Medical Examiner System Research Articles

Reform of the death investigation system in Japan.

The autopsy rate in Japan is lower than that in other countries, and most death investigations have historically been conducted by police officers through external inspection. Although medicolegal autopsy was not performed during the samurai administration, the European death investigation system was adopted in the second half of the 19th century and judicial autopsy began in universities' forensic medicine departments. After World War II, the medical examiner system was introduced under US influence, but it was only adopted in certain areas. Further reforms were introduced in the 21st century-in 2012, two laws relating to death investigation were enacted: The Act on Promotion of Death Investigation (Promotion Act), which provided foundational principles and included measures for investigating the causes of death and identification of bodies, and the Act on the Investigation of Cause of Death and on Identification of Bodies Handled by the Police, which recommended a procedure for death investigation, including a new autopsy system.The Death Investigation Promotion Program was to meant to be decided by the government in 2014. However, the relevant Act expired after it ran out of time. Later, in 2019, the Basic Act for Promotion of Death Investigation, the successor to the Promotion Act, was passed. This Act is significant because it sets the basic foundational principle and imposes plans created by the government. However, it remains unclear how these measures can be implemented, so further discussion and financial investment are now required.

Establishing an enduring Military Trauma Mortality Review: Misconceptions and lessons learned.

Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III.

United States Special Operations Command fatality study of subcommands, units, and trends.

Death from injury occurs predominantly in prehospital settings. Injury prevention and prehospital care of military forces is the responsibility of combatant commanders. Medical examiner and trauma systems should routinely study fatalities and inform commanders of mortality trends. Data reported on US Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018, were reevaluated to compare subcommands, units, and trends. Injury was assessed by mechanism, severity, operational posture, and survivability. Death was assessed by manner, cause, classification, mechanism, and preventability. Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%), 67.6% occurred in the Army command, of which 49.2% occurred in the Special Forces command. Battle injury accounted for 60.1% of USSOCOM fatalities. Most battle-injured fatalities in each subcommand had nonsurvivable injuries and nonpreventable deaths. For each subcommand except Marine Corps, fatalities with nonsurvivable injuries sustained injuries primarily while mounted. By subcommand, the primary cause of death for fatalities with nonsurvivable injuries was blast for Army (57.6%), multiple/blunt force for Navy (60.0%), gunshot wound for Air Force (55.6%), and split between blast (50.0%) and gunshot wound (50.0%) for Marine Corps. For each subcommand except Air Force, fatalities with potentially survivable-survivable injuries sustained injuries primarily while dismounted, and the mechanism of death was primarily hemorrhage plus other mechanism or hemorrhage alone. Hemorrhage only mechanism of death was surpassed over time by complex multimechanism death. Potential for injury survivability and death preventability was greatest during early and later years of conflict. Organizational differences in mortality characteristics and trends were identified from which commanders can refine efforts to prevent and treat injury and improve survival. Fatality analyses inform operational risk matrices and advance casualty prevention and response efforts. Prevention, assessment, and treatment strategies must evolve to reduce death from hemorrhage plus coexisting mechanisms. Performance Improvement and Epidemiological, level IV.

Digital biomicroscopy system of compulsory preliminary and periodic medical examinations

The effectiveness of digital eye biomicroscopy in the system of mandatory, preliminary and periodic medical examinations was investigated. Proved highly informative method, the possibility of archiving, data transfer, use of Statistical methods that can be used both for the purpose of diagnosis and monitoring of various diseases.

Origins of the Armed Forces Medical Examiner System.

The Armed Forces Medical Examiner System (AFMES) is the only medicolegal death investigation system of the US federal government. Its origins can be traced to three dried tissue specimens placed on a shelf by a Civil War Surgeon General in 1862. The collections and the library of the Army Surgeon General spawned the Armed Forces Institute of Pathology (AFIP), the National Museum of Health and Medicine, the Walter Reed Army Institute of Research, and the National Library of Medicine. Pathologists of the Army Medical Museum performed the autopsies of assassinated Presidents Lincoln and Garfield and assisted with that of Kennedy. The now defunct AFIP created the first forensic pathology training program approved by the American Board of Pathology and then the AFMES. Col Ed Johnston, CAPT Charlie Stahl, and Col Dick Froede were the original pioneers of the AFMES.

Mathematical model for determining the effectiveness of medical examination of military personnel

The article is of interest to health professionals operating in the system of the Ministry of defense of Ukraine and Armed Forces of Ukraine and other state authorities, institutions and non-government organizations. Also, the results of the study will be useful to the representatives of the medical service, as service is a direct participant in the process of evaluating the effectiveness of the military personnel’s medical examination system. The place and role of the clinical examination of personnel in the health care system have been established. This has allowed to identify the internal and external factors in the context of the issues of this article. Internal and external factors were investigated in the context of managed and unmanaged factors. The paper presents a mathematical model of the medical care for servicemen who undergo medical examinations with using a semi-Markov random process. A quantitative criterion for the effectiveness of health care, called the employability ratio, is proposed. To establish the dependence of the employability ratio on the model parameters, an exponential law of time distribution between diseases was used. Such a law can be considered as a characteristic of the military personnel of a relatively young age. The results of this study are the starting point for solving the scientific task of substantiating the scientific and methodological apparatus for assessing the effectiveness of the prophylactic medical examination in the system of medical support of servicemen of the Ministry of defense of Ukraine and Armed Forces of Ukraine. In further studies will be shown the dependence of the employability ratio on the model parameters, as well as the cost of staying a serviceman in a healthy condition.

DETECTION RATE OF OCCUPATIONAL DISEASES IN PUBLIC HEALTH EMPLOYEES ACCORDING TO RESULTS OF MEDICAL INSPECTIONS

Introduction. This article presents the results on the detection rate of occupational diseases (OD) among health workers for an 18-year period (2000-2017) in the North-West Federal District (NWFD). The purpose of the study is to study the structure and dynamics of occupational diseases in medical workers during periodic medical examinations, to assess the effectiveness of the system of periodic medical examinations (PME), and to suggest ways to improve their effectiveness. material and methods. A retrospective analysis of archival data from 2000-2017 was performed on occupational morbidity of health care workers according to the materials of the North-West Scientific Center for Hygiene and Public Health and regional centers of occupational pathology of subjects of the North-West Federal District (N = 259), the average age of the surveyed is 46.1 ± 11.8 years, of which 231 (89%) women, 28 (11%) men, 80 surveyed (30.9%) have the status of a doctor, 124 (47.9%) - nurses and 55 (21.2%) - laboratory technicians, nurses, etc. Results. During the study period from 2000 to 2017 among the medical workers of the NWFD, 259 primary OD cases were officially identified. At the same time, the effectiveness of PME in medical workers was established to be very low. More than 7.2% of patients with OD signs were identified upon the fact that the patient actively sought medical attention. Even the system of clinical examination of the working population (where there is no explicit task to actively detect the OD signs) has a performance index by 3% higher than the PME. Conclusion. The problem we have touched upon is probably related to a complex of both medical (features of the organization of the PME system) and social factors (subjective assessments of the patient with respect to the prospect of benefits or negative effects in terms of continuing their professional career after official registration of the OD) in order to establish more accurately long laborious research.

IMPROVING THE CRITERIA FOR THE EXPERTISE OF PROFESSIONAL SUITABILITY AS ONE OF THE CONDITIONS FOR CONSERVATION OF PROFESSIONAL HEALTH OF MEDICAL WORKERS

Introduction. Among medical workers, both in the Russian Federation and in foreign countries, a significant number of people with chronic diseases are identified. This problem is already noted among medical students. In such a situation, an effective system of examination of the professional fitness of medical workers is necessary. Its goal is to prevent specialists with health disorders from working in harmful and dangerous conditions, which create a real risk of progression of existing diseases. Material and methods. The authors analyzed the regulatory acts of the Russian Federation, determining the procedure for the examination of the professional working ability of medical workers. The adequacy and possible effectiveness of these acts were evaluated on the basis of the practical experience of the occupational physician. Results. The existing system of medical examinations of applicants of medical schools does not allow to assess the risk of deterioration of their health disorders in the process of possible future work. Periodically, there are situations when a student with a health disorder receives training in a medical specialty, the work in which will then be recognized as contraindicated. The current system of examination of professional fitness in a number of cases allows the adoption of obviously illogical decisions concerning medical workers. This is possible both with regard to the prohibition to perform hazardous work, as well as with regard to the permission to perform them. Conclusion. Normative acts in this area need for substantial reforms. Medical examinations of enrollees and students of medical schools should be able to determine the risk deterioration of health in the event of exposure to all harmful occupational factors typical for medical workers. The increased intensity of the labor process must be included in the list of harmful occupational factors, under the influence of which expertise is necessarily carried out for th eoccupational suitability. When employing medical workers, the examination of professional fitness should be based on a risk-oriented approach.

Advancing mitochondrial genome data interpretation in missing persons casework

Massively parallel sequencing techniques have made possible the adoption of mitogenome sequencing for missing persons casework. In order to expand the family pedigree and population data necessary for sequence comparisons and statistical analysis, complete mitochondrial genome (mitogenome) haplotypes were generated by the Armed Forces Medical Examiner System’s Armed Forces DNA Identification Laboratory using an automated laboratory workflow and robust analysis pipeline. Over 600 CEPH family pedigree samples from 87 lineages were processed in order to characterize the expected number of differences in mitogenome sequences between maternal relatives. Although stochastic artifacts in the CEPH cell lines elevated the point heteroplasmy rate three-fold compared to population sample data (1.8 vs. 0.46 point heteroplasmies per individual, on average), the CEPH family sequences exhibited a maximum of two substitutions between any two maternal relatives in nearly 500 generational events. The family study furthermore showed that elevating the variant detection threshold may create false substitutions at heteroplasmic sites. Results from an initial 2000 reference database samples indicate a first-pass success rate of 85%, with 97% unique mitogenome haplotypes. These data demonstrate advancements made toward the interpretation of mitogenome sequence data in missing persons casework.

Extraction of DNA from skeletal remains buried in acidic soils

The Armed Forces Medical Examiner System – Armed Forces DNA Identification Laboratory (AFMES-AFDIL) and the Defense POW/MIA Accounting Agency (DPAA) are partners in the identification of missing United States service members. Skeletal materials are recovered world-wide from past military conflicts; however, this project examines the relative success of skeletal materials recovered from Southeast Asia. The soils in Southeast Asia are known to be largely acidic, with the majority being classified as acrisol or gleysol (pH4.4–7.2). Acidic soils are thought to compromise the structural integrity of buried skeletal materials leading to a degradation of the DNA found within. This study evaluates whether this idea is apocryphal or if acidic soils truly have an impact.

Sequencing of full mitochondrial genomes for NIST population samples

The U.S. National Institute of Standards and Technology in collaboration with the Armed Forces Medical Examiner System’s Armed Forces DNA Identification Laboratory has undertaken a population sequencing study of 607 mitochondrial genomes (mtGenomes). The goal of the study is to increase the availability of high-quality whole mtGenome sequences for haplotype frequency estimations, allowing the increased discrimination power of the entire extranuclear genome to be used. Whole mtGenome sequencing is enabled by next generation sequencing workflows, which are vastly simplified compared to Sanger-type sequencing. Here we evaluated the relative performance of mtGenome versus sequencing the control region of the mtGenome alone.

Relationship of health literacy with utilization of health-care services in a general Japanese population.

Many studies have explored the association between health literacy and health-care utilization; however, the majority assessed functional health literacy in terms of basic skills. Japan's health-care and medical examination system in workplaces is different from that of other major countries. This study examined the relationship of health literacy with health-care use (emergency visit, hospitalization, dental checkup, and health checkup or cancer screening); it focused on differences by occupation and health-care service utilization among general Japanese using the communicative and critical health literacy scale. We conducted a cross-sectional observational study of 1002 Japanese residents. Through a questionnaire, we investigated socioeconomic status, health status, health-care use, and health literacy. Among all participants and non-workers, logistic regression analyses revealed that health literacy was significantly associated with health checkup or cancer screening after adjusting for sex, age, marital status, education, and having a disease or disorder (adjusted odds ratio [OR] = 1.431, 95% confidence interval [CI], 1.131–1.810; adjusted OR = 1.614, 95% CI, 1.114–2.339, respectively). Among workers, we observed no significant association between health literacy and health-care utilization. These results indicate that health literacy is closely related to use of preventive health-care. Japan's health-care system in workplaces may promote use of preventive health-care services regardless of health literacy, whereas improving health literacy may be more critical among non-workers.

Author response: Underestimation of sudden deaths among patients with seizures and epilepsy.

We appreciate the constructive comments by Dr. Giannouli in response to our article on the underestimation of sudden unexpected death in epilepsy (SUDEP).1 We agree that patients with epilepsy, parents of children with epilepsy, and caretakers of disabled adults with epilepsy should be educated about the risk factors for SUDEP. We also agree that there is a need for more systematic surveillance of SUDEP through collaborative efforts of medical examiners, coroners, and neurologists. However, the medical examiner systems in the United States, and many other countries, are understaffed to accomplish the systematic review of cases that we were able to accomplish with the support of NIH funding. It is essential that all who experience sudden death be evaluated for a history of seizures by interviewing family members and others and reviewing medical records. However, many victims of SUDEP come from lower socioeconomic groups with limited access to neurologic care, newer medications, and epilepsy surgery. We have a long way to go on many fronts to understand and prevent SUDEP.

Editors' note: Underestimation of sudden deaths among patients with seizures and epilepsy

In “Underestimation of sudden deaths among patients with seizures and epilepsy,” Devinsky et al. aimed to determine the definite and potential frequency of seizures and epilepsy as a cause of death and how often this goes unrecognized. Commenting on the article, Dr. Gionnouli discusses the need for better education on the risk factors for sudden unexplained death in epilepsy and the need for better systematic surveillance through collaborative efforts of medical examiners, coroners, and neurologists. Devinsky et al., authors of the study, agree and lament the understaffing of the medical examiner systems and stress the importance of thorough evaluation of patients who experience sudden death. In “Underestimation of sudden deaths among patients with seizures and epilepsy,” Devinsky et al. aimed to determine the definite and potential frequency of seizures and epilepsy as a cause of death and how often this goes unrecognized. Commenting on the article, Dr. Gionnouli discusses the need for better education on the risk factors for sudden unexplained death in epilepsy and the need for better systematic surveillance through collaborative efforts of medical examiners, coroners, and neurologists.

Coagulopathy and Mortality in Combat Casualties: Do the Kidneys Play a Role?

Acute traumatic coagulopathy (ATC) is a common condition after traumatic injury and is known to be associated with an increase in morbidity and mortality in trauma patients. ATC has been implicated as a causative factor in both early hemorrhage and late organ failure in this population, yet the pathophysiology remains largely unknown. Additionally, acute kidney injury (AKI) is a common condition among critically injured trauma patients. AKI has been associated with an elevated International Normalized Ratio (INR) and warfarin use, but its development has not been well studied in the setting of ATC. We hypothesized that the presence of ATC influences the development of AKI and may mediate mortality in combat casualties. Data were obtained from the Department of Defense Trauma Registry, Medical Data Store and Composite Healthcare System, and the Armed Forces Medical Examiner System. A retrospective review was conducted of US service members injured in Iraq or Afghanistan between February 1, 2002 and February 1, 2011, who required ICU level care and survived evacuation out of theater. Exclusions were made for missing data. Cox proportional hazard regression was performed to determine the effect of ATC (a priori defined as first INR > 1.3) on the development of AKI. Further analysis was conducted to determine the influence of these variables on 30-d mortality, and multiple sensitivity analyses were performed to determine the effect of ATC on both AKI and mortality. A total of 1,288 patients were identified for analysis. ATC was a risk factor for subsequent AKI after adjustment (HR 1.67, 95% CI 1.28-2.18; p < 0.001). However, ATC was not a risk factor for mortality after adjustment in the full model (HR 1.87, 95% CI 0.95-3.65; p = 0.069). On sensitivity analyses exploring alternate definitions of ATC, an INR of 1.2 remained associated with AKI (HR 1.46, 95% CI 1.13-1.88; p = 0.004) and an INR of 1.5 became significant for mortality (HR 1.76, 95% CI 1.32-2.35; p < 0.001). ATC is independently associated with the development of AKI. Although ATC is associated with mortality in the unadjusted model, it is not significant after adjustment for AKI. This implies that the kidneys may play a role in the adverse outcomes observed after ATC. Increased awareness and monitoring for coagulopathy and the subsequent development of AKI in combat casualty patients may lead to earlier diagnosis and treatment of these conditions, possibly decreasing morbidity and mortality.

Deaths due to electrocution: An evaluation of death scene investigations and autopsy findings

The purpose of the study was to delineate the epidemiological characteristics of electrocution deaths in Maryland, identify any potential risks, and address preventive measures. A retrospective review of all the deaths due to electrocution was conducted at the Office of the Chief Medical Examiner in the State of Maryland from 2005 to 2015. During the 11-year period, a total of 55 electrocution deaths were identified from the autopsy cases at the statewide medical examiner system. More males died of electrocution than females with its ratio of (M: F) = 9:1. Of the 55 cases, 67.3% were White, 18.2% were African-American, 12.7% were Hispanic, and 1.8% were other races. The age of the victims ranged from 4 to 83 years with mean age of 40 years. >96% deaths due to accidents and 3.4% were suicide. The majority of deaths (70.9%) were caused by high-voltage circuits. Approximately 64% of fatalities were work-related accidents. The study indicated that electrocution deaths frequently affected young male workers who were in contact with a high-voltage currents while on the job. The detailed death scene investigation and autopsy findings are presented. The potential hazards of electricity must continue to be addressed in public safety campaigns to prevent such deaths. Strategies should ensure safe work environments for any contact with electric currents.

Selection and Management of Medical Official during the Yuan Dynasty.

Although the healthcare system of the Yuan Dynasty followed that of the Song Dynasty, there are certain differences between these two dynasties in terms of practices. Including appointing 'Yihus' in 'Zhusehuji' and setting up 'Guanyitijusi' to oversee Yihus, the Yuan Dynasty developed an effective management system for their physicians and, soon after the coronation of Khubilai, built 'Yixue (Medical school)' all over its territories in order to establish an organized and substantial medical training system. Moreover, the Yuan Dynasty not only revived the civil service examination system system between 1314 and 1320 as well as the medical examination system, but also increased the quota for qualification to twice that of Confucian examination in Song. These changes resulted in producing many brilliant people at the time. In the second half of the reign of Emperor Chengzong it was decided that the incompetence of the government healthcare organizations and the abundance of charlatans could not be neglected any longer. Existing policies and systems was limited in educating and training proper physicians, and this problem was not restricted to the field of medicine. The need for new systems that could reform the social order led to the restoration of the civil service examination system. The civil service examination system for Confucianism and for medicine began in 1314 and 1316, respectively. The purpose of the medical examination system was to select medical officials. The medical examination system which started in 1316 had a significant impact on the medicine of the Yuan dynasty for many reasons. Firstly, the qualification to apply to the medical examination did not remain constricted to 'Yixue' but opened to all 'Zhusehuji'; and secondly, the examination system did not have a restriction on the number of applicants was not restricted. The most important aspect of the examination system was that the number of test takers that passed the first test was one hundred and the number of passers of the second test were thirty, which were not low compared to the number of passers of the Confucianism examination. As such, the impact of the medical examination on the Yuan society was substantial. The Confucian examination selected 300 persons to pass the first test. The second test had 100 test takers which was equally divided among the four social classes at 25 percent each. The medical system selected 100 persons in the first test and 30 in the second. What is important is that unlike the Confucian examination system, the medical system was not divided into four classes. Hypothetically, the 30 qualified persons could all be South Chinese. In terms of the number of passers, it was much more promising for the South Chinese to flourish through the medical test than through Confucian examination test. Such facts support the claim that the Yuan Dynasty emphasized the field of medicine compared to the Song Dynasty. Although the Song Dynasty implemented the civil service examination system early on, the medical system was not implemented until 1115, which started with the founding of 'Yixue' across the country and assigning student capacity. During the Song Dynasty, the number of students in the medical system was 15 percent of that in the Confucianism system, and compared to that in Yuan, it raised to 30 percent, which is twofold. The indications of the Yuan Dynasty valuing medicine and making an effort to educate and train medical experts can be seen in the 'Yihu system', 'Guanyitijusi', Yixuetijusi', and medical school as well as the ratio of the medical system capacity.

THE ROLE OF MEDICAL EXAMINATIONS IN PREVENTING SUDDEN DEATH AMONG MILITARY PERSONNEL

Objective. Stratify the risk of sudden cardiac death in the military, depending on the findings of the medical examination of cardiac rhythm and conduction disorders. Materials and methods. An analysis of medical documents of 254 servicemen, recognized by the military medical commission (therapeutic) profile of the S. M. Kirov Military Medical Academy, that are limited to fit and not fit for military service, was conducted. Based on the classification of the risk of sudden cardiac death, proposed by R. Fogoros, the stratified military personnel were assessed for the risk of sudden cardiac death, based on the cardiac arrhythmias. Results of the study. According to the results of the work, it is shown that every third serviceman, recognized by the military medical commission as being limited to fit or not fit for military service, was recognized as such because of his cardiac arrhythmias and conduction. Only 13.2% of military personnel with cardiac rhythm and conduction disorders had a structurally normal heart. 51.8% of the surveyed military personnel with cardiac arrhythmias and conduction had a low risk of sudden death, 42.2% had an average risk of sudden cardiac death, and 6% had a high risk. Conclusion. The system of medical examination of servicemen based on the results of the survey allows stratification of military personnel in the risk of sudden cardiac death and, subject to this, make a legally meaningful decision on its category of fitness for military service (4 tables, bibliography: 8 refs).

Beyond the Forensic Pathology Investigation: Improving Warfighter Survivability.

The Armed Forces Medical Examiner System (AFMES) conducts forensic pathology investigations in accordance with Title 10 U.S. Code 1471. Since 2004, the AFMES has incorporated advanced radiologic imaging, such as computed tomography, into its protocol. This incorporation has led to increased fidelity in depicting injuries, efficient localization of foreign bodies, and the ability to accurately document medical therapy - all of which enhance the forensic pathology investigation. As with most jurisdictions, information contained in the forensic pathology investigation is disseminated to family members and criminal investigating authorities. In addition, AFMES also disseminates information regarding the location of resuscitative devices to casualty care providers and trainers, collaborates with trauma physicians and medical providers in regards to evaluating injuries and treatment for the assessment of potential improvements in medical care and survivability, and provides information and subject matter expertise to investigative boards and other organizations that reconstruct fatal events. The overarching goal of these additional collaborations is to enhance the understanding of the nature of traumatic injuries, improve casualty care, and ultimately decrease morbidity while improving survivability.

선원의 정기건강검진 만족도에 관한 연구

This research is conducted to investigate the system of Periodic medical Examination for seamen and the satisfaction of items through the questionnaire analysis of the 386 respondents, in order to provide the Periodic Health Examination are made for the specific characteristic of seafarers. The result shows high figures in the Periodic Health Examination system satisfaction with age, rank, and career (p 0.01, p 0.05), however, the satisfaction level with examination items was lower than the Periodic Health Examination system. Also, the numbers was not statistically significant. The needs for cancer and cerebral-cardiovascular disease tests were high on next checkups. Furthermore, it was found that the post-care management for seamen was weaker compare to in-land workers. After considering all the factors, it is required to select the appropriate items of Periodic Health Examination for the work characteristics with more various researches, and supplement the policy in post-care management urgently.