Children's Lead Concentrations Research Articles

Environmental Public Health Tracking in England- support for Health Impact Assessments

Abstract Environmental epidemiology is a key function for the public health service with regards to investigating the public health effects of environmental hazards, monitoring the public health efforts to control the environmental risks, and providing the evidence that informs decisions making and preparedness. At the United Kingdom Health Security Agency (UKHSA), the Environmental Public Health Tracking (EPHT) Programme, initiated in 2010, has developed a number of data streams to help link environment and health data, to support Health Impact Assessment (HIA). The main aims of the EPHT programme in England are to: 1. Identify populations at risk from exposure to significant environmental and chemical hazards 2. Investigate relationships between hazard and disease 3. Inform public health policy making 4. Optimise intervention and prevention strategies 5. Generate hypotheses for further research. Such EPHT functions are based on three key components: a) by building a national EPHT program that integrates surveillance of environmental hazards, exposures and related health outcomes, to allow data linkage and assessment of environmental and health information; b) strengthening the epidemiology science, by conducting research and training of the workforce and c) developing strategies for response to immediate risks, incidents and preparing for future risks. Examples to support HIA include a) developing an air pollution exposure surveillance work programme, that has designed a pilot population vulnerability indicator; b) developing indicators for climate change impacts for public health, c) reporting regularly on the health impacts of public fluoridation water supply schemes (as mandated by Government) and d) exploring risk factors associated with elevated blood lead concentration in children, through laboratory reporting to surveillance systems. The talk will highlight some examples of practice and outline how the EPHT programme in England has supported HIA practices.

Evaluation of Airborne Lead Pollution and Its Association with Children's Urinary Lead Levels

Despite the measures taken by most countries, lead pollution still poses an environmental and health risk to humans, especially children. Therefore, the current study aims to evaluate lead in the air and its impact on children's health. Lead samples from the air and children's urine were collected from three different areas within Kerbala Governorate: the urban city center residential areas, and rural areas as a reference area for comparison. A suspended dust collector was used to collect lead samples, and then the lead concentration was measured using an atomic spectrometer after digesting them with acids. The results of the study showed that the highest concentration of lead was in the center of the urban area (3.150 ?g/m3) and its mean concentration in the air was 1.703 (?g/m3), which is higher than the US Environmental Protection Agency limits, with statistically significant differences between the study areas p < 0.01. The mean concentration of lead in children's urine was 0.622 (?g/dL) with statistically significant differences between the areas p < 0.01. Pearson's correlation coefficient indicated a significant positive correlation between the concentration of lead in the air and children's urine (r = 0.651; p < 0.05). This means that high lead concentrations in children's urine are due to lead air pollution and are an indicator of lead pollution in the environment and warn of potential risks to children's health. Therefore, the study recommends reducing lead emission sources and conducting periodic examinations.

Systematic Review of the Health and Equity Impacts of Remediation and Redevelopment of Contaminated Sites.

(1) Background: Globally there is a vast legacy of contaminated sites from past industrial, commercial and military activity, waste disposal, and mineral extraction. This review examined the extent to which the remediation of contaminated sites reduces health risks to new and existing populations. (2) Methods: Standard academic databases were searched for papers that reported on health-related outcomes in humans following remediation and redevelopment of contaminated sites. Title/abstract screening, followed by full-text screening identified sixteen papers that met the eligibility criteria. (3) Results: Most studies were set in the United States of America and reported changes in blood lead concentrations in children, following soil remediation and, in some cases, public health campaigns to reduce exposure. Two further studies examined the impacts of remediation on soil contaminated with chromium and sediments contaminated with polychlorinated biphenyls (PCBs). (4) Conclusions: Overall, the evidence suggests that remediation via removal, capping, and replacing soil, and planting vegetation is effective at reducing concentrations of lead and chromium in blood and urine in children. There is also evidence that sediment dredging can reduce PCB concentrations in umbilical cords in infants. Study designs are relatively weak and some recommendations are provided for those wishing to examine the health impacts of remediation.

The role of dietary factors on blood lead concentration in children and adolescents - Results from the nationally representative German Environmental Survey 2014–2017 (GerES V)

In industrialized nations, human lead exposure has decreased significantly in recent decades. Nevertheless, due to its toxic effects, this heavy metal remains a public health concern with children and adolescents being particularly at risk. In Europe nowadays, oral intake via food and drinking water is the predominant exposure pathway for lead. The objective of the present study was to investigate the association between dietary factors and blood lead (PbB) level of 3- to 17-year-old children and adolescents living in Germany, using data from the fifth German Environmental Health Survey (GerES V) and the Child and Adolescent Health Survey (KiGGS Wave 2). GerES V and KiGGS Wave 2 are two national population-representative studies conducted between 2014 and 2017, including measurement of lead concentrations in blood from 720 children and adolescents aged 3–17 years (mean age = 10.21, SD age = 4.36). Using multiple linear regression, sociodemographic and environmental characteristics as well as dietary factors could be identified as significant exposure determinants of PbB concentrations. Lead intake via domestic tap water was the strongest predictor of elevated PbB levels with 27.6% (p-value< .001) higher concentrations of highest compared to none lead intake via tap water. Other foods which were found to be relevant to PbB levels were meat, fruit, and fruit juice. While meat or fruit consumption were each associated with about 13% (p-value < .05) lower PbB levels, fruit juice drinking was associated with up to 12.2% (p-value = .04) higher PbB levels. In conclusion, results indicate the importance of dietary habits for lead exposure in children and adolescents. To protect vulnerable groups, it is recommended that future research and lead-reducing measures pay more attention to dietary links.

Reduction in Blood Lead Concentration in Children across the Republic of Georgia following Interventions to Address Widespread Exceedance of Reference Value in 2019.

In recent years, reports of lead contamination have dramatically increased in Georgia. Given concerns about the exposure of children to lead (Pb), the National Multiple Indicator Cluster Survey (MICS-2018) included a blood sampling component. The results showed that 41% of the children that participated had blood Pb levels (BLL) ≥ 5 µg/dL and that BLL in children living in Western Georgia were higher than those in Eastern regions. In response to these findings, NCDC implemented written and verbal advice to the families of children who participated in the MICS-2018 on how to reduce Pb exposure. From August 2019 onwards, the state program of clinical follow-up was implemented. The design of this study was a longitudinal study. The intervention of interest was the public health advice and medical follow-up, and the outcome was defined as the difference in BLL between the MICS-2018 survey and the state program follow-up. We observed a significant overall reduction in median BLL between MICS-2018 and state program follow-up in both August 2019 and the latest results (until December 2019). However, we did not observe any significant further reduction between August and the most recent BLL results. In the Georgian setting, written and verbal communication targeting individual households, alongside home visits to the most exposed, effectively reduced BLL in children.

Blood lead concentrations in children with iron deficiency anemia: a systematic review and meta-analysis.

Iron deficiency is the most common nutritional disorder detrimentalto the behavior, cognitive performance, immune system, and physical growth of infants and preschool- and school-age children.Iron deficiency anemia (IDA)increaseschildren's susceptibility to some metals, including the highly toxic lead (Pb), but the character of this relationship is still disputed. Thus, this study aimed to review and meta-analyze the association between the IDA and blood lead levels (BLL) among children, based on papers indexed by international scientific databases and published up to September 2021. A search was performed of the literature in several databases including the ISI Web of Science, PubMed, and Scopus. The final papers were assessed concerning their quality based on the Newcastle-Ottawa Scale (NOS) for cross-sectional studies. Moreover, analyses were performed using R statistical software with the "meta" package. Of the 1528 articles found, only 12studies met the inclusion criteria and were considered in the meta-analysis. Significantly higher BLL in IDA children (SMD = 2.40; CI 95%, 0.93-3.87µg/L; p = 0.0014) was seen when compared to non-IDA children. Moreover, the pooled OR is equal to 2.75 (CI 95%, 1.10-6.85µg/L; p = 0.0303) suggesting a higher risk of IDA development among children with BLL > 10µg/dL.Thus, we recommend systematic monitoring of Fe and Pb levels among children, especially in countries with limited sources of nutritious food. Since only a few studies were available for this meta-analysis, further studies are necessary to examine the association between IDA and BLL in detail.

A multimedia Environmental Model to Predict the Lead Concentration in Children’s Blood Near Al-Dorah Refinery in Baghdad

Lead-contaminated water, soil, and air have been perceived as potential sources of lead exposure for a considerable length of time, which continues to threaten human health; particularly that of young children. An Integrated Exposure, Uptake, and Biokinetic (IEUBK) as a human health risk model were applied to predict the Blood lead levels (BLLs) in children. A variety of data for air, soil, and water were obtained from the industrial region in Al-Dorah city in Baghdad for the period 2012- 2014. The result found that the predicted BLLs value of 11.17 μg/dL obtained from the IEUBK model was exceeding the agency’s threshold of concern of 10 μg/jdL which was considered as the lowest level of concern for BLL in children, this result of the IEUBK model was in agreement with the actual value of BLLs which were taken from previous literature for 24 blood samples of school children matched for age curried out in the same Al-Dorah region. This technique propels logical comprehension of the connection between BLLs in children and environmental media in both air and soil for the pollute condition. It can control national health-based benchmarks for lead and related community public health decisions.

Lead in children's jewelry: the impact of regulation.

In 2016 we identified a regulatory gap in Israel reflecting a lack of restrictions on lead in children's jewelry. We conducted surveys that found high levels of lead in children's jewelry. Following the findings, a new standard restricting lead content was introduced in 2018. The goal of this study is to assess whether the new standard had an impact on lead concentrations in children's jewelry on the market 4 months after entry into force, and to examine factors that influenced the standard's effectiveness. Thirty-five items of children's jewelry were sampled from stores in Israel in 2018. Lead content of 130 subsamples of these items was tested with X-ray Fluorescence Spectrometry (XRF). We compared these findings to those before the introduction of the standard. We also conducted five structured interviews with professionals from government ministries, industry and expert bodies to examine factors influencing the standard's enactment and implementation. 17% of jewelry samples exceeded the ASTM lead standard in 2018 compared with 50% in 2016. The mean of the jewelry subsamples analyzed in 2018 was 936 (±1700) compared to 1420 (±5740) ppm in 2016. Scientific and regulatory consensus among those setting the new standard led to its swift enactment. However, enforcement challenges may reduce the standard's impact. A new standard on lead in children's jewelry was followed by a decline in lead concentrations, but some products with lead exceedances remained available on the market. Public health campaigns, standards and compliance monitoring, and higher penalties will all help to reach the goal of protecting public health.

Blood lead levels in low-income and middle-income countries: a systematic review

Since the global phase-out of leaded petrol, reports have suggested that lead exposure remains substantial or is increasing in some low-income and middle-income countries (LMICs). However, few studies have attempted to systematically assess blood lead levels over the full range of LMICs. We aimed to describe values for blood lead level in LMICs. In this systematic review, we searched PubMed for studies published between Jan 1, 2010, and Oct 31, 2019, that reported blood lead levels in the 137 countries in World Bank LMIC groupings. Studies were reviewed for inclusion if they contained blood lead level data from human populations residing in any given country; comprised at least 30 participants; presented blood lead level data derived from venous, capillary, or umbilical cord samples of whole blood; had data that were collected after Dec 31, 2004; and were published in English. Data on blood lead level were extracted and pooled, as appropriate, to make country-specific estimates of the distribution of background blood lead levels among children and adults, along with information on specific sources of exposure where available. This study is registered with PROSPERO, number CRD42018108706. Our search yielded 12 695 studies, of which 520 were eligible for inclusion (1100 sampled populations from 49 countries comprising 1 003 455 individuals). Pooled mean blood lead concentrations in children ranged from 1·66 μg/dL (SD 3·31) in Ethiopia to 9·30 μg/dL (11·73) in Palestine, and in adults from 0·39 μg/dL (1·25) in Sudan to 11·36 μg/dL (5·20) in Pakistan. Background values for blood lead level in children could be pooled in 34 countries and were used to estimate background distributions for 1·30 billion of them. 632 million children (95% CI 394 million-780 million; 48·5%) were estimated to have a blood lead level exceeding the US Centers for Disease Control's reference value of 5 μg/dL. Major sources of lead exposure were informal lead acid battery recycling and manufacture, metal mining and processing, electronic waste, and the use of lead as a food adulterant, primarily in spices. Many children have a blood lead level exceeding 5 μg/dL in LMICs, despite leaded petrol phase-outs. Given the toxicity of lead, even at low amounts of exposure, urgent attention is required to control exposures and to expand population-based sampling in countries with no or scant data. This work was supported by the United States Agency for International Development (Cooperative Agreement number AID-OAA-A-16-00019).

Time for a change in blood lead reference value for Chinese children

In China, the first and also the latest version of national childhood lead exposure control guidelines was issued by the National Health Commission in 2006, when the reference value of high blood lead exposure was set at 100 μg/L and lead poisoning was set at 200 μg/L. Lead exposure levels have been decreasing in China over the last few decades, with almost all blood lead concentrations in children under 7 years of age being under 100 μg/L in non-industrial areas. However, lead concentrations lower than 100 μg/L in blood in children are associated with neurodevelopmental deficits. Thus, if the reference value remains at a high level, a large percent of children with exposure levels that are high but lower than the current reference value will be diagnosed as ‘safe’ and be ignored. Thus, we appeal that the reference value should be lowered according to local actual exposure level. A more stringent reference value would give care givers, doctors, communities, and officials more opportunities to take action earlier.

Heavy metal pollution and health risk assessment of soils from open dumps in the Metropolitan Area of Buenos Aires, Argentina.

We assessed heavy metal pollution and potential health risk by ingestion of soil in six open dumps in the Metropolitan Area of Buenos Aires (MABA), Argentina. For the determination of Cd, Cu, Ni, Pb, Zn, Hg, and Cr, soil samples were taken from the first 10cm using sampling grids installed between the boundaries of the waste final disposal sites and the beginning of the urban area. Soil samples were considered contaminated if at least one metal exceeded the maximum levels established by the Argentine regulation. Potential health risk by soil ingestion was calculated using deterministic analysis for both adults and children and stochastic analysis only for children. In 39.8% (N = 171) of the soil samples, the concentration of at least one metal was above the guide levels. Concentrations of Pb, Cu, and Zn exceeded maximum permissible values in all open dumps. Except for Hg, heavy metal concentrations differed significantly among open dumps. Hazard indexes > 1 were obtained for the children's population using both deterministic and stochastic models. The most sensitive variables in the stochastic model were exposure frequency and soil ingestion rate, together explaining 70% of the variation in the forecasts. The calculated risks were highly dependent on Pb concentrations. The determination of blood lead concentration in children and the assessment of other exposure routes are needed in areas of open dump influence in MABA.

Blood lead in children and associations with trace elements and sociodemographic factors

BackgroundNo safe blood lead concentration in children has been identified. Lead can affect nearly every system in the body and is especially harmful to the developing central nervous system of children.The aim of this study is to analyze blood lead in a population of children and its association with sociodemographic variables, biochemical parameters, copper, iron, selenium and zinc. MethodsWe recruited 155 children (86 boys and 69 girls) with a mean age of 7.3 (SD:4.1). Blood lead and serum selenium concentrations were measured by electrothermal atomic absorption spectrometry. Serum copper and zinc concentrations were measured by flame atomic absorption spectrometry. Serum iron levels were determined by colorimetric assay. A risk exposure questionnaire for lead was administered to the participants. ResultsThe median blood lead level was 1.1 (IQR 0.7–1.6) μg/dL. Regarding risk exposure factors, the youngest children (<2 years) who played outdoors presented a median blood lead concentration of 1.1 μg/dL IQR: 0.48–1.48, compared to the median of 0.3 μg/dL IQR:0.2-0.48 in the children who stated they played at home (p = 0.024). Significant differences were also found when taking into account those parents who smoked (median 1.3 IQR 0.8–1.9 μg/dL vs 0.9 IQR 0.5–1.4 μg/dL of non-smokers, p = 0.002). Children who drank tap water had higher blood lead levels (median 1.2 IQR 0.7–1.6 μg/dL) than those who drank bottled water (median 0.7 IQR 0.2–1.3 μg/dL p = 0.014). In addition, children whose mothers had not finished school had higher blood lead levels (median 1.7 IQR 1.2–2.3 μg/dL) than those whose mothers had finished school (median 1.2 IQR 0.7–1.7 μg/dL) and those whose mothers had gone to university (median 0.9 IQR 0.5–1.4 μg/dL) p = 0.034. In the multivariate lineal regression analysis we continue to observe the association between mother’s higher level of education and lower blood levels (p = 0.04) and the interaction between age and outdoor play (p = 0.0145). ConclusionsIn spite of the decline in blood lead concentrations, associated risk factors continue to exist in vulnerable populations such as children.

Koncentracija olova u krvi kod dece koja žive u blizini topionice olova i rudnika antimona u Srbiji

Objective of this cross-sectional study was to determine blood lead concentrations in children, living in the vicinity of the Zajača lead-antimony mining-milling-smelting complex. Other aims were to compare blood lead levels (BLLs) of exposed children to those of partially exposed and non-exposed, and correlate values of BLLs from two consecutive sampling series in 2012 and 2013. Performed laboratory method was atomic absorption spectrometry (AAS). Statistical significance of comparisons was tested by univariate methods and non-parametric tests for the attributable variables: Hi-square test, proportion test. In the case of non-parametric variables, following tests were used: Kolmogorov-Smirnov Z test for testing distribution's normality; ANOVA for the normal distribution, while a Kruskal Wallis Test was used in cases without normal distribution. 142 participants were tested on lead in blood: exposed, partially exposed, and non-exposed). Mean BLLs in children living at less than 1 km from the smelter was 18.98 µg/dl , at first test series, and 12.21 µg/dl, in the second round. For those living further than 3 km mean BLLs at first series was 8.30, and at the second series it was 5.85). Blood lead concentrations in children from Zajača are highest.

Nutritional status and diet as predictors of children's lead concentrations in blood and urine

Lead exposure remains an important public health problem. Contaminated foods may act as a source of lead exposure, while certain nutrients may reduce lead absorption. We examined the cross-sectional associations of dietary patterns and the intake of several nutrients and foods with blood (Pb-B) and urinary (Pb-U) lead concentrations in children (5–8y) from Montevideo, Uruguay. From two 24-hour recalls completed by caregivers, we derived the mean daily intake of select nutrients and food groups (dairy, milk, fruit, root vegetables, foods rich in heme and non-heme iron), as well as “nutrient dense” and “processed” food patterns. Pb-B (n=315) was measured using atomic absorption spectrometry; Pb-U (n=321) using ICP-MS. Pb-U was adjusted for specific gravity and log-transformed to approximate a normal distribution. Iron deficiency (ID) and dietary variables were tested as predictors of Pb-B and log-Pb-U in covariate-adjusted regressions. Median [5%, 95%] Pb-B and Pb-U were 3.8 [0.8–7.8] μg/dL and 1.9 [0.6–5.1] μg/L, respectively; ~25% of Pb-B above current U.S. CDC reference concentration of 5μg/dL. ID was associated with 0.75μg/dL higher Pb-B, compared to non-ID (p<0.05). Consumption of root vegetables was not associated with Pb-B or log-Pb-U. Higher scores on the nutrient-dense pattern were related with higher Pb-Bs, possibly due to consumption of green leafy vegetables. Dietary intake of iron or iron-rich foods was not associated with biomarkers of lead. Conversely, children consuming more calcium, dairy, milk and yogurt had lower Pb-B and log-Pb-U. Our findings appear consistent with existing recommendations on including calcium-rich, but not iron- or vitamin-C-rich foods in the diets of lead-exposed children, especially where the consumption of these foods is low.

Late effects of low blood lead concentrations in children on school performance and cognitive functions

BackgroundAlthough it is known that lead is a neurotoxin that negatively impacts cognitive functions at low blood concentrations (B-Pb), little is known about the impact of early exposure on later cognitive functions. ObjectivesThis study assesses the effects of very low lead exposure in early childhood on teenage cognitive performance. MethodsUsing data collected between 1978 and 2007, we analyzed B-Pb (median 30μg/L; six-fold decrease over time) in 3176 Swedish children (age 7–12). School performance in grade 9 (age 16; boys and girls) and over-all IQs measured during conscription examinations (age 18–19; mainly boys) were obtained from registers. In multivariate models, potential confounders (age at blood sampling, sex, parents’ education, family economy, and country of birth of child and parents) and effect modifiers (socioeconomic; father's IQ at conscription examination) were included. ResultsThere were statistically significant adjusted negative associations between school performance (Grades up to 1991: P<0.0001; Merits 1992-2007:P<0.0001) and IQ (P=0.03) and B-Pb. The dose–response relationships were non-linear. Effects were more pronounced for B-Pb≤50μg/L than for higher levels. In the B-Pb range 5–50μg/L, the average IQ loss corresponded to about 5 IU. There was no significant effect modification associated with socioeconomic factors. ConclusionsLead causes neurotoxic effects at very low exposures (B-Pb<50μg/L) in childhood and these effects remain for many years.

G325(P) Prevalence of high lead levels in children with global developmental delay and moderate to severe learning difficulty in Leeds and Wakefield: A cohort study

AimsExposure to Lead is still an ongoing problem in children. High blood levels have been associated with global developmental delay and learning difficulties. In the UK there is no reliable...

The Impact of Succimer Chelation on Blood Cadmium in Children with Background Exposures: A Randomized Trial

Succimer lowers blood lead concentrations in children, and the structure of succimer chelates of lead and cadmium are similar. Using blood samples from a randomized trial of succimer for lead poisoning, however, we found that succimer did not lower blood cadmium in children with background exposure.

Hair lead levels to evaluate the subclinical impact of lead on growth in Sardinian children (Italy)

The aim of this study was to determine if there are significant relationships between lead concentrations in children's hair and height, sitting height, and estimated leg length. We analyzed three samples collected at different times: 1998, 2002, 2007. The total sample consisted of 825 children between 11 and 14 years of age living in different municipalities of Sardinia (Italy). Inductively coupled plasma atomic emission spectrometry (1998), inductively coupled plasma atomic absorption spectrometry (2002), and inductively coupled mass spectrometry (2007) were used to measure the lead concentration in hair (PbH). Some AAS measurements were also performed on the 1998 and 2007 samples to check the reliability of the data. The mean PbH is much higher in 1998 (5.84 μg/g) than in 2002 (1.49 μg/g) and 2007 (0.78 μg/g). Multivariate regression analysis of the three samples, controlling for age and sex, indicates a subclinical impact of lead on growth that differs according to the mean lead concentration in the hair. In fact, for 1998, the relationships between all three anthropometric variables and logPbH are significantly negative. For 2002, there are significant negative associations between height and estimated leg length and logPbH but not between sitting height and logPbH. For 2007, there are not significant associations between logPbH and anthropometric variables. Our results support the use of hair lead levels as a biomarker to assess the impact of subclinical lead on the physical growth of children, especially when the study area presents medium and/or high levels of lead pollution.

Efficacy of Succimer Chelation of Mercury at Background Exposures in Toddlers: A Randomized Trial

To examine whether succimer, a mercaptan compound known to reduce blood lead concentration in children, reduces blood mercury concentration. We used samples from a randomized clinical trial of succimer chelation for lead-exposed children. We measured mercury levels in pre-treatment samples from 767 children. We also measured mercury levels in blood samples drawn 1 week after treatment began (n = 768) and in a 20% random sample of the children who received the maximum 3 courses of treatment (n = 67). A bootstrap-based isotonic regression method was used to compare the trend with time in the difference between the adjusted mean mercury concentrations in the succimer group and that in the placebo group. The adjusted mean organic mercury concentration in the succimer group relative to the placebo group fell from 99% at baseline to 82% after 3 courses of treatment (P for trend = .048), but this resulted from the prevention of the age-related increase in the succimer group. Succimer chelation for low level organic mercury exposure in children has limited efficacy.

Low dietary quality is related to high blood lead concentration in school aged children

Lead is a toxic metal widely spread in the environment with bioaccumulative features that raises public health concern. Diet might be associated with blood lead concentration in children. In order to evaluate the association between dietary intake and blood lead concentration, a cross‐sectional study was conducted on 2,050 children aged 7 to 8 years residing in urban areas in Korea while assessing dietary intake by a semi‐quantitative food frequency questionnaire and blood lead concentration by the graphite furnace atomic absorption spectrophotometer. Children were divided into high (n=617) and low (n=1,433) lead groups using a 2 μg/dl cutoff point. In multivariate logistic regression analyses, higher intakes of vegetable protein and iron, phosphorous, potassium, zinc, folic acid and vitamin E were related to lower blood lead concentration. Blood lead concentration was associated positively with intakes of white rice, ramyun, salted vegetables, ice cream and soft drink, and negatively with mixed rice, spinach, seaweed, fruits, and white milk consumptions. These findings suggest low dietary quality may be a risk factor for high blood lead concentration in children. (Supported by a grant from the Ministry of Environment, Korea in 2006)