krantarat peeyananjarassri

Objective: To determine the positive predictive value of the combined symptoms of severe dysmenorrhea with the sign of tenderness and/or nodularity of the cul-de-sac and/or uterosacral ligament(s) in diagnosing endometriosis clinically. Material and method: In this prospective study, 116 patients with severe dysmenorrhea, after excluding urinary and gastrointestinal disease, underwent pelvic examination by the same investigator. Women having adnexal mass on pelvic examination were excluded Tenderness, and also nodularity, of the cul-de-sac, right and left uterosacral ligament were recorded separately. The laparoscopist did not know the findings of the pelvic examination. The diagnosis of endometriosis was made visually when lesions were typical and all other lesions were biopsied. Results: The prevalence of endometriosis was 78.4%. Tenderness, nodularity, tenderness and nodularity, and also tenderness or nodularity of cul-de-sac and/or uterosacral ligament(s) were all statistically significantly associated with the presence of endometriosis (P = .048, .005, .004, and .004 respectively). The positive predictive values were 85.5%, 94.0%, 94.6% and 86.7%, respectively. Conclusion: The positive predictive value of severe dysmenorrhea with nodularity of the cul-de-sac and/or uterosacral ligament(s) was 94.0%.

 ภาวะตรวจไม่พบตัวอสุจิ พบได้ร้อยละ 10-15 ของภาวะมีบุตรยากในเพศชาย แบ่งสาเหตุได้เป็น การสร้างตัวอสุจิ ที่อัณฑะผิดปกติ การทำงานของสมองส่วนไฮโปทาลามัสและต่อมใต้สมองผิดปกติ และการเคลื่อนที่ของอสุจิผิดปกติ สาเหตุ ทางพันธุกรรมโดยเฉพาะอย่างยิ่งกลุ่มอาการไคลน์เฟลเตอร์ เป็นสาเหตุส่วนใหญ่ของการสร้างตัวอสุจิของอัณฑะผิดปกติ กลุ่ม อาการคาลแมนน์เป็นสาเหตุหนึ่งของไฮโปธาลามัสและต่อมใต้สมองผิดปกติที่มีอาการไม่ได้กลิ่นร่วมด้วย ในกลุ่มการเคลื่อนที่ ของตัวอสุจิผิดปกติพบว่า ภาวะตรวจไม่พบตัวอสุจิร้อยละ 4-25 มีภาวะไม่มีท่อนำอสุจิทั้งสองข้างแต่กำเนิด หลังจากซักประวัติ และตรวจร่างกาย การส่งตรวจฮอร์โมนพื้นฐานอันได้แก่ ฮอร์โมนเทสโทสเตอโรน (ที) ลูทิไนซิงฮอร์โมน (แอลเอช) และฟอล ลิเคิลสติมิวเลติงฮอร์โมน (เอฟเอสเอช) ผลของเอฟเอสเอชสูงหรือต่ำร่วมกับฮอร์โมนทีต่ำทำให้สงสัยว่า กระบวนการสร้าง อสุจิผิดปกติ เรียกรวมว่าการทำงานของอัณฑะผิดปกติ หรือสมองส่วนไฮโปทาลามัสและต่อมใต้สมองผิดปกติ เป็นกลุ่มภาวะ ตรวจไม่พบตัวอสุจิชนิดไม่อุดกั้น แต่ถ้าผลเอฟเอสเอชและฮอร์โมนทีปกติ ทำให้สงสัยการเคลื่อนที่ของอสุจิผิดปกติ หรือเป็น ภาวะตรวจไ...

The incidence and prognosis of cervical cancer after radiation treatment were not affected by hormone therapy for menopausal symptoms. Cervical cancer patients who have undergone radiotherapy and still have the uterus should be monitored closely for early detection of abnormal lesion in the uterine cavity when using unopposed estrogen, as there is some evidence indicating normal menstrual cycles in cervical cancer patients who have undergone ovarian transposition surgery before radiotherapy surgery and also some evidence indicating normal endometrial response to exogenous hormones.

ObjectiveTo perform an in‐depth analysis and evaluate the causes of maternal deaths in a university hospital in Southern Thailand.MethodsA retrospective descriptive study was conducted. Medical records of all women who died during pregnancy or within 42 days of termination of pregnancy at Songklanagarind Hospital from January 2006 to December 2021 were reviewed.ResultsThere were 51 910 live births during the 16‐year period and 68 maternal deaths (31 of direct cause, 36 of indirect cause, and one of unknown cause). The maternal mortality ratio was 131 per 100 000 live births. There was a decreasing trend in the maternal mortality ratio, especially during the past 4 years. The leading causes of death were cardiac disease (n = 17), hypertensive disorders in pregnancy (n = 9), and postpartum hemorrhage (n = 7). The most common indirect causes of maternal death were cardiac disease, hematologic disease, and dengue hemorrhagic fever. There was a decreasing trend in indirect to direct deat...

Cervical cancer in pregnancy is increasingly reported worldwide nowadays. We studied eleven Thai pregnant women presenting with the clinical symptoms and signs of cervical cancer at Songklanagarind Hospital in Hat-Yai, Thailand between 1982-2001. Their mean age was 35.5 (range 30 to 41) years. The most common presenting symptom was vaginal bleeding, occurring in six patients (54.5%). Four patients (36.4%) were asymptomatic. The diagnosis of cervical cancer was made by biopsy of a gross lesion in seven of the women (63.6%). Four patients were referred for an abnormal Papanicolaou smear, and invasive disease was confirmed by colposcopic directed biopsy. A cone biopsy was performed without complications to the pregnancy in one patient diagnosed with microinvasion. Five patients (45.5%) were diagnosed before 20 weeks gestation. Most patients had stage I lesions. The predominant histologic cell type was squamous cell carcinoma in 8 cases (72.7%), followed by adenocarcinoma in 3 cases (27...

Objective: To assess the prevalence and management of preterm birth and low birth weight (LBW) infants, including the exploration of known risk factors for preterm birth and LBW, recorded in field testing of a web-based surveillance system of maternal-newborn health in southern Thailand.Material and Methods: The data of 2,459 women who delivered in six community hospitals and two referral hospitals in Songkhla province, southern Thailand were extracted from the field testing records of an experimental surveillance system. The incidences of preterm and LBW and their management with attributed factors to the specific problems and associated factors were analyzed by univariate analysis and multiple logistic regression.Results:The incidences of preterm birth and LBW were 5.6% and 9.8%, respectively. Maternal age, parity, preeclampsia, antenatal care visits, birth attendant and type of hospital were significantly associated with the incidence of preterm birth or LBW. Of women with preter...

Objective: To examine the incidence, clinical presentation and characteristics of ovarian tumors in children and adolescents Study design: Retrospective, descriptive study Materials and methods: We retrospectively collected cases of ovarian tumors in patients < 19 years of age at Songklanagarind Hospital occuring between April 1989 and March 2001. Results: There were 54 cases, or 4.7% of all ovarian tumors (1,140 cases). Fifty-three patients (98%) were nulliparous. The common presenting symptoms were abdominal mass (37%) and abdominal distension (35%). Seven patients (13%) had tumor related complications. Twenty-four patients (44%) had tumors between 6 and 15 cm in greatest diameter and the bilaterality rate was 5.6%. Of these 54 cases, 21 cases (38%) were benign and 33 cases (61%) were malignant. The most common was a germ cell tumor (65%). Conservative and radical surgery were performed in 78% and 22% of patients, respectively. Conclusions: Ovarian tumors in children and adoles...

To determine the cutoff score for identifying hirsute, Thai women, by using modified Ferriman-Gallwey-Lorenzo (mF-G-L) method. Hirsutism was defined as an amount of terminal hair in the androgen-sensitive skin areas that the women themselves would consider obviously abnormal, and their mF-G-L score was above 97.5 percentile of general population. The subjects were consecutive unselected premenopausal women who came to our hospital for their yearly Papanicolaou smear check up, without any complaint. Acne and oily skin were also assessed. Five hundred and thirty-one women underwent a physical exam. The women who had the total hair-growth score of 0, 1 and 2 by mF-G-L method accounted for 97.8% of all the subjects. All of the 11 subjects with a total score of 3 or more considered themselves to have excessive growth of hair. None of these 11 women had acne. The authors purposed that the cutoff score to diagnose Thai hirsutism may be 3 or more by mF-G-L method.

OBJECTIVE To study sexual functioning and attitudes towards sexuality in postmenopausal women. MATERIAL AND METHOD A cross-sectional study was conducted among 219 healthy postmenopausal women with a uterus, aged 45-55 years, and not taking hormone therapy, who attended the gynecological and menopause clinic, Songklanagarind Hospital. The Female Sexual Function Index (FSFI) questionnaire was used as the instrument. RESULTS The median age at enrollment and menopause age of women were 52 and 49, respectively. All the women had engaged in sexual intercourse. Sixty nine percent reported being sexually active once or twice in the previous four weeks, 27.9% three to four times and 3.1% more than four times. The mean total FSFI score was 20.4 while the proportion of women with female sexual dysfunction based on FSFI overall scores of 26.5 or less was 82.2%. Almost all the women displayed a positive attitude towards sexuality. Ninety six percent reported having sex in menopause as a natural ...

OBJECTIVE To assess the effect of an audit and feedback intervention on the accuracy of the diagnosis summary in the medical records of gynecologic patients in Songklanagarind Hospital. MATERIAL AND METHOD An audit was conducted on the medical records of 468 gynecologic patients that visited between January 2006 and March 2007. They were divided into non-malignant and malignant conditions both before and after the planned intervention. RESULTS The accuracy of the summary of the diagnosis for non-malignant conditions was better than malignant conditions. The correction to the principle diagnosis in medical records of patients with malignant conditions increased significantly from 16.7% to 42.9% (p < 0.001) after the audit and feedback. In medical records of non-malignant conditions, corrections to the principle diagnosis and any complications also significantly increased from 72.0% to 82.0% (p = 0.01) and 76.0% to 90.7% (p = 0.002), respectively. CONCLUSION Audit and feedback is e...

BACKGROUND Endometrial hyperplasia has long been considered a precursor of endometrial cancer but there is no consensus regarding its management. OBJECTIVE To identify management practices and evaluate outcomes of treatments for women diagnosed with endometrial hyperplasia (EH). MATERIAL AND METHOD The medical records of endometrial hyperplasia at Songklanagarind Hospital between January 2000 and December 2012 were retrospectively reviewed. RESULTS Two hundred ninety seven patients were diagnosed with endometrial hyperplasia during the study period. Four patients who did not come for treatment and could not be contacted were excluded Therefore, 293 patients were included in the study. Simple hyperplasia (SH) was the most common diagnosis accounting for 79.2% of all cases, followed by complex hyperplasia (CH) 13.0%, complex atypical hyperplasia (CAH) 5.8%, and simple atypical hyperplasia (SAH) 2.0%. Seventy-eight percent (18/23) of the patients with atypical endometrial hyperplasia w...

Background Menopausal symptoms can affect the quality of life (QoL) of women. Objectives To determine menopause-related symptoms and QoL in peri- and postmenopausal women in Thailand undergoing various treatment. Methods A prospective cohort study was conducted at 9 menopause clinics in 4 regions of Thailand. Peri- and postmenopausal women newly registered at the clinics were recruited and followed up for 12 months. A standardized medical record form was used to collect data regarding demographic characteristics, menopause-related symptoms, and treatment. QoL was evaluated using a specific questionnaire. Results We included 870 women who were 51.8 ± 5.6 years old. We compared demographic characteristics and baseline health profiles of women with normal QoL and impaired QoL. Women with impaired QoL were significantly younger (51.2 ± 4.4 vs. 52.0 ± 6.0 y, P = 0.035) and included more from northeast Thailand (11.4% vs. 6.6%, P = 0.022). The 3 most common menopause-related symptoms were...

OBJECTIVE To determine the positive predictive value of the combined symptoms of severe dysmenorrhea with the sign of tenderness and/or nodularity of the cul-de-sac and/or uterosacral ligament(s) in diagnosing endometriosis clinically. MATERIAL AND METHOD In this prospective study, 116 patients with severe dysmenorrhea, after excluding urinary and gastrointestinal disease, underwent pelvic examination by the same investigator. Women having adnexal mass on pelvic examination were excluded Tenderness, and also nodularity, of the cul-de-sac, right and left uterosacral ligament were recorded separately. The laparoscopist did not know the findings of the pelvic examination. The diagnosis of endometriosis was made visually when lesions were typical and all other lesions were biopsied. RESULTS The prevalence of endometriosis was 78.4%. Tenderness, nodularity, tenderness and nodularity, and also tenderness or nodularity of cul-de-sac and/or uterosacral ligament(s) were all statistically sig...

Objective: To identify the rates and indications of cesarean section (CS) using the Robson classification during 2014- 2016 in a university hospital in southern Thailand. Material and Methods: A cross-sectional study of women who delivered between January 1, 2014 and December 31, 2016 was conducted. The data were analyzed using the Robson classification. Results: A total of 10,474 births were included in the analysis. The overall CS rate was 55.5%. The trends of CS rates in most Robson classification groups over the 3-year period were static. The CS rates in nulliparous or multiparous women with induction of labor decreased over the 3-year period, while the rate in multiparous women with fetal breech presentation increased. Women with previous cesarean section (Robson group 5) were the largest contributor to the overall CS rate (32.1%), followed by the nulliparous women with a single cephalic pregnancy, ≥37 weeks gestation in spontaneous labor (Robson group 1) (24.5%). Cephalopelvic...

6572 Background: Cervical cancer is one of the most preventable cancers, not only presence of effective HPV vaccination but also simple and robust screening methods such as Pap test. Nevertheless, there were some women at risk whom were unable to access screening cause of incarceration. Hence, in 2018, together with Songkhla Woman Correctional Institute, we launched a cancer screening campaign including clinical breast exam, mobile mammography and Pap test. This is the first report of cervical cancer screening result demonstrated the essential of cervical cancer screening in these disadvantaged women. Methods: Due to the regulation of the jail, we had to limited bring-in tools, allowed staffs and operating-time, therefore we used a pre-screening questionnaire, included 5 items: HIV infection, number of partner, parity, age at first sexual intercourse and number of term baby and each of them scored as 2 for “high-risk” and 1 for “low-risk”, total score ranged from 5 to 10. We ranked ...

BACKGROUND During elective (planned) caesarean sections, some obstetricians routinely dilate the cervix intraoperatively, using sponge forceps, a finger, or other instruments, because the cervix of women not in labour may not be dilated, and this may cause obstruction of blood or lochia drainage. However, mechanical cervical dilatation during caesarean section may result in contamination by vaginal micro-organisms during dilatation, and increase the risk of infection or cervical trauma. OBJECTIVES To determine the effects of mechanical dilatation of the cervix during elective caesarean section on postoperative morbidity. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved studies on 20 September 2017. SELECTION CRITERIA We included all randomised, quasi-randomised, and cluster-randomised controlled trials comparing intraoperative cervical dilatation using a finger, sponge forceps, or other instruments during elective caesarean section versus no mechanical dilatation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included eight studies with a total of 2227 women undergoing elective caesarean section. Of these, 1097 underwent intraoperative cervical dilatation with a double-gloved index finger or Hegar dilator inserted into the cervical canal to dilate, and 1130 did not undergo intraoperative cervical dilatation. Six of the eight included trials had high risk of bias for some of the risk of bias domains.Very low-quality evidence suggested it was unclear whether cervical dilatation had any impact on postpartum haemorrhage (estimated blood loss greater than 1000 mL; risk ratio (RR) 1.97, 95% confidence interval (CI) 0.48 to 8.13; 5/205 versus 3/242; one study, 447 women).Low- or very low-quality evidence showed no clear difference for the need for blood transfusion (RR 3.54, 95% CI 0.37 to 33.79; two studies, 847 women); postoperative haemoglobin (mean difference (MD -0.05, 95% CI -0.15 to 0.06; three studies, 749 women), or haematocrit (MD 0.01%, 95% CI -0.18 to 0.20; one study, 400 women); the incidence of drop from baseline haemoglobin above 0.5 g/dL (RR 0.92, 95% CI 0.64 to 1.31; two studies, 722 women), or amount of haemoglobin drop (MD -0.01 g/dL, 95% -0.14 to 0.13; three studies, 796 women); the incidence of secondary postpartum haemorrhage within six weeks (RR 1.18, 95% CI 0.07 to 18.76; one study, 447 women); febrile morbidity (RR 1.18, 95% CI 0.76 to 1.85; seven studies, 2126 women); endometritis (RR 0.94, 95% CI 0.35 to 2.52; four studies, 1536 women); or uterine subinvolution (RR 0.34, 95% CI 0.08 to 1.36; two studies, 654 women); the results crossed the line of no effect for all of the outcomes. There were no data for cervical trauma.We found a slight improvement with mechanical dilatation for these secondary outcomes, not prespecified in the protocol: mean blood loss, endometrial cavity thickness, retained products of conception, distortion of uterine incision, and healing ratio. The evidence for these outcomes was based on one or two studies. Cervical dilatation did not have a clear effect on these secondary outcomes, not prespecified in the protocol: wound infection, urinary tract infection, operative time, infectious morbidity, and integrity of uterine scar. AUTHORS' CONCLUSIONS At this time, the evidence does not support or refute the use of mechanical dilatation of the cervix during elective caesarean section for reducing postoperative morbidity.Further large, well-designed studies are required to compare the effect of intraoperative mechanical dilatation of the cervix with no intraoperative mechanical cervical dilatation for reducing postoperative morbidity.

Endometrial hyperplasia has long been considered a precursor of endometrial cancer but there is no consensus regarding its management. To identify management practices and evaluate outcomes of treatments for women diagnosed with endometrial hyperplasia (EH). The medical records of endometrial hyperplasia at Songklanagarind Hospital between January 2000 and December 2012 were retrospectively reviewed. Two hundred ninety seven patients were diagnosed with endometrial hyperplasia during the study period. Four patients who did not come for treatment and could not be contacted were excluded Therefore, 293 patients were included in the study. Simple hyperplasia (SH) was the most common diagnosis accounting for 79.2% of all cases, followed by complex hyperplasia (CH) 13.0%, complex atypical hyperplasia (CAH) 5.8%, and simple atypical hyperplasia (SAH) 2.0%. Seventy-eight percent (18/23) of the patients with atypical endometrial hyperplasia were treated by hysterectomy compared with 9.6% (2...

To determine the positive predictive value of the combined symptoms of severe dysmenorrhea with the sign of tenderness and/or nodularity of the cul-de-sac and/or uterosacral ligament(s) in diagnosing endometriosis clinically. In this prospective study, 116 patients with severe dysmenorrhea, after excluding urinary and gastrointestinal disease, underwent pelvic examination by the same investigator. Women having adnexal mass on pelvic examination were excluded Tenderness, and also nodularity, of the cul-de-sac, right and left uterosacral ligament were recorded separately. The laparoscopist did not know the findings of the pelvic examination. The diagnosis of endometriosis was made visually when lesions were typical and all other lesions were biopsied. The prevalence of endometriosis was 78.4%. Tenderness, nodularity, tenderness and nodularity, and also tenderness or nodularity of cul-de-sac and/or uterosacral ligament(s) were all statistically significantly associated with the presenc...

To determine the optimal interval of injections of intramuscular depot medroxyprogesterone acetate 150 mg in the long-term treatment of endometriosis-associated pain. 112 patients with symptomatic endometriosis were randomized to receive either injections every month for 6 months, then every 3 months for a total of 15 months or injections every 3 months for 15 months. The primary outcome measure was patients' satisfaction. At months 3, 6, 9, 12 and 15 of the treatment phase, there was no statistically significant difference of percentages of patients with satisfaction between the two regimens (85.7 vs. 76.8%, 76.8 vs. 73.2%, 66.1 vs. 58.9%, 60.7 vs. 55.4%, 60.7 vs. 55.4%, respectively). The optimal interval of injections of depot medroxyprogesterone acetate 150 mg is every 3 months.

First, to determine the extent of the effects of low-dose hormone therapy (HT) on menopausal symptoms, bone mineral density, endometrium, and the cardiovascular system, and, second, to determine the adverse effects of low-dose HT. A literature review of electronic databases was conducted to identify all prospective, randomized trials comparing the effects of low-dose HT with placebo or standard-dose therapy, using key words such as: hormone replacement therapy (HRT), low-dose HRT/conjugated equine estrogens (CEE)/estradiol, lower-dose HRT/CEE/estradiol, ultra-low-dose HRT/CEE/estradiol, menopause, cardiovascular risk, bone metabolism. Low-dose HT has been shown to improve menopausal and vulvovaginal atrophic symptoms, compared to placebo, and is less likely to give rise to unacceptable side-effects, including irregular bleeding and/or breast tenderness. When compared to standard-dose HT, the low-dose HT has comparable effects on a range of menopausal symptoms and on bone density and has similar beneficial effects on surrogate end-points of coronary heart disease. A change to low-dose HT has been advocated following adverse findings in recent trials of standard-dose HT. Although a literature review has shown low-dose HT to alleviate menopausal symptoms and maintain or improve bone density with fewer side-effects than standard-dose therapy, further research is required to determine what effect the lower-dose therapy will have on fracture, cardiovascular and breast disease.

To evaluate menopausal symptoms and quality of life in middle-aged women. Hospital-based, cross-sectional study. A survey was conducted among 270 women aged 45-65 years who attended the gynecological and menopause clinic, Songklanagarind Hospital. We used the MENQOL questionnaire as the instrument. The average age at menopause of the postmenopausal women was 48.7 years (range 40-57 years). The prevalences of the classical menopausal symptoms--hot flushes, night sweats, and vaginal dryness--in the women aged 45-65 years were 36.8%, 20.8 and 55.3%, respectively. The three most prevalent symptoms in perimenopause were aching in muscles and joints, experiencing poor memory, and change in sexual desire. Within the four domains (vasomotor, psychological, physical, and sexual symptoms), more suffering was reported in the perimenopausal and postmenopausal subjects than in the premenopausal subjects (p < 0.001). Peri- and postmenopausal women had a significant decrease in quality of life compared to premenopausal women.

To study sexual functioning and attitudes towards sexuality in postmenopausal women. A cross-sectional study was conducted among 219 healthy postmenopausal women with a uterus, aged 45-55 years, and not taking hormone therapy, who attended the gynecological and menopause clinic, Songklanagarind Hospital. The Female Sexual Function Index (FSFI) questionnaire was used as the instrument. The median age at enrollment and menopause age of women were 52 and 49, respectively. All the women had engaged in sexual intercourse. Sixty nine percent reported being sexually active once or twice in the previous four weeks, 27.9% three to four times and 3.1% more than four times. The mean total FSFI score was 20.4 while the proportion of women with female sexual dysfunction based on FSFI overall scores of 26.5 or less was 82.2%. Almost all the women displayed a positive attitude towards sexuality. Ninety six percent reported having sex in menopause as a natural normal part of life, 95% regarded havi...

To determine the cutoff score for identifying hirsute, Thai women, by using modified Ferriman-Gallwey-Lorenzo (mF-G-L) method. Hirsutism was defined as an amount of terminal hair in the androgen-sensitive skin areas that the women themselves would consider obviously abnormal, and their mF-G-L score was above 97.5 percentile of general population. The subjects were consecutive unselected premenopausal women who came to our hospital for their yearly Papanicolaou smear check up, without any complaint. Acne and oily skin were also assessed. Five hundred and thirty-one women underwent a physical exam. The women who had the total hair-growth score of 0, 1 and 2 by mF-G-L method accounted for 97.8% of all the subjects. All of the 11 subjects with a total score of 3 or more considered themselves to have excessive growth of hair. None of these 11 women had acne. The authors purposed that the cutoff score to diagnose Thai hirsutism may be 3 or more by mF-G-L method.

To assess the effect of an audit and feedback intervention on the accuracy of the diagnosis summary in the medical records of gynecologic patients in Songklanagarind Hospital. An audit was conducted on the medical records of 468 gynecologic patients that visited between January 2006 and March 2007. They were divided into non-malignant and malignant conditions both before and after the planned intervention. The accuracy of the summary of the diagnosis for non-malignant conditions was better than malignant conditions. The correction to the principle diagnosis in medical records of patients with malignant conditions increased significantly from 16.7% to 42.9% (p < 0.001) after the audit and feedback. In medical records of non-malignant conditions, corrections to the principle diagnosis and any complications also significantly increased from 72.0% to 82.0% (p = 0.01) and 76.0% to 90.7% (p = 0.002), respectively. Audit and feedback is effective for improving the accuracy of the diagno...