Health Reference Center Research Articles

Pituitary Incidentaloma Complicated by Pan Hypopituitarism at the Health Reference Centre of Commune III of the District of Bamako: Case Report

A frequent mode of discovery since the improvement of imaging techniques is the pituitary incidentaloma, defined as the discovery of a pituitary adenoma without clinical signs on a scanner or magnetic resonance imaging (MRI) performed for another reason. We report a case of pituitary macroadenoma complicated by panhypopituitarism, discovered incidentally as part of the macroangiopathic complications of type 2 diabetes at the reference health centre in commune III of the Bamako district. It has poor semiological characteristics but poses a diagnostic problem. In our case, the patient presented with physical asthenia and headaches. On biology, the patient presented with 5 lines of anteropituitary insufficiency. A scan revealed a pituitary adenoma measuring 27x22. Anatomopathological examination of the surgical specimen concluded that it was a pituitary adenoma. The patient received hydrocortisone and thyroid hormones prior to excision. This case highlights the delay in the diagnosis and management of pituitary adenomas.

Influences on COVID-19 Vaccine Adherence among Pregnant Women: The Role of Internet Access and Pre-Vaccination Emotions.

The onset of the COVID-19 pandemic brought about global uncertainties and fears, escalating the dissemination of fake news. This study aims to analyze the impact of fake news on COVID-19 vaccine adherence among pregnant women, providing crucial insights for effective communication strategies during the pandemic. A cross-sectional, exploratory study was conducted with 113 pregnant women under care at a Women's Health Reference Center. Data analysis included relative frequency and odds ratio to assess the relationship between sociodemographic and behavioral variables regarding vaccination. In the behavioral context of vaccination, internet access shows a significant association with decision-making, influencing vaccine refusal due to online information. Nuances in the odds ratios results highlight the complexity of vaccine hesitancy, emphasizing the importance of information quality. Pre-vaccination sentiments include stress (87.61%), fear (50.44%), and anxiety (40.7%), indicating the need for sensitive communication strategies. Results revealed that pregnant women with higher education tend to adhere more to vaccination. Exposure to news about vaccine inefficacy had a subtle association with hesitancy, while finding secure sources was negatively associated with hesitancy. The behavioral complexity in the relationship between online information access and vaccination decision underscores the need for effective communication strategies. In the face of this challenging scenario, proactive strategies, such as developing specific campaigns for pregnant women, are essential. These should provide clear information, debunk myths, and address doubts. A user-centered approach, understanding their needs, is crucial. Furthermore, ensuring information quality and promoting secure sources are fundamental measures to strengthen trust in vaccination and enhance long-term public health.

Survey on the Quality of Dietary Diversification in Malnourished Children Aged 6 to 24 Months Hospitalised at the Ureni of the Reference Health Centre in Commune V of the Bamako District

Survey on the Quality of Dietary Diversification in Malnourished Children Aged 6 to 24 Months Hospitalised at the Ureni of the Reference Health Centre in Commune V of the Bamako District

Selection of the Discriming Feature Using the BEMD’s BIMF for Classification of Breast Cancer Mammography Image

Mammogram exam images are useful in identifying diseases, such as breast cancer, which is one of the deadliest cancers, affecting adult women around the world. Computational image analysis and machine learning techniques can help experts identify abnormalities in these images. In this work we present a new system to help diagnose and analyze breast mammogram images. To do this, the system a method the Selection of the Most Discriminant Attributes of the images preprocessed by BEMD “SMDA-BEMD”, this entails picking the most pertinent traits from the collection of variables that characterize the state under study. A reduction of attribute based on a transformation of the data also called an extraction of characteristics by extracting the Haralick attributes from the Co-occurrence Matrices Methods “GLCM” this reduction which consists of replacing the initial set of data by a new reduced set, constructed at from the initial set of features extracted by images decomposed using Bidimensional Empirical Multimodal Decomposition “BEMD”, for discrimination of breast mammogram images (healthy and pathology) using BEMD. This decomposition makes it possible to decompose an image into several Bidimensional Intrinsic Mode Functions “BIMFs” modes and a residue. The results obtained show that mammographic images can be represented in a relatively short space by selecting the most discriminating features based on a supervised method where they can be differentiated with high reliability between healthy mammographic images and pathologies, However, certain aspects and findings demonstrate how successful the suggested strategy is to detect the tumor. A BEMD technique is used as preprocessing on mammographic images. This suggested methodology makes it possible to obtain consistent results and establishes the discrimination threshold for mammography images (healthy and pathological), the classification rate is improved (98.6%) compared to existing cutting-edge techniques in the field. This approach is tested and validated on mammographic medical images from the Kenitra-Morocco reproductive health reference center (CRSRKM) which contains breast mammographic images of normal and pathological cases.

Epidemiological and Clinical Profile of Ectopic Pregnancy at the “Major Moussa Diakité” Reference Health Center in Kati

Introduction: Ectopic pregnancy is a common cause of morbidity and sometimes mortality in women of childbearing age [1]. Method: This was a descriptive cross-sectional study with retrospective data collection over a five-year period from January 1, 2019 to December 31, 2023. All cases of ectopic pregnancy received and taken were included in the study. In charge at the “Major Moussa DIAKITE” Reference Health Center in Kati during the study period. Results: out of a total of 26,133 live births, we managed 67 cases of ectopic pregnancy, i.e. a frequency of 2.5%. Married women (92.5%) and those with a history of sexually transmitted infections (35.8%) were the most affected. The average time from onset of symptoms to admission was 120 hours. The average gestational age at diagnosis was 14 weeks of amenorrhea (8 -20 weeks). The diagnosis was clinical in 62.2% of cases and in 37.8% on ultrasound coupled with hormonal dosage (B HCG). On admission the general condition of the patients was good in 60% of cases; with an average hemoglobin level estimated at 8.5 g/dl and the average hemoperitoneum volume was 925 milliliters. The ectopic pregnancy was ruptured in 98%, it involved the tubal ampulla in 88.1% of cases and the ovary in 2.9%. The contralateral appendix was clinically healthy in 91% of cases. The treatment was surgical from the outset in 98% of cases and one (01) case was medical (i.e. 2%) without success. Seven (07) patients or 10% were transfused. No maternal death was observed postoperatively. Conclusion: ectopic pregnancy was frequent in our structure; the diagnosis was essentially clinical and the treatment was surgical by laparotomy.

Childbirth Among Primiparous Versus Multiparous Women in the Gynecology and Obstetrics Department of the “Major Moussa Diakité” Reference Health Center in Kati/Mali

Introduction: The relationship between parity and pregnancy complications continues to arouse interest for obstetricians. Objective: To study childbirth among primiparous versus multiparous women in the gynecology and obstetrics department of the Kati reference health center. Method: We carried out a comparative, cross-sectional retrospective collection study covering primiparous and multiparous women over a period of 12 months (from January 1, 2021 to December 31, 2021) in the gynecology and obstetrics department of the health center. Reference “Major Moussa DIAKITE” from Kati. Results: out of a total of 3050 deliveries, primiparous women represented 12.8% and multiparous women 11.4%. The average age for primiparous women was 18.9 years with the extremes ranging from 15 years to 30 years and for multiparous women 29.3 years with the extremes ranging from 20 years to 45 years. They were almost completely married (primiparous 89.9% and multiparous 100%) and housewives (primiparous 65.0%; multiparous 87.7%), not in school (primiparous 63.0% and multiparous 74.5%). The total duration of labor was between 06-08 hours (primiparous 83% and multiparous 79.1%). The delivery was carried out vaginally (primiparous 87.8% and multiparous 79.1%). The APGAR score at the 1st minute was good (primiparous 89.8% and multiparous 93.4%). The complications found were dominated in first-time mothers by severe anemia (45.8%), and high blood pressure (47.9%). While in multiparous women they were severe anemia (45.8%), high blood pressure (41.7%) and postpartum hemorrhage (12.5%). We recorded no maternal deaths in either group. Conclusion: the maternal and perinatal prognosis of childbirth in primiparous women was almost similar to multiparous women. He was generally good in both groups.

Abstract PO5-17-07: MUCINOUS BREAST CARCINOMA: REAL WORLD DATA IN A REFERENCE CENTER IN SÃO PAULO

Abstract BACKGROUND: Mucinous breast carcinoma (MC) is a subtype of invasive carcinoma that corresponds to 1 to 6% of all types of breast cancer. It occurs when the mucinous component accounts for more than 50% of the tumor producing extracellular mucin in large scale. Mucin is a complex carbohydrate engaged in processes such as epithelial differentiation, adhesion modulation and cell signaling. Along with other special types of breast neoplasia, MC appears to have an unique behavior and, since it’s low amount of cases, a detailed clinical evaluation has been difficult. OBJECTIVES: To describe the profile of patients with breast MC that were treated in a reference center in São Paulo, Brazil as well as evaluate its management and outcomes. METHODS: A descriptive longitudinal observation study conducted at São Paulo’s Women’s Health Reference Center - Hospital da Mulher from July 2022 to January 2023, based on 192 medical records of patients diagnosed with MC from 2003 to 2018. RESULTS: 192 patient’s records were included. The age range was 31-93 years, out of which 74,3% of the patients were older than 50 when diagnosed. 48,7% identified as white and 43,7% showed earlier diagnoses of systemic hypertension. The time range between diagnosis and first treatment was 4,5 months. Out of the histopathological features, the nuclear grade was 3 in 69 patients (34,6% of the cases), and histological grade 1 in 52,7%. About pathological staging, the size of the tumors went form 0,5 to 9,5 cm, with an average of ± 4,7cm, the majority of them showed positive ER (89,4%), negative PR (85%), and were negative for Her-2 (76%). Greater number of patients (92,4%) went through both clinical and surgical treatment. Only 15 (7,5%) had isolated clinical treatment. 31% of the patients received systemic chemotherapy treatment, 25% of those were neoadjuvant. 81,9% of patients received aromatase inhibitor and only 17% radiotherapy. Distant metastasis were diagnosed in 27 patients (13,5%) and the local recurrence was observed in 15,3%. Out of distant metastasis, pulmonary type was more prevalent, registered in 45,7% of patients, followed by osseous (22,88%) and hepatic (14,2%). 33 patients (16,5%) progressed to death, however, the specific cause was not determined. CONCLUSION: MC is a rare subtype of breast cancer, more prevalent in post-menopausal and white women. Frequently shows low histological grade and positive hormonal receptors, which reinforces the idea of a indolent behavior. The treatment is mostly surgical, with adjuvance if necessary. Metastasis are infrequent and knowing the profile of patients with MC, as well as it’s behavior, allows the better management when facing this diagnosis. Citation Format: Marina Fleury De Figueiredo, Andre Mattar, Felipe Cavagna, Ana Lígia Minatel da Silva, Rafaella Nadai, Juliana Medeiros de Oliveira, Luma Fleury de Figueiredo. MUCINOUS BREAST CARCINOMA: REAL WORLD DATA IN A REFERENCE CENTER IN SÃO PAULO [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-17-07.

Corticosteroid Sclerotherapy of Morel-Lavallée Syndrome: about a Case at the Reference Health Center (CSRéf) Commune III of Bamako

Morel-Lavallée syndrome corresponds to a serolymphatic effusion secondary to tangential trauma in relation to a richly vascularized tissue. It is a pathology little mentioned in the medical literature. We report the case of a female patient, victim of a road traffic accident which caused a Morel-lavallée lesion and who was successfully treated by sclerotherapy with corticosteroid (triamcinolone). There is currently no universally accepted treatment algorithm for the management of Morel-Lavallée lesions. Corticosteroids constitute a valid therapeutic option as a sclerosing agent in the treatment of this pathology. Conclusion: Corticosteroids constitute a valid therapeutic option as a sclerosing agent in the treatment of Morel-lavallée syndrome with satisfactory results.

Acute Surgical Abdomens at the Dioila Reference Health Center

Objectives: To study acute surgical abdomens by describing the clinical, paraclinical and therapeutic aspects. Methodology: This was a retrospective descriptive study from July 2019 to June 2021 including all patients taken in the surgical unit for acute surgical abdomens. Results: In 24 months, we collected 117 cases of acute surgical abdomens, or 19.1% of surgical interventions. The mean age was 30.6 ± 16.95 years. The sex ratio was 1.78. The reason for consultation was abdominal pain (100% of cases). The stopping of materials and gases represented 10.3% of cases. Intraperitoneal collection was the most common ultrasound sign found in 47.1% of cases. Acute appendicitis was the most frequent intraoperative diagnosis in 60.7% of cases. The surgical procedure performed was appendectomy (71.8%). The average length of hospitalization was four days. Morbidity was 6.8%. We recorded two deaths. Conclusion: Acute surgical abdomens occupy an important place in surgery due to their high frequency. The care is multidisciplinary.

Perception and practice of self-medication by parents on their children: A study carried out in the saint joseph health area of Kisangani (The democratic republic of Congo)

Introduction: Self-medication is a major public health problem in view of the risks involved, such as therapeutic failures and the emergence of multi-resistant bacteria. The aim of the study is to demonstrate how self-medication of children is perceived by parents living in the Saint Joseph Health Area, to identify the satisfaction that parents derive from self-medication, to determine the way in which these parents self-medicate their children, and to present what parents can expect from self-medication. Methodology: This was a qualitative, phenomenological study based on free, face-to-face interviews. It concerned 4 mothers found in pre-school consultations at the Saint Joseph Reference Health Centre from June 15 to 30, 2023. Results: With regard to perception, the respondents had demonstrated the significance of self-medication, the determining factors, and their experience on this subject by often resorting to old prescriptions and medicine leaflets. Low income and the time it takes to get to the hospital were the determining factors. The respondents found self-medication satisfying. They were aware of the dangers and risks associated with self-medication. Risk prevention consisted of giving the child palm oil and skimmed milk. Their expectation of self-medicating was always to be cured. Conclusion: Self-medication in Kisangani is a real phenomenon, with the majority of parents practicing it for themselves and their children due to a lack of financial means, as medical care is expensive. Free medical care would be one way of combating this practice.

Tuberculous Spondylodiscitis or Pott's Disease: Diagnostic Problem of Patients Referred to the Reference Health Center (CSRef) Commune III of Bamako for Anti-Tuberculosis Treatment

Introduction: Tuberculosis is an infectious disease that can affect different organs. The spinal disorder is called tuberculous spondylodiscitis (Pott's disease). The objective: Was to elucidate the aspects taken into account by caregivers in the diagnosis of tuberculosis spondylodiscitis in patients referred to the reference health center of commune III of Bamako for anti-tuberculosis treatment. Methodology: This was a descriptive, retrospective study covering all patients referred to CSRef CIII from different health structures with the diagnosis of Pott's disease for treatment during the study period. Results: During the study period, we collected 156 patients. The male sex represented 54% with a sex ratio of 1.18. The average age was 39.3 years with extremes of 12 and 92 years. All patients presented with spinal pain, fever was present in 11.11% of patients and 2.7% had respiratory symptoms. Tuberculin IDR was positive in 95.8% and 2 patients were AFB sputum positive. X-ray (of the lumbar spine) was negative in 18%; there were images of degenerative lesions in 41.6% and only 40.2% of patients had presumptive radiological signs. CT was carried out in all patients revealing 33.33% of sequelae of fractures and degenerative lesions and 55.55% of presumptive signs of tuberculous spondylodiscitis. Only 41.66 of the cases were referred by specialist doctors. Conclusion: In our context, the diagnosis of Pott's disease seems to be based mainly on chronic spinal pain and positive IDR and is not often made by appropriate personnel.

Retinal Complications of Arterial Hypertension during Pregnancy in the Reference Health Center of Kalaban-Coro (Mali)

Our study aimed to investigate the retina complictions of arterial hypertension during pregnancy in the reference health center of Kalaban-Coro. This was a descriptive cross-sectional study over a period of five months from August 1 to December 31, 2021. It involved 185 hypertensive patients admitted to the gyneco-obstetrics department. The frequency of the association of high blood pressure and pregnancy was 18.84%. The most represented age group was 25-34 years with a frequency of 44,9%. Most of our patients had normal visual activity in both eyes. Retinal lesios were in 5,4%of patients. Retinal hemorrhage was the most frequent region with 80%. Only one patient had papilledema, including Stage III, hypertensive retionpathy whiich disppeared on the 30th day.

Chronic Pathologies Associated with Severe Acute Malnutrition in Children Hospitalised at the Ureni Reference Health Centre in Commune V

Introduction: The objective was to study chronic pathologies associated with severe acute malnutrition in children aged 6 to 59 months hospitalized at URENI. Methodology: This was a retrospective, descriptive and analytical study running from January 1 to December 31, 2017. Results: During the study period 352 children were hospitalized for severe acute malnutrition at the URENI of the CSREF CV. Among them, 18 presented a chronic pathology, i.e. a frequency of 5.11%. The male gender was predominant, i.e. 61.1% with a sex ratio of 1.57. The 12-24 month age group represented 50% of cases. Thirty-three percent of children had a history of neonatal resuscitation and 16.7% were formerly premature babies. Marasmus was of the severe acute malnutrition type the most represented, i.e. 77.8% of the cases. The association of malnutrition with HIV infection and Cerebral Palsy (CP) were accounted for 27.8% each. More than half of the patients (55.6%) stayed between 15 - 21 days in the structure. Conclusion: HIV infection and cerebral palsy constitute the chronic pathologies most associated with severe acute malnutrition in children at the Csref of commune V.

Sinonasal Inverted Papilloma: A Case Report from Mali

Inverted papilloma (IP) or also called Schneiderian Papilloma is an unusual and rare type of nasal tumor. Generally benign, but can have osteolytic powers and the possibility of transformation into malignancy during its evolution. Several hypotheses emerge in the literature, however the most frequent remains viral origin with the involvement of human papillomavirus (HPV). This is a case of bilateral inverted papilloma in a 60-year-old male patient at the Reference Health Center of the VI commune of the Bamako-Mali district. The symptoms appeared about 14 months ago, marked by a bilateral anterior rhinorrhea, of gradual appearance, associated with nasal obstruction, epistaxis, headaches and anosmia. Thus the diagnosis was made using physical examination and additional examinations such as the scanner of the facial massif, the anatomopathological examination of the operating room, and the test of the human papillomavirus, which turned out to be positive for HPV16 and HPV18. The management consisted of endonasal surgery, with the complete macroscopic removal of the mass and an average meatotomy accompanied by two years of follow-up after the surgical procedure. Since the PI is an aggressive tumor, its management must require long-term surveillance due to the possibility of recidivism and malignant degeneration finally to act early for these eventualities.

Experience of working women in Kisangani (DRC) on the practice of exclusive breastfeeding

Introduction: The aim of the study was to demonstrate working mothers' experience of exclusive breastfeeding, to identify what these working mothers expect from exclusive breastfeeding, to assess the satisfaction they derive from exclusive breastfeeding, to determine their representation of exclusive breastfeeding and to analyze their attitudes towards exclusive breastfeeding. Methodology: We used a qualitative and phenomenological approach, based on free direct interviews. It involved 5 working women found in pre-school consultations at the Saint Joseph Reference Health Centre from August 1st to September 12, 2023. Results: Respondents were aware of exclusive breastfeeding from a variety of sources. Almost all the respondents had practiced exclusive breastfeeding in spite of their daily occupations. They expected their children to be healthy and protected from illness. They had experienced satisfaction in practicing exclusive breastfeeding in spite of their daily occupations, but they were not so satisfied with the fact that in their workplaces there was no suitable space for practicing exclusive breastfeeding. The respondents were relatively convinced that breast milk provided good health for their children and was an ideal and natural means of contraception. Conclusion: The combination of work and exclusive breastfeeding is a serious problem for working women. Daily occupation could be a handicap for promoting exclusive breastfeeding.

Duplication of Hypospad of the Urethra Associated with Bulbar Stricture in a Young Man aged 29 Years: Case Report from the Urology Unit of the Bamako Commune I Reference Health Center

Duplication of Hypospad of the Urethra Associated with Bulbar Stricture in a Young Man aged 29 Years: Case Report from the Urology Unit of the Bamako Commune I Reference Health Center

Comparative Study of Extracapsular Extraction with Manual Sutureless Phaco Alternative in Cataract Surgery at the Reference Health Center in Ouelessebougou

Cataract is a significant public health issue in developing countries, necessitating surgical treatment. The aim of this study was to compare extracapsular extraction with manual sutureless phaco alternative in terms of outcomes and functionality. It was a prospective study conducted from June 2023 to December 2023, involving 200 eyes followed up to Day 30 at the secondary ophthalmology center in Ouelessebougou. Data were analyzed using IBM SPSS and Excel 2016 software. Almost all of our patients, 92% in Phaco-A and 89% in EECC+ICP, underwent biometry. At Day 30 postoperative with spectacle correction, phaco alternative yielded 82% good results compared to 60% for extracapsular extraction. At Day 30 with spectacle correction in Phaco-A, 91% of patients had good visual acuity compared to 75% in EECC+ICP. This result is comparable to those of Konaté M [17] and Windinmanegdé Djiguimdé et al., [18], who achieved 83.49% and 79.6% good visual acuities. Phaco alternative provides better postoperative results in cataract surgery at the secondary ophthalmology center in Ouelessebougou.

Low Birth Weight in the Gynecology-Obstetrics Department of the Commune I Reference Health Center in the District of Bamako

Low birth weight is an important public health indicator because of the strong association between birth weight and infant mortality and morbidity. The objectives were to determine the frequency of low birth weight, to describe the sociodemographic characteristics, to determine the risk factors associated with low birth weight and to determine the neonatal prognosis in the gynaecology and obstetrics department of the reference health center in Commune I of the Bamako district. Material and Methods: This was a cross-sectional, descriptive and analytical study in the department from 31 December 2020 to 30 June 2022. We carried out exhaustive sampling, taking into account all live newborns with a low birth weight. All newborns born in the department weighing between 500g and 2499g during the study period were included. Results: We recorded 4,292 births, 180 of which were low birth weight, giving an overall incidence rate of 4.2%. Of the 180 low birth weight babies, we found 111 cases of prematurity (61.7%) and 69 cases of hypotrophy (38.3%). We found that the proportion of low birth weight babies was higher in the young mothers in our study, at 60.5% for the under-19 age group. Our study showed that the extreme ages of the mother were a factor favouring or even predisposing to the occurrence of low birth weight. We noted a high frequency of primiparous women (38.7%) followed by multiparous women (32.5%). Other maternal risk factors included hypertension (8%) and a body mass index of less than 18.5% kg/m2 in 41.2% of cases. Half of the new borns (47.8%) weighed between [1501-2000g]. Among the transferred newborns, 53.3% received kangaroo mother care and 6.8% of the newborns died during the first thirty days of life. We recorded a mortality rate of 6.8%. Conclusion: Low birth weight is a public health problem because of its high prevalence and its harmful consequences, especially for infants.

The Role of Blood Transfusion in the Management of Obstetric Emergencies in the Gynaecological-Obstetrics department of the Reference Health Center of Commune I

It is a prospective and cross-sectional study, carried out at the Gynecological-Obstetrics department of the reference health center of commune I "Dr. Koniba PLEAH" from January 1, 2020 to December 31, 2020, i.e. 12 months. The main objective was to contribute to the study of the place of blood transfusion in the management of obstetric emergencies. During the study period, we recorded 480 cases of obstetric emergencies, of which 160 cases were emergency blood transfusions, i.e. 33.33%. Postpartum haemorrhage (PPH) was the first indication for blood transfusion with a frequency of 28.8% of patients. Management was based on: Blood transfusion with diversified PSLs (whole blood, CGR, PFC). MVA, salpingectomy, caesarean section, hysterorrhaphy, and hysterectomy.

Antibioprophylaxis in the General Surgery Department of the Commune 1 Reference Health Center in the District of Bamako

The aim of our study was to investigate antibiotic prophylaxis in the general surgery department of the C I commune referral health centre. This was a 12-month prospective study from 01 February 2021 to 31 January 2022 on antibiotic prophylaxis in general surgery. 129 patients were selected according to our inclusion criteria (patients who had received ceftriaxone at the time of anaesthetic induction. Patients belonging to Altemeier class I (clean surgery) with an infectious risk of estimated at 2 by the NNISS score and Altemeier class II (contaminated clean surgery). The antibiotic used was ceftriaz (ceftriaxone). The dose was two (2) grams. A single dose was given at the time of anaesthetic induction. The intravenous route was used exclusively. Patients underwent constant clinical monitoring. We had four (4) cases of surgical site infection (3.1%). The average post-operative hospital stay was two (2) days. Analysis of our results enabled us to identify a number of infectious risk factors: type of surgery, ASA score, emergency, anaemia and blood glucose level. Among the germs isolated, Escherichia coli was the most frequent (50%).