HEALTH SEEKING BEHAVIOUR OF WOMEN & CHILDREN LESS THAN FIVE YEARS AMONG THARU ETHNIC COMMUNITY IN TRIYUGA MUNICIPALITY, NEPAL

Background: Under 5yrs mortality rates among male child is 30 and among female is 26 and overall infant mortality rate 24 per thousand respectively; these are the most vulnerable groups to different morbidity and mortality, and they ought to be fully dependent on parental knowledge and awareness to meet their health needs. Health seeking behavior (HSB) has become a tool for understanding the approach of people towards the health care systems in their respective socio-economic, cultural and demographic circumstances. A Community based Methods: descriptive study among “Tharu” ethnic women with children less than ?ve years of age in Triyuga Municipality, Nepal. Semi- structured questionnaire was used to collect socio-demographic information,, knowledge and current practice regarding health seeking behavior, including awareness and accessibility of health services. Among 406 respondents, 388 of Results: their children were reported ill within last 1 year, with fever accounting for 70%, followed by ARI (65%), diarrhea (6%) and others. Where 52.8% of respondents had appropriate HSB, taking their ill children to hospitals. More than 52% of respondents had hospitals as the ?rst preference for treatment for every morbidity. Except for access to health care facility, there was no signi?cant association of HSB was seen with parent's literacy,income, gender preference. With satisfactory Conclusion: awareness, literacy, and accessibility of health care centers, the HSB among tharu women, for the children morbidity seemed to be satisfactory in comparison to national scenario and other marginalized groups

Quality assurance of malaria rapid diagnostic tests: An aid in malaria elimination

Background & objectives: India targets malaria elimination by 2030 in a phased manner, so malaria’s assured diagnosis is crucial. Introduction of rapid diagnostic kits in India in 2010 has revolutionized malaria surveillance. The storage temperature of rapid diagnostic tests (RDTs), kit components and handling in transportations impact the results of RDTs. Therefore, quality assurance (QA) is required before it reaches end-users. The Indian Council of Medical Research-National Institute of Malaria Research (ICMR-NIMR) has a World Health Organization (WHO) recognized lot-testing laboratory facility to assure the quality of RDTs. Methods: The ICMR-NIMR receives RDTs from different manufacturing companies as well as various agencies such as National and State Programmes and Central Medical Services Society. The WHO standard protocol is followed to conduct all the tests, including long-term and post-dispatch testing. Results: A total of 323 lots tested during January 2014-March 2021 were received from different agencies. Amongst them, 299 lots passed the quality of test and 24 failed. In long-term testing, 179 lots were tested and only nine failed. A total of 7741 RDTs were received from end-users for post-dispatch testing of which 7540 qualified the QA test with a score of 97.4 per cent. Interpretation & conclusions: RDTs received for quality testing showed compliance with QA evaluation of malaria RDTs based on the protocol recommended by the WHO. However, continuous monitoring of the quality of RDTs is required under QA programme. Quality-assured RDTs have a major role, especially in areas where low parasitaemia of parasites persists.

Ectopic teeth with disparate migration: A literature review and new case series

Purpose@#Ectopic eruption can be defined as the emergence of a tooth in an abnormal location, where the tooth does not follow its typical eruption pathway. While ectopic eruption within the dentate region is well-documented in the literature, ectopic eruption in non-dentate regions is relatively rare. This study aimed to report 6 cases of ectopic teeth and present a systematic review of the English-language literature on ectopic teeth, emphasizing demographic characteristics, radiographic features, potential complications, and treatment options. @*Materials and Methods@#A literature search was conducted using the PubMed, Medline, Web of Science, and Cochrane databases. The demographic data and radiographic findings of patients presenting with ectopic teeth were recorded. @*Results@#The literature review yielded 61 cases of ectopic teeth, with patients ranging in age from 3 to 74 years. The findings from these previously reported cases demonstrated that the most common location for ectopic teeth was the maxillary sinus, which is consistent with this case series. The Pearson chi-square test was performed to evaluate the correlation between age and location of ectopic teeth, and the results were found to be statistically significant (P<0.05). However, no statistically significant relationship was observed between sex and the location of ectopic teeth. @*Conclusion@#The distinct features of these cases warrant reporting. This study presents the first case of supernumerary teeth in the condyle without any associated pathosis. Another notable characteristic is the pre-eruptive resorption of 2 inverted supernumerary teeth ectopically located in the palate, which predisposes to sinus opacification.

Cone-beam computed tomographic imaging of central giant cell granuloma: A comprehensive review

Purpose@#The aim of this study was to characterize the cone-beam computed tomographic (CBCT) imaging features of central giant cell granuloma (CGCG) of the jawbone. @*Materials and Methods@#This study retrospectively reviewed 26 CBCT studies of histologically proven cases of CGCG during a period of 20 years, from 1999 to 2019. Patients’ demographic data were recorded, and radiographic features were assessed (location, border, cortication, appearance of the internal structure, locularity, septation, expansion, cortical perforation, effects on surrounding tissue, whether the lesion crossed the midline, and lesion volume). @*Results@#In this study, CGCGs were seen almost twice as often in the mandible than in the maxilla, and 64.7% of mandibular lesions involved the anterior region. Only 26.9% of lesions crossed the midline, a feature that was considered characteristic of CGCG. Furthermore, 65.4% of lesions were unilocular and 34.6% were multilocular. The correlation between a lesion’s size and its locularity was statistically significant, and larger lesions showed a multilocular appearance. The mean volume of multilocular lesions was greater than that of unilocular lesions. @*Conclusion@#CGCGs showed variable radiographic features on CBCT, and this imaging modality is highly effective at demonstrating the radiographic spectrum and lesional extent of CGCGs in the jawbone.

Present tense: A peculiar case of Pemphigus Vulgaris presenting with tense blisters during the COVID-19 pandemic

@#Pemphigus vulgaris is an autoimmune bullous dermatosis presenting with flaccid blisters and erosions. The morphology of pemphigus reflects the more superficial intraepidermal level of split seen histologically in contrast with pemphigoid, where the level of split is deep below the epidermis. This is a case of a 58-year-old male clinically presenting with arcuate tense bullae, which are more characteristic of the pemphigoid group of disorders, which revealed an intraepidermal split and tombstoning pattern of the basal epidermis on histopathology. Direct immunofluorescence revealed intercellular IgG and C3 distribution. Although this patient presented clinically with tense bullae, the histopathology and direct immunofluorescence results were consistent with pemphigus vulgaris.

Effects of exercise on improving sleep quality among elderly patients: A systematic review and meta-analysis / The Health Sciences Journal

INTRODUCTION@#Several studies on the effectiveness of exercise in improving sleep quality in the elderly have been done but have conficting results. This meta-analysis aimed to determine the effect of low- to moderate-intensity aerobic exercise in improving sleep quality among the elderly.@*METHODS@#EBSCO, ClinicalKey, PubMed, Wiley Online Library, and Cochrane Library were searched for articles using the terms “exercise AND sleep quality AND elderly”. The risk of bias assessment was done using the Cochrane Collaboration tool and encoded using RevMan 5.4. Data on outcome measures were subjected to meta-analysis using inverse variance methods.@*RESULTS@#Seven articles with a total of 225 participants were included. There was a statistically signifcant improvement in sleep quality with low to moderate intensity aerobic exercise (MD = -3.87 points; 95% CI -5.56, -2.19 points; p < 0.001). There was a statistically signifcant decrease in total sleep time after intervention (MD = -8.86; 95% CI -16.31, -1.41 points; p = 0.02). There was no improvement in sleep effciency.@*CONCLUSION@#Low and moderate intensity exercise improves sleep quality in the elderly and may be used as a non-pharmacologic intervention to enhance sleep quality.

Association of Socio-Demographic and Clinicopathological Risk Factors with Oral Cancers: A 19-Year Retrospective Study

ABSTRACT Objective: To determine the association of socio-demographic and clinic-pathological risk factors with oral cancer in Kelantan, Malaysia. Material and Methods: A 19-year cross-sectional survey was performed in Hospital Universiti Sains Malaysia (HUSM), Malaysia. Medical record of 301 oral cancer patients was retrieved from the Medical Records office. Results: The majority of the oral cancer cases were male (62.8%), non-smokers (57.5%), non-alcohol consumers (83.4%), non-betel quid chewers (96.7%), and belonged to Malay ethnicity (68.8%). At the time of diagnosis, most of the patients were at stage II (38.9%). Approximately one-third (30.6%) of the total OC patients experienced loco-regional/distant metastasis, whereas no metastasis was detected in around two-thirds of cases (69.4%). A combination of surgery and radiotherapy was the most commonly employed treatment modality (27.2%). At the time of this study, the survival status of most of the patients was alive (69.1%). The most frequently encountered oral cancer in the Kelantanese population was oral squamous cell carcinoma (70.1%), with the tongue being the most frequently involved oral cavity site (35.5%). Conclusion: More than three-fourths of the cases were alive at follow-up, which included the cases that did not undergo any form of treatment.

FNAC of Different Breast Lesions in Subset of Rural Areas of Sindh

Background: In the 1970’s the introduction of Fine Need Aspiration Cytology (FNAC) proved to be the key method for examining the nature and malignant potential of many palpable lesions like thyroid, salivary glands and lymphadenopathies. Breast pathologies is one of the entity that can also be diagnosed with FNAC. Breast cancer is the most common malignancy of women with overall 100,000 cases being reported annually around the globe. The most frequent lesion encountered using FNAC in breast is fibro-adenoma followed by fibrocystic disease, breast abscess, chronic inflammatory conditions and suspicious malignant masses. In current cross sectional study we tried to find frequency of different breast lesions by FNAC.Methodology and Results: 649 samples were recruited from the Vital Laboratory Larkana with different pathological lesions of breast during the year 2014 and 2015 by non-probability consecutive sampling. 613 (95%) were females and 32 (5%) were male withmean age of 30.812.8 years. Majority of case were of 20-39 years of age (55.8%). Most of the cases were diagnosed with benign lesions (329, 51%) followed by inflammatory lesions (132, 20.5%) and gynecomastia (15, 2.3%). Right breast was moreaffected (329, 51%). In present study we found a strong association of diagnosis with gender (p =0.000) and age (p =0.000).Conclusion: So in this study it isconcluded that large number of females with breast pathologies present with benign lesions like fibro-adenomaat the age of 20-39 years. It isalso concluded that in this age group mastitis and abscesses are common due to different risk factors

To Study the Outcome of Inguinal Hernia Repair with Sutureless Self-Gripping Mesh in Terms of Postoperative Pain, Complications and Recurrence

The concept of sutureless mesh as well as light weight mesh came into play because of inguinodynia. Thisstudy was chosen most importantly to determine the post-operative persisting chronic pain after the use ofsutureless mesh. Data was collected from patients attending Govt. Medical College & Hospital, Jammu OPD,admitted in the department of surgery that underwent sutureless mesh hernioplasty for inguinal hernias. Thesepatients were followed up at 3 days, 3 weeks, 3 months and 6 months for postoperative pain, any recurrenceor development of complications. In this study, 40 patients having inguinal hernia were taken. 38 (95%) weremales and 2 (5%) were females. The age of the patients ranged between 30 to 80 years with mean age of54.53±14.88 years. Post-operative pain was studied according to VISUAL ANALOG SCALE scoring, out of10. Mean post-operative pain score after 3 days was 2.70±1.16, which decreased to 0.85± 1.10 at 3 weeks(68.52% decrease) and after 3 months it was 0.30±0.72 (with an 88.89% decrease). There were no othercomplications. The study concluded that the use of self-fixating mesh in open inguinal hernia repair is asimple, safe, rapid and effective option and is associated with low post-operative pain.

Changing Trends in the Histological Types of Lung Carcinoma

Introduction: Lung cancer is a major cause of cancer-relatedmortality and morbidity in males and females. Althoughsmoking is the major cause of lung cancer, only 10 % of heavysmokers develop lung cancer suggesting that other factorsmay also act independently or synergistically with smoking.Recent studies have suggested that there are changes inhistological type in recent years.Objectives: This study was to determine incidence of varioushistological types of lung carcinoma and analyse their changingtrends.Material and Methods: This is a prospective study. A total of184 cases of lung carcinoma were undertaken to analyse from2011 to 2014 in a tertiary care centre.Results: Overall adenocarcinoma was found to be mostcommon with 73 (39.67%) cases followed by squamous cellcarcinoma with 68 (36.96%) cases. However, in malessquamous cell carcinoma still remains predominant with 59(43%) cases followed by adenocarcinoma with 49 (35.7%)cases .Male to female ratio was 2.9:1. In females,adenocarcinoma was the most common type.Conclusion: Overall adenocarcinoma was the mostpredominant variant of lung carcinoma in our region closelyfollowed by squamous cell carcinoma. However, in malessquamous cell carcinoma was most common histological type.Incidence of lung tumor also shows increase in femalesthereby decreasing the male to female ratio to 2.9.

Study to assess the knowledge, attitude and practice of Kangaroo mother care among post-natal mothers in a tertiary care centre of Mangalore, Karnataka, India

Background: Kangaroo mother care (KMC) is a practical low-cost intervention which is very cost effective in developing countries for babies weighing less than 2500g. This study aimed to evaluate the knowledge, attitude and practice of post-natal mothers of LBW babies after giving a teaching session by trained personnel in a tertiary care center in Karnataka.Methods: A cross sectional descriptive study of 90 mothers whose neonates were weighing less than 2.5kg from May to October 2018.Mothers were interviewed at enrolment and were assessed about their knowledge and were oriented on its practice.Results: At recruitment (95.5%) mothers did not know about KMC.80% of mothers followed in first sitting and 86.6% of the mothers felt photo exhibition was better than verbal.96.6% of mothers thought KMC is beneficial and it was believed that other family members can even provide KMC.Conclusions: Maternal knowledge was low before now they are happily practicing KMC in hospital and thereafter at home.

A correlative study of body mass index with oxidative stress parameters (serum uric acid and serum malondialdihyde) in essential hypertension

Background: Hypertension is most commonly documented modifiable risk factor for cardiovascular diseases. A growing body of data proposes an appreciated pathogenic role of an elevated serum uric acid in atherosclerosis and cardiovascular disease (CVD). Increased oxidative stress could be involved in the pathogenesis of hypertension. Oxidative stress marker, serum uric acid (SUA) and serum malondialdyhyde level (S. MDA) are affected by both genetic and environmental factors and related to biological factors as gender, age and body mass. So, the aim of the study is to access the association of body mass index (BMI) with oxidative stress parameters in essential hypertension (EHT).Methods: For the said purpose, this case control study was carried out on a total of 200, age and sex matched 75 hypertensives, 75 prehypertensive and 50 healthy subjects. After diagnosis of cases, SUA was estimated by standard kit method and S. MDA was estimated manually by Buege and Aust method.Results: This study represents that systolic and diastolic blood pressure were increased with increased BMI in all groups. Oxidative stress marker, SUA and S. MDA level increased significantly with increasing BMI in all groups and were positively correlated.Conclusions: Our study indicates that monitoring of the blood pressure, SUA and S. MDA at regular interval and maintaining of the oxidative balance would be helpful in preventing the development of hypertension and associated cardio-vascular morbidities.

Linear And Whorled Nevoid Hypermelanosis: A Rare Familial Case Report

Linear and whorled nevoid hypermelanosis (LWNH), also known as ‘zebra-like pigmentation’ is characterized by linear and swirling streaks of hyperpigmentation along the Blaschko’slines without preceding inflammation and atrophy. It is mainly located on trunk and limbs. The hyperpigmentation may be present at birth or may develop by early childhood. Very rarely, familial cases have been described. Here, we are reporting one such rare case of familial LWNH in a 19-year-old female

In vitro tissue culture studies and synthetic seed formation from Plumbago zeylanica L.

Synthetic seeds and in vitro propagation are the need of the hour, especially for conservation of medicinal plants which are under the threat of extinction due to extensive exploitation. The plumbagin, Plumbago zeylanica L., is one such highly exploited medicinal plant. Here, we attempted in vitro propagation of its roots by tissue culture and also synthetic seed development towards conservation of this plant. Its leaves were used as the explant. Surface sterilized explants were aseptically cultured on MS medium supplemented with different plant growth hormones. The embryoid callus produced from tissue culture was then used to produce synthetic seed for large scale production of the plants and to reduce the risk of maintenance, storage and transportation of the cultured plants. For the production of synthetic seed, the embryoid callus were chopped aseptically and were encapsulated with sodium alginate and liquid MS medium without CaCl2 supplemented with growth hormones of similar concentration as used in tissue culture. Best result of callus induction and root regeneration was observed on MS medium supplemented by 2 ppm NAA (naphthalene acetic acid).

In Vivo Study Of Efficacy Of Trailokyasundar Rasa In Chronic Myeloid Leukemia

Trailokyasundar rasa is one of the Rasakalpa which is explained in Rasaratnasamucchaya, and is suggestive of its efficacy in Pandu roga. Pandu roga is a Pitta pradhanavyadhi in which Rasadhatu and raktadhatu are mainly affected. According to modern texts, all disorders of vitiated digestion, absorption and assimilation can be considered under Pandu. According to modern texts, all disorders of vitiated digestion, absorption and assimilation can be considered under Pandu. Therefore, it can be said that Pandu is a very broad term comprising various rasa and Raktpradoshajvikara such as anaemia, megaloblastic anaemia, blood disorders, leukemia’s etc. Material and method: On the basis of this information animal models were planned to evaluate the effect of self-prepared test drug. Study duration -1 month Discussion and results: The activity of Trailokyasundar rasa is highly significant by reducing tumour volume and growth inhibition in animal models of chronic myeloid leukemia. On the 29thday of the experiment tumour size of the control group was 20.05 mm. comparatively in the study group, mean tumour size was of 5.26 mm. Also it prevented decrease in the platelet count and Hb% as compared to untreated mice of CML. Rate of increment of WBC’s was also comparatively reduced in Trailokyasundar rasa treated mice.

Desarrollo y validación de escalas para medir el valor que las mujeres dan a la saciedad y a la alimentación: un factor crítico para el tratamiento de la obesidad / Development and validation of scales to measure women's eating and satiation values: a criti- cal factor in the treatment of obesity

La sobrevaloración de la alimentación y de la saciedad en familias que viven en un medio influenciado por la globalización y desarrollo de la industria alimentaria, puede estar teniendo un efecto sinérgico en el desarrollo de la obesidad y sus comorbilidades en países de ingreso medio. El objetivo de este trabajo fue desarrollar y validar escalas para medir el valor otorgado a la alimentación y la saciedad en mujeres. Se desarrolló un instrumento y se aplicó en querétaro, México (n=243), se midieron variables socioeconómicas y de percepción de peso corporal. Se realizó análisis factorial explorato- rio, confirmatorio y ANOVA. Las escalas del valor que las mujeres dan a la alimentación como base del bienestar, a la saciedad y a la alimentación como base del bienestar del hijo, se validaron (α-Cronbach>0.66) y se confirmaron (CFI>0.98;RMSEA<0.05). Los puntajes de valor de la alimentación y de la saciedad se asociaron con un menor nivel socioeconómico y educativo, inseguridad alimentaria en el pasado, menor intención de perder peso y con percepción bajo peso en los hijos. En conclusión, las es- calas para medir el valor de la alimentación y la saciedad tienen validez para ser utilizadas en futuros estudios; su utilización puede contribuir a desarrollar estrategias que consideren la verdadera motivación de la alimentación en los segmentos poblacionales más desfavorecidos(AU)

The overvaluation of eating and satiation in families whose environment has been influenced by globalization and the food industry, could be inducing obesity and its co-morbidities in midd- le income countries. The objective was to develop and validate scales to measure women's eating and satiation values. A measurement instrument was developed and ad- ministered to women from querétaro, Mexico (n=243), it also measured socioeconomic (SE) and body weight per- ception variables. Analyses included exploratory and con- firmatory factorial analyses and ANOVA. The scales that represented the value of feeding as basis of wealth, the va- lue of satiation and the value of feeding a child as the basis of the child's wealth, were validated (Cronbach-α>0.66) and confirmed (CFI >0.98; RMSEA<0.05).The scores were associated with a lower SE status, lower education level, childhood food insecurity, low intention to lose weight and with an underweighted child perception. In conclusion, the scales that measure the value of eating and satiation have the validity to be used in future studies; its utilization can contribute to develop strategies to improve eating behavior of underprivileged population segments, that take into consideration the real motives of eating(AU)

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children / 대한소아소화기영양학회지

PURPOSE: Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients. METHODS: Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement. RESULTS: Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8–5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9–4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p < 0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing. CONCLUSION: The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

Association Between Psychosocial Factors With Upper Extremity Musculoskeletal Disorders: An Academic Review

Work-related upper-extremity disorders (WRUEDs) are frequently occurring among workers in general. Various researches support the empirical results of the Autogenic factors related to such problems of health and safety. Research shows the association of different aspects of work organization strengthen the possibilities of work-related stress and other psychosocial factors, which may lead towards adverse health conditions. To review the previous work done for finding the association between psychosocial factors and upper extremity disorders. Findings from different studies have been reviewed to examine the psychosocial factors association in developing WRUEDs. Published studies, which were primarily focused on WRUEDs and psychosocial factors association, were reviewed. Various studies have shown the relationship between psychosocial factors and UEDs. Due to the different nature of epidemiology of the disorder and variable differences, findings from different studies contradicts. Finally, this review presents the limitations in existing studies, and further research has been proposed for future.

Association of serum zinc level with pre eclampsia

Background: Pre eclampsia is the commonest obstetrical complication in pregnant women. The etiology of pre eclampsia has yet not been clearly understood. It has a worldwide prevalence of 2-10% of pregnancies and one of the major causes of increase in maternal and perinatal morbidity and mortality. Zinc plays an important role in the course and eventual outcome of human pregnancy and is essential for normal embryogenesis and fetal growth. Zinc deficiency in pregnancy is thought to be associated with pre-eclampsia

Objective: The aim of this study was to investigate the serum zinc level in pre-eclampsia

Patients and Methods: This Hospital based study conducted at Gynecology Department of Indus Medical Collage, Tando Muhammad Khan, Sindh from October 2015 to March 2016 with the Permission of Head of the Department and Principal of Institute. The study groups consist of 40 consecutive diagnosed cases of pre eclampsia and 40 women with normal pregnancies. The serum zinc level of the subjects under this study was determined using Atomic Absorption Spectrophotometer

Results: The results of our study showed that serum Zinc level among the pre-eclamptic and was statistically significantly low as compared to normotensive pregnant women

Conclusion: The findings of current work are statistically significant to establish that concentration of serum zinc among preeclamptic subjects is lower than in the normotensive women during pregnancy

Morbidity patterns among the welders of eastern Nepal: a cross-sectional study

BACKGROUND: Welding process has many hazards that the welders are exposed to resulting in numbers of health effects and diseases. Safety measures and practices among welders are important ways of preventing or reducing the health hazards associated with this occupation. We conducted this study to find out the morbidity patterns among the welders working in eastern Nepal. METHODS: A cross sectional study was conducted among 300 welders using semi structured questionnaire. Morbidity categories were classified based on symptoms experienced in past 6 months. RESULTS: All the welders learned welding by apprenticeship, without any formal health and safety training. Injury was the most common problem at work followed by skin problems and eye symptoms. Age of the welders, duration of employment & welding hours per day were associated with the morbidities among the welders. CONCLUSIONS: There is a need for occupational health services for welders in Nepal. While further research may be required to make policy recommendations, the current study provides a baseline morbidity burden among these welders to look for interventions to promote health and safety at work for this neglected group of workers in Nepal.