National Guard Health Affairs Research Articles

BRCA 1 and BRCA 2 mutations in Saudi breast cancer patients (single institution).

10 Background: Breast cancer is the commonest malignancy among Saudi females accounting for 25% of all female cancers with a median age at diagnosis of 47 years (1,2). In Saudi, breast cancer showed an increased incidence attributed to many factors such as different lifestyles, reproductive pattern, family history, which was reported to account for 59%, dietary or cultural practice of Saudi women (2,3,4,5). The multifunctional and highly penetrant BRCA 1 and BRCA 2 are the two major breast cancer pre-disposition genes, accounting for about 20% of breast cancer families (6,7). To our knowledge, the prevalence of BRCA 1 and BRCA 2 mutations in native Saudi population is sparse (8,9). Our aim is to describe the findings of BRCA mutation testing in native Saudi patients with breast cancer in a large Ministry of National Guard Health Affairs (NGHA) community-based teaching hospital. Methods: In this study, 75 out of 516 patients with breast cancer who were clinically and histopathologically diagnosed at NGHA from October 2010 to April 2014 were included. Selection criteria: aged ≤ 40 years bilateral breast cancer, triple-negative breast cancer, strongly first degree family history at young age and male breast cancer. Molecular alterations were performed by direct gene sequencing, multiple ligation – dependent probe amplification (MLPA) at Bioscentia human genetic testing in Germany. Results: 75 native Saudi were enrolled and test performed for them. 18 patients (24%) were found to have mutation of which 10 in BRCA One and six in BRCA 2. Two have both BRCA 1 and BRCA 2. Seven patients have the same with deleterious mutations in BRCA 1 gene. Two of them are mother and daughter and other five are unrelated. The mean age of breast cancer diagnosis in the mutation carriers was 38 years. Triple negative breast cancer (TNBC) diagnosed in six patients, bilateral breast cancer diagnosed in one, first-degree family history in eight and second degree in 10 patients and four with no family history. Conclusions: BRCA 1 and BRCA 2 mutations are an important contributor to the etiology of breast cancer in Saudi women. A mutation in BRCA 1, C 1648 > C p, Asn550His in exon 10 has been reported as disease causing (11) and it is found in our study in seven patients. Such mutation might be specific for Saudi, so further studies are highly recommended.

Do we Achieve the Targets for Diabetic Patients; Deep Looks to Primary Care Practice

Introduction: Diabetes care to the standard targets is an art need trained health care provider’s work in harmony. It is not an easy job; it is a continuous process of hard team works. Primary care practice is a busy practice where diabetes care is part of a complex daily care covering other health problems. In spite of this multiple daily care services, we raised the question if our care took our patients to meet target goals settled by the American diabetes association or not?. Assessing the current situation is the first step to catch the standards. Objectives: To determine the degree of glycemic control by using HbA1c and lipid profile control by measuring total cholesterol, low density lipo-protein, high density lipo-protein and triglycerides. To detect variations in HbA1c, lipid or Vit D control during the year 2013 Methodology: Cross sectional study was designed and conducted at Alwaha medical specialist center; one of the National Guard health affairs / WR primary care centers. Chronic disease registry was designed. A list of 1224 diabetic patients' records were reviewed and 302 patients' records were randomly selected. HbA1c values were detected with total cholesterol (T-Chol), low density lipoprotein (LDL) and vitamin D. HbA1c and lipid profiles were clustered into three groups; group A (1st Jan – 30st April 2013), group B (1st May – 31st August 2013). Group C (1st Sep – 31st Dec 2013). The American Diabetes Association 2014 target goals for diabetic patients were adopted. Data was collected and analyzed using SPSS software. Results: Three hundred and two, medical records were reviewed (110 males, 192 females) with mean age 57.31 ± 11.47. The overall means of HbA1c 8.73 ± 2.04 , total cholesterol (T-Chol) 4.6 ± 1.17 mmol/L, low density lipoprotein (LDL) 2.7 ± 0.85 mmol/L, high density lipoprotein (HDL) 1.02 ± 0.23 mmol/L, Triglyceride (TG) 1.68 ± 1.08 mmol/L and vitamin D 42.32 ± 22.56 nmol/l were calculated as shown. There were no statistical differences in HbA1c between groups A vs B or C (7.65 ± 3.49 vs 8.03 ± 2.85 and 7.69 ± 3.28), P values were 0.3 and 0.9. For Vit D means there were no statistical differences between groups (32.46 ± 26.12 nmol/l vs 31.83 ± nmol/l and 29.54 ± 29.68 nmol/l; P values were 0.8 and 0.36. There was no statistically difference between male and female in their overall mean HbA1c values (HbA1c 8.49 ± 1.86 vs 8.86 ± 2.14); P value was 0.13. Males showed better LDL means than females; 2.54 ± 0.88 vs 2.81 ± 0.83 (P value 0.0082). Interestedly, those who did there HbA1c once, twice and thrice were 42.4%, 31.8% and 25.8% respectively while 61.2% meet ADA HbA1c target goal. Conclusion: Targeted glycemic and lipid control was difficult to achieve in primary care setting. More studies were recommended to analyzed barriers to achieve control and how to overcome them.

National Guard Health Affairs

National Guard Health Affairs

RETRACTED: Attitudes of Saudi Nursing Students on AIDS and Predictors of Willingness to Provide Care for Patients in Central Saudi Arabia

1. Mostafa A. Abolfotouh[1][1] 2. Samar A. Al Saleh[1][1] 3. Aisha A. Mahfouz[1][1] 4. Sherif M. Abolfotouh[2][2] 5. Haya M. Al Fozan[3][3] 1. 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia 2. 2Alexandria University, Egypt 3. 3King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 1. Mostafa A. Abolfotouh, Biobanking Section, King Abdullah International Medical Research Center (KAIMRC), Mail Code 1515, King Saud Bin-Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, National Guard Health Affairs, P.O.B 22490, Riyadh 11426, Saudi Arabia. Email: mabolfotouh{at}gmail.com This study aimed to assess acquired immune deficiency syndrome (AIDS)-related knowledge, attitudes, and risk perception among Saudi nursing students, and to identify predictors of their willingness to provide care for patients with AIDS. A cross-sectional study of 260 baccalaureate nursing students at King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, was done using a previously validated instrument. Students’ knowledge percentage mean score (PMS) on AIDS was 72.93 ± 10.67 reflecting an average level of knowledge. There were many misconceptions about how AIDS is transmitted, for example, use of same toilets and bathrooms and washing clothes together (24.9%), swimming (53.7%), and coughing and sneezing (49.6%). Nursing students reported an overall negative attitude toward AIDS, with a PMS of 43.48 ± 9.21. The majority of students agreed that AIDS patients should be isolated from other patients (83%), and should not share the room with other noninfected patients (81.8%), and some reported that people living with AIDS deserve what has happened to them (24.7%). After controlling for confounders, students’ poor knowledge and negative attitude were associated only with having never been given nursing education as their primary university education “Stream 2 students” ( p = .012 and p = .01, respectively). These findings have implications for development of teaching strategies and curricular approaches for nursing to address this health care issue. [1]: #aff-1 [2]: #aff-2 [3]: #aff-3

Novel frameshift mutations in ADAMTS13 in two families with hereditary thrombotic thrombocytopenic purpura

Pediatric Blood & CancerVolume 60, Issue 9 p. 1559-1560 Letter To The Editor Novel frameshift mutations in ADAMTS13 in two families with hereditary thrombotic thrombocytopenic purpura Abdulrahman Alsultan, Corresponding Author Abdulrahman Alsultan Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia Correspondence to: Abdulrahman Alsultan, MD, Department of Pediatrics, College of Medicine, King Saud University, PO Box 261691, Riyadh 11342, Saudi Arabia. E-mail: aalsultan1@ksu.edu.saSearch for more papers by this authorMohammed Jarrar, Mohammed Jarrar Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi ArabiaSearch for more papers by this authorTalal Al-Harbi, Talal Al-Harbi Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi ArabiaSearch for more papers by this authorMohammed AL Balwi, Mohammed AL Balwi Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia King Abdullah International Medical Research Center, Riyadh, Saudi Arabia College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSearch for more papers by this author Abdulrahman Alsultan, Corresponding Author Abdulrahman Alsultan Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia Correspondence to: Abdulrahman Alsultan, MD, Department of Pediatrics, College of Medicine, King Saud University, PO Box 261691, Riyadh 11342, Saudi Arabia. E-mail: aalsultan1@ksu.edu.saSearch for more papers by this authorMohammed Jarrar, Mohammed Jarrar Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi ArabiaSearch for more papers by this authorTalal Al-Harbi, Talal Al-Harbi Department of Oncology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi ArabiaSearch for more papers by this authorMohammed AL Balwi, Mohammed AL Balwi Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia King Abdullah International Medical Research Center, Riyadh, Saudi Arabia College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSearch for more papers by this author First published: 16 May 2013 https://doi.org/10.1002/pbc.24594Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume60, Issue9September 2013Pages 1559-1560 RelatedInformation

Parental Knowledge , Attitude and Practice on Antibiotic Use for Upper Respiratory Tract Infections in Children

Background: Several factors are evidently associated with the overuse of antibiotics both at the doctor`s level and the parents of children level. Objectives: To assess the level of knowledge and practice of parents about antibiotics use for upper respiratory tract infection (URTI) in their children as well as to determine the contributing factors for inappropriate use. Material and Methods: A cross-sectional study was carried out in two PHC centres in National Guard Health Affairs, Riyadh, between 1 January 2012 and 29 February 2012. It included parents of children (age from birth to 12 years) presenting with URTI symptoms. Results: The study included 352 parents of Saudi children. Most of the parents (71%) reported doctors as their source of antibiotic information. Only 1.4% of the participants identified correctly all antibiotics while 35.8% of them did not identify any antibiotic correctly. Factor analysis showed that the three common underlying factors responsible for antibiotics overuse were: parental self-prescribing tendency, parental tendency of asking for antibiotics from doctor and parental carefree attitude regarding over use and the three common underlying factors responsible for cautious approach to antibiotics use were: parental cautious nature, parental preference of advice over antibiotics and parental belief that URTI are mostly self-limiting. Conclusions: Parents are self-prescribing because of their easy access of antibiotics without prescription and their indifferent attitude toward microbial resistance.

Evaluation of off-service rotations at National Guard Health Affairs: Results from a perception survey of off-service residents

Context:“Off-service” clinical rotations are part of the necessary requirements for many residency training programs. Because these rotations are off-service, little attention is given to their structure and quality of training. This often leads to suboptimal educational experience for the residents on these rotations.Aims:The aim of this study was to assess medical residents’ perceptions, opinions, and levels of satisfaction with their “off-service” rotations at a major residency training site in Saudi Arabia. It was also to evaluate the reliability and validity of a questionnaire used for quality assurance in these rotations. Improved reliability and validity of this questionnaire may help to improve the educational experience of residents in their “off-service” rotations.Materials and Methods:A close-ended questionnaire was developed, Pilot tested and distributed to 110 off-service residents in training programs of different specializations at King Fahad Naitonal Guard Hospital and King Abdulziz Medical City, Riyadh, Saudi Arabia, between September 2011 and December 2011.Results:A total of 80 out of 110 residents completed and returned the questionnaire. Only 33% of these residents had a clear set of goals and educational learning objectives before the beginning of their off-service rotations to direct their training. Surgical specializations had low satisfaction mean scores of 57.2 (11.9) compared to emergency medicine, which had 70.7 (16.2), P value (0.03). The reliability of the questionnaire was Cronbach's alpha 0.57. The factor analysis yielded a 4-factor solution (educational environment, educational balance, educational goals and objectives, and learning ability); thus, accounting for 51% variance in the data.Conclusion:Our data suggest that there were significant weaknesses in the curriculum for off-service clinical rotations in KAMC and that residents were not completely satisfied with their training.

Awareness, Attitude, and Concerns of Workers and Stakeholders of an Environmental Organization Toward the Environment

1. Siham H. Shoukry[1][1] 2. Samia G. Saad[2][2] 3. Ayman M. Eltemsahi[3][3] 4. Mostafa A. Abolfotouh[2][2] 1. 1Alexandria Sanitary and Drainage Company, Egypt 2. 2University of Alexandria, Egypt 3. 3Arab Academy for Science, Technology and Maritime Transport, Alexandria, Egypt 1. Mostafa A. Abolfotouh, Biobanking Section, King Abdullah International Medical Research Center, King Saud Bin-Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box 22490, Riyadh 11426, Saudi Arabia Email: mabolfotouh{at}gmail.com Environmental issues such as environmental attitudes are important socioenvironmental subjects for the non-Western countries such as Egypt. This study aimed to determine levels of attitude, awareness, and concern toward environmental issues among Alexandria Sanitary and Drainage Company (ASDCO) workers and stakeholders. A total of 284 participants (199 [70%] workers and 85 [30%] stakeholders) were surveyed by the New Ecological Paradigm (NEP) scale of environmental attitude. Descriptive and analytic statistics were applied, and significance was considered at p ≤ .05. Respondents showed low awareness to environmental laws and guidelines (23.8% ± 33.2%), neutral attitude toward ecological issues (66.1% ± 6.2%), and high concern about different environmental problems (74.5% ± 26.3%). Awareness score was significantly and positively associated with attitude (χ2 = 8.63, p = .013) and worry (χ2 = 8.68, p = .013) scores. Respondents are quite aware that legislation is the key role in protection of environment. This study reflects low level of knowledge and high concern to different environmental problems. Knowledge is consistently and positively related to attitudes. Planning training and management needs to be linked to the environmental goals and objectives of the company. [1]: #aff-1 [2]: #aff-2 [3]: #aff-3

Acute renal failure and severe rhabdomyolysis in a patient with resistant thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder. This paper describes the case of a 39-year-old Sudanese male who presented to the emergency room with fever, jaundice, decreased level of consciousness, and worsening kidney function for 7 days, a high lactate dehydrogenase level (1947), severe thrombocytopenia (platelets 8), and numerous schistocytes in the peripheral blood smear. The patient was admitted with a diagnosis of TTP for plasma exchange. Fourteen days later, his creatinine kinase (CK) level rose to >50,000 IU; rhabdomyolysis was suggested. Continuous venovenous hemodialysis (CVVHD) was started. The patient’s CK level remained high, despite CVVHD, until the 6th day, after which this parameter gradually started to decrease. This report highlights a resistant case of TTP that presented with concomitant severe rhabdomyolysis, which demanded aggressive, continuous intervention.

InnoDiff: A project-based model for successful IT innovation diffusion

In spite of the importance of information technology (IT) for many organizations to help manage the enterprise daily transactions, IT project failure rates still remain high and are of great concern. This obliges continued exploration of new process models and organization structures to nurture strong project performance. This paper presents a new generic model for successful implementation of IT projects referred to as InnoDiff. The model uses Enterprise Resource Planning (ERP) as a test bed. Furthermore, the paper also presents a case study that demonstrates the detailed application of InnoDiff during the course of executing the Human Resource Management System (HRMS) within the Wide Access Network (WAN) at the National Guard Health Affairs (NGHA) in Saudi Arabia.

Implementation of computerized physician order entry in National Guard Hospitals: assessment of critical success factors.

Objective:The purpose of this study is to describe the needs, process and experience of implementing a computerized physician order entry (CPOE) system in a leading healthcare organization in Saudi Arabia.Materials and Methods:The National Guard Health Affairs (NGHA) deployed the CPOE in a pilot department, which was the intensive care unit (ICU) in order to assess its benefits and risks and to test the system. After the CPOE was implemented in the ICU area, a survey was sent to the ICU clinicians to assess their perception on the importance of 32 critical success factors (CSFs) that was acquired from the literature. The project team also had several meetings to gather lessons learned from the pilot project in order to utilize them for the expansion of the project to other NGHA clinics and hospitals.Results:The results of the survey indicated that the selected CSFs, even though they were developed with regard to international settings, are very much applicable for the pilot area. The top three CSFs rated by the survey respondents were: The “before go-live training”, the adequate clinical resources during implementation, and the ordering time. After the assessment of the survey and the lessons learned from the pilot project, NGHA decided that the potential benefits of the CPOE are expected to be greater the risks expected. The project was then expanded to cover all NGHA clinics and hospitals in a phased approach. Currently, the project is in its final stages and expected to be completed by the end of 2011.Conclusion:The role of CPOE systems is very important in hospitals in order to reduce medication errors and to improve the quality of care. In spite of their great benefits, many studies suggest that a high percentage of these projects fail. In order to increase the chances of success and due to the fact that CPOE is a clinical system, NGHA implemented the system first in a pilot area in order to test the system without putting patients at risk and to learn from mistakes before expanding the system to other areas. As a result of the pilot project, NGHA developed a list of CSFs to increase the likelihood of project success for the expansion of the system to other clinics and hospitals. The authors recommend a future study for the CPOE implementation to be done that covers the implementation in all the four NGHA hospitals. The results of the study can then be generalized to other hospitals in Saudi Arabia.

Epidemiology of invasive pneumococcal infection in children aged five years and under in Saudi Arabia: a five-year retrospective surveillance study

The epidemiology of invasive pneumococcal disease (IPD) in children aged <or=5 years in Saudi Arabia has not been described. We conducted a retrospective surveillance study to describe the epidemiology of IPD in the population of children aged <or=5 years served by the National Guard Health Affairs hospitals in central and western regions of Saudi Arabia. We reviewed the medical records of children <or=5 years old admitted to the King Abdulaziz Medical City hospitals in Riyadh and Jeddah with pneumococcal infections for the period January 1999 through December 2003. Only microbiologically confirmed IPD cases (meningitis or bacteremia) were included in the analysis. A total of 82 IPD cases, 19 (23.2%) meningitis and 63 (76.8%) bacteremia, were diagnosed during the five-year period. Of these, 12.2% (10/82) died, with a case-fatality slightly but insignificantly higher in cases of meningitis (15.8%) than bacteremia (11.1%). The average annual IPD incidence was 17.4 per 100,000 (4.0 for meningitis and 13.4 for bacteremia). The incidence was roughly similar in males and females (18.3 and 16.6, respectively; p=0.663) and was almost 4-fold higher in the first year of life compared to the next four years (40.6 and 11.5, respectively; p<0.001). The average annual IPD mortality was 2.1 per 100,000 and was higher in the first year of life compared to the next four years (5.2 and 1.3 , respectively; p=0.043). In the pre-vaccination era (1999-2003) in Saudi Arabia, IPD incidence was comparable to the pre-vaccination incidence rates from many industrialized countries, with children aged <or=1 year suffering the highest IPD risk among those aged <or=5 years.

Incidence trends of viral hepatitis A, B, and C seropositivity over eight years of surveillance in Saudi Arabia

In Saudi Arabia, viral hepatitis ranked the second most common reportable viral disease in 2007, with almost 9000 new cases diagnosed in that year. The objective of this study was to determine the incidence trends of viral hepatitis seropositivity among the population served by the National Guard Health Affairs (NGHA) hospitals in the central, eastern, and western Saudi Arabia regions. The surveillance system at King Abdulaziz Medical City in Riyadh receives weekly reports of laboratory confirmed hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV) cases from all NGHA-served regions. In this study the viral hepatitis surveillance data for the period from January 2000 through December 2007 were analyzed. Between 2000 and 2007, a total of 14 224 seropositive cases of viral hepatitis were reported to the surveillance system. The average annual incidence of seropositivity per 100 000 served population was highest for HBV (104.6), followed by HCV (78.4), and lowest for HAV (13.6). Saudis had higher HBV and HAV incidence, but lower HCV incidence compared to non-Saudis. Over the eight years (2000-2007), the incidence of all three viral hepatitis types showed a 20-30% declining trend. Only HAV incidence followed a clear seasonal cyclic pattern. Despite the declining trend over the eight-year period, viral hepatitis, especially that caused by HBV and HCV, remains a major public health problem in Saudi Arabia, and has probably been underestimated in previous reports. There is a need for more comprehensive prevention strategies.

Diabetes control in a primary care setting: a retrospective study of 651 patients.

BACKGROUND AND OBJECTIVESAs part of an ongoing evaluation of the process of care, the management of type 2 diabetes in primary healthcare settings was studied in a series of audits with the objective of improving diabetes care in a primary care center of the Saudi National Guard Health Affairs, Riyadh, Saudi Arabia.METHODSA sample of 30 files was randomly selected every 2 weeks from a sampling frame of medical records of type 2 diabetes patients seen over the previous two weeks. The criterion of good management was arbitrarily defined as a glycated hemoglobin (HbA1c) less than 7%, with a test frequency of once every 3 months. The proportion of patients not conforming to the criterion was reported back to the care providers. Specially trained nurses did all randomization, data extraction, and entry.RESULTSData were extracted form 651 medical records, including 355 (54.5%) for females and 296 (45.5%) for males. Both the mean and median age of those studied was 53 years. Mean HbA1c was 9.0±2.0%, mean fasting plasma glucose was 9.9±3.9 mmol/L, and mean 2-hour postprandial plasma glucose was 15.0±5.3 mmol/L. In 20.6% (134/651) (95% CI, 17.5%–23.9%) of patients the HbA1c level was less than 7%. Only 10.4% (68/651) (95% CI, 8.2%–13.0%) had HbA1c measured in the previous 3 months that was less than 7.0% and thus met the criterion for good management. In the previous 3 months, 55.4% (95% CI, 51.5%–59.3%) had been tested for HbA1c.CONCLUSIONSManagement of diabetes at the primary care level leaves much to be desired. There is a need for an ongoing process of evaluation to follow up the implementation of care guidelines.

Management of community-acquired pneumonia at a tertiary care medical center in Lebanon.

ANTOINE J. CHERFAN, PHARM.D., is Clinical Pharmacist, Pharmaceutical Care Department, National Guard Health Affairs—King Abdulazis Medical City, Riyadh, Saudi Arabia. ABDUL RAHMAN N. BIZRI, M.D., M.SC., DLSHTM, is Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, and SOUZAN W. STEITIEH, B.SC., is Research Assistant, Faculty of Health Sciences, Department of Epidemiology and Biostatistics, American University of Beirut Medical Center, Beirut, Lebanon. OUSSAYMA E. MOUKHACHEN, PHARM.D., BCPS, is Clinical Assistant Professor, School of Pharmacy, Lebanese American University, Byblos, Lebanon. Address correspondence to Dr. Moukhachen at the School of Pharmacy, Lebanese American University, P.O. Box 36, Byblos, Lebanon (omoukhachen@lau.edu.lb). Presented at the ASHP Midyear Clinical Meeting, New Orleans, LA, December 2001.