Thesis (MMed)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background Rectovaginal endometriosis accounts for 5-10% of cases of endometriosis and constitutes one of the forms of deep infiltrating endometriosis. . Deep infiltrating endometriosis involving the bowel is most frequently encountered in the rectovaginal septum and is considered to be the most severe form of the disease and the most difficult to treat surgically owing to its invasive nature. There are currently no studies on this topic pertaining to a South African context. Study Objective To document the outcomes in 112 patients undergoing laparoscopic surgery for rectovaginal endometriosis. Methods A retrospective audit of 112 women undergoing laparoscopic surgery for rectovaginal endometriosis at Vincent Pallotti's Aevitas Fertility Clinic was undertaken. Eligibility was established by identifying women from a surgical database based on medical aid coding as well as a review of individual case notes. Patients were telephonically contacted to gather any missing information and to assess further outcomes. Design Classification Study number S11/11/036. This study was approved by the Health Research Ethics Committee at Stellenbosch University and was conducted according to ethical guidelines and principles of The International Declaration of Helsinki, South African Guidelines for Good Clinical Practice and the Medical Research Council (MRC) Ethical Guidelines for Research. Setting Vincent Pallotti’s Aevitas Reproductive Medicine Clinic Patients 112 consecutive patients suffering from rectovaginal endometriosis Interventions: Laparoscopic surgery for treatment of deep infiltrating, namely rectovaginal endometriosis Measurements and Main Results Primary outcome: Complications of laparoscopic surgery for rectovaginal endometriosis included one patient requiring a blood transfusion (0,9%), three cases of rectovaginal fistula (2,7%), two bowel injuries (1,8%)-detected and managed intra-operatively , one ureteric injury (0,9%), one pelvic abscess (0,9%) and the need for three urgent re-operations (2,68%). Secondary outcome: Of the 71 patients desiring fertility 39 (54,9%) fell pregnant of which 27 (69,2%) were spontaneous. Conclusion To our knowledge this is the first study assessing surgical outcomes in the management of deep infiltrating endometriosis from South Africa. These outcomes are in keeping with complication rates quoted in the international literature. Most of the surgery was performed using the shaving technique, in keeping with international trends, whilst fourteen cases required the performance of a segmental resection owing to extensive disease. In trained hands laparoscopic surgery is a valid management option in the management of rectovaginal endometriosis. / AFRIKAANSE OPSOMMING: Agtergrond Vyf tot tien persent van alle endometriose gevalle kan toegeskryf word aan rektovaginale endometriose. Dit word beskou as een van die vorme van diep infiltrerende endometriose. Diep infiltrerende endometriose van die derm kom meestal in die rektovaginale septum voor en word as die ernstigste vorm van die siekte beskou. Dit is die moeilikste om chirurgies te behandel weens sy indringende aard. Daar is tans geen studies beskikbaar oor hierdie onderwerp in die Suid-Afrikaanse konteks nie. Doel van die studie Om die uitkomste te dokumenteer van 112 pasiënte wat laparoskopiese chirurgie vir rektovaginale endometriose ondergaan het. Metodes 'n Retrospektiewe oudit is by Vincent Pallotti se Aevitas Fertiliteitskliniek gedoen van 112 vroue wat laparoskopiese chirurgie vir rektovaginale endometriose ondergaan het. Geskikte pasiënte is geïdentifiseer vanaf 'n chirurgiese databasis gebaseer op mediese kodering, sowel as vanaf 'n oorsig van pasiënt notas. Pasiënte is telefonies genader om ontbrekende inligting in te samel en verdere uitkomste te evalueer. Klassifikasie Ontwerp Studie nommer S11/11/036. Hierdie studie is deur die Gesondheids Navorsing Etiese Komitee van die Universiteit van Stellenbosch goedgekeur en uitgevoer volgens die etiese riglyne en beginsels van die Internasionale Verklaring van Helsinki, Suid-Afrikaanse Riglyne vir Goeie Kliniese Praktyk en die Mediese Navorsingsraad (MNR) se Etiese Riglyne vir Navorsing. Instelling Vincent Pallotti se Aevitas Reproduktiewe Medisyne Kliniek Pasiënte 112 agtereenvolgende pasiënte met rektovaginale endometriose. Ingrepe: Laparoskopiese chirurgie vir die behandeling van diep infiltrende, rektovaginale endometriose. Resultate Primêre uitkoms: Komplikasies van laparoskopiese chirurgie vir rektovaginale endometriose het ingesluit: een pasiënt wat 'n bloedoortapping benodig het (0,9%), drie gevalle van rektovaginale fistels (2,7%), twee dermbeserings (1,8%) - intraoperatief gediagnoseer en herstel, een ureter besering (0,9%), een bekkenabses (0,9%) en drie dringende herhaal operasies (2,68%). Sekondêre uitkoms: Van die 71 pasiënte wat fertiliteit verlang het: 39 (54,9%) het swanger geraak, waarvan 27 (69,2%) spontaan was. Gevolgtrekking Sover ons kennis strek, is dit die eerste Suid-Afrikaanse studie waar daar na die chirurgiese uitkomste in die behandeling van diep infiltrerende endometriose gekyk is. Hierdie uitkomste stem ooreen met internasionale literatuur in terme van komplikasie syfers. Die meeste van die operasies is uitgevoer met behulp van die skeer-tegniek, in ooreenstemming met internasionale tendense, terwyl veertien gevalle segmentele reseksies vereis het weens uitgebreide siekte. In goed opgeleide hande is die laparoskopiese behandeling van rektovaginale endometriose ‘n geldige behandelings opsie.

published_or_final_version / Community Medicine / Master / Master of Public Health

Habilitacijos procedūrai teikiamoje mokslo darbų apžvalgoje apibendrinama minimaliai invazinės endokrininių liaukų chirurgijos patirtis Vilniaus universiteto Pilvo chirurgijos centre. Apžvelgtos minimaliai invazinės skydliaukės operacijos, išanalizuoti ir apibendrinti dviejų klinikinių studijų rezultatai. 2004-2006 m. atliktoje perspektyvioje atsitiktinių imčių studijoje ,,Endoskopinės adrenalektomijos dviejų metodų įvertinimas“ pateikti ir išanalizuoti 70 pacientų, operuotų dėl įvairios antinksčių patologijos dviem minimaliai invaziniais būdais (laparoskopiniu bei endoskopiniu retroperitoniniu), rezultatai. Išanalizuota operacijos trukmės priklausomybė nuo antinksčio naviko dydžio, paciento kūno masės, palyginta kraujo netektis operacijos metu, operacinių komplikacijų skaičius. Įvertinus visus duomenis, prieita išvados, kad abu operacijos būdai geri, tačiau laparoskopinės adrenalektomijos išmokstama greičiau. 2005-2007 m. atliktame darbe ,,Minimaliai invazinė fokusuota ir tradicinė paratiroidektomija, gydant pirminį hiperparatiroidizmą: perspektyvioji, atsitiktinių imčių studija“ pateikiami pirminiu hiperparatiroidizmu sergančių pacientų, operuotų dviem būdais, gydymo rezultatai. Atsitiktinių imčių būdu 47 pacientai suskirstyti į dvi grupes: operuotų minimaliai invaziniu būdu (24 pacientai) ir operuotų tradiciniu Kocherio būdu (23 pacientai). Išanalizuota prieskydinės liaukos adenomos instrumentinių tyrimų diagnostinė vertė, palyginta operacijos trukmė, komplikacijų... [toliau žr. visą tekstą] / The experience of minimally invasive endocrine surgery accumulated at Vilnius University Centre of Abdominal Surgery is presented in this review of scientific publications submitted for habilitation procedure. The material concerning minimally invasive thyroid gland operations is summarized and the results of two clinical trials are evaluated. The results of prospective randomized study “Evaluation of two methods endoscopic adrenalectomy” were presented and analyzed; this study included 70 patients who underwent surgery for various pathology of adrenal glands; one group of the patients underwent laparoscopic minimally invasive operation and another one – endoscopic retroperitoneal minimally invasive surgery. The relationship between the size of adrenal gland tumour, patients’ body weight and duration of operation was analyzed; blood loss and rate of operative complications were compared. The evaluation of all data showed that both methods of surgery were acceptable; however, laparoscopic adrenalectomy was more was easier to learn. Clinical study “Minimally invasive focused and traditional parathyroidectomy for treatment of primary hyperparathyroidism: a prospective randomized study” was performed during the period since 2005 till 2007; the results of treatment of patients by means of two methods of surgery were presented. The patients (n = 47) were randomized into two groups; one group included 24 patients who were operated on using minimally invasive technique and another... [to full text]

Traditional laparoscopic surgery continues to require significant training on the part of the surgeon before entering the operating room. Augmented Reality (AR) has been investigated for use in visual guidance in training and during surgery, but little work is available investigating the effectiveness of AR techniques in providing the user better awareness of depth and space. In this work we propose several 2D AR overlays for visual guidance in training for laparoscopic surgery, with the goal of aiding the user's perception of depth and space in that limiting environment. A pilot study of 30 subjects (22 male and 8 female) was performed with results showing the effect of the various overlays on subject performance of a path following task in the Computer Assisted Surgical Trainer (CAST-III) system developed in the Model Based Design Lab. Deviation, economy of movement, and completion time are considered as metrics. Providing a reference indicator for the nearest point on the optimal path is found to result in significant reduction (p < 0.05) in subject deviation from the path. The data also indicates a reduction in subject deviation along the depth axis and total path length with overlays designed to provide depth information. Avenues for further investigation are presented.

Gastric banding as a weight loss surgery has increased in popularity in the United States since its approval by the Food and Drug Administration in 2001. Successful weight loss after weight loss surgery is most frequently defined as greater than 50 percent of excess weight loss (EWL). Systematic reviews show that the band is widely effective in achieving successful weight loss in most patients, however individual studies show more inconsistent outcomes. Although previous research supports gastric bypass surgery as having a positive effect on quality of life after gastric bypass, there is very little data to support this relationship in gastric banding patients. Weight loss outcomes after gastric banding surgery at Virginia Commonwealth Health System were less than 50 per cent EWL at one and two years. A retrospective, descriptive study sought to answer the following questions: 1) What is the relationship between physical activity, eating behaviors and hunger control on weight loss and quality of life after gastric banding surgery and 2) Does successful weight loss at one year predict successful weight loss at two years. The International Physical Activity Questionnaire Sort Form (IPAQ) was used to assess participation in physical activity. The Medical Outcomes Study Short Form (SF-36) was used to determine quality of life. Weight loss outcomes were 34.6 per cent at one year and 39.7 per cent at two years, which was less than the established success rate of greater than 50 per cent EWL, However, most patients lost some weight and demonstrated a significant improvement in most domains of health related quality of life. Participation in physical activity increased fro preoperatively to year one but decreased in year two. Although participation in physical activities overall decreased from year one to year two, there was a significant relationship between participation in greater than 150 minutes per week of moderate or vigorous physical activity and adequate weight loss (p =0.025) and participation in health enhancing physical activities and adequate weight loss (p < 0.05). There was no statistically significant relationship noted between any of these eating behaviors and the percentage of excess weight loss at one or two years. There was a significant relationship between degree of hunger reported by patients and successful weight loss at one year (p < 0.05). There is sufficient statistical evidence of a positive linear relationship between two- year weight loss and one- year weight loss (p < 0.05). That is, one-year weight loss is a significant predictor for two- year weight loss. Based on the results of this study, it is recommended that gastric banding patients participate in at least 150 minutes per week of moderate to vigorous physical activity. Additionally, clinicians should consider development of adjustment protocols that achieve early reduction of hunger in the banding patient.

Orientador: Sony Dimas Bicudo / Resumo: O objetivo do presente trabalho foi avaliar os corpos lúteos (CL) formados em decorrência da aspiração folicular guiada por laparoscopia (LOPU) na espécie ovina, quanto ao desenvolvimento morfológico, funcionalidade e potencial de desenvolvimento gestacional. Foram realizados dois experimentos, em ambos o estro das ovelhas foi sincronizado utilizando dispositivo intravaginal de acetato de medroxiprogesterona por 14 dias, aplicação de 140 μg cloprostenol no quarto dia e retirada do dispositivo no décimo quarto dia com concomitante administração de gonadotrofina coriônica equina (eCG). No Experimento I, 48 horas após a remoção do dispositivo realizou-se a LOPU dos folículos ovarinos em seis ovelhas (Grupo LOPU – LG), ou a LOPU associada com reposição de células em sete animais (Grupo reposição – RG) em cinco animais a ovulação foi espontânea (Grupo controle – CG). Foi realizada avaliação ultrassonográfica ovariana dos animais diariamente até o momento de uma nova ovulação e coleta de sangue para dosagem de progesterona (P4) plasmática a cada 48 horas até o decimo quinto dia. Os animais do LG (1,7±0,5) e RG (1,4±0,5) formaram mais CLs do que os animais do CG (1,0±0,0). A área lútea individual dos CLs foi menor no LG (0,69±0,30 cm2), em comparação ao RG (0,79±0,25 cm2) e CG (0,85±0,32 cm2). A área lútea total foi semelhante entre o LG (1,2±0,4 cm2) e RG (1,1±0,5 cm2), sendo ambas maiores que a do CG (0,9±0,3 cm2). A concentração de P4 plasmática não diferiu entre os grupos, fican... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The aim of the present study was to evaluate the corpus luteum (CL) formed as a result of laparoscopic ovum pick-up (LOPU) in the ovine, regarding the morphological development, functionality and potential of gestational development. Two experiments were carried out, in both of them, the oestrous of the ewes was synchronized using a 14-day intravaginal device of medroxyprogesterone acetate, 140 μg cloprostenol on the fourth day and withdrawal of the device on the fourteenth day with concomitant administration of equine chorionic gonadotrophin (eCG). In Experiment I, 48 hours after the removal of the device, was realized a LOPU of the ovarian follicles in six sheep (LOPU Group - LG), or LOPU associated with cell replacement in seven animals (Replacement Group - RG) was performed in five animals a ovulation was spontaneous (Control Group - CG). Ultrasonographic evaluation of the animals was performed daily until the time of ovulation and blood collection for progesterone plasma concentration (P4) every 48 hours until the 15th day. LG animals (1.7 ± 0.5) and RG (1.4 ± 0.5) formed more CLs than CG animals (1.0 ± 0.0). The individual luteal area of CLs was lower in LG (0.69 ± 0.30 cm2), compared to RG (0.79 ± 0.25 cm2) and CG (0.85 ± 0.32 cm2). The total luteal area was similar between LG (1.2 ± 0.4 cm2) and RG (1.1 ± 0.5 cm2), both larger than CG (0.9 ± 0.3 cm2). Plasma P4 concentration did not differ between groups, being above 2 ng / mL in the static phase of CLs development. I... (Complete abstract click electronic access below) / Doutor

Este trabalho teve por objetivo desenvolver e caracterizar um conjunto transdutor piezelétrico de potência e pinça laparoscópica para cortes homeostáticos, o qual constitui parte fundamental do projeto do Bisturi Ultrassônico Nacional. O transdutor, do tipo Langevin, é composto por quatro cerâmicas piezelétricas que convertem energia elétrica em deslocamento mecânico. Um componente importante do transdutor é o amplificador mecânico, cuja finalidade é aumentar a amplitude do deslocamento. O transdutor e o amplificador foram desenvolvidos através de um modelo axissimétrico de elementos finitos implementado no software ANSYS e a lâmina foi desenvolvida através de um modelo tridimensional em elementos finitos. Para cada associação, entre os componentes, os resultados numéricos da resposta em frequência da impedância elétrica e do coeficiente de acoplamento eletromecânico, foram comparados com os resultados experimentais. Também foi desenvolvido um mecanismo inovador de acionamento da pinça laparoscópica. O resultado desta pesquisa proporcionou uma inovação tecnológica na área médica, contribuindo assim para o progresso tecnológico do país. / The aim of this work was to develop and characterize a high power piezoelectric transducer coupled to a laparoscopic forceps for homeostatic cuts, which is a fundamental part of the National Ultrasonic Scalpel Project. The Langevin type transducer consists of four piezoelectric ceramics that convert electrical energy into mechanical displacement. An important component of the transducer is the mechanical amplifier, which increases the amplitude of displacement. The transducer and amplifier have been developed through an axisymmetric finite element model, implemented in ANSYS, and the blade was developed using a three-dimensional finite element model. For each association between the components, the numerical results of the frequency response of the electrical impedance and electromechanical coupling coefficient were compared with the experimental results. An innovative drive mechanism was developed for the laparoscopic forceps. The result of this research provided a technological innovation in the medical field, thus contributing to the technological progress of the country.

Bakgrund: Att förebygga och behandla postoperativ smärta är anestesisjuksköterskans ansvar genom det perioperativa förloppet. Tidigare studier har visat att förekomsten av postoperativ smärta efter laparoskopisk kolecystektomi är hög. Syfte: Syftet med studien var att beskriva postoperativ smärtskattning hos patienter som genomgått laparoskopisk kolecystektomi på en sluten operationsavdelning och en dagkirurgisk operationsavdelning. Syftet var också att undersöka skillnader i förekomst av postoperativ smärta mellan män och kvinnor, yngre och äldre patienter samt mellan patienter som opererats på sluten- respektive dagkirurgisk operationsavdelning. Metod: Studien var en retrospektiv registerstudie med kvantitativ ansats. Registerdata innehållande data från 338 patienter inhämtades från kvalitetsregistret Svenskt Perioperativt Register från år 2016–2018. Materialet analyserades med beskrivande och jämförande statistik. Resultat: Resultatet visade att 70 % av patienterna skattade måttlig till svår postoperativ smärta (NRS 4-10). Det framkom även att kvinnor samt yngre patienter (&lt;50 år) på den dagkirurgiska operationsavdelningen skattade signifikant högre postoperativ smärta jämfört med män och äldre patienter. Slutsatser: Även om inga generella slutsatser kan dras tyder resultaten på att kvinnor samt patienter 50 år och yngre är särskilt utsatta för otillräcklig smärtbehandling i samband med laparoskopisk kolecystektomi. Eftersom alla människor har rätt till god smärtlindring behöver omvårdnaden således anpassas efter patientens individuella förutsättningar och behov. När anestesisjuksköterskan når en förtrolig relation till patienten finns goda förutsättningar för en tillfredställande postoperativ omvårdnad.

Background and Aims Colorectal cancer is the third most common type of cancer in Sweden, male and female, with 6500 (4500 colonic/2000 rectal) new cases each year. Surgery remains the treatment of choice. Previous studies show that laparoscopic procedure may lead to fewer complications, shorter postoperative stays and a lesser inflammatory response compared to open procedure. The study examines whether laparoscopic surgery of sigmoid cancer differs from open surgery, regarding inflammatory response through analysis of routine measurements. It also investigates differences in peri- and postoperative quality data from Swedish Colorectal Cancer Registry. Material and Methods 307 consecutive patients underwent surgical sigmoidectomy from February 2007- February 2017, from which elective patients with sigmoid cancer were included. Pre-and postoperative CRP and postoperative WBC, Haemoglobin and Creatinine were collected from medical records at the Department of Surgery, Örebro University hospital. Patient related and perioperative variables were collected from SCRCR (e.g. postoperative stay, bleeding, complications). Results 158 patients fulfilled the inclusion criteria. There was a marked increase in CRP postoperative in both laparoscopic (89) and open (69) groups, but no significant difference comparing the groups. There was a significant difference in perioperative bleeding (p&lt;0.05) and length of stay (p&lt;0.05). Conclusion Sigmoidectomy, laparoscopic or open, cause an increase in CRP. No significant difference in inflammatory response was noted between the groups. Patients undergoing laparoscopic, compared to open sigmoidectomy has: less perioperative bleeding, shorter postoperative stay and a longer duration of surgery, like previous studies.

Abstract Rectal prolapse and internal rectal prolapse with symptoms of obstructed defecation and/or faecal incontinence are debilitating conditions. Often, symptoms coexist from other pelvic compartments, reducing quality of life. Robot-assisted surgery with its advanced features may offer better conditions in narrow pelvic space to correct rectal prolapses with rectopexy operation. In this thesis, we compared robot-assisted and laparoscopic techniques during the early learning curve in a ‘matched-pairs’ feasibility study (n = 30, follow-up three months) and in a prospective randomized series (n = 33, follow-up 24 months). The long-term functional results were assessed in a retrospective multicenter study with cross-sectional questionnaire assessment (n = 508, median follow-up 44 months). In the randomised series, as demonstrated with MR defecography, ventral rectopexy corrects the posterior compartment defects, external and internal rectal prolapses and recto-enteroceles. The operation restores the posterior and middle compartment anatomy and reduces pelvic organ mobility with a minor impact on the anterior compartment. Pelvic floor dysfunction and symptom-specific quality of life is improved after rectopexy; specifically, the colorectal-anal and the pelvic organ prolapse subscales in the questionnaires showed improvement. We found equality between robot-assisted rectopexy and laparoscopic rectopexy in most relevant outcome measures, which does not justify the added cost of the routine use of robots in rectopexy operations. The health-related quality of life and cost-utility analysis in our cohort indicated, however, that in long-term the technique may be cost-effective. The functional results are retained in the long term. The rate of recurrences (7.1%) and complications (10%) are acceptable and mesh-related complications (1.4%) are rare. Denovo symptoms, such as the urge to defecate or urinary incontinence, may arise, while urinary symptoms may be alleviated. In the long-run, patients with external rectal prolapse benefit more than patients with internal rectal prolapse. In part, the results of this thesis support using a multidisciplinary approach in examining patients with posterior pelvic floor dysfunction. Furthermore, the indications for robotic use in rectopexy operations need to be explored in larger patient samples. / Tiivistelmä Rektumprolapsi ja peräsuolen sisäinen tuppeuma eli interni prolapsi aiheuttavat hankalia oireita, kuten ulostusvaikeuksia, ulosteinkontinenssia ja lantion kipua. Elämänlaatua heikentäviä oireita esiintyy usein samanaikaisesti myös muissa lantion osissa. Robottiavusteinen kirurgia tarjoaa paremmat leikkausolosuhteet lantion ahtaassa tilassa tehtävään rektopeksialeikkaukseen ja mahdollisesti edut voivat näkyä leikkaustuloksessa. Tässä väitöskirjassa vertailimme robottiavusteista ja laparoskooppista leikkaustekniikkaa oppimiskäyrän alkuvaiheessa käyttökelpoisuustutkimuksessa kaltaistetussa parivertailuasetelmassa (n = 40, seuranta-aika 3 kk) sekä prospektiivisessa randomoidussa tutkimussarjassa (n = 33, seuranta-aika 24 kk). Monikeskustutkimuksessa (n = 508, seuranta-ajan mediaani 44 kk) selvitimme laajassa aineistossa laparoskooppisen ventraalisen rektopeksian pitkäaikaistuloksia liittämällä aineiston analyysiin poikkileikkauskyselytutkimuksen tulokset. Randomoidussa sarjassa MR-defekografialla todennettiin, että rektopeksialeikkauksen jälkeen peräsuolen sisäinen tuppeuma, rektoseele ja enteroseele korjaantuvat. Rektopeksialeikkaus palauttaa lantion taka- ja keskiosan anatomian, vähentää elinten dynaamista liikkuvuutta ja parantaa lantionpohjan toimintaa sekä oireisiin liittyvää elämänlaatua, erityisesti suolioireiden ja gynekologisten laskeumaoireiden osalta. Robottiavusteinen ja laparoskooppinen tekniikka olivat samanvertaisia perioperatiivisten parametrien, komplikaatioiden, anatomisten ja toiminnallisten tulosten suhteen. Vaikka kustannusvertailussa kalliimpi robottikirurgia voi osoittautua kustannustehokkaaksi pitkäaikaisseurannassa, yhdenvertaiset tulokset eivät oikeuta menetelmää rutiinikäyttöön. Retrospektiivisen tutkimuksen poikkileikkauskyselyn mukaan toiminnalliset tulokset säilyvät pitkäaikaisseurannassa, residiivien (7,1 %) ja komplikaatioiden (10 %) määrä on hyväksyttävä ja verkkoon liittyviä komplikaatioita esiintyy vähän (1,4 %). Leikkauksen jälkeen ilmenee myös uusia oireita, kuten ulostuspakkoa tai virtsankarkailua. Toisaalta virtsankarkailuoire voi korjaantuakin. Pitkäaikaisseurannassa totaalin rektumprolapsin vuoksi leikatut potilaat hyötyvät leikkauksesta enemmän kuin oireisen internin prolapsin vuoksi leikatut. Osa väitöskirjatyön tuloksista tukee moniammatillisen lähestymistavan käyttöä potilaiden arvioinnissa. Jatkossa robottikirurgian käytön indikaatioita rektopeksialeikkauksissa tulisi arvioida isommissa potilasaineistoissa.