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3a womens health > Sexual Health > Flashcards

Sexual Health Flashcards

1
Q

What is Bacterial Vaginosis

A

an overgrowth of bacteria in the vagina, specifically anaerobic bacteria

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2
Q

What causes Bacterial Vaginosis

A

overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis
–> fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

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3
Q

What anaerobic bacteria is associated with Bacterial Vaginosis

A

Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species

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4
Q

What risk factors are associated with Bacterial Vaginosis

A
  • Multiple sexual partners
  • Excessive vaginal cleaning
  • Recent antibiotics
  • Smoking
  • Copper coil
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5
Q

How does BV present

A

thin, white homogenous discharge
‘fishy’ smell
asymptomatic in 50%
vaginal swab and exclude other causes of symptom

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6
Q

How is BV investigated?

A

clue cells on microscopy
Vaginal pH > 4.5

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7
Q

How is BV managed

A

oral metronidazole for 5-7 days

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8
Q

WHat advice should be given with metronidazole prescription and why

A

avoid alcohol

can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

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9
Q

What are complication of BV

A
  • increase the risk of catching sexually transmitted infections
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10
Q

What are complication of BV in pregnant women

A

Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis

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11
Q

What is candidiasis

A

thrush
vaginal infectuin with yeast if candida family
mc:candida albicans

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12
Q

What are risk factors of thrust

A

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
Poorly controlled diabetes
Immunosuppression (e.g. using corticosteroids)
Broad-spectrum antibiotics

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13
Q

How does thrust commonly present

A

Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort

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14
Q

What can severe thrush lead to

A

Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation

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15
Q

How is thrush investigated

A

often Tx started empirically based on presentation
vaginal pH swab
charcoal swab w microscopy to confirm

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16
Q

What is the vaginal pH of thrust

A

< 4.5

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17
Q

What is the vaginal pH of BV and trichomonas

A

> 4.5

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18
Q

How can thrust treatment be delivered

A
  • Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
  • Antifungal pessary (i.e. clotrimazole)
  • Oral antifungal tablets (i.e. fluconazole)
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19
Q

How is thrust treated

A
  • A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
  • A single dose of clotrimazole pessary (500mg) at night
  • Three doses of clotrimazole pessaries (200mg) over three nights
  • A single dose of fluconazole (150mg)
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20
Q

What is the name of the standard over the counter thursh treatment

A

Canesten Duo

contains a single fluconazole tablet and clotrimazole cream for vuvla symptoms

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21
Q

what should sexually active women keep in mind when using antifugal treatment

A

antifungal creams and pessaries can damage latex condoms and prevent spermicides from working

alternative contraceptive is required for at least five days after use.

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22
Q

What is Trichomonas vaginalis

A

a type of parasite spread through sexual intercourse

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23
Q

how is Trichomonas classed

A

protozoan, and is a single-celled organism with flagella

four flagella at the front and a single flagellum at the back

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24
Q

Where does Trichomonas live

A

lives in the urethra of men and women and the vagina of women.

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25
Q

What can Trichomonas increase the risk of

A

Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.

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26
Q

How does Trichomonas vaginalis present

A

50% asymptomatic

Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)

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27
Q

What is the characteristic description of Trichomonas vaginalis vaginal discharge

A

frothy and yellow-green
may have a fishy smell

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28
Q

What does Trichomonas vaginalis show on cervical examination

A

characteristic “strawberry cervix” (also called colpitis macularis)

caused by inflammation
tiny haemorrhages across the surface

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29
Q

How is Trichomonas vaginalis diagnosed

A

charcoal swab with microscopy

  • Swabs should be taken from the posterior fornix of the vagina
  • A urethral swab or first-catch urine is used in men.
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30
Q

how is Trichomonas vaginalis treated

A

metronidazole 500mg twice daily for 5-7 days

contact tracing needed
full sexual health screen.
sexual intercourse avoided til treated

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31
Q

What is a complication of trichomoniasis in pregnancy

A

An increased risk of premature rupture of membranes and preterm birth.

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32
Q

What is Chlamydia

A

gram-negative bacteria
intracellular organism
MC STI
significant cause of infertility

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33
Q

what is a intracellular organism

A

enters and replicates within cells before rupturing the cell and spreading to others

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34
Q

Is there a screening program for chlamydia

A

yes, National Chlamydia Screening Programme (NCSP)

screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner

those who test positive should have a re-test three months after treatment.

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35
Q

What STIs are tested in an STI screen as minimum

A

Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)

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36
Q

What two types of swabs are used in sexual health

A

Charcoal swabs
Nucleic acid amplification test (NAAT) swabs

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37
Q

What are Charcoal swabs used for

A

microscopy
culture
sensitivities

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38
Q

What is the trasnport medium for charcoal medium

A

Amies transport medium

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39
Q

What are locations of swabs for charcoal swabs in womne

A

endocervical swabs
high vaginal swabs (HVS).

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40
Q

What can charocal swabs confirm

A

Bacterial vaginosis
Candidiasis
Gonorrhoeae (specifically endocervical swab)
Trichomonas vaginalis (specifically a swab from the posterior fornix)
Other bacteria, such as group B streptococcus (GBS)

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41
Q

What does NAAT look at

A

DNA or RNA of the organism.

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42
Q

What is NAAT used to test for

A

chlamydia and gonorrhoea
&
Mycoplasma genitalium

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43
Q

What types samples are used for NAAT testing

A

endocervical
vulvovaginal (self taken)
and then urine

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44
Q

how does chlamydia present in women

A

majority asymptomatic

Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)

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45
Q

How does chlamydia present in men

A

Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis

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46
Q

What are symptoms of rectal chlamydia and lymphogranuloma venereum

A

anorectal symptoms

such as discomfort, discharge, bleeding and change in bowel habits.

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47
Q

What findings would you see on examination for chlamydia

A

Pelvic or abdominal tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge

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48
Q

How is chlamydia diagnosed

A

NAAT

Vulvovaginal swab
Endocervical swab
First-catch urine sample (in women or men)
Urethral swab in men
Rectal swab (after anal sex)
Pharyngeal swab (after oral sex)

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49
Q

What is 1st line management for uncomplicated chlamydia

A

doxycycline 100mg twice a day for 7 days.

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50
Q

What is management for chlamydia in pregnancy or breastfeeding

A

Azithromycin 1g stat then 500mg once a day for 2 days

or

Erythromycin 500mg four times daily for 7 days

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51
Q

Name an Abx contraindicated in pregnancy

A

doxycycline

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52
Q

Other factors to consider in chlamydia treatment

A

Abstain from sex for seven days of treatment
Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
Test for and treat any other
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse

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53
Q

Name 3 complications of chlamydia

A

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis

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54
Q

Name three pregnancy complications of chlamydia

A

Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)

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55
Q

What is Lymphogranuloma Venereum (LGV)

A

A sexually transmitted disease caused by L1–3 serovars of Chlamydia trachomatis

affecting the lymphoid tissue around the site of infection

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56
Q

What primary stage LGV

A

a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex

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57
Q

who does LGV typically affect

A

men who have sex with men (MSM)

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58
Q

What is secondary stage LGV

A

lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria

inguinal or femoral lymph nodes

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59
Q

What is tertiary stage LGV

A

inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge.

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60
Q

What is tenesmus

A

feeling of needing to empty the bowels

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61
Q

How is LGV treated

A

Doxycycline 100mg twice daily for 21 days

alt abx = Erythromycin, azithromycin and ofloxacin

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62
Q

What is gonorrhoea

A

Neisseria gonorrhoeae

gram-negative diplococcus bacteria

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63
Q

What type of tissue does gonorrhoea infect

A

mucous membranes with a columnar epithelium

such as the endocervix in women, urethra, rectum, conjunctiva and pharynx.

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64
Q

What increases risk of having gonorrhoea

A

Young, sexually active and having multiple partners

Having other sexually transmitted infections,

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65
Q

What ABx does gonorrhoea have resistance to

A

ciprofloxacin or azithromycin

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66
Q

How does gonorrhoea present in women

A

50% of women are symptomatic

Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain

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67
Q

How does gonorrhoea present in men

A

90% of men are symptomatic

Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)

68
Q

How does Prostatitis present

A

perineal pain, urinary symptoms and prostate tenderness on examination

69
Q

How does gonorrhoea rectal infection present

A

anal or rectal discomfort and discharge, but is often asymptomatic.

70
Q

How is gonorrhoea diagnosed

A

NAAT
endocervical, vulvovaginal or urethral swabs, or in a first-catch urine

Rectal and pharyngeal swab for MSM

71
Q

What other testing should be done before treatment is started

A

A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics

72
Q

How is gonorrhoea managed

A

referred to GUM clinics to coordinate testing, treatment and contact tracing

73
Q

How is uncomplicated gonorrhoea treated if the sensitivities are NOT known

A

A single dose of intramuscular ceftriaxone 1g

74
Q

How is uncomplicated gonorrhoea treated if the sensitivities ARE known

A

A single dose of oral ciprofloxacin 500mg

75
Q

How is complicated gonorrhoea treated most of the time

A

single dose of intramuscular ceftriaxone

76
Q

What test should be done after treatment for gonorrhoea

A

follow-up “test of cure” given the high antibiotic resistance

77
Q

When should a “test of cure” be done for gonorrhoea

A

72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT

78
Q

What other factors should be considered for gonorrhoea management

A

Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people

79
Q

Name 5 complications of gonorrhoea

A
  • Disseminated gonococcal infection
  • Conjunctivitis
  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Urethral strictures
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome
  • Septic arthritis
  • Endocarditis
80
Q

What is a key gonorrhoea complciation in neonate

A

gonococcal conjunctivitis in neonate

81
Q

What is gonococcal conjunctivitis

A

ophthalmia neonatorum

a medical emergency and is associated with sepsis, perforation of the eye and blindness.

82
Q

What is disseminated gonococcal infection

A

a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints

83
Q

What does disseminated gonococcal cause (symptoms)

A

Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue

84
Q

What is syphilis

A

caused by bacteria called Treponema pallidum

spirochete, a spiral-shaped bacteria

85
Q

How long is the incubation period of syphilis between the initial infection and symptoms

A

21 days

86
Q

How is syphilis transmitted

A
  • Oral, vaginal or anal sex involving direct contact with an infected area
  • Vertical transmission from mother to baby during pregnancy
  • Intravenous drug use
  • Blood transfusions and other transplants (although this is rare due to screening of blood products)
87
Q

What is primary syphilis

A

a painless ulcer called a chancre at the original site of infection (usually on the genitals).

88
Q

what is secondary syphilis

A

systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks

89
Q

What is latent syphilis

A

symptoms disappear and the patient becomes asymptomatic despite still being infected.

90
Q

when does early latent syphilis occur

A

within two years of the initial infection

91
Q

when does late latent syphilis occur

A

occurs from two years after the initial infection onwards.

92
Q

what is tertiary syphilis

A

can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.

93
Q

what is neurosyphilis

A

occurs if the infection involves the central nervous system, presenting with neurological symptoms

94
Q

How does primary syphilis present

A

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy

95
Q

How does secondary syphilis present

A

starts after the chancre has healed with symptoms of

  • Maculopapular rash
  • Condylomata lata (grey wart-like lesions around the genitals and anus)
  • Low-grade fever
  • Lymphadenopathy
  • Alopecia (localised hair loss)
  • Oral lesions
96
Q

How does tertiary syphilis present

A
  • Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
  • Aortic aneurysms
  • Neurosyphilis
97
Q

How does neurosyphilis present

A

can occur at any stage if the infection reaches

Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment

98
Q

What is Argyll-Robertson pupil

A

specific finding in neurosyphilis

a constricted pupil that accommodates when focusing on a near object but does not react to light

prostitutes pupil
it accommodates but does not react

99
Q

What is the screening test for syphilis.

A

Antibody testing for antibodies to the T. pallidum

100
Q

how are samples from site of syphilis infection tested to confirm the presence of T. pallidum

A

Dark field microscopy and Polymerase chain reaction (PCR)

101
Q

What test is used to assess for active syphilis infection (can be used to monitor response to treatment) and name an issue with this test

A

rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)

the tests are non-specific, meaning they often produce false-positive

102
Q

what is medical management of syphilis

A

A single deep intramuscular dose of benzathine benzylpenicillin (penicillin)

late latentm = IM penicillin for 3 weeks + 3 days steroids

neuropsyphilis = IM penicillin for 2 weeks = oral probenecid + 3 days steroids

103
Q

how is syphilis managed

A

managed and followed up by a specialist service, such as GUM

Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections

104
Q

how is early syphilis managed in pregnancy

A

In early syphilis, the treatment is a single dose penicillin in the first and second trimesters or 2 doses if diagnosed in the third trimester.

105
Q

how is late latent syphilis and neurosyphilis managed in pregnancy

A

the first line treatment is the same during pregnancy as it is normally.

106
Q

What is jarisch-Herxheimer reaction

A

reaction to syphilis treatment.

acute febrile illness, presenting with headache, myalgia, chills and rigours

in pregnancy can cause contractions, fetal heart rate abnormalities and stillbirth

107
Q

What is is the causative agent of herpes simplex virus

A

HSV-1 and HSV-2

108
Q

How is herpes simplex virus transmitted

A

double-stranded DNA viruses transmitted through mucosal surfaces or broken skin.

109
Q

what are the clinical features of herpes simplex virus

A

can be asymptomatic

blisters which progress to painful ulcers
dysuria, discharge and inguinal lymphadenopath

110
Q

When do herpes simplex virus patients develop symptoms

A

33% symptomatic at time of infection

lifelong infection with periods of reactivation and symptoms.

111
Q

Where does herpes simplex virus lay dormant

A

within local sensory ganglia

lifelong infection with periods of reactivation and symptoms.

112
Q

What herpes strain is more likely to cause recurrent symptoms

A

HSV-2 is around four times more likely than HSV-1 to cause recurrent symptoms.

113
Q

how is herpes simplex virus investigated

A

diagnosed using PCR

the lesion should be burst and a swab taken from the base of the ulcer.

no lesion = no test

114
Q

how is herpes simplex virus managed

A

Symptomatic episodes can be treated with aciclovir 400mg orally TDS for five days

full sexual health screen

115
Q

What are complications of herpes simplex virus

A
  • Urinary retention: may require catheterisation
  • HSV keratitis: dendritic lesion on the cornea
  • Aseptic meningitis
  • Herpes proctitis
  • Neonatal HSV: an increased risk if the mother becomes infected in the third trimester
  • Herpetic whitlow
116
Q

What sexual health advice should be given to those with herpes

A

full sexual health screen
no requirement for contact tracing
refrain from intercourse when they have lesions
Condoms

117
Q

What is the causative agent of genital warts

A

Human papillomavirus (HPV) 6 and 11 (in most cases)

118
Q

How is genital warts transmitted

A

double-stranded DNA virus is mainly transmitted via direct skin-to-skin contact

rarely perinatally

119
Q

how long is the incubation period from exposure to infection for genital warts

A

up to 8 months.

120
Q

What are the clinical feature of genital warts

A

textured, soft growths.

Anogenital warts can be keratinised (hard surface) or non-keratinised (soft surface).

121
Q

Where can gential warts affect

A

anogenital area

anus, cervix and urethral meatus can all be affected

122
Q

how are genital warts investigated

A

clinical, based on characteristic examination findings.

123
Q

What should be done if gential wart appear atypical or suspicious

A

a biopsy should be performed to exclude an oncogenic HPV virus type.

124
Q

what are topical treatment for genital warts

A

Topical podophyllotoxin (Warticon® and Condyline®)
Topical imiquimod (patients should be made aware that this damages condoms)

125
Q

what are physical ablation therapy options for genital warts

A

Cryotherapy
Surgical excision

126
Q

what increases the risk of gential wart recurrence

A

smoking

127
Q

What are complications of genital warts

A

Ano-genital cancer
Scarring following treatment

128
Q

What is HIV

A

human immunodeficiency virus (HIV)

RNA retrovirus

129
Q

What is AIDS

A

Acquired immunodeficiency syndrome (AIDS) occurs when HIV is not treated

Immunodeficiency leads to opportunistic infections and AIDS-defining illnesses.

130
Q

What is mc type of HIV

A

HIV-1

HIV-2 is mainly found in West Africa

131
Q

What does HIV destroy

A

enters and destroys the CD4 T-helper cells of the immune system.

132
Q

What is the disease progression of HIV

A

An initial seroconversion flu-like illness occurs within a few weeks of infection.

infection is then asymptomatic until the condition progresses to immunodeficiency (might be several years)

133
Q

How is HIV transmitted

A

Unprotected anal, vaginal or oral sexual activity
mother to child
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids

134
Q

what is vertical transmission

A

Mother to child at any stage of pregnancy, birth or breastfeedin

135
Q

name 3 AIDS defining illnesses

A

Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis

136
Q

What are fourth-generation laboratory test for HIV

A

checks for antibodies to HIV and the p24 antigen

window period of 45 days

First line test

137
Q

What is a window period

A

it can take up to X days after exposure to the virus for the test to turn positive

138
Q

When do most people develop antibodies to HIV

A

4-6 weeks but 99% do by 3 months

139
Q

What are point of care tests for HIV

A

tests for HIV antibodies give a result within minutes.

90-day window period.

140
Q

What medication therapy regimen is used to treat HIV regardless of viral load of CD4 count

A

antiretroviral therapy (ART)

141
Q

Name three classes of antiretroviral therapy

A
  • Protease inhibitors (PI)
  • Integrase inhibitors (II)
  • Nucleoside reverse transcriptase inhibitors (NRTI)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTI)
  • Entry inhibitors (EI)
142
Q

What is the usual starting medication regime for HIV

A

two NRTIs (e.g., tenofovir plus emtricitabine)

plus a third agent (e.g., bictegravir)

143
Q

What is the treatment aim for HIV

A

a normal CD4 count and undetectable viral load

144
Q

What additional medication is given to HIV patients with CD count under 200/mm3 and why

A

Prophylactic co-trimoxazole

to protect against pneumocystis jirovecii pneumonia (PCP).

145
Q

What appears to prevent the spread of HIV even during unprotected sex

A

Effective treatment combined with an undetectable viral load

146
Q

What mode of delivery is indicated in a HIV+ mother with viral load of under 50 copies/ml

A

Normal vaginal delivery

147
Q

What mode of delivery is indicated in a HIV+ mother with viral load of over 50 copies/ml

A

Consider a pre-labour caesarean section

148
Q

What mode of delivery is indicated in a HIV+ mother with viral load of over 400 copies/ml

A

Pre-labour caesarean section is recommended

149
Q

What medication is given during labor and delivery in a HIV+ mother if the viral load is unknown or above 1000 copies/ml

A

IV zidovudine

150
Q

What prophylaxis is given to low risk babies to HIV+ mothers

A

zidovudine for 2-4 weeks

151
Q

What prophylaxis is given to high risk babies to HIV+ mothers

A

zidovudine, lamivudine and nevirapine for four weeks

152
Q

what viral load is considered low risk for HIV

A

Under 50 copies per ml

153
Q

What window must Post-exposure prophylaxis (PEP) be started with

A

72 hours

sooner the better

154
Q

What medication regime is included in PEP for HIV

A

emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.

155
Q

What is the usual choice for Pre-exposure prophylaxis (PrEP)

A

emtricitabine/tenofovir (Truvada).

156
Q

What is adive for HIV+ mother breast feeding

A

in the UK all women should be advised NOT to breast feed

157
Q

What is balanitis

A

inflammation of the glans penis and sometimes extends to the underside of the foreskin (balanoposthitis)

158
Q

What is the mc cause of balanitis

A

infective (both bacterial and candidal)

159
Q

What is the main treatment for balanitis

A

Simple hygiene is a key part of the treatment of balanitis

160
Q

what can make balanitis worse

A

improper washing under the foreskin and the presence of a tight foreskin

161
Q

How is balanitis diagnoses

A

made clinically based on the history and examination

162
Q

What key features are importatnt to note with balanitis

A

itching or discharge

163
Q

how is staphylococcus spp. or Group B Streptococcus spp. balanitis treated

A

oral flucloxacillin or clarithromycin if penicillin allergic

164
Q

how is candidiasis balanitis treated

A

topical clotrimazole for two weeks

165
Q

What is Chancroid

A

tropical disease caused by Haemophilus ducreyi.

166
Q

how does chancroid present

A

painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement

167
Q

how do chancroid ulcers appear on examination

A

sharply defined, ragged, undermined border.

3a womens health (5 decks)

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