1- Programme Title: Doctorate (MD) in Anesthesia and Surgical intensive care. 2- Final Award: MD degree in Anesthesia and Surgical intensive care.

Transcription

1 Zagazig University Faculty of Medicine جامعة الزقازيق كلية الطب Department of Anesthesia & Surgical Intensive care DEGREE: Doctorate (MD) in Anesthesia and Surgical intensive care (AIMD ) Programme Specification 0/0 Date: /0 ABasic Information Programme Title: Doctorate (MD) in Anesthesia and Surgical intensive care. Final Award: MD degree in Anesthesia and Surgical intensive care. Programme type: Single Double Multiple Responsible Departments: Anesthesia and Surgical intensive care department. Public health department. Pharmacology department. programme duration: academic years. Number Programme courses: courses {Prerequisite courses in :statistics & methodology for MD students (MS), Computer and internet application in medicine (CA)}, Applied physiology and clinical measurements (AIMD 0) Applied Pharmacology (AIMD 0) Anesthesia and surgical ICU(AIMD 0) Thesis (MDTH). 7Coordinator: Prof.Dr./ Zainab Mostafa Attia. 8External evaluators: Prof. Dr. Walaa Elkharbotly. Mansoura University, Faculty of Medicine, Anesthesia and surgical ICU department.

2 9Last date of programme specifications approval: 0 0 Programme management team: Prof.Dr./ Zainab Hamed Swan. Prof.Dr./ Tarek Gaafar. Prof.Dr./ Mostafa Magdy. BProfessional Information: Programme aims: The aim of this programme is to produce a knowledgeable and skillful anesthesiologist who is competent to anaesthetize all categories of patients from ASAI to V with medical problems for every type of elective and emergency surgery, able to diagnose and treat acute and chronic pain conditions, competent to manage critically ill patients in emergency and ICU requiring routine to advanced monitoring, mechanical ventilation and other interventions, aware of the recent advances and developments in medical sciences as related to anesthesia, analgesia and critical care and is competent to teach acquired skills to medical and paramedical professionals. Intended Learning Outcomes (ILOs): By the end of the MD programme the candidate will be able to: A Knowledge and Understanding KU Define the applied physiology of different body systems and the clinical measurements related to anesthesia and intensive care medicine. KU Summarize Clinical Pharmacology for drugs used in anesthesia and intensive care medicine. KU. Recognize methods of statistics and use of computer in medical science. KU. Summarize pre and post operative care in case of medical disorders. KU. Explain general basics for anesthesia practice.

3 KU. Explain anesthesia for pediatric and neonate surgery. KU7. Recognize all types of anesthesia for general surgery, plastic, vascular, and laparoscopic surgeries. KU8. Demonstrate a thorough understanding of the complexity of the breadth of neurosurgery/neuroradiology and neurocritical care. KU9. Outline a structured approach for dealing with the complexity of the breadth of cardiac, thoracic surgeries and interventional cardiology. KU0. Summarize research methodology and ethics. KU. Outline an evidence based approach to safe anesthetic management of day case procedures for patients with a range of significant comorbidities and patient selection protocols. KU. Demonstrate anesthetic techniques used for more complex ENT, maxillofacial and dental surgery. KU. Recall / describe an evidence based approach to the management of complex ASA IIV patients for elective and emergency major urological and gynecological surgery. KU. Describe in depth anesthetic management for liver and renal transplantation and for patient with transplanted liver or kidney. KU. Discuss current advances and controversies in obstetrics. KU. Recommend an evidence based approach to the management of complex ASA IIV patients for elective and emergency major orthopedic [including spine] surgery.

4 KU7. Specify in depth the responsibilities associated with the role of trauma team leader. KU8. Develop a detailed knowledge of the majority of conditions presenting to ICU, and a wide experience of ICM (intensive care management) in varied situations. KU9. Demonstrate a comprehensive knowledge of Pain Medicine service delivery. KU0. Demonstrate the different techniques of regional and local blookade. KU. Understand the national code of ethics issued by the Egyptian Medical Syndicate. KU. Outlines the effects of his professional practices on the community. KU. Outlines the infection control guidelines, in intensive care units &operative rooms. KU. Outline indepth, the periprocedure [diagnostic or therapeutic, elective or emergency] anesthetic/sedation needs for complex ASA patients that may take place outside the operating theatre, including remote sites including but not exclusively in the following settings: The Radiology suites, Radiotherapy and ECT B: Intellectual Skills IS. Internalize why effective decision making and organization skills are required by anesthetists to ensure clinical sessions are delivered safely, efficiently and effectively to the benefit of both patients and the organization; this implies an ability to recognize the importance of providing overall leadership of the multidisciplinary team when necessary.

5 IS. Observe a safe behavior in prescribing practice to all members of the multidisciplinary team. IS. Adopt strategies to reduce risk [e.g. the use of the WHO Safe Surgery Checklist] and a willingness to participate in improvement strategies [e.g. critical incident reporting]; acts to rectify error immediately if it is made. IS. Analyze, interpret, objectively evaluate and prioritize information, recognizing its limitations. IS. Prioritize the problems in critical cases. IS. Use personal judgment for analytical and critical problem solving and seek out information. IS7. Design an initial course of management for stabilization of patients with serious illnesses. IS8. Recognize and cope with uncertainty that is unavoidable in the practice of medicine by accepting and reacting to uncertain situation. IS9. Perform and write a scientific paper IS0. Analyze problems in his specialty and the creative ability to solve facing problems. C Professional/practical skills PS. Manage the perioperative airway and anesthetic care for a wide variety of patients with complex airway problems and for complex ENT, maxillofacial and dental surgical cases independently PS. Plan for safe perioperative anesthetic care of patients having combined surgical / radiological procedures, including those performed in isolated sites using either regional or general anesthesia PS. Write standard operating procedure, (SOPs) and checklists PS. Establish invasive monitoring of arterial and filling blood pressure And perform central venous access insertion.

6 PS. Use a comprehensive number of neural blockade procedures and imaging techniques for pain management including acute and chronic pain. PS. Demonstrate competency in cardiopulmonary resuscitation and advanced lifesupport. PS7. Plan comprehensive safe anesthetic care to all ASA adult patients and children for all types of elective and emergency surgery either under general anesthesia or monitored anesthesia care PS8. Utilize international standards algorisms for resuscitation of the patient adopted in the basic and advanced life support, advanced trauma life support, pediatric life support, airway and major incident management PS9. Apply scientific evidence medicine on patient in intensive care and anesthesia PS0. Administer competently and safely the required types of anesthesia in all age groups for both elective and emergency situations. D General &Transferable skills GS. Develop & make database search in the library & internet. GS. Work within a multidisciplinary team, demonstrates the necessary communication, teamwork, leadership, professional and practical [anesthetic] skills needed to manage patients on all elective and emergency surgical lists, safely and effectively. GS. Learn and evaluate others. GS.Use information, and communication technology effectively. GS. Solve problems related to work management and among colleagues. GS. Practice the different types of effective communication. GS7. Evaluate him/herself and assess the personal educational needs. GS8. Use different resources to gain knowledge and information. GS9. Develop rules and indicators to evaluate the performance of others. GS0. Manage seminars in addition to the effective time management.

7 GS. Learn by self and in a continuous manner. GS. Adopt an empathic and holistic approach to the patients and their problems management decisions. GS. Understand and respect the different cultural beliefs and values in the community they serve.. Academic standards: a. Generic standards of postgraduate programmes, prepared by National Authority of Quality Assurance and Accreditation of Education (NAQAAE). المعاييرالقياسية العامة لبرامج الدراسات العليا التي أعدتها الهيئة القومية لضمان جودة التعليم واالعتماد فبراير (009) b. External reference (Benchmark) (attached): Doctoate (MD) degree in Anesthesia and Surgical intensive care Programme of the Royal College of Anaesthetists (RCoA) c. Matrices: Comparison between the intended learning outcomes (ILOs) of the Faculty of Medicine Zagazig university MD in Anesthesia and Surgical intensive care programme and that of the Generic Academic standards of postgraduate programme prepared by National Authority of Quality Assurance and Accreditation of Education. Generic Academic standards of MD programme المعايير العامة لبرامج الدراسات العليا)برامج الدكتوراة ) المعرفة و الفهم أ النظريات و األساسيات والحديث من المعارف فى مجال التخصص وكذا في المجاالت ذات العالقة ب المبادئ األخالقية و القانونية للممارسة المهنية في Comparable ILOs in the MD in Anesthesia and Surgical intensive care programme KU to KU Remarks 00 % is fulfilled 7

8 التخصص. مجال المهنية الممارسات في الجودة أساسيات و مبادئ ت التخصص. مجال في وأدواته العلمي البحث أخالقيات و أساسيات ث المختلفة على المهنية ممارسته بآثار المتعلقة المعارف ج وصيانتها البيئة تنمية وطرق البيئة الذهنية المهارات التخصص مجال في المعلومات تقييم و تحليل أ منها. واإلسباط عليها والقياس المعطيات على استنادا المتخصصة المشاكل حل ب المتاحة المشاكل لحل المختلفة المعارف بين الربط ت المهنية. المعارف. إلى تضف بحثية دراسة اجراء ث مجال في المهنية الممارسات في المخاطر تقييم ج التخصص. التخصص. مجال في األداء لتطوير التخطيط ح متنوعة. مهنية سياقات في المهنية القرارات أتخاذ خ علمية أوراق صياغة د واإلبداع. اإلبتكار ذ واألدلة. البراهين على المبنى والنقاش الحوار ر المهنية المهارات في الحديثة و األساسية المهنية المهارات اتقان أ التخصص. مجال المهنية. التقارير تقييم و كتابة ب مجال في القائمة واألدوات الطرق وتطوير تقييم ت التخصص الممارسة يخدم بما التكنولوجية الوسائل جإستخدام المهنية. آداء وتنمية المهنية الممارسة لتطور التخطيط ح اآلخرين. المتنقلة و العامة المهارات المختلفة بأنواعه الفعال التواصل أ الممارسة يخدم بما المعلومات تكنولوجيا استخدام ب المهنية. والمستمر الذاتي التقييم ت علي للحصول المختلفة المصادر استخدام ث IS IS0 PS to PS9 GS to GS 00% is fulfilled 00% is fulfilled 00% is fulfilled 8

9 المعلومات والمعارف. ج تعلييم اآلخرين وتقييم آداءهم. ح العمل في فريق و قيادة فرق في سياقات مهنية مختلفة. خ إدارة اللقاءات العلمية والوقت بكفاءة. د التعلم الذاتي و المستمر. Comparison between the ILOs of the MD programme in Anesthesia and Surgical intensive care, Faculty of medicinezagazig university and that of Anesthesia and Surgical intensive care MD Programme of the Royal College of Anaesthetists (RCoA) ILOs in MD of Anesthesia and Surgical intensive care Programme of the Royal College of Anaesthetists (RCoA) ILOs in MD of Anesthesia and Surgical intensive care programme Faculty of medicine, Zagazig University Approximate achievable ILOs Knowledge &Understanding: To have a thorough understanding of the complexity of the breadth of neurosurgery/neuroradiology performed and provide clinical leadership to any patient requiring neurocritical care. To be capable of undertaking the perioperative anaesthetic care for a wide variety of complex cardiothoracic surgical cases and cardiological procedures. Gain mastery in the delivery of safe and effective perioperative airway and anaesthetic care to patients with complex airway problems involving all types of surgery. Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex/major ENT, maxillofacial and dental surgery. Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex intraabdominal surgical procedures. Gain mastery in the delivery of safe and KU8 KU9 KU9, KU0 KU,KU,KU7,KU8,KU KU,KU7,KU,KU. 80 % is fulfilled 9

10 effective perioperative anaesthetic care to patients undergoing complex hepatobiliary surgical procedures. 7Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex vascular procedures [including intrathoracic], both elective and emergency and intheatre and in imaging suites. 8Gain mastery in all aspects of the perioperative anaesthetic management of all patients presenting for day surgery. 9Gain mastery in the delivery of safe and effective periprocedural conscious sedation to patients of all ASA grades [frequently with serious comorbidities] undergoing a wide variety of simple to complex procedures often in remote areas. 0Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex orthopaedic procedures Gain mastery in a wide range of regional anaesthetic techniques using a variety of methods to assist in the identification and safe placement of needles and catheters, including indepth understanding of the place and use of ultrasound. Gain mastery in leading the delivery of safe and effective multidisciplinary care to multiplyinjured patients as Trauma Team Leader Have a detailed knowledge of the majority of conditions presenting to ICU. Have a wide experience of ICM in varied situations, be able to manage initial resuscitation and stabilisation of any acutely ill patient, adult or child, prior to transfer to an appropriate specialist centre,be able to operate unsupervised and take on a management and leadership role in an ICU. Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex obstetric procedures. To be capable of undertaking the perioperative anaesthetic care for a wide variety of complex paediatric [including neonates] procedures independently. 7Being aware of the treatment options available to provide effective management for patients with acute, chronic and cancer pain. KU KU7,KU9 KU KU KU KU0 KU7 KU8 KU,KU8 KU KU KU9

11 8Gain mastery in the delivery of safe and effective perioperative anaesthetic care to patients undergoing complex burns and plastics procedures, both elective and emergency. Intellectual Skills:. Observe a safe behavior in prescribing practice to all members of the multidisciplinary team. Clinical problem solving skills. Analysis and evaluation skills.. Understanding evidence based medicine.. Analyze, interpret, objectively evaluate and prioritize information, recognizing its limitations..adopt strategies to reduce risk [e.g. the use of the WHO Safe Surgery Checklist] and a willingness to participate in improvement strategies [e.g. critical incident reporting]; acts to rectify error immediately if it is made. General &Transferable skills Commits to the importance of being a good team member,. provide high quality clinical care in all clinical situations regularly.develops a personal learning network of individuals and organisations including; attending specialist educational meetings and reads specialist journals in special interest areas of practice. able to receive feedback appropriately for the purpose of selfimprovement and provides feedback to others when asked. Communication with staff, patients and relatives.. Make effective oral and written presentations of work. Professional/practical skills:. Direct observation of trainee during list focusing on their capacity to make accurate observations of clinical signs and physiological data leading to appropriate characterization of the patient s status...strategies for maintaining the patient s safety. Preoperative assessment, investigation, KU7 IS,IS IS7,IS0 IS,IS IS8,IS9 IS IS GS GS,GS GS,GS,GS8,GS0 GS,GS,GS7,GS GS,GS GS9 PS, PS PS 0 80% is fulfilled 80% is fulfilled 80% is fulfilled

12 evaluation of patient and planning of anaesthesia. Focus on safety during management of induction and emergence. Promptness and suitability and adequacy of response to problems during anaesthesia and in recovery. Apply scientific evidence medicine on patient in intensive care and anesthesia.. Demonstrate competency in cardiopulmonary resuscitation and advanced lifesupport. PS PS,PS,PS7 PS8,PS9 PS,PS Comparison between the ILOs of the MD programme in Anesthesia and Surgical intensive care and that of the courses (Computer, Statistics, Physiology &clinical measurements, Pharmacology, Anesthesia and Surgical intensive care and Anesthesia and Surgical intensive care ). Programme of MD in Anesthesia and Surgical intensive care MDTH Anest AIMD 0 KU KU KU From KUto KU IS IS0 IS9 From IS to IS0 PS PS0 PS9 From PS to PS0 GS GS GS8 From GS to GS Programme structure: Course units Teaching hours Phys & cl. meas AIM D 0 KU KU IS IS7 Phar AIMD 0 CA KU KU KU MS IS IS, IS IS, IS PS PS PS9 PS9 GS GS8, GS GS8, GS weeks GS, GS8 Academic year Computer (CA) 8 st part GS, GS8

13 Computer CA Statistics (MS) 9 st part Pharmacology (AIMD 0) Physiology&measure. (AIMD 0) st part 8 st part Anesth (AIMD 0) 8 9 nd part Thesis (MDTH) Thesis nd part (supervision) Total 9 N.B. MD candidates in addition to lectures hours ( hours / week), attend rotation schedule for subspecialty days / week.( 8 hours / day) included in caring of regular continuing clinical education sessions. Also there are journal clubs, departmental meetings and research seminars. Teaching for units is overlapping in the same weeks.. Programme courses. Code Units No Title How to locate the proper source for health and medical information How to decode URLs and identify file types How to formulate an effective search statements How to evaluate the internet information Citing internet documents and avoiding plagiarism Web.0 and social / collaborative internet tools Using of Internet tools in EvidenceBased Medicine Health on the net code of ethics Using of Free online Journal Databases Scope, uses, application of PubMed Medline database Theoreti cal & seminars No of hours Practical total No of weeks

14 Physiology &clinical measurments AIMD 0 Statistics MS Medical Wiki, Blogs, groups, multimedia, and Health.0 tools Introduction to medical statistics Types of research methodology Population sampling Types of data, presentation Summarization of data Normal distribution curve Tests of significance Types of errors, bias Correlation, regression Total 7 Code No. Units Title GENERAL PHYSIOLOGY BODY FLUIDS, THE FUNCTIONS AND CONSTITUENTS HAEMATOLOGY AND IMMUNOLOGY MUSCLE PHYSIOLOGY HEART/CIRCULATION PHYSIOLOGY PHYSIOLOGY OF RENAL TRACT PHYSIOLOGY OF RESPIRATION PHYSIOLOGY OF NERVOUS SYSTEM LIVER PHYSIOLOGY GASTROINTESTINAL PHYSIOLOGY PHYSIOLOGY OF METABOLISM AND BODY TEMPERATURE PHYSIOLOGY OF ENDOCRINOLOGY No of hours Theoretical Practical & seminars total No of weeks

15 Anesth. AIMD 0 Pharmacology AIMD 0 Total Total PHYSIOLOGY OF OBSTETRICS AND PAEDIATRICS PHYSIOLOGY OF GERIATRICS CLINICAL MEASUREMENT GENERAL PHARMACOLOGY NEUROMUSCULAR CENTRAL NERVOUS SYSTEM THERAPEUTIC GASES LOCAL ANESTHETICS CARDIOVASCULAR SYSTEM and BLOOD RESPIRATORY SYSTEM RENAL SYSTEM GASTROINTESTINAL SYSTEM ENDOCINE ANTIMICROBIAL THERAPY EYE TOXICOLOGY Code No. Unit Title GENERAL BASICS FOR ANESTHESIA PRACTICE ANESTHESIA FOR PEDIATRIC SURGERY ANESTHESIA FOR GENERAL SURGERY ANESTHESIA FOR ENT ANESTHESIA FOR DENTAL AND MAXILLOFACIAL SURGERY ANESTHESIA FOR NEUROSURGERY No of hours Theoretical & seminars Practical 7 total 0 8 No of weeks 9

16 ANESTHESIA FOR OBSTETRIC AND GYNECOLOGY ANESTHESIA FOR ORTHOPEDIC SURGERY ANESTHESIA FOR OPHTHALMIC SURGERY ANESTHESIA FOR CARDIOTHORACIC SURGERY ANESTHESIA FOR RENAL AND GENITOURINARY SYSTEM ANESTHESIA FOR DAY CASE SURGERY ANESTHESIA FOR TRAUMA AND EMERGENCY GERIATRIC ANESTHESIA ANESTHESIA AT REMOTE LOCATION REGIONAL ANESTHESIA PAIN MANAGEMENT SURGICAL INTENSIVE CARE Special courses Total 90 9 MDTH RESEARCH in ANESTHESIA and SURGICAL INTENSIVE CARE N.B. The courses are parallel to each other. Programme admission requirements Master degree in anesthesia and surgical ICU. 7 Regulations for progression and programme completion 9 weeks weeks At the end of st Academic Year * fulfillment of the of log book. * Pass examinations in the computer, statistics, applied pharmacology (AIMD 0) and physiology and clinical measurements (AIMD 0) courses.

17 rd Academic Year * fulfillment of the of log book. * Pass examination in the course AIMD 0. * Perform the MD thesis in anesthesia and surgical intensive care (MDTH): fulfillment of the supervisors report every months. * perform a seminar about the thesis results. * Acceptance of the MD thesis from judgment committee nominated by department council. 8 Evaluation of programme intended learning outcomes Evaluator Tool Sample Exams results Results analysis Report Students Questionnaires All the students Graduates achieving MD degree Stakeholders * teaching staff. * Regional medical institutes * International medical institutes. * other Governmental faculties * Non governmental faculties External Evaluator Others (If Present) References : VIIA) Essential Books: Questionnaires group discussion Interviews Internet contact Phone calls Questionnaires Questionnaires Anesthesia (00) Miller RD, edt, 7 th ed. 0 at least 0 at least Clinical Anesthesiology (00), Morgan GE et al, edt, th ed Marino PL (007) rd ED. Problem oriented anesthesia (Yao & Artusio 008.) Regional Anesthesia (M.Zenz,C.Panhans,H.Chr.Niesel,H.Kreuscher008.) 7

18 VIIB) SUGGESTED MATERIALS: Uptodate Web sites: www. MD Linx Anethesia. moemen.com Journals of anesthesia British Journal of Anaesthesiology. Journal of Intensive Care Medicine. Anaesthesia and Intensive Care. Anesthesia & Analgesia. Journal of Clinical Anesthesia. Journal of Local and Regional Anesthesia. Journal of Cardiothoracic and Vascular Anesthesia. Egyptian Journal of Anesthesia. Saudi Journal of Anesthesia. Supports for Candidates and their Learning: Candidates and their learning are supported in a number of ways: Printed copies of the programme and anesthesia and surgical intensive care courses (Candidates aware of the ILOs and requirement of the MD degree in anesthesia and surgical intensive care. Availability of University central liberary. Availability of the Faculty postgraduate library Availability of the Department Postgraduate library. Availability of the faculty digital library. Availability of the other educational resources included in every course. MD thesis Supervisors (three Staff members according to the research specialty for each candidate). 8

19 Methods used for improving the programme: Peer teaching observations and feedback to the programme management team and the coordinator (written reports at the end of the courses). Faculty appointed external examiners. Candidates evaluation of teaching (Questionnaires). Committee with responsibility for monitoring and evaluating quality: Internal Evaluators: Prof. Dr. ADEL RIZK (Head of anesthesia and surgical intensive care Department). Member from Quality unit in the faculty. External Evaluator : Prof. Dr. Walaa Elkharbotly. Mansoura University, Faculty of Medicine, Anesthesia and surgical ICU department. Regulations of assessment bylaws of the MD degree postgraduate of the faculty of medicine: Computer course (CA) Attendance of at least 7% of the teaching courses. Log book fulfilled and approved by the head of the department. Tools Mark Percentage of the total mark Written exam 80 80% Oral and Practical exam 0 0 % Total marks 00 Statistics course (MS) Attendance of at least 7% of the teaching courses. Log book fulfilled and approved by the head of the department. Tools Mark Percentage of the total mark Written exam 00 00% Total marks 00 Physiology and clinical measurement course (AIMD 0) Attendance of at least 7% of the teaching courses. Log book fulfilled and approved by the head of the department. 9

20 Tools Mark Percentage of the total mark Written exam 00 0% Oral exam 00 0 % Total marks 00 Pharmacology course (AIMD 0) Attendance of at least 7% of the teaching courses. Log book fulfilled and approved by the head of the department. Tools Mark Percentage of the total mark Written exam 00 0% Oral exam 00 0 % Total marks 00 Anesth (AIMD 0) Pass examinations in the computer, statistics, applied pharmacology and physiology and clinical measurements courses. (at least 0% of total Mark). Attendance of at least 7% of the teaching courses. Log book fulfilled and approved by the head of the department. Tools Mark Percentage of the total mark Written exam 00.7% Oral exam (include ECG and imaging exam) 0.7 % Practical exam 0.7% Total marks 00 NB: Examinations are conducted twice yearly. MDTH * Preregistration seminar * Registration of the thesis title. * Perform the thesis within at least months of registration. * After finishing the thesis Candidate perform a seminar about the thesis results. * progression reports are introduced by each supervisor (one every months). * MD thesis acceptance by the supervisors. * MD thesis acceptance by the judgment committee in an advertised public session by three professors including one of the supervisors, one from the faculty and third from other faculty.. * Four copies of the thesis must be given to the postgraduate library. Rules for awarding the MD Degree in anesthesia and surgical intensive care:

21 * Candidates must pass the computer, statistics, physiology and pharmacology courses exams (at least 0%) as a prerequisite for the registration of AIMD 0 course and MD thesis (MDTH). * MD thesis must be accepted by the judgment committee. * Candidates must pass the final exam of course AIMD 0 (at least 0% ).