scholarly journals Incidence of SUDEP in a cohort of patients with refractory epilepsy: the role of surgery and lesion localization

2010 ◽  
Vol 68 (6) ◽  
pp. 898-902 ◽  
Author(s):  
Andrea Garcia de Almeida ◽  
Magda Lahorgue Nunes ◽  
André Luis Fernandes Palmini ◽  
Jaderson Costa da Costa
Keyword(s):  
Refractory Epilepsy ◽  
Epileptiform Activity ◽  
University Hospital ◽  
Seizure Type ◽  
Mri Findings ◽  
Unexpected Death ◽  
Cross Sectional ◽  
Epileptiform Discharges ◽  
Significant Difference ◽  
Lesion Localization

OBJECTIVE: The aim of this study was to verify incidence and characteristics of sudden unexpected death in patients (SUDEP) with refractory epilepsy and its relation to previous surgery and lesion localization. METHOD: A cross sectional study was carried out in a cohort of 550 patients with refractory epilepsy followed up by the Epilepsy Surgery Program of the University Hospital of PUCRS, Porto Alegre, Brazil, between January, 1992 and July, 2002. Patients were allocated in two groups (operated and non operated). Seizure type, distribution of interictal spikes and MRI findings were correlated with the SUDEP outcome. RESULTS: The estimated incidence of probable SUDEP amounted to 29:1000 individuals. Probable SUDEP occurred in 1.2% of the 166 patients of the non operated group and in 3.7% of the 384 patients who were operated (OR=3.02, 95% CI 0.69-13.16) (p=0.11). Comparing patients who died to patients alive in the operated group a significant difference was observed concerning the following variables: SUDEP patients had a predominance of generalized seizures (p=0.002), extratemporal lesion on MRI (p<0.001) and epileptiform activity over extratemporal regions (p=0.001). CONCLUSION: In surgically treated patients with refractory epilepsy, an extratemporal location of the lesion and of the epileptiform discharges significantly correlated to SUDEP. Thus it is possible that in those patients; the underlying disease may play a role in the pathogenesis of SUDEP.

scholarly journals Clinical characteristics and in-hospital outcome of heart failure in women: a single center registry from Egyptian cardiac care unit

2019 ◽  
Vol 71 (1) ◽  
Author(s):  
Hala Mahfouz Badran ◽  
Marwa Ahmed Elgharably ◽  
Naglaa Faheem
Keyword(s):  
Clinical Characteristics ◽  
Heart Diseases ◽  
University Hospital ◽  
Cardiac Care ◽  
Single Center ◽  
Term Outcome ◽  
Cross Sectional ◽  
Valvular Heart Diseases ◽  
Significant Difference ◽  
Cardiac Care Unit

Abstract Background This study represents figures from a cardiac care unit (CCU) of a university hospital; it describes an example of a tertiary academic center in Egypt and provides an epidemiological view of the female HF patients, their risk profile, and short-term outcome during hospitalization. Results It is a local single-center cross-sectional observational registry of CCU patients 1 year from July 2015 to July 2016. Patient’s data were collected through a special software program. Women with evidence of HF were thoroughly studied. Among the 1006 patients admitted to CCU in 1 year, 345 (34.2%) patients were females and 118 (34.2%) had evidence of HF, whereas 661 (65.7%) were males and 178 (26.9%) of them had HF. Women with HF showed 11.7% prevalence of the total population admitted to CCU. 72.7% were HFrEF and 27.3% were HFpEF. Compared to men, women with HF were older in age, more obese, less symptomatic than men, had higher incidence of associated co-morbidities, less likely to be re-admitted for HF, and less likely to have ACS and PCI. Valvular heart diseases and cardiomyopathies were the commonest etiologies of their HF. Women had more frequent normal ECG, higher EF%, and smaller LA size. There is no difference in medications and CCU procedures. While females had shorter stay, there is no significant difference in hospital mortality compared to male patients. Conclusions Despite higher prevalence of HF in females admitted to CCU and different clinical characteristics and etiology of HF, female gender was associated with similar prognosis during hospital course compared to male gender.

scholarly journals The Frequency of Malnutrition in Patients with Type 2 Diabetes

2021 ◽  
Author(s):  
Miraç Vural Keskinler ◽  
Güneş Feyizoğlu ◽  
Kübra Yıldız ◽  
Aytekin Oğuz
Keyword(s):  
Type 2 Diabetes ◽  
Outpatient Clinic ◽  
High Body Mass Index ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Nutritional Risk ◽  
Cross Sectional ◽  
Significant Difference ◽  
Nrs 2002

Objective: Obesity is one of the most common comorbidities of diabetes mellitus (DM) whose frequency is rapidly increasing nowadays. Although obesity caused by excessive and unbalanced nutrition often accompanies diabetes; malnutrition is another complication of diabetes. This study was conducted to investigate the frequency of malnutrition in individuals with diabetes. Method: This study is a cross-sectional study. The patients with type 2 diabetes followed up in the diabetes outpatient clinic of a university hospital between February and March 2018 were included in the study. Anthropometric measurements of the patients and “Nutritional Risk Screening-2002” (NRS-2002) scores were recorded. Results: A total of 222 (F: 132 59.4%) patients were included in the study. When two groups with higher NRS (≥3) and lower NRS (<3) scores less than 3 were compared, any significant difference was not detected between two groups in terms of age, waist circumference and HbA1c values. Only BMI was found to be lower in the group with malnutrition risk (p: 0.030). When the patients were evaluated in terms of diabetes treatments and risk of malnutrition, any significant intergroup difference was not found (p: 0.847). Conclusion: It was found that there is a risk of malnutrition in one of every seven diabetics with a high body mass index who were being followed up in the diabetes outpatient clinic.

scholarly journals Position of lips and tongue in rest in newborns with and without ankyloglossia

CoDAS ◽  
2021 ◽  
Vol 33 (6) ◽  
Author(s):  
Silvia Márcia Andrade Campanha ◽  
Roberta Lopes de Castro Martinelli ◽  
Durval Batista Palhares
Keyword(s):  
Visual Inspection ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Sectional Study ◽  
Hospital Data ◽  
Chi Square ◽  
Cross Sectional ◽  
Significance Level ◽  
Significant Difference ◽  
Chi Square Test

ABSTRACT Purpose Verify the position of lips and tongue at rest in newborns with and without ankyloglossia. Methods Cross-sectional study, carried out with 130 newborns in University Hospital. Data collection was performed by the researcher and speech-language pathologists from the Hospital. Information on gestational age, sex, weight, height and days of life was collected. The position of the lips and tongue at rest was evaluated through visual inspection with the newborns asleep. After the newborns were awakened, Neonatal Screening of the validated Protocol for the evaluation of the lingual frenulum for infants was performed to detect the alteration of the lingual frenulum. The data obtained were described and submitted to statistical analysis using the Chi-Square test to verify the association between the position of the lips with the tongue and to compare the position of the lips and tongue with and without ankyloglossia. The Mann-Whitney test was used to verify the behavior of the variables the differed between newborns with and without ankyloglossia. The significance level of 5% was adopted. Results When comparing the data, a significant difference was found between: weight and height with and without ankyloglossia; position of lips and tongue. An association between the position of the tongue and lips with and without ankyloglossia was also found. Conclusion Newborns without alteration of the lingual frenulum have a tendency to remain with their lips closed and their tongue elevated during rest and newborns with ankyloglossia have a tendency to keep their lips parted and their tongue low during rest.

scholarly journals A comparison of pain registration by Visual Analog Scale and Numeric Rating Scale – a cross-sectional study of primary triage registration

2020 ◽  
Author(s):  
Jofrid Kollltveit ◽  
Malin Osaland ◽  
Marianne Reimers ◽  
Magnus Berle
Keyword(s):  
Emergency Department ◽  
Visual Analog Scale ◽  
Rating Scale ◽  
Emergency Admission ◽  
Numeric Rating Scale ◽  
University Hospital ◽  
Analog Scale ◽  
Cross Sectional ◽  
Significant Difference ◽  
Numeric Rating

BackgroundPain is a subjective sensation; self-reporting is important for quantifying pain intensity. There are several different validated tools for this, such as Visual Analog Scale and Numeric Rating Scale. In the clinic, these terms are often used as equivalent. The objective of this study was to examine correlation and agreement between the pain registration tools in triage in an emergency department.Materials and MethodsThe study was performed in the Department of Emergency Medicine at Haukeland University Hospital in the period June-August 2019. We registered the pain score with two tools in 200 unselected patients in emergency admission with pain. In addition, we registrered gender, age, triage and general department affiliation.ResultsWe found a strong correlation between the pain registration tools by Spearmans correlation test (rho=0,930, p<0,001). There were no significant difference between the pain registration tools within the subgroups. Bland-Altman analysis show agreement between the two pain registration tools.ConclusionsIn an Emergency Department triage is it acceptable to use Visual Analog Scale and Numeric Rating Scale as equivalent, as long as the correct terminology is used.

Evaluation of Hepatitis C Patients' Satisfaction Regarding Care and Treatment in Different Hospitals in Cairo, Egypt, 2020

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Shaimaa S Yousef ◽  
Lamyaa S Al Bagoury ◽  
Sahar A Dewedar ◽  
Sahar M Sabbour ◽  
Wagida A Anwar
Keyword(s):  
Viral Hepatitis ◽  
Demographic Data ◽  
University Hospital ◽  
Health Providers ◽  
Cross Sectional ◽  
Indirect Measure ◽  
Patients Satisfaction ◽  
Significant Difference ◽  
Care And Treatment

Abstract Background Patient satisfaction can be considered as an indirect measure of health outcomes and quality of provided services. Objectives To compare HCV patients' satisfaction regarding care and treatment in different selected Viral Hepatitis Outpatients Clinics in Cairo. Method: The current study is a cross sectional study. It recruited 300 HCV patients from Viral Hepatitis Outpatients Clinics in University, Ministry of Health (MOH) and Insurance Hospitals (100 HCV patients from each clinic). Recruited HCV patients attended at least 2 visits to the Viral Hepatitis Clinics. They completed an interview questionnaire about socio- demographic data, history of diagnosis of HCV, onset and type of treatment and Hepatitis Patients Satisfaction Questionnaire (HPSQ). Results Mean age of HCV patients were (48.9 ±13.5), (50.4 ± 10.4), and (54.8 ± 10.9) from University, MOH and Insurance Hospitals, respectively. Females accounted for (63%) of HCV patients in University Hospital sample however, males were (54%) and (57%) in MOH and Insurance Hospitals, respectively. Most of studied HCV patients were referred by specialists; (59%), (86%) and (87%) from University, MOH, and Insurance Hospitals, respectively. A statistically significant difference was found between the 3 Clinics as regards rating the quality of received HCV services, meeting patients’ needs, coping with HCV disease, and helping patients access to specialist services (p &lt; 0.01). The study revealed that the majority of health providers in the 3 Viral Hepatitis Clinics didn't involve HCV patients in making decisions about their treatment. Conclusion HPSQ findings identified University Hospital's patients more satisfied about their HCV treatment management than MOH and Insurance Hospitals' patients except for involvement of HCV patients in making decisions which was lacking in the 3 hospitals.

scholarly journals Prevalence and profile of daily smokers seen at three primary health care units in Pelotas, southern Brazil

2012 ◽  
Vol 34 (3) ◽  
pp. 154-160 ◽  
Author(s):  
Mariane Ricardo Acosta Lopez ◽  
Karen Jansen ◽  
Luciano Dias de Mattos Souza ◽  
Ricardo Tavares Pinheiro ◽  
Elaine Tomasi ◽  
...  
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Total Sample ◽  
Tobacco Consumption ◽  
University Hospital ◽  
Daily Smoking ◽  
Southern Brazil ◽  
Cross Sectional ◽  
Primary Health ◽  
Significant Difference

Objectives: To estimate the prevalence of daily smoking among users of three primary health care units affiliated with a university hospital in the municipality of Pelotas, southern Brazil, and to identify factors associated with daily tobacco consumption. Methods: This cross-sectional study included all individuals over 14 years of age who sought treatment at the health care units between June 29, 2009, and February 23, 2010, and lived in the area covered by the unit. Interviews were conducted during home visits to collect data on sociodemographic characteristics and health behaviors; the Mini International Neuropsychiatric Interview (MINI) was used to assess the presence of mood disorders; and a question from the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) on the daily use of tobacco in the past 3 months was used to assess smoking. Results: The total sample comprised 1,848 individuals, mostly female (72.9%), aged between 46 and 60 years (28.5%), and belonging to socioeconomic class C (61%). The prevalence of daily smoking was 23.4% (n = 432), and there was a statistically significant difference between men and women: 27 vs. 22.1% (p < 0.050). Conclusion: Our findings confirm a high prevalence of smoking among users of primary health care units, underscoring the need for a more accurate process of diagnosis and treatment at these facilities.

scholarly journals Ring chromosome 20 syndrome – A rare chromosomal cause of refractory epilepsy in children

2017 ◽  
Vol 04 (01) ◽  
pp. 087-089 ◽  
Author(s):  
Umesh Kalane ◽  
Chaitanya Datar ◽  
Shilpa Kalane
Keyword(s):  
Chromosomal Abnormalities ◽  
Refractory Epilepsy ◽  
Genetic Disorders ◽  
Epileptiform Activity ◽  
Intractable Epilepsy ◽  
Ring Chromosome ◽  
Normal Karyotype ◽  
Epileptiform Discharges ◽  
Chromosome 20 ◽  
Work Up

AbstractGenetic disorders and chromosomal abnormalities have been shown to represent 2–3% of all cases of epilepsy. Ring chromosome 20 syndrome is a rare chromosomal abnormality and a rare cause of intractable epilepsy. Exact prevalence of ring chromosome 20 is not known. We report a case of a 10-year old boy who had had intractable epilepsy since 2 years of age. Birth history was insignificant and there was no obvious dysmorphism. His motor milestones were normal but cognition and speech were delayed. Electroencephalography showed progressive worsening from initial bi-frontal epileptiform activity to generalized discharges. Neuroimaging and metabolic work up was normal. Karyotype study showed ring chromosome 20. Diagnosis of ring chromosome 20 or r(20) syndrome was made. Ring chromosome 20 syndrome is a rare cause of refractory epilepsy A patient who present with intractable epilepsy with frontal epileptiform discharges, mental developmental delay, without dysmorphic features should be suspected of chromosomal abnormalities especially ring chromosome 20.

P0080INTERLEUKIN-17A GENE POLYMORPHISM (RS2275913G>A) IN SLE PATIENTS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Nehal Atef elshabrawy ◽  
Hussein Sheashaa ◽  
Adel L Abdelsalam ◽  
Ahmed Mohammed Abd El Wahab
Keyword(s):  
Lupus Nephritis ◽  
Gene Polymorphism ◽  
Inflammatory Diseases ◽  
Statistical Significance ◽  
Group Versus ◽  
University Hospital ◽  
Control Group ◽  
Cross Sectional ◽  
Dsdna Antibody ◽  
Significant Difference

Abstract Background and Aims There are six IL-17-family ligands [IL-17A, IL-17B, IL-17C, IL-17D, IL-17E (IL-25) and IL-17F]. Interleukin-17A (IL-17A) also commonly called IL-17, is produced by the T helper17 (Th17) subset of CD4+ T cells.Interleukin-17 and other Th17 cytokines are linked to the pathogenesis of diverse autoimmune and inflammatory diseases. IL-17A is detected in synovial fluids and synovium from RA patients and induces proinflammatory cytokine production from synoviocytes, also expression of IL-17A was higher in SLE patients and its level positively correlated with the severity of lupus nephritis, because of its contribution to increasing anti-double-stranded DNA (dsDNA) antibody production in SLE. The aim of the present study is to determine the IL-17A gene polymorphism (rs2275913 G&gt;A) frequency in patients with SLE and lupus nephritis, and to determine the association of this polymorphism with the disease activity. Method This cross-sectional, observational, case control study was carried out on 50 females patients, with their age ranged from 15 to 50 years (mean 25.67±9.29 years) with SLE attending Mansoura University Hospital .A control group of 50 healthy females of matched age were also included. The patient group was subdivided into patients with and those without lupus Nephritis (35 and 15 patients, respectively). Lupus nephritis was confirmed by renal biopsy. All patients were subjected to a thorough clinical evaluation and routine laboratory tests. SLEDAI score was calculated for all patients to determine the degree of lupus activity. DNA extraction was performed for all patients as well as controls, One SNPs of IL-17A (rs2275913G&gt;A) was genotyped utilizing PCR- RFLP technique. Results The frequency of rs2275913 A allele was significantly higher in SLE patients than the control group (34.0% vs. 21.0%, respectively; p=0.04, OR =1.9, 95%CI =1.03-3.65). While G allele was significantly higher in control group, (P=0.04)). Moreover, AA genotype was significantly higher in the SLE patients than in the control group (8.0% vs. 0.0%, respectively; p=0.036) and associated with higher SLEDAI, ANA, and anti-dsDNA antibodies titer, (P=0.03, P=.039, P=0.047 respectively).on the other hand there was no significant difference in GG and GA genotypes in the SLE patients versus the control group. The frequency of both genotype GA and AA was higher in the SLE patients than the controls (60% vs. 42%, respectivley; OR=2.07, CI-95%=0.9-5.59); although the difference was not statistically significant (P= 0.07).Although A allele was numerically higher in lupus nephritis group versus non nephritis group(37.0% vs 27.0%, respectively), the Analysis of the frequency of IL-17A rs2275913 alleles and genotypes showed no statistical differences between the two groups. Moreover there was no statistical significance between different genotypes in cases of nephritis regard lupus nephritis class (P=0.9) and no statistical significance between different genotypes (GG-GA-AA) regarding activity indices (AI) or chronicity indices (CI) in lupus nephritis group (P=0.18, P=0.56 respectively). Conclusion We suggest that there was a significant association between IL-17A rs2275913 G&gt;A polymorphism and SLE, as A allele and AA genotype were increased in SLE patients, lupus nephritis especially those with high activity

scholarly journals Magnetic Resonance Imaging Findings in Childhood Epilepsy at a Tertiary Hospital in Kenya

2021 ◽  
Vol 12 ◽  
Author(s):  
Pauline Samia ◽  
Nicholas Odero ◽  
Maureen Njoroge ◽  
Shem Ochieng ◽  
Jacqueline Mavuti ◽  
...  
Keyword(s):  
Hippocampal Sclerosis ◽  
Periventricular Leukomalacia ◽  
Epileptiform Activity ◽  
Tertiary Hospital ◽  
Sub Saharan Africa ◽  
University Hospital ◽  
Childhood Epilepsy ◽  
Imaging Findings ◽  
Categorical Data Analysis ◽  
Mri Findings

Background: Neuroimaging is important for determining etiology and guiding care in early childhood epilepsy. However, access to appropriate imaging in sub-Saharan Africa is modest, and as a consequence, etiological descriptions of childhood epilepsy in the region have been limited. We sought to describe MRI findings in children with epilepsy presenting to a tertiary hospital in Nairobi, Kenya, over a 6-year period of routine care.Materials and Methods: We undertook a retrospective review of MRI findings of children aged between 0 and 18 years with a diagnosis of epilepsy presenting to the pediatric neurology department of Aga Khan University Hospital in Nairobi, Kenya, between January 2014 and July 2020. Over this period, the hospital had 1.5T MRI machines (GE1.5T Signa Excite and GE 1.5T Signa Explorer) and a 3T MRI machine (Philips 3T Ingenia). MRI images were independently reviewed by two study radiologists, and the findings were summarized and categorized into a study database. Related clinical and electroencephalographic (EEG) details were extracted from patient records. Categorical data analysis methods were applied to investigate for relationships between clinically relevant neuroimaging findings and key clinical and EEG observations.Results: Over the study period, 288 children with a confirmed diagnosis of epilepsy had an MRI. They were of median age of 6 [interquartile range (IQR) 2–11] years. Ninety-five (33%) children had abnormal findings on imaging. The most common findings were encephalomalacia related to chronic infarcts (n = 18: 6.3%), cerebral atrophy (n = 11: 3.8%), disorders of neuronal migration (n = 11: 3.8%), periventricular leukomalacia (n = 9: 3.1%), and hippocampal sclerosis (n = 8: 2.8%). Findings related to infectious etiology were only observed in four children. Clinical comorbidity and inter-ictal epileptiform activity on EEG were independently associated with abnormal findings on imaging.Conclusion: Up to a third of the children who underwent an MRI had a positive yield for abnormal findings. Imaging findings related to infectious etiologies were little observed in our cohort, in contradistinction to etiology studies in similar settings. At the time of the study, comorbidity and inter-ictal epileptiform activity on EEG were associated with abnormal findings on imaging and should be considered in informing prioritization for imaging in childhood epilepsy in this setting.

scholarly journals Nurses’ Awareness on Patient Safety Culture in A Newly Established University Hospital

2020 ◽  
Vol 23 (2) ◽  
pp. 119-127
Author(s):  
Mohd Said Nurumal ◽  
Najwatul Madihah Sabran ◽  
Siti Hazariah Abdul Hamid ◽  
Muhammad Kamil Che Hasan
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Safety Culture ◽  
Care Delivery ◽  
Medical Center ◽  
Patient Safety Culture ◽  
University Hospital ◽  
Cross Sectional ◽  
Significant Difference ◽  
Post Hoc

As a vital part of patient care delivery, patient safety culture contributes to the quality of care provided by nurses. Safe patient care is positively linked to the attitudes of nurses. This study aimed to assess the perception of nurses working in a newly established teaching hospital. A cross-sectional study involving 194 nurses from three different units was conducted by using a 24-item Hospital Survey of Patient Safety Culture. Data on gender, working unit, age, years of working, and attendance in workshops on patient safety were also collected. The majority of the nurses had a positive total score of patient safety culture. The lowest score was 76 (63%), and the highest score was 120 (96%). The awareness on patient safety culture significantly differed between gender, years of working, and working units. Post-hoc comparisons using Tukey’s HSD test yielded a significant difference between nurses from critical care units and those from medical and surgical units. The mean score and total positive score on awareness on patient safety culture of the former were higher than those of the latter. Overall, the majority of the staff nurses in International Islamic University Malaysia Medical Center had a positive total score on awareness on patient safety culture. Awareness on patient safety, which is considered crucial worldwide, should be enhanced to influence the development of a positive patient safety culture within hospitals. This implementation would directly develop high-quality care to patients and positively impact health organizations.Abstrak  Kesadaran Perawat terhadap Budaya Keselamatan Pasien di Rumah Sakit Universitas yang Baru Dibangun. Sebagai bagian penting dari pemberian perawatan pasien, budaya keselamatan pasien berkontribusi pada kualitas perawatan yang diberikan oleh perawat. Perawatan pasien yang aman secara positif terkait dengan sikap perawat. Penelitian ini bertujuan untuk menilai persepsi perawat yang bekerja di rumah sakit pendidikan yang baru dibangun. Sebuah studi cross-sectional yang melibatkan 194 perawat dari tiga unit yang berbeda dilakukan dengan menggunakan Survei Rumah Sakit Budaya Keselamatan Pasien. Data tentang jenis kelamin, unit kerja, usia, tahun kerja, dan kehadiran dalam lokakarya tentang keselamatan pasien juga dikumpulkan. Mayoritas perawat memiliki skor total positif dari budaya keselamatan pasien. Skor terendah adalah 76 (63%), dan skor tertinggi adalah 120 (96%). Kesadaran tentang budaya keselamatan pasien berbeda secara signifikan antara jenis kelamin, tahun kerja, dan unit kerja. Perbandingan post-hoc menggunakan uji HSD Tukey menghasilkan perbedaan yang signifikan antara perawat dari unit perawatan kritis dan mereka dari unit medis dan bedah. Skor rata-rata dan skor total positif pada kesadaran tentang budaya keselamatan pasien dari yang pertama lebih tinggi daripada yang terakhir. Secara keseluruhan, mayoritas staf perawat di International Islamic University Malaysia Medical Center memiliki skor total positif pada kesadaran tentang budaya keselamatan pasien. Kesadaran akan keselamatan pasien, yang dianggap penting di seluruh dunia, harus ditingkatkan untuk memengaruhi perkembangan budaya keselamatan pasien yang positif di rumah sakit. Implementasi ini secara langsung akan mengembangkan perawatan berkualitas tinggi kepada pasien dan berdampak positif bagi organisasi kesehatan.Kata Kunci: budaya, perawat, keselamatan pasien, rumah sakit

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