CN110811831A - Accurate automatic evaluation method and device for kidney surgery - Google Patents
Accurate automatic evaluation method and device for kidney surgery Download PDFInfo
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/10—Computer-aided planning, simulation or modelling of surgical operations
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Abstract
The invention provides a method and a device for accurate and automatic evaluation of kidney surgery, and relates to the field of computers, wherein the method comprises the following steps: the method comprises the following steps: acquiring a medical image and/or a three-dimensional model; assessing whether a renal resection can be performed, and if a renal resection can be performed, further assessing whether a blockage can be performed; selecting a target area to be subjected to nutrient blood vessel blocking, evaluating whether the blocking can be carried out or not, and further evaluating the operation difficulty if the blocking can be carried out; evaluating the operation difficulty and recommending the operation mode. The invention also provides a device for realizing accurate automatic evaluation of the kidney surgery and a computer readable storage medium. The method and the device provided by the invention can accurately implement automatic evaluation of the kidney operation according to the medical image and/or the three-dimensional model, realize high-efficiency decision making, avoid the influence caused by artificial subjective factors or insufficient experience, are favorable for providing objective operation scheme suggestions and establishing standardized standard processes, and are convenient for clinical popularization and use.
Description
[ technical field ] A method for producing a semiconductor device
The invention relates to the field of medical treatment, in particular to a method and a device for accurate and automatic evaluation of kidney surgery.
[ technical background ] A method for producing a semiconductor device
Compared with the traditional kidney extirpation type total resection, people tend to reserve viscera to the greatest extent on the premise of ensuring the treatment effect in the operation, so that better prognosis of patients is facilitated. In recent years, nephrotomy with preserved nephrons has similar oncological efficacy compared to radical nephrectomy versus small kidney cancer, but is more beneficial for long-term survival of patients. Thus, the current treatment modalities for localized renal cancer in larger medical centers at home and abroad are gradually moving towards nephrotomy with preserved nephrons. However, the difficulty of visualization, complete removal, and reconstruction of the renal parenchyma and renal pelvis in partial nephrectomy varies greatly from renal tumor to renal tumor. Therefore, it is very important to make a perfect surgical plan before surgery, and it mainly depends on the operator to perform detailed and deep analysis and judgment on the anatomy of the kidney and tumor according to the imaging data. CT is the gold standard of present kidney tumor evaluation, can accurately evaluate anatomical structures of blood vessels, kidneys and tumors, and provides a basis for making a preoperative plan. The following disadvantages exist only from CT images and even three-dimensional models for surgical planning and evaluation: 1, the evaluation is carried out according to the clinical experience of doctors, and doctors with different experiences may draw different evaluation conclusions on the same case; 2, the position relation among tissues such as blood vessels, tumors, kidneys and the like is difficult to quantify, and the implementation of later operations is not facilitated; and 3, finishing effect evaluation after the operation, and failing to form quantitative contrast with the operation and giving quantitative evaluation.
Patent CN201210452526.4 provides a three-dimensional renal tumor surgery simulation method based on CT film, which is based on qualitative analysis of CT film and then performs surgery simulation according to the analysis result, the diameter and volume of tumor are difficult to analyze on the film, the volume of kidney and the overall distribution of blood vessels are difficult to calculate, the size of tumor, the upper or lower pole of kidney, etc. can only be known approximately, quantitative evaluation cannot be given, and each evaluation parameter is obtained by human observation, the accuracy cannot be guaranteed, and it is difficult to popularize and use in clinic in large quantities.
[ summary of the invention ]
In view of the above, the present invention provides a method and a device for accurate and automatic evaluation of kidney surgery, and aims to solve the following problems: the quantitative evaluation conclusion can be quickly and automatically given, and the method is widely popularized and used in clinic.
According to some embodiments of the present disclosure, a method for accurate and automatic evaluation of renal surgery is provided, which includes:
acquiring a medical image and/or a three-dimensional model;
automatically evaluating whether a partial kidney resection can be performed;
selecting a target area to be subjected to nutrient vascular occlusion, and automatically evaluating whether the occlusion can be carried out or not;
and automatically evaluating the operation difficulty and recommending an operation mode.
In some embodiments, the medical image comprises one or any combination of an electronic computed tomography, CT, image, or a magnetic resonance, MRI, image; the three-dimensional model includes a model built by a volume rendering manner and a model built by a surface rendering manner.
In some embodiments, the automated evaluation of whether or not a partial kidney resection may be performed is performed according to the following scoring rules, wherein the characteristic indexes in table 1 are recorded and scored in combination with table 1:
table 1: scoring rule table for partial resection
| Characteristic index | 1 minute (1) | 2 is divided into | 3 points of |
| Tumor diameter (cm) | ≤4 | 4～7 | >7 |
| Tumor evagination rate (%) | ≥50％ | <50％ | 0 (complete endogenous tumor) |
| Relationship to a collection system | Is irrelevant | To a | - |
| In relation to the renal sinuses | Is irrelevant | To a | - |
| Ventral-dorsal position | Back side | Ventral side | - |
| Longitudinal position | Upper/lower stage | Middle part | - |
Wherein:
the diameter of the tumor is any two points with the maximum distance between the surfaces of the tumors;
the outward tumor protrusion rate is (1- (intersection of the outer tumor surface and the kidney)/tumor outer surface area) × 100%;
when the tumor intersects with the set system, the tumor is related, otherwise, the tumor is unrelated;
when the tumor intersects with the renal sinus, the tumor is related, otherwise, the tumor is unrelated;
taking the maximum cross section of the kidney as an interface, when the tumor volume is more than 50 percent of the tumor volume in the abdomen, the tumor volume is the ventral side, otherwise, the tumor volume is the dorsal side;
respectively generating a horizontal line at the top end and the bottom end of the kidney assembly system, wherein an upper pole is arranged above the horizontal line at the top end, a lower pole is arranged below the horizontal line at the bottom end, and the middle part is the middle part;
automatically calculating and counting the sum of scores of 6 items of feature data, dividing the scores into a high grade, a medium grade and a low grade according to the score results, dividing the scores into a low grade 6-7, a medium grade 8-9 and a high grade 10-14, and automatically evaluating whether the kidney resection can be implemented according to the score results: when the scoring result is high grade, the kidney full resection is recommended, and if the full resection is performed, further evaluation is not performed; when the score was medium and low, renal resection was recommended and further evaluation was performed.
In some embodiments, the automatically evaluating whether occlusion is possible includes clicking any point in the medical image set as a target point for which a trophic vascular occlusion is to be performed, and automatically calculating all possible maximum xs for the target pointmaxAnd maximum YmaxThe specific calculation method is as follows:
defining the target point as a blocking point of the layer, and generating a point passing through the central axis of the renal portal vein and two tangent points of the kidney, wherein the distance between the blocking point and a straight line LA formed by the two tangent points of the kidney is X, the distance between the blocking point and a straight line LB passing through the central axis of the renal portal vein and perpendicular to the straight line LA is Y, calculating X, Y in the same way on a plurality of layers above and below the layer to be blocked, and selecting the maximum X from the X set formed by all the X and the Y set formed by all the YmaxAnd maximum Ymax. X of the point of occlusion of a blood vessel to be nourishedmaxAnd YmaxWhether blocking is brought in is automatically judged by the following formula:
SRAC＝ex/(1+ex)，
wherein X is 12.360+ 4.803Xmax-8.848*Ymax，
And if the SARC > is 0.65, the nutrient vessel at the point can be blocked, the operation difficulty evaluation is further carried out, otherwise, the nutrient vessel at the point is not qualified, another point can be selected again for evaluation, and if all the selected points are not qualified, the further evaluation is not needed.
In some embodiments, the surgical difficulty assessment is performed automatically on the nutrient vessels that are occluded, and the degree of difficulty of the occlusion is automatically judged by the following formula:
CLAMP＝(X+Y)1×1+(X+Y)2×1/2+…(X+Y)n×1/n，
wherein (X + Y) nx1/n represents the individual score of the nth blood vessel to be blocked, the sorting priority of the blood vessels to be blocked is obtained according to the corresponding score of (X + Y), and the calculation rules of the scores of X and Y are as follows:
table 2: x and Y scoring rule table in operation difficulty evaluation index
| Score term | 1 minute (1) | 2 is divided into | 3 points of |
| X | 0 to 1.1cm (inclusive) | 1.1 to 1.5cm inclusive | Greater than 1.5cm |
| Y | 0 to 0.6cm (inclusive) | 0.6 to 0.7cm (inclusive) | Greater than 0.7cm |
The value of CLAMP is automatically calculated, and the operation difficulty grade is automatically evaluated according to the value of CLAMP: the method comprises the following steps of dividing the CLAMP into high, medium and low difficulties, wherein the CLAMP value is 2-6, 6 (inclusive) -10 is medium difficulty, and is more than or equal to 10, the partial resection is not recommended corresponding to the high difficulty, the partial resection is recommended corresponding to the medium difficulty by an experienced operator, and the partial resection is recommended corresponding to the low difficulty.
According to other embodiments of the present disclosure, an apparatus for precise and automatic evaluation of renal surgery is provided, which includes:
the data transmission module is used for inputting or outputting data, such as medical image data and/or three-dimensional model data into the device and outputting an evaluation result;
auxiliary tools module, including tools for adding/deleting points, lines, tools for hiding/displaying, rotating, zooming, moving images or models;
the automatic evaluation module comprises a partial resection evaluation submodule, a blocking evaluation submodule and an operation difficulty evaluation submodule, and is used for automatically evaluating whether the kidney can perform partial resection or not, whether a target area can be blocked or not and evaluating the operation difficulty respectively, and giving an evaluation conclusion;
the storage module is used for storing the data of each module;
the data transmission module can input the medical image data and/or the three-dimensional model data into the device in a contact or non-contact mode, implement automatic evaluation and output data such as an evaluation result and the like; the automatic evaluation module automatically evaluates whether the kidney partial resection can be implemented or not according to the related data, if so, the auxiliary tool module is utilized to select a target area of the medical image data and/or the three-dimensional model, automatically evaluates whether the target area can be blocked or not and the operation difficulty, and gives an evaluation conclusion; the storage module is used for storing the data of the data transmission module and the evaluation conclusion of the automatic evaluation module in a local or cloud end.
According to other embodiments of the present disclosure, the data transmission mode of the data transmission module includes contact type and non-contact type transmission, the contact type includes usb disk transmission, optical disk transmission, hard disk transmission and wired network transmission, and the non-contact type includes wireless network transmission, WIFI transmission, 4G network transmission, 5G network transmission and bluetooth transmission.
According to other embodiments of the disclosure, the storage mode of the storage module includes a local storage mode and a cloud storage mode, the local storage mode can store data in a hard disk, a U disk or an optical disk, and the cloud storage mode can store data in a network cloud disk, a cloud storage or a cloud server.
According to other embodiments of the present disclosure, an apparatus for precise and automatic evaluation of renal surgery is provided, which includes: a memory; and a processor coupled to the memory, the processor configured to perform a method of automated evaluation of renal procedure precision as in any one of the preceding embodiments based on instructions stored in the memory device.
According to still further embodiments of the present disclosure, there is provided a computer-readable storage medium for automated evaluation of renal surgery precision, on which a computer program is stored, wherein the program, when executed by a processor, implements the steps of the method for automated evaluation of renal surgery precision as in any one of the preceding embodiments.
The beneficial effects of the invention are as follows: the kidney surgery automatic evaluation is accurately implemented according to the medical image and/or the three-dimensional model, high-efficiency decision making is realized, the influence caused by artificial subjective factors or insufficient experience can be avoided, objective surgery scheme suggestions can be provided, the establishment of a standardized standard flow is facilitated, and the clinical popularization and use are facilitated.
[ description of the drawings ]
In order to more clearly illustrate the embodiments of the present disclosure or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, it is obvious that the drawings in the following description are only some embodiments of the present disclosure, and other drawings can be obtained by those skilled in the art without creative efforts.
Fig. 1 illustrates a flow diagram of a method for automated evaluation of renal surgery precision in some embodiments of the present disclosure.
Fig. 2 shows a schematic structural diagram of an apparatus for precise automated evaluation of renal surgery according to some embodiments of the present disclosure.
Fig. 3 shows a schematic structural diagram of an apparatus for precise automated evaluation of renal surgery according to some embodiments of the present disclosure.
Fig. 4 is a schematic structural diagram of an apparatus for precise automated evaluation of renal surgery according to another embodiment of the present disclosure.
Fig. 5 is a schematic structural diagram of an apparatus for precise automated evaluation of renal surgery according to still another embodiment of the present disclosure.
Detailed Description
The technical solutions in the embodiments of the present disclosure will be clearly and completely described below with reference to the drawings in the embodiments of the present disclosure, and it is obvious that the described embodiments are only a part of the embodiments of the present disclosure, and not all of the embodiments. The following description of at least one exemplary embodiment is merely illustrative in nature and is in no way intended to limit the disclosure, its application, or uses. All other embodiments, which can be derived by a person skilled in the art from the embodiments disclosed herein without making any creative effort, shall fall within the protection scope of the present disclosure.
The method for accurately and automatically evaluating the kidney surgery provided by the present disclosure will be described with reference to fig. 1.
Fig. 1 is a flow chart illustrating a method for performing an automated evaluation of renal surgery accuracy according to some embodiments. Includes steps S101 to S104:
s101, acquiring a medical image and/or a three-dimensional model: acquiring related data;
s102, automatically evaluating whether a partial kidney resection can be performed: from the data obtained in S101, the following score table is derived:
table 3: score table for evaluation of partial resection
| Characteristic index | Characteristic value | Score of |
| Tumor diameter (cm) | 3.1 | 1 |
| Tumor evagination rate (%) | 30％ | 2 |
| Relationship to a collection system | To a | 2 |
| In relation to the renal sinuses | Is irrelevant | 1 |
| Ventral-dorsal side | Back side | 1 |
| Longitudinal position | Middle part | 2 |
Automatically calculating and counting the sum of scores of the six characteristic data to be 9 points, recommending the kidney resection if the evaluation result is a medium grade, and further evaluating whether the blocking can be carried out;
s103, automatically evaluating whether blocking can be carried out: any point clicked in the medical image set is used as a target point for implementing the occlusion of the nutrition vessel, and all possible maximum X of the target point are automatically calculatedmaxAnd maximum YmaxThe specific calculation method is as follows:
defining the target point as a blocking point of the Nth layer and generating a point passing through the central axis of the renal portal vein and two tangent points of the kidney, wherein a straight line LA formed by the blocking point and the two tangent points of the kidneyNIs XN1.14cm, the point of occlusion being a straight line LB passing through the central axis of the renal portal vein and perpendicular to the straight line LANIs a distance of YNX, Y were calculated in the same manner for several layers above and below the layer to be blocked at 0.56cm, and the largest X was selected among the X set of all X components and the Y set of all Y componentsmaxAnd maximum Ymax. As shown in table 4:
table 4: numerical value tables of X and Y
So Xmax1.37 and maximum Ymax＝0.71
X of the target pointmaxAnd YmaxWhether blocking is brought in is automatically judged by the following formula:
SRAC＝ex/(1+ex)，
wherein X is 12.360+ 4.803Xmax-8.848*Ymax，
Calculating to obtain the SARC of the target point which can be included in the blocking point as 0.99> 0.65;
in this embodiment, only the target point meets the requirement, and the blocking point can be included.
S104, evaluating the operation difficulty: the difficulty degree of the blocking is automatically judged by the following formula, and because the embodiment has only one blocking point, the operation difficulty is evaluated:
CLAMP＝(X+Y)，
the calculation rule of the scores of X and Y of the target blocking point is as follows:
CLAMP evaluation index X and Y scoring table
| Score term | Characteristic value | Score value |
| X | 1.37 | 2 |
| Y | 0.71 | 3 |
So CLAMP is (2+3) 5;
the surgery difficulty rating is low according to the score value of CLAMP, and the use of partial resection is positively recommended.
The present disclosure further provides an apparatus for accurate and automatic evaluation of a renal surgery, which is described with reference to fig. 2.
Fig. 2 and 3 are block diagrams of some embodiments of the device for accurately and automatically evaluating a renal surgery according to the present disclosure, and as shown in fig. 2 and 3, the device for accurately and automatically evaluating a renal surgery according to the embodiments includes: the data transmission module 201, the auxiliary tool module 202, the automatic evaluation module 203, and the storage module 204 include a partial resection evaluation sub-module 2031, a blockage evaluation sub-module 2032, and a surgery difficulty evaluation sub-module 2033. The data transmission module 201 is used for data input or output, such as inputting medical image data and/or three-dimensional model data into a device and outputting an evaluation result; the auxiliary tools module 202, including tools for adding/deleting points, lines, tools for hiding/displaying, rotating, zooming, moving images or models; the automatic evaluation module 203 comprises a partial resection evaluation submodule, a blocking evaluation submodule and an operation difficulty evaluation submodule, and is used for automatically evaluating whether the kidney can perform partial resection, whether a target area can be blocked and evaluating operation difficulty respectively, and giving an evaluation conclusion; a storage module 204, configured to store data of each module; the data transmission module 201 can input the medical image data and/or the three-dimensional model data into the system in a contact or non-contact manner; measuring and setting points and/or lines on the medical image data and/or the three-dimensional model by using the tool module 202 to obtain a required value; the automatic evaluation module automatically evaluates whether the kidney partial resection can be implemented or not according to the related data, if so, the auxiliary tool module is utilized to select a target area of the medical image data and/or the three-dimensional model, automatically evaluates whether the target area can be blocked or not and the operation difficulty, and gives an evaluation conclusion; the storage module is used for storing the data of the data transmission module and the evaluation conclusion of the automatic evaluation module in a local or cloud end.
The device for accurate and automatic evaluation of renal surgery in the embodiments of the present disclosure may be implemented by various computing devices or computer systems, which are described below with reference to fig. 4 and 5.
Fig. 4 is a block diagram of some embodiments of the presently disclosed apparatus for automated evaluation of renal surgery precision. As shown in fig. 4, the apparatus 30 of this embodiment includes: a memory 301 and a processor 302 coupled to the memory 301, the processor 302 being configured to perform the method of medical image and three-dimensional model based communication and archiving in any of the embodiments of the present disclosure based on instructions stored in the memory 301.
Fig. 5 is a block diagram of another embodiment of the device for accurate automated evaluation of renal surgery according to the present disclosure. As shown in fig. 5, the apparatus 40 of this embodiment includes: the bus 401, memory 404, and processor 402 are similar to the memory 301 and processor 302, respectively. An input output interface 403, a storage interface 405, a network interface 406, etc. may also be included. These interfaces 403, 405, 406 and the memory 404 may be connected to the processor 402, for example, via a bus 401. The input/output interface 403 provides a connection interface for input/output devices such as a display, a mouse, a keyboard, and a touch screen. The storage interface 405 provides a connection interface for external storage devices such as an SD card and a usb disk. The network interface 406 provides a connection interface for various networked devices, such as may connect to a database server or a cloud storage server, among others.
The present disclosure also provides a computer-readable storage medium, on which a computer program is stored, which when executed by a processor, implements the steps of the method for automated evaluation of renal surgery precision of any of the foregoing embodiments.
As will be appreciated by one skilled in the art, embodiments of the present disclosure may be provided as a method, system, or computer program product. Accordingly, the present disclosure may take the form of an entirely hardware embodiment, an entirely software embodiment or an embodiment combining software and hardware aspects. Furthermore, the present disclosure may take the form of a computer program product embodied on one or more computer-usable non-transitory storage media (including, but not limited to, disk storage, CD-ROM, optical storage, and the like) having computer-usable program code embodied therein.
The present disclosure is described with reference to flowchart illustrations and/or block diagrams of methods, apparatus (systems), and computer program products according to embodiments of the disclosure. It will be understood that each flow and/or block of the flow diagrams and/or block diagrams, and combinations of flows and/or blocks in the flow diagrams and/or block diagrams, can be implemented by computer program instructions. These computer program instructions may be provided to a processor of a general purpose computer, special purpose computer, embedded processor, or other programmable data processing apparatus to produce a machine, such that the instructions, which execute via the processor of the computer or other programmable data processing apparatus, create means for implementing the functions specified in the flowchart flow or flows and/or block diagram block or blocks.
These computer program instructions may also be stored in a computer-readable memory that can direct a computer or other programmable data processing apparatus to function in a particular manner, such that the instructions stored in the computer-readable memory produce an article of manufacture including instruction means which implement the function specified in the flowchart flow or flows and/or block diagram block or blocks.
These computer program instructions may also be loaded onto a computer or other programmable data processing apparatus to cause a series of operational steps to be performed on the computer or other programmable apparatus to produce a computer implemented process such that the instructions which execute on the computer or other programmable apparatus provide steps for implementing the functions specified in the flowchart flow or flows and/or block diagram block or blocks.
The above description is only exemplary of the present disclosure and is not intended to limit the present disclosure, which is to be construed in any way as imposing limitations thereon, such as the appended claims, and all changes and equivalents that fall within the true spirit and scope of the present disclosure.
Claims (10)
1. The method for the accurate and automatic evaluation of the kidney surgery is characterized by comprising the following steps:
acquiring a medical image and/or a three-dimensional model;
automatically evaluating whether a partial kidney resection can be performed;
selecting a target area to be subjected to nutrient vascular occlusion, and automatically evaluating whether the occlusion can be carried out or not;
and automatically evaluating the operation difficulty and recommending an operation mode.
2. The method of claim 1, wherein the medical image comprises one or any combination of an electron Computed Tomography (CT) image, or a Magnetic Resonance (MRI) image; the three-dimensional model includes a model built by a volume rendering manner and a model built by a surface rendering manner.
3. The method of claim 1, wherein the automatic evaluation of whether or not partial renal resection is possible is performed by performing a comprehensive evaluation based on six indexes, i.e., tumor diameter, outward tumor ratio, association with the collective system, association with renal sinus, ventral position, and longitudinal position, classifying the evaluation results into three grades, i.e., high, medium, and low, based on the results of the characteristic indexes, and performing a total resection operation if the evaluation results are high grade, based on the evaluation results, a total renal resection is recommended; when the evaluation results were medium-grade and low-grade, renal resection was recommended, and whether or not blockade was possible was further evaluated.
4. The method of claim 1, wherein said assessing whether occlusion is possible comprises, clicking any point in said medical image set as a target point at which a trophic vascular occlusion is to be performed, assessing whether the target point is available for occlusion.
5. The method of claim 1, wherein said assessing the difficulty of the surgery and recommending a surgical approach comprises: and comprehensively evaluating the operation difficulty evaluation indexes, wherein the operation difficulty evaluation grades are divided into high, medium and low difficulties, partial resection is not recommended to be used corresponding to the high difficulty, a person who needs experience is recommended to use the partial resection corresponding to the medium difficulty, and the partial resection is actively recommended to be used corresponding to the low difficulty.
6. Device of accurate automatic evaluation of kidney operation, its characterized in that includes:
the data transmission module is used for inputting or outputting data, such as medical image data and/or three-dimensional model data into the device and outputting an evaluation result;
auxiliary tools module, including tools for adding/deleting points, lines, tools for hiding/displaying, rotating, zooming, moving images or models;
the automatic evaluation module comprises a partial resection evaluation submodule, a blocking evaluation submodule and an operation difficulty evaluation submodule, and is used for evaluating whether the kidney can perform partial resection, whether a target area can be blocked and evaluating operation difficulty respectively and giving an evaluation conclusion;
and the storage module is used for storing the data of each module.
7. The kidney surgery precision automatic evaluation device according to claim 6, wherein the data transmission mode of the data transmission module comprises contact type and non-contact type transmission, the contact type comprises USB disk transmission, optical disk transmission, hard disk transmission and wired network transmission, and the non-contact type comprises wireless network transmission, WIFI transmission, 4G network transmission, 5G network transmission and Bluetooth transmission.
8. The device for automated evaluation of kidney surgery precision according to claim 6, wherein the storage means of the storage module comprises a local storage means and a cloud storage means, the local storage means can store data in a hard disk, a U disk or an optical disk, the cloud storage means can store data in a network cloud disk, a cloud storage or a cloud server.
9. The device for precise automated evaluation of renal surgery of claim 6, comprising: a memory; and a processor coupled to the memory, the processor configured to perform a method of automated evaluation of renal procedure precision as in any one of the preceding embodiments based on instructions stored in the memory device.
10. A kidney surgery precision automatic evaluation computer readable storage medium, on which a computer program is stored, characterized in that the program, when being executed by a processor, implements the steps of the provided kidney surgery precision automatic evaluation method according to any one of the preceding embodiments.
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