The Pattern of Presentation and Trends of Childhood Diabetes Mellitus in Port Harcourt, Southern Nigeria

Jaja Tamunopriye, Yarhere Iroro

Journal of Advances in Medicine and Medical Research, Page Childhood
DOI: 10.9734/BJMMR/2015/12153

Aim: To look at the Pattern of presentation trends of childhood DM in Port Harcourt, Southern Nigeria.
Study Design: Retrospective study.
Place and Duration of Study: Department of Paediatrics, Endocrinology unit between April 2009 and April 2014.
Methods: Twenty one patients presented with diabetes mellitus during the study period but only 20 patients had complete data and were studied, 6 males and 14 females, age range 2 years to 17 years. Information on patient biodata, clinical features, treatment and outcome were retrieved from endocrine registers, case files, and clinic and ward records.
Results: Diabetes mellitus in children accounted for 0.35% of total admissions over study period. Mean age of patients at diagnosis was 10.55±4.03. 14(70%) were females. The commonest presenting features were polyuria, polydipsia and weight loss with 14(70%) presenting with Diabetic ketoacidosis (DKA). Mean duration of symptoms was 5.45 weeks with 65% presenting with duration of symptoms less than 30days. 14(67%) of the patients were diagnosed in the rainy months April to September. There was positive family history of DM in 14(70%) and 80% of patients were from low socioeconomic class. Only one child was obese. Hospital case fatality rate was 4.8%. All patients were on twice daily mixtard insulin.
Conclusion: This report highlights a reducing number of children are presenting with DKA in our centre. Clinical features have remained easily recognizable symptoms of polyuria, polydipsia which will aid early diagnosis. There is still a high prevalence of DKA in our environment, which is a risk factor for increased mortality amongst our children with diabetes. Hospital fatality is also lower. There is need for creation of more awareness amongst the health workers and the general public on childhood diabetes.

Left Ventricular Noncompaction: A Rare Cause of Heart Failure in a HIV Patient

Dane D. Gruenebaum, Jagadeesh K. Kalavakunta, Joel M. Cohn, Heather S. Laird-Fick

Journal of Advances in Medicine and Medical Research, Page 270-274
DOI: 10.9734/BJMMR/2015/12983

Background: Heart failure in patients with human immunodeficiency virus (HIV) is often from dilated cardiomyopathy as a result of HIV itself, drug myotoxicity, secondary infections, or drug-induced atherosclerosis. Left ventricular noncompaction (LVNC) is a rare cardiac congenital abnormality which occurs due to early arrest of endomyocardial morphogenesis.
Case: A 47- year-old female patient with HIV presented with sudden onset shortness of breath and symptoms of congestive heart failure. Echocardiography showed noncompacted endocardium with reduced left ventricular function. She was subsequently diagnosed with LVNC.
Discussion: Multiple etiologies have been implicated in cardiomyopathy among HIV patients. LVNC is a rare cause of left ventricular failure, particularly in this population. Echocardiography plays a pivotal role in the diagnosis.
Conclusion: It is often challenging to identify the underlying cause of cardiomyopathy in a patient with HIV. While LVNC is a rare cause of left ventricular failure, typical findings on echocardiography can obviate the need for a more complex evaluative strategy.

Platelet Rich Fibrin and Nanocrystalline Hydroxyapatite with Collagen Combination in Treatment of Periapical Lesion: A Novel Clinical Approach

Hena Rahman, Anil Chandra, Abdul Aziz, Ramesh Bharti

Journal of Advances in Medicine and Medical Research, Page 275-282
DOI: 10.9734/BJMMR/2015/12648

Aims: To use platelet rich fibrin (PRF), which is an autologous platelet concentrate, along with nanocrystalline hydroxyapatite with collagen for treatment of periapical lesion and negotiation of calcified canal of adjacent tooth.
Case Presentation: A 19-year-old female reported to the Department of Conservative Dentistry and Endodontics with chief complaint of pain in maxillary right central incisor. Past dental history revealed trauma which she sustained 10 yrs back in the same region. On intraoral examination, there was a draining sinus, in relation to the apex of 11. Also discolouration and crown fracture was found in relation to 11. Periapical radiograph revealed a large diffused periapical radiolucency in relation to 11 and 12, open apex of 11 and calcified root canal in relation to 12.
Technique Used in the Study: A periapical surgery under local anaesthesia was planned in the region of maxillary right anterior region in relation to tooth no 11 and 12. Before surgery calcified canal of tooth no 12 was negotiated. PRF and nanocrystalline hydroxyapatite with collagen combination were placed in bony cavity. Follow up of the case was done for period of 6 months.
Discussion: In present case combination of nanocrystalline hydroxyapatite with collagen and PRF is used, as it helps in faster bone regeneration. Graft material is osteoconductive and collagen network provides a better scaffold for clot formation and bone regeneration.
Conclusion: The combination of PRF and nanocrystalline hydroxyapatite with collagen has been demonstrated to be an effective approach to induce faster periapical healing in present case with large periapical lesion.

Unfollowed Pregnancy and Unexpected Result: A Harlequin Neonate

Ilker Kahramanoglu, Seyma Ozsuer, Fatma Ferda Verit

Journal of Advances in Medicine and Medical Research, Page 283-285
DOI: 10.9734/BJMMR/2015/12738

Background: Prenatal consultation of a couple and medical follow-up of a pregnant woman is an essential part of health care while absence of these is associated with significant perinatal morbidity and mortality. Herein, a non-followed pregnancy resulted birth of a neonate with harlequin ichthyosis is presented. Harlequin fetus is rarely seen autosomal recessive disorder and is the most severe form of the congenital icthyosis, charachterized by thickened, hyperkeratotic skin with deep fissures over the entire of the body. However, diagnosis in first trimester is difficult, high risk patients for autosomal recessive disorders can be identified with prenatal consultation or diagnosis can be suspected with second or third trimester ultrasonography. Thus, an unfavourable outcome can be averted.

Monomelic Amyotrophy after Permethrin Poisoning

Dash Sandip Kumar

Journal of Advances in Medicine and Medical Research, Page 286-288
DOI: 10.9734/BJMMR/2015/11574

Monomelic amyotrophy (MMA) known as Hirayama disease (HD). The first report appeared in 1959 when Hirayama described 12 patients [1] then, a large group of patients was found from Japan [2,3]. MMA from South India was also reported in 1984 [4]. The disease accounted for males over 80% of cases, especially between 15 and 25 years of age. The disorder has been recognized as, unilateral or bilateral asymmetric atrophy of hand and forearm with sparing of brachioradialis giving the characteristic appearance of oblique amyotrophy. Symmetrically bilateral disease has also been recognized. It is believed to be a cervical flexion myelopathy [5].
Pyrethroids are used as insecticides due to their high potency. These are highly toxic to a wide range of insects but have low toxicity to humans. Pyrethroids are known to cause neurotoxicity in humans like seizures, tremors, and dizziness. Motor neuron damage has been reported in acute toxicity due to ingestion of pyrethroids and organochlorines [6] and MND (Motor neuron disease) like features after chronic exposure has been reported [7]. Here a case of monomelic amyotrophy following massive ingestion of permethrin, amytriptyline and benzodiazepine tablets is reported.

Management of Grossly Displaced Paediatric Supracondylar Humeral Fractures with Delayed Presentation by Closed Reduction and Percutaneous Pinning

Kopuri Ravi Kiran, S. Suresh Babu, T. V. Suresh Babu, K. Deepti

Journal of Advances in Medicine and Medical Research, Page 254-269
DOI: 10.9734/BJMMR/2015/12732

Background: Management guidelines are not yet clear for these patients who present late with displaced supracondylar fracture. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 24 hours or more after injury.
Patients and Methods: This prospective study was conducted at the Orthopaedic and Trauma Department of Dr Pinnamaneni Siddartha Institute of Medical Sciences and Research Foundation, Chinnoutpalli from January 2010 to July 2011. A total of 44 children were included in this study who had displaced supracondylar fracture of humerus presenting late ie, after 24 hours after injury and within a week. They were treated with closed reduction of the fracture and percutaneous pinning. Follow-up was done up to 12 months.
Conclusion: Our preliminary results support our recommendation ie, closed reduction and percutaneous pin fixation as an effective treatment option for grossly displaced supracondylar fractures presenting late but requires good and careful judgment and also technique by the surgeon to avoid complications. Our results also support the chances of spontaneous recovery of peripheral nerve palsy and brachial artery spasm post reduction over a period of time in majority of cases though they present late.

Screening for Vascular Disease in Pulmonary Rehabilitation

Sofia Arruda, Marty Tam, Marianne Vest, Joel Hughes, John Gunstad, Mary Dolansky, Richard Sukeena, Richard Josephson

Journal of Advances in Medicine and Medical Research, Page 169-177
DOI: 10.9734/BJMMR/2015/13110

Background: Several of the comorbidities and risk factors associated with COPD and other pulmonary disorders are also similar to those for lower extremity peripheral artery disease (PAD) and cerebrovascular disease. The later condition is often manifested as cognitive impairment, not only from large vessel associated stroke, but also from vascular cognitive impairment (VCI). We hypothesized that pulmonary rehabilitation (PR) would be an appropriate site to discern the prevalence of both PAD and mild cognitive impairment (MCI).Individuals in PR with severe pulmonary disease may have impaired cognition, which could impact learning and treatment adherence while PAD may contribute to functional limitation.
Study Design: In this pilot study of 14 patients enrolled in phase II PR, we describe the prevalence of PAD and cognitive impairment, the utility of screening tools, and the potential relationship between PAD, depression, and cognitive impairment.
Results: Twenty-eight percent of patients had an abnormal ABI with two subjects manifesting low (<0.90) and two subjects with abnormally high (>1.40) ABI. The Edinburgh Claudication Questionnaire was negative in all subjects and was not useful in the detection of PAD (sensitivity 0%, specificity 11%, PPV 0%, NPV 78.57%). The Walking Impairment Questionnaire did not differentiate patients with or without abnormal ABIs with respect to walking distance (40.02 vs. 64.46 meters, P=.154), speed (27.15 vs. 25.92 miles per hour, P=.545), or symptoms (46.88 vs. 63.75, P=.152). Furthermore, eleven of the fourteen patients (79%) had an overall score of less than 26 on the Montreal Cognitive Assessment, indicating cognitive impairment. Scores indicating mild to moderate depression or anxiety measured by the PHQ-9 and STAI questionnaires revealed a concurrence between depressive and anxiety symptoms.
Conclusion: Our results have leaded us to postulate a possible relationship between PAD and MCI, along with that of PAD and depression and anxiety. Future studies, with a large sample size, will provide more insight on ameliorating care for patients whose vascular disease affects cognitive function and mental health.

A Prospective Drug Utilization Study in Geriatric Hypertensive Patients in a Tertiary Care Hospital, Mumbai

Gauri Billa, Shirish Joshi, Santosh Salagre, Karan Thakkar

Journal of Advances in Medicine and Medical Research, Page 178-190
DOI: 10.9734/BJMMR/2015/12876

Introduction: The geriatric population assumes great significance in terms of both preventive and curative health care services utilized. The patho-physio-psychological changes associated with ageing make their problems unique. In the geriatric population, hypertension accounts for a huge proportion of cardiovascular and all cause mortality and morbidity. We conducted a study to describe the patterns of antihypertensive drug use in the geriatric population, compare it to the current recommendations and conduct an analysis using the WHO-INRUD drug use indicators.
Methods: A prospective cross sectional drug utilization study of 100 prescriptions of hypertensive patients (as per JNC 7) of either sex and ≥60 years was undertaken as per the WHO – DUS and the STROBE guidelines.
Results: Statistically significant relation was found between BP control, and addictions and CIRS-G score. The 100 prescriptions contained 344 drugs, out of which, 171 were antihypertensive drugs. Three percent of antihypertensive drugs were prescribed by generic names. Seventy nine percent of antihypertensive drugs were prescribed from the ‘hospital drug schedule’. Amlodipine, Hydrochlorothiazide, Losartan and Telmisartan were prescribed to 79%, 24%, 11%, 11% respectively. The combination of ARB (Angiotensin Receptor Blocker) + Diuretic was prescribed to 36% and that of ARB + CCB (Calcium Channel Blocker) was prescribed to 21%. The PDD/DDD ratios of Carvedilol, Losartan, Furosemide and Telmisartan were 0.7, 0.8,1 and1.2, respectively.
Conclusion: Creating awareness regarding the role of addiction in BP control and advocating lifestyle changes is paramount in HTN management. Overall, the principles of rational prescribing were followed. The prescription pattern observed was as per current recommendations.

Race/Ethnicity and Income Disparities in US Adult Mortality

Augustine J. Kposowa

Journal of Advances in Medicine and Medical Research, Page 191-202
DOI: 10.9734/BJMMR/2015/12433

Objectives: The objectives of the study were to investigate associations between socioeconomic status and all-cause mortality in the United States, and racial/ethnic differences in this association. We stratify analysis by race/ethnicity to test whether the consequences of SES variables are more pronounced among certain racial/ethnic groups than others.
Methods: Data employed were obtained from the National Longitudinal Mortality Study. It is a study of respondents in the Current Population Surveys of the early 1980s whose mortality experiences were followed through the 1990s. The sample includes 707169 individuals aged 18 and above at baseline of which 88489 had died at the end of the 11 year follow-up period. Proportional hazards regression models were fitted to the data.
Results: The socioeconomic variables education and income were strongly associated with all-cause mortality. Persons with less than high school education were 64% (ARR=1.64, 95% CI=1.58, 1.70) more likely to die than those with graduate or professional education. Individuals making less than $10,000 per year were 59% more likely to die during the follow up period than their counterparts making$60,000 or more (ARR=1.59, 95% CI=1.54, 1.65). Persons without health insurance were 14% as likely to die as those with health insurance (ARR=1.14, 95% CI=1.13, 1.16).
Conclusion: Results were generally consistent with past studies on the contribution of SES to mortality. This was the first study to note that the effects of SES on mortality vary significantly by racial/ethnic groups. Although college education is a much stronger predictor of mortality among whites, it is not a strong mortality covariate among African Americans and Hispanics. Among African Americans, low income has more devastating consequences than it does among Whites. Future studies on the SES-mortality relationship ought to stratify samples by race in order to get a more accurate understanding of the effects of SES.

Risk Factors of Dyslipidaemia in a Cohort of Geriatric Nigerians with Essential Hypertension in a Rural Hospital in Eastern Nigeria

Gabriel Uche Pascal Iloh, Agwu Nkwa Amadi

Journal of Advances in Medicine and Medical Research, Page 203-212
DOI: 10.9734/BJMMR/2015/11614

Background: Evidence has demonstrated the metabolic relationship between dyslipidaemia and hypertension which are independent cardio-metabolic risk factors. As socio-economic and environmental dynamics in rural Nigeria changes, geriatric Nigerians tend to adopt lifestyles that predispose to atherosclerotic cardiovascular diseases.
Aim: This study was designed to determine the risk factors of dyslipidaemia in a cohort of geriatric Nigerians with essential hypertension in a rural hospital in Eastern Nigeria.
Study Design: This was a cross sectional study conducted on a cohort of 122 geriatric Nigerians with essential hypertension.
Place and Duration of Study: The study was conducted in a rural hospital in Eastern Nigeria between June 2008 and June 2011.
Methodology: Risk factor variables were examined using a pretested, structured and interviewer-administered questionnaire. Hypertension and dyslipidaemia were defined using JNC VII and The Third Report of National Cholesterol Education Panel in adult (ATP III) criteria respectively.
Results: The risk factors significantly associated with dyslipidaemia were advanced old age (p=.039), abdominal obesity (p=.022) and physical inactivity (p=.042). The abdominally obese patients were three times more likely to have dyslipidaemia compared to the non-abdominally obese patients.
Conclusion: Risk factors of dyslipidaemia exist in geriatric Nigerians with essential hypertension. Dyslipidaemia was significantly associated with advanced old age, abdominal obesity and physical inactivity. These risk factors should be considered alongside the complex of other cardio-metabolic risk factors during clinical encounter with geriatric hypertensives.

Comparison of Psychological Factors in Patients with Irritable Bowel Syndrome and Inflammatory Bowel Diseases

Journal of Advances in Medicine and Medical Research, Page 213-220
DOI: 10.9734/BJMMR/2015/11734

Introduction: Irritable bowel syndrome (IBS) and Inflammatory Bowel Disease (IBD) are two common diseases of lower gastrointestinal symptoms and discomfort. Although research has demonstrated the inï¬‚uence of psychological processes on gastrointestinal functions, few studies compared the role of psychological factors in IBS and IBD disease. The present study aimed to assess the psychological factors in patients suffering from IBS and IBD.
Methodology: This current cross-sectional study was done on 90 subjects with diagnosed IBD (15 women, 15 men), IBS (15 women, 15 men), and 30 non-IBS/non-IBD in the Gastroenterology Department of Babol University of Medical Sciences. All subjects filled out three questionnaires; Rahim Organizational Conflict Inventory-II (ROCI-II), Symptom Checklist-90-Revised (SCL-90-R), and 20-item Toronto Alexithymia Scale (TAS-20).
Results: The IBS and IBD patients had higher scores in unconstructive management conflict (dominating and avoiding) ways than the controls, but did not differ from each other. Although both the IBS and IBD patients had higher alexithymia scores than control subjects, IBS patients were more alexithymic than IBD patients. Significantly, higher scores were found in patients with IBS compared to IBD for some psychiatric symptoms (depression 17.2±11.3 vs 10.7±6.8, anxiety 12.7±8.2 vs 7.5±4.5, and the total score of psychiatric symptoms 115.4±62.6 vs 83.3±44.8).
Conclusion: Although both the IBS and IBD patients experienced more psychiatric symptoms, unconstructive conflict management styles, and alexithymia than controls, IBS patients had worse psychiatric and alexithymic symptoms than IBD.

Cohort Study of Factors Contributing to Mortality Two Months after Exacerbation of COPD According to Patient Destination from Emergency Department

Marisa Baré, Concepción Montón, Xavier Pomares, Juli Font, Núria Torà, Cristina Estirado, José Maria Quintana, Ana Santiago, Silvia Vidal, The IRYSS-COPD Appropriateness Study Group

Journal of Advances in Medicine and Medical Research, Page 221-234
DOI: 10.9734/BJMMR/2015/11853

Background: We aimed to determine the mortality two months after exacerbation of chronic obstructive pulmonary disease (eCOPD) and to identify factors associated with mortality, comparing patients admitted to wards and those discharged to home from the emergency department.
Methods: This prospective multicentre study included all consecutive patients presenting with eCOPD at emergency departments in 16 public hospitals in Spain. Clinical variables were recorded from a standardized questionnaire. Independent predictors of mortality were modelled by logistic regression analysis. The calibration and discriminative power of the models for the two groups (discharged and admitted) were estimated by the Hosmer-Lemeshow test and the area under the curve (AUC), respectively. Bootstrap methods were applied for internal validation.
Results: 2487 patients were included; 1537 (62%) of these were admitted to wards. A total of 155 (6.2%; 95% CI: 5.2% - 7.1%) patients had died at 2 months: mortality was four times higher in patients admitted than in patients discharged. Age ≥ 80 years, Charlson score >2, and pronounced dyspnoea were independent factors for mortality in both groups; in admitted patients, Glasgow scale, baseline treatments for COPD, previous heart disease, complications during hospitalization, and corticoids at discharge were also independent factors.
Conclusions: In eCOPD, age, comorbidities, and dyspnoea are important for short-term prognosis in both patients admitted to wards and those discharged to home. In patients admitted to wards, the severity of baseline disease and eCOPD and corticoid treatment affect the short-term prognosis.

Validating the Persian Version of the Hill-Bone’s Scale of “Compliance to High Blood Pressure Therapy”

Mahlagha Dehghan, Nahid Dehghan Nayeri, Sedigheh Iranmanesh

Journal of Advances in Medicine and Medical Research, Page 235-246
DOI: 10.9734/BJMMR/2015/13061

Introduction: Hypertension is a global public health concern. Among the factors that contribute to this crisis, the poor control of hypertensive patients is a major concern. Patients’ lack of adherence to the medication regimen is often considered to be the main reason for this failure. Several medication-adherence scales were designed to measure the extent to which patients adhere to their medication and treatment regimens. Since these scales must be very reliable and have strong validity if they are to be used in clinics and research, this study was performed to test the reliability and validity of the Hill-Bone’s scale of “Compliance to High Blood Pressure Therapy.”
Methods: After using a modified forward/backward translation procedure to create a Persian version of the Hill-Bone’s scale, we conducted a cross-sectional study in which two hundred and eighty hypertensive patients participated to validate the Persian version. Exploratory and confirmatory factor analysis, criterion validity, Cronbach’s alpha, and test-retest reliability were used to determine the validity and reliability of the Persian scales’ psychometric properties.
Results: The analysis of the data showed that the scale had excellent stability (Intraclass Correlation Coefficient = 0.97) and low acceptability of internal consistency (Cronbach’s Alpha = 0.44). The exploratory factor analysis did not clarify meaningful patterns among the subscales. The confirmatory factor analysis failed to fit the observed items with the latent subscales. The scale scores were not correlated with blood pressure (P > 0.05).
Conclusion: Although some of the psychometric properties of the Persian version of the Hill-Bone’s scale and its modified version were acceptable, they were not sufficient to recommend the Persian version for general use. More studies are needed to revise and develop a more comprehensive scale that is appropriate for use in the context of the mentioned population.

Patience O. Osadebe, Estella U. Odoh, Philip F. Uzor

Journal of Advances in Medicine and Medical Research, Page 134-159
DOI: 10.9734/BJMMR/2015/8764

Diabetes is a chronic metabolic disorder with high mortality rate and with defects in multiple biological systems. Two major types of diabetes are recognized, type 1 and 2 with type 2 diabetes (T2D) being by far the more prevalent type. As diabetes affects multiple biological functions, the use of multiple drug classes having different mode of actions is required in order to optimize therapy in diabetic patients. Five major classes of oral antidiabetic agents (OHA) have traditionally been used for the management of patients with T2D. These include the sulphonylureas, meglitinides, biguanides, thiazolidinediones and the alpha-glucosidase inhibitors. Several newer classes of agents have also been introduced recently in the pharmacotherapy of T2D, including the incretin mimetics, the dipeptidy peptidase 4 (DPP-4) inhibitors, the sodium glucose co-transporter 2 (SGLT 2) inhibitors and more recently, the dual peroxisome proliferator-activated receptor (PPAR) agonists. Each of these agents has been shown in various experimental and clinical settings to be efficacious in T2D, but each is also associated with a number of adverse effects. Despite the vast array of drugs introduced, metformin, a biguanide, largely remains the first choice mono therapy in T2D patients but several combination options are also available in poly pharmacy when mono therapy fails to produce the required glycemic control. The increasing number of drugs, together with numerous combination options in poly pharmacy, presents with the clinician an increasing complexity of therapeutic options. The likely pathogenetic mechanism of diabetes operating in the patient, as well as the mode of action, efficacy and safety of the drugs are some of the major considerations in the choice of any given agent or its combinations. This review therefore focuses on the mode of action, pharmacokinetics, indications, efficacy and adverse effects of the OHA used in T2D.

Control of Measles in Nigeria: A Critical Review of the Literature

Adekunle A. Salako, Oluwafolahan O. Sholeye

Journal of Advances in Medicine and Medical Research, Page 160-168
DOI: 10.9734/BJMMR/2015/4333

The Millennium Development Goals identify the health and wellbeing of children as important indices of meaningful development. An important aspect of child survival is the control of vaccine-preventable diseases. Measles remains an important cause of death among young children globally, despite the availability of a safe and effective vaccine. Although global measles deaths have been reduced by 74% between year 2000 and 2010, the world measles burden still resides in the developing world with measles epidemics occurring in a large and recurrent manner with associated high mortality. These outbreaks can forestall the effects of the control and eradication of measles globally. Nigeria has been experiencing the incidence of measles outbreaks which have occurred in the year 2004, 2005, 2006, 2007, 2008, and 2011. These outbreaks are a cause of concern particularly the outbreak in 2011 which occurred following a mass measles vaccination campaign earlier that year. Efforts to improve control have been on-going and progress has been made particularly with the establishment in 2006 of a system of measles case-based surveillance, however in the myriad of factors plaguing the control of measles in the country, low immunization coverage is still the main factor involved. The inability to control measles is a reflection of the work that needs to be done as regards our immunization coverage and structures that are needed to be put in place.
Chronic low immunization and the factors that contribute to it should be addressed with measures and structures that can achieve long term effect. These factors have already been identified and solutions tailored to them need to start taking place. The effect of political and financial committment in achieving this is invaluable especially if the country would achieve the fourth millenium development goal to reduce under-five mortality by two-thirds to which measles is a significant contributor in this part of the world.