Trend of Paediatric Medical admissions and outcome of care at a Tertiary Health Facility in Lafia Nasarawa State North-Central Nigeria

doi:10.21203/rs.3.rs-4795994/v1

Background

The burden of preventable childhood morbidity and mortality in developing countries is on the increase. This is worrisome in Nigeria adjudged as one of the countries with the worst under-five mortality report globally and impeding the attainment of Sustainable Development Goal 3 target. We described the trend of Paediatric admissions and outcome over a six-year period at a tertiary facility.

Methods

We reviewed data of all patients aged 29days to < 18years admitted into the Children Medical Ward of the Dalhatu Araf Specialist Hospital Lafia from 1st January 2018 to 31st December 2023. Secondary data abstraction was undertaken for the required information. Data analysis was done using the Statistical Package for Social Sciences. The results were presented as frequencies and percentages and reported as tables and graphs.

Results

We documented 9,228 admissions, with more males giving a male to female ratio of 1.3: 1. We successfully managed and discharged 8,300 (89.9%) and recorded 674 (7.3%) deaths, 187 (2.0%) absconded, 99 (1.1%) were discharged against medical advice while 31 (0.3%) were referred for care. An increasing trend in the admissions with declining mortalities were noticed. On the contrary, rising pattern of patients abscondment were observed over the years. The commonest causes of admissions were malaria, pneumonia and diarrhea diseases.

Conclusions

There is a progressive increase in the paediatric medical admission pattern in this study. The childhood mortality rate is high but with a progressive decline in the rate over the years. Discharge against medical advice remained high while the rate of child abscondment is worrisome. Malaria is the commonest reason for admission at our facility, others are Pneumonia, Diarrhea diseases, Sickle cell crisis, and Meningitis. Use of malaria chemoprevention, early diagnosis with a good turnaround time and training will help in improving quality of care and coping with the increasing trend of admissions.

Abscondment

Childhood

Outcome

Medical

Mortality

Trend

Childhood mortality provides an insight into a country’s growth and development, as well as portraying the nation’s priorities and values [1]. The menace of preventable childhood deaths is worrisome in the developing countries [1, 2]. Nigeria has been adjudged to have the eight worst under-five mortality in the world; a stumbling block to the country’s realization of the set targets of Sustainable Development Goal 3 by 2030 [3, 4].

For a facility, the pattern of hospital morbidity and mortality through self-auditing is an essential instrument for evaluating the accessibility and quality of healthcare services a facility is offering to the surrounding community it was established to serve and with the aim of improving on client’s experience of care [5, 6].

The UNICEF 2015 World Children’s report revealed that for every 13 newborns, one dies before their first birthday, same as one in every eight that failed to survive their fifth birthday [7]. Preventable diseases such as pneumonia, diarrheal diseases and malaria are the major causes of childhood morbidity and mortality in sub – Saharan Africa [8].

A study in Port-Harcourt South-South Nigeria reported a 7.7% mortality rate among children over a ten-year period [9]. Another study reported 4.5% mortality rate among admitted children in Calabar Nigeria [10]. Most studies found higher mortalities among male children [2, 5, 10].

An earlier study on childhood mortality across the state revealed severe malaria, sepsis, diarrhea diseases and respiratory tract infection as the leading causes of under five deaths [6]. Other studies found malaria, sepsis and diarrhea diseases as the commonest causes of childhood deaths at Asaba, South-south Nigeria while malaria, malnutrition and pneumonia were the leading causes of childhood deaths reported at Azare, North-east Nigeria [4, 8].

We conducted a retrospective cross-sectional study using secondary data to describe the trend and outcome of paediatric medical admissions in a State-owned tertiary health facility in Lafia North – Central Nigeria.

Study Design

This was a retrospective cross-sectional study of Paediatric admissions of children aged 29 days to less than 18 years (based on our hospital policy) attended to from 1st January 2018 to the 31st December 2023.

Study setting

The study was done at the Emergency Paediatric Unit and the Children Medical Ward of the Dalhatu Araf Specialist Hospital (DASH) Lafia.

Study Population

The study was done among children that are Post neonatal (> 28 days) but less than 18 years of age who presented to and are admitted to either the Children Medical Ward through the Emergency Paediatrics Unit of DASH Lafia.

Study area

Lafia is the Capital of Nasarawa State, one of the six states that makes up the North-Central zone of the country Nigeria. The State shares boundary with the Federal Capital Territory, Kaduna, Plateau, Taraba, Benue and Kogi States respectively. The hospital is the only state-owned tertiary health facility but also catering for the secondary healthcare level services as there is no secondary health facility in Lafia where it is situated. Dalhatu Araf Specialist Hospital is a 400 bedded healthcare facility, with the paediatric unit served by five paediatrician, four senior registrars, five registrars, six medical officers and thirty-seven nurses across the Emergency Paediatric Unit (EPU), Children Medical Ward, Special Care Baby Unit (SCBU), Paediatric Specialty clinic and the Paediatric Out-patient clinic respectively. The emergency units for this study (EPU) have a mini side laboratory with the capacity to undertake tests like Urinalysis, Rapid Diagnostic Test for malaria and HIV, Random blood sugar and Packed Cell Volume. This mini laboratory operates 24-hours in a day and daily in a week. It is wholly run by the Paediatric residents with support of a laboratory technician within the working hours of 8:00am – 2:00pm and on official working days. The facility also has more advanced laboratory support from the haematology, microbiology, chemical pathology and anatomic pathology laboratories. The hospital has a resident medical microbiologist and two anatomic pathologists as well as and thirty-five laboratory scientists.

Sample size

The study included data from the medical records of all paediatric age group aged 29 days to 18 years that were admitted in the facility from 1st January 2018 to the 31st of December 2023.

Data source and management

Secondary data was collected apriori from the designated departmental computer meant for storage of the departments Morbidity and Mortality. All the annual morbidity and mortality reports are stored on this computer after errors noted during their presentations have been duly corrected.

Data Quality

The unit senior registrar of the respective teams meticulously checked the report to be sure all issues identified have been satisfactorily addressed. This is further verified by the unit Consultant before such report is forwarded to the departmental Chief resident for storage and safe keeping in a departmental computer.

Data analysis

The retrieved data from the well secured and passworded departmental computer was exported to the Statistical Package for Social Sciences (SPSS). The frequency and percentages of categorical variables were computed and reported as tables and graphs.

Ethical approval

Approval was obtained from the Dalhatu Araf Specialist Hospital Research Ethics Committee before the commencement of the study with approval number DASHREC/399. Consent for participation from individual participants was not relevant in this case since the study make use of secondary data of clients that agreed to be managed in the facility. There is no use of data that can disclose the identity of participants as such privacy and confidentiality is guaranteed.

Clinical Trial Number: Not applicable.

Of the 9,228 total admission among children outside the neonatal age group, 8,300 (89.9%) were successfully managed and discharged home. We recorded 674 (7.3%) deaths, 187 (2.0%) abscondments, 99 (1.1%) were discharged against medical advice (DAMA) while 31 (0.3%) were referred to other facilities for further care.

There is a steady increase in the number of admissions and discharges except for the year 2021. There was no DAMA, abscondment or referral reported in the year 2021. The least mortality (5.4%) was recorded in year 2023 while the highest admission was recorded in the year 2022 (26.4%) of all admissions Table 1.

The commonest cause of childhood medical admission for children aged 29days to less than 18 years within the study period in our facility is Severe Malaria (22.2%). Others are Pneumonia (19.6%), Diarrhea diseases (18.8%), Sickle cell crisis (11.8%) and Meningitis (8.1%) Table 2.

There are more males than the females over the six – year study period with total males of 5,295 and females 3,933 giving a male to female ratio of 1.3: 1 Figure 1.

For the years under review, there was a gradual decline in the number of admissions from January to June, with reversal of this trend from July to January, and overall peak in November to December Figure 2.

From the above graph, the overall trend of childhood mortalities appeared similar but with a noticeable decline in deaths rate more so in year 2023. The least was recorded in the month June and September with a peak in August and December. The relative surge in mortality rates between July to August may be due to peak of malaria admissions while the surge from December to May can be explained by the peak months of admission for pneumonia and diarrhea diseases as seen in the charts below. Figure 3.

The Figure above showed a sustained increase in the proportion of children that were discharged against medical advice and those that absconded from care with a worse trend in the latter Figure 4.

The highest peak for malaria morbidity was recorded from the months of July to October from where it begins to decline and reaches its nadir in April across the six-year period of review Figure 5.

The peak of pneumonia was recorded from October to March across the study period as shown in Figure 6.

Diarrhea disease is highest in the months of December, and begins to decline from January till September to October when is lowest. Figure 7.

The present study found more males than females among our admissions over the years with a male to female ratio of 1.3:1. This male predominance has been reported in several earlier studies [4,6,8].The plausible reason for this may not be unconnected with the genetic susceptibility of males to infection [5].

The admission pattern has been on the increase except for the year 2021 due to a three months local industrial disharmony in the months of June, August and September. The admission trend almost double in the year 2022 and this can be explained by the expansion of our Children ward from eighteen to thirty-six beds in late 2021. The yearly childhood morbidity pattern as shown by our admissions over the years is higher than the Gusau reports which is a State Specialist Hospital like ours [5]. Our admissions are equally higher than the reports from Federal Medical Centre (FMC) Asaba and from the Niger Delta University Teaching Hospital Bayelsa in a 5-year admission trend [3,8]. Similarly, it is higher than the yearly admissions reported from the University of Port-Harcourt Teaching Hospital (UPTH) Port-Harcourt. The higher admission in the current study may be because the current study location is the only tertiary healthcare facility in Lafia the State Capital which also lacks a secondary hospital. Consequently, the hospital enjoins high patronage as it provides both the secondary and tertiary healthcare services. It is equally accessible and cheaper than most Government tertiary hospitals around. On the other hand, most of the health facilities listed above are located where there is a secondary health facility and sometimes an additional tertiary health facility like Gusau. Apart from these, others have a smaller admission capacity like FMC Asaba which is a 7-bedded Children emergency unit [8]. Proximity to other orthodox facilities with improved personnel’s and admission capacity are other possibles reasons.

Our finding is comparable with the report by Sa’ad et al from the FMC Azare as it is also the only tertiary health facility in Azare. The admission burden is however smaller to the reports by Yarhere et al at UPTH Port-Harcourt and Sa’id et al at the NHA Abuja. Both studies were done over ten years and included the children of the neonatal age groups.

The overall childhood mortality rate in this study is 7.3%. This is higher than the 4.9% reported by Sa’id et al [6] in Abuja. The better outcome from their study may be due to a possible better education, income earning and hence a well-informed healthful practice of their clients residing at Federal Capital Territory. In addition, healthcare workers preference for city life and availability of better staffing and equipment’s in such city facilities can be a contributing factor. Similarly, our finding is higher than the 2.8% found by George et al [2] in a two-year survey in Port-Harcourt South-South Nigeria. The well-known better health indices from the Southern part of Nigeria as a result of some variables such as a better female education, reduced fertility level, higher immunization coverage, improved accessibility and a better health seeking behaviour could have contributed to this finding. Our finding is equally higher than the 4.5% earlier reported in Calabar South-South Nigeria [10]. Their study is a whole hospital wide type that included all mortalities including the adults hence not focused on children like our present study.

The finding in this current study is lower but somewhat comparable to the 7.9% earlier reported by Yarhere and his colleagues in Port-Harcourt among children over a ten-year period [9]. The inclusion of neonates which increased their admission figure remarkably thereby increasing the denominator could explain the finding.

In contrast, Sa’ad et al [1[ reported a higher childhood death rate of 10.6% in a study conducted over a year in Azare North-Eastern Nigeria over a decade ago. Likewise, Garba and her colleagues in Gusau North-Western Nigeria who also reported a higher mortality of 11.2% in a study done over twelve months [5]. These studies with were conducted in the Northern part of Nigeria known for unacceptably higher and poorer childhood healthcare outcomes. This is partly due to among others, low maternal health education, unhindered male spouse and grandparents’ influence / power, unhealthful cultural practices, poor environmental hygiene and sanitation and the worsening insecurity in these regions.

Our finding is comparable to the 7.1% reported by Duru et al [3] in Niger delta in a five-year review. This comparison can be attributed to the similarity in study population and duration ours. Also, the North-Central States proximity to the Federal Capital Territory and a gateway between the core Northern and the Southern States affords it some leverage of possessing a somewhat comparable approach to healthcare.

Overall, there is a gradual decline in the number of admissions from January to June, with reversal of this trend from July to December but with a peak from October to February across the years under review. This trend is supported by the pattern of admissions from the three common causes of admissions (Malaria, Pneumonia and Diarrhea diseases) in this study that ranges from July to March but with peak from August to January. A comparable finding was reported by Sa’ad and colleagues that reported highest admissions from August to November [1]. The surge in mosquito breeding with the peak of raining season causing malaria and the dusty dry harmattan causing respiratory tract and diarrhea diseases may explain the increase admissions during this period. In contrast, Duru et al found the highest admissions in April to May and October to December [3].Possibly due to the all-year-round rainfall in the Swampy Niger delta resulting in malaria.

We observed highest childhood mortalities in the months of July to August as well as November to December. The mortalities can be from varying morbidity predominating at the period in time. This is comparable to the report by George et al in PH who found the highest mortalities from the month of April to September [2].

The rate of childhood mortalities in this report have been on the decline albeit gradual unlike the findings by Ezeonwu et al where the reported death rate was on the increase [8]. Their study was done many years ago. The least mortality was recorded in the year 2023 (5.4%) probably due to an improved quality of care occasioned by more qualified man-power from the healthcare workers (residents progressing through the ranks as we now have full accreditation of the West African College, more trained paediatric nurses), improved medical supplies of equipment’s such as Pause oximeters, Oxygen concentrators, Suctioning machines etc by the State Government through the hospital management.

The rate of discharge against medical advice (DAMA) in our study was 1.1% which is lower to the 5.0% reported in Asaba by Ezeonwu et al [8] and the 1.9% reported by Garba et al [5] in Gusau. This finding could be due to the availability of other referral-level facilities in these study locations. As patients sometimes depart facility against medical advice to access care in other facilities if such facilities are available and within reach.

Absconsion in this study is worrisome as its increasing in a geometric proportion, with an overall prevalence of 2.0%, higher than the 0.4% found by an author from Gusau Nigeria [5].The possible explanation here may be that patients that were counselled and discouraged from DAMA ended up absconding from care. It may also be a reflection of variation in economic and social support of the study population of the different studies. The presence of and variation in numbers of ward guards in some of these studies may also be a reason [12]. In the current study, there are no ward guards to deter and track patients from escaping.

The commonest causes of morbidity leading to admissions in our study are malaria, pneumonia, diarrhea diseases, meningitis and sickle cell crisis. This is similar to many earlier studies [1,2,5,8,9]. Malaria accounted for one in every five of our admissions, similar to an earlier publication in the same centre [11].

There is unacceptably high burden of childhood mortality in this study.
The commonest causes of post neonatal childhood admissions are Malaria, Pneumonia, Diarrhea diseases, Sickle cell crisis and Meningitis.
There is an increase in the admission pattern over the years.
The prevalences of discharges against medical advice and abscondments are on the increase respectively.

Increasing man-power and giving them a conducive working environment with incentive as morale booster as well as enhanced diagnostic facilities for efficient and effective quality of care delivery.
Use of malaria chemoprevention, early diagnosis with a good turnaround time and training will help in improving quality of care and coping with the increasing trend of admissions
Establishment of a Secondary health facility in Lafia is in order, so as to enable the tertiary facility like ours better able to do what is expected of her.
Training and retraining of healthcare workers to be able to provide quality healthcare in the midst of high patient flow is advocated

ACKNOWLEDGEMENTS

All the resident doctors, the House officers and the Nurses working at the Emergency Paediatric Unit (EPU) and the Children Medical Ward within the study period are appreciated for their record keeping efforts. Mr. Tanze Yakubu Danbaba the Medical Laboratory Technician attached to the EPU for support during working hours is hereby appreciated.

Availability of data source

The secondary data used in this study can be made available if needed.

Declarations

Funding

The researchers funded this study without any external funding

Conflict of interest

There is no conflict of interest

Ethical Consideration

This is a secondary data that has no means of personal identification thereby ensuring privacy of client’s data. We sought and obtained permission of the Dalhatu Araf Specialist Hospital research ethics committee. We equally took measures to limit the number of personnels with access to the data, data coding and a passworded access required as a confidentiality to client’s information. Ethical approval number: DASHREC/399.

Clinical trial number: Not applicable.

Authors contributions

SOB; Conception of idea, Literature review, Data collection and analysis, Writing of manuscript, Review of final version and agreement with submission. TOO; Conception of idea, Literature review, Data analysis, Writing of manuscript, Review of final version and agreement with submission. TLI; Conception of idea, Data collection and analysis, Writing of manuscript, Review of final version and agreement with submission. SM; Conception of idea, Data analysis, Writing of manuscript, Review of final version and agreement with submission. SIO; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. HA; Data analysis, Writing of manuscript, Review of final version and agreement with submission. HEO; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. JA; Literature review, Data collection and analysis, Writing of manuscript, Review of final version and agreement with submission. VON; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. CLS; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission FEA; Data collection, Writing of manuscript, Review of final version and agreement with submission. AOU; Data collection, Writing of manuscript, Review of final version and agreement with submission. MKI; Data collection and analysis, Writing of manuscript, Review of final version and agreement with submission. AAO; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. GO; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. VE; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. KMK; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. ICA; Data collection, Writing of manuscript, Review of final version and agreement with submission. AY; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. ESA; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission. UAS; Literature review, Data collection, Writing of manuscript, Review of final version and agreement with submission DA; Data analysis, Writing of manuscript, Review of final version and agreement with submission. MMD; Data analysis, Writing of manuscript, Review of final version and agreement with submission.

Author’s details

Surajudeen Oyeleke Bello¹, Taofik Oluwaseun Ogunkunle¹, Tajudeen Lanre Ibrahim¹, Suleiman Mayaki¹, Sunday Ikupla’si Ozhe¹, Hadizatu Aliyu¹, Halim Emmanuel Odiachi¹, John Ayinor¹, Victor Onuh Noah¹, Christiana Lane Simon¹, Favour Ene Agbo¹, Ann Okwuchukwu Ugwu¹, Moses Kelechi Ikekwe¹, Adijat Ajoke Onigbanjo¹, Grace Offo¹, Victor Embugushiki¹, Khadija Mohammad Kabir², Immaculata Chinwe Anderson¹, Yakubu Abdullahi¹, Esther Solomon Audu³,Usman Abiola Sanni⁴, Dayo Adeyemi⁵, Mahmood Dalhat⁶.

Department of Paediatrics

Dalhatu Araf Specialist Hospital

Lafia Nasarawa State

Nigeria

Department of Family Medicine

Dalhatu Araf Specialist Hospital

Lafia Nasarawa State

Nigeria

Department of Medical Microbiology

Dalhatu Araf Specialist Hospital

Lafia Nasarawa State

Nigeria

Department of Paediatrics

Koidu Government Hospital

Koidu, Kono

Sierra Leone.

Department of Community Medicine

Dalhatu Araf Specialist Hospital

Lafia Nasarawa State

Nigeria

Kaduna State University / Infectious Diseases Control Centre

Kaduna Kaduna State

Nigeria.

Corresponding author;

Surajudeen Oyeleke Bello

Department of Paediatrics

Dalhatu Araf Specialist Hospital

Lafia

Nasarawa State

Nigeria

+2347064641540

[email protected]

Duru C, Paul NI, Peterside O and Akinbami F. Pattern of mortality among Childhood emergencies at the Niger Delta University Teaching Hospital, Bayelsa State, Nigeria. Niger J Paediatr 2019; 46 (2): 55 – 60. DOI: http://dx.doi.org/10.4314/njp.v46i2.3
Sa’ad YM, Hayatu A, Al-Mustapha II, Orahachi YM, Hauwa MU. Morbidity and mortality of childhood illnesses at the emergency pediatric unit of a tertiary hospital, north-eastern Nigeria. Sahel Med J 2015; 18:1 – 3.
George IO, Alex-Hart BA and Frank-Briggs AI. Mortality Pattern in Children: A Hospital Based Study in Nigeria. Int J Biomed Sci 2009; 5 (4): 369 – 372.
Said MA, Audu L, Mairami. A. Review of Paediatric Mortality in a Tertiary Hospital in Nigeria. International Journal of Science and Research. 2018; 9 (2): 1350 – 1354.
Garba IB, Muhammad SA, Onazi OS, Edem B, Aghadueki S, Adelakun BM. Pattern of medical childhood morbidity and mortality in a new specialist hospital in Gusau, Nigeria. Annals of Nigerian Medicine. 2014; 8 (1): 15 – 19.
Bello SO, Hassan II, Ogunkunle TO, Ibrahim OR, Issa A, Afolabi OF, Olasinde YT, Omefe PN, Lawal AA, Adedayo A. Assessment of the Causes and Predictors of Under-five Mortality in Nasarawa State. Nig Del Med J 2021; 5(2): 16-24
United Nation Children Emergency Fund (UNICEF). Infant, under-five and maternal mortality rate. UNICEF State of the World’s Children Report 2015
Ezeonwu BU, Chima OU, Oguonu T1, Ikefuna AN1, Nwafor I. Morbidity and Mortality Pattern of Childhood Illnesses Seen at the Children Emergency Unit of Federal Medical Center, Asaba, Nigeria. Annals of Medical and Health Sciences Research. 2014; 4 (3): 239 – 244.
Yarhere IE, Nte AR. A Ten-year review of all cause paediatric mortality in University of Port Harcourt Teaching Hospital, Nigeria (2006 – 2015). Niger J Paediatr 2018; 45 (4):185 – 191. DOI:http://dx.doi.org/10.4314/njp.v45i4.4
Okoroiwu HU, Uchendu KI, Essien RA. Causes of morbidity and mortality among patients admitted in a tertiary hospital in southern Nigeria: A 6-year evaluation. PLoS ONE 15(8): 1 – 15. e0237313. https://doi.org/10.1371/journal.
Bello SO, Abolodje E, Hassan I, Othman IA. Pattern and Outcome of Severe Malaria at the Emergency Paediatrics Unit of a Tertiary Hospital, North-Central Nigeria. International Journal of Science and Research. 2019; 8 (3): 874 – 877. https://doi.org.10.21275/ART20196091
Moradpour M, Amiresmaili M, Nekoei-Moghadam M and Dehesh T. The reasons why patients abscond from public hospitals in South-eastern Iran: a qualitative study. Archives of Public Health. 2021; 79: 106 – 111. https://doi.org/10.1186/s13690-021-00634-z

Table 1: Morbidity and mortality statistics across the years 2018 to 2022

Variables	2018	2019	2020	2021	2022	2023	Total
Admissions	1202	1243	1523	843	2435	1982	9228
Discharges	1086	1093	1378	841	2150	1752	8300
DAMA	5	19	18	0	25	32	99
Abscondments	12	15	7	0	73	80	187
Referral	0	4	6	0	10	11	31
Deaths	99	112	114	65	177	107	674
% Mortality	8.2	9.0	7.5	7.7	7.3	5.4	7.3

Table 2: Commonest causes of Paediatric Medical Admissions

Diagnosis	2018	2019	2020	2021	2022	2023	Total N (%)
Malaria	312	386	365	146	460	377	2046 (22.2%)
Pneumonia	176	252	275	172	496	436	1807 (19.6%)
Diarrhea	145	131	344	115	506	496	1737 (18.8%)
Sickle cell crisis	226	244	136	67	216	198	1087 (11.8%)
Meningitis	22	128	316	35	145	99	745 (8.1%)
Others	321	102	87	308	612	376	1806 (19.5%)

No competing interests reported.

Trend of Paediatric Medical admissions and outcome of care at a Tertiary Health Facility in Lafia Nasarawa State North-Central Nigeria

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

INTRODUCTION

MATERIALS AND METHODS

Study Design

Study setting

Study Population

Study area

Sample size

Data source and management

Data Quality

Data analysis

Results

Discussion

Conclusion

Recommendations

Declarations

References

Tables

Additional Declarations

Status:

Version 1