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Best Hospital for Vascular Disease Treatment in Chennai

How can we identify blood clots in blood vessels?

Blood clots are solid masses of blood that form inside the veins. They can occur in any part of the body but are most common in the arms and legs. Blood clots can cause pain, swelling, and redness in the affected area. If a blood clot breaks free from its vein, it can travel through the bloodstream and block an artery elsewhere in the body. Clots can also form in the smaller arteries and block blood flow to the heart or brain. There are various ways that blood clots can form, but the most common is when a piece of debris or another object gets caught in a blood vessel. When this happens, the blood flow to the area is blocked and cause several problems. If you’re at risk for developing blood clots, it is critical to get checked regularly.

How do we identify blood clots in blood vessels or common symptoms?

Identification of blood clots is crucial to prevent their formation and minimize the potential for complications. Blood clot identification can be difficult, but several methods help you identify a blood clot-Swelling at certain parts of legs and arms or full puffing. For inflated and twisted clots located under the skin of your leg, you can go for varicose vein laser treatment in Chennai.

→ Swelling at certain parts of legs and arms or full puffing. For inflated and twisted clots located under the skin of your leg, you can go for varicose vein laser treatment in Chennai.

→ You may notice a change in color like a blue tinge and itchiness in your arms and leg.

→ If there is a clot in a particular area, you may feel constant pain, hurt, or soreness. The pain can get intense too.

→ In case of a clot, you may feel warmer in certain areas of your skin when compared to the other skin areas.

→ With clots in the lower leg and calf, you may feel the pain or cramp there.

→ You may feel swelling or pain in the veins. This sensation can increase upon touching.

→ When clots form in the large veins, they can travel to the lungs and cause a pressing health problem called pulmonary embolism. If not treated quickly, clots can cause death.

→ You can even get a cough or feel dizzy. It requires immediate medical attention.

→ You may even a chest pain leading to a heart attack or stroke.

Methods of detecting blood clots?

It is crucial to detect a blood clot on time. An examination can provide the size and shape of the blood clot. There are many ways to identify blood clots, most common methods are blood test, an ultrasound scan, or an X-ray. Other methods include imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI).

Treatment for blood clots

Treatment for blood clots includes anticoagulants (blood thinners), angioplasty (to break up the clot), and surgery. In the case of varicose veins get an immediate consultation for varicose veins laser treatment in Chennai. With the best treatment for varicose veins in Chennai, you can save the life of yourself and your loved ones. While treating blood clots may be expensive, you can get varicose veins treatment cost in Chennai before starting the treatment.

Endovenous Laser Therapy for Varicose Veins

Endo Venous Laser Therapy (EVLT) is a new method of treating varicose veins without surgery. While the discolored, bulging look of varicose veins bother a few, others experience itching, pain, and tiredness in their legs. Bleeding, vein hardening, and skin ulcers around the ankle are extreme symptoms that indicate serious vascular disease requiring early venous ulcers treatment in Chennai. Although these symptoms of varicose veins can be improved by conservative management with compression therapy, it is not a cure. Surgery, which has been considered for a long time, the best way to eliminate incompetence using ligation and removal of the abnormal varicose vein, has essentially been replaced by EVLT with high success and low complication rates over the last few years.

What is EVLT for varicose veins?

Endo venous means inside the vein. EVLT always begins with a thorough examination to determine the cause of the varicose vein and to create a long-term treatment plan. EVLT surgery is a procedure that uses heat from a laser to treat varicose veins. A laser is a device that sends a thin beam of radiation in the form of light that closes and shrinks the varicose vein.


Medical lasers are highly-concentrated beams of light that have the capability to effectively target diseased tissue inside a varicose vein with extreme precision. The mechanism of action focuses on the underlying goal for all thermal ablation procedures to deliver sufficient heat energy to the wall of the incompetent vein segment that produces irreversible occlusion, fibrosis and ultimately leads to the disappearance of the vein.

The surgeon makes a small cut or incision in the skin to insert the catheter that will be guided into the varicose vein. A laser fiber that is put into the catheter, heats up the length of the vein as the surgeon slowly pulls out the catheter. The vein will then close up and should eventually shrink over a period of time. The whole procedure is usually done in less than an hour. There are no stitches needed at the tiny cut or incision through which the catheter was inserted, just a bandage will be used to cover the site. This procedure is generally performed within a clinical setup on an ambulatory basis with local anesthetic and typically requires no sedation. Following the procedure, compression stockings are applied and advised on daily walks. The procedure has no complications, does not cause scarring, offers a quick recovery and immediate return to normal activity.

Target veins for EVLT

Varicose veins are caused by malfunction of venous valves and reduced elasticity of the vein wall restricting the normal upward flow of blood and allowing the blood to pool within the veins of the calf and thigh. These veins begin to deform and become engorged. About 40% of adults are affected by varicose veins in the legs and are more commonly severe in obese people and in multiparous women. EVLT is a minimally-invasive and well-tolerated procedure that can help to treat varicose veins of the leg and improve venous circulation in people with venous function deficiency. EVLT generally treats most varicose veins successfully but additional therapy may be needed in certain target veins.

All aspects of the EVLT procedure for venous ulcers treatment in Chennai use ultrasound technology to ensure accurate identification of the targeted veins. Almost all patients with varicose veins are suitable for EVLT. It can be successfully and safely used to treat the great and small saphenous veins, the anterior and posterior accessory great saphenous vein, the superficial accessory saphenous vein, the anterior and posterior circumflex veins of the thigh as well as the thigh extensions of the small saphenous vein. EVLT has been effectively used to treat long straight competent tributary veins outside the superficial fascia, particularly in obese individuals where other methods such as sclerotherapy or micro phlebectomy would be difficult, time-consuming, and pose risks of side effects.

Benefits of EVLT for varicose veins

Varicose veins arising from venous disease are highly prevalent and contribute to significant pain, debility, and quality of life reduction in affected people. Many of them who suffer from this condition may not seek treatment due to a lack of awareness of the latest, pain-free methods of treatment. A plethora of options are available and EVLT is a minimally invasive, same-day procedure has been proven to deliver consistent results with minimal complications. Benefits of EVLT for varicose vein are:

  1. – Performed within outpatient clinical facilities under local anesthesia.
  2. – No IV, hospital stay, or recovery room time is involved.
  3. – Minimally invasive, resulting in rare chances of risk conditions.
  4. – Overall procedure time is less than 1 hour.
  5. – Rapid recovery.
  6. – Normal daily activities are advised to be resumed immediately post EVLT.
  7. – Return to work at the earliest possible.
  8. – Clinical and aesthetic results are excellent.
  9. – Painless procedure as compared to other treatment methods.
  10. – More cost-effective and time-saving than traditional treatments.

Surgery vs EVLT for varicose veins

Surgery has been the mainstay for many years in the treatment of varicose veins, but it has been demonstrated through studies that there is a period of post-operative impact on the quality of life. Surgery using vein ligation and stripping leads to painful and prolonged recovery along with risks of infection, haematoma, and nerve injury in many patients. Persistent reflux and significant recurrent rates have demanded a need for a development that aims for any new treatment.

Newer, less invasive wound healing treatment in Chennai through EVLT being available is an advantage to seek:        

  • – Treatment that avoids the morbidity of surgery
  • – Performed as a day-case procedure under a local anesthetic
  • – Treatment that could offer lower recurrence rates
  • – A procedure that allows an early return to work.

EVLT is a fascinating therapy that has taken over surgery clinically, scientifically, and commercially. Clinically because of its very high success rate with minimal complications, scientifically because of the consented mechanism of action, and commercially because the mechanism of action created space for a wide variety of treatment protocols in the treatment of leg varicosities.

Types of Wounds, Symptoms and Wound Care

Wounds

Wound is an injury to any part of our body. It can be just on the skin or damage to the skin, underlying tissues and even to the bones. In some cases, the wound may not be seen from the surface of the skin but the underlying muscle or tissue might have got hurt or damaged.

Wounds are classified into three types:

  • 1. Open Wounds
  • 2. Closed Wounds
  • 3. Ulcers

Open Wounds

Open wounds are those injuries where the skin is cut open through various means. The muscles and tissues below that may or may not be injured. Depending on how the injury has hurt the body, open wounds are again divided into two categories:

Penetrating Wounds – Where the skin is injured and the injury is little deeper into the tissue or muscle in the affected area. Penetrating wounds include:

  1. 1. Puncture wounds (Such as those happened with a sharp object piercing)
  2. 2. Surgical Wounds and Incisions
  3. 3. Burns due to heat, spillage of chemicals or even due to heavy electrical circuits
  4. 4. Animal bites, stings etc
  5. 5. Injuries due to piercing objects such as bullets, arrows or high velocity objects.

Blunt Force Trauma Wounds – Such wounds are caused when you slide hard over a surface or when sharp objects cut through any part of the body.

  1. Abrasions – This is smallest type of blunt force trauma that happens when you slide roughly on any hard surface. It shows up as just scratches on the skin.
  2. Lacerations – A big cut on the skin with deeper muscle injury
  3. Skin Tears

Closed Wounds

Closed wounds are those that are not visible from the outside most of the time but the internal tissue/muscles are damaged and may have internal bleeding.

Types of closed wounds include:

  1. Contusions – It’s a medical term for bruise. Typically in such cases, the skin turns reddish brown, blue or black after sometime.
  2. Blisters
  3. Seroma – Accumulation of fluids under the skin or tissues
  4. Hematoma – Accumulation of blood under the skin or tissues. This typically happens when there is an internal bleeding due to damage of vein(s) or arteries. 
  5. Crush injuries – typically seen on fingers, hands or legs.

Ulcers

Ulcers are sores that can occur on the external or internal surface of the body. They can range from small painful sores to serious ulcers in the stomach or intestines.

Ulcers are classified into 4 types:

  • 1. Pressure Ulcers
  • 2. Venous Ulcers
  • 3. Arterial Ulcers
  • 4. Neuropathic Ulcers.

Pressure Ulcers, also called ‘Pressure Sores or Bed Sores’ are injuries caused to the skin and also to the underlying tissue due to pressure. In most cases, it is due to the own weight of the body when lying in bed for a long time in the same position. Typically this may be seen in people who are bedridden after an accident or those who are in vegetative state or coma. 

Venous Ulcers and Arterial Ulcers form due to the problem with circulation of blood through them. As you may be aware, arteries supplies good blood from heart to all parts of the body; veins transport impure blood from all parts of the body to the heart. Any damage to veins or arteries in any part of the body can disrupt the supply of blood and result in formation of ulcers in the area. Typically such ulcers are seen in legs or feet and can result in infections such as cellulitis.

Neuropathic Ulcers are painless wounds that occur on the body but not usually noticed because of damage to the nerves in the region. The loss of sensation in the affected area due to the damage of nerves (that conduct messages to and from spinal cord and brain) is called peripheral neuropathy. Peripheral neuropathy and neuropathic ulcers can be seen in diabetics. 

Symptoms of Wounds

Common symptoms of wounds include pain, swelling, and bleeding. Depending on the location and type of the wound, the severity of symptoms may vary. Some may just swell and bleed a little whereas severe cuts and deep injuries may bleed profusely and need immediate medical attention.

Wounds that don’t close or heal must be treated by a doctor to avoid infection that can sometimes lead to amputation of a body part to save the rest of the body. Infected wounds often swell, become tender to touch, and ooze pus out of them along with little blood.

Wounds that need treatment by a doctor:

  1. If the injury is caused by force or a bad accident
  2. If the wound continues to bleed even after trying to stop with pressure or elevation – such wounds may require stitches
  3. Insect (not all but some stings) and animal bites. 
  4. Wounds that drain a lot of pus and are difficult to clean

Why do some wounds take a long time to heal?

There are several reasons why some wounds, even very small/minor take a long time to heal in some people. That can be due to improper care, exposing the wound to air, having a weak immune system, etc. Apart from these, there are other conditions that can delay the healing of wounds:

  1. Medical conditions such as anemia, diabetes, cancer, arthritis, or kidney diseases.
  2. High blood pressure
  3. Cardiovascular diseases
  4. Varicose veins
  5. Unhealthy habits that hurt the immune system include smoking, bad diet, drug abuse, etc.
  6. A weakened immune system due to previous medical interventions such as chemotherapy, administering immunosuppressive medications, or a chronic disease like AIDS.
  7. Infected wounds, ulcers, and usage of certain medications.

Treatment of wounds and caring through recovery

It is important to see a good doctor to treat a wound or injury if it is not healing in a few days. Typically all small/minor injuries or wounds heal themselves in less than a week. If it is taking longer than a week and if you see that the skin is changing color on the surface and associated with pain, itching or swelling, or even bleeding, or if pus is leaking out, you must see a doctor immediately.

What types of wounds are treated at our clinic in Chennai?

From minor, nonhealing scratches to traumatic severe cuts, burns, and injuries, our specialists are highly experienced in treating all types of wounds. We also treat surgical wounds if they haven’t healed in time and are showing signs of infection. Pressure ulcers at any stage can be treated with proper diagnosis and medication. Our multispecialty clinic also offers Hyperbaric Oxygen Therapy to treat even the toughest wounds that don’t respond to normal medicines and treatment procedures and can also avoid amputation of body parts when treated on time.

FAQs on Laser Vein Treatment in Varicose Veins

What are varicose veins?
Varicose veins are enlarged, often swollen, twisted veins due to damage to the valves inside them. The valves in veins facilitate blood flow in only one direction, from the rest of the body to the heart. Most of the time, they pose a cosmetic problem but in some cases, varicose veins can cause pain and discomfort.


What is the difference between varicose veins and spider veins?
Varicose veins are usually large and appear twisted and bulged (due to the swelling). They are clearly seen as swelling along the vein. Spider veins are very tiny but visible blood vessels right under the skin. Spider veins typically develop on the face and legs while varicose veins are often seen on thighs, backs, and front of the calves (above the ankle and below the knee of legs).


What causes varicose veins (or veins to bulge)?
Veins and Arteries in the body have valves inside them. These valves allow blood to flow only in one direction. (Veins – from other parts of the body to the heart; Arteries – from the heart to other parts of the body). When the valves in the veins are damaged (for some reason unknown), the blood doesn’t flow to the heart and just gets stagnated in the region resulting in swelling of the vein along its path. Possible causes of varicose veins are heredity, pregnancy, hormonal changes in the body, overweight or obesity, sitting or standing for extended periods of time, age, injury to veins, etc.

What are the symptoms of varicose veins?
Typically varicose pose a cosmetic issue but some people with varicose veins feel aching or burning sensation in their legs, swelling of ankles, leg cramps, itching on the skin around the swollen vein area, etc. Skin ulcers can also be a result of varicose veins.


What are the treatment options for varicose veins?
Whatever may be the treatment method chosen, ultimate idea is to close (shut off) the damaged vein and divert the blood flow through good veins. The blocking of veins is done using any of the following procedures that your doctor thinks is right:
– Endovenous laser treatment
– Transilluminated powered phlebectomy
– Radiofrequency ablation
Sclerotherapy
– Ligation and Stripping
– Surgical removal of varicose veins


What is the Nd: Yag laser used in treating varicose veins?
The Yag laser is used to treat or fade the spider veins. The tiny veins are blocked using the energy from the laser and eventually, the veins are absorbed by the body effectively removing the veins from the affected area. The laser works without cutting the top layer of the skin. (Non-ablative treatment).


What is the typical recovery time after Nd: Yag laser treatment for varicose veins?
The typical recovery time is 2 weeks after laser treatment. The patient may feel like a severe sunburn and the doctor will advise him/her to apply topical creams to reduce the burning sensation in the area.


Is there any clinic in Chennai that employs laser treatment for varicose veins?
Laser Vein Clinic is one of the finest vein clinics offering laser treatment for varicose veins, spider veins, venous ulcer treatment, and other vascular diseases. The doctors here are highly trained and highly experienced professionals practicing medicine for 28 years. If you compare varicose veins laser treatment before and after, you will see a marked difference.


What are the possible complications of varicose vein surgery?
In most cases, treatment for varicose veins has no side effects or complications. In some rare cases, the patient may see bleeding, blood clots in the vein of the leg causing inflammation, and a condition called ‘Chronic Venous Insufficiency’. Chronic Venous Insufficiency is a condition when the skin does not exchange oxygen, nutrients, and waste products with the blood properly because of poor blood flow.


What are the risk factors of varicose veins?
While there are no clear-cut reasons, medical experts have figured out some conditions that they believe might be risk factors for the development of varicose veins. They include:
– Menopause
– Pregnancy
– Age over 50 years
– A profession that involves sitting or standing for long hours
– Heredity
– Obesity or being overweight

Reference:
https://www.medicalnewstoday.com/articles/240129
https://www.peachmedicalgroup.com/blog/laser-spider-vein-treatment-faq-and-patient-instructions
https://www.hearthousenj.com/services/vein-center/frequently-asked-questions/

How does laser treatment reduce the symptoms of varicose veins?

Veins carry blood from different parts of the body to the heart. Veins have valves inside them that restrict the flow of blood in only one direction. When these valves get damaged for any reason, the blood will not be able to flow to the heart and gets blocked there, causing enlargement of veins.

The condition of veins enlargement due to the blockage of blood is called varicose veins. The area may look purple in color due to the spreading of blood to nearby tissues. Enlargement of veins under the skin is also seen in most people.  The first line of treatment for varicose veins is to change the lifestyle habits that might be causing the problem and wearing tight stockings as advised by your doctor. If there is severe pain, skin problems, and blood clots in the body, your vascular surgeon may recommend surgery.

Factors that decide the type of treatment for varicose veins symptoms

  1. Your age and overall health.
  2. Your lifestyle including your workout routine, smoking and alcohol drinking habits.
  3. The location of varicose veins and the symptoms
  4. Whether you are getting a medical condition addressed or you want to just cover up the superficial varicose veins
  5. The expertise of your doctor in treating varicose veins – helps him/her determine the right procedure for you.

Treatment of varicose veins in few sentences

The aim of any treatment method of varicose veins is to block the vein that is damaged and reroute the blood through other veins. The damaged vein is either blocked somehow or it is removed. Now let’s look at various methods how this is achieved.

  1. Sclerotherapy: A solution is injected into the vein that has damaged valves. This scars the vein and blocks the flow of blood through it. As a result, blood finds alternative routes to reach the heart.  This is an out-patient (day care) procedure done at doctor’s office/clinic and doesn’t require any hospitalization. You will have to see your doctor multiple times with a gap of 4 to 6 weeks to complete the treatment sessions. Post that, you will be required to wear compression stockings for few weeks after each session.

Micro-sclerotherapy is the very same procedure with the only difference being, a smaller needle will be used to inject the solution to block the vein(s).

  • Laser therapy for treatment of varicose veins’ symptoms: Veins are closed with the energy from laser. Small bursts of laser light are focused on the damaged veins that will cause them to close.  The benefit of laser treatment for varicose veins is that, there is no pricking or cutting/incision involved in this treatment. Most often laser treatment is done for smaller varicose veins.
  • Endovenous Ablation Therapy: In this treatment method, you will first be given local anesthesia. A small incision will be made in a place through which a thin tube will be inserted into your body. The tube emits radio waves or laser (energy of some kind) that will close the vein. Later the area will be wrapped in bandage and then you will be allowed to go home after a couple of hours.
  • Endoscopic Vein Surgery: A small incision is made through which a thin tube with camera at it’s end is inserted into the vein. Once the end of the vein is reached, your doctor shuts it off (closes the vein). This procedure is typically done when there are skin ulcers caused due to varicose veins. Recovery takes about 10 to 14 days after which you will be able to return to your normal life activities.

Now, let’s look at some procedures in which the damaged vein is removed surgically.

  1. Ambulatory Phlebectomy:  This procedure is done when the vein is closer to the skin surface. Local anesthesia is given and after the area goes numb, a small incision/cut is made and the vein is removed. This is a day care / out-patient procedure, after which you will be able to go home.
  1. Vein Stripping and Ligation: This is a little more complex procedure done in serious cases. Full body anesthesia is given before the procedure. Incisions will be made on the skin, veins will be tied and removed. If possible, a vein called Saphenous vein (a long vein that exists from ankle to the groin) will be left in place just in case, if you may end up going for a heart bypass in the future.

This procedure may require hospitalization for a day or two after which you will be allowed to go home. Recovery time is typically 4 weeks.

Post operative expectations after varicocele vein treatment

Just like any surgery, bruising, inflammation may be seen in the area of surgery. Recovery will be normal unless if the veins are removed. Complications of the surgery include blood clots, pain, infection, and scarring at the surgical site.

You will need to follow your doctor’s advice including taking medication, wearing stockings or bandages for a couple of weeks. Once recovered, you will need to take care of yourself with a healthy lifestyle including regular workouts, eating healthy. With respect to legs, you will need to raise your feet while sitting, make sure you don’t cross your legs, or wear tight clothes that can affect the blood flow.

If you see any unusual complications (other than what your doctor has mentioned during discharge), you should contact your vascular surgeon immediately.

References:

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/endovenous-laser-varicose-vein-surgery

https://www.webmd.com/skin-problems-and-treatments/surgery-for-varicose-veins

Venous Ulcers – Diagnosis and Treatment

Venous Ulcers – Diagnosis and Treatment

Venous ulcers (also called Statis Ulcers) is a shallow wound that occurs in the lower part of the leg, typically between the calf and the ankle and on to the sides of the leg(s). Venous leg ulcers heal slowly and pose a risk of recurrence if not treated properly.

Poor blood circulation in the legs leads to venous ulcers. Veins carry blood from all parts of the body to the heart. This is a one-way flow of blood and is regulated with valves in veins which restrict the blood flow in other directions. When the valves in the veins (near the legs) are damaged, the blood that is supposed to flow gets blocked in that area. The blocked blood flows into the surrounding tissues and results in breaking down of the tissue resulting in ulcers. As the blood flows into the surrounding areas, the skin in the area turns dark red or purple. The skin may become thick, dry, and itchy as the ulcer develops. In extreme cases, the ulcers may start leaking puss-like fluids.

Risk factors for developing venous leg ulcers

  1. Over weight – Being overweight puts tremendous pressure on several parts of the body such as the pelvis and legs. This also puts a heavy load on the blood circulation system.
  2. Age – With age, every part of the body becomes less efficient in performing its functions. As the skin of aged people is more fragile, the chances of forming an ulcer are higher.
  3. Smoking, lack of physical activities, deep venous thrombosis, and previous leg injuries can also cause venous ulcers on the legs.
  4. People suffering from varicose veins, high blood pressure, blood clotting disorders are at higher risk of developing venous leg ulcers.

Symptoms of Venous Ulcers

Many times, the ulcers cause no discomfort. But when the ulcers are infected, they can become painful. Symptoms of venous ulcers include:

  1. Inflammation of the area of the ulcer
  2. Swelling and Aching
  3. Itchy and Hard skin
  4. Scabbing or flaking
  5. Discharge from ulcer.

Diagnosis of Venous Ulcers

Your vascular surgeon usually starts with physical examination of the affected area. He/she will check for symptoms such as swelling of ankles, darkened skin or anything that is leaking out from the affected area. Then your doctor will try to find the root cause of the ulcer. (If the root cause is not found but the ulcer is treated, it is bound to recur after sometime). You need to let your doctor know if you have diabetes, DVT (deep vein thrombosis), Injury to your leg or any previous ulcer. Your doctor will be easily able to make out, if varicose veins are the cause of the ulcer. Your doctor may check the pulse in the ankle region to check for flow of blood through the arteries.

Then, you may be advised to get a Doppler study done which will check the flow of blood through the arteries by comparing the pressure. It is important to do a Doppler study because the treatment of venous ulcers involves using compression bandages or stockings to improve the blood circulation through veins in the legs. If your doctor sees that the blood pressure at the ankle is lower, bandages and stockings may not be advised.

Treatment of venous ulcers

The bottom line of venous ulcer treatment is to improve the blood flow to the affected area.  Antibiotics may be prescribed if your doctor sees that there may be infection that might be the cause of the problem or antibiotics may be given as a pre-emptive measure.

If your doctor puts you onto bandage or stockings, he/she will train you on how to properly wear them and also dress your ulcer. Painkillers may be given to reduce the pain caused at the site.

If the cause of venous ulcers is varicose veins, your doctor may recommend appropriate treatment for varicose veins.  Laser treatment for varicose veins is one popular treatment option employed many vascular surgeons in Chennai and across the world.

Can you ignore venous ulcers?

Ignoring venous ulcers and leaving them untreated can result in serious complications. It is good if you can see your doctor when you experience pain or inflammation of between calf and the ankles on the sides of the legs.

If is important to treat the root cause than getting some over the counter medicines that can help in relieving the symptoms.

References:

http://vascularcenterwf.com/conditions/venous-leg-ulcer/

https://www.nhs.uk/conditions/leg-ulcer/treatment/