Burden of informal care in stroke survivors and its determinants: a prospective observational study in an Asian setting.

BACKGROUND: Informal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor's outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore. METHODS: Stroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients' likelihood of requiring informal care, hours of informal care required, and informal caregivers' Zarit's Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients' and informal caregivers' demographic characteristics, arrangement of informal care, and patients' health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities. RESULTS: Three hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit's Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden. CONCLUSIONS: Informal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden.

Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.

BACKGROUND: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. METHOD: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke. RESULTS: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. CONCLUSION: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Stroke Rehabilitation Use and Caregiver Psychosocial Health Profiles in Singapore: A Latent Profile Transition Analysis.

OBJECTIVES: To identify and describe caregiver profiles based on their psychosocial health characteristics over a 12-month period and transitions among these profiles, to determine if stroke rehabilitation use at 12 months post-stroke differed by caregiver profile transition patterns, and to investigate if caregiver profiles at 3 months post-stroke moderate the association of stroke rehabilitation use at 3 months and 12 months post-stroke after accounting for covariates. DESIGN: Latent profile transition analysis of caregiver psychosocial health with stroke rehabilitation use at 12 month post-stroke as outcome. SETTING AND PARTICIPANTS: A total of 149 stroke patient-caregiver dyads from the Singapore Stroke Study. METHODS: Cross-sectional latent profile analyses were conducted on caregiver psychosocial health indicators of burden, depression, health status, quality of relationship with patient, and social support. Changes in latent profile classification over 3 time points (baseline, 3 months, and 12 months post-stroke) were analyzed using latent transition analysis. A transition model with stroke rehabilitation use at 12 months post-stroke as the outcome was tested after accounting for covariates. RESULTS: Two distinct caregiver psychosocial health latent profiles were found across time: nondistressed and distressed. Most caregivers were classified as nondistressed and remained nondistressed over time. Distressed caregivers at baseline were 76% likely to become nondistressed at 12 month post-stroke. Regardless of profile transition patterns, nondistressed caregivers at 12 months post-stroke tended to have cared for stroke rehabilitation nonusers at 12 months post-stroke. Patient depression explained profile classification at 3 months and 12 months post-stroke. After accounting for covariates, rehabilitation users at 3 months post-stroke tended to continue using rehabilitation at 12 months post-stroke only when they had nondistressed caregivers at 3 months post-stroke. CONCLUSIONS AND IMPLICATIONS: Whether caregiver adaptation explains the associations between the latent profile transition patterns and rehabilitation use at 12 months post-stroke should be examined. Early psychosocial health assessment and sustained support should be made available to stroke caregivers to enhance their well-being and subsequent patient rehabilitation participation.

A novel hospital capacity versus clinical justification triage score (CCTS) for prioritization of spinal surgeries in the "new normal state" of the COVID-19 pandemic.

INTRODUCTION: During the Coronavirus disease 2019 outbreak, while healthcare systems and hospitals are diverting their resources to combat the pandemic, patients who require spinal surgeries continue to accumulate. The aim of this study is to describe a novel hospital capacity versus clinical justification triage score (CCTS) to prioritize patients who require surgery during the "new normal state" of the COVID-19 pandemic. METHODOLOGY: A consensus study using the Delphi technique was carried out among clinicians from the Orthopaedic Surgery, Neurosurgery, and Anaesthesia departments. Three rounds of consensus were carried out via survey and Webinar discussions. RESULTS: A 50-points score system consisting of 4 domains with 4 subdomains was formed. The CCTS were categorized into the hospital capacity, patient factors, disease severity, and surgery complexity domains. A score between 30 and 50 points indicated that the proposed operation should proceed without delay. A score of less than 20 indicates that the proposed operation should be postponed. A score between 20 and 29 indicates that the surgery falls within a grey area where further discussion should be undertaken to make a joint justification for approval of surgery. CONCLUSION: This study is a proof of concept for the novel CCTS scoring system to prioritize surgeries to meet the rapidly changing demands of the COVID-19 pandemic. It offers a simple and objective method to stratify patients who require surgery and allows these complex and difficult decisions to be unbiased and made transparently among surgeons and hospital administrators.

Dyadic approach to supervised community rehabilitation participation in an Asian setting post-stroke: exploring the role of caregiver and patient characteristics in a prospective cohort study.

OBJECTIVE: To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting. DESIGN: Prospective cohort study. SETTING: Community setting. PARTICIPANTS: We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke. OUTCOME MEASURES: SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke RESULTS: 251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor's disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver's positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068). CONCLUSION: We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics.

AIM: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore. METHODS: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. RESULTS: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. CONCLUSION: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.

BACKGROUND: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.

BACKGROUND: Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients. METHODS: A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types. RESULTS: We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%. CONCLUSIONS: The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Intradural Spinal Tumors-Review of Postoperative Outcomes Comparing Intramedullary and Extramedullary Tumors from a Single Institution's Experience.

BACKGROUND: Intradural spinal tumors are rare and can be classified into extramedullary or intramedullary. They commonly present with symptoms such as intractable back pain or neurologic deficits. We retrospectively reviewed 91 cases of intradural spinal tumors that underwent surgery in our institution from 2011 to 2016 and assessed their clinical outcomes. The majority of intradural tumors were extramedullary (89%), and the most common pathology was schwannoma (38.5%) followed by meningioma (29.7%). Comparing extramedullary versus intramedullary tumors, both groups experienced similar improvement in neurologic status post surgery (92.6% vs. 90%, P = 0.77). We achieved gross total resection in the majority of patients with both extramedullary and intramedullary tumors (65.4% vs. 70%, P = 0.91). Patients younger than 65 years (odds ratio [OR] 4.40, confidence interval [CI] 0.72-26.9, P = 0.11) and those who had complete resection of tumor (OR 2.92, CI 0.61-14.0, P = 0.18) were associated with higher odds of improved clinical outcomes, but the results were not statistically significant. The use of intraoperative neurophysiologic monitoring was not associated with improved neurologic outcomes compared with cases where it was not used (OR 0.56, CI 0.10-3.05, P = 0.50).

Cerebral hyperperfusion syndrome after superficial temporal artery-middle cerebral artery bypass for severe intracranial steno-occlusive disease: a case control study.

BACKGROUND: Intracranial stenoses carry increased risk for cerebral ischemia. We perform external carotid-internal carotid (EC-IC) artery bypass in our patients with severe stenosis of the intracranial internal carotid (ICA) or middle cerebral artery (MCA) with impaired cerebral vasodilatory reserve (CVR). OBJECTIVE: To evaluate cerebral hemodynamics and cerebral hyperperfusion syndrome (HPS) in patients who develop focal neurological deficits after EC-IC bypass surgery. METHODS: Patients with severe intracranial ICA or MCA stenosis and impaired CVR on transcranial Doppler (TCD) derived breath-holding index (BHI) were evaluated with acetazolamide-challenged technetium-99m hexamethylpropyleneamineoxime-single-photon emission computed tomography (SPECT). EC-IC bypass surgery was offered to patients with impaired CVR on SPECT. Close monitoring was performed in patients developing focal neurological deficits within 7 days of surgery. RESULTS: Of 112 patients with severe intracranial ICA/MCA stenosis, 77 (69%) showed impaired CVR and 46 (41%) underwent EC-IC bypass. Transient neurological deficits within 7 days of surgery developed in 8 (17%). HPS was confirmed by CT perfusion and/or SPECT in 7 cases. A strong correlation was observed between HPS and preoperative TCD-BHI values (0%, 6.3%, and 41% in patients with BHI 0.3-0.69, 0-0.3 and <0, respectively; P = .012). HPS patients showed more than a 50% increase in MCA flow velocity on TCD (compared with preoperative values) on the operated side (63.3% vs 3.3% on control side, P < .001). Meticulous control of blood pressure and hydration led to rapid and complete resolution of neurological deficits in all cases. CONCLUSION: Symptomatic cerebral HPS is common in the early postoperative period after EC-IC bypass surgery. Early diagnosis and appropriate management might prevent the complications of this syndrome.

Autoclaved autologous bone graft for orbital reconstruction for recurrent temporal bone orbital osteosarcoma.

Post-tumor excision and reconstruction of the craniofacial region is a complex and technically demanding process due to its proximity to numerous vital structures and irregularly shaped bony tissue. As such, novel methods are needed when reconstruction of irregularly shaped structures is necessary. Autoclaving of autologous bone grafts is an established practice in orthopedic and neurosurgical practice, but has only been described twice previously for orbital reconstruction. We performed grafting of an autoclaved autologous bone segment as part of surgery on a 30-year-old man to treat his recurrent temporal osteosarcoma with orbital involvement, which is rare. In addition, we went on to highlight key differences between bone autoclaving and pasteurization, an alternative heat treatment technique, for orbital reconstruction post-tumor excision. Although he suffered a second recurrence 8 months later, there was no evidence of recurrence in the autoclaved bone. To treat his second recurrence, he subsequently underwent a modified eyelid-conjunctiva sparing orbital exenteration, also an uncommonly performed procedure. Also, we subsequently examined the novel technique of a lid-sparing and conjunctiva-sparing orbital exenteration and its benefits. He continues to remain under follow-up.

Changes in cerebral hemodynamic and cognitive parameters after external carotid-internal carotid bypass surgery in patients with severe steno-occlusive disease: a pilot study.

BACKGROUND: The direct impact of external carotid-internal carotid (EC-IC) bypass surgery on cognition of patients with severe steno-occlusive disease of internal carotid (ICA) or middle cerebral artery (MCA) is unknown. In this pilot study, we evaluated changes in cerebral hemodynamic and cognition in these patients. METHODS: Patients with severe steno-occlusive disease and impaired cerebral vasodilatory reserve (CVR) with transcranial Doppler (TCD) breath holding index (BHI) and acetazolamide-challenged HMPAO-Single Photon Emission Tomographic (SPECT) imaging were offered EC-IC bypass surgery. CVR and cognitive performance using a formal neuropsychological battery were evaluated before and 3-6 months after surgery. RESULTS: Nine patients and 9 matched controls were recruited. Significant CVR improvement from TCD-BHI [median 0 (Inter-quartile range IQR 0.45) to 1.10 (IQR 0.73), p<0.001] and SPECT (p<0.001) was observed in surgery patients. EC-IC bypass patients had significant improvement in verbal memory (p=0.037) and executive function (p=0.043) and a trend of improvement in visual memory (p=0.052) compared to controls. CONCLUSION: EC-IC bypass surgery in carefully selected patients could improve cerebral hemodynamics and verbal memory and executive function.

Role of Multimodal Evaluation of Cerebral Hemodynamics in Selecting Patients with Symptomatic Carotid or Middle Cerebral Artery Steno-occlusive Disease for Revascularization.

BACKGROUND: The circle of Willis provides collateral pathways to perfuse the affected vascular territories in patients with severe stenoocclusive disease of major arteries. The collateral perfusion may become insufficient in certain physiological circumstances due to failed vasodilatory reserve and intracranial steal phenomenon, so-called 'Reversed-Robinhood syndrome'. We evaluated cerebral hemodynamics and vasodilatory reserve in patients with symptomatic distal internal carotid (ICA) or middle cerebral artery (MCA) severe steno-occlusive disease. METHODS: Diagnostic transcranial Doppler (TCD) and TCD-monitoring with voluntary breath-holding according to a standard scanning protocol were performed in patients with severe ICA or MCA steno-occlusive disease. The steal phenomenon was detected as transient, spontaneous, or vasodilatory stimuli-induced velocity reductions in affected arteries at the time of velocity increase in normal vessels. Patients with exhausted vasomotor reactivity and intracranial steal phenomenon during breath-holding were further evaluated by (99)technetium(m)-hexamethyl propylene amine oxime single photon emission computed tomography (HMPAO-SPECT) with acetazolamide challenge. RESULTS: Sixteen patients (age 27-74 years, 11 men) fulfilled our TCD criteria for exhausted vasomotor reactivity and intracranial steal phenomenon during the standard vasomotor testing by breath holding. Acetazolamide-challenged HMPAO-SPECT demonstrated significant hypoperfusion in 12 patients in affected arterial territories, suggestive of failed vasodilatory reserve. A breath-holding index of ≤0.3 on TCD was associated with an abnormal HMPAO-SPECT with acetazolamide challenge. TCD findings of a breath holding index of ≤0.3 and intracranial steal during the procedure were determinants of a significant abnormality on HMPAO-SPECT with acetazolamide challenge. CONCLUSION: Multimodal evaluation of cerebral hemodynamics in symptomatic patients with severe steno-occlusive disease of the ICA or MCA is helpful in the identification and quantification of failed vasodilatory reserve. This approach may be useful in selecting patients for possible revascularization procedures.

Cranioplasty after trephination using a novel biodegradable burr hole cover: technical case report.

OBJECTIVE AND IMPORTANCE: We have developed novel biodegradable polymer implants by using the rapid prototyping technology fused deposition modeling. Early results of a clinical pilot study for cranioplasty are presented. CLINICAL PRESENTATION: Five patients with the diagnosis of chronic subdural hematoma were included in the study. After trephination and evacuation of the subdural hematoma, burr holes (diameter, 14 mm) were closed using a biodegradable implant made of polycaprolactone. Implants were computer designed with an upper rim diameter of 16 mm and a 14 mm body diameter with a fully interconnected, honeycomb-like architecture of 400 to 600 microm in pore size. INTERVENTION: Postoperative computed tomographic scans indicated that the plugs were stably anchored in the osseous host environment with no fluid collection detectable. The postoperative course was uneventful, and patients were discharged after 5 days. Follow-up scans after 3, 6, and 12 months showed that the implants were well integrated in the surrounding calvarial bone with new bone filling the porous space. CONCLUSION: These novel polymer scaffolds made of the slow-degrading material polycaprolactone represent a suitable implant for closure of post-trephination defects.

Identification of mature nocistatin and nociceptin in human brain and cerebrospinal fluid by mass spectrometry combined with affinity chromatography and HPLC.

Nocistatin (NST) and nociceptin/orphanin FQ (NCP) are two important bio-peptides derived from the precursor protein prepronociceptin (ppNCP), involved in several central nervous system (CNS) functions including pain transmission. Since the actual form of human NST in CNS is not fully characterized, we studied the structure of NST from human brain tissue and cerebrospinal fluid (CSF) samples. NST and NCP were isolated from human brain and CSF samples by affinity chromatography combined with HPLC. Mass spectrometry was used for the identification and characterization of the peptides. The total NST immunoreactivity was detected as 11.5+/-2.3 pmol/g tissue for the brain and 0.44 pmol/ml for the pooled CSF sample after the HPLC purification by radioimmunoassay. The presence of two different forms of mature nocistatin (NST-17 and NST-30) and a possible N-terminal methionine cleaved NST-29 were confirmed by both radioimmunoassay and mass spectrometry. Affinity chromatography, HPLC and mass spectrometry methods used in this study were highly sensitive and suitable for identification of actual chemical structures and quantification of very small amounts of peptides in biological samples. The present findings may help further for search for new treatment of neuropathic pain, which is often poorly managed by current therapies.