1
|
Ogawa S, Tayama J, Murota H, Kobayashi M, Kinoshita H, Nakamichi S. The reliability and validity of a developed anxiety scale specific to primary focal hyperhidrosis symptoms. Biopsychosoc Med 2024; 18:14. [PMID: 38835082 DOI: 10.1186/s13030-024-00310-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/24/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Patients with primary focal hyperhidrosis (hyperhidrosis) are known to have higher levels of anxiety induced by sweating than those who do not. However, in hyperhidrosis, no scale has been developed to measure anxiety specific to hyperhidrosis symptoms. Therefore, this study aimed to develop an anxiety scale specific to hyperhidrosis symptoms (ASSHS) and to verify its reliability and validity. METHODS Based on previous studies on hyperhidrosis and a preliminary survey conducted with 26 university students who met the diagnostic criteria for hyperhidrosis, 40 items that adequately reflected anxiety specific to hyperhidrosis symptoms were obtained. A survey was done to examine the internal consistency and validity of the our developed ASSHS. In total, 1,207 participants (680 male and 527 female; mean age ± standard deviation 18.7 ± 0.9 years) were included. A second survey (re-survey) was conducted three weeks later to verify the reliability. It included 201 participants (85 male and 116 female; mean age ± standard deviation 18.6 ± 0.7 years). The survey items included (1) the diagnostic criteria for hyperhidrosis, (2) our anxiety scale developed for primary focal hyperhidrosis symptoms (ASSHS), (3) Hyperhidrosis Disease Severity Scale (HDSS), (4) State-Trait Anxiety Inventory (STAI), (5) Hospital Anxiety and Depression Scale (HADS), (6) Dermatology Life Quality Index (DLQI), and (7) presence of anxiety induced by sweating. RESULTS The results of the factor analysis revealed 10 items with one factor, "anxiety specific to hyperhidrosis symptoms." The alpha coefficient of the ASSHS was α = 0.94. The correlation coefficient between the scores at re-test was r = 0.75. A moderate positive correlation was found between the ASSHS, HDSS (r = 0.53), and anxiety induced by sweating (r = 0.47) (all p < 0.001). Additionally, participants with hyperhidrosis symptoms had significantly higher ASSHS scores than did those without hyperhidrosis symptoms (p < 0.001). Those with mild/moderate hyperhidrosis and those with severe hyperhidrosis had significantly higher the ASSHS scores than did those without hyperhidrosis (p < 0.001). CONCLUSIONS This scale has sufficient reliability and validity as an instrument to measure anxiety specific to hyperhidrosis symptoms.
Collapse
Affiliation(s)
- Sayaka Ogawa
- Faculty of Humanities, Nagasaki Junshin Catholic University, 235 Mitsuyama-Mach, Nagasaki, 852-8558, Japan.
| | - Jun Tayama
- Faculty of Human Sciences, Waseda University, 2-579-15 Mikajima, Tokorozawa, 359-1192, Japan
| | - Hiroyuki Murota
- Department of Dermatology, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masakazu Kobayashi
- Health Center, Nagasaki University, 1-14 Bunkyo-Machi, Nagasaki, 852-8521, Japan
| | - Hirohisa Kinoshita
- Health Center, Nagasaki University, 1-14 Bunkyo-Machi, Nagasaki, 852-8521, Japan
| | - Seiko Nakamichi
- Health Center, Nagasaki University, 1-14 Bunkyo-Machi, Nagasaki, 852-8521, Japan
| |
Collapse
|
2
|
Lima SO, Neto JM, Fontes LM, Galrão de Almeida Figueiredo MB, Santos JM, Santana VR. Evaluation of quality of life (QOL) of young patients with primary hyperhidrosis (PH) before and after endoscopic thoracic sympathectomy (ETS). J Am Acad Dermatol 2023; 88:e197-e201. [PMID: 37069802 DOI: 10.1016/j.jaad.2015.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 04/19/2023]
Abstract
BACKGROUND Primary hyperhidrosis (PH) affects young patients and may cause emotional distress and a negative quality of life (QOL). OBJECTIVE We sought to evaluate the QOL of children and adolescents with PH treated by endoscopic thoracic sympathectomy. METHODS A study of 220 patients was performed, based on submitted QOL questionnaires from their first consultation. Patients were evaluated within 1 week and 24 months after surgery. RESULTS Before endoscopic thoracic sympathectomy, the QOL in relation to PH was declared very poor by 141 patients, and poor by the remaining 79 (P = .552). Postoperative cure was reported in 100% of palmar and axillary PH cases, and in 91.7% of facial PH. After 24 months, the QOL was described as much better by 212 patients, a little better by 6 patients, and 2 patients reported no change. LIMITATIONS Convenience sampling was used and patients were taken from private practice only, raising the possibility of bias in gathering the data. CONCLUSION Onset of PH symptoms was mainly before the age of 10 years and substantially affected daily activities. Endoscopic thoracic sympathectomy cured PH and promoted significant improvement in the QOL of these young patients.
Collapse
|
3
|
Ogawa S, Tayama J, Murota H, Kobayashi M, Kinoshita H, Nishino T. Association of primary focal hyperhidrosis with anxiety induced by sweating: A cross-sectional study of Japanese university students focusing on the severity of hyperhidrosis and site of sweating. J Dermatol 2023; 50:364-374. [PMID: 36282908 DOI: 10.1111/1346-8138.16617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 12/01/2022]
Abstract
Hyperhidrosis significantly reduces patients' quality of life, with many reporting feeling highly anxious. However, the relationship between hyperhidrosis and anxiety induced by sweating has not been examined in detail. The current study examined the relationship between: (1) the presence of hyperhidrosis symptoms, (2) hyperhidrosis severity, and (3) the sites of the most sweating and anxiety induced by sweating. A cross-sectional web-based survey was conducted among university students, and 1080 consenting participants (600 males and 480 females; mean age, 18.8 years) were included in the analysis. The survey items were: (1) diagnostic criteria for hyperhidrosis, (2) Hyperhidrosis Disease Severity Scale, (3) presence of anxiety induced by sweating, and (4) site of the most sweating. The results of multiple logistic regression analysis adjusted for sex and age showed that the odds ratio (OR) for anxiety induced by sweating was significantly higher in participants who screened positive for hyperhidrosis than in those who screened negative (OR, 9.72 [95% CI, 5.80-16.27]). The OR of anxiety induced by sweating was 7.11 (95% CI, 3.99-12.65) for mild/moderate hyperhidrosis and 23.46 (95% CI, 7.15-76.93) for severe hyperhidrosis, compared with those who screened negative for hyperhidrosis. Compared with those who screened negative for hyperhidrosis, the OR for anxiety induced by sweating in those with the palmar, plantar, axillary, and head/face as the site of the most sweating was 7.74 (95% CI, 3.91-15.33), 14.86 (95% CI, 1.83-120.58), 16.92 (95% CI, 5.95-48.14), and 5.38 (95% CI, 1.39-20.74), respectively. Our findings suggest that participants who screened positive for hyperhidrosis, mild/moderate or severe, are at a higher risk of anxiety induced by sweating than participants who screened negative for hyperhidrosis.
Collapse
Affiliation(s)
- Sayaka Ogawa
- Health Center, Nagasaki University, Nagasaki, Japan
| | - Jun Tayama
- Faculty of Human Sciences, Waseda University, Tokorozawa, Japan
| | - Hiroyuki Murota
- Department of Dermatology, Nagasaki University, Nagasaki, Japan
| | | | | | | |
Collapse
|
4
|
Long-term Outcomes of Endoscopic Thoracoscopic Sympathectomy for Primary Focal Palmar Hyperhidrosis: High Patient Satisfaction Rates Despite Significant Compensatory Hyperhidrosis. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2022; 32:730-735. [PMID: 36130719 DOI: 10.1097/sle.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Endoscopic thoracoscopic sympathectomy (ETS) is the gold standard therapy for primary focal palmar hyperhidrosis (PFPH), resulting in high patient satisfaction rates. The most common side effect of ETS is compensatory hyperhidrosis (CH). Previous studies followed patients' satisfaction degree of surgery and the incidence of CH during a limited follow-up period of 1 to 3 years. The purpose of this study was to investigate the long-term outcomes and patient satisfaction after ETS. MATERIALS AND METHODS After approval of our institutional review board, we conducted a retrospective review of all consecutive patients who underwent ETS for PFPH at our institution between 1998 and 2019. Electronic medical records were reviewed for short-term outcomes. Long-term outcomes were collected through telephone questionnaires. Primary outcome was the resolution of PFPH. Secondary outcomes were CH and long-term patient satisfaction. RESULTS During the study period, 256 patients underwent ETS to treat primary focal palmar hyperhidrosis at our institution between the years 1998-2019. One-hundred and fifty (58.6%) patients agreed to participate in the study and were included in the final analysis. The mean age was 23.8 (17 to 58) years, 56% were females. The mean follow-up time was 11±6.1 (1 to 22) years. Ninety-four percent reported resolution of PFPH; however, CH was reported by 90% of participants. CH decreased mean patient satisfaction score from 4.8±0.5 to 3.8±2 (P=0.009). This effect was more pronounced in patients with CH of the head and neck (P=0.009). Patients' satisfaction decreased over time from a mean of 4.8±0.4 in the first year after surgery to a mean of 3.7±1.4 12 years or more after surgery (P <0.001). Despite this, 79% of patients reported they would recommend ETS to other patients. CONCLUSIONS ETS for PFPH is highly effective and results in high patient satisfaction rates even after long-term follow-up. Despite high rates of postoperative CH, nearly 80% of patients would still recommend the procedure to fellow patients, justifying its reputation as the gold standard treatment for PFPH.
Collapse
|
5
|
Park SC, Kim YK. Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1191:187-196. [DOI: 10.1007/978-981-32-9705-0_12] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
6
|
The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review. J Am Acad Dermatol 2019; 81:657-666. [DOI: 10.1016/j.jaad.2018.12.071] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 12/18/2022]
|
7
|
López-López D, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Rodríguez-Sanz D, Palomo-López P, Calvo-Lobo C. Relationship between depression scores and degree of skin perspiration: A novel cross-sectional study. Int Wound J 2018; 16:139-143. [PMID: 30251361 DOI: 10.1111/iwj.13004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022] Open
Abstract
Primary hyperhidrosis (PH) is a common pathological condition related to excessive sweating. It may be associated with depression. Therefore, the main aim of this study was to analyse and compare depression scores between subjects without PH (degree-I) and patients with PH (degrees-II, -III, and -IV). The secondary aim was to describe and compare depression scores among subjects with different PH degrees (I-without perceptible perspiration, II-tolerable perspiration, III-hardly tolerable perspiration, and IV-intolerable perspiration). A sample of 100 subjects with a median age of 23.00 ± 6.00 years was recruited from an outpatient medical centre, where medical history data were registered. The degree of PH was determined using the Hyperhidrosis Disease Severity Scale from degrees I (mild) to IV (very severe). The depression scores were analysed using the Beck Depression Inventory (BDI). Statistically significant differences (P < 0.001) were observed for higher BDI scores in the patients with PH (degrees II, III, and IV) than in those without PH (degree-I). Kruskal-Wallis tests demonstrated statistically significant differences for BDI scores (P < 0.001), with higher values for degree-III with respect to degree-I and degree-IV with respect to degree-I. Patients with a greater degree (especially III/IV) of PH showed higher BDI scores compared with subjects without PH.
Collapse
Affiliation(s)
- Daniel López-López
- Research, Health and Podiatry Unit, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, Ferrol, Spain
| | | | | | - David Rodríguez-Sanz
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain.,Faculty of Sports Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - César Calvo-Lobo
- Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, Universidad de León, Ponferrada, León, Spain
| |
Collapse
|
8
|
PALMA PRISCILADECAMARGO, NEUFELD CARMEMBEATRIZ, BRUST-RENCK PRISCILAGOERGEN, ROSSETTO CAROLINAPRATESFERREIRA, CRIPPA JOSÉALEXANDREDESOUZA. False memories in social anxiety disorder. ARCH CLIN PSYCHIAT 2017. [DOI: 10.1590/0101-60830000000133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
9
|
Mavrogiorgou P, Juckel G. [Dermatological diseases and their importance for psychiatry]. DER NERVENARZT 2017; 88:254-267. [PMID: 26975652 DOI: 10.1007/s00115-016-0082-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The relationship between skin and psychiatric disorders is not an uncommon occurrence in the clinical practice; however, there are only a few systematic studies and in addition knowledge about the neurobiological and immunological mechanisms is lacking. Impairments and disorders of the skin are often an (early) sign of a psychiatric disorder. In the sense of true psychosomatics, psychiatrists should also be aware of this relationship as far as possible. This review article focuses on the most important dermatological diagnoses in relation to the respective psychiatric comorbidities and presents the most important aspects of epidemiology, symptomatology, pathophysiology and treatment options.
Collapse
Affiliation(s)
- P Mavrogiorgou
- Klinik für Psychiatrie Psychotherapie und Präventivmedizin, LWL-Universitätsklinikum der Ruhr Universität Bochum, Alexandrinenstr.1, 44791, Bochum, Deutschland
| | - G Juckel
- Klinik für Psychiatrie Psychotherapie und Präventivmedizin, LWL-Universitätsklinikum der Ruhr Universität Bochum, Alexandrinenstr.1, 44791, Bochum, Deutschland.
| |
Collapse
|
10
|
Bahar R, Zhou P, Liu Y, Huang Y, Phillips A, Lee TK, Su M, Yang S, Kalia S, Zhang X, Zhou Y. The prevalence of anxiety and depression in patients with or without hyperhidrosis (HH). J Am Acad Dermatol 2016; 75:1126-1133. [DOI: 10.1016/j.jaad.2016.07.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/28/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022]
|
11
|
|
12
|
DIAS LUCIARAIRENEDENADAI, MIRANDA ELIANACRISTINAMARTINS, TORO IVANFELIZARDOCONTRERA, MUSSI RICARDOKALAF. Relationship between anxiety, depression and quality of life with the intensity of reflex sweating after thoracoscopic sympathectomy for treatment of primary hyperhidrosis. Rev Col Bras Cir 2016; 43:354-359. [DOI: 10.1590/0100-69912016005013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/04/2016] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to compare the intensity of reflex sweating with the degree of anxiety and its interference in the quality of life of patients undergoing Thoracoscopic (VATS) sympathectomy in the pre- and postoperative period. Methods: we evaluated 54 patients with a mean age of 26 years (16-49 years) undergoing sympathectomy in the R3-R4 level. We applied two questionnaires at three different times: "Quality of life in patients with primary hyperhidrosis" and "Scale for anxiety and depression". Results: of the patients studied, 93% showed significant improvement in quality of life 30 days after surgery, the effects remaining after six months. There were no postoperative complications. The patient's level of anxiety is highly correlated with the intensity of reflex sweating after 30 and 180 days. Conclusion: Thoracoscopic sympathectomy improves quality of life of patients with primary hyperhidrosis, even with the emergence of reflex sweating. Anxiety directly relates to the intensity of reflex sweating, without compromising the degree of patient satisfaction.
Collapse
|
13
|
|
14
|
Fields of Anhidrotic Effects of AbobotulinumtoxinA in Patients With Compensatory Hyperhidrosis. Dermatol Surg 2015; 41 Suppl 1:S93-100. [DOI: 10.1097/01.dss.0000452649.99141.69] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Heimberg RG, Hofmann SG, Liebowitz MR, Schneier FR, Smits JAJ, Stein MB, Hinton DE, Craske MG. Social anxiety disorder in DSM-5. Depress Anxiety 2014; 31:472-9. [PMID: 24395386 DOI: 10.1002/da.22231] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/09/2013] [Accepted: 11/28/2013] [Indexed: 11/09/2022] Open
Abstract
With the publication of DSM-5, the diagnostic criteria for social anxiety disorder (SAD, also known as social phobia) have undergone several changes, which have important conceptual and clinical implications. In this paper, we first provide a brief history of the diagnosis. We then review a number of these changes, including (1) the primary name of the disorder, (2) the increased emphasis on fear of negative evaluation, (3) the importance of sociocultural context in determining whether an anxious response to a social situation is out of proportion to the actual threat, (4) the diagnosis of SAD in the context of a medical condition, and (5) the way in which we think about variations in the presentation of SAD (the specifier issue). We then consider the clinical implications of changes in DSM-5 related to these issues.
Collapse
Affiliation(s)
- Richard G Heimberg
- Department of Psychology, Adult Anxiety Clinic, Temple University, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Open-label treatment with escitalopram in patients with social anxiety disorder and fear of blushing. J Clin Psychopharmacol 2013; 33:695-8. [PMID: 23948787 DOI: 10.1097/jcp.0b013e31829a878b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fear of blushing (FB) is a form of social anxiety disorder (SAD) characterized by an intense and obsessive threat of blushing in front of other people. No data are available on the specific efficacy of antidepressants on FB. This open-label pilot study investigated whether the selective serotonin reuptake inhibitor escitalopram specifically improves symptoms of FB in SAD patients. Thirty-nine patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for SAD and presenting a significant FB according to the Salpêtrière Erythrophobia Questionnaire (SEQ) were administered open-label escitalopram (10-30 mg/d) for 12 weeks. A systematic assessment, at baseline and at week 12, included the SEQ, the Liebowitz Social Anxiety Scale, and the Hospital Anxiety and Depression scale. From the 39 patients included, 31 attended the week 4 visit, and 28 the week 12 visit. Significant reductions of FB were observed after 4 weeks of treatment and were more pronounced at the end of the 12-week treatment since patients experienced a 60% decrease in their FB symptoms (P < 0.001). Nineteen subjects (67.8%) reported a 50% decrease or more of their SEQ score, and 14 (50%) met criteria for remission of FB (SEQ score <7). The effect sizes of changes on SEQ, Liebowitz Social Anxiety Scale, and Hospital Anxiety and Depression scale scores were high, with η² ranging between 0.53 and 0.86. Results of this open-label study suggest that escitalopram can be a useful treatment for FB associated with SAD, even if large controlled trials are now needed to further evaluate this result.
Collapse
|
17
|
Bergler-Czop B, Brzezińska-Wcisło L. Dermatological problems of the puberty. Postepy Dermatol Alergol 2013; 30:178-87. [PMID: 24278071 PMCID: PMC3834713 DOI: 10.5114/pdia.2013.35621] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/29/2012] [Accepted: 02/10/2013] [Indexed: 02/06/2023] Open
Abstract
Puberty is a period of life between childhood and adulthood. It is characterized by many changes in morphology and appearance of the body (biological maturation), in the psyche - development of personality (psychological maturation), and in the attitude towards one's own and the opposite sex (psychosexual maturation), and in the social role (social maturation). Dermatological problems of adolescence are mainly related to fluctuations in hormone levels, mainly androgens. They include acne, hair problems and excessive sweating. Acne vulgaris is the most frequently diagnosed dermatosis in patients aged between 11 and 30 years. It is believed that it affects about 80% of persons in this age group or even, taking into account lesions of low intensity, 100% of young people. Excessive sweating is a condition characterised by excessive production of sweat, resulting from high activity of sweat glands. The sweat glands are localised in almost all areas of the body surface but on the hands, feet, armpits and around the groin they are found at the highest density. Seborrhoeic dermatitis of the scalp is a chronic, relapsing, inflammatory dermatosis, which currently affects about 5% of the population. It affects mostly young people, particularly men.
Collapse
Affiliation(s)
- Beata Bergler-Czop
- Department of Dermatology, Silesian Medical University, Katowice, Poland. Head: Prof. Ligia Brzezińska-Wcisło MD, PhD
| | | |
Collapse
|