An answer to rising costs and chronic illness

Our health services are at and in many places beyond breaking point. While we can hope the new government will restore some of the funding it is clear that health needs and costs are continuing to rise. In the next 15 years those living with a major illness are forecast to rise by 2.5 million to 9.1 million (i). 

So what can tackle rising costs and massively rising ill-health?

In this blog I will look at part of the answer that is already being tried with some wonderful results in terms of cutting costs and improved health outcomes. Perhaps the best articulation of the approach is the book “The Community Cure. Transforming Health Outcomes Together” by James Maskell (ii).

Maskell notes that we are facing a profound and worsening epidemic of loneliness and this is exacerbating chronic disease. He cites many examples of isolation as a social determinant of health including a 2017 questionnaire-based study where Medicare recipients older than 50, who ultimately were defined as “lonely”, experienced death rates 31% higher than their peers who did not self-identify as socially isolated. 

This research is not new - there is loads showing a range of health conditions associated with loneliness and social isolation, including heart disease and stroke, type 2 diabetes, rheumatoid arthritis and cancer. Even recovery following heart surgery can be compromised by isolation.

In the book Maskell argues that to counter this we should turn to group medical appointments; a supportive community provides the space to help develop healthy behaviors - a key to reversing chronic illness. This also can ‘shift our collective focus to prevention and root cause resolution’.

The book looks at the many ways group medical visits are being used - and the powerful evidence of them as a treatment for the loneliness epidemic. 

One of the examples Maskell looks at is the work of Dr Jeffrey Geller’s. This doctor found that patients who lacked support systems accessed medical care at a greater rate, so he decided to create a support system by forming group visits with a cohort of diabetes patients. Geller notes “People’s loneliness improved, people’s depression improved, they lost weight … blood pressure reduced by 5-10 points, and hemoglobin A1C also reduced”. 

I’ve personally seen the benefits of a group of people coming together and supporting each other - the peer-led Wigwam cancer support groups are a great example. See my blog post on this; ‘What makes the biggest difference to our healing’: https://yestolife.org.uk/what-can-make-the-biggest-difference-to-our-healing/

I’ve also seen benefits accruing from groups like the Cancer Exercise group at Stratford Park Leisure Centre supported by Stroud District Council. I believe there is huge potential for more of this intentional coming together.

One obvious possibility might be the one-off prehab talk now being run by local cancer services. Could that be expanded into a series of group activities looking more at nutrition, exercise, sleep, stress and more? This of course doesn’t mean there will not be some individual appointments but the bulk of issues can be raised in the groups. One of the findings into researching this approach showed that folk didn’t have time to raise key stuff in an individual appointment but there was time in the groups. Furthermore some patients were more shy to raise issues and found it useful that others in the group asked those questions.

‘Confidentiality’ I hear some folks cry. Yes any group work needs to consider this issue, Maskell has a section in his book on this, but it seems clear to me that group visits don’t destroy a patients privacy. What they do offer is a safe space for folks to be vulnerable and this can be a key part in healing.

Maskell writes: “We need more connection, more empathy, more social connectivity, and less loneliness, less social isolation. In a culture and society that emphases and prioritises privacy, we’ve inadvertently contributing to the very epidemic we’re trying to solve."

Maskell provides many resources for those interested in starting their own group visits, primarily through his website, “Evolution of Medicine.” I also know there are many skilled practitioners within our NHS who no doubt already have the skills to develop this approach.

With families and communities no longer meeting our needs we have seen what Maskell calls ‘total commodification’. We need ever more money to pay for counselling, babysitters, care and more - these were once shared by the community itself. It seems we now only look to the market or government for solutions. It’s time for a refocus…..group appointments are a way whose time has come. It would be great to see if there are opportunities to expand these ideas in Gloucestershire?

Update 10.01.25: Just heard this useful podcast re James Maskell: https://creators.spotify.com/pod/show/robin-daly6/episodes/James-Maskell--Diana-Lindsay-e2sjofc

There are many other podcasts with James Maskell on his website and online. Here are a couple:

Dr Chatterjee interview: https://drchatterjee.com/the-secret-to-radically-improving-your-health-that-nobodys-talking-about-with-james-maskell/

Oncologist Nasha Winter's interview: https://www.youtube.com/watch?v=HJanBC_xi3o&t=1s

Here are a couple more of my blogs looking at the impact of social support and community:

See blog about building a community of Wigwam Cancer Support Groups:

https://myunexpectedguide.blogspot.com/2021/05/building-community-of-peer-led-support.html

See blog on social prescribing and anti-social prescribing: 

https://myunexpectedguide.blogspot.com/2019/12/social-prescribing-for-people-living.html

Notes:

1. https://www.health.org.uk/reports-and-analysis/reports/health-in-2040-projected-patterns-of-illness-in-england
2. https://thecommunitycure.com/getyourcopy

Reiki proven to provide symptom relief

Research out last month showed that energy healing, in the form of Reiki therapy, can provide significant symptom relief in cancer patients receiving standard treatments. In this study published in the Journal of Pain and Symptom Management, they found that patients given Reiki during chemotherapy experienced a clinically significant improvement in nausea, pain, fatigue anxiety.

As someone who took a basic reiki course many years ago I don't doubt this - while my brain can hardly compute how it could work I have seen first hand the evidence of improved wellbeing when reiki has been used. I also used it for myself when I was going through radiotherapy and do return to it when it feels the right approach.

Indeed this is not the only research supporting energy healing - a great book I read a couple of years ago is David Hamilton's 'Why Woo-Woo Works, The Surprising Science Behind Meditation, Reiki, Crystals and Other Alternative Practices'. There is a whole chapter on Reiki including research on using it with cancer patients to lessen the impact of treatments.

Change NHS: a look at submissions

In November 2024 the UK public were invited by Health & Social Care Secretary, Wes Streeting, to contribute ideas to rescue the NHS; “Our NHS is broken, but not beaten. Together we can fix it.” See details here: https://change.nhs.uk/en-GB/

Amazingly the previous government left Cancer care out of its 10-year plan altogether. Given the scale of the current statistics this was surely deeply misjudged. In this blog I cover the excellent response by Yes to Life and note some other key points.

Robin Daly, Founder and Chair of Yes to Life, writes: "This was the introduction to Change NHS, a once-in-a-lifetime opportunity to have our say, that we at Yes to Life immediately knew we had to respond to. Although there are no certainties as to what effect this unprecedented public input will have, we felt the need to express clearly the changes we would like to see, and to argue the case that these will provide solutions to many of the key ills affecting UK healthcare in the twenty-first century".

Yes to Life have now made their submission public. It relates strongly to the Charter for Oncology that Yes to Life published earlier this year. This Charter sets out "the ethos for an entirely new relationship between those delivering and those in need of healthcare, one that opens up unlimited potential for rapid improvements in resources, methods and most importantly results, as well as approaches to prevention and health promotion that are currently totally absent from mainstream healthcare".

Don't forget to sign the petition for the Charter: https://www.change.org/p/implement-the-yes-to-life-charter-for-oncology-in-all-nhs-cancer-units

The Yes to Life submission by Robin Daly and Dr Penny Kechagioglou, NHS Oncologist and Lead Advisor to Yes to Life on Integrative Oncology, can be read at: https://yestolife.org.uk/wp-content/uploads/2024/12/Change-NHS-Booklet-1.pdf

The Charter is a key element of the submission but also there are other key points that they make in more detail than I note here - these include:

- The need for a deep cultural shift towards patient-centred care (not lip service) - it has been enshrined in the NHS Charter but is still barely discernible. Similarly we need a return to clinical judgement as a key element of evidence-based decisions.

- Integrative Oncology as a model of care is well developed in other countries, cost-effective and has better clinical outcomes; lifestyle changes are key yet the NHS is ill-equipped to deliver

- Prevention is ultimately where solutions lie

- More collaboration both within the NHS and with external providers

- More than half of Cancer patients adopt lifestyle or complementary approaches independently but are unsupported during and after treatment. Clinicians don't need to be experts but do need to know facts when it comes to its potential. Training key to help with changes.

- Improvements to data

The Patients Association

Many organisations and individuals are submitting responses  to Change NHS. One of the others I've read is by the Patients Association - see here. Their submission also strongly calls for the patient voice to be heard. It is full of detail and is informed by 290 responses to a call they made for comments. They found that the respondents to their survey were generally in favour of the three shifts proposed by the Government – shifting from hospitals to the community; from analogue to digital; and from sickness to prevention. There was also an understanding about the challenges that may arise from implementing these shifts. 

Among the key points are calls for shorter waiting times, integrated digital health records, better prevention strategies, and equitable care for underserved groups. Workforce recruitment and retention, alongside stronger patient partnerships, were also seen as critical to success.

One key issues that impacts on the NHS that needs emphasising is around how social determinants of health impact patients. This includes external factors that contribute to a patient’s health and wellbeing, like their income level, if they have access to safe housing, and whether they come from a minoritised community, like being Black or LGBTQ+. This is huge and something this blog has touched on in the past. Again as we've argued in the past part of the answers involve really involving patients.

Lastly here's a link to World Cancer Research Funds submission which also has some good stuff: https://www.wcrf.org/wp-content/uploads/2024/12/Comments-10-year-health-plan-England-Dec-2024.pdf

Getting the oral microbiome right

Last year I posted a link to a video about the importance of dental care - see here - it seems our oral microbiome is increasingly been seen as a key element in our health. Anyone interested in this could do well to listen to this podcast with Dr Victoria Sampson (pictured) - nearly 800,000 views in the last two weeks since it's been out: https://www.youtube.com/watch?v=p3fSwd1cF08&t=118s 

A friend has recently seen Victoria Sampson and shared how useful the test of her oral microbiome was - sadly at £350 a pop it is likely to be out of reach of many but it is exciting to see this field develop. In the video Victoria shares what you can do to look after your teeth and much more. 

We have known for a while about the importance of the microbiome and cancer - here's a paper from 2019 that looks at the health of the microbiome and how that impacts on prostate cancer. Consideration of the oral microbiome is newer - who knew we even had one of those?!! 

Research is at a very early stage but here's a paper from 2020 saying: "Several meta-analyses have confirmed the suspicion that periodontal disease should be considered as a risk factor in several types of cancers. In fact in a meta-analysis by Corbella et al., they found that a statistically significant association was found for all cancers studied, both combined and individually (digestive tract, pancreatic, prostate, breast, corpus uteri, lung, hematological, esophageal/oropharyngeal and Non-Hodgkin lymphoma)."

One study from 2022 looking at pancreatic cancer notes: "In summary, poor oral health, oral microbial dysbiosis and the development and progression of PC are interlinked. However, the underlying mechanisms of the oral microbiota’s influence in PC diagnosis and treatment have yet to be elucidated. Thus, these data beg for further research, particularly as it relates to mechanisms, human diversity and the implementation of precision medicine."

Drug Repurposing - a great introduction

This week's Yes to Life show on Health Radio with Robin Daly talks to Jane McLelland - she is the wonderful pioneer whose groundbreaking book first introduced this topic to a wider audience. 

"Knowledge about drugs intended for one purpose that actually have beneficial effects in another, say cancer, has been around for a long time, but the lack of financial incentives in off-patent drugs has meant that the research has generally collected dust – until, that is, Jane’s need to survive terminal cancer spurred her into a deep dive into the medical literature."

The show also looks at the Somatic theory of cancer vs the metabolic approach - often the root of why many oncologists are so dismissive of an integrative approach. We so need oncologists and more to understand where those of us taking an integrative approach are coming from.

Listen to the Jane McLelland show at: https://yestolife.org.uk/radio_shows/drug-repurposing/

This Yes to Life radio show is well worth a listen every week - you can also listen back on all the previous shows (8 years worth) with many other pioneers in an integrative approach - see: https://yestolife.org.uk/radio-shows/

See my very short interview with her from 2018:

https://myunexpectedguide.blogspot.com/2018/09/can-we-starve-our-cancer.html
Great 30 min documentary on this topic: https://myunexpectedguide.blogspot.com/2020/10/starving-cancer-new-documentary.html

Previous blog on approached to cancer: https://myunexpectedguide.blogspot.com/2023/05/could-this-be-day-world-changes-for.html

High-dose IV vitamin C plus chemo doubles survival in advanced pancreatic cancer

Research this month concludes: "A randomized, phase 2 clinical trial shows that adding high-dose, intravenous (IV) vitamin C to chemotherapy doubles the overall survival of patients with late-stage metastatic pancreatic cancer from eight months to 16 months. The finding adds to mounting evidence of the benefits of high-dose, IV vitamin C in treating cancer."
https://www.sciencedaily.com/releases/2024/11/241118125040.htm#google_vignette

Wow as author Jane McLelland says: "Who has been told by their doctor not to waste your money on intravenous vitamin C? This study should be HEADLINES in every paper as it DOUBLES survival times. If it were a patented drug the excitement would be intense....My lowest ever cancer markers when I had stage 4 was when I took a combination of dugs/supplements with IVC. IVC should not be considered "alternative" it should be considered as a standard treatment.....IVC works by increasing #ferroptosis which you are not allowed to know about as my second edition which discusses this topic is still deemed 'offensive' by @amazon and is still not reinstated. Shame on you. Pancreatic cancer is one of the worst diagnoses."

Update 8/1/25: https://rumble.com/v5ylhwb-intravenous-vitamin-c-and-cancer.html

Universal screening for prostate cancer?

Seven years ago I blogged here about whether a PSA test should be standard for over 50s - see here - at that time there were strong reasons for and against testing. However the evidence is growing for 'a targeted national prostate cancer screening programme'....

In the most recent Newsletter from Prostate Cancer Research (PCR) (pictured) they cover a report in which they look at the crucial issue of over diagnosis and over treatment - a huge issue - their argument is that with improvements in MRI (mpMRI) and guided transperineal biopsies the picture is very different. There is also more acceptance of active surveillance rather than going straight to invasive treatments.

We know the current situation does not work: "The existing “informed choice” system for requesting testing places the onus on men to understand their risk and actively seek testing. This system is both ineffective and inefficient and contributes to the fact that men from high-risk groups, particularly Black men, are more likely to be diagnosed late and are more than twice as likely to die from this disease."

Deloitte's were commissioned to look at a cost-benefit analysis for change. This indicates that the introduction of a targeted national prostate cancer screening programme for high-risk groups using the current pathway could deliver:

• Around 650 earlier diagnoses annually for men with a family history of prostate cancer aged 45-69 and in the region of 170 for Black men aged 45-69.

• For these groups, almost 230 men with a family history of prostate cancer per year being spared a stage 4 diagnosis, when prostate cancer becomes incurable. For Black men, 60 avoided stage 4 diagnoses.

• Up to £14,000 net socio-economic benefit for every high-risk man diagnosed.

This would be achieved using current technologies and pathways, and by targeting men from high-risk groups:  Black men and those with a family history of prostate cancer (including those with BRCA1/2 mutations).

Here are the headline figures noted in their newsletter:

The report concludes that with the introduction of an effective 'reflex test' between a PSA and MRI in the critical pathway, a universal screening programme for men aged 50-69 could save lives and benefit the country economically. This would also move the UK from being one of the worst OECD performers on prostate cancer to being one of the best.

PCR are taking their report forward and meeting with Members of Parliament to put the case. It is also interesting to note in a further landmark report presenting evidence for change the three key areas to go forward. See here: https://www.prostate-cancer-research.org.uk/PFYP/

Here they are taken directly from their report:

1. Introduce targeted prostate cancer screening for high-risk groups as soon as possible
Right now, we need to optimise screening using a PSA test, focusing on high-risk groups – Black men, those with a family history, and those with a BRCA1 or BRCA2 mutation. This approach, prioritising those at highest risk of prostate cancer, has been shown in our report to provide economic benefits, while requiring the lowest level of health system change.
2. Trial new diagnostic tests in clinical practice
Alongside more targeted PSA testing, we need to focus on getting new diagnostic technologies into trial (e.g. reflex tests), to gather real-world evidence and understand the benefit in diverse populations. Once the value of this has been demonstrated, we should expand the screening programme to cover the general population using a test with greater accuracy, as this will realise the greatest economic benefits.
3. Adopt AI-driven tech to enhance patient outcomes and efficiencies
To further improve patient outcomes and the economic benefits of earlier detection, we need to integrate AI technology into the NHS. We need to leverage its potential to improve the accuracy and reliability of screening, avoiding the need for unnecessary biopsies, while also boosting operational efficiencies. By adopting AI-driven technologies in imaging, we can streamline processes, reduce diagnostic errors and ensure resources are allocated more effectively.

Thank you PCR!

20 tips to reduce prostate cancer risk

This article from three weeks ago by Professor Robert Thomas has some good reminders of what we can all do:
https://www.nationalworld.com/health/prostate-cancer-oncologist-gives-20-tips-to-slash-mens-risk-4848581

Osteopenia

Back in 2021 I had a Dexa scan to look at bones - it showed I had Osteopenia and this was likely caused by the cancer treatment - see my blog post here. Well I just read today a great article that looks at bone health - I was pleased to see I'm doing all of that but thought it worth posting on this blog - take a look at: https://chriswoollamshealthwatch.com/your-illness/general-health/osteoporosis-six-simple-steps-for-strong-bones/

Here are Chris Woollams six simple steps to maintaining strong bones – 

• Heal your gut,
• Focus on vitamin D (and possibly K2 for prevention), 
• Magnesium, Phosphorus, Boron,
• Natural calcium intake from plants, 
• Iodine, and
• Weight bearing exercise.

Cancer and the New Biology of Water; Deuterium, Quinton and more

There are so many ways of looking at cancer - in recent blogs I’ve been writing about Mark Lintern’s view - see more here and here. Our health services are still focusing on removing (surgery), burning out (radiation), or poisoning (chemotherapy), yet what we have learnt about cancer shows there is so much more we can be doing.

In Cancer and the New Biology of Water, Thomas Cowan, MD, argues similar to Mark Lintern that this failure was inevitable because “the oncogene theory is incorrect—or at least incomplete—and based on a flawed concept of biology in which DNA controls our cellular function and therefore our health”. Indeed the evidence is overwhelming regarding the oncogene theory.

Dr. Cowan sees the root cause is metabolic dysfunction that deteriorates the structured water that forms the basis of cytoplasmic—and therefore, cellular—health. I am not sure how this fit’s with Marks work but I found his ideas about ‘structured water’ and it’s role in cellular health fascinating.

In the book, Dr. Cowan writes about the four states of water, three that we know well are ice, liquid, and steam. The one that I had not come across he defines as “gel.” This gel is the body’s ‘life force’ within all our cells and this determines how healthy we are. He argues that by restoring this intracellular gel we have a key to treating cancer more effectively.

In the book Dr. Cowan reviews quite a number of promising treatments and calls for research on them - these include many that I’ve come across like the ketogenic diet, mushrooms, Gerson, Vitamin C, reducing electromagnetic frequencies, mistletoe, saunas and more. However some I had not come across. What was interesting was that he explained in the light of his theory how these treatments might work with cancer.

Quinton Plasma

One of those treatments I hadn’t come across was Quinton Plasma or Quinton isotonic seawater. He quotes the work of René Quinton, a biologist who lived in France (1867 to 1925), who noted that our blood serum has the same mineral composition as seawater. When we eat processed salt, we create an imbalance that causes ailments. Quinton learned how to refine ocean water to create a plasma that was used to treat disease during his lifetime. Dr. Cowan feels this marine plasma is a key to restoring balance in the human body.

Deuterium-depleted water

Another factor Dr. Cowan identifies that decreases health is deuterium in the water we drink. He argues deuterium affects energy pathways in the cells and can cause errors in our DNA. As we age, greater amounts of deuterium accumulate in our bodies, leading to an unhealthy imbalance. This reminded me of some reading I did a couple of years ago but didn’t follow up….

In 2022 I was sent a copy of the book ‘Deuterium Depletion – A New Way in Curing Cancer and Preserving Health’ by Gábor Somlyai; it appeared in English in February 2022 and I was asked to review. This was a fascinating book looking at how deuterium depletion inhibits the growth of cancer cells in the body. However most studies into deuterium, although very positive, are still on animals - and purchasing such water is sadly not a cheap option so I’ve not pursued further - but it is certainly one to watch!

For a good overview see this hour long podcast (if you can bear the repeated adverts) from Ricci Flow looking at: ‘Deuterium Depletion & Defeating Cancer with Gábor Somlyai’: https://youtu.be/imwnUK4XYbM?feature=shared

Then here is Somlyai talking about reducing metastases: https://youtu.be/tl8UF8snJN8?feature=shared

Here is some of the research that backed up Somlyai’s work: https://www.researchgate.net/profile/Gabor-Somlyai

Many of these treatments Dr Cowan discusses are crying out for research. I remember reading “Outsmart your cancer. Alternative Non-Toxic Treatments That Work” by Tanya Harter Pierce (2009) which looks at a whole host of other treatments like Rife, apricot kernels, Gerson, Hoxsey and Essiac that have been used over years. Some of the stories are fascinating - but they just don’t have the peer reviewed science to support them, although the many case studies may well be enough to persuade some to try. I think the book should carry a warning that some of those treatments could well be dangerous. Having said that some listed seem harmless and some may well be supportive to someone with cancer. It is a huge challenge negotiating all the hundreds of claims that folk make around cancer. 

For me many of these treatments need more evidence before I would embark on them - but at the same time I do not judge those who may well want to try what some consider to be wacky! Indeed I have in the past and may well do again. Let us not forget that many conventional treatments are not wholly safe with massive side-effects and too often mainstream health professionals are too ready to dismiss possible ways forward. It was probably less than 20 years ago that the idea of a microbiome was dismissed yet now we know the huge and key role it plays. As always check out any treatment with your medical team.

Here’s Dr Cowan in a 45 minute podcast that looks at many of the issues he raises in his book: https://youtu.be/Vecoxzvi1ok?feature=shared

'Finding Your Way' Booklet cold help improve outcomes

Just out is a new booklet......'Finding Your Way'. It is designed to provide people with cancer with an entry point into Integrative Medicine (ie getting the best from conventional, lifestyle and complimentary treatments). I was fortunate to meet the author of the booklet, Melanie, at the recent Yes to Life conference. When going through her own treatment she could see it was so hard finding out what else you can do to support conventional treatment. Hence she wrote this booklet then raised money to get it printed! This booklet info was taken from the much, much more comprehensive book, The Cancer Revolution - a book listed as one of the top three books to get when first diagnosed - see my blog here. Indeed that book is still a very useful resource now.....

The booklet is a wonderful introduction to an integrative approach to cancer - it is a guide and should not be read as gospel - it is for each of us to find what works best for ourselves. One issue I took slight issue with was to 'Reduce coffee and tea' - certainly that is true if you are drinking lots and also very true if your genetics/SNPs say you don't tolerate caffeine so well. However the evidence is a bit mixed and it looks as if for some coffee could be good - see my blog from a while ago here.

Another addition to the booklet I would make is a mention of strength bearing exercises - these are particularly important for some cancers like prostate. See my blog on exercise here. Having said that the list of exercises in the booklet does include ones that are strength bearing but doesn't make a specific point about them.

Signed copy!!

Anyhow many of us would like to see the booklet being available in waiting rooms and reception areas across the country, in places where newly diagnosed patients will have a chance to see them. I will be exploring options in Gloucestershire - would love some help! Do get in touch.

Download the booklet here: https://yestolife.org.uk/resource/finding_your_way/

Order copies here!

Please take a copy with you to appointments and ask staff if they would be willing to offer them, and if so, the person and address to send them to and the quantity they would like. It’s important to get ‘buy in’ before we send them, to ensure they don’t end up as landfill! You can order copies here:Finding Your Way - Yes to Life

Prostate cancer treatment options: HIFU, NanoKnife, Watchful Waiting and more

Robin Daly, Chair and Founder of Yes To Life has a great radio show every week. I am a regular listener and many of the shows are worth a listen - this one I’ve linked here is a great update looking at advances in prostate cancer. Robin talks to The Focal Therapy Clinic which gives some ideas of treatment options and what is available in UK. 

The Clinic specialises in HIFU and NanoKnife - I tried to get on a HIFU trial but the start was delayed too much so I wasn’t able to take part. Sadly much of the treatment offered by the Focal Therapy Clinic (and indeed wider options) is still only available to those with money - things are changing but we have a way to go. 

Here’s the description re the show: "Prostate cancer therapies are advancing rapidly with marked improvements to outcomes, but holistic support for men after treatment is still lacking. The Focal Therapy Clinic brings choices to those with prostate cancer who might otherwise have nothing on offer between waiting for further developments, and radical treatment with its attendant risks and side effects. This week’s guests, Brian Lynch, Clare Delmar and Dr Marie Edison talk about focal therapies and also about a new one-year programme they have developed as comprehensive rehabilitation support for men after prostate cancer treatment".

See the show at: https://yestolife.org.uk/radio_shows/focused-support/https://www.thefocaltherapyclinic.co.uk/focal-therapy/medical-suitability/