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The Giles family is celebrating two miracles after the 20 year-old mom opened her eyes and saw a picture of her newborn child.
Sharista Giles awakened this week from a four month coma that doctors had feared would be permanent and learned that she had given birth to a baby boy.
Sharista was four-months pregnant when she was involved in a car crash near Nashville, Tennessee. Doctors told her family she had a 10% chance of coming out of the coma.
"The doctors were telling us there was nothing else they could do," her aunt Beverly Giles, 49, told ABC News. "They already gave up hope. We never gave up. She's fought this hard."
The infant, who is being called "Baby L" until his mom is able to give him a proper name, weighed just over 1 pound when he was welcomed into the world a month after the accident.
But now he's healthy, weighing 6 pounds and 4 ounces, and proving he's as strong as his mother - who still hasn't spoken yet.
Sharista's father held up a picture of "Baby L" when she woke up, and she never took her eyes off the image, her aunt told ABC News. "When he turned around to put it back on the bulletin board, she turned her neck, her whole head trying to follow and find the picture again."
Informatics programs that allow med/surg nurses to cut down on documentation and increase patient safety at the touch of a button are becoming more essential in today’s fast-paced healthcare environment.
“Most all nurses use the electronic health record in their daily practice,” said Jill Arzouman, MSN, RN, ACNS-BC, CMSRN, president of the Academy of Medical-Surgical Nurses and clinical nurse specialist in surgical oncology at the University of Arizona Medical Center, Tucson. The university has computer stations inside each patient room for access to charting, she said, and some hospitals are investing in iPads to facilitate charting. Arzouman is a DNP candidate.
Med/surg nurses at New York’s Montefiore Health System in the Bronx use informatics throughout the day to document patients’ electronic medical records and provide direct care to patients, said Maureen Scanlan, MSN, RN-BC, vice president, nursing and patient care services and former director of informatics for the health system. “Electronic documentation has provided us the ability to track and trend patient outcomes data in a more efficient manner. We have the added benefit of decision support alerts to guide practice and documentation. We then can leverage information collected from the records to streamline workflows and improve patient safety.”
According to a HealthIt.gov study “Benefits of EHRs,” (www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes), having quick, up-to-date access to patients’ information can also reduce errors and support better patient outcomes by keeping a record of a patient’s medications or allergies, checking for problems whenever a new medication is prescribed and alerting the clinician to potential conflicts.
“The ability to clearly read a medication order printed from a computer is vastly different than trying to decipher a handwritten order,” said Arzouman.
In addition, staff can revisit patient information at any time.
“Many of the systems are very intuitive and allow the entire interdisciplinary team to document and communicate with precision and ease,” she said “A medical/surgical nurse may be busy with another patient but she or he can go back and read documentation from the dietitian who may have visited the patient at the same time.“
A reduction in medication errors was the catalyst for a project using computerized EHRs at Abington (Penn.) Health. When staff realized that patients with heart failure were being readmitted largely because of incorrect medication lists upon discharge, Diane Humbrecht, MSN, RN-BC, chief nursing informatics officer, devised a plan to evaluate the accuracy of such lists.
Humbrecht, a DNP candidate who is also a chapter director for the American Nursing Informatics Association, has worked in both cardiac and home care during her career and said she had experienced heart failure patients going home with medication lists that were either incorrect or missing information.
“It was very frustrating for both the patient and the nurse who is trying to follow up,” she said.
As part of her DNP program, Humbrecht decided to focus on transitions of care for this vulnerable population to help correct their discharge medication instructions and reduce their risk for readmission.
“As I began researching, I saw medication errors on medication discharge lists were the main reasons patients were readmitted to the hospital,” she said. •
Her findings were validated, she said, when the transition nurses who were involved in the postop discharge process informed her of problems with patients going home with incorrect medication lists. “Medication reconciliation and discharge instructions are done by the physician, but the nurses are the ones who review them and they were finding these errors after discharge,” she said.
Humbrecht implemented three changes to remedy the situation. The first step was to bring the pharmacists in on the front end. Pharmacists already performed patient rounding on units, but they were not involved in medication reconciliation at all, she said. The new protocol called for pharmacists to come in within 24 hours of a patient’s admittance to review the co-medications. The input from the pharmacists on the front end was crucial. “The pharmacists had to change about 80% of the lists,” Humbrecht said.
Next, upon discharge, the nurses perform a thorough review of the co-medications list that was corrected by the pharmacist. “If anything needed to be corrected, the nurse then called the physician to tell them they need to change a medication,” Humbrecht said. “Once that was done, it caused the physician to perform medication reconciliation again, automatically updating the entire medication list.”
The transition nurses were the final piece to the puzzle. Prior to the new protocol, upon calling the discharged patient and finding any errors, the nurse would make notations on paper. If the patient was readmitted, and the change was not transferred onto the patient’s EHR, the incorrect information was still in the system. Now, using the computerized medication list, any errors are updated immediately in the system.
The changes worked. Since implementation last fall, the transition nurses have found one error on the medication list of a discharged patient, Humbrecht said.
“We figured if we can get the home medication list correct on the front end by using the pharmacists and double-checked and changed as needed by the nurses on the back end, then the transition nurses should find less errors,” she said.
Besides documentation and patient safety, med/surg nurses are using informatics to enhance patient care. “Our staff nurses provide expert advice when we are defining a new process for delivering patient care,” said Scanlan, who holds board certification in nursing informatics. “A recent implementation of a new lab system that changed the way specimens are collected was successful due to workflow and hardware recommendations from the frontline staff.”
Scanlan said staff nurses recently have contributed to revising the electronic skin assessment template as well.
“Although not a clear time saver,” she said, “it has significantly improved the ability to track, trend and communicate hospital-acquired pressure ulcers [and] has supported performance improvement efforts that are led by the nursing staff.”
Arzouman also noted innovative uses. “For a postoperative patient who needs to continue to ambulate and exercise while at home, a medical/surgical nurse can teach the patient how to track his activity using a smart phone app,” she said. “I have had the opportunity to trial an app on my smart phone that translates basic medical information into many different languages without needing to use a translator. For something simple like ‘Hi, my name is Jill and I will be the nurse coordinating your care today,’ it is a very helpful tool.”
Formerly conjoined twins Knatalye Hope and Adeline Faith Mata celebrated their first birthday with a "Frozen"-themed party at the hospital.
A team at Texas Children's Hospital separated the girls on Feb. 17 in a 26-hour surgery. They are still in the pediatric intensive care unit and have each had a few surgeries since the separation, but their mother, Elysse Mata, decorated their room with snowflakes and balloons.
"It's been a year," Mata said, surrounded by presents as the hospital filmed her. "It went by so fast. I feel like just yesterday they were born."
Earlier in the week, Mata had a party for everyone at the hospital who helped her babies over the last year. She said she was sad to leave some of the doctors from before the separation, but she knows it's a positive thing.
"Now they're good and healthy and hopefully headed towards home," said Mata, 25, of Lubbock, Texas.
Mata was shocked to learn the twins were conjoined when she was pregnant with them, she told ABC News in July.
"I was speechless, it was so unexpected,” she said.
The girls were born on April 11, 2014 at Texas Children's Hospital. They shared a chest wall, diaphragm, intestines, lungs, lining of the heart and pelvis. Their middle names are Hope and Faith because you can't have one without the other, she said.
"Nightline" was at the hospital in February as 12 surgeons operated on the Mata twins, and Elysse, her husband and 20 family members camped out in the waiting room.
In February, Medical News Today reported that an Italian surgeon is to announce updated plans to conduct the world's first human head transplant within the next 2 years. Now, a 30-year-old Russian man is set to become the first person to undergo the procedure.
Dr. Sergio Canavero, of the Turin Advanced Neuromodulation Group (TANG) in Italy, first spoke of his plans to carry out the first human head transplantation in July 2013 - a project named HEAVEN-GEMINI.
At the American Academy of Neurological and Orthopedic Surgeons' 39th Annual Conference in Annapolis, MD, in June, Dr. Canavero will present updated plans for the project, addressing some of the previously identified challenges that come with it.
Though researchers have seriously questioned the feasibility of Dr. Canavero's plans, it seems the first human head transplantation is a step closer to becoming a reality; Valery Spiridonov, a 30-year-old computer scientist from Vladimir, Russia, is the first person to volunteer for the procedure.
Spiridonov has Werdnig-Hoffman disease - a rare genetic muscle wasting condition, also referred to as type 1 spinal muscular atrophy (SMA). The condition is caused by the loss of motor neurons in the spinal cord and the brain region connected to the spinal cord. Individuals with the disease are unable to walk and are often unable to sit unaided.
Spiridonov was diagnosed with Werdnig-Hoffman disease at the age of 1 and told MailOnline that he volunteered for HEAVEN-GEMINI because he wants the chance of a new body before he dies.
'"I can hardly control my body now," he said. "I need help every day, every minute. I am now 30 years old, although people rarely live to more than 20 with this disease."
Donor body will be attached to recipient's head through spinal cord fusion
Dr. Canavero told CNN he has received an array of emails and letters from people asking to be considered for the procedure, many of which have been from transgender individuals seeking a new body. However, the surgeon says the first people to undergo the procedure will be those with muscle wasting conditions like Spiridonov.
The procedure - which is estimated to take 100 surgeons around 36 hours to complete - will involve spinal cord fusion (SCF). The head from a donor body will be removed using an "ultra-sharp blade" in order to limit the amount of damage the spinal cord sustains.
"The key to SCF is a sharp severance of the cords themselves," Dr. Canavero explains in a paper published earlier this year, "with its attendant minimal damage to both the axons in the white matter and the neurons in the gray laminae. This is a key point."
The spinal cord of the donor body will then be fused with the spinal cord of the recipient's head. Chemicals called polyethylene glycol or chitosan can be used to encourage SCF, according to Dr. Canavero. The muscles and blood supply will then be sutured.
The recipient will be kept in a coma for around 3-4 weeks, says Dr. Canavero, during which time the spinal cord will be subject to electrical stimulation via implanted electrodes in order to boost the new nerve connections.
The surgeon estimates that - with the help of physical therapy - the patient would be able to walk within 1 year.
Spiridonov admits he is worried about undergoing the procedure. "Am I afraid? Yes, of course I am," he told MailOnline. "But it is not just very scary, but also very interesting."
"You have to understand that I don't really have many choices," he added. "If I don't try this chance my fate will be very sad. With every year my state is getting worse."
Spiridonov talks more about his decision to participate in HEAVEN-GEMINI in the video below:
Dr. Canavero branded 'nuts'
Dr. Canavero has previously admitted there are two major challenges with HEAVEN-GEMINI: reconnecting the severed spinal cord, and stopping the immune system from rejecting the head. But he claims that recent animal studies have shown the procedure is "feasible."
Unsurprisingly, however, researchers worldwide are highly skeptical of the proposal. Talking to CNN, Arthur Caplan, PhD, director of medical ethics and NYU Langone Medical Center in New York, NY, even called Dr. Canavero "nuts."
Caplan said the procedure needs to be conducted many more times on animals before it is applied to humans, adding that if the technique is feasible then Dr. Canavero should be trying to help paralyzed patients before attempting whole body transplants.
And talking to New Scientist earlier this year, Harry Goldsmith, a clinical professor of neurosurgery at the University of California-Davis, said the project is so "overwhelming" that it is the chances of it going ahead are unlikely.
"I don't believe it will ever work," he added, "there are too many problems with the procedure. Trying to keep someone healthy in a coma for 4 weeks - it's not going to happen."
Spiridonov says he is well aware of the risks, though he is still willing to take a chance on Dr. Canavero.
"He's a very experienced neurosurgeon and has conducted many serious operations. Of course he has never done anything like this and we have to think carefully through all the possible risks," he told MailOnline, but adds that "if you want something to be done, you need to participate in it."
Though it not been confirmed when the procedure will be performed, Spiridonov says it could be as early as next year.
Researchers have identified a signal in the amygdala brain region of young children that stimulates aversion to the opposite sex and induces interest in the opposite sex as children enter puberty.
Published in the Journal of Cognitive Neuroscience, the study challenges previous beliefs about the role of the amygdala, according to the researchers.
Lead investigator Eva Telzer, of the University of Illinois at Urbana-Champaign, says the amygdala was once believed to be a threat detector. "But increasing evidence indicates that it is activated whenever someone detects something meaningful in the environment," she notes. "It is a significance detector."
To reach their findings, Telzer and her team enrolled 93 youths aged 7-17 years to the study and assessed their attitudes toward children of the same sex and of the opposite sex.
In addition, the researchers used functional magnetic resonance imaging (fMRI) to assess the brain activity of 52 youths aged 4-18 as they viewed same- and opposite-sex faces.
Amygdala activity wanes between the ages of 10 and 12
The team found that young children aged 4-7 years had more negative attitudes toward the opposite sex - a finding they say supports the "cooties" phenomenon, in which young children steer clear of the opposite sex with the belief that they may "contaminate" them if they get too close.
"Only the youngest children in our sample demonstrated a behavioral sex bias such that they rated same-sex peers as having more positive (and less negative) attributes than opposite-sex peers," say the researchers.
Interestingly, children of this age showed increased brain activity in the amygdala region of the brain as they viewed faces of the opposite sex. "And so we think the amygdala is signaling the significance of cooties at this developmental period," says Telzer.
The researchers found that among children between ages of 10 and 12, there was no difference in the amygdala's response to same- and opposite-sex faces.
However, they saw a significant increase in amygdala response to the opposite sex from 12 years onwards - just as children begin to enter puberty. The researchers say this may correspond with the "crush" phenomenon, in which pubescent youths become captivated with the opposite sex.
"When puberty hits, gender becomes more significant again, whether it's because your body is changing, or because of sexual attraction or you are becoming aware of more rigid sexual boundaries as you become more sexually mature," says Telzer. "The brain is responding very appropriately, in terms of what's changing developmentally."
In May 2014, Medical News Today reported on a study published in the Proceedings of the National Academy of Sciences, in which researchers found changes in cerebral blood flow levels differ between girls and boys during puberty, with such levels rising in girls and reducing in boys.
The researchers of that study - led by Dr. Theodore Satterthwaite of Perelman School of Medicine at the University of Pennsylvania - say the findings were linked to higher risk of anxiety in females and increased risk of schizophrenia in males.
"These findings help us understand normal neurodevelopment and could be a step toward creating normal 'growth charts' for brain development in kids," says Dr. Satterthwaite. "These results also show what every parent knows: boys and girls grow differently. This applies to the brain as well."
Matt and Danielle Davis had been married only seven months when a devastating motorcycle accident left Matt on life support and in a coma.
Given only a 10% chance of waking up, Davis told WTOC that doctors advised her to pull the plug on her husband. She recalled hearing them say, "That's what they'd want their family to do."
Danielle refused to give up on him. "We didn't really have a chance to start our life together, I wasn't going to give up."
Matt spent three months in the coma, and moved from the hospital to their home where Danielle cared for him 24/7.
Then one day, against all odds, Matt said, "I'm trying."
He eventually came out of his coma, but he didn't remember anything that had happened in the last three years. He retained no memory of his father's death, or even meeting and marrying his wife.
But in the time that has passed since the accident, Matt has made amazing progress. Physical therapy has helped him learn to walk again.
They play scrabble and enjoy going to yoga classes together, and he's recently started driving a stick shift car for fun because he loves cars.
"One conversation with Matt will change your life," Danielle shared. "He has a servant's heart and a love for people. He never complains or feels anger about his circumstance. He just wants to make a difference and give hope."
The couple is currently trying to raise funds for Matt to continue his therapy.
A promising technique for making brain tumors glow so they'll be easier for surgeons to remove is now being tested in cancer patients.
Eighteen months ago, Shots first told readers about tumor paint, an experimental substance derived from scorpion venom. Inject tumor paint into a patient's vein, and it will actually cross the blood-brain barrier and find its way to a brain tumor. Shine near-infrared light on a tumor coated with tumor paint, and the tumor will glow.
The main architect of the tumor paint idea is a pediatric oncologist named Dr. Jim Olson. As a physician who treats kids with brain cancer, Olson knows that removing a tumor is tricky.
"The surgeons right now use their eyes and their fingers and their thumbs to distinguish cancer from normal brain," says Olson. But poking around in someone's brain with only those tools, it's inevitable surgeons will sometimes miss bits of tumor or, just as bad, damage healthy brain cells.
So Olson and his colleagues at the Fred Hutchinson Cancer Center in Seattle came up with tumor paint. They handed off commercial development of the compound to Blaze Bioscience.
After initial studies in dogs showed promise, the company won approval to try tumor paint on human subjects. Those trials are taking place at the Cedars Sinai Medical Center in Los Angeles.
Dr. Chirag Patil is one of those surgeons. He says it's remarkable that you can inject tumor paint into a vein in a patient's arm, have it go to the brain and attach to a tumor, and only a tumor. "That's a concept that neurosurgeons have probably been dreaming about for 50 years," he says.
Patil says they've now used tumor paint on a about a half dozen patients with brain tumors. They use a special camera to see if the tumor is glowing.
"The first case we did was a deep tumor," says Patil. "So with the camera, we couldn't really shine it into this deep small cavity. But when we took that first piece out and we put it on the table. And the question was, 'Does it glow?' And when we saw that it glows, it was just one of those moments ...'Wow, this works.' "
In this first study of tumor paint in humans, the goal is just to prove that it's reaching the tumor. Future studies will see if it actually helps surgeons remove tumors and, even more importantly, if it results in a better outcome for the patient.
That won't be quick or easy. Just getting to this point has been a long slog, and there are bound to be hurdles ahead.
And even if tumor paint does exactly what it's designed to do, Dr. Keith Black, who directs neurosurgery at Cedars-Sinai, says it probably isn't the long-term solution to brain cancer. "Because surgery is still a very crude technique," he says.
Even in the best of circumstances, Black says, surgery is traumatic for the patients, and tracking down every last cell of a tumor is probably impossible. Plus, it's inevitable that some healthy brain tissue will be damaged in removing the tumor.
"Ultimately, we want to eliminate the need to do surgery," says Black. A start in that direction will be to use a compound like tumor paint to deliver not just a dye, but an anti-cancer drug directly to a tumor. That's a goal several research groups, including Jim Olson's, are working on.
A boy in Canada mysteriously became allergic to fish and nuts after he received a blood transfusion, according to a new case report.
The 8-year-old boy had no history of being allergic to any foods, and was undergoing treatment for medulloblastoma, a type of brain cancer. A few weeks after receiving a blood transfusion, he experienced a severe allergic reaction called anaphylaxis within 10 minutes of eating salmon, according to the report, published online April 7 in the Canadian Medical Association Journal.
His doctors suspected that the blood transfusion had triggered the reaction, they wrote in the report. After treating the patient with a drug containing antihistamines, the doctors advised him to avoid fish and to carry an epinephrine injector in case he had another reaction. [9 Weirdest Allergies]
But four days later, the boy was back in the emergency department after eating a chocolate peanut butter cup. Blood tests and a skin prick test suggested that he was allergic — at least temporarily — to peanuts and salmon, so his doctors advised him to avoid nuts and fish.
"It's very rare to have an allergic reaction to a previously tolerated food," said the report's senior author, Dr. Julia Upton, a specialist in clinical immunology and allergy at the Hospital for Sick Children in Toronto. "The overall idea is that he wasn't allergic to these foods," but in the blood transfusion, he received the protein that triggers an allergic reaction to them, she said.
That protein, called immunoglobulin E, is an antibody associated with food allergies, Upton said. When it encounters a specific allergen, it causes immune cells to release chemicals such as histamine that lead to an allergic reaction.
However, because the boy's body itself did not make such antibodies against fish and nuts, his doctors said they suspected his allergies would go away within a few months.
Acquiring allergies from a blood donor is rare, but not without precedent. The researchers found two other case reports, both in adults, in which patients acquired temporary allergies from blood plasma. In a 2007 case, an 80-year-old woman had an anaphylactic reaction to peanuts. An investigation showed that her 19-year-old plasma donor had a peanut allergy, according to the report in the journal Archives of Internal Medicine.
In the new case, the 8-year-old also received plasma, the liquid part of blood that contains antibodies. The researchers inquired about the donor to Canadian Blood Services, and found that the donor did have an allergy to nuts, fish and shellfish. The service did not have any more blood from the donor, and subsequently excluded the individual from making future donations, the researchers said.
About five months later, blood tests showed that the boy's immunoglobulin E levels to salmon and peanut were undetectable. By six months, his parents had gradually and successfully reintroduced nuts and fish back into their son's diet.
However, Upton said, "In general, we would recommend that this be done under medical supervision," just in case there is a medical emergency.
It's unclear how doctors could prevent future cases, she said. Neither Canadian nor American blood service organizations bar people with allergies from donating blood. And testing donated blood for levels of immunoglobulin E doesn't always predict allergies. Some people with high levels of immunoglobulin E don't have allergies, and others with low levels of the protein do, she said.
"Clearly, the safety of the [blood] supply is of everyone's utmost concern," but more research is needed to determine how best to avoid the transfer of allergies, and how frequently this happens, Upton said.
"I think it's hard to make sweeping recommendations based on one case report," Upton said.
In the United States, "If a donor is feeling well and healthy on the day of donation, they are typically eligible to donate," said Dr. Courtney Hopkins, the acting chief medical officer for the east division of the American Red Cross. "We will defer donors on the day of donation if they are not feeling well and healthy, if they have a fever, or if we notice they have problems breathing through their mouth."
Donors can learn more about blood-donation eligibility here. Individuals with allergies shouldn't be dissuaded from donating, Hopkins added.
"We always need blood. We always need blood donors," Hopkins told Live Science.
Researchers testing the origins of human breast milk samples available for purchase online found that around 10% of the samples they examined contained significant amounts of added cow's milk.
The pressure on parents to feed newborn infants with breast milk may be leading many to purchase human breast milk online. However, the milk they receive from online vendors may not match up to what is being offered.
"They purchase the milk online based on a posted description of the type and quantity of the milk or the health habits of the seller," writes study author Dr. Sarah Keim. "But when they think they're getting nutritious, high-quality breast milk, some of them are actually receiving human milk mixed with cow's milk."
Human breast milk is widely recognized as providing many health benefits to young infants. According to the American Academy of Pediatrics (AAP), breastfeeding can protect against diseases and conditions such as diarrhea, diabetes and childhood obesity.
However, many new mothers find themselves unable to breastfeed. In 2012, a survey published in Pediatrics found that two-thirds of mothers nursing newborns are unable to manage breastfeeding for as long as they intended.
"Some women are unable to produce enough milk for their infant or perceive they cannot meet their infant's needs, yet they may be reluctant to feed formula," write the researchers of the new study. For these mothers, the Internet represents an alternative way of providing human milk for their children.
'You do not truly know what you are receiving'
For the study, published in Pediatrics, Dr. Keim and her colleagues purchased 102 samples of what was advertised as human milk from sellers on the Internet. These milk samples were subjected to DNA testing in order to verify their human origins and to assess whether any cow's milk was also present.
While all of the purchased Internet samples contained human DNA, 11 also contained bovine DNA. Of these, 10 contained bovine DNA concentrations significant enough to suggest that cow's milk had been added to human milk, being so high that accidental contamination was unlikely.
The inclusion of cow's milk in human breast milk can be problematic for babies. It can potentially be harmful due to cow's milk allergies, health conditions or formula sensitivities. The inclusion of cow's milk could also reduce a baby's access to the essential nutrients and fats that are in formulas and human breast milk but not cow milk.
"The truth of the matter is that you do not truly know what you are receiving when you buy milk from a stranger over the Internet," explains Dr. Keim.
"Selling breast milk gives people an incentive to add cow's milk or formula to the milk in order to sell more. When money is involved in an unregulated process like this, you cannot know for sure that the milk is safe to give to your baby."
Although the sample used in the study is acknowledged as small by the authors, they state the sample is representative of Internet sellers and has given the researchers findings that may at least generalize to milk being sold via the Internet.
"Our findings confirm the previously theoretical risk that human milk being sold via the Internet may not be 100% human milk," the authors conclude. "Because buyers have little means to verify the composition of the milk they receive, all should be aware of the possibility that it may be adulterated."
Previously, in a report published in The BMJ, experts claimed that breast milk purchased online can pose serious health risks to infants, largely due to a lack of regulation. Human milk is not tested for contamination or disease and could be stored incorrectly.
Informatics programs that allow med/surg nurses to cut down on documentation and increase patient safety at the touch of a button are becoming more essential in today’s fast-paced healthcare environment.
In February, 
Researchers have identified a signal in the amygdala brain region of young children that stimulates aversion to the opposite sex and induces interest in the opposite sex as children enter puberty.
A promi
A boy in Canada mysteriously became allergic to fish and nuts after he received a blood transfusion, according to a new case report.
Researchers testing the origins of human breast milk samples available for purchase online found that around 10% of the samples they examined contained significant amounts of added cow's milk.