scholarly journals Postoperative Neurological Complications after a Cranial Surgery: A Multicentre Prospective Observational Study

2020 ◽  
Author(s):  
Ramesh J. Venkatapura ◽  
Surya K. Dubey ◽  
Nidhi Panda ◽  
Dhritiman Chakrabarti ◽  
Sudhir Venkataramaiah ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Tertiary Care ◽  
Neurological Complications ◽  
Vascular Pathology ◽  
Neurological Deficits ◽  
Motor Deficit ◽  
Fisher Exact Test ◽  
Chi Square ◽  
Exact Test ◽  
Cranial Surgery

Abstract Background  Cranial surgery is associated with multiple postoperative complications varying from simple nausea and vomiting to devastating complications such as stroke and death. This multicentre collaborative effort was envisioned to collect observational data regarding postoperative complications in cranial surgeries among the Indian population. The aim of this study was to describe the postoperative neurological complications occurring within the first 24 hours after surgery and to identify the predictive factors. Methods Data was collected from three participating tertiary care academic institutions. The study was prospective, observational, multicentre design with data collected over a period of two months or 100 cases, whichever is earlier, from each participating institute. A predesigned Microsoft excel sheet was distributed among all three centers to maintain uniformity. All patients aged 18 years and above of both sexes undergoing elective or emergency craniotomies were included in the study. The postoperative neurological complications (within 24 hours) assessed were: (1) Neurological deficit (ND) defined as new focal neurological motor deficit relative to preoperative status. (2) Sensorium deterioration (SD) defined as reduction in Glasgow coma score (GCS) by 2 or more points compared with preoperative GCS. (4) Postoperative seizures (SZs) defined as any seizure activity. All possible variables associated with the above neurological complications were tested using Chi-square/Fisher exact test or Mann–Whitney U test. The predictors, which were statistically significant at p < 0.2, were entered into a multiple logistic regression model. Alpha error of 5% was taken as significant. Results Data from three institutions was collected with a total of 279 cases. In total, there were 53 (19%) neurological complications. There were 28 patients with new postoperative NDs (10.04%), 24 patients had SD (8.6%), and 17 patients had seizures (6.1%). Neurological deficits were significantly less in institution 2. Diagnosis of traumatic brain injury (TBI) was associated with very low risk of ND, and vascular pathology was associated with higher chance of a ND. The duration of anesthesia was found to be significantly predictive of SD (OR/CI = 1.01 / 1–1.02). None of the factors were predictive of PS. Conclusion The incidences of postoperative ND, SD and postoperative seizures were 10%, 8.6%, and 6.1%, respectively. Studies with a much larger sample size are required for a better and detailed analysis of these complications.

scholarly journals 2145. Carbapenem-Resistant Enterobacteriaceae infections at the Maharaj Nakorn Chiang Mai Hospital

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S727-S727
Author(s):  
Romanee Chaiwarith ◽  
Wisarut Supparatpinyo
Keyword(s):  
Univariate Analysis ◽  
Tertiary Care ◽  
Control Measures ◽  
Fisher Exact Test ◽  
Care Hospital ◽  
Chiang Mai ◽  
Chi Square ◽  
Exact Test ◽  
Carbapenem Resistant ◽  
Carbapenem Resistant Enterobacteriaceae

Abstract Background Nowadays, carbapenem-resistant enterobacteriaceae (CRE) infection has been spreading worldwide in a tertiary care hospital and causing globally health damage. In Thailand, the studies of the epidemiology of CRE are scarce. This study aimed to describe epidemiology, clinical characteristics and treatment outcome of CRE infection. Methods A retrospective cohort study was conducted among patients admitted to the Maharaj Nakorn Chiang Mai Hospital between January 2014 and December 2016 who had clinical diagnosis of CRE infection. Characteristics between groups were compared using Chi-square, Fisher exact test or Student t-test, Mann–Whitney U test. Factors associated with mortality in univariate analysis were analyzed in the logistic regression model. Results Among 241 patients who had clinical specimens grew CRE, 51 had infection. Twenty-five patients (49%) were previously hospitalized within 90 days and 42 patients (82.4%) had exposed to antibiotics before documented CRE infection. The most common sites of clinical isolates were urine (33.3%), sputum (29.4%), and blood (21.6%). The mortality rate was 47.1%, which 17 (33.3%) patients’ death was attributable to CRE infection. Factor associated with mortality was higher body temperature (OR 4.8, P = 0.005) and thrombocytopenia. Conclusion CRE infections cause high mortality. Strategies to prevent emergence through prudent uses of antibiotics and transmission through infection control measures should be implemented in order to reduce mortality. Disclosures All authors: No reported disclosures.

scholarly journals Assessment of surgical patients’ knowledge about anaesthesia and anaesthesiologist in a tertiary care teaching institute-a survey

2018 ◽  
Vol 6 (2) ◽  
pp. 486 ◽  
Author(s):  
Vinay Marulasiddappa ◽  
Nethra H. N.
Keyword(s):  
Tertiary Care ◽  
Cross Sectional Study ◽  
Work Place ◽  
Fisher Exact Test ◽  
Care Hospital ◽  
Chi Square ◽  
Cross Sectional ◽  
Exact Test ◽  
Adequate Knowledge ◽  
Survey Population

Background: Anaesthesia is a speciality, playing a crucial role in the perioperative care of patients. Complex surgeries are facilitated due to the anaesthesiologists catering to the ever-advancing surgical field requirements. Although an important speciality, patients are unaware of the speciality of anaesthesia and anaesthesiologist. Patients are subjecting themselves for surgical procedures without having adequate knowledge of anaesthesia and anaesthesiologist. Hence, the survey was designed with the aim to assess the patients’ knowledge about anaesthesia and anaesthesiologist in surgical patients.Methods: A cross sectional study conducted on four hundred surgical inpatients using predesigned questionnaire containing questions related to the knowledge of anaesthesia and anaesthesiologist. The results were expressed as percentages. Chi-square/ Fisher Exact test was used to find the significance of study parameters.Results: Anaesthesiologists were considered as “doctors” by 60.5% of patients; Thirty three percent of the survey population had “no idea” of Anaesthesia. The survey populations’ knowledge about complications was 32.25%. Awareness about separate consent for anaesthesia was 49%. Anaesthesiologists’ work place was not known to 77.5% of survey population. Anaesthesiologists’ role in operation theatre was known only in 59.5% and remaining 40.5% were unaware of Anaesthesiologists’ role. None of the patients preferred to meet the Anaesthesiologists before surgery.Conclusions: Surgical inpatients in tertiary care hospital have a poor understanding of anaesthesia and poor recognition of the role of anaesthesiologist. The knowledge about anaesthesia and anaesthesiologist is not known in general population. Hence, anaesthesiologists must work towards getting recognition for the speciality of anaesthesiology and the anaesthesiologists.

Venous Thromboembolism and High Grade Gliomas

1993 ◽  
Vol 70 (03) ◽  
pp. 393-396 ◽  
Author(s):  
Mandeep S Dhami ◽  
Robert D Bona ◽  
John A Calogero ◽  
Richard M Hellman
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Medical Center ◽  
Significant Risk ◽  
Bleeding Complications ◽  
Fisher Exact Test ◽  
High Grade ◽  
Chi Square ◽  
Exact Test ◽  
High Grade Gliomas

SummaryA retrospective study was done to determine the incidence of and the risk factors predisposing to clinical venous thromboembolism (VTE) in patients treated for high grade gliomas. Medical records of 68 consecutive patients diagnosed and treated at Saint Francis Hospital and Medical Center from January 1986 to June 1991 were reviewed. The follow up was to time of death or at least 6 months (up to December 1991). All clinically suspected episodes of VTE were confirmed by objective tests. Sixteen episodes of VTE were detected in 13 patients for an overall episode rate of 23.5%. Administration of chemotherapy (p = 0.027, two tailed Fisher exact test) and presence of paresis (p = 0.031, two tailed Fisher exact test) were statistically significant risk factors for the development of VTE. Thrombotic events were more likely to occur in the paretic limb and this difference was statistically significant (p = 0.00049, chi square test, with Yates correction). No major bleeding complications were seen in the nine episodes treated with long term anticoagulation.We conclude that venous thromboembolic complications are frequently encountered in patients being treated for high grade gliomas and the presence of paresis and the administration of chemotherapy increases the risk of such complications.

Comparison of Clinical Outcomes With Drug Coated Balloons Versus Plain Balloon Angioplasty In Chronic Limb-Threatening Ischemia

2021 ◽  
pp. 153857442110225
Author(s):  
Joel Mathew John ◽  
Vimalin Samuel ◽  
Dheepak Selvaraj ◽  
Prabhu Premkumar ◽  
Albert A Kota ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Interventional Procedure ◽  
Tertiary Care ◽  
Arterial Disease ◽  
Multivariable Logistic Regression Analysis ◽  
Tertiary Care Centre ◽  
Chi Square ◽  
Exact Test ◽  
Institutional Review ◽  
Chi Square Test

Objective: The use of drug coated balloon (DCB) for angioplasty has shown superior efficacy against plain balloons for treating complex infrainguinal arterial disease. We report and compare the clinical outcomes following application of DCB(Paclitaxel) and plain angioplasty (POBA) in our tertiary care centre. Methods: A retrospective, single centre analysis of 301 patients with chronic limb-threatening ischemia involving the infrainguinal segment was conducted between September 2014 and September 2018, after approval from the Institutional review board. We analyzed clinical outcomes by measuring postoperative ABI improvement, restenosis requiring reintervention procedure, minor and major amputations at the end of 18 months. . To find the association between the group variables (POBA and DCB) and other risk variables, Chi-square test/Fisher’s exact test was used. Multivariable logistic regression analysis was used. Results: Patients who underwent treatment with plain balloon (POBA) and DCB(Paclitaxel) angioplasty were 246(81.7%) and 55(18.3%) respectively. Our study group was predominantly male (Male: Female = 6.7:1), most patients were more than 50 years of age (n = 251, 83.4%). Smoking (n = 199, 66.1%) and diabetes (n = 210, 69.8%) were the most common atherosclerotic risk factors. Postoperative Ankle Brachial Pressure Index (ABI) improvement were similar in both groups (POBA = 57.7%; DCB = 69.8%; p = 0.103). Minor and major amputations following POBA were 26% and 22%; and DCB were 12.7% and 16.4% respectively. Re-stenosis requiring a re-interventional procedure within 18 months was 15%, (n = 37) following POBA; and 12.7% (n = 7) following DCB (p = 0.661). Conclusions: This retrospective study shows similar clinical limb related outcomes following POBA and DCB at 18 months. However, our comparative analysis between the POBA and DCB groups was totally unadjusted and not adjusted for common confounders such as age and sex. Hence, for one to draw definitive conclusions leading to changes in clinical practice; a randomized, prospective study with a larger patient cohort is needed.

A year of hepatocellular carcinoma at a glance. Demographics, biochemical and radiological characteristics and treatment modalities from a specialized facility of Pakistan

2021 ◽  
pp. 1-6
Author(s):  
Laima Alam
Keyword(s):  
Hepatocellular Carcinoma ◽  
Cross Sectional Study ◽  
Treatment Modalities ◽  
Fisher Exact Test ◽  
Tumour Staging ◽  
Chi Square ◽  
Cross Sectional ◽  
Exact Test ◽  
Team Meetings ◽  
Contrast Enhanced Ct

Objectives:Relation of demographics of hepatocellular-carcinoma with the aetiology.Tumour characteristics in relation to anti-viral therapy and presence of viral-DNA/RNATreatment modalities offeredMethods: This cross-sectional study enrolled all the patients aged 18-70 years with diagnosed hepatocellular carcinoma either through Triphasic Contrast-Enhanced-CT scan and/or Magnetic Resonance Imaging or biopsy presenting to the Outpatient-Department or multi-disciplinary-team meetings for the year 2019. Demographic variables, biochemical analysis including liver profile and stage of cirrhosis, viral-status, tumour staging and the treatment modalities offered were all noted. ANOVA (normal) and Kruskal-Wallis (non-normal) tests were used to compare quantitative data whereas chi-square-test and fisher-exact-test were used to compare qualitative-data.Results: Out of 195 patients with hepatocellular carcinoma, 76% were males in their fifth to sixth decades of life, 96% had cirrhosis, 94% corresponded to viral hepatocellular-carcinoma (82% Hepatitis-C-Virus, 9% Hepatitis-B-Virus and 3% coinfection), 60% of the cirrhotics landed in Child-Pugh A category with tumour staging BCLC-B being the predominant one (43.6%) and single and multiple bilateral nodules were the commonest lesions encountered. Platelets and Alanine-Transaminase had a significant relation across aetiological groups. Lymph-nodes were the most common extra-hepatic organs for metastasis and the presence of viral PCR had a significant impact on the tumour aggressiveness. Thirty-two percent of the patients were amenable to curative treatment.Conclusion: Viral infection is the main cause of rising prevalence of this tumour in Pakistan. Treatment modalities are expensive and expertise are lacking. A nationwide cancer registry is required for the exact disease burden and tumour behaviour for our population. Continuous....

scholarly journals Phlebitis associated with peripheral intravenous catheters in adults admitted to hospital in the Western Brazilian Amazon

2016 ◽  
Vol 50 (2) ◽  
pp. 263-271 ◽  
Author(s):  
Sandra Maria Sampaio Enes ◽  
Simone Perufo Opitz ◽  
André Ricardo Maia da Costa de Faro ◽  
Mavilde de Luz Gonçalves Pedreira
Keyword(s):  
Intermittent Infusion ◽  
Brazilian Amazon ◽  
Fisher Exact Test ◽  
Intravenous Therapy ◽  
Chi Square ◽  
Significance Level ◽  
Exact Test ◽  
Dorsal Hand Vein ◽  
Mean Time ◽  
Intravenous Catheters

Abstract OBJECTIVE To identify the presence of phlebitis and the factors that influence the development of this complication in adult patients admitted to hospital in the western Brazilian Amazon. METHOD Exploratory study with a sample of 122 peripheral intravenous catheters inserted in 122 patients in a medical unit. Variables related to the patient and intravenous therapy were analyzed. For the analysis, we used chi-square tests of Pearson and Fisher exact test, with 5% significance level. RESULTS Complication was the main reason for catheter removal (67.2%), phlebitis was the most frequent complication (31.1%). The mean duration of intravenous therapy use was 8.81 days in continuous and intermittent infusion (61.5%), in 20G catheter (39.3%), inserted in the dorsal hand vein arc (36.9 %), with mean time of usage of 68.4 hours. The type of infusion (p=0.044) and the presence of chronic disease (p=0.005) and infection (p=0.007) affected the development of phlebitis. CONCLUSION There was a high frequency of phlebitis in the sample, being influenced by concomitant use of continuous and intermittent infusion of drugs and solutions, and more frequent in patients with chronic diseases and infection.

scholarly journals FAKTOR-FAKTOR YANG MEMENGARUHI NEUROPATI PERIFER TERKAIT HIV DI MANADO

2018 ◽  
Vol 35 (3) ◽  
Author(s):  
Deivy Cirayow ◽  
Arthur Hendrik Philips Mawuntu ◽  
Herlyani Khosama
Keyword(s):  
Neuropathic Pain ◽  
Peripheral Neuropathy ◽  
Influencing Factors ◽  
Categorical Variables ◽  
Fisher Exact Test ◽  
Hiv Dementia ◽  
Chi Square ◽  
Exact Test ◽  
International Hiv Dementia Scale ◽  
Hiv Aids

FACTORS THAT INFLUENCE HIV ASSOCIATED PERIPHERAL NEUROPATHY IN MANADOABSTRACTIntroduction: There are  several sociodemographic and clinical factors that influence the development of HIV associated peripheral  neuropathy (HIV-PN). Manado has different sociodemographic and clinical characteristics  from other regions. However, the percentage of HIV-PN and its influencing factors are unknown.Aims: To know the percentage of HIV-PN and factors that influence this disorder in Manado.Methods: A crosssectional study conducted in HIV/AIDS clinic R.D. Kandou hospital Manado between November2016–January 2017. Neuropathy evaluation was performed using brief peripheral neuropathy screening (BPNS), neuropathic pain diagnostic questionnaire (DN4), and electroneurography. A Chi-square or Fisher exact test was done to analyze categorical variables, independent T or Mann-Whitney test was done for numerical variables, and linear regression was done in multivariate analysis.Results: 50 subjects were included, most were male (70%), and the mean age was 32.98 (±9.726) years, with HIV- NP percentage was 46%. Age >30 years old, low hemoglobin count, CD4, and low international  HIV dementia scale (IHDS) significantly associated with HIV-NP. Working subjects were 13.6 times more likely to have HIV-PN.Discussion: HIV-PN prevalence was relatively high, influenced by age >30 years old an low hemoglobin, CD4, andIHDS. As a factor, working was escalating the likelihood of NP-HIV by 13.9 times.Keywords: HIV/AIDS, influencing factors, peripheral neuropathyABSTRAKPendahuluan: Neuropati perifer terkait human immunodeficiency virus/HIV (NP-HIV) dapat dipengaruhi oleh beberapa faktor klinis dan sosiodemografis. Manado mempunyai karakteristik yang berbeda dengan daerah lain, namun belum diketahui persentase NP-HIV dan faktor-faktor yang memengaruhinya.Tujuan: Mengetahui persentase NP-HIV dan faktor-faktor yang memengaruhinya di Manado.Metode: Penelitian potong lintang terhadap pasien HIV/AIDS di poliklinik HIV/AIDS RSUP Prof. dr. R.D. Kandou, Manado, pada November 2016–Januari 2017.  Evaluasi neuropati dilakukan menggunakan brief peripheral  neuropathy screening (BPNS), neuropathic pain diagnostic questionnaire (DN4), dan elektroneurografi. Digunakan uji Chi-square atau Fisher exact untuk menganalisis variabel kategorik, uji T independen atau Mann-Whitney untuk variabel numerik, dan regresi linear untuk analisis multivariat.Hasil: Didapatkan 50 subjek yang memenuhi kriteria penelitian dengan mayoritas laki-laki (70%), rerata usia32,98±9,726 tahun, dan mengalami NP-HIV sebanyak 46%. Usia >30 tahun, kadar hemoglobin, jumlah CD4, dan skor international  HIV dementia scale (IHDS) yang rendah berhubungan secara bermakna dengan adanya NP-HIV. Adapun subjek yang bekerja berisiko 13,6 kali lebih besar mengalami NP-HIV.Diskusi: Didapatkan prevalensi NP-HIV yang cukup tinggi dengan dipengaruhi oleh usia >30 tahun serta kadar hemoglobin, CD4, dan skor IHDS yang rendah. Faktor bekerja juga meningkatkan kecenderungan 13,9 kali mengalami NP terkait HIV.Kata kunci: Faktor-faktor yang memengaruhi, HIV/AIDS, neuropati perifer

scholarly journals Status Pekerjaan Dan Pengetahuan Ibu Menyusui Terhadap Pemberian ASI Eksklusif

2018 ◽  
Vol 16 (2) ◽  
pp. 236-244
Author(s):  
Happy Marthalena Simanungkalit
Keyword(s):  
Fisher Exact Test ◽  
Chi Square ◽  
Cross Sectional ◽  
Exact Test

Latar Belakang : Air Susu Ibu (ASI) selain merupakan makanan paling baik untuk bayi, juga terbukti dapat mencegah penyakit pada bayi dan memberi manfaat bagi ibu, keluarga, dan masyarakat. Memberikan ASI selama 6 bulan dapat menyelamatkan 1,3 juta jiwa di seluruh dunia. Tahun 2016 capaian pemberian ASI eksklusif di Wilayah Kerja Puskesmas Jekan Raya masih rendah. Tujuan Penelitian: Penelitian ini merupakan crosssectional study yang bersifat analitik Populasinya adalah seluruh ibu yang memiliki anak usia 6-12 bulan. Metode Penelitian: Penelitian ini menggunakan penelitian observasional analitik dengan metode Cross Sectional. Jumlah sampel yaitu sebanyak 79 responden. Adapun cara pengumpulan data dengan wawancara. Uji statistik yang digunakan adalah uji Chi-square (X2) dan Fisher Exact Test. Hasil penelitian: Variabel yang memiliki hubungan dengan pemberian ASI eksklusif yaitu pengetahuan (p=0,000). Sedangkan untuk variabel lainnya, yaitu umur (Fisher Exact Test = 0,120), pendidikan (p = 0,075) dan pekerjaan (p = 0,976) tidak menunjukkan adanya hubungan dengan pemberian ASI eksklusif. Kesimpulan: Variabel pengetahuan menunjukkan hubungan yang bermakna dengan pemberian ASI eksklusif. Variabel umur, pendidikan dan pekerjaan menunjukkan hubungan yang tidak bermakna dengan pemberian ASI eksklusif.

scholarly journals Evaluation of toxoplasmosis risk on anxiety and perception of cat owner pregnant women

2021 ◽  
Vol 38 (2) ◽  
pp. 154-158
Author(s):  
Nur DOKUZEYLUL GÜNGÖR ◽  
Tuğba GÜRBÜZ ◽  
Selma Bozkurt ZİNCİR ◽  
Banu DOKUZEYLÜL ◽  
Erman OR ◽  
...  
Keyword(s):  
Toxoplasma Gondii ◽  
Pregnant Women ◽  
Health Anxiety ◽  
Anxiety Level ◽  
Fisher Exact Test ◽  
Chi Square ◽  
Exact Test ◽  
Main Host ◽  
The Difference ◽  
At Home

Cats are the main host of Toxoplasma gondii and pregnant women who own cats at home may be at risk. This condition may cause anxiety and stress in pregnant women. The aim of this study is to evaluate toxoplasmosis risk on anxiety and perception of cat owner pregnant women. The study group consisted of 59 pregnant women feeding cats in the home and 369 pregnant women not feeding cats. A Health Anxiety Inventory (HAI-18) was used to measure the anxiety of all participants. Age and anxiety variables were analyzed using a two-sample independent t-test. Gravida, education, and job status were analyzed using chi-square tests, and live to abort ratio & pregnancy number were analyzed using Fisher exact test. Measurement of the anxiety level between the two groups showed that anxiety is significantly higher among the pregnant women who feed cats in their house with an average of 32.03±8.72. The average anxiety level among the pregnant women who don't have cats in their house was 25.94±8.99. The difference between the Health Anxiety Inventory of the two groups was significant (p= 0.0001) It was shown in the literature that pets can reduce anxiety but not studied in pregnant women, yet. Our results showed that pregnant women who own cats at home had more environmental anxiety than women who don’t feed cats at home which is possibly associated with fear of Toxoplasma gondii transmission. This anxiety may also cause unfavorable pregnancy outcomes like eclampsia, preterm birth, low birth weight and high incidence of cesarean delivery.

scholarly journals A Study of Occupational Exposure to Patient's Blood and Saliva among Dental Students of Shahid Sadoughi Yazd University in 2016-2017

2020 ◽  
Author(s):  
Farzane Vaziri ◽  
Fahimeh Rashidi Maybodi ◽  
Mohammad Hasan Akhavan-Karbassi ◽  
Elahe Mansoori ◽  
Nasrin Faal Rastegar
Keyword(s):  
Occupational Exposure ◽  
High Speed ◽  
Dental Students ◽  
Fisher Exact Test ◽  
Medical Sciences ◽  
Chi Square ◽  
Exact Test ◽  
Skin Contamination ◽  
School Of Dentistry ◽  
Dental Schools

Introduction: Occupational exposure in dentistry is defined as exposing the skin or mucosa to blood, saliva, or infectious discharge of the patient. Dentists are in contact with sharp and high-speed rotary devices that increase the chance of occupational exposure. The purpose of this study was to determine the occupational exposure to blood and saliva of patients in dental students of Shahid Sadoughi University of Medical Sciencesin 2016-2017. Methods: A descriptive analytical study was conducted on 70 senior dental students at the School of Dentistry of Shahid Sadoughi University of Medical Sciences in Yazd, Iran. A standard questionnaire was used for collecting the data. After collecting the data, they were coded and entered into the SPSS 20 software and analyzed using descriptive statistics, Chi-square and Fisher exact test. Results: Based on the results, 49 (70%) of 70 students have been suffered from sharp devices. The skin or mucosa of the 62 students (88.6%) infected with saliva or other body fluids of the patients. Only 15.7% of the injuries were reported with sharp objects and 14.3% of mucosal-skin contamination with blood or saliva. Conclusion: Occupational exposure in dentistry environment is a common problem and many cases, which are related to these subjects were not reported. In order to reduce the risks of this, infection control issues should be taught to dental students. Therefore, occupational exposure management, follow-up centers and guidelines should be established for dental schools.  

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