scholarly journals Evaluation of Anticoagulation Control among Patients Taking Warfarin in University of Gondar Hospital, Northwest Ethiopia

2021 ◽  
Vol 2021 ◽  
pp. 1-8
Author(s):  
Zelalem Liyew ◽  
Abilo Tadesse ◽  
Nebiyu Bekele ◽  
Tewodros Tsegaye
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Therapeutic Range ◽  
Multivariate Logistic Regression Analysis ◽  
Warfarin Dose ◽  
Northwest Ethiopia ◽  
Dose Titration ◽  
Cross Sectional ◽  
Anticoagulation Control

Introduction. Warfarin is a widely used oral anticoagulant in clinical practice. It has variable intraindividual and interindividual dose response and a narrow therapeutic index. Therefore, it requires frequent and regular international normalized ratio (INR) determination to maintain the INR within the therapeutic range. The study evaluated parameters of anticoagulation control among patients on warfarin. Methods. A cross-sectional study was conducted at University of Gondar hospital. A consecutive sampling method was used to recruit study subjects. The anticoagulation control was evaluated by determining the proportion of desired INRs and the proportion of time spent in the therapeutic range (TTR). Logistic regression analysis was used to identify associated factors with adequate TTR. A P value <0.05 was used to declare significant association. Result. A total of 338 study subjects were included in the study. The mean age of patients was 48.8 (SD = 16.4) years. Atrial fibrillation was the commonest indication for warfarin therapy. One-third (33%) of study subjects achieved the desired INRs of 2.0–3.0, while about one-tenth (13%) of patients attained good INR control (TTR ≥ 65%). Multivariate logistic regression analysis revealed no significant association of sociodemographic and clinical characteristics with good TTR outcome. Conclusion. The level of anticoagulation control with warfarin among study subjects was very low. The authors recommend to implement a validated warfarin-dose titration protocol and to establish anticoagulation clinics to mitigate the low anticoagulation level.

ANALISIS HUBUNGAN SARANA, PENGETAHUAN, DAN SIKAP BIDAN PRAKTIK MANDIRI DENGAN KEPATUHAN MENJALANKAN STANDAR PELAYANAN ANTENATAL CARE DI KOTA PADANGSIDIMPUAN

2019 ◽  
Vol 2 (1) ◽  
pp. 27-33
Author(s):  
Megawati Sinambela ◽  
Evi Erianty Hasibuan
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Antenatal Care ◽  
Pregnant Women ◽  
Logistic Regression Analysis ◽  
Care Service ◽  
Multivariate Logistic Regression Analysis ◽  
Bivariate Analysis ◽  
Cross Sectional ◽  
The North

Antenatal care is a service provided to pregnant women to monitor, support maternal health and detect mothers whether normal or problematic pregnant women. According to the WHO, globally more than 70% of maternal deaths are caused by complications of pregnancy and childbirth such as hemorrhage, hypertension, sepsis, and abortion. Based on data obtained from the profile of the North Sumatra provincial health office in 2017, in the city of Padangsidimpuan in 2017 the coverage of ANC visits reached (76.58%) and had not reached the target in accordance with the 2017 Provincial Health Office strategy plan (95%). This type of research was an observational analytic study with a cross sectional design. The population in this study were independent practice midwives who were in the Padangsidimpuan, the sample in this study amounted to 102 respondents. The technique of collecting data used questionnaires and data analysis used univariate, bivariate and multivariate analysis with logistic regression analysis. Based on bivariate analysis showed that there was a relationship between facilities, knowledge and attitudes of independent midwives with compliance with the standards of antenatal care services with a value of p <0.05. The results of the study with multivariate logistic regression analysis showed that the factors associated with the compliance of independent midwives in carrying out antenatal care service standards were attitudes with values (p = 0.026).

Cross-Sectional Examination of Homocysteine Levels with Sarcopenia and Its Components in Memory Clinic Outpatients

2021 ◽  
pp. 1-10
Author(s):  
Yosuke Yamada ◽  
Hiroyuki Umegaki ◽  
Fumie Kinoshita ◽  
Chi Hsien Huang ◽  
Taiki Sugimoto ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Cognitive Impairment ◽  
Cognitive Function ◽  
Linear Regression ◽  
Logistic Regression Analysis ◽  
Linear Regression Analysis ◽  
Multivariate Logistic Regression Analysis ◽  
Memory Clinic ◽  
Cross Sectional

Background: Homocysteine is a common risk factor for cognitive impairment and sarcopenia. However, very few studies have shown an association between sarcopenia and serum homocysteine levels after adjustment for cognitive function. Objective: The purpose of this study was to investigate the relationship between homocysteine and sarcopenia in memory clinic patients. Methods: This cross-sectional study investigated outpatients in a memory clinic. We enrolled 1,774 participants (≥65 years old) with measured skeletal muscle mass index (SMI), hand grip strength (HGS), and homocysteine. All participants had undergone cognitive assessments and were diagnosed with dementia, mild cognitive impairment, or normal cognition. Patient characteristics were compared according to sarcopenia presence, SMI level, or HGS. Multivariate logistic regression analysis was performed to determine the association of homocysteine with sarcopenia, low SMI, or low HGS. Next, linear regression analysis was performed using HGS as a continuous variable. Results: Logistic regression analysis showed that low HGS was significantly associated with homocysteine levels (p = 0.002), but sarcopenia and low SMI were not. In linear regression analysis, HGS was negatively associated with homocysteine levels after adjustment for Mini-Mental State Examination score (β= –2.790, p <  0.001) or clinical diagnosis of dementia (β= –3.145, p <  0.001). These results were similar for men and women. Conclusion: Our results showed a negative association between homocysteine and HGS after adjustment for cognitive function. Our findings strengthen the assumed association between homocysteine and HGS. Further research is needed to determine whether lower homocysteine levels lead to prevent muscle weakness.

scholarly journals Musculoskeletal Symptoms among Radiologists in Saudi Arabia: A Multi-Center Cross-Sectional Study

2019 ◽  
Author(s):  
Malak Al Shammari ◽  
Ali Hassan ◽  
Omran Al Dandan ◽  
Mohammed Al Gadeeb ◽  
Dalal Bubshait
Keyword(s):  
Logistic Regression ◽  
Saudi Arabia ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Online Survey ◽  
Multivariate Logistic Regression Analysis ◽  
Musculoskeletal Symptoms ◽  
Body Region ◽  
Viewing Distance ◽  
Cross Sectional

Abstract Background : Musculoskeletal symptoms account for the majority of work-related illnesses resulting in a significant economic burden on society. Computer users are subject to unique repetitive strains that predispose them to musculoskeletal symptoms. In the digitalized field of radiology, radiologists spend long hours interpreting medical images on computers. This study aimed to determine the prevalence of musculoskeletal symptoms among radiologists in Saudi Arabia and their contributing factors. Methods : An online survey was sent to radiologists in all hospitals (academic, public and private) in the major cities of the Eastern Province of Saudi Arabia covering demographic characteristics, workload (e.g. the time spent at a computer workstation), and workstation environments including the number of monitors as well as the adjustability of the height of the workstation and the viewing distance. This survey of 263 radiologists was conducted in April 2019. It included an evaluation of musculoskeletal symptoms using the Nordic Musculoskeletal Questionnaire. The study outcome was the presence of disabling musculoskeletal symptoms in any body region, which restricted the performance of normal activities in the last 12 months. Results were analyzed descriptively using a Chi-square test and logistic regression analysis to estimate the odd ratio of experiencing disabling musculoskeletal symptoms in the last 12 months. Results : The survey was completed by 198 participants (111 men and 87 women) with a response rate of 75.3%. Most participants (71.2%) were aged below 40 years. A multivariate logistic regression analysis revealed being a female radiologist (OR = 2.7; 95% CI: 1.2–6.5), aged 30–39 years (OR = 4.1; 95% CI: 1.1–15.3), and predominantly reviewing computed tomography (CT) images (OR = 4.1; 95% CI: 1.4–12.3) or ultrasound scans (OR = 5.9; 95% CI: 1.4–25.3) were associated with higher prevalence of disabling musculoskeletal symptoms, compared to those aged below 30 years and those who reviewed various imaging modalities, respectively. Conclusions : Musculoskeletal symptoms are common among radiologists with lower back and neck pain being the most frequent complaints. Being a female radiologist, aged 30–39 years, and reviewing CT or ultrasound scans were associated with higher rates of disabling musculoskeletal symptoms.

scholarly journals Musculoskeletal symptoms among radiologists in Saudi Arabia: a multi-center cross-sectional study

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Malak Al Shammari ◽  
Ali Hassan ◽  
Omran Al Dandan ◽  
Mohammed Al Gadeeb ◽  
Dalal Bubshait
Keyword(s):  
Logistic Regression ◽  
Saudi Arabia ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Online Survey ◽  
Multivariate Logistic Regression Analysis ◽  
Musculoskeletal Symptoms ◽  
Body Region ◽  
Viewing Distance ◽  
Cross Sectional

Abstract Background Musculoskeletal symptoms account for the majority of work-related illnesses resulting in a significant economic burden on society. Computer users are subject to unique repetitive strains that predispose them to musculoskeletal symptoms. In the digitalized field of radiology, radiologists spend long hours interpreting medical images on computers. This study aimed to determine the prevalence of musculoskeletal symptoms among radiologists in Saudi Arabia and their contributing factors. Methods An online survey was sent to radiologists in all hospitals (academic, public and private) in the major cities of the Eastern Province of Saudi Arabia covering demographic characteristics, workload (e.g. the time spent at a computer workstation), and workstation environments including the number of monitors as well as the adjustability of the height of the workstation and the viewing distance. This survey of 263 radiologists was conducted in April 2019. It included an evaluation of musculoskeletal symptoms using the Nordic Musculoskeletal Questionnaire. The study outcome was the presence of disabling musculoskeletal symptoms in any body region, which restricted the performance of normal activities in the last 12 months. Results were analyzed descriptively using a Chi-square test and logistic regression analysis to estimate the odd ratio of experiencing disabling musculoskeletal symptoms in the last 12 months. Results The survey was completed by 198 participants (111 men and 87 women) with a response rate of 75.3%. Most participants (71.2%) were aged below 40 years. A multivariate logistic regression analysis revealed being a female radiologist (OR = 2.7; 95% CI: 1.2–6.5), aged 30–39 years (OR = 4.1; 95% CI: 1.1–15.3), and predominantly reviewing computed tomography (CT) images (OR = 4.1; 95% CI: 1.4–12.3) or ultrasound scans (OR = 5.9; 95% CI: 1.4–25.3) were associated with higher prevalence of disabling musculoskeletal symptoms, compared to those aged below 30 years and those who reviewed various imaging modalities, respectively. Conclusions Musculoskeletal symptoms are common among radiologists with lower back and neck pain being the most frequent complaints. Being a female radiologist, aged 30–39 years, and reviewing CT or ultrasound scans were associated with higher rates of disabling musculoskeletal symptoms.

scholarly journals Musculoskeletal Symptoms among Radiologists in Saudi Arabia: A Multi-Center Cross-Sectional Study

2019 ◽  
Author(s):  
Malak Al Shammari ◽  
Ali Hassan ◽  
Omran Al Dandan ◽  
Mohammed Al Gadeeb ◽  
Dalal Bubshait
Keyword(s):  
Logistic Regression ◽  
Saudi Arabia ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Online Survey ◽  
Multivariate Logistic Regression Analysis ◽  
Musculoskeletal Symptoms ◽  
Body Region ◽  
Viewing Distance ◽  
Cross Sectional

Abstract Background : Musculoskeletal symptoms account for the majority of work-related illnesses resulting in a significant economic burden on society. Computer users are subject to unique repetitive strains that predispose them to musculoskeletal symptoms. In the digitalized field of radiology, radiologists spend long hours interpreting medical images on computers. This study aimed to determine the prevalence of musculoskeletal symptoms among radiologists in Saudi Arabia and their contributing factors. Methods : An online survey was sent to radiologists in all hospitals (academic, public and private) in the major cities of the Eastern Province of Saudi Arabia covering demographic characteristics, workload (e.g. the time spent at a computer workstation), and workstation environments including the number of monitors as well as the adjustability of the height of the workstation and the viewing distance. This survey of 263 radiologists was conducted in April 2019. It included an evaluation of musculoskeletal symptoms using the Nordic Musculoskeletal Questionnaire. The study outcome was the presence of disabling musculoskeletal symptoms in any body region, which restricted the performance of normal activities in the last 12 months. Results were analyzed descriptively using a Chi-square test and logistic regression analysis to estimate the odd ratio of experiencing disabling musculoskeletal symptoms in the last 12 months. Results : The survey was completed by 198 participants (111 men and 87 women) with a response rate of 75.3%. Most participants (71.2%) were aged below 40 years. A multivariate logistic regression analysis revealed being a female radiologist (OR = 2.7; 95% CI: 1.2–6.5), aged 30–39 years (OR = 4.1; 95% CI: 1.1–15.3), and predominantly reviewing computed tomography (CT) images (OR = 4.1; 95% CI: 1.4–12.3) or ultrasound scans (OR = 5.9; 95% CI: 1.4–25.3) were associated with higher prevalence of disabling musculoskeletal symptoms, compared to those aged below 30 years and those who reviewed various imaging modalities, respectively. Conclusions : Musculoskeletal symptoms are common among radiologists with lower back and neck pain being the most frequent complaints. Being a female radiologist, aged 30–39 years, and reviewing CT or ultrasound scans were associated with higher rates of disabling musculoskeletal symptoms.

scholarly journals A predictive nomogram: a cross-sectional study on a simple-to-use model for screening 12-year-old children for severe caries in middle schools

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Shaoying Duan ◽  
Meng Li ◽  
Jialiang Zhao ◽  
Huiyu Yang ◽  
Jinfeng He ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Cross Validation ◽  
Multivariate Logistic Regression Analysis ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Multivariate Logistic Regression ◽  
Cross Sectional ◽  
Dental Professionals

Abstract Background A nomogram is a tool that transforms complex regression equations into simple and visual graphs and enables clinicians and patients to conveniently compute output probabilities without needing medical knowledge and complex formulas. The aim of this study was to develop and validate a predictive nomogram to screen for severe caries among 12-year-old children based on risk factors in Sichuan Province, China. Methods A cross-sectional study of 4573 12-year-olds was conducted up to May 2016 in middle schools from three districts and three counties in Sichuan Province, China. All the children underwent oral examinations and completed questionnaires to assess general information, oral impacts on daily performance, dietary habits, subjective health conditions, history of dental trauma, frequency of toothache, dental visits, and knowledge, attitudes, and behaviours toward oral hygiene. Univariate analysis and multivariate logistic regression analysis were used to determine which variables were significantly associated with severe caries (operationalized as DMFT ≥ 3). A nomogram was developed and validated by using the ‘rms’ package and two cross-validation methods. Results Severe caries was found in 537 of the 4573 children (11.74%). Multivariate logistic regression analysis revealed that the following variables predicted a higher risk of severe caries: ‘female’ [odds ratio (OR) = 1.985, 95% confidence interval (95% CI): 1.63–2.411], ‘urban’ (OR = 2.389, 95% CI: 1.96–2.91), ‘non-only child’ (OR = 1.317, 95% CI: 1.07–1.625), ‘very poor self-assessment of oral health status’ (OR = 2.157, 95% CI: 1.34–3.467) and ‘visited a dentist less than 6 months’ (OR = 1.861, 95% CI: 1.38–2.505). Multivariate logistic regression analysis also indicated that the following variables predicted a lower risk of severe caries: ‘middle level of urbanization’ (OR = 0.395, 95% CI: 0.32–0.495) and ‘high level of urbanization’ (OR = 0.466, 95% CI: 0.37–0.596). Both the fivefold and leave-one-out cross-validation methods indicated that the nomogram model built by these 6 variables displayed good disease recognition ability. Conclusions The nomogram was a simple-to-use model to screen children for severe caries. This model was found to facilitate non-dental professionals in assessing risk values without oral examinations and making referrals to dental professionals.

scholarly journals Levels of the health system workforce’s competence and predictors to lead, manage, and govern in northwest Ethiopia

2020 ◽  
Author(s):  
Yeshambel Agumas Ambelie ◽  
Getu Degu Alene ◽  
Damen Hailemariam Gebrekiros
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Health System ◽  
Logistic Regression Analysis ◽  
Cross Sectional Study ◽  
Northwest Ethiopia ◽  
Sectional Study ◽  
Cross Sectional ◽  
Ordinal Logistic Regression Analysis ◽  
Very High

Abstract Aim: The purpose of this study was to determine the levels of competence and predictors to lead, manage, and govern among the health system workforce. Methods: A cross-sectional study was carried out in northwest Ethiopia. Eight hundred thirteen workforce were participated in the study. Competence to lead, manage, and govern was computed from 20 items. It was also leveled into four categories. Ordinal logistic regression analysis was conducted to identify predictors of this competence. Results: From 813 participants, 396 (48.7%) and 582 (71.6%) were females and service owners respectively. The estimates for low, moderate, high and very high levels of competence to lead, manage and govern were 41.3%; 42.7%; 13.5% and 2.5% respectively. Sex (p = .031) and responsibility (p = .019) were identified as main predictors. Conclusions: Competence to lead, manage and govern among the health system workforce in northwest Ethiopia is inadequate. Policymakers, program planners and researchers need to take action giving due attention to females and service owners. Feature research could be conducted considering hierarchical variables.

scholarly journals Workplace Violence Against Nurses in Psychiatric Hospital Settings: Perspectives from Saudi Arabia

2019 ◽  
Vol 19 (1) ◽  
pp. 19 ◽  
Author(s):  
Wafa Basfr ◽  
Ahlam Hamdan ◽  
Samia Al-Habib
Keyword(s):  
Logistic Regression ◽  
Saudi Arabia ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Workplace Violence ◽  
Multivariate Logistic Regression Analysis ◽  
Psychiatric Hospitals ◽  
Multivariate Logistic Regression ◽  
Violent Behaviour ◽  
Cross Sectional

Objectives: Workplace violence (WPV) has become a world-wide concern. This study aimed to measure the prevalence of WPV among nurses working in psychiatric hospitals in Saudi Arabia. Methods: This cross-sectional study was conducted at three psychiatric hospitals in Saudi Arabia between March and May 2017. Participants completed a self-reported questionnaire which was used to measure the prevalence and explore the associated factors of WPV. A multivariate logistic regression analysis was also performed. Results: A total of 310 nurses (response rate: 62%) were included in this study. The prevalence of WPV against nurses was 90.3%, of which 57.7% had been exposed to both physical and verbal abuse. More nurses were exposed to WPV during the morning shift than the evening shift (58.4% versus 42.3%). Violent behaviour was exhibited mostly by the patients themselves (81.3%). Over half of the nurses (57.4%) required medical intervention in such cases. The majority of nurses felt either stressed (64.2%) or anxious (53.5%) and 34.2% felt depressed after the incident. Multivariate logistic regression analysis revealed that time of violence, source of violence, patient dissatisfaction with medical care and lack of organisational support for nurses were significantly associated with the occurrence of WPV in psychiatric units. Conclusion: WPV has reached an alarming rate among nurses in psychiatric hospitals in Saudi Arabia. It is crucial to invest in the prevention of WPV by constant training of workers and a mutual policy with the police and the civic prosecutor in Saudi Arabia on how to respond to violent psychiatric patients. Keywords: Workplace Violence; Psychiatry; Nurse; Mental Health; Saudi Arabia.

scholarly journals Predictors of low perceptual-motor skills in children at 4-5 years of age

2020 ◽  
Vol 20 (3) ◽  
pp. 759-767
Author(s):  
Emanuelle Mandú Meira dos Santos ◽  
Bruna Constantino ◽  
Marina Monzani da Rocha ◽  
Marco Fabio Mastroeni
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Motor Skills ◽  
Logistic Regression Analysis ◽  
Household Income ◽  
Multivariate Logistic Regression Analysis ◽  
Cross Sectional Study ◽  
Preschool Age ◽  
Cross Sectional ◽  
Perceptual Motor Skills

Abstract Objectives: the purpose of this study was to evaluate the predictors of low perceptual-motor skills in children at preschool age. Methods: this is a cross-sectional study nested in a birth cohort involving mother-child pairs. The children’s perceptual-motor skills were assessed individually in their homes when they were 4-5 years old using the Pre-Literacy Skills and Knowledge Test (THCP®), a vali-dated Brazilian instrument. Logistic regression analysis was used to estimate the association between cognitive perceptual-motor skills and potential maternal and child risk factors. Results: of the 199 children included in the study, 53.8% were boys, 90.8% attended school, and 91.1% were enrolled in a public school. Among the children, 114 (57.3%), 41 (20.6%) and 44 (22.1%) had low, moderate and high perceptual-motor skills, respectively. Multivariate logistic regression analysis revealed greater odds of children at preschool age having low perceptual motor skills for boys (OR=2.10; CI95%= 1.14-3.88), children who did not attend school (OR=4.61; CI95%= 1.21-17.49), and those with a household income <5 minimum wages (MW) (OR=4.28; CI95%= 1.49-12.26). Conclusions: our study showed that male gender, not attending school and a monthly household income <5 MW were predictors of low perceptual-motor skills in children at 4-5 years of age.

scholarly journals Musculoskeletal Symptoms among Radiologists in Saudi Arabia: A Multi-Center Cross-Sectional Study

2019 ◽  
Author(s):  
Malak Al Shammari ◽  
Ali Hassan ◽  
Omran Al Dandan ◽  
Mohammed Al Gadeeb ◽  
Dalal Bubshait
Keyword(s):  
Logistic Regression ◽  
Saudi Arabia ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Online Survey ◽  
Multivariate Logistic Regression Analysis ◽  
Musculoskeletal Symptoms ◽  
Body Region ◽  
Viewing Distance ◽  
Cross Sectional

Abstract Background : Musculoskeletal symptoms account for the majority of work-related illnesses resulting in a significant economic burden on society. Computer users are subject to unique repetitive strains that predispose them to musculoskeletal symptoms. In the digitalized field of radiology, radiologists spend long hours interpreting medical images on computers. This study aimed to determine the prevalence of musculoskeletal symptoms among radiologists in Saudi Arabia and their contributing factors. Methods : An online survey was sent to radiologists in all hospitals (academic, public and private) in the major cities of the Eastern Province of Saudi Arabia covering demographic characteristics, workload (e.g. the time spent at a computer workstation), and workstation environments including the number of monitors as well as the adjustability of the height of the workstation and the viewing distance. This survey of 263 radiologists was conducted in April 2019. It included an evaluation of musculoskeletal symptoms using the Nordic Musculoskeletal Questionnaire. The study outcome was the presence of disabling musculoskeletal symptoms in any body region, which restricted the performance of normal activities in the last 12 months. Results were analyzed descriptively using a Chi-square test and logistic regression analysis to estimate the odd ratio of experiencing disabling musculoskeletal symptoms in the last 12 months. Results : The survey was completed by 198 participants (111 men and 87 women) with a response rate of 75.3%. Most participants (71.2%) were aged below 40 years. A multivariate logistic regression analysis revealed being a female radiologist (OR = 2.7; 95% CI: 1.2–6.5), aged 30–39 years (OR = 4.1; 95% CI: 1.1–15.3), and predominantly reviewing computed tomography (CT) images (OR = 4.1; 95% CI: 1.4–12.3) or ultrasound scans (OR = 5.9; 95% CI: 1.4–25.3) were associated with higher prevalence of disabling musculoskeletal symptoms, compared to those aged below 30 years and those who reviewed various imaging modalities, respectively. Conclusions : Musculoskeletal symptoms are common among radiologists with lower back and neck pain being the most frequent complaints. Being a female radiologist, aged 30–39 years, and reviewing CT or ultrasound scans were associated with higher rates of disabling musculoskeletal symptoms.

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