Reports Of Complaints Research Articles

CHARACTERIZING INDIVIDUALS WITH SUBJECTIVE COGNITIVE DECLINE: THE SUBJECTIVE COGNITIVE IMPAIRMENT COHORT (SCIENCE)

Subjective Cognitive Decline (SCD) is a potential first symptom of Alzheimer's Disease (AD). Nonetheless, in most patients with SCD, Alzheimer's pathology is not the cause of complaints. Subthreshold psychiatric symptoms can be an alternative origin of SCD. We initiated the Subjective Cognitive ImpairmENt Cohort (SCIENCe) to study the earliest changes leading to AD. We aim to describe the SCIENCe study design and participant characteristics. We included consecutive memory clinic patients with SCD in SCIENCe (n=151, age 64±8, 44% female, MMSE 29±2, APOE e4 38%). Participants received extensive neuropsychological testing, psychiatric and lifestyle questionnaires, MRI, blood, DNA and CSF collection, and optional amyloid-PET scan. We measured memory complaints with the Cognitive Change Index and quality of life with the EuroQol. Amyloid status was available for n=114(75%). Attempting to characterize different subgroups of SCD patients, we classified participants in three categories: (i) preclinical AD (amyloid positive), (ii) subthreshold psychiatric symptoms (questionnaire indicative of depression, anxiety, personality traits), or (iii) undetermined (neither category i or ii). We assessed differences between categories using ANOVA or chi-squared tests. We investigated associations between SCD-plus criteria (age>60, APOE e4, caregiver reports decline, onset<5year) and preclinical AD using logistic regression analyses. 28(25% of sample with available amyloid status) participants had preclinical AD, n=58(38%) had subthreshold psychiatry, and n=65(43%) were classified undetermined. 8/28(29%) participants with preclinical AD also had subthreshold psychiatry. In subthreshold psychiatry both self and caregiver report of memory complaints was higher, and quality of life lower, than in the undetermined category (both p<0.01), with preclinical AD in between. Evaluating SCD-plus criteria as indicators of preclinical AD, we found that age>60 (Odds Ratio 7.7(95% CI 1.7–38.9)) and APOE e4 (OR 4.8(1.6–15.0)) were independently associated with preclinical AD, while caregiver report (OR 1.9(0.6–5.7)) and onset<5 years (OR 0.9(0.3–2.7)) were not. The SCIENCe project extensively investigates factors potentially related to the subjective experience of cognitive decline. Evaluation of the first 151 participants revealed a heterogeneous group, with besides preclinical AD also subthreshold psychiatric features, and roughly half having no clear origin of complaints. Furthermore, some, but not all, SCD-plus criteria were associated with preclinical AD.

Shoulder pain in adolescent athletes: prevalence, associated factors and its influence on upper limb function

BackgroundSports that require the constant use of an upper limb demand the maximum kinetic chain efficiency in this segment. Immaturity of the musculoskeletal system, followed by failure in motor skills can expose adolescents to major reports of pain complaints, particularly for the shoulder. ObjectiveTo evaluate the prevalence of shoulder pain in adolescent athletes and identify possible factors associated with the complaint. MethodA total of 310 athletes, of both sexes and aged between 10 and 19 years old participated on this study. The subjects filled out a questionnaire with personal, sports and upper limb function (Quick-DASH) questions. We evaluated the height, body mass, shoulder rotation range and stability of the upper limb using the CKCUES-test. The association between pain and the variables was analyzed using multilevel modeling logistic regression. We used the Mann–Whitney test for comparing between pain and function. ResultsThe prevalence of shoulder pain was 43.5%. Athletes between 15 and 19 years, handball and judo practitioners, are 1.86, 2.14 and 3.07 more likely to report shoulder pain, respectively, when compared with other sports and ages. Shoulder pain reduced function scores (p<0.001) and increased changes in the range of motion (p<0.04). ConclusionShoulder pain is highly prevalent and is associated especially with older adolescent athletes of handball and judo, and affects the levels of function and the range of the shoulder.

地域苦情データにおける現状，要望表現の識別

地域苦情データにおける現状，要望表現の識別

Exploring and analyzing Internet crimes and their behaviours

Summary The world today is experiencing an exponential growth in cyberspace. Nevertheless, India too has witnessed a significant ascend in Internet activities and it is quite assertive to say that such phenomenal growth in access to information on one hand leads to empowered individuals and organization and on the other hand also poses new challenges to government and citizens. To make the cyber world safe is the need of the hour. Putting up deterrent measures against cybercrime is essential to national cyber security in protecting critical infrastructure of the nation as well as for individuals. In this regard, the prime objective of the government is to prevent cyber attacks and to protect the country's critical infrastructure. It also focuses on reducing vulnerability to cyber attacks so as to reduce and minimize damage and recovery time. To prevent the cyber crimes, individuals and governments need to clearly understand the crime schemes in the cyberspace and the contemporary and continuing Internet trends and behaviours of these criminals. This paper gives a brief outline of categories of cybercrimes. These crimes are categorized as crimes against individuals, property, organizations and governments. Various Internet crime scheme are evaluated and behaviour of criminals to perform the cybercrimes has been analyzed. A critical evaluation of report of cybercrime complaints under IT Act 2000 has been presented.

Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE.

Introduction: routine cognitive screening for in-patients aged ≥75 years is recommended, but there is uncertainty around how this should be operationalised. We therefore determined the feasibility and reliability of the Abbreviated mental test score (AMTS/10) and its relationship to subjective memory complaint, Montreal Cognitive Assessment (MoCA/30) and informant report in unselected older admissions.Methods: consecutive acute general medicine patients aged ≥75 years admitted over 10 weeks (March–May 2013) had AMTS and a question regarding subjective memory complaint (if no known dementia/delirium). At ≥72 h, the 30-point Montreal Cognitive Assessment (MoCA) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were done. Cognitive impairment was defined as AMTS < 9 or MoCA < 26 (mild impairment) and MoCA < 20 (moderate/severe impairment) or IQCODE ≥ 3.6.Results: among 264 patients (mean age/SD = 84.3/5.6 years, 117 (44%) male), 228 (86%) were testable with AMTS. 49/50 (98%) testable patients with dementia/delirium had low AMTS compared with 79/199 (44%) of those without (P < 0.001). Subjective memory complaint agreed poorly with objective cognitive deficit (39% denying a memory problem had AMTS < 9 (kappa = 0.134, P = 0.086)) as did informant report (kappa = 0.18, P = 0.15). In contrast, correlation between AMTS and MoCA was strong (R2 = 0.59, P < 0.001) with good agreement between AMTS < 9 and MoCA < 20 (kappa = 0.50, P < 0.01), although 85% of patients with normal AMTS had MoCA < 26.Conclusions: the AMTS was feasible and valid in older acute medicine patients agreeing well with the MoCA albeit with a ceiling effect. Objective cognitive deficits were prevalent in patients without known dementia or delirium but were not reliably identified by subjective cognitive complaint or informant report.

Isokinetic Assessment and Musculoskeletal Complaints in Paralympic Athletes: A Longitudinal Study.

The aim of this study was to assess and monitor the peak torque of the knee extensor and flexor muscles in flexion and extension and the reports of musculoskeletal complaints in members of the main Brazilian Paralympic athletics team through 1 yr. Fourteen healthy athletes from both sexes were assessed three times in 1 yr. The volunteers were assessed for the presence of musculoskeletal complaints and muscle strength at three time points: (1) at the onset of the preparatory phase on December 2009, (2) at a follow-up assessment on June 2010, and (3) before actual competition on December 2010. The athletes' self-reported musculoskeletal complaints were assessed in structured interviews, and the muscle strength was assessed by means of isokinetic dynamometry. The knee flexor and extensor muscle strength exhibited significant increase in both the right and left lower limbs at the second and third assessments compared with the first one (P < 0.05). Muscle imbalance was associated with knee and thigh complaints at all three assessments (P < 0.05). The knee flexor and extensor muscle strength exhibited a gradual increase in both lower limbs during the course of the three assessments. In parallel, muscle imbalance was associated with the occurrence of knee and thigh complaints.

Self-Reported Memory Failures: Associations with Future Dementia in a Population-Based Study with Long-Term Follow-Up.

To examine the association between self-reported memory failures and incident dementia in individuals aged 60 and older. Longitudinal, community based. Betula Prospective Cohort Study, a population-based study in Umeå, Sweden. Individuals with a mean age of 71.5 ± 8.8 (range 60-90) (N = 1,547). Participants rated the frequency of everyday memory failures using the 16-item Prospective and Retrospective Memory Questionnaire (PRMQ) and underwent objective memory testing at baseline. Participant self-reports of complaints of poor memory by family and friends were evaluated. Dementia status was followed-up for 10 to 12 years. Over the study period, 225 participants developed dementia (132 with Alzheimer's disease (AD)). In Cox proportional hazard regression models adjusted for demographic factors, PRMQz-scores predicted incident dementia (hazard ratio (HR) = 1.21 for all-cause dementia; HR = 1.25 for AD, Ps < .01). The significant associations remained when depressive symptoms and objective memory performance were adjusted for, when low performers on objective memory (≥1 standard deviations below the age group mean) were excluded, and in analyses with delayed entry (survival time ≥ 5 years). Similar patterns were observed for the prospective and retrospective subscales, although including how often participants self-reported that others complained about their poor memory eliminated the association between PRMQ scores and dementia and itself emerged as a significant predictor. Self-reported memory failure predicted future dementia or AD independent of objective memory performance. Subjective reports of complaints by family and friends appear to be an even more-important indicator of preclinical impairments, and physicians should not ignore them, even in the absence of objective memory deficits.

Valuing the prevention of elder abuse

We develop a framework for valuing cases of serious elder abuse. We use the preferences of the elderly who are abused, the victims, to help identify: what offenses are of concern, the seriousness of any particular offense and the value of preventing any particular offense. The variable revealing the valuations is the victim’s willingness to prosecute in New York City police complaint reports. Using our framework we found that it took a loss of $38 462 in order to be classed as a serious financial offense. With this monetary magnitude as a benchmark we were able to value nonfinancial serious offenses at up to $50 000 per offense.

Temporomandibular Disorders in a Young Adolescent Brazilian Population: Epidemiologic Characterization and Associated Factors.

To carry out an epidemiologic characterization of the most common subtypes of temporomandibular disorders (TMD) and to identify associated factors in a Brazilian sample of young adolescents. From a population of public schoolchildren (12 to 14 years of age), 3,117 students were randomly invited to participate in this study. TMD was assessed according to the Research Diagnostic Criteria for TMD (RDC/TMD) Axis I, in addition to some questions of the Axis II history questionnaire. The associated factors, ie, difficulty with concentration/attention, anger, sadness, anxiety, headache complaints, oral parafunctions, diurnal jaw clenching, tooth grinding at night, and parents not living together, were assessed based on the responses of the adolescents and their parents to structured questions. For the statistical analyses, descriptive statistics, chi-square tests, odds ratio, and logistic regression models were used, adopting a 95% confidence interval and 5% level of significance. The sample consisted of 1,307 individuals (response rate of 41.9%), 56.8% (n = 742) girls. Overall, 397 (30.4%) adolescents presented with TMD, of whom 330 (25.2%) had painful TMD diagnoses. The majority of these had painful TMD of muscular origin (13.1%) and comprised chronic cases (14.9%). Girls presented higher frequencies of TMD overall, painful TMD, painful combined TMD, and chronic painful TMD diagnoses The final multivariate logistic regression model revealed that headache complaints (odds ratio 2.87; confidence intervals 2.21-3.72), oral parafunctions (2.08; 1.26-3.44), tooth grinding at night (2.05; 1.56-2.70), diurnal jaw clenching (1.96; 1.50-2.55), and parents not living together (1.38; 1.07-1.80) were the factors significantly associated with a TMD (overall) diagnosis. About 25% of the adolescents evaluated presented painful TMD, and the majority of these comprised muscular and chronic cases. Some factors, such as reports of headache complaints, oral parafunctions, tooth grinding at night, and parents not living together, were associated with this condition among young Brazilian adolescents. Special attention should be given to these factors among adolescents with TMD.

Looking at the factors associated with bullying and visits to the school nurse, in the United States

The purpose of this study was to examine the relationships among perceived school climate, self-reported psychosomatic symptoms, visits to the school nurse for reported psychosomatic symptoms and reports of bullying behaviours among students' grades 3–12. In the study self-reported bullying behaviours were proposed to predict psychosomatic complaints at the school health office. Negatively perceived school climate was proposed to predict bullying behaviours. Lastly, the combination of bullying and negative school climate were proposed to predict psychosomatic complaints. Reports of bullying behaviours were found to significantly predict reports of psychosomatic complaints in school age children (Beta = 0.35, t = 5.5, P &lt; 0.001). Bullying behaviours significantly predicted visits to the school health office for psychosomatic symptoms (Beta = .24, t = 3.7, P &lt; 0.001). Negatively perceived school climate significantly predicted reports of bullying behaviours (Beta = 0.16, t = 2.3, P &lt; 0.02). Negative perceived school climate significantly predicts reports of psychosomatic symptoms related to bullying (Beta = 0.35, t = 5.5, P &lt; 0.001).

Investigation on legal problems encountered by emergency medicine physicians in Turkey.

BackgroundMedicine is a profession that carries certain risks. One risky area of practice is the emergency department. Emergency physicians diagnose and treat a high volume of patients, and are also responsible for preparing reports for forensic cases. In this study, we aim to investigate emergency physicians’ legal-administrative problems and reveal their level of understanding on forensic cases.MethodsAn electronic questionnaire form was prepared after the approval of an ethical committee. This form was sent to the residents, specialists and academicians of emergency medicine by e-mail. The physicians were asked to fill out the form online. All the gathered data was analyzed. Descriptive statistics were presented as frequency percentages with mean and standard deviation. Chi-square tests were used to compare the groups. Correlation between number of complaint cases and age, sex, career, institution, and duration of service in emergency department were investigated. p<0.05 was considered statistically significant.Results294 physicians participated in the questionnaire. According to the questionnaire, 170 of the physicians were reported to the patient communication units due to medical malpractice. Mean number of compliant reports was 3.20±3.5. 29 of the physicians received administrative penalties. 42 of the physicians were judged in the court for medical malpractice. 1 physician was fined 5000 Turkish Liras as a result of these judgments.ConclusionWe found that the number of complaint reports is negatively correlated with duration of service in emergency medicine and age. There was a significant difference between number of complaint reports and career (p<0.05). The physicians’ level of awareness on forensic cases was found to be insufficient. Lack of legislation knowledge may be an important cause of complaint reports concerning emergency physicians, who have a high load of patients. Thus, we think that increasing the frequency of post-graduate education sessions and periodical reviews might be beneficial.

Association Between Bacterial Infection and Radiologically Confirmed Pneumonia Among Children

The role of chest radiograph (CXR) among children with community-acquired pneumonia is controversial. We aimed to assess if there is association between a specific etiology and radiologically confirmed pneumonia. This was a prospective cross-sectional study. Based on report of respiratory complaints and fever/difficulty breathing plus the detection of pulmonary infiltrate/pleural effusion on the CXR taken upon admission read by the pediatrician on duty, children <5-year-old hospitalized with community-acquired pneumonia were enrolled. On admission, clinical data and biological samples were collected to investigate 19 etiological agents (11 viruses and 8 bacteria). CXR taken upon admission was independently read by a pediatric radiologist blinded to clinical data. The study group comprised 209 cases with evaluated CXR and establishment of a probable etiology. Radiologically confirmed pneumonia, normal CXR and other radiographic diagnoses were described for 165 (79.0%), 36 (17.2%) and 8 (3.8%) patients, respectively. Viral infection was significantly more common among patients without radiologically confirmed pneumonia (68.2% vs. 47.9%; P = 0.02), particularly among those with normal CXR (66.7% vs. 47.9%; P = 0.04) when compared with patients with radiologically confirmed pneumonia. Bacterial infection was more frequent among cases with radiologically confirmed pneumonia (52.1% vs. 31.8%; P = 0.02). Likewise, pneumococcal infection was more frequently detected among children with radiologically confirmed pneumonia in regard to children with normal CXR (24.2% vs. 8.3%; P = 0.04). Sensitivity (95% confidence interval) of radiologically confirmed pneumonia for pneumococcal infection was 93% (80-98%), and negative predictive value (95% confidence interval) of normal CXR for pneumococcal infection was 92% (77-98%). Bacterial infection, especially pneumococcal one, is associated with radiologically confirmed pneumonia.

Comparing Simulated Nursing Performance to Actual Practice

Between 2007 and 2013, the Arizona Board of Nursing (BON), a community college, and a university developed the Nursing Performance Profile (NPP), a legally defensible competency evaluation using simulation. Using the NPP, the board evaluated the competency of nurses who were reported to the BON for unsafe practice. Then, we compared the unsafe behaviors revealed by the NPP evaluation with those reported to the BON in the original complaint and investigative reports (IRs). The comparative analysis revealed remarkable consistency between the IRs and the NPP findings. Between 2007 and 2013, the Arizona Board of Nursing (BON), a community college, and a university developed the Nursing Performance Profile (NPP), a legally defensible competency evaluation using simulation. Using the NPP, the board evaluated the competency of nurses who were reported to the BON for unsafe practice. Then, we compared the unsafe behaviors revealed by the NPP evaluation with those reported to the BON in the original complaint and investigative reports (IRs). The comparative analysis revealed remarkable consistency between the IRs and the NPP findings.

Automatic Classification of Complaint Reports about City Park

Recently, it has become easy for the growing Goverment 2.0 movement to report complaints. On the other hand, there is a clearly identified and growing delay in responses from the government side due to an overload on government capacity to deal with the increasing number of complaint reports as the movement grows. In this paper, we propose a method of automatically categorizing complaint reports as a first step to reduce the pressure on the government side. We conducted experiments in categorizing the complaint reports. The experimental results showed the following findings: (1) Feature selection is key to improving the accuracy (F-score) of the categorization of complaint reports. The percentage of words that are strongly effective for categorization is about 3.9% of the total of distinct words. (2) Proposed Mutual-Information(MI)-based methods outperform a conventional Random-Forest(RF)-based method. (3) The City management section seems to classify complaint reports by focusing on demands expressed in the reports. (4) The categorization performance usually high if training data includes various types of categories of data.

Reports of Complaints with Tinnitus Patients: A Qualitative Study

Introduction: Tinnitus, also called acúfeno or zumbido, is the sound perceived in the absence of an external sound stimulus. This is considered the third worst symptom in humans. It is a disorder that produces great discomfort, hampering social life, and diary activities. Patients with tinnitus complain of insomnia, lack of concentration, and irritation, such events affect the quality of life of these individuals. In addition, tinnitus is often associated with emotional issues such as depression, anxiety, and other disorders.

Characterizing the longitudinal relations between depressive and menstrual symptoms in adolescent girls.

This study examined the association between depressive and menstrual symptoms in adolescent girls in a 3-year longitudinal study. It was hypothesized that menstrual symptoms would increase in early adolescence and decrease in later adolescence, that girls with greater depressive symptoms would report greater menstrual symptoms, and that effects would persist after adjusting for general somatic complaints. A community sample of girls (n = 262) enrolled in an observational study by age cohort (11, 13, 15, 17 years) completed three annual visits. At each time point, girls completed the Menstrual Symptom Questionnaire, Children's Depression Inventory, and the Youth Self Report to assess general somatic complaints. Menstrual symptoms increased significantly across adolescence (p = .006) and began to plateau in later adolescence (p = .020). Depressive symptoms at study entry were significantly associated with menstrual symptoms (p < .001). When general somatic complaints were included in the models, the effect of depressive symptoms on menstrual symptoms remained significant for the sum score (p = .015) and the menstrual somatic symptoms subscale (p = .001). After adjusting for somatic complaints, initial report of depressive symptoms predicted change in menstrual symptoms only for girls with the lowest menstrual symptoms sum score (p = .025). Initial report of somatic complaints predicted change in menstrual symptoms (p = .020). Girls with higher depressive symptoms and higher somatic complaints are at greater risk for experiencing menstrual symptoms and increasing symptoms across adolescence, with a heightened vulnerability for girls with lower baseline menstrual symptoms.

The impact of an exercise therapy on psychosocial health of children with benign epilepsy: A pilot study

ObjectivesThe purposes of the current study were to test the feasibility of exercise therapy for children with benign epilepsy with centrotemporal spikes (BECTS) and to collect pilot data about the impact of exercise therapy on neurocognitive, emotional, and behavioral outcomes. MethodsTen children with BECTS (9.7±1.42years) participated in a therapeutic exercise program consisting of ten supervised exercise sessions and home-based exercises for five weeks. Electroencephalography (EEG), seizure frequency, and neurocognitive and psychological factors, including attention, executive function, depression, anxiety, behavioral problems, and quality of life, were assessed before and after the exercise program. ResultsNo clinical symptoms were observed to worsen during the study, demonstrating that the exercise therapy was safe and also feasible. After five weeks of exercise therapy, significant improvements in neurocognitive domains such as simple visual and auditory attention, sustained attention, divided attention, psychomotor speed, and inhibition–disinhibition were observed. Furthermore, parent ratings of internalizing behavioral problems and social problems and mood-related well-being from quality of life improved after exercise therapy. Although not statistically significant, trends were noted toward improvement in children's self-reports of negative mood/somatization, parent reports of somatic complaints, and general health on a quality-of-life measure. ConclusionsA five-week structured exercise program was successfully implemented, with preliminary data suggesting beneficial impact on neurocognitive and psychobehavioral function. Exercise therapy should be further evaluated as a part of a comprehensive treatment program for children with benign epilepsy.

The Classification of Residential Defects (Case Study: Citra Garden Residence in Indonesia)

The classification of residential defects (case study: Citra Garden Residence in Indonesia) was studied. This study aims to more satisfied customers. The study begins with the literature review to formulate the classification of house defects. Then classify the defect of house into two, namely the classification of house defects based on period of post hand over, and the classification of house defects based on category of the defects. Further studies followed by dividing the classification of house defects based on period of post-hand over into three parts, namely before hand over period (inviting time), hand over period, and post-hand over period. The next step is to check the complaint report from the customer service in Citra Garden Residence in Indonesia to quantificate the defects of the house. The classification of house defects based on category of the defects divided into two, namely structural defect (minor, moderate, serious), and nonstructural defect (minor, moderate, serious). The next step is also to check the complaint report from the customer service in Citra Garden Residence in Indonesia to quantificate the defects of the house.The results show that complaint hand over in the level minor defect is the highest complaint. Complaint in the serious defect is the lowest complaint.

Adverse events attributed to traditional Korean medical practices: 1999–2010

To investigate adverse events attributed to traditional medical treatments in the Republic of Korea. Adverse events recorded in the Republic of Korea between 1999 and 2010 - by the Food and Drug Administration, the Consumer Agency or the Association of Traditional Korean Medicine - were reviewed. Records of adverse events attributed to the use of traditional medical practices, including reports of medicinal accidents and consumers' complaints, were investigated. Overall, 9624 records of adverse events attributed to traditional medical practices - including 522 linked to herbal treatments - were identified. Liver problems were the most frequently reported adverse events. Only eight of the adverse events were recorded by the pharmacovigilance system run by the Food and Drug Administration. Of the 9624 events, 1389 - mostly infections, cases of pneumothorax and burns - were linked to physical therapy (n = 285) or acupuncture/moxibustion (n = 1104). In the Republic of Korea, traditional medical practices often appear to have adverse effects, yet almost all of the adverse events attributed to such practices between 1999 and 2010 were missed by the national pharmacovigilance system. The Consumer Agency and the Association of Traditional Korean Medicine should be included in the national pharmacovigilance system.

Eventos adversos e queixas técnicas relacionados ao fio para sutura cirúrgica comercializado no Brasil

Surgical suture (SS) is a medical material used invasively for positioning biological tissues and is regarded as a critical product due to its contact with skin, vessels and other tissues. The present study aimed to critically analyze the Brazilian National Adverse Event and Product Complaint Reporting (Notivisa) data related to SS. Descriptions of reports made between 2006 and 2009 were thoroughly evaluated. There were 256 reports associated with SS, of which 94 (36.7%) were related to adverse events and 162 (63.3%) to product complaints. The analysis of Notivisa data showed some conceptual inconsistencies and incomplete reports. Most reports were related to suture products including low tensile strength and breaking as well as problems with suture needles. The reports analyzed involved 51% of surgical suture companies doing business in Brazil and there was more than one reporting for 28 batches. These findings stress the importance of implementing a compulsory product certification system with mandatory minimum quality requirements and show a need for ongoing training of those involved in the reporting process. More accurate, faster reporting process would support timely action by health surveillance agents and product companies to prevent or minimize unfavorable health outcomes in the exposed populations.