Risk factors of involuntary referral by police to ER psychiatric services for patients with a severe mental illness: A GEE analysis

This study aimed to identify risk factors for involuntary referral by police to emergency room (ER) psychiatric services for community-based patients with a mental illness via a generalized estimating equation (GEE) analysis. The analysis was based on data from the Management Information System of Psychiatric Care (MISPC) system for patients with a severe mental illness in Taipei, Taiwan and registered referral records of the police. Data on 6378 patients aged ≥20 years were used in this study, including 164 patients who were involuntarily referred to the ER by the police and 6214 patients who were not during the period of January 1, 2018 to December 31, 2020. GEEs were utilized to explore possible risk factors of repeated involuntary referral to ER psychiatric services for patients with a severe mental illness. The logistic regressions indicated that patients defined as "severe" according to the Mental Health Act of Taiwan (crude odds ratio (OR): 3.840, 95 % confidence interval (CI): 2.407-6.126), with a disability (crude OR: 3.567, 95 % CI: 1.339-9.501), with two or more family members with a psychiatric disorder (crude OR: 1.598, 95 % CI: 1.002-2.548), with a history of a suicide attempt (crude OR: 25.582, 95 % CI: 17.608-37.167), and with a history of domestic violence (crude OR: 16.141, 95 % CI: 11.539-22.579) were positively associated with involuntary referral to ER psychiatric services. However, age (crude OR: 0.971, 95 % CI: 0.960-0.983) and the MISPC score (crude OR: 0.834, 95 % CI: 0.800-0.869) were inversely associated with involuntary referral to ER psychiatric services. After adjusting for demographics and potential confounders, we found that patients defined as "severe" (Exp (β): 3.236), with a disability (Exp (β): 3.715), with a history of a suicide attempt (Exp (β): 8.706), and with a history of domestic violence (Exp (β): 8.826), as well as age (Exp (β): 0.986) and the MISPC score (Exp (β): 0.902) remained significantly associated with repeated involuntary referral to ER psychiatric services. In conclusion, community-based mentally ill patients with a history of a suicide attempt, with a history of domestic violence, with a severe illness, and with a profound level of disability were highly associated with involuntary referral to ER psychiatric services. We suggest that community mental health case managers identify significant factors associated with involuntary referral to ER psychiatric services to accordingly arrange case management plans.

Development of wearable posture monitoring system for dynamic assessment of sitting posture

There have been increasing cases of people seeking treatment for neck and back pain. The most common cause of neck and back pain is due to long-term poor sitting posture. The most common poor sitting posture cases are humpback, and head and neck being too far forward. It is easy to cause neck and back pain and other symptoms. Therefore, the development of wearable posture monitoring system for dynamic assessment of sitting posture becomes both helpful and necessary. In addition to recording the wearer's posture when sitting with quantitative assessment, it is needed to execute real-time action feedback for correctness of posture, in order to reduce neck and back pain due to long-term poor sitting posture. This study completed an instant recording and dynamic assessment of position measurement and feedback system. The system consists of a number of dynamic measurement units that can describe the posture trajectory, which integrates three-axis gyro meter, three-axis accelerometer, and magnetometer in order to measure the dynamic tracking. In the reliability analysis experiment, angle measurement error is less than 2%. The correlation coefficient between correlation analysis and Motion Analysis (MA) is 0.97. It is shown that the motion trajectory of this system is highly correlated with MA. In the feasibility test of sitting position detection, it is possible to detect the sitting position from the basic action of the walking, standing, sitting and lying down, and the sensitivity reaches 95.84%. In the assessment of the sitting position, the information published by the Canadian Centre for Occupational Health and Safety was used, as well as the recommendations of professional physicians as a basis for evaluating the threshold of the sitting measurement parameters and immediately feedback to the subjects. The system developed in this study can be helpful to reduce neck and back pain due to long-term poor sitting posture.

Large Collective Lamb Shift of Two Distant Superconducting Artificial Atoms

Virtual photons can mediate interaction between atoms, resulting in an energy shift known as a collective Lamb shift. Observing the collective Lamb shift is challenging, since it can be obscured by radiative decay and direct atom-atom interactions. Here, we place two superconducting qubits in a transmission line terminated by a mirror, which suppresses decay. We measure a collective Lamb shift reaching 0.8% of the qubit transition frequency and twice the transition linewidth. We also show that the qubits can interact via the transmission line even if one of them does not decay into it.

Radiomics features analysis of PET images in oropharyngeal and hypopharyngeal cancer

This study used radiomics image analysis to examine the differences of texture feature values extracted from oropharyngeal and hypopharyngeal cancer positron emission tomography (PET) images on various tumor segmentations, and finds the proper and stable feature groups. A total of 80 oropharyngeal and hypopharyngeal cancer cases were retrospectively recruited. Radiomics method was applied to the PET image for the 80 oropharyngeal and hypopharyngeal cancer cases to extract texture features from various defined metabolic volumes. Kruskal-Wallis one-way analysis of variance method was used to test whether feature value difference exists between groups, which were grouped by stage, response to treatment, and recurrence. If there was a significant difference, the corresponding feature cutoff value was applied to the Kaplan-Meier estimator to estimate the survival functions. For the various defined metabolic volumes, there were 16 features that had significant differences between early (T1, T2) and late tumor stages (T3, T4). Five images and 2 textural features were found to be able to predict the tumor response and recurrence, respectively, with the areas under the receiver operating characteristic curves reaching 0.7. The histogram entropy was found to be a good predictor of overall survival (OS) and primary relapse-free survival (PRFS) of oropharyngeal and hypopharyngeal cancer patients. Textural features from PET images provide predictive and prognostic information in tumor staging, tumor response, recurrence, and have the potential to be a prognosticator for OS and PRFS in oropharyngeal and hypopharyngeal cancer.

RECOVERING EEG SIGNALS: MUSCLE ARTIFACT SUPPRESSION USING WAVELET-ENHANCED, INDEPENDENT COMPONENT ANALYSIS INTEGRATED WITH ADAPTIVE FILTER

Independent component analysis (ICA) has been proven to be a powerful tool for removing artifacts from electroencephalogram (EEG) recordings in the form of blind source separation (BSS). Independent components (ICs) come from undesired sources that are mixed with the useful signal, and the assessment of such ICs allows them to be detected. But the unwanted ICs also can contain some useful information. To overcome this problem, wavelet-enhanced ICA (wICA) can be used, and this method applies a wavelet threshold for each wavelet coefficient to suppress abnormal deformation in each wavelet coefficient. Using the wICA algorithm to suppress artifacts provides an EEG signal with less distortion in the amplitude and in the phase of the cerebral part of the EEG, and the cerebral part of the EEG can be estimated and obtained very similar to control conditions. However, the EEG signals are affected by various artifact components, and those that have the greatest influence are electromyography (EMG) and electrooculography (EOG). These artifacts may appear simultaneously, randomly or interruptedly, so a fixed threshold level is not really appropriate. We proposed a system including wICA integrated with an adaptive filter model, and this combination system can provide the best prediction of the impacts of artifacts to set up a threshold value that is adaptive and suitable. Our experimental results showed that are approach provided better rejection of artifacts than the wICA system.

RECOGNITION OF SLEEP STAGES BASED ON A COMBINED NEURAL NETWORK AND FUZZY SYSTEM USING WAVELET TRANSFORM FEATURES

Recognition of sleep stages is an important task in the assessment of the quality of sleep. Several biomedical signals, such as EEG, ECG, EMG and EOG are used extensively to classify the stages of sleep, which is very important for the diagnosis of sleep disorders. Many sleep studies have been conducted that focused on the automatic classification of sleep stages. In this research, a new classification method is presented that uses an Elman neural network combined with fuzzy rules to extract sleep features based on wavelet decompositions. The nine subjects who participated in this study were recruited from Cheng-Ching General Hospital in Taichung, Taiwan. The sampling frequency was 250 Hz, and a single-channel (C3-A1) EEG signal was acquired for each subject. The system consisted of a combined neural network and fuzzy system that was used to recognize sleep stages based on epochs (10-second segments of data). The classification results relied on the strong points of combined neural network and fuzzy system, which achieved an average specificity of approximately 96% and an average accuracy of approximately 94%.

Highly efficient beamline and spectrometer for inelastic soft X-ray scattering at high resolution

The design, construction and commissioning of a beamline and spectrometer for inelastic soft X-ray scattering at high resolution in a highly efficient system are presented. Based on the energy-compensation principle of grating dispersion, the design of the monochromator-spectrometer system greatly enhances the efficiency of measurement of inelastic soft X-rays scattering. Comprising two bendable gratings, the set-up effectively diminishes the defocus and coma aberrations. At commissioning, this system showed results of spin-flip, d-d and charge-transfer excitations of NiO. These results are consistent with published results but exhibit improved spectral resolution and increased efficiency of measurement. The best energy resolution of the set-up in terms of full width at half-maximum is 108 meV at an incident photon energy tuned about the Ni L3-edge.

Acoustic features for identifying constitutions in traditional Chinese medicine

OBJECTIVES

Constitutions are Traditional Chinese Medicine syndromes that are used to classify symptoms. The present study sought to identify objective acoustic features for eight commonly occurring abnormal constitutions.

METHODS

Speech signals were obtained from 281 subjects through a 1-second vowel sound, /a/, uttered by the subjects. For each constitution, differences in acoustic parameters between the low-score and high-score groups were compared.

RESULTS

Subjects in the high-score groups for Yin-deficiency, Qi-deficiency, Phlegm-wet, Blood-stasis, and Qi-depression showed lower acoustic intensities than subjects in the corresponding low-score groups (all p<0.05). Subjects in the high-score groups of Qi-deficiency and Blood-stasis exhibited higher maximum pitches and higher minimum pitches than subjects in the low-score groups (all p<0.01). The average number of zero-crossings was lower in the high-score groups of Qi-deficiency and Blood-stasis than in the low-score groups for both constitutions (p<0.05). Subjects in the high-score group of special diathesis demonstrated higher low-spectral-energy ratios than subjects in the low-score group (p<0.05), and subjects in the high-score group of Blood-stasis had higher middle spectral energy ratios than subjects in the low-score group (p<0.05). In contrast, the middle spectral energy ratio in the high-score group of special diathesis was lower than in its corresponding low-score group (p<0.05). The high spectral energy ratios were lower in the high-score groups for Yin-deficiency and Blood-stasis (both p<0.05) than in the low-score groups.

CONCLUSIONS

The present study identified acoustic features for constitutions and established objective methods for constitutional diagnosis. These acoustic features can potentially be applied in the expert system of Traditional Chinese Medicine for the diagnosis of constitutions in the general population.

Competition between harmonic cyclotron maser interactions in the terahertz regime

Cyclotron harmonic interactions are a key physics issue of critical importance to the generation of terahertz radiation via the electron cyclotron maser instability for practical magnetic field strengths. We present an inherent mechanism, as well as a deciding factor, which governs the competition between low- and high-harmonic interactions. Multimode simulations reveal the physical process in which a significant advantage develops for the lower-harmonic interaction, which eventually dominates in the fully nonlinear stage. The results also suggest a start-up scenario for persistent higher-harmonic operation.

Dynamic cerebral autoregulation assessment using chaotic analysis in diabetic autonomic neuropathy

Cerebral autoregulation (CA) was assessed by chaotic analysis based on mean arterial blood pressure (MABP) and mean cerebral blood flow velocity (MCBFV) in 19 diabetics with autonomic neuropathy (AN) and 11 age-matched normal subjects. MABP in diabetics dropped significantly in response to tilting (91.6 +/- 14.9 vs. 74.1 +/- 13.4 mmHg, P < 0.05). Valsalva ratio of heart rate was reduced in diabetics compared to normal (1.1 +/- 0.1 vs. 1.5 +/- 0.2, P < 0.05). It indicated AN affects the vasomotor tone of peripheral vessels and baroreflex. Nonlinear results showed higher correlation dimension values of MABP and MCBFV in diabetics compared to normal, especially MABP (3.7 +/- 2.3 vs. 2.0 +/- 0.8, P < 0.05). It indicated CA is more complicated in diabetics. The lower Lyapunov exponent and the higher Kolmogorov entropy values in diabetics indicated less predictable behavior and higher chaotic degree. This study suggests impaired autoregulation would be more chaotic and less predictable.

Twenty-year follow-up of the Carpentier-Edwards standard porcine bioprosthesis in the Oriental population

AIM

The 20-year period long-term results of porcine bioprosthetic valve use are limited. In addition, the majority of these reports come from Western countries. Given the scanty information reported in Oriental countries, this study was therefore designed to examine 20-year long-term results in patients who received a Carpentier-Edwards porcine bioprosthetic valve in an effort to contribute further information on the long-term clinical performance of porcine prosthetic valves from a viewpoint of results in the Oriental population.

METHODS

From July 1979 to April 2001, 82 patients received valve replacement with a standard Carpentier-Edwards porcine valve. There were 40 men and 42 women with a mean age of 42.3+/-15.1 years (range 16 to 73 years). Follow-up time extended more than 20 years (mean 10.9+/-3.2 years, range 0.5 to 21.5 years ) for a total of 719.5 patient-years.

RESULTS

The overall operative mortality was 16.9% (14 of 83 procedures). At 5, 10, 15, and 20 years, the actuarial survival rate of patients was 71.7%, 66.9%, 55.5%, and 44.4%, respectively. Actuarial estimates of freedom from structural valvular deterioration (SVD) at 5, 10, 15, and 17 years were 96.3%, 64.0%, 24.3%, and 24.3%, respectively; from reoperation 96.3%, 64.5%, 24.5%, and 24.5%; from operated valvular endocarditis 96.8%, 92.6%, 92.6%, and 92.6%; and from overall thromboembolism 96.3%, 88.5%, 67.2%, and 52.2%. In normal sinus rhythm, actuarial estimates of freedom from thromboembolism at 5, 10, 15, and 17 years were 100.0%, 100.0%, 81.8%, and 81.8%, respectively. Whereas for those in patients with atrial fibrillation, the estimates of freedom from thromboembolism were 94.5%, 82.4%, 57.7%, and 38.5%.

CONCLUSION

This study demonstrates the very satisfactory 20-year period long-term performance of freedom from bleeding events, thromboembolism (except in patients with atrial fibrillation), and valvular endocarditis in Oriental patients undergoing replacement with a porcine valve. However, the remarkable rate of SVD and reoperation ensued at 6 years after bioprosthesis implanted which does not differ from the series reported from Western countries.

Objective assessment of blood stasis using computerized inspection of sublingual veins

In traditional Chinese tongue diagnosis, inspection of the sublingual veins has been developed as a new diagnostic examination method especially for determining blood stasis. The main purpose of this research is to develop a computerized inspection system, used to quantitatively extract the chromatic and geometrical properties of sublingual veins. A method based on color equalization is presented to assist the image segmentation of sublingual veins. Color image analysis techniques are applied to extract the length, width, area and color information from sublingual veins. Experimental results are compared with the visual inspection of physicians. The severity of blood stasis was classified into three groups: normal, moderate and pronounced. Each group consisted of eight subjects. The overall recognition rate is 87.5% in the leaving-one-out classification using the developed system.

Lack of CYP3A4 inhibition by grapefruit juice and ketoconazole upon clozapine administration in vivo

The drug-food and drug-drug interaction between grapefruit juice (GFJ) and ketoconazole (KETO) was evaluated in schizophrenic patients given a single dose of clozapine (CLZ). CLZ is metabolized primarily by CYP isozymes 3A4 and 1A2 to two principal metabolites, desmethylclozapine (DCLZ) and clozapine N-oxide (CNO). GFJ and KETO are well known potent CYP 3A4 inhibitors in the gastrointestinal tract and hepatic isozymes, respectively. Twenty-one schizophrenic patients participated in the co-administration of CLZ 50 mg and GFJ. After a one-week washout, five patients were given double the GFJ (HGFJ) dose for 7 consecutive days. In another group of five patients, ketoconazole (KETO) 400 mg was given for 7 consecutive days. At the end of the 7-day period for both groups, CLZ was coadministered with the HGFJ and KETO groups. CLZ, DCLZ and CNO were assayed by HPLC. GFJ, HGJF and ketoconazole failed to significantly change CLZ disposition. Metabolites DCLZ and CNO concentrations remained unchanged during the study. The only exception was decreased Cmax in DCLZ and CNO concentrations. These results indicate that CYP 3A4 inhibition may not be clinically significant compared to CYP 1A2, as previous studies show a dramatic increase in CLZ plasma concentrations with fluvoxamine (CYP 1A2 inhibitor). The reasons for the lack of drug-food and drug-drug interactions with CLZ and CYP 3A4 inhibitors can be explained by the higher Ki values for gastrointestinal and hepatic CYP 3A4 isozymes.

Assessment of cerebral autoregulation using time-domain cross-correlation analysis

Time domain cross-correlation analysis of pre-filtered mean arterial blood pressure (MABP) and mean cerebral blood flow velocity (MCBFV) was applied to assess the cerebral autoregulation (CA). Beat-to-beat time series of spontaneous arterial blood pressure and cerebral blood flow velocity were obtained from 13 young normal volunteers with the Finapres device and the transcranial Doppler for periods of approximately 5 min in the supine position. Cross-correlation functions (CCFs) were estimated using a 64 beat wide moving window. Mean CCF patterns were obtained for each subject and for the entire population. The MABP and MCBFV signals were bandpass filtered in the very low-frequency range (VLF, 0.015-0.07 Hz), low-frequency range (LF, 0.07-0.15 Hz) and high-frequency range (HF, 0.15-0.40 Hz) before applying CCF for the purpose of studying the effect of different bandwidths on the resulting mean CCFs. Results revealed that the corresponding time lags of the peak values of the MABP-MCBFV CCFs increased significantly between the LF and HF frequency ranges (LF: -1.20+/-0.91 s, HF: -0.07+/-0.42 s,p < 0.001; paired sign test). The left-shift (negative lag) of the CCF peak between MABP and MCBFV is a result of the phase-lead property. The increasing time lag of the CCF peak indicated evidence of the autoregulatory disturbance. The CCF of pre-filtered spontaneous MABP and MCBFV could be a useful tool to estimate the CA dynamic response.

Correlation of human papillomavirus 16 and 18 with cervical neoplasia in histological typing and clinical stage in Taiwan: an in-situ polymerase chain reaction approach

BACKGROUND AND OBJECTIVES

In situ polymerase chain reaction (ISPCR) promises to considerably enhance our ability to detect a few copies of target nucleic acid sequences in fixed tissues and cells. The aim of this study was to investigate cervical carcinoma to determine the human papillomavirus (HPV) types on paraffin-embedded tissue sections by ISPCR and standard in situ hybridization. The results will correlate the morphological characteristics of lesions with viral typing results.

METHODS

This study examined prevalence of HPV 16 and 18 DNA in biopsies from 85 cervical cancer patients by ISPCR, employing HPV 16, 18 consensus primers. There are 45 patients with squamous cell carcinomas, 13 with adenocarcinoma, 2 with adenosquamous carcinomas, 3 with small cell carcinomas, and 22 carcinoma in situ. The relation between the types of HPV detected, tumor type, and clinical stage were analyzed.

RESULTS

Fifty-two of 85 biopsies were HPV 16- or 18-positive, HPV 16 being the most prevalent type. Squamous cell carcinoma had a high prevalence of HPV 16 and adenocarcinoma had a high prevalence of HPV 18. HPV 18 was the predominant type among high clinical stage (III-IV) cases while HPV 16 and mixed HPV 16 with HPV18 were significantly correlated with low clinical stage (0-I-II).

CONCLUSION

Our results indicate that certain malignant cervical tumor phenotypes and stages correlate with specific HPV type, and that ISPCR is a sensitive and fast method to detect HPV in these patients.

Repeated ingestion of grapefruit juice does not alter clozapine's steady-state plasma levels, effectiveness, and tolerability

BACKGROUND

Grapefruit juice can inhibit the gastrointestinal activity of cytochrome P450 (CYP) 3A4, while its effect on CYP1A2 remains controversial. Several grapefruit juice bioflavonoids also modulate the activity of the drug transporter P-glycoprotein in the gut and in the blood-brain barrier. Both CYP1A2 and CYP3A4 are involved in clozapine metabolism. This study investigated the effects of repeated ingestion of grapefruit juice on multiple-dose pharmacokinetics and pharmacodynamics of clozapine in schizophrenic patients.

METHOD

Clozapine therapy was initiated for fifteen treatment-resistant schizophrenic inpatients (DSM-IV criteria). The doses were individually titrated from day -35 to day -15 and then kept unchanged from day -14 to day 49. Regular-strength grapefruit juice (250 mL) was coadministered b.i.d. with each clozapine dose from day 15 to day 28. Plasma levels of clozapine and its main metabolites (norclozapine and clozapine N-oxide) were obtained, and clinical efficacy and safety assessments were completed prior to juice administration (days 0, 7, and 14), during the coadministration (days 17, 21, and 28), and after cessation of the juice (days 35, 42, and 49).

RESULTS

After reaching steady states, plasma concentrations of clozapine and its metabolites and Positive and Negative Syndrome Scale scores were not significantly altered by the effect of grapefruit juice ingestion. The Clinical Global Impressions scale scores, Calgary Depression Scale scores, and side effect profiles (by the Extrapyramidal Symptom Rating Scale, the UKU Side Effect Rating Scale, and thorough examinations including electrocardiography and electroencephalography) also remained constant during the study.

CONCLUSION

Consumption of regular-strength grapefruit juice, 250 mL b.i.d., for 14 days did not significantly impact clozapine metabolism, clinical efficacy, or tolerability. One reason is that enzymes other than CYP3A4 also mediate clozapine disposition. Also, grapefruit juice inhibits CYP3A4 in the gut, but not in the liver. The preliminary results also suggest that clozapine is unlikely to be a P-glycoprotein substrate. Further rigorous studies are necessary to reconfirm these findings.

Clinical use of permanent pacemaker for conversion of intraatrial reentry tachycardia in children

The use of the implanted atrial-based pacemaker to overdrive postsurgical intraatrial reentry tachycardia (IART) was evaluated in a large group of pediatric patients over a 14-year study period. The authors sought to determine the feasibility of this noninvasive technique in the management of this specialized population and to determine factors associated with successful conversion. They examined 128 manual overdrive attempts performed on 22 consecutive patients. There were 10 patients with post-Fontan repair, 7 with post-Mustard/Senning procedure, and 5 with miscellaneous lesion types. The number of IART episodes for overdrive pacing per patient ranged from 1 to 15. The first overdrive pacing attempt was successful in 63% (14/22) of the patients. The mean IART cycle length was 278 +/- 59 ms. The mean pacing rate for effective conversion of IART was 66 +/- 10% faster than the IART rate. By controlling for repeated measures for individual patients, three factors were found to be independently associated with a successful outcome: (1) lesion type other than Fontan surgery (P = 0.007), (2) lack of acceleration of IART with the overdrive attempt (P < 0.001), and (3) patient use of amiodarone with attempt (P = 0.005). There were three procedural complications: two inadvertent overdrive pacing episodes, and one episode of acceleration of IART cycle length and conduction resulting in need for cardioversion. Manual pacemaker overdrive conversion of IART is a useful adjunct in the management of postsurgical IART in the pediatric population and should be considered as an initial treatment option.

Intractable ventricular tachycardia in a patient with left ventricular epicardial lipoma

Primary cardiac lipomas are rare and are often reported as incidental findings during operations or autopsies. Lipoma-induced arrhythmia, especially ventricular tachycardia (VT), is an unusual complication of primary cardiac lipoma. We describe the case of a 43-year-old woman who presented with VT without any cardiac abnormality except for a left ventricular tumor. Electrophysiologic study (EPS) failed to detect the origin of the arrhythmia, although VT could be induced by EPS preoperatively. Due to suspicion of a relationship between the tumor and the VT, wide tumor resection was performed using cardiopulmonary bypass support. The excised lipoma measured about 10 x 8 x 3 cm and weighed 120 g, and was without pathohistologic evidence of malignant change. The patient was well without further postoperative need for antiarrhythmic drugs at 36 months' follow-up, and VT was no longer inducible on subsequent EPS mappings.

Persistent fifth aortic arch: an ignored and underestimated disease

We report two unique cases of persistent fifth aortic arch with a systemic-to-pulmonary connection. All previously reported cases with such a connection in the literature have either been cases of pulmonary atresia or an aortic arch anomaly, and the existence of a fifth aortic arch was a benefit to the underlying great vessel anomaly. However, our two cases did not have this associated great vessel anomaly, and the fifth arch resulted in a large left-to-right shunt with severe pulmonary hypertension and heart failure. The first case was misdiagnosed preoperatively; an accurate diagnosis was made after cardiac surgery. Because of its rarity and complexity, a persistent fifth aortic arch is often ignored and misdiagnosed.

Objective auscultation for traditional chinese medical diagnosis using novel acoustic parameters

The goal of this work is to propose novel acoustic parameters of voice for the purpose of providing a quantitative analysis of auscultation in traditional Chinese medical diagnosis. There is rare amount of available literature related to this topic. Four novel acoustic parameters, the average number of zero-crossings, the variations in local peaks and valleys, the variations in first and second formant frequencies, and the spectral energy ratio, are presented to analyze and identify the characteristics among non-vacuity, qi-vacuity, and yin-vacuity subjects. Among these acoustic parameters, two temporal parameters, the average number of zero-crossings and the variations in local peaks and valleys, outperformed other parameters in classifying both non-vacuity and deficient subjects. The spectral energy ratio was adequate for the classification between qi-vacuity and yin-vacuity patients. This research is a first step in an ongoing effort to modernize the auscultation in traditional Chinese medical diagnosis.

Pharmacological effects of an aldehyde type alpha/beta-adrenoceptor blocking agent with vasodilating properties

KMUP 880723 (0.5, 1.0, and 3.0 mg/kg, iv) produced dose-dependent hypotensive and bradycardia responses in pentobarbital-anesthetized Wistar rats. KMUP 880723 (1.0 mg/kg, iv) also markedly inhibited both the tachycardia effects induced by (-)isoproterenol and arterial pressor responses induced by phenylephrine. In the isolated Wistar rat right atria, left atria, and guinea pig tracheal strips, KMUP 880723 competitively antagonized the (-)isoproterenol-induced positive chronotropic effects, inotropic effects, and tracheal relaxation effects in a concentration-dependent manner. The parallel shift to the right of the concentration-response curve of (-)isoproterenol suggested that KMUP 880723 was a beta(1)/beta(2)-adrenoceptor competitive antagonist. The apparent pA(2) values were 6.89+/-0.10 in the right atria, 7.02+/-0.09 in the left atria, and 6.59+/-0.11 in the trachea, indicating that KMUP 880723 was a nonselective beta-adrenoceptor blocker. In thoracic aorta experiments, KMUP 880723 also produced a competitive antagonism of norepinephrine-induced contraction with a pA(2) value of 7.14+/-0.06. In isolated rat thoracic aorta, KMUP 880723 more potently relaxed the contractions induced by norepinephrine (3 x 10(-6) M) than those by high K(+) (75 mM). In the radioligand-binding assay, the pK(i) values of [3H]CGP-12177 binding to rat ventricle and lung membranes were 6.56 and 6.40, respectively, and the value of [3H]prazosin binding to rat brain membranes was 6.66. These results further confirmed the alpha/beta-adrenoceptor blocking activities of KMUP 880723 reported in the functional studies. We conclude that KMUP 880723 is a nonselective beta-adrenoceptor antagonist with alpha-adrenoceptor blocking-associated vasorelaxant activity.

Cyanosis caused by a huge obstructive right ventricular fibroma

Cardiac fibromas are rare lesions which occur more often in infants and children than in adults. These tumors are benign proliferations of connective tissue most often found in the left ventricular myocardium or septum. In an 8-month-old infant with cyanosis and progressive exertional dyspnea, a huge cardiac tumor obstructing the right ventricular outflow tract (RVOT) was diagnosed by means of 2-dimensional echocardiography and cardiac catheterization. At surgery, a whitish gray solitary tumor measuring 5.0 x 4.5 cm could be well visualized. It was nearly totally resected, and the RVOT was reconstructed with an Equine pericardial patch. Histologic examination classified the tumor as a fibroma. Although surgical mortality in cardiac fibroma with RVOT obstruction is extremely high, early diagnosis and prompt excision of the tumor is mandatory in relieving its dangerous symptoms.

Self-organizing arterial pressure pulse classification using neural networks: theoretical considerations and clinical applicability

A self-organizing classification system for the arterial pressure pulse based on the ART2 (adaptive resonance theory) network was developed. The system consists of a preprocessor and an ART2 recognition network. The preprocessor removes the arterial pressure pulse servo component signals from Finapres, detects the systolic pressure points and divides the acquired signals into minimal cardiac cycles. The ART2 network input is the minimal cardiac cycle detected by the preprocessor. The classification results can be used to assist physicians in evaluating the signs of abnormal and normal autonomic control and has shown its clinical applicability for the examination of the autonomic nervous system.

A novel approach based on computerized image analysis for traditional Chinese medical diagnosis of the tongue

This research is aimed at building a computerized tongue examination system (CTES) based on computerized image analysis for the purpose of quantizing the tongue properties in traditional Chinese medical diagnosis. The chromatic algorithm is developed to identify the colors of the tongue and the thickness of its coating. The textural algorithm is used to detect the grimy coating. CTES is shown to be significantly consistent within itself with P > 0.05 using the Hotelling multivariate statistical test. The overall rate of correctness for CTES to identify the colors of tongue, verifying the thickness of its coating and detecting of any grimy coating exceeds 86%. Therefore, the CTES is helpful to provide the physicians a systematic and objective diagnostic standard for the tongue diagnosis in the clinical practice and research.

Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation

OBJECTIVE

To determine the ambulatory outcome and predictive factors of successful ambulation training in patients with both hemiplegia and lower extremity amputation.

DESIGN

A retrospective study.

SETTING

A rehabilitation center of a university hospital.

PATIENTS

Twenty-three patients with dual disabilities consecutively admitted to the rehabilitation center from 1984 to 1994.

MAIN OUTCOME MEASURES

Ambulatory outcome was measured using physical therapists' and physicians' notes at discharge or the last available clinical visit. Ambulation ability was graded as community and noncommunity ambulation, which included indoor ambulation and nonambulation. Several clinical features were reviewed to assess their association with ambulation outcome.

RESULTS

About two thirds of the 23 patients could be trained to be ambulatory: 10 (43.8%) achieved community ambulation and 5 (21.7%) achieved indoor ambulation. Of the clinical factors, only mental status showed a statistically significant association with good ambulation outcome (p<.05). When odds ratios were considered, several factors, including mild motor involvement, transtibial amputation, amputation before cerebrovascular accident, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation, showed trends toward association with increased ambulation achievement, although these associations were not statistically significant.

CONCLUSION

Impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation. If subjects with dual disabilities are properly selected, satisfactory results of ambulation training will be obtained.

Suppression of ultraviolet irradiation-induced apoptosis by overexpression of focal adhesion kinase in Madin-Darby canine kidney cells

Focal adhesion kinase (FAK) has been implicated to play a role in suppression of apoptosis. In this study, we have demonstrated that UV irradiation induced cleavage of FAK and two of its interacting proteins Src and p130(Cas) in Madin-Darby canine kidney cells, concomitant with an increase in cell death. The cleavage of these proteins upon UV irradiation was completely inhibited by ZVAD-FMK, a broad range inhibitor of caspases, and apparently delayed by Bcl2 overexpression. To examine if FAK plays a role in suppressing UV-induced apoptosis, stable Madin-Darby canine kidney cell lines overexpressing FAK were established. Our results showed that a marked (30-40%) increase in cell survival upon UV irradiation was achieved by this strategy. In our efforts to determine the mechanism by which FAK transduces survival signals to the downstream, we found that a FAK mutant deficient in binding to phosphatidylinositol 3-kinase failed to promote cell survival. Moreover, the expression of the Src homology 3 domain of p130(Cas), which competed with endogenous p130(Cas) for FAK binding, abrogated the FAK-promoted cell survival. Together, these results suggest that the integrity of FAK and its binding to phosphatidylinositol 3-kinase and p130(Cas) are required for FAK to exert its antiapoptotic function.

Eugenodilol: a third-generation beta-adrenoceptor blocker, derived from eugenol, with alpha-adrenoceptor blocking and beta2-adrenoceptor agonist-associated vasorelaxant activities

Eugenodilol, derived from natural eugenol, was first investigated with in vivo and in vitro models. In our in vivo study, eugenodilol (0.5, 1.0, and 1.5 mg/kg, i.v.) produced dose-dependent hypotensive and bradycardic responses in pentobarbital-anesthetized Wistar rats. Eugenodilol also inhibited the tachycardia and arterial pressor effects induced by (-)isoproterenol and phenylephrine, respectively. In our in vitro study, eugenodilol competitively antagonized (-)isoproterenol-induced positive inotropic and chronotropic effects and tracheal-relaxation responses on isolated guinea pig tissues in a concentration-dependent manner. The apparent pA2 values were 7.88+/-0.12 for right atria, 7.52+/-0.05 for left atria, and 7.33+/-0.15 for trachea, indicating that eugenodilol was a nonselective beta-adrenoceptor blocker. In thoracic aorta experiments, the apparent pA2 values of alpha-adrenoceptor blockade were 7.05+/-0.25 and 6.87+/-0.08 for eugenodilol and labetalol, respectively. In addition, eugenodilol produced cumulative relaxation responses on isolated guinea pig tracheal strips. The effects were competitively antagonized by ICI 118,551 (10(-8)-10(-6) M), a relatively selective beta2-adrenoceptor antagonist. In the radioligand-binding assay, the Ki values of [3H]CGP-12177 binding to rat ventricle and lung membranes were 9.72 and 48.29 nM, respectively, and the value of [3H]prazosin binding to rat brain membrane was 38.72 nM. These results further confirmed the alpha/beta-adrenoceptors-blocking activities of eugenodilol reported in the functional studies. We conclude that eugenodilol is a novel third-generation beta-adrenoceptor blocker with ancillary blocking activity at alpha-adrenoceptors and weak sympathomimetic activity at beta2-adrenoceptors.

Cloning, sequencing, expression and characterization of the manganese superoxide dismutase gene from Vibrio alginolyticus

The sodA gene coding for manganese superoxide dismutase from the marine microorganism Vibrio alginolyticus was cloned, sequenced and over-expressed in Escherichia coli using the pET20b (+) expression vector. The full-length gene was consisted of 603bp open reading frame, which encoded a polypeptide of 201 amino acid residues, with a calculated molecular weight of 22672Da. The deduced amino acid sequence of the sodA showed considerable homology to other Mn-SODs. The recombinant enzyme was efficiently purified from crude E. coli cell lysate by the metal ion affinity chromatography. The recombinant VAMn-SOD resisted thermo-denaturation up to 60 degrees C and was insensitive to inhibitors such as H2O2, NaN3 and diethyldithiocarbamic acid.

Gene transfer via pollen-tube pathway for anti-fusarium wilt in watermelon

In order to obtain transgenic fusarium wilt resistant watermelon plants, squash DNA was introduced into the ovaries of watermelon plants via the pollen-tube pathway. The introduction of foreign genes into ovaries was accomplished using co-transformation with the CaMV35S-GUS as a marker. Transformed watermelon plants contained integrated copies of the GUS activity and the seeds of transformed progeny produced a blue color when stained with 5-bromo-4-chloro-3-indolyl glucuronide, whereas seeds from untransformed control plants did not. Of 200 transformed seedlings, ten were wilt resistant. The presence of the GUS activity in the genome of stable transgenic seedlings was confirmed by Southern blot analysis. Furthermore, the generation of random amplified polymorphic DNA (RAPD) fingerprints using primers with embedded restriction sites showed amplification products unique to these transgenic plants. Primers OPA-1 and OPA-9 gave distinct band patterns of genomic DNA using the polymerase chain reaction.

Apoptosis in nasopharyngeal carcinoma as related to histopathological characteristics and clinical stage

AIMS

We investigated the significance of apoptosis, using the terminal deoxynucleotidyl transferase mediated dUTP-digoxigenin nick end-labelling method, in nasopharyngeal carcinoma biopsy samples.

METHODS AND RESULTS

The apoptotic index (AI) in 50 nasopharyngeal carcinomas was compared with various histopathological features and clinical stage. Also, the AI was correlated with p53, bcl-2 and Ki67 expression by immunohistochemistry. In histopathological studies, the AI was significantly higher in mixed cellular type (MC) than in keratizing squamous cell type (KS) and spindle cell type (SC) (P < 0.001) which worsens prognosis. In tumour stage analyses, AI was higher in early stage (stage 2 and 3) than in high stage (stage 4). In addition, there was a significant correlation between the AI and p53 expression (P < 0.001) but not with proliferative activity (P = 0.15). In NPC containing p53 protein positive tumour cells, there was a significantly higher apoptotic rate.

CONCLUSIONS

These findings indicate that apoptosis is related to type and stage of nasopharyngeal carcinoma. They also confirm the role of p53 in regulating tumour apoptosis.

Impact of programmed sensitivity safety factor on atrial sensing in children

The relationship between the pacemaker sensitivity safety factor (PSSF) and atrial under- or oversensing as documented by 24-hour Holter monitoring was examined. Our study comprised 78 transvenous fixed atrial leads implanted between 1983-1995 in 71 children. Overall, 210 Holter reports identified 143 (68%) Holters with normal atrial sensing function, 31 (15%) with undersensing, 32 (15%) with oversensing, and 4 (2%) with both problems. From 161 Holter reports in which the PSSF was available, the incidence of undersensing at a PSSF of 2.0 (range 1.5-2.4) was 25% (14/57). There was a dramatic decline in undersensing when the PSSF was > or = 3 (3%) compared to a PSSF < 3 (21%) (P < 0.001). A PSSF cut-off point of 2.0 best predicted occurrence of undersensing with a sensitivity of 79% and a specificity of 67%. Other variable were also examined by multiple logistic regression analysis, but only PSSF remained highly associated with undersensing (odds ratio [OR] = 0.6, P = 0.03). In contrast, PSSF did not have a significant role in predicting oversensing, but presence of sick sinus syndrome (OR = 10.5) or unipolar lead (OR = 5.6) were significantly associated with oversensing (P = 0.0001). The majority of undersensing problems can be avoided by routinely allowing for at least a threefold or more programmed sensitivity margin. Other factors may increase the risk of oversensing, regardless of the PSSF.

Ménétrier's disease: a new variant with duodenal involvement

Ménétrier's disease is a rare cause of hypertrophic gastropathy, usually confined to gastric body and fundus, which is characterized by giant rugae, hypoalbuminemia, and foveolar hyperplasia. The etiology of this disease is still unknown. We report a case of a 74-yr-old man who had dyspepsia, hypoalbuminemia, weight loss, and diffuse polypoid, nodular lesions affecting the whole stomach and proximal duodenum on gastroscopy and barium meal study. The histology of gastric and duodenal mucosal lesions fulfilled the diagnosis of Ménétrier's disease, that was not described to involve duodenum in the literature. The disease resolved clinically, endoscopically, and pathologically after therapy with famotidine for 3 months. We speculated that extensive pyloric metaplasia and then foveolar hyperplasia of duodenum in this patient might be a variant of Ménétrier's disease with favorable clinical course.

Coexistent mitral stenosis and coronary artery fistula presenting as myocardial ischemia: case report

We report a 50-year-old female case of mitral stenosis with congenital coronary artery fistula communicating the left anterior descending artery to pulmonary artery. In reviewing the literature, mitral stenosis associated with coronary artery fistula is rare. The case was initially treated medically for congestive heart failure. The electrocardiogram revealed severe myocardial ischemia and no obvious etiology was found clinically. The coronary angiogram demonstrated the diagnosis of coronary artery fistula. Myocardial ischemia improved markedly after surgical correction of the valvular disease and the fistula. The patient continued to do well during 2 years and 10 months follow up. The concomitant mitral stenosis masked the symptoms of coronary artery fistula, and made us fall to diagnose the condition initially. Valvular heart disease associated with severe myocardial ischemia without obvious atherosclerotic stenosis of coronary artery reminded us of the possibility of coronary artery fistula, though it has rarely been reported.

Giant aneurysm of main pulmonary artery

Aneurysm of the main pulmonary artery is an extremely rare entity. The first successful repair of an aneurysm of the main pulmonary artery was reported in 1971. Since then, surgical correction of the aneurysm of main pulmonary artery has been undertaken in only 6 cases. A thorough survey of the literature, including autopsy cases, medical cases, and surgical cases, shows the aneurysm in the present case to be one of the largest.

Surgical correction of giant patent ductus arteriosus

In reviewing the literature, there was only one report having the ductus over 30 mm in width. Recently, we utilized cardiopulmonary bypass, hypothermia, and low flow through a transpulmonary approach to close 2 cases of giant patent ductus arteriosus. Both cases complicated with systemic pulmonary hypertension. Its outside diameters were 31 mm and 36 mm respectively based on the measurement from magnetic resonance imaging. To our knowledge, its seem the biggest ductus in comparison to previous reports. Both cases survived the operation and doing well for a follow-up time of 5 years and 4 years 10 months respectively.

Postoperative diaphragmatic dysfunction in patients undergoing open-heart surgery

Diaphragmatic elevation after cardiac surgery may result in compromized post operative respiratory function, prolonged ventilator use, longer intensive care unit (ICU) stays, poor quality of life and even mortality. 200 patients receiving open-heart surgery during the two years from October 1990 to October 1992 were studied retrospectively. 26 patients developed postoperative diaphragmatic elevation (Group 2). On the other hand, 174 patients did not (Group 1). The mean age of Group 1 (37.3 +/- 20.0 years) was younger than that of Group 2 (57.4 +/- 9.1 years), P < 0.0001. The mean aortic cross-clamp time was 70.1 +/- 38.1 minutes in Group 1. On the other hand, Group 2 had a longer crossclamp time (84.5 +/- 31.3 Minutes), p < 0.03. Our study revealed that the patients who suffered post operative diaphragmatic dysfunction were older and had a longer aortic crossclamp time than the patients who did not.

Isolated persistent fifth aortic arch with right-sided aortic arch

A persistent fifth aortic arch was recognized in a 4-year-old boy by echocardiography, magnetic resonance imaging and angiocardiography. The case was unique in at least two respects: right-sided aortic arch, and systemic-to-pulmonary connection without intracardiac lesion. This rare type of anomaly was correctly diagnosed and successfully repaired by patch closure of the arch. This is the first report of this combination of lesions in the Orient.

The use of right gastroepiploic artery for the bypass of left anterior descending coronary artery--case reports

The right gastroepiploic artery (RGEA), a branch of the gastroduodenal artery, supplies the greater curvature of the stomach. It is capable of easily reaching the posterior and lateral surface of the heart as a reliable arterial conduit when appropriately harvested. In the previous reports, it has usually been anastomosed to the right coronary artery (RCA) or left circumflex coronary artery (LCX). Here, we present two cases of ischemic heart disease undergoing coronary revascularization. The RGEA was anastomosed to the left anterior decending coronary artery (LAD), which is the most important coronary artery in terms of patient outcome. Thallium-201 myocardial scintigraphy has proven that the RGEA can provide sufficient blood flow to the territory of the LAD. Thus, in coronary artery bypass grafting (CABG), the RGEA is a reliable arterial conduit for LAD revascularization.

Surgical treatment of pericardial effusion in cancer patients

31 cancer patients with symptomatic pericardial effusion were treated by subxiphoid pericardiotomy with simultaneous pleuropericardial window creation. There were no patients who died during surgery. In all patients, relief of cardiac compression by the effusion was immediate and complete. 10 patients died of advanced malignancy within 30 days after operation without evidence of recurrent pericardial effusion. During the period of follow-up, another seventeen patients died, and no death was related to pericardial effusion. It is concluded that pleuropericardial window through the subxiphoid approach is the treatment of choice for pericardial effusion in cancer patients. The procedure provides immediate and long-lasting relief of cardiac compression with acceptable mortality and morbidity.

Electromagnetic imaging for complex cylindrical objects

Electronic imaging of complex cylindrical objects with arbitrary cross sections was investigated, assuming an incident wave upon both penetrable inhomogeneous dielectric cylinders and perfectly conducting cylinders with known shape, and external measurements of the scanned field. By properly processing the scattered held measurements, the dielectric permittivity distribution of the scanned object can be reconstructed. A theoretical formulation was based on proper arrangement of the incident field directions resulting in a set of integral equations derived and solved by the moment method and the unrelated illumination method. Numerical results demonstrate the capability of the imaging algorithm. Good reconstruction results were obtained even in the presence of additive random noise. In addition, noise effects on the reconstruction results were investigated.

Surgical correction of sinus venosus atrial septal defect associated with partial anomalous pulmonary venous connection to high superior vena cava--case report

A 63-year-old woman complained of general malaise and insomnia initially. Atrial septal defect was diagnosed by transthoracic echocardiography thereafter. She had not received complete cardiac studies until progressive dyspnea was noted half a year later. After a series of examinations, sinus venosus type atrial septal defect (ASD) associated with partial anomalous pulmonary venous connection to high superior vena cava (SVC) and persistent left SVC was documented. Surgical correction was performed later. The postoperative course was smooth and her condition improved gradually at 10-month follow-up.

Use of glutaraldehyde solution in the treatment of acute aortic dissections

We report on a promising method for toughening and strengthening the fragile aortic wall that involves the direct application of a 25% glutaraldehyde solution and that has proved to be both technically simple and safe. The operation was successfully employed in 5 patients with acute aortic dissections, 3 with a Stanford type A and 2 with a type B dissection. Histologic examination of the glutaraldehyde-treated portions of the aortic wall showed no detectable difference between them and the sections of untreated aortic wall. All patients survived the operation. The duration of follow-up ranged from 9 to 31 months (mean, 14.0 months). All 5 patients were in good condition at the time of the last follow-up. The preliminary results indicate that the use of a 25% glutaraldehyde solution to strengthen the aortic wall during operations for the repair of acute aortic dissections, regardless of whether they are type A or type B, may reduce the incidence of catastrophic perioperative bleeding and promote favorable results.

Correction of aortico-left ventricular tunnel in a small Oriental infant: a brief clinical review

In reviewing 56 cases of aortico-left ventricular tunnel from 39 reported articles, none of the patients operated on were Oriental. In this report, a 4 month-old male infant was successfully operated on. The tunnel was closed with a Dacron patch on the aortic orifice. The child is now free from symptoms, except for mild residual aortic regurgitation, and is developing normally 5 year-11 month after repair. A brief clinical review has been attempted in these reported cases.

Open heart surgery in a patient with an implanted pacemaker: case report

When a patient has a pacemaker and requires operation, surgeons have to consider some possible intraoperative pacemaker complications induced by electrocautery. Electrocautery is commonly used during surgery to achieve hemostasis. However, this very effective tool may introduce innumerable problems in the paced patient, including irreversible damage to the pulse generator, pacemaker reprogramming, induction of a rise in the capture threshold, and ventricular fibrillation. Although electrocautery may be avoided in some surgical procedures, open heart surgery cannot be performed without it. One case is presented to illustrate how to achieve hemostasis while decreasing electric interference and how to protect the permanent pacemaker while avoiding those possible complications during the defibrillation. The purpose of this article is to call attention to potential problems induced by electrocautery and in an effect to facilitate the perioperative management of the paced patient undergoing open heart surgery.

Can daily dietary arginine supplement affect the function and subpopulation of lymphocytes in patients with advanced gastric cancer?

Since arginine can stimulate lymphocyte proliferation in the healthy human, its effect on lymphocyte proliferation in vitro was studied in 7 patients with far advanced gastric cancer. These patients with normal nourishment were ambulatory and could consume a regular diet. A daily dietary supplement of 30 g arginine for 7 days did not alter the total lymphocyte counts or the T/B cell ratio in the peripheral blood. Enhancement of lymphocyte proliferation in response to mitogen stimulation was not observed. Furthermore, an in vitro study on the effect of arginine on phytohemagglutinin-stimulated lymphocyte proliferation showed that lymphocytes from gastric cancer patients had poorer responses than those obtained from normal subjects, despite the supplement in the culture medium with normal serum, patient serum, or fetal bovine serum. Arginine ingestion did not impair liver function and had no detectable side effects except transient nausea in 1 patient. These results indicate that dietary arginine supplement appears safe but does not stimulate lymphocyte function in far advanced gastric cancer patients. The suppressed immune function in gastric cancer patients may be the result of their intrinsic lymphocyte defect.

Alteration of intracellular DNA and RNA patterns by liver arginase studied with flow cytometry

Previous study of lymphocyte proliferation in the presence of liver arginase has indicated that arginine-depletion in the culture medium plays an important role in inhibiting cell proliferation. The inhibitory effect of both liver arginase and arginine-free condition on DNA, RNA and protein syntheses in PHA-stimulated lymphocytes were studied in cultures by measuring the incorporation of labeled precursors. Simultaneously, their influence on DNA and RNA contents in cells stained by acridine orange was investigated by automated flow cytometry. With 3 micrograms/ml arginase, the syntheses of DNA, RNA and protein were markedly inhibited after 72 h of culture. The degrees of inhibition were close to that induced in an arginine-free condition. The DNA and RNA contents of the individual cell, either cultured with 3 micrograms/ml arginase or in arginine-free medium, were arrested in G0/G1 phase. The results of cell arrest in G0/G1 phase were similar whether the cells were cultured for 24, 48 or 72 h.