Summary: Inflammation of the throat (PHARYNX).

Top Publications

  1. Shulman S, Bisno A, Clegg H, Gerber M, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55:e86-102 pubmed publisher
    ..intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and ..
  2. Shulman S, Bisno A, Clegg H, Gerber M, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55:1279-82 pubmed publisher
    ..intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and ..
  3. Little P, Hobbs F, Moore M, Mant D, Williamson I, McNulty C, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013;347:f5806 pubmed publisher
    ..Antigen tests used according to a clinical score provide similar benefits but with no clear advantages over a clinical score alone. ISRCTN32027234. ..
  4. Fine A, Nizet V, Mandl K. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172:847-52 pubmed publisher
    The Centor and McIsaac scores guide testing and treatment for group A streptococcal (GAS) pharyngitis in patients presenting with a sore throat, but they were derived on relatively small samples...
  5. Renner B, Mueller C, Shephard A. Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat). Inflamm Res. 2012;61:1041-52 pubmed publisher
    The aim of this review is to examine the causes, pathophysiology and experimental models of non-infectious pharyngitis (sore throat)...
  6. Silva Costa C, Friães A, Ramirez M, Melo Cristino J. Differences between macrolide-resistant and -susceptible Streptococcus pyogenes: importance of clonal properties in addition to antibiotic consumption. Antimicrob Agents Chemother. 2012;56:5661-6 pubmed publisher
    ..we characterized both macrolide-susceptible and -resistant GAS associated with a diagnosis of tonsillo-pharyngitis recovered in the period from 2000 to 2005 in Portugal...
  7. Rimoin A, Walker C, Hamza H, Elminawi N, Ghafar H, Vince A, et al. The utility of rapid antigen detection testing for the diagnosis of streptococcal pharyngitis in low-resource settings. Int J Infect Dis. 2010;14:e1048-53 pubmed publisher
    ..evaluate the utility of rapid antigen detection testing (RADT) for the diagnosis of group A streptococcal (GAS) pharyngitis in pediatric outpatient clinics in four countries with varied socio-economic and geographic profiles...
  8. Xu Y, Wang S, Ren Y, Zhu Y, Tan Z. A smaller endotracheal tube combined with intravenous lidocaine decreases post-operative sore throat - a randomized controlled trial. Acta Anaesthesiol Scand. 2012;56:1314-20 pubmed publisher
    ..05). Use of smaller-sized ETT combined with i.v. lidocaine decreases the incidence and severity of POST in women undergoing thyroid surgery. ..
  9. Kolly L, Busso N, von Scheven Gete A, Bagnoud N, Moix I, Holzinger D, et al. Periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome is linked to dysregulated monocyte IL-1? production. J Allergy Clin Immunol. 2013;131:1635-43 pubmed publisher
    The exact pathogenesis of the pediatric disorder periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis (PFAPA) syndrome is unknown...

More Information


  1. Jaensson M, Gupta A, Nilsson U. Risk factors for development of postoperative sore throat and hoarseness after endotracheal intubation in women: a secondary analysis. AANA J. 2012;80:S67-73 pubmed
    ..02). The only risk factor found to be significantly associated with developing hoarseness was an endotracheal cuff pressure below 20 centimeters of water (P = .04). Larger studies are needed to confirm these risk factors. ..
  2. Førsvoll J, Kristoffersen E, Øymar K. Incidence, clinical characteristics and outcome in Norwegian children with periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; a population-based study. Acta Paediatr. 2013;102:187-92 pubmed publisher
    To describe the incidence, epidemiology, clinical presentation and clinical outcome of children with the syndrome of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) in a population-based study.
  3. Ogawa T, Terao Y, Okuni H, Ninomiya K, Sakata H, Ikebe K, et al. Biofilm formation or internalization into epithelial cells enable Streptococcus pyogenes to evade antibiotic eradication in patients with pharyngitis. Microb Pathog. 2011;51:58-68 pubmed publisher
    Streptococcus pyogenes is the bacterium most frequently isolated from patients with pharyngitis. Although various antibiotics including penicillin are effective, antibiotic treatment failure in cases of streptococcal pharyngitis have ..
  4. Cohen J, Chalumeau M, Levy C, Bidet P, Thollot F, Wollner A, et al. Spectrum and inoculum size effect of a rapid antigen detection test for group A streptococcus in children with pharyngitis. PLoS ONE. 2012;7:e39085 pubmed publisher
    ..Throat swabs were collected from 785 children with pharyngitis in an office-based, prospective, multicenter study (2009-2010). We analysed the effect of clinical spectrum (i...
  5. Park S, Kim S, Lee S, Chae W, Jin H, Lee J, et al. Application of triamcinolone acetonide paste to the endotracheal tube reduces postoperative sore throat: a randomized controlled trial. Can J Anaesth. 2011;58:436-42 pubmed publisher number, NCT00908817). ..
  6. Garavello W, Pignataro L, Gaini L, Torretta S, Somigliana E, Gaini R. Tonsillectomy in children with periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. J Pediatr. 2011;159:138-42 pubmed publisher
    ..Available evidence is limited, however, and the precise role of surgery remains to be clarified. We suggest considering this option when symptoms markedly interfere with the child's quality of life and medical treatment has failed. ..
  7. Shea P, Ewbank A, Gonzalez Lugo J, Martagon Rosado A, Martinez Gutierrez J, Rehman H, et al. Group A Streptococcus emm gene types in pharyngeal isolates, Ontario, Canada, 2002-2010. Emerg Infect Dis. 2011;17:2010-7 pubmed publisher
    Group A Streptococcus (GAS) is a human-adapted pathogen that causes a variety of diseases, including pharyngitis and invasive infections...
  8. Kasper M, Wierzba T, Sovann L, Blair P, Putnam S. Evaluation of an influenza-like illness case definition in the diagnosis of influenza among patients with acute febrile illness in Cambodia. BMC Infect Dis. 2010;10:320 pubmed publisher
    ..However, testing samples based on the criteria of fever alone increased our case detection by 34%. ..
  9. Cohen J, Chalumeau M, Levy C, Bidet P, Benani M, Koskas M, et al. Effect of clinical spectrum, inoculum size and physician characteristics on sensitivity of a rapid antigen detection test for group A streptococcal pharyngitis. Eur J Clin Microbiol Infect Dis. 2013;32:787-93 pubmed publisher
    ..Double throat swabs were collected from 1,482 children with pharyngitis and 294 asymptomatic children in a French prospective, office-based, multicenter (n = 17) study, from October ..
  10. Di Pierro F, Adami T, Rapacioli G, Giardini N, Streitberger C. Clinical evaluation of the oral probiotic Streptococcus salivarius K12 in the prevention of recurrent pharyngitis and/or tonsillitis caused by Streptococcus pyogenes in adults. Expert Opin Biol Ther. 2013;13:339-43 pubmed publisher
    ..Because of its ability to colonize the oral cavity, we have tested the strain K12 for its efficacy in preventing streptococcal pharyngitis and/or tonsillitis in adults.
  11. Little P, Hobbs F, Mant D, McNulty C, Mullee M. Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study. Br J Gen Pract. 2012;62:e787-94 pubmed publisher
    Management of pharyngitis is commonly based on features which are thought to be associated with Lancefield group A beta-haemolytic streptococci (GABHS) but it is debatable which features best predict GABHS...
  12. Slinger R, Goldfarb D, Rajakumar D, Moldovan I, Barrowman N, Tam R, et al. Rapid PCR detection of group A Streptococcus from flocked throat swabs: a retrospective clinical study. Ann Clin Microbiol Antimicrob. 2011;10:33 pubmed publisher
    Rapid diagnosis of GAS pharyngitis may improve patient care by ensuring that patients with GAS pharyngitis are treated quickly and also avoiding unnecessary use of antibiotics in those without GAS infection...
  13. Aalbers J, O Brien K, Chan W, Falk G, Teljeur C, Dimitrov B, et al. Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score. BMC Med. 2011;9:67 pubmed publisher
    ..a clinical prediction rule (CPR), the Centor score, for predicting group A ?-haemolytic streptococcal (GABHS) pharyngitis in adults (> 14 years of age) presenting with sore throat symptoms...
  14. Jaensson M, Gupta A, Nilsson U. Gender differences in risk factors for airway symptoms following tracheal intubation. Acta Anaesthesiol Scand. 2012;56:1306-13 pubmed publisher
    ..Identification of these factors pre-operatively may increase awareness among anaesthesia personnel and possibly reduce the incidence of these minor but distressing symptoms. ..
  15. Chiappini E, Regoli M, Bonsignori F, Sollai S, Parretti A, Galli L, et al. Analysis of different recommendations from international guidelines for the management of acute pharyngitis in adults and children. Clin Ther. 2011;33:48-58 pubmed publisher
    Streptococcal pharyngitis is a frequently observed condition, but its optimal management continues to be debated...
  16. Stojanov S, Lapidus S, Chitkara P, Feder H, Salazar J, Fleisher T, et al. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is a disorder of innate immunity and Th1 activation responsive to IL-1 blockade. Proc Natl Acad Sci U S A. 2011;108:7148-53 pubmed publisher
    The syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common periodic fever disease in children. However, the pathogenesis is unknown...
  17. Worrall G, Hutchinson J, Sherman G, Griffiths J. Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids. Can Fam Physician. 2007;53:666-71 pubmed
    ..Use of rapid antigen tests might allow physicians to persuade patients that negative results (and hence, viral infection) mean antibiotic therapy is not required. ..
  18. Smeesters P, Campos D, Van Melderen L, de Aguiar E, Vanderpas J, Vergison A. Pharyngitis in low-resources settings: a pragmatic clinical approach to reduce unnecessary antibiotic use. Pediatrics. 2006;118:e1607-11 pubmed
    Existing scoring systems for the diagnosis of group A streptococcus pharyngitis are insensitive or inapplicable in low-resources settings...
  19. Garavello W, Romagnoli M, Gaini R. Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. J Pediatr. 2009;155:250-3 pubmed publisher
    ..adenotonsillectomy leads to complete resolution in children with PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) syndrome...
  20. Tasher D, Somekh E, Dalal I. PFAPA syndrome: new clinical aspects disclosed. Arch Dis Child. 2006;91:981-4 pubmed
    The recently described PFAPA (Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis) syndrome is characterised by periodic fever, aphthous stomatitis, pharyngitis and adenitis...
  21. Centor R, Cohen S. Pharyngitis management: focusing on where we agree. Arch Intern Med. 2006;166:1345-6 pubmed
  22. Arroll B. Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med. 2005;99:255-61 pubmed
  23. Kumar R, Vohra H, Chakraborty A, Sharma Y, Bandhopadhya S, Dhanda V, et al. Epidemiology of group A streptococcal pharyngitis & impetigo: a cross-sectional & follow up study in a rural community of northern India. Indian J Med Res. 2009;130:765-71 pubmed
    ..Hence, disease burden due to GAS in 5-15 yr old school children in northern India was studied and emm typing of GAS isolates was carried out to help in designing prevention strategies...
  24. Tazeh Kand N, Eslami B, Mohammadian K. Inhaled fluticasone propionate reduces postoperative sore throat, cough, and hoarseness. Anesth Analg. 2010;111:895-8 pubmed publisher
    ..05). Inhaled fluticasone propionate decreases the incidence and severity of postoperative sore throat, cough, and hoarseness in patients undergoing cesarean delivery under general anesthesia. ..
  25. Rachelefsky G, Liao Y, Faruqi R. Impact of inhaled corticosteroid-induced oropharyngeal adverse events: results from a meta-analysis. Ann Allergy Asthma Immunol. 2007;98:225-38 pubmed
    ..To calculate the risk of ICS-induced oral candidiasis, dysphonia, and pharyngitis among currently available therapies and to determine related effects of dose and device...
  26. Choby B. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79:383-90 pubmed
    Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy...
  27. Hubbert M, Sievers H, Lehnfeld R, Kehrl W. Efficacy and tolerability of a spray with Salvia officinalis in the treatment of acute pharyngitis - a randomised, double-blind, placebo-controlled study with adaptive design and interim analysis. Eur J Med Res. 2006;11:20-6 pubmed
    ..II/III study with adaptive two-stage design and interim analysis compared the efficacy and tolerability of spray (containing a Salvia officinalis fluid extract) against placebo in the treatment of patients with acute viral pharyngitis. -
  28. Stojanov S, Hoffmann F, Kéry A, Renner E, Hartl D, Lohse P, et al. Cytokine profile in PFAPA syndrome suggests continuous inflammation and reduced anti-inflammatory response. Eur Cytokine Netw. 2006;17:90-7 pubmed
    PFAPA syndrome is characterized by periodic episodes of high fever, aphthous stomatitis, pharyngitis, and/or cervical adenitis. It is of unknown etiology and manifests usually before 5 years of age...
  29. Dunn N, Lane D, Everitt H, Little P. Use of antibiotics for sore throat and incidence of quinsy. Br J Gen Pract. 2007;57:45-9 pubmed
    ..6, 95% CI = 0.3 to 1.3), but no evidence that antibiotics prevent quinsy for cases labelled as sore throat or pharyngitis (OR = 1.2, 95% CI = 0.7 to 2.2)...
  30. Li M, Wang F. [Review of acupuncture treatment for chronic pharyngitis]. Zhongguo Zhen Jiu. 2010;30:349-51 pubmed
    ..of CNKI and VIP access was performed to gather relevant literature about acupuncture treatment for chronic pharyngitis to evaluate and analyze the present situation of clinical research...
  31. Ebneshahidi A, Mohseni M. Strepsils® tablets reduce sore throat and hoarseness after tracheal intubation. Anesth Analg. 2010;111:892-4 pubmed publisher
    ..2% in the Strepsils group and 19.4% in the placebo group, but the difference remained statistically significant (P < 0.05). Perioperative use of Strepsils tablets reduces postoperative sore throat and hoarseness of voice. ..
  32. Lennon D, Stewart J, Farrell E, Palmer A, Mason H. School-based prevention of acute rheumatic fever: a group randomized trial in New Zealand. Pediatr Infect Dis J. 2009;28:787-94 pubmed publisher the prevention of a primary attack of rheumatic fever in children using oral medication for streptococcal pharyngitis is poorly supported...
  33. Goldfarb D, Slinger R, Tam R, Barrowman N, Chan F. Assessment of flocked swabs for use in identification of streptococcal pharyngitis. J Clin Microbiol. 2009;47:3029-30 pubmed publisher
    ..of flocked swabs to that of traditional swabs for culture of beta-hemolytic streptococci in children with pharyngitis. Sensitivity was higher for flocked swabs, but this did not reach statistical significance...
  34. Danchin M, Rogers S, Kelpie L, Selvaraj G, Curtis N, Carlin J, et al. Burden of acute sore throat and group A streptococcal pharyngitis in school-aged children and their families in Australia. Pediatrics. 2007;120:950-7 pubmed
    ..this study was to determine the incidence, transmission, carriage, and risk factors for group A streptococcal pharyngitis in school-aged children and their families...
  35. Jaensson M, Olowsson L, Nilsson U. Endotracheal tube size and sore throat following surgery: a randomized-controlled study. Acta Anaesthesiol Scand. 2010;54:147-53 pubmed publisher
    ..The remaining symptoms lasted up to 96 h post-operatively in 11%, irrespective of the tube size. Use of a smaller-sized ETT can alleviate sore throat and discomfort in women at the post-anaesthesia care unit. ..
  36. de la Hoz R, Shohet M, Cohen J. Occupational rhinosinusitis and upper airway disease: the world trade center experience. Curr Allergy Asthma Rep. 2010;10:77-83 pubmed publisher
    ..World Trade Center-related UAD is considered an irritant-induced disease but not, in many cases, of acute onset. No data thus far suggest an increased upper airway cancer incidence. ..
  37. Bhalla R, Taylor W, Jones A, Roland N. The inflammation produced by corticosteroid inhalers in the pharynx in asthmatics. Clin Otolaryngol. 2008;33:581-6 pubmed publisher
    ..Histological markers of inflammation and their correlation with pharyngitis. Statistical modelling included univariate and multivariate analyses, which included multiple linear and ..
  38. Maltezou H, Tsagris V, Antoniadou A, Galani L, Douros C, Katsarolis I, et al. Evaluation of a rapid antigen detection test in the diagnosis of streptococcal pharyngitis in children and its impact on antibiotic prescription. J Antimicrob Chemother. 2008;62:1407-12 pubmed publisher
    ..Becton-Dickinson Link 2 Strep A Rapid Test, a rapid antigen detection test (RADT) for diagnosing streptococcal pharyngitis in children presenting to private offices and to the Pediatric Outpatient Clinic of a university hospital, in ..
  39. Matthys J, De Meyere M, Van Driel M, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007;5:436-43 pubmed
    Many countries have national guidelines for the treatment of pharyngitis. We wanted to compare the recommendations and the reported evidence in national guidelines for the management of acute sore throat in adults...
  40. Atlas S, McDermott S, Mannone C, Barry M. The role of point of care testing for patients with acute pharyngitis. J Gen Intern Med. 2005;20:759-61 pubmed
    There is no consensus favoring a particular strategy for evaluating patients with pharyngitis. To compare a clinical decision aid and a rapid office-based point of care (POC) test with routine culture for group A beta-hemolytic ..
  41. Tan T. The appropriate management of pharyngitis in children and adults. Expert Rev Anti Infect Ther. 2005;3:751-6 pubmed
    Acute pharyngitis, or the complaint of a sore throat, is one of the most common illnesses for which both adult and pediatric patients seek medical care from primary care physicians...
  42. Carapetis J, Steer A, Mulholland E, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5:685-94 pubmed
    ..are more than 111 million prevalent cases of GAS pyoderma, and over 616 million incident cases per year of GAS pharyngitis. Epidemiological data from developing countries for most diseases is poor...
  43. Pires R, Rolo D, Mato R, Feio de Almeida J, Johansson C, Henriques Normark B, et al. Resistance to bacitracin in Streptococcus pyogenes from oropharyngeal colonization and noninvasive infections in Portugal was caused by two clones of distinct virulence genotypes. FEMS Microbiol Lett. 2009;296:235-40 pubmed publisher
    ..One high-level bacitracin-resistant isolate, associated with a tonsillitis/pharyngitis episode, is cMLS(B)-macrolide-resistant and tetracycline-resistant member of the emm74/ST120 lineage, which was ..
  44. Ogata J, Minami K, Horishita T, Shiraishi M, Okamoto T, Terada T, et al. Gargling with sodium azulene sulfonate reduces the postoperative sore throat after intubation of the trachea. Anesth Analg. 2005;101:290-3, table of contents pubmed
    ..The incidence of POST and verbal analog pain scale scores in the Azunol group decreased significantly compared with the control group. We demonstrated that gargling with Azunol effectively attenuated POST with no adverse reactions. ..
  45. Grivea I, Al Lahham A, Katopodis G, Syrogiannopoulos G, Reinert R. Resistance to erythromycin and telithromycin in Streptococcus pyogenes isolates obtained between 1999 and 2002 from Greek children with tonsillopharyngitis: phenotypic and genotypic analysis. Antimicrob Agents Chemother. 2006;50:256-61 pubmed
    ..High incidence of macrolide resistance and clonal spread of telithromycin resistance were the characteristics of the Greek S. pyogenes isolates obtained from 1999 to 2002. ..
  46. Agarwal A, Nath S, Goswami D, Gupta D, Dhiraaj S, Singh P. An evaluation of the efficacy of aspirin and benzydamine hydrochloride gargle for attenuating postoperative sore throat: a prospective, randomized, single-blind study. Anesth Analg. 2006;103:1001-3 pubmed
    ..POST was more severe in the control group at 0 and 2 h (P < 0.05). Aspirin and benzydamine hydrochloride gargles significantly reduced the incidence and severity of POST (P < 0.05). ..
  47. Centor R, Allison J, Cohen S. Pharyngitis management: defining the controversy. J Gen Intern Med. 2007;22:127-30 pubmed
    ..and cost-effective analyses, controversy persists regarding the appropriate management strategy for adult pharyngitis. In this perspective, we explore this controversy by comparing two competing clinical guidelines...
  48. Marín Cañada J, Cubillo Serna A, Gómez Escalonilla Cruz N, Garzón de la Iglesia J, Benito Ortiz L, Reyes Fernández M. [Is streptococcal pharyngitis diagnosis possible?]. Aten Primaria. 2007;39:361-5 pubmed
    ..cervical adenopathy, tonsillar exudate, fever, and absence of catarrh symptoms) in diagnosing streptococcal pharyngitis (gold standard: throat swab). Descriptive study. San Fernando 2 Health Centre, Madrid (outer urban area), Spain...
  49. Pfoh E, Wessels M, Goldmann D, Lee G. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics. 2008;121:229-34 pubmed publisher
    Our aim was to describe the morbidity, medical costs, and nonmedical costs associated with group A streptococcal pharyngitis in school-aged children...
  50. Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol. 2005;22:307-11 pubmed
    ..Postoperative throat complaints frequently arise after tracheal intubation for general anaesthesia in the first 2 postoperative days, but they are of limited intensity and duration. ..
  51. Al Qahtani A, Messahel F. Quality improvement in anesthetic practice--incidence of sore throat after using small tracheal tube. Middle East J Anaesthesiol. 2005;18:179-83 pubmed
    ..Accordingly, patient satisfaction has been reported to be high. ..
  52. Ayranci U, Akgun Y, Unluoglu I, Kiremitci A. Antibiotic prescribing patterns for sore throat infections in a university-based primary care clinic. Ann Saudi Med. 2005;25:22-8 pubmed
    ..3%). Throat cultures were positive in 56 patients (16.5%). Most of patients were diagnosed as having pharyngitis (22.7%), and the most frequently prescribed medicine was an oral penicillin (39.1%)...
  53. Hannaford P, Simpson J, Bisset A, Davis A, McKerrow W, Mills R. The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland. Fam Pract. 2005;22:227-33 pubmed
    ..To assess the prevalence of ear, nose and throat (ENT) symptoms experienced by individuals living in Scotland, and their use of GP or hospital services for these problems...