GHM open最新文献

{"title":"Factors associated with withholding of invasive mechanical ventilation in the early phase of the COVID-19 response and their ethical analyses.","authors":"Shinichiro Morioka, Kyoko Takashima, Yusuke Asai, Tetsuya Suzuki, Hidetoshi Nomoto, Sho Saito, Kumiko Suzuki, Setsuko Suzuki, Lubna Sato, Keiji Nakamura, Mio Nikaido, Nobuaki Matsunaga, Kayoko Hayakawa, Masanori Mori, Keiichiro Yamamoto, Norio Ohmagari","doi":"10.35772/ghmo.2025.01002","DOIUrl":"10.35772/ghmo.2025.01002","url":null,"abstract":"<p><p>End-of-life decision making regarding invasive mechanical ventilation (IMV) for patients with severe coronavirus disease (COVID-19) is challenging. We aimed to explore the factors associated with the withholding of IMV in patients with COVID-19. This retrospective study included patients registered in a nationwide COVID-19 Registry Japan. We enrolled patients with COVID-19 admitted between January 1, 2020, and June 30, 2021, and died during hospitalization. The enrolled patients were divided into two groups: those who received IMV (IMV group) and those who did not (non-IMV group). To identify the factors associated with withholding of IMV among patients with COVID-19 who died during hospitalization, we conducted a multivariate logistic regression analysis. A total of 2,401 patients were enrolled. Of these, 588 (24.5%) were in the IMV group and 1813 (75.5%) in the non-IMV group. Withholding IMV was positively associated with older age (95% confidence interval [CI]: 0.82-0.88, <i>p</i> < 0.0001), dementia (95% CI: 0.81-0.91, <i>p</i> < 0.0001), chronic lung disease (95% CI: 0.88-1.00, <i>p</i> = 0.036), and malignancy (95% CI: 0.82-0.94, <i>p</i> < 0.0004) although inversely associated with male sex (95% CI: 1.04-1.15, <i>p</i> = 0.0008), body mass index (95% CI: 1.01-1.02, <i>p</i> < 0.0001), and National Early Warning Score (95% CI: 1.01-1.03, <i>p</i> < 0.0001). We subsequently analyzed these results to inform preparedness for future emerging infectious disease pandemics by retrospectively examining the decision-making processes during the COVID-19 crisis, with particular attention to the role of multidisciplinary collaboration. Based on this study, it will be essential in future pandemics to assess decisions concerning life-sustaining treatments, including IMV, from both scientific and ethical perspectives.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"30-36"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231357/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144586081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The frequency of peripheral blood eosinophilia and its clinical significance in patients with dermatomyositis.","authors":"Kayoko Tabata, Yutaka Inaba, Tomoyuki Hara, Kayo Kunimoto, Yuki Yamamoto, Ryo Matsumiya, Masatoshi Jinnin, Takao Fujii","doi":"10.35772/ghmo.2023.01027","DOIUrl":"10.35772/ghmo.2023.01027","url":null,"abstract":"<p><p>In connective tissue diseases, eosinophil is thought to varying extents to be involved in the pathogenesis. Increased eosinophils in the skin tissues of patients with dermatomyositis (DM) have been reported, but there have been no investigations of blood eosinophilia in patients with DM. This study is the aim of determining the frequency of peripheral blood eosinophilia and elucidating its clinical significance. We retrospectively collected the clinical records of 48 patients (15 men and 35 women) who were diagnosed with classical DM (<i>n</i> = 34), ADM (<i>n</i> = 13), and JDM (<i>n</i> = 1), on the basis of the 2017 EULAR/ACR classification criteria for adult and juvenile idiopathic inflammatory myopathies. Eosinophil count ≥ 400/mm³ was observed in 14.6% (<i>n</i> = 7) of the patients, while 4.2% (<i>n</i> = 2) of patients had eosinophil counts >1,000/mm³. Regarding the clinical significance of peripheral blood eosinophilia in DM patients, in seven patients with increased blood eosinophil counts, the prevalence of Gottron's sign/papules, heliotrope rash, V-neck sign, shawl sign, pruritus, internal malignancy, and positive anti-TIF1-γ antibody were more frequent than in those without (85.7% , 85.7%, 71.4%, 71.4%, 85.7%, 42.9%, 28.6% <i>vs.</i> 92.7% <i>p</i> = 0.48, 61.0% <i>p</i> = 0.40, 36.6% <i>p</i> = 0.11, 39.0% <i>p</i> = 0.22, 36.6% <i>p</i> = 0.034, 19.5% <i>p</i> = 0.33, and 19.5% <i>p</i> = 0.63, respectively). Among them, pruritus was more common in patients with elevated eosinophil counts with statistical significance. The activity of eosinophilia and severity of skin eruptions also tended to be correlated. In summary, our study suggests that blood eosinophilia is correlated with the presence of pruritus, but not disease-associated autoantibodies or internal malignancy.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"37-42"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231347/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144586083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A path analysis of factors influencing life satisfaction among patients with narcolepsy in Japan.","authors":"Sayaka Kon, Chieko Kato, Yoshiomi Otsuka, Takako Negishi","doi":"10.35772/ghmo.2024.01002","DOIUrl":"10.35772/ghmo.2024.01002","url":null,"abstract":"<p><p>Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness, impaired psychosomatic functioning, and a reduced quality of life. We identified several factors influencing life satisfaction and suggested ways to improve it in patients with narcolepsy. To the best of our knowledge, this is the first study to measure life satisfaction in patients with narcolepsy and to examine the interdependence of various factors related to life satisfaction using path analysis. A questionnaire was administered to 87 individuals diagnosed with narcolepsy. A hypothetical model was tested to determine its effect on life satisfaction. The results of the path analysis were <i>χ</i> ² = 11.94 (<i>p</i> = 0.53), GFI = 0.96, AGFI = 0.92, CFI = 1.00, and RMSEA = 0.00. The overall effects were impact on activities (β = 0.41), self-acceptance (β = 0.36), adaptive attitude (β = 0.36), excessive daytime sleepiness (β = 0.13), mental disorder (β = 0.10) and attention-deficit/hyperactivity disorder (β = 0.08). The results indicate that medical conditions such as sleepiness do not impair life satisfaction. This study suggests that life satisfaction can be increased through self-understanding and engaging in adaptive cognition.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"58-61"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12226771/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A fatal case of pyogenic spondylitis rapidly progressing to epidural abscess caused by a novel ST-type methicillin-susceptible <i>Staphylococcus aureus</i> ST9378.","authors":"Takeru Inoue, Tomoe Setoguchi, Michiaki Akashi, Nobuyuki Shimono, Yasuhisa Iwao, Shoko Kutsuno, Junzo Hisatsune","doi":"10.35772/ghmo.2025.01001","DOIUrl":"10.35772/ghmo.2025.01001","url":null,"abstract":"<p><p>Pyogenic spondylitis can be life-threatening; however, its diagnosis remains challenging because of the initial presentation of nonspecific symptoms. Given the vulnerability of the infected site, patients are highly at risk for severe complications, such as epidural abscesses or bacterial meningitis, which can considerably worsen the prognosis. Herein, we report a case of lumbar pyogenic spondylitis initially identified through methicillin-susceptible <i>Staphylococcus aureus</i> bacteremia, which subsequently progressed to an epidural abscess. The abscess rapidly ascended to the cervical region, causing bacterial meningitis and ultimately, a fatal outcome. The strain (JARB-OU3818) was positive for the virulence factor genes of the enterotoxin gene cluster (<i>seg</i>, <i>sei</i>, <i>sem</i>, <i>sen</i>, and <i>seo</i>) but negative for the Panton-Valentine leucocidin (PVL) and toxic shock syndrome toxin-1 (TSST-1) coding genes. Additionally, JARB-OU3818 was ST9378 belonging to the clonal complex 45 lineage. Clinicians should recognize that pyogenic spondylitis may follow an aggressively progressive clinical course, as demonstrated by this case.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"47-51"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231359/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144586078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Seven-year experience in pathology capacity development project including education for pathology residents and pathology technologists in Cambodia: Challenges and opportunities.","authors":"Hiroyuki Kiyohara, Tomomi Matsushita, Rei Haruyama, Sumiyo Okawa, Shinsuke Murai, Yuriko Egami, Pintuna Pich, Serey Vathana Chhut, Yasuyo Matsumoto, Noriko Fujita","doi":"10.35772/ghmo.2025.01003","DOIUrl":"10.35772/ghmo.2025.01003","url":null,"abstract":"<p><p>This article discusses a 7-year (2017-2023) collaborative project aimed at pathology capacity development in Cambodia, where the pathology workforce is limited due to historical and infrastructural challenges. Cambodia's increasing cancer burden necessitates the expansion of pathology services; however, the country has only a small number of health professionals related to pathological services. Since 2017, the project, funded by Japan's Ministry of Health, Labor, and Welfare, has involved Japanese pathologists providing lectures and technical advice and Cambodian pathologists gaining training in Japan. Over time, the project expanded to support both pathologists and pathology technologists, focusing on capacity building, through a residency program for pathologists and a bridging course for laboratory technologists. The project faced several challenges, including maintaining the quality and sustainability of education, improving practical training environments, and addressing the international migration of a trained workforce. Despite these obstacles, the program trained several residents and led to the development of educational materials. The project also highlighted opportunities to mobilize Cambodian pathologists working abroad and incorporate digital technology into the education system. The article concludes that strengthening the local pathology workforce requires systemic changes, including developing the capacity of Cambodian pathologists to take on leadership roles in teaching and supporting the education system, as well as utilizing Cambodian pathologists abroad as a resource for education and service delivery.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"71-75"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12226769/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A scoping review on mindfulness-based interventions for families of patients with advanced cancer.","authors":"Junko Morishita, Yuka Takita","doi":"10.35772/ghmo.2024.01015","DOIUrl":"10.35772/ghmo.2024.01015","url":null,"abstract":"<p><p>We aimed to conduct a scoping review to investigate mindfulness-based interventions targeting the families of patients with advanced cancer to elucidate the characteristics of the target population, program content, and evaluation methods. The review followed the Joanna Briggs Institute guidelines, and relevant studies were identified through searches in the PubMed, CINAHL, and Cochrane databases. A total of 13 studies were included, with only one focusing solely on family members, while the rest involved both family members and patients. Among the 13 studies, 4 were randomized controlled trials (RCTs), and 10 were pilot studies. The sample sizes varied, with seven studies involving single-group designs, four using two-group designs, one with a three-group design, and one study where no information on group size was provided. The framework and content of the programs were adapted from existing mindfulness-based stress reduction techniques to suit the target context and were evaluated using multiple measures, including assessments of anxiety and depression. Most studies recruited families and patients together, and programs targeting families alone were underdeveloped. Future studies should address the needs and challenges faced by the families of patients with advanced cancer, refining program content and evaluation methods from the perspective of nurses.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"8-20"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231351/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144586079","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comprehensive multidisciplinary approach in the long-term hospitalization of a child with obsessive - compulsive disorder and autism spectrum disorder: Emphasizing nursing practice.","authors":"Mami Ono, Ikuhiro Harada, Kotoe Itagaki, Masahide Usami","doi":"10.35772/ghmo.2023.01019","DOIUrl":"10.35772/ghmo.2023.01019","url":null,"abstract":"<p><p>This article presents the case of a boy diagnosed with both obsessive-compulsive disorder (OCD) and autism spectrum disorder. Long-term hospitalization was required to improve the patient's OCD symptoms and family relationship. In his last year of compulsory schooling, a multidisciplinary team, led by a nurse, took various approaches to help him self-determine his pathway. In their role of assisting the patient with daily living, the nurses were at risk of becoming involved in his compulsive behavior and developing negative feelings. To support his self-determination, having a mutually supportive environment was essential between the multidisciplinary team and team members, which included discussing his daily living concerns and venting out negative feelings. In this case, ongoing dialog with the medical staff was important for the individual and parents to move forward positively within a supportive framework.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"62-66"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12226770/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From prototype to implementation: Development of the DMIST scoring system for monitoring diabetic foot ulcers.","authors":"Rie R Yotsu, Makoto Oe, Hiromi Sanada, Takeshi Tamaki","doi":"10.35772/ghmo.2023.01024","DOIUrl":"10.35772/ghmo.2023.01024","url":null,"abstract":"<p><p>Diabetic foot ulcers (DFUs) pose a significant health challenge, marked by high morbidity, mortality, and healthcare costs. Effective evaluation of the DFU healing process is crucial to prevent delays and enhance patient outcomes. Traditional wound healing scales like PUSH and DESIGN have proven suboptimal for DFUs, necessitating a disease-specific approach. This communication introduces a qualitative study, which served as the first step in developing the DMIST scale, a tool to monitor and assess DFUs over time. Using a morpho-qualitative analysis method, we examined 50 DFUs in 42 patients from a hospital in Tokyo, classifying ulcers by primary pathogenic factors and healing periods. Our analysis identified 8 categories and 33 sub-categories of morphological characteristics. Key findings included identification of features such as the \"red ring\", \"hyperkeratosis\", and \"rolled wound edges\", each affecting healing times. The DMIST scale integrates these visual signs, offering a practical tool for DFU management, particularly valuable in low-resource settings. This scale has undergone validation and refinement through international collaboration, with the aim to improve DFU patient outcomes globally. We hope the DMIST scale to be widely adapted and that our experience in its development will aid future development of wound assessment tools from various causes.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"52-57"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12226772/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577561","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Academic Research Organization Alliance for Southeast and East Asia (ARISE) in the new era: An international trials network towards pandemic preparedness.","authors":"Phuong Mai Le, Sifa Marie Joelle Muchanga, Maria Ruriko Umano Urbiztondo, Marlinang Diarta Siburian, Katsumi Ishii, Naoki Tomotsugu, Koji Wada, Daisuke Tokita, Wataru Sugiura","doi":"10.35772/ghmo.2025.01000","DOIUrl":"10.35772/ghmo.2025.01000","url":null,"abstract":"<p><p>The Academic Research Organizations (ARO) Alliance for Southeast and East Asia (ARISE), established in 2021, is a network of academic research organizations in Southeast and East Asia. Its founding vision was focused on conducting effective, high-quality clinical research and providing timely access to new medicinal products during health crises. Through its focused efforts, ARISE has fostered regional cooperation and contributed to implementing clinical trials of medical products in its network. In response to global health challenges, the Government of Japan is establishing a new organization, the Japan Institute for Health Security, with functions encompassing infectious disease control and pandemic preparedness. As ARISE continues to fulfill its mission of addressing emerging infectious diseases, the ongoing changes in its founding organization will significantly impact its operations. With this article, we aim to highlight ARISEs achievements in its first two years and to explain how its strategy has been adapted to the new organizational structure and evolving global health landscape. ARISE strives to strengthen its network collaboration and further enhance the ability of member organizations to respond rapidly and effectively to future health emergencies.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"67-70"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12226768/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577563","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The impact of a health education program on cervical cancer screening uptake: A survey among primary school teachers in Phnom Penh, Cambodia.","authors":"Miwa Kanda, Lumpiny Kim, Rei Haruyama, Chansoeung Sann, Noriko Fujita, Maryan Chhit, Sovanara Hang, Rayonnette Krouch, Jun Kobayashi, Fumiko Shibuya, Takashi Asakura, Yutaka Osuga, Kanal Koum, Rie Takeuchi","doi":"10.35772/ghmo.2024.01017","DOIUrl":"10.35772/ghmo.2024.01017","url":null,"abstract":"<p><p>This study aimed to evaluate the impact of a health education intervention on women's cervical cancer screening uptake. It was conducted using data from the collaborative project by the Cambodian Society of Gynecology and Obstetrics and the Japan Society of Obstetrics and Gynecology to improve cervical cancer services in Cambodia. A prospective observational study was conducted from August 2022 to May 2023, involving 1,538 female teachers from 80 public primary schools in Phnom Penh, Cambodia. A total of 815 participants (intervention group [<i>n</i> = 355] and control group [<i>n</i> = 460]) were eligible for analysis. The intervention group received a tailored health education program and an invitation to register for free cervical cancer screening, while the control group only received the invitation to screening. The intervention group demonstrated a significantly higher screening registration (32.1% <i>vs.</i> 18.8%, <i>p</i> < 0.001) and uptake (24.1% <i>vs.</i> 12.7%, <i>p</i> < 0.001) than the control group. When comparing changes in knowledge and attitude between baseline and endline assessments, the intervention group showed a notable improvement in knowledge regarding the causes, symptoms, prevention, and benefits of early detection of cervical cancer. For instance, the proportion of women who recognized human papillomavirus as the cause of cervical cancer significantly increased in the intervention group (baseline: 23.7%, endline: 57.5%, <i>p</i> < 0.001), while no significant change was observed in the control group (baseline: 24.4%, endline: 29.1%, <i>p</i> = 0.101). In conclusion, the health education program effectively increased cervical cancer screening uptake, knowledge and attitude on cervical cancer. Further improvements in screening uptake may require educational interventions that influence individual health behaviors and systematic encouragement for screening participation.</p>","PeriodicalId":520484,"journal":{"name":"GHM open","volume":"5 1","pages":"21-29"},"PeriodicalIF":0.0,"publicationDate":"2025-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231358/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144586084","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}