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Background: The purpose of this study was to investigate the association between Attention Deficit/Hyperactivity Disorder (ADHD) and various factors using a representative sample of US children in a comprehensive manner. This includes variables that have not been previously studied such as watching TV/playing video games, computer usage, family member's smoking, and participation in sports., Methods: This was a cross-sectional study of 68,634 children, 5-17 years old, from the National Survey of Children's Health (NSCH, 2007-2008). We performed bivariate and multivariate logistic regression analyses with ADHD classification as the response variable and the following explanatory variables: sex, race, depression, anxiety, body mass index, healthcare coverage, family structure, socio-economic status, family members' smoking status, education, computer usage, watching television (TV)/playing video games, participation in sports, and participation in clubs/organizations., Results: Approximately 10% of the sample was classified as having ADHD. We found depression, anxiety, healthcare coverage, and male sex of child to have increased odds of being diagnosed with ADHD. One of the salient features of this study was observing a significant association between ADHD and variables such as TV usage, participation in sports, two-parent family structure, and family members' smoking status. Obesity was not found to be significantly associated with ADHD, contrary to some previous studies., Conclusions: The current study uncovered several factors associated with ADHD at the national level, including some that have not been studied earlier in such a setting. However, we caution that due to the cross-sectional and observational nature of the data, a cause and effect relationship between ADHD and the associated factors can not be deduced from this study. Future research on ADHD should take into consideration these factors, preferably through a longitudinal study design.

The objective of this study was to examine hospital discharge data on 5 tobacco-related diagnoses before and after implementation of a smoking ban in a small Texas city. We compared hospital discharge rates for 2 years before and 2 years after implementation of the ban in the intervention city with discharge rates during the same time in a similar city with no ban. The discharge rates for blacks and whites combined declined significantly after the ban in the intervention city for acute myocardial infarction (MI) (rate ratio [RR], 0.74; 95% confidence interval [CI], 0.65-0.85) and for stroke or cerebrovascular accident (RR, 0.71; 95% CI, 0.62-0.82); discharge rates in the intervention city also declined significantly for chronic obstructive pulmonary disease (RR, 0.64; 95% CI, 0.54-0.75) and asthma (RR, 0.69; 95% CI, 0.52-0.91) for whites only. Discharge rates for 4 of 5 diagnoses in the control city did not change. Although postban reduction in acute MI is well documented, this is one of the first studies to show a racial disparity in health benefits and a decline in tobacco-related diagnoses other than acute MI after implementation of a city-wide smoking ban.

Background: Patients with pulmonary tuberculosis are likely to develop pulmonary impairment after tuberculosis (PIAT). The stability of PIAT and the relationship of PIAT to the duration of delay in tuberculosis diagnosis and treatment have not been fully characterized., Methods: We performed serial pulmonary function tests (PFTs) in a cohort treated for pulmonary tuberculosis after 20 weeks of tuberculosis therapy and again on or after treatment completion to determine the stability of PIAT. PFTs were compared with the duration of delay in tuberculosis diagnosis and treatment, as well as other demographic variables., Results: The median duration between the first and second tests was 15 (interquartile range 9-34) weeks. The mean change in FVC was -0.02l (95% confidence interval [CI] -0.09, 0.06), and the % predicted was -0.02 (95% CI -2.17, 2.12). FEV1 changes were 0l (95% CI -0.05, 0.06), and the % predicted was -0.11 (95% CI -1.82, 1.60). PIAT was not related to the duration of delay in tuberculosis diagnosis or treatment, age or smoking., Conclusions: PIAT was not associated with the duration of delay in tuberculosis diagnosis and treatment and did not significantly change during follow-up. These data demonstrate that, for many individuals, the completion of tuberculosis treatment is the beginning, not the end, of their tuberculosis illness., (Published by Elsevier Ltd.)

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality caused by cigarette smoking and other environmental exposures. While variation in exposures may affect COPD morbidity and mortality, little is known about geographic variation, a surrogate of exposures. The objective of this manuscript is to explore the geographic variation in COPD hospitalization rates among the Texas population in 2006., Methods: The study population consisted of all Texas residents with COPD hospitalizations in the 2006 Texas Health Care Information Council (THCIC) data. County population estimates stratified by race, age, and gender were linked to THCIC data to calculate county level COPD hospitalization rates per 100,000 admissions. The data were merged with Urban Influence Codes by county, and metropolitan status was determined by United States Department of Agriculture (USDA) criteria. Variation in COPD hospitalization rates were analyzed using Poisson Regression., Results: Overall, non Hispanic (NH) Whites had the highest rate of hospitalization, followed by NH Blacks (rate ratio=0.42) and Hispanics (RR=0.17), the 65+ age category had the highest rates of hospitalization. In the metropolitan counties COPD hospitalization rates were lower than non-metropolitan counties, however in metropolitan counties the rates of hospitalization were significantly higher (p<0.0001) in females compared to males. The rates were significantly higher in males in public health regions 10 and 11, which are predominantly non-metropolitan counties., Conclusions: In Texas there is substantial geographic variation in hospitalization rates associated with gender and race/ethnicity. Other factors that may contribute to the variation and require further investigation include differences in smoking and exposure to other environmental risk factors, access to primary care, medical practice patterns, and coding practices., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Purpose: Geographic disparities in hospitalization rates for chronic obstructive pulmonary disease (COPD) have been observed in Texas. However, little is known about the sources of these variations. The purpose of this manuscript is to further explore the geographic disparity of COPD hospitalization rates in Texas by examining county-level factors affecting access to care., Patients and Methods: The study is a cross-sectional analysis of the 2007 Texas Health Care Information Council, Texas, demographer population projections and the 2009 Area Resource File (ARF). The unit of analysis was county-specific hospitalization rate, calculated as the number of discharges of county residents divided by county-level population estimates. Indicators of access to care included: type of safety-net facility and number of pulmonary specialists in a county. Safety-net facilities of interest were federally qualified health centers (FQHCs) and rural health clinics (RHCs)., Results: There was a significant difference (P < 0.05) in hospitalization rates according to health center presence. Counties with only FQHCs had the lowest COPD hospitalization rate (132 per 100,000 observations), and counties with only RHCs had the highest hospitalization rate (229 per 100,000 observations). The presence of a pulmonary specialist was associated with a significant decrease (25%) in hospitalization rates among counties with only FQHCs., Conclusion: In Texas, counties with only FQHCs were associated with lower COPD hospitalization rates. The presence of a RHC alone may be insufficient to decrease hospitalizations from COPD. There are a number of factors that may contribute to these variations in hospitalization rates, such as racial/ethnic distribution, types and quality of services provided, and the level of rurality, which creates greater distances to care and lower concentration of hospitals and pulmonary specialists.

Objective: The recommendations of health care providers have been shown to be a predictor of future healthy behaviors. However, patient adherence to these recommendations may differ based upon the type of health care professional providing the information. This study explored patient compliance in the United States over a 12-month period and contracted the patient response to recommendations given by chiropractors versus medical doctors., Methods: Multiple logistic regression models were used for analyses of data from the Sample Adult Core component of the 2006 National Health Interview Survey (n = 24 275). Analyses were performed separately for recommendation and compliance of weight loss, increase exercise, and diet change by health profession subtype (chiropractor and medical doctor)., Results: About 30.5% of the respondents reported receiving advice from their provider. Among these, 88.0% indicated they complied with the advice they received. Patients who were advised were more likely to comply (odds ratio [OR] [95% CI], 10.41[9.34-11.24]). Adjusting for seeing a physical therapist, age, and body mass index, chiropractors were less likely to advice patients compared to medical doctors (OR [95% CI], 0.38 [0.30-0.50]). In general, there was a 21% increased odds that patients who received and complied with health promotion advice from their health care provider would report an improved health status (OR [95% CI], 1.21 [1.10-1.33]) compared with those who did not comply or were not advised., Conclusion: Chiropractors in the United States give health promotion recommendation to their patients but are less likely to do so than general medical doctors. Patients tend to comply with health providers' recommendations and those who do report better health., (Copyright 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Objective: The importance of integrating healthy behavior counseling into routine health care is universal but may depend on the type of medical care provider as well as the conditions presented by patients. The purpose of this study was to evaluate whether health promotion (HP) recommendations for known risk factors of arthritis differed between general medical doctors and doctors of chiropractic (DCs) in a nationally representative US population with arthritis., Methods: Multiple logistic regression models were used for analyses of data from the Sample Adult Core component of the 2006 National Health Interview Survey (n = 6374 diagnosed with arthritis). Analyses were performed separately for recommendation of weight loss and increase in exercise by health profession subtype (chiropractor and medical doctor)., Results: Comparing the reported HP efforts between DCs and medical doctors (MDs), while adjusting for the effect of physical therapist and body mass index, we observed no significant differences (weight loss: adjusted odds ratio [95% confidence interval] = 0.76 [0.50-1.18]; increased exercise: adjusted odds ratio [95% confidence interval] = 0.87 [0.59-1.29])., Conclusion: Health promotion efforts to patients with arthritis do not differ significantly between MDs and DCs, as reported by National Health Interview Survey 2006. This investigation makes it difficult to suggest that DCs or MDs are doing all they can do to manage arthritis through suggested modification of lifestyle in their patients. More research specific to what is and can be recommended to those with arthritis should be conducted particularly because it relates to health-promoting behaviors. Given the recent implementation of required clinical competencies in HP into chiropractic college curriculums, future studies regarding translation of HP messages into public practice should be more informative., (Copyright 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to develop a novel pelvic model and determine the accuracy and the inter- and intraexaminer reliability of anterior superior iliac spine (ASIS) positional asymmetry assessment from both sides of the model by osteopathic predoctoral fellows and osteopathic physicians and to evaluate the effect of training., Methods: Five osteopathic predoctoral fellows and 5 osteopathic physicians assessed 13 settings of varied ASIS asymmetry of a novel pelvic model for superior/inferior positional asymmetry from both sides of the model in a random order. Assessment from the right and left sides of the model occurred on 2 separate days. Fellows were trained for a week and retested., Results: Average interexaminer reliability was greatest from the left side of the model for physicians and from the right side for fellows (physicians: kappa = 0.46, fellows: kappa = 0.37), whereas intraexaminer reliability was greatest from the right in both groups (physicians: kappa = 0.49, fellows: kappa = 0.52). Following training of fellows, interexaminer reliability remained highest from the right side of the model (right: kappa = 0.48, left: kappa = 0.36), whereas intraexaminer reliability was higher from the left side (right: kappa = 0.53, left: kappa = 0.59). Physicians and fellows before training were more accurate from the right side of the model (kappa = 0.56 and kappa = 0.52, respectively). Following training of fellows, accuracy increased from both sides of the model (right: kappa = 0.59, left: kappa = 0.53)., Conclusions: A novel pelvic model was developed to allow assessment of accuracy and reliability of ASIS asymmetry assessment. Individually, physicians and fellows varied in accuracy and inter-/intraexaminer reliability. Further investigation is warranted to understand the clinical and educational application of these results., (Copyright (c) 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Background: The health impacts of pulmonary impairment after tuberculosis (TB) treatment have not been included in assessments of TB burden. Therefore, previous global and national TB burden estimates do not reflect the full consequences of surviving TB. We assessed the burden of TB including pulmonary impairment after tuberculosis in Tarrant County, Texas using Disability-adjusted Life Years (DALYs)., Methods: TB burden was calculated for all culture-confirmed TB patients treated at Tarrant County Public Health between January 2005 and December 2006 using identical methods and life tables as the Global Burden of Disease Study. Years of life-lost were calculated as the difference between life expectancy using standardized life tables and age-at-death from TB. Years lived-with-disability were calculated from age and gender-specific TB disease incidence using published disability weights. Non-fatal health impacts of TB were divided into years lived-with-disability-acute and years lived-with-disability-chronic. Years lived-with-disability-acute was defined as TB burden resulting from illness prior to completion of treatment including the burden from treatment-related side effects. Years lived-with-disability-chronic was defined as TB burden from disability resulting from pulmonary impairment after tuberculosis., Results: There were 224 TB cases in the time period, of these 177 were culture confirmed. These 177 subjects lost a total of 1189 DALYs. Of these 1189 DALYs 23% were from years of life-lost, 2% were from years lived-with-disability-acute and 75% were from years lived-with-disability-chronic., Conclusions: Our findings demonstrate that the disease burden from TB is greater than previously estimated. Pulmonary impairment after tuberculosis was responsible for the majority of the burden. These data demonstrate that successful TB control efforts may reduce the health burden more than previously recognized.

Objectives: To describe the uninsured population in the United States, to determine factors of uninsurance and to test the association between insurance status and use of preventive care., Methods: Using the 2008 Behavioral Risk Factor Surveillance System, we conducted univariate logistic regression and stratified, multivariate and multinomial analyses, adjusting for confounders., Results: Respondents aged > or =65 years, regardless of their race/ethnicity, were much less likely to be uninsured than those aged 18 to 44 years. Lower annual income and unemployment were statistically significant factors of uninsurance for all racial/ethnic groups. Marital status was associated with lack of insurance, but only among non-Hispanic Whites, non-Hispanic Blacks and those in the other racial/ethnic category. Those with health insurance were almost 4 to 8 times more likely to report having one of more individuals they thought of as their personal doctor or healthcare provider. Compared to the uninsured, the insured had greater odds of having a physical within the past year, across all racial/ethnic groups. The same finding was true for having a dental check-up within the past year, but only among non-Hispanic Whites, non-Hispanic Blacks, and Hispanics., Conclusions: The access of preventive care such as routine physical and dental exams differs by health insurance status and among racial/ethnic groups. As the number of uninsured grows, the US healthcare system needs to determine sustainable ways to increase health insurance coverage and improve access to preventive care for this population.

The authors compared disability and functional limitation among elder Hispanic subgroups by using data from the 2001-2003 National Health Interview Survey (National Center for Health Statistics 2008a). The authors applied chi-square analysis for bivariate comparisons and used multiple logistic regression analyses for making comparisons, estimating odds ratios, and predicting disabilities. Results revealed a 21.4% rate of disability of any type in Hispanics. Puerto Ricans reported the highest rates of Activity of Daily Living (ADL) and Instrumental Activity of Daily Living (IADL) disabilities compared with other Hispanic subgroups (Mexicans, Cubans, Central and South Americans) and reported a higher rate than did Blacks. Cubans showed the lowest rate of IADL and any disability among Hispanics and a lower rate than did Whites. These findings highlight the high rates of intragroup variability among the U. S. Hispanic population. Among seniors, ADLs and IADLs were significant predictors of admission to nursing homes and use of paid home care, physician services, and palliative care.

The mini mental state examination (MMSE) is a common tool for measuring cognitive decline in Alzhiemer's Disease (AD) subjects. Subjects are usually observed for a specified period of time or until death to determine the trajectory of the decline which for the most part appears to be linear. However, it may be noted that the decline may not be modeled by a single linear model over a specified period of time. There may be a point called a change point where the rate or gradient of the decline may change depending on the length of time of observation. A Bayesian approach is used to model the trajectory and determine an appropriate posterior estimate of the change point as well as the predicted model of decline before and after the change point. Estimates of the appropriate parameters as well as their posterior credible regions or regions of interest are established. Coherent prior to posterior analysis using mainly non informative priors for the parameters of interest is provided. This approach is applied to an existing AD database.

Background: To explore the association between obesity and asthma in US children and adolescents with adjustment of other structural and behavioral factors., Method: Prevalence and associated risk factors of asthma were explored in 102,273 children and adolescents in the National Survey of Children's Health (2003-2004). Subgroup analysis was performed for subjects of 0-6 year-old, 7-12 year-old, and 13-17 year-old. Crude and adjusted odds ratios for the potential risk factors were examined in univariate and multivariate logistic regressions., Results: The overall prevalence of obesity was 24.5% and that of asthma was 12.5%. The adjusted odds ratio of asthma with obesity remains significantly bigger than 1 for children in the 7-12 and the 13-17 year-old age-groups. Gender and race were significantly associated with asthma in all age groups. The two parent family structure showed significant protectiveness against asthma with children in the 0-6 year-old age group. Poverty was positively associated with asthma in the 7-12 years old age group. Having a smoker in the household increased the odds of asthma by 29% and 23.5% in the 0-6 and 13-17 year-old age-groups, respectively. Higher education level of the parents and access to healthcare showed positive association with asthma in the 13-17 year-old age group., Conclusion: Gender and race were significantly associated with asthma. In the 13-17 year-old age-groups, obesity, household education level, healthcare coverage, and household smoking were positively associated with asthma. Further studies should characterize how the family structure and household education level influence childhood asthma in 0-6 and 13-17 year-old age-groups respectively.

The overall goal of this study was to determine the role of ethnicity on features of hot flashes (HFs) in a population of menopausal women in North Central Texas. A total of 397 ethnically diverse menopausal women from North Central Texas were administered our Menopausal Vasomotor Symptoms (MVS) survey to ascertain accurate information about number, length, intensity and behaviorally disruptive effects of hot flash episodes for subsequent analysis for the role of ethnicity in the occurrence of hot flashes. The mean (SD) age for participants was 50.2 (5.3) years; 40% were Caucasian, 38% were African-American and 22% were Hispanic. To evaluate and identify potential associations of hot flash (HF) features, ethnicity, and other independent variables, ordinal/multinomial/binary logistic regression models were used to calculate crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). The analysis demonstrates strong associations with ethnicity and the number of HF's/day, the length of each HF episode, the intensity of HFs, and the interruption of daily activities and sleep. Ethnicity was important in the crude and adjusted model describing the association between the number of HFs per day and ethnicity. African-American women were 2.22 (95% CI, 1.38-3.56) times and Hispanic women were 1.85 (95% CI, 1.08-3.18) times more likely to experience more frequent HFs per day than Caucasian women. In contrast, Hispanic women were less likely than Caucasian women to experience sweating and disruption of both daily activities and sleep. Collectively, our results show more frequent and more bothersome HFs in African-American women and more frequent, but less intense and bothersome HFs in Hispanic women in comparison to Caucasian women.

Background: The purpose of this study is to identify factors affecting CSHCN's receiving needed specialty care among different socioeconomic levels. Previous literature has shown that Socioeconomic Status (SES) is a significant factor in CHSHCN receiving access to healthcare. Other literature has shown that factors of insurance, family size, race/ethnicity and sex also have effects on these children's receipt of care. However, this literature does not address whether other factors such as maternal education, geographic location, age, insurance type, severity of condition, or race/ethnicity have different effects on receiving needed specialty care for children in each SES level., Methods: Data were obtained from the National Survey of Children with Special Health Care Needs, 2000-2002. The study analyzed the survey which studies whether CHSCN who needed specialty care received it. The analysis included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for SES levels defined by federal poverty level: < 199%; 200-299%; >or= 300%., Results: For the poorest children (,199% FPL) being uninsured had a strong negative effect on receiving all needed specialty care. Being Hispanic was a protective factor. Having more than one adult in the household had a positive impact on receipt of needed specialty care but a larger number of children in the family had a negative impact. For the middle income group of children (200-299% of FPL severity of condition had a strong negative association with receipt of needed specialty care. Children in highest income group (> 300% FPL) were positively impacted by living in the Midwest and were negatively impacted by the mother having only some college compared to a four-year degree., Conclusion: Factors affecting CSHCN receiving all needed specialty care differed among socioeconomic groups. These differences should be addressed in policy and practice. Future research should explore the CSHCN population by income groups to better serve this population.

Purpose: The purpose of this research study was to identify factors that are associated with receiving care in a medical home for children with special health care needs (CSHCN) and to identify how these factors vary among different socioeconomic levels., Methods: Data were obtained from the National Survey of Children with Special Health Care Needs, 2000-2002. Access to a medical home was derived using an algorithm. This survey analysis also included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for socioeconomic status (SES) levels defined by federal poverty level (FPL): <133%; 133-199%; 200-299%; > or =300%., Results: Age group was significant in all but the 200-299% of FPL stratum. Severity of condition was significant in all strata. Race was significant in all but the > or =300% stratum. Maternal education was borderline significant in the lowest and highest strata. Insurance type/status was significant in all but the 133-199% of FPL stratum. Geographical location was significant in the lowest and highest strata. The language of the interview was only significant in the lowest stratum. The relationship of the respondent to the child was significant in the middle two strata. The total number of adults in the household was significant in the highest stratum, and the total number of children in the household was significant in the 200-299% of FPL stratum., Conclusions: Factors affecting access to a medical home differed among socioeconomic groups. Future research should explore the CSHCN population by income groups to better serve this population.

Objective: The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States., Methods: Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months., Results: Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor., Conclusions: Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

Aim: To assess racial/ethnic differences in diabetes self-management behaviors and quality of care in Texas., Methods: This cross-sectional study assessed self-management behaviors and quality of care in 1720 adults with diabetes in the 2002-2004 Texas Behavioral Risk Factor Surveillance Survey. Multiple logistic regression models were used for assessing the independent association between race/ethnicity, self-management behaviors, and quality of care variables controlling for covariates. SAS (SAS Institute Inc, 2002-2003) was used for statistical analysis., Results: Eighteen percent of Hispanics, 14% of Blacks, and 10% of Whites reported never performing home glucose testing. Seventeen percent of Hispanics, 11% of Blacks, and 10% of Whites reported never doing home foot exam. Thirty-two percent of Hispanics, 21% of Blacks, and 16% of Whites did not have an A1C test in the prior 12 months. Twelve percent of Hispanics, 10% of Blacks, and 6% of Whites did not have a dilated eye exam in the prior 12 months. Fifty-four percent of Whites, 42% of Blacks, and 40% of Hispanics received a flu shot. Forty-nine percent of Whites, 30% of Blacks, and 26% of Hispanics received a pneumonia shot. In adjusted models, Hispanics were more likely to be sedentary (OR, 1.64; 95% CI, 1.08-2.49) compared to Whites. Blacks did not differ significantly from Whites (OR, 1.46; 95% CI, 0.92-2.34). Hispanics (OR, 1.61; 95% CI, 1.01-2.57) and Blacks (OR, 1.83; 95% CI, 1.10-3.03) were more likely to get an annual foot exam by a provider compared to Whites. Hispanics (OR, 0.54; 95% CI, 0.34-0.85) and Blacks (OR, 0.58; 95% CI, 0.35-0.98) were less likely to get a pneumonia shot compared to Whites., Conclusions: Hispanics have poorer access to care and poorer health status compared to Whites or Blacks. Controlling for socioeconomic and access to care variables eliminated disparities in self-management but did not eliminate disparities in quality of diabetes care.

Objective: The purpose of this study was to assess the prevalence, distribution, severity, risk factors of, and response to musculoskeletal injuries to the low back, hand/wrist, and neck/shoulder among chiropractic students while receiving and/or administering adjustments/manipulation while attending a chiropractic college., Methods: The study was an epidemiologic survey of chiropractic students at all levels of training (n = 890) at one chiropractic college. A self-administered anonymous 3-paged questionnaire was used. The questionnaire was divided into sections for collecting data separately on injuries associated with receiving or administering chiropractic adjustments., Results: The response rate was 64.3% with 62.6% male respondents. The overall prevalence of injuries sustained in college was 31.5%, 44.4% of which was exacerbations of prior complaints. Injuries from receiving adjustments/manipulation were most prevalent to neck/shoulder (65.7%), whereas hand/wrist injuries were most common when administering adjustments (45.6%). The risk difference among students receiving adjustments was 81.6/1000 neck/shoulder injuries, and the etiologic fraction was 76.6%. The risk difference was 170/1000 hand/wrist injuries with etiologic fraction of 96.5% among students administering adjustments. Diversified, Gonstead, and upper cervical adjusting techniques were perceived to be the most injury-related., Conclusion: Some students enroll in a chiropractic college with preexisting injuries that can easily be exacerbated. Others sustain new injuries of moderate severity from receiving and administering adjustments. Potential risk factors may include height, body mass index, and nonexercising. The risk factors and mechanisms responsible for the high levels of hand/wrist injuries need further examination. This research identifies an important need to design a comprehensive and logical protocol to prevent injury to chiropractic students.

Objective: The purpose of this study was to report the prevalence, distribution, and severity of injuries to students before entering chiropractic college and to explore the possible demographic risk factors to these injuries., Methods: A cross-sectional survey was administered to first-year chiropractic students (n = 255) of one chiropractic college. Survey questions were adopted from the Standardized Nordic and Outcome Assessment Health Status Questionnaires. Data were collected on severity and period of last perception of low back, hand/wrist (HW), and neck/shoulder (NS) injuries of the students before attending chiropractic college., Results: The response rate was 98.8% (N = 252), among which 66.7% were males. Injury prevalence to low back, HW, and NS before attending chiropractic college was 50.4%, 40.1%, and 53.2%, respectively. Of the respondents, 48.8% were overweight/obese and they were more likely to report injuries to HW (odds ratio, 2.10; 95% confidence interval, 1.25-3.51) and NS (odds ratio, 1.70; 95% confidence interval, 1.04-2.73) compared with those with normal weight. Among those with injuries, the mean body mass index for the females was significantly greater than for the males., Conclusion: This study identified a high prevalence of musculoskeletal injuries among students before attending this particular chiropractic college. Only a small percentage of those injuries were severe enough to impede normal daily work. From this study sample, it seems that males entering this chiropractic college tend to report more injuries than females. However, females with high BMI seemed to report more previous injuries.

Child mortality is a persistent health problem faced by developing nations. In 2000 the United Nations (UN) established a set of high priority goals to address global problems of poverty and health, the Millennium Development Goals, which address extreme poverty, hunger, primary education, child mortality, maternal health, infectious diseases, environmental sustainability, and partnerships for development. Goal 4 aims to reduce by two thirds, between 2000 and 2015, the under-five mortality rate in developing countries. In sub-Saharan Africa from 2000 to 2006 these rates have only been reduced from 167 per 1,000 live births to 157, and 27 nations in this region have made no progress towards the goal. A country-specific database was developed from the UN Millennium Development Goal tracking project and other international sources which include age distribution, under-nutrition, per capita income, government expenditures on health, external resources for health, civil liberties, and political rights. A multiple regression analysis examined the extent to which these factors explain the variance in child mortality rates in developing countries. Nutrition, external resources, and per capita income were shown to be significant factors in child survivability. Policy options include developed countries' renewed commitment of resources, and developing nations' commitments towards governance, development, equity, and transparency.

Background: Cardiorespiratory fitness (CRF) and physical activity (PA) are inversely related to the occurrence of type 2 diabetes (T2D). Both play an important role in reducing serum ferritin (SF) concentration. Increased SF concentration is considered a contributing factor for developing T2D., Methods: The present cohort study investigated 5,512 adult participants enrolled in the Aerobics Center Longitudinal Study (ACLS) between 1995 and 2001. The subjects completed a comprehensive medical examination and a SF evaluation, and had been followed up until either diabetes onset, death, or the cut-off date of November 2007. Three CRF levels were categorized. SF quartile levels were defined by gender and menopausal status. The incidence of T2D was calculated for 10,000 person-years, and hazard ratios (HR) were computed to predict the incidence of T2D based on SF quartiles and CRF levels., Results: SF concentration was significantly higher in males than in females (148.5 +/- 104.7 ng/ml vs. 52.2 +/- 45.9 ng/ml) and was inversely associated with CRF levels. In the high CRF group, 32.7% of participants had a low SF concentration whereas only 16.8% of participants had a high SF concentration level. After adjusting for potential confounders, male participants in the highest SF quartile level had a 1.7 times (HR: 1.67, 95% CI: 1.05, 2.66; p-trend = 0.027) increased risk for developing T2D compared with those in the lowest SF quartile group., Conclusion: Lower SF concentration was associated with lower risk of developing T2D in those regularly participating in CRF. The findings from this study suggest that SF concentration could be used as a diabetic predictor. Based on these results clinicians and public health professionals should promote regular physical activity or fitness to reduce the incidence of T2D.

Safety climate survey was sent to 642 plants in 2003 to explore safety climate practices in the Korean manufacturing plants, especially in hazardous chemical treating plants. Out of 642 plants contacted 195 (30.4%) participated in the surveys. Data were collected by e-mail using SQL-server and mail. The main objective of this study was to explore safety climate practices (level of safety climate and the underlying problems). In addition, the variables that may influence the level of safety climate among managers and workers were explored. The questionnaires developed by health and safety executive (HSE) in the UK were modified to incorporate differences in Korean culture. Eleven important factors were summarized. Internal reliability of these factors was validated. Number of employees in the company varied from less than 30 employees (9.2%) to over 1000 employees (37.4%). Both managers and workers showed generally high level of safety climate awareness. The major underlying problems identified were inadequate health and safety procedures/rules, pressure for production, and rule breaking. The length of employment was a significant contributing factor to the level of safety climate. In this study, participants showed generally high level of safety climate, and length of employment affected the differences in the level of safety climate. Managers' commitment to comply safety rules, procedures, and effective safety education and training are recommended.

Purpose: To determine the role of RLIP76 in providing protection from radiation and chemotherapy. In the present report, we used RLIP76 to refer to both the mouse (Ralbp1) and the human (RLIP76) 76-kDa splice variant proteins (RLIP76) for convenience and to avoid confusion. In other reports, Ralbp1 refers to the mouse enzyme (encoded by the Ralbp1 gene), which is structurally and functionally homologous to RLIP76, the human protein encoded by the human RALBP1 gene., Methods and Materials: Median lethal dose studies were performed in RLIP76(-/-) and RLIP76(+/+) C57B mice after treatment with a single dose of RLIP76 liposomes 14 h after whole body radiation. The radiosensitivity of the cultured mouse embryonic fibroblasts and the effects of buthionine sulfoximine (BSO), amifostine, c-jun N-terminal kinase (JNK), protein kinase B (Akt), and MAPK/ERK kinase (MEK) were determined by colony-forming assays. Glutathione-linked enzyme activities were measured by spectrophotometric assays, glutathione by dithiobis-2-nitrobenzoic acid (DTNB), lipid hydroperoxides by iodometric titration, and aldehydes and metabolites by thiobarbitauric acid reactive substances and liquid chromatography-mass spectrometry (LCMS)., Results: RLIP76(-/-) mice were significantly more sensitive to radiation than were the wild-type, and RLIP76 liposomes prolonged survival in a dose-dependent manner in both genotypes. The levels of 4-hydroxynonenal and glutathione-conjugate of 4-hydroxynonenal were significantly increased in RLIP76(-/-) tissues compared with RLIP76(+/+). RLIP76(-/-) mouse embryonic fibroblasts were markedly more radiosensitive than RLIP76(+/+) mouse embryonic fibroblasts, despite increased glutathione levels in the former. RLIP76 augmentation had a remarkably greater protective effect compared with amifostine. The magnitude of effects of RLIP76 loss on radiation sensitivity was greater than those caused by perturbations of JNK, MEK, or Akt, and the effects of RLIP76 loss could not be completely compensated for by modulating the levels of these signaling proteins., Conclusion: The results of our study have shown that RLIP76 plays a central role in radiation resistance.

Objectives: The primary objective was to compare the efficacy and tolerability of quetiapine and risperidone in the treatment of mood symptoms, drug cravings, and drug use in outpatients with concurrent DSM-IV-defined bipolar I or II disorder and cocaine or methamphetamine dependence., Method: Men and women of all ethnic origins, 20 to 50 years of age, were eligible to participate. Persons were excluded if they were inpatients, met DSM-IV criteria for substance-induced mood disorder, had any other substance dependence, were euthymic or suicidal, had any life-threatening illnesses, or were currently receiving antipsychotic medications. Duration of the trial was 20 weeks. Study participants attended weekly visits and were evaluated for mood symptoms, drug cravings, drug use, and medication side effects. Treatment outcomes were analyzed using linear mixed models. Fixed-effects terms for medication group, study week, and group-by-study-week were included in the models. The study was conducted between October 2002 and November 2006., Results: Of 124 consenting outpatients, an evaluable sample of 80 patients who attended baseline and at least 1 follow-up study visit was formed. The mean +/- SD exit dose for quetiapine was 303.6 +/- 151.9 mg/day and 3.1 +/- 1.2 mg/day for risperidone. Both quetiapine (N = 42) and risperidone (N = 38) significantly improved manic and depressive symptoms and reduced drug cravings (p < .0005) compared to baseline. Decreased drug cravings were related to less frequent drug use (p = .03). The 2 medications did not significantly differ in their effects on mood symptoms, drug craving, or drug use., Conclusions: Relative to baseline mood and drug-craving status, both quetiapine and risperidone were associated with manic, mixed, and depressive symptom improvement and reduced drug cravings. Both medications were well tolerated. The interpretation of these results is limited by the absence of a placebo control., Trial Registration: clinicaltrials.gov Identifier: NCT00227123.

Background: The purpose of this study was to compare disability and functional limitations among elderly Asian American subgroups using datasets from the National Health Interview Survey 2001-2003., Methods: This retrospective cross-sectional study analyzed whether activities of daily living (ADL) and instrumental ADL (IADL) disabilities were different among Asian American subgroups in the United States using data retrieved from the 2001-2003 National Health Interview Survey. For comparing all Asian American subgroups, χ(2) analysis was applied for the bivariate comparisons., Results: Rates of 7.1% and 12.2% for ADL and IADL disability, respectively, within Asian American group were found. The elder Chinese subgroup accounted for the highest ADL and IADL disability (11.6% and 17.3%, respectively, p < .05). Being female, not married, and older was associated with higher ADL and IADL disability (p < .05)., Conclusions: The findings of the study highlight the intergroup variability among the elder Asian American subpopulations.

Objective: BMI and waist circumference are used to define risk from excess body fat. Limited data in women suggest that there may be racial/ethnic differences in visceral adipose tissue (VAT) at a given BMI or waist circumference. This study tested the hypothesis that racial/ethnic differences exist in both men and women in the relationship of anthropometric measures of body composition and computed tomography (CT)-determined VAT or subcutaneous adipose tissue (SAT)., Methods and Procedures: Subjects included 66 African American, 72 Hispanic, and 47 white men and women, aged > or =45. Waist circumference and BMI were measured using standard methods. Total abdominal and L4L5 VAT and SAT were measured using CT., Results: Among both men and women, groups did not differ in waist circumference or BMI. White men had greater L4L5 VAT than African-American men, and both white and Hispanic men had greater total VAT than African-American men. Among women, Hispanics and whites had greater L4L5 VAT than African Americans, and Hispanics had greater total VAT than African Americans. The slope of the linear relationship between BMI or waist circumference and VAT was lower in African Americans than in Hispanics and/or whites., Discussion: Middle-aged and older African-American men and women had lower VAT despite similar BMI and waist circumference measurements. Altered relationships between anthropometric measures and VAT may have implications for defining metabolic risk in different populations. Different waist circumference or BMI cutoff points may be necessary to adequately reflect risk in different racial/ethnic groups.

Objectives: To examine the association between female adolescents in high school who use illicit drugs and seriously consider attempting suicide., Methods: Data were analyzed from the 2003 Youth Risk Behavioral Surveillance System. Variables for suicidal thought, illicit drugs, and covariables were chosen to explore the association., Results: Seriously considering attempting suicide was associated with Hispanics, suburban youth, use of marijuana, inhalants, methamphetamines, and steroids without MD's prescription., Conclusions: Greater effort may be necessary to raise awareness about the physical and mental health status of Hispanic adolescents and to ensure good mental health programs are available.

Introduction: Pulmonary tuberculosis (PTB) can result in anatomic and functional changes that are associated with pulmonary impairment after tuberculosis that occurs frequently and varies in severity. We completed the St. George Respiratory Questionnaire (SGRQ), a health-related quality-of-life (HRQoL) instrument validated for several types of lung disease, for patients in whom PTB or latent tuberculosis infection (LTBI) has been diagnosed. We measured HRQoL pattern changes and the usefulness of the SGRQ in their ascertainment., Methods: Participants with known pulmonary function and a history of PTB or LTBI completed HRQoL questionnaires. The SGRQ was validated for content and construct using pulmonary function tests and the Medical Outcomes Study questionnaire. Internal consistency and test-retest methods assessed reliability. Significance of findings was determined with one-way analysis of variance with between-group comparisons., Results: Over 15 months, 313 subjects completed the SGRQ. The SGRQ was valid and reliable in the study population (intraclass correlation, 0.927; p<0.01; Cronbach alpha, 0.93). The mean total score for posttuberculosis patients was significantly higher than for that for LTBI score (23.5 [SE, 2.2] vs 10.3 [SE, 1.0], respectively; p<0.001)., Conclusions: We validated the SGRQ in a diverse population microbiologically cured of tuberculosis and found a mean 13.5-U difference in SGRQ score between these patients and a comparison group with similar risk factors (p<0.001). This difference indicates impairment after PTB has a substantial impact on human health worldwide. The microbiological cure of tuberculosis is not sufficient to avert chronic health loss. More aggressive treatment of LTBI and other case-preventing strategies is warranted worldwide.

Objective: To assess the differences in health behavior between multiple-member and single-member households by gender., Methods: Face-to-face household survey interviews were conducted. The relationship between health behaviors and living arrangement was assessed by adjusting for SES., Results: Women living alone exercised more and ate less food high in fat. More highly educated men were less likely to exercise 5 or more times a week than high school or less educated men., Conclusions: By analyzing local data, a profile can be established to develop and implement appropriate public health programs aimed at these various target communities for effective intervention and healthy change in the community.

Background: Pulmonary impairment subsequent to a cure of pulmonary tuberculosis has been described only in selected populations., Methods: We compared pulmonary function in a case-control study of 107 prospectively identified patients with pulmonary tuberculosis who had completed at least 20 weeks of therapy and 210 patients with latent tuberculosis infection (LTBI)., Results: Both groups had similar risk factors for pulmonary impairment. Impairment was present in 59% of tuberculosis subjects and 20% of LTBI control subjects. FVC, FEV1, FEV1/FVC ratio, and the midexpiratory phase of forced expiratory flow were significantly lower in the treated pulmonary tuberculosis patients than in the comparison group. Ten patients with a history of pulmonary tuberculosis (9.4%) had less than half of their expected vital capacity vs one patient (0.53%) in the LTBI group. Another 42 patients (39%) with tuberculosis had between 20% and 50% of the expected vital capacity vs 36 patients with LTBI (17%). After adjusting for risk, survivors of tuberculosis were 5.4 times more likely to have abnormal pulmonary function test results than were LTBI patients (p > 0.001; 95% confidence interval, 2.98 to 9.68). Birth in the United States (odds ratio [OR], 2.64; p = 0.003) and age (OR, 1.03; p = 0.005) increased the odds of impairment. Pulmonary impairment was more common in cigarette smokers; however, after adjusting for demographic and other risk factors, the difference did not reach statistical significance (p = 0.074)., Conclusions: These findings indicate that pulmonary impairment after tuberculosis is associated with disability worldwide and support more aggressive case prevention strategies and posttreatment evaluation. For many persons with tuberculosis, a microbiological cure is the beginning not the end of their illness.

There is increasing interest in the identification of predictors of risk for in-hospital mortality due to acute myocardial infarction (AMI). This study identified significant predictors of in-hospital mortality among AMI patients using a patient level clinical database. The study population consisted of 4167 cases admitted between October 1999 and April 2001 with a principal diagnosis of AMI to 36 hospitals in three US states. Of the 182 available variables in the clinical data set, 30 variables were used as candidate predictors, and 19 showed significant univariate association with AMI in-hospital mortality. By applying multiple logistic regression and stepwise selection, a final prediction model for AMI in-hospital mortality was developed. Variables included in the final model were age, arrived from cardiac rehabilitation centre, cardiopulmonary resuscitation (CPR) on arrival, Killip class, AMI with co-morbid conditions, AMI with complications, percutaneous transluminal coronary angioplasty (PTCA) performed, beta-blockers given, angiotensin-converting enzyme (ACE) inhibitors given, Plavix given. A 10-variable in-hospital mortality prediction model for AMI patients, which includes both risk factors and beneficial treatment procedures, was developed. chi(2) goodness of fit test suggested a good fit for the model.

Background: The purpose of this study was to determine the prevalence of high blood pressure (HBP) and associated risk factors in school children 8 to 13 years of age., Methods: Elementary school children (n = 1,066) were examined. Associations between HBP, body mass index (BMI), gender, ethnicity, and acanthosis nigricans (AN) were investigated using a school based cross-sectional study. Blood pressure was measured and the 95th percentile was used to determine HBP. Comparisons between children with and without HBP were utilized. The crude and multiple logistic regression adjusted odds ratios were used as measures of association., Results: Females, Hispanics, overweight children, and children with AN had an increased likelihood of HBP. Overweight children (BMI > or = 85th percentile) and those with AN were at least twice as likely to present with HBP after controlling for confounding factors., Conclusion: Twenty one percent of school children had HBP, especially the prevalence was higher among the overweight and Hispanic group. The association identified here can be used as independent markers for increased likelihood of HBP in children.

Objectives: To examine socioeconomic characteristics associated with planned methadone maintenance treatment (MMT)., Methods: We performed multiple logistic regressions using data from the 1998 Treatment Episode Data Set, which tracks admissions for substance abuse treatment., Results: MMT was more prevalent among heroin users than nonheroin users. Among heroin users, females, Hispanics, Southerners, the employed, and those who are not homeless or in jail are more likely to be planned to receive MMT. Among nonheroin users, females were less likely to be planned for MMT., Conclusions: Greater effort may be necessary to extend MMT to vulnerable populations.

Background: For the purpose of reducing inflammation causing radiculopathy, lumbar transforaminal and interlaminar epidural injections deliver corticosteroid to the vicinity of the spinal nerve, nerve roots, and intervertebral disc. Although acceptable, the efficacy of transforaminal injections is limited and variable. An indwelling epidural catheter offers the distinct advantages of delivering greater concentrations of corticosteroid directly to the site of pathology, over an extended duration. This extended exposure to corticosteroid may benefit the site of pathology., Objective: To evaluate the safety and efficacy of corticosteroid administered through a disposable indwelling epidural catheter and infusion pump to treat pain and dysfunction caused by lumbosacral radiculopathy., Study Design: A pilot investigation consisting of a prospective consecutive series of 10 patients, conducted in a specialty hospital., Methods: An indwelling epidural catheter dispensed corticosteroid into the epidural space at the suspect level of pathology. The catheter was attached to an external, lightweight, spring-pressurized, and disposable reservoir pump holding 8.0 mg dexamethasone diluted with bacteriostatic normal saline to a total volume of 72 ml. After each patient's hospital discharge, the medication was administered into the epidural space at a rate of 1 ml per hour over a 72-hour period. Follow-up at six weeks was achieved in 100% of the patients., Outcome Measures: The outcome measures, recorded at pre-treatment and six weeks post-treatment were assessed using: the Visual Analog Scale (VAS); MOS 36-Item Short-Form Health Survey (SF-36); Pain Symptoms Survey; Oswestry Disability Index; Beck Inventory; Work History Survey; Work Index; Expectations Met Survey; Activities of Daily Living Form; and the Satisfaction With Treatment Form., Results: There was no patient morbidity or mortality associated with this treatment, and patients, on average, experienced decreased pain levels after treatment. Mean delta VAS improvement was 4.1 (SD = 2.6, R =-9.6 to +1.5). The mean percent improvement was 46.7%., Conclusions: Safe and effective treatment of lower extremity radiculopathy symptoms may be obtained with this new method.

The objective of this study was to identify the behavior risk factors associated with suicide attempt in adolescents and to determine gender-specific patterns of risk factors. In 2001, the Center for Disease Control and Prevention (CDC) conducted National Youth Risk Behavior Survey for 13,601 high school students in the U.S. Data were analyzed with logistic regressions to identify the risk behaviors. New significant risk factors (being offered illegal drugs at school, being abused by a boyfriend/girlfriend, gender, and ethnicity) were identified for suicidal attempt in adolescents. Patterns of risk behaviors differed among male and female groups. Several new risk behaviors associated with suicide attempt in adolescents were identified. There were notable differences in risk behaviors between two gender groups, especially in the area of depression. These findings could have potentially important implications for preventing adolescent suicide attempts.

Purpose: To assess risk factors for type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) with the hypothesis that risk for T2DM in children would be associated with an increase in risk factors for CVD., Methods: Subjects from a group of Mexican-American school children (aged 10-12 years) identified to be at risk for T2DM, and their siblings, were selected for this study. There were 68 children with acanthosis nigricans (AN+), and 71 without AN (AN-). Both AN+ and AN- children were assessed for T2DM and CVD risk factors. Probands and siblings were evaluated by physical examination, family history, and fasting serum parameters: glucose, insulin, body mass index (BMI), serum lipoproteins, and oxidized lipids. Data were analyzed by descriptive, univariate, and multivariate procedures., Results: BMI, waist/hip ratio, systolic and diastolic blood pressure were all significantly higher (p <.002) in AN+, whereas Tanner stages were similar in both groups. Fasting serum glucose was in the normal range, whereas insulin was elevated in AN+ compared with AN- (30.0 +/- 1.9 microU/mL vs. 14.8 +/- 1.0 p <.0001). Insulin resistance as assessed by the homeostasis assessment model (HOMA-IR) was elevated in both groups, although higher among AN+ (p <.0001). High-density lipoprotein-cholesterol (HDL-C) was lower (6.2 mg/dL) in the AN+ group (p <.003). The lower HDL-C in AN+ was associated with elevated triglycerides and a higher serum total cholesterol TC/HDL-C ratio when contrasted with the AN- values (145.9 +/- 7.6 mg/dL vs. 97.1 +/- 0.07, p <.0001; 4.1 +/- 0.2 vs. 3.4 +/- 0.1, p <.0001, respectively). In addition to the high prevalence of overweight/obesity (BMI > 85th percentile) in this population (76.3%, 106/139), elevated insulin (59.7% >15 microU/mL), low HDL-C (27.3% <40 mg/dL), and elevated low-density lipoprotein cholesterol (LDL-C) (41.0% >100 mg/dL) were also detected., Conclusions: The altered metabolic pattern observed in this group of Mexican-American children is characteristic of metabolic syndrome, a condition associated with obesity and increased risk for both T2DM and CVD in adults. This study points to the value of BMI and acanthosis nigricans as easily accessible markers for children and nuclear families at increased risk for developing T2DM and CVD.

Background: Fibromyalgia (FM), one of the most common musculoskeletal disorders, is associated with high levels of impaired health and inadequate or limited symptom relief. The cause of this complex syndrome is unknown, and there is no known cure. Numerous research results indicate that a combination of physical exercise and mind-body therapy is effective in symptom management. T'ai Chi, an ancient Chinese exercise, combines physical exercise with mindbody therapy., Purpose: To investigate the effects of T'ai Chi exercise on FM symptoms and health-related quality of life., Design: Pilot study, one group pre-to-post posttest design., Methods: Participants with FM (n = 39) formed a single group for 6 weeks of 1-hour, twice weekly T'ai Chi exercise classes. FM symptoms and health-related quality of life were measured before and after exercise., Findings: Twenty-one participants completed at least 10 of the 12 exercise sessions. Although the dropout rate was higher than expected, measurements on both the Fibromyalgia Impact Questionnaire (FIQ) (Buckhardt, Clark, & Bennett, 1991) and the Short Form-36 (SE-36) (Ware & Sherbourne, 1992) revealed statistically significant improvement in symptom management and health-related quality of life., Implications for Nursing Research: Knowledge of interventions to enhance health for the patient with musculoskeletal problems is a National Association of Orthopaedic Nurses priority. Tai Chi is potentially beneficial to patients with FM. Further research is needed to support evidence-based practice.