Role of the Sodium-Dependent Organic Anion Transporter (SOAT/SLC10A6) in Physiology and Pathophysiology.

The sodium-dependent organic anion transporter (SOAT, gene symbol SLC10A6) specifically transports 3'- and 17'-monosulfated steroid hormones, such as estrone sulfate and dehydroepiandrosterone sulfate, into specific target cells. These biologically inactive sulfo-conjugated steroids occur in high concentrations in the blood circulation and serve as precursors for the intracrine formation of active estrogens and androgens that contribute to the overall regulation of steroids in many peripheral tissues. Although SOAT expression has been detected in several hormone-responsive peripheral tissues, its quantitative contribution to steroid sulfate uptake in different organs is still not completely clear. Given this fact, the present review provides a comprehensive overview of the current knowledge about the SOAT by summarizing all experimental findings obtained since its first cloning in 2004 and by processing SOAT/SLC10A6-related data from genome-wide protein and mRNA expression databases. In conclusion, despite a significantly increased understanding of the function and physiological significance of the SOAT over the past 20 years, further studies are needed to finally establish it as a potential drug target for endocrine-based therapy of steroid-responsive diseases such as hormone-dependent breast cancer.

Assessing the Burden on Caregivers of MECP2 Duplication Syndrome.

BACKGROUND: MECP2 duplication syndrome (MDS) is a rare neurogenetic disorder characterized by severe neurodevelopmental disorder, refractory epilepsy, recurrent infections, and functional gastrointestinal problems. Because of the significant clinical problems and lifelong disability of children with this disorder we hypothesized that the burden on parents/caregivers of these children is significant. However, there are no reports of the impact on caregivers of individuals with MDS. METHODS: We developed and validated a burden scale to investigate the challenges of caregivers of children and adults with MDS and identified factors contributing to the burden on caregivers. We developed a Health Insurance Portability and Accountability Act-compliant patient registry for families with MDS and delivered caregiver burden survey through the registry. RESULTS: Of 237 completed surveys, 101 were eligible for the study. We identified increased levels of self-perceived anxiety, depression, and emotional exhaustion in caregivers that correlated with higher burden scores. Epilepsy was the only clinical feature that caused a higher burden in caregivers of individuals with MDS. In addition, a higher burden was found in Hispanic caregivers. The duration of care negatively correlated with burden score. CONCLUSIONS: This is the first study to investigate the burden on caregivers of individuals with MDS and identify several factors contributing to increased burden. Addressing these concerns has the potential to improve the health of individuals with MDS and contribute to the well-being of their caretakers.

Exploring the characteristics and most bothersome symptoms in MECP2 duplication syndrome to pave the path toward developing parent-oriented outcome measures.

BACKGROUND: MECP2 Duplication Syndrome (MDS), resulting from the duplication of Xq28 region, including MECP2, is a rare disorder with a nascent understanding in clinical features and severity. Studies using antisense oligonucleotides revealed a broad phenotypic rescue in transgenic mice. With human clinical trials on the horizon, there is a need to develop clinical outcome measures for MDS. METHODS: We surveyed caregivers of MDS individuals to explore the frequency and severity of MDS clinical features, and identify the most meaningful symptoms/domains that need to be included in the outcome measure scales. RESULTS: A total of 101 responses were eligible for the survey. The top six most meaningful symptoms to caregivers in descending order included epilepsy, gross motor, fine motor, communication, infection, and constipation problems. Epilepsy was present in 58.4% of the subjects and 75% were drug-resistant, Furthermore, ~12% required intensive care unit (ICU) admission. Infections were present in 55% of the subjects, and one-fourth of them required ICU admission. Constipation was present in ~85% of the subjects and one-third required enemas/suppositories. CONCLUSION: Our study is one of the largest cohorts conducted on MDS individuals characterizing the frequency and severity of MDS symptoms. Additionally, these study results will contribute to establishing a foundation to develop parent-reported outcomes in MDS.

Urinary cortisol metabolites are reduced in MDR1 mutant dogs in a pilot targeted GC-MS urinary steroid hormone metabolome analysis.

P-glycoprotein (P-gp) is the gene product of the multidrug resistance gene (MDR1, syn. ABCB1) that normally restricts the transfer of cortisol across the blood-brain barrier. In the absence of P-gp, cortisol access to the hypothalamus is increased and, by feedback inhibition, this finally leads to lower endogenous plasma cortisol levels in dogs with homozygous nt230(del4) MDR1 mutation (MDR1-/- mutant dogs). While a previous study only focused on plasma cortisol levels, the present study used urinary steroid hormone metabolites to analyze cortisol metabolism in MDR1-/- mutant dogs. Morning void urine was collected from 23 MDR1-/- mutant and 16 MDR1+/+ normal dogs and was subjected to targeted GC-MS steroid hormone metabolome analysis. Seven cortisol metabolites, cortisol itself, and 13 other steroid metabolites were detected. In general, all cortisol metabolites were lower in the urine of the MDR1-/- mutant dogs, with allo-tetrahydro-cortisol and ß-cortol reaching the level of significance. In addition, 11-keto-pregnanetriol levels were significantly lower in the urine of the MDR1-/- mutant dogs, indicating that also the 17alpha-OH-progesterone-derived metabolism was altered. In conclusion, the present study provides the first steroid hormone metabolome analysis in the urine of MDR1-/- mutant dogs. Significant differences in the steroid metabolome of MDR1-/- mutant dogs point to a significant role of P-gp for cortisol metabolism and excretion and so indirectly also for hypothalamic-pituitary-adrenal axis regulation in dogs.

COVID-19 vaccine hesitancy in people with migratory backgrounds: a cross-sectional study among Turkish- and German-speaking citizens in Munich.

BACKGROUND: This study aimed to investigate the knowledge, attitudes, behaviors, and COVID-19 vaccine hesitancy of people with migratory backgrounds among Turkish- and German-speaking patients in Munich. METHODS: Primary outcomes were the intention to get vaccinated for COVID-19 and COVID-19 knowledge levels (25 true/false items). Other variables included demographics, attitudes to COVID-19 and vaccination (7 items), and behaviors regarding COVID-19 (7 items). The attitude and behavior questions had 5-point Likert scales. Of the 10 Turkish-speaking family physicians in Munich, six agreed to administer Turkish or German questionnaires to consecutive patients in February 2021. Furthermore, participants with either citizenship, country of origin, native language, or place of birth being non-German were categorized as "Having a migratory background." Data from 420 respondents were analyzed. RESULTS: Women constituted 41.4% (n = 174), the mean age was 42.2 ± 15.5 years, 245 (58.3%) preferred the Turkish questionnaire, 348 (82.9%) had a migratory background, and 197 (47.9%) intended to be vaccinated. The mean knowledge, attitude, and behavioral scores were 21.5 ± 3.2 (max = 25), 3.7 ± 0.8 (max = 5), and 4.0 ± 0.5 (max = 5). While 42.3% (n = 145) of the participants with a migratory background considered getting vaccinated, this proportion was 76.5% (n = 52) for non-immigrant Germans (Chi-square = 26.818, p < 0.001). Non-migratory background (odds ratio (OR): 3.082), high attitude scores (OR: 2.877), male sex (OR: 2.185), years of schooling (OR: 1.064), and age (OR: 1.022) were positively associated with vaccination intention. CONCLUSIONS: We suggest initiating or supporting projects run by persons or groups with immigrant backgrounds to attempt to elaborate and change their vaccination attitudes.

Antibiotic prescription in primary care from the perspective of family physicians: a qualitative study.

INTRODUCTION: Antibiotic consumption increases worldwide steadily. Turkey is now top on the list of global consumption and became a prototype of excessive use of antibiotics. In the last two decades, family physicians (FPs) have become key figures in the healthcare system. This study aims to understand the reasons for inappropriate antibiotic prescribing and elicit suggestions for improving antibiotic use in primary care from doctors themselves. METHODOLOGY: This is a qualitative semi-structured interview study with research dialogues guided by the Vancouver School of interpretive phenomenology. Fourteen FPs from different parts of Turkey were questioned on inappropriate antibiotic prescriptions and their suggestions for improving antibiotic use. RESULTS: The most important reasons for prescribing antibiotics without acceptable indications were patient expectations, defensive medical decision making, constraints due to workload, and limited access to laboratories. The most remarkable inference was the personal feeling of an insecure job environment of the FPs. The most potent suggestions for improving the quality of antibiotic prescription were public campaigns, improvements in the diagnostic infrastructures of primary care centers, and enhancing the social status of FPs. The FPs expressed strong concerns related to the complaints that patients make to administrative bodies. CONCLUSIONS: Primary care physicians work under immense pressure, stemming mainly from workload, patient expectations, and obstacles related to diagnostic processes. Improving the social status of physicians, increasing public awareness, and the facilitation of diagnostic procedures was the methods suggested for increasing antibiotic prescription accuracy.

Delayed diagnosis of a case of Zenker's diverticulum. What may happen when a family physician does not visit his family physician.

INTRODUCTION: Zenker's diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle. It occurs commonly in elderly patients (over 70 years) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss. CASE: We are reporting dysphagia in a 49-years old man who was treated as having Helicobacter Pylori gastritis for three years. Being a family physician himself, the patient applied to specialists in gastroenterology, bypassing primary care. During a casual interview on his symptoms, a family physician referred him to undergo a repeated endoscopy with suspected Zenker's diverticulum. After being diagnosed with Zenker's diverticulum, the patient underwent surgical intervention at the department of thoracic surgery and made a full recovery. He regained five kilograms at the end of five weeks after the operation. CONCLUSION: This case demonstrates once more the importance of history taking and follow-up in medical care. Attentive listening by a family physician could have probably prevented the delay of service in this case.

Patient satisfaction with family practice in Turkey: Three-year trend from 2010 to 2012.

BACKGROUND: After the health reform in 2003, a need emerged to monitor patient satisfaction in Turkey. OBJECTIVE: To evaluate patient satisfaction with family practice in Turkey and compare with some other European countries. METHODS: The study was performed on a countrywide representative sample from all the 81 provinces of Turkey. Data were collected during the years 2010-2012 from patients visiting family practice centres. A three-year repeated cross-sectional study was conducted using the EUROPEP instrument. Twenty-six questions with a five-point Likert scale were applied. Primary outcome measures of the study were the mean EUROPEP scores (min. 1, max. 5). RESULTS: Mean (± SD) EUROPEP scores for the years 2010 (n = 34 472), 2011 (n = 34 764), and 2012 (n = 32 667) were 4.09 ± 0.77, 4.29 ± 0.59, and 4.42 ± 0.54 respectively (F = 1565.37; P < 0.001). The mean satisfaction percentage was calculated as 88.3%. Areas of lowest satisfaction were 'Being able to speak to the GP on the telephone,' 'Getting through to the practice on the phone,' and 'Physical conditions of the family practice.' CONCLUSION: Although in small increments, patient satisfaction with family practices in Turkey has increased during the last few years.

The effect of pedometer use on physical activity and body weight in obese women.

Physical activity and healthy eating are of the utmost importance in treatment of obesity. However obese generally tend to have a sedentary lifestyle. Walking is a form of physical activity that is both simple and can be performed by everyone, but it requires an objective measurement. Number of steps taken during tracking can be recorded with the pedometer, a device used to measure the level of physical activity. We aimed to investigate whether or not using pedometers as a motivational technique to increase the level of physical activity in obese women has an impact on weight loss. Eighty-four obese women who are similar age referring to Ataturk University Faculty of Medicine Healthy Living Clinic, Turkey were randomly divided into two groups. Intervention group were given pedometers, and control group were prescribed similar diet and physical activity with a three-month follow-up plan without pedometers. Mean weight in pedometer group initially was 88.9 ± 8.4 kg, which decreased to 80.2 ± 8.7 kg after the programme. Mean weight in control group was 86.1 ± 9.2 kg at the beginning, and it decreased to 84.7 ± 8.8 kg after three months. It was observed in pedometer group that the mean number of steps 8817 ± 2725 steps/day at the beginning increased to mean 9716 ± 2811 steps/day at the end of the study. Weight, body mass index, body fat percentage and waist circumference measurements decreased more greatly in the pedometer when compared to the control group (p < 0.001). Pedometers may be recommended to obese patients to monitor and increase the level of physical activity and to promote weight loss.

What do trainers think about trainer training courses?

OBJECTIVE: To evaluate the effectiveness of the training-of-trainer courses given to medical school faculty members, and to ensure the standardisation of training.. METHODS: The study comprised faculty members attending seven training-of-trainer courses held at the Ataturk University, Turkey, from November 2010 to May 2011. Tests were administered to the participants evaluating their level of knowledge on course content before and after the five-day course, which covered topics including concepts of teaching/learning, curriculum development, assessment and evaluation, training methods, and training skills. Oral and written feedbacks were obtained from all participants on the last day of each course. Volunteers from among the participants evaluated the impact of training through a questionnaire after at least two months. SPSS 20 was used for statistical analysis. RESULTS: A total of 136 faculty members participated in the 7 training-of-trainer courses. The mean scores for the pretest and post-test were 6.6 +/- 2.2 vs. 13.9 +/- 3.7, (p < 0.001). Questions with highest percentage of correct answers in the pre-test were those about learning style 78 (70.9%) and the one about presentation skills (66.4%). CONCLUSION: A structured training-of-trainer course is effective in increasing faculty members' level of knowledge about training. Such programmes are necessary for faculty members who work in the academic field without receiving formal training in teaching as it is the case with medical education in several countries.

Acupuncture decreases matrix metalloproteinase-2 activity in patients with migraine.

OBJECTIVE: To evaluate the effect of acupuncture on the serum matrix metalloproteinase-2 (MMP-2) level and activity in patients with migraine. METHODS: After baseline testing, eligible patients with migraine according to the criteria of the International Headache Society who volunteered to join the study were included (n=27). The patients received 10 sessions of acupuncture treatment. The points selected were bilateral ST8, ST44, LI4, LI11, LIV3, SP6, GB1, GB14, GB20, GV14, GV20, Yintang, Taiyang and ear Shenmen. Pain was measured using a visual analogue scale (VAS). Short form-36 (SF-36) was used to determine their quality of life. Blood samples were taken before treatment and after the first and last sessions of acupuncture for measurement of MMP-2 concentration and activity. RESULTS: The mean VAS was 85.5±16.6 before acupuncture and was significantly decreased to 39.8±20.6 after 10 sessions of acupuncture (p<0.0001). There was a significant increase in all SF-36 scores after acupuncture compared with values before treatment (p<0.0001). No significant differences were found in MMP-2 concentrations before treatment and after the first and last sessions (p>0.05). However, there were significant changes in MMP-2 activity (p<0.0001). CONCLUSIONS: The results of this study showed a clinically relevant decrease in MMP-2 activity in patients with migraine treated with acupuncture. The mechanism underlying the effect of acupuncture in alleviating pain may be associated with a decrease in MMP-2 activity.

The changing rate of suspected rabies bites after begin to act animal shelter in erzurum city.

OBJECTIVE: We aimed to evaluate the relationship between establishing an animal shelter in Erzurum and the number of suspected rabies bites between the years 2005 and 2012. MATERIALS AND METHODS: A retrospective, repeated cross-sectional study was planned in Erzurum in the year 2013. Records between the years 2005 and 2012 were obtained from the Communicable Diseases Department of the Erzurum Health Directorate. Data for 5789 cases exposed to suspected rabies bites were analyzed. RESULTS: 5789 suspected rabies bites were encountered in Erzurum between the years 2005 and 2012. After establishing the animal shelter in 2009, 4239 dogs were collected from the streets within four years and 426 of them were released after immunization. Additionally, the following services were given in the animal shelter between 2009 and 2012: immunization of 2935 dogs, sterilization of 1735 dogs, and release of 2082 dogs back to the street. 4-years before the establishment of the animal shelter, the number of dog-bites had decreased from 3403 cases to 2386 cases; 4-years after the establishment of the shelter, it declined by 29.8%. While there were 1096 suspected rabies cases during the year 2008, this ratio decreased by 40.9% after the establishment of the animal shelter in the year 2009. During the year 2010, where we had the highest number of homeless dog collection to the animal shelter, the decrease in suspected rabies bites reached the maximum decrease, namely 51.0%. Spearman correlation analysis showed a strong negative correlation between the number of collected animals and suspected rabies bites (r = -0,862; p=0.006). CONCLUSION: Suspected rabies cases are common in Turkey and some cases of rabies are encountered. The number of suspected rabies bites in Erzurum has decreased significantly after establishing the animal shelter. It is an evident that establishing rehabilitation centers for homeless animals in all cities will have an important role in controlling zoonotic diseases including rabies.

Continuing medical education as a national strategy to improve access to primary care in Saudi Arabia.

The purpose of this study was to describe the development, implementation, and evaluation of an educational program in family medicine for general practitioners in Saudi Arabia from 2009 to 2011. A continuing medical education program called Family Medicine Education (FAME) was developed with 7 modules each consisting of 12-14 hours of teaching to be delivered in 3 day blocks, over 45 days. Twenty percent (2,761) of all general practitioners participated in the FAME program. Initial assessment of the program showed significant improvement of knowledge from scores of 49% on a pre-test to 89% on post-tests. FAME program in Saudi Arabia facilitated primary care physicians' knowledge.

[Knowledge, attitudes, and behavior of people living in rural areas of Erzurum about Crimean-Congo hemorrhagic fever]. / Erzurum Ili Kirsalinda Halkin Kirim Kongo Kanamali Atesi Hakkinda Bilgi, Tutum ve Davranislari

OBJECTIVE: After 2002 more and more Crimean-Congo Hemorrhagic Fever (CCHF) cases have been reported and it has become a major public health problem in Turkey. In order to fight CCHF, it is important to inform the public and direct them towards appropriatet attitudes and behavior. Therefore assessment of the effectiveness of health education in the community is essential. METHODS: A research was carried out for this purpose in the province of Erzurum between May 2010 and September 2010 through a survey. RESULTS: The results depicted that the majority of participants have knowledge that CCHF transmitted by ticks and they should be removed as soon as possible from the body through safe methods. However, in terms of correct attitude and behavior, women were found to have a lower level compared with men. CONCLUSION: The training of health workers and an increase in the efforts to make the community, especially the women, aware of this problem is ugently needed.

An objective structured biostatistics examination: a pilot study based on computer-assisted evaluation for undergraduates.

We designed and evaluated an objective structured biostatistics examination (OSBE) on a trial basis to determine whether it was feasible for formative or summative assessment. At Ataturk University, we have a seminar system for curriculum for every cohort of all five years undergraduate education. Each seminar consists of an integrated system for different subjects, every year three to six seminars that meet for six to eight weeks, and at the end of each seminar term we conduct an examination as a formative assessment. In 2010, 201 students took the OSBE, and in 2011, 211 students took the same examination at the end of a seminar that had biostatistics as one module. The examination was conducted in four groups and we examined two groups together. Each group had to complete 5 stations in each row therefore we had two parallel lines with different instructions to be followed, thus we simultaneously examined 10 students in these two parallel lines. The students were invited after the examination to receive feedback from the examiners and provide their reflections. There was a significant (P=0.004) difference between male and female scores in the 2010 students, but no gender difference was found in 2011. The comparison among the parallel lines and among the four groups showed that two groups, A and B, did not show a significant difference (P>0.05) in either class. Nonetheless, among the four groups, there was a significant difference in both 2010 (P=0.001) and 2011 (P=0.001). The inter-rater reliability coefficient was 0.60. Overall, the students were satisfied with the testing method; however, they felt some stress. The overall experience of the OSBE was useful in terms of learning, as well as for assessment.

Dealing with uncertainty in general practice: an essential skill for the general practitioner.

Many patients attending general practice do not have an obvious diagnosis at presentation. Skills to deal with uncertainty are particularly important in general practice as undifferentiated and unorganised problems are a common challenge for general practitioners (GPs). This paper describes the management of uncertainty as an essential skill which should be included in educational programmes for both trainee and established GPs. Philosophers, psychologists and sociologists use different approaches to the conceptualisation of managing uncertainty. The literature on dealing with uncertainty focuses largely on identifying relevant evidence and decision making. Existing models of the consultation should be improved in order to understand consultations involving uncertainty. An alternative approach focusing on shared decision making and understanding the consultation from the patient's perspective is suggested. A good doctor-patient relationship is vital, creating trust and mutual respect, developed over time with good communication skills. Evidence-based medicine should be used, including discussion of probabilities where available. Trainers need to be aware of their own use of heuristics as they act as role models for trainees. Expression of feelings by trainees should be encouraged and acknowledged by trainers as a useful tool in dealing with uncertainty. Skills to deal with uncertainty should be regarded as quality improvement tools and included in educational programmes involving both trainee and established GPs.

Evaluation of the Learning Environment for Diploma in Family Medicine with the Dundee Ready Education Environment (DREEM) Inventory.

The primary healthcare system is at a turning point in Saudi Arabia. However, the sustainability of family medicine as the core element of that system is increasingly being called into question because of lack of family physicians. In keeping view this problem; a postgraduate diploma program in family medicine has started in 2008. A validated measure of educational environment i.e., Dundee Ready Education Environment (DREEM) questionnaire consisting of 50 questions having five domains of perception was administered to all 13 trainees of the diploma course at the completion of the program to check their perception about learning evironment. The trainees comprised of 4 males (40%) and 6 females (60%). The overall score showed more positive than negative side (147/200). There is no significant difference (P > 0.05) in the mean scores of five different domains of perception. The subclasses of five domains showed that teaching perceived as positive by 50%, moving towards right direction by 80%, feeling more positive by 50%, positive attitude by 80% and the 70% scored the course as not too bad. The overall high score and positive attitude towards the course assures the better teaching environment. However, there are areas to improve and it requires continuous evaluation.

Sexual activity among Turkish adolescents: once more the distinguished male.

UNLABELLED: The mean age of first sexual intercourse in Western countries is around 17 years and decreasing. Although Turkey is a bridge between East and West, embracing different cultures, little data are available on sexual issues in the population. METHODS: A questionnaire was administered to all students in the study year 2004-2005, collecting demographic data, sexual activities, sexual and contraceptive attitudes, and contraceptive knowledge. Of 7,657 applicants invited, 3,970 questionnaires could be analyzed. RESULTS: Median age of the participants was 18 years (48.0% female, 52% male). Median age at first sexual intercourse was 17 years for females and 16 years for males. 46.5% of the males and 3.0% of the females had sexual intercourse experience. While 68% of the girls had their first sexual intercourse with their lovers, this ratio was 44.8 % for males (Chi square = 59.963, p <.001). Significantly more girls than boys were planning to have their sexual partner as future spouses (Chi square = 55.569, p <.001). Three fourth of the males approved premarital sex for males; this ratio was reversed for females (Chi square = 574.838, p <.001). Although both sexes disapproved premarital sexual intercourse of women, girls were significantly more conservative in this regard (78.6% vs. 92.5%) (Chi square = 110.460, p <.001). CONCLUSION: Although the adolescent sexual intercourse rate in Turkey is low compared with Western countries, there is a tendency to increase. Therefore, sexual education is needed. When augmenting sexual education programs in undergraduate education, gender difference and cultural factors should be further evaluated.

Knowledge of hepatitis B and vaccination status of some expatriate ethnic groups of blue collar workers in northern saudi arabia.

OBJECTIVE: To find out the level of knowledge and vaccination status of some expatriate ethnic groups of blue color workers. BACKGROUND: Hepatitis B (HBV) infection is relatively common throughout the world, but more prevalent in low socioeconomic and underprivileged classes. The chronic infection may lead to severe consequences including Hepatocellular carcinoma (HCC). METHOD: A cross-sectional, community-based survey of some ethnic expatriate groups of blue color workers (n=665) living in four main areas along the Northern Borders of Saudi Arabia was completed in 2005. We examined knowledge of HBV and vaccination status and compared them with some socio-demographic factors. RESULTS: The mean age of the participants was 45.61 years (±8.44), 53% of whom were Non-Arabs (Non Arabic speaking). Of the total, 41.6% gave seven or more correct answers out of 12 questions addressing knowledge about the transmission and sequelae of HBV. Almost 40% of the respondents had not been vaccinated while the remaining respondents had had three full doses of vaccination. A high level of knowledge (≥ 7 correct answers) was significantly associated (p<0.05) with higher level of education, vaccination status, ethnic groups, occupation, age, marital status, and the time spent in Saudi Arabia. Income and type of accommodation were not associated (p>0.05) with level of knowledge. However, vaccination status was associated (p<0.05) with almost all socio-demographic factors. CONCLUSION: Hepatitis screening programs for expatriates in the Kingdom of Saudi Arabia started 10 years ago and are expected to have a great impact on the combat against HBV infections and their complications. However, beyond screening, health promotion, vaccination campaigns, and access to vaccine for the underprivileged classes are some necessary measures towards achieving success.