Clinical Psychiatry News articles from October 2004

Clinical Psychiatry News archives from October 2004

Training still key issue in psychiatry.(Practice Trends)
October 1, 2004... Dr. Christine Wittmann, a 4th-year resident in psychiatry, has had mixed experiences with turning over patients to new residents. In some cases, the outcome has been positive. But in others, patients under her care have had difficulty...

FDA panels back black box warning on antidepressants: analysis of 24 pediatric trials showed an increased suicidality risk of 2%-3%.(Child/Adolescent Psychiatry)
October 1, 2004... BETHESDA, MD. -- A black box warning alerting prescribers to the risk of suicidal behavior and ideation with antidepressants in pediatric patients will likely be added to the labels of antidepressants, as recommended by the majority of the...

Uninsured rate increases as employers cut costs: government coverage rose slightly in 2003.(News)
October 1, 2004... WASHINGTON -- The number of people in the United States without health insurance rose to 45 million in 2003, U.S. Census Bureau data show. The increase from 2002 to 2003 amounted to 1.4 million unin sured Americans, with the per centage of...

Rising Alzheimer's rates, costs expected to 'overwhelm' U.S. health care system.(News)
October 1, 2004... PHILADELPHIA -- Rising rates of Alzheimer's disease and its projected costs will likely pose a major burden to the U.S. health care system in coming years, data from three studies presented at the 9th International Conference on Alzheimer's...

Physician groups still support trials registry.(News)
October 1, 2004... WASHINGTON -- The pharmaceutical industry's new Web-based database on U.S. clinical drug trial results does not eliminate the need for required trial registration, physician groups contend. On Oct. 1, the Pharmaceutical Researchers and...

Congress upset by dearth of antidepressant data.(News)
October 1, 2004... WASHINGTON -- For at least 6 months, the House Energy & Commerce Subcommittee on Oversight and Investigations has been seeking to determine what the Food and Drug Administration and pharmaceutical manufacturers know about safety and efficacy of...

Don't avoid opioids in the elderly.(GUEST EDITORIAL)
October 1, 2004... Opioids can be extremely safe drugs for many elderly patients with any type of chronic pain. When used correctly, they enhance well-being and quality of life immensely. But older patients do not receive these products as often as they...

The values debate in health care.(GUEST EDITORIAL)
October 1, 2004... Most developed countries face similar challenges in attempting to stem rising health care costs. The common forces driving utilization and costs are medical technology advancement, demanding consumers, and an aging population. But the most...

Lovesick: the quirky romances of Patrice Leconte.(REEL LIFE)(Intimate Strangers)(Movie Review)
October 1, 2004... French director Patrice Leconte is fascinated by offbeat relationships, especially quirky love stories. "Monsieur Hire" (1989) concerns a forlorn voyeur obsessed with a beautiful woman. "The Hairdresser's Husband" (1990) is about an eccentric...

Ten-point plan addresses disparities.(GUEST EDITORIAL)(Editorial)
October 1, 2004... We hear a great deal about "closing the gap" in health disparities in this country. To address these disparities, we must apply a multifaceted approach with leadership from the federal, educational, professional, financial, and business...

Rethinking electroconvulsive therapy.(FINK! STILL AT LARGE)
October 1, 2004... Electroconvulsive therapy is a safe and effective treatment for patients with drug-resistant depression. But the procedure continues to carry with it a stigma that impedes its acceptance. Have you used electroconvulsive therapy in treating your...

Social hugging.(LETTERS)(Letter to the Editor)
October 1, 2004... Although I don't disagree with Dr. Paul J. Fink and the others on the issue of "Physical Contact With Patients," I would like to present another facet based upon the context of treatment (Fink! Still at Large, June 2004, p. 8). I have been...

Prescribing law is no surprise.(LETTERS)(Letter to the Editor)
October 1, 2004... I continue to be amazed that psychiatrists are so up in arms about having psychologists prescribe medications after added training in psychopharmacology ("Prescribing Law in Louisiana Rankles Psychiatrists," July 2004, p. 1). We have no...

TV: a catalyst for ADHD?(LETTERS)(Letter to the Editor)
October 1, 2004... Inasmuch as the somewhat addictive and rapidly changing images of the television set are thought by some to be a very significant variable in the etiology of ADHD, one cannot be surprised to read "10-Year Study: ADHD Persists as Boys Become...

The Kerry proposal presented.(HEALTH CARE 2004: YOU DECIDE)
October 1, 2004... John Kerry understands that our health care system faces important challenges and it will require national leadership to meet them. The number of people who do not have health care coverage is going up, overall health care costs are going...

The Bush proposal presented.(HEALTH CARE 2004: YOU DECIDE)
October 1, 2004... Americans can take pride that we have the best health care in the world--committed doctors and nurses, state-of-the-art medical devices, and life-saving prescription drugs. Despite our successes, there are still too many gaps in quality, too...

Problems persist among Trade Center rescuers.(Adult Psychiatry)(Brief Article)
October 1, 2004... Rescue and recovery workers who labored at the World Trade Center site in New York following the Sept. 11, 2001, attacks experienced physical and mental problems that persisted for at least a year and perhaps longer, according to a report by...

Mental health help up a bit after 9/11 in NYC.(Adult Psychiatry)
October 1, 2004... CHICAGO -- Use of mental health services among New Yorkers increased only moderately in the year after the Sept. 11, 2001, terrorist attacks on the city, reported Joseph A. Boscarino, Ph.D., of the New York Academy of Medicine. A telephone...

Luteal-phase treatment may be best for PMDD.(Adult Psychiatry)
October 1, 2004... PARIS -- Treatment of premenstrual dysphoric disorder may be more effective if a selective serotonin reuptake inhibitor is used throughout the luteal phase and not withheld until symptoms appear, Ellen W. Freeman, Ph.D., said in a poster...

Alcohol complicates, compromises anxiety Tx: treatment of choice is usually an SRI; benzodiazepines should be used with caution.(PRACTICAL PSYCHOPHARMACOLOGY)
October 1, 2004... Given the prevalence of each diagnosis, it is not surprising that anxiety and substance-use disorders are often seen together. In the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), lead investigator Bridget F....

Benzodiazepines give anxiety Tx a jump start.(Adult Psychiatry)
October 1, 2004... SAN DIEGO -- The sedative effects and potential for abuse associated with benzodiazepines haven't scared physicians away from using the drugs to treat anxiety or panic disorder, Dr. Javaid I. Sheikh said at a psychopharmacology congress...

Lithium augmentation of venlafaxine.(EVIDENCE-BASED PSYCHIATRIC MEDICINE)
October 1, 2004... The Problem You have an adult patient diagnosed with major depressive disorder. He has been treated with venlafaxine, which has shown partial efficacy at maximal dosage, and you are now considering augmentation with lithium. The...

Psychoanalytic view of gender draws criticism.(Adult Psychiatry)
October 1, 2004... SAN FRANCISCO -- Gender is not genetically determined. The "complex matrix" that culminates in a gender identity includes myriad parent-child exchanges, social influences, and physical experiences, Ken Corbett, Ph.D., said at the annual...

The art of Nancy Bryant.(VISIONARY ART)(Biography)
October 1, 2004... Nancy Bryant has had to make enormous sacrifices simply to practice her art and manage her life with bipolar disorder. The road to stability has left her unable to work and forced her to cut all ties with her family. But she has found salvation...

Outpatient care made better.(THE PSYCHIATRIST'S TOOLBOX)
October 1, 2004... We've all been inundated with propaganda from insurance companies arguing that briefer patient encounters and care provided by people with less training are better for the patient--and the bottom line. But I've got a story to tell: Better care,...

Fluoxetine-resistant depression.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... Low serum folate levels, but not low vitamin [B.sub.12] levels or elevated homocysteine levels, are associated with an increased risk of further treatment resistance in patients with major depressive disorder who had previously failed to...

Risperidone long-acting injection.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... In everyday clinical practice, risperidone long-acting injection (RLAI) was judged moderately effective for patients with schizophrenia or schizoaffective disorder who are noncompliant with atypicals or intolerant of conventional depot...

Bupropion no help longer term.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... The antidepressant bupropion hydrochloride does not significantly increase longer-term smoking cessation rates for some patients, despite several recent studies touting its use for this purpose, Dr. Joel A. Simon and his colleagues reported....

Absence of racial disparity.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... No racial disparity was observed in the prevalence of major depressive disorder (MDD) among black and white home health care patients, according to Denise C. Fyffe, Ph.D., of the University of Medicine and Dentistry of New Jersey, School of...

Education key to suicide prevention on campus.(Adult Psychiatry)
October 1, 2004... BALTIMORE -- Suicide is the second-leading cause of death on college campuses, and academic advisers and professors should be trained to look out for the early warning signs of depression, said Dr. Boglarka Szabo in a presentation at a...

Developer of DBT predicts wider use of modality: Marsha M. Linehan, Ph.D., thinks suicidal patients other than those diagnosed with BPD would benefit.(Adult Psychiatry)
October 1, 2004... Research may one day allow suicidal behavior to be directly treated--independently of other comorbidities. But very little data are available on effective treatments for suicidal behavior. Marsha M. Linehan, Ph.D., known for her work...

Study on high-functioning autism underway.(Child/Adolescent Psychiatry)
October 1, 2004... BALTIMORE -- Individualized treatments for children with high-functioning autism have the potential to improve the quality and number of relationships such children have with peers, Connie Kasari, Ph.D., said at a meeting on developmental...

Drug trends hold steady.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... The overall rate of current illicit drug use among youths aged 12-17 years remained fairly consistent between 2002 (11.6%) and 2003 (11.2%), according to the 2003 National Survey on Drug Use and Health produced by the Substance and Mental...

EC knowledge doesn't raise risk.(CLINICAL CAPSULES)(emergency contraception)(Brief Article)
October 1, 2004... Knowledge of emergency contraception (EC) was not associated with increased sexual risk-taking in a telephone survey of 1,158 adolescents aged 14-19 years in Monroe County, N.Y., Dr. Elizabeth Kelts of the University of Rochester said at the...

Peer suicide traumatizes teens.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... Traumatic grief after exposure to a peer's suicide occurred independently of depression and posttraumatic stress disorder in a study of 146 friends of 26 suicide victims, said Nadine M. Melhem, Ph.D., and her colleagues at the University of...

Lithium has little effect on Mania.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... The first published placebo-controlled study of lithium for treatment of acute mania in children and adolescents failed to support long-term treatment, said Dr. Vivian Kafantaris and her colleagues in the psychiatric research division of Zucker...

Family discord, child depression.(CLINICAL CAPSULES)(Brief Article)
October 1, 2004... The high levels of discord in families with a depressed parent may contribute to depression in both mothers and children, said Constance Hammen, Ph.D., of the University of California, Los Angeles, and her colleagues. Environmental stress...

Racism may affect adolescents' metabolic health.(Child/Adolescent Psychiatry)(Brief Article)
October 1, 2004... DETROIT -- Internalized racism--the degree to which blacks agree with the racist stereotypes about themselves--may have adverse effects on metabolic health in adolescents, Earle C. Chambers, Ph.D., reported at a meeting sponsored by the...

Obesity one of top threats to children's health.(Child/Adolescent Psychiatry)
October 1, 2004... WASHINGTON -- Obesity is one of the top threats to children's health, according to a government report that also found a slight increase in the number of children living in poverty. The eighth annual comprehensive report, America's Children...

A different take on child fat, fast food.(Child/Adolescent Psychiatry)(Brief Article)
October 1, 2004... HONOLULU -- Researchers who have found it difficult to substantiate the popular belief that many obese children come from depressed families may need to include fast food as a variable in their research, Melvin Davis, Ph.D., said at the annual...

Cognitive therapy may beat drugs in OCD.(Child/Adolescent Psychiatry)(obsessive-compulsive disorder )
October 1, 2004... HONOLULU -- Cognitive therapy and training improve obsessive-compulsive disorder in children as much as medication and may be beneficial for a greater number of them, according to two studies presented at the annual meeting of the American...

Fluoxetine plus CBT best for depressed teens.(Child/Adolescent Psychiatry)
October 1, 2004... Depressed adolescents respond best to a combination of fluoxetine and cognitive-behavioral therapy, said Dr. John S. March of Duke University, Durham, N.C., and his colleagues on the Treatment for Adolescents with Depression Study. In a...

Primary care docs often don't screen for mental illness.(Child/Adolescent Psychiatry)
October 1, 2004... Only half of the primary care physicians responding to a recent survey said they routinely screen their adolescent patients for mental illness and always ask them about their mental health. The doctors surveyed gave many reasons for their...

Long-term donepezil may hold other benefits: cognition of Alzheimer's patients may appear unchanged, but behavioral benefits may result.(Geriatric Psychiatry)
October 1, 2004... PHILADELPHIA -- Some patients with Alzheimer's disease may derive behavioral benefits from drug treatment, even when their cognition and global status appear unchanged or deteriorate, Dr. Peter Johannsen reported at the Ninth International...

Depression rates different among dementia subtypes.(Geriatric Psychiatry)(Brief Article)
October 1, 2004... PHILADELPHIA -- Rates of depression vary by dementia subtype, Dr. Annette L. Fitzpatrick said in a poster presentation at the Ninth International Conference on Alzheimer's Disease and Related Disorders. The prevalence of depression among...

Galantamine shows safety and efficacy as Tx for dementia with Lewy bodies.(Geriatric Psychiatry)
October 1, 2004... PHILADELPHIA -- Treatment with galantamine was safe and effective for improving behavior and global function in patients with dementia with Lewy bodies in an uncontrolled study of 40 patients. Galantamine treatment also improved clinical...

No decline in dementia risk with estrogen use.(Geriatric Psychiatry)
October 1, 2004... Unopposed estrogen therapy was not associated with a reduction in the incidence of probable dementia or mild cognitive impairment in women aged 65-79 years, according to newly released data from the Women's Health Initiative Memory Study. ...

Mini-Mental State Exam misses memory problems.(Geriatric Psychiatry)
October 1, 2004... PHILADELPHIA -- The Mini-Mental State Examination, often the first choice of primary care physicians to assess memory in elderly patients, may miss many cases of memory impairment, Amy E. Kane reported in a poster presentation at the Ninth...

Book's 2-week 'Memory Prescription' makes a difference in Brain metabolism.(Geriatric Psychiatry)
October 1, 2004... PHILADELPHIA -- For patients (and physicians) who want to maintain their brains, Dr. Gary W. Small has the prescription. His new book, "The Memory Prescription: Dr. Gary Small's 14-Day Plan to Keep Your Brain and Body Young" (New York:...

'Willpower' might be key in quitting after all: change in thinking about why smokers fail to quit could lead to new direction for cessation programs.(Addiction Psychiatry)
October 1, 2004... HONOLULU -- Smokers just might lack willpower, Thomas H. Brandon, Ph.D., said at the annual meeting of the American Psychological Association. According to Dr. Brandon, a small group of researchers examining the question of why so many...

Implementing an MST program.(Community Psychiatry)(Brief Article)
October 1, 2004... The juvenile justice system in this country is intended to be rehabilitative, yet this is often not the case. Simply because youth are incarcerated and in residential treatment does not mean they are getting what they need. Studies have...

Addressing the needs of Juvenile offenders.(PREVENTION IN ACTION)
October 1, 2004... When it comes to juvenile offenders, the wheels of justice often spin out of sync with community mental health needs and services. About 50%-75% of incarcerated youth nationwide suffer from a mental or emotional disorder, compared to the...

Tape-recorded test beats MMSE in early cognitive change diagnosis.(Neuropsychiatric Medicine)
October 1, 2004... BAL HARBOUR, FLA. -- A tape-recorded, self-administered test appears to be an accurate and inexpensive means of diagnosing early cognitive dysfunction--particularly memory failure--in adults. When compared with the Mini-Mental State...

Study leading some experts to question the existence of 'second-impact syndrome'.(Neuropsychiatric Medicine)(Brief Article)
October 1, 2004... MONTEREY, CALIF. -- The so-called "second-impact syndrome" may not actually exist, Dr. Greg Landry said at a meeting on pediatric and adolescent sports medicine sponsored by the American Academy of Pediatrics. The term was coined by R.C....

Cognitive function and mood remain stable in HIV patients during antiretroviral therapy interruptions.(Neuropsychiatric Medicine)(Brief Article)
October 1, 2004... SAN FRANCISCO -- Interruptions in highly active antiretroviral therapy in HIV-infected patients appear to be safe in terms of possible changes in cognitive function and mood, Dr. Meredith E. Childers said at the annual meeting of the American...

Chronic pain interventions avoid surgery, drugs.(Pain Medicine)
October 1, 2004... SAN FRANCISCO -- A number of interventions offer patients with chronic pain something more than medications but less than surgery, Dr. Barbara S. Mallett said at a joint conference of the American Society on Aging and the National Council on...

Studies highlight racial, gender disparities in pain treatment.(Pain Medicine)
October 1, 2004... VANCOUVER, B.C. -- Women, minorities, and the elderly do not get treated for pain as well or as often as white males do, speakers said at a special session of the annual meeting of the American Pain Society. Inadequate treatment of pain can...

Young women use sleep to self-manage headache.(Pain Medicine)
October 1, 2004... PHILADELPHIA -- Going to sleep or napping is the most common and most effective behavioral self-management intervention reported by college-age, tension-type headache suffers, according to a small preliminary study presented at the annual...

Paroxetine effective for irritable bowel syndrome; treatment with SSRI eased patients' IBS symptoms in first double-blind, placebo-controlled trial.(Psychosomatic Medicine)
October 1, 2004... PARIS -- Treatment with paroxetine led to a significant improvement in the clinical status of patients with irritable bowel syndrome in a randomized, placebo-controlled study with 74 patients. Results from open-label studies had suggested...

Other risk factors for depression are more significant than diabetes.(Psychosomatic Medicine)
October 1, 2004... ORLANDO, FLA. -- Gender, ethnicity, and smoking are stronger predictors of depression than a diagnosis of diabetes, according to a large cohort study of primarily lower income, African American patients treated at community health centers in...

Phobic anxiety increases cardiac death in women.(Psychosomatic Medicine)(Brief Article)
October 1, 2004... SAN FRANCISCO -- Women with high scores on a phobic anxiety scale were significantly more likely to die of coronary heart disease and sudden cardiac death than those with low anxiety scores, Dr. Christine M. Albert reported in a poster at a...

Expressive writing may not help asthmatics.(Psychosomatic Medicine)
October 1, 2004... HONOLULU -- An increasingly popular psychosocial treatment for several chronic diseases may not have benefit for asthmatics, Alex H.S. Harris, Ph.D., said in a poster presentation at the annual meeting of the American Psychological Association....

Eating disorder Tx: men and women not equal.(Psychosomatic Medicine)(Brief Article)
October 1, 2004... WASHINGTON -- Men with eating disorders are more likely than women to follow their treatment plans and have fewer problems with treatment, Pamela Bean, Ph.D., reported at the annual conference of the American Society of Addiction Medicine. ...

Melatonin for jet lag and sleep disorders.(ALTERNATIVE MEDICINE)
October 1, 2004... Mechanisms of Action Melatonin was first described nearly 50 years ago from bovine pineal tissue. Experiments on tadpoles showed that it was a powerful skin-lightening agent that inhibited melanin dispersal in melanocytes (Best Pract. Res....

Hypertension study fails to end clinical debate; ALLHAT found increase in new-onset diabetes did not translate into higher risk of heart disease events.(Across Specialties)
October 1, 2004... NEW YORK -- ALLHAT, the trial that was supposed to end the bickering about drug choice in hypertension, has fallen far short of that goal, according to reports presented at the annual meeting of the American Society of Hypertension. For...

Higher risk of ALS seen among most vets who served in 20th century.(Across Specialties)
October 1, 2004... SAN FRANCISCO -- The elevated risk of amyotrophic lateral sclerosis documented in Gulf War veterans in two recent studies isn't specific to that group, but is increased in U.S. military veterans who served at any point throughout most of the...

Attitude adjustment may help metabolic control.(Across Specialties)
October 1, 2004... ORLANDO, FLA. -- An attitude problem--"psychological insulin resistance"--contributes to the prevalence of poor metabolic control in people with diabetes, Dr. Mary T. Korytkowski said at the annual scientific sessions of the American Diabetes...

Policy & practice.(Practice Trends)
October 1, 2004... Adolescent Substance Abuse Rising The number of adolescents admitted to substance abuse-treatment facilities rose for the 10th consecutive year, according to a report from the Substance Abuse and Mental Health Services Administration. The...

'Bush on the Couch'.(BOOKS, THE CHILDREN OF THE BRAIN)(Book Review)
October 1, 2004... Jonathan Swift was probably not thinking about psychopharmacology or cognitive-behavioral therapy when he wrote that books are "the children of the brain," but we're going to appropriate his very fitting statement for this look at popular books...

CMS launches Medicare drug comparison tool.(Practice Trends)
October 1, 2004... The Centers for Medicare and Medicaid Services is offering Medicare beneficiaries a way to compare prices for similar drugs used to treat the same condition. The "Lower Cost Rx Comparison Tool" is available online at www.medicare.gov or by...

How physician couples make marriage work.(THE REST OF YOUR LIFE)(Interview)
October 1, 2004... For Dr. Tamir Keshen and Dr. Roberta Sengelmann, it's the little things that help keep their marriage intact, such as maintaining the same sleep schedule and spending the first hour or two of nearly every morning together working out. ...

Phone therapy expands doctors' reach and lowers costs.(Practice Trends)
October 1, 2004... Telephone psychotherapy could be a low-cost adjunct to pharmacotherapy for patients beginning treatment for depression, said Dr. Gregory E. Simon and his associates at the Center for Health Studies, Group Health Cooperative, Seattle. ...

Higher health care costs lead to increased fraud.(Practice Trends)
October 1, 2004... WASHINGTON -- Health care fraud continues to grow, fueled largely by rising health care expenditures, several experts said at a forum sponsored by the Blue Cross and Blue Shield Association. "Unfortunately, health care fraud is alive and...

Separation anxiety and school.(FYI)(Brief Article)
October 1, 2004... The American Academy of Child and Adolescent Psychiatry's "Facts for Families" program features a fact sheet on separation anxiety and school. "Children Who Won't Go to School" offers tips to parents on how to recognize signs of separation...

Migraine prophylaxis.(FYI)(Brief Article)
October 1, 2004... Topamax (topiramate) tablets and sprinkle capsules are approved for use as migraine prophylaxis in adults. For more information, contact Ortho-McNeil Pharmaceutical Inc., www.topamax.com, 800-682-6532.

Online Psychological help center.(FYI)(Brief Article)
October 1, 2004... The American Psychological Association has launched a redesigned online help center. The Web site offers expanded free information, facts, and tips about mental health issues. For more information, visit www.apahelpcenter.org.

Genome Research Implications.(FYI)(Brief Article)
October 1, 2004... The National Human Genome Research Institute will be awarding $20 million in grants over the next 5 years to fund Centers for Excellence in Ethical, Legal, and Social Implications Research. The first four centers are being established in...

Rapid-dissolving Parkinson's drug.(FYI)(Brief Article)
October 1, 2004... Parcopa (carbidopa-levodopa orally disintegrating tablets) are available for the treatment of symptoms of Parkinson's disease. The tablets are available in 10 mg/100 mg, 25 mg/100 mg, and 25 mg/250 mg. For more information, contact Schwarz...

Suicide prevention resource.(FYI)(Brief Article)
October 1, 2004... The Stop a Suicide, Today! Web site offers information on how to recognize the signs of suicide and how to respond to suicide emergencies. For more information, contact Screening for Mental Health Inc., www.stopasuicide.org.

Generic schizophrenia drug.(FYI)(Brief Article)
October 1, 2004... Prochlorperazine edisylate injection is approved for the treatment of schizophrenia. The drug is also indicated for the control of severe nausea and vomiting. For more information, contact Bedford Laboratories, 440-232-3320,...

Back to school 2004.(FYI)(Brief Article)
October 1, 2004... The "15+ Make Time to Listen, Take Time to Talk" educational program provides resources to encourage parents to set aside at least 15 minutes a day to talk with their children. For more information on the free materials available, contact the...

Electronic chart system.(FYI)(SpringCharts practice software )(Brief Article)
October 1, 2004... SpringCharts Version 5 medical office system offers several new features, including automated data backup, intraoffice instant messaging, and an improved user interface. For more information, contact Spring Medical Systems Inc. online at...