Aprepitant para la prevención de la nausea y el vomito postoperatorio, una revisión sistemática de la literatura.

Objetivo: Comparar la efectividad y seguridad del uso de aprepitant contra placebo y otros antieméticos para la prevención de nausea y vomito posoperatorio (NVPO). Métodos: Se realizo una revisión sistemática incluyendo experimentos clínicos controlados realizados en pacientes adultos sometidos a cirugías bajo anestesia general. Se hizo una búsqueda en bases de datos (PUBMED, EMBASE, LILACS) y con los estudios pertinentes, se complementó con una nueva búsqueda en bola de nieve y en fuentes de literatura gris Resultados: Se incluyeron seis estudios, dos considerados de bajo riesgo, uno de riesgo incierto y tres de alto riesgo, comparando aprepitant contra placebo y contra otros antieméticos, encontrando el aprepitant tiene diferencia significativa con respecto a placebo como profilaxis de nausea y vomito postoperatorio (NVPO) con (RR 0,48; IC 95%, 0,37 a 0,64 con una p < 0.001), no hay diferencia significativa comparando su efectividad contra ondansetron (RR: 0.90, IC 95%, 0.75 a 1.07 con una p = 0.24). Al igual no se encontró diferencias significativas de estancia en unidad de cuidado post anestésicos (UCPA) (RR: 6.5, IC 95%: -21.54 a 8.54 con una p = 0.40) ni en efectos adversos cuando se compara contra otros antieméticos de (RR: 0.95 con IC 95%: 0.86 a 1.04con una p de 0.67) Conclusiones: El aprepitant es una opción atractiva para su uso como profilaxis de NVPO comprobada eficacia contra placebo, aunque no ha demostrado superioridad ante los otros grupos de fármacos y con un perfil de seguridad similar a los otros medicamentos antieméticos.

COMP1205 Student Presentations M-P

Tuesday 13th May Building 34 Room 3001, 16.15-17.45 Elena & Rikki/Jian Presenting: Groups: M, N, O, P Marking Groups: Q, R, S, T Schedule and Topics 16.15-16.20: Introduction and protocol for the session 16.20 Group M: Serious games – gaming as a driver for applications online 16.40 Group N: Open Education OERs 17.00 Group O: Big Data – the big picture 17.20 Group P: Rights and equality in the workplace 17.40-18.00: Wash-up: feedback session for presentation groups

Estudio Costo-Efectividad de Lidocaína tópica como adyuvante a Pregabalina y Gabapentina en dolor neuropático periférico en una I.P.S de Bogotá 2011.

Introducción: el dolor neuropático es una patología de considerable prevalencia e impacto socio-económico en la población latinoamericana, la evidencia clínica sugiere que los ligandos de canales de calcio y el parche de Lidocaína pueden tratar exitosamente el dolor neuropático periférico y localizado. Metodología: se realizo una evaluación económica tipo costo-efectividad, observacional y retrospectiva con datos extraídos de las historias clínicas de pacientes atendidos en la clínica de dolor de la IPS. La variable primaria de efectividad fue la mejoría del dolor medida mediante escala visual análoga. Resultados: se estudiaron 94 pacientes tratados con: Gabapentina (G) 21, Pregabalina (P) 24, Gabapentina+ lidocaína (G/P) 24, Pregabalina + Lidocaína (P/L) 25, los costos asociados al tratamiento son los siguientes COP$114.070.835, COP$105.855.920, COP$88.717.481 COP$89.854.712 respectivamente, el número de pacientes con mejoría significativa de dolor fue: 8,10,9 y 21 pacientes respectivamente. El ICER de G/L con respecto a G fue: COP$ -25.353.354. El ICER de P/L con respecto a P fue: COP$ -1.454.655. Conclusiones: la adición del parche de lidocaína a la terapia regular con P/L represento una disminución de consumo de recursos en salud como uso de medicamentos co-analgésicos, analgésicos de rescate y fármacos para controlar reacciones adversas, de la misma forma que consultas a profesionales de la salud. Cada paciente manejado con P/L representa un ahorro de COP $1.454.655 al contrario si se manejase con el anticonvulsivante de manera exclusiva, en el caso de G/L este ahorro es de COP $ 25.353.354 frente a G sola.

Morbilidad laboral en el sector agrícola en trabajadores afiliados a una administradora de riesgos laborales (ARL) de Colombia, durante el periodo 2011-2012.

Este estudio muestra la prevalencia por enfermedad laboral de un grupo de trabajadores afiliados a una ARL en Colombia. Compara la morbilidad laboral entre dos grupo de trabajadores expuestos y no expuestos al trabajo agrícola y al interior del grupo de trabajadores agrícolas agrupados en las actividades de corte de caña, cultivo de banano y flores. Se realizó un estudio descriptivo de tipo transversal durante el periodo 2011-2012, mediante la revisión de una base de datos de morbilidad laboral. Se realizó un análisis uni-variado y Bi-variado y se comparó la morbilidad con datos sociodemográficos, grupos de trabajadores agrícolas y no agrícolas, y actividad productiva del sector agrícola. Se revisaron 3129 diagnósticos de enfermedad profesional durante el periodo de estudio, 433 diagnósticos fueron trabajadores agrícolas y 2696 pertenecieron a otros grupos de trabajadores. Los desórdenes Osteomusculares fueron los diagnósticos más prevalentes en el grupo Agro 92% y No Agro 86% y en las actividades de corte de caña, cultivo de banano y flores. Entre el grupo Agrícola y no agrícola se encontraron diferencias significativas en los siguientes diagnósticos: Síndrome del túnel del carpo, Síndrome de manguito rotador, Otras sinovitis y tenosinovitis, Lumbago no Especificado, Hipoacusia Neurosensorial Bilateral y epicondilitis lateral; de igual manera se encontraron diferencias entre las actividades de corte de caña y cultivo de banano y flores en los diagnósticos de: Epicondilitis, Sinovitis, Síndrome del túnel del Carpo y Trastorno lumbar. El factor de riesgo más prevalente en el grupo agrícola fue el Ergonómico con el 92.8% de los casos

Impacto funcional con el uso de clavo telescopico tipo Fassier Duval en pacientes con osteogénesis imperfecta

Introducción: la osteogénesis es una patología de origen genético caracterizada por fragilidad ósea, en su curso natural los pacientes que la padecen se enfrentan a múltiples fracturas y múltiples intervenciones quirúrgicas, este tipo de pacientes por ser de alto riesgo necesitan técnicas quirúrgicas que aumenten el tiempo entre cada intervención y que demuestren un mayor impacto en el estado funcional. Objetivo: Determinar el impacto en el estado funcional de los pacientes con osteogénesis imperfecta llevados a tratamiento quirúrgico con clavos telescopados tipo Fassier Duval. Diseño: Estudio descriptivo prospectivo en el que se incluyeron 8 pacientes con diagnóstico de osteogénesis imperfecta, llevados a tratamiento quirúrgico con clavos telescopados tipo Fassier Duval desde el 2009 al 2013 a los cuales se les realizó seguimiento menor de 1 año del post operatorio. Resultados: La respuesta encontrada fue satisfactoria en la mayoría de los pacientes analizados 6 de 8, con cercanía a un estado funcional normal; un riesgo de caída bajo, incorporación y deambulación adecuada y una valoración funcional motora gruesa con valores cercanos al 100% identificando un buen nivel de independencia funcional. Se pudo demostrar que existieron cambios en los valores de la escala y que estos fueron estadísticamente significativos con p=0,028 indicando que el aumento dichos valores en el posoperatorio están relacionados con el procedimiento quirúrgico al utilizado en este grupo de pacientes. Conclusión: El tratamiento quirúrgico con el clavo telescopado de Fassier Duval en nuestra experiencia demostró tener una mejoría en el estado funcional de los pacientes del presente estudio, por lo tanto se sugiere la posibilidad de implementar su uso según este indicado con el fin de obtener un mejor resultado quirúrgico y funcional. Palabras clave: Osteogénesis Imperfecta, Clavo de Fassier Duval, Valoración Funcional Motora

Desenvolupament de mètodes de preconcentració emprant membranes líquides suportades i extracció en fase sòlida per a la determinació de l'herbicida glifosat i el seu metabòlit AMPA en aigües naturals

El glifosat, N-(fosfonometil) glicina, és un dels herbicides més utilitzats arreu del món a causa de la seva baixa toxicitat i al seu ampli espectre d'aplicació. A conseqüència del gran ús que se'n fa, és necessari monitoritzar aquest compost i el seu principal metabòlit, l'àcid aminometilfosfònic (AMPA), en el medi ambient. S'han descrit diversos mètodes instrumentals basats en cromatografia de gasos (GC) i de líquids (HPLC), sent aquesta darrera l'opció més favorable a causa del caràcter polar dels anàlits. Per assolir nivells de concentració baixos cal, però, la preconcentració dels anàlits. En aquest treball s'estudien diferents alternatives amb aquest objectiu. S'ha avaluat la tècnica de membrana líquida suportada (SLM) on la membrana consisteix en una dissolució orgànica, que conté un transportador (en el nostre cas, un bescanviador d'anions comercial, Aliquat 336), que impregna un suport polimèric microporós que se situa entre dues solucions aquoses: la de càrrega, que conté els anàlits inicialment, i la receptora, on es retenen els anàlits després del seu transport a través de la membrana. Les condicions d'extracció més adequades s'obtenen treballant en medi bàsic amb NaOH on els anàlits estan en forma aniònica i les majors recuperacions s'obtenen amb HCl 0,1 M o NaCl 0,5 M, la qual cosa indica que l'ió clorur és la força impulsora del transport. Un cop dissenyat el sistema, es duen a terme experiments de preconcentració amb dues geometries diferents: un sistema de membrana laminar (LSLM) on recircula la fase receptora i un sistema de fibra buida (HFSLM). Els millors resultats s'obtenen amb el mòdul de fibra buida, amb factors de concentració de 25 i 3 per a glifosat i AMPA, respectivament, fent recircular durant 24 hores 100 ml de solució de càrrega i 4 ml de solució receptora. També s'aplica una tècnica més selectiva, la cromatografia d'afinitat amb ió metàl·lic immobilitzat (IMAC), basada en la interacció entre els anàlits i un metall immobilitzat en una resina a través d'un grup funcional d'aquesta. En aquest estudi s'immobilitza pal·ladi al grup funcional 8-hidroxiquinoleïna de la resina amb matriu acrílica Spheron Oxine 1000 i s'avalua per a l'extracció i preconcentració de glifosat i AMPA. Per a ambdós anàlits l'adsorció és del 100 % i les recuperacions són superiors al 80 % i al 60 % per a glifosat i AMPA, respectivament, utilitzant HCl 0,1 M + NaCl 1 M com a eluent. Aquests resultats es comparen amb els obtinguts amb dues resines més, també carregades amb pal·ladi: Iontosorb Oxin 100, que té el mateix grup funcional però matriu de cel·lulosa, i Spheron Thiol 1000, on el grup funcional és un tiol i la matriu també és acrílica. Per al glifosat els resultats són similars amb totes les resines, però per a l'AMPA la resina Spheron Thiol és la única que proporciona recuperacions superiors al 93 %. Finalment, una altra opció estudiada és l'acoblament de dues columnes de cromatografia líquida (LC-LC). En l'estudi l'objectiu és millorar el mètode existent per a glifosat i AMPA en aigües naturals on el LOD era de 0,25 ug/l. El mètode consisteix en la derivatització precolumna amb el reactiu fluorescent FMOC i l'anàlisi amb l'acoblament LC-LC-fluorescència. Variant lleugerament les condicions de derivatització s'aconsegueix quantificar 0,1 ug/l de glifosat i AMPA. Es fortifiquen aigües naturals amb 0,1, 1 i 10 ug/l dels anàlits per validar el mètode. S'obtenen recuperacions d'entre el 85 % i el 100 %, amb desviacions estàndard relatives inferiors al 8 %. Aplicant una tècnica de preconcentració prèvia a la derivatització i anàlisi utilitzant una resina de bescanvi aniònic, Amberlite IRA-900, es millora la sensibilitat del mètode i s'assoleix un LOD per al glifosat de 0,02 ug/l.

Decomposition and phosphorus release from organic residues as affected by residue quality and added inorganic phosphorus

The combined use of organic residue and inorganic fertiliser-phosphorus (P) is appropriate in meeting both the short and long-term P requirement of crops. To assess the influence of added inorganic fertiliser-P on the processes of decomposition and P release from the residue and the relationships with quality, prunings of Gliricidia sepium, Leucaena leucocephela, Senna siamea, Acacia mangium and Paraserienthus falcataria were incubated without and with added inorganic fertiliser-P for 56 days. Soil was added only as inoculum. Decomposition rate and amounts of acid extractable-P (P release) were in the same order: G. sepium > S. siamea > L. leucocepheta > P falcataria > A. mangium. Unlike the other residues, A. mangium released no P despite the loss of half its mass during the 8 weeks of incubation. The residue P content correlated with P release. However, decomposition rate did not correlate with residue P content but with the lignin, polyphenol and cellulose content, and ratios to P. These ratios were negatively correlated with P release suggesting that lignin and polyphenol contents influence P release more when the residue-P content is low. Results suggest that rate of decomposition influences the release of P. The critical residue P content for P release was estimated to be 0.12% < P < 0.19%. Added P had no effect on decomposition and P release from the residues.

Proliferative and anti-proliferative effects of titanium- and iron-based metallocene anti-cancer drugs

In previous work we have found that Cp2TiCl2 and its corresponding deriv. of tamoxifen, Titanocene tamoxifen, show an unexpected proliferative effect on hormone dependent breast cancer cells MCF-7. In order to check if this behavior is a general trend for titanocene derivs. we have tested two other titanocene derivs., Titanocene Y and Titanocene K, on this cell line. Interestingly, these two titanocene complexes behave in a totally different manner. Titanocene K is highly proliferative on MCF-7 cells even at low concns. (0.5 .mu.M), thus behave almost similarly to Cp2TiCl2. This proliferative effect is also obsd. in the presence of bovine serum albumin (BSA). In contrast, Titanocene Y alone has almost no effect on MCF-7 at a concn. of 10 .mu.M, but exhibits a significant dose dependent cytotoxic effect of up to 50% when incubated with BSA (20-50 .mu.g/mL). This confirms the crucial role played by the binding to serum proteins in the expression of the in vivo, cytotoxicity of the titanocene complexes. From the hydridolithiation reaction of 6-p-anisylfulvene with LiBEt3H followed by transmetallation with iron dichloride [bis-[(p-methoxy-benzyl)cyclopentadienyl]iron(II)] (Ferrocene Y) was synthesized. This complex, which was characterized by single crystal X-ray diffraction, contains the robust ferrocenyl unit instead of Ti assocd. with easily leaving groups such as chlorine and shows only a modest cytotoxicity against MCF-7 or MDA-MB-231 cells.

Effects of corn silage derived from a genetically modified variety containing two Transgenes on feed intake, milk production, and composition, and the absence of detectable Transgenic deoxyribonucleic acid in milk in holstein dairy cows

The objectives were to compare the chemical composition, nutritive value, feed intake, milk production and composition, and presence in milk of transgenic DNA and the encoded protein Cry1Ab when corn silages containing 2 transgenes (2GM: herbicide tolerance: mepsps and insect resistance: cry1Ab) were fed as part of a standard total mixed ration (TMR) compared with a near isogenic corn silage ( C) to 8 multiparous lactating Holstein dairy cows in a single reversal design study. Cows were fed a TMR ration ad libitum and milked twice daily. Diets contained [ dry matter (DM) basis] 45% corn silage, 10% alfalfa hay, and 45% concentrate (1.66 Mcal of net energy for lactation/kg of DM, 15.8% crude protein, 35% neutral detergent fiber, and 4.1% fat). Each period was 28-d long. During the last 4 d of each period, feed intake and milk production data were recorded and milk samples taken for compositional analysis, including the presence of transgenic DNA and Cry1Ab protein. There was no significant difference in the chemical composition between C and 2GM silages, and both were within the expected range (37.6% DM, 1.51 Mcal of net energy for lactation/kg, 8.6% crude protein, 40% neutral detergent fiber, 19.6% acid detergent fiber, pH 3.76, and 62% in vitro DM digestibility). Cows fed the 2GM silage produced milk with slightly higher protein (3.09 vs. 3.00%), lactose ( 4.83 vs. 4.72%) and solids-not-fat (8.60 vs. 8.40%) compared with C. However, the yield (kg/d) of milk (36.5), 3.5% fat-corrected milk (34.4), fat (1.151), protein (1.106), lactose (1.738), and solids-not-fat ( 3.094), somatic cell count (log(10): 2.11), change in body weight (+ 7.8 kg), and condition score (+ 0.09) were not affected by type of silage, indicating no overall production difference. All milk samples were negative for the presence of transgenic DNA from either trait or the Cry1Ab protein. Results indicate that the 2GM silage modified with 2 transgenes did not affect nutrient composition of the silages and had no effect on animal performance and milk composition. No transgenic DNA and Cry1Ab protein were detected in milk.

Effect of hyaluronidase on ocular motility and eyelid function in sub-Tenon's anaesthesia: randomised controlled trial

Purpose: To assess the effect of hyaluronidase on eye and eyelid movements when used as an adjunct in sub-Tenon's anaesthesia. Methods: A total of 60 patients who had sub-Tenon's anaesthesia prior to phacoemulsification surgery were divided into two equal groups in a double-masked randomised controlled fashion. Of these, Group A had 4 ml lignocaine 2%, while Group B had 4ml lignocaine 2% with the addition of sodium hyaluronidase 75 IU/ml. Ocular motility, levator, and orbicularis oculi function were measured in all patients at 5 and 8 min. Levator function was scored from 0 (no function) to 3 (complete function) while orbicularis function was scored from 0 to 2. The score for ocular motility was the sum in four positions of gaze, each position scoring from 0 to 2. Results were compared using a nonparametric test. Results Group B achieved significantly better ocular and lid akinesia than Group A both at 5 and 8 min with P < 0.01. The median scores for levator function at 5 and 8 min were 2 for Group A and 0 for Group B. For orbicularis function, the median scores at both time intervals were 2 for Group A and 1 for Group B. For ocular motility, the median score for Group A at 5 min was 3 and at 8 min was 2.5; for Group B at 5 min was 0.5 and at 8 min was 0. Conclusions: The addition of hyaluronidase in sub-Tenon's anaesthesia has a significant effect in improving ocular and lid (levator and orbicularis) akinesia.

Bis- and tris-(methylphosphonic) acid derivatives of a 14-membered tetraazamacrocycle containing pyridine: synthesis, protonation and complexation studies

Two N-methylphosphonic acid derivatives of a 14-membered tetraazamacrocycle containing pyridine have been synthesized, H4L1 and H6L2. The protonation constants of these compounds and the stability constants of complexes of both ligands with Ni2+, Cu2+ and Zn2+ were determined by potentiometric methods at 298 K and ionic strength 0.10 mol dm(-3) in NMe4NO3. The high overall basicity of both compounds is ascribed to the presence of the phosphonate arms. H-1 and P-31 NMR spectroscopic titrations were performed to elucidate the sequence of protonation, which were complemented by conformational analysis studies. The complexes of these ligands have stability constants of the order of or higher than those formed with ligands having the same macrocyclic backbone but acetate arms. At pH = 7 the highest pM values were found for solutions containing the compound with three acetate groups, followed immediately by those of H6L2, however, as expected, the increasing pH favours the complexes of ligands containing phosphonate groups. The single-crystal structure of Na-2[Cu(HL1)]NO3.8H(2)O has shown that the coordination geometry around the copper atom is a distorted square pyramid. Three nitrogen atoms of the macrocyclic backbone and one oxygen atom from one methylphosphonate arm define the basal plane, and the apical coordination is accomplished via the nitrogen atom trans to the pyridine ring of the macrocycle. To achieve this geometric arrangement, the macrocycle adopts a folded conformation. This structure seems consistent with Uv-vis-NIR spectroscopy for the Ni2+ and the Cu2+ complexes and with the EPR for the latter.

Low-molecular-weight gelators: Elucidating the principles of gelation based on gelator solubility and a cooperative self-assembly model

This paper highlights the key role played by solubility in influencing gelation and demonstrates that many facets of the gelation process depend on this vital parameter. In particular, we relate thermal stability (T-gel) and minimum gelation concentration (MGC) values of small-molecule gelation in terms of the solubility and cooperative self-assembly of gelator building blocks. By employing a van't Hoff analysis of solubility data, determined from simple NMR measurements, we are able to generate T-calc values that reflect the calculated temperature for complete solubilization of the networked gelator. The concentration dependence of T-calc allows the previously difficult to rationalize "plateau-region" thermal stability values to be elucidated in terms of gelator molecular design. This is demonstrated for a family of four gelators with lysine units attached to each end of an aliphatic diamine, with different peripheral groups (Z or Bee) in different locations on the periphery of the molecule. By tuning the peripheral protecting groups of the gelators, the solubility of the system is modified, which in turn controls the saturation point of the system and hence controls the concentration at which network formation takes place. We report that the critical concentration (C-crit) of gelator incorporated into the solid-phase sample-spanning network within the gel is invariant of gelator structural design. However, because some systems have higher solubilities, they are less effective gelators and require the application of higher total concentrations to achieve gelation, hence shedding light on the role of the MGC parameter in gelation. Furthermore, gelator structural design also modulates the level of cooperative self-assembly through solubility effects, as determined by applying a cooperative binding model to NMR data. Finally, the effect of gelator chemical design on the spatial organization of the networked gelator was probed by small-angle neutron and X-ray scattering (SANS/SAXS) on the native gel, and a tentative self-assembly model was proposed.

Electrochemical characterisation and anodic stripping voltammetry at mesoporous platinum rotating disc electrodes

Using the technique of liquid crystal templating a rotating disc electrode (RDE) was modified with a high surface area mesoporous platinum film. The surface area of the electrode was characterised by acid voltammetry, and found to be very high (ca. 86 cm(2)). Acid characterisation of the electrode produced distorted voltammograms was interpreted as being due to the extremely large surface area which produced a combination of effects such as localised pH change within the pore environment and also ohmic drop effects. Acid voltammetry in the presence of two different types of surfactant, namely Tween 20 and Triton X-100, suggested antifouling properties associated with the mesoporous deposit. Further analysis of the modified electrode using a redox couple in solution showed typical RDE behaviour although extra capacitive currents were observed due to the large surface area of the electrode. The phenomenon of underpotential deposition was exploited for the purpose of anodic stripping voltammetry and results were compared with data collected for microelectrodes. Underpotential deposition of metal ions at the mesoporous RDE was found to be similar to that at conventional platinum electrodes and mesoporous microelectrodes although the rate of surface coverage was found to be slower at a mesoporous RDE. It was found that a mesoporous RDE forms a suitable system for quantification of silver ions in solution.

Drug interaction and location in liposomes: correlation with polar surface areas

An important step in liposome characterization is to determine the location of a drug within the liposome. This work thus investigated the interaction of dipalmitoylphosphatidylcholine liposomes with drugs of varied water solubility, polar surface area (PSA) and partition coefficient using high sensitivity differential scanning calorimetry. Lipophilic estradiol (ES) interacted strongest with the acyl chains of the lipid membrane, followed by the somewhat polar 5-fluorouracil (5-FU). Strongly hydrophilic mannitol (MAN) showed no evidence of interaction but water soluble polymers inulin (IN) and an antisense oligonucleotide (OLG), which have very high PSAs, interacted with the lipid head groups. Accordingly, the drugs could be classified as: hydrophilic ones situated in the aqueous core and which may interact with the head groups; those located at the water-bilayer interface with some degree of penetration into the lipid bilayer; those lipophilic drugs constrained within the bilayer. (c) 2004 Elsevier B.V. All rights reserved.

The synthesis and properties of [Fe3(CO)11(RCN)] derivatives, and a high-yield general route to mono- and di-substituted derivatives of [Fe3(CO)12]; the crystal and molecular structure of [Fe3(CO)11(NCC6H4-2-Me)]

The clusters [Fe3(CO)11(RCN)] (1: R = Me, C3H5, C6H5, or C6H4-2-Me) have been prepared at low temperature from [Fe3(CO)12] and RCN in the presence of Me3NO. Compounds 1 react essentially quantitatively with a wide range of two-electron donors, L, (viz.: CO, PPh3, P(OMe)3, PPh2H, PPh2Me, PF3, CyNC (Cy = cyclohexyl), P(OEt)3, SbPh3, PBu3, AsPh3, or SnR2 (R = CH(SiMe3)2)) to give [Fe3(CO)11L] (2). In some cases (2), on treatment with Me3NO and then L′ (L′ = a second two-electron donor) yields [Fe3(CO)10LL′] in high yield. The crystal and molecular structures of 1 (L = NCC6H4Me-2) have been determined by a full single crystal structure analysis, and shown to have an axial nitrile coordinated at the unique iron atom, with two CO groups bridging the other two metal atoms.