Amebic vaginitis

　　I. Etiology

　　Infection can occur by drinking water and food contaminated with cysts. Not all individuals infected with amebas will become ill, as the occurrence of the disease depends on the host's resistance, the number of trophozoites, and the virulence of the strain. Most amebas in the reproductive tract come from the trophozoites in the intestinal tract of the host, while a very few are transmitted through sexual contact.

　　II. Pathogenesis

　　The pathogenic ameba is Entamoeba histolytica, which has a life cycle with two stages: trophozoite stage and cyst stage. The trophozoites can cause tissue damage in the host organism, while the cysts can cause infection between organisms. Infection between humans and animals is rare. After the ameba invades the mucosa of the reproductive tract, it relies on the tissue lysin secreted by it to dissolve surrounding tissues, causing mucosal damage, ulcer formation. Strains with strong virulence can also invade the submucosal tissue, so the ulcers are often larger and deeper, leaving scars after healing. The local lesions are filled with necrotic substances and cell fragments in a yellow-brown color, mucus, red blood cells, and white blood cells. The lesions are also surrounded by lymphocytes and a few plasma cells.

　　Amebic vaginitis (Amebicvaginitis) often occurs secondary to intestinal infection, with complications mainly including intestinal and extra-intestinal complications that arise from amebic dysentery.

　　I. Intestinal complications

　　1. Intestinal bleeding:Ulceration of the intestinal wall involving blood vessels can cause intestinal bleeding, with varying amounts of bleeding. In cases of severe bleeding, patients often exhibit pale complexion, rapid pulse, and blood pressure drop, among other signs of hemorrhagic shock.

　　2, Intestinal perforation:More common in fulminant type, with the blind肠 (appendix) and ascending colon being more common in perforation sites. Acute perforation can cause diffuse peritonitis, with serious condition. Chronic perforation causes adhesion of surrounding tissues, forming local abscesses.

　　3, Appendicitis:The symptoms of amebic appendicitis are similar to those of ordinary appendicitis, and are prone to form abscesses. If there is a history of chronic diarrhea or amebic dysentery, and amebic trophozoites or cysts are found in the stool, it can help with the differential diagnosis of the two.

　　4, Non-dysenteric colonic lesions:Caused by proliferative lesions, including amebic tumors, intestinal amebic granulomas, and fibrous stenosis. Amebic tumors are inflammatory pseudotumors of the colonic wall, with the most common symptoms being abdominal pain and changes in defecation habits, some with intermittent dysentery, which can induce intussusception and intestinal obstruction. The main signs are: palpable movable, smooth, egg-shaped or intestinal loop-like masses in the right iliac region, with locoregional lesions seen on X-ray, and good response to amebic treatment.

　　Second, Extra-intestinal complications:Amebic trophozoites can spread to distant organs from the intestines through blood and lymph, causing various extra-intestinal complications such as liver, lung, pleura, pericardium, brain, peritoneum, and urinary and reproductive tract, forming abscesses or ulcers, among which liver abscesses are the most common.

　　The vaginal secretion is serous or mucoid, and large trophozoites can be found. When the vaginal mucosa forms ulcers and bleeding, the secretion can turn into purulent or bloody. Sometimes, fragile ulcers can appear in the cervix, vulva, and merge into large necrotic areas. In some cases, due to severe fibrotic tissue reaction, irregular tumor-like hyperplasia can occur, with hard texture and ulcer surfaces covered with bloody mucoid secretion, which is easy to be misdiagnosed as malignant tumors.

　　To prevent amebic vaginitis, first pay attention to personal and dietary hygiene, wash hands before and after meals, keep the perineum clean, prevent the stool from continuing to contaminate the perineum and vagina, so as not to be infected with amebic trophozoites; pay attention to disinfection, isolation, prohibit sexual life, and seek timely medical treatment after onset.

　　1, Direct microscopic observation:Directly observe the amebic trophozoites under a microscope using wet films of physiological saline from vaginal secretions.

　　2, Culture method of amebic trophozoites in vaginal and cervical secretions:Highly suspected clinically, and both of the above two methods are negative, then vaginal and cervical secretions can be taken for culture. However, amebic culture requires high conditions and complex technology, which is generally difficult to do in general hospitals.

　　3, Tissue biopsy:Take living tissue from the edge of the ulcer for pathological section, and amebic trophozoites can be seen.

　　First, Food Therapy Recipe:

　　1, Double Ossose Soup

　　Preparation: Take 8 grams of桑螵蛸 (Sangshen), 15 grams each of 海螵蛸 (Haishu), 关沙苑 (Guanshayuan), 鹿角霜 (Lujiaoshuang), 金樱子 (Jinyingzi), 10 grams of BaiZhu (Atractylodes macrocephala), decoct in water, take once.

　　Commentary: Warms the kidneys and strengthens the spleen, consolidates essence and stops leukorrhea. Mainly used for bacterial vaginitis with kidney deficiency, symptoms include increased leukorrhea, thin and clear, accompanied by low back pain and knee weakness, dizziness and tinnitus, loose stools, etc.

　　2, White-bud Chicken Soup

　　Preparation: Kill a hen weighing about 500 grams, remove feathers and internal organs, clean; wash 30 grams of lotus seed meat, 15 grams of glutinous rice, and a little pepper. Place 10 whitebait, lotus seed meat, glutinous rice, and pepper in the hen's abdominal cavity, seal the opening, place in a steaming bowl with a cover, steam with low heat for 2-3 hours until the hen is tender, season and serve (can be eaten in 2-3 doses, drink the soup, eat the meat, whitebait, etc.).

　　Note: Tonify the spleen and kidney, astringe and stop leucorrhea, mainly for bacterial vaginitis with symptoms of both spleen and kidney deficiency, such as emaciation, sallow complexion, shortness of breath, fatigue, soreness in the loins and knees, increased leucorrhea, colorless and tasteless, and sticky texture.

　　3, Horse-tail grass drink

　　Preparation: Wash 50 grams of fresh horse-tail grass, soak in cold water again, cut into small pieces, blend in a blender, squeeze the fresh juice, add 25 milliliters of honey, mix well, and then simmer in a water bath until cooked, take in two doses.

　　Note: Clear heat and detoxify, eliminate dampness and stop leucorrhea, mainly for bacterial vaginitis with symptoms of damp-heat or internal heat-toxin excess. Horse-tail grass, also known as瓜菜, is sour and cold in nature, with the functions of clearing heat and detoxifying, eliminating dampness and stopping leucorrhea. It has certain inhibitory effects on Shigella, Enterobacter, Streptobacillus, Shiga toxin-producing Escherichia coli, Salmonella typhi, Escherichia coli, and Staphylococcus aureus. Horse-tail grass can anti-inflammatory, so it has a therapeutic effect on increased leucorrhea caused by genital tract inflammation. Contraindicated for pregnant women.

　　4, Garlic carp

　　Material preparation: Clean and wash a carp, remove the internal organs, add 50 grams of garlic, and cook together.

　　Note: 'Ancient Prescriptions for Modern Use' introduces that 30 grams of garlic can be used to wash the affected area. Additionally, 'The Dictionary of Chinese Materia Medica' records: 50% garlic glycerin gelatin suppositories, inserted into the vagina once a day, for 7 consecutive days, effective.

　　5, Onion pork kidney

　　Ingredients: Onions 50 grams, pork kidney 1 piece

　　Preparation: Mash onions into a paste, process pork kidney following usual methods, and cook together. Alternatively, you can also use onion paste to wash the affected area.

　　6, Walnut tofu

　　Take 10 walnuts, peel and remove the tip. Boil 2 pieces of tofu with walnuts following usual methods.

　　7, Qinpi Wu梅 decoction

　　Ingredients: Qinpi 12 grams, Wu梅 30 grams

　　Preparation: Boil the above two ingredients with an appropriate amount of water, remove the residue and take the juice, then add sugar before serving.

　　Usage: Take twice a day, on an empty stomach in the morning and evening, one dose per day, for 5 consecutive days.

　　Note: Clear heat, eliminate dampness, and kill parasites, mainly for trichomonal vaginitis, symptoms include yellow and smelly leucorrhea and vulvar itching.

　　8, Chicken crown flower egg soup

　　Ingredients: Chicken crown flower 30 grams, eggs 2 pieces

　　Preparation: Wash the chicken crown flower; boil 2 eggs, remove the shells. Place all the ingredients in a pot, add an appropriate amount of water, bring to a boil with high heat, then simmer with low heat for about 1 hour, season and serve.

　　Note: Eliminate dampness and stop leucorrhea, mainly for trichomonal vaginitis with excessive dampness and turbidity, symptoms include fatigue, increased leucorrhea, white and fishy smell, thin and watery texture, or difficulty in urination, and pruritus vulvae.

　　9, Baibu Wu梅 decoction

　　Ingredients: Baibu 15 grams, Wu梅 30 grams, sugar to taste

　　Preparation: Boil Baibu and Wu梅 with an appropriate amount of water, remove the residue and take the juice, then add sugar to boil.

　　Usage: Take while hot, in 2-3 doses, one dose per day, for 3-5 consecutive days.

　　Note: Clear heat, eliminate dampness, and kill parasites, mainly for damp-heat type trichomonal vaginitis, symptoms include yellow and thick leucorrhea with an unpleasant odor, and significant vulvar itching.

　　10. Huai山药 Fish Bladder Lean Pork Soup

　　Cooking: Wash 30 grams of Huai山药 clean; wash 250 grams of lean pork clean, cut into pieces; soak 15 grams of fish bladder in water until it swells, wash it clean, and cut it into strips. Put all the ingredients in a pot, add an appropriate amount of water, boil with high heat, then simmer with low heat for 2 hours, season to taste, and serve.

　　Commentary: Nourish yin and kidney, astringe essence and stop leukorrhea, mainly for senile vaginitis due to kidney and liver yin deficiency, with symptoms of sore lower back, weak legs, dizziness and tinnitus, continuous leukorrhea, sticky and stringy, feverish feeling in the five heart regions, night sweats, also suitable for postpartum anemia dizziness.

　　11. Herba Verbena officinalis Pork Stomach Soup

　　Method: Wash 30 grams of Herba Verbena officinalis clean, cut into small pieces; slice 60-100 grams of pork stomach. Boil the water, pour the pork stomach and Herba Verbena officinalis into the boiling water. Remove the dregs and take the juice, once a day.

　　Commentary: Detoxify and kill parasites, clear heat and eliminate dampness, mainly for various types of candidal vaginitis. But pregnant women and people with weak spleen and stomach should be cautious when using it.

　　12. Shanyao Euryale ferox Soup

　　Preparation: Soak 100 grams of Shanyao (Haliotis aspersa) and 50 grams of dried cuttlefish in clean water until soft, wash them clean, cut into 3-4 segments; wash 20 grams of Euryale ferox clean; wash 100 grams of lean pork clean. Put all the ingredients in a pot, add an appropriate amount of water, boil with high heat, then simmer with low heat for 2 hours, and season to taste, drink at will.

　　Commentary: Nourish yin and clear heat, contract and stop leukorrhea, mainly for candidal vaginitis due to kidney yin deficiency or yin deficiency with heat. Symptoms include excessive leukorrhea, slightly yellow color and thin texture, or leukorrhea with yellow and red mixed color, thick like paste, or accompanied by vaginal heat and irritation, even pain, restlessness, insomnia, dry mouth, dry stools, etc. Also suitable for women with yin deficiency体质 or after fever, menopausal or postmenopausal women with leukorrhea due to yin deficiency or internal heat.

　　13. Sophora flavescens, Stemona root, Garlic Soup

　　Preparation: Boil 15 grams of Sophora flavescens, 15 grams of Stemona root, and 10 cloves of garlic together in water, remove the dregs to get the juice, add an appropriate amount of sugar to adjust the taste, take twice a day, for 3-7 days in each course of treatment.

　　Commentary: Eliminate dampness, detoxify and kill parasites, mainly for candidal vaginitis due to damp-heat accumulation.

　　14. Sophora flavescens and Notopterygium Drink

　　Preparation: Boil 15 grams of Sophora flavescens and 15 grams of Notopterygium incisum in water, remove the dregs to get the juice, add an appropriate amount of sugar when taking, twice a day, for 5-10 days in each course of treatment.

　　Commentary: Detoxify and eliminate dampness, kill parasites and relieve itching, mainly for candidal vaginitis due to damp-heat accumulation.

　　15. Portulaca oleracea and White Fruit Egg Soup

　　Preparation: Break 3 eggs and take the egg whites, mix 60 grams of fresh Portulaca oleracea and 7 white fruit kernels, crush them together, mix well with egg whites, and serve with boiling water. Take on an empty stomach, once a day, for 4-5 days in each course of treatment.

　　Commentary: Clear heat and eliminate dampness, stop leukorrhea, mainly for bacterial vaginitis, with symptoms of damp-heat descending, yellow and thick leukorrhea, and yellow urine.

　　16. Honghua Porridge

　　Preparation: Add 30 grams of Honghua (Broussonetia papyrifera) to an appropriate amount of water, boil and remove the dregs to get the juice, then add 500 grams of rice to cook porridge, eat after the porridge is done, once a day, for 7 days in each course of treatment.

　　Commentary: Clear heat and eliminate dampness, mainly for bacterial vaginitis, with symptoms of yellowish and smelly leukorrhea.

　　17. Winter Melon and White Fruit Drink

　　Preparation: 30 grams of winter melon seeds, 10 white fruits, wash them clean, then put winter melon seeds, white fruits and 1 and a half cups of water into a pot to boil, and eat after boiling. Drink frequently as tea, but not for a long time.

　　Annotation: Clear heat, drain dampness, and stop leukorrhea, mainly for bacterial vaginitis, with symptoms of yellow and smelly leukorrhea.

　　18. White fungus kernel and egg

　　Preparation: Grind 1 white fungus kernel into powder, pierce a small hole in 1 egg, put the white fungus powder into the egg, seal the mouth with wet toilet paper, steam and remove the shell. Take 1 each time, in the morning and evening on an empty stomach, and take for 1 week.

　　Annotation: Strengthen the body and tonify Qi, astringe essence and stop leukorrhea, mainly for chronic leukorrhea due to unstable Chong and Ren channels, and long-term seminal loss.

　　19. Cistanche deserticola drink

　　Preparation: 20 grams of Cistanche deserticola, decocted, taken twice a day, once in the morning and once in the evening.

　　Annotation: Warm the yang and tonify the kidneys, mainly for leukorrhea due to kidney deficiency, seen in early marriage or frequent childbirth, which damages kidney Qi, with symptoms such as excessive leukorrhea, thin and clear, and persistent dripping, waist pain as if broken.

　　20. Chrysanthemum leaf and egg

　　Preparation: Clean 60 grams of chrysanthemum leaves and chop them, mix them with 2 beaten eggs, stir-fry them in a pot without salt or oil, add half a bowl of water when they are about to be cooked, bring to a boil, and take it all at once.

　　Annotation: Soothe the liver and relieve depression, reinforce the body and build the center, mainly for leukorrhea caused by liver depression and spleen injury.

　　21. Hawthorn berries stewed with rock sugar

　　Preparation: Wash 30 grams of hawthorn berries clean, place them in a炖盅, add 15 grams of rock sugar and an appropriate amount of boiling water, cover the炖盅, simmer over low heat for 1 hour, and drink freely.

　　Annotation: Tonify the kidneys and consolidate essence, astringe and stop leukorrhea, mainly for bacterial vaginitis, with symptoms of kidney Qi deficiency and loss of control, with symptoms such as excessive leukorrhea, colorless and thin quality, or dizziness, tinnitus, insomnia, and frequent dreams. It is most suitable for people with weak physique, or those with chronic kidney disease, or those with aging kidney Qi deficiency leading to leukorrhea.

　　Secondly, unsuitable foods to eat:

　　1. Avoid spicy foods.Spicy foods (such as chili, ginger, scallions, garlic, etc.) can easily produce dryness and heat when eaten in large quantities, causing internal organs to accumulate heat toxins, resulting in symptoms such as swollen gums, oral ulcers, short and red urine, burning sensation in the anus, and itching and pain in the anterior and posterior vulvae, which can worsen the symptoms of the disease.

　　2. Avoid seafood that causes eruptions.Seafood such as mandarin fish, yellow croaker, hairtail, black fish, shrimp, and crab can promote damp-heat, and eating them can worsen pruritus of the external genitalia, which is not conducive to the regression of inflammation, so they should be avoided.

　　3. Avoid sweet and greasy foods.Oily foods such as lard, fatty pork, butter, beef butter, and mutton butter, and high-sugar foods such as chocolate, candy, sweet pastries, and cream cakes, all have the effect of promoting dampness and heat, which can increase the secretion of leukorrhea and affect the effectiveness of treatment.

　　4. Avoid smoking and alcohol.Smoking can worsen the disease, as nicotine in tobacco can weaken the binding force of arterial blood and oxygen, and alcohol can promote damp-heat, so it should be avoided. Similarly, alcoholic beverages such as rice wine and medicinal wine are not suitable for drinking.

　　What is good to eat for amebic vaginitis:

　　Pay attention to dietary nutrition; it is advisable to eat more fresh vegetables and fruits to keep the bowels smooth; drink more water; prevent urinary tract infections.

　　To prevent amebic vaginitis, one must first pay attention to personal and dietary hygiene, washing hands before and after meals and defecation. Secondly, the external genitalia should be kept clean to prevent feces from continuing to contaminate the external genitalia and vagina, to avoid contacting amebic trophozoites; attention should be paid to disinfection and isolation, and sexual activity should be prohibited. After onset, timely treatment should be sought.

　　1. Treatment methods of amebic vaginitis in traditional Chinese medicine

　　Treatment method and prescription: The treatment of this disease should be based on the characteristics of the symptoms, and differentiated treatment should be carried out. According to the symptoms of vaginal itching, burning pain, thick, yellow, malodorous leukorrhea, and mixed with blood丝, these symptoms are mostly related to the dysfunction of the liver and spleen organs, so the treatment should focus on regulating the liver and spleen functions, combined with pulse and syndrome differentiation in formulating prescriptions and using medicines. For those with spleen deficiency and dampness accumulation with heat, it is advisable to focus on strengthening the spleen and benefiting dampness; for those with damp-heat in the liver meridian descending and causing the disease, it is advisable to focus on clearing the liver and benefiting dampness, while also paying attention to the combination of detoxifying and killing parasites, internal and external treatment, which is conducive to the treatment of this disease.

　　1. Differentiation of symptoms and selection of formulas

　　(1) Spleen deficiency damp-heat

　　Treatment method: Strengthen the spleen, clear heat, and kill parasites.

　　Prescription: Ge Gen Shen Shi Decoction with modification. Ophiopogon japonicus 20g, Coix seed 15g, Phellodendron amurense 15g, Akebia 15g, Poria 15g, Alisma orientale 15g, Talcum 15g, Atractylodes macrocephala 15g, Zingiber officinale 10g. Add 15g of Niu Bang Zi, 10g of Toosendan, 10g of Hemerocallis, and 15g of Inula hirta if pruritus and pain in the vagina are significant.

　　(2) Liver meridian damp-heat

　　Treatment method: Clear the liver and relieve heat, eliminate dampness and kill parasites.

　　Prescription: Long Dan Xie Gan Decoction with modification. Scutellaria baicalensis 30g, Bupleurum 15g, Fructus Gardeniae 10g, Scutellaria baicalensis 15g, Glycyrrhiza uralensis 10g, Alisma orientale 10g, Coptis chinensis 10g, Akebia 10g, Platycodon grandiflorus 15g, Angelica sinensis 10g, Inula hirta 15g, Apis mellifera 10g. Add 10g of rhubarb if accompanied by bitter mouth and constipation.

　　2. Special formulas and prescriptions

　　(1) Take an appropriate amount of soapberry, burn the soapberry with straw, smoke the genital area for more than 10 times, relieve pruritus and pain.

　　(2) Baibu 50g, add 1.5 kilograms of water, boil for 30 minutes, discard the residue, sit in warm water for 10 to 20 minutes, twice a day. Cure within 3 to 7 days.

　　3. Traditional Chinese medicine:

　　(1) Gynecological Bai Dai Wan: This formula strengthens the spleen and benefits dampness,补肾固冲, strengthens the kidneys and consolidates the fetus, contracts the vagina, and is suitable for spleen deficiency damp-heat syndrome. Take 50 grains (about 3g) three times a day, for 2 weeks to 1 month.

　　(2) Tun Jing Bai Dai Wan: This formula strengthens the spleen and boosts Qi, eliminates dampness and stops leukorrhea. Take 9g orally once a day, one course of treatment every half month.

　　(3) Bai Dai Wan: This formula clears heat and dries dampness, suitable for damp-heat syndrome of the liver meridian. Take one pill (about 9g) twice a day, one course of treatment every half month.

　　4. Home remedies:

　　(1) Bird's gall for the treatment of trichomonal vaginitis

　　Prescription: 20 bird's gall (with skin removed).

　　Preparation and usage: Use half a cup of water to decoct the bird's gall, reduce it to half a cup, and pour the decoction into a sterilized bowl. Use a sterile syringe to inject 20 to 40 milliliters of the medicine into the vagina each time. For mild cases, do it once; for severe cases, 2 to 3 times.

　　Effectiveness: Kill parasites and eliminate dampness. Treat trichomonal vaginitis.

　　(2) Peach seeds for the treatment of trichomonal vaginitis

　　Prescription: Appropriate amount of peach seeds.

　　Preparation and usage: Crush peach seeds into a paste, wrap it in gauze, and insert it into the vagina. Change once a day, and continue for several times.

　　Effectiveness: Detoxify and kill parasites. Treat trichomonal vaginitis.

　　(3) Aloe vera for the treatment of trichomonal vaginitis

　　Prescription: Aloe vera 6g, Cnidium monnieri, and Phellodendron amurense each 15g.

　　Prepare and decoct the above three ingredients in water. Before use, clean the genital area with cotton and then insert the soaked cotton ball into the vagina. The patient lies on their back, and this treatment is done for 3 consecutive nights, once a night.

　　Effect: Anti-inflammatory, sterilizing, and killing worms. Treat trichomonal vaginitis.

　　(4) Fresh peach leaf treatment for vulvar itching

　　Recipe: Fresh peach leaves 120 grams.

　　Preparation and use: Wash the fresh peach leaves clean, decoct the decoction, and wash the vagina.

　　Effect: Treat trichomonal vaginitis.

　　(5) Radish juice vinegar treatment for trichomonal vaginitis

　　Recipe: Radish juice, vinegar in appropriate amounts.

　　Preparation and use: Wash the vagina with vinegar, then wipe and fill the vagina with radish juice. Generally, 10 times is a course of treatment.

　　Effect: Clear heat and detoxify, kill worms. Suitable for trichomonal vaginitis.

　　5. When suffering from acute mucor vaginitis, patients should choose food therapy recipes with the effect of clearing heat and eliminating dampness.

　　(1): Polygonum aviculare, Rhizoma corydalis, a little glutinous rice and rock sugar. First, boil Polygonum aviculare and Rhizoma corydalis with an appropriate amount of water to get the juice and remove the dregs, then cook porridge with glutinous rice, and add rock sugar when eating. This recipe has the effect of promoting diuresis, clearing dampness, and inhibiting itching.

　　(2): Toona sinensis bark, white birch bark, Phellodendron amurense. Boil with an appropriate amount of water. This recipe can clear heat and eliminate dampness.

　　6. Chronic Mucor Vaginitis, the symptoms of vulvar itching and pain may not be obvious, and there is a lot of white leukorrhea in daily life. At this time, it is advisable to choose food therapy recipes with the effect of invigorating the spleen and eliminating dampness.

　　(1): White Dolichos lablab, white atractylodes, rock sugar in appropriate amounts. After boiling the white atractylodes with white Dolichos lablab, remove the bag, add rock sugar, and drink the soup while eating the beans.

　　(2): Dolichos lablab flower, Chinese yam in appropriate amounts. Dry the unopened Dolichos lablab flower in the sun, grind into powder, cook rice porridge with appropriate Chinese yam, add the flower powder to the porridge, and boil it again. This recipe has the effect of invigorating the spleen and eliminating dampness.

　　Second, Western Medicine Treatment Methods for Amoebic Vaginitis

　　The treatment of this disease focuses on killing insects and sterilizing.

　　1. Local Treatment

　　(1) Use 250ml of 0.2% metronidazole injection for vaginal lavage, add 10 grains of norfloxacin to retain the powder and sprinkle on the vaginal wall, once a day, 5～7 times as a course of treatment.

　　(2) Quinacrine 5g, sprinkled on the vaginal wall, once a day, 7 days as a course of treatment.

　　2. General Treatment

　　(1) Metronidazole tablets 200～400mg, taken orally 3 times a day, 10～14 days as a course of treatment.

　　(2) Quinacrine 0.5～0.75g, taken orally 3 times a day, 7 days as a course of treatment, and additional Tetracycline 0.5～10g should be taken to improve efficacy.