Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities

BACKGROUND

Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health.

OBJECTIVE

To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs).

DESIGN AND PARTICIPANTS

Interrupted time series study of utilization among IPC patients.

MAIN MEASURES

Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups.

RESULTS

Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92).

CONCLUSIONS

An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.

Associations of Body Mass Index and Waist Circumference in Young Adulthood with Later Life Incident Diabetes

CONTEXT

The independent contribution of young adult exposure to overweight and obesity to later-life incident diabetes is not well studied.

OBJECTIVE

To assess the associations of exposures to elevated body mass index (BMI) and waist circumference (WC) in young adulthood (ages 18-39 years) with incident diabetes later in life (≥40 years).

DESIGN

Pooled data from 6 US prospective cohorts (Atherosclerosis Risk in Communities Study, Cardiovascular Risk Development in Young Adults Study, Cardiovascular Health Study, (4) Framingham Heart Study Offspring Cohort, (5) Health, Aging and Body Composition Study, and (6) Multi-Ethnic Study of Atherosclerosis.

SETTING

Population-based cohort studies.

PARTICIPANTS

30 780 participants (56.1% female, 69.8% non-Hispanic white) without a diagnosis of diabetes by age 40.

INTERVENTIONS

We imputed BMI and WC trajectories from age 18 for every participant and estimated time-weighted average exposures to BMI or WC during young adulthood and later life.

MAIN OUTCOME MEASURE(S)

Incident diabetes defined as fasting glucose ≥126 mg/dL, nonfasting glucose ≥200 mg/dL, or use of diabetes medications.

RESULTS

During a 9-year median follow-up, 4323 participants developed incident diabetes. Young adult BMI and WC were associated with later-life incident diabetes after controlling for later-life exposures [hazard ratios (HR) 1.99 for BMI ≥ 30 kg/m2 and 2.13 for WC > 88cm (women)/>102cm (men) compared to normal ranges]. Young adult homeostatic model of insulin resistance mediated 49% and 44% of the association between BMI and WC with later-life incident diabetes. High-density lipoproteins and triglycerides mediated a smaller proportion of these associations.

CONCLUSIONS

Elevated BMI and WC during young adulthood were independently associated with later-life incident diabetes. Insulin resistance may be a key mediator.

Cognition and 20-year subsequent sleep disturbances

INTRODUCTION

There is a paucity of data exploring the extent that preclinical cognitive changes are predictive of subsequent sleep outcomes.

METHODS

Logistic regression models were used to evaluate data from a cohort of 196 African American adults who had measures of cognitive function assessed at 2 time points during a 20-year period across the mid- to late-life transition. Cognitive testing included the Delayed Word Recall, the Digit Symbol Substitution, and the Word Fluency tests, which were summarized as a composite cognitive z-score. Sleep apnea was measured by in-home sleep apnea testing and sleep duration and quality were derived from 7-day wrist actigraphy at the end of the study period.

RESULTS

A one standard deviation (SD) lower composite cognitive z-score at baseline was significantly associated with greater odds of low sleep efficiency (<85%) (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.13, 3.04) and greater odds of increased wakefulness after sleep onset time (WASO; >60 minutes) (OR = 1.65, 95% CI = 1.05, 2.60) in adjusted models. A one SD faster rate of cognitive decline over the study period was significantly associated with greater odds of low sleep efficiency (OR = 1.68, 95% CI = 1.04, 2.73), greater odds of sleep fragmentation (>35%); (OR = 1.73, 95% CI = 1.05, 2.85), and greater odds of increased WASO (OR = 1.85, 95% CI = 1.15, 2.95) in adjusted models. Neither baseline cognitive z-score nor rate of cognitive decline was associated with sleep apnea or the total average sleep duration.

CONCLUSION

Cognition at baseline and change over time predicts sleep quality and may reflect common neural mechanisms and vulnerabilities.

Associations of serum uric acid with incident dementia and cognitive decline in the ARIC-NCS cohort

INTRODUCTION

Elevated serum uric acid (SUA) is associated with cardiovascular risk factors, which often contribute to dementia and dementia-like morbidity, yet several cross-sectional studies have shown protective associations with cognition, which would be consistent with other work showing benefits of elevated SUA through its antioxidant properties.

METHODS

We studied 11,169 participants free of dementia and cardiovascular disease from the Atherosclerosis Risk in Communities (ARIC) cohort. SUA was measured in blood samples collected in 1990-92, baseline for this study (age range 47-70 years). Incident dementia was ascertained based on clinical assessments in 2011-13 and 2016-17, surveillance based on dementia screeners conducted over telephone interviews, hospitalization discharge codes, and death certificates. Cognitive function was assessed up to four times between 1990 and 92 and 2016-17. We estimated the association of SUA, categorized into quartiles, with incidence of dementia using Cox regression models adjusting for potential confounders. The association between cognitive decline and SUA was assessed using generalized estimating equations.

RESULTS

Over a median follow-up period of 24.1 years, 2005 cases of dementia were identified. High baseline SUA was associated with incident dementia (HR, 1.29; 95% CI, 1.12, 1.47) when adjusted for sociodemographic variables. However, after further adjustment including cardiovascular risk factors, this relationship disappeared (HR, 1.03; 95% CI, 0.88, 1.21). Elevated baseline SUA was associated with faster cognitive decline even after further adjustment (25-year global z-score difference, -0.149; 95% CI, -0.246, -0.052).

CONCLUSION

Higher levels of mid-life SUA were associated with faster cognitive decline, but not necessarily with higher risk of dementia.

Sex-specific associations of inflammation markers with cognitive decline

BACKGROUND/OBJECTIVE

Inflammation is implicated in cognitive decline; however, there is a paucity of data for African American populations and for sex-specific associations.

DESIGN

Prospective cohort study.

SETTING

Genetic Epidemiology Network of Arteriopathy/Genetics of Microangiopathic Brain Injury studies.

PARTICIPANTS

African-American sibships (N = 1010).

MEASUREMENTS

Neurocognitive tests assessed global cognition and four cognitive domains: processing speed, memory, language, and executive function at two time points over seven years. Circulating levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor receptor (TNFR)-1 and TNFR2 were measured at study baseline. Linear mixed models were used to investigate the association between inflammation markers and cognitive decline.

RESULTS

Among men, a one SD increase in CRP was associated with an increased rate of decline over 7 years in global cognitive Z-score (adjusted difference in slopes = -0.31, p = 0.006) and in processing speed Z-score (adjusted difference in slopes = -0.10, p = 0.02), but not declines in memory, language, or executive function Z-scores. Also among men, a one SD increase in IL-6 was associated with an increased decline rate in global cognitive Z-score (adjusted difference in slopes = -0.33, p = 0.002) and in processing speed Z-score (adjusted difference in slopes = -0.12, p = 0.007). There was no difference in decline rates by CRP or IL-6 level in adjusted analyses among women for any cognitive scores. Among men and women combined, a one SD increase in baseline sTNFR1 was associated with a faster rate of decline in memory Z-score (adjusted difference in slopes = -0.09, p = 0.02). Baseline sTNFR2 levels did not significantly predict rate of cognitive decline in any cognitive domains.

CONCLUSIONS

Circulating markers of CRP and IL-6 may be differential risk factors for men and women in relation to cognitive decline. A novel inflammation marker, sTNFR1, may be a useful predictor of memory decline in older adults.

Neuroimaging findings in midlife and risk of late-life dementia over 20 years of follow-up

OBJECTIVE

To examine the association between neuroimaging features in a predominantly middle-aged cohort and risk of late-life dementia.

METHODS

Cerebral MRI was performed on 1,881 individuals with no history of stroke from the Atherosclerosis Risk in Communities Study cohort in 1993 to 1995. White matter hyperintensities (WMH), ventricular size, and sulcal size were graded on a semiquantitative scale, and presence of silent cerebral infarcts was identified. In 2011 to 2013, dementia was determined from neuropsychological testing, informant interview, hospital ICD-9 codes, and death certificate dementia codes. Cox regression was used to evaluate associations between MRI findings and dementia.

RESULTS

Over 20 years of follow-up, dementia developed in 279 participants (14.8%). High-grade WMH and high-grade ventricular size were independently associated with increased dementia risk (hazard ratio [HR] for WMH 1.62, 95% confidence interval [CI] 1.14-2.30; HR for ventricular size 1.46, 95% CI 1.06-2.03). There was an increased risk of dementia for diabetic participants with silent infarcts (HR 2.56, 95% CI 1.23-5.31) but not among nondiabetic participants (HR 0.87, 95% CI 0.56-1.37). Each 1-unit increase in the total number of high-grade cerebral abnormalities at baseline (count values range 0-4) showed increased dementia risk, with a considerably higher risk among diabetic participants (HR for diabetes mellitus 1.97, 95% CI 1.44-2.69; HR for no diabetes mellitus 1.20, 95% CI 1.03-1.39).

CONCLUSION

In adults without evidence of clinical stroke, MRI-detected WMH and ventricular enlargement in midlife may represent markers of brain injury that increase risk for later-life cognitive impairment. The presence of diabetes mellitus may modify the association between silent infarcts and dementia.

Adiposity, Change in Adiposity, and Cognitive Decline in Mid- and Late Life

OBJECTIVES

To examine associations between adiposity and adiposity change (loss, stable, gain) and subsequent longitudinal cognitive performance in African Americans in mid and late life.

DESIGN

Cohort study using linear mixed models.

SETTING

Genetic Epidemiology Network of Arteriopathy.

PARTICIPANTS

African-American sibships with hypertension in Jackson, Mississippi (N = 1,108).

MEASUREMENTS

Waist circumference and body mass index (BMI) were measured at two examinations 5 years apart. Stable adiposity was defined as values within 5% of the first measure. A composite cognitive Z-score was derived from individual cognitive test Z-scores at two study visits 6 years apart.

RESULTS

Larger waist circumference was associated with greater rate of cognitive decline during follow-up (beta = -0.0009 per year, P = .001); BMI, change in waist circumference, and change in BMI were not associated with rate of decline. Loss of adiposity in midlife was associated with higher cognitive Z-scores in middle-aged individuals, and loss of adiposity in late life was associated with lower Z-scores in older adults (P = .01 for interaction between waist circumference and age; P = .04 for interaction between BMI and age). Simultaneous inclusion of waist circumference and BMI in the cross-sectional model suggested an association between larger waist circumference and poorer cognitive performance (beta = -0.009, P = .006) and between higher BMI and better cognitive performance (beta = 0.014, P = .06).

CONCLUSION

The results suggested a differential pattern of the relationship between adiposity and cognition according to age (mid- or late life) and regional distribution of adiposity.

Cognitive decline and the PPAR-γ Pro12Ala genotype: variation by sex and ethnicity

Objective

We investigated the association between the peroxisome proliferator-activated receptor (PPAR)-gamma Pro12Ala polymorphism and cognitive decline in older adults.

Methods

Participants from a population-based cohort of older Hispanic and non-Hispanic white adults (n = 492) were administered the Mini Mental State Examination (MMSE), a multi-domain cognitive screening tool, and the Behavioral Dyscontrol Scale (BDS), a measure of executive cognitive function, at baseline and at follow-up, an average of 22 months later. Multiple linear regression was used to investigate the association between the two cognitive test scores and the Pro12Ala polymorphism.

Results

At baseline, presence of the Ala12 allele was not significantly associated with MMSE score (P = 0.62) nor with BDS score (P = 0.85). Heterogeneity was present for cognitive decline as measured by the MMSE among ethnic, sex and Ala12 allele status (P = 0.04 for three-way interaction term). Stratification by the cross-classification of sex and ethnicity revealed significantly greater declines in MMSE score among male Hispanic carriers of the Ala12 allele compared to male Hispanic non-carriers (decline = 4.0 versus 1.6 points; P = 0.02). A significant difference in decline between Ala12 carriers and non-carriers was not present among the other sex/ethnic groups.

Conclusions

Carriers of the PPAR-γ Ala12 allele showed greater cognitive decline compared to non-carriers as detected by the MMSE but the risk varied across sex and ethnic groups. Male Ala12 carriers of Hispanic origin may be a high-risk group for cognitive decline.

Prescription opioid exposures and adverse outcomes among older adults

PURPOSE

A high prevalence of chronic pain and high rates of polypharmacy among older adults suggest that this age group may be particularly susceptible to unintentional misuse of prescription opioids. We examined recent trends in misuse of prescription opioids and associated medical outcomes among older-aged adults (60+ years) and compared the patterns with trends among younger-aged adults (20-59 years).

METHODS

Linear regression trend analysis was used to analyze 57 681 misuse cases reported to participating US poison centers during 2006-2014.

RESULTS

Population rates of misuse of prescription opioids were higher for older adults than for younger adults, and this disparity increased over time. Rates among the older ages increased each year, although the rate of increase slowed over time (p < 0.0001 for negative quadratic trend). In contrast, among the younger adults, there was a significant negative quadratic trend in population rates (p < 0.0001) with a rise in rates during 2006-2010 followed by a decline during 2011-2014. Rates of serious medical outcomes among the older ages followed an increasing linear trend (p < 0.0001); in contrast, rates among younger adults rose and fell during the period, with recent rates trending downward (p < 0.0001 for quadratic trend).

CONCLUSIONS

Recent increases in rates of misuse of prescription opioids and associated unfavorable medical outcomes among older adults have important implications as the USA undergoes a rapid expansion of its elderly population. Copyright © 2015 John Wiley & Sons, Ltd.

The Relationship of Longitudinal Levels of Complement Bb During Pregnancy with Preeclampsia

PROBLEM

To determine the understudied relationship between complement Bb during pregnancy in subjects with preeclampsia compared with normotensive controls.

METHOD OF STUDY

Nested case-control study.

RESULTS

Average Bb levels significantly decreased over time in pregnancy [weekly slope (S.E.): -0.0094 (0.0005), P < 0.01]. Cross-sectionally, at less than 10 weeks, Bb levels decreased with increasing gestational age in women who remained normotensive [weekly slope (S.E.): -0.007 (0.02) and for women who developed preeclampsia (weekly slope (S.E.): -0.059 (0.03) P = 0.12]. Among women who developed preeclampsia, Bb levels were greatest when samples were drawn in the gestational window of 15-20 weeks [(weekly slope (S.E.): 0.06 (0.02)], while levels among normotensive women were inversely related with gestational age [weekly slope (S.E.): -0.02 (0.01)]. The differences in slopes between cases and controls between 10 and 21 weeks' gestation were statistically significant (P = 0.003).

CONCLUSIONS

We suggest dysregulation of Bb activation between 10 and 20 weeks' gestation in women who develop preeclampsia.

Fetal weight estimation in diabetic pregnancies using the gestation-adjusted projection method: comparison of two timing strategies for third-trimester sonography

OBJECTIVES

The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes.

METHODS

We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g).

RESULTS

The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27).

CONCLUSIONS

Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days.

Trends in abuse and misuse of prescription opioids among older adults

BACKGROUND

Dramatic increases in the prescriptive use of opioid analgesics during the past two decades have been paralleled by alarming increases in rates of the abuse and intentional misuse of these drugs. We examined recent trends in the abuse and misuse and associated fatal outcomes among older adults (60+ years) and compared these to trends among younger adults (20-59 years).

METHODS

Trend analysis using linear regression models was used to analyze 184,136 cases and 1149 deaths associated with abuse and misuse of the prescription opioids oxycodone, fentanyl, hydrocodone, morphine, oxymorphone, hydromorphone, methadone, buprenorphine, tramadol, and tapentadol that were reported to participating U.S. Poison Centers of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS(®)) System between 2006-Q1 and 2013-Q4.

RESULTS

Rates of abuse and misuse of prescription opioids were lower for older adults than for younger adults; however, mortality rates among the older ages followed an increasing linear trend (P < 0.0001) and surpassed rates for younger adults in 2012 and 2013. In contrast, mortality rates among younger adults rose and fell during the period, with recent rates trending downward (P = 0.0003 for quadratic trend). Sub-analysis revealed an increasing linear trend among older adults specifically for suicidal intent (P < 0.0001), whereas these rates increased and then decreased among younger adults (P < 0.0001 for quadratic trend).

CONCLUSION

Recent linear increases in rates of death and use of prescription opioids with suicidal intent among older adults have important implications as the U.S. undergoes a rapid expansion of its elderly population.

Trends with corticosteroid use in males with Duchenne muscular dystrophy born 1982-2001

This study examines trends in corticosteroid use for males with Duchenne muscular dystrophy by birth year, race/ethnicity, and knowledge of Duchenne muscular dystrophy family history. Firstborn males (n = 521) selected from a population-based surveillance system of Duchenne muscular dystrophy were analyzed using Kaplan Meier and regression methods. Comparing males born 1982 to 1986 with males born 1997 to 2001, steroid use increased from 54% to 72% and mean age at steroid initiation decreased from 8.2 to 7.1 years. Hispanics and non-Hispanic Black males used steroids less frequently and delayed initiation compared to white males. Compared to males without a Duchenne muscular dystrophy family history, males with known family history were half as likely to use steroids. Duration of steroid use increased over time and age at initiation decreased. Racial/ethnic disparities exist for steroid use and should be addressed to improve outcome and quality of life for boys with Duchenne muscular dystrophy.

A higher-complex carbohydrate diet in gestational diabetes mellitus achieves glucose targets and lowers postprandial lipids: a randomized crossover study

OBJECTIVE

The conventional diet approach to gestational diabetes mellitus (GDM) advocates carbohydrate restriction, resulting in higher fat (HF), also a substrate for fetal fat accretion and associated with maternal insulin resistance. Consequently, there is no consensus about the ideal GDM diet. We hypothesized that, compared with a conventional, lower-carbohydrate/HF diet (40% carbohydrate/45% fat/15% protein), consumption of a higher-complex carbohydrate (HCC)/lower-fat (LF) Choosing Healthy Options in Carbohydrate Energy (CHOICE) diet (60/25/15%) would result in 24-h glucose area under the curve (AUC) profiles within therapeutic targets and lower postprandial lipids.

RESEARCH DESIGN AND METHODS

Using a randomized, crossover design, we provided 16 GDM women (BMI 34 ± 1 kg/m2) with two 3-day isocaloric diets at 31 ± 0.5 weeks (washout between diets) and performed continuous glucose monitoring. On day 4 of each diet, we determined postprandial (5 h) glucose, insulin, triglycerides (TGs), and free fatty acids (FFAs) following a controlled breakfast meal.

RESULTS

There were no between-diet differences for fasting or mean nocturnal glucose, but 24-h AUC was slightly higher (∼6%) on the HCC/LF CHOICE diet (P = 0.02). The continuous glucose monitoring system (CGMS) revealed modestly higher 1- and 2-h postprandial glucose on CHOICE (1 h, 115 ± 2 vs. 107 ± 3 mg/dL, P ≤ 0.01; 2 h, 106 ± 3 vs. 97 ± 3 mg/dL, P = 0.001) but well below current targets. After breakfast, 5-h glucose and insulin AUCs were slightly higher (P < 0.05), TG AUC was no different, but the FFA AUC was significantly lower (∼19%; P ≤ 0.01) on the CHOICE diet.

CONCLUSIONS

This highly controlled study randomizing isocaloric diets and using a CGMS is the first to show that liberalizing complex carbohydrates and reducing fat still achieved glycemia below current treatment targets and lower postprandial FFAs. This diet strategy may have important implications for preventing macrosomia.

Patterns of growth in ambulatory males with Duchenne muscular dystrophy

OBJECTIVE

To provide weight-for-age, height-for-age, and body mass index-for-age growth reference standards for ambulatory, steroid-naïve males, ages 2-12 years, with Duchenne muscular dystrophy (DMD) and to compare these growth curves to the 2000 Centers for Disease Control and Prevention growth charts for boys, which serve as references of physical size and growth for the general male pediatric population in the US.

STUDY DESIGN

Through a multi-state population-based surveillance of individuals with muscular dystrophy, a total of 1877 weight and 1544 height measurements ascertained during 1985-2010 from 513 males with DMD were obtained retrospectively from medical record review. Cases were classified as DMD if loss of ambulation occurred before the 12th birthday or, if younger than 12 years and still ambulating, the earliest symptoms of dystrophinopathy occurred before the 6th birthday. Each growth chart was constructed using 5 percentiles: 10th, 25th, 50th, 75th, and 90th. Smoothing procedures were applied in 2 stages to the irregular plots of the empirical percentile values.

RESULTS

A set of growth curves, derived from a large cohort of male youth with DMD, are presented. These curves demonstrate that DMD males are shorter and tend to the extremes of weight and body mass index compared with the general male pediatric population in the US.

CONCLUSION

Charts representing the pattern of growth in ambulatory, steroid-naïve males with DMD can facilitate monitoring of growth and early detection of unusual growth patterns. Use of these growth standards also will assist in monitoring responses to corticosteroid treatment.

Comparison of two waist circumference measurement protocols: the SEARCH for diabetes in youth study

BACKGROUND

Reports comparing waist circumference (WC) measurements from young populations are scarce.

OBJECTIVES

We compared two protocols for measuring waist circumference in a sample of youth with diabetes.

METHODS

Participants were enrolled in the SEARCH for Diabetes in Youth Study (SEARCH). WC was measured at least twice by the National Health and Nutrition Examination Survey (NHANES) protocol and twice by the World Health Organization (WHO) protocol. Method-specific averages were used in these analyses.

RESULTS

Among 6248 participants, the mean NHANES WC (76.3 cm) was greater than the mean WHO WC (71.9 cm). Discrepancies between protocols were greater for females than males, among older participants, and in those with higher body mass index (BMI). In both sexes and four age strata, the WCs using either method were highly correlated with BMI z-score. The within-method differences between the first and second measurements were similar for the two methods.

CONCLUSIONS

These analyses do not provide evidence that one of these two methods is more reproducible or is a better indicator of obesity as defined by BMI z-scores.

Prepregnancy obesity and complement system activation in early pregnancy and the subsequent development of preeclampsia

OBJECTIVE

We hypothesized that women who are obese before they become pregnant and also have elevations of complement Bb and C3a in the top quartile in early pregnancy would have the highest risk of preeclampsia compared with a referent group of women who were not obese and had levels of complement less than the top quartile.

STUDY DESIGN

This was a prospective study of 1013 women recruited at less than 20 weeks' gestation. An EDTA-plasma sample was obtained, and complement fragments were measured using enzyme-linked immunosorbent assays. The data were analyzed using univariable and multivariable logistic regression analysis.

RESULTS

Women who were obese with levels of Bb or C3a in the top quartile were 10.0 (95% confidence interval, 3.3-30) and 8.8 (95% confidence interval, 3-24) times, respectively, more likely to develop preeclampsia compared with the referent group.

CONCLUSION

We demonstrate a combined impact of obesity and elevated complement on the development of preeclampsia.

Cardiovascular risk factors in children exposed to maternal diabetes in utero

AIMS/HYPOTHESIS

Recent studies have provided evidence that intrauterine exposure to maternal diabetes has lifelong effects on adult offspring, including increased risks of obesity, type 2 diabetes and cardiovascular disease. The aim of this study was to assess the relationship between exposure to maternal diabetes in utero and cardiovascular risk factors in healthy children and to investigate whether these associations are independent of maternal prepregnancy BMI and offspring attained BMI.

METHODS

Data were from a retrospective cohort of children aged 6-13 years born during 1994-2002. Multiple linear regression was used to examine the associations between exposure and cardiovascular risk factors with adjustment for demographic factors and pubertal stage and additionally for maternal prepregnancy BMI and offspring attained BMI.

RESULTS

Ninety-nine offspring of diabetic pregnancies had significantly increased E-selectin, vascular adhesion molecule 1 (VCAM1), leptin, waist circumference, BMI and systolic blood pressure and decreased adiponectin levels compared with 422 offspring of non-diabetic pregnancies after adjustment for age, sex and race/ethnicity (p < 0.05 for each risk factor). Additional adjustment for maternal prepregnancy BMI substantially attenuated group differences in the risk factors except for E-selectin, VCAM1 and waist circumference, which remained significantly higher in exposed children.

CONCLUSIONS/INTERPRETATION

Compared with unexposed children, healthy offspring exposed to maternal diabetes in utero have a worse cardiovascular risk profile. In particular, offspring have substantially increased levels of circulating cellular adhesion molecules, which are biomarkers of adverse endothelium perturbation and may be related to the earliest preclinical stages of atherosclerosis and diabetes.

Association of insulin sensitivity to lipids across the lifespan in people with Type 1 diabetes

AIMS

Insulin resistance and dyslipidaemia both increase cardiovascular risk in Type 1 diabetes. However, little data exist on the associations of insulin resistance to lipids in Type 1 diabetes. Our objective was to explore the associations between insulin resistance (assessed by glucose infusion rate) and lipids in people with Type 1 diabetes and determine whether adiposity and/or average glycaemia influence these associations.

METHODS

Hyperinsulinaemic-euglycaemic clamp studies were performed in 60 subjects with Type 1 diabetes aged 12-19 years (age 15±2 years, 57% female, duration of diabetes 6.3±3.8 years, HbA(1c) 8.6±1.5%, IFCC=70 mmol/mol) and 40 subjects with Type 1 diabetes aged 27-61 years (age 45±9 years, 53% female, duration of diabetes 23±8 years, HbA(1c) 7.5±0.9%, IFCC=58 mmol/mol). Multiple linear regression models were fit to examine the association between glucose infusion rate and fasting lipid levels with adjustment for possible confounders.

RESULTS

Lower glucose infusion rate was significantly associated with lower levels of HDL cholesterol in youths with Type 1 diabetes and with higher levels of triglycerides and higher triglyceride/HDL ratio in both youths and adults. The magnitude of the associations between glucose infusion rate and lipid levels translate into interquartile differences of 0.098 mmol/l for HDL cholesterol, 0.17 mmol/l for triglycerides and 1.06 for triglycerides/HDL in the adolescents and 0.20 mmol/l for triglycerides and 1.01 for triglycerides/HDL in the adults. The associations were attenuated and no longer statistically significant by adjustment for adiposity among adults, while adjustment for HbA(1c) had a small effect in youths and adults.

CONCLUSIONS

Lower insulin sensitivity is associated with a more atherogenic lipid profile in both youths and adults with Type 1 diabetes.

Epidemiology of type 1 diabetes

This article describes the epidemiology of type 1 diabetes mellitus (T1D) around the world and across the lifespan. Epidemiologic patterns of T1D by demographic, geographic, biologic, cultural, and other factors in populations are presented to gain insight about the causes, natural history, risks, and complications of T1D. Data from large epidemiologic studies worldwide indicate that the incidence of T1D has been increasing by 2% to 5% worldwide and that the prevalence of T1D is approximately 1 in 300 in the United States by 18 years of age. Research on risk factors for T1D is an active area of research to identify genetic and environmental triggers that could potentially be targeted for intervention. Although significant advances have been made in the clinical care of T1D with resultant improvements in quality of life and clinical outcomes, much more needs to be done to improve care of, and ultimately find a cure for, T1D. Epidemiologic studies have an important ongoing role to investigate the complex causes, clinical care, prevention, and cure of T1D.

Inflammatory markers are increased in youth with type 1 diabetes: the SEARCH Case-Control study

CONTEXT

Increased inflammation may contribute to type 1 diabetes (T1D) complications.

OBJECTIVE

The objective of the study was to investigate the association of inflammation with obesity, hyperglycemia and dyslipidemia in youth with T1D.

DESIGN

This was a cross-sectional study of youth with and without T1D.

SETTING

The study was conducted in Colorado and South Carolina.

PATIENTS

SEARCH Case-Control participants with T1D [n = 553, mean age 15 yr (range 10-22), median duration 2.7 yr] and without diabetes [n = 215, mean age 15 yr (range 10-22)].

INTERVENTION

This was an observational study.

MAIN OUTCOME MEASURES

IL-6, high-sensitivity C-reactive protein (hsCRP), fibrinogen, and leptin were measured.

RESULTS

Inflammatory markers were evaluated by diabetes status, quartiles of glycated hemoglobin, and obesity using multiple linear regression analyses, adjusted for age, sex, study site, race/ethnicity, T1D duration, body mass index, and pubertal status. Compared with controls, youth with T1D had higher IL-6 and fibrinogen levels at all levels of glycemia and obesity, and hsCRP levels were significantly higher in youth with T1D in the top three quartiles of glycated hemoglobin (> or = 7.2%) and among normal-weight subjects. Leptin was lower in youth with poor glycemic control. Higher hsCRP and fibrinogen were correlated with higher total and LDL cholesterol, and apolipoprotein B in youth with T1D, whereas higher fibrinogen was correlated with higher LDL and apolipoprotein B in controls.

CONCLUSIONS

T1D is characterized by excess inflammation, independent of adiposity and glycemic control. Even T1D youth in good glycemic control had higher levels of IL-6 and fibrinogen than controls. Elevated inflammatory markers were associated with an atherogenic lipid profile, which may contribute to accelerated atherosclerosis in youth with T1D.

Effects of family history and apolipoprotein E epsilon4 status on cognitive decline in the absence of Alzheimer dementia: the Cache County Study

OBJECTIVE

To evaluate the influences of a family history of Alzheimer dementia (FHxAD) and the apolipoprotein E epsilon4 genotype (APOE epsilon4) on cognitive decline.

DESIGN, SETTING, AND PARTICIPANTS

Residents of Cache County, Utah, aged 65 years or older, were invited to participate. At baseline, 2957 participants provided DNA for genotyping of APOE and a detailed FHxAD. They also completed the Modified Mini-Mental State Examination. Cognitive status was reexamined after 3 and 7 years. We used mixed-effects models to examine the association among FHxAD, APOE epsilon4, and cognitive trajectories.

MAIN OUTCOME MEASURE

Modified Mini-Mental State Examination score trajectories over time.

RESULTS

Compared with participants who did not have APOE epsilon4 or an FHxAD, those with APOE epsilon4 scored lower on the Modified Mini-Mental State Examination at baseline (-0.70 points; 95% confidence interval [CI], -1.15 to -0.24). Participants with an FHxAD and APOE epsilon4 differed less, if at all, in baseline score (-0.46 points; 95% CI, -1.09 to 0.16) but declined faster during the 7-year study (-9.75 points [95% CI, -10.82 to -8.67] vs -2.91 points [95% CI, -3.37 to -2.44]). After exclusion of participants who developed prodromal AD or incident dementia, the group with an FHxAD and APOE epsilon4 declined much less during the 7-year study (-1.54; 95% CI, -2.59 to -0.50).

CONCLUSIONS

Much of the association among FHxAD, APOE epsilon4, and cognitive decline may be attributed to undetected incipient (latent) disease. In the absence of latent disease, the 2 factors do not appear individually to be associated with cognitive decline, although they may be additive.

Body adiposity in late life and risk of dementia or cognitive impairment in a longitudinal community-based study

BACKGROUND

The association between body adiposity at older ages and the development of cognitive impairment is unclear.

METHODS

The association of body mass index (BMI) and waist circumference in late life with incidence of cognitive impairment was prospectively examined in a cohort study of 1,351 Latinos, aged 60-101 and residents of the Sacramento, CA, area at study baseline. The status of dementia and "cognitive impairment but not demented" (CIND) was determined at baseline and at each of five follow-up examinations by a multistage assessment protocol. Incident cases of dementia and CIND were combined (dementia/CIND) for more than 8 years of follow-up. BMI was categorized as less than 25.0, 25.0-29.9 (overweight), and 30 kg/m(2) or greater (obese). Waist circumference was categorized into sex-specific tertiles.

RESULTS

Dementia/CIND was diagnosed in 110 (8.2%) participants. Compared with the lowest BMI category, overweight participants had a 48% decreased rate of dementia/CIND (adjusted hazard ratio [HR] = 0.52, 95% confidence interval [CI]: 0.30-0.91) and obese participants had a 61% decreased rate of dementia/CIND (HR = 0.39, 95% CI: 0.20-0.78). Rates of dementia/CIND for the middle and high tertile of waist circumference, compared with the low tertile, were 80% and 90% higher, respectively (adjusted HR = 1.8, 95% CI: 1.1-3.1, and adjusted HR = 1.9, 95% CI: 0.91-3.8).

CONCLUSIONS

Abdominal fat in late life appears to confer an increased risk for dementia/CIND, whereas overall obesity appears to be protective. This may reflect age-related changes in body composition and the association of visceral fat with metabolic dysregulation.

Cardiovascular risk factors among youth with and without type 2 diabetes: differences and possible mechanisms

OBJECTIVE

To compare cardiovascular disease (CVD) risk factors among recently diagnosed youth with type 2 diabetes and nondiabetic youth and investigate whether demographic, behavioral, or metabolic factors might account for observed differences.

RESEARCH DESIGN AND METHODS

Data from 106 type 2 diabetic and 189 nondiabetic multiethnic youth, aged 10-22 years, were analyzed. Prevalence of CVD risk factors were age and race/ethnicity adjusted using direct standardization. Multiple linear regression models were sequentially adjusted for demographic, behavioral (dietary saturated fat intake and physical activity), and metabolic (body adiposity and glycemia) factors to explore possible mechanisms associated with differences in CVD risk factors between the case and control groups.

RESULTS

Compared with control subjects, youth with type 2 diabetes had a higher prevalence of elevated blood pressure, obesity, large waist circumference, low HDL cholesterol, high triglycerides, and high albumin-to-creatinine ratio (P < 0.05 for each risk factor). Type 2 diabetic youth also had higher levels of apolipoprotein B, fibrinogen, interleukin (IL)-6, C-reactive protein, and leptin; lower adiponectin levels; and denser LDL particles (P < 0.05 for each risk factor). Adjustment for BMI, waist circumference, and A1C substantially attenuated differences in the CVD risk factors between the case/control groups, except for fibrinogen and IL-6, which remained significantly higher in type 2 diabetic youth.

CONCLUSIONS

Compared with control youth, type 2 diabetic youth have a less favorable CVD risk factor profile. Adiposity and glycemia are important contributors to differences in CVD risk profiles among type 2 diabetic and control youth. Inflammatory and prothrombotic factors may also play an important role.

The PPAR-gamma Pro12Ala polymorphism and risk of cognitive impairment in a longitudinal study

The Pro12Ala polymorphism in the PPAR-gamma gene has been associated with reduced incidence of type 2 diabetes. Although diabetes has been implicated as a risk factor for dementia, the association of Pro12Ala with cognitive impairment is unclear. Dementia and cognitive impairment without dementia (CIND) were determined during six annual follow-up evaluations in a cohort of 929 older Latinos. Among those with diabetes at baseline, there was an increased rate of dementia/CIND for Ala carriers compared to non-carriers (adjusted hazard ratio (HR)=2.5, 95% confidence interval (CI): 1.3-4.9) but not among non-diabetic participants (adjusted HR=0.94; 95% CI: 0.49-1.8). Among males, there was also an increased rate for Ala carriers (adjusted HR=2.7, 95% CI: 1.4-5.2) but not among female carriers (adjusted HR=0.88; 95% CI: 0.47-1.6). The rate of dementia/CIND was highest in diabetic male Ala carriers (adjusted HR=4.2; 95% CI: 1.5-11) compared to non-diabetic male carriers (adjusted HR=2.9; 95% CI: 1.1-7.4), diabetic female carriers (HR=1.6; 95% CI: 0.66-4.1), and non-diabetic female carriers (HR=0.52; 95% CI: 0.21-1.3). These data suggest that although the Ala variant is associated with a reduced risk of type 2 diabetes, it may increase the risk of cognitive impairment in individuals once diabetes has developed. Male Ala carriers may also have a greater risk of dementia/CIND.

Is the metabolic syndrome, with or without diabetes, associated with progressive disability in older Mexican Americans?

BACKGROUND

The metabolic syndrome (MetS) is highly prevalent in the growing U.S. Latino population. We hypothesize that MetS, with or without diabetes, is associated with progressive disability in older Mexican Americans.

METHODS

Data from Mexican Americans 60-98 years old participating in the Sacramento Area Latino Study on Aging (SALSA) were analyzed from baseline through 3 years (3 years of follow-up). Disability was assessed by self-reported limitations in activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility/strength tasks. MetS (46% of sample) was defined by National Cholesterol Education Program (NCEP) Adult Treatment Panel III criteria. Diabetes (DM, 33%) was defined by fasting blood sugar>125 mg/dL, physician diagnosis, and/or medication use. Four metabolic groups were defined: MetS with diabetes (MetS+DM+, n=402); MetS without diabetes (MetS+DM-, n=330); diabetes without MetS (MetS-DM+, n=125); and neither (MetS-DM-, n=749). Generalized estimating equation (GEE) regression models were used to evaluate the effect of metabolic group on physical limitations and disability changes over time.

RESULTS

Diabetes, with or without MetS, was associated with a higher percent rate of increase over 3 years in ADL and IADL disability than was no diabetes, even after controlling for demographics, body mass index (BMI), and incident disease. The mean ADL score had a 35% higher rate of increase (higher = more impairment) for the MetS+DM+ group and 68% higher for the MetS-DM+ group. Results for IADL were similar. The baseline MetS, without or with diabetes, was associated with a significantly higher rate of increase in mobility/strength limitations (8% and 36.5%, respectively).

CONCLUSIONS

In older Mexican Americans, MetS is associated with progressive limitations in mobility and strength. Preventing progressive mobility/strength limitations may require assessing and treating these impairments in people with MetS regardless of the presence of diabetes. However, preventing the progression of MetS without to MetS with diabetes may be important to limit the progression of ADL and IADL disability found in people with MetS and diabetes.

C-reactive protein and rate of dementia in carriers and non carriers of Apolipoprotein APOE4 genotype

BACKGROUND

Those with an Apolipoprotein APOE4 allele (APOE4) have lower C-reactive protein (CRP) than those without APOE4. Whether APOE4 modifies the effects of CRP on rate of all cause dementia, cognitive impairment or Alzheimer's disease (AD) is not established.

METHODS

All cause dementia and cognitive impairment without dementia (CIND) was determined over five follow up visits from 1998 to 2006 in an ongoing cohort of older Latinos. The association between high sensitivity CRP and dementia/CIND, all cause dementia and Alzheimer's disease by APOE4 status was examined in semi-parametric survival models with covariate adjustments.

RESULTS

CRP was significantly lower among those with APOE4 than in those without. Among those with APOE4, CRP was associated with lower rates of combined dementia/CIND (HR: 0.60, 95% CL: 0.20-0.91, p=0.03) from a fully adjusted model. Among those with no APOE4, there was no effect of CRP on dementia/CIND rates (HR: 0.94, 95% CL: 0.67-1.33).

CONCLUSIONS

Lower CRP in those with APOE4 may reflect immune effects of the APOE4 genotype. Higher CRP in those with APOE4 may be a marker of better immune function, leading to lower rate of dementia and AD.

Conversion to dementia from mild cognitive disorder: the Cache County Study

OBJECTIVE

To examine 3-year rates of conversion to dementia, and risk factors for such conversion, in a population-based sample with diverse types of cognitive impairment.

METHODS

All elderly (aged 65 or older) residents of Cache County, UT, were invited to undergo two waves of dementia screening and assessment. Three-year follow-up data were available for 120 participants who had some form of mild cognitive impairment at baseline. Of these, 51 had been classified at baseline with prodromal Alzheimer disease (proAD), and 69 with other cognitive syndromes (CS).

RESULTS

Three-year rates of conversion to dementia were 46% among those with cognitive impairment at baseline. By comparison, 3.3% without impairment converted to dementia in the interval. Among converters, AD was the most common type of dementia. In individuals with at least one APOE epsilon4 allele, those with proAD or CS exhibited a 22- to 25-fold higher risk of dementia than cognitively unimpaired individuals (vs 5- to 10-fold higher risk in those without epsilon4).

CONCLUSIONS

Individuals with all types of mild cognitive impairment have an elevated risk of dementia over 3 years, more so in those with an APOE epsilon4 allele. These results suggest value in dementia surveillance for broad groups of cognitively impaired individuals beyond any specific category, and utility of APOE genotyping as a prognostic method.

Antioxidant intake and risk of osteoporotic hip fracture in Utah: an effect modified by smoking status

The role of antioxidant intake in osteoporotic hip fracture risk is uncertain and may be modified by smoking. In the Utah Study of Nutrition and Bone Health, a statewide, population-based case-control study, the authors investigated whether antioxidant intake was associated with risk of osteoporotic hip fracture and whether this association was modified by smoking status. The analyses included data on 1,215 male and female cases aged > or = 50 years who incurred a hip fracture during 1997-2001 and 1,349 age- and sex-matched controls. Diet was assessed by food frequency questionnaire. Among ever smokers, participants in the highest quintile of vitamin E intake (vs. the lowest) had a lower risk of hip fracture after adjustment for confounders (odds ratio = 0.29, 95% confidence interval (CI): 0.16, 0.52; p-trend < 0.0001). The corresponding odds ratio for beta-carotene intake was 0.39 (95% CI: 0.23, 0.68; p-trend = 0.0004), and for selenium intake it was 0.27 (95% CI: 0.12, 0.58; p-trend = 0.0003). Vitamin C intake did not have a significant graded association with hip fracture risk among ever smokers. Similar findings were obtained when an overall antioxidant intake score was used (odds ratio = 0.19, 95% CI: 0.10, 0.37; p-trend < 0.0001). No similar associations were found in never smokers. Antioxidant intake was associated with reduced risk of osteoporotic hip fracture in these elderly subjects, and the effect was strongly modified by smoking status.

Number of children and the risk of obesity in older women

BACKGROUND

The purpose of this study is to examine number of live births, other reproductive factors, and health behaviors in relation to obesity risk among older women.

METHODS

Data were collected during in-person and telephone-based interviews from a population-based cohort in Utah.

RESULTS

A total of 2,035 women aged 66-102 are included in this report. Overall, 403 (20%) older women were determined to be obese. The rates of obesity were significantly higher with increasing numbers of children, demonstrating a dose-response relationship (P < 0.05). After adjustment for age, education, marital status, BMI at age 18, use of oral contraceptives, hysterectomy status, physical activity, current use of hormone therapy, and age at menarche, the risk of obesity increased 11% with each additional live birth. In additional analyses that excluded nulliparous women, after adjusting for cumulative months of breast-feeding, the risk of obesity increased 7% with each live birth. In this cohort of older women, we found higher rates of obesity with increasing number of children that was independent of socioeconomic status and other confounding factors.

CONCLUSIONS

In a cohort of older women, higher rates of obesity were associated with increasing number of children that was independent of socioeconomic status and other confounding factors.

Dietary protein intake and risk of osteoporotic hip fracture in elderly residents of Utah

The role of protein intake in osteoporosis is unclear. In a case-control study in Utah (n = 2501), increasing level of protein intake was associated with a decreased risk of hip fracture in men and women 50-69 years of age but not in those 70-89 years of age. Protein intake may be important for optimal bone health.

INTRODUCTION

Protein is an important component of bone, but the role of dietary protein intake in osteoporosis and fracture risk remains controversial.

MATERIAL AND METHODS

The role of dietary protein intake in osteoporotic hip fracture was evaluated in a statewide case-control study in Utah. Patients, 50-89 years of age, with hip fracture (cases) were ascertained through surveillance of 18 Utah hospitals during 1997-2001. Age- and gender-matched controls were randomly selected. Participants were interviewed in their place of residence, and diet was assessed using a picture-sort food frequency questionnaire previously reported to give a useful measure of usual dietary intake in the elderly Utah population. The association between protein intake and risk of hip fracture was examined across quartiles of protein intake and stratified by age group for 1167 cases (831 women, 336 men) and 1334 controls (885 women, 449 men).

RESULTS

In logistic regression analyses that controlled for gender, body mass index, smoking status, alcohol use, calcium, vitamin D, potassium, physical activity, and estrogen use in women, the odds ratios (OR) of hip fracture decreased across increasing quartiles of total protein intake for participants 50-69 years of age (OR: 1.0 [reference]; 0.51 [95% CI: 0.30-0.87]; 0.53 [0.31-0.89]; 0.35 [0.21-0.59]; p < 0.001). No similar associations were observed among participants 70-89 years of age. Results from analyses stratified by low and high calcium and potassium intake did not differ appreciably from the results presented above.

CONCLUSION

Higher total protein intake was associated with a reduced risk of hip fracture in men and women 50-69 years of age but not in men and women 70-89 years of age. The association between dietary protein intake and risk of hip fracture may be modified by age. Our study supports the hypothesis that adequate dietary protein is important for optimal bone health in the elderly 50-69 years of age.

Comparison of a picture-sort food-frequency questionnaire with 24-hour dietary recalls in an elderly Utah population

OBJECTIVE

To evaluate the 137-item Utah Picture-sort Food-frequency Questionnaire (FFQ) in the measurement of usual dietary intake in older adults.

DESIGN

The picture-sort FFQ was administered at baseline and again one year later. Three seasonal 24-hour dietary recall interviews were collected during the year between the two FFQs. Mean nutrient intakes were compared between methods and between administrations of the FFQ.

SETTING

The FFQ interviews were administered in respondents' homes or care-centres. The 24-hour diet recalls were conducted by telephone interview on random days of the week.

SUBJECTS

Two-hundred-and-eight men and women aged 55-84 years were recruited by random sample of controls from a case-control study of nutrition and bone health in Utah.

RESULTS

After adjustment for total energy intake, median Spearman rank correlation coefficients between the two picture-sort FFQs were 0.69 for men aged < or = 69 years, 0.66 for men aged > 69 years; and 0.68 for women aged < or = 69 years, 0.67 for women aged > 69 years. Median correlation coefficients between methods were 0.50 for men < or = 69 years old, 0.52 for men > 69 years old; 0.55 for women < or = 69 years old, 0.46 for women > 69 years old.

CONCLUSIONS

We report intake correlations between methods and administrations comparable to those reported in the literature for traditional paper-and-pencil FFQs and one other picture-sort method of FFQ. This dietary assessment method may improve ease and accuracy of response in this and other populations with low literacy levels, poor memory skill, impaired hearing, or poor vision.