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Li WW, Zhang JX, Wang J, Chen YQ, Lai S, Qiu ZK. Bidirectional two-sample Mendelian randomization analysis identifies causal associations between migraine and five psychiatric disorders. Front Neurol 2024; 15:1432966. [PMID: 39161872 PMCID: PMC11330824 DOI: 10.3389/fneur.2024.1432966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024] Open
Abstract
Background The question of whether a correlation exists between migraine and five psychiatric disorders, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), anorexia nervosa (AN), bipolar disorder (BIP), and schizophrenia (SCZ), remains a matter of controversy. Hence, this research aims to investigate whether there is a possible association between migraine and five psychiatric disorders. Methods We performed a bidirectional 2-sample Mendelian randomization (MR) analysis to assess the causality between migraine and five psychiatric disorders. Genetic associations of PTSD, MDD, AN, BIP, and SCZ were obtained from the Psychiatric Genomics Consortium (PGC) database and genetic associations of migraine with aura and migraine without aura were obtained from the FinnGen dataset. We used the inverse-variance weighted (IVW), weighted median, weighted mode, MR Pleiotropy RESidual Sum and Outlier (MR-PRESSO), and MR Egger regression methods to evaluate the association of genetically predicted exposure with the risk of outcome. Results MR demonstrated that MDD was associated with a high risk of migraine without aura (OR = 1.930578, 95% confidence interview (CI): 1.224510, 3.043550, p < 0.05), but BIP was related to a low risk of migraine without aura (OR = 0.758650, 95%CI: 0.639601, 0.899858, p < 0.05). According to the results of reverse MR, migraine with aura was associated with a high risk of BIP (OR = 1.019100, 95%CI: 1.002538, 1.035935, p < 0.05), and migraine without aura was associated with an increased risk of AN (OR = 1.055634, 95%CI: 1.023859, 1.088394, p < 0.05). Conclusion Our results provide evidence of the potential causal association between migraine and some psychiatric disorders. It may contribute to the prevention of migraine and some psychiatric disorders.
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Affiliation(s)
| | | | | | | | - Sha Lai
- *Correspondence: Sha Lai, ; Zhi-Kun Qiu,
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Brewerton TD, Dennis K, Wiss DA. Dismantling the myth of "all foods fit" in eating disorder treatment. J Eat Disord 2024; 12:60. [PMID: 38760858 PMCID: PMC11102136 DOI: 10.1186/s40337-024-01017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
We call for a reevaluation of the long-standing dogmatic nutritional principle that "all foods fit" for all cases of eating disorders (EDs) and its corollary, "there are no bad foods" (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.
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Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Kim Dennis
- SunCloud Health, Chicago, IL, USA
- Department of Psychiatry, University of Illinois Chicago College of Medicine, Chicago, IL, USA
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Downey AE, Chaphekar AV, Woolley J, Raymond-Flesch M. Psilocybin therapy and anorexia nervosa: a narrative review of safety considerations for researchers and clinicians. J Eat Disord 2024; 12:49. [PMID: 38659049 PMCID: PMC11040882 DOI: 10.1186/s40337-024-01005-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Clinical trials using psilocybin therapy to treat anorexia nervosa (AN) are currently underway. The safety and tolerability of psilocybin is of utmost importance in individuals with AN who may present unique medical vulnerabilities. The purpose of this review is to describe how the common physiologic adverse effects of psilocybin may impact medical complications experienced by individuals with AN in clinical trials of psilocybin therapy. MAIN BODY The physiologic underpinnings of common adverse effects following psilocybin administration are described, including tachycardia, hypertension, electrocardiogram changes, nausea, headache, and lightheadedness. These anticipated physiologic changes are described in relation to the common medical correlates seen in individuals with AN. Risk mitigation strategies for each adverse effect are proposed. CONCLUSION Early evidence suggests that psilocybin therapy is well-tolerated in individuals with AN. Understanding the unique medical complications of AN, and how they may be impacted by common physiologic adverse effects of psilocybin administration, leads to tailored risk mitigation strategies to enhance safety and tolerability of this novel intervention.
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Affiliation(s)
- Amanda E Downey
- Department of Pediatrics, University of California, San Francisco, CA, USA.
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.
| | - Anita V Chaphekar
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Joshua Woolley
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
- San Francisco Veteran's Affairs Medical Center, San Francisco, CA, USA
| | - Marissa Raymond-Flesch
- Department of Pediatrics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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Brewerton TD, Perlman MM, Gavidia I, Suro G, Jahraus J. Headache, eating disorders, PTSD, and comorbidity: implications for assessment and treatment. Eat Weight Disord 2022; 27:2693-2700. [PMID: 35604548 DOI: 10.1007/s40519-022-01414-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/30/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Severe headaches (HAs) have been associated with eating disorders (ED) as well as with trauma, posttraumatic stress disorder (PTSD), major depression and anxiety. However, data addressing all of these factors in the same subjects are limited. METHODS In a large sample of patients (n = 1461, 93% female) admitted to residential treatment (RT) for an ED, we assessed within 48-72 h of admission subjective reports of frequent HAs and their associations with severity of ED, PTSD, major depressive and state-trait anxiety symptoms, as well as quality of life measures. HA ratings were significantly correlated to the number of lifetime trauma types as well as to symptoms of PTSD, major depression, and state-trait anxiety. RESULTS Results indicated that 39% of patients endorsed that frequent HAs occurred "often" or "always" (HA+) in association with their eating or weight issues. This HA-positive (HA+) group had statistically significant higher numbers of lifetime trauma types, higher scores on measures of ED, PTSD, major depressive, and state-trait anxiety symptoms, and worse quality of life measures (p ≤ 0.001) in comparison to the HA-negative (HA-) group, who endorsed that frequent HAs occurred "never," "rarely," or "sometimes" in association with their eating or weight issues. The HA + group also had a significantly higher rate of a provisional PTSD diagnosis (64%) than the HA- group (35%) (p ≤ .001). Following comprehensive RT, HA frequency significantly improved (p ≤ .001). CONCLUSION These findings have important implications for the assessment and treatment of HAs in the context of ED, PTSD and related psychiatric comorbidities, especially at higher levels of care. In addition, the importance of identifying traumatic histories and treating comorbid PTSD and related psychopathology in individuals presenting with severe HAs is emphasized. LEVEL OF EVIDENCE III Evidence obtained from well-designed cohort or case-control analytic studies.
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Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA. .,Timothy D. Brewerton, MD, LLC, Mt. Pleasant, SC, USA. .,Monte Nido and Affiliates, Miami, FL, USA.
| | - Molly M Perlman
- Monte Nido and Affiliates, Miami, FL, USA.,Department of Psychiatry and Behavioral Health, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
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de Oliveira-Souza AIS, da Silva Freitas D, Ximenes RCC, Raposo MCF, de Oliveira DA. The presence of migraine symptoms was associated with a higher likelihood to present eating disorders symptoms among teenage students. Eat Weight Disord 2022; 27:1661-1667. [PMID: 34562226 DOI: 10.1007/s40519-021-01302-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/08/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To investigate the association between migraine and signs and symptoms of eating disorders among teenagers. And as secondary objectives: to investigate the prevalence of eating disorders signs and symptoms and to identify the prevalence of migraine among teenagers. METHODS Cross-sectional study was carried out in public schools which included adolescents aged 11-18 years, of both sexes. For eating disorders evaluation two self-reported questionnaires were used: Eating Attitudes Test-26 (EAT-26) and The Bulimic Investigatory Test of Edinburg (BITE). The presence and characterization of headache were verified following the International Classification of Headache Disorders (ICHD-II). RESULTS 607 adolescents (388 females) with mean age of 13.9 years (95% CI: 13.7; 14) were included. The eating disorders symptoms based on EAT-26 (p = 0.041) and the bulimia nervosa symptoms (p = 0.014) evaluation were more prevalent among teenagers with migraine compared with non-migraine. Also, in multivariate analysis, the adjusted odds ratio (OR) to present bulimia nervosa symptoms is 1.85 times higher among females than males. And, the adjusted OR to present bulimia nervosa symptoms among teenagers with migraine is 1.51 times (OR) higher than among non-migraine. CONCLUSIONS The presence of migraine symptoms were associated with a higher likelihood to present eating disorders symptoms among teenagers, especially in females, that was associated with a 1.85-fold increase in the risk to present bulimia nervosa symptoms. LEVEL OF EVIDENCE III, Evidence obtained from cross-sectional study.
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Affiliation(s)
- Ana Izabela Sobral de Oliveira-Souza
- Physiotherapy Department, Federal University of Pernambuco (UFPE), Av. Jorn. Aníbal Fernandes, w/n, Cidade Universitária, Recife, PE, 50740-560, Brazil.
| | - Dayzene da Silva Freitas
- Physiotherapy Department, Federal University of Pernambuco (UFPE), Av. Jorn. Aníbal Fernandes, w/n, Cidade Universitária, Recife, PE, 50740-560, Brazil
| | | | | | - Daniella Araújo de Oliveira
- Physiotherapy Department, Federal University of Pernambuco (UFPE), Av. Jorn. Aníbal Fernandes, w/n, Cidade Universitária, Recife, PE, 50740-560, Brazil
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Meylakh N, Marciszewski KK, Di Pietro F, Macefield VG, Macey PM, Henderson LA. Altered regional cerebral blood flow and hypothalamic connectivity immediately prior to a migraine headache. Cephalalgia 2020; 40:448-460. [PMID: 32164427 DOI: 10.1177/0333102420911623] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is evidence of altered resting hypothalamic activity patterns and connectivity prior to a migraine, however it remains unknown if these changes are driven by changes in overall hypothalamic activity levels. If they are, it would corroborate the idea that changes in hypothalamic function result in alteration in brainstem pain processing sensitivity, which either triggers a migraine headache itself or allows an external trigger to initiate a migraine headache. We hypothesise that hypothalamic activity increases immediately prior to a migraine headache and this is accompanied by altered functional connectivity to pain processing sites in the brainstem. METHODS In 34 migraineurs and 26 healthy controls, we collected a series comprising 108 pseudo-continuous arterial spin labelling images and 180 gradient-echo echo planar resting-state functional magnetic resonance volumes to measure resting regional cerebral blood flow and functional connectivity respectively. Images were pre-processed and analysed using custom SPM12 and Matlab software. RESULTS Our results reflect that immediately prior to a migraine headache, resting regional cerebral blood flow decreases in the lateral hypothalamus. In addition, resting functional connectivity strength decreased between the lateral hypothalamus and important regions of the pain processing pathway, such as the midbrain periaqueductal gray, dorsal pons, rostral ventromedial medulla and cingulate cortex, only during this critical period before a migraine headache. CONCLUSION These data suggest altered hypothalamic function and connectivity in the period immediately prior to a migraine headache and supports the hypothesis that the hypothalamus is involved in migraine initiation.
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Affiliation(s)
- Noemi Meylakh
- Department of Anatomy and Histology, University of Sydney, Sydney, NSW, Australia
| | - Kasia K Marciszewski
- Department of Anatomy and Histology, University of Sydney, Sydney, NSW, Australia
| | - Flavia Di Pietro
- Department of Anatomy and Histology, University of Sydney, Sydney, NSW, Australia
| | | | - Paul M Macey
- UCLA School of Nursing and Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Luke A Henderson
- Department of Anatomy and Histology, University of Sydney, Sydney, NSW, Australia
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Kandemir G, Hesapcioglu ST, Kurt ANC. What Are the Psychosocial Factors Associated With Migraine in the Child? Comorbid Psychiatric Disorders, Family Functioning, Parenting Style, or Mom's Psychiatric Symptoms? J Child Neurol 2018; 33:174-181. [PMID: 29334851 DOI: 10.1177/0883073817749377] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Psychiatric diagnoses, parenting style, family functioning among children and adolescents with migraine, and psychiatric symptoms of their mothers were examined. METHODS The K-SADS and other measurements were used to assess psychiatric disorders in 50 children with migraine (aged 8-18) and matched 50 controls. RESULTS At least one psychiatric disorder was diagnosed in 56% of the migraine group. The presence of any psychiatric disorder in children (odds ratio [OR] = 2.765, P = .027) and somatization symptoms in their mothers (OR = 2.061, P = .025) were increasing the risk of migraine diagnosis. The parenting style scale assessments revealed that parents in the migraine group grant their children less autonomy. CONCLUSION Psychiatric comorbidity, especially depression and anxiety disorders, is more common in children with migraine. The frequency of eating disorder is also higher. Evaluating comorbidity, family functioning, and particularly affective responsiveness in migraine families may guide the clinician to a targeted treatment plan.
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Affiliation(s)
- Gozde Kandemir
- 1 Department of Child and Adolescent Psychiatry, Ankara Yildirim Beyazit University School of Medicine, Ankara, Turkey
| | - Selma Tural Hesapcioglu
- 1 Department of Child and Adolescent Psychiatry, Ankara Yildirim Beyazit University School of Medicine, Ankara, Turkey
| | - Aysegül N Citak Kurt
- 2 Department of Pediatric Neurology, Ankara Yildirim Beyazit University School of Medicine, Ankara, Turkey
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Prakash S, Kumar Singh A, Rathore C. Chronic Migraine Responding to Intravenous Thiamine: A Report of Two Cases. Headache 2016; 56:1204-9. [PMID: 27197607 DOI: 10.1111/head.12838] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/07/2016] [Accepted: 03/07/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Migraine is a risk factor for thiamine deficiency and Wernicke's encephalopathy (WE). WE is a highly underdiagnosed condition. The misdiagnosis is associated more with early or mild WE. The interrelation between migraine and thiamine deficiency is unknown CASE REPORTS Here, we report two female patients with chronic migraine. During examinations, we also noted clinical signs pertinent with a diagnosis of WE. Both patients had low blood thiamine level. Intravenous thiamine supplementation led to the improvement of both WE and associated headaches. DISCUSSION Nausea, vomiting, and anorexia of migraine may lead to mild to moderate thiamine deficiency and WE. Review of the literature suggests that WE in early or subclinical form will have nonspecific symptoms that may include frequent headache, nausea, vomiting, and anorexia. So, WE in the early stage may simulate migrainous features and this will further aggravate thiamine deficiency and a vicious cycle may be formed, and that will progressively increase the chronicity of headaches and other features. Breaking of this cycle by thiamine supplementation might be a promising therapy in a subset of patients with chronic migraine. CONCLUSION Thiamine deficiency due to nausea, vomiting and anorexia of migraine may further aggravate migraine like headaches in cyclical pattern.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Piperia, Baroda, Gujarat, India
| | - Ajai Kumar Singh
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Gomti Nagar - Lucknow, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Piperia, Sumandeep Vidyapeeth University, Baroda, Gujarat, India
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Roux H, Blanchet C, Stheneur C, Chapelon E, Godart N. Somatic outcome among patients hospitalised for anorexia nervosa in adolescence: disorders reported and links with global outcome. Eat Weight Disord 2013; 18:175-82. [PMID: 23760846 DOI: 10.1007/s40519-013-0030-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 04/10/2013] [Indexed: 11/29/2022] Open
Abstract
AIMS (1) To describe the frequency of somatic pathologies and depression among former anorexia nervosa (AN) patients; (2) to study links with subjects' clinical history and global outcomes. METHODS 97 women hospitalised for AN during adolescence, 9.00 ± 1.92 years previously, were interviewed using structured questionnaires concerning somatic and psychiatric disorders that they had experienced. RESULTS Iron deficiency, migraine, cystitis, upper digestive system disorders, fractures, osteoporosis, and dental problems were reported with a frequency >20 %. Depression was reported by 2/3 of the sample. Osteoporosis was 14 times more frequent in case of vitamin D deficiency. Fractures were three times more frequent in presence of osteoporosis and less frequent when the overall outcome was better. CONCLUSION Among women who had AN in adolescence, somatic comorbidities are frequent in adulthood. They are linked to the severity and the duration of AN, and to the overall outcome of the subject.
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Affiliation(s)
- Hélène Roux
- Department of Psychiatry, Institut Mutualiste Montsouris, Paris, France
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D'Andrea G, Ostuzzi R, Bolner A, Colavito D, Leon A. Is migraine a risk factor for the occurrence of eating disorders? Prevalence and biochemical evidences. Neurol Sci 2013; 33 Suppl 1:S71-6. [PMID: 22644175 DOI: 10.1007/s10072-012-1045-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The eating disorders (ED), anorexia nervosa (AN) and bulimia nervosa (BN), are severe psychiatric and somatic conditions occurring mainly in young woman. Although the aetiology is largely unknown, same evidences suggest that biological and psychological factors play a relevant role in the pathogenesis, along with monoamine, indole and same hypothalamic hormonal dysfunctions. Migraine is characterized by similar metabolic and psychological anomalies suggesting that a possible relationship exists between the two pathological conditions. To understand the possible relationship between migraine and ED, we have investigated the prevalence of migraine and the other primary headaches in a large group of AN and BN patients. In addition, we have studied the role of tyrosine metabolism in the same group of AN and BN young woman sufferers. In particular, we measured plasma levels of elusive amines: tyramine (Tyr) and octopamine (Oct) and catecholamines: noradrenalin (NE), dopamine (DA). The results of this study show that the prevalence of migraine in the woman affected by ED is very high (<75 %). The levels of Tyr and DA were higher and levels of NE were lower in the ED patients in respect to the control subjects. These biochemical findings suggest that abnormalities of limbic and hypothalamic circuitries play a role in the pathogenesis of ED. The very high prevalence of migraine in our group of ED sufferers and the biochemical profile of migraine, similar to that of ED patients shown in this study, suggest that migraine may constitute a risk factor for the occurrence of ED in young females. This hypothesis is supported by the onset of migraine attacks that initiated, in the majority of the patients, before the occurrence of ED symptoms.
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Affiliation(s)
- Giovanni D'Andrea
- Biochemistry Laboratory for the Study of Primary Headaches and Neurological Diseases, Research and Innovation SpA, Padova, Italy.
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Seidel S, Karwautz A, Wagner G, Zormann A, Eder H, Huemer J, Nattiashvili S, Wöber C, Wöber-Bingöl Ç. Migraine in Patients With Eating Disorders: A Study Using a Sister-Pair Comparison Design. Headache 2011; 51:220-5. [DOI: 10.1111/j.1526-4610.2010.01822.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Coughlin JW, Edwards RR, Redgrave GW, Guarda AS. Pain severity in eating disorders predicts longer inpatient hospitalization. Int J Eat Disord 2010; 43:737-42. [PMID: 19842161 DOI: 10.1002/eat.20766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study examined pain intensity (PI) in eating disorders. METHOD Comparisons between inpatients (N = 208) reporting moderate to severe pain (HiP) and no pain or mild pain (LoP) at admission were made, and the relationship between PI and treatment response was examined. RESULTS Patients with HiP were older, had a greater likelihood of having a bingeing and/or purging diagnosis, and reported greater body dissatisfaction, drive for thinness, depressive symptomatology, and neuroticism in comparison to those with LoP. They were also more likely to report widespread pain, to catastrophize about pain and to use praying and hoping to cope with pain. PI was associated with longer length of inpatient hospitalization, even after controlling for degree of underweight, depressive symptomatology, and neurotic personality features. DISCUSSION This is the first observation of a relationship between pain and health care utilization in eating disorders. The results imply that pain management is an important component of treatment.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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