Other Pharmacy and Pharmaceutical Sciences Commons^™

Dermaseptin-Based Antiviral Peptides To Prevent Covid-19 Through In Silico Molecular Docking Studies Against Sars-Cov-2 Spike Protein, Taufik Muhammad Fakih

Pharmaceutical Sciences and Research

A pandemic coronavirus disease of 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has now been declared a global pandemic by the World Health Organization. The search for new drugs, especially by utilizing antiviral peptides is a very potential area. Through this study, protein-peptide docking and protein-protein docking simulations were conducted using in silico methods to identify, evaluate, and explore the molecular affinity and interaction of dermaseptin peptide molecules produced by frogs of the genus Phyllomedusa against the SARS-CoV-2 spike protein macromolecule, and its effect on attachment to the surface of the ACE-2 (Angiotensin Converting Enzyme-2) receptor. …

Remdesivir: Mechanism And Effectiveness For Coronavirus Disease 2019 (Covid-19), Vina Neldi, Suharjono Suharjono

Pharmaceutical Sciences and Research

Currently, coronavirus disease 2019 (COVID-19) is a very serious health problem. The World Health Organization (WHO) has characterized this disease as a pandemic. Recommendations related to vaccines and drugs are not available yet because they are still in the clinical trial phase, and one of the superior drugs is remdesivir which has an antiviral activity. Several clinical trials of this drug are being carried out with the aim of evaluating its safety and efficacy in COVID-19 patients. There are two clinical trials with completed recruitment status, which are NCT04257656 and NCT04280705. NCT04257656 showed that remdesivir had faster time for clinical …

The Potential Roles Of Jamu For Covid-19: A Learn From The Traditional Chinese Medicine, Dwi Hartanti, Binar Asrining Dhiani, Shintia Lintang Charisma, Retno Wahyuningrum

Pharmaceutical Sciences and Research

As the pandemic of the coronavirus disease 2019 (COVID-19) continues while there is no drug and vaccine available, every effort to discover one should be considered. This review aimed to discuss the potential use of jamu, the Indonesian traditional herbal medicine, to deal with COVID-19 by following those of more-established traditional Chinese medicine (TCM). The online literature search using the PubMed database, as well as the circulars from the Indonesian Ministry of Health, were carried out to collect data up to June 07, 2020. The use of TCM for the treatment and prevention of COVID-19 has been officiated in the …

In-Vitro Assessment Of Cb1/Cb2 Receptor Binding And Function, Joey M. Davis

Honors Theses

Cannabinoid receptors CB1 and CB2 are G protein-coupled receptors that have a variety of physiological effects on the human body. Many natural product agonists and antagonists are presumed to interact with the cannabinoid receptors and are therefore heavily studied in drug discovery. Assays are used to study the binding of compounds to these receptors. However, a limited number of these assays are efficient in determining the functional activity of ligands associated with CB1 and CB2. Of those, many use radioactivity which is both expensive and potentially dangerous to the researcher. In this study, we first validated the assays already found …

Evaluation Of Potential Drug Interaction Of Analgesic In Cancer Patient Receiving Palliative Care In Dharmais Cancer Hospital, Eme Stepani Sitepu, Atika Wahyu Puspitasari, Nuriza Ulul Azmi, Lila Nilam Sari

Pharmaceutical Sciences and Research

Analgesics are mostly used in cancer patients receiving palliative care to improve the quality of life of patients. Besides analgesics, cancer patients receiving palliative care were also given other drugs in combination to overcome other symptoms of cancer, and this combination could potentially cause drug interactions. This study was aimed to analyze the potential of drug interactions with analgesics in cancer patients. The study design was cross-sectional with a retrospective method and descriptive study. The sample of this study was cancer palliative care patient’s prescription at Dharmais Cancer Hospital in the period of January – December 2017. The sample analyzed …

Formulasi Gel Ekstrak Daun Kelor (Moringa Oleifera Lamk) Sebagai Sediaan Antiinflamasi, Nining Sugihartini, Syauqul Jannah, Tedjo Yuwono

Pharmaceutical Sciences and Research

The development of anti-inflammatory gel of Moringa oleifera leaf extract has been performed. This study aimed to determine the physical properties, irritation index and anti-inflammatory activity of gel with various concentration of Moringa oleifera leaf extract. The extract was obtained by maceration method using ethanol 70%. The extracts were formulated in a gel with a concentration of 3%, 6%, 9% by using Carbopol 940 as gelling agent. The gel was evaluated for its physical properties (viscosity, pH, spreadability, adhesivity), irritation index with rabbit test animals and anti-inflammatory activity with mice test animals based on epidermal thickness parameters. The test results …

Profil Terapi Antihipertensi Dan Antihiperlipidemia Terhadap Fungsi Ginjal Pasien Diabetes Melitus Tipe 2 Dengan Komplikasi Penyakit Ginjal Kronis Di Rsup Dr. Hasan Sadikin, Fitri Rachmaini, Lia Amalia, Cherry Rahayu

Pharmaceutical Sciences and Research

Chronic Kidney Disease (CKD) complication increases the risk of morbidity and mortality in type 2 diabetes mellitus (DMT2) patients. The presence of hypertension and dyslipidemia as comorbidity increases the risk of macrovascular and microvascular complications and further adding to the list of drugs used. Management of this comorbidity is essential to prevent cardiovascular events and minimize kidney damage. This study aimed to evaluate therapeutic profile of antihypertensive and antihyperlipidemia drugs towards kidney function in DMT2 patients with CKD complication at Dr. Hasan Sadikin Hospital. Study was done by using a prospective single cohort design with consecutive sampling technique and obtained …

An Exploration Of Electrospun Fibers Containing Drug-Cyclodextrin Inclusion Complexes, Fatimah Fatimah, Zeynep Aytac, Tamer Uyar, George Pasparakis, Gareth R. Williams

Pharmaceutical Sciences and Research

A series of new core-shell fibers were developed containing anticancer drugs (5-fluorouracil or ferulic acid) and their cyclodextrin inclusion complexes, with a gadolinium-based magnetic resonance imaging (MRI) contrast agent. These were prepared by electrospinning, a simple method for producing ultra-fine fibers through the application of a strong electrostatic force on a polymer solution. The shell of the fibers was formed from Eudragit S100, and the drugs were loaded in the core. Scanning electron microscopy images showed the formation of smooth ribbon-like fibers, with diameters ranging from 1.4 to 5.1 μm, and transmission electron microscopy reveals a transparent interface between the …

Development Of Ethanolic Extract Of Pinang Masak Jambi (Areca Catechu L.) As A Modulator Of Doxorubicin Cytotoxic Effect In Breast Cancer Therapy, Fitrianingsih Fitrianingsih, Indri Maharini, Diah Tri Utami

Pharmaceutical Sciences and Research

Doxorubicin is one of the chemotherapy agents that is often used in breast cancer therapy. Phenomenon of breast cancer cell resistance to chemotherapy agents has been traced to the molecular level. The development of compounds that can overcome drug resistance chemotherapy needs to be continuously developed, especially agents with specific molecular targets, namely P-glycoprotein (Pgp), NFkB, cyclin, and cyclin-dependent kinase (CDK). Another alternative is the combination of chemotherapy agents with chemopreventive agents (co-chemotherapy) to reduce side effects and increase sensitivity of cancer cells. Doxorubicin is often used in breast cancer therapy. This study was performed to determine the effect of …

Anti-Proliferative Effects Of A Coumarin Benjaminin On Four Human Cancer Cell Lines, Siau Hui Mah, Soek Sin Teh, Ahmad Azri Fitri Ismail, Gwendoline Cheng Lian Ee

Pharmaceutical Sciences and Research

Cancer is a major health issue around the globe. Chemotherapy and radiation therapy are no longer the standard treatments for patients as these remedies lead to many adverse effects. Thus, the development of alternative effective drugs from lead compounds, especially natural products is necessary. This study aimed to isolate cytotoxic phytochemical constituents from a plant Calophyllum inophyllum, which has been used as traditional medicine since ancient time. The root of C. inophyllum was extracted and subjected for phytochemical constituent isolation. A coumarin, benjaminin (1) was isolated successfully from the chloroform extract and its structural elucidation was performed by spectroscopy analyses …

Ace Inhibitory Activity And Functional Group Analysis Of Solvent- Partitioned Fractions Of Eleusine Indica, Jade Celon Cometa, Liahona Faith Roldan Mancol, Anthony Nalzaro Yen, Joanne Katherine Talens Manlusoc

Pharmaceutical Sciences and Research

Eleusine indica Linn. Gaerth or Indian goose grass has been widely used as an alternative natural anti-hypertensive agent. However, the rationale behind this mechanism is still unknown. The purpose of this study is to confirm the presence of functional groups that may be responsible for its ACE inhibitory activity and its possible synergism. Each solvent-portioned fraction was analyzed by FTIR, individual ACE inhibitory activity, and combination of fractions. FTIR results of solvent- partitioned fractions revealed that O-H and C-H stretches were present in all fractions. In addition to this, C-O and C=O groups were also present in all fractions except …

Assessment Of Depression Among Older Adults Staying In Old Home Care In Klang, Malaysia, Muhammad Qamar, Nurul Zahirah, Sohail Ahmad

Pharmaceutical Sciences and Research

Mental disorders such as depression are widespread, often underdiagnosed, and usually inappropriately treated. The early recognition of factors that may promote depression with the help of depression screening aid can help to plan better care for the patient. Therefore, this study aimed to determine the depression prevalence among the older adults staying in old home care, to explore any association and differences of depression across various socio-demographic variables, and to study the predictors of depression among study subjects. A cross-sectional study was conducted with a convenience sample of 141 elderly by using the validated tool. The study instrument was divided …

Interaction Of Thymidine With Sodium Bis(2-Ethylhexyl) Sulfosuccinate In Alcohol And Water: Studies With Uv-Vis Technique, Indu M. Paudel, Ajaya Bhattarai

Pharmaceutical Sciences and Research

The accurate measurement of thymidine absorbance in the presence of sodium bis(2-ethylhexyl) sulfosuccinate (AOT) in ethanol and water systems at room temperature by UV-vis technique has been reported. The AOT concentrations varied from 0.0005 to 0.014 [mol/L] in ethanol whereas from 0.0002 to 0.042 [mol/L] in water. The concentration of thymidine was 0.0073 [mol/L] during UV-vis spectrum registration. The thymidine spectrum was examined in the presence of AOT concentration. Using a statistical method of non-linear regression (NLREG), thymidine binding and thymidine distribution constants were evaluated. A noticeable decrease in thymidine absorbance in the presence of AOT concentration was shown in …

Encapsulation Of Temulawak Extract By Using Nanocrystalline Cassava And Sago Starches And Maltodextrin, Titi Candra Sunarti, Fatimah J. Pasaribu, Christina Winarti

Pharmaceutical Sciences and Research

This study was conducted to evaluate the performance of Curcuma zanthorrhiza crude extract after encapsulated in nanocrystalline starch, and to investigate the effect of the ratio of nanocrystalline starches and maltodextrin; and the effect of concentration of temulawak extract on nanocapsule characteristics, as well as encapsulation effect on the stability of antioxidant activity. Preparation of nanocrystalline starch was conducted by using lintnerization and ethanol precipitation of cassava and sago starches. Nanocrystalline starch and maltodextrin were used as matrices with the ratio varied from 25:75, 50:50, and 75:25. The mixture of temulawak extract and matrices were homogenized and spray dried. Nanocapsules …

Antiproliferative And Apoptotic Effects Of Proteins From Black Seeds (Nigella Sativa) On Human Breast Mcf-7 Cancer Cell Line, Yamna Khursid, Basir Syed, Shabana U. Simjee, Obaid Beg, Aftab Ahmed

Pharmacy Faculty Articles and Research

Background

Nigella sativa (NS), a member of family Ranunculaceae is commonly known as black seed or kalonji. It has been well studied for its therapeutic role in various diseases, particularly cancer. Literature is full of bioactive compounds from NS seed. However, fewer studies have been reported on the pharmacological activity of proteins. The current study was designed to evaluate the anticancer property of NS seed proteins on the MCF-7 cell line.

Methods

NS seed extract was prepared in phosphate-buffered saline (PBS), and proteins were precipitated using 80% ammonium sulfate. The crude seed proteins were partially purified using gel filtration …

Identification And Evaluation Of Antibacterial Compounds From The Vibrio Sp. Associated With The Ascidian Pycnoclavella Diminuta, Abdurraafi’ Maududi Dermawan, Elin Julianti, Masteria Yunovilsa Putra

Pharmaceutical Sciences and Research

This study aims to obtain secondary metabolites that have antibacterial activity from bacteria endophytic of ascidian Pycnoclavella diminuta collected from the coast of Bitung, North Sulawesi, Indonesia. The research was started with screening antibacterial activity of six bacteria isolated from P. diminuta. The active bacteria were selected for identification using standard biological molecular method and further fermentation to produce secondary metabolites. The isolation of secondary metabolites was conducted by various chromatography method and then selected fraction was based on the antibacterial activity from bioautography results. The result showed that the active isolate by coding M2.Tnk.Bt 5.10-3.2 was identified as Vibrio …

Chemical Components Of Ocimum Basilicum L. And Ocimum Tenuiflorum L. Stem Essential Oils And Evaluation Of Their Antioxidant Activities Using Dpph Method, Ni Putu Ermi Hikmawanti, Hariyanti, Nurkamalia, Sahera Nurhidayah

Pharmaceutical Sciences and Research

Ocimum basilicum L. and Ocimum tenuiflorum L. are two types of plants from Ocimum (Lamiaceae). One of their chemical compounds is essential oil. Essential oil might have an antioxidant activities. The part of the plants which are often wasted and never used are stem. This study aimed to analyze the chemical components of O. basilicum L. and O. tenuiflorum L. stem essential oils and evaluate their antioxidant activities. Essential oils were obtained by steam-water distillation. Analysis of chemical component of essential oil was performed using Gas Chromatography-Mass Spectroscopy (GC-MS). Antioxidant activities were evaluated with DPPH method and then the IC50 …

Cytotoxic Activity Of Stem Of Pycnarrhena Cauliflora Through Apoptosis Induction On Human Breast Cancer Cell Line T47d, Masriani, Rudiyansyah, Rini Muharini, Eny Enawaty

Pharmaceutical Sciences and Research

Cytotoxic activities of extracts of Pycnarrhena cauliflora leaves, stems and roots on some human cancer cells have been known. However, the cytotoxicity of stem of Pycnarrhena cauliflora on human breast cancer cell line T47D through an apoptosis induction has not been proven yet. This study was an effort in understanding the cytotoxic activity of stem of Pycnarrhena cauliflora through apoptosis induction. The crude ethanol extract was partitioned between n-hexane and dichloromethane at pH 3, 7 and 9, which was subsequently tested for their cytotoxic activity against human breast cancer cell line T47D by using 3-(4,5-dimethylthiazol-2-yl)- 2,5-diphenyltetrazolium bromide (MTT). Flow cytometric …

Model Hewan Coba Pada Penelitian Diabetes, Fauzul Husna, Franciscus D. Suyatna, Wawaimuli Arozal, Erni H. Purwaningsih

Pharmaceutical Sciences and Research

The animal model has been widely used and contributed vastly to the scientific research over the years. While it can be used as an alternate subject in a study, the selection of the animal is crucial to assess and investigate the influence of the environment and genes on the pathogenesis of a disease. Many factors contribute to the choosing of the animal. They can be ranged from the similarities with the modelled object, easily looked after with less expensive cost, good reproductive performance, ability to produce blood and tissue samples, well-known genetic composition, and the status of the disease can …

Cannabinoids For The Treatment Of Chronic Headaches, Kevin Krivanek, Lucy K. Wagala, Brian Heilbronner, Kimberly Loughlin, David Kinder

Pharmacy and Wellness Review

Species of the Cannabis plant genus were among the earliest medicinal plants cultivated by man, with historical accounts of their medicinal uses dating back before the Common Era. Despite its current legal status, Cannabis has garnered nationwide attention as a therapeutic agent for various disease states, including chronic headaches, due to its medical indications as an antispastic, analgesic, antiemetic, neuroprotective and anti-inflammatory agent. Since headaches have a high prevalence in the American population and greatly impair simple daily aspects of living, chronic headaches have become a particular point of interest in regard to the therapeutic potential of Cannabis. Clinical trials …

Marijuana And Its Cardiovascular Implications, Albert Bui, Daniel Powell, Victoria Cho, Kelsey Lindsley, Lindsey Peters

Pharmacy and Wellness Review

As marijuana becomes legalized for medical use, it is important for prescribers and pharmacists to be knowledgeable about the important aspects of marijuana such as mechanism of action, indications and abuse potential. Although marijuana's medicinal benefits are frequently reported, the risks, namely cardiovascular risks, associated with its utilization are often overlooked. Use of marijuana has been reported to increase the risk of myocardial infarction, tachycardia and hypotension, among others. Health care providers must determine if marijuana's benefits outweigh such risks when marijuana therapy is an option. It is also important for pharmacists to understand how to successfully counsel patients using …

Purification And Characterization Of A Nonspecific Lipid Transfer Protein 1 (Nsltp1) From Ajwain (Trachyspermum Ammi) Seeds, Meshal Nazeer, Humera Waheed, Maria Saeed, Saman Yousuf Ali, M. Iqbal Choudhary, Zaheer Ul-Haq, Aftab Ahmed

Pharmacy Faculty Articles and Research

Ajwain (Trachyspermum ammi) belongs to the family Umbelliferae, is commonly used in traditional, and folk medicine due to its carminative, stimulant, antiseptic, diuretic, antihypertensive, and hepatoprotective activities. Non-specific lipid transfer proteins (nsLTPs) reported from various plants are known to be involved in transferring lipids between membranes and in plants defense response. Here, we describe the complete primary structure of a monomeric non-specific lipid transfer protein 1 (nsLTP1), with molecular weight of 9.66 kDa, from ajwain seeds. The nsLTP1 has been purified by combination of chromatographic techniques, and further characterized by mass spectrometry, and Edman degradation. The ajwain nsLTP1 …

Evaluasi Kesesuaian Dosis Pada Pasien Pediatri Bronkitis Akut Di Rumah Sakit Tentara Kartika Husada Kubu Raya, Variandini Aldhila Kharis, Rise Desnita, Hariyanto Ih

Pharmaceutical Sciences and Research

Selection and usage of rational drugs determine the success of expected therapeutic effect, especially for pediatrics. Acute bronchitis in pediatrics is one of the highest incidents of Acute Respiratory Infection (ARI) in Army Hospital Kartika Husada Kubu Raya. This study aimed to evaluate rationality of drug doses conformity in outpatient pediatric acute bronchitis in Army Hospital Kartika Husada Kubu Raya on 2015. This research was a descriptive observational research with cross-sectional design. The sample was taken with purposive sampling amounted to 36 prescriptions. Then the evaluation of drug doses conformity was counted according to the literature. The results showed that …

Pemodelan Molekul Turunan P-Metoksi Sinnamoil Hidrazida Sebagai Inhibitor Checkpoint Kinase 1 Dan Inhibitor Aromatase Secara In Silico, Galih Satrio Putra, Melanny Ika Sulistyowatya, Juni Ekowati, Tutuk Budiati

Pharmaceutical Sciences and Research

The development of anticancer drugs from ethyl p-methoxycinnamate (EPMC) derivatives has been done to compounds high activity in inducing cancer cells apoptosis and minimal side effects. p-Methoxycinnamoyl hydrazide derivates, modified from EPMC structure, were docked into the ligand-binding pocket of Check point kinase 1 enzymes (2YWP) and the aromatase enzyme (3S7S) using software Molegro Virtual Docker (MVD) Ver.5.5. We compared the Rerank score of native ligand with p-Methoxycinnamoyl hydrazide derivates. Rerank scores of compounds 4b and 4c (-99.98 Kcal/mol and -99.80 Kcal/mol) were lower than the native ligand A42 in inhibiting the enzyme checkpoint kinase 1. Rerank values of p-Methoxycinnamoyl …

Evaluasi Kesesuaian Penulisan Resep Pada Kasus Ispa Non Pneumonia Di Poli Mtbs Puskesmas Kecamatan Cengkareng, Jakarta, Rani Sauriasari, Annisa Azka Hikmawati Aulia, Adisa Swastika

Pharmaceutical Sciences and Research

Acute respiratory infections (ARI) is one of the major health problems in Indonesia. There are three classifications of cases of ARI, consist of pneumonia, severe pneumonia and non pneumonia. This study aimed to find an overview of the use of antibiotics and the evaluation of suitability prescriptions performed in cases of non pneumonia Acute Respiratory Infections (ARI) in IMCI Polyclinic, Cengkareng District Community Health Centre (Puskesmas Cengkareng), West Jakarta. Evaluation for the prescription suitability was useful to find the percentage of the suitability of prescribing on the existing management. This activity was done using retrospective method with data of 100 …

L-Citrulline As Alternative Pharmacological Substance In Protecting Against Cardiovascular Disease, Andrea Laurentius, Gregorius Bhaskara Wikanendra, Tzeto Han Cong, Wawaimuli Arozal

Pharmaceutical Sciences and Research

Cardiovascular disease (CVD) has taken up to average 30% of death diagnoses in the world. Prevalent attempts of physicians to treat this disease came down to focus on using drugs with their specific mechanism of action. Since the method only cures the symptoms and need to be pharmacologically monitored, physicians and scientists have been struggling to find other treatment strategies. This problem led us to search for another substance dealing with CVD via preventive therapy, which does not require such close monitoring by physicians in its use. The answer relies on using L-citrulline as potential therapeutics in treating and preventing …

A V-To-F Substitution In Sk2 Channels Causes Ca2+ Hypersensitivity And Improves Locomotion In A C. Elegans Als Model, Young-Woo Nam, Sabia N. Baskoylu, Dimitris Gazgalis, Razan Orfali, Meng Cui, Anne C. Hart, Miao Zhang

Pharmacy Faculty Articles and Research

Small-conductance Ca2+-activated K+ (SK) channels mediate medium afterhyperpolarization in the neurons and play a key role in the regulation of neuronal excitability. SK channels are potential drug targets for ataxia and Amyotrophic Lateral Sclerosis (ALS). SK channels are activated exclusively by the Ca2+-bound calmodulin. Previously, we identified an intrinsically disordered fragment that is essential for the mechanical coupling between Ca2+/calmodulin binding and channel opening. Here, we report that substitution of a valine to phenylalanine (V407F) in the intrinsically disordered fragment caused a ~6 fold increase in the Ca2+ sensitivity of SK2-a channels. This substitution resulted in a novel interaction between …

Aktivitas Mukolitik Kombinasi Ekstrak Etanol Daun Kemangi Dan Ekstrak Etanol Daun Sirih Merah, Neng Fisheri Kurniati, Deden Winda Suwandi, Safira Yuniati

Pharmaceutical Sciences and Research

A cough is a protective physiological mechanism that is useful for removing and clearing the respiratory tract from sputum and foreign particles that can cause infection. Treatments for cough disorders using medicinal plants were conducted because medicinal plants were widely known to have less side effects than synthetic drugs. Basil leaves (Ocimum sanctum L.) and red betel leaves (Piper crocatum Ruiz and Pav) have been used traditionally to treat a cough. The purpose of this study was to determine the mucolytic activity, and the effective concentration of the combination of basil and red betel leaves ethanol extract. The mucolytic activity …

Peran Tenaga Kefarmasian Dalam Penanggulangan Bencana Role Of Pharmacist In Disaster Management, Meutia Faradilla

Pharmaceutical Sciences and Research

Indonesia is a country that has high potency to be affected by disaster, either by natural or man-made disaster. After the 2004 tsunami, Indonesian government has improved its disaster prevention policy and program. In disaster management study, health management in disaster setting is aimed to assure the implementation of health service toward victims accordingly. As integrated part of the healthcare team in disaster management, pharmacists have to understand the importance of pharmaceutical care in pre-disaster, disaster, and post-disaster phase. This article aims to provide an overview on pharmacists’ role in disaster management from preparing and distributing medicine and medical devices …

Sensitivity Of Escherichia Coli Bacteria Towards Antibiotics In Patient With Diabetic Foot Ulcer, Rafika Sari, Pratiwi Apridamayanti, Indira Diah Puspita

Pharmaceutical Sciences and Research

Chronic complication of diabetes mellitus is diabetic foot ulcers. Diabetic foot ulcer can be defined as an open wound in the feet which will become infected as the result of high blood sugar levels that develops and become place of bacteria. One of the bacteria in diabetic foot ulcer is Escherichia coli. Imprecise use of antibiotics in the treatment of diabetic foot ulcers can cause antibiotic resistance to bacteria. This study aims to determine antibiotic sensitivity of Escherichia coli bacteria in diabetic foot ulcer Wagner grade III and IV. Samples of diabetic foot ulcer swab’s with Wagner grade III and …