COMPARATIVE ANALYSIS OF CLOSED REDUCTION AND EXPERT TIBIA NAILING WITH OPEN REDUCTION AND PLATE & SCREW FIXATION IN THE TREATMENT OF PROXIMAL TIBIA EXTRAARTICULAR FRACTURES

2018 ◽  
Author(s):  
Anil Pandey ◽  
Setul Shah ◽  
Deepak S Maravi ◽  
S Uikey
Keyword(s):  
Intramedullary Nailing ◽  
Closed Reduction ◽  
Proximal Tibia ◽  
Plate Fixation ◽  
Surgical Site Infections ◽  
Delayed Union ◽  
Large Sample Size ◽  
Multicentric Study ◽  
Group A ◽  
Group B

Introduction:- Extra-articular proximal tibial fractures account for 5–10 % of all tibial shaft fractures and it result from high-velocity trauma. Closed reduction with minimally invasive plating and locked intramedullary  nailing have been widely used for treatment of proximal tibia extraarticular fractures. Our pupose is to compare the pros and cons of these two methods. Materials and methods:- 22 patients were included in this study for a period of 2 years. Patients treated with IMN were kept in group A patients treated with percutaneus plating were kept in group B. Standard approach of nailing and plating were used and proper follow up were taken for next upcoming 1 year. Results:- Combined average age was 38years. Male were more commonly affected than female (13:8). Majority of fracture were of type A33. Operative time was < 2 hours in both groups. Less blood loss occurred during intramedullary nailing as compared to locking plate fixation. Surgical site infections (SSIs) were seen in two patients in the PTP group. Delayed union occurred in two patients in the IMN group. The average range of motion was 119.7(range 90-150, SD= 19.18) in group A and 115.2(range 80-150, SD = 17.28) in group B. Conclusion:- in treatment of proximal tibia extra articular fracture use of IMN and PTLCP gives comparable results. To validate this issue further a large sample size multicentric study is recommended   Key words: intramedullary nailing (IMN), Extraarticular tibialn fracture, Surgical site infection.

scholarly journals Precisely Closed Reduction of Nasal Bone Fracture Assisted With Plain Film Measurements Under the Picture Archiving and Communication System

2021 ◽  
pp. 014556132110121
Author(s):  
Tzu-Hsien Yang ◽  
Chien-Liang Fang ◽  
Chong-Bin Tsai ◽  
Ming-Shan Chen ◽  
Chih-Hsuan Changchien ◽  
...  
Keyword(s):  
Bone Fracture ◽  
Communication System ◽  
Closed Reduction ◽  
Operative Time ◽  
Nasal Bone ◽  
Plain Film ◽  
Ao Classification ◽  
Group A ◽  
Picture Archiving And Communication ◽  
Group B

Objectives: To prevent aesthetic and functional deformities, precisely closed reduction is crucial in the management of nasal fractures. Plain film radiography (PF), ultrasonography (USG), and computed tomography can help confirm the diagnosis and classification of fractures and assist in performing closed reduction. However, no study in the literature reports on precisely closed reduction assisted with PF measurements under the picture archiving and communication system (PACS). Methods: We retrospectively evaluated 153 patients with nasal bone fracture between January 2013 and December 2017. Surgeons conducted precisely closed reduction assisted with PF measurement of the distance between the fracture site and nasal tip under PACS on 34 patients (group A). Another group on 119 patients were reduced under surgeon’s experience (group B). Results: No significant differences in age, gender, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and reduction outcome were observed between group A and group B ( P > .05). The operative time of the group A was significantly lower (12.50 ± 4.64 minutes) compared to group B (23.78 ± 11.20 minutes; P < .001). After adjusted age, gender, and AO classification, patients in group A scored 10.46 minutes less on the operative time than those in group B ( P < .001). In addition, the severity of nasal bone fracture (AO classification, β = 3.37, P = .002) was positive associated with the operative time. Conclusions: In this study, closed reduction in nasal bone fracture assisted with PF measurements under PACS was performed precisely, thereby effectively decreasing operative time and the occurrence of complications. This procedure requires neither the use of new instruments or C-arm nor USG or navigation experience. Moreover, reduction can be easily performed using this method, and it requires short operative time, helps achieve great reduction, less radiation exposures, and is cost-effective.

scholarly journals Non-locking buttress plate in distal tibial metaphyseal fractures

2018 ◽  
Vol 1 (2) ◽  
pp. 87-91
Author(s):  
Norman Lamichhane ◽  
Bhogendra Bahadur KC ◽  
Chandra Bahadur Mishra ◽  
Sabita Dhakal
Keyword(s):  
Soft Tissue ◽  
Weight Bearing ◽  
Delayed Union ◽  
Full Weight Bearing ◽  
Distal Fibula ◽  
Fibula Fracture ◽  
Group A ◽  
The Mean ◽  
Group B ◽  
Metaphyseal Fractures

Background: Treatment of distal tibial metaphyseal fractures is often challenging and no single technique has been unanimously advocated. Open reduction and internal fixation with plates and screws allows better restoration of anatomical alignment but with more soft tissue complication. Simultaneous fixation of the fibula is not universally carried out. This study aims at evaluation of the outcome of plating technique and the effect of fixation of fibula fracture in treatment of distal tibial metaphyseal fractures. Material and methods: Thirty-one cases (14 cases in Group A with concomitant distal fibula fracture and 17 cases in Group B without distal fibula fracture) were analyzed retrospectively for the mean duration of full weight bearing, mean union time and complications, and compared. Results: The mean time for full weight bearing and radiological union in our study was 14.2 weeks (15.9 in Group A and 13.1 in Group B) and 23.8 weeks (26.6 in Group A and 21.5 in Group B) respectively. 16.1% of cases had post-operative complications including one case of deep infection and malalignment of 6 degree varus (following delayed union) was seen in one case of Group A. Range of motion (ROM) at ankle was not problem in any of the cases except the one delayed union which had 5 degrees of dorsiflexion and 15 degrees of plantiflexion. Conclusion: Open reduction and internal fixation with plate and screws in distal tibial metaphyseal fracture is more economic means of treatment modality with comparable incidence of post-union malalignment and union time,though more soft tissue complications compared to other modalities. Fixation of fibula fracture aids in reducing the incidence of malalignment.

scholarly journals Comparison of outcome of two plate fixation with one plate fixation along with arch bar in management of parasymphysis; A Randomized Control Trial.

2020 ◽  
Vol 27 (09) ◽  
pp. 2007-2013
Author(s):  
Mohammad Umar ◽  
Jawad Ahmad Kundi ◽  
Muhammad Sulaiman ◽  
Muhammad Zaib Khan ◽  
Ali Altaf
Keyword(s):  
Plate Fixation ◽  
Maxillofacial Surgery ◽  
Treatment Protocol ◽  
Advantages And Disadvantages ◽  
Arch Bar ◽  
Group A ◽  
Group B ◽  
Inferior Border ◽  
Two Miniplates

Objectives: The aim of this study is to compare two plate fixation and one plate along with arch bar in the treatment of parasymphsis, and to analyze the advantages and disadvantages over one another. Study Design: Randomized Clinical Trial. Setting: Department of Oral and Maxillofacial Surgery Sardar Begam Dental College and Northwest General Hospital Peshawar. Period: Over a period of one year from June 2017 to August 2018. Material & Methods: 60 patients with parasymphysis fracture after diagnosis established on clinical and radiological examination were equally divided into two groups, 30 patients in each. Group (A) were treated with two miniplates, while Group (B) one miniplate along with arch  bar under general anesthesia with proper antibiotics coverage in the pre- and post-operative period. Results: The infection rate 4 (13.3%) patients in Group B while 0 in Group A. No Loosening /fracture of screw or plate occur in any subject in group A at any follow up visit, while it occurred in 4 subjects in group B at 15 days follow up period. 9 patients in Group A and 6 in Group B presented with immediate post of paresthesia, which was reduced to 7 patients in group A and 6 in group B at 15 days follow up, and to 4 patients in Group A and 5 in Group B at 1 month follow up. Similarly, no subject had inferior border misalignment in group A at any follow up period while 3 subjects have immediate post -op inferior border discrepancy in group B and 6 subjects in the same group shows inferior border discrepancy at 15 days , but the overall result of this variable was also statistically non-significant. Conclusion: Isolated mandibular parasymphysis fracture can be treated with either two miniplates or one miniplate along with arch bar for 6 weeks. Both treatment protocol shows advantages and disadvantages with the aim of achieving the best treatment outcome for the patients.

scholarly journals Best technique for fixation of displaced transverse olecranon fractures: tension band wiring or plate fixation?

2020 ◽  
Vol 6 (5) ◽  
pp. 1012
Author(s):  
Lokesh Kumar Yogi ◽  
Gagandeep Mahi ◽  
C. R. Thorat ◽  
Moti Janardhan Naik
Keyword(s):  
Functional Outcome ◽  
Large Scale ◽  
Plate Fixation ◽  
Tension Band ◽  
Tension Band Wiring ◽  
Clinical Event ◽  
Dash Score ◽  
Group A ◽  
Group B ◽  
Olecranon Fractures

<p><strong>Background:</strong> Fractures of olecranon are common fractures in upper limb. Tension band wiring (TBW) and plate fixation (PF) are mostly used techniques but choice is based on type of fracture and surgeon’s preference.</p><p><strong>Methods:</strong>  A study assessed functional results in 28 patients that were enrolled after the clinical event of trauma has occurred. Patients were divided into two groups- Group (A) for TBW and Group (B) for PF; here gender, age and side of fracture were ignored. Post-operative functional outcome were evaluated by using the Mayo Elbow Performance (MEP) and the Disabilities of the Arm, Shoulder and Hand (DASH) score parameters.</p><p><strong>Results:<em> </em></strong>Mean (SD) union time as determined by postoperative radiographs was 8.5 (1.48) weeks for group (A) and 9 (2.08) weeks for group (B). Mean (SD) MEP score at 9 months in group (A) 84.28 (7.28) and 80.71 (10.92) in group (B). Mean (SD) DASH at 9 months in group (A) 12.2 (8.8) and 11.7 (10.4) in group (B). Complications were reported in group (A) 6 patient (42.85%) out of 14 patients and in group (B) 1 patient (7.14%) out of 14 patients.</p><p><strong>Conclusions:<em> </em></strong>The current study shows that there are no significant differences in functional outcome between both the study groups. Due to lesser complications, we recommend the plate fixation approach as the better choice for transverse displaced olecranon fractures. More large scale studies are required to further confirm our results.</p>

scholarly journals Intra-incisional versus intravenous route of antibiotic administration in preventing surgical site infections: a randomized controlled trial

2018 ◽  
Vol 5 (4) ◽  
pp. 1438
Author(s):  
Aditya N. Patil ◽  
Veerendra M. Uppin
Keyword(s):  
Single Dose ◽  
Surgical Site Infection ◽  
Tertiary Care ◽  
Surgical Site Infections ◽  
Intravenous Route ◽  
Antibiotic Administration ◽  
Site Infection ◽  
Open Appendicectomy ◽  
Group A ◽  
Group B

Background: Surgical site infection (SSI) is one of the most common postoperative complications following abdominal surgeries. Whilst the use of prophylactic antibiotics has been shown to reduce postoperative wound infection, controversy still remains as to the optimum route of administration and the duration of treatment. This study aims to compare the efficacy of a preoperative single dose of a cephalosporin antibiotic (cefotaxime) administered intraincisionally versus that administered intravenously, in preventing postoperative surgical site infections following appendicectomy.Methods: Sixty consecutive cases diagnosed as uncomplicated appendicitis who consented for open appendicectomy at a tertiary care institute were included in the study. Cases were randomized to 2 comparable groups of 30 patients each. Preoperatively, patients in Group A received a single dose of Inj. Cefotaxime 1g intraincisionally while those in Group B received the same intravenously. Incision sites were examined every alternative day starting on postoperative day 3 until removal of sutures. Signs of surgical site infection, if any, were recorded and outcomes were statistically tested for significance.Results: One patient in Group A (3.3%) and 4 patients in Group B (13.3%) showed signs of postoperative surgical site infection (p >0.05) during the follow up period which prolonged their hospital stay.Conclusions: This study showed that a single dose preoperative intraincisional administration of cefotaxime was as effective as intravenous administration for prevention of postoperative surgical site infection after open appendicectomy. Although the difference was not statistically significant, there was a reduced incidence of SSI in individuals who received intraincisional antibiotic. These results are encouraging for a way forward in reducing unnecessary burdening of systemic antibiotics in patients undergoing abdominal surgeries. 

scholarly journals FIXATION OF POSTERIOR TIBIAL PLATEAU FRACTURE AND ITS OUTCOME: A COMPARATIVE STUDY

2020 ◽  
Vol 4 (1) ◽  
Author(s):  
Hrishikesh Saodekar ◽  
Kamal Agrawal
Keyword(s):  
Functional Outcome ◽  
Tibial Plateau ◽  
Tibial Plateau Fracture ◽  
Plate Fixation ◽  
Tibial Plateau Fractures ◽  
Fracture Union ◽  
Posterior Tibial ◽  
Plateau Fracture ◽  
Group A ◽  
Group B

Introduction: Tibial plateau fractures are complex injuries of proximal tibia which are produced by high- or low-energy trauma and principally affect young adult population. These fractures usually have associated soft-tissue lesions affecting the treatment. Posterior tibial plateau fractures (PTPF), may be medial or lateral, are common and they occur in about 28.8% patients as a part of bicondylar tibial plateau fractures. These fractures are difficult to reduce, therefore articular incongruity was not found to be detrimental factor in final functional outcomes. Studies have supported the fact that residual articular incongruence is well tolerated by proximal tibial plateau fracture in the form of minimal functional limitation or onset of arthrosis.  Anterolateral and anteromedial surgical approaches do not show adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is advised to reduce and fix the fracture through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement. Material and Methods: This comparative prospective cohort study on done on 50 adult patients. Two groups were formed: Group A – double-plate fixation with both posterior and anterolateral  having 25 participants and Group B – single anterolateral plate fixation having 25 participants in PTPFs were followed up to 1 year. For Group A, the reduction was done under direct vision and assisted with fluoroscopy in two planes. The reduction was assessed with submeniscal approach. In Group B posterior fragment was reduced by screws through the anterolateral plate followed by CT scan. Patients were evaluated by radiographs every 6 weeks till fracture union is evident. Fracture union was assessed by cortical continuity and progressive loss of fracture line on X-rays. Functional status at 1-year postoperative CT scanogram was done at final follow up to record articular subsidence, nonunion, coronal, or sagittal deformities. Knee functions were assessed by the International Knee Documentation Committee 2000 subjective knee evaluation form and objective functional Knee Society Score (KSS). Results: There were 22 male and 3 female in Group A while in Group B there were 20 male and 5 female. Right tibial fracture was observed in 15 cases and left in 10 cases in group A while in Group B right fracture was seen in 17 cases and in 8 cases left sided fracture. 23 cases each in group A and B were associated with RTA. Operative time (minutes) in group A and group B was 124 ± 26.7 and 79.52± 16.22 respectively. Total mean hospitalization days were 9.4±2.6 in group A and 8.2±1.5 in group B. Union time in group A was 14.6±3.4 weeks while in group B was 15.4±3.2. Statistically significant correlation was observed in group A and B with respect to KSS clinical outcome and KSS functional outcome. Flexion deformity was observed in 3 (12%) cases in group A and in 6 (24%) cases in group B. Conclusion:  PTPF can achieve an early and satisfactory functional outcome. Rehabilitation and fracture healing are better in PTPF. Keywords: Tibial plateau fractures, PTPF, Open reduction and internal fixation (ORIF)

scholarly journals Comparison of efficacy of chlorhexidine alcohol with povidone iodine for prevention of surgical site infection: a prospective study

2018 ◽  
Vol 5 (5) ◽  
pp. 1668
Author(s):  
Binni John ◽  
Rajith Kishore K. K. ◽  
Vipinchandran C.
Keyword(s):  
Prospective Study ◽  
Povidone Iodine ◽  
Surgical Site Infections ◽  
E Coli ◽  
Prophylactic Measures ◽  
Group A ◽  
The Difference ◽  
Group B ◽  
Clean Contaminated ◽  
Culture Positive

Background: Surgical site infections (SSI’s)are the major risk factors of postoperative morbidity and mortality. The incidence of these SSI’scan be minimized by taking prophylactic measures such as using effective preoperative antiseptics such as chlorhexidine (CHG) or povidone-iodine (PVI). The aim of the present study was to compare the efficacy of 2.5% chlorhexidine-alcohol with that of 10% povidone iodine for preventing SSI’sin clean contaminated elective surgeries.Methods: This prospective study included 100 patients who were undergoing for clean contaminated elective surgeries at Government Medical College, Kottayam from April 2014 to September 2015. Group A included 50 patients in which 2.5% chlorhexidine alcohol (chlorhexidine 2.5% in 70% ethanol) was used for preoperative skin cleansing and Group B included 50 patients in which 10%povidone-iodine aqueous was used. Incidence of SSI’s in terms of efficacy was compared between the groups.Results: Female preponderance was seen in both the groups, but the difference was not significant statistically. The SSI’swere seen in 5 patients in group A and in 12 patients in group B and this difference was found statistically significant (p=0.0084).Out of 5, in group A, 3 sites were culture positive showing the presence of S. aureus culture in 1 case and E. coli in 2 cases and in group B, out of 12, 6 sites were culture positive consisting of S. aureus and E. coli in 3 cases each.Conclusions: Chlorhexidine (2.5%) significantly reduced the risk of postoperative SSIs and colonization of bacteria in elective surgeries when compared to 10% povidone iodine.

scholarly journals Comparison of functional outcome after open and closed reduction of mandibular subcondylar fracture

2020 ◽  
pp. 1-12
Author(s):  
Samira Shabbir Balouch ◽  
Rana Sohail ◽  
Sadia Awais ◽  
Riaz Ahmad Warraich ◽  
Mir Ibrahim Sajid
Keyword(s):  
Internal Fixation ◽  
Closed Reduction ◽  
Open Reduction ◽  
Maxillofacial Surgery ◽  
Mouth Opening ◽  
Treatment Modalities ◽  
Oral And Maxillofacial Surgery ◽  
Subcondylar Fracture ◽  
Group A ◽  
Group B

Abstract Objective: To compare open reduction with internal fixation of mandibular subcondylar fracture with closed reduction in terms of adequate mouth opening. Method: The randomised clinical trial was conducted from March 2014 to February 2015 at the Oral and Maxillofacial Surgery Department, King Edward Medical University and Allied Hospitals, Lahore, Pakistan, and comprised patients who presented with unilateral subcondylar fractures. The patients were randomly divided into 2 groups. Group-A patients were treated with closed reduction and immobilisation and were discharged the same day, while Group-B patients were treated by open reduction with internal fixation and retained in ward for 1 day. Both were recalled for periodic follow-ups, and were compared in terms of achieving adequate mouth opening. Data was analysed using SPSS 20. Results: Of the 70 patients, 35(50%) were in each of the two groups. The mean age in Group-A was 28.88±11.86 years compared to 28.22±10.80 years in Group-B (p>0.05). Mean mouth opening in  the two groups were consistently positive, and significant at the last two follow-ups(p<0.001). Conclusion: The difference in results of both treatment modalities was significant, indicating that open reduction and internal fixation should be the preferred treatment. Key Words: Mandibular sub-condylar fracture, Open reduction, Closed reduction, Internal fixation, Mouth opening.

scholarly journals A comparative prospective observational study on the use of ulipristal acetate versus mifepristone in reduction of the size of uterine leiomyoma

2022 ◽  
Vol 13 (1) ◽  
pp. 129-135
Author(s):  
Lipika Ghosh ◽  
Abhijit Rakshit ◽  
Madhumita De
Keyword(s):  
Uterine Leiomyoma ◽  
Reproductive Age ◽  
Loss Assessment ◽  
Multicentric Study ◽  
Valid Conclusion ◽  
Ulipristal Acetate ◽  
Common Benign Tumor ◽  
Group A ◽  
Group B ◽  
Reproductive Age Group

Background: Fibroid or uterine leiomyoma is the most common benign tumor of the uterus in the reproductive age group and found in one out of every four women. They are symptomatic in 50% of women, with the peak incidence occurring among women in their 30s or 40s. Fibroid can cause a variety of symptoms which include menstrual disturbances commonly menorrhagia and dysmenorrhea. It is a common indication of hysterectomy in Indians. An effective medical treatment option may reduce hysterectomy-associated morbidity and mortality. This study is undertaken to evaluate the efficacy and safety of medical management of myoma and contribution in the reduction of myoma size comparing the two drugs ulipristal and mifepristone. Aims and Objectives: The study was conducted to compare reduction of menorrhagia (By pictorial blood loss assessment chart score), reduction of fibroid size (using transvaginal ultrasonography), and improvement of hemoglobin (Hb) level. We are also evaluating safety or side effects using these drugs. Materials and Methods: The study includes 210 patients who are divided into two groups. Group A includes 105 patients who are treated with tablet Ulipristal Acetate 5 mg daily for 3 months and Group B includes 105 patients who are treated with tablet mifepristone 25 mg daily for 3 months. Results: Ulipristal and mifepristone both are effective in reduction of menorrhagia and improvement of Hb levels, but Ulipristal is more effective in reduction of size of uterine myoma than mifepristone after 3 months of treatment. Conclusion: Multicentric study over a larger population is required to reach a valid conclusion.

scholarly journals Single vs Multiple Antibiotic Drug Regimen in Preventing Infectious Morbidity in Caesarean Section: A Randomised Clinical Trial

2021 ◽  
Author(s):  
Subhashchandra R Mudanur ◽  
Shreedevi S Kori ◽  
Aruna Biradar ◽  
Rajasri G Yaliwal ◽  
Dayanand S Biradar ◽  
...  
Keyword(s):  
Single Dose ◽  
Caesarean Section ◽  
Multiple Dose ◽  
Caesarean Delivery ◽  
Surgical Site Infections ◽  
Cost Effective ◽  
P Value ◽  
Infectious Morbidity ◽  
Group A ◽  
Group B

Introduction: Surgical site infections are a serious cause of maternal morbidity and mortality. Various preventive measures are being used to reduce the incidence of surgical site infections. One of them is the use of prophylactic antibiotics. In this study, authors have evaluated three antibiotic regimen with respect to preventing infectious morbidity in caesarean section. Aim: To study the efficacy and cost-effectiveness of a single dose (ceftriaxone) versus multiple doses of antibiotic therapy (ceftriaxone and ornidazole) administered preoperatively in women undergoing caesarean delivery. Materials and Methods: A prospective interventional study was conducted on 300 pregnant women undergoing emergency or elective caesarean delivery. Study was conducted at BLDE (DU) Shri BM Patil Medical College and Research Centre, Vijayapur, Karnataka, India. Patients were randomly assigned to three groups by block random sampling with 100 women in each group. Group A received Inj. ceftriaxone 1 gm single dose 60 minutes prior to commencement of surgery. Group B received Inj. ceftriaxone 1 gm along with Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and Group C received Inj. ceftriaxone 1 gm and Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and a repeat dose 12th hourly for 24 hours followed by Tab. cefixime 200 mg and Tab. ornidazole 500 mg twice daily for four days postoperatively. The effectiveness of therapy was measured in terms of adverse effects of antibiotics such as nausea and vomiting and postoperative complications like pyrexia, foul smelling lochia, surgical site infections, uterine tenderness, peritonitis and endometritis. Results: There was no statistical difference in outcome measures in side-effects of antibiotics (p-value=0.13), fever (p-value=0.68), lochia discharge (p-value=0.88), wound infection (p-value=0.39) and peritonitis (p-value=0.30) among the three groups. The single dose medication in group A had a cost of Rs.60 INR (0.82 cents USD), which was significantly less compared to the multiple dose regimens in group B that cost Rs.203 INR ($2.76 USD). The mean hospital stay in non infectious and infectious patients were 5 and 10 days in present study (p<0.0001). Conclusion: Caesarean delivery poses 5-20 times greater risk of postoperative infection when compared to vaginal birth. There has been a shifting trend of increasing caesarean deliveries and postoperative infections can contribute to overwhelming health and economic burden. Present study shows outcome measures which were statistically insignificant among the three study groups with different prophylactic regimen for caesarean delivery, so it’s safe to state that both single dose and multiple dose regimen provided equal protective coverage in reducing maternal infectious morbidity. Also, single dose regimen proved to be cost-effective. So, to conclude single dose prophylactic antibiotic given preoperatively in caesarean section is both cost-effective and as is efficient.

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