REVIEW ARTICLE | May 27, 2021
Interrogating the Practices and Attitudes of the International Oil Companies in the Oil and Gas Industry in Nigeria and the Need for a Shift
Christian Chukwuma Obeagu
Page no 315-319 |
10.36348/sijlcj.2021.v04i05.008
This paper examined the operational practices and attitudes of the International Oil Companies (IOCs) in the Nigeria’s Oil and Gas industry, and interrogated the rationale behind such; much more as the negative effects were glaring. It drew a conclusion from these prevailing habits but afterwards offered recommendations towards improved holistic results.
ORIGINAL RESEARCH ARTICLE | May 27, 2021
Detection of Sodium Channel SCN1A Gene Mutations among Patients with Epilepsy
Sanaa Abdalaziz Mohamed, Sawsan A.H. Aldeaf, Rasha Elhassan, Abasshar Hussein, Alsadig Gassoum, AbdElkarim A. Abdrabo
Page no 115-118 |
10.36348/sjm.2021.v06i05.010
Epilepsy is one of the most common neurological disorders, nearly 70% of patients with epilepsy lack an obvious pathogenetic cause, genetic is believed to play an important role in its causation. Objectives: to determine the association of sodium channel SCN1A gene mutation with epilepsy. Methods: The current study is a cross-sectional study that had been performed at Sheikh Mohamed Khair centre, Banat, Omdurman, and National Centre for Neurological Sciences (NCNS) Khartoum state, during the period November 2016 to February 2019. Ninety-nine patients were enrolled in this study. Demographic data were collected in a predesigned questionnaire. Blood samples were tested for biochemical and molecular tests. Results: sequencing analysis detected AT deletion in 71% of the samples. Conclusion: Genetic mutations have an effective role in developing epilepsy, AT deletion in SCN1A gene, indirectly, affects Gamma aminobutyric acid function which is inhibition of neuronal activity.
ORIGINAL RESEARCH ARTICLE | May 26, 2021
Phytochemical Screening and Study of the Acute Oral Toxicity of the Aqueous Extract of The Leaves of Diospyros hoyleana F.white (Ebenaceae)
FANNANG Simone Véronique, TANKEU Séverin Elisée, ETAME LOE Gisèle Marie Marguerite, YINYANG Jacques, NGOUONDJOU FOZE Teclaire, BAMAL Hans Denis, MBIDA MVOMO Benoit Deschamps
Page no 230-235 |
10.36348/sjmps.2021.v07i05.006
Despite the advent of generic drugs, many treatments still remain financially inaccessible to economically disadvantaged populations who constantly continue to turn to bioactive molecules from nature to find essential remedies that are gentle, more effective and with few side effects. Medicinal plants are still the primary reservoir of new drugs. The material used during this study consisted of plant material, animal material and technical material. 500 g of the sprayed plant drug was macerated in 2.5 L of distilled water for one duration of 48 hours. Numerous secondary metabolites of the aqueous extract of the leaves of Diospyros hoyleana F. White have been demonstrated. The acute oral toxicity experiment was conducted according to OECD protocol guideline 423. The mass of crude extract obtained after drying in an oven at 60 °C. was 64 g with a yield of 12.8%. Tests for Flavonoids, Saponins, Phenols, Tannins and Anthraquinones were found to be positive with the aqueous extract of the leaves of Diospyros hoyleana F. White while those for Alkaloids, Sterols, Terpenes and Coumarins were found to be Negative. After the acute oral toxicity study, no abnormalities of the physiological parameters observed in rats were observed. In addition, no deaths have been recorded. The LD50 was therefore greater than 5000 mg/kg. The body masses of the animals were generally increasing during the study regardless of the chosen batch. The rats were sacrificed and the masses of the internal organs were weighed. Four blood biochemical parameters of the groups of rats studied were assayed.
ORIGINAL RESEARCH ARTICLE | May 26, 2021
Epidemiology of Cesarean Section in a Single Center Study
Dr. Farida Begum, Dr. Nahid Akter
Page no 210-213 |
10.36348/sijog.2021.v04i05.007
Introduction: Cesarean delivery is increasing in both developed and developing countries. Though it is considered as a lifesaving surgical procedure for the pregnant women and the neonate, it has various risk factors and complications. Objective: The aim of this study was to assess the epidemiology and the results of the cesarean section in a single center of Bangladesh. Study Design: Retrospective observational study. Place and Duration of the study: The study was conducted in the department of Gynae & Obstetrics, Sher E Bangla Medical College Hospital, Barishal, Bangladesh, during the period from January 2019 to December2019. Methods: This is a retrospective observational study. Among the total number of cesarean patients, we recruited 75 women who were age 25-35 years with gestational age 37-42 weeks of pregnancy. Those who were less than 37 weeks of gestational age, the patients with multiple pregnancy complications, and those who were referred were excluded from the study. Written consent was taken. Collected data were compiled and analyzed using computer-based software, statistical package for social science (SPSS). Result: In this study, a total of 75 women who had a cesarean delivery were included. The baseline characteristics of the study people were: maximum 45(60.0%) study people were from the age group of 25-35, multipara was 54 (72.0%), and primipara was 21 (28.0%), most of the study people 39(52%) had normal BMI 10(25.3%) had overweight, 9(12.00%) had obese, 8(10.7%) had underweight. The majority 22(29.3%) of the study people were secondary educated. Most of the study people 37(49.3%) had 37-42 gestational age. The indications of cesarean delivery, 31 (41.3%) had repeat cesarean delivery, 12 (16.0%) had failed to progress, 9 (12.0%) had fetal distress, 8 (10.7%) breech presentation, 7 (9.3%) had antepartum hemorrhage, 6 (8.0%) had hypertension and 2 (2.7%) had diabetes mellitus. SAB was used in 61 (81.33%), pfannenstiel incision was used in 70 (93.3%), and the average operating time was 51.2 minutes. Subcuticular was mostly used 42(56%) for skin stitch followed by vertical mattress in 33(44.0%). Intraoperative antibiotic was used in 11 (14.7%), postoperative antibiotic was used in 9 (12.0%), both of these mentioned antibiotics were used in 6 (8.0%), and no antibiotic was used for 49 (65.3%). Conclusion: Repeat cesarean deliveries were found in most of the study people of the cesarean section. Surgical site infection was the most common complication.
ORIGINAL RESEARCH ARTICLE | May 26, 2021
Psychological and Socio-Economic Impact of COVID 19 among the OPD Patients in a Tertiary Care Hospital, Bangladesh
Dr. Md. Ferdous Khan, Dr. Mohammad Abdur Rahman, Dr. Daharul Islam, Dr. Somnath, Dr. Sanjida Rahman
Page no 99-103 |
10.36348/sjm.2021.v06i05.006
Background: The outbreak of Covid-19 is a new but one of the most intense pandemics in the world now. Although this disease is accountable for limited symptoms and complications like severe acute respiratory syndrome, fever, headache, diarrhea, malaise, and weakness, its probability of affecting people is very high. For this reason, its psychological and socio-economic impact demanded more attention from the world community. Aim of the study: The aim of this study was to evaluate the psychological and socio-economic impact of Covid 19 among the OPD patients in a tertiary care hospital in Bangladesh. Methods: This was a prospective interview-based study conducted in the Department of Medicine, Ibn Sina Specialized Hospital, and Dhaka, Bangladesh during the period from July 2020 to December 2020. In total 120 patients with several health problems, physically or virtually attended the OPD of the mentioned hospital were enrolled as the study population. The ethical committee of the mentioned hospital had been approved the studyl. All data were processed, analyzed, and disseminated by MS Office and SPSS version as needed. Result: In this study analyzing the negative impact of Covid 19 on the mental health of participants, we found feeling of suffocation, exhaustion, fear of falling ill, anxiety about the future, and feeling of loneliness were found as some major negative mental impacts on the respondents which were 11.67%, 10.83%, 8.33%, 7.5%, and 6.67%. Besides these, due to Covid 19 continuing, remote socialization, intolerance to others, random commitment violation, and ended social life were found 10%, 5.83%, 4.17%, and 1.67% participants respectively. In analyzing the negative impact on the economy of participants, we observed, the monthly family income was decreased up to 25%, 50%, 75%, and 100% of 21.67%, 12.50%, 5%, and 1.67% participants respectively. That means negative impact like decreasing monthly family income was found around 49%. Conclusion: Pandemic of Covid 19 is a new experience for the world community. The psychological and socio-economic impact of Covid 19 among patients as well as general people demanded more concentration now. Besides general people and patients, the whole economy and social structure of Bangladesh have already been affected by COVID-19. Unemployment and uncertainty of family income are responsible for secondary negative impact on the mental, physical health of general people as well as patients here. So, government policymakers, as well as world leaders, should be more conscious about these impacts and find out the proper way to resolve such pandemic.
ORIGINAL RESEARCH ARTICLE | May 26, 2021
Effects of Four Weeks Intervention of Yogic Practices on Cricket Specific Motor Fitness
Subhashis Biswas, Ankur Biswas, Nita Bandyopadhyay
Page no 125-130 |
10.36348/jaspe.2021.v04i05.007
The potentiality of yogic practices to improve physical and mental ability is well-known. The inclusion of yogic practice in cricket training protocol is a controversial topic. Plenty of research literature suggested that yogic asana improves physical fitness and controls competition pressure as well as match stress. So, the study was carried out to find out the effect of yogic practice schedule on cricket specific motor fitness. Thirty male district level cricketers with a mean age of 17.8 ± 1.6 years were selected and randomly divided into two equal groups. One group underwent through selected yogic asana practices along with their regular training and another group did not include yogic asana practice in their training schedule. Basic physical and physiological parameters along with some cricket specific motor fitness components were measured before and after four weeks of yogic practices. The basic physical appearances of two groups were merely similar and a low resting heart rate has been observed among cricketers. Four weeks of yogic practice significantly improved the muscle endurance, agility and balance. A positive effect has also been observed in the predicted V̇O2 max. The study revealed inclusion of yogic practice in training sessions for cricketers plays an important role to improve motor fitness which is a key factor of performance.
ORIGINAL RESEARCH ARTICLE | May 24, 2021
Effectiveness of Self Mouth Examination Method in Case Finding of Oral Cancers and Oral Potentially Malignant Disorders among High Risk Rural Population in India
BC Manjunath, Br Chandra Shekhar, Vatchala Rani, Manas Bajpai, Radhey Shyam, Mansi Mendiratta, Madhavi Wig
Page no 85-92 |
10.36348/sjm.2021.v06i05.004
Objectives: To assess the feasibility of self mouth examination (SME) in case finding of oral cancers and potentially malignant disorders (OPMD) among high risk rural population in India. Materials and methods: 15,000 pretested pictorial handout (brochure) with instructions (local language) depicting the signs of oral cancer and self mouth examination procedures were distributed among every households (n= 3500), People were also demonstrated self mouth examination (SME) technique. One week later a three day cancer detection camp was carried out. Individuals were instructed to conduct self mouth examination (SME) and report the cancer detection camp if any questionable lesions were noticed. Individuals who reported were screened for oral cancer with the use of toluidine blue vital staining, oral exfoliative cytology and final diagnosis through biopsy. Results: The total population consisted on 579 individuals out of which 372 (64.25%) were males and 207 (35.75) were females. The total percentage of self mouth examination (SME) performance was 95.34%. 53.20% of the study population identified suspicious lesions in the oral cavity. After thorough oral examination, malignant lesions like oral cancer (2 cases) and many cases of oral potentially malignant disorders were found. The sensitivity of mouth self examination was 48.66% where as the specificity was 44.75%. The positive predictive value was 23.54% where as the negative predictive value was 71.37%. Conclusions: Self mouth examination is an effective tool which can be used in the case finding of oral cancers and oral potentially malignant disorders.
ORIGINAL RESEARCH ARTICLE | May 24, 2021
A Three Year (2017–2019) Review of Hypertension in the University of Port Harcourt Teaching Hospital (UPTH)
Godswill Melford Arugu, Charles Tobin-West, John Nwolim Paul
Page no 93-98 |
10.36348/sjm.2021.v06i05.005
Aims: Include determining the prevalence of hypertension in UPTH from January 2017 to December 2019, to describe the risk factors associated with hypertension, to describe the demographic distribution of patients with hypertension and to determine the outcome of hypertension in UPTH. Study design: The study is a descriptive cross-sectional study. Place and Duration of Study: The research was carried out at the University of Port Harcourt Teaching Hospital between January and June, 2020. Methodology: A multi-stage random sampling method was used in selecting the records of all patients admitted to the medical wards of the UPTH (between January 2017 – December 2019), with essential hypertension. The first stage involved the use of disproportionate sampling method (where each of the years, 2017-2019 constituted a stratum) to select all the hypertensive cases admitted in each of the years. Simple random sampling was then used in the second stage to select 70 samples from each year, to make up the 210 sample size. This was generated through the use of random numbers. The data were analyzed manually by sorting, tallying and collated into data sheet. Both descriptive and inferential statistics were used to analyze the data. Results: There were a total of 3,200 medical admissions during the period under review (2017-2019), and the prevalence of hypertension was 16.8% (537).The records of 210 (6.6%) hypertensive patients were reviewed and analyzed. There were 109 (51.9%) males and 101 (48.1%) females with a male: female predilection of 1.1:1. The mean age was 55.7 ± 4.5 years with a mode of 62 years. Urban dwellers were 63.3% while 36.7% were rural dwellers. Also, 57.1% of these patients were in social class V (unskilled workers, farmers, traders and housewives); and only 2.9% in social class I (professionals). More so, chronic alcohol intake accounted for 16.7% of the admitted cases, followed by diabetes mellitus with 12.4%.Smoking and obesity were 1.9% each. Heart failure was the commonest complication of hypertension (39.5%), while stroke was the commonest cause of fatality (25.0%). Conclusion: Hypertension is an important health problem in the world over. Hence emphasis should be placed on the primary prevention of hypertension through intensive campaigns on lifestyle modifications and regular blood pressure checks. In addition, efficient record keeping and the establishment of a stroke registry would help in the management of hypertension.
ORIGINAL RESEARCH ARTICLE | May 24, 2021
A Prospective Comparative Study of Endometrium by Transvaginal Sonogram and its Correlation with Histopathology in Peri-Menopausal Women with Abnormal Uterine Bleeding
Dr. Priya Thakur, Dr. B.S Duggal, Dr. Santosh Sidid
Page no 202-209 |
10.36348/sijog.2021.v04i05.006
Introduction: Abnormal uterine bleeding (AUB) is the most common reason for gynecological visits for perimenopausal bleeding and may account for more than 25% of all hysterectomies. The perimenopause is often characterized by irregularities in the menstrual cycle in volume and frequency. This is due to fluctuating estrogen levels. These changes are unique for each woman and are unpredictable. Although irregular bleeding patterns are normal and expected to be part of perimenopause, the incidence of uterine pathology and associated medical complications increase in this age group [3]. The more accurate diagnosis of endometrial pathology better the chances for alternative treatment and hysterectomies could be avoided. The accuracy or the superiority of the relatively non-invasive methods like TVS, Hysteroscopy, and SIS over histopathology have not been clearly established. Thus this study was undertaken to compare the diagnostic efficiency of TVS over the histopathology study of the endometrium and to test their agreement. Materials & Methods: 48 cases of perimenopausal women above 40 yrs. age not yet attained menopause. Patient with AUB in any other age group, any vaginal or cervical cause of bleeding, Patient with blood dyscrasias, Pregnancy related causes of bleeding, Patient with h/o of drug intake (Anticoagulant & hormone replacement therapy) has been excluded. The cases were studied for a period of 11 months in Noble hospital & research Centre. Detailed history & clinical examination including per vaginal and per speculum examination carried out. All the patient then subjected to transvaginal ultrasound & endometrial sampling. Results were correlated between transvaginal ultrasound & histopathology in these patients. Results: In this study, 72.4% of women with normal endometrium had an endometrial thickness of less than 12mm below which there was no endometrial pathology. Above this cut off level of 12mm, 88.6 % were found to be associated with endometrial pathology. The sensitivity and specificity were found to be 61.9% and 77.8%. Distribution of histopathology findings differ significantly between groups of cases with less than 12mm and more than 12 mm endometrial thickness (P-value < 0.048). Conclusion: Transvaginal sonogram is a simple, non-invasive convenient way to indirectly visualize the endometrium & endometrial cavity. The vaginal probe examination if incorporated into the gynecologist office setting and when combined with bimanual pelvic examination can enhance our anatomic diagnosis. Transvaginal sonography is useful as a first step diagnostic procedure in the evaluation of perimenopausal bleeding. When combined with dilatation and curettage it can supplement the shortcomings of dilatation and curettage.
CASE REPORT | May 23, 2021
Case Report: Misdiagnosed Case of Cervical Ectopic Pregnancy with Catastrophic Bleeding
Dr. Santosh Sidid, Dr. Priya Thakur Dubey, Dr. B. S. Duggal
Page no 199-201 |
10.36348/sijog.2021.v04i05.005
Cervical ectopic pregnancy is a rare form of ectopic pregnancy with implantation of fertilized ovum in the cervical canal below the internal os. Incidence of cervical pregnancy varies 1:1000-95000 and associated with high maternal morbidity and mortality due to high chances of pregnancy being misdiagnosed. To reduce maternal mortality, it is indeed necessary to understand the importance of correct diagnosis by clinical or radiological or biochemical methods available. Here we present a case of a 36-year-old female reported to us in Noble hospital as a misdiagnosed case of cervical ectopic pregnancy with catastrophic bleeding. Management of the cervical ectopic pregnancy is dependent on several factors such as the patient's gestational age, fetal cardiac activity, stability of the patient, patient's interest in retaining future fertility, and the availability of resources and expertise of the practicing gynaecologist. The cervical ectopic pregnancies though rare, do occur, and their incidence is increasing. A high index of suspicion, clinical and radiological correlation, especially in cases with previous uterine scars can pick up this rare entity preoperatively. If diagnosed early conservative management can be offered. However, missed diagnosis can lead to high morbidity and mortality.
CASE REPORT | May 23, 2021
An Uncommon Case of Ovarian Torsion Hyper-Stimulated With Clomiphene Citrate
Intissar Benzina, Yassine Edahri, Sarah Talib, Aziz Slaoui, Soufiane Nader, Aziz Baydada, Aicha Kharbach
Page no 104-107 |
10.36348/sjls.2021.v06i05.004
Background: Clomiphene citrate is an orally active nonsteroidal triphenylethylene derivative, commonly used for ovarian stimulation; it is an ovulation inductor, an important tool in various assisted reproduction treatments. The side effects are unusual however they are listed in the OHSS ovarian hyperstimulation syndrome, which is an exaggerated response to excess hormones that can lead to significant complications. Case presentation: This is a case is about a unilateral adnexal torsion secondary to clomiphene citrate’s stimulation, without associated pregnancy which was managed in our department of gynecology in the maternity of Rabat. Conclusion: The ovarian hyperstimulation syndrome is becoming more common as the number of women undergoing in vitro fertilization increases. A worsening of the symptoms of OHS can still normally be managed in outpatient form, but can also have serious complications resulting from are much less common and can involve risk to life.
ORIGINAL RESEARCH ARTICLE | May 23, 2021
Heat Shock Protein-60 Levels in Serum and Saliva of Patients with and Without Periodontitis- A Comparative Study
Rajasekar S, Anitha CM, Senthil Kumar S, Sethupathy S, John William Felix
Page no 211-215 |
10.36348/sjodr.2021.v06i05.007
Background and Objectives: There is increasing evidence that mitochondrial dysfunction and oxidative stress may be central to both chronic periodontitis and type 2 diabetes mellitus pathogenesis. HSP 60 is a mitochondrial stress protein believed to be caused by mitochondrial dysfunction. The aim of this research was therefore to test the salivary and circulatory expression of HSP 60 in periodontitis patients. Methods: A total of 30 patients aged 35-50 were chosen and classified into two groups; (1) Healthy controls; (2) Chronic periodontitis and systemically healthy. HSP 60 in serum and saliva was estimated using a specific ELISA kit and correlated with periodontal parameters using statistical tests. Results: The serum and salivary levels of heat shock proteins were significantly higher in chronic periodontitis patients compared to healthy controls. Conclusion: Salivary levels of HSP 60 can be used as a biomarker to determine periodontitis severity. Patients with chronic periodontitis had higher salivary HSP 60 levels.
CASE REPORT | May 23, 2021
“Treatment of Severe Crowding and Bimaxillary Dental Protrusion in a Patient with Angle’s Class I Malocclusion and a Vertical Growth Pattern” – A Case Report on Orthodontic Camouflage
Dr. Bhushan Jawale, Dr. Lishoy Rodrigues, Dr Anup Belludi, Dr. Shrinivas Ashtekar, Dr. Anand Patil, Dr. RK Suryawanshi
Page no 203-210 |
10.36348/sjodr.2021.v06i05.006
The aim of orthodontic treatment in a bimaxillary protrusion case is to obtain an esthetically pleasing face with harmonious soft tissue profile, stable occlusion and pleasant smile. The etiology of bimaxillary protrusion is multifactorial involving both genetic and environmental causes like mouth breathing, tongue and lip habits and tongue volume. The following case report is management of class I bimaxillary protrusion malocclusion in a hyperdivergent case with extraction of all first premolars. The effective management of space without losing anchorage is itself a big challenge. the results produced a pleasant facial profile with attainment of good occlusion. The case required extraction of 1st premolars for correction of the proclined, forwardly placed and crowded upper and lower anterior teeth. Clinical and cephalometric evaluation revealed skeletal Class I pattern and clinical examination revealed presence of an orthognathic facial profile, a vertical growth pattern, increased overjet and average overbite, crowding in maxillary and mandibular anterior region, potentially incompetent lips, increased lip fullness and lip strain, a gummy smile with an unaesthetic smile arc and a decreased nasolabial angle. Following fixed orthodontic treatment by removal of all 1st premolars and with retraction of anterior segment, a marked improvement in patient's smile, facial profile and occlusion was achieved and there was a remarkable increase in the patient's confidence and quality of life. The profile changes and treatment results were demonstrated with proper case selection and good patient cooperation with fixed appliance therapy.
ORIGINAL RESEARCH ARTICLE | May 23, 2021
“Impact of Extraction in Preservation of Palatal Rugae Pattern as a Personal Identification Marker- A Prospective Study”
Dr. Johara Maria Cruz, Dr. Keerthi Narayan. V, Dr. Vidya Kaliyan
Page no 216-220 |
10.36348/sjodr.2021.v06i05.008
Rugae patterns are used in forensic investigations, owing to its uniqueness. In severely deceased burn victims, palatal rugae aid in identification process due to the resistance of hard palate. However changes in rugae form seen in diseases or trauma are intense in nature to alter identification process. Studies focusing on the effects of growth, tooth loss, or its combination are very few. Hence, the present study was carried out to determine the influence of tooth loss following extraction on rugae pattern in dentulous maxillary arch. A total of 25 patients with completely or partially dentulous maxillary arch indicated for extraction were selected based on inclusion and exclusion criteria. Following consent, Impressions of maxillary arch of patients were made using irreversible hydrocolloid material, and a cast was poured. The procedure was repeated over a period of 6 months after extraction and the rugae patterns traced every month were compared with the previous cast. All the observations were subjected to statistical evaluation. Based on the rugae pattern it was observed that line (mean 1.0 ± S.D 1.22), curved (1.3 ± 1.37) and sinnous (1.9 ± 1.56) patterns were predominant while circular, interrupted and trifurcated rugae patterns were less common. Though the frequency of circular rugae was low; conversely, it showed a high statistically significant difference between post-extraction follow up (P<0.001*) in their mean followed by Line and bi-furcated rugae pattern. We conclude that rugae patterns are not always consistent, as they are susceptible to changes during extractions that can alter substantial identification process.
REVIEW ARTICLE | May 23, 2021
Enzyme Vs Chemotherapy for the Treatment of Acute Lymphoblastic Leukemia
Hadia Naseem, Iqra Kanwal, Muhammad Haseeb Anwar Tarar, Sabahat Irfan, Taiyyibah Basharat, Muhammad Adnan, Nabeela Fatima, Usman Ghani
Page no 42-51 |
10.36348/sijb.2021.v04i04.002
Cancer is re-unowned by production of neoplastic cells. In cancer, un-developed cells are produced by bone marrow. After their entry into the blood normal cells are un-able to produce and cause anemia. Several oncogenes, including the p53, c-fms and Ras genes, can be activated by point mutations that change the amino acid sequence in the critical portion of protein. L-asparaginase is an enzyme which, by hydrolysis, produces aspartic acid and ammonia. It is used as medicine and in the food industry. It acts as a chemo-therapeutic agent to diagnose the ALL and lymphoproliferative syndrome. The level of Asparagine reduced in plasma decreases the formation of Deoxy ribonucleic acid and Ribonucleic acid. In ALL, asparaginase used in chemotherapy medicines for dealing the patients. it donates the important development in therapy results and helps achieve reform sullener approximately 90% of patients.