Yazar "Sari, Elif" seçeneğine göre listele
Listeleniyor 1 - 20 / 28
Sayfa Başına Sonuç
Sıralama seçenekleri
Öğe Analysis of web height ratios according to age and sex(Informa Healthcare, 2015) Sari, ElifEach component of the web space, a three-dimensional structure, should be carefully created during reconstruction of web space loss. One of these web space components is the web height. In this study, the dorsal view of subjects' hands was analyzed to determine the web height ratios. The web height ratios were then compared with respect to age and sex. The second and third web height ratios differed between adult men and women and between children and adults. However, no differences were observed among children. This study is unique because it focuses on the web height ratios of all web spaces according to age and sex and provides a very easy-to-use scale that may help surgeons to perform web space reconstruction. Moreover, the present study adds to the literature by providing information on the first web height ratios of the hand.Öğe Combination of rhomboid flap and double Z-plasty technique for reconstruction of palmar and dorsal web space burn contractures(Elsevier Sci Ltd, 2015) Sari, Elif; Tellioglu, Ali Teoman; Altuntas, Nurgul; Seven, Ergin; Ozakpinar, Hulda RifatBackground: Web space contractures after a burn can cause severe impairments in hand function along with esthetic deformities. In this study we present our experience with the combined treatment technique consisted of rhomboid flap and double Z-plasty for palmar and dorsal web space contractures. Materials and methods: Combined rhomboid flap and double Z-plasty was performed in eight patients with eleven web space contractures occurred after burn. The average follow-up was 10.9 months. Results: The average age of 8 patients was 16.3 years. The average duration of burn contractures was 6 years (range 1-13 years). The right third web of the patients was the most common contracted web space. In the postoperative period hematoma, infection, partial or total flap loss was not observed in any patient. Web and hand function and esthetic appearance of web spaces were satisfactory in the late postoperative period. Conclusion: Rhomboid flap combined with a double Z-plasty technique was an effective choice for the treatment of palmar and dorsal web space contracture after burn. (C) 2014 Elsevier Ltd and ISBI. All rights reserved.Öğe Comparison of Subciliary Approaches in Orbito-Zygomatic Fractures: Skin Flap Versus Skin-Muscle Flap(Lippincott Williams & Wilkins, 2015) Ozakpinar, Hulda Rifat; Sari, Elif; Tellioglu, Ali Teoman; Sandikci, Mert Muhittin; Inozu, Emre; Seven, Ergin; Karamursel, SebatBackground:Because of the complications of classical subciliary incision, some modified subciliary approaches have been described in recent literature.Objectives:The aim of this study was to compare 2 commonly used subciliary approaches according to development of postoperative complications (scar formation, and ectropion).Materials and Methods:Ninety patients were included in this retrospective study. Subciliary skin flap technique (SF group) was performed to 39 patients, while the others were operated by using skin-muscle (stepped) flap technique (SMF group). Fitzpatrick skin types, genders, ages, scar scores, and ectropion scores of the patients also were recorded.Results:The mean age of the patients was 39.3 (18-99) years, and the mean follow-up period was 2.1 (1-6) years. Fitzpatrick skin-type levels were between 2 and 4 (median=3). No difference was found between 2 groups in terms of age, follow-up period, and Fitzpatrick skin-type levels. However, the scar values of the SMF group were significantly lower than the SF group statistically. Also, there was no significant difference between males and females in SF and SMF groups in terms of scar and ectropion formation. On the other hand, scar values were lower in SMF groups rather than SF group in males. Although ectropion values were not different between SF and SMF groups in females, ectropion values of SMF group were significantly lower than SF group in males statistically.Conclusion:Subciliary skin-muscle (stepped) flap technique can be more reliable than subciliary skin flap technique for approach to orbitozygomatic fractures.Öğe The effect of low-dose methotrexate on autologous fat graft survival(Tubitak Scientific & Technical Research Council Turkey, 2016) Sari, Elif; Bakar, Bulent; Sarkarati, Bahram; Bozdogan, Onder; Cavusoglu, TarikBackground/aim: The survival of autologous fat graft tissue is dependent on various factors such as vascularization and inflammation. The aim of the present study was to evaluate the possible beneficial effects of low-dose methotrexate (LD-MTX) on fat graft volume and survival. Materials and methods: A total of 13 male Wistar albino rats were divided into two groups, a control group and an LD-MTX group. An autologous fat graft obtained from the inguinal region of each rat was transferred to its back. LD-MTX was administered intraperitoneally in the LD-MTX group once a week for 4 weeks after the surgical procedure. The control group underwent surgery but was not administered MTX. Fat grafts were harvested for analyses. Results: The results showed that 2 months postoperatively the fat graft weights of the control and LD-MTX groups were not significantly different. In addition, the vascularity of the grafts was higher in the LD-MTX group than it was in the control group. The mean lipid peroxidation levels were essentially the same in the two groups, but myeloperoxidation was significantly lower in the LD-MTX group than it was in the other group. Conclusion: The results showed that LD-MTX administration may not preserve the quality and volume of transplanted fat tissue in rats.Öğe Effect of piracetam and nimodipine on full-thickness skin burns in rabbits(Wiley, 2016) Sari, Elif; Dincel, Gungor C.The potential of several drugs for full-thickness skin burns has been investigated, but the treatment of such burns remains a challenge in plastic surgery. The present study was designed to determine the effect of systemic and topical administration of piracetam and nimodipine on full-thickness skin burn wound healing. A total of 36 New Zealand male rabbits were divided into six groups. Full-thickness skin burns were produced in all the groups, except the control group. Piracetam was administered systemically (piracetam-IV) and topically (piracetam-C) for 14 days, and nimodipine was administered systemically (nimodipine-IV) and topically (nimodipine-C) over the burn wounds for 14 days. The sham group underwent burn injury but was not administered any drug. After 21 days, gross examination and histopathological analysis were performed and the results were compared statistically. Nimodipine-C and nimodipine-IV had no effect on burn wound healing. However, both piracetam-IV and piracetam-C significantly enhanced the healing of the full-thickness skin burn wounds, although the latter was more effective, useful and practical in burn wound healing. The histopathological features of the wounds in the piracetam-C group were closer to those of the control group than those of the other groups. Piracetam-C rather than piracetam-IV may promote full-thickness burn wound healing in rabbits.Öğe Effectiveness of Dimethylsulfoxide on the Survival and Volume Preservation of Autologous Fat Graft Tissue: A Preliminary Study(Oxford Univ Press Inc, 2016) Sari, Elif; Bakar, Bulent; Sarkarati, Bahram; Bozdogan, Onder; Cavusoglu, TarikBackground: The survival of autologous fat graft tissue is dependent on various factors, such as vascularization and inflammation. Objective: This study aims to evaluate the possible beneficial effects of dimethylsulfoxide (DMSO) on fat graft volume and survival. Methods: Eighteen male Wistar albino rats were divided randomly into three groups. An autologous fat graft obtained from the inguinal region of each rat was transferred to its back. DMSO was administered intraperitoneally (IP) in the DMSO-IP group and cutaneously (C) in the DMSO-C group once daily for 15 days after the surgical procedure. The control group underwent surgery but was not administered with DMSO. Two months after surgery, the grafted fatty tissues were harvested for histopathological and biochemical analyses. Results: The results showed that 2 months postoperatively, fat grafts of the DMSO-C and DMSO-IP groups weighed significantly more than the grafts of the control group. Moreover, the vascularity of the grafts was higher in the DMSO-C group than in the control group, and no significant difference was found between the two DMSO groups. The mean lipid peroxidation levels were the same in the three groups, but myeloperoxidation was significantly lower in the DMSO-C group than in the other two groups. Conclusions: The study results showed that cutaneous rather than intraperitoneal DMSO administration could preserve the quality and volume of transplanted fat tissue in rats by enhancing vascularity and decreasing inflammation.Öğe Effectiveness of the Biophysical Barriers to the Peridural Fibrosis in Rat Laminectomy Model(Taylor & Francis Inc, 2019) Akkurt, Ibrahim; Bakar, Bulent; Dincel, Gungor Cagdas; Yildiran, Fatma Azize Budak; Ogden, Mustafa; Nursoy, Egemen; Sari, ElifPurpose: Peridural fibrosis which could occur after the spinal surgery could adhere neural tissue closely and may cause to neural entrapment symptoms and require surgical reintervention. Aim of the study: Present study was designed to reduce occurrence of peridural fibrosis in rat laminectomy model by using biophysical barriers called hyaluronic acid (HAS) dural barrier, activated polyethylene glycol and polyethylene imine (PEG) dural barrier, and platelet-rich plasma (PRP). Materials and methods: In this study, 2 of 26 male Wistar albino rats (325-350 g body weight), which were not included into study groups were sacrificed by removing their total blood and their blood was used for preparation of PRP, and remaining rats were randomly delivered into four groups called SHAM, HAS, PEG, and PRP groups. Then L3-4-5 laminectomy was performed to all animals and experimental agents were administered to the selected groups mentioned above. Spinal colons of all animals were removed gross total after 6-week period and investigated histopathologically. Additionally, real-time-polymerase chain reaction was used to obtain collagen type I and type III, transforming growth factor-1 beta, and tumor necrosis factor-alpha gene expressions. Results: All results demonstrated that polyethylene glycol and polyethylene imine dural barrier and PRP could decrease peridural fibrosis formation efficiently in rat. Conclusion: Present study results suggested that to reduce or block formation of peridural fibrosis, either polyethylene glycol and polyethylene imine dural barrier or PRP could be used effectively in human subjects after they will be closely investigated in future studies.Öğe Effects of DMSO on a rabbit ear hypertrophic scar model: A controlled randomized experimental study(Elsevier Sci Ltd, 2017) Sari, Elif; Bakar, Bulent; Dincel, Gungor Cagdas; Yildiran, Fatma Azize BudakDimethyl sulfoxide (DMSO) is an anti-inflammatory, antibacterial, analgesic drug widely used to treat several diseases as reported in the literature. It has a detractive effect on collagen deposition in the abnormal tissue. This study aimed to investigate the possible therapeutic effects of DMSO on hypertrophic scar formation in rabbits. Twenty-four New Zealand male albino rabbits were randomly divided into four groups: control, sham, DMSO, and TRA (triamcinolone acetonide). Except the control group, punch biopsy defects were created on each animal's right ear. Following the hypertrophic scar formation on day 28, intralesional DMSO and triamcinolone acetonide were administered once a week for 4 weeks into these scars of the DMSO and TRA groups, respectively. No therapeutic agent was administered to the control and sham groups. One week after the last injection, ear samples were collected for histopathological, immunohistochemical, and real-time polymerase chain reaction gene expression analyses. Histopathological examination revealed that the epithelium in the DMSO group was thicker than that in the control and TRA groups, but thinner than that in the sham group. Connective tissue thickness and vascularity level of the sham group were higher than those of the control, DMSO, and TRA groups. The collagen type I immunoreactivity level of the sham and TRA groups was higher than those of the control and DMSO groups. The collagen type III immunoreactivity level was higher in the sham group than in all other groups. Collagen type I/type III immunoreactivity ratios were lower in the DMSO group. The alignment of collagen fibers was normal in the DMSO group, but was irregular in the sham and TRA groups. The collagen type I gene expression levels of the DMSO and TRA groups were lower than that of the sham group. Collagen type III and IFN-gamma mRNA expression levels were almost similar among the groups. TGF-1 beta mRNA expression levels were higher in the DMSO and TRA groups than in the control and sham groups. On the basis of the results, it can be concluded that intralesional administration of DMSO decreases hypertrophic scar formation easily and safely. (C) 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.Öğe Effects of Low Dose Methotrexate in Cerebral Ischemia Reperfusion Injury in Rat(Journal Neurological Sciences, 2015) Bakar, Bulent; Kose, Emine Arzu; Sari, Elif; Sarkarati, Bahram; Atasoy, PinarBackground: During cerebral ischemia reperfusion injury, oxidative stress leads to excitotoxicity, blood brain barrier dysfunction and inflammation. This study was designed to evaluate possible protective effects of low dose methotrexate on cerebral transient ischemia reperfusion injury in rat. Methods: Except CONTROL group, temporary aneurysm clips were performed to both common carotid arteries of rats for duration of 30 minutes. Four hours later, except CONTROL and SHAM groups, methotrexate (1.25 mg/kg/day) was administered intraperitoneally. Seventy two hours later, animals of CONTROL, MTX-A and SHAM-A group; and ten days later animals of MTX-C and SHAM-C group were sacrificed and hippocampal pyknotic neuronal cell count results and tissue lipid peroxidation (LPO) values were analyzed statistically. Results: Pyknotic cell count values of CONTROL group were lower than SHAM-A, SHAM-C, MTX-A and MTX-C group values. Cell count values of SHAM-A and MTX-A group were higher than SHAM-C and MTX-C values, respectively. LPO values of CONTROL group were lower than SHAM-A and MTX-A values, but not different from MTX-C and SHAM-C values. LPO values of MTX-A group higher than MTX-C group values. Conclusion: Cell count values and LPO values demonstrated that low dose methotrexate could not prevent neuronal cells from destructive effects of transient ischemia reperfusion injury in rat.Öğe Estimated beginning time of local anesthesia effectiveness in forced cold air application: A preliminary study(Taylor & Francis Inc, 2016) Sari, Elif; Sandikci, Mert Muhittin; Bakar, Bulent; Tellioglu, Ali TeomanBackground: The literature has reported that forced cold air anesthesia decreases the discomfort effect of various laser therapies. The aim of this preliminary study was to determine the average beginning time of the local anesthetic effect of the forced cold air application when it is applied to all body surfaces except the face. Materials and methods: A total of 52 participants (26 females and 26 males) were included in this study. During application of the forced cold air, the beginning time of local anesthesia effectiveness for each volunteer was determined by giving painful stimuli. The results were then analyzed statistically. Results: The mean beginning time value of the local anesthesia was 52.88 (ranging between 30 and 60) seconds in the female group and 56.34 (ranging between 30 and 60) seconds in the male group. The mean beginning time value of the local anesthesia was 54.61 (ranging between 30 and 60) seconds in both genders. There was no statistical difference between the two groups (Z = - 0.834, p = 0.404). Conclusion: Forced cold air anesthesia-which is a quick, safe, cost-effective, and practical local anesthesia method-seems to be useful and effective when used alone in laser treatment.Öğe Intranasal Extramucosal Access: A New Access for Lateral Osteotomy in Open Rhinoplasty(Lippincott Williams & Wilkins, 2016) Tellioglu, Ali Teoman; Sari, Elif; Ozakpinar, Hulda Rifat; Eryilmaz, Tolga; Inozu, Emre; Sen, Tulin; Tekdemir, IbrahimBackground and Objective: Different accesses have been used to perform lateral osteotomies in rhinoplasty. All of them have some disadvantages. The aim of this paper was to report a new access to overcome drawbacks of the other techniques in lateral osteotomy during open rhinoplasty. Methods: An anatomical study was designed to search possibility of intranasal extramucosal access (open sky access) for the lateral osteotomy in open rhinoplasty. It was performed directly on the lateral wall of piriform aperture, and then possible advantages of this technique were investigated. Five fixed cadavers were used for this purpose. No drawbacks were observed during procedure in cadavers. Then the same procedure was performed in 23 consecutive rhinoplasty patients. Nineteen operations were primary and 4 operations were secondary. Median oblique osteotomies were added to the procedure in all patients. The mean follow-up was 17 months. Results: Intranasal extramucosal access during lateral osteotomy was easily performed in all patients. Hemorrhage due to angular vessel injury was not occurred during intraoperative period. Edema and ecchymosis was minimal. Intranasal examination did not show any sign for nasal mucosal tearing in all patients. Residual bone spurs or bone irregularities were not observed in any patients. Conclusion: Intranasal extramucosal access that produces precise, predictable, and reproducible aesthetic and functional results could also provide better exposure during lateral osteotomy. Additionally, open sky access minimizes scars because it does not need additional incisions on the skin and mucosa. Protection of the internal periosteum of the nasal bones may be the main advantages of this technique.Öğe Is it Subungual Melanoma? Fungal Melanonychia due to Phoma Glomerata(Cukurova Univ, Fac Medicine, 2015) Sari, Elif; Iseri, Latife; Kocak, Mukadder; Yildiz, DilaraA 32-years-old female patient referred to our clinic with melanotic color change at her right thumb nail. It was suspected from subungual melanoma. Therefore a full thickness biopsy and an excavation example was taken from the nail for the histologic and microbiologic examination. The lesion was reported as fungal melanonychia which was occured by Phoma Glomerata. As far as we know this is the first case that occured by Phoma Glomerata. Also the case could be misdiagnosed as subungual melanoma. Therefore we aimed to share this case with our colleagues.Öğe Keloid of the circumcision scar: a rare complication(Wiley-Blackwell, 2015) Ozakpinar, Hulda R.; Sari, Elif; Horoz, Ugur; Durgun, Mustafa; Tellioglu, Ali T.; Acikgoz, Bilgihan…Öğe New autologous material for the frontalis suspension technique: superficial temporal fascia(Ijo Press, 2016) Sari, Elif; Ozakpinar, Hulda Rifat; Tellioglu, Ali Teoman…Öğe Non-metastatic Non-melanoma Skin Cancers: Our 3 Years of Clinical Experiences(Iranian Plastic & Reconstructive Surgery Assoc, 2017) Sari, ElifBACKGROUND Nonmelanoma skin cancers (NMSC) constitute the largest group of skin cancers. In this study, NMSCs were analyzed retrospectively. METHODS Between June 2013 and March 2017, demographics and comorbidities of patients underwent reconstructive surgery for NMSC; their risk factors, types, diameters, differentiation, localizations, follow-up times, treatment methods and complications were compared and statistically analyzed. RESULTS Totally, 163 tumors [111 basal cell carcinoma and 52 cutaneous squamous cell carcinoma (cSCC)] were excized from 148 patients (63 females, 85 males). Mean age was 70.8 years. Fitzpatrick skin types were between 2-4 and 74 patients. Comorbidities were detected in 63 patients. Tumors were mostly localized in head and neck regions. Forty two lesions in cSCC group were good and 10 were medium differentiated. Defects were reconstructed with flaps in 108 patients. Others underwent primer suturation and grafting. Mean follow-up time was 16.2 months. There was not any complication except one graft failure. There were not significant statistical differences between two groups in terms of skin type, comorbidity, tumor size, fallow-up time and gender values. Conversely, differences of risk factor and age values between the groups were significant. There was a positive correlation between the tumor diameter and poor differentiation in cSCC group. Moreover, there was a negative correlation between tumor size and skin type values in groups. CONCLUSION Our results are quite different from literature needing further multicentric studies on NMSC to clarify the difference.Öğe Personality traits in aesthetic surgery patients(Cukurova Univ, Fac Medicine, 2016) Buturak, S. Visal; Sari, Elif; Oguzturk, Omer; Gunes, Aslihan KiriciPurpose: It has been known that psychological factors have an important effect on the decision to undergo aesthetic surgery. In this study, we aimed to test the hypothesis that the personality traits of people admitted for aesthetic surgery differ from those of people who have never planned to undergo aesthetic surgery in their lives. Material and Methods: Forty-seven patients who were referred to the outpatient clinic of the Faculty of Medicine, Department of Plastic, Reconstructive, and Aesthetic Surgery, Kirikkale University to undergo aesthetic surgery were enrolled in the study. Forty-three subjects who neither underwent nor planned to undergo aesthetic surgery at any time in their lives were included in the study as a control group. Psychometric evaluation of the patients and the control group was conducted using the Turkish version of the Minnesota Multiphasic Personality Inventory (MMPI). Results: Taking 65 as a cut-off point, the ratio of patients who scored >= 65 on the hysteria subscale of the MMPI was found to be significantly higher in the sugery group than in the control group and the ratio on social introversion subscale was also higher in the patient group than in the control group, very closely approaching significance. Conclusion: It should be kept in mind that people who have personality traits that can be partially improved with psyachiatric treatment, such as social introverted, lonely, timid, shy, and hysterical and feel the need for validation by others, may be more often admitted for aesthetic surgery.Öğe Rare Localizations of Basal Cell Carcinoma: Lower Lip and Popliteal Area(Medknow Publications & Media Pvt Ltd, 2016) Sari, Elif; Bekircan, Kagan; Bozdogan, OnderIn this report, we describe two cases of basal cell carcinoma (BCC), one of them is on the lower lip and the other is on the popliteal area. A 45-year-old male patient with an unhealed wound on the lower lip and a 38-year-old male patient with an unhealed wound over the popliteal skin were admitted to our clinic. There was no sun exposure and trauma in their medical history. A biopsy was taken from each case. The results were BCC in two patients. BCC is usually seen in the head and neck regions, but it may be also localized in rare areas such as the lower lip and lower extremity. These unpredictable areas should be considered for tumor surgery.Öğe A rare type of burn injury due to butane gas inhalation(Turkish Assoc Trauma Emergency Surgery, 2017) Seven, Ergin; Horoz, Ugur; Sari, Elif; Ozakpinar, Hulda Rifat; Sandikci, Mert Muhittin; Inozu, Emre; Tellioglu, Ali TeomanBACKGROUND: Abusive inhalation of butane gas is becoming a serious public health problem among teenagers and young adult population; however, there has been little reporting on explosion burns associated with abuse of butane cigarette lighter fluid. METHODS: Retrospective study was conducted of 22 patients who were burned in last 2 years in explosion of butane gas, a flammable, odorless, and colorless aliphatic hydrocarbon. RESULTS: Details of sociodemographic profile of the patients, any underlying psychiatric illness, alcohol abuse, depth of burn injury, any associated injury, duration of hospitalization, and percentage of burned area were recorded and analyzed. CONCLUSION: All of the patients were young men, and most had superficial burn injury. Hospital stay ranged from 0 to 11 days. All of the patients were treated with conservative management.Öğe Repair of Full-Thickness Nasal Alar Defects Using Nasolabial Perforator Flaps(Lippincott Williams & Wilkins, 2015) Durgun, Mustafa; Ozakpinar, Hulda Rifat; Selcuk, Caferi Tayyar; Sari, Elif; Seven, Ergin; Inozu, EmreBackground The repair of full-thickness nasal alar defects presents difficulties because of their complex 3-dimensional structure. Reconstructions using inappropriate methods may lead to asymmetries and dissatisfying functional results. In this study, our aim was to present the repairs of full-thickness alar defects performed using cartilage-supported nasolabial perforator flaps. Materials and Methods Eight patients who presented to our clinic between January 2011 and April 2014 with full-thickness defects in the alar wings were included in this study. The nasolabial perforator flap was prepared on the basis of the closest perforator to the defect area and in a way to include 2 to 3 mm of subcutaneous adipose tissue. The medial section of the flap was adapted to form the nasal lining. In the 7 patients in whom cartilage support was used, the cartilage graft was obtained from the septum nasi. After the cartilage was placed on the flap, the lateral section of the flap was folded over the medial section and the defect was repaired. In 1 patient in whom cartilage support was not required, the flap was folded over itself before the repair was performed. The flap donor area was primarily repaired. Results No detachment around the suture lines, infection, venous insufficiency in the flap, or partial or total flap losses were observed in any of the patients. Retraction developed in 1 patient in whom no cartilage support was used. No retraction was observed in any of the patients in whom cartilage support was used. The results were functionally and esthetically satisfying in all the patients. Conclusions The greatest advantage of perforator-based nasolabial flaps is the greater mobilization achieved in comparison with the other nasolabial flaps. Thus, full-thickness defects can be repaired in 1 session in some patients, no revision is required around the flap pedicle, and much less donor area morbidity occurs. Nasal alar reconstructions performed using this type of flap lead to both esthetically and functionally satisfying results.Öğe Socio-cultural Features and Satisfaction Levels of Reconstructive and Aesthetic Patients Applied to Our Clinic(Medknow Publications & Media Pvt Ltd, 2016) Sari, ElifObjective: The aim of this study was to determine the socio-cultural differences between aesthetic and reconstructive patients admitted to our clinic and evaluate their level of knowledge about plastic surgery and degree of the patients' satisfaction from our staff and doctors. Material and Methods: A questionnaire was answered by 169 patients admitted to our clinic. The questions were about patients' demographic features and our department's quality. The statistical differences between aesthetic and reconstructive patents and also between three education degrees were analyzed. Results: Our results showed that there was no statistically significant difference among groups. However, it was demonstrated that a significant number of patients were not satisfied by the service quality of the hospital staff. The major factor affecting the clinic preference was recommendation of another patient. On the contrary, many patients choose their doctor accidentally. Conclusion: The members of our staff are not well-educated about working in various departments. In addition, they do not have any professional education about plastic surgery procedures. Sometimes, patients may refuse to undergo surgery because of bad behaviors of the staff. Therefore, determining the patients' profile and satisfaction could help us train our staff and improve our clinic's quality.
