Hospitalizations for individuals with injection drug use-related infective endocarditis (IDU-IE) represent an increasing portion of all patients with endocarditis. This study describes the evolving trends in demographics, clinical characteristics, rates of surgical intervention, and mortality among patients hospitalized with IE, comparing those with and without injection drug use.International Classification of Diseases, Ninth Revision code and verified by the modified Duke Criteria for IE. The clinical characteristics, microbiology, site of infection, complications of IE, and outcome were all abstracted by chart review. Rates of surgical consultation and surgical intervention within 90 days of admission were obtained, and assessment of surgical risk calculated was by EuroSCORE II . Subsequent hospitalizations for all causes were also reviewed.This is a retrospective cohort study of patients admitted between January 1, 2007 to June 30, 2015 at a tertiary care center in Boston, Massachusetts. Endocarditis was defined by P = .58).Injection drug use-related infective endocarditis occurred in younger patients with lower rates of diabetes, renal dysfunction, and prior cardiothoracic (CT) surgery than those without IDU. Injection drug use-related infective endocarditis was associated with higher rates of complications, CT surgery consultation, and surgery within 90 days for absolute surgical indication. Readmissions for endocarditis occurred in 20% of IDU-IE patients and 9% of those with non-IDU IE. All-cause 1-year mortality rates were similar (IDU-IE 16%, non-IDU IE 13%; Despite younger age, fewer medical comorbidities, and fewer prior cardiac surgeries, all-cause 1-year mortality was similar for patients after sentinel admission for IDU-IE compared with non-IDU IE. Interventions in the acute hospital setting and after discharge are needed to support patients with IDU-IE, focusing on harm reduction and treatment of addiction to reduce the unexpectedly high mortality of this young population. Injection drug use (IDU) is responsible for an increasing number of cases of infective endocarditis (IE) in the United States, an observation that correlates with the increase in overdoses and overdose deaths secondary to opioid and heroin use , 2. InjeThe reason for the reported difference in clinical outcomes in individuals with IDU-IE is unclear, particularly because these patients typically are younger with fewer comorbidities. It is possible that patients who present with IDU-IE face a more challenging clinical course due to the virulence of the responsible pathogen, embolic phenomena, coinfections, continued drug use, or different care received with respect to timing of surgical intervention when warranted . Our stuWe performed a retrospective review of individuals admitted from January 1, 2007 to June 30, 2015 with a diagnosis of IE at a large tertiary care center in Boston, Massachusetts. These dates were selected based on availability of a complete electronic medical record. The Committee on Clinical Investigations at the Beth Israel Deaconess Medical Center approved the study.International Classification of Diseases, Ninth Revision codes . Charts were reviewed to confirm the presence of definite IE as defined by modified Duke criteria  1935-2014  vs 17 [16%]), although the prevalence of human immunodeficiency virus was similar (4 [4.8%] vs 7 [8.0%]). Patients with IDU-IE were less likely to have concurrent diabetes, renal dysfunction, and prior cardiac surgery.Between January 1, 2007 and September 30, 2015, 381 patients were admitted with definite IE, 103 (27%) of whom had IDU-IE. Baseline demographics and clinical characteristics are detailed in Staphylococcus aureus was the most common species causing endocarditis in both groups; however, it was responsible for approximately twice the percentage of the cases in those with IDU (67 [65%] in IDU-IE and 97 [35%] in non-IDU IE), with methicillin-sensitive S aureus (MSSA) occurring more frequently than methicillin-resistant S aureus (MRSA) in both groups.The microbiologic cause for endocarditis is also illustrated in P < .01), systemic emboli , and resistant organisms . Cardiothoracic surgery was more frequently consulted in IDU-IE (74 [72%]) compared with non-IDU IE (155 [56%]). The presence of 1 or more absolute surgical indication was similar in both groups. Cardiothoracic surgical intervention within 90 days of sentinel admission was more frequent in cases of IDU-IE (40 [39%] vs 79 [28%]), which was statistically significant when surgical intervention was stratified by the presence of at least 1 absolute surgical indication .P = .06).As detailed in P = .66).The clinical outcomes shown in P = .36). Among our discharged IDU-IE patients, 82 of 96 received their postdischarge antibiotic treatment at 1 of 2 state-run, long-term care facilities.Although 90 of the 103 IDU-IE patients met with social work, only 50 individuals were seen by either an addiction nurse specialist or a psychiatrist. Nine of the 96 patients (9%) who survived until discharge were started on medication to treat their opioid addiction, and all were alive at 1 year  among patients with IDU-IE as there were cases of S aureus and Streptococcal spp combined (67%) in non-IDU IE. In both groups, those with and without IDU, S aureus isolates were more commonly methicillin susceptible than resistant, and, in particular, individuals with IDU-IE had MSSA infection approximately 2.5 times more frequently than MRSA. Infection with S aureus puts patients with IDU-IE at increased risk of severe sepsis, multiorgan dysfunction, major neurological events, and death [The microbiology and site of infection with IE have changed over time. The incidence of ountries , 19. Thiountries . In our ombined 6% in non-nd death . In thisThe International Collaboration on Endocarditis-Prospective Cohort Study investigators found most cases of IE in a pooled international population involve vegetations on either the aortic (38%) or mitral valves 41%) compared with the tricuspid valve (12%) 1% compar, 20. InfA higher percentage of IDU-IE patients underwent cardiac surgery than did those in the non-IDU group (38% vs 28%). This trend was even more pronounced when there was an absolute surgical indication present 64% vs 43%). In the context of comparable EuroSCOREs, the surgery rates reflect a willingness to aggressively provide surgical treatment for the IDU-IE population. Age of 60 or less, large vegetation, paravalvular abscess, and increased EuroSCORE were associated with cardiac surgery within 90 days The 90-day window for cardiac surgical intervention was selected based on previous efforts to capture surgical interventions linked to the sentinel IE admission while limiting confounding surgical interventions for recurrent IE 4% vs 43%. As expeIn this study, both patient groups had high rates of re-admission for endocarditis; 9% of the non-IDU patients and 20% of those with IDU. Of note, however, the vast majority of the non-IDU re-admissions for endocarditis  were considered to have persistent or relapsed infection, meaning recurrence of same pathogen within 6 months of initial endocarditis. In contrast, among the IDU patients admitted for endocarditis, a majority of cases  had de novo infection .Our study has several limitations. It is a retrospective review performed at a single urban academic institution that may limit its generalizability to nonacademic, nonurban settings. Because this is a single-center study, patients may have received care at other institutions after sentinel admission at our facility, which could alter our surgical and IE re-admissions rates. If such occurred, however, it would only increase the rates or re-admission for endocarditis. Given that we have a much higher than national average percentage of patients whose endocarditis is related to IDU, our clinical care and willingness to perform surgical interventions may be different than that in other settings. Finally, we may have underestimated mortality, because the SSDI at the time of review only includes documented deaths through 2014. Therefore, we may have not accurately calculated mortality if our electronic medical record did not capture deaths occurring after 2014, particularly in patients who died out of the hospital, because most of our patients with IDU-IE were transfers from outside facilities. We recognize that the IDU-related deaths in particular may not be reported back to this medical center or seen in publicly available obituaries to a higher degree than the non-IDU IE group, thus underestimating the out-of-hospital mortality rate in the IDU-IE group.The potential impact that treatment of OUD could have on the long-term outcomes of patients with IDU-IE represents a growing area of research and possibly one of the most significant opportunities to improve outcome. Englander et al  reportedIn spite of an increase in patients with IDU-IE, universal infectious disease subspecialty care, and a surgical service that has demonstrated a willingness to perform surgical procedures to treat IDU-IE patients with an absolute surgical indication, addiction treatment and harm reduction interventions are only beginning to be offered consistently in our setting. The challenge to provide wraparound services to those with substance use disorder, including prompt referral for addiction treatment, harm reduction interventions, and follow-up longitudinal care, will be critical to optimal management of OUD and complicating endocarditis or other infections. It is incumbent upon physicians treating patients with IDU-IE and other IDU-related infections to bridge this care if the annual number of opioid deaths, which are now projected to reach over 80 000 by 2025 , are to In conclusion, IE remains a highly morbid condition, disproportionally so in patients with IDU-IE. Our data suggest that although patients with IDU-IE are much younger, have fewer comorbid conditions, and receive aggressive surgical management when indicated, they suffer mortality rates similar to a more at-risk non-IDU IE cohort. Further studies are warranted to investigate the more nuanced impact of IDU on the management of IE and whether additional interventions, particularly targeting underlying substance use disorder, can improve outcomes for patients with IDU-IE.


IIM patients showed significantly reduced global longitudinal PS (GLPS) and longitudinal PS at apical slice, whereas all strain parameters decreased in non-IIM patients. Except GLPS and longitudinal PS at apical slice, all strain parameters in non-IIM patients were lower than those in IIM patients. By Pearson’s correlation analysis, the LV global radial and circumferential PS were correlated to N-terminal pro-brain natriuretic peptide level and LV ejection fraction in both IIM and non-IIM patients. This study indicated that CTD patients showed abnormal LV deformation despite with preserved LVEF. The impairment of LV deformation differed between IIM and non-IIM patients.The aim of this study was to assess left ventricular (LV) myocardial strain in patients with connective tissue disease (CTD) and compare LV deformation between subgroups of idiopathic inflammatory myopathy (IIM) and non-IIM. Ninety-eight patients with CTD, comprising 56 with IIM and 42 with non-IIM, and 30 healthy subjects were enrolled and underwent 3.0T cardiac magnetic resonance imaging (MRI) scanning. The LV function and strain parameters were measured and assessed. Our result revealed that CTD patients had preserved LV ejection fraction (60.85%) and had significantly decreased global and regional peak strain (PS) in radial, circumferential, and longitudinal directions (all  Given that the cardiovascular manifestations in CTD can be clinically non-specific and insidious2, it is imperative for physicians to detect cardiac involvement early, before subclinical left ventricular (LV) dysfunction progresses to irreversible heart failure.Cardiovascular complications in patients with CTD are among the leading causes of death4. As the myocardium is a modified skeletal muscle, possibilities are that the immune-mediated inflammation also acts in myocardial disease in patients with IIM5. In other CTD, the underlying mechanisms of myocardial involvement are not fully understood; while, consequent autoantibody-related injury in the myocardium has been reported6.IIM is characterized by muscle weakness and inflammatory cell infiltration in skeletal muscle8. However, to the best of our knowledge, few studies have evaluated myocardial dysfunction in patients with CTD using cardiac MRI tissue tracking10. Furthermore, there exists limited information regarding the differences in LV deformation between IIM and other CTD. Therefore, the present study aimed to quantitate the V myocardial systolic strain in patients with CTD and investigate whether the LV myocardial deformation was different between patients with IIM and non-IIM.Cardiac magnetic resonance imaging (MRI) tissue tracking has recently been developed for the assessment of myocardial deformation and subclinical cardiac dysfunction prior to a reduction in the LV ejection fraction (LVEF)p < 0.05]. In patients with CTD, LVEF was preserved (LVEF > 50%) in both the IIM [63.9 ] and non-IIM [56 ] group. The LV function parameters, including LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV stroke volume (LVSV), showed no differences between the normal controls and patients with CTD .All basic characteristics are summarized in Table p < 0.001; GCPS, −20.9 ± 1.9 vs. −18.5 ± 5.1%, p = 0.019; GLPS, −10.4 ± 3.2 vs. −8.3 ± 2.8%, p = 0.001].The magnitude of regional PS in all three directions was also significantly decreased .The global and regional strain parameters of all subjects are shown in Table p = 0.006) and longitudinal PS at the apical slice  were significantly reduced in the IIM group, whereas the magnitude of all global and regional strain parameters in the three directions were decreased in the non-IIM group . In the non-IIM group, the magnitude of all strain parameters in the radial, circumferential, and longitudinal directions were lower than those in the IIM group, with the exception of GLPS and longitudinal PS at the apical slice   analysis identified GRPS , GCPS  and GLPS  to differentiate IIM from non-IIM.p = 0.005) and GCPS and GLPS were positively correlated with NT-proBNP level . In the IIM group, NT-proBNP was correlated with GRPS , as well as GCPS  and there was no correlation between NT-proBNP and GLPS   , GCPS , and GLPS  in the non-IIM group. In the IIM group, LVEF was also associated with GRPS , GCPS , and GLPS  14. While, there exists accumulating evidence emphasizing the role of cardiac MRI tissue tracking in overcoming the shortcomings of low tissue resolution and dependency of an acoustic window in STE for the evaluation of myocardial strain and cardiac dysfunction15.Cardiac involvement in patients with CTD is mostly subclinical and may lead to cardiac-related death due to myocarditis, myocardial fibrosis, valve disorders, coronary vasculitis, and pericarditisIn the present study, we applied cardiac MRI tissue tracking to evaluate LV myocardial systolic strain in patients with CTD and compared LV deformation between IIM and non-IIM subgroups. The main findings were: (1) patients with CTD had impaired global and regional LV systolic strain in the three directions, even though the LVEF was preserved; (2) compared with normal controls, the damaged strain in IIM patients mainly involved GLPS and longitudinal PS at the apical slice, whereas all strain values were impaired in non-IIM patients; (3) with the exception of GLPS and longitudinal PS at the apical slice, the magnitude of all strain parameters in non-IIM patients were lower than those in IIM patients; and (4) GPRS and GCPS showed correlations with LVEF and NT-proBNP level in both IIM and non-IIM patients.16. Recently, CMR tissue tracking has been gradually used to quantitatively measure LV function via different strain parameters from the radial, circumferential, and longitudinal directions18 with high sensitivity and reproducibility20. One of the findings of the present study was that, compared with healthy controls, the magnitude of global and regional PS in the three directions was decreased in CTD patients with preserved LVEF, which is consistent with STE results13. This finding may assist the explanation of the impairment of LV deformation detected by cardiac MRI tissue tracking prior to conventional LVEF in patients with CTD. Another finding was that GRPS, GCPS, and GLPS were correlated with LVEF in patients with CTD, which is similar to the previous literature reports in other diseases21.The LV wall is composed of cardiomyocytes, of which the orientation continuously rotates from epicardium to endocardium23. In our research, IIM patients with preserved LVEF were found to have impaired strain manifested as the magnitude reduction in GLPS and longitudinal PS at the apical slice, suggesting subclinical LV myocardial systolic impairment. Previous literature has been reported that IIM patients showed impaired LV myocardial microvascular dysfunction25, and that the abnormal LV myocardial deformation was associated with microvascular dysfunction in other diseases26. Thus, we presume that the magnitude reduction in longitudinal myocardial strain of IIM patients in our present study may be related to microvascular ischemia. Analogous to our results, recent studies have reported that IIM patients with preserved LVEF have decreased global longitudinal strain23. Guerra et al.22 described impaired longitudinal strain involved in the basal and mid-segments detected by STE, which is not consistent with our findings in the apical segment. The reasons for this discrepancy might be related to the difference in techniques used to measure LV deformation or the heterogeneity of patient populations. In addition, compared with healthy subjects, the magnitude of global and regional PS in the three directions was decreased in non-IIM patients with preserved LVEF, which is in agreement with previous reports demonstrating subclinical cardiac systolic dysfunction in other CTD besides IIM, such as SLE, RA, and SSc, as detected by STE27.An increasing number of studies have shown subclinical cardiac dysfunction in IIM patients detected by STEOur research revealed that the magnitude of all strain values in non-IIM patients were lower than those in IIM patients . Taken together, these findings support that impairment of LV deformation is different between IIM and non-IIM patients. We presume that myocardial damage manifesting as myocardial perfusion dysfunction and fibrosis differ between IIM and non-IIM. Thus, further studies are required to explore the relationships between LV deformation and the aforementioned myocardial damage detected using multi-parametric cardiac MRI, such as first-pass perfusion and late gadolinium enhancement (LGE) in IIM and non-IIM. In our present study, there was no difference between IIM patients and non-IIM patients in GLPS, and this finding might be contributed to explain GLPS was relative poor parameter  to differentiate IIM patients from non-IIM patients. Furthermore, the data obtained from the ROC analysis supported that the combination of GRPS and GCPS might be a better parameter than any one alone to differentiate IIM patients from non-IIM patients with a relative high sensitivity and specificity.28. Myocardial cell injury induced by persistent systemic inflammation and immune dysfunction could increase NT-proBNP level in CTD29. In the present study, NT-proBNP in non-IIM patients was higher than that in IIM patients, suggesting that the severity of myocardial damage might be different between IIM and non-IIM. Another finding demonstrated that NT-proBNP level was correlated with the global strain parameters in the three directions, which might indicate that LV global deformation is related to myocardial injury in patients with CTD. Similar to our findings, NT-proBNP has been reported to be increased in patients with CTD and correlated with subclinical cardiac disease30.NT-proBNP is a biologically inactive N-terminal fragment of the active hormone BNP, which is secreted by the myocardium when stimulated by an increase in ventricular overload, ventricular wall stretchesor stress, and is a standard marker of myocardial damageThe limitations of this study include the following: first, this was a retrospective and single center study, and potential center-specific bias cannot be excluded. Second, LGE data was not involved in our present study and the relationship between LV deformation and myocardial damage detected by cardiac MRI first-pass perfusion or LGE technologies is not known; thus, further studies are required to explore this. Finally, although cardiac MRI tissue tracking demonstrated high reproducibility, the accuracy needs to be further verified because of the absence of a reference standard.In conclusion, patients with CTD showed impaired LV deformation detected by cardiac MRI tissue tracking, even though they had preserved LVEF. The impairment of LV deformation was different between IIM and non-IIM patients. Early detection of subclinical impaired LV deformation may help to screen high-risk patients with CTD for early treatment.31. Informed consent was obtained from all subjects.The study cohort retrospectively enrolled 121 patients with CTD at our hospital from January 2015 to January 2019. CTD was diagnosed according to the criteria of the American College of Rheumatology or the European League Against Rheumatism, respectively. The exclusion criteria included coronary artery disease, cardiomyopathy, congenital heart disease, heart valve disease, and contraindication for cardiac MRI. Finally, 98 patients with CTD  were eligible for the study, including 56 patients with IIM and 42 patients with non-IIM . Considering the variety of CTD, these patients were divided into two subgroups: the IIM group (n = 56) and the non-IIM group (n = 42). A total of 30 age- and gender-matched healthy volunteers  with no history of cardiovascular or systematic disease were included as the normal controls. All participants underwent cardiac MRI scanning and were examined for the clinical marker, NT-proBNP. The study protocol was approved by the West China Hospital of Sichuan University Biomedical Research Ethics Committee and conducted in an accordance with the ethical guidelines of the Declaration of Helsinki (2013 EDITION)All patients were examined using a 3.0T whole-body scanner with a 32-channel phase-array cardiovascular coil . All participants were examined in the supine position. The breath-hold technique and a manufacturer’s standard electrocardiographic gating device were used for monitoring the participant’s breathing and electrocardiogram values, respectively. The continuous data were acquired during the breath-holding period. A series of 8–12 continuous cardiac MRI cine sections were acquired in the short-axis from the mitral valve level to the LV apex using a balanced steady state free precession (bSSFP) sequence . The cardiac cine series in the long-axis two-, three-, and four-chamber views were also obtained.32. LV myocardial strain measurement was performed by loading short-axis, long-axis two- and four-chamber slices into the three-dimensional tissue tracking module33. All series of the endocardial and epicardial borders were outlined manually in each slice at the end-diastolic period (reference phase)  strain parameters, including the myocardial PS in the radial, circumferential, and longitudinal directions, were obtained automatically using the aforementioned software.Post-processing of all images was performed offline by two experienced radiologists using commercial software . The LV functional parameters, including LVEDV, LVESV, LVSV, and LVEF were calculated using the aforementioned software following manual contouring of the endocardial and epicardial borders at the end-diastolic and end-systolic periods of the short-axis cine images with the papillary muscles and moderator bands included. Reduced LVEF was defined as <50%Intra-observer variability was assessed by comparing the tissue tracking measurements obtained randomly among 30 individuals by the same observer at an interval of 2 weeks. Inter-observer variability was also obtained randomly among 30 individuals and was determined by comparing the independent tissue tracking measurements of two experienced and double-blinded observers.t-test or Mann–Whitney U test, whereas those parameters among normal controls, IIM and non-IIM subgroups were compared by one-way repeated analysis of variance (ANOVA) or the Kruskal–Wallis rank test, as appropriate. Least-Significant-Difference test was used for multiple pairwise comparisons among the three groups of normal controls, IIM group, and non-IIM group when the p-value of one-way ANOVA was less than 0.05. Pearson’s correlation was used to evaluate the relationship between strain parameters and NT-proBNP and LVEF. ROC analysis was performed to determine whether the global strain parameters can be used to differentiate IIM from non-IIM patients. Intra- and inter-observer variabilities for reproducibility were assessed using the ICC. A two-tailed p value of < 0.05 was considered statistically significant.Statistical analysis was performed using IBM SPSS Statistics for Windows . All continuous variables were tested for normality using the Kolmogorov–Smirnov test. The homogeneity of variance was assessed using Levene’s test. Continuous variables are expressed as the mean ± standard deviation (SD) or the median (interquartile range). LV function and strain parameters between normal controls and CTD groups were compared using a Student’s Left Ventricular Deformation in Patients with Connective Tissue Disease: Evaluated by 3.0T Cardiac Magnetic Resonance Tissue Tracking


Integrating seasonal malaria chemoprevention (SMC), recommended by the WHO since 2012 to prevent malaria infection, with nutrition interventions may improve health outcomes and operational efficiencies. This study assessed the effects of co-packaging interventions on distribution coverage, nutrition, and clinical malaria outcomes in northern Nigeria. From August to November 2014, community volunteers delivered sulfadoxine-pyrimethamine and amodiaquine (SP-AQ) door-to-door each month to approximately 7,000 children aged 6–24 months in seven wards of Madobi, Kano State, Nigeria. In three of the wards children additionally received a lipid-based nutrient supplement (LNS–medium quantity), Plumpy Doz. Coverage, adherence, and anthropometric outcomes were assessed through baseline, midline, and endline household surveys. A facility-based case-control study was also conducted to estimate impact on clinical malaria outcomes. Coverage of SP-AQ was similar between arms at 89%  in the SP-AQ only arm and 90%  in the SP-AQ plus LNS arm (p = 0.52). Coverage of LNS was 83% . Whilst there were marked changes in anthropometric status between baseline, midline and endline, these were largely accounted for by socioeconomic status and must be interpreted with care due to possible measurement issues, especially length-based indices. Overall nutritional status of our most robust measure, weight-for-age, does appear to have improved by endline, but was similar in the two study arms, suggesting no additional benefit of the LNS. While the odds of clinical malaria among those who received the intended intervention were lower in each study arm compared to children who did not receive interventions , LNS was not shown to have an additional impact. Coverage of SMC was high regardless of integrating LNS delivery into the SMC campaign. Supplementation with LNS did not appear to impact nutritional outcomes, but appeared to enhance the impact of SP-AQ on clinical odds of malaria. These results indicate that combining nutritional interventions with seasonal malaria chemoprevention in high-risk areas can be done successfully, warranting further exploration with other products or dosing.11413895Trial Registration: ISRCTN  Malnutrition and malaria are priority challenges for global child health. Nutritional disorders are implicated in over three million deaths in children under five annually  while malaria contributed to the deaths of 306,000 children in 2015 [African children at risk for malaria are often also at risk for malnutrition. While the relationship between malnutrition and infectious disease is accepted to be generally synergistic, the specific malnutrition-malaria interaction is not well-defined –5. Risk Interventions targeting both acute malnutrition and infectious disease may therefore act synergistically to improve overall child health. Previous research has shown that integrating community interventions for multiple diseases increases coverage, improves health outcomes, and is cost-effective –22. In nSeasonal malaria chemoprevention (SMC), in which children under five years are given a monthly dose of anti-malarial drugs, is recommended since 2012 by the World Health Organization (WHO) in certain areas where malaria transmission is highly seasonal, such as the Sahel sub-region of Africa . SMC hasSMC campaigns may provide an opportunity for delivery of an integrated package of child health interventions. Medium-quantity lipid-based nutrient supplements (LNS-medium quantity), such as Plumpy Doz, are used in food-insecure settings to provide additional calories, protein, fats, and micronutrients to young children who are moderately malnourished and/or at risk for severe acute malnutrition. While studies of the effect of LNS on anthropometric indicators have found mixed results, provision of LNS to children at risk of undernutrition has improved weight gain, cognitive function, and hemoglobin concentration in some settings –32. ConvP. falciparum prevalence among 2–10 year olds in 2014 was 30.4% in the SP-AQ only area and 28.4% in the SP-AQ plus LNS area) and seasonality (the two intervention areas are separated by approximately 4 km) [This study was designed as a pragmatic cluster controlled trial with a nested case-control. Delivery of SMC combined with LNS was evaluated against delivery of SMC alone from August 2014 to May 2015 in Madobi Local Government Area (LGA) of Kano State, Nigeria. Madobi had an estimated population of 11,000 children under five years old in 2014, using projected figures from the 2006 National Census . The stuly 4 km) . DensityChildren aged 6 to 24 months as of August 2014 living in the study wards were eligible to participate in the trial. Children were excluded if: they had an allergy to any component of the intervention; had taken SP or AQ within 30 days of intervention delivery; were HIV-positive and taking co-trimoxazole; were unable to take oral medication; had suffered a severe acute illness including severe acute malnutrition (SAM), or had confirmed or suspected malaria at the time of the household visit. Any child with severe acute illness or high fever was referred to the nearest public health facility.Children in the study population who sought care for fever in one of the 13 primary health care facilities in the seven intervention wards between August 28 and November 30, 2014 were also eligible for recruitment in the unmatched health facility-based case-control study. Children not eligible for the intervention (SP-AQ or SP-AQ plus LNS) were excluded as well as children referred to a CMAM facility in the past month or diagnosed with severe acute malnutrition (mid-upper arm circumference (MUAC) <11.5cm). A case was defined as any child from the study population with a current or reported history of fever of ≥37.5 C within the past 48 hours with a positive malaria rapid diagnostic test (mRDT). A control was defined as a child from the study population with a current or reported history of fever of ≥37.5 C within the past 48 hours and a negative mRDT test.The seven study wards were split into two groups based on geographic proximity. Children in the northern wards of Kafin Agur, Burji, Kanwa, and Kauran Mata received SP-AQ only, while children in the southern wards of Kubaraci, Rikadawa, and Yakun received SP-AQ and LNS. The group of wards, or arm, receiving the LNS intervention was randomly selected. Following community sensitization activities, a monthly SMC campaign of WHO pre-qualified, co-blistered sulfadoxine-pyrimethamine plus amodiaquine  was delivered door-to-door in all seven wards by the Kano State Ministry of Health (KSMOH) network of Community-Directed Distributors (CDDs) for four consecutive months from August to November 2014. Timing of delivery coincided with the typical malaria season and the period before November harvest when food is most scarce. Children aged 6 months to 11 months received SP 262.5mg + AQ 75mg, while children aged 12 to 24 months received SP 525mg + AQ 150mg. All drugs were formulated as a three-day course of tablets. All CDDs were trained in directly observed therapy (DOT) administration and remained at households for 15 minutes following ingestion of the first dose of SP-AQ (and LNS if applicable) to monitor for adverse reactions. Parents/guardians were given the remainder of the treatment courses with administration instructions.In one of the two groups of wards, the southern group of Kubaraci, Rikadawa, and Yakun,each monthly SP-AQ distribution was bundled with a one-month supply of the LNS product Plumpy’Doz (Nutriset). Neither the deliverers of the intervention nor the outcome assessors were blinded to the group allocations. For LNS, caregivers were instructed to feed children aged 6–11 months the recommended dose of 23 grams per day, or 1.5 teaspoons three times per day, while children 12–24 months received 46 grams per day, or three teaspoons three times per day (in addition to breastmilk and other available foods) . A dailyThe Kano State Hospitals Management Board (KSHMB Reference #HMB/GEN/488/VOL. I) approved all study protocols. Data collectors obtained written informed consent from a parent or guardian aged 18 years or older for all study participants via signature, or fingerprint for non-literate participants. The Kano State Hospitals Management Board approved the consent procedure.Coverage, adherence, and nutrition outcomes were measured using repeated cross-sectional household surveys. Three household surveys were conducted: prior to the first round of distribution in August 2014 among children aged 6–24 months (baseline), following the last round of distribution in November 2014 among children aged 9–27 months (midline), and six months after the last round of distribution among children 15–33 months old (endline) . An elecFor the case-control study, each of the 13 primary health care facilities in the study area participated in a training based on national guidelines, covering mRDT performance and safety, recruiting cases and controls, and completing study questionnaires. Facilities were supplied with mRDTs during the study. Information on the cases and controls was collected from caregivers by a healthcare worker using a register book, including: age and gender, history of disease including current and previous symptoms, mRDT results, recall of interventions received in the last 30 days (SP-AQ only or SP-AQ plus LNS), and other malaria prevention measures such as insecticide-treated net (ITN) use or indoor residual spraying (IRS) within the home.Selection of households for surveys was done using a two-step design with enumeration areas delineated for the 2006 National Census as the primary sampling unit, and households as the secondary sampling unit. Using ward-level population estimates, a probability-proportional-to-size calculation determined how many enumeration areas to include from each ward to obtain a sample of 750 households from each intervention area . Simple Sampling weights were calculated based on the MEASURE DHS approach for design and sampling weights . WeightsThe case-control study aimed to include 604 controls and 302 cases, based on a ratio of 2 controls:1 case, assuming 60% intervention coverage, a detectable odds ratio of 0.6 of receiving SP-AQ plus LNS compared with SP-AQ only, and an average of 6 confirmed malaria cases per facility per month .Primary outcomes were intervention coverage and adherence, nutritional status of children, and clinical malaria incidence . AnalysiZ-scores were generated using the WHO Anthro macro for Stata, which allows for comparison of anthropometric measures with 2006 WHO Child Growth Standards . StuntinEvidence for a difference in coverage and adherence between arms was assessed using a Wald test. The test statistic was obtained by dividing the difference in coverage or adherence by the cluster-adjusted standard error of the difference and comparing the resulting test statistic to a standard normal distribution. The means and proportions were weighted to reflect the sampling design and standard errors were adjusted for clustering within enumeration areas using the Huber-White “sandwich” estimator of robust standard errors ,47. DiffA logistic regression model was used to compare the impact of intervention (SP-AQ or SP-AQ plus LNS versus no intervention), study arm, and the interaction between intervention and study arm on the odds of clinical confirmed malaria in cases versus controls, taking into account clustering at the health facility. The model adjusted for demographics, month of recruitment, illness in the two weeks prior to enrollment, and ITN use . AnalysiApproximately 7,000 children aged 6–24 months as of August 2014  were eligible to receive an intervention . Over thThere were 1,492 households at baseline, 1,220 households at midline, and 1,579 households at endline with children 6–24 months old as of August 2014 . The midA total of 4,968 children were sampled from the 4,291 households across both intervention groups over the three surveys . HousehoCoverage and adherence results  in the SP-AQ only area and 77.5%  in the SP-AQ plus LNS area .Adherence to LNS was also measured immediately following the final distribution round. Among children 6–24 months old as of August 2014 who were visited by a CDD in the fourth distribution round, 56.9%  reportedly consumed it in the 24 hours prior to the midline survey. Respondents of children who consumed LNS were also asked how much was fed per dose. Among children 6–9 months of age during the intervention, the median dose reported was 6 teaspoons ; among children 10–24 months the median daily consumption was 7 teaspoons . During the endline survey, respondents were asked to recall whether any doses of LNS had been missed; reported complete treatment (no doses missed) was reported for 80.6%  of children 6–9 months old during the intervention and 83.7%  of children 10–24 months old during the intervention.Nutrition outcome results .Baseline stunting prevalence (LAZ<-2) was 78.9%  in the SP-AQ only arm and 74.9%  in the SP-AQ plus LNS arm. Underweight prevalence (WAZ<-2) was 55.1%  in the SP-AQ only arm and 51.5%  in the SP-AQ plus LNS arm at baseline, and wasting prevalence (WHZ<-2) was 15.1%  in the SP-AQ only arm and 13.8%  in the SP-AQ plus LNS arm at baseline. Low MUAC baseline prevalence (<11.5 cm) was 3.8%  in the SP-AQ only arm and 5.7%  in the SP-AQ plus LNS arm. At baseline, more than 1 in 10 children in the study area had severe acute malnutrition as indicated by WHZ<-3 and/or low MUAC: 10.1%  of children in the SP-AQ only arm and 11.6%  of children in the SP-AQ plus LNS arm.Between baseline and endline, prevalence of stunting, underweight, low MUAC, and severe acute malnutrition were significantly lower within both intervention arms , while prevalence of wasting was similar in both study arms at baseline and endline . CompariHousehold wealth was the only variable included in the final model due to an imbalance between arms at baseline. After adjustment for household wealth in multivariable regression analysis of the intervention impact comparing the study arms over time, children in the SP-AQ plus LNS area had significantly higher mean z-scores for MUAC than those in the SP-AQ only area. No difference in mean z-scores was observed between intervention arms with respect to any other nutritional anthropometric outcome .In the case-control study, 380 children were recruited, of whom, 368 children were included in the analysis .The results of this study indicated nearly 90% coverage was achieved through door-to-door delivery of the intervention. The high coverage attained during this intervention may be partly credited to the local knowledge and experience of the CDDs in Kano State, who also work on polio vaccination campaigns and other door-to-door delivery schemes for public health. This result is important to public health intervention programming because coverage was high despite the potential for decreased operational efficiency due to delivery of two interventions. The LNS product used in this study was packaged in cartons of 36 325-gram cups (a one-week supply per cup), requiring four cups delivered per eligible child each month . Thus, eThis study also provides further evidence that SMC exposure is associated with reduced clinical malaria episodes, an important result to consider as SMC is scaled up across the Sahel, where reaching 23 million children considered at risk is a major operational challenge .Apart from an improvement in MUAC z-scores, no impact was demonstrated on nutrition outcomes with the addition of LNS to the SMC campaign. While an impact on stunting and mean HAZ would not be expected due to the relatively brief timeframe of the intervention, some improvements in weight gain and reductions in wasting were expected within the SP-AQ plus LNS intervention arm. LNS may not have been consumed in the appropriate doses to generate significant impact, or the type of supplement selected may not have delivered sufficient nutrients for children at high risk for malnutrition, even when provided at the recommended dose. Other LNS evaluations have shown mixed results across intervention settings –31,49. IThe differences in anthropometric indicators over time across both study arms were unanticipated. The very high prevalence of stunting at baseline and midline and the apparent marked improvement of both percent stunting and mean LAZ at endline was particularly striking. Also striking was that baseline and midline WLZ were not correspondingly low as would be expected in a very stunted, nutritionally compromised population. These observations may be explained by several factors, and it is likely that a mix of these reasons rather than one alone is responsible. First, there may have been seasonal improvements in food availability –this is Frequent infections are known to contribute to poor nutritional status by increasing the body’s nutritional demands, reducing appetite, and driving direct nutrient losses ,9. SimilThe odds of clinical malaria were lower in children who took SP-AQ compared to those who did not in this study, providing further evidence that exposure to SMC has a protective effect on clinical malaria incidence ,27. The This study may provide useful considerations for communities in the Sahel sub-region of Africa where SMC campaigns are currently planned or ongoing. The cost-effectiveness of scaling up such a program must also be considered; purchasing LNS may be a substantial barrier as the cost of LNS per child, including shipping and taxes, is over 20 times the cost of SP-AQ and bundling SP-AQ with LNS added 18% to the cost of an SP-AQ-only delivery campaign.This study was subject to several limitations. First, the repeated cross-sectional study design resulted in measurements taken from different children within the study population during each survey round. This made it possible to assess changes in nutritional measurements only at the population level. In addition, it was not possible to assess the potential impact of SP-AQ on nutrition without a comparison group for the LNS intervention.Second, possible measurement errors resulted in considerable loss of data available for anthropometric analysis. Twenty-three percent of surveyed households at midline were excluded due to an error in the eligible age range of children during sampling, resulting in uneven sample sizes between survey rounds. As discussed, a number of children were also excluded from analysis due to extreme anthropometric z-scores ; this coThird, recall bias may have been introduced in the surveys, especially around dosage for Plumpy’Doz. The recommended dosage is 4.5 grams per day for children under one year of age and nine grams per day for children 1–2 years of age; reported quantities consumed ranged from 1–20 grams per day. This wide range of dosages may be reflective of problems with recall, sharing the commodity with other members of the household, or misunderstanding dosage instructions. Inconsistent dosing may have under- or over-estimated the overall effect of LNS following the intervention.Fourth, baseline food availability was reportedly high, and remained high throughout the study, which may have limited our ability to detect an impact of adding LNS on health outcomes. However, while two-thirds of households reported no food insecurity at baseline, more than 70% of children measured at baseline were found to be stunted. This could indicate discordance between households’ perception of food security and actual nutrient intake by young children, or could point to other contributing factors, such as frequent infection and/or poor water, sanitation, and hygiene practices.Finally, the nested case-control was subject to several limitations by design. Selection bias may have been introduced since only public health facility patients were included; children who sought treatment in the private sector, where nearly half of malaria treatment-seeking in Nigeria is estimated to occur, would not have had the opportunity to participate . In addiThis study investigated the operational and health impacts of combining nutrition and antimalarial interventions. The sustained high coverage and adherence to an integrated intervention strategy supports the efficiency of such bundled campaigns, and provides evidence that SMC campaigns can be further improved beyond the current model. Whilst our anthropometric outcomes  should be interpreted with care due to possible measurement and other limitations discussed, results of the case-control study indicated that the addition of nutrition interventions may be beneficial to reduction of malaria. The best nutrition products in terms of cost efficiency and health outcomes should be considered as candidates for distribution in malnourished areas across the Sahel, including other types of LNS and other WHO-recommended supplementary foods such as centrally-produced fortified blended foods or micronutrient powders. Alternatively, “nutrition-sensitive” interventions such as vouchers or cash, as was recently tested with successful outcomes in Niger ,53, coulMore generally, this study provides new evidence for how delivery of community health interventions may be improved. Given that addition of LNS, a bulky product, had no impact on coverage achieved through SMC campaigns, programs could consider adding different types of products to existing campaigns to enhance the efficiency of improving child health, such as vaccines, essential medicines, education, and other health interventions.S1 FigChildren in Kafin Agur, Burji, Kanwa, and Kauran Mata Wards received only SP-AQ (SP-AQ only area), while children in Kubaraci, Rikadawa, and Yakun received Plumpy’Doz LNS in addition to SP-AQ (SP-AQ plus LNS area).(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 TableVariables denoted with (*) were similar at baseline and endline but significantly different at midline (p<0.05).(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S1 File(PDF)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


Do physicians who order a high frequency of 1 low-value screening test also order a high frequency of other low-value screening tests?In this cohort study of 2394 primary care physicians, 18.4% of the physicians were in the top ordering quintile of at least 2 of 4 low-value screening tests. These physicians ordered 39.2% of all low-value screening tests.The study findings suggest that efforts to reduce low-value care should consider strategies that focus on physicians who order a high frequency of low-value care. This cohort study measures physician-level use rates of 4 low-value screening tests in primary care—repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs—to investigate the characteristics of primary care physicians who frequently order low-value care. Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently.To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care.A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests—repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)—among low-risk outpatients rostered to a common cohort of primary care physicians.Physician sex, years since medical school graduation, and primary care model.This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score  reflects a physician’s propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users  or generalized frequent users for 2 or more tests .The final sample consisted of 2394 primary care physicians , who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation , and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests  after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male , further removed from medical school graduation , or in an enhanced fee-for-service payment model  vs a capitated payment model   had increased odds of being generalized frequent users.This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care. To this end, prior studies20 have identified several tests, treatments, or procedures labeled as low value by 1 or more CW recommendations that are commonly used in clinical practice with substantial ordering variation among health care professionals. While previous investigations have described ordering rates of individual tests, there has been little research on understanding individual physician ordering patterns and, in particular, whether physicians who frequently order 1 low-value test are more likely to order other low-value tests. Measuring physician-level ordering frequency of low-value care across several CW recommendations may assist in the development of targeted interventions that are more physician centric and less test centric.To achieve meaningful reductions in low-value care, Kerr and colleaguesThe present study aimed to investigate whether physician-level ordering rates of different low-value screening tests are dependent. We hypothesized that physicians who frequently order 1 type of low-value test would be more likely to order other low-value tests with high frequency, thereby exhibiting a general pattern of overuse. We then identified characteristics associated with frequent physician-level ordering across tests.STROBE) reporting guideline. We conducted a retrospective cohort study in Ontario, Canada, using population-based administrative health care databases held at the Institute for Clinical Evaluative Sciences (ICES).21 These databases include the following: (1) the Registered Persons Database, which contains demographic information on all Ontario residents eligible for the Ontario Health Insurance Plan; (2) the Ontario Health Insurance Plan database, which includes all billing claims made by physicians to the Ontario Ministry of Health and Long-Term Care; (3) Client Agency Program Enrolment tables, which can identify patients rostered to primary care physicians; and (4) the ICES Physician Database, which contains demographic information on all physicians in Ontario. These data sets were linked using unique encoded identifiers and analyzed at the ICES. Use of data in this project was authorized under §45 of Ontario’s Personal Health Information Protection Act, which does not require review by a research ethics board.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (23 (2) electrocardiograms (ECGs) for patients at low risk for cardiovascular disease,25 (3) Papanicolaou (Pap) tests for women younger than 21 years or older than 69 years,25 and (4) chest radiographs (CXRs) for patients at low risk for cardiopulmonary disease.25 Previous studies15 of administrative data have demonstrated substantial overuse of these services and/or extensive gaps in performance among groups of physicians. Moreover, we chose these recommendations because they are clinical scenarios routinely encountered in primary care, often as part of an annual health examination (AHE).25We measured use of 4 screening tests identified as low value in the following clinical scenarios by CW Canada recommendations: (1) repeated dual-energy x-ray absorptiometry (DXA) scans for patients with a prior DXA scan in the past 2 years,15 that similarly measured the frequency of these tests using administrative data at the ICES. These prior studies predominantly measured use among physician billing groups,15 and methods were modified to enable physician-level measurement.27 eTable 1 in the 15Our methods for measuring these low-value care services were adapted from previously published studies15 Alternatively, an opportunity to order a repeated DXA was defined as a prior DXA scan between April 1, 2012, and March 31, 2014, for a patient 40 years or older.7 A shorter accrual window relative to the AHE-based measures was necessary to allow a 2-year observation window for subsequent testing.We first identified test-specific cohorts composed of health care services considered to be clinical opportunities to order that low-value screening test. Opportunities to order an ECG, a Pap test, or a CXR were defined as AHEs occurring between April 1, 2012, and March 31, 2016, with a primary care physician and an outpatient at low risk for either cardiovascular disease, cervical cancer, or cardiopulmonary disease, respectively.15 For the ECG and CXR cohorts, only AHEs with adult patients (18 years or older) were eligible. For the Pap test cohort, only AHEs with female patients between 13 and 20 years old or older than 69 years were included.25 If a patient had multiple DXA scans within the accrual window, the first DXA was chosen as the index scan and attributed to the patient’s physician at the time of the scan. We excluded any opportunities involving patients with an invalid health card number, those older than 105 years, or individuals with incomplete or missing demographic data .15 Individual patients could contribute multiple opportunities per denominator.For all 3 AHE-based cohorts, the physician responsible for conducting the examination was identified.15 Only tests for which claims could be definitively linked to the physician  attributed to the preceding opportunity were counted in the numerator.15 The expressed linkage of opportunities and any subsequent tests to a specific primary care physician was necessary to ensure that resulting measures of individual performance only involved components of care reasonably within his or her control.28Among each cohort detailed in the preceding subsection, we observed whether opportunities resulted in the patient having the corresponding screening test of interest, respectively, defined as at least 1 claim for a repeated DXA scan within 2 years of a prior DXA scan, an ECG within 30 days after an AHE, a Pap test within 7 days after an AHE, or a CXR within 7 days after an AHE .15 Primary care models in Ontario differ with respect to their remuneration methods.30 For example, the primary mechanism for physician reimbursement is capitation in family health organizations, teams, and networks vs fee-for-service in family health groups.30For all physicians identified, we denoted their sex, international medical graduate status, and years since medical school graduation.26Individual physician and billing group ordering rates were independently calculated per test as the ratio of the number of tests ordered to the number of opportunities to order that test .To enable observation of ordering patterns across all 4 tests within a common physician cohort, we excluded any physicians with fewer than 50 opportunities to order any of the 4 tests from our analyses.33 For example, a physician in the top ordering quintile for 3 of 4 tests would receive a score of 3. Physicians were classified according to their cross-test score as infrequent users , isolated frequent users , or generalized frequent users of 2 tests , 3 tests , or all tests . The distribution of baseline characteristics by cross-test score was summarized and compared via χ2 tests of independence for categorical variables and via Kruskal-Wallis tests for continuous variables. To investigate whether physician-level ordering rates for the 4 tests were correlated, we used a 1-way χ2 test to compare observed and expected proportions (specified assuming independence of test rates) by cross-test score value.We stratified physician-level ordering rates into quintiles for each of the 4 low-value screening tests. Per physician, we assigned 1 point for each test for which he or she belonged to the top ordering quintile to denote use of that test as frequent. The total number of points  was investigated to compute a physician’s cross-test score, a measure meant to assess physician tendency to frequently order low-value screening tests across all 4 scenarios.2 tests indicating that physicians with frequent use of at least 1 test are more likely to frequently use another test. Furthermore, ordinal and binary versions of the cross-test score were found to have strong, positive correlation .Physicians were dichotomized into infrequent or isolated frequent users  vs generalized frequent users for 2 or more tests . The cutoff value of 2 was informed by the median of the cross-test score distribution and the results of our 1-way χ15 Random, group-specific intercepts were included to account for the clustered nature of the data (physicians within physician groups) and to enable calculation of 2 measures of group-level heterogeneity, the intracluster correlation coefficient and the median odds ratio.38 For mixed-effects logistic regression, any fixed-effect odds ratio is group specific.34 This is problematic for interpreting the association of a group characteristic, which has a constant value for all physicians within a group.34 Accordingly, we calculated interval odds ratios for group-level characteristics, which represents the middle 80% of the distribution of odds ratios comparing 2 physicians in 2 different groups with differing values of that characteristic .37 Physicians with incomplete or missing data for any of the listed covariates were excluded, under the assumption that data were missing completely at random.Multivariable mixed-effects logistic regression was used to assess a physician’s odds of generalized frequent use across tests, with adjustment for physician sex, international medical graduate status, and years since medical school graduation, in addition to the billing group characteristics (primary care model and the number of patients per physician).To investigate how the decision to combine infrequent users and isolated frequent users into a single category  might have influenced the results of our primary regression analysis, we conducted a sensitivity analysis examining characteristics of physicians in the infrequent, isolated frequent, or generalized frequent user groups. Infrequent users were set as the reference group.P value of .05.All analyses were performed using statistical software . Statistical significance was assessed using a 2-tailed The final sample consisted of 2394 primary care physicians , who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation , and primarily reimbursed via fee-for-service in a family health group (1130 [47.2%]). eTable 2 in the Among our cohort of 2394 physicians, the median physician-level ordering rates were 19.5%  for repeated DXA scans, 4.8%  for ECGs, 5.1%  for Pap tests, and 0.9%  for CXRs . Among 5The eFigure in the 2 test for the cross-test score indicate that observed proportions of physicians across the 5 possible levels significantly deviate from expected proportions, assuming independence of the different testing rates . The significant result appears to be driven by a greater proportion of physicians observed with frequent use of ECGs and CXRs  than expected  if ordering rates were truly independent  of physicians were classified as generalized frequent users  and ordered 39.2% of all low-value tests. Generalized frequent users were more likely to be male, trained domestically, with more years in practice, and part of a billing group primarily remunerated via fee-for-service. The results demonstrate that, while most physicians exhibit infrequent or isolated frequent use of low-value screening tests, there is a minority of physicians who are responsible for a large proportion of all low-value testing ordered. These results have potential implications for the future design of interventions to reduce low-value testing.In this large, retrospective cohort study of primary care physicians in Ontario, we observed frequent ordering of low-value screening tests, with widespread physician-level variation.40 For example, a prior study by Makarov and colleagues40 found regional associations between low-value breast and prostate cancer imaging, suggesting that regional physician practice explains some of the ordering variability in low-value imaging tests. Furthermore, a study by Lipitz-Snyderman and colleagues41 demonstrated that use of low-value cancer care was physician dependent, rather than driven by patient needs or preferences. Our study builds on these results by describing, for the first time to date, a small group of individual physicians who order a high frequency of these low-value screening tests, which represent a significant portion of the total low-value care ordered.Our findings show that a subgroup of primary care physicians demonstrating a pattern of overuse across multiple screening scenarios ordered a disproportionate number of low-value tests. While this finding is novel, review of prior literature suggests that this result is not surprising. First, prior work has clearly demonstrated significant ordering variation in low-value testing among individual physicians, with positive correlations between ordering rates of different low-value tests.15 Physicians in fee-for-service payment models were also more likely to order a higher frequency of low-value care than those in capitated models. These findings fit into a previously described framework of the drivers of low-value care, which includes factors at both the professional and health system level.42 Even after adjustment for many physician-level and group-level characteristics, we found a substantial degree of unexplained variation, suggesting other potential, unmeasured drivers of physician ordering. Understanding how these drivers, including health system drivers , influence physician ordering behavior will be critical in the design of future interventions.Consistent with prior research, our study found that physicians who were male and further removed from medical school graduation were more likely to frequently order low-value care.14 Local interventions designed to reduce low-value care, such as computerized decision support tools or audit and feedback, are usually implemented for all physicians.3 To date, the results of CW campaigns have been marginal, possibly because the interventions are either not intensive enough to influence change or are too broadly implemented.44 Most physicians do not order low-value care frequently enough for interventions to make a significant difference in ordering practice.15 Worse, the increased administrative burden that goes along with most interventions, such as decision support tools, may lead to increased frustration and physician burnout. Our data suggest that future interventions should consider a more focused, intensive approach on the minority of physicians who frequently order low-value care. One could imagine a higher-intensity intervention aimed at the minority of high-ordering physicians  and a lower-intensity intervention  aimed at physicians who order low-value care infrequently. Such an approach would avoid exposing physicians who infrequently order low-value care to potentially burdensome quality improvement initiatives for which the marginal benefit may be limited and may be more cost-effective.45 More research on the effectiveness of such a multipronged strategy to reduce low-value care is warranted.Worldwide CW campaigns have aimed to raise general awareness among physicians and patients on the issue of low-value care. The importance of reducing low-value care is not only to avoid the cost of the initial screening test but also to prevent unnecessary downstream care resulting from false-positive results.8 The physicians in our cohort were more likely to be further removed from medical school graduation and have a higher median number of patients per physician than those physicians who were ultimately excluded. These systematic differences could limit the generalizability of the results, particularly given that years in practice was significantly associated with increased odds of being a generalized frequent user. In addition, our investigation of a test’s value did not account for considerations beyond the scope of CW recommendations.25 For instance, if advocating against the provision of these 4 low-value tests causes physicians to use more expensive or invasive alternatives for low-risk patients, then the overall influence of these 4 tests is not as negative as CW recommendations would suggest.39 Our study only examined 4 tests,15 and investigating low-value care ordering patterns across a greater number of tests, treatments, and procedures may better describe the extent to which low-value care provision is correlated across services and help create more reliable physician profiles.32Our findings should be considered within the context of the study’s limitations. First, administrative data lack clinical granularity, such as new symptoms, physical examination findings, and laboratory data, which may inform the reason for the test being ordered.This large, retrospective population-based cohort study identified a group of physicians who ordered a high frequency of low-value care that was responsible for almost 40% of all low-value tests ordered. Future investigations are warranted to focus on understanding drivers of low-value care and interventions to reduce its frequency, particularly in the generalized frequent user physician population.


Introduction: It has been difficult to state specific guidelines for IV-tPA use in cancer patients. Many of the randomized tPA-trials included too few patients with cancer or excluded patients with cancer entirely. In this report, we aimed to study the use of IV-tPA in patients with active cancer and acute ischemic stroke. We also investigated if the cancer patients who received IV-tPA experienced adverse events.Methods: All patients with ischemic stroke admitted to the Stroke Unit at Haukeland University Hospital were prospectively registered in the NORSTROKE database and every patient's medical record was searched for cancer diagnoses.Results: Of 1,646 patients admitted with ischemic stroke, 82 (5.0%) patients had active cancer. The total number of patients treated with IV-tPA was 16.2%. Five patients with stroke and active cancer were treated with IV-tPA (6.1%) and none suffered adverse events. Of the patients with no history of cancer, 261 (16.7%) were treated with IV-tPA and 3.8% experienced tPA-related adverse events.Conclusions: Few patients with active cancer receive thrombolysis for acute ischemic stroke. We report five cancer patients (three known and two occult) treated with IV-tPA for ischemic stroke without tPA-related adverse events. Cancer can induce hypercoagulability, leading to both venous and arterial thromboembolism . The preIn this report, we aimed to study the use of IV-tPA in patients with active cancer and acute ischemic stroke. We compared IV-tPA treated patients with active cancer to IV-tPA treated patients with no history of cancer. We also investigated if the cancer patients who received IV-tPA experienced any tPA-related adverse events.before or after the index stroke. Patients were dichotomized as patients with known active cancer (CS) and no evidence of active cancer (NCS). Adverse events were defined as any unwanted side effect from the IV-tPA, including intracerebral hemorrhage (ICH).Inclusion of patients started in January 2006 and ended in September 2012. All patients with ischemic stroke admitted to the Stroke Unit at Haukeland University Hospital were registered in the NORSTROKE database, a comprehensive research registry, and every patient's medical record was searched for cancer diagnoses. Ischemic stroke was defined in accordance to the Baltimore-Washington Cooperative Young Stroke Study Criteria as neurological deficit lasting more than 24 h or transient ischemic attacks (TIA) where computed tomography (CT) or magnetic resonance imaging (MRI) showed infarctions related to the clinical findings . Stroke Of 1,646 patients admitted with ischemic stroke, 82 (5.0%) patients were diagnosed with cancer within 12 months prior to or post-stroke ictus (CS), of whom 46 were diagnosed pre stroke and 36 were diagnosed post-stroke. Thus, 1,564 stroke patients had no history of cancer for the duration of the study.Of all stroke patients, 266 patients were treated with IV-tPA upon admission (16.2%). Five of the CS patients were treated with IV-tPA (6.1%), while 261 (16.7%) of NCS patients were treated with IV-tPA for their acute ischemic stroke. Of the IV-tPA-treated CS, three were diagnosed pre stroke, while two CS were diagnosed shortly post-stroke and thus had occult cancer at stroke ictus.Table p = 0.5]. Equally, for the patients who did not receive IV-tPA , the time from stroke ictus to admission was similar between CS- and NCS patients .Time from ictus to admission was somewhat shorter for IV-tPA-treated CS patients, but not significantly so [73.1 min (IQR 45.0–123.8) vs. 90 min (IQR 59.1–135.0), Fifteen CS patients (19.2%) and 277 (21.3%) NCS patients arrived at the hospital within 270 min and were as such eligible for IV-tPA, yet did not receive IV-tPA for varying reasons and contraindications.Table Only one of the patients was treated with chemotherapy prior to stroke. None of the five IV-tPA-CS patients experienced ICH or any other adverse event from the IV-tPA treatment.In our cohort, ~16% of NCS patients were treated with IV-tPA for their acute ischemic stroke. Meanwhile, of patients with active cancer, only about 6% of the CS patients were treated with IV-tPA. The largest report to date on thrombolysis in cancer patients with acute stroke, had yet a lower IV-tPA-rate of 1.6% for CS patients, and 2.9% for NCS patients . In the As postulated by Graus et al., we wondered if fewer patients with cancer received IV-tPA due to less focal and milder stroke symptoms . On the It is not inconceivable that some cancer patients do not receive IV-tPA due to the treating physician's uncertainty. This could be due to both the inherent fear of adverse events and hemorrhage, but possibly also the belief that because of significant CS patient co-morbidity, IV-tPA treatment ultimately is futile in bettering the outcome. As such, the willingness to risk tPA-related hemorrhage could diminish further. Cancer is not an established contraindication for IV-tPA, yet, due to lack of empirical evidence of the safety of IV-tPA in cancer patients, physicians have been hesitant to use it. Some cancer patients have coagulation disorders, some have thrombocytopenia, a relative contraindication, or even non-bacterial endocarditis, associated with hemorrhage , 12. AltThe most important question remains; is it safe to use thrombolysis in patients with active cancer? In our report, we present five patients with active cancer who received IV-tPA, of whom none experienced adverse events. As mentioned, the largest study on this topic with >800 CS patients also concluded that it was safe. However, this study used administrative data and International Classification of Disease codes for their analyses and may have missed significant patient data . The mosA limitation to this report is the low number of patients included. The small study population thus leaves us with lack of power to compare the findings to other studies. Higher numbers of patients and varying cancer types and data on cancer stage and treatment is needed to create guidelines for treating cancer patients with IV-tPA.Few patients with active cancer receive thrombolysis for acute stroke. The literature indicates that IV-tPA treatment is equally safe in patients with stroke and cancer. In accordance, we report five cancer patients (three known and two occult) treated with IV-tPA for ischemic stroke without tPA-related adverse events.Informed consent, or consent from legal guardian, was obtained from all patients. The study was approved by the Regional Committee for medical and health research ethics (REK Vest).HS is the main author of this report, she has performed the statistical analyses and written the first draft of the paper. She has contributed in all parts of the paper-writing process, as well as contributed HN in data collection. CK has contributed to the main hypothesis and idea of the paper, and he has supervised its process until completion. He also had the final read-through. HN is the one who founded the research registry used, and is thus responsible for data collection and patient data. He has also contributed in the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Circular RNAs (circRNAs) are a class of long non-coding RNAs (lncRNAs) which have a circular and closed loop structure. They are ubiquitous, stable, conserved and diverse RNA molecules with a range of activities such as translation and splicing regulation, which are able to interacting with RNA-binding proteins and specially miRNA sponge. The expression patterns of the circRNAs exhibited tissue specificity and also, step and stage specificity. Accumulating evidences approved the critical role of circular RNAs in many cancers such as ovarian cancer. Given that these molecules exert their effects through multiple cellular and molecular mechanisms  which are involved in cancer pathogenesis, circular RNAs, in particular, act by controlling cell proliferation in ovarian cancer, so that, it has been shown that the deregulation of these molecules is associated with initiation and progression of ovarian cancer. Therefore, they are attractive molecules which have introduced them as cancer biomarkers. Moreover, they could be used as new therapeutic candidates for developing novel treatment strategies. Here, for first time, we have provided a comprehensive review on the recent knowledge of circular RNAs and their pathological roles in the ovarian cancer. The majority portion of genome (approximately 98%) is assigned to non-coding RNAs (ncRNAs) rather than protein coding mRNAs . They arCircular RNAs (circRNAs) group is a member of lncRNAs with a large variation in length ranged from hundreds to thousands nucleotides . During Like other lncRNAs, circRNAs could be implicated in RNA or protein sponging to modulate gene expression. The most well-known mechanisms is in miRNA regulation by acting as competing endogenous miRNA sponge elements; in this way they post-transcriptionally provided mRNA escape miRNA repression , 10. BesOvarian cancer is one of the most common gynecologic disease worldwide. In 2018, more than 295,000 new cases were diagnosed and approximately 184,000 deaths were reported worldwide . DespiteIn eukaryotic genes, non-coding introns that are between exons are removed after transcription by alternative splicing of pre-mRNA transcript.  . After tBased on sequences and genomic origins, circRNAs are divided into three classes: intronic, exon-intron and exonic, which is the most prevalent form of circRNAs Fig.  15]. Ex. Ex15]. Exon skipping is the other model of splicing for producing of exonic circRNAs. In this process, when one or maybe more of the exons skipped, the introns with a loop structure, known as lariat (which resembles lasso), can formed exon-containing lariat during internal splicing –21.Generally, in eukaryotic genes, introns undergoing standard splicing is separated and degraded by enzymes. However, some of the introns have conservative sequences at both ends of them. These motifs are GU-rich element (7-nucleotide) located at the near 5′ splice site and the C-rich element (11-nucleotide) at 3′-branch site. Due to preserve motifs, The lariat introns escape of debranching enzymes, consequently, RNAs can be circularized and circular intronic RNAs (ciRNAs) are produced , 22. A fFinally, exon-intron circular RNAs (EIciRNAs) can be produced from circularized exons with intron preserved between exons Fig. . AccordiRecently, it is shown that some classes of the enzyme are effective in circRNAs biogenesis. RNA binding proteins (RBPs) is a group of enzymes that have a role in the generation of circRNAs in some situations and is demonstrated to act as a regulator in activation or repression circRNAs. Actually, it is proven that they play a crucial role in the control of RNA such as splicing . Ashwal-Cancer is one of very important health problems , 30. It During a study, the expression of circ-104,916 was investigated in gastric cancer (GC) by microarray. In this inquiry, circ-104,916 was downregulated in tissue GC compare with normal tissue. After that, they performed quantitative real-time PCR (in 70 pairs of human GC specimens) to confirm the results of the microarray and figured out that the results were matched. They also showed that the overexpression of circ-104,916 via pcDNA-circ-104,916 in two GC cell line  lead to significantly suppressed proliferation, invasion, and migration via changing the epithelial-mesenchymal transition (EMT) manner. According to the results, they claim that circ-104,916 would be appropriate biomarker for GC . RecentlThe bladder cancer-related circular RNA-2 (BCRC-2), also known as circHIPK3, expression level was explored in bladder tissue. On the basis of their result, it was shown that circHIPK3 was markedly decreased in bladder cancer cell lines and tissues. Actually, the circHIPK3 suppressed the expression of heparanase (HPSE) through sponging miR-558 . HPSE isIn 2015, a study has surveyed the alteration in the expression level of circ-ITCH in esophageal squamous cell carcinoma (ESCC) tissues. They have manifested that circ-ITCH could act as a tumor suppressor in ESCC and an increase in circ-ITCH expression ITCH leaded to represses the Wnt/β-catenin pathway through the destruction of phosphorylated Dvl2 via sponge of miR-7, miR-17 and miR-214. Their results also revealed an association between circRNAs, mRNAs, and protein and were proved that aberrant alteration among them may cause cancer beginning and progression. They have announced the down-regulation expression of cir-ITCH in ESCC tissue compare with matched normal tissue. Subsequently, the level of ITCH positively with circ-ITCH reduced and the expression of oncogenes including miR-7, miR-17 and miR-214 overexpressed in ESCC and the Wnt/β-catenin pathway not be repressed .A significant overexpression of circMYO9B was reported in breast cancer (BC) tissue. Specific siRNA against circMYO9B caused suppression in proliferation, invasion and migration in MCF7 and MDA-231 cell lines. Likewise, the in vivo assay had shown a decrease in level circMYO9B tumor growth. They also described the mechanism of circMYO9B that sponged miR-4316 and enhanced expression of FOXP4 which act as tumor suppressors and oncogene, respectively , 73. CleAnother group of scientists had reported a novel circRNA named circITGA7 which was markedly downregulated in colorectal cancer CRC) tissue and cell lines. They also found that the linear form of ITGA7 has been downregulated in this cancer. The downregulation of circITGA7 and ITGA7 were associated with CRC progression. To the examine circITGA7 and ITGA7 roles in CRC, ectopic circITGA7 were overexpressed and observed proliferation and metastasis repression in CRC cells, in vitro and in vivo. CircITGA7 could sponge miR-370-3p and indirectly leaded to an increase in neurofibromin 1 (NF1) which is its target and a negative regulator of Ras pathway. On the other hand, CircITGA7 through suppressing RREB1, a transcription factor which activate Ras pathway transcription factor, leaded to ITGA7 overexpression. RNA-Seq and KEGG pathway analysis showed that ITGA7 may be concomitant in cytokine-related signaling pathways .It is well-known that the miR-17-3p and miR-181b-5p overexpression are contribute to the progression of hepatocellular carcinoma (HCC) , 75. Yu One report described the expression and function of Circular SMARCA5 (circ-SMARCA5) in prostate cancer (PCa). Due to circ-SMARCA5 up-regulation in PCa tissues and cell lines, it is known as oncogenic circRNAs in this cancer. The double hydrogen testosterone (DHT), is a natural hormone and can be used as a medication, treatment resulted in circ-SMARCA5 down-regulation which can be concluded that it is an androgen-inducible circRNA. The circ-SMARCA5 silencing in DU145, a PCa originated cell line, inhibited cell cycle, cell proliferation and motivated apoptosis in PCa cells .The circFARSA, derived from phenylalanyl-tRNA synthetase alpha chain (FARSA) gene, has been upregulated in non-small cell lung cancer (NSCLC) tissue compared to non-cancerous tissue. The circFARSA overexpression leaded to migration and invasion NSCLC cells. In silico analysis and HITS-CLIP experiment showed that miR-330-5p and miR-326 counterparted in the fatty acid synthesis and they were introduced as circFARSA direct targets. It is the hypothesis that circFARSA act as the sponger for miR-330-5p and miR-326 and subsequently when overexpressed lead to upregulation of FASN, a target of both miRNAs .CircNOL10 can be described as a round RNA whose expression takes place in low amounts when experiencing lung cancer, although there is no clear information on the functioning mechanisms in this disease . Nan andCircNOL10 elevates the expression of the transcribing factor of sex comb on midleg-like 1 (SCML1) through inhibition of ubiquitination, which subsequently influences the balance of HN polypeptide group through SCML1. Moreover, circNOL10 can influence the performance of mitochondria by regulation of the HN polypeptide group along with its effects on several signaling routes, which will eventually hamper multiplication of the cell along with the development of its cycle. As a result, apoptosis is promoted in the lung cancer cells and results in the inhibition of their growth.The present research aimed to find out how circNOL10 acts and what molecular mechanisms are involved in advancement of lung cancer in addition to indicating its engagement in the transcriptional regulation of the HN polypeptide group via SCML1. According to the findings, HN could hamper the development of lung cancer cells. The information obtained through this study may be helpful in identification of new molecular treatments for lung cancer .In oral squamous cell carcinomas (OSCC), circRNA_100290 was significantly upregulated in tissue compared with adjacent non-cancerous tissue. Actually, it was represented that circRNA_100290 regulate CDK6 expression with the competing endogenous RNA (ceRNA) mechanism. CircRNA_100290 could act as spongers for miR-29 family such as miR-29a, miR-29b, and miR-29c. Among them, it was clarified that CDK6 is a direct target of miR-29b. On the basis of considerations, it was exposed to circRNA_100290 and CDK6 were up-regulated in OSCC. To investigate the circRNA_100290 function in OSCC cell lines, the CDK6 expression was downregulated and caused cell proliferation in vitro and in vivo with knocking down of this circRNA .The last circular RNA that introduced in this part is circ_001564. The circ_001564 was highly upregulated in osteosarcoma tissue and cell lines. In order to represent the circ_001564 mechanisms, it was knocked down in osteosarcoma cell lines (HOS and MG-63). The results manifested restraining the cell proliferation, induced cell cycle arrest in G0/G1 phase and increased apoptosis in osteosarcoma cell lines. Base on bioinformatics analysis, miR-29c-3p might be bonded to circ_001564 complementary; consequently, the oncogenic effect of hsa_circ_001564 was be reversed. In addition, the circ_001564 had function as miR-29c-3p sponge that proposed competing endogenous RNAs (ceRNAs) mechanisms in osteosarcoma .For the first time, Huang et al., considered the existence of circRNAs in exosomes . As a reTwo presumptions can be considered regarding how circRNAs act in exosomes. According to the first one, they facilitate cell correspondence through the existing substance in exosomes, making distal cells’ material and transmission of information possible. Based on the second assumption, circRNAs in exosomes assist in elimination of circRNAs collected in cells. However, recent studies do not provide clear information on these presumptions. Lasda et al. endeavored to examine this assumption and they accordingly hypothesized that circRNAs in exosomes along with extracellular vesicles could play the role of a mechanism removing endogenous circRNAs .Analysis of the corresponding number of circRNAs along with linear RNAs was performed in the present study taking extracellular vesicles (consisting of exosomes) of the Hela, 293 t, U2OS cells into account. According to the findings circRNAs outperformed the linear RNAs. Accordingly, it was stated that cells would probably have the potential to manage circRNAs by their excretion through extracellular vesicles. Since, it would be possible fot the EVs to be captured by other cells, such as macrophages, their function as message carriers could be possible in order to maintain intercellular communication. This is a new presumption which of course needs to be validated.Enrichment of circRNAs was performed in another study in platelet due to exonuclease . But theThree types of colorectal cancer cell lines were investigated in the present research, including DLD-1, DKO-1  as well as DKs-8 . The circRNAs of the three mentioned cell types underwent analysis through RNA-Seq. Considerable down-regulation of circRNAs was observed in DLD-1 as well as DKO-1 cells rather than DKs-8 cells.Later, examination of two other colorectal cancer cell lines including HCT116  and HKe3  went on, with the findings obtained from sequencing confirming the fact that overall expression of circRNAs was higher in HKe3 compared with HCT116. CircRNAs associated with colorectal cancer is found in exosomes and considerable down-regulation of circFAT1 was observed contrary to up-regulation of circRTN4. However, there were no evident changes in the respective linear mRNA which was under regulating effects of these genes as it was evident in circRNAs. Moreover, it could be stated that transmission of cirRNAs into exosomes would be performed through an elective procedure .Accumulating studies have confirmed interplay between circRNAs and human disorders including embryonic development, Alzheimer’s disease, diabetes and also cancers , 76. OvaFor the first time, Ahmed, et al., performed a robust circRNAs expression analysis in clinical ovarian tumors. They reported that abundant number of circRNAs differentially expressed in tumor samples. They also examined differential mRNA and circRNA expression signatures between primary and metastasis ovarian tumor. Regarding the RNA exonuclease resistance and stability of circRNAs , they diThe circ-CSPP1 or circ-0001806 is derived from centrosome/spindle pole-associated protein 1 (CSPP1) gene which is located in 8q13.2 region of human genome. The oncogenic function of CSPP1 have determined in luminal breast cancer and B-cell lymphoma , 97. AlsThe overexpression of circRNA-000479, or circEPSTI1 was reported in triple-negative breast (TNBC) cancer tissues. The high level of circEPSTI1 was correlated with reduced survival in these patients. The circEPSTI1 promoted proliferation and clonal formation and suppressed apoptosis in TNBC cell lines. Moreover, xenograft and invitro experiments confirmed its role as a decoy of miR-4753 and miR-6809 to modulate BCLI 1A . The cirThe role of circHIPK3 was investigated in some human malignancies. For instance, the circHIPK3 overexpression was reported in prostate cancer tissues which was correlated with tumor stage. This circRNA relieved MCL1 expression by sponge miR-193-3p . Its expAlso, it was investigated the circHIPK3 expression correlation with clinicopathological factors in the tissues associated with ovarian cancer.The circHIPK3 profiling revealed an increased expression in tumor samples. The over expressed cases suffered from node invasion and inappropriate prognosis . ContradEmerging evidence represented the over expression and oncogenic role of miR-10a in ovarian cancer , 105. LuPreviously, circRNAs were known as errors during RNA splicing. Developing technology in recent years improved our knowledge about this class of lncRNAs. Nowadays, they are understood to be a frequently stable RNA molecule which expressed in various tissues and cells. The circRNAs represent a miRNAs decoy role to indirectly modulate their target genes. Accumulating evidences revealed the critical regulatory roles of them in tumorigenesis, with cancer-type specific distinguishable expression levels. CircRNAs biological functions, such as interactions with specific mRNA, protein and specifically miRNAs provide a regulatory network for cancer progression and invasion, so promise to providing more reliable, sensitive diagnoses and more effective cancer therapy. Based on reports, ovarian cancer is the sixth and one of the lethality cancer type in women worldwide. Without doubt, accurate knowledge about regulating molecular mechanisms, including circRNAs role provides a promising opportunity to better understanding of ovarian cancer. Subsequently novel approaches can be identified to early diagnosis, prognosis, follow up and therapeutics of ovarian cancers.