Displaying publications 1 - 20 of 55 in total

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  1. Karupaiah T, Tan CH, Chinna K, Sundram K
    J Am Coll Nutr, 2011 Dec;30(6):511-21.
    PMID: 22331686
    OBJECTIVE: Saturated fats increase total cholesterol (TC) and low density lipoprotein-cholesterol (LDL-C) and are linked to coronary artery disease risk. The effect of variance in chain length of saturated fatty acids (SFA) on coronary artery disease in human postprandial lipemia is not well elucidated.

    METHODS: A total of 20 healthy volunteers were challenged with 3 test meals, similar in fat content (~31% en) but varying in saturated SFA content and polyunsaturated/saturated fatty acid ratios (P/S). The 3 meals were lauric + myristic acid-rich (LM), P/S 0.19; palmitic acid-rich (POL), P/S 0.31; and stearic acid-rich (STE), P/S 0.22. Blood was sampled at fasted baseline and 2, 4, 5, 6, and 8 hours. Plasma lipids (triacylglycerol [TAG]) and lipoproteins (TC, LDL-C, high density lipoprotein-cholesterol [HDL-C]) were evaluated.

    RESULTS: Varying SFA in the test meal significantly impacted postprandial TAG response (p < 0.05). Plasma TAG peaked at 5 hours for STE, 4 hours for POL, and 2 hours for LM test meals. Area-under-the-curve (AUC) for plasma TAG was increased significantly after STE treatment (STE > LM by 32.2%, p = 0.003; STE > POL by 27.9%, p = 0.023) but was not significantly different between POL and LM (POL > LM by 6.0%, p > 0.05). At 2 hours, plasma HDL-C increased significantly after the LM and POL test meals compared with STE (p < 0.05). In comparison to the STE test meal, HDL-C AUC was elevated 14.0% (p = 0.005) and 7.6% (p = 0.023) by the LM and POL test meals, respectively. The TC response was also increased significantly by LM compared with both POL and STE test meals (p < 0.05).

    CONCLUSIONS: Chain length of saturates clearly mediated postmeal plasma TAG and HDL-C changes.

    Matched MeSH terms: Risk Management
  2. Vicknasingam B, Mazlan M, Schottenfeld RS, Chawarski MC
    Drug Alcohol Depend, 2010 Sep 1;111(1-2):44-9.
    PMID: 20478668 DOI: 10.1016/j.drugalcdep.2010.03.014
    Buprenorphine maintenance is efficacious for treating opioid dependence, but problems with diversion and misuse of buprenorphine (BUP) may limit its acceptability and dissemination. The buprenorphine/naloxone combination tablet (BNX) was developed to reduce potential problems with diversion and abuse. This paper provides data regarding the characteristics of BUP injection drug users in Malaysia and preliminary data regarding the impact of withdrawing BUP and introducing BNX. BUP was introduced in 2002 and subsequently withdrawn from the Malaysian market in 2006. BNX was introduced in 2007.
    Matched MeSH terms: Risk Management
  3. Lee YS, Oh YS, Choi EK, Chern AKC, Jiampo P, Chutinet A, et al.
    Open Heart, 2021 12;8(2).
    PMID: 34857666 DOI: 10.1136/openhrt-2021-001745
    PURPOSE: Dabigatran is a direct thrombin inhibitor approved for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Real-world data about patient preference, satisfaction and convenience in patients in Asia are not available. The study aimed to explore the perception of patients with newly diagnosed NVAF regarding dabigatran versus vitamin K antagonists (VKAs), when used for stroke prevention.

    PATIENTS AND METHODS: This was a multinational, multicentre, non-interventional study involving 49 sites across 5 countries in South East Asia and South Korea where 934 patients newly diagnosed with NVAF were initiated on either dabigatran (N=591) or VKA (N=343). Data were collected at baseline and over two follow-up visits across 6 months. Treatment satisfaction and patient convenience were evaluated using the Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2).

    RESULTS: The mean age of the patients was 65.9±10.4 years, and 64.2% were male. Mean CHA2DS2-VASc score was 2.4±1.5, and mean HAS-BLED score was 1.2±0.9. At baseline, patients initiated on dabigatran had higher stroke risk, bleeding risk, creatinine clearance and proportion of patients with concomitant illnesses compared with patients initiated on VKAs. Treatment convenience was perceived to be significantly better with dabigatran versus VKAs at visits 2 and 3 (p=0.0423 and 0.0287, respectively). Treatment satisfaction was significantly better with dabigatran compared with VKAs at visit 3 (p=0.0300).

    CONCLUSION: In this study, dabigatran is associated with better patient perception in terms of treatment convenience and satisfaction compared with VKAs when used for stroke prevention in newly diagnosed NVAF patients from South East Asia and South Korea.

    TRIAL REGISTRATION NUMBER: NCT02849509.

    PLAIN LANGUAGE SUMMARY: Patient satisfaction with dabigatran versus VKAs in South East Asia. Patients with atrial fibrillation are at high risk of stroke and require anticoagulants for stroke prevention. Two such anticoagulants are dabigatran and VKAs. We wanted to compare the extent of satisfaction and treatment convenience among newly diagnosed patients with atrial fibrillation from the South East Asian region when they were given either dabigatran or VKAs. Consenting patients filled out a standardised questionnaire called the PACT-Q2 over three visits after they were started on either dabigatran (591 patients) or VKAs (343 patients). We found that satisfaction and convenience were significantly higher when patients received dabigatran than when they received VKAs.

    Matched MeSH terms: Risk Management
  4. Chua SS, Tea MH, Rahman MH
    J Clin Pharm Ther, 2009 Apr;34(2):215-23.
    PMID: 19250142 DOI: 10.1111/j.1365-2710.2008.00997.x
    Drug administration errors were the second most frequent type of medication errors, after prescribing errors but the latter were often intercepted hence, administration errors were more probably to reach the patients. Therefore, this study was conducted to determine the frequency and types of drug administration errors in a Malaysian hospital ward.
    Matched MeSH terms: Risk Management
  5. Lim KS, Fong SL, Thuy Le MA, Ahmad Bazir S, Narayanan V, Ismail N, et al.
    Epilepsy Res, 2020 05;162:106298.
    PMID: 32172144 DOI: 10.1016/j.eplepsyres.2020.106298
    INTRODUCTION: Video-EEG monitoring is one of the key investigations in epilepsy pre-surgical evaluation but limited by cost. This study aimed to determine the efficacy and safety of a 48-hour (3-day) video EEG monitoring, with rapid pre-monitoring antiepileptic drugs withdrawal.

    MATERIAL AND METHODS: This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till August 2016.

    RESULTS: A total of 137 cases were included. The mean age was 34.5 years old (range 15-62) and 76 (55.8 %) were male. On the first 24 -h of recording (D1), 81 cases (59.1 %) had seizure occurrence, and 109 (79.6 %) by day 2 (D2). One-hundred and nine VEMs (79.6 %) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 h but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis such as psychogenic non-epileptic seizure was made. Twenty-eight patients had extension of VEM for another 24-48 h, and 11 developed seizures during the extension period. Extra-temporal lobe epilepsy and seizure frequency were significant predictors for diagnostic 48 -h VEM. Three patients developed complications, including status epilepticus required anaesthetic agents (1), seizure clusters (2) with postictal psychosis or dysphasia, and all recovered subsequently.

    CONCLUSIONS: 48-h video EEG monitoring is cost-effective in resource limited setting.

    Matched MeSH terms: Risk Management
  6. Sundram BM, Dahlui M, Chinna K
    Ind Health, 2016 Jun 10;54(3):204-14.
    PMID: 26726829 DOI: 10.2486/indhealth.2014-0091
    The aim of this study was to examine the effectiveness of Progressive Muscle Relaxation (PMR) as part of a Worksite Health Promotion Program on self-perceived stress, anxiety and depression among male automotive assembly-line workers through a quasi-experimental trial. Two assembly plants were chosen with one receiving PMR therapy and the other Pamphlets. Intention-to-treat analysis was conducted to test the effectiveness of the relaxation therapy. Stress, Depression and Anxiety levels were measured using the shortened DASS-21 questionnaire. Data were analyzed using Chi-square, Independent sample t test and Repeated-measures analysis of variance to test the significance of the effects of intervention (time * group) for the measures of Stress, Depression and Anxiety. Significant favourable intervention effects on stress were found in the PMR group (Effect size=0.6) as compared to the Pamphlet group (Effect size=0.2). There was a significant group *time interaction effect (p<0.001) on Stress levels. Depression and Anxiety levels were minimal at baseline in both the groups with mild or no reduction in levels. The improvement in stress levels showed the potential of PMR therapy as a coping strategy at the workplace. Further research in this field is necessary to examine the beneficial effects of coping strategies in the workplace.
    Matched MeSH terms: Risk Management
  7. Shin JY, Shin E, Jeong HE, Kim JH, Lee EK
    Pharmacoepidemiol Drug Saf, 2019 03;28(3):362-369.
    PMID: 30648304 DOI: 10.1002/pds.4717
    PURPOSE: Regulatory discrepancies may exist in pharmacovigilance (PV) structure, process, and outcome status worldwide. Our study's objective was to survey the current status of PV in each regulatory body in the Asia-Pacific Economic Cooperation (APEC) region.

    METHODS: A modified questionnaire was sent to the PV team heads of 21 PV agencies based in the APEC countries, between June 28 and September 12, 2017, to gather information on the structure, process, and outcome of PV status in these countries.

    RESULTS: Of the 21 APEC countries, 15 responded. We found harmonized laws and regulations for general PV and risk management systems. However, variations were found in PV structure: for example, 11 out of 15 countries had national regulatory representatives responsible for PV in pharmaceutical companies, while four did not. For PV process, discrepancies were also found in the source type of adverse drug reaction (ADR) reports and reporting of medication errors and therapeutic ineffectiveness in cumulative ADR reports. With respect to PV outcomes, among countries that performed active surveillance, the United States of America was more active, with hundreds of projects including additional pharmacoepidemiological studies etc. Among the nine countries that responded, Japan had the greatest number of product label changes followed by Taiwan, Malaysia, and Korea.

    CONCLUSION: We have identified substantial variations in the structures, processes, and outcomes of PV status among the countries of the APEC region. Therefore, efforts to reduce variations in the PV administration and regulation are warranted for harmonization of PV within the APEC region.

    Matched MeSH terms: Risk Management
  8. Narita K, Hoshide S, Tsoi K, Siddique S, Shin J, Chia YC, et al.
    J Clin Hypertens (Greenwich), 2021 03;23(3):575-583.
    PMID: 33527663 DOI: 10.1111/jch.14192
    The incidence of large disasters has been increasing worldwide. This has led to a growing interest in disaster medicine. In this review, we report current evidence related to disasters and coronavirus disease-2019 (COVID-19) pandemic, such as cardiovascular diseases during disasters, management of disaster hypertension, and cardiovascular diseases associated with COVID-19. This review summarizes the time course and mechanisms of disaster-related diseases. It also discusses the use of information and communication technology (ICT) as a cardiovascular risk management strategy to prevent cardiovascular events. During the 2011 Great East Japan Earthquake, we used the "Disaster Cardiovascular Prevention" system that was employed for blood pressure (BP) monitoring and risk management using ICT. We introduced an ICT-based BP monitoring device at evacuation centers and shared patients' BP values in the database to support BP management by remote monitoring, which led to improved BP control. Effective use of telemedicine using ICT is important for risk management of cardiovascular diseases during disasters and pandemics in the future.
    Matched MeSH terms: Risk Management
  9. Yoon SY, Thong MK, Taib NA, Yip CH, Teo SH
    Fam Cancer, 2011 Jun;10(2):199-205.
    PMID: 21318382 DOI: 10.1007/s10689-011-9420-7
    Genetic counseling (GC) and genetic testing are vital risk management strategies in hereditary breast and ovarian cancer (HBOC) syndromes. Hitherto, cancer genetic testing amongst Asians has been described only in developed and high-income Asian countries. We studied the uptake and acceptance of GC and genetic testing services to Asian BRCA carriers in a middle-income country. A total of 363 patients were tested by full sequencing and large rearrangement analysis of both BRCA1 and BRCA2 genes in the Malaysian Breast Cancer (MyBrCa) Genetic Study. Of these, 49 index patients (13.5%) were found to carry deleterious mutations. GC pre- and post- result disclosures were provided and these groups of patients and their families were studied. GC and genetic testing were accepted by 82% of Malaysian patients at high risk for HBOC syndromes. However, risk assessment was limited by large, geographically dispersed, often polygamous or polyandrous families, and the lack of complete cancer registry. Cultural taboos about cancer diagnoses, social marginalization and lack of regulatory control of genetic discrimination were significant concerns. Only 78% of index patients informed their families of their risks and 11% of relatives came forward when offered free counseling and testing. Even when GC and genetic testing are provided at no cost, there remain significant societal and regulatory barriers to effective cancer genetic services in this underserved Asian population. Families believe there is a need for regulatory protection against genetic discrimination. Further studies are needed in the area of increasing awareness about the potential benefits of GC and genetic testing in Asians.
    Matched MeSH terms: Risk Management
  10. Fatokun O
    Curr Drug Saf, 2020;15(3):181-189.
    PMID: 32538733 DOI: 10.2174/1573403X16666200615144946
    BACKGROUND: While off-label drug use is common and sometimes necessary, it also presents considerable risks. Therefore, measures intended to prevent or reduce the potential exposure to off-label risks have been recommended. However, little is known about community pharmacists' beliefs regarding these measures in Malaysia.

    OBJECTIVES: This study examined community pharmacists' beliefs towards risk minimization measures in off-label drug use in Malaysia and assessed the relationship between perceived risk of off-label drug use and beliefs towards risk minimization measures.

    METHODS: A cross-sectional survey was conducted among 154 pharmacists practicing in randomly selected community pharmacies in Kuala Lumpur and the State of Selangor, Malaysia.

    RESULTS: The majority agreed or strongly agreed that adverse drug events from the off-label drug should be reported to the regulatory authority (90.9%) and the off-label drug should only be used when the benefit outweighs potential risks (88.3%). Less than half (48.1%) agreed or strongly agreed that written informed consent should be obtained before dispensing off-label drugs and a majority (63.7%) agreed or strongly agreed that the informed consent process will be burdensome to healthcare professionals. Beliefs towards risk minimization measures were significantly associated with perceived risk of off-label drug use regarding efficacy (p = 0. 033), safety (p = 0.001), adverse drug rection (p = 0.001) and medication errors (p = 0.002).

    CONCLUSION: The community pharmacists have positive beliefs towards most of the risk minimization measures. However, beliefs towards written informed consent requirements are not encouraging. Enhancing risk perception may help influence positive beliefs towards risk minimization measures.

    Matched MeSH terms: Risk Management/methods
  11. Jarrar M, Al-Bsheish M, Dardas LA, Meri A, Sobri Minai M
    Int J Health Plann Manage, 2020 Jan;35(1):104-119.
    PMID: 31271233 DOI: 10.1002/hpm.2822
    PURPOSE: In Malaysia, private healthcare sector has become a major player in delivering healthcare services alongside the government healthcare sector. However, wide disparities in health outcomes have been recorded, and adverse events in these contexts have yet to be explored. The purpose of this study was to explore associations between nurse's ethnicity and experience, hospital size, accreditation, and teaching status with adverse events in Malaysian private hospitals.

    METHODS: A cross-sectional survey was conducted in 12 private hospitals in Malaysia. A total of 652 (response rate = 61.8%) nurses participated in the study. Data were collected using self-administered questionnaire on nurses' characteristic, adverse events and events reporting, and perceived patient safety.

    RESULTS: Patient and family complaints events were the most common adverse events in Malaysian private hospitals as result of increased cost of care (3.24 ± 0.95) and verbal miscommunication (3.52 ± 0.87).

    CONCLUSION: Hospital size, accreditation status, teaching status, and nurse ethnicity had a mixed effect on patient safety, perceived adverse events, and events reporting. Policy makers can benefit that errors are related to several human and system related factors. Several system reforms and multidisciplinary efforts were recommended for optimizing health, healthcare and preventing patient harm.

    Matched MeSH terms: Risk Management/statistics & numerical data
  12. Samsiah A, Othman N, Jamshed S, Hassali MA
    Int J Clin Pharm, 2020 Aug;42(4):1118-1127.
    PMID: 32494990 DOI: 10.1007/s11096-020-01041-0
    Background Medication errors are the most common types of medical errors that occur in health care organisations; however, these errors are largely underreported. Objective This study assessed knowledge on medication error reporting, perceived barriers to reporting medication errors, motivations for reporting medication errors and medication error reporting practices among various health care practitioners working at primary care clinics. Setting This study was conducted in 27 primary care clinics in Malaysia. Methods A self-administered survey was distributed to family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. Main outcome measures Health care practitioners' knowledge, perceived barriers and motivations for reporting medication errors. Results Of all respondents (N = 376), nurses represented 31.9% (n = 120), followed by doctors (n = 87, 23.1%), pharmacists (n = 63, 16.8%), assistant medical officers (n = 53, 14.1%), pharmacist assistants (n = 46, 12.2%) and family medicine specialists (n = 7, 1.9%). Of the survey respondents who had experience reporting medication errors, 56% (n = 62) had submitted medication error reports in the preceding 12 months. Results showed that 41.2% (n = 155) of respondents were classified as having good knowledge on medication error and medication error reporting. The mean score of knowledge was significantly higher among prescribers and pharmacists than nurses, pharmacist assistants and assistant medical officers (p 
    Matched MeSH terms: Risk Management/statistics & numerical data
  13. Chong VC, Lee PK, Lau CM
    J Fish Biol, 2010 Jun;76(9):2009-66.
    PMID: 20557654 DOI: 10.1111/j.1095-8649.2010.02685.x
    A total of 1951 species of freshwater and marine fishes belonging to 704 genera and 186 families are recorded in Malaysia. Almost half (48%) are currently threatened to some degree, while nearly one third (27%) mostly from the marine and coral habitats require urgent scientific studies to evaluate their status. Freshwater habitats encompass the highest percentage of threatened fish species (87%) followed by estuarine habitats (66%). Of the 32 species of highly threatened (HT) species, 16 are freshwater and 16 are largely marine-euryhaline species. Fish extinctions in Malaysia are confined to two freshwater species, but both freshwater and marine species are being increasingly threatened by largely habitat loss or modification (76%), overfishing (27%) and by-catch (23%). The most important threat to freshwater fishes is habitat modification and overfishing, while 35 species are threatened due to their endemism. Brackish-water, euryhaline and marine fishes are threatened mainly by overfishing, by-catch and habitat modification. Sedimentation (pollution) additionally threatens coral-reef fishes. The study provides recommendations to governments, fish managers, scientists and stakeholders to address the increasing and unabated extinction risks faced by the Malaysian fish fauna.
    Matched MeSH terms: Risk Management
  14. Purmal K, Nambiar P
    Int Dent J, 2009 Jun;59(3):155-60.
    PMID: 19637524
    To study the success and failures of the mediation process of complaints from 2004-2007 by the Complaints Bureau Steering Committee and the Public Complaints Bureau Committee of the Malaysian Dental Association (MDA).
    Matched MeSH terms: Risk Management
  15. Maakip I, Keegel T, Oakman J
    Appl Ergon, 2016 Mar;53 Pt A:252-7.
    PMID: 26499952 DOI: 10.1016/j.apergo.2015.10.008
    Musculoskeletal disorders (MSDs) are a major occupational health issue for workers in developed and developing countries, including Malaysia. Most research related to MSDs has been undertaken in developed countries; given the different regulatory and cultural practices it is plausible that contributions of hazard and risk factors may be different. A population of Malaysian public service office workers were surveyed (N = 417, 65.5% response rate) to determine prevalence and associated predictors of MSD discomfort. The 6-month period prevalence of MSD discomfort was 92.8% (95%CI = 90.2-95.2%). Akaike's Information Criterion (AIC) analyses was used to compare a range of models and determine a model of best fit. Contributions associated with MSD discomfort in the final model consisted of physical demands (61%), workload (14%), gender (13%), work-home balance (9%) and psychosocial factors (3%). Factors associated with MSD discomfort were similar in developed and developing countries but the relative contribution of factors was different, providing insight into future development of risk management strategies.
    Matched MeSH terms: Risk Management
  16. Somboonsook B, Wakerman J, Hattch CT, Collison M, Barnes A, Kyi W, et al.
    Med J Malaysia, 1995 Sep;50(3):212-20.
    PMID: 8926897
    This study was the first assessment of a nationwide risk approach system to antenatal management introduced to Malaysia in 1989. Three rapid, record-based surveys on three different study groups were conducted to determine risk factor prevalence, accuracy of risk assignment, action after risk assignment and the relationship of risk level and place of delivery. The most frequent risk factors were short birth interval, high parity and first pregnancy. Accuracy of risk assignment was highest at the lowest levels of risk and poorest at the highest levels. Women at the lowest levels of risk were more likely to be seen by a doctor than women at highest risk. These was a trend to deliver in hospital, rather than at home, as level of risk increased; but many women at high risk still delivered at home. Recommendations are made on modifications to the system prior to future evaluation.
    Matched MeSH terms: Risk Management
  17. Dikshit A, Pradhan B, Alamri AM
    Sci Total Environ, 2021 Feb 10;755(Pt 2):142638.
    PMID: 33049536 DOI: 10.1016/j.scitotenv.2020.142638
    Drought forecasting with a long lead time is essential for early warning systems and risk management strategies. The use of machine learning algorithms has been proven to be beneficial in forecasting droughts. However, forecasting at long lead times remains a challenge due to the effects of climate change and the complexities involved in drought assessment. The rise of deep learning techniques can solve this issue, and the present work aims to use a stacked long short-term memory (LSTM) architecture to forecast a commonly used drought measure, namely, the Standard Precipitation Evaporation Index. The model was then applied to the New South Wales region of Australia, with hydrometeorological and climatic variables as predictors. The multivariate interpolated grid of the Climatic Research Unit was used to compute the index at monthly scales, with meteorological variables as predictors. The architecture was trained using data from the period of 1901-2000 and tested on data from the period of 2001-2018. The results were then forecasted at lead times ranging from 1 month to 12 months. The forecasted results were analysed in terms of drought characteristics, such as drought intensity, drought onset, spatial extent and number of drought months, to elucidate how these characteristics improve the understanding of drought forecasting. The drought intensity forecasting capability of the model used two statistical metrics, namely, the coefficient of determination (R2) and root-mean-square error. The variation in the number of drought months was examined using the threat score technique. The results of this study showed that the stacked LSTM model can forecast effectively at short-term and long-term lead times. Such findings will be essential for government agencies and can be further tested to understand the forecasting capability of the presented architecture at shorter temporal scales, which can range from days to weeks.
    Matched MeSH terms: Risk Management
  18. Lay US, Pradhan B, Yusoff ZBM, Abdallah AFB, Aryal J, Park HJ
    Sensors (Basel), 2019 Aug 07;19(16).
    PMID: 31394777 DOI: 10.3390/s19163451
    Cameron Highland is a popular tourist hub in the mountainous area of Peninsular Malaysia. Most communities in this area suffer frequent incidence of debris flow, especially during monsoon seasons. Despite the loss of lives and properties recorded annually from debris flow, most studies in the region concentrate on landslides and flood susceptibilities. In this study, debris-flow susceptibility prediction was carried out using two data mining techniques; Multivariate Adaptive Regression Splines (MARS) and Support Vector Regression (SVR) models. The existing inventory of debris-flow events (640 points) were selected for training 70% (448) and validation 30% (192). Twelve conditioning factors namely; elevation, plan-curvature, slope angle, total curvature, slope aspect, Stream Transport Index (STI), profile curvature, roughness index, Stream Catchment Area (SCA), Stream Power Index (SPI), Topographic Wetness Index (TWI) and Topographic Position Index (TPI) were selected from Light Detection and Ranging (LiDAR)-derived Digital Elevation Model (DEM) data. Multi-collinearity was checked using Information Factor, Cramer's V, and Gini Index to identify the relative importance of conditioning factors. The susceptibility models were produced and categorized into five classes; not-susceptible, low, moderate, high and very-high classes. Models performances were evaluated using success and prediction rates where the area under the curve (AUC) showed a higher performance of MARS (93% and 83%) over SVR (76% and 72%). The result of this study will be important in contingency hazards and risks management plans to reduce the loss of lives and properties in the area.
    Matched MeSH terms: Risk Management
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