scholarly journals Risk Factors of Severe Adult-onset Asthma: A Multi-factor Approach

2021 ◽  
Author(s):  
Sanna Toppila-Salmi ◽  
Riikka Lemmetyinen ◽  
Sebastien Chanoine ◽  
Jussi Karjalainen ◽  
Juha Pekkanen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Severe Asthma ◽  
Professional Training ◽  
Univariate Analysis ◽  
Personal Characteristics ◽  
Population Based ◽  
Additional Risk Factor ◽  
Adult Onset ◽  
Asthma Symptoms ◽  
Male Sex

Abstract Background: The aim was to identify risk factors of severe adult-onset asthma.Methods: We used data from 1350 population-based asthmatics (Adult Asthma in Finland) with adult-onset asthma (age range 31-93 years) from Finnish national registers. Severe asthma was defined as self-reported severe asthma AND asthma symptoms causing much harm AND regular impairment AND (≥1 oral corticosteroid course/year OR regular oral corticosteroids OR wake up in the night due to asthma symptoms/wheezing attach ≥ a few times/month). Sixteen covariates covering several domains (personal characteristics, education, life-style, early life factors, asthma characteristics and multimorbidities) were selected based on literature and were studied in association with severe asthma using logistic regressions. Results: The study population included 100 (7.4 %) individuals with severe asthma. In a univariate analysis, severe asthma was associated with male sex, age, low education, no professional training, ever smoking, ≥ 2 siblings, ≥ 1 chronic comorbidity and Non-steroidal anti-inflammatory drug (NSAID) -exacerbated respiratory disease (NERD) (p<0.05); and trends for association (p<0.2) were observed for severe childhood infection, presence of chronic rhinosinusitis with nasal polyps, and being the 1st child. The 10 variables (being 1st child was removed due to multicolinearity) were thus entered in a multivariate regression model and severe asthma was significantly associated with male sex (OR [CI95%] = 1.96 [1.16-3.30]), ever smoking (1.98 [1.11-3.52]), chronic comorbidities (2.68 [1.35-5.31]), NERD (3.29 [1.75-6.19]), and ≥ 2 siblings (2.51 [1.17-5.41]). There was a dose-response effect of the total sum of these five factors on severe asthma (OR [CI95%] = 2.30 [1.81-2.93] for each increase of one unit of the score). Conclusions: Male sex, smoking, NERD, comorbidity, age and number of siblings were independent risk factors for self-reported severe asthma. The effects of these factors seem to be additive; each additional risk factor gradually increase with the risk of severe asthma.

scholarly journals Risk factors of severe adult-onset asthma: a multi-factor approach

2020 ◽  
Author(s):  
Sanna Toppila-Salmi ◽  
Riikka Lemmetyinen ◽  
Sebastien Chanoine ◽  
Jussi Karjalainen ◽  
Juha Pekkanen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Severe Asthma ◽  
Professional Training ◽  
Univariate Analysis ◽  
Personal Characteristics ◽  
Population Based ◽  
Additional Risk Factor ◽  
Adult Onset ◽  
Asthma Symptoms ◽  
Male Sex

Abstract Background The aim was to identify risk factors of severe adult-onset asthma. Methods We used data from 1350 population-based asthmatics (Adult Asthma in Finland) with adult-onset asthma (age range 31-93 years) from Finnish national registers. Severe asthma was defined as self-reported severe asthma AND asthma symptoms causing much harm AND regular impairment AND (≥1 oral corticosteroid course/year OR regular oral corticosteroids OR wake up in the night due to asthma symptoms/wheezing attach ≥ a few times/month). Sixteen covariates covering several domains (personal characteristics, education, life-style, early life factors, asthma characteristics and multimorbidities) were selected based on literature and were studied in association with severe asthma using logistic regressions. Results The study population included 100 (7.4%) individuals with severe asthma. In a univariate analysis, severe asthma was associated with male sex, age, low education, no professional training, ever smoking, ≥ 2 siblings, ≥ 1 chronic comorbidity and Non-steroidal anti-inflammatory drug (NSAID) -exacerbated respiratory disease (NERD) (p<0.05); and trends for association (p<0.2) were observed for severe childhood infection, presence of chronic rhinosinusitis with nasal polyps, and being the 1 st child. The 10 variables (being 1 st child was removed due to multicolinearity) were thus entered in a multivariate regression model and severe asthma was significantly associated with male sex (OR [CI95%] = 1.96 [1.16-3.30]), ever smoking (1.98 [1.11-3.52]), chronic comorbidities (2.68 [1.35-5.31]), NERD (3.29 [1.75-6.19]), and ≥ 2 siblings (2.51 [1.17-5.41]). There was a dose-response effect of the total sum of these five factors on severe asthma (OR [CI95%] = 2.30 [1.81-2.93] for each increase of one unit of the score). Conclusions Male sex, smoking, NERD, comorbidity, age and number of siblings were independent risk factors for self-reported severe asthma. The effects of these factors seem to be additive; each additional risk factor gradually increase with the risk of severe asthma.

scholarly journals Risk factors for severe adult-onset asthma: a multi-factor approach

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sanna Toppila-Salmi ◽  
Riikka Lemmetyinen ◽  
Sebastien Chanoine ◽  
Jussi Karjalainen ◽  
Juha Pekkanen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Severe Asthma ◽  
Professional Training ◽  
Univariate Analysis ◽  
Personal Characteristics ◽  
Population Based ◽  
Additional Risk Factor ◽  
Adult Onset ◽  
Asthma Symptoms ◽  
Male Sex

Abstract Background The aim was to identify risk factors for severe adult-onset asthma. Methods We used data from a population-based sample (Adult Asthma in Finland) of 1350 patients with adult-onset asthma (age range 31–93 years) from Finnish national registers. Severe asthma was defined as self-reported severe asthma and asthma symptoms causing much harm and regular impairment and ≥ 1 oral corticosteroid course/year or regular oral corticosteroids or waking up in the night due to asthma symptoms/wheezing ≥ a few times/month. Sixteen covariates covering several domains (personal characteristics, education, lifestyle, early-life factors, asthma characteristics and multiple morbidities) were selected based on the literature and were studied in association with severe asthma using logistic regressions. Results The study population included 100 (7.4%) individuals with severe asthma. In a univariate analysis, severe asthma was associated with male sex, age, a low education level, no professional training, ever smoking, ≥ 2 siblings, ≥ 1 chronic comorbidity and non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD) (p < 0.05), and trends for association (p < 0.2) were observed for severe childhood infection, the presence of chronic rhinosinusitis with nasal polyps, and being the 1st child. The 10 variables (being a 1st child was removed due to multicollinearity) were thus entered in a multivariate regression model, and severe asthma was significantly associated with male sex (OR [95% CI] = 1.96 [1.16–3.30]), ever smoking (1.98 [1.11–3.52]), chronic comorbidities (2.68 [1.35–5.31]), NERD (3.29 [1.75–6.19]), and ≥ 2 siblings (2.51 [1.17–5.41]). There was a dose–response effect of the total sum of these five factors on severe asthma (OR [95% CI] = 2.30 [1.81–2.93] for each one-unit increase in the score). Conclusions Male sex, smoking, NERD, comorbidities, and ≥ 2 siblings were independent risk factors for self-reported severe asthma. The effects of these factors seem to be cumulative; each additional risk factor gradually increases the risk of severe asthma.

scholarly journals A population-based exposure assessment of risk factors associated with gastrointestinal pathogens: a Campylobacter study

2012 ◽  
Vol 141 (5) ◽  
pp. 976-986 ◽  
Author(s):  
L. A. MacRITCHIE ◽  
C. J. HUNTER ◽  
N. J. C. STRACHAN
Keyword(s):  
Risk Factors ◽  
Population Density ◽  
Exposure Assessment ◽  
Disease Incidence ◽  
Univariate Analysis ◽  
Age Groups ◽  
Multivariate Logistic Regression Analysis ◽  
Environmental Water ◽  
Population Based ◽  
Elevated Exposure

SUMMARYA questionnaire survey was undertaken to determine the exposure of a study population to campylobacteriosis source risk factors (environmental, water, food) and results were stratified by age, population density and deprivation. Data were gathered using an exposure assessment carried out by telephone in the Grampian region of Scotland. Univariate analysis showed that children aged 5–14 years, living in low population density (0–44·4 persons/km2) and affluent areas had elevated exposure to environmental and water risk factors. Multivariate logistic regression analysis revealed that younger age groups and lower population density were significant indicators for most environmental risk factors. The results compared to reported disease incidence in Grampian showed that greater exposure to risk factors does not necessarily coincide with greater disease incidence for age groups, particularly for the 0–4 years age group. Further research is required to explain the relationship between exposure and disease incidence.

scholarly journals Pneumonia hospitalisation and case-fatality rates in older Australians with and without risk factors for pneumococcal disease: implications for vaccine policy

2019 ◽  
Vol 147 ◽  
Author(s):  
S. Dirmesropian ◽  
B. Liu ◽  
J. G. Wood ◽  
C. R. MacIntyre ◽  
P. McIntyre ◽  
...  
Keyword(s):  
Risk Factors ◽  
Older Adults ◽  
Risk Factor ◽  
Pneumococcal Disease ◽  
Large Population ◽  
Case Fatality ◽  
Population Based ◽  
Additional Risk Factor ◽  
Additional Risk ◽  
Non Invasive

AbstractCommunity-acquired pneumonia (CAP) results in substantial numbers of hospitalisations and deaths in older adults. There are known lifestyle and medical risk factors for pneumococcal disease but the magnitude of the additional risk is not well quantified in Australia. We used a large population-based prospective cohort study of older adults in the state of New South Wales (45 and Up Study) linked to cause-specific hospitalisations, disease notifications and death registrations from 2006 to 2015. We estimated the age-specific incidence of CAP hospitalisation (ICD-10 J12-18), invasive pneumococcal disease (IPD) notification and presumptive non-invasive pneumococcal CAP hospitalisation (J13 + J18.1, excluding IPD), comparing those with at least one risk factor to those with no risk factors. The hospitalised case-fatality rate (CFR) included deaths in a 30-day window after hospitalisation. Among 266 951 participants followed for 1 850 000 person-years there were 8747 first hospitalisations for CAP, 157 IPD notifications and 305 non-invasive pneumococcal CAP hospitalisations. In persons 65–84 years, 54.7% had at least one identified risk factor, increasing to 57.0% in those ⩾85 years. The incidence of CAP hospitalisation in those ⩾65 years with at least one risk factor was twofold higher than in those without risk factors, 1091/100 000 (95% confidence interval (CI) 1060–1122) compared with 522/100 000 (95% CI 501–545) and IPD in equivalent groups was almost threefold higher (18.40/100 000 (95% CI 14.61–22.87) vs. 6.82/100 000 (95% CI 4.56–9.79)). The CFR increased with age but there were limited difference by risk status, except in those aged 45 to 64 years. Adults ⩾65 years with at least one risk factor have much higher rates of CAP and IPD suggesting that additional risk factor-based vaccination strategies may be cost-effective.

scholarly journals Venous Thromboembolism and Its Risk Factors in Children with Acute Lymphoblastic Leukemia in Israel: A Population-Based Study

Cancers ◽  
2020 ◽  
Vol 12 (10) ◽  
pp. 2759
Author(s):  
Shlomit Barzilai-Birenboim ◽  
Ronit Nirel ◽  
Nira Arad-Cohen ◽  
Galia Avrahami ◽  
Miri Ben Harush ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Acute Lymphoblastic Leukemia ◽  
Lymphoblastic Leukemia ◽  
Univariate Analysis ◽  
Population Based ◽  
Population Based Study ◽  
Inherited Thrombophilia ◽  
Severe Hypertriglyceridemia

Venous thromboembolism (VTE) is a serious complication of acute lymphoblastic leukemia (ALL) therapy. The aim of this population-based study was to evaluate the rate, risk factors, and long-term sequelae of VTE in children treated for ALL. The cohort included 1191 children aged 1–19 years diagnosed with ALL between 2003–2018, prospectively enrolled in two consecutive protocols: ALL-IC BFM 2002 and AIEOP-BFM ALL 2009. VTEs occurred in 89 patients (7.5%). Long-term sequelae were uncommon. By univariate analysis, we identified four significant risk factors for VTEs: Severe hypertriglyceridemia (p = 0.005), inherited thrombophilia (p < 0.001), age >10 years (p = 0.015), and high-risk ALL group (p = 0.039). In addition, the incidence of VTE was significantly higher in patients enrolled in AIEOP-BFM ALL 2009 than in those enrolled in ALL-IC BFM 2002 (p = 0.001). Severe VTE occurred in 24 children (2%), all of whom had at least one risk factor. Elevated triglyceride levels at diagnosis did not predict hypertriglyceridemia during therapy. In a multivariate analysis of 388 children, severe hypertriglyceridemia and inherited thrombophilia were independent risk factors for VTE. Routine evaluation for these risk factors in children treated for ALL may help identify candidates for intervention.

scholarly journals Incidence and Risk Factors of Diabetic Foot Ulcer: A Population-Based Diabetic Foot Cohort (ADFC Study)—Two-Year Follow-Up Study

2018 ◽  
Vol 2018 ◽  
pp. 1-9 ◽  
Author(s):  
Leila Yazdanpanah ◽  
Hajieh Shahbazian ◽  
Iraj Nazari ◽  
Hamid Reza Arti ◽  
Fatemeh Ahmadi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Diabetic Foot ◽  
Univariate Analysis ◽  
Previous History ◽  
Foot Ulcer ◽  
Diabetic Foot Ulcer ◽  
Population Based ◽  
University Hospital ◽  
Foot Deformity ◽  
History Of

Aim/Introduction. This study was carried out to assess the incidence and risk factors of diabetic foot ulcer (DFU). Materials and Methods. In this prospective cohort study in a university hospital, all the participants were examined and followed up for new DFU as final outcome for two years. To analyze the data, the variables were first evaluated with a univariate analysis. Then variables with P value < 0.2 were tested with a multivariate analysis, using backward-elimination multiple logistic regression. Results. Among 605 patients, 39 cases had DFU, so we followed up the remaining 566 patients without any present or history of DFU. A two-year cumulative incidence of diabetic foot ulcer was 5.62% (95% CI 3.89–8.02). After analysis, previous history of DFU or amputation [OR = 9.65, 95% CI (2.13–43.78), P value = 0.003], insulin usage [OR = 5.78, 95% CI (2.37–14.07), P value < 0.01], gender [OR = 3.23, 95% CI (1.33–7.83), P value = 0.01], distal neuropathy [OR = 3.37, 95% CI (1.40–8.09), P value = 0.007], and foot deformity [OR = 3.02, 95% CI (1.10–8.29), P value = 0.032] had a statistically significant relationship with DFU incidence. Conclusion. Our data showed that the average annual DFU incidence is about 2.8%. Independent risk factors of DFU development were previous history of DFU or amputation, insulin consumption, gender, distal neuropathy, and foot deformity. These findings provide support for a multifactorial etiology for DFU.

Risk Stratification for Survival and Leukemic Transformation in Essential Thrombocythemia: A Single Institutional Study of 605 Patients.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3599-3599
Author(s):  
Naseema Gangat ◽  
Alexandra Wolanskyj ◽  
Rebecca F. McClure ◽  
Chin Y. Li ◽  
Susan M. Schwager ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Univariate Analysis ◽  
Low Risk ◽  
Prognostic Models ◽  
Intermediate Risk ◽  
Prognostic Variables ◽  
Leukemic Transformation ◽  
Male Sex

Abstract Background It is widely recognized that advanced age and prior thrombosis predict recurrent thrombosis in essential thrombocythemia (ET) and are used to risk-stratify patients. However, the paucity of large sample size and long-term follow-up has limited the development of similar prognostic models for survival and leukemic transformation (LT). Methods Data was abstracted from the medical records of a consecutive cohort of patients with WHO-defined ET seen at the Mayo Clinic. Cox proportional hazards was used to determine the impact of clinical and laboratory variables on survival and LT. Overall survival and leukemia-free survival was estimated by Kaplan-Meier plots. Results i. Patient characteristics and outcome The study cohort included 605 patients of which 399 (66%) were females (median age, 57 years; range 5–91). Median follow-up was 84 months (range; 0–424). During this period, 155 patients (26%) have died and LT was documented in 20 patients (3.3%) occurring at a median of 138 months (range; 23–422) from ET diagnosis. ii. Prognostic variables for overall survival Univariate analysis of parameters at diagnosis identified age ≥ 60 years, hemoglobin less than normal (defined as < 12 g/dL in females and < 13.5 g/dL in males), leukocyte count ≥ 15 x 109/L, tobacco use, diabetes mellitus, thrombosis, male sex, and the absence of microvascular symptoms as independent predictors of inferior survival. All of the above except the last two (i.e. male sex and the absence of microvascular symptoms) sustained their prognostic significance on multivariate analysis. Based on the first three prognostic variables: age, hemoglobin level, and leukocyte count, we constructed a prognostic model for survival: low-risk (none of the risk factors), intermediate-risk (1of 3 risk factors), and high-risk (≥ 2 risk factors). The respective median survivals were 278, 200, and 111 months (p<0.0001; Figure 1) iii. Prognostic variables for leukemic transformation On univariate analysis of parameters at ET diagnosis, LT was significantly associated with platelet count ≥ 1000 x 109/L, hemoglobin less than normal, and exposure to P-32. However, on multivariate analysis, only hemoglobin less than normal and platelet count ≥ 1000 x 109/L maintained independent prognostic value. Accordingly, we utilized these two variables, to construct a prognostic model for LT: low-risk (none of the risk factors), intermediate-risk (1 risk factor), and high-risk (both risk factors). Only 1 of the 239 patients (0.4%) in the low-risk group vs. 14 of the 289 (4.8%) in the intermediate-risk and 5 of the 77 (6.5%) in the high-risk group underwent LT (p=0.0009; Figure 2). Conclusion The current study provides clinician-friendly prognostic models for both survival and LT in ET. Figure 1 Figure 1. Figure 2 Figure 2.

Perinatal Risk Factors in Young Adult-Onset Type 1 and Type 2 Diabetes—A Population-Based Case-Control Study

2009 ◽  
Vol 64 (8) ◽  
pp. 511-512
Author(s):  
Niina Lammi ◽  
Paul A. Blomstedt ◽  
Elena Moltchanova ◽  
Johan G. Eriksson ◽  
Jaakko Tuomilehto ◽  
...  
Keyword(s):  
Risk Factors ◽  
Type 2 Diabetes ◽  
Case Control Study ◽  
Population Based ◽  
Case Control ◽  
Adult Onset ◽  
Perinatal Risk Factors ◽  
Control Study

scholarly journals The irreversible HCV-associated risk of gastric cancer following interferon-based therapy: a joint study of hospital-based cases and nationwide population-based cohorts

2019 ◽  
Vol 12 ◽  
pp. 175628481985573 ◽  
Author(s):  
Chun-Wei Chen ◽  
Jur-Shan Cheng ◽  
Tai-Di Chen ◽  
Puo-Hsien Le ◽  
Hsin-Ping Ku ◽  
...  
Keyword(s):  
Risk Factors ◽  
Gastric Cancer ◽  
Cancer Risk ◽  
Cancer Patients ◽  
Population Based ◽  
Hcv Infection ◽  
Research Database ◽  
Gastric Cancer Risk ◽  
Male Sex ◽  
Gastric Cancer Patients

Background: Hepatitis C virus (HCV) infection causes many extrahepatic malignancies; whether it increases gastric cancer risk and the risk reverses after anti-HCV therapy remain elusive. Method: A nationwide population-based cohort study of Taiwan National Health Insurance Research Database (TNHIRD) was conducted. In parallel, the risk factors and HCV-core-protein expressions were surveyed in gastric cancer patients from a tertiary care center. Results: From 2003 to 2012, of 11,712,928 patients, three 1:4:4, propensity-score-matched TNHIRD cohorts including HCV-treated (7545 patients with interferon-based therapy ⩾ 6 months), HCV-untreated ( n = 30,180), and HCV-uninfected cohorts ( n = 30,180) were enrolled. The cumulative incidences of gastric cancer [HCV-treated: 0.452%; 95% confidence interval (CI): 0.149–1.136%; HCV-untreated: 0.472%; 95% CI: 0.274–0.776%; HCV-uninfected: 0.146%; 95% CI 0.071–0.280%] were lowest in HCV-uninfected cohort ( p = 0.0028), but indifferent between treated and untreated cohorts. HCV infection [hazards ratio (HR): 2.364; 95% CI: 1.337–4.181], male sex (HR: 1.823; 95% CI: 1.09–3.05) and age ⩾ 49 years (HR: 3.066; 95% CI: 1.56–6.026) were associated with incident gastric cancers. Among 887 (males: 68.4%; mean age: 66.5 ± 12.9 years, 2008–2018) hospitalized gastric cancer patients, HCV Ab-positive rate was 7.8%. None of the investigated factors exhibited different rates between HCV Ab-positive and Ab-negative patients. No HCV-core-positive cells were demonstrated in gastric cancer tissues. Conclusions: HCV infection, male sex and old age were risk factors for gastric cancer development. HCV-associated gastric cancer risk might be neither reversed by interferon-based therapy, nor associated with in situ HCV-core-related carcinogenesis.

scholarly journals Risk factors for recurrence of radically resected mucinous colorectal adenocarcinoma

2021 ◽  
Author(s):  
Qing Huang ◽  
Min-hong Zou ◽  
Jian-chang Wei ◽  
Ye Jiang ◽  
Zhuan-peng Chen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Local Recurrence ◽  
Blood Loss ◽  
Distant Metastasis ◽  
Mucinous Adenocarcinoma ◽  
Colorectal Adenocarcinoma ◽  
Univariate Analysis ◽  
Operative Blood Loss ◽  
T4 Stage ◽  
Male Sex

Abstract Background Local recurrence and distant metastasis are major challenges to overcome in order to improve the survival of patients with colorectal cancer (CRC) after surgery. Mucinous adenocarcinoma (MA) is a subtype of CRC associated with a higher incidence of local extension and worse survival compared to non-mucinous adenocarcinoma, but few studies have investigated predictors for poor clinical outcome of MA. Therefore, we aimed to elucidate the predictors for local recurrence and remote metastasis of MA after surgery.Methods This study retrospectively analyzed 162 patients with mucinous colorectal adenocarcinoma (MAC) after radical resection. Analysis variables included demographics, clinical indicators, pathologic stage, surgical procedure, adjuvant therapy, and recurrence. Univariate and multivariate analyses were performed to investigate the risk factors for local and distant tumor relapse.Results A total of 162 patients (86 male) with a mean age of 58.26 years were included; 70.37% of patients had colonic tumors, and 29.63% had rectal tumors. The 5-year disease-free survival (DFS) rates for these patients were as follows: 100% for TNM stage I, 71.2% for stage II, and 47.8% for stage III. Five-year DFS rates of MAC, colonic and rectal MA were 62.0%, 65.8%, and 51.7%, respectively. Local recurrence occurred in 38 patients (23.5%) and distant metastasis in 33 patients (20.4%). In univariate analysis, predictors for local recurrence of MAC were intra-operative blood loss (p=0.004, OR=1.005), intra-operative transfusion (p=0.002, OR=5.179), and N2 stage (p=0.000, OR=4.643), and predictors for distant metastasis were male sex (p=0.035, OR=2.410), CA199 (p=0.011, OR=1.004), CEA (p=0.020, OR=1.010), intra-operative blood loss (p=0.022, OR=1.003), T4 stage (p=0.007, OR=4.125), and N2 stage (p=0.018, OR=3.4). In multivariate analysis, predictors for local recurrence of colorectal MA were intra-operative transfusion (p=0.04, OR=4.175) and N2 stage (p=0.000, OR=5.291), and predictors for distant metastasis were male sex (p=0.049, OR=2.410), CA199 (p=0.02, OR=1.003), and T4 stage (p=0.007, OR=4.006).Conclusions Intra-operative transfusion and N2 stage were significant predictors for local recurrence. Male sex, CA199, and T4 stage were significant predictors for distant metastasis. Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to treatment and follow-up of mucinous colorectal adenocarcinoma.

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