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One Third (one + third)
Kinds of One Third Selected AbstractsEU Enlargement to Turkey?EUROCHOICES, Issue 1 2005Rural Areas: EU Erweiterung um die Türkei?, The Challenges Anead for Agriculture Summary EU Enlargement to Turkey? The Challenges Ahead for Agriculture and Rural Areas In December 2004 the European Council agreed that accession negotiations with Turkey could begin in October 2005. Although the Copenhagen political criteria have been decisive so far, the criteria relating to the functioning of markets and ability to implement EU legislation will weigh heavily in the negotiations. Despite recent policy reforms, Turkey's agriculture still enjoys levels of protection similar or higher than those of the EU, but its gross value added per worker is relatively very low. One third of Turkey's employment is in agriculture, where most farms are small. The animal health situation is far below the standard achieved in the EU. Food supply chains are fragmented and inefficient. To survive and compete within the single market of the EU, the agricultural and food sectors must undergo deep structural change, which will have far-reaching economic and social repercussions. Projections according to current policy trends show that Turkey could take over one-third of the total cohesion budget allocation. However, the scalingdown or delaying of budget transfers would be short-sighted. If the EU accepts Turkey as a member, it would be in the interest of the EU as a whole that Turkey's economy - and especially its backward rural economy - should embark on a sustainable growth path as soon as possible. Elargir l'UE à la Turquie ? Les défis en perspective pour l'agriculture et les zones rurales. En decembre 2004, le Conseil de l'Union europ6enne a decide douvrir des negociations d'adhesion avec la Turquie en octobre 2005. A la difference de ce qui s'est passe jusqu'ici, le fonctionnement des marches et la capacite a mettre en vigueur l'acquis communautaire seront les crittres principaux, a la place des crittres politiques de Copenhague. Malgrk des reformes politiques recentes, l'agriculture turque profite toujours d'un taw de protection extkrieure analogue a celui de I'UE ou plus Clevi Cependant, sa valeur ajoutee brute par actifest relativement trks basse. Le tiers des emplois en Turquie se trouve dans le secteur agricole, oi,la plupart des exploitations sont de peute taille. La situation sanitaire du cheptel se situe bien au-dessous du niveau de I'UE. Les filieres agro-alimentaires sont fragmentees et peu efficaces. Pour être en mesure de faire face a la concurrence du Marche unique europken, les secteurs agricoles et alimentaires en Turquie devront subir une restructuration profonde, laquelle aura des consequences economiques et sociales de grande envergure. Des projections basees sur les tendances politiques actuelles montrent que la Turquie pourrait bkneficier de plus du tiers des fonds de cohesion de I'UE. Ceci dit, une decision de diminuer ou de dfikrer les transferts budgetaires serait faire preuve d'un manque de prevoyance. Si I'UE accepte la Turquie comme membre, il serait dans I'intkr8t de l'ensemble de 1'Union que I'Cconomie turque - et surtout son economie rurale arrierke - s'engage aussitbt que possible sur un sentier de croissance rapide et durable. EU Erweiterung um die Tükei? Herausforderungen für die Landwirtschaft und ländliche Räume Im Dezember 2004 hat der Europasche Rat beschlossen, dass im Oktober 2005 die Beitnttsverhandlungen mit der Turkei beginnen konnen Auch wenn die Kopenhagener politischen Kriterien bisher entscheidend waren, werden die Kriterien hinsichtlich der Funktionsfhhigkeit der Markte und die Fahigkeit, die EU Gesetzgebung lmplementieren zu konnen, besonderes Gewicht haben. Trotz der letzten Politikreformen 1st die Agrarprotektion in der Turkei gleich hoch oder hoher als in der EU, aber die turkische Bruttowertschopfung le Arbeitskraft ist relativ sehr klein Ein Dnttel der turklschen Arbeitskrafte sind in der Landmrtschaft beschaftigt und die meisten Betriebe sind klein Die Gesundheit der Tiere 1st weit unter den Niveau der EU Die Nahrungsmittel-Zuheferungskette 1st klem struktunert und ineffizient Der Agrar- und Ernahrungssektor kann im Gemeinsamen Markt nur dann uberleben und wettbewerbsfahig sein, wenn em intensiver Strukturwandel mit weit reichenden okonomischen und sozialen Wirkungen einsetzt. Projektionen der gegenwartigen Politikentwicklungen zeigen, dass die Turkei uber ein Dnttel der Mittel des Kohasionsfonds erhalten wurde. Doch wurde die Kurzung oder Veaogerung der Finanzhilfen kurzsichtig sen Wenn dre EU die Turkei als Mitglied akzeptiert, 1st es im Interesse der EU insgesamt, dass die Turkei und insbesondere ihre ruckstandige Agramirtschaft so schnell wie moglich auf einen stabden Wachstumspfad kommt. [source] The Christian Religion in Modern European and World History: A Review of The Cambridge History of Christianity, 1815,2000HISTORY COMPASS (ELECTRONIC), Issue 6 2008David Lindenfeld Volumes 8 and 9 of the Cambridge History, representing the work of 72 scholars, reflect two major recent historiographical trends: 1) the increased attention paid to religion in modern European history, and 2) the increasing importance of Christianity in as a topic in world history. While these volumes serve to summarize the work already done in the first field, with articles on a wide variety of European countries, they should significantly move the second field forward by bringing together the work of specialists on many different parts of the world in a single place. Volume 8 summarizes scholarship on the Western religious revivals of the nineteenth century, both Catholic and Protestant. By integrating religion and politics, it also presents a more complex picture of the formation of European national identities than Benedict Anderson's Imagined Communities suggests. One third of the volume is devoted to the spread of Christianity to the non-Western world. In Volume 9, the European and world history perspectives are more evenly interspersed. Major themes include the papacy, ecumenism, colonialism, Pentecostalism, and the independent churches of Africa and Asia. The 1960s emerge as a turning point, if for different reasons in different parts of the world. This was the decisive period of secularization in Europe, and the final section documents the social and cultural impact of that shift, particularly on the arts. Although there are inevitable gaps in coverage, these volumes will serve as an invaluable research tool for years to come. [source] Low prevalence of RAS-RAF -activating mutations in Spitz melanocytic nevi compared with other melanocytic lesionsJOURNAL OF CUTANEOUS PATHOLOGY, Issue 6 2007James O. Indsto One of 22 (4.5%) SN tested showed an HRAS G61L mutation. Another lesion, a ,halo' SN, showed a BRAF V600E (T1796A) mutation. BRAF V600E mutations were found in two thirds (20/31) of CBN, while a further 19% (6/31) showed NRAS codon 61 mutations. One third of CMM (10/30) had various BRAF mutations of codon 600, and a further 6% (2/31) showed NRAS codon 61 mutations. Seventeen SN tested for loss of heterozygosity (LOH) at 9p and 10q regions, known to be frequently deleted in melanoma, showed LOH at the 9p loci D9S942 and IFNA. A further lesion was found with low-level microsatellite instability at one locus, D10S214. The low rate of RAS-RAF mutations (2/22, 9.1%) observed in SN suggests that these lesions harbor as yet undetected activating mutations in other components of the RAS-RAF-MEK-ERK-MAPK pathway. Germline DNA from members of 111 multiple-case melanoma families, representing a range of known (CDKN2A) and unknown predisposing gene defects, was analyzed for germline BRAF mutations, but none was found. [source] Characteristics and Predictors of Aortic Plaques in Patients with Transient Ischemic Attacks and StrokesJOURNAL OF NEUROIMAGING, Issue 1 2004Abutaher M. Yahia MD ABSTRACT Objective. To identify the prevalence and characteristics of aortic atherosclerotic plaque disease and its association with cerebrovascular risk factors in patients with cerebral ischemic events. Background. Aortic atheroma is associated with ischemic stroke. Its characteristics, including morphology and distribution among different stroke subtypes, are not well described. Method. From July 2000 to August 2001, all patients evaluated by transesophageal echocardiography (TEE) with diagnoses of transient ischemic attacks (TIAs) and strokes were prospectively studied. Demographics, including age, gender, ethnicity, cerebrovascular risk factors, and stroke subtypes, were collected. Results. Thoracic aortic atheromas (TAAs) were present in 141 of 237 patients (59%) (mean age = 59 ± 14, 119 [50%] male). Mild plaque (<2mm) was present in 13 of 237 (5%), moderate plaque (2,4 mm) in 49 (21%), severe plaque (,4 mm) in 79 (33%), and complex plaque in 64 (27%). Patients' ages (odds ratio [OR] = 1.05, confidence interval [CI] 1.03,1.08, P < .001), coronary artery disease (OR = 2.2, CI 1.02,4.8, P < .042), and patent foramen ovale (PFO) (OR = 0.39, CI 0.22,0.70, P < .002) were associated with the severity and complexity of aortic plaque. In multivariate analysis, age (OR = 1.06, CI 1.03,1.08, P < .001) and the presence of PFO (OR = 0.35, CI 0.18,0.65, P < .001) continued to be significant to the severity and complexity of aortic atheroma. Gender, history of stroke, hypertension, diabetes mellitus, hyperlipidemia, and history of smoking were not associated with TAA. Conclusion. One third of TAA plaques are severe and complex in nature and more frequently present in the descending aorta and the arch of the aorta than in the ascending aorta. TEE should be considered for the early detection and treatment of TAA in patients without identified causes of stroke. [source] Human Papillomavirus and Cervical Cancer Knowledge, Health Beliefs, and Preventative Practices in Older WomenJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 3 2010Kymberlee Montgomery ABSTRACT Objective: To explore knowledge of Human Papillomavirus (HPV) and cervical cancer, health beliefs, and preventative practices in women 40 to 70 years. Design: Cross-sectional descriptive. Setting: Three urban ambulatory Obstetrics and Gynecology offices connected with a teaching hospital's Department of Obstetrics and Gynecology in the Mid-Atlantic section of the United States. Participants: A convenience sample of 149 women age 40 to 70. Methods: To assess HPV and cervical cancer knowledge, health beliefs, and preventative practices a self-administered survey, the Awareness of HPV and Cervical Cancer Questionnaire was distributed to women as they waited for their well-woman gynecologic exam. Results: The mean knowledge score was 7.39 (SD=3.42) out of 15. One third of the questions about the relationship of HPV and risks for cervical cancer were answered incorrectly by more than 75% of these women. Although most appreciate the seriousness of cervical cancer, they believed themselves not particularly susceptible. Conclusion: There is a need for HPV and cervical cancer awareness and education for women older than age 40. Women's health care professionals are well positioned to act as a catalyst to improve HPV and cervical cancer knowledge, health beliefs, and preventative practice to ensure optimum health promotion for all women. [source] Perineal Trauma and Postpartum Perineal Morbidity in Asian and Non-Asian Primiparous Women Giving Birth in AustraliaJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 4 2008Hannah Dahlen ABSTRACT Objectives: To describe the postpartum perineal morbidity of primiparous women who had a vaginal birth and compare outcomes between Asian and non-Asian women in the first 2 days following the birth and at 6 and 12 weeks postpartum. Design: Data from a randomized clinical trial of a perineal management technique (perineal warm packs) were used to address the study objective. Setting: Two maternity hospitals in Sydney, Australia. Participants: Primiparous women who had a vaginal birth in the trial were included (n=697). One third of the women were identified as "Asian." Results: Compared with non-Asian women, Asian women were significantly more likely to have an episiotomy; require perineal suturing; sustain a third- or fourth-degree perineal tear; and report their perineal pain as being moderate to severe on day 1 following the birth. Asian women were less likely to give birth in an upright position or to resume sexual intercourse by 6 or 12 weeks following the birth. Conclusion: More research is needed into methods that could reduce the high rates of perineal trauma experienced by Asian women, and midwives need to be able to offer appropriate support for Asian women. [source] Urban-Rural Flows of PhysiciansTHE JOURNAL OF RURAL HEALTH, Issue 4 2007Thomas C. Ricketts PhD ABSTRACT:,Context:Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies. Purpose: To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs. Methods: Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003. Findings: Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003. Conclusions: The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population. [source] Salvage Conservation Laryngeal Surgery after Irradiation Failure for Early Laryngeal CancerTHE LARYNGOSCOPE, Issue 3 2006Mehdi Motamed FRCS Abstract Objectives: One third of recurrences after radiotherapy for early laryngeal cancer remain localized. Salvage conservation laryngeal surgery, with total laryngectomy held as reserve, is a surgical management option that is arguably underused. The aim of this review is to report the oncologic and functional results of salvage conservation laryngeal surgery, using the external or the endolaryngeal laser approach. Study Design: Review article. Methods: A computerized literature search of the Medline database from 1985 to 2005 was performed using the following search strategy: laryngeal neoplasm/AND salvage therapy/. Studies with a sample size less than 10 and an average follow-up of less than 24 months were excluded from analysis. The oncologic outcome, functional outcome, length of hospitalization, and the frequency of complications were recorded. Results: The average reported local control rate for recurrent early glottic cancer after radiotherapy salvaged by using the external or the endolaryngeal laser approach is 77% and 65%, respectively. The average reported overall local control rate, including cases that subsequently required total laryngectomy, is 90% and 83%, respectively. The endolaryngeal approach when compared with the extralaryngeal approach does have the advantage of reduced complications, lesser requirement for tracheostomy and nasogastric feeding, and shortened hospitalization time. Conclusions: Conservation laryngeal surgery is a safe and effective treatment for recurrent localized disease after radiotherapy for early stage glottic cancer. Local control may be achieved without the sacrifice of laryngeal function, and total laryngectomy may be held in reserve as the ultimate option for salvage without compromising ultimate survival significantly. [source] Hearing Loss in Union Army Veterans from 1862 to 1920,THE LARYNGOSCOPE, Issue 12 2004Ryan K. Sewell MD Abstract Objectives: To examine the prevalence of hearing loss (HL) in Union Army (UA) veterans by year, birth cohort, and occupation, and to compare Civil War pension and contemporary disability programs by examining monthly dollar awards. Study Design: A retrospective review of medical records for 17,722 UA veteran pension applicants, a subset of some 35,000 soldiers retrieved randomly from the Military Archives. Methods: The diagnosis of HL was based on review of medical records, which used gross measurements because of the unavailability of audiometric testing. Results: One third (5,891 or 33%) of pensioners sampled received compensation for HL. The veterans with HL suffered predominantly from left-sided HL (4,091 or 70%), which is consistent with noise-induced HL in a right-handed individual firing a rifle. Comparison of civilian occupations reveals minimal variation in prevalence of HL. Civil War pensions for unilateral HL averaged $134.04 per year, representing nearly one third of the average annual income in 1890. Bilateral HL received nearly twice that amount. Today, military veterans receive $1,248 annually for unilateral loss and $27,288 annually for bilateral loss. Social Security disability benefits are granted only for bilateral HL, with an average 60-year-old individual receiving $11,400 per year. Conclusion: HL was a common disability among UA Civil War veterans, with noise exposure a likely etiology for the HL. The differing levels of compensation for HL may reflect differing perceptions on the incapacitating effects of HL. [source] Cold Machine Perfusion Versus Static Cold Storage of Kidneys Donated After Cardiac Death: A UK Multicenter Randomized Controlled TrialAMERICAN JOURNAL OF TRANSPLANTATION, Issue 9 2010C. J. E. Watson One third of deceased donor kidneys for transplantation in the UK are donated following cardiac death (DCD). Such kidneys have a high rate of delayed graft function (DGF) following transplantation. We conducted a multicenter, randomized controlled trial to determine whether kidney preservation using cold, pulsatile machine perfusion (MP) was superior to simple cold storage (CS) for DCD kidneys. One kidney from each DCD donor was randomly allocated to CS, the other to MP. A sequential trial design was used with the primary endpoint being DGF, defined as the necessity for dialysis within the first 7 days following transplant. The trial was stopped when data were available for 45 pairs of kidneys. There was no difference in the incidence of DGF between kidneys assigned to MP or CS (58% vs. 56%, respectively), in the context of an asystolic period of 15 min and median cold ischemic times of 13.9 h for MP and 14.3 h for CS kidneys. Renal function at 3 and 12 months was similar between groups, as was graft and patient survival. For kidneys from controlled DCD donors (with mean cold ischemic times around 14 h), MP offers no advantage over CS, which is cheaper and more straightforward. [source] Access to dental care by young South Australian adultsAUSTRALIAN DENTAL JOURNAL, Issue 3 2003KF Roberts-Thomson Abstract Background: Despite reported concern over the dental care of young adults little research has been done on their use of dental services in Australia. The aim of this study was to investigate the patterns of dental utilization of young South Australian adults aged 20,24 years. Methods: A random sample of 2300 young adults was selected from the electoral roll. Partial or complete addresses and possible phone numbers were obtained for 1921 persons. Telephone interviews were conducted for 1261 subjects to obtain information on socio-demographics, health behaviour and dental visiting (response rate 65.6 per cent). Results: One third of young adults (34 per cent) had not made a dental visit in the previous two years and 38 per cent usually visited for a problem rather than a check-up. Making a dental visit in the last two years was significantly associated with a number of socio-demographic variables including age and gender, with holders of private dental insurance and those who have not avoided care because of cost having higher odds of making a visit and males and government concession card holders having lower odds of visiting. Usual reason for visiting a dentist for a problem was significantly associated with no private dental insurance, holding a government concession card, no tertiary education and avoiding care because of cost. Conclusions: This study suggests that demographic and economic factors influenced use of dental services and reason for visiting of young South Australian adults. [source] Does sweeping of membranes beyond 40 weeks reduce the need for formal induction of labour?BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 6 2002S.F. Wong Objective To assess the efficacy of sweeping of membranes beyond 40 weeks of gestation in reducing the incidence of induction of labour, when induction was planned at 42 weeks. Design Prospective randomised controlled trial. Setting A regional obstetric unit in Hong Kong. Population and methods A total of 120 women with certain gestational age, determined by early pregnancy ultrasound scan, were recruited from 1st July, 1998 to 31st December, 1999. Sixty women were randomly allocated to sweeping of membranes and the other 60 women acted as control. The satisfaction for women allocated to sweeping of membranes was assessed by a questionnaire after the procedure. The two groups were assessed on intention-to-treat basis. Main outcome measures The incidence of formal induction of labour was compared between the two groups. Possible complications of sweeping of membranes such as rupture of membranes, intrapartum infection, postpartum infection, and neonatal infection were also assessed. Maternal and perinatal outcomes were also assessed. Results The recruitment to delivery interval was significantly shorter among women who had sweeping of membranes (3.2 versus 4.2 days, P < 0.05). The incidence of induction of labour was comparable (35.5%versus 38%, RR 0.91, 95% CI 0.57,1.46). The incidences of caesarean section and assisted vaginal delivery were comparable. The incidences of premature rupture of membranes, intrapartum, and postpartum infection were comparable. The perinatal outcomes were also comparable between the two groups. Up to 70% of women found that this procedure was associated with significant discomfort. One third of these women complained of significant pain. Conclusions Sweeping of membranes beyond 40 weeks does not reduce the need for formal induction of labour at 42 weeks. Although it is safe, the majority of women felt uncomfortable during the procedure. [source] Safety and efficacy of carotid stenting in the very elderly,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 5 2010Arthur Grant MD Abstract Background: Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (,80-year-old) are one subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% was reported in very elderly patients during the roll-in phase of Carotid Revascularization Endarterectomy versus Stent Trial (CREST). We are reporting on a large clinical series of CAS with independent neurological assessment in the very elderly. Methods: Between 1994 and 2008, a consecutive series of 418 CAS patients (,80-year-old) were treated at four high-volume centers with extensive CAS experience. Independent neurologic assessment was performed after CAS procedures. Thirty-day follow-up information was available in 389 patients. Results: The average age was 83.2 ± 2.8 years. Most patients were male (63.2%), and the target lesion carotid stenosis was asymptomatic in two-thirds (68.2%) of patients. The majority of patients treated with CAS had a history of coronary artery disease (74.4%), hypertension (87.8%), and dyslipidemia (71.1%). One third (30.1%) were diabetic and more than half (56.5%) were current or former smokers. Embolic protection devices (EPD) were used in 78.7% of cases with the CAS procedure being performed before EPD availability being the most common reason for not using them. The overall 30-day incidence of stroke and death was 2.8% (11/389). The cumulative incidence of major cardiovascular events (stroke, death, or myocardial infarction) during that time period was 3.3% (13/389). Conclusions: This large series of CAS with independent neurologic assessment is convincing evidence that the very elderly (,80 years) can safely undergo CAS with stroke and death rates comparable to younger patients. The key to obtaining these excellent results is that CAS be performed by high volume, experienced operators who exercise restraint regarding patient selection. © 2009 Wiley-Liss, Inc. [source] Ophthalmic lymphoma: epidemiology and pathogenesisACTA OPHTHALMOLOGICA, Issue thesis1 2009Lene Dissing Sjö Abstract With a lifetime risk of 1% and 700 new cases per year, Non-Hodgkin lymphoma (NHL) is the seventh most frequent type of cancer in Denmark. The incidence of NHL has increased considerably in Western countries over the last decades; consequently, NHL is an increasing clinical problem. Ophthalmic lymphoma, (lymphoma localized in the ocular region, i.e. eyelid, conjunctiva, lacrimal sac, lacrimal gland, orbit, or intraocularly) is relatively uncommon, accounting for 5%,10% of all extranodal lymphomas. It is, however, the most common orbital malignancy. The purpose of this thesis was to review specimens from all Danish patients with a diagnosis of ophthalmic lymphoma during the period 1980,2005, in order to determine the distribution of lymphoma subtypes, and the incidence- and time trends in incidence for ophthalmic lymphoma. Furthermore, an extended analysis of the most frequent subtype, extranodal marginal zone lymphoma (MALT lymphoma), was done to analyse clinical factors and cytogenetic changes with influence on prognosis. A total of 228 Danish patients with a biopsy-reviewed verified diagnosis of ocular adnexal-, orbital-, or intraocular lymphoma were identified. We found that more than 50% of orbital- and ocular adnexal lymphomas were of the MALT lymphoma subtype, whereas diffuse large B-cell lymphoma (DLBCL) predominated intraocularly (Sjo et al. 2008a). Furthermore, lymphoma arising in the lacrimal sac was surprisingly predominantly DLBCL (Sjo et al. 2006). Incidence rates were highly dependent on patient age. There was an increase in incidence rates for the whole population from 1980 to 2005, corresponding to an annual average increase of 3.4% (Sjo et al. 2008a). MALT lymphoma arising in the ocular region was found in 116 patients (Sjo et al. 2008b). One third of patients had a relapse or progression of disease after initial therapy and relapses were frequently found at extra-ocular sites. Overall survival, however, was not significantly poorer for patients with relapse. Furthermore, we found that the frequency of translocations involving the MALT1- and IGH-gene loci is low in ocular region MALT lymphoma (2 of 42, 5%), but may predict increased risk of relapse (Sjo et al. 2008b). In conclusion the incidence of ophthalmic lymphoma is increasing at a high rate in Denmark. Ophthalmic lymphoma consists primarily of MALT lymphoma. The molecular pathogenesis of MALT lymphoma arising in the ocular region rarely involves translocations in the MALT1- and IGH-gene loci. [source] Heart Failure Drug Utilization Patterns for Medicaid Patients Before and After a Heart Failure-Related HospitalizationCONGESTIVE HEART FAILURE, Issue 3 2005Patricia A. Howard PharmD The authors examined heart failure (HF) drug utilization patterns in Medicaid patients before and after a HF-related hospitalization. This was a retrospective claims analysis of Kansas Medicaid beneficiaries hospitalized for HF between July 1, 2000, and March 31, 2001. HF drugs were tracked 6 months prior and 6 months following the admission. Angiotensin-converting enzyme (ACE) inhibitor doses were compared with target ranges. The cohort of 135 patients had a mean age of 53.6 years and was predominantly female (66.7%) and Caucasian (70.4%) with a high prevalence of cardiovascular comorbidities. Before hospitalization, less than one third of patients were receiving ACE inhibitors, angiotensin receptor blockers, , blockers, digoxin, or vasodilators. Following hospitalization, increased utilization was observed for , blockers, digoxin, and angiotensin receptor blockers, but overall usage remained low. ACE inhibitors and vasodilator use remained constant. ACE-inhibitor doses were below target ranges before and after hospitalization. In this Medicaid cohort, HF-related hospitalizations did not lead to improved HF therapy. [source] Antidepressant use in a nationally representative sample of community-dwelling US Latinos with and without depressive and anxiety disorders,DEPRESSION AND ANXIETY, Issue 7 2009Hector M. González Ph.D. Abstract Background: Antidepressant drugs are among the most widely prescribed drugs in the United States; however, little is known about their use among major ethnic minority groups. Method: Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of Latino and non-Latino White adults antidepressant use. Setting: The 48 coterminous United States was the setting. Participants: Household residents aged 18 years and older (N=9,250). Main outcome: Past year antidepressant use. Results: Compared to non-Latino Whites, few Latinos, primarily Mexican Americans, with 12-month depressive and/or anxiety disorders reported past year antidepressant use. Mexican Americans (OR=0.48; 95%CI=0.30,0.77) had significantly lower odds of use compared to non-Latino Whites, which were largely unaffected by factors associated with access to care. Over half of antidepressant use was by respondents not meeting 12-month criteria for depressive or anxiety disorders. Lifetime depressive and anxiety disorders explained another 21% of past year antidepressant use, leaving another 31% of drug use unexplained. Discussion: We found a disparity in antidepressant use for Mexican Americans compared to non-Latino Whites that was not accounted for by differences in need and factors associated with access to care. About one third of antidepressant use was by respondents not meeting criteria for depressive or anxiety disorders. Our findings underscore the importance of disaggregating Latino ethnic groups. Additional work is needed to understand the medical and economic value of antidepressant use beyond their primary clinical targets. Depression and Anxiety, 2009. Published 2009 Wiley-Liss, Inc. [source] Use of the Broselow Tape May Result in the Underresuscitation of ChildrenACADEMIC EMERGENCY MEDICINE, Issue 10 2006ACNP, Carolyn T. Nieman MSN Abstract Objectives The purpose of this study was to determine the concordance of the Broselow tape with the measured heights and weights of a community-based population of children, especially in light of the increase in obesity in today's children. Methods The authors examined more than 7,500 children in a cross-sectional, descriptive study in two different cohorts of children to compare their actual weight with their predicted weight by a color-coded tape measure. Results In all patients, the percent agreement and , values of the Broselow color predicted by height versus the actual color by weight for the 2002A tape were 66.2% and 0.61, respectively. The concordance was best in infants, followed by school-age children, toddlers, and preschoolers (,= 0.66, 0.44, 0.39, and 0.39, respectively; percent agreement, 81.3%, 58.2%, 60.7%, and 64.0%, respectively). The tapes accurately predicted (within 10%) medication dosages for resuscitation in 55.3%,60.0% of the children. The number of children who were underdosed (by ,10%) exceeded those who were overdosed (by ,10%) by 2.5 to 4.4 times (p < 0.05). The tapes accurately predicted uncuffed endotracheal tube sizes when compared with age-based guidelines in 71% of the children, with undersizing (,0.5 mm) exceeding oversizing by threefold to fourfold (p < 0.05). Conclusions The Broselow tape color-coded system inaccurately predicted actual weight in one third of children. Caregivers need to take into consideration the accuracy of this device when estimating children's weight during the resuscitation of a child. [source] International survey on esophageal cancer: part II staging and neoadjuvant therapyDISEASES OF THE ESOPHAGUS, Issue 3 2009J. Boone SUMMARY The outcome of esophagectomy could be improved by optimal diagnostic strategies leading to adequate preoperative patient selection. Neoadjuvant therapy could improve outcome by increasing the number of radical resections and by controlling metastatic disease. The purposes of this study were to gain insight into the current worldwide practice of staging modalities and neoadjuvant therapy in esophageal cancer, and to detect intercontinental differences. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology , Group d'Etude Européen des Maladies de l'Oesophage, and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding staging modalities, neoadjuvant therapy, and response evaluation applied in esophageal cancer patients. Of 567 invited surgeons, 269 participated resulting in a response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%) represented 41 countries across the six continents. Esophagogastroscopy with biopsy and computed tomography (CT) scanning were routinely performed by 98% of responders for diagnosing and staging esophageal cancer, while endoscopic ultrasound (EUS) and barium esophagography were routinely applied by 58% and 51%, respectively. Neoadjuvant therapy is routinely administered by 33% and occasionally by 63% of responders. Of the responders that administer identical neoadjuvant regimens to esophageal adenocarcinoma (AC) and squamous cell carcinoma, 54% favor chemoradiotherapy. For AC, chemotherapy is preferred by 31% of the responders that administer neoadjuvant therapy, whereas for squamous cell carcinoma, the majority of responders (38%) prefer chemoradiotherapy. Response to neoadjuvant therapy is predominantly assessed by CT scanning of the chest and abdomen (86%). Barium esophagography, EUS, and combined CT/PET scan are requested for response monitoring in equal frequency (25%). Substantial differences in applied staging modalities and neoadjuvant regimens were detected between surgeons from different continents. In conclusion, currently the most commonly applied diagnostic modalities for staging and restaging esophageal cancer are CT scanning of the chest and abdomen, gastroscopy, barium esophagography and EUS. Neoadjuvant therapy is routinely applied by one third of the responders. Intercontinental differences have been detected in the diagnostic modalities applied in esophageal cancer staging and in the administration of neoadjuvant therapy. The results of this survey provide baseline data for future research and for the development of international guidelines. [source] Pharmacogenetics of antihypertensive treatmentDRUG DEVELOPMENT RESEARCH, Issue 3 2004Donna K. Arnett Abstract Hypertension is a common disorder associated with increased cardiovascular morbidity and mortality. Unfortunately, in the United States, only about one third of those who are aware of their hypertensive status successfully control their blood pressure. One reason for this is the variable and unpredictable response individuals have to pharmacologic treatment. Clinicians often resort to a trial-and-error approach to match patients with effective drug treatment. It is the goal of hypertension pharmacogenetics to apply knowledge of genetic predictors of treatment response to drugs that lower blood pressure and to translate this knowledge into clinical practice. To date, more than 30 studies have investigated associations between specific genetic polymorphisms and response to particular antihypertensive drugs. Angiotensin-converting enzyme inhibitors have been most frequently studied, followed by diuretics, beta-blockers, angiotensin II blockers, adrenergic alpha-agonists, and calcium channel blockers. Renin,angiotensin,aldosterone system genes have been the most widely studied, with the angiotensin-converting enzyme I/D variant being typed in about one third of all hypertension pharmacogenetic studies to date. In a number of cases, significant and potentially promising associations between genes and drug treatments have been reported. However, taken in sum, the literature suggests that the path from gene-drug-outcome association studies to clinically useful knowledge may be neither short nor direct. In the future, carefully designed studies must acknowledge that hypertension is caused by multiple genes and environmental factors that act in concert. These considerations, along with a better understanding of the complexities of the biology of hypertension, open the next set of opportunities for hypertension pharmacogenetics research. Drug Dev. Res. 62:191,199, 2004. © 2004 Wiley-Liss, Inc. [source] The Russian ,flat tax' reformECONOMIC POLICY, Issue 43 2005Anna Ivanova SUMMARY Russian's ,flat tax' In 2001, Russia dramatically reduced its higher rates of personal income tax (PIT), establishing a single marginal rate at the low level of 13%. In the following year, real revenue from the PIT increased by about 26%. This ,flat tax' experience has attracted much attention (and emulation), making it perhaps the most important tax reform of recent years. But it has been little studied. This paper asks whether the strong performance of PIT revenue was itself a consequence of this reform, using both macro evidence and, in particular, micro level data on the experiences of individuals and households affected by the reform to varying degrees. It concludes that there is no evidence of a strong supply side effect of the reform. Compliance, however, does appear to have improved quite substantially , by about one third, according to our estimates , though it remains unclear whether this was due to the parametric tax reform or to accompanying changes in enforcement. , Anna Ivanova, Michael Keen and Alexander Klemm [source] Review article: Indications for thoracolumbar imaging in blunt trauma patients: A review of current literatureEMERGENCY MEDICINE AUSTRALASIA, Issue 2 2009Enda O'Connor Abstract Thoracolumbar spine injury is a common complication of blunt multitrauma and up to one third of fractures are associated with spinal cord dysfunction. Delayed fracture diagnosis increases the risk of neurological complications. While validated screening guidelines exist for traumatic c-spine injury equivalent guidelines for thoracolumbar screening are lacking. We conducted a literature review evaluating studies of thoracolumbar injury in trauma patients to generate indications for thoracolumbar imaging. We performed MEDLINE and Pubmed searches using MeSH terms "Wounds, Nonpenetrating", "Spinal Fractures", "Spinal Injuries" and "Diagnostic Errors", MeSH/subheading terms "Thoracic Vertebrae/injuries" and "Lumbar Vertebrae/injuries" and keyword search terms "thoracolumbar fractures", "thoracolumbar injuries", "thoracolumbar trauma", "missed diagnoses" and "delayed diagnoses". Limits and inclusion criteria were defined prior to searching. We evaluated 16 articles; 5 prospective observational studies (1 cohort study) and 11 retrospective observational studies. Predictors of TL injury in prospective studies , high-risk injury mechanism, distracting injury, impaired cognition, symptoms/signs of vertebral fracture and known cervical fracture , were defined and used to construct a decision algorithm, which in a total of 14189 trauma patients from all eligible studies recommended TL screening in 856(99.1%) of 864 patients with TL fractures and would probably have directed TL imaging in the remaining 8 patients. There is limited low level evidence guiding surveillance TL imaging in adult blunt trauma patients. Despite this, we propose and evaluate an algorithm with a high negative predictive value for TL fractures. This should be incorporated into spinal injury assessment protocols. [source] Risk assessment of herbicide mixtures in a large European lakeENVIRONMENTAL TOXICOLOGY, Issue 2 2008Nathalie Chèvre Abstract Lake Geneva is one of the largest European lakes with a surface area of 580 km2. Its catchment area covers 7400 km2, of which ,20% is arable land. Monitoring campaigns have been carried out in 2004 and 2005 to determine the contamination of the lake by pesticides. The results highlight the widespread presence of herbicides in water, the measured concentrations for most substances remaining constant in 2004 and 2005. However, for some individual herbicides the concentrations increased drastically (e.g., the herbicide foramsulfuron). We assessed the environmental risk of the herbicides detected in the lake using water quality criteria recently determined for the Swiss environmental protection agency. Furthermore, we assessed the risk of herbicide mixtures, grouped based upon their mode of action. Generally, the risk estimated for all single substances is low, except for some sulfonylurea compounds. For these substances, the measured concentrations are higher than the predicted no-effect concentration. Impact on the flora of the lake can therefore not be excluded. When mixtures of pesticides with similar mode of action are taken into account, the risk remains lower than the mixture water quality criteria for all groups, but can reach as high as one third of this quality criteria. A further step would therefore be to assess the risk of the total pesticide mixture, including similar and dissimilar modes of action. © 2008 Wiley Periodicals, Inc. Environ Toxicol, 2008. [source] Effects of Antiepileptic Drugs on Refractory Seizures in the Intact Immature Corticohippocampal Formation In VitroEPILEPSIA, Issue 11 2003Pascale Paule Quilichini Summary:,Purpose: We developed a new in vitro preparation of immature rats, in which intact corticohippocampal formations (CHFs) depleted in magnesium ions become progressively epileptic. The better to characterize this model, we examined the effects of 14 antiepileptic drugs (AEDs) currently used in clinical practice. Methods: Recurrent ictal-like seizures (ILEs, four per hour) were generated in intact CHFs of P7,8 rats, and extracellular recordings were performed in the hippocampus and neocortex. AEDs were applied at clinically relevant concentrations (at least two), during 30 min after the third ILE. Their ability to prevent or to delay the next ILE was examined. Results: Valproic acid and benzodiazepines (clobazam and midazolam) but also phenobarbital and levetiracetam prevent the occurrence of seizures. In contrast, usual concentrations of carbamazepine (CBZ), phenytoin, vigabatrin, tiagabine, gabapentin, lamotrigine (LTG), topiramate, felbamate, and ethosuximide did not suppress ILEs. In addition, LTG and CBZ aggravate seizures in one third of the cases. Conclusions: This intact in vitro preparation in immature animals appears to be quite resistant to most AEDs. Blockade of seizures was achieved with drugs acting mainly at the ,-aminobutyric acid (GABA)A -receptor site but not with those that increase the amount of GABA. Drugs with a broad spectrum of activity are efficient but not those preferentially used in partial seizures or absences. We suggest that this preparation may correspond to a model of epilepsy with generalized convulsive seizures and could be helpful to develop new AEDs for refractory infantile epilepsies. [source] A Study of 43 Patients with Panayiotopoulos Syndrome, a Common and Benign Childhood Seizure SusceptibilityEPILEPSIA, Issue 1 2003Christina Lada Summary: ,Purpose: To determine prevalence, clinical, EEG features, and prognosis of Panayiotopoulos syndrome and to examine the proposition that clinical manifestations are more important than EEG findings. Methods: We analyzed retrospectively the clinical and EEG records of 1,340 children with one or more focal seizures seen in the last 18 years, supplemented with a prospective study from 1998. Panayiotopoulos syndrome was defined by clinical criteria, mainly ictal emesis, irrespective of EEG findings. Results: We analyzed 43 of 90 patients with Panayiotopoulos syndrome who were seizure free >2 years. Girls predominated. Mean age at first seizure was 5 years. Seizures consisted mainly of autonomic manifestations; ictal emesis was often the first symptom, culminating in vomiting in 86%. Of nonautonomic manifestations, lateral eye deviation was the most common; visual symptoms were exceptional. Impairment of consciousness ensued in all seizures, half of which ended with hemi or generalized convulsions. Nearly 46.5% of cases had at least one seizure >30 min, constituting autonomic status epilepticus. Seizures during sleep (84%) were more common than those in wakefulness. EEG showed occipital spikes in 29 patients. Of the other 14 cases, five had extraoccipital abnormalities or brief generalized discharges, and nine had normal awake and sleep EEG. Prognosis was excellent. All 43 children have been free of seizures for ,2 years, 53% having a single seizure, and 47%, an average two to three seizures. Conclusions: Panayiotopoulos syndrome is common and needs wider recognition. EEG shows occipital or extraoccipital abnormalities, is normal in one third of patients, and does not determine clinical manifestations or prognosis, which is excellent despite the high prevalence of lengthy seizures. [source] A Detailed Analysis of Symptomatic Posterior Cortex Seizure Semiology in Children Younger Than Seven YearsEPILEPSIA, Issue 1 2003András Fogarasi Summary: ,Purpose: To analyze the semiology of seizure onset and evolution in young children with posterior cortex epilepsy (PCE), compare this with adult reports, and assess age-related differences. Methods: We videotaped and analyzed 110 seizures from 18 patients with PCE, aged 3,81 months. All had a good prognosis after posterior epileptogenic zone removal. Ictal events were categorized by behavioral, consciousness, autonomic, and sensory features, as well as motor patterns, which included myoclonic, tonic, clonic, unclassified motor seizures, and epileptic spasm. A time-scaled data sheet was developed to record each epileptic event as onset, very early, early, or late manifestation. Results: Patients had a high seizure frequency with ,100 attacks/day; one third of them showed a cluster tendency. The mean duration of seizures was 67 s. The most common seizure components were motor manifestations (with myoclonic and tonic seizures), but psychomotor (automotor), hypomotor attacks, and isolated auras also were frequently observed. Clinical seizure spread was frequent; auras and visual sensory signs were difficult to record in this age. Typical phenomena during seizures included behavioral changes, ictal vocalization, smile, flush, head nod, oculomotor features, and late-appearing oral automatisms, whereas hypermotor and secondarily generalized tonic,clonic seizures were not seen. Conclusions: Our results suggest that PCE in infants and young children is very heterogeneous but shows important age-related features. Compared with adults, children with PCE have shorter but more frequent seizures; they rarely report aura or visual sensory signs, only sporadically develop hypermotor and secondarily generalized tonic,clonic seizures, whereas ictal smile, flush, head nod, and behavioral change are typical features at this age. Because of frequent subtle ictal phenomena, long-term video-EEG monitoring is a useful diagnostic tool with infants and young children with PCE. [source] Preventing biofilm formation: promoting cell separation with terpenesFEMS MICROBIOLOGY ECOLOGY, Issue 3 2007Carla C.C.R. De Carvalho Abstract Both carveol and carvone were effective in dispersing Rhodococcus erythropolis cells that were being stimulated to aggregate by the presence of organic solvents. The two terpenes influenced the fatty acid composition of the cell membrane, decreasing the percentage of fatty acids with more than 16 carbon atoms, and thus cell hydrophobicity, and also the degree of saturation of the fatty acids. In the presence of 250 ,mol of terpene, the volume of biofilm was reduced by one third in comparison with biofilms in the absence of terpenes. The percentage of aggregated cells was also found to depend on carvone concentration during the bioconversion of carveol to carvone, in a membrane reactor. The extent of cell aggregation decreased from 90% to 10% when carvone concentration reached ca. 48 mM in the organic phase. [source] Social Movement, Action and Change: The Influence of Women's Movements on City Government in Mumbai and LondonGENDER, WORK & ORGANISATION, Issue 2 2004Jim Barry This article reports on a research investigation into gender and local government in Mumbai in India and London in England. In both these cities female representation at the political level stands at around one third, achieved in London slowly in recent years and in Mumbai more rapidly through the adoption of a quota, or seat reservation system, implemented in 1992. In considering the experience of the women concerned it is argued that their presence and aspirations have been influenced through the networks of their respective women's movements, operating through civil society and the local state. In considering the ways in which they organize and manage the duties of office and their gendered identities, as well as in their focus on the most disadvantaged in their communities and in their dealings with others, the part played by social movements in influencing change is examined. [source] Application of the 1988 International Headache Society Diagnostic Criteria in Nine Italian Headache Centers using a Computerized Structured RecordHEADACHE, Issue 10 2002Virgilio Gallai MD Background.,The actual application of the current International Headache Society (IHS) diagnostic criteria in clinical practice has not been investigated thoroughly. Objectives.,To develop a computerized, structured, medical record based exclusively on the IHS classification system. Design and Method.,We tested the computerized structured record by entering and analyzing data reported on the case sheets of 500 consecutive patients attending nine headache centers in Italy. All clinical diagnoses in the study were made according to current IHS criteria. The rate of concordance between the diagnosis provided by the computerized structured record and that reported by clinicians on the case sheets was calculated, and reasons for any discrepancies between the two diagnoses were analyzed. Results.,Concordance between the two diagnoses was found in 345 of 500 cases examined (69%). In the remaining 155 cases, diagnoses reached with the computerized structured record and case sheets were impossible or discordant with respect to the diagnoses made by the clinician. In 144 of these cases (28.8%), this was due to missing information or errors in the diagnosis recorded by the clinicians on the patient case sheet. In particular, the diagnosis could not be reached using the computerized structured record in 105 cases (20.6%) because of a lack of one or more data needed in formulating a correct diagnosis according to the IHS operational criteria for one of the primary headache disorders. In the remaining 41 cases some data were missing, but the data available were sufficient to reach a diagnosis according to the IHS criteria. Moreover, the diagnoses reached using the computerized structured record were not in agreement with those made by the clinicians in another 39 cases (7.9%) due to an incorrect interpretation by the clinicians of the data reported on the patients' case sheets. In only 2.2% of the cases (n = 11) misdiagnoses were due to errors of the program that were promptly corrected. Conclusions.,The present study suggests that incorrect application of IHS criteria for the diagnosis of primary headache may occur in as many as one third of patients attending headache centers and that use of a computerized structured record based exclusively on current IHS criteria may overcome this deficiency. [source] Long-term outcomes of positive fluorescence in situ hybridization tests in primary sclerosing cholangitis,HEPATOLOGY, Issue 1 2010Sanjay Y. Bangarulingam Patients with primary sclerosing cholangitis (PSC) are at increased risk for developing cholangiocarcinoma (CCA). Fluorescence in situ hybridization (FISH) is a cytological test designed to enhance early CCA diagnosis. The long-term outcome of PSC patients with a positive FISH test (polysomy, trisomy/tetrasomy) are unclear. All PSC patients with at least one FISH test were identified and defined to have CCA if they had a positive tissue biopsy, positive cytology, or evidence of cancer in the explant after liver transplantation. A total of 235 PSC patients had at least one FISH test performed, and 56 patients had CCA on histopathology (n = 35) or cytology (n = 21). Overall, 120 of 235 (51%) of PSC patients tested for FISH were positive, but only one third of these positive patients had CCA. Sensitivity and specificity for FISH polysomy were 46% and 88%, and for trisomy/tetrasomy they were 25% and 67%, respectively. Survival analysis showed that patients with FISH polysomy had an outcome similar to patients with CCA; whereas FISH trisomy/tetrasomy patients had an outcome similar to patients with negative FISH tests. The FISH polysomy patients without cancer compared with those with CCA had lower serum bilirubin, lower carbohydrate antigen 19-9 (CA 19-9), lower Mayo risk score, and lower occurrence of dominant strictures. Conclusion: In PSC patients, the presence of a dominant stricture plus FISH polysomy has a specificity of 88% for CCA. Patients with FISH showing trisomy or tetrasomy have a similar outcome to patients with negative FISH. FISH testing should be used selectively in patients with other signs indicating CCA and not as a screening tool in all PSC patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). (HEPATOLOGY 2009.) [source] Engineered measles virus as a novel oncolytic viral therapy system for hepatocellular carcinoma,HEPATOLOGY, Issue 6 2006Boris Blechacz The oncolytic measles virus Edmonston strain (MV-Edm), a nonpathogenic virus targeting cells expressing abundant CD46, selectively destroys neoplastic tissue. Clinical development of MV-Edm would benefit from noninvasive monitoring strategies to determine the speed and extent of the spread of the virus in treated patients and the location of virus-infected cells. We evaluated recombinant MV-Edm expressing carcinoembryonic antigen (CEA) or the human sodium iodide symporter (hNIS) for oncolytic potential in hepatocellular carcinoma (HCC) and efficiency in tracking viruses in vivo by noninvasive monitoring. CD46 expression in human HCC and primary hepatocytes was assessed by flow cytometry and immunohistochemistry. Infectivity, syncytium formation, and cytotoxicity of recombinant MV-Edm in HCC cell lines were evaluated by fluorescence microscopy, crystal violet staining, and the MTS assay. Transgene expression in HCC cell lines after infection with recombinant MV-Edm in vitro and in vivo was assessed by CEA concentration, 125I-uptake, and 123I-imaging studies. Toxicology studies were performed in IfnarKO×CD46 transgenic mice. The CD46 receptor was highly expressed in HCC compared to nonmalignant hepatic tissue. Recombinant MV-Edm efficiently infected HCC cell lines, resulting in extensive syncytium formation followed by cell death. Transduction of HCC cell lines and subcutaneous HCC xenografts with recombinant MV-Edm resulted in high-level expression of transgenes in vitro and in vivo. MV-Edm was nontoxic in susceptible mice. Intratumoral and intravenous therapy with recombinant MV-Edm resulted in inhibition of tumor growth and prolongation of survival with complete tumor regression in up to one third of animals. In conclusion, engineered MV-Edm may be a potent and novel cancer gene therapy system for HCC. MV-Edm expressing CEA or hNIS elicited oncolytic effects in human HCC cell lines in vitro and in vivo, enabling the spread of the virus to be monitored in a noninvasive manner. (HEPATOLOGY 2006;44:1465,1477.) [source] | ||||||||||||||||||||||||||||||||||||||||||||||