Despite modern anti-tuberculous chemotherapy, approximately 2% of all cases of pulmonary mycobacterial infection require surgical treatment.Therefore, surgical treatment of pulmonary mycobacterial disease is rarely necessary.Types of surgical procedures for PTB include: Collapse therapy, pulmonary resection, lung decortication, drainage procedures such as closed tube thoracostomy, rib resection and open window thoracotomy beside pulmonary resection+ collapse therapy (thoracoplasty). The decreasing morbidity and mortality of pulmonary resection for PTB is due to careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF), improved anaesthetic techniques, stapling devices and better chemotherapy.The prognosis after successful resection is excellent ( 90% survive and remain disease free).
Pulmonary tuberculosis is a very common disease in developing counteries and a big health hazard. Drug therapy is main treatment.Surgery is required mainly for its complications.In this ppp I have described this topic in a simple way
Hemopneumothorax, or haemopneumothorax is the condition of having air in the chest cavity (pneumothorax) and blood in the chest cavity (hemothorax). A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Or •Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchBronchiectasis.
Presented at 2nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda, Kigali, Rwanda, Africa, on 5th – 6th May 1999. Pictured in Hotel Mille Collins, rendered famous in the movie "Hotel Rwanda", which depicted the genocide in Rwanda in 1994. "Hotel Rwanda" is Hotel Mille Collins ('Thousand Hills).
Pulmonary tuberculosis is a very common disease in developing counteries and a big health hazard. Drug therapy is main treatment.Surgery is required mainly for its complications.In this ppp I have described this topic in a simple way
Hemopneumothorax, or haemopneumothorax is the condition of having air in the chest cavity (pneumothorax) and blood in the chest cavity (hemothorax). A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Or •Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchBronchiectasis.
Presented at 2nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda, Kigali, Rwanda, Africa, on 5th – 6th May 1999. Pictured in Hotel Mille Collins, rendered famous in the movie "Hotel Rwanda", which depicted the genocide in Rwanda in 1994. "Hotel Rwanda" is Hotel Mille Collins ('Thousand Hills).
Pulmonary resection in basrah: personal experienceAbdulsalam Taha
Basra Journal of Surgery, March 2004
Abstract:
Pulmonary resection is the operation that defines the thoracic surgeon. It represents the appropriate surgical treatment for many pulmonary lesions. This is the first study on pulmonary resection in Basrah, south of Iraq. The study is conducted in the Section of Thoracic and Cardiovascular Surgery in Basrah Teaching Hospital over a 5-year period (August 1996 to July 2001). The aim of the study is to present the personal experience of the author in lung resection, analyze the indications, surgical and anaesthetic management and outcome including morbidity and mortality in view of the literature. Thirty patients (17 males and 13 females) underwent pulmonary resection for different indications were retrospectively analyzed. The results of this study indicate that despite the small number of patients and the difficulties in anaesthetic management, pulmonary resection is practiced safely in Basrah, south of Iraq.
Basra Journal of Surgery, September 2002
Abstract:
Pulmonary tuberculosis (PTB) is endemic in Iraq with its incidence progressively increasing under the influence of the sanction since 1990. Nevertheless, the diagnosis of PTB should not be made easily without the appropriate investigations. Otherwise, the correct diagnosis of important thoracic disorder (sometimes a serious one like malignancy) may be missed. In this study, six patients with different benign and malignant thoracic lesions chosen among many others are presented. All of them were misdiagnosed and five were treated as tuberculosis. The study reminds the clinician in TB endemic areas that TB can be simulated by many thoracic lesions.
This is an Original Life Saving Surgical technique developed and published by me for treatment of Masiive or Recurrent Hemoptysis where standard lung resection is technically very difficult and or hazardous
This lecture covers all aspects of surgery of tuberculosis of the chest. It should be a great teaching aid for all people dealing with this old and current disease.
Abstract Lung Abscess is a liquefactive necrosis of the lung tissue and arrangement of cavitation (in excess of 2 cm) containing necrotic debris and liquid brought about by parenchymal infection. It very well may be brought about by yearning, which may happen during changed cognizance and it for the most part causes a discharge filled depression. In addition, liquor addiction is the most widely recognized condition inclining to lung abscesses. Lung abscess is viewed as essential (60%) when it comes about because of existing lung parenchymal process and is named auxiliary when it entangles another procedure, e.g., vascular emboli or follows rupture of extrapulmonary abscess into lung. There are a few imaging strategies which can distinguish the material inside the thorax, for example, electronic tomography (CT) output of the thorax and ultrasound of the thorax. Broad Spectrum anti-biotics to cover blended vegetation is the pillar of treatment. Pneumonic physiotherapy and postural drainage are additionally significant. Surgeries are required in specific patients for pneumonic resection Keywords: Lung abscess, anti-bodies, video-assissted thoracoscopic medical procedure (VATS), thoracoscopy
Transsternsl transpericardial closure of postpneumonectomy bronchopleural fis...Abdulsalam Taha
There is no standard treatment for post-pneumonectomy bronchopleural fistula and the successful management is a challenge to the thoracic surgeon. Most of the treatment options are staged procedures.Transsternal transpericardial closure (TSTP) is attractive as it is a one stage operation, that avoids the infected pneumonectomy space and does not result in patients disfigurement. The single disadvantage of TSTP closure is that it does not address the problem of the pneumonectomy space.Herein, we report a case of chronic BPF after pneumonectomy successfully closed via the transsternal transpericardial approach.The relevant literature is reviewed to throw light on the indications and the results of this operation.
Trans sternal trans pericardial closure of post pneumonectomy bronchopleural ...Abdulsalam Taha
The occurrence of a broncho-pleural (BPF) after pneumonectomy is an infrequent but severe complication accompanied by a high morbidity and mortality. Small BPFs may heal either spontaneously or with drainage only. However, the majority of patients with persistent BPFs require operative intervention. There is no standard treatment to this complication and the successful management is a challenge to the thoracic surgeon. While most of the treatment options are staged operations, the trans-sternal trans-pericardial (TSTP) closure is attractive as it is a one stage operation that avoids the infected pneumonectomy space and does not result in patient’s disfigurement. The technique was first used in Italy and then used extensively in the former Soviet Union. Herein, we report a case of chronic BPF after pneumoectomy successfully closed via the TSTP approach. The relevant literature is reviewed to throw light on the indications and the results of this operation.
Key Words: BPF, Pneumonectomy, Empyaema and TSTP Approach.
Publication Date: Mar 2010
Publication Name: Basra Journal of Surgery
view on iasj.net
The global spread of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of M. tuberculosis have resulted in a resurgence of almost incurable and even fatal cases for which only a few therapeutic options are available. Surgery has been applied to improve treatment success rates in MDR-TB patients and a combined medical and surgical approach is increasingly being used to treat patients with M/XDR-TB. This presentation discuss the history, indications,contraindication and the perioperative workup for TB patients that might need surgery
this presentation is based on the lastest WHO recommendation for surgery for pulmonary TB
ERCP is although a routine procedure but is not free of complications. This is a case report where patient developed bilateral pneumothoraces, pneumoperitoneum and pneumoretroperitoneum after endoscopic retrograde cholangiopancreatography. The report discusses in detail the possible causes and relationship of this complication.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Surgery for pulmonary tuberculosis
1. SURGERY FOR PULMONARY
TUBERCULOSIS
PROFESSOR
ABDULSALAM Y TAHA
School of Medicine/ University of Sulaimani/ Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha
1
4. Historical Background
Neolithic Time
– 2400 BC - Egyptian
mummies spinal columns
460 BC
– Hippocrates, Greece
First clinical description:
Phthisis / Consumption
(I am wasting away)
500-1500 AD
– Roman occupation of
Europe it spread to Britain
1650-1900 AD
– White plague of Europe,
causing one in five deaths
4
5. Diagnostic discoveries
24th March 1882 (Robert
Koch) TB Day
– Discovery of staining
technique that identified
Tuberculosis bacillus
– Definite diagnosis made
possible and thus
treatment could begin
1890 (Robert Koch)
– Tuberculin discovered
– Diagnostic use when
injected into skin
1895 (Roentgen)
– Discovery of X-rays
– Early diagnosis of
pulmonary disease
5
9. Smear positive are highly
infectious
– Pulmonary cavitary
cases are usually
smear positive
– Immediate isolation is
necessary until proven
conversion
– HIV positive are more
often smear negative
pulmonary or extra
pulmonary cases –
should they be isolated
– Culturing is needed in
9 smear negative cases.
10. Diagnosis by X-ray
Chest x-rays: Multi
nodular infiltrate
above or behind the
clavicle with or
without pleural
effusion unilaterally
or bilaterally.
10
11. Types of drug resistance
Drug resistance in
TB may be broadly
classified as primary
or acquired. When
drug resistance is
demonstrated in a
patient who has
never received anti-
TB treatment
previously, it is
termed primary
11
12. Surgery for PTB
Despite modern anti-tuberculous
chemotherapy, approximately 2% of all cases
of pulmonary mycobacterial infection require
surgical treatment.
Therefore, surgical treatment of pulmonary
mycobacterial disease is rarely necessary.
Prof Y D Al-Naman:
65% of patients can be cured medically.
25% need surgical treatment.
12 10% fail to respond to therapy.
14. COLLAPSE THERAPY
It is based on the concept that
collapsing the affected portion of the
lung allows the diseased area to rest
and recover.
The efficacy of collapse therapy
probably is derived from the lowering of
O2 tensions in the collapsed portion of
the lung thereby inhibiting growth of M
14 tuberculosis, a strict aerobe.
16. THORACOPLASTY
It is the decostalization of chest wall.
Tailoring thoracoplasty is done in
stages:
First stage: removing ribs 1, 2 and 3.
Second stage: after two weeks;
removing rib 4 and 5.
Third stage: removing rib 6 and 7 in a
tailoring fashion, leaving more rib
16 anteriorly each time after the third.
24. THORACOPLASTY
Extrapleural paravertebral
thoracoplasty was the most
frequently employed surgical
procedure for the treatment of
pulmonary tuberculosis before the
discovery of effective
chemotherapy for tuberculosis.
24
25. THORACOPLASTY
Closure of cavities was achieved in
more than 80% of patients without
chemotherapy by using
thoracoplasty.
Today, it is rarely indicated as
primary treatment for pulmonary
tuberculosis.
25
26. POSTURE AFTER THORACOPLASTY
The posture
following two-stage,
seven-rib left
thoracoplasty.
The grossly
diminished left
shoulder movement
and marked
scoliosis are shown.
The deformity is
irreversible;
prevention is
26 essential.
33. PULMONARY RESECTION
Resection of the diseased portion of the lung.
Types:
Wedge resection, Segmentectomy.
Lobectomy, Bilobectomy, Pneumonectomy.
Pleuropneumonectomy.
• The extent of resection depends on the
extent of the mycobacterial disease. All gross
33 evidence of disease should be resected.
34. ACCEPTED INDICATIONS FOR
PULMONARY RESECTION
Persistent positive sputum cultures with
cavitation.
Localized pulmonary disease due to atypical
mycobacterium ( M avium intracellulare) or
drug resistent M tuberculosis.
A mass lesion of the lung in an area of
tuberculous involvement.
Massive life-threatening haemoptysis or
34 recurrent severe haemoptysis.
35. INDICATIONS FOR RESECTION..
In stabilized patients with a localized
site of bleeding, lobectomy is the most
definitive form of therapy for massive or
recurrent haemoptysis.
A bronchopleural fistula secondary to
mycobacterial infection that does not
respond to tube thoracostomy.
35
36. OTHER INDICATIONS
Patients severely symptomatic from a
destroyed lobe or bronchiectatic area of the
lung may benefit from resection.
Patients with thick-walled cavities who have
reactivated mycobacterial disease or who
can not comply with prolonged chemotherapy
may benefit from resection of the diseased
area.
A patient with trapped lung: decortication.
Secondary fungal infection of tuberculous
36 cavity ( Aspergillosis).
39. ADVANTAGES OF LUNG RESECTION
Prompt conversion into sputum-negative
status in a single session.
No chest wall deformity is
produced.
No limitation of ventilatory capacity.
39
41. PREOPERATIVE MEASURES
Adequate cardiopulmonary reserve.
Conversion of the patient into sputum-negative
status.
Adequate physical and pulmonary
toilet.
Adequate nutritional support.
Preoperative bronchoscopy.
41
42. INTRAOPERATIVE MEASURES
The use of a double-lumen
endotracheal tube can make
operation for PTB technically
easier and safer.
Bronchoscopy may be required at
the conclusion of the operation to
clear infected secretions or blood
42 from the airway.
43. COMPLICATIONS OF RESECTION
Empyaema with or without
BPF.
Bronchogenic spread of
mycobacterial disease.
43
44. COMPLICATIONS
Both complications are more frequent
when the patient is sputum positive at
the time of operation.
Judicious use of thoracoplasty or liberal
use of muscle flaps in such patients at
the time of operation can minimize the
incidence of BPF and apical space
problems.
44
45. RESULTS OF RESECTION
The decreasing morbidity and mortality of
pulmonary resection for PTB is due to:
1. Careful patient selection ( failure of
chemotherapy, massive haemoptysis, BPF).
2. Improved anaesthetic techniques.
3. Stapling devices.
4. Better chemotherapy.
•The prognosis after successful resection is
excellent ( 90% survive and remain disease
45 free).