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Abstract Background We aimed to compare anticoagulation control and outcomes between usual medical care (UMC) and pharmacist-led anticoagulation services (PLAS) in patients receiving warfarin at the Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia. Methods A quasi-experimental study was conducted, including 350 (66.7%) and 175 (33.3%) patients from the UMC and PLAS groups, respectively, from 525 patients. The time in therapeutic range (TTR) was determined using the Rosendaal method, with a TTR ≥ 65% set as the cut-off for optimal anticoagulation. The two-sample Wilcoxon rank-sum (Mann–Whitney U) test was used to compare continuous variables between groups. Categorical variables were compared between groups using Pearson’s chi-square test or Fisher’s exact test. Logistic regression and negative binomial regression analyses were conducted to identify the factors associated with suboptimal TTR and secondary outcomes, respectively, at the p values

IntroductionThe prevalence of drug therapy problems in patients with epilepsy has been reported to be as high as 70–90%. Moreover, elderly patients with epilepsy are highly vulnerable to inappropriate therapies. This study aimed to evaluate potentially inappropriate prescriptions (PIP) in elderly patients with epilepsy at the adult neurology clinics of two referral hospitals in Addis Ababa, Ethiopia.MethodsA cross-sectional study was conducted on 81 patients with epilepsy and the medication appropriateness index (MAI), the Beers, and Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to the Right Treatment (STOPP/START) criteria were used to assess PIP. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.ResultsOf the 81 study participants, 41(50.6%) were male, and the mean age was 67.33 ± 17.43 years. One-fourth of the study participants (25.9%) had polypharmacy and drug-drug interactions (DDIs) were documented in 64 (79%) patients. Based on the MAI, of the 263 medications that were prescribed for elderly epileptic patients, 110 (41.8%) had drug interactions, 44 (16.7%) had inappropriate indications, 31 (11.8%) were ineffective, and 12 (4.6%) were prescribed incorrect doses. Based on the STOPP and START criteria, PIP was reported in 31(38.3%) and 13(16.1%) patients, respectively.ConclusionPolypharmacy and DDIs are common in elderly epilepsy patients. The MAI, Beer’s criteria, and STOPP/START criteria indicate a high prevalence of PIP in elderly patients with epilepsy.

Anticoagulation management using warfarin is challenging in clinical practice. This study aimed to evaluate the knowledge, adherence, and satisfaction with warfarin therapy and associated factors among outpatients at the Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. An interview-based cross-sectional study was conducted among 350 patients receiving warfarin therapy at cardiac and hematology clinics of TASH. Anticoagulation knowledge assessment (AKA) questionnaires assessed the patients’ warfarin knowledge. Adherence to warfarin was evaluated using the Morisky Green Levine Scale (MGLS), and patient satisfaction with warfarin therapy was assessed using the 17-item anticlot treatment scale (ACTS). Binary logistic regression was used to determine factors associated with the outcome variables, and p

Abstract Background Hemophilia is a rare genetic condition that is often overlooked and underdiagnosed, particularly in low-income countries. Long-term spontaneous joint bleeding and soft tissues can have a significant negative impact on a patient’s health-related quality of life (HRQoL). The objective of this study was to assess HRQoL and its associated factors in Ethiopian patients with hemophilia. Methods A cross-sectional survey was conducted among patients with hemophilia at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. Patients were recruited consecutively during follow-up visits. The European Quality of Life Group’s 5-Domain Questionnaires at five levels (EQ-5D-5L) and Euro Quality of Life Group’s Visual Analog Scale (EQ-VAS) instruments were used to assess HRQoL. The EQ-5D-5L utility score was computed using the disutility coefficients. We applied the Krukal-Wallis and Mann–Whitney U tests to determine the differences in EQ-5D-5L and EQ-VAS utility scores between patient groups. A multivariate Tobit regression model was used to identify factors associated with HRQoL. Statistical analyses were performed using STATA version 14 and statistical significance was determined at p

ABSTRACTThis study aimed to evaluate the knowledge and attitudes of community pharmacists (CPs) on vaccination and assess the barriers and willingness to implement community pharmacy-based vaccination services (CPBVS) in Ethiopia. An online cross-sectional study was conducted on 423 CPs in Ethiopia, and questionnaires were distributed to CPs through the Ethiopian Pharmaceutical Association telegram group and e-mail invitations. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 27. Most CPs (92%) had good knowledge of vaccination, and 43.5% strongly agreed that the population’s immunization rates would rise if CPs were authorized to provide vaccinations. The overall mean attitude score (±SD) toward vaccination was 35.95 (±4.11) out of a total score of 45, with 187 (44.2%) scoring below the mean. The most common barriers were lack of authorization (94.1%), costs and time associated with professional development and training (71.4%), time requirements for professional development (70%), and insufficient staff or resources for implementation (70%). Two hundred thirty CPs (54.4%) expressed a willingness to implement CPBVS. Educational qualifications were significantly associated with knowledge of CPs regarding vaccination. Those with inadequate knowledge had about 2.5 times (AOR = 2.51, 95% CI: 1.19, 5.31, p = .016) a poorer attitude toward vaccination services compared with those with adequate knowledge. Those study participants who had a good attitude toward vaccination services were nearly seven (AOR = 6.80, 95% CI: 4.36–10.59, p = .0001) times more willing to provide CPBVS when compared with their counterparts. Implementing CPBVS in Ethiopia requires overcoming barriers and providing professional development opportunities.

Abstract Background Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia’s Oromia region in September 2019. Methods Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs. Results Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs. Conclusions ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients.

Abstract Background Oral anticoagulation therapy with warfarin requires frequent monitoring level of anticoagulation by the international normalized ratio (INR). In Africa, studies that explore anticoagulation control, treatment outcomes, and associated factors are reported in various ways in long-term patients receiving warfarin therapy to generate concrete scientific evidence. Methods The literature search was conducted in PubMed, Cochrane Library, African Journal of Online databases, Google Scholar, and Google. An advanced search strategy was computed to retrieve relevant studies related to anticoagulation control and outcomes. Duplication, title and abstract screening, and full-text assessment were conducted in Covidence software. Study quality was assessed using the Joanna Briggs Institute Critical appraisal quality assessment tool. The systematic review is registered in PROSPERO (CRD42021260772) and performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. Results Out of 298 identified articles, 18 articles were eligible for the final review and analysis. The mean of 39.4 ± 8.4% time in therapeutic range (TTR) (29.4 to 57.3%), 36.7 ± 11.5% TTR (range 25.2–49.7%) and 46% TTR (43.5–48.5%) was computed from studies that determined TTR by Rosendaal, direct and cross-section-of-the-files methods, respectively. In this review, the lowest percentage of TTR was 13.7%, while the highest was 57.3%. The highest percentage of patients (32.25%) who had TTR ≥ 65% was reported in Tunisia, but the lowest percentages were in Namibia (10%, TTR ≥ 65%) and Kenya (10.4%, TTR ≥ 70%). Most of the included studies (11 out of 18) used Rosendaal’s method while the direct method was employed by three studies. Generally, 10.4–32.3% of study participants achieved desired optimal anticoagulation level. Regarding secondary outcomes, 1.6–7.5% and 0.006–59% of patients experienced thromboembolic complications and bleeding events, respectively. Having chronic comorbidities, taking more than two drugs, and presence of medications that potentially interact with warfarin, and patient-related factors (patients aged

Objectives: Health-related quality of life of people living with epilepsy is significantly impaired. The disease causes a significant psychological and social impact on daily living conditions and usually has lifelong consequences for the patient and family. Therefore, this study aimed to investigate the health-related quality of life of people living with epilepsy and its predictors in Dessie Referral Hospital, Dessie, Ethiopia. Methods: A facility-based cross-sectional study was conducted from April to June 2020. Systematic random sampling was used to recruit a total of 385 study participants. Written informed consent was obtained for each participant, and data were collected using World Health Organization Quality of Life Brief Version and Hospital Anxiety and Depression Scale questionnaires. Descriptive statistics were used to summarize the data, while multivariate logistic regression analyses were used to examine factors affecting the quality of life. P value ⩽ 0.05 was considered statistically significant. Results: About 95.80% of the study participants had a generalized seizure, and 64.30% were on two antiepileptic drugs. Of the total, 12.20% and 37.00% suffered from depression and anxiety, respectively, based on the Hospital Anxiety and Depression Scale score. The mean total health-related quality of life score was 51.98 (standard deviation: ± 10.08; 95% confidence interval: 41.90–62.06) out of 100. Age, education level, marital status, occupation, residence, current comorbidity, family support, and recreational activities were associated with good health-related quality of life ( p ⩽ 0.05) Conclusion: The average overall quality of life of people living with epilepsy in the Dessie Referral Hospital was low. Therefore, concerted efforts must be made to improve the quality of life of patients over the healthcare services provided.

Abstract Background Despite the availability of effective drugs, tuberculosis remains a major public health problem that predominantly affects low- and middle-income countries. This study aimed to assess tuberculosis treatment outcomes among patients treated at one of the primary health care levels in Addis Ababa, Ethiopia. Methods An institutional-based retrospective cross-sectional study was conducted at a tuberculosis clinic in public primary healthcare facility. The study populations were all patients with tuberculosis who had been completed their treatment course in the center from July 2014 to July 2018. After getting Ethical clearance and permission from the health center, trained data collectors working in the center were recruited. The collected data were checked for completeness every day by the principal investigators. Data were edited, cleaned, and analyzed using SPSS version 25. Descriptive statistics were used to summarize the data while multinomial logistic regression was employed to explore associations among variables of interest, and p

Introduction: Venous thromboembolism is a major cause of mortality and morbidity among hospitalized patients and thromboprophylaxis is one of the key strategies to reduce such events. We aimed to assess venous thromboembolism risk using Padua prediction score, thromboprophylaxis practice, and outcomes in hospitalized medical patients at Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia. Methods: A cross-sectional study was conducted among 219 patients admitted to Tibebe Ghion Specialized Hospital from 1 December 2018 to 31 May 2019. Data were collected from patients’ medical records using a pre-tested data abstraction format to collect patients’ clinical information and venous thromboembolism risk using the Padua prediction score. We used Statistical Package for the Social Sciences version 26 for data analysis. Descriptive statistics was used to summarize the findings, and binary logistic regression analysis was used to assess association between the variables of interest. Results: Reduced mobility, recent trauma and/or surgery, heart and/or respiratory failure, and active cancer were the frequently identified venous thromboembolism risk factors. Based on Padua prediction score, 48.4% of patients were at high risk of developing venous thromboembolism. The venous thromboembolism prophylaxis was given only for 55 (25.1%) patients and 15 of them were at low risk of developing venous thromboembolism (

Background Patient satisfaction is a widely used indicator to measure quality of pharmacy services. Currently, a transformational pharmacy service called auditable pharmaceutical transactions and services is being implemented nationally in Ethiopia. However, there is a dearth of evidence regarding the national impact of this system on patient satisfaction. Objective To assess patient satisfaction in hospital pharmacies that have implemented auditable pharmaceutical transactions and services in Ethiopia. Method This is a national study conducted based on a cross-sectional study design. Data were collected using a structured questionnaire from September 5 to October 5, 2020. The collected data was analyzed using spreadsheet excel and Statistical Package for the Social Sciences (SPSS) version 23. The proportions, ratios, and percentages were used for presenting data. A binary logistic regression test was used to determine the association of patient satisfaction with dispensary infrastructure, medicines availability, scores of labeling, and scores of patient knowledge on dispensed medicines. A p value

Anticoagulation is the cornerstone in the prevention of stroke in atrial fibrillation. This study aimed at assessing the anticoagulation control and outcome and predictive factors in atrial fibrillation patients on warfarin therapy. A retrospective chart review was used to evaluate patients with atrial fibrillation who were on warfarin during two years follow up at the anticoagulation clinic of the hospital. The time in therapeutic range (TTR) was calculated using Rosendaal's method. Data were analyzed using SPSS software version 25. Univariable and multivariable analyses were computed to determine factors affecting TTR and bleeding events. We included 300 patients in this study. The mean percentage TTR was 42.03 ± 18.75. Only 38 (12.67%) patients achieved a TTR of above 65%. The average international normalized ratio (INR) testing frequency was 35 days (16.3-67.2 days). Taking 1 or 2 drugs along with warfarin was found to be better in achieving good TTR as compared to taking more than two drugs ( p = .014). Having heart failure was associated with a 2.45 times odds of poor anticoagulation control (TTR

Abstract Objective This study aimed at assessing the management practice of febrile neutropenia (FN) in pediatric cancer patients at Tikur Anbessa Specialized Hospital (TASH), Ethiopia by reviewing patients’ charts from 135 participants retrospectively. Data was entered into Epi-info 7 and exported to SPSS 20 for analysis. Results Empiric antibiotics therapy (EAT) was given to all patients in which ceftriaxone with gentamycin constituted of 71.8% followed by ceftriaxone monotherapy. EATs were converted to others in 20 (14.8%) and 2 (1.5%) patients for the first and second times respectively, mainly based on poor clinical response without conducting culture and sensitivity tests. These tests were done only for 13 (9.6%) participants and growth was seen in 5 patients; and definitive therapy was given for 2 patients. ANC value was above 500 cell/mm3 in 80.7% of patients and 98.5% of study participants were afebrile after completion FN treatment. Most of them (70.4%) were treated for FN and 7 of patients died due to all case mortality. The hospital should not rely mainly only on ceftriaxone with gentamycin as EAT and should do culture and sensitivity test to optimize therapy based on susceptibility result before conversion and modification of therapy in management of FN.

Background Psoriasis is a chronic inflammatory disease characterized by keratinocyte hyperproliferation and aberrant differentiation with great negative impact on patients’ quality of life (QoL). This study aimed at assessing factors influencing management practice, and QoL and its associated factors among ambulatory psoriatic patients visiting All Africa Leprosy, Tuberculosis and Rehabilitation Training (ALERT) Center in Addis Ababa, Ethiopia. Materials and methods A cross sectional study was conducted in 207 patients with psoriasis attending the dermatology clinic of ALERT Center in Addis Ababa, Ethiopia. Data were collected using structured questionnaire and patients’ chart review. Dermatology Life Quality Index (DLQI) was used to measure patients’ QoL. Patients’ characteristics were summarized using descriptive statistics and predictors of QoL were identified by binary logistic regression. Results Among 207 study participants, 122 (58.9%) were females. The mean age of the study population was 37.92 (SD = 14.86) years (ranging from 16 to 68 years). The mean age at which diagnosis of psoriasis made was 32 (SD = 13.7) years ranging from 10 to 62 years. The duration of the disease in 112 (54.1%) patients were more than or equal to 5 years. Majority of study participants 145 (70.0%) had plaque psoriasis followed by sebopsoriasis, 24 (11.6%). The majority of plaque psoriasis (80%) cases were managed by topical corticosteroids with or without salicylic acid or coal tar and only 21 (14.5%) treated by methotrexate alone. The mean DLQI was 6.25 corresponding to a moderate effect. Symptoms and feelings were the most affected domains of QoL. Factors associated with poor QoL were female [AOR = 0.17 (95%CI: 0.06, 0.48)], low, above average and high family income ([AOR = 0.12 (95% CI: 0.02, 0.56)], [AOR = 0.06 (95% CI:0.01, 0.32)], and [AOR = 0.03 (95% CI: 0.01, 0.22)]), respectively, and primary education level [AOR = 0.14 (95% CI: 0.03, 0.64)] while being on systemic therapy [AOR = 4.26 (CI: 1.18, 15.35)] was predictor of better QoL. Poor QoL was predominant in females [AOR = 0.17 (95%CI: 0.06, 0.48)], low income [AOR = 0.12 (95% CI: 0.02, 0.56] patients, and patients with primary education level [AOR = 0.14 (95% CI: 0.03, 0.64)]. Patients on systemic therapy [AOR = 4.26 (CI: 1.18, 15.35)] had good QoL. Conclusion Our study identified that topical corticosteroids were the mainstay of psoriasis treatment in the dermatology clinic of ALERT Center in Addis Ababa, Ethiopia. Moderate effect QoL was achieved by study participants based on DLQL score.

Abstract Objective Surgical site infections (SSIs) were the most common healthcare-associated infection mainly in developing countries. Inappropriate use of surgical antibiotic prophylaxis, in terms of antibiotic choice, timing, and duration, can lead to the selection of resistant microorganisms and high costs. The aim of this study was to investigate the pattern of antibiotic use, incidence and predictors of SSIs at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Results From 131 patients, 55.7% were male study participants. Ninety (68.7%) patients received preoperative prophylaxis. Ceftriaxone was the most 76 (84.5%) prescribed agent for prophylaxis. Twenty-seven (20.6%) patients developed surgical site infection. Previous surgery AOR = 3.22 (95% CI [1.14–9.13]) and alcohol use AOR = 7.04 (95% CI [2.56–23.12, p = 0.000]) were independent predictors of SSIs in multivariate logistic regression analysis.

Abstract Background Warfarin is the most widely used anticoagulant in the world. The difficulty of managing warfarin contributes to great potential for patient harm, both from excessive anticoagulation and insufficient anticoagulation. This study assessed the International Normalized Ratio (INR) control outcome measures and warfarin dose adjustment practices at cardiology and hematology outpatient clinics at a teaching hospital in Addis Ababa, Ethiopia. Methods The study was based on a cross - sectional study design involving 360 retrospective patients’ chart review among outpatients who received warfarin for its various indications. Results The mean frequency of INR monitoring per patient was 62.9 days (17.2–143.7 days). Patients spent 52.2%, 29.0% and 18.8% of the time in sub-therapeutic, therapeutic and supra-therapeutic ranges, respectively. The daily warfarin dose was increased 50.9% and 36.9% and decreased in 52.8% and 60.9% of the time for occurrences of sub-therapeutic and supra-therapeutic INRs to achieve target ranges of 2.0–3.0 and 2.5–3.5, respectively. Conclusion The quality of anticoagulation management with warfarin among outpatients in Tikur Anbessa Specialized Hospital was sub-optimal. This was reflected by low Time in Therapeutic Range (TTR), longer than recommended INR monitoring frequency, and minimal actions taken to adjust warfarin dose after occurrences of non-therapeutic INRs.

Deep vein thrombosis (DVT) is a major health problem affecting a significant portion of population. Primary complications are Pulmonary Embolism (PE) in the short term and Post-Thrombotic Syndrome (PTS) in the long term. Thrombolytic drugs act by activating plasminogen which in turn forms the enzyme plasmin. Plasmin consequently degrades blood clots by breaking down the fibrin molecules which make up the clots help to degrade the already formed clot. They can be used using different route of administration, doses and durations. The purpose of this systematic review was to assess the outcome of thrombolytic therapy in terms of the efficacy, safety and effectiveness of the medicines. Electronic searches of databases (MEDLINE and Google Scholar) were queried for articles written in English since 2000 GC. A total of 760 results were obtained using the search keys, and after excluding duplicates, 275 articles were selected. Finally, 9 randomized controlled trials (RCTs) which met the language of publication, study design and exclusion criteria were included in this systematic review. The data were obtained from nine trials (6 countries), providing a study-level data of 1309 participants. Almost all studies revealed that thrombolytic treatment was effective in the management of acute DVT. In most of the studies, the rate of rethrombosis was lower in case of thrombolytic than standard management. Hence, addition of thrombolytic results in persistence and increases the clinical benefits. Thrombolytic therapy was very effective in reversing closed veins, in boosting the patency rate, while reflux was higher in patients treated with anticoagulants. Thrombolytic offers potential advantages over the standard treatment of DVT by reducing the proportion of patients with chronic disabling leg symptoms (such as PTS) by triple in the longer term. However, the incident of major bleeding was higher in patients receiving thrombolytics

This study aimed to assess the prevalence, characteristics, and treatment of MRH among undergraduate female students at the College of Health Sciences, Addis Ababa University, Ethiopia. Methods: A cross-sectional study was conducted among undergraduate female students from May to June 2023. A random sample of 1000 females were approached who fulfilled the eligibility criteria using the online electronic method. Descriptive statistics were used to summarize participant characteristics. Multivariate logistic regression analysis was performed to identify factors associated with the severity of pain. All statistical analyses were performed using SPSS version 26. A p-value ≤ 0.05 was considered statistically significant. Results: Of the 1000 students who approached online, 757 were included in the final analyses. The prevalence of MRH was (86, 11.4%) and 32.6% of them has experienced the headache before two to three days of menses. The median number of days of missed social activities and reduced productivity was three and one day, respectively. Being single was 6.24 times more likely to have severe MRH (AOR = 6.24, 95% CI: 2.73– 14.26, p=0.001) and pharmacy students were less likely (AOR = 0.31, 95% CI: 0.16– 0.61, p = 0.001) to have severe pain. Conclusion: Our findings illustrated that MRH among young female students adversely affects students' productivity and social life. This demands interventions to reduce the impact and should pay attention in the future, particularly to create awareness to enhance screening and rendering various treatment options for the target population. [ABSTRACT FROM AUTHOR]

To assess the reliability and validity of the Amharic version of the Hill–Bone Adherence to High Blood Pressure Therapy Scale (HBTS) among Ethiopian hypertensive patients.Methods: A cross-sectional study was conducted among 294 hypertensive patients at two health facilities from 1st October to 30th December 2021 using the culturally adapted HBTS. Psychometric properties were assessed in terms of acceptability, internal consistency, construct validity, and predictive validity. Statistical Package for Social Sciences version 26 was used to perform statistical tests at a significance level of p-value < 0.05. The Statistical Package for Social Sciences AMOS version 26 was used for the confirmatory factor analysis.Results: Cronbach of the 14-item HBTS was initially 0.801. After excluding one item from the appointment-keeping subscale, Cronbach of the modified 13-item HBTS was 0.806. The initial principal component analysis revealed four constructs for the 14-item and three for the 12-item with a total explained variance of 58.65% and 55.73%, respectively. The confirmatory factor analysis failed to fit the observed items with the latent subscales. The predictive validity test showed that the modified 12-item Amharic version was correlated (r= 0.118;p< 0.043) with systolic blood pressure.Conclusion: The modified 13-item Amharic version of the HBTS is a reliable and valid tool with adequate psychometric properties. It can be used to assess adherence to antihypertensive medications in Amharic-speaking patients in Ethiopia. [ABSTRACT FROM AUTHOR]