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Quality Index (quality + index)
Kinds of Quality Index Selected AbstractsRING CHARACTERIZATION OF QUALITY INDICES IN BUTTERHEAD LETTUCE CULTIVATED UNDER MULCH AND BARE SOILJOURNAL OF FOOD QUALITY, Issue 4 2010MARÍA G. GOÑI ABSTRACT Butterhead lettuce was characterized by physical, microbiological and nutritional quality indices as a function of plant zoning and soil management (bare soil and mulch). Quality indices were measured in all the rings from the external toward the internal ratio. Assayed indices were: relative water content, water content, free and bound water, and the ratio between free water and total water, leaf area and color, total microbial counts (TMC) and ascorbic acid content (AA). The lettuce characterization by rings showed a remarkable plant zoning as a function of leaf age and development; also, some initial indices were affected by the soil management employed. Plastic mulches affect the microclimate around the plant, resulting in better plant water status. However, the use of black plastic covers could absorb sunlight therefore increasing soil temperature and causing lower AA and higher TMC in lettuce tissue. PRACTICAL APPLICATIONS During lettuce development, each leaf had a different level of exposure to environmental conditions, such as light, humidity, nutrients absorption and temperature affecting the quality indices of the raw material and introducing a source of variability in the physico-chemical, biochemical, nutritional and microbiological indices within the plant. In this way, the location of the leaf within the whole plant is an important factor to be considered. Moreover, during lettuce heads trading, it is a common practice to remove the external leaves as storage advances. These leaves are more perishable than middle and internal ones because of their direct exposure to environmental conditions. Understanding the way in which physical, microbiological and nutritional indices were distributed in the whole lettuce plant could be of interest, to know the value of the losses of regular green grocers' practices, from a nutritional and a safety point of view. [source] Subjective and objective sleep among depressed and non-depressed postnatal womenACTA PSYCHIATRICA SCANDINAVICA, Issue 2 2009S. K. Dørheim Objective:, Women sleep less in the postnatal period and it has been suggested that mothers diagnosed with depression alternatively could be suffering from the effects of chronic sleep deprivation. Method:, From a population-based study, we recruited 42 women, of whom 21 scored ,10 on the Edinburgh Postnatal Depression Scale. Sleep was registered by the Pittsburgh Sleep Quality Index (PSQI), sleep diaries and actigraphy 2 months after delivery. Results:, There were significant differences in subjective sleep measured retrospectively by the PSQI between depressed and non-depressed women. In contrast, there were no significant differences in sleep measured prospectively by sleep diaries and actigraphy. Both depressed and non-depressed women had impaired sleep efficiency (82%) and were awake for about 1.5 h during the night. Primipara had worse sleep, measured by actigraphy, compared with multipara. Conclusion:, Measured objectively and prospectively, women with depression did not have worse sleep than non-depressed women. [source] Depressive symptoms among mothers of children with epilepsy: A review of prevalence, associated factors, and impact on childrenEPILEPSIA, Issue 11 2009Mark A. Ferro Summary The impact of epilepsy is not limited to the child experiencing seizures, but affects all members of the family. As primary caregivers, mothers are particularly at risk for experiencing increased depressive symptoms and risk for clinical depression. The objective of this systematic review was to critically assess available evidence regarding the prevalence, associated factors, and impact of maternal depressive symptoms on child outcomes in epilepsy. Using a modified version of the Quality Index, studies were rigorously evaluated in terms of reporting, external validity, and internal validity. Limitations in the study designs and analytic techniques of previous research are discussed, and study methods to overcome these barriers are presented in order to advance this research area. Up to 50% of mothers of children with epilepsy are at risk for clinical depression. Correlates of maternal depressive symptoms include a number of modifiable risk factors such as role ambiguity, worry, and satisfaction with relationships. In addition, studies suggest that depressive symptoms in mothers have a negative impact on child outcomes in epilepsy including behavior problems and health-related quality of life. The overall mean score on the Quality Index was 9.7, indicating a midrange quality score, suggesting a need for more methodologically robust studies. [source] Sleep disruption, daytime somnolence and ,sleep attacks' in Parkinson's disease: a clinical survey in PD patients and age-matched healthy volunteersEUROPEAN JOURNAL OF NEUROLOGY, Issue 3 2006J. J. Ferreira Recent case reports of ,sleep attacks' (SA) in patients with Parkinson's disease (PD) generated concerns about drug-induced daytime somnolence in this population. However, there are nearly no comparative data on sleep and vigilance problems between PD patients and normal controls. We performed a cross-sectional survey in PD patients and age-matched controls using a structured questionnaire on PD history, treatments, co-morbidity, activities of daily living, habits, exercise, sleep pattern, driving, pre-existing nocturnal problems, daytime somnolence, episodes of SA and the circumstances in which such episodes occurred. Daytime somnolence was also measured with the Epworth Sleepiness Scale (ESS) and sleep quality with the Pittsburgh Sleep Quality Index (PSQI). 176 PD patients and 174 controls were included. The same proportion of PD patients (27%) and controls (32%) reported episodes of SA, but these were more frequent in PD patients and occurred more frequently during situations requiring attention (10.8% vs. 1.7%, p<10,3). More PD patients had abnormal daytime somnolence (ESS) and poor sleeping quality (PSQI). The most consistent factor associated with SA was the duration of levodopa therapy and the predictive value of an abnormal ESS score was rather poor (40.7%). Abnormal daytime somnolence and poor sleep quality at night are more frequent in PD patients than in normals. However, SA are reported in both groups, although less frequently in the normals during activities that requires attention. [source] Fatigue in primary biliary cirrhosis is associated with excessive daytime somnolence,HEPATOLOGY, Issue 1 2006Julia L. Newton A significant proportion of patients with primary biliary cirrhosis (PBC) suffer from severe fatigue. The aim of this study was to characterize patterns of daytime sleep in patients with PBC (using both objective and subjective assessment approaches) and to study the association between sleep abnormality and fatigue severity. Fatigue severity was assessed in 48 female subjects with PBC (using a disease-specific quality of life instrument (the PBC-40) and a generic fatigue measure (Fatigue Impact Scale [FIS]) as well as 48 case-matched normal controls. All participants also completed the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS, which assesses daytime hypersomnolence). Objective sleep assessment was performed using accelerometry over 7 days. Global sleep quality assessed by the PSQI was significantly lower in the PBC group compared to controls (P < .0001). ESS scores were significantly higher in patients with PBC than controls (P = .0001), suggesting significantly greater daytime somnolence in the patients with PBC. Objective sleep assessment confirmed that subjects with PBC were sleeping on average almost twice as long as controls during the daytime. Both degree of daytime somnolence (ESS) and actual daytime sleep activity (accelerometry) correlated strongly with fatigue severity in the patient group (r2 = 0.5, P < .0001 and r2 = 0.2, P < .01, respectively). In conclusion, Sleep abnormality, in the form of excessive daytime somnolence, is present in a significant proportion of patients with PBC, with the degree of daytime somnolence correlating strongly with the degree of fatigue. Existing agents effective at reducing daytime somnolence (such as modafinil) hold potential for the treatment of fatigue in PBC. (HEPATOLOGY 2006;44:91,98.) [source] Levocetirizine is an effective treatment in patients suffering from chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled, parallel, multicenter studyINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 4 2006Alexander Kapp MD Background, Chronic idiopathic urticaria (CIU) is defined by the almost daily presence of urticaria for at least 6 weeks without an identifiable cause. Symptoms include short-lived wheals, itching, and erythema. CIU impedes significantly a patient's quality of life (QoL). Levocetirizine is an antihistamine from the latest generation approved for CIU. Aim, To investigate the efficacy of levocetirizine, 5 mg, and placebo for the symptoms and signs of CIU, as well as for the QoL and productivity. Methods, The primary criteria of evaluation were the pruritus severity scores over 1 week of treatment and over 4 weeks. The QoL was assessed via the Dermatology Life Quality Index (DLQI). Results, Baseline pruritus severity scores were comparable in the two treatment groups (2.06 ± 0.58). After 1 week, levocetirizine was superior to placebo and demonstrated a considerable efficacy (difference = 0.78, P < 0.001). This efficacy was maintained over the entire study period (4 weeks, P < 0.001). The number and size of wheals were considerably reduced compared with placebo over 1 week and over the total treatment period (P , 0.001). This was paralleled by an improvement in the QoL (DLQI: 7.3 units in the levocetirizine group and 2.4 units in the placebo group) and a higher productivity at work in the levocetirizine group (3.0 workdays lost per patient per month in the placebo group, 0.3 in the levocetirizine group). No unexpected adverse events occurred. Conclusions, Levocetirizine, 5 mg once daily, is an effective treatment for CIU, characterized not only by a rapid and sustained response, but also by an important improvement in QoL. [source] Subjectively reported sleep quality and excessive daytime somnolence in Parkinson's disease with and without dementia, dementia with Lewy bodies and Alzheimer's diseaseINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 6 2007Frauke Boddy Abstract Objective We compared subjective sleep quality and excessive daytime somnolence (EDS) in controls, Parkinson's disease with (PDD) and without dementia (PD), dementia with Lewy bodies (DLB) and Alzheimer's disease (AD). We investigated whether sleep dysfunction and EDS associate with motor phenotype in PD, PDD and DLB. Method Assessments included the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Results EDS was more frequent in PD, DLB and PDD patients than in AD. PDD, PD and DLB patients also had worse sleep quality when compared with AD and controls. Baseline postural instability-gait difficulty (PIGD) motor phenotype in PDD was associated with a higher ESS score and frequency of EDS, but this association was lost at two years. PSQI scores did not differ between PIGD dominant and non-dominant PD, PDD and DLB patients. Conclusion EDS and poor sleep quality are greater in PD, PDD and DLB, compared with AD. The dissociation of EDS and motor phenotype suggests their pathophysiology is anatomically and/or temporally distinct. Copyright © 2006 John Wiley & Sons, Ltd. [source] Night-time frequency, sleep disturbance and general health-related quality of life: Is there a relation?INTERNATIONAL JOURNAL OF UROLOGY, Issue 1 2009Koji Yoshimura Objectives: We conducted a community-based study to determine the relationship among night-time frequency, sleep disturbance and general health-related quality of life (GHQL). Methods: A total of 2271 participants, men and women, aged 41,70 and randomly selected in three Japanese towns completed a postal questionnaire survey. This questionnaire included: the International Prostate Symptom Score, the overall incontinence score of the International Consultation of Incontinence Questionnaire Short Form for lower urinary tract symptoms, the Pittsburg Sleep Quality Index for sleep problems, the Medical Outcome Study Short Form-8 for GHQL, and medical history of disease, cigarette smoking, and alcohol consumption. A multiple regression model was used for statistical analysis, and P < 0.05 was considered significant. Results: Although night-time frequency by itself was closely associated with most aspects of GHQL, this association disappeared in four domains (general health perception, vitality, mental health and emotional role) and in the two summary scores of the Medical Outcome Study Short Form-8 after inclusion of the influence of sleep problems represented by the total score on the Pittsburg Sleep Quality Index. However, three domains (physical function, physical role, and social function) remained significantly associated with night-time frequency. Sleep problems were by far the worst risk factor for the deterioration of GHQL. Conclusions: Night-time frequency appeared to be associated with GHQL mainly by affecting sleep conditions, a symptom that independently influenced some aspects of GHQL. [source] Cost-effectiveness of psoriasis therapy with etanercept in GermanyJOURNAL DER DEUTSCHEN DERMATOLOGISCHEN GESELLSCHAFT, Issue 9 2007Tatjana Heinen-Kammerer Summary Background: We estimated the cost-effectiveness of intermittent therapy with etanercept in patients with moderate-to-severe plaque-type psoriasis in comparison to non-systemic therapy in Germany. Patients and Methods: We performed a cost-utility analysis using the endpoint costs per quality-adjusted life year gained (costs/QALY). For this purpose, we adapted a UK-based Markov model by means of resource use data that we derived from a German cost study. Efficacy data, information on frequency of adverse events and changes in quality of life were derived from three pooled clinical trials. We extrapolated the further course of the disease and its treatment over a 10 year course. Results: For patients with an initial Psoriasis Area and Severity Index (PASI) > 10 and a Dermatology Life Quality Index (DLQI) > 10 the incremental cost-effectiveness ratio (ICER) for etanercept compared to non-systemic therapy was 45,491 ,/QALY. For patients with PASI and DLQI > 15 costs/QALY were 32,058 , and among patients with severe plaque psoriasis (DLQI and PASI > 20) 18,154 , . Conclusions: According to internationally accepted levels of cost-effectiveness thresholds, the intermittent treatment of (moderate to) severe plaque-type psoriasis with etanercept is a cost-effective measure within the German healthcare system. [source] Insomnia Severity Index: psychometric properties with Chinese community-dwelling older peopleJOURNAL OF ADVANCED NURSING, Issue 10 2010Doris S.F. Yu yu d.s.f. (2010) Insomnia Severity Index: psychometric properties with Chinese community-dwelling older people. Journal of Advanced Nursing,66(10), 2350,2359. Abstract Aim., This paper is a report of a study to evaluate the psychometric properties of the Chinese version of the Insomnia Severity Index. Background., Despite the high prevalence of insomnia in older people and its detrimental impact on well-being and healthcare costs, this problem is almost always undetected and consequently under-treated. The Insomnia Severity Index is psychometrically sound in measuring perceived insomnia severity. However, it has had very limited application in non-White populations. Methods., An instrument validation study was carried out between October 2008 and April 2009. The Insomnia Severity Index was translated into Chinese using Brislin's model and administered to a convenience sample of 585 older Chinese people recruited from three community centres for elders. Other instruments were also administered, including the Chinese version of the Pittsburgh Sleep Quality Index and the Geriatric Depression Scale. Results., Cronbach's alpha of the Chinese version of the Insomnia Severity Index was 0·81, with item-to-total correlations in the range of 0·34,0·67. Construct validity was supported by its moderate relationship with the Chinese Pittsburgh Sleep Quality Index and sleep efficiency. The Chinese version of the Insomnia Severity Index also indicated more severe level of insomnia in older people who reported depressed mood on the Geriatric Depression Scale. Discriminant validity was supported as the Chinese version of the Insomnia Severity Index could discriminate poorer sleepers from normal sleepers. Exploratory factor analysis identified a two-factor structure for the Chinese version of the Insomnia Severity Index in measuring the severity and impacts of insomnia on the Chinese older people. Conclusion., The Chinese version of the Insomnia Severity Index is a culturally-relevant and psychometrically-sound instrument for assessing severity and impact of insomnia in Chinese community-dwelling older people. Nurses can use this tool to assess older people's perceptions of insomnia. [source] Self-Reported Napping and Duration and Quality of Sleep in the Lifestyle Interventions and Independence for Elders Pilot StudyJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2008Jennifer L. Picarsic MD OBJECTIVES: To determine the prevalence of self-reported napping and its association with subjective nighttime sleep duration and quality, as measured according to sleep-onset latency and sleep efficiency. DESIGN: Cross-sectional study. SETTING: Lifestyle Interventions and Independence for Elders Pilot Study. PARTICIPANTS: Community-dwelling older adults (N=414) aged 70 to 89. MEASUREMENTS: Self-report questionnaire on napping and sleep derived from the Pittsburgh Sleep Quality Index (PSQI) scale. RESULTS: Fifty-four percent of participants reported napping, with mean nap duration of 55.0±41.2 minutes. Nappers were more likely to be male (37.3% vs 23.8%, P=.003) and African American (20.4% vs 14.4%, P=.06) and to have diabetes mellitus (28% vs 14.3%, P=.007) than non-nappers. Nappers and non-nappers had similar nighttime sleep duration and quality, but nappers spent approximately 10% of their 24-hour sleep occupied in napping. In a multivariate model, the odds of napping were higher for subjects with diabetes mellitus (odds ratio (OR)=1.9, 95% confidence interval (CI)=1.2,3.0) and men (OR=1.9, 95% CI=1.2,3.0). In nappers, diabetes mellitus (,=12.3 minutes, P=.005), male sex (,=9.0 minutes, P=.04), higher body mass index (,=0.8 minutes, P=.02), and lower Mini-Mental State Examination score (,=2.2 minutes, P=.03) were independently associated with longer nap duration. CONCLUSION: Napping was a common practice in community-dwelling older adults and did not detract from nighttime sleep duration or quality. Given its high prevalence and association with diabetes mellitus, napping behavior should be assessed as part of sleep behavior in future research and in clinical practice. [source] Effect of hypnosis on oral function and psychological factors in temporomandibular disorders patientsJOURNAL OF ORAL REHABILITATION, Issue 8 2009R. ABRAHAMSEN Summary, This study investigated the effect of hypnosis in patients with temporomandibular disorders (TMD) with focus on oral function and psychological outcomes. Forty women (mean age ± s.d.: 38·6 ± 10·8 years) suffering from TMD (mean duration 11·9 ± 9·9 years) were randomized to four individual 1-hour sessions of either hypnotic intervention or a control condition of simple relaxation. Pain intensity was assessed three times daily on a 0,10 Numerical Rating Scale. Additional outcomes were TMD-associated symptoms assessed by the Research Diagnostic Criteria examination form and questionnaire, psychological symptoms (Symptom Check List 60), pain coping strategies (Coping Strategies Questionnaire), sleep difficulties (Pittsburgh Sleep Quality Index) and use of analgesics. Data were analyzed with between-groups within-subjects anovas. The hypnosis group significantly reduced the daily NRS pain scores from 4·5 ± 2·1 at baseline to 2·9 ± 2·4 after treatment (P < 0·001) compared to the control group where no significant changes were found (4·2 ± 1·4 to 3·9 ± 1·5) (P = 0·733). Number needed to treat for a 50% pain reduction was 4·0. The hypnosis group also increased use of the coping strategy ,reinterpreting pain sensations' from 5·2 ± 6·9 to 10·3 ± 6·8 (P < 0·001). Both groups exhibited significant reductions in the number of painful muscle palpation sites and pain on palpation (P < 0·004), in number of awakenings due to pain (P < 0·006), and in somatization, obsessive compulsive symptoms and anxiety (P < 0·004). Hypnosis thus appears to effectively reduce some aspects of complex TMD pain. [source] Treatment of Hypertriglyceridemia With Omega-3 Fatty Acids: A Systematic ReviewJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 9 2004Amanda Lewis MS Purpose To (a) critically appraise available randomized controlled trials (RCTs) addressing the efficacy of long-chain omega-3 fatty acids as secondary agents for prevention of hypertriglyceridemia and (b) make recommendations for clinical practice. Data Sources Two independent reviewers examined all RCTs from 1994 to 2003 identified in several databases, extracted data from each study, and used the previously tested Boyack and Lookinland Methodological Quality Index (MQI) to determine study quality. Conclusions Ten studies reported long-chain omega-3 fatty acids to be effective in the treatment of hypertriglyceridemia. The average decrease in triglycerides was 29%, total cholesterol 11.6%, very low density lipoprotein (VLDL) 30.2%, and low-density lipoprotein (LDL) 32.5%. One study found LDLs to increase by 25%. The average increase in highdensity lipoprotein was 10%. The overall average MQI score was 36% (range = 26% to 54%). Many of the RCTs had serious shortcomings, including short duration, lack of a power analysis, no intention-to-treat analysis, no report of blind assessment of outcome, and lack of dietary control as a confounding variable. Implications for Practice Overall study methodology was weak. Although the evidence supporting use of long-chain omega-3 fatty acids in the secondary prevention of hypertriglyceridemia is reasonably strong, until there are larger RCTs of better methodological quality, it is not recommended that practitioners treat hypertriglyceridemia with omega-3 fatty acid supplementation in lieu of lipid-lowering medications. [source] Quality of life in patients with lepromatous leprosy in ChinaJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 7 2010J-G An Abstract Background, Leprosy has an impact on patients' quality of life (QoL). However, there has been no study specifically on the impact of the severest type of leprosy-lepromatous leprosy on QoL. Objective, To describe the use of Dermatology Life Quality Index (DLQI) among patients with lepromatous leprosy in China. Methods, Sixty-four inpatients with lepromatous leprosy of Shangluo hospital and Hanzhong hospital and sixty-four controls (healthy volunteers or patients with other dermatoses) matched for age and gender were asked to complete DLQI questionnaires from 2 September 2008 to 20 December 2008. Extensive data were collected besides DLQI, including demographic data and disease-related characteristics. Absence or presence of disability among patients with lepromatous leprosy was evaluated at the same time. Results, The overall mean DLQI score for lepromatous leprosy (18.78) was higher than that for control (9.00) (P < 0.001). Patients with lepromatous leprosy scored significantly higher for all items (P < 0.001) except Q4 (clothes choice). Controls scored significantly lower for all domains of DLQI. Scores of LL increased markedly with increasing clinical severity, but were not associated with educational level, gender, age and disease duration. The inter-item correlation averaged 0.240 and Cronbach's alpha was 0.759, indicating high internal consistency. Conclusions, This is the first exclusive study to attempt to measure the impact of lepromatous leprosy on QoL. Lepromatous leprosy has a severe impact on QoL. [source] Quality of life in patients with facial steroid dermatitis before and after treatmentJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 6 2008Z-H Liu Abstract Background, Improper long-term, even low-dose, topical corticosteroids, especially application to the face, could induce steroid dermatitis, which was refractory and detrimental to the quality of life. Objective, To evaluate the quality of life in patients with facial steroid dermatitis before and after the treatment of doxycycline and indomethacin plus support therapy. Study design, A prospective study. Setting, Outpatients of the Department of dermatology, the Third Hospital of Hangzhou, from August 2, 2004, to April 20, 2005. Subjects, Fifty consecutive outpatients completed the treatment. Intervention, The intervention is doxycycline 10 mg twice a day and indomethacin 25 mg twice a day for 4 weeks, cetirizine or loratadine 10 mg daily if pruritic, topical white petroleum if feeling dry and wet dressing if burning and oedema, plus psychological support and health education. Main outcome measure, The efficacy of the treatment was quantified using a 24-point steroid clinical score. The detriment of the quality of life was quantified using a 30-point Dermatology Life Quality Index. Results, The steroid dermatitis clinical score decreased significantly from 15.06 ± 4.61 at baseline to 4.52 ± 3.39 at 2 weeks after the end of treatment (week 6; P < 0.001). Twenty-one patients underwent a rebound phenomenon and the steroid dermatitis clinical score increased significantly from 13.71 ± 4.33 at baseline (week 0) to 19.24 ± 3.40 at 1 week after treatment (week 1; P < 0.001). Quality of life score decreased significantly from 13.76 ± 7.68 at baseline to 3.44 ± 2.57 at 2 weeks after the end of treatment (week 6; P < 0.001). Conclusions, The quality of life was profoundly affected by facial steroid dermatitis. Doxycycline and indomethacin plus support therapy might be effective in patients with facial steroid dermatitis. [source] The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSDJOURNAL OF TRAUMATIC STRESS, Issue 4 2001Barry Krakow Abstract Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity. [source] Diode laser hair removal does not interfere with botulinum toxin A treatment against axillary hyperhidrosisLASERS IN SURGERY AND MEDICINE, Issue 3 2010Anna Paul MD Abstract Background and Objective The possible interference of combined laser hair removal and Botulinum toxin A (BoNT/A) injections in the treatment of axillary hyperhidrosis has not previously been explored. In order to examine this potential interference, we assessed the effect of BoNT/A on axillary hyperhidrosis with and without concomitant diode laser axillary hair removal. Study Design/Materials and Methods In a prospective, double blind, randomized cross over trial, nine patients suffering from primary axillary hyperhidrosis were laser-treated on one randomly assigned axilla. One week later, both axillas were injected intradermally with BoNT/A (100,MU per axilla). During the same session, the previously untreated axilla was lasered. Axillary sweat rates (in g/5,minutes.) were determined by gravimetry and compared at rest, during mental exercise, and during physical exercise. Additionally, subjective outcome measures were assessed by a visual analogue scale, Dermatology Life Quality Index, and Global Clinical Impression score. Results No differences were found regarding the effect of BoNT/A on previously laser-treated and laser co-treated sides over time course for any of the outcome parameters. Sweat production was reduced 3 weeks after BoNT/A treatment by 93.5% at rest, 96.5% during mental exercise, and 67% during physical exercise. Conclusions Concomitant laser hair removal does not interfere with BoNT/A treatment on axillary hyperhidrosis. Lasers Surg. Med. 42:211,214, 2010. © 2010 Wiley-Liss, Inc. [source] Effects of ,1-Blockers for Lower Urinary Tract Symptoms and Sleep Disorders in Patients with Benign Prostatic HyperplasiaLUTS, Issue 2 2010Takahiro SAKUMA Objectives: We evaluated the association of lower urinary tract symptoms (LUTS) and sleep disorders (SD) in patients with benign prostatic hyperplasia (BPH). We also examined improvement of SD following the ,1-blocker therapy for LUTS. Methods: Sixty-eight male patients were enrolled in the study, consisting of 38 cases with LUTS and BPH (BPH group), and 30 men without significant LUTS or BPH (non-BPH group). The degree of LUTS and SD was evaluated by the International Prostate Symptom Score and the Pittsburg Sleep Quality Index (PSQI), respectively. The patients of BPH group then were treated with ,1-blocker for 4 weeks, and were re-examined by all the questionnaires to evaluate the therapeutic efficacies. Results: The correlation analyses showed a significant association of LUTS with SD in BPH group (r = 0.4995, P = 0.0068). Twenty cases (52.6%) in BPH group showed 5.5 or more PSQI scores. Following 4 weeks of ,1-blocker administration, the average PSQI decreased significantly from 6.3 to 4.8 points (P < 0.001). Significant improvement was observed in domains of "sleep quality" and "sleep disturbances" among PSQI (P = 0.0215 and 0.0391, respectively). Moreover, significant association between ,1-blocker induced improvements of nocturia and SD was identified in patients with 5.5 or more PSQI score at baseline (r = 0.445, P = 0.0334). Conclusion: These results suggested that SD is associated with LUTS among BPH patients and therapeutic effects of ,1-blockers on LUTS lead to improvements of SD. [source] How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily vs PRN and quality of lifeALLERGY, Issue 4 2009J.-J. Grob Background:, Chronic idiopathic urticaria (CIU) impairs quality of life (QoL). Currently, no consensus exists regarding how second-generation H1 -antihistamines (proven to control CIU symptoms) should be taken long-term: as daily treatment or only when symptoms return (PRN). We sought to determine which regimen improves or better maintains QoL in CIU: desloratadine (DL) daily or PRN. Methods:, Subjects with CIU initially responding to DL 5 mg/day for 4 weeks were randomized for an additional 8 weeks, to DL 5 mg/day (arm 1: ,continuous', n = 46) or to DL only on days when urticarial wheals were present (arm 2: "PRN", n = 60). To ensure blinding, treatment was presented in both arms as a combination of daily treatment (arm 1: DL; arm 2: placebo), plus a "rescue" tablet (arm 1: placebo; arm 2: DL) to be taken only in case of symptoms. The main outcome measure was QoL assessed by the VQ-Dermato, a validated French QoL instrument, and the Dermatology Life Quality Index (DLQI). Results:, At 4 and 8 weeks after randomization, subjects taking continuous DL showed statistically significant improvements in VQ-Dermato Global Index score (P = 0.001 and P = 0.016, respectively) and dimension scores for daily living activity, mood state, and social functioning vs subjects taking DL PRN. Improvement in DLQI score at Week 4 was also significantly greater with continuous DL (P = 0.001). Conclusion:, Continuous daily therapy with DL 5 mg is a better regimen than PRN treatment to maintain or improve QoL in subjects with CIU. [source] Prevalence of restless legs syndrome in a rural community in Japan,MOVEMENT DISORDERS, Issue 16 2008Takashi Nomura MD Abstract To assess the prevalence and clinical significance of restless legs syndrome (RLS) in a Japanese population, we carried out a community-based survey in a rural area of Japan. We sent questionnaires requesting information on demographics, the Center for Epidemiological Studies Depression scale, the Short Form-8, the Pittsburgh Sleep Quality Index, the National Institutes of Health/International RLS Study Group (IRLSSG) consensus questionnaire, and the IRLSSG severity scale for RLS (IRLS) to 5,528 eligible adult residents in the town of Daisen in the Tottori prefecture of Japan. Next, we performed telephone interviews to identify subjects with probable RLS. Of the 2,812 subjects (51.1%) who gave complete answers on the IRLSSG questionnaire, 50 (1.8%) were judged as RLS positive. The prevalence of RLS was significantly higher in women than in men, and significantly lower in individuals 60 years of age or older. Multiple logistic regression analysis revealed that the existence of RLS was significantly associated with depression, lowered mental quality of life, and sleep disturbances. The prevalence of RLS in adult Japanese populations may be lower than that reported in Caucasian populations. However, in a group of Japanese subjects, RLS had a significant impact on daytime functioning as well as subjective sleep quality. © 2008 Movement Disorder Society [source] Latest news and product developmentsPRESCRIBER, Issue 3 2008Article first published online: 26 FEB 200 Higher risk of CV events in aspirin resistance More than one in four patients may have aspirin resistance, a new metaanalysis shows, and they face a four-to sixfold increased risk of a major cardiovascular event or death compared with aspirin-sensitive patients taking low-dose aspirin (BMJ online: 17 Jan 2008; doi:10. 1136/bmj.39430.529549.BE). The analysis included 20 studies involving a total of 2930 patients with cardiovascular disease. Of these, 28 per cent were defined as having aspirin resistance (according to the various definitions in each study). Compared with aspirin-sensitive patients, the odds ratio of any cardiovascular event or acute coronary syndrome was about 4 and the odds ratio of death was 6. Aspirin-resistant patients did not benefit from other antiplatelet treatment. ADOPT: rosiglitazone fracture risk in women A new analysis of the ADOPT trial (N Engl J Med 2006;355: 2427-43) has found that the risk of fractures during treatment with rosiglitazone (Avandia) is approximately twice as high as with metformin or glibenclamide, but mainly in women (Diabetes Care online: 25 Jan 2008; doi: 10.2337/dc07-2270). The study found a significant difference in risk between the drugs only for women, with a cumulative incidence of 15.1 per cent with rosiglitazone, 7.3 per cent with metformin and 7.7 per cent with glibenclamide after five years. No risk factors were identified although the incidence of fractures was higher among postmenopausal than premenopausal women. New from NICE Infliximab for the treatment of adults with psoriasis. Technology Appraisal Guidance No. 134, Jan 2008 Infliximab (Remicade), a monoclonal antibody against TNF-alpha, should be an option for treating very severe plaque psoriasis in adults, NICE recommends. Using its fast-track single technology appraisal procedure, NICE concluded that infliximab should be considered when standard therapies,methotrexate or ciclosporin (Neoral), or PUVA , have failed or are unsuitable. The criteria for disease severity are defined by the Psoriasis Area Severity Index (PASI) score (,20) and the Dermatology Life Quality Index (DLQI) score (>18). Treatment response is also defined by these measures and infliximab should be continued for longer than 10 weeks only when predefined thresholds are met. Infliximab costs an average of £11 750 annually. In 2006, NICE recommended etanercept (Enbrel) and efalizumab (Raptiva) for patients with severe psoriasis (PASI ,10 and DLQI >10). Commons committee wants tougher targets Most GPs get full QOF points for medicines management even though there is inexplicably large variation in good prescribing practice between PCTs, the Public Accounts Select Committee points out in its latest report, Prescribing Costs in Primary Care. The Committee wants to see tougher QOF targets among several initiatives to reduce prescribing costs. Although most publicity centred on its endorsement of the National Audit Office claim that GPs could save £200 million by prescribing lower-cost drugs, the report contains some more far-reaching proposals. GPs should prescribe generic alternatives within a therapeutic category, so when a brand is not available generically, eg Lipitor, a different drug that is, eg simvastatin, should be used when clinically appropriate. Further, this form of substitution should be rewarded via QOF targets. There should be greater uniformity in the appearance, labelling and packaging of generic and branded equivalents. The Department of Health should consider raising awareness of the value of medicines by printing the cost on packaging, and to reduce the £100 million wasted annually in dumped medicines, it should investigate which drugs aren't used and why patients won't take them. Strategic health authorities should work with the National Prescribing Centre to develop more prescribing indicators with which to measure PCT performance and support PCTs to promulgate best practice. They should also collaborate on promoting joint primary-secondary care formularies and increase the consistency of prescribing, not only between hospital specialists and GPs but also between PCTs. To monitor the influence of the pharmaceutical industry, PCTs should keep a record of gifts and hospitality and publish a register. Questions to ask about mental health treatment The Department of Health has published a booklet designed to raise awareness of medicines management issues affecting people using mental health services and their carers, and professionals in the health and social services. Although one aim of Medicines Management: Everybody's Business is to empower people with mental health problems to ask about their medication, its formal style is better suited to staff who need to improve their person-centred approach to care. It covers what information people should expect and what questions to ask when drug treatment is being considered, what to expect at review and issues to consider when contemplating stopping treatment. Copies can be downloaded at www.dh.gov.uk. Consider statins for all patients with diabetes Treatment with a statin should be considered for all patients with diabetes unless their risk is low, say the authors of a new study (Lancet 2008;371:117-25). Their meta-analysis of 14 randomised trials involving 18 686 people with diabetes and an average follow-up of 4.3 years found that statins reduced vascular events and vascular mortality as much as in nondiabetic populations. The overall benefit was 42 fewer major events per 1000 people treated for five years. This was independent of a history of vascular disease or other baseline characteristics. No evidence for OTC cough medicines There is no evidence that over-the-counter cough medicines for adults and children are effective in relieving acute cough, a new Cochrane review has concluded (Cochrane Database of Systematic Reviews 2008, Issue 1). The review of 17 randomised trials involving 2876 adults and eight involving 616 children reported conflicting findings of uncertain clinical relevance. The trials were heterogeneous and of low quality. Copyright © 2008 Wiley Interface Ltd [source] Subjective sleep quality and suggested immobilization test in restless leg syndrome and periodic limb movement disorderPSYCHIATRY AND CLINICAL NEUROSCIENCES, Issue 3 2002YUICHI INOUE md Abstract The severity of restless leg syndrome (RLS) and/or periodic limb movement disorder (PLMD) was investigated by using a suggested immobilization test (SIT) and by measuring the influence of these disorders on the subjective sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI). Patients with RLS and those with both RLS and PLMD showed remarkably high values for PSQI and SIT, whereas patients with PLMD only showed normal values for PSQI. These findings suggest that there is only a small pathological significance for periodic limb movements, and demonstrate the efficacy of SIT and PSQI for evaluating the severity of these disorders. [source] Patterns and predictors of sleep pattern disturbance after cardiac surgeryRESEARCH IN NURSING & HEALTH, Issue 4 2004Nancy S. Redeker Abstract The purposes of this study were to examine changes in sleep patterns after cardiac surgery and the contributions of preoperative sleep to postoperative sleep. Seventy-two cardiac surgery patients wore wrist actigraphs for 3 days during the preoperative period (T1) and the 1st (T2), 4th (T3), and 8th (T4) postoperative weeks. They completed the Pittsburgh Sleep Quality Index at T1, T3, and T4. Sleep was most disturbed during the 1st postoperative week and improved at T3 and T4. Overall, sleep pattern disturbance was higher at T3 and T4 than at T1. Age, gender, preoperative New York Heart Association Functional Class, and preoperative sleep variables explained 20%,50% of the variance in sleep at T2, T3, and T4. Sleep disturbance is present preoperatively and continues during the postoperative period. © 2004 Wiley Periodicals, Inc. Res Nurs Health 27:217,224, 2004 [source] Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgarisTHE JOURNAL OF DERMATOLOGY, Issue 11 2006Yoshie MATSUOKA ABSTRACT Acne vulgaris significantly affects patients' quality of life (QOL) and their lives in various ways, including social behavior and body dissatisfaction. This may be heightened by acne's typical involvement of the face. We investigated whether the use of skin care and makeup could influence the QOL of affected patients without deteriorating conventional acne treatments. Fifty female patients with acne were recruited for our study. Twenty-five patients were instructed how to use skin care and cosmetics, while 25 patients received no specific instructions from dermatologists. Both groups received conventional topical and/or oral medication for acne during the study period for 4 weeks. Both groups did not show any significant difference in clinical improvement of acne severity. Two validated QOL questionnaires, World Health Organization (WHO)QOL26 and the Dermatology Life Quality Index (DLQI) were administered to all patients at first visit and 4 weeks later. The mean scores of psychological and overall domains in WHOQOL26 for patients with instructions were improved significantly, while only the overall score was significantly improved for patients without instructions. The total mean scores and all domains except work/school in DLQI for patients with instructions were improved significantly, while the total scores and all domains except discomfort for treatment in DLQI were significantly improved for patients without instructions. Thus, instructions on the use of skin care and cosmetics for female acne patients did not deteriorate acne treatment and influenced patients' QOL effectively. We therefore suggest that instructions for using skin care and cosmetics complement conventional medical treatments for acne. [source] ORIGINAL RESEARCH,PAIN: Sexual Dysfunction in Patients with Chronic Hand Eczema in the Turkish PopulationTHE JOURNAL OF SEXUAL MEDICINE, Issue 6 2007Mahizer Ergün MD ABSTRACT Introduction., Hand eczema can cause considerable psychosocial disorders, such as anxiety, depression, and difficulties at work, and it may also cause sexual dysfunction. Aim., The aim of this study was to investigate sexual function in patients with hand eczema and to find out whether concomitant depression has an additional negative effect on sexual function in these patients. Main Outcome Measures., Sexual functions were evaluated in hand eczema patients. Methods., Ninety-one female (43 patients vs. 48 controls) and 79 male (45 patients vs. 34 controls) subjects were enrolled in the study. Hand eczema severity index was used to determine severity of hand eczema. The Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF) were used to assess sexual function. Quality of life was assessed with the Dermatology Life Quality Index. Diagnosis of depression was made based on the Structured Clinical Interview for the DSM-IV, while the Hamilton Depression Rate Scale was used for grading depression. Results., Among 43 female subjects with hand eczema, 26 had depression (60.46%); of the 45 male patients, 11 had depression (24.44%). FSFI total score was found to be significantly decreased in female patients with both eczema and depression compared with controls (20.84 ± 9.19 vs. 24.04 ± 3.40, P < 0.05). FSFI total score was found to be significantly decreased in female patients with both eczema and depression compared with those without depression (20.84 ± 9.19 vs. 22.23 ± 5.82, P < 0.05). IIEF total score was also found to be significantly decreased in male patients with or without depression compared with controls (52.36 ± 14.83 vs. 59.88 ± 5.65 vs. 62.03 ± 11.04, P < 0.05). Conclusions., The results of the study demonstrated that patients with hand eczema had sexual dysfunction, and concomitant depression had an additional negative effect on sexual dysfunction. Patients with hand eczema should be evaluated with regard to sexual function and depression to provide a better quality of life. Ergün M, Türel Ermertcan A, Öztürkcan S, Temelta, G, Deveci A, and Dinç G. Sexual dysfunction in patients with chronic hand eczema in the Turkish population. J Sex Med 2007;4:1684,1690. [source] The Skin Cancer Index: Clinical Responsiveness and Predictors of Quality of Life,THE LARYNGOSCOPE, Issue 3 2007John S. Rhee MD Abstract Objective: To establish the clinical responsiveness of the Skin Cancer Index (SCI), a new disease-specific quality of life (QOL) instrument, and to assess demographic and clinical factors which impact QOL in patients with nonmelanoma skin cancer (NMSC). Study Design: Prospective study of 183 patients with NMSC of the face and neck referred to a tertiary care Mohs surgery clinic. Methods: The SCI is a 15 item, validated, disease-specific QOL instrument with 3 distinct subscales, Emotion, Social, and Appearance. Higher scores reflect better QOL. The SCI and the Dermatology Life Quality Index (DLQI), a general dermatology instrument, was administered at initial consultation and 4 months after surgical treatment. Multivariate analysis was conducted to assess demographic and clinical factors predictive of QOL for both instruments. Results: The SCI total score and all three subscale scores increased with treatment, demonstrating strong evidence of responsiveness over time (P < .001) in contrast with the DLQI (P = .46). Predictors of poorer QOL for the SCI included female sex and cancers located on the lip. Patients who demonstrated greatest improvement in QOL with treatment included those who were younger (<50 yr) and had lower reported household income. Also, first time NMSC patients and those patients who underwent less extensive reconstructions demonstrated greater improvements in QOL. Conclusion: The SCI is a sensitive and responsive QOL instrument for patients with NMSC. Distinct demographic and clinical variables that impact QOL have been demonstrated using this multidimensional, disease-specific instrument. [source] Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesityBRITISH JOURNAL OF DERMATOLOGY, Issue 4 2009K. Sartorius Summary Background, Hidradenitis suppurativa (HS) is a long-standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS. Objectives, To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity. Methods, Two hundred and fifty-one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty-six patients completed the Dermatology Life Quality Index (DLQI). Results, The median (interquartile range, IQR) HSS for all patients was 38 (18,66): women 38 (18,71) and men 37 (19,51). Median (IQR) HSS for smokers was 41 (22,75·5), former smokers 27 (16,53) and nonsmokers 22 (10,57). Median (IQR) HSS for patients with BMI < 25 kg m,2 was 32 (12,54), BMI 25,30 kg m,2 44 (22,56) and BMI , 30 kg m,2 50 (18,86). Mean ± SD DLQI for the whole group of patients was 10·3 ± 7·5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women. Conclusions, The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS. [source] Objective vs. subjective factors in the psychological impact of vitiligo: the experience from a French referral centreBRITISH JOURNAL OF DERMATOLOGY, Issue 1 2009P. Kostopoulou Summary Background, Vitiligo affects around 0·5% of the population. The burden of disease perceived by patients seems to be underestimated by the medical community. Objectives, To analyse the impact of objective and psychological factors on the quality of life (QoL) and self-body image of patients with vitiligo. Methods, Demographic data, medical information and psychological factors (perceived severity, trait anxiety, trait depression, trait self-esteem, body image and QoL) were prospectively collected for all patients. Results, Forty-eight patients with a mean age of 43·9 years were included in the study. Vitiligo caused overall a moderate effect on patients' QoL with a 7·17 Dermatology Life Quality Index (DLQI) mean score (out of 30) without correlation with gender. According to distribution, no or minimal (DLQI 0,1), mild (2,5), moderate (6,11) and severe (12,20) impairment of QoL was found in five (10%), 14 (29%), 18 (38%) and 11 (23%) patients, respectively. The mean perceived severity evaluated by the patients was 4·91 based on visual analogue scale from 0 to 10. The self-body image was influenced by gender, perceived severity and disease characteristics. Perceived severity and patient personality were predictors of QoL impairment. Perceived severity of vitiligo was explained mainly by the patients' personality and less significantly by objective criteria. Conclusions, Subjective as well as objective factors should be included in the assessment of disease severity and follow-up of patients with vitiligo. A simple perceived severity scale is useful in clinical practice. [source] Willingness-to-pay and quality of life in patients with vitiligoBRITISH JOURNAL OF DERMATOLOGY, Issue 1 2009M.A. Radtke Summary Background, Vitiligo is a chronic pigmentary disorder of the skin, affecting 1,2% of the general population. Although not life threatening, vitiligo may considerably influence patients' health-related quality of life (QoL) and psychological well-being. Willingness-to-pay (WTP) is a construct reflecting disease burden and QoL reduction which has not yet been used in vitiligo. Objectives, To assess the WTP and the QoL of patients with vitiligo. Methods, Patients with vitiligo were included in a nationwide German postal survey. WTP was assessed by two standardized items, and QoL was evaluated using the Dermatology Life Quality Index (DLQI) and the EuroQol (EQ-5D) questionnaire. QoL data were compared with n = 1511 patients from a national survey on psoriasis. Results, The questionnaire was completed by 1023 patients (71·5% women, mean age 44·4 years, mean disease duration 20·3 years) with vitiligo. The mean DLQI was 7·0 (7·5 in women, 5·5 in men) compared with 8·6 in psoriasis. Of the patients with vitiligo, 24·6% had a DLQI > 10 which indicates severe QoL reductions, compared with 34·1% in patients with psoriasis. The highest mean DLQI value was observed in the patient group aged 20,29 years. EQ-5D mean score was 83·6 compared with 75·3 in psoriasis. Of the patients with vitiligo, 32·9% would pay more than 5000 Euro in order to achieve complete disease remission. WTP was highest among middle-aged patients (30,60 years). There was a significant correlation between DLQI scores and WTP (,2 = 65·43, P < 0·001). Moreover, WTP significantly correlated with duration of disease, and with body surface area affected (P < 0·001). Conclusions, Vitiligo causes substantial disease burden as reflected by QoL impairment and high WTP, especially in women. These results should draw the attention of physicians to this disease, as appropriate education and treatment are likely to improve the QoL of patients with vitiligo and may support patients' compliance and empowerment. [source] Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasisBRITISH JOURNAL OF DERMATOLOGY, Issue 5 2009K. Reich Summary Background, Because psoriatic arthritis (PsA) usually develops years after the first manifestation of skin symptoms, in many cases the initial diagnosis of PsA depends on the dermatologist. Objectives, To investigate the prevalence and clinical pattern of PsA in a daily practice population of patients with psoriasis. Methods, Patients were enrolled in an observational prospective cross-sectional cohort study at 48 community and academic centres. Demographic and medical parameters were recorded, including severity of skin symptoms (Psoriasis Area and Severity Index, PASI), previous and current treatments, concomitant diseases, and the impact of psoriasis on productivity and health-related quality of life (Dermatology Life Quality Index, DLQI). Patients with joint symptoms were referred to a rheumatologist for diagnosis and to record the activity and pattern of arthritis. Results, Among 1511 patients 20·6% had PsA; in 85% of the cases PsA was newly diagnosed. Of these patients more than 95% had active arthritis and 53·0% had five or more joints affected. Polyarthritis (58·7%) was the most common manifestation pattern, followed by oligoarthritis (31·6%) and arthritis mutilans (4·9%). Distal interphalangeal involvement was present in 41·0% and dactylitis in 23·7% of the patients. Compared with patients without arthritis, patients with PsA had more severe skin symptoms (mean PASI 14·3 vs. 11·5), a lower quality of life (mean DLQI 11·6 vs. 7·7) and greater impairment of productivity parameters. Conclusions, The findings are consistent with a high prevalence of undiagnosed cases of active PsA among patients with psoriasis seen by dermatologists. As many of these patients also have significant skin symptoms, treatment strategies are required that are equally effective in the control of skin and joint symptoms of psoriasis. [source] | ||||||||||||||||||||||||||||||||||||||||||||||