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Renown Advanced Wound Care provides specialized treatment for wound healing, ostomy care and foot and nail care. Our team of certified nurses and physicians is uniquely qualified, experienced and dedicated to providing care for severe and chronic wounds.

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Personalized Robotic Surgery Renown Health is proud to offer Mako SmartRobotics™, an innovative solution for those suffering from painful arthritis in the knee or hip. Each patient is unique and can experience joint pain for different reasons. It's important to talk to your doctor about the reason for your joint pain so you can understand the treatment options available to you. It is common for patients to try medication and other treatments to treat their knee or hip pain. If you haven't experienced the adequate relief with those treatment options, you may be a candidate for Mako SmartRobotics™ for Total Knee, Total Hip, or Partial Knee replacement. How Mako SmartRobotics™ Works Mako SmartRobotics™ uses 3D CT-based planning software so your surgeon can create a personalized surgical plan. This 3D model is used to preplan and assist your surgeon in performing your joint replacement surgery. In the operating room, your surgeon follows your personalized surgical plan while preparing the bone for the implant. The surgeon guides Mako's robotic arm within the predefined area, and Mako's AccuStop™ technology helps the surgeon stay within the planned boundaries that were defined when the personalized preoperative plan was created. By guiding your doctor during surgery, Mako's AccuStop™ technology allows your surgeon to cut less by cutting precisely what's planned to help protect your healthy bone. It's important to understand that the surgery is performed by an orthopedic surgeon who guides Mako's robotic arm during the surgery to position the implant in the knee and hip joints. Mako SmartRobotics™ does not perform surgery, make decisions on its own or move without the surgeon guiding it. Mako SmartRobotics™ also allows your surgeon to make adjustments to your plan during surgery as needed. Why Choose Mako SmartRobotics™ In clinical studies, compared to manual surgery, Mako SmartRobotics™ procedures resulted in:  More accurate implant placement compared to manually surgery, which may result in improved outcomes and functioning of the joint. Less pain in the days and weeks following surgery. A shorter hospital stay. Quicker recovery, where 9 out of 10 patients were walking without aid, such as a cane or walker, three weeks after surgery. 97% of patients satisfied or very satisfied 10 years after surgery.

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A clubfoot is where the foot is turned in on itself and points toward the ground. A clubfoot diagnosis during pregnancy is surprising and challenging during any circumstance. And in the case of parents anticipating surgery during a pandemic, options can be scarce. These parents took a deep breath, and with the help of Michael J. Elliott, MD, pediatric surgeon with Renown Children’s Hospital, their baby is on the road to recovery.

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An arthritis diagnosis doesn’t mean your exercise routine has to end. In fact, a consistent routine can actually improve mobility. Although stiff and painful joints can make it difficult to keep moving, staying active is essential for easing pain. October 11 is World Arthritis Day, so we asked Michelle Higgins, MPT at Renown Physical Therapy & Rehab some advice about exercising with arthritis. According to the Arthritis Foundation, arthritis affects one in five adults and 300,000 children. As a matter of fact arthritis is the nation’s leading cause of disability. Your joints certainly don’t need to suffer when you exercise. In general exercise is actually necessary for those with arthritis. Not only does it reduce joint pain, but it also increases strength and flexibility. Furthermore those adopting a regular exercise routine also have more energy, deeper sleep and find it easier to maintain a healthy weight. “Exercise is a necessary component to managing your arthritis,” says Higgins. “Consistent participation in an exercise program has been shown to promote long-term pain relief, increased body function and an improved quality of life. Alternatively, a lack of exercise can actually increase joint pain or stiffness and eventually lead to long term disability and suffering.” Exercising With Arthritis Exercise truly is the most effective non-drug arthritis treatment available for reducing pain and improving movement. And it can even include daily activities like gardening, dancing or walking your dog. Of course talk to your doctor or physical therapist about what exercises fit into your specific treatment plan. With this is mind, the four specific components below are important to an effective arthritis exercise program: Range of motion Moving joints through their full available range of movement is important. This frequently increases function and decreases joint stiffness and pain. For this reason, aim to complete these exercises daily. Examples include bending, straightening, and rotating specific joints, or static and dynamic stretching. Strengthening These exercises target muscles supporting and protecting our joints and bones. Strengthening is also necessary for weight control, so two-to-three sessions per week are recommended. In order to allow your body to adapt, begin with light resistance and start slow. Strength exercises include weightlifting and using resistance bands. Low-impact aerobic exercise Aerobic exercise is certainly necessary for overall well-being, weight management and heart health. Aim for two-to-three sessions a week. Low-impact exercises include walking, swimming, cycling, elliptical machine exercises and water aerobics. Balance Good balance is also vital for an effective arthritis program. On the positive side, solid balance prevents falls by increasing your ability to stay upright whether you are moving or sitting still. Likewise, it improves your confidence with walking and daily activities. In order to keep excellent balance, incorporate daily balance exercises. Examples of balance exercises include the use of an exercise ball, Tai Chi and exercises such as standing on one foot. Start Slow, Finish Strong As you begin your exercise program, remember to listen to your body. Start slowly – it can take several weeks for your body to adjust to exercise. Consult your doctor, or physical therapist, if you experience increasing pain or swelling which doesn’t go away with rest. Above all, incorporate fun and motivating activities so you’ll stick to them long term and improve your results. Renown Physical Therapy & Rehab 775-982-5001 Through outpatient physical, occupational and speech therapy, Renown Physical Therapy & Rehab gives you hands-on, individualized treatment in convenient Reno/Sparks locations. We have the latest, most advanced physical therapy and rehab equipment, specialty services and treatments. Renown Physical Therapy & Rehab is now open on Robb Drive in addition to three additional locations in Reno and Sparks. Call 775-982-5001 or visit us online.

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Michael Elliott, MD, head of the Department of Pediatric Orthopedics and Scoliosis, answers some common questions about bone fractures. Is there a difference between broken bones and fractures? No, these are two different names for the same injury. Of course the common term is a broken bone. Using either name will describe your concerns. Medical personnel typically describe a broken bone as a fracture to a specific bone. For example, a broken wrist is also a fractured distal radius. To clarify, this describes the injured bone and the precise location. How do I know  if my child has broken their bone? Many times children will fall and complain of their arm or leg hurting. In most cases the pain goes away and the child will return to their activities. When there is a deformity to the limb (curve in arm) and the child is complaining of pain, it is probably a fracture. If the arm or leg looks straight, look to see if there is any swelling or bruising. Both are signs of a possible fracture. Finally, if the limb looks normal but the child continues to complain, gently push on the bone. Likewise if it causes the same pain, then they likely have a fracture and should have an x-ray. My child fractured their growth plate, what does this mean? Growth comes from this area of the bone. In detail, these are located all over the body but typically at the end of the bones. With this in mind, fractures to these areas can result in the bone growing abnormally. Because of potential shortening of the arm or leg, or bones growing crooked, it is important to follow fractures closely (up to 1-2 years or longer). It is better to identify a problem early. Small problems can be treated with small surgeries. What if the bones of the x-ray do not line up? Because children are growing, unlike adults, their bones will remodel and straighten with growth. The amount of remodeling occurring depends on a child’s age, the bone fractured and the location. In many cases an angled bone will grow straight over the course of a year. For this reason, someone with experience in caring for children needs to follow bone growth. How long does it take fractures to heal? Factors deciding when a cast can come off include: Child’s age. Bone fractured. Fracture location. Young children heal faster than teens, teens heal faster than young adults, who heal faster than older adults. In young children most fractures heal in 4-6 weeks. However, teens generally take 6 weeks to heal, and adults can take much longer. Although your child  is out of their cast, it may not be healed completely to return to all activities. Placing a splint is during this time is common. This typically gives them added protection for several weeks after their cast is removed -  in case they forget their limitations. What if my child is still limping? Whether a child is in a walking or non-weight bearing cast, removing it often leaves them stiff and sore. Therefore many children will walk as though they still have a cast in place. In most cases this resolves in about three weeks. Regardless, if your child is still limping or walking abnormally after three weeks, contact the treating doctor. They may benefit from physical therapy or a repeat evaluation.  (This article was original published in the July 2019 issue of South Reno Kids & Sports.)

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For Michael J. Elliott, MD, a pediatric orthopedic surgeon specializing in scoliosis, it’s just another day helping patients. But to local five-year-old Makenna Christensen, her substantial spine correction is life-changing. Though her journey to body confidence was months in the making, her smiles are a reminder that a thorough, thoughtful treatment plan can yield amazing results. A Surprising Start Words don’t adequately describe the feelings you have when you unexpectedly learn your child has a birth defect. For Nicole and Nick Christensen it was a shocking surprise. During Nicole’s sonogram appointment something unusual was seen. After an amniocentesis, their baby girl was diagnosed with Noonan syndrome, which can affect a child’s height and bones. To prepare, the couple read all they could on the subject. Fortunately their daughter Makenna, was born full term and healthy. Shortly after birth, Makenna had some feeding issues and returned to the hospital. Although they resolved and she had no major complications, both parents felt unsure about their newborn’s future. With the help of Nevada Early Intervention Services , Makenna’s development was monitored until she was three years old. “Her posture has been an issue her whole life,” says Nicole. Nick also noticed when Makenna started walking her range of motion was poor. It was especially noticeable when she got dressed and raised her arms to put on clothing. Nicole observed Makenna was falling a lot in preschool. She asked Makenna’s pediatrician about physical therapy to support her coordination and muscle tone. Although physical therapy was helping Makenna, her therapist suggested Nicole seek the opinion of Dr. Michael Elliott, a pediatric specialist in orthopedics at Renown Children’s Hospital. Scoliosis Casting - A Successful Treatment Approach Dr. Elliott diagnosed Makenna with scoliosis, an abnormal curvature of the spine. While this condition is most common during a teenage growth spurt, it can also happen in early childhood. Affecting about four million people in the United States, it is estimated 20 percent of all spinal deformities in the U.S. are people living with scoliosis. Makenna’s spinal curve was significant – over 30 degrees. Through years of experience Dr. Elliott opted to put Makenna in a spinal cast, instead of multiple surgeries. “My approach is to postpone surgery as long as possible - it is tough for the patient and families,” he says. “Often excellent results can be achieved through non-invasive treatments such as, casting and bracing.” Nicole appreciated Dr. Elliott’s reassurance through the treatment plan. “It was obvious through the X-rays that there was a significant issue,” she shares. “He guided us through the timing and process and how correcting it sooner would help keep her future growth on track.” For seven months Makenna wore a cast that looked like a tank top, bracing her spine while allowing movement. Now she wears a hard plastic brace, specially fitted to her body.  “Kids tolerate casting well,” explains Dr. Elliott.  “It is a 45-minute procedure. The patient sleeps while their spine is put into traction as the cast dries.” She will continue to wear larger braces as she grows, eventually only wearing them at night. A Straight Path into the Future Dr. Elliott admits, “Not every cast is a cure. Two thirds of a child’s spinal growth happens by the age of five. Getting past the five-year mark means fewer surgeries. It’s wonderful to see Makenna’s body image improved.” Nicole agrees, “The way Makenna holds herself is completely different. She’s more confident on her feet and more balanced.” She can now play with her sister Aria, 4, and brother Lexi, 8 months, without the fear of falling. Nick is in awe of the improvements she has made, “Seeing her thrive more has been wonderful.” The Christensen’s are hopeful about the future. “Makenna is doing really good. She’s wearing her hard brace full time and her growth is consistent,” expresses Nicole. “She’s even starting swim lessons this week.” With mask wearing at every doctor visit during the COVID-19 pandemic, Makenna and Dr. Elliott look forward to seeing each other’s smiles in the future. Makenna’s story highlights the over 18 different specialty options for children locally at Renown Children’s Hospital.

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Read More About Summer Health Hazards - Bites and Stings

Whether it’s cross-country or downhill skiing, snowboarding or snowshoeing, your off-season preparation is vital to an injury-free and healthy experience once the snow starts to fall. We’ve got you covered with expert tips that will make you the king or queen of the hill. Millions of skiers and snowboarders hit the slopes annually. So whether you’re a weekend warrior or stay active year-round, you need to prepare your body for the demands of your favorite winter sport to avoid minor aches, pains or even severe injury. Count on two to three weeks for your body to adapt to the physical challenges ahead if you’re active. Otherwise, give yourself a minimum of six weeks to gear up for the snow. Ready to shred? Here are some conditioning tips to help put you on the path to a fun, successful winter season. 1. Start With Cardio Cardiovascular exercise increases endurance as it conditions the heart, lungs and muscles and provides a solid foundation for other forms of exercise. And when you live and play at altitude, you need even more endurance. “Research shows that our maximum heart rate, cardiac output and ability to exercise are suppressed at altitudes over 5,000 feet,” explains Daniel Staffa, PT, DPT, OCS, of Renown Rehabilitation Hospital. “In the Reno-Tahoe area, altitudes can quickly rise over 8,000 feet when we exercise in the Sierras, so it’s critical to have cardiovascular fitness to avoid associated fatigue and decreased mental alertness on the slopes.” Try this: Pick an aerobic activity you enjoy — speed walking, running, hiking, biking or a cardio machine like the elliptical trainer. Build up to a minimum of 30 minutes, three days a week. 2. Increase Your Strength Your core works overtime to stabilize the body and absorb the shock of pivots and turns and variable snow conditions. Strengthen your core, lower back, hamstrings and calves and you’ll go a long way toward guarding against ligament tears and damage to other joint structures. Stronger muscles will also allow you to relax while maintaining control and making those quick adjustments that uneven terrain demands. Try this: Squats, wall sits and lunges. Work your core and lower and upper extremities with a variation of sit-ups, crunches, back extensions and planks. 3. Integrate Plyometrics Staffa explains that if your legs aren’t used to absorbing the impact of landing, severe injuries can occur. Preempt such trauma with plyometric exercises, or “explosive movements,” that simulate the movements of your favorite sport. You’ll develop greater power in your legs when you combine plyometrics with your strength training. Try this: Incorporate multi-directional drills — such as lateral jumps and forward and backward jumps — on variable surfaces like a trampoline, solid ground, or a box or step. Here’s a challenge for the more advanced: Stand in front of a bench or box (12 inches or so). Jump up and then immediately back down. Do this 10 to 30 seconds at a time, rest and repeat. Or get old school and bust out the jump rope. 4. Improve Your flexibility Flexibility is the ability to move joints through their entire range of motion, from a flexed to an extended position. Being flexible will allow you to pivot, twist and turn and navigate varying snow conditions with ease. You can increase your flexibility while maintaining bone alignment with stretching. Don’t forget to warm up and cool down. Try taking it easy the first 15 minutes of your day on the hill; try starting with a beginner’s run or walk to warm up and prepare your body. Do the same at the end of the day or go for a brisk walk to cool down. Stretching will help return muscles to their normal length. Try this: Dynamic stretches such as leg swings, arm swings and torso twists. Target your quads, hamstrings, calves, and lower back. 5. Fuel for the Hill Staffa suggests loading up on healthy complex carbohydrates the day before you go out and bring along your favorite protein snacks. Assess the slopes before making that first run — is the snow heavy, fresh or wet — and stay mindful of your fatigue level throughout the day. Don’t forget to hydrate and re-hydrate before, during and after exercise. And most important, have fun! Visit Renown Physical Therapy and Rehab for more information. Or call 775-982-5001 to consult with our sports and orthopedic experts who can help you develop an individualized training program in preparation for the winter season, including methods for overcoming previous injuries and limitations.

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National Radiologic Technology Week is from Nov. 5-11, 2023. Join us in celebrating Renown's Interventional Radiology department!Try to put yourself in the shoes of someone who is told that they have a massive blood clot in their lung, someone who needs a biopsy to determine the next steps of their care, someone facing a stroke or brain aneurysm or someone who needs a catheter to receive treatment such as chemotherapy. You may immediately think that an intense and intimidating surgery is on the horizon. What if, instead of surgery, your care teams were able to use the necessary tools to treat your blockage or administer your medicine with an image-guided procedure?  That’s precisely what the Interventional Radiology (IR) team at Renown Health does. Behind the doors of this department is where you’ll find a team of highly skilled individuals who operate like a well-oiled machine, ensuring that each procedure is executed with precision and care. Their commitment to excellence knows no bounds as they provide essential interventions to patients of all ages, from the tiniest newborns to the elderly. Their mission extends beyond diagnostic and therapeutic procedures; they are experts in understanding and serving the ever-evolving needs of their patients.  Minimally Invasive, Maximally Impactful  With their advanced expertise, our IR teams at both Renown Regional Medical Center and Renown South Meadows Medical Center harness the power of X-ray, CT and ultrasound technologies to navigate their way through life-saving minimally invasive procedures, such as thrombectomies, angioplasties, stent placements, embolizations, catheter and drain insertions and needle biopsies. In the world of medicine, Interventional Radiology often offers an alternative to traditional surgical methods, reducing the risk of hospitalization and helping patients embrace recovery more quickly.  Our IR teams have a diverse and busy daily work life in order to make these complex and life-saving interventions happen – and they all have each other’s backs to ensure that every patient gets the care they deserve.  “Every day is different, and no two days are alike,” said Ryan Nunes, Specialty Procedure IR Technologist at Renown Regional. “The day can start off first thing in the morning with several emergent cases, such as ruptured brain aneurysms to brain blockages. We all work really well together; we help each other out and come together to do things as a team.”   Like every other team at Renown, patient well-being is always a number one priority. The IR department takes this commitment seriously, upholding the highest standards of ethics and safety.  “We start the day by preparing rooms and making sure they are well-stocked, checking that all devices are working, performing safety checks and making sure the entire team is well-prepared for whatever cases come through the door,” said Aubrey Goldsmith, Supervisor of Clinical Nursing in IR at Renown Regional. “We have routine cases like drain placements, biopsies, line placements and more, and we also have life-threatening cases that come at a moment’s notice. Our nurses are responsible for monitoring patients throughout the procedure to make sure they are doing well the entire time and are there to respond if the patient has a decline.”  "After completing the prior assessment of each patient, we look for any medical problems the patient may have before confirming it is safe for the patient to have procedure done,” said Brandon Hartwig, Interventional Radiology RN at Renown South Meadows. “We work closely with the physicians on all our cases while assessing each patient, going through labs and vitals and personalizing the procedure for each patient.”  Even though the procedures they oversee are minimally invasive, the IR team understands that any procedure, regardless of the severity, can be incredibly frightening for any patient. Their best tool for handling patient anxieties? Communication.  "The best thing we can do to reduce anxieties and fears in patients is to have communication with them to ensure they know what is going on and what to expect,” said Megan Rios, IR Technologist at Renown Regional. "We set clear expectations for the patients and give reassurance throughout the entire procedure.”  "All of our team members are very attentive to our patients when it comes to potential fears and anxieties that they may have,” added Jazmynn Kimsey, IR Technologist at Renown Regional. “We always take the extra time to listen to our patients and break things down, explaining every step before, during and after the procedure.”  Knowledge sharing is also a crucial part of the IR process. No patient will ever have to wonder, “what exactly is going on here?”  “We provide each patient with education and advocacy throughout the process,” said Blaire Henderson, Interventional Radiology RN at Renown Regional. “We ensure every patient is as comfortable as possible at all times.”  “When it comes to procedures, patients tend to be scared and nervous,” added Ryan Nunes. “The silver lining to what we do is that it is all done through very small openings of the skin, and we all explain this to patients. Most procedures we do are done under moderate sedation which helps put the patient more at ease.”  In a world where advanced medical care meets the human touch, the IR team exemplifies Renown’s commitment to making a genuine difference in the health and well-being of everyone they serve.

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The imaging department is where scientific precision and patient connection come together in harmony to help diagnose a multitude of conditions. When a mystery needs to be unraveled, experts in X-ray, CT, MRI, ultrasound, echocardiography, mammography and nuclear medicine step in to provide a deeper lens into each patient’s inner workings. At Renown Health, our imaging specialists exemplify this and more.  With the inpatient teams at Renown Regional Medical Center and Renown South Meadows Medical Center and many outpatient locations across Reno and Sparks, our dedicated and compassionate imaging and radiology technologists make this symphony of healing a melodious reality. Through the lens of their expertise and the state-of-the-art equipment at their fingertips, the invisible becomes visible, pain transforms into answers and the path to recovery.  A Picture Tells a Thousand Words  Every patient image tells a story, and Renown’s Imaging department is full of master storytellers. From X-rays that capture the intricate architecture of bones to MRIs that unveil the complex structure of organs, these team members use sophisticated techniques to make sure every patient receives the highest standard of care.  Within the imaging landscape, no day looks the same – and each team can expect a different set of challenges to overcome, all while helping providers gain better diagnostic clarity.  “Every day in imaging is a little bit different, and I love that,” said Savannah Terrana, Outpatient CT Scan Technologist at Renown X-Ray and Imaging – Vista. “We start like everyone else: getting our rooms stocked and ready for patients and protocoling the day's exams. We have a lot of different types of scans, like x-ray, CT and bone density, and a variety of conditions that we are evaluating for the ordering providers, like fractures, cancer, bleeds and more.  “When we get into work, we get a daily assignment that decides whether we are in one of our outpatient or inpatient rooms,” added Ireland Bennett, Echo Technologist at Renown Regional. “Then when we are on inpatients, we get our assignments for whether we are assigned to transesophageal echocardiograms, the cath lab or pediatrics. When we are on outpatients, we get a set schedule for the day with patients every hour from 7:15 a.m. until 4:15 p.m. We do our best to be efficient as possible to not delay any patient care or discharges.”  “X-rays aren’t just for bones; we do chest X-rays to look for pneumonia and intestinal issues, and we also do fluoroscopy, which is a live video X-rays while patients drink contrast or while surgeons fix fractures with screws and other hardware in the operating room,” said Amethyst Winters, Inpatient Diagnostics Imaging Lead at Renown South Meadows. “There is a lot of variety, and we provide imaging for patients in the entire hospital.”  Equipped with advanced technologies and the unique skills they acquired in a trade program, at the university-level or in the military, the Imaging department can deliver precise and comprehensive information to help providers make accurate diagnoses. And their role transcends beyond the image scanner.  “A typical day for an MRI Technologist depends greatly on outpatient or inpatient settings,” said Sean Fryer, Supervisor of Imaging for Renown X-Ray and Imaging – Pringle. “There is a lot of screen time and usually in dark areas, but this is where our technologist skill set comes into play – manipulating parameters to either increase quality by signal/resolution or decrease them a little to gain time."  “A day in the life as an ultrasound tech would of course be performing ultrasounds on our patient community, but there is much more to it,” added Mary Rushton, Ultrasound Specialist at the Renown Breast Center. “This includes keeping rooms clean and stocked with supplies, protocoling exams and studying patient history so you can give the best patient care possible, continuing education and training to keep up with new technologies and being an aide to your radiologist. Working with many different personalities, you recognize that you cannot complete every step of the patient care process all by yourself – it requires collaboration from your team to give the ultimate patient care experience."  Mary brings up an excellent point about the wide variety of people her team meets every day, on both the patient and employee side, with the common goal of solving diagnostic mysteries. This aspect of their work has become one of the highlights of their career.  “Working in imaging allows us to meet many members of our community,” Teresa Shutts, Breast Health Coordinator at Renown X-Ray and Imaging – Pringle. “We are responsible for providing imaging exams, managing patient needs and creating a comfortable and caring environment for people who are possibly going through the worst times of their lives.”  Along with every day being different, our Imaging team members thrive in their dynamic and fast-paced work environment, where efficiency and urgency are vital, especially among a constant stream of patients in need of timely diagnoses.  “Our days in CT are very fast paced,” said Shelly Lavin, Imaging Lead for Inpatient Diagnostics at Renown Regional. “Our modality is the first choice for assessing stroke and trauma patients. We are fortunate to have very competent tech aides who help work up CT orders by checking orders, IV status and labs. We generally have inpatients scheduled every half hour, and we work these around a very full ER list.  When we get extremely busy, we have to strategize how we schedule our patients in the various scanners to expedite exams and not delay patient care.”  “We provide patient care for those who come in for emergencies, trauma, inpatient care, surgery and fluoroscopy studies,” added Sean Elliott, Inpatient Radiology Technologist at Renown Regional. “I was always told in school that our main purpose was to help doctors better diagnose patients, and imaging provides many modalities to appropriately diagnose.”  Behind-the-scenes, our Imaging surgery schedulers are the keys to ensuring each appointment runs smoothly, communicating directly with patients to get their exams off to a good start.   “Every day it is my task to make sure we have everything we need to do the exam that is ordered for a patient,” said Isela Gonzalez, Surgery Scheduler for Renown X-Ray and Imaging – Double R. “This includes the order, authorization approval, completing the protocol, confirming the appointment, re-stating the address and directions, going over any prep for the exam and giving them their estimate cost for the exam. I always do my best to give the patient the best experience possible.”  Whether they are in the weeds of radiology or in the depths of patient coordination, Renown’s Imaging department is unmatched – and the direct beneficiaries are their patients.

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