Grande Medical Journal <p>Grande Medical Journal (GMJ) is an annual, open, peer-reviewed interdisciplinary journal that encompasses all fields of medicine and clinical practice. GMJ will be published both in print and online. It will be freely accessible via the journal's website and at NepJOL with open access to the full text of all its articles. There will be no subscription fees to the readers or processing fees for the authors.</p> <p>GMJ seeks to publish original, high-quality, peer-reviewed papers including original clinical and editorials, clinical reviews, and correspondence on matters that will provide comprehensive coverage on all aspects and subspecialties of medicine. GMJ will be initially published with contributions from national and international physicians and scientists.</p> <p>The journal's articles are licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License - CC BY.</a></p> Academic & Research Department, Grande International Hospital en-US Grande Medical Journal 2661-6238 Degenerative spondylolisthesis – Functional outcome after transforaminal lumbar interbody fusion (TLIF) using single cage and without posterolateral fusion (PLF) <p><strong>Introduction</strong></p> <p>Results of surgical treatment of symptomatic degenerative spondylolisthesis (DS) with or without spinal canal stenosis is better than that of the non-operative treatment. Indications for surgical treatment includes: failed adequate trials of non-operative treatment at least for 3 to 6 months, progressive neurological deficits, bowel / bladder involvement. Different surgical options of neural decompression with or without instrumentation have been described in literatures. We present our result of Transforaminal Lumbar Interbody Fusion (TLIF) using single cage and without posterolateral fusion.</p> <p><strong>Material and methods</strong></p> <p>Over a period of 5 years between January 2013 and November 2018, files of 32 patients having Degenerative Spondylolisthesis treated surgically by TLIF procedure have been reviewed retrospectively.</p> <p>All patients’ neurological status, preoperative visual analogue score and modified Oswestry Disability scores were recorded. All patients were subjected to standing antero-posterior and flexion / extension lateral views of lumbo-sacral spine. Percentage of the slip was calculated. They were subjected to Magnetic Resonance Imaging (MRI) to evaluate for amount of neural tissue compromise and status of the adjacent disc. Post-operatively all patients were followed up at 6 weeks, 3 months, 6 months, 1 year and subsequently every year. Post-operative improvement in VAS and ODI were recorded. Post-operative changes in the follow up x-rays were noted.</p> <p><strong>Results</strong></p> <p>There were 18 females and 14 males having average age of 55.19 + 10.14 years. The mean follow up period was 27. 47 <u>+</u> 17.62 months. Preoperative VAS score improved from 8.12 <u>+</u> 1.91 to 1.59 <u>+</u>1.41 and modified ODI reduced to 20 from 68.06 <u>+</u> 7.87 at last follow up. All patients demonstrated significant improvement in walking distance, which was only 40.78 <u>+</u> 36.41 meters before surgery.</p> <p><strong>Conclusions</strong></p> <p>TLIF is one of the viable options for surgical treatment of symptomatic Degenerative Spondylolisthesis with or without spinal canal stenosis. Use of single cage and interbody bone graft obtained from resection of the facet joint and without posterolateral fusion can produce comparable good to excellent results. It avoids morbidity associated with harvesting bone graft from the iliac crest.</p> Binod Bijukachhe Ram Krishna Dahal Javed Ahmad Khan Aayush Shrestha Promish Maharjan Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 1 11 Vascular calcification in breast and its association with atherosclerosis in common carotid artery <p><strong>Introduction</strong></p> <p>Breast arterial calcifications (BAC) seen in mammogram are calcifications of the internal mammary artery. Atherosclerosis, in general, is an independent predictor of acute coronary, cerebrovascular and other vascular diseases. We evaluated the association between common carotid artery intima media thickness (C-IMT) in patients with and without breast arterial calcifications (BAC) on mammogram.</p> <p><strong>&nbsp;</strong></p> <p><strong>Methods</strong></p> <p>This case control study included 108 women who underwent mammographic examination of breast in department of Radiology, TUTH, Maharajgunj, Kathmandu, Nepal. Cases &nbsp;were defined as patients with BAC on mammogram and matched controls without BAC were selected after obtaining ethical clearance from the Institutional Review Committee. Grading of BAC was done.&nbsp; Mean IMT of bilateral Common Carotid Artery (CCA) in cases and controls was measured on sonography.&nbsp; All the relevant data were entered in predesignated proforma and the findings tabulated.&nbsp; The mean IMT was calculated in cases and controls and compared using SPSS statistics.&nbsp; The null hypothesis was tested using independent t test.</p> <p><strong>&nbsp;</strong></p> <p><strong>Results</strong></p> <p>The age ranged from 34 to 78 years. Maximum number of cases had grade &nbsp;BAC score of 1.&nbsp;&nbsp; The mean value of IMT in right CCA was 0.79mm and 0.57mm, &nbsp;that of left CCA was 0.78mm and 0.57 mm in cases and controls, respectively. The mean IMT was higher in patients with higher BAC score. Null hypothesis was rejected by independent t test and odd’s ratio was&gt; 1, showing significance of association between vascular calcification in breast and CCA IMT.</p> <p><strong>&nbsp;</strong></p> <p><strong>Conclusion</strong></p> <p>Our study shows a significant association between the BAC and intima media thickness of CCA, latter being higher in patients with BAC and increasing with grade.</p> Anamika Jha Rabin Kumar Ghimire Benu Lohani Sujit Kumar Jha Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 Outcome prediction in spontaneous intracerebral hemorrhage: A comparative study of ICH, WFNS, and GVS scoring systems <p><strong>Introduction</strong></p> <p>A good predicting scoring system for intracerebral hemorrhage (ICH) has been a concern for decades as this will help in guiding the treatment and prognostication. The most widely accepted one is the Hemphill ICH score, but this conventional scoring system requires complex memorization and calculation making it difficult to apply in clinical practice. Hence, there is a need for a simpler and more accurate scoring system for ICH for prognosis that can be readily determined. This study was undertaken to compare simple scoring systems, such as WFNS, GVS and ICH scores, in predicting in-hospital mortality and outcomes at discharge and at three months in patients with spontaneous ICH. This study was carried out in the Department of Neurosurgery and Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.</p> <p><strong>&nbsp;</strong></p> <p><strong>Materials and Methods</strong></p> <p>Patients with primary spontaneous ICH aged ≥ 16 years admitted in the Department of Neurosurgery and Neurology participated in the study. The ICH, WFNS and GVS scores were measured at the earliest possible time during admission by a single observer. Modified Rankin scale (mRS) was measured at discharge and at three-months follow up. Mortality was used as the primary outcome measure.</p> <p><strong>Results</strong></p> <p>A total of 130 patients were included in the study. The mean age of the study population was 60.7 ± 16 years. There was an increase in mortality rate among ICH cases with higher scores of ICH, WFNS and GVS. The area under ROC curve for ICH, WFNS and GVS scores for prediction of mortality was 0.895 (95 % CI; 0.838 - 0.952; <em>p</em> &lt; 0.001), 0.876 (95 % CI; 0.813 - 0.938; <em>p</em> &lt; 0.001) and 0.887 (95 % CI; 0.823 - 0.950; <em>p</em> &lt; 0.001), respectively, suggesting a good discrimination ability of all these three scores in predicting death. All three scores showed good discrimination ability of good outcomes but only fair prediction of bad outcome.</p> <p><strong>&nbsp;</strong></p> <p><strong>Conclusions</strong></p> <p>Both GVS and WFNS scores are simple, easy to use and comparable to ICH score for the prediction of mortality and good outcome in patients with spontaneous ICH. All three scores are inferior for the prediction of bad outcome. ICH score is marginally better than other two scores in all outcome subgroups but was not statistically significant. In all three outcomes, ICH score was marginally better but comparable with the other two scores.</p> Binod Rajbhandari Gopal Sedain Dipendra Kumar Shrestha Prakash Kafle Amit Bahadur Pradhanang Sushil Krishna Shilpakar Mohan Raj Sharma Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 16 24 Radiological profile in COVID-19 patients during second wave in Nepal Police Hospital: A descriptive cross-sectional study <p><strong>Introduction</strong></p> <p>Chest Radiography is a primary tool available in the clinical assessment for chest manifestation in a patient with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. This study was conducted to determine the utility of chest radiography and characterize the spectrum of chest imaging among COVID-19 patients.&nbsp;</p> <p><strong>Methods</strong></p> <p>We retrospectively reviewed chest radiographs of 370 confirmed COVID-19 patients presenting to Nepal Police Hospital, Kathmandu from 5 May to 20 June, 2021. The pattern of chest radiography was interpreted and the radiography findings were analyzed based on Modified Chest X-ray scoring system to enhance clinical understanding and prompt assessment of the COVID-19 patients. Pearson’s correlation analysis was used to establish the linear correlation between clinical severity and the Modified Chest X-ray severity score.</p> <p><strong>Result</strong></p> <p>&nbsp;Out of 370 confirmed COVID-19 patients, 246 patients (66.49%) were male and 124 patients (33.51%) were female. 185 (50%) patients were admitted from the emergency where 154 (83.24 %) patients among 185 patients were discharged after recovery whereas 31 patients (24 male and 7 female) died. 229 patients in the study showed normal chest X-ray findings. Among 141 patients with abnormal chest radiography, 121 patients (85.81 %) showed bilateral lung involvement with predominantly ground glass opacity and more on peripheral distribution. Lower zone involvement was the most common findings followed by middle zone involvement. On Modified Chest X-ray severity score, 35.46% were mild, 47.51% were moderate and 17.03% were severe. The scoring showed a moderate positive correlation with the clinical severity of the patient.&nbsp;</p> <p><strong>Conclusion</strong></p> <p>Chest radiography pattern and scoring system can be used as tools to predict the disease severity in COVID-19 infection. Chest radiography in conjunction with clinical judgment can enhance specific treatment strategies in COVID-19 infection.</p> Subash Thapa Bijaya Ram Shrestha Santosh Joshi Deepa Nhuchhe Pradhan Nirmal Ghimire Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 29 35 Spontaneous pneumomediastinum in patients with COVID-19: A case series <p>As the COVID-19, pneumonia has evolved into global pandemic and with increase in numbers of various strains, wide range of imaging findings are being recognised. One of the rare imaging findings seen in patients with COVID-19 pneumonia is pneumomediastinum. Although most of the cases of pneumomediastinum are related to barotrauma secondary to iatrogenic intubation and mechanical ventilation, there have been multiple cases presenting with spontaneous pneumomediastinum. Here we describe five different COVID-19 positive patients who were diagnosed with spontaneous pneumomediastinum in CT scan of chest. Exact mechanism regarding this is still being debated nevertheless; one theory states the cause as diffuse alveolar injury due to cytokine storm and inflammatory response. The resultant air then tracks along the peribronchial and perivascular sheath to the mediastinum. Pneumomediastinum can have life threatening consequences and represent poor prognosis of the patients.</p> Prakash Kayastha Sharma Paudel Pradeep Raj Regmi Prasoon Ghimire Govinda Adhikari Santosh Maharjan Rudra Prasad Upadhyaya Sasmita Tuladhar Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 36 42 Evaluation of hand hygiene compliance rates of five years in critical care unit of a tertiary hospital in Nepal <p><strong>Introduction</strong></p> <p>Hand hygiene (HH) has been proven as the most effective measure in controlling healthcare associated infections. However, HH compliance rates among health care workers in hospitals are often significantly low. There are no studies to address HH compliance and interventions to increase compliance in Nepal. We aimed to evaluate the compliance of hand hygiene in critical care setting in a tertiary care center in Nepal.</p> <p><strong>&nbsp;</strong></p> <p><strong>Methods</strong></p> <p>This is a descriptive cross-sectional study conducted from 1<sup>st</sup> January 2016 to 31<sup>st</sup> December 2021 among nurses and physicians working in critical care units of Grande International Hospital in Kathmandu. Data regarding the compliance to hand hygiene were collected. The rate missed opportunities among ‘My five moments of hand hygiene’ were also studied. Data was entered and analyzed in Microsoft Excel. Point estimate at 99% confidence interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data.</p> <p><strong>&nbsp;</strong></p> <p><strong>Results</strong></p> <p>Out of 4908 hand hygiene opportunities observed, compliance rate was found to be 66% (64.26-67.74 at 99% Confidence Interval). Among different health care personnel working in Intensive Care Unit, consultant physicians were found to have highest compliance rate followed by nursing staff.</p> <p><strong>&nbsp;</strong></p> <p><strong>Conclusion</strong></p> <p>Systematically structured hand hygiene strategy along with education programs, continuous monitoring and evaluation, feedback and team approach could result in increased compliance rate but continuous effort is needed to sustain this improvement.</p> Shirish Raj Joshi Reshma Dangol Laxmi Dangol Roshani Rana Sushil Khanal Subash Prasad Acharya Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 43 50 Outcome of tibial fractures in children managed by titanium elastic nailing system (TENS) <p><strong>Introduction</strong></p> <p>Fractures of the tibia are among the most common fractures of the long bone in children and adolescents. Although the most common method of management of tibial shaft is through closed reduction and cast application, operative management may be required in cases such as unstable tibia fractures in which adequate reduction cannot be achieved, loss of reduction of the fracture, fractures associated with other injuries and open fractures. Titanium elastic nailing system (TENS) can be a good option for fractures that are displaced, unstable and difficult to manage in plaster cast. TENS is a simple, minimally invasive, stable and effective method with excellent outcome and minimal complications.</p> <p><strong>&nbsp;</strong></p> <p><strong>Methods</strong></p> <p>This was a prospective study in which children between the ages of 6 to 14 years with diaphyseal fracture tibia treated with intramedullary fixation with TENS. All the patients were followed up for period of at least 6 months. The alignment of fracture, range of motion of knee joint and complications were evaluated during follow-up examinations. The time taken for the union of the fracture was evaluated with the help of the RUST criteria and final outcome was measured by Flynn’s criteria<sup>1</sup>.</p> <p><strong>&nbsp;</strong></p> <p><strong>Results</strong></p> <p>A total of 33 patients (22 were males) with the mean age of 9.51 years were studied. The mean duration of surgery was about 44 minutes. Oblique pattern of fracture was the most common type while middle third of the diaphysis was most commonly involved. The average duration of hospital stay was 7.8 days with average time of union being 11.39 weeks (range: 6-22 weeks). The most common complication seen in 2 patients was skin irritation due to prominence of the implant. None of the fracture had angulation greater than 10 degrees in coronal or sagittal planes and 1 cm of leg length discrepancy (shortening) was seen in a case of comminuted fracture. The outcome according to Flynn’s criteria was excellent in 28 cases, good in 4 cases and fair in 1 case.</p> <p><strong>&nbsp;</strong></p> <p><strong>Conclusions</strong></p> <p>TENS is an effective method that for the treatment of tibial shaft fractures in children in preventing damage to the epiphysis without interfering with fracture hematoma, while avoiding stiffness of the knee and limb length discrepancies and thereby decreasing the morbidity of the patient. The operative procedure is simple, has a low rate of complication, and prevents damage to the growing physis. It allows for early mobilization and decreases the duration of hospital stay.</p> Aayush Shrestha Hemant K Gupta Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 51 57 Challenges faced by the laboratory professionals during COVID-19 pandemic at tertiary care hospital, Kathmandu, Nepal <p>COVID-19 pandemic has affected most sectors of health care services operations and staffs. National lockdown also negatively affected the number of OPD patients and non-essential medical services. Routine laboratory tests declined drastically during the lockdown period. Outsourced tests, quality control, reagent demand and supply, reagent, maintenance of equipment were negatively affected during the pandemic. Staff members faced immense pressure to maintain workplace safety and provide the best service with limited resources. To counter the effects of the pandemic, different strategies and policies were implemented at the department of the laboratory at Grande International Hospital. The limited laboratory workers were divided into different groups as duty shifts to reduce the chances of infection among the co-workers. In this article, we share the challenges and experiences at our work in six-month duration during the pandemic during the first lockdown enforced by the Government of Nepal.</p> Krijan Man Vaidya Bipin Nepal Sabindra Maharjan Bina Gurung Ravi Mahat Nabin Narayan Munankarmi Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 Outcome analysis of decompressive craniectomy in a tertiary center in Nepal <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p><strong>ABSTRACT</strong></p> </div> </div> <div class="layoutArea"> <div class="column"> <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p><strong>Introduction</strong></p> </div> </div> </div> </div> <p>Decompressive Craniectomy (DC) is used as a surgical procedure to treat intractable intracranial hypertension when all other treatments have failed. Role of DC for various pathologies still is uncertain. Our study’s aim was to describe the demographic, clinical, and operative characteristics of patients who underwent DC for various conditions at our tertiary care center and to identify subpopulations that benefit the most from surgical intervention.</p> <p><strong>Materials and Methods</strong></p> <p>All patients who underwent DC in Department of Neurosurgery, Green City Hospital, Kathmandu, Nepal from January 1, 2018 to December 31, 2020 were included in this study. This was a retrospective study and different variables affecting the outcome were analyzed. The follow up period was six months.</p> <p><strong>Results</strong></p> <p>During the course of our study, 68 patients underwent DC with age 21-77 years with a mean age of 46.0 ±13.3 years. The gender ratio was 1.6:1. (42 males to 26 females). Glasgow Outcome Scale (GOS) was used to assess patient outcome. There was better outcome of DC in age &lt;50 years in our study. Patients with GCS less than 8 had unfavorable outcomes in 70.3% of cases, while patients with GCS &gt; 8 had unfavorable outcomes in 32.2% of cases (p=0.0018). Favorable outcomes were more common in DC performed for trauma, aneurysm, and sinus thrombosis than ischemic stroke and hemorrhagic stroke. Favorable outcome was seen with intact bilateral pupillary reflexes (59%; p=0.022) in our study.</p> <p><strong>Conclusions</strong></p> <p>The outcome of decompressive craniectomy was better in patients with trauma, cerebral venous thrombosis and aneurysmal subarachnoid hemorrhage than in patients with intracerebral hemorrhage and ischemia. The preoperative pupillary status (bilateral equal and reactive), GCS &gt; 8 and age less than 50 were the variables associated with a favorable outcome in these patients.</p> </div> </div> </div> </div> Binod Rajbhandari Sameer Aryal Anjan Singh Karki Maya Bhattachan Gopal Sedain Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 77 84 Arterial occlusion following radial artery cannulation <p>A 65-year-old lady, admitted to ICU for septic shock, underwent left radial artery cannulation with 20G cannula for hemodynamic monitoring. She was on mechanical ventilation for severe community acquired pneumonia and was treated with antibiotics and vasopressors (noradrenaline and vasopressin). On the fourth day of arterial cannulation, she developed bluish discoloration of her left hand and digits (Figure 1a), associated with coldness and impaired capillary refill. The other hand did not show any features of compromised circulation. Ultrasonography of left radial artery revealed intraluminal thrombus and absence of color flow in color Doppler (Figure 1b). The radial catheter was removed and she received therapeutic dose of enoxaparin. She expired three days later due to refractory shock.</p> Gentle Sunder Shrestha Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 75 76 Concurrent encephalopathy and peripheral neuropathy: A rare case of metronidazole toxicity <p>Metronidazole is a nitroimidazole antibiotic widely used in clinical practice for anaerobic bacteria and protozoa. Though well tolerated, it rarely has severe neurological toxicity. We are reporting a case of a 59-year old female with liver abscess who developed concurrent encephalopathy and peripheral neuropathy after a few days of high-dose metronidazole therapy.&nbsp; MRI brain of patient showed characteristic hyperintense lesion in bilateral dentate nuclei of cerebellum. Nerve conduction study showed demyelinating pattern and sensory neuropathy predominantly affecting lower limbs. The patient recovered well after the withdrawal of the offending agent.</p> Bhupendra Shah Raju Paudel Nawli Manandhar Paras Thapa Vivek Sharma Sharma Paudel Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 72 74 Pancreatic cancer stem cells and their exosomes: What is unique about them? <p>.</p> Dipesh Kumar Yadav Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 i ii Cancer surgery during the Covid-19 pandemic: Experience from a single surgical unit of a cancer hospital in Nepal <p><strong>Background</strong></p> <p>The Novel Coronavirus disease (COVID-19) rapidly evolved as a pandemic in late 2019 AD. Many hospitals had to reduce cancer diagnosis and treatment for various reasons such as, re-allocation of resources, work force for COVID-19 care and to reduce infection to health care workers. Our unit made a policy to continue cancer surgery. The aim of the present study is to report peri-operative variables, outcome and adaptation we made to continue the surgical services.</p> <p><strong>Materials and methods</strong></p> <p>All consecutive patients who underwent surgery in a single unit of a cancer hospital from March 2020 to February 2021 were included in the study. Data was extracted from the prospectively maintained database of our unit.</p> <p><strong>Results</strong></p> <p>One hundred and seventy-eight surgeries for cancer were performed over the study period. The median age of patients was 53.5 years (IQR: 43-65years), 22 patients were more than 70 years of age. Majority of patients were American Society of Anaesthesiologist (ASA) status I (69.66%). The most common pathology was gastrointestinal (43%) followed by breast cancer (29%). Except initial 12 patients, rest 166 patients underwent pre-operative screening with RT-PCR test for COVID-19.</p> <p>None of the patients developed symptoms of COVID-19 in post-operative period. There were 30 Clavein-Dindo grade I/II, 1 grade IIIb and 2 grade V complications. There was no unusual post-operative course or delay in discharge due COVID-19 disease.</p> <p><strong>Conclusion</strong></p> <p>By following previously known standardised protocols and adapting the new ones for COVID-19, surgical services for cancer can be conducted safely during pandemic.</p> Deep Lamichhane Suraj Suwal Resham Rana Rishikesh Narayan Shrestha Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 63 67 Laparoscopic radical hysterectomy: A safe and effective surgical treatment for early-stage cervical cancer <p><strong>Background and aims</strong></p> <p>Laparoscopic techniques to treat early stage cervical cancer have been recently begun by gynecologic oncologist. The aim of our study was to retrospectively evaluate the oncological outcomes of laparoscopic radical hysterectomy for early stage cervical cancer.</p> <p>&nbsp;</p> <p><strong>Methods</strong></p> <p>A retrospective review of medical records was performed to identify patients who underwent laparoscopic radical hysterectomy. Data was obtained from the medical record department and analyzed.</p> <p>&nbsp;</p> <p><strong>Result</strong></p> <p>Laparoscopic radical hysterectomy was done in nine patients in a period of last 1.5 yrs. The mean age was 50.2 years and BMI was 24.29 respectively. Most of the cases (5) of were stage l followed by stage ll in four cases. Five patients had attained menopause while four were having normal menstrual cycle. Average blood loss during surgery was 200 ml with mean surgery time of 3.8 hrs. Most of the patients were discharged in 5 days however one had longest hospital stay of 10 days. Histopathological report of four patients showed adenocarcinoma and five had squamous cell carcinoma. None of the patients had positive lymph node. One patient had right iliac vein injury during surgery.</p> <p>&nbsp;</p> <p><strong>Conclusion</strong></p> <p>Laparoscopic radical hysterectomy provides excellent oncologic outcome to patients with early stage cervical cancer.</p> Nilam Subedi Asmita Ghimire Asmita Shrestha Samriddha Raj Pant Padam Raj Pant Copyright (c) 2021 Grande Medical Journal 2021-12-30 2021-12-30 3 1 68 71