Feeling Of Lump Research Articles

An unusual etiology of Globus pharyngeus – the Killian–Jamieson diverticulum

Mucosal outpouching between the muscles of the pharynx and proximal esophagus are known as pharyngoesophageal diverticula. These are rare acquired causes of dysphagia and globus sensation in the middle aged and elderly. This report is about a gentleman who presented with globus pharyngeus. Globus pharyngeus or feeling of lump in throat is a common presenting complaint. This is usually due to gastroesophageal reflux disease or psychosocial factors including stress in most cases. However, in this case on investigation, he was found to have a symptomatic Killian–Jamieson diverticulum. This is one of the rarer types of cricopharyngeal diverticula and a cause of globus pharyngeus. He was treated surgically by a transcervical stapled diverticulectomy. A cricopharyngeal diverticulum should be thought of in the differential diagnosis of cause of globus pharyngeus.

Effect of Intravaginal Application of Palasha Udumbaradi Ointment on Pelvic Organ Prolapse

Prolapse is a downward descent of the female pelvic organs as a result of weakness of the structures that normally retain them in position. The main symptoms of pelvic organ prolapse include micturition disturbances like stress incontinence, imperfect control of micturition, a feeling of lump coming down, postural low back ache, constipation and leucorrhoea. The management of pelvic organ prolapse includes preventive conservative and surgical measures. Surgery is indicated when conservative management fails. The three different conditions like Phalini, Prasramsini and Mahayoni vyapath mentioned by different Acharyas explain the prolapsed condition according to the stage and part prolapsed out. Palasha udumbaradi yoga mentioned in Bhaishajya Ratnavali containing ingredients such as Palasha beeja, Udumbara phala, Thilathaila and Madhu was taken for this study. The Lepa was applied in the modified form of an ointment. The study is an attempt to assess the effect of Palasha udumbaradi ointment on uterine prolapse. The ointment was applied intra vaginally. The presence of dense blood vasculature makes the vagina a potential site for local and systemic drug administration. The key advantages of vaginal drug delivery over oral administration is that this is able to circumvent the harsh gastric environment and also bypass hepatic first-pass metabolism. A 38 year woman with complaints of increased frequency of micturition, stress incontinence, burning micturition, low back ache and dyspareunia consulted the OPD of Govt. Ayurveda Medical College, Tripunithura. Palasha udumbaradi ointment was self-applied intra-vaginally. Administration of ointment was advised for 60 consecutive days excluding the days of menstruation with follow up on 90th day. Assessment was done on 0th, 30th and 60th day and follow up was done on 90th day using POP-Q Scale, urinary incontinence scale, and visual analogue scale.

Outcome Evaluation of Eyelid Laceration Surgery in Kariadi General Hospital Semarang

Abstract
 Introduction & Objectives : Eyelid laceration are common in cases of trauma involving the eye. This study will discuss cases of eyelid lacerations, procedures, and the follow-up of patients who underwent surgery at Kariadi General Hospital Semarang.
 Methods : This study used an observational analytic design and was conducted retrospectively. All patients who underwent eyelid surgery April 2019 to January 2023. Age, gender, laceration location, mechanism of trauma, canalicular involvement, and surgery were recorded, subjective complaints and patient complications after surgery.
 Results : Of the 76 patients (94 eyelid lacerations) included in the study, men exhibited a greater vulnerability (56,75%) and mostly aged around 16-<50 years (43, 57%). In terms of the laceration location, it occurred in right lower (39,36%), right upper (35,10%), left lower (13,82%), and left upper (11,70%) eyelids. Blunt trauma (83,78%) was the main mechanism, with motor vehicle accidents leading (40,54%). Canalicular involvement was present in 35 cases (47,29%). All patients underwent surgery, with eyelid repair to all of the patient following by recanalization (39,18%). The most common complaint of patients after surgery in the first week of control was pain (47,29%) followed by a feeling of lump (13,51%). A total of 25 patients (33,78%) stated that they had no complaints.
 Conclusion : Eyelid lacerations mainly involve young adult people, right lower eyelid. Blunt trauma, particularly motor vehicle accidents, is the main cause. Most of the patients had no complaints in the1 week postoperative control, and they increased in subsequent controls.

Sebuah Kasus : Post Tonsilektomi Dengan Komplikasi Syok Hipovolemik

Tonsillitis is inflammation of the palatine tonsils. Infection of the tonsils occurs if antigens, whether inhaled or ingested, easily enter the tonsils and the body resists and a focus of infection forms. Initially, the infection is acute, generally caused by viruses that grow on the mucous membrane, then followed by bacterial infection. As a result of chronic inflammation, the size of the tonsils will increase due to parenchymal hyperplasia or fibrinoid degeneration with tonsillar crypt obstruction. The definitive treatment for chronic tonsillitis is surgical removal of the tonsils or tonsillectomy where one of the complications is bleeding which triggers hypovolemic shock. This case report presents a 19 year old man who complained of pain in swallowing and a feeling of lump in the throat and based on the history, physical examination and supporting examinations that had been carried out, the patient was diagnosed with tonsillitis and planned to undergo a tonsillectomy. After the procedure, the patient experienced hypovolemic shock due to bleeding and died

A bird's-eye view of pathologist over diagnostic confusion of oral cavity lesions.

Oral cavity can be host to multitude of neoplastic, premalignant or non neoplastic pathological lesions. Diagnosis of lesions of oral cavity is always of interest to clinician and pathologist and rely on clinical appearance of lesions. There can be variation in diagnosis of clinical lesion with histopathology. Many oral carcinomas arise within the sites that previously had premalignant lesion. Incidence of oral cancers in population has increased among younger generations related to habits and lifestyle. These lesions during clinical presentation are misleading and create diagnostic dilemma owing to age, sex and distribution of lesions. Understanding distribution of oral mucosal lesions helps to diagnose lesions of oral cavity. Purpose of this study is to observe the variation in clinical diagnosis with histopathological diagnosis in patients with inflammatory, premalignant, benign and malignant lesions of oral cavity and oropharynx and also clinical distribution of lesions of oral cavity and oropharynx lesions by histopathology. Out of total 105 lesions, ulcer in oral cavity seen in 58 (55.23%) of patients, followed by swelling or feeling of lump in oral cavity in 36 (34.29%) of patients and foreign body sensation in 23 (21.90%) of patients with tongue as most frequent site for most of lesions of oral cavity accounting in 33 (31.43%) of cases, and less frequently lesions were seen in retro molar trigone area in 2 (1.90%) patients. Histopathological diagnosis of premalignant, non neoplastic and inflammatory lesions was made in 24 (22.85%) cases, benign tumours were diagnosed in 14 (13.33%) cases and rest of 67 (63.81%) lesions were malignant. Mucocoel were seen in five (4.76%) cases, radicular cyst was seen in one (0.95%) case of female patient and four cases of Leukoplakia with one case showing mild dysplasia. Among benign tumours 11 (10.47%) patients presented with gingivitis turned out to be squamous papillomas were seen in five (4.76%) cases, fibroma was diagnosed in four (3.80%) cases, pyogenic granuloma was diagnosed in four (3.80%) cases most commonly seen over gingiva and myoepithelioma of minor salivary gland was observed in one (0.95%) case over soft palate. Out of 67 cases of malignant lesions squamous cell carcinomas were seen in 59 (88.05%) cases followed by verrucous carcinoma in 3 (4.47%) cases, 2 (2.99%) cases were basaloid squamous cell carcinomas, mucoepidermoid carcinoma was seen in 2 (2.99%) cases and 1 (1.49%) case of adenoid cystic carcinoma was seen. Majority of squamous cell carcinomas cases in study were well differentiated in 49 (73.13%) cases followed by moderately differentiated in 16 (23.88%) cases and poorly differentiated in 2 (2.99%) cases. Malignant transformation of tonsil tissue post operatively was observed in 1 (0.95%) patients on histopathology. One (2.5%) case of myoepithelioma was seen in 60 years male over soft palate. Of all oral biopsies reported in study, increasing trend of malignancies in lower age groups of population making it an emerging threat to community and highlighting need to take effective measures to increase public awareness about risk factors and consequences of this condition. Screening programmes targeted to population over 25 years are recommended to overcome this.

“Lump In The Throat”: Approach To Patient, Differential Diagnosis And Management

Feeling of lump in the throat is a common reason for referral of patients to the oto-rhinolaryngology and head and neck clinic. The impression of the referring physician notwithstanding, the onus is on the otorhinolaryngologist to objectively evaluate every patient and manage as appropriate. This review is a summary of scientific information search outcome from Medline bibliographic database, published scholarly references, abstracts and/or full texts of articles and textbooks. The focus is on clinical approach to the patient, differential diagnoses and management options, and the search terms were globus pharyngeus, lump in the throat, laryngopharyngeal reflux. In the present paper, we highlight a useful working guide for history taking, physical examination, investigation and management of a patient with complaint of lump in the throat.

Clinical and Therapeutic Aspects of Genital Prolapse at Hôpital du Mali about 100 Cases

To study the epidemio-clinical aspects, and the therapeutic attitudes of genital prolapse (GP) in the gynecology department of Hôpital du Mali (HDM). This is a descriptive retro-prospective study over five (5) years from January 2015 to December 2019, conducted in the gynecology department of HDM. We had collected 100 cases of GP out of 989 surgeries, with a frequency of 9.89%. The age group of 60 years and over accounted for 33% of our patients, with a mean age of 50 years. Multiparous were the most affected (89%). The notion of obstructed labor was observed in 52% of patients. The most found reason for consultation was the feeling of lump in a vagina, with 65%. Grade III according to BADEN-WALKER classification system (BWCS) concerned 72% of our patients. Triple perineal surgery and hysterectomy involved 56% of our patients. Spinal anesthesia was performed in 96% of cases. Per and postoperative complications were dominated by urinary retention in 4% and by infection of the surgical site in 2%. The average hospital stay was 3.2 days. We recorded 88% of satisfied patients after the intervention. No deaths were recorded during the study. The management of genital prolapse remains essentially surgical; it requires a semiological analysis and a mastery of the surgical technique.

Sexual Aversion and Lack of Sexual Desire in Woman: a Case from Clinical Practice

The article presents a clinical case with a 25-year-old female patient A., who has been married for 1 year, but before she was in a commonlaw marriage during 5 years with her present spouse, who is 30. They have not got any children. When she sought medical advice the patient informed that during 1.5 years she had been feeling sexual aversion to her husband (when he tried to take her in his arms, she had creeping sensations on her arms and back, a feeling of lump in her throat, and a desire to cry). She attributed it to the fact that her husband “does not pay enough attention to me”, he did not defend her against accusations from the side of his relatives and stood with his mother, faulting the patient for causing conflictual relations between the women. She did not feel any sexual desire toward her husband. Their sexual life was once a week. She let her husband loose with her only after she drank alcohol. A month before it was the end of their 8-month period, when she did not let her husband loose with her at all. Her husband put up with restrictions in their sexual life; he did not have any lover. Four months before she parted with her lover, with whom she was going 3-4 months. She did not feel any aversion to him. With time, by means of long conversations she succeeded in making her husband completely take her part in the conflict with his parents, and the spouses even severed any contacts with them.
 Our additional examination succeeded in revealing a number of the patient’s characterological peculiarities, particularly histrionic personality disorder, this fact confirming our clinical observations. The following diagnosis was made: sexual aversion, absence of sexual desire (selective variants) with development by the conversion (hysterical) mechanism. Treatment was provided with help of cognitive effects and hypnosuggestive therapy (its seven sessions were given). The cognitive effects were targeted at the patient’s complete acceptance of the belief that her husband fully supported her at that time and was entirely reliable. It was explained that in some cases disorders might base on the mechanism of conditioned pleasantness/desirability (conversion mechanism). But it was done in a very nuanced and kind way, since a straight-line explanation of this mechanism (“it is in your interests”) may cause a negative response and the treatment may be discontinued by patients.
 It was pointed out that sexual dysfunctions could result from influence of psychological factors: her bad relationships with her husband’s parents and with him. Suggestion in the hypnotic state was particularly targeted at elimination of sexual aversion, appearance of sexual desire toward her husband, generation of pleasant sensations during his caresses and kisses, presence of voluptuous (lascivious) sensations in frictions during coitus. Sexual intercourses were modeled too. It was also suggested that her husband was her defender, he stood with her and was entirely reliable. As the result of the given treatment, sexual aversion to the patient’s husband was nullified and her sexual desire toward him was completely restored.

Malignant peripheral nerve sheath tumor of mesocolon: A rare case

Malignant peripheral nerve sheath tumor (MPNST) is a soft-tissue sarcoma arising from or differentiating toward peripheral nerve sheath cells. It accounts for 5%–10% of soft-tissue sarcomas. The most common sites of origin are proximal portion of upper, lower limbs and trunk. MPNST arising from the nerve plexus of gastrointestinal tract is extremely rare, and only very few cases have been reported in literature. In this report, we are describing a case of MPNST from mesocolon. An 82-year-old male presented to hospital with complaint of pain abdomen and feeling of lump on the left side of lower abdomen for the past 2 months. On contrast-enhanced computed tomography (CECT) of chest and abdomen, there was 15 cm × 10 cm mass palpable in left lumbar region without ascites and multiple random subpleural nodules in bilateral lung. Intraoperatively, there was 15 cm × 10 cm hard irregular mass in left paracolic gutter infiltrating mesentry of descending colon. Left hemicolectomy was performed with end-to-end anastomosis. Histopathological examination revealed malignant peripheral nerve sheath tumor, and on immunohistochemistry, tumor cells were positive for S-100 and negative for C-kit and Smooth Muscle Actin (SMA). The patient was started on tamoxifen in view of old age and lung metastasis. The patient is on follow-up from 2 years with stable disease. In this report, we highlight the possibility of clinical differential diagnosis of MPNST arising from mesocolon should be kept while dealing with mesenchymal tumors of colon. Radical surgery with negative margins is required for achieving palliation, and adjuvant tamoxifen could offer advantage in patient who cannot tolerate chemotherapy.

Laryngopharyngeal reflux: clinical significance, modern approaches to diagnosis and treatment

Gastroesophageal reflux disease (GERD) is one of the most common pathologies in modern clinical practice. Laryngopharyngeal reflux (LPR) is considered to be an extraesophageal manifestation of GERD and is characterized by retrograde ingestion of gastric content into the larynx and pharynx, leading to recurrent otolaryngological symptoms. Classical manifestations of LPR are hoarseness, perspiration, dryness and feeling of lump in the throat, coughing. There is no «gold standard» for the diagnosis of LPR. At the same time, several instrumental methods are used in clinical practice to verify the diagnosis: laryngoscopy and EGDS are the most common, and in some cases - 24-hour pH-metry and impedancemetry. In the case of an established diagnosis of LPR, it is recommended to use a standard dosage of PPI twice a day for 3–6 months.

Hepatic echinococcosis: A review.

Cystic echinococcosis (CE) is a widely endemic helminthic disease caused by infection with metacestodes (larval stage) of the Echinococcus granulosus tapeworm and transmitted by dogs. E. granulosus are common parasites in certain parts of the world, and are present on every continent with the exception of Antarctica. As a result, a large number of people are affected by CE. In humans, the disease is characterized by slowly growing cyst commonly occurring in liver and lungs. Clinical features are mainly right upper quadrant pain, feeling of lump and enlarged tender liver. The cyst may be complicated by infection or rupture and may lead to anaphylactic reaction. The diagnosis depends on clinical suspicion. They appear in two ways as general (systemic) symptoms, and local symptoms based on the site and organ on which the larva settles. While cysts sometimes recover spontaneously, more severe clinical presentations are observed in immunosuppressed individuals. Ultrasonography supported by serology is the main diagnostic modality. The treatment varies from surgical intervention to minimally invasive treatments (percutaneous drainage) or medical therapies. Surgery is still the best treatment modality. Percutaneous drainage of the cyst is a good option in selected cases. New sensitive and specific diagnostic methods and effective therapeutic approaches against echinococcosis have been developed in the last 10 years.

Reliability and validity of the Japanese version of the Glasgow Edinburgh Throat Scale (GETS-J): Use for a symptom scale of globus sensation

ObjectiveGlobus sensation, a feeling of lump or something stuck in the throat, could be caused by structural, functional, and psychogenic diseases. Due to a possible multifactorial nature of the disease, neither diagnosing test battery nor standard treatment for globus sensation has been established. Therefore, a questionnaire to accurately identify globus patients and evaluate the severity of the disease is desired. Glasgow Edinburgh Throat Scale (GETS) is a 10-item questionnaire about the throat symptoms consisting of three subscales relating to dysphagia, globus sensation, and pain/swelling in the throat. It was reported that globus patients marked high scores specifically for the globus scale among three scales, indicating that GETS can be used as a valid symptom scale for globus sensation. Aims of this study were to translate GETS into Japanese and to test its reliability and validity. MethodsFifty-five patients complaining of globus sensation without abnormal endoscopic and CT findings were enrolled into the study. They were asked to answer the questions of GETS translated into Japanese (GETS-J). Reliability (internal consistency) of the questionnaire was tested using Cronbach’s coefficient alpha. To test the validity, principal components analysis was used to identify the factorial structure of the questionnaire and GETS-J data were compared with those reported in the original GETS. Contribution of psychiatric comorbidities to globus sensation was also investigated by examining the correlation between Hospital Anxiety and Depression Scale (HADS) and GETS-J. ResultsReliability of the questionnaire examined by the Cronbach’s coefficient alpha was satisfactory and all higher than 0.75. Principal components analysis identified following three questions as the globus scale: Q1, Feeling something stuck in the throat; Q5, Throat closing off; Q9, Want to swallow all the time. Somatic distress, i.e., patients’ reaction to throat symptoms, was significantly correlated with globus scale (r=0.680). Anxiety component of HADS was significantly correlated with somatic distress but not with globus scale. These results were consistent with those of the original GETS except for the replacement of Q3 (discomfort/irritation in the throat) to Q5 (throat closing off) for globus scale in GETS-J. ConclusionTranslation of GETS into Japanese showed high reliability and validity, suggesting that translation and cross-cultural adaptation were not problematic. High correlation of globus scale of GETS-J with somatic distress indicated that GETS-J could be a useful questionnaire to identify the globus patients and evaluate the severity of the disease. Anxiety may complicate the somatic distress in patients with globus sensation.

An epidemiological study of foreign body sensation throat in the population of Garhwal region of Uttrakhand

Foreign body sensation or feeling of lump in throat is one of the commonest complaint, with which patient presents to ENT out patient’s department. The patient usually complains of “something being stuck in my throat” or “heaviness of throat” or “sticky sensation in throat”. Although sometime there may be a pathology found in the throat to go with the symptom but most of the time the symptoms are vague and after extensive workup also no significant cause could be found. This study aims at finding the diseases associated with the symptom along with the gender, occupational, regional propensity of the symptom amongst the population of Garhwal region of Uttrakhand. Keywords: Globu pharyngeus, Throat, Pharyngitis, Thyroid, Laryngitis

Teacher's voice: vocal tract discomfort symptoms, vocal intensity and noise in the classroom.

To identify a possible correlation between teachers vocal intensity and the noise in the classroom, as well as between vocal intensity and the symptoms of vocal tract discomfort before and after classes. 27 Elementary School I teachers participated in the study. We used the questionnaires "Vocal Production Condition of the Teacher" and "Vocal Tract Discomfort Scale - VTD" which were applied before and after the class. A properly calibrated noise meter was used for measuring noise in the classroom and the teachers' vocal intensity. There was a moderate positive correlation between vocal intensity and noise and also a significant difference between the VTD scale and the teachers with and without vocal complaint before and after classes. When compared separately on both occasions, there was an increase in the group's scores for both groups and with and without complaints. We found association of the vocal tract symptoms before and after classes, frequency of burning, itching, sore throat and sensitive throat were observed. The intensity of symptoms was significant for sore throat, itching and feeling of lump in the throat. We observed significant values of vocal intensity and frequency and intensity of symptoms for sensitive throat and lump in the throat before the class, and sore throat and lump in the throat after the. The increase in teacher's vocal intensity correlates to high noise levels in the classroom. The evidence suggests correlation between vocal intensity and discomfort of the vocal tract, with most of the symptoms reported in greater frequency and intensity after the class.

Cirugía reconstructiva de la pelvis en el prolapso genital severo con uso de prótesis anterior y fijación al ligamento sacroespinoso

Una alternativa con algunas ventajas e iguales resultados en el manejo quirúrgico del prolapso genital total para la fijación de la cúpula al sacro por vía abdominal es la fijación de la cúpula al ligamento sacroespinoso. Objetivo: Evaluar los resultados del empleo de malla anterior y fijación al ligamento sacroespinoso en el prolapso genital total. Diseño: Estudio retrospectivo y descriptivo. Institución: Servicio de Ginecología Especializada, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú. Participantes: Mujeres con diagnóstico de prolapso genital total. Método: Revisión retrospectiva de 12 pacientes con diagnóstico de prolapso genital total y que tuvieron cirugía reconstructiva pélvica con empleo de malla anterior y fijación al ligamento sacroespinoso. Principales medidas de resultados: Resultados de las técnicas. Resultados: La edad promedio fue 64 años. La comorbilidad principal fue la obesidad. La histerectomía abdominal fue el antecedente quirúrgico más frecuente. Se realizó histerectomía vaginal más colocación de malla anterior con fijación al ligamento sacroespinoso a tres pacientes, solo malla anterior con fijación sacroespinosa a cuatro pacientes, malla anterior con fijación sacroespinosa y malla transobturatiz (TOT) a tres pacientes, histerectomía vaginal con malla anterior, fijación sacroespinosa y TOT a dos pacientes. Como complicaciones hubo extrusión de malla en un paciente; dos pacientes a las que no se colocó TOT presentaron incontinencia de orina al esfuerzo, una urgencia miccional nueva, una dispareunia; dos pacientes presentaron granuloma de sutura y una refirió dolor pélvico inespecífico, síntomas que evolucionaron favorablemente. La evaluación del prolapso genital después de la cirugía no fue mayor de grado I. Conclusiones: Al fijar el compartimento apical al sacroespinoso mediante el uso de TOT y de la malla anterior garantizó que no se presentara incontinencia urinaria de esfuerzo, recidiva o aparición de defectos del compartimiento anterior.

Epithelial cyst of the spleen-a rare presentation.

Splenic cysts are rare and epithelial cysts are still rarer. Symptoms emerge because of enlargement, infection, hemorrhage, or ruptures. Traditionally, splenectomy was the treatment of choice. However, with the recognition of the important immunological function of the spleen, preservation procedures such as partial splenectomy or total splenectomy with splenorrhaphy have been increasingly used during the past decade. We report a case of a 23-year-old woman presented with left hypochondrial pain and feeling of lump.

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

Background Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair. Methods We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors. Results Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain ( P = .05), feeling of lump ( P = .02), and foreign body perception ( P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group ( P = .26). Conclusions A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.

The role of psychiatric factors in symptoms of hiatus hernia or gastric reflux.

The study comprised 26 patients with somatic symptoms indicating a hernia-reflux syndrome referred to a university hospital ear, nose and throat department. The aim was to throw light on the hypothesis that this syndrome is largely a psychosomatic problem. The patients were divided into two groups: subjects with and without laboratory findings of physical pathology of hernia and/or reflux. Intergroup comparisons were made of symptoms, a psychological test and psychiatric ratings. Those who had no laboratory findings of physical pathology often reported "phobia" and "feeling of lump in the throat", which were interpreted as signs of hysterical or somatizing mechanisms. Most of these patients showed a high level of anxiety in the psychological test. "Agitation", "depression" and "frustration" were characteristics of patients with laboratory findings of reflux. "Depression" was interpreted as a reaction to the somatic illness. The group with reflux contained more old male patients and that without more younger female patients.