Urogynecology (Hagerstown, Md.)最新文献

{"title":"How do you solve a problem like mirabegron?","authors":"Lauren A Cadish, Jonathan P Shepherd","doi":"10.1097/SPV.0000000000001662","DOIUrl":"https://doi.org/10.1097/SPV.0000000000001662","url":null,"abstract":"","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980899","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Why wasn't mirabegron chosen for the first year of the CMS negotiation program?","authors":"Lauren A Cadish, Jonathan P Shepherd","doi":"10.1097/SPV.0000000000001663","DOIUrl":"https://doi.org/10.1097/SPV.0000000000001663","url":null,"abstract":"<p><strong>Abstract: </strong>Importance: The most used overactive bladder (OAB) medications are anticholinergics, which professional societies recommend avoiding in older patients given dementia risk. Cost prevents patients from switching to preferred beta-3 agonists. Mirabegron was the only beta-3 agonist eligible for the Centers for Medicare/Medicaid Services (CMS) 2023 Drug Negotiation Program (DNP). While mirabegron's price would be markedly reduced by inclusion in the DNP, only ten drugs were chosen in its first year.Objectives: We sought to explain mirabegron's absence from CMS's 2023 DNP and estimate the percentage of anticholinergic to mirabegron conversions needed to merit DNP inclusion.Study design: We modeled CMS's 2023 selection process using publicly available dashboards from 2017-2021. Among the 20 costliest drugs, we excluded ineligible drugs and categorized the remainder as DNP chosen/not chosen. For drugs not chosen, we used price inflation and beneficiary utilization trends to project total 2023 costs.Results: In 2021, mirabegron was the 14th most costly drug overall-9th when excluding ineligibles-and the only top-20 drug eligible but not selected for the 2023 DNP. We estimated mirabegron to be 96.7% the cost of the 10th most costly drug. Switching 1.2% of 2021 anticholinergic prescriptions to mirabegron would have led to DNP inclusion, presenting an interesting dilemma where more patients would use mirabegron if it were cheaper, but insufficient patients used it for DNP inclusion to make it cheaper.Conclusions: Mirabegron came exceedingly close to DNP selection in 2023, and its future inclusion in the DNP would likely herald a massive shift of Medicare patients away from anticholinergics.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Phenotypes of Pelvic Organ Prolapse.","authors":"Zoe Sayler, Katie Weston, Colin M Johnson, Victoria Cunningham, Catherine S Bradley, Kimberly A Kenne, Linder Wendt, Patrick Ten Eyck, Joseph T Kowalski","doi":"10.1097/SPV.0000000000001640","DOIUrl":"https://doi.org/10.1097/SPV.0000000000001640","url":null,"abstract":"<p><strong>Importance: </strong>The Pelvic Organ Prolapse Quantification (POP-Q) stages do not correlate with symptoms or characterize important prolapse subtypes.</p><p><strong>Objectives: </strong>We hypothesize that clinically meaningful prolapse \"phenotypes\" utilizing POP-Q measurements can be defined. The primary aim was to define the phenotypes and their frequency. Secondary aims were to compare demographics, medical characteristics, and symptoms between phenotypes.</p><p><strong>Study design: </strong>Patients who previously underwent prolapse surgery were retrospectively categorized into 1 of 8 phenotypes based on 2 principles: (1) prolapse exists when the anterior or posterior vaginal wall descend to the hymen or the apex descends half total vaginal length, and (2) prolapse may exist in anterior, posterior, and/or apical compartments. Demographics, medical characteristics, and Pelvic Floor Distress Inventory-20 (PFDI-20) responses were compared. Linear and logistic regression models were used for comparisons.</p><p><strong>Results: </strong>The AC (anterior-predominant and apical) phenotype was most common (231 of 501 patients, 46.1%) and served as the reference for comparisons. The no prolapse, P (isolated posterior), C (isolated apical), and PC (posterior-predominant and apical) phenotypes were younger. The A (isolated anterior) phenotype was older. P, PC, and APC (anterior and posterior and apical) phenotypes had greater body mass index. The P phenotype Colorectal-Anal Distress Inventory scores were higher. Similarly, the PC phenotype had higher scores for bowel splinting and rectal prolapse. Conversely, the C phenotype total PFDI-20 scores were lower (P = 0.01). Only the APC phenotype had no significant differences in any PFDI-20 question compared with the AC phenotype.</p><p><strong>Conclusion: </strong>These phenotypes may allow for improved understanding, communication, and counseling about prolapse and prolapse treatment.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142980969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing the Impact of Overactive Bladder Medications on Cognition.","authors":"Darlene Vargas Maldonado, Phillip J Schulte, Laureano Rangel Latuche, Maria Vassilaki, Ronald C Petersen, John A Occhino, Brian J Linder","doi":"10.1097/SPV.0000000000001522","DOIUrl":"10.1097/SPV.0000000000001522","url":null,"abstract":"<p><strong>Importance: </strong>Emerging literature has associated the use of anticholinergic medications to cognitive decline.</p><p><strong>Objective: </strong>The aim of this study was to evaluate the association of overactive bladder medications on cognitive function with prospective longitudinal cognitive assessments.</p><p><strong>Study design: </strong>A population-based cohort of individuals 50 years and older who had serial validated cognitive assessment, in accordance with the Mayo Clinic Study of Aging, was evaluated from October 2004 through December 2021. Anticholinergic overactive bladder medications were grouped by traditional anticholinergic medications and central nervous system (CNS)- sparing anticholinergic medications and compared to no medication exposure. A linear mixed effects model with time-dependent exposures evaluated the association between overactive bladder anticholinergic medication exposure and subsequent trajectories of cognitive z-scores.</p><p><strong>Results: </strong>We included 5,872 participants with a median follow-up of 6.4 years. Four hundred forty-three were exposed to traditional anticholinergic medications, 60 to CNS-sparing medications, and 5,369 had no exposure. On multivariable analyses, exposure to any anticholinergic overactive bladder medication was significantly associated with deterioration in longitudinal cognitive scores in the language and attention assessments compared to the control cohort. Traditional anticholinergic medication exposure was associated with worse attention scores than nonexposed participants. Exposure to CNS-sparing anticholinergic medications was associated with a deterioration in the language domain compared to those unexposed. Among women, traditional anticholinergic medication exposure was associated with worse global and visuospatial scores than nonexposed participants, but this association was not identified in the CNS-sparing group.</p><p><strong>Conclusion: </strong>Exposure to anticholinergic overactive bladder medications was associated with small but significantly worse decline in cognitive scoring in the language and attention domains when compared to nonexposed individuals.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"10-17"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140864716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management.","authors":"Amy Alagh, Olga Ramm, Liisa L Lyon, Miranda L Ritterman Weintraub, Abigail Shatkin-Margolis","doi":"10.1097/SPV.0000000000001501","DOIUrl":"10.1097/SPV.0000000000001501","url":null,"abstract":"<p><strong>Importance: </strong>Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation.</p><p><strong>Objective: </strong>The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status.</p><p><strong>Study design: </strong>This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI.</p><p><strong>Results: </strong>Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% ( P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures ( P = 0.01). When controlling for age, no clinically significant difference was demonstrated.</p><p><strong>Conclusions: </strong>Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"26-33"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11380043/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140095310","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":"Antibiotic Duration and UTI Outcomes in Recurrent UTI Patients.","authors":"Julia Shinnick, Isabel Josephs, Johanna A Suskin, Kathryn Kurchena, Lindsey Pileika, Spencer Darveau, Matthew M Scarpaci, Cassandra Carberry","doi":"10.1097/SPV.0000000000001497","DOIUrl":"10.1097/SPV.0000000000001497","url":null,"abstract":"<p><strong>Importance: </strong>Little evidence is available to inform management of acute urinary tract infections (UTIs) in women with recurrent urinary tract infection (rUTI).</p><p><strong>Objective: </strong>This study aimed to compare the proportion of acute UTIs with persistence/relapse or recurrence based on duration of treatment antibiotics (acute UTI guideline-consistent versus extended).</p><p><strong>Study design: </strong>A retrospective noninferiority study of women with rUTI was performed at an academic tertiary referral center from January 2016 to December 2020. Exposure was UTI treatment with acute UTI guideline-consistent versus extended antibiotics. Outcomes were persistent/relapsed UTI (subsequent culture with the same pathogen requiring additional antibiotics within 4 weeks), recurrent UTI (culture with different pathogen), or resolution. Sample size was calculated under the null hypothesis that the proportion of acute UTIs with persistence/relapse or recurrence after acute UTI guideline-consistent antibiotics would be within a 10% noninferiority margin of extended duration ( α = 0.05, β = 0.20, 2-sided tests, P < 0.05 significant).</p><p><strong>Results: </strong>We included 219 patients with 553 acute UTIs. The mean ± SD number of UTIs per patient was 2.53 ± 1.88, the mean ± SD age was 68.60 ± 16.29 years, and the mean ± SD body mass index was 29.73 ± 7 (calculated as weight in kilograms divided by height in meters squared). There were no differences in prior surgical procedures postvoid residual volume, pelvic floor disorders, or preventive treatments between groups. Two-hundred sixty UTIs (260 of 553 [47%]) were treated with acute UTI guideline-consistent antibiotics. Overall, 86 of 553 UTIs (15.6%) persisted/relapsed, and 29 of 553 (5.2%) recurred. The difference in the proportions of UTIs with persistence/relapse or recurrence excluded the noninferiority margin (4.4%; 95% confidence interval, -0.04 to 6.80%). In total, 115 of 553 UTIs (20.8%) had persistence/relapse or recurrence.</p><p><strong>Conclusion: </strong>In this cohort of patients with rUTI experiencing acute UTIs, acute UTI guideline-consistent duration of antibiotics was noninferior.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"34-42"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140856808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Bladder Distension for Cystoscopy and Urodynamics During Intravenous Fluid Shortages.","authors":"Jonathan P Shepherd, Patricia Giglio-Ayers, Cheryl B Iglesia, Megan Bradley","doi":"10.1097/SPV.0000000000001611","DOIUrl":"10.1097/SPV.0000000000001611","url":null,"abstract":"","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"3-6"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142514424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perioperative Opioid Use in Urogynecologic Mesh Removal.","authors":"Amanda M Artsen, Roseanne Gichuru, Michael Bonidie, Lauren Giugale, Pamela A Moalli","doi":"10.1097/SPV.0000000000001527","DOIUrl":"10.1097/SPV.0000000000001527","url":null,"abstract":"<p><strong>Importance: </strong>Forty percent of patients with urogynecologic mesh pain complications are taking narcotics.</p><p><strong>Objectives: </strong>We aimed to compare comorbidities and pain scores between patients with and without narcotic use and assess postoperative narcotic use rates.</p><p><strong>Study design: </strong>This was a secondary analysis of a prospective cohort study of patients undergoing urogynecologic mesh removal. Patients with mesh removal for pain within 7 years were included due to data availability. Narcotic prescriptions were verified using the Pennsylvania Prescription Drug Monitoring Program. Pain scores were assessed at baseline and 6-24 months postoperatively.</p><p><strong>Results: </strong>Of 139 patients, 30 (21.6%) filled narcotic prescriptions within 3 months preceding surgery. These patients were younger and more likely to have a chronic pain condition. Narcotic use did not differ by sling versus prolapse mesh, or presence of exposure. Patients taking preoperative narcotics had a 27-point higher median baseline visual analog scale pelvic pain score (P = 0.01). Patients with pain comorbidities had 6 times odds of using preoperative narcotics. Younger patients had less improvement in pelvic pain after removal. Only 8 (27%) of those taking narcotics discontinued use postoperatively with no significant predictors of prolonged (≥3 months) use. Eighty-seven percent of patients with prolonged postoperative use had a prior pain diagnosis, commonly joint and back pain.</p><p><strong>Conclusions: </strong>In patients with mesh-related pain, those with chronic pain conditions had much higher odds of taking preoperative narcotics, and in most, mesh removal did not eliminate narcotic use. Counseling is warranted in patients with chronic pain conditions that pain and narcotic use are likely to persist after removal.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":"31 1","pages":"18-25"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11658796/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142848643","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":"Online Search Strategies and Results From a Crowdsourced Survey on Asymptomatic Bacteriuria.","authors":"Megan S Bradley, Melanie D Hetzel-Riggin, Julia C Knight, Ashley Murillo, Halina Zyczynski, Christopher R Shelton","doi":"10.1097/SPV.0000000000001500","DOIUrl":"10.1097/SPV.0000000000001500","url":null,"abstract":"<p><strong>Importance: </strong>Despite the prevalence of asymptomatic bacteriuria (ASB), what proportion of the population is aware of this condition and the quality of internet resources are currently unknown.</p><p><strong>Objective: </strong>This study aimed to use an online crowdsourcing platform to explore general knowledge and internet search strategies, along with the quality of information, on ASB.</p><p><strong>Study design: </strong>An online survey was administered through a crowdsourcing platform to women 50 years or older via Qualtrics, which is a sophisticated online survey tool. Participants completed a survey on ASB, and participants were asked how they would search the internet for information both on urinary test results and on ASB. Outcomes included survey responses, and qualitative data were coded and analyzed thematically. χ 2 Testing and regression modeling were used to look for variables associated with concern for ASB.</p><p><strong>Results: </strong>There were a total of 518 participants who passed attention check qualifications, and only 45 respondents (8.7%) had heard of ASB. Many were concerned about progress to a worsening infection (n = 387 [77.6%]). When controlling for confounders, education beyond a college degree was not associated with a lower concern for ASB when compared with those with a high school education or less (adjusted odds ratio, 0.63; 95% confidence interval, 0.25-1.55; P = 0.31). Medical providers were the target audience for a majority of the websites, and many of the patient-facing results were of poor quality.</p><p><strong>Conclusions: </strong>Our national survey of women demonstrated a prevalent knowledge deficit surrounding ASB. We must seek to create high-quality, readily available, patient-facing information to increase awareness of ASB, allay concerns, and increase antibiotic stewardship.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"43-50"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140159725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Obesity and Native Tissue Repairs: A Secondary Analysis of the OPTIMAL Trial.","authors":"Meghan K Hagedorn, Tonja M Locklear, Sarah Evans, Natalie E Karp, W Jerod Greer","doi":"10.1097/SPV.0000000000001498","DOIUrl":"10.1097/SPV.0000000000001498","url":null,"abstract":"<p><strong>Importance: </strong>The Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) Trial compared sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) surgical outcomes. Increasing body mass index (BMI) is associated with an increased risk of pelvic organ prolapse, and the prevalence of obesity is increasing worldwide.</p><p><strong>Objective: </strong>The purpose of this study was to better understand the effect of obesity on the results of native tissue vaginal apical suspension procedures.</p><p><strong>Study design: </strong>This was a secondary analysis of the OPTIMAL Trial data set. Subgroup analysis was performed to compare surgical failure rates between SSLF and ULS across BMI subgroups after 2 years.</p><p><strong>Results: </strong>There were 75, 120, 63, and 39 patients in the normal, overweight, class 1 obesity, and class 2 obesity or greater BMI subgroups, respectively. There were no statistically significant differences in surgical failure rates between SSLF and ULS within BMI subgroups; however, failure rates increased in the ULS group between the nonobese and obese groups (normal, 35.9% SSLF vs 30.6% ULS [ P = 0.81]; overweight, 38.6% vs 30.2% [ P = 0.44]; class 1 obesity, 38.7% vs 40.6% [ P = 0.92]; class 2 obesity or greater, 21.1% vs 45% [ P = 0.21]).</p><p><strong>Conclusions: </strong>The risk of surgical failure between SSLF and ULS was not significant across BMI subgroups. Additional investigation is required to further elucidate whether SSLF or ULS is a more reliable option for obese patients.</p>","PeriodicalId":75288,"journal":{"name":"Urogynecology (Hagerstown, Md.)","volume":" ","pages":"51-57"},"PeriodicalIF":0.8,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140289807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}