scholarly journals Prevalence of Spina Bifida among Newborns in Africa: A Systematic Review and Meta-Analysis

Scientifica ◽  
2020 ◽  
Vol 2020 ◽  
pp. 1-12
Author(s):  
Mohammed Oumer ◽  
Molla Taye ◽  
Hailu Aragie ◽  
Ashenafi Tazebew
Keyword(s):  
Systematic Review ◽  
Spina Bifida ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Fetal Loss ◽  
Cochrane Library ◽  
Forest Plot ◽  
Birth Prevalence ◽  
Pooled Prevalence

Spina bifida is an abnormal closure of the neural tube during the fourth week of development. It is the major cause of fetal loss and considerable disabilities in newborns. The aim of this review is to determine the pooled prevalence of spina bifida among newborns in Africa. PubMed/Medline, Google Scholar, Science Direct, Joanna Briggs Institute (JBI) Library, Cochrane Library, Web of Science, African Journals Online, and Embase databases were systematically searched. Cochran Q test and I2 test statistics were applied to assess heterogeneity across studies. A random-effect model was applied to calculate the pooled prevalence of spina bifida. Forest plot and Galbraith’s plot were used to visualize heterogeneity. Subgroup, sensitivity, meta-regression, and meta-cumulative analyses were performed. All essential data were extracted using a standardized data extraction format, and the JBI quality appraisal checklist was used to assess the quality of studies. Egger’s test and Begg’s test were used in order to detect the publication bias. In the present systematic review and meta-analysis, 6,587,298 births in twenty-seven studies were included. The pooled birth prevalence of spina bifida in Africa was 0.13% with a range between 0.12% and 0.14%. In Africa, the highest burden of spina bifida was detected in Algeria (0.43%), Ethiopia (0.32%), Tanzania (0.26%), Cameron (0.12%), Egypt (0.10%), and South Africa (0.10%). The lowest burden of spina bifida was detected in Libya (0.006%) and Tunisia (0.009%). The high birth prevalence of spina bifida was detected in Africa. There was a significant variation in the prevalence of spina bifida among study countries in Africa. The authors recommend that special awareness creation with the help of health education intervention should be provided for mothers to focus on prevention in order to reduce the burden of spina bifida.

scholarly journals Prevalence of anencephaly in Africa: a systematic review and meta-analysis

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Mohammed Oumer ◽  
Anteneh Ayelign Kibret ◽  
Amanuel Girma ◽  
Ashenafi Tazebew ◽  
Mezgebu Silamsaw
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Random Effect ◽  
Fetal Loss ◽  
Control Measures ◽  
Cochrane Library ◽  
Forest Plot ◽  
Analysis Model ◽  
Birth Prevalence ◽  
Folic Acid Fortification

AbstractAnencephaly is a severe anomaly of the brain that results from the failure of the cephalic part of the neural tube to close during the fourth week. It occurs at least in one per thousand births and is the major cause of fetal loss and disabilities in newborns. The objective of this review is to determine the birth prevalence of anencephaly in Africa. We identified relevant studies via a search of databases like PubMed Central, PubMed/Medline, Science Direct, Joanna Briggs Institute, African Journals Online, Embase, Google Scholar, Web of Science, and Cochrane Library. After examining the heterogeneity of studies via the Cochran Q test and I2 test (and Forest plot for visual inspection), the prevalence of anencephaly was estimated using the random-effect meta-analysis model. Consequently, we carried out subgroup, sensitivity, meta-regression, trim and fill, time-trend, and meta-cumulative analyses. In this systematic review and meta-analysis, the twenty-four studies reported a total of 4,963,266 births. The pooled birth prevalence of anencephaly in Africa was 0.14% (95% CI: 0.12, 0.15%). Higher burden of anencephaly was detected in Ethiopia (0.37%, CI: 0.15, 0.58%), Algeria (0.24%, CI: 0.24, 0.25%), and Eritrea (0.19%, CI: 0.19, 0.19%). The higher pooled prevalence of anencephaly was observed in the studies that included both live births and stillbirths (0.16%) and in studies done after the year 2010 (0.25%) whereas, the lower burden was detected among countries that had a mandatory folic acid fortification (0.05%). High birth prevalence of anencephaly was detected in Africa. Strong prevention and control measures should be the priority because of an increment in the magnitude of anencephaly. Helping in prevention programs, which should be the ultimate contribution of this study to the field.

scholarly journals Primary and secondary infertility in Africa: systematic review with meta-analysis

2020 ◽  
Vol 6 (1) ◽  
Author(s):  
Melese Shenkut Abebe ◽  
Mekbeb Afework ◽  
Yeshiwas Abaynew
Keyword(s):  
Inflammatory Diseases ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Degree Of Freedom ◽  
Cochrane Library ◽  
Forest Plot ◽  
Secondary Infertility ◽  
Chi Square ◽  
Pooled Prevalence

Abstract BACKGROUND Infertility is a practical concern of Africans due to social disgrace and exclusion. This meta-analysis aims to analyze the proportion of primary and secondary infertility and identify the etiologic factors based on the studies conducted in Africa. METHODS An internet-based search was conducted on the following databases; PubMed/Medline, EMBASE, Cochrane library, and google scholar. Both population and institution-based studies conducted among African couples, males, and females were included. Data extraction and critical appraisal of the articles were done by two independent investigators. Meta-analysis using a random effect model was conducted by Stata version 14. Forest plot, heterogeneity test, and funnel plot for publication bias were performed. RESULTS The pooled proportion of primary and secondary infertility in Africa was 49.91% (I2 = 98.7, chi-square = 1509.01, degree of freedom = 19 and p < 0.001) and 49.79% (I2 = 98.7, chi-square = 1472.69, degree of freedom = 19 and p < 0.001) respectively. The pooled prevalence of the causes of infertility indicated that 54.01% and 22.26% of the infertility cases were respectively due to female and male-related problems. In 21.36% of infertility cases, both sexes were affected, while 10.4% of the causes of infertility were unexplained. The pooled prevalence of mostly reported causes of male infertility was 31% (oligospermia), 19.39% (asthenozoospermia), and 19.2% (varicocele). The most commonly identified causes of female infertility were pelvic inflammatory disease, tubal factors, and abortion with a pooled prevalence of 39.38%, 39.17%, and 36.41% respectively. Conclusions In Africa, the proportion of primary and secondary infertility is approximately equal. Infertility is mostly due to female-related causes like; pelvic inflammatory diseases, uterine tube related problems, and abortion. Oligospermia, asthenozoospermia, and varicocele were the commonest causes of male-related infertility. It is suggested that interpretation and utilization of these findings should consider the presence of substantial heterogeneity between the included studies.

scholarly journals Magnitude and determinants of neural tube defect in Africa: a systematic review and meta-analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Daniel Atlaw ◽  
Yohannes Tekalegn ◽  
Biniyam Sahiledengle ◽  
Kenbon Seyoum ◽  
Damtew Solomon ◽  
...  
Keyword(s):  
Systematic Review ◽  
Neural Tube ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Folic Acid Supplementation ◽  
Maternal Exposure ◽  
X Ray ◽  
Effect Model ◽  
Pooled Prevalence

Abstract Background Neural tube defects (NTDs) are a group of disorders that arise from the failure of the neural tube close between 21 and 28 days after conception. About 90% of neural tube defects and 95% of death due to these defects occurs in low-income countries. Since these NTDs cause considerable morbidity and mortality, this study aimed to determine the prevalence and associated factors of NTDs in Africa. Methods The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO number: CRD42020149356). All major databases such as PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, African Journals Online (AJOL), and Google Scholar search engine were systematically searched. A random-effect model was used to estimate the pooled prevalence of NTDs in Africa, and Cochran’s Q-statistics and I2 tests were used to assess heterogeneity between included studies. Publication bias was assessed using Begg ’s tests, and the association between determinant factors and NTDs was estimated using a random-effect model. Results Of the total 2679 articles, 37 articles fulfilled the inclusion criteria and were included in this systematic review and meta-analysis. The pooled prevalence of NTDs in Africa was 50.71 per 10,000 births (95% CI: 48.03, 53.44). Folic acid supplementation (AOR: 0.40; 95% CI: 0.19–0.85), maternal exposure to pesticide (AOR: 3.29; 95% CI: 1.04–10.39), mothers with a previous history of stillbirth (AOR: 3.35, 95% CI: 1.99–5.65) and maternal exposure to x-ray radiation (AOR 2.34; 95% CI: 1.27–4.31) were found to be determinants of NTDs. Conclusions The pooled prevalence of NTDs in Africa was found to be high. Maternal exposure to pesticides and x-ray radiation were significantly associated with NTDs. Folic acid supplementation before and within the first month of pregnancy was found to be a protective factor for NTDs.

scholarly journals Front-line staff's perspective on patient safety culture in Iranian medical centers: A systematic review and meta-analysis

2020 ◽  
Vol 31 (4) ◽  
pp. 193-207
Author(s):  
Omid Khosravizadeh ◽  
Mohammad Mohseni ◽  
Najmeh Baghian ◽  
Aisa Maleki ◽  
Ailar Hashtroodi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Safety Culture ◽  
Medical Center ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Computer Software ◽  
Patient Safety Culture ◽  
Forest Plot

BACKGROUND: The prerequisite for promoting safety culture is to assess the existing safety culture level of institutes, because safety precautions without appropriate evaluation increase costs and unforeseen risks. OBJECTIVE: This study aimed to systematically review the status of patient safety culture from the perspective of clinical personnel at Iranian hospitals through a meta-analysis of studies using the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. METHODS: The present systematic review and meta-analysis was conducted in 2018. Data were gathered by searching Google Scholar, Scopus, PubMed, and Web of Science databases up to November 2018. Search keywords were “patient”, “safety”, “culture”, “healthcare”, “hospital”, “medical center”, “HSOPSC tool”, and “Iran”. The search protocol was limited to 10 years. To estimate the PSC score, computer software CMA:2 (Comprehensive Meta-Analysis) was used. The presence of heterogeneity across the studies was assessed with the I2 statistic. A forest plot was used to report the results. Publication bias was assessed through a funnel plot. RESULTS: The meta-analysis of studies showed that the PSC score based on the random effect model was 52.7% (95% CI: 50.2%–55.2%), (Q = 522.3, df = 54, P < 0.05, I2 = 89.6). A mean of 12 dimensions of HSOPSC showed that the “Teamwork within units” dimension had the highest PSC score (67.2%) and “Non-punitive response to error” had the lowest score (40.4%). CONCLUSIONS: Managers and policymakers should be directed towards non-punitive responses to errors and persuade staff to report errors and execute the approach to learn from mistakes. Also, a periodic government evaluation of the patient safety culture will help further its sustainable development.

scholarly journals Prevalence of Syphilis among Pregnant Women in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 2019 ◽  
pp. 1-10 ◽  
Author(s):  
Siraj Hussen ◽  
Birkneh Tilahun Tadesse
Keyword(s):  
Systematic Review ◽  
Pregnant Women ◽  
Screening Program ◽  
Meta Analysis ◽  
Relevant Literature ◽  
Sub Saharan Africa ◽  
Cochrane Library ◽  
Forest Plot ◽  
Pooled Prevalence ◽  
Sub Saharan

Objective. Syphilis is one of the most imperative STIs, caused by the spirochete Treponema pallidum. During pregnancy it is associated with disastrous health outcomes in the newborn. In sub-Saharan Africa, study findings on the prevalence of syphilis among pregnant women are highly dispersed and inconsistent. The aim of the current review is to conduct a systematic review and meta-analysis of syphilis in sub-Saharan Africa among pregnant women. Design. Systematic review and meta-analysis. Data Sources. Databases including MEDLINE, PubMed, Cochrane Library, Google Scholar, and HINARI and reference lists of previous prevalence studies were systematically searched for relevant literature from January 1999 to November 2018. Results were presented in forest plot, tables, and figures. Random-effects model was used for the meta-analysis. For the purpose of this review, a case of syphilis was defined as positive treponemal or nontreponemal tests among pregnant women. Data Extraction. Our search gave a total of 262 citations from all searched databases. Of these, 44 studies fulfilling the inclusion criteria and comprising 175,546 subjects were finally included. Results. The pooled prevalence of syphilis among pregnant women in sub-Saharan Africa was 2.9% (95%CI: 2.4%-3.4%). East and Southern African regions had a higher syphilis prevalence among pregnant women (3.2%, 95% CI: 2.3%-4.2% and 3.6%, 95%CI: 2.0%-5.1%, respectively) than the sub-Saharan African pooled prevalence. The prevalence of syphilis among pregnant women in most parts of the region seemed to have decreased over the past 20 years except for the East African region. However, prevalence did not significantly differ by region and time period. Conclusion. This review showed a high prevalence of syphilis in sub-Saharan Africa among pregnant women. The evidence suggests strengthening the screening program during pregnancy as part of the care package during antenatal care visits. Programs focusing on primary prevention of syphilis in women should also be strengthened.

scholarly journals Prevalence and determinants of undernutrition among school children of Ethiopia: a systematic review and meta-analysis

2019 ◽  
Author(s):  
Tamirat Hailegebreil
Keyword(s):  
Systematic Review ◽  
Family Size ◽  
School Children ◽  
Family Income ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Large Family ◽  
Pooled Prevalence ◽  
Male Sex

Abstract Background: Ethiopia is the second populous countries in Africa where millions of children are affected by malnutrition. Several original works are available online about child malnutrition in Ethiopia. The aim of this study was to summarize the existing epidemiological data on undernutrition and possible determinants among school children in Ethiopia. Methods: We conducted a systematic review using open access articles which report prevalence of stunting and wasting/thinness from PubMed Central, Scopus and Science direct. From 358 articles accessed online, 39 of them were eligible for this meta-analysis. The heterogeneities among studies were evaluated using I2 test and the pooled prevalence was calculated using a random effect model. Results: A total of 24, 716 school children were included in 39 eligible articles for this meta-analysis. The pooled prevalence of stunting and wasting/thinness among school children in Ethiopia were 23.1% (95% CI: 19.0 - 27.0%) and 22% (95% CI: 17% - 26%), respectively. The risk of stunting was increased among the student with meal frequency ≤ 3 times a day (OR= 3.02, 95% CI: 1.90 - 4.14), age > 10 years (OR= 2.16, 95% CI: 1.47 - 2.85) and family size ≥ 5 (OR= 1.88, 95% CI: 1.40 - 2.35). Similarly, the risk of wasting/thinness was increased with male sex (OR= 2.06, 95% CI: 1.54 - 2.58), low family income (OR= 2.16, 95% CI: 1.30 - 3.01) and age > 10 years (OR= 1.78, 95% CI: 0.74 - 2.82). High heterogeneity about the prevalence of stunting and wasting/thinness was observed among studies included in this meta-analysis (I2 > 98.6). Conclusions: This study showed that stunting and wasting/thinness are common nutritional problems in school children in Ethiopia. Large family size, male sex and age above 10 years were consistently associated with stunting and wasting/thinness in children. The finding of this study highlights the importance of new strategies to reduce undernutrition in Ethiopia. Keywords: stunting, wasting, thinness, undernutrition, systematic review, meta-analysis

scholarly journals The Prevalence of Metabolic Syndrome in Ethiopian Population: A Protocol for Systematic Review and Meta-analysis

2020 ◽  
Author(s):  
Sintayehu Ambachew ◽  
Aklilu Endalamaw ◽  
Belete Biadgo ◽  
Abebaw Worede ◽  
Mulugeta Melku
Keyword(s):  
Systematic Review ◽  
Metabolic Syndrome ◽  
English Language ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Group Analysis ◽  
Published Data ◽  
The Metabolic Syndrome ◽  
Pooled Prevalence

Abstract Background: The metabolic syndrome is a clustering of hyperglycemia/insulin resistance, hypertension, dyslipidemia and obesity which are risk factors for cardiovascular disease, type 2 diabetes, stroke and all-cause mortality. The burden of metabolic syndrome is emerging alarmingly in low-and middle income countries like Ethiopia. This is the protocol to determine the pooled prevalence of metabolic syndrome in Ethiopian population.Methods: This systematic review and meta-analysis will include original articles of observational studies published in the English language. Searches will be carried out in PubMed, Google Scholar, and Africa Journals up to April 2019. A Fixed/Random-effect model will be used to estimate the pooled prevalence of metabolic syndrome in Ethiopia. Heterogeneity will be assessed using I² statistic. Sub-group analysis will also be conducted based on sex, study subjects, and methodological differences. Funnel plots and egger’s and Begg’s test will be used to asses publication bias.Ethics and dissemination: The review is based on published data; therefore, ethical approval is not required. The systematic review and meta-analysis will summarize the existing data on the prevalence of metabolic syndrome in Ethiopian population. This provides the empirical evidence necessary for researchers, policy-makers, and public health stakeholders to derive health-promoting policies, allocate resources, and set priorities for monitoring future trends. The final result will be presented at annual scientific meetings, conferences, and seminars. Moreover, it will also be published in the peer-reviewed reputable journal. We also plan to review every 5 years to provide updated information.Protocol registration number: PROSPERO International Prospective Register of Systematic Reviews (CRD42018090944)

scholarly journals Burden of cervical lesion in Ethiopia: Systematic review and meta-analysis

2019 ◽  
Author(s):  
Ayele Semachew ◽  
Tadesse Dagget ◽  
Yeshiwork Beyene ◽  
Getnet Dessie ◽  
Aklilu Endalamaw ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cervical Cancer ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Cervical Lesion ◽  
Online Databases ◽  
Pooled Prevalence ◽  
Meta Regression Analysis ◽  
Study Participants

Abstract Though cervical cancer is largely preventable, it is still the second most common female cancer globally and the leading cause of cancer deaths among females in African. Though many efforts has been done to study the burden of the disease in Ethiopia, there are still fragmented primary studies reported cervical lesion. Hence, this systematic review and meta-analysis aimed in estimating the pooled prevalence of cervical cancer and its trend in Ethiopia. Methods: This systematic review and meta-analysis was conducted using available data. PubMed, Web of Science, SCOPUS, Science Direct, Google Scholar, African Index Medicus (AIM), African Journals Online databases and Ethiopian University research repositories were searched following the Preferred Items for Systematic review and Meta-analysis (PRISMA) guideline. STATA 15 statistical software was used to analyse the data. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) quality appraisal tool for meta-analysis. Heterogeneity between studies was assessed using Cochrane Q test and I2 test statistics based on the random effects model. A random effect model was computed to estimate the pooled prevalence of cervical lesion in Ethiopia. In addition, the trend of cervical lesion in the country was depicted. Result: Fifteen studies with a total of 25,348 participants were included in the analysis. The overall pooled prevalence of cervical lesion was 16.36 (95 CI: 10.97-21.75). The subgroup analysis by region showed the highest prevalence of cervical lesion at the Southern Nations and Nationalities Peoples Region (19.65%; 95% CI: 15.51 – 23.80). The trend of cervical lesion showed an increased pattern overtime from 1992 to 2018 in the meta-regression analysis. Conclusion: One among six of the study participants had cervical lesion. The trend also showed that there is still an increased cervical lesion in the country. Best practices in achieving high vaccination coverage shall be adapted from other successful countries. Key words: Cervical cancer, cervical lesion, systematic review, Ethiopia

scholarly journals Do Corticosteroids Affect Prenatal Biophysical Parameters? A Systematic Review and Meta-analysis

2020 ◽  
Vol 8 (3) ◽  
pp. 259-264
Author(s):  
Sanaz Musavi ◽  
Leila Nikniaz ◽  
Hosein Hoseinifard ◽  
Arezou Hamzehzadeh ◽  
Shabnam Vazifekhah
Keyword(s):  
Systematic Review ◽  
Heart Rate ◽  
Heart Rate Variability ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Cochrane Library ◽  
Effect Model ◽  
Biophysical Profile ◽  
Betamethasone And Dexamethasone

This systematic review and meta-analysis aimed to evaluate the effect of betamethasone and dexamethasone on biophysical profile (BPP) parameters. In addition, it was performed in 2017, using several databases such as PubMed/MEDLINE, Scopus, EMBASE, Cochrane library, ISI Web of science, Proquest, and Google scholar, along with Magiran SID and IranMedex. Eligible studies were selected by two reviewers and the outcomes of interest were extracted as well. Meta-analysis was done using the random effect model. Further, I-square statistic test was used for heterogeneity analysis and the presence of publication bias was also checked. At last, 12 studies were included and a random and fixed effect model was used for analysis. The pooled event rates were 4.5% (95% CI = 0.01-64.3, P=0.1), 76.8% (% 95 CI=33.5-95.6, P=0.21), 71.8% (% 95 CI=38.8-91.1, P=0.18), 70.9% (%95 CI=38.4-90.5, P=0.20), and 92.3% (%95 CI=76.0-97.8, P<0.001) for the reduced amniotic fluid volume, baseline fetal heart rate reactivity, fetal breathing, fetal movement, and heart rate variability, respectively. In summary, a significant decrease was observed in heart rate variability following betamethasone and dexamethasone administration. However, further systematic reviews are necessary to differentiate steroid induced changes in the fetal BPP from those due to fetal compromise

scholarly journals Association of human papilloma Virus infection other than cervical cancer: Systematic Review and Meta Analysis

2021 ◽  
Vol 44 (1) ◽  
pp. 119-128
Author(s):  
Habtamu Molla ◽  
Habtamu Temesgen ◽  
Dereje Beyene
Keyword(s):  
Systematic Review ◽  
Cervical Cancer ◽  
Human Papilloma Virus ◽  
Publication Bias ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Hpv Infection ◽  
Papilloma Virus ◽  
Pooled Prevalence

Human Papilloma Virus (hpv) infection causes different cancer diseases. Cervical cancer is the most common hpv related disease. hpv infection also causes cancer of anus, vulva, vagina, penis, skin, bladder, prostate, breast, oral and others because the hpv virus is epithelium-tropic. But the association of hpv infection other than cervical cancer, for example breast cancer, bladder cancer, prostate cancer etc is still inconclusive. Thus, the objective of this review was to collect published information on hpv infection other than cervix to explore the pooled prevalence of hpv infection as well as related types of cancers.  Publish research articles of hpv infection and cancer risks other than cervical cancer were systematically searched through Internet. The preferred reporting items for systematic review and meta-analysis guidelines were followed. Joanna Brigg’s Institute Meta-Analysis of Statistics Assessment and Review Instrument (jbi-mastari) adapted for cross sectional/case control study design was used for quality assessment of each individual study. A total of 22 studies were extracted and analyzed using stata 14. The random effect model was used to estimate the pooled prevalence; whereas subgroup analysis and meta-regression was performed to identify the probable source of heterogeneity. Both Egger’s and Begg’s tests were used to check publication bias.  The totals of 486 studies were retrieved and 22 studies were included in this meta- analysis. The meta-analysis result showed that the pooled prevalence of hpv infection other than cervix was 34.36% (95% CI: 23.75, 44.97) with severe heterogeneity (I2 = 99.5%; p<0.001) with no publication bias. The highest pooled prevalence of hpv infection other than cervix was related to genital cancer which is 58.63% (95% CI: 51.86, 65.39), followed by oral cancer (47.15% with 95% CI: 19.67, 74.63). Although cervical cancer is primarily hpv induced cancer which well articulated with so many researches, other cancer types (based on the location of the hpv infection) are also increasing across the world based on this systematic and meta-analysis study. hpv infection increases the risk of developing cancers other than cervical cancer.

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