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Öğe Anesthetic approach to adult moyamoya disease: A case report(Gulhane Askeri Tip Akademisi, 2010) Said Aydo?an M.; Yücel A.; Özgül U.; Öztürk E.; Konur H.; Namik Öztanir M.; Özcan Ersoy M.Moyamoya disease is an entity, which is caused by obstruction or stenosis in the area between the internal carotid artery, and anterior and middle cerebral arteries, identified angiographically, and does not have an exactly known etiology. The most frequent symptoms of onset are hemorrhage in adults and ischemia in children. In the treatment of moyamoya disease revascularization surgery is performed in order to decrease the vascular fragility. A specialized care is required in the perioperative period since surgery is often complicated by cerebral ischemia or cerebral hemorrhage. Aim in the perioperative anesthetic management is to provide the balance between oxygen supply to and use in the brain. In this case report we aimed to discuss the anesthetic management in a 22-year-old male patient with moyamoya disease in whom a multipl burr hole surgery was performed. © Gülhane Askeri Ti{dotless}p Akademisi 2010.Öğe Anesthetical approach in a patient undergoing beating heart coronary artery bypass surgery with adrenal insufficiency(Turkish Anaesthesiology and Intensive Care Society, 2008) Erdil F.; Begeç Z.; Öztürk E.; But A.K.; Nisano?lu V.; Ersoy M.Ö.Glucocorticoids were released with a high amount from adrenal cortex in physiological and surgical stress situations to supply homeostasis. But the patients who had adrenal insufficiency, as a result of anesthesia and surgical stress or the insufficiency in glucocorticoid treatment, life threating adrenal crisis can exist. In this case report, we discuss the successful anesthesia technique and cortisol treatment in a patient who underwent beating heart coronary artery bypass surgery with bilateral adrenalectomy surgery for Cushing Syndrome and who have been taken glucocorticoid treatment for several years.Öğe Antioxidant effects of midazolam, isoflurane and desflurane during coronary artery by-pass grafting surgery(2009) Öztürk E.; But A.; Toprak H.I.; Demirbilek S.; Güleç M.; Ersoy M.Ö.It has been suggested that the reactive oxygen species (ROS) have essential role in the pathogenesis of myocardial ischemia-reperfusion injury. ROS may cause cardiac problems such as myocardial stunning, tissue damage and reperfusion cardiac arrhythmias may occur during weaning from pump in coronary artery bypass grafting (CABG). The aim of this study was compare the effects of midazolam, isoflurane, and desflurarie on the oxidative stress and hemodynamic parameters during CABG. After standard anesthesia induction, ninety patients were randomly allocated to Group M (midazolam), Group 1 (isoflurane), Group D (desflurane). Blood samples were obtained from the retrograde cannula placed in the coronary sinus; just prior to connecting to the pump (T1) and 5 minute after the cross-clamp removal (T2). In group M, superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and adenosine deaminase (ADA) significantly increased, and nitric oxide (NO) and malondialdehyde (MDA) decreased at the T2 compared to the T1 (p<0.05). In Group 1, SOD and ADA increased at the T2 compared to the T1. While NO and MDA decreased, ADA increased in Group D at the T2 in comparison with the T1 (p<0.05). GSH-Px was significantly higher in Group M than Group 1 and D at the T2 (p<0.05). Although ADA was lower at the T2 in Group M than Group 1 and D, but there was only statistically significant difference between Group M and D (p<0.05). Midazolam had greater stimulating capacity on the endogenous antioxidant system and may caused less cellular damage than isoflurane and desjlurane due to its effects on the ADA.Öğe Comparison of haemodynamic profile and recovery characteristics of total intravenous anaesthesia and desflurane anaesthesia in paediatric outpatient surgery(2005) Özpolat Z.; To?al T.; Toprak H.I.; Öztürk E.; Çiçek M.; Ülger H.; Ersoy M.O.Aim: We aimed to compare the intraoperative haemodynamic profile and recovery characteristics of total intravenous anaesthesia (TIVA) with remifentanilpropofol and inhalation anaesthesia with desflurane-N2O in paediatric patients. Materials and Methods: Fifty children, ASA I, aged 4-12 years undergoing tonsillectomy, adenoidectomy or insertion of ventilation tubes, were included into the study. After premedication with midazolam orally, induction was performed intravenously with lidoeaine 1 mg kg-1, remifentanil 1 ?g kg-1, propofol 3 mg kg-1 and vecuronium 0.1 mg kg-1. Patients were divided into two groups: In Group I, remifentanil 0.5 ?g kg-1 min-1 and propofol 50 ug kg-1 min-1 were given; in Group II, desflurane 8.3 % and N2O 50 % in O2 were given. The heart rate (HR), mean arterial pressure (MAP), SpO2, PETCO2 and body temperature were monitorized. Emergence and recovery times, side effects like hypoxia, laryngospasm, nausea-vomiting, pain, and agitation were recorded. Results: In Group I, MAP increased at all times except after induction when compared with baseline, and decreased at all times except after intubation and surgical incision in Group II. HR decreased at surgical incision, 10, 20 and 30 minutes after incision in Group I when compared with baseline, and at all times except after intubation and surgical incision in Group II (p<0.05). In Group II, MAP was lower and HR was higher when compared with Group I. Eve-opening time and time to reach Aldrete score >8 in Group II was longer than in Group I. The time of spontaneous ventilation and extubation, and side effects were similar between groups. The incidence of postoperative pain and agitation was high in both groups. Conclusion: We concluded that both TIVA with propofol-remifentanil and desflurane-N2O based anaesthesia are suitable methods with short postoperative recovery for outpatient paediatric cases. However haemodynamic instability, postoperative agitation and pain are serious problems with both methods that should be solved.Öğe Does the supplementation of fentanyl to bupivacaine affect unilateral spinal block?(2001) Durmuş M.; Türköz A.; To?al T.; Ayas A.; Öztürk E.; Ersoy M.O.The purpose of this study was to evaluate the affects of supplementation of fentanyl to rapid administered low dose hyperbaric bupivacaine for unilateral spinal anaesthesia in arthroscopic surgery. Thirty patients undergoing arthroscopic surgery were placed in the lateral position. After dural puncture (25-gauge Whitacre spinal needle), the needle hole was turned toward the dependent side and patients were randomly assigned to receive 7.5 mg of 0.5 % hyperbaric bupivacaine (Group I, n=15) or 7.5 mg of 0.5 % hiperbaric bupivacaine + 25 ?g fentanyl (Group II, n=15). Lateral and horizontal positions were maintained for 15 min before the patients were turned to supine position. Sensory block levels were assessed with three minutes intervals during lateral position and 5 minutes intervals during supine position and motor block levels were assessed with 15 minutes intervals. Spinal anaesthesia was unilateral in 80 % of group I and 13 % of group II at the end of the 15 min; after 60 min, spinal anaesthesia was unilateral in 80 % of group I and 0 % of group II (p<0.005). We conclude that fentanyl supplementation to low dose hyperbaric bupivacaine was disadvantageous in obtaining unilateral spinal anaesthesia although we can obtain long-term sensory block.Öğe Effect of inhalation anesthesia in postoperative atrial fibrillation after coronary artery bypass surgery(2009) Erdil F.; Begeç Z.; Öztürk E.; But A.K.; Gedik E.; Ersoy M.Ö.Atrial fibrillation (AF) is an important rhytm problem which occurs in the ratio of 10-50 % after CABP. It is shown that the inhalation anaesthetics have important role on protection of cardiac function in the early postoperative period. The purpose of this study is searching the effects of the inhalation agents retrospectively on the frequency of AF which occur after CABG in the early postoperative period. Patients were assigned into three groups as isoflurane (Group I; n=260), sevoflurane (Group S; n=308) and desflurane (Group D; n=349) according to the inhalation anaesthetic administered. Continue ECG monitorization was performed to each patients who was hospitalizated in intensive care unit. Routine ECG monitorization was performed to the patients at just after the operation and in the postoperative 1st., 2nd. and 4th. days. The rhythm controls were assessed by the assistant doctors by palpitation of radial artery four times a day at service controls. ECG monitorization was performed to the suspected patients except this routine clinical assessment. It was recorded when AF was occurred. Atrial fibrillation occurred in a ratio of 11.8 % in the all cases. There was no difference between the groups for development of AF (Group D: 11.5 %, Group I: 12 %, Group S: 11.7 %, p>0.05). In our cases age, Euroscore, postoperative need for inotropic agents, periods for cross-clemping and perfusion were found as independent risk factors in the analyzing of multivariant risks for determining the risk factors (p<0.05). As a result; we think that the uses of sevoflurane, isoflurane and desflurane have similar effects on development of AF in the patients after CABP.Öğe The effect of intra-abdominal insufflation pressure on liver function in adult patients undergoing laparoscopic cholecystectomy(2005) Özpolat Z.; Durmuş M.; Toprak H.I.; Öztürk E.; Temel I.; Ersoy M.Ö.Aim: The relation between age and the effect of laparoscopic cholecystectomy on hepatocellular integrity has not been evaluated. We aimed to compare conventional liver function tests in two groups of adults of differing age undergoing elective laparoscopic cholecystectomy. Materials and Methods: We studied 43 patients divided into two groups according to age: Group 1, age 18-60 years (n=22) and Group 2, over 65 years (n=21). All patients received general anesthesia. CO2 was used to insufflate the peritoneal cavity, and intraperitoneal pressure was maintained at 10-14 mmHg during cholecystectomy. Reverse Trendelenburg position was maintained after CO2 insufflation. Arterial blood was sampled before the induction of anesthesia, at the end of surgery, and 1, 3, 6 and 24h after surgery for determination serum alanine aminotransferase (ALT) aspartate aminotransferase (AST), alpha-glutathione S-transferase (alpha-GST), and ganima-glutamyl transpeptidase (GGT) concentrations. Results: Baseline values of alpha-GST were within normal limits in both groups. Alpha-GST increased significantly in two groups at the end of surgery and at 1st hour after surgery. The increase of alpha-GST in Group 2 was higher than Group 1. Alpha-GST returned to normal values at 3,6 and 24h after surgery in both groups. Alpha-GST returned to the preoperative value at 24th h after surgery in Group 1 but not in Group 2. Conclusion: We conclude that elderly patients undergoing laparoscopic cholecystectomy have more hepatocellular injury when intraperitoneal pressure is greater than 10 mmHg.Öğe The effect of lidocaine infusion on neurocognitive dysfuction after cardiopulmonary bypass(2003) Ilksen Toprak H.; Türköz A.; To?al T.; Özcan Y.; Durmuş M.; Öztürk E.; Ersoy M.Ö.Although technically, surgical, and pharmacological research to prevent neuropsychological (NP) dysfunction are ongoing, NP dysfunction after cardiopulmonary bypass (CPB) is among the most important causes of postoperative morbidity and mortality. In recent years lidocaine, which has being investigated for being its effects on cerebral protection, showed many side effects on central nervous system even at clinical doses. In this study, we investigated whether lidocaine at clinical doses increase the disturbances on cognitive functions after CPB. Twenty-three cases enrolled in this study with coronary artery disease were divided into two groups randomly. Just after the pump, the first group (group I) was received 100 mg IV bolus of lidocaine and 1 mg min-1 lidocaine infusion, and the other group (group II) received same amounts of saline solution. Infusions were stopped at postoperative 24th hour. Cases were evaluated by a psychiatrist who does mot know the groups of patients for NP functions by Wechsler Memory Scale-Revised Form with seven subtests, one day before (ti), 24 hours after operation (ts) and at postoperative 7th day (tt). There was a significant decrease in score of two subtests evaluated at ts compared with ti in group I and it was observed that total NP function scores at ts were significantly decreased compared to ti. Whereas, in group II, there was a significant decrease in only one subtest and there was no significant difference in comparison of total scores. In addition, when two groups were compared, decrease in logical memory score and total NP function score at ts were more significant in group I than in group II. It was thought that lidocaine used after CPB could increase postoperative NP dysfunction. Nevertheless, a psychometric test with wider content should be used and we think that our results should be supported by other studies.Öğe Effects of dexmedetomidine and midazolam sedation on the haemodynamic response to epinephrine(Anestezi Dergisi, 2007) Erdil F.; But A.K.; Toprak H.I.; Öztürk E.; Ersoy M.Ö.Objective: The aim of our study is to evaluate the haemodynamic response of midazolam and dexmedetomidine sedation to local anaesthetic (LA) infiltration containing epinephrine and the analgesic effects and sedation during septoplasty operations. Methods: Dexmedetomidine (Group D; n:25) and midazolam (Group M; n:20) were given to patients as their sedation levels reached 3-4. The mean blood pressure (MBP), heart rate (HR), and visual analog scale (VAS) values were recorded preoperatively, after induction doses of sedation agents, after the infiltration of local anesthesia containing epinephrine and perioperatively. Postoperatively MBP and HR were recorded at 1, 2, 4, 6, 12, and 24 hours and the pain score of the patients was evaluated by VAS. Results: In group D, MBP after 10. minutes perioperatively, and HR after the dexmedetomidine induction, perioperatively at 20 and 30 minutes and postoperatively in the first hour were significantly lower when compared with the initial values (p<0.05). In group M, MBP after the induction and postoperatively at the 2nd hour was significantly lower when compared with the initial values, but HR was significantly increased after the induction, until the perioperative 30th minute (p<0.05). As for the evaluation of the groups: in group D, MBP till the perioperative 30th minute and postoperatively at 1, 4 and 24 hours, and HR between the end of induction and the perioperative 30th minute were significantly lower when compared with group M (p<0.05). Total diclophenac consumption was significantly lower and the time to the first analgesic requirement was also significantly longer in group D when compared with group M (p<0.05). Postoperative VAS values were significantly lower in group D when compared with group M. Conclusion: The results of our study showed that dexmedetomidine sedation could be preferred in septoplasty operations because of its beneficial effects on haemodynamic response after LA infiltration containing epinephrine and for its analgesic properties which is important in the postoperative period.Öğe The effects of fetal sex on local anaesthetic requirement in cesarean sections(2005) Gülhaş N.; Demirbilek S.; Öztürk E.; But A.K.; Do?an Z.; Ersoy M.Ö.Aim: Anaesthetic needs are different between female and male adults. The effect of fetal sex on maternal local anaesthetic requirements has not been examined in detail. The aim of this study was to assess if fetal sex was associated with maternal regional anaesthetic requirements in elective cesarean sections. Material and Methods: After obtaining hospital Ethics Committee approval, 46 elective cesarean sections in ASA class I and II patients were reviewed. After a pre-load of 10 mL kg-1 Ringer Lactate, combined spinal epidural anaesthesia was administered. Spinal block was performed with 7.5 mg hyperbaric bupivacaine. If the sensory block didn't reach the T 4 dermotome 5 mL of 7.5% ropivacaine was administered through the epidural catheter. Time to reach T4 sensory block and required local anaesthetic doses were recorded. Results: Sensory block levels of mothers with female fetuses were statistically higher at 5 min after subarachnoid injection (p<0.05). Additionally time to reach T4 was shorter and required less ropivacaine in the group with female fetuses (p<0.05). Conclusion: The results of this trial, suggest that mothers with female fetuses have reduced regional anesthetic requirements for Cesarian section. Further studies are warrated.Öğe The efficacy of remifentanil combined with either propofol, sevoflurane or desflurane during controlled hypotension(2004) Demirbilek S.; Gülhaş N.; Öztürk E.; But A.K.; Aslan Ü.; Ersoy M.Ö.The aim of this study was to compare the effects of a combination of remifentanil with propofol, desflurane or sevoflurane on intraoperative controlled hypotension, quality of the surgical field and recovery characteristics in patients undergoing nose surgery. ASA physical status I, 18-47 yr of age, 54 patients were randomly divided to three groups and received remifentanil 1?g kg-1 as a bolus dose followed by a continuous infusion of 0.25 ?g kg-1 min-1. In propofol group, anesthesia was induced 1.5-2 mg kg-1 of propofol and maintained with a continuous infusion of 100-200 ?g kg-1 min-1. In sevoflurane group, anesthesia was induced with 7% sevoflurane in 100% oxygen, and was maintained with 1-2% sevoflurane and air in oxygen. In desflurane group, anesthesia was induced 1.5-2 mg kg-1 of propofol and maintained with 4-6% desflurane and air in oxygen. The study drug titration was adjusted to keep the systolic blood pressure (SBP) between 80-100 mmHg during surgery. During controlled hypotension, while SBP was significantly lower in desflurane and sevoflurane groups than in propofol group, mean blood pressure (MBP) was significantly lower in sevoflurane group than in other groups (p<0.05). Supplemental hypotensive agent was administered to 2 patients in propofol group and 1 patient in desflurane group. After extubation, MBP and heart rate (HR) significantly increased in propofol group, HR significantly increased in sevoflurane group, SBP, MBP and HR significantly increased in desflurane group according to preinduction values (p<0.05). Estimated blood loss and surgical field score was similar in all three groups. The time to extubation and early recovery was significantly shorter in desflurane group than in sevoflurane and propofol groups (p<0.05). We concluded that since all three anesthetic techniques provided hemodynamic stability and good visualization of the surgical field, they may be used for controlled hypotension management. However, sevoflurane-remifentanil combination may be preferable, because it did not cause any increase in blood pressure after extubation.Öğe Hemodynamic effects of bupivacaine and ropivacaine in cesarean section(AVES İbrahim KARA, 2006) Öztürk E.; But A.; Gülhaş N.; Begeç Z.; Do?an Z.; Yapici E.; Ersoy M.Ö.Aim: Local anesthetics for spinal aneaesthesia, provides a comfortable anaesthesia with their sensorial and motor block effect. However symphatic block causes hypotension in patients and this hypotension may cause nausea, vomiting and decrease in uterine blood flow, The purpose of this study is to compare the hemodynamic effects of equivalent doses of each ropivacainc and bupivaciane given intratecally in combination with fentanyl for elective cesarean section. Materials and Methods: Tthirty-six ASA I-II patients undergoing elective cesarean section were enrolled the study. After administration of 15 mL kg ringers lactate on sitting position combined spinal-epidural anesthesia performed. Patients randomly allocated in group B (n=18) (bupivacaine heavy 11 mg) and group R (n=18) (ropivacaine heavy 11 mg) and 25 ?g Fentanyl added to local anesthetics. Systolic arterial pressure (SAP), heart rate (HR) and sensorial block levels were recorded during the operation. Ephedrine infusion was used to obtaining a stable hemodynamia during the operation. Results: Total ephedrine infusion and total ephedrine consumption was greater in group R than in group B (p<0.01). SAP values at 2, 4, 6, 8, 10 min in Group B were significantly lower than baseline value (p<0.05). HR values at 2, 4, 6, 8, min in Group R were significantly higher compared to the baseline value (p<0.05). HR values were significantly higher than baseline value at all times except HR 20 in group B. Mean sensorial block level was (T6) in Group R and (T4) in Group B (p=0.001). Additional local anesthetic was administered the 8 patients in only group R through epidural catheter (p=0,001). No patients in group B needed to additional local anesthetics Conclusion: Lower sensorial block levels were obtained with ropivacaine when compared to the similar doses of bupivacaine. It was concluded that bupivacaine is more potent than ropivacaine in spite of opioid addition.Öğe Hemodynamic, Hepatorenal and Postoperative Effects of Desflurane-Fentanyl and Midazolam-Fentanyl Anaesthesia in Coronary Artery Bypass Surgery(2004) But A.K.; Durmuş M.; Toprak H.I.; Öztürk E.; Demirbilek S.; Ersoy M.O.In this study, we aimed to compare the hemodynamic, hepatorenal and postoperative effects of desflurane-fentanyl and midazolam-fentanyl anaesthesia during coronary artery bypass surgery. Sixty patients undergoing elective coronary artery bypass surgery with ejection fraction of more than 45% were included in the study. Patients were randomly divided into two groups as desflurane (Group D, n=30) and midazolam (Group M, n=30). Anaesthesia was induced with etomidate, 0.2 mg kg-1 and fentanyl, 5 ?g kg -1 in Group D and with midazolam, 0.1-0.3 mg kg-1 and fentanyl, 5 ?g kg-1 in Group M. For the maintenance of anaesthesia; desflurane, 2-6% and fentanyl, 15-25 ?g kg-1 were given in group D and infusion of midazolam at a rate of 0.1-0.5 mg kg -1 hr-1 and fentanyl at a rate of 15-25 ?g kg -1 were used in group M. Heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, systemic vascular resistance index, pulmonary vascular resistance index, left ventricle stroke work index and right ventricle stroke work index were measured before induction (t0), after induction (t1), after intubation (t2), after incision (t3), after sternotomy (t4), before cardiopulmonary bypass (t5), after protamine administration (t6) and at the end of the surgery (t7). Blood samples were taken to measure total bilirubine, aspartate amino transferase, gamma glutamyl transferase, lactate dehydrogenase, alkalane phosphatase, creatinine and blood urea nitrogen just before induction and at the 1st 4th and 14th days of postoperative period. In conclusion; intraoperative hemodynamic responses were similar in both of the groups and transient hepatic and renal dysfunction were observed in the postoperative period in both groups. The extubation and ICU discharge time were found to be shorter in the desflurane-fentanyl group.Öğe Magnesium Sulphate Given Intraoperatively Can Reduce Blood Loss Without Effecting the Coagulation System(2003) Hasçalik M.; Durmuş M.; Öztürk E.; To?al T.; Ersoy M.Ö.The prevention of bleeding that will occur during surgical procedure is very important for the surgeon and for the anaesthesiologist. The aim of the current study is to determine the effects of magnesium that can be used in controlled hypotension on amount of bleeding, surgeon bleeding score, coagulation tests and hemodynamic parameters. This study was performed in fourty ASA physical score I adult patients who underwent septorhinoplasty procedures. Patients were divided as Magnesium (n=20) and Control groups (n=20). The patients in the magnesium group were given a bolus dose of magnesium sulphate 50 mg kg-1 in 50 mL of serum physiologic solution and had magnesium infusion at a rate of 15 mg kg-1 h-1 whereas the latients in the control group received a bolus of 50 mL of serum physiologic solution and infusion. During the procedure hemodynamic parameters were recorded in every 5 minutes. Venous blood samples were taken for analysing serum magnesium, calcium, hemoglobin and fibrinogen levels, prothrombin time, partial thromboplastine time, INR, and platelet count before and after the operation and at the postoperative 6th hour. In Magnesium group, the of serum fibrinogen level between before operation value and after operation value was lower than the difference of serum fibrinogen level between before operation value and after operation value in placebo group (p<0.05). The amount of bleeding in magnesium group was 50 mL less than the amount of bleeding in the plasebo group but this was not significant (p>0.0.5). The additional narcotic use and surgeon bleeding scores between two groups were significantly different (p<0.05). As a conclusion; we suggest that magnesium sulphate which is not contraindicated in ASA physical score I patients can provide a stabil blood pressure at the given doses and can affect surgeon bleeding score at a positive manner without any significant effect on the coagulation system.Öğe Short-term vitreoretinal tamponade with perfl uorodecalin for retinal detachment(Gazi Eye Foundation, 2021) Öztürk E.; Yildizli Y.; Özsoy E.; Gündüz A.Purpose: The aim of this study was to use perfl uorodecalin (PFD) as a short-term postoperative vitreoretinal tamponade and evaluate its effectiveness in retinal detachment. Materials and Methods: This retrospective case series consisted of eight consecutive patients (four female, four male) who presented with retinal detachment (traumatic, secondary to inferior retinal tear, presence of proliferative vitreoretinopathy) at a tertiary university medical center in 2018-2019. All patients underwent pars plana vitrectomy with short-term PFD tamponade. Patients with a minimum follow-up of 3 months were included in the study. The medical charts were analyzed for patient demographics, retinal attachment rates, pre- and postoperative visual acuity, and postoperative complications. Results: The mean duration of PFD tamponade was 16.5 ± 6.3 (range, 7-27) days. The mean follow-up time for the patients was 8.63 ± 2.5 months. The retina was reattached intraoperatively in all patients. In seven patients (87.5%), the retina was still attached throughout follow-up without further vitrectomies. A statistically signifi cant increase was observed when preoperative mean best-corrected visual acuity (BCVA) was compared with mean BCVA in the last follow-up visit (2.9 ± 0.3, 1.3 ± 0.7 logMAR respectively, p=0.018). In seven (87.5%) patients, BCVA improved postoperatively compared with preoperatively. In the postoperative period, pupillary membrane formation was observed in two (25.0%) patients, retrolental membrane in one (12.5%) patient, and epiretinal membrane in one (12.5%) patient. Conclusion: PFD seems to be safe to use as a short-term postoperative vitreoretinal tamponade, and it is useful in retinal detachment. © 2021 Gazi Eye Foundation. All rights reserved.
