Nurses’ Attitude About Pap Smear As An Early Screening Method For Cervical Cancer In The Private Hospital

The prevalence of cervical cancer in Indonesia is very high, which it is estimated that every day 40-45 new cases appear. The purpose of this study was to describe nurses’ attitude about pap smear as an early detection of cervical cancer in a hospital in western Indonesia. The research method was used descriptive quantitative with purposive sampling technique. The results of this study shows that most of the respondents have the positive attitude in performing pap smears in the Western Indonesia hospitals with the percentage of 97,5% and the rest indicate negative attitude. The conclusion of this study is that the positive attitude of nurses towards early detection of pap smears is expected to be maintained and furthermore the hospital continues to provide health facilities for female nurses to carry out early detection of cervical cancer as an annual program from hospital.

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Effectiveness of Visual Inspection with Acetic Acid and Pap Smear for Early Detection of Cervical Cancer among Women attending Gynecology O.P.D of Tertiary Level Hospital Gwalior (M.P) India

Nepal Medical Journal ◽

10.37080/nmj.177 ◽

2021 ◽

Vol 4 (1) ◽

pp. 44-50

Author(s):

Nisha Mehta ◽

Saroj Singh

Keyword(s):

Cervical Cancer ◽

Acetic Acid ◽

Early Detection ◽

Visual Inspection ◽

Pap Smear ◽

Sampling Technique ◽

Tertiary Level ◽

Cross Sectional ◽

Screening Programs ◽

Level Hospital

Introduction: Cervical cancer is the fourth most common cause of cancer in women in the world and the second most common cancer among Indian women. About 23% of the global cervical cancer burden is beard by India alone. The screening of cervical cancer is commonly done by a pap smear, visual inspection of acetic acid, human papillomavirus DNA testing etc. These identify precancerous changes which when treated can prevent the development of cancer. The objectives of the study were to screen the patient at Gynecology OPD by visual Inspection with acetic acid (VIA) and Pap smear for early detection of cervical cancer and to evaluate the efficacy of visual inspection with acetic acid and Pap smear in the early detection of cervical cancer. Methods: A descriptive cross-sectional study was conducted among 60 women attending Gynecology O.P.D of a Tertiary Level Hospital, Gwalior (India) by non-probability purposive sampling technique between 1st August to 30th August 2017. Pap smear was taken from each woman followed by VIA. Women with positive VIA and/or positive Pap smear were referred for colposcopy-directed cervical biopsy. Results: After the application of 3% VIA among 60 women, 16 (26.67%) developed acetowhite while 44 (73.33%) didn’t. While the result of Pap smear shows, 22 (36.66%) had an inflammatory smear, 6(10%) shows benign smear, 9(15%) bacterial vaginosis, 1(1.66%) squamous metaplastic cells, 12 (20%) shows adenocarcinoma and 10(16.66%) normal pap smear. Conclusion: The study concludes that VIA and pap smear were effective methods for the early detection of cervical cancer. Visual inspection of the cervix after acetic acid application (VIA) is widely recommended as the method of choice in cervical cancer screening programs in resource-limited settings and developing countries because of its simplicity, cost-effectiveness and ability to link with immediate treatment.

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Onkogenesis, Morfologi, dan Modalitas Deteksi Dini Karsinoma Serviks

Medical Scope Journal ◽

10.35790/msj.3.1.2021.33543 ◽

2021 ◽

Vol 3 (1) ◽

pp. 47

Author(s):

Elsani P. L. Rapar ◽

Maria K. Sambuaga ◽

Meilany F. Durry

Keyword(s):

Cervical Cancer ◽

High Risk ◽

Early Detection ◽

Cervical Carcinoma ◽

Pap Smear ◽

Morphological Changes ◽

Screening Tests ◽

Pap Smears ◽

Hpv Dna ◽

E6 And E7

Abstract: The incidence and mortality rates of cervical cancer in developing countries are relatively high compared to developed countries. The main risk factor for cervical cancer is high risk human papilloma virus (HPV) infection, such as types 16 and 18. Types of high-risk HPV expresses oncoproteins E6 and E7 which play an essential role in the pathogenesis of cervical carcinoma through inhibition of the activity of gene group expression products that play a role in suppressing tumor growth, such as p53 and pRB. This process will cause morphological changes in the squamous epithelium from precancerous lesions to cancer. The development of squamous epithelial cell cancer can be prevented through screening tests in order to detect cervical cancer early. This study was aimed to obtain the oncogenesis, morphology, and early detection modality of cervical carcinoma. This was a literature review study using three databases, as follows: ClinicalKey, PubMed, and Google Scholar. The results explained that p53 and pRB suppression by high-risk HPV oncoproteins E6 and E7 played an important role in the pathogenesis of cervical carcinoma. The most common histological type is squamous cell carcinoma. Screening tests such as visual inspection with acetic acid (VIA), Pap smears and HPV DNA have an important role as modalities for early detection of malignancy. More specifically VIA and Pap smears are suitable for Indonesia which is a developing country, especially when implemented in peripheral areas.Keywords: oncogenesis; morphological changes; early detection; cervical carcinoma Abstrak: Insidens dan mortalitas kanker serviks di negara berkembang relatif tinggi dibandingkan negara maju. Faktor risiko utama dari kanker serviks adalah infeksi human papilloma virus (HPV) risiko tinggi yaitu tipe 16 dan 18. HPV tipe risiko tinggi mengekspresikan onkoprotein E6 dan E7, yang berperan penting dalam patogenesis karsinoma serviks melalui inhibisi terhadap aktivitas produk-produk ekspresi kelompok gen yang berperan dalam menekan pertumbuhan tumor, seperti p53 dan pRB. Proses ini akan menyebabkan perubahan morfologik pada epitel skuamosa mulai dari lesi prakanker sampai kanker. Perkembangan kanker sel epitel skuamosa dapat dicegah melalui pemeriksaan skrining guna mendeteksi dini kanker serviks. Penelitian ini bertujuan untuk mengetahui onkogenesis, morfologi, dan modalitas deteksi dini karsinoma serviks. Jenis penelitian ialah literature review menggunakan tiga basis data yaitu ClinicalKey, PubMed, dan Google Scholar. Hasil penelitian mendapatkan bahwa penekanan p53 dan pRB oleh onkoprotein HPV risiko tinggi E6 dan E7 sangat berperan penting dalam patogenesis karsinoma serviks. Tipe histologik tersering ialah tipe karsinoma sel skuamosa. Pemeriksaan skrining seperti pemeriksaan inspeksi visual dengan asam asetat (IVA), Pap smear dan HPV DNA memiliki peran penting sebagai modalitas deteksi dini keganasan. Lebih khusus IVA dan Pap smear cocok untuk negara Indonesia yang merupakan negara berkembang, terutama bila diimplementasikan di daerah perifer.Kata kunci: onkogenesis; perubahan morfologik; deteksi dini; karsinoma serviks

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HUBUNGAN PENGETAHUAN DAN SIKAP IBU TERHADAP DETEKSI DINI KANKER SERVIKS DENGAN PEMERIKSAAN IVA DI PUSKESMAS SEKUPANG

Zona Kedokteran: Program Studi Pendidikan Dokter Universitas Batam ◽

10.37776/zked.v7i3.7 ◽

2019 ◽

Vol 7 (3) ◽

pp. 38-44

Author(s):

Suratin Suratin ◽

Susanti Susanti

Keyword(s):

Cervical Cancer ◽

Early Detection ◽

Health Center ◽

Health Centre ◽

Negative Attitude ◽

Sampling Technique ◽

Survey Study ◽

Adult Women ◽

Cross Sectional ◽

Knowledge Levels

One of the most possible ways of early detection for cervical cancer is through theVIA examination. This study aims to determine the correlation of knowledge levels and attitude of adult female on early detection for cervical cancer with VIAtest.This research is an analytical survey study with cross sectional approach. The population investigated isthe fertile age couples attended the Sekupang Health Centre dated from June to July 2017. Furtherfrom the population, 71 respondents were selected as the sample through accidental sampling technique. This research utilizes questionnaires to collect the data, then analyzed by chi square statistical test. The result presents that74.6% female adults have good knowledge level, 64.8% of them show negative attitude, and 64.8% women do not perform the VIA test.The correlation coefficients obtained for the knowledge is p = 0.000 and attitude is p = 0.010 (p<0.05). These findings verified that there is a significant correlation between knowledge levels and attitude of adult women on early detection of cervical cancer by performing the VIA test, particularly at Sekupang Public Health Center in 2017. Finally, it is suggested for health workersof Sekupang Health Center to develop a more intensive and innovative counseling program on the cervical cancer as well as on how to detect the early sign of the cancers in women for general

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Point-of-care digital cytology with artificial intelligence for cervical cancer screening at a peripheral clinic in Kenya

10.1101/2020.08.12.20172346 ◽

2020 ◽

Author(s):

Oscar Holmstrom ◽

Nina Linder ◽

Harrison Kaingu ◽

Ngali Mbuuko ◽

Jumaa Mbete ◽

...

Keyword(s):

Cervical Cancer ◽

Pap Smear ◽

Point Of Care ◽

Screening Method ◽

Machine Learning Algorithms ◽

Learning System ◽

Pap Smears ◽

Low Grade ◽

High Grade ◽

Predictive Values

Cervical cancer is highly preventable but remains a common and deadly cancer in areas without screening programmes. Pap smear analysis is the most commonly used screening method but is labour-intensive, subjective and requires access to medical experts. We developed a diagnostic system in which microscopy samples are digitized at the point-of-care (POC) and analysed by a cloud-based deep-learning system (DLS) and evaluated the system for the detection of cervical cell atypia in Pap smears at a peripheral clinic in Kenya. A total of 740 conventional Pap smears were collected, digitized with a portable slide scanner and uploaded over mobile networks to a cloud server for training and validation of the system. In total, 16,133 manually-annotated image regions where used for training of the DLS. The DLS achieved a high average sensitivity (97.85%; 95% confidence interval (CI) 83.95-99.75%) and area under the curve (AUCs) (0.95) for the detection of cervical-cellular atypia, compared to the pathologist assessment of digital and physical slides. Specificity was higher for high-grade atypia (95.9%; 95% CI 94.9-97.6%) than for low-grade atypia (84.2%; 95% CI 79.9-87.9%). Negative predictive values were high (99.3-100%), and no samples classified as high grade by manual sample analysis had false-negative assessments by the DLS. The study shows that advanced digital microscopy diagnostics supported by machine learning algorithms is implementable in rural, resource-constrained areas, and can achieve a diagnostic accuracy close to the level of highly trained experts.

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KARAKTERISTIK WANITA USIA SUBUR DENGAN TINDAKAN PENCEGAHAN KANKER SERVIKS

THE JOURNAL OF MUHAMMADIYAH MEDICAL LABORATORY TECHNOLOGIST ◽

10.30651/jmlt.v3i2.6672 ◽

2020 ◽

Vol 3 (2) ◽

pp. 100

Author(s):

Supatmi Supatmi

Keyword(s):

Cervical Cancer ◽

Early Detection ◽

Cancer Prevention ◽

Pap Smear ◽

Cervical Cancer Prevention ◽

Pap Smears ◽

Prevention Measures ◽

Childbearing Age ◽

Cross Sectional ◽

Significance Level

AbstractBackground: The awareness of Indonesian women to carry out early detection of cervical cancer on a regular basis have been still low. Cervical cancer can be prevented and cured by taking early detection measures because it has a long preinfassive phase. Cervical cancer prevention measures are influenced by several factors including age, education level, occupation and parity, Aims: analyze the characteristics of women of childbearing age with cervical cancer prevention measures (HPV, IVA and Pap smear immunization) Methods: Quantitative analytic research design with cross sectional approach. The population was 193 women of fertile age in RW 9 Kelurahan Kapasan Surabaya with n Cluster Samples, the sample was 130 WUS. The research instrument used a characteristic questionnaire and cervical cancer prevention measures with a Dichotomy Question. The research variables were WUS cataristic and cervical cancer prevention behavior. Analysis with Chi-Square with a significance level of 0.05Results: There was a relationship between age and HPV immunization (p = 0.066) and pap smear (p = 0.058), IVA action had not relationship (p = 0.770), education was related to HPV immunization (p = 0.346). IVA (0.005) was not related to pap smears = 0.603) Occupation was related to HPV immunization (p = 0.280), IVA (p = 0.000) and pap smears (p = 0.216), parity was related to HPV immunization (p = 0.003) ) and Pap smear (p = 0.117) meanwhile parity had not relationship with IVA (p = 0.839). Studying the characteristics of WUS is a first step to increase preventive efforts for cervical cancer both primary and secondary prevention Keyword: Characteristics of WUS, Prevention, Cervical Cancer

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EARLY DETECTION KANKER SERVIKS SEBAGAI UPAYA PENINGKATAN DERAJAT HIDUP PEREMPUAN

SELAPARANG Jurnal Pengabdian Masyarakat Berkemajuan ◽

10.31764/jpmb.v3i2.1883 ◽

2020 ◽

Vol 3 (2) ◽

pp. 144

Author(s):

Evicenna Naftuchah Riani ◽

Dewi Ambarwati

Keyword(s):

Cervical Cancer ◽

Early Detection ◽

Pap Smear ◽

Cancer Survival ◽

Public Awareness ◽

Pap Smears ◽

Central Java ◽

Questions And Answers ◽

Stage 1 ◽

Smear Testing

ABSTRAKKanker merupakan penyebab kematian terbesar di dunia. Pada tahun 2018 terdapat 18,1 juta kasus dengan angka kematian sebesar 9,6 juta. Di Indonesia kanker serviks menduduki peringkat kedua setelah kanker payudara yang diderita oleh perempuan dengan angka kejadian 23,4/100.000 penduduk dengan rata-rata kematian sebesar 13,9/100.000 penduduk. Menurut perkiraan Kementrian Kesehatan RI saat ini, jumlah perempuan penderita baru kanker serviks berkisar 90-100 kasus per 100.000 penduduk dan setiap tahun terjadi 40 ribu kasus kanker serviks. Jawa Tengah merupakan propinsi tertinggi kedua di Indonesia dengan angka kejadaian kanker serviks sebesar 19.734 kasus. Kabupaten Banyumas tiap tahun meningkat, tahun 2010 terdapat 196 kasus, tahun 2011 terdapat 243 kasus dan pada tahun 2012 terdapat 268 kasus. Pasien yang dirawat di Rumah Sakit rata-rata sudah memasuki stadium lanjut, hanya 18,5% yang masih tahap stadium 1. Tujuan dilakukan kegiatan ibm untuk meningkatkan pengetahuan early detection kanker serviks sebagai upaya peningkatan derajat hidup perempuan. Metode yang digunakan dengan ceramah, diskusi, tanya jawab, demonstrasi iva dan pap smear serta evaluasi kegiatan. Terdapat peningkatan pengetahuan tentang tanda gejala kanker serviks dan peningkatan kesadaran masyarakat akan pentingnya pemeriksaan IVA dan papsmear sebagai upaya peningkatan derajat hidup perempuan. Kata kunci : early detection; kanker serviks; derajat hidup perempuan. ABSTRACTCancer is the biggest cause of death in the world. In 2018 there were 18.1 million cases with a mortality rate of 9.6 million. In Indonesia cervical cancer is ranked second after breast cancer suffered by women with an incidence of 23.4 / 100,000 population with an average death of 13.9 / 100,000 population. According to current estimates of the Indonesian Ministry of Health, the number of women with new cervical cancer ranges from 90-100 cases per 100,000 population and 40 thousand cases of cervical cancer occur annually. Central Java is the second highest province in Indonesia with a cervical cancer survival rate of 19,734 cases. Banyumas Regency has increased every year, in 2010 there were 196 cases, in 2011 there were 243 cases and in 2012 there were 268 cases. Patients treated at the hospital on average had entered an advanced stage, only 18.5% were still in stage 1. The aim was to carry out ibm activities to increase knowledge of early detection of cervical cancer as an effort to increase the degree of life of women. The method used by lectures, discussions, questions and answers, demonstrations iva and pap smears and evaluation of activities. There is an increase in knowledge about the symptoms of cervical cancer and an increase in public awareness of the importance of IVA and Pap smear testing in an effort to increase the degree of life of women. Keywords : early detection; cervical cancer; degree of life of women.

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Cervical Cancer Screening

Annals of King Edward Medical University ◽

10.21649/akemu.v23i1.1505 ◽

2017 ◽

Vol 23 (1) ◽

Author(s):

Prof. Tayyiba Wasim

Keyword(s):

Cervical Cancer ◽

Developing Countries ◽

Acetic Acid ◽

Cancer Screening ◽

Early Detection ◽

Visual Inspection ◽

Pap Smear ◽

Screening Method ◽

Effective Screening ◽

The World

Cervical cancer is the fourth most common cancer in women in the world and second commonest cancer in less developed countries. It is estimated that 528, 000 cases are reported ever year with 80% reported in underdeveloped countries.1 It is one of the few cancers which have a well defined, approachable and early detectable pre cancerous stage which takes 10 – 15 years to transform into invasive disease. Exposure to HPV infection especially 16 & 18 along with risk factors of early age in first intercourse, multiple sexual partners, and smoking and low socio economic status all make women more vulnerable to cervical cancer.2 According to recent PDHS survey, women in Pakistan marry at a median age of 19.5 years and 8% of teenage pregnancy happen.3 Extra marital sex is prevalent although not talked about much. In Pakistan incidence of cervical cancer is reported to be 3.6% of all cancers with screening coverage of 1.9%.4 Effective screening program of Pap smear has resulted in decline of incidence and mortality in the developed world. The standard practice is to screen women using cytology every 3 years starting from 21 – 65 years.5 In contrast, this program is a failure in the developing countries because of lack of laboratory infrastructure, trained cytologist, cost and follow up visit requirement especially in rural areas. The menace of disease is visible when it is already spreaded adding the threat to human life and burden to health care system. The visual inspection of cervix with acetic acid (VIA) has been advocated as an alternative screening method to Pap smear in developing countries. It comprises of application of 5% acetic acid to the cervix and visualization of acetowhite area. It is simple, cheap, and easy to perform, does not require lab infrastructure and can be learnt easily. WHO guideline6 suggests VIA as recommended screening method in developing countries. VIA has been evaluated in large number of clinical trials in India, Bangladesh and Africa in terms of sensitivity, specificity, positive & negative predictive value in detecting CIN and has been found a reliable screening test.7-10 HPV DNA testing is now the recommended screening test according to recent AS-CO guideline.11 Screening in developing countries has been addressed in this guideline for the very first time and VIA has been suggested for basic settings. Effective treatment approaches in the form of Cryotherapy, LEEP/LETTZ and cold knife conization are present for cervical premalignancy. Screen and treat approach at single visit is now recommended by WHO in low and middle income countries.6 More than 2 million women worldwide have cervical cancer. Despite evidence that cervical cancer has declined in certain regions of the world and that survival in women with this cancer has improved, far too many women die from this cancer every year in developing countries due to lack of effective screening programmes. Primary prevention in the form of HPV vaccine was introduced 10 years ago but it is still not widely used in resource poor countries due to its cost.12 Interventions that do not require massive capital investment are available and need to be explored in low resource settings, where access to early detection of cervical cancer is generally limited. It is hoped that decision makers are enlightened about possible alternative strategy in the form of visual inspection of acetic acid for cervical cancer screening that could improve the lives of women by early detection, destigmatize this disease in community, and ensure that they remain on the healthcare agenda. A three prong strategy including sexual health education, screening and HPV vaccination should be global health priority to reduce burden of this highly preventable cancer.

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Pathways to Early Detection of Cervical Cancer for a Multiethnic, Indigent, Emergency Department Population

Health Education Quarterly ◽

10.1177/109019819602301s08 ◽

1996 ◽

Vol 23 (1_suppl) ◽

pp. 89-104 ◽

Cited By ~ 5

Author(s):

Linda Engelstad ◽

Katherine Bedeian ◽

Kimberley Schorr ◽

Susan Stewart

Keyword(s):

Cervical Cancer ◽

Early Detection ◽

Low Income ◽

Pap Smear ◽

Screening Program ◽

Alternative Pathway ◽

Cervical Screening ◽

High Risk Population ◽

Pap Smears ◽

Access To Primary Care

When access to primary care is limited, low-income women of all races and ethnicities seek care in public hospital emergency departments (EDs) in which preventive services are often unavailable. This project implemented and evaluated a cervical screening program in an inner-city ED. Clinicians were asked to offer Pap smears to women undergoing diagnostic pelvic examinations. Women with abnormal results were randomized to follow-up in one of two settings. Women with normal results received an intervention promoting annual rescreening. In 12 months, 1,523 Pap smears were performed on 1,442 women; 58% were African American; 21%, Hispanic; and 7%, Asian. Among these women, more than 22 languages were spoken, and 26% did not recall having a prior Pap smear. Preliminary findings suggest that cervical cancer screening can be incorporated into routine ED care, creating an important alternative pathway to early detection for a high-risk population.

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Comparative study of conventional Pap smear and liquid based cytology as a screening method for cervical cancer

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20213096 ◽

2021 ◽

Vol 9 (8) ◽

pp. 2439

Author(s):

Bhagyalakshmi Atla ◽

Uma Prasad ◽

Venkata Satya Kartheek Botta ◽

Uma Namballa ◽

Lahari Pujari ◽

...

Keyword(s):

Cervical Cancer ◽

Epithelial Cell ◽

Pap Smear ◽

Screening Method ◽

P Value ◽

Pap Smears ◽

Cervical Lesions ◽

Malignant Lesions ◽

Liquid Based Cytology

Background: Pap smear is the conventional screening procedure for cervical cancer. Liquid based cytology has been developed as a cost effective alternative as it has a short screening time, better morphology and clean background while also providing residual material to test for HPV DNA. Therefore this study is undertaken to know the role of Liquid-based cytology in evaluating pre-malignant and malignant lesions of cervix. Objectives of current study were to study the distribution of various cervical lesions on liquid-based cytology and compare them with conventional Pap smears. To know the role of liquid-based cytology in evaluating pre-malignant and malignant lesions of cervixMethods: This study included 200 women attending to gynaecology OPD and the samples were taken for both conventional cytology and liquid based cytology. The smears were studied in detail and were interpreted as per The Bethesda system 2014 of reporting pap smears and results are recorded and compared.Results: The commonest cervical lesions on pap smears by liquid-based cytology are NILM-reactive changes (N=92, 46%), NILM Candida infection is seen in 9 cases (4.5%) and trichomonas vaginalis infection in 5 cases (2.5%). Unsatisfactory smears on LBC is less when compared to conventional smears as the coefficient of correlation is significant with p value of 0.000422 (<0.05). The number of cases with a diagnosis of ASCUS is reported more in liquid-based cytology (9 cases) when compared to conventional Pap (8 cases). The number of cases with diagnosis of HSIL, SCC is reported more in liquid based cytology (7 cases) when compared to conventional Pap (4 cases). Epithelial cell abnormality were easily diagnosed on LBC smears with significant p value of 0.002414 (<0.05).Conclusions: Liquid-based cytology has advantages of fewer unsatisfactory smears and better detection of epithelial cell abnormalities when compared to conventional Pap smears. LBC is better for the screening of premalignant and malignant lesions of cervix even though it is costly.

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Women’s health concern in Jordan: knowledge, practice and barriers toward cervical cancer screening

International Journal of Human Rights in Healthcare ◽

10.1108/ijhrh-04-2021-0085 ◽

2021 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Roqia Saleem Maabreh ◽

Raya Yousef Al-Husban ◽

Hekmat Yousef Al-Akash ◽

Noha Al-Shdayfat

Keyword(s):

Risk Factors ◽

Cervical Cancer ◽

Pap Smear ◽

Cervical Screening ◽

Health Concern ◽

Cancer Awareness ◽

Early Screening ◽

Cross Sectional ◽

Content Type ◽

Knowledge Barriers

Purpose Cervical cancer (CC) is one of the most important health issues faced by women worldwide. The purpose of this study is to identify Jordanian women’s knowledge, barriers and measures pertaining to risk factors and screening choices of CC (Pap smear tests). Design/methodology/approach This study applied a cross sectional design by collecting data from a convenient sample of 200 women between 20 and 70 years of age in health and public centers in Jordan. Data was then analyzed using the descriptive statistical tools of SPSS, version 21. Findings The findings revealed that 55.5% of the participants had no information about the Pap smear, and 75% did not know the risk factors. Moreover, 50% of the sample did not know where to take the test, and 50% reported a lack of encouragement from the husband to undertake the test. More than half of the participants (56.5%) expressed fear that cervical screening would be a painful examination even though they reported not having any previous experience with the test. Originality/value Based on these findings, public education about CC screening is essential, including advertising and a campaign similar to the breast cancer awareness programs in Jordan, as a way of encouraging early screening to improve the health of women.

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