Economical Communication and Finance for Evolving Farmer Producer Organizations (FPOs): The Hope & Inevitability for a Prosperous Rural Odisha

Farmer producer organizations (FPOs) help reduce risk, improve new corridors for entrepreneurship, and a new institutional expanse for redefining the value of agriculture for the 21st century. This organization has got the ability to usher a perennial impact on the farm community essential for their evolutionary growth. Economical communication of FPO members has been the driving force for further institutional growth and expansion both by time and space. This study aimed to estimate the inter and intra-level of interaction between sets of predicted variable, economical communication, and predictor variables (x1-x24) and to generate policy at the micro-level. The research design selected for the study was ex post facto design. One hundred (100) respondents were selected from two FPOs, fifty (50) from each FPO of Ranpur block of Nayagarh district of Odisha to conduct the study following the snowball sampling method. The correlation coefficients found that mean family education has been showcasing higher economical communication. Regression results implied that 24 causal variables together have contributed 66.70 percent of the variance in the consequent variable, economical communication (y). The results of path analysis revealed that the variable size of holding has got the highest indirect effect on economical communication. This empirical study has got tremendous policy implications for Odisha and anywhere in India as well.

A retrospective clinicopathological analysis of rhino-orbital mucormycosis in second wave of COVID-19

Background: During the present surge of COVID-19 positive cases, concurrent multifold increase in the incidence of mucormycosis cases has resulted into significant morbidity and mortality. We retrospectively evaluated the clinicopathological features along with microbiological examination findings in histologically diagnosed cases of rhino-orbital mucormycosis. Material and Methods: All the H and E and special stained slides of included mucormycosis cases were retrieved from the records and were evaluated with microbiological findings including screening KOH mount examination and culture results. Results: Out of 16 cases with available details, 10 cases had the previous history of diabetes mellitus. The most frequent single site of involvement was maxillary sinus (7/25) followed by nasal cavity, orbit, ethmoid and sphenoid sinuses. While comparing the histological diagnosis with KOH mount findings and culture results, 15 cases revealed consistent results. Conclusion: A high clinical suspicion, monitoring, early diagnosis, and timely management can improve the morbidity and mortality of this life-threatening complication.

Evaluation of variable p16 immunostaining patterns, Ki-67 indices and HPV status in cervical SILs and squamous cell carcinomas: An institutional experience

Objective: The present study evaluates the immunoexpression of p16 and Ki-67 in cervical squamous intraepithelial lesion (SIL) and carcinomas and correlates their expression with clinicopathological features and HPV-DNA status. Material and Methods: A total 36 included cases of SIL and squamous cell carcinoma (SCC) were subjected to p16 and Ki-67 immunostaining. p16 staining was evaluated depending on grading, distribution, localization pattern, intensity and IHC score. Ki-67 expression was graded based on percentage of positive cells. Results: Incidence of HSIL and SCC cases was found to be significantly increased with parity > 5. p16 grade III diffuse nucleocytoplasmic immunostaining was observed in 62.5% LSIL, 80% HSIL and 87% SCC cases. Significant association of p16 staining intensity, IHC score and Ki-67 indices was noted with increasing grades of SILs and carcinomas. Conclusion: Our experience indicates that a combination of p16 and Ki-67 immunostaining may be useful to determine the severity of dysplastic change.

Duration of screen time and its effect on reaction time in 1st year MBBS students in a medical college of Southern Odisha

Background: Smartphones, PC, tablets, and TV have become integral parts of our lives. The smartphone in particular is the lifeline of everyone, regardless of their age group. Overuse of smartphones is increasing, resulting in a great deal of physical and psychological effects. It is found to negatively impact health and increase the risk of stress, depression, and anxiety. In addition to this, sleep disorders, restlessness, and fatigue are also being reported which can lead to cognitive impairment. The reaction time (RT) is the interval between the application of a stimulus and the response. It is an indication of neural processing between a stimulus and the response which is expressed in milliseconds. Aims and Objectives: The primary objective of this study was to estimate screen time, auditory and visual RTs, and the association between screen time and RT (visual reaction time [VRT] and auditory reaction time [ART]). Materials and Methods: The present cross-sectional study was conducted on 232 1st year MBBS students in the age group of 18–23 years. Average screen time was noted from their respective gadgets. RT for the targeted stimulus, yellow light for the VRT and beep sound for the ART, was determined using the Biochart application system by Biostar Health care (Computer software) on the laptop. The task was to press the space bar as soon as the stimulus was presented. Average RT for both the stimuli (ART and VRT) were calculated using ten readings for each. Data obtained were analyzed. Results: Our study shows that ART is faster than VRT for both males and females. Screen time with VRT has a moderate positive significant relationship (P < 0.001), while for the ART, it has a weak positive relation. Conclusion: Based on our findings, it can be concluded that there is a positive correlation between screen time and RT. Screen time alone has a 21% effect on the RT as per our study. It also suggests that ART is faster than VRT. The females have a higher RT than the males in a similar age group.

A cross-sectional study on the relationship between obesity and lifestyle factors among doctors working in a tertiary health-care center in Southern Odisha, India

Background: Non-communicable diseases are affecting millions of people worldwide. These diseases are linked to the lifestyle of the population. Hence, lifestyle modification may help reduce the disease burden. Due to work-life misbalance, many doctors are vulnerable to lifestyle-related disorders. Aims and Objectives: The objective of this study was to find the obesity parameters and lifestyle pattern and to find if any correlation exists between the obesity parameters and lifestyle score. Materials and Methods: We conducted this study in a tertiary care teaching hospital situated in Southern Odisha, India. The doctors attached to the teaching hospital were taken as a convenience sample. The anthropometric parameters were measured in the departmental research laboratory and the lifestyle score was obtained by the FANTASTIC lifestyle assessment instrument. The correlation between the FANTASTIC score and body fatness variables was tested. Results: A total of 152 doctors with a mean of 40.09 ± 9.92 years of age participated in this study. We found a significant negative correlation coefficient of FANTASTIC score with body mass index (BMI) (r = ?0.36, P < 0.0001), body fat % (r = ?0.25, P = 0.002), and visceral fat % (r = ?0.28, P < 0.0001). The age, waist circumference, and fat-free mass did not show any significant correlation. Conclusion: Some of the obesity parameters such as BMI, body fat, and visceral fat are negatively correlated with lifestyle scores. Hence, doctors with the lower lifestyle scores may tend to show a higher tendency toward obesity and vice versa. The doctors and the stakeholders should take care of healthy lifestyle promotion.

Immunoexpression of PTEN, HER2/neu, and Ki-67 in endoscopic gastric carcinoma biopsies; their correlation with histological subtypes and one-year survival

Background: Gastric carcinoma is a major cause of cancer-related morbidity and mortality worldwide. Gastric neoplasms arise from genetic and epigenetic changes in various genes. Present study evaluates the immunoexpression of PTEN, HER2/neu, and Ki-67 in endoscopic gastric carcinoma biopsies and correlates the expression of these proteins with clinicopathological features. Material and Methods: Adequate endoscopic biopsies of 27 cases of gastric carcinoma were evaluated for World Health Organization (WHO) and Lauren's classification subtypes along with HER2/neu, PTEN, and Ki-67 immunoexpression. HER2/neu immunostaining was scored as proposed in the Trastuzumab for gastric cancer (ToGA) trial while PTEN staining and downregulation were assessed using an immunoreactive score. The cut-off for Ki-67 expression was taken as 90th percentile of the values in adjacent non-neoplastic tissue. All statistical analysis was done at 5% level of significance with SPSS v22 statistical software. Results: Tubular adenocarcinoma was the commonest WHO histological subtype and 56% of cases were of intestinal type as per Lauren's classification. 55.6% of cases showed a complete loss of PTEN expression in neoplastic tissue. 17 of the 19 cases with adjacent non-neoplastic tissue showed PTEN downregulation in neoplastic tissue. 81.5% of cases had a high Ki-67 index and HER2/neu overexpression was noted in 36% of cases. All the four cases who died had high Ki-67 proliferation indices; 3 patients had loss of PTEN expression and HER2/neu overexpression. Conclusion: We conclude that these immunomarkers can play important role in the behavior of gastric carcinomas and can be targeted for new therapies.

Correlation of body fat percentage, fat mass, fat free mass, and fat free mass index with hand grip strength in healthy young males in a tertiary health care center of South Odisha

Background: Handgrip strength (HGS) is an important parameter to assess the upper extremity muscular strength. Aims and Objectives: Aim of the study is to record HGS in healthy young males and to compare with fat mass (FM), fat-free mass, fat-free mass index, and to find out which is better correlated. Materials and Methods: A total of one hundred and fourteen first year male medical students of age between 17 and 22 years were taken as sample. Results: The correlation between fat free mass, fat free mass index with HGS was found to be extremely significant whereas correlation between FAT%, FM with HGS was not significant. Conclusion: Increase in lean body mass increases muscular strength as fat-free mass and fat-free mass index positively and significantly correlated with HGS.

Technology Socialization Process of Pulse Enterprise: The Structural and Functional Analysis

Technology socialization process has operationally been defined as the interactive summation of all possible responses to a technology application process in terms of adoption, rejection, discontinuance and reinvention. Here, this interactive summation is measured against a set of standard practices applied in pulse enterprises and the level of socialization as measured against a “recommended technology”. The following specific objectives are set to intervene the present study. Those are, to generate basic information on socialization of pulse crop in the study area to identify and standardize the variables, dependent and independent, impacting on both socialization of pulse crop in the study area, to elucidate inter and intra level interaction between dependent variables i.e. Socialization with those of selected socio economic and ecological variables, to delineate the micro level policy based on the empirical result on effective socialization process. The study has been carried out in two developed block namely Chakdah and Haringhata of Nadia District in West Bengal. The multistage purposive and random sample techniques were the key to contrast sampling design in the present study. The following variables, gross return, area under pulse cultivation, training received, yield, farmer’s attitude towards pulse cultivation have been found generating significant functional impacts on the predicted character, technology Socialization. The statistical tools like mean, standard deviation and coefficient of variation, coefficient of variation, coefficient of correlation, multiple regression, step down multiple regression and path analysis. The study also responded to the inquiry as to where and how the classical crop production process can be replaced with pulse crop and whereas this replacement will be much rewarding and beneficiary to the common farmer. The determinants like gross return, area under pulse crop, training received, productivity of pulse crop and farmer’s attitude are decisively characterizing the socialization process of pulse crop.

Amount of Waste used for Different Purposes: A Socio-ecological Impact

Waste is a ceaselessly developing issue at worldwide and territorial just as at neighborhood levels. Due to vigorous globalization and product proliferation in recent years, more waste has been produced by the soaring manufacturing activities. The social ecology of waste recycling implies the structural, functional and managerial intervention of waste generation process. The specific objective of the research was to isolate and identify the system variables characterizing and the management of waste recycling process and to estimate intra and inter level of interaction amongst and between the variables for respective, inductive and interactive contribution. The present study takes a look into the approach, process and impact of ongoing waste management process, followed by the both kalyani and jalpaiguri municipalities. A set of agro-ecological, socio-economic and techno managerial factors have been developed by selecting two sets of operating variables: Independent Variables: Age(x1), Education(x2), Family member(x3), Total cost of energy(x4), Household land(x5), Income(x6), Expenditure of family(x7), Volume of waste generation per household(x8), Water consumption per day(x9), Total bio diversity(x10), Impact of waste management on health(x11), Impact of waste management on agriculture(x12), Impact of waste management on livestock(x13), Impact of waste management on water(x14), Impact of waste management on soil(x15), Impact of waste management on micro flora and fauna(x16), Exposure to media(x17),Training received(x18), Participation on waste recycling programmer (x19), Perception on environmental impact of waste management(x20), Waste management at household level with value addition by percentage (x21a), Waste management at household level with value addition by percentage (x21b). Dependent variables: Volume of waste used for different purposes (y1). The following independent variables have come out with stark contribution on this consequent variable. Result suggested that in terms of variable, behavior and responses there have been stark differences between jalapaiguri and kalyani municipal areas. In kalyani, some few variables like perception of environmental impact on waste management, waste management at household level with value addition by percentage, impact of waste management on agriculture have recorded the distinct contribution on volume of waste used for different purposes and in jalpaiguri total household land, volume of waste generation from household, water consumption per day have gone in the determinant way. So, in kalyani and jalpaiguri municipal areas these variables have maximum influence on the dependent variable. Household wastes mostly are bio degradable in nature. It can be converted to organic manure which has a great nutritional value for plants and if these bio wastes can be converted into organic manure then amount of waste will be reduced. Not only bio waste but we can use non bio degradable wastes for energy production also.

Rooftop Gardening: Estimation of Income from a Score of Socio-Ecological Variables

Aims: To study the relationship of total income was incurred from the rooftop gardening with various socio economic and behavioural aspects and elicit the future opportunity for this innovative method in this global warming situation where the world is facing the increasing crisis of availability of the land resources, support sustainability, contamination of ground water, food accessibility, and economic sustainability. Study Design: The locale was selected by purposive sampling technique and the respondents following rooftop gardening had been interacted and was selected by the snowball sampling method. Place and Duration of Study: The study was carried out during 2017 and 2018. The place, Janai Road of Srirampur, Khanakul-I and Khanakul-II block of Hooghly district, Budge Budge-II, Bishnupur-I and Bishnupur-II of South 24 Parganas and various areas in Kolkata were selected for the study. Methodology: In this present study 50 respondents following rooftop gardens have been interacted and are selected by the snowball sampling method. A semi-structured schedule has been administered to generate women information regarding family composition, the rationale for opting rooftop gardening, the ecological views on roof gardening, and the cost opportunity analysis. The gathered data had been put into multivariate analysis (Statistical Package for the Social Sciences V20.0 (SPSS) of IBM was used for analyzing the Coefficient of Correlation, Stepwise Regression and Path Analysis). Results: Education (X2), rooftop area (X4), diversity of plants (X6), labour charges (X8), organic manure (X11), fertilizer (X13) variables have been found to exert strong and determining contribution to total income. Respondents revealed that it had provided a certain amount of income in addition to the conventional farming income. Conclusion: The study had revealed that Rooftop gardening is not only eco-friendly horticulture but also a successful enterprise, having all the three critical echelons viz. economy, ecology, and equity as well.

Neonatal ovarian cyst complicating as subacute intestinal obstruction: a case report

Congenital Ovarian cysts are among the commonest intra-abdominal masses encountered in foetuses on antenatal screening, mostly during the third trimester of pregnancy. Though the etiology remains unknown, the most prevalent hypothesis holds maternal hormonal stimulation responsible for the pathology. Most are asymptomatic but potential complications can be life-threatening. A case of a 7 day old female baby was reported with normal antenatal scans and complaints of abdominal distension and vomiting since day 1 of life. Imaging included a Ultrasonographic diagnosis of suspected ovarian lesion and an MRI diagnosis of omental cyst. Due to progressive abdominal distension, authors proceeded with laparotomy. Left salpingo-oophorectomy was done as no ovarian tissue was salvageable. Post-operative period was uneventful. The histopathological picture was that of benign follicular cyst of ovary.

Clinical features and management of COVID-19: A systematic review

@#Novel coronavirus disease, the latest world pandemic is one of the most contagious viral infections to date. There has been a lack of uniformity on recognizing this condition clinically because of poorly understood pathophysiology and clinical nature. Also due to ongoing clinical trials, its management is also varied. This is a systematic review from evidence-based studies until March 1st, 2020, covering an update on its clinical features and management. This study shows the multisystem involvement of COVID-19 with dominant respiratory features followed by the musculoskeletal, gastrointestinal system and others. The clinical features varied from asymptomatic to severe forms. Major causes of fatality were acute respiratory distress syndrome, shock, acute cardiac injury, acute kidney injury, rhabdomyolysis, and arrhythmia. Major modalities of management included supportive, antiviral and antibiotic therapy. There was no direct relationship between the specific treatment and the outcome.

Adverse outcomes in SAR-CoV-2 (COVID-19) and SARS virus related pregnancies with probable vertical transmission

The global severe acute respiratory syndrome-related coronavirus SARS-CoV-2 (COVID-19) pandemic has had an unprecedented impact on all aspects of daily life and healthcare. Information on the infection risks for pregnant women and their offspring have so far been limited to small case series, until a large UK report on 427 SARS-CoV-2 infected pregnant women was published. Previous SARS epidemic experiences were drawn upon. Diagnostic use of real time polymerase chain reaction (RT-PCR) and IgG and IgM antibody tests are fraught with concerns of non-validation and false negative results, as are sampling methodologies. Virtually no information on controls accompany these reports. Infection of the mother and baby has serious implications for obstetric and neonatal care. Information on early and late stage pregnancy infection and the relationship to severity of infection on fetal development is both useful and clearly warranted. An increasing number of reports centre around mildly infected women showing no evidence of fetal infection while a few reports suggesting vertical transmission require further validation. Vertical transmission from mother to baby however small would have profound health implications for obstetric and neonatal care and fetal abnormalities. Some data suggesting intrapartum vertical transmission from mother to baby cannot be dismissed given the lack of controls and limitations of diagnostic viral tests. This analysis covers some key early reports addressing pregnancy outcomes following SARS-CoV-2 infection. (AU)

Primary epithelial splenic cyst: A rare encounter

Splenic cysts are rare with an overall incidence of 0.07% in a large autopsy series and 0.5% among all the splenectomies done. The parasitic splenic cysts, usually caused by Echinococcus granulosus, account for 60% of all primary splenic cysts. The primary epithelial cysts account for 10% of all splenic cysts. We report a case of 30-year-old female presenting with left upper abdominal pain and heaviness. Computed tomography revealed a multiloculated cyst in spleen. Hydatid serology was negative. Total splenectomy was done. Histopathological evaluation was done and a diagnosis of primary epithelial splenic cyst was given.

Hydrogel applications for yield improvement of capsicum with deficit irrigation at cold desert Ladakh region

Aim: The study aimed to evaluate the effects of hydrogel application on growth, physiological responses and yield of capsicum under high altitude cold desert conditions with deficit irrigation of Ladakh region. Methodology: Field experiment was conducted with five levels of hydrogel treatment (viz. 0, 5, 10, 15 and 20 kg ha-1) at cold desert Ladakh region with two irrigation intervals (7 and 11 days) during 2014-15 cropping season. Plant growth characters, root morphology, physiological parameters and capsicum yield were analyzed according to standard methods during the experiments. Results: Hydrogel application in deficit irrigation improved physiological parameters viz. leaf chlorophyll content, relative water content, membrane stability index and significant reduction in electrolyte leakage in capsicum plant. Significant improvement in root morphology was also recorded when hydrogel was applied @ 15 and 20 kg ha-1. Improvement of yield attributing characters as influenced by hydrogel application @ 15 and 20 kg ha-1 resulted in significant increase in capsicum yield with reduced water requirement. Interpretation: Hydrogel has potential for growth of capsicum crop through improved root morphology and physiology of plant in deficit irrigation under arid and semi-arid regions where availability of water for irrigation is scarce or average rainfall is quite low.

Role of CD71 in acute leukemia– An immunophenotypic marker for erythroid lineage or proliferation?

Background: CD71 or Transferrin receptor is expressed on the surface of erythroid lineage cells. CD71 expression has been found to be significantly increased in rapidly proliferating cells. Methods: This cross-sectional study included 37 bone marrow samples of acute leukemia cases diagnosed between October 2016 to April 2018. The samples were analysed on BD FACS Canto II. We evaluated the expression of CD71 on leukemic blasts and compared median fluorescent intensities (MFI) of blasts in different types of acute leukemias. Results: The 37 cases comprised of 21 Acute Myeloid Leukemia (AML), 13 B-Acute Lymphoblastic Leukemia (B-ALL), 2 T- Acute Lymphoblastic Leukemia (T-ALL) and 1 mixed phenotypic acute leukemia (MPAL), T/Myeloid. CD 71 expression was noted in 70.3% (n= 26/37) of acute leukemia cases. CD71 expression was most commonly observed in AML (n= 15/21;71.4%), followed by B-ALL (n= 9/13;69.2%) and T-ALL (n= 1/2;50%). Single case of MPAL revealed blasts positive for CD71. MFI of leukemic blasts of single CD71 positive T-ALL was found to be highest, followed by AML, MPAL (T/Myeloid) and least in B ALL. Of the AML cases, the blasts of AML-M6, acute promyelocytic leukemia and AML-M1 showed higher CD71 expression in terms of MFI. Conclusions: Surface CD71 expression is not only found in erythroid lineage cells, but also in proliferating cells. CD71 MFI is highest in T lymphoblasts followed by leukemic erythroblasts, myeloblasts and least in B lymphoblasts.

Factors affecting medication adherence among chronic obstructive pulmonary disease patients attending at teaching Hospital, Chitwan

Background: Medication adherence is crucial for optimizing clinical outcomes in chronic obstructive pulmonary disease (COPD) patients because non-adherence possess significant burden in health and economy. Patients’ medication adherence is influenced by numerous factors. Objective: The objective of this study was to identify the factors affecting medication adherence among COPD patients attending at teaching hospital, Chitwan. Materials and Methods: A descriptive cross-sectional study was carried out among 121 clinically diagnosed COPD patients attending at a teaching hospital, Chitwan. Non-probability purposive sampling technique was used to select patients for the study. Ethical approval was taken from Chitwan Medical College – Institutional Review Committee and informed consent was obtained from patients. Pre-tested semi-structured interview schedule and a standardized tool “Morisky Medication Adherence Scale, 2008" were used to gather the data by the researcher from November 16, 2016, to December 15, 2016. Bivariate and multinomial logistic regression analyses were performed to analyze the data. Results: Findings of the study revealed that out of 121 patients, 55.4% had medium level, 28.9% had a high level, and 15.7% had a low level of medication adherence. Bivariate analysis showed that patients’ level of medication adherence was significantly associated with an understanding of disease condition from family members (P = 0.03), support from neighbors as needed (P = 0.02), having own monthly income (P = 0.04), and affordability of medication cost (P = 0.02). Multinomial logistic regression analysis identified that patients who can afford the cost of medication (odds ratio [OR]: 6.39, 95% confidence interval [CI]: 1.27–32.11), had family understanding about disease condition (OR: 11.18; 95% CI: 1.76–70.66), get support from neighbor as needed (OR: 11.92; 95% CI: 2.39–59.34), and had accessible to health facilities at <30 min distance (OR: 0.10; 95% CI: 0.02–0.55) were more likely to have high level of medication adherence. Conclusion: Only one-third of the COPD patients have a high level of medication adherence. Hence, local health-care planners need to organize the educational program on medication adherence for COPD patients by considering the notable factors to enhance their quality of life.

Comparative study of the effectiveness between balancing exercises and strengthening exercises with common use of TENS to improve functional ability in Osteoarthritis involving knee joint.

Background and purpose: People with knee Osteoarthritis (OA) sometimes report episodes of knee instability that limit their activities of daily living. Proprioception and balance are important aspects of osteoarthritis treatment because of their strong correlation with function in the knee. The purpose of this study is to evaluate the effects of balancing exercises and strengthening exercises to improve functional ability in knee osteoarthritis patients and also it may be helpful to identify the use of best treatment protocol for OA knee. Material and methods: Thirty OA knee patients randomly allocated into two groups and received either balancing exercises (Group A) or strengthening exercises (Group B). Both the groups received TENS and taken treatment for 4 days a week for 4 weeks. The outcome measures were VAS and WOMAC. VAS was used to measure intensity of knee pain and WOMAC was used for assessment of perceived pain, stiffness and functional ability. Results: After 4 weeks of treatment, significant reduction in the WOMAC score and VAS was found in both the Groups. The result showing statistical improvement is more in Group A than Group B. Conclusion: The results of the study shows that balancing exercise is more effective than strengthening exercise to improve the functional ability of OA involving knee joint. The improvement in Group A is more than Group B and having statistically highly significant.

Net facility aiding medical students towards their education.

Background: Use of computer and information technology has revolutionized the current concepts of learning. The internet, one of the key developments in this field, provides instant access to latest medical information. As the scenario of medical practice is becoming evidence based, it is imperative for the current generation medical students to become updated. Aim: To estimate the extent and purpose of internet usage for upgrading of knowledge among undergraduates of a medical university. Material and Method: This study was conducted at J.N Medical College, Wardha. Two-hundred and six MBBS students were given a validated questionnaire survey to fill and the data was then interpreted. Descriptive statistical analysis was done using frequency and percentages. Results: Eighty-three percent of students used internet facility, 52% percent used it for academic purpose. Only 2% used it for more than 2 hours in a day mostly to prepare seminars (97%) and search topics (95%) of interest as persuaded by the professors. Students (27%) felt the need to use the net for viewing clinical exams and online lectures and fourteen percent read journals to advance their knowledge. Students felt that internet is helpful for learning (82%) and it should be part of the curriculum (72%). Conclusion: The medical students have still not mentally accepted internet facility to increase their academic proficiency and updating the fast changing advancement and researches in medical sciences.