­term follow­up, surviving patients were classified as NYHA classes I­-II. Of 110 patients discharged from the clinic, we were able to trace the fate of 69 patients, which accounted for 62.7%. In the long-­term period, 3 patients from group 1 died. Thus, long­term mortality in the general group was 2.72%.

Conclusions: Reconstructive surgery has significant advantages over tricuspid valve replacement using various artificial heart valve models: lower rates of in-­hospital and long­-term mortality and specific complications, higher quality of life. Compliance with principles and methods of pathogenetic treatment of electrode­induced IE guarantees a success in the cohort of severe patients. The technique of reconstruction and restoration of tricuspid valve structures and functions in case of active tricuspid valve IE with detachment of the chords and destruction of the leaflets demonstrated high surgical efficiency.

Introduction: There is no adequate and easily reproducible model of complicated necrotizing enterocolitis (NEC) that allows to study its etiopathogenesis and test various surgical treatment options in an experiment.

Objective: To devise a method for in vivo modeling of complicated NEC using laparoscopy.

Materials and methods: Our study was conducted at the premises of the Laboratory of Experimental Surgery and Oncology (Scientific Research Institute of Experimental Medicine, Kursk State Medical University) in compliance with international ethical standards and guidelines for humane animal treatment. Fifteen immature male rabbits underwent laparoscopy under inhalation anesthesia and then subserosal injection of damaging solutions (33% H₂O₂, 10% CaCl₂, 4% KCl, 70% C₂H₅OH, 10% CH₂O) into the intestinal wall. In 24 hours, we performed laparotomy, assessed pathological changes visually, and resected the section of the intestinal tube at the injection site. Then we performed a single­layer end­to­end intestinal anastomosis. Histological samples were made from a biopsy specimen. Morphological assessment of the changes was performed.

Results: The most pronounced macro­ and microscopic changes were found in the animals injected with hydrogen peroxide. We assessed changes in the abdominal cavity 24 hours since the start of modeling and observed a pattern of partial intestinal obstruction and serous peritonitis. The morphological pattern was characterized by acute circulatory disorder in the intestinal wall with ulcerative necrotic defects and perforations.

Conclusions: Based on morphological manifestations we devised a method for modeling complicated NEC using laparoscopy. It is easily reproducible in an in vivo experiment, close to the clinical situation, and allows to simulate typical morphological changes during severe NEC.

Background: The quality of mesh integration and adhesion formation in the intraperitoneal onlay mesh hernia repair (IPOM) is considered to depend not only on the mesh structure but also on a complex of other factors. This study aims to evaluate the correlation between the adhesion formation, mesh deformation, and shrinkage on the fixation method and the mesh location in the abdominal cavity.

Materials and methods: During laparoscopy (IPOM), 6 different meshes (2 each in the epi-, meso-, and hypogastric regions) were installed in the intraperitoneal position in each of 3 pigs. For mesh fixation, absorbable poly-D, L-lactide or non-absorbable stainless steel and polyetheretherketone (PEEK) tacks were randomly selected. Relaparoscopy was performed after 45 days, autopsy after 90 days. The results were calculated for meshes with absorbable and non-absorbable tacks and for meshes placed in the epi-, meso-, and hypogastrium.

Results: The fixation methods did not significantly affect the deformation and shrinkage of the mesh. Absorbable tacks were associated with higher adhesion formation for most indicators at all stages of the study. The difference between absorbable and non-absorbable fixation reached a maximum by day 90, when the number of mesh pieces with adhesions was 66.7% vs 11.1% (P = .05), and the adhesion scores were 5 (0-6) vs 0 (0-0) (P = .01). The mesh location on the abdominal wall did not significantly affect its deformation and shrinkage. At the same time, most of the adhesion indicators depended on the mesh location. Starting from hypogastrium, the extent and the type of adhesions increased and were maximal in epigastrium. The greatest difference between the epi-, meso-, and hypogastrium was noted by day 45, when the number of mesh pieces with adhesions was 100%, 50%, and 16.7% (P = .014), and the adhesion scores were 6 (5-7), 2 (0-4), and 0 (0-0) (P = .007).

Conclusions: The fixation method and the intraperitoneal mesh location do not affect its deformation and shrinkage but significantly affect the adhesion formation.

Objective: To evaluate the efficacy and safety of endovascular treatment of extracranial dissection of the internal carotid artery, as well as pseudoaneurysm associated with dissection.

Clinical cases: In this article we report the results of endovascular treatment of 2 patients with iatrogenic and spontaneous dissection of the cervical segment of the internal carotid artery.

Conclusions: Internal carotid artery dissection can lead to significant narrowing of the vessel lumen, occlusion or pseudoaneurysm followed by hemodynamic or embolic stroke despite anticoagulant therapy. In some cases, endovascular stenting for dissection is a safe and effective method of restoring vessel lumen integrity with a good clinical outcome.

Introduction: The article discusses formation and development of the Kuban school of thought in thoracic surgery. We reviewed the main aspects of the accumulation of knowledge and experience in thoracic surgery and formation of a scientific association of thoracic surgeons that further developed into a school of thought first regionally, then internationally.

Objective: To analyze the main stages of the development of the Kuban school of thought in thoracic surgery through the prism of scholars who made major contributions to the formation of the school’s research concept, as well as through succession (transfer of scientific and medical experience).

Materials and methods: Our methodology involved a comparative historical analysis of the most important stages of the development of the school of thought in thoracic surgery, a retrospective evaluation of the contributions made by the surgeons who transformed the surgical community, and a comprehensive analysis of research materials on this subject. We used retrospective, biographical, analytical, and comparative research methods.

Results: We identified the fundamental trends in the development of the Kuban school of thought in thoracic surgery, key directions for improving the methods of chest pathology diagnosis and surgical treatment that have been forming in the Kuban over the past 100 years.

The education and training of staff, as well as formation of a scientific medical community and its international integration clearly demonstrated the transformation dynamics of the Krasnodar Krai’s research potential in thoracic surgery.

Despite adequate therapy, interstitial lung diseases (ILD) can cause progressive scarring of lung tissue. This type of ILD is known as progressive fibrosing ILD (PF­-ILD). The challenge in diagnosing PF-­ILD lies in the lack of uniformly accepted criteria for a progressive fibrosing phenotype. Most authors use criteria based on clinical features and assessment of functional imaging and radiological findings over time. However, forced vital capacity (FVC) measurement is limited by its variability, and the follow­up lasts 1­2 years. The above diagnostic challenges prevent from prescribing early adequate therapy in patients with progressive ILD, indicting the need to search for new biomarkers of the progressive fibrosing phenotype. We review the most studied and informative biomarkers of fibrosis progression in patients with ILD.

Adequate postoperative pain management remains a challenge. We discuss pathophysiology of pain after cardiac surgery and describe in detail multimodal and regional anesthesia, their advantages and disadvantages.

A mutation in the CFTR gene causes the malfunctioning of the CFTR protein that is located on the apical membrane of epithelial cells and functions as a chloride channel. The discovery of CFTR modulators is an advance in cystic fibrosis treatment.

Objective: To analyze modern Russian and foreign literature on targeted therapy for cystic fibrosis in children. We also describe the history of cystic fibrosis, evolution in its diagnosis and treatment, and mechanisms behind targeted therapy for cystic fibrosis.

Professor Stanislav Vladimirovich Ochapovsky (1878-1945)—Doctor of Medical Science, Honored Scientist of the Russian Soviet Federative Socialist Republic—was a Soviet ophthalmologist, public figure, local historian, and honorary citizen of the Caucasus, Uchkulan, and Beslan. He organized the fight against trachoma in the North Caucasus, founded the school of Kuban ophthalmology, and laid the groundwork for regional medicine and ophthalmology.