University of Thi-Qar Journal Of Medicine

Transobturator Tape (TOT) in Management of Female Stress Urinary Incontinence

2019-08-02T16:20:32+00:00

BACKGROUND

Transobtorator tape (TOT) is a minimally invasive procedure that gained increased popularity in the surgical field for management of patients with stress urinary incontinence . The use of TOT had significantly simplified the surgical procedure and made it safer.

OBJECTIVES

To evaluate the safety and efficacy of the TOT procedure in women with SUI

PATIENTS AND METHOD

Thirty female patient are complaining of urinary incontinence presented at urology department of Ghazi Al-Hariri surgical specialties hospital from January 2012-Oct. 2013 were enrolled in this study. All of our patients are with pure SUI. The procedure was done under spinal anesthesia. TOT require placement of macroporous polypropylene tape at the mid urethra through the obturator membrane with minimal vaginal incision. The patients were followed up before discharge, 1 month and six month using cough test.

RESULTS

Mean patients age is 48.2 year (range 30-60 year) with a mean parity of 5(range from 3-7 child). The mean operating time is 26.5 minutes (ranging from 20-30 minutes). Intraoperative complications occur in 6 patients (20%), include hemorrhage in 5 patients, hematoma in one patient. The total incidence of postoperative complication was 36%, transient thigh pain occurred in seven patients, two patients got retention, two patients got de novo urgency. The objective cure rate was 93.3%

CONCLUSION

The TOT procedure is a safe and effective technique for the management of patient complaining of SUI.

Molecular Characterization Of MDR3 And MDR4 Genes Of Aspergillus Fumigates Isolated From Lung Disease Patients

2019-08-02T16:59:00+00:00

Background:Triazoles are the mainstay of treatment for aspergillosis. However, azole resistance is an emerging problem reported worldwide in Aspergillus infection mainly caused by A.fumigatus. Increase azole resistance in A.fumigatus has reported with treatment failure and become a significant challenge in effective management of aspergillosis.

Aim: The aim of this study is to investigate the triazole-resistant of A. fumigatus and underlying MDR pump genes in viable clinical isolates which obtained from patients suffering pulmonary infections in Thi-Qar province.

Methods:The conventional Polymerase Chain Reaction (PCR) was used to confirm antifungal resistance by detecting the presence of MDR pump genes (MDR3 and MDR4).

Results:The results of using this technique showed that A. fumigatusisolates were positive to MDR pump genes with 90% and 96% for MDR3 and MDR4 genes, respectively.

Conclusions: Our study revealed that the MDR pump genes are predominant in azole resistance isolates. Furthermore, PCR was proven to be highly effective method for identifying these genes.

Establishment Of Chronic Strongyloides ratti Infection Model And Its Diagnostic Significance

2019-08-02T17:28:37+00:00

Infection with Strongyloides stercoralis is associated with asymptomatic chronic disease involving the gut and respiratory systems and can persist for long period undetected leading to development of fatal hyperinfection syndrome. The severity is even more in immunocompromised individuals or patients undergoing immune suppressive therapy. Unfortunately the disease is difficult to diagnose due to low parasite load and the irregular larval output. Development of efficient diagnostic techniques requires large supply of infective larvae and this can be achieved through in vivo maintenance of the parasite. In this regard, S. ratti is being used as a model instead of S. stercoralis due to difficulty and risk of infection. In this study, a significant amount of previously characterized filariform (iL3) larvae of S. ratti was collected. Chronic infection was successfully established and maintained by experimentally induced immunosuppression of Wistar rats following oral administration of prednisolone. This model can serve as a good source of infective larvae for production of monoclonal antibodies and development of diagnostic assays for prevention of the disease. It can also provide room for further research in diagnostics of human strongyloidiasis.

Risk Factors For Major Amputation In Diabetic Foot Patients

2019-08-02T17:45:38+00:00

Objectives : this study to identify the clinical and laboratory factors associated with the risk factors of major amputation in diabetic foot patients.

Patents, materials and method: this is cross sectional study carried out in Basra general hospital between November 2013 to June 2016. 100 diabetic foot patients evaluated for duration of the illness, type of diabetes, socioeconomic state, smoking history, previous amputation, retinopathy, nephropathy, neuropathy, cardiac disease, foot deformities. The foot ulcers were classified according to Wagner classification, foot ischemia was assessed by Doppler study, baseline laboratory investigations done include Hb%, WBC, ESR, Fasting blood sugar, Hb A1c, blood urea, serum creatinine, serum albumin, ECG, Chest x-ray.

Results: number of risk factors found to be associated with risk of major amputation in diabetic foot patient include male sex, age>60 years, nephropathy, retinopathy, neuropathy, foot deformity, previous amputation, duration of diabetes >15 years, low socioeconomic state, Hb<10gm/dl, ESR>80, Hb A1c>8%, serum albumin<2.5gm/dl, Doppler score>6, high Wagner score.

Conclusion:

Wagner grade 4 and 5 are the major independent risk factor for major amputation.
WBC count is poor predictor for the severity of diabetic foot.
Scoring system can be arranged for each patient according which appropriate decision can be made amputation and conservative treatment.

Table 1: Diabetic Foot Scoring System

Number	Risk factor	score
1	Male sex	1
2	Age > 60 year	1
3	DM duration > 16year	1
4	Wagner grade 4 and 5	One for each
5	Smoking	1
6	Low socioeconomic state	1
7	Neuropathy	1
8	Nephropathy	1
9	Retinopathy	1
10	Cardiac disease	1
11	Previous amputation	1
12	Foot deformities	1
13	Hb<10gm/dl	1
14	Albumin level<2.5gm/dl	1
15	Fasting blood sugar	1
16	Doppler score	1
17	ESR>80	1
18	Doppler score >6	1
19	Total score	23

In Vitro Antimicrobial Activity and GC-MS Analysis of Crude Aqueous Methanolic Extract Produced from Leaves of Eucalyptus species

2019-08-02T18:01:55+00:00

Objectives:To evaluate the antimicrobial activity of the aqueous methanolic extract was given by the leaves of Eucalyptus sp.growing in Thi-Qar Province, south of Iraq. Additionally, to detect the compounds within the extract by using the technique of gas chromatography-mass spectrometry (GC-MS).

Methodology: The healthy leaves of Eucalyptus sp. were collected, washed with tap water then by distilled water, dried, and pulverized through using a small mill to make the dried leaves as a powder. The leaves powder was extracted by absolute petroleum ether then aqueous methanol (80%) for obtaining a sticky crude extract of the aqueous methanol filtrate. The crude extract was tested against some microbial pathogens as well as analysis of the extract using the technique of GC-MS and phytochemical tests.

Results:The current study showed the antimicrobial activity of the crude aqueous methanolic extract obtained from Leaves ofEucalyptus sp. by which 40000 µg∕ml of the extract exhibited inhibition zones around Staphylococcus aureus, Streptococcus mutans, Escherichia coli, and Klebsiella sp. besides Candida albicans that the inhibition zones were measured to be 30, 27, 26, 30, and 38 mm respectively. The chemical tests appeared the crude extract containsalkaloids, glycosides, flavonoids, tannins, andsaponin glycosides. GC-MS analysis detected constituents of the extract are dimethylsulfoxoniumformylmethylide, diethyl phthalate, benzene,1,1'-(1,2-cyclobutanediyl)bis-trans-,diisoctyladipate, and 2-methyl-7-phenylindole.

Conclusion: The present study concluded that the leaves ofEucalyptussp. possess the bioactive products which are needed to be separatedas the pure compoundsby using techniques of chromatography in order to separately tested in vitro and in vivo, then application of spectrometry techniques for characterization of their chemical structure. Finally, these compounds can be used to treat diseasesas drugs in hospitals.

The Role Of Safe Margin Of Hypermetropia In Protection Against Post Lasik Regression In Myopic Patients

2019-08-02T20:39:21+00:00

Purpose:To determine post lasik aim of refraction in young myopic patient that ensure slight over correction (safe margin of hypermetropiaSMH) which help in reducing possibility of regressionand post lasik myopic shift, however this SMH should be easily overcomedby accommodation , doesn’t affect UCVA or induce eyestrain.

Patients and methods:400 patients (800 eyes) were taken in this study, all of them had myopia and myopic astigmatism with -1.0 to – 6.0 D(spherical equivalent) during the period between 2008-2014 in Nassirya city, south of Iraq. Those patients were divided into 5 groups each group with 80 patients (160 eyes) and planned to have post lasik refraction ofemmetrope, +0.5, +0.75, +1.0 and +1.25 D, for groups from no.1 to no.5 respectively and these groups followed up in term of UCVA, spherical equivalent, myopic shift, and asthenopia (eyestrain) for three years.

Result:Three yearsfollow up for the 5 groups showed that, in group no.1 (27.5%) of eyes had VA of 6/9 or worse, (33.125%) of eyes had myopic shift and(11.25%) of patients had eyestrain. In group no.2 (19.375%) of eyes had VA of 6/9 or worse ( 21.875%) of eyes had myopic shift and (8.75%) of patients had eyestrain. In group no.3 (11.25%)of eyes had VA of 6/9 or worse (9.375%) of eyes had myopic shift and (2.5%) of patients had eyestrain. In group no.4 ( 4.375%) of eyes had VA of 6/9 or worse, no myopic shift and (2.5%) of patients had eyestrain. In group no.5(12.5%) of eyes had VA of 6/9 or worse, no myopic shift and (15%) of patients had eye strain.

Conclusion: In young myopic patients with low to moderate myopia, we can choose post lasik aim of refraction of +1.0 D, this safe margin of hypermetropia SMH can ensure best UCVA without eyestrain (asthenopia), help in reducing regression and myopic shift.

Study of BRCA1 and BRCA2 Gene Mutations and Clinicopathological Criteria of Breast Cancer in Thi-Qar

2019-08-02T21:02:35+00:00

Breast cancer is the commonest type of malignancy in Iraq. For this reason we study risk factors that associated with this disease in Thi Qar province patients. Such as mutations of breast cancer susceptibility genes 1 and 2 (BRCA1 and BRCA2), clinicopathological parameter ( age, family history and tumor site) .

Eighty five blood samples were taken from patients who attended Al-Hussain teaching hospital and oncology unit in Al-Habboby hospital during the period (from August /2014 to April /2017) , fifty blood samples were collected from healthy women as a control. Blood samples were using in genetic study. For histopathological analysis fifty tissue samples were collected from fifty patients with breast cancer who were undergoing surgical resection (mastectomy) to prepare paraffin embedded blocks which have been used for histopathological diagnosis.

The present study results revealed that a highest incidence of breast cancer occur in the age group between 40-49 years of age (41%),there is a significant difference among patients age groups (P ≤ 0.01).

Family history of breast cancer indicates a strong association with risk of developing breast cancer. The present study showed that family history positive in 31 cases (36.47%), and 54 cases (63.52%) had negative family history of breast cancer. Also the results of present study showed that the 34 cases (41.5%) had first birth at age (20-29years), 18 cases (23.37%) had their first birth in age groups (15-19 years) and (30-39 years), and 7 cases (9.09%) had first birth at age (≥40 years). Most of patients (50.5%) breast cancers were located in right breast and (38.8%) of cases breast cancers were located in left side.

Histopathologically, carcinoma was divided into 44 cases (88%) were ductal carcinoma {from which 42 cases(84%) were invasive ductal carcinoma, and 2 cases (4%) were comedocarcinoma}, and 6 (12%) cases were invasive lobular carcinoma. Results revealed that 2 cases (4%) were stage I, 13 cases (26%) were stage II, 24 cases (48%) were stage III and 11 cases (22%) were stage IV, also our results showed that 2 cases (4%) were grade I, 23 cases (46%) were grade II, and 25 cases (50%) were grade III.

The DNA was extracted from blood samples by using Accupower® genomic DNA extraction kit. The concentration and purity of all DNA samples have been measured by Nanodrop. Samples with a purity ranged from 1.7 to 1.9 have been enrolled in this study for the molecular detection of BRCA1/2 gene mutation in patients and control groups. In 85 cases of breast cancer, detection of BRCA1/2 gene mutation by multiplex PCR done for the serum revealed that; (185 del AG) mutation in BRCA1 gene was detected in 6 patients (7.05%), and (5382 ins C) mutation in the same gene was detected in 2

patients (2.35%). Regarding (6174 del T) mutation in BRCA2 gene was detected in 3 patients (3.52%). In the control patients gene mutations of any types didn’t detected.

Assessment Of Joint Hypermobility In Iraqi Patients With Inflammatory Bowel Diseases

2019-08-02T21:16:01+00:00

Background

Joint hypermobility is a common condition characterized by joint laxity and an increased range of joint motion and may be associated with joint pain. joint pain is common in inflammatory bowel disease (IBD) and is often attributed to seronegative arthropathy.

Objective

To assess JHM in Iraqi patients with IBD and to evaluate the associates of this possible relationship.

Patients And Method

A case-control study was conducted on 83 patients with IBD who were randomly seen between December 2014 and June 2015 at the gastrointestinal and liver diseases center of the medical city and the endoscopy unit of Baghdad Teaching Hospital compared to a 83 healthy individuals served as a control group who were randomly selected during the period of the study and matched for age and sex to the patient group.. Full history was taken and complete clinical examination was done for all individuals in both groups . Beighton’s Score for joint hypermobility was performed on patients and controls.

Results

Joint hypermobility was found in 12(14.5%) of IBD patients and 10 12% in healthy controls (p> 0.05) JHM was present and 6(17.6%) of 34 CD patients and 6 12.2% of 49 UC patients (P> 0.05).

The presence of JHM was significantly associated with younger age, short in duration of the disease, positive family history of JHM and low BMI (p< 0.05).

Conclusion

JHM was comparable in IBD and controls. Younger age, short duration of the disease, positive family history of JHM and low BMI were significant associates with JHM.

Study Of TiO2 Nanoparticles Induction For Biological System

2019-08-02T21:26:40+00:00

Background:

The biological activity of NPs strongly depends on physicochemical parameters but these are not routinely considered in toxicity screening, such as dose metrics which is studied by many researchers.Titanium dioxide nanoparticles (nano-TiO2) are extensively used in the cosmetics, pharmaceutical, and paint industries as a coloring material due to its high stability, anticorrosion and photocatalytic properties

Aim: This study represents the study of TiO2 nanoparticles induction for biological systems.

Method:Curve fitting in matlab program is used to study the effect of parameters of the system on the cell levels with existence TNPs.

Results:

The Consequences showed that nanoparticles induce human embryonic kidney cells (HEK-293) the generation of reactive oxygen species (ROS) followed by significant depletion of glutathione levels and increased lipid peroxidation.

From the results, we observe that the behavior of can be predicated by estimating the equations which described the variation of culler effecting by increased the TNPs concentration at different exposure times.

Native Radiocephalic Arteriovenous Fistula Creation in Al – Hussein Teaching Hospital ( 2013-2019 ): Review of 50 cases

2019-08-02T21:40:19+00:00

Objective : To present the advantages of native radio-cephalic AVF creation over native brachio-cephalic AVF creation in patients with chronic renal failure and on regular hemo – dialysis.

Patients : This is a retrospective study of 50 patients for whom native radio-cephalic AVF was created in the upper limb under local anesthesia over a period of about seven years ( from 1_st of March 2013 till 1_st of February 2019 ).

Methods: The case sheets of relevant patients for whom an AVF was created were reviewed to collect information like patient's sex, age, site of AVF, type of anastomosis, etc…

Results : Native radio-cephalic AVF creation was offered for different age groups and for both sexes. Side to side anastomosis was carried out for most patients and the preferred site was just above the wrist joint on the lateral aspect of forearm between the radial artery and a nearby superficial vein which was mostly the cephalic vein or one of it's tributaries. The time of first cannulation after AVF creation was variable depending on several factors. Different complications but no mortality had been recorded perioperatively.

Conclusions : Native radio-cephalic AVF creation is always preferred over native brachio-cephalic AVF creation and every effort was made to search for a suitable distally located superficial vein for the purpose of AVF creation.

The region just above the wrist joint on the lateral aspect of forearm was a suitable site for patients with CKD and those with comorbidities because the proximal locations of AVF creation are associated with more complications than the distal ones. Side to side anastomosis for AVF creation was the procedure of choice and the priority was for the non dominant upper limb if possible.

Oxidative Stress Status In Patients With Rheumatoid Arthritis

2019-08-03T14:47:32+00:00

Background:

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis, which is an autoimmune disease characterized by chronic inflammation of synovial joints, ultimately leading to joint destructions and permanent disability.

In RA oxidative stress are impaired (which caused by free radicals) might have an essential role in the etiology of RA.

Objectives:

The objective of this study was to determine oxidative stress by measuring malondialdehyde and enzymatic status by estimating superoxide dismutase, catalase and glutathione peroxidase in patients of RA and then comparing with healthy individuals.

Setting and design:

A total 42 patients with Rheumatoid Arthritis (20 females, 22 males) in the age of 30-50 years were included, as a control, 50 matched healthy volunteers (20 females and 30 males) were involve, non of the subjects smokes nor receiving any form of drugs. Subjects with any acute infections or with coexisting system disease such as coronary artery disease, hypertension or chronic renal failure were excluded.

Methods:

Antioxidant enzymes in erythrocyte , superoxide dismutase (SOD), glutathione peroxidase (Gpx) and Cayalase (CAT) was measured.

Malondialdehyde (MDA) along with Copper, Zink and Iron are measured by using the serum of the patients and control group.

Results:

The serum level of MDL was higher in RA patients compared with the control group, the differences among both groups was statistically significant (P < 0.001)

Conclusion

There is oxidative stress in RA patients evidenced by increased serum MDA and decreased antioxidant enzymes activity.

Histopathological Characters Of Solitary Thyroid Nodule In Patient Undergoing Surgery At 3 Years (2015 - 2017) In Al - Nasiriyah City

2019-08-03T14:57:37+00:00

Background: The morbidity of solitary thyroid nodule to be benign or malignantaffecting different age group and gender are generallynotwellestablished need to more focus about details histopathology and identified the characters of histopathology.

Aim of study: To know histopathological characters of solitary thyroid nodule in patients undergoing in Nasiriya city at (2015_2016_2017).

Patients and method: This cross-sectional analytical study was carried out at the department of general surgery, Al_Hussain teaching hospital. It is retrospective study during 3 years ago(2015,2016,2017).

The study include the collection samples of known cases of solitary thyroid nodule from operation room in ,Al_Hussain teaching hospital for 3 years about 162 cases and send it into histopathology in lab. In same hospital in Nasiriya city about 360 km south Baghdad the capital, and take the result of histopathology from lab. In same hospital.

The study include different ages All age groups were included in this study. Classified into :

Child and adolescence less than 18 years old
Young adult(18_45) years old
Old adult (45_65) years old
Elderly (65years old and above)

And both sexes (male and female).

Results:

A total samples collection to study are 162 of patients with STN during three years (2015-2017),The female (157) and the male( 5 ).

majority of the studied population were female (96.9%), and most of them were at age of 18-45 years (67.9%), followed by the old adult 29.6%, while the other groups were having an equal percent of 1.25%., a studied total number were attending the Al-Hussien teaching hospital mostly coming at the 2016followed by 2017 then 2015.were most of them at the 2016 (41.1%), followed by 2017 (39%), while the 2015 were the smallest proportions of the contributors.

most of the presented cases were with follicular adenoma (57.4%) followed by papillary carcinoma (35.2%) then follicular carcinoma (5.6%), while medullary Ca were the littlest proportion (1.9%).

Child and elderly show no case of lymph node involvement, highest proportion were among adult cases, while the old adult show only (6,3%) L.N involvement , where M.Ca showing no L.N involvement, while(15.8%) of the papillary carcinoma show L.N involvement, regarding follicular Carcinoma only 11.1% of them showing L.N involvement.

Conclusion:

This study showed that solitary thyroid nodules are benign more than malignant found as follicular adenoma, and the most common type of thyroid cancer was papillary thyroid carcinoma. There was no cases of anaplastic carcinoma.

Period-Prevalence Of Vitamin D Deficiency Among Referral Individuals In Sulaimanyah Province

2019-08-03T19:54:56+00:00

BACKGROUND AND OBJECTIVE:

Vitamin D deficiency is recognized as a global public health problem which has effect on the health of the skeletal and extra skeletal tissues. The goal of this study was to determine the prevalence of Vitamin D deficiency in the Sulaimanyah population and to compare different age groups, gender and season of the year.

MATERIALS AND METHODS:

This was a cross sectional study that involved 19,267 patients who visited Sulaimanyah (private and governerate) clinical laboratories, of which 6304 males and 12,963 females their ages ranged between (1-95) years in the period between January 2013 and January 2017, all vitamin D measured by electrochemiluminescence (ECL) techniques were enrolled in this study.

RESULTS:

A total of 19,267 persons were analyzed, the overall vitamin D deficiency (below 20 ng/ml) was 68.1%. The prevalence of vitamin D deficiency was increased in those patients their age groups between 30-39 years (13.6%), was greater among women (48.8%) and more common during winter (19.6%).

CONCLUSION:

The currently available study on the Sulaimanyah population suggests that the Vitamin D deficiency is common. This indicates that strategies are needed at the population level to improve vitamin D status of Sulaimanyah province.

Analysis Of Routine Bacterial Contamination Checking Feedback Of Nasiriyah City Hospitals During 2016

2019-08-03T20:12:41+00:00

Hospital contamination is an important cause of nosocomial infection. This study aims to assess the occurrence of bacterial contamination in 70 different departments of two private and five public hospitals in Nasseriah city (south of Iraq) during 2016. From 50 to 200 swabs collected weekly from each wards, were isolated 213 positive culture bacterial isolates, comprised 11 bacterial species detected by biochemical and enzymatic tests. The contamination was ranged between Pseudomonas species that represent the most contaminant species (30%) to Micrococcus spp. and Citrobacters pp were the fewest (0.46%). Generally, the private hospitals were less contaminated than public ones, the winter and summer months were less contaminated than spring and autumn, and multi- specialty hospital have more contamination than single-specialty one.

A Giant Cerebral Hydatid Cyst Required Urgent Operation: Case Report

2019-08-04T22:15:44+00:00

A case report a Giant Cerebral Hydatid Cyst Required Urgent Operation

University of Thi-Qar Journal Of Medicine

Transobturator Tape (TOT) in Management of Female Stress Urinary Incontinence

BACKGROUND

Transobtorator tape (TOT) is a minimally invasive procedure that gained increased popularity in the surgical field for management of patients with stress urinary incontinence . The use of TOT had significantly simplified the surgical procedure and made it safer.

OBJECTIVES

To evaluate the safety and efficacy of the TOT procedure in women with SUI

PATIENTS AND METHOD

RESULTS

CONCLUSION

The TOT procedure is a safe and effective technique for the management of patient complaining of SUI.

Molecular Characterization Of MDR3 And MDR4 Genes Of Aspergillus Fumigates Isolated From Lung Disease Patients

Aim: The aim of this study is to investigate the triazole-resistant of A. fumigatus and underlying MDR pump genes in viable clinical isolates which obtained from patients suffering pulmonary infections in Thi-Qar province.

Methods:The conventional Polymerase Chain Reaction (PCR) was used to confirm antifungal resistance by detecting the presence of MDR pump genes (MDR3 and MDR4).

Results:The results of using this technique showed that A. fumigatusisolates were positive to MDR pump genes with 90% and 96% for MDR3 and MDR4 genes, respectively.

Conclusions: Our study revealed that the MDR pump genes are predominant in azole resistance isolates. Furthermore, PCR was proven to be highly effective method for identifying these genes.

Establishment Of Chronic Strongyloides ratti Infection Model And Its Diagnostic Significance

Risk Factors For Major Amputation In Diabetic Foot Patients

Objectives : this study to identify the clinical and laboratory factors associated with the risk factors of major amputation in diabetic foot patients.

Conclusion:

Wagner grade 4 and 5 are the major independent risk factor for major amputation.

WBC count is poor predictor for the severity of diabetic foot.

Scoring system can be arranged for each patient according which appropriate decision can be made amputation and conservative treatment.

Table 1: Diabetic Foot Scoring System

Number

Risk factor

score

1

Male sex

1

2

Age > 60 year

1

3

DM duration > 16year

1

4

Wagner grade 4 and 5

One for each

5

Smoking

1

6

Low socioeconomic state

1

7

Neuropathy

1

8

Nephropathy

1

9

Retinopathy

1

10

Cardiac disease

1

11

Previous amputation

1

12

Foot deformities

1

13

Hb<10gm/dl

1

14

Albumin level<2.5gm/dl

1

15

Fasting blood sugar

1

16

Doppler score

1

17

ESR>80

1

18

Doppler score >6

1

Patients : This is a retrospective study of 50 patients for whom native radio-cephalic AVF was created in the upper limb under local anesthesia over a period of about seven years ( from 1_st of March 2013 till 1_st of February 2019 ).