|Year : 2022 | Volume
| Issue : 1 | Page : 21-29
Setting up of an integrative center for the management of mild-moderate COVID-19
Tanuja Manoj Nesari1, Prasanth Dharmarajan2, Arun Kumar Mahapatra3, S Rajagopala4, Manoj Nesari5, Alka Kapoor6, Deepak Bhati7, Anil Kumar8, Sonam Kumari3, PS Arshathjyothi9, Aparna Dileep3
1 Director, All India Institute of Ayurveda, New Delhi, India
2 Department of Panchakarma, AIIA, New Delhi, India
3 Department of Kaumarabhritya, AIIA, New Delhi, India
4 Medical Superintendent, AIIA, New Delhi, India
5 Advisor, Ministry of AYUSH Govt. of India, New Delhi, India
6 Deputy Medical Superintendent, AIIA, New Delhi, India
7 Senior Medical Officer and Casualty Section Head, AIIA, New Delhi, India
8 Research Director, AIIA, New Delhi, India
9 Department of Kayachikitsa, AIIA, New Delhi, India
|Date of Submission||02-Feb-2022|
|Date of Decision||05-Apr-2022|
|Date of Acceptance||06-May-2022|
|Date of Web Publication||15-Jun-2022|
Department of Kaumarabhritya, All India Institute of Ayurveda, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Besides the expansion of vaccine drive, the discovery of new strains of corona virus is creating havoc all around the world. Based on the pragmatic trial conducted, there is an increasing recognition that an effective integrated holistic approach is urgently needed to combat the COVID pandemic. During an infectious outbreak, a health-care unit is anticipated to function as a high-level isolation unit. Herein, we describe the execution plan, experiences, observations, and challenges that were encountered during the establishment and functioning of COVID Health-Care Ward at All India Institute of Ayurveda.
Methodology: Since the situation was novel, standard operative procedures and protocols were developed accordingly. Strategic plans carried out in infrastructure, biomedical waste management, surveillance, and observations were compiled directly from the hospital administration.
Results: Till date when the 29th team has completed the duty rotation, about 600 COVID mild-to-moderate positive cases have been successfully managed. Zero incidence of nosocomial COVID transmission or death has been reported so far. The recovery speed of patients was found to be remarkably faster at COVID Health Center-AIIA as compared to all other hospitals of the state and a significant number of patients were recovered with the use of Ayurvedic medications alone. On follow-up, only a limited number of patients (two patients) turned up with mild severity of post-COVID complications. Mild respiratory discomfort was noted in these patients for a period of 2 months. The score for Anxiety Depression Scale of among patients and health-care workers reduced significantly.
Conclusion: Indigenous system of medicines is comparatively less explored in pandemic times. Here, a tertiary care hospital has upgraded to integrative health-care model in the management of mild-to-moderate COVID-19 cases.
Keywords: Holistic approach, hospital management, severe acute respiratory syndrome coronavirus 2
|How to cite this article:|
Nesari TM, Dharmarajan P, Mahapatra AK, Rajagopala S, Nesari M, Kapoor A, Bhati D, Kumar A, Kumari S, Arshathjyothi P S, Dileep A. Setting up of an integrative center for the management of mild-moderate COVID-19. Indian J Ayurveda lntegr Med 2022;3:21-9
|How to cite this URL:|
Nesari TM, Dharmarajan P, Mahapatra AK, Rajagopala S, Nesari M, Kapoor A, Bhati D, Kumar A, Kumari S, Arshathjyothi P S, Dileep A. Setting up of an integrative center for the management of mild-moderate COVID-19. Indian J Ayurveda lntegr Med [serial online] 2022 [cited 2022 Dec 3];3:21-9. Available from: http://www.ijaim.in/text.asp?2022/3/1/21/347500
| Introduction|| |
When the world is undergoing vaccination drive, the emerging of various strains of severe acute respiratory syndrome coronavirus 2 is causing a dilemma among the people to opt over various systems of medicine. Ayurveda has proved its potential and possibilities for the prevention and curative option for different communicable diseases. The concept of Vyādhikshamatva (immunity) and prevention of Janapadodwaṃsa vikāra (epidemic diseases) described in the classical text find significant position in the current pandemic.
The AYUSH Ministry has released self-care guidelines for preventing the current pandemic and boosting immunity with special reference to respiratory health since the early outbreak days of COVID-19 from March 2020. Guidelines for management of COVID-19 pandemic for registered practitioners of respective system of AYUSH vetted by the interdisciplinary AYUSH Research and Development Task Force of Ministry were also released. As per the clinical severity of the disease, the medicines, dietary measures, and Yoga protocol were detailed. The Ministry of Health and Family Welfare has released post COVID management protocol citing the references from Rasāyana concept to boost immunity. Thus, there is a growing international recognition and collective understanding on the effectiveness of the integrative approach in the management of COVID-19. However, the ground-level reality regarding the system reveals lack of proper working model in the integrative management of pandemic situations. Hence, such a facility should be developed on a pilot model to establish this as a working model for future references. This would be major milestone in the field of Ayurveda if it is practically possible in other tertiary care settings. Globally several attempts related with the integrative approach are in budding phase, especially in Chinese traditional medicine.
A patient without evident breathlessness or hypoxia (normal saturation), with uncomplicated upper respiratory tract infection, with mild symptoms such as fever, headache, cough, sore throat, or nasal congestion, is recognized as mild case of COVID-19. Moderate case of COVID-19 has a clinical presentation of pneumonia without any severe signs, i.e., dyspnea, fever, cough, and SpO2 <94% on room air with respiratory rate ≤24/min (child – <2 months: ≥60/min, 2–11 months: ≥50/min, and 1–5 years: ≥40/min). It was evident that Ayurveda could manage mild-to-moderate cases of COVID-19. As the number of positive cases was rising in Delhi and it was a need of the hour, COVID Health Center (CHC) to manage mild-to-moderate case of COVID-19 was established at All India Institute of Ayurveda in the month of June 2020.
The article describes how the CHC was set up and steps taken to solve the challenges faced during the functioning of the ward.
Objectives of the study
The current article consists of three major objectives.
- To disseminate the COVID-19 logistics done in a tertiary care Ayurvedic hospital and promote the methodology for further research and manage unprecedented outbreaks
- To establish the efficacy of integrative model in the management of COVID-19
- To communicate the execution plan, experiences, and challenges faced while setting up the CHC ward in Ayurveda hospital with the medical fraternity.
Challenge No. 1: Identification of site for COVID health-care unit
All India Institute of Ayurveda, hospital is a fully functioning National Accreditation Board for Hospitals and Healthcare Providers accredited chronic disease tertiary hospital setup under the Ministry of AYUSH with a daily visit of an average of 3000 outpatient department (OPD) patients and inpatient department (IPD) stay of 200 beds. The hospital has 5 floors; ground, 1st and 2nd floors occupied with specialized OPDs, an emergency care unit, operation theater, labor room, and theater for the department of Panchakarma, Kaumarabhritya, and Shalakyatantra; the 3rd, 4th, and 5th floors were inpatient Block. As setting up a CHC ward was an immediate priority, a set of 14 committees with specific tasks were framed under the guidance of a core committee chaired by the Director of the institute [Table 1]. The patients admitted in the IPD were gradually discharged, and the number of footfalls in OPD per day was reduced. The whole blueprint of hospital was revamped, separating an infective strait from the rest of noninfective area. It is mandatory to have either a separate building that will function as an infectious disease unit or an area that will be physically disengage from the non-COVID area in a hospital with preferably separate entry\exit.
The following amendments were done to achieve the same:
Division into zones
The Inpatient Block at 4th floor of the hospital was remodeled as CHC ward and the 5th floor was designated as the residential area for the health-care workers (HCWs). It is prerequisite to demarcate and label the unit into contaminated, semi-contaminated and clean zone. Thus, the IPD ward was subdivided into red, orange, and green zones. The red zone was occupied with a total of 45 beds. It was considered the infective zone and a HCW would enter the area only after donning a personal protective equipment (PPE) kit. The zone had an entry from the green zone and exit toward the orange zone, installed with high-speed air-curtains to prevent cross air contamination. The green zone was viewed as a noninfective area and was dedicated as the free working space for the HCWs inclusive of nursing station, central patient observation, supervision, pantry, pharmacy, equipment store, and resting rooms for the HCWs. The orange zone was created for doffing and disinfecting the HCWs coming out after visiting the red zone. It was divided into (a) doffing area equipped with appliances essential for sanitizing and discarding the infectious prone articles as per standard biomedical waste (BMW) management practices and (b) bathroom, thus a complete decontamination was ensured after exiting from the orange zone. Thus, separate rooms were allocated for donning and doffing the PPE kit within the green and orange zones, respectively [Figure 1].
It was essential to ensure noncontagious movement in and out of the green zone along with controlled vertical transport of COVID-positive patients and BMW within infective zone. As lift was kept as the only mode of transport to and fro the entire ward, 3 individual lifts were selectively utilized. One was used for the transportation for the green zone, and two lifts exclusively were meant for red zone. One of two lifts within red zone was assigned for the BMW and laundry conveyance and the other was used for transportation of patients.
As a part of isolating the contamination zone, one of the entries of ground floor of the hospital was modified as screening cum billing counter. The route and gateway for the entry as well as exit of the patients were the same. As soon as a COVID-positive patient arrives, the paramedical staff checks the patient and, if found to be of mild-to-moderate case, then after clearing the admission process, escorts the patient through the lift to the ward [Figure 2]. After attending the patient up to the assigned bed, the staff exits from the red zone to the orange zone. Any personal belongings of the patient brought later to admission, which were also a potential source of infection, after sanitization was dropped and conveyed through the same route with the guidance of the on-duty security.
Challenge No. 2: 24 × 7 surveillance and communication
Information communication technology
Installation of an Internet protocol network and hospital public address system are essential components to minimize the physical contact and to ensure convenient communication. The areas of screening cum billing counter, the complete red zone, and the orange zone were installed with multiple closed-circuit televisions and speakers, which were monitored within the green zone. This enabled the staffs to observe and guide a person within the restricted area. Video call with mic and speaker and intercom, connecting the nursing stations, were installed and a tablet phone along with a mobile phone was kept within the red zone. A well-functioning internet network was set up within the ward, facilitating easy communication.
The zone-wise division narrowed the patient–physician face-to-face communication. The problem was resolved by using electronic devices (tablet) within the red zone for the purpose of history taking and other case documentations. Beside the routine patient rounds, telephonic and video call communications were introduced to monitor the symptoms of the patients. Conversational hand gestures were designed, and training was given to the staffs before entering the zone, to convey message in situations when vocal communication was not possible.
Challenge No. 3: Air distribution system
In an infectious care hospital, it is a prerequisite to check recirculation of air among the various zones, whereas it is also essential to provide thermal comfort to the patients by considering the air quality.
Prior to COVID pandemic, the heating, ventilation, and air conditioning system of the hospital recirculated the air within the hospital premises. Now, as per the guidelines formulated by the Indian Society of Heating, Refrigerating and Air-Conditioning Engineers, the centralized air-conditioners and blowers were restricted within the ward to prevent the air contamination. As it was unbearable for patients to withstand the extreme climate temperatures ranging from 1°C to 47°C, individual room heaters and air conditioners were installed so as to limit the flow of air.
Prior to functioning, the water, electricity, and oxygen supplies were checked within the CHC ward. As the ward was under 24 × 7 surveillance and hospital was equipped with necessary emergency facilities to manage unanticipated health emergencies including central gas line and ventilators, the electricity generators were installed to ensured activation of standby power within 10 s.
Challenge No. 4: Infection control measures
Zone-wise division with air curtains, discrete lifts, etc., was a part of infrastructural infection control. Infection prevention and control training among HCWs are precondition; therefore, prior to duty, the team was trained for the same. Within the green zone, masks, glows, and head cap were considered a part of uniform. Regular hand sanitizing was also ensured. Before entering and after exiting the red zone, in order to assure proper donning and doffing, standard operating procedures (SOPs) were formulated [Figure 3] and [Figure 4].
The transfer and disposal of BMW should be management carefully. Once started functioning, anything from the CHC ward was considered infective and the waste generated, no matter be it from green zone, was regarded as BMW. Considering the risk of post sanitization, disposable utensils were used within the CHC ward. The food wastes, medical wastes, clinical laboratory wastes, and infective wastes were segregated as per BMW management color coding method. Transfer and disposal of BMW were carried out through the lift within the red zone as per specific guidelines given by the Central Pollution Control Board for infection control of COVID pandemic, and the data of the same were updated in BMW application.
Laboratory and radiological services
The inpatient testing conducted before and after treatment were complete blood count, erythrocyte sedimentation rate, kidney function test, liver function test, lipid profile, serum ferritin, lactate dehydrogenase, C-reactive protein quantitative, fasting/random blood glucose-d-dimer, coagulation profile, electrocardiogram, and X-ray chest.
There was a necessity to set forth the protocol for conducting the essential radiological and laboratory investigations. A COVID-dedicated radiology room with a deputed radiologist was set up within the restricted premises of the hospital. On-duty nursing staffs collected the essential samples, and these were transported within protective containers to laboratory of the hospital for evaluation.
Challenge No. 5: Establishing a self-reliant COVID health center unit
Indenting and transporting the medicines around the clock from the central pharmacy of the hospital was a tedious process. Therefore, a full-fledged pharmacy was established within the green zone. It had almost all Ayurvedic medicines as per requirement and modern medicines essential in case of emergency. Some of the medicines were kept within the red zone to minimize the number of entries. The medicines were arranged as per Kalpana preparations for the ease of handling. As and when needed, the extra medicines were provided by the hospital pharmacy. An inventory was maintained for the same.
As and when required, different formulations were to be prepared in accordance with the patients' condition. Ergo, a medicine pantry, was settled within the green zone, equipped with all the instruments essential for preparing medicines such as mortar-pestle, vessels, and induction cooker. Fresh parts of plants were provided from the herbal garden of AIIA as per need.
On rotation basis, a team of 24 HCWs consisting of doctors (one senior consultant, one medical officer, and two postgraduate scholars), 4 staff nurses, 4 attendants, 4 housekeeping staffs, 4 securities, and 4 supply and laundry maintenance were assigned for 10 days duty at CHC ward. Apart from respective designated duties, a set of tasks assigned to each member were:
- Preparation of medications like Swarasa (herbal extracts), kalka (pastes), Kwātha (decoctions), and managing the in-house pharmacy
- Data documentation and analysis
- Maintaining quality and timing of diet for of the patients and staff
- BMW management, laundry, and housekeeping
- Inventory management and census and daily update with hospital authorities.
Total 4–5 compulsory visits were planned in a day in addition to medical care as per need. In order to minimize multiple exposures of HCWs and ensure maximum output in a single visit, the tasks like handing over medicines, cleaning material, inventory, and bed sheets were merged as per the requirement along with the timing of the food. The HCW allotted to do his/her routine work was advised to move along food trolley inside red zone, executing all the other essential tasks for the visit. One of the doctors was in-charge to preplan and chart the tasks before each visit and supervise the execution of the same.
Integrative approach to management
The CHC was formed based on integrative approach in the management aspects. The team consists of additional emergency medical officer and BSc. staff nurses to meet unforeseen incidents. Patients with mild-to-moderate COVID-19 be given symptomatic Ayurvedic treatment, adequate nutrition, and appropriate rehydration. Patients with comorbidities were also managed with Ayurvedic drugs under continuous monitoring of oxygen saturation and other vitals. Immediate administration of supplemental oxygen therapy was advised to patients with emergency signs and to patient without emergency signs having SpO2 <90%. Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma, and/or convulsions) should receive emergency airway management and oxygen therapy during resuscitation to target SpO2 ≥94%. Oxygen flow rates were monitored with appropriate delivery devices (e.g., use nasal cannula for rates up to 5 L/min; venturi mask for flow rates 6–10 L/min; and face mask with reservoir bag for flow rates 10–15 L/min). All the chief consultants maintained integrative protocol and had healthy discussion with emergency medical team. It was observed that the crux of integration depends on the continuous patient monitoring and delivering appropriate intervention. Eventually, the team gets into a rapport in between them and that supported for the smooth functioning in the ward.
Challenge No. 6: Patient care
Although patient is the most important factor in a hospital, the whole system was designed keeping in view of patient as well as staff wellness and safety. To minimize contact, physical examination was limited and history taking was considered essential to assess patient's condition for deciding the treatment. A holistic approach was adopted in patient care considering both physical and mental aspects of life [Figure 5].
As per Ayurveda, Bheṣaja (medicine) and Āhāra (food) go hand in hand. Thus, after analyzing the Daśavidha parīkṣā (ten folds of examination in Ayurveda), a customized treatment and diet were planned for every single patient, considering the comorbid conditions of the patients' alike diabetes, hypertension, dyslipidemia, etc.
The patients had severe psychological impact of the disease and it caused further anxiety and stress since they were away from their family. Presence of all the HCWs in PPE kit also created an add-on stress to the patients. This was resolved by conducting regular patient–doctor interaction through video call, recreational, and stress relieving activities.
A daily routine for patients was charted inculcating the National Clinical Management Protocol based on Ayurveda and Yoga for management of COVID-19, Ministry of AYUSH [Table 2].
Routine physical evaluation of the patient helped in monitoring the disease condition. A symptomatic patient with at least 3 days without symptoms, i.e., without fever or respiratory complaints after 10 days of onset of symptoms was eligible for discharge.
Challenge No. 7: Developing standard operating procedures and resolving personal protective equipment
No matter how efficiently a system is designed, the challenges will come into sight only when it starts functioning. Dilemma that turned up within the CHC ward was resolved by amending the existing and developing new SOPs [Table 2] and [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
PPE kit is an essential protective gear advised to be worn by the health-care professional to protect themselves from harmful biological hazards. There are certain guidelines to be followed while doing donning and doffing (the process/practice of putting on protective clothing and uniforms [PPE] and taking off, respectively) and must be done with utmost care. The PPE is made up of air- and water-resistant material to prevent the entry of droplets. This creates a barrier between the outer environment to the body (skin and mucous membrane) causing significant discomfort, restricting vision due to fogging of PPE goggles and face shield by evaporated sweat. Due to these reasons, working with a PPE kit on during summer weather with an average temperature of 45°C for more than 60 min led to dizziness, severe dehydration, hyperventilation, anxiety, headache, and other complications. Following improvising were made:
- Adequate fluids and nutrition were provided before donning to prevent dehydration
- A PPE buddy (who was designated to ensure proper donning and doffing as per checklist) would continuously monitor and guide the worker visiting the red zone to perform his assigned tasks within shortest period [Figure 6].
Challenge No. 8: Emboldening the health-care workers
Facing the social stigma and working in area with a high risk of infection were a major cause of stress and psychological disturbance among the HCW. A reward system was adopted within the HCW to maintain their moral high. The committed HCWs were entitled as “STAR OF THE DAY.” Alike the daily regimen of the patients, staffs were encouraged to adhere to the practice of Aṇutaila nasya, Haridra-saindhava Ganduṣa, Yoga, Prāṇāyāma, and timely intake of AYUSH Kwātha and golden milk. After the completion of duty rotation, the HCWs were rewarded with a certificate of appreciation. Thus, both the physical and mental health of the HCWs were considered.
Both the patients and HCWs were subjected to the following assessment criteria [Figure 7].
- Among patients – Reverse transcription polymerase chain reaction (RTPCR), laboratory investigations, radiological imaging, vitals, and cardinal symptom score.
RTPCR sampling was done as per ICMR guidelines; laboratory investigations and radiological imaging were done soon after admission and prior to discharge; vitals and cardinal symptom score were recorded daily four times a day and as per requirement. These parameters were essential as per integrative management protocol developed within the hospital for evaluating the severity, framing the customized treatment and diet.
- Among HCWs – RTPCR
RTPCR sampling was done 72 h prior to duty and 5 days after the completion of the duty. This helped to check infection in and out of the CHC ward.
- Among patients – Hospital Anxiety Depression Scale.
Among the patients, HAD scaling was evaluated soon after admission and prior to discharge. The scaling was done by the patients under the surveillance of trained PG scholars. These helped to improve the quality-of-service render by the HCWs, thus boosting their mental health.
- Among HCWs – Hamilton Anxiety and Depression Scale.,
Among the HCWs, Hamilton Anxiety and Depression Scaling were evaluated on the starting day and at the end of their respective duty rotation. The scaling was done by the HCWs under the surveillance core committee. This helped the hospital management to assure psychological well-being of the HCWs.
Till date (March 3, 2021), 29 team rotations have been completed and 615 COVID-19 mild-to-moderate positive cases have been successfully managed in which nearly 696 HCWs were exposed. No incidence of nosocomial COVID-19 transmission has been reported so far. Since the time from functioning of the hospital, it was observed that the recovery speed of patients was remarkably faster at CHC-AIIA as compared to recovery of mild-to-moderate patients from other hospitals of the state. A significant number of patients recovered with the use of Ayurvedic medications alone. Referral of patients to higher centers was not many. On follow-up, only a limited number of patients turned up with mild severity of post-COVID-19 complications. The score for Anxiety Depression Scale of among patients (Anxiety Scale BT – 16.4 ± 0.67, AT – 2.67 ± 0.7, P ≤ 0.05, and Depression Scale BT – 17.4 ± 0.7, AT – 2.67 ± 0.7, P ≤ 0.05) and HCWs (Anxiety Scale before posting – 28.7 ± 0.87, after posting – 22.67 ± 0.7, P ≤ 0.05, and Depression Scale before posting – 5.1 ± 0.3, after posting – 1.8 ± 0.7, P ≤ 0.05) reduced significantly [Figure 8] and [Figure 9]. It is evident to evaluate the fact that how does the entire setup can contribute to the future aspects of science. All the discharged patients from this CHC are in complete surveillance and follow-up. All their queries, compliances, complications, etc., were strictly documented to generate evidence-based outcome. All the frontline HCWs are duly equipped with evidence-based practices to contain similar situation in the battlefield. Based on the challenges faced in the pandemic condition, similar protocols would be helpful for future implementation and practices. Simplified models can be established in primary health center levels too. Modification is necessary according to the type of population.
| Discussion|| |
A COVID health-care center without hampering the regular functioning of the hospital was successfully achieved. The zone-wise division of the ward helped to check infection into the green zone. It was observed that the patients came for admission mostly during night hours. The 24 × 7 functioning screening cum billing counter facilitated admission, discharge, and referral at any time. The pharmacy and medicine pantry ensured administration of freshly prepared medicines as per condition even at mid-night. The scheduled task chart prepared before each visit helped in minimizing the number of exposures of HCW into the red zone. Zero nosocomial transmission exhibited the efficacy of infection control measures adopted within the CHC ward. The resolutions of the challenges practically faced within the ward helped in developing new SOPs. Modern intervention as per need and timely referral of patients to higher centers in emergency condition also helped in reducing the complications among patient and achieving zero death event. On follow-up, it was noted that the patients were following the daily regimen which were practiced within the ward. Many successful case reports from this COVID health-care center were published. Thus, it is evident that the holistic approach inculcated with the integrative Ayurvedic management has significant benefits.
| Conclusion|| |
A massive infectious outbreak like COVID-19 demands swift health system resilience. A tertiary hospital is expected to be prepared for transformation as per the needs and conditions. Ayurveda has tremendous potency to combat a pandemic situation. Since the immune status of patients plays an essential role in COVID-19 infection, Ayurvedic management provides preventive as well as therapeutic solution for patients with COVID-19 infection. Since the disease is observed to have unexpected acute manifestations, the possible approach must be integrative and holistic. The major contribution of the article is to disseminate the logistics related to the transformation of a chronic disease tertiary care hospital to an integrated CHC. The standard operative procedures and protocols developed in this model can be utilized in similar situations of pandemic conditions in future. Challenges faced during time have been transformed to opportunities. Being a CHC, the beneficiaries were mild-to-moderate cases. In unprecedented outbreaks, this model can be upgraded to COVID-dedicated centers with the help of super-specialty integration and multidisciplinary care units.
The authors acknowledge Late Dr. Sanjay Gupta who contributed by giving a structure to the CHC ward and dedicated his immense services for its proper functioning as the medical superintendent of AIIA Hospital, the administrative and other technical support received from Dr. Umesh Tagade, Joint Director, AIIA, Estate Unit of AIIA, and Ministry of AYUSH for all support and opportunity to establish the exclusive Ayurveda CHC at AIIA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2]