Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Exceptions to order 10mg loxitane amex mental health treatment 1930s this recommendation include blood loss in adults of 1500 mL or more in adults and haemodilution to cost of loxitane list of mental disorders in toddlers 15 mL/kg or less (Scottish Inter collegiate Guideline Network purchase discount loxitane on line mental health treatment for young adults, 2008). Penicillin-allergic patients Many prophylactic regimens rely heavily on cephalosporins, which can create problems when patients give a history of penicillin allergy. If possible, document the nature of the allergy, as patients sometimes assume, or are told by others, that an adverse event such as nausea, headache or diarrhoea is a manifestation of hypersensitivity. The local policy antibiotic policy should be consulted in order to identify an alternative agent. These strains appear to be more transmissible than their earlier counterparts, but the exact contribution of other factors to the sharp increase Meticillin-resistant Staphylococcus aureus 297 Table 22. In addition, narrower-spectrum cephalosporins have better activity than extended-spectrum agents against staphylococci. The latter can also be used to assist in the choice of prophylactic antimicrobials if preoperative treatment of infection is not possible. It is worth noting, however, that many guideline recommendations are based on non-controlled trials and descriptive studies. Asymptomatic carriers are most frequently colonised in the anterior nares, but some may also have axillary, perineal or throat carriage. Ulcers or pressure sores and the bladder in patients with in-dwelling catheters may also be sites of colonisation. Screening, however, remains con tentious and the debate is likely to remain unresolved for some time. This counters the prob lem that screening may produce falsely negative results but increases the risk of resistance to erad ication agents. Hair also to be washed twice with this preparation at least twice during this time. Other measures include the following: Meticillin-resistant Staphylococcus aureus 299 Box 22. Requires regular monitoring of full blood count because of possible thrombocytopenia, leucopenia and anaemia Quinupristin with Streptogramins Expensive. Intravenous only, but cannot be given dalfopristin through a peripheral cannula Daptomycin Lipopeptide Expensive. Damage to the colonic mucosa is caused by the production of two toxins toxin A (entero toxin) and toxin B (cytotoxin). The presence of a nasogastric tube and recent gastrointestinal surgery are also risk fac tors. Endoscopy to identify pathognomic pseudo-membranes? is of poor sensitivity and is not without risk to the patient, and its routine use is not recommended. Note that patients may become symptomatically better shortly after commencing metronidazole but should complete a full course of therapy because of the high risk of relapse. If the relapses are associated with mild or moderate disease, then a second course of metronidazole can be used. Management of multiply relapsing patients is problematic; approaches include the use of probiotics, which include bacteria such as Lactobacillus spp. Another, rather more unusual, way of attempting this is through faecal transplants in which faecal material from healthy volunteers is given as an enema. In addi tion, the new antimicrobial nitazoxanide is being evaluated for patients with multiply relapsing disease. Management of patients with multiple relapses is problematic and the role of probiotics in this setting is still unclear. There is much evidence to suggest that this increase in severity may be associated with a new hypervirulent? strain of C. The strain produces 15?20 times the amount of toxin A and toxin B compared with other strains, as well as another toxin binary toxin. Clinical manifestations, treatment and control of infections caused by Clostridium dif? There are two facets to this problem: the risk of patients becoming infected as a result of sur gery, and the risk of patients who already have such infections transmitting them to the surgi cal team and other patients. It is imperative that surgeons and other healthcare workers involved in surgical practice have a thorough understanding, and are cognisant with the mode of transmission of such infec tive agents. This will help them to prevent these infections by following good infection control practice. However, because surgical patients are frequently given transfusions of blood or blood prod ucts, and because hospital staff often incur accidental needlestick injury, it is the viruses that can potentially be transmitted by these routes that are of prime importance to surgeons and their patients. Hepatitis A virus Hepatitis A virus belongs to the picornaviruses family and causes infectious hepatitis. It is transmitted via the faecal?oral route and there is no asymptomatic carrier status. Clinical course the incubation period ranges from 40 days to 160 days (average 60?90 days). Interferon alfa is clinically useful for the treatment of chronic hepatitis B infections. Epidemiology the three main modes of transmission are via blood, from sexual intercourse and perinatally from mother to newborn. In high prevalence areas, infection is acquired primarily in childhood by perinatal transmission or horizontal transmission between young children. In low-prevalence areas, transmission occurs mostly in adulthood via sexual intercourse and via sharing of contaminated needles and equip ment among intravenous drug users (Figure 23. It is well known to be the major cause of parenteral transmission of non-A, non-B hepatitis.
See Systemic lupus erythematosus Sickle cell anemia Sleep order loxitane 10mg online mental health conditions symptoms, changes in best order for loxitane mental health 939, as death characterization of discount loxitane 10mg on line mental health treatment for cutters, 328?329 approaches, 580 complications of, 329t?330t Snakes. See also imaging of, 607?608 Corticosteroid(s) injury to, methylprednisolone for, biosynthetic pathway of, 254f 991?992 for chemotherapy-induced nausea, Spinal dysraphism, 608 574 Spirillum minus, in animal bites, for spinal cord compression, 568 96t Stimate Spiritual changes, as death approaches, formulary entry for, 765?766 580 for von Willebrand disease, Spirometry, 588?590, 590t 347t Spironolactone (Aldactone) Stimulant(s) formulary entry for, 950 cocaine as, 43?44 for hypertension, 501t ecstasy as, 44 with renal failure, 1034t Stomach. See Nausea and vomiting for girls, 529f von Willebrand disease Wellbutrin, dosage/side effects for, characterization of, 347t 1005t hepatic factors in, 345b Wenckebach. If advanced airway, 8?10 breaths per minute with continuous chest compressions Shock Energy for Defibrillation First shock 2 J/kg, second shock 4 J/kg, subsequent shocks? It determines the overall performance of a student in all the subjects taken during a period covering more than one semester. Each student immediately after enrolment fills up all the Registration cards under the guidance of Student Advisor. Among other things, the Advisors shall help the students in planning their academic programme. The semester Time-Table shall include one hour duration per week for the meeting of students with Advisors. The Associate Dean of the college will conduct Registration and Orientation programmes for the benefit of the students joining the University for the first time. Registration of students shall not be allowed after the expiry of 25% of the working days in the semester of admission. The student in each batch shall have to register for the set of courses offered in Toto? for the semester and fill in the registration cards. The students having backlog courses can register for a part of the total set of courses fixed for that batch and fill in the registration cards. The minimum limit of attendance shall be reckoned for theory and practical classes separately, for every course. A student who fails to put in the minimum attendance either in theory or practical in any course shall not be permitted to appear for the Semester final examinations and his/her Registration for that course shall be treated as cancelled. The number of conducted classes shall be uniform for the entire class except in case of year of admission into the course. However, the entire period of deputation of students participating in Pre Republic Day and Republic Day camps shall be only condoned and no relaxation of any sort will be admissible in respect of Semester Final Examinations. Only a Committee consisting of Associate Dean of the College, Advisor of student concerned, and the College Medical Officer as a co opted member wherever necessary shall consider readmission of such student after assessment of valid grounds/proofs. If the Committee is satisfied, the Associate Dean may pass an order permitting the student to continue studies by registering the courses in which he/she has shortage of attendance, when offered next time in the corresponding Academic Year. Where the period of break/absence exceeds one year, but does not exceed two years, a reference should be made to the University and decision of the University shall be final. In addition, the Associate Dean of the College may order suspension of the Course, if deemed necessary. There shall be one Midterm(Internal) examination to be conducted by the teacher offering the course after completing 60% of the working days in a semester. Unless a student appears for the midterm examination and practical examination, the student should not be permitted to appear for the Semester Final Theory examinations in the course concerned. Syllabus/Lecture outlines of the concerned Course shall be sent to the External Examiner for setting the Question Paper and the question paper shall be moderated by the concerned faculty at University, if necessary. The answer scripts will be coded and send to the External examiner for evaluation. The Honorarium for setting the Question paper and evaluating the Answer scripts shall be as per University norms. All examinations must be completed in time so that the results are announced before the commencement of the ensuing Semester. Performance during practicals (observation of the skills with which each student executes the practicals): 10% iii. Practical examination (written examination, spotting, conducting experiment, problem solving etc. The phrase, use of unfair means? includes possession of any information or material by the student, talking to other students, copying from other students or from printed or written material etc. The invigilator/s concerned, on finding the use of unfair means? by any student may take the answer script of the student and the material evidence, if any, and the explanation from the student. The Invigilator/s concerned shall immediately report each case of Unfair Means directly to the Associate Dean with full details of the incident, enclosing the answer script of the student, the other available evidence and the explanation of the concerned student, if any. The Associate Dean on receipt of the reportshall give an opportunity to the concerned student to represent the case. Considering all the available evidence, the Associate Dean shall take appropriate action immediately. The penalty shall be as indicated below; (a) A student found involving in use of unfair means? during the Midterm (Internal) Examination or practical examination shall be deemed to have failed in that course. In such cases, the student shall not be permitted to take the remaining examinations, if any, in that semester and shall also be deemed to have attempted and Failed? in that examination. If further or more severe punishment is felt necessary, the Associate Dean shall immediately inform the University about the full details of the case together with all the material evidence, if any, along with his/her recommendations. The explanation or representation of the student obtained/received, if any, may also be sent. The Vice Chancellor after examining the case, may debar the student for a further period or permanently. The Associate Dean shall inform the parent/guardian of the concerned Student about the incident and of any punishment awarded to the Student and also the reasons thereof.
Scrutiny of Final theory Answer scripts and Grades: a) the student may apply to buy 10 mg loxitane free shipping mental treatment ulcer the Associate Dean of the College within one week after the announcement of the Grades for scrutiny of the totaling of marks of the External Theory Examination or Calculation of Grade Points obtained by the student purchase loxitane online mental health parity conditions, advancing sufficient reasons for such a request order discount loxitane line mental health month 2014. If any question is found uncorrected by the evaluator, the answer script shall be sent to the evaluator for doing the needful corrections and the result (s) shall be revised accordingly. The scheduled date of compartmental examination under no circumstances shall be changed on this account. The provisions for moderation shall not be applicable to compartmental examinations. The examination pattern shall consist of one internal mid-term examination & a practical examination and Final External Theory Examination. The distribution of marks between Internal and (Mid-term Theory plus Practical examinations) and External (Theory examination) is 50: 50. The distribution (as per weightage) of marks with different credit loads of theory and practical components is as follows; i. Courses having only Theory Component: Mid-term Examination Internal (40%) + Assignment (10%) and Final Theory Examination External (50%) ii. Courses with Theory and Practical components: Mid-term theory Examination Internal (30%) + Assignment (5%) + Practical component (15%) + Final Theory Examination External (50%) d) Student obtaining a grade point of not less than 5. Any student claiming to be sick and indisposed or the loss of life of his close relatives (father, mother, grand parents, siblings) may be permitted after the production of a medical certificate from a Civil Surgeon/Asst. Hospitals or discharge certificate issued by a qualified doctor in case of Private Nursing home, provided the student was hospitalized for a minimum period of 24 hours, in case of disease/illness or a death certificate from the Mandal Revenue Officer or from the local bodies like Panchayats/Municipalities in case of death of close relatives. The Supplementary Midterm (Internal) Examination shall be conducted before the last date of instruction of that Semester only. The duration of the programme shall be of 20 weeks, out of which the students will spend 19 weeks period for undergoing training and one (1) week for the preparation of final report. For this purpose, the following committee shall be constituted consisting of members; i. Afterdeclaration of the results the academic status of students shall be as per the regulation 13. They are expected to keep constantly in touch with their Advisors so that the latter may watch their progress and guide them in the right direction. In no case will a regulation be waived or exemption made simply because a student pleads ignorance of it. If it is found that the result of a candidate has been vitiated by malpractices, fraud or other improper conduct where by a student has been benefited and that he/she has in the opinion of the Vice-Chancellor, been a party to or conceived at malpractice, fraud or improper conduct, the Vice-Chancellor shall have the power at any time, notwithstanding the award of a Degree or a Certificate or Prize or a Scholarship, to amend the result of such candidate and to make such declaration as the Vice-Chancellor may deem necessary in that behalf, including debarring of the candidate from the University for such a period as may be specified and the cancellation of the result of the candidate in such a manner as the Vice-Chancellor may decide. The duration of this program is of 20 weeks, the credits allotted are 20 and all the 20 credits are evaluated. The duration of this program is of 20 weeks, the credits allotted are 28 and all the credits are evaluated credits the curriculum of this semester is scrupulously planned in such a way to initiate and develop Entrepreneurship capabilities among the students by accommodating certain selected Course work, Programmes aimed to learn through experience, Programmes that develop skill in the selected field, Preparation of proposals for research projects etc. He/she will prepare a research project plan and it will be presented in-front of committee appointed by the Associate Dean of the respective college. Also, for each student, one Advisor will be provided, who will guide the student in completion of proposed research plan. The evaluation for the same will be conducted by committee appointed by the Associate Dean of the respective college. The evaluation for the same will be conducted by the committee appointed by the Associate Dean of the respective college. Agriculture; Systems of aquaculture: pond culture, pen culture, cage culture, running water culture and zero water exchange system. Extensive, semi intensive, intensive and super-intensive aquaculture in different types of water bodies viz. Principles of pond culture: Pre-stocking and post-stocking pond management; Carrying capacity of pond; Factors influencing carrying capacity; Criteria for selection of candidate species for aquaculture. Major candidate species for aquaculture in fresh, brackish and marine waters; in monoculture, polyculture and integrated culture systems. Water and soil quality in relation to fish production: Physical, chemical and biological factors affecting productivity of ponds. Culture phases and Management practices: Nursery, rearing and grow-out pond preparation; Management: control of aquatic weeds, algal blooms, predatory and weed fishes; Other management practices: Liming, fertilization/manuring, use of biofertilizers, supplementary feeding, water quality management. Traits of important cultivable fish and shellfish and their culture methods: Indian major carps, exotic carps, air breathing fishes, cold water fishes, freshwater prawns, mussels. Study on effect of manuring and fertilization on hydrobiology of ponds and growth of fish and shellfishes. Collection, identification and control of weed fishes and eggs and larval forms of fishes. Nutritional energetics: Definition and forms of energy partitioning; Methods of feed formulation and manufacturing; Forms of feeds: wet feeds, moist feeds, dry feeds, mashes, pelleted feeds, floating and sinking pellets. Feed additives: Binders, antioxidants, enzymes, pigments, growth promoters, feed stimulants. Non-nutrient dietary components: Non-conventional feed ingredients and antinutritional factors; Digestive enzymes, feed digestibility; Factors affecting digestibility. A manual on the preparation and preservation of compound feeds for shrimp and fish in aquaculture. Natural breeding: Selection of riverine spawn collection sites; Gears used and methods of collection; Spawn quality and quantity indices; Advantages and disadvantages of riverine seed collection; Sexual maturity and breeding season of various cultivable species; Development of gametes in male and female; Fish egg and embryonic development.
Br J Clin Pharmacol 2001; Association; American College of Car acute coronary syndromes undergoing 52: 333-336 purchase cheap loxitane line mental disorders pooh bear. Low-dose aspirin for sec cyclooxygenase with controlled release buy loxitane 25mg overnight delivery mental health zebulon nc, Association; American College of Physi ondary cardiovascular prevention car low-dose aspirin purchase genuine loxitane line mental shock treatment videos. Prevention of premature discon diovascular risks after its perioperative 20: 652-656. Rautanen M, Gullichsen E, Riutta A, continuation review and meta-analy in patients with coronary artery stents: Kuttila K, Mucha I, Nelimarkka O, Ni sis. Crit Care can College of Surgeons, and American Escaned J, Alfonso F, Banuelos C, Costa Med 1997; 25: 1215-1221. Eldor A, Lellouche F, Goldfarb A, Rach withdrawal is associated with proinflam cians. In vivo platelet matory and prothrombotic effects in pa activation in beta-thalassemia major tients with diabetes and coronary artery 2357. Best Pract Res Clin Anaesthesiol 2007; recent withdrawal of oral antiplatelet 2379. Clopidogrel is not associ Essentials of Practice Management: Bill 2010; 125: 406-412. Randelli F, Biggi F, Della Rocca G, Gros pliance in Interventional Pain Manage 2392. Ono S, Fujishiro M, Kodashima S, Taka si P, Imberti D, Landolfi R, Palareti G, ment. R, Asada-Hirayama I, Konno-Shimizu statement on antithrombotic prophy M, Tsuji Y, Mochizuki S, Niimi K, Yama 2402. Electronic medical records in laxis in hip and knee replacement and in michi N, Kaneko M, Yatomi Y, Koike K. Centers for Medicare and Medicaid Ser grel in orthopaedic patients: A review of operatively? Acta Anaesthesiol Essentials of Practice Management: Bill Yokoi C, Akiyama J, Sugawara M, Oda I, Scand 2010; 54: 16-41. Procedural cod moto Y, Okada K, Morita Y, Fujiwara S, gional anaesthesia and antithrombotic ing systems. Eur J Coding, and Compliance in Interventional the management of antithrombotic Anaesthesiol 2010; 27: 999-1015. Myckowiak V, Myckowiak M, Practice Management: Billing, Coding, and pliance in Interventional Pain Manage Manchikanti L. Government audits and inves Coding, and Compliance in Interventional 2012, pp 313-326. Essentials of Practice Management: sentials of Practice Management: Billing, ing for physical therapy services. In: Billing, Coding, and Compliance in Inter Coding, and Compliance in Interventional Manchikanti L (ed). Preparations Route Formulation Dexamethasone Base Content Tablets 500 micrograms, 2mg and 4mg Soluble tablets 2mg, 4mg and 8mg Oral (as dexamethasone sodium phosphate) Oral solution 2mg/5ml, 10mg/5ml, 20mg/5ml (as dexamethasone sodium phosphate) a a Injection (as dexamethasone sodium phosphate) 3. Some brands may not be licensed for sub-cut use refer to Syringe Pump guideline. Dose and administration the initial dose of dexamethasone varies according to use. Please refer to the relevant section(s) of the Scottish Palliative Care Guidelines for detailed dosing advice. The following table is for guidance and the doses prescribed may vary dependent on individual patient assessment. Dose conversions Equivalent anti-inflammatory doses of corticosteroids Approximate equivalent anti-inflammatory doses and duration of action of corticosteroids (note: takes no account of mineralocorticoid effects). Corticosteroid Dose Duration of action (hours) Hydrocortisone 20mg 8-12 Prednisolone 5mg 12-36 Dexamethasone 0. For pragmatic purposes, 4mg of oral dexamethasone can be considered approximately equivalent to 3. This conversion results in injection volumes which can be measured accurately using the 3. The dose can be reduced fairly rapidly, for example by 50% every 3-5 days to 2mg daily, then more slowly as the physiological dose is reached, for example reduce by 0. Monitor for symptom recurrence and consider maintaining at the lowest dose which controls symptoms. However, all cases should be assessed individually and it may be beneficial to continue to achieve symptom control. In use product safety assessment report for Dexamethasone injection 2014 [cited 2018 Oct 02]; Available from. Clinical Question: In patients with lower back pain, do lumbar X-rays modify any patient outcome? Bottom-line: In non-specific low back pain, X-rays do nothing to improve outcomes and may worsen some (such as pain). Tools for Practice is a biweekly article summarizing medical evidence with a focus on topical issues and practice modifying information. Each article is peer-reviewed, ensuring it maintains a high standard of quality, accuracy, and academic integrity. This communication reflects the opinion of the authors and does not necessarily mirror the perspective and policy of the Alberta College of Family Physicians. The goals of the guideline rec ommendations are to assist in delivering optimum ef?
10mg loxitane with mastercard. Increased Intracranial Pressure Nursing Pathophysiology NCLEX Symptoms (Cerebral Perfusion Pressure).
A fibrous tissue expansion known as capsulopalpebral fascia extends from the inferior rectus muscle to buy generic loxitane 25mg line mental health treatment before freud the anterior surface of the lower tarsus buy cheap loxitane 10 mg on line list of mental disorders that cause violent behavior, transmitting pull from the inferior rectus muscle order loxitane with paypal mental health 19128. This fascia is analogous to the levator aponeurosis, and is capable of moving the lower eyelid approximately 4?5 mm from extreme upward gaze to extreme downward gaze. The inferior orbital septum fuses to the capsulopalpebral fascia 3?4 mm inferior to the tarsus. They provide structural stability to the eyelids and also serve as a platform upon which the orbicularis muscle and levator muscle insert. The tarsal plates are tethered medially and laterally by their respective canthal tendons, forming a tarsoligamentous sling upon which the forces of the protractors and the retractors act. The vertical length of the tarsal plates is generally 10 mm centrally in the upper eyelid and 4?5 mm in the lower eyelid (Fig. These glands contribute the oily portion of the tear film, which is important for stabilizing the tear film, and preventing rapid evaporation. The meibomian glands are found in greater numbers in the upper eyelid compared to the lower eyelid (approximately 40 versus 25). Both of these factors may explain the increased production of lipid material by glands of the upper eyelid relative to the lower eyelid. The meibomian glands are a frequent site of chronic granulomatous inflammation of the lids, and rarely may undergo malignant transformation into sebaceous cell carcinomas. Histologically, it is composed of a nonkeratinized stratified epithelium with goblet cells. The underlying substantia propria, or stroma, is richly vascularized and contains numerous immune defense cells. The histology of the epithelium varies depending on location, from squamous epithelium near the lid margin to columnar epithelium in the tarsal area. In the fornix, the conjunctiva transitions to a prismatic cell type, and to a cuboidal cell type in the bulbar area. The marginal mucosa of the conjunctiva is responsible for spreading the tear film. These attachments maintain the shape and integrity of the fornices and prevent prolapse of the conjunctival tissue into the lid aperture. The fornices also contain numerous accessory lacrimal glands of Wolfring and Krause within its submucosal tissue. These lacrimal structures are more numerous in the superior fornix than inferior fornix. Eyelid margin the lid margin is a short 2-mm wide segment that contains the mucocutaneous junction that demarcates keratinized epithelium anteriorly and conjunctival nonkeratinized epithelium posteriorly, and is composed of pseudostratified squamous mucosa. At the posterior eyelid margin, where the horizontal component of the eyelid ends and the vertical component begins, the mucosa makes an abrupt transition into stratified columnar epithelium. Anterior to this lies the gray line which represents an optical reflection of the marginal portion of the orbicularis (muscle of Riolan), and which lies coincident with meibomian gland orifices. The mucocutaneous junction itself lies just posterior to the gray line and is not clinically apparent. Chronic inflammation, as in the case of blepharitis, can lead to disruption of these distinct transitions as well as effacement and anterior migration of the mucocutaneous junction. These important structures are supported by the medial and lateral canthal tendons, which create a sling-like structure to support the lid margin and maintain apposition against the globe. The anterior limb is a broader band arising from the superficial head of the pretarsal orbicularis muscle and inserting onto the anterior lacrimal crest. The posterior limb of the medial canthal tendon arises from the deep head of the pretarsal and preseptal orbicularis muscles and inserts onto the posterior lacrimal crest. The lateral canthal tendon has a superior crus arising from the superior tarsus and an inferior crus arising from the inferior tarsus. It extends from the periorbita of the trochlea medially to the frontozygomatic suture laterally. It attaches medially to the medial canthal tendon and laterally to the lateral canthal tendon. The medial fat pad is firmer and pale white in color, and is associated with the medial palpebral artery and infratrochlear nerve. The preaponeurotic fat pad is more yellow in color due to increased carotenoid content and extends laterally over the lacrimal gland. Due to their close proximity to the trochlea, superior oblique palsy and Brown syndrome have been reported following excision of fat during upper eyelid blepharoplasty. The medial and central fat compartments are separated by the inferior oblique muscle. The central and lateral fat compartments are separated by the arcuate expansion of the inferior oblique muscle. The inferior orbital fat compartments are bordered posterosuperiorly by the capsulopalpebral fascia and anteriorly by the orbital septum. The lower eyelid has a single arcade that lies between the inferior tarsal muscle and the confluence of the orbital septum and capsulopalpebral fascia, just below the inferior limit of the tarsus. At the medial canthus, the superior and inferior palpebral arcades receive contributions from the medial palpebral arteries, arising from the ophthalmic branch of the internal carotid artery. The superomedial portion receives contributions from the supratrochlear and supraorbital arteries, which are also derived from the ophthalmic artery. At the superolateral aspect of the orbit, the superior palpebral arcade anastomoses with the zygomatico-orbital branch of the superficial temporal artery. Near the lateral canthal area, the superior and inferior palpebral arcades anastomose with the two lateral palpebral branches from the lacrimal artery, a branch of the ophthalmic artery. The inferolateral lower eyelid receives most of its contributions from the transverse facial artery, whereas the inferomedial lower eyelid receives major contributions from the angular artery, a terminal branch of the facial artery.