Dissertações em Assistência Farmacêutica (Mestrado) - PPGAF/ICS

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Desenvolvimento de um roteiro de inspeção sanitária para sala de serviços de vacinação em farmácias e drogarias
(Universidade Federal do Pará, 2022-08-17) SALES, Clarisse Andrade; SENA, Luann Wendel Pereira de; http://lattes.cnpq.br/6233488431016391; https://orcid.org/0000-0001-9363-5766; MELO, Amanda Gabryelle Nunes Cardoso; http://lattes.cnpq.br/8951750304102610; https://orcid.org/0000-0001-7661-1615
Introduction: Immunizations are strongly linked to public health actions, being recognized worldwide as an effective measure in the prevention of infectious diseases. Community pharmacies are seen as the first point of health care, allowing the pharmacist to guide the population on their benefits, clarifying doubts and demystifying misconceptions, which are often the cause of non-adherence to medication. Objective: To analyze the health management process related to vaccination services provided by pharmacists in a pharmacy network in Brazil. Methodology: The study is characterized by being a descriptive retrospective study, whose purpose is to describe the vaccination service in community pharmacies. The study population consisted of pharmacists and patients who performed vaccination procedures and who spontaneously sought services and/or clinical care, respectively. Results: 2981 doses of vaccines were applied in the years 2020 the 2021 in 18 establishments in Brazil. The state that obtained the highest number of vaccinations was São Paulo. The most sought-after vaccine was Influenza with 2934 doses administered. Conclusion: It was found that the vaccination service in pharmacies is evolving, and the pharmaceutical professional has a fundamental role in this process, being able to contribute to the access and increase of vaccination coverage rates in the country.
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Desenvolvimento de uma cartilha de dispensação farmacêutica em Farmácias comunitárias
(Universidade Federal do Pará, 2022-09-05) SOUZA, Marcos Felipe Rodrigues de; SENA, Luann Wendel Pereira de; http://lattes.cnpq.br/6233488431016391; https://orcid.org/0000-0001-9363-5766
Introduction: The pharmacist is currently the most accessible member of the health team and the first source of assistance and advice in general health care. Its rapprochement with the pharmacy and performance in patient care, no longer focusing its actions exclusively on the medication, meant that the dispensing process was understood as an essential action for the promotion of health and the rational use of medications (URM), in addition to including pharmaceutical services, which encompasses a set of actions performed by a pharmaceutical professional. Objectives: To develop a pharmaceutical dispensing booklet in community pharmacies in order to improve pharmaceutical dispensing, as well as guide new pharmaceutical professionals in the commercial pharmacy market. Methodology: The study is characterized by being an analytical descriptive study aiming at the development of a pharmaceutical dispensing flowchart. This consists of showing the drug dispensing process in a safe and coherent way, analyzing all decisions. Results and discussions: The method of care in dispensing medicines and pharmaceutical services in community pharmacies are presented in a flowchart format, aiming to establish a standard method to be adopted in any establishment that performs direct dispensing to the user and guarantee quality of care. Final considerations: Pharmaceutical clinical services develop great attributions for the professional who has theoretical and practical knowledge. Therefore, the provision of pharmaceutical care through the first contact that usually takes place at the time of dispensing requires care and attention, given that in this process, in addition to dispensing, a complete anamnesis with the patient and relevant information regarding education in health, drug interactions and other questions that the patient may have. Therefore, the activity of pharmaceutical care needs to be more effective in a community pharmacy.
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Rastreamento em saúde de casos suspeitos de covid-19 realizados por farmacêuticos em uma rede de farmácias do Estado do Pará
(Universidade Federal do Pará, 2022-11-17) MELO, Renato Bruno Cavalcante de; SENA, Luann Wendel Pereira de; http://lattes.cnpq.br/6233488431016391; https://orcid.org/0000-0001-9363-5766
Introduction: Health screening can contribute to the care of the health needs of a population and is important for the prevention, early detection and treatment of diseases in asymptomatic individuals or susceptible to its development. Drugstores are seen as places of first access to the health system and this characteristic allows the pharmacist to screen and track patients suspected of being with COVID-19. Objective: To analyze health screening based on data from suspected cases of COVID-19 of patients seen by pharmacists in a pharmacy network in the state of Pará. Methodology: This is a cross-sectional descriptive study, whose purpose is to investigate the health screening, from the database, of patients who sought spontaneous demand for the care of the pharmaceutical professional to perform the test for COVID19 in the pharmacy. Results: We analyzed 121 pharmacies existing in the State of Pará and only 36 of these, offered the rapid test for COVID-19. In total, 78,849 tests were performed in 2020 and 2021 and the antigen test was the most frequent. Females and people with brown characteristics were the most prevalent. As a result, only 10,276 were positive for the antigen test and 9,706 were positive for the antibody test. The most prevalent symptoms and symptoms were cough and sore throat. Conclusion: Community pharmacies because they are considered as a place of first access and contact of the population in the health field showed their importance in offering the population pharmaceutical services and procedures that help to improve the quality of life of the individual, because they have a qualified and available professional to contribute to the better education of the population.
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Desenvolvimento de uma ficha de admissão para pacientes hospitalizados com COVID-19 em um hospital no estado do Pará
(Universidade Federal do Pará, 2022-11-18) CASTRO, Eline Fernandes Ribeiro de; RIBEIRO, Carolina Heitmann Mares Azevedo; http://lattes.cnpq.br/3848996822163999; https://orcid.org/0000-0002-9457-2733; ALBÉRIO, Carlos Augusto Abreu; http://lattes.cnpq.br/2335187399740995; https://orcid.org/0000-0002-9364-3990
Objective: Develop an admission form for patients hospitalized for COVID-19 in a private hospital in the state of Pará. The application of the admission form aims at a more assertive clinical decision-making and the reduction of negative outcomes. Methodology: This is a retrospective, cross-sectional and quantitative study, carried out by collecting data from adult patients hospitalized with a diagnosis of COVID-19 from March to June 2020 at the hospital under study. Data collection was divided between patient-related information such as personal data and clinical data such as signs/symptoms on admission, comorbidities and length of stay. Records of vital signs and results of laboratory tests and imaging were also collected. The data obtained were tabulated in Microsoft Excel and statistical analysis Odds ratio and Chi-square with a significance level of 5%. Results: A total of 212 hospitalized patients were evaluated, predominantly male and aged between 60 and 80 years. The presence of comorbidities was identified in 70.8% (n 150) of the patients and, in this case, the occurrence of negative outcomes was higher. After the univariate analysis, the variables that proved to be significant in relation to the negative outcomes were: male gender, age group ≥80 years, presence of some comorbidity, palliative care, hospitalization time >20 days. Conclusion: These results create the possibility of conducting prospective studies to improve care tools for patients with COVID-19, including the development of predictive scales for severe illness. Key Words: COVID-19; SARS-Cov-2; Comorbidities; Hospitalization.
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Institucionalização da assistência farmacêutica no município de Benevides, Pará
(Universidade Federal do Pará, 2022-11-25) TORRES, Andréa Sarmento Figueiredo; SOLER, Orenzio; http://lattes.cnpq.br/4041958877867484; https://orcid.org/0000-0003-2246-0019
Introduction: Pharmaceutical Assistance deals with a set of actions aimed at promoting, protecting, and recovering health; both individual and collective, with medicine as an essential input and aiming at access and rational use. Objective: To establish a theoretical model of governance, management by results and situational strategic planning for Pharmaceutical Assistance in the municipality of Benevides, Standard Operating Procedure of the Pharmaceutical Supply Center and Manual of Pharmaceutical Assistance in the Municipality of Benevides. Method: It is an exploratory, crosssectional, and descriptive study, carried out between 2021 and 2022, based on action research and method triangulation. Data were collected through research in the database and the application of structured forms. Results: It was observed that pharmaceutical assistance is included within the main planning and management instruments of the Unified Health System. There is no inventory control management system via the Horus system. Does not fully comply with management, management and governance practices at the level of Pharmaceutical Assistance Coordination, in particular in the field of technical management of pharmaceutical assistance and clinical management of medication. Conclusion: Pharmaceutical Assistance is institutionalized in the municipality of Benevides, Pará, needing to improve the governance and management process, where there are still gaps in aspects related to the technicalmanagerial and technicalassistance fields. Keywords: Governance. Health Management. Health Information. Pharmaceutical Assistance. Medicines.
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Assistência farmacêutica nos municípios da região de saúde do Xingu do estado do Pará
(Universidade Federal do Pará, 2022-11-29) SILVA, Kleber Farias da; QUEIROZ, Luana Melo Diogo de; http://lattes.cnpq.br/9775224837043003; https://orcid.org/0000-0001-5036-5639; SOLER, Orenzio; http://lattes.cnpq.br/4041958877867484; https://orcid.org/0000-0003-2246-0019
Introduction: The institutionalization of pharmaceutical assistance is a social and politicaladministrative process, which is expressed in the creation and implementation of formal structures in the health system, in the organization of services, in structure and financing mechanisms, management tools, involvement in participation and social control and carrying out practices and activities inherent to pharmaceutical care as a component of comprehensive health care. Objective: Implement a Technical Chamber of Pharmaceutical Assistance in the context of the Transamazônica and Xingu Regional Intermanagement Council in the state of Pará. Methodology: This is an exploratory, retrospective, descriptive, analytical research; based on action research, triangulation of methods and knowledge translation. Results: The municipalities in the Xingu Health Region (10th Health Region in the state of Pará) still do not fully comply with the regulatory frameworks and guidelines that establish the institutionalization of Pharmaceutical Assistance. Approval of the creation of the Technical Commission for Pharmaceutical Assistance via the Regional Intermanager Council. Conclusion: The findings indicate the need to reorient the structure, organization, governance, planning and management of pharmaceutical care in the context of the Xingu Health Region (10th Health Region in the state of Pará). A Conceptual Model of Technical Chamber of Pharmaceutical Assistance is presented in the context of the Transamazônica and Xingu Regional Intermanagement Council of the state of Pará, with their respective indicators for monitoring and evaluation.
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Segurança no uso de medicamentos: ações de melhoria em um hospital em Belém, Pará, Amazônia
(Universidade Federal do Pará, 2022-11-29) OLIVEIRA, Thais Castro; SANTOS, Valéria Regina Cavalcante dos; http://lattes.cnpq.br/0213999310674716; https://orcid.org/0000-0002-1264-8125
Introduction: Health services, especially hospital institutions, are complex systems that involve several risks, which can be exemplified by drug therapy. Investigation and knowledge of the factors that determine the occurrence of medication errors allow for actions that strengthen safety in the medication chain and the patient. Objective: Implement actions to improve safety, prescription, administration and quality use of medicines in a hospital in Belém, Pará, Amazon. Method: The study took place in a philanthropic hospital, located in the city of Belém, Pará. A quantitative study was carried out in the action-research modality, data collection took place from December to January 2022, a semi-structured form was applied to assess patient safety in dispensing, preparation and administration. Results and discussion: 43 collaborators participated in this study, the analysis of the responses to the workers' behavior allowed us to identify that the professionals reported unsatisfactory performance of 4 actions (event notification; multidose recording; recording of temperature and medication by verbal order). From the weaknesses found, strategies were presented to minimize these occurrences, they are: elaboration of the safety protocol, use and administration of medications, standard operating procedure for high-alert medication and protocol for the use of multi-dose medications. Conclusion: It was identified that despite the knowledge of the risks and the need to guarantee patient safety through protocols for health services, it was noticed the need to implement basic and fundamental actions through institutional standards and routines, in accordance with with the local reality. Actions, when systematized, become possible applications in the safety of medication use and contribute to reducing potential risks and promoting safety and quality in the health work process.
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Acompanhamento farmacoterapêutico de pacientes pediátricos submetidos à sedoanalgesia em um hospital de alta complexidade em Belém-Pa
(Universidade Federal do Pará, 2022-12-06) ELMESCANY, Sâmella Benoliel; RIBEIRO, Carolina Heitmann Mares Azevedo; http://lattes.cnpq.br/3848996822163999; https://orcid.org/0000-0002-9457-2733; FONTES JÚNIOR, Enéas de Andrade; http://lattes.cnpq.br/7056265073849866; https://orcid.org/0000-0002-6186-9581
Introduction: The Intensive Care Unit (ICU) is a hospitalization unit for critically ill patients, whomostly use sedatives and analgesics. Seeking tominimize undesirable events, clinical follow-up of patients, especially pediatric patients, is necessary. Objective: To propose an instrument for pharmacotherapeutic monitoring of patients undergoing sedoanalgesia in the pediatric ICU. Method: Retrospective study, with data collected from medical records of patients aged 0 to 14 years, admitted to the pediatric ICU during the study period, who used sedoanalgesics. Results and discussion: In 326 prescriptions in the 90-day period involving 96 children, the age group of07-09 years predominated, with 49.2% underweight and predominantly male. Among the drugs prescribed were antimicrobials, sedoanalgesics, antipyretics and proton pump inhibitors. The average length of hospital stay was 18.5 days and approximately 32.7% of the patients had Withdrawal Syndrome (AS), corroborating the literature, where it is postulated that the longer thetime of use of these drugs, the greater the risk of SA. In 25% of the patients, 42.5% used antidotesother than those recommended by the Pediatrics and Pediatric & Neonatal Dosage Handbook. Asa product, a Manual for the Use of Sedoanalgesics was prepared to guide the multidisciplinary team in the care of patients during therapy. Conclusion: The data from this research indicated anunderweight public, the occurrence of medication errors and withdrawal syndrome, among otherfactors that reinforce the need for the elaboration of an institutionalized protocol for the administration of sedoanalgesics, aiming to guarantee patient safety, prevent the occurrence of adverse events related to its use and direct the multidisciplinary team on the care to be adopted.
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Proposta de intervenção para sensibilização dos gestores municipais quanto à implementação do serviço de acupuntura na saúde mental do municípo Castanhal, Pará
(Universidade Federal do Pará, 2023-05-10) SILVA, Jessé Jerônimo Fernandes e; SILVA, Marcos Valério Santos da; http://lattes.cnpq.br/0379783635000306; https://orcid.org/0000-0002-7824-0042; COSTA, Russany Silva da; http://lattes.cnpq.br/0435018266499256; https://orcid.org/0000-0002-2705-1591
Introduction: Depression encompasses biopsychosocial imbalances and is potentiated by stressful events. The progression of this, restricting quality of life through the exacerbation of negative symptoms and escape and avoidance behavior. Among the treatment approaches, acupuncture has proven effective for therapeutic success Objective: Application of the acupuncture technique in patients with depression disorder as an intervention proposal to sensitize municipal managers regarding the implementation of the mental health service in the municipality of Castanhal, Pará. Method: This was a quasi-experimental study with a quanti-qualitative approach, without a control group, with 17 participants. The data collection used a sociodemographic questionnaire, acupuncture form, Hamilton Scale, SF-12 Quality of Life questionnaire and field diary, the latter categorized into three domains, "quality of sleep", "quality of life" and "anxiety". Nine sessions were performed with a maximum use of 20 needles in each session. The data obtained were analyzed by descriptive statistics with the aid of SPSS software, using the chi-square test and the Student's t-test. Results: The majority of participants were female, in the age range 31 to 40 years, married, high school education, no fixed income, practice evangelism, perform household labor activities, have no children, smoker, sedentary, with unstable relationship in childhood and sexual abuse. The results showed improvement in the signs and symptoms associated with depression with a reduction in the Hamilton score from 19.3 ± 3.77 to 13.13 ± 2.43, student's t=5.6830, p=0.001, besides the improvement in the perception of general health status from the SF-12 from 4.06 ± 1.09 to 1.86 ± 0.83, p=0.001. Conclusion: The intervention with systemic acupuncture showed effective results in patients with depression, besides reducing complaints of anxiety crisis, improvement in sleep quality and concentration of the participants.
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Análise da adesão medicamentosa de pacientes hansenianos em uma Unidade Básica de Saúde
(Universidade Federal do Pará, 2023-06-16) PINHEIRO, Alcivaldo Mendes; MELLO, Amanda Gabryelle Nunes Cardoso; http://lattes.cnpq.br/8951750304102610; https://orcid.org/0000-0001-7661-1615
Introduction: Leprosy is a chronic transmissible infectious disease that still persists as a public health problem in Brazil. However, through the analysis of polychemotherapy medication adherence, a better quality of life is sought for diagnosed leprosy patients, with the pharmacist playing an important role in promoting early diagnosis and rational use of medication. Objective: To analyze the therapeutic adherence of patients undergoing treatment for leprosy treated at a basic health unit in Belém. Methodology: It is a prospective observational study to characterize the sociodemographic profile of patients undergoing polychemotherapy drug treatment at the Basic Health Unit located in the Guamá neighborhood, in Belém do Pará. Results: The study had the participation of 75 patients, 60 were undergoing treatment and 15 had already been discharged, in which the latter were consulted only to assess the dermatological quality of life. For the demographic and economic survey of patients, those who did not have confirmed diagnoses or had not started treatment were excluded. Final considerations: The predominant age group was between 50 and 59 years old, approximately (11.25%), male (41.25%), self-declared black patients (18.75%), married (21, 0%), high school (15.75%) and who had a formal contract with an income of up to one minimum wage (11.25%). Most patients adhered positively to the treatment, and at the end of the research a Therapeutic Adherence Manual was prepared for the follow-up of patients with leprosy, aiming at updating pharmaceutical practices with an exclusive focus on the care of patients with leprosy.
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Processo de gestão e gerenciamento de órteses, próteses e materiais especiais pelo serviço de farmácia de um hospital público referência em cardiologia, Belém, Pará
(Universidade Federal do Pará, 2023-08-01) RIBEIRO, Saulo Coelho Assis; SOLER, Orenzio; http://lattes.cnpq.br/4041958877867484; https://orcid.org/0000-0003-2246-0019; REIS, Danielle Saraiva Tuma dos; http://lattes.cnpq.br/0078006954066414; https://orcid.org/0000-0003-3966-2901
INTRODUCTION: Orthoses, Prostheses and Special Materials (OPME) are products used in medical, dental and physiotherapy procedures; as well as in the diagnosis, treatment, rehabilitation or monitoring of patients. OBJECTIVE: To investigate the management process of Orthoses, Prostheses and Special Materials (OPME) used by the Hemodynamics Service, aiming to present potential complications for their qualification. METHODOLOGY: This is a cross-sectional, quantitative and retrospective action research (January to December 2021). Based on the Hemodynamics OPME form from the Fundação Hospital de Clínicas Gaspar Vianna (FHCGV) and the Electronic Administrative Process (PAE) of the State of Pará. The proposals with potential interventions were based on the tool Strengths, Weaknesses, Opportunities and Threats - Strengths, Opportunities, Weaknesses and Threats (SWOT/FOFA). RESULT: a record of 18 prosthesis implantation procedures for occlusion of the Interatrial Communication was found, for both sexes, with a cost of R$ 524,995.00. There were 63 endovascular procedures in 2021, and it was found that the average waiting time for patients is approximately 88.6 days. With regard to the processing time of bidding processes, in the internal phase, the longest time identified was in the Permanent Bidding Committee (CPL) sector, totaling five months, referring to endovascular and congenital OPME. In the external phase, both classes of materials also took the longest processing time. Furthermore, there is a difference of R$ 883,153.00 reimbursed to the Hospital through the SIGTAP/SUS table. A low rate of studies that could support the research was noted, however, the Pharmaceutical Assistance (AF) cycle is an essential method for improving the management and management process. It was found that the bidding process in the public service is slow, as it crosses several sectors, generating an impact on the time required to request/acquire this material, also affecting the time to carry out the procedure. CONCLUSION: The OPME topic is complex and little explored by scholars, however, it requires “many hands” to obtain the biggest objective, which is the quality provided to the user. It is believed that interventions to qualify the OPME management process at FHCGV will provide improvements in the management of the OPME sector, as well as the Institution's processes and flows that will provide quality service to the user.
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Aplicativo web para manejo de queixas clínicas relacionadas ao tratamento da tuberculose multidrogarresistente
(Universidade Federal do Pará, 2023-08-16) SOUZA, Raquel Ribeiro de; ALBÉRIO, Carlos Augusto Abreu; http://lattes.cnpq.br/2335187399740995; https://orcid.org/0000-0002-9364-3990
INTRODUCTION: Tuberculosis (TB) is an infectious disease that remains a serious global public health problem, and lack of adherence to treatment contributes to the development of resistant strains. OBJECTIVE: To build a web application as a technology to assist in the management of adverse reactions related to the treatment of MDR TB in patients treated at the João de Barros Barreto University Hospital (HUJBB). METHODOLOGY: This is a cross sectional, observational, descriptive study on patients diagnosed with multidrug-resistant TB (MDR TB) in the intensive phase of treatment. In addition, methodological research into technological development was carried out, which consists of building a product that can be implemented in the care of patients with MDR TB. The web application was validated by health professionals who work at the MDR TB Outpatient Clinic and the HUJBB Outpatient Pharmacy using the form with responses on the Likert scale. RESULTS: In this study, 17 patients were evaluated, with a predominance of females (52.94%), between 50 and 59 years old (29.41%). Furthermore, regarding the lifestyle habits of the researched population, it was found that 7 claimed to be alcohol drinkers (33.33%), 5 smokers (23.81%) and 3 illicit drug users (14.29%). The most predominant clinical complaints were arthralgia, nausea, vomiting and anxiety. Regarding comorbidities, 60% reported having diabetic mellitus (DM), while the other items, such as systemic arterial hypertension (SAH), asthma, osteoporosis and neuropathy presented equal distribution with 10% each. Regarding laboratory tests, the hematimetric parameters of 47.06% of the patients presented anemia, while the biochemical parameters were observed values above the reference for: fasting glycemia, creatinine, TGO, TGP, alkaline phosphatase, GAMMA GT, amylase, lipase and in total bilirubin and fractions. Based on this information, a web application was built and, subsequently, the application was validated using a Likert scale with health professionals. Thus, a Global Content Validation Index (Global CVI) of 0.93 was obtained. To be considered valid, the Global CVI must present a value equal to or greater than 0.78. CONCLUSION: The application proved to be valid for use as a tool for managing complaints related to the treatment of MDR TB.
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Elaboração de manual para medicamentos orais administrados via sonda em Unidade de Terapia Intensiva (UTI) neonatal
(Universidade Federal do Pará, 2023-09-01) AZEVEDO, Lucília Lima; COSTA, Russany Silva da; http://lattes.cnpq.br/0435018266499256; https://orcid.org/0000-0002-2705-1591
Neonatal Intensive Care Units (NICU) accommodate several health professionals, working together to ensure comprehensive care for patients. Since the 1990s, the pharmaceutical professional has been proposed as one of the fundamental members of the multidisciplinary team caring for critically ill patients. The challenge of safe and appropriate drug use in the neonatal period is daunting and is made more complicated by the notorious lack of evidence based data to guide decision-making. The present work aimed to develop a manual for the use of oral medications prescribed for administration via tube to hospitalized patients, to support the development of a guidance instrument for the multidisciplinary team. This is a documentary study of a descriptive, analytical and retrospective nature with a quantitative approach, where data were analyzed from medical prescriptions from the NICU in the period from January 1, 2020 to December 31, 2021, excluding newborns with length of stay of less than 24 hours and/or who did not have a prescription for medication to be administered via a tube and nursing report forms. During the study, 633 newborns were admitted to the NICU, of which 23.5% were excluded due to a length of stay of less than 24 hours, 18.4% due to lack of information in the medical record and 34.1% because they did not have a medication prescription via tube. In this sense, the study population consisted of 151 newborns, of which 53.6% were male and 46.4% were female, the majority of which were born through surgical delivery (59.6%). This population weighed between 750g and 4,515g, with the statistically significant majority being underweight (59.6%), followed by those with very low weight (23.8%). The average stay in the ICU was 12.6 days, with a minimum of 2 days and a maximum of 40 days. Furthermore, the most prevalent diagnosis was prematurity, which reached 72.2%, with 47.7% of isolated prematurity and 24.5% of prematurity plus Respiratory Distress Syndrome (RDS), with the proportion of prematurity being statistically significant in in relation to other diagnoses. Almost 50% of newborns were prescribed three or more medications, where it was found that the most prescribed medications were antiphysetics and antiemetics (Simethicone/Domperidone: 42.2 and Bromopride: 24.6%), the most frequent pharmaceutical form was liquid (90.7%), and can be administered through a tube (98.0%), without interacting with medication (98.0%) or with diet (parenteral nutrition) (89.4%). In nursing reports, 79.2% stated that they had prepared/administered a medication prescribed for administration via tube and 73% of professionals stated that they had doubts regarding the preparation and administration of medications. The most frequent question was about administration (10 out of 14-71.4%). There were also doubts regarding dilution and incompatibility of the medicine (35.7% both), as well as preparation, crushing and closing time (21.4% each). Therefore, the need to develop a Manual that will contribute as a tool for good practices in the administration of medications via tube stands out, as a tool aimed mainly at the nursing professional, an active participant in this process.

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