Internal Medicine News articles from November 2007

Internal Medicine News archives from November 2007

Team care yields results in diabetes.(Endocrinology)
November 1, 2007... A new team-based approach to care has helped physicians and their staffs in the Abington Physician Network achieve goals for blood pressure, cholesterol levels, and hemoglobin [A.sub.1c] levels in their diabetic patients. It's not that...

Median compensation for internists.(VITAL SIGNS)(Survey)(Brief article)
November 1, 2007... Median Compensation for Internists Notes: Based on survey data from 490 providers. Amounts adjusted for inflation to 2002 dollars based on Bureau of Labor Statistics data. Source: Medical Group Management Association ELSEVIER...

Hemoglobin [A.sub.1c], obesity linked to colonic neoplasia: poor glycemic control predicts polyp risk.(News)
November 1, 2007... PHILADELPHIA -- New evidence that insulin and related hormones promote the growth of colonic polyps and colorectal neoplasia came from two studies reported at the annual meeting of the American College of Gastroenterology. In a review of...

Officials urge use of flu vaccine beyond November.(News)
November 1, 2007... WASHINGTON -- For the second year in a row, federal officials and professional societies are urging health care providers to administer influenza vaccination beyond the traditional months of October and November. A record number of doses...

FDA cites reports of Byetta-related pancreatitis.(News)
November 1, 2007... The Food and Drug Administration has issued an alert on exenatide (Byetta), warning that the agency has received 30 postmarketing reports of acute pancreatitis in patients taking the drug. Exenatide is approved as adjunctive therapy to improve...

Moderate alcohol tied to lower fasting glucose.(News)
November 1, 2007... AMSTERDAM -- Initiation of moderate daily alcohol consumption among patients with type 2 diabetes results in decreased fasting plasma glucose levels, particularly among patients with worse control at baseline, Iris Shai, Ph.D., reported at the...

Medihoney Dressings.(NEW & APPROVED)
November 1, 2007... Medihoney Dressings (active Manuka honey absorbent dressing, Derma Sciences Inc.) A honey-based wound dressing that "provides a moist environment conducive to wound healing," indicated for moderate to heavily exuding wounds such as...

Azor.(NEW & APPROVED)
November 1, 2007... Azor (amlodipine plus olmesartan, Daiichi Sankyo Inc.) A fixed-dose combination formulation of the calcium channel blocker and the angiotensin II receptor blocker for use in the treatment of hypertension, alone or with other...

FDA approves sixth vaccine against influenza.(News)
November 1, 2007... The Food and Drug Administration has approved the sixth trivalent influenza vaccine, lending more credence to the government's prediction that there will be a record-setting number of doses available this flu season. CSL Biotherapies'...

Bisphosphonates, atrial fib risk under scrutiny.(News)
November 1, 2007... The Food and Drug Administration will seek data for an "in-depth evaluation" of atrial fibrillation for the entire bisphosphonate class of drugs and will continue to monitor any spontaneous postmarketing reports of the heart rhythm disorder,...

FluMist receives FDA approval for 2- to 5-year-olds.(News)(Brief article)
November 1, 2007... The Food and Drug Administration has approved the nasal influenza vaccine FluMist for children aged 2 to 5 years, a decision that could help push up childhood vaccination rates. FluMist manufacturer MedImmune Inc. said that it anticipated...

Should retail clinics eventually manage chronic conditions?(POINT/COUNTERPOINT)
November 1, 2007... Such clinics could manage some conditions. Many people who have no health insurance or too little insurance fail to seek treatment for their chronic disease until it presents an acute complication. When this happens, they usually go to...

How about hybrid health care?(GUEST EDITORIAL)
November 1, 2007... What is the best way to provide health care for the nearly 47 million individuals in the United States who lack health insurance? Divergent viewpoints were presented earlier this year by Dr. Kevin Grumbach and Dr. Robert Moffit (INTERNAL...

Misconceptions about addiction.(LETTERS)(Letter to the editor)
November 1, 2007... Physicians should be aware of buprenor-phine as a new option for the treatment of opioid addiction, but Dr. James Cocores' comments are misleading ("Beware of Buprenorphine," Letters, Aug. 15, 2007, p. 6). It would be unfortunate if the...

CTD is easier than HCTZ.(LETTERS)(Letter to the editor)
November 1, 2007... It makes sense to me that chlorthalidone would be a wise substitute for hydrochlorothiazide (HCTZ) in that it is a generically inexpensive diuretic that has better efficacy and a longer duration of action, but no abbreviation ("Prescribing...

FDA: lumiracoxib is 'not approvable' for OA pain.(Rheumatology)
November 1, 2007... The Food and Drug Administration has issued a "not approvable" letter on the cyclooxygenase-2 inhibitor lumiracoxib for osteoarthritic pain. "Now that we have the FDA's decision, we will start the discussions with them as soon as possible...

Nondrug options can ease osteoarthritis pain.(Rheumatology)(Brief article)
November 1, 2007... BIRMINGHAM, ENGLAND--Structural modification for treatment of osteoarthritis may be worthwhile because it offers more than just symptom relief, Dr. Paul Dieppe said at the annual meeting of the British Society for Rheumatology. Findings...

Crystal shape, size distinguish types of gout.(Rheumatology)
November 1, 2007... BOSTON -- To differentiate definitively between acute gout and pseudogout, look at the crystals. On UV light microscopy, fluid aspirated from the inflamed joint of a patient with pseudogout will be teeming with rhomboid-shaped calcium...

TNF-[alpha] drugs tied to risk of infections.(Rheumatology)(tumor necrosis factor)
November 1, 2007... BOSTON -- The increased risk of tuberculosis and other serious infections associated with anti-tumor necrosis factor-[alpha] therapy should be "seriously considered" when making treatment decisions, but it should not preclude the use of these...

Prolotherapy for chronic back pain.(ALTERNATIVE MEDICINE)
November 1, 2007... History and Rationale for Use Prolotherapy, or proliferative injection therapy, involves the injection of irritant substances into regions of ligaments and tendons with the intention of strengthening the ligaments through local...

Advice on fish intake in pregnancy sparks debate.(Women's Health)(National Healthy Mothers, Healthy Babies Coalition )
November 1, 2007... A coalition that advocates for healthy pregnancies came under criticism after issuing an advisory urging pregnant women to eat more fish, based on an evidence review that received financial support from the fisheries industry. In a...

Nursing moms warned of codeine risk to infants.(Women's Health)
November 1, 2007... The Food and Drug Administration has advised patients and physicians that some women metabolize codeine so quickly that levels of morphine, a codeine metabolite, in breast milk can threaten the lives of nursing babies. The warning comes...

Cervical Ca guidelines focus on special groups.(Women's Health)
November 1, 2007... MINNEAPOLIS -- The American Society for Colposcopy and Cervical Pathology has issued new consensus guidelines on the management of women with abnormal cervical screening tests and cervical intraepithelial neoplasia, emphasizing changes for...

Obese women less likely to get screenings.(Women's Health)(Brief article)
November 1, 2007... HOUSTON -- Obesity is a barrier to screening for breast and cervical cancer, Dr. Jeanne Ferrante reported at the annual meeting of the American Society of Preventive Oncology. She and her colleagues at the New Jersey Medical School, Newark,...

Federal officials launch major ADHD study.(Psychiatry)(attention deficit hyperactivity disorder)
November 1, 2007... Officials at the Food and Drug Administration and the Agency for Healthcare Research and Quality are launching a large-scale study aimed at determining whether the medications used to treat attention-deficit/hyperactivity disorder expose...

Military creating 'action plan' for mental health.(Psychiatry)
November 1, 2007... ROCKVILLE, MD. -- The recent release of a Department of Defense task force report on the state of mental health care in the armed services may mark an important change in the way the military approaches the mental health of active and former...

Sertraline and fluoxetine are effective for treating PTSD.(Psychiatry)(posttraumatic stress disorder)
November 1, 2007... HONOLULU -- Selective serotonin reuptake inhibitors generally tend to be effective first-line treatments for posttraumatic stress disorder, Julia M. Whealin, Ph.D., reported at the annual meeting of the National Medical Association. Dr....

Adult obesity rose in 31 states, declined in none.(Endocrinology)
November 1, 2007... Adult obesity is on the rise in 31 states, and no states have experienced a drop in obesity, according to a study from Trust for America's Health. Mississippi topped the list of the fattest states, with the highest adult obesity rates for...

Prevalence of diabetes complications.(DATA WATCH)(Table)(Brief article)
November 1, 2007... Prevalence of Diabetes Complications Microvascular Chronic kidney disease 27.8% Foot problems 22.9% Eye damage 18.9% Macrovascular Heart attack 9.8% Chest pain 9.5% Coronary...

Cut caffeine to aid glucose control in type 2.(Endocrinology)
November 1, 2007... ST. LOUIS -- Convincing your diabetic patients to stop consuming caffeine could significantly reduce their postprandial glucose levels and possibly improve their overall metabolic control, Richard S. Surwit, Ph.D., said at the annual meeting of...

Equation ties Hb[A.sub.1c] to average blood glucose.(Endocrinology)
November 1, 2007... AMSTERDAM -- Data from an international trial have yielded a formula that accurately converts hemoglobin [A.sub.1c] values to an estimated average blood glucose level. The results of the [A.sub.1c]-Derived Average Glucose (ADAG) study,...

Maker of blood glucose meter issues device correction.(Endocrinology)(Abbott Laboratories)(Brief article)
November 1, 2007... Patients using blood glucose meters made by Abbott Laboratories should take caution and examine the display screens carefully if the meters have been dropped on a hard surface, the company warned. If any Precision Xtra, Optium, ReliOn...

Robotic prostatectomy has fairly low complication rate.(Urology)
November 1, 2007... SAN FRANCISCO -- Radical robotic prostatectomy had a complication rate of about 5.1% and promising medium-term outcomes, according to a large case series presented in two posters at the annual meeting of the Society of Laparoendoscopic...

BMI linked with robotic prostatectomy morbidity.(Urology)(body mass index)(Clinical report)
November 1, 2007... SAN FRANCISCO -- Men who are overweight or obese have poorer outcomes following robotic radical prostatectomy, according to a poster presentation by Dr. Jay D. Raman and colleagues at the annual meeting of the Society of Laparoendoscopic...

Bone pain points to worse survival in prostate cancer.(Urology)(Brief article)(Clinical report)
November 1, 2007... CHICAGO -- Once bone pain appears in patients with hormone-refractory prostate cancer, it is often too late for docetaxel therapy to improve survival, according to a poster presentation at the annual meeting of the American Society of Clinical...

Maintaining quality of life is chief concern in prostate Ca.(Urology)(Survey)
November 1, 2007... CHICAGO -- Quality of life issues are the top concerns of men with prostate cancer, according to a poster presented at the annual meeting of the American Society of Clinical Oncology. In a Web-based survey of 2,128 men with prostate cancer,...

Pulmonary rehabilitation.(THE EFFECTIVE PHYSICIAN)
November 1, 2007... Background Enhancing functional status in patients with chronic obstructive pulmonary disease is a common challenge for internists. The American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary...

Daily budesonide, formoterol works for asthma.(Pulmonary Medicine)(Clinical report)
November 1, 2007... SAN FRANCISCO -- Used once daily, a single pressurized metered-dose inhaler containing both budesonide and formoterol provided good asthma control in patients with mild to moderate persistent asthma, according to a series of poster...

Exacerbations of asthma reduced with combo.(Pulmonary Medicine)(Brief article)
November 1, 2007... SAN FRANCISCO -- Patients with moderate to severe asthma experience fewer exacerbations and use adjunctive and rescue medications for shorter periods when taking combined budesonide and formoterol, compared with those taking budesonide alone,...

CT sharpens differential diagnosis in potential PE.(Pulmonary Medicine)(computed tomography)(pulmonary embolism)
November 1, 2007... WASHINGTON -- CT imaging can be a useful tool to distinguish pulmonary embolism from other conditions with similar symptoms, provided you're familiar with some of the common pitfalls, Dr. J. Jeffrey Carr said at the annual meeting of the...

Cardiac troponin I may signal risk of pulmonary embolism.(Pulmonary Medicine)
November 1, 2007... CHICAGO -- Cardiac troponin I is a useful test in patients with a suspected pulmonary embolism. A cardiac troponin I (cTnI) level greater than 0.08 ng/mL should raise concern for central pulmonary vascular obstruction, especially in...

Cardiac catheterization a must in PAH diagnosis.(Cardiovascular Medicine)(pulmonary arterial hypertension)
November 1, 2007... NEW YORK -- Any patient with suspected pulmonary hypertension must have a thorough work-up, including right heart catheterization, before initiating treatment, Dr. Roxana Sulica said at a meeting sponsored by the Pulmonary Hypertension...

Pulmonary arterial hypertension guidelines reflect new data.(Cardiovascular Medicine)
November 1, 2007... The American College of Chest Physicians has issued updated clinical practice guidelines for the medical management of pulmonary arterial hypertension that reflect findings from several recent clinical trials as well as the additional drugs...

Bosentan slows progression in class II PAH.(Cardiovascular Medicine)(pulmonary arterial hypertension)(Clinical report)
November 1, 2007... VIENNA -- Patients with functional class II pulmonary arterial hypertension had significantly slower disease progression when treated with bosentan in a study with 185 patients, a finding that may shift the time to diagnose and start treatment...

Treatment of pulmonary arterial hypertension is evolving.(Cardiovascular Medicine)
November 1, 2007... NEW YORK -- As an increasing number of medical therapies become available for the treatment of pulmonary arterial hypertension and clinical experience accrues, questions have begun to arise as to how to initiate and optimize treatment, and how...

Adiposity is a risk factor for ischemic stroke.(Cardiovascular Medicine)
November 1, 2007... VIENNA -- Adiposity as reflected in body mass index proved a strong risk factor for ischemic stroke in both men and women in a study of 50,000 Finnish adults followed for an average of 20 years, Dr. Jaakko Tuomilehto said at the annual congress...

Generic carvedilol formulations.(PRODUCTS)(Brief article)
November 1, 2007... The first generic formulations of the [beta]-blocker carvedilol (Coreg) have been approved by the Food and Drug Administration for treating hypertension, mild to severe chronic heart failure, and left ventricular dysfunction following a...

New ranolazine tablet.(PRODUCTS)(Brief article)
November 1, 2007... The Food and Drug Administration has approved 1,000-mg extended-release ranolazine (Ranexa) tablets; previously, only 500-mg tablets were approved, according to CV Therapeutics Inc. Ranolazine is indicated for chronic angina in patients who...

New antiretroviral drug.(PRODUCTS)(Brief article)
November 1, 2007... Selzentry (maraviroc) is approved for the treatment of patients infected with CCR5-tropic HIV-1. Dosage forms are 150- and 300-mg tablets. In tandem with the drug, an assay designed to identify candidates for maraviroc treatment will be...

Antimicrobial cream.(PRODUCTS)
November 1, 2007... Silcryst, a prescription antimicrobial cream containing NPI 32101, is a broad-spectrum antimicrobial wound-care cream containing nanocrystalline silver. Clinical trials involving more than 600 adults showed that the cream was an effective...

Software for 'Chemofog'.(PRODUCTS)
November 1, 2007... A new software product, "MindFit Back on Track," is aimed at reducing cognitive dysfunction that occurs in some women during and after chemotherapy for breast cancer. Used for 20 minutes a day, 3 days a week, the product includes exercises to...

Continuous Glucose Monitor.(PRODUCTS)(DexCom Inc)(Brief article)
November 1, 2007... The Food and Drug Administration has approved a device that measures glucose for up to 7 days in people with diabetes. The STS-7 Continuous Glucose Monitoring System includes a subcutaneous, patient-insertable sensor that wirelessly transmits...

New insulin pen.(PRODUCTS)(Lantus)(Brief article)
November 1, 2007... The Food and Drug Administration has approved the Lantus SoloStar, a disposable pen prefilled with insulin glargine recombinant (Lantus), which is indicated for the treatment of hyperglycemia in adults with type 2 diabetes or adults and...

Higher dose of Stalevo.(PRODUCTS)(Brief article)
November 1, 2007... The Parkinson disease drug Stalevo (carbidopa, levodopa, and entacapone) is now approved in a higher 200-mg dose indicated to help minimize the end-of-dose "wearing off" recurrence of Parkinson symptoms. Stalevo is manufactured by Novartis...

Webcast training recordings.(PRODUCTS)
November 1, 2007... Recordings of training and informative seminars geared to the health care industry are available from the National Technical Information Service. The seminars are broadcast by the Centers for Medicare and Medicaid Services and have been...

HIV patients as overweight as general population.(Infectious Diseases)(Human immunodeficiency virus)
November 1, 2007... SAN DIEGO -- In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting. But today, these patients are becoming just as overweight and obese as the general population of the United States,...

In HIV, antisocial personality disorder blunts therapy benefits.(Infectious Diseases)(Human immunodeficiency virus)
November 1, 2007... MONTREAL -- Comorbid antisocial personality disorder blunts the brain dysfunction associated with HIV/AIDS but also blunts the brain benefits associated with antiretroviral therapy, reported Lance Bauer, Ph.D., professor of psychiatry at the...

Total HIV/AIDS federal funding in 2006.(DATA WATCH)
November 1, 2007... Total HIV/AIDS Federal Funding in 2006 (in millions of dollars) Source: Kaiser State Health Facts ELSEVIER GLOBAL MEDICAL NEWS

FDA targets unapproved hydrocodone products.(Infectious Diseases)(Food and Drug Administration )
November 1, 2007... The Food and Drug Administration has requested manufacturers and distributors of unapproved cough suppressants containing hydrocodone to stop marketing their products or face legal action. "The industry has been and is well aware that its...

Antibiotics don't clear plasma cell endometritis.(Infectious Diseases)
November 1, 2007... BOSTON -- Antimicrobial therapy does not clear plasma cell endometritis in many women who have or are at risk for asymptomatic gonorrhea, chlamydia, or bacterial vaginosis, Dr. Harold C. Wiesenfeld reported at the annual meeting of the...

Esophagectomy deaths not tied to case volume.(Gastroenterology)
November 1, 2007... Mortality after esophagectomy is related more to patient factors than to the volume of procedures performed annually at any given hospital, or even by an individual surgeon, according to an analysis of data extracted from the Nationwide...

Western diet linked to colon cancer return.(Gastroenterology)
November 1, 2007... Colon cancer patients who eat a typical Western diet appear to have triple the risk of recurrence, compared with those who do not follow a Western diet. After a potentially curative resection of stage III colon cancer and adjuvant...

Endoluminal devices to treat GERD are lacking.(Gastroenterology)(gastroesophageal reflux disease )
November 1, 2007... LAS VEGAS -- Not long ago, Dr. C. Daniel Smith showed a slide at an American College of Surgeons meeting that proclaimed endoluminal approaches to gastroesophageal reflux disease were "here to stay." A mere 2 years later, he's not so sure....

Insurer starts paying for OTC omeprazole.(Gastroenterology)(over-the-counter)(Brief article)
November 1, 2007... Blue Cross Blue Shield of Michigan now is covering Prilosec OTC for heartburn and acid reflux disease, reflecting increasing attention from insurers to over-the-counter drugs as vehicles for savings. Patients who switch from prescription...

IBD information resource available.(Gastroenterology)(Brief article)
November 1, 2007... The Crohn's and Colitis Foundation has a new information resource center that is designed to give support and information about those diseases to patients and physicians. It is staffed by public health educators with advanced degrees. ...

N.Y. city gives cash incentives for health care.(Practice Trends)(New York )
November 1, 2007... NEW YORK -- A new program in New York City that pays low-income families for obtaining preventive medical care and for maintaining health insurance is garnering its share of praise and skepticism among physicians who practice there. Under...

Families might override organ donation plans.(Practice Trends)(Brief article)
November 1, 2007... ORLANDO -- Patient wishes for organ donation were overridden by family members in about 20% of cases, creating "missed opportunities" for organ procurement, according to research conducted at a level I trauma center in Charlotte, N.C. Dr....

Checklist templates help with complex conditions.(REINVENTING YOUR PRACTICE)
November 1, 2007... Dr. Nasreen Ilias took a somewhat troubling report of her own performance and used it as inspiration to create a reminder system that appears to be improving the care of her patients. She has created templates for all the things she needs...

Wallet cards provide a traveling medical history.(Practice Trends)
November 1, 2007... When patients travel, they sometimes need medical attention or end up in the emergency department while far from home. "With people traveling domestically and internationally now more than ever, you never know where your patients will be...

Hotline expands Medicare advice.(Practice Trends)(Brief article)
November 1, 2007... The Medicare Rights Center's Professional Hotline has expanded its service to include guidance and advice on Medicare benefits, rights, and options to professionals working with older adults and people with disabilities who are on Medicare. ...

Edwards outlines tort and health care reform.(Practice Trends)
November 1, 2007... WASHINGTON -- According to Democratic presidential candidate and malpractice attorney John Edwards, the way to solve the malpractice insurance crisis is to put the onus on... the malpractice attorneys. "The bulk of the problem is created...

Medicare cuts may cause layoffs.(POLICY & PRACTICE)(Survey)(Brief article)
November 1, 2007... The impending 9.9% cut in the Medicare physician fee schedule is likely to result in staff and infrastructure cutbacks by medical group practices, according to a poll taken by the Medical Group Management Association. Of 613 group practice...

Partisan views on health reform.(POLICY & PRACTICE)(Survey)(Brief article)
November 1, 2007... While 82% of Democrats agreed that "it is the government's duty to ensure that all Americans have adequate health care coverage," only 47% of Republicans agreed with that statement, according to a WSJ.com/Harris Interactive online survey of...

Social programs eat Federal Funds.(POLICY & PRACTICE)(Report)(Brief article)
November 1, 2007... Social Security, Medicare, and Medicaid combined take up almost half of the federal government's nondefense, nonintelligence spending in 2005, according to the latest edition of the Census Bureau's Consolidated Federal Funds Report, which...

Put health records in the Vault.(POLICY & PRACTICE)(Brief article)
November 1, 2007... Microsoft has launched Health Vault, a Web site where consumers can post and maintain their personal health records. Individuals can input their health and medical data on the free site and give permission for their health care providers to...

Medicare plans resume marketing.(POLICY & PRACTICE)(Brief article)
November 1, 2007... All seven of the private fee-for-service Medicare plans that voluntarily suspended marketing last summer (INTERNAL MEDICINE NEWS, Sept. 1, p. 50) have been found to be compliant with Centers for Medicare and Medicaid Services requirements and...

Dispatch from Kenya: 'i can be just a doctor'.(WORLD WIDE MED)(Interview)
November 1, 2007... Although Dr. Michael Chung works for the University of Washington, Seattle, his office is far from his colleagues in the Division of Allergy and Infectious Diseases. Based at Kenyatta National Hospital in Nairobi, Kenya, he also works at the...

End-of-life care tailored for dementia patients.(Practice Trends)
November 1, 2007... The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made....

Congress, White House eye SCHIP compromises.(Practice Trends)
November 1, 2007... Congress and the Bush administration headed back to the negotiating table in mid-October after the House of Representatives failed to override President Bush's veto of the State Children's Health Insurance Program reauthorization legislation....

Newfangled hotline baffles callers.(INDICATIONS)(Survey)(Brief article)
November 1, 2007... About 21% of callers to the 1-800-MEDICARE hotline hung up before their question was answered, up from 12% in 2004, according to a survey by the Department of Health and Human Services' Office of Inspector General, reported by Reuters. And less...

Race cars crash, Journal reports.(INDICATIONS)(Brief article)
November 1, 2007... An article in the British Journal of Sports Medicine reported that professional Formula 1 and MotoGP motorbike racing is "inherently dangerous." The authors recommended "innovative clothing" to "selectively defend key anatomical structures"...

Helium-hogging MRIs ruin birthdays.(INDICATIONS)(Magnetic resonance imaging)(Brief article)
November 1, 2007... As a worldwide helium shortage worsens, many groups are blaming MRI machines--which use helium to cool their powerful magnets--for hogging the resource, reported the CBC, a Canadian news outlet. About one-fifth of the world's helium supply is...

Beer makes you smart.(INDICATIONS)(Brief article)
November 1, 2007... Moderate alcohol consumption may enhance cognition, according to research published in the Journal of Neuroscience. In a study, rats were fed liquid diets containing varying amounts of alcohol. Some had no alcohol; some had a moderate amount;...

Diet, exercise help prevent cancer.(News)
November 15, 2007... WASHINGTON -- A new comprehensive evidence-based report issued by an international expert panel provides an unprecedented analysis supporting the preventability of cancer via diet, exercise, and avoidance of obesity. Developed over a...