Category Archives: JCCM 2026

Emergency anticancer therapy in intensive care medicine: A mainland China survey

Hao Zhang1, DongHao Wang2, ChangSong Wang3, Xue-Zhong Xing1

1 National Cancer Center/National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
2 Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
3 First Affiliated Hospital of Harbin Medical University, Harbin, China

DOI: 10.2478/jccm-2026-0017

Objective: To identify intensivists‘ attitudes toward emergency anticancer therapy (EAT) in patients with cancer in intensive care units (ICUs).
Material and methods: A 11-question survey was performed among intensivists in the Cancer Critical Care Medicine Committee of the Chinese Anti-Cancer Association and Critical Care Medicine Committee of Beijing Association of Oncology between November 11 and December 11, 2024. Response were compared between mixed and oncologic ICU physicians.
Results: In total, 120 intensivists completed the survey. For 9 of 11 questions, the agreement rate exceeded 85%. There were 61.5% mixed ICU physicican and 35.5% oncologic ICU physicians in favor of compostion of the composition of a multidisciplinary team (MDT) composing of an intensivist, an oncologis and a pharmacist, respectively. However this difference was not significant (P=0.281).
Conclusions: Intensivists in China generally hold positive attitudes toward emergency anticancer therapy in ICUs for critically ill patients with cancer-related organ dysfunction. However, opinions differ regarding the MDT composition between mixed and oncologic ICU physicicans.

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Early outcomes of pediatric heart transplantation: Impact of mechanical circulatory support and perioperative challenges. A single-center retrospective study

Muhammad Shahzad, Reem Beheri, Bushra Algethami, Yasser Alheraish, Dimpna Albert, Felix W Tsai, Zohair Alhalees, Khaled Alarwan

King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia

DOI: 10.2478/jccm-2026-0033

Background: Pediatric heart transplantation stays the gold standard treatment for end-stage heart failure, but outcomes are influenced by pre-transplant status and bridging strategies, particularly mechanical circulatory support (MCS).
Objectives: To evaluate early outcomes following pediatric heart transplantation and assess the impact of pre-transplant MCS on survival and complications.
Methods: We retrospectively analyzed all pediatric patients (<14 years) who underwent orthotopic heart transplantation at a single tertiary center between January 2020 and January 2025. Demographics, pre-transplant support, intraoperative data, and early outcomes were collected. Primary outcome was 30-day survival; secondary outcomes included acute rejection, infection, acute kidney injury (AKI), neurologic complications, and ICU/hospital length of stay (LOS). Comparative analyses were performed between patients having ECMO- and ventricular assist devises (VAD) using Fisher’s exact and Wilcoxon rank-sum tests. Kaplan–Meier survival estimates were generated.
Results: Thirty patients were transplanted (median age 9 years, 63.3% female). Most (96.7%) needed MCS, including 11 ECMO and 18 VAD. Thirty-day survival was 28/30 (93.5%, 95% CI 78–99). Acute rejection occurred in 3 (10%), infections in 4 (13.3%), AKI in 8 (26.7%), with two requiring CRRT, and neurologic complications in 3 (10.3%). Median ICU and hospital LOS were 20 and 37 days, respectively. ECMO patients had longer post-transplant ventilation (12 vs 6 days, p = 0.04) and ICU length of stay (LOS) compared to VAD patients. Total Ischemic time, and CPB times were associated with increased morbidity.
Conclusions: Early outcomes after pediatric heart transplantation prove high short-term survival but substantial morbidity. ECMO bridging was associated with greater resource use than VAD. Improving donor heart ischemic time, donor-recipient matching, perioperative management, and early initiation of durable MCS may further improve outcomes.

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Case report: Necrotizing enterocolitis with gastric perforation in a 24-day old preterm neonate

Tamas Toth1, Reka Borka-Balas2, Manuela Cucerea3, Radu-Alexandru Prisca4

1 Institution Organizing University Doctoral Studies (IOSUD) George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures; Pediatric Surgery and Orthopedics Department, Targu Mures Emergency Clinical County Hospital, Targu Mures, Romania
2 Pediatric Clinic I, Targu Mures Emergency Clinical County Hospital; George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
3 Neonatology Department, Targu Mures Emergency Clinical County Hospital; George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
4 Pediatric Surgery and Orthopedics Department, Targu Mures Emergency Clinical County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2026-0034

Introduction: Neonatal gastric perforation (NGP) is a rare, life-threatening surgical emergency that predominantly affects premature and extremely low birth weight (ELBW) infants and remains associated with high mortality.
Case presentation: A 600 g female infant born at 25/26 weeks of gestational age developed necrotizing enterocolitis (NEC) during the third postnatal week and deteriorated with abdominal distension and pneumoperitoneum. Emergency laparotomy on day 24 revealed a single posterior gastric wall perforation with circumferential necrotic margins; the nasogastric tube tip was located at the defect. After minimal debridement and primary two-layer closure, the infant survived a prolonged intensive care course complicated by recurrent sepsis, cholestasis, bronchopulmonary dysplasia, and later adhesive obstruction requiring adhesiolysis.
Conclusions: Gastric perforation may represent an uncommon manifestation of severe NEC in ELBW infants. Delayed onset, necrotic margins, and systemic inflammatory deterioration may favor ischemic NEC-related injury over iatrogenic trauma. Early radiographic evaluation and prompt surgical exploration are crucial for survival.

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Balanced crystalloids versus normal saline for initial fluid resuscitation in diabetic ketoacidosis: A systematic review and meta-analysis of randomized controlled trials

Khaled Ahmed Reda Soliman1, Ahmed Osman Hassan Ali2, Farrukh Ameer3, Bashaer Alharbi4, Mohamed Hany Elmasry5, Rawabi Mohammed Alwashmi6, Bandar Saad Alshreef7, Mohammad Saleh H Almabouth8, Kinda Ahmed Hardan9, Aymen Ali Alqurain10

1 Department of Emergency Medicine, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
2 Department of Critical Care Medicine, Dr. Soliman Fakeeh Hospital, Riyadh, Saudi Arabia
3 Department of Adult Cardiology, Dr. Soliman Fakeeh Hospital, Fakeeh Care Group, Riyadh, Saudi Arabia
4 Department of Clinical Pharmacy, Ministry of Health, Jeddah, Saudi Arabia
5 Department of ICU and Anesthesia, Care Medical Hospital Almalaz, Riyadh, Saudi Arabia
6 Burydah College, Qassim, Saudi Arabia
7 Healthcare Management, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia
8 Department of Internal Medicine, NSH, Medina, Saudi Arabia
9 Senior House Officer of General Medicine, International University of Africa, Riyadh, Saudi Arabia
10 Department of Clinical Practice, Faculty of Pharmacy, Northern Border University, Saudi Arabia

DOI: 10.2478/jccm-2026-0031

Objective: To systematically synthesize evidence from RCTs that evaluate the efficacy and safety of balanced crystalloids compared with normal saline for initial fluid resuscitation of patients with DKA.
Methods: This systematic review and meta-analysis were performed considering PRISMA guidelines and was registered in PROSPERO. A comprehensive search was performed to identify RCTs comparing balanced crystalloids with normal saline in adults and children with DKA. The risk of bias was assessed by using Cochrane RoB 2 tool. A random-effects meta-analysis was performed using R software to calculate pooled Mean Differences for continuous outcomes and Odds Ratios for dichotomous outcomes with 95% Confidence Intervals.
Results: Eleven RCTs were included. In the quantitative synthesis of six RCTs (n = 491) using continuous time-to-event data, balanced crystalloids were not associated with a statistically significant reduction in time to DKA resolution compared with normal saline (Mean Difference [MD] = -1.50 hours; 95% CI: -3.79 to 0.79; p=0.15), with moderate heterogeneity (I2 = 36.2%). The 95% prediction interval ranged from -5.44 to 2.44 hours. However, balanced crystalloids resulted in a significantly greater increase in serum bicarbonate at 12 hours (MD = +2.50 mmol/L; 95% CI: 1.51 to 3.48; p=0.004; I2 = 0.0%). Subgroup analyses by fluid type, DKA severity, and age group showed no significant subgroup differences.
Conclusion: Initial fluid resuscitation with balanced crystalloids was not associated with a shorter time to DKA resolution compared with normal saline, and they were associated with a rapid increase in serum bicarbonate levels; however, this biochemical improvement did not translate into a shorter time to DKA resolution or other clinical benefits. The choice of crystalloids for initial DKA resuscitation remains an area of clinical equipoise because of the substantial heterogeneity and methodological limitations of the available evidence, emphasizing the need for further high-quality research.

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Echocardiographic factors associated with prolonged duration of inotrope therapy and ICU length of stay in a retrospective study of cardiac surgery patients

Kelly Tankard1, William Vasquez McTeigue2, Matthew Smith2, Ariel Mueller2, Timothy Houle2, Eriberto Michel2, Judy Hung2, Adam Dalia2, Jerome Crowley2, Kenneth Shelton2

1 Department of Anesthesiology, University of Kansas Medical Center, Kansas City, USA
2 Department of Anesthesiology, Massachusetts General Hospital, Boston, USA

DOI: 10.2478/jccm-2026-0032

Introduction: Post-operative heart failure following cardiac surgery carries risk and can impact patient outcomes. Preoperative echocardiography can be useful for stratifying risk. Although there has been a historical focus on left ventricular ejection fraction (LVEF), the importance of left ventricular (LV) size, as measured by left ventricle end-diastolic diameter (LVEDD), may be an underappreciated echocardiographic factor which can help predict risk in patients undergoing cardiac surgery.
Aim of the study: To investigate the association between LVEF and LVEDD with inotrope use, inotrope duration, and intensive care unit (ICU) length of stay (LOS) in patients undergoing cardiac surgery.
Materials and methods: Retrospective cohort study including 2,965 adult patients undergoing non-emergent cardiac surgery at a single academic institution between February 2017 and October 2021. Primary outcomes were the use of inotropes and duration of inotrope therapy. The secondary outcome was ICU LOS.
Results: In adjusted analyses, a one standard deviation increase in LVEF was associated with decreased odds of inotrope initiation (OR 0.45, 95% CI: 0.41 to 0.50; P < 0.001), while a one standard deviation increase in LVEDD was associated with increased odds of receiving inotropes (OR 1.18, 95% CI: 1.07 to 1.31; P = 0.001). Among those receiving inotropes, a one standard deviation increase in LVEF was associated with a 25% decrease in inotrope hours in adjusted analyses (0.75, 95% CI: 0.68 to 0.82; P < 0.001). An interaction was observed such that LVEDD modified the association between LVEF and ICU LOS (0.98, 95% CI: 0.95 to 0.99; P = 0.03).
Conclusions: Preoperative LVEDD, particularly when combined with LVEF, can predict risk after cardiac surgery.

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Effect of premorbid beta-blockers on cardiac function and clinical outcomes in septic patients: a retrospective study

Siyu Yang, Rongyao Feng, Xiangzhou Fang, Chaojie Wei

Zhongnan Hospital of Wuhan University, Wuhan Hubei, China

DOI: 10.2478/jccm-2026-0030

Background: Beta-blockers have been reported to exert potential beneficial effects in sepsis in recent years. However, their clinical application in sepsis remains limited due to concerns regarding hemodynamic impacts. This study aims to explore whether premorbid use of beta-blockers is associated with improvements in cardiac function and favorable clinical outcomes among patients with sepsis.
Methods: This single-center, retrospective cohort study was conducted in the Intensive Care Unit (ICU) of a university-affiliated hospital. All patients diagnosed with sepsis admitted between August 2022 and March 2024 were enrolled. Exclusion criteria included age < 18 years, hospitalization duration < 48 hours, a history of severe underlying cardiac conditions, and incomplete clinical records. Primary outcomes included myocardial injury markers, echocardiographic parameters, and electrocardiographic indices to assess cardiac function. Secondary outcome was mortality.
Results: Among 1005 septic patients, 228 had received premorbid beta-blockers. No significant difference in baseline disease severity was observed between the two groups. Patients with premorbid beta-blocker exposure had lower levels of cardiac troponin I (TnI, 87.9 [IQR, 23.4-306.0] vs 142.0 [IQR, 37.8-481.2]), lactic dehydrogenase (LDH, 274.0 [IQR, 175.0-496.0] vs 319.0 [IQR, 229.0-456.8]), and B-type natriuretic peptide (BNP, 267.9 [IQR, 118.1-1065.1] vs 509.3 [IQR, 184.8-1203.0]). Echocardiographic assessments revealed that premorbid beta-blockers were associated with a higher left ventricular ejection fraction (LVEF, 58% [IQR 52-60] vs 55% [IQR 50-60]). Additionally, premorbid beta-blockers were linked to lower 14-day (13.6% [IQR 9.1-18.1] vs 21.5% [IQR 18.6-24.4]), 28-day (17.5% [IQR 12.6-22.5] vs 27.4% [IQR 24.3-30.6]), and in-hospital (18.9% [IQR 13.7-24.0] vs 28.8% [IQR 25.6-32.0]) mortality rates.
Conclusions: Among septic patients, premorbid beta-blockers are associated with preserved cardiac function and improved clinical outcomes. These findings highlight the need for prospective or randomized controlled trials to further explore the potential cardioprotective role of beta-blockers in sepsis.

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Evaluation of muscle strength and renal function in survivors of severe COVID-19: A 12-month follow-up study

Roberto Marco1, Sayane Marlla Silva Leite Montenegro2, Daniela Cassula1, Tayline Gabriel1, Alessandra Lima da Silva Martins1, Rosani Teresa de Siqueira e Silva1, Rosilene Motta Elias1, Maria Aparecida Dalboni1

1 Universidade Nove de Julho – Campus Vergueiro, São Paulo, Brazil
2 Instituto Federal de Pernambuco: Instituto Federal de Educacao Ciencia e Tecnologia de Pernambuco

DOI: 10.2478/jccm-2026-0022

Introduction: Severe COVID-19 is known to cause kidney injury via ACE2-mediated mechanisms, inflammation, and microvascular damage potentially leading to long-term renal impairment. Critically ill patients are particularly vulnerable to muscle loss and sarcopenia due to immobility, poor nutrition, and cytokine storm–induced catabolism. Post-COVID-19 syndrome often includes fatigue, muscle weakness, and reduced quality of life, yet evidence on long-term outcomes remains limited. This study evaluated kidney function, sarcopenia risk, and quality of life 12 months after intensive care unit (ICU) discharge in patients without pre-existing chronic kidney disease (CKD).
Methods: This retrospective observational cohort included 82 patients without CKD admitted to the ICU between February 2020 and April 2022 who recovered from severe COVID-19. Data collected included serum creatinine, estimated glomerular filtration rate (eGFR), and sarcopenia risk assessed via the SARC-CalF (SARC-F combined with calf circumference). Functional outcomes were assessed by SF-36, pain by a Visual Analog Scale (VAS), and lower limb strength by the 30-second sit-to-stand test.
Results: The mean age was 52 ± 12 years; 90% were male, 46% had hypertension, and 31% diabetes. At 12 months, patients showed low functional scores (SF-36: 47 ± 21), high pain prevalence (VAS: 57%), reduced lower limb strength (sit-to-stand: 8 ± 5 repetitions), and high sarcopenia risk (SARC-F: 46%). Higher sarcopenia scores correlated with poorer physical functioning (r = -0.60; p < 0.001) and greater pain (r = -0.44; p < 0.001). In 49 patients without hypertension, diabetes, or prior acute kidney injury (AKI), creatinine significantly increased (0.95 ± 0.2 to 1.10 ± 0.2 mg/dL; p = 0.007) and eGFR significantly declined (87 ± 22 to 77 ± 18 mL/min; p = 0.001), representing a mean reduction of 10 mL/min.
Conclusion: Critically ill COVID-19 survivors experienced significant declines in kidney function, muscle strength, and functional capacity, alongside increased pain 12 months post-ICU discharge. These results underscore the need for multidisciplinary follow-up, incorporating nephrology, physiotherapy, and nutritional support.

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Predictive value of NLMR, PLR, and ferritin in relation to SOFA, APACHE II, and SAPS II in sepsis patients

Oana Coman1, Bianca-Liana Grigorescu2 Adina Hutanu3,4, Stefania Raluca Fodor2, Marius Petrisor1, Leonard Azamfirei1

1 Department of Simulation Applied in Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Anaesthesiology and Intensive Therapy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Laboratory Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Centre for Advanced Medical and Pharmaceutical Research, Immunology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2026-0029

Introduction: Sepsis, a critical topic in the medical field, remains one of the deadliest pathologies in intensive care units. It involves an overzealous immune system, with a hyperinflammatory phase that overlaps with a subsequent hypoinflammatory phase.
Aim of the study: To ease the burden on medical systems, this study aimed to assess the predictive value of clinical severity scores (Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the Simplified Acute Physiology Score II (SAPS II)) and inflammatory biomarkers (neutrophile-to-lymphocyte-to-monocyte ratio (NLMR), and platelet-to-lymphocyte ratio (PLR), carboxyhemoglobin (COHb) and ferritin) in predicting outcomes of critically ill intensive care unit (ICU) patients.
Material and methods: This prospective, observational study included 101critically ill patients, for whom we assessed the parameters on the first and fifth days after confirmation of either sepsis or septic shock in ICU, according to the Sepsis-3 Consensus.
Results: Severity scores showed significant correlations on both day 1 and day 5 across all groups. APACHE II and SAPS II correlated with ferritin on day 5 in sepsis, septic shock, and non-survivors. The severity scores correlated with COHb on day 5 in survivors, and on day 1 in non-survivors. NLMR and PLR correlated consistently across groups, with additional associations between these ratios, ferritin, and COHb, particularly in non-survivors. Regarding mortality, NLMR on day 1 showed only modest predictive value, which declined to non-significant by day 5. In contrast, the SOFA, APACHE II, and SAPS II scores demonstrated good discriminatory ability on both days, confirming their strong and reliable performance in predicting mortality.
Conclusions: The study shows that simple cellular ratios and severity scores correlate with ferritin, COHb, and each other, reflecting inflammation, oxidative stress, and organ dysfunction in sepsis. Because these markers are inexpensive and easy to monitor, they may enhance bedside risk stratification, though broader prospective studies are still required.

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The effect of oral protein and carbohydrate solution administration on NLR, IL-6 and CRP levels in patients undergoing surgery

Mahendratama P. Adhi1, Oscar Febriano1, Alfi Yasmina2, Iwan Nuryawan1, Agung Ary Wibowo3, Kenanga Marwan Sikumbang1

1 Department of Anesthesiology, Faculty of Medicine and Health Sciences, Lambung Mangkurat University, Banjarmasin, Indonesia
2 Department of Pharmacology, Faculty of Medicine and Health Sciences, Lambung Mangkurat University, Indonesia
3 Department of Surgery, Digestive Division, Faculty of Medicine and Health Sciences, Lambung Mangkurat University, Indonesia

DOI: 10.2478/jccm-2026-0028

Aims: To determine the effect of administering oral protein and carbohydrate solutions the C-Reactive Protein (CRP), Interleukin-6 (IL-6), and Neutrophil-Lymphocyte Ratio (NLR) in patients planned any surgery
Methods: a double-blind, randomized clinical study, at Ulin Regional Hospital, Banjarmasin with patients planned any surgery. This research had 80 patients in total (40 subjects in the control group and 40 subjects in the intervention group). Before surgery, 200 mL of a protein and carbohydrate solution per oral was given to the intervention group, while a placebo was given to the control group. Twenty-four hours after surgery, each subject’s levels of CRP, IL-6 and NLR were measured. Statistical Package for the Social Sciences Version 29 was used to analyze the data.
Results: NLR at 24 hours postoperatively in the intervention group was lower than in the control group, but not statistically different (8.65±4.33 vs. 7.86±4.65, p=0.308). The IL-6 level at 24 hours postoperatively in the intervention group was significantly lower than in the control group (9.49 (6.03-22.65) vs. 20.08 (11.64-50.11), p=0.011). Although not statistically different, the CRP level at 24 hours postoperatively in the intervention group was lower than in the control group (15.10 (7.20-41.60) vs. 34.70 (11.87-71.55), p=0.056). There was no difference in postoperative nausea or vomiting between the two groups.
Conclusion: Postoperative interleukin-6 levels have been demonstrated to decrease when oral protein and carbohydrate solutions are given to patients undergoing surgery; however, NLR and CRP levels have not been seen to decrease.

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Early clinical outcomes and quality of life assessment after HeartMate 3 implantation: A single-centre descriptive study

Samuel Michelini1, Marius Mihai Harpa1,2, Dan Nistor2, David-Emanuel Anitei3, Alexandru Stan3, Paul Calburean4, Emil Marian Arbanasi5, Dragos-Florin Baba6, Sabrina Mancino1, Horatiu Suciu2,7

1 George Emil Palade University of Medicine Pharmacy Science and Technology of Targu Mures, Targu Mures, Romania
2 Department of Cardiovascular Surgery, Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, Romania
3 Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science and, Technology of Targu Mures, Targu Mures, Romania
4 Department of Biostatistics and Medical Informatics, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
5 Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
6 Department of Cell and Molecular Biology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
7 Department of Surgery IV, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania

DOI: 10.2478/jccm-2026-0025

Background: Advanced heart failure remains a leading cause of morbidity and mortality worldwide, with limited access to transplantation, particularly in Eastern Europe. Left ventricular assist device therapy offers improved survival and quality of life for end-stage disease. HeartMate 3, a modern form of mechanical circulatory support, is used as bridge-to-transplant or destination therapy. Despite increasing global experience with the HeartMate 3, clinical data from Romanian centers remain scarce. This study aimed to assess early clinical outcomes, postoperative complications, and quality of life after HeartMate 3 implantation at a single cardiovascular surgery center in Romania.
Materials and methods: We conducted a retrospective observational cohort study including 13 patients with Advanced heart failure who underwent HeartMate 3 implantation between September 2023 and March 2025. Preoperative variables (demographics, comorbidities, INTERMACS profile, EuroSCORE II, echocardiographic findings) and postoperative outcomes were analyzed. Quality of life was assessed in 10 surviving patients using a 16-item structured telephone questionnaire addressing physical function, autonomy, social reintegration, and psychological well-being.
Results: The cohort was predominantly male (84.6%); mean age 47.2 ± 12.3 years. Implant strategy: bridge-to-transplant 76.9%, destination therapy 23.1%. Early mortality was 23.1% (n = 3), occurring primarily in patients with EuroSCORE II >8% and INTERMACS I–II. The most frequent postoperative complications were significant perioperative bleeding (61.5%) and right ventricular failure (23.1%). Among survivors, all reported improved mobility, greater independence in activities of daily living, and better social reintegration; 7/10 rated overall quality of life as good or excellent. Psychological distress was frequent early after surgery but showed progressive improvement over time.
Conclusions: HeartMate 3 implantation resulted in favorable early clinical outcomes and significant improvements in quality of life, aligning with international data. Optimizing outcomes with left ventricular assist device therapy relies on timely referral, rigorous patient selection, and comprehensive postoperative management, including psychological and social support.

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