Number Of Hospitalizations For Asthma Research Articles

Effect of the COVID-19 pandemic on asthma exacerbations in New Zealand: An interrupted time series analysis.

New Zealand (NZ) implemented some of the strictest restrictions during the novel coronavirus pandemic (coronavirus disease 2019 [COVID-19]), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). How this impacted asthma exacerbation rates in NZ is unknown. We sought to explore the effects of the COVID-19 restrictions on asthma exacerbations in NZ during 2020. We used a population-based, interrupted time series to examine the impact of the first COVID-19 lockdown in NZ on asthma exacerbation rate. The primary outcome measure was change in the monthly exacerbation rate, defined as hospitalization and/or course of corticosteroids, before and after the first lockdown. In a secondary analysis, we quantified the number of patients with asthma, the actual asthma exacerbation rate from March to December 2019 versus March to December 2020, and the number of asthma hospitalizations. There was a significant drop in the exacerbation rate immediately after lockdown (-3.02; P< .0001) followed by a significant and sustained increasing trend; the rate postlockdown increased relative to that prelockdown (0.27; P< .0001). Similar patterns were observed in all sociodemographic groups. In our secondary analysis, we identified 507,622 people with asthma; this reduced to 458,023 in 2020 postlockdown. The overall asthma exacerbation rate was 33.3% less in 2020 than in 2019 (reduction from 48.6/1000 patients to 32.4/1000 patients). The rate of asthma hospitalizations decreased from 9.5 per 1000 patients in 2019 to 6.2 per 1000 patients in 2020; this decrease was observed across all demographic groups. The first COVID-19 lockdown in 2020 in NZ significantly reduced asthma exacerbation rates across all sociodemographic groups. Whether these reductions are sustained requires further investigation.

Association between hospitalizations for asthma exacerbation and weather conditions in Qingdao: an ecological study.

BackgroundThe hospitalization for asthma exacerbation has varied with seasons, however, the underlying weather reasons have not been fully explored yet. This study is aimed to explore the effect of weather factors on increased number of hospitalization due to worsening of asthma symptoms. This will provide more information to the relevant authorities to allocate appropriate medical resources as per the weather conditions in Qingdao, China.MethodsAll adult patients admitted for asthma exacerbation from 1 January, 2017 to 31 December, 2019 were enrolled from 13 main hospitals of Qingdao. The clinical data, including age, sex, smoking history, etc., were collected from the electronic medical record (EMR) systems. The hourly air quality of Qingdao from 2017–2019, including the air quality index (AQI), PM2.5 and PM10, was obtained from the China National Environmental Monitoring Centre. All these parameters during 2017–2019 were compared monthly. For meteorological data, the monthly horizontal wind at 850 hPa and vertical velocity at 500 hPa during 1960–2020 were obtained from National Center for Environmental Prediction (NCEP) and the National Center for Atmospheric Research (NCAR) global reanalysis dataset. The correlation analysis was applied to determine the association between asthma hospitalizations and the environmental factors, including atmospheric pressure, humidity, vertical visibility, and etc., monthly.ResultsIn all, 10,549 asthmatic inpatients (45.7% males, 54.3% females) were included in the study. The inpatients number for asthma exacerbation had a plateau lasting from March to June of 2019, accompanied with high PM2.5 and PM10, as well as bad air quality from January to March of 2019, potentially governed by the El Niño event in 2018. However, there was no significance correlation between the number of asthma hospitalizations and the average value of all environmental factors.ConclusionsThe high rate of hospitalization for asthma exacerbation in Qingdao during the spring of 2019 was associated with the unfavorable weather conditions, which might be linked to the atmospheric circulation in East Asia.

Study of the impact of anti-tobacco legislation on public health in the Russian Federation

Abstract Background Smoking increases the risk of developing many diseases, both non-infectious and infectious. On February 23, 2013, the Russian Federation adopted an anti-smoking law, which provided for a two-stage ban on smoking in public places. Since June 1, 2013, smoking has been banned in schools, hospitals, public transport, railway stations, workplaces, and since June 1, 2014 - in trains, hotels, bars, restaurants. Purpose To study the dynamics of monthly hospitalization rates for respiratory diseases and acute otitis media in three regions of the Russian Federation (Chuvash Republic, Samara and Arkhangelsk regions). Methods A retrospective analysis of the monthly hospital incidence of pneumonia of various etiologies (ICD-10 J12-J18), other acute lower respiratory infections (J20-J22), asthma (J45), status asthmaticus (J46) and acute otitis media (H65.0, H65.1, H66.0) from 2012 to 2017. The data were analyzed by the method of interrupted time series. The information was provided by the regional Fund of Medical Insurance. Results Two control points were identified - June 2013 and June 2014. We demonstrated the reduction of hospitalization rates for acute lower respiratory infections and pneumonia immediately after each of the two stages of the anti-smoking policy implementation in all regions studied. In the Arkhangelsk region, the decrease was 19% in 2013 and 22% in 2014, in the Samara region - 20% and 23%, and in the Chuvash Republic - 31% and 39%. The reduction of hospitalization for asthma, status asthmaticus and acute otitis media was observed only in Chuvash Republic: the decrease in the number of hospitalizations for asthma and status asthmaticus was 11% in 2013 and 12% in 2014, and for acute otitis media - 25% and 35%. In other regions the decline was non-significant. Conclusions Anti-tobacco legislation leads to an immediate and significant reduction in the number of hospitalizations for lower respiratory tract infections. Key messages The ban on smoking in public places reduces infections of the lower respiratory tract and acute otitis media. Anti-tobacco legislation has a positive impact on public health.

Asthma and Indoor Environment: Usefulness of a Global Allergen Avoidance Method on Asthma Control and Exposure to Molds

The usefulness and feasibility of a global allergens avoidance method with counselors visiting patients' home for allergens measures and adapted advices were prospectively evaluated through asthma control and environment evaluation. Twenty seven patients were prospectively included and compared to a cohort of 30 control patients. The level of control of asthma at inclusion and after 1 year was evaluated by the clinical signs, the evolution of the FEV1, and the healthcare use. Environmental measurements included the fungal load of 5 surfaces of the dwellings and the evaluation of moisture. A significant clinical improvement in the population that benefited from the home counselors visit was observed compared to the baseline (p < 0.0001), as well as a decreased number of hospitalizations for asthma and of the consumption of anti-asthma drugs (p < 0.01). Dampness markers slightly improved with an improvement of the fungal loads in two-third of the dwellings.

The Effect of Parental Smoking on the Severity of Asthma in Children: A Cross-Sectional Study

BACKGROUND: Several environmental factors trigger attacks of asthma by immunological and non-immunological mechanisms. Among these factors are cited the passive or second hand smoking (SHS) which has a deleterious effect on the prognosis of childhood asthma and induces a resistance to treatment by corticosteroids. The aim of the present study was to identify parents of children with asthma who are smokers and to explore the possible negative impact of SHS exposure on the disease of asthmatic children.MATERIALS &amp; METHODS: A cross sectional study was conducted from February 2012 to February 2013.The study population consisted of children with asthma. The information concerning the patients was collected from their medical records filled out by the physician in a clinical setting in direct communication with the patients, or their parents when it is a little child. A group of 100 children age between 2 and 15 years, with asthma were recruited for the study. The study children were divided into two groups: cases with 28 children from smoking families, and controls with 73 children from non-smoking families. Analysis of the number of respiratory infections, asthma exacerbations per year, and the average number of hospitalization was done in both groups.RESULTS: Pearson chi2 test was adopted. We showed that smoking among the father was positively correlated with a higher number of hospitalizations for asthma, higher incidence of lower respiratory tract infections and asthma exacerbations. Similarly, the maternal smoking was positively correlated with a higher number of hospitalizations for asthma, lower respiratory tract infections and asthma exacerbations.CONCLUSION: Passive smoking causes respiratory illness, asthma, poor growth, neurological disorders in children. To avoid the risk of respiratory and allergic diseases by environmental tobacco smoke, absolute smoking cessation by parents is strongly recommended.

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

ABSTRACTObjective: To examine the effect of ambulatory health care processes on asthma hospitalizations. Methods: A retrospective cohort study using electronic health records was completed. Patients aged 2–18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. Results: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09–1.78). Conclusions: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.

Fuzzy model to estimate the number of hospitalizations for asthma and pneumonia under the effects of air pollution.

ABSTRACTOBJECTIVE Predict the number of hospitalizations for asthma and pneumonia associated with exposure to air pollutants in the city of São José dos Campos, São Paulo State.METHODS This is a computational model using fuzzy logic based on Mamdani’s inference method. For the fuzzification of the input variables of particulate matter, ozone, sulfur dioxide and apparent temperature, we considered two relevancy functions for each variable with the linguistic approach: good and bad. For the output variable number of hospitalizations for asthma and pneumonia, we considered five relevancy functions: very low, low, medium, high and very high. DATASUS was our source for the number of hospitalizations in the year 2007 and the result provided by the model was correlated with the actual data of hospitalization with lag from zero to two days. The accuracy of the model was estimated by the ROC curve for each pollutant and in those lags.RESULTS In the year of 2007, 1,710 hospitalizations by pneumonia and asthma were recorded in São José dos Campos, State of São Paulo, with a daily average of 4.9 hospitalizations (SD = 2.9). The model output data showed positive and significant correlation (r = 0.38) with the actual data; the accuracies evaluated for the model were higher for sulfur dioxide in lag 0 and 2 and for particulate matter in lag 1.CONCLUSIONS Fuzzy modeling proved accurate for the pollutant exposure effects and hospitalization for pneumonia and asthma approach.

Safety and Feasibility of Bronchial Thermoplasty in Asthma Patients with Very Severe Fixed Airflow Obstruction: A Case Series

Objective. Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction. Methods. We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15–72 weeks following BT. Results. The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV1) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV1 (p = .4). Conclusion. We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.

Étude comparative des émissions de gaz volcanique du Piton de la Fournaise et des hospitalisations pour asthme de la population réunionnaise de 2005 à 2007

Introduction Several epidemiological studies show that asthma is a more frequent pathology at Reunion Island than in metropolitan France. One of the peculiarities of this island is the presence of a particularly active volcano, which amongst others is a significant sulfur dioxide (SO 2) emitter. The latter is known for its toxic effects on the upper human airways. A recent study on the gas emissions of the volcano Kilauea in Hawaii shows that the high levels of SO 2 emitted during eruptions can entail bronchial irritations and asthma attacks to the most vulnerable ones. Purpose of the study We want to compare the number of hospitalizations for asthma of the Reunion population with the levels of SO 2 recorded during the various volcanic eruptions from 2005 to 2007. Patients and methods Inventory of the patients by the data PMSI supplied by the Drass and comparison with the SO 2 concentrations measured by Observatoire Réunionnais de l’Air (Ora) during various campaigns during and off the volcanic eruptions from 2005 to 2007. Results There was no global increase of hospitalizations for asthma during eruptions, but a significant increase in certain areas of the island according to the measured SO 2 concentrations and meteorological conditions. Conclusion A prospective study with additional measurements (eg. fine particles…), in collaboration between Ora, Météo-France, Observatoire volcanique du Piton de la Fournaise (OVPF/IPGP), the emergency services and the general practitioners, is necessary to record quantitatively any consultancy for asthma, in connection with the atmospheric emissions during the eruptions of the Piton de la Fournaise.

The Impact of Alexithymia on Asthma Patient Management and Communication with Health Care Providers: A Pilot Study

Background and objectives. Alexithymia is a personality trait associated with difficulty identifying and verbalizing feelings. It has been associated with poorly controlled asthma and near-fatal asthma. The primary objectives were to () determine the prevalence of alexithymia in a group of moderate to severe asthmatics who attended an Outpatient Clinic; and () investigate the relationship between alexithymia and asthma control, management, and communication. Methods. Twenty-five moderate to severe asthma patients were recruited from the Royal Adelaide Hospital Outpatient Respiratory Clinic. Participants were either mailed the questionnaire pack or completed it after a clinic appointment. Existing validated questionnaires were used to collect data. The primary outcome measures were alexithymia, asthma control, adherence to medication; patient satisfaction with communication with health care providers and health-related quality of life. Data were analyzed using Pearson correlations, linear regression and analysis of variance (ANOVA) in SPSS. A p value ≤ 0.05 was required for statistical significance. Results. A total of 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years ± 11) participated. Alexithymia scores ranged between 23.0-76.0 ( = 48.3, SD = 13.2); 12% of participants reported high alexithymia scores, 32% reported borderline alexithymia scores, and 56% reported low alexithymia scores. Alexithymia mean scores were not statistically different across sociodemographic variables. A higher alexithymia score was associated with worse asthma control score (r = 0.57, p < 0.01) (where higher asthma control scores indicate worse asthma control); poor adherence (p = 0.03), and worse quality of life (r = - 0.65, p < 0.01). Alexithymia score was not correlated with satisfaction with communication (r = − 0.27, p = 0.2).), or the number of hospitalizations for asthma (p = 0.25). Conclusions. This is the first study to investigate relationships between alexithymia, asthma control, asthma management and communication with health care professionals. The study reaffirms associations between alexithymia and asthma control, but a larger sample size is needed to determine the impact of alexithymia on self-management and provision of clinical care for asthma.

Inhaled corticosteroids: Impact on asthma morbidity and mortality

Inhaled corticosteroids are now recommended as first-line therapy for asthma. Although these drugs clearly improve the symptoms of the disease and the associated physiologic abnormalities, epidemiologic studies provide important information on their effectiveness in preventing asthma morbidity and mortality. We review the evidence regarding the role of inhaled corticosteroids in the prevention of asthma fatality and hospitalization. In the process, we discuss the methodologic complexities of the nonexperimental studies and the implications of the methodologic issues on the evaluation of the impact of these drugs. Eight of the cohort and ecologic studies conducted to date strongly suggest that inhaled corticosteroids, when taken regularly, decrease the number of hospitalizations for asthma by up to 80%. For asthma death, the results of 11 investigations appear less consistent, especially those of several cohort and case-control studies whose principal objective was to examine not the benefit of inhaled corticosteroids but the adverse effects of other drug classes. Much of the inconsistency in the results, however, can be explained by weaknesses in study design and analysis—in particular, the failure to consider exposure in terms of regular use of inhaled corticosteroids. When the most recent study involving the use of the Saskatchewan databases is considered, it is evident that regular treatment with conventional or low-dose inhaled cortico-steroids results in a significant reduction in fatalities due to asthma. In all, the evidence to date strongly indicates that regular use of inhaled corticosteroids, even at low doses, would prevent the major portion of asthma hospitalizations and deaths. (J Allergy Clin Immunol 2001;107:937-44.)

Asthma and sex hormones.

A chronic in ammatory state of the airways is considered the hallmark of asthma (1). However, the incidence, severity, and prognosis of asthma can be affected by a number of factors, including the patient's sex and age. The sex of the fetus seems to in uence the development of the respiratory apparatus. In fact, between weeks 28 and 40 of gestation, the lungs are in a more advanced state in females than in males (2), a fact which could explain, at least in part, the higher incidence of respiratory distress in male infants (3). Clinical observations and epidemiologic studies agree that childhood asthma is more frequent in boys than in girls (4). Moreover, in some children, usually boys, asthmatic symptoms that started in infancy disappear around puberty (5), while many girls have the disease only during adolescence (6). Age has been implicated in the severity of asthma. Asthma beginning during adulthood is generally more severe than childhood-onset asthma (7). Asthma that starts around the menopause or in old age is generally quite severe (5). According to two recent epidemiologic investigations, the patient's sex and age affect the hospitalization rate for asthma (8, 9), which is a marker of severity. In the ®rst study (a retrospective study of 33 269 patients), the admission rate of boys in the 0±10-year age group was almost twice that of girls. In the next decade, sex differences in the hospitalization rate were irrelevant, although there was a small, but signi®cant prevalence of females. At all ages above 20 years, hospital admission rates were higher in women than men, with a female/ male ratio ranging from 3:1 in subjects aged 20±50 years to 2.5:1 in those over 50 years of age (8). Similar data were reported by Elliasson (9). Both studies found a relationship between the age and sex of the patient and the severity of the asthma attack as indicated by duration of hospitalization. In fact, the duration of hospitalization increased with age in both sexes; moreover, hospital stays were longer in women over 30 years of age than in men of the same age (8, 9). Abbreviations. FSH: follicle-stimulating hormone; LH: luteinizing hormone; NK cell: natural killer cell; IL-1, -4, -5, -6: interleukin-1, -4, -5, -6; TGF-b: tumor growth factor-beta; PEFR: peak expiratory ow rate. Allergy 2001: 56: 13±20 Printed in UK. All rights reserved Copyright # Munksgaard 2001

Correction: Low-Dose Inhaled Corticosteroids and the Prevention of Death from Asthma.

Low-dose inhaled corticosteroids and the prevention of death from asthma S Suissa, P Ernst, S Benayoun, M Baltzan, B Cai Background: Although inhaled corticosteroids are effective for the treatment of asthma, it is uncertain whether their use can prevent death from asthma. Methods: We used the Saskatchewan Health data bases to form a population-based cohort of all subjects from 5–44 years of age who were using antiasthma drugs during the period 1975–1991. We followed subjects until the end of 1997, their 55th birthday, death, emigration, or termination of health insurance coverage, whichever came first. We conducted a nested case-control study in which subjects who died of asthma were matched with controls within the cohort according to the length of follow-up at the time of death of the case patient (the index date), the date of study entry, and the severity of asthma. We calculated rate ratios after adjustment for the subject's age and sex; the number of prescriptions of theophylline, nebulized and oral beta-adrenergic agonists, and oral corticosteroids in the year before the index date; the number of canisters of inhaled beta-adrenergic agonists used in the year before the index date; and the number of hospitalizations for asthma in the two years before the index date. Results: The cohort consisted of 30,569 subjects. Of the 562 deaths, 77 were classified as due to asthma. We matched the 66 subjects who died of asthma for whom there were complete data with 2681 controls. Fifty-three percent of the case patients and 46% of the control patients had used inhaled corticosteroids in the previous year, most commonly low-dose beclomethasone. The mean number of canisters was 1.18 for the patients who died and 1.57 for the controls. On the basis of a continuous dose-response analysis, we calculated that the rate of death from asthma …

Low-dose inhaled corticosteroids and the prevention of death from asthma.

Although inhaled corticosteroids are effective for the treatment of asthma, it is uncertain whether their use can prevent death from asthma. We used the Saskatchewan Health data bases to form a population-based cohort of all subjects from 5 through 44 years of age who were using antiasthma drugs during the period from 1975 through 1991. We followed subjects until the end of 1997, their 55th birthday, death, emigration, or termination of health insurance coverage; whichever came first. We conducted a nested case-control study in which subjects who died of asthma were matched with controls within the cohort according to the length of follow-up at the time of death of the case patient (the index date), the date of study entry, and the severity of asthma. We calculated rate ratios after adjustment for the subject's age and sex; the number of prescriptions of theophylline, nebulized and oral beta-adrenergic agonists, and oral corticosteroids in the year before the index date; the number of canisters of inhaled beta-adrenergic agonists used in the year before the index date; and the number of hospitalizations for asthma in the two years before the index date. The cohort consisted of 30,569 subjects. Of the 562 deaths, 77 were classified as due to asthma. We matched the 66 subjects who died of asthma for whom there were complete data with 2681 controls. Fifty-three percent of the case patients and 46 percent of the control patients had used inhaled corticosteroids in the previous year, most commonly low-dose beclomethasone. The mean number of canisters was 1.18 for the patients who died and 1.57 for the controls. On the basis of a continuous dose-response analysis, we calculated that the rate of death from asthma decreased by 21 percent with each additional canister of inhaled corticosteroids used in the previous year (adjusted rate ratio, 0.79; 95 percent confidence interval, 0.65 to 0.97). The rate of death from asthma during the first three months after discontinuation of inhaled corticosteroids was higher than the rate among patients who continued to use the drugs. The regular use of low-dose inhaled corticosteroids is associated with a decreased risk of death from asthma.

RISK OF FATAL AND NEAR-FATAL ASTHMA IN RELATION TO INHALED CORTICOSTEROID USE

Purpose of the Study. To examine the relationship between patterns of use of inhaled beclomethasone dipropionate (50 µg/puff) and the risk of fatal and near-fatal asthma. Study Population. A cohort of 12 301 individuals aged 5 to 54 years was identified from the residents of Saskatchewan, Canada. These were asthma patients dispensed ten or more prescriptions for drugs in common use for asthma treatment from 1978 to 1987. Methods. A case control analysis was performed. Cases were defined as persons within the cohort who met predetermined criteria for having fatal or near-fatal asthma. These were matched with 655 controls within the cohort who had asthma, but no fatality or near-fatality. The subjects were then stratified as to their use of inhaled beclomethasone dipropionate for the 12 months prior to the fatal or near-fatal event, or index date for controls. Each person's use of inhaled beclomethasone was divided into three groups: no medication in the prior 12 months, less than 12 units in the previous 12 months, or greater than 12 units over the previous 12 months. Findings. Of the 784 cases and controls, 269 had been dispensed inhaled beclomethasone in the prior 12 months. Of these, 232 had been dispensed less than 12 units, and only 37 had been dispensed 12 or more units. Matched odds ratio adjusted for use of other medications and number of hospitalizations for asthma showed a 1.6 times increased risk of fatal and near-fatal asthma in the group using less than 12 units of beclomethasone per year as compared to the group using none, but this did not meet statistical significance.

A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists.

The association between the use of inhaled beta-agonists and the risk of death and near-death from asthma has previously been reported. It was based on a nested case-control study of 129 cases and 655 control subjects selected from a cohort of 12,301 users of asthma drugs followed during the period 1980 through 1987. In this paper we examine the question of asthma and non-asthma mortality using data from the entire cohort of 12,301 asthmatics. There were 46 asthma and 134 non-asthma deaths in this cohort, for which there were 47,842 person-years of follow-up. The overall rate of asthma death was 9.6 per 10,000 asthmatics per year. This rate varied significantly according to the use of fenoterol, albuterol, or oral corticosteroids in the prior 12 months and the number of asthma hospitalizations in the prior 2 years. The rate decreased significantly, by 0.6 asthma deaths per 10,000 asthmatics per year over the study period, after controlling for the effect of the four other risk factors. It also increased significantly with the use of all beta-agonists, and more so for fenoterol than for albuterol, although this difference was partly explained by the dose inequivalence of the two drugs. Change-point dose-response curves showed that the risk of asthma death began to escalate drastically at about 1.4 canisters (of 20,000 micrograms each) per month of inhaled beta-agonist, the recommended limit. For non-asthma death, the overall rate of 28 deaths per 10,000 asthmatics per year was not related to the use of inhaled beta-agonists.(ABSTRACT TRUNCATED AT 250 WORDS)