scholarly journals Expansion of the Surgical Apgar Score across All Surgical Subspecialties as a Means to Predict Postoperative Mortality

2011 ◽  
Vol 114 (6) ◽  
pp. 1305-1312 ◽  
Author(s):  
Paul Q. Reynolds ◽  
Neal W. Sanders ◽  
Jonathan S. Schildcrout ◽  
Nathaniel D. Mercaldo ◽  
Paul J. St. Jacques
Keyword(s):  
Apgar Score ◽  
Scoring System ◽  
Postoperative Mortality ◽  
Predictive Ability ◽  
Apgar Scores ◽  
Logistic Regression Models ◽  
Risk Of Death ◽  
Estimated Blood Loss ◽  
Increased Risk ◽  
Surgical Apgar Score

Background A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties. Methods Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score. Results Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties. Conclusion A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

Apgar Score and Risk of Cerebral Palsy in Preterm Infants: A Population-Based Cohort Study

2021 ◽  
Author(s):  
Damjan Osredkar ◽  
Ivan Verdenik ◽  
Anja Troha Gergeli ◽  
Ksenija Gersak ◽  
Miha Lucovnik
Keyword(s):  
Cerebral Palsy ◽  
Preterm Infants ◽  
Apgar Score ◽  
Preterm Neonates ◽  
Adjusted Relative Risk ◽  
Term Infants ◽  
Apgar Scores ◽  
Risk Of Death ◽  
Increased Risk ◽  
Minute Apgar Score

AbstractA low Apgar score is associated with increased risk of cerebral palsy (CP) in term infants, while such association remains controversial in preterm neonates. The objective of this study was to assess association between 5-minute Apgar scores and CP in different subcategories of preterm birth based on gestational age. The Slovenian National Perinatal Information System was used to identify singleton children without congenital malformations live-born at 22 to 37 weeks of gestation between 2002 and 2010. Data were linked to the Slovenian Registry of Cerebral Palsy in children born between 2002 and 2010. CP was diagnosed at a minimum of 5 years of age. Of 11,924 children included, 241 (2.0%) died before discharge and 153 (1.3%) were diagnosed with CP. Five-minute Apgar scores <7 were significantly associated with higher risk of death or CP (compared with scores ≥9) at all preterm gestations. CP alone was associated with Apgar scores <7 only at moderately or late preterm gestation (32–36 weeks) (adjusted relative risk [aRR]: 8.27; 95% confidence interval [CI]: 1.87–36.64 for scores 0–4 and aRR: 4.96; 95% CI 1.89–13.06 for scores 5–6). In conclusion, a low 5-minute Apgar score was associated with combined outcome of neonatal death or CP in all preterm births, while in surviving preterm infants at >32 weeks a low 5-minute Apgar score was associated with CP.

Validation of the surgical Apgar score in a neurosurgical patient population

2013 ◽  
Vol 118 (2) ◽  
pp. 270-279 ◽  
Author(s):  
John E. Ziewacz ◽  
Matthew C. Davis ◽  
Darryl Lau ◽  
Abdulrahman M. El-Sayed ◽  
Scott E. Regenbogen ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Hospital Stay ◽  
Apgar Score ◽  
Univariate Analysis ◽  
Postoperative Mortality ◽  
Neurosurgical Procedures ◽  
Complication Rates ◽  
Risk Of Death ◽  
Neurosurgical Patient ◽  
Surgical Apgar Score

Object The surgical Apgar score (SAS) reliably predicts postoperative death and complications and has been validated in a large cohort of general and vascular surgery patients. However, there has been limited study of the utility of the score in the neurosurgical population. The authors tested the hypothesis that the SAS would predict postoperative complications and length of stay after neurosurgical procedures. Methods A cohort of 918 intracranial and spine surgery patients treated over a 3-year period were retrospectively evaluated. The 10-point SAS was calculated and postoperative 30-day mortality and complications rates, intensive care unit (ICU) stay, and hospital stay were assessed by 2 independent raters. Univariate analysis and multivariate logistic regression were performed. Results There were 145 patients (15.8%) with at least 1 complication and 24 patients (2.6%) who died within 30 days of surgery. Surgical Apgar scores were significantly associated with the likelihood of postoperative complications (p < 0.001) and death (p = 0.002); scores varied inversely with postoperative complication and mortality risk in a multivariate analysis. Low SASs also predicted prolonged ICU and hospital stay. Patients with scores of 0–2 stayed a mean of 18.9 days (p < 0.001) and patients with scores of 3–4 stayed an average of 14.3 days (p < 0.001) compared with 4.1 days in patients with scores of 9–10. Conclusions The application of the surgical Apgar score to a neurosurgical cohort predicted 30-day postoperative mortality and complication rates as well as extended ICU and hospital stay. This readily calculated score may help neurosurgical teams efficiently direct postoperative care to those at highest risk of death and complications.

scholarly journals A PROSPECTIVE STUDY TO DETERMINE POST OPERATIE MORBIDITY AND MORTALITY USING SURGICAL APGAR SCORE

2021 ◽  
pp. 1-7
Author(s):  
Suraj Girish ◽  
P S Saravanan ◽  
K Suresh babu
Keyword(s):  
Surgical Procedures ◽  
Apgar Score ◽  
Scoring System ◽  
Tamil Nadu ◽  
Beta Blockers ◽  
Accurate Method ◽  
Estimated Blood Loss ◽  
Patients At Risk ◽  
Surgical Apgar Score ◽  
Type Of Surgery

Introduction: Predicting the post-operative complication earlier will help surgeons take necessary precautions Pre and Peri-operatively. It reduces the direct as well as indirect medical cost. The main risk factors which have effect on morbidity as well as mortality are Age ,Type of surgery, History of Diabetes, Hypertension, Smoking, Renal disease, Cardiovascular disease, COPD, Asthma, steroid intake etc. Atul Gawande et al developed a scoring system as a boon for surgeons termed as surgical Apgar scoring system. Though initially devised for Colorectal surgeries this scoring system can be applied for general surgical procedures and predicts major complications as well as mortality using Lowest Heart Rate intra operatively, Lowest Mean Arterial Pressure intra operatively and Estimated Blood Loss. Existing prediction scoring system that involve lab investigation needs meticulous procedure. Hence this study is being carried out to evaluate the ability of Surgical APGAR score to predict post-operative morbidity and 30 days for General Surgical procedures. Materials and methods: Descriptive longitudinal study carried out at Department of General surgery, Meenakshi Medical College & Research Institute, Kanchipuram, Tamil Nadu, for a period of 12 months With a sample size of 200 Inclusion criteria: Patients aged between 15-75 years undergoing Emergency or Elective General surgical procedures under General, Spinal or Epidural anesthesia. Exclusion criteria: Patient on Beta Blockers and those undergoing procedures under Local Anesthesia were excluded. Results: Among the comorbid conditions COPD, Asthma and Renal failure have statistically significant association with Surgical Apgar score. There is statistically significant association between type of surgery and Surgical Apgar score. There is statistically significant association between Surgical Apgar score and complications. There is statistically significant association between surgical Apgar score and mortality. Among 8 individuals who had high risk score 6 individuals had mortality. Conclusion: The 10-point Surgical Apgar Scoring system is an easy and fairly accurate method of identifying the patients at risk of complications and mortality in the post-operative period. Patients with low surgical Apgar score would require more intensive monitoring in the postoperative period even if they are undergoing a minor procedure.

Prognostic significance of international normalised ratio and prothrombin time in Chinese acute ischaemic stroke patients

2022 ◽  
pp. postgradmedj-2021-141204
Author(s):  
Shoujiang You ◽  
Qiao Han ◽  
Xiaofeng Dong ◽  
Chongke Zhong ◽  
Huaping Du ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischaemic Stroke ◽  
Prothrombin Time ◽  
Hospital Discharge ◽  
Acute Ischaemic Stroke ◽  
Regression Models ◽  
Logistic Regression Models ◽  
Risk Of Death ◽  
Increased Risk ◽  
International Normalised Ratio

BackgroundWe investigated the association between international normalised ratio (INR) and prothrombin time (PT) levels on hospital admission and in-hospital outcomes in acute ischaemic stroke (AIS) patients.MethodsA total of 3175 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included. We divided patients into four groups according to their level of admission INR: (<0.92), Q2 (0.92–0.98), Q3 (0.98–1.04) and Q4 (≥1.04) and PT. Logistic regression models were used to estimate the effect of INR and PT on death or major disability (modified Rankin Scale score (mRS)>3), death and major disability (mRS scores 4–5) separately on discharge in AIS patients.ResultsHaving an INR level in the highest quartile (Q4) was associated with an increased risk of death or major disability (OR 1.69; 95% CI 1.23 to 2.31; P-trend=0.001), death (OR, 2.64; 95% CI 1.12 to 6.19; P-trend=0.002) and major disability on discharge (OR, 1.56; 95% CI 1.13 to 2.15; P-trend=0.008) in comparison to Q1 after adjusting for potential covariates. Moreover, in multivariable logistic regression models, having a PT level in the highest quartile also significantly increased the risk of death (OR, 2.38; 95% CI 1.06 to 5.32; P-trend=0.006) but not death or major disability (P-trend=0.240), major disability (P-trend=0.606) on discharge.ConclusionsHigh INR at admission was independently associated with death or major disability, death and major disability at hospital discharge in AIS patients and increased PT was also associated with death at hospital discharge.

Decision to Incision and Risk for Fetal Acidemia, Low Apgar Scores, and Hypoxic Ischemic Encephalopathy

2020 ◽  
Author(s):  
Sabine Bousleiman ◽  
Dwight J. Rouse ◽  
Cynthia Gyamfi-Bannerman ◽  
Yongmei Huang ◽  
Mary E. D'Alton ◽  
...  
Keyword(s):  
Umbilical Cord ◽  
Apgar Score ◽  
Hypoxic Ischemic Encephalopathy ◽  
Apgar Scores ◽  
Fetal Heart Rate Monitoring ◽  
Emergency Cesarean ◽  
Increased Risk ◽  
Secondary Outcomes ◽  
Ischemic Encephalopathy ◽  
Umbilical Cord Ph

Objective This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery. Study Design This unplanned secondary analysis of the Maternal–Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH ≤7.0, and Apgar score ≤4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or ≥50 minutes. As secondary outcomes umbilical cord pH ≤7.1, umbilical artery pH ≤7.0, and Apgar score ≤5 at 5 minutes were analyzed. Results Of 5,784 women included in the primary analysis, 12.4% had a decision-to-incision interval ≤10 minutes, 20.2% 11 to 20 minutes, 14.9% 21 to 30 minutes, 18.2% 31 to 50 minutes, and 16.5% >50 minutes. Risk for umbilical cord pH ≤7.0 was highest at ≤10 and 11 to 20 minutes (10.2 and 7.9%, respectively), and lowest at 21 to 30 minutes (3.9%), 31 to 50 minutes (3.9%), and >50 minutes (3.5%) (p < 0.01). Risk for Apgar scores ≤4 at 5 minutes was also higher with decision-to-incision intervals ≤10 and 11 to 20 minutes (4.3 and 4.4%, respectively) compared with intervals of 21 to 30 minutes (1.7%), 31 to 50 minutes (2.1%), and >50 minutes (2.0%) (p < 0.01). Hypoxic ischemic encephalopathy occurred in 1.5 and 1.0% of women with decision-to-incision intervals of ≤10 and 11 to 20 minutes compared with 0.3 and 0.5% for women with decision-to-incision intervals of 21 to 30 minutes and 31 to 50 minutes (p = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals. Conclusion Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean. Key Points

scholarly journals Risk and predictors of in-hospital mortality from COVID-19 in patients with diabetes and cardiovascular disease

2020 ◽  
Author(s):  
Hadith Rastad ◽  
Hossein Karim ◽  
Hanieh-Sadat Ejtahed ◽  
Ramin Tajbakhsh ◽  
Mohammad Noorisepehr ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Hospital Mortality ◽  
Lymphocyte Count ◽  
Mortality Data ◽  
Diabetic Patients ◽  
Logistic Regression Models ◽  
Risk Of Death ◽  
Number Of Patients ◽  
Increased Risk ◽  
Novel Coronavirus

Abstract Background: Diabetes mellitus (DM) and cardiovascular disease (CVD) are present in a large number of patients with novel Coronavirus disease 2019 (COVID-19). We aimed to determine the risk and predictors of in-hospital mortality from COVID-19 in patients with DM and CVD.Methods: This retrospective cohort study included hospitalized patients aged ≥ 18 years with confirmed COVID-19 in Alborz province, Iran, from 20 February 2020 to 25 March 2020. Data on demographic, clinical and outcome (in-hospital mortality) data were obtained from electronic medical records. Self-reported comorbidities were classified into the following groups: “DM” (having DM with or without other comorbidities), “only DM” (having DM without other comorbidities), “CVD” (having CVD with or without other comorbidities), “only CVD” (having CVD without other comorbidities), and “having any comorbidity”. Multivariate logistic regression models were fitted to quantify the risk and predictors of in-hospital mortality from COVID-19 in patients with these comorbidities.Results: Among 2957 patients with COVID-19, 2656 were discharged as cured, and 301 died. In multivariate model, DM (OR: 1.62 (95%CI: 1.14-2.30)) and only DM (1.69 (1.05-2.74)) increased the risk of death from COVID-19; but, both CVD and only CVD showed non-significant associations (p>0.05). Moreover, “having any comorbidities” increased the risk of in-hospital mortality from COVID-19 (OR: 2.66 (95%CI: 2.09 -3.40)). Significant predictors of mortality from COVID-19 in patients with DM were lymphocyte count, creatinine and C-reactive protein (CRP) level (all P- values < 0.05).Conclusions: Our findings suggest that diabetic patients have an increased risk of in-hospital mortality following COVID-19; also, lymphocyte count, creatinine and CRP concentrations could be considered as significant predictors for the death of COVID-19 in these patients.

Effect of preoperative bilirubin on outcomes of completely resected hilar cholangiocarcinoma: A multi-institutional analysis.

2016 ◽  
Vol 34 (4_suppl) ◽  
pp. 326-326
Author(s):  
Harveshp Mogal ◽  
Rebecca Dodson ◽  
Nora Fino ◽  
Cecilia Grace Ethun ◽  
Timothy M. Pawlik ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Multivariate Analysis ◽  
Hilar Cholangiocarcinoma ◽  
Perioperative Complications ◽  
Postoperative Mortality ◽  
Preoperative Biliary Drainage ◽  
Factors Affecting ◽  
Logistic Regression Models ◽  
R1 Resection ◽  
Increased Risk

326 Background: Perioperative and long-term outcomes of patients with Hilar cholangiocarcinoma (HC) and preoperative hyperbilirubinemia have not been clearly defined. Methods: Patients with HC undergoing hepatectomy with a complete (R0/R1) resection between 2000 and 2014 were identified within a 10-institution prospectively maintained database. Using receiver operating characteristic curves from logistic regression models, a peak bilirubin cutoff point that minimized the difference between the sensitivity and specificity, was determined. Factors affecting perioperative complications were estimated using logistic regression. Results: 191 of 328 (58.2%) patients who underwent complete resection with a hepatectomy, with available preoperative bilirubin data were analyzed. 37.2% (n = 71) had bilirubin > 7.9. Patients with higher preoperative bilirubin were more likely to have a higher CA 19-9 (1776±3721.5 vs 302.1±518.6, p = 0.0006), more comorbidities (1.6±0.8 vs 1.4±0.9; p = 0.002), preoperative biliary drainage (PBD) (91.4% vs 75.6%, p = 0.007), positive lymph nodes (48.5% vs 31.5%, p = 0.025) and perioperative death (14.5% vs 5.2%, p = 0.0292). Multivariate analysis identified PBD (OR 3.2, CI 1.4-7.5; p = 0.008) and smoking (OR 2.3, CI 1.2-4.4; p = 0.016) to be independent predictors of any and major complications. Peak bilirubin > 7.9 (OR 3.1, CI 1.1-8.9; p = 0.04) and preoperative systemic sepsis (PSS) (OR 5.0, CI 1.2-21.5; p = 0.03) were associated with increased risk of postoperative mortality. However, on multivariate analysis only PSS was significant (OR 14.4, CI 2.2-93.9; p = 0.005); 5/13 (23.1%) of patients with PSS died within 30 days after surgery. Conclusions: PSS portends increased operative mortality in HC patients undergoing hepatectomy, independent of preoperative peak bilirubin levels. Prevention and aggressive treatment of PSS should be the priority in the preoperative optimization of these patients.

Risk Assessment of Pancreatic Surgery by Surgical Apgar Score and Body Mass Index

2016 ◽  
Vol 101 (5-6) ◽  
pp. 263-269 ◽  
Author(s):  
Toru Aoyama ◽  
Yusuke Katayama ◽  
Masaaki Murakawa ◽  
Koichiro Yamaoku ◽  
Amane Kanazawa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pancreatic Cancer ◽  
Body Mass Index ◽  
Body Mass ◽  
Apgar Score ◽  
Pancreatic Surgery ◽  
Significant Risk ◽  
Cancer Center ◽  
Estimated Blood Loss ◽  
Surgical Apgar Score

Postoperative morbidity is high after pancreatic surgery. Recently, a simple and easy-to-use surgical complication prediction system, the surgical Apgar score (SAS), calculated using 3 intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate) has been proposed for general surgery. In this study, we evaluated the predictability of the SAS for severe complications after pancreatic surgery for pancreatic cancer. We investigated 189 patients who underwent pancreatic surgery at Kanagawa Cancer Center between 2005 and 2014. Clinicopathologic data, including the intraoperative parameters, were collected retrospectively. In this study, the patients with postoperative morbidities classified as Clavien-Dindo grade 2 or higher were classified as having severe complications. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for morbidity. Postoperative complications were identified in 73 patients, and the overall morbidity rate was 38.6%. The results of both univariate and multivariate analyses of various factors for overall operative morbidity showed that an SAS of 0 to 4 points and a body mass index ≥25 kg/m2 were significant independent risk factors for overall morbidity (P = 0.046 and P = 0.013). The SAS and body mass index were significant risk factors for surgical complications after pancreatic surgery for pancreatic cancer.

Preoperative Surgical Risk Predictions Are Not Meaningfully Improved by Including the Surgical Apgar Score

2015 ◽  
Vol 123 (5) ◽  
pp. 1059-1066 ◽  
Author(s):  
Maxim A. Terekhov ◽  
Jesse M. Ehrenfeld ◽  
Jonathan P. Wanderer
Keyword(s):  
Risk Stratification ◽  
Apgar Score ◽  
Information Criteria ◽  
Brier Score ◽  
Clinical Parameters ◽  
Preoperative Risk ◽  
Surgical Risk ◽  
Estimated Blood Loss ◽  
Surgical Apgar Score ◽  
Relative Quality

Abstract Background Estimating surgical risk is critical for perioperative decision making and risk stratification. Current risk-adjustment measures do not integrate dynamic clinical parameters along with baseline patient characteristics, which may allow a more accurate prediction of surgical risk. The goal of this study was to determine whether the preoperative Risk Quantification Index (RQI) and Present-On-Admission Risk (POARisk) models would be improved by including the intraoperative Surgical Apgar Score (SAS). Methods The authors identified adult patients admitted after noncardiac surgery. The RQI and POARisk were calculated using published methodologies, and model performance was compared with and without the SAS. Relative quality was measured using Akaike and Bayesian information criteria. Calibration was compared by the Brier score. Discrimination was compared by the area under the receiver operating curves (AUROCs) using a bootstrapping procedure for bias correction. Results SAS alone was a statistically significant predictor of both 30-day mortality and in-hospital mortality (P &lt; 0.0001). The RQI had excellent discrimination with an AUROC of 0.8433, which increased to 0.8529 with the addition of the SAS. The POARisk had excellent discrimination with an AUROC of 0.8608, which increased to 0.8645 by including the SAS. Similarly, overall performance and relative quality increased. Conclusions While AUROC values increased, the RQI and POARisk preoperative risk models were not meaningfully improved by adding intraoperative risk using the SAS. In addition to the estimated blood loss, lowest heart rate, and lowest mean arterial pressure, other dynamic clinical parameters from the patient’s intraoperative course may need to be combined with procedural risk estimate models to improve risk stratification.

scholarly journals The Impact of the Surgical Apgar Score On Oncological Outcomes in Patients With Colorectal Cancer: A Single-Center Retrospective Cohort Study

2021 ◽  
Author(s):  
Atsushi Sugimoto ◽  
Tatsunari Fukuoka ◽  
Hisashi Nagahara ◽  
Masatsune Shibutani ◽  
Yasuhito Iseki ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Apgar Score ◽  
Tumor Type ◽  
Cancer Specific Survival ◽  
Receiver Operating Characteristic Curves ◽  
Oncological Outcomes ◽  
Estimated Blood Loss ◽  
Comorbidity Index ◽  
The Impact ◽  
Surgical Apgar Score

Abstract Background: The surgical Apgar score (SAS) predicts postoperative complications (POCs) following gastrointestinal cancer surgery. Recently, the SAS was reported to be a predictor of not only POCs but also the prognosis. However, the impact of the SAS on oncological outcomes in patients with colorectal cancer (CRC) has not been fully examined. The present study therefore explored the oncological significance of the SAS in patients with CRC.Methods: We retrospectively analyzed 639 patients who underwent radical surgery for CRC. The SAS was calculated based on three intraoperative parameters: estimated blood loss, lowest mean arterial pressure and lowest heart rate. The optimal cut-off value of the SAS was determined by receiver operating characteristic curves. All patients were classified into 2 groups based on the SAS (≤6 and >6). The association of the SAS with the recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) was analyzed.Results: Univariate analyses revealed that a lower SAS (≤6) was significantly associated with a worse RFS, OS and CSS. A multivariate analysis revealed that age ≥75 years old, Charlson comorbidity index ≥1, ASA-Physical Status ≥3, SAS ≤6, histologically undifferentiated tumor type and an advanced pStage were independent factors for the OS, and an SAS ≤6 and advanced pStage were independent factors for the CSS.Conclusions: A lower SAS (≤6) was an independent prognostic factor for not only the OS but also the CSS in patients with CRC, suggesting that the SAS might be a useful biomarker predicting oncological outcomes in patients with CRC.

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