Monday, March 31, 2008
Pack your bags, we're moving!
Are you a faithful "Paging Dr. Gupta" blogger? Come join us here on our new blog page!
Our URL will now be http://pagingdrgupta.blogs.cnn.com/ Don't forget to change your bookmarks! Thanks, The Paging Dr. Gupta Blog team 2 Comments
 Add a commentFriday, March 28, 2008
Autism & CNN
By Tim Langmaid Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Hospital shopping
By Caleb Hellerman Senior Medical Producer Since you're reading this on your computer, you're probably used to shopping online. Comparing sellers of books, clothes, cameras or music. But what about doctors, or hospitals? For anyone who likes to make informed choices, there are registries of doctors who have faced complaints, and plenty of Web sites asking you to "rate this doctor," but not much useful information. Bit by bit, that's changing. Here's one example: Today, an organization called the Hospital Quality Alliance (HQA) - essentially the hospital industry, doctors and nurses groups, some insurers and the federal government - are rolling out a revamped version of their site www.HospitalCompare.hhs.gov, which displays data from more than 2,500 hospitals, on important measures of quality. You can look at hospitals in your area, or anywhere in the country, and see how often they provide appropriate antibiotics before surgery, how often their heart attack patients survive, and all sorts of other interesting information. A few months back, my cousin had surgery to fuse discs in his back. If he had checked out this site beforehand, he would have seen that the hospital he chose ranked worst among hospitals in his area in almost every category. As it turned out, the surgery itself was a success but my cousin - usually a stoic type - complained for months about the experience; he said nurses and doctors were rude, ignored him for hours and shortchanged him on pain medication for days after the surgery. Today, the HQA will make available another big load of information: the results of patient surveys, looking at how well each hospital managed their pain, how well the staff communicated with them and how clean the place was. Web sites like this are popular with anyone who thinks we need more choice and transparency in the health care system. This view is especially popular with conservatives, who say informed consumers making better choices will increase competition, drive down costs and improve the quality of care. But even a site like Hospital Compare is just a baby step. It measures a fraction of the things that go into high-quality care, and it looks only at hospitals - not individual doctors. Doctors and medical centers have long been wary of being measured by "objective" criteria, because, they say, it's hard to make apples to apples comparisons. For example, a physician who sees patients with more serious conditions might show a lower success rate in treating them. What information do you want, before choosing a doctor or hospital? And do you feel you really have a choice in where you go for medical care? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Take home paternity test
by Dr. Sanjay Gupta
Chief Medical Correspondent How times have changed. This morning I reported about DNA paternity tests. That's right - you can go to the drugstore today and buy a genetic test that can determine who is the father of the child. In fact my producer Danielle bought two from the Rite Aid by her house - she did get a few funny looks. According to the directions, you take a cotton swab and rub it inside the child's mouth. That will provide enough DNA for the test. The man who may or may not be the father has to do the same. After you collect the DNA and send it in, it takes three to five days for the test to come back, and you can even go to a confidential Web site and get the results. The big question is of course, how accurate is the test? You really wouldn't want to be wrong about this. Well, according to an expert we interviewed, these tests rely on around 15 markers, and that makes it pretty accurate. If you are able to collect the child's, the potential dad's and the mom's DNA, the test is 99.9 percent accurate. With just the child's and the potential dad's DNA, it is closer to 99 percent accurate. Not bad. But the truth is, we don't know exactly how accurate these tests are because they aren't regulated by the FDA. The manufacturer says this is the same test forensic and legal agencies have been using for years. The test costs around $20, but if you read the smaller print, you will see that there is also a $119 lab processing fee, so not cheap. And, as the included materials state, if there are multiple "alleged" fathers, the costs will be even higher... hmmm. So, here we are in 2008. Over-the-counter genetic tests now are available - testing everything from paternity to your risk of developing diseases such as Alzheimer's. I actually took five different DNA test kits to compare their accuracy (watch Dr. Gupta's report on take home paternity tests and the DNA tests here). I'm still waiting for the results but I'll blog about it when they come in. What do you think about over-the-counter genetic tests? Would you use one? Do you trust them? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Monday, March 24, 2008
Aging eyes
by Val Willingham
Medical Producer I have a passion for reading: books, magazines, even catalogs, you name it. And I never had a tough time following the fine print, until I got into my 40s. I just couldn't see up close. Although I had been wearing glasses since I was in sixth grade, all of a sudden, the words were out of focus. When I finally went to the eye doctor, he prescribed (here comes the dreaded word, most middle-age people hate to hear): Bifocals! Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Thursday, March 20, 2008
Sleep well
by Danielle Dellorto
Associate Medical Producer How many hours of sleep did you get last night? The U.S. Centers for Disease Control and Prevention says 10 percent of Americans aren't getting the recommended seven to nine hours each night. And being sleep deprived can take a serious toll on your health. Most of us are what experts describe as, "partially sleep deprived." A partially sleep deprived person gets about six hours' sleep a night but his or her body needs closer to eight hours. Over a two-week span, those lost hours add up and the body starts to mimic someone who's been up all night. According to the American Academy of Sleep Medicine, when you don't get enough sleep, your memory is weaker, your reaction times are slower and you're more irritable than a well-rested colleague. And you can blame lack of sleep for those extra pounds as well. Sleepy people tend to overeat. Experts tell us that most Americans think they function great on five or six hours a night. The truth is, we get adjusted to functioning on less sleep and literally forget what it feels like to be fully alert. One common question we hear: How can I fall asleep quickly once I make it to bed? The sleep experts we spoke to offer these tips: - Unwind for 45 minutes before going to bed. Relax, listen to music and don't do any tasks (like folding the laundry or working on the computer). This will keep your mind from racing, which prevents you from falling asleep quickly. - Don't just lie there! If you are wide awake after 15 minute, get up and go to another room. Clock watching or "thinking about sleeping" can leave you alert for hours. What works for you? Let us know your tips for a great night sleep. Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Wednesday, March 19, 2008
Vacation souvenir: A low hospital bill
By Danielle Dellorto
Associate Medical Producer I recently returned from a wonderful vacation in Paris with an interesting story to share. Yes, we visited the usual hot-spots: Notre Dame, the Eiffel Tower, the Louvre. But I unexpectedly experienced France's health care system, too. My husband woke up around 4 a.m. on our last night in Paris very sick - throwing up, pale, severe stomach pain. Perhaps a bit naive, I figured it would pass. I was wrong. Nearly 12 hours later he was still throwing up and was having a hard time breathing. His throat was starting to swell. At that point, I made the call to head to a hospital in Paris. On the ride over, I started to think about the quality of care he was about to get. The cost also crossed my mind. Emergency room visits are never cheap and we would have to pay the bill up front and submit to our insurance company in the U.S. upon our return. I made sure my credit card was handy, expecting the bill to be a few thousand dollars. Within five minutes of our arrival, my husband was checked in and getting settled into a hospital room. Ten minutes later, he had an IV in his arm and blood was being drawn. The doctor conducted his evaluation, took a throat culture, and administered several medications all within 45 minutes. Two IV bags, a cortisone shot and five hours later, we were heading to the billing department. "Oh no," I told my husband. "I can just imagine how much this bill is going to be." To my surprise, the total bill was 275 Euro, or roughly $450. For five hours of high-quality treatment. And this amount is not my co-payment or "my portion" of the bill. It is the total cost of care for the day. To put that in perspective, according to Blue Cross Blue Shield of Georgia, the average cost of a day spent in a hospital in the U.S. is $4,700. Interesting to note, if I were a French citizen, I would have paid, out of pocket, 1 Euro for the visit. But before you start thinking health care is "free" in France, let me point out the taxes they pay. Approximately 21 percent of a French salary goes to France's version of Social Security, which includes mandatory health insurance, supplemental health insurance and retirement benefits. So what do you make of it? Do you think we overpay for health care in the U.S.? Would you favor higher taxes if it meant our health care would be a few dollars a visit? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Monday, March 17, 2008
The air we breathe
By A. Chris Gajilan
Senior Medical Producer Could the air you breathe cause permanent damage to your health? That is one of the reasons marathon runner and world record holder Haile Gebrselassie has said he will not compete at the Beijing Olympics this summer. While the 34-year-old Ethiopian says he won't run the marathon, he has said that he hopes to run the 10,000 meter race. Gebrsealassie has exercise-induced asthma and is concerned that the longer marathon may cause permanent damage to his health. Without a doubt, the air in Beijing is bad, but does it really have the potential to cause long-lasting damage in someone who would spend about a month on the ground? When I was there in the early 1990s, the air was thick and hazy. There was a layer of soot from the nearby coal-operated factories. Since then, Beijing has boomed economically, and cars and industries have sprung up everywhere. Today, one measure of air pollution is nearly double the safe limit levels according to Dr. Homer Boushey of the Health Effects Institute. Fine particulate matter, which is found in haze, smoke and dust, has been measured at levels close to 300 microns/cubic meter. The safe upper limit is 150 microns/cubic meter. While Dr. Boushey says that it's unlikely that two to three weeks in Beijing will cause permanent damage to the lungs or the body, he does acknowledge that exercising in bad air exposes us to more pollutants. When we exercise heavily, we breathe mostly through the mouth, bypassing the body's first line of defense against pollution, the nose. Dr. Boushey points to one 1980s study of track meet results. Researchers found that the higher the levels of ozone on a particular competition day, the worse the winning times. He says there's a direct correlation between pollution conditions and athletic performance. In addition, there is a well-established relationship between ozone and particulate levels, and all cause mortality including heart attacks and respiratory disease. When air pollution levels are bad, there is a measurable increase in asthma attacks and emergency room visits due to respiratory problems. At greatest risk for health problems due to pollution are the elderly, children, those with chronic obstructive pulmonary disease, asthmatics and those with chronic bronchitis. Are you concerned about air pollution? How do you think it affects human health? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Friday, March 14, 2008
The myths of Autism
By A. Chris Gajilan
Senior Medical Producer Over the past few years, CNN Medical News has provided extensive coverage of autism. From the stories of parents and children living with the disorder to the latest science on possible causes to a vast array of treatments and therapies, we have followed most major developments in the field. Every story we report on autism has been stirred an incredible amount of passion from our viewers and our readers. Now it's your turn to have some of your own questions answered. CNN is planning a comprehensive day of coverage in recognition of World Autism Awareness Day on April 2. The latest statistics from the Centers for Disease Control and Prevention say that at least 1 in 150 children are affected in the United States. In a report called, the "Myths of Autism" we hope to dispel any misperceptions about the disorder and the people who live with it. We also want to be very clear that there is still a great deal the scientific community has yet to learn about autism and its related disorders. Here are some ideas that we hope to address: - Every autistic person has savant abilities in some area such as Dustin Hoffman in Rain Man. Eg: math or memorization - Thimerosal in vaccines is the main cause for autism. - Autistic adults will never be able to live on their own. They will always need assisted living care. Do you think that there are prevailing myths related to autism? What are they? What questions do you need answered? Does autism touch your life? Tell us your story here: Autism iReport Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Minding your knees as you age
By Val Willingham
Medical Producer When I was young, I used to run. I ran my first 10K at Miami-Dade Community College in South Miami, almost 25 years ago. And I still remember every step, every breath. It was exhilarating. But when I came to the finish line, it was also painful. I continued to run for about three years until my joints couldn't take it anymore. Maybe I wasn't training very well. Maybe I wasn't cut out for running, but I knew if I continued, I would eventually injure myself permanently. So I hung up my shoes. But there are people out there who will always run the course. Take my friend, Patrick Avon. He is a man obsessed. The guy never stops. Even now, he's in constant motion. As head of his own "boot camp" fitness program, Avon practices what he preaches. A marathon runner and a triathlete, he works out daily to keep his body in shape. He says it keeps him young and he wants to use his body as if he were 15 years old again. The problem is he's not 15 any more and after years of running, 45-year-old Avon had knee surgery. Five months later, he ran the Marine Corps Marathon. He says he just heals well and "recovered wicked fast." But Avon was lucky. He got back on track. That's not the case for all of us. As we age, many parts of our body start to suffer from wear and tear, especially our knees. According to Dr. Wiemi Douoguih, a sports medicine specialist and orthopedic surgeon at Washington Hospital Center in Washington, D.C., we unintentionally abuse our knees. "Whether it's running, jumping, changing direction, the whole upper body is all supported by the knee and ankle," he says. (Watch Video) According to the American Academy of orthopedic surgeons, past traumas such as sprains and falls, can cause wearing away of the knee cartilage lining. Injuries to the ligaments and the tendons can lead to osteoarthritis, which needs to be corrected with surgery. To keep your knees in top shape, doctors suggest you modify your exercise; watch how you use your body and avoid doing the same thing over and over. Repetition can be stressful to the knees. Think about other ways to remain active and change your program. According to Douoguih, this is this commonly known as cross training. "It's a very effective way of avoiding injury," he says. "It's important not to overdo anything." As you get older, arthritis can become an issue, especially if the knees have taken a beating in your younger years. You could end up with knee replacement surgery. More than 300,000 operations are performed on knees each year, but doctors shy away from replacements until patients get older. They say the longer a patient can wait to put in a knee replacement the better it is because the components they put in the knee wear out. Ideally doctors would like to insert an implant that will outlast the patient! Physicians suggest that as you get older look for lower impact activity; yoga, swimming, even cycling puts less stress on the knees. Even light weight lifting can help with older joints. And if you're in pain, don't ignore it. Douoguih warns that you should listen to your body. "If it starts to hurt, back off." As for my friend, Patrick? There's no stopping him. He says he'll continue his daily routine in order to keep on the road. And even though he may face a few setbacks, he hopes he'll be running for years to come. As I said, he's a man obsessed. Do you have problems with your knees? How do you take care of them? We'd like to hear about it. Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Monday, March 10, 2008
Young men and the HPV vaccine
By Amy Burkholder
Medical Producer The army of "Gardasil girls" featured in Merck's aggressive ad campaign may soon have new recruits in the fight to be "one less" woman with cervical cancer - boys. And while some tenets of the debate are the same - vaccinating kids for the sexually transmitted human papapilloma virus well before they're even old enough for their first high school dance - there's a gender twist: Some see it as submitting boys to an altruistic vaccine, one they'd get to protect girls. Now, families with both teen girls and teen boys may find themselves at an intersection of morals and mandates - where virtue meets virus. (Read about one mother's struggle over vaccinating her daughters.) Merck tells CNN that studies on Gardasil in boys should be completed this year, and it hopes to have the vaccine approved and available to young men as early as next year, likely for 16-to 23-year-olds - in the form of the same series of three shots that young women now receive. It's not just a vaccine to prevent cervical cancer, Merck insists. Merck says Gardasil is showing promise of protecting boys from genital, penile and rectal warts. Experts say among gay men, cancer of the anus is becoming almost as common as cervical cancer, and some clinics are starting to do regular HPV smears in men. But just as approval for girls wasn't an easy road, the issue of "should or must get" is stickier with boys. After the FDA approved the vaccine last June for girls and women ages 9 to 26, the CDC immunization advisory panel later recommended all 11-and 12-year-old girls get the shots. Some facts to consider: HPV is the leading cause of cervical cancer in women, among the top cancer-killers of women. If boys could be vaccinated, the spread of the virus would slow considerably, according to public health officials. According to the CDC, 50 percent of sexually active men and women acquire genital HPV infection at some point in their lives. Gardasil protects girls and women against four of the dozens of strains of human, or HPV, two of which are responsible for 70 percent of cervical cancer cases. The other two types account for 90 percent of genital warts, which affect both men and women. Of course, there are other things that protect teens from HPV, including abstinence. Critics say that should be the focus, rather than pushing a vaccine on them. "Only in the past few decades have we said that it is OK and natural," writes one blogger on the issue of Gardasil for boys. "Baloney. I would teach my child fornication is wrong, and that a young man should retain his virginity until marriage." Do you think boys should be vaccinated against HPV? Why or why not? We'd love to hear from you. Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Friday, March 07, 2008
Parents in vaccine case still see good in shots
By Dr. Sanjay Gupta
Chief Medical Correspondent I had a chance to meet the Poling family last night. Their 9-year-old daughter Hannah was diagnosed with "symptoms of autism spectrum disorder" and the government has recommended the federal vaccine court pay the family compensation (read more about Hannah's underlying condition here). Dr. Jon Poling, a neurologist, and Terry Poling, a nurse, are Hannah's parents. With all that has happened (watch video of Hannah's father talking about her reaction to the vaccinations) to their daughter, they still made it very clear they are not anti-vaccine. They agree, as most people do, that vaccines have been a great medical accomplishment and have saved and improved countless lives. The question they seem to raise, though, are they as safe as they can be? I want to continue the discussion today. Couple of points. First of all, it seems as if parents bring up concerns about vaccines, they are automatically portrayed as anti-vaccine. Why is that? Is it possible to completely believe in the power and benefits of vaccines, but still have legitimate and credible concerns? Given that thimerosal, the mercury-laden preservative, is now essentially out of vaccines (it may be present in trace amounts according to the FDA) except for flu vaccines, does that put that issue to rest for you? Or, do you believe there is something about the vaccines themselves - even without the thimerosal - that might be problematic? And, what would you do about it? Split up the shots? Delay them? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Thursday, March 06, 2008
Vaccines and autism
 Hannah PolingChief Medical Correspondent Some new news to share about autism today. At a press conference this morning, a Georgia family will describe how the government has conceded that a vaccine "contributed" to their daughter's autism symptoms. The family will receive compensation from a federal vaccine court. That doesn't mean the federal government agrees that vaccines cause autism (click here for more on autism). Nor does this 9-year-old girl's case mean the 4,900 other families in the vaccine court have won their claim that vaccines resulted in their children's autism. That case continues. Advocates who see a vaccine-autism link point to Hannah Poling's case as a big victory for their cause - evidence of the potentially disastrous side effects of vaccines. Within 48 hours after receiving her vaccinations, Hannah, then 19 months old and by all accounts a normal little girl, developed a high fever, inconsolable crying and some signs of regression, including difficulty walking and speaking. Over the next several months, she had countless visits with doctors finally culminating in the diagnosis of encephalopathy with features of autism spectrum disorder. At the same time, and this is potentially very important, she had genetic testing and was found to have the gene for an underlying mitochondrial disorder (click here for more about mitochondrial disorder). So, did the vaccines worsen an already existing condition leading to the symptoms of autism? That is what the government seems to have conceded. And, if so, was it caused by the mercury preservative thimerosal, which was present in Hannah's vaccines several years ago, or was it the profound immune response that vaccinations cause in the body? The Centers for Diseases Control, American Academy of Pediatrics, Institute of Medicine and other prestigious medical organizations maintain there is no link between vaccines and autism. As many experts have told me, this case is likely to raise more questions than it answers. But, these are good questions and important ones for anyone who cares about this issue. What do you think? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. Monday, March 03, 2008
Would you get weight-loss surgery?
By A. Chris Gajilan
Senior Medical Producer A few weeks ago, a good friend told me that she'd be getting a Lap-Band procedure done. She told me about her upcoming weight-loss surgery over a sushi lunch and very excitedly explained all aspects of the procedure. It would be minor surgery -- minimally invasive, take about an hour, no major side effects, covered by insurance for a mere co-pay of $20. She wouldn't need to stay overnight in the hospital, she told me, but her doctor liked to be safe. "I have the same doctor as Al Roker for when he had it done," she added. To be honest, I was stunned, when I know I shouldn't have been. After all, we do weight-loss stories of all kinds as part of the Fit Nation series. Lap-Bands, which restrict the size of the stomach, really do work for a lot of people. In fact, in a January issue of the Journal of the American Medical Association, one small study found that 75 percent of people who got Lap-Band surgery experienced a remission of their type 2 diabetes -- possibly because of fewer calories being consumed. In the group that just tried diet and exercise, only about 14 percent experienced remission. But my friend hasn't been diagnosed with any major disease. While she may have a family history of health problems, she lives a very healthy lifestyle. No diabetes, no heart disease, no high blood pressure. She works out three to four times a week. In fact, while I'm not as heavy in weight or body mass index, she's far fitter than I am. Even so, her body mass index is over 40 -- well into the category considered obese. According to the Mayo Clinic, more than 200,000 Americans had bariatric surgery last year. (The two most popular procedures are gastric bypass and the Lap-Band.) The latest numbers say that four out of every 1,000 patients who have gastric surgery die, either at the hospital or at home. The ideal candidate is someone who has a body mass index of 40 or more -- which equates to about 100 pounds over your ideal body weight. Someone considering weight-loss surgery must pass extensive psychological and medical exams to be approved for the surgery. While I was concerned about safety, she assuaged my fears by telling me that Lap-Band is much safer than gastric bypass. A previous CNN.com story (Full Story), described the procedure: "A small adjustable band is placed around the upper part of the stomach to restrict the amount of food the stomach will hold. The band creates a small pouch opening to the stomach. The amount of food your stomach will hold is controlled by injecting or removing fluid from the band." While I know my friend is the ideal candidate, I can't help but feel some reservations about it. I can't help but wonder if I would do the same if I were in the same position. Would you get weight-loss surgery? What would you tell a friend considering it? Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation. |
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