Successful Prophylactic Embolization of a Renal Artery Aneurysm During Pregnancy.

Renal artery aneurysms (RAA) have an increased risk of rupture during pregnancy with high mortality rates for the mother and fetus. There are many reports on the treatment of ruptured RAA during pregnancy and the Society for Vascular Surgery recommends to prophylactically treat unruptured RAA of any size in women of reproductive age to limit risk of rupture during pregnancy. However, to the best of our knowledge, there is no reported case of prophylactic treatment of unruptured RAA during pregnancy. Here we report the case of a 39-year-old G2P1 who had prophylactic endovascular coiling of an unruptured left RAA during her second trimester of pregnancy. Our case report is the first to demonstrate that unruptured RAA can be safely intervened endovascularly to prevent rupture without disrupting the pregnancy.

Clinical Conundrum: A 39-Year-Old With Chronic Retained Products of Conception and Concurrent Uterine Arteriovenous Malformation.

A 39-year-old woman presented with bleeding 4 months after a surgical termination of pregnancy. Persistent beta-human chorionic gonadotropin levels were suggestive of retained products of conception (RPOC). However, multimodal imaging revealed a concurrent uterine arteriovenous malformation (AVM). Although most stable AVMs can be managed conservatively, the need for surgical management of chronic RPOC and consequential hemorrhage risk complicates this approach. Patient-determined management prioritized blood conservation while minimizing risks to fertility. This case is discussed with respect to the rare concurrent existence of RPOC and AVM. Little is known regarding the optimal tandem therapeutic approach. As depicted, successful treatment requires careful diagnostic workup and a multidisciplinary approach.

Giant Carotid Artery Aneurysm.

Carotid artery aneurysms account for 4% of peripheral aneurysms and may present as a neck mass, with hemispheric ischaemic symptoms, or with symptoms secondary to local compression. This case explores the presentation, investigations and management of a presumed mycotic common carotid artery aneurysm in a 77-year-old male, which was repaired using end-to-end interposition vein graft using long saphenous vein. This report discusses the aetiology, presentation and surgical management for carotid artery aneurysms, as well as focusing on that of the rare mycotic carotid artery aneurysm.

Hospital pharmacists' experiences of participating in a partnered pharmacist medication charting credentialing program: a qualitative study.

BACKGROUND: Medication-related errors are one of the most frequently reported incidents in hospitals. With the aim of reducing the medication error rate, a Partnered Pharmacist Medication Charting (PPMC) model was trialled in seven Australian hospitals from 2016 to 2017. Participating pharmacists completed a credentialing program to equip them with skills to participate in the trial as a medication-charting pharmacist. Skills included obtaining a comprehensive medication history to chart pre-admission medications in collaboration with an admitting medical officer. The program involved both theoretical and practical components to assess the competency of pharmacists. METHODS: A qualitative evaluation of the multi-site PPMC implementation trial was undertaken. Pharmacists and key informants involved in the trial participated in an interview or focus group session to share their experiences and attitudes regarding the PPMC credentialing program. An interview schedule was used to guide sessions. Transcripts were analysed using a pragmatic inductive-deductive thematic approach. RESULTS: A total of 125 participants were involved in interviews or focus groups during early and late implementation data collection periods. Three themes pertaining to the PPMC credentialing program were identified: (1) credentialing as an upskilling opportunity, (2) identifying the essential components of credentialing, and (3) implementing and sustaining the PPMC credentialing program. CONCLUSIONS: The PPMC credentialing program provided pharmacists with an opportunity to expand their scope of practice and consolidate clinical knowledge. Local adaptations to the PPMC credentialing program enabled pharmacists to meet the varying needs and capacities of hospitals, including the policies and procedures of different clinical settings. These findings highlight key issues to consider when implementation a credentialing program for pharmacists in the hospital setting.

A marking of the cricothyroid membrane with extended neck returns to correct position after neck manipulation and repositioning.

BACKGROUND: Emergency front of neck airway access by anaesthetists carries a high failure rate and it is recommended to identify the cricothyroid membrane before induction of anaesthesia in patients with a predicted difficult airway. We have investigated whether a marking of the cricothyroid membrane done in the extended neck position remains correct after the patient's neck has been manipulated and subsequently repositioned. METHODS: The subject was first placed in the extended head and neck position and had the cricothyroid membrane identified and marked with 3 methods, palpation, 'laryngeal handshake' and ultrasonography and the distance from the suprasternal notch to the cricothyroid membrane was measured. The subject then moved off the table and sat on a chair and subsequently returned to the extended neck position and examinations were repeated. RESULTS: Skin markings of all 11 subjects lay within the boundaries of the cricothyroid membrane when the subject was repositioned back to the extended neck position and the median difference between the two measurements of the distance from the suprasternal notch was 0 mm (range 0-2 mm). CONCLUSION: The cricothyroid membrane can be identified and marked with the subject in the extended neck position. Then the patient's position can be changed as needed, for example to the 'sniffing' neck position for conventional intubation. If a front of neck airway access is required during subsequent airway management, the patient can be returned expediently to the extended-neck position, and the marking of the centre of the membrane will still be in the correct place.

Barriers to a software reminder system for risk assessment of stroke in atrial fibrillation: a process evaluation of a cluster randomised trial in general practice.

BACKGROUND: Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation (AF), but are underused. AURAS-AF (AUtomated Risk Assessment for Stroke in AF) is a software tool designed to identify eligible patients and promote discussions within consultations about initiating anticoagulants. AIM: To investigate the implementation of the software in UK general practice. DESIGN AND SETTING: Process evaluation involving 23 practices randomly allocated to use AURAS-AF during a cluster randomised trial. METHOD: An initial invitation to discuss anticoagulation was followed by screen reminders appearing during consultations until a decision had been made. The reminders required responses, giving reasons for cases where an anticoagulant was not initiated. Qualitative interviews with clinicians and patients explored acceptability and usability. RESULTS: In a sample of 476 patients eligible for the invitation letter, only 159 (33.4%) were considered suitable for invitation by their GPs. Reasons given were frequently based on frailty, and risk of falls or haemorrhage. Of those invited, 35 (22%) started an anticoagulant (7.4% of those originally identified). A total of 1695 main-screen reminders occurred in 940 patients. In 883 instances, the decision was taken not to initiate and a range of reasons offered. Interviews with 15 patients and seven clinicians indicated that the intervention was acceptable, though the issue of disruptive screen reminders was raised. CONCLUSION: Automated risk assessment for stroke in atrial fibrillation and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake.

Identifying Primary Care Pathways from Quality of Care to Outcomes and Satisfaction Using Structural Equation Modeling.

OBJECTIVE: To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making. DATA SOURCES: A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012. STUDY DESIGN: Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care ("quality assurance," "education and training," "medicine management," "access," "clinical management," and "patient-centered care"), health outcomes ("intermediate outcomes" and "patient-reported health status"), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling. PRINCIPAL FINDINGS: The model supported two independent paths. In the first path, "access" was associated with "patient-centered care" (ß = 0.63), which in turn was strongly associated with "patient satisfaction" (ß = 0.88). In the second path, "education and training" was associated with "clinical management" (ß = 0.32), which in turn was associated with "intermediate outcomes" (ß = 0.69). "Patient-reported health status" was weakly associated with "patient-centered care" (ß = -0.05) and "patient satisfaction" (ß = 0.09), and not associated with "clinical management" or "intermediate outcomes." CONCLUSIONS: This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives.

Automated Software System to Promote Anticoagulation and Reduce Stroke Risk: Cluster-Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Oral anticoagulants (OAC) substantially reduce risk of stroke in atrial fibrillation, but uptake is suboptimal. Electronic health records enable automated identification of people at risk but not receiving treatment. We investigated the effectiveness of a software tool (AURAS-AF [Automated Risk Assessment for Stroke in Atrial Fibrillation]) designed to identify such individuals during routine care through a cluster-randomized trial. METHODS: Screen reminders appeared each time the electronic health records of an eligible patient was accessed until a decision had been taken over OAC treatment. Where OAC was not started, clinicians were prompted to indicate a reason. Control practices continued usual care. The primary outcome was the proportion of eligible individuals receiving OAC at 6 months. Secondary outcomes included rates of cardiovascular events and reports of adverse effects of the software on clinical decision-making. RESULTS: Forty-seven practices were randomized. The mean proportion-prescribed OAC at 6 months was 66.3% (SD=9.3) in the intervention arm and 63.9% (9.5) in the control arm (adjusted difference 1.21% [95% confidence interval -0.72 to 3.13]). Incidence of recorded transient ischemic attack was higher in the intervention practices (median 10.0 versus 2.3 per 1000 patients with atrial fibrillation; P=0.027), but at 12 months, we found a lower incidence of both all cause stroke (P=0.06) and hemorrhage (P=0.054). No adverse effects of the software were reported. CONCLUSIONS: No significant change in OAC prescribing occurred. A greater rate of diagnosis of transient ischemic attack (possibly because of improved detection or overdiagnosis) was associated with a reduction (of borderline significance) in stroke and hemorrhage over 12 months. CLINICAL TRIAL REGISTRATION: URL: http://www.isrctn.com. Unique Identifier: ISRCTN55722437.

Paper Tape Prevents Foot Blisters: A Randomized Prevention Trial Assessing Paper Tape in Endurance Distances II (Pre-TAPED II).

OBJECTIVE: To determine whether paper tape prevents foot blisters in multistage ultramarathon runners. DESIGN: Multisite prospective randomized trial. SETTING: The 2014 250-km (155-mile) 6-stage RacingThePlanet ultramarathons in Jordan, Gobi, Madagascar, and Atacama Deserts. PARTICIPANTS: One hundred twenty-eight participants were enrolled: 19 (15%) from the Jordan, 35 (27%) from Gobi, 21 (16%) from Madagascar, and 53 (41%) from the Atacama Desert. The mean age was 39.3 years (22-63) and body mass index was 24.2 kg/m (17.4-35.1), with 31 (22.5%) females. INTERVENTIONS: Paper tape was applied to a randomly selected foot before the race, either to participants' blister-prone areas or randomly selected location if there was no blister history, with untaped areas of the same foot used as the control. MAIN OUTCOME MEASURES: Development of a blister anywhere on the study foot. RESULTS: One hundred six (83%) participants developed 117 blisters, with treatment success in 98 (77%) runners. Paper tape reduced blisters by 40% (P < 0.01, 95% confidence interval, 28-52) with a number needed to treat of 1.31. Most of the study participants had 1 blister (78%), with most common locations on the toes (n = 58, 50%) and heel (n = 27, 23%), with 94 (80%) blisters occurring by the end of stage 2. Treatment success was associated with earlier stages [odds ratio (OR), 74.9, P < 0.01] and time spent running (OR, 0.66, P = 0.01). CONCLUSION: Paper tape was found to prevent both the incidence and frequency of foot blisters in runners.

Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling.

BACKGROUND: Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation. OBJECTIVE: To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD. DATA SOURCES: We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature. METHODS: In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year. RESULTS: A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention. LIMITATION: Heterogeneity in meta-analyses. CONCLUSIONS: While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013003727. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Impact of the Prevalence of Concordant and Discordant Conditions on the Quality of Diabetes Care in Family Practices in England.

PURPOSE: The purpose of this study was to examine the association between the prevalence of both diabetes-concordant and diabetes-discordant conditions and the quality of diabetes care at the family practice level in England. We hypothesized that the prevalence of concordant (or discordant) conditions would be associated with better (or worse) quality of diabetes care. METHODS: We conducted a cross-sectional study using practice-level data (7,884 practices). We estimated the practice-level prevalence of diabetes and 15 other chronic conditions, which were classified as diabetes concordant (ie, with the same pathophysiologic risk profile and therefore more likely to be part of the same management plan) or diabetes discordant (ie, not directly related in either their pathogenesis or management). We measured quality of diabetes care with diabetes-specific indicators (8 processes and 3 intermediate outcomes of care). We used linear regression models to quantify the effect of the prevalence of the conditions on aggregate achievement rate for quality of diabetes care. RESULTS: Consistent with the proposed model, the prevalence rates of 4 of 7 concordant conditions (obesity, chronic kidney disease, atrial fibrillation, heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for 2 of the 8 discordant conditions (epilepsy, mental health). Observations for other concordant and discordant conditions did not match predictions in the hypothesized model. CONCLUSIONS: The quality of diabetes care provided in English family practices is associated with the prevalence of other major chronic conditions at the practice level. The nature and direction of the observed associations cannot be fully explained by the concordant-discordant model.

Economic evaluation of a group-based exercise program for falls prevention among the older community-dwelling population.

BACKGROUND: Falls among older people are of growing concern globally. Implementing cost-effective strategies for their prevention is of utmost importance given the ageing population and associated potential for increased costs of fall-related injury over the next decades. The purpose of this study was to undertake a cost-utility analysis and secondary cost-effectiveness analysis from a healthcare system perspective, of a group-based exercise program compared to routine care for falls prevention in an older community-dwelling population. METHODS: A decision analysis using a decision tree model was based on the results of a previously published randomised controlled trial with a community-dwelling population aged over 70. Measures of falls, fall-related injuries and resource use were directly obtained from trial data and supplemented by literature-based utility measures. A sub-group analysis was performed of women only. Cost estimates are reported in 2010 British Pound Sterling (GBP). RESULTS: The ICER of GBP£51,483 per QALY for the base case analysis was well above the accepted cost-effectiveness threshold of GBP£20,000 to £30,000 per QALY, but in a sensitivity analysis with minimised program implementation the incremental cost reached GBP£25,678 per QALY. The ICER value at 95% confidence in the base case analysis was GBP£99,664 per QALY and GBP£50,549 per QALY in the lower cost analysis. Males had a 44% lower injury rate if they fell, compared to females resulting in a more favourable ICER for the women only analysis. For women only the ICER was GBP£22,986 per QALY in the base case and was below the cost-effectiveness threshold for all other variations of program implementation. The ICER value at 95% confidence was GBP£48,212 in the women only base case analysis and GBP£23,645 in the lower cost analysis. The base case incremental cost per fall averted was GBP£652 (GBP£616 for women only). A threshold analysis indicates that this exercise program cannot realistically break even. CONCLUSIONS: The results suggest that this exercise program is cost-effective for women only. There is no evidence to support its cost-effectiveness in a group of mixed gender unless the costs of program implementation are minimal. Conservative assumptions may have underestimated the true cost-effectiveness of the program.

Polarization spectroscopy of a velocity-selected molecular sample.

This Letter demonstrates polarization spectroscopy of a velocity selected and vibrationally excited molecular sample. Specifically, the anisotropy induced by a circularly polarized IR pump beam tuned to the R(14.5)(1/2)v=1←v=0 transition of nitric oxide is observed using an IR probe resonant with the R(15.5)(1/2)v=2←v=1 hot band transition. Using two detectors in combination with the rapidly swept probe allows both the absorptive and dispersive components of the excited state polarization to be observed for the first time. The data are well described by simulations based upon a three-level density matrix model.

Pump and probe spectroscopy with continuous wave quantum cascade lasers.

This paper details infra-red pump and probe studies on nitric oxide conducted with two continuous wave quantum cascade lasers both operating around 5 µm. The pump laser prepares a velocity selected population in a chosen rotational quantum state of the v = 1 level which is subsequently probed using a second laser tuned to a rotational transition within the v = 2 ← v = 1 hot band. The rapid frequency scan of the probe (with respect to the molecular collision rate) in combination with the velocity selective pumping allows observation of marked rapid passage signatures in the transient absorption profiles from the polarized vibrationally excited sample. These coherent transient signals are influenced by the underlying hyperfine structure of the pump and probe transitions, the sample pressure, and the coherent properties of the lasers. Pulsed pump and probe studies show that the transient absorption signals decay within 1 µs at 50 mTorr total pressure, reflecting both the polarization and population dephasing times of the vibrationally excited sample. The experimental observations are supported by simulation based upon solving the optical Bloch equations for a two level system.

Impact of universal health insurance coverage on hypertension management: a cross-national study in the United States and England.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) galvanised debate in the United States (US) over universal health coverage. Comparison with countries providing universal coverage may illustrate whether the ACA can improve health outcomes and reduce disparities. We aimed to compare quality and disparities in hypertension management by socio-economic position in the US and England, the latter of which has universal health care. METHOD: We used data from the Health and Retirement Survey in the US, and the English Longitudinal Study for Aging from England, including non-Hispanic White respondents aged 50-64 years (US market-based v NHS) and >65 years (US-Medicare v NHS) with diagnosed hypertension. We compared blood pressure control to clinical guideline (140/90 mmHg) and audit (150/90 mmHg) targets; mean systolic and diastolic blood pressure and antihypertensive prescribing, and disparities in each by educational attainment, income and wealth, using regression models. RESULTS: There were no significant differences in aggregate achievement of clinical targets aged 50 to 65 years (US market-based vs. NHS--62.3% vs. 61.3% [p = 0.835]). There was, however, greater control in the US in patients aged 65 years and over (US Medicare vs. NHS--53.5% vs. 58.2% [p = 0.043]). England had no significant socioeconomic disparity in blood pressure control (60.9% vs. 63.5% [p = 0.588], high and low wealth aged ≥65 years). The US had socioeconomic differences in the 50-64 years group (71.7% vs. 55.2% [p = 0.003], high and low wealth); these were attenuated but not abolished in Medicare beneficiaries. CONCLUSION: Moves towards universal health coverage in the US may reduce disparities in hypertension management. The current situation, providing universal coverage for residents aged 65 years and over, may not be sufficient for equality in care.

Ethnic group differences in cardiovascular risk assessment scores: national cross-sectional study.

OBJECTIVES: There are marked inequalities in cardiovascular disease (CVD) incidence and outcomes between ethnic groups. CVD risk scores are increasingly used in preventive medicine and should aim to accurately reflect differences between ethnic groups. Ethnicity, as an independent risk factor for CVD, can be accounted for in CVD risk scores primarily using two methods, either directly incorporating it as a risk factor in the algorithm or through a post hoc adjustment of risk. We aim to compare these two methods in terms of their prediction of CVD across ethnic groups using representative national data from England. DESIGN: A cross-sectional study using data from the Health Survey for England. We measured ethnic group differences in risk estimation between the QRISK2, which includes ethnicity and Joint British Societies 2 (JBS2) algorithm, which uses post hoc risk adjustment factor for South Asian men. RESULTS: The QRISK2 score produces lower median estimates of CVD risk than JBS2 overall (6.6% [lower quartile-upper quartile (LQ-UQ)=4.0-18.6] compared with 9.3% [LQ-UQ=2.3-16.9]). Differences in median risk scores are significantly greater in South Asian men (7.5% [LQ-UQ=3.6-12.5]) compared with White men (3.0% [LQ-UQ=0.7-5.9]). Using QRISK2, 19.1% [95% confidence interval (CI)=16.2-22.0] fewer South Asian men are designated at high risk compared with 8.8% (95% CI=5.9-7.8) fewer in White men. Across all ethnic groups, women had a lower median QRISK2 score (0.72 [LQ-UQ=- 0.6 to 2.13]), although relatively more (2.0% [95% CI=1.4-2.6]) were at high risk than with JBS2. CONCLUSIONS: Ethnicity is an important CVD risk factor. Current scoring tools used in the UK produce significantly different estimates of CVD risk within ethnic groups, particularly in South Asian men. Work to accurately estimate CVD risk in ethnic minority groups is important if CVD prevention programmes are to address health inequalities.

Do-it-yourself healthcare: the current landscape, prospects and consequences.

The wider availability and increasing use of mHealth tools - covering health applications, smartphone plug-ins and gadgets is significant for healthcare. This trend epitomises broader trajectories in access to and delivery of healthcare, with greater consumer involvement and decentralisation. This shift may be conceptualised as 'do-it-yourself Healthcare' - allowing consumers to monitor and manage their health, and guide their healthcare consumption. Technology that enables data collection by patients informs them about vital health metrics, giving them more control over experiences of health or illness. The information can be used alone as empowered consumers or together with healthcare professionals in an environment of patient-centred care. Current evidence suggests a large scope for do-it-yourself Healthcare, given the availability of technologies, whilst mHealth tools enhance diagnostics, improve treatment, increase access to services and lower costs. There are, however, limitations to do-it-yourself Healthcare. Notably, its evidence base is less well developed than the availability of technologies to facilitate it. A more complex model and understanding is needed to explain motivations for and consequences of engaging in do-it-yourself Healthcare. That said, its introduction alongside existing medicine may improve quality and reduce costs - potentially improving health system sustainability whilst future generations - tomorrow's middle-aged and the elderly, will become more conducive to its spread.