scholarly journals Assessment of Musculoskeletal Disorders Between lorry Drivers in Qom, Iran

2014 ◽  
Vol 3 (3) ◽  
pp. 182-88
Author(s):  
Abolfazl Mozafari ◽  
Mohsen Najafi ◽  
Mostafa Vahedian ◽  
Siamak Mohebi
Keyword(s):  
Musculoskeletal Disorders ◽  
High Weight ◽  
Demographic Data ◽  
Cross Sectional Study ◽  
P Value ◽  
Cross Sectional ◽  
Body Regions ◽  
Work Duration ◽  
Lumbar Area ◽  
Musculoskeletal Problems

Background: Musculoskeletal disorders represent a substantial cause of morbidity worldwide. The contribution of work to these disorders has been well established by various epidemiological and laboratory-based researches. The aim of this study is to investigate the prevalence and associated factors of musculoskeletal disorders in truck drivers.Materials and methods: This cross sectional study included truck drivers referred to Transportation Company in Qom province. We evaluated musculoskeletal disorders by Nordic questionnaire and demographic data. The questionnaire was filled by direct interview. Data analysis was done in SPSS and P value below  0.05 was significant.Results: Age of 173 male participated in this study was 38.82 years with body mass index (BMI) of 26.02 (Kg/m2) and mean work duration of 8.85 years. In the period of past week and past year, prevalences of musculoskeletal disorders at all of the nine body regions of drivers were 56.6% and 78.6%, respectively. The most common musculoskeletal involvement was lumbar, back and neck regions. There were significant relationship among musculoskeletal problems with age, work duration, and BMI (P<0.05).Conclusion: This investigation showed the importance of frequent musculoskeletal disorders among  drivers in different body regions particularly in lumbar area and its  correlation with work duration, high weight, and age.

scholarly journals POS0548 OPTIMAL ASSESSMENT OF THE RHEUMATOID ARTHRITIS ANKLE AND HINDFOOT: A COMPARATIVE STUDY BETWEEN CLINICAL EXAMINATION AND ULTRASONOGRAPHY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 508.2-509
Author(s):  
K. Maatallah ◽  
H. Boussaa ◽  
H. Riahi ◽  
H. Ferjani ◽  
M. Habechi ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Clinical Examination ◽  
Demographic Data ◽  
Power Doppler ◽  
Cross Sectional Study ◽  
P Value ◽  
Cross Sectional ◽  
Therapeutic Decisions ◽  
The Mean ◽  
Foot Disease

Background:Foot disease is a common problem in rheumatoid arthritis (RA). Therapeutic decisions are often based on clinical examination (CE) alone, which can be adversely affected by factors such as deformity, obesity, and peripheral edema. Ultrasonography (US) has previously been shown to be more sensitive than CE for detecting synovitis and tenosynovitis in RA forefeet, but few data exist for the hindfoot and ankle.Objectives:The aim of this study was to compare CE and US for the detection of hindfoot and ankle synovitis and tenosynovitis in patients with established RA.Methods:We conducted a cross-sectional study including patients with RA (ACR/EULAR 2010). Demographic data and disease parameters were collected. CE was performed by a rheumatologist for the presence or absence of tenderness, swelling, and mobility restriction of both ankles. The following tendons were examined for tenosynovitis: tibialis anterior (TA) and posterior (TP), fibularis longus (FL), and brevis (FB) (assessed together). In a second time, US examination of the tibiotalar, talonavicular, and subtalar joints and the same tendons as CE was performed by a blinded radiologist experienced in musculoskeletal imaging using a Philips HD11 device with a high-frequency linear transducer. The presence or absence of synovitis and tenosynovitis was recorded, and the composite synovitis score (power doppler / grayscale ultrasound (PDUS)) was measured for each joint. The US score of each patient was defined by the sum of the composite scores of the joints studied (0-30). A p-value <0.05 was considered significant.Results:Sixty-two feet were examined in 31 RA patients (25 women and six men) with a mean age of 54.8±10.8 years old [32-70]. The mean disease duration was 8.5±7.2 years [1-37]. Rheumatoid Factor (RF) and Anti-Citrullinated Peptides Antibodies (ACPA) were positive in 61.3% and 83.8% of cases. The mean DAS28 ESR was 3.8±1.5 [0.6-7].Clinical examination of ankles revealed tenderness in 57.4% of cases, swelling in 38.8% of cases, and restriction in the range of motion in 11.1% of cases. TA tenosynovitis was noted in 14.8% of cases, TP tenosynovitis in 22.2% of cases, and FL and FB tenosynovitis in 31.5% of cases.US showed tibiotalar synovitis in 59.3% of cases, talonavicular synovitis in 64.8% of cases, and subtalar synovitis in 46.3% of cases. TA tenosynovitis was noted in 5.6% of cases, TP tenosynovitis in 22.2% of cases, and FB and FL tenosynovitis in 25% and 11.1% of cases respectively.An association was found between clinical tenderness and US synovitis of the tibiotalar joint (p=0.013) and the talonavicular joint (p=0.027). No association was noted between clinical swelling and US synovitis in these joints.No association was noted between clinical and US tenosynovitis of TA (p=0.279), TP (p=0.436), FB (p=0.495) and FL (p=0.315).Conclusion:Clinical examination of RA ankles may be challenging and needs to be coupled with US, which is more sensitive and accurate in the detection of synovitis and tenosynovitis.Disclosure of Interests:None declared

Frequency of Atrial Fibrillation in Heart Failure Patients

2021 ◽  
Vol 15 (11) ◽  
pp. 3261-3264
Author(s):  
Syed Mohammad Haleem ◽  
Muhammad Hashim Kalwar ◽  
Muhammad Hassan Butt ◽  
Jehangir Hasan ◽  
Javed Khurshed Shaikh ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Demographic Data ◽  
Treatment Options ◽  
Cross Sectional Study ◽  
P Value ◽  
Cross Sectional ◽  
Heart Failure Patients ◽  
Cardiac Symptoms ◽  
Patients With Heart Failure

Background: An increasing number of people around the world suffer from cardiovascular diseases such as atrial fibrillation (AF) and heart failure (HF). Atrial fibrillation (AF) has been linked to poor prognosis in heart failure (HF) patients with mild to moderate LV dysfunction, and it is most prominent in these patients. Despite advancements in care and treatment options like catheter ablation, managing AF is still a therapeutic challenge even with these advances. Aim/Objective: To determine the frequency of atrial fibrillation in heart failure patients. Subjects and Methods: This cross-sectional study was conducted on 246 patients at Adult Cardiology, NICVD, Karachi for Six months after approval from 31-08-2019 till 29-02-2020. Patients' consent was obtained verbally before data were collected prospectively. There were 246 patients with heart failure who had been diagnosed and met the diagnostic criteria. An overview of the event's history was gathered, as well as demographic data. Qualitative variables were presented as frequency and percentages, while quantitative data were given as simple descriptive statistics such as mean and standard deviation. A p-value of 0.05 or lower is considered statistically significant. Results: A total of 246 patients with heart failure were included in this study. The mean age in our study was 56.78±2.81 years. Whereas, mean BNP and ejection fraction in our study was 1144±87.81 pg./ml and 34.65±4.14 %. 136 (55.3%) were male and 110 (44.7%) were female. Out of 246 patients with heart failure, 52 (21.1%) had atrial fibrillation and 194 (78.9%) did not have atrial fibrillation. Conclusion: The results of this research demonstrated that a large percentage of heart failure patients had atrial fibrillation. Thus, it is essential to focus on a comprehensive way of management of heart failure and its comorbidities rather than primarily treating the cardiac symptoms. Keywords: Heart failure and atrial fibrillation.

scholarly journals Evaluating the Prevalence and Risk Factors of Musculoskeletal Disorders Among Technicians of Surgery

2019 ◽  
Vol 5 (4) ◽  
pp. 199-208
Author(s):  
Seyyedeh Haniyeh Mousavibaghi ◽  
◽  
Kamran Ezzati ◽  
Mahmood Abedinzade ◽  
Sadegh MoshtaghiKoojel ◽  
...  
Keyword(s):  
Risk Factors ◽  
Musculoskeletal Disorders ◽  
Work Experience ◽  
Occupational Injuries ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Work Related ◽  
Body Regions ◽  
Check Method ◽  
One Year

Background: Musculoskeletal disorders are among the prevalent occupational injuries and disabilities in developing countries. Objectives: The current study was conducted to determine the prevalence and risk factors of musculoskeletal disorders among surgery technicians. Materials & Methods: samples (n=179) of this analytical and cross-sectional study were selected using a census method among the surgical technicians who had at least one year of work experience. The disorders of different parts of their bodies were evaluated by Nordic questionnaire, and the risk of catching the musculoskeletal disorders was assessed using quick exposure check method. Statistical analyses were done in SPSS V. 16. Results: According to the Nordic questionnaire, the most prevalent work-related disorders in the past year were found in the back (71.5%), neck (57%), wrist (50.8%), and shoulder (49.7%) of the study subjects. The quick exposure check results showed that the level of exposure to musculoskeletal risks was in action level one for 32.4% of the surgery technicians, and action level three for 33% of them. This study showed associations between the prevalence of work-related symptoms in different body regions and some individual and occupational characteristics (P<0.05). Conclusion: The prevalence of Musculoskeletal Disorders (MSDs) is high among surgical technicians and lumbar disorders are the most common types. Risk factors for MSDs include undesirable physical posture, weight, time spent for shifting loads, excessive force applied by one or both hands at work, working speed, and staff stress levels. among near half of the studied surgical technicians, there were high and very high risks for injury, indicating the vulnerable condition and environment of this job.

scholarly journals Mean difference of visual acuity with auto refraction and subjective refraction.

2020 ◽  
Vol 36 (1) ◽  
Author(s):  
Shakeel Ahmad ◽  
Rashida RIaz ◽  
Muhammad Haseeb ◽  
Hafiza Ammara Rasheed ◽  
Samia Iqbal
Keyword(s):  
Visual Acuity ◽  
Demographic Data ◽  
Anterior Segment ◽  
Cross Sectional Study ◽  
Mean Difference ◽  
P Value ◽  
Cross Sectional ◽  
Department Of Ophthalmology ◽  
The Mean ◽  
Cylindrical Axis

Purpose: To compare the mean difference of visual acuity as measured by auto refraction and subjective refraction. Study Design:  Descriptive cross-sectional study. Place and Duration of Study:  Department of ophthalmology, Services hospital Lahore from November 2013 to April 2014. Material and Methods:  Using non-probability consecutive sampling 300 eyes of 300 patients fulfilling inclusion criteria were recruited through OPD registration slip. Demographic data including age and gender was recorded. Complete ophthalmic examination was performed. This included measurement of refractive error by auto-refraction as well as subjective refraction. Detailed anterior segment examination with slit lamp and dilated fundus examination with indirect ophthalmoscopy was performed. The collected data was analyzed by using software SPSS version 17. Results:  The mean age of patients was 34.71 ± 7.45 years. There were 156 (52%) males and 144 (48%) females. There were 263 (87.69%) patients who had visual acuity of 6/6 and 37 (12.33%) had 6/9. Mean spherical auto-refraction and subjective refraction was 0.0290 ± 2.58 and -0.2842 ± 2.37 D with mean difference of -0.3133 ± 1.27 D. The mean cylindrical auto and subjective refraction in this study was -.9742 ± 0.78 D and -0.7500 ± 0.81 D and mean difference was 0.2242 ± 0.74 D. The mean cylindrical axis of auto and subjective refraction was 114.88 ± 49.75 and 115.60 ± 49.70 with mean difference as 0.72 ± 3.02 D (p-value < 0.05). Conclusion:  Difference of spherical, cylindrical and cylindrical axis in auto and subjective refraction was significantly different.

scholarly journals Association of Pre-hypertension with blood groups in young population.

2019 ◽  
Vol 26 (11) ◽  
pp. 1820-1824
Author(s):  
Benash Altaf ◽  
Shireen Jawed ◽  
Fakiha Behram ◽  
Zeeshan Ali Khan ◽  
Shakeela Naz
Keyword(s):  
Blood Group ◽  
Demographic Data ◽  
Cross Sectional Study ◽  
Blood Groups ◽  
P Value ◽  
Continuous Variables ◽  
Cross Sectional ◽  
Blood Group A ◽  
Significant Difference ◽  
Group A

Objectives: Pakistan has highest mortality rate due to hypertension and its complications. Hypertension is a squealed of Pre- hypertension which is believed to start at adolescent and continue to adulthood. Association of blood group with hypertension is evident but still hypothesized. This study aims to find the frequency of prehypertension and its association with blood group. Study Design: Cross sectional study. Setting:  Aziz Fatimah Medical and Dental College, Faisalabad. Period: 15 March’18 to 15 Sep’18. Material and Methods:  It was comprised of in comprised of 100 MBBS students. Demographic data including age, weight, height, waist and hip circumference, and BMI was determined. Blood group was determined with help of conventional slide method. Blood pressure was measured by auscultatory method. Data was analyzed by using SPSS 21. Continuous variables are given in mean and standard deviation. Categorical data was given in frequency and percentages. P value≤ 0.05 is taken as significant. Results: Out of 100 participants most common blood group was group ‘O’ (43%) followed by B (35 %) and AB (13%) and A (9%).36% of total population was pre-hypertensive and 64% were normotensive. Prehypertension is most commonly found in blood group ‘A’ (77%) followed by blood group ‘O’ (46.5%). Significant difference was found in means of SBP (p value= 0.001*) and DBP (p value= 0.000*) among the various blood groups. Conclusion: Most common blood group in studied population was ‘O’ although hypertension was most commonly observed in blood group A followed by ‘O’.

scholarly journals Prevalence Of Musculoskeletal Disorders In Patients Undergoing Haemodialysis in a Tertiary Care Hospital: A Cross-sectional study

2020 ◽  
pp. 1-4
Author(s):  
Sanjaitha Jayaprakash ◽  
Deepak B. Anap
Keyword(s):  
Arteriovenous Fistula ◽  
Musculoskeletal Disorders ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Public Health Problem ◽  
Cross Sectional Study ◽  
Care Hospital ◽  
Low Back ◽  
Cross Sectional ◽  
Body Regions

Background: Chronic kidney disease (CKD) is a significant public health problem. Dialysis is the mainstream method of treatment in these patients. This causes the patients to have a monotonous and restricted daily life, joint pain, limiting their activities after treatment onset. Hence this study was carried out to find the prevalence of common musculoskeletal disorders in patients undergoing haemodialysis in a tertiary care hospital. Method: 50 participants undergoing dialysis in a tertiary care hospital under the age group of 18-70 years diagnosed with stage V CKD were included using convenient sampling. They were assessed using Nordic Questionnaire to locate the different areas of pain. Result: The first group consisted of 41 participants who underwent dialysis from 2- 41 months. Body regions commonly affected in the last 7 days were low back 25(60.97%); neck 21(51.21%); shoulder 15(36.58%); elbow 14(34.14%) in the extremity with arteriovenous fistula; upper back 14(34.14%); hips/thighs, knees 9(21.95); wrist/hands 7(17.07%) in the extremity with arteriovenous fistula; ankle/feet 6(14.63%). The second group consisted of 9 participants who underwent dialysis from 42-84 months. Body regions commonly affected in the last 7 days were low back 8(88.88%); upper back 7(77.77%); hip/thigh 6(66.66%); neck, knee 5(55.55%); elbow 4(44.44%) in the extremity with arteriovenous fistula; shoulder, ankle/feet, wrist/hands 3(33.33%). Conclusion: The study concluded that the highest prevalence of musculoskeletal disorders in the participants undergoing haemodialysis was low back pain (66%) followed by neck (52%), upper back (42%), shoulder (36%), elbow (36%), hips/thighs (30%), knees (28%), wrist/hands (20%) and ankle/feet pain (18%).

scholarly journals Assessment of Finger Proprioception and Lateral Pinch Strength in Amateur and Professional Guitarists

2020 ◽  
Vol 06 (04) ◽  
pp. 6-11
Author(s):  
Hannah D’souza ◽  
Keyword(s):  
Demographic Data ◽  
Movement Patterns ◽  
Cross Sectional Study ◽  
Pinch Strength ◽  
P Value ◽  
Sectional Study ◽  
Cross Sectional ◽  
Left Hand ◽  
Good Strength ◽  
The Right

Background: Guitarists use complex and different movement patterns in both hands simultaneously. Applying pressure on the strings and strumming both require good strength whereas playing the melody on the fret-board demands good proprioception. There is a need to find out if guitarists perform functionally well with respect to pinch strength and proprioception which are prerequisites for playing the guitar. Therefore, the aim of the study is to assess and compare finger proprioception and pinch strength in amateur and professional guitarists. Methodology: A cross sectional study was conducted on 50 amateur and 50 professional guitarists from Mumbai. A self-made questionnaire including their demographic data was asked to be filled. Proprioception was measured using the pinch aperture proprioception device and lateral pinch strength was measured using the Jamar® Hydraulic Pinch Gauge. The average of 3 trials was taken for finger proprioception and lateral pinch strength. The data obtained was then taken for further analysis. Result: Professional guitarists had better finger proprioception (p value = 0.0001 for both right & left hands) and lateral pinch strength (p value =0.0159, 0.0001 for the right & left hand respectively) than amateur guitarists. Also, the left hand had better finger proprioception (p value <0.0001, 0.0059 for amateur & professional guitarists respectively) and right hand had better lateral pinch strength (p value=0.0001 for both professional and amateur guitarists) in both professional and amateur guitarists. Conclusion: Professional guitarists had significantly better finger Proprioception and lateral pinch strength as compared to the amateur guitarists.

scholarly journals Investigating Different Dimensions of Nomophobia among Medical Students: A Cross-Sectional Study

2019 ◽  
Vol 7 (4) ◽  
pp. 573-578 ◽  
Author(s):  
Mohammad Darvishi ◽  
Majid Noori ◽  
Mohammad Reza Nazer ◽  
Soheil Sheikholeslami ◽  
Ebrahim Karimi
Keyword(s):  
Medical Students ◽  
Mobile Phone ◽  
Mobile Phones ◽  
Cell Phone ◽  
Demographic Data ◽  
Cross Sectional Study ◽  
P Value ◽  
Sectional Study ◽  
Cross Sectional ◽  
Significance Level

BACKGROUND: Today, mobile phones are recognised as an inseparable part of our daily lives, facilitating communication between users. Based on the studies, addiction to cell phones can lead to several complications including depression, anxiety, anger, and aggression. AIM: This study aimed to investigate nomophobia (no mobile phone phobia) among medical students of Islamic Azad University, Tehran Branch. METHODS: This descriptive cross-sectional study was conducted on 100 students studying in different majors of medical sciences in Islamic Azad University, Tehran Branch, from 2016 to 2017. Demographic data of all participants were recorded in a data sheet. In the next stage, a questionnaire was designed by the researcher to evaluate the effect of age, gender, education, and the duration of using cell phone variables on discomfort, anxiety, and insecurity due to lack of access to cell phone or other related issues. Raw data were analysed using SPSS statistical software version 21. The significance level was considered P < 0.05. RESULTS: The results of the study showed that participants with lower mean age felt more discomfort, anger, anxiety, and insecurity due to lack of access to mobile phones and other related issues compared to other people. However, no variable was statistically significant (P-value > 0.05). Except anxiety, results showed that longer duration of mobile phone use might lead to a significant decrease in discomfort, anger, and insensibility variables among users (P-value > 0.05). The incidence of nomophobia (with its different aspects) was significantly lower in females (P-value > 0.05). Also, in participants with higher educational status, the nomophobia was recorded to be more frequent (P-Value > 0.05). CONCLUSION: Understanding the pattern of nomophobia occurrence among cell phone users can facilitate our path to prevent its harms including discomfort, anger, anxiety, and feeling of insecurity among users of technology.

Musculoskeletal Disorders Among Iranian Instrumentalists

2012 ◽  
Vol 27 (4) ◽  
pp. 193-196 ◽  
Author(s):  
Amir H Mehrparvar ◽  
Mehrdad Mostaghaci ◽  
Raman F Gerami
Keyword(s):  
Musculoskeletal Disorders ◽  
Cross Sectional Study ◽  
Occupational Group ◽  
Cross Sectional ◽  
Group Type ◽  
Chi Squared ◽  
Musculoskeletal Problems ◽  
Position Data ◽  
Ergonomic Exposures ◽  
Ergonomic Risk Factors

Musicians as an occupational group are exposed to various ergonomic exposures which may lead to musculoskeletal problems. In this study we assessed the frequency of musculoskeletal disorders (MSDs) among Iranian instrumentalists (using traditional Iranian and western instruments). Methods: In a cross-sectional study we assessed the frequency of MSDs in 356 Iranian instrumentalists by standardized Nordic musculoskeletal questionnaire according to age group, type of instrument, duration of playing, and playing/sitting position. Data were analyzed using chi-squared, t-test and ANOVA. Results: Overall, 158 of 356 subjects (44.4%) experienced MSDs, mostly with mild or moderate symptoms. Frequency of MSDs was significantly higher in females but it was not significantly related to body mass index, duration of employment, and duration of playing or teaching. Conclusion: Our study showed a high frequency of MSDs among Iranian instrumentalists, so paying attention to the ergonomic exposures of instrumentalists as an occupational group is important. To the best of our knowledge, this is the first study on players of different Iranian instruments to have considered ergonomic risk factors.

scholarly journals Sikap Kerja dan Risiko Musculoskeletal Disorders pada Pekerja Laundry

2014 ◽  
pp. 330
Author(s):  
Nur Ulfah ◽  
Siti Harwanti ◽  
Panuwun Joko Nurcahyo
Keyword(s):  
Musculoskeletal Disorders ◽  
Muscle Power ◽  
Sampling Technique ◽  
Cross Sectional Study ◽  
P Value ◽  
Exclusion Criteria ◽  
Cross Sectional ◽  
Work Activities ◽  
Work Related ◽  
Quota Sampling

Kelainan otot rangka merupakan gangguan fungsi otot, tendon, saraf, pembuluh darah, tulang dan ligamen yang biasa diderita oleh pekerja dengan aktivitas kerja menggunakan kekuatan otot, seperti pekerja laundry. Penelitian ini bertujuan mengetahui sikap kerja pekerja laundry dan hubungan dengan risiko musculoskeletal disorders di Kecamatan Purwokerto Utara. Penelitian ini menggunakan desain studi potong lintang dengan teknik pengambilan sampel menggunakan quota sampling dengan kriteria inklusi responden bekerja hanya pada satu bagian kerja tertentu dari laundry, tidak memiliki keterbatasan komunikasi dan kriteria eksklusi responden keluar dari pekerjaan dan tidak bersedia dijadikan responden. Sampel sebanyak 150 orang dengan kuota masing-masing bagian diambil sebagai sampel sebanyak 30 orang, meliputi bagian penimbangan, pencucian, pengeringan, penyetrikaan dan pengemasan. Penelitian menemukan sikap kerja yang berhubungan dengan risiko kelainan otot rangka adalah pada bagian pencucian (nilai p = 0,014, nilai p < 0,05). Sedangkan sikap kerja bagian penimbangan (nilai p = 0,77), pengeringan (nilai p = 0,257), penyetrikaan (nilai p = 0,109) dan pengemasan (nilai p =0,370) tidak berhubungan dengan risiko MSDs (nilai p > 0,05). Hanya sikap kerja pada bagian pencucian yang berisiko menimbulkan MSDs, sehingga perlu dilakukan intervensi berupa pelatihan sikap kerja mencuci yang benar.Musculoskeletal disorders (MSDs) are disorders of muscle function, tendons, nerves, blood vessels, bones and ligaments that usually occur in workers with work activities using muscle power, such as laundry workers. The study aimed to determine the attitude of the working relationship with the risk of MSDs in the Nothren Purwokerto district. Type cross-sectional study with a quantitative approach. The sampling technique using quota sampling with inclusion criteria of the respondents worked only on one particular part of the laundry work, they do not have any communication limilimitations and exclusion criteria respondents out of work and not willing to be the respondent. Based on these criteria obtained a sample of 150 people with a quota of each section is taken as a sample of 30 people, which is part of the weighing, washing, drying, ironing and packing. The results showed that the attitude of work-related MSDs are at the risk of leaching (p value= 0.014, p< 0.05). While the attitude of the weighing part employment (p= 0.77), drying (p= 0.257), ironing (p= 0.109), and packaging (p= 0.370) was not associated with risk of MSDs, because the value of p> 0.05. So it is concluded that only work attitude on the part pose a risk of MSDs washing. Therefore, it is necessary to intervene in the form of job training wash right attitude.

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