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OJHAS Vol. 10, Issue 3:
(Jul-Sep 2011) |
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| Study of the Clinical Patterns in Varicella in a Tertiary Hospital at
Coastal Karnataka |
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Girish PN, Associate
Professor,
Narendra Shetty J, Professor and Head,
Vinma Shetty H, Assistant
Professor
Geoffrey Vaz F, Postgraduate Student,
Department of Dermatology, AJ Institute of Medical Sciences,
Mangalore - 575004, Karnataka State, India. |
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Address for Correspondence |
Skin specialist,
1st floor, Hemavathy Building,
Balmatta, Mangalore-575001
Karnataka State, India.
E-mail:
pattegiri@yahoo.co.in |
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Girish PN, Shetty NJ, Shetty VH, Vaz GF. Study of the Clinical Patterns in Varicella in a Tertiary Hospital at
Coastal Karnataka. Online J Health Allied Scs.
2011;10(3):6 |
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Submitted: Jul 29,
2011; Accepted: Oct 25, 2011; Published: Nov 15, 2011 |
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| Abstract: |
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Context: There are very
few studies regarding the clinical patterns and manifestations of a
very common viral infection, Varicella, especially from south India. Aims: To
study the cutaneous manifestation of Varicella with an emphasis on vaccination
status. Settings and Design:
Cross sectional study. Methods
and Material: A total of 118 patients attending the Dermatology
OPD of a private medical college in coastal Karnataka with cutaneous
manifestations of varicella were enrolled. Study period was from January
2010 to December 2010. Statistical analysis used:
Data was analysed using SPSS version 11.5. Various frequency distribution
tables, diagrams and chi square test were used to describe and analyse
the data. Results:
Majority of the patients were males (62.7%) and 21-30 years was the
most common age group involved. There were 74 students, out of which
eight were in the preschool group aged between 3-4 years. Most of the
patients visited the hospital on the second day after onset of the symptoms.
108(91.5%) patients complained about the presence of various prodromal
symptoms. Scalp was the most common (39.8%) site of onset of the rash.
Itching was experienced by 76(64.4%) patients. Peak number of cases
(35.6%) was seen in the month of January. The cutaneous rash was most
commonly (57.7%) distributed over face, scalp, trunk, upper and lower
limbs, with predominantly central distribution. Soft palate was the
most common site (87%) involved in the oral cavity. Conclusions: A
wide variety of combination symptoms with classical cutaneous polymorphic
vesicular rash and oral lesions was seen.
Key Words:
Varicella; Cutaneous manifestations; Vaccination
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Varicella is a highly infectious
acute viral infection caused by Varicella-zoster virus of Herpesviridae
family.1 Heberden in 1767 distinguished chickenpox from smallpox.2
The word chickenpox comes either from “chichen-pois” for chick pea,
describing the pea sized blisters or “gican” meaning to itch.2
In 1888 von Bokay first noticed the association between varicella and
herpes zoster.2 Availability of varicella vaccine and subsequent
breakthrough varicella may possess diagnostic challenge. There are very
few studies and data regarding the varied clinical features of varicella
which may help in diagnosing the infection early and hence this study
was conducted.
Patients attending
the Dermatology OPD of a private medical college in south India were
included in the study. A total of 118 patients were enrolled for the
cross sectional study from January 2010 to December 2010. Diagnosis
of varicella was made clinically by the presence of characteristic polymorphic
papulovesicular rash. A detailed history regarding the prodrome, site
of onset, progression of skin rash, associated symptoms, contact, recurrence,
pregnancy & vaccination status were recorded. A thorough clinical
examination was done including the site-wise distribution of various
skin & mucosal lesions, and lymphadenopathy. Routine blood investigation
like complete hemogram, liver and renal function test, random blood
sugar, ELISA for Human Immunodeficiency Virus (HIV) and routine urine
examination were conducted in selected patients.
Of the total
118 varicella patients studied, 74(62.7%) were males. Maximum number
of patients (50) was in the age group of 21-30 years (Table 1).
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Table1:
Age-sex distribution of the study subjects.
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Age in
years |
Males No. (%) |
Females No. (%) |
Total No. (%) |
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<10 |
24(20.3) |
10(8.5) |
34(28.8) |
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11-20 |
11(9.3) |
8(6.8) |
19(16.1) |
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21-30 |
30(25.3) |
20(16.9) |
50(42.4) |
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31-40 |
2(1.7) |
4(3.4) |
6(5.1) |
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41-50 |
2(1.7) |
2(1.7) |
4(3.4) |
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51-60 |
2(1.7) |
0(0) |
2(1.7) |
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61-70 |
3(2.5) |
0(0) |
3(2.5) |
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Total |
74(62.7) |
44(37.3) |
118(100) |
Mean
age ± SD was 20.3±13.6 years, with age ranging from 3 to 70 years.
Majority of the patients were students 74(62.7%), out of which school
going (5-15 years) constituted 37.9% of the student subgroup (Table
2, 3).
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Table 2:
Distribution of the study subjects on the basis of occupation (n=118)
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Occupation |
No. (%) |
| Students |
74 (62.7) |
| Skilled workers |
2 (1.7) |
| Unskilled
workers |
10 (8.4) |
| Professional |
20 (17) |
| Retired |
2 (1.7) |
| Housewife |
8 (6.8) |
| Others* |
2 (1.7) |
| Total |
118 (100) |
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*Business etc. |
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Table 3:
Distribution of the study subjects on the basis of occupation (student
subset n=74) |
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Students |
No. (%) |
| Pre-school
(3-4 yr) |
8 (10.8) |
| School (5-15
yr) |
28(37.9) |
| Medical students |
14 (18.9) |
| Nursing students |
4 (5.4) |
| Non-medical
college students |
20 (27) |
| Total |
74 (100) |
Maximum number of patients (45.7%) had symptoms since 2 days,
with a mean duration of 2 days. Various prodromal symptoms like fever,
malaise, coryza, headache, joint pain, loss of appetite & nausea
were present among 108(91.5%) patients (Table 4).
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Table 4:
Prodrome symptoms among the study subjects (n=108) |
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Prodrome |
No. (%) |
| Fever |
26(24.1) |
| Malaise |
2(1.9) |
| Loss of appetite |
12(11) |
| Other combination
symptoms |
68(63) |
| Total |
108 (100) |
Fever alone and in
combination with other prodrome symptom was seen in 90(76.2%) patients.
The most common combination prodrome symptom was fever with loss of
appetite, seen in 16(13.6%) patients (Table 5). There is no association
between fever & loss of appetite combination prodrome symptom with itching,
and the association found to be insignificant (p>0.05).
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Table 5:
Combination prodrome symptoms among the study subjects (n=68) |
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Combination
symptoms |
No. (%) |
| F,M |
10(14.8) |
| F,LA |
16(23.6) |
| M,F,C,H |
2(2.9) |
| M,F,H |
2(2.9) |
| F,C,LA |
8(11.9) |
| F,JP |
2(2.9) |
| F,C,H |
2(2.9) |
| M,F,H,LA |
2(2.9) |
| F,N |
2(2.9) |
| F,H,LA |
2(2.9) |
| M,H |
2(2.9) |
| M,F,C,LA |
2(2.9) |
| M,F,LA |
10(14.8) |
| M,LA |
2(2.9) |
| F,H |
4(5.9) |
| Total |
68(100) |
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F-Fever
M-Malaise LA-Loss of appetite C-Coryza H-Headache
JP-Joint pain N-Nausea. |
Cephalocaudal
progression of the skin rash was seen in 88(74.5%) patients. Majority
of the patients (39.8%) first noticed the rash over the scalp followed
by face (34.7%). Among the 76(64.4%) patients who had itching, majority
(54 patients) experienced mild intensity itching. The number of
cases (35.6%) peaked during the month of January (Graph 1). Second episode
of varicella was seen in two patients aged 55 & 58 years, age of
first episode was 8 & 10 years respectively.
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Table 6:
Duration between contact with varicella/herpes zoster and onset of symptoms |
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No. of
days |
No. (%) |
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< =7 days |
14 (19.5) |
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8-10 days |
6(8.3) |
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11-14 days |
50(69.5) |
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>=15 days |
2(2.7) |
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Total |
72(100) |
Graph 1:
Showing the seasonal distribution of the study subjects |
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Contact with
a patient of varicella (93%) or herpes zoster (7%) was seen in 72(61%)
patients. Maximum number of varicella cases developed after 11-14 days
of contact (Table 6). Two patients were pregnant who developed varicella
at 7 th & 8 th month of gestation. However
there were no complications associated with varicella among these patients.
Only six patients with varicella were previously vaccinated with a single
dose of varicella vaccine (Table 7).
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Table 7:
Age distribution of the vaccinated subjects (n=6)
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Age of
the study subject in years |
Vaccination age in years |
Duration between varicella
and vaccination
in years |
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3 |
2 |
1 |
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3 |
1 |
2 |
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6 |
3 |
3 |
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6 |
4 |
2 |
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16 |
6 |
10 |
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17 |
6 |
11 |
There were
no history of associated illness like diabetes mellitus, hypertension
and immunocompromised state (HIV infection) among the study subjects.
The cutaneous
rash was most commonly (57.7%) distributed over face, scalp, trunk,
upper limbs, and lower limbs (Table 8), with predominantly central distribution.
Macule, papule & vesicle (polymorphic) were the most common morphological
cutaneous lesions observed during the study (Graph 2). Vesicles were
predominantly elliptical and few round, 2-4 mm in diameter on erythematous
base. Skin rash were distributed more on medial than on lateral aspect
of the limbs. Palms were involved in 11.8% of the patients, with vesicle
being the most common morphology. None of the patients had sole involvement.
Soft palate was the most common site (87%) involved in the oral cavity,
with vesicles being the most common lesion (Graph 3). Lymphadenopathy
was seen in 18 patients, consisting of cervical (10), submandibular
(6) & inguinal (2) lymph nodes. Routine blood investigation showed
leucopenia & lymphocytosis in 72 % of the selected patients and
none of them tested positive for HIV.
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Graph 2:
Showing the morphology of the most common skin site |
Graph 3:
Showing the morphology of oral mucosal lesions |
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Table 8:
Distribution of the most common site of skin rash |
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Site |
No. (%) |
| Face |
2(1.7) |
| Trunk
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6(5) |
| Face,trunk |
6(5) |
| Face, scalp |
4(3.4) |
| Face, scalp,
trunk |
2(1.7) |
| Face, trunk,
UL |
2(1.7) |
| Face, trunk,
UL,LL |
6(5) |
| Face,scalp,
trunk,UL,LL |
68(57.7) |
| Face, scalp,
trunk, UL, LL,palms |
14(11.9) |
| Face,scalp,trunk,
UL |
8(6.9) |
| Total |
118(100) |
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UL- Upper limbs
LL-Lower limbs |
Figure 1
(right):
Characteristic oval vesicles on erythematous base over the back.
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Varicella is
a highly infectious acute viral infection clinically characterized by
a vesicular exanthem, and frequently associated with fever and malaise.1
Severity of infection in adults is usually more with numerous lesions
and prolonged febrile illness.1,2
Significant mortality and morbidity is seen in immunocompromised patients
(like HIV infection), with skin lesions being extensive and often hemorrhagic.2
Epidemiology
of varicella is different in temperate and tropical countries, with
maximum number of infection occurring before adolescence in temperate
countries.1 In tropical country like India seroprevalence
pattern showed the varicella mainly affecting the young adult population,
as also observed in our study.1,3-6
This late susceptibility in tropics (more in rural areas) may be due
to epidemiological interference from other viruses and less exposure
to varicella zoster virus.7
In our study majority of the patients (62.7%) were students (school
going student subset of 37.9%), likely due to higher exposure
from the educational institutions. This high exposure may be due to
highly contagiousness, 1-2 days even before the onset of varicella rash
and due to the occurrence of subclinical cases.1,8 Heininger U et al1 describes that there is no sex
difference in varicella, but majority of our patients were males (62.7%).
This higher number of male patients was due to an outbreak in boy’s
school.
Varicella
manifests abruptly in young children with the simultaneous onset of
rash and low grade fever, and in our study mean duration of symptoms
was 2 days.2 The various prodromal symptoms common in adolescents
and adults, like fever, malaise, coryza, headache, joint pain, loss
of appetite & nausea, were present in 91.5% of our patients.8
Heininger U et al1
and Chen MT et al8 describes varicella as an febrile
illness, although fever was seen in only 76.2% of our patients.
When varicella rash is seen in the absence of fever, the risk of transmission
to family members or colleagues increases as there is a possibility
to ignore since varicella is believed to be a febrile disease. The most
common combination prodrome symptom was fever with loss of appetite,
seen in 13.6% of our patients, may be useful clue to the diagnosis of
varicella.
Majority of
the patients (39.8%) in our study first noticed the rash over the scalp
followed by face (34.7%) and cephalocaudal progression of the skin rash
was seen in 74.5% of the patients, as also mentioned by Chen MT et
al.8 Monica L et al2 describes pruritus in varicella as almost universal, associated
with the skin rash, while in our study only 64.4% patients had itching,
and majority (71%) experienced mild intensity itching. Peak incidence
of varicella is seen in the cooler, drier months (winter or spring)
as the virus is heat labile.9 Similarly in our study peak
number of cases (35.6%) were seen during the month of January (Graph
1). According to Chen MT et al
8 progressive and recurrent varicella was observed more frequently
in immunocompromised patients. Second episode of varicella was seen
in two of our immunocompetent patients aged 55 & 58 years.
Range of incubation
period of varicella is 10-21 days with an average of 14 days.1,8 In our study maximum number of varicella cases developed 11-14
days after the contact, which is consistent with the above data regarding
incubation period. Two were pregnant in the third trimester without
any complications in our study. Risk of congenital malformation with
the infection after first 20 weeks of pregnancy is approximately 2%.2
Varicella pneumonia and its complications is a risk to the mother when
infection occurs in the third trimester.10 Only six patients
were previously vaccinated with a single dose of varicella vaccine and
the clinical presentation in them remained to be the same with the rest
of the patients (Table 7). Chaves SS et al
11 describes that approximately 1 in every 5 children exposed
to varicella zoster virus, who receives one dose of varicella vaccine
may develop varicella. Breakthrough varicella is varicella
disease in previously vaccinated individuals, may be difficult to diagnose
as they tend to be milder.1 Need for two-dose policy for
varicella vaccine may be considered for the 15-20% of the vaccinees
who are not fully protected after one dose.11,12 According
to Agampodi SB et al13 incidence of varicella in
medical undergraduates is very high. Medical, nursing students and nursing
staff are in intimate contact with patients and thus vaccinating these
susceptible will reduce work loss as well as transmission of infection
in the hospital.
There was no
history of associated illness among the study subjects, as varicella
related complications are high in patients with coexisting diseases.14
None of our patients were smokers, as the risk of varicella pneumonia
is high in this group.15
The distribution
of skin rash in majority of the patients (57.7%) was seen over face,
scalp, trunk, upper and lower limbs with relative sparing of extremities
(Table 8) consistent with description by Straus SE et al.16
Macule, papule & vesicle (Figure 1)were the most common skin lesions
(Graph 2) as the mean duration of onset in our patients was two days,
because it takes 24-48 hours to form crust.1,2 Straus SE
et al 16 describes the skin rash being more dense in
the small of the back and between shoulder blades than on scapulae and
buttocks. They also mention regarding the numerous lesions more profuse
on the medial than on the lateral limbs, which was also seen in our
study.16 Soft palate was the most common site (87%) involved
in the oral cavity, with vesicles being the most common lesion (Graph
3), as vesicle can rupture to form erosions later.
Varicella is
an acute viral exanthem with varied clinical presentation. It can pose
a diagnostic difficulty if a patient presents to a doctor too early
before the occurrence of vesicles. Scalp being the most common site
of onset of the rash, a high degree of suspicion is required for making
the diagnosis in preventing its transmission in the community. Varicella
classically described as a febrile and pruritic exanthem was seen only
in 76.2% and 64.4% of our patients respectively.2,8 Thus diagnosis should be based on the presence of polymorphic
skin lesions with a characteristic vesicular exanthem with cephalocaudal
progression. Oral cavity was involved in 39% of our patients, with soft
palate being the commonest site involved with vesicle and erosions,
which should be examined to aid in the diagnosis. Young adults were
the commonest age group involved by varicella as the study was conducted
in a tropical country. Large number of cases can be expected in cooler
and drier months like January and February. Vaccinating susceptible
medical, nursing students and nursing staff will reduce work loss as
well as transmission of infection in the hospital. Despite the number
of vaccinated patients were few in our study, data may be useful in
conducting exclusive study regarding varicella in vaccinees and to consider
two-dose varicella vaccine policy for the 15-20% of the vaccinees who
are not fully protected after one dose.11,
12 Further extensive clinical study involving large number of
patients is required in the post vaccination era.
We thank immensely
our bio-statistician Mrs. Manjula Anil for her help in statistical analysis
of the study.
- Heininger U,
Seward JF. Varicella. Lancet 2006;368:1365-1376
- McCrary ML, Severson
J, Tyring SK. Varicella zoster virus. J Am Acad Dermatol 1999;41:1-14
- Liyange NP, Fernado
S, Malavige GN, Mallikahewa R, Sivayogan S, Jiffry MT et al. Seroprevalence
of varicella zoster virus infections in Colombo District, Sri Lanka.
Indian J Med Sci 2007;61:128-134
- Lokeshwar MR, Agarwal
A, Subbarao SD, Chakraborty MS, Ram Prasad AV, Weil J et al. Age related
seroprevalence of antibodies to varicella in India. Indian Pediatr 2000;37:714-719
- Venkitaraman AR,
John TJ. The epidemiology of varicella in staff and students of a hospital
in the tropics. Int J Epidemiol 1984;13:502-505
- Garnett GP, Cox
MJ, Bundy DA, Didier JM, St Catharine J. The age of infection with varicella-zoster
virus in St Lucia, West Indies. Epidemiol Infect 1993;110:361-372
- Mandal BK, Mukherjee
PP, Murphy C, Mukherjee R, Naik T. Adult susceptibility to varicella
in the tropics is a rural phenomenon due to the lack of previous exposure.
J Infect Dis 1998;178:52-54
- Chen TM, George
S, Woodruff CA, Hsu S. Clinical manifestations of varicella-zoster virus
infection. Dermatol Clin 2002;20:267-282
- Lee BW. Review of
varicella zoster seroepidemiology in India and Southeast Asia. Trop
Med Int Health 1998;3:886-890
- Paryani SG, Arvin
AM. Intrauterine infection with varicella-zoster virus after maternal
varicella. N Engl J Med 1986;314:1542-1546
- Chaves SS, Zhang
J, Civen R, Watson BM, Carbajal T, Perella D et al. Varicella disease
among vaccinated persons: clinical and epidemiological characteristics,
1997-2005. J Infect Dis 2008;197:127-131
- Lopez AS, Guris
D, Zimmerman L, Gladden L, Moore T, Haselow DT et al. One dose of varicella
vaccine does not prevent school outbreaks- is it time for a second dose?
Pediatrics 2006;117:1070-1077
- Agampodi SB, Dharmaratne
SD, Thevanesam V, Dassanayake S, Kumarihamy P, Ratnayake A. Incidence
and effects of Varicella Zoster Virus infection on academic activities
of medical undergraduates- a five-year follow-up study from Sri Lanka.
BMC Infect Dis 2010;10:117
- Welgama U, Wickramasinghe
C, Perera J. Varicella-zoster virus infection in the Infectious Diseases
Hospital, Sri Lanka. Ceylon Med J 2003;48:119-121
- Fairley CK, Miller
E. Varicella-zoster virus epidemiology—a changing scene? J Infect Dis 1996;174:314-319
- Straus SE, Oxman
MN, Schmader KE. Varicella and Herpes Zoster. In Wolf K, Goldsmith LA,
Katz SI, Gilchrest BA, Paller AS, Leffell DJ editors. Fitzpatrick’s
Dermatology in General Medicine. 7th edition. New York: McGraw Hill;
2008. p.1885-1898
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