Performance based financing and job satisfaction in a semiurban health district in Cameroon.

The performance based financing approach is being tested in four regions of Cameroon, including the Littoral region. Our study aimed to study the effects associated with the implementation of the performance based financing approach within the health facilities based in the health district of Edea in the Littoral region in Cameroon. We've carried out a crosssectional analytical study among 178 health personnel from 21 health facilities under PBF-contract within the health district of Edea. We have studied their sociodemographic characteristics, the individual and collective effects resulting from the performance based financing subsidies and the level of job satisfaction. Participants' job satisfaction was measured with the French version of the Minnesota satisfaction scale. The results were presented in a descriptive and analytical form at the alpha = 5% and the P-value 5%. We recruited 113 women and 65 men. The mean age was 39.19 ± 8.95 years. The individual results of the performance based financing were the regular collection of subsidies between F CFA 20-40.000 (42.1%), the improvement of working conditions (74.2%) and living conditions (67.4%) and the acquisition of new skills (69.7%). Collectively, participants confirmed the increase of the users attendance (65.7%), the improvement of the internal organization (79.8%), the purchase of new equipment (84.3%) and the improved quality of health care (86%). Satisfaction is influenced by age (P=0.016), gender (P=0.01), occupational category (P=0.04), type of health facility (P=0.02) and the amount of subsidies (P=0.03). The healthcare personnel's were satisfied with the improvement of their social conditions (66.67%), working conditions (62.88%), the transparency in health centers management (69%) and their involvement in the health centers' functioning (76.6%). Participants were dissatisfied with their salaries (70.2%) and the lack of opportunities for advancement (47.8%). The positive effects of the performance based financing approach contributed to the job satisfaction of the healthcare workers in the Edea health district. These results should prompt the government to extend the performance based financing approach to communities and other health districts in Cameroon.

Color vision deficiency among biomedical students: a cross-sectional study.

PURPOSE: To determine the prevalence of color vision deficiency (CVD) among first-cycle students of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I. PATIENTS AND METHODS: A cross-sectional descriptive study was carried out between October 1, 2015 and May 31, 2016. Distant visual acuity was measured and color vision test done for all consenting students. Ishihara's plates were used to test all the participants. Those who failed the test were tested with the Roth's 28 Hue test for confirmation of CVD and classification. RESULTS: A total of 303 students were included, among whom 155 were males (50.8%) and 148 were females (49.2%). The mean age was 20.2±2 years. Five students (1.6%) failed the Ishihara's plate testing. Roth's 28 Hue test confirmed CVD in 4 of those cases, giving a prevalence of 1.3%. There were equal numbers of protan and deutan CVD. CONCLUSION: Despite its low prevalence among first-cycle students of the Faculty of Medicine and Biomedical Sciences, CVD screening should be performed in order to raise awareness, which will go a long way to help orientate the choice of future specialty.

Stages of development of traditional simulation unit of surgery for manual extra capsular cataract extraction in sub-Saharan African region.

The manual extracapsular extraction of the lens is the surgical technique that is most practiced for the treatment of cataract in sub-Saharan Africa. Learning this technique requires the creation of a surgical simulation unit within training institutes. We describe the development stages of a traditional simulation unit. For this purpose, we present a description of four steps involved in the development of a simulation unit for cataract surgery: the physical creation of the room, the aseptic and antisepsis conditions, the management of the eyes, the development of a curriculum and the administrative policies.

Association of insulin treatment versus oral hypoglycaemic agents with diabetic retinopathy and its severity in type 2 diabetes patients in Cameroon, sub-Saharan Africa.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease associated with multiple macro and microvascular complications, diabetic retinopathy (DR) being the commonest one. Recent literature has reported an increased risk of DR with insulin use. METHODS: We carried out a cross-sectional study at the Ophthalmology Department of the Douala General Hospital (DGH) during a 2-year period to explore the association between insulin treatment and both DR and its severity as compared with oral hypoglycemic agents (OHAs) in Cameroonian T2DM patients aged ≥35 years, and who were all screened for DR through eye examination including exhaustive retinal evaluation. RESULTS: In total, medical files of 134 T2DM patients were analyzed. The frequency of DR was 54.1% among patients on OHA and 73.9% among those on insulin treatment, giving an overall frequency of 57.5%. There were significantly more OHA treated patients than insulin treated patients (82.8% vs. 17.2%, P<0.001). As expected, both the OHA and insulin groups were comparable by age, sex, duration of diabetes, past history of hypertension, alcohol misuse, and current tobacco smoking. DR was almost significantly more frequent in T2DM patients under insulin regimen than in patients under OHA [73.9% vs. 54.1%; odds ratio (OR) 2.4; 95% confidence interval (CI), 0.9-6.6; P=0.06]. Proliferative diabetic retinopathy (PDR) was significantly more observed in insulin treated patients than in OHA treated patients (34.8% vs. 15.3%; OR 2.95; 95% CI, 1.1-8; P=0.035). Irrespective of staging, the frequency of diabetic macular edema (DME) was significantly higher in the insulin group than in the OHA group (43.5% vs. 19.8%; OR 3.1; 95% CI, 1.2-8; P=0.019). CONCLUSIONS: Compared with OHA, insulin therapy may be associated with DR, DR severity and DME in these T2DM sub-Saharan African patients.

Diabetes and visual impairment in sub-Saharan Africa: evidence from Cameroon.

BACKGROUND: "Vision 2020 - the right to sight" is a program which purpose is to eliminate avoidable blindness by the year 2020 through the implementation of concrete action plans at the national and district levels. Accordingly, baseline data are needed for the planning, monitoring, follow-up and evaluation of this program. The present study aimed to better characterize visual impairment and blindness in Cameroonian diabetics by providing with baseline data on the prevalence and main causes of these affections. METHODS: This was a hospital-based cross-sectional study, conducted from October 2004 to October 2006 at the Department of Ophthalmology of the Douala General Hospital, Cameroon. We included 407 diabetic patients who were referred from diabetes clinics for ophthalmologic evaluation. Ophthalmologic data included visual acuity, intra-ocular pressure, fundoscopy and fluorescein angiography. RESULTS: The prevalence of blindness and poor vision were respectively 12.3% and 17.4% with regard to the worst eyes. Fifty nine (14.5%) patients were found with diabetic maculopathy, of whom 25.4% (15/59) had poor vision, and 25.4% (15/59) were blind. The prevalence of sight threatening retinopathy (severe non-proliferative and proliferative) was 17.4%. The degree of visual impairment was comparable in both diabetic types (p = 0.825), and it increased with the severity of retinopathy (p < 0.0001), as well as that of maculopathy (p <0.0001). The prevalence of glaucoma was 15% (61/407) when considering the worst eyes. The severity of visual impairment increased with the severity of glaucoma (p = 0.001). One hundred and twenty-one (29.7%) patients presented with cataract irrespective of its location or severity. Cataract was significantly associated with poor vision and blindness (p < 0.0001). Hypertensive retinopathy (4.9%), papillary ischaemia (2.7%), vaso-occlusive eye disease (2.5%), and age-related macular edema (2%) were the other potential causes of visual impairment and blindness encountered the most in our setting. Age ≥ 50 years, male sex, duration of diabetes and hypertension variously increased the risk of having glaucoma, cataract, diabetic retinopathy or maculopathy. CONCLUSION: Poor vision and blindness are frequent in Cameroonian diabetics, and their causes are similar to those reported by various other surveys: mainly cataract, glaucoma, diabetic retinopathy and maculopathy.

Epidemiology and treatment outcomes of diabetic retinopathy in a diabetic population from Cameroon.

BACKGROUND: Diabetic retinopathy (DR) is the most common microvascular complication of diabetes. It can lead to significant visual loss. The aim of this study was to determine the frequency and clinical profile of diabetic retinopathy, and assess the outcomes of laser photocoagulation therapy in a diabetic population in Cameroon. METHODS: We carried out a prospective cohort study during 24 months in the Department of Ophthalmology of the Douala General Hospital, Cameroon. We included all diabetic patients who were referred from diabetes clinics for ophthalmologic evaluation. Data included type and duration of diabetes, visual acuity, intra-ocular pressure, results of fundoscopy and fluorescein angiography, and outcomes two months after treatment with laser photocoagulation. RESULTS: We included 407 patients; 88% had type 2 diabetes. Their mean duration of diabetes was 6.4 years (SD=6.6). Forty point three percent (164/407) of patients were found to have DR on fundoscopy. Of the 164 patients with DR, 63.4% (104/164) had non-proliferative and 36.6% (60/164) had proliferative DR. Diabetic maculopathy was found in 14.5% (59/407) of all participants, and 36% (59/164) of patients with DR. There was a strong correlation between the duration of diabetes and retinopathy status (p < 0.001, r = 0.9541). Overall, 17.4% (71/407) of patients were eligible for laser photocoagulation. Of these, 66.2% (47/71) were treated, and 78.7% (37/47) of treated patients came back for control two months later. Among these treated patients an improvement of the retinopathy was noted in 73% (27/37), no change in 16.2% (6/37) and a worsening in 10.8% (4/37). Severe proliferative DR was significantly associated with treatment failure (p < 0.001). CONCLUSIONS: The frequency of DR may be high among diabetic patients in Cameroon. There was a good uptake of laser photocoagulation therapy among patients affected by DR in our setting, with good treatment outcomes. Interventions to prevent diabetes and increase the precocity of diagnosis and treatment of DR should be scaled up.

Refractive errors in Cameroonians diagnosed with complete oculocutaneous albinism.

BACKGROUND: Albinism causes significant eye morbidity and amblyopia in children. The aim of this study was to determine the refractive state in patients with complete oculocutaneous albinism who were treated at the Gynaeco-Obstetric and Paediatric Hospital, Yaoundé, Cameroon and evaluate its effect on vision. METHODS: We carried out this retrospective study at the ophthalmology unit of our hospital. All oculocutaneous albino patients who were treated between March 1, 2003 and December 31, 2011 were included. RESULTS: Thirty-five patients (70 eyes) diagnosed with complete oculocutaneous albinism were enrolled. Myopic astigmatism was the most common refractive error (40%). Compared with myopic patients, those with myopic astigmatism and hypermetropic astigmatism were four and ten times less likely, respectively, to demonstrate significant improvement in distance visual acuity following optical correction. CONCLUSION: Managing refractive errors is an important way to reduce eye morbidity-associated low vision in oculocutaneous albino patients.

Eye malformations in Cameroonian children: a clinical survey.

SUMMARY: The aim of this work was to describe the clinical aspects of eye malformations observed at the ophthalmology unit of the Yaoundé Gynaecology, Obstetrics and Pediatrics Hospital. PATIENTS AND METHODS: We carried out a retrospective study of all malformations of the eye and its adnexae observed among children aged 0-5 years who were seen at the ophthalmology unit from January 2003 to December 2009. RESULTS: Out of the 2254 children who were examined, 150 (6.65%) presented eye malformations. The mean age was 14.40 ± 4 months. Eye malformations were diagnosed in 71.66% of cases during the first year of life. The most frequent malformations were congenital lacrimal duct obstruction (66.66%), congenital cataract (10.9%), congenital glaucoma (10.9%), microphthalmos (5.03%), and congenital ptosis (3.77%). CONCLUSION: Eye malformations among children can lead to visual impairment and are a cause for discomfort to children and parents. Therefore, systematic postnatal screening is recommended to enable early management.

Prevalence and causes of blindness at a tertiary hospital in Douala, Cameroon.

PURPOSE: The aim of this study was to determine the prevalence and causes of bilateral and unilateral blindness in the town of Douala and its environs based on data from the ophthalmic unit of a tertiary hospital in Douala. METHODS: We conducted a retrospective epidemiological survey of consultations at the eye unit of the Douala General Hospital over the last 20 years (from January 1, 1990 to December 31, 2009). RESULTS: Out of the 1927 cases of blindness, 1000 were unilateral, corresponding to a hospital prevalence of 1.84% and 927 cases were bilateral, corresponding to a hospital prevalence of 1.71%. No statistically significant difference was noted between the two (P = 0.14). The leading causes of bilateral blindness were cataract (50.1%), glaucoma (19.7%), and diabetic retinopathy (7.8%) while the leading causes of unilateral blindness were cataract (40.4%), glaucoma (14.1%), and retinal detachment (9.1%). Cataract (51.2%), cortical blindness (16.3%), and congenital glaucoma (10%) were the leading causes of bilateral blindness in children aged less than 10 years. CONCLUSION: Blindness remains a public health problem in the Douala region with a hospital prevalence which is relatively higher than the national estimate given by the National Blindness Control Program.

Secondary cataract: an epidemiologic and clinical survey at the Yaounde Gynaeco-obstetric and Paediatric Hospital.

OBJECTIVE: To determine the incidence and risk factors of secondary cataract. MATERIALS AND METHODS: A retrospective study involving a review of medical records in the ophthalmology unit of the Yaoundé Gynaeco-obstetric and Paediatric Hospital in Yaoundé, Cameroon, was carried out. All patients who had cataract surgery between January 2006 and September 2010 were included. Variables included age, sex, past medical history, morphology of primary cataract, type of surgery, intraocular lens implantation, site of implantation, intra- and postoperative complications, and the time lapse for the presentation of secondary cataract. Both univariate and bivariate analyses were carried out. The χ(2) test was used to compare proportions, and P-values <0.05 were considered statistically significant. RESULTS: A total of 864 eyes of 718 patients had cataract surgery. Ninety-two eyes developed posterior capsule opacification, giving an incidence of 10.65%. The mean age of patients who developed secondary cataract was 52.3 ± 23.05 years, with a range of 4 years to 84 years. Secondary cataract was more frequent in the age group of 0-20 years. The time lapse for presentation of secondary cataract was 64.7 ± 9.53 days, with a range of 1 to 504 days. Risk factors for the development of secondary cataract were age (P = 0.000), sex (P = 0.011), cortical cataract (P = 0.000), and postoperative inflammation (P = 0.000). CONCLUSION: The incidence of secondary cataract, though high in this study, is lower than that reported in other studies.

Indications for destructive eye surgeries at the Yaounde Gynaeco-Obstetric and Paediatric Hospital.

OBJECTIVE: To determine the indications and rate of acceptance for destructive eye surgeries at the ophthalmology unit of the Yaoundé Gynaeco-Obstetric and Paediatric Hospital. METHODS: A retrospective consecutive case series in which the medical records of all patients consulting in this unit over a 9-year period (2002 to 2010) were reviewed. Records in which destructive surgery was recommended were retained. Information collected included demographic data, eye affected, clinical diagnosis, acceptance or refusal of surgery, and the outcome in those in whom surgery was performed. RESULTS: A total of 48 patients had a recommendation for destructive eye surgery, of whom 30 (62.5%) were males and 18 (37.5%) were females. Mean age was 43.78 (SD = 28.11; range 1 month to 91 years). Children <10 years comprised 23.10%. The leading causes were endophthalmitis/panophthalmitis (47.9%), neoplasm (20.8%), and absolute glaucoma (14.6%). Surgery was done in 20 cases (41.7%). Evisceration was the most performed surgical procedure (50%), with endophthalmitis/panophthalmitis and neoplasm combined accounting for 65% of surgeries. CONCLUSION: The high rate of refusal is an indication of the psychological devastation undergone by patients or the families of children in whom eye removal is recommended. Awareness should be raised on preventive measures and the need to rapidly seek eye care.

Central corneal thickness and intraocular pressure in the Cameroonian nonglaucomatous population.

AIM: We performed a prospective, analytical study from 01 January to 31 March 2009 in the Ophthalmology Unit of the Gyneco-Obstetric and Pediatric Hospital of Yaounde, aiming to determine the profile of central corneal thickness (CCT) in the Cameroonian nonglaucomatous black population and its relationship with intraocular pressure (IOP). RESULTS AND DISCUSSION: Four hundred and eighty-five patients (970 eyes) meeting our inclusion criteria were selected for this study. The average CCT was 529.29 +/- 35.9 mum in the right eye (95% confidence interval [CI]: 526.09-532.49), 528.19 +/- 35.9 mum in the left eye (95% CI: 524.99-531.40) and 528.74 +/- 35.89 mum in both eyes (95% CI: 526.48-531.00), range 440 to 670 mum. The average IOP was 13.01 +/- 2.97 mmHg in both eyes (95% CI: 12.82-13.19). A rise in CCT by 100 mum was followed by an increase in IOP of about 2.8 mmHg (95% CI: 2.3-3.6) for both eyes taken together. Linear regression analysis showed that corneal thickness was negatively correlated with age and IOP was positively related with age. CONCLUSION: CCT in the Cameroonian nonglaucomatous black population was found to be lower compared with CCT values in Caucasian and Asian populations. On the basis of reference values ranging between 527 and 560 mum, an adjustment of IOP values by a correction factor is required for many Cameroonian patients. This will improve the diagnosis and follow-up of glaucoma by helping to detect true ocular hypertension.

[Eye disease in children aged 6 to 15 years: a hospital-based study in Yaounde]. / La pathologie oculaire de l'enfant âgé de 6 à 15 ans: étude hospitalière à Yaoundé.

UNLABELLED: This prospective study was conducted in the ophthalmology department of the Gynaeco-Obstetric and Paediatric Hospital in Yaoundé and included 422 children recruited from January to April 2008. The aim was to identify the eye diseases seen frequently seen in school-aged children from 6 to 15 years and examine their epidemiological characteristics. RESULTS AND DISCUSSION: The study group included 201 boys and 221 girls, with a mean age of 10,3 +/- 3.2 years. The most frequent disease was ametropia (refractive errors, 43.1%), including hyperopia, which had a prevalence of 23.7% Conjunctival disorders came next, accounting for 33%, more than half due to tropical endemic limbo conjunctivitis (17.8%). Binocular blindness affected 0.9% (n = 4), and low vision 0.7% (n = 3). CONCLUSION: This study, the first in its kind for the age group of 6-15 years in a developing country, allowed us to identify refractive errors as the principal complaint in consultations and led us to propose a reinforcement of screening in schools.

Prevalence and etiologies of visual handicaps in leprosy patients in the south of Cameroon.

UNLABELLED: We report on a prospective study undertaken in April 2008, in 11 leper villages of the Southern Cameroon. Our aim was to determine the prevalence and the causes of bilateral blindness, low vision and unilateral blindness in the population of leprosy patients, irrespective of the clinical aspects of the illness. RESULTS: Two hundred thirty-five known and newly diagnosed leprosy patients were examined. These patients included 149 cases (63.4%) of multibacillary leprosy and 86 cases (36.6%) of paucibacillary leprosy. There were 111 case of visual handicap, representing 47.2% of the population. These visual handicap cases were subdivided into 45 cases (19%) of bilateral blindness, 35 cases (15%) of unilateral blindness and 31 cases (13.2%) of low vision. DISCUSSION: The prevalence of visual handicap among leprosy patients in Cameroon is too high. Causes in the majority of cases are age-related degenerative pathologies, and one third of cases are linked to the leprosy mycobacterium. CONCLUSION: Discovering a cure for ophthalmic pathologies is important in order to provide a better quality of life for this particular population.

Unilateral childhood blindness: a hospital-based study in Yaoundé, Cameroon.

INTRODUCTION: We performed an analytic and prospective study over a period of 12 months from January 2nd to December 31st, 2008, at the Gynaeco-Obstetric and Paediatric Hospital of Yaoundé, Cameroon. Our aim was to determine the prevalence and causes of unilateral blindness in school children aged 6 to 15 years. RESULTS: Among the 1,266 children aged 6 to 15 years who were recruited, 60 presented with unilateral blindness (4.7%): 42 boys (6.96%) and 18 girls (2.71%). The mean age was 10.15 +/- 3.4 years. In patients with unilateral blindness, 65% was due to ocular trauma. DISCUSSION: The hospital-based prevalence of unilateral blindness in children is relatively high and ocular trauma is the leading etiology. CONCLUSION: Unilateral blindness in school children is avoidable and its incidence could be markedly reduced by emphasizing an information strategy and education based on prevention of ocular trauma. Early management of nontraumatic diseases such as infantile glaucoma and some tumors could improve outcome and avoid blindness.

Intraocular live male filarial Loa loa worm.

We report a case of Loa loa filariasis in an 8-month-old child who presented with a 3-month history of irritated acute red eye and insomnia. Examination revealed a living and active adult Loa loa worm in the anterior chamber of the left eye. The worm was extracted under general anesthetic.

Surgical management of primary exotropia in Cameroon.

AIM: To assess the results of surgery of primary exotropia in Cameroon. PATIENTS AND METHODS: This is a retrospective study of all patients operated for primary exotropia in the Reference Hospital, Douala-Cameroon, between January 1992 and December 2005. Each case was operated once. The preoperative squint angle was measured the previous evening to surgery and the postoperative angle one year after surgery. The result was considered good when the postoperative angle was less than 10 prismatic dioptries (PD < 10). RESULTS: 61.3% of the 41 patients operated had good results. The average age of patients at the time of surgery was 18.7 years +/- 11.2. 80% of the patients had bilateral recession of the lateral recti and resection of the medial rectus of the more squinting eye under general anesthesia. The average preoperative angle of deviation was 44 +/- 9.5 PD and the average postoperative angle was 7.4 +/- 6.6 PD. None of the following factors affected the postoperative result: age at which squint manifested, preoperative angle, age at surgery, surgical technique, presence of amblyopia and whether the squint was intermittent or constant. CONCLUSION: Our results are encouraging and reinforce our plea for the training of more ophthalmologists and the equipment of more hospitals for squint surgery.

[Prevalence of glaucomas in a Black Cameroonian population]. / La prévalence des glaucomes dans une population de Noirs camerounais.

OBJECTIVES: To determine the prevalence and the various types of glaucoma in a Black urban Cameroonian population. MATERIAL AND METHOD: A retrospective analysis of 1,343 glaucomatous patients' files (757 men and 586 women) from a total of 24,462 Cameroonian patients of all ages was carried out from January 1991 to December 2001 in the Douala General Hospital in Cameroon in Central Africa. RESULTS: The prevalence of glaucoma of all types is 5.5%. It increases with age. Of subjects with glaucoma, 79.6% had not been previously diagnosed. The mean patient's age is 53.3 (+/-17.1) years. The mean intraocular pressure is 29.6 (+/-12.6) mmHg. The mean vertical cup-disc ratio is 0.7 (+/-0.2). The prevalence of primary glaucoma of any type is 4.5%. The overall prevalence of primary open-angle glaucoma, primary angle-closure glaucoma and congenital glaucoma was 4.3%, 0.03% and 0.07%, respectively. The normal-tension glaucoma is rare in this study (6.3% of primary open-angle glaucoma).The most common form of primary angle closure glaucoma is chronic angle closure glaucoma (61,1%) and is usually undiagnosed due to a lack of gonioscopic evaluation. The prevalence of secondary glaucoma of any type is 1%. The most common forms of secondary angle closure glaucoma were neovascular glaucoma (47.4% of cases with the prevalence of 0.5%) and post-traumatic glaucoma (23.1% of cases with the prevalence of 0.2%). Prevalence of bilateral and monocular blindness due to glaucoma is 8% (108/1,343) and 32.9% (441/1,343) respectively of glaucoma patients. CONCLUSION: This study confirms the high prevalence of glaucoma in a black African population. Gonioscopy is an important diagnostic tool that should be promoted to guide more effective glaucoma treatment in our region. The very high rate of blindness among the glaucoma patients in Cameroon is due to a lack of care. The patients are young, the disease is advanced, and compliance and follow-up are poor. Glaucoma surgery therefore offers a favourable option from an economical standpoint. Glaucoma is a devastating disease and constitutes a significant public health problem.

[Torticollis in a group of strabismic patients in Cameroon]. / Le torticolis dans une population de strabiques camerounais.

PURPOSE: Our aim was to study the characteristics of torticollis in a group of strabismic patients in Cameroon. PATIENTS AND METHODS: This was a prospective study carried out in the ophthalmology service of the General Hospital, Douala from January 1991 to December 2004. All strabismic patients followed up in our service were included in this study and they all had a complete strabologic and ophthalmological examination. Torticollis was analysed using photographs and classified according to its configuration, degree and variability. RESULTS: We examined 379 strabismic patients of which 227 were divergent (59.9%) and 152 convergent (40.1%). We found 166 cases of torticollis (43.8%). This pathology was found in 52.6% of patients with esotropia versus 37.9% in exotropia. Torticollis was classified as severe in 14.5% of patients, moderate in 45.8% and mild in 39.7%. Two out of three early esotropias had alternating torticollis. In congenital monophthalmus syndrome, torticollis was found in 68.4% of cases and in 100% of cases with the alphabetic syndrome. Moreover 63.8% of strabismics with torticollis have astigmatism. CONCLUSION: Torticollis in strabismic patients is a cause for concern as it is frequent and its functional consequences are severe.