La proprioception cervicale joue un rôle important dans le contrôle postural, mais la nature exacte de sa contribution est controversée. Dans certains cas de « coup du lapin », une atteinte posturale a été démontrée, sans que l'atteinte du rachis cervical puisse être tenue pour seule responsable. Malgré la forte prévalence des pathologies cervicales dégénératives, leurs conséquences posturales ont été peu étudiées dans la littérature scientifique. Il n'existe aucune publication centrée sur les deux types de pathologie responsables de névralgies cervicobrachiales : les hernies discales cervicales et l'arthrose cervicale. Cette étude a eu pour but d'évaluer le contrôle postural de deux groupes de patients présentant une pathologie cervicale dégénérative avec et sans stimulation optocinétique avant et après traitement chirurgical. Dix-sept patients présentant une radiculalgie ont été inclus dans cette étude et répartis en deux groupes selon l'origine arthrosique ou discale de la compression neurologique. Tous les patients ainsi que 31 témoins ont été soumis à un examen de posturographie statique comprenant 12 enregistrements : les quatre premiers enregistrements ont été réalisés la tête dans l'axe (à 0°) : yeux fermés, yeux ouverts sans stimulation optocinétique, yeux ouverts avec stimulation optocinétique dans le sens horaire, puis antihoraire. Ces quatre situations sensorielles ont été répétées tête tournée 30° à gauche, puis 30° à droite. Les patients ont à nouveau été soumis à ces 12 enregistrements six semaines après l'intervention. Aucun patient ne s'est plaint de sensations vertigineuses que ce soit en pré ou en postopératoire. Avant intervention, les yeux fermés, le groupe hernie discale était plus stable que le groupe arthrose. Après intervention, la contribution visuelle au contrôle postural avait diminué dans les deux groupes dans un environnement visuel dynamique, alors que dans un environnement visuel stable, elle n'avait diminué que dans le groupe arthrose. L'importance relative des informations visuelles et proprioceptives pour le contrôle postural varie selon le type de pathologie et la chirurgie tend à réduire la contribution visuelle surtout pour les patients présentant une arthrose cervicale / Cervical proprioception plays a key role in postural control, but its specific contribution is controversial. Postural impairment was shown in whiplash injuries without demonstrating the sole involvement of the cervical spine. The consequences of degenerative cervical spine diseases are underreported in posture-related scientific literature in spite of their high prevalence. No report has focused on the two different mechanisms underlying cervicobrachial pain: herniated discs and spondylosis. This study aimed to evaluate postural control of two groups of patients with degenerative cervical spine diseases with or without optokinetic stimulation before and after surgical treatment. Seventeen patients with radiculopathy were recruited and divided into two groups according to the spondylotic or discal origin of the nerve compression. All patients and a control population of 31 healthy individuals underwent a static posturographic test with 12 recordings; the first four recordings with the head in 0° position: eyes closed, eyes open without optokinetic stimulation, with clockwise and counter clockwise optokinetic stimulations. These four sensorial situations were repeated with the head rotated 30° to the left and to the right. Patients repeated these 12 recordings 6 weeks postoperatively. None of the patients reported vertigo or balance disorders before or after surgery. Prior to surgery, in the eyes closed condition, the herniated disc group was more stable than the spondylosis group. After surgery, the contribution of visual input to postural control in a dynamic visual environment was reduced in both cervical spine diseases whereas in a stable visual environment visual contribution was reduced only in the spondylosis group. The relative importance of visual and proprioceptive inputs to postural control varies according to the type of pathology and surgery tends to reduce visual contribution mostly in the spondylosis group

Submitted by SBI Biblioteca Digital (sbi.bibliotecadigital@puc-campinas.edu.br) on 2018-05-04T14:27:54Z No. of bitstreams: 1 RODRIGO MASELLI THOM? GARCIA.pdf: 1139747 bytes, checksum: 918a44a313fb8cf1d56fef9b097af761 (MD5) / Made available in DSpace on 2018-05-04T14:27:54Z (GMT). No. of bitstreams: 1 RODRIGO MASELLI THOM? GARCIA.pdf: 1139747 bytes, checksum: 918a44a313fb8cf1d56fef9b097af761 (MD5) Previous issue date: 2018-02-28 / Introduction: Acute Scrotum Syndrome is a medical emergency. Some children and adolescents cannot be cared for by a specialist or accustomed to this pathological condition of the acute scrotum, especially torsion of the spermatic cord, also called testicular torsion. Delays in care, misinformation by patients, family members or healthcare professionals can cause irreversible damage to the patient. Objective: to correlate factors that delayed the diagnosis and treatment of acute scrotal syndrome with loss of testis. Method: The charts of 127 patients from March 2007 to May 2017 were analyzed in the Patient Record Services of Hospital e Maternidade Celso Pierro. Patients who underwent surgery are included in the study (n = 71). Patients with incomplete records, age greater than 18 years or who did not undergo surgical treatment were not included in the study (n = 56). Exploratory data analysis was performed through descriptive measures (mean, standard deviation, minimum, median, maximum, frequency and percentage). Orchiectomy and orchidopexy groups were compared using the Mann-Whitney test (age, distance from the house to the hospital, time of symptoms and time in the Hospital e Maternidade Celso Pierro) or Qui-Square (race, agreement, side affected and pr?-hospital care). Factors related to orchiectomy were assessed through Logistic Regression. In the multiple analysis, the variable selection criterion used was stepwise. The level of significance was 5%. Results: Among the 71 patients diagnosed with Acute Scrotum Syndrome undergoing surgery, 22 (31%) were between 0 and 12 years of age and 49 (69%) were older than 12 years. It was evidenced that there is significant difference between the groups for the variables that measure time. The time of symptoms and time of Hospital e Maternidade Celso Pierro is greater for the orchidectomy group. For the other variables, no significant differences were found between groups. The group of patients most submitted to orchiectomy are non-white patients, with no private medical insurance, right testicle affected and without pr?- hospital care. On the other hand, the group of patients most submitted to orchidopexy are the whites, also without private medical care or pre-hospital care and the affected left testicle. The 1 hour increase in symptom time increases the chance of orchiectomy by 4%. The 1 hour increase in Hospital e Maternidade Celso Pierro increases the chance of orchiectomy by 0.2%. Conclusion: Elapsed time of symptoms remains the main factor associated with loss of the testis in Acute Scrotum Syndrome and torsion of the spermatic cord. Even without data with statistical significance, we can also conclude that this study showed that patients with more than 12 years of age, not white, with right side affected, without private medical care and pr?-hospital care are the most submitted to orchiectomy. / Introdu??o: a S?ndrome do Escroto Agudo configura uma emerg?ncia m?dica. Algumas crian?as e adolescentes n?o conseguem ser atendidas por um profissional especializado ou habituado nessa condi??o patol?gica do escroto agudo em especial a Tor??o do Cord?o Esperm?tico, muito chamada tamb?m de tor??o testicular. A demora no atendimento e tratamento desses pacientes, desinforma??o dos pr?prios pacientes, familiares ou profissionais da ?rea da sa?de podem causar danos irrevers?veis ao test?culo. Objetivo: correlacionar fatores que atrasaram o diagn?stico e tratamento da s?ndrome do escroto agudo com a perda do test?culo. M?todo: os prontu?rios de 127 pacientes desde mar?o de 2007 a maio de 2017 foram analisados nos Servi?os de Prontu?rio de Pacientes do Hospital e Maternidade Celso Pierro. Os pacientes que foram submetidos ? cirurgia est?o inclusos no estudo (n=71). Pacientes com prontu?rios incompletos, idade maior que 18 anos ou que n?o foram submetidos ao tratamento cir?rgico n?o foram inclu?dos no estudo (n=56). Foi realizada an?lise explorat?ria de dados atrav?s de medidas descritivas (m?dia, desvio padr?o, m?nimo, mediana, m?ximo, frequ?ncia e porcentagem). Os grupos de orquiectomia e orquidopexia foram comparados atrav?s do teste de MannWhitney (idade, dist?ncia da casa at? o hospital, tempo de sintomas e tempo no Hospital e Maternidade Celso Pierro) ou Qui-Quadrado (etnia, conv?nio, lado acometido e atendimento pr?-hospitalar). Os fatores relacionados ? orquiectomia foram avaliados atrav?s de Regress?o Log?stica. Na an?lise m?ltipla o crit?rio de sele??o de vari?veis usado foi o stepwise. O n?vel de signific?ncia adotado foi de 5%. Resultados: Entre os 71 pacientes avaliados com o diagn?stico de S?ndrome do Escroto Agudo submetidos ? cirurgia, 22 deles (31%) tem idades entre 0 e 12 anos e 49 (69%) tem idades maior que 12 anos. Evidenciou-se que existe diferen?a significativa entre os grupos para as vari?veis que medem tempo. O tempo de sintomas e tempo de Hospital e Maternidade Celso Pierro ? maior para o grupo de orquiectomia. Para as demais vari?veis n?o foram encontradas diferen?as significativas entre os grupos. O grupo de pacientes mais submetidos ? orquiectomia s?o os n?o brancos, sem conv?nio m?dico particular, test?culo direito acometido e sem atendimento pr?-hospitalar. J? o grupo de pacientes mais submetidos ? orquidopexia s?o os brancos, tamb?m sem conv?nio m?dico particular ou atendimento pr?-hospitalar e test?culo esquerdo acometido. O aumento em uma hora no tempo de sintomas aumenta a chance de orquiectomia em 4%. O aumento em 1 hora no tempo de Hospital e Maternidade Celso Pierro aumenta a chance de orquiectomia em 0,2%. Conclus?o: o tempo decorrido de sintomas ainda permanece o principal fator associado ? perda do test?culo na S?ndrome do Escroto Agudo e Tor??o do Cord?o Esperm?tico. Mesmo sem dados com signific?ncia estat?stica, podemos concluir tamb?m que esse estudo mostrou que os pacientes com mais de 12 anos, n?o branco, com lado direito acometido, sem conv?nio m?dico particular e atendimento pr?-hospitalar s?o os mais submetidos ? orquiectomia.

The obstructive sleep apnea and hypopnea syndrome (OSAS) is characterized by repeated episodes of complete or partial interruption of the airflow as consequence of upper airway obstruction during sleep. Indications for the surgical treatment of OSAS, as well as the evidence on the efficacy and safety of the surgical techniques available merit further scientific scrutiny. Objective: To perform a systematic review on the efficacy of genioglossus advancement (GA) when compared to maxillomandibular advancement (MMA) for the treatment of patients with OSAS. Method: A systematic electronic search was conducted in the LILACS, PubMed and SciELO databases to identify studies involving patients undergoing MMA and GA for the treatment of OSAS. The guidelines presented by the PRISMA statement were followed. The eligible articles were subjectively evaluated regarding their methodological quality based on a checklist of the Critical Appraisal Skills Programme (CASP). A meta-analysis was carried out with the aid of RevMan. Results: The systematic literature search resulted in 889 records, of which 41 articles were examined for their content. After full text analysis, six studies were included in this review and allowed for inferences about the efficacy of surgical procedures at hand. Conclusion: GA showed lower treatment efficacy, as evidenced by the apnea-hypopnea index recorded by polysomnography. The results of the meta-analysis show that the MMA is superior to GA in the context of surgical treatments for OSAS. / A Síndrome da Apneia e Hipopneia Obstrutiva do Sono (SAHOS) caracteriza-se por repetidos episódios de interrupção completa ou parcial do fluxo de ar inspirado durante o sono em função da obstrução das vias aéreas superiores. Os critérios para a indicação de tratamento cirúrgico da SAHOS, bem como as evidências sobre a eficácia e segurança das técnicas cirúrgicas que impactam as vias aéreas superiores ainda merecem exploração científica adicional.Objetivo: Avaliar, por meio de uma revisão sistemática, a eficácia do avanço do músculo genioglosso (AMG) comparado ao avanço maxilo-mandibular (AMM) no tratamento de pacientes com SAHOS.Método:uma busca eletrônica sistemática foi realizada nas bases de dados LILACS, PubMed e SciELO com o intuito de identificar estudos com pacientes submetidos a cirurgia de avanço maxilo-mandibular e avanço do musculo genioglosso para o tratamento da SAHOS. A metodologia seguiu as diretrizes do PRISMA statement.Os artigos elegíveis foram avaliados subjetivamente quanto à qualidade metodológica com baseem um dos questionários do Critical Appraisal Skills Programme(CASP).Uma meta-análise dos artigos incluídos foi realizada com o auxílio do software RevMan.Resultados:A busca sistemática da literatura resultou em889 registros, dos quais 41 artigos foram examinados quanto a seu conteúdo. Depois da análise dos textos completos, seis estudos foram incluídos nesta revisão, permitindo inferências sobre a eficácia dos procedimentos cirúrgicos em questão.Conclusão:O avanço do músculo genioglosso demonstrou eficácia inferior à do avanço do músculo genioglosso, o que foi evidenciado por meio do índice de apneia hipopneia registrados através de polissonografias.Os resultados da meta-análise mostram que o AMM apresenta eficácia superior àquela doAMG no contexto do tratamento cirúrgico da SAHOS. / Lagarto, SE

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-22T12:05:16Z No. of bitstreams: 1 ricardoaugustopalettaguedes.pdf: 29477997 bytes, checksum: 211b12a02f343517656d1362450971d3 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-22T15:41:53Z (GMT) No. of bitstreams: 1 ricardoaugustopalettaguedes.pdf: 29477997 bytes, checksum: 211b12a02f343517656d1362450971d3 (MD5) / Made available in DSpace on 2016-07-22T15:41:53Z (GMT). No. of bitstreams: 1 ricardoaugustopalettaguedes.pdf: 29477997 bytes, checksum: 211b12a02f343517656d1362450971d3 (MD5) Previous issue date: 2016-04-29 / O glaucoma é considerado pela Organização Mundial de Saúde como a principal causa de cegueira irreversível no Brasil e no mundo. A forma mais comum, o glaucoma primário de ângulo aberto, tem bases genéticas, portanto sua prevenção primária ainda é inviável do ponto de vista prático. As principais ações para evitar a progressão para cegueira estão voltadas para sua prevenção secundária (diagnóstico precoce e tratamento eficaz). O principal fator de risco para a progressão da doença é a hipertensão ocular. Nos pacientes glaucomatosos, a pressão intraocular se eleva por uma obstrução gradativa da via de escoamento do humor aquoso no olho, chamada trabeculado. O tratamento do glaucoma pode ser realizado através de colírios, laser ou cirurgia. O envelhecimento da população mundial requer uma alocação custo-efetiva de recursos no tratamento e no controle do glaucoma primário de ângulo aberto. Com a previsão do aumento da incidência e da prevalência do glaucoma no futuro, o impacto econômico aumentará significativamente. O objetivo deste estudo é avaliar a eficiência comparativa do tratamento do glaucoma primário de ângulo aberto no Brasil, através de uma avaliação de custo-utilidade de diferentes estratégias de tratamento. O estudo de custo-utilidade foi realizado através de modelagem de Markov. Os dados (custos, efetividades e probabilidades de transição) para a construção do modelo foram obtidos na literatura e através da análise de um banco de dados de pacientes portadores de glaucoma primário de ângulo aberto em tratamento e cadastrados pelo pesquisador. A perspectiva utilizada foi a do Sistema Único de Saúde financiador e o horizonte temporal foi o da expectativa de vida média da população brasileira. As alternativas de tratamento testadas nos modelos foram observação, tratamento clínico com colírios, tratamento com laser e tratamento com cirurgia. Construíram-se 3 modelos de Markov de acordo com o estágio evolutivo da doença: Modelo 1 para glaucoma inicial, Modelo 2 para glaucoma moderado e Modelo 3 para glaucoma avançado. As medidas de desfecho analisadas foram os custos (em reais), o ganho em qualidade de vida (utilidades) e a razão de custo-utilidade incremental. Encontrou-se que no Modelo 1, a razão de custo-utilidade incremental do tratamento inicial com laser e do tratamento inicial com colírios, em relação à observação, foi R$2.811,39/QALY (Quality-adjusted life year) e R$3.450,47/QALY, respectivamente. Ambas as estratégias foram custo-efetivas, proporcionando ganhos significativos de qualidade de vida (em torno de 2,5 QALYs para o tratamento a laser e 5,0 QALYs para o tratamento com colírios). No Modelo 2, tanto o laser quanto a cirurgia foram bastante custo-efetivos. O tratamento inicial com colírios apresentou custos elevados e quase ultrapassou o limiar de custoefetividade sugerido pela organização Mundial de Saúde. Para o Modelo 3, tanto o tratamento inicial com colírios quanto o com cirurgia foram custo-efetivos. Em todos os modelos, a idade de entrada teve um impacto grande nos resultados. Quanto mais jovem o paciente, mais custo-efetivos eram os tratamentos iniciais com laser e com cirurgia. Concluiu-se, portanto, que todas as estratégias de tratamento do glaucoma primário de ângulo aberto foram custo-efetivas e proporcionaram ganhos reais na qualidade de vida. Os resultados sugerem quais as estratégias mais custoefetivas de acordo com o estágio evolutivo do glaucoma primário de ângulo aberto. / Glaucoma is the main cause of irreversible blindness in the world and in Brazil. The most common type, primary open-angle glaucoma, has genetic basis, therefore primary prevention (avoiding occurrence of the disease) is difficult to perform. Main actions to prevent glaucoma blindness target secondary prevention (early diagnosis and effective treatment). The most important risk factor for glaucoma is ocular hypertension. In glaucomatous patients, intra-ocular pressure elevates as aqueous humor outflow pathways (trabecular meshwork) are progressively obstructed. Glaucoma treatment involves medications, laser or surgery. As world population grows and becomes older, both incidence and prevalence of primary open-angle glaucoma tend to be higher in the future. Hence, there is an urgent need for a costeffective resource allocation in order to reducing its economic impact. The purpose of this study is to determine the most cost-effective strategy for the treatment of primary open-angle glaucoma in Brazil. Participants were a hypothetical cohort of primary open-angle glaucoma patients, separated into early, moderate and advanced stages. We developed 3 Markov models (one for each glaucoma stage), from the perspective of the Brazilian Public Health System and a horizon of the average life expectancy of the Brazilian population. We tested different strategies for each model. Main outcome measures were incremental cost-utility ratio, medical direct costs and quality-adjusted life year. The results show that in early glaucoma, incremental cost-utility ratio of initial laser and initial medical treatment over observation only, were R$2.811,39/QALY (Quality-adjusted life year) and R$3.450,47/QALY, respectively. Both strategies were cost-effective. The two alternatives have provided significant gains in quality of life over no treatment. In moderate glaucoma, both laser and surgery were highly cost-effective. Initial medical therapy in this group led to higher costs and was marginally cost-effective. For advanced glaucoma patients, both surgery and medications were cost-effective. In all models, starting age had a great impact on results. Both laser and surgery were more cost-effective, the younger the patient. In conclusion, from early to advanced glaucoma, all tested treatment strategies were cost-effective and provided real gains in quality of life. We suggest different strategies for different glaucoma stages, according to a cost-effectiveness ratio ranking.

Cette thèse est basée sur ma contribution à différents projets liés à la recherche clinique sur les anévrismes intracrâniens, le traitement endovasculaire, la compréhension des patients et la participation aux essais cliniques. Ce travail a donné lieu à quatre publications à ce jour. Pour cette thèse, je fournis d'abord quelques informations sur les anévrismes cérébraux et la façon dont ils sont gérés. Deuxièmement, je passerai brièvement en revue les principes de l'éthique médicale et de la recherche. J'aborde ensuite l'essai de soins ‘Comprehensive Aneurysm Management (CAM)’, car une partie du travail effectué pour ma thèse consistait à rendre compte des taux de recrutement dans CAM. J'ai également contribué à un article sur la démarcation recherche-soins, et pourquoi elle doit être révisée, ainsi qu'à un éditorial qui affirme que la recherche clinique doit être conçue dans le meilleur intérêt des patients. Enfin, j'ai apporté des contributions originales en concevant une enquête et en interrogeant des patients neurovasculaires avant qu'ils ne soient vus par un médecin dans le cadre d'un suivi. Les résultats de cette étude ont montré que les patients ont une meilleure compréhension de l'incertitude clinique et de l'existence d'options alternatives de prise en charge lorsqu'ils ont participé à des essais de soins. / This thesis is based on my contribution to different projects related to clinical research on intracranial aneurysms, endovascular treatment, patient understanding and participation in clinical trials. This work has led to four publications thus far. For this thesis, I first provide some background on cerebral aneurysms and how they are managed. Second, I briefly review medical and research ethics principles. I then discuss the Comprehensive Aneurysm Management (CAM) care trial because a portion of the work done for my thesis was to report on the recruitment rates in CAM. I also contributed to a paper on the research-care demarcation and why it must be revised, as well as to an editorial claiming that clinical research should be designed in patients' best interests. Finally, I made original contributions by designing a survey and interviewing neurovascular patients prior to being seen by a physician in follow-up. The results of that study showed that patients have a better understanding of clinical uncertainty and the existence of alternative management options when participating in care trials.

Purpose Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study reviewed outcomes in patients treated surgically for CMI by open treatment (OT) and endovascular treatment (ET), analyzing risk factors for endovascular failure. Methods Clinical data for 36 patients treated for CMI from 2007 to 2017 were retrospectively analyzed. The study’s primary endpoint was symptom-free survival. The secondary endpoint was the primary technical success for endovascular and open surgical treatments. Risk factors for endovascular failure were identified by using univariate analysis. Results Patients were analyzed as treated: 21 patients (58.3%) in the ET and 15 (41.6%) in the OT group. Overall, 20 patients (56%) presented with abdominal angina, 9 (25%) with rest pain, and 7 (19%) without symptoms. An ET was initially attempted in 31 patients (86.1%). The conversion rate from ET to OT was 32.3%, which resulted in a primary technical success of 67.6% in ET and 100% in OT. Six patients from the ET group (19.3%) required surgical revision due to restenosis. One-year (OT 91.6% vs. ET 96.8%; n.s.) and three-year primary patency (OT 91.6% vs. ET 80.6%; n.s.) as well as 3-year symptom-free survival did not differ between the groups (OT 62.5% vs. ET 69.4%; n.s). Overall, in-hospital mortality was 2.8% (n = 1), which was not statistically different between the groups (OT 6% vs. ET 0%; n.s.). High-grade stenosis of the superior mesenteric artery tended to be associated with higher technical failure (P = 0.06). Conclusions ET showed a comparable perioperative outcome with higher technical failure. OT was distinguished by excellent early and late technical success.

Univerzita Karlova v Praze 1. lékařská fakulta Autoreferát disertační práce Optimalizace indikací chirurgického a endovaskulárního ošetření intrakraniálních aneurysmat Anna Štekláčová 2018 2 Doktorské studijní programy v biomedicíně Univerzita Karlova v Praze a Akademie věd České republiky Obor: Neurovědy Předseda oborové rady: Prof. MUDr. Karel Šonka, DrSc. Školicí pracoviště: Neurochirurgická a neuroonkologická klinika 1. LF UK a ÚVN, Praha Školitel: Prof. MUDr. Vladimír Beneš, DrSc. Disertační práce bude nejméně pět pracovních dnů před konáním obhajoby zveřejněna k nahlížení veřejnosti v tištěné podobě na Oddělení pro vědeckou činnost a zahraniční styky Děkanátu 1. lékařské fakulty. 3 Obsah Abstrakt - Česky ..................................................................................... 4 Abstract - English ................................................................................... 5 Úvod........................................................................................................ 6 Hypotézy a cíle studie............................................................................. 6 Materiál a metody ................................................................................... 7 Výsledky...

Psychologist and bariatric tretment of obesity PhDr.Jitka Herlesová Tutor: PhDr.Tamara Hrachovinová, CSc. Abstract The aim of the dissertation thesis is to map psychosocial characteristics associated with obesity and their changes after bariatric surgery. The Empirical part follows the points settled in the Theoretical part. Obesity is a disease, whose prevalence rises. Bariatric and metabolic surgery is one of the most effective treatment of obesity and its comorbidities. The mental diseases are associated with high levels of obesity. The standard part of pre-bariatric examination is the psychological assessment. Several changes accompany the weight loss after bariatric surgery, such as normalization of psychosocial functioning, the decrease of mental disorders but in some cases the changes might be also negative. The Empirical part focuses on the psychosocial characteristics of bariatric surgery candidates assessed during the psychological evaluation and the changes after operation. The data from semi-structured psychological interview, Three factor eating questionnaire, Beck Depression Inventory-II, Obesity Weight Loss Quality of Life and Weight Related Symptom Measure were evaluated. The changes after surgery were assessed after 6, 12 and 24 months. Statistically significant differences were ascertained...