home Audience 12 Determination of mpv index in a blood test and interpretation of the results. Decoding the MPV indicator in a blood test

Determination of mpv index in a blood test and interpretation of the results. Decoding the MPV indicator in a blood test

A blood test for MPV can help identify problems with blood clotting and determine the average platelet volume. What indicators are included in the reference values and what does their increase and decrease indicate?

What is MPV

MPV (mean platelet volume) is the average platelet volume, which is important for making a diagnosis. By their nature, platelets are small blood cells without an internal nucleus that take part in the process of blood clotting and ensure integrity blood vessels. MPV allows you to determine the maturity of the plates and the biological content in them active substances.

To conduct the study, blood is used from a vein or finger, which is taken in the morning on an empty stomach. As a result of hematological tests, a histogram is drawn. If the graph is shifted to the left, this indicates a predominance of old cells; if to the right, immature plates occupy a predominant number. As platelets age, their number and volume decrease significantly.

Norm and diagnostic value

MPV is measured in femtoliters and the reference value is 7.5-10 fl. In children, the normal limits are slightly lower and equal to 8.9 fl, and with age the highest limit increases to 11 fl.

Average platelet counts are extremely important because the analysis reflects qualitative characteristics. Young cells have quite big size, increased activity and contain the maximum amount of biologically active substances. They regulate the process of blood clotting and form blood clots to close the lumen in the vessel. A blood test for MPV can identify the risk of bleeding and determine a number of pathological changes in organism.

High MPV

An increased content of the average platelet count indicates a large number of immature forms in the blood. As a rule, indicators go beyond normal limits in the presence of physiological conditions associated with blood loss: menstrual flow, surgical intervention, multiple injuries and internal bleeding. The causes of increased MPV can be various diseases: thyrotoxicosis, diabetes, thrombocytopenia, atherosclerosis, enlarged spleen, alcoholism, etc.

Low MPV

A decrease in the MPV level below the acceptable reference value may indicate a number of physiological processes and diseases. Most often, such results are detected in liver cirrhosis, iron deficiency anemia, most cancers (leukemia, sarcoma or lymphoma), hypo- or hyperthyroidism, myocardial infarction and kidney diseases (amyloidosis or glomerulonephritis). Less commonly, this indicator is detected when there is presence in the body inflammatory processes or in case of development of autoimmune diseases.

Reduced MPV levels can be diagnosed during pregnancy. If this result is accompanied by a decrease general level platelets, this may become a threat premature birth or miscarriage.

A blood test for MPV can identify a number of diseases and pathological changes in the human body. It also provides grounds for other diagnostic procedures.

MPV (Mean platelet volume) – MPV in a clinical blood test is an indicator normal level platelets contained in the blood, when maintained in a normal state, indicates good condition health.

While a deficiency threatens not only minor complications, but their excess concentration can even lead to death.

Platelets take an important part in the life of the body, carrying out blood clotting, blood clot formation, and vascular restoration.

They are fragments of plasma, without a nucleus, and have a disc-shaped shape.

The bone marrow is responsible for the production of platelets. Most of they are found in the blood, circulating throughout the body, and 1/3 in the spleen. And the average life time is from 7 to 10 days.

Platelets are beneficial to the body in three ways:

Prevents extensive blood loss from developing, in case of violation of the integrity of the vessel. In such a situation, platelets stick together and cling to the surface of the walls of blood vessels, which does not allow the body to die prematurely;
Strengthens collagen production, which is involved in the restoration of vessel integrity after damage;
Viruses and fungi cannot penetrate cells, due to the membrane reinforced by them.

You should not neglect the MVP analysis, and donate blood at least once a year for adults, and at least twice a year for children.

What are the normal levels of platelets in the blood?

Deviation in one direction or another may indicate the development of pathologies; in such cases, it is better to consult a doctor immediately.

There are old and young cells that have different shapes.

Old cells are smaller in size, while young ones are enlarged.

So the doctor is interested not only quantitative indicator platelets, but also high quality.

If the body works as it should, then the norm for adults is: 7.5 – 11 fl. (femtoliters).

Natural human factors also influence the results of the MVP analysis, in which case treatment in most cases is not required:

Age;
Period;
Gestational age;
Selected medications.

Table 1

If the platelet count decreases in pregnant women, there is a possibility of miscarriage. During pregnancy, the number of these cells in the blood should be monitored more frequently and more carefully.

In the case of children, the figures vary slightly from 6.8 to 11.5 fl. This is explained by the fact that hormonal system children are not yet stable.

To fully understand the results, you should initially have an understanding of how the MPV analysis itself takes place. In order to donate blood for an average platelet count, it is necessary to exclude heavy foods from the diet in advance, alcoholic drinks and medicines.

Blood for MPV is taken on an empty stomach, from a vein or finger. Afterwards, specialized dyes are added to the blood and added to a special apparatus, in which it is already clear from the color which cells are present.

Using MPV, you can determine how many young cells are in the blood and how many are old.

The analysis must be carried out within 2 hours, otherwise the indicators will be changed and the diagnosis will be incorrect.

The resulting histogram is a curve and shows qualitative and quantitative blood analysis.

For the ratio of cells, there are certain standards:

Old cells – 5-6%;
Young cells – 90% of the total;
Recently formed - 0.2-0.8%;
Degenerative – no more than 0.2%;

After analyzing all these features, a curve is formed. If the number of old and degenerative cells in more, then a shift to the left, and if there are many senescent cells, then to the right.

MVP in a clinical blood test suggests an indicator of the average platelet volume - also called the platelet index. This indicator characterizes the maturity of the records.

What to do if platelets have dropped?

With low MVP, thrombocytopenia actively develops.

If the indicators keep the bar below normal, then the histogram shows a low number of working cells, while there are many old and newly appeared ones.

Aging cells cannot perform their functions at full capacity, and do not carry a biological load, but only those created are not yet ready for this.

The disease is especially in that with a sufficient number of platelets, their quality can contribute to the development of pathologies.

There are three types of thrombocytopenia:

The bone marrow reduces the synthesis of newly appeared cells. This may be a consequence chronic alcoholism and problems with the liver or spleen.
Increased platelet death indicates diseases of the spleen and liver, and also as a result of autoimmune diseases.
Imbalance of platelet mass during distribution - many platelets are stored in the spleen, when they are not in demand.

Detect thrombocytopenia early stages difficult, due to the fact that external symptoms do not appear. But when tested for MVP, this disease can be detected.

At later stages, manifestations begin directly external symptoms diseases:

The nose and gums bleed;
Callos and urine contain blood;
Vomiting blood;
Longer and more unpleasant menstruation in women;
Hemorrhages under the skin, with a significant area.

Low platelet levels also occur for the following reasons:

Blood diseases (congenital);
Oncology;
Viruses and microbes in the body.

Reduced MVP may indicate the following diseases:

If the platelet count decreases in pregnant women, there is a possibility of miscarriage.

During pregnancy, the number of these cells in the blood should be monitored more frequently and more carefully.

What to do if the MVP level is increased?

A thrombus, circulating with blood throughout the body, can enter a vessel of the heart or brain.

An increase in MVP production indicates that more cells are being produced than required.

Due to this, the consistency of the blood increases and the concentration becomes thicker. This disease is called thrombocytosis.

Thrombocytosis is dangerous because in excess they begin to create blood clots, which, reaching impressive sizes, are capable of blocking the vessel and limiting the blood supply.

Fatal outcomes are quite possible. Subsequently, it leads to heart attack and stroke, after which a third of sick people die.

Thrombocytosis is of two types:

Relative– the norm is not significantly exceeded (from 20 to 30%)
Critical– the norm is exceeded by 3-5 times.

In a critical case, urgent medical intervention is required!

An increase in MVP indicators is possible in two options:

Certain physiological states of the body;
Development of pathologies.

Physiological condition includes:

Heavy menstrual bleeding;
Certain medications;
Features of the child's body;
Various types of bleeding.

The development of such pathologies affects the increase in MVP:

Injuries (mostly in large numbers);
Surgical interventions;
Various types of bleeding.

The main reasons for increasing MVP are some diseases:

A peculiarity in pregnant women is a frequent increase in platelets, which in the vast majority of cases is as it should be. Since the body of the expectant mother changes and adapts to more comfortable conditions for gestation. This can be explained by the fact that the fetus needs its own circulatory system. It is for this purpose that a woman’s circulatory system produces more platelets.

How to treat elevated MVP?

If clinical analysis blood indicated an increase in MVP, we need to find the root cause. If it is physiological and characteristic of a given individual, then no measures are taken as such.

In case of pathologies, therapy is provided in a complex form:

Blood thinners. Used to normalize blood to natural thickness;
Application hormonal treatment, for normal platelet production;
Drinking large amounts of water and diuretics;
Diet.

In life-threatening situations, doctors perform hemodialysis. A person’s blood passes through a device that retains platelets, as a result of which the level returns to normal.

If the platelet production disorder is caused by the bone marrow, a bone marrow transplant is performed.

How to keep your MVP metrics healthy?

To maintain the average volume and MVP within normal limits, it is necessary to do prevention, which consists of the following actions:

Take a clinical blood test with MVP indicators at least once every three months;
Carefully select medications during treatment. Some drugs negatively affect platelet function;
Bring your diet back to normal. Reduce the amount of fatty foods, and instead of fatty meat, it is recommended to use fish, turkey or rabbit meat;
Drink enough water.

At any MVP level, it always reflects the level of human health. Timely blood tests will allow you to detect pathologies, if any, in advance and begin treatment. After all, in the early stages external factors there is almost no disease.

Treatment in the early stages is much easier and cheaper!

Video: MPV Blood Test

Should I be concerned if my doctor says my average platelet count is high?

Blood, like a mirror, reflects the processes occurring in the body, and any deviation from the standard in blood parameters indicates a problem.

After reading the article, you will learn what disorders cause the average volume of platelet cells to increase and what are the causes of this anomaly.

Platelets are blood cells that do not contain nuclei, formed from the cytoplasm of megakaryocytes, giant cells of the bone marrow.

Platelet bodies are detached from megakaryocytes and represent the cytoplasm of giant cells surrounded by their own membrane.

A platelet lives in the blood for no more than 10 days. During the day, the platelet level increases or decreases, the fluctuation limit is approximately 10%.

The elements participate in the process of blood clotting, forming a clot. In addition, platelets perform a transport function, carrying immune complexes on their membranes.

Platelet elements are capable of sticking together, forming dense formations - blood clots. Thrombosis is a beneficial process that protects the body from blood loss.

However, with an increase in the concentration of platelets or an increase in their average volume, there is a danger of the bodies sticking together directly in the bloodstream, which is fraught with life-threatening conditions.

Therefore, people who have a high average platelet volume should take blood thinning measures and undergo treatment to reduce the risk of blood clots.

Platelet elements are the smallest blood cells. In fact, they are not even cells, since they do not have a nucleus.

Under a microscope, platelets are visible as biconvex discs, much smaller in size than red and white blood cells.

Platelet bodies circulate freely in the plasma and, when a vessel is damaged, rush to the hole, where they stick together and seal it with a thrombus like a plug.

Symptoms of an increase in the average volume of platelet elements:

minor hemorrhages on the skin and mucous membranes;
pain in the fingertips, increased sensitivity fingers;
paleness of the skin and mucous membranes;
weakness, dizziness are a sign of anemia, which may be accompanied by an increase in platelet volume;
visual impairment.

The most dangerous consequence An increase in the average volume of platelet cells causes blockage of the arteries, resulting in a heart attack or stroke.

The danger of blockage appears if, simultaneously with an increase in the average size, the number of platelets has increased.

A heart attack or stroke can cause death in a person whose blood has an increased volume of platelet elements.

Features of a blood test for platelet bodies

The platelet count is determined using total clinical trial blood. In modern times, this indicator is not calculated manually, but automatic hematological analyzers are used - devices that simultaneously determine up to two dozen blood parameters, including the number and average size of platelets.

The device can draw a line of distribution of platelet bodies by volume. If there are predominantly young cells in the blood, then the graph shifts to the right. The more old elements in the plasma, the more pronounced left side graphic arts.

A few decades ago, equipment could only determine platelet levels. Modern diagnostics has much wider capabilities, including the ability to calculate the average platelet volume.

The device produces results in an unusual form - each indicator is represented by several letters of the Latin alphabet.

The vast majority of patients and even some providers do not understand what is printed on the study form.

Mean platelet volume is abbreviated MPV. It is considered normal when this indicator falls within the range of 3.6 – 9.4 µm 3 .

Only a few drops of blood are required to determine MPV. The test allows you to determine the concentration and average volume of platelet elements.

A feature of the platelet test is its efficiency - the study must be carried out no later than 2 hours after collecting the material. If you do this later, the test result will not be considered reliable.

Normal platelet bodies should be:

in children in the first weeks of life (99 – 421)*10 9 /l;
in adults (180 – 320)*10 9 /l.

If the average platelet volume is increased, this means that the bone marrow produces platelet bodies in excess, and they do not have time to be eliminated from the body. An excess of platelet elements in the plasma makes the blood thick and viscous.

If the analysis shows that the average platelet volume is increased, then you cannot independently draw conclusions about the presence of the disease.

When analyzing blood counts, you need to rely on many parameters. This work can only be done by a specialist. If necessary, the doctor will prescribe additional examinations and drug therapy.

Reasons for the increase

The number of platelet elements can increase primarily oncological diseases of the hematopoietic organs, Sokolsky-Buyo disease, rheumatoid arthritis, tuberculosis, proliferation connective tissue liver, colitis

An increase in plasma platelet levels is called thrombocytosis. Pathology can be primary or secondary. In the first case, the level is increased due to the primary proliferation of giant cells.

At secondary thrombocytosis the number of elements increases against the background of any disease. Increased MPV is observed after spleen removal and in the postoperative periods.

What to do if the test results show borderline state, that is, MPV has not yet been increased, but is already at the normal limit?

Such an increase may indicate physiological conditions rather than pathology. For newborns, an increased MPV is the norm, since the hematopoietic organs of babies are still immature.

An increased average volume is considered normal after treatment that stimulates hematopoiesis, after chronic or acute blood loss.

The listed conditions provoke increased formation of platelets, which are designed to restore blood loss.

Naturally, this increases MPV. If, after surgery or injury accompanied by severe blood loss, the average platelet volume does not increase, then this indicates bad work hematopoietic organs.

The volume of platelets determines their activity, content useful substances, tendency to stick together. The older the platelet, the smaller its volume.

High platelet levels increase blood viscosity and promote the formation of blood clots.

If the platelet level is not lowered in time, the consequences can be dire: thrombosis, heart attack, stroke.

Prevention and treatment

If the average platelet volume is elevated, what does this mean? This deviation from the standard clearly indicates the presence of a disease.

The doctor will most likely order a repeat test to rule out the possibility of error. If the new test confirms the increase, then it will be necessary to find out the cause of the anomaly. Most likely, doctors will look for the causes of the shift in the hematopoietic organs.

A high platelet count and an increased average platelet volume in the blood are not the same thing. In the first case we're talking about about thrombocytosis.

An increase in the average volume characterizes not quantitative, but qualitative changes in the blood. Platelet bodies leave the hematopoietic organs immature and structureless, which is why their volume is increased.

If young immature platelet elements begin to predominate in the blood, then the analysis will show an increase in the average volume.

The average volume indicator characterizes the usefulness of platelets in the blood. The more pronounced the increase in volume, the fewer full-fledged platelets in the blood that are capable of doing their job.

There is a relationship between the number of platelets and their average volume. Usually, inverse proportionality is observed - the higher the level of platelets, the lower their average volume will be, and vice versa, with an increase in the average volume, the number of platelet elements decreases.

There are exceptions to this rule:

after blood loss, both indicators should be increased;
in case of bone marrow failure caused by radiation or poisoning, including medications, both indicators are reduced.

To maintain platelet levels within standard limits, you need to follow a healthy diet.

Harmful animal fats should be replaced with plant fats rich in omega-3 fatty acids- olive or linseed oil.

It makes sense to replace pork with rabbit, turkey and lean fish.

To reduce blood viscosity, it is very important to drink enough water. Drink at least 2 liters per day.

Drinking plenty of fluids helps thin the plasma and can prevent heart attacks and strokes.

It is important that water, being excreted through the kidneys, “captures” with it potassium and lithium ions necessary for the production of platelet elements, therefore drinking plenty of fluids reduces the production of young cells, and therefore reduces the average volume.

Thrombocytosis and an increase in MPV are only symptoms, so it is not necessary to reduce the volume or concentration of these bodies, but to treat the underlying disease.

In many cases, an increase in MPV does not manifest itself in any way externally, so an annual preventive medical examination will allow you to identify health problems in time and quickly take measures to eliminate them.

The question of what mpv is in a blood test and what it means worries many when conducting various examinations. The MPV value reflects the platelet content. Their level is playing great importance at various injuries or conditions accompanied by blood loss. A decrease or increase in the indicator indicates the development of a process that is not characteristic of a healthy organism.

What are platelets

Platelets are blood elements. They are components of the cytoplasm that lack a nucleus. The formation of these elements occurs in bone marrow. Some of them are in the spleen, and some enter the bloodstream. Their life expectancy is on average 10 days.

Among the functions of platelets are:

Preventing large blood loss due to vascular damage. The implementation of this function occurs due to the ability of the elements to stick together with each other, as well as attach to the vascular wall.
The ability to activate the production of collagen cells involved in regenerative processes when the integrity of the blood vessel is violated.
Strengthening cell membranes, which makes it impossible for pathogenic microorganisms to penetrate.

An important indicator of the level of platelets in the blood is the average volume of these elements. When asked: what is mpv, the doctor points to the platelet index. It is this that reflects the maturity of these blood elements. After taking biological material it is examined using hematology analyzers. The latter depict a curve characterizing the distribution of plates by volume. In the case when the histogram shifts to the right, we speak of the predominance of immature forms. A large number of of old cells is manifested by a shift to the left.

Study of platelet index

The mpv study plays a role in blood testing important role to study the hematopoietic function of the body. After all, not just the functioning of the body, but also human life depends on its high-quality implementation. Changes in the platelet index indicate the presence of various diseases, determine the cause and begin treatment. Research in blood mpv It is necessary to carry out this procedure for adults - 1 time per year, for children - 2 times.

A blood test to study the platelet index is carried out after taking material from a finger. Biological fluid is examined under a microscope. The specificity of the analysis is that the study of the material should be carried out in the first 2 hours after blood collection.

If the time requirements are not met, the indicators change, which ultimately leads to an incorrect diagnosis.

An increased platelet count is reflected in an increase in blood viscosity and the risk of developing blood clots. In the presence of concomitant diseases this process is dangerous not only by the development of complications, but also fatal. A decrease in the number of platelets produced creates a risk of dangerous blood loss even with minor injuries or injuries. In any case, mpv and the norm of this indicator indicate the presence or absence of pathological processes, the treatment of which is necessary and important for human health.

Normal values

In order to find out whether the average platelet volume corresponds to mpv normal indicators, the obtained data is correlated with certain values. They are present in any laboratory. The average platelet volume in the blood for a healthy adult population is 7-12 fl (femtoliters).

However, there are natural factors, which may affect the analysis performance. These include:

age category;
presence of menstrual bleeding;
term of interesting position;
use of certain medications.

If the average platelet count is lower than normal in a pregnant woman, this is normal in most cases. However, in parallel it is necessary to monitor the course of pregnancy. In some cases, a significant decrease in indicators may indicate a threat of miscarriage. The following values are normal for different categories of subjects:

When indicators are elevated

When testing blood for the platelet index, the questions are quite natural: what to do if the average volume of platelets is increased and what does this mean. An increase in MPV indicators is possible in two ways: in certain physiological conditions and in the development of a pathological process. TO physiological conditions include:

heavy menstruation;
specificity of hematopoietic function in children;
use of certain medications.

The occurrence of a pathological process is possible as a result of:

getting injured;
surgical intervention;
the presence of bleeding of various natures.

Among the main reasons when mpv indicators are increased are development:

In addition, the reasons for an increase in the platelet index are an enlarged spleen (due to various circumstances) and alcoholism. Their presence will necessarily indicate a disruption in the normal functioning of the body.

What to do if indicators increase

If the interpretation of the analysis showed that the average platelet volume is increased, a search is necessary main reason. In the case when it turns out to be physiological and associated with phenomena characteristic of humans, then no special measures are taken. In the presence of a pathological process, therapy is carried out in two directions:

Use of blood thinning medications. This is necessary in order to normalize the natural thickness of biological fluid and reduce the load on the heart muscle.
Use of hormonal treatment. Necessary in order to restore the normal process of platelet formation.

All healing process carried out in a hospital setting, under the supervision of specialists. You should not self-prescribe medications. Indeed, with their incorrect dosage, it is possible to develop side effects and complications.

When indicators are reduced

The platelet index can not only increase, but also decrease. The main reasons for this include the development of:

splenomegaly;
liver cirrhosis;
anemia of various etiologies;
some hereditary diseases;
oncological processes: sarcoma, leukemia;
inflammatory processes;
autoimmune diseases;
heart attack;
kidney pathologies;
dysfunction of the thyroid gland;
hypoproteinemia.

In addition, the average platelet volume is reduced when using certain medications and while pregnant. The answer to the question: why the average volume of platelets is reduced and what this means can only be given by a specialist based on general research, which includes not only a blood test, but also an examination, collection of complaints, and in some cases, additional diagnostic procedures.

Preventive actions

To ensure that the average platelet volume and mpv indicators always correspond normal values compliance is required preventive measures. These include the following:

Carry out a platelet index study in the presence of chronic diseases at least once every trimester.
Carefully select medications when treating diseases caused by viruses. After all, some medications negatively affect platelet production and mpv levels.
Monitor your diet. It is better to replace animal fats with vegetable ones. And instead of fatty meat, it is better to use rabbit, turkey, and fish when preparing dishes.
Observe drinking regime, that is, drink enough water.

In addition to the main preventive measures, you should consult a doctor if:

there is a sharp weight loss;
there is constant fatigue;
available constant bleeding from the nose;
often concerned about tachycardia and hypertension;
observed sharp deterioration health;
skin and mucous membranes have changed color;
Hematomas appear for no particular reason.

Any platelet level: high, low or normal reflects a person's level of health. The study of platelet index allows you to detect in time pathological processes and start timely treatment the resulting state. Indeed, in some cases, the development of the disease on early stages does not have bright external signs. Studying the platelet count will save valuable time and not miss out on health.

In contact with

Very often, when familiarizing yourself with the results of the analyzes carried out, you can come across a note saying about a decrease in the average platelet count(by the way, do you know what to do?). This condition of the blood coagulation system is called thrombocytopenia. This state of the coagulation system is a signal of the presence in the body that has this disorder, quite serious problems with health.

Blood plates are essential element, which is part of the blood. If integrity violations occur circulatory system these shaped elements ensure the formation of blood clots and stop bleeding at sites of injury. This reaction is protective and prevents blood loss in the body. Decrease in number blood platelets in the bloodstream can lead to prolonged bleeding, which can be a threat to human life. What is the reason that the average platelet volume in a person’s blood is lower than normal? The average platelet volume can decrease for a variety of reasons.

Average platelet volume is below normal, causes, treatment

Thrombocytopenia may have hereditary causes . Often, some genetic diseases are accompanied by a decrease in the number of blood platelets. In addition, some genetic diseases can cause disturbances in the process of platelet formation and breakdown. Very often, the cause of thrombocytopenia is the presence of an autoimmune disease accompanied by the formation of special antibodies that contribute to the destruction of human blood platelets.

The presence of thrombocytopenia in a person may indicate that the patient has developing cancer. An example of such a phenomenon in the body is a decrease in the number of blood platelets if it has malignant tumors in the bone marrow, as well as the presence of developing leukemia. The presence of HIV infection in a person or infectious diseases such as rubella, measles and complex forms of influenza affect the number of platelets in the blood.

Liver cirrhosis can lead to a significant drop in the number of blood platelets; in addition, diseases of the spleen lead to a decrease in the number of platelets. This is due to the fact that it is the tissue of the liver and spleen that are responsible for the destruction of platelets, which are old.

The average platelet volume is below normal and their number depends on the proper functioning of the thyroid gland. For this reason, any violations associated with normal functioning organs influence the platelet count. With the development of hyperthyroidism and thyrotoxicosis, there is a significant and long-term drop in the number of blood platelets in the bloodstream of the body. In addition to all of the above, the quantitative composition of blood platelets big influence has the use of certain medications.

What manifestations does thrombocytopenia have in the body? First of all, this disease is manifested by numerous and frequent small hemorrhages. For example, on the body of patients who have been diagnosed with this disease without any special visible reasons bruising occurs, minor bleeding appears on the mucous membranes. Microhemorrhages in the sclera of the eyes are especially noticeable in such a situation. In this case, the sclera takes on a reddish appearance. In some cases, small blisters filled with blood appear on the skin. If any of the above symptoms are detected, it is recommended to immediately seek help from a medical facility.