ABSTRACT
Neutrophil myeloperoxidase (MPO) is an essential enzyme for the innate immune system. Measuring MPO activity is vital for understanding neutrophil characteristics and functions in various diseases. MPO activity can be measured using several methods, including spectrophotometric and fluorometric protocols. This paper introduces a fluorometric method for specifically quantifying MPO activity based on the H2O2-dependent oxidation of thiamine. We optimized this new method using the robust statistical approach response surface methodology (RSM) and Box Benken Design (BBD). We extensively examined the effects of several experimental parameters using the RSM methodology and determined the best conditions for accurate and sensitive MPO activity measurement. The optimal conditions were determined using the analysis of variance (ANOVA) for second-order polynomial equations. The resulting F-value (4.86) indicated that the model was significant. However, the lack-of-fitness F-value (1.79) suggested it did not differ significantly from the corresponding p-value. The greatest MPO activity (30 ± 2 U L-1) was obtained under optimum conditions, which were 1000 µM of H2O2, 10 min incubation time, and 1000 µM of thiamine. Our results suggest that this advanced fluorometric method has significant accuracy, sensitivity, and linearity up to 60 IU. The new and standard colorimetric methods also showed a good correlation. These results indicate that the new fluorometric method can be dependable and efficient for assessing MPO activity. The new method is characterized by excellent accuracy, sensitivity, and linearity, making it a valuable protocol for researchers and clinicians interested in assessing MPO activity.
Subject(s)
Hydrogen Peroxide , Peroxidase , Peroxidase/metabolism , Neutrophils/metabolism , Oxidation-Reduction , ThiamineABSTRACT
Abstract Poultry industry is expanding rapidly and producing million tons of feather waste annually. Massive production of keratinaceous byproducts in the form of industrial wastes throughout the world necessitates its justified utilization. Chemical treatment of keratin waste is proclaimed as an eco-destructive approach by various researchers since it generates secondary pollutants. Keratinase released by a variety of microbes (bacteria and fungi) can be used for the effective treatment of keratin waste. Microbial degradation of keratin waste is an emerging and eco-friendly approach and offers dual benefits, i.e., treatment of recalcitrant pollutant (keratin) and procurement of a commercially important enzyme (keratinase). This study involves the isolation, characterization, and potential utility of fungal species for the degradation of chicken-feather waste through submerged and solid-state fermentation. The isolated fungus was identified and characterized as Aspergillus (A.) flavus. In a trial of 30 days, it was appeared that 74 and 8% feather weight was reduced through sub-merged and solid-state fermentation, respectively by A. flavus. The pH of the growth media in submerged fermentation was changed from 4.8 to 8.35. The exploited application of keratinolytic microbes is, therefore, recommended for the treatment of keratinaceous wastes to achieve dual benefits of remediation.
Resumo A indústria avícola está se expandindo rapidamente e produzindo milhões de toneladas de resíduos de penas anualmente. A produção massiva de subprodutos queratinosos na forma de resíduos agrícolas e industriais em todo o mundo exige sua utilização justificada. O tratamento químico de resíduos de queratina é proclamado como uma abordagem ecodestrutiva por vários pesquisadores, uma vez que gera poluentes secundários. A queratinase liberada por uma variedade de micróbios (bactérias e fungos) pode ser usada para o tratamento eficaz de resíduos de queratina. A degradação microbiana de resíduos de queratina é uma abordagem emergente e ecológica e oferece benefícios duplos, ou seja, tratamento de poluente recalcitrante (queratina) e obtenção de uma enzima comercialmente importante (queratinase). Este estudo envolve o isolamento, caracterização e utilidade potencial de espécies de fungos para a degradação de resíduos de penas de frango por meio da fermentação submersa e em estado sólido. O fungo isolado foi identificado e caracterizado como Aspergillus (A.) flavus. Em um ensaio de 30 dias, constatou-se que 74% e 8% do peso das penas foram reduzidos por A. flavus, respectivamente, por meio da fermentação submersa e em estado sólido. O pH do meio de crescimento em fermentação submersa foi alterado de 4,8 para 8,35. A aplicação explorada de micróbios queratinolíticos é, portanto, recomendada para o tratamento de resíduos ceratinosos para obter benefícios duplos de remediação.
Subject(s)
Animals , Chickens , Feathers , Fermentation , Fungi , Industrial Waste , Keratins/metabolismABSTRACT
Poultry industry is expanding rapidly and producing million tons of feather waste annually. Massive production of keratinaceous byproducts in the form of industrial wastes throughout the world necessitates its justified utilization. Chemical treatment of keratin waste is proclaimed as an eco-destructive approach by various researchers since it generates secondary pollutants. Keratinase released by a variety of microbes (bacteria and fungi) can be used for the effective treatment of keratin waste. Microbial degradation of keratin waste is an emerging and eco-friendly approach and offers dual benefits, i.e., treatment of recalcitrant pollutant (keratin) and procurement of a commercially important enzyme (keratinase). This study involves the isolation, characterization, and potential utility of fungal species for the degradation of chicken-feather waste through submerged and solid-state fermentation. The isolated fungus was identified and characterized as Aspergillus (A.) flavus. In a trial of 30 days, it was appeared that 74 and 8% feather weight was reduced through sub-merged and solid-state fermentation, respectively by A. flavus. The pH of the growth media in submerged fermentation was changed from 4.8 to 8.35. The exploited application of keratinolytic microbes is, therefore, recommended for the treatment of keratinaceous wastes to achieve dual benefits of remediation.
A indústria avícola está se expandindo rapidamente e produzindo milhões de toneladas de resíduos de penas anualmente. A produção massiva de subprodutos queratinosos na forma de resíduos agrícolas e industriais em todo o mundo exige sua utilização justificada. O tratamento químico de resíduos de queratina é proclamado como uma abordagem ecodestrutiva por vários pesquisadores, uma vez que gera poluentes secundários. A queratinase liberada por uma variedade de micróbios (bactérias e fungos) pode ser usada para o tratamento eficaz de resíduos de queratina. A degradação microbiana de resíduos de queratina é uma abordagem emergente e ecológica e oferece benefícios duplos, ou seja, tratamento de poluente recalcitrante (queratina) e obtenção de uma enzima comercialmente importante (queratinase). Este estudo envolve o isolamento, caracterização e utilidade potencial de espécies de fungos para a degradação de resíduos de penas de frango por meio da fermentação submersa e em estado sólido. O fungo isolado foi identificado e caracterizado como Aspergillus (A.) flavus. Em um ensaio de 30 dias, constatou-se que 74% e 8% do peso das penas foram reduzidos por A. flavus, respectivamente, por meio da fermentação submersa e em estado sólido. O pH do meio de crescimento em fermentação submersa foi alterado de 4,8 para 8,35. A aplicação explorada de micróbios queratinolíticos é, portanto, recomendada para o tratamento de resíduos ceratinosos para obter benefícios duplos de remediação.
Subject(s)
Aspergillus flavus/isolation & purification , Biotransformation , Keratins/analysis , Keratins/toxicityABSTRACT
Abstract Poultry industry is expanding rapidly and producing million tons of feather waste annually. Massive production of keratinaceous byproducts in the form of industrial wastes throughout the world necessitates its justified utilization. Chemical treatment of keratin waste is proclaimed as an eco-destructive approach by various researchers since it generates secondary pollutants. Keratinase released by a variety of microbes (bacteria and fungi) can be used for the effective treatment of keratin waste. Microbial degradation of keratin waste is an emerging and eco-friendly approach and offers dual benefits, i.e., treatment of recalcitrant pollutant (keratin) and procurement of a commercially important enzyme (keratinase). This study involves the isolation, characterization, and potential utility of fungal species for the degradation of chicken-feather waste through submerged and solid-state fermentation. The isolated fungus was identified and characterized as Aspergillus (A.) flavus. In a trial of 30 days, it was appeared that 74 and 8% feather weight was reduced through sub-merged and solid-state fermentation, respectively by A. flavus. The pH of the growth media in submerged fermentation was changed from 4.8 to 8.35. The exploited application of keratinolytic microbes is, therefore, recommended for the treatment of keratinaceous wastes to achieve dual benefits of remediation.
Resumo A indústria avícola está se expandindo rapidamente e produzindo milhões de toneladas de resíduos de penas anualmente. A produção massiva de subprodutos queratinosos na forma de resíduos agrícolas e industriais em todo o mundo exige sua utilização justificada. O tratamento químico de resíduos de queratina é proclamado como uma abordagem ecodestrutiva por vários pesquisadores, uma vez que gera poluentes secundários. A queratinase liberada por uma variedade de micróbios (bactérias e fungos) pode ser usada para o tratamento eficaz de resíduos de queratina. A degradação microbiana de resíduos de queratina é uma abordagem emergente e ecológica e oferece benefícios duplos, ou seja, tratamento de poluente recalcitrante (queratina) e obtenção de uma enzima comercialmente importante (queratinase). Este estudo envolve o isolamento, caracterização e utilidade potencial de espécies de fungos para a degradação de resíduos de penas de frango por meio da fermentação submersa e em estado sólido. O fungo isolado foi identificado e caracterizado como Aspergillus (A.) flavus. Em um ensaio de 30 dias, constatou-se que 74% e 8% do peso das penas foram reduzidos por A. flavus, respectivamente, por meio da fermentação submersa e em estado sólido. O pH do meio de crescimento em fermentação submersa foi alterado de 4,8 para 8,35. A aplicação explorada de micróbios queratinolíticos é, portanto, recomendada para o tratamento de resíduos ceratinosos para obter benefícios duplos de remediação.
ABSTRACT
Poultry industry is expanding rapidly and producing million tons of feather waste annually. Massive production of keratinaceous byproducts in the form of industrial wastes throughout the world necessitates its justified utilization. Chemical treatment of keratin waste is proclaimed as an eco-destructive approach by various researchers since it generates secondary pollutants. Keratinase released by a variety of microbes (bacteria and fungi) can be used for the effective treatment of keratin waste. Microbial degradation of keratin waste is an emerging and eco-friendly approach and offers dual benefits, i.e., treatment of recalcitrant pollutant (keratin) and procurement of a commercially important enzyme (keratinase). This study involves the isolation, characterization, and potential utility of fungal species for the degradation of chicken-feather waste through submerged and solid-state fermentation. The isolated fungus was identified and characterized as Aspergillus (A.) flavus. In a trial of 30 days, it was appeared that 74 and 8% feather weight was reduced through sub-merged and solid-state fermentation, respectively by A. flavus. The pH of the growth media in submerged fermentation was changed from 4.8 to 8.35. The exploited application of keratinolytic microbes is, therefore, recommended for the treatment of keratinaceous wastes to achieve dual benefits of remediation.
Subject(s)
Chickens , Feathers , Animals , Fermentation , Fungi , Industrial Waste , Keratins/metabolismABSTRACT
OBJECTIVE: To assess the levels and predictors of formaldehyde, nitrogen dioxide (NO2), carbon monoxide (CO) and fine particulate matter with diameter less than 2.5 µm (PM2.5) in Karachi, Pakistan.METHODS: A total of 1629 households were selected through multistage cluster sampling in a community-based cross-sectional survey. Formaldehyde, NO2 and CO levels were measured using YesAir Indoor air monitor and for PM2.5, UCB-PATS (University of California Berkeley Particle and Temperature Sensor) was used. Clusters were classified either as planned (areas of planned housing) or unplanned (informal settlements).RESULTS: We found the median concentrations to be as follows: formaldehyde, 0.03 ppm (IQR 0.00-0.090); CO, 0.00 ppm (IQR 0.00-1.00); NO2, 0 ppm (IQR 0.00-0.00) and PM2.5, 0.278 mg/m³ (IQR 0.162-0.526). We found a significant association of the upper quartiles of formaldehyde and PM2.5 levels with type of cluster. The risk of obtaining formaldehyde and PM2.5 levels in the upper quartile was higher in unplanned clusters than in planned clusters (adjusted odds ratio [aOR] 33.0, 95% CI 4.02-271.5 and aOR 0.10, 95% CI 0.001-0.16, respectively). No significant association was observed between levels of CO and cluster type (aOR 0.84, 95%CI 0.62-1.14).CONCLUSION: This study reports high levels of indoor air pollutants in Karachi, with considerable variation across planned vs. unplanned clusters.
Subject(s)
Air Pollutants , Air Pollution, Indoor , Air Pollution , Air Pollutants/adverse effects , Air Pollutants/analysis , Air Pollution/analysis , Air Pollution, Indoor/analysis , Cross-Sectional Studies , Environmental Monitoring , Humans , Pakistan , Particulate Matter/analysisABSTRACT
OBJECTIVE: To determine prevalence of and risk factors for respiratory symptoms in an adult urban Pakistani population.METHODS: We conducted a multi-stage, community-based, cross-sectional survey from May 2014 to August 2015, comprising 1629 adults from 75 random clusters in Karachi using questionnaire-based interviews.RESULTS: Around 60% of participants were females and 43% belonged to the >37 years age group. At least one respiratory symptom was reported by 37.5% of participants. Breathlessness was the most common symptom (25.2%, 95%CI 23.1-27.3), followed by acute wheeze (10.1%, 95%CI 8.7-11.7). Multivariable models revealed that males and those aged >37 years were more likely to report acute and chronic phlegm and bronchitis, and breathlessness. Participants with a higher level of education were less likely to report acute and chronic cough. Participants with >5 years pack-years of smoking were more likely to report acute and chronic cough and breathlessness. Other risk factors included passive smoking, regular use of air conditioning and mosquito coils, wet spots and mould in the house, and exposure to dusty jobs.CONCLUSION: We found breathlessness to be the most prevalent respiratory symptom and identified various risk factors for respiratory symptoms.
Subject(s)
Respiratory Sounds , Adult , Cross-Sectional Studies , Female , Humans , Male , Prevalence , Respiratory Sounds/etiology , Risk Factors , Urban PopulationABSTRACT
BACKGROUND: Uric acid (UA) is crucial for sperm metabolism as it protects seminal plasma against oxidative damage. Zinc also plays a central role in sperm metabolism. The current study was designed to investigate the role of zinc supplementation on qualitative and quantitative properties of seminal fluid, in parallel with the UA level and urate pathway enzymes in the semen of patients with asthenozoospermia. MATERIALS AND METHODS: The study was designed as a randomized controlled trial of 60 asthenozoospermic subfertile men. The current study, which was conducted during one year, involved 60 fertile and 60 asthenozoospermic subfertile men belonging to Hilla City, Iraq. Semen samples were obtained from the participants before and after treatment with zinc supplements. The levels of UA, xanthine oxidase (XO), adenosine deaminase (ADA) and 5'-nucleotidase (5'-NU) activities were determined in spermatozoa and seminal plasma of both groups. RESULTS: UA levels (P=0.034) and 5'-NU activity (P=0.046) were significantly lower but ADA (P=0.05) and XO (P=0.015) activities were significantly higher in infertile men than in healthy men. Treatment with zinc sulfate induced an increase in UA (P=0.001) level and 5'-NU activity (P=0.001), but a decrease in ADA (P=0.016) and XO (P=0.05) activities. CONCLUSION: Zinc supplementation restores UA levels and the activities of enzymes involved in the urate pathway (XO and ADA) in the seminal plasma and spermatozoa of patients with asthenozoospermia, to reference values. Supplementation of Zn compounds enhances the qualitative and quantitative properties of semen (Registration number: NCT03361618).
ABSTRACT
A thiol group plays an essential role in sperm metabolism and the antioxidative defense state. Zinc is the second most abundant element in the human body, following iron. The present study was conducted to study the effect of zinc supplementation on the characteristics of semen along with thiol and thiol-related enzymes in semen of asthenospermic patients. Semen samples were obtained from 60 fertile and 60 asthenospermic men, from couples who had consulted the infertility clinic of Babil Hospital (Hillah city, Iraq). The subfertile group was treated with zinc; every participant took two 220 mg capsules of zinc sulfate per day for 3 months. Semen samples were obtained (before and after zinc supplementation). The levels of reduced thiol, oxidized thiol, thiol oxido-reductive index, and thiol-related enzymes activities were determined in spermatozoa and seminal plasma of patients and healthy groups. Oxidized thiol levels were significantly higher in the infertile patients compared to that in the fertile group. Conversely, reduced thiol level, sulfhydryl oxidase activity, and glutathione peroxidase activity significantly decreased in the infertile patients compared to that in the fertile group. Oxidized thiol levels, reduced thiol levels, and thiol-related enzymes activities of the infertile patients were restored to normal values after treatment with zinc. However, reduced and oxidized thiol levels in spermatozoa did not change significantly in the group treated with zinc. The quantitative values for RSH/RSSR and thiol-related enzymes may provide useful means to qualitatively express the oxidant/antioxidant balance in clinical and epidemiologic studies. ClinicalTrials.gov Identifier: NCT02985905.
Subject(s)
Asthenozoospermia/metabolism , Semen/metabolism , Spermatozoa/metabolism , Sulfhydryl Compounds/metabolism , Zinc/administration & dosage , Administration, Oral , Adult , Antioxidants/metabolism , Asthenozoospermia/drug therapy , Asthenozoospermia/epidemiology , Dietary Supplements , Glutathione Peroxidase/metabolism , Humans , Iraq/epidemiology , Male , Oxidation-Reduction/drug effects , Oxidoreductases/metabolism , Semen/drug effects , Spermatozoa/drug effectsABSTRACT
BACKGROUND: Oxidative stress and decreased antioxidant levels have been projected as potential factors involved in the pathophysiology of diverse male infertility types, including asthenospermia. The present study was conducted to examine the effect of zinc supplementation on the quantitative and qualitative characteristics of semen along with oxido-sensitive index level (superoxide dismutase/xanthine oxidase ratio) in the seminal plasma of asthenospermic patients. METHODS: Semen samples were obtained from 60 fertile (age 31.6 ± 3.3 years) and 60 asthenospermic men (age 32.5 ± 3.23 years) from July 2011 to July 2012, from couples who had consulted the infertility clinic of the Babil hospital of maternity (Hillah, Iraq). The subfertile group was treated with zinc sulfate, every participant took 2 capsules (220 mg each) of zinc sulfate per day for 3 months. Semen samples were obtained (before and after zinc sulfate supplementation). Oxido-sensitive index level, catalase-like activity and various sperm parameters were measured. RESULTS: The value of the oxido-sensitive index of fertile controls (1.28 + 0.31 in seminal plasma and 1.57 + 0.62 in spermatozoa) was significantly higher than that of the infertile patient group (0.56 + 0.48 in seminal plasma and 0.65 + 0.57 spermatozoa) (p = 0.0001). Oxido-sensitive index levels were significantly higher in the infertile group treated with zinc sulfate (1.13 + 0.22 in seminal plasma and 1.15 + 0.16 in spermatozoa) (p = 0.001). Catalase-like activity was increased significantly in spermatozoa and seminal plasma of patients compared to that of healthy controls. Volume of semen, progressive sperm motility and total normal sperm count were increased after zinc supplementation. CONCLUSION: Zinc supplementation restores oxido-sensitive index and catalase-like activity in semen of asthenozoospermic subjects to normal ranges.
Subject(s)
Free Radical Scavengers/metabolism , Spermatozoa/drug effects , Spermatozoa/metabolism , Zinc/administration & dosage , Zinc/pharmacology , Dietary Supplements , Humans , Male , Sperm Count , Superoxides/metabolismABSTRACT
BACKGROUND: Low concentrations of nitric oxide (NO) are necessary for the biology and physiology of spermatozoa, but high levels of NO are toxic and have negative effects on sperm functions. Although several studies have considered the relationship between infertility and semen NO concentrations, no study on the effects of asthenospermia treatments such as oral zinc supplementation on concentrations of NO, which are important in fertility, has been reported. Studies have shown that oral zinc supplementation develops sperm count, motility and the physical characteristics of sperm in animals and in some groups of infertile men. The present study was conducted to study the effect of zinc supplementation on the quantitative and qualitative characteristics of semen, along with enzymes of the NO pathway in the seminal plasma of asthenospermic patients. METHODS: Semen samples were obtained from 60 fertile and 60 asthenozoospermic infertile men of matched age. The subfertile group was treated with zinc sulfate; each participant took two capsules (220 mg per capsule) per day for 3 months. Semen samples were obtained (before and after zinc sulfate supplementation). After liquefaction of the seminal fluid at room temperature, routine semen analyses were performed. The stable metabolites of NO (nitrite) in seminal plasma were measured by nitrophenol assay. Arginase activity and NO synthase activity were measured spectrophotometrically. RESULTS: Peroxynitrite levels, arginase activity, NO synthase activity and various sperm parameters were compared among fertile controls and infertile patients (before and after treatment with zinc sulfate). Peroxynitrite levels and NO synthase activity were significantly higher in the infertile patients compared to the fertile group. Conversely, arginase activity was significantly higher in the fertile group than the infertile patients. Peroxynitrite levels, arginase activity and NO synthase activity of the infertile patient were restored to normal values after treatment with zinc sulfate. Volume of semen, progressive sperm motility percentage and total normal sperm count were increased after zinc supplementation. CONCLUSIONS: Treatment of asthenospermic patients with zinc supplementation leads to restored peroxynitrite levels, arginase activity and NO synthase activity to normal values and gives a statistically significant improvement of semen parameters compared with controls.
Subject(s)
Arginase/metabolism , Asthenozoospermia/metabolism , Nitric Oxide Synthase/metabolism , Peroxynitrous Acid/metabolism , Semen/metabolism , Zinc/administration & dosage , Administration, Oral , Asthenozoospermia/drug therapy , Asthenozoospermia/epidemiology , Dietary Supplements , Enzyme Activation/drug effects , Enzyme Activation/physiology , Humans , Iraq/epidemiology , Male , Semen/drug effects , Treatment OutcomeABSTRACT
BACKGROUND: Zinc in human seminal plasma is divided into three types of ligands which are high (HMW), intermediate (IMW), and low molecular weight ligands (LMW). The present study was aimed to study the effect of Zn supplementation on the quantitative and qualitative characteristics of semen along with Zinc Binding Protein levels in the seminal plasma in asthenozoospermic patients. METHODS: Semen samples were obtained from 37 fertile and 37 asthenozoospermic infertile men with matched age. The subfertile group was treated with zinc sulfate, every participant took two capsules per day for three months (each one 220 mg). Semen samples were obtained (before and after zinc sulfate supplementation). After liquefaction seminal fluid at room temperature, routine semen analyses were performed. For determination of the amount of zinc binding proteins, the gel filtration of seminal plasma on Sephadex G-75 was performed. All the fractions were investigated for protein and for zinc concentration by atomic absorption spectrophotometry. Evaluation of chromatograms was made directly from the zinc concentration in each fraction. RESULTS: A significant high molecular weight zinc binding ligands percentage (HMW-Zn %) was observed in seminal plasma of fertile males compared with subfertile males. However, seminal low molecular weight ligands (LMW-Zn) have opposite behavior. The mean value of semen volume, progressive sperm motility percentage and total normal sperm count were increased after zinc sulfate supplementation. CONCLUSIONS: Zinc supplementation restores HMW-Zn% in seminal plasma of asthenozoospermic subjects to normal value. Zinc supplementation elevates LMW-Zn% in seminal plasma of asthenozoospermic subjects to more than normal value. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01612403.
Subject(s)
Carrier Proteins/metabolism , Dietary Supplements , Infertility, Male/drug therapy , Infertility, Male/metabolism , Semen/drug effects , Semen/metabolism , Zinc Sulfate/administration & dosage , Administration, Oral , Adult , Humans , Infertility, Male/epidemiology , Iraq/epidemiology , Male , Reference ValuesABSTRACT
BACKGROUND AND OBJECTIVE: Previous research has shown that a preoperative assessment clinic enhances hospital cost-efficiency. However, the differences in organization of the patient flow have not been analysed. In this descriptive study, we evaluated the consequences of the organization of the patient flow of a preoperative assessment clinic on its performance, by analysing two Dutch university hospitals, which are organized essentially differently. METHODS: In the final analysis, the study included 880 patients who visited either academic centre. The performance of the two preoperative assessment clinics was evaluated by measuring patient flow time, various procedure times and the total waiting time. Patients' age, ASA physical status and any preoperative tests requested by the physician were also recorded. RESULTS: There was a significant difference in patient flow time between the two preoperative assessment clinics. More time was needed for the preoperative assessment when patients' ASA class was higher. The patient flow time was longer when electrocardiogram and venepuncture were performed at the general outpatient laboratory than when they were performed at the preoperative assessment clinic due to longer waiting times. More tests were requested when they were performed at the preoperative assessment clinic. CONCLUSIONS: This study shows that the organization of patient flow is an important aspect of the logistic processes of the preoperative assessment clinic. It might influence patient flow times as well as the number of preoperative tests requested. Together with other aspects of logistic performance, patient satisfaction and quality of medical assessment, patient flow logistics can be used to assess the quality of a preoperative assessment clinic.
