Family Practice News articles from March 2009

Family Practice News archives from March 2009

Big Apple targets diabetes outcomes.(NEWS)
March 1, 2009... [ILLUSTRATION OMITTED] New York City's diabetes prevalence and control numbers paint a dismal picture, but public health officials hope that the now 3-year-old hemoglobin [A.sub.1c] registry will help brighten the future for the city's...

Stimulus law to target health IT, primary care: $17 billion available for EHR incentives.(NEWS)(electronic health records)
March 1, 2009... The newly enacted economic stimulus law will infuse tens of billions of dollars into the health care sector, providing incentives for using health information technology, increasing funds for primary care training, and launching initiatives in...

Guidelines address use of opioids for chronic pain.(NEWS)
March 1, 2009... Newly released guidelines on opioid treatment of chronic noncancer pain address the dramatic increase in the use of opioids for this indication and provide evidence-based recommendations geared toward both specialists and primary care...

NYC's diabetes "not so nice" numbers.(NEWS)(The New York City Health and Nutrition Examination Survey)
March 1, 2009... The NYC HANES data revealed some telling facts about New York City's diabetic population. Diabetes prevalence in NYC HANES increased with age. from 3% among those aged 20-39 years to 28% among adults aged 60 years and older, but did not...

Multivitamin use questioned in postmenopausal women.(NEWS)
March 1, 2009... The use of multivitamins does not alter risk for several common cancers, cardiovascular disease, or death in postmenopausal women, according to a recent study. Data on 161,808 women participating in the Women's Health Initiative "provide...

Vitamin supplement use mismatched to need.(NEWS)
March 1, 2009... Vitamin and mineral supplements are used mostly by children and adolescents who don't need them, while those at greatest risk for deficiencies use supplements the least, according to a report. Analysis of data from the 1994-2004 National...

Febuxostat becomes first gout drug approved in decades.(NEWS)
March 1, 2009... For the first time since 1964, the Food and Drug Administration has approved a drug for treating patients with gout. Last month, the FDA approved febuxostat for the long-term management of chronic hyperuricemia in patients with gout....

FDA to require risk strategy for some opioids.(NEWS)(Food and Drug Administration)
March 1, 2009... A risk-management plan will be required to address the ongoing problems of inappropriate prescribing, misuse, abuse, and accidental overdoses of certain opioid medications, the Food and Drug Administration recently announced. The agency...

Doping 101.(EXPERT COMMENTARY)(Essay)
March 1, 2009... The recent admission by base-ball superstar Alex Rodriguez that he used banned drugs earlier in his career is only one chapter in the ongoing saga of performance-enhancing products in sports, as athletes seek an edge and regulators try to keep...

Hyperthyroidism in kids presents as cardiac, behavioral symptoms.(CARDIOVASCULAR MEDICINE)
March 1, 2009... Cardiac symptoms in a child should raise a high index of suspicion of hyperthyroidism, based on the results of a single-center study that also found prominent behavioral and mood issues in many children with the diagnosis. Hyperthyroidism...

Companies to study plavix's inconsistency.(CARDIOVASCULAR MEDICINE)
March 1, 2009... The Food and Drug Administration said that Sanofi-Aventis and Bristol-Myers Squibb Co. have agreed to conduct studies to better characterize the effectiveness of clopidogrel (Plavix) in patients with certain genetic factors. The two...

Aldosterone blockers viewed as key drugs in obese patients.(CARDIOVASCULAR MEDICINE)
March 1, 2009... NEW YORK -- Two aldosterone receptor blocking drugs--spironolactone and eplerenone--have almost overnight become important, second-line antihypertensive drugs for obese patients. "Aldosterone receptor blockers were never on the list [of...

Heredity strongly influences insulin clearance.(METABOLIC DISORDERS)
March 1, 2009... Insulin clearance is a highly heritable trait that has now been tracked to specific regions of two chromosomes, a finding that may have important implications for risk assessment in diabetes, polycystic ovary syndrome, and the metabolic...

Use of glitazone associated with diabetic macular edema.(METABOLIC DISORDERS)
March 1, 2009... Glitazone use was associated with an increased risk of diabetic macular edema even after accounting for confounding factors, according to the results of a large, prospective cohort study. Insulin use and meglitinide use also resulted in...

Diabetes, prediabetes top 40% among U.S. adults.(METABOLIC DISORDERS)
March 1, 2009... More than 40% of American adults aged 20 years and older have hyperglycemic conditions, according to review of data from the 2005-2006 National Health and Nutrition Examination Survey. In this study, Catherine Cowie, Ph.D., of the National...

A. baumannii infections emerge in vets, families.(INFECTIOUS DISEASES)(acinetobacter baumannii infections in veterans)
March 1, 2009... SINT MAARTEN, NETHERLANDS ANTILLES -- Be on the lookout for Acinetobacter baumannii infections among wounded military personnel returning to the United States, an expert warned. "This is a major problem with our soldiers returning from Iraq...

RSV burden much worse than previously recognized.(INFECTIOUS DISEASES)(respiratory syncytial virus)
March 1, 2009... An estimated 2 million children under age 5 years require medical attention for respiratory syncytial virus each year, a "much larger burden than previously recognized," according to an analysis of surveillance data on more than 5,000 children....

Non-AIDS-Defining cancer rates still high in HIV infected.(INFECTIOUS DISEASES)
March 1, 2009... MONTREAL -- Although the rates of AIDS-defining cancers have declined significantly among people with HIV infection since the advent of antiretroviral therapy, the rates of non-AIDS-defining cancers--particularly those associated with an...

Doxycycline, metronidazole effective for rosacea.(SKIN DISORDERS)
March 1, 2009... SINT MAARTEN, NETHERLANDS ANTILLES -- A combination of doxycycline and metronidazole cleared more inflammatory rosacea lesions and worked faster than metronidazole alone in a randomized controlled trial. This combination should be...

Minimize side effects from treatment of acne, rosacea.(SKIN DISORDERS)
March 1, 2009... When treating rosacea and acne, pay close attention to the potential for adverse effects ranging from skin irritation to drug resistance, according to Dr. Joseph F. Fowler Jr. Irritation is especially common in rosacea patients, and there...

Each beach vacation raises risk of small nevi in kids.(SKIN DISORDERS)
March 1, 2009... Each beach vacation from birth to age 6 by white Colorado children was associated with a 5% increase in small nevi when the children were examined at age 7, but not with large nevi development. In addition, the total estimated UV dose...

Postnatal depression headed off by nurses, peers.(MENTAL HEALTH)
March 1, 2009... Two forms of postnatal intervention--one with trained nurses or midwives, and another with a peer--significantly reduced the likelihood of postnatal depression, according to the findings of two studies. The studies "add to the growing...

Prepregancy obesity linked to postpartum depression.(MENTAL HEALTH)
March 1, 2009... SAN DIEGO -- Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates. "While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so...

Holistic steps advised for respiratory health.(PULMONARY MEDICINE)
March 1, 2009... SAN DIEGO -- Taking an integrative holistic medical approach to treating respiratory disease requires addressing the patient's environment, immune system balance, and emotional health. At a meeting sponsored by the Scripps Center for...

Probiotic use cut GI infections in preschoolers.(DIGESTIVE DISORDERS)
March 1, 2009... Preschool-aged children taking a multispecies probiotic showed a significant reduction in gastrointestinal infection, both over the short and long term, according to a Taiwanese study. Although single-strain probiotics did not have such an...

Planned c-section found risky in low-risk women.(WOMEN'S HEALTH)(cesarean delivery)
March 1, 2009... SAN DIEGO -- Planned primary cesarean delivery was associated with increased morbidity, compared with vaginal delivery, among low-risk primiparous women at term, results from a large population-based study showed. Clinicians have debated...

Birth events unexpectedly common in cerebral palsy.(WOMEN'S HEALTH)
March 1, 2009... SAN DIEGO -- The development of cerebral palsy is associated with adverse intrapartum events in about 27% of term infants and 38% of preterm infants with the condition, according to findings from a large, retrospective population-based cohort...

SSRIs and PPHN revisited.(DRUGS, PREGNANCY & LACTATION)(selective serotonin reuptake inhibitor, persistent pulmonary hypertension of the newborn)
March 1, 2009... The risks associated with selective serotonin reuptake inhibitor use in pregnancy have been addressed in previous columns because of the accumulating data suggesting that depression during pregnancy is common and that many pregnant women use...

Bone health advice in cancer updated.(WOMEN'S HEALTH)
March 1, 2009... SAN ANTONIO -- Current American Society of Clinical Oncology guidelines for the maintenance of bone health in breast cancer patients are outdated and do not sufficiently protect against fractures, a prominent European expert asserted at the San...

IVF appears to increase risk of ovarian cancer.(WOMEN'S HEALTH)
March 1, 2009... SAN ANTONIO -- Ovarian stimulation for in vitro fertilization was linked to an increased risk of ovarian cancer 15 years later in a large cohort study that followed thousands of women in the Netherlands. Compared with controls who had...

Prior breast ca warrants MRI screen.(WOMEN'S HEALTH)(magnetic resonance imaging)
March 1, 2009... CHICAGO -- Screening by breast magnetic resonance imaging is warranted in women with a personal history of breast cancer, data from a retrospective study of 144 women suggest. A review of 1,699 breast MRI studies performed at Memorial...

Liver enzymes elevated with two RA biologics.(MUSCULOSKELETAL DISORDERS)
March 1, 2009... SAN FRANCISCO -- Patients being treated for rheumatoid arthritis with infliximab or adahmuma--but not etanercept--were more likely to have elevated levels of liver enzymes, compared with patients on nonbiologic disease-modifying antirheumatic...

Modified running technique reduced injuries.(SPORTS MEDICINE)(ChiRunning)
March 1, 2009... RIO GRANDE, P.R. -- Injury rates among recreational runners were significantly reduced after they adopted a running technique called ChiRunning, according to results of a survey of 2,500 runners. Previous research has suggested that...

Mild septal deformation may be safe in athletes with LVH.(SPORTS MEDICINE)(left ventricular hypertrophy)
March 1, 2009... Endurance athletes with left ventricular hypertrophy had deformation values within normal limits, based on echocardiographic findings from 182 adults who participated in a study. Because hypertrophic cardiomyopathy (HCM) is a leading cause...

Ankle replacement may not preclude sports participation.(SPORTS MEDICINE)
March 1, 2009... Most patients who undergo a total ankle arthroplasty are able to resume their sports activities at presurgical levels, an observational study has found. Of the 101 patients surveyed, 62% were active in sports before surgery and 66% after...

Sedatives used in ICU may impair brain function.(CLINICAL ROUNDS)(intensive care unit)
March 1, 2009... NASHVILLE, TENN. -- Cognitive outcomes are significantly better in mechanically ventilated patients who are allowed a daily trial of spontaneous awakening and breathing, a finding that has led researchers to conclude that the sedatives used to...

CAP guides may adversely affect antibiotic use.(CLINICAL ROUNDS)
March 1, 2009... Hospitals' responsibility to report compliance with guidelines on community-acquired pneumonia to the Centers for Medicare and Medicaid Services may influence many emergency physicians to prescribe antibiotics to patients they do not believe...

A family history call to action: genomic medicine.(GENOMIC MEDICINE)
March 1, 2009... One of my big pet peeves with electronic health record systems has been the lack of attention to family history capabilities. Most provide only a text box for data collection, and although a few systems collect structured data, in most cases...

Medicare coverage of CT colonography is unlikely.(PRACTICE TRENDS)(computed tomography)
March 1, 2009... The Centers for Medicare and Medicaid Services has proposed to refuse coverage of computed tomography colonography for colorectel cancer screening. "The evidence is inadequate to conclude that CT colonography (CTC) is an appropriate...

CMS limits bariatric surgery coverage for type 2 diabetes.(PRACTICE TRENDS)
March 1, 2009... The Centers for Medicare and Medicaid Services has made it official: Medicare beneficiaries with type 2 diabetes and a body mass index less than 35 kg/[m.sup.2] will not receive coverage for bariatric surgery. The announcement finalizes a...

Court shields billing records.(POLICY & PRACTICE)(Brief article)
March 1, 2009... An appeals court has ruled against the release of Medicare billing records, which was sought by the group Consumers" Checkbook so that it could grade physicians on quality. The nonprofit had filed a Freedom of Information Act request for all...

IOM report: HIPAA is inadequate.(POLICY & PRACTICE)
March 1, 2009... The government's main health-privacy rule doesn't adequately protect people's health information, yet it hinders important health research, a report from the Institute of Medicine concluded. The privacy rule, stemming from the Health Insurance...

Many people go without drugs.(POLICY & PRACTICE)(Brief article)
March 1, 2009... More children and working-age adults are failing to take needed prescription medications because of cost concerns, according to a national study by the Center for Studying Health System Change. In 2007, 1 in 7 Americans under age 65 years...

FDA on 'high-risk' list.(POLICY & PRACTICE)(Food and Drug Administration)(Brief article)
March 1, 2009... The Food and Drug Administration faces significant challenges that compromise its ability to protect Americans from unsafe and ineffective products, the Government Accountability Office said in adding the FDA to its biennial "high-risk" list....

Poll: affordability is tops.(POLICY & PRACTICE)(Brief article)
March 1, 2009... Making health insurance more affordable trumps improving quality and expanding coverage among the public's priorities for health care reform, according to a new poll. The survey from the Kaiser Family Foundation and the Harvard School of Public...

Humana supports ID cards.(POLICY & PRACTICE)(Brief article)
March 1, 2009... Humane has become the first health insurer to publicly support the Medical Group Management Association's drive to get standardized, machine-readable insurance cards into people's wallets by next January. "'Our goal is to continue working with...

National children's study recruitment underway.
March 1, 2009... Researchers in North Carolina and New York are beginning to recruit volunteers as part of a huge federal study that will examine the effects of genes and environment on children's development. The researchers plan to track 100,000 women...

Thinking about golf.(INDICATIONS)
March 1, 2009... Thinking About Golf "Dude, where's my cart?" "It's in the guest bedroom, sir, exactly where you left it." "Right! That was one hetluva round." "Really sir, and does one crash into the house after a good round or a bad one?" ...

HPV vaccine shows efficacy in males.(INFECTIOUS DISEASES)(human papillomavirus)
March 15, 2009... [ILLUSTRATION OMITTED] ATLANTA -- The human papillomavirus vaccine was efficacious in preventing persistent infections and genital warts caused by HPV strains 6, 11, 16, and 18 in a Merck-sponsored study of 4,065 males aged 16-26 years....

FDA urged to step up regulation of supplements: adverse events are largely underreported.(NEWS)
March 15, 2009... The days when the dietary supplements industry is allowed to regulate itself may be numbered following release of a federal report addressing growing concerns about dietary supplement industry. The report, issued this month by the...

Guidelines tout prostate cancer chemoprevention.(CLINICAL ROUNDS)
March 15, 2009... Healthy men with a prostate-specific antigen score of 3.0 or lower should consider taking a 5-alpha reductase inhibitor to prevent prostate cancer, according to newly released clinical practice guidelines. The guidelines, issued by the...

Dietary guidelines address eating behaviors: the recommendations identify the range of possible influences on contemporary eating patterns.(NEWS)
March 15, 2009... The American Heart Association and several other health-advocacy groups have had healthy-diet recommendations on the table for several years while obesity raged on. Now the AHA has released a plan on how America can make better diets part of...

Stronger warning on dyskinesia risk required on metoclopramide.(NEWS FROM THE FDA)
March 15, 2009... A boxed warning about an increased risk of tardive dyskinesia associated with the chronic use of metoclopramide will be added to the drug's label, according to the Food and Drug Administration. In a written statement issued last month, the...

Check serum bicarbonate before zonisamide therapy.(NEWS FROM THE FDA)(Brief article)
March 15, 2009... Serum bicarbonate levels should be checked in patients before initiating treatment with the antiepileptic drug zonisamide because of an association between the drug and metabolic acidosis, according to an alert issued by the Food and Drug...

Primary care docs balk at herpes vaccine costs.(NEWS)
March 15, 2009... ATLANTA -- About half of family physicians and internists currently stock and administer the herpes zoster vaccine in their offices, but most administer it to very few of their eligible patients, citing cost and reimbursement hurdles as major...

Initiative offers coverage for obesity prevention.(NEWS)
March 15, 2009... Nearly a million children would gain health insurance coverage for weight-management counseling under an obesity prevention initiative spearheaded by former President Bill Clinton. As part of the initiative, a group of health insurers and...

Analysts predict big jump in health care share of GDP.(NEWS)
March 15, 2009... WASHINGTON -- Even as the economic downturn causes private health spending to slow, public sector health spending is rising, according to a federal analysis. An estimated 3.4 million people may lose private health insurance coverage in...

President's budget earmarks $634 billion for health reform.(NEWS)
March 15, 2009... President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding coverage to all Americans. The proposed...

Let's admit what isn't working.(COMMENTARY)(Kaiser Family Foundation)
March 15, 2009... If there's one statistic that says it all about the impact of this recession on health care, it's this one: More than half of Americans (53%) report that they have had to cut back on health care in the past 12 months because of cost concerns,...

United's medical home gamble.(COMMENTARY)(UnitedHealth Group Inc.)
March 15, 2009... UnitedHealth Group's proposal for a "medical home" program in Florida sounded like a reasonable idea. It's hard to argue with developing performance measures and improving quality for patients. United's proposal also addressed one thing I...

Dyslipidemia in kids predicts carotid thickening.(CARDIOVASCULAR MEDICINE)
March 15, 2009... Adolescents with dyslipidemia--especially those who were overweight or obese--were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people...

Opinion-based ACC/AHA recommendations raise concern.(CARDIOVASCULAR MEDICINE)(American College of Cardiology, American Heart Association)
March 15, 2009... Nearly half of the current clinical practice recommendations issued by the American College of Cardiology and the American Heart Association are based on expert opinion, case studies, or standards of care, and hence are not evidence based. ...

Hep A vaccine advised for adoptee contacts.(INFECTIOUS DISEASES)(hepatitis A vaccination)
March 15, 2009... ATLANTA -- Hepatitis A vaccination should be given to all previously unvaccinated nontraveling individuals who will be in close personal contact with an internationally adopted child, the Advisory Committee on Immunization Practices of the...

Influenza A appears resistant to oseltamivir.(INFECTIOUS DISEASES)
March 15, 2009... The dominant strain of influenza A during the current flu season is nearly completely resistant to oseltamivir because of a mutation that leaves its virulence intact, according to two studies that upset long-held ideas about...

Outreach boosts quality of rural diabetes care.(METABOLIC DISORDERS)
March 15, 2009... NEW YORK -- A concerted effort to bring diabetes educators to rural primary care practices in the Pittsburgh area led to substantial improvements in the quality of patient care. In one practice, for example, use of critical monitoring tools...

[HbA.sub.1c] may soon be top diabetes diagnostic test.(METABOLIC DISORDERS)
March 15, 2009... The way that diabetes is diagnosed in the United States is about to change. Later this year, an expert panel organized by the American Diabetes Association will issue a report making blood level of glycosylated hemoglobin ([HbA.sub.1c]) an...

Thiazolidinedione use linked to increased fracture risk.(METABOLIC DISORDERS)
March 15, 2009... NEW YORK -- Treatment with a thiazolidinedione, either pioglitazone or rosiglitazone, has been linked to an increased rate of bone fractures, particularly in women, in several recently published reports. [ILLUSTRATION OMITTED] Although...

Melanoma field cells may explain local recurrence.(SKIN DISORDERS)
March 15, 2009... MAUI, HAWAII -- The recent discovery of an entity called melanoma field cells that are often present in seemingly normal skin surrounding primary melanomas could ultimately force an overhaul of standard recommended excision margins. These...

Solubilized gel bests combination acne Tx.(SKIN DISORDERS)
March 15, 2009... A new preparation of 5% benzoyl peroxide solubilized in a gel proved better than a 5% benzoyl peroxide/1% clindamycin preparation for treating ache vulgaris, according to the results of a poster presented at the annual Hawaii Dermatology...

[B.sub.12] level may predict neural tube defect risk.(WOMEN'S HEALTH)
March 15, 2009... A low vitamin [B.sub.12] blood level was an independent and significant risk factor for having a pregnancy affected by a neural tube defect in a study of Irish women, in what the authors say is the first study to examine the risk of the birth...

GI disorders found common in autistic children.(DIGESTIVE DISORDERS)
March 15, 2009... Children with autism spectrum disorders had a 5.3-fold greater probability of having a gastrointestinal disorder than their nonautistic siblings in a large study of families enrolled in the Autism Genetic Resource Exchange Consortium. ...

Device improves articular injection outcomes.(MUSCULOSKELETAL)
March 15, 2009... A combination of ultrasound and a novel two-barrel syringe significantly decreased the nonresponder rate in intra-articular injections compared with a traditional, palpation-guided, single-barrel syringe method, according to findings from a...

RA patients on anti-TNF-alpha agents at risk for herpes zoster.(MUSCULOSKELETAL)(rheumatoid arthritis, tumor necrosis factor)(Brief article)
March 15, 2009... Rheumatoid arthritis patients who are taking monoclonal anti-tumor necrosis factor--alpha agents such as infliximab and adalimumab may be at increased risk for developing herpes zoster, according to a report. An analysis of data from the...

Deep brain stimulator approved for OCD.(MENTAL HEALTH)(obsessive-compulsive disorder)
March 15, 2009... The Food and Drug Administration has approved humanitarian use of Medtronic's experimental deep brain stimulation device to treat severe obsessive-compulsive disorder. It is the first approval for deep brain stimulation for a psychiatric...

Alcohol abuse may lead depression's development.(MENTAL HEALTH)
March 15, 2009... Alcohol abuse and dependence appear to lead to major depression, rather than vice versa, according to a collection of statistical analyses reported in the Archives of General Psychiatry. Researchers used data from the Christchurch Health...

Second-generation antidepressants.(CLINICAL GUIDELINES FOR FAMILY PHYSICIANS)
March 15, 2009... The American College of Physicians developed evidence-based recommendations for the treatment of depressive disorders using second-generation antidepressants. Evidence was examined for acute, continuation, and maintenance phases of major...

Obstructive sleep apnea ups death after stroke.(PULMONARY)(Clinical report)
March 15, 2009... SAN DIEGO -- The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results results from a single-center study showed. The finding underscores the importance of screening for...

Weight loss improved mild apnea in adults.(PULMONARY)
March 15, 2009... Weight loss significantly improved mild obstructive sleep apnea, according to results of a study of overweight adults. Obesity is a risk factor for obstructive sleep apnea (OSA), but no randomized trials have addressed whether weight...

Four factors help to predict prostate Ca risk.(CLINICAL ROUNDS)
March 15, 2009... A Dutch study of 5,176 men found four factors to be helpful in predicting a man's risk of developing prostate cancer: serum prostate-specific antigen, a previous negative biopsy of the prostate, family history of prostate cancer, and prostate...

Imaging advances boost detection of microbleeds.(CLINICAL ROUNDS)
March 15, 2009... [ILLUSTRATION OMITTED] SAN DIEGO -- Various [T.sub.2.sup.*]-weighted MRI techniques are improving the ability to detect microbleeds, which are clear markers of hypertensive vasculopathy and other underlying small vessel disease. In...

Rosuvastatin may cut risk of stroke by half.(CLINICAL ROUNDS)
March 15, 2009... SAN DIEGO -- Patients with normal lipid levels but elevated C-reactive protein showed a 48% reduction in the risk of stroke when taking rosuvastatin, according to a study presented at the International Stroke Conference. These results came...

"Golden-hour" stroke patients are twice as likely to get TPA.(CLINICAL ROUNDS)(tissue plasminogen activator)
March 15, 2009... SAN DIEGO -- Patients with ischemic stroke who arrive within 1 hour of symptom onset at a hospital participating in the Get With the Guidelines-Stroke program were significantly more likely to receive thrombolytic therapy, according to a study...

Silent cerebral infarction trumps stroke risk in midlife.(CLINICAL ROUNDS)
March 15, 2009... SAN DIEGO -- Silent cerebral infarction occurs in midlife more than five times as often as clinical stroke, according to an analysis of data from the Framingham Heart Study. "Silent cerebral infarcts have been referred to as 'silent"...

Reminders effective for screening.(POLICY & PRACTICE)(Brief article)
March 15, 2009... Mailed reminders to patients do work in prompting colorectal cancer screening, and electronic reminders to physicians may increase screening among some patients, a study in the Archives of Internal Medicine indicated. The researchers randomly...