Cancer Tips and Solutions!!!

Saturday, 15 July 2017

Hormone replacement therapies help breast cancer grow, spread

Hormone replacement therapies could cause specialized cancer cells to induce growth, metastasis

Source: University of Missouri-Columbia
Summary:: Women who take hormone replacement therapies have a higher incidence of breast cancer, research shows. Now, researchers have linked natural and synthetic progestins to the body's production of specialized cancer cells that act like stem cells in humans. Findings could help scientists target these rare cells that proliferate in breast cancers and metastasize elsewhere, and may help clinicians identify immunotherapies to combat the spread of the disease.

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Hormone replacement therapies, or medications containing female hormones, may help cancer to spread.

Credit: © Ivelin Radkov / Fotolia

Hormone replacement therapies, or medications containing female hormones that substitute those no longer produced by the body, often are prescribed to reduce the effects of menopausal symptoms in women. Research has indicated that women who take hormone replacement therapies have a higher incidence of breast cancer. Now, researchers at the University of Missouri have linked natural and synthetic progestins to the body's production of specialized cancer cells that act like stem cells in humans. Findings could help scientists target these rare cells that proliferate in breast cancers and metastasize elsewhere, and may help clinicians identify immunotherapies to combat the spread of the disease.

             "In previous studies, we have shown that both natural and synthetic progestins accelerate the development of breast cancer and increase their metastasis to lymph nodes," said Salman Hyder, the Zalk Endowed Professor in Tumor Angiogenesis and professor of biomedical sciences in the College of Veterinary Medicine and the Dalton Cardiovascular Research Center. "Our laboratory is committed to identifying the cell mechanisms that bring about increased breast cancer risks. Recently, our research focused on special cells which are called 'cancer stem cell-like cells' -- that induce aggressive tumor growth, metastasis and cancer recurrence."
             In a series of tests, the team used hormone-responsive human breast cancer cells to examine the effects of progestin on the cell markers typically found in breast cancers. Both natural and synthetic progestins significantly increased protein expression of CD44, a molecule involved in cell proliferation, cell communication and migration. Additionally, the presence of progestins caused these components to behave like cancer stem cell-like cells.
            These rare cells are a small population of cells that -- acting like normal stem cells are self-renewing, create identical copies of themselves and proliferate exponentially. Further testing showed that the rare subset of cancer cells actually were enriched by progestin.
"The findings show that exposure to natural and synthetic progestins leads to the development of these cancer stem-cell like cells," Hyder said. "These cells greatly increase the likelihood of resistance to therapies and the risk for metastasis. Our findings also suggest that clinicians may be able to combat the progestin-dependent tumor growth through immunotherapy."

Wednesday, 12 July 2017

Experimental 'enhancer' drug may boost conventional therapies for deadly pediatric brain cancers

Test tube and mouse studies show TAK228 enhances the tumor-killing effects of radiation and chemotherapy

Source:: Johns Hopkins Medicine
Summary:: Laboratory studies suggest that an experimental drug already in early clinical trials for a variety of adult cancers might enhance radiation and chemotherapy for two childhood brain cancers that currently are virtually always fatal.

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Laboratory studies suggest that an experimental drug already in early clinical trials for a variety of adult cancers might enhance radiation and chemotherapy for two childhood brain cancers that currently are virtually always fatal.

In a report on two studies conducted by Johns Hopkins Kimmel Cancer Center researchers, the drug, known as TAK228, suppressed the growth of human cancer cells cultured in the laboratory and significantly extended the lives of mice implanted with cells from the two cancers, diffuse intrinsic pontine glioma (DIPG) and atypical teratoid/rhabdoid tumors (AT/RTs).
DIPG a cancer in the brainstem affecting about 3,000 children worldwide each year -- is universally fatal even with currently available treatments including surgery, chemotherapy and radiation. AT/RTs, the most common brain cancer in infants, have a similarly poor prognosis, with most patients surviving between six and 11 months after diagnosis.
             Hoping to help beat these odds, Johns Hopkins researchers and their colleagues, led by Eric H. Raabe, M.D., Ph.D., assistant professor of oncology and instructor of pathology at the Johns Hopkins Kimmel Cancer Center, focused their attention on TAK228. Previous research showed the drug (also known as MLN0128) can cross the blood-brain barrier and reduces the production of a protein called mTOR, which appears to sustain cancer by combining with other proteins to signal the cells to grow, invade tissues and survive therapy. Both pediatric cancer types typically have genetic alterations that lead to increases in mTOR activity, thus Raabe and his team's hypothesis that TAK228 could be an effective treatment for these cancers.
            In one set of experiments, Raabe and his colleagues applied the drug to cells of each cancer type isolated from human patients. Results showed that TAK228 reduced proliferation of DIPG cells cancer cells by about 30 percent compared with control (untreated) cells and killed about 6 percent of the cells.
However, when combined with radiation -- currently the most effective treatment for extending life in children with DIPG nearly double the number of cells were killed compared with radiation alone, suggesting that TAK228 might sensitize cells to make radiation more effective, Raabe says.
When the team tested TAK228 on AT/RT cells, they found similar reductions in tumor cell proliferation and increases in cancer cell death. Further, when they gave a combination of TAK228 and cisplatin, a chemotherapy commonly used to treat AT/RTs, to mice bearing implanted human AT/RT tumors, the mice receiving the combined treatment lived approximately 30 days longer than those that received either treatment alone. Some 40 percent of the combination-treated mice were long-term survivors (living more than 60 days after tumor injection), while none of the mice treated with either chemotherapy or TAK228 alone lived longer than 25 days.
             A report of the experiments in DIPG is published online April 25 in Cancer Letters, and the AT/RT report is published June 3 in Neuro-Oncology. Together, Raabe says, these results suggest that TAK228 could hold promise for human patients.
"Both of these papers set the stage for clinical trials for TAK228," he says. "Our experiments show that TAK228 can make traditional chemotherapy and radiation more effective, which may offer hope to patients for whom current therapy doesn't work very well."
The team is currently investigating further how the drug works with radiation and chemotherapy, and if other drugs might be able to heighten this synergistic effect.

Drinking coffee could lead to a longer life, scientist says

Whether it's caffeinated or decaffeinated, coffee is associated with lower mortality, which suggests the association is not tied to caffeine

Source: University of Southern California
Summary:: Scientists have found that people who drink coffee appear to live longer. Drinking coffee was associated with lower risk of death due to heart disease, cancer, stroke, diabetes, and kidney disease. People who consumed a cup of coffee a day were 12 percent less likely to die compared to those who didn't drink coffee. This association was even stronger for those who drank two to three cups a day 18 percent reduced chance of death.

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People who drink coffee live longer, new research suggests.

Credit: © iko / Fotolia

Here's another reason to start the day with a cup of joe: Scientists have found that people who drink coffee appear to live longer.

             Drinking coffee was associated with a lower risk of death due to heart disease, cancer, stroke, diabetes, and respiratory and kidney disease for African-Americans, Japanese-Americans, Latinos and whites.
People who consumed a cup of coffee a day were 12 percent less likely to die compared to those who didn't drink coffee. This association was even stronger for those who drank two to three cups a day 18 percent reduced chance of death.
Lower mortality was present regardless of whether people drank regular or decaffeinated coffee, suggesting the association is not tied to caffeine, said Veronica W. Setiawan, lead author of the study and an associate professor of preventive medicine at the Keck School of Medicine of USC.
           "We cannot say drinking coffee will prolong your life, but we see an association," Setiawan said. "If you like to drink coffee, drink up! If you're not a coffee drinker, then you need to consider if you should start."
The study, which will be published in the July 11 issue of Annals of Internal Medicine, used data from the Multiethnic Cohort Study, a collaborative effort between the University of Hawaii Cancer Center and the Keck School of Medicine.
The ongoing Multiethnic Cohort Study has more than 215,000 participants and bills itself as the most ethnically diverse study examining lifestyle risk factors that may lead to cancer.
         "Until now, few data have been available on the association between coffee consumption and mortality in nonwhites in the United States and elsewhere," the study stated. "Such investigations are important because lifestyle patterns and disease risks can vary substantially across racial and ethnic backgrounds, and findings in one group may not necessarily apply to others."
Since the association was seen in four different ethnicities, Setiawan said it is safe to say the results apply to other groups.
"This study is the largest of its kind and includes minorities who have very different lifestyles," Setiawan said. "Seeing a similar pattern across different populations gives stronger biological backing to the argument that coffee is good for you whether you are white, African-American, Latino or Asian."
                                                                                                                                                                Benefits of drinking coffee
            Previous research by USC and others have indicated that drinking coffee is associated with reduced risk of several types of cancer, diabetes, liver disease, Parkinson's disease, Type 2 diabetes and other chronic diseases.
Setiawan, who drinks one to two cups of coffee daily, said any positive effects from drinking coffee are far-reaching because of the number of people who enjoy or rely on the beverage every day.
"Coffee contains a lot of antioxidants and phenolic compounds that play an important role in cancer prevention," Setiawan said. "Although this study does not show causation or point to what chemicals in coffee may have this 'elixir effect,' it is clear that coffee can be incorporated into a healthy diet and lifestyle."
About 62 percent of Americans drink coffee daily, a 5 percent increase from 2016 numbers, reported the National Coffee Association.
         As a research institution, USC has scientists from across disciplines working to find a cure for cancer and better ways for people to manage the disease.
The Keck School of Medicine and USC Norris Comprehensive Cancer Center manage a state-mandated database called the Los Angeles Cancer Surveillance Program, which provides scientists with essential statistics on cancer for a diverse population.
Researchers from the USC Norris Comprehensive Cancer Center have found that drinking coffee lowers the risk of colorectal cancer.
But drinking piping hot coffee or beverages probably causes cancer in the esophagus, according to a World Health Organization panel of scientists that included Mariana Stern from the Keck School of Medicine.
                                                                                                                                                              Hearing from the WHO
             In some respects, coffee is regaining its honor for wellness benefits. After 25 years of labeling coffee a carcinogen linked to bladder cancer, the World Health Organization last year announced that drinking coffee reduces the risk for liver and uterine cancer.
"Some people worry drinking coffee can be bad for you because it might increase the risk of heart disease, stunt growth or lead to stomach ulcers and heartburn," Setiawan said. "But research on coffee have mostly shown no harm to people's health."
                                                                                                                                                            Coffee by the numbers
             Setiawan and her colleagues examined the data of 185,855 African-Americans (17 percent), Native Hawaiians (7 percent), Japanese-Americans (29 percent), Latinos (22 percent) and whites (25 percent) ages 45 to 75 at recruitment. Participants answered questionnaires about diet, lifestyle, and family and personal medical history.
They reported their coffee drinking habits when they entered the study and updated them about every five years, checking one of nine boxes that ranged from "never or hardly ever" to "4 or more cups daily." They also reported whether they drank caffeinated or decaffeinated coffee. The average follow-up period was 16 years.
              Sixteen percent of participants reported that they did not drink coffee, 31 percent drank one cup per day, 25 percent drank two to three cups per day and 7 percent drank four or more cups per day. The remaining 21 percent had irregular coffee consumption habits.
Over the course of the study, 58,397 participants about 31 percent died. Cardiovascular disease (36 percent) and cancer (31 percent) were the leading killers.
The data was adjusted for age, sex, ethnicity, smoking habits, education, preexisting disease, vigorous physical exercise and alcohol consumption.
Setiawan's previous research found that coffee reduces the risk of liver cancer and chronic liver disease. She is currently examining how coffee is associated with the risk of developing specific cancers.
Researchers from the University of Hawaii Cancer Center and the National Cancer Institute contributed to this study. The study used data from the Multiethnic Cohort Study, which is supported by a $19,008,359 grant from the National Cancer Institute of the National Institutes of Health.

Chronic liver inflammation linked to Western diet

Food, antibiotics, and gender are just some of the factors that can throw off the balance between the gut and liver, according to a new report in The American Journal of Pathology

Source: Elsevier
Summary:: A new study reports that mice fed a Western diet, which is high in fat and sugar, resulted in hepatic inflammation, especially in males. Moreover, liver inflammation was most pronounced in Western diet-fed male mice that also lacked farnesoid x receptor (FXR), a bile acid receptor.

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(A) Histology of control diet (CD) and Western diet (WD)-fed wild-type (WT) and FXR knockout (KO) mice of both genders. (B) Histology of antibiotic-treated male mice. Abx is a cocktail of antibiotics that provides broad-spectrum coverage. Vancomycin (Vcm) and polymyxin B (PolyB) cover Gram-positive and negative bacteria, respectively. (C) Relative abundance of cecal microbiota of CD and WD-fed WT as well as FXR KO mice of both genders. (D) Relative abundance of cecal microbiota of antibiotic-treated CD- and WD-fed FXR KO male mice. (Mean values are shown)

Credit: The American Journal of Pathology

A new study in The American Journal of Pathology reports that mice fed a Western diet, which is high in fat and sugar, resulted in hepatic inflammation, especially in males. Moreover, liver inflammation was most pronounced in Western diet-fed male mice that also lacked farnesoid x receptor (FXR), a bile acid receptor.

The study is important because it links diet to changes in the gut microbiota as well as bile acid profile, opening the possibility that probiotics and bile acid receptor agonists may be useful for the prevention and treatment of hepatic inflammation and progression into advanced liver diseases such as cancer.
"We know the transition from steatosis, or fatty liver, to steatohepatitis (inflammation in the fatty liver) plays a crucial role in liver injury and carcinogenesis. Because the liver receives 70% of its blood supply from the intestine, it is important to understand how the gut contributes to liver disease development," explained lead investigator Yu-Jui Yvonne Wan, PhD, Professor and Vice Chair of the Department of Pathology and Laboratory Medicine at UC Davis Health. "Our data show that diet, gender, and different antibiotic treatments alter the gut microbiota as well as bile acid profile and have different effects on liver inflammation."
           Dr. Wan and her team used an FXR-deficient mouse model (FXR KO), which has become an important tool to better understand the role of diet and inflammation in the development of liver diseases including cancer because patients with cirrhosis or liver cancer also have low FXR levels.
Other published data have already shown that FXR-deficient mice spontaneously develop steatohepatitis and liver tumors even when they are fed a normal rodent diet. In this study, wild-type and FXR-deficient mice were fed either a Western diet or a matching control diet for 10 months. They found similarities between Western diet intake and FXR deficiency. For instance, both Western diet-fed wild-type mice and control diet-fed FXR KO mice developed steatosis, which also was more severe in males than females. Interestingly, however, only the FXR-deficient male mice had massive lymphocyte and neutrophil infiltration in the liver, and only Western diet-fed male FXR KO mice had fatty adenomas.
"These studies show that a Western diet intake and FXR inactivation also increased hepatic inflammatory signaling, with a combined enhanced effect," Dr. Wan said. "Introducing antibiotics to reduce inflammation also had different effects based on the diets the mice received."
           Depending on what type of diet was provided, broad-spectrum antibiotics, which eliminated most gut bacteria, affected hepatic inflammation differently in FXR-deficient mice. In control diet-fed mice, a cocktail of ampicillin, neomycin, metronidazole, and vancomycin completely blocked hepatic neutrophil and lymphocyte infiltration. However, this cocktail of antibiotics (Abx) was not able to eliminate hepatic inflammation in Western diet-fed FXR KO mice. Additional analysis showed that many inflammatory genes had higher expression levels in Western diet than control diet-fed FXR KO mice after Abx treatment.
Analyzing the composition of the gut microbiota, investigators found that Proteobacteria and Bacteroidetes persisted after the broad-spectrum antibiotic treatment in the Western diet-fed FXR KO mice. In contrast, Gram-negative coverage antibiotic, i.e., polymyxin B, increased Firmicutes and decreased Proteobacteria as well as hepatic inflammation in Western diet-fed FXR KO male mice. They suggest that the adverse effects of Western diet on the liver may be explained in part by the persistence of pro-inflammatory Proteobacteria as well as the reduction of anti-inflammatory Firmicutes in the gut.
         Primary and secondary bile acids are synthesized by liver cells and gut bacteria, respectively. Bile acids are signaling molecules for lipid and sugar homeostasis as well as inflammatory response. The data generated from this group revealed that the reduced hepatic inflammation by antibiotics was accompanied by decreased free and conjugated secondary bile acids in a gender-dependent manner.
"Gut and liver health are linked. It is clear that microbial imbalance and dysregulated bile acid synthesis are inseparable, and they jointly contribute to hepatic inflammation via the gut-liver axis. In addition, gut microbiota and bile acid profiles may explain gender difference in liver disease as liver cancer incidence is much higher in men than women. Moreover, in antibiotic-treated mice, the change in the profile of bile acids can also be primary as well as secondary to the alterations in gut microbiota because antibiotics can directly eliminate bile acid-generating bacteria, which in turn causes additional changes in the bile acid composition," noted Dr. Wan. "Our results suggest that probiotics and FXR agonists hold promise for the prevention and treatment of hepatic inflammation and progression into advanced liver diseases such as cancer."

Monday, 10 July 2017

Nurse-led intervention helps carers' manage medication and cancer pain

Source: SAGE
Summary:: The potential benefits of a new nurse-led intervention in supporting carers to manage pain medication in people with terminal cancer have been revealed in a new article.

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A study funded by Marie Curie and Dimbleby Cancer Care published today shows the potential benefits of a new nurse-led intervention in supporting carers to manage pain medication in people with terminal cancer.1

Researchers from the University of Southampton, Cardiff University and University of Leeds have developed a nurse-led intervention to help carers with medication management, and evaluated its use in routine practice.
The Cancer Carers' Medicines Management (CCMM) intervention addresses carers' beliefs, knowledge and skills and promotes self-evaluation of competence. It centres on a structured conversational process between a nurse and carer.
It is the first time that a study has attempted to integrate an intervention developed using input from carers and nurses into routine palliative care.
             The research showed that the CCMM intervention compared favourably with current practice as it offered a more systematic and comprehensive approach to supporting carer management of pain medicines.
Researchers noted that nurses particularly valued the toolkit resource -- which included information about opioids and simple charts for documenting pain and medication, because they were of immediate practical value to carers.
The findings also identified some positive changes in medicines management, such as increased acceptance of the need for opiates, and behavioural changes, responding more readily to patients' request for pain relief and improved systems in place for giving and recording medicines.
Many people with advanced cancer experience persistent pain and are typically prescribed analgesics, including opioids. Carers often help patients to manage pain medicines, especially near the end of life, but often do not receive the support they need.
Professor Sue Latter, the lead researcher from the University of Southampton, said: "Despite the heavy burden placed on carers to help manage pain medication at home, there is a real lack of reliable research on effective methods of supporting carers with medicines management.
            "Medication management requires knowledge and practical skill, and involves carers in monitoring and interpreting symptoms, as well as selecting, administering and evaluating the effectiveness of medicines. Often, carers will not have trainingfor their role and will have preconceived views about pain and analgesics, particularly opioids."
Professor Jane Hopkinson from Cardiff University, and co-author, said: "Cancer Carers' Medicines Management made clinical sense to nurses, who recognised the challenges faced by carers managing analgesics at the end of life and saw potential benefits in improving education and support."
Most studies conclude that healthcare professionals need to provide carers with more information, training and continuing support.
            Dee Sissons, Director of Nursing at Marie Curie, said: "The responsibility of taking on a caring role for someone who is terminally ill can be immensely rewarding, but also daunting. Family carers play a critical role in supporting people with a terminal illness so they can be cared for and die at home when this is their wish.
This new study shows that nurses and carers can work together to better manage pain medication at home and enable carers to respond more readily to their loved ones request for pain relief with greater confidence."
The nurses who participated in the study also provided feedback on how to use the intervention more widely in palliative care nursing practice. Their suggestions included: involving patients with other terminal illnesses, including other 'end of life care' medication and introducing it earlier in the course of a patient's illness, which could increase benefits to carers.
The study results have informed further NIHR funded research on nurses supporting self-management of medicines at the end of life.

New epigenomic strategies in the clinical management of cancer of unknown primary

Source: IDIBELL-Bellvitge Biomedical Research Institute
Summary:: The invention of the EPICUP epigenetic test and its impact in the clinical management of Cancer of Unknown Primary is discussed in a new article.

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This is a microphotography of a tumor of unknown primary identified as lung cancer the EPICUP(R) test.

Credit: IDIBELL

The invention of the EPICUP® epigenetic test last year allowed physicians to elucidate what type of primary tumor had metastasized in patients with Cancer of Unknown Primary (CUP). Today, an article published in Nature Reviews Clinical Oncology by Dr. Manel Esteller, coordinator of the Epigenetics and Cancer Biology Program of the Bellvitge Biomedical Research Institute (IDIBELL), ICREA Researcher and Professor of Genetics at the University of Barcelona, explains how this test is being transferred to the clinical practice and the new advances that can develop from it.

" Traditional methods can only detect the primary tumor in 30% of cases of metastases of unknown origin. Some molecular methods could increase this percentage, but they are often expensive and use the RNA molecule (ribonucleic acid), which is very fragile and is often easily broken down in the samples available in the pathological anatomy services of hospitals," Dr. Manel Esteller explains.
"The EPICUP® test, on the other hand, is based on the DNA molecule, which is very stable, so it can be sent from the hospital where the patient is to the analysis laboratory in a simpler way. The results can be obtained in a week " adds the researcher.
Cancer of Unknown Primary (CUP) represents 10% of those human tumors in which metastasis is detected, but the primary tumor cannot be located despite several exploratory tests. Since the tumor type is not known, the survival of these patients is very low; the implementation of the EPICUP® test will lead to the development of more specific treatments in the future, according to the results presented in Nature Reviews Clinical Oncology: "Prospective trials are now needed to determine how these CUP patients, now correctly diagnosed, can benefit from more specific and less aggressive treatments for their disease" Dr. Esteller concludes.

Thursday, 6 July 2017

Bowel cancer diagnosis delayed by other illness

Source: University of Exeter
Summary:: A new study revealed that additional serious long-term health conditions, such as heart disease, can push a bowel cancer diagnosis back by up to twenty six days. The latest figures suggest that around 70% of people have at least one of these potentially serious long-term health conditions at the time they are diagnosed with cancer.

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The researchers from the University of Exeter analysed clinical data from over 4,500 patients across the UK who were later diagnosed with bowel cancer. In a study published in the British Journal of Cancer, they looked at whether pre-existing illness affected the time it took them to get a cancer diagnosis, making it one of the first studies to investigate this.

They found that if you have a single serious illness or mental health issue unrelated to cancer, such as depression or heart disease, your bowel cancer is diagnosed on average 10 days later than usual , a 13% increase from the usual time taken for a diagnosis. This could go up to over one month when patients had multiple illnesses. These illnesses may take up a lot of time in visits to the GP and leave not enough time available to investigate symptoms or signs linked to cancer.
           A bowel cancer sign or symptom which can be explained by a pre-existing condition, such as stomach pains, delayed cancer diagnosis by 9 days on average, a 12% increase from the usual time taken for a diagnosis. These cancer signs and symptom can be explained by the additional illness that the patient has so doctors are 'led astray', making it more difficult to arrive at a cancer diagnosis.
They also found that if you have Inflammatory Bowel Disease (IBD), it can delay a bowel cancer diagnosis by 26 days.
            Professor Jose Valderas, one of the lead researchers from the University of Exeter Medical School, said: "When you're trying to diagnose cancer, other illnesses can be a distraction either because they also require attention or because they can mask what would otherwise be flagged as a possible sign of cancer.
"It's vital that doctors realise that existing illnesses make a diagnosis of cancer more difficult and stay alert to recognize signs and symptoms of cancer as such. It's also important that patients flag symptoms with their doctor as early as possible, whether it's unexplained weight loss or changes to your bowel habits."
Professor Willie Hamilton, one of the lead researchers from the University of Exeter, said: "A ten day delay may not sound much but it may be the difference between a well-planned admission and an emergency admission with a complication. This really matters -- as the complications may kill."
The study, 'Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records' is published in the British Journal of Cancer. Authors are Luke TA Mounce, Sarah Price, Jose M Valderas, and Willie Hamilton.
           Commenting on the study, Deborah Alsina MBE, Chief Executive of Bowel Cancer UK, said: "As symptoms of bowel cancer can relate to later stage of disease it is important that delays in diagnosis are minimised. While the delays highlighted in this study are relatively small, if they add onto delays in patients presenting to their GP with symptoms, or in a diagnostic appointment, they become more serious. Currently around 20% of people are diagnosed with bowel cancer as an emergency when outcomes are generally poorer and almost 50% in later stages of the disease when it is harder to treat. "This interesting study highlights another aspect of the complexity of diagnosing bowel cancer as the majority of patients have multiple conditions. Therefore finding quicker, more effective ways to identify and diagnose these patients is crucial to help GPs and other clinicians identify or rule out bowel cancer quickly to give people the very best opportunity for successful treatment. Bowel cancer is after all, treatable and curable especially if diagnosed early."