Community Flashcards
(110 cards)
1
Q
Physical consequences of loneliness
A
Earlier death
Take more risks
Harder to self regulate
2
Q
Risk factors for loneliness
A
Lives alone Bereavement/ recent transition Suffering from an illness/ chronic disease Mobility Sensory impairment Close family nearby Quality of social contact
3
Q
Define the social theory of disengagment
A
Ageing is an inevitable,mutual withdrawal or disengagement, resulting in decreased interaction between the raging person and others in the social system he or she belongs to
Innate, universal and unidirectional
4
Q
Define social exclusion
A
Dynamic process of being shut out, fully or partially from any social, economic, political or cultural systems which determine the social integration of a person in society.
5
Q
List the domains of social exclusion
A
Material resources Basic services Civil activities Neighbourhood Social relationships
6
Q
List the potential causes of social exclusion
A
Poor health Sensory impairment Poverty Housing issues Fear of crime Transport Discrimination
7
Q
List initiatives currently attempting to combat loneliness
A
Age UK Siverline Circle of friends Dementia Housing (flexible care, planing for older people) Mindfullness of ageing Sod 70
8
Q
Explain Maslows Hierarchy of needs
A
1) Physiological: breathing, food, water, sex, sleep, excretion
2) Safety: Security of body, of employment, of resources, of morality, of the family, of health, of property
3) Love/Belonging: Friendship, family, sexual intimacy
4) Esteem: Self-esteem, confidence, achievement, respect of others, respect by others
5) Self-actualization: Morality, creativity, problem solving , lack of prejudice
9
Q
List the possible groups who are vulnerable to homelessness and the possible causes
A
Ex-service men
Mentally unwell
Local authority care leavers
Ex-prisioners
Causes
- Eviction/Economic hardship
- Relationship breakdown
- Mental illness
- Unemployment
- Substance abuse
- Bereavement
10
Q
List the health issues that may affect those who are homeless
A
Infectious diseases Poor foot and teeth health Resp problems (TB) Sexual health Serious mental health illness Poor nutrition Addictions/substance misuse
11
Q
Define the inverse care law
A
The availability of good medical or social care tends to vary inversely with the need of the population served
Barriers to healthcare
- Difficulties with access
- Lack of integration between mainstream care services and other agencies
- Other worries
- Lack of knowledge
- Discrimination
12
Q
What factors affect the travelling communities health and what barriers do they face when accessing healthcare
A
- Education
- High rates of smoking
- Poor uptake of ANC
Barriers
- Reluctance to vist healthcare professionals
- Illiterate
- Communications difficulties
- Lack of a permanent site
- Lack of choice
13
Q
Define refugee
A
A person granted asylum and refugee status. Leave to remain for 5yrs and then reapply
Out of their home and country
14
Q
Define asylum seeker
A
Person who has submitted an application to be recognised as a refugee and is waiting for their claim to be decided by the home office
1951 convention on refugees
Anyone has the right to apply for asylum in the UK and remain until a final decision on their applications has been made
15
Q
Define Humanitarian Protection
A
Failed to demonstrate a claim for asylum but face a serious threat to life if they return to their country
16
Q
What health issues affect refugees
A
Illness linked to country of origin Injuries linked to warfare and travel No health screening Malnutrition Infections Untreated chronic disease Mental health - PTSD -Depression -Sleep disturbance -Psychosis -Self harm
17
Q
Define an unaccompanied asylum child
A
Crossed an international border in the search of safety and refugee status
Applying for asylum in his/her right
Under the age of 18 or in the absence of documentary evidence appears to be under that age
Without family members or guardians to trust in this country
18
Q
Define epigenetics
A
Expression of the genome dependent on the enviroment
19
Q
Define allostasis
A
Stability through change, our physiological systems have adapted to react rapidly to environmental stressors
20
Q
Define allostatic load
A
Long term overtaxation of our physiological systems that leads to impaired stress
21
Q
Define salutogenesis
A
Favourable physiological changes secondary to experiences which promote healing and health
22
Q
Define emotional intelligence
A
The ability to identify and mange ones own emotions as well as those of others
23
Q
List the dangers of overprescribing antibiotics
A
Unnecessary side effects
Medicalise self-limiting conditions
Antibiotic resistance
24
Q
Role of primary health care
A
Managing illness and clinical relationship overtime
Finding the best available clinical solutions to clinical problems
Preventing illness
Promoting health
Managing clinical uncertainity
Shared decision making with the patients
25
Define public health
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
26
List the three domains of public health
Health improvement
- Societal interventions to promote health and prevent disease
- Reduce inequalities
Health protection
- Measures to control infections diseases
- Reduce environmental hazards
Improving services
- Organisation and delivery of safe, high quality services for prevention, treatment and care
- Clinical effectiveness
27
Key concerns for public health
Inequalities in health care
Wider determinants of health
Prevention
28
Define health needs assessment
Systematic method for reviewing the health issues facing a population.
Leading to agreed policies
Resource allocation
Improve health and reduce inequalities
29
Discuss the domains of health needs assessment
Need: Ability to benefit from an intervention
Demand: What people ask for
Supply: What is provided
Health need: Need for health, measured using mortality, morbidity and socio-demographic measures
Health care need: Need for health care, ability to benefit from health care
30
Sociological perspective on need
Felt need: Individual perceptions of variations from normal health
Expressed need: Individuals seek help to overcome variation in normal health
Normative need: professional defines interventions appropriate for the expressed need
Comparative need: Comparison between severity, range of interventions and cost
31
Different approaches to health needs
Epidemiological
Comparative
Corporate
32
Discuss the epidemiological approach to health needs assessment and list the advantages and disadvantages
```
Epidemiological:
Define the problem
Available services
Evidence base
Models of care ( outcomes measured)
```
ADVANTAGES
- Uses existing data
- Provides data on disease incidence/mortality/morbidity
- Evaluate services by trends over time
DISADVANTAGES
- Quality of data variable
- Data collected may not be the data required
- Does not consider the felt needs or experiences of the people affected
33
Discuss the comparative approach to health needs assessment and list the advantages and disadvantages
Compares the services received by a population with others
Examine
- Health status
- Service provision
- Service utilisation
ADVANTAGES
- Quick and cheap
- Compares health service provisions in different areas
DISADVANTAGES
- Difficult to find a comparative population
34
Discuss the coparate approach to health needs assessment and list the advantages and disadvantages
Ask the population what their needs are
Use focus groups, interviews and public meetings
ADVANTAGES
- based on felt and expressed needs
- Recognised detailed knowledge of those working in the population
- Takes into account a wider range of view
DISADVANTAGES
- Difficult to distinguish need from demand
- Vested interest
- Influenced by political agendas
35
List the different types of prevention
Primary prevention: preventing disease before it has happened
Eg: Lifestyle advice
Secondary prevention: Intervention to prevent symptoms of the disease. Catching the disease in the pre-clinical/early phase.
Eg: Statins, lifestyle
Tertiary preventions: Preventing complications of the disease
Eg: Dual antiplatlets
36
List the different approaches to prevention
Population approach: preventative measures (Dietary salt reduction through legislation)
High-risk population: Identify individuals above a chosen cut off and treat. (Screening for a high BP)
37
Define the prevention paradox
A preventative measure which brings much benefit to the population often offers little to each participating individual
38
Define screening
A process which sorts out apparently well people who have the disease or a precursor or suitability to a disease from those who do not
39
List the different types of screening
```
Population based screening programmes
Opportunistic screening
Screening for communicable diseases
Pre-employment and occupational needs
Commercially provided screening
```
40
Names and discuss the screening criteria
Condition must be an important health problem
An acceptable treatment must exist for the condition
Facilities available for diagnosis and treatment
A clear latent or early phase of the disease
Suitable test of examinations
The test must be acceptable for the popluation
Clear policy of who to treat and when to treat them
The disease must have a natural history
Continous process
Economically viable
41
Disadvantages of screening
Exposure of well individuals to distressing or harmful diagnostic tests
Detection and treatment of sub-clinical disease that would never have caused any problems
Preventive interventions that may cause harm to individuals or population
42
Important screening calculations
Sensitivity: the proportion of people with the disease who are correctly identified by the screening test (a/a+c)
Specificity: the proportion of people without the disease who are correctly excluded by the screening test (d/b+d)
Positive predictive value: the proportion of people with a positive test results who actually have the disease (a/a+b)
Negative predictive values: the proportion of people with a positive test result who do not have the disease (d/c+d)
This goes down as prevalence goes up.
PREDICTIVE VALUES ARE DEPENDENT ON PREVALENCE
43
Lead time basis
Screening identifies an outcome earlier than it would otherwise have been identified this results in an apparent increase in survival time, even if screening has no effect on outcome
44
Length time basis
Type of basis resulting from the differences in the length of time taken for a condition to progress to severe effects
Affect the efficacy of the screening method
45
Classify the different types of study design and give examples of each.
Observational
- Descriptive
- Descriptive and analytical
- Analytical
Experimental
- Randomised control trial
- Non-randomised control trial
46
Discuss the different types of variables
An independent variable can be altered in a study
| A dependent variable is a variable that is dependent on a independent variable or one that cannot be altered.
47
Define odds and odds ratio
Odds of an event is the ratio of the probability of the event occurring against the probability of the non occurrence of the event
Odds= probability/(1-probability)
Odds ratio is the ratio of odds of the exposed group against the ration of the unexposed group
OR= (Pexposed/1-Pexposed)/(Unexposed/1-Punexposed)
OR can be interrupted as relative risk when the event is rare
48
Define epidemiology
Study of frequency, distribution and determinants of disease and health related states in populations in order to prevent and control disease
49
Key epidemiological components
Incidence: measure of the probability of occurrence of a given medical condition in a population within a specified period of time.
Prevalence: Number of existing cases at s specific time point
Person time: measure of time at risk, time from entry to a study to (i) disease onset, (ii)loss to follow up (iii) end of study.
Incidence rate = number of persons who have become cases in a given time period/ Total persons - time at risk period
50
Discuss the types of risk
Absolute risk: Actual numbers involved 50 deaths per 1000
Attributable risk: rate of disease in the exposed that may be attributable to the exposure. Is about the size of effect in absolute terms.
Relative risk: Ratio of risk of disease in the exposed to the risk in the unexposed. Strength of association between a risk factor and a disease.
Relative risk reduction: RRR is the reduction in rate of outcome in the intervention group relative to the control group
Absolute risk reduction: Absolute difference in the rates of events between the two groups and gives an indication of the baseline risk and intervention effect.
Numbers needed to treat ( NNT): Number of patients needed to treat to prevent one bad outcome
51
Explanations for association between an exposure and an outcome
```
Bias
Chance
Confounding
Reverse causality
A true causal association
```
52
Define bias and classify the types of bias
A systemic deviation from the estimation of the association between exposure and outcome
- Selection bias: a systemic error in the selection of study participants or the allocation of study participants
- Information bias: a systematic error in the measurement of the classification of exposure or outcome.
Sources of information bias
(i) Observer ( observer bias)
(ii) Participant ( recall bias, reporting bias)
(iii) Instrument ( wrongly calibrated instrument)
- Publication bias
53
Define confounding
A situation in which the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor that is also independently associated with the outcome
54
Define reverse causality
A situation where the association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the otucome
55
List the Bradford-Hill criteria ( causality criteria)
Strength of association: magnitude of relative risk
Dose-response: the higher the exposure the higher the risk
Consistency: similar results from different reasearchers
Temporality: dose exposure precede the outcome
Reversibility: removal of exposure reduces disease risk
Biological plausibility: biological mechanism explaining the link
Coherence: consistency with other information
Analogy: similarity with other established cause and effect)
Specificity: relationship specific to outcome of interest)
56
Define addiction
Craving, tolerance, compulsive drug-seeking behaviour, physiological withdrawal state.
57
Effect of dependent drug use
Physical
- Acute
* complications injecting
* overdose
* poor pregnancy outcomes
* side effects of opiates
- Chronic
* Blood-borne virus transmission
* Effects of poverty
* side effects of cocaine
Social
* Effects on families
* Drive to criminality
* Imprisonment
* Social exclusion
Psychological
* Fear of withdrawal
* Craving
* Guilt
58
Discuss the mechanism of action of heroin, effects and treatment options
Acts on the opiate receptors
Effects
- Euphoria
- Intense relatation
- Miosis
- Drowsiness
Harm reduction
- Prevent deaths
- Prevent blood borne viruses (not sharing needles, safer sex, screening, vaccinations)
- Referral ( specialist drug services, voluntary sector services, infectious diseases)
Detoxification
- Buprenorphine (1st line) Partial agonist of the mu-opoid receptors
Maintenance
- Methodone ( full agnoist) or buprenorphine ( partial agoinst)
- Reduces drug-related mortality
- Significantly reduces mortality
- Reduces crimes
- Reduces risk taking behaviour
Relapse prevention
- Naltrexone
- Supervised adminsistration
All the alt stuff
59
Discuss the mechanism of action of cocaine, effects and treatment options
Blocks reuptake of serotonin and dopamine at synapses
= intense pleasurable sensation
Depletion at secretory neurone = anxiety, panic, adrenaline secretion, wired.
Effects
- Confidence
- Wellbeing
- Euphoria
- Impulsivity
- Increased energy
- Alterness
- Impaired judgement
```
TREATMENT
Harm reduction ( as above)
```
Brief intervention
- explain the risks
- explain the effects
- advice on controlled use
TEAM WORK
- refer to sexual health centre
- referral to voluntary agency
- referral for specialist advice
In chronic coke users tactile and sensory hallucinations of insects crawling on skin are typically seen ( Fomications)
60
Offers of help for a newly presenting drug user
```
Health check
Screening for blood borne virus
Contraception
Sexual health advice
Immunisations are up to date
Sign post additional help
Information on the local drug service
```
61
Aims of treatment for drug users
Reduce harm to the user, family and society
Improve health
Stables lifestyle
Reduce crime
62
List the different types of health behavouirs
Health behaviour: aimed to prevent disease (healthy eating)
Illness behaviour: behaviour aimed to seek remedy (going to the doctor)
Sick role behaviour: activity aimed at getting well (taking the anti b's)
63
Theory of planned behaviour
The best predictor of behaviour is intention
Intention is determined by
- persons attitude to behaviour
- perceived social pressures to undertake the behaviour (subjective norms)
- persons appraisal of their ability to perform the behaviour
64
Criticism of the theory of planned behaviour
Lack of temporal element
| Lack of direction or causality
65
Discuss the stage models of health behaviour
```
Precontemplation
Contemplation
Preparation
Action
Maintenance
```
66
Define motivational interviewing
A counselling approach for initiating behaviour change by resolving ambivalence.
67
Define the nudge theory
Nudge the environment to make best option the easiest
Examples
- Opt out pension schemes
- Fruit at supermarket check outs
68
Factors that can influence behaviour change
Impact of personality traits on health behaviour
Assessment of risk perception
Impact of past behaviour/habit
Automatic influences on on health behaviour
Predictors of maintenance of health behaviours
Social norms
69
Role of NCSCT
Delivers training and assessment programmes
Support services for local and national providers
Conducts research in behavioural support for smoking cessation
70
Role of the consultant in communicable disease control
Surveillance: using notification, lab and other data to monitor communicable disease
Prevention: stop people from getting infections diseases
Control: Management of routine cases or outbreaks
71
Protocol for managing outbreaks
```
Clarify the problem
Decide if it is an outbreak ( 2 or more related cases of a communicable disease)
Include relavant practitioners
- Microbiologists
- Health visitors
- Consultant in ID
Call on outbreak meeting
Id the cause
Initiate the control measures
```
72
Modes of transmission
```
Food borne: acquired from food or water
Faecal-oral spread: inanimate objects
Resp route: hard to control
Direct physical contact: contagion (includes STDs)
Acquired from animals: zoonoses
```
73
Discuss the different types of prevention
Primary: intervention implemented before there is evidence of disease or injury
Eg Lifestyle factors for DMII
Secondary prevention: An intervention implemented after a disease has begun but before it is symptomatic
Eg: DM foot screening
Tertiary prevention: Intervention implemented after a disease or injury is established
Eg: Special boos to protect diabetic feet that have neuropathy
74
Define herd immunity
the resistance to the spread of a contagious disease within a population that results if a sufficiently high proportion of individuals are immune to a disease
75
Ethical dilemmas concerning the immunisation of children
Less mature immune systems
Autonomy
Consent
Personal choice vs risk of the population
Form of neglect not to immunise
Justice in the distribution and access of certain vaccinations
76
Define domestic abuse
Any indicator of controlling, coercive, threatening behaviour, violence or abuse between the aged >16 who are/ have been intimate partners or family members regardless of gender or sexuality
77
List the five areas of domestic abuse
```
Physical
Sexual
Emotional
Financial
Psychological
```
78
Explain Duluths model
```
Describes that males use violence within relationships to exercise power + control
They do this through
- using children as threats
- use of male privilege
- using intimidation
- financial abuse
- using isolation
- using coercion + threats
```
79
Impact of domestic abuse on health
Traumatic injuries following assault: fractures
Somatic problems/ Chronic illness: GI disorders
Psychological/ Psychosocial problems: PTSD, substance misuse
80
Public health interventions to reduce and help those involved in domestic abuse
Display helpline posters and contact cards
Focus on patient safety and that of their children
Ask direct Q's
Be open to working with other organisations and professionals
Health records are important
81
Discuss the risk levels of domestic abuse
STANDARD
Current evidence does not indicate likelihood of causing serious harm
MEDIUM
Identifiable indicators of risk of serious harm. Offenders has potential to cause serious harm unless under toxic circumstances
HIGH
Identifiable indicators of imminent risk of serious harm,
DYNAMIC: could happen at anytime and impact would be serious
For standard/medium give local helpline and national helpline
High risk refer to MARAC/IDVAS wherever possible with consent ( can can break confidentiality)
82
Explain the DASH tool
Domestic Abuse Stalking behaviour and Harressment : no actual score. Gives info favour perpetrator and children
83
Discuss the help agencies involved
MARAC: Multi-agency risk assessment conference which gets together every 2 months to discuss cases
IDVAS: Independent domestic violence advocates
Represent high risk women
Provide advice about safety planing
DHR: Domestic homocide review
Reivew circumstances on which the death of a person >16 appears to have resulted from violence, abuse or neglect
84
Explain the toxic triangle with reference to domestic abuse
(Re: child protection)
Triad:
Domestic abuse
Alcohol/substance misuse
Parent mental health
85
Give several criticism of the health belief model
1) Alternative factors may predict health behaviour
- Outcome expectancy: whether an individual feels they will be heathlier as a result of their behaviour
- Self-efficacy: the person's belief in their ability to carry out the preventative behaviour
2) As a cognitively based model it does not consider the impact of emotions on behaviour
3) Does not differentiate between the first time and repeat behaviour
4) Cues to action are often missing
86
What are the 3 factors influencing intentions in the theory of planned behaviour model?
Attitude
Subjective norms
Perceived behavioural control
87
What is the main influence of behavioural change in the theory of planned behaviour model
Intentions
88
Apply the theory of planned behaviour model to smoking cessation
Attitude
" I don't think smoking is good"
Social norms
" Most people close to me/ important to me want me to give up"
Intention
" I intend to give up smoking"
Behaviour
" Stop smoking"
89
What is the third stage of the transtheoretical model
Preparation
90
Considering NICE guidelines on behavioural change ..... identify typical transition points
```
(Wally BURPS)
Work ( entry to the work force)
Bereavement
Unemployed
Retirement
Parent ( becoming a parent)
School ( leaving school)
```
91
Three main types of behaviour related to health. Specify types and provide examples for each
Health behaviour: a behaviour aimed to prevent disease
Illness behaviour: behaviour aimed to seek remedy
Sick role behaviour: activity aimed at getting better ( taking prescribed medicine)
92
Interventions are rarely restricted to one level, discuss how a brief primary care intervention aimed at decreasing alcohol consumptions among individuals could have a feed through impact on other populations
Individual behaviour
- Individual health outcomes
- Incidence of domestic violence
Local community
- local alcohol sales
- Alcohol related crime
- A&E events
Population level
- National alcohol sales and consumption
- National stats on alcohol related crime
- Demographic patterns of liver cirrhosis
93
Why might knowledge of risk factors not influence a patients behaviour
Unrealistic optimism theory
1) Individual has an inaccurate perception of guilt
2) Individual has an inaccurate perception of susceptibility
```
Also
Health beliefs
Situational rationality
Culture variability
Socioeconomic factors
Stress
Age
```
94
Explain the major theory which contributes to people engaging in damaging health behaviours
Unrealistic optimism
| Individuals continue to engage in health damaging behaviours due to inaccurate perceptions of risk and susceptibility.
95
Donabedians " structure, process, outcome is a useful framework to use when carrying out evaluation of health services . Explain what is meant by structure
Structure includes all of the factors that affect the context in which care is delivered. This includes the physical facilities, equipment and human resources, as well as organisational characteristics such as staff training and payment methods
Structure is often easy to observe and measure as it may be the upstream cause of the problem identified in the process.
Donabedians defined structure as the settings, qualifications of providers and administrative system which care takes place
96
When assessing the quality of health services, Maxwells classification list 6 dimensions. List the 6 and explain them
Accessibility: is the service provided? Location, waiting times
Appropriateness: is the right treatment being given to the right people at the right time
Acceptability: is the service offered of a high enough standard
Efficiency: is the output maximised for a given input
Effectiveness: does the service produce the desired effect
Equity: are patients being treated fairly
97
Explain the difference between horizontal and ventricle equity in relation to health care
Horizontal health care: equal treatment for equal needs
Vertical: describes unequal treatment for unequal needs
i.e. those with poorer health require higher expenditure on the health service
98
Explain the differences between public health interventions delivered at population level, using one example for each to illustrate your answer
Public health interventions differ depending on the target audience.
A public health intervention at an individual level focuses on the safety of that individual and is patient centred.
Eg: Needle exchange programme
Interventions at a population level consider the wider determinants of health and are influenced by data obtained from ecological studies
Eg: introduction of a sugar tax to reduce the incidence of DM II
99
Although using measures of health outcomes is desirable in evaluation of health services, there are potential limitations. Explain who it may be difficult to attribute a health outcome to a service provider
Data may not be available
Issues with data quality (completeness, accuracy, relevance, timelines)
Large sample sizes may be needed to detect statistical significant effects
Time lag between the service provided and the outcome may be long ( healthy eating intervention and DM TII in kids long time to take effect)
The link between the health service provided and health outcome may be difficult to establish as many other factors may be involved. ( confounding factors)
100
Explain the differences between 2 and 3 prevention
Secondary prevention: aims to alter the course of a disease, reduce the recurrence of disease/medical incident and detect the disease at early stages
Eg: Screening programmes
Tertiary prevention: aims to manage and control chronic disease s to avoid the development of complications
Eg management of DM to prevent peripheral neuropathy
101
Explain what is meant by the comparative approach to health needs assessment
Frameworks for health needs assessment are built on 3 main approaches
Epidemiological, Comparative and corporate
The comparative approach compares services received by a population or subgroup in one area with those received in other areas. Comparisons have proved to be powerful tools for investigating the health services. They can examine health status, service provisions, service utilisation and health outcomes. The companies approach is quick and cheap if the data is available. It gives a measure of relative performance. Problems with the comparative approach are the it may be difficult to find a comparative population, data may not be available and it may not yield the most appropriate levels.
102
Give three potential limitations of the epidemiological approach to health needs assessment
Does not consider the felt needs of those affected
The required data may not be available
May be variability in the data quality
103
Define Bolam's rule and Bolitto's rule
Bolam: Would a reasonable doc do the same
Bolitto: Would it be reasonable for them to do so
104
List the health determinants
Genes
Environment
Lifestyle
Healthcare
105
List the different types of equity
Horizontal equity: equal treatment for equal need
| Vertical equality: equal treatment for unequal need
106
Define equality and equity
Equality: concerned with equal shares
Equity: unequal rx for unequal need
107
List the forms of health care equity
```
(AEHOU)
Equal access for equal needs
Equal expenditure for equal needs
Equal health
Equal health outcomes for equal need
Equal utilisation for equal needs
```
108
Discuss the difficulties faced when trying research health outcomes
Difficulties collecting data
Issues with data quality
Large sample size required
Difficult to establish a true cause and effect due to confounders/ time lag between the the service provided and the health outcome
109
List the two types of health behaviours
Health damaging
- Smoking
- Weight > 25
- Decreased activity
- Increased alcohol
Health Promotion
- Exercise
- Heathy eating
- Vaccinations
- Medication
110
List the different types of models of behavioural change
```
Transtheoretical model/ Stages of changes
Social norms theory
Theory of planned behaviour
Health belief model
Nudge theory
Social marketing
Motivational interviewing
```
