Cases Of Various Forms Research Articles

Rhinocerebral mucoromycosis. Clinical case

In recent years, there has been an increase in the number in Ukraine and the world clinical cases of various forms of mucoromycosis. It can be associated with severe immunosuppression caused by transmitted SARS-CoV-2, an increase in the number of patients with diabetes, which creates favourable conditions for development of fungal microflora. Rhinocerebral mucormycosis is usually severe and often fatal if not diagnosed early and actively treated. Necrotic lesions appear on the nasal mucosa or sometimes on the palate. Vascular invasion of hyphae leads to thrombosis and progressive tissue necrosis, which may involve the nasal septum, palate and bones, surrounding the orbit or sinuses. Verification of the diagnosis is difficult due to the inexperience of doctors in working with this disease, the disease has a tendency to progress rapidly. The article describes the case of treatment of a patient with rhinocerebral mucoromycosis, which had a severe clinical course.

Clinical study of various forms of acute pancreatitis in a tertiary care centre

Background: Acute pancreatitis is an acute inflammatory process of the pancreas with variable involvement of regional tissues and remote organ system. Severe acute pancreatitis (SAP) is characterized by a short course of progressive multi organ dysfunction syndrome (MODS), early hypoxemia and increased incidence of necrosis, infection, and abdominal compartment syndrome (ACS). The average mortality rate in severe acute pancreatitis approaches 2-10%. This study was conducted to observe etiological factors, the clinical presentations and outcome of various form of acute pancreatitis.Methods: A hospital record based retrospective study on one hundred (100) cases of various forms of acute pancreatitis in the department of surgery at tertiary care teaching hospital of South Gujarat from January 2019 to December 2019 to know the clinical presentation of acute pancreatitis patients.Results: The maximum patients were belonged to age group between 31-40 years. There was a high incidence of alcoholic pancreatitis as compared to the gallstone pancreatitis. In both males and females, alcohol was the main etiological factor. Few patients needed ICU admission and oxygenation. Surgery was the modality for some patients. Out of total, 89 cases were recovered.Conclusions: Early identification of sever and complicated acute pancreatitis prompts the highly dependent intensive care and early intervention. Gall stones are considered most common etiological factor for acute pancreatitis in India but alcoholism crosses this limit suggests changing life style of our people. Outcome is favourable in expectant conservative management of any form of acute pancreatitis.

Hemangiomas of the optic nerve head

The article presents five cases of various forms of hemangiomas of the optic nerve head (ONH) and juxtapapillary retina that were monitored and analyzed using ocular visualization methods. The obtained data allowed a conclusion that capillary hemangioma of the ONH features clearly-seen boundaries of the lesion both on ophthalmoscopy and optical coherence tomography (OCT) images; on the other hand, juxtapapillary granuloma can be characterized by blurred outlines on ophthalmoscopy and a gradual transition of the altered retina on OCT images with secondary changes seen in the macular area. When comorbid, capillary hemangioma of the ONH and retina feature a combination of these visualization signs.

Dynamics of epidemiological indicators of thyroid pathology in the population of the Russian Federation: analytical report for the period 2009-2018

ОБОСНОВАНИЕ. Уровень потребления йода населением во многом определяет спектр тиреоидной патологии. На сегодняшний день в РФ йододефицитные заболевания (ЙДЗ) занимают лидирующие позиции в структуре всех заболеваний щитовидной железы (ЩЖ). Хронический дефицит йода (ЙД) приводит к неблагоприятным последствиям для здоровья и существенным экономическим затратам на их устранение в масштабах страны. Кроме того, спектр тиреоидной патологии в условиях ЙД не ограничивается проблемой ЙД, и изучение остальных заболеваний ЩЖ также представляет интерес.ЦЕЛЬ. Проанализировать динамику основных эпидемиологических показателей ЙДЗ и других заболеваний ЩЖ у всего населения РФ за период 2009–2018 гг., используя данные официальной государственной статистики.МЕТОДЫ. Проанализированы заболеваемость и распространенность заболеваний ЩЖ у всего населения РФ с использованием данных официальной государственной статистики. Использованы статистические формы №63 МЗ СР РФ «Сведения о заболеваниях, связанных с микронутриентной недостаточностью» и №12 «Сведения о числе заболеваний, зарегистрированных у больных, проживающих в районе обслуживания лечебного учреждения, РОССТАТ». Анализируемый период — 2009–2018 гг. Для оценки динамики распространенности и заболеваемости были построены линейные регрессионные модели.РЕЗУЛЬТАТЫ. Данные проанализированы в соответствии с представленной в статистической отчетности структурой заболеваний: зоб, тиреоидит, гипотиреоз, тиреотоксикоз, синдром врожденной йодной недостаточности. За десятилетний период 2009–2018 гг. отмечается статистически значимый рост распространенности различных форм зоба, тиреотоксикоза, синдрома врожденной йодной недостаточности у всего населения РФ. В течение периода наблюдения выявлен рост заболеваемости тиреотоксикозом. В отношении заболеваемости синдромом врожденной йодной недостаточности выявлена лишь тенденция к росту. Несмотря на то что в течение периода наблюдения число новых случаев различных форм зоба уменьшилось, распространенность зоба среди населения РФ остается высокой: 1,2% населения к 1 января 2019 г. В отношении тиреоидита выявлен статистически значимый рост распространенности и заболеваемости, что может быть связано с ростом аутоиммунной патологии, совершенствованием уровня диагностики, а также, в некоторых случаях, с гипердиагностикой (например, при постановке диагноза аутоиммунного тиреоидита у лиц с бессимптомным носительством антитиреоидных антител). Существующие на сегодняшний день подходы к йодной профилактике недостаточно эффективны.ЗАКЛЮЧЕНИЕ. Результаты проведенного анализа свидетельствуют преимущественно о росте распространенности тиреоидной патологии среди населения РФ на фоне проводимых региональных мероприятий. Проблема ЙДЗ остается нерешенной, что диктует необходимость внедрения всеобщего обязательного йодирования соли на территории РФ.

Identification of Radar Signals Based on Time-Frequency Agility using Short-Time Fourier Transform

With modern advances in radar technologies and increased complexity in aerial battle, there is need for knowledge acquisition on the abilities and operating characteristics of intercepted hostile systems. The required knowledge obtained through advanced signal processing is necessary for either real time-warning or in order to determine Electronic Order of Battle (EOB) of these systems. An algorithm was therefore developed in this paper based on a joint Time-Frequency Distribution (TFD) in order to identify the time-frequency agility of radar signals based on its changing pulse characteristics. The joint TFD used in this paper was the square magnitude of the Short-Time Fourier Transform (STFT), where power and frequency obtained at instants of time from its Time-Frequency Representation (TFR) was used to estimate the time and frequency parameters of the radar signals respectively. Identification was thereafter done through classification of the signals using a rule-based classifier formed from the estimated time and frequency parameters. The signals considered in this paper were the simple pulsed, pulse repetition interval modulated, frequency hopping and the agile pulsed radar signals, which represent cases of various forms of agility associated with modern radar technologies. Classification accuracy was verified using the Monte Carlo simulation performed at various ranges of Signal-to-Noise Ratios (SNRs) in the presence of noise modelled by the Additive White Gaussian Noise (AWGN). Results obtained showed identification accuracy of 99% irrespective of the signal at a minimum SNR of 0dB where signal and noise power were the same. The obtained minimum SNR at this classification accuracy showed that the developed algorithm can be deployed practically in the electronic warfare field for accurate agility classification of airborne radar signals.

Assessment of the mammary glands in polycystic ovary syndrome during high level of exposure to manganese and nickel

Introduction. The authors of previous studies have found a high level of exposure to manganese and nickel in women with polycystic ovary (PCOS).Objective — to study the condition of mammary glands (MG) in women with PCOS and determine values of estradiol, prolactin (PRL) and Sex hormone-binding globulin (SHBG). To estimate possible consequences of increased exposure to manganese and nickel to the formation of MG pathology during PCOS.Material and methods. Studies were conducted in two groups of women. The first control group consisted of healthy women of reproductive age. The second group consisted of women with PCOS. The women with thyroid disease, diabetes, prolactinomas and other endocrine diseases were excluded from the study. The examination of MG was performed using ultrasound scanners. The number of cases of various forms of mastopathy was monitored. Determination of estradiol, PRL and SHBG in serum was carried out using immunoassay methods. All studies were performed with the consent of the patient and with compliance with ethical standards. Statistical processing was carried out with the definition of arithmetic mean, median. The validity of the obtained results was evaluated using following indicators: Chi-square, Shapiro-Wilka test, Fisher's F-test, Mann-Whitney’s U-test.Results. Ultrasound examination of MG was performed for 108 women in the control group and for 97 women with PCOS. In the control group, the pathology of MG was detected in 29 women (26.85%). In the second group, the pathology of MG was detected in 67 cases (69.7%; p<0.0001). In women with PCOS, the median PRL score was higher by 44.83% (p = 0.0179) compared to control. Level of estradiol did not differ in both groups (p = 0.9616). In the group of women with PCOS, the SHBG indices were slightly lower compared to controls, but differences did not find statistical confirmation (p = 0.2756).Conclusions. In women with polycystic ovary syndrome more than 2 times more often there are benign mammary gland diseases. We did not find differences in the rates of estradiol and SHBG. Exposure to manganese can lead to an increase in prolactin levels. This can stimulate the proliferative processes of MG in the absence of ovulation in women with PCOS.

Bacterial Meningitis: A Review in the Upper East Region of Ghana 2010-2014

Introduction: Meningitis is an acute inflammation of the protective membranes covering the brain and the spinal cord. It can cause severe brain damage and is fatal in 50% of cases if untreated. The Upper East Region (UER) of Ghana recorded 70 case-patients in 2014 with a case fatality of 10%. Furthermore, there have been series of out outbreaks of bacterial meningitis in the region. The study reviewed meningitis surveillance data to assess the progress towards interruption of meningitis transmission and identified opportunities for surveillance improvement in the UER. Methods: This involved records review and secondary data analysis of all reported meningitis cases in the Region from 2010 to 2014. Data quality was assessed: described by person, place, time, causative agents involved and identified opportunities for system improvement. Results: Of 1142 suspected cases of meningitis recorded at the health facilities and communities in the UER, 352(30.8%) were confirmed cases of various forms of Bacterial meningitis. Majority of the cases (50.7%) were males. The age group 0-9 years was mostly 491(43.0%) affected. There were 146 deaths, giving a case fatality rate of 13.0%. The identified etiological agents were Neisseria meningitides (Nm W135) 50.3%, Streptococcus pneumonia (41.7%), Neisseria meningitides (Nm A) 1.7%, Neisseria meningitides (Nm Y 5%), Haemophilus Influenzae Type B1.5%. Majority of the case-patients were observed in 2010 (34.7%) and 2012 (44.2%) between February and April (%). The Kassena Nankana Municipal recorded the highest number of cases 234(20.5%) and the Bulsa South District recorded no case of bacterial meningitis cases. 69 (6%) of case-patients had no lumber puncture done. Time spent before presentation of case-patients to the health facilities had no significant association with the outcome of the infection (p= 0.319). Conclusions: There has been a consistent outbreak of Bacterial meningitis in the Upper East Region that involved many cases-patients with some mortality. More bacterial meningitis cases were recorded in children compared to adults. Lumber puncture was not performed in all case-patients. Many case-patients were recorded in the first quarter of the year with the majority in the Kassena Nankana District. There is an urgent need to review the management of meningitis, coupled with enhanced strategies in prevention of occurrences of the disease in the Upper East Region of Ghana.

The effect of clonazepam (Ro 5-4023) in the syndrome of infantile spasms with hypsarrhythmia and in petit mal variant of Lennox syndrome. Preliminary report.

From a material of 179 cases of various forms of childhood epilepsy treated with clonazepam (Ro 5-4023) the results in 79 cases with two major forms—syndrome of infantile spasms with hypsarrhythmia and petit mal variant or Lennox-syndrome—are presented. The overall effect was complete clinical and EEG control in about one third of the cases, and partial improvement of seizure and/or hypersynchronous EEG activity in a large part of the cases. Clonazepam can therefore be considered as a very important new anti-epileptic medicament for treatment of these forms of severe childhood epilepsy.

Simit Epidemiological Multicentric Study on Hospitalized Immigrants in Italy During 2002

The aim of this article is to retrospectively evaluate the patient characteristics and the most common infectious diseases in immigrant patients hospitalized in 46 Italian infectious disease clinics during 2002. The main Italian infectious disease clinics were invited to fill in a questionnaire that regarded the number and type of hospital admissions, the country of origin, and demographic features (age, sex, and resident state) of immigrants. A total of 46 clinics including 2255 patients participated in the study. Most patients were men (63%) with an age between 16 and 40 years (63.4%) covered by the National Health Service (71%) and coming from Africa (44.3%). The main infectious diseases observed were: 378 (16.76%) cases of HIV infection, 303 (13.43%) cases of tuberculosis diseases, 282 (12.5%) cases of various forms of viral hepatitis, 177 (7.84%) cases of respiratory diseases, and 196 (8.69%) gastrointestinal diseases. Tropical diseases found were 134 (5.94%) including 95 cases of malaria (70.9%). In conclusion, a broad range of diseases was noted in immigrants which were directly correlated with conditions of poverty. Only a few tropical diseases were diagnosed and therefore the immigrant should not be considered as an infectious disease carrier.

Western blotting analysis of the beta-hexosaminidase alpha- and beta-subunits in cultured fibroblasts from cases of various forms of GM2 gangliosidosis.

The GM2 gangliosidoses are a group of genetic disorders caused by the accumulation of ganglioside GM2 in neuronal cells. We examined the alpha- and beta-subunits of beta-hexosaminidases by a non-radioisotopes detecting system to evaluate whether it was a useful method for understanding of the pathophysiologies of GM2 gangliosidoses. We investigated the alpha- and beta-subunits of beta-hexosaminidases in cultured fibroblasts from cases of various forms of GM2 gangliosidosis by means of Western blotting and a chemiluminescence detection system. In a patient with infantile Tay-Sachs disease [HEXA genotype, Int5-SA(g-1-->t)/Int5-SA(g-1-->t)], the mature alpha-subunit was undetectable. In a patient with infantile Sandhoff disease (HEXB genotype, C534Y/C534Y), the mature beta-subunit was deficient. However, a small amount of the mature beta-subunit was detected in a patient with adult Sandhoff disease (HEXB genotype, R505Q(+I207V)/R505Q(+I207V)), which may have resulted in the residual enzyme activity and mild clinical course. Normal amounts of alpha- and beta-subunits were detected in a patient with GM2 activator deficiency. This method is easy and sensitive for detecting target proteins, and is useful for clarification of the pathophysiologies of GM2 gangliosidoses.

Studies on Criteria of the European Academy of Dermatology and Venerology for the Classification of Cutaneous Lupus Erythematosus

A group of 140 cases of various forms of lupus erythematosus (LE) were examined for 24 variables, including the 11 criteria of the American Rheumatism Association (ARA) for the classification of systemic lupus erythematosus (SLE), and 13 additional criteria suggested by the European Academy of Dermatology and Venerology (EADV) for studies of cutaneous LE with or without systemic involvement. The EADV study factors included skin histopathology and immunopathology, complement and IgG levels, and other laboratory tests, as well as selected clinical findings, most notably the papulosquamous and/or annular lesions that characterize subacute cutaneous LE (SCLE). The patients examined included 50 SLE, 35 SCLE, 30 discoid LE (DLE), 25 disseminated DLE (DDLE), and 17 polymorphous light eruption (PMLE) cases. Preliminary analyses of the data reveal the following: (1) The SCLE cases differed significantly from SLE, DLE, and DDLE in 10 of 11 ARA criteria (all but photosensitivity). (2) The frequencies of positive findings in SCLE also differed significantly for 11 of 13 EADV study factors. (3) While no significant differences appeared in the frequency of photosensitivity between the five study groups, photo-testing revealed significant increases in the frequency of persistence of the photo reactions for 10 days and their Koebnerization in the SCLE cases. (4) The presence of SS-A (Ro)/SS-B (La) antibodies had some predictive value for the appearance of systemic involvement in SCLE, as seen by the increased frequencies of five or more ARA criteria, although highly significant differences from SLE occurred in the absence of renal involvement and lower frequency of ANA and LE band test.(ABSTRACT TRUNCATED AT 250 WORDS)

Atheromatous renal disease

Atheroma as a cause of renal failure has been largely overlooked. We wanted to report our experience with atheromatous renal disease over a 12-year period. Observations on 32 cases of various forms of renal failure in patients with atheromatous renal disease are presented. These patients had been hypertensive for an average of 10.2 +/- 9.2 years. The length of deterioration was an average of 17 months, and at presentation renal insufficiency was severe, with serum creatinine levels of (mean +/- SD) 616 +/- 358 mumol/liter (6.8 +/- 4.0 mg/dl). At this stage, the clinical picture was indistinguishable from other common causes of chronic renal failure in the elderly. Thus, the precise diagnosis would have been overlooked without an aggressive diagnostic workup. All patients underwent angiography and six patients underwent renal biopsy. In 22 cases, renal insufficiency was mainly due to atheromatous stenosis of renal arteries. In six of six patients, the results of renal biopsy showed cholesterol crystal embolism. In four additional cases, there was clinical or histologic evidence of extrarenal cholesterol embolism. In eight, renal artery plaques coexisted with cholesterol embolism. In two patients, renal failure was due only to cholesterol embolism. Renal atheromatous stenoses were developing, as shown on serial angiographies performed in five cases. In seven cases, stenoses involved both the main trunks of renal arteries and several intrarenal branches of too small a diameter to allow reconstructive surgery or percutaneous transluminal angioplasty. In addition, the general condition of most patients was so poor as to preclude surgery. Dialysis was begun in 11 patients, four other patients died, and renal failure was managed conservatively in 11. When undertaken, reconstructive surgery was successful in five of six patients. Atheromatous renal disease is a frequent and easily overlooked cause of chronic renal insufficiency. It is not only due to renal artery stenosis but also to complex intrarenal lesions, with multiple stenoses of intrarenal vasculature and cholesterol embolism. It should be diagnosed by early angiography and renal biopsy, before the stage of multivisceral complications and at a time when surgery can still be undertaken.

Urticaria Pigmentosa in Identical Twins

Urticaria pigmentosa (UP), or cutaneous mastocytosis, is the most common mast cell disease of childhood. It produces no visceral lesions or systemic symptoms and usually improves by adolescence.¹ During the last 100 years, the literature has reported cases of various forms of mastocytosis in 40 families in which more than one member was affected.²Among these cases were 11 sets of twins and one set of triplets. Seven pairs of identical twins and the triplets were concordant for the disorder, while two identical twin pairs and the two fraternal sets were discordant. We report an eighth set of identical twins who both have UP, and we discuss the genetics of this condition. <h3>Report of Cases</h3> Twins 1 and 2 were black, male infants who were seen at the age of 4 months. Their parents were not related, and there was no family history of skin disease. The delivering

Glomerular C3 receptors in human renal disease

The relationship between glomerular C3 receptor activity and intraglomerular C3 deposition was studied in 73 cases of various forms of renal disease. C3 receptor activity was measured by enumeration of complement-coated sheep red blood cells (IgM EAC) that adhered to glomeruli in frozen sections and expressed as a percentage of the mean number present in control kidneys. Adjacent sections were studied for the presence and distribution of C3 deposits. The precise location of corresponding dense deposits was determined through 1-mu sections or electron micrographs. Marked depression of C3 receptor activity was found in most cases in which there was accumulation of C3 along the glomerular basement membrane, irrespective of whether the deposits were in a subepithelial, intramembranous, or subendothelial location. In contrast, when C3 was not detectable or was found exclusively in the mesangium, C3 receptor activity was affected only moderately, if at all. These data are consistent with the hypothesis that the interaction of C3 with podocytes is a major determinant in the loss of C3 receptor activity in glomerular disease, but do not exclude the possibility that interaction with mesangial or endothelial cells may also influence C3 receptor activity.

Immunopathological aspects of hepatitis type B.

Tissue samples from 180 unselected necropsy cases of various forms of hepatitis were examined by histopathology and immunofluorescence. The hepatitis forms studied included acute fulminant hepatitis (28 patients), subacute hepatitis (48 patients), acute fatal hepatitis (24 patients), chronic aggressive hepatitis (26 patients), liver cirrhosis (49 patients), and "minimal" hepatitis (5 patients). Hepatitis B surface antigen and hepatitis B core antigen were detected in 101 patients (56.1 per cent). In these, lesion-bound immune complexes of hepatitis B surface antigen were found in the liver and extrahepatic locations in 77 patients (76.2 per cent). The latter included activated germinal centers of lymph nodes and spleen, focal hyaline lesions of splenic and renal arterioles, necrotic and/or proliferative lesions of small and medium-sized arteries, and kidney glomeruli with mild proliferative and degenerative lesions. There was an inverse relation of the approximate amounts of hepatitis B surface antigen in the liver and the liver damage, the latter being directly proportional to the amount of HBS Ag immune complexes in the liver and indirectly proportional to their amount in extrahepatic locations and to the severity of lesions at these sites.

Immunosuppressants in the treatment of pemphigus.

Summary The results are presented of parenteral treatment with methotrexate (12·5 mg. twice a week) in 19 cases of various forms of pemphigus; small doses of corticosteroids (usually 8–32 mg. daily) were given in addition. Two other cases, both of pemphigus erythematosus, were treated with azathioprine. The response to immunosuppressants was good, chiefly in pemphigus erythematosus. In pemphigus vulgaris. cutaneous lesions responded much better than mucosal ones, which in some cases improved only some weeks after discontinuation of the treatment with methotrexate. Locally applied corticosteroids proved to be very valuable. Attention is called to the large number of complications, chiefly bacterial infections due to the lowering of the resistance of the organism in general. Methotrexate cannot be regarded as completely safe, and it would be premature to try to evaluate its long–term results in comparison with those of corticosteroid therapy alone.

Cardiopathy in Muscular Dystrophy

In previous communications 12 , 13 certain electrocardiographic changes, described under myopathic pattern, were reported in a series of patients suffering from various types of muscular dystrophy. The present report is a further elaboration of the cardiac status in these patients. One hundred and sixty cases of various forms of myopathy were studied. Findings suggestive of cardiopathy were limited only to pseudohypertrophic muscular dystrophy (sex linked Duchenne type myopathy). Except for the coincidental finding of congenital or rheumatic heart disease in four cases, only two showed clinically recognizable cardiopathy in the form of congestive cardiac failure. This was confirmed in one of the cases with histopathologic evidence on necropsy. Another three cases had cardiac enlargement on radiologic studies. Seventy-five per cent of the cases of pseudohypertrophic muscular dystrophy showed “myopathic pattern” 13 in the electrocardiogram. Right heart catheterization done in nine cases confirmed the congenital cardiac lesion in one and showed incipient right heart failure in another. Findings were in the upper limits of normal in two more cases. This was shown when pressure was applied in the right hypochondrium. However, resting studies showed normal findings in all these cases. Various lacunae in our knowledge regarding the limitation of “myopathic pattern” to pseudohypertrophic muscular dystrophy group, the genesis of electrocardiographic changes and the relative rarity of congestive cardiac failure are emphasized.

Sodium Para-Aminobenzoate (“PABA”) in the Treatment of Dermatoses

Weiner (1) and Loewenthal (2) have recently reported good therapeutic results when sodium para-aminobenzoate (PABA) was given orally in daily doses of 6 to 16 Gms. to patients with atopic dermatitis and other dermatitides. Weiner noted an excellent and lasting response in 8 of 16 cases of atopic dermatitis Four other patients showed an initial improvement but had a subsequent relapse. In the other four patients the effect of PABA was unsatisfactory. Loewenthal reported similar results in 18 cases of atopic dermatitis. Thirtyseven additional cases of various forms of eczema showed an even more satisfactory response than the atopic patients.

An analysis of a consecutive series of cases of various forms of arthritis, treated by ileocolostomy or colectomy

Journal Article An analysis of a consecutive series of cases of various forms of arthritis, treated by ileocolostomy or colectomy Get access C H Fagge, C H Fagge London Search for other works by this author on: Oxford Academic Google Scholar E C Hughes E C Hughes London Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 2, Issue 8, January 1914, Pages 657–664, https://doi.org/10.1002/bjs.1800020813 Published: 02 March 2006

The Albumen in the Cerebro-Spinal Fluid in Cases of Mental Disease

The following short paper is based upon observations made during the examination of the cerebro-spinal fluid from a series of cases of various forms of mental disorder. A good deal of attention has recently been paid to the examination of this fluid in conditions of disease; there have been numerous observers, and several important tests have been devised. In this series of cases a routine examination was followed in every case, which embraced the tests described by Noguchi, and by Ross and Jones, an examination of the cells present, and an estimation of the amount of albumen in the fluid. It is to the last of these methods of examination only that attention is directed in this paper.