Irish Journal of Medical Science

Article	Citations
Radiotherapy after radical prostatectomy for prostate cancer: clinical outcomes and factors influencing biochemical recurrence	103
Persistent basal ganglia involvement in aminoacylase-1 deficiency: expanding imaging findings and review of literature	100
YKL-40 in serum: a promising biomarker of juvenile SLE and strongly correlated with disease duration	66
Delirium care in hospitals in Ireland on World Delirium Awareness Day 2023	56
Eosinophilic granulomatosis with polyangiitis as a rare cause of the syndrome of inappropriate antidiuretic hormone secretion	49
Evaluation of liver and spleen stiffness measurement with shear wave elastography in brucellosis	49
Promoting research and scholarship in the medical and health humanities in Ireland	43
Addressing iatrophobia in transgender patients	40
Perceptions of academic staff toward the objective structured clinical examination (OSCE) in clinical nursing: Assessment method	38
Laryngopharyngeal reflux induced sleep-related laryngospasm	34
Duration time of labor progression for pregnant women of vaginal birth after cesarean in Hubei, China	32
Correction to: Virtual fracture clinic reduces patient X‑ray volume for common wrist and ankle fractures	31
Hyponatremia as a predictor of outcome and mortality: results from a second-level urban emergency department population	28
Comparison of hip abductor and adductor muscle performance between healthy and osteitis pubis professional footballers	27
The link between serum neuregulin-1 and atherogenic index in type 2 diabetes mellitus	27
Illuminating the path: the role of photodynamic therapy in comprehensive periodontal treatment	27
Dyslipidaemia management in the cardiac rehabilitation clinic of a tertiary referral centre: analysis of the impact of new ESC guidance on LDL-C target achievement	26
Paediatric Escherichia coli urinary tract infection: susceptibility trends and clinical management—a retrospective analysis of a 10-year period	25
Different application procedures of Nd:YAG laser as an adjunct to scaling and root planning in smokers with stage III grade C periodontitis: a single-blind, randomized controlled trial	24
Breast cancer recurrence: factors impacting occurrence and survival	23
The triglycerides and glucose index is highly associated with non-alcoholic fatty liver disease in overweight and obese women	23
Serum soluble α-Klotho levels in patients with diabetic nephropathy	22
Intestinal fatty-acid binding protein as a diagnosis marker in younger with celiac diseases	21
Evaluation of Ireland’s Sugar-Sweetened Beverage Tax (SSBT)	21
Prediction of surgical necessity in children with ureteropelvic junction obstruction using machine learning	21

Digital nerve injury: to repair or not?	21
“Textbook outcome(s)” in colorectal surgery: a systematic review and meta-analysis	21
A national survey of publicly funded chronic pain management services in Ireland	20
The need to maintain skills in both direct and videolaryngoscopy—insights from a national survey of anaesthesia trainees in Ireland	20
Artificial intelligence in medical science: a review	20
Prognostic value of progesterone receptor expression in non-small cell lung cancer tissue	19
Fluid and electrolyte management: increasing the knowledge of House Officers using an interactive eLearning tool	17
Adding eosinophil count to EMERALD rules predicts subarachnoid haemorrhage better in emergency department	17
Pre-vaccination immune response to COVID-19	17
Anatomical variation in the branching pattern of the aortic arch: a literature review	17
Meeting abstracts from the 2020 UCD School of Medicine Summer Student Research Awards (SSRA 2020)	17
Improving the quality of transurethral resection of bladder tumour (TURBT) operative notes following the European Association of Urology guidelines	17
Triple assessment breast clinics: The value of clinical core biopsies	16
A relook at gastroenteropancreatic neuroendocrine tumours as per 2019 WHO classification—A tertiary centre experience	16
Patient information leaflet in the era of digitalisation: a cross-sectional study on patients’ attitudes and practices	16
Early lactate clearance for predicting outcomes in patients with gastrointestinal bleeding	16
Appendicitis-related acute referrals to Children’s Health Ireland from Non-Specialist Paediatric Surgical Centres	15
Diagnostic role of thoracic ultrasound in patients with acute respiratory failure at emergency service	15
The role of unconventional T cells in COVID-19	15
The utility of cemented femoral stems in modern THA: a 10-year comparative analysis of the Charnley and Exeter stems	15
Efficacy, safety, and prognostic factors of drug-eluting beads transarterial chemoembolization using CalliSpheres in treating huge hepatocellular carcinoma patients	14
Competency in trauma surgery: a national survey of trainees and consultants	14
Diet quality, sleep and quality of life in Parkinson’s disease: a cross-sectional study	14
Evaluating the utility of robotic axillary lymph node dissection in patients with invasive breast cancer: a systematic review	14
Systemic methotrexate (MTX) in early pregnancy: a retrospective study of a tertiary maternity hospital	14
Clinical characteristics of two groups commonly referred to an Irish hypertension service—patients with resistant hypertension and young adults with hypertension	14
Mechanism of injury, resource utilisation and outcomes for patients admitted with head injuries under General Surgery	13
Clinical characteristics, diagnosis, and outcomes of orbital biopsies in a single Irish centre	13
How does treadmill training contribute to botulinum toxin application plus routine physical therapy in ambulatory children with spastic bilateral cerebral palsy? A randomized controlled trial	13
“One stop” clinic for upper gastrointestinal cancer—an alternative to “straight to test” referrals?	12
A single-centre prospective cohort study: prone positioning in awake, non-intubated patients with covid-19 hypoxemic failure	12
Prognostic relationship between high sensitivity troponin I level, hematoma volume and glasgow coma score in patients diagnosed with spontaneous intracerebral hemorrhage	12
Correction to: Age‑related volume decrease in subcortical gray matter is a part of healthy brain aging in men	12
Reproductive health services: attitudes and practices of Saudi community pharmacists	12
The impact of the SARS-CoV-2 pandemic on referral characteristics in a national tertiary spinal injuries unit	12
Ascaris lumbricoides and the surgical complications: our experience from Medical College Hospital	12
Evaluation of pain, disease activity, anxiety, depression, and neuropathic pain levels after COVID-19 infection in fibromyalgia patients	12
A scoping review of historical and contemporary management strategies for paediatric scrotal trauma	12
An extremely rare case of hypoglycemia with a novel mutation and review of the literature: fructose-1,6 bisphosphatase deficiency in an adult man	12
Glucometrics utilisation in an urban teaching hospital in ireland: current practice and future aims	12
Survey of consultant psychiatrists about the draft heads of a bill to amend the mental health act	12
Perspectives of educators and students on the efficacy of online teaching and learning strategies employed during COVID-19 in a health sciences institution	12
Application of norepinephrine in the treatment of septic shock: a meta-analysis	12
Long non-coding RNA myocardial infarction associated transcript expression and clinical significance in patients with hypertension during pregnancy	11
The role of data science in healthcare advancements: applications, benefits, and future prospects	11
Clinical, biochemical profile and atherosclerotic cardiovascular risk score (ASCVD) in patients with high HDL cholesterol	11
Improved performance of cementless total knee arthroplasty (TKA)across international registries: a comparative review	11
Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients	11
COVID-19 outbreak impact on emergency trauma visits and trauma surgery in a level 3 trauma center	11
Surgical aspects and controversies in the management of medullary thyroid cancer	11

Uremic pruritus: prevalence, determinants, and its impact on health-related quality of life and sleep in Indian patients undergoing hemodialysis	11
UBA2 promotes the progression of renal cell carcinoma by suppressing the p53 signaling	11
Morbidity and mortality of traumatic cervical spinal cord injuries in a geriatric cohort	11
From preparation to success: assessing the effectiveness of Saudi Pharmacists Licensure Examination (SPLE) preparation strategies in Saudi Arabia	10
Harmful alcohol consumption in elite sports players in Ireland	10
Effects of resistance training on the physical symptoms and functional capacity of patients with fibromyalgia: a systematic review and meta-analysis of randomized clinical trials	10
Anxiety and depression in the first 24 h in COVID-19 patients who underwent non-invasive mechanical ventilation in the intensive care unit	10
Alcohol-related acute medical reviews in an acute hospital before and immediately after the introduction of minimum unit pricing	10
A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease	10
Psychological supports for people living with a rare disease in Ireland: an online survey-based study	10
Challenges and effectiveness of remote neurological follow-up of children with concussion following TBI using telemedicine	10
Irish Roma: a literature review	10
Outcomes from 7 years of a direct to audiology referral pathway	10
Menstrual abnormalities post-COVID vaccination: a cross-sectional study on adult Lebanese women	10
Liraglutide combined with metformin treatment for obese people with type 2 diabetes mellitus: a systematic review and meta-analysis	9
The impact of the COVID-19 pandemic on the performance of the Rapid Access Lung Cancer Clinic	9
Effect of oral naloxone on opioid-induced constipation in methadone maintenance treatment patients, a double-blind, placebo-control, clinical trial	9
Paediatric major trauma: demographics, management and outcomes at Cork University Hospital	9
Hospital mortality and length of stay differences in emergency medical admissions related to ‘on-call’ specialty	9
Breast cancer risk coordinators: Artificial intelligence–based density measurement and Mullerian-inhibiting substance	9
Mediterranean Diet and its Effect on Endothelial Function: A Meta-analysis and Systematic Review	9
Antibody responses after two doses of CoronaVac of the participants with or without the diagnosis of COVID-19	9
Implication of cognitive-behavioral stress management on anxiety, depression, and quality of life in acute myocardial infarction patients after percutaneous coronary intervention: a multicenter, rando	9
Percutaneous image-guided treatment of mucoid degeneration of the ACL in advanced knee osteoarthritis—Preliminary observations	9
Apatinib plus chemotherapy versus chemotherapy alone as neoadjuvant therapy in locally advanced gastric carcinoma patients: a prospective, cohort study	9
Second-trimester miscarriage: a review of postnatal investigations and subsequent pregnancy outcomes	9
Child protection concern in patients during the COVID-19 lockdown	9
Cross-sectional analysis of coding, patient characteristics, consultation frequency and pharmacological treatment of adults with severe mental disorders in Irish general practice	9
The impact of SGLT 2 inhibitors: Heart failure and beyond	9
Observations on local interventions for colorectal cancer metastases to liver and lung	9
Diagnostic accuracy of CT enterography correlated to histopathology in the diagnosis of small bowel Crohnʼs disease	8
Clinical outcomes at medium-term follow-up of sub-acromial balloon spacer insertion in the operative management of massive rotator cuff tears	8
The effectiveness of virtual reality simulation as learning strategy in the acquisition of medical skills in nursing education: a systematic review	8
A prospective study of wake-up stroke patients presenting to the emergency department: a single-center cohort study	8
Recurrence rates of periocular basal cell carcinoma following intra-operative en-face frozen section margin controlled excision	8
Prevalence and factors influencing slow gait speed among geriatric patients at outpatient clinic of a tertiary care hospital	8
The reliability and validity of the 3-m backward walk test in people with Parkinson’s disease	8
Quantitative but not qualitative flavor recognition impairments in COVID-19 patients	8
A preliminary prospective observational study of the effectiveness of high-concentration capsaicin cutaneous patch in the management of chronic post-surgical neuropathic pain	8
Factors influencing accidental food allergic reactions in schools and preschools	8
Comparative evaluation of microleakage of four restorative materials using confocal laser scanning microscopy: an in vitro study	8
A systematic review and meta-analysis assessing the use of tranexamic acid (TXA) in acute gastrointestinal bleeding	8
Persistence of inadequate consent training for interns	8
A case series of successfully managing exomphalos major with awake graduated compression dressing and early enteral feeding	8
Correction to: Child protection concern in patients during the COVID‑19 lockdown	8
The clinical significance and burden of thyroid nodules discovered incidentally	8
CRP/albumin, Glasgow prognostic score, and prognostic nutritional index as a predictor of mortality among delirium patients	8
Retinal ultrastructural, electrophysiological, and microvascular morphological outcomes in diabetic macular edema treated with intravitreal bevacizumab	8
Knowledge, attitudes and practices of Irish doctors regarding stop smoking care and electronic cigarettes	8
Burden of anxiety and depression among hospitalized patients with irritable bowel syndrome: a nationwide analysis	8
Impact of antidepressant use on post-operative weight loss following bariatric surgery	8
Prone positioning for mechanically ventilated patients with coronavirus disease 2019: the experience of an Irish regional hospital intensive care unit	7
A new radiographic classification of fifth distal metacarpal fractures	7
Ultrasound-guided vs. laparoscopic-guided transversus abdominis plane block for postoperative pain following laparoscopic cholecystectomy: a systematic review and meta-analysis	7
Management of appendiceal neuroendocrine tumors in the light of new guidelines	7
Long-term renal function following radical cystectomy and ileal conduit creation	7
Using menopausal hormone therapy after a cancer diagnosis in Ireland	7
Efficacy of different routes of vitamin B12 supplementation for the treatment of patients with vitamin B12 deficiency: A systematic review and network meta-analysis	7
Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting	7
Correlation between maternal and infant vitamin B12 levels in severe malnutrition in infants under 6 months	7
Serum levels of mu-opioid receptor according to menstrual cycle phases are associated with postoperative pain and opioid consumption in laparoscopic gynecological surgeries: a prospective observationa	7
Virtual triaging in an eye emergency department during the COVID-19 pandemic	7
Hyponatremia and malnutrition: a comprehensive review	7
An evaluation of the effectiveness of induction programmes on foundation doctor preparedness: a rapid review of the literature	7
Association between lipocalin-2 levels and diabetic retinopathy in patients with overweight/obese type 2 diabetes mellitus	7
Two-scale assessment of anxiety and depression in postoperative non-small cell lung cancer patients: their prevalence, risk factors, and prognostic potency	7
Investigation of the effect of Ramadan fasting on serum levels of melatonin, cortisol, and serotonin: the case of Turkey	7
Do patients with larger body sizes undergo more CT exams?	7
Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A THESIS questionnaire survey of members of the Irish Endocrine Society	7
Compulsory vaccination against COVID-19: a legal and ethical perspective on public good versus personal reticence	7
Factors influencing burnout in millennial medical students during the COVID-19 pandemic!	7
Recurrent sclerosing cholangitis post-transplant: increased recurrence rates following re-transplantation	7
An evaluation of the utilisation of biosimilar monoclonal antibody drugs in Ireland and barriers to their usage	7
Correction to: Implementation of an on‑site simulation programme during COVID‑19 and the assessment of its impact on medical students’ competence	7
Persistent pruritus following COVID-19 vaccination	7
Risk factors of in-hospital mortality for isolated on-pump coronary artery bypass graft surgery in the northeast of Iran from 2007 to 2016	7
Early detection and treatment device for diabetic foot neuropathy	7
Correction to: The effect of video exercise‑based telerehabilitation on clinical outcomes, expectation, satisfaction, and motivation in patients with chronic low back pain	6
Value of serum free prostate-specific antigen density in the diagnosis of prostate cancer	6
Kidney function estimation equations: a narrative review	6

Single-surgeon perspective: is there ever a need to open extension-type supracondylar fractures?	6
COVID-19 vaccination uptake and hesitancy reasons in food production workers	6
Hepatitis C community prevalence is over-estimated: a prospective, birth cohort study	6
Real-world outcomes of continuous glucose monitoring in adults with diabetes mellitus attending an Irish tertiary hospital	6
Impact of USMLE Step 1 transition to pass/fail scoring system on medical students’ anxiety, sleep quality, and burnout	6
Aberrant expression of WNK lysine deficient protein kinase 1 is associated with poor prognosis of colon adenocarcinoma	6
Synchronous and asynchronous remote core stability exercises in patients with axial spondyloarthritis: a randomized-controlled clinical trial	6
A single-center audit of a novel tonsil long-waiter outpatient clinic	6
PCR vs karyotype for CVS and amniocentesis—the experience at one tertiary fetal medicine unit	6
Documentation of chaperone presence in breast clinic, a complete audit cycle	6
Inquiries/comments about a patient with adrenaline-triggered mid-ventricular Takotsubo syndrome	6
Transition to telehealth	6
Dedicated orthopaedic elective unit: our experience from a district general hospital	6
Tumor keratin 15 expression links with less extent of invasion and better prognosis in papillary thyroid cancer patients receiving tumor resection	6
Dermatological disease prediction and diagnosis system using deep learning	6
Letter to the editor regarding penicillin allergy de-labelling in Ireland	6
The role of thiol-disulfide homeostasis and ischemia-modified albumin in osteosarcopenia	6
Serum free prostate-specific antigen density (fPSAD) as a predictor of prostate cancer: a new parameter worthy of attention	6
Diagnostic value of pseudocapsule ring hyperenhancement in contrast-enhanced ultrasound in renal focal lesions	6
The GLVC scoring system: a single-center model for predicting survival and hospitalization in patients with heart failure	6
Correction to: The bowel and beyond: extracolonic findings from CT colonography	6
PHLPP and LAMP2 predict favorable treatment response and survival in multiple myeloma patients who receive induction treatment with bortezomib	6
Correction to: Predictors of improvement in resting heart rate after exercise training in patients with chronic obstructive pulmonary disease	6
Barriers to attendance at a tertiary hospital’s perinatal mortality meeting	6
Palliative care in a Graduate Entry Medical Curriculum: exploring students’ attitudes on the importance of receiving teaching in palliative care	6
Breaking barriers: exploring physiotherapists’ willingness and challenges in embracing telerehabilitation in a developing country	6
Trainees’ perceptions of course quality in postgraduate General Practice training in Ireland	6
Toxoplasma gondii vaccine candidates: a concise review	6
A new neuromodulation method in chronic migraine; non-ınvasive pulsed radiofrequency, a single-blinded, randomised, controlled trial	6
The effect of indicators of CALLY index on survival in glioblastoma	6
Short-term, nonsurgical periodontal therapy boosts interleukin-12 levels and reduces oral cancer risk	6
Letter to the editor – simultaneous bilateral total hip arthroplasty survey	6
Factors Affecting COVID-19-Related Fear and Burnout in Surgical Nurses	5
Outcomes and patient perspectives of a novel virtual spinal referral pathway in a non-specialist centre	5
A retrospective analysis of infantile haemangioma referrals: a comparison with the IH European Task Force ‘Infantile Haemangioma Referral Score’	5
CCT6A promotes esophageal squamous cell carcinoma cell proliferation, invasion and epithelial-mesenchymal transition by activating TGF-β/Smad/c-Myc pathway	5
A large outbreak of the Kappa mutation of COVID-19 in Cork, Ireland, April–May 2021	5
Expanded central role of the respiratory physiotherapists in the community setting	5
‘Closing the loop’: re-audit of the diagnosis and management of vitamin B12 deficiency in general practice	5
Letter to the editor about the article: “The psychological impact of COVID-19 on ear, nose and throat (ENT) specialists”	5
Sotagliflozin: an insight into the first dual SGLT inhibitor now approved for heart failure	5
The effect of iron deficiency anaemia treatment on mean platelet volume	5
Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland	5
COVID-19-related mortality in cancer patients in an Irish setting	5
Symptomatic and asymptomatic pontine hyperintensities: are they central pontine myelinolysis? Case series	5
Real-life experience: sensitivity and specificity of nasal and saliva samples for COVID-19 diagnosis	5
Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment caesarean section: a randomised controlled study	5
Virtual recovery: efficacy of telerehabilitation on dyspnea, pain, and functional capacity in post-COVID-19 syndrome	5
Role of apalutamide in the treatment landscape for patients with advanced prostate cancer: an expert opinion statement of European clinical practice	5
Survey of Laboratory Medicine’s national response to the HSE cyberattack in the Republic of Ireland	5
A radiographic analysis of humerus shaft fractures to predict non-union	5
Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm	5
Study of prevalence, risk factors for acute kidney injury, and mortality in liver cirrhosis patients	5
A case series of musical hallucinations in psychiatry of old age—in search of the sound of silence	5
Audit of outcomes following attendance at the City West drive-through IOP glaucoma clinic during the COVID-19 pandemic	5
Evaluation of diagnostic efficiency of bedside cardiac ultrasonography performed by emergency specialist	5
Knowledge and practice of foot self-care behaviours in Irish diabetes patients with high-risk feet	5
Functional and patient reported outcomes of Pyrocardan implants for carpometacarpal osteoarthritis	5
Text generative artificial intelligence tools for clinical applications: scope and concerns	5
Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes	5
Design and initial testing of a novel disposable oscillating positive expiratory pressure device	5
The prognostic value of the derived neutrophil-to-lymphocyte ratio (dNLR) in patients treated with immune checkpoint inhibitors	5
No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-c	5
Comparison of national early warning score-2 and qSOFA in predicting the prognosis of older adults with altered mental status	5
MRI findings in atraumatic shoulder pain—patterns of disease correlated with age and gender	5
‘Out of hours’ orthopaedics in an Irish regional trauma unit and the impact of COVID-19	5
THRIVE, ASTRAL, and iScore scales for predicting prognosis of mechanical thrombectomy in patients with acute ischemic stroke	5
Effect of calcium and vitamin D supplementation on the clinical, hormonal, and metabolic profile in non-obese women with polycystic ovary syndrome	5
Maximal exercise outcomes with a face mask: the effects of gender and age differences on cardiorespiratory responses	5
Syndesmotic injury with ankle fracture: A systematic review of screw vs dynamic fixation	5
Ending tuberculosis: the cost of missing the World Health Organization target in a low-incidence country	5
Evaluation of the ischemia modified albumin levels in familial Mediterranean fever patients	5
The impact of ketogenic diet on drug-resistant epilepsy in children: A comprehensive review and meta-analysis	5
Postoperative survival after lumbar instrumented surgery for metastatic spinal tumors: a nationwide population-based cohort analysis	5
The effects of the renin–angiotensin–aldosterone system blockers on serum ischemia-modified albumin levels in autosomal dominant polycystic kidney disease	5
The effect of COVID-19 on fear, anxiety, and sleep in nursing students	5
The reliability and validity of the balance tests in hearing-impaired athletes	5
The interplay of long noncoding RNA HULC with microRNA-128-3p and their correlations with lipid level, stenosis degree, inflammatory cytokines, and cell adhesion molecules in coronary heart disease pa	5
The cost of rejection: an internal audit of the clinical genetics service active triage pathway at CHI Crumlin, Ireland	5
Measuring and monitoring patient safety in hospitals in the Republic of Ireland	5
The therapeutic effect of co-administration of pentoxifylline and zinc in men with idiopathic infertility	5
Medical fitness to drive, emergency service vehicles and crash risk	5
Letter to the editor: “Effect of an early occupational therapy intervention on length of stay in moderate and severe traumatic brain injury patients”	4
JKAP, Th1 cells, and Th17 cells are dysregulated and inter-correlated, among them JKAP and Th17 cells relate to cognitive impairment progression in Alzheimer’s disease patients	4
Impacts of gait freeze on quality of life in Parkinson’s disease, from the perspectives of patients and their carers	4
Alcohol branding during rugby union matches in Ireland after commencement of Sect. 15 from the Public Health (Alcohol) Act: a frequency analysis of highlights from the European Rugby Champions Cup and	4
The role of the physician associate: an overview	4
How can physical activity promotion be optimised in general practice: a narrative review of the literature	4
There is an association between gastro-oesophageal reflux and cow’s milk protein intolerance	4
Patient–healthcare provider communication and age-related hearing loss: a qualitative study of patients’ perspectives	4
The effect of video exercise-based telerehabilitation on clinical outcomes, expectation, satisfaction, and motivation in patients with chronic low back pain	4
Correction to: Specialist cancer hospital‑based smoking cessation service provision in Ireland	4
CTRIAL-IE (ICORG) 15–34: The impact of the 21 gene breast recurrence score® assay on chemotherapy prescribing in oestrogen receptor positive, lymph node positive early stage breast cancer in Ireland	4
The use of radiomic analysis of magnetic resonance imaging findings in predicting features of early osteoarthritis of the knee—a systematic review and meta-analysis	4
Roles of ghrelin, hepcidin and HIF-2α in iron metabolism in iron deficiency anemia	4