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Glasgow Coma Scale on Presentation Predicts Outcome in Endovascular Treatment for Acute Posterior Large-Vessel Occlusion [INTERVENTIONAL]

SUMMARY:

Use of mechanical thrombectomy for stroke has increased since the publication of trials describing outcome improvement when used in the anterior circulation. These results, however, cannot be directly translated to the posterior circulation. While a high NIHSS score has demonstrated an association with poor outcomes in posterior stroke, the NIHSS is weighted toward hemispheric disease, and complex scores potentially delay definitive imaging diagnosis. We performed a retrospective analysis to ascertain whether any rapidly obtainable demographic or clinical and imaging data have a correlation with patient outcome postthrombectomy. Seventy-three cases were audited between September 2010 and October 2017. Presenting with a Glasgow Coma Scale score of >13 meant that the odds of reaching the primary end point of functional independence (defined as a 90-day modified Rankin Scale score of 0–2) were 5.70 times greater; similarly, presenting with a posterior circulation ASPECTS of >9 resulted in the odds of reaching the primary end point being 4.03 times greater. Older age correlated to a lower odds of independence (0.97, p = .04).




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White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear.

MATERIALS AND METHODS:

In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0–2) and moderate-to-severe (van Swieten score, 3–4) white matter disease using logistic regression: 90-day mRS 3–6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery.

RESULTS:

Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58–79 years). A van Swieten score of 3–4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3–6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34–5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3–4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56–2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93–4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed.

CONCLUSIONS:

Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.




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Contrast-Induced Acute Kidney Injury in Radiologic Management of Acute Ischemic Stroke in the Emergency Setting [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

The use of invasive cerebral angiography with CTA for active treatment of patients with suspected ischemic strokes has been increasing recently. This study aimed to identify the incidence of postcontrast acute kidney injury using baseline renal function when CTA and cerebral angiography were performed sequentially.

MATERIALS AND METHODS:

This retrospective observational study evaluated adults (18 years of age or older) with ischemic stroke who underwent CTA and cerebral angiography sequentially between 2010 and 2018. The incidence of postcontrast acute kidney injury was determined using the baseline estimated glomerular filtration rate. The value of the baseline estimated glomerular filtration rate at which the occurrence of postcontrast acute kidney injury increased was also determined.

RESULTS:

Postcontrast acute kidney injury occurred in 57/601 (9.5%) patients. Those with a baseline estimated glomerular filtration rate of <30 mL/min/1.73 m2 showed a higher incidence of acute kidney injury. Age, chronic kidney disease, medication (nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, statins, and insulin) use following contrast media exposure, and serum albumin affected the incidence of postcontrast acute kidney injury. The incidence of postcontrast acute kidney injury increased when the baseline estimated glomerular filtration rate was <43 mL/min/1.73 m2.

CONCLUSIONS:

Patients with low baseline renal function had the highest incidence of postcontrast acute kidney injury after CTA and cerebral angiography, but no fatal adverse effects were documented. Thus, patients suspected of having a stroke should be actively managed with respect to neurovascular function.




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MRI Vessel Wall Imaging after Intra-Arterial Treatment for Acute Ischemic Stroke [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Vessel wall imaging is increasingly performed in the diagnostic work-up of patients with ischemic stroke. The aim of this study was to compare vessel wall enhancement after intra-arterial thrombosuction with that in patients not treated with thrombosuction.

MATERIALS AND METHODS:

From 2009 to 2017, forty-nine patients with an ischemic stroke underwent 7T MR imaging within 3 months after symptom onset as part of a prospective intracranial vessel wall imaging study. Fourteen of these patients underwent intra-arterial treatment using thrombosuction (intra-arterial treatment group). In the intra-arterial treatment group, vessel walls were evaluated for major vessel wall changes. All patients underwent pre- and postcontrast vessel wall imaging to assess enhancing foci of the vessel wall using coregistered subtraction images. A Wilcoxon signed rank test was performed to test for differences.

RESULTS:

In the intra-arterial treatment group, 11 of 14 patients (79%) showed vessel wall enhancement compared with 17 of 35 patients without intra-arterial treatment (49%). In the intra-arterial treatment group, more enhancing foci were detected on the ipsilateral side (n = 18.5) compared with the contralateral side (n = 3, P = .005). Enhancement was more often concentric on the ipsilateral side (n = 8) compared with contralateral side (n = 0, P = .01). No differences were found in the group without intra-arterial treatment between the number and configuration of ipsilateral and contralateral enhancing foci.

CONCLUSIONS:

Patients with intra-arterial treatment by means of thrombosuction showed more (concentric) enhancing foci of the vessel wall ipsilateral compared with contralateral to the treated artery than the patients without intra-arterial treatment, suggesting reactive changes of the vessel wall. This finding should be taken into account when assessing vessel wall MR images in patients with stroke.




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Suspected Metallic Embolization Distal to Coiled Intracranial Aneurysms Detectable by Susceptibility-Weighted MR Imaging [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

After endovascular coiling of intracranial aneurysms, round dark parenchymal lesions believed to be particulate metal are sometimes encountered in MR imaging studies of the brain. We used SWI to assess the frequency of such occurrences, in addition to exploring likely causes and clinical implications.

MATERIALS AND METHODS:

We reviewed 700 MR imaging studies performed between September 2018 and March 2019 at our institution as follow-up monitoring of coiled intracranial aneurysms. Any sizeable (>5 mm) rounded dark-signal lesions encountered were presumed to be metallic. The magnitudes and locations of such lesions were recorded. In patients with these lesions, pertinent procedural documentation was screened for devices used, including coils, microcatheters, microguidewires, and stents. Medical records were also examined to determine whether any related symptoms ensued.

RESULTS:

Twenty patients (2.8%) exhibited a total of 25 lesions on SWI. Diameters ranged from 5 to 11 mm (median, 8 mm). All except 2 lesions were located in brain regions downstream from aneurysms, but all lesions occupied vascular territories of vessels used to place guiding catheters. Other than the Synchro 14, which was routinely deployed, no device was regularly used in patients with SWI-detectable lesions; and none of the affected patients developed focal neurologic symptoms as a consequence.

CONCLUSIONS:

Although the origins remain unclear, distal embolization of particulate metal distal to coiled cerebral aneurysms is occasionally observed on follow-up MR imaging studies. Such lesions, however, seem to have no apparent clinical impact.




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Reliability of CT Angiography in Cerebral Vasospasm: A Systematic Review of the Literature and an Inter- and Intraobserver Study [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Computed tomography angiography offers a non-invasive alternative to DSA for the assessment of cerebral vasospasm following subarachnoid hemorrhage but there is limited evidence regarding its reliability. Our aim was to perform a systematic review (Part I) and to assess (Part II) the inter- and intraobserver reliability of CTA in the diagnosis of cerebral vasospasm.

MATERIALS AND METHODS:

In Part I, articles reporting the reliability of CTA up to May 2018 were systematically searched and evaluated. In Part II, 11 raters independently graded 17 arterial segments in each of 50 patients with SAH for the presence of vasospasm using a 4-category scale. Raters were additionally asked to judge the presence of any moderate/severe vasospasm (≥ 50% narrowing) and whether findings would justify augmentation of medical treatment or conventional angiography ± balloon angioplasty. Four raters took part in the intraobserver reliability study.

RESULTS:

In Part I, the systematic review revealed few studies with heterogeneous vasospasm definitions. In Part II, we found interrater reliability to be moderate at best ( ≤ 0.6), even when results were stratified according to specialty and experience. Intrarater reliability was substantial ( > 0.6) in 3/4 readers. In the per arterial segment analysis, substantial agreement was reached only for the middle cerebral arteries, and only when senior raters’ judgments were dichotomized (presence or absence of ≥50% narrowing). Agreement on the medical or angiographic management of vasospasm based on CTA alone was less than substantial ( ≤ 0.6).

CONCLUSIONS:

The diagnosis of vasospasm using CTA alone was not sufficiently repeatable among observers to support its general use to guide decisions in the clinical management of patients with SAH.




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CT Angiography in Evaluating Large-Vessel Occlusion in Acute Anterior Circulation Ischemic Stroke: Factors Associated with Diagnostic Error in Clinical Practice [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

It is currently not completely clear how well radiologists perform in evaluating large-vessel occlusion on CTA in acute ischemic stroke. The purpose of this study was to investigate potential factors associated with diagnostic error.

MATERIALS AND METHODS:

Five hundred twenty consecutive patients with a clinical diagnosis of acute ischemic stroke (49.4% men; mean age, 72 years) who underwent CTA to evaluate large-vessel occlusion of the proximal anterior circulation were included. CTA scans were retrospectively reviewed by a consensus panel of 2 neuroradiologists. Logistic regression analysis was performed to investigate the association between several variables and missed large-vessel occlusion at the initial CTA interpretation.

RESULTS:

The prevalence of large-vessel occlusion was 16% (84/520 patients); 20% (17/84) of large-vessel occlusions were missed at the initial CTA evaluation. In multivariate analysis, non-neuroradiologists were more likely to miss large-vessel occlusion compared with neuroradiologists (OR = 5.62; 95% CI, 1.06–29.85; P = .04), and occlusions of the M2 segment were more likely to be missed compared with occlusions of the distal internal carotid artery and/or M1 segment (OR = 5.69; 95% CI, 1.44–22.57; P = .01). There were no calcified emboli in initially correctly identified large-vessel occlusions. However, calcified emboli were present in 4 of 17 (24%) initially missed or misinterpreted large-vessel occlusions.

CONCLUSIONS:

Several factors may have an association with missing a large-vessel occlusion on CTA, including the CTA interpreter (non-neuroradiologists versus neuroradiologists), large-vessel occlusion location (M2 segment versus the distal internal carotid artery and/or M1 segment), and large-vessel occlusion caused by calcified emboli. Awareness of these factors may improve the accuracy in interpreting CTA and eventually improve stroke outcome.




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The Lateral Ventricles: A Detailed Review of Anatomy, Development, and Anatomic Variations [review-article]

SUMMARY:

The cerebral ventricles have been studied since the fourth century BC and were originally thought to harbor the soul and higher executive functions. During the infancy of neuroradiology, alterations to the ventricular shape and position on pneumoencephalography and ventriculography were signs of mass effect or volume loss. However, in the current era of high-resolution cross-sectional imaging, variation in ventricular anatomy is more easily detectable and its clinical significance is still being investigated. Interpreting radiologists must be aware of anatomic variations of the ventricular system to prevent mistaking normal variants for pathology. We will review of the anatomy and development of the lateral ventricles and discuss several ventricular variations.




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Strict penalties needed to prevent fraudulent real estate businesses

Real estate insiders and experts said it is essential to develop strict penalties to combat those operating fraudulent property businesses to protect the legitimate rights of consumers and legitimate enterprises.




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9 mistakes that prevent your listed home from finding buyers

Every seller wants his homes to be sold smoothly and quickly with the highest possible price. However, there are still houses which have been listed on the market for months without any potential buyer because the sellers make one, or maybe more, of the following popular mistakes:





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Xbox Series X June Event to Focus on Platform and Services

Microsoft earlier announced it will share new information on the Xbox Series X every month in 2020 calling it "Xbox 20/20." The first event will be held on May 7th at 8am PT / 11am ET and will focus on gameplay from third-party partners. 

The event in June has now been revealed it will focus on platform and services, according to Bloomberg.

It is possible the June event will see the unveiling of the long rumored weaker next generation Xbox, codenamed Lockhart, with an expected official name of Xbox Series S. The price and launch date for the Xbox Series X is also possible, as well as information on Game Pass, Xbox Live Gold and Project xCloud. 

The July event will be focused on upcoming first-party games from Xbox Game Studios. 

"These monthly moments will take place throughout the rest of the year and will be a way for us to engage, connect and celebrate with you about what’s in store for the next generation of gaming, including what’s next for Xbox Series X, Xbox Game Studios, Xbox Game Pass and Project xCloud," said Microsoft. "Every month will bring something different. Stay tuned to Xbox Wire for more details."

The Xbox Series X will launch in Holiday 2020.

A life-long and avid gamer, William D'Angelo was first introduced to VGChartz in 2007. After years of supporting the site, he was brought on in 2010 as a junior analyst, working his way up to lead analyst in 2012. He has expanded his involvement in the gaming community by producing content on his own YouTube channel and Twitch channel dedicated to gaming Let's Plays and tutorials. You can contact the author at wdangelo@vgchartz.com or on Twitter @TrunksWD.

Full Article - https://www.vgchartz.com/article/443395/xbox-series-x-june-event-to-focus-on-platform-and-services/




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Horror Adventure Game Scorn Xbox Series X Trailer Released

ebb software has released a new trailer for the Xbox Series X version of the atmospheric first-person horror adventure, Scorn. The game is in development for the Xbox Series X and Windows PC via Steam and Windows Store.

View the Xbox Series X trailer below:

Here is an overview of the game:

Scorn is set in a nightmarish universe of odd forms and somber tapestry. It is designed around the idea of "being thrown into the world". Isolated and lost inside this dream-like world, you will explore different interconnected regions in a non-linear fashion. Every location contains its own theme, puzzles and characters that are integral in creating a cohesive world.

A life-long and avid gamer, William D'Angelo was first introduced to VGChartz in 2007. After years of supporting the site, he was brought on in 2010 as a junior analyst, working his way up to lead analyst in 2012. He has expanded his involvement in the gaming community by producing content on his own YouTube channel and Twitch channel dedicated to gaming Let's Plays and tutorials. You can contact the author at wdangelo@vgchartz.com or on Twitter @TrunksWD.

Full Article - https://www.vgchartz.com/article/443422/horror-adventure-game-scorn-xbox-series-x-trailer-released/




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Ironbark: Did two spies really prevent all-out nuclear war?

Ironbark is one of 2020’s anticipated movies. Benedict Cumberbatch plays the MI6 handler of a Russian spy who may have helped prevent nuclear war




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How DeepMind's artificial intelligence is reinventing the eye exam

Join Pearse Keane to find out why the NHS is collaborating with AI company DeepMind and how deep learning could transform ophthalmology




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PTC: Pokemon Go-style tech used to speed up ventilator production



COMPUTER services company PTC is using augmented reality , the enhanced visual technology seen in Pokemon Go smartphone games and Iron Man movies, to produce ventilators in record time for the NHS.




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Drones: For When Medical Intervention Has to Get There Before an Ambulance Can

New York City study shows that drones could deliver life-saving medical supplies several minutes before an ambulance arrives




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Peekaboo!: Home Air Vent Dragons With Light-Up Eyes

These are the vent dragons made and sold by artist David Lee Pancake. The dragons are available in a variety of dragony colors, cost $200 apiece, and are made to be hung on the wall, NOT cover an actual air vent. "But--" Hey, if you want to be hot all summer because the A/C isn't blowing in the living room, that's up to you.

Vent Dragons comes with a little remote control to light up the eyes of the two little monsters and surprise your guests and friends. The lights are powered by 3 AA batteries and should burn for 150 hours before you need to replace them. To replace the batteries unscrew the grate and lift off, the batteries are in a small pack inside. The lighted eyes have 8 different settings from fast blinking to continually glowing and there is a timer to turn them off in 6 hours. Enjoy! Size: 12x7 inches. Do NOT install in an actual heating/AC vent.
Gosh, just think how much you could save on home heating and cooling costs if you had ACTUAL fire and ice breathing dragons living in your air vents. I mean granted they'd have to be trained, but I have seen all those movies. Keep going for a few more shots of some of the different colors.



  • a/c
  • aircon! i need aircon! (that was supposed to be ed from 90 day fiance: before the 90 days)
  • baby dragons
  • dang i wish i had $200 to spend on vent dragons
  • dragons
  • heating and cooling
  • light effects
  • sure why not
  • that's cool i'm into that

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Fortnite Party Royale Event Skin 'Nightlife' available from Epic Games Item Shop



The new Nightlife reactive skin is now live ahead of the Fortnite Party Royale event which starts later today.




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Fortnite Party Royale Event Warning and server Status Epic Games next live event



Epic Games has issued a warning ahead of the Party Royale event, but it might not be the only problem facing players this evening.




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Fortnite Party Royale Event COUNTDOWN: Start time, Epic Games Rewards and more



Fortnite Party Royale event starts soon. Here's everything you need to know including start times for Deadmau5, Dillon Francis and Steve Aoki - PLUS how to claim the many live event rewards available from Epic Games as they celebrate 350 million players.




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China to reform disease prevention system




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Quaranstream: Free events and services to watch online while self-quarantining

As novel coronavirus spreads throughout the United States, millions of Americans are spending more time at home.MORE: Here's everything coming to Disney+ in AprilBut whether you're doing so because of a job loss, working from home situation or otherwise taking part in the mass effort to stay safe, chances are you've been bored once or twice while living under quarantine.Thankfully, some very talented people have been creating extra-special performances and experiences that you can enjoy to help you cope with the new normal and that don't break any social distancing rules. ...





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The Willoughbys review – imaginative animated Netflix adventure

A manic pre-summer caper skirts near dark territory but remains a mostly kid-friendly tale of an unusual family

A year after Sony’s wonderfully inventive Into the Spider-Verse became the first non-Pixar/Disney/Dreamworks film to win the best animated feature Oscar since 2011, the race was again populated by outliers. Frozen 2 was snubbed and instead Laika crept back into the spotlight with Missing Link (after winning the Golden Globe) and Netflix snuck in with two originals – Klaus and I Lost My Body – marking the streamer’s first time breaking into the pack. While Toy Story 4 might have ultimately won out, the lineup continued to reflect both a widening field and an embrace of more left-field choices, a much-needed jolt of energy in what used to be a two-horse race.

Related: Trolls World Tour review – eyeball-frazzling sequel offers same again

Continue reading...




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'Fortnite' Party Royale Event With Steve Aoki & Deadmau5 - Tracklist & What Happened

"Fortnite" Party Royale had another big show on May 8. Here's everything you need to know about the Dillion Francis, Steve Aoki and deadmau5 concert that just took place.




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'ARK' Crystal Isles PC Release Date & 5th Anniversary Event Announced

"ARK: Survival Evolved" Crystal Isles is coming to PC soon, alongside a huge anniversary event on all platforms. Get the full details here.




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Which covid-19 patients will get a ventilator if there's a shortage?

If there's a ventilator shortage, doctors and ethicists say priority should be given to people with the best chance of recovery and most years likely left to live




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How DeepMind's artificial intelligence is reinventing the eye exam

Join Pearse Keane to find out why the NHS is collaborating with AI company DeepMind and how deep learning could transform ophthalmology




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People put on ventilators for covid-19 may need lengthy rehabilitation

Healthcare systems need to prepare for the extensive physiotherapy and mental rehabilitation that people put on ventilators for covid-19 will need as they recover




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'The need to do more': Province unveils Saskatchewan suicide prevention plan

Pillars For Life: The Saskatchewan Suicide Prevention Plan, released Friday, "will guide activities specific to suicide prevention based on Saskatchewan’s context," Rural and Remote Health Minister Warren Kaeding said in a statement.




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The Helpers: Sask. venture capital firm helps seniors connect with loved ones

Just over 300 iPads, with fully paid data plans, will be going out to Saskatchewan Health Authority long term care homes to help residents stay in touch with their families.




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2021 European Athletics Indoor Championships Event Schedule Released

The 36th edition of the European Athletics Indoor Championships is scheduled to take place from March 5 to 7 next year in Torun, Poland.





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Final Olympic Archery Qualification Event In June Next Year

India have so far grabbed men's full quota and one individual place in women's category for Tokyo Olympics.





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How does the brain link events to form a memory? Study reveals unexpected mental processes

The brain has a powerful ability to remember and connect events separated in time. And now, in a new study in mice, scientists have shed light on how the brain can form such enduring links.




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Mental health calls on the rise as Saskatchewan announces new suicide prevention plan

"For people that already have mental health concerns it might be more escalated and others who have not had mental health concerns are now experiencing (them) because of some of the anxiety and stress that's caused by COVID-19."




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Google delays Android 11 Beta, announces I/O replacement event for June 3

Google I/O isn’t happening this year, but we’ll get all the normal info next month.




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Germany to donate 60 ventilators to the NHS as scramble for Covid-19 equipment continues

Read our live updates on coronavirus HERE Coronavirus: The symptoms




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Ventilators from set of BBC drama Holby City donated to new NHS Nightingale Hospital in London

Read our live coronavirus updates HERE Coronavirus: The symptoms




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Prince William praises Church of Scotland for &apos;reinventing itself&apos; amid coronavirus pandemic

Read our live coronavirus updates HERE




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Dad-of-two with &apos;zero chance&apos; of surviving Covid-19 &apos;still here&apos; after 17 days on ventilator and is getting better

Follow our live coronavirus updates HERE Coronavirus: The symptoms




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Cats and coronavirus: Vet chiefs urge people to keep pets indoors and avoid hugging them to prevent Covid-19 spread

Follow our live Covid-19 updates HERE Coronavirus: The symptoms




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Boris Johnson&apos;s fiancee Carrie Symonds calls for live animal meat markets to be banned to prevent another Covid-19-like pandemic

Carrie Symonds has signed a petition calling for a worldwide ban on live animal meat markets after coronavirus is thought to have emerged at a "wet market" in Wuhan, China.




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Top civil servant back tracks on claim UK not joining EU ventilator scheme was &apos;political decision&apos;

The Foreign Office's top civil servant has backtracked after saying ministers took a "political decision" not to take part in an EU scheme to get vital coronavirus equipment.




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&apos;Ten years worth of ventilators to be made in ten weeks&apos; amid UK coronavirus pandemic

Ten years worth of ventilators are to be made in around just ten weeks to cope with demand during the coronavirus outbreak, the head of a consortium of manufacturers has said.




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Professor Stephen Hawking&apos;s ventilator donated to NHS to help coronavirus patients

Stephen Hawking's ventilator has been donated to the NHS to help treat coronavirus patients at a hospital in Cambridge.




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Matt Hancock forced to deny UK not joining EU ventilator scheme was &apos;political decision&apos;

The Health Secretary has been forced to deny the UK's failure to take part in an EU scheme to get vital ventilators for the coronavirus crisis was politically motivated.




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Nurse dies at hospital where she worked with her sister — who is now on ventilator

A nurse has died with coronavirus in the London hospital where she worked alongside her sister — who is now fighting for life in intensive care.




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Two-thirds of coronavirus patients who were put on ventilator have died in critical care

Around two-thirds of coronavirus patients who required advanced respiratory support in intensive care have died, according to a study of critical care outcomes.




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Chelsea Flower Show unveils online displays and exhibitions after event cancelled

The Royal Horticultural Society (RHS) said this summer would mark its first ever "virtual" version of the event at Royal Hospital Chelsea, London.




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City in Sweden to dump chicken manure on park to prevent festival gatherings during coronavirus outbreak

A Swedish city plans to cover its main park with a tonne of chicken manure to discourage people from going there during the coronavirus outbreak.