A 5-year-old girl is referred to the community paediatrician by her reception class teacher due to concerns about her social interactions and communication. She has excellent rote memory for facts about dinosaurs but does not engage in pretend play with peers. She becomes extremely distressed by changes to routine and insists on wearing the same clothes daily. She has age-appropriate gross motor skills but struggles with pencil control. Her speech is clear but she rarely initiates conversation and does not make eye contact. What is the most likely diagnosis?
Q52
A 3-year-old boy is brought to the emergency department by his mother with a bruise to his forehead. She states he fell from a sofa while playing. Examination reveals a 3cm bruise over the frontal bone, and you also notice multiple small, round, well-demarcated bruises of different colours on his upper back and chest, measuring 1-2cm in diameter. The child appears withdrawn and makes little eye contact. What is the most appropriate immediate action?
Q53
A paediatric registrar is teaching medical students about normal patterns of childhood growth. A parent brings a growth chart showing their 18-month-old child's weight, which has been tracking along the 25th centile since birth but has recently crossed down to just below the 9th centile over the past 6 months. The child is otherwise well, developmentally appropriate, and eating a varied diet. What is the most likely explanation for this growth pattern?
Q54
A health visitor is conducting a 2-year developmental assessment on a toddler. The child can run, kick a ball, and climb stairs holding the rail with two feet per step. She uses 50+ words and combines two words together. During the assessment, the child feeds herself with a spoon but spills frequently. The parents ask when their daughter should be toilet trained. What is the most appropriate response regarding typical toilet training readiness?
Q55
A 10-month-old infant is brought to the GP for routine developmental assessment. The parents report that the baby sits unsupported, passes toys from hand to hand, and responds to their own name. When offered a toy, the infant reaches for it using their whole hand in a palmar grasp. Which developmental milestone would you typically expect to be achieved next?
Q56
A paediatric consultant reviews a complex safeguarding case involving a 7-year-old boy with recurrent hospital admissions for apparent seizures. Video telemetry has not captured electrical seizure activity despite multiple witnessed 'seizures'. The mother is a healthcare professional and provides detailed accounts of severe symptoms. The child is asymptomatic when not with the mother. School reports no concerns. Which feature most strongly supports a diagnosis of fabricated or induced illness (FII)?
Q57
A 11-month-old infant is brought to the GP for developmental review. The parents report the baby can sit unsupported and is starting to pull to stand. She can transfer objects between hands and has a pincer grip. She babbles with tuneful variation ('mama', 'dada' non-specifically). She waves 'bye-bye' and plays peek-a-boo. Birth history was unremarkable. What is the most appropriate action?
Q58
A GP attends a safeguarding training session on emotional abuse and neglect. Which of the following scenarios best exemplifies emotional abuse as the primary safeguarding concern?
Q59
A 35-month-old boy is reviewed in a developmental clinic. He can jump with both feet off the ground, throw a ball overhand, and pedal a tricycle. He can copy a circle and a vertical line. He speaks in 3-4 word sentences that are understood by strangers most of the time. He can use a spoon and fork independently and is dry during the day. What is the most accurate description of this child's developmental status?
Q60
A paediatric registrar is teaching medical students about growth assessment. A 9-year-old boy has had static height measurements on the 2nd centile for the past 3 years. His weight is on the 9th centile. His father's height is on the 10th centile and mother's height is on the 5th centile. Bone age X-ray is concordant with chronological age. What is the most likely diagnosis?
Growth, Development & Safeguarding UK Medical PG Practice Questions and MCQs
Question 51: A 5-year-old girl is referred to the community paediatrician by her reception class teacher due to concerns about her social interactions and communication. She has excellent rote memory for facts about dinosaurs but does not engage in pretend play with peers. She becomes extremely distressed by changes to routine and insists on wearing the same clothes daily. She has age-appropriate gross motor skills but struggles with pencil control. Her speech is clear but she rarely initiates conversation and does not make eye contact. What is the most likely diagnosis?
A. Attention deficit hyperactivity disorder
B. Autism spectrum disorder (Correct Answer)
C. Developmental language disorder
D. Developmental coordination disorder
E. Attachment disorder secondary to neglect
Explanation: ***Autism spectrum disorder***
- Characterized by persistent deficits in **social communication** and **social interaction**, such as lacking **pretend play**, poor **eye contact**, and difficulty initiating social conversations.
- Includes restricted, repetitive patterns of behavior, such as a **highly fixed interest** (dinosaurs), **insistence on sameness**, and extreme distress over changes in routine.
*Attention deficit hyperactivity disorder*
- Primarily presents with persistent patterns of **inattention**, **hyperactivity**, and **impulsivity** that interfere with functioning.
- Does not typically involve the core deficits in **social reciprocity** or the rigid **repetitive behaviors** seen in this patient.
*Developmental language disorder*
- Characterized by significant difficulties in **acquiring and using language** despite adequate intelligence and sensory abilities.
- This patient has **clear speech** and age-appropriate vocabulary, which makes a primary language disorder unlikely.
*Developmental coordination disorder*
- Defined by impaired **motor coordination** (like poor pencil control) that interferes with daily living and is below developmental expectations.
- While fine motor issues can co-occur with other conditions, this child's primary deficits are **socio-communicative**, which point toward a broader developmental diagnosis.
*Attachment disorder secondary to neglect*
- Involves patterns of **disturbed social relatedness** (either inhibited or indiscriminate) arising from inadequate caregiving or **neglect**.
- Typically presents with emotional dysregulation and lacks the specific **repetitive behaviors** or intense **rote-memory interests** seen in ASD.
Question 52: A 3-year-old boy is brought to the emergency department by his mother with a bruise to his forehead. She states he fell from a sofa while playing. Examination reveals a 3cm bruise over the frontal bone, and you also notice multiple small, round, well-demarcated bruises of different colours on his upper back and chest, measuring 1-2cm in diameter. The child appears withdrawn and makes little eye contact. What is the most appropriate immediate action?
A. Document findings and arrange outpatient paediatric follow-up in 2 weeks
B. Reassure the mother that bruising is common in active toddlers and discharge
C. Request clotting studies and full blood count to exclude bleeding disorder
D. Contact the safeguarding team and document concerns about non-accidental injury (Correct Answer)
E. Arrange an urgent skeletal survey and CT head before involving social services
Explanation: ***Contact the safeguarding team and document concerns about non-accidental injury***
- The presence of **multiple bruises of different colors and ages** on **protected areas** like the **upper back and chest**, inconsistent with the reported fall, is highly suspicious for **non-accidental injury (NAI)**.
- The child's **withdrawn appearance** and **lack of eye contact** are behavioral indicators often associated with abuse, making immediate **safeguarding team involvement** crucial.
*Document findings and arrange outpatient paediatric follow-up in 2 weeks*
- Delaying action for two weeks in a case with strong suspicion of NAI is unacceptable and places the child at **continued risk of harm**.
- **Suspected child abuse** requires an **immediate and urgent response** to ensure the child's safety, not a routine outpatient appointment.
*Reassure the mother that bruising is common in active toddlers and discharge*
- While bruising is common in active toddlers, it typically occurs over **bony prominences** (e.g., shins, knees) and is usually consistent with the reported mechanism.
- Discharging the child without addressing the significant **red flags** (bruise pattern, location, different ages, child's behavior) would be a severe **breach of duty of care**.
*Request clotting studies and full blood count to exclude bleeding disorder*
- Although medical causes of bruising should be considered, the **pattern, location on protected areas**, and presence of **bruises of different ages** are highly suggestive of NAI, not typically explained by a primary bleeding disorder.
- While relevant tests may be part of a comprehensive assessment, they should not delay the **immediate safeguarding referral**, which is the priority.
*Arrange an urgent skeletal survey and CT head before involving social services*
- **Skeletal surveys** and **CT heads** are important investigations in the workup of NAI to identify occult injuries.
- However, the involvement of the **safeguarding team** (which includes social services) should occur **concurrently** with or even precede these extensive medical investigations to coordinate care and ensure child protection effectively.
Question 53: A paediatric registrar is teaching medical students about normal patterns of childhood growth. A parent brings a growth chart showing their 18-month-old child's weight, which has been tracking along the 25th centile since birth but has recently crossed down to just below the 9th centile over the past 6 months. The child is otherwise well, developmentally appropriate, and eating a varied diet. What is the most likely explanation for this growth pattern?
A. Coeliac disease causing malabsorption
B. Constitutional delay of growth and puberty
C. Normal centile shift as the child finds their genetic trajectory (Correct Answer)
D. Neglect with inadequate nutritional provision
E. Growth hormone deficiency requiring investigation
Explanation: ***Normal centile shift as the child finds their genetic trajectory***
- In the first **2-3 years** of life, it is common for children to cross centiles as their growth shifts from being influenced by **maternal/intrauterine factors** to their **genetic potential**.
- Since the child is **clinically well**, developmentally on track, and the shift is mild (dropping less than two major centile spaces), this is considered a **physiological adjustment**.
*Coeliac disease causing malabsorption*
- This typically presents with **gastrointestinal symptoms** such as bloating, diarrhea, or irritability following the introduction of gluten.
- Failure to thrive in **Coeliac disease** usually involves more significant weight loss and often affects linear growth as well.
*Constitutional delay of growth and puberty*
- This condition typically presents in **late childhood or adolescence** with delayed bone age and late onset of puberty.
- It primarily affects **height trajectory** rather than isolated weight shifting in an 18-month-old.
*Neglect with inadequate nutritional provision*
- While crossing centiles can be a sign of **non-organic failure to thrive**, the child is described as having a **varied diet** and being developmentally appropriate.
- Professional assessment would look for other **safeguarding red flags** or signs of poor bonding, which are absent in this clinical vignette.
*Growth hormone deficiency requiring investigation*
- **Growth hormone deficiency** predominantly results in a decline in **height velocity** rather than a primary drop in the weight centile.
- Children with this condition often maintain their weight or appear relatively **chubby** because weight is preserved while linear growth slows down.
Question 54: A health visitor is conducting a 2-year developmental assessment on a toddler. The child can run, kick a ball, and climb stairs holding the rail with two feet per step. She uses 50+ words and combines two words together. During the assessment, the child feeds herself with a spoon but spills frequently. The parents ask when their daughter should be toilet trained. What is the most appropriate response regarding typical toilet training readiness?
A. Toilet training should begin immediately as motor skills are adequate
B. Most children achieve daytime bowel and bladder control by 3-4 years of age (Correct Answer)
C. Toilet training readiness typically begins at 18 months when walking is established
D. Children should be fully toilet trained by 2 years to prevent developmental delay
E. Toilet training should wait until the child can speak in 3-word sentences
Explanation: ***Most children achieve daytime bowel and bladder control by 3-4 years of age***
- While the physiological ability to control **sphincters** begins earlier, the consistent achievement of **daytime continence** usually falls within the 3 to 4-year range.
- This child is showing normal **2-year-old development** (running, 2-word phrases), and parents should be reassured that control is a progressive milestone rather than an immediate expectation.
*Toilet training should begin immediately as motor skills are adequate*
- Motor skills like walking and sitting are only one part of readiness; **behavioral and cognitive readiness**, such as following instructions and desire to please, are also required.
- Forcing training solely based on physical ability can lead to **power struggles**, constipation, or regression.
*Toilet training readiness typically begins at 18 months when walking is established*
- Although some children show interest at **18 months**, many do not demonstrate the necessary **neurological maturity** or awareness of a full bladder until later.
- Walking is a prerequisite but not the primary trigger; signs of **readiness** include remaining dry for two hours and a developmental ability to communicate needs.
*Children should be fully toilet trained by 2 years to prevent developmental delay*
- Not being trained by age 2 is **not a sign of developmental delay**; the timing of toilet training is influenced by cultural, social, and individual physiological factors.
- Pressuring a child before they are ready can lead to **stool withholding** and chronic **constipation**.
*Toilet training should wait until the child can speak in 3-word sentences*
- While **communication skills** are vital for telling a caregiver they need to go, the specific milestone of 3-word sentences (usually 3 years) is not a strict requirement.
- Toddlers can often initiate training using single words or **gestures** to indicate a soiled diaper, which are already present in this child's repertoire.
Question 55: A 10-month-old infant is brought to the GP for routine developmental assessment. The parents report that the baby sits unsupported, passes toys from hand to hand, and responds to their own name. When offered a toy, the infant reaches for it using their whole hand in a palmar grasp. Which developmental milestone would you typically expect to be achieved next?
A. Mature pincer grasp with thumb and index finger (Correct Answer)
B. Walking independently without support
C. Speaking first recognisable words with meaning
D. Scribbling spontaneously with a crayon
E. Building a tower of two cubes
Explanation: ***Mature pincer grasp with thumb and index finger***
- Fine motor development progresses from a **palmar grasp** (around 6 months) to an **immature pincer grasp** (around 9 months) and finally to a **mature pincer grasp** by 10-12 months.
- The 10-month-old infant in the scenario is currently using a whole-hand **palmar grasp**, making the refinement to **thumb-index finger pincer grasp** the next expected developmental step.
*Walking independently without support*
- **Independent walking** is a gross motor milestone usually achieved later, typically between 12 and 15 months of age.
- At 10 months, infants are more likely to be **cruising** (walking while holding onto furniture) rather than walking independently.
*Speaking first recognisable words with meaning*
- While infants begin **polysyllabic babbling** around 7-9 months, the first **specific, meaningful words** (like "Mama" or "Dada") usually emerge around 12 months.
- This is a **language milestone** that typically follows the development of more refined fine motor skills and babbling.
*Scribbling spontaneously with a crayon*
- The ability to **scribble spontaneously** with a crayon is a more advanced fine motor and cognitive skill, commonly achieved around 15-18 months.
- This requires significant **hand-eye coordination** and fine motor control that is beyond a typical 10-month-old's capability.
*Building a tower of two cubes*
- Constructing a **tower of two blocks** is a fine motor milestone typically observed between 15 and 18 months of age.
- This skill requires the prior development of **voluntary release** of objects, which itself follows the mastery of grasping techniques like the pincer grasp.
Question 56: A paediatric consultant reviews a complex safeguarding case involving a 7-year-old boy with recurrent hospital admissions for apparent seizures. Video telemetry has not captured electrical seizure activity despite multiple witnessed 'seizures'. The mother is a healthcare professional and provides detailed accounts of severe symptoms. The child is asymptomatic when not with the mother. School reports no concerns. Which feature most strongly supports a diagnosis of fabricated or induced illness (FII)?
A. The mother's healthcare background providing detailed symptom descriptions
B. Discrepancy between reported symptoms and objective clinical findings with symptoms only in mother's presence (Correct Answer)
C. Multiple hospital admissions for the same complaint
D. Normal behaviour and health reported by the school
E. Negative video telemetry not capturing seizure activity
Explanation: ***Discrepancy between reported symptoms and objective clinical findings with symptoms only in mother's presence*** - A primary indicator of **Fabricated or Induced Illness (FII)** is a marked **discrepancy** between the caregiver's reports of severe symptoms and objective clinical observations, particularly when symptoms cease in the caregiver's absence or in a neutral environment like **school**. - The finding that **video telemetry** captured no electrical seizure activity, coupled with the child being asymptomatic away from the mother, strongly points towards a non-organic cause or deliberate fabrication of illness. *The mother's healthcare background providing detailed symptom descriptions* - While a **healthcare background** in the caregiver can facilitate the fabrication of convincing symptoms due to medical knowledge, it is not diagnostic of **FII** in isolation. - Many parents of children with **complex medical needs** acquire detailed knowledge about their child's condition and symptoms without any malicious intent. *Multiple hospital admissions for the same complaint* - Frequent hospital admissions are common for children with **genuine chronic or complex medical conditions**, especially those that are difficult to diagnose or manage effectively. - This feature primarily indicates the perceived severity and persistence of the child's symptoms but does not, by itself, distinguish between genuine illness and **FII**. *Normal behaviour and health reported by the school* - School reports providing evidence of normal behaviour and health are highly **supportive** of a discrepancy, as the child appears well in an environment away from the primary caregiver. - However, while crucial for building a safeguarding case, this observation is less direct evidence than the failure of **objective medical investigations** to capture physiological abnormalities during observed 'seizures'. *Negative video telemetry not capturing seizure activity* - While negative **video telemetry** is a critical piece of evidence against genuine epileptic seizures, it can also be consistent with conditions such as **non-epileptic attack disorder (NEAD)** or very infrequent true seizures. - The most compelling evidence for **FII** arises when this objective negative finding is directly contradicted by the parent's highly detailed reports and the observed presence of symptoms *only* in their presence.
Question 57: A 11-month-old infant is brought to the GP for developmental review. The parents report the baby can sit unsupported and is starting to pull to stand. She can transfer objects between hands and has a pincer grip. She babbles with tuneful variation ('mama', 'dada' non-specifically). She waves 'bye-bye' and plays peek-a-boo. Birth history was unremarkable. What is the most appropriate action?
A. Reassure parents development is normal and arrange review at 2 years (Correct Answer)
B. Refer to paediatrics for assessment of gross motor delay
C. Arrange urgent hearing assessment
D. Refer to speech and language therapy for language delay
E. Request physiotherapy assessment for delayed mobility
Explanation: ***Reassure parents development is normal and arrange review at 2 years***- The infant is meeting all appropriate **developmental milestones** for an 11-month-old, including **pincer grip** (9 months) and **pulling to stand** (9-10 months), demonstrating normal fine and gross motor skills.- Routine developmental reviews, often under the **Healthy Child Programme**, are typically conducted at 9-12 months and then again at **2-2.5 years**, making reassurance and a 2-year follow-up the correct next step.*Refer to paediatrics for assessment of gross motor delay*- Referral is not needed as **pulling to stand** and **sitting unsupported** are age-appropriate; independent walking only becomes a concern if not achieved by **18 months**.- There are no **red flags** such as loss of skills, asymmetry, or persistent primitive reflexes to justify a specialist paediatric referral.*Arrange urgent hearing assessment*- The child exhibits **tuneful babbling** and responds to verbal cues like 'mama/dada' and social games, strongly suggesting adequate **auditory function**.- Urgent hearing assessments are typically indicated for children showing **speech delay**, lack of response to sounds, or concerns raised by screening, none of which are present here.*Refer to speech and language therapy for language delay*- Using 'mama' and 'dada' **non-specifically** and babbling with tuneful variation is exactly what is expected for the **9-12 month** age bracket.- Speech and language therapy is reserved for children not meeting specific milestones, such as producing 1-2 words with **meaning** by 12-15 months, which is not applicable here.*Request physiotherapy assessment for delayed mobility*- **Gross motor progress** is within the normal range; most children do not walk independently until **12-15 months**, well beyond this infant's current age of 11 months.- Physiotherapy would only be indicated for infants with **asymmetric movements**, abnormal muscle tone, or failure to meet earlier milestones like **sitting by 9 months**.
Question 58: A GP attends a safeguarding training session on emotional abuse and neglect. Which of the following scenarios best exemplifies emotional abuse as the primary safeguarding concern?
A. A 4-year-old child whose parents are going through an acrimonious divorce and is witnessing frequent arguments
B. An 8-year-old child who is regularly told by their parent that they are 'worthless' and 'should never have been born', with age-inappropriate parenting expectations (Correct Answer)
C. A 6-year-old child with poor school attendance and inadequate winter clothing
D. A 10-year-old child who is socially isolated and has limited interaction with peers
E. A 5-year-old child who has witnessed domestic violence between parents on two occasions
Explanation: ***An 8-year-old child who is regularly told by their parent that they are 'worthless' and 'should never have been born', with age-inappropriate parenting expectations***
- This scenario exemplifies **emotional abuse** through persistent **verbal denigration** and direct emotional maltreatment, aimed at the child's self-worth.
- The presence of **age-inappropriate parenting expectations** is a key indicator of psychological harm and a feature used to define emotional abuse.
*A 4-year-old child whose parents are going through an acrimonious divorce and is witnessing frequent arguments*
- While witnessing parental conflict causes significant emotional harm, it is often categorized as **exposure to domestic conflict**, rather than direct emotional abuse *of the child*.
- This scenario lacks the **direct, targeted verbal or psychological attacks** on the child's identity that define primary emotional abuse.
*A 6-year-old child with poor school attendance and inadequate winter clothing*
- These issues are classic signs of **neglect**, indicating a failure to meet the child's basic physical, educational, and safety needs.
- Neglect is a distinct safeguarding category from emotional abuse, though they can frequently **co-exist**.
*A 10-year-old child who is socially isolated and has limited interaction with peers*
- **Social isolation** is a non-specific indicator that warrants further assessment, but it is not itself an act of emotional abuse.
- This could stem from various factors including the child's personality, mental health issues, or bullying, without direct evidence of **parental emotional maltreatment**.
*A 5-year-old child who has witnessed domestic violence between parents on two occasions*
- Witnessing **domestic violence** is a severe form of emotional harm and a critical safeguarding concern.
- However, the primary definition of emotional abuse often focuses on **direct, persistent psychological harm** inflicted *upon the child* by a caregiver, which is more explicitly detailed in the correct option.
Question 59: A 35-month-old boy is reviewed in a developmental clinic. He can jump with both feet off the ground, throw a ball overhand, and pedal a tricycle. He can copy a circle and a vertical line. He speaks in 3-4 word sentences that are understood by strangers most of the time. He can use a spoon and fork independently and is dry during the day. What is the most accurate description of this child's developmental status?
A. Gross motor skills advanced, other domains age-appropriate
B. All developmental domains age-appropriate for 35 months (Correct Answer)
C. Fine motor skills delayed requiring occupational therapy
D. Language delay requiring speech therapy referral
E. Social skills delayed requiring further assessment
Explanation: ***All developmental domains age-appropriate for 35 months***
- The child's ability to **jump with both feet**, **throw a ball overhand**, and **pedal a tricycle** are all typical **gross motor milestones** for a 3-year-old (36 months).
- **Copying a circle**, a **vertical line**, and using a **spoon and fork independently** are expected **fine motor and adaptive skills** for this age, along with speaking in **3-4 word sentences** and being **daytime dry**.
*Gross motor skills advanced, other domains age-appropriate*
- **Pedaling a tricycle** and **jumping with both feet** are standard milestones for a **3-year-old**, not considered advanced for 35 months.
- Advanced gross motor skills for this age might include hopping on one foot or standing on one foot for a few seconds, which are typically seen later.
*Fine motor skills delayed requiring occupational therapy*
- **Copying a circle** and a **vertical line** are age-appropriate fine motor skills expected around 36 months, as is independent use of **utensils**.
- A delay would be indicated if the child could not perform these tasks or struggled significantly with basic drawing or self-feeding activities.
*Language delay requiring speech therapy referral*
- Speaking in **3-4 word sentences** and having speech understood by **strangers most of the time** (approximately 75% intelligibility) is a normal **language development** for a child approaching 3 years.
- A language delay would typically involve fewer than two-word phrases, significant difficulty in being understood, or a limited vocabulary for their age.
*Social skills delayed requiring further assessment*
- The child being **dry during the day** and using a **spoon and fork independently** demonstrates appropriate **social and adaptive development**.
- Signs of social delay might include a lack of imaginative play, poor eye contact, or difficulty interacting with peers, none of which are mentioned here.
Question 60: A paediatric registrar is teaching medical students about growth assessment. A 9-year-old boy has had static height measurements on the 2nd centile for the past 3 years. His weight is on the 9th centile. His father's height is on the 10th centile and mother's height is on the 5th centile. Bone age X-ray is concordant with chronological age. What is the most likely diagnosis?
A. Familial short stature (Correct Answer)
B. Constitutional delay of growth and puberty
C. Growth hormone deficiency
D. Hypothyroidism
E. Malabsorption syndrome
Explanation: ***Familial short stature***
- The child's height is consistently tracking on a low centile (2nd centile) with a growth velocity that aligns with his **mid-parental height** (parents on 5th and 10th centiles).
- A key diagnostic feature is the **bone age matching chronological age**, indicating that the child is growing at his predetermined genetic potential without pathological delay.
*Constitutional delay of growth and puberty*
- This condition is characterized by a **delayed bone age** (usually 2 or more years behind chronological age) and a late "spurt" in growth.
- Growth velocity often dips below the centile line in mid-childhood before normalizing, unlike the **stable centile tracking** seen here.
*Growth hormone deficiency*
- Typically presents with **progressive centile crossing** (falling off the growth curve) and a significantly reduced **growth velocity**.
- It is almost always associated with **delayed bone age** and sometimes specific midline facial defects or truncal obesity.
*Hypothyroidism*
- Usually results in a significant decline in growth velocity leading to **stunted height** and a weight centile that often remains higher than the height centile.
- This endocrine pathology is associated with a distinct **delay in bone maturation** rather than concordant bone age.
*Malabsorption syndrome*
- Children with malabsorption (like Celiac disease) typically show **weight crossing centiles** before height is affected, leading to a low weight-for-height ratio.
- The growth failure is usually **progressive** and accompanied by gastrointestinal symptoms, which are absent in this presentation.
