Professional Documents
Culture Documents
TITLE
INVESTIGATOR:
DR.SHARMIN AKTER,
MD (Internal Medicine)
GUIDE:
DR. SHOMAN SARKER,
Associate Professor,
MBBS, MD (Medicine),
Department of Medicine,
Chittagong Medical College
To
The Principal
Chittagong Medical College
Chattogram.
Subject: Application for the approval of Thesis Protocol with the title, “Microalbuminuria
as a Prognostic Marker in Patients with Acute Ischemic Stroke admitted to a Tertiary
Hospital in Bangladesh”
Sir,
With due respect and humble submission, I would like to state that I am a student of MD
residency (Internal Medicine), Phase-B at BSMMU, Dhaka. As per requirement of the
course, I would like to perform my research work on the thesis with the above-mentionedtitle
under the direct supervision of Dr. Shoman Sarker, Associate Professor, Department of
Medicine, Chittagong Medical College and Hospital, Chattogram, Bangladesh.
I therefore, like to request you to approve my protocol so that I can commence my work in
your esteemed institute to complete my thesis in due time.
Obediently Yours
3. Category : Government
7. Any collaboration : No
Department of Medicine,
Chattogram, Bangladesh
10. Name of the Co-Guide : Dr. Rabiul Alom, Assistant Professor, Department
1. Summary : Attached
I agree to obtain approval of the Ethical Review Committee for any changes involving the
rights and welfare of subjects or any changes of the methodology before making any such
changes.
…………………………………
Principal investigator/Student
Forwarded by
………………………………
Guide
…………………………..
Signature of the Student
PART-C
Globally, stroke remains the second-leading cause of death and the third-leading
cause of death and disability combined. From 1990 to 2019, the burden increased
substantially (70.0% increase in incident strokes, 43.0% deaths from stroke, 102.0%
prevalent strokes, and 143.0% DALYs), with the bulk of the global stroke burden
(86.0% of deaths and 89.0% of DALYs) residing in lower-income and lower-middle-
income countries (LMIC) (Feigin et al., 2022). According to the latest WHO data
published in 2020 Stroke Deaths in Bangladesh reached 134,166 or 18.74% of total
deaths (World Health Ranking 2020) keeping it at the top of the list of ‘leading causes
of death in Bangladesh’.A recent prevalence survey on stroke conducted throughout
the Bangladesh from a representative sample of the populationrevealed a high burden
of stroke with an overall prevalence of 11.39 per 1000 adult population, which is
higher than other LIMCs (5.36 to 10.40 per thousand) (Mondal et al., 2022). Stroke is
the most common condition among neurology in-patients (48%) and out-patients
(24%) of Bangladesh (Chowdhury et al., 2014; Uddin et al., 2018). It places a
tremendous burden on health resources in Bangladesh. Timely intervention can
dramatically improve outcome and reduce disability.
One third of ischemic stroke patients will die within some months after the stroke or
its complications. Approximately half of ischemic stroke survivors remain disabled,
and 20% require institutionalization (Benjamin et al. 2018; Kim et al. 2020).
Exploring the key prognostic factors is crucial for clinicians to design the treatments
accordingly and improve the clinical outcomes of stroke patients.The baseline
ischemic stroke severity as measured using the National Institutes of Health Stroke
Scale (NIHSS) (Brott et al. 1989) and disability as measured using the modified
Rankin score (mRS) (Van Swieten et al., 1988) have been used as clinical predictors
of ischemic stroke outcome. NIHSS scores were more useful in predicting functional
short-term outcome after ischemic stroke onset than laboratory biomarkers reflecting
different pathophysiological mechanisms involved in ischemic stroke (Ozkan et al.
2013).
Over the last 4 decades, several prospective clinical studies have identified a series of
independent risk factors for stroke. One such emerging vascular risk factor is
microalbuminuria (Lee et al., 2010). The term “microalbuminuria” denotes an
increase in albumin excretion that remains below the lower limits of sensitivity for
routine diagnostic methods and defined as a urine albumin:creatinine ratio (ACR)
within the specific range of 30–300 mg/g (Viberti et al., 1982). Microalbuminuria was
originally introduced to clinical practice as a marker for incipient diabetic
nephropathy. In the past decade the role of microalbuminuria has become apparent in
acute diseases such as myocardial infarction and stroke (Rocco et al., 2010).
3.1 Research question: Does microalbuminuria has any prognostic utility for the
prediction of outcome among patients with ischemic stroke admitted to a tertiary-
level hospital in Bangladesh?
4. Objectives:
5.4. Study population: Adult patients admitted to this hospital with a diagnosis of
ischemic stroke during the study period.
Ischemic stroke: In the study ischemic stroke will be defined as the cases having
radiological findings of ischemia on CT scan of brain.
The severity of the stroke will be assessed by NIHS Scale. The patient will be
followed up clinically during hospital stay days. Clinical follow-up will be given to
record the severity of the stroke and the deterioration of clinical parameters.
Immediate hospital outcomes will be recorded on the day of discharge. On the 90th
day, a visit by the patient to the follow-up clinic or research physician will visit the
patient to document the patient’s outcome with a mRS.
Data will be recorded in the form of Excel worksheet. After completion of data
collection, they will be fed into SPSS for processing analysis. Continuous data will be
expressed as mean ± standard deviation (SD) for normally distributed data ormedian
and 25%–75% interquartile range for non-normally distributed data. Categorical
variables will be presented as frequency (percentages) or proportions. Study
population will be divided into good and poor outcome groups. Between these groups,
continuous and categorical variables will be analyzed. Student's t-test will be used to
analyze normally distributed continuous variables, while Mann–Whitney U-test will
be used for non-normally distributed continuous variables. Categorical variables will
be compared by means of Chi-square test. Correlations will be determined using
Pearson or Spearman correlation. Multivariate analysis will be performed by binary
logistic regression analysis, which allows adjustment for confounding factors (age, the
NIHSS score, infarct volume, stroke syndrome, vascular risk factors, and other
laboratory biomarkers). Results will be expressed as adjusted odds ratios (OR) with
the corresponding 95% confidence intervals (CIs). Receiver operating characteristic
(ROC) curves will be utilized to evaluate the accuracy of microalbuminuria to predict
outcomes. All statistical analysis will be performed with SPSS for Windows, version
26.0 (SPSS IBM, USA). Statistical significance will be defined as p<0.05.
6. Utilization of result:The results of the study would be utilized for the clinical
decision making for the hospitalized patients with acute ischemic stroke. Based on the
study findings, future interventional study could be conducted at the study site.
Overall, the study results would increase the awareness of the clinicians of
Bangladesh for If predictors of early outcomes can be recognized and appropriately
managed, initial worsening can be prevented, and long-term outcome improved. That
will surely reduce the huge burden of disability due to ischemic stroke.
7. Dissemination:
Benjamin, E.J., Virani, S.S., Callaway, C.W., Chamberlain, A.M., Chang, A.R.,
Cheng, S., Chiuve, S.E., Cushman, M., Delling, F.N., Deo, R. and de Ferranti, S.D.,
2018. Heart disease and stroke statistics—2018 update: a report from the American
Heart Association. Circulation, 137(12), pp.e67-e492.
Blanco, M., Rodríguez-Yáñez, M., Sobrino, T., Leira, R. and Castillo, J., 2005.
Platelets, inflammation, and atherothrombotic neurovascular disease: the role of
endothelial dysfunction. Cerebrovascular diseases, 20(Suppl. 2), pp.32-39.
Bondy, S.J., Victor, J.C. and Diemert, L.M., 2009. Origin and use of the 100 cigarette
criterion in tobacco surveys. Tobacco control, 18(4), pp.317-323.
Brott, T., Adams Jr, H.P., Olinger, C.P., Marler, J.R., Barsan, W.G., Biller, J., Spilker,
J., Holleran, R., Eberle, R. and Hertzberg, V., 1989. Measurements of acute cerebral
infarction: a clinical examination scale. Stroke, 20(7), pp.864-870.
Cho, B.H., Kim, J.T., Chang, J., Choi, K.H., Nam, T.S., Choi, S.M., Lee, S.H., Park,
M.S., Kim, B.C., Kim, M.K. and Cho, K.H., 2012. Early clinical implications of
microalbuminuria in patients with acute ischaemic stroke. Postgraduate medical
journal, 88(1045), pp.632-638.
Chowdhury, J., Sultana, N., Ahmed, S., Rahman, M.M., Akter, M. and Rafique, T.,
2012. Microalbuminuria as a predictor of short-term mortality in acute ischemic
stroke. Bangladesh Journal of Medical Biochemistry, 5(1), pp.16-19.
Chowdhury, R.N., Hasan, A.T.M., Rahman, Y.U., Khan, S.I., Hussain, A.R. and
Ahsan, S., 2014. Pattern of neurological disease seen among patients admitted in
tertiary care hospital. BMC research notes, 7(1), pp.1-5.
Chudý, P., Kotulicová, D., Staško, J. and Kubisz, P., 2011. The relationship among
TAFI, t-PA, PAI-1 and F1+ 2 in type 2 diabetic patients with normoalbuminuria and
microalbuminuria. Blood Coagulation & Fibrinolysis, 22(6), pp.493-498.
De Bruijne, E.L.E., Gils, A., Guimarães, A.H.C., Dippel, D.W.J., Deckers, J.W., Van
Den Meiracker, A.H., Poldermans, D., Rijken, D.C., Declerck, P.J., De Maat, M.P.M.
and Leebeek, F.W.G., 2009. The role of thrombin activatable fibrinolysis inhibitor in
arterial thrombosis at a young age: the ATTAC study. Journal of Thrombosis and
Haemostasis, 7(6), pp.919-927.
Elyas, S., Shore, A.C., Kingwell, H., Keenan, S., Boxall, L., Stewart, J., James, M.A.
and Strain, W.D., 2016. Microalbuminuria could improve risk stratification in patients
with TIA and minor stroke. Annals of clinical and translational neurology, 3(9),
pp.678-683.
Feigin, V.L., Brainin, M., Norrving, B., Martins, S., Sacco, R.L., Hacke, W., Fisher,
M., Pandian, J. and Lindsay, P., 2022. World Stroke Organization (WSO): global
stroke fact sheet 2022. International Journal of Stroke, 17(1), pp.18-29.
Gumbinger, C., Sykora, M., Diedler, J., Ringleb, P. and Rocco, A., 2012.
Microalbuminuria: A potential prognostic marker for acute stroke. Der
Nervenarzt, 83(10), pp.1357-1360.
Gupta, V.P., Garton, A.L., Sisti, J.A., Christophe, B.R., Lord, A.S., Lewis, A.K.,
Frey, H.P., Claassen, J. and Connolly Jr, E.S., 2017. Prognosticating functional
outcome after intracerebral hemorrhage: the ICHOP score. World neurosurgery, 101,
pp.577-583.
Kim, J., Thayabaranathan, T., Donnan, G.A., Howard, G., Howard, V.J., Rothwell,
P.M., Feigin, V., Norrving, B., Owolabi, M., Pandian, J. and Liu, L., 2020. Global
stroke statistics 2019. International Journal of Stroke, 15(8), pp.819-838.
Lee, M., Saver, J.L., Chang, K.H., Liao, H.W., Chang, S.C. and Ovbiagele, B., 2010.
Impact of microalbuminuria on incident stroke: a meta-analysis. Stroke, 41(11),
pp.2625-2631.
Mondal, M.B.A., Hasan, A.H., Khan, N. and Mohammad, Q.D., 2022. Prevalence and
risk factors of stroke in Bangladesh: A nationwide population-based
survey. Eneurologicalsci, 28, p.100414.
Levey, A.S., Coresh, J., Bolton, K., Culleton, B., Harvey, K.S., Ikizler, T.A., Johnson,
C.A., Kausz, A., Kimmel, P.L., Kusek, J. and Levin, A., 2002. K/DOQI clinical
practice guidelines for chronic kidney disease: evaluation, classification, and
stratification. American Journal of Kidney Diseases, 39(2 SUPPL. 1), pp.S1-266.
Rocco, A., Heerlein, K., Diedler, J., Sykora, M., Barrows, R., Hacke, W. and Steiner,
T., 2010. Microalbuminuria in cerebrovascular disease: a modifiable risk
factor?. International Journal of Stroke, 5(1), pp.30-34.
Uddin, M.S., Al Mamun, A., Asaduzzaman, M.D., Hosn, F., Sufian, M.A., Takeda,
S., Herrera-Calderon, O., Abdel-Daim, M.M., Uddin, G.S., Noor, M.A.A. and Begum,
M.M., 2018. Spectrum of disease and prescription pattern for outpatients with
neurological disorders: an empirical pilot study in Bangladesh. Annals of
Neurosciences, 25(1), pp.25-37.
Umemura, T., Senda, J., Fukami, Y., Mashita, S., Kawamura, T., Sakakibara, T. and
Sobue, G., 2014. Impact of albuminuria on early neurological deterioration and lesion
volume expansion in lenticulostriate small infarcts. Stroke, 45(2), pp.587-590.
Van Swieten, J.C., Koudstaal, P.J., Visser, M.C., Schouten, H.J. and Van Gijn, J.,
1988. Interobserver agreement for the assessment of handicap in stroke
patients. stroke, 19(5), pp.604-607.
Viberti, G.C., Jarrett, R.J. and Keen, H., 1982. Microalbuminuria as prediction of
nephropathy in diabetics. Lancet (London, England), 2(8298), pp.611-611.
Wang, D., Pan, Y., Li, H., Yan, H., Meng, X., Lin, J., Wang, H., Matsushita, K.,
Shlipak, M.G., Zhou, Y. and Wang, Y., 2022. The Association between Baseline and
3-Month Albuminuria and 1-Year Prognosis of Ischemic Stroke. Cerebrovascular
Diseases, 51(1), pp.67-74.
World Health Rankings. 2018, (Online) Retrieved on June 01, 2020, from:
https://www.worldlife expectancy.com/ bangladesh-stroke.
Part E
Budget:
Sl. No. Head of expense
1st instalment
1 Research tools development 10,000/-
2 Office assistance for organizing the materials 5,000/-
Data collection ----
3 Data analysis ----
4 Report composing 30,000/-
5 Printing 5,000/-
6 Stationaries 5,000/-
7 Transport/conveyance -----
8 Miscellaneous -----
Total amount
Appendix-A
A Identification
1 ID no.
5 Contact number
B Demographic information
1 Age …yrs
2 Sex Male=1 Female=2
C Risk factors
1 Smoking Never=0 Ex=1 Current=3
2 Alcohol consumption Never=0 Ex=1 Current=3
3 Hypertension Absent=0 Newly diagnosed=1 Previously
diagnosed=2
4 Diabetes Absent=0 Newly diagnosed=1 Previously
diagnosed=2
5 Ischemic heart diseases Absent=0 Newly diagnosed=1 Previously
diagnosed=2
6 Dyslipidemia Absent=0 Newly diagnosed=1 Previously
diagnosed=2
7 Atrial fibrillation Absent=0 Newly diagnosed=1 Previously
diagnosed=2
8 Generalized Obesity Absent=0 Present=1 (BMI >25.0kgm2
9 Abdominal obesity Absent=0 Present=1 (WtHtR=>0.5)
10 Waist circumference cm
E Investigations findings
1 Hemoglobin ….mg/dl
2 RBS …..mg/dl
3 Serum creatinine ……mg/dl
4 Lipid profile TC= TG= LDL= HDL=
5 ECG
6 Echocardiography
7 Urinary ACR
8 CT Scan of Brain
G Stroke outcome
1 Length of stay in hospital …day
2 In hospital mortality No=0 Yes=1
3 MRS at discharge
4 90-day mortality No=0 Yes=1
5 MRS at 90-day
4. Facial palsy
Ask – or use pantomime to encourage – the 0= Normal
patient to show teeth or raise eyebrows and close 1= Minor paralysis
eyes. Score symmetry of grimace in response to 2= Partial paralysis
noxious stimuli in the poorly responsive or non- 3= Complete paralysis
comprehending patient.
5. Motor Arm
The limb is placed in the appropriate position: 0= No drift
extend the arms (palms down) 90 degrees (if 1= Drift
sitting) or 45 degrees (if supine). Drift is scored if 2= Some effort against gravity
the arm falls before 10 seconds. The aphasic 3= No effort against gravity
patient is encouraged using urgency in the voice 4= No movement
and pantomime, but not noxious stimulation. Each UN Amputation
limb is tested in turn, beginning with the non- 5a. Left arm
paretic arm. 5b. Right arm
6. Motor Leg
The limb is placed in the appropriate position: 0= No drift
hold the leg at 30 degrees (always tested supine). 1= Drift
Drift is scored if the leg falls before 5 seconds. 2= Some effort against gravity
The aphasic patient is encouraged using urgency 3= No effort against gravity
in the voice and pantomime, but not noxious 4= No movement
stimulation. Each limb is tested in turn, beginning UN Amputation
with the non-paretic leg. 5a. Left leg
5b. Right leg
7. Limb atxia
Test with eyes open. The finger-nose-finger and 0= Absent
heel-shin tests are performed on both sides, and 1= Present in one limb
ataxia is scored only if present out of proportion 2= Present in two limbs
to weakness. Ataxia is absent in the patient who UN Amputation
cannot understand or is paralyzed.
8. Sensory
Sensation or grimace to pinprick when tested, or 0= Normal, no sensory loss
withdrawal from noxious stimulus in the obtunded 1= Mild to moderate sensory loss
or aphasic patient. 2= Moderate ot severe sensory loss
9. Best language
The patient is asked to describe what is happening 0= No aphasia, normal
in the attached picture, to name the items on the 1= Mild to moderate aphasia
attached naming sheet and to read from the 2= Severe aphasia
attached list of sentences. 3= Mute or global aphasia
10. Dysarthria
If patient is thought to be normal, an adequate 0= Normal, no dysarthria
sample of speech must be obtained by asking 1= Mild to moderate dysarthria
patient to read or repeat words from the attached 2= Severe dysarthria
list.
11. Extinction and inattention
Sufficient information to identify neglect may be 0= No abnormality
obtained during the prior testing. 1= Visual, tactile, auditory or spatial
2= Profound hemi-inattention
Total:
Appendix B (i)
তথ্যবিিরণী
গবেষণারশিবরানাম:
“বাাংলাদেদেরএকটিিারশেযাশরহাসপাতাদলভশতিএশকউিইদেশিকদরাদকরদরাগীদেরিদযেএকটিপ্রগদ া
শিকিাকিারশহসাদবিাইদরাঅ্োলবুশি ুশরযারভূ শিকািূলোয ।”
ফেনআমাবেঅংিশনবতেলাহবি?
আপশনোআপনারবরাগীবরােবরাবগআক্রান্ত।আমরাএরেমপ্রায়১০০জনবরাগীরউপরএইগবেষণােরশে
।
অংিগ্রহণবেিায়: আমাবেশেঅংিশনবতহবে?
আপশনযশেনাচানতবেআপনাবেঅংিশনবতহবেনা।গবেষণাশুরুহওয়ারপবরআপশনঅংিগ্রহণনােরারো
প্রতযাহারনােরারশিদ্ধান্তশনবতপাবরন।আপশনবোনোরণোড়াবযবোনিময়প্রতযাহারেরবতপাবরন.
এটিআপনারোআপনাররুগীরশচশেৎিাবেপ্রভাশেতেরবেনা।
গবেষণায়অংিশনবতআমারশেশেেযখরচহবে?
এইগবেষণায়অংিগ্রহবণরজনযআপনাবেবোবনাঅথেযয়েরবতহবেনা।এইগবেষণায়অংিবনওয়ারজনয
ি
আপনাবেবোবনাঅথপ্রোনেরাহবেনা।
ি
তবথযরঅশধোর: আমারবোনপ্রশ্নথােবলআশমশেেরবতপাশর?
এইতথযপেটিপড়ারপবরযশেআপনারবোনপ্রশ্নথাবে,
তাহবলঅংিগ্রহণেরবেনশেনাতাশিদ্ধান্তবনওয়ারআবগআপশনআমারগাইডোআমারিাবথআবলাচনাে
রারিুবযাগপাবেন।গবেষণাচলাোলীনিমবয়, আমরাবযবোবনাপ্রবশ্নরউত্তরশেবতওোধযথােে।
আশমঅংিশনবলশেহবে? আপশনযশেশিদ্ধান্তবননবযআপশনঅংিগ্রহণেরবেন,
তাহবলগবেষণািম্পবেিআপনারবযবোনঅশতশরক্তপ্রশ্নথােবতপাবরতাআশমেযাখযােরেএেংআপনাবেি
ম্মশতেমটিপূ
ি রণেরবতেলাহবে।আপশনযশেঅংিশনবতিম্মতহন,
আশমআপনাবেশেেযপ্রশ্নচ্ছজজ্ঞািােরে, শেেযিারীশরেপরীক্ষােরে,
এেংপরীক্ষােরারজনযআপনাররক্তওপ্রস্রােিংগ্রহেরে.
আশমআপনারবরাগএেংশচশেত্িািংক্রান্তিমস্ততথযিংগ্রহেরেএেংহািপাতাবলথাোোলীনিমবয়আপ
নারঅেস্থারপশরশেতিনশলশপেদ্ধেরে.
আপনারবরাবগর৯০শেনঅশতক্রান্তহবলআশমআপনারিারীশরেঅেস্থাপুনরায়পরীক্ষােবরবেখে।হািপা
তাবলরপ্রবিােলএেংিংশিষ্টশচশেৎিেবেরশিদ্ধান্তঅনুযায়ীআপনারশচশেৎিাচলবে।আশমশুধুমােআপ
নাবেপযবেক্ষণেরে।
ি
শনরাপত্তা: অংিবনওয়াশেআমারজনযক্ষশতেরোশেপজ্জনে?
গবেষণাোবজঅংিবনওয়ারবোনশেপেবনই।আপশনঅংিশনবল,
আপনারশচশেত্িারপদ্ধশতপশরেতিনেরাহবেনা।
ফগাপনীয়তা: আমারতবথযরশেহবে?
এইগবেষণায়িংগৃহীততথযগবেষেেতৃে
ি বগাপনীয়থােবে।শুধুমােগবেষণারেলােলউপস্থাপনেরাবয
ফতপাবরোএেটিবেজ্ঞাশনেজানাবলপ্রোশিতহবে।
ি
ফোনিমিযাোপ্রবশ্নরবক্ষবেআশমোরিাবথবযাগাবযাগেরবতপাশর?
Why are we doing this research? Stroke is a highly deadly disease. In addition to
immediate death from this disease, surviving patients have to live with various
disabilities. Many patients become worse after some time of infection. If these
predisposing conditions are known earlier, it is possible to improve the patient's
condition by taking appropriate measures. In this study, we will try to determine
whether albumin excreted in urine is helpful in this case.
You or your patient has had a stroke. We are doing this study on about 100 such
patients. Why am I being asked to participate?
You don't have to participate if you don't want to. You may decide not to participate
or withdraw after the study has begun. You can withdraw at any time without reason.
It will not affect your or your patient's treatment.
There is no cost to you to participate in this study. You will not be paid for
participating in this study. Will it cost me anything to participate in the study?
Right to information: What can I do if I have questions? If you have any questions
after reading this information sheet, you will have the opportunity to discuss them
with my guide or me before deciding whether or not to participate. During the
research, we will also be obliged to answer any questions.
Benefits: What are the benefits of participating in this study? If you decide to
participate, you may not benefit directly, but this research will help future patients.
Protocol ID: - -
Title of the
research:“বাাংলাদেদেরএকটিিারশেযাশরহাসপাতাদলভশতিএশকউিইদেশিকদরাদকরদরাগীদেরিদযেএ
কটিপ্রগদ াশিকিাকিারশহসাদবিাইদরাঅ্োলবুশি ুশরযারভূ শিকািূলোয ।.”
1. I have explained the research’s purpose, procedures, risks, benefits, and details.
2. I have understood my or my patient’s role in the research.
3. I am informed that we may stop participating in this research at any time we wish without
showing any reason and without losing any of my rights as a patient here.
4. I understand that my personal information and medical records will be kept strictly
confidential and used for research purposes only.
5. I agree that my patient or I will voluntarily participate in the research without any
prejudice.
Date: ID No:
Name and address of the Investigator for any further information on the research-
DR. Sharmin Akter,
MD (Internal Medicine) Student, Phase B, Residency,
Department of Medicine, Chittagong Medical College and Hospital.
Cell: 01552674054
সম্মতি পত্র
প্রট োকলআইত িঃ - -
গটেষণোরতেষয়িঃ“”
িোতরখিঃআইত নং
ররোগীরনোমিঃঅংশগ্রহণকোরীরঅতিিোেটকরনোমিঃ
প্রক্রিয়োচলোকোলীনসমটয়আপনোরযতিটকোনপ্রশ্নথোটক,
আপতনটযটকোনসময়িোজোনটিপোটরন।আপনোরআরওতকছুজোনোরথোকটলআপতনতনম্নতলতখি োক্তোটররসো
রথটযোগোটযোগকরটিপোটরন।