J Trauma Acute Care Surg Volume 76, Number 1
David R. King, MD Knight Surgical Research Laboratory Harvard Medical School Division of Trauma Emergency Surgery, and Surgical Critical Care Massachusetts General Hospital Boston, Massachusetts
Weaning from mechanical ventilation in severe blunt trauma with pulmonary contusion: Is oxygenation index a promising parameter?
Letters to the Editor
tation of P/F ratio and A-a difference. In this line, there are correlations of chest x-radiographic or computed tomographic scans that reinforce interpretation of gas exchange deterioration and how P/F and A-a difference are index to a proper decisions for extubation.5 We think that this information could be essential to establish predictive capacity.5 We think that further large prospective trials will consolidate the predictive value of oxygenation index in blunt trauma patients with pulmonary contusion. *The authors declare no conflict of interest.
Antonio M. Esquinas, MD, PhD Intensive Care Unit Hospital Morales Meseguer Murcia, Spain
Gu¨niz Koksal, MD To the Editor: echanical ventilation is a lifesaving therapeutic treatment in severe blunt thoracic trauma (BTT) patients. However, in some cases, evolution to difficult and delayed endotracheal extubation may adversely influence in-hospital outcome.1 In this regard, defining sensitive and safe predictive extubation factors in this specific population is essential, but current studies are limited.1 Bilello et al.2 analyzed in a retrospective study in severe BTT adequate predictors of extubation and detected that an oxygenation index such as PaO2/FIO2 (P/F) ratio of less than 290 and alveolar arterial A-a oxygen difference of 100 mm Hg are determinants of failure of extubation. These results make a great contribution to weaning predictive models in BTT patients. However, we should take into account some concerns about the practical extrapolation of these parameters. First, although a measurement of index of P/F is easy to calculate, it could suffer influences by other cofactors during the weaning period and before extubation. Briefly, it could be differentiated as follows: it is influenced by mechanical ventilator settings such as inspiratory oxygenation fraction (FIO2) value, positive end-expiratory pressure setting, and level of alveolar recruitments.3 In addition, other nonmechanical ventilatory parameters could be acting before extubation, such as fluid overload and atelectasis.4 In this study, no information is given regarding these parameters. Second, measurement of (A-a) oxygen difference was not measured directly and was calculated for each patient as stated in the article, and clinical results are put forth, making those calculated values accurate. Finally, some studies recommend the use of information regarding patterns of radiologic affectation to reinforce interpre-
M
Department of Anaesthesiology and Reanimation Istanbul University Cerrahpasa Medical Faculty Istanbul, Turkey
REFERENCES 1. Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71Y81. 2. Bilello JF, Davis JW, Cagle KM, et al. Predicting extubation failure in blunt trauma patients with pulmonary contusion. J Trauma Acute Care Surg. 2013;75(2):229Y233. 3. Schreiter D, Reske A, Stichert B, et al. Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med. 2004;32(4): 968Y975. 4. Sharpe JP, Weinberg JA, Magnotti LJ, et al. Does plasma transfusion portend pulmonary dysfunction? A tale of two ratios. J Trauma Acute Care Surg. 2013;75(1):32Y36. 5. de Moya MA, Manolakaki D, Chang Y, et al. Blunt pulmonary contusion: admission computed tomography scan mechanical predicts ventilation. J Trauma. 2011;71(6):1543Y1547.
Re: Weaning from mechanical ventilation in severe blunt trauma with pulmonary contusion: Is oxygenation index a promising parameter? In Reply: e appreciate the questions posed by Drs. Antonio Esquinas and Guniz Koksal regarding our recent publication,
W
‘‘Predicting extubation failure in blunt trauma patients with pulmonary contusion.’’1 As corresponding author, I am glad to address their concerns. Dr. Esquinas was concerned that parameters such as fluid overload, atelectasis, and other ventilatory parameters (FIO2, positive endexpiratory pressure) were not addressed in our analysis. FIO2, of course, is an integral part of the calculation of both PaO2/FIO2 (P/F) ratio and A-a difference, and this variable was identified as statistically but not clinically significant between the two groups studied (0.34 vs. 0.38, p = 0.002). Positive end-expiratory pressure per se was not always relevant in our study because many patients were on airway pressure release ventilation, especially at the time of unplanned extubations. Atelectasis is a qualitative radiographic finding that is difficult to quantify. All of our patients had pulmonary contusion identified on radiographic studies as the common denominator. There was no significant difference in the Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score, preextubation Glasgow Coma Scale (GCST), presence of sternal or rib fractures, pneumothorax, or hemothorax between the successful and failed extubation groups. One would think that atelectasis would follow suit in light of these more potentially life-threatening radiographic findings. Moreover, Brown et al.2 showed that the presence of atelectasis did not affect successful extubation in trauma patients. We agree that fluid status may be an important parameter in patients with traumatic lung injury. However, we hope that we supported the simple, bedside construct that all the previously mentioned variables boil down to the ability of patients to protect their airway (GCST), oxygenate (P/F), and effectively exchange oxygen at the alveolar level (A-a difference). In addition, it is pulmonary contusion itself (i.e., localized parenchymal edema) that we are addressing as a factor in failed extubations. I am not sure what Drs. Esquinas and Koksal meant by the A-a difference not being measured ‘‘directly.’’ The A-a difference is a calculation that involves both oxygenation and ventilation at one single point in time. Although it has defined assumptions (respiratory quotient, barometric pressure, water vapor pressure), it has been used in previous studies as an adjunct to defining other respiratory pathologies.3,4 Just like any other calculated physiologic parameter, it is only an adjunct to good clinical judgment. As for the last query regarding radiographic findings associated with blunt trauma patients, this issue again was addressed by showing that there was no significant difference between the failed and successful extubation
* 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
249
J Trauma Acute Care Surg Volume 76, Number 1
Letters to the Editor
groups in the presence of sternal fractures, rib fractures, pneumothorax, or hemothorax. We appreciate the interest and input from Drs. Esquinas and Koksal. We hope that our reply answers their questions in a satisfactory manner. *The author declares no conflict of interest.
John F. Bilello, MD University of California San Francisco-Fresno Fresno, California
REFERENCES 1. Bilello JF, Davis JW, Cagle KM, et al. Predicting extubation failure in blunt trauma patients with pulmonary contusion. J Trauma Acute Care Surg. 2013;75:229Y233. 2. Brown CV, Daigle JB, Foulkrod KH, et al. Risk factors associated with early reintubation in trauma patients: a prospective study. J Trauma. 2011;71:37Y42. 3. Covelli HD, Nessan VJ, Tuttle WK. Oxygen derived variables in acute respiratory failure. Crit Care Med. 1983;11:646Y649. 4. Stein PD, Goldhaber SZ, Henry JW. Alveolararterial oxygen gradient in assessment of acute pulmonary embolism. Chest. 1995:107:139Y143.
It is time to reassess critical care evacuation To the Editor: e read with great interest the article by Olson et al. entitled ‘‘Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy.’’1 They bring needed attention to the continuing discussion of the gap that exists between wounding and more definitive care.2 The findings of Apodaca et al.,3 also in this issue, noted lower than expected mortality in patients with higher Injury Severity Scores (ISS) on Medical Emergency Response Team (MERT) and adds to the literature demonstrating improved outcome with intensivist-led teams in blunt trauma, in head injury, and in the military setting. The MERT concept that Olson et al. discuss use selected physicians trained in emergency medicine and anesthesiology. Similarly, US Air Force critical care air transport teams use intensivists with backgrounds in anesthesiology, emergency medicine, and critical care. These critical care response teams have demonstrated the ability to accomplish resuscitative tasks on the way to surgical facilities. Retasking personnel from current Level/Role 2 facilities can broaden the available pool of qualified intensivists. A program that
W
250
provides for trained intensivists augmenting missions that meet specified severity/injury criteria would assure a distributed, flexible asset that would be available throughout the battle space on ground-, air-, and sea-based platforms. For such a system to be effective, a reassessment of the current evacuation system is called for. Rather than a hierarchical system that moves patients linearly through a system of numbered levels, a more fluid solution respects the physiologic continuum that exists between wounding and source control of hemorrhage.4 This approach bypasses intermediate treatment stops in the more traditional system and is contingent on just the sort of evacuation platform that Olson et al. describe. The inclusion of intensivists on evacuation platforms is not without controversy. The authors point to the study of Calderbank et al.5 in which a physician flew on 88% of MERT missions but was ‘‘felt not to be clinically beneficial in 77% of missions.’’ While the criteria for ‘‘not beneficial’’ are poorly defined, it is fair to say that physician presence was beneficial in at least 23% of the missions. The complex skill set that defines the practice of critical care medicine is required to treat severely injured patients. While most transport missions will not require this skill set, approximately one in four patients will benefit from the presence of an intensivist. It is hard to imagine any other patient population in which one quarter of patients would benefit from a given therapy and then see the provision of that therapy resisted. We now have a unique opportunity to innovate improved care for our wounded service members. This particularly holds true in an asymmetric battleground. While a blanket implementation of far forward resuscitative capability needs to be tempered by the tactical environment and maturity of the theater, the time has come not to ask ‘‘why should we do this,’’ but rather ‘‘why aren’t we doing this.’’ *The authors declare no conflict of interest.
Joshua M. Tobin, MD Division of Critical Care Department of Anesthesiology David Geffen School of Medicine UCLA Los Angeles, California
Thomas J. Nelson, MD John D. Moore, MD 1st Medical Battalion 1st Marine Logistics Group Camp Pendleton, California
REFERENCES 1. Olson CM, Bailey J, Mabry R, et al. Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy. J Trauma Acute Care Surg. 2013;75(2 Supp 2):S130YS136.
2. Tobin JM. Tactical evacuationVimproving care from tourniquet to trauma center. Marine Corps Gazette. 2013;97(2):56Y57. 3. Apodaca A, Olson CM Jr, Bailey J, et al. Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):S157YS163. 4. Tobin JM, Via DK, Carter T. Tactical evacuation: extending critical care on rotary wing platforms to forward surgical facilities. Mil Med. 2011;176 (1):4Y6. 5. Calderbank P, Woolley T, Mercer S, et al. Doctor on board? What is the optimal skill-mix in military pre-hospital care? Emerg Med J. 2011;28(10):882Y883.
Re: It is time to reassess critical care evacuation In Reply: e sincerely appreciate the comments by Dr. Tobin and colleagues who insightfully recommend the implementation of a program in which trained intensivists would augment medical evacuation teams when specific physiologic parameters of an injured combatant warrant their participation during en route care. When we drafted the section of our review examining the way ahead for US policy, this is precisely what we envisioned for the future of US forward aeromedical evacuation (FAME), that is, a scalable platform(s) coupled with smart tasking. Although our review focused on platform capability rather than provider degrees or credentials, it was our hope that military and civilian medical leaders would come forward with suggestions for a more clearly defined way ahead. To this end, we applaud Dr. Tobin and colleagues for engaging in this important discussion and encourage others to do the same. In so far as bypassing Level/Role 2 facilities for a more fluid evacuation model as suggested by Dr. Tobin, we agree that en route critical care coupled with smart tasking does offer a more permissive environment for extending evacuation times for some casualties. It is worth noting that all patients in the study of Apodaca et al.1 were moved from point of injury directly to a Role 3 facility, bypassing any Role 2 facilities that may have existed, so there is no means to compare outcomes between the two evacuation groups. In terms of tactical and provider skill levels, the current system consisting of the US emergency medical team (EMT)-basicY and EMT-paramedicYled teams and the British intensivistYled team used in Afghanistan not only has offered commanders a variety of capabilities to deploy in specific scenarios but
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
David R. King, MD Knight Surgical Research Laboratory Harvard Medical School Division of Trauma Emergency Surgery, and Surgical Critical Care Massachusetts General Hospital Boston, Massachusetts
Weaning from mechanical ventilation in severe blunt trauma with pulmonary contusion: Is oxygenation index a promising parameter?
Letters to the Editor
tation of P/F ratio and A-a difference. In this line, there are correlations of chest x-radiographic or computed tomographic scans that reinforce interpretation of gas exchange deterioration and how P/F and A-a difference are index to a proper decisions for extubation.5 We think that this information could be essential to establish predictive capacity.5 We think that further large prospective trials will consolidate the predictive value of oxygenation index in blunt trauma patients with pulmonary contusion. *The authors declare no conflict of interest.
Antonio M. Esquinas, MD, PhD Intensive Care Unit Hospital Morales Meseguer Murcia, Spain
Gu¨niz Koksal, MD To the Editor: echanical ventilation is a lifesaving therapeutic treatment in severe blunt thoracic trauma (BTT) patients. However, in some cases, evolution to difficult and delayed endotracheal extubation may adversely influence in-hospital outcome.1 In this regard, defining sensitive and safe predictive extubation factors in this specific population is essential, but current studies are limited.1 Bilello et al.2 analyzed in a retrospective study in severe BTT adequate predictors of extubation and detected that an oxygenation index such as PaO2/FIO2 (P/F) ratio of less than 290 and alveolar arterial A-a oxygen difference of 100 mm Hg are determinants of failure of extubation. These results make a great contribution to weaning predictive models in BTT patients. However, we should take into account some concerns about the practical extrapolation of these parameters. First, although a measurement of index of P/F is easy to calculate, it could suffer influences by other cofactors during the weaning period and before extubation. Briefly, it could be differentiated as follows: it is influenced by mechanical ventilator settings such as inspiratory oxygenation fraction (FIO2) value, positive end-expiratory pressure setting, and level of alveolar recruitments.3 In addition, other nonmechanical ventilatory parameters could be acting before extubation, such as fluid overload and atelectasis.4 In this study, no information is given regarding these parameters. Second, measurement of (A-a) oxygen difference was not measured directly and was calculated for each patient as stated in the article, and clinical results are put forth, making those calculated values accurate. Finally, some studies recommend the use of information regarding patterns of radiologic affectation to reinforce interpre-
M
Department of Anaesthesiology and Reanimation Istanbul University Cerrahpasa Medical Faculty Istanbul, Turkey
REFERENCES 1. Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71Y81. 2. Bilello JF, Davis JW, Cagle KM, et al. Predicting extubation failure in blunt trauma patients with pulmonary contusion. J Trauma Acute Care Surg. 2013;75(2):229Y233. 3. Schreiter D, Reske A, Stichert B, et al. Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med. 2004;32(4): 968Y975. 4. Sharpe JP, Weinberg JA, Magnotti LJ, et al. Does plasma transfusion portend pulmonary dysfunction? A tale of two ratios. J Trauma Acute Care Surg. 2013;75(1):32Y36. 5. de Moya MA, Manolakaki D, Chang Y, et al. Blunt pulmonary contusion: admission computed tomography scan mechanical predicts ventilation. J Trauma. 2011;71(6):1543Y1547.
Re: Weaning from mechanical ventilation in severe blunt trauma with pulmonary contusion: Is oxygenation index a promising parameter? In Reply: e appreciate the questions posed by Drs. Antonio Esquinas and Guniz Koksal regarding our recent publication,
W
‘‘Predicting extubation failure in blunt trauma patients with pulmonary contusion.’’1 As corresponding author, I am glad to address their concerns. Dr. Esquinas was concerned that parameters such as fluid overload, atelectasis, and other ventilatory parameters (FIO2, positive endexpiratory pressure) were not addressed in our analysis. FIO2, of course, is an integral part of the calculation of both PaO2/FIO2 (P/F) ratio and A-a difference, and this variable was identified as statistically but not clinically significant between the two groups studied (0.34 vs. 0.38, p = 0.002). Positive end-expiratory pressure per se was not always relevant in our study because many patients were on airway pressure release ventilation, especially at the time of unplanned extubations. Atelectasis is a qualitative radiographic finding that is difficult to quantify. All of our patients had pulmonary contusion identified on radiographic studies as the common denominator. There was no significant difference in the Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score, preextubation Glasgow Coma Scale (GCST), presence of sternal or rib fractures, pneumothorax, or hemothorax between the successful and failed extubation groups. One would think that atelectasis would follow suit in light of these more potentially life-threatening radiographic findings. Moreover, Brown et al.2 showed that the presence of atelectasis did not affect successful extubation in trauma patients. We agree that fluid status may be an important parameter in patients with traumatic lung injury. However, we hope that we supported the simple, bedside construct that all the previously mentioned variables boil down to the ability of patients to protect their airway (GCST), oxygenate (P/F), and effectively exchange oxygen at the alveolar level (A-a difference). In addition, it is pulmonary contusion itself (i.e., localized parenchymal edema) that we are addressing as a factor in failed extubations. I am not sure what Drs. Esquinas and Koksal meant by the A-a difference not being measured ‘‘directly.’’ The A-a difference is a calculation that involves both oxygenation and ventilation at one single point in time. Although it has defined assumptions (respiratory quotient, barometric pressure, water vapor pressure), it has been used in previous studies as an adjunct to defining other respiratory pathologies.3,4 Just like any other calculated physiologic parameter, it is only an adjunct to good clinical judgment. As for the last query regarding radiographic findings associated with blunt trauma patients, this issue again was addressed by showing that there was no significant difference between the failed and successful extubation
* 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
249
J Trauma Acute Care Surg Volume 76, Number 1
Letters to the Editor
groups in the presence of sternal fractures, rib fractures, pneumothorax, or hemothorax. We appreciate the interest and input from Drs. Esquinas and Koksal. We hope that our reply answers their questions in a satisfactory manner. *The author declares no conflict of interest.
John F. Bilello, MD University of California San Francisco-Fresno Fresno, California
REFERENCES 1. Bilello JF, Davis JW, Cagle KM, et al. Predicting extubation failure in blunt trauma patients with pulmonary contusion. J Trauma Acute Care Surg. 2013;75:229Y233. 2. Brown CV, Daigle JB, Foulkrod KH, et al. Risk factors associated with early reintubation in trauma patients: a prospective study. J Trauma. 2011;71:37Y42. 3. Covelli HD, Nessan VJ, Tuttle WK. Oxygen derived variables in acute respiratory failure. Crit Care Med. 1983;11:646Y649. 4. Stein PD, Goldhaber SZ, Henry JW. Alveolararterial oxygen gradient in assessment of acute pulmonary embolism. Chest. 1995:107:139Y143.
It is time to reassess critical care evacuation To the Editor: e read with great interest the article by Olson et al. entitled ‘‘Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy.’’1 They bring needed attention to the continuing discussion of the gap that exists between wounding and more definitive care.2 The findings of Apodaca et al.,3 also in this issue, noted lower than expected mortality in patients with higher Injury Severity Scores (ISS) on Medical Emergency Response Team (MERT) and adds to the literature demonstrating improved outcome with intensivist-led teams in blunt trauma, in head injury, and in the military setting. The MERT concept that Olson et al. discuss use selected physicians trained in emergency medicine and anesthesiology. Similarly, US Air Force critical care air transport teams use intensivists with backgrounds in anesthesiology, emergency medicine, and critical care. These critical care response teams have demonstrated the ability to accomplish resuscitative tasks on the way to surgical facilities. Retasking personnel from current Level/Role 2 facilities can broaden the available pool of qualified intensivists. A program that
W
250
provides for trained intensivists augmenting missions that meet specified severity/injury criteria would assure a distributed, flexible asset that would be available throughout the battle space on ground-, air-, and sea-based platforms. For such a system to be effective, a reassessment of the current evacuation system is called for. Rather than a hierarchical system that moves patients linearly through a system of numbered levels, a more fluid solution respects the physiologic continuum that exists between wounding and source control of hemorrhage.4 This approach bypasses intermediate treatment stops in the more traditional system and is contingent on just the sort of evacuation platform that Olson et al. describe. The inclusion of intensivists on evacuation platforms is not without controversy. The authors point to the study of Calderbank et al.5 in which a physician flew on 88% of MERT missions but was ‘‘felt not to be clinically beneficial in 77% of missions.’’ While the criteria for ‘‘not beneficial’’ are poorly defined, it is fair to say that physician presence was beneficial in at least 23% of the missions. The complex skill set that defines the practice of critical care medicine is required to treat severely injured patients. While most transport missions will not require this skill set, approximately one in four patients will benefit from the presence of an intensivist. It is hard to imagine any other patient population in which one quarter of patients would benefit from a given therapy and then see the provision of that therapy resisted. We now have a unique opportunity to innovate improved care for our wounded service members. This particularly holds true in an asymmetric battleground. While a blanket implementation of far forward resuscitative capability needs to be tempered by the tactical environment and maturity of the theater, the time has come not to ask ‘‘why should we do this,’’ but rather ‘‘why aren’t we doing this.’’ *The authors declare no conflict of interest.
Joshua M. Tobin, MD Division of Critical Care Department of Anesthesiology David Geffen School of Medicine UCLA Los Angeles, California
Thomas J. Nelson, MD John D. Moore, MD 1st Medical Battalion 1st Marine Logistics Group Camp Pendleton, California
REFERENCES 1. Olson CM, Bailey J, Mabry R, et al. Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy. J Trauma Acute Care Surg. 2013;75(2 Supp 2):S130YS136.
2. Tobin JM. Tactical evacuationVimproving care from tourniquet to trauma center. Marine Corps Gazette. 2013;97(2):56Y57. 3. Apodaca A, Olson CM Jr, Bailey J, et al. Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):S157YS163. 4. Tobin JM, Via DK, Carter T. Tactical evacuation: extending critical care on rotary wing platforms to forward surgical facilities. Mil Med. 2011;176 (1):4Y6. 5. Calderbank P, Woolley T, Mercer S, et al. Doctor on board? What is the optimal skill-mix in military pre-hospital care? Emerg Med J. 2011;28(10):882Y883.
Re: It is time to reassess critical care evacuation In Reply: e sincerely appreciate the comments by Dr. Tobin and colleagues who insightfully recommend the implementation of a program in which trained intensivists would augment medical evacuation teams when specific physiologic parameters of an injured combatant warrant their participation during en route care. When we drafted the section of our review examining the way ahead for US policy, this is precisely what we envisioned for the future of US forward aeromedical evacuation (FAME), that is, a scalable platform(s) coupled with smart tasking. Although our review focused on platform capability rather than provider degrees or credentials, it was our hope that military and civilian medical leaders would come forward with suggestions for a more clearly defined way ahead. To this end, we applaud Dr. Tobin and colleagues for engaging in this important discussion and encourage others to do the same. In so far as bypassing Level/Role 2 facilities for a more fluid evacuation model as suggested by Dr. Tobin, we agree that en route critical care coupled with smart tasking does offer a more permissive environment for extending evacuation times for some casualties. It is worth noting that all patients in the study of Apodaca et al.1 were moved from point of injury directly to a Role 3 facility, bypassing any Role 2 facilities that may have existed, so there is no means to compare outcomes between the two evacuation groups. In terms of tactical and provider skill levels, the current system consisting of the US emergency medical team (EMT)-basicY and EMT-paramedicYled teams and the British intensivistYled team used in Afghanistan not only has offered commanders a variety of capabilities to deploy in specific scenarios but
W
* 2014 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
