Family Practice News articles from February 2006

Family Practice News archives from February 2006

NYC diabetics put under a microscope.(Metabolic Disorders)
February 1, 2006... A diabetes monitoring program starting last month in New York City is drawing praise while also raising questions about confidentiality. Under the program, clinical laboratories now send the results of all hemoglobin [A.sub.1c] tests that...

Vital signs.
February 1, 2006... VITAL SIGNS Health Plans Voted the Best in 2005 Rank Plan Name State 1 Harvard Pilgrim Health Care MA, ME 2 Harvard Pilgrim Health Care of New...

Focused ultrasound noninvasively eases fibroid symptoms: MRI guides treatment, checks temperature.(Women's Health)
February 1, 2006... CHICAGO -- The first noninvasive therapy for the treatment of uterine fibroids provides symptom relief for 1 year and beyond without serious side effects, according to a clinical trial of MR-guided focused ultrasound surgery presented at the...

Medicare's drug benefit deemed anemic next to VA's.(Practice Trends)
February 1, 2006... Medicare's new prescription drug benefit offers meager savings on drug prices, according to a Families USA survey. For 19 out of the top 20 drugs prescribed to seniors in 2004 in several regions of the country, Families USA found that...

Systemic bug bite reactions receive subpar care, guidelines aren't followed.(News)
February 1, 2006... ANAHEIM, CALIF. -- Epinephrine is generally underutilized in the treatment of potentially life threatening systemic reactions to insect bites or stings, and few patients receive referrals to an allergist once they've been treated in an...

For GERD, PPIs as effective as surgery; study finds.(News)(gastroesophageal reflux disease)
February 1, 2006... Proton pump inhibitors are as effective as surgery for the treatment of most patients with uncomplicated gastroesophageal reflux disease, according to a new report from the Agency for Healthcare Research and Quality, Rockville, Md. The...

Cough guidelines stress diagnosing the cause.(News)
February 1, 2006... The American College of Chest Physicians' new evidence-based practice guidelines on cough made national headlines last month for the conclusion that most over-the-counter cough suppressants are ineffective for common coughs. But Dr. Richard S....

IP chemo's benefits for ovarian ca can no longer be ignored.(News)
February 1, 2006... A clinical announcement issued by the National Cancer Institute on intraperitoneal chemotherapy for ovarian cancer should win the treatment widespread and overdue acceptance, predict physicians who have administered the treatment for years. ...

Cerebral palsy; perinatal viral exposure link found.(News)
February 1, 2006... Newborns whose blood samples showed exposure to potentially neurotropic viral infections were significantly more likely to be diagnosed as having cerebral palsy than were those with no such exposure, reported Catherine S. Gibson, Ph.D., of the...

Requiring a credit card.(Letters)(Letter to the Editor)
February 1, 2006... I would like to receive a copy of the credit card policy letter that Dr. Joseph S. Eastern gives to patients at the time of check-in that has greatly reduced accounts receivable ("Slash Accounts Receivable: Stop Extending Credit," Guest...

Docs and staff last in line.(Letters)(Letter to the Editor)
February 1, 2006... Flu shots for physicians and their staff is a great idea, but only if a supply of the flu vaccine is made available ("CDC Calls on Doctors to Line Up Early for Flu Shots,'" Oct. 15, 2005, p. 1). Our office has been on the "wait list" since...

More details sought.(Letters)(Letter to the Editor)
February 1, 2006... It would be very useful to get a bit more detail on the adverse events connected to the maternal use of citalopram during pregnancy reported to the Food and Drug Administration since 1998 ("Maternal Citalopram Treatment Prompts Adverse Event...

Defending the drug man.(physicians and pharmaceutical representatives)(Editorial)
February 1, 2006... "The fault, dear Brutus, is not in our stars, But in ourselves, that we are underlings.... "' Cassius in Julius Caesar, Act I, Sc. 2, Line 145 --William Shakespeare Over the past several years, the pharmaceutical industry has...

Pain relievers.(Opinion)(Cartoon)
February 1, 2006... "Are you sure it's the sniffles? According to my internet research, I'm suffering from acute Himalayan spotted fever!" [ILLUSTRATION OMITTED]

Should PCOS be treated with insulin sensitizers or oral contraceptives?(Point/Counterpoint)(polycystic ovary syndrome)
February 1, 2006... Insulin Sensitizers Polycystic ovary syndrome (PCOS) is characterized by androgen excess and oligoovulation. It is the most common cause of infertility in the United States and affects more than 5 million women. Oral contraceptives...

Elevated fibrinogen predicts PVD before age 60.(Cardiovascular Medicine)(peripheral vascular disease)
February 1, 2006... Coronary artery disease and elevated serum fibrinogen were stronger predictors of peripheral vascular disease in subjects younger than 60 years than in older subjects, according to a study that used the results of the National Health and...

Pharmacy service helps PAD patients achieve lipid control.(Cardiovascular Medicine)(peripheral arterial disease)
February 1, 2006... Patients with peripheral arterial disease often are under-treated with regard to atherosclerotic risk factor modification. Such patients can benefit from the use of a clinical pharmacy service in conjunction with physician recommendations...

Novel postmarketing surveillance system confirms Bosentan's safety.(Cardiovascular Medicine)
February 1, 2006... STOCKHOLM -- An Internet-based postmarketing surveillance program has provided reassurance regarding the long-term safety of bosentan (Tracleer) in routine clinical practice for treating various subgroups of pulmonary arterial hypertension. ...

Post-MI depression, anxiety underappreciated.(Cardiovascular Medicine)
February 1, 2006... SANTA ANA PUEBLO, N.M. -- Residents and nurse practitioners are better at spotting anxiety than depression in patients recovering from acute myocardial infarction--but both disorders are underdiagnosed and undertreated, Dr. Felicia A. Smith...

Brief questionnaire identifies MI patients needing anxiety treatment.(Cardiovascular Medicine)(myocardial infarction)(brief symptom inventory)(state anxiety instrument)
February 1, 2006... DALLAS -- A quick, six-question survey can diagnose anxiety in patients who've had a myocardial infarction and identify those who need treatment with an anxiolytic. "The Brief Symptom Inventory [BSI] is performed similarly to the State...

Echocardiography ferrets out post-myocardial infarction risk.(Cardiovascular Medicine)
February 1, 2006... SAN FRANCISCO -- Echocardiography provides a great deal of information to help determine a patient's risk following a myocardial infarction, Dr. Thomas Ryan said at a cardiovascular imaging conference sponsored by the American College of...

Amiodarone plus [beta]-blocker prevent implant shocks.(Cardiovascular Medicine)
February 1, 2006... During the first year after activation of an implantable cardioverter defibrillator, a combination of amiodarone plus a [beta]-blocker significantly reduced the risk of shock, compared with B-blocker alone or sotalol alone. Because ICD...

Guidant's woes make patients leery of ICDs: the device manufacturer has been at the center of controversy about disclosing malfunctions.(Cardiovascular Medicine)
February 1, 2006... While Guidant Corp., the troubled maker of implantable cardioverter defibrillators, struggles to repair its reputation and salvage its acquisition by Johnson & Johnson, physicians are finding it increasingly difficult to convince patients of...

For heart implant patients, feelings of depression, anxiety will ease.(Cardiovascular Medicine)
February 1, 2006... STOCKHOLM -- Patients who get implanted cardioverter defibrillators may feel depressed and anxious at first, but with time usually feel better emotionally, according to results from a study of 70 patients who were followed for 4 years after...

Automated home monitoring found to improve heart failure outcomes.(Cardiovascular Medicine)
February 1, 2006... BOCA RATON, FLA. -- Automated home monitoring improved short-term outcomes for patients with heart failure, compared with standard disease management alone, in a multicenter, randomized study, Dr. Andrew R. Weintraub reported at the annual...

Dental care for diabetics falls short in most states.(Metabolic Disorders)
February 1, 2006... Most states have not yet reached national targets set for dental health care in patients with diabetes, or have not made significant improvements in the past 5 years--a finding that "underscore(s) the need to increase awareness and support for...

Limited mobility impairs more than one in four adult diabetics.(Metabolic Disorders)(lower extremity disease )
February 1, 2006... Adults with diagnosed diabetes were significantly more likely to have limited mobility than were those without the disease (27% vs. 16%), according to preliminary findings from an analysis of data from the National Health and Nutrition...

U.S. activity levels stagnant.(Clinical Capsules)(Brief Article)
February 1, 2006... Most U.S. adults did not engage in the minimum recommended level of physical activity in 2003, according to the Centers for Disease Control and Prevention. Results from the nationwide Behavioral Risk Factor Surveillance System (BRFSS)...

Bariatric surgery rates balloon.(Clinical Capsules)(Brief Article)
February 1, 2006... The recent growth of bariatric surgery in the United States appears highly correlated with the development of laparoscopic bariatric surgery, reported Dr. Ninh T. Nguyen and colleagues at the University of California, Irvine. From 1998...

Same old, same old aids weight loss.(Clinical Capsules)(Brief Article)
February 1, 2006... Limiting the variety of snack foods consumed to a subject's favorite snack may decrease the craving for that food, according to Hollie A. Raynor, Ph.D., and her colleagues at Brown University, Providence, R.I. Thirty overweight and obese...

Rosiglitazone tied to macular edema, FDA warns.(Metabolic Disorders)(Food and Drug Administration)
February 1, 2006... The Food and Drug Administration and GlaxoSmithKline are notifying physicians of the possibility of new onset or worsening diabetic macular edema associated with drugs containing rosiglitazone. In a "Dear Health Care Provider" letter posted...

Combined Tx best for obesity.(Metabolic Disorders)(Brief Article)
February 1, 2006... Group lifestyle modification should be prescribed along with weight-loss medication to obese patients trying to lose weight, said Thomas A. Wadden, Ph.D., of the University of Pennsylvania in Philadelphia, and his colleagues. In a 1-year...

Iplex.(New & Approved)(mecasermin rinfabate )
February 1, 2006... Iplex (mecasermin rinfabate [rDNA origin] injection, Insmed Inc.) The Food and Drug Administration approved Iplex (mecasermin rinfabate [rDNA origin] injection) for treatment of growth failure in children with severe, primary...

C. difficile outbreak not from antibiotics.(Infectious Diseases)
February 1, 2006... WASHINGTON -- Quebec's recent outbreak of Clostridium difficile-associated diarrhea does not appear to have been associated with any specific antibiotic use pattern. Rather, poor infection control practices are likely to blame. That was...

Mechanical ventilation increases CDAD.(Infectious Diseases)(C. difficile-associated diarrhea)(Brief Article)
February 1, 2006... WASHINGTON -- Mechanical ventilation significantly increases the risk that a hospitalized patient will develop Clostridium difficile--associated diarrhea, Dr. Chad A. Spangler and Dr. George F. Risi reported in a poster at the annual...

Probiotics cut antibiotic-associated diarrhea.(Infectious Diseases)
February 1, 2006... WASHINGTON -- In hospitalized patients taking antibiotics, coadministration of the probiotic Saccharomyces boulardii can reduce costs, shorten hospital stays, and may save lives, Allyson L. Rovetto and her associates reported in a poster at the...

CDC updates TB prevention guidelines for health providers.(Infectious Diseases)(Centers for Disease Control and Prevention)
February 1, 2006... The Centers for Disease Control and Prevention closed out 2005 by updating its 1994 guidelines for preventing Mycobacterium tuberculosis in health care settings. The exhaustive guidelines were updated in an effort to respond to "shifts in...

Target teens for the meningitis vaccine: the majority of cases--most often caused by serogroups C and Y--could be prevented.(Infectious Diseases)
February 1, 2006... CAMBRIDGE, MASS. -- Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population "makes perfect sense," said Dr....

Think legionnaires' when kids with pneumonia don't respond to therapy.(Infectious Diseases)
February 1, 2006... WASHINGTON -- Consider the diagnosis of legionnaires' disease in any child with pneumonia who doesn't respond to [beta]-lactam antibiotic therapy, Dr. David Greenberg and his associates advised in a poster presented at the annual Interscience...

Cephalosporins superior for GABHS.(Infectious Diseases)
February 1, 2006... WASHINGTON -- Cefdinir is superior to penicillin in eradicating group A streptococci in children with tonsillitis, Dr. Itzhak Brook and Dr. Perry A. Foote reported in a poster at the annual Interscience Conference on Antimicrobial Agents and...

Treating depression in alcoholics curbs drinking.(Mental Health)
February 1, 2006... SCOTTSDALE, ARIZ. -- Most physicians who treat alcohol-dependent patients know that studies have shown that depressed patients are much less likely to quit, or reduce, their drinking. It is less well known that treating depression in these...

Keep patients on acamprosate through relapse.(Mental Health)(Brief article)
February 1, 2006... SCOTTSDALE, ARIZ. -- Alcohol abusers who take acamprosate and relapse are still better off continuing to take the drug because they have an improved chance of achieving abstinence, company data show. Pooled data from three separate,...

Dementia diagnosis brings patient, caregiver relief.(Mental Health)
February 1, 2006... ORLANDO -- Contrary to many physicians' fears, disclosing a diagnosis of dementia to patients and their caregivers does not produce negative reactions, and in some cases actually lowers their anxiety and depression levels, according to a...

Bosentan prevents scleroderma ulcers.(Skin Disorders)
February 1, 2006... SAN DIEGO -- A second randomized clinical trial has confirmed that treatment with bosentan can help pre vent the formation of digital ulcers in patients with scleroderma, Dr. James R. Seibold reported at the annual meeting of the American...

iPLEDGE registry back on track despite delays: patients not registered and activated in the system by March 1 will not be able to be prescribed isotretinoin.(Skin Disorders)
February 1, 2006... NEW YORK -- Despite bugs in the system that have delayed implementation of the iPLEDGE isotretinoin registry and physicians' dismay at the increased red tape and monitoring they are facing, the program is moving forward--and ultimately may be...

Derm Dx.(Skin Disorders)
February 1, 2006... An 26-year-old law student presented with an asymptomatic, reticulated, hyperpigmented rash on her right thigh that had been creasing in size. Some degree of erythema also was present. She was otherwise healthy, was not taking any medications,...

Adenomyosis responds to uterine artery embolization, MRI confirmation is key.(Women's Health)
February 1, 2006... NICE, FRANCE -- Uterine artery embolization should not be withheld from women with adenomyosis, according to investigators who conducted a prospective, multicenter study in 42 symptomatic patients. At a median clinical follow-up of 17...

Embolization radiation exposure safely minimized.(Women's Health)
February 1, 2006... NICE, FRANCE -- German investigators significantly reduced radiation exposures without causing complications in 64 women undergoing uterine fibroid embolization. Bilateral embolization was possible in 63 patients, Dr. Dierk Vorwerk...

Urine test enhances breast ca risk picture.(Women's Health)
February 1, 2006... SAN ANTONIO -- A simple urine test for selected matrix metalloproteinases may provide a novel noninvasive means of assessing a woman's risk of developing breast cancer, Dr. Susan E. Pories reported at a breast cancer symposium sponsored by the...

Many at-risk women opt for lifestyle changes over tamoxifen.(Women's Health)
February 1, 2006... SAN ANTONIO -- Lifestyle approaches to breast cancer risk reduction have assumed considerable importance for the many women who have turned a cold shoulder to tamoxifen for chemoprevention, according to Leslie Bernstein, Ph.D., professor of...

The FDA advisory on paroxetine.(Drugs, Pregnancy, And Lactation)
February 1, 2006... Multiple studies over the past decade have been supportive of the reproductive safety of the selective serotonin reuptake inhibitors (SSRIs) when used during the first trimester; these studies include one recent metaanalysis and other extensive...

Lifestyle practices key to breast ca risk reduction.(Women's Health)
February 1, 2006... SAN ANTONIO -- The three most practical public health-type lifestyle interventions at present for reducing breast cancer risk are to encourage breast-feeding, get young girls started exercising regularly to lay the groundwork for a lifelong...

Best surveillance of Barrett's takes an overview.(Digestive Disorders)
February 1, 2006... COPENHAGEN -- High-resolution, white-light endoscopy was as good as more targeted endoscopy methods for diagnosing high-grade dysplasia or early cancer in patients with Barrett's esophagus, based on study results from 28 patients. "The...

Novel PPI-NSAID pill may prevent GI mucosal injury.(Digestive Disorders)
February 1, 2006... HONOLULU -- A novel fixed-combination tablet comprising an immediate-release proton pump inhibitor plus an enteric-coated NSAID showed considerable promise for the prevention of upper GI mucosal injury in a pilot study, Dr. W. James Alexander...

Genetic polymorphism test could identify Barrett's patients at risk for progression.(Digestive Disorders)
February 1, 2006... MONTREAL -- Genetic testing of patients with Barrett's esophagus to determine their risk for progression to esophageal adenocarcinoma might be a reasonable consideration in the near future, according to Alan G. Casson, M.B., professor of...

Rehabilitating a stiff neck.(Exercise Rx)(acute torticollis)
February 1, 2006... Acute torticollis, also known among some physicians as wry neck, is essentially a stiffness of the neck due to a muscular spasm. In fact, an approximate translation from the Latin-based "acute torticollis" is twisted collar or twisted neck....

Tenotomy relieves tennis elbow nonsurgically.(Clinical Rounds)
February 1, 2006... CHICAGO -- Common extensor tendinosis, or backhand tennis elbow pain, can be alleviated with ultrasound-guided percutaneous needle tenotomy, Dr. Levon N. Nazarian of Thomas Jefferson University Hospital in Philadelphia reported. Also known...

Botulinum toxin injections may be in tennis elbow's future.(Clinical Rounds)(Brief Article)
February 1, 2006... Botulinum toxin injections may provide short-term pain relief for patients with lateral epicondylitis, Chinese researchers have reported. A randomized, placebo-controlled trial of botulinum toxin in 60 patients with lateral epicondylitis...

Intranasal flu vaccine safety confirmed.(Clinical Capsules)
February 1, 2006... No unexpected serious adverse events were reported with the appropriate use of live, attenuated intranasal influenza vaccine in the first two seasons after it was approved for use in the United States. About 2.5 million people have received...

Worry impairs function.(Clinical Capsules)(Brief Article)
February 1, 2006... Persistent worry about illness is associated with functional impairment, reported Dr. Russell Noyes Jr. of the University of Iowa, Iowa City, and his associates. In a random sample of 937 adults, 13% (123) reported at least 1 month of...

Treating chronic cough in GERD.(Clinical Capsules)(gastroesophageal reflux disease)(Brief Article)
February 1, 2006... Use of a proton pump inhibitor to treat persistent cough associated with gastroesophageal reflux disease has some effect in some adults, but the effect is less universal than suggested in consensus guidelines on chronic cough, according to a...

Erectile dysfunction and CVD.(Clinical Capsules)(Brief Article)
February 1, 2006... Erectile dysfunction should be considered a red flag that a man is at increased risk for cardiovascular disease, Dr. Ian M. Thompson of the University of Texas, San Antonio, and his associates wrote. They prospectively assessed a cohort of...

Migraine prophylaxis.(Drug Update)
February 1, 2006... Headache experts generally recommend that prophylactic treatment of migraines be offered to those patients reporting 4-5 migraine days per month with normal functioning, 3 migraine days per month with some impairment, or 2 migraine days per...

Medicare Rx benefit causes 'confusion and paralysis'.(Practice Trends)
February 1, 2006... WASHINGTON -- Delegates to the 2005 White House Conference on Aging made it clear that they weren't happy with Medicare's new prescription drug benefit. Challenging administration claims that the benefit's tools were accessible and easy to...

Medicare patients welcome.(Policy & Practice)(Brief Article)
February 1, 2006... Most physicians have kept their doors open to Medicare patients despite previous reductions in their pay, according to a study from the Center for Studying Health System Change (HSC). The proportion of U.S. physicians willing to treat Medicare...

Ban on false information.(Policy & Practice)
February 1, 2006... The Health and Human Services Department may not deliberately disseminate false or misleading scientific information under a recent federal law. The provision, part of the fiscal 2006 HHS appropriations law, also prohibits the questioning of...

Cardiac rehab coverage expanded.(Policy & Practice)(Brief Article)
February 1, 2006... Medicare is proposing to expand national coverage for cardiac rehabilitation services to three additional groups of beneficiaries: those who have had heart valve repair or replacement, percutaneous transluminal coronary angioplasty (PTCA), and...

Patterns of trial registration.(Policy & Practice)(Brief Article)
February 1, 2006... The act of clinical trial registration alone is not a good indicator of adherence to registration policies, according to a study that analyzed the quality of information provided during the registration process, and patterns of trial...

Top stories of 2005.(Policy & Practice)
February 1, 2006... The growing number of uninsured patients, the public health impact of Hurricane Katrina, and registration for the new Medicare drug benefit were among the top health policy stories of 2005, according to an informal Commonwealth Fund/Health...

Physician-rating game fraught with problems.(Practice Trends)
February 1, 2006... WASHINGTON -- The lists of "best doctors" published in magazines may not be all they're cracked up to be, several speakers said at a health care competition conference sponsored by Health Affairs journal and the Center for Studying Health...

Advanced software for GI camera.(Products)
February 1, 2006... Rapid 4, the most recent version of the diagnostic software for use with PillCam video system, is now available. The software includes new tools to help in the diagnosis of small-bowel mucosa abnormalities. For more information, contact Given...

Xopenex HFA inhaler available.(Products)
February 1, 2006... Xopenex HFA (levalbuterol tartrate) inhalation aerosol is now available. The short-acting [beta]-agonist is indicated for the treatment or prevention of bronchospasm in patients aged 4 years and older with reversible obstructive airway disease....

Make better decisions about dystocia.(Products)
February 1, 2006... The CALM Shoulder Screen is a software program for assessing the risk of shoulder dystocia with injury at or before the onset of labor. The program provides analysis of labor progression to help clinicians determine whether a cesarean section...

Hypoallergenic infant formula improved.(Products)
February 1, 2006... The new and improved formulation of Neocate Infant formula produces less separation and residue and can now be mixed with cool water. The formula is amino acid-based and is designed for infants 0-12 months with cow milk allergy, multiple food...

Full face mask for sleep apnea Tx.(Products)
February 1, 2006... The ComfortFull 2 full face mask is a designed treatment for patients with obstructive sleep apnea who have trouble complying with nasal mask therapy due to mouth breathing. The mask fits broader noses and the entrainment valve split washer...

Implant treats spinal stenosis.(Products)
February 1, 2006... The X STOP Interspinous Process Decompression System is approved for the alleviation of the symptoms of lumbar spinal stenosis. The device can be implanted under local anesthesia in less than an hour. The procedure is completely reversible. For...

Kit spells it out.(Products)
February 1, 2006... The Joint Commission Resources' "Spell It Out!" kit includes items to remind physicians and staff about the list of do-not-use abbreviations and the rationale for spelling out the terms. The kit includes clipboards, posters, quick reference...

Support for smokers to quit.(www.committedquitters.com)(Brief Article)
February 1, 2006... The Committed Quitters Web site offers tools, helpful tips, and information and resources to help smokers deal with the challenges associated with quitting the habit. The site is sponsored by Glaxo SmithKline, the maker of the Nicoderm CQ...

Test identifies Flu A or B.(Products)
February 1, 2006... The BD Directigen Flu A+B test kit differentiates flu A from flu B in two steps. In addition, analytical studies have demonstrated that the kit can detect avian influenza (H5N1) isolates and the A/California/07/2004 strain. For more...

Technology offers CPR feedback.(Products)
February 1, 2006... Q-CPR provides real-time cardiopulmonary resuscitation monitoring and feedback for advanced life support-trained responders. The technology is available on the HeartStart MRx monitor/defibrillator and offers corrective feedback on the rate and...

All the lonely people.(electronic hugs)(Brief Article)
February 1, 2006... Love, sweet love, "is what brings us together today." Like the Impressive Clergyman with the speech impediment in the 1987 film "The Princess Bride," we at the Bureau of Indications are celebrating love in all its forms in honor of Valentine's...

Can't buy me love.(paying for sex)(Brief Article)
February 1, 2006... Speaking of love substitutions, the world's oldest profession is a growth market. Findings from two national surveys of British adults conducted between 1990 and 2000 showed that 5.6% of men interviewed in 1990 said they had ever paid for sex,...

Lucy in the sky with diamonds.(Indications)(baby boomers use of drugs for sexual dysfunction)(Brief article)
February 1, 2006... Over the course of their lifetime, some of the baby boom generation have gone from using hallucinogenics to enhance their sexual experience to relying on prescriptions and supplements to keep the party going. The first prescription agents were...

Do you want to know a secret?(Indications)(attraction to body symmetry)(Brief article)
February 1, 2006... Symmetry is a turn on. Good dancers tend to be symmetrical and thus attractive to observers who are looking for a mate. Darwin said it first, suggesting that dancing in any social set is an important part of the courtship rituals. But an...