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Fulltext Functional transcriptome analysis of the postnatal brain of the Ts1Cje mouse model for Down syndrome reveals global disruption of interferon-related molecular networks

Ling KH, Hewitt CA, Tan KL, Cheah PS, Vidyadaran S, Lai MI, et al.

BMC Genomics, 2014;15:624.
PMID: 25052193 DOI: 10.1186/1471-2164-15-624

The Ts1Cje mouse model of Down syndrome (DS) has partial triplication of mouse chromosome 16 (MMU16), which is partially homologous to human chromosome 21. These mice develop various neuropathological features identified in DS individuals. We analysed the effect of partial triplication of the MMU16 segment on global gene expression in the cerebral cortex, cerebellum and hippocampus of Ts1Cje mice at 4 time-points: postnatal day (P)1, P15, P30 and P84.
Fulltext Depression among the urban poor in Peninsular Malaysia: a community based cross-sectional study

Tan KL, Yadav H

J Health Psychol, 2013 Jan;18(1):121-7.
PMID: 22322990 DOI: 10.1177/1359105311433908

This community based cross-sectional study examined the prevalence and factors associated with depression among urban poor in Peninsular Malaysia. The Patient Health Questionnaire (PHQ-9) was used to determine the presence or absence of depression. The prevalence of depression among the urban poor was 12.3%. Factors significantly associated with depression included respondents under 25 years old, male gender, living in the area for less than four years and those who do not exercise regularly. It is important to identify individuals with depression and its associated factors early because depression can severely affect the quality of life.
Fulltext MicroRNAs and intellectual disability (ID) in Down syndrome, X-linked ID, and Fragile X syndrome

Siew WH, Tan KL, Babaei MA, Cheah PS, Ling KH

Front Cell Neurosci, 2013;7:41.
PMID: 23596395 DOI: 10.3389/fncel.2013.00041

Intellectual disability (ID) is one of the many features manifested in various genetic syndromes leading to deficits in cognitive function among affected individuals. ID is a feature affected by polygenes and multiple environmental factors. It leads to a broad spectrum of affected clinical and behavioral characteristics among patients. Until now, the causative mechanism of ID is unknown and the progression of the condition is poorly understood. Advancement in technology and research had identified various genetic abnormalities and defects as the potential cause of ID. However, the link between these abnormalities with ID is remained inconclusive and the roles of many newly discovered genetic components such as non-coding RNAs have not been thoroughly investigated. In this review, we aim to consolidate and assimilate the latest development and findings on a class of small non-coding RNAs known as microRNAs (miRNAs) involvement in ID development and progression with special focus on Down syndrome (DS) and X-linked ID (XLID) [including Fragile X syndrome (FXS)].
Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor

Tan KL, Chong AW, Amin MA, Raman R

J Laryngol Otol, 2012 Jul;126(7):751-5.
PMID: 22578299 DOI: 10.1017/S0022215112000795

To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.
Chemopreventive potential of Annona muricata L leaves on chemically-induced skin papillomagenesis in mice

Hamizah S, Roslida AH, Fezah O, Tan KL, Tor YS, Tan CI

Asian Pac J Cancer Prev, 2012;13(6):2533-9.
PMID: 22938417

Annona muricata L (Annonaceae), commonly known as soursop has a long, rich history in herbal medicine with a lengthy recorded indigenous use. It had also been found to be a promising new anti-tumor agent in numerous in vitro studies. The present investigation concerns chemopreventive effects in a two-stage model of skin papillomagenesis. Chemopreventive effects of an ethanolic extract of A. muricata leaves (AMLE) was evaluated in 6-7 week old ICR mice given a single topical application of 7,12-dimethylbenza(α)anthracene (DMBA 100 μg/100 μl acetone) and promotion by repeated application of croton oil (1% in acetone/ twice a week) for 10 weeks. Morphological tumor incidence, burden and volume were measured, with histological evaluation of skin tissue. Topical application of AMLE at 30, 100 and 300 mg/kg significantly reduced DMBA/croton oil induced mice skin papillomagenesis in (i) peri-initiation protocol (AMLE from 7 days prior to 7 days after DMBA), (ii) promotion protocol (AMLE 30 minutes after croton oil), or (iii) both peri-initiation and promotion protocol (AMLE 7 days prior to 7 day after DMBA and AMLE 30 minutes after croton oil throughout the experimental period), in a dose dependent manner (p<0.05) as compared to carcinogen-treated control. Furthermore, the average latent period was significantly increased in the AMLE-treated group. Interestingly, At 100 and 300 mg/ kg, AMLE completely inhibited the tumor development in all stages. Histopathological study revealed that tumor growth from the AMLE-treated groups showed only slight hyperplasia and absence of keratin pearls and rete ridges. The results, thus suggest that the A.muricata leaves extract was able to suppress tumor initiation as well as tumor promotion even at lower dosage.
Method development and validation for the simultaneous determination of imatinib mesylate and N-desmethyl imatinib using rapid resolution high performance liquid chromatography coupled with UV-detection

Tan KL, Ankathil R, Gan SH

J Chromatogr B Analyt Technol Biomed Life Sci, 2011 Nov 15;879(30):3583-91.
PMID: 22000961 DOI: 10.1016/j.jchromb.2011.09.048

We developed a simple and sensitive method for the simultaneous detection of imatinib mesylate (IM) and its active metabolite, N-desmethyl imatinib (M1), in human serum samples. Separation was successfully achieved using an Agilent(®) ZORBAX Eclipse plus C(18) reversed phase column (50 mm × 2.1 mm, i.d.; 1.8 μm) under isocratic mobile phase conditions consisting of acetonitrile: 0.02 M potassium dihydrogen phosphate with 0.2% triethylamine at pH 3 (25:75, v/v) and ultra-violet detection was achieved at 235 nm. Extraction of the target compounds was completed using 100% cold acetonitrile. Good linearities (r(2)>0.99) for both IM and M1 were achieved for the concentration ranges of 50-1800 ng/mL and 50-360 ng/mL, respectively. The detection limits were 20 ng/mL and 10 ng/mL for M1 and IM, respectively. The intra- and inter-day precisions were less than 1% with percent recoveries of more than 90%. The method was successfully applied to calculate the pharmacokinetic parameters of chronic myeloid leukemia patients receiving imatinib. The method is suitable to be routinely applied for determination of IM and M1 in serum.
Fulltext Factors associated with exclusive breastfeeding among infants under six months of age in peninsular malaysia

Tan KL

Int Breastfeed J, 2011 Feb 02;6(1):2.
PMID: 21284889 DOI: 10.1186/1746-4358-6-2

BACKGROUND: Breastfeeding is accepted as the natural form of infant feeding. For mothers to be able to breastfeed exclusively to the recommended six months, it is important to understand the factors that influence exclusive breastfeeding. The aim of the study was to identify factors associated with exclusive breastfeeding in Peninsular Malaysia.
METHODS: This was a cross-sectional study involving 682 mother-infant pairs with infants up to six months attending maternal and child health section of the government health clinics in Klang, Malaysia. Data were collected by face-to-face interviews using a pre-tested structured questionnaire over 4 months in 2006. Data on breastfeeding were based on practice in the previous one month period. Logistic regression was used to assess the independent association between the independent variables and exclusive breastfeeding adjusting for infant age.
RESULTS: The prevalence of exclusive breastfeeding among mothers with infants aged between one and six months was 43.1% (95% CI: 39.4, 46.8). In the multivariate model exclusive breastfeeding was positively associated with rural residence, Malay mothers, non-working and non-smoking mothers, multiparous mothers, term infants, mothers with husbands who support breastfeeding and mothers who practice bed-sharing.
CONCLUSIONS: Interventions that seek to increase exclusive breastfeeding should focus on women who are at risk of early discontinuation of breastfeeding.
Fulltext Pre-auricular sinus: an uncommon presentation

Ng JWS, Chew YK, Tan KL, Chong AW

Malays Fam Physician, 2011;6(1):32-33.
PMID: 25606218 MyJurnal

An infected pre-auricular sinus presenting as a post-auricular swelling is commonly misdiagnosed as an infected dermoid or sebaceous cyst. It may even mimic a mastoid abscess leading to further unwarranted investigations and interventions. We present a case of a 25-year-old Malay man who was initially diagnosed with recurrent infected dermoid cyst. At presentation, a right post-auricular inflamed swelling was noted with an overlying old incision and drainage scar. An auricular pit was found at the crus of helix. Using a blunt probe inserted along the sinus tract pus was drained without the need for further surgical incision. Six weeks after the acute episode, patient underwent excision of the pre-auricular sinus with no evidence of recurrence at three months follow up. Awareness by the attending physician of this ‘variant type’ of pre-auricular sinus at patient’s first presentation may negate the need for unnecessary incision and drainage which may subsequently impact the outcome of surgical excision and reduce the risk of recurrence.
Fulltext Prevalence of onodi cells in Hospital Raja Permaisuri Bainun, Ipoh, Malaysia

Tan KL, Harvinder S

Med J Malaysia, 2010 Jun;65(2):101-2.
PMID: 23756790 MyJurnal

Onodi cell is a posterior ethmoid air cell that pneumatizes into the sphenoid sinus, It is an important entity for clinicians when performing endoscopic sinus surgery (EES) because it encroaches into the optic nerve and internal carotid artery. CT-scans are the road map for ESS to prevent damage to structures mentioned above. Its prevalence in Malaysia is unknown.
Fulltext High prevalence of alpha- and beta-thalassemia in the Kadazandusuns in East Malaysia: challenges in providing effective health care for an indigenous group

Tan JA, Lee PC, Wee YC, Tan KL, Mahali NF, George E, et al.

J Biomed Biotechnol, 2010;2010.
PMID: 20871816 DOI: 10.1155/2010/706872

Thalassemia can lead to severe transfusion-dependent anemia, and it is the most common genetic disorder in Malaysia. This paper aims to determine the prevalence of thalassemia in the Kadazandusuns, the largest indigenous group in Sabah, East Malaysia. α- and β-thalassemia were confirmed in 33.6% and 12.8%, of the individuals studied respectively. The high prevalence of α- and β-thalassemia in the Kadazandusuns indicates that thalassemia screening, genetic counseling, and prenatal diagnosis should be included as part of their healthcare system. This preliminary paper serves as a baseline for further investigations into the health and genetic defects of the major indigenous population in Sabah, East Malaysia.
Fulltext The prevalence and characteristics associated with mother-infant bed-sharing in Klang district, Malaysia

Tan KL, Ghani SN, Moy FM

Med J Malaysia, 2009 Dec;64(4):311-5.
PMID: 20954557 MyJurnal

This was a cross-sectional study to determine the prevalence and characteristics of mother-infant bed-sharing practice in Klang district, Malaysia. Data was collected by face-to-face interview using a structured questionnaire for a four month period in 2006. A total of 682 mother-infant pairs attending government health clinics were included in the study. Data regarding socio-demographic characteristics of the mothers, information on the infants, bed-sharing and breastfeeding practices were collected. The mean maternal age was 28.4 +/- 5.1 years while the mean infant gestational age was 38.8 +/- 1.8 weeks. The study showed the prevalence of bed-sharing was 73.5% (95% CI: 70.0, 76.7). In multivariate analysis; area of interview, maternal occupation, family income, breastfeeding and infant birth weight were associated with bed-sharing after adjusted for maternal ethnicity, age, marital status, educational level, parity, infant gender and infant gestational age. In conclusion, bed-sharing is a common practice in Klang district, Malaysia, not specific to ethnicity, but strongly associated with low family income and breastfeeding.
Bed sharing among mother-infant pairs in Klang district, Peninsular Malaysia and its relationship to breast-feeding

Tan KL

J Dev Behav Pediatr, 2009 Oct;30(5):420-5.
PMID: 19827222 DOI: 10.1097/DBP.0b013e3181ba083a

OBJECTIVE: The aim of the study was to determine the prevalence of mother-infant bed sharing in Klang district, Peninsular Malaysia and to identify factors associated with bed sharing.

METHOD: This was a cross-sectional study involving 682 mother-infant pairs with infants up to 6 months attending government clinics in Klang district, Peninsular Malaysia. Data were collected by face-to-face interview using a pretested structured questionnaire for a 4-month period in 2006. Data regarding maternal, paternal, obstetric, infant, occupancy, breast-feeding characteristics, and bed-sharing practice were collected. Data on bed sharing were based on practice in the past 1-month period. Bed sharing was defined as an infant sharing a bed with mother, and infant must be within arms reach from the mother, whereas a bed was defined as either a sleeping mattress placed on a bed frame or placed on the floor. The prevalence of bed sharing was estimated. Relationship and magnitude of association between independent factors and bed sharing were examined using odds ratio and 95% confidence interval. Logistic regression analysis was used to control for confounding factors.

RESULTS: The prevalence of bed sharing among mothers with infants aged between 1 and 6 months was 73.5% (95% confidence interval: 70.0-76.7). In multivariate analysis, urban/rural differences, mothers' ethnicity, occupation, family income, husbands' support on bed sharing, number of children younger than 12 years staying in the house, and breast-feeding were associated with bed sharing.

CONCLUSIONS: These factors need to be considered in analyzing the overall risks and benefits of bed sharing, paying attention to breastfeeding practices.
Interaction of Hb South Florida (codon 1; GTG-->ATG) and HbE, with beta-thalassemia (IVS1-1; G-->A): expression of different clinical phenotypes

Tan JA, Tan KL, Omar KZ, Chan LL, Wee YC, George E

Eur J Pediatr, 2009 Sep;168(9):1049-54.
PMID: 19034506 DOI: 10.1007/s00431-008-0877-9

INTRODUCTION: Interactions of different hemoglobin variants with thalassemia alleles can result in various clinical phenotypes. HbE-beta-thalassemia generally manifests with severe anemia where individuals exhibit beta-thalassemia major with regular blood transfusions or beta-thalassemia intermedia with periodic blood transfusions. This study presents a unique Malay family with three beta-globin gene defects-HbE, Hb South Florida, and IVS1-1 (G-->A).
MATERIALS AND METHODS: HbE activates a cryptic splice site that produces non-functional mRNAs. Hb South Florida is a rare beta-hemoglobin variant, and its interactions with other beta-thalassemia alleles have not been reported. IVS1-1 is a Mediterranean mutation that affects mRNA processing giving rise to beta(o)-thalassemia.
RESULTS AND DISCUSSION: Fifteen mutations along the beta-globin gene complex were analyzed using the amplification refractory mutation system. Hb South Florida was identified by direct sequencing using genomic DNA.
CONCLUSION: The affected child with HbE/IVS1-1 produced a beta-thalassemia major phenotype. Compound heterozygosity for Hb South Florida/IVS1-1 produced a beta-thalassemia carrier phenotype in the mother.
Fulltext Molecular characterisation of Haemoglobin Constant Spring and Haemoglobin Quong Sze with a Combine-Amplification Refractory Mutation System

Wee YC, Tan KL, Chua KH, George E, Tan JA

Malays J Med Sci, 2009 Jul;16(3):21-8.
PMID: 22589661 MyJurnal

BACKGROUND: The interaction of the non-deletional α(+)-thalassaemia mutations Haemoglobin Constant Spring and Haemoglobin Quong Sze with the Southeast Asian double α-globin gene deletion results in non-deletional Haemoglobin H disease. Accurate detection of non-deletional Haemoglobin H disease, which is associated with severe phenotypes, is necessary as these mutations have been confirmed in the Malaysian population.
METHODS: DNA from two families with Haemoglobin H disease was extracted from EDTA-anticoagulated whole blood and subjected to molecular analysis for α-thalassaemia. A duplex polymerase chain reaction was used to detect the Southeast Asian α-globin gene deletion. Polymerase chain reaction-restriction fragment length polymorphism analysis was then carried out to determine the presence of Haemoglobin Constant Spring and Haemoglobin Quong Sze. A combine-amplification refractory mutation system protocol was optimised and implemented for the rapid and specific molecular characterisation of Haemoglobin Constant Spring and Haemoglobin Quong Sze in a single polymerase chain reaction.
RESULTS AND CONCLUSIONS: The combine-amplification refractory mutation system for Haemoglobin Constant Spring and Haemoglobin Quong Sze, together with the duplex polymerase chain reaction, provides accurate pre- and postnatal diagnosis of non-deletional Haemoglobin H disease and allows detailed genotype analyses using minimal quantities of DNA.
KEYWORDS: Combine-ARMS; Hb Constant Spring; Hb Quong Sze; medical sciences
Fulltext Factors Associated with Non-exclusive Breastfeeding among 4-Week Post-partum Mothers in Klang District, Peninsular Malaysia

Tan KL

Malays J Nutr, 2009 Mar;15(1):11-8.
PMID: 22691800 MyJurnal

This is a cross-sectional study which investigated the association between non-exclusive breastfeeding and maternal, paternal, obstetric and infant factors. Data on maternal, paternal, obstetric and infant factors were collected through face-to-face interview using a structured questionnaire from 498 mothers with four-week-old infants who attended government clinics in Klang district between 17 and 28 July 2006. The prevalence of non-exclusive breastfeeding at four weeks was 45.8%. Factors significantly associated with non-exclusive breastfeeding at four weeks included Indian ethnic mother (OR = 4.06), working mother (OR = 3.55), mother from high household income (OR = 1.90), mother who smokes (OR = 7.27), primiparous (OR = 1.97), infant not sharing a bed with mother (OR = 1.75) and infant born prematurely (OR = 7.69). Identification of risk factors should assist in targeting women who are at increased risk of non-exclusive breastfeeding.
Thalassemia intermedia in HbH-CS disease with compound heterozygosity for beta-thalassemia: challenges in hemoglobin analysis and clinical diagnosis

Tan JA, Kok JL, Tan KL, Wee YC, George E

Genes Genet Syst, 2009 Feb;84(1):67-71.
PMID: 19420802

Co-inheritance of alpha-thalassemia with homozygosity or compound heterozygosity for beta-thalassemia may ameliorate beta-thalassemia major. A wide range of clinical phenotypes is produced depending on the number of alpha-thalassemia alleles (-alpha/alphaalpha --/alphaalpha, --/-alpha). The co-inheritance of beta-thalassemia with alpha-thalassemia with a single gene deletion (-alpha/alphaalpha) is usually associated with thalassemia major. In contrast, the co-inheritance of beta-thalassemia with two alpha-genes deleted in cis or trans (--/alphaalpha or -alpha/-alpha) generally produces beta-thalassemia intermedia. In Southeast Asia, the most common defect responsible for alpha-thalassemia is the Southeast Asian (SEA) deletion of 20.5 kilobases. The presence of the SEA deletion with Hb Constant Spring (HbCS) produces HbH-CS disease. Co-inheritance of HbH-CS with compound heterozygosity for beta-thalassemia is very rare. This study presents a Malay patient with HbH-CS disorder and beta degrees/beta+-thalassemia. The SEA deletion was confirmed in the patient using a duplex-PCR. A Combine-Amplification Refractory Mutation System (C-ARMS) technique to simultaneously detect HbCS and Hb Quong Sze confirmed HbCS in the patient. Compound heterozygosity for CD41/42 and Poly A was confirmed using the ARMS. This is a unique case as the SEA alpha-gene deletion in cis (--SEA/alphaalpha) is generally not present in the Malays, who more commonly possess the two alpha-gene deletion in trans (-alpha/-alpha). In addition, the beta-globin gene mutation at CD41/42 is a common mutation in the Chinese and not in the Malays. The presence of both the SEA deletion and CD41/42 in the mother of the patient suggests the possible introduction of these two defects into the family by marriage with a Chinese.
Fulltext Knowledge, attitude and practice on breastfeeding in Klang, Malaysia

Tan KL

International Medical Journal Malaysia, 2009;8(1):17-21.
MyJurnal

Introduction: In Klang, a district in the state of Selangor in Peninsular Malaysia, the effects of westernization and urbanization in recent years have had an impact on infant feeding. The objective of this study was to evaluate the practice, knowledge and attitude to breastfeeding and to assess factors associated with breastfeeding among women in Klang, Malaysia. Materials and Methods: A cross-sectional study was carried out between June and October 2006 involving 220 women with infants aged six months from two randomly selected health clinics were selected and interviewed. Data on socio-demographic, infant factors, infant feeding in the first six months of life, knowledge and attitude towards breastfeeding were collected. Results: Exclusive breastfeeding was reported by 32.8%, mixed feeding was reported by 14.5% and infant formula feeding was reported by 52.7% of the respondents. Chinese women were more likely not to practice exclusive breastfeeding compared to Malay women (odds ratio 18.27, 95% CI: 3.95, 84.54) while working women were more likely not to practice exclusive breastfeeding compared to non working women (odds ratio 3.75, 95% CI: 1.64 , 8.55). Positive association with not exclusive breastfeeding included women with high household income and women with male infants. Malaysian women had a positive attitude but work place and short maternity leave had a negative impact on breastfeeding. Conclusion: Women of Chinese ethnicity, working, from high family income and with male infants were less likely to exclusively breastfeed. Adopting facilitatory measures at hospitals and work place could increase the rate of exclusive breastfeeding.
Fulltext Assessing the development of children with disability in Malaysia

Tan KL, Yadav H

Med J Malaysia, 2008 Aug;63(3):199-202.
PMID: 19248689 MyJurnal

This is a cross-sectional study investigating the profile of children with disability registered with the primary health care clinics in Malaysia. The purpose of the study was to assess the developmental stage of children with disability. Secondary data from the pilot project conducted by the Family Health Development Division, Ministry of Health Malaysia was used in this study. The study period was for six months from 1st August 2004 until 31st January 2005. A total of 900 disabled children were selected in this study. Schedule of Growing Scale (SGS) II was used for analysis. Results showed more boys than girls were affected with a ratio of 6:4. The mean total SGS score increases as the age of the child increased. The score was highest in delayed speech cases and lowest in cerebral palsy cases. The performance among children with delayed speech was the highest while children with cerebral palsy were the lowest. There was a statistically significant difference between the major ethnic groups in delayed speech and attention deficit hyperactive disorder.
Questionnaire: Denver Developmental Assessment Test II chart; DSST; Schedule of Growing Scale II; SGS
Fulltext Reassessment on the development of children with disability in Malaysia

Tan KL, Yadav H

Med J Malaysia, 2008 Mar;63(1):17-20.
PMID: 18935725 MyJurnal

This is a cohort study investigating the profile of children with disability registered with the primary health care clinics in Malaysia. The purpose of the study was to determine whether reassessment on the development of children with disability under rehabilitation should be done at three months interval or six months interval. Secondary data from the pilot project conducted by the Family Health Development Division, Ministry of Health Malaysia was used in this study. The study was carried out for seven months from 1st August 2004 until 28th February 2005. A total of 168 disabled children followed up for six months were selected in this study. Schedule of Growing Scale (SGS) II was the tool used for analysis. Results showed a statistically significant difference in the mean total SGS score at six months interval but not at three months interval. The result suggests that reassessment on children with Down Syndrome, Autism, Cerebral Palsy, mental retardation and delayed speech under rehabilitation should be carried out every six months while children with gross developmental delay and slow learner might need a longer interval for reassessment.
Alpha-thalassaemia in association with beta-thalassaemia patients in Malaysia: a study on the co-inheritance of both disorders

Wee YC, Tan KL, Kuldip K, Tai KS, George E, Tan PC, et al.

Community Genet, 2008;11(3):129-34.
PMID: 18376108 DOI: 10.1159/000113874

BACKGROUND/AIMS: Individuals with double heterozygosity for alpha- and beta-thalassaemia and heterozygous beta-thalassaemia show a similar haematological picture. Co-inheritance of alpha- and beta-thalassaemia in both partners may result in pregnancies with either Hb Bart's hydrops foetalis or beta-thalassaemia major, or pregnancies with both disorders.
METHODS: The co-inheritance of alpha-thalassaemia in 322 beta-thalassaemia carriers in Malaysia was studied.
RESULTS: The frequency of alpha-thalassaemia in the beta-thalassaemia carriers was 12.7% (41/322), with a carrier frequency of 7.8% for the SEA deletion, 3.7% for the -alpha(3.7) deletion, 0.9% for Hb Constant Spring and 0.3% for the -alpha(4.2) deletion.
CONCLUSION: Double heterozygosity for alpha- and beta-thalassaemia was confirmed in 5 out of the 41 couples and the risk of the fatal condition Hb Bart's hydrops foetalis was confirmed in two of these couples. Detection of the Southeast Asian (SEA) deletion in the Malaysian Malays in this study confirms that Hb Bart's hydrops foetalis can occur in this ethnic group. Results of this study have provided new information on the frequency and different types of alpha-thalassaemia (--(SEA), -alpha(3.7) and -alpha(4.2) deletions, Hb Constant Spring) in Malaysian beta-thalassaemia carriers.

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