Changes in self-reported sleep duration with age - a 36-year longitudinal study of Finnish adults

Abstract Background Sleep deprivation is often claimed to be increasingly common, but most studies show small changes in sleep duration over the last decades. Our aim was to analyze long-term patterns in self-reported sleep duration in a population-based cohort. Methods Members of the Older Finnish Twin Cohort have responded to questionnaires in 1975 (N = 30,915 individuals, response rate 89%, mean age 36 years), 1981 (24,535, 84%, 41 years), 1990 (12,450, 77%, 44 years), and 2011 (8334, 72%, 60 years). Weibull regression models were used to model the effects of follow-up time and age simultaneously. Results Sleep duration has decreased in all adult age groups and in both genders. The mean duration was in men 7.57 h in 1975 and 7.39 in 2011, and in women 7.69 and 7.37, respectively. The decrease was about 0.5 min in men and 0.9 in women per year of follow-up. In the age-group 18–34 years, mean sleep length was 7.69 h in 1975 and 7.53 in 1990. Among 35–54-year-old it was 7.57 h in 1975 and 7.34 in 2011, and in the age group of 55+ year olds 7.52 and 7.38, correspondingly. The change was largest in middle-aged group: about 23 min or about 0.6 min per year of follow-up. Conclusions There has been a slight decrease in mean sleep duration during the 36-year follow-up. Although the sleep duration was longer in 1970s and 1980s, the probable main cause for the change in this study population is the effect of aging.

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Changes In Self-Reported Sleep Duration With Age - A 36-Year Longitudinal Study Of Finnish Adults

10.21203/rs.3.rs-26590/v3 ◽

2020 ◽

Author(s):

Christer Hublin ◽

Lassi Haasio ◽

Jaakko Kaprio

Keyword(s):

Sleep Duration ◽

Age Groups ◽

Population Based ◽

Age Group ◽

Weibull Regression ◽

Adult Age ◽

Study Population ◽

Sleep Length

Abstract Background: Sleep deprivation is often claimed to be increasingly common, but most studies show small changes in sleep duration over the last decades. Our aim was to analyze long-term patterns in self-reported sleep duration in a population-based cohort. Methods: Members of the Older Finnish Twin Cohort have responded to questionnaires in 1975 (N = 30,915 individuals, response rate 89%, mean age 36 years), 1981 (24,506, 84%, 41 years), 1990 (12,502, 77%, 44 years), and 2011 (8510, 72%, 60 years). Weibull regression models were used to model the effects of follow-up time and age simultaneously. Results: Sleep duration has decreased in all adult age groups and in both genders. The mean duration was in men 7.57 hours in 1975 and 7.39 in 2011, and in women 7.69 and 7.37, respectively. The decrease was about 0.5 minutes in men and 0.9 in women per year of follow-up. In the age-group 18-34 years, mean sleep length was 7.69 hours in 1975 and 7.53 in 1990. Among 35-54-year-old it was 7.57 hours in 1975 and 7.34 in 2011, and in the age group of 55+ year olds 7.52 and 7.38, correspondingly. The change was largest in middle-aged group: about 23 minutes or about 0.6 minutes per year of follow-up. Conclusions: There has been a slight decrease in mean sleep duration during the 36-year follow-up. Although the sleep duration was longer in 1970s and 1980s, the probable main cause for the change in this study population is the effect of aging.

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Changes in Self-Reported Sleep Duration With Age - a 36-Year Longitudinal Study of Finnish Adults

10.21203/rs.3.rs-26590/v2 ◽

2020 ◽

Author(s):

Christer Hublin ◽

Lassi Haasio ◽

Jaakko Kaprio

Keyword(s):

Sleep Duration ◽

Age Groups ◽

Population Based ◽

Age Group ◽

Weibull Regression ◽

Adult Age ◽

Study Population ◽

Sleep Length

Abstract Background Sleep deprivation is often claimed to be increasingly common, but most studies show small changes in sleep duration over the last decades. Our aim was to analyze long-term patterns in self-reported sleep duration in a population-based cohort. Methods Members of the Older Finnish Twin Cohort have responded to questionnaires in 1975 (N = 30,915 individuals, response rate 89%, mean age 36 years), 1981 (24,506, 84%, 41 years), 1990 (12,502, 77%, 44 years), and 2011 (8510, 72%, 60 years). Weibull regression models were used to model the effects of follow-up time and age simultaneously. Results Sleep duration has decreased in all adult age groups and in both genders. The mean duration was in men 7.57 hours in 1975 and 7.39 in 2011, and in women 7.69 and 7.37, respectively. The decrease was about 0.5 minutes in men and 0.9 in women per year of follow-up. In the age-group 18-34 years, mean sleep length was 7.69 hours in 1975 and 7.53 in 1990. Among 35-54-year-old it was 7.57 hours in 1975 and 7.34 in 2011, and in the age group of 55+ year olds 7.52 and 7.38, correspondingly. The change was largest in middle-aged group: about 23 minutes or about 0.6 minutes per year of follow-up. Conclusions There has been a slight decrease in mean sleep duration during the 36-year follow-up. Although the sleep duration was longer in 1970s and 1980s, the probable main cause for the change in this study population is the effect of aging.

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Changes In Self-Reported Sleep Duration With Age - A 36-Year Longitudinal Study of Finnish Adults

10.21203/rs.3.rs-26590/v1 ◽

2020 ◽

Author(s):

Christer Hublin ◽

Lassi Haasio ◽

Jaakko Kaprio

Keyword(s):

Sleep Duration ◽

Regression Models ◽

Age Groups ◽

Population Based ◽

Age Group ◽

Weibull Regression ◽

Adult Age ◽

Sleep Length

Abstract Background: Sleep deprivation is often claimed to be increasingly common, but most studies show small changes in sleep duration over the last decades. Our aim was to analyze long-term patterns in self-reported sleep durationin a population-based cohort.Methods: Members ofthe Older Finnish Twin Cohort have responded to questionnaires in 1975 (N = 30,915 individuals,response rate 89%, mean age 36 years), 1981 (24,506, 84%, 41 years), 1990 (12,502,77%, 44 years), and 2011 (8510, 72%, 60 years).Weibull regression models were used to model the effects of follow-up time and age simultaneously.Results: Sleep duration has decreased in all adult age groups and in both genders.The mean duration was in men 7.57 hours in 1975 and 7.39 in 2011, and in women 7.69 and 7.37, respectively. The decrease was about 0.5minutes in men and 0.9in women per year of follow-up. In the age-group 18-34 years, mean sleep length was 7.69 hours in 1975 and 7.53 in 1990. Among 35-54-year-old it was 7.57 hours in 1975 and 7.34 in 2011, and in the age group of 55+ year olds7.52 and 7.38, correspondingly. The change was largest in middle-aged group: about 23 minutes or about 0.6 minutes per year of follow-up.Conclusions: There has been a slight decrease in mean sleep duration during the 36-year follow-up.Although the sleep duration was longer in 1970s and 1980s, the probablemain cause for the change in this study populationis the effect of aging.

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Indications and outcomes of paediatric tracheotomy: a descriptive study using a Japanese claims database

BMJ Open ◽

10.1136/bmjopen-2019-031816 ◽

2019 ◽

Vol 9 (12) ◽

pp. e031816 ◽

Cited By ~ 1

Author(s):

Kayoko Mizuno ◽

Masato Takeuchi ◽

Yo Kishimoto ◽

Koji Kawakami ◽

Koichi Omori

Keyword(s):

Descriptive Analysis ◽

Upper Airway ◽

Population Based ◽

Claims Database ◽

Mechanical Ventilation Duration ◽

Study Population ◽

Underlying Diseases

ObjectiveTo examine the incidence of and indications for paediatric tracheotomy to clarify the disease burden relevant to tracheotomy in a population-based context.DesignA descriptive analysis of a retrospective cohort.SettingThis study utilised a nationwide claims database in Japan constructed by JMDC (Tokyo, Japan). The database includes claims data for approximately 3.75 million insured persons (approximately 3.1% of the population of Japan) comprising mainly company employees and their family members.ParticipantsWe identified children registered to have undergone tracheotomy from 2005 to 2017 among about 1.2 million children aged 0–15 years.Main outcome measuresThe characteristics of the study population, and indications for tracheotomy, duration of hospital stay, duration of mechanical ventilation, duration of tracheotomy dependence, complications related to tracheotomy and death were assessed. When there were multiple indications, classification for a child into multiple groups was allowed.ResultsThe study included 215 children (120 males, 56%). The median age at tracheotomy was 0.8 years. The most common age at tracheotomy was less than 12 months (n=127, 59.1%). The most common indications for tracheotomy were chronic lung disease (n=79, 36.7%), followed by neuromuscular disease (n=77, 35.8%), cardiovascular disease (n=53, 24.3%), upper airway obstruction (n=43, 20%), premature birth and related conditions (n=34, 15.8%), trauma (n=16, 7.4%), prolonged ventilation due to other causes (n=12, 5.6%) and malignancy (n=9, 4.2%). The median duration of tracheotomy dependence was 17.2 months. During the follow-up period, decannulation was achieved in 84 children (39.1%), and the median time from tracheotomy to decannulation was 12.0 months.ConclusionsMost paediatric tracheotomies were performed due to chronic underlying diseases, and the mean duration of tracheotomy dependence was nearly 1-½ years. The long-term duration of tracheotomy dependence might have some impacts on patients’ physical and mental development and the quality of life.

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A BAYESIAN WEIBULL ANALYSIS OF BREAST CANCER DATA WITH LONG-TERM SURVIVORS IN PARANA STATE, BRAZIL

REVISTA BRASILEIRA DE BIOMETRIA ◽

10.28951/rbb.v39i2.469 ◽

2021 ◽

Vol 39 (2) ◽

pp. 293-310

Author(s):

Talita Evelin Nabarrete Tristão de MORAES ◽

Isolde PREVIDELLI ◽

Giovani Loiola da SILVA

Keyword(s):

Breast Cancer ◽

Survival Data ◽

White Women ◽

Age Groups ◽

Population Based ◽

Breast Cancer Data ◽

Weibull Regression ◽

Cancer Data ◽

Long Term Survivors

Breast cancer is one of the most common diseases among women worldwide with about 25% of new cases each year. In Brazil, 59,700 new cases of breast cancer were expected in 2019, according to the Brazilian National Cancer Institute (INCA). Survival analysis has been an useful tool for the identifying the risk and prognostic factors for cancer patients. This work aims to characterize the prognostic value of demographic, clinical and pathological variables in relation to the survival time of 2,092 patients diagnosed with breast cancer in Parana State, Brazil, from 2004 to 2016. In this sense, we propose a Bayesian analysis of survival data with long-term survivors by using Weibull regression models through integrated nested Laplace approximations (INLA). The results point to a proportion of long-term survivors around 57:6% in the population under study. In regard to potential risk factors, we namely concluded that 40-50 year age group has superior survival than younger and older age groups, white women have higher breast cancer risk than other races, and marital status decreases that risk. Caution on the general use of these results is nevertheless advised, since we have analyzed population-based breast cancer data without proper monitoring by a healthprofessional.

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Incidence and Survival of Multiple Myeloma; A Population-Based Study on 10 961 Patients Diagnosed 1982-2017

Blood ◽

10.1182/blood-2019-129816 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4380-4380 ◽

Cited By ~ 1

Author(s):

Øystein Langseth ◽

Tor Åge Myklebust ◽

Tom Børge Johannesen ◽

Øyvind Hjertner ◽

Anders Waage

Keyword(s):

Multiple Myeloma ◽

Age Groups ◽

Relative Survival ◽

Population Based ◽

New Drugs ◽

Steady Increase ◽

Age Group ◽

Calendar Period ◽

Population Based Study

Background: Several population-based studies on multiple myeloma (MM) have shown an improvement in relative survival (RS) for patients aged 65 years or younger at the time of diagnosis. In patients aged 75 years or older, the improvement in long-term RS is absent in most reports or much less pronounced. To our knowledge, only 2 studies based on the Surveillance, Epidemiology and End Results (SEER) database have demonstrated a significant increase in RS for this age-group. (Pulte et al. 2011, Costa et al. 2017) We performed a population-based study on Norwegian MM-patients to provide up-to-date estimates on changes in relative survival during the past 3 decades. Methods: The Cancer Registry of Norway (CRN) was established in 1951 and provides high-quality nationwide cancer statistics. For MM, the reported completeness of case-ascertainment is above 95%. Incidence data and all reported cases of MM diagnosed between January 1, 1982 and December 31, 2017 were retrieved from the CRN (n=10 961). Nationwide drug consumption statistics for drugs used in myeloma treatment were retrieved from the Norwegian Drug Wholesales Statistics and the Norwegian Prescriptions Database, Norwegian Institute of Public Health. Follow-up ended December 31, 2017. The time of MM-diagnosis was divided into 7 categories: 1982-1987, 1988-1992 (melphalan-prednisone), 1993-1997(early high-dose melphalan with autologous stem-cell transplant (HDM-ASCT)), 1998-2002 (introduction of thalidomide), 2003-2007 (early thalidomide upfront, introduction of bortezomib), 2008-2012 (thalidomide and bortezomib upfront, introduction of lenalidomide), 2013-2017 (lenalidomide upfront, early pomalidomide, daratumumab, panobinostat and carfilzomib). Age at diagnosis was divided into 3 categories; <65 years, 65-79 years and 80 years or older. We estimated relative survival ratios (RSR) with 95% confidence intervals 5 and 10 years after the time of diagnosis by the Ederer-II method. The analysis was stratified by age-group and calendar period of diagnosis. Cohort analysis was applied to calendar periods with complete follow-up, and period analysis was applied where complete-follow up was not available (2013-2017 and 10-year estimates for 2008-2012). Non-overlapping confidence intervals were considered statistically significant. Results: The age-standardized incidence rate was stable until approximately year 2000, followed by an increasing tendency reaching 8.4 cases per 100 000 persons in 2017. Figure 1. Patients diagnosed before the age of 65 had a steady increase in both 5 and 10-year RSR across all calendar periods. For patients aged 65-79 years, the 5- and 10-year RSR's were stable at approximately 0.3 and 0.1, respectively, until the calendar period 1998-2002. In the following years, an improvement in both 5- and 10-year RSR was observed. The 5-year RSR improved significantly from 0.31 (95% CI; 0.27-0.35) in the first calendar period to 0.43 (95% CI;0.39- 0.47) during 2008-2012. The predicted 5-year RSR for 2013-2017 was 0.48 (95% CI; 0.44-0.52). There were also signs of improved 10-year RSR, predicted to 0.23 (95% CI; 0.18-0.27) during 2013-2017 compared to 0.11 (95% CI; 0.08-0.14) during 1982-1987. The 5-year RSR for patients aged 80+ years was 0.11 (95% CI; 0.01-0.17) during 1982-1987 and the 10-year RSR was 0.03 (95% CI; 0.01-0.11). In the following 4 calendar periods the RSR-estimates fluctuated before a rising tendency during the last 2 periods. The 5-year RSR improved significantly to 0.26 (95% CI; 0.20-0.32) during 2008-2012 and further rising to a predicted value of 0.32 (95% CI; 0.25-0.38) during 2013-2017. Figure 2. Additionally, complete annual prescription statistics for the oral agents thalidomide, lenalidomide and pomalidomide were obtained. Conclusions: We provide real-world observations on changes in RS in a population-based cohort of 10 961 MM-patients. We demonstrate an improvement in 5-year relative survival across all age-groups, including patients aged 80 years or older. For patients <65 years, there was a steady increase in RS since 1982 and we see no obvious impact of the implementation of HDM-ASCT. For the other age-groups, the improvement in RS coincides with the introduction of new drugs. The increase in incidence since 2000 may be due to increased testing for M-protein. We can point to the introduction of new drugs and increased incidence of indolent cases as possible reasons for increasing RS. Disclosures No relevant conflicts of interest to declare.

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COVID-19 among young adults in Sweden: self-reported long-term symptoms and associated factors

Scandinavian Journal of Public Health ◽

10.1177/14034948211025425 ◽

2021 ◽

pp. 140349482110254

Author(s):

Sandra Ekström ◽

Niklas Andersson ◽

Alexandra Lövquist ◽

André Lauber ◽

Antonios Georgelis ◽

...

Keyword(s):

Young Adults ◽

Chronic Conditions ◽

Population Based ◽

Lifestyle Factors ◽

Swedish Population ◽

Significant Difference ◽

Study Population ◽

Web Questionnaire

Aims: The main aim of the study was to describe self-reported symptoms of COVID-19 and examine if long-term symptoms are associated with lifestyle factors or common chronic diseases among Swedish young adults. A secondary aim was to compare the prevalence of smoking and snuff use before and during the COVID-19 pandemic. Methods: The study population includes 1644 participants aged 23–26 years from the Swedish population-based birth cohort BAMSE. From August to November 2020, the participants answered a web questionnaire on COVID-19 symptoms, lifestyle and health. Information on tobacco use was compared against the previous study follow-up in 2016–2019. Results: The prevalence of suspected COVID-19 symptoms was 45.3% ( n=742), and 80 of these (10.8%) reported long-term symptoms (⩾4 weeks). There was no significant difference in sociodemographic or lifestyle factors in relation to the duration of suspected COVID-19 symptoms. Rhinitis, migraine and lower self-rated health before the pandemic was more common among participants with long-term symptoms. In addition, there was a tendency for higher prevalences of asthma, chronic bronchitis and depression in this group. The prevalence of smoking decreased from 18.9% before the pandemic to 14.7% during the pandemic, while snuff use increased from 12.7% to 22.4% ( P<0.001). Conclusions: Almost half of Swedish young adults have had symptoms of suspected COVID-19 from February up to August 2020. Among these, one out of 10 have had long-term symptoms for at least 4 weeks. Long-term symptoms of suspected COVID-19 were associated with several common chronic conditions. Smoking may have decreased during the pandemic, while snuff use may have increased.

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Abstract 13267: Age-Related Long-Term Benefit of Cardiac Resynchronization Therapy in LBBB Patients - a MADIT-CRT Long-Term Follow-Up Substudy

Circulation ◽

10.1161/circ.130.suppl_2.13267 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Sabu Thomas ◽

Arthur J Moss ◽

Wojciech Zareba ◽

Scott McNitt ◽

Alon Barsheshet ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Age Groups ◽

Cardiac Resynchronization ◽

Age Group ◽

Resynchronization Therapy ◽

All Cause Mortality ◽

Long Term Follow Up

Background: Among patients with heart failure (HF), cardiac resynchronization therapy (CRT) combined with a defibrillator (CRT-D) reduces HF events and mortality compared with a defibrillator (ICD) alone. Whether these benefits extend to all age-groups during long-term follow-up is unclear. Hypothesis: We hypothesized that CRT-D would benefit all age groups with respect to reductions in HF events and all-cause mortality. Methods: We assessed the effect of age on HF events and death among patients in the MADIT-CRT long-term follow up study. 1281 patients with class I or II heart failure and left-bundle branch block (LBBB) were randomized to CRT-D or ICD alone. Patients were divided into 3 age groups: <60, 60-74 or ≥75 years and evaluated over 7 years for mortality and HF events. We compared cumulative events using the log-rank test and adjustments were made using a multivariate logistic regression model with various pre-specified covariates. Results: Overall 761 patients received CRT-D and 520 received ICD alone. The median age was 65 years. Among the three age groups, <60, 60-74 and ≥75 there were 399, 651 and 231 patients respectively. Multivariate analysis (Table) revealed that CRT-D compared to ICD alone significantly reduced the composite outcome of HF or death across all age groups: <60 years relative risk reduction (RRR)=39%, p=0.0236; 60-74 years RRR=59%, p<0.001; ≥75 years RRR=55%, p<0.001. CRT-D also significantly reduced HF events in all age groups <60 years RRR=52%, p=0.003; 60-74 years RRR=61%, p<0.001; ≥75 years RRR=73%, p<0.001. CRT-D was associated with significant mortality reduction only in the 60-74 year age group RRR 58%, p<0.001. Conclusion: Among patients with asymptomatic or mild heart failure, reduced LVEF and LBBB, CRT-D results in significant reduction of HF events and in the composite of all-cause mortality and HF events during long-term follow-up. All-cause mortality was significantly reduced with CRT-D only in the 60-74 year age group.

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The incidence and effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele: a population-based study

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.4.peds19722 ◽

2020 ◽

Vol 26 (3) ◽

pp. 269-274 ◽

Cited By ~ 1

Author(s):

Joel Haakon Borgstedt-Bakke ◽

Thea Overgaard Wichmann ◽

Gudrun Gudmundsdottir ◽

Mikkel Mylius Rasmussen

Keyword(s):

Surgical Procedures ◽

Tethered Cord ◽

Population Based ◽

Short Term ◽

Population Based Study ◽

Long Term Follow Up ◽

Study Population ◽

The Mean

OBJECTIVEThe goal of this study was to establish an incidence and assess the effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele.METHODSThe study population was based on the Western Denmark Myelomeningocele Database, which contains all patients born with myelomeningocele in western Denmark since 1970. The study population was cross-referenced in 2015 with a database for surgical procedures containing all surgical procedures performed in the central Denmark region since 1996. Patients alive between 1996 and 2015 were identified. Incidences was calculated and presented for year of age. File reviews were conducted for all patients who underwent the procedure. Follow-up was divided into short-term and long-term follow-up.RESULTSOne hundred sixty-six patients were alive during various time periods between 1996 and 2015. Of these, 45 patients underwent the procedure. Seven underwent reoperation. The median age for the procedure was 12 years and the highest incidence was found at 15 years of age. Incidence was bimodal with highest incidence in children and adolescents. The most common indications were progressive spine deformity (40%), deteriorating ambulation (38%), and deteriorating neurogenic bladder and/or bowel dysfunction (32%). The mean short-term follow-up was 4.7 months and the mean long-term follow-up was 72.6 months. Postoperatively, the majority had improved (27%) or stabilized (27%) at short-term follow-up. At long-term follow-up, most patients were stable (27%) or had deteriorated (24%). For both follow-up terms there was a loss of approximately one-third of all patients. Complications occurred in 17% of the procedures.CONCLUSIONSIn this population-based study, tethered cord release has the highest incidence in children and adolescents. The beneficial effect of the procedure seems to be short term. Due to the uncertainty of a long-term effect of the procedure in patients with myelomeningocele and the registered complications, the authors suggest that this surgical indication should be reserved for well-selected patients.

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No relation between biomarkers at age 47–49 and aortic diameter after 14–19 years of follow-up – a population-based study

VASA ◽

10.1024/0301-1526/a000632 ◽

2017 ◽

Vol 46 (4) ◽

pp. 291-295 ◽

Cited By ~ 2

Author(s):

Soumia Taimour ◽

Moncef Zarrouk ◽

Jan Holst ◽

Olle Melander ◽

Gunar Engström ◽

...

Keyword(s):

Population Based ◽

Aortic Diameter ◽

Aortic Dilatation ◽

Population Based Study ◽

Reactive Protein ◽

Abdominal Aortic ◽

Long Term Follow Up ◽

Old Men

Abstract. Background: Biomarkers reflecting diverse pathophysiological pathways may play an important role in the pathogenesis of abdominal aortic aneurysm (aortic diameter ≥30 mm, AAA), levels of many biomarkers are elevated and correlated to aortic diameter among 65-year-old men undergoing ultrasound (US) screening for AAA. Probands and methods: To evaluate potential relationships between biomarkers and aortic dilatation after long-term follow-up, levels of C-reactive protein (CRP), proneurotensin (PNT), copeptin (CPT), lipoprotein-associated phospholipase 2 (Lp-PLA2), cystatin C (Cyst C), midregional proatrial natriuretic peptide (MR-proANP), and midregional proadrenomedullin (MR-proADM) were measured in 117 subjects (114 [97 %] men) aged 47–49 in a prospective population-based cohort study, and related to aortic diameter at US examination of the aorta after 14–19 years of follow-up. Results: Biomarker levels at baseline did not correlate with aortic diameter after 14–19 years of follow up (CRP [r = 0.153], PNT [r = 0.070], CPT [r = –.156], Lp-PLA2 [r = .024], Cyst C [r = –.015], MR-proANP [r = 0.014], MR-proADM [r = –.117]). Adjusting for age and smoking at baseline in a linear regression model did not reveal any significant correlations. Conclusions: Tested biomarker levels at age 47–49 were not associated with aortic diameter at ultrasound examination after 14–19 years of follow-up. If there are relationships between these biomarkers and aortic dilatation, they are not relevant until closer to AAA diagnosis.

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