The respective proportions at

The respective proportions at re-audit were very similar (6%, 65%, 10%, 10% and 10%). In those patients who were known to have been prescribed medication prior to admission, the proportions in which the drug name and dose were clearly documented were similar across adult, elderly and forensic services, being 73%, 77% and 89% at baseline, and 77%, 77% and 77% at re-audit. Documentation of an assessment of medication adherence is shown in Figure

2. Figure 2. Documentation Inhibitors,research,lifescience,medical of adherence to prescribed medication in acute adult, acute elderly and forensic services, for those in whom medication was prescribed, at baseline and re-audit. There was no documented statement about adherence Inhibitors,research,lifescience,medical to medication in 41% adults, … Documentation of the reconciliation process Bosutinib overall was generally good and accurately reflected the practice described above in over 80% of cases. Examples of the reconciliation discrepancies described by clinical teams Inhibitors,research,lifescience,medical are shown in Table 4. Note that these data are presented in a pragmatic way that is likely to be meaningful to practising clinicians. They were not subject to quantitative or qualitative

analyses and no theoretical model was applied. Table 4. Examples of discrepancies identified during medicines reconciliation, and their potential to be clinically significant. Discussion In this QIP, our proxy measure of medicines reconciliation practice was the proportion of newly admitted patients for whom two or more sources of information about the medicines they were taking immediately prior Inhibitors,research,lifescience,medical to hospital admission had been checked. We found that this proportion, representing all those patients for whom medicines reconciliation was possible, Inhibitors,research,lifescience,medical increased modestly between baseline (71%) and re-audit (79%). Most of

the activity related to checking sources occurred in the first 24 h of admission to hospital, irrespective of the time of admission, and most of this activity was documented in patients’ clinical records. The sources of Brefeldin_A information most frequently consulted were the primary care medical records and patients themselves. The primary care record was the only source of information that was consulted significantly more frequently at re-audit, compared with baseline, and this source also yielded the highest proportion of discrepancies. Medicines reconciliation as a source of medication error Of the total national sample for whom two or more sources of information had been checked, discrepancies were identified in 25% at baseline, and 31% at re-audit.

Therefore, T-tau has not been suggested as a marker for the diff

Therefore, T-tau has not been suggested as a marker for the differential diagnosis of AD.T-tau rather reflects unspecific processes of axonal damage and neuronal degeneration. This notion is further

supported by the Increase in CSF T-tau In disorders with extensive and/or rapid neuronal degeneration, such as CJD.86,87 A highly significant Increase of 580% was documented in CJD compared to AD patients. At a cutoff level of 2130 pg/mL, T-tau yielded a sensitivity of 93% and a specificity of 100% between AD and CJD.88 An elevation of CSF T-tau, correlating with clinical Inhibitors,research,lifescience,medical severity, has been shown in normal pressure hydrocephalus.89 Moreover, a marked transient increase In CSF T-tau Inhibitors,research,lifescience,medical has been demonstrated after acute stroke. The transient

Increase In CSF T-tau correlated with the infarct size measured by cranial OF.90 Elevated levels of CSF T-tau have been found In considering patients with diffuse axonal damage after traumatic brain Injury, which decrease with clinical Improvement.91 In contrast, In neurological disorders that are mainly linked to more restricted cerebral locations and number of cells, such as alcoholic dementia, PD, progressive Inhibitors,research,lifescience,medical supranuclear palsy, and cortlcobasal degeneration, elevated CSF T-tau concentrations have been only occasionally reported48,60,68,76,92,93 or were normal.77 Predictive value of CSF T-tau in MCI for AD In patients suffering from MCI who converted to AD during follow-up, elevated T-tau levels were found In relatively few samples

at baseline.43,66 Memory-Impaired subjects who later progressed to manifest AD could Inhibitors,research,lifescience,medical be discriminated Inhibitors,research,lifescience,medical by high CSF T-tau from those who did not progress with 90% sensitivity and 100% specificity.66 Longitudinally, elevated CSF levels of T-tau were found In MCI subjects and remained elevated after conversion to clinical AD.49 Another study showed that 88% of patients with MCI had elevated T-tau concentrations and/or low CSF Aβ1-42 levels at baseline.94 Thus, elevated CSF T-tau In MCI may have the potential to predict AD. Phosphorylated Cilengitide tau protein In order to Improve specificity of measurement of tau protein as a biomarker of AD, assays have been developed to specifically detect phosphorylated tau protein (P-tau) In CSF. These assays use monoclonal antibodies specific for phosphorylated epitopes of tau: tau protein phosphorylated at serine 199 (P-tau199), selleck chemicals llc threonine 231 and serine 235 (P-tau231-235),23 threonine 231 (P-tau231),24 threonine 181 (P-tau181),22,95 and serine 396 and serine 404 (P-tau396/404).96 A marked Increase In the CSF level of P-tau Is found In AD.83 This Increase probably reflects the phosphorylation state of tau, and thus possibly also the formation of tangles In AD.

8 mm) which

are attached to precisely defined positions o

8 mm) which

are attached to precisely defined positions on moving body parts. The ultrasonic system evaluates transmission times of ultrasound impulses (40 kHz), emitted from these markers and received by three microphones mounted on a stationary frame. Thus, a local coordinate system is determined, and three-dimensional coordinates of the markers can be derived by triangulation (Figure 1. ). By this technique, the spatial positions of the markers are sampled at a frequency of up to 100 Hz, which corresponds #selleck chemical keyword# a temporal resolution of 10 ms. The spatial resolution of the system is less than 0.6 mm. Many spatial and temporal motor parameters can be computed by using special software packages. Excellent, reproducibility and accuracy of the device has been demonstrated in several Inhibitors,research,lifescience,medical studies.23,24 Figure 1. Ultrasonic movement analysis: calculation of the three-dimensional spatial position (coordinates: x, y, z) of ultrasonic emitters on the different transmission times (t1-3) of the ultrasound signals to the three microphones. Inhibitors,research,lifescience,medical US, ultrasonic. Analysis of gait disturbances in patients By using this system, we assessed the locomotor patterns of gait in schizophrenic patients and differentiated intrinsic effects of the illness from those caused by conventional and atypical neuroleptic treatment.25

Gait parameters of 16 drug-nai’ve, 25 conventionally treated (halopcridol: n=17, mean dose 6.4 +/- thenthereby standard deviation Inhibitors,research,lifescience,medical [SD] 3.4 mg/day; fluphenazine: n=5, 11.2 +/- SD 7.7 mg/day; flupentixol:

n=3, 6.7 +/- SD 2.9 mg/day) and 25 atypically treated patients (olanzapine: n=20, mean dose 16.2 +/- SD 6.3 mg/day; amisulpridc: n=5; 560 +/- SD 89 mg/day), as well as 25 control subjects, were evaluated. Differences in gait, velocity and in stride length between the four investigated groups were highly significant, (analysis of variance [ANOVA]: P<0.001). Mean gait velocities of all patient groups were significantly slower Inhibitors,research,lifescience,medical than those of controls, with the most, striking difference observed between the control group and patients treated with conventional neuroleptics (P<0.001). Amongst the patient, groups, significant differences were detected between patients treated with conventional neuroleptics, and both patients treated with atypical neuroleptics and drug-nai've patients (P<0.05), but not between untreated Anacetrapib and atypically treated patients. In all patient, groups the reduction in gait velocity was due to a smaller mean stride length, while the cadence (steps per minute) was not, changed. These results indicate that schizophrenia causes a primary disturbance of stride length regulation. Conventional antipsychotic treatment, intensifies this deficit, whereas atypical antipsychotic treatment docs not cause any additional gait, disturbances.

OXY-TDS (Oxytrol®; Watson Pharma, Corona, CA) offers a number of

OXY-TDS (Oxytrol®; Watson Pharma, Corona, CA) offers a number of advantages over oral drug administration, including improved pharmacokinetics, enhanced adherence, and a lower incidence of anticholinergic side effects. OXY-TDS is a matrix-type system composed of 3 layers; the middle layer contains oxybutynin and a skin permeation enhancer called triacetin. Triacetin controls the rate of drug absorption through the stratum corneum by its physiochemical interaction with skin lipids. Once through the stratum corneum, oxybutynin enters the systemic circulation via small capillaries located in the dermis. The 39 cm2 patch containing 36 mg of oxybutynin delivers 3.9 mg of oxybutynin daily. Steady-state

Inhibitors,research,lifescience,medical plasma concentrations are maintained Inhibitors,research,lifescience,medical for approximately 96 hours, eliminating the peaks and troughs associated with oral OXY-IR and allowing for twice-weekly application.18 Bioequivalence has been demonstrated when applied to the abdomen, buttock, and thigh, enabling the patient to rotate sites and lower adverse site reactions. Patient adherence with prescribed therapy is affected by a number of factors, including pill burden, complexity of dosing schedule, memory lapses, and adverse events.19 In studies, patients have been shown to Inhibitors,research,lifescience,medical fail to take less

than 50% of their prescribed dose of medication,20 and adherence has been improved by less-frequent dosing intervals.21 OXY-TDS applied twice weekly has the potential to improve patient adherence, selleck chemical Lenalidomide especially in older polypharmacy patients. Transdermal delivery of oxybutynin results in a lower incidence of anticholinergic side effects by avoiding first-pass

Inhibitors,research,lifescience,medical gastrointestinal and hepatic metabolism associated with oral administration. Avoidance of first-pass metabolism dramatically reduces the amount of N-DEO present in the systemic circulation, resulting in improved tolerability, with reported dry mouth and constipation rates similar to placebo.22 Inhibitors,research,lifescience,medical The most common treatment-related systemic adverse events experienced with OXY-TDS in integrated phase III studies include dry mouth (7.0%), constipation (2.1%), dizziness (0.8%), dysuria (1.2%), nausea (2.1%), and abnormal vision (1.2%).22,23 The lower levels of N-DEO relative to parent drug have similarly been shown to have smaller declines in saliva output.18 The literature supports the efficacy of OXY-TDS in treating patients with OAB. In a randomized, placebo-controlled, AV-951 phase III trial, OXY-TDS significantly reduced the number of weekly incontinence episodes (median selleck bio change, −19.0 vs −14.5; P = .0165), 24-hour frequency of urination (mean change, −2.3 vs −1.7; P = .0457), and increased the mean volume voided (median change, 24 vs 6 mL; P = .0063).22 In a subsequent head-to-head, placebo-controlled trial comparing OXY-TDS to extended-release tolterodine, both medications were equally effective in reducing incontinence episodes and urinary frequency, and superior to placebo23 (Figure 1).

38 Domains of social cognitive neuroscience: strengths and limits

38 Domains of social cognitive neuroscience: strengths and limits Social cognitive neuroscience has emphasized that apprehending and coping with socially relevant material #figure 2 randurls[1|1|,|CHEM1|]# heavily relies on general cognitive abilities, such as perception, attention, memory, and language. These abilities and the brain systems related to them are critically engaged in processing discriminating Inhibitors,research,lifescience,medical features

(from physical traits to abstract principles) that are important for guiding choice preference, group belonging/formation, and other species-specific activities, and more generally for optimizing social interactions, with con-specifics (eg, friends, family, coworkers) or institutions. The notion of “social interactions” is often intended as the interplay

between cooperation and competition among individuals and groups (family, kinship, hierarchical dominance) of the same species. Under such a view, an operating model for the self is left implicit in the background and is scientific assay similar in its assumptions to Inhibitors,research,lifescience,medical the classical economic agent.39 Inhibitors,research,lifescience,medical This implicit operating model of the self is also framed in reference to Darwinian evolution and the struggle for life. The current success of the field of neuroeconomics stems apparently from such a view.40-42 In the field of social cognitive neuroscience, a substantial crosstalk exists between animal and human research. Evolutionary hypotheses and a comparative perspective have become integral to the normal discourse on social cognition and to the endeavor of uncovering treatments for psychiatry, based on the paradigm of animal models. The field seems to be generally highly receptive Inhibitors,research,lifescience,medical to scientific work telling stories of overlap between findings from animal Inhibitors,research,lifescience,medical models and human studies (eg, amygdala and fear, or striatum and reward43,44). In spite of the large and still-developing research effort, including functional neuroimaging, few hypotheses have emerged that are autochthonous to

human research and reach a plausible level of psychological integration (eg, see literature on Default Mode Network45,46). The progression of the application to humans of hypotheses related to animal research (an ambitious research program that has been pursued over a few decades that has seen some exceptional developments (eg, refs GSK-3 47,48) while seeking the precision necessary to a scientific field has so far led to the development of a social neuroscience that has not adequately addressed some critical issues (for relative exceptions see refs 49-51). When borrowing from animal studies to develop hypotheses on humans that are directly relevant to psychiatry, an example of a critical question is to what extent animal emotions are germane to the homologous emotions in humans (beyond the use of common terminology and reference to a common evolutionary background).

Ejection fraction and palliative care appropriateness Eleven

Ejection fraction and palliative care appropriateness Eleven patients had both clinical diagnosis and confirmed ejection fraction ≤45%. A further 11 patients had chronic heart failure specified in their notes as a reason for their admission but had an ejection fraction of greater than 45%. Six were clinically identified as having CHF as a significant reason for admission by their ward medical staff during the census but had no ECHO data on file three months after the census date. Of the 17 patients with no supporting ECHO data (i.e. no ECHO result n = 6, or an ECHO result showing Inhibitors,research,lifescience,medical normal

function n = 11), five (29.4%) were identified as being appropriate for palliative care. Characteristics of patients appropriate for palliative care Those patients appropriate for palliative care had a mean of 5.1 unresolved symptoms and problems at 7 days Inhibitors,research,lifescience,medical post-admission. The characteristics of the following two groups were compared to the remaining patients with a clinical CHF diagnosis: a) those identified

as appropriate for palliative care irrespective of ECHO data, and b) those with ejection fraction ≤45% and palliative care appropriate. Compared to the remaining patients with a clinical CHF diagnosis (n = 12), those identified Inhibitors,research,lifescience,medical as palliative care appropriate (n = 16) had a statistically significant higher mean number of previous admissions (1.53 Inhibitors,research,lifescience,medical compared to 0.44, p = 0.024, t = -2.433); were being seen by a significantly greater number of multiprofessional inpatient staff (i.e. 2.1 staff compared to 0.9, P = 0.045, T = -2.169), and were significantly more likely to have a “do not resuscitate order” in their notes (43.8% compared

to 0%, p = 0.011, x2 = 6.497). Compared to all those remaining patients with a clinical diagnosis of CHF (n = 17), those with an ejection fraction ≤45% and appropriate for palliative care (n = 11) had a statistically significant Inhibitors,research,lifescience,medical higher mean number of previous admissions (1.9 compared to 0.57, p = 0.012, Brefeldin_A t = -2.733). Discussion Given the challenges of decision-making regarding palliative care initiation for CHF patients due to Y27632 movement between NYHA classification levels, the data describing characteristics associated with palliative care appropriateness is useful, particularly in the absence of ECHO data. The number of clinically identified CHF patients without ECHO data is indicative of the relevance of palliative care to all heart failure patients, including those elderly patients with normal systolic function, right sided heart failure and those with diastolic dysfunction. Limitations of the present study This data is likely to report a conservative estimate of the point prevalence of CHF inpatients appropriate for palliative care, i.e. 2.7% after confirmed ECHO data.

15 The average working hours per week for male workers of the car

15 The average working hours per week for male workers of the car battery industry was more than 50 which possibly leads to the fatigue-related impact of long working hours and occupational dissatisfaction. However, a recent study on 96915 workers in the United States indicates that although males show greater risks of injury compared to females, working hours is significantly associated with toxic risk only for women. This is probably due to the decreased recovery time and inadequate sleep, and elevated fatigue-related impact of long working hours for female workers.17 Nevertheless, additional objective measures are warranted in order to come to a more reliable conclusion.

Chronic lead exposure Inhibitors,research,lifescience,medical is implicated in the development of hypertension.18 Although 23.2% of workers had higher than normal systolic or diastolic blood pressures, the diagnosis of hypertension could not be made in the first-time visit. Our findings showed no association between systolic/diastolic blood pressure and BLC, which was consistent with Inhibitors,research,lifescience,medical other reports.19,20 It seems that lead Inhibitors,research,lifescience,medical exposure was not sufficiently durable to cause hypertension in this young

population. In this study, the level of education was inversely correlated with BLC which was consistent with the reports from other developing countries.21-23 Thus, improvement of education and socioeconomic status plays key role in the prevention of lead poisoning in these countries. According to guidelines,14 workers with severe lead poisoning should be hospitalized and treated with parenteral infusion. Since no severe case of lead poisoning was found among the studied population, Inhibitors,research,lifescience,medical workers were asked to avoid lead exposure and/or treated as outpatients. Toxicokinetics With normal renal function, lead is

excreted in the urine. Random urine sample shows short-term exposure to heavy metals.24,25 Urine and blood lead correlations are not reliable enough to substitute urine lead selleck bio concentration for BLC, especially when the exposure is mild and BLC is less than 100 µg/L.24,26 Gulson et al, believed that the inaccuracy in predicting BLC by measuring ULC mostly applies Inhibitors,research,lifescience,medical to children and female adults because of the potential Carfilzomib contamination during sampling.24 On the other hand, Moreira et al. claimed that spot urine test could be used to replace blood sampling for the evaluation of occupational lead exposure in both children and adults.27 Hematologic Manifestations Lead poisoning is a known cause of microcytic anemia.1 Although we failed to detect depressed Hb/Hct concentrations in workers, Mean Corpuscular Hemoglobin (MCH) and Mean Corposcular Hemoglobin Concentration (MCHC) values were negatively correlated with blood lead concentration. Other RBC indices were not significantly affected. Katavolos et al. demonstrated that MCHC and hemoglobin concentration in two avian species decreased significantly with rising blood lead concentration.

Another call to focus on political uses of time representations c

Another call to focus on political uses of time representations comes from Carol Greenhouse.7 For the American anthropologist, social time is about “the vulnerability of political institutions to legitimacy crises of different kinds” (p 15). Facing these crises, social actors manipulate time representations,

either in order to defend or increase the legitimacy of the political institutions at stake, or to make them accountable. Greenhouse clearly opposes the notion of unitary time representations Inhibitors,research,lifescience,medical that would originate from a society as a whole and be shared by all its members at all times; for her, representations of time are instruments of power used by some segments of a society in their struggle against others. About the linear model of time, she writes, for instance: “If linear time dominates public life in the West, then, it is because its primary efficacy is in the construction and management of dominant social institutions, Inhibitors,research,lifescience,medical not because it is the only ‘kind’

of time that is culturally available” (p 23). Other representations of time (as cyclical, for instance) are not made invalid by linear time; they coexist with Inhibitors,research,lifescience,medical it, but only the latter is dominant, which is evident in the fact that it is proclaimed to be objectively real. According to Greenhouse, which representation of time dominates in a given society has everything to do with political discourse and nothing with bodily experience. Present times In this second section, I move away from anthropologists’ preoccupations with time and turn to two topics that have been treated mostly by, respectively, sociologists Inhibitors,research,lifescience,medical and historians. The first one is the “acceleration” of everyday life in the contemporary, technological world; the second one is the predominance of the present in contemporary Western societies’ temporal order. Both topics deal with representations of time, much like what precedes, but, in addition, they provide insights into common, present-day experiences of time. An accelerating world Since the 1990s, sociologists and social theorists have

been widely preoccupied with what they saw as an increase Inhibitors,research,lifescience,medical in the pace of social life in so-called modern GSK-3 societies. Not only have the rhythms of life become faster, they argue, but social and cultural change has also speeded up. Some of them refer to this phenomenon as acceleration,11,12 others as time-space compression,13 instantaneous time,14 or timeless time,15 thereby alluding to the invention and spread of technologies (of transport, communication, etc) that sellekchem radically shorten or even eliminate spatial and temporal distances. Information and communication technologies (ICTs), like mobile phones, personal computers, and the Internet, for instance, have revolutionized our lives by introducing simultaneity and instantaneity.16,17 ICTs, among other technological advances, are supposed to reduce the amount of time necessary to undertake certain actions.

0 g/dL (maximum of 3 L removed) and infused with a combination of

0 g/dL (maximum of 3 L removed) and infused with a combination of albumin and crystalloid to restore isovolemia. Prospective randomized controlled studies demonstrate that it is safe and that ANH protected against allogeneic transfusions (22,28). As compared with standard volume management, Jarnagin et al. demonstrated that ANH resulted in fewer intraoperative transfusions (1.6% versus Inhibitors,research,lifescience,medical 10.4%, P=0.04). While interesting in concept, ANH is not routinely used in many centers at this time. We have not adopted

this strategy yet in our own practice. Blood loss-limiting surgical techniques Surgeons can take measures during hepatic parenchymal transection to further limit hemorrhage. These include temporary hepatic inflow occlusion (Pringle maneuver) and total vascular exclusion (TVE). These techniques are designed to isolate hepatic circulation (inflow and/or outflow) from the systemic circulation and minimize blood loss during dissection and Inhibitors,research,lifescience,medical transection of the hepatic parenchyma (Figure 1). A central Inhibitors,research,lifescience,medical tenet to the success of vascular exclusion is based on the premise that the liver (and

patient) is more tolerant to warm ischemia with reperfusion than to bleeding and the consequences of bleeding (e.g. transfusions.). Figure 1 Demonstration of potential sites of vascular occlusion. Pringle maneuver Originally performed for hepatic trauma, the Pringle maneuver is a straightforward way to minimizing blood loss during hepatectomy (47). A noncrushing clamp or a rumel tourniquet is placed around the structures in the porta hepatis to occlude

hepatic Inhibitors,research,lifescience,medical venous and arterial inflow during parenchymal transection. This can be performed in an intermittent or continuous manner with similar outcomes. It is recommended that the occlusion time be limited to an hour or less, as the ischemic insult will ultimately result in further hepatic parenchymal loss. After hepatic pedicle clamping with the Pringle, there is a 10% decrease in the cardiac index with a 40% increase in SVR and a 40% increase in mean arterial pressure (48-51). Inhibitors,research,lifescience,medical As compared with the previously mentioned occlusion techniques, the Pringle maneuver is relatively well-tolerated, but the anesthesiology staff should be continuously informed when it is applied because of the possibility of cardiac dysfunction and of air embolism, particularly if the hepatectomy is being done under low CVP. The potential sequela Brefeldin_A of air emboli, in the patient with a low CVP who may have an open hepatic vein, can be minimized by placing the patient in 15 degree Trendelenberg (24,25,52). The Pringle maneuver can be applied in a continuous or intermittent fashion. Many retrospective studies and prospective clinical trials have been performed examining the role and type of the Pringle maneuver, and its relationship to blood loss and reperfusion injury. Belghiti et al.

Copies of all AMIS forms involving incidents classified as red re

Copies of all AMIS forms involving incidents classified as red response were sent to the project manager every other

week throughout the study. The EMCCs also sent copies of ambulance records from all red STI 571 responses which involved ground or boat ambulances. In cases where doctors on-call, casualty clinics, primary care doctors Inhibitors,research,lifescience,medical or air ambulances had been involved, copies of medical records were requested and collected selleck products separately. This collection of medical records continued also after the study period, until October 2008. To secure a uniform use of the variables in the AMIS program, a meeting was held between the persons in charge of the participating EMCCs. The severity of the medical problem was classified using The National Committee on Aeronautics (NACA) Score System based on all available information [12]. In the NACA system, the patient’s status is classified from Inhibitors,research,lifescience,medical 0 to 7, zero indicating no disease or injury, while seven indicates the patient being dead. NACA score was categorised in the analyses as NACA 0-1 (patient with either no symptoms/injuries or in no need of medical treatment), NACA 2-3 (patient in need of medical help, where value 3 indicates need Inhibitors,research,lifescience,medical of hospitalisation, but still not a life-threatening situation), NACA 4-6 (4 is a potentially,

Inhibitors,research,lifescience,medical and 5 and 6 are definitely, life-threatening medical situations) and NACA 7 (dead person). Based on information from all available forms and medical records the cases were also classified into symptom groups according to the International Classification of Primary Care – 2 (ICPC – 2) [13]. The analyses presented in the results-section are based on the patients who were given the code A10 – Chest pain. Results Inhibitors,research,lifescience,medical on all the clinical categories and symptom groups, are published in

a previous article [1]. Statistical analyses The statistical analyses were performed using Statistical Package for the Social Cilengitide Sciences (SPSS version 15). Standard univariate statistics, including median and percentiles, were used to characterise the sample. Median, with 25th-75th percentiles, was used to analyse data where normal distribution was not present. Rates are presented as numbers of red responses per 1 000 inhabitants per year with a 95%-confidence interval (CI). Mann-Whitney U test was used for comparing age between males and females, for other comparisons the Pearson Chi-Square test was used. A P-value of < 0.05 was considered statistically significant. Ethics and approvals Approval of the study was given by the Privacy Ombudsman for Research, Regional Committee for Medical Research Ethics, and the Norwegian Directorate of Health.