A STUDY TO ASSESS THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON

KNOWLEDGE OF MOTHERS REGARDING

IMPORTANCE OF VITAMIN B AT SELECTED RURAL

AREAS, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT

FOR

DISSERTATION

MISS.SEEMA YADAV

1ST YEAR M.Sc. NURSING

COMMUNITY HEALTH NURSING

YEAR 2010-2012

HARSHA COLLEGE OF NURSING

HARSHA HOSPITAL CAMPUS

193/4, SONDEKOPPA CIRCLE

NH-4, NELAMANGALA,

BANGALORE-562123

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION

NAME OF THE CANDIDATE AND ADDRESS

MISS. SEEMA YADAV1ST YEAR M.SC.NURSINGHARSHA COLLEGE OF NURSING HARSHA HOSPITAL CAMPUS♯193/4, SONDEKOPPA CIRCLENH-4, NELAMANGALA,BANGALORE-562123

NAME OF THEINSTITUTION

Harsha College of NursingBangalore

COURSE OF THE STUDY AND SUBJECT

1 year M.sc.NursingCommunity Health Nursing.

DATE OF ADMISSION 10/05/2010

TITLE OF THE STUDY

To Assess The Effectiveness Of Structured

Teaching Programme On Knowledge Of

Mothers Regarding Importance Of Vitamin

B.

6. BRIEF RESUME OF INTENDED WORK:

INTRODUCTION

All those vitamins aren't to keep death at bay;

They’re to keep deterioration at bay.

Jeanne Moreau

Vitamins are essential for life maintenance of normal life. These act as

cofactor in many enzyme systems and therefore cardinal for various bodily

function such as energy production, hemopoiesis, reproduction, neurological

functions, hydroxylation, and synthesis of fat, amino acids, nucleic acids, and

nucleoprotein.

The term vitamin was historically derived from "vitamine," a

combination word made up by Polish scientist Casimir Funk from vital and

amine, meaning amine of life, because it was suggested in 1912 that the

organic micronutrient food factors which prevented beriberi and perhaps other

similar dietary-deficiency diseases, might be chemical amines. This proved

incorrect for the micronutrient class, and the word was shortened to vitamin.

Vitamins are required in every minute quantity in the diet. The fetus and

the infant get adequate vitamins from the mother during pregnancy and

lactation. Dietary intake of vitamins may be low and marginal during infancy

and early childhood. There is increased requirement of vitamins in preterm

babies, during post operative stress, infections and in some genetic metabolic

disorders. Intestinal absorption of vitamins is impaired in chronic diarrhea, mal

absorption, and bacterial overgrowth in intestines. Certain drugs may have

adverse effect on the enzyme systems, which require vitamins. 1

The body needs vitamins to stay healthy and a varied diet usually gives

you all the vitamins you need. Vitamins do not provide energy (calories)

directly, but they do help regulate energy-producing processes. With the

exception of vitamin D and K, vitamins cannot be synthesized by the human

body and must be obtained from the diet. Vitamins have to come from food

because they are not manufactured or formed by the body. 2

In 1881, Russian surgeon Nikolai Lunin studied the effects of scurvy

while at the University of Tartu in present-day Estonia. He fed mice an

artificial mixture of all the separate constituents of milk known at that time,

namely the proteins, fats, carbohydrates, and salts. The mice that received only

the individual constituents died, while the mice fed by milk itself developed

normally. He made a conclusion that "a natural food such as milk must

therefore contain, besides these known principal ingredients, small quantities of

unknown substances essential to life." However, his conclusions were rejected

by other researchers when they were unable to reproduce his results. One

difference was that he had used table sugar (sucrose), while other researchers

had used milk sugar (lactose) that still contained small amounts of vitamin B. 3

Vitamins are classified as either water-soluble or fat soluble. In humans

there are 13 vitamins: 4 fat-soluble (A, D, E and K) and 9 water-soluble (8 B

vitamins and vitamin C). Water-soluble vitamins dissolve easily in water, and

in general, are readily excreted from the body, to the degree that urinary output

is a strong predictor of vitamin consumption. Because they are not readily

stored, consistent daily intake is important. Many types of water-soluble

vitamins are synthesized by bacteria. 4

The B vitamins are a group of water-soluble vitamins that play

important roles in cell metabolism. The B vitamins were once thought to be a

single vitamin, referred to as vitamin B (much as people refer to vitamin C or

vitamin D). Later research showed that they are chemically distinct vitamins

that often coexist in the same foods. In general, supplements containing all

eight are referred to as a vitamin B complex. Individual B vitamin supplements

are referred to by the specific name of each vitamin (e.g., B1, B2, B3 etc.). 5

6.1 NEED FOR THE STUDY:

“A mother is one to whom you hurry when you are troubled”

-- Emily Dickinson

Vitamins are natural substances found in plants and animals and known

as Essential nutrients for human beings. The name vitamin is obtained from

"vital amines" as it was originally thought that these substances were all

amines. Human body uses these substances to stay healthy and support its

many functions. There are two types of vitamins: water-soluble and fat-soluble. 4

Evidence supports a role for folic acid and vitamin B12 supplements in

lowering homocysteine levels, but results from several large prospective

studies have not shown that these supplements decrease the risk of

cardiovascular disease. In the Women’s Antioxidant and Folic Acid

Cardiovascular Study, women at high risk of cardiovascular disease who took

daily supplements containing 1 mg vitamin B12, 2.5 mg folic acid, and 50 mg

vitamin B6 for 7.3 years did not have a reduced risk of major cardiovascular

events, despite lowered homocysteine levels. 5

The Heart Outcomes Prevention Evaluation (HOPE) 2 trial, which

included 5,522 patients older than 54 years with vascular disease or diabetes,

found that daily treatment with 2.5 mg folic acid, 50 mg vitamin B6, and 1 mg

vitamin B12 for an average of 5 years reduced homocysteine levels and the risk

of stroke but did not reduce the risk of major cardiovascular events. In the

Western Norway B Vitamin Intervention Trial, which included 3,096 patients

undergoing coronary angiography, daily supplements of 0.4 mg vitamin B12

and 0.8 mg folic acid with or without 40 mg vitamin B6 for 1 year reduced

homocysteine levels by 30% but did not affect total mortality or the risk of

major cardiovascular events during 38 months of follow-up. The American

Heart Association has concluded that the available evidence is inadequate to

support a role for B vitamins in reducing cardiovascular risk. 6

Researchers have long been interested in the potential connection

between vitamin B12 deficiency and dementia . A deficiency in vitamin B12

causes an accumulation of homocysteine in the blood and might decrease

levels of substances needed to metabolize neurotransmitters . Observational

studies show positive associations between elevated homocysteine levels and

the incidence of both Alzheimer's disease and dementia . Low vitamin B12

status has also been positively associated with cognitive decline. 7

Despite evidence that vitamin B12 lowers homocysteine levels and

correlations between low vitamin B12 levels and cognitive decline, research

has not shown that vitamin B12 has an independent effect on cognition . In one

randomized, double-blind, placebo-controlled trial, 195 subjects aged 70 years

or older with no or moderate cognitive impairment received 1,000 mcg vitamin

B12, 1,000 mcg vitamin B12 plus 400 mcg folic acid, or placebo for 24 weeks .

Treatment with vitamin B12 plus folic acid reduced homocysteine

concentrations by 36%, but neither vitamin B12 treatment nor vitamin B12 plus

folic acid treatment improved cognitive function. 8

Women at high risk of cardiovascular disease who participated in the

Women’s Antioxidant and Folic Acid Cardiovascular Study were randomly

assigned to receive daily supplements containing 1 mg vitamin B12, 2.5 mg

folic acid and 50 mg vitamin B6, or placebo. After a mean of 1.2 years, B-

vitamin supplementation did not affect mean cognitive change from baseline

compared with placebo. However, in a subset of women with low baseline

dietary intake of B vitamins, supplementation significantly slowed the rate of

cognitive decline. In a trial conducted by the Alzheimer's Disease Cooperative

Study consortium that included individuals with mild-to-moderate Alzheimer's

disease, daily supplements of 1 mg vitamin B12, 5 mg folic acid, and 25 mg

vitamin B6 for 18 months did not slow cognitive decline compared with

placebo. Another study found similar results in 142 individuals at risk of

dementia who received supplements of 2 mg folic acid and 1 mg vitamin B12

for 12 weeks. 9

The authors of two Cochrane reviews and a systematic review of

randomized trials of the effects of B vitamins on cognitive function concluded

that insufficient evidence is available to show whether vitamin B12 alone or in

combination with vitamin B6 or folic acid has an effect on cognitive function

or dementia. Additional large clinical trials of vitamin B12 supplementation are

needed to assess whether vitamin B12 has a direct effect on cognitive function

and dementia. 10

According to the 2005 Dietary Guidelines for Americans, "nutrient

needs should be met primarily through consuming foods. Foods provide an

array of nutrients and other compounds that may have beneficial effects on

health. In certain cases, fortified foods and dietary supplements may be useful

sources of one or more nutrients that otherwise might be consumed in less than

recommended amounts. However, dietary supplements, while recommended in

some cases, cannot replace a healthful diet." 11

About 25% of US households do not have balanced meals to meet the

requirements that the body needs in digesting enough nutrients to sustain the

body's health and fuel factors. Research has shown that almost all varieties of

disease can be produced by the deficiency of vitamins, minerals, amino acids,

and other nutrients. Vitamins are vital for your skin. The most important factor

of nutritional deficiencies is the intense processing and refining of foods like

cereals and sugar. 12

Hence the investigator felt that these studies help the mothers to enhance

their knowledge regarding importance of vitamin B, if they receive advance

and adequate information to lead a better life.

6.2 REVIEW OF LITERATURE

A review of literature refers to activities involved in identifying and

searching for information on a topic, developing and understanding the state of

knowledge on a topic. It is an extensive, systematic selection of potential

sources of previous work, which acquaints the investigator with fact finding

work after scrutinization. Polit& Hungle state that review of literature provides

readers with a background for understanding the significant of the study. 13

The review of literature is divided in to following headings

Section A: Review of literature related to general information of vitamin B

Section B: Review of literature related to importance of vitamin B

Section C: Review of literature related to deficiency of vitamin B

Section A: Review of literature related to general information of vitamin B

A 2010 study concluded that taking folic acid (B9), Vitamins B6 and

B12 may slow brain atrophy in patients with Mild Cognitive Impairment

(MCI). Such atrophy is one predictor of conversion from MCI to Alzheimer's

disease.However, the study was conducted by a former collaborator of Patrick

Holford, a controversial figure who promotes vitamins as cures for ailments

ranging from HIV to autism, and the result has been criticised by Carl

Heneghan, Director of the Centre for Evidence Based Medicine and clinical

lecturer at the University of Oxford, for excluding the one third of initial

participants who dropped out or were not followed up,and for quoting a "30%

reduction in rate of decline" which translates to only a 0.3% absolute change. 14

Another popular means of increasing one's vitamin B intake is through

the use of dietary supplements purchased at supermarkets, health centers, or

natural food stores. B vitamins are also commonly added to energy drinks.

Many energy drinks have been marketed with large amounts of B vitamins 6,

120% of B12, 140% of niacin (vitamin B3) with claims that this will cause the

consumer to "sail through your day without feeling jittery or tense."

Nutritionists, such as Case Western University Professor Hope Barkoukis,

dismiss these claims: "It's brilliant marketing, but it doesn't have any basis. 15

Section B: Review of literature related to importance of vitamin B

A randomized controlled study Effects of B vitamins and omega 3 fatty

acids on cardiovascular diseases: a randomized placebo controlled trial the

objective of the study was To investigate whether dietary supplementation with

B vitamins or omega 3 fatty acids, or both, could prevent major cardiovascular

events in patients with a history of ischemic heart disease or stroke .samples are

2501 patients with a history of myocardial infarction, unstable angina, or

ischaemic results shown that stroke Allocation to B vitamins lowered plasma

homocysteine concentrations by 19% compared with placebo, but had no

significant effects on major vascular events (75 v 82 patients, hazard ratio, 0.90

(95% confidence interval 0.66 to 1.23, P=0.50)). Allocation to omega 3 fatty

acids increased plasma concentrations of omega 3 fatty acids by 37% compared

with placebo, but also had no significant effect on major vascular events. 16

A survey was conducted by National Health and Nutrition Examination stated

that folic acid and to folate and vitamin B-12 status. They estimated usual daily

folic acid intakes above the UL and adjusted serum and red blood cell folate,

serum vitamin B-12, homocysteine, and methylmalonic acid (MMA)

concentrations in US children by age group and by the following 3 major folic

acid intake sources: enriched cereal-grain products (ECGP), ready-to-eat

cereals (RTE), and supplements containing folic acid. The result showed that a

total of 19-48% of children consumed folic acid from ECGP only. Intakes

above the UL varied from 0-0.1% of children who consumed ECGP only to 15-

78% of children who consumed ECGP+RTE+SUP. In children aged 1-8 y, 99-

100% of those who consumed ≥200 μg folic acid/d from supplements exceeded

their UL. Although <0.5% of children had folate deficiency or low vitamin B-

12 status, the consumption of RTE or SUP with folic acid was associated with

higher mean folate and vitamin B-12 concentrations and, in some older

children, with lower homocysteine and MMA concentrations. 17

An experimental research was conducted on Antioxidant vitamins

intake, ataxia telangiectasia mutated (ATM) genetic polymorphisms, and breast

cancer risk, it shows that Ataxia telangiectasia mutated (ATM) cells exist under

a constant state of oxidative stress with high levels of reactive oxygen species,

which are removed by cellular antioxidant vitamins. We investigated the

independent and combined effect of antioxidant vitamins intake and the ATM

genotype or diplotype on the breast cancer risk. Analyses included 323 cases

and age-matched controls who participated in the Korean Breast Cancer Study

during 2001-2003 with complete dietary information. The vitamin A (P < 0.01)

and α-tocopherol (P < 0.01) were associated with lower breast cancer risk as

well as some water-soluble vitamins including vitamin B(2) (P = 0.01), vitamin

C (P < 0.01), and folic acid (P = 0.02) intake. The association between ATM

diplotype and the breast cancer risk was predominantly among women with

low intake of antioxidant vitamins including vitamin A, vitamin C, and folic

acid. This study suggested that some antioxidant vitamins intake may modify

the effect of ATM diplotype on the breast cancer risk among Korean women. 18

Section C: Review of literature related to deficiency of vitamin B

A cohort study was conducted on B vitamins and the aging brain it showed that

Deficiencies of the vitamins folate, B(12) , and B(6) are associated with

neurological and psychological dysfunction and with congenital defects. In the

elderly, cognitive impairment and incident dementia may be related to the high

prevalence of inadequate B vitamin status and to elevations of plasma

homocysteine. Plausible mechanisms include homocysteine neurotoxicity,

vasotoxicity, and impaired S-adenosylmethionine-dependent methylation

reactions vital to central nervous system function. In light of this, it is

imperative to find safe ways of improving vitamin B status in the elderly

without exposing some individuals to undue risk. 19

A Randomized, double-blind, placebo-controlled trial on B-vitamins reduce the

long-term risk of depression after stroke The purpose of this research was to

determine if treatment with B-vitamins reduces the hazard of poststroke

depression compared with placebo samples were 10.5 years in survivors of

stroke result shows that Among 273 people who completed the final

assessment after 7.1 ± 2.1 years (mean ± standard deviation) of follow up,

random assignment to B-vitamins was associated with a lower hazard of major

depression compared with placebo (18.4% vs 23.3%, adjusted hazard ratio

[HR] = 0.48; 95% confidence interval [CI] = 0.31-0.76) and a trend toward a

lower odds of major or minor depression at the end of the trial compared with

placebo. 20

A study was conducted on Serum vitamin B(12) concentrations within

reference values do not exclude functional vitamin B(12) deficiency in

phenylketonurea patients of various ages the objective of the study were The

aim of this study was to investigate the prevalence of functional vitamin B(12)

deficiency in continuously treated PKU patients and the association of

parameters of vitamin B(12) and metabolic control samples were 75

continuously treated phenylketonurea patients of 1-37years of age, the result

shown that Eight patients had vitamin B(12) concentrations below normal. Out

of these eight patients, two had elevated MMA and/or Hcy concentrations. Ten

other patients with normal vitamin B(12) concentrations had elevated

concentrations methylmalonic acid, Homocysteine (Hcy) and in particular

methylmalonic acid (MMA) are considered reliable parameters for vitamin

B(12) status in healthy individuals. 21

STATEMENT OF THE PROBLEM

A Study to Assess the Effectiveness of Structured Teaching Programme

on Knowledge of Mothers Regarding Importance of Vitamin B at Selected

Rural Areas, Bangalore.

6.4 OBJECTIVES

1. To assess the pre test level of knowledge among mothers on Importance

of Vitamin B.

2. To assess the post test level of knowledge among mothers on

Importance of Vitamin B.

3. To evaluate the effectiveness of structured teaching programme on

Importance of Vitamin B among mothers.

4. To associate pre test level of knowledge of mothers regarding

Importance of Vitamin B with selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. Effectiveness: Refers to gain in knowledge as determined by significant

difference in pre and post test knowledge scores

2. Structured teaching programme: Refers to systematically organized

teaching strategy on Importance of Vitamin B.

3. Knowledge: It is refers to a level of understanding and awareness of

Mothers on importance of vitamin B as assessed by self administered

questionnaire.

4. Mothers: women who is having one or more children

5. Vitamin B: It is a micronutrient

6.6 ASSUMPTIONS.

1. Mothers may have insufficient knowledge regarding importance of vitamin B.

2. Structured teaching programme may have effect on knowledge of mothers

regarding importance of vitamin B.

6.7. HYPOTHESIS

H1- There will be a significant difference between pre and post test level of

knowledge on importance of vitamin B among mothers.

H2- There is a significant association between pre test level of knowledge among

mothers with selected demographic variables.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from mothers of selected rural areas, Bangalore.

7.2 METHODS OF DATA COLLECTION

i. Research Design :

Pre experimental: one group pretest & post test design

ii .Research Variables

1. Dependent variables: knowledge of mothers on importance of vitamin B.

2. Independent variable: Structured teaching programme regarding importance

of vitamin B on mothers.

3. Demographic variables: Age, religion, family income, education, source of

information.

iii. Setting

The study will be conducted at selected rural areas, Bangalore.

iv. Population

The mothers living in a selected rural areas.

v. Sample

The mothers living in selected rural areas who fulfills the inclusion criteria.

Sample size is 60.

vi. Criteria for sample selection

Inclusion Criteria

The mothers between the age group of 25 to 40.

Who are willing to give consent.

Who knows either kannada or english.

Exclusion Criteria

Who are not willing to participate.

vii. Sampling technique

Probability sampling, simple random sampling(lottery mathod).

viii. Tool for data collection

The tool consists of following sections

Section A: Consists of Demographic Performa of mothers like age, religion,

family income, education, source of information.

Selection B: Consists of structured questionnaire to assess the knowledge of

mothers regarding importance of vitamin B.

Section C: Consists of Structured teaching programme on importance of vitamin

B.

ix. Method of data collection

The researcher will collect the data from subjects after informed consent and

Obtaining the permission from concerned authorities.

Phase I: Pre-test will be conducted to assess the existing knowledge with the help

of structured questionnaire of mothers on importance of vitamin B.

Phase II: Structured teaching programme on importance of vitamin B will be

conducted.

Phase III: After seven days post test will be conducted to assess the level of

knowledge.

Duration of the study: Four weeks

x. Plan for data analysis

The data collected will be analyzed by using descriptive & inferential statistics.

Descriptive Statistics

Frequency, percentage distribution, mean, median & standard deviation will be

used to assess the knowledge of mothers on importance of vitamin B.

.

Inferential Statistics

Paired’ test will be used to compare the pre-test & post test knowledge. Chi-

square will be used to associate the knowledge of mothers with selected demographic

variable.

xi. Projected outcome

The investigator will be able to give appropriate instructions to the mothers

regarding the aspects of importance of vitamin B. It will help to reduce the

vitamin deficiency and help to maintain the health.

7.3. Does the study require any investigation to the patients or other

human beings of animals?

Yes. Structured teaching programme will be given as an intervention to the

mothers regarding importance of vitamin B at selected rural areas, Bangalore

7.4. Has ethical clearance been obtained from your college? YES, informed consent will be obtained from the institution, authorities,

privacy; confidentiality and anonymity will be guarded. Scientific objectivity of

the study will be maintained with honesty and impartiality.

8. BIBLIOGRAPHY

1. Swaminathan M Advanced Text book of Food and Nutrition Vol: p

556-64, 2002.

2. V Srilakshmi dietetic. Nutritional and food requirements, new age

international private limited publocations, New Delhi, p72-84, 2004.

3. Indian council of medical research, recommended dietary intake for

Indians, ICMR, New Delhi 2008.

4. Gupta JNP and SrivastavR K profile of medical sciences, an analytical

aspect AIMLTA chronicle, volume 21 April 2008.

5. Herbert V. Vitamin B12 in Present Knowledge in Nutrition. 17th ed.

Washington, DC: International Life Sciences Institute Press, 1996.

6. Herbert V, Das K. Vitamin B12 in Modern Nutrition in Health and

Disease. 8th ed. Baltimore, MD: Williams & Wilkins, 1994.

7. Combs G. Vitamin B12 in The Vitamins. New York: Academic Press,

Inc., 1992.

8. Zittoun J, Zittoun R. Modern clinical testing strategies in cobalamin

and folate deficiency. Sem Hematol 1999;36:35-46. [PubMed abstract]

9. Institute of Medicine. Food and Nutrition Board. Dietary Reference

Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin

B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National

Academy Press, 1998.

10. Clarke R. B-vitamins and prevention of dementia. Proc Nutr Soc

2008;67:75-81. [PubMed abstract]

11. Klee GG. Cobalamin and folate evaluation: measurement of

methylmalonic acid and homocysteine vs vitamin B(12) and folate.

Clin Chem 2000;46:1277-83. [PubMed abstract]

12. Carmel R. How I treat cobalamin (vitamin B12) deficiency.

Blood.2008;112:2214-21. [PubMed abstract]

13. Laura A. Talbot., Principles & Practice of Nursing Research , 1st

edition, Mosby Publications, 1995.1

14. Kapadia CR. Vitamin B12 in health and disease: part I—inherited

disorders of function, absorption, and transport. Gastroenterologist

1995;3:329-44. [PubMed abstract]

15. Johnson MA. If high folic acid aggravates vitamin B12 deficiency what

should be done about it? Nutr Rev 2007;65:451-8. [PubMed abstract]

16. Andrès E, Federici L, Affenberger S, Vidal-Alaball J, Loukili NH,

Zimmer J, et al. B12 deficiency: a look beyond pernicious anemia. J

Fam Pract 2007;56:537-42. [PubMed abstract]

17. U.S. Department of Agriculture, Agricultural Research Service. 2009.

USDA National Nutrient Database for Standard Reference, Release 22.

Nutrient Data Laboratory Home Page,

http://www.ars.usda.gov/ba/bhnrc/ndl

18. Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of

nutrients among US adults, 1989 to 1991. J Am Diet Assoc

1998;98:537-47. [PubMed abstract]

19. Tucker KL, Rich S, Rosenberg I, Jacques P, Dallal G, Wilson WF, et

al. Plasma vitamin B12 concentrations relate to intake source in the

Framingham Offspring Study. Am J Clin Nutr 2000;71:514-22.

[PubMed abstract]

20. Yazaki Y, Chow G, Mattie M. A single-center, double-blinded,

randomized controlled study to evaluate the relative efficacy of

sublingual and oral vitamin B-complex administration in reducing total

serum homocysteine levels. J Altern Complement Med 2006;12:881-5.

[PubMed abstract]

21. Sharabi A, Cohen E, Sulkes J, Garty M. Replacement therapy for

vitamin B12 deficiency: comparison between the sublingual and oral

route. Br J Clin Pharmacol 2003;56:635-8. [PubMed abstract]

9. Signature of the candidate :

10. Remarks of the guide :

.

11. Name and designation of

11.1 Guide :

11.2 Signature :

11.3 Co- guide (if any) :

11.4 Signature :

11.5 Head of the department :

12.1 Remarks of the principal : This study is feasible and applicable for the

Specialty chosen.

12.2 Signature :