Medicine and Health Sciences Commons^™

Porokeratosis Ptychotropica With Scalp Involvement: A Case Report, Kobpat Phadungsaksawasdi, Pravit Asawanonda

Chulalongkorn Medical Journal

Porokeratosis, a spectrum of disorders characterized by abnormal keratinization, includes the rare variant, porokeratosis ptychotropica, typically manifests with hyperkeratotic plaques on the buttocks and genital area. Its clinical mimicry to various skin diseases, coupled with under-recognition of the disorder, results in frequent misdiagnosis. This challenge is compounded by the resistance of porokeratosis ptychotropica to treatment.

We report a 62-year-old Thai male with persistent pruritic hypertrophic plaques affecting the genitogluteal area, extremities, and scalp over five years, unresponsive to diverse topical agents. Histopathological findings revealed acanthotic epidermis with a cornoid lamella, consistent with porokeratosis ptychotropica. He was given oral acitretin at …

A Rare Presentation Of Giant Hepatic Hemangioma Mimicking Fibrolamellar Hepatocellular Carcinoma, Bikash Parida, Sherry Garg, Somadatta Das

Chulalongkorn Medical Journal

Hepatic hemangioma is a frequently occurring benign liver lesion detected on Imaging. It might be challenging to make a definite diagnosis of Hepatic hemangioma since its radiological characteristics can mimic those of hepatic malignancies such as metastatic liver cancer. A 65-year-old female patient complained of a month-long reduction in appetite and distension of abdominal discomfort in the right hypochondriac area. A B-mode ultrasound was suggested for the patient. On USG, there was a large, poorly defined heterogeneous lesion that entirely occupied the right lobe of the liver. It had a hyperechoic periphery, an irregular hypoechoic patch in the center, necrosis, …

Identification And Characterization Of Malaria Box Compounds Possessing Inhibition Effect On The Sars-Cov2 Spike Protein, Chotiyapat Sangvansindhu

Chulalongkorn Medical Journal

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of infections and deaths worldwide since 2019. The repurposing existing drugs is a practical and promising alternative.

Objectives: To evaluate the binding interactions and inhibitory effect of malaria box compounds on the B-cell epitope regions of SARS-CoV-2 spike protein.

Methods: Molecular docking of 400 malaria box compounds against the predicted B-cell epitopes of the spike was performed. The inhibitory effect of the malaria box compounds on the spike RBD were determined using competitive ELISA. The binding affinity between malaria box compounds and non-RBD epitopes were examined by surface …

The Impact Of Covid-19 Booster Vaccination On Reducing Mortality In Patients Hospitalized With Covid-19 At Sisaket Hospital, Nidhikul Tem-Eiam

Chulalongkorn Medical Journal

The COVID-19 vaccine has the potential to decrease hospitalizations and fatalities, even when different vaccine types are administered. Towards the end of 2021, during the ongoing COVID-19 pandemic, there were guidelines suggesting the administration of booster shots following the completion of the primary vaccine series. Consequently, this study aims to investigate the efficacy of COVID-19 booster vaccinations and the timing between booster shots in terms of preventing fatalities among COVID-19-infected patients receiving care at Si Sa Ket Hospital

A retrospective cohort study was conducted on individuals aged 18 and above who were hospitalized with COVID-19 infection at Si Sa Ket …

Endogenous Car T Cell Activation Signal-Based Dual Car Construct, Asmita Khaniya, Koramit Suppipat M.D., Supannikar Tawinwung Ph.D., Nattiya Hirankarn M.D., Ph.D.

Chulalongkorn Medical Journal

Background: Despite the notable success of chimeric receptor (CAR) T-cell therapy in treating hematological malignancies, many challenges limit its therapeutic effectiveness. To overcome antigen loss mediated disease relapses, strategies like dual antigen-targeted CAR constructs have been used. However, this strategyrequires robust promoters, to ensure sufficient CAR expression on the cell surface. Utilization of multiple promoters cause the constitutive and simultaneous expression of CARs which lead to issues with CAR T cell tonic signaling and exhaustion.

Objective: This study aimed to utilize the endogenous CAR T cell activation signals to explore the dual CAR T cell-based platform.

Methods: Using scFv …

Factors Related To Physical Activity Of Patients With Permanent Cardiac Pacemaker, Priyaporn Phruksahiran, Noraluk Ua-Kit

Chulalongkorn Medical Journal

Background: Over 1.3 million patients worldwide have permanent cardiac pacemakers (PPM). Patients with PPM, in the first to third months after implantation, still report problems with physical activity (PA), such as limitations in their lives, jobs, and exercise, inability to perform activities as before, and decreased PA.

Objectives: This study aimed to investigate the PA of patients with PPM and identify factors (age, perceived self-efficacy, perceived benefits, perceived barriers, social support, and health literacy) related to the PA of patients with PPM.

Methods: This descriptive-correlational study included 110 male and female patients with PPM from three tertiary hospitals in …

Trends Of Methicillin-Resistant Staphylococcus Aureus Infections Among Thai Pediatric Patients, Pintip Suchartlikitwong, Nopphon Wuthinantiwong, Watsamon Jantarabenjakul, Noppadol Wacharachaisurapol, Jiratchaya Sophonphan, Tanittha Chatsuwan, Thanyawee Puthanakit

Chulalongkorn Medical Journal

Background While reductions in methicillin-resistant Staphylococcus aureus (MRSA) infections have been reported, vancomycin prescription rates have remained high.

Objectives We aimed to update trends in pediatric prevalence and antibiotic susceptibilities of MRSA infections.

Methods We conducted a retrospective study in patients aged S. aureus infections during 2016-2022 at a Thai tertiary-care hospital. MRSA was defined when resistant to cefoxitin or oxacillin MIC of >4 µg/mL. Patients with MRSA infections and their first isolates were classified into HA-MRSA or CA-MRSA based on surveillance definitions. Antibiotic susceptibilities were tested using the VITEK 2XL automated system and disk diffusion. The annual prevalence of …

Sinonasal Anatomical Analysis In Nonsyndromic Bilateral Coronal Suture Craniosynostosis Using Computerized Tomography, Tunchanok Paprad, Netsiri Dumromgpisutikul, Warunee Napakaew

Chulalongkorn Medical Journal

Background: Craniosynostosis is a deformity of the skull associated with the premature fusion of one or more cranial sutures. In children with syndromic craniosynostosis, anomalies related to the cranial base and midface contribute to midface hypoplasia, affecting the diameter of the axial facial concavity. Nonsyndromic craniosynostosis, especially bilateral coronal suture craniosynostosis, may result in abnormal facial proportions and affect sinonasal anatomy.

Objectives: The aim of our study was to determine and analyze morphometric measurement values in the sinonasal cavity of patients with nonsyndromic bilateral coronal suture craniosynostosis.

Methods: A retrospective study was conducted on 91 children, aged 0 - 10 …

Inhibitors Angptl3 And Their Effects To Hyperlipidemia And Atherosclerosis, Wanee Plengpanich

Chulalongkorn Medical Journal

Angiopoietin-like protein 3 (ANGPTL3) has emerged as important regulators of lipid metabolism. Current innovative therapeutic options using monoclonal antibodies, antisense oligonucleotide (ASO) or vaccine approaches to block this protein may minimize the risk of atherosclerosis in dyslipidemic individuals. The purpose of this review is to discuss the effectiveness of these new ANGPTL3 inhibitors.

Implications Of Face Mask Usage On Diverse Populations: Challenges And Considerations, Simaporn Promsarn, Walaiporn Wongsrisakunkaew

Chulalongkorn Medical Journal

The COVID-19 pandemic has underscored the importance of face mask usage as a preventive measure against viral transmission. Extensive studies have confirmed the efficacy of face masks in curtailing respiratory infections caused by viruses, including influenza and COVID-19. The significance of consistent face mask implementation over extended periods has become evident, particularly in high-risk environments such as healthcare facilities and public spaces. Despite their effectiveness, it is imperative to acknowledge the potential challenges and side effects that different populations may experience during prolonged mask usage. This comprehensive review examines the implications of face mask usage across diverse groups, encompassing healthy …

Effectiveness Of The Novel Ventilation System In The Ambulance For Airborne Particle Reduction, Dhanadol Rojanasarntikul

Chulalongkorn Medical Journal

Background: During the Coronavirus disease (COVID-19) pandemic, emergency medical service (EMS) workers areexposed to infectious particles in closed spaces such as in the ambulance. Few studies have demonstrated the effectiveness of ambulance ventilation system in reducing airborne particles.

Objective: To assess the effectiveness of an ambulance ventilation system in reducing the volume density of airborne particles and return-to-background time.

Methods: Aerosol particles of various sizes were administered into the cabin via nebulization for one minute. The aerosol volume concentrations of particles at 0.5-1; 1-2.5; and 2.5-5 microns were measured with three different ventilation rates (switched off, medium and maximum) …

Beyond Mitragynine: Composition Survey And Stability Assessment Of Kratom Tea Ordered Via Food Delivery Platforms In Bangkok, Thailand, Yuta Tokuda, Apinya Tubtimrattana, Nat Tansrisawad, Kornvalee Meesilpavikkai, Parath Thirati

Chulalongkorn Medical Journal

Background: Kratom is a native tree to Southeast Asia. Kratom leaves have long been used medicinally and recreationally due to their stimulative and opioid-like effects attributed to high endogenous levels of mitragynine and related alkaloids. Kratom is widely consumed as tea and is now publicly sold, including on food delivery platforms, after recent decriminalization despite selling of kratom products being still considered illegal by other acts.

Objectives: To assess the formulas of kratom teas sold on Thai food delivery platform together with their consistency and the stability of refrigerated teas.

Methods: Kratom alkaloids, mitragynine and 7-hydroxymitragynine, and additive contents of …

High Carotenoid Values In People With Flexibility Training, Chanachai Lohasaptawee Mr., Ponlapat Rojnuckarin Professor Dr., Natthaya Lekhawatthanapong Miss

Chulalongkorn Medical Journal

Background: Free radicals play essential roles in the aging and various pathological processes. Antioxidants may be helpful to prevent these conditions. Therefore, the body should have high antioxidant values and carotenoids can be a representative of antioxidants.

Objectives: The purpose of the study was to use the BioPhotonic Scanner S3 and resonant Raman spectroscopy technology for comparing the skin carotenoid values between those who exercised frequently and those who did not exercised within a 6-month period.

Methods: Four equal groups of six hundred male and female volunteers, ages 20 to 60 years, who resided in Bangkok Metropolitan Region were formed, …

Determination Of Initial Hepatitis B Surface Antigen (Hbsag) Cutoff Index (Coi) Threshold For Reporting Hbsag Reactivity, Piya Wongchampa, Arkom Chaiwongkot, Rangsima Reantragoon

Chulalongkorn Medical Journal

Background: The Hepatitis B surface antigen (HBsAg) commercially-available screening test suggests a confirmatory testing in all cases that are reactive, but this will take a long time to reporting of results and increase the total test cost.

Objectives: To investigate the correlation between cutoff index (COI) values of initial HBsAg screening test and their corresponding confirmatory neutralization results in order to identify a COI value for distinguishing samples that truly need confirmatory neutralization testing.

Methods: A retrospective study of 72,496 HBsAg screening test results using the Elecsys HBsAg II kit of patients at King Chulalongkorn Memorial Hospital, the Thai Red …

Perceptions Of Emergency Physician Professionalism Among Healthcare Providers And Patients: A Multicenter Study In Thailand And The Us, Khuansiri Narajeenron Md, Mhpe, Tanawat Tarapan Md, Jasmina Dukovic, Krongkarn Sutham Md, Intanon Imsuwan Md, Ar-Aishah Dadeh Md, Tanyaporn Nakornchai Md, Deena Bengiamin Md, Bharath Chakravarthy Md, Mph, Craig Anderson Phd, Mph, Somchit Eiam-Ong Phd, Wirachin Hoonpongsimanont Md, Ms

Chulalongkorn Medical Journal

Background: Universal standards for emergency physician professionalism (EPP) amongst different groups of healthcare workers do not exist.

Objective: The aim of this study was to explore perceptions of EPP among attending physicians (APs), emergency medicine (EM) residents, first- and fourth-year medical students (MS1s and MS4s, respectively), EM nurses and emergency department (ED) patients.

Methods: A multicenter, cross-sectional study conducted at seven university-based EDs in Thailand and the US from July 2016 - January 2018. We created 39 cards (13 core elements) describing behaviors derived from a global literature review. Subjects ranked each card from the most to least important for …

A Case Report : Rosai-Dorfman Disease Of The Breast, Jenjeera Prueksadee

Chulalongkorn Medical Journal

Abstract

A case report of Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) of the breast is one of the rare diseases, characterized by benign proliferative disorder of histiocyte. Most occur within lymph nodes whereas the rest involve extranodal sites. Breast involvement is considered extremely rare but considerable because of radiological findings simulating breast cancer. We report the case of a 59-year-old Thai woman who underwent screening mammography. Her biopsy resulted in abnormal histiocytes with S-100 protein expression, some of them with emperipolesis (lymphophagocytosis). Recognition of Rosai-Dorfman disease leads to correct diagnosis and further appropriate proper treatment strategy.

Primary Lung And Pleural Malignancies In Children: Imaging Of A Case Series, Teerasak Phewplung, Tanitha Phruksahirun

Chulalongkorn Medical Journal

Early diagnosis of primary lung and pleural malignancies is a challenge because it is extremely rare in children. The patient often presents with metastatic disease and non-neoplastic lesions. Clinical detection and imaging studies are nonspecific findings and may be indistinguishable from other lung malformations, resulting in a delay in diagnosis and treatment and an increase in tumor morbidity and mortality.

We present four cases of children whose clinical presentation and initial imaging had suspicious abnormalities and were eventually revealed to be primary lung and pleural malignancies. The literature on primary lung and pleural malignancies is also reviewed.

Comparison Study Of Endoscopic-Guided Versus Electromyography-Guided Botulinum Toxin Injection Treatments In Adductor Spasmodic Dysphonia, Manintorn Praditthum, Premsuda Sombuntham

Chulalongkorn Medical Journal

Background: Electromyography (EMG)-guided botulinum injection is recommended in clinical practice guideline for spasmodic dysphonia. However, other alternative techniques have been practiced in absence of EMG machine. Comparison of techniques is limited in the literatures.

Objective: This pilot study aims to compare the effectiveness of treatment between the EMG-guided technique and the endoscopic-guided technique in adductor spasmodic dysphonia.

Method: Five patients who were diagnosed with Adductor spasmodic dysphonia (AdSD) were enrolled and then randomized into 2 groups. Patient data (before and after treatment) were collected. The outcome measurement included voice analysis, voice handicap index (VHI), duration aspiration, duration of breathiness, mean …

The Effect Of Fluid Replacement During 60 Minutes Of Moderate-Intensity Running On Splanchnic Blood Flow., Warot Rangsimahariwong, Onanong Kulaputana, Tanat Tabtieang, Sompol Sanguanrungsirikul, Natthaya Chuaypen

Chulalongkorn Medical Journal

Background: Exercise-induced splanchnic hypoperfusion has been linked to impaired gastrointestinal function and associated symptoms. The effectiveness of fluid replacement in protecting against splanchnic hypoperfusion is less clear.

Objectives: To evaluate the effects of fluid replacement during 60 minutes of moderate-intensity running on the splanchnic blood flow (SBF) using non-invasive Doppler ultrasound.

Methods: Seven healthy men aged 35 ± 7 years participated in two 60-minute running trials at moderate-intensity: the first trial with no water replacement (NW) followed by the second trial with ambient temperature water (28-29oC) replacement (AW). A minimum interval of 48 hours was introduced for the washout period …

Does Asymptomatic Generalized Joint Hypermobility Influence Musculotendinous Extensibility And Knee Joint Proprioception?, Pawan Chaiparinya, Sujitra Boonyong, Chitanongk Gaogasigam

Chulalongkorn Medical Journal

Background: It is unclear whether generalized joint hypermobility (GJH) influences the musculotendinous unit (MTU) extensibility or proprioception of the knee joint in individuals with asymptomatic GJH.

Objectives: To compare the quadriceps and hamstring MTU length as well as knee joint force sense (FS) and joint position sense (JPS) between individuals with asymptomatic GJH and non-GJH controls.

Methods: Thirty-two female subjects were recruited, with 16 subjects in the GJH and non-GJH groups. The angles measured from modified prone knee bend (mPKB) and straight leg raising (SLR) tests were used to identify the quadriceps and hamstrings MTU extensibility using photographic-based angle measurements. …

The Electrical Conductivity Of 24-H Urine Is Decreased In Patients With Calcium Oxalate Urolithiasis., Kamonchat Boonkam

Chulalongkorn Medical Journal

Background: Electrical conductivity (EC) of urine depends on the ionic substance-to-water ratio. Calcium oxalate (CaOx) is the most common type of urinary stone, and its formation is driven by decreased urine volume, increased lithogenic substances, and decreased stone inhibitory compounds (specifically citrate). Low urinary citrate excretion (hypocitraturia) is a prominent risk factor in Thai urolithiasis patients.

Objective: To measure the urinary EC, urinary calcium, and urine specific gravity in CaOx stone patients compared with non-stone forming (NSF) subjects.

Method: The urinary EC was measured in 24-h urine samples obtained from 42 CaOx stone patients and 121 NSF subjects. Urinary calcium …

Pediatric Appendicitis Or Not? A Retrospective Cohort Study From A Single Institution - Our Management And Factors Determining The Disease, Nimmita Srisan, Teerasak Phewplung, Katawaetee Decharun, Prapapan Rajatapiti, Paisarn Vejchapipat

Chulalongkorn Medical Journal

Purpose: The aims were to assess our treatment guidelines and to determine factors in differentiating children with acute appendicitis from other diseases.

Methods: Pediatric surgery consultations for suspected appendicitis from October 2019 to October 2021 was retrospectively studied. The treatment guidelines of children with suspected appendicitis were elucidated. Moreover, factors identifying the diagnosis of appendicitis were analyzed using multi-variate logistic regression.

Results: Ninety-one children were consulted for suspected appendicitis. Forty-one children (45.1%) were promptly successfully treated without observation or ultrasonography, except one negative appendectomy (2.4%). The other 50 children (54.9%), showed equivocal clinical symptoms and signs, requiring further management either …

Analysis Of Breast Mri Performed On Patients With Axillary Nodal Metastasis And Negative Mammogram And Ultrasound, Pakpawee Pichayakul, Palita Hansakul

Chulalongkorn Medical Journal

Background: Occult breast cancer is a rare type of breast cancer which magnetic resonance imaging (MRI) has an immense role to confirm diagnosis and disclose non-demonstrable finding on initial modality.

Objective: To analysis breast MRI findings in patients with axillary nodal metastasis and negative mammogram and ultrasound, and retrospective review of the initial mammography and second-look ultrasound.

Methods: From January 2010 to January 2023, women who diagnosed occult breast cancer by presenting metastatic axillary lymph node on pathological report with negative mammography and ultrasonography, underwent breast MRI to identify occult breast carcinoma. Their breast MRI were retrospectively reviewed …

Postoperative Intussusception After Congenital Diaphragmatic Hernia Repair: A Report Of 2 Cases, Saralee Matanaromyakit, Nimmita Srisan, Somboon Roekwibunsi, Paisarn Vejchapipat

Chulalongkorn Medical Journal

Background: A postoperative intestinal intussusception is one of complications after abdominal surgery. However current evidence of intussusception after congenital diaphragmatic repair still received little attention. Previous literature reported possible cause from atony of the herniated bowel that could be a functional leading point of intussusception.

Case report: A 7-month-old female with history of respiratory distress in newborn, with no obvious abdominal signs was scheduled for diaphragmatic hernia repair. The chest X ray showed the presence of large soft tissue density at the posterior aspect of the left hemothorax. She early came to OPD due to many episodes of non-bilious vomiting …

Exonic Variants Of Gpihbp1 Gene In Thai Subjects With Severe Hypertriglyceridemia, Wanee Plengpanich

Chulalongkorn Medical Journal

Background: Hypertriglyceridemia (HTG) is one of the risk factors for cardiovascular disease and acute pancreatitis. It is associated with genetic variations in various genes involved in triglyceride metabolism. Glycosylphosphatidylinositol-anchored high-density lipoprotein-binding protein 1 (GPIHBP1) encodes a membrane protein involved in an intravascular triglyceride hydrolysis. Objective: The purpose of this study was to examine the genetic variants in the exons of GPIHBP1 gene in Thai subjects with severe HTG. Methods: All 4 exons of the GPIHBP1 gene were sequenced in 101 Thai subjects with severe HTG. All subjects had triglyceride levels e” 10 mmol/L or 886 mg/dL. Subjects with normolipidemia (n …

Association Of Pnpla3, Tm6sf2 And Hsd17b13 Variants With Nafld Risk In Hiv And Non-Hiv Individuals, Varis Ruamviboonsuk

Chulalongkorn Medical Journal

Background: Non-alcoholic fatty liver disease (NAFLD) has multiple risk factors, including genetic risk factors. Patients with certain genetic variants are more susceptible to the disease. People living with human immunodeficiency virus (PLWH) have higher prevalence of NAFLD compared to those without human immunodeficiency virus (HIV) infection. However, the evidence on genetic factors in PLWH with NAFLD is limited. Objectives: This study aimed to investigate whether carriers of PNPLA3 rs738409, TM6SF2 rs58542926, and HSD17B13 rs6834314 had association with the risk of NAFLD, and whether PLWH with NAFLD also had similar genetic risk factors as those with NAFLD alone. Methods: These single …

Anopheles Population Belonging To Barbirostris Complex In Narathiwat Province And Its Vectorial Status For Human And Simian Malaria, Surasuk Yanmanee, Sunee Seethamchai, Napaporn Kuamsab, Taweesak Tia, Somchai Jongwutiwes, Chaturong Putaporntip

Chulalongkorn Medical Journal

Background: Besides well-perceived species of Plasmodium infecting humans, at least four simian malaria species including P. knowlesi, P. cynomolgi, P. inui and P. fieldi have been incriminated in human infections in Thailand. The vectors of simian malaria in this country have been recently identified to be Anopheles latens and An. introlatus.

Objectives: To address whether mosquitoes in Barbirostris complex in Narathiwat Province could vector simian malaria and to analyze species distribution of Anopheles in this complex from the sampled population.

Methods: A total of 115 mosquitoes from Sukhirin and Waeng Districts in Narathiwat Province morphologically assigned to …

Attitudes Toward End-Of-Life Care And Advance Directives: A Prospective Survey In A Family Medicine Clinic, Bangkok, Thailand, Basmon Manomaipiboon

Chulalongkorn Medical Journal

Background: Advance directives (ADs) have long been legalized and advocated, still few patients complete ADs in Thailand. In our setting, advance directive information will be provided to interested patients and palliative care patients. Objectives: This study examined the attitude toward end-of-life care and ADs, the prevalence of ADs completion and identified the factors associated with advance care planning among patients who attended a family medicine clinic, Faculty of Medicine, Vajira Hospital, Navamindhradhiraj university, Bangkok, Thailand. Methods: A total of 300 subjects completed a self-administered structured questionnaire, including sociodemographic factors, individuals’ health status, healthcare experiences, and other factors influencing advance care …

Factors Related To Positive Airway Pressure Adherence In Patients With Obstructive Sleep Apnea At King Chulalongkorn Memorial Hospital, Puntarik Srisawart

Chulalongkorn Medical Journal

Background: Positive airway pressure (PAPs) is a standard and efficacious treatment for obstructive sleep apnea (OSA). Poor adherence could lead to impaired daytime performance, increasing risk of traffic accidents, hypertension, cardiovascular events, and neuropsychological disturbances. Previous studies reported rates and factors influencing PAPs adherence, but the data in Thailand was still lacking.

Objectives: To investigate the rate of PAPs adherence, the prevalence of depressive and anxiety symptoms, and the factors associated with PAPs adherence among patients with OSA.

Methods: This is a cross-sectional descriptive study that was conducted during June 2021 to September 2022. The data was collected from patients …

Effect Of Exergame Training With Motor Imagery On Balance, Cognitive Functions And Motor Learning In Healthy Adults: Preliminary Study, Kanokwan Srisupornkornkool

Chulalongkorn Medical Journal

Background: Previous studies reported that exergames could improve balance and cognitive function. Also, motor imagery (MI) applied with actual movements cloud increase balance control. If both are combined, balance and cognitive function may increase more.

Objectives: To investigate the effect of exergame training with MI on balance, cognitive function and motor learning in healthy adults.

Methods: Twelve participants were divided into 2 groups, the exergame training (ET, n = 6) and the exergame with MI training (ET + MI, n = 6). Both groups practiced exergame for 20 minutes. Then, the ET + MI group imagined exergame for 10 minutes. …