Original Article
Effects of massage on vital signs, pain and comfort levels in liver
transplant patients
Bilsev Demir
a, Serdar Saritas
b,*
aVocational School of Health Sciences, Sel¸cuk University, Konya, Turkey b
Department of Surgical Nursing, Faculty of Nursing, Inonu University, Malatya, Turkey
A R T I C L E I N F O A B S T R A C T
Objectives: This study aimed to determine the effects of back massage on postoperative vital signs, pain, and comfort levels in liver transplant patients.
Methods: A quasi-experimental model with a pretest, a posttest, and a control group was used. The popula-tion of the study comprised adult patients who had liver transplantapopula-tion for thefirst time. The study sample comprised 84 adult patients who had liver transplantation: 42 experimental (study group) and 42 control group, selected by power analysis and the random sampling method from the population. The data were col-lected between May and September 2016 using the short-form McGill Pain Questionnaire (SF-MPQ) and the General Comfort Scale. In the study group, the researcher performed back massage twice per day in the morning and evening in the organ transplant service. No treatment was performed in the control group. To analyse the data, descriptive statistics, a chi-squared test, a t-test for dependant groups, and a t-test for inde-pendent groups were used.
Results: According to morning and evening follow-ups after liver transplantation, the mean scores of pulse rate, respiration rate, blood pressure values, and pain intensity was lower, and the mean score of sPO2 (oxy-gen saturation) levels and comfort levels was higher, with a statistical significance in the experimental group compared with the control group in all measurements before and after back massage (p< 0.001).
Conclusions: The back massage applied to liver transplant patients positively affected vital signs, decreased the severity of pain, and increased the comfort levels of the patients.
© 2019 Elsevier Inc. All rights reserved.
Keywords: Liver transplantation Back massage Pain Comfort Level Vital Signs Practical Applications
Greater reductions in pain intensity occurred in the group submitted to massage therapy compared with the groups that only received one of these therapies.
Patients were very satisfied with their care choice of massage therapy.
A study of these results and patients could help improve pain care and comfort levels.
Introduction
Today, liver transplantation has become a vital and permanent treatment for patients with end-stage chronic liver disease.1
Although the survival rates of patients after liver transplantation are
high, their quality of life is low.2Liver transplant patients have acute
pain and fatigue in the early period and chronic pain and fatigue are more common in the late period.3 Many studies have found that
patients have a higher level of pain after liver transplantation.4 7In
addition, many vital signs and the functions of patients are negatively affected after surgical interventions; therefore, a decrease in comfort level occurs due to the impairment of physiological indicators of patients.8 10
Recently, the need to increase patient participation in their care, attempts to reduce disease symptoms, high cost of treatments, and desire to increase patients’ self-image have increased the interest in complementary therapies. These factors have influenced patients to us adjuvant treatments.11,12Massage is widely used in
complemen-tary therapies and has recently also been used in surgical practices.13 16Massage is one of the oldest treatment methods; uses contact methods such as touching, pressing, stroking, kneading, and squeezing; and is applied in the treatment of various diseases. Mas-sage is defined as manual or mechanical stimulation of the soft tis-sues of the body for therapeutic goals such as maintaining blood and lymphflow, dilating the muscles, reducing swelling, relieving pain, and increasing sleep quality.17,18 Massage therapy is a scientific * Corresponding author.
E-mail address:serdar.saritas@inonu.edu.tr(S. Saritas).
https://doi.org/10.1016/j.explore.2019.10.004
1550-8307/© 2019 Elsevier Inc. All rights reserved.
Contents lists available atScienceDirect
Explore
manipulation of body tissues with psychological, physiological, neu-rological, and biomechanical effects.19
Many studies on massage therapy have shown decreases in the severity of the patient's pain and their blood pressure and pulse rate, and cortisol levels return to normal after a massage session.20 24A
group of patients with cancer subjected to back massage therapy experienced better moods and lower stress levels.25The back
mas-sage therapy in patients undergoing cardiac catheterisation reduced diastolic blood pressure, respiratory rate, stress levels, and severity of pain.26 Although many studies13 16,27 have demonstrated the ef
fi-cacy of massage therapy, no study has investigated the effect of this therapy on vital signs and pain and comfort levels in patients with liver transplantation.
Therefore, our study is thefirst on this subject in the literature. This hypothesis of this study was that massage therapy in liver trans-plant patients would contribute to scientific nursing practice.
Materials and methods Study design and participants
This study used a quasi-experimental pretest and posttest design with an experimental (study group) and a control group. The popula-tion of the study comprised adult patients who had liver transplanta-tion for thefirst time.
The sample size was calculated by power analysis (significance level = 0.05; medium effect size = 0.6; power = 0.97). The sample group comprised 84 patients that were selected from the population by using an improbable random sampling method. Patients in the experimental and control groups were selected according to random-isation until the groups comprised the specified number of members.
The sample comprised 42 in the experiment group and 42 in the con-trol group (Fig. 1).
This study included patients with no problems that prevented communication, no obstacle to massage therapy (e.g. cellulitis, infec-tion), and no use of narcotic analgesics for postoperative pain control. The patients were subjected to the same treatment protocol on the second day of the inpatient stay after hospitalisation in postoperative intensive care unit and defined pain severity as 4 or higher.
Interventions
The study group wasfirst informed about the aim of the study; next, the researcher completed the patient introduction form by using a face-to-face interview technique. To perform the massage in a comfortable environment and prevent the patient from being in flu-enced by his/her relatives during the pain evaluation, the patient’s relatives were not present. The environment was brightly lit, and no music played. Each patient’s room was a single occupancy. Back mas-sage was performed by the researcher while the patients were in bed. The data were collected by the researcher.
The duration to perform all procedures, including data collection and back massage therapy, was 25 min. During thefirst visit, in the morning, the Personal Information Form, the short-form McGill Pain Questionnaire (visual analogue scale [VAS] and general pain severity), and the General Comfort Scale (GCS) were applied as a pretest, and vital signs were measured in the experiment and control groups. Pain intensity was assessed with the VAS, and vital signs were measured for each patient in the experiment group at thefirst and second hours after completing 10 to 15 min of back massage. In the control group, the same evaluation was performed at the beginning and the end of the back massage. During the second visit, in the evening, the pain intensity was assessed with VAS, and the vital signs of the Fig. 1. Flow of participants for each stage in this study.
experiment and control groups were measured before the back mas-sage. Pain intensity was assessed with VAS, vital signs were measured for each patient in the experiment group at thefirst and second hours after completing 10 to 15 min of back massage, and the GCS was applied as a posttest at the second hour. Additionally, general pain severity was measured by a posttest at the second hour in the even-ing. The patients in the control group were subjected to a posttest evaluation at the beginning and the end of the back massage. GCS was applied in the morning before the back massage and at the sec-ond hour after the evening massage.
In the study group, back massage was administered twice a day after the pretest, in the morning and evening in the patients' rooms, whereas no treatment was performed in the control group.
Instruments
The data were collected by using a patient information form, the short McGill Pain Questionnaire (SF-MPQ), and the GCS. Patient infor-mation form comprised 6 questions about the descriptive character-istics of the patients (age, gender, educational level, marital status, occupation, aetiology of liver transplantation, and vital signs).
The SF-MPQ was developed by Melzack in 1987 and is a multidi-mensional scale commonly used for postoperative pain assessment.28 The SF-MPQ comprises 3 sections: the quality of pain is assessed in thefirst section; the present severity of pain is assessed in the second section (with the use of a VAS); and the general pain severity is assessed in thefinal section. Studies of SF-MPQ for validity and reli-ability were performed by Yakut et al. (2006) in Turkey, and the Cron-bach’s alpha value obtained from the scale was 0.705.29In this study,
the mean Cronbach’s alpha value was 0.859.
The GCS was developed by Kolcaba in 1992 and adapted to Turk-ish by Kuguoglu and Karabacak in 2004. The Cronbach’s alpha value obtained from the scale was 0.85. This GCS uses a 4-point Likert-type scale comprising 48 items: 24 positive items and 24 negative items. The highest score 4” for the positive items corresponds to the highest comfort level and the lowest score“1” to the lowest comfort level.
When evaluating the scale, the negative points obtained are coded in reverse and evaluated along with the positive items. The highest total that can be obtained from the scale is 192 and the lowest total is 48.30
Ethical considerations
Prior to the data collection, ethics approval was obtained from a university hospital Inonu University Clinic Research Ethics Commit-tee with decision number 2016/70. Additionally, all the patients were informed about the study; the patients in the experimental and con-trol groups read the informed consent form; and patients who agreed to volunteer to participate in the study were included. Patients were also informed that their information would be protected and with-drawn on request. Verbal and written consents were received from the participants.
Statistical analyses
IBM SPSS Statistics Version 16.0 (Statistical Package for Social Sci-ences; SPSS Inc., Chicago, IL, USA) software was used for the statistical analyses of research data. The results were evaluated at a confidence interval of 95% and a significance level of p < 0.05. The data were expressed as percentage, mean, and standard deviation. The statisti-cal methods used a chi-square test and t-test for the independent groups and a matched t-test and an RMANOVA was conducted to evaluate the effect of the intervention on pain and comfort scores and vital signs.
Results
A total of 84 patients participated in the study (26 female, 58 male; mean age 46.34 years, range 20 69 years). No significant differences were found between the control group and the experi-mental group regarding any of the demographic characteristics, including sex, age, education, employment and marital status, and aetiology of liver transplantation (Table 1).
Table 1
Comparison of control variables of study and control groups.
Study group Control group
N = 42 N = 42
Characteristics Number % Number %
Test and significance Sex Female 14 33.3 12 28.6 X2 = 0.223a Male 28 66.7 30 71.4 p = 0.109 Marital status Married 37 88.1 30 71.4 X2 = 3.614a Single 5 11.9 12 28.6 p = 0.057 Educational level Illiterate 1 2.4 2 4.8 X2 = 2.141a Literate 2 4.8 1 2.4 p = 0.710 Primary school 20 47.6 24 57.1 High school 15 35.7 10 23.8 University 4 9.5 5 11.9 Employment Status Employed 12 28.6 15 35.7 X2 = 0.491a Unemployed 30 71.4 27 64.3 p = 0.483
Aetiology of Liver transplantation
Hepatitis B 16 38.1 27 64.3 X2 = 8.504a
Idiopathic Liver Failure 15 35.7 6 14.3 p = 0.075
Hepatitis C 5 11.9 3 7.1
HCC 2 4.8 4 9.5
Others (Wilson’s disease, Primary Sclerosing Cholangitis) 4 9.5 2 4.8 X§ SD Age (years) 45.57§ 13.51 47.11§ 12.06 t = 0.554b p = 0.581 a X2 test. bt-test.
The intra-group comparison of the pre-massage and post-mas-sage vital signs of the patients in the morning showed a decrease in mean systolic and diastolic blood pressures, pulse and respiration rates, and severity of pain, and an increase in sPO2(oxygen
satura-tion) levels in Table 2. According to the RMANOVA, in the study group, the decrease in systolic blood pressure, diastolic blood pres-sure, and pulse rate and the increase in sPO2(oxygen saturation)
lev-els were statistically significant (p < 0.001), and the decrease in respiratory rate was not statistically significant (p > 0.05). The decrease in the severity of pain was statistically significant (p< 0.001). The patients in the control group had increased diastolic and systolic blood pressure levels, sPO2(oxygen saturation) levels,
and pain intensity and a decrease in pulse and respiratory rates at the time that corresponded to after the massage in the experiment group compared with before the massage. The difference in vital signs in the control group was statistically insignificant (p > 0.05), and only the increase in pain severity was statistically significant (p < 0.001) (Table 2).
The intra-group comparison of the pre-massage and post-mas-sage vital signs of the patients in the evening showed a decrease in their mean body temperatures, systolic and diastolic blood pressures, pulse and respiration rates, and severity of pain and an increase in sPO2 (oxygen saturation) levels (Table 3). According to the
RMA-NOVA, in the study group, the decrease in body temperature, systolic
Table 3
Comparisons of the mean scores of pre- and post-massage vital signs and pain severity (VAS) of patients in the study and control groups (n = 84). Evening
Mean scores of vital signs and pain intensity Study control
Pre-massage x§ sd Post-massage 1st Hour x§ sd Post-massage 2nd hour x§ sd F P
Body temperature Study 36.36§ 0.24 36.30§ 0.20 36.26§ 0.21 6.840 0.003*
Control 36.36§ 0.21 36.38§ 0.16 36.36§ 0.19 0.215 0.807 test t:-0.096 t:-2.011 t:-2.271 Systolic BP Study 120.26§ 12.84 112.31§ 12.69 108.36§ 12.13 77.783 0.001* Control 128.67§ 14.47 124.78§ 12.43 123.33§ 13.27 5.160 0.008* test t:-2.814 t:-4.550 t:-5.397 Diastolic BP Study 73.78§ 8.43 66.83§ 12.23 65.92§ 8.44 16.140 0.001* Control 78.52§ 11.21 78.04§ 10.08 76.95§ 10.63 0.613 0.544 test t:-2.188 t:-4.583 t:-5.262 Pulse Study 89.71§ 10.55 84.21§ 9.09 81.23§ 9.93 35.448 0.001* Control 85.71§ 10.44 84.83§ 11.19 85.64§ 12.51 0.490 0.614 test t:1.745 t:-0.278 t:-1.798 Respiratory Study 21.19§ 1.08 21.23§ 1.07 21.19§ 1.17 0.031 0.970 Control 21.47§ 1.40 21.66§ 1.45 21.95§ 1.56 2.457 0.105 test t:-1.044 t:-1.531 t:-2.528
sPO2(oxygen saturation) Study 96.78§ 1.38 97.78§ 1.07 98.19§ 0.89 1.456 0.001*
Control 95.90§ 1.84 96.26§ 1.62 96.04§ 1.72 2.063 0.134 test t:2.472 t:5.076 t:7.157 VAS Study 4.52§ 0.86 3.78§ 0.81 3.66§ 0.75 32.921 0.001* Control 4.92§ 0.55 4.64§ 0.65 4.66§ 0.68 6.546 0.002* test t:-2.554 t:-5.319 t:-6.353 * Statistically significant at p < 0.05. Table 2
Comparisons of the mean scores of pre- and post-massage vital signs and pain severity (VAS) of patients in the study and control groups (n = 84). Morning
Mean scores of vital signs and pain intensity Study control
Pre-massage x§ sd Post-massage 1st hour x§ sd Post-massage 2nd hour x§ sd F p
Body Temperature Study 36.33§ 0.27 36.30§ 0.23 36.30§ 0.32 0.639 0.494 Control 36.34§ 0.19 36.38§ 0.16 36.3§ 0.19 1.211 0.303 test t: -0.92 t:-1.820 t:-1.336 Systolic BP Study 122.62§ 15.56 118.31§ 16.7 115.5§ 15.47 10.975 0.001* Control 126.62§ 15.40 127.02§ 13.8 129.14§ 14.45 0.710 0.472 test t:-1.184 t:-2.909 t:-4177 Diastolic BP Study 74.52§ 10.27 72.02§ 10.03 70.19§ 10.02 7.372 0.001* Control 76.59§ 10.98 78.83§ 11.53 78.50§ 10.04 1.183 0.304 test t:-0.892 t:-2.888 t:-3.795 Pulse Study 96.0§ 12.81 91.0§ 11.79 88.07§ 11.41 51.104 0.001* Control 87.40§ 10.53 86.50§ 13.63 86.30§ 10.51 0.192 0.797 test t:3.357 t:1.618 t:0.736 Respiratory Study 21.38§ 1.49 21.42§ 1.01 21.33§ 1.05 0.075 0.928 Control 22.04§ 1.36 22.04§ 1.43 21.71§ 1.29 1.117 0.332 test t:-2.136 t:-2.287 t:-1.481
sPO2(oxygen saturation) Study 95.78§ 2.55 96.88§ 2.02 97.23§ 1.30 17.842 0.001*
Control 95.90§ 1.64 96.04§ 1.97 96.23§ 2.00 0.724 0.417 test t:-0.254 t:1.909 t:2.706 VAS Study 5.16§ 0.82 4.09§ 0.61 4.14§ 0.78 106.14 0.001* Control 4.45§ 0.63 4.47§ 0.59 4.83§ 0.65 7.774 0.001* test t:4.456 t:-2.882 t:-4.371 * Statistically significant at p < 0.05.
blood pressure, diastolic blood pressure, pulse rate, and pain severity and the increase in sPO2(oxygen saturation) levels were significant
(p< 0.001). The patients in the control group has a decrease in sys-tolic blood pressure levels and pain intensity and an increase in respi-ratory rates and sPO2(oxygen saturation) levels after the massage in
the experiment group compared with before the massage. The differ-ence in the systolic blood pressures and pain intensity of the patients in the control group was significant (p < 0.001), and the difference in the other vital signs was insignificant (p > 0.05;Table 3).
The inter-group comparison of the mean pretest scores of the study and control groups showed no significant difference in the total and relaxation subdimensions of the GCS and the mean scores of the short-form McGill Pain Questionnaire (SF-MPQ) between the groups (p > 0.05). Additionally, there was a significant difference in the mean scores of the subdimensions of "relief" (t: 3.54) and "Over-coming Problems” between the pretest of the study and control groups (p< 0.05) (Table 4).
The inter-group comparison of the mean posttest scores of the study and control groups showed that there was a significant differ-ence between the groups in terms of the total scale and the subdi-mensions of relief, relaxation, and overcoming problems in the GCS (p< 0.001). There was a significant difference between the groups in terms of the mean posttest scores of the SF-MPQ between the study and control groups (t: 5.32, p< 0.001;Table 4).
Discussion
Patients with liver disease experience many symptoms caused by the disease and liver transplant surgery. Surgical interventions are a trauma with a very wide range of effects on a patients and deteriorate the level of patient comfort.31In the literature, many studies21,32 34
have demonstrated that massage therapy in nursing care contributes positively to vital signs, pain intensity, and comfort level, but this study was thefirst to apply this therapy to liver transplant patients.
Patients’ morning and evening measurements of pain intensity according to the GCS demonstrated a significant decrease in pain lev-els at thefirst and second hours after the back massage compared with pre-massage values in the study group. There was a statistically significant difference especially between the values before massage and thefirst and second hours after massage (p < 0.001).
Similarly, the postoperative morning and evening follow-up of the patients in the control group showed an increase in the pain severity scores according to the GCS with a statistical significance (p < 0.05). Although the mean pain severity scores of the patients in both groups changed at all time points, the difference in the study group had a higher level of statistical significance (p < 0.001).
Dion et al. reported that post-massage pain intensity was lower compared with pre-massage pain intensity in patients who under-went thoracic surgery.35Kaada and Torsteinb assessed post-massage
plasma beta endorphin levels and found that the levels of endorphins
secreted after massage were maintained up to the 5th, 30th, 60th, and 90th minute after massage.36
In a study evaluating the effect of back massage applied in the morning and evening in patients who underwent total hip or knee prosthesis surgeries, Buyukyilmaz reported that the pain intensity of the experiment group at thefirst- and measurements was signifi-cantly lower than that of the control group.32Thisfinding suggests
that the effect of back massage was maintained until the second hour after massage therapy. Chen et al. reported a significant decrease in the severity of pain according to the results of the GCS after back massage in patients with heart failure.21Another a study assessing
pain management with back massage applied to patients after ster-notomy or abdominal surgery, Mitchinson et al. separated the patients into 3 groups and examined their levels of pain and anxiety. They found a significant reduction in the severity of pain in patients who underwent back massage (p< 0.05).37In a study of the
effective-ness of message after cardiac surgery, Albert et al. found that pain levels and anxiety states decreased, and mood states improved signif-icantly in post-massage patients.38These results indicate that back
massage is effective in reducing the pain levels of patients. Investigat-ing the effectiveness of back massage, Holland and Pokorny found, as a result of a 3-day intervention, a significant difference in respiratory rate, pulse rate, systolic and diastolic blood pressures in the study group compared with the control group.39 McNamara, Burnham,
Smith, and Carroll examined the effect of back massage before cardiac catheterisation and revealed a significant decrease in systolic-dia-stolic blood pressure and pain intensity after a 20-min back massage.26
Chen et al. examined physiologic parameters after back massage in patients diagnosed with heart failure and found a significant decrease in heart rate and systolic and diastolic blood pressure levels and a significant increase in sPO2levels.21 Mohebbi et al. reported
that back massage in patients with hypertension provided a signi fi-cant reduction in systolic and diastolic blood pressure levels in the study group compared with the control group.40 Khaledifar et al.
examined stress levels and vitalfindings of patients who underwent back massage and reflexology therapy before coronary angiography and found a significant decrease in post-massage parameters includ-ing systolic and diastolic blood pressure levels, body temperature, respiratory rate, pulse rate, and stress levels compared with the pre-massage parameters (p< 0.05).24These results demonstrate the
posi-tive effects of back massage on vital signs.
In our study, the mean pretest scores of the GCS and its subdimen-sions and the SF-MPQ before morning massage were comparable between the study and control groups. However, a statistically signif-icant difference was observed in the subdimensions of relief and overcoming problems (p< 0.05), and no significant difference was found between the study and control groups in their scores in the Total GCS and its sub-dimension of relaxation or their scores in gen-eral pain severity (p> 0.05). This finding suggests that back massage Table 4
Comparison of the mean pretest and posttest scores of the general comfort scale and the short-form McGill pain questionnaire between the patients in the study and control groups.
Pre-test Post-test Scale Study group (n = 42) x§ sd Control group (n = 42) x§ sd ta p Study group (n = 42) x§ sd Control group (n = 42) x§ sd ta P General comfort total 2.57§ 0.31 2.72§ 0.23 2.37 0.20 3.22§ 0.20 2.68§ 0.20 12.19 0.001*
Relief 2.52§ 0.34 2.74§ 0.20 3.54 0.001* 3.02§ 0.24 2.66§ 0.22 6.95 0.001*
Relaxation 2.52§ 0.40 2.53§ 0.28 0.03 0.971 3.31§ 0.27 2.54§ 0.27 12.66 0.001*
Overcoming problems 2.67§ 0.33 2.88§ 0.30 2.98 0.004* 3.34§ 0.22 2.84§ 0.27 9.22 0.001*
Short-form McGill pain questionnaire (general pain severity)
1.76§ 0.61 1.52§ 0.59 1.80 0,075 1.0§ 0.38 1.69§ 0.74 5.32 0.001*
Note. Thefirst measurement in the morning and the last measurement in the evening were used as the basis for the pretest and posttest, respectively. * Statistically significant at p < 0.05.
a
did not cause a significant difference between the study and control groups in our study. The results show that both groups had compara-ble pre-massage pain and general comfort levels, but a significant dif-ference was observed between the groups in terms of relief and overcoming problems in the subdimensions of the GCS.
We found a positive increase in the mean posttest score of the GCS and its subdimensions of relief, relaxation, and overcoming problems and a positive decrease in the mean posttest score of the general pain severity according to SF-MPQ in the study group relative to the con-trol group. These results indicate that the difference between the pre-test and postpre-test scores was highly significant (p < 0.001). In the literature review, we found no study that investigated back massage in liver transplant patients. However, in studies investigating back massage in different patient groups, massage helped reduce the level of pain experienced by patients and had positive and therapeutic effects that increased comfort levels of patients.37,38,41
Chen et al. examined the effects of back massage on anxiety and comfort levels and physiological parameters in patients with heart failure and compared pre-massage parameters and post-massage fol-low-up parameters on thefirst, second, and third days. Their study reported a significant decrease in pain severity and a positive increase in comfort levels (p< 0.01).21 Lesley et al. reported that
post-cardiac massage improved relief by reducing pain and anxiety levels and increased patient satisfaction (p< 0.001).42In a study that
compared the effect of massage on patient comfort between study and control groups, Kolcaba et al. reported that massage therapy pro-vided a high level of comfort in the experiment group (p< 0.05).31
Thisfinding suggests that back massage has a positive effect on relax-ation and comfort levels. Our study demonstrated that back massage allowed vital signs to remain within normal ranges and reduced pain levels in the experiment group. Additionally, back massage was dem-onstrated to increase patient comfort level.
Conclusions
The results of our study demonstrate that back massage, a com-plementary therapy, when used in combination with pharmacologi-cal treatments, is effective in decreasing post-transplant pain, increasing comfort levels, relieving potential symptoms, and achiev-ing recovery in liver transplant patients. Usachiev-ing complementary thera-pies such as back massage in addition to medicine would increase the quality of nursing care. Nurses could be offered training opportu-nities to use back massage of after liver transplant. Further research could be conducted with a wider and more diverse group.
Funding sources
There is no any sources of support from any company. All sources are belongs to researchers.
Disclosure
This research; It was conducted by Bilsev Demir as doctoral thesis under the supervision of Serdar Saritas.
Declaration of Competing Interest
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. No con-flict of interest has been declared by the author(s).
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