scholarly journals Prospective Analysis of Wound Infection Following Cesarean Section

2020 ◽  
Author(s):  
Sahrun Al Shukkur ◽  
Bharathi Rao ◽  
Sabah Mohd Zubair
Keyword(s):  
Staphylococcus Aureus ◽  
Wound Infection ◽  
Caesarean Delivery ◽  
Suture Material ◽  
Methicillin Resistance ◽  
Subcutaneous Tissue ◽  
Surgical Site Infections ◽  
Categorical Variables ◽  
P Value ◽  
Skin Closure

Abstract Background: To study the risk factors among women who develop postoperative wound infection following caesarean section, and to analyze the microbiological pattern and antibiotic sensitivity. Method: This prospective hospital-based cross-sectional study conducted in government Lady Goschen Hospital, Mangalore, between October 2016 to March 2018, enrolled women who developed surgical site infections (SSI) within 30 days of caesarean delivery performed in the hospital. Descriptive statistics were used for socio-demographic variables and appropriate univariate and multivariate analysis used to find the association between continuous and categorical variables with a p-value of <0.05 taken as statistically significant.Results: Out of 4540 cesarean deliveries, 52 (1.1%) cases developed SSI. Surgical site infections were found significantly associated with maternal age above 25years, BMI>27Kg/m2 (p<0.001), hypertension, diabetes (p<0.001), the urgency of caesarean delivery, prolonged operative duration, technique and suture material (p<0.001) used. Poliglecaprone (monofilament) was found suitable for subcutaneous tissue and skin closure. Out of 38 cases with microbial growth, 52% cultured Staphylococcus aureus with 60% displaying methicillin resistance, followed by Diphtherioids (22%) and Pseudomonas (10.5%). Majority isolates showed higher sensitivity to Linezolid, Clindamycin and Vancomycin.Conclusion: Apart from maternal factors, the surgeon’s operative skill & technique, and suture material also contribute significantly to the development of SSI. A developing trend towards resistance to higher antibiotics was noted among Methicillin-resistant Staphylococcus aureus. Gentamicin and Linezolid were found as effective as second-line agents. Hence maintenance of quality asepsis and a hospital-based antibiotic policy is vital.

scholarly journals Sanguiin H-6 Fractionated from Cloudberry (Rubus chamaemorus) Seeds Can Prevent the Methicillin-Resistant Staphylococcus aureus Biofilm Development during Wound Infection

Antibiotics ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 1481
Author(s):  
John Jairo Aguilera-Correa ◽  
Sara Fernández-López ◽  
Iskra Dennisse Cuñas-Figueroa ◽  
Sandra Pérez-Rial ◽  
Hanna-Leena Alakomi ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Wound Infection ◽  
Preventive Measure ◽  
Surgical Site Infections ◽  
Infection Model ◽  
Growth Media ◽  
Methicillin Resistant ◽  
Biofilm Development

Staphylococcus aureus is the most common cause of surgical site infections and its treatment is challenging due to the emergence of multi-drug resistant strains such as methicillin-resistant S. aureus (MRSA). Natural berry-derived compounds have shown antimicrobial potential, e.g., ellagitannins such as sanguiin H-6 and lambertianin C, the main phenolic compounds in Rubus seeds, have shown antimicrobial activity. The aim of this study was to evaluate the effect of sanguiin H-6 and lambertianin C fractionated from cloudberry seeds, on the MRSA growth, and as treatment of a MRSA biofilm development in different growth media in vitro and in vivo by using a murine wound infection model where sanguiin H-6 and lambertianin C were used to prevent the MRSA infection. Sanguiin H-6 and lambertianin C inhibited the in vitro biofilm development and growth of MRSA. Furthermore, sanguiin H-6 showed significant anti-MRSA effect in the in vivo wound model. Our study shows the possible use of sanguiin H-6 as a preventive measure in surgical sites to avoid postoperative infections, whilst lambertianin C showed no anti-MRSA activity.

scholarly journals Correlation between mazEF Toxin-Antitoxin System Expression and Methicillin Susceptibility in Staphylococcus aureus and Its Relation to Biofilm-Formation

2021 ◽  
Vol 9 (11) ◽  
pp. 2274
Author(s):  
Aya Abd El rahman ◽  
Yasmine El kholy ◽  
Rania Y. Shash
Keyword(s):  
Staphylococcus Aureus ◽  
Biofilm Formation ◽  
Methicillin Resistance ◽  
Diffusion Method ◽  
P Value ◽  
Sequence Motifs ◽  
University Hospitals ◽  
Specific Sequence ◽  
Disk Diffusion Method ◽  
Cellular Mrnas

Methicillin resistance in Staphylococcus aureus has become prevalent globally. Moreover, biofilm-formation makes it more difficult to eradicate bacteria by antibiotics. The mazEF toxin-antitoxin system encodes for mazF, which acts as an endoribonuclease that cleaves cellular mRNAs at specific sequence motifs (ACA), and mazE, which opposes the mazF action. Our goal was to detect mazEF expression in methicillin-resistant S. aureus (MRSA) isolates compared with methicillin-sensitive S. aureus (MSSA) isolates and determine its relation to methicillin susceptibility as well as biofilm-formation. According to their susceptibility to cefoxitin disks, 100 S. aureus isolates obtained from patients admitted to Cairo University Hospitals were categorized into 50 MSSA and 50 MRSA according to their susceptibility to cefoxitin disks (30 µg). Antimicrobial susceptibility and biofilm-formation were investigated using the disk diffusion method and tissue culture plate method, respectively. Finally, using real-time PCR, mazEF expression was estimated and correlated to methicillin susceptibility and biofilm formation. Both MRSA and MSSA isolates showed the best sensitivity results with linezolid and gentamicin, where about 88% of MRSA isolates and 96% of MSSA isolates were sensitive to linezolid while 76% of MRSA isolates and 84% of MSSA isolates were sensitive to gentamicin. MRSA isolates were significantly more able to form biofilm than MSSA isolates (p-value = 0.037). The mazEF expression was significantly correlated to methicillin resistance in S. aureus (p-value < 0.001), but not to biofilm-formation.

scholarly journals Single vs Multiple Antibiotic Drug Regimen in Preventing Infectious Morbidity in Caesarean Section: A Randomised Clinical Trial

2021 ◽  
Author(s):  
Subhashchandra R Mudanur ◽  
Shreedevi S Kori ◽  
Aruna Biradar ◽  
Rajasri G Yaliwal ◽  
Dayanand S Biradar ◽  
...  
Keyword(s):  
Single Dose ◽  
Caesarean Section ◽  
Multiple Dose ◽  
Caesarean Delivery ◽  
Surgical Site Infections ◽  
Cost Effective ◽  
P Value ◽  
Infectious Morbidity ◽  
Group A ◽  
Group B

Introduction: Surgical site infections are a serious cause of maternal morbidity and mortality. Various preventive measures are being used to reduce the incidence of surgical site infections. One of them is the use of prophylactic antibiotics. In this study, authors have evaluated three antibiotic regimen with respect to preventing infectious morbidity in caesarean section. Aim: To study the efficacy and cost-effectiveness of a single dose (ceftriaxone) versus multiple doses of antibiotic therapy (ceftriaxone and ornidazole) administered preoperatively in women undergoing caesarean delivery. Materials and Methods: A prospective interventional study was conducted on 300 pregnant women undergoing emergency or elective caesarean delivery. Study was conducted at BLDE (DU) Shri BM Patil Medical College and Research Centre, Vijayapur, Karnataka, India. Patients were randomly assigned to three groups by block random sampling with 100 women in each group. Group A received Inj. ceftriaxone 1 gm single dose 60 minutes prior to commencement of surgery. Group B received Inj. ceftriaxone 1 gm along with Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and Group C received Inj. ceftriaxone 1 gm and Inj. ornidazole 500 mg intravenous infusion 60 minutes prior to commencement of surgery and a repeat dose 12th hourly for 24 hours followed by Tab. cefixime 200 mg and Tab. ornidazole 500 mg twice daily for four days postoperatively. The effectiveness of therapy was measured in terms of adverse effects of antibiotics such as nausea and vomiting and postoperative complications like pyrexia, foul smelling lochia, surgical site infections, uterine tenderness, peritonitis and endometritis. Results: There was no statistical difference in outcome measures in side-effects of antibiotics (p-value=0.13), fever (p-value=0.68), lochia discharge (p-value=0.88), wound infection (p-value=0.39) and peritonitis (p-value=0.30) among the three groups. The single dose medication in group A had a cost of Rs.60 INR (0.82 cents USD), which was significantly less compared to the multiple dose regimens in group B that cost Rs.203 INR ($2.76 USD). The mean hospital stay in non infectious and infectious patients were 5 and 10 days in present study (p<0.0001). Conclusion: Caesarean delivery poses 5-20 times greater risk of postoperative infection when compared to vaginal birth. There has been a shifting trend of increasing caesarean deliveries and postoperative infections can contribute to overwhelming health and economic burden. Present study shows outcome measures which were statistically insignificant among the three study groups with different prophylactic regimen for caesarean delivery, so it’s safe to state that both single dose and multiple dose regimen provided equal protective coverage in reducing maternal infectious morbidity. Also, single dose regimen proved to be cost-effective. So, to conclude single dose prophylactic antibiotic given preoperatively in caesarean section is both cost-effective and as is efficient.

Clinical profile of patients with post-caesarean wound infection: experience of Patan Hospital, Nepal

2020 ◽  
Vol 7 (1) ◽  
pp. 107-112
Author(s):  
Ekta Jaiswal ◽  
Paban Sharma ◽  
Alka Singh
Keyword(s):  
Health Care ◽  
Caesarean Section ◽  
Wound Infection ◽  
Infection Rate ◽  
Health Care Professionals ◽  
Caesarean Delivery ◽  
Antibiotic Sensitivity ◽  
Perinatal Period ◽  
Skin Closure ◽  
Coagulase Negative Staphylococci

Introduction: Would infection following caesarean delivery adds physical, psychological, and health burden to individual and health care system. This hospital based study aim to determine the rate of infection, the risk factors, pathogens and antibiotic sensitivity. Method: A prospective study was carried out to analyze the wound infection in women following caesarean delivery in the Department of Obstetrics and Gynecology, Patan Hospital, Nepal, between January 2018 to December 2018. The study was approved from the institutional review committee. Clinicodemographic data during perinatal period of caesarean delivery were descriptive analyzed in relation to wound infection. Result: Wound infection occurred in 102 (3.1%)of 3285 caesarean section (of total 7131 deliveries during the study period. The caesarean SSI rate was 3.1%, all were incisional SSI (84 superficial and 18 deep) and there were no organ-space SSI. Majority (81.3%) SSI cases were detected in emergency LSCS. Coagulase Negative Staphylococci was the most common organism isolated from wound swab. Routine postoperative antibiotics did not have a major impact in reducing wound infection rate. Multiple per vaginal examinations, prolonged rupture of membrane and staples for skin closure were more commonly associated with SSI. Conclusion: Reduction in caesarean rate is the major key factor for decreasing the post caesarean wound infection. Protocol should be developed and strictly implemented by all the health care professionals in order to minimize and prevent the infection rate after caesarean section.

Does a Care Bundle Reduce Racial Disparities in Postcesarean Surgical Site Infections?

2019 ◽  
Vol 36 (13) ◽  
pp. 1325-1331
Author(s):  
Tetsuya Kawakita ◽  
Jason G. Umans
Keyword(s):  
Cohort Study ◽  
Racial Disparities ◽  
Confidence Intervals ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Subcutaneous Tissue ◽  
Surgical Site Infections ◽  
Care Bundle ◽  
Skin Closure ◽  
Skin Preparation

Objective To examine the effect of a care bundle on racial disparities in surgical site infections (SSIs). Study Design This was a retrospective cohort study of women undergoing cesarean delivery at ≥23 weeks' gestation. The care bundle included routine antibiotics (both cefazolin and azithromycin), chlorhexidine skin preparation, clippers, vaginal cleansing, placental removal by cord traction, subcutaneous tissue closure, suture skin closure, dressing removal in 24 to 48 hours, and postoperative chlorhexidine soap. Our primary outcome was SSI (superficial incisional, deep incisional, and organ/space) occurring up to 6 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were calculated, adjusting for predefined covariates. Results Of 2,696 women, 1,947 were black (1,014 in the preimplementation period and 933 in the postimplementation period) and 749 were nonblack (370 in the preimplementation period and 379 in the postimplementation period). Regardless of race, women in the postimplementation period had lower rates of SSI compared with those in the preimplementation period (black: 2.9 vs. 5.2%, aOR: 0.53 [95% CI: 0.33–0.85]; nonblack: 1.1 vs. 3.5%, aOR: 0.28 [95% CI: 0.09–0.89]). There was no interaction by race (p for interaction = 0.94). Conclusion The care bundle decreased SSI in both black and nonblack women but did not reduce racial disparities.

scholarly journals Isolation, Detection and Molecular Characterization of Staphylococcus aureus from Postoperative Infections

2020 ◽  
pp. 63-67
Author(s):  
Ritya Mary Jibu ◽  
R. V. Geetha ◽  
T. Lakshmi
Keyword(s):  
Staphylococcus Aureus ◽  
Wound Infection ◽  
Molecular Characterization ◽  
Methicillin Resistance ◽  
Healthcare Associated Infection ◽  
Postoperative Infections ◽  
Coagulase Negative Staphylococci ◽  
Mrsa Strains ◽  
Healthcare Associated

Post operative infections that occur after surgical procedures can cause a lot of complications like sepsis, organ failure or even death. These are the third most commonly reported healthcare associated infection. The most common cause of wound infection regardless of procedure performed remains gram-positive cocci which comprise more than 50% of all infections. Specifically, Staphylococcus aureus and coagulase-negative staphylococci are the most frequent organisms isolated from a wound infection. There has been an increasing incidence of MRSA strains reported in hospitals across the globe. The main aim of our study is isolation, detection and molecular characterization of Staphylococcus aureus from postoperative infections.  Samples were collected from post operative patients with infected wounds. The area around the wound was cleaned. Exudates were collected from the wound with a sterile swab stick. The samples were inoculated on different solid culture mediums and the plates were incubated in the presence of oxygen at 37°C overnight. There were many standard procedures done in which tube coagulase was taken as the main criteria. Antibiotic susceptibility testing was done by Kirby Bauer method following Clinical and Laboratory Standards Institute (CLSI) guidelines using commercially available cefoxitin (30 μg) disc (HiMedia) and the results were compared with Staphylococcus aureus ATCC 25923 and MRSA ATCC 43300 control strains. The MRSA strains were identified and detection of Mec A gene that codes for methicillin resistance is done using PCR technique.

scholarly journals SURGICAL SITE INFECTIONS;

2017 ◽  
Vol 24 (01) ◽  
pp. 57-63
Author(s):  
Abdul Rashid Surahio ◽  
Altaf Ahmed Talpur ◽  
Abdul Salam `Memon ◽  
Afzal Junejo ◽  
Abdul Aziz Laghari
Keyword(s):  
Staphylococcus Aureus ◽  
Private Sector ◽  
Wound Infection ◽  
Surgical Techniques ◽  
Surgical Site Infections ◽  
E Coli ◽  
Sensitivity Pattern ◽  
Long Time ◽  
Grade Ii ◽  
Preoperative Antibiotics

Background: Wound infection has been a major problem in the surgical fieldsince long time. Significant improvements in sterilization, preoperative preparation of patient forsurgery, surgical techniques & prophylactic usage of preoperative antibiotics have not been ableto eradicate wound infections. Development of wound infection increases the hospital stay, costof treatment & increase morbidity & mortality associated with surgery. Objectives: To assesstype of organism responsible for postoperative wound infection & its drug sensitivity patterns atPublic & private sector hospitals of Hyderabad. Study Design: Prospective, descriptive study.Setting: Public & Private Sector Hospitals of Hyderabad, Pakistan. Period: June 2013 to May2014. Materials & Method: All patients of either sex above the age of 13 years who underwentsurgery & developed wound infection were included in the study. Samples to assess culture &sensitivity pattern of organism were taken from infected wounds. Subject’s data was collectedon preformed proforma for age, sex, diagnosis, co morbid illness, type of surgery, presence orabsence of wound infection, grade of infection, and culture & sensitivity pattern of organismisolated. Results: During this 1 year period total of 424 patients of different pathologies relatedto General surgery were finally included in analysis. Mean age was 27.35 years with 61.08%were male and 38.91% female. Inguinoscrotal operations were the commonest proceduresperformed in 113(26.65%) patients followed by Appendicectomy in 102(24.06%) patients.Surgical site infection was noticed in 54(12.74%) patients with 47(13.27%) had this of grade II& above. It includes 23(22.55%) patients of Appendicectomy followed by 09(33.33%) patientsof Laparotomy. 47(13.27%) samples were sent for Culture & sensitivity with 41(11.58%) ofthem showed positive yield. E. coli noticed as commonest organism isolated in 26(63.41%)patients followed by Staphylococcus Aureus in 08(19.51%). Most sensitive antibiotics againstnoted were Meropenem & Pipracillin with Tazobactum which showed sensitivity to E.coli in25(96.15%) patients & 24(92.31%) patients respectively while their sensitivity against S.Aureus was 07(87.5%) & 06(75%) patients respectively. Vancomycin was found sensitiveagainst Staphylococcus Aureus in 07(87.5%) patients. Sensitivity of Ampicillin to most ofthese organisms was found significantly low. Conclusion: Wound infection is responsible forsignificant morbidity in developing world with the frequency of 15.53% in this study. It puts upsignificant economic burden on the hospitals.

scholarly journals Superficial surgical site infections following stone and non-stone bile duct surgery- A comparative analysis

2021 ◽  
Vol 11 (2) ◽  
pp. 458-462
Author(s):  
Chishti Tanhar Bakth Choudhury ◽  
BH Nazma Yasmeen ◽  
Manir Hossain Khan ◽  
AHM Towhidul Alam ◽  
Shirin Akhter
Keyword(s):  
Bile Duct ◽  
Surgical Site Infection ◽  
Wound Infection ◽  
Surgical Site Infections ◽  
Stone Disease ◽  
P Value ◽  
Site Infection ◽  
Causative Agents ◽  
Group A ◽  
Group B

Background : Superficial surgical site infection (SSSI) is a vital issue after biliary surgery. Surgical site infections remain a major cause of illness in the post-operative period. Objectives : The purpose of the present study was to compare the number of wound infection and the causative organism of surgical site infection of patient of stone and non-stone bile duct surgery. Methodology : This cross-sectional study was carried out in the Department of Surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from May 2017 to April 2018 for a period of 12 months. Patients presented with biliary disease of stone and non-stone variety were selected as study population. Patients were divided into 2 groups designated as group A and group B. Patients with the biliary stone disease were enrolled in group A and the biliary nonstone disease patients were in the group B. Patients were followed up in the postoperative period up to 2 weeks to find out the incidence of wound infection and its risk factors, causative agents, and some other variables. Certain variables were closely monitored to find the postoperative outcome as these variables were standard parameters in assessment of the outcome of the study. Results : A total number of 50 patients were recruited for this study of which 25 patients were enrolled in group A and the 25 patients were enrolled in group B. Mean age was 42.48 ± 17.21 years in group A and 40.04 ± 21.37 years in group B. The difference was not statistically significant ( p=0.659). Males were predominant in both groups. Male female ratio was 1.77:1 and 1.08:1 in group A and group B respectively. Inflammatory evidence of gall bladder with pericholecystic collection was found in 5 (20%) and 6 (24%) patients in group A and group B. There was evidence of cholangitis in 8 (32%) and 4 (16%) patients in group A and group B respectively. Evidence of inflammation at the wound site, was found in 14 (56%) patients in group A and 7 (28%) patients in group B. There was statistically significant difference between these 2 groups in the incidence of superficial surgical site infection, ( p value is 0.045). Regarding per operative collected bile, we found E. Coli in 4 cases in group A and 3 cases in group B ( p value is 0.408). Klebsiella spp. was found in 1 patient in group A. Wound swab C/S identified E. Coli in 1 patient in group A. Staph aureus was found in 1 and 2 patients in group A and group B respectively ( p value is nonsignificant). Conclusion : In conclusion, there is a difference in the incidence of occurrence of surgical site infection and causative agents after stone and non-stone bile duct surgery. Stone disease has increased chance of wound infection than nonstone disease of bile ducts. Northern International Medical College Journal Vol.11 (2) Jan 2020: 458-462

scholarly journals Antimicrobial Susceptibility Pattern of Bacterial Isolates from Surgical Site Infections in a Tertiary Care Hospital

2021 ◽  
Vol 10 (11) ◽  
pp. 369-375
Author(s):  
Anusuya Devi Devaraju S. Latha Roy
Keyword(s):  
Escherichia Coli ◽  
Staphylococcus Aureus ◽  
Pseudomonas Aeruginosa ◽  
Klebsiella Pneumoniae ◽  
Antimicrobial Susceptibility ◽  
Methicillin Resistance ◽  
Surgical Site Infections ◽  
Cost Of Care ◽  
Esbl Production ◽  
Susceptibility Patterns

Background Surgical site infections are ranked among the most common health care associated infections. They cause significant morbidity, increased cost of care and prolonged hospital stay. A spectrum of microorganisms with varied antimicrobial susceptibility patterns have been identified as causative agents of SSI which vary with time, hospital, and with the type of surgical procedure performed. We conducted this study with an objective to assess the burden of SSI, its causative aerobic bacteria and their in vitro antibiotic susceptibility patterns. Aims & objectives 1) To identify the aerobic bacteriological profile of isolates causing surgical site infections. 2) To determine the antibiotic sensitivity pattern of the isolates. Method: This study includes 266 clinically diagnosed cases of SSIs over a period of 8 months. Isolates were identified by conventional methods. Isolates of Staphylococcus aureus were tested for methicillin resistance by cefoxitin. Isolates of Escherichia coli and Klebsiella pneumoniae which showed resistance to cefotaxime and ceftazidime were tested for ESBL production by CLSI guidelines. Isolates of Pseudomonas aeruginosa were screened for MBL production using Imipenem disc diffusion test. Results of the 266 samples processed, 193(72.5%) were culture positive samples which yielded 204 isolates. Staphylococcus aureus 60 (29.4%) was found to be the predominant organism causing SSI followed by Pseudomonas aeruginosa 40 (19.6%). Methicillin resistance was observed in 12 (20%) of Staphylococcus aureus strains. ESBL production was observed in 20.5% of Klebsiella pneumoniae isolates and 13.2 % Escherichia coli isolates. MBL production was not seen Pseudomonas aeruginosa isolates. Conclusion: The present study showed the commonest bacteria responsible for the surgical site infections like Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. Hence Implementation of an effective infection control programme and judicious use of antibiotic prophylaxis reduces the incidence of SSI in the hospital.

scholarly journals A comparative study on surgical site infections after primary closure and delayed primary closure in clean contaminated laparotomy cases

2019 ◽  
Vol 6 (3) ◽  
pp. 989
Author(s):  
T. J. Pauly ◽  
T. V. Haridas ◽  
E. Manoj Prabhakar ◽  
Roshjo Roshan
Keyword(s):  
Surgical Site Infection ◽  
Primary Closure ◽  
Surgical Site Infections ◽  
P Value ◽  
Skin Closure ◽  
Site Infection ◽  
Chi Square ◽  
Delayed Primary Closure ◽  
Laparotomy Wound ◽  
Clean Contaminated

Background: Surgical site infection is a significant cause of post operative morbidity. Timing of skin closure following a surgery and its relation to incidence of infection has been studied. The debate whether primary or delayed primary closure have been around for a long time. The aim of this study is to compare the rate of infection in a laparotomy wound in clean contaminated laparotomy cases after primary and delayed primary closure.Methods: 132 patients who underwent laparotomy for clean contaminated were selected. Of this primary closure of the skin was done in 66 cases and delayed primary closure at 48 hours were done in the other 66 patients. Wounds were followed up till post op day 7. The results between two groups were compared using chi square test.Results: two out of 66 cases developed SSI in the delayed primary sutured group whereas 8 out of 66 cases developed SSI in primary suturing group. The results were compared using chi square test and the chi square statistic was 3.8951 and the p value is 0.048428 (<0.05) proving the result significant.Conclusions: The incidence of surgical site infection in laparotomy wound after a primary closure was higher compared to delayed primary closure in clean contaminated laparotomy wounds and the difference is significant based on statistical evaluation.

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