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Year 3 Medicine > Infectious Diseases > Flashcards

Infectious Diseases Flashcards

1
Q

Hep A is an RNA virus, how is it spread? What is the incubation period?

A

Faecal - Oral spread or by shellfish

Incubation period is 2-6 weeks

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2
Q

Name four risk factors for Hepatitis

A

Personal contact
IVDU
MSM
Health workers

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3
Q

Give 5 symptoms of Hepatitis A

A 
Nausea
Malaise
Arthralgia
Jaundice
Pale Stools/Dark Urine
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4
Q

What investigations would you do for Hepatitis A, and what would they show?

A

Immunoglobulins (raised IgG for acute infection)
LFTs (ALT raised, potential damage to synthetic function)
USS to exclude other diagnoses

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5
Q

How is Hepatitis A managed?

A 
Supportive
Avoid alcohol
Vaccine available (works for one year or twenty with booster)
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6
Q

Hep B is a DNA virus, how is it spread? What is it’s incubation period?

A

Spread by blood products, sexual contact or vertically

Incubation is 1-6 months

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7
Q

Give 6 symptoms of Hep B

A 
Nausea
Malaise
Arthralgia
Urticaria
Jaundice
RUQ Ache
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8
Q

Describe the following Hep B Serology: HbsAg, HbeAg, Antibodies to core antigen, Antibodies to surface antigen

A

HbsAg - present 1-6 months after exposure (if persists past 6 months then it is chronic)
HbeAg - present 1.5-3 months after exposure (implies high infectivity)
Antibodies to core antigen imply past infection
Antibodies to surface antigen imply vaccination

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9
Q

Describe the management of Hep B

A

Supportive
Immunise sexual contacts
Any signs of chronic liver inflammation - 48/52 of retrovirals such as Peginterferon Alfa-2a

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10
Q

State two complications of Hep B

A

Cirrhosis

Hepatocellular Carcinoma

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11
Q

Hep C is a RNA virus, how is it spread? What is its incubation period?

A

Spread is via IVDU, Blood Transfusions and Sexual

Incubation is 6-9 weeks

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12
Q

How would acute Hep C present?

A

Often asymptomatic, may just be jaundiced

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13
Q

How would chronic Hep C present?

A

Over 80% of cases are chronic

Malaise, Weakness, Anorexia

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14
Q

Name three possible investigations for Hep C

A

LFTs
PCR of the virus to confirm ongoing infectivity
If PCR +ve then do a liver biopsy to assess damage

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15
Q

Describe the management of Hep C

A

Stop alcohol/smoking
Start anti-virals
NO VACCINE AVAILABLE

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16
Q

What is Hep D?

A

A co - infection for Hep B (as it is an incomplete RNA virus)

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17
Q

How would you investigate Hep D?

A

You would test for Anti Hep B antibody, and then if that was positive, proceed to do the Anti Hep D antibody

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18
Q

How would you manage Hep D?

A

Peginterferon Alfa-2a has limited success so a liver transplant may be required

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19
Q

Describe three features of Hep E’s pathophysiology/epidemiology

A

RNA virus similar to Hep A
Common in Indochina
Associated with pigs

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20
Q

Describe the pathophysiology of Meningitis

A

Inflammation of the leptomeninges (arachnoid and pia) by virus/bacteria/non infective causes

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21
Q

Give four risk factors for Meningitis

A

Young Age
Immunosupression
Crowding
Spinal Procedures

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22
Q

Name the causative organisms of bacterial meningitis in neonates

A

Group B Strep

E.Coli

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23
Q

Name the causative organisms of bacterial meningitis in adults

A

Haemophilus Influenza
Strep Pneumoniae
Neisseria Meningitidis

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24
Q

Name the causative organisms of bacterial meningitis in the elderly

A

Strep Pneumoniae

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25
Q

What is Aseptic Meningitis? Give 4 examples

A

When no bacteria can be cultured

Viral Infections, Fungal Infections, TB, Partially treated meningitis

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26
Q

Give 4 causes of non infective Meningitis

A

Malignant Cells (Leukaemias, Lymphomas)
Medication (NSAIDs, Trimethoprim)
Sarcoidosis
SLE

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27
Q

Give 5 symptoms of Meningitis

A 
Fever
Nausea
Headache
Nuchal Rigidity 
Photophobia
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28
Q

What are some differentials for Meningitis?

A

Intracranial Abscess
SAH
Encephalitis

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29
Q

What investigations should be performed if Meningitis is suspected?

A 
Immediate Lumbar Puncture (pre abx)
FBC, CRP
Blood Culture
ABG
Coagulation Screen
EEG (if seizing)
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30
Q

Describe the management of viral Meningitis

A

Supportive

IV Aciclovir if Herpes Simplex Virus is suspected

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31
Q

Describe the management of bacterial Meningitis

A

Supportive

IV Ceftriaxone AND Dexamethasone

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32
Q

Give 3 complications of Meningitis

A

Cerebral Oedema
SIADH
Waterhouse Friderichson Syndrome

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33
Q

What is Cellulitis?

A

Infection of the dermis and deep subcutaneous tissue with poorly demarcated borders
Likely due to Streptococcus Pyogenes or Staphylococcus Aureus

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34
Q

Give 4 risk factors for Cellulitis

A

Previous Cellulitis
Venous Insufficiency
Alcoholism
IVDU

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35
Q

How would Cellulitis present?

A

Usually unilateral and in lower limb
May have an area of damaged skin
Localised Erythema/Pain/Swelling
May have systemic symptoms

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36
Q

State 4 investigations you could do for suspected Cellulitis

A

Skin Swab
CRP
Fine Needle Aspirate
Culture

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37
Q

Give 3 features of a Cellulitis Management plan

A

Supportive (Rest, Elevation, Analgesia)
Flucloxacillin 500mg QTS (or Erythromycin if pen allergic)
Emollient to keep skin hydrated

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38
Q

Describe the pathophysiology of Malaria

A

Parasite infection from Plasmodium species of Mosquito (female only)
Most common is Falciparum followed by Vivax and Ovale
Sporozoites travel to the liver and become Merozoites

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39
Q

Give 4 clinical presentations of Malaria

A

High Fevers
Malaise
Headache
Myalgia

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40
Q

Name 2 signs OE of Malaria

A

Jaundice

Hepatosplenomegaly

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41
Q

Give three diagnostic techniques for Malaria

A

Microscopy
Rapid Diagnostic Test of Parasite Antigen
LFTS

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42
Q

How would you treat Malaria (P.Vivax and P.Ovale)?

A

Chloroquine

Primaquine (prevention of relapse - test for G6PDH first)

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43
Q

How would you treat Malaria (P.Falciparum)?

A

Oral Quinine Sulphate and Doxycycline

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44
Q

Give 3 risk factors for Gastroenteritis

A

Poor Personal Hygiene
Immunocompromised
Achlorhydria

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45
Q

What are the incubation periods of different Gastroenteritis infectants?

A

Viral - a day
Bacteria - Few hours to 4 days
Parasites - 7-10 days

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46
Q

Diagnosis of Gastroenteritis is normally clinical, but what investigations could you do?

A

Stool - Microscopy, Culture and Staining
Blood Tests
Imaging (if bowel distension)

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47
Q

What is the management of Gastroenteritis?

A

Supportive

Anti- Motility if required (eg Loperamide)

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48
Q

What is Osteomyelitis?

A

Infection of the bone marrow which can affect the cortex and periosteum (necrosis) via spread through Haversian Canals.

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49
Q

What are the most common pathogens causing Osteomyelitis?

A

Staphylococcus Aureus (most common)
Haemophilus Influenza
Escherichia Coli

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50
Q

Give four risk factors for Osteomyelitis

A

Trauma, Diabetes, IVDU, Peripheral Arterial Disease

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51
Q

How would Osteomyelitis of a long bone present?

A

Acutely febrile, Painful immobile limb

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52
Q

How would Osteomyelitis of vertebrae present?

A

Back pain worse at rest
Localised Oedema
Localised tenderness

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53
Q

What is Potts Disease? How would it present?

A

Osteomyelitis of the vertebrae, specifically as a result of TB
Causes vertebral body collapse, and abscess formation

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54
Q

What investigations would you do for suspected Osteomyelitis? What would they show?

A

FBC - Elevated white cells and inflammatory markers
Blood culture/bone culture
MRI - Bone marrow oedema

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55
Q

How would you manage acute osteomyelitis?

A

Extensive surgical cleaning

Flucloxacillin for 4-6 weeks

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56
Q

How would you manage chronic osteomyelitis?

A

Extensive surgical cleaning

Antibiotics for 3-6 months

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57
Q

Describe the pathophysiology of Infective Endocarditis in 3 steps

A

1) Turbulent flow damages endothelium
2) Platelets and fibrin adhere to give non bacterial thrombotic endocarditis
3) Circulating bacteria adhere to vegetation on the valves

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58
Q

What are the common causative organisms of Infective Endocarditis

A

Usually Strep Viridans
Staph Aureus in IVDU
May be fungal in immunocompromised/IVDU

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59
Q

Give three risk factors for Infective Endocarditis

A

Skin Breaches
Immunocompromised
Valvular Disease

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60
Q

Give 3 symptoms of Infective Endocarditis

A

Fevers
Rigors
Night Sweats

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61
Q

Give 3 signs of Infective Endocarditis

A

Splinter Haemorrhages
Janeway Lesions
New/Modified Cardiac Murmurs (usually Aortic Regurg)

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62
Q

A common complication of Infective Endocarditis is the formation of an Aortic Root Abscess, how would this present?

A

Prolonged PR Interval
AV block
Left Ventricular Failure

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63
Q

What investigations would you do for suspected Infective Endocarditis?

A

Trans-Oesophageal Echocardiography
Blood Cultures
ECG
CXR

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64
Q

How would you manage Infective Endocardtis?

A

Initial empirical treatment with Amoxicillin and Gentamicin while awaiting sensitivity results
Surgery indicated if heart failure or valvular obstruction

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65
Q

How is Typhoid fever transmitted? What is it’s incubation period?

A

Transmission is faecal-oral

Incubation is 6-30 days

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66
Q

Give 4 symptoms of Typhoid Fever

A

Fever
Malaise
Anorexia
Dry cough

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67
Q

Give 3 signs characteristic of Typhoid Fever

A

Faget’s Sign (Bradycardia and Fever)
Rose Spots
Hepatosplenomegaly

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68
Q

Give 3 investigations for Typhoid Fever

A

FBC
Blood Culture
Stool Culture

69
Q

How would you manage Typhoid Fever?

A

Avoid Abx until diagnosis is confirmed

Azithromycine (1g PO on the first day, then 500mg daily after)

70
Q

Define Pyrexia of Unknown Origin

A

Temperature more than 38 degrees on more than one occasion
Illness>3 weeks duration
No diagnosis despite 1 weeks worth of inpatient

71
Q

Categories of causes of PUO include Infective/Autoimmune/Neoplastic and Other. Give 2 examples of each.

A

Infective - TB, Brucellosis (slow growing)
Autoimmune - Temporal Arteritis, Wegener’s Granulomatosis
Neoplastic - Leukaemia, Lymphoma
Other - Thromboembolism, Hyperthyroidism

72
Q

What percentage of the population does C.Diff harmlessly colonate?

A

2-5%

73
Q

What investigations would you do for C.Diff?

A

Stool tests (PCR for C.Diff proteins, ELISA for C.Diff toxins)

74
Q

How would you manage mild and severe C.Diff respectively?

A

Stop causative antibiotic if possible
Mild - 400mg Metronidazole every 8 hours
Severe - 500mg Vancomycin every 6 hours (ideally PR due to better enteral penetration)

75
Q

Give two complications of C.Diff

A 
Toxic Megacolon (requiring urgent colectomy)
Multi System Organ Failure
76
Q

What is MRSA resistant to?

A

Beta Lactams

77
Q

What percentage of the population is nasally colonised with MRSA?

A

20-30%

78
Q

What investigation is carried out for suspected MRSA?

A

PCR for mecA gene

79
Q

What is the management of an MRSA skin/soft tissue infection?

A

Incision and drainage

Tetracycline + Rifampicin OR Clindamycin

80
Q

What is the management of a resp MRSA infection?

A

Tetracycline or Clindamycin

81
Q

What is conjunctival suffusion? What is it caused by?

A

Reddening of the conjunctiva

Leptospirosis

82
Q

Give 5 causes of splenomegaly

A 
Malaria
Leishmaniasis
Typhoid
Brucellosis
EBV
83
Q

Describe the pathophysiology of HIV in four steps

A

1) HIV binds to CD4 receptors on T cells
2) HIV uses reverse transcriptase to bind to host DNA
3) DNA replication
4) Causes inflammation and spreads to other tissues

84
Q

How is HIV transmitted

A

Via bodily fluids

85
Q

Give 5 symptoms of primary HIV

A 
Flu like
Maculopapular Rash
Myalgia
Lymphadenopathy
Weight Loss
86
Q

Describe the 5 stages of HIV in terms of CD4

A 
Primary - Normal CD4
Stage 1 - >500 CD4
Stage 2 - <500 CD4
Stage 3 - <350 CD4
Stage 4 - <200 CD4 (AIDs Defining)
87
Q

Give 3 investigations for HIV

A

ELISA for HIV antigen and antibody
Rapid Immuno- Assay Kit
Nucleic Acid Testing (for viral RNA)

88
Q

State 5 Opportunistic diseases seen in HIV

A 
PCP Pneumonia
Candidiasis 
Cryptococcus Neoformans causing Meningitis
Kaposi's Sarcoma
Lymphoma
89
Q

Name the four targets of HIV anti retrovirals

A 
Inhibiting viral entry
Inhibiting reverse transcriptase
Inhibiting viral integration
Inhibiting protease (viral maturation)
90
Q

How is TB spread?

A

Aerosol inhalation causing pulmonary infection and subsequent haematogenous spread

91
Q

What is the Quantiferon test?

A

Assesses the amount of interferon gamma released from T cells when exposed to mycobacterium
CANNOT differentiate between active and latent

92
Q

What is the T Spot test?

A

Same principle as Quantiferon test but tests an individual T lymphocyte (good for immunosupressed patients)

93
Q

How is latent TB treated?

A

Not treated if over 35 usually (high risk of hepatotoxicity)

3 months Rifampicin and Isoniazid OR 6 months Isoniazis

94
Q

Give 4 symptoms of active TB

A

Non resolving cough
Weight loss
Night sweats
Haemoptysis

95
Q

Describe 3 features seen on a TB XRay

A

Mediastinal lymphadenopathy
Cavitating Pneumonia
Pleural Effusion

96
Q

What would be seen on a CT scan of TB?

A

Lymphadenopathy (often with central necrosis)

97
Q

How would you aim to take a biopsy from a suspected pulmonary TB patient?

A

FIrst try a sputum sample
If the sputum sample is negative then proceed to bronchoscopy/EBUS to take sample from pulmonary lymph nodes (caseating granulomatous inflammation)

98
Q

What would you see on the lumbar puncture of meningeal TB?

A

Inreased lymphocytes
HIGH protein
Low glucose

99
Q

What is the paradoxical reaction in TB?

A

As bacteria die there is an increase in inflammation causing worsening symptoms
Steroids are initiated if this is in a place where an increase in inflammation would not be tolerable (eg CNS)

100
Q

Describe the treatment plan for Active TB

A

2 months of Rifampicin/Isoniazid/Pyrazinamide/Ethabutol along with Pyridoxine
4 months of Rifampicin/Isoniazid plus Pyridoxine

101
Q

Name 2 side effects of Rifampicin

A

Orange Urine

Drug induced hepatitis

102
Q

Name 3 side effects of Isoniazid

A

Peripheral Neuropathy (vit B deficiency)
Colour Blindness
Drug induced hepatitis

103
Q

Name a side effect of Pyrazinamide

A

Drug induced hepatitis

104
Q

Name a side effect of Ethambutol

A

Reduced visual acuity

105
Q

Give three features of infection control in TB

A

Contact tracing
Nursed in a side room until they’ve had atleast two weeks of treatment
Wear a mask if giving aerosol treatment such as nebuliser

106
Q

What subtypes of Human Herpes Viruses are involved in Herpes Simplex Virus?

A

Human Herpes 1 & 2

107
Q

Describe the pathophysiology of Herpes Simplex Virus

A

Viruses multiply in epithelial cells on skins surface producing vesicles/ulcers
Can enter sensory neurones and remain latent

108
Q

Describe how primary Herpes Simplex VIrus would present

A

May have a prodrome of tingling along the sensory nerve
Vesicles/Shallows ulcers (healing in 8-12d)
Fever
Malaise
Lymphadenopathy

109
Q

How would reactivation of Herpes Simplex Virus present?

A

Usually less severe than primary infection

110
Q

What is Gingivostomatitis? How would it present?

A

Herpes infection of oral mucosa and gums

Fever, Sore throat, Tender oropharyngeal vesicles

111
Q

How is active Herpes Simplex Virus treated?

A

Aciclovir (IV route if encephalitis)

112
Q

How is VZV (HHV 3) transmitted? What is its incubation period?

A

Respiratory droplet infection

14-21d

113
Q

Describe the pathophysiology of VZV

A

Infects respiratory mucosa
Multiplies in lymph nodes
Disseminates via mononuclear cells to skin epithelia
Can lay dormant in root of sensory nerve

114
Q

How might chickenpox present?

A

May have a prodrome of fever/malaise/headache

Pruritic rash with vesicles that crust in 48h

115
Q

What is the infectious period of chickenpox?

A

Infectious 1-2 days before lesions appear, and 5d after lesions have scabbed over

116
Q

How would Shingles present?

A

Painful hyperaesthetic area

Vesicular rash in dermatomal region

117
Q

Name two complications of Shingles

A

Post Herpetetic Neuralgia

Ramsey Hunt Syndrome

118
Q

You only investigate VZV if the patient is immunocompromsied, what technique would you use?

A

Viral PCR

119
Q

VZV is only treated in adults, how would you manage it?

A

Adults - Oral Aciclovir/Valaciclovir within 48h of rash

Immunocompromised/Pregnant - IV Aciclovir

120
Q

What is a VZV vaccination?

A

Vaccination against Shingles given to over 70s

121
Q

Describe the pathophysiology of EBV (HHV4)

A

Virus targetting circulating B lymphocytes and squamous epithelia of oropharynx

122
Q

There are two ways in which EBV can present, describe them

A

Asymptomatic (normally in childhood)

Infectious Mononucleosis

123
Q

What are the signs/symptoms of Infectious Mononucleosis?

A 
Sore Throat
Fever
Anorexia
Lymphadenopathy (especially in post.triangle)
Hepatosplenomegaly
Jaundice
124
Q

What would a blood film of EBV show?

A

Lymphocytosis

125
Q

Apart from a blood film, what other diagnostic tests could you do for EBV?

A

Viral PCR

Monospot (Heterophile antibodies produced by immune cells when exposed to EBV)

126
Q

Name 4 cancers associated with EBV

A

Burkitts Lymphoma
Hodgekin’s Lymphoma
B Cell Lymphoma
Gastric Cancer

127
Q

How do immunocompetent people infected with CMV (HHV5) present?

A

Often asymptomatic
May present as hepatitis
May present like Infectious Mononucleosis

128
Q

How would immunocompromised people present with CMV?

A

Pneumonia - Fever, SOB

129
Q

Who is at risk of congenital CMV?

A

When mothers do not have pre-existing immunity

130
Q

How would congenital CMV present?

A

May appear healthy in utero
Sensorineural hearing loss
Mental Retardation
Cerebral Palsy

131
Q

What situation puts patients at risk of CMV?

A

Organ Transplant (can even occur if patient is seropositive due to different strains)

132
Q

Only immunodeficient and congenital patients are treated for CMV, what are they treated with?

A

Ganciclovir

133
Q

How can CMV be prevented in transplantation?

A

both seronegative - leukodepleted blood and products

recipient serongeative - prophylaxis with Ganciclovir

134
Q

What are the symptoms of Neisseria Gonorrhoea infections in men and women respectively?

A

Men - Urethral discharge/Dysuria

Women - Discharge/Dysuria/Lower abdo pain/Altered menstrual bleeding

135
Q

How would you investigate suspected Gonorrhoea?

A

NAAT on first catch urine (men) or endocervical swab (women)

136
Q

How would you manage Gonorrhoea pharmacologically?

A

500mg Ceftriaxone IM

1g Azithromycin PO

137
Q

Give two complications of Gonorrhoea each for men and women

A

Men - Prostatitis, Epididymitis

Women - Salpingitis, Ectopic Pregnancy

138
Q

How would Chlamydia present in a woman?

A

Dysparenuria
Dysuria
Post Coital Bleeding
Increased Discharge

139
Q

What is an atypical presentation of Chlamydia?

A

Reiter’s Syndrome (Urethritis, Arthritis, Conjunctivitis)

140
Q

How is Chlamydia managed pharmacologically?

A

100mg Doxycycline BD for one week

141
Q

Name four ways Syphilis can be transmitted

A

Sexual contact with infectious lesions
Vertical transmission in utero
Blood transfusions
Break in skin

142
Q

How does primary syphilis present?

A

Develops at site of infection less than 3 months after
Progresses from macule - papule - chancre
Enlarged regional lymph nodes

143
Q

What is a chancre?

A

Painless ulcer with central sloughing and rolled edges

144
Q

How does secondary syphilis present?

A

Occurs roughly 6 weeks after primary infection
Night time headaches
Malaise
Slight fever
Polymorphic rash affecting palms, soles of feet and face

145
Q

Name the three categories of tertiary syphilis

A

Neurological (may be asymptomatic or may have sensory ataxia, dementia etc)
Cardiovascular (Aortitis)
Gummata (Inflammatory nodules/plaques in any organ which may be locally destructive)

146
Q

How can you investigate Syphilis?

A

Treponemal Enzyme Immunoassay for IgM (early) or IgG

147
Q

How would you treat Primary, Secondary and early latent Syphilis?

A

Benzathine Penacillin 2.4 mega units IM

148
Q

How would you treat late latent Syphilis?

A

Benzathine Penicillin weekly for 3 weeks

149
Q

Name two complications of Syphilis or its treatment

A

Miscarriage/Stillbirth

Jarisch Herxheimer Reaction (to treatment, febrile, headache, myalgia, chills)

150
Q

What strains of HPV cause genital warts?

A

HPV6 and HPV11

151
Q

How might Genital Warts present?

A

Painless lesions that may cause itching/bleeding/dysparenuria

152
Q

How would you educate a patient with Genital Warts?

A

The virus has a long latent period
Recurrence of warts does not mean reinfection with virus/infidelity
Condom use until lesions have resolved

153
Q

How would you treat Genital Warts?

A

May choose no treatment, will regress spontaneously in 6m
Non Keratinised - Podophyllotoxin cream
Keratinised - Imiquimod Cream

154
Q

What is Trichomonas Vaginalis

A

A protozoal infection spread almost exclusively by sexual intercourse

155
Q

What is ‘Strawberry Cervix’

A

Cervicitis caused by Trichomonas Vaginalis causing a strawberry appearance

156
Q

How is Bacterial Vaginosis caused?

A

When Gardnerella Vaginalis outgrow the lactobacilli which normal inhabit the vagina, increasing the pH

157
Q

Name 3 protective factors of Bacterial Vaginosis

A

COCP
Condom Use
Circumcised Partner

158
Q

How is Bacterial Vaginosis managed?

A

Oral Metronidazole 400-500mg BD for 5-7 days

159
Q

What is Schistosomiasis?

A

Fluke infection transmitted by contaminated water

160
Q

How would acute Schistosomiasis present?

A 
Swimmer's Rash
Katayama Syndrome (Fever, Urticaria, Diarrhoea)
161
Q

How would chronic Schistosomiasis present?

A 
Intestinal Disease (pain,bloody stools)
Urogenital Disease (Dysuria, CKD, Bladder Cancer)
Lung Disease (Pulmonary Htn)
162
Q

How is Schistosomiasis diagnosed?

A

Ova in urine/faeces
Abdo Xray - Bladder Calcification
USS - Hydronephrosis and thickened bladder wall

163
Q

How is Schistosomiasis treated?

A

Praziquental

Steroids for Katayama Fever

164
Q

Describe the pathophysiology of Tetanus

A

Caused by anaeobic Clostrodium Tetani spores in soil
Enters small wounds and produces neurotoxin (Tetanospasmin)
Neurotoxin disseminates via blood and lymphatics causing unopposed muscle contraction and spasm
Incubation of 3d to 3w

165
Q

How would generalised Tetanus present?

A 
Prodrome (fever,malaise,headache)
Trismus (lock jaw)
Neck Stiffness
Swallowing Difficulties
Muscular Spasms
166
Q

How is Tetanus managed?

A

In ITU
IV Tetanus IG
Metronidazole
Benzodiazepines for spasms

167
Q

Describe two screening methods for Latent TB

A

Mantoux

IGRA (Quantiferon or T Spot)

168
Q

What do the results of the Mantoux test mean?

A

Negative: <6mm induration
Positive: >6mm induration
Strongly Positive: >15mm induration

Year 3 Medicine (15 decks)

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