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Background : Autism is one of the fastest spreading neuro-developmental disorders in the worldwide.Children with Autism spectrum disorder may be risk of suboptimal development which leads to increases morbidity, poor physical activity and performances. The aim of present study was to compare nutritional status between children with Autism spectrum disorder and normal children of Bangladesh. Materials and methods: It was cross-sectional and observational study. The study population was Group A consists of 100 normal Bangladeshi children and Group B consists of 100 Bangladeshi children with Autism spectrum disorder, aged between 02 and 18 years collected by convenient sampling. Height, weight, triceps skin fold thickness, suprailiac skin fold thickness and Body Mass Index (BMI) were analyzed. Results: Children with autism spectrum disorder had statistically significant lower height and weight; thicker triceps and suprailiac skin fold, were mostly under weight as compared to normal children. Conclusion: The results of this study provide the baseline information about nutritional status of normal children and children with autism spectrum disorder in Bangladesh which will help to monitor nutritional growth of children. Chatt Maa Shi Hosp Med Coll J; Vol.20 (2); July 2021; Page 55-59

Background: Tandem Gait (TG) testing is known as a clinical method for studying the walking function with complicated coordination. The precise biomechanical walking parameters in this test remain poorly investigated. Moreover, TG is a modified locomotion of walking. In general, walking is a highly automated movement. TG introduces a component of voluntary control into it. Aims: A study of functional and biomechanical symptoms in children after the treatment for the posterior fossa tumor in the long term. Methods: The study involved 15 healthy subjects aged 12 to 35 years (20.47.2), among them 4 men and 11 women control group. The group of patients comprised 33 children who had a tumor of the posterior cranial fossa (HF) at the age of 7 to 17 years (12.33.1), of these 15 boys and 18 girls, who were admitted for rehabilitation treatment to the "Russkoe pole" Rehabilitation Center. A study on the TG kinematics was performed with the Optitrack system. Results: The results showed asymmetry in the duration of the step cycle and an increase in its duration proportional to the severity of the functional state. The pelvic movements showed different abnormalities. The flexion-extension movements in the hip joints were characterized by an extension lag at the end of the transfer period and a slight decrease in the amplitude, which probably became more pronounced with an increase in the degree of the motor impairment. The movements in the knee joints demonstrated two main phenomena: an increase in the flexion setting of the joint and a decrease in the amplitude of the main swing flexion. In addition, there was a delay in the maximum of the swing flexion. The kinematic parameters of the TG of the examined patients, in contrast to the control group, are not stable. This is, presumably, due to the fact, that normally such a modification of walking is easily automated and does not require voluntary control. In patients with SCF, each step in the TG mode requires additional voluntary control, and under these conditions, the stability and repeatability of a movement are dramatically reduced. Conclusions: In contrast to the routine clinical version of the test, the analysis of the movement biomechanics allows one to present an accurate qualitative and quantitative characterization of functional disorders. According to our research, motor function disorders develop at various levels of the musculoskeletal system. The degree of their severity is in a good agreement with the expert assessment of the patient's functional state.

To investigate the role and correlation of IL-35 and ILC2 in children with allergic rhinitis. 50 cases of children with allergic rhinitis admitted to our hospital from February 2018 to March 2020 were selected as the research subjects and set as the study group. During the same period, 50 cases of normal children admitted to our hospital for physical examination were selected as the control group. The differences in the expression of IL-35 and ILC2 between the two groups and the correlation with the severity of allergic rhinitis were compared. In BMI, the study group was significantly lower than the control group, and the difference was statistically significant (P

Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. They can be assessed by measuring intercondylar distance (ICD), clinical tibiofemoral angle (cTFA) or radiologic TFA (rTFA). We aim to determine the knee measurement values among three groups of children. Medline (1946-) and EMBase (1947-) were searched until 31 July 2020 using a search strategy. Studies with original data which reported knee measurements among children with normal alignment, physiologic and pathologic bowing between the ages of 0-3 years were included. In total 1897 studies were identified, and 16 studies included after title and abstract screening. These studies involved 1335 patients with normal alignment, 286 with physiologic and 184 with pathologic bowing. Five studies provided data on ICD, seven on cTFA and eight on rTFA which were pooled for meta-analyses. Normal children had neither measurable ICD nor demonstrable varus on cTFA after 19 months old. The mean (95% confidence interval) ICD for children with pathologic genu varus at 18 months was 4.41 (4.19-4.63). The rTFA for children with pathologic compared to the physiologic bowing by age groups was; 11-20 months: 24.74°(23.22°-26.26°) vs. 19.44°(17.05°-21.84°), 21-30 months: 20.35°(18.13°-22.56°) vs. 14.72°(12.32°-17.12°) and 12-36 months: 32.60°(26.40°-38.80°) vs. 19.14°(17.78°-20.50°). Children above the age of 18 months with genu varus should be closely monitored clinically using ICD or cTFA. An ICD of more than 4 cm may warrant further investigation for pathologic cause. rTFA has limited use in the detection of pathologic varus.

BACKGROUND: One of features of Visual preference in autism spectrum disorder (ASD) is that they tend to social stimuli to nonsocial stimuli. Though it has been studied widely, until now the results are still not consistent. One of the most important reasons may be that the stimuli of the past visual preference paradigm have different movement patterns. Therefore, the present study aimed to improve the visual preference paradigm to reduce the bias caused by different movement of stimuli and explore the features of visual preference of ASD further. METHODS: Two hundred and seven children who met DSM-5 criteria for ASD and 125 typically developmental (TD) children were enrolled. They were matched in age and gender. Visual preference was measured by eye tracking technology. The subjects presented simultaneously with dynamic object images (DOI) and dynamic social images (DSI) with the same type and same speed of repetitive movement. Social interaction deficits of ASD were assessed by parents with Aberrant Behavior Checklist (ABC). RESULTS: Compared with TD children, the following findings were noted: (I) children with ASD paid less attention to social stimuli and more attention to nonsocial stimuli (t=6.417, P

The purpose of the study was two-fold: The first purpose of the research was to conduct the "adaptation study of Brigance K & 1 screen II to Turkish," while the second was to “investigate the effect of the enrichment program applied to gifted children and their classmates in the 1st grade of primary education on their performance in multiple intelligence fields". The research was conducted in the screening model and experimental design. The study group consisted of 477 primary schools first grade students (6 years old). Data collection tools are as follows, Brigance K & 1 Screen II scale, Goodenough-Harris draw-a-person test, Teele Multiple Intelligence Preference Inventory (TIMI), Enrichment Program Pre-test -Post-test, and "Project Evaluation Criteria List." After the screening process, a class-wide enrichment program based on multiple intelligence was applied to gifted and talented children and their classmates. Statistical Package for the Social Sciences (SPSS) was used to analyze the data at hand. The findings of the study revealed that Brigance K & 1 Screen II scale was effective in determining gifted children attending the first grade of primary school with a rough evaluation. The enrichment program results were different from the existing school program in favor of enrichment. The class-wide enrichment program has improved all children, with a more potential for gifted children. As a part of the program, a total of 163 students were given project assignments. At the end of the evaluation, it was determined that the students improved in multiple intelligence areas.

Patient-reported outcome measures such as the Pediatric Eye Questionnaire (PedEyeQ) are increasingly recognized as important in healthcare assessment. Defining normal PedEyeQ thresholds would allow classification of individual children as having reduced versus normal domain scores. We prospectively enrolled visually normal children (aged 0-17 years; n = 310) to calculate normal PedEyeQ domain thresholds. In addition, 48 children with bilateral visual impairment (VI; best-eye acuity worse than 20/70 or 20/70 or better with limited visual fields) were enrolled for validation. The Child PedEyeQ (four domains) was completed by 5- to 17-year-olds. Parents completed Proxy (five domains) and Parent PedEyeQ (four domains). Each domain was Rasch scored (converted to 0-100); normal thresholds were defined as the 5th percentile of scores in visually normal controls. For Child 5-11 PedEyeQ, 39%-78% of VI children had reduced domain scores, and 88%-100% for 12- to 17-year-olds. For Proxy PedEyeQ, proportions ranged from 55% to 100% and for Parent PedEyeQ ≥83% had reduced scores. High prevalence of reduced PedEyeQ domain scores in the VI cohort, validates the use of normal thresholds. Nevertheless, variability in child self-reporting creates challenges for identifying individual 5- to 11-year-olds with reduced scores.

Motor stereotypies are rhythmic, repetitive, prolonged, predictable, and purposeless movements that stop with distraction. Although once believed to occur only in children with neurodevelopmental disorders such as autism, the presence and persistence of complex motor stereotypies (CMS) in otherwise typically developing children (primary CMS) has been well-established. Little, however, is known about the underlying pathophysiology of these unwanted actions. The aim of the present study was to use resting-state functional magnetic resonance imaging to evaluate functional connectivity within frontal-striatal circuits that are essential for goal-directed and habitual activity in children with primary complex motor stereotypies. Functional connectivity between prefrontal cortical and striatal regions, considered essential for developing goal-directed behaviors, was reduced in children with primary CMS compared to their typically developing peers. In contrast, functional connectivity between motor/premotor and striatal regions, critical for developing and regulating habitual behaviors, did not differ between groups. This documented alteration of prefrontal to striatal connectivity could provide the underlying mechanism for the presence and persistence of complex motor stereotypies in otherwise developmentally normal children.

This study aims to analyze the implementation of education policies on the existence of inclusive schools contained in the Minister of National Education Regulation Number 70 of 2009. Starting from the gap that arises when children with special needs have education separately from normal children, namely in SLB eventough in Article 31 of the 1945 Constitution state that all citizens without exception have the right to get education. The method used is the Qualitative method with library research studies. The source of the data come from the policy literature and several previous studies related to the inclussion school. Policy analysis theory uses the E.S. Quade theory with the result of research that show that the policies related to inclusive school contain some systematic education implementation which ultimately can realize the principles of Education for all. However, problems arise related to the unpreparedness of school providing inclussion education service which result in learning processes that seem forced and ultimately result learning is not optimal. This requires a new policy from goverment related to te classification of eligible school to carry out inclusive education and minimum IQ standardtation of student so that they are able to follow the learning process to the fullest. Keywords: policy, inclussion school.

One of the most widespread disorders in childhood is called autism spectrum disorder (ASD), which affects the brain's function. Previously, many efforts have been made to develop an intelligent system to detect disease using brain activity. However, accurate diagnosis of ASD remains a challenging issue among scientists. The purpose of this study was to diagnose ASD at an early age using a low computationally algorithm based on electroencephalography (EEG) signal. In this study, we classified two groups of normal and autistic children using brain signals at resting-state. Two brain channels (C3 and C4) of 61 children including 27 normal children and 34 autistic children in the age range of 4 to 8 years were studied. For the first time, we characterized the EEGs using innovative polar-based lagged state-space indices. The classification was performed using the support vector machine (SVM). The results demonstrated the highest average accuracy of 81.96% using the indices of two EEG channels. Using single-channel EEG measures, the maximum average classification rate of 78.68% was achieved using C4. To sum up, the results revealed that despite the limited number of brain channels and computational simplicity, the proposed algorithm was able to distinguish the two groups of normal and autistic children with satisfactory accuracy.

Corona virus is a virus transmitted by animals and humans that has been declared a world pandemic by WHO. Washing hands is the most common practice as a form of early prevention of transmission of the corona virus. Children with special needs are children who have abnormalities / deviations from the average condition of normal children, generally in terms of physical, mental and social behavior characteristics. The purpose of this study was to increase the knowledge and ability to wash hands in students with special needs. The activity was carried out on November 22, 2020. The method used in this study is lectures and discussions as well as the practice of washing hands through video conferencing accompanied by special delivery by a sign language interpreter. Participants in this activity totaled 14 Students with Special Needs. The results obtained were increased knowledge of students with special needs and the ability to practice washing hands properly.

The development of child motor skills is closely related to nutritional status. Stunted children generally experience delays in motor development. The objective was to determine the relationship between stunting, socioeconomic status, and children’s motor skill development. This research was conducted in 2018 using a cross-sectional method. Respondents were 80 children aged 48-60 months in urban and rural areas of West Java. The researcher used a simple random technique data collection on anthropometric, socioeconomic, and motor skills development. Then it was analyzed using chi-square and Fisher exact methods. The researcher used a simple random technique data collection on anthropometric, socioeconomic, and motor skills development. Then it was analyzed using chi-square and Fisher exact methods. We found that stunting prevalence in rural areas was higher than in urban areas. As much as 30 % of children in rural areas and only 12.5 % of children in urban areas were categorized as stunted. There is no significant association between stunting with the family’s socioeconomic status and motor skill development. The weight for the age variable showed a significant association with stunting. Children who are malnourished have a stunting risk of 10.9 times greater than normal children (OR 10.9 p 0.001).

Purpose of review Ready-to-use therapeutic foods (RUTF) allow effective community-based management of severe acute malnutrition (SAM). Current interest focuses on their optimal composition and use. Recent findings Studies of alternative RUTF have yielded differing results. Partial soybean, sorghum flour, and whey protein replacement RUTF were inferior to standard RUTF. In contrast, soy-based RUTF was as effective as milk-based RUTF and an alternative RUTF with added oats lead to superior recovery in comparison to standard RUTF.Reducing the dose of RUTF in the later phases of SAM recovery resulted in small reductions in the growth of uncertain clinical significance.Although iron and vitamin A status improve during treatment with standard RUTF, a significant proportion of children remained deficient. Alternative soya, maize, and sorghum-based formulas with no milk protein may improve recovery of iron status compared to standard RUTF.Finally, in children with SAM, plasma essential fatty acids and conversion to long-chain polyunsaturated fatty acids are reduced. Despite the improvement, these parameters remain lower than in normal children after 3 months. Summary New RUTF formulations may provide a cost-effective alternative to standard RUTF. Future research should focus on addressing micronutrient deficiency, lipid metabolism, and long-term recovery.

Aim: Assessment and comparison of oral hygiene status and caries experience between the institutionalized special children and a group of healthy children, along with, association of oral hygiene with various sociodemographic variables (age, sex, etc.) and clinical variables (brushing frequency, cleaning mode, material used, etc.). Materials and Method: A cross-sectional study was conducted in district Mandi of Himachal Pradesh on 384 children aged 6–17 years, of which 184 belonged to special health-care needs and 200 healthy subjects were selected randomly from three other government schools. Oral hygiene status and caries were clinically examined using simplified oral hygiene index (OHI-S) index, decayed, missing, filled teeth (DMFT), and decayed-extracted-filled teeth index, respectively. Results: Mean OHI(S) scores for mentally retarded, visually impaired, hearing impaired, and healthy children were 3.08 ± 1.35, 1.49 ± 1.44, 0.81 ± 0.95, and 1.14 ± 0.97, respectively, and the results were statistically significant (P < 0.05). Mean DMFT scores for mentally retarded, visually impaired, hearing impaired, and healthy children were 1.48 ± 1.96, 0.85 ± 1.06, 0.68 ± 1.23, and 1.64 ± 1.70, respectively, and were statistically significant (P < 0.05). Conclusion: Mean OHI(S) score was significantly more for mentally retarded children followed by visually impaired, healthy, and hearing impaired whereas mean DMFT score was significantly more for healthy children followed by mentally retarded, visually impaired and hearing-impaired children.

To investigate the relationship between muscle strength and sEMG of biceps brachii during elbow flexion by measuring the maximum muscle strength and sEMG value of normal children and adults, and to analyze their sources, so as to lay a theoretical foundation for the method of motor program reconstruction to restore the function after brain injury, 30 healthy children aged 9 - 10 years and 30 adults aged 20 - 30 years were randomly selected. The muscle strength and sEMG of biceps brachii during elbow flexion were detected and recorded, and the data were statistically analyzed. The muscle strength of children was significantly lower than that of adults (P

Not every child born in this world always experiences normal development. Many of them experience obstacles, disturbances, delays, or have risk factors so that to achieve optimal development, special treatment or intervention is required. This group became known as children with special needs or extraordinary children. In understanding children with special needs or outside children, it is necessary to have an understanding of the types of disabilities (children with special needs) and the consequences that occur to sufferers. Children with special needs are referred to as children with disabilities because they include children whose growth and development experience deviations or abnormalities, both physically, mentally, emotionally, and socially when compared to normal children.

Meibomian gland lipid secretion is important to the stability of the tear film and ocular surface comfort. Changes in the tear film’s lipid layer thickness (LLT) after orthokeratology treatment may reflect underlying changes to the meibomian gland function. The purpose of this study was to investigate the features of the tear lipid layer in normal children and the effects of short-term orthokeratology treatment. Altogether, 163 myopic children (age: 10.7 ± 1.9 years, 8–15 years; 71 males) with no contact lens use history were enrolled in this study, of whom 56 were successfully fitted with orthokeratology lenses and completed the 1-month study. The tear film’s LLT (average, maximum, and minimum) and blinking pattern were measured by a LipiView® interferometer in 163 participants at baseline and in 56 orthokeratology participants at 1 week and 1 month after overnight lens wear. Results show that LLT (average) was 58.09 ± 21.66 nm in Chinese normal children. LLT was significantly correlated with rate of partial blinks at every follow-up (all p < 0.05 ). Compared to baseline, the LLT (average and minimum) and partial blinks (number and rate) at 1 week and 1 month after orthokeratology treatment both significantly increased, and the increase of LLT was correlated with elevation of rate of partial blinks. In conclusion, LLT was shown to be elevated after short-term overnight orthokeratology treatment and was related to change in rate of partial blinks. Further studies are needed to clarify the long-term effect and the underlying mechanism.

Introduction: Having children changes the dynamics of family functioning and parenting role can become a source of stress for parents, even if their child is following a normal growth pattern without any unusual problem. A maximal number of studies in our setup have been conducted to assess stress levels in parents who have differently abled (special needs) children. This study, in contrast, will assess the perceived stress level in parents who have normal children following a normal growth pattern. Aims & Objectives: 1) To determine perceived stress levels in parents having normal children ≤10 years of age. 2) To identify the association of perceived stress levels in parents with socio-demographic factors. Place and duration of study: Shalamar Hospital, Dec 18, 2019-Mar 19, 2020. Material & Methods: A cross-sectional study was conducted in one tertiary level hospital in Lahore. The study subjects were parents with normal children ≤10 years of age. Purposive sampling technique was applied to recruit the subjects. Study variables were: a) sociodemographic b) variables of perceived stress among parents. Data was collected upon the Perceived Stress Scale (PSS), and a structured socio-demographic Performa. Data was analyzed using SPSS 20, with perceived stress as the outcome. Descriptive statistics were calculated, while the Independent Samples T-test was used to test differences between PSS scores and characteristics of the family. Multivariable Logistic Regression model was applied for studying associations of perceived stress with socio-demographic characteristics. Results: From a total of 390 respondents, the mean parental perceived stress score was 41.59±8.27. Among these, 32.6% were categorized in low stress, 50.8% moderate, and 16.6% in high stress category. A significant association was found between perceived stress and the working status of the mother (pvalue= 0.011), and with the father’s monthly income (p-value=0.000). The Independent sample t-test showed significant differences between PSS total score and structural types of the family (p-value=0.001). Conclusion: The development of a child with parents’ positive mental health is important, and parental stress compromises the healthy growth of children. The current results warrant further study at a community level with a representative sample to have a more in-depth analysis of the application of some intervention at an early stage. This will assist in minimizing parental stress and improve parenting quality.

Children with special needs are those who need education provided according to each individual’s need. They should receive proper education in the same way as other normal children to develop their potential without any discrimination against their backgrounds. Inclusive schools become one of the answers to meet these needs. Many things must certainly be prepared by educational institutions before implementing the inclusive-based school model amid the community because this will be capable of minimizing learning problems in the future. Grounded in this issue, the researcher sought to find out more deeply the problems of implementing an inclusive education at Elementary School of Taman Siswa in Rejang Lebong. This study applied a qualitative approach, and the data were garnered by means of observation, interviews, and documentation. The data were further analyzed using qualitative analysis stages. This study found the following conclusions. The problems faced by teachers in terms of inclusive-school learning are teachers’ competences, no specific tutor for students with special needs, parents' knowledge, students’ difficulties in receiving materials, the readiness of school management, lack of government’s attention and public awareness. The efforts made by the school to overcome these problems include: implementing learning by using fun methods and media, involving students with special needs in each learning activity, providing additional time for students with special needs, and trying to make use of learning facilities individually.

This research intends to know and describe how the group's guidance in social interaction at Yayasan Adi Nugraha Boyolali. The type of research used is qualitative research. Penelitin sees, observations, collects and interprets the data in the field as it is to then draw conclusions. The subject in this study was the chairman of Yayasan Adi Nugraha Boyolali, 2 guiding teachers and two deaf children. Data collection techniques using interviews and observations. Data analysis methods used are data reduction, data presentation and withdrawal of conclusions. Validity of data using source trianggulation. The results of this study showed that the process of mentoring child groups will be given motivation so that the child is always positive thinking, foster self-confidence and way of interacting socially with normal children. While in the process of implementing group guidance there are 4 stages, namely: the initial stage of the group, the transition phase, the activity stage, the final stage of the group.

Dyslexic children who are said to have problems in learning actually have their unique learning styles. Thus, they required learning aids that are suitable with their conditions which are not similar with normal children. One of the issues of dyslexic children is the ability to figure out on how to peruse. Reading aptitudes are the most critical essential abilities. Without this ability, learning process is very challenging. Perceiving this significance and the motivation to support the dyslexic children, pondering or identification activity is led to distinguish the type of reading aids that are suitable to the necessities and requirements of dyslexic children. The case study was successfully conducted with children (6 to 9 years old) by Malaysian Dyslexia Association in Klang Valley, Malaysia. The finding from this preliminary research shows that reading in the form of interactive motion is easily accepted by the dyslexia children. In fact, the finding from this study provides a valuable learning style for these dyslexic children to use and practice. This new learning style is very enjoyable and manage to engage the children to read more in the classroom.Keywords: Dyslexia, Dyslexic Children, Interactive Motion, Reading

Stunting merupakan bentuk kekurangan gizi kronis yang dapat terjadi intergenerasi. Ibu hamil yang mengalami malnutrisi berisiko lebih besar menghasilkan anak stunting. Kondisi ini berkontribusi terhadap penurunan kualitas sumber daya manusia dan peningkatan morbiditas dan mortalitas. Tujuan dari penelitian ini adalah mengetahui adanya perbedaan kadar hemoglobin dan lingkar lengan atas ibu hamil antara baduta yang mengalami stunting dan normal di wilayah kerja Puskesmas Cibungbulang Kabupaten Bogor. Desain penelitian yang digunakan adalah deskriptif analitik dengan pendekatan cross sectional. Jumlah sampel sebanyak 115 responden yang didapatkan dengan teknik purposive sampling. Hasil penelitian menunjukkan bahwa tidak ada terdapat perbedaan kadar hemoglobin (p-value=0,835) dan lingkar lengan atas (p-value=0,114) ibu hamil antara baduta stunting dan normal. Stunting perlu difokuskan tidak hanya pada masa pra konsepsi tetapi perbaikan gizi selama periode 1000 hari pertama kehidupan karena masa tersebut merupakan masa kejar tumbuh dan menentukan kualitas individu pada fase kehidupan selanjutnya.

Objective To determine the prevalence and practices of exposure to screen-based media in children by 15-18 months of age. Methods This observational descriptive study was conducted from March to August, 2019. Mothers of 370 healthy developmentally normal children (15-18 months of age) were enrolled during their visit to immunization clinic of a medical college affiliated hospital. Parental response to a semi-structured questionnaire was recorded to assess the initiation, frequency and duration of screen exposure, and related parental perceptions. Results 369 (99.7%) children were exposed to screen-based media till 18 months of age, starting from median (IQR) age of 10 (8, 12) months. Smartphone and television were being viewed by 354 (96%) and 328 (89%) children, respectively. Screen time was >1 hour/day in 328 (88.7%) and >2 hours/day in 209 (56.5%) children (median (IQR): 120 (80, 180) minutes/d). Most (72%) parents were not concerned with their child's screen time. Conclusion Almost all young children seem to be exposed to screen-based media by 18 months of age in the urban setting. Extensive use of screen-based media by young children calls for formulation of guidelines on toddlers' screen use and their dissemination to parents.

Purpose : To determine the effect of Inherited Cleft Lip and Palate Management on microbial migration in forked lip and palate (CLP) children. Material and methods: Fifteen forked lip and palate children and fifteen standard children (the control group), aged 3 months to 36 months were selected from the out clinic of Faculty of Dental Medicine, Al-Azhar University for Girls. Dribble samples were collected after the breakfast by inserting sterile cotton gauze in the entry from the jaws before and after construction of obturator. Results: The highest (mean±SD) value of log bacterial count (CFU/μl) was found in the cleft patients pre-operatively (5.64±1.06), while post-operatively there was a significant reduction in value (0.60±0.06) (P