To Identify the Dangerous Length of External Laryngeal Nerve In Relation to Thyroid Pole In Cadaveric Thyroid Glands

Introduction: The external laryngeal nerve passes through the “space of Reeve” cricothyroid space. It has also been described as lying in the Joll’s triangle. It is often inadvertently neglected during thyroid surgeries. It has been named after a singer who lost her voice after a thyroid surgery, as the “nerve of Galli Curci” Aim: To identify the dangerous length of the external laryngeal nerve in relation to the thyroid pole. Material and Methods: Fifty laryngeal nerves were dissected using conventional method of dissection, in twentyfive embalmed cadavers used for teaching purpose at Karpaga Vinayaga Institute of Medical Sciences and Research, Madurantakam. The observations were noted and photographs taken. The course and relations were carefully noted. Results: 38 specimens (76%) had the superior laryngeal nerve measuring 4cm. in 8 specimens (16%) it was 3.5 cm and in 04 specimens (8%) it measured 3.8 cm. It was observed that the external laryngeal nerve crossed the superior thyroid pole at less than 1cm only in three (6%) of the fifty nerves. Conclusions: The critical length of the nerve would be dangerous if the nerve crosses the superior thyroid pedicle close to thyroid pole at less than 1 cm. The consequences of neglecting the critical length would injure the nerve and cause dysphonia or raspy voice.

Cardiopulmonary Bypass Surgery?Cold Alert!

The term 揷old agglutinin (CA)� refers to a group of disorders caused by anti?erythrocyte autoantibodies that preferentially bind RBCs at cold temperatures (4癈�癈). CAs contribute to 10 to 15% of autoimmune hemolytic anemia. We report a case of CAs diagnosed intraoperatively during emergency mitral valve replacement.

A Prospective Study of Various Anesthetic Techniques in Patients with Acyanotic Congenital Heart Diseases Undergoing Device Closure

Background and Aims:Transcatheter device closure of congenital heart defects (CHD) has recently gained popularity. As limited literature exists regarding the ideal anesthetic technique for these procedures, we studied the perioperative anesthetic management and its effects on hemodynamics and complication rate in patients undergoing device closure. Methods: In this prospective observational study, all patients of 1 month to 50 years of age with acyanotic congenital heart diseases undergoing device closure were included. The anesthesia technique, i.e., general anesthesia with endotracheal tube (GETA)/supraglottic airway device (SGD) or conscious sedation with face mask (S?FM), and intravenous induction agent used was noted. Intraoperatively vital parameters, use of transesophageal echocardiography (TEE), and perioperative complications if any, were noted. Descriptive statistical analysis was done using a statistical package for the social sciences (SPSS) version 15. Results: GETA was used in the atrial septal defect (ASD) (62.8%), patent ductus arteriosus (PDA) (66.7%), ventricular septal defect (VSD) (65%) patients, SGD in ASD (6.3%), PDA (16.7%), and VSD (13.3%) patients. S?FM in ASD (31.3%), PDA (16.7%) and VSD (21.7%) patients. Etomidate was used as an induction agent in 30.61% of the patients and propofol in 69.39% of the patients. The mean arterial pressure (MAP) in the etomidate and propofol groups was statistically insignificant while decreased heart rate was noted in both groups. Complications like SGD dislodgement, supraventricular tachycardia, and device dislodgements were seen. Conclusion: In PDA device closure patients, GETA should be preferred. Patients for VSD device closure should receive general anesthesia as complications are common. In ASD device closure, patients without TEE use can be done under general anesthesia with SGD.

Evaluation of three different remineralizing agents on artificially demineralized enamel lesions Using scanning electron microscopy-energy dispersive X-ray and magic-angle spinning nuclear magnetic resonance - An in vitro study

Aim: Demineralization can be arrested or reversed when remineralization agents are applied to incipient carious or noncavitated carious lesions. A large number of therapeutic agents, including nonfluoridated products, have been developed to promote enamel remineralization. This study aims to evaluate the efficacy of different remineralizing agents on artificially demineralized enamel lesions. Materials and Methods: The present in vitro study was conducted on 75 sound premolars divided into three groups of normal, demineralized (n = 15 each), and remineralized teeth (n = 45). The remineralized teeth were further subdivided into three groups (n = 15) as remineralized with 2% sodium fluoride (NaF), 2% NaF, and Psoralea corylifolia (bakuchi) and white mineral trioxide aggregate. Specimens of each group were treated with the above-mentioned remineralizing agents and then subjected to Vickers hardness number (VHN), scanning electron microscopy–energy dispersive X-ray (SEM-EDX), and magic-angle spinning nuclear magnetic resonance (MAS-NMR) for further evaluation. Results: The test results showed significantly the highest VHN and the emission peak of elements under the EDX test, such as calcium, phosphorous, oxygen, and fluorine with remineralized with NaF + bakuchi. MAS-NMR spectra showed fluorine and phosphorous peak in a group with NaF + bakuchi indicative of the increase in remineralization. NaF + bakuchi showed effective results in VHN, SEM-EDX, and MAS-NMR with no antagonist interaction. Conclusion: Thus, P. Corylifolia presents an advantage in enhancing remineralization and inhibiting demineralization for early carious lesions and can be used as a herbal extract for effective reduction in pathogenic bacteria.

The Effect of Multi-source Feedback on Core Competencies of Pediatric Residents

Objective: The study was conducted to evaluate impact of multisource feedback in pediatric residency training. Methods: A crossover study of pediatric residents at Wadia Children’s Hospital was conducted with assessment of core competencies like knowledge, practice-based learning, system-based practice, professionalism, communication skills and interpersonal interaction. After randomization both groups (A and B) were given MSF and traditional feedback, respectively and later the groups were crossed over to other method of feedback. Control faculty assessed both groups at three points – Pre-intervention, after first and after second intervention. Results: There were 16 residents in each group (13,7,7 in first, second and third year of residency, respectively). Both groups had comparable scores in all six competencies at entry point. Group A after MSF showed significant improvement in all six competencies (all P<0.01). No significant improvement was observed in group B after traditional feedback. After cross-over to MSF, group B showed statistically significant improvement in all core competencies. Traditional feedback to group A after crossover showed statistically significant improvement only in knowledge, professionalism and system based practice. Outcome: MSF was beneficial in improving competency based performance scores in pediatric residents.

Early weight trends in preterm babies post discharge

Background: Prematurity is the major determinant of morbidity and mortality in newborns. Infants born preterm are at increased risk for impaired growth. The postnatal growth pattern is dependent on biological factors like birth weight, gestational age, sex and intrauterine growth. The present study was undertaken to study the risk factors associated with the preterm delivery and to study the weight gain pattern among the preterm neonates after NICU discharge for a period of one month. Aims and objectives to study the risk factors associated with preterm and to analyze the weight gain pattern of the preterm till one-month post NICU discharge.Methods: A total of 40 preterm were included during the study period of 2 months, the various maternal risk factors were studied and correlated with preterm delivery. The neonatal complications were studied. The neonates were divided on the basis of their gestational age and birth weight. They were then followed for a period of 1-month post NICU discharge.Results: There was significant correlation of lower gestational age with neonatal complications and prolonged duration of hospitalization. The weight gain pattern was highly variable with a maximum gain of 188 gm after first week of NICU discharge. Weight gain was significantly more in first week after discharge amongst neonates who had birth weight less than 1.5 kg and also the total weight gain was significantly more in neonates who weighed less than 1.5 kg at birth.Conclusions: Lower gestational age group 28-32 weeks was significantly associated with neonatal complications and prolonged duration of hospitalization. Immediate follow up of the preterm is necessary as there is wide variability in the weight gain pattern in various gestational age groups.

Syncope in children clinicoetiological correlation

Background: Syncope is the abrupt cessation of cerebral blood flow leading to temporary loss of consciousness. Identification of etiology is utmost important as any syncopal event may be life threatening. Aim was to correlate the clinical and etiological causes of syncope in children and to note their investigational profile.Methods: Among 40 patients presenting with syncope and presyncope were studied. History of the event, precipitating factors were noted. They were investigated with the help of blood pressure, Electrocardiogram (ECG), 2D Echocardiogram and Electroencephalogram (EEG).Results: Out of the 40 patients of syncope 65% were above the age of 10 years with male preponderance (60%). Vasovagal syncope (57%) was the most common cause of syncope followed by orthostatic hypotension (15%), neurological (15%), and cardiac etiology (6%). In the neurological etiology the EEG showed diffuse slow background with occasional sharp bursts in right frontal area in 2 patients while in 4 patients sharp bursts were present in the centero-temporal region. 17% were classified as presyncope, 60% as mild and 22% as having severe syncope. There was a significant correlation of etiology of syncope with duration of hospitalization of more than 4 days and with recurrence of syncope. There was significant correlation of Evaluation of Guidelines in Syncope (EGSYS) score >3 with cardiogenic syncope. On follow up, neurological syncope patients had significant decrease in the number of syncopal episodes as they were immediately started on antiepileptics.Conclusions: Electrocardiogram, 2D Echocardiogram and Electroencephalogram are important tools for the early management and treatment of cardiac and neurological etiology of syncope.

Study To Assess The Knowledge & Awareness Regarding Eye Donation Among Students Of Cims Bilaspur (C.G.)

Background-Eye donation is an act of donating ones eye after his/her death. it is an act of charity,purely for the benefit of the society and is totally voluntary. age or systemic illness such as diabetes or hypertension, heart disease \,kidney disease is not barrier for eye donation.. eye disease are a significant cause of visual impairment and blindness in the developing world.approximately 18.7 million people are blind in india and 1,90,000 are blind from bilateral corneal disease.For such people corneal transplantation helps in restoring their sight. According to the eye bank association of india the current cornea procurement rate in india is 22,000 per year.Programme and activities conducted across the country to impart the significance of eye donation and its useful to visual impaired people. Objectives- 1.To assess sociodemographic profile of the students.2.To assess the knowledge & awareness regarding eye donation among study subject. Methodology-Study Subject;-Medical student CIMS college Bilaspur. Type Of Study :-Observational Cross sectional study. Study Area :- CIMS medical college Study Duration:-July 2017 to December 2017. Sample Size :- 100medical students in CIMS medical college Bilaspur(C.G) Study Tools :- Pre designed questionnaires Results:- In the present study, there was nearly 46% male and 54% female. 100% of the participants had heard about eye donation.The commonest source of knowledge on eye donation, Dr (32%) followed by TV(25%), Friends (20%). Majority (63%) of participants had correct knowledge that eye should be removed from dead donor within 6 hours.80% of the participants replied eye donation is done by all age group people. Conclusion:- Majority (63%) of participant had correct knowledge regarding eye donation. Majority (79%) of the students have willingness regarding eye donation

A histopathological observation made on cystic kidneys obtained from human cadavers

Introduction: Cysts in the kidneys have been described as being heterogeneous, and occur due to hereditary,developmental and acquired disorders. They account for 6-8% of diseases that go for dialysis. Evaluating cysticdiseases is important for pathological diagnosis and treatment procedures for the patient.Objective: Present study aimed at finding the types of cysts prevalent in human cadaveric kidneys by making ahistopathological observation. The study was made to review the incidence of cysts in kidneys and to find outwhat are the commonest types of cysts that are identified.Material and Methods: Thirty formalin fixed adult cadavers were used for the study. Twenty were male and tenwere female cadavers used for routine dissection and teaching purposes for the first year medical students in thedepartment of Anatomy, P.E.S Institute of Medical Sciences and Research. The kidneys were dissected out from thecadavers from both sides. The fat and fascia were removed carefully and first photographed for gross appearance,before handing the specimens to the department of pathology for further study by making sections.Results: Cystic kidneys were seen in seven cadavers out of the thirty cadavers. The other cadavers had no cystickidneys. The incidence of cysts has been calculated in this study as 23.3%. The normal kidneys were 76.6%. Inthree female cadavers unilateral cysts were seen in the right kidney. In male cadavers, one had unilateral cystand the remaining three presented with bilateral cystic kidneys. One among the four showed multiple bilateralcysts ranging from one to forty five cysts.Conclusion: From this study it is evident that cysts of the kidney may occur without disturbing the normalfunctioning of the kidneys. The incidence of multiple cysts was more in males than in females. No of cysts weremore in the right than in the left kidneys. For a person to lead a normal life one fifth of the kidney is sufficient ifit functions normally.

Management of ventricular storm with thoracic epidural anesthesia

The incidence of recurrent ventricular arrhythmias is increasing these days. Ventricular electrical storm can be of three types as follows: monomorphic ventricular tachycardia (VT), polymorphic VT, and ventricular fibrillation. The mechanism of ventricular storm is complex, and its management is quite a challenge for the clinicians due to its life-threatening consequences. We report a case of ventricular storm in whom all the conventional methods for the management of arrhythmias were ineffective, and the case is managed effectively with thoracic epidural anesthesia (TEA). A 60-year-old male patient was admitted to recurrent ventricular arrhythmias. He received defibrillator shocks and other antiarrhythmic drugs, but he was not responding to the treatment. We managed to revert the ventricular arrhythmias to the sinus rhythm with TEA. Ventricular storm is a challenging complication, which can be managed effectively with timely diagnosis and effective management.

Anesthetic management of patent ductus arteriosus in adults.

Patent ductus arteriosus (PDA) is an extracardiac left to right shunt. It should be corrected at an early age, but some patients may survive into adult life even without repair. Anesthetic management for adult patients with PDA poses many challenges for the anesthesiologist due to alterations in the cardiopulmonary physiology. We report successful anesthesia management of a case of an adult patient of PDA with moderate pulmonary artery hypertension with infective endarteritis (two large mobile vegetations at the pulmonary end of the duct).

Knowledge, Attitude, and Compliance of Healthcare-associated Infection Control among Nurses in the Western Development Region, Nepal / 병원감염관리

BACKGROUND: Healthcare-associated infection (HAI) affects the morbidity and mortality of inpatients worldwide. Nepal is a developing country in which HAIs pose a major problem in terms of patient safety. Therefore, this study was designed to assess the level of knowledge and attitude toward HAIs and compliance for infection control among nurses. METHODS: A cross-sectional survey was conducted using a self-administered questionnaire including general characteristics, and knowledge of, attitude toward, and compliance with HAI control practices, on a sample of 259 nurses from 11 hospitals in 3 cities in Nepal, from July 17 to August 5, 2014. RESULTS: The average score on knowledge of HAI was 6.56, on a 13-point scale. In total, 59 nurses had undergone HAI control training and 211 nurses reported that they were governed by some guidelines, but there were no significant differences. The overall level of compliance with HAI control guidelines was 79.2 points based on a 100-point scale, which did not differ in terms of age, exposure to infection control training, and the presence of any guidelines. CONCLUSION: The level of knowledge of HAI control among nurses was very low and a majority had never undergone any HAI control training. Evidently, there is an urgent need to provide HAI control training to nurses, and to develop infrastructure to provide training for them.

Extra Hilar Branching of Renal Arteries: An Anatomical Study.

Introduction: The objective of this study was to observe the patterns of different arteries that supply the kidneys. The kidney has a segmental distribution of arteries. The kidneys are divided into five vascular segments. The arteries that arise from the aorta above or below the main renal artery and reach the hilum are called accessory renal arteries. They are persistent embryonic lateral splanchnic arteries. Accessory renal arteries may arise from the celiac or superior mesenteric arteries, near the bifurcation or from the common iliac arteries. The present study has attempted to find out accessory, and aberrant arteries to kidneys with review of literature. Materials and Methods: The study was done on 52 kidneys randomly selected from cadavers that were used for the purpose of teaching in the department of Anatomy at P.E.S Medical College. The kidneys were removed from the cadavers en-block with the arteries and veins intact. The renal artery was observed for its pattern of branching. Observations and Discussion: The pre-hilar branching pattern was absent only in six kidneys out of the 52 kidneys selected. The branches given before entering the hilum were either in the form of a fork pattern or a ladder pattern in the remaining 46 kidneys. The fork pattern wherein the branches arose from a single point was found in 42 kidneys. The ladder patterns were seen in two posterior segment arteries and two anterior segment arteries. The anterior division often showed the fork patterns which were either duplicate or triplicate outside the hilum more proximally, with further division into duplicate or triplicate terminal branches closer to the hilum but significantly outside.

Personal concept of chronic illness in rural population-identifying myths and beliefs.

Background: The morbidity of Chronic Renal Failure (CRF) is not only physical but also psychological and social. The study aimed at identifying whether there was any mythological belief in being afflicted with such a chronic illness and the personal concept of a chronic illness. Therefore patients with chronic renal failure were selected for the study. Methods: The study includes two different groups of patients, 25 per group examined at two different places at two different points of time. The two groups attended different hospitals in their local areas. Patients who were suffering from chronic renal failure were examined and selected for the study. In both groups results were obtained based on questions designed to get information on four themes: their economic status, their status of work, their dependency status and their personal concept of the illness. All the patients belong to rural areas and have had less than formal education or no education at all. Results: The most important finding in this study was a belief expressed in five patients (Two males and three female). They believed that indulging in sex in their marital life itself was a cause of the illness. One other female patient who had a bad obstetric history felt that her illness was due to the number of abortions she had. Conclusion: In a country like India especially in rural India where people believe in alternative medicine, magico-religious methods of native healers, it is difficult to convince people to go for a counselling service. They have to be provided such a service after the initial physical treatments have been started. It is essential that a service of such kind is provided free of cost at any level, even in a primary health centre. Where possible it is necessary to use diagnostic tools to designate severity of the problem. Otherwise personal ideas about illness that marital life has caused the disease can reflect adversely on the harmony and quality of life of patients. This study has enough potential to conduct more such studies to identify outcomes of chronic illnesses and design interventions accordingly.

Designing A Contemporary Anatomy Museum: Anatomists' Perspective.

Background: A research study was conducted in sixteen anatomy museums across India. Aim: The aim of the study is to have an integrated approach while designing a museum. Objective: The objective is to stress on the need to have a holistic approach while designing a museum so that that the museum is well planned and organised and has a huge sectional diversity that spans all aspects related to anatomy. Materials and Methods: All the museums were studied using a planned proforma that emphasised on special features of the museum with special emphasis on sectional variety. Observations: The various techniques of specimen preparation, preservation, mounting and display were observed and photographed. The sectional variety was noted. Moreover the various methods of maintaining specimen related information in pictorial and computerised catalogues was observed. Results and Conclusion: A design of a contemporary anatomymuseumcan nowbe conceived that incorporates all aspects of anatomy from history, evolution, embryology, cross-sectional anatomy, comparative anatomy, teratology, genetics and clinical anatomy to sections with modern techniques like plastination. Such amuseum will certainly have a more holistic approach to anatomy and will be more educative and scientific.

Communicating root of auriculotemporal nerve with inferior alveolar nerve-looping around accessory meningeal artery.

Background: The auriculotemporal nerve has been described as having two roots in standard textbooks of anatomy. It lies on the tensor veli palatini muscle while passing backwards behind the lateral pterygoid muscle. It runs behind the temporomandibular joint after passing between the sphenomandibular ligament and the neck of mandible. It ascends over the posterior root of zygoma posterior to superficial temporal vessels. It gives superficial temporal branches and also branches to facial nerve and otic ganglion. The branches to the facial nerve join at the posterior border of masseter. On the face the cutaneous branches supply the tragus, part of the adjoining auricle of the ear and posterior part of temple. Methods: Variations in the origin of the auriculotemporal nerve have been described by many authors in the past and this prompted the study of the auriculotemporal nerve, its origin and course, in 36 specimens (18 cadaveric heads) in bodies that were allotted for dissection purpose to first year medical students in the department of anatomy in P.E.S Medical College, Kuppam. Results: It was seen that the auriculotemporal nerve had two roots of origin and they formed a loop to enclose the middle meningeal artery in all the 35 specimens except in one side of the cadaveric heads. In only one half of a cadaveric head it was found to arise by three roots which formed two nerve loops. The first and second nerve roots joined with each other to form a nerve loop. The third root joined with the inferior alveolar nerve and formed the second nerve loop. The accessory meningeal artery passed through the second nerve loop. The normal presentation of two roots enclosing the middle meningeal artery was not present. Instead the accessory meningeal artery was enclosed between the third root and the inferior alveolar nerve. The middle meningeal artery entered the skull through the foramen spinosum as usual but was not enclosed by the nerve roots. The trunk of the auriculo temporal nerve was seen between the middle meningeal artery and inferior alveolar nerve and the study reports the presence of variant nerve loops encircling the accessory meningeal artery. Conclusion: The variations in the roots of auriculotemporal nerve have been reported in the past and since it is important in the clinical implications of the region especially for the facio-maxillary surgeons and dental surgeons. The incidence of variation has to be documented as this helps in updating the clinical database for surgical procedures and treatment in the region of infratemporal fossa.

The effect of Propolis and Xylitol chewing gums on salivary Streptococcus mutans count: A clinical trial.

Background: Streptococcus mutans is one of the most common cariogenic microorganisms. Use of natural anticariogenic agents, such as Xylitol has been well‑established in the literature. On the other hand, there is a scarcity of studies that have reported the antimicrobial potential of Propolis as an anticariogenic chewing agent; hence, the present study was designed. Aims: To evaluate and compare the anticariogenic action of two commercial chewing gums Propolis and Xylitol on the salivary S. mutans count in a group of children from Bengaluru city. Settings and Design: Clinical setting and experimental design. Materials and Methods: Thirty healthy children aged 8–11 years with decayed, missing, and filled teeth (dmft)/DMFT index score ≥3 were included in the study. Before the test, unstimulated saliva was collected. Children divided into Group I and II were given Propolis and Xylitol chewing gums respectively; to chew for 15 min. Saliva samples were then collected at 15 min (just after spitting) and after 1 h. The amount of S. mutans in saliva was evaluated using a selective media (MSAB). In addition, compliance of the two chewing gums among the children was tested with a questionnaire. Statistical Analysis Used: Student’s t‑test. Results: Six samples out of 30 were excluded due to no growth. The total number of bacterial colonies was significantly reduced when compared to baseline in both the groups. Propolis gum showed statistically significant reduction in the number of colonies as compared to Xylitol. Xylitol gum was more preferred than Propolis gum by the children. Conclusions: Propolis chewing gum can be used as an anticariogenic agent in children.

Unusual branching pattern of external carotid artery in the left carotid triangle.

During the routine dissection of the neck for the first MBBS students, we have found the abnormal branching of the external carotid artery in the carotid triangle. The external carotid artery is a terminal branch of the common carotid artery arises at the level of superior border of the thyroid cartilage in the carotid triangle. It supplies the structures of head and neck regions by its eight branches. The knowledge of variations is very important for the general, head & neck, ENT and oncosurgeons, to avoid unforeseen complication in the form of bleeding by injuring the abnormal arteries. It is also important for the vascular surgeons and radiologists while performing the procedures on the arteries.

Bupivacaine 0.125% versus bupivacaine 0.125% with different doses of fentanyl for epidural labour analgesia: A randomised double blind study.

Background: Epidural analgesia is the most commonly used method for labour analgesia. Aims & Objective: To evaluate the safe dose of fentanyl added to Bupivacaine 0.125% and its effect on quality and duration of analgesia with side-effects. Materials and Methods: Forty-five healthy nulliparous women, ASA physical status I and II with an uncomplicated pregnancy and single fetus in vertex position were given lumbar epidural analgesia. Patients in Group A (n=15) received Bupivacaine 0.125 percent; Group B (n=15) and C (n=15) received the same agents as Group A but with addition to the initial dose of 2 mcg/ml or 4 mcg/ml of fentanyl respectively. All the patients were evaluated for duration and quality of analgesia, duration of labour, method of delivery and side effects. Results: Addition of either 2 mcg/ml or 4mcg/ml of fentanyl resulted in longer duration of analgesia (132.2 ± 12.4 minutes and 188.20 ± 18.5 minutes respectively versus 92.5 ± 10.2 minutes) and also decreased number of top up doses significantly. Quality of analgesia was better in Group B and Group C as compared to Group A. Addition of fentanyl did not affect the duration of labour, the method of delivery and fetal outcome. Conclusion: Combination of Fentanyl 2 mcg/ml and Fentanyl 4 mcg/ml with Bupivacaine 0.125% is both and safe for providing labour analgesia via epidural route.

Brachiocephalic Trunk and Left Common Carotid Artery Arising from Aortic Arch as a Single Trunk.

Branches of aortic arch usually are brachiocephalic trunk, left common carotid artery and left subclavian artery from right to left direction. Arch of aorta show more variations in branching patterns. One among which is origin of only two branches in which brachiocephalic trunk and left common carotid artery arise together as a common trunk and other branch is left subclavian artery. The variations occur due to abnormal development of arch of aorta. During routine dissection of superior mediastinum of thoracic region, we have found the left common carotid artery and brachiocephalic trunk was arising from the arch of aorta as a common trunk. These kinds of variations are very rare and knowledge of which is very important for neck surgeons, cardiologists and interventional radiologists while doing surgeries and instrumentation procedures.