Displaying publications 41 - 60 of 1065 in total

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  1. Yun YS, Jaapar SZS, Fadzil NA, Cheng KY
    Malays J Med Sci, 2018 Nov;25(6):127-136.
    PMID: 30914886 MyJurnal DOI: 10.21315/mjms2018.25.6.13
    Background: Caregivers of patients with mental illness are exposed to stigma. The internalisation of this stigma among caregivers is known as affiliate stigma and can be measured by the Affiliate Stigma Scale (ASS). The aim of this study was to validate the Malay version of the ASS.
    Methods: A cross-sectional study was performed from May to December 2017 with 372 caregivers of patients with mental illness. The ASS was first translated into Malay using standard forward and backward translation procedures. The final version of the ASS-Malay (ASS-M) was completed by participants. The data analyses involved assessment of construct validity by exploratory factor analysis, confirmatory factor analysis and construct reliability.
    Results: The final model of the ASS-M consists of four factors with 21 items, as compared to the original version, which has three factors with 22 items. The results showed that the final model has good model fit based on RMSEA (0.065) and SRMR (0.055) and a satisfactory composite reliability (affective = 0.827, cognitive = 0.857, behaviour = 0.764, self-esteem = 0.861).
    Conclusion: The study showed that the four-factor, 21-item ASS-M model has good psychometric properties. The scale is valid and reliable for measuring affiliate stigma among caregivers of patients with mental illness in Malaysia.
  2. Yun TC, Ahmad SR, Quee DKS
    Malays J Med Sci, 2018 May;25(3):56-66.
    PMID: 30899187 DOI: 10.21315/mjms2018.25.3.6
    Background: Young adults are at risk of developing obesity, especially when transitioning into university life as they become responsible for their daily eating and lifestyles. This study estimates the prevalence of overweight/obesity and explores the eating patterns and lifestyle practices of university students.

    Methods: A cross-sectional study was conducted at Universiti Brunei Darussalam (UBD). A total of 303 students participated. Data was collected from January to April 2016. Self-designed questionnaires comprised questions pertaining to current weight, self-reported height data, information on eating habits, exercise and knowledge of the food pyramid. The collected data were used to compare and contrast eating habits and lifestyle practices among overweight/obese students with those of non-overweight/obese students.

    Results: The prevalence of overweight/obesity was 28.8% (95% CI: 24.0%, 34.0%). The majority ate regular daily meals, but more than half skipped breakfast. Frequent snacking, fried food consumption at least three times per week and low intake of daily fruits and vegetables were common. The frequency of visits to fast food restaurants was significantly higher in the overweight/obese. 25.4% of the students exercised at least three times per week. Almost all students are aware of balanced nutrition and the food pyramid.

    Conclusions: Most university students had poor eating habits, although the majority had good nutrition knowledge. By way of recommendation, the university is encouraged to provide a multi-disciplinary team specialising in health promotion that includes nutrition and physical activity programmes to increase the awareness among the university students.

  3. Yudin ZM, Yaacob LH, Hassan NB, Ismail SB, Draman N, Yusoff SSM
    Malays J Med Sci, 2017 May;24(3):44-50.
    PMID: 28814932 MyJurnal DOI: 10.21315/mjms2016.24.3.6
    BACKGROUND: Statins are a class of potent drugs that can be used to reduce cholesterol, especially low-density lipoprotein cholesterol (LDL-C). However, their effectiveness is limited if adherence to treatment is poor. The objectives of the study are to estimate the proportion of diabetic patient who has achieved LDL-C goal and to determine the association of LDL-C achievement with socio demographic factors and statin therapy adherence.

    METHODS: This is a cross-sectional study involving 234 patients with type 2 diabetes mellitus (T2DM) and dyslipidaemia attending an outpatient clinic in a hospital in Kelantan. Interviews and self-administered questionnaires were used to determine their sociodemographic and clinical characteristics. Adherence to therapy was assessed using the Medication Compliance Questionnaire (MCQ). The associations between the achievement of LDL targets and sociodemographic/clinical factors, including adherence, were analysed with simple logistic regression.

    RESULTS: About 37.6% of patients achieved their LDL-C target. The percentage of patients who adhered to statin use was 98.3%, and 20.5% of these patients reported full adherence. There was no significant association between achievement of LDL-C targets with adherence or any other sociodemographic factors, such as age, gender and educational or economic status (all P-value < 0.05).

    CONCLUSION: Despite a high level of adherence, the majority of patients failed to achieve LDL-C targets. More concerted efforts are needed to improve this.

    Study site: primary
    care clinic in Hospital Universiti Sains Malaysia,
  4. Youssef EF, Shanb AA
    Malays J Med Sci, 2016 Nov;23(6):83-93.
    PMID: 28090182 DOI: 10.21315/mjms2016.23.6.9
    BACKGROUND: Aging is associated with a progressive decline in physical capabilities and a disturbance of both postural control and daily living activities. The aim of this study was to evaluate the effects of supervised versus home exercise programs on muscle strength, balance and functional activities in older participants.

    METHODS: Forty older participants were equally assigned to a supervised exercise program (group-I) or a home exercise program (group-II). Each participant performed the exercise program for 35-45 minutes, two times per week for four months. Balance indices and isometric muscle strength were measured with the Biodex Balance System and Hand-Held Dynamometer. Functional activities were evaluated by the Berg Balance Scale (BBS) and the timed get-up-and-go test (TUG).

    RESULTS: The mean values of the Biodex balance indices and the BBS improved significantly after both the supervised and home exercise programs (P < 0.05). However, the mean values of the TUG and muscle strength at the ankle, knee and hip improved significantly only after the supervised program. A comparison between the supervised and home exercise programs revealed there were only significant differences in the BBS, TUG and muscle strength.

    CONCLUSIONS: Both the supervised and home exercise training programs significantly increased balance performance. The supervised program was superior to the home program in restoring functional activities and isometric muscle strength in older participants.

  5. You HW, Tajuddin NSA, Anwar YAS
    Malays J Med Sci, 2019 Sep;26(5):113-121.
    PMID: 31728123 MyJurnal DOI: 10.21315/mjms2019.26.5.10
    Background: This study is aimed to analyse the availability, prices and affordability of medicines for ischaemic heart disease (IHD) in Bangi, Selangor, Malaysia.

    Methods: A quantitative research was carried out using the methodology developed by the World Health Organization and Health Action International (WHO/HAI). The prices were compared with international reference prices (IRPs) to obtain a median price ratio. The daily wage of the lowest paid unskilled government worker was used as the standard of the affordability for the medicines. In this study, ten medicines of the IHD were included. The data were collected from 10 private medicine outlets for both originator brand (OB) and lowest-priced generic brand (LPG) in Bangi, Selangor.

    Results: From the results, the mean availability of OB and LPG were 30% and 42%, respectively. Final patient prices for LPG and OB were about 10.77 and 24.09 times their IRPs, respectively. Medicines that consumes more than a day's wage are considered unaffordable. Almost half of the IHD medications cost more than one day's wage. For example, the lowest paid unskilled government worker would need 1.4 days' wage for captopril, while 1.2 days' wage to purchase enalapril for LPG. Meanwhile, for OB, the costs rise to 3.4 days' wage for amlodipine and 3.3 days' wage for simvastatin.

    Conclusion: The findings of this study emphasise the need of focusing and financing, particularly in the private sector, on making chronic disease medicines accessible. This requires multi-faceted interventions, as well as the review of policies and regulations.

  6. Yong R
    Malays J Med Sci, 2013 Oct;20(5):1-4.
    PMID: 24643391
    Our objective is to enable the blind to use smartphones with touchscreens to make calls and to send text messages (sms) with ease, speed, and accuracy. We believe that with our proposed platform, which enables the blind to locate the position of the keypads, new games and education, and safety applications will be increasingly developed for the blind. This innovative idea can also be implemented on tablets for the blind, allowing them to use information websites such as Wikipedia and newspaper portals.
  7. Yikilmaz AŞ, Akinci S, Bakanay ŞM, Dilek İ
    Malays J Med Sci, 2020 Feb;27(1):70-77.
    PMID: 32158346 DOI: 10.21315/mjms2020.27.1.7
    Introduction: Vitamin D, which is known for its effects on calcium and bone metabolism, has recently been associated with haematological malignancies. We aimed to investigate the relationship between disease findings and vitamin D deficiency in essential thrombocythemia (ET) and polycythemia vera (PV).

    Material and Methods: This retrospective cohort study conducted in Turkey included 73 patients diagnosed with PV or ET according to WHO criteria between 2012 and 2018. Vitamin D deficiency was defined as 25-OH vitamin D < 20 ng/mL. Polymerase chain reaction (PCR) was used to detect the Janus kinase 2 (JAK2) V617F mutation.

    Results: Vitamin D deficiency was found in 66.7% of PV and 74.2% of ET patients. The median follow-up time of ET and PV patients was 48 months and 47 months, respectively. Patients with the JAK2 mutation had a higher prevalence of a history of thrombosis and age older than 65 years. There was a significant relationship between JAK2 positivity and vitamin D deficiency.

    Conclusion: There was a remarkably higher prevalence of vitamin D deficiency in JAK2 mutation-positive ET and PV patients. These patients should be carefully evaluated for vitamin D deficiency. More studies are required to further investigate the association between JAK2 and vitamin D.

  8. Yi LS, Alias A, Ghani ARI, Bidin MBL
    Malays J Med Sci, 2019 May;26(3):64-71.
    PMID: 31303851 MyJurnal DOI: 10.21315/mjms2019.26.3.5
    Introduction: The present study analysed the (i) remission and preservation of hormones, (ii) endocrinological and anatomical complications and (iii) visual improvement after endoscopic transsphenoidal surgery (ETS).

    Methods: The retrospective observational study of all consecutive cases of pituitary adenoma treated with ETS in Hospital Kuala Lumpur (HKL) between 2006 and 2015. Age, sex, pre- and post-operative hormone level, tumour size, and complications were noted.

    Results: A total of 67 patients were diagnosed with non-functioning pituitary adenoma throughout this period. Of these, 11 patients had both visual and hormonal improvement post-operation. Of the 27 patients with tumour invaded into the cavernous sinus, 13 showed an improved vision. In the adenoma patients who had impaired hormonal function before the surgery, the hormone level normalised post-surgery in 42 patients. Moreover, 39 patients were diagnosed with functioning pituitary adenoma. Ten patients recovered from acromegaly and four patients recovered from Cushing disease within seven days post-operative. Also, five patients with functioning adenoma suffered complications.

    Conclusion: Outcome for the preservation and hormone recovery in non-functioning pituitary adenoma group was satisfactory, with only one patient's hormonal level worsening. No visual deterioration and mortality were detected throughout this study. A dedicated team specialised in endoscopic transsphenoidal pituitary surgery further improved the outcome of this surgical method.

  9. Yeo L, Fan SH, Say YH
    Malays J Med Sci, 2012 Jan;19(1):43-51.
    PMID: 22977374 MyJurnal
    BACKGROUND: Cocaine- and amphetamine-regulated transcript (CART) is a hypothalamic anorectic neuropeptide that controls feeding behaviour and body weight. The study objective was to investigate the association of the CART prepropeptide gene (CARTPT) rs2239670 variant with obesity and its related anthropometric indicators among patients of a Malaysian health clinic in Kampar, Perak, Malaysia.
    METHODS: A total of 300 Malay/Peninsular Bumiputera, Chinese, and Indian subjects (115 males, 185 females; 163 non-obese, 137 obese) were recruited by convenience sampling, and anthropometric measurements, blood pressures, and pulse rate were taken. Genotyping was performed using AvaII polymerase chain reaction-restriction fragment length polymorphism.
    RESULTS: Genotyping revealed 203 (67.7%), 90 (30.0%), and 7 (2.3%) subjects with the GG, GA, and AA genotypes, respectively, with a minor allele (A) frequency of 0.17. No significant difference in the CARTPT rs2239670 genotype and allele distribution was found between obese and non-obese subjects, and logistic regression showed no association between the mutated genotypes (GA, AA) and allele (A) with obesity, even after adjusting for age, gender, and ethnicity. Furthermore, the measurements did not differ significantly between the genotypes and alleles. No significant difference in the genotype and allele distribution was found among genders, but they were significantly different among ethnicities (P = 0.030 and P = 0.019, respectively).
    CONCLUSION: CARTPT rs2239670 is not a predictor for obesity among the Malaysian subjects in this study.
    KEYWORDS: Malaysia; anthropometry; cocaine- and amphetamine-regulated transcript protein; genetic association study; obesity; single nucleotide polymorphism
  10. Yelamanchi R, Agrawal H, Durga CK
    Malays J Med Sci, 2020 Dec;27(6):187-189.
    PMID: 33447144 DOI: 10.21315/mjms2020.27.6.16
    Breast complaints are a very common cause of healthcare visits in the female population. They range in severity from benign to malignant, and treatment options vary from simple observation to mastectomy. As healthcare facilities are overburdened with coronavirus disease 2019 (COVID-19) patients, properly triaging patients diagnosed with breast disorders is necessary for the optimal use of limited resources in developing countries. We are proposing a concise triage system for timely intervention among patients with breast disorders during the havoc of the COVID-19 pandemic.
  11. Yee AS, Tharakan J, Idris Z, Bhaskar S, Halim SA, Razak SA, et al.
    Malays J Med Sci, 2017 Dec;24(6):97-102.
    PMID: 29379392 DOI: 10.21315/mjms2017.24.6.12
    Epilepsy surgery has been performed by a few centres in Malaysia, including Hospital Universiti Sains Malaysia (HUSM). To date, a total of 15 patients have undergone epilepsy surgery in HUSM. The epilepsy surgery included anterior temporal lobectomy (ATL) with amygdalohippocampectomy (AH) and Vagal nerve stimulation (VNS). The surgical outcomes of the patients were assessed using the International League Against Epilepsy (ILAE) outcome scale. The ILAE scores for patients who underwent ATL with AH were comparatively better than those who underwent VNS. One of the patient who underwent ATL with AH and frontal lesionectomy was found to have psychosis during follow up. Epilepsy surgery has proven to be an important treatment for medically resistant epilepsy. Thus it is important to raise public awareness regarding epilepsy and its treatment.
  12. Yap SF, Boo NY, Pramod DS, Thaw Z, Liew SF, Woo LF, et al.
    Malays J Med Sci, 2020 Mar;27(2):120-128.
    PMID: 32788848 MyJurnal DOI: 10.21315/mjms2020.27.2.13
    Background: Studies on sarcopenia among Malaysian older people (OP ≥ 60 years of age) living in the community but not in long-term care (LTC) homes have been reported previously. This study aimed to determine the prevalence of sarcopenia and its risk factors in OP in Malaysian LTC homes.

    Methods: This cross-sectional study was conducted with 202 independently mobile OP (males 32%) in seven LTC homes in the Klang Valley of Malaysia. Trained personnel measured their anthropometrics, body composition, gait speed, hand grip strength and timed up-and-go (TUG) duration. Criteria of the European Working Group on Sarcopenia in Older People (EWGSOP) and of the Asian Working Group for Sarcopenia were used to identify the presence of sarcopenia. The mini-nutritional assessment (MNA) was used to determine their nutritional status. Additionally, logistic regression analysis was performed to identify significant risk factors associated with pre-sarcopenia/sarcopenia.

    Results: Pre-sarcopenia/sarcopenia was detected in 103 (51%) OP. The significant risk factors were body mass index (BMI, weight/height2; adjusted odds ratio [AOR] = 0.44, P < 0.001), percentage of body fat (PBF; AOR = 1.26, P < 0.001), age group (≥ 80 years; AOR = 3.63, P = 0.025) and 'at risk of malnutrition' status (AOR = 2.63, P = 0.049).

    Conclusion: Sarcopenia is common among OP in LCT homes. The risk increases with decreasing BMI, increasing PBF, age ≥ 80 years and suboptimal nutrition status.

  13. Yajid AI, Ab Rahman HS, Wong MPK, Wan Zain WZ
    Malays J Med Sci, 2018 Feb;25(1):5-15.
    PMID: 29599630 DOI: 10.21315/mjms2018.25.1.2
    The incidence of cancer is increasing each year, which generates concerns regarding the efficacy of the current treatment options. This has caused patients to seek alternatives to complement or to replace surgery, chemotherapy and radiotherapy.Annona muricataand other plants have been shown to have promising compounds that can be utilised in the treatment of cancer. Native to the tropical and subtropical parts of the world,A. muricataplant extracts contain compounds that are particularly effective against cancer cells. In light of increasing concerns regarding the limitations of cancer treatment in hospitals, this review attempts to highlight the benefits ofA. muricataand its potential to be integrated as one of the treatment options against cancer.
  14. Yaakob Y, Rodrigues KF, Opook F, William T, John DV
    Malays J Med Sci, 2017 Oct;24(5):44-51.
    PMID: 29386971 DOI: 10.21315/mjms2017.24.5.5
    Background: Synthetic biology is emerging as a viable alternative for the production of recombinant antigens for diagnostic applications. It offers a safe alternative for the synthesis of antigenic principles derived from organisms that pose a high biological risk.

    Methods: Here, we describe an enzyme-linked immunosorbent assay (ELISA) using the synthetic recombinant LipL32 (rLipL32) protein expressed in Escherichia coli for the detection of Leptospira-specific antibodies in human serum samples. The rLipL32-based ELISA was compared with a microscopic agglutination test (MAT), which is currently used as the gold standard for the diagnosis of leptospirosis.

    Results: Our results showed that all the MAT-positive serum samples were positive for Leptospira-specific IgG in an ELISA, while 65% (n = 13) of these samples were also positive for Leptospira-specific IgM. In the MAT-negative serum samples, 80% and 55% of the samples were detected as negative by an ELISA for Leptospira-specific IgM and IgG, respectively.

    Conclusion: An ELISA using the synthetic rLipL32 antigen was able to distinguish Leptospira-specific IgM (sensitivity 65% and specificity 80%) and IgG (sensitivity 100% and specificity 55%) in human serum samples and has the potential to serve as a rapid diagnostic test for leptospirosis.

  15. Yaacob Y, Zakaria R, Mohammad Z, Ralib AR, Muda AS
    Malays J Med Sci, 2011 Oct;18(4):98-102.
    PMID: 22589680
    Central venous catheter placement is indicated in patients requiring long-term therapy. With repeated venous catheterisations, conventional venous access sites can be exhausted. This case illustrates the expanding role of radiology in managing difficult venous access. We present a case of translumbar, transhepatic, and transcollateral placement of central catheter in a woman with a difficult venous access problem who required lifelong parenteral nutrition secondary to short bowel syndrome. This case highlights the technical aspects of interventional radiology in vascular access management.
  16. Yaacob MJ
    Malays J Med Sci, 2006 Jan;13(1):21-4.
    PMID: 22589586
    Psychoanalysts believed that early mother-child relationships form the prototype of all future relationships and the outcome of adolescents development depends on their ego-strength. Object relations theory believed that intrapsychic process mediates interpersonal interaction to develop a sense of secure self and adolescents must relinquish the internalized other in order to develop a more mature sense of self. Social-relation theory believed that mothers and fathers provide different socialization experiences. Self-esteem depends on the functioning of the whole family in which adolescent is intimately related to the dyadic relationship in a family. There is an association between interparental conflict and adolescent's self-esteem and problem behaviour.
  17. Yaacob BM
    Malays J Med Sci, 1999 Jul;6(2):30-1.
    PMID: 22589687 MyJurnal
    Munchausen syndrome by proxy is a rare disorder in child psychiatric practice. A case of Munchausen syndrome by proxy that was managed in the Child Psychiatric clinic, Universiti Sains Malaysia Hospital is reported. Factors that suggest the diagnosis are discussed. Multidisciplinary approach to the management of such cases is warranted.
  18. Wui NB, Ahmad Anuar MA, Abdul Wahid AM
    Malays J Med Sci, 2020 Jul;27(4):64-71.
    PMID: 32863746 MyJurnal DOI: 10.21315/mjms2020.27.4.6
    Background: The management of fractures around the knee in the elderly population can be challenging due to the complexity of the patients and the fracture characteristics. In this study, we aimed to investigate the short-term outcome of elderly patients who had fractures around the knee and who were treated with primary total knee arthroplasty. The study included patients who were at least 70 years old with poor bone quality and who presented with a fracture around the knee that would be difficult to treat with open reduction and internal fixation (ORIF) as well as patients who were at least 55 years old presenting with severe concomitant knee osteoarthritis.

    Methods: This is a cross-sectional study in which all the elderly patients who underwent early primary total knee replacement due to trauma around the knee at the Segamat Hospital between January 2015 and June 2019 were identified. Data were collected from clinical and operative notes. The clinical outcomes of these patients were evaluated by the range of motion of the knee and the Knee Society Score (KSS).

    Results: Ten patients were identified to have undergone this procedure. Six patients sustained supracondylar femur fractures, two patients had tibial plateau fractures and two patients had concurrent supracondylar femur and tibial plateau fractures. The mean follow-up duration was 22.3 ± 13.9 months, the mean knee score was 87.7 ± 10.0 and the mean functional knee score was 56 ± 41.9.

    Conclusion: In this cohort, good short-term outcomes close to pre-fracture condition was noted in patients who did not suffer from any complications during the post-operative period. Two patients who had surgical site infection had lower functional knee scores. Another two patients with lower knee scores experienced surgical site infection of the distal tibia and contralateral fixed flexion deformity of the knee. Early primary total knee replacement remains a viable option in treating fractures around the knee in the elderly. Infection, which in this study affected 20% of the patients, is the main deterring factor in performing this procedure.

  19. Wu SK, Wong JE, Poh BK
    Malays J Med Sci, 2023 Dec;30(6):108-119.
    PMID: 38239253 DOI: 10.21315/mjms2023.30.6.11
    BACKGROUND: Understanding of psychosocial factors of physical activity (PA) in children is crucial in encouraging sustained PA, which in turn is associated with important health outcomes. This study aimed to examine how children's attraction to physical activity (CAPA) is associated with PA.

    METHODS: This cross-sectional study was conducted among 219 primary school children (105 boys; 114 girls) aged 7 years old-10 years old in Kuala Lumpur, Malaysia in 2016-2017. Children from three main ethnicities, namely Malay, Chinese and Indian, were recruited. Weight, height and waist circumference were measured; body composition was assessed by deuterium dilution technique. CAPA and level of PA were obtained through self-administered questionnaires and reported as CAPA and PA scores.

    RESULTS: Median CAPA and PA scores were 3.40 (Q1 = 3.00, Q3 = 3.80) and 2.31 (Q1 = 1.95, Q3 = 2.74), respectively. Significant gender differences were found in CAPA and PA scores, with boys being more attracted to PA (3.16 [Q1 = 2.90, Q3 = 3.44]; P = 0.001) and more physically active compared with girls (2.47 [Q1 = 2.07, Q3 = 3.07]; P = 0.001). CAPA and PA scores correlated positively in both sexes. Boys scored higher than girls in 'liking of games and sports' (ρ = 0.301, P = 0.002) and 'liking of vigorous PA' (ρ = 0.227, P = 0.02) CAPA subscales, which also correlated positively with PA scores. Girls' PA scores correlated with 'peer acceptance in games and sports' (ρ = 0.329, P < 0.001).

    CONCLUSION: Boys are more physically active and have higher attraction to PA compared with girls. Differences in PA scores between the sexes were related to gender differences in CAPA scores. Thus, attention should be given to gender differences in CAPA related psychosocial factors when planning interventions to promote PA among children.

  20. Wong YP, Tan GC, Aziz S, Pongprakyun S, Ismail F
    Malays J Med Sci, 2015 Jul-Aug;22(4):76-80.
    PMID: 26715912 MyJurnal
    Overexpression of beta-human chorionic gonadotropin (β-hCG) is frequently associated with germ cell tumours, especially choriocarcinoma. Ectopic secretion of β-hCG by non-small cell lung cancer is exceptional. We present an exceedingly rare case of pulmonary adenocarcinoma that secretes β-hCG. Our patient is a 62-year-old postmenopausal woman, a nonsmoker, who presented with a six-month history of progressive dyspnoea, associated with decreased appetite and significant weight loss. Her serum β-hCG was very high (11211.9 mIU/ml), which prompted investigations to exclude germ cell tumour. Radiological imaging revealed a 10-cm right lung mass with adrenal metastasis. No other focal lesions were detected. Microscopy of the lung biopsy specimen showed replacement of normal lung tissue by sheets of malignant cells, forming vague glands in some areas. Immunohistochemically, the malignant cells showed focal immunopositivity for thyroid transcription factor 1 (TTF-1), napsin A, cytokeratin 7 (CK7) and β-hCG. A diagnosis of β-hCG-secreting pulmonary poorly differentiated adenocarcinoma was rendered. Serum β-hCG level decreased significantly to 168.6 mIU/ml after the first cycle of chemotherapy. In conclusion, β-hCG expression in lung cancer should be recognised to facilitate prompt diagnosis and initiation of appropriate intervention.
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