Analyzing the incidence, survival, and demographic trends of B-cell prolymphocytic leukemia

Background: B-cell prolymphocytic leukemia (B-PLL) is a rare disease, consisting <1% of mature B-cell malignancies. B-PLL is often refractory to chemotherapy, with a median survival of 3 years. Due to its rarity, no large cohort studies exist elucidating outcomes. Methods: All B-PLL patients >15 years were identified in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database between 2000-2020. Statistical analysis explored demographic variables like age; categorized as adolescent or young adult (AYA) and adults. In adults, differences in survival due to factors such as sex, race/ethnicity, household income, rurality, and age categorized in 10-15 year buckets was analyzed. Results: B-PLL patients were predominantly white (78%), over 40 years (96%) and mostly residing in metropolitan areas (90%). Interestingly, the AYA cohort were mostly female (70%). 35% of the AYA patients were Hispanic, while being only 9% in adults. Among adults, the rate of Asian/Pacific-Islander patients that were alive at the time of the data query was 53% compared to 34% in Hispanic, 31% in black, and 24% in white patients (p=0.025). Younger age was also associated with greater chances of survival (p<0.001). Conclusions: In line with known poor prognosis of the disease, 23% patients were alive at the time of data query. Female and Hispanic patients were overrepresented in the AYA age group. In the adult group Asian/Pacific-Islander patients had better survival outcomes, as did younger patients. Further research is necessary to explore why B-PLL incidence in AYA patients is higher among Hispanic and females.

Pseudotumor of muscle - focal myositis

Focal myositis is a rare disease, and to date, 250 cases have been reported in literature. It is a benign dysimmune disease of unknown etiology. It is defined as myopathy affecting a single muscle without systemic manifestation with a historically proven inflammatory myositis process. It usually presents as a mass ranging from 1 to 20 centimeters, growing insidiously over weeks to months, and may be painless or tender. Or the growth can be rapid and with a lot of pain and disability. It's common in lower limbs and rare in facial muscles. It usually regresses spontaneously and does not invade the surrounding structures. In 18% of cases, there may be a relapse. Laboratory studies may show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Creatine kinase (CK) is usually not elevated significantly. Autoantigens are often normal or may be marginally elevated. Magnetic resonance imaging (MRI) is a diagnostic tool of choice and is done with relative ease. Electromyography (EMG) occasionally shows recordable spontaneous and repetitive discharges. Nerve conduction velocity (NCV) may be helpful if nerves are involved. A muscle biopsy usually confirms the diagnosis with specific features. Tumours of muscle and Inflammatory myositis need to be differentiated. Sometimes focal myositis may be associated with immune-mediated inflammatory disease (IMID), neoplasms, radiculopathy, and trauma. Focal myositis is usually self-limiting and benign. It usually responds to NSAID and occasionally may require a short course of steroids, especially in those with elevated ESR and CRP.

Cost effective analysis of open and laparoscopic inguinal mesh hernioplasty

Background: Inguinal Hernia mesh repair surgery is one of the most commonly conducted surgical procedures. Between two approaches: open and laparoscopic, which is better for the patient in terms of cost and outcome in terms of quality of life and return to economic activity. To facilitate comparability across studies, cost effectiveness analysis requires measurement of both costs and quality adjusted life years (QALY). Methods: Descriptive, observational study which entails classifying costs, identifying cost centres, tracing all costs related to the elective procedures for inguinal mesh hernioplasty by both open and laparoscopic methods followed by checking the Quality of life pre and post-surgery of these patients through the EQ-5D-3L by telephonic interview. A Cost Effective analysis was conducted by the end of the study. Based on available data, we took 35 cases of laparoscopic procedure and 45 cases of open surgery as a universal sample size. Results: Traditional costing showed a difference of approximately INR 3245.93/- in the 2 procedures with laparoscopic surgery being costlier. Significant improvements were noted in patients post laparoscopic surgeries with less people complaining of post operative pain/discomfort and early resumption of daily activities and mobility within a month after the surgery. ICER is tilted in favour of laparoscopic surgeries by a value of Rs 1,08,197.66 per QALY. Conclusions: The difference in cost is minimal but the difference in the QALY scores and ultimately the ICER determines that laparoscopic surgery has an edge over open surgery in terms of outcome and patient comfort.

Sheehan’s syndrome of a 50 years old female with bipolar disorder: a case report

Empty Sella syndrome (ESS) pertains to a phenomenon in which the Turkish sale seems through radiography to be larger and perhaps partially or entirely filled with brain fluids. It can be major illness/ develop as a result of pituitary medical procedures, radiation therapy cerebral infarction/bleeding process. A 50 years old female patient was admitted in emergency medicine ward with chief complaint of pain in abdomen, weakness and vomiting. MRI scan of pituitary cerebrospinal fluid (CSF) signal intensity is seen in Sella with no visible anterior pituitary gland tissue noted-likely suggestive of secondary empty Sella (SES). Long-term steroid use is principal therapy for adrenocorticotropic hormone deficiency (IAD). In this instance, ESS, which can be primary/secondary, also noticed.

Assessment of risk factors for hypertension among undergraduate students in a medical college of Himachal Pradesh, India

Background: Hypertension is a commonest cardiovascular disorder and is major cause of premature death worldwide. An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, most (two-thirds) living in low and middle-income countries. So present study was undertaken to assess the risk factors for hypertension among First year MBBS students so that suitable preventive measures may be undertaken. Methods: It is cross sectional study conducted among first year MBBS students in DRKGMC Hamirpur. The duration of study is three months. The tools of study used were modified structured pretested self-administered questionnaire; WHO stepwise approach to chronic disease risk factor surveillance (STEPS). Weighing machine, measuring tape, digital BP apparatus and steadiometer. Results: A total of 115 students of MBBS first year participated in the study. There were a total of 31.3% (36) boys and 68.7% (79) girls. Thirty three percent (38) had a family history of hypertension. 16.52% (19) had a BMI more than the normal. Among the study participants only 5 students (4.35%) used to consume alcohol and smoke cigarettes. Most of study participants consume fast food and junk food. Conclusions: High prevalence of different modifiable risk factors for hypertension revealed among the study subjects.There is need to screen the modifiable risk factors from very early age.

Effectiveness of structured teaching programme regarding knowledge about uses of menstrual cup among nursing students

Background: Menstruation is a normal biological process experienced by millions of women around the world each month. Good menstrual hygiene practices can prevent infections among women. During menstruation women are using different sanitary products like reusable cloth pads, commercial sanitary pads, tampons, pads made from wool, reusable tampons, and menstrual cups. The menstrual cup was developed as an alternative of sanitary napkins and eco-friendly sanitary product but due to lack of awareness in India it抯 uses are very limited. Methods: Quasi experimental one group pre-test and post-test research design was used in this research study. A total 201 nursing students of were selected by using purposive sampling technique. After the pretest structured teaching programme regarding knowledge of menstrual cap uses was implemented among nursing students and on 10th day of STP post-test was done by using the same tools. Results: During the pre-test researcher found that majority (81.59%) of nursing students had inadequate knowledge regarding menstrual cups uses. The mean knowledge score was significantly (p<0.05) increases from pre-test (7�06) to post-test (15�36) where mean difference was 8. Conclusions: The study results highlighted that the STP was highly effective in increase the knowledge among nursing students. Educational intervention programs must give importance in Professional Institutions, which will motivate female抯 students to start practice of menstrual cups during menstruation. This is eco-friendly initiative.

Evaluating maternal and perinatal outcomes of eclampsia at a tertiary healthcare facility in Bihar, India: a retrospective study

Background: Eclampsia, characterized by seizures in women with preeclampsia, is a leading cause of mother and neonatal illness and death globally. Despite advancements in obstetric care, eclampsia remains a significant concern, especially in nations with poor and medium incomes. The aim of the study is to comprehensively assess the maternal and perinatal outcomes associated with eclampsia cases treated at a tertiary healthcare centre with the goal of improving understanding and management strategies for this serious medical condition. Methods: This retrospective observational study was conducted over 12 months. Data were collected from 200 eclampsia cases, focusing on demographic information, obstetric history, clinical characteristics, obstetric interventions, maternal complications, and perinatal outcomes. Statistical analysis was accomplished using SPSS version 21. Results: The mean age of patients was 28.5 years, with a majority (65%) being multiparous. Antepartum eclampsia was the most common clinical type (60%). Emergency caesarean section was performed in 70% of cases. Maternal complications included pulmonary edema (45%) and renal failure (25%), with a maternal mortality rate of 5%. Pre-term births occurred in 40% of cases, with an average gestational age at birth of 32 weeks. Additionally, 35% of newborns were low birth weight, and the perinatal mortality rate was 15%. Conclusions: This study highlights the substantial burden of neonatal and mother morbidity and death related with eclampsia in Bihar, India. Effective management strategies, including timely diagnosis, obstetric interventions, and preventive measures, are crucial in mitigating the adverse outcomes of eclampsia. Improving access to antenatal care, early detection of pre-eclampsia, and enhancing obstetric care services are essential in reducing the impact of eclampsia. Furthermore, continuous medical education programs for healthcare providers can enhance their knowledge and skills in managing eclampsia cases effectively.

Screening of infants and young children with hyperbilirubinemia for sensorineural hearing impairment: an institutional study

Background: Jaundice is one of the most common problems occurring in newborns. Severe neonatal hyperbilirubinemia is a common cause of sensory neural hearing loss. It is important to identify and treat the jaundice early, to prevent complications like encephalopathy leading to hearing loss. Early detection of hearing loss is important for early intervention. The aim of the study was to evaluate the prevalence of sensorineural hearing loss (SNHL) in children with hyperbilirubinemia and to correlate the degree of hearing loss with degree of hyperbilirubinemia. Methods: The 50 cases including newborn and young children (<12 years of age) having history of hyperbilirubinemia and exchange transfusion were included in this study. After the approval and clearance from institutional ethical committee, this study was conducted from April 2021 to March 2022 in the department of ENT, govt. medical college Amritsar in co-ordination with department of pediatrics. Results: On comparing brain stem evoked response audiometry (BERA) and otoacoustic emissions (OAE) results, it was found that out of 50 patients BERA was abnormal in 8 patients while 42 had normal BERA. 18% (9) patients had abnormal OAE results out of which 7 had bilateral REFER result while 2 had unilateral REFER result. On comparing the OAE and BERA for sensitivity and specificity, the sensitivity was 92.9% in right ear while specificity was 62.5%, whereas in left ear sensitivity was 95.2% while specificity was 75%. Conclusions: According to our study the prevalence of sensorineural hearing impairment comes out to be 16% as per BERA. BERA is more sensitive and specific as compared to OAE. But still OAE can be used as screening test considering the cost factor and ease of conducting OAE test while BERA is a confirmatory test for SNHL.

Cracking of enigma of Evans: a rare association with Sjogren and systemic lupus erythematosus

Evans syndrome (ES) is characterized by the simultaneous or consecutive occurrence of warm autoimmune hemolytic anemia (AIHA) along with immune thrombocytopenia (ITP), and less commonly, autoimmune neutropenia. It may manifest spontaneously or as a result of autoimmune, malignancy or lymphoproliferative disease. Clinical manifestations may be associated with hemolysis and thrombocytopenia, potentially leading to life-threatening outcomes. ES is a rare diagnosis of exclusion. Due to its infrequency, the treatment is typically empirical, relying largely on intravenous corticosteroids or immunoglobulins. We are presenting case of a 46-year-old- female with bleeding from the mouth and gums and rashes all over the body with no prior diagnosis of rheumatological disorder. This case is pivotal as it highlights a key factor contributing to ES and presents a pragmatic method for addressing the condition.

Effectiveness of William’s Flexion Exercises on Non-Specific Low Back Pain Among Nurses

Background: Spinal Cord Injury is one of the severe injuries results in loss of sensory and motor function below the level of injury which deteriorates the quality of life. The bio-psycho-social model also emphasizes on the improving the quality of life than enhancing the physical function as the primary goals of SCI rehabilitation. Many authors have reported that there is significant positive effect on activities of daily living. Therefore, improving the quality of life in individuals with SCI. Aim: To study the Relationship between Functional Status and Quality of Life in Patients with Spinal Cord Injury. Methodology: Ten subjects were enrolled according to the inclusion and exclusion criteria of the study. WHOQOL-BREF and SCIM was administered at 3rd, 6th and 9th month of injury to assess the Quality of life and Functional Status of the individuals with Spinal Cord Injury. Result: There was significant correlation between SCIM Vs Psychological domain (r=-0.66, p= 0.03*) at 3rd month, SCIM Vs Social domain (r= 0.57, p= 0.08*) at 3rd month, SCIM Vs Environmental domain (r= 0.57, p= 0.07*) at 9th month post injury. Conclusion: The study concluded that there was a positive association between the functional status and quality of life in patients with spinal cord injury at 3, 6 and 9 months of injury.

Mental health: a stigma and neglected public health issue and time to break the barrier

Global mental health, impacting over a billion individuals, is addressed by the World Health Organization’s (WHO) 2023 special initiative for mental health, targeting accessible community-based care for 100 million people. The complexity of mental health dynamics, influenced by diverse factors, shapes an individual's position on the continuum. Depression and suicide rates highlight the global crisis, with 970 million affected in 2019. India grapples with a treatment gap and economic implications, exacerbated by mental health stigma. Neglected in public health agendas, mental health imposes a significant burden, necessitating targeted policies and interventions. Breaking barriers requires collective efforts, including celebrity advocacy, organizational initiatives, and public education. Global interventions focus on suicide prevention through access restriction and responsible media reporting. Child and adolescent mental health necessitate policies promoting well-being and caregiver support, as seen in India's Mental Healthcare Act of 2017. In conclusion, global mental health, a priority, faces persistent barriers, particularly stigma. Urgent action is needed to integrate mental health into broader public health strategies, dismantle discriminatory practices, and ensure equitable access to care for a future prioritizing universal well-being.

Reversible blindness in cryptococcal meningitis with human immunodeficiency virus infection

Ocular complications in cryptococcal meningitis (CM) are commonly attributed to elevated intracranial pressure (ICP). We report a case of reversible vision loss complicating acquired immunodeficiency syndrome (AIDS) related to CM with a normal ICP. The patient had sudden onset painless blindness during the anti-retroviral therapy (ART) and anti-fungal therapy. On evaluation, clinical and radiological findings of optic neuritis were present. While reviewing the literature for causes of blindness in CM, we concluded the cause was optic neuritis due to immune reconstitution inflammatory syndrome (IRIS) because of concomitant ART intake by the patient. We witnessed dramatic visual improvement after the use of systemic corticosteroids. The potential significance of this case report is to highlight the possible role of corticosteroids in the prevention of blindness due to CM.

An evaluation of effectiveness of Ilizarov external fixation in treating infected non-union tibial fractures: a prospective observational study

Background: Infected non-union tibial fractures pose significant challenges in orthopedic care. Ilizarov external fixation has emerged as a promising treatment option for such complex fractures. The purpose of this research is to evaluate the efficacy and safety of Ilizarov fixation in non-union, infected tibial fractures. Methods: A prospective observational study was conducted on 30 patients at Indira Gandhi Institute of Medical Sciences. Inclusion criteria involved patients aged 20-65 with clinical and radiological signs of infection and non-union of the tibia. Data on patient demographics, injury details, treatment history, and outcomes were collected. Ilizarov fixation was performed, and patients were followed up. Results: The study cohort, primarily males (80%), with mean age of 35.75 years, displayed a high incidence of type III compound injuries (63.33%). Monofocal and bifocal osteosynthesis effectively reduced limb shortening, with an overall average residual shortening of 1.8 cm. Bony outcomes were favorable, with 16 cases achieving excellence. Functional outcomes were also promising. Complications included stiffness, infections, and deformities. Conclusions: Ilizarov external fixation demonstrates potential in managing infected non-union tibial fractures, offering favorable bony and functional outcomes. However, post-operative complications require vigilant management. Further research is needed to validate and optimize this approach.

An epidemiological trend in surgical management of pelvis and acetabulum fractures at Indira Gandhi Institute of Medical Sciences level-1 trauma centre in Patna: a retrospective study

Background: Pelvic and acetabular fractures, principally resulting from high-energy trauma like motor vehicle accidents, are challenging orthopedic injuries that can lead to significant morbidity and functional impairment. Understanding their epidemiology, treatment, and outcomes is crucial for improving patient care. Methods: This retrospective cohort study involving 34 patients who underwent surgery for pelvic and acetabular fractures from April 2021 to September 2023. Data on patient demographics, injury mechanisms, fracture types, surgical approaches, and post-operative outcomes were collected and analyzed. Results: The study group comprised predominantly males (67%) with mean age of 35 years. Road traffic accidents were the leading cause of injuries (95%). The most common fracture types were the posterior wall of the acetabulum (10%) and type II anteroposterior compression fractures (10%). Related injuries included long bone fractures (62.5%) and posterior hip dislocation (33.33%). Surgical treatment primarily involved open reduction and internal fixation with various approaches. Postoperative complications included sciatic nerve palsy (4.17%), venous thromboembolism (20.83%), and wound infections (12.5%), but both post-operative mortality and heterotopic ossification were absent. Conclusions: The study highlights the prevalence of pelvic and acetabular fractures due to road traffic accidents and the complexity of their surgical management. The associated injuries and postoperative complications underscore the need for specialized orthopedic care.

Navigating the caregiver’s strain: psychosocial well-being among sandwich generation caregivers in India

Background: Sandwich generation caregivers, while providing simultaneous care to two generations, face unique challenges and responsibilities. This research tried to understand the intricate aspects of this caregiving paradigm, with an emphasis on the difficulties faced by the sandwich generation in India and its impact on their psychosocial well-being. Methods: The study used the Montgomery Borgatta caregiver burden scale to measure the burden experienced by the caregivers. Furthermore, both bivariate and multivariate analyses were done to understand the effects of background factors on the burden experienced by the caregiver. Results: The findings demonstrate significant associations with demographic characteristics such as age, caste, education, income, religion, and employment status, emphasizing the multidimensional nature of the burdens. Younger caregivers experienced greater objective and demand burdens, suggesting that the caregiving challenges intensify as caregivers age. Higher education and income were associated with increased subjective demand burden, possibly due to higher expectations and greater responsibilities. Conclusions: The study results highlight the critical need for tailored support systems that identify and address the unique issues of sandwich generation caregiving. As population ageing continues to impact societies worldwide, understanding and addressing the concerns of sandwich generation caregivers is crucial for the well-being of individuals, families, and communities.

A comparative and prospective study of ventral hernia repair by laparoscopic and open technique

Background: Ventral hernia repair is becoming more common through laparoscopic techniques; however, there is a lack of comprehensive data on the associated complication rates. We undertook a prospective study to contrast the early establishments of laparoscopic and open ventral hernia surgeries in order to fill this gap. The aim of the study was to assess and contrast the efficiency and reliability of open and laparoscopic techniques for the treatment of ventral hernias. Methods: A prospective study was carried out at All India Institute of Medical Science, New Delhi, India between 2011 and 2014 to assess the dissimilarities between open and laparoscopic approaches in ventral hernia repairs. The study included a total of 40 cases each for open/laparoscopic ventral hernia repair procedures. Results: Eighty cases were investigated, forty of which underwent open repairs and forty of which underwent laparoscopic procedures. In this study, the oldest patient was 77 years old, and the youngest patient was 25 years old. The vast majority (49%) of patients were in their fourth to sixth decades of life. Incisional hernias were in bulk, that had formed from earlier midline lower scars. In both open and laparascopic surgery, there were 40 patients- 43 females and 37 males. Conclusions: Ventral hernia repair via laparoscopic surgery is showing encouraging results and is currently a widely used technique. When compared to open repairs, it has benefits like decreased postoperative pain, shorter hospital stays, and fewer short-term problems. Laparoscopic hernia surgery also results in a lower risk of wound infections, an earlier restoration of bowel function, and a quicker return to regular activities.

Evaluation of Demirjian stage of the third molar as a reliable predictor of 18 years age

Background: In accordance with section 3(1) of the 1875 Indian majority act, any individual residing in India must reach the majority age when they reach the age of 18 and not before. Third molar formation begins approximately the age of 18. This study aims to distinguish the third molar Demirjian stage(s) indicate that the individual is under the age of 18, and which do not, we will be able to determine the person's age. Methods: In this research, 202 patients' OPG radiographs aged 14-25 years were obtained. Their radiographs revealed 742 third molars in total. Third molar development was examined using Demirjian's eight-stage method, and average age was then calculated for each step of third molar growth. Stages under the age of eighteen and stages over the age of eighteen were analyzed. Results: Data revealed that a person was in stage C most likely under the age of 18 (minor) and at stage H, a person was most likely over the age of 18 (major). Stages A and B were not evident in the age range studied. The age associated with stage C was less than 18 years, while the age associated with stage H was greater than 18 years. Conclusions: Assessing third molar growth stages is a reliable non-invasive method for estimating an individual's age. Stage H indicates a likely age over 18 with completed root development, while stage C suggests an age under 18 with ongoing root development, making it a quick and useful approach.

The prevalence of seroma formation after modified radical mastectomy: an observational analysis of risk factors

Background: Seroma, a medically apparent subcutaneous accumulation of effusion fluid after breast carcinoma, growing in 30% of patients. The main hurdle in breast cancer surgery is the formation of a seroma, with an unknown root cause. The objective of this study was to determine the relation between some elements connected with, modified radical mastectomy and seroma formation before the operative period, during the operative period, and after the operative period. Methods: This was an observational study including 200 female patients who were undergoing modified radical mastectomy at All India Institute of Medical Sciences, New Delhi, Delhi from January 2011 to December 2014. After the surgery, the patient was kept under observation for seroma formation. Chi square and t tests were used for the statistical analysis of this study. Results: Seroma formation was more prevalent in old-age patients and overweight patients. The more the initial drain volume the more will be the seroma formation. After the operation, arm physiotherapy was started. 40 patients of older age had the formation of seroma. 30 patients developed seroma whose tumor size was more than 3 cm. Conclusions: The occurrence of seroma was more prominent in older age patients and overweight patients. With prompt physiotherapy and flap fixation under muscles can reduce the occurrence of seroma formation and some interventions in the time of operation can help in decreasing seroma formation.

Unraveling the mysteries of moyamoya: a rare case report of stroke in young

Moyamoya disease is a unique cerebrovascular disease that is characterized by chronic progressive stenosis of distal part of internal carotid artery with consequent development of a network of collateral vessels in response to brain ischemia. It is mainly seen in individuals of Asian descent and is the most common cause of stroke in Asian children. However, it is rare in Indian subcontinent. Here we report a case of young adult who manifested with moyamoya disease, evident from acute onset ischemic stroke. The patient underwent a diagnostic cerebral angiogram that showed bilateral posterior cerebral artery stenosis with pathognomonic collateral moyamoya vessels. The patient subsequently underwent elective surgical intervention procedures to prevent further complications.

Effectiveness of Benson’s Relaxation Technique In Stressed PCOD Women

Background: Polycystic Ovary Syndrome (PCOS) is a prevalent endocrinological disorder in women, causing metabolic dysfunction and body composition changes. As of June 30, 2022, WHO estimates indicate over 116 million women (3.4%) globally are affected by PCOS. Stress, defined as worry and mental tension from difficult situations, is a major contributor to reproductive dysfunction. Reports increasingly highlight stress’s role in PCOS manifestation. The study aims to assess the Benson relaxation technique’s effectiveness in alleviating stress in women with PCOS.Aim: To determine the effectiveness of Benson’s relaxation technique in stressed PCOD.Methodology: Study Design: Experimental study, Study setting: Dr. B.R. Ambedkar Medical College and Hospital, Department of Physiotherapy, Bangalore -560045 Sample design: Purposive sampling. Sample size: 30 patients.Result: A significant reduction in stress among PCOD women was observed with the use of Benson’s Relaxation Technique. The pre-perceived stress score before the technique was 22.63±5.26, decreasing to 18.23±5.98 post-intervention. The enhancement score was 4.40, with a t-value of 11.08. The analysis indicates a substantial stress reduction among PCOD women using Benson’s Relaxation Technique, as assessed through the Perceived Stress Scale (p<0.001).Conclusion: The study conclusively demonstrated the efficacy of Benson’s Relaxation Technique in alleviating stress among women with PCOD. The analysis revealed a significant shift in stress levels, with 33.4% transitioning from high to moderate stress, 30.3% from moderate to low, and 30% maintaining moderate stress. Only 3.3% had persistent low stress, and the same percentage had persistent high stress. The pre-intervention stress score was 22.63526, decreasing to 18.2315.98 post-intervention, yielding a noteworthy enhancement score of 4.40. This signifies a statistically significant reduction in perceived stress (p<0.001), supported by a t-value of 11.08.