Transcript: Past Medical History Chief complaint: Labs Clinical Case Presentation Case Presentation Physical Exam HPI: S.F. is a 5 week old otherwise healthy infant. Choking episode PEDS 7501 Logo
Transcript: Treatment Details (cont.) 1. Non surgical root canal treatment, post and core, and crown. 2. Non surgical RCT, core, and crown. 3. Non surgical RCT and composite class V restoration. After assessing the remaining tooth structures. Nature of Pain: Pain started two weeks ago Spontaneous continuous pain Increases by cold stimulus and at night Disturbed sleep Sharp, Burning pain Pain diffuses to the left ear and left eye. Patient is taking Paracetamol ( 2 tablets 500 mg / qid. Multiple remaining roots due to caries (long time ago - Pt didn't recall). Number of visits Local anesthetic agent, amount, technique Rubber dam clamp used Number of canals Coronal flaring Working length: Reference point Measurement Initial file size Use of Electronic Apex Locators Diagnostic WL radiograph Instrumentation technique (N) Normal response (+) Mild (++) Moderate (+++) hypersensitive response (0) no response (D) delayed P.S. note: All anatomical structures are within normal limits No facial swelling No soft tissue inflammation Endodontic Diagnosis MAF size: size 40 Last step-back file size: size 80 Name, concentration, and volume of irrigant used: 3 ml of 2.6% NaOCl sodium hypochlorite. Treatment Details (cont.) No sinus tract No swelling No tooth discoloration Deep caries extends about half of the crown of #23 facially. Clinical Case Presentation Extra-Oral Examination Treatment Option Medication Pulpal diagnosis #23: Symptomatic irreversible pulpitis Periapical diagnosis #23: Normal periapical tissues Treatment Details Symptomatic irreversible pulpitis with normal periapical tissues Temperature: 37 °C Pulse rate: 86 beats per minute Pulse Rhythm: Regular Respiration rate: 18 breaths per minute Blood pressure: 125/75 mm Hg Previous dental treatment: Multiple extractions Restorations Multiple RCTs Crowns The photos were taken after the treatment of tooth #23 It was emergency treatment Medical History Working length: Reference point: Cusp tip Measurement: 28.5 mm Initial file size: 15 Electronic Apex Locator was used to determine the apical constriction Vital Signs Radiographic findings: Normal lamina dura Deep caries No PA radiolucency No PA radiopacity No dilaceration Not calcified canal Atorvastatin Aspirin Lisinopril Metoprolol Plavix insulin injection Local anesthetic agent, amount, technique: Lidocaine hydrochloride 2% epinephrine 1:80,000 2 carpules 2/3 of the 1st carpule --> Buccal infiltration 1/3 of the 1st carpule --> infiltration of the greater palatine nerve (palatal injection). 2nd carpule was used during giving intra-pulpal injection. " I have pain in my left upper side and I have multiple remaining roots that need to be extracted " Endodontic and Restorative Treatment Plan of The Involved Tooth Last dental visit: 25/7/2016 Intra-Oral Examination Rubber dam clamp used: Anterior clamp #9 (RDCM9) Isolate tooth #23. Number of canals: Single canal Coronal flaring: Endo-z bur Gates glidden #3 and #2 Number of visits: One single visit Date case started and finished: 30/10/2016 Thank you Intermediate radiograph Intra-Oral Examination (cont.) Treatment Details (cont.) Treatment Details (cont.) Treatment Details (cont.) ENDD 512 Prepared by : 33 08 01 505 MAF size Last step-back file size Name, concentration, and volume of irrigant used. Obturation: Master cone size Diagnostic master cone radiograph Obturation technique Spreader size used Accessory cone size Type of sealer Coronal restoration Final radiograph Instrumentation technique Balanced force technique Step-back technique Recapitulation with k-file size 10 Use irrigation NaOCl and EDTA Gender: Male Age: 55 years old Nationality: Saudi Marital Status: Married Level of Education: High school diploma Occupation: Retired Attitude: Cooperative Patient Data Q & A Obturation: Master cone size: size 40 Obturation technique: Lateral compaction Spreader size used: Finger spreader size F,MF,FF Accessory cone size: Fine and medium fine Type of sealer: Epoxy resin AH 26 Diagnostic master cone radiograph Endodontic Examination Diagnostic WL radiograph Dental History The prognosis of tooth #23 is favorable Reason for last dental visit: Temporary crown for tooth #11 Diagnostic Preoperative Periapical Radiograph History of Present Condition Tooth of interest : Tooth #23 Treatment Details (cont.) Treatment Details (cont.) Coronal restoration: cavit + GIC ( double seal restoration) Final radiograph Patient Medical History Chief Complaint Diabetes type II Myocardial infarction 1 year and 5 months ago Coronary artery stents Cardiac catheterization surgery Smoker RCT Post and core ? Crown lengthening ? All ceramic crown ASA III
Transcript: PLAN/GOALS OF TX Fix cause IMMEDIATE TRANSFER TO ST VINCENTS + Large parietal/occipital extradural bleed with midline shift +Midline shift >1cm and brainstem distortion on CTB are findings that require rapid and aggressive treatment Whats wrong with this picture??? PSYCHOSOCIAL/ FAMILY: PATHOPHYSIOLOGY of EXTRADURAL BLEED Assessment- interprate this ECG Cameron, P,. Jelinek, G., Kelly, A., Murray, L. & Brown A,F, T. (2009) Textbook of Adult Emergency Medicine 3rd edition. Sydney: Churchill Livingstone Elsevier Chauvet, D., Reina, V., Clarencon, F., Bitar, A. & Cornu, P. (2013) Conservative Management of Large Occipital Extradural Haematoma. British Jounral of Neurosurgery, 27 (4), 526-528. Nadig, A, S. & King, A. T. (2012) Traumatic extradural haematoma revealed after collateral decompressive craniectomy. British Journal of Neurosurgery, 26(6), 877-879. Urden, L, D., Stacy, K, M. & Lough, M. E. (2014) Critical Care Nursing: Diagnosis and Management. St Louis, Missouri: Elsevier CTB results...... MORPHINE - sedation/analgesia Clinical Case Presentation - Ms Jones Traumatic Brain Injury MIDAZOLAM - sedation MANNITOL ACTION: GABA receptor agonist, chloride channel activation Advantages:- rapid onset/offset, reduces ICP, raises seizure threshold, less hypotensive than propofol +highly lipid soluable, + metabolised by liver Disadvantages:- can reduce MAP, delirium, withdrawl syndrome, resp & cough supression Dosage: induction 0.1/kg Maintenance sedation 0.01-0.2/kg/hr Pharmcokinetics : onset 6min, hepatically metabolised, Advantages: long term analgesic, hyponotic agent, low cost, haemodynamic stability Disadvantages: hypotension, bradycardias,respiratory & cough depression, constipation, nausea, Doseage : 0.05-0.1mg/kg Given as infusion Morph50mg/Midaz 50mg in 50ml Action: osmotic diuretic, elevates blood plasma osmolarity, thereby enhacing excretion of water from tissues as a result cerebral odema, elevated ICP is reduced Advantages:Reduces acutely raised ICP and cerebral oedema in critical care. Disadvantages:- fluid overload, rebound cerebral oedema Dosage: 0.05-0.1/kg PATHOPHYSIOLOGY of EXTRADURAL BLEED Sinus bradycardia 42 BPM flatterned T waves in LI,II &III & V5 &V6 +Maintenance of airway +Maintenance of cerebral pressures +Correct hypotension (systolic >90mmHg ) & hypoxia (PaoO2 > 60mmHg ) + sedation & analgesia - Morph/midaz + 30 degrees head up to < ICP +immediate transfer to St Vincents Hospital for Neurosurgery Patient Presentation Intubation Stabilise patient :- stabilise airway NPA, prepare for intubation. RSI- Fluid preload, Prop 40mg , Midaz 5mg and Suxamethonium 100mg IV to sedate and intubate. Adequate sedation and analgesia infusion-Morph/midaz CTB Maintain pt at 30 degree angle Maintain O2 and perfusion for cerebral blood flow NGT CXR Nursing and medical mangement TIME IS BRAIN Intubated size 7.5 ETT 22cm at lips SIMV volume control Vt 500, RR 2o, Fio2 100% Peep 5cm H2o, ETCo2 42 on monitor Morphine/Midaz infusion commenced Propofol boluses for aggitation Taken to CTB + Serous & uncommon complication of head injury + Occurs in only 3% of TBI, 75% in skull fractures + Injury to blood vessel causing formation of haematoma by stripping the dura mater from the skull +It is important to remember to involve the family, communicate honestly and effectively +Ensure adequate supports in place. + Involve care-co +If care-co not avail provide couseling to immediate family when appropriate +46 YO Female was BIBA after witnessed fall at a wedding. +Headstrike & lac to occiput +Nil LOC or seizure activity. +6-7 ETOH drinks on board + Recently fit and well +Past medical hx - C section +Medications- NIL +NKDA + 200mg IN Fentanyl, 10mg IV Maxalon on route via IVC R) hand Setting the scene + Maintenance of adequate tissue metabolism via ensuring delivery of oxygen, fuels to meet cellular demand. Cerebral perfusion pressure (CPP) Mean arterial pressure (MAP) Intracranial pressure (ICP) Cerebral Blood Flow MAP-ICP= CPP PRIMARY SURVEY A- Obstructed, requiring jaw thrust & suction of vomit, NPA insitu B- Spont resps requiring BVM, laboured breathing, Sp02 ?94% C- PW slight diaphretic, HR 40-70 SB-SR with pauses, bilat IVC, stat fluids, manual BP 150 systole D- uneven pupils, GCS4, decerebrate posturing E- C spine precautions, lac to occiput ASSESSMENT Stages of compensation & decompensation in intracranial hypertension Cushing's reflex/ triad +The presence of HTN, bradycardia and abnormal respirations associated with increased intracranial pressure (ICP) +Late finding +Sympathetic nervous system is activated = peripheral vasoconstriction, inc in cardiac output to inc MAP MAP> ICP = restored blood flow +Baroreceptors in carotid bodies detect high pressures and respond by dramatically reducing HR. Setting the scene + Initally GCS 14-15 E3V5M6 + Haemodynamically stable + During AV handover pt rapidly deteriorates GCS 4 E1V1M2 + Irregular pupils + Airway obstruction + Immediate transfer to Resus + Prepare for
Transcript: Renal Failure Inflammation + autolytic destruction (Bugiantella et al., 2016; Trikudanathan et al., 2019) Activation pancreatic enzymes Clinical Case Presentation Clinical Evidence: GFR: 16 Cr:357 low concentrated urine output compromised pancreatic tissue and leakage of fluid Monitor davol and VAC drain output Monitor CBC (Crawford & Harris, 2011) Acute Kidney Injury initiation of systemic inflammatory cascade Hyperkalemis: Prolonged PR Peaked T Ventricular Dysrhythmias APP (abdominal perfusion pressure = MAP - IAP Interventions Open abdomen with ABThera VAC dressing High output rectal tube Tube feed / inadequate hydration High Output Rectal Tube Expected Results: increase in sodium bicarbonate increase in CO2 neutralization of pH C.diff (-) Bacterial enteric Panel (-) ** Most likely Abx related Early abdominal decompression is associated with better outcomes (Spencer, Kinsman, & Fuzzard, 2008) Evolving Davol Drain output altered membrane integrity + vasodilation Brown / green thick mucous --> sanguineous output with clots Intra abdominal abscess and fistula formation Ad Dx: Necrotizing Pancreatitis Norepinephrine Day 2 Patient Care extravasion of intravascular volume and potential bacterial trans-location Imparied / Slowed Filtration hypervolemic state hyperkalemia decreased excretion of H+ Midline laparotomy with small bowel resection (Crawford & Harris, 2011; Fuijii, Udy, Licari, Romero, & Bellomo, 2019) Potential Adverse Effects: Antibiotic Therapy Ciprofloxacin (quinolone) meropenem (carbapenems) Result of Tug - of - War ICU Admission Hx: Admitted to RGH Nov. 25 with two ICU admissions Transferred to FMC end of December to HPB team Re admitted to ICU post code 66 Patient Outcome Interventions Hemoglobin Stabilization Improvement in VAC drainage Pt K+ 3.2 --> 3.6 in 24 hours neutrophils 12 Hypokalemia: altered cellular metabolism decreased cardiac contractility respiratory depression Investigation of Etiology (Crawford & Harris, 2011) allergic reaction - rash development diarrhea - C.diff (Leppaniemi et al., 2019) ***Caution Too quick a drop = Cerebral Pop Recomendations Hopkins Medicine, 2013 Pancreatic enzyme degradation of vasculature and underlying tissues Wound Cx: klebsiella pneumoniae candida Positive Blood Cultures Current Pancreatits management (Crawford & Harris, 2011; Petejova & Martinek, 2013; Spencer et al., 2008) Anti fungal micafungin [Na+] - 156 [K+] - 3.2 Phos - 3.00 Ionized Ca - 1.88 pH 7.33 / HCO3 - 17/ CO2 - 33 Base excess (-8) ICP = hemorrhage, tissue edema, increased third spacing Actual Effect: maintain perfusion to vital organs mitigation of organ dysfunction maintain urine output Lactate 7 --> 2.4 11.4 (30) Free Water administration via NJ @ 100 ml/hr IV fluid administration (post NJ removal) OG Output High output rectal tube High output rectal tube Renal Failure Potential Interventions: IV sodium bicarbonate Change sin Ventilator settings Sanguineous Davol Drain Output Patient Results: minimal shift in pH with sodium bicarbonate administration minimal compensation once ventilation initiated Hypokalemia Correction Patient Presentation Heightened Systemic inflammatory response Pre Renal Cause: Increased Intra abdominal Pressure SIRS / Hypovolemia Pancreatic Enzymes Abdominal Hemorrhage and Bowel Perforation side effect of Late Phase Necrotizing Pancreatitis Intravascular volume depletion Potassium excretion bicarbonate excretion Phosphate excretion Fine Needle aspiration and Cultures WBC 13.7 Intra abdominal infection and hemodynamic instability Intra - abdominal Pressure Monitoring Electrolyte disturbances and Metabolic Acidosis Potential Adverse Effects: decreased perfusion to extremities bradycardia and arrhythmia's decreased urine output and renal failure Etiology Potential Adverse Effects: Cessation of Hemorrhage: Outcome Compromised skin integrity at wound edges CT Findings: bowel perforation and intraabdominal hemorrhage (Leppaniemi et al., 2019; Trikudanathan et al., 2019) OG losses ******Davol Drain output Contents Unknown Metabolic Acidosis Correction Return to OR in 48 hours for anastomosis (Bugiantella et al., 2016; Fitzgerald, Chrangha, Masterson, & Sigurdsson, 2013; Trikudanathan et al., 2019) (Bendersky, Mallipeddi, Alexander, & Papps, 2016; Bugiantella et al., 2016' Leppaniemi et al., 2019; Spencer et al., 2008) 58 y.o Male No Known Allergies PmHx: Atrial fibrillation and Burgada syndrome Delay / Drain / Debride / Surgery TPN vs. Parenteral Nutrition (Crawford & Harris, 2011) 9.6 (21) Interventions Renal Failure Patient Lab Values Why the H+ does it matter? MOA : Alpha adrenergic receptor MAP goal > 65 mmHg NPO status with TPN initiation Rectal Tube Output Prophylactic Antibiotics Etiology ICP 20 - 25 mmHg = intervention required Etiology Labs Patient Assessment: No Hematoma No Changes on palpation (semi firm) No apparent drain migration Hbg 89 --> 73 OG drain Davol Drain Renal Failure affects K+ Na + pH (Bugiantella et al., 2016; Spencer at al., 2008)
Transcript: Justification Treatment to date Progression What ? Impact on my treatment plan Clinical case Presentation, Wednesday the 29th of January 2014 By Sigrid Aakre Treatment plan Improvements Now What Self reflection Treatment three, a pivot point So What ? Working Hypothesis Summary of the patient Risk Factor and Red Flags Differential Diagnosis Examination
Transcript: Name: D.R.M Gender: Male Age: 38 y/o Race: Filipino Height: 154 cm Weight: 66kg Date admitted: March 13, 2016 medications goals / therapeutic management DIAGNOSTIC / LABS : " body weakness " astrocytoma "astrocytes" "-oma" -tumor March 22 WBC : 22.83 (H) Hgb : 175 (H) Hct : 0.54 (H) Neutrophils : 0.90 (H) Microbiology Specimen : Endotrachel aspirate Specie : Enterobacter aerogenes resistance: Amox-Clav., Cefaclor Sensitivity: Ciprofloxacin, Meropenem, Imipinem Gram Stain gram negative rods gram negative cocci pus cells patient's profile DIAGNOSTIC / LABS : astrocytes star-shaped neuroglia cells. has microfilaments - for support Blood brain barrier - for selective permeability March 23 GCS 3 March 24 no brain function march 25 Pneumonia, both lower lobes March 27 Astrocytoma VAP Diabetes Insipidus SIGNS AND SYMPTOMS: ? pharmaceutical care plan DIAGNOSTIC / LABS : March 18 CT Scan : tumor oligodendroglioma w/ cerebral swelling. March 20: Clinically brain dead. March 21: Diabetes inspidus Fluctuating BP 3 days PTA, the patient complains of generalized body weakness. Patient is diagnosed with intracerebral left frontal mass. S/P biopsy AD : medial frontal body of corpus callosum tumor S/P biopsy. FD : medial frontal body of corpus callosum tumor, Astrocytma Clinical Case Presentation thank you. PATHOPHYSIOLOGY: Reporter: Korina V. Tuano chief complaint: Biopsy: Astrocytoma, grade II -III, unresectable tumor date: pharmaceutical care issues: intervention : follow up: 3/29 Domperidone, Terlipressin, Ivabradine monitor QT BP, HR, Tachycardia, (these agents prolong QT interval) prolongation or Bradycardia (LEXICOMP) 3/29 Clopidogrel and Esomeprazole may use Prothrombin time (esomeprazole may diminis effect lansoprazole FDT w/c can be crushed (pxnt is on NGT. (PubMed) diagnosis: history - korina
Transcript: Questions? Does ambulating increase risk for PE or new DVT? Compared four randomized trials found on research databases Compared: ambulation and compression vs bed rest and compression ambulation and compression vs bed rest alone No significance in development of PE or new thrombus Ok to prescribe ambulation for DVT patients Education Plan Enoxaparin (Lovenox) 130 mg SQ q12 hr Acetaminophen (Tylenol) 650 mg PO q4 PRN Tramadol 50 mg PO q6 PRN 49 year old male, 230 lbs Presented to UVMC with R calf pain Acute saddle pulmonary embolism without acute cor pulmonale, bilateral DVT Admitted to Birchwood 10/15 Ambulating with walker, stand by assist References Tuesday: Patient will read provided literature. Patient will verbalize any questions over medication Thursday: Patient will teach back medication highlights (purpose, side effects, precautions) Long term: Patient will state that he has sufficient knowledge of medication before discharge from Birchwood Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale Clinical Case Presentation Tuesday: Patient will safely ambulate with RW for 10 min, 2 times per shift Thursday: Patient will saftly ambulate with RW for 10 min, 3 times per shift Long term: Patient will be able to ambulate without use of assitive decice by date of discharge Ambulation after Deep Vein Thrombosis: A Systematic Review Cathy M. Anderson, Tom J. Overend, Julie Godwin, Christina Sealy, Aisha Sunderji Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal Of Community Health Nursing, 24(2), 119-129 11p. Rationale Knowing the pt's preffered leardning mode will allow customization of the teaching plan, help the teaching stick Allows nurse to gauge where they need to concentrate eduction, able to correct misunderstood information Additional chance to see what they have already been taught Coallboration ensures patient knows goals, helped make Education should be reinforced with patient appropriate reading material Method gives patient opportunity to ask questions, steer direction of discussion, elaborate Goals Problem: Knowledge deficit Related to: New long-term anticoagulation treatment As evidenced by: Request for more information on Enoxaparin Data: "I would like to make menu choices that are safe with Enoxaparin" "They didn't tell me much in the hospital about this medication" Evaluation Plan of Care https://www.uvmhealth.org/medcenter/Pages/eHealth/HealthwiseContent/default.aspx?hid=d03041a1 Assessment Assess pain before, during, after ambulate using numerical pain scale Assess gait while ambulating Preform Homan's test Care Stand by assist while ambulating Discuss PRN medications and benefits of taking before ambulating Arrange objects in room to allow for safe ambulation Consult with physical therapist, attend sessions Prompt pt to do PT prescribed exercises while in room Suggest sitercise attendance Research Education Anderson, C., Overend, T., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: a systematic review. Physiotherapy Canada, 61(3), 133-140 8p. doi:10.3138/physio.61.3.133 Medications Patient Health Problem and Medications Ellie Anderson http://www.drug3k.com/drug/Lovenox-11588.htm http://www.dvtanswers.com/AboutDVT/symptoms-illustration.html http://www.mayoclinic.org/healthy-lifestyle/healthy-aging/multimedia/walker/sls-20076469?s=1 https://www.pinterest.com/pin/227220743674908523/ http://www.vibrantlifenames.com/karl/E/A/1/t2.htm https://www.uvmhealth.org/medcenter/Pages/eHealth/HealthwiseContent/default.aspx?hid=d03041a1 Anderson, C., Overend, T., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: a systematic review. Physiotherapy Canada, 61(3), 133-140 8p. doi:10.3138/physio.61.3.133 Autar, R. (1996). Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale. Journal Of Advanced Nursing, 23(4), 763-770. doi:10.1111/1365-2648.ep8543738 Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal Of Community Health Nursing, 24(2), 119-129 11p. Rationale Pain can inhibit ability/motivation to ambulate, evaluate how ambulation effects pain level Look for gait pattern alteration and quality of movement to see if pt is favoring painful limb, look for potential fall risks (shuffling, dragging feet) Dorsiflexion test to indicate (with caution) a DVT, observing if it pain from test worsen with ambulation Stay near pt when ambualting to monitor safety and assist if needed Better to stay ahead of pain then catch up, taking PRN pain medication 30-60 min. before ambulating may help decrease overall pain caused by ambulating Cluttered floor/room is a safety hazard, clearing a path decreases risk of fall Collaborating with PT will provide more insight into patient progress and goals Encourage pt to preform exercises while in room to improve ROM,
Transcript: Fundamental Therapy Solutions Goals 9 year old male in 3rd grade Behavior: Amazing behavior. Very calm and compliant. Diagnosis: Dyslexia Evaluation: 9yrs 2 m CELF 5- within normal range Core Language 102 Receptive Language 103 Expressive Language 108 Mild deficits in social pragmatic language Clinical observations significant progress in reading and spelling, but still has large deficits in these areas. School spelling words LiPS program Prewritten paragraph deck edit HELP for Language book (idiom worksheets) Phonological Awareness: Track 3-4 syllable words with 80% accuracy. Pragmatics: Problem solve appropriately in 4 out of 5 trials. Pragmatics: Ask for help when appropriate in 4 out of 5 trials. Reading: Retell a story including main ideal and supporting details with 80% accuracy. (GOAL MET) Reading Fluency: Read grade-level text at 110 words per minute. (GOAL MET) Reading: Read age appropriate words (2-3 syllables) including short and long vowel sounds with 80% accuracy. Spelling: Spell age appropriate words (2-3 syllables) including short and long vowel sounds with 80% accuracy. Receptive Language: Improve memory recall for details on tasks such as spelling, retelling a story, or therapy activities with 80% accuracy. Receptive/Figurative Language: Identify and interpret the meanings of idioms, metaphors, similes, or proverbs with 80% accuracy. Expressive Language: Edit a pre-written paragraph for errors with spelling, punctuation, grammar, and mechanics with 80% accuracy to improve reading and spelling ability. Clinical Case Presentation Janelle Logan Patient T Based on the results of the reevaluation the client would continue to benefit from reading and spelling intervention 2x/week for 60min. Prognosis: Good. Counseling: Everyday we talk to dad and give him things to practice at home. Also, dad just told us that T went from a D in Language Arts to a C which he was excited about. I plan for T's sessions now. I tried to add in a game during therapy, but T couldn't focus so now we are back to more drill. I wouldn't change anything. Funtherapysolutions.com Out Patient Pediatric SLP, OT, and Psychologist Variety of patients: Delayed language Articulation Autism Expressive/Receptive Language Delay Dyslexia ETC... Therapy Materials
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