Technique of Atypical Amputation of the Foot in Patients with a Complicated Course of Diabetic Foot Syndrome

2015 ◽  
Vol 22 (3) ◽  
pp. 43-49 ◽  
Author(s):  
Гвазава ◽  
T. Gvazava
Keyword(s):  
Diabetes Mellitus ◽  
Blood Flow ◽  
Diabetic Foot ◽  
Blood Circulation ◽  
Lower Extremities ◽  
Duplex Ultrasound ◽  
Diabetic Foot Syndrome ◽  
Control Group ◽  
Ultrasound Study ◽  
Complicated Course

Abstract. Introduction. Diabetes mellitus is one of the most common and socially important diseases in the world. The diabetic foot syndrome is one of the most complex diseases with a view to pathogenesis and one of the most serious complications of diabetes mellitus. This syndrome is characterized by disorders and changes of all structures of lower extremities, causes the ulcerous and necrotic processes. At the current moment, a traditional method in treatment of complications of the diabetic foot syndrome is amputation of lower extremities. Due to the large number of postoperative complications, the most preferable are economic amputations at the level of foot step. In modern conditions in the first stage of complex treatment of patients with purulent-necrotic process in the lower extremities, the recovery of main arterial blood circulation of the lower extremities in the form of open or endovascular angioplasty is effective. The most effective method is revascularization performed according to angiosomes areas of blood flow in footstep. Purpose of this study is to carry out a comparative assessment of the effectiveness of typical and atypical amputations at the level of footstep in patients with the most complicated course of the diabetic foot syndrome. Material. The objects of this study were patients with diabetes mellitus (DM) type 2 with purulent-necrotic complications of diabetic foot, treated at the surgical department department of the National N.I. Pirogov Surgical and Medical Center of the Saint- Petersburg of the SPb Clinical centre for the period 2010-2013. The main group included 68 patients. These patients were performed atypical interventions according to angiosomes blood flow to the tissues of the foot. Operative interventions at the level of footstep were carried out to 47 patients of the control group. Methods. An objective study to assess the local status, laboratory tests (clinical blood test, basic coagulogram, carbohydrate metabolism indexes) and duplex ultrasound study (USDI) of vessels of lower extremities were carried out. Obligatory angiography was performed in all patients. Surgical intervention in the form of dissection, drainage of purulent focus was carried out on an emergency basis prior to angiography only in patients with acute purulent processes in the lower extremities. In all other cases, the individual peculiarities of blood circulation disorder in lower extremities determined the choice of tactics of operative treatment. In 76% and 46% accordingly for each group after angiography, a balloon angioplasty was carried out for reconstruction of the main blood flow. Results and discussion. The average duration of the in-patient treatment in study group was 14,4±2,3. In the control group - 18,2±3,1. Duration of hospitalization differed significantly (p<0.05), but significant group of patients (31 and 18, respectively) were re-hospitalized during the period from 2 to 6 weeks after discharge from the hospital for the purpose of autodermoplasty for closure of surgical wounds. There were no significant differences between the postoperative healing time of wounds and wound surfaces after reconstructive interventions. This indicates the correct choice and method of operation, as well as indications for secondary wound closure. The authors note the difference in number of re-operations for recurrent purulent-necrotic process (2 patients in the study group and 9 patients in the control group). Re-operation was considered in the case of a destructive process to heal the original wound. Relapse necrotic phenomena was the main cause of the increase in terms of the impossibility of independent movement and 6.3±1,2 and 13.1±3.4 days, respectively (p<0.05). The authors explain these results by the fact that the leading role belongs to the qualitative blood circulation of paravulnar tissues in the postoperative wound healing in patients with diabetic foot syndrome. Conclusions. 1. Preoperative angiography is prescribed to patients with purulent-necrotic complications of diabetic foot syndrome. If required, angioplasty before performing surgery on the tissues of the feet. 2. The application of the principle angiosomes blood flow on the basis of the duplex ultrasound study (USDI) of arteries and angiography allows to choose the most rational tactics of surgical treatment. 3. The use of atypical technique of amputations in the foot after preoperative examination can reduce the number of postoperative complications and the duration of inpatient treatment, to improve postoperative mobility and difficulty walking patients.

scholarly journals The process of repair of trophic ulcers in patients with diabetes

2004 ◽  
Vol 50 (2) ◽  
pp. 34-38
Author(s):  
N. A. Myskina ◽  
A. Yu. Tokmakova ◽  
M. B. Antsiferov
Keyword(s):  
Diabetes Mellitus ◽  
Blood Flow ◽  
Diabetic Foot ◽  
Neurological Disorders ◽  
Sharp Increase ◽  
Lower Extremities ◽  
Late Complications ◽  
Diabetic Foot Syndrome ◽  
Industrialized Countries ◽  
Patients With Diabetes

In the last 30 years, there has been a sharp increase in the incidence of diabetes mellitus (DM), especially in industrialized countries, and its prevalence tends to further increase [3]. The main cause of disability and death of patients are late complications of this disease. Among them, it is especially important to identify developing diabetic foot syndrome (DFS), which is defined as infection, ulcer and / or destruction of deep tissues, associated with neurological disorders and decreased main blood flow in the arteries of the lower extremities of varying degrees severity (International Diabetic Foot Agreement, Netherlands, 1999)

scholarly journals Morphological research of the effectiveness of perioperative local use of anesthetics and antiseptics in patients with purulent-necrotic lesions of lower extremities in diabetes mellitus

2021 ◽  
Vol 27 (3) ◽  
pp. 22-28
Author(s):  
Yu.M. Babina ◽  
D.V. Dmyrtriiev ◽  
O.A. Nazarchuk ◽  
P.P. Hormash
Keyword(s):  
Diabetes Mellitus ◽  
Wound Healing ◽  
Granulation Tissue ◽  
Diabetic Foot ◽  
Povidone Iodine ◽  
Local Treatment ◽  
Lower Extremities ◽  
Diabetic Foot Syndrome ◽  
Patients With Diabetes ◽  
Infiltration Anesthesia

Ulcer-necrotic lesions of the feet are detected in 5-15% of patients with diabetes mellitus (DM). According to the literature today in Ukraine, patients with DM perform high amputation of the lower extremities with diabetic foot syndrome with a frequency of 19.6-42.6%, at the same time, mortality ranges from 8.9% to 25.0%, and the total mortality rate at the DM varies from 6.6% to 13.5%, often associated with the occurrence of postoperative complications. The aim of the work was to study morphological indicators of reparation of soft tissues of the lower extremities in patients with diabetic foot syndrome on the background of local treatment during the perioperative period. We investigated changes in histologic structure and character of reactions of skin tissues, muscles and fascia during the period of visceral disease in patients with diabetes mellitus after different types of local treatment. Then, samples of skin tissues, muscles and fascia were photographed and analyzed using a light microscope OLIMPUS BX 41. In the first group of the comparison, which used standard methods of anesthesia and local antiseptic povidone-iodine, granulation tissue was characterized by the complete absence of fibrous structures (collagen fibers) and the presence of a small number of newly formed small diameter vessels with blistered endothelium. Vessels of young granulation tissue were dilated, full-blooded, the endothelium was swollen, there was significant perivascular edema. In the second group of patients (where povidone-iodine and infiltration anesthesia with 2% lidocaine solution anesthetic was used locally) there were almost no remains of necrotic tissues in the affected tissues. It should be noted that there was better granulation development with fewer inflammatory-cell elements, more young forms of fibroblasts and a moderate pathological vascular reaction. In the first (control) group, wound healing by 3-7 days is characterized by somewhat slow regeneration. Wound healing was most favorable in patients of the second group, where infiltration anesthesia was used by local anesthetic and antiseptic povidone-iodine.

scholarly journals EFEKTIVITAS SPA KAKI DIABETIK TERHADAP SIRKULASI DARAH PERIFER PADA PASIEN DIABETES MELLITUS TIPE 2 DI WILAYAH KERJA PUSKESMAS WONOKROMO SURABAYA

2018 ◽  
Vol 10 (1) ◽  
Author(s):  
Rahmi Affiani ◽  
Puji Astuti
Keyword(s):  
Diabetes Mellitus ◽  
Treatment Group ◽  
Diabetic Foot ◽  
Peripheral Blood ◽  
Blood Circulation ◽  
Control Group ◽  
Public Health Centre ◽  
Study Results ◽  
Peripheral Blood Circulation

Diabetes mellitus type 2 is often occur and became chronic complication of vascular peripheral disease caused by decreasing peripheral blood circulation. One of therapy to improve peripheral blood circulation is diabetic foot spa, The purpose of this study is to find out the effectiveness of diabetic foot spa towards peripheral blood circulation. Design of this study is Quasy-Experiment. The population were all diabetes mellitus patients type 2 in Public Health Centre Wonokromo Surabaya. Number of sample was 46 person, divided into 2 group, that are treatment group and control group, with 23 person each group, taken by purposive sampling technique. Data analyzed by Mann-Whitney test with α=0.05. Study results on treatment group before giving diabetic foot spa majority (52.2%) of peripheral blood circulation in mild category and for control group mostly (60.9%) have blood circulation in mild category as well. After the foot spa was give to the treatment group, almost entirely (91.3%) had normal peripheral blood circulation, whereas in the control group majority (73.9%) remain mild. Analysis of MannWhitney test P=0.000 < α=0.05, which means diabetic foot spa is effective towards blood circulation. The more frequent perform of diabetic foot spa, the better peripheral blood circulation, it can prevent complications of diabetes mellitus.

scholarly journals Spontaneous and induced secretion of the pro-inflammatory and anti-inflammatory cytokines in patients with type 2 diabetes mellitus and diabetic foot syndrome

2020 ◽  
Vol 23 (3) ◽  
pp. 210-222
Author(s):  
E. V. Shikh ◽  
N. A. Petunina ◽  
L. V. Nedosugova ◽  
K. O. Galstyan ◽  
K. I. Kolmychkova ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Diabetic Foot ◽  
Diabetic Foot Syndrome ◽  
Control Group ◽  
Metabolic Drug ◽  
Anti Inflammatory

AIMS:Investigation of spontaneous and induced secretion of the pro-inflammatory cytokine tumor necrosis factor- (TNF-) and the anti-inflammatory chemokine C-C Motif Chemokine Ligand 18 (CCL18) by monocytes isolated from blood of patients with long-term type 2 diabetes mellitus (T2DM), both with or without foot ulcers and the effect of the course use of the combined metabolic drug Kokarnit as part of complex therapy on the dynamics of the severity of symptoms of DSPN and the cytokine phenotype in patients with long-term non-healing ulcers of the lower extremities MATERIALS AND METHODS:121 patients with T2DM, 79 without diabetic foot syndrome (DFS) and 42 patients with DFS were included. CD14+ monocytes were isolated from patients blood and stimulated by interferon- (IFN-) and interleukine-4 (IL-4) for induction of pro- and anti-inflammatory monocyte activation, respectively. The concentrations of TNF- and CCL18 in the culture medium were measured using ELISA on day 1 and day 6 after cell stimulation in all patients before taking the combined metabolic drug Kokarnit. Then they were randomly allocated either to the control group (57 people), to whom Kokarnit was added to standard treatment, or to the comparison group. After a 9-day course of application of Kokarnit, the dynamics of indicators was evaluated on a TSS scale. Assessment of cytokine status was carried out in 18 people with long-term non-healing ulcerative defects of the lower extremities, on the first and ninth day of treatment. RESULTS:A correlation was found between HbA1cand levels of stimulated secretion of TNF (r=0.726, p=0.027), CCL18 (r=-0.949, p=0.051) in patients with DSPN. In all patients with different duration of VDS, an increase in secretion of TNF- and CCL18 was observed (p0.05). However, stimulation of anti-inflammatory activation was not observed in patients with ulcerative defects lasting more than 6 months (p=0.033). The use of cocarnit in these patients had a decrease in stimulated secretion of TNF and an increase in CCL18. Throughout the entire observation period with the therapy, the score for the symptoms of polyneuropathy on the TSS scale in patients of the control group was statistically significantly higher. CONCLUSION:Against the background of therapy in patients of the main group, a statistically significant dynamics of indicators on the TSS scale was established. The cytokine modulating ability of Kokarnit to switch the cytokine status into the category of anti-inflammatory.

Severe Vitamin D3 Deficiency in the Majority of Patients with Diabetic Foot Ulcers

2018 ◽  
Vol 50 (08) ◽  
pp. 615-619 ◽  
Author(s):  
Joachim Feldkamp ◽  
Karsten Jungheim ◽  
Matthias Schott ◽  
Beatrix Jacobs ◽  
Michael Roden
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Foot ◽  
Cell Function ◽  
Glycosylated Hemoglobin ◽  
Diabetic Foot Syndrome ◽  
Foot Ulcers ◽  
Control Group ◽  
Diabetic Foot Ulcers ◽  
Healthy Humans ◽  
Patients With Diabetes

AbstractDiabetic foot ulcers are a severe complication in patients with diabetes mellitus. Vitamin D is associated with impaired β-cell function and insulin resistance, and is necessary for wound healing and bone metabolism. We measured the serum concentrations of 25-hydroxyvitamin D3 in 104 patients (63 inpatients, 41 outpatients) with diabetic foot ulcers and compared them to 99 healthy humans (control) and 103 patients with diabetes mellitus type 2 without diabetic foot ulcers. Calcium, creatinine, and parathyroid hormone were measured in patients with diabetic foot ulcers. The data were analysed together with glycosylated hemoglobin A1c and the severity of diabetic foot lesions according to the Armstrong classification. Levels of 25-hydroxyvitamin D3 were lower (11.8±11.3 ng/ml, p<0.001) in patients with diabetic foot ulcers (mean age 70±12 years) than in the control group (27.2±12.2 ng/ml). No difference was found between in- and outpatients. Fifty-eight (55.8%) of patients with diabetic foot ulcers had a severe 25-hydroxyvitamin D3 deficiency with levels below 10 ng/ml. Only 12% of the patients had 25-hydroxyvitamin D3 levels above 20 ng/ml. Secondary hyperparathyroidism was found in 27.9% of patients and 11.5% of the patients were hypocalcemic. There was a negative correlation (r=–0.241) (p<00.1) between Armstrong classification and 25-hydroxyvitamin D3 status. In conclusion, patients with diabetic foot syndrome are at high risk of 25-hydroxyvitamin D3 deficiency. Thus, any patient with diabetic foot syndrome should undergo 25-hydroxyvitamin D3 measurement and supplementation, if values are found to be decreased.

scholarly journals Communication Of Quality Of Life Indicators, Functional Methods Of Research And Neuromarker BNDF In Patients With Diabetes Mellitus 2 With Diabetic Foot Syndrome

2021 ◽  
Vol 03 (05) ◽  
pp. 12-23
Author(s):  
Alimkhanov Olimkhon Omilkhonovich ◽  
◽  
Kamalov Telman Tulyaganovich ◽  
Keyword(s):  
Quality Of Life ◽  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Diabetic Foot ◽  
Neuromuscular Transmission ◽  
Glycated Haemoglobin ◽  
Diabetic Foot Syndrome ◽  
Control Group

The purpose of the study is to study the correlation rate of the quality of life, electroneuromyography, doppler and neuro markers BNDF in the blood in patients with a type 2 of type with diabetic foot syndrome. Methods: The following 2 groups of patients were formed: 1 gr. - SDS patients, neuropathic form -37 patients, 2 gr. - SDS patients, neuroichmic form -35 patients, 3 gr. - Control group, these are 20 healthy persons of the appropriate age and gender. Results: In all groups of patients, the quality of life is significantly different in the FSHC questionnaire compared with the control group (p <0.05). In patients with a neuroecemic form of diabetic foot syndrome, a significant decrease was found (p <0.05). All indicators of doppler song vessels of legs compared with patients with neuropathic shape. Revealed significant correlations of FSHK and laboratory and instrumental indicators. A correlation connection with the duration of the disease, the duration of the disease, the levels of glycemia of an empty stomach, the level of the glycated haemoglobin, BNDF in the blood, the speed of blood flow in the femoral artery, in the lower leg, is discovered. The definition of neuromuscular transmission showed that the patients of the 1st and 2nd groups have a weak reduction in muscle contraction involuntarily. This confirmed the impairment of neuromuscular transmission in both groups. Conclusions: 1) A questionnaire to determine the quality indicators - FSHK is the most sensitive and informative to determine the quality of life in patients with type 2 diabetes mellitus with neuropathic and neuroecemic forms 2) FSHP questionnaire can be used for dynamic assessment of type 2 diabetes patients with neuropathic and neuroecemic forms in outpatient clinical practice. 3) Revealed significant correlations of FSHK and laboratory and instrumental indicators. A correlation connection with the duration of the disease, the duration of the disease, the levels of glycemia on an empty stomach, the level of the glycated haemoglobin, BNDF in the blood, the speed of blood flow in the femoral artery, in the shin, M-answer when stimulating a tibial nerve.

scholarly journals The Role of Physical Therapy in the Combined Treatment of Patients with Lower Extremities Diabetic Angiopathies

2021 ◽  
Vol 20 (2) ◽  
pp. 80-87
Author(s):  
Denis V. Frolov
Keyword(s):  
Diabetes Mellitus ◽  
Physical Therapy ◽  
High Mortality ◽  
Physical Training ◽  
Diabetic Foot ◽  
Vascular Complications ◽  
Lower Extremities ◽  
Diabetic Polyneuropathy ◽  
Diabetic Foot Syndrome ◽  
Diabetic Angiopathies

One of the most disabling complications of diabetes mellitus is angiopathy of the lower extremities. Diabetic polyneuropathy and diabetic foot syndrome are closely associated with vascular complications of diabetes mellitus, which significantly aggravate the course of the disease and contribute to high mortality. Diabetic polyneuropathy and diabetic foot syndrome are closely associated with the diabetes mellitus vascular complications that significantly aggravate the course of the disease and contribute to high mortality. Despite the improvement in the results of pharmacotherapy of diabetes mellitus, the problem of treating its vascular complications is far from being solved. Traditionally, therapeutic physical training is used among the methods of non-drug treatment of diabetes mellitus and its complications. As a method of pathogenetic focus on many risk factors for the development of diabetes and its complications, physical therapy exercises contribute to the correction of the syndrome of hypodynamia, obesity, and muscle atrophy. At the same time, there is insufficient data on how exercise therapy affects the quality of life of patients, functional characteristics of walking and objective indicators of blood flow in the lower extremities. This review identifies the main approaches to the application, advantages and disadvantages of individual methods of therapeutic physical training in the correction of functional disorders in patients with lower extremities diabetic angiopathies. We can currently talk about the proven safety of the physical therapy use in patients with diabetic angiopathies. Meanwhile, the scientific data on the high efficiency of this method is still insufficient.

scholarly journals HEMORHEOLOGICAL FAILURE IN THE PATHOLOGY OF CARDIO-VASCULAR COMPLICATIONS IN PATIENTS WITH DIABETIC FOOT SYNDROME

2016 ◽  
Vol 6 ◽  
pp. 57-62
Author(s):  
Еlina Кorobko
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Foot ◽  
Blood Circulation ◽  
Vascular Complications ◽  
Cardiovascular Complications ◽  
Diabetic Foot Syndrome ◽  
Steady Growth ◽  
Myocardium Infarction ◽  
The World ◽  
Cardio Vascular

The literature that includes the study of cardiovascular complications in patients with diabetic foot syndrome was analyzed. The topicality of this problem is caused by the steady growth of diabetes mellitus morbidity among people. For today there are more than 170 mln people throughout the world with diabetes mellitus, among them 65–80 % have cardiovascular complications (myocardium infarction, acute disorder of brain blood circulation and so on). It is established for today, that pathogenesis of diabetic foot syndrome is multi-factor one and the development of purulent-necrotic stages of DFS is connected with the combination of different factors, especially microcirculation disorder. In this article we’ll consider the mechanisms of diabetic angiopathy development, the state of platelet-vascular hemostasis link in this category of patients.

scholarly journals Lymphocyte plasma membrane blebbing in patients with atherosclerosis of the main arteries and ischemic diabetic foot

2020 ◽  
Vol 4 (7) ◽  
pp. 452-456
Author(s):  
S.S. Dunaevskaya ◽  
◽  
A.T. Khachatryan ◽  
V.V. Deulina ◽  
◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Blood Flow ◽  
Plasma Membrane ◽  
Lower Limb ◽  
Diabetic Foot ◽  
Glycated Hemoglobin ◽  
Control Group ◽  
Flow State ◽  
Lymphocyte Membrane ◽  
Membrane Blebbing

Aim: to assess the blood flow state and the lymphocyte plasma membrane blebbing in atherosclerosis of the lower limb arteries and the ischemic diabetic foot (IDF).Patients and Methods: 75 patients (51 (68%) of them — women) underwent a prospective study with IDF and signs of chronic obliterating disease of lower limb arteries. In the majority of cases (92%), IDF occurred in the setting of type 2 diabetes mellitus. Blood circulation disorder corresponded to the stage II–III Fontaine–Pokrovsky classification, ulcerative defects — to the PEDIS grade 1–2 without signs of infection and with signs of local inflammation. The control group consisted of 25 healthy patients. Blood flow state (using Doppler ultrasound of the lower limb arteries) and diabetes mellitus compensation degree (by the level of glycated hemoglobin), as well as the lymphocyte membrane state were evaluated.Results: 72% of patients had a total occlusion of tibial and foot segments, 28% — stenosis. The level of glycated hemoglobin was 10.3 [8.5; 14.3]%, which indicated insufficient compensation of carbohydrate metabolism disorders. Total and terminal blebbing was 30.1 [25.4; 33.2]% and 15.8 [11.8; 18.4]%, which was 3 and 5 times higher than the control group, respectively. A high positive correlation was observed between the level of glycated hemoglobin and total (rS=0.72; p=0.001) and terminal (rS=0.78; p=0.001) lymphocyte membrane blebbing.Conclusion: given the presence of a high correlation between the indicator of glycated hemoglobin and lymphocyte plasma membrane blebbing, an increase in glycated hemoglobin can be used as a marker for the development of endothelial insufficiency in atherosclerosis of the lower limbs and IDF. At the same time, the level of total and terminal blebbing can be considered as a pathogenetic marker of macroangiopathy. KEYWORDS: diabetes mellitus, atherosclerosis, ischemia, hemodynamics, blebbing, glycated hemoglobin.FOR CITATION: Dunaevskaya S.S., Khachatryan A.T., Deulina V.V. Blebbing of plasma membrane of lymphocytes in patients with atherosclerosis of main arteries and ischemic form of diabetic foot syndrome. Russian Medical Inquiry. 2020;4(7):452–456. DOI: 10.32364/2587-6821-2020-4-7-452-456.

scholarly journals Effect of negative pressure therapy on repair of soft tissues of the lower extremities in patients with neuropathic and neuroischaemic forms of diabetic foot syndrome

2014 ◽  
Vol 17 (3) ◽  
pp. 113-121
Author(s):  
Ekaterina Leonidovna Zaytseva ◽  
Ludmila Petrovna Doronina ◽  
Roman Vakhtangovich Molchkov ◽  
Iya Alexandrovna Voronkova ◽  
Valeriy Afanasievich Mitish ◽  
...  
Keyword(s):  
Negative Pressure ◽  
Diabetic Foot ◽  
Standard Therapy ◽  
Soft Tissues ◽  
Lower Extremities ◽  
Perioperative Period ◽  
Diabetic Foot Syndrome ◽  
Control Group ◽  
Negative Pressure Therapy ◽  
Pressure Therapy

Aim. To evaluate the efficiency of topical negative pressure wound therapy (NPWT) compared with standard therapy for the regeneration of the soft tissues of the lower extremities in patients with diabetic foot syndrome. Materials and Methods. The effects of negative pressure therapy on the clinical (size, tissue oxygenation), histological (light microscopy) and immunohistochemical (CD68, MMP-9, TIMP-1) aspects of repair of the soft tissue of the lower extremities in patients with diabetes mellitus were compared with those of standard treatment. Thirty-one patients with diabetic foot ulcers were included in the study from the moment of debridement until the plastic closure of the wound. During the perioperative period, 13 patients received NPWT (-90 to -120 mmHg) and 18 patients received standard therapy. Results. A reduction of the wound area (26.6%?17.2%) and the depth of the defects (40.5%?25.6%) were achieved with negative pressure therapy compared with baseline data. In the control group, the corresponding values were 25.3%?19.4% and 21.8%?21.6%, respectively. The results of transcutaneous oximetry showed a greater increase in the level of local hemodynamics in the study group (p

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