Risk Factors for Hypothalamic Obesity in Patients With Adult-Onset Craniopharyngioma: A Consecutive Series of 120 Cases

ContextHypothalamic obesity (HO) is a severe complication following craniopharyngioma, but studies regarding the sequelae in adult-onset patients with craniopharyngioma are sparse.ObjectiveThe objective of the study was to describe weight changes after surgical treatment in adult-onset craniopharyngioma patients and to analyze risk factors for postoperative weight gain and HO.Subjects and MethodA retrospective analysis was conducted of 120 adult-onset patients who underwent surgery for craniopharyngioma and follow-up at the institution of the authors between January 2018 and September 2020. Clinical characteristics, anthropometric data, image features, treatment modalities, and endocrine indices were collected. Multivariable logistic regression analysis was used to identify independent risk factors for postoperative weight gain and HO.ResultsForty-nine (40.8%) patients had clinically meaningful weight gain (≥5%) in a median follow-up time of 12.0 months (range 1.0–41.0 months) after surgery. The mean postoperative weight gain in this subgroup was 17.59 ± 12.28 (%). Weight gain continued in the first year following surgery. Patients with lower preoperative BMI [OR 0.78, 95% CI (0.67–0.90), P = 0.001] and the adamantinomatous subtype [OR 3.46, 95% CI (1.02–11.76), P = 0.047] were more likely to experience postoperative weight gain ≥5%. The prevalence of HO was 19.2% preoperatively and increased to 29.2% at last follow-up postoperatively. Only preoperative BMI [OR 2.51, 95% CI (1.64–3.85), P < 0.001] was identified as an independent risk factor for postoperative HO.ConclusionsHO is a common complication in patients with adult-onset craniopharyngioma. Patients with higher preoperative BMI had a greater risk for developing HO postoperatively.

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Weight Gain After Thyroidectomy: A Systematic Review and Meta-Analysis

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa754 ◽

2020 ◽

Vol 106 (1) ◽

pp. 282-291 ◽

Cited By ~ 1

Author(s):

Christine N Huynh ◽

Janina V Pearce ◽

Le Kang ◽

Francesco S Celi

Keyword(s):

Systematic Review ◽

Weight Gain ◽

Weight Change ◽

Meta Analysis ◽

Random Effect ◽

Treatment Modalities ◽

Weight Changes ◽

Indication For Surgery ◽

Subgroup Analyses

Abstract Context Weight gain is a major driver of dissatisfaction and decreased quality of life in patients with hypothyroidism. Data on the changes in body weight following thyroidectomy are conflicting. Objective To perform a systematic review of the literature and a meta-analysis of weight changes following total thyroidectomy. Data Sources Literature search on PubMed. Study Selection Studies in English published between September 1998 and May 2018 reporting post-thyroidectomy weight changes. Data extraction Data were reviewed and compared by 3 investigators; discrepancies were resolved by consensus. Meta-analyses were performed using fixed and random effect models. Univariable and multivariable meta-regression models for weight change were implemented against study follow-up, gender, and age. Exploratory subgroup analyses were performed for indication for surgery. Data Synthesis Seventeen studies (3164 patients) with 23.8 ± 23.6 months follow-up were included. Severe heterogeneity across studies was observed. Using a random effect model, the estimated overall weight change was a gain of 2.13 kg, 95% confidence interval (CI; 0.95, 3.30). Age was negatively associated with weight change (β = -0.238, P < 0.001). In subgroup analyses, weight gain was more evident in patients undergoing thyroidectomy for hyperthyroidism: 5.19 kg, 95% CI (3.21, 7.17) vs goiter or malignancy 1.55 kg, 95% CI (0.82, 2.27) and 1.30 kg, 95% CI (0.45, 2.15), respectively. Conclusions Patients undergoing thyroidectomy experience possible mild weight gain, particularly younger individuals and those with hyperthyroidism as the indication for surgery. Prospective studies directed to assess the pathophysiology of weight gain post-thyroidectomy, and to test novel treatment modalities, are needed to better characterize post-thyroidectomy weight changes.

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High Prevalence of Weight Gain in Childhood Brain Tumor Survivors and Its Association With Hypothalamic-Pituitary Dysfunction

Journal of Clinical Oncology ◽

10.1200/jco.20.01765 ◽

2021 ◽

pp. JCO.20.01765

Author(s):

Jiska van Schaik ◽

Ichelle M. A. A. van Roessel ◽

Netteke A. Y. N. Schouten-van Meeteren ◽

Laura van Iersel ◽

Sarah C. Clement ◽

...

Keyword(s):

Risk Factors ◽

Brain Tumor ◽

Weight Gain ◽

Standard Deviation Score ◽

Cardiometabolic Health ◽

Low Grade ◽

Childhood Brain Tumor ◽

Significant Weight Gain ◽

Overweight Or Obesity

PURPOSE Childhood brain tumor survivors (CBTS) are at risk for developing obesity, which negatively influences cardiometabolic health. The prevalence of obesity in CBTS may have been overestimated in previous cohorts because of inclusion of children with craniopharyngioma. On the contrary, the degree of weight gain may have been underestimated because of exclusion of CBTS who experienced weight gain, but were neither overweight nor obese. Weight gain may be an indicator of underlying hypothalamic-pituitary (HP) dysfunction. We aimed to study prevalence of and risk factors for significant weight gain, overweight, or obesity, and its association with HP dysfunction in a national cohort of noncraniopharyngioma and nonpituitary CBTS. METHODS Prevalence of and risk factors for significant weight gain (body mass index [BMI] change ≥ +2.0 standard deviation score [SDS]), overweight, or obesity at follow-up, and its association with HP dysfunction were studied in a nationwide cohort of CBTS, diagnosed in a 10-year period (2002-2012), excluding all craniopharyngioma and pituitary tumors. RESULTS Of 661 CBTS, with a median age at follow-up of 7.3 years, 33.1% had significant weight gain, overweight, or obesity. Of the CBTS between 4 and 20 years of age, 28.7% were overweight or obese, compared with 13.2% of the general population between 4 and 20 years of age. BMI SDS at diagnosis, diagnosis of low-grade glioma, diabetes insipidus, and central precocious puberty were associated with weight gain, overweight, or obesity. The prevalence of HP dysfunction was higher in overweight and obese CTBS compared with normal-weight CBTS. CONCLUSION Overweight, obesity, and significant weight gain are prevalent in CBTS. An increase in BMI during follow-up may be a reflection of HP dysfunction, necessitating more intense endocrine surveillance.

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Syncope in a Working-Age Population: Recurrence Risk and Related Risk Factors

Journal of Clinical Medicine ◽

10.3390/jcm8020150 ◽

2019 ◽

Vol 8 (2) ◽

pp. 150 ◽

Cited By ~ 4

Author(s):

Franca Barbic ◽

Franca Dipaola ◽

Giovanni Casazza ◽

Marta Borella ◽

Maura Minonzio ◽

...

Keyword(s):

Diabetes Mellitus ◽

Risk Factors ◽

Recurrence Risk ◽

Multivariable Logistic Regression Analysis ◽

Related Risk ◽

Working Age ◽

Working Age Population ◽

The Individual ◽

Syncope Episode

Syncope in a worker undertaking risky tasks may result in fatalities for the individual or for third parties. We aimed at assessing the rate of syncope recurrence and the risk factors underlying the likelihood of syncope relapse in a working-age population. A prospective cohort of all patients aged 18–65 years consecutively admitted to the Emergency Department for syncope was enrolled. Risk of syncope relapse was assessed at a six-month, 1-year, and 5-year follow-up. Predictors of syncope recurrence have been evaluated at six months and 1 year from the syncope index by a multivariable logistic regression analysis. 348 patients were enrolled. Risk of syncope relapse was 9.2% at 6 months, 11.8% at 1 year, and 23.4% at 5 years. At 6-month follow-up, predictor of syncope recurrence was ≥3 prior lifetime syncope episodes. At 1-year, ≥3 prior lifetime syncope episodes, diabetes mellitus, and anaemia were risk factors for syncope relapse. There was an exceeding risk of recurrence in the first 6 months and a reduced risk of 3.5% per year after the first year. Anaemia, diabetes mellitus, and prior lifetime syncope burden are of importance when giving advice about the resumption of “high risk” jobs following a syncope episode.

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Weight change over two years in people prescribed olanzapine, quetiapine and risperidone in UK primary care: Cohort study in THIN, a UK primary care database

Journal of Psychopharmacology ◽

10.1177/0269881118780011 ◽

2018 ◽

Vol 32 (10) ◽

pp. 1098-1103 ◽

Cited By ~ 3

Author(s):

David PJ Osborn ◽

Irene Petersen ◽

Nick Beckley ◽

Kate Walters ◽

Irwin Nazareth ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Weight Gain ◽

Confidence Interval ◽

Weight Change ◽

Antipsychotic Treatment ◽

Weight Changes ◽

Baseline Weight ◽

Care Database

Background: Follow-up studies of weight gain related to antipsychotic treatment beyond a year are limited in number. We compared weight change in the three most commonly prescribed antipsychotics in a representative UK General Practice database. Method: We conducted a cohort study in United Kingdom primary care records of people newly prescribed olanzapine, quetiapine or risperidone. The primary outcome was weight in each six month period for two years after treatment initiation. Weight changes were compared using linear regression, adjusted for age, baseline weight and diagnosis. Results: N = 6338 people received olanzapine, 12,984 quetiapine and 6556 risperidone. Baseline weight was lowest for men treated with olanzapine (80.8 kg versus 83.5 kg quetiapine, 82.0 kg risperidone) and women treated with olanzapine (67.7 kg versus 71.5 kg quetiapine 68.4 kg risperidone. Weight gain occurred during treatment with all three drugs. Compared with risperidone mean weight gain was higher with olanzapine (adjusted co-efficient +1.24 kg (95% confidence interval: 0.69–1.79 kg per six months) for men and +0.77 kg (95% confidence interval: 0.29–1.24 kg) for women). Weight gain with quetiapine was lower in unadjusted models compared with risperidone, but this difference was not significant after adjustment. Conclusion: Olanzapine is more commonly prescribed to people with lower weight. However, after accounting for baseline weight, age, sex and diagnosis, olanzapine is still associated with greater weight gain over two years than risperidone or quetiapine. Baseline weight does not ameliorate the risks of weight gain associated with antipsychotic medication. Weight gain should be assertively discussed and managed for people prescribed antipsychotics, especially olanzapine.

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The use of dual-mobility bearings in patients at high risk of dislocation

The Bone & Joint Journal ◽

10.1302/0301-620x.101b1.bjj-2018-0506.r1 ◽

2019 ◽

Vol 101-B (1_Supple_A) ◽

pp. 41-45 ◽

Cited By ~ 23

Author(s):

C. W. Jones ◽

I. De Martino ◽

R. D’Apolito ◽

A. A. Nocon ◽

P. K. Sculco ◽

...

Keyword(s):

Risk Factors ◽

New York ◽

High Risk ◽

High Body Mass Index ◽

High Volume ◽

Consecutive Series ◽

Dual Mobility ◽

Radiographic Outcomes ◽

Stable Reconstruction

Aims Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years. Materials and Methods We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum. Results There were 151 patients who met the classification of high-risk according to the inclusion criteria and received DM THA during the study period. Mean age was 82 years old (73 to 95) and 114 patients (77.5%) were female. Mean follow-up was 3.6 years (1.9 to 6.1), with five patients lost to follow-up and one patient who died (for a reason unrelated to the index procedure). One patient (0.66%) sustained an intraprosthetic dislocation; there were no other dislocations. Conclusion At mid-term follow-up, the use of a DM bearing for primary THA in patients at high risk of dislocation provided a stable reconstruction option with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions.

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Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity

Journal of Neurosurgery Spine ◽

10.3171/2014.9.spine131176 ◽

2014 ◽

Vol 21 (6) ◽

pp. 994-1003 ◽

Cited By ~ 106

Author(s):

Justin S. Smith ◽

Ellen Shaffrey ◽

Eric Klineberg ◽

Christopher I. Shaffrey ◽

Virginie Lafage ◽

...

Keyword(s):

Risk Factors ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Full Length ◽

Consecutive Series ◽

Inclusion Criteria ◽

The Mean ◽

Spine Radiographs ◽

Rod Fracture

Object Improved understanding of rod fracture (RF) following adult spinal deformity (ASD) surgery could prove valuable for surgical planning, patient counseling, and implant design. The objective of this study was to prospectively assess the rates of and risk factors for RF following surgery for ASD. Methods This was a prospective, multicenter, consecutive series. Inclusion criteria were ASD, age > 18 years, ≥5 levels posterior instrumented fusion, baseline full-length standing spine radiographs, and either development of RF or full-length standing spine radiographs obtained at least 1 year after surgery that demonstrated lack of RF. ASD was defined as presence of at least one of the following: coronal Cobb angle ≥20°, sagittal vertical axis (SVA) ≥5 cm, pelvic tilt (PT) ≥25°, and thoracic kyphosis ≥60°. Results Of 287 patients who otherwise met inclusion criteria, 200 (70%) either demonstrated RF or had radiographic imaging obtained at a minimum of 1 year after surgery showing lack of RF. The patients' mean age was 54.8 ± 15.8 years; 81% were women; 10% were smokers; the mean body mass index (BMI) was 27.1 ± 6.5; the mean number of levels fused was 12.0 ± 3.8; and 50 patients (25%) had a pedicle subtraction osteotomy (PSO). The rod material was cobalt chromium (CC) in 53%, stainless steel (SS), in 26%, or titanium alloy (TA) in 21% of cases; the rod diameters were 5.5 mm (in 68% of cases), 6.0 mm (in 13%), or 6.35 mm (in 19%). RF occurred in 18 cases (9.0%) at a mean of 14.7 months (range 3–27 months); patients without RF had a mean follow-up of 19 months (range 12–24 months). Patients with RF were older (62.3 vs 54.1 years, p = 0.036), had greater BMI (30.6 vs 26.7, p = 0.019), had greater baseline sagittal malalignment (SVA 11.8 vs 5.0 cm, p = 0.001; PT 29.1° vs 21.9°, p = 0.016; and pelvic incidence [PI]–lumbar lordosis [LL] mismatch 29.6° vs 12.0°, p = 0.002), and had greater sagittal alignment correction following surgery (SVA reduction by 9.6 vs 2.8 cm, p < 0.001; and PI-LL mismatch reduction by 26.3° vs 10.9°, p = 0.003). RF occurred in 22.0% of patients with PSO (10 of the 11 fractures occurred adjacent to the PSO level), with rates ranging from 10.0% to 31.6% across centers. CC rods were used in 68% of PSO cases, including all with RF. Smoking, levels fused, and rod diameter did not differ significantly between patients with and without RF (p > 0.05). In cases including a PSO, the rate of RF was significantly higher with CC rods than with TA or SS rods (33% vs 0%, p = 0.010). On multivariate analysis, only PSO was associated with RF (p = 0.001, OR 5.76, 95% CI 2.01–15.8). Conclusions Rod fracture occurred in 9.0% of ASD patients and in 22.0% of PSO patients with a minimum of 1-year follow-up. With further follow-up these rates would likely be even higher. There was a substantial range in the rate of RF with PSO across centers, suggesting potential variations in technique that warrant future investigation. Due to higher rates of RF with PSO, alternative instrumentation strategies should be considered for these cases.

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Risk Factors for Weight Gain Following Switch to Integrase Inhibitor–Based Antiretroviral Therapy

Clinical Infectious Diseases ◽

10.1093/cid/ciaa177 ◽

2020 ◽

Vol 71 (9) ◽

pp. e471-e477 ◽

Cited By ~ 17

Author(s):

Jordan E Lake ◽

Kunling Wu ◽

Sara H Bares ◽

Paula Debroy ◽

Catherine Godfrey ◽

...

Keyword(s):

Weight Gain ◽

T Cell ◽

Waist Circumference ◽

Cell Count ◽

Cd4 T Cell ◽

Weight Changes ◽

Nonlinear Trends ◽

Hiv 1 ◽

Cd4 T Cell Count

Abstract Background Treatment initiation with integrase strand transfer inhibitors (INSTIs) has been associated with excess weight gain. Whether similar gains are seen after switch to INSTIs among virologically suppressed persons is less clear. We assessed pre/post-INSTI weight changes from AIDS Clinical Trials Group participants (A5001 and A5322). Methods Participants who were in follow-up from 1997–2017 and switched to INSTI-based antiretroviral regimens were included. Piecewise linear mixed-effects models adjusting for age, sex, race/ethnicity, baseline BMI, nadir and current CD4+ T-cell count, smoking, diabetes and follow-up time with suppressed HIV-1 RNA examined weight and waist circumference change before and after first switch to INSTIs. Linear spline models with a single knot at time of switch accounted for nonlinear trends. Results The 972 participants who switched to INSTIs were 81% male and 50% nonwhite with a median age at switch of 50 years, CD4+ T-cell count 512 cells/μL, and BMI 26.4 kg/m2. Restricting to persons with suppressed HIV-1 RNA at switch (n = 691), women, blacks, and persons ≥60 years experienced greater weight gain in the 2 years after versus before switch. In adjusted models, white or black race, age ≥60, and BMI ≥30 kg/m2 at switch were associated with greater weight gain following switch among women; age ≥60 was the greatest risk factor among men. Trends for waist circumference were similar. Conclusions Yearly weight gain increased following switch to INSTIs, particularly for women, blacks, and persons aged ≥60. Concomitant increases in waist circumference suggest that this weight gain is associated with an increase in fat mass.

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Microbial Safety and Sanitary Quality of Strawberry Primary Production in Belgium: Risk Factors for Salmonella and Shiga Toxin-Producing Escherichia coli Contamination

Applied and Environmental Microbiology ◽

10.1128/aem.03930-14 ◽

2015 ◽

Vol 81 (7) ◽

pp. 2562-2570 ◽

Cited By ~ 16

Author(s):

Stefanie Delbeke ◽

Siele Ceuppens ◽

Claudia Titze Hessel ◽

Irene Castro ◽

Liesbeth Jacxsens ◽

...

Keyword(s):

Risk Factors ◽

Escherichia Coli ◽

Shiga Toxin ◽

Irrigation Water ◽

Multivariable Logistic Regression Analysis ◽

Content Type ◽

E Coli ◽

Production And Consumption

ABSTRACTStrawberries are an important fruit in Belgium in both production and consumption, but little information is available about the presence ofSalmonellaand Shiga toxin-producingEscherichia coli(STEC) in these berries, the risk factors in agricultural production, and possible specific mitigation options. In 2012, a survey was undertaken of three soil and three soilless cultivation systems in Belgium. NoSalmonellaspp. were isolated. No STEC was detected in the strawberry samples (0 of 72), but STEC was detected by PCR in 11 of 78 irrigation water and 2 of 24 substrate samples. Culture isolates were obtained for 2 of 11 PCR-positive irrigation water samples and 2 of 2 substrate samples. Multivariable logistic regression analysis revealed elevated genericE. colinumbers (the odds ratio [OR] for a 1 log increase being 4.6) as the most important risk factor for STEC, together with the berry-picking season (elevated risk in summer). The presence of genericE. coliin the irrigation water (≥1 CFU per 100 ml) was mainly influenced by the type of irrigation water (collected rainfall water stored in ponds was more often contaminated than groundwater pumped from boreholes [OR = 5.8]) and the lack of prior treatment (untreated water versus water subjected to sand filtration prior to use [OR = 19.2]). The follow-up study in 2013 at one of the producer locations indicated cattle to be the most likely source of STEC contamination of the irrigation water.

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Changes and variations of body weight as risk factors for coronary heart disease

Medicinski pregled ◽

10.2298/mpns0806274j ◽

2008 ◽

Vol 61 (5-6) ◽

pp. 274-280 ◽

Cited By ~ 1

Author(s):

Dragana Jovanovic ◽

Branko Jakovljevic ◽

Katarina Paunovic ◽

Dusan Grubor ◽

Aleksandar Milovanovic

Keyword(s):

Risk Factors ◽

Blood Pressure ◽

Coronary Heart Disease ◽

Weight Loss ◽

Body Weight ◽

Heart Disease ◽

Weight Gain ◽

Weight Change ◽

Healthy Controls ◽

Weight Changes

Introduction Weight variations are a common phenomenon. Therefore, concern has been raised about the association between weight changes and weight variations and coronary heart disease (CHD). The aim of this study was to estimate the influence of weight change and weight variations as risk factors for coronary heart disease. Materials and methods The investigation was conducted as an observational cross-sectional study, including 102 participants of both genders: 61 patients with CHD and 41 healthy controls. All participants underwent anthropometric measurements and completed a questionnaire that included 1) weight changes in adulthood (maximum and minimum weight), 2) presence and number of weight variations in the 10 years prior to the onset of disease and 3) the size of weight change (weight gain or weight loss in kg). One weight variation was defined as weight loss followed by weight gain for more than 10% of body weight, or about 7 kg. Multivariant logistic regression was used for the estimation of significant predictors for the occurrence of coronary heart disease. Results Participants with CHD had higher values of body weight in adulthood compared to healthy controls, larger number of weight variations in the last 10 years, and more frequently reported weight gain and weight loss for more than 10 kg. The highest risk for the occurrence of coronary heart disease was observed for participants who had more than 3 weight variations for 10% (OR=2.13; 95%CI=0.98-5.48), those with weight loss over 10 kg (OR=2.16; 95%CI=1.71-2.72) and those with weight gain over 10 kg (OR=2.71; 95%CI=1.08-6.83), regardless of gender, age, smoking, body mass index and blood pressure. Discussion Several mechanisms are suggested to explain the relationship between weight changes and variations and coronary heart disease, including changes in plasma lipid levels, insulin levels, decrease of HDL cholesterol, increase of C-reactive protein and increase of blood pressure. Conclusion This study suggests that frequent and very intense weight changes can be considered important predictors for the occurrence of coronary heart disease.

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Prospective study of dietary energy density and weight gain in a Japanese adult population

British Journal Of Nutrition ◽

10.1017/s0007114517000484 ◽

2017 ◽

Vol 117 (6) ◽

pp. 822-828 ◽

Cited By ~ 3

Author(s):

K. M. Sasaki ◽

K. Wada ◽

J. L. L. Zeredo ◽

C. Nagata

Keyword(s):

Weight Gain ◽

Energy Density ◽

Dietary Habits ◽

Smoking Status ◽

Adult Population ◽

Dietary Energy ◽

Long Term Effects ◽

Weight Changes ◽

Dietary Energy Density

AbstractHigh dietary energy density (ED) has been associated with weight gain. However, little is known about the long-term effects of ED on weight changes among free-living subjects, particularly in Japanese and other Asian populations. In this study, we assessed dietary habits and weight changes in participants (5778 males and 7440 females, 35–69 years old) of the Takayama study. ED was estimated using a validated FFQ at baseline only. Information on body weight (BW) was obtained by self-administered questionnaires at baseline and follow-up. Mean BW difference in 9·8 years was 17 (se 4221) g for men and −210 (se 3889) g for women. In men, ED was positively associated with BW at follow-up after controlling for age, BW, height, physical activity score, alcohol consumption, energy intake, years of education at the baseline and change of smoking status during the follow-up. On average, men in the highest quartile of ED (>5·322 kJ/g (>1·272 kcal/g)) gained 138 (se 111) g, whereas men in the lowest ED (<1·057) lost 22 (se 111) g (Pfor trend=0·01). The association between ED and BW gain was stronger in men with normal weight. In women, the association between ED and weight change was not statistically significant. In conclusion, contrary to some studies that report an association between ED and weight gain in the overweight only, our data suggest that high-ED diets may be associated with weight gain in the lean population as well, at least in male subjects.

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