human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objective : To assess the medical and psychosocial effects of  early hospital discharge after surgery for breast cancer on complication rate , patient satisfaction , and psychosocial outcomes . Design : R and omised trial comparing discharge from hospital 4 days after surgery ( with drain in situ ) with discharge after drain removal ( mean 9 days in hospital ) . Psychosocial measurements performed before surgery and 1 and 4 months after . Setting : General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population . Subjects : 125 women with operable breast cancer . Main outcome measures : Incidence of complications after surgery for breast cancer , patient satisfaction with treatment , and psychosocial effects of short stay or long stay in hospital . Results : Patient satisfaction with the short stay in hospital was high ; only 4 % ( 2/56 at 1 month after surgery and 2/52 at 4 months after surgery ) of patients indicated that they would have preferred a longer stay . There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups ( median 8 v 9 days respectively , P=0.45 ) or the incidence of wound complications ( 10 patients v 9 patients ) . The median number of seroma aspirations per patient was higher for the long stay group ( 1 v 3.5 , P=0.04 ) . Leakage along the drain occurred more frequently in short stay patients ( 21 v 10 patients , P=0.04 ) . The two groups did not differ in scores for psychosocial problems ( uncertainty , anxiety , loneliness , disturbed sleep , loss of control , threat to self esteem ) , physical or psychological complaints , or in the coping strategies used . Before surgery , short stay patients scored higher on scales of depression ( P=0.03 ) and after surgery they were more likely to discuss their disease with their families ( at 1 month P=0.004 , at 4 months P=0.04 ) . Conclusions : Early discharge from hospital after surgery for breast cancer is safe and is well received by patients . Early discharge seems to enhance the opportunity for social support within the family . Key messages Early discharge from hospital after breast cancer surgery does not lead to an increase in the incidence of wound infection or seroma formation A short stay in hospital , with support from community nurses on the patient 's return home , is acceptable to patients Psychosocial rehabilitation is not influenced by early discharge Recovery in the family environment may facilitate discussion of the illness Patients recovering from surgery for breast cancer need not spend more than three days in hospital provided that they are in good physical condition and there is adequate nursing support available in the OBJECTIVES To assess whether omission of postoperative radiotherapy in women with ' low-risk ' axillary node negative breast cancer ( T0 - 2 ) treated by breast-conserving surgery and endocrine therapy improves quality of life and is more cost-effective . DESIGN A r and omised controlled clinical trial , using a method of minimisation balanced by centre , grade of cancer , age , lymphatic/vascular invasion and preoperative endocrine therapy , was performed . A non-r and omised cohort was also recruited , in order to complete a comprehensive cohort study . SETTING The setting was breast cancer clinics in cancer centres in the UK . PARTICIPANTS Patients aged 65 years or more were eligible provided that their cancers were considered to be at low risk of local recurrence , were suitable for breast-conservation surgery , were receiving endocrine therapy and were able and willing to give informed consent . INTERVENTIONS The st and ard treatment of postoperative breast irradiation or the omission of radiotherapy . MAIN OUTCOME MEASURES Quality of life was the primary outcome measure , together with anxiety and depression and cost-effectiveness . Secondary outcome measures were recurrence rates , functional status , treatment-related morbidity and cosmesis . The principal method of data collection was by question naire , completed at home with a research nurse at four times over 15 months . RESULTS The hypothesised improvement in overall quality of life with the omission of radiotherapy was not seen in the EuroQol assessment or in the functionality and symptoms summary domains of the European Organisation for Research in the Treatment of Cancer ( EORTC ) scales . Some differences were apparent within subscales of the EORTC question naires , and insights into the impact of treatment were also provided by the qualitative data obtained by open-ended questions . Differences were most apparent shortly after the time of completion of radiotherapy . Radiotherapy was then associated with increased breast symptoms and with greater fatigue but with less insomnia and endocrine side-effects . Patients had significant concerns about the delivery of radiotherapy services , such as transport , accommodation and travel costs associated with receiving radiotherapy . By the end of follow-up , patients receiving radiotherapy were expressing less anxiety about recurrence than those who had not received radiotherapy .  Functionality was not greatly affected by treatment . Within the r and omised controlled trial , the Barthel Index demonstrated a small but significant fall in functionality with radiotherapy compared with the no radiotherapy arm of the trial . Results from the non-r and omised patients did not confirm this effect , however . Cosmetic results were better in those not receiving radiotherapy but this did not appear to be an important issue to the patients . The use of home-based assessment s by a research nurse proved to be an effective way of obtaining high- quality data . Costs to the NHS associated with postoperative radiotherapy were calculated to be of the order of 2000 pounds per patient . In the follow-up in this study , there were no recurrences , and the quality of life utilities from EuroQol were almost identical . CONCLUSIONS Although there are no differences in overall quality of life scores between the patients treated with and without radiotherapy , there are several dimensions that exhibit significant advantage to the omission of irradiation . Over the first 15 months , radiotherapy for this population is not a cost-effective treatment . However , the early postoperative outcome does not give a complete answer and the eventual cost-effectiveness will only become clear after long-term follow-up . Extrapolations from these data suggest that radiotherapy may not be a cost-effective treatment unless it results in a recurrence rate that is at least 5 % lower in absolute terms than those treated without radiotherapy . Further research is needed into a number of areas including the long-term aspects of quality of life , clinical outcomes , costs and consequences of omitting radiotherapy In a prospect i ve , r and omized study , an individual psychosocial support intervention performed by specially trained oncology nurses , or psychologists , were compared with st and ard care .  Consecutive primary breast cancer patients about to start adjuvant therapy ( n = 179 ) were included . Data were supplied by the question naires European Organisation for Research and Treatment of Cancer Quality of Life Study Group Core Quality of life question naire with 30 questions ( EORTC QLQ-C30 ) and Breast Cancer Module with 23 questions ( BR23 ) , the Hospital Anxiety and Depression Scale , Spielberger 's State-Trait Anxiety Inventory , and the Impact of Event Scale before r and omization and 1 , 3 , and 6 months later . Patient files provided data on utilization of psychosocial support offered in routine care . Global quality of life/health status , nausea and vomiting , and systemic therapy side effects were the subscales showing significant Group by Time interactions , favoring the interventions . Intervention groups improved statistically significantly more than the st and ard care group regarding insomnia , dyspnea , and financial difficulties . Nurse patients experienced less intrusion compared with the st and ard care group . All groups showed statistically and clinical ly significant improvements with time on several subscales . The intervention groups , however , improved to a greater extent . Fewer patients in the intervention groups used psychosocial hospital support compared with the st and ard care group . In conclusion , psychosocial support by specially trained nurses using techniques derived from cognitive behavioral therapy is beneficial for breast cancer patients and may be a realistic alternative in routine cancer care Objectives : To test experimentally whether a psychological intervention reduces depression-related symptoms and markers of inflammation among cancer patients and to test one mechanism for the intervention effects . Depression and inflammation are common among cancer patients . Data suggest that inflammation can contribute to depressive symptoms , although the converse remains untested . Methods : As part of a r and omized clinical trial , newly diagnosed breast cancer patients ( n = 45 ) with clinical ly significant depressive symptoms were evaluated and r and omized to psychological intervention with assessment or assessment only study arms . The intervention spanned 12 months , with assessment s at baseline , 4 , 8 , and 12 months . Mixed-effects modeling tested the hypothesis that the intervention reduced self-reported depressive symptoms ( Center for Epidemiological Studies Depression scale , Profile of Mood States Depression and Fatigue subscales , and Medical Outcomes Study -Short Form 36 Bodily Pain subscale ) and immune cell numbers that are elevated in the presence of inflammation ( white blood cell count , neutrophil count , and helper/suppressor ratio ) . Mediation analyses tested whether change in depressive symptoms , pain , or fatigue predicted change in white blood cell count , neutrophil count , or the helper/suppressor ratio . Results : The intervention reduced significantly depressive symptoms , pain , fatigue , and inflammation markers . Moreover , the intervention effect on inflammation was mediated by its effect on depressive symptoms . Conclusions : This is the first experiment to test whether psychological treatment effective in reducing depressive symptoms would also reduce indicators of inflammation . Data show that the intervention reduced directly depressive symptoms and reduced indirectly inflammation . Psychological treatment may treat effectively depressive symptoms , pain , and fatigue among cancer patients . CES-D = Center for Epidemiological Studies -Depression scale , Iowa short form ; SF-36 = Medical Outcomes Study -Short Form 36 ; KPS = Karnofsky Performance Status Summary Background . Fatigue can significantly interfere with a cancer patient ’s ability to fulfill daily responsibilities and enjoy life . It commonly co-exists with depression in patients undergoing chemotherapy , suggesting that administration of an antidepressant that alleviates symptoms of depression could also reduce fatigue . Methods . We report on a double-blind clinical trial of 94 female breast cancer patients receiving at least four cycles of chemotherapy r and omly assigned to receive either  20 mg of the selective serotonin re-uptake inhibitor ( SSRI ) paroxetine ( Paxil ® , SmithKline Beecham Pharmaceuticals ) or an identical-appearing placebo . Patients began their study medication seven days following their first on- study treatment and continued until seven days following their fourth on- study treatment . Seven days after each treatment , participants completed question naires measuring fatigue ( Multidimensional Assessment of Fatigue , Profile of Mood States-Fatigue/Inertia subscale and Fatigue Symptom Checklist ) and depression ( Profile of Mood States-Depression subscale [ POMS-DD ] and Center for Epidemiologic Studies -Depression [ CES-D ] ) . Results . Repeated- measures ANOVAs , after controlling for baseline measures , showed that paroxetine was more effective than placebo in reducing depression during chemotherapy as measured by the CES-D ( p=0.006 ) and the POMS-DD ( p=0.07 ) but not in reducing fatigue ( all measures , ps > 0.27 ) . Conclusions . Although depression was significantly reduced in the 44 patients receiving paroxetine  compared to the 50 patients receiving placebo , indicating that a biologically active dose was used , no significant differences between groups on any of the measures of fatigued were observed . Results suggest that modulation of serotonin may not be a primary mechanism of fatigue related to cancer treatment Goal of workTo study the effect of support intervention on immune function in breast cancer patients . Material s and methods Breast cancer patients from an ongoing prospect i ve r and omised quality -of -life study were chosen for assaying immune functions in relation to a support-group intervention program running on a residential basis . Twenty-one women received adjuvant-combined radio-chemotherapy ( CT-RT ) and 20 women radiotherapy ( RT ) . Eleven CT-RT and ten RT patients were r and omised to  support-group intervention , the rest served as controls .  Immune tests for NK cells and NK-cell cytotoxicity , as well as lymphocyte sub population s and response to antigen were performed before intervention , 2 , 6 , and 12 months later , in parallel to controls and healthy volunteers ( n = 11 ) .  Depression , anxiety and fatigue were evaluated by the Hospital Anxiety and Depression ( HAD ) and the Norwegian Fatigue question naire . The density of NK cell receptors and in vitro quantitation of functional NK cytotoxicity against K562 cell line were evaluated . Four-colour flow cytometry was used to detect signal transduction molecules and cytokine expression . T-cell proliferate response to purified protein derivate ( PPD ) antigen was evaluated . Results No significant immune effect of support intervention could be found . The immune variables were severely disarranged compared to healthy volunteers but showed a statistically significant improvement over time . The majority of patients suffered from fatigue but had low scores for depression and anxiety . Conclusion No effect on immune parameters could be detected from support intervention . The long-lasting immune suppression might override a putative effect of the intervention . Low depression scores may contribute to the absence of a detectable effect CONTEXT AND OBJECTIVE Guaraná ( Paullinia cupana ) has been used medicinally for centuries . The aim of this study is evaluate the effectiveness of guaraná in the treatment of postradiation depression and fatigue . DESIGN AND SETTING This study had a double-blind r and omized design with crossover between experimental arms , at Faculdade de Medicina da Fundação do ABC . METHODS We conducted a r and omized double-blind crossover trial with 36 patients with breast cancer undergoing adjuvant radiation therapy . We r and omized patients to either guaraná 75 mg daily p.o . or to placebo . Patients were switched to the other experimental arm at the middle of the radiation treatment , which consisted of  
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objective : To assess the medical and psychosocial effects of  early hospital discharge after surgery for breast cancer on complication rate , patient satisfaction , and psychosocial outcomes . Design : R and omised trial comparing discharge from hospital 4 days after surgery ( with drain in situ ) with discharge after drain removal ( mean 9 days in hospital ) . Psychosocial measurements performed before surgery and 1 and 4 months after . Setting : General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population . Subjects : 125 women with operable breast cancer . Main outcome measures : Incidence of complications after surgery for breast cancer , patient satisfaction with treatment , and psychosocial effects of short stay or long stay in hospital . Results : Patient satisfaction with the short stay in hospital was high ; only 4 % ( 2/56 at 1 month after surgery and 2/52 at 4 months after surgery ) of patients indicated that they would have preferred a longer stay . There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups ( median 8 v 9 days respectively , P=0.45 ) or the incidence of wound complications ( 10 patients v 9 patients ) . The median number of seroma aspirations per patient was higher for the long stay group ( 1 v 3.5 , P=0.04 ) . Leakage along the drain occurred more frequently in short stay patients ( 21 v 10 patients , P=0.04 ) . The two groups did not differ in scores for psychosocial problems ( uncertainty , anxiety , loneliness , disturbed sleep , loss of control , threat to self esteem ) , physical or psychological complaints , or in the coping strategies used . Before surgery , short stay patients scored higher on scales of depression ( P=0.03 ) and after surgery they were more likely to discuss their disease with their families ( at 1 month P=0.004 , at 4 months P=0.04 ) . Conclusions : Early discharge from hospital after surgery for breast cancer is safe and is well received by patients . Early discharge seems to enhance the opportunity for social support within the family . Key messages Early discharge from hospital after breast cancer surgery does not lead to an increase in the incidence of wound infection or seroma formation A short stay in hospital , with support from community nurses on the patient 's return home , is acceptable to patients Psychosocial rehabilitation is not influenced by early discharge Recovery in the family environment may facilitate discussion of the illness Patients recovering from surgery for breast cancer need not spend more than three days in hospital provided that they are in good physical condition and there is adequate nursing support available in the OBJECTIVES To assess whether omission of postoperative radiotherapy in women with ' low-risk ' axillary node negative breast cancer ( T0 - 2 ) treated by breast-conserving surgery and endocrine therapy improves quality of life and is more cost-effective . DESIGN A r and omised controlled clinical trial , using a method of minimisation balanced by centre , grade of cancer , age , lymphatic/vascular invasion and preoperative endocrine therapy , was performed . A non-r and omised cohort was also recruited , in order to complete a comprehensive cohort study . SETTING The setting was breast cancer clinics in cancer centres in the UK . PARTICIPANTS Patients aged 65 years or more were eligible provided that their cancers were considered to be at low risk of local recurrence , were suitable for breast-conservation surgery , were receiving endocrine therapy and were able and willing to give informed consent . INTERVENTIONS The st and ard treatment of postoperative breast irradiation or the omission of radiotherapy . MAIN OUTCOME MEASURES Quality of life was the primary outcome measure , together with anxiety and depression and cost-effectiveness . Secondary outcome measures were recurrence rates , functional status , treatment-related morbidity and cosmesis . The principal method of data collection was by question naire , completed at home with a research nurse at four times over 15 months . RESULTS The hypothesised improvement in overall quality of life with the omission of radiotherapy was not seen in the EuroQol assessment or in the functionality and symptoms summary domains of the European Organisation for Research in the Treatment of Cancer ( EORTC ) scales . Some differences were apparent within subscales of the EORTC question naires , and insights into the impact of treatment were also provided by the qualitative data obtained by open-ended questions . Differences were most apparent shortly after the time of completion of radiotherapy . Radiotherapy was then associated with increased breast symptoms and with greater fatigue but with less insomnia and endocrine side-effects . Patients had significant concerns about the delivery of radiotherapy services , such as transport , accommodation and travel costs associated with receiving radiotherapy . By the end of follow-up , patients receiving radiotherapy were expressing less anxiety about recurrence than those who had not received radiotherapy .  Functionality was not greatly affected by treatment . Within the r and omised controlled trial , the Barthel Index demonstrated a small but significant fall in functionality with radiotherapy compared with the no radiotherapy arm of the trial . Results from the non-r and omised patients did not confirm this effect , however . Cosmetic results were better in those not receiving radiotherapy but this did not appear to be an important issue to the patients . The use of home-based assessment s by a research nurse proved to be an effective way of obtaining high- quality data . Costs to the NHS associated with postoperative radiotherapy were calculated to be of the order of 2000 pounds per patient . In the follow-up in this study , there were no recurrences , and the quality of life utilities from EuroQol were almost identical . CONCLUSIONS Although there are no differences in overall quality of life scores between the patients treated with and without radiotherapy , there are several dimensions that exhibit significant advantage to the omission of irradiation . Over the first 15 months , radiotherapy for this population is not a cost-effective treatment . However , the early postoperative outcome does not give a complete answer and the eventual cost-effectiveness will only become clear after long-term follow-up . Extrapolations from these data suggest that radiotherapy may not be a cost-effective treatment unless it results in a recurrence rate that is at least 5 % lower in absolute terms than those treated without radiotherapy . Further research is needed into a number of areas including the long-term aspects of quality of life , clinical outcomes , costs and consequences of omitting radiotherapy In a prospect i ve , r and omized study , an individual psychosocial support intervention performed by specially trained oncology nurses , or psychologists , were compared with st and ard care .  Consecutive primary breast cancer patients about to start adjuvant therapy ( n = 179 ) were included . Data were supplied by the question naires European Organisation for Research and Treatment of Cancer Quality of Life Study Group Core Quality of life question naire with 30 questions ( EORTC QLQ-C30 ) and Breast Cancer Module with 23 questions ( BR23 ) , the Hospital Anxiety and Depression Scale , Spielberger 's State-Trait Anxiety Inventory , and the Impact of Event Scale before r and omization and 1 , 3 , and 6 months later . Patient files provided data on utilization of psychosocial support offered in routine care . Global quality of life/health status , nausea and vomiting , and systemic therapy side effects were the subscales showing significant Group by Time interactions , favoring the interventions . Intervention groups improved statistically significantly more than the st and ard care group regarding insomnia , dyspnea , and financial difficulties . Nurse patients experienced less intrusion compared with the st and ard care group . All groups showed statistically and clinical ly significant improvements with time on several subscales . The intervention groups , however , improved to a greater extent . Fewer patients in the intervention groups used psychosocial hospital support compared with the st and ard care group . In conclusion , psychosocial support by specially trained nurses using techniques derived from cognitive behavioral therapy is beneficial for breast cancer patients and may be a realistic alternative in routine cancer care Objectives : To test experimentally whether a psychological intervention reduces depression-related symptoms and markers of inflammation among cancer patients and to test one mechanism for the intervention effects . Depression and inflammation are common among cancer patients . Data suggest that inflammation can contribute to depressive symptoms , although the converse remains untested . Methods : As part of a r and omized clinical trial , newly diagnosed breast cancer patients ( n = 45 ) with clinical ly significant depressive symptoms were evaluated and r and omized to psychological intervention with assessment or assessment only study arms . The intervention spanned 12 months , with assessment s at baseline , 4 , 8 , and 12 months . Mixed-effects modeling tested the hypothesis that the intervention reduced self-reported depressive symptoms ( Center for Epidemiological Studies Depression scale , Profile of Mood States Depression and Fatigue subscales , and Medical Outcomes Study -Short Form 36 Bodily Pain subscale ) and immune cell numbers that are elevated in the presence of inflammation ( white blood cell count , neutrophil count , and helper/suppressor ratio ) . Mediation analyses tested whether change in depressive symptoms , pain , or fatigue predicted change in white blood cell count , neutrophil count , or the helper/suppressor ratio . Results : The intervention reduced significantly depressive symptoms , pain , fatigue , and inflammation markers . Moreover , the intervention effect on inflammation was mediated by its effect on depressive symptoms . Conclusions : This is the first experiment to test whether psychological treatment effective in reducing depressive symptoms would also reduce indicators of inflammation . Data show that the intervention reduced directly depressive symptoms and reduced indirectly inflammation . Psychological treatment may treat effectively depressive symptoms , pain , and fatigue among cancer patients . CES-D = Center for Epidemiological Studies -Depression scale , Iowa short form ; SF-36 = Medical Outcomes Study -Short Form 36 ; KPS = Karnofsky Performance Status Summary Background . Fatigue can significantly interfere with a cancer patient ’s ability to fulfill daily responsibilities and enjoy life . It commonly co-exists with depression in patients undergoing chemotherapy , suggesting that administration of an antidepressant that alleviates symptoms of depression could also reduce fatigue . Methods . We report on a double-blind clinical trial of 94 female breast cancer patients receiving at least four cycles of chemotherapy r and omly assigned to receive either  20 mg of the selective serotonin re-uptake inhibitor ( SSRI ) paroxetine ( Paxil ® , SmithKline Beecham Pharmaceuticals ) or an identical-appearing placebo . Patients began their study medication seven days following their first on- study treatment and continued until seven days following their fourth on- study treatment . Seven days after each treatment , participants completed question naires measuring fatigue ( Multidimensional Assessment of Fatigue , Profile of Mood States-Fatigue/Inertia subscale and Fatigue Symptom Checklist ) and depression ( Profile of Mood States-Depression subscale [ POMS-DD ] and Center for Epidemiologic Studies -Depression [ CES-D ] ) . Results . Repeated- measures ANOVAs , after controlling for baseline measures , showed that paroxetine was more effective than placebo in reducing depression during chemotherapy as measured by the CES-D ( p=0.006 ) and the POMS-DD ( p=0.07 ) but not in reducing fatigue ( all measures , ps > 0.27 ) . Conclusions . Although depression was significantly reduced in the 44 patients receiving paroxetine  compared to the 50 patients receiving placebo , indicating that a biologically active dose was used , no significant differences between groups on any of the measures of fatigued were observed . Results suggest that modulation of serotonin may not be a primary mechanism of fatigue related to cancer treatment Goal of workTo study the effect of support intervention on immune function in breast cancer patients . Material s and methods Breast cancer patients from an ongoing prospect i ve r and omised quality -of -life study were chosen for assaying immune functions in relation to a support-group intervention program running on a residential basis . Twenty-one women received adjuvant-combined radio-chemotherapy ( CT-RT ) and 20 women radiotherapy ( RT ) . Eleven CT-RT and ten RT patients were r and omised to  support-group intervention , the rest served as controls .  Immune tests for NK cells and NK-cell cytotoxicity , as well as lymphocyte sub population s and response to antigen were performed before intervention , 2 , 6 , and 12 months later , in parallel to controls and healthy volunteers ( n = 11 ) .  Depression , anxiety and fatigue were evaluated by the Hospital Anxiety and Depression ( HAD ) and the Norwegian Fatigue question naire . The density of NK cell receptors and in vitro quantitation of functional NK cytotoxicity against K562 cell line were evaluated . Four-colour flow cytometry was used to detect signal transduction molecules and cytokine expression . T-cell proliferate response to purified protein derivate ( PPD ) antigen was evaluated . Results No significant immune effect of support intervention could be found . The immune variables were severely disarranged compared to healthy volunteers but showed a statistically significant improvement over time . The majority of patients suffered from fatigue but had low scores for depression and anxiety . Conclusion No effect on immune parameters could be detected from support intervention . The long-lasting immune suppression might override a putative effect of the intervention . Low depression scores may contribute to the absence of a detectable effect CONTEXT AND OBJECTIVE Guaraná ( Paullinia cupana ) has been used medicinally for centuries . The aim of this study is evaluate the effectiveness of guaraná in the treatment of postradiation depression and fatigue . DESIGN AND SETTING This study had a double-blind r and omized design with crossover between experimental arms , at Faculdade de Medicina da Fundação do ABC . METHODS We conducted a r and omized double-blind crossover trial with 36 patients with breast cancer undergoing adjuvant radiation therapy . We r and omized patients to either guaraná 75 mg daily p.o . or to placebo . Patients were switched to the other experimental arm at the middle of the radiation treatment , which consisted of  
    Output:
    