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Study explores how value decisions are coded into the brain



A recent study by the University of California has discovered the area of the brain where value decisions are made.

An area within the cerebrum known as the retrosplenial cortex (RSC), they found, is the site that we use to make value choices such as which restaurant we decide to visit for tonight’s dinner. We then update the RSC with fresh information based on the new impressions of how much we enjoyed the evening’s soup and pasta. New research led by Division of Biological Sciences postdoctoral scholar Ryoma Hattori and Professor Takaki Komiyama is now revealing details about how such dynamic information is processed. The results showed that persistency allowed value signals to be most effectively represented, or “coded,” across different areas of the brain, especially the RSC. To investigate the details of how brain activity represents value-based decision making, a core animal behaviour that is impaired in neurological conditions such as schizophrenia, dementia and addiction, the researchers set up reinforcement learning experiments in which mice were presented with options and their choices were rewarded with certain probabilities. They recorded corresponding brain activities during reinforcement learning.

experiments in which mice were presented with options and their choices were rewarded with certain probabilities. They recorded corresponding brain activities during reinforcement learning.

The resulting data and network simulations pointed to the significance of persistent coding in how the mice and their value decisions were represented and the RSC as a nexus for this activity.

“These results suggest that, although information coding is highly distributed, not all of the information represented in neural activity may be used in each area,” the authors explained in the paper.” These results reveal that context-dependent, untangled persistency facilitates reliable signal coding and its distribution across the brain,” they wrote. According to Hattori, neurons are known to cycle through different activity patterns, with some neurons spiking in activity and others remaining silent.

These brain activity patterns have been shown to correlate to certain task-related information such as valuable information for decision making. Because the RSC plays a central role in connecting several brain networks and functions, the new findings reinforce ideas about the site’s fundamental importance.”We think that in mouse brain the RSC functions as a stable reservoir for valuable information.

The RSC appears to distribute valuable information to other brain areas that are vital for further processing of the value signals when mice perform reinforcement learning and decision making,” said Hattori. To further test their findings, Hattori and Komiyama tapped into their “big data” trove of more than 100,000 mouse decisions recorded during the experiments. They programmed artificial intelligence (AI) networks to imitate behavioural strategies in computer-based reinforcement trials and found remarkably similar results to the real-world experiments.

“When we trained the artificial intelligence network to do the same behaviour, it adopted the same strategy and the same way of representing the information in neural activity,” said Komiyama, who is a professor of neurobiology (Division of Biological Sciences) and neurosciences (Department of Neurosciences, School of Medicine), with affiliations in UC San Diego’s Center for Neural Circuits and Behavior and Data Science Institute.”

This suggests that this is an evolutionarily selected strategy for neural circuits to perform this behaviour. This parallel between the biological brain and the AI that Ryoma trained is really interesting,” concluded Komiyama.

The research has been published in ‘Neuron Journal’ .

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Medically Speaking




Musculoskeletal disorders, also known as MSDs, are soft-tissue injuries that affect the movement of the human body or the musculoskeletal system, including muscles, nerves, tendons, ligaments, discs, and blood vessels. Repetitive stress injury, repetitive motion injury, overuse injury, and much more are commonly used terminologies for MSDs.

The titles may vary, but musculoskeletal disorder by itself indicates one singular cause of damage, and that is stress and repetition. From simple back pain to shoulder pain to inflammation of the tendon, these and a few more are some of the musculoskeletal disorders that can gradually develop or worsen with constant overexertion or improper use.

Typically, in the case of a lower back sprain or strain, the cause is the same: soft tissues get inflamed and result in immense pain and muscle spasms, which can be very debilitating to a person’s activities and movements of daily living. Overall, the underlying triggers of this condition could be related to daily life, work, or age. The initial signs that MSDs show include pain, discomfort, and a loss of mobility, which may deteriorate if not addressed on time. MSDs can also affect your quality of life in the short-term as well as


MSDs most often emerge in the workplace since they are an outcome of frequent and repetitive movements that cause trauma to the skeletal and muscular structures. However, the reasons can also be associated with your day-to-day activities at home or elsewhere.


One of the most common symptoms of MSDs is severe pain, which progresses with time and movement. The initial few signs could begin with an affected limb that gives a little ache. This pain then advances to a consistent pain that persists and impacts one’s functionality. Eventually, someone with an MSD will start noticing stiff joints, swelling, or tight muscles. Those who indulge in repetitive tasks, whether it’s lifting heavy materials for hours together or typing on the computer for 10 hours a day, are most likely to experience these symptoms. Hence, it’s important to be aware of even the minute signs and manage them proactively than wait for a more serious injury or strain.


Warm up and stretch: Before you start any activities that are repetitive, or prolonged, ensure you warm up and stretch well. Before you start any activities that are repetitive, or prolonged, ensure you warm up and stretch well.

This not only helps prepare your body for the work ahead of you, but also offers an opportunity to break the monotony of your routine.

Alter your work technique: Identify the best way to complete a job by keeping the goal of reducing your risk factors in mind.

For example, when you want to lift and move heavy materials, use helpful equipment like carts, forklifts, and hand trucks to safeguard yourselves from any injury.

Change positions from time to time: The foremost preventive step you must take is to respect pain. Pause an activity or change positions whenever any task causes pain. While sitting, maintain an erect position of the neck and back with relaxed shoulders.

Reducing twisting and bending motions. Keep your upper arms as close to your body as possible. Always keep your feet flat on the floor whenever seated.

The author is Chief Medical Officer, Innoplexus Ex-Global Clinical Development Leader (Merck, Roche, and Amgen) 20+ years of experience in drug development and discovery. He has worked extensively in clinical trials, research, and therapeutic concepts.

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Natural ways to cleanse body and mind: Take toxins out of your life



Our bodies can detox themselves from environmental and food toxins. However, sometimes the frequency of the toxic load is so high that the body finds it difficult to rid itself of it; in such cases, outside assistance is required.

While food toxins are commonly found in processed foods, junk foods, sugar, and fried foods, other toxins present in our daily lives are the chemicals found in cosmetics products, materials such as plastic, billing receipts, and air pollutants like nitrogen oxide, sulphur dioxide, etc. It is important to be mindful of our exposure to such toxic elements to allow ourselves to heal and feel better.

The following are some methods for reducing toxic load:

• Fasting activates the natural detox process inside the body, which leads to apoptosis, or the death of toxic cells. It is recommended to fast for 16–18 hours daily or for a 24 hour water fast at least 2-3 times a month.

• Consume fresh, healthy vegetables and salads. They engulf the toxic cells present in the body and eliminate them through excretion.

• Excrete daily. It is one method to remove toxic waste from the body.

• Keep yourself hydrated. Plain water consumption can control our weight and reduce our intakes of sugar, sodium, and saturated fats. It also helps to flush out waste from the body through urination, perspiration, and bowel movements.

• Exercise regularly. It helps your body detox by maintaining good liver and kidney health.

• Use metal or glass water bottles. Both of them can keep your drinks free from chemicals as they are non-corrosive, BPA-free, and leach-proof.

• Avoid plastic water bottles for drinking especially if they have been exposed to sunlight for a longer period as they can release toxins and chemical substances into the water which can harm our health in long run.

• Cook food in cast iron or steel utensils only, and avoid non-stick pans with Teflon coating as high temperature can break down the coating which may release toxic chemicals in the air and can lead to various medical conditions.

• Mental cleansing is also important: Meditate daily. It will help you keep negative thoughts at bay.

Stop putting yourself in a flight or fight mode all the time which means your sympathetic nervous system is overactive, get into a parasympathetic mode, relax, and take Epsom salt Baths and massages regularly.

The author is MBBS, MD, and CMD–LiveNutriFit.

‘Meditation will help you keep negative thoughts at bay. Stop putting yourself in a flight or fight mode all the time which means your sympathetic nervous system is overactive; get into a parasympathetic mode, relax, and take Epsom salt baths and massages regularly’.

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Intraoperative radiotherapy is a treatment delivery technique that dates back to the early twentieth century and involves the use of orthovoltage energy, with limited applicability due to its energy properties.



Breast cancer is an illness in which the cells of the breast multiply uncontrollably. There are various types of breast cancer. The type of breast cancer is determined by which cells in the breast become cancerous. Breast cancer can start in a variety of places in the breast.

Lobules, ducts, and connective tissue are the three primary components of a breast. The glands that generate milk are known as lobules. The ducts are tubes that transport milk from the breast to the nipple. Everything is held together by connective tissue, which is made up of fibrous and fatty tissue.

Breast cancer usually starts in the ducts or lobules. Breast cancer can spread to other parts of the body via blood and lymph vessels. Breast cancer is said to have metastasized when it spreads to other regions of the body.

Intraoperative radiotherapy (IORT) is a treatment delivery technique that dates back to the early twentieth century and involves the use of orthovoltage energy, with limited applicability due to its energy properties. The procedure was cumbersome. This was until the development of a mini-LINAC technology called Intrabeam that could be easily moved and used in the operating room. This has made IORT feasible and practicle. The technique of IORT called TARGETED INTRAOPERATIVE RADIO Therapy (TARGIT) has been used for breast cancer patients over the past few years.

During surgery, therapeutic levels of radiation are usually delivered to the tumour bed while the area is exposed. IORT is usually used in conjunction with external beam radiation, surgery, and chemotherapy in the multidisciplinary treatment of locally advanced and recurring cancer.

IORT can also be used in earlier-stage cancers like prostate and breast cancer, which has become more popular in recent years.

IORT has been demonstrated to be effective and practicable in the multidisciplinary management of a variety of solid tumours, but further research is needed to pinpoint the benefits. It is mostly used in selected breast cancer cases. However, IORT has been suggested to play a role in brain tumours and cerebral metastases, locally advanced and recurrent rectal cancer, skin cancer, retroperitoneal sarcoma, pancreatic cancer, and certain gynecologic and genitourinary malignancies based on single-institution experiences. If repeated EBRT is no longer possible, irradiation with IORT is the only radiotherapeutic option for local recurrences, aside from brachytherapy. In some instances the intraoperative radiation therapy is delivered after the surgery instead of during it. Your surgeon will have to reopen your incision if that is necessary. After the procedure, be sure to get enough rest, stay hydrated and eat nutritious meals. Some studies have shown that intraoperative radiation therapy is just as effective as external beam radiation therapy. Other studies have proven that women who have IORT are more likely to have local recurrence (the cancer returns in the same breast) than those who had whole breast EBRT. Patient selection for IORT is of vital importance and requires a multidisciplinary approach.

Accordingly, we set-up our criteria based on the consensus of a joint committee of surgical oncologists, pathologists and radiation oncologists.

For the first time, we categorized patients according to age and tumor size and accordingly older patients with larger tumor sizes were considered appropriate candidates for IORT in our series.


Intraoperative radiation therapy (IORT) is a type of radiation treatment in which a high dose of radiation is delivered to a malignant tumour site during surgery after it has been removed. Recovery is normal after surgery, and no more external radiotherapy is required. In the case of selected low-risk breast cancer patients, this saves patients the time, effort, and side effects associated with 30–40 days of treatment.

IORT is a type of intensive radiation therapy that is given during surgery and is reported to be more precise, with fewer problems and a shorter treatment time. For early breast cancer, IORT helps radiate the tumour bed directly during a lumpectomy. Individuals over 50 with early-stage breast cancer that hasn’t spread might benefit the most from IORT.

With direct visualisation in the operating room, IORT provides the advantage of delivering a tumoricidal radiation dose in a single session while tailoring the therapy to the region of highest risk of disease recurrence. This results in a high relative biological effectiveness while minimising dosage to normal tissue through tumour bed devascularisation, elimination of inter-fraction tumour cell repopulation, and maybe a systemic immunological impact.

Furthermore, the elimination or decrease of outpatient treatment appointments, which typically last 5–6 weeks for standard postoperative radiation, provides practical benefits to the patient, such as increased quality of life, reduced side effects, and financial advantages. IORT is frequently used in conjunction with EBRT or chemotherapy and may be equally effective as standard radiation for some tumours, while also shielding healthy cells from the harmful effects of radiation.


IORT is a less time-consuming method. Instead of being administered in multiple doses over several weeks, IORT is given in a single dose.

When compared to EBRT, IORT has fewer side effects. The dose of radiation delivered by IORT is higher. IORT kills cancer cells while leaving healthy tissues alone. Because IORT eliminates microscopic illness promptly, it may lower the risk of cancer recurrence (EBRT might not start until a month later, giving the cancer time to return). IORT can also be repeated, but, EBRT cannot.


For decades, whole-breast radiation has been a routine and highly effective therapy option. Continuous research and advancements have resulted in a 70% reduction in five-year recurrence risk, saving and improving the lives of millions of women.

However, it comes with a slew of negative side effects, including exhaustion, scarring, and a five-to seven-week commitment to daily treatments, which is inconvenient and often unattainable for many women.

As a result, IORT is becoming a more appealing alternative for eligible people. When compared to whole-breast therapy, studies have revealed that IORT is extremely successful.

A longer-term study involving a larger number of patients, according to some observers, is needed to acquire a clearer picture of its effectiveness.

Patients are often keen on this procedure as it offers a significant improvement in convenience.

Using treatment technologies already in the RT arsenal, opportunities to enhance dose, improve accuracy, and optimise treatment for personalised treatment planning may improve results after IORT. The role of IORT will be defined by further improvement of patient selection for APBI in general and IORT in particular.

The author is director-department of Surgical Oncology & Robotic & Laparoscopic Surgery Fortis Hospitals, Bannerghatta Road, Bengaluru.

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Depression can be a debilitating condition that significantly diminishes quality of life. While there is no one-size-fits-all treatment for depression, there are a variety of essential remedies that can be very effective for treating this condition.

What are some essential remedies for depression?

There are many different types of depression and many different essential remedies for depression. The most common type of depression, major depressive disorder, is a serious mental illness that negatively impacts a person’s mood, thoughts, and behavior. Left untreated, depression can lead to significant impairment in daily functioning and even suicide.

Some essential remedies for depression include medication, therapy, and lifestyle changes. Medication may include antidepressants, mood stabilizers, or antipsychotics. Therapy may include cognitive-behavioral therapy, interpersonal therapy, or family therapy. Lifestyle changes may include exercise, adequate sleep, and healthy eating.

It is important to seek help if you are experiencing symptoms of depression. Talk to your healthcare provider or a mental health professional to find out what treatment is right for you.

How can aromatherapy help to relieve symptoms of depression?

Aromatherapy is the use of essential oils to improve physical, emotional, and spiritual health. Aromatherapy has been used to treat a variety of health conditions, including depression.

There are a number of essential oils that have been shown to be helpful in treating depression. Some of the most popular oils for depression include lavender, rose, orange, and bergamot.

Lavender oil is a relaxant and has been shown to be helpful in relieving stress and anxiety, which can aggravate depression. Rose oil is a mood booster and has been shown to be helpful in relieving symptoms of depression. Orange oil is a citrus oil that is uplifting and has been shown to be helpful in relieving symptoms of depression. Bergamot oil is also uplifting and has been shown to be helpful in relieving symptoms of depression.

In addition to using essential oils, there are a number of other ways that aromatherapy can be helpful in treating depression. One way is to use aromatherapy in conjunction with other forms of treatment, such as therapy or medication. Aromatherapy can also be used to improve sleep and relieve stress, both of which can aggravate symptoms of depression.

Aromatherapy is a safe and natural way to treat depression and can be used in conjunction with other forms of treatment. If you are experiencing symptoms of depression, please consult with a healthcare professional.

Depression and exercise: The benefits of physical activity

There is a plethora of scientific evidence that documents the benefits of physical activity for people who suffer from depression. Exercise can help to improve mood, self-esteem, sleep quality, and overall physical health.

In fact, a systematic review published in The Cochrane Library in 2016 found that exercise is an effective treatment for depression. The review analyzed data from twenty-six trials with a total of 2,128 participants. The authors of the review found that exercise was associated with a small to moderate improvement in depressive symptoms.

The benefits of exercise for people with depression are likely due to a combination of factors. Exercise releases neurotransmitters like serotonin and norepinephrine, which help to improve mood. Exercise also has positive effects on brain function and structure. For example, exercise increases the volume of the hippocampus, which is a region of the brain that is involved in memory and emotion.

Exercise is also beneficial for overall physical health. People who are physically active are less likely to develop chronic diseases like heart disease, stroke, and diabetes. Exercise is also helpful for managing weight and improving mood. If you are suffering from depression, I encourage you to participate in physical activity. There are many different types of exercise that you can try, so find something that you enjoy and stick with it. Start with a moderate amount of exercise and gradually increase the intensity and duration.

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Managing diabetes during wedding and festive season

Dr Anish Desai



Weddings and the festive season are important in India because they serve as a reason for family gatherings. These events are filled with sugary sweets and snacks, which lead to overindulgence. If you have diabetes, the current pandemic, wedding, and holiday season are all reasons to pay extra attention to your health. Managing glucose and HbA1C levels, maintaining a healthy lifestyle, and consulting with a doctor regularly are all essential for effectively controlling diabetes. It is difficult to maintain a healthy diet plan during the wedding and holiday season because they are often primarily focused on food.

Diabetes patients must manage their health smartly and effectively because they are at risk of heart disease, foot problems, and kidney disorders.



Better planning: It’s essential to devise a meal plan before attending any event. If we only intend to have snacks, we should choose foods with fewer calories. Making a low-calorie snack choice will help to reduce blood sugar spikes. Dips and sauces should not be consumed since they include calories, salt, and sugar that are hidden.

Avoid skipping meals: Skipping meals over the holiday and wedding seasons can impact blood sugar levels. Try to eat a protein bar that is healthy and keeps your blood sugar stable.

Drink a lot of water: Recent studies have shown that drinking plenty of water and staying hydrated is essential for good health and also aids in calorie burning. Typically, drinking water is linked to consuming fewer calories that are high in sugar, cholesterol, and salt.

Avoid alcohol: Alcohol contains more sugar and calories than other beverages, which might raise blood sugar levels. So, abstaining from alcohol can assist in keeping blood sugar levels under control.

Eat low carbohydrate food: Choosing low-carb foods such as veggies, nuts, meats, etc. during the wedding season can help to keep yourself in a safe zone. Carry some guilt-free snacks to avoid extra oily and processed snacks for emergencies.

Do regular exercise or yoga: Yoga or exercise in the morning will reduce blood sugar levels and burn additional calories.

Monitor blood sugar level: It’s easy to lose track of your sugar levels during the holidays because of all the celebrations at home and all the guests.

Checking your blood glucose levels before and after meals will help you monitor any fluctuations, which is especially important during the holidays. This can also provide you with a decent indicator of whether you need to completely stop consuming sweets or reduce your intake for the next few weeks until your blood sugar levels are under control.

Different nutraceuticals are found to be effective in the management of diabetes

Dietary fiber supplements: These are a diverse range of processed grains, natural food sources, and commercial supplements. It is made up of lignin, oligosaccharides, polysaccharides, and other related plant compounds.

In both diabetics and healthy patients, eating dietary fiber is linked to decreased postprandial glucose levels and greater insulin sensitivity.

Phytoestrogen: Soy and phytoestrogens have received a lot of attention due to the health benefits associated with soy consumption. They help to reduce fat and boost glucose absorption.

Vitamins: Vitamin C, D, and E consumption has an antioxidant effect on the body and can delay or avoid diabetes problems.

Omega-3 fatty acids: Omega-3 fatty acid supplementation has a positive effect on blood pressure, inflammatory indicators associated with diabetes, VLDL cholesterol, triglycerides, and other factors.

The author is MD, Clinical Pharmacologist and Nutra-ceutical Physician, Founder and CEO IntelliMed Health-care Suctions.

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Multiple sclerosis, or MS, is a long-lasting disease that can affect your brain, spinal cord, and the optic nerves in your eyes. It can cause problems with vision, balance, muscle control, and other basic body functions.



Multiple sclerosis (MS) is a neurological disease affecting millions of people worldwide. While no cure for MS has been found, several approved drugs are now available for the long-term management of MS. These have been shown to reduce the number and severity of MS attacks, along with possibly slowing disease progression and managing MS symptoms.


Multiple sclerosis is a neurological disease affecting millions of people worldwide. It is a condition affecting the central nervous system (CNS), which comprises the brain and the spinal cord.

In this condition, the immune system of the body attacks myelin, the protective sheath covering nerve fibres in the CNS. This leads to communication issues between the brain and the body and eventually results in irreversible damage to the nerves.


More than 2.3 million people are affected by MS worldwide. There is no known cause of MS, but following frisk, actors may increase the risk of developing MS.

Age: MS can occur at any age, but onset usually occurs around 20 and 40 years of age.

Sex: Women are more than two to three times as likely as men to have MS.

Family history: If one of the parents or siblings has had MS, then there is a risk of developing MS in the family.

Infections: A variety of viruses have been linked to MS, including Epstein-Barr virus (EBV), the virus that causes infectious mononucleosis.

Vitamin D: Having low levels of vitamin D and low exposure to sunlight is associated with a greater risk of MS.

Smoking: People who smoke appear to be more likely to develop MS and have a worse disease. They also tend to have more lesions and brain shrinkage than non-smokers.

MS is not contagious and is inherited. Individuals may be “genetically susceptible,” increasing their risk of MS. This risk is slight, with only a 3 to 4% chance of a child (with a parent who has MS) being diagnosed with MS.


Signs and symptoms of MS vary widely from person to person and depend on the amount of nerve damage and which nerves are affected. Following are the symptoms generally associated with MS.

• Fatigue

• Numbness

• Tremors

• Vision problems

• Speech issues

• Poor balance

• Difficulty in walking

• Bowel and bladder issues

• Memory issues

It is not possible to predict how multiple sclerosis (MS) will progress in any individual. Some people have mild symptoms, such as blurred vision, numbness, and tingling in their limbs. In severe cases, a person may experience paralysis, vision loss, and mobility problems.


An MS relapse is also known as an “attack” or an “exacerbation” of MS and is usually a worsening of MS symptoms or new MS symptoms lasting more than 24 hours and not due to infection or fever.

An attack may be mild or severe; it may or may not correlate with MRI changes. Many patients have a daily variation of their symptoms; this is not an attack. Similarly, some patients may develop transient symptoms lasting only seconds, such as twitching in an arm or leg. This is also not an attack. Attacks are one marker of disease activity.


Relapse-remitting MS (RRMS): This is the most common form. Around 85% of people with MS are initially diagnosed with RRMS. RRMS involves episodes of new or increasing symptoms, followed by periods of remission, during which symptoms go away partially or totally.

Primary progressive MS (PPMS): Symptoms worsen progressively, without early relapses or remissions.

Some people may experience times of stability and periods when symptoms worsen and then get better. Around 15% of people with MS have PPMS.

Secondary progressive MS (SPMS): At first, people will experience episodes of relapse and remission, but then the disease will start to progress steadily.

How can MS be diagnosed?

A healthcare professional, often a neurologist, is needed to perform a neurological exam. A detailed clinical history and a series of other diagnostic tests are required to determine MS.

Diagnostic testing may include the following:

MRI scan: To detect active and inactive lesions throughout the brain and spinal cord.

Optical coherence tomography (OCT): To check for thinning around the optic nerve.

Spinal tap (lumbar puncture): To find abnormalities in your cerebrospinal fluid (CSF). This test can help rule out infectious diseases. It can also be used to look for oligoclonal bands (OCBs), which can be used to diagnose MS.

Blood tests: Help eliminate the possibility of other conditions that have similar symptoms.

Visual evoked potentials (VEP) test: To analyse electrical activity in the brain.


While no cure for MS has been found, several approved drugs are now available for the long-term management of MS. These have been shown to reduce the number and severity of MS attacks, along with possibly slowing disease progression and managing MS symptoms.

Some are oral medications such as Dimethyl Fumarate, Teriflunomide, Fingolimod, and Siponimod. The injectable medications include Interferons (Avonex, Rebif, Plegridy), Glatiramer Acetate, and Ofatumumab. The infusion medications include Ocrelizumab, Natalizumab, Alemtuzumab, and Rituximab.

The efficacy and duration of the treatment depend upon the clinical symptoms, the frequency and severity of relapses, and MRI scans.Advances in treating and understanding MS are made every year, hopefully moving research closer to identifying a cure.

Multiple sclerosis (MS) is a chronic neurological disease of unknown cause sustained by a widespread inflammatory process within the central nervous system (CNS) leading to multifocal demyelination and axonal loss mostly in the white matter but importantly also in the grey matter of both brain and spinal cord.

Clinical manifestations are heterogeneous depending on the anatomical location of inflammatory lesions, and are expression of acute demyelination which can fully or partially resolve, of chronic demyelination and neuroaxonal injury, that are generally irreversible, or both.

Based on the predominance of episodic acute demyelinating events or of the chronic neurodegenerative process, the clinical course is defined either relapsing-remitting, which represents around 60% of prevalent cases or progressive or secondary.

The author is a Professor in Dept of neurology, PGIMER and incharge of MS Clinic .

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