Preventive Medicine Programs Research Articles

<b>Parasitological findings and antiparasitic treatment of captive Jaguarundis <I>Herpailurus yagouaroundi</I> (Carnivora: Felidae) in a conservation center in Brazil</b>

Ex situ management of wildlife provides a possibility for species maintenance, research development and environmental education. But as captive facilities are usually much smaller than the area occupied by a species in the natural habitat, cleaning might be insufficient, domestic species such as cats might be in close proximity, and wild animals in captivity are inevitably stressed, animals kept in these facilities are more at risk of acquiring parasitic infections. Therefore, an appropriate prophylactic protocol and consequent anti-parasitic therapy of affected animals are fundamental for any wildlife conservation center. This report describes the procedures adopted in a conservation center for wild felines in which four adult Jaguarundis were diagnosed with severe infection with gastrointestinal parasites and flea infestation. Two animals died and based on the necropsy findings and fecal examinations, infections with Ancylostoma caninum and Toxocara cati were diagnosed, as well as severe infestations with Ctenocephalides felis felis fleas, all common parasites of domestic cats. We discuss the applied therapy and the adopted environmental management, along with the importance of regular health assessments and a preventive medicine program for this species in captivity.

A Descriptive Analysis of EtOH Intoxication in our Latino Trauma Patients: An Indication for a Preventive Program.

We sought to determine patterns of injury in our Latino trauma community targeting alcohol (EtOH) intoxication as an influential variable. With the information gained in our culturally specific and culturally sensitive trauma community, we can use the information to fine-tune our trauma preventive medicine programs. Trauma injuries are the third largest contributor to racial disparities in the United States. Alcohol is involved in approximately half of all trauma admissions to trauma centers around the country. Some investigators have shown that Latinos have higher rates of high-risk drinking, and this factor is independently associated with mortality after trauma. This study is a retrospective review of 524 Latino blunt and penetrating trauma admissions for years (2012-2014). Electronic medical records with the hospital trauma registry charts were evaluated. The trauma registry database included age, gender, EtOH, mechanism of injury, location, insurance, and disposition. Statistical significance was used with chi-square test. Our results show a predominantly male population with falls being the primary mechanism of injury. Intoxicated injuries occurred mostly at bars/clubs, but a substantial amount occurred at the workplace. Despite having a majority of the injuries occurring with patients that have Medicaid or Charity Care insurance, a certain amount of the alcohol-related injuries had private insurance. Many of our Latino trauma patients are still suffering from trauma-related EtOH intoxication. With the information obtained from our project, we will be able to fine-tune and target our trauma preventive medicine program to provide education for our inner-city Latino community of EtOH intoxication-related trauma injuries.

The status of preventive medicine program of the National Natural Science Foundation of China in 2017

The status of preventive medicine program of the National Natural Science Foundation of China in 2017

Origin of Azeris (Iran) according to HLA genes

Azeris from Iran North West provinces (Tabriz city) have been studied for HLA alleles. A total of 8.902 HLA-bearing chromosomes (Chr 6) have been used for comparing their relatedness with other Middle East, Caucasus, Mediterranean and Central Asia populations. Mediterranean, Central Asian and Caucasus extended HLA haplotypes were found, i.e.: A*24:02-B*35:01-DBR1*11:01-DBQ1*03:01 and A*01:02-B*08:01-DRB1*03:01-DQB1*02:01. Genetic distances, Neighbour Joining and Correspondence analyses also showed that Azeris were close to Kurds, who have shown a closer Mediterranean/Caucasus HLA profile, and Gorgan (Turkmen) who have shown a closer Central Asia profile, as expected. It is shown that three different Iranian populations according to Language, History and Geography: Gorgans, Kurds and Azeris are genetically close. In fact, old Azeri language (Adari) was an Iranian language and not a Turkic one, which they nowadays speak. Also, present study does not support “Aryan” invasion from the East in accordance with many other previous studies. Finally, our results are useful for establishing Preventive Medicine programs in Transplantation and HLA and Pharmacogenomics/Disease linkage. Keywords : HLA, Pharmacogenomics, Disease, Transplantation, Iran, Irak, Georgia, Turkey, Azerbajan, Azeris, Gorgan, Kurds, Yazd, Baloch, Aryan, Dene Caucasian, Zoroastro,Persia.

Culling from the actors’ perspectives—Decision-making criteria for culling in Québec dairy herds enrolled in a veterinary preventive medicine program

The series of events leading to the decision to cull a cow is complex, involving both individual-level and herd-level factors. While the decision is guided by financial returns, it is also influenced by social and psychological factors. Research studies on the motivational and behavioural aspects of farmers’ decision utility are sparse, and nonexistent regarding culling expectations and its decision process. Our goal was to identify shared criteria on culling decisions held by dairy producers and farm advisers, with the help of the Q-methodology.Forty-one dairy producers and 42 advisers (17 veterinarians, 13 feed mill advisers, and 12 dairy herd improvement (DHI) advisers) undertook a Q-sort with 40 statements that represented a range of views about cow and herd health, production performance, management issues, and material factors that might impact their culling decision-making process. The sorts were analysed by-person using factor analysis and oblimin rotation.A single view on culling could be identified among dairy producers that can be extended to dairy farm advisers, who showed two variations of the same well-structured, uni-dimensional decision-making process. Udder health, milk production performance, and milk quota management were the key criteria for the culling decision. Farm management parameters (debts, amortization, employees, milking parlour capacity, herd size) did not play any role in the decision process. Three key differences were, however, identified between producers and the two types of advisers. One group of advisers followed the recommendations from mathematical models, where pregnancy is a major determinant of a cow's value. They assessed the cow in a more abstract way than did the other participants, still taking into account udder health and milk production, but adding economic considerations, like the availability of financial incentives and an evaluation of the post-partum health of the cow. Dairy producers were also more concerned about producing healthy and safe milk, which might reflect a different value given to dairy farming than by advisers. Very different degrees of importance were given to animal welfare by the three groups, which could represent different views on the attributed relationships between dairy farmers and their animals.Our findings suggest that dairy producers and their advisers hold a general common view regarding culling decision-making. However there are significant differences between producers and advisers, and among advisers. Understanding and managing these differences is important for assisting the change management processes required to increase farm profitability, and call for further investigation.

Overview of health in the Mexican Armed Forces

The Social Security Institute for the Mexican Armed Forces (ISSFAM) is an important member of the institutions that ensure the social security of Mexican people. In addition to health, it also offers benefi ts such as pensions, housing, scholarships and many others that are part of the social rights of soldiers, sailors, and their families. The health system of the Mexican Armed Forces is different from others in our country. While it provides integral medical service to its successors, it is also designed as a technical service that supports the military deployment in the fulfi llment of their general missions. Through the construction, modernization and expansion of health infrastructure, the constant training of our own human resources, the acquisition of last generation medical equipment and the implementation of campaigns and preventive medicine programs, detection and timely treatment of diseases have been achieved, as well as the decrease in the main causes of mortality in our military and their families.

Preventive medicine as a first- or second-choice course: a cross-sectional survey into students\u2019 motivational differences and implications for information provision

BackgroundChallenges in recruiting and retaining medical staff in preventive medical specialties have recently been the subject of numerous studies. To improve selection procedures, it is important to understand the career preferences and incentives of students in preventive medicine (PM), who initially marked the program as either their first choice or second choice. 1386 PM students in four Vietnamese medical schools participated in a survey using a structured, written questionnaire. Students were asked about their reasons for entering medical school and studying PM, their perceptions of PM during the academic course, and their expected career path following graduation.ResultsFirst-choice PM students (group 1) more often had siblings working as a preventive doctor, while second-choice PM students’ siblings (group 2) were more often medical students or clinical doctors. Group 1 had gathered more information about PM by consulting their high-school teachers and the national career guide. They were mainly drawn to the PM program by the newness of the profession, the prospect of a high-income job, its low entry criteria and low study burden compared to general medicine, their desire to uphold their family tradition, and to fulfill their family’s wish of having a doctor in the family. Group 2 chose to study PM because they wanted to pursue their dream of becoming a doctor. Compared to the first group, their perception of PM more frequently changed during the later years of the curriculum and they more frequently envisioned becoming a clinical doctor following graduation.ConclusionsInterest in and motivation for PM may be cultivated among prospective or current students by improving information provision, diffusing knowledge, and otherwise acquainting students better with the PM specialty before and during the program.

Analysis of the Preventive Medicine Undergraduate Curriculum in China: The West China School of Public Heath Experience: A Case Study

In China, the preventive medicine undergraduate professional training program is the major approach to training public health practitioners. The history of undergraduate education in public health/preventive medicine in China is reviewed utilizing the example of the West China School of Public Health at Sichuan University as an example for analyzing this undergraduate major and its curriculum. Needed reforms in the Chinese undergraduate preventive medicine programs are presented including: review of the traditional preventive medicine course content, revision of its curriculum structure, the need to increase practical experience and to develop variety in teaching and assessment techniques, and systematic planning for curriculum reform. Current efforts at reform of the preventive medicine undergraduate program at Sichuan University’s West China School of Public Health are presented.

Social Impact Bonds - Applicability In Preventive Medicine

Social impact bonds (SIBs) are a relatively new financial model which suggests the entry of private investors into the public sector, in fields which are under the responsibility of government establishments. The private investor goal is to initiate a social program agreed upon together with the government. The investor will receive payment only according to the program’s success in achieving its objectives. The growing rate in obesity and related chronic diseases calls for new creative and innovative solutions. PURPOSE: To assess the applicability of SIB in preventive medicine and health promotion programs. METHODS: Reviewing of all the available academic and governmental publications on existing SIBs and analyzing the reasons for their success and failure. RESULTS: Sixty SIBs were launched between 2010-2016 in 15 countries mainly UK, USA, Australia, and Israel focusing on issues of: education, prisoners’ rehabilitation, unemployment, health and family care. Out of 22 projects whose data has been delivered, 21 show a very positive outcome. The first SIB ever launched was to reduce recidivism. The project matured in 2016 was declared a success and returned in full the investors’ capital. CONCLUSIONS: The SIB is a novel model that has the potential to make a dramatic change in the strategy of funding health promotion programs (e.g., obesity epidemic). The model is applicable in preventive medicine and health promotion programs given that a clear and fair contract is signed between the public authority and the private investor. To note, SIBs can be a primary catalyzer in health promotion programs, but cannot substitute government’s responsibility for permanent solutions.

Ancestry of Amerindians and its Impact in Anthropology, Transplantation, HLA Pharmacogenomics and Epidemiology by HLA Study in Wiwa Colombian Population

Background:HLA autosomic genes are unique because they conform the most polymorphic human system. Importance of this system is recognized in Medicine for Transplantation, Epidemiology (HLA and disease linkage), Pharmacogenomics (HLA linked to drug side effects) and for defining the origin of populations in both male and female lineages.Objectives:Studying HLA profile of a isolated Amerindian group from North Colombia (Wiwa) in order to draw conclusions about its Preventive Medicine, the genetic relationship with Worldwide populations and America peopling, since this last issue is hotly debated.Methodology:A total of 14,660 HLA chromosomes were included. Peripheral blood was obtained from volunteer blood donors belonging to Wiwa (also named Arsario) ethnic group. HLA-A, -B, -C, -DRB1 and -DQB1 genes were analyzed by standard methods. Wiwa Amerindians relationships with others were calculated by using Arlequin, Dispan and Vista software computer packages.Results:Extended HLA, -A, -B, -C, -DRB1 and -DQB1 haplotypes have been studied for the first time in this population. Classical Amerindian haplotypes have been found and also new Wiwa (Arsario) Amerindian haplotypes. New haplotypes are A*68:01 - B*15:01 - C*03:03 - DRB1*14:02 - DQB1*03:02, A*11:01 - B*07:02 - C*07:02 - DRB1*15:03 - DQB1*06:02 and A*68:01 - B*15:01 - C*03:04 - DRB1*14:02 - DQB1*03:01.Conclusion:They have been reached after exhaustive comparisons of Wiwa with other Amerindians and Worldwide populations by using genetic distances, Neighbor Joining trees, correspondence analysis and specific group of alleles which are common and frequent in both Amerindians and Pacific Islanders. They are: 1) The Americas First Inhabitants have been probably come through Bering Strait and also through Pacific (from Austronesia and Asia) and Atlantic (from Europe) routes. A bidirectional gene flow is not discarded. 2) Genetic HLA Amerindian profile is separated from that of other Worldwide populations. 3) Amerindians geographical proximity groups’ relatedness is not concordant with HLA genetic relatedness, neither with language. This may be explained by a substantial population decrease that occurred after Europeans invaded America in 1492 and carried new pathogens and epidemics. 4) Our results are also useful for Wiwa and other Amerindians future preventive medicine (HLA linked diseases), HLA pharmacogenomics and transplantation regional programs.

The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures.

The objective of this study was to evaluate the impact on health care utilization and expenditure trends over time of a personalized preventive medicine program delivering individualized care focused on lifestyle behavior modification, disease prevention, and compliance with quality-related metrics. MD-Value in Prevention (MDVIP) is a network of affiliated primary care physicians who utilize a model of health care delivery based on an augmented physician-patient relationship and focused on personalized preventive health care. Multivariate modeling was used to control for demographics, socioeconomics, supply of health care services, and health status among 10,186 MDVIP members and randomly selected, matched nonmembers. Health care utilization and expenditure trends were tracked from the pre period prior to member enrollment for a period of up to 3 years post enrollment. MDVIP members experienced reduced utilization of emergency room and urgent care services compared to nonmembers. Program savings ranges indicated that, over time, increasing percentages of members achieved cost savings compared to nonmembers. Older age groups were more likely to realize savings in the early years with preventive activities indicating condition management, and younger age groups were most likely to achieve savings by the third year after enrollment. These results indicate that a primary care model based on an enhanced physician-patient relationship and focused on quality and personalized preventive care within a time frame of 3 years can achieve positive health care expenditure outcomes and improved health management.

Evidence for Wild Crocodiles as a Risk for Human Leptospirosis, Mexico.

Sentinel species such as crocodilians are used to monitor the health of ecosystems. However, few studies have documented the presence of zoonotic diseases in wild populations of these reptiles. Herein we analyzed 48 serum samples from Crocodylus acutus (n=34) and C. moreletii (n=14) from different sites in the state of Quintana Roo (Mexico) to detect antibodies to Leptospira interrogans by means of a microscopic agglutination test (MAT). Crocodylus acutus and C. moreletii tested positive to 11 and 9 serovars, respectively, with Grippotyphosa being the serovar with the highest prevalence in Cozumel island (100%), Banco Chinchorro Biosphere Reserve (70.6%), and Río Hondo (100%), while in Chichankanab Lake, it was Bratislava (75%). Titers ranged from 1:50 to 1:3200, and the most frequent was 1:50 in all study sites. Leptospira is present in fresh and saltwater individuals due to the resistance of the bacterium in both environments. Cases of infected people involved with crocodile handling and egg collection suggest that these reptiles could play an important role in the transmission of leptospirosis. Preventive medicine programs should consider the monitoring of reptiles, and testing the soil and water, to prevent outbreaks of leptospirosis in facilities containing crocodiles.

LESSONS FROM A RETROSPECTIVE ANALYSIS OF A 5-YR PERIOD OF QUARANTINE AT SAN DIEGO ZOO: A RISK-BASED APPROACH TO QUARANTINE ISOLATION AND TESTING MAY BENEFIT ANIMAL WELFARE.

Quarantine is designed primarily to prevent the introduction of transmissible diseases to zoological collections. Improvements in preventive medicine, disease eradication, and comprehensive pathology programs call into question current industry quarantine standards. Disease risk analysis was used at the San Diego Zoo (SDZ) and the SDZ Safari Park to eliminate quarantine isolation and transmissible disease testing for animals transferred between the two institutions. To determine if a risk-based approach might be valid between other institutions and SDZ, we reviewed quarantine data for animals arriving at SDZ from 81 Association of Zoos and Aquariums (AZA)-accredited and 124 other sources (e.g., non-AZA-accredited institutions, private breeders, private dealers, governmental bodies) over a 5-yr period (2009-2013). No mammal or herptile failed quarantine due to transmissible diseases of concern. Approximately 2.5% of incoming birds failed quarantine due to transmissible disease; however, all 14 failed individuals were obtained from three nonaccredited sources (private breeders, confiscation). The results of our study suggest that a risk-based approach could be used to minimize or eliminate quarantine for the transfer of animals from institutions with comprehensive disease surveillance programs and/or preshipment testing practices. Quarantine isolation with testing remains an essential defense against introducing transmissible diseases of concern when there is a lack of health knowledge about the animals being received.

HLA genes in Chimila Amerindians (Colombia), the Peopling of America and Medical implications

Our aim is to study the HLA-A, -B, -C, -DRB1 and -DQB1 gene frequencies in the Chimila Amerindian (Colombia) ethnic group. Results are compared with other World populations in order to obtain information about Chimila and Amerindian Health promotion, Amerindian origins and America peopling. Written consent was obtained from Chimila subjects to be included in this study. Peripheral blood was drawn and HLA DNA genotyping was carried out by standard methods. Analyses of Chimila relatedness with other Amerindians and worldwide populations was performed with a standard NJ dendrogram and correspondence analyses methodology. Chimila HLA gene profile showed to be related to that of other Amerindians groups. New complete HLA extended haplotypes were obtained. Some of them are described for the first time. Also, specific genealogical comparisons were done between Chimila Amerindians and Pacific Islanders by using specific HLA alleles. Our conclusions are: 1) These new data and HLA extended haplotypes are useful for present and future Chimila Preventive Medicine (HLA linked diseases), HLA Pharmacogenomics and transplantation regional programs, 2) Classical accepted origin of America peopling should be revised: Pacific (Asian and Austronesian) and Atlantic (European) populations gene exchange may have occurred before 1492 AD. This is confirmed by our present studies using HLA autosomic genetic markers. 3) Genetic HLA Amerindian profile is separated from that of other World populations. Keywords : America peopling, Amerindians, Anthropology, Chimila, Epidemiology, HLA and Transplantation.

Application of preventive medicine resources in the health insurance system.

ABSTRACTObjective To identify the financial resources and investments provided for preventive medicine programs by health insurance companies of all kinds.Methods Data were collected from 30 large health insurance companies, with over 100 thousand individuals recorded, and registered at the Agência Nacional de Saúde Suplementar.Results It was possible to identify the percentage of participants of the programs in relation to the total number of beneficiaries of the health insurance companies, the prevention and promotion actions held in preventive medicine programs, the inclusion criteria for the programs, as well as the evaluation of human resources and organizational structure of the preventive medicine programs.Conclusion Most of the respondents (46.7%) invested more than US$ 50,000.00 in preventive medicine program, while 26.7% invested more than US$ 500,000.00. The remaining, about 20%, invested less than US$ 50,000.00, and 3.3% did not report the value applied.

SEROLOGIC SURVEY AND RESULTS OF URINARY PCR TESTING FOR LEPTOSPIROSIS IN CAPTIVE BLACK-TAILED PRAIRIE DOGS (CYNOMYS LUDOVICIANUS).

Leptospirosis is an important zoonotic disease occurring clinically and subclinically in humans and a wide variety of mammal species worldwide. Often, rodents and wild animals are identified as important reservoirs for the disease. Twenty-two captive black-tailed prairie dogs (Cynomys ludovicianus) housed within a zoo were examined as part of a routine census and preventive medicine program. During examinations, blood and urine were collected to screen for exposure to, or infection with, leptospirosis. All animals were apparently healthy at the time of examination. Leptospira microscopic agglutination test identified 12 of 22 (54.5%) prairie dogs with antibody titers ≥1 : 100 against Leptospira interrogans serovar bratislava on initial serologic examination. All prairie dogs within this collection were serologically negative for L. interrogans serovars canicola, hardjo, icterohaemorrhagiae, and pomona and Leptospira kirschneri serovar grippotyphosa. Leptospira polymerase chain reaction (PCR) testing of urine was negative in all animals tested. This report describes evidence that captive prairie dogs may be exposed to leptospirosis, most likely from wild rodent reservoirs; however, serum titers are low, and lack of leptospiral DNA detected by PCR indicates that these captive animals are unlikely to be important reservoirs for the disease.

Integrative Medicine in Preventive Medicine Education: Competency and Curriculum Development for Preventive Medicine and Other Specialty Residency Programs.

During 2012, the USDHHS’s Health Resources and Services Administration funded 12 accredited preventive medicine residencies to incorporate an evidence-based integrative medicine curriculum into their training programs. It also funded a national coordinating center at the American College of Preventive Medicine, known as the Integrative Medicine in Preventive Medicine Education (IMPriME) Center, to provide technical assistance to the 12 grantees. To help with this task, the IMPriME Center established a multidisciplinary steering committee, versed in integrative medicine, whose primary aim was to develop integrative medicine core competencies for incorporation into preventive medicine graduate medical education training. The competency development process was informed by central integrative medicine definitions and principles, preventive medicine’s dual role in clinical and population-based prevention, and the burgeoning evidence base of integrative medicine. The steering committee considered an interdisciplinary integrative medicine contextual framework guided by several themes related to workforce development and population health. A list of nine competencies, mapped to the six general domains of competence approved by the Accreditation Council of Graduate Medical Education, was operationalized through an iterative exercise with the 12 grantees in a process that included mapping each site’s competency and curriculum products to the core competencies. The competencies, along with central curricular components informed by grantees’ work presented elsewhere in this supplement, are outlined as a roadmap for residency programs aiming to incorporate integrative medicine content into their curricula. This set of competencies adds to the larger efforts of the IMPriME initiative to facilitate and enhance further curriculum development and implementation by not only the current grantees but other stakeholders in graduate medical education around integrative medicine training.

Body mass index and the risk of giant cell arteritis: results from a prospective study.

The aim of this study was to examine potential risk factors for GCA in a nested case-control study based on two prospective health surveys. We used two population-based health surveys, the Malmö Preventive Medicine Program (MPMP) and the Malmö Diet Cancer Study (MDCS). Individuals who developed GCA after inclusion were identified by linking the MPMP and MDCS databases to several patient administrative registers. A structured review of the medical records of all identified cases was performed. Four controls for every confirmed case, matched for sex, year of birth and year of screening, were selected from the corresponding databases. Potential predictors of GCA were examined in conditional logistic regression models. Eighty-three patients (70% women, 64% biopsy positive, mean age at diagnosis 71 years) had a confirmed diagnosis of GCA after inclusion in the MPMP or MDCS. A higher BMI was associated with a significantly reduced risk of subsequent development of GCA [odds ratio (OR) 0.91/kg/m(2) (95% CI 0.84, 0.98)]. Smoking was not a risk factor for GCA overall [OR 1.36 (95% CI 0.77, 2.57)], although there was a trend towards an increased risk in female smokers [OR 2.14 (95% CI 0.97, 4.68)]. In multivariate analysis, adjusted for smoking and level of formal education, the inverse association between BMI and GCA remained significant (P = 0.027). In this study, GCA was predicted by a lower BMI at baseline. Potential explanations include an effect of reduced adipose tissue on hormonal pathways regulating inflammation.

Empowering village doctors and enhancing rural healthcare using cloud computing in a rural area of mainland China

BackgroundChina's healthcare system often struggles to meet the needs of its 900 million people living in rural areas due to major challenges in preventive medicine and management of chronic diseases. Here we address some of these challenges by equipping village doctors (ViDs) with Health Information Technology and developing an electronic health record (EHR) system which collects individual patient information electronically to aid with implementation of chronic disease management programs. MethodsAn EHR system based on a cloud-computing architecture was developed and deployed in Xilingol county of Inner Mongolia using various computing resources (hardware and software) to deliver services over the health network using Internet when available. The system supports the work at all levels of the healthcare system, including the work of ViDs in rural areas. An analysis done on 291,087 EHRs created from November 2008 to June 2011 evaluated the impact the EHR system has on preventive medicine and chronic disease management programs in rural China. ResultsFrom 2008 to 2011 health records were created for 291,087 (26.25%) from 1,108,951 total Xilingol residents with 10,240 cases of hypertension and 1152 cases of diabetes diagnosed and registered. Furthermore, 2945 hypertensive and 305 diabetic patients enrolled in follow-up. Implementing the EHR system revealed a high rate of cholecystectomies leading to investigations and findings of drinking water contaminated with metals. Measures were taken to inform the population and clean drinking water was supplied. ConclusionsThe cloud-based EHR approach improved the care provision for ViDs in rural China and increased the efficiency of the healthcare system to monitor the health status of the population and to manage preventive care efforts. It also helped discover contaminated water in one of the project areas revealing further benefits if the system is expanded and improved.

FRI0097 High body mass index is associated with a reduced risk of developing rheumatoid arthritis in men

BackgroundIn a previous study from the United States (1), obesity has been associated with increasing incidence of rheumatoid arthritis (RA) in women. In a small study of autoantibody positive individuals...