A systematic review and meta-analysis on ChatGPT and its utilization in medical and dental research.

Since its release, ChatGPT has taken the world by storm with its utilization in various fields of life. This review's main goal was to offer a thorough and fact-based evaluation of ChatGPT's potential as a tool for medical and dental research, which could direct subsequent research and influence clinical practices. METHODS: Different online databases were scoured for relevant articles that were in accordance with the study objectives. A team of reviewers was assembled to devise a proper methodological framework for inclusion of articles and meta-analysis. RESULTS: 11 descriptive studies were considered for this review that evaluated the accuracy of ChatGPT in answering medical queries related to different domains such as systematic reviews, cancer, liver diseases, diagnostic imaging, education, and COVID-19 vaccination. The studies reported different accuracy ranges, from 18.3 % to 100 %, across various datasets and specialties. The meta-analysis showed an odds ratio (OR) of 2.25 and a relative risk (RR) of 1.47 with a 95 % confidence interval (CI), indicating that the accuracy of ChatGPT in providing correct responses was significantly higher compared to the total responses for queries. However, significant heterogeneity was present among the studies, suggesting considerable variability in the effect sizes across the included studies. CONCLUSION: The observations indicate that ChatGPT has the ability to provide appropriate solutions to questions in the medical and dentistry areas, but researchers and doctors should cautiously assess its responses because they might not always be dependable. Overall, the importance of this study rests in shedding light on ChatGPT's accuracy in the medical and dentistry fields and emphasizing the need for additional investigation to enhance its performance. © 2017 Elsevier Inc. All rights reserved.

Impact of Nutritional Interventions on Alzheimer's Disease: A Systematic Review and Meta-Analysis.

The most prevalent type of dementia, especially in older persons, is Alzheimer's disease (AD), which has clinical signs of progressive cognitive decline and functional impairment. However, new research indicates that AD patients' dietary patterns and nutritional intake could hold the key to staving off some of the complications. Therefore, the primary aim of this investigation was to analyze various dietary patterns and the subsequent impact of the resulting nutritional intake on AD patients. Various online databases (PubMed, Scopus, Web of Science, and Google Scholar) were searched using appropriate keywords, reference searches, and citation searches. The databases were accessed using the search phrases "Alzheimer's disease," "dietary habits," "minerals," "nutritional profile," and "vitamins." Fifteen of the 21 investigations that we selected for our systematic review and subsequent meta-analysis revealed that micronutrient supplementation and some dietary patterns were helpful in alleviating a few of the symptoms of AD, especially with regard to the progression of dementia in the assessed patients. It was shown that dietary interventions and nutritional adjustments can considerably delay the onset of AD and the varying degrees of dementia that often accompany it. However, there were some areas of ambiguity in our findings because a few of the chosen studies did not document any noticeable improvements in the patient's conditions.

Neurological Implications of Vitamin B12 Deficiency in Diet: A Systematic Review and Meta-Analysis.

BACKGROUND: Vitamin B12 is one of the most important B-Vitamins that the human body needs on a daily basis, the lack of which can precipitate several neurological issues. OBJECTIVES: This systematic aimed to investigate the neurological implications of Vitamin B12 deficiency and the effects when B12 levels were corrected in susceptible individuals. METHODS: The databases PubMed-MEDLINE, Web of Science, Cochrane, and Scopus were all searched using pertinent keywords, reference searches, and citation searches. The terms used to access the database were "Cognition", "Dietary patterns", "Neurology", "Nutritional profile", and "Vitamin B12". RESULTS: Vitamin B12 was shown to noticeably improve cognition and other neurological parameters in the short term in older adults and the short-to-medium term in children; however, there was no perceived increase/improvement when the Vitamin was administered in the longer term, either alone or in conjunction with other similar nutritional interventions. CONCLUSION: Vitamin B12's role in the improvement of neurological functions over a long-term period remains somewhat inconclusive to date, as the majority of our selected control trials did not display much correlation between the two factors. However, Vitamin B12 did improve cognition levels in both children and older adults over a short course of administration.

Investigation on Enamel and Dentine of Tooth through 1D Photonic Structure to Identify the Caries in Human Teeth.

In this research, a one-dimensional (1D) photonic structure was employed to study the nature of both enamel and dentine teeth at the signal of 1.8 THz. A simple three layer one-dimensional crystal is chosen to avoid fabrication intricacy. The materials and methods for sample preparations are discussed. The principle of investigation of caries in the teeth relies on the amount of reflected signal from the structure. Similarly, reflectance is a function of refractive indices and thickness of each layer, the nature of both substrate and infiltrated materials, and the configuration of the structure. Apart from this, the fabrication process of one-dimensional structure and experimental set-up was proposed in this article. The numerical treatment is explained here to obtain reflectance, and subsequently, the output potential. Comparison studies on output potential between enamel and dentine are also shown through graphical representation. The output result in terms of milli-Volt (mV) were obtained at the output end and collected at the photodiode. Interesting results were also observed at the photodetector. For example; the output potential of the reflected signal is around 0.18 mV for both enamel and dentine teeth whereas the potential is more than 0.26 mV and 0.31 mV for caries in dentine and enamel, respectively. Finally, it was inferred that the nature of teeth pertaining to the caries in the enamel and dentine teeth can be investigated by identifying the amount of potential at the output end.

Exploring the Novel Computational Drug Target and Associated Key Pathways of Oral Cancer.

Oral cancer (OC) is a serious health concern that has a high fatality rate. The oral cavity has seven kinds of OC, including the lip, tongue, and floor of the mouth, as well as the buccal, hard palate, alveolar, retromolar trigone, and soft palate. The goal of this study is to look into new biomarkers and important pathways that might be used as diagnostic biomarkers and therapeutic candidates in OC. The publicly available repository the Gene Expression Omnibus (GEO) was to the source for the collection of OC-related datasets. GSE74530, GSE23558, and GSE3524 microarray datasets were collected for analysis. Minimum cut-off criteria of |log fold-change (FC)| > 1 and adjusted p < 0.05 were applied to calculate the upregulated and downregulated differential expression genes (DEGs) from the three datasets. After that only common DEGs in all three datasets were collected to apply further analysis. Gene ontology (GO) and pathway analysis were implemented to explore the functional behaviors of DEGs. Then protein−protein interaction (PPI) networks were built to identify the most active genes, and a clustering algorithm was also implemented to identify complex parts of PPI. TF-miRNA networks were also constructed to study OC-associated DEGs in-depth. Finally, top gene performers from PPI networks were used to apply drug signature analysis. After applying filtration and cut-off criteria, 2508, 3377, and 670 DEGs were found for GSE74530, GSE23558, and GSE3524 respectively, and 166 common DEGs were found in every dataset. The GO annotation remarks that most of the DEGs were associated with the terms of type I interferon signaling pathway. The pathways of KEGG reported that the common DEGs are related to the cell cycle and influenza A. The PPI network holds 88 nodes and 492 edges, and CDC6 had the highest number of connections. Four clusters were identified from the PPI. Drug signatures doxorubicin and resveratrol showed high significance according to the hub genes. We anticipate that our bioinformatics research will aid in the definition of OC pathophysiology and the development of new therapies for OC.

Knowledge, attitude and practice of schoolteachers towards students with epilepsy in Al-Jouf, Saudi Arabia.

BACKGROUND: Epilepsy is a common disorder in which brain activity becomes abnormal that causes recurrent seizures or periods of jerky movement of the whole body. Immediately after a seizure, people are often transiently confused, weak and unable to communicate. OBJECTIVE: This study assesses the knowledge, attitude, and practice (KAP) of school teachers towards an epileptic child. METHODS: This cross-sectional study was conducted among primary and secondary school teachers from different schools in Sakaka, Domat Al-Jandal, Al-Qurayyat, Tabarjal Northern region of Aljouf, Saudi Arabia. They were assessed on their KAP toward students with epilepsy using a self-administrated questionnaire. RESULTS: 306 respondents participated and completed the questionnaire. The practice was poor among the teachers. Practice scores were significantly different among the male and female teachers. Teachers would do the following to the seizing child: 159 (52%) would pull the child's tongue out (p-value 0.012), 66 (21.6%) would put a spoon in the mouth (p-value 0.055), 43 (14.1%) would remove any tight clothes (p-value 0.009) and 244 (79.7 %) would take the child to the hospital (p-value 0.029). There were significant differences among senior teachers and those with longer years of teaching experience: 83.6% of teachers with > 20 years of teaching experience think that the student with epilepsy has no need of a special classroom (P = 0.053), 89.6% of those with > 20 years of teaching experience said that they did not move the child during seizure in comparison with less years of teaching experience (p = 0.048), in which 97% of those with experience > 20 years said that they would ensure normal breathing (p = 0.015). CONCLUSION: The majority of Aljouf schoolteachers were adequately knowledgeable about students with epilepsy, but they need more information about the correct way of practice towards the student with epilepsy.

Knowledge and Attitude of Saudi Students towards Plagiarism-A Cross-Sectional Survey Study.

BACKGROUND: Plagiarism (Plg) is an unacceptable practice since it affects the integrity of scientific literature. AIM AND OBJECTIVES: To seek students' knowledge and attitude regarding Plg and solicit suggestions to prevent Plg in our institute. The specific objectives of the study were to ascertain whether students' knowledge and attitudes about Plg differ by their demographic characteristics and academic years. METHODOLOGY: A 32 item questionnaire was given to all the undergraduate (UG) students of the College of Medicine and Dentistry, Jouf University, KSA. The research questions focused on demographic information, knowledge and attitude regarding Plg, and suggestions to curb Plg. RESULTS: A total of 134 UG students filled out the survey. The samples consisted of 97 males and 37 females. Most of the students displayed adequate knowledge regarding Plg in terms of copying words or ideas, quoting references, and copying words without changing the matter. As compared to female students, male students had better awareness regarding meaningful and harmful effects of practicing Plg (p < 0.05). Additionally, our results indicate that as students climb the academic ladder, their awareness on Plg tends to rise. Common reasons for plagiarizing are discussed here together with suggestions to combat Plg. CONCLUSION: The results of this study can be mainly taken as an eye opener which demonstrates the vital factors pertaining to the level of students' knowledge about Plg, and to eradicate the problem, there is a need for more discussions and training on this topic for students.

Surface Electromyography (sEMG) Activity of Masticatory Muscle (Masseter and Temporalis) with Three Different Types of Orthodontic Bracket.

OBJECTIVE: This pre-post study is aimed at determining the effects of masticatory muscle activity (masseter and temporalis) measured via sEMG between conventional, self-ligating, and ceramic bracket after six months of orthodontic treatment. METHODS: A total of eighteen (18) malocclusion patients were identified. Malocclusion patients were subdivided into 3 groups based on the bracket selection (conventional, self-ligating, and ceramic bracket) with 6 patients for each group. sEMG of muscles were done using a two-channel electromyography device, where pregelled and self-adhesive electrodes (bilateral) were applied. Chewing and clenching of masseter and temporalis muscle activity were recorded for 20 s pre and 6 months of orthodontic treatment using sEMG (frequency 60 Hz). The data were analysed by using repeated measures ANOVA in IBM SPSS Statistics Version 24.0. RESULTS: Chewing and clenching for masseter muscle showed no significant difference (P > 0.05) in sEMG activity of three types of the brackets. However, for temporalis muscle, there was a significant difference found in sEMG activity during chewing (P < 0.05) and clenching (P < 0.05) between these three brackets. CONCLUSION: The activity of temporalis muscle showed significant changes in chewing and clenching, where the conventional group demonstrated better muscle activity pre and at six months of fixed appliances.

Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic.

Stroke is a key cerebrovascular disease that is related to high morbidity and mortality in the globe. The Kingdom of Saudi Arabia (KSA) is not an exception where stroke is fast developing into a serious challenge due to the high mortality rate. Additionally, stroke presents a tremendous economic burden and has a devastating effect on the quality of lives of individuals. The number of stroke cases are increasing yearly, thus posing a major challenge to the health care system. Therefore, it is crucial to implement primary and secondary prevention strategies in the KSA. Nevertheless, as compared with developed countries, information on the prevalence, socio-demographic properties and prevention of stroke remains scarce that could be attributed to the shortage of research conducted in this specified region. The review is written to address the various aspects of stroke in the KSA, based on current literatures search using PubMed, Scopus, Web of Science and Google Scholar databases, to identify studies published since inception to Dec 2020.

External Apical Root Resorption and IL-1A, IL-1RN Gene Polymorphisms: A Systematic Review and Meta-Analysis of Prospective Studies

ABSTRACT Objective: To reconnoiter the IL-1A (-889) and IL-1RN (+2018) gene polymorphisms and their association with EARR. Material and Methods: The Science Direct, PubMed and Scopus databases were comprehensively searched by two independent reviewers. In addition, the bibliographies of all relevant publications and textbooks were searched manually. A meta-analysis was performed using data available up to May 9, 2020. Results: A total of 13 and 9 publications were selected for the systematic review and meta-analysis, respectively for both IL-1A and IL-1RN genes. Odds ratio (OR) was used to evaluate the association of the gene polymorphism and the risk of EARR. The risk of EARR was estimated using the overall OR from the published studies. No association was found for IL-1A gene for the risk of EARR. However, the dominant and co-dominant models of IL-1RN gene polymorphism were associated with the risk of EARR. Conclusion: More studies are warranted to determine the relationship between IL-1A and IL-1RN gene polymorphisms and EARR for a clearer understanding of their interactions.

Soft Tissue Cephalometric Measurements Among Malaysian Malays and Chinese

Abstract Objective: To obtain the standardized values of individuals of Malaysian Malay and Chinese for further relevant research, such as treatment planning and aesthetical considerations. Material and Methods: In this retrospective study, 440 (305 were Malays and 135 were Chinese) standardized lateral cephalometric radiographs of orthodontic patients selected through simple random sampling are profiled using Holdaway's analysis. The independent t-test was used to assess the disparities in race and gender. The significant level was p<0.05. Results: Significant differences were found between the Malays and Chinese in their skeletal profile convexity, superior sulcus depth, inferior sulcus to the H line and nose prominence. Between Malay females and males, there are significant differences in superior sulcus depth, soft tissue subnasale to H line, basic upper lip thickness, upper lip thickness and nose prominence. Between Chinese males and females, there were differences in their skeletal profile convexity, upper lip to H line, basic upper lip thickness and upper lip thickness. Conclusion: The findings demonstrated the difference between standardized norms and the unique profiles of Malaysian Malays and Chinese. There are significant gender disparities in the soft tissue cephalometric measurements among Malaysian Malay and Chinese subjects.

Class III Malocclusion: Missense Mutations in DUSP6 Gene

Objective: To determine the DUSP6 gene mutation in three generations of Malaysian Malay subjects having Class III malocclusion. Material and Methods: Genetic analyses of DUSP6 gene were carried out in 30 subjects by selecting three individuals representing three generations, respectively, from ten Malaysian Malay families having Class III malocclusion and 30 healthy controls. They were submitted Clinical Evaluation to clinical examination, lateral cephalometric radiographs, dental casts, and/ or facial and intra-oral photographs. Buccal cell was taken from each participant of Class III malocclusion and control groups. DNA extractions from buccal cell were carried out using Gentra puregene buccal cell kit. Bio Edit Sequence Alignment Editor software was used to see the sequencing result. Results: A heterozygous missense mutation c.1094C>T (p. Thr 365 Ile) was identified in DUSP6 gene in three members of one family with Class III malocclusion, whereas no mutation was found in the control group. Conclusion: Current study successfully identified a missense mutation in DUSP6 gene among one Malaysian Malay family affected by Class III malocclusion. The outcome of this study broadened the mutation spectrum of Class III malocclusion and the importance of DUSP6 gene in skeletal functions.

Association between genetic polymorphisms and external apical root resorption: A systematic review and meta-analysis.

OBJECTIVE: To date, only a few studies have investigated the relationships between genetic polymorphisms and external apical root resorption (EARR). Hence, the aim of this systematic review was to explore the relationship between different gene polymorphisms and their association with EARR. METHODS: A complete literature search was conducted by two independent reviewers. The PubMed, Science Direct, and Scopus databases were searched. In addition, the bibliographies of all textbooks and relevant articles were searched manually. A meta-analysis was performed using data entered into the electronic databases until February 28, 2017. RESULTS: On the basis of the search, we identified 17 and 7 publications for the systematic review and meta-analysis, respectively. Odds ratio (OR) was used to evaluate the association of the interleukin 1B (+3954) polymorphism and the risk of EARR. The overall OR from the studies was used to estimate the risk of EARR. However, no association was found and no publication bias was apparent for the risk of EARR in patients receiving orthodontic treatment. CONCLUSIONS: More research on the relationship between gene polymorphism and EARR is necessary to determine better specificity of possible interactions.

Association between muscle activity and overjet in class II malocclusion with surface electromyography.

OBJECTIVES: The aim of the study was to assess the association and correlation between the overjet and muscle activity (the masseter and temporalis muscles) in patient with Class II malocclusion in different genders using surface electromyography (sEMG). MATERIALS AND METHODS: The overjet (measured clinically) and electromyographical activity (rest, chew, post chew rest, clench and post clench rest) of the masseter and temporalis muscle of class II malocclusion patient were assessed in 18 patients (3 males and 15 females) from the School of Dental Science, Hospital University Sains Malaysia. RESULTS: The results were compared by simple linear regression test to evaluate the association between overjet and muscle activity in different genders. Class II malocclusion patients with increased overjet group showed significant association with masseter muscle activity on chewing stage (P = 0.005, F = 6.081 and adj-R2 = 0.473). Left temporalis muscle in class II malocclusion showed a significant linear association (P = 0.014, F = 0.812 and adj-R2= -0.034) with gender during clench. CONCLUSION: In conclusion, class II malocclusion patient with increased overjet can affect masticatory muscle function and as well as clench force may differ in gender.

3D CBCT morphometric assessment of mental foramen in Arabic population and global comparison: imperative for invasive and non-invasive procedures in mandible.

BACKGROUND: Recent advancements in clinical dentistry have increased the possibilities of surgical procedures in the mental region. A detailed knowledge of mental foramen (MF) morphometry is significant to preserve integrity of the mental nerve trunk in surgical interventions such as orthognathic surgery, implant placement and anaesthetic block. OBJECTIVE: The aim of this study was to determine the most accurate position of the mental foramen by using new assessment approach in a sample of dental patients presenting to the specialist dental clinic, College of Dentistry, Al Jouf University, Saudi Arabia. STUDY DESIGN: A retrospective study was performed using cone beam computed tomography (CBCT) of 600 patients (40.1 ± 11.78 years old). Following inclusion and exclusion criteria, 395 CBCT were finally obtained and analyzed for the most accurate position of the mental foramen (MF) by OnDemand 3D software (Seoul, Korea). Prevalence of shape of MF and accessory MF were also assessed. Pearson chi-square test was employed to test significant differences between genders and races. RESULTS: The most common horizontal and vertical position of the mental foramen was in line with the long axis of 2nd premolar (41.3%) and below the root apex level (93.2%), respectively. The most common shape of MF was round type (72.66%). The prevalence of accessory 2MF and 3MF was 2.28% and 0.25%, respectively. CONCLUSION: New information about MF presented in this article can help anatomists, prosthodontists, orthodontists, surgeons, forensic odontologists and paleoanthropologists to predict the position of the MF and perform safer surgeries.

Uses of electromyography in dentistry: An overview with meta-analysis.

OBJECTIVE: The purpose of this study was to review the uses of electromyography (EMG) in dentistry in the last few years in related research. EMG is an advanced technique to record and evaluate muscle activity. In the previous days, EMG was only used for medical sciences, but now EMG playing a tremendous role in medical as well as dental sector. MATERIALS AND METHODS: Several electronic databases such as Google Scholar, PubMed, Science Direct, and Web of Science were systematically searched for studies published until July 2015. RESULTS: EMG can be used in both diagnosis and treatment purpose to record neuromuscular activity. In dentistry, we can utilize EMG to evaluate muscular activity in function such as chewing and biting or parafunctional activities such as clenching and bruxism. In case of TMJ and myofascial pain disorders, EMG widely is used in the last few years. CONCLUSIONS: EMG is one of biometric tests that occur in the modern evidence-based dentistry practice.

Correction: Dental Implants - Perceiving Patients' Satisfaction in Relation to Clinical and Electromyography Study on Implant Patients.

[This corrects the article DOI: 10.1371/journal.pone.0140438.].

Multiracial Facial Golden Ratio and Evaluation of Facial Appearance.

UNLABELLED: This study aimed to investigate the association of facial proportion and its relation to the golden ratio with the evaluation of facial appearance among Malaysian population. This was a cross-sectional study with 286 randomly selected from Universiti Sains Malaysia (USM) Health Campus students (150 females and 136 males; 100 Malaysian Chinese, 100 Malaysian Malay and 86 Malaysian Indian), with the mean age of 21.54 ± 1.56 (Age range, 18-25). Facial indices obtained from direct facial measurements were used for the classification of facial shape into short, ideal and long. A validated structured questionnaire was used to assess subjects' evaluation of their own facial appearance. The mean facial indices of Malaysian Indian (MI), Malaysian Chinese (MC) and Malaysian Malay (MM) were 1.59 ± 0.19, 1.57 ± 0.25 and 1.54 ± 0.23 respectively. Only MC showed significant sexual dimorphism in facial index (P = 0.047; P<0.05) but no significant difference was found between races. Out of the 286 subjects, 49 (17.1%) were of ideal facial shape, 156 (54.5%) short and 81 (28.3%) long. The facial evaluation questionnaire showed that MC had the lowest satisfaction with mean score of 2.18 ± 0.97 for overall impression and 2.15 ± 1.04 for facial parts, compared to MM and MI, with mean score of 1.80 ± 0.97 and 1.64 ± 0.74 respectively for overall impression; 1.75 ± 0.95 and 1.70 ± 0.83 respectively for facial parts. IN CONCLUSION: 1) Only 17.1% of Malaysian facial proportion conformed to the golden ratio, with majority of the population having short face (54.5%); 2) Facial index did not depend significantly on races; 3) Significant sexual dimorphism was shown among Malaysian Chinese; 4) All three races are generally satisfied with their own facial appearance; 5) No significant association was found between golden ratio and facial evaluation score among Malaysian population.

Dental Implants - Perceiving Patients' Satisfaction in Relation to Clinical and Electromyography Study on Implant Patients.

The aim of this study is to evaluate the satisfaction of patients with posterior implants in relation to the clinical success criteria and surface electromyography (sEMG) findings of the masseter and temporalis muscles. Total 42 subjects were investigated. Twenty one subjects with posterior dental implants were interviewed using a questionnaire and the clinical success criteria were determined based on The International Congress of Oral Implantologists. The myofunction of the masticatory muscles were assessed using sEMG (21 subjects) and compared to the control group of subjects without implants (21 subjects). Out of 21 subjects, all were satisfied with the aesthetics of their implant. Twenty of them (95.2%) were satisfied with its function and stability. As for clinical criteria, 100% (50) of the implants were successful with no pain, mobility or exudates. sEMG findings showed that patients have significantly lower (p<0.01) basal or resting median power frequency but with muscle burst. During chewing, control subjects showed faster chewing action. There was no difference in reaction and recovery time of clenching for both groups. In conclusion, the satisfaction of implant patients was high, and which was in relation to the successful clinical success criteria and sEMG findings.

Burden of bacterial meningitis: a retrospective review on laboratory parameters and factors associated with death in meningitis, kelantan malaysia.

To describe the clinical characteristics and the risk factors associated with mortality in patients with meningitis. This is a retrospective review of patients diagnosed to have meningitis with positive culture of the cerebrospinal fluid (CSF) specimen. All cases aged 19 > years who were admitted to Hospital USM between January 2004 and December 2011 were included in the study. The CSF results database were obtained from the Department of Medical Microbiology and Parasitology, Hospital USM, Kelantan. A checklist was used to record the clinical characteristics. A total of 125 cases met the inclusion criteria. The age of patients ranged between newborn and 19 years old (Mean±SD, 74.5±80.6 months). The majority of them were males (65.6%). Fever was the most common presentation (73.6%) followed by poor oral intake (48.0%), seizure (36.0%) and headache (24.8%). The mortality rate was 31.2%. Coagulase negative staphylococcus was the most frequent pathogens isolated (21.6%), followed by Acinetobacter spp. (17.6%), Staphylococcus aureus (13.6%), Streptococcus spp. (11.2%) and Klebsiella pneumoniae (6.4%). There were significant association of in-hospital death with age (p=0.020) and conscious level (p=0.001). Infectious meningitis is a big health concern, especially among children. We found that coagulase negative staphylococcus, Acinetobacter species, S. aureus, Streptococcus spp and K. pneumoniae were prevalent in our hospital. These microorganisms were hospital associated pathogens. The 31% mortality linked to hospital acquired meningitis specifies the need for focused physician attention especially among younger aged patients.