Disinfectants and Antiseptics Disinfection denotes the inactivation or killing of pathogens (protozoa, bacteria, fungi, viruses) in the human environ- ment. This can be achieved by chemical or physical means; the latter will not be discussed here. Sterilization refers to the killing of all germs, whether patho- genic, dormant, or nonpathogenic. Anti- sepsis refers to the reduction by chemi- cal agents of germ numbers on skin and mucosal surfaces. Agents for chemical disinfection ideally should cause rapid, complete, and persistent inactivation of all germs, but at the same time exhibit low toxic- ity (systemic toxicity, tissue irritancy, antigenicity) and be non-deleterious to inanimate materials. These require- ments call for chemical properties that may exclude each other; therefore, compromises guided by the intended use have to be made. Disinfectants come from various chemical classes, including oxidants, halogens or halogen-releasing agents, alcohols, aldehydes, organic acids, phe- nols, cationic surfactants (detergents) and formerly also heavy metals. The ba- sic mechanisms of action involve de- naturation of proteins, inhibition of en- zymes, or a dehydration. Effects are de- pendent on concentration and contact time. Activity spectrum. Disinfectants inactivate bacteria (gram-positive > gram-negative > mycobacteria), less ef- fectively their sporal forms, and a few (e.g., formaldehyde) are virucidal. Applications Skin “disinfection.” Reduction of germ counts prior to punctures or surgical procedures is desirable if the risk of wound infection is to be minimized. Useful agents include: alcohols (1- and 2-propanol; ethanol 60–90%; iodine-re- leasing agents like polyvinylpyrrolidone [povidone, PVP]-iodine as a depot form of the active principle iodine, instead of iodine tincture), cationic surfactants, and mixtures of these. Minimal contact times should be at least 15 s on skin are- as with few sebaceous glands and at least 10 min on sebaceous gland-rich ones. Mucosal disinfection: Germ counts can be reduced by PVP iodine or chlor- hexidine (contact time 2 min), although not as effectively as on skin. Wound disinfection can be achieved with hydrogen peroxide (0.3%–1% solu- tion; short, foaming action on contact with blood and thus wound cleansing) or with potassium permanganate (0.0015% solution, slightly astringent), as well as PVP iodine, chlorhexidine, and biguanidines. Hygienic and surgical hand disinfec- tion: The former is required after a sus- pected contamination, the latter before surgical procedures. Alcohols, mixtures of alcohols and phenols, cationic surfac- tants, or acids are available for this pur- pose. Admixture of other agents pro- longs duration of action and reduces flammability. Disinfection of instruments: Instru- ments that cannot be heat- or steam- sterilized can be precleaned and then disinfected with aldehydes and deter- gents. Surface (floor) disinfection employs aldehydes combined with cationic sur- factants and oxidants or, more rarely, acidic or alkalizing agents. Room disinfection: room air and surfaces can be disinfected by spraying or vaporizing of aldehydes, provided that germs are freely accessible. 290 Disinfectants Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Disinfectants 291 Tissue A. Disinfectants Application sites Examples Active principles 1. Oxidants 2. Halogens chlorine sodium hypochlorite iodine tincture Skin 3. Alcohols R-OH (R=C 2 -C 6 ) e. g., ethanol isopropanol Regular e.g., hands Acute, e.g., before local procedures 4. Aldehydes e. g., formaldehyde glutaraldehyde 5. Organic acids e. g., lactic acid Mucous membranes 6. Phenols Nonhalogenated: e. g., phenylphenol eugenol thymol halogenated: chlormethylphenol 7. Cationic surfactants Cationic soaps e. g., benzalkonium chlorhexidine 8. Heavy metal salts Inanimate material: durable against chemical + physical measures Inanimate matter: sensitive to heat, acids, oxidation etc. Disinfection of instruments Skin disinfection Disinfection of floors or excrement Disinfection of mucous membranes Wound disinfection Phenols NaOCl Cationic surfactants Phenols Cationic surfactants Alcohols Iodine tincture Chlor- hexidine Chlor- hexidine Chlor- hexidine KMnO 4 H 2 O 2 STOP Cationic surfactants Aldehydes Disinfectants do not afford selective inhibition of bacteria viruses, or fungi e. g., hydrogen peroxide, potassium permanganate, peroxycarbonic acids e. g., phenylmercury borate Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Drugs for Treating Endo- and Ectoparasitic Infestations Adverse hygienic conditions favor hu- man infestation with multicellular or- ganisms (referred to here as parasites). Skin and hair are colonization sites for arthropod ectoparasites, such as insects (lice, fleas) and arachnids (mites). Against these, insecticidal or arachnici- dal agents, respectively, can be used. Endoparasites invade the intestines or even internal organs, and are mostly members of the phyla of flatworms and roundworms. They are combated with anthelmintics. Anthelmintics. As shown in the ta- ble, the newer agents praziquantel and mebendazole are adequate for the treat- ment of diverse worm diseases. They are generally well tolerated, as are the other agents listed. Insecticides. Whereas fleas can be effectively dealt with by disinfection of clothes and living quarters, lice and mites require the topical application of insecticides to the infested subject. Chlorphenothane (DDT) kills in- sects after absorption of a very small amount, e.g., via foot contact with sprayed surfaces (contact insecticide). The cause of death is nervous system damage and seizures. In humans DDT causes acute neurotoxicity only after absorption of very large amounts. DDT is chemically stable and degraded in the environment and body at extremely slow rates. As a highly lipophilic sub- stance, it accumulates in fat tissues. Widespread use of DDT in pest control has led to its accumulation in food chains to alarming levels. For this rea- son its use has now been banned in many countries. Lindane is the active γ-isomer of hexachlorocyclohexane. It also exerts a neurotoxic action on insects (as well as humans). Irritation of skin or mucous membranes may occur after topical use. Lindane is active also against intrader- mal mites (Sarcoptes scabiei, causative agent of scabies), besides lice and fleas. It is more readily degraded than DDT. Permethrin, a synthetic pyreth- roid, exhibits similar anti-ectoparasitic activity and may be the drug of choice due to its slower cutaneous absorption, fast hydrolytic inactivation, and rapid renal elimination. 292 Antiparasitic Agents Worms (helminths) Anthelmintic drug of choice Flatworms (platyhelminths) tape worms (cestodes) praziquantel* flukes (trematodes) e.g., Schistosoma praziquantel species (bilharziasis) Roundworms (nematodes) pinworm (Enterobius vermicularis) mebendazole or pyrantel pamoate whipworm (Trichuris trichiura) mebendazole Ascaris lumbricoides mebendazole or pyrantel pamoate Trichinella spiralis** mebendazole and thiabendazole Strongyloides stercoralis thiabendazole Hookworm (Necator americanus, and mebendazole or pyrantel pamoate Ancylostoma duodenale) mebendazole or pyrantel pamoate * not for ocular or spinal cord cysticercosis ** [thiabendazole: intestinal phase; mebendazole: tissue phase] Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Antiparasitic Agents 293 Flea Damage to nervous system: convulsions, death A. Endo- and ectoparasites: therapeutic agents Tapeworms e.g., beef tapeworm Louse Round- worms, e.g., ascaris Pinworm Trichinella larvae Scabies mite Spasm, injury of integument Praziquantel Mebendazole Hexachlorocyclo- hexane (Lindane) Chlor- phenothane (DDT) Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Antimalarials The causative agents of malaria are plas- modia, unicellular organisms belonging to the order hemosporidia (class proto- zoa). The infective form, the sporozoite, is inoculated into skin capillaries when infected female Anopheles mosquitoes (A) suck blood from humans. The sporo- zoites invade liver parenchymal cells where they develop into primary tissue schizonts. After multiple fission, these schizonts produce numerous mero- zoites that enter the blood. The pre- erythrocytic stage is symptom free. In blood, the parasite enters erythrocytes (erythrocytic stage) where it again mul- tiplies by schizogony, resulting in the formation of more merozoites. Rupture of the infected erythrocytes releases the merozoites and pyrogens. A fever attack ensues and more erythrocytes are in- fected. The generation period for the next crop of merozoites determines the interval between fever attacks. With Plasmodium vivax and P. ovale, there can be a parallel multiplication in the liver (paraerythrocytic stage). Moreover, some sporozoites may become dormant in the liver as “hypnozoites” before en- tering schizogony. When the sexual forms (gametocytes) are ingested by a feeding mosquito, they can initiate the sexual reproductive stage of the cycle that results in a new generation of transmittable sporozoites. Different antimalarials selectively kill the parasite’s different developmen- tal forms. The mechanism of action is known for some of them: pyrimetha- mine and dapsone inhibit dihydrofolate reductase (p. 273), as does chlorguanide (proguanil) via its active metabolite. The sulfonamide sulfadoxine inhibits syn- thesis of dihydrofolic acid (p. 272). Chlo- roquine and quinine accumulate within the acidic vacuoles of blood schizonts and inhibit polymerization of heme, the latter substance being toxic for the schizonts. Antimalarial drug choice takes into account tolerability and plasmodial re- sistance. Tolerability. The first available antimalarial, quinine, has the smallest therapeutic margin. All newer agents are rather well tolerated. Plasmodium (P.) falciparum, re- sponsible for the most dangerous form of malaria, is particularly prone to de- velop drug resistance. The incidence of resistant strains rises with increasing frequency of drug use. Resistance has been reported for chloroquine and also for the combination pyrimethamine/ sulfadoxine. Drug choice for antimalarial chemoprophylaxis. In areas with a risk of malaria, continuous intake of antima- larials affords the best protection against the disease, although not against infection. The drug of choice is chloroquine. Because of its slow excre- tion (plasma t 1/2 = 3d and longer), a sin- gle weekly dose is sufficient. In areas with resistant P. falciparum, alternative regimens are chloroquine plus pyri- methamine/sulfadoxine (or proguanil, or doxycycline), the chloroquine ana- logue amodiaquine, as well as quinine or the better tolerated derivative meflo- quine (blood-schizonticidal). Agents ac- tive against blood schizonts do not pre- vent the (symptom-free) hepatic infec- tion, only the disease-causing infection of erythrocytes (“suppression therapy”). On return from an endemic malaria re- gion, a 2 wk course of primaquine is ad- equate for eradication of the late hepat- ic stages (P. vivax and P. ovale). Protection from mosquito bites (net, skin-covering clothes, etc.) is a very important prophylactic measure. Antimalarial therapy employs the same agents and is based on the same principles. The blood-schizonticidal halofantrine is reserved for therapy on- ly. The pyrimethamine-sulfadoxine combination may be used for initial self- treatment. Drug resistance is accelerating in many endemic areas; malaria vaccines may hold the greatest hope for control of infection. 294 Antiparasitic Drugs Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Antiparasitic Drugs 295 A. Malaria: stages of the plasmodial life cycle in the human; h i h Fever Fever Primaquine Primaquine Chloroquine Quinine Proguanil Pyrimethamine Fever 2 days : Tertian malaria Pl. vivax, Pl. ovale 3 days: Quartan malaria Pl. malariae No fever periodicity: Pernicious malaria: Pl. falciparum not P. falcip. Pl. falcip. Hepatocyte Primary tissue schizont Sulfadoxine Chloroquine Mefloquine Halofantrine Quinine Proguanil Pyrimethamine Merozoites Hypnozoite Preerythrocytic cycle 1-4 weeks Erythrocytic cycle Blood schizont Erythrocyte Only Pl. vivax Pl. ovale Gametocytes Sporozoites Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Chemotherapy of Malignant Tumors A tumor (neoplasm) consists of cells that proliferate independently of the body’s inherent “building plan.” A ma- lignant tumor (cancer) is present when the tumor tissue destructively invades healthy surrounding tissue or when dis- lodged tumor cells form secondary tu- mors (metastases) in other organs. A cure requires the elimination of all ma- lignant cells (curative therapy). When this is not possible, attempts can be made to slow tumor growth and there- by prolong the patient’s life or improve quality of life (palliative therapy). Chemotherapy is faced with the prob- lem that the malignant cells are endoge- nous and are not endowed with special metabolic properties. Cytostatics (A) are cytotoxic sub- stances that particularly affect prolife- rating or dividing cells. Rapidly dividing malignant cells are preferentially in- jured. Damage to mitotic processes not only retards tumor growth but may also initiate apoptosis (programmed cell death). Tissues with a low mitotic rate are largely unaffected; likewise, most healthy tissues. This, however, also ap- plies to malignant tumors consisting of slowly dividing differentiated cells. Tis- sues that have a physiologically high mitotic rate are bound to be affected by cytostatic therapy. Thus, typical ad- verse effects occur: Loss of hair results from injury to hair follicles; gastrointestinal distur- bances, such as diarrhea, from inad- equate replacement of enterocytes whose life span is limited to a few days; nausea and vomiting from stimulation of area postrema chemoreceptors (p. 330); and lowered resistance to infection from weakening of the immune system (p. 300). In addition, cytostatics cause bone marrow depression. Resupply of blood cells depends on the mitotic activity of bone marrow stem and daughter cells. When myeloid proliferation is arrested, the short-lived granulocytes are the first to be affected (neutropenia), then blood platelets (thrombopenia) and, finally, the more long-lived erythrocytes (ane- mia). Infertility is caused by suppression of spermatogenesis or follicle matura- tion. Most cytostatics disrupt DNA me- tabolism. This entails the risk of a po- tential genomic alteration in healthy cells (mutagenic effect). Conceivably, the latter accounts for the occurrence of leukemias several years after cytostatic therapy (carcinogenic effect). Further- more, congenital malformations are to be expected when cytostatics must be used during pregnancy (teratogenic ef- fect). Cytostatics possess different mech- anisms of action. Damage to the mitotic spindle (B). The contractile proteins of the spindle apparatus must draw apart the replicat- ed chromosomes before the cell can di- vide. This process is prevented by the so-called spindle poisons (see also col- chicine, p. 316) that arrest mitosis at metaphase by disrupting the assembly of microtubules into spindle threads. The vinca alkaloids, vincristine and vin- blastine (from the periwinkle plant, Vin- ca rosea) exert such a cell-cycle-specific effect. Damage to the nervous system is a predicted adverse effect arising from injury to microtubule-operated axonal transport mechanisms. Paclitaxel, from the bark of the pa- cific yew (Taxus brevifolia), inhibits dis- assembly of microtubules and induces atypical ones. Docetaxel is a semisyn- thetic derivative. 296 Anticancer Drugs Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Anticancer Drugs 297 A. Chemotherapy of tumors: principal and adverse effects B. Cytostatics: inhibition of mitosis Malignant tissue with numerous mitoses Wanted effect: inhibition of tumor growth Healthy tissue with few mitoses Little effect Healthy tissue with numerous mitoses Lymph node Inhibition of lymphocyte multiplication: immune weakness Unwanted effects Diarrhea Germinal cell damage Lowered resistance to infection Bone marrow Inhibition of granulo-, thrombocyto-, and erythropoiesis Vinca alkaloids Vinca rosea Paclitaxel Western yew tree Damage to hair follicle Hair loss Inhibition of ephithelial renewal Cytostatics inhibit cell division Inhibition of formation Microtubules of mitotic spindle Inhibition of degradation Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Inhibition of DNA and RNA syn- thesis (A). Mitosis is preceded by repli- cation of chromosomes (DNA synthesis) and increased protein synthesis (RNA synthesis). Existing DNA (gray) serves as a template for the synthesis of new (blue) DNA or RNA. De novo synthesis may be inhibited by: Damage to the template (1). Alky- lating cytostatics are reactive com- pounds that transfer alkyl residues into a covalent bond with DNA. For instance, mechlorethamine (nitrogen mustard) is able to cross-link double-stranded DNA on giving off its chlorine atoms. Correct reading of genetic information is there- by rendered impossible. Other alkylat- ing agents are chlorambucil, melphalan, thio-TEPA, cyclophosphamide (p. 300, 320), ifosfamide, lomustine, and busul- fan. Specific adverse reactions include irreversible pulmonary fibrosis due to busulfan and hemorrhagic cystitis caused by the cyclophosphamide me- tabolite acrolein (preventable by the uroprotectant mesna). Cisplatin binds to (but does not alkylate) DNA strands. Cystostatic antibiotics insert them- selves into the DNA double strand; this may lead to strand breakage (e.g., with bleomycin). The anthracycline antibiotics daunorubicin and adriamycin (doxorubi- cin) may induce cardiomyopathy. Ble- omycin can also cause pulmonary fibro- sis. The epipodophyllotoxins, etopo- side and teniposide, interact with topo- isomerase II, which functions to split, transpose, and reseal DNA strands (p. 274); these agents cause strand breakage by inhibiting resealing. Inhibition of nucleobase synthe- sis (2). Tetrahydrofolic acid (THF) is re- quired for the synthesis of both purine bases and thymidine. Formation of THF from folic acid involves dihydrofolate reductase (p. 272). The folate analogues aminopterin and methotrexate (ame- thopterin) inhibit enzyme activity as false substrates. As cellular stores of THF are depleted, synthesis of DNA and RNA building blocks ceases. The effect of these antimetabolites can be reversed by administration of folinic acid (5-for- myl-THF, leucovorin, citrovorum fac- tor). Incorporation of false building blocks (3). Unnatural nucleobases (6- mercaptopurine; 5-fluorouracil) or nu- cleosides with incorrect sugars (cytara- bine) act as antimetabolites. They inhib- it DNA/RNA synthesis or lead to synthe- sis of missense nucleic acids. 6-Mercaptopurine results from bio- transformation of the inactive precursor azathioprine (p. 37). The uricostatic allo- purinol inhibits the degradation of 6- mercaptopurine such that co-adminis- tration of the two drugs permits dose reduction of the latter. Frequently, the combination of cy- tostatics permits an improved thera- peutic effect with fewer adverse reac- tions. Initial success can be followed by loss of effect because of the emergence of resistant tumor cells. Mechanisms of resistance are multifactorial: Diminished cellular uptake may re- sult from reduced synthesis of a trans- port protein that may be needed for membrane penetration (e.g., metho- trexate). Augmented drug extrusion: in- creased synthesis of the P-glycoprotein that extrudes drugs from the cell (e.g., anthracyclines, vinca alkaloids, epipo- dophyllotoxins, and paclitaxel) is re- ponsible for multi-drug resistance (mdr-1 gene amplification). Diminished bioactivation of a pro- drug, e.g., cytarabine, which requires intracellular phosphorylation to be- come cytotoxic. Change in site of action: e.g., in- creased synthesis of dihydrofolate re- ductase may occur as a compensatory response to methotrexate. Damage repair: DNA repair en- zymes may become more efficient in re- pairing defects caused by cisplatin. 298 Anticancer Drugs Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. Anticancer Drugs 299 A. Cytostatics: alkylating agents and cytostatic antibiotics (1), inhibitors of tetrahydrofolate synthesis (2), antimetabolites (3) instead of instead of Damage to template Alkylation e. g., by mechlor- ethamine Insertion of daunorubicin, doxorubicin, bleomycin, actinomycin D, etc. Streptomyces bacteria Inhibition of nucleotide synthesis Purines Thymine Nucleotide Tetrahydro- folate Dihydrofolate Reductase Folic acid Inhibition by Purine antimetabolite Insertion of incorrect building blocks Pyrimidine antimetabolite 6-Mercaptopurine from Azathioprine Adenine Uracil Cytarabine Cytosine Cytosine Desoxyribose instead of 5-Fluorouracil Arabinose Aminopterin Methotrexate DNA DNA DNA 3 2 1 RNA Building blocks Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. [...]... attenuate tissue rejection Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved Usage subject to terms and conditions of license Immune Modulators Antigen Macrophage Virus-infected cell, transplanted cell tumor cell Phagocytosis Degradation Presentation Synthesis of "foreign" proteins Presentation Glucocorticoids Inhibition of transcription of cytokines, e g., IL-1 MHC II IL-1 301... Chelation of lead ions by EDTA Dimercaprol (i.m.) Arsenic, mercury, gold ions DMPS Dimercaptopropane sulfonate Deferoxamine D-Penicillamine Fe3+ β,β-Dimethylcysteine chelation with Cu2+ and Pb2+ Dissolution of cystine stones: Cysteine-S-S-Cysteine Inhibition of collagen polymerization B Chelators Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved Usage subject to terms and conditions of. .. Transcription of cytokines e g., IL-2 Proliferation and differentiation into plasma cells Cytotoxic, antiproliferative drugs Cytotoxic T-lymphocytes Azathioprine, Methotrexate, Cyclophosphamide, Mycophenolate mofetil Cytokines: chemotaxis Antibody-mediated immune reaction Immune reaction: delayed hypersensitivity Elimination of “foreign” cells A Immune reaction and immunosuppressives Lüllmann, Color Atlas of Pharmacology. .. aldehydes, whereby polymerization of collagen molecules into fibrils is inhibited Unwanted effects are: cutaneous damage (diminished resistance to mechanical stress with a tendency to form blisters), nephrotoxicity, bone marrow depression, and taste disturbances Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved Usage subject to terms and conditions of license Antidotes Ca2+ 2Na+...300 Immune Modulators Inhibition of Immune Responses Both the prevention of transplant rejection and the treatment of autoimmune disorders call for a suppression of immune responses However, immune suppression also entails weakened defenses against infectious pathogens and a long-term increase in the risk of neoplasms A specific immune response begins with the binding of antigen by lymphocytes carrying... that promote formation of methemoglobin (B) may cause a lethal deficiency of O2 Tolonium chloride is a redox dye that can be given i.v to reduce methemoglobin Obidoxime is an antidote used to treat poisoning with insecticides of the organophosphate type (p 102) Phosphorylation of acetylcholinesterase causes an irreversible inhibition of ace- tylcholine breakdown and hence flooding of the organism with... intestines Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved Usage subject to terms and conditions of license 305 Antidotes Sulfur donors Potassium KCN cyanide SCNH+ Sodium thiosulfate Rhodanese H+ + CN- Hydrogen HCN cyanide K+ Na2S2O3 FeIII-Hb Methemoglobin formation DMAP Fe3+ Complex formation Mitochondrial cytochrome oxidase Hydroxocobalamin Vit.B12a Inhibition of cellular respiration... formation of cyanmethemoglobin Hydroxocobalamin is an alternative, very effective antidote because its central cobalt atom binds CN- with high affinity to generate cyanocobalamin Tolonium chloride (Toluidin Blue) Brown-colored methemoglobin, containing tri- instead of divalent iron, is incapable of carrying O2 Under normal conditions, methemoglobin is produced continuously, but reduced again with the help of. .. graft rejection) II Inhibition of cytokine production or action Glucocorticoids modulate the expression of numerous genes; thus, the production of IL-1 and IL-2 is inhibited, which explains the suppression of T-cell-dependent immune responses Glucocorticoids are used in organ transplantations, autoimmune diseases, and allergic disorders Systemic use carries the risk of iatrogenic Cushing’s syndrome... excretion of iron Oral administration is indicated only if enteral absorption of iron is to be curtailed Unwanted effects include allergic reactions It should be noted that blood letting is the most effective means of removing iron from the body; however, this method is unsuitable for treating conditions of iron overload associated with anemia D-penicillamine can promote the elimination of copper (e.g., . by spraying or vaporizing of aldehydes, provided that germs are freely accessible. 290 Disinfectants Lüllmann, Color Atlas of Pharmacology © 2000 Thieme. control of infection. 294 Antiparasitic Drugs Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Usage subject to terms and conditions of