Background: Type 2 diabetes mellitus (T2DM) is a crucial public health issue causing physical, financial, and psychosocial crises globally. Objectives: To estimate the effectiveness of diabetes self-management education (DSME) on self-care behavior among T2DM patients. Materials and Methods: A systematic review and meta-analysis of intervention trials promoting self-care behavior among T2DM patients was done by searching MEDLINE, Clinicaltrials.gov, Microsoft Academics, ScienceDirect, ICTRP, OAISTER, LILACS and CINAHL to identify eligible trials starting from inception till August 26, 2021. Studies which did not have a self-care behavior intervention, couldn't be found or translated in English, didn't have control arm or had multiple study arms, had <30 study participants per arm, or included adolescent or pregnant individuals were excluded. Data screening, extraction, and analysis were done with help of Rayyan software, Microsoft Excel and JASP software. Cochrane risk of bias tool was used to assess bias in the studies. Results: The search yielded 4023 results, of which 20 studies were included in meta-analysis. Our main outcome was “change in self-care behaviour score” owing to the DSME intervention. The pooled standardized mean difference in self-care behaviour was 1.38 (95% confidence interval 0.50–2.27, I² ¼ 99.2, P < 0.001) with Dersimonian and Laird random effects method. Conclusion: Owing to the paucity of studies in low- and middle-income countries, further studies are needed to evaluate the DSME effectiveness in preventing diabetes related complications and enhancing patients' quality of life.

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Background: Nurses among the health care providers play a vital role in the success of the health care system. Their continuous hours of working and the existing lacunae in regard to their mental health in the current study setting, this study was conducted to elicit if the nurses are posed to any such mental health risks and perceive any stress? Objectives:

• To determine the prevalence of psychological distress and the perceived stress among the study subjects.
• To assess the factors associated with psychological distress and perceived stress.

Materials and Methods: This is a cross-sectional study conducted among all the nursing staffs at our tertiary care centre for 2 months. A predesigned and pretested semi-structured self-administered questionnaire including general health questionnaire (GHQ)-12 and perceived stress scale (PSS)-10 were used to collect the data and to asses psychological distress and perceived stress considering the cut-off scores of a minimum of 12 and 19, respectively. Data were entered into Microsoft Excel 2010 and analyzed using the SPSS software version 20.0, Armonk, NY, USA: IBM Corp. Results: The mean age of the participants was 24.4 ± 3.7 years. Mean GHQ-12 score was 11. As per the scores, the cutoff of at least 12 was found in 35% of the respondents indicating the prevalence of psychological distress among 35.0% and as per the screening tool PSS-10 used, majority of the study subjects (93.0%) perceived moderate level of stress with a median score of 19. Conclusion: Nearly one-third of the nursing personnel were under psychological distress and almost the entire nursing faculty perceived moderate level of stress.

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Background: The outcome of eLearning is being studied comprehensively. Parents' perception toward e-devices is the financial burden during the lockdown and the outcome of education by remote learning. Receptive adaptation had to be made with inexperience. The new indefinite pandemic had psychological, social, emotional, and financial stress on parents as education of the child is always a priority. Introduction: Lockdown following the COVID-19 pandemic introduced a concept of eLearning as schools were shut. This increases access to electronic devices and Internet among the children. Objective: The objective of this study was to assess parents' perception regarding electronic device use among children following the COVID-19 lockdown. Materials and Methods: It is a cross-sectional study conducted in the field practice area of Urban Health Centre of a Medical College in Anantapur. The calculated sample size was 178 and the sampling method was convenience sampling. People living in the study area having at least one child of attending school were the study population. Required ethical clearance and individual informed consent was taken. Data were collected using a predesigned, prevalidated, and self-administered questionnaire. It had two scales 10-itemed “perceived demerits of eLearning by parents” and 4-itemed “perceived merits of eLearning by parents.” Statistical analysis was done using descriptive statistics and nonparametric tests. Results: Out of the total 180 participants, 154 (85.6%) were stressed about the extra cost imposed to facilitate online classes. Perceived demerits of eLearning by parent's scale had a median score of 8 out of 10. However, 167 (92.8%) agreed that eLearning was the only viable option for schooling during the lockdown. Conclusion: Most of the parents in the study agree with the benefits of eLearning; however, they are aware and weary of its ill effects and stressed due to added costs related to it.

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Background: Pregnancy is a fragile state, and it is prone to anxiety and depression which may affect the outcome of pregnancy. Due to the unprecedented COVID pandemic, health-care services were limited to emergency care which hampered mental well-being of pregnant women. Objective: The present study was aimed to assess the stress related to COVID-19 in pregnant and nonpregnant women. Subjects and Methods: It was a field-based comparative cross-sectional study, conducted in the urban field practicing area of Osmania Medical College, Hyderabad, Telangana, for a period of 3 months during the second wave of the COVID pandemic, among 120 pregnant and 120 nonpregnant women. The questionnaire consisted of sociodemographic details, experiences with COVID-19 and lockdown, KAP on COVID-19, impact on health-care services, and various stress scales (Perceived Stress Scale [PSS], Generalized Anxiety Disorder (GAD), and World Health Organization Disability Assessment Schedule [DAS] 2.0). Results: Majority of the study population were in the 18–35 years of age group; there were higher PSS mean score, GAD-7 mean Score, and DAS 2.0 mean score, among pregnant women compared nonpregnant women. PSS mean score for pregnant women was 18.80 ± 3.779 and for nonpregnant women was 12.50 ± 3.098 (P < 0.00001). GAD-7 mean score for pregnant women was 5.50 ± 3.087 and for nonpregnant women was 2.20 ± 1.804 (P < 0.00001). DAS 2.0 mean score for pregnant women was 22.87 ± 7.033 and for nonpregnant women was 16.10 ± 6.432 (P < 0.00001). Practices of preventive measures of COVID-19 were appropriate among both the groups. Conclusion: Although both the groups were affected mentally by the pandemic, stress, anxiety, and disability were common among the pregnant women.

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Background: Constipation not only bothers children but also their parents. Even then, it remains neglected and leads to delayed medical care. It leads to physical as well as psychological morbidity. It affects the quality of life of children. Lack of timely medical care compounds the problem. The child may lose his/her self-esteem. About 1%–3% of children may develop impaction of the feces and may lead to soiling with fecal matter. Objective: The objective was to study the prevalence and clinicopsychological profile of functional constipation (FC) among children aged 1–12 years. Materials and Methods: This was a hospital-based cross-sectional study carried out among 156 children aged 1–12 years attending the tertiary care center for 1 year. During the study, 911 children aged 1–12 years attended the hospital. We applied Rome IV criteria for the diagnosis of FC. Using these criteria, 156 children were found to have FC, and all of them were included in the present study. Results: The prevalence of FC among the children was 17.1%. It was more in the toddler group (43.6%) with a slight female preponderance (51.3%). It was more in urban resident children (69.2%) and children belonging to the low socioeconomic group (33.3%). Painful defecation was the most common presenting complaint (81.4%). Most of the children passed Bristol Type II stool <three times a week. Majority of children were taking low-fiber diet, had poor physical activity, and aversion to school. Conclusion: The prevalence FC among children was high at 17.1%. Low-fiber diet, poor physical activity, and aversion to school were common in children with FC.

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Background: Pregnancy-induced hypertension (PIH) can affect the eyes of pregnant women. There is dysfunction of vascular endothelium among them. There can be further leakage from capillaries and vasospasm if it is left untreated. Objective: The objective of this study was to study the prevalence and risk factors of ocular fundus changes among pregnant women with PIH. Materials and Methods: A hospital-based, cross-sectional study was carried out among 130 pregnant women with PIH. History of symptoms related to the eyes, age, and gravida was recorded. Torchlight was used to examine the anterior segment. One percentage of tropicamide was used to dilate pupils. Direct ophthalmoscope was used to examine the fundus. Blood pressure was measured as per the standard guidelines. Urine sample was taken to look for the presence of proteins in urine. Results: The majority belonged to 23–27 years (50%) and the majority (54.6%) had gestational age >37 weeks. The majority (75.38%) had gestational hypertension. The prevalence of retinopathy was 11.5%. Grade I retinopathy was the most common (7.7%). Age was not associated with retinopathy. The prevalence of PIH among women with preeclampsia was 29.1% compared to 5.1% in women with gestational hypertension and it was significant (P < 0.05). The prevalence of PIH among women with blood pressure >150/100 mmHg was 43.3% compared to 2% in women with blood pressure <150/100 mmHg, and it was significant (P < 0.05). The prevalence of PIH among women with severe proteinuria (+++) was 60% compared to 42.9% in moderate proteinuria (++), 20% in mild proteinuria (+), and only 5.4% in women without proteinuria. These differences were significant (P < 0.05). Conclusion: The prevalence of retinopathy among pregnant women with PIH was high. High blood pressure and severe proteinuria and preeclampsia were significantly associated with retinopathy.

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Background: Cervical cancer is the fourth-leading cause of death in females among noncommunicable diseases. Hence, knowledge of risk factors, symptoms, and screening in females, especially in rural areas is important to reduce the burden of disease. Objective: The objective of this study was to estimate the level of knowledge, attitude, and practice (KAP) regarding risk factors, symptoms, and preventive measures of cervical cancer, and screening the females by means of Papanicolaou test (PAP) smear. Subjects and Methods: A cross-sectional study was conducted among 30–65 years females of Mulugu Mandal from October 2021 to February 2022. After obtaining informed consent, 505 females were interviewed by house-to-house visit using a semistructured questionnaire with questions regarding KAP on risk factors, symptoms, and preventive measures of cervical cancer, and motivated female for PAP smear if willing, was brought to the institution. Data were analyzed using SPSS 22. Results: The mean age of the study participants was 47.46 ± 9.698. Good knowledge, positive attitude, and regular practice were 11.28%, 43.8%, and 14.1%, respectively, on cervical cancer. PAP smear acceptance rate was 14.059% result and showed 12.6% have atypical squamous cells of undetermined significance and 87.3% have an inflammatory smear. Conclusion: Knowledge on risk factors, symptoms and screening for cervical cancer is low, and the acceptance rate of PAP smear is very low.

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Background: Studies on complications of hypertension (HTN) are required to identify risk factors so that patients with HTN can be educated. Individuals are more amenable as they seek advice from the clinician and this fact can be taken advantage of, in preventing or delaying complications. Objective: The objective of this study is to study the prevalence and risk factors of complications of HTN. Materials and Methods: Hospital-based cross-sectional study was carried out among 200 patients with known HTN. Blood pressure was recorded using standard equipment and standard guidelines. Anthropometric measurements such as height and weight were measured as per the standard guidelines. Investigations such as electrocardiogram, ophthalmoscopy, and urine albumin were carried out for all enrolled patients to assess the presence of complications of HTN. Binary logistic regression analysis was carried out to study the independent association between variables and complications of HTN. Results: The prevalence of complications of HTN was 57% in the present study. The most common complication of HTN was an ischemic cerebrovascular accident in 25% of the cases and coronary artery disease as well as left ventricular hypertrophy in 21% of the cases each. The odds of having complications of HTN among smokers was 3.138 (95% confidence interval [CI] =1.141–8.629; P = 0.027) times more compared to nonsmokers. The odds of having complications of HTN among those without regular treatment was 8.265 (95% CI = 3.977–17.177; P = 0.000) times more compared to those taking regular treatment. The odds of complications of HTN increased by 1.113 (95% CI = 1.045–1.186; P = 0.001) times with each increase in the duration of HTN. Conclusion: The prevalence of complications of HTN among known hypertensive was high in the present study. It was significantly associated with smoking, irregular treatment, and duration of HTN.

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Background: Diabetes can be managed well by adherence to prescribed oral hypoglycemic agents (OHAs) and/or insulin. Between 33% and 69% of all medication-related hospital admissions in the US are due to poor medication adherence, at a cost ranging from ≥100 to ≥300 annually. Objective: The objective of this study was to study the prevalence of poor medication adherence among known diabetics and its association between poor medication adherence and glycemic control among adults known type II diabetes. Materials and Methods: A cross-sectional study was carried out among 225 adults with known type II diabetes. Known diabetics with type II and adults above the age of 30 years taking treatment at Malla Reddy Hospital were included in the study. Morisky Green Levine Medication Adherence Scale (MGLS) was used to assess patients' adherence to diabetic medications. The American College of Physicians guidelines on glycated hemoglobin (HbA1c) was used to classify glycemic control. Results: The majority (40%) were 60–69 years, males (64%) and (69.3%) were from urban areas. 37.8% were illiterate. 47.6% were doing business or service. The majority (82.7%) had diabetes for >5 years. As per the American College of Physicians guidelines, HbA1c should be kept at 7%–8% for diabetics. Accordingly, only 16.4% had HbA1c levels of <8%. The majority were using OHA only (80.4%). As per MGLS classification, only 29.3% had high adherence. 57.8% were found to have intermediate adherence and 12.9% had low adherence. The mean levels of HbA1c were significantly higher in those with low medication adherence (13.01 ± 1.3) compared to those with intermediate and high adherence (P < 0.05). Conclusion: The poor medication adherence was high in the present study. It was affecting glycemic control. It was significantly associated with the poor glycemic control.

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Unilateral facial nerve palsy and vestibulocochlear neuropathy due to herpes zoster are named Ramsay Hunt syndrome (RHS). Rarely, this infection may affect multiple cranial nerves concurrently. Through this report, we are describing a case of RHS, where the VII, VIII, IX, and X cranial nerves were involved simultaneously. This 65-year-old man presented with right lower motor neuron facial nerve palsy, hoarseness, dysphagia, hearing deficit, and vertigo following painful vesicular eruptions on his right ear. Systemic corticosteroids and antiviral agents were administered, subsequent to which the patient improved with the resolution of all the symptoms and signs.

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Background: Breast cancer (BC) is the most prevalent cancer among Indian women. The Indian Council of Medical Research found 1.5 lakh new cases in 2016. In 2020, globally 2.3 million women were diagnosed; 685,000 deaths occurred. Lack of awareness about risk factors, signs, symptoms, and preventive practices is the main cause for its increasing incidence. Breast self-examination (BSE) has a role in the early detection of cancer. Its treatment is effective when diagnosed in the early stages. Objective: The objective of this study was to determine the impact of health education on preventive practices of BC among women. Subjects and Methods: A community-based interventional follow-up study was conducted in a rural field practicing area of government medical college, Hyderabad. Using multistage sampling, 260 women in the 20–50 years of age group were selected. Data regarding knowledge of BC were collected by pretested questionnaire in the preintervention phase. In the intervention phase, health education on BC and BSE was imparted through audiovisual aids and flip charts. In the postintervention phase, the impact of health education was assessed 2 weeks later using the same questionnaire. Data were entered in MS Excel and analyzed by Epi Info version 7. Results: In pre and postintervention phases, the knowledge regarding BSE practice increased from (5%) to (77.7%); obesity (20.8%) to (71.5%) ;breast lump (7.7%) to (71.2%) ;advancing age (5.8%) to (68.5%); nipple discharge (3.8%) to (63.1%); alcohol (6.6%) to (61.9%) and family history (13.5%) to (60%). Conclusion: The study highlights the importance of health education on preventive practices of BC in increasing knowledge.

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Nonmetric characteristics, epigenetic traits, and cranial distinct traits are indicated by tubercles, ossicles, bony protuberances, foramina/notches, and other features on the human skull. For decades, they have piqued the interest of anatomists and anthropologists by supporting and providing evidence for human evolution. Torus occipitale is one such cranial nonmetric variation which is the projection/prominence of inion (midpoint of external occipital protuberance). According to studies, it is caused by the ossification of the ligamentum nuchae's connection to the external occipital protuberance. Yet another nonmetric trait, occipital bun is the posterior projection of the squamous part of the occipital bone below internal occipital protuberance. This case series reports how autapomorphic traits such as torus occipitale and occipital bun are helpful to determine race and the relationship between living taxa and paleontology. These tiny qualitative differences can be used as phenotypic connection markers between groups. We hereby report four types of torus occipitale and cases of occipital bun with their clinical and anthropological relevance.

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Background: Numerous tests are available for determining the cause of exudate, but all these tests lack sensitivity and specificity, and they are not generally available. Adenosine deaminase (ADA) activity in pleural or peritoneal fluid is simple and useful investigation in diagnosis of exudate effusion, particularly in differentiating tuberculous from nontuberculous exudative effusion. Objectives: To estimate the diagnostic utility of pleural and peritoneal fluid ADA/serum ADA ratio, in the diagnosis of tubercular pleural effusion. Materials and Methods: A hospital-based cross-sectional diagnostic evaluation study was carried out among 50 patients with pleural effusions selected to assay ADA activity in pleural fluid and serum along with pleural fluid analysis. Effusions were classified into transudative and exudative after careful evaluation of all biochemical parameters of pleural fluid. Cutoff value for pleural ADA was taken as 60 U/L and for pleural/serum ADA was taken as 2.5. Results: Forty-three patients had exudative effusions among which 38 were tubercular and five were nontubercular, seven cases were transudative. Mean pleural ADA levels in tuberculous group (80.31 ± 24.84 U/L) were higher (P < 0.01) than nontubercular group (23.00 ± 5.22 U/L). Serum ADA levels in tubercular group (27.23 ± 7.32 U/L) were significantly higher (P < 0.0l) as compared to nontubercular group (14.95 ± 7.04 U/L). Serum ADA levels in tubercular group (27.23 ± 7.32 U/L) were also significantly higher as compared to the control group of healthy individuals (13.00 ± 2.75 U/L). Pleural ADA cutoff at 60 U/L gave a sensitivity and specificity of 81% and 100%, respectively, whereas pleural serum ADA ratio at a cutoff of 2.5 gave a sensitivity and specificity of 71% and 81%, respectively. Conclusion: The measurement of ADA in tubercular pleural effusion is not only relevant, but also of a high diagnostic value when other clinical and laboratory tests are either negative or inconclusive.

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Background: Amid the COVID-19 period and lockdowns, medical education has witnessed major changes. Shifting from face-to-face offline education to online education in such an important branch of education dealing with human lives and serving mankind is really very challenging. In this distance learning process, student satisfaction is important and prediction of their satisfaction and other important parameters will help in improving the online system of medical education. Objective: To evaluate students' perception about distance learning education based on different domains given in the Distance learning Education Environment survey scale. Materials and Methods: A cross-sectional study was conducted among first-year and final-year MBBS students of the Institute of Medical Sciences, BHU. The total number of students who participated in the study was 123. The Distance Education Learning Environments Survey (DELES) scale which was validated for higher education by Scott L was used. The domain represents instructor support (D1), student interaction and collaboration (D2), personal relevance (D3), authentic learning (D4), active learning (D5), student autonomy (D6), and student satisfaction in distance learning process (D7). Results: The mean and standard deviation for each domain of the DELES were calculated. For instructor support, the mean was 25.9 for first-year students and 21.3 for final-year students. For the domain of authentic learning, the mean score was low, i.e. 15.7, for the first year and 13.3 for the final year. In the learning domain for the question about students satisfaction, the mean score was 19.8 for first-year students and 17.9 for final-year students. Conclusion: The finding of this study indicated that the majority of students were satisfied with instructor's support and personal relevance of the online learning classes, but were unsatisfied with opportunities of student interaction and group discussion, which is essential in medical education.

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Risk of bone necrosis is increased in patients with COVID-19 due to hypercoagulability. The hypercoagulability is caused by gene encoding for pro-inflammatory proteins which is due to single nucleotide polymorphism. All these mechanisms namely aggregation of leukocytes, hypercoagulability, and inflammation of the vessels can lead to reduced blood supply to the bone. This can ultimately lead to necrosis of the bone. The present case series of 20 cases attempts to study the avascular necrosis (AVN) of hip joint in patients with COVID-19. A history related to AVN was recorded. The patient was screened with plain radiographs of the affected joint. Magnetic resonance imaging (MRI) examination of Hip joint was done on the same day as plain radiograph. The Modified Ficat classification system for MRI was used for staging AVN of the femoral head. The mean interval between the onset of initial symptoms and MRI was 2–4 weeks. Majority of the patients were diagnosed as Stage I (45%). Males were affected more than females, i.e., 70% versus 30%. Fever and hip pain were the most common presenting symptoms. We conclude from the present case series that COVID-19 may be associated with AVN of hip joint as all post-COVID cases had AVN. Hence, all patients who recovered from COVID-19 should be screened for AVN for early diagnosis and prompt treatment.

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Background: Correlation between chest X-ray findings and drug resistance can provide valuable guide for physicians working at low-resource settings. Objective: To study tuberculosis (TB) drug sensitivity pattern as per the radiological presentation. Materials and Methods: A hospital-based prospective study was conducted among 67 newly diagnosed sputum-positive pulmonary TB patients who never took anti-TB treatment. They were subjected to history, systemic examination, radiology, and sputum smear examination. Ten patterns of chest X-ray were studied in the present study, which was not studied before. Chest X-ray radiology pattern was correlated with the drug resistance. Results: Isoniazid (INH) monoresistance was present in 11.9% of patients. 1.5% had rifampicin (RIF) resistance but no INH resistance. RIF and INH both resistance (multidrug-resistant [MDR]) was present in 7.5% of cases. Pattern Four was the most common radiological presentation in our patients being present in 20 (29.9%) patients. In this pattern, bacteria of 5.0% were RIF resistant. 15.0% were INH resistant, and 5.0% were both RIF and INH resistant (MDR). RIF resistance was most common in chest X-ray PA view with “Pattern Two” being present in bacteria of 21.42% of patients. Conclusion: Radiological patterns 2, 3, and 4 were highly correlated with the multidrug resistance, but it was not statistically significant. Patients' chest X-ray showing these patterns can be suspected to have MDR-TB and sent for further evaluation for early diagnosis and treatment of MDR-TB, which will give us good outcome. Further studies on this hypothesis should be conducted with bigger sample size to throw more light in this field.

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Background: Men with diabetes who develop erectile dysfunction (ED) experience a substantial waning in quality-of-life as well as a rise in depressive symptoms. Regrettably, ED may go unnoticed as many clinicians do not question about sexual health. Objective: The objective is to determine the prevalence and risk factors of ED among patients with type II diabetes mellitus Methods: Analytical, cross-sectional study was carried out among 720 individuals with type II diabetes aged 30–70 years at the diabetes clinic of Malla Reddy Hospital from January 2019 to January 2022 after obtaining ethics committee approval. Peripheral artery disease (PAD) was assessed by taking a ratio of systolic blood pressure recorded at ankle to that recorded in the arm as per standard guidelines. Abridged version of the International Index of Erectile Function was used to assess ED. Glycated hemoglobin (HbA1c), serum testosterone levels, and lipid profile were determined on fasting blood. Results: Mean age was 58.4 ± 7.8 years. The overall prevalence of ED in the present study was 68.7%. On univariable analysis, higher age, longer duration of diabetes, presence of hypertension, presence of peripheral arterial disease, higher levels of HbA1c, and lower levels of serum testosterone were significantly associated with the ED. On multivariable analysis increase in the duration of diabetes every 5 years, presence of hypertension, presence of peripheral arterial disease, HbA1c ≥7%, and testosterone <8 nmol/L except age were found to be significantly and independently associated with the ED. Conclusions: The prevalence of the ED was high in the present study. It was significantly and independently associated with the deficiency of the testosterone, poor control of the blood sugar, presence of the PAD, and the longer duration of the diabetes.

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Introduction: The Indian population is considered to have a high risk of developing diabetes mellitus. High-risk people are advised to undergo opportunistic screening since early detection allows for an early start of treatments targeted at improving glycemic control, thereby reducing or delaying the onset of complications. Through this study, we aim to utilize this golden opportunity for screening diabetes among apparently healthy individuals and thus determine the prevalence of diabetes among them. Materials and Methods: In June of 2022, an opportunistic screening camp for diabetes was organized during the annual Wari procession by the ADORE trust in a hall at Saswad. Using a public address system, the people who voluntarily entered the premises of the hall were shown a poster exhibit briefed about general knowledge about diabetes including its risk factors, complications, the silent killer nature, and on the Dixit lifestyle to prevent and reverse diabetes. Following this, the people were encouraged to consent to a blood sugar test voluntarily. The team of volunteers used glucometers, systematically recorded random blood sugar level (Random BSL) readings of the participants, and contacted the people with Random BSL above 200 mg/dl to counsel them for further follow-up. Results: Out of the 1734 people screened, 269 people were found to have a Random BSL above 200 mg/dl. Thus, 15.51% of the total people screened could be categorized into the “diabetic” category. Out of the 269 people who were found to have a Random BSL above 200 mg/dl, 195 were male and 94 were female. Conclusion: An opportunistic screening program is cost-effective, feasible, and has large-scale implications. Such programs must be implemented on a national scale as part of various schemes to combat health issues such as, but not limited to, noncommunicable diseases. From our initiative of opportunistic screening for diabetes, 269 participants whose Random BSL was not in the normal range were picked up. With proper counseling, they can be set on a path to reverse their course and prevent unnecessary complications.

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