Dogs undergoing surgical excision of mast cell tumors are not at increased risk of incisional complications

Abstract OBJECTIVE To retrospectively compare the incidence of incisional complications in dogs undergoing surgery for mast cell tumors (MCTs) and soft tissue sarcomas (STSs). ANIMALS 218 dogs. PROCEDURES Dogs that underwent excision of ≥ 1 MCT, STS, or both from January 2014 to July 2019 and had ≥ 30 days postoperative follow-up were included. Signalment; anesthesia and surgery time; administration of propofol; tumor type, grade, location, and size; intended surgical margins; histologic margins; perioperative radiation, chemotherapy, and corticosteroid and antihistamine (MCT group) treatments; and incisional complications (classified as major or minor) were recorded. Follow-up information was obtained from owners or primary care veterinarians, if needed. Incidence and severity of incisional complications were compared between the MCT and STS groups. Potential risk factors were assessed for associations with incisional complications by simple and multiple logistic regression analysis. RESULTS The 218 dogs underwent surgery for 293 tumors (209 MCTs and 84 STSs). Complication rates did not differ between MCT (28/209 [13%]) and STS (12/84 [14%]) groups. For the MCT group, incomplete margins (vs complete or narrow), increasing Patnaik tumor grade, and postoperative chemotherapy (yes vs no) were associated with increased odds of incisional complications on simple regression. On multiple logistic regression, postoperative chemotherapy was associated with increased odds of incisional complications for the MCT group and both groups combined. CONCLUSIONS AND CLINICAL RELEVANCE On the basis of the results, we suggest that chemotherapy be used with caution ≤ 30 days after surgery for dogs with MCTs. Corticosteroid administration was not associated with incisional complications for the MCT group in this study.

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145 Outcomes of Unstable Distal Radius Fractures – A Meta-Analysis of Bridging External Fixation Versus Volar Plating

British Journal of Surgery ◽

10.1093/bjs/znab135.012 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

J Mulrain ◽

K Joshi ◽

F Doyle ◽

A Abdulkarim

Keyword(s):

External Fixation ◽

Distal Radius ◽

Plate Fixation ◽

Meta Analysis ◽

Distal Radius Fractures ◽

Complication Rates ◽

Volar Plating ◽

Radius Fractures ◽

Increased Risk

Abstract Introduction Distal radius fractures are common and trends for fixation have changed with increased use of volar locking plates in recent time. A meta-analysis will summarise the best evidence for treatment. Method A systematic review was conducted using PRISMA methodology to identify studies that reported clinical and/or radiological outcomes in patients with AO type C distal radius fractures when treated with external fixation versus ORIF. Results 10 randomised trials were included in this review, reporting on 967 patients. Clinical outcomes are in favour of volar plating at 3 months post-operation, but no difference between the two groups is seen at 6 or 12 months. Analysis of complication rates shows a minute increase in risk-ratio for volar plating versus external fixation. Subgroup analysis showed significantly higher re-operations after plate fixation and significantly higher infection after external fixation. Conclusions Internal fixation of complex distal radius fractures confers an improved clinical outcome at early follow up only and a minimally increased risk of complications. The improved grip strength with volar plating is only superior at early follow up and no long-term superiority is seen with either intervention. The type of surgery in this injury type therefore remains at the surgeon’s consideration on a case-by-case basis.

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When can total knee arthroplasty be safely performed following prior arthroscopy?

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03859-1 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Jin-Ning Ma ◽

Xiao-Lin Li ◽

Pan Liang ◽

Sheng-Li Yu

Keyword(s):

Total Knee Arthroplasty ◽

Postoperative Complications ◽

Knee Arthroplasty ◽

Acl Injury ◽

Control Group ◽

Optimal Timing ◽

Complication Rates ◽

Increased Risk ◽

Total Knee

Abstract Background The optimal timing to perform a total knee arthroplasty (TKA) after knee arthroscopy (KA) was controversial in the literature. We aimed to 1) explore the effect of prior KA on the subsequent TKA; 2) identify who were not suitable for TKA in patients with prior KA, and 3) determine the timing of TKA following prior KA. Methods We retrospectively reviewed 87 TKAs with prior KA and 174 controls using propensity score matching in our institution. The minimum follow-up was 2 years. Postoperative clinical outcomes were compared between groups. Kaplan-Meier curves were created with reoperation as an endpoint. Multivariate Cox proportional hazards regressions were performed to identify risk factors of severe complications in the KA group. The two-piecewise linear regression analysis was performed to examine the optimal timing of TKA following prior KA. Results The all-cause reoperation, revision, and complication rates of the KA group were significantly higher than those of the control group (p < 0.05). The survivorship of the KA group and control group was 92.0 and 99.4% at the 2-year follow-up (p = 0.002), respectively. Male (Hazards ratio [HR] = 3.2) and prior KA for anterior cruciate ligament (ACL) injury (HR = 4.4) were associated with postoperative complications in the KA group. There was a non-linear relationship between time from prior KA to TKA and postoperative complications with the turning point at 9.4 months. Conclusion Prior KA is associated with worse outcomes following subsequent TKA, especially male patients and those with prior KA for ACL injury. There is an increased risk of postoperative complications when TKA is performed within nine months of KA. Surgeons should keep these findings in mind when treating patients who are scheduled to undergo TKA with prior KA.

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Risk factors and outcomes of postoperative emergency response team activation: a matched case-control study

Critical Care and Resuscitation ◽

10.51893/2020.1.oa1 ◽

2020 ◽

Vol 22 (1) ◽

pp. 6-14

Author(s):

Matthew I Hardman ◽

◽

S Chandralekha Kruthiventi ◽

Michelle R Schmugge ◽

Alexandre N Cavalcante ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Postoperative Complications ◽

Emergency Response ◽

Case Control Study ◽

Case Control ◽

Multiple Logistic Regression ◽

Increased Risk ◽

Response Team ◽

Control Study

OBJECTIVE: To determine patient and perioperative characteristics associated with unexpected postoperative clinical deterioration as determined for the need of a postoperative emergency response team (ERT) activation. DESIGN: Retrospective case–control study. SETTING: Tertiary academic hospital. PARTICIPANTS: Patients who underwent general anaesthesia discharged to regular wards between 1 January 2013 and 31 December 2015 and required ERT activation within 48 postoperative hours. Controls were matched based on age, sex and procedure. MAIN OUTCOME MEASURES: Baseline patient and perioperative characteristics were abstracted to develop a multiple logistic regression model to assess for potential associations for increased risk for postoperative ERT. RESULTS: Among 105 345 patients, 797 had ERT calls, with a rate of 7.6 (95% CI, 7.1–8.1) calls per 1000 anaesthetics (0.76%). Multiple logistic regression analysis showed the following risk factors for postoperative ERT: cardiovascular disease (odds ratio [OR], 1.61; 95% CI, 1.18–2.18), neurological disease (OR, 1.57; 95% CI, 1.11–2.22), preoperative gabapentin (OR, 1.60; 95% CI, 1.17–2.20), longer surgical duration (OR, 1.06; 95% CI, 1.02–1.11, per 30 min), emergency procedure (OR, 1.54; 95% CI, 1.09–2.18), and intraoperative use of colloids (OR, 1.50; 95% CI, 1.17–1.92). Compared with control participants, ERT patients had a longer hospital stay, a higher rate of admissions to critical care (55.5%), increased postoperative complications, and a higher 30-day mortality rate (OR, 3.36; 95% CI, 1.73–6.54). CONCLUSION: We identified several patient and procedural characteristics associated with increased likelihood of postoperative ERT activation. ERT intervention is a marker for increased rates of postoperative complications and death.

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717. Cumulative Incidence of Asthma/Wheezing Among Neonates/Infants/Toddlers Clinically Diagnosed with Respiratory Syncytial Virus Infection in the United States: A Retrospective Database Analysis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.724 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S257-S258

Author(s):

Veronique Wyffels ◽

Maartje Smulders ◽

Sandra Gavart ◽

Debasish Mazumder ◽

Rohit Tyagi ◽

...

Keyword(s):

Logistic Regression ◽

Respiratory Syncytial Virus ◽

Cumulative Incidence ◽

The United States ◽

Term Infants ◽

Increased Risk ◽

Study Results ◽

Syncytial Virus ◽

Time Required

Abstract Background The role of respiratory syncytial virus (RSV) in the development of asthma/wheezing (AW) has been evaluated in several studies, mostly among pre-term infants or among infants after developing severe RSV-related disease. We describe the cumulative incidence (CI) of AW among hospitalized/ambulatory neonates/infants/toddlers after RSV/bronchiolitis infection diagnosis, in a large clinical database. Methods Using deidentified Optum Integrated commercial claims and electronic medical records, we identified patients (0–<3 years old) with a first clinical diagnosis of RSV/bronchiolitis infection from 01 January 2008–31 March 2016. Patients with a diagnosis of asthma/wheezing ≤30 days after first RSV/bronchiolitis diagnosis were excluded. Three cohorts were created with 1/3/5 years of follow-up time required, respectively. Patients were grouped by specific high-risk factors (HRF+/−), including pre-term births and predefined pre-existing disease. Descriptive statistics are reported, with comparisons made by logistic regression analyses. Results 9,811/4,524/1,788 patients with RSV/bronchiolitis infection and HRF− were included in the 1/3/5-years follow-up cohorts. 14.9%/28.2%/36.3% had AW events by the end of follow-up in the three cohorts. 6.5%/6.9%/5.8% were hospitalized for RSV/bronchiolitis. 3,030/1,378/552 patients with RSV/bronchiolitis infection and HRF+ were included in the 1/3/5-years follow-up cohorts. 18.1%/32.9%/37.9% had AW events by the end of follow-up in the three cohorts. 11.4%/11.1%/11.6% were hospitalized for RSV/bronchiolitis. The CI rates of AW in the 1/3/5-year HRF+/− cohorts, stratified by hospitalized for RSV/bronchiolitis Y/N, are shown in Figure 1. Logistic regression confirmed that hospitalization for RSV/bronchiolitis was associated with an increased (P < 0.05) likelihood of AW, for HRF+ and HRF− patients at each follow-up year. Conclusion Thirty-eight percent of RSV/bronchiolitis infants/neonates/toddlers HRF+, and 36% among infants/neonates/toddlers HRF−, developed AW in the 5 years after first RSV/bronchiolitis diagnosis. RSV/bronchiolitis hospitalization was associated with a significantly increased risk of AW development in 1/3/5 years of follow-up; confirming previous observational study results. Disclosures V. Wyffels, Janssen: Employee, Salary. M. Smulders, SmaertAnalyst: Consultant, Consulting fee. S. Gavart, Janssen: Employee, Salary. D. Mazumder, SmartAnalyst: Consultant, Consulting fee. R. Tyagi, SmartAnalyst: Consultant, Consulting fee. N. Gupta, SmartAnalyst: Consultant, Consulting fee. R. Fleischhackl, Janssen: Employee, Salary.

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Does Flipping the Tubercle for Improved Cartilage Repair Exposure Increase the Risk for Arthrofibrosis?

Cartilage ◽

10.1177/1947603520968209 ◽

2020 ◽

pp. 194760352096820

Author(s):

Gergo Merkely ◽

Jakob Ackermann ◽

Emily Sheehy ◽

Andreas H. Gomoll

Keyword(s):

Logistic Regression ◽

Cartilage Repair ◽

Regression Models ◽

Case Control Study ◽

Level Of Evidence ◽

Logistic Regression Models ◽

Increased Risk ◽

Repair Procedure ◽

Control Study

Objective We sought to determine whether rates of postoperative arthrofibrosis following tibial tuberosity osteotomy (TTO) with complete mobilization of the fragment (TTO-HD) are comparable to TTOs where the hinge remained intact (TTO-HI). Design Patients who underwent TTO with concomitant cartilage repair procedure between January 2007 and May 2017, with at least 2 years of follow-up were included in this study. Postoperative reinterventions following TTO-HD and TTO-HI were assessed and multivariant logistic regression models were used to identify whether postoperative reinterventions can be attributed to either technique when controlled for defect size or defect number. Results A total of 127 patients (TTO-HD, n = 80; TTO-HI, n = 47) were included in this study. Significantly more patients in the TTO-HD group (31.2%) developed postoperative arthrofibrosis compared with TTO-HI (6.4%; P < 0.05). Multivariant logistic regression revealed that TTO-HD is an independent risk factor for predicting postoperative arthrofibrosis (OR 6.5, CI = 1.7-24.2, P < 0.05). Conclusion Patients who underwent TTO with distal hinge detachment and a proximally flipped tubercle for better exposure during concomitant cartilage repair were at a significantly higher risk of postoperative arthrofibrosis than patients with similar size and number of defects treated without mobilization of the tubercle. While certain procedures can benefit from larger exposure, surgeons should be aware of the increased risk of postoperative arthrofibrosis. Level of Evidence Level III, case-control study.

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Temporal and farm-management-associated variation in faecal-pat prevalence ofCampylobacter fetusin sheep and cattle

Epidemiology and Infection ◽

10.1017/s0950268813002379 ◽

2013 ◽

Vol 142 (6) ◽

pp. 1196-1204 ◽

Cited By ~ 2

Author(s):

J. S. DUNCAN ◽

A. J. H. LEATHERBARROW ◽

N. P. FRENCH ◽

D. H. GROVE-WHITE

Keyword(s):

Logistic Regression ◽

Farm Management ◽

Multiple Logistic Regression ◽

Seasonal Periodicity ◽

Culture Techniques ◽

Regression Modelling ◽

Increased Risk ◽

Geographical Regions ◽

Logistic Regression Modelling ◽

Cattle And Sheep

SUMMARYThe faecal-pat prevalence (as estimated by culture) ofCampylobacter fetusfrom cattle and sheep on 19 farms in rural Lancashire was investigated using standardCampylobacterculture techniques and PCR during a 2-year longitudinal study.C. fetuswas isolated from 9·48% [95% confidence interval (CI) 8·48–10·48] of cattle faecal pats and 7·29% (95% CI 6·21–9·62) of sheep faecal pats. There was evidence of significant differences in shedding prevalence between geographical regions; cows in geographical zone 3 had an increased risk of sheddingC. fetuscompared to cows in geographical zones 1 and 2 (OR 6·64, 95% CI 1·67–26·5,P = 0·007), as did cows at pasture (OR 1·66, 95% CI 1·01–2·73,P = 0·046) compared to when housed. Multiple logistic regression modelling demonstrated underlying seasonal periodicity in both species.

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Operative Management of Unstable Radial Head Fractures in a Young Active Population

Hand ◽

10.1177/1558944717715136 ◽

2017 ◽

Vol 13 (4) ◽

pp. 473-480 ◽

Cited By ~ 4

Author(s):

Nicholas Kusnezov ◽

Emmanuel Eisenstein ◽

John C. Dunn ◽

Austin Fares ◽

Justin Mitchell ◽

...

Keyword(s):

Upper Extremity ◽

Radial Head ◽

Operative Management ◽

Elbow Fracture ◽

Complication Rates ◽

Radial Head Fractures ◽

Radial Head Arthroplasty ◽

Increased Risk ◽

Ligamentous Repair

Background: Radial head and neck fractures are the most common elbow fracture in the general adult population; however, the optimal treatment for radial head fractures remains a topic of ongoing clinical controversy. The purpose of this study was to determine the rate of return to function, complications, and reoperation following operative management of unstable radial head fractures in a young, active patient population with intense upper extremity demands. Methods: A military health care database was queried for all US military servicemembers undergoing open reduction with internal fixation (ORIF; Current Procedural Terminology [CPT] code: 24665) and radial head arthroplasty (RHA; CPT code: 24666) between 2010 and 2015. All patients with minimum 2-year follow-up were included. Univariate and chi-square analyses were performed to evaluate the association between potential risk factors and the primary outcome measures. Results: A total of 67 ORIF (n = 69 elbows) and 10 RHA patients were included. The average age was 31 ± 8.0 years. At mean follow-up of 3.5 ± 1.1 years, 90% of patients overall were able to return to active military service, 96% of which with unrestricted upper extremity function. Nearly one-third (31.2%) of patients developed at least 1 postoperative complication. RHA has higher overall complication rates (70% vs 48%) when compared with ORIF, but this finding did not reach statistical significance ( P = .073). However, RHA had significantly higher rates of implant failure (20% vs 2.9%, P = .0498). Seventeen (21%) individuals required reoperation, 5 of which (6.3%) were revision procedures. Dislocation, coronoid fracture, and concomitant ligamentous repair portended a significantly increased risk of sustaining 1 or more complications ( P < .05), while dislocation and requirement for ligamentous repair independently predicted revision surgery ( P < .05). Conclusions: Arthroplasty and ORIF are both viable options for treating unstable radial head fractures in a young, athletic population, offering comparable return to function despite increased complications with RHA.

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An analysis of tumor-related potential spinal column instability (Spine Instability Neoplastic Scores 7–12) eventually requiring surgery with a 1-year follow-up

Neurosurgical FOCUS ◽

10.3171/2021.2.focus201098 ◽

2021 ◽

Vol 50 (5) ◽

pp. E6

Author(s):

Enrique Vargas ◽

Dennis T. Lockney ◽

Praveen V. Mummaneni ◽

Alexander F. Haddad ◽

Joshua Rivera ◽

...

Keyword(s):

Logistic Regression ◽

San Francisco ◽

Surgical Intervention ◽

Nonoperative Management ◽

Multivariable Analysis ◽

Spinal Instability ◽

Karnofsky Performance Scale ◽

Surgery Group ◽

Increased Risk

OBJECTIVE Within the Spine Instability Neoplastic Score (SINS) classification, tumor-related potential spinal instability (SINS 7–12) may not have a clear treatment approach. The authors aimed to examine the proportion of patients in this indeterminate zone who later required surgical stabilization after initial nonoperative management. By studying this patient population, they sought to determine if a clear SINS cutoff existed whereby the spine is potentially unstable due to a lesion and would be more likely to require stabilization. METHODS Records from patients treated at the University of California, San Francisco, for metastatic spine disease from 2005 to 2019 were retrospectively reviewed. Seventy-five patients with tumor-related potential spinal instability (SINS 7–12) who were initially treated nonoperatively were included. All patients had at least a 1-year follow-up with complete medical records. A univariate chi-square test and Student t-test were used to compare categorical and continuous outcomes, respectively, between patients who ultimately underwent surgery and those who did not. A backward likelihood multivariate binary logistic regression model was used to investigate the relationship between clinical characteristics and surgical intervention. Recursive partitioning analysis (RPA) and single-variable logistic regression were performed as a function of SINS. RESULTS Seventy-five patients with a total of 292 spinal metastatic sites were included in this study; 26 (34.7%) patients underwent surgical intervention, and 49 (65.3%) did not. There was no difference in age, sex, comorbidities, or lesion location between the groups. However, there were more patients with a SINS of 12 in the surgery group (55.2%) than in the no surgery group (44.8%) (p = 0.003). On multivariate analysis, SINS > 11 (OR 8.09, CI 1.96–33.4, p = 0.004) and Karnofsky Performance Scale (KPS) score < 60 (OR 0.94, CI 0.89–0.98, p = 0.008) were associated with an increased risk of surgery. KPS score was not correlated with SINS (p = 0.4). RPA by each spinal lesion identified an optimal cutoff value of SINS > 10, which were associated with an increased risk of surgical intervention. Patients with a surgical intervention had a higher incidence of complications on multivariable analysis (OR 2.96, CI 1.01–8.71, p = 0.048). CONCLUSIONS Patients with a mean SINS of 11 or greater may be at increased risk of mechanical instability requiring surgery after initial nonoperative management. RPA showed that patients with a KPS score of 60 or lower and a SINS of greater than 10 had increased surgery rates.

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Bipolar Transurethral Enucleation of the Prostate: Is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia?

PLoS ONE ◽

10.1371/journal.pone.0253083 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0253083

Author(s):

Carolina Bebi ◽

Matteo Turetti ◽

Elena Lievore ◽

Francesco Ripa ◽

Lorenzo Rocchini ◽

...

Keyword(s):

Logistic Regression ◽

Postoperative Complications ◽

Prostate Volume ◽

Symptom Relief ◽

Urinary Flow ◽

Complication Rates ◽

Symptomatic Benign Prostatic Hyperplasia ◽

Sexual Symptoms ◽

First Choice

Background Bipolar Transurethral Enucleation of the Prostate (B-TUEP) is recommended as a first-choice treatment for benign prostatic obstruction in prostates >80 ml. Differently, B-TUEP is only considered as an alternative option after TURP for smaller prostates (30–80 ml). The aim of our study is to assess the relation between prostate size and surgical outcomes after B-TUEP. Methods We performed a retrospective analysis of data collected from 172 patients submitted to B-TUEP. Patients were segregated according to tertiles of prostate volume (PV) (≤60 ml, 61–110 ml, >110 ml). For each group we evaluated enucleation efficacy (enucleated weight/enucleation time), complication rates, urinary and sexual function parameters. Functional and sexual parameters were compared between groups at baseline, 1 and 3 months follow up. Descriptive statistics and linear and logistic regression models tested the association between PV and postoperative complications/outcomes. Results Operative time and weight of enucleated adenomas increased along with prostate volumes (all p≤0.01). Enucleation efficacy was higher in men with PV >110 ml compared to other groups (p≤0.001). Length of hospital stay, catheterization time and rates of postoperative complications, such as transfusion and clot evacuation rates and bladder neck/urethral strictures, were comparable between groups. Urinary symptoms improved at 1-and 3-months in each group as compared to baseline evaluation (all p<0.01) but they did not differ according to PV. In each group maximum urinary flow and post-void residual volume significantly improved at 3 months compared to baseline (all p≤0.01), without differences according to PV. Sexual symptoms were similar between groups at each follow up assessment. At multivariable linear and logistic regression analysis, prostate volume was not associated with postoperative functional outcomes and complications. Conversely, patient’s comorbid status and antiplatelet/anticoagulation use were independently associated with postoperative complications. Conclusion According to our findings, B-TUEP should be considered a “size independent procedure” as it can provide symptom relief in men with prostates of all sizes with the same efficacy and safety profile.

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The Importance of Stroke as a Risk Factor of Cognitive Decline in Community Dwelling Older and Oldest peoples : The SONIC Study

10.21203/rs.2.15994/v3 ◽

2020 ◽

Author(s):

Werayuth Srithum ◽

Mai Kabayama ◽

Yasuyuki Gondo ◽

Yukie Masui ◽

Yuya Akagi ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Risk Factor ◽

Protective Factors ◽

Cognitive Decline ◽

Educational Level ◽

Community Dwelling ◽

Multiple Logistic Regression ◽

History Of

Abstract Background: Cognitive impairment is a major health concern among older and oldest people.Moreover, stroke is a relevant contributor for cognitive decline and development of dementia. The study of cognitive decline focused on stroke as the important risk factor by recruiting older and oldest is still lagging behind. Therefore, the aim of this study was to investigate the importance of stroke as a risk factor of cognitive decline during three years in community dwelling older and oldest people. Methods: This study was longitudinal study with a 3-year follow-up in Japan. The participants were 1,333community dwelling older and oldest people (70 years old = 675, 80 years old = 589, and 90 years old = 69). Data collected included basic data (age, sex, and history of stroke), vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, and current smoking), and social factors (educational level, frequency of going outdoors, long-term care (LTC) service used, and residential area). The Japanese version of the Montreal Cognitive Assessment (MoCA-J) was decline of ≥ 2 points was defined as cognitive decline. Multiple logistic regression analysis was used to investigate the association between stroke and other risk factors with cognitive decline during a 3-year follow-up. Results: The fit of the hypothesized model by multiple logistic regression showed that a history of stroke, advanced age, and greater MoCA-J score at the baseline were important risk factors, while the presence of dyslipidemia and a higher educational level were protective factors that were significantly correlated with cognitive decline during the 3-year follow-up. Conclusions: The cognitive decline after the 3-year follow-up was influenced by the history of stroke and advanced age, while greater MoCA-J score at the baseline was positively associated with subsequent 3 years cognitive decline. The protective factors were the presence of dyslipidemia and a higher educational level. Therefore, these factors are considered important and should be taken into consideration when searching for creative solutions to prevent cognitive decline after stroke in community dwelling older and oldest people.

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