Photoprotection habits, attitudes and knowledge among school communities in the Costa del sol (Spain).

BACKGROUND: Scholar photoprotection campaigns are among the most effective strategies for preventing skin cancer. Analysis of the target population constitutes a valuable starting point for the implementation of primary prevention strategies. Our aim is to study photoprotection habits, attitudes and knowledge among a Spanish school community. METHODS: Descriptive cross-sectional study targeting schoolchildren, parents and teachers at 20 schools in the area of the Costa del Sol Health Agency in southern Spain. Two population-specific, validated questionnaires were used: the CHRESI (for children aged 0-10 years) and CHACES Questionnaire(for adults and adolescents aged > 11 years). We collected demographic data, skin colour, skin phototype, sunburn episodes, sun exposure and photoprotection practices, attitudes and knowledge. RESULTS: 1728 questionnaires were analyzed (22% parents, 14.5% teachers, 44.8% adolescents and 18.6% children). The average ages were 8 years (children), 16 years (adolescents), 39 years (teachers) and 42 years (parents). Globally, the predominant features were: male sex (52%), Spanish nationality (92%) and phototypes II-III (61%). Children, followed by adolescents, reported the highest exposure to the sun, both in frequency and in duration. Adolescents had the higher rate of sunburn (75%), followed by parents/teachers (54.1%) and children (44.1%). Children and their parents were the most likely to adopt photoprotection measures, while adolescents presented more risky attitudes. Knowledge regarding photoprotection was acceptable (6.9/10). CONCLUSIONS: This study highlights the need to improve photoprotection knowledge, habits and attitudes among our target population. Scholars, parents and teachers in our area should be addressed in campaigns to promote healthy sun exposure habits, thus reducing skin cancer-related morbidity and mortality in this region.

Usefulness of High-Frequency Ultrasound in the Classification of Histologic Subtypes of Primary Basal Cell Carcinoma. / Utilidad de la ecografía cutánea en la clasificación de subtipos de los carcinomas basocelulares primarios.

INTRODUCTION: Incisional biopsy may not always provide a correct classification of histologic subtypes of basal cell carcinoma (BCC). High-frequency ultrasound (HFUS) imaging of the skin is useful for the diagnosis and management of this tumor. OBJECTIVES: The main aim of this study was to compare the diagnostic value of HFUS compared with punch biopsy for the correct classification of histologic subtypes of primary BCC. We also analyzed the influence of tumor size and histologic subtype (single subtype vs. mixed) on the diagnostic yield of HFUS and punch biopsy. METHODS: Retrospective observational study of primary BCCs treated by the Dermatology Department of Hospital Costa del Sol in Marbella, Spain, between october 2013 and may 2014. Surgical excision was preceded by HFUS imaging (Dermascan C©, 20-MHz linear probe) and a punch biopsy in all cases. We compared the overall diagnostic yield and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of HFUS and punch biopsy against the gold standard (excisional biopsy with serial sections) for overall and subgroup results. RESULTS: We studied 156 cases. The overall diagnostic yield was 73.7% for HFUS (sensitivity, 74.5%; specificity, 73%) and 79.9% for punch biopsy (sensitivity, 76%; specificity, 82%). In the subgroup analyses, HFUS had a PPV of 93.3% for superficial BCC (vs. 92% for punch biopsy). In the analysis by tumor size, HFUS achieved an overall diagnostic yield of 70.4% for tumors measuring 40mm2 or less and 77.3% for larger tumors; the NPV was 82% in both size groups. Punch biopsy performed better in the diagnosis of small lesions (overall diagnostic yield of 86.4% for lesions ≤40mm2 vs. 72.6% for lesions >40mm2). CONCLUSIONS: HFUS imaging was particularly useful for ruling out infiltrating BCCs, diagnosing simple, superficial BCCs, and correctly classifying BCCs larger than 40mm2.

Usefulness of the Paramedian Forehead Flap in Nasal Reconstructive Surgery: A Retrospective Series of 41 Patients.

INTRODUCTION: Surgical reconstruction of the external nose, a common site for nonmelanoma skin cancer, is difficult. Oncologic surgery often leaves large skin defects, occasionally involving the underlying cartilage and nasal mucosa. We describe our experience with the paramedian forehead flap for reconstruction of nasal defects. METHODOLOGY: We performed a retrospective study of consecutive patients in whom a paramedian forehead flap was used to repair surgical defects of the nose between July 2004 and March 2011. We describe the clinical and epidemiologic characteristics, the surgical technique, complications, secondary procedures, and cosmetic results. RESULTS: The series comprised 41 patients with a mean (SD) age of 67 (10.36) years. The majority were men (male to female ratio, 2.4:1). Associated risk factors included diabetes in 27% of patients, cardiovascular risk factors in 49%, and smoking or drinking in 19.5%. The tissue defects were distal in 80% of cases and nonpenetrating in 78%. The mean (SD) diameter was 21.6 (6.78) mm. Early postoperative complications occurred in 14.6% of patients and late complications in 31.7% (trap door effect in 22% and hair transposition in 19%), with a need for Readjustment in a second operation was needed in 19.5% of patients. The cosmetic results were considered acceptable or excellent in 90.2% of cases. DISCUSSION: The paramedian forehead flap is versatile and provides skin of a similar color and texture to that of the external nose. It has a reliable vascular pedicle that guarantees the viability not only of the flap but also of other tissues that may be used in combination, such as chondromucosal or chondrocutaneous grafts. Revision of the technique in a second operation may sometimes be required to achieve an optimal result.

Axillary Silicone Granulomas in Patients With Melanoma. / Siliconomas axilares en pacientes con melanoma.

Subcutaneous lesions may be detected during follow-up of patients with melanoma. The main entities that should be contemplated in the differential diagnosis in such cases are in-transit and regional lymph node metastases. We describe 2 cases of women with breast implants who developed palpable subcutaneous lesions in the axillary region during follow-up of melanoma. In both cases, the ultrasound study showed diffuse hyperechoic signals forming the characteristic snowstorm sign in the subcutaneous tissue. Ultrasound proved to be a key diagnostic tool for ruling out melanoma-related disease, such as in-transit metastases and regional lymph node metastases.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer.

INTRODUCTION: The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published. OBJECTIVES: To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment. MATERIAL AND METHODS: A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages. RESULTS: Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%. CONCLUSIONS: The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

[Interventional ultrasound]. / Ecografía intervencionista.

High-frequency ultrasound has become increasingly used in dermatology. This technique is accessible, non-invasive, and rapid and provides information in real time. Consequently, it has become of great diagnostic value in dermatology. However, high-frequency ultrasound also has a promising future as a complementary technique in interventional diagnostic procedures, even though its application in this field has been little studied by dermatologists.

Clinical and pathological features of melanoma in europeans living on the Western costa del sol in southern Spain.

OBJECTIVE: To compare clinical and pathological features of melanoma in Spanish patients with those of patients from Central or Northern Europe living in the health district of Costa del Sol Occidental in southern Spain. METHODS: We conducted a descriptive cross-sectional study of all cases of primary cutaneous melanoma histologically confirmed between 2005 and 2011 in the health care district covered by Hospital Costa del Sol in Marbella. We analyzed clinical and pathological features and performed a descriptive analysis of the 2 populations, in addition to univariate analysis with place of birth (Spain vs Central or Northern Europe) as the independent variable. RESULTS: Compared with Spaniards, patients from Central or Northern Europe were 10 years older at the time of melanoma diagnosis (66.2 vs 56.2 years, P<.001), had lighter skin (types I or II) (90.3% vs 67.1%, P<.001), and greater recreational sun exposure (93.7% vs 66.2%, P<.001). In addition, multiple melanomas (17.6% vs 4.4%, P=.001), nonmelanoma skin cancer (47.2% vs 15.7%, P<.001), and a family history of melanoma (9.5% vs 2.3%, P=.01) were more common in these patients. Central and Northern Europeans also had a higher overall frequency of melanoma on the trunk (46.3% vs 38.7%) and melanoma in situ (54.7% vs 41.8%, P=.03). CONCLUSION: Differences in melanoma presentation between Spanish patients and patients from Central or Northern Europe appear to be linked to phenotypic and lifestyle factors. A better understanding of these differences will help to tailor melanoma prevention and follow-up programs for multicultural populations, such as those on Spain's Costa del Sol.

Positive impact of Distintivo Soludable on implementation of sun protection policies and practices in schools of Andalusia, Spain.

The incidence of skin cancer is increasing worldwide even though its main risk factor is preventable. This study evaluated the impact of the Distintivo Soludable pilot intervention on implementation of photoprotection policies and practices in preschool and primary schools in Andalusia, Spain. We completed two rounds of a Sun Protection Policies and Practices Survey (SPPPS) nine months apart. At baseline, 67 Andalusian schools earned a median score of 3/12 points (range 0-8; IQR: 2). Ten schools involved in Distintivo Soludable intervention group significantly increased their scores from 4 to 7.5/12 points (p = 0.014). We also detected a modest positive effect in 57 control group schools, an increase from 2 to 3 points (p = 0.002). This pilot study demonstrated that the main achievement of the Distintivo Soludable intervention was implementation of organizational policies regarding sun protection, an essential starting point for establishing positive attitudes toward sun protection in school communities.

Preoperative 15-MHz ultrasound assessment of tumor thickness in malignant melanoma.

BACKGROUND: Tumor thickness is of great importance in the management of cutaneous malignant melanoma (MM): this variable not only affects prognosis but is also a key factor in planning surgical margins and selecting candidates for sentinel node biopsy. Breslow depth is the standard histologic measure of thickness, but technological advances have provided imaging techniques such as cutaneous ultrasound that can potentially assess tumor thickness and enable prompt initiation of definitive treatment. OBJECTIVES: a) To evaluate the utility of ultrasound assessment of tumor thickness in MM, and b) to analyze histologic variables that affect ultrasound assessments of thickness. MATERIALS AND METHODS: Retrospective study of a consecutive series of 79 primary cutaneous MMs in which tumor thickness had been assessed by 15-MHz ultrasound before surgery. We gathered data from histology reports, studying Breslow depth and the presence of ulceration, regression, inflammatory infiltrate, and associated nevi. Correlation coefficients were calculated to evaluate the strength of association between Breslow depth and thickness assessed by ultrasound. We also calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound measurement in the diagnosis of MMs more than 1mm thick. Associations between histologic variables and the overestimation of thickness by ultrasound were also analyzed. RESULTS: The 79 primary MMs studied had a mean (SD) Breslow depth of 0.8 (1.4) mm. There was moderate correlation and agreement between Breslow depth and the ultrasound assessment of thickness (Pearson correlation coefficient, 0.678; intraclass correlation coefficient, 0.78). The tendency of ultrasound to overestimate thickness was nonsignificantly related to the presence of a moderate to intense infiltrate and associated nevi (P>.05). The sensitivity of ultrasound for the diagnosis of MM over 1mm thick was 82%; specificity was 80%, and positive and negative predictive values were 54% and 94%, respectively. CONCLUSIONS: Ultrasound imaging quite correctly identifies thin MMs and can be useful for planning adequate surgical margins; however, there are limitations on its usefulness in the diagnosis of thick MMs. Additional studies are required to confirm whether certain histologic characteristics, such as the presence of a moderate to intense inflammatory infiltrate or associated nevi can lead to overestimation of thickness by ultrasound, limiting the clinical utility of this imaging technique in MM management.

Sun exposure practices, attitudes and knowledge among students and teachers at a University School of Health Sciences in Ecuador.

Skin cancer incidence is increasing worldwide. Late adolescence and young adulthood are fundamental stages of life to acquire good sun exposure practices, regarding both personal involvement in skin cancer prevention and being a role model for others, especially in a health education environment. This descriptive cross-sectional study is based on the validated CHACES questionnaire to study sun exposure and photoprotection behavior among students and teachers at the School of Health Sciences in the National University of Chimborazo, Riobamba (Ecuador). University members (814 students (89.8 %) and 93 teachers (10.2 %)) were studied, with a predominance of females and light-skin phototypes in both groups. Similar results were obtained regarding sun exposure, with higher recreative exposure in the teachers' group and higher occupational exposure in students. However, students significantly showed lower avoiding midday sun (41.9 % vs 60.9 %), and lower use of sunglasses (10.1 % vs. 41.6 %). Attitudes towards the sun and photoprotection knowledge issues were also equivalent between students and teachers (6.1/10 vs 6.2/10). Students' sunburn rate last year reaches 88.4 % and 52.7 % in teachers (p < 0.001). Using a multivariable logistic regression model, we identified risk factors associated with a greater risk of sunburn in our population. This study highlights areas to be improved regarding knowledge, attitudes and, especially, practices of photoprotection, among students and teachers at the University of Chimborazo. These results point out that awareness-raising campaigns should be implemented to reduce sunburns, morbidity and mortality of skin cancer in this environment.

Comparative epidemiological study of non-melanoma skin cancer between Spanish and north and central European residents on the Costa del Sol.

BACKGROUND: Non-melanoma skin cancer (NMSC) is the most common tumour in white people. The progressive increase of these malignancies in such populations as those found in Europe represents an important public health concern which it is presumed will have a great impact on healthcare costs. However, the lack of comparable epidemiological information between countries hinders the development of a common health policy. OBJECTIVES: The aim of this study was to describe the epidemiological, clinical and therapeutic aspects of NMSC in the public health area of the western part of the Costa del Sol, in southern Spain, and study the differences between the Spanish (S) population and that originally between the north and centre of Europe (N). METHODS: We undertook a retrospective analysis of all patients with histologically confirmed tumours in both populations during the period 1 January 2006 to 30 June 2009. RESULTS: In comparison with the Spanish, the patients from the north and centre of Europe were more likely to have phototype I/II (S: 56.9%; N: 85.8%), recreational photoexposure (S: 48.4%; N: 83.8%), multiple carcinomas (S: 16.8%; N: 28.2%) and more carcinomas per patient (S: 1.7 ± 1.3; N: 2.3 ± 2.3). The tumours were more often located on the trunk and limbs (S: 28.3%; N: 50.2%) with a predominance of the less aggressive histological types (S: 34.7%; N: 42.6%) and non-invasive treatments in patients from the north and centre of Europe (S: 25.6%; N: 35.3%) when compared with the Spanish population. CONCLUSION: Persons from the north and centre of Europe living on the Costa del Sol present a different pattern of NMSC to the local Spanish population and usually require a less invasive therapeutic approach. These findings highlight the need to define prevention and treatment policies for NMSC according to the characteristics of each particular population. This would help reduce not only the frequency but also the associated morbimortality of this disease, particularly in high-risk populations.

[Cost analysis of Mohs micrographic surgery in high-risk facial basal cell carcinoma]. / Análisis de costes de la cirugía micrográfica de Mohs en el carcinoma basocelular facial de alto riesgo.

INTRODUCTION: Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost. OBJECTIVES: To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS. MATERIAL AND METHODS: Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence. RESULTS: Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534). CONCLUSIONS: MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

Cost Analysis of Mohs Micrographic Surgery in High-Risk Facial Basal Cell Carcinoma. / Análisis de costes de la cirugía micrográfica de Mohs en el carcinoma basocelular facial de alto riesgo.

INTRODUCTION: Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost. OBJECTIVES: To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS. MATERIAL AND METHODS: Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence. RESULTS: Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534). CONCLUSIONS: MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

Validation of a Questionnaire Designed to Study Knowledge, Attitudes, and Habits Related to Sun Exposure Among Young Adults: The CHACES Questionnaire. / Validación de un cuestionario para el estudio sobre hábitos, actitudes y conocimientos en fotoprotección en la población adultojuvenil: «cuestionario CHACES¼.

Skin cancer prevention campaigns in schools have been shown to be both effective and cost-effective. The success of such programs depends on the use of an appropriate design informed by a prior survey of the target population (pupils, teachers, and parents). There are, however, very few validated Spanish-language questionnaires designed to study the habits and knowledge of this population with respect to sun exposure in childhood and none designed for use with a young adult population. OBJECTIVES: To construct and validate a questionnaire designed to explore sun exposure behaviors in a young adult population. METHODOLOGY: Two questionnaires were developed, one for adults (18+) and the other for young adults (11-17); both included demographic information, skin color, Fitzpatrick skin type, and history of sunburn as well as questions on knowledge, attitudes and practices related to sun exposure. The content was then piloted and its validity analyzed. The subsequent validation study was divided into 2 phases as follows: 1) analysis of the validity and internal consistency of the items in a cross-sectional study of 1,482 adults and adolescents, using exploratory factor analysis to test construct validity and Cronbach α to measure internal consistency; and 2) evaluation of test-retest reliability in 39 individuals. RESULTS: The pilot study demonstrated the content validity of both questionnaires. Principal component analysis revealed that 2 components in each of the dimensions studied accounted for over 50% of the variance. A good correlation was found between the items studied. Validity was demonstrated in the first phase of the analysis with a Cronbach α of between 0.45 and 0.8 for all components except knowledge (0.335). In the second phase, test-retest reliability was demonstrated (absolute agreement>60%). CONCLUSIONS: The psychometric properties of the questionnaire make it a valid and reliable tool for the study of knowledge, attitudes, and habits with respect to sun exposure in the young adult school population.

Creation Of The «Soludable¼ Sun Protection Accreditation Program For Schools. / Creación del distintivo Soludable: un modelo de certificación en fotoprotección para centros escolares.

INTRODUCTION: Sun exposure during childhood is the main risk factor for skin cancer in later life. School-based sun protection policies and practices have proven to be the most effective and cost-effective strategies for preventing skin cancer. OBJECTIVE: To develop a sun protection accreditation program known as «Soludable¼ (a play on the Spanish words sol [sun] and saludable [healthy]) to objectively identify schools that actively promote sun protection behaviors among students. METHODS: The consensus method used was a 2-round Delphi technique with input from a panel of experts. We then calculated the median scores for the importance and feasibility of each of the recommendations proposed and the level of complexity assigned to each recommendation by counting the percentage of experts who chose each difficulty category. RESULTS: The resulting accreditation model consists of 14 recommendations with corresponding evaluation criteria divided into 7 domains: 1) organizational leadership (5 recommendations), 2) effective communication (2 recommendations), 3) structural elements (2 recommendations), 4) training of professionals (1 recommendation), 5) school curriculum (1 recommendation), 6) behavioral models (2 recommendations), and 7) student habits (1 recommendation). A high level of agreement among experts was observed for all recommendations, in terms of both their perceived importance and feasibility and their categorization by levels of complexity. CONCLUSIONS: This is the first sun protection accreditation program developed for Spanish schools. Studies are needed to evaluate how this program is received and how it affects students' sun protection behaviors.

Responsiveness of the Spanish Version of the "Skin Cancer Index".

Background. Skin Cancer Index (SCI) is a specific questionnaire measuring health related quality of life (HRQL) in patients with cervicofacial non-melanoma skin cancer (CFNMSC). The original scale has recently been adapted and validated into Spanish. Objectives. Evaluate the responsiveness of the Spanish version of SCI. Methods. Patients with CFNMSC candidate for surgical treatment were administered the questionnaire at time of diagnostic (t0), 7 days after surgery (t1), and 5 months after surgery (t2). The scale and subscales scores (C1: social/appearance, C2: emotional) were then evaluated. Differences between t0-t1, t1-t2, and t0-t2 were determined and a gender-and-age segmented analysis was performed. Results. 88 patients, 54.8% male, mean age 62.5 years, completed the study. Differences between t0-t1 and t1-t2 scores were statistically significant (p < 0.05). The lowest values were found at time of diagnosis and postsurgery. Women and patients under 65 years showed the lowest values at the three times. Limitations. Concrete geographic and cultural area. Clinical and histological variables are not analysed. Conclusions. Our results confirm responsiveness of the Spanish version of the SCI. Further development of the instrument in Spanish-speaking countries and populations will make it possible to extend worldwide research and knowledge horizons on skin cancer.