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Ceribell Training Flashcards

1
Q

Describe a Level 1 Trauma Hospital, 3-4 main points

A

24 Hour IN HOUSE coverage by general surgeons, prompt availability of trauma surgeons, neurosurgery, Emergency medicine, Critical care, and pediatrics

Referral resource for communities in nearby regions

Have tech and equipment a level 2 does not

Likely a hub for receipt of transfers and usually the “hub” for a health system IDN

They keep the sickest of the sick patients

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2
Q

Describe a Level 2 Trauma Hospital, 3-4 main points

A

24 hour immediate (on call, not on location) coverage by general surgeons

Tertiary care needs: may refer cardiac and other surgeries to a Level 1 Center

Likely transfer patients to nearby level 1

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3
Q

Compare Level 3 Trauma centers to Level 4 Trauma centers

A

Level 3 has 24/7 immediate coverage by emergency med, and on call general surgery. Provides back up care for rural and community hospitals. Transfer patients to level 1+2

Level 4 main focus is trauma support and fast transfer to a higher level trauma center

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4
Q

What are our Level 1 Call Points? 6 departments

A

Neuro ICU (Neurointensivist, Neurocritical care fellows, Neurosurgeons)

Medical ICU (cardiac arrests,sepsis, etc) Don’t overlook

Surgical ICU (TBIs)
Stroke Team
ED
Epileptologist

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5
Q

What are our Level 2 Call Points?

A

ALL ICUs (ICU Medical Director, Intensivists, ICU APPs)

Neurosurgery? If they work with TBI/Tumor

Stroke Team

ED
Neurohospitalist?
Epileptologist/Reading Neurologists

Likely have 1-2 EEG Techs - need to assess hours/coverage days

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6
Q

What are our Level 3 Call Points?

A

All ICUs
Stroke Team
ED
Epileptologist/Reading Neurologists

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7
Q

How can Ceribell help lower Level Trauma Centers with transfers? / Making sure transfers are accepted?

A

Provides the team with clear cut DATA that the patient is having a NCS / NCSE.

removes the guessing game

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8
Q

How can Ceribell help a center avoid unnecessary transfers? 3 typical scenarios

A

Maybe they couldn’t do 12 or 24 hour EEG studies previously? Patient would have needed a transfer. But with Ceribell - they can put a headband on for a 12-24 hour test and keep them on site

Ceribell can also RULE OUT NCS/NCSE to shoe it isn’t necessary to transfer

Patient is confirmed to have NCS/NCSE by Ceribell (EEG otherwise not available). Leads to quicker treatment and effectiveness of meds. Seizure activity subsisdes, and patient can stay at current hospital

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9
Q

What are the two main types of strokes?

A

Ischemic (Ih-scheme-ick) and Hemorrhagic

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10
Q

What is an Ischemic Stroke? How is it treated?

A

Usually caused by a clot. Something is creating a blockage of blood flow to the brain.

Treated with expensive, high risk blood thinner. Typically less sever than Hemorrhagic

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11
Q

What is a Hemorrhagic stroke? How is it treated?

A

Active bleeding in the brain. Usually requires surgical intervention to stop the bleeding

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12
Q

Name the 4 types of Stroke Centers

A

Acute Stroke Ready Hospital
Primary Stroke Center
Thrombectomy-Capable stroke center
Comprehensive stroke center

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13
Q

Define Acute Stroke Ready Hospitals

A

Least acute of the 4 stroke centers.

Can take a stroke patient, give a clot busting med, and then transfer out.

Rarely retains stroke patients.

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14
Q

Define Primary Stroke Centers

A

Can accept and keep most Ischemic strokes. Will transfer out most hemorrhagic strokes

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15
Q

Define Thrombectomy-Capable Stroke Center

A

Can accept and keep Ischemic strokes (Even thosee that require thrombectomy Surgical removal of a blood clot)

Still transfer out most hemmorhagic strokes

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16
Q

What is a thrombectomy?

A

Surgical removal of a blood clot

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17
Q

Define Comprehensive Stroke Center

A

Keeps ALL strokes. Highest end Stroke service

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18
Q

What providers are found in General/Mixed/Medical ICU’s?

A

Intensivists (Provides care for critically ill patients)

Pulmonologists (Lung conditions)

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19
Q

What providers are found in Neuro ICU?

A

Neurointensivists
Stroke Neurologists
Neurosurgery
Epilepsy

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20
Q

What providers are found in Cardiac ICU/ CVICU? Two main types

A

Intensivists
Cardiac Surgeons
Midlevels/fellows

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21
Q

What providers are found in Surgical ICU/Trauma ICU?

A

Surgeons
Anesthesia
Ortho

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22
Q

What patients are treated in General/Mixed/Medical ICUs?

A

Sepsis, Cardiac Arrests, Substance Use Disorders/Overdose

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23
Q

What patients are treated in Neuro ICUs?

A

Brain Tumors
Strokes

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24
Q

What patients are treated in Cardiac ICUs?

A

Cardiovascular intervention
Cardiac surgery
Open heart procedures

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25
Q

What patients are treated in Surgical ICUs?

A

Trauma
Traumatic brain injuries
falls

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26
Q

Difference between Trauma level designations?

A

Level 1s keep all patients. Levels 2 and 3 transfer

Level 1 typically have better neurodiagnostic coverage

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27
Q

4 Main Impacts Ceribell has on Patient Transfers?

A

Ruling in can help with rapid, more effective treatment

Ruling in can help expedite the patient to where they need to go (Transfer acceptance)

Ability to do 24 hour studies

Ruling out - potential to avoid unnecessary transfer for high suspicion

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28
Q

Main difference between Comprehensive and Primary stroke center accreditations?

A

Comprehensive - keeps all strokes
Primary - keeps Ischemic strokes (Clots) transfers out hemorrhages

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29
Q

What are the 4 main types of ICUs? What are their main patient/conditions they treat?

A

Medical - Sepsis, toxic/metabolic, cardiac arrest

Surgical/Trauma - Complex TBIs

Neuro - Neuro deficits, epilepsy, brain tumors

Cardiac - cardiac surgeries, cath lab interventions

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30
Q

2 Minute Pitch to an ED Provider - what do they want to hear?

A

What is Ceribell? How will it benefit them and their patients? Does/How does it work? When do they use it? Do they have to put it on? TIME TIME TIME

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31
Q

Stroke Neurologists - overview?

A

Expertise in stroke and cerebrovascular disease.

Usually on at the hospital/on call 24/7

Can do “wet reads”

They understand and are passionate about “Time is Brain”

Understand the necessity for having something quickly at the bedside. May be familiar with AI Technologies

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32
Q

Who/what are Hospitalists?

A

Focus on all aspects of care a patient receives while in the hospital, coordinate care b/w multiple specialists.

Follow a patient throughout their stay

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33
Q

What is the best time to Cold Call in the ED?

A

Early in the morning before they get really busy. Right before shift change (~6-6:30am)

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34
Q

What % of Cardiac Arrest patients could be experiencing NCSE? Non Convulsive Status Epilepticus

A

10-30%

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35
Q

Heart Attack vs. Sudden Cardiac Arrest - what are the causes? What is the risk of death?

A

Heart attack: Circulation issue, blocked blood supply to the heart. Classic “chest pain, shortness of breath heart attack” Many patients survive with early and appropriate treatment

Sudden Cardiac Arrest: Electrical issue. Abnormal heart rythym called ventricular fibrillation. Victims lose consciousness and may be found gasping for air. Death can occur within minutes without an AED

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36
Q

Describe a toxic/metabolic patient. What is TME?

A

TME - Toxic-Metabolic Encephalopathy

Results from an acute cerebral dysfunction due to different metabolic disturbances including meds or drugs. Leads to altered consciosness, from delirium to coma

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37
Q

What is ETOH?

A

Alcohol Withdrawal - during withdrawal, when the suppressive activity of alcohol is removed - your brain will be more susceptible to seizures than it normally would

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38
Q

What is the prevalence of seizures in ETOH patients?

A

~20%

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39
Q

What % of seizures in critically ill patients are unrecognized at the bedside? Since manifestations are often absent or subtle. Can only be diagnosed with EEG

A

60-90%

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40
Q

What do Non Convulsive Seizures look like? 7 main symptoms

A

Altered Mental state
Unusual Behavior
Myoclonus
Speech Disturbance
Anxiety, Agitation, and/or delirium
Extrapyramidal Signs - like dystonia, movement, tremor
Hallucinations

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41
Q

What is Myoclonus?

A

Sudden, brief involuntary twitching or jerking of a muscle or group of muscles

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42
Q

What is AMS? What is standard workup for AMS? Where can Ceribell fit in?

A

Altered Mental Status

Glucose fingerstick –>Monitor Vital Signs –>Head CT Scan –> Order Lab Tests

Opportunity to add Continuous EEG Monitoring at the end of this workflow. Why wouldn’t you? You can put it on immediately and monitor

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43
Q

Describe Psychogenic Non-epileptic (PNEs) seizures and Ceribell use?

A

Visible active convulsions but nonepileptic

Prioritize Neurology to review the EEG. Never suggest the Clarity algorithm is perfect for these patients. Neurology must read so that nothing is missed

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44
Q

Difference b/w strokes and seizures?

A

Strokes are a result of a blocked or ruptured blood vessel in the brain

Seizure is due to abnormal electrical activity in the brain

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45
Q

What are the patient indications for POC EEG that resonate BEST with the ED?

A

AMS
Stroke Vs Seizure
Post Ictal (Prior convulsive seizure)
Toxic metablic (ETOH Withdrawal)

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46
Q

What are the main driving mindsets of the ICU?

A

“Organized Chaos”

ICU wants to UNDERSTAND THE UNDERLYING REASONS FOR THEIR PATIENT’S ILLNESS - think full system, head to toe.

Patients regularly undergo a neuro workup to understand “Neurological Deficits”

47
Q

What are the best times to call on the ICU for Day shift and night shift?

A

Day shift: after 10/11am-4pm (May be able to catch ICU attending before rounds 7a-8am)

Night Shift: 5am-6:30am OR 9-11PM

48
Q

ICU - What are interdisciplinary rounds?

A

Take place at least once a day. Sometimes 2x. Essentially multidisciplinary review of patients, current states, and developing care plans for patient.

“Wouldn’t it be helpful if you had Ceribell data prior to rounding on the patient?”

NEVER interrupt morning rounds unless you’ve been asked

49
Q

ICU - What is a Neuro Intensivist?

A

Critical Care MD that specializes in Neurocritical care - treats life threatening diseases of the nervous system and identifies, prevents, and treats secondary brain injury

50
Q

ICU - What is a Pulmonologist?

A

Specializes in diseases of the respiratory system. May have had exposure to reading EEGs in the past

51
Q

What time is typical shift change for nursing in the ICU?

A

7am and 7pm

52
Q

Nursing CNS (What’s it stand for?) Why is it important?

A

ICU Clinical Educator / Clinical Nurse Specialist - Has to go through a masters program to obtain credential. Passionate about staff education, great ambassador for us. Definitely connect with one at every account to set up in-services and stuff

53
Q

What are the main financial pain points in the ICU?

A

Patient transfers - always ask if they are transferring patients then they can’t get an EEG or can’t do more than a spot study

LOS - Length of Stay?

54
Q

What are the main Clinical Pain Points in thee ICU?

A

Patient Outcomes/Delay in Care - having actionable data at the bedside is advantageous

Adhering to NCS and AHA Guidelines

55
Q

Patient Population - AMS

What does it stand for? What is the prevalence of Seizures in patients with undifferentiated AMS?

A

Altered Mental Status

10%

56
Q

Patient Population - Sepsis

Define it. What is the most important thing when treating sepsis? What is the prevalence of seizures in severe sepsis patients?

A

Sepsis is the life threatening complication of an infection. Most important thing is preventing multisystem organ failure and finding cause of infection

32% prevalence of seizures in severe sepsis patients

57
Q

Patient Population - Cardiac Arrest

Define it

What is prevalence of seizures?

A

NOT the same as a heart attack. (Heart attack is blockage in arteries that can CAUSE cardiac arrest).

Cardiac arrest is when the heart suddenly stops beating which in turn stops blood flow to the body/brain.

Prevalence of seizures 10-30%

58
Q

What is Targeted Temperature Management (TTM)?

A

a method the team will use to ensure patient does not spike any fevers. Goal is to preserve neurological function

59
Q

Patient Population - Toxic/Metabolic Encephalopathy

Define it

A

Delirium and confusional state in the absence of a structural brain disease.

Substance use, hypolycemia, electrolytes way off, alcohol withdrawal

These patients are at high risk for seizure activity

60
Q

What is the Stepdown Unit?

A

Where patients go when they have “graduated” from the ICU but are not quite ready for the floor.

“You wouldn’t want to admit the patient to the ICU just for Ceribell right?”

61
Q

Key takeaways for Ceribell for ED

A

Rapid triage, get the patient out of the ED as soon as possible

Real actionable information in five minutes

62
Q

Key takeaways for Ceirbell for ICU

A

Figure out underlying cause for AMS, ensure nothing is getting missed, get the patient out of ICU as soon as possible

63
Q

What is the definition of Status Epilepticus?

How does it present?

A

Single seizure lasting more than 5 minutes, or 2 or more seizures within a 5 minute period without the person returning to normal between them.

CONVULSIVE SE presents with a regular pattern of contraction and extension of the arms and legs.

NONCONVULSIVE SE is a change in a person’s level of consciousness without large-scale outward clinical signs

64
Q

What % of seizures in critically ill patients are unrecognized at the bedside? Since manifestations are often absent or subtle?

A

60-90%. Can only be diagnosed with EEG

65
Q

What is main objective of ED?

A

Throughput and Triage

66
Q

Define Empirical Treament

A

Treatment given based on experience, without precise knowledge of the cause or nature of a disorder.

67
Q

What is the difference b/w Neurologist and Epileptologist?

A

Epileptologist IS a NL, but they then specialized in Epilepsy

68
Q

What is the mindset of an Epileptologist?

A

They want to find out EXACTLY where the first started in the brain? Traditionally they use technology to determine location of origination of seizure.

They need guidance to undersatnding the utility of determining the entire brain is on fire via Ceribell

69
Q

What is an EMU in a hospital?

A

Epilepsy Monitoring Unit - bring patients in for observation in hopes they will have a seizure and it can be analyzed

70
Q

RM vs. FM Montage for electrodes?

A

RM = Reduced Montage
FM = Full Montage

Equates to coverage/number of electrodes. Ceribell is a RM system since we have less electrodes than conventional EEG

71
Q

Define/What are differences b/w Routine EEGs and Long Term EEGs

A

Routine - anything less than 2 hours. Known as “short” EEGs

72
Q

RVU Definition

A

Relative Value Unit

73
Q

What is Clarity?

A

First FDA cleared Beside Alert indicating status epilepticus

Continuous EEG monitoring and seizure burden display optimized to detect prolonged seizures

74
Q

What is the sensitivity and specificity of Clarity algorithm? What is negative predicted value?

A

Sensitivity is 95%
Specificity is 97%
Negative predicted value is 95%

75
Q

What is the sensitivity of the Clarity Algorithm? What does this mean?

A

95%. Possibility of a positive read when Status/Activity is present. Means that there are few false negative results

76
Q

What is the Specificity of the Clarity algorithm? What does this mean?

A

97%. Specificity is the possibility of clarity to specify that there is NO Status/Activity present

77
Q

What is the negative predicted value of the Clarity algorithm? What does this mean?

A

95%. The likelihood that a person who has a negative test result indeed does not have the disease, condition, biomarker, or mutation (change) in the gene being tested. The negative predictive value is a way of measuring how accurate a specific test is.

78
Q

Difference b/w Clarity and Clarity Pro?

A

Pro does same thing as Clarity, but it can also alert for Electrographic Status Epilepticus

79
Q

what is an “undercall” with clarity?

A

When the algorithm misses a seizure

80
Q

What is the definition of Electrographic Status Apilepticus?

A

Greater than 10 minutes of continuous electrographic seizure activity

OR.

a total duration of greater than or equal to 12 minutes of any 60 minute period of recording

81
Q

What are the 5 objections to know for Neurologist?

A

Time - Concerned about work/life balance . no phone calls in the middle of the night? No - the tech is gonna rule in/rule out. Rule in - treat. Rule out - read EEG in morning

Pay - easy one. You will get paid.

Parasagittal region - Similar to signal quality- we aren’t here to decide where things started. Don’t need it. We want to know there IS a fire, not where the fire started. Plus - Parasagittal seizures have physical signs clinically

Technicians - HCA Example - engagement survey 70% engagement to 100% after Ceribell, your people are going to be taken care of. Less turnover

Signal quality - This is a tool to rule in/rule out “brain on fire.”

82
Q

What if a Neurologist pushes back on Parasagittal Seizure coverage with Ceribell?

A

Very rare in adults. Also manifests itself clinically - patient will show physical signs

83
Q

Define DRG from a hospital reimbursement/billing standpoint

A

A diagnosis-related group (DRG) is a case-mix complexity system implemented to categorize patients with similar clinical diagnoses in order to better control hospital costs and determine payor reimbursement rates.

84
Q

What does NTAP stand for?

A

New Technology Add On Payment - Government assigned designation for additional reimbursement from new disruptive medical technologies.

Only 30 companies can get “NTAP” label per year.

Clarity Pro’s NTAP effective date October 1 2023. Only a 3 year designation

85
Q

What are the 5 objections from Neurologists? How do we blunt them?

A

Signal Quality - They are used to having 20 electrodes on a patient’s head. We only have 10. In order for us to get FDA approval in the first place we had to compare ourselves to traditional EEG. Only a 2-8% variance amongst all EEG technologies.

Parasagittal Seizure area - Because we do not cover this area. The purpose of Ceribell is to detect NCSE. It is not to detect tiny seizure spikes in the Parasagittal region. Also - Parasagittal Seizures in adults are extremely rare. Only .7% of the time. Plus - these seizures show themselves clinically. Physical responses.

Payment - Do they get paid to read? Yes. Ceribell qualifies for the same CPT codes as conventional EEG. We qualify for “routine” EEGs and “Long Term” EEGs. All reimbursabl

Improving quality of life of their techs - NLs are very protective of their techs. HCA conducted an engagement survey before and after implementation. It went from 70% to 100%. Gave quality of life back to these techs. No longer called in on nights and weekends for patients that are perfectly fine. They are only called in for long term monitoring.

Quality of life for NLs - They do not want to be woken up in the middle of the night. They can choose when to be notified on reads. They are also heavily involved in constructing the workflow.

86
Q

What is the minimum patient age for the Ceribell Status Epilepticus Monitor software? Per the FDA?

A

18

87
Q

Can you trigger an electrographic status epilepticus alert without first triggering a continuous seizure susptected alert?

A

NO! In all cases, the continuous seizure susptected alert will trigger first at 4.5 minutes of seizure. If Seizure burden stays at 100% for a total of 10 continuous minutes, the ALERT will be displayer

88
Q

What is the Ictal-Interictal Continuum?

A

Describes seizure-like EEG activity that doesn’t qualify as seizure yet may be abnormal, but the optimal treatment is often unclear.

89
Q

In the IIC (Ictal Interictal Continuum) what are GPDs? What are LPDs? How are they different?

A

Generalized Periodic Discharges - can manifest as sharp waves or spikes occurring in a generalized and periodic manner

Lateralized periodic Discharges - Patterns may appear as sharp waves, spikes, or spike and wave complexes and can be rhythmic

GPDs Occur in the same manner on BOTH sides of the brain. LPDs only occur on ONE side of the brain.

90
Q

Can the insight bar detect GPDs, LPDs, and short seizures?

Is there a bedside alert associated with the insight bar?

A

It is not validated to label epileptiform abnormalities. It highlights “Possible areas of concern”

NO alert at bedside. Perhaps in the future as we gather evidence.

91
Q

Define a “Wet Read”

A

A quick, cursory read of an EEG at bedside to determine next care pathway. Not a full diagnostic right up/determination.

92
Q

What is SIMPACT?

A

Post usage survey that pops up on our readers. Asks about key metrics - improved decision making, intubation avoidance, transfers, etc.

Allows us to capture workflow improvements, patient flow improvements, etc and emphasize ROI

93
Q

What is our typical “Diagnostic Yield” for Seizure Burden/Detection?

A

% of time an abnormality is detected
Seizure + Alarm Rate

Typically:

5 - 10% NCSE
15 - 25% Seizure Activity
~65% Rule Out

94
Q

What is “Intra Rater Variability”?

A

Variability on analysis/reads by individual readers. Not all readers agree on conclusions drawn from EEG reads. Important to understand that there is always a level of Intra Rater Variability

95
Q

What is a great 3 step process for educating/in-servicing teams?

A

“See one, Teach one, Do one”

96
Q

What percent of head sizes do our headbands fit?

A

95% - though it is important to note that hardly anyone in the field has seen one that didn’t fit

97
Q

Define “Post ROSC”

A

Return of spontaneous circulation after a cardiac arrest.

98
Q

What is a negative charge case to the hospital? Why is it important to NTAP?

A

If hospital costs for the patient are greater than the DRG. It is important because it is one of the criteria for a hospital to claim NTAP

99
Q

What are the 4 Criteria for NTAP Reimbursement?

A

Clarity Pro
Inpatient
Traditional Medicare/Medicare Adv.
Negative Charge Case

100
Q

What is the EEG Guideline from the Neurocritical Care Society?

A

EEG should be initiated within 15-60 minutes of suspected Status Epilepticus IN ALL PATIENTS

*2012 NCS Guidelines for Evaluation and Management of Status Epilepticus

101
Q

What is the American Heart Association’s guideline for EEG in Post ROSC Patients? When was it released?

A

EEG should be promptly performed and interpreted for the diagnosis of seizures in ALL comatose patients after ROSC

*2020 AHA Guidelines for CPR and ECC Recommendations for Seizure Diagnosis and Management

102
Q

What are the Joint Commission Requirements for EEG?

A

2022 Joint Commission requires compliance to the 2020 AHA Guidelines for prompt EEG for POST ROSC Patients

103
Q

Healthcare Economics - Define CC/MCC

A

Complication or Comorbidity/Major Complication or Comorbidity.

Presence of additional diagnosis or procedure that may result in reassignment of patient discharge to MS-DRG with higher resource utilization

104
Q

Healthcare economics - Define MS-DRG

A

Bundled payment that accounts for reimbursement of products and service provided to Medicare beneficiary.

DRG = Diagnosis Related Group

105
Q

Healthcare economics - Define Chargemaster

A

Comprehensive list of hospital products, procedures, and services. Includes CPT Codes, charge per unit, revenue code, status flags

106
Q

Healthcare economics - 3 main ways Ceribell positively impacts hospital finances?

A

CAPTURE VALUE - Uses existing CPT codes for EEG reimbursement, Eliminate diagnostic EEG transfers (Retain full primary DRG payment, $7k avg.), Bill for diagnosed seizures Can’t bill for what you can’t diagnose, Potential NTAP payment

REDUCE COST - Decrease medication and intubation rates, reduce length of stay, eliminate transfers, reduced after hours and on call time

ALLOCATE VALUABLE RESOURCES - Allow EEG Techs to focus on outpatient care, reduce after hours and on call time, raise staff satisfaction and retention (HCA Engagement EEG Tech Survey)

107
Q

Healthcare economics - What are the two main categories of reimbursement we focus on? Where are these applied? (I.E. what department, in patient? Outpatient?)

A

CPT Codes (ED/Outpatient) - Professional and Technical Components (Neurologist read fee + technical fee for placing the headband)

DRG (In-Patient) - CPT Professional ONLY (Read-fee only), DRG Codes, and potential CC/MCC CPT Professsional

108
Q

Healthcare economics - Define CPT Professional Component for Reimbursement - where does it apply?

A

Fee that is going to the “professional”…. going to the Neurologist

“Neurologist Read-Fee” Code

Also potential CC/MCC CPT Professional Code

Does not matter if ED/ICU/Outpatient/Inpatient. No matter what - the NL will be paid for reading the EEG

109
Q

Healthcare economics - Define CPT Technical Component Reimbursement - where does it apply?

A

Technical fee for placing the headband - ONLY applies to ED/Outpatient Setting

110
Q

What are our three Indications for Emergent EEG?

A

1 - Seizure Assessment
2 - Post Cardiac Arrest
3 - AMS (Altered Mental Status)

111
Q

Define “Seizure Assessment” as an indication for Emergent EEG. 3 components

A

Recent convulsive seizure without return to baseline

Episodic or repetitive movements concerning for seizure

Seizure activity requiring active medication titration

112
Q

Define “Post Cardiac Arrest” as an indication for Emergent EEG. 3 components

A

Post-ROSC without return to baseline/comatose

2020 AHA Class 1 Guideline

Sedated or TTM seizure monitoring

113
Q

Define Altered Mental Status (AMS) as an indication for Emergent EEG. 3 components.

A

Altered mental status without explanation

Persistent altered state and acute brain injury

Unresponsive to treatment of primary condition - especially sepsis, hepatic failure

CAM Territory Planning (4 decks)

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