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2009

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Articles 2011 - 2040 of 4384

Full-Text Articles in Medicine and Health Sciences

Double Blind Placebo Controlled Trial Of Homoeopathic Medicines In The Management Of Withdrawal Symptoms In Opium Addicts And Its Alkaloid Derivatives-Dependents, Ajay Grover, Bharat Bhushan, Rajesh Goel Mar 2009

Double Blind Placebo Controlled Trial Of Homoeopathic Medicines In The Management Of Withdrawal Symptoms In Opium Addicts And Its Alkaloid Derivatives-Dependents, Ajay Grover, Bharat Bhushan, Rajesh Goel

Indian Journal of Research in Homoeopathy

Objectives: To ascertain the efficacy of Homoeopathic medicines in the management of withdrawal symptoms in Opium addicts & its alkaloid derivatives-dependents. Methods: 169 patients addicted primarily to opium, its alkaloid derivatives either natural or synthetic (Morphine, Codeine, Heroine, Pethidine and other Narcotic etc.) were enrolled for the study between September 2002 to August 2005. Only male patients within 15 - 50 yrs of age coming to the O.P.D. were admitted and included in the study. The study was conducted at Navjyoti Drug Demand Reduction Training Institute, New Delhi. Indicated homoeopathic medicines ( on the basis of characteristic symptoms of each …


Predictors Of Recurrence Of Urethral Stricture Disease Following Optical Urethrotomy, Ali Akbar Zehri, M. H. Ather, Q. Afshan Mar 2009

Predictors Of Recurrence Of Urethral Stricture Disease Following Optical Urethrotomy, Ali Akbar Zehri, M. H. Ather, Q. Afshan

Faculty of Health Sciences, East Africa

Objective:

To assess the predictors of recurrence in Optical urethrotomy (OU) for male urethral strictures.

Methods: 148 male patients treated with OU with intent to treat during the period of January 2003– December 2008 were included in the study. Charts were reviewed for demographics, cause of stricture, stricture length and need for ancillary procedure following OU. The time to recurrence following OU was noted. All patients were evaluated postoperatively with uroflowmetry monthly for the first 3 months, every 3 months during year 1 and every 6 months during year 2. After year 2 most patients were followed annually.

Results:

139 …


Wellness Characteristics And Health Risk Behaviors Of Young Adult University Students, Nicole Mareno Phd Mar 2009

Wellness Characteristics And Health Risk Behaviors Of Young Adult University Students, Nicole Mareno Phd

Dissertations

The purpose of this study was to examine wellness and health risk behaviors of young adults at a university in the southwest. Nutrition, physical activity, alcohol use, and safe sexual practices are high priority health concerns on college campuses. Health promotion is integral to nursing. Early identification of risky health behaviors allows for the design of campus health interventions. Health behaviors continue to be formed during college and interventions may have a lasting impact on health promotion and disease prevention. This study added to the research on demographic factors impacting wellness. A correlation between BMI and wellness level was also …


Recent Trends In Soft-Tissue Infection Imaging., Nicholas Petruzzi, Md, Nylla Shanthly, Mbbs, Drm, Mathew L. Thakur, Phd Mar 2009

Recent Trends In Soft-Tissue Infection Imaging., Nicholas Petruzzi, Md, Nylla Shanthly, Mbbs, Drm, Mathew L. Thakur, Phd

Department of Radiation Oncology Faculty Papers

This article discusses the current techniques and future directions of infection imaging with particular attention to respiratory, central nervous system, abdominal, and postoperative infections. The agents currently in use localize to areas of infection and inflammation. An infection-specific imaging agent would greatly improve the utility of scintigraphy in imaging occult infections. The superior spatial resolution of (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) and its lack of reliance on a functional immune system, gives this agent certain advantages over the other radiopharmaceuticals. In respiratory tract infection imaging, an important advancement would be the ability to quantitatively delineate lung inflammation, allowing one to …


Ethnic Differences In Trajectories Of Depressive Symptoms: Disadvantage In Family Background, High School Experiences, And Adult Characteristics, Katrina M. Walsemann, Gilbert C. Gee, Arline T. Geronimus Mar 2009

Ethnic Differences In Trajectories Of Depressive Symptoms: Disadvantage In Family Background, High School Experiences, And Adult Characteristics, Katrina M. Walsemann, Gilbert C. Gee, Arline T. Geronimus

Faculty Publications

Although research investigating ethnic differences in mental health has increased in recent years, we know relatively little about how mental health trajectories vary across ethnic groups. Do these differences occur at certain ages, but not others? We investigate variations in trajectories of depressive symptoms, and examine the extent to which disadvantages in family background, high school experiences, and adult characteristics explain these differences. Employing random-coefficient modeling using the National Longitudinal Survey of Youth, we find that blacks and Hispanics experience higher symptom levels in early adulthood in comparison to whites, but equivalent levels by middle-age. Ethnic differences remained in early …


Physical And Social Contexts Of Physical Activities Among Adolescent Girls, Joanne Kuo, Kathryn H. Schmitz, Kelly R. Evenson, Thomas L. Mckenzie, Jared B. Jobe, Ariane L. Rung, Joel Gittelsohn, Russell R. Pate Mar 2009

Physical And Social Contexts Of Physical Activities Among Adolescent Girls, Joanne Kuo, Kathryn H. Schmitz, Kelly R. Evenson, Thomas L. Mckenzie, Jared B. Jobe, Ariane L. Rung, Joel Gittelsohn, Russell R. Pate

Faculty Publications

Background: With limited opportunities for physical activity during school hours, it is important to understand the contexts of physical activities done outside of school time. Given the importance of physical and social aspects of environments, the purpose of this study was to describe where and with whom girls participate in physical activities outside of school. Methods: Participants were 1925 sixth-grade girls in the Trial of Activity for Adolescent Girls (TAAG). At baseline, they completed a 3-day physical activity recall (3DPAR), reporting the main activity performed during 30-minute intervals and the physical and social contexts of physical activities. Results: The most …


Oncolog Volume 54, Number 03, March 2009, Joe Munch Mar 2009

Oncolog Volume 54, Number 03, March 2009, Joe Munch

OncoLog MD Anderson's Report to Physicians (All issues) Archives

  • Rare Tumors: Finding Common Ground
  • Neuroendocrine Tumors
  • House Call: How You Can Help a Seriously Ill Friend


Assisting Nursing Students To Plan For Retirement, Pamela K. Strohfus, Vivian Schrader Mar 2009

Assisting Nursing Students To Plan For Retirement, Pamela K. Strohfus, Vivian Schrader

Nursing Faculty Publications and Presentations

The Nursing Leadership and Management faculty felt it was very important to teach "career and retirement life lessons". "Inadequate retirement savings is an issue that many nurses may face,…preparing for a secure retirement isn't taught in nursing school" says Monica Vollmuth, (ANA's Congress of Nursing Practice and Economics). In response, this content was included in a one credit senior seminar course.


Review Of Nicotine Nasal Spray Neither Effective Nor Well-Tolerated By Adolescent Smokers, William P. Adelman Mar 2009

Review Of Nicotine Nasal Spray Neither Effective Nor Well-Tolerated By Adolescent Smokers, William P. Adelman

Uniformed Services University of the Health Sciences

This is an important and well-designed first study of the effect of nicotine nasal spray (NNS) on adolescent smoking cessation that supports current evidence-based guidelines that nicotine replacement therapy is neither effective nor recommended for adolescents. NNS theoretically could succeed for adolescents where other forms of nicotine replacement failed.


Multimeric Hemicellulases Facilitate Biomass Conversion, Zhanmin Fan, Kurt Wagschal, Wei Chen, Michael D. Montross, Charles C. Lee, Ling Yuan Mar 2009

Multimeric Hemicellulases Facilitate Biomass Conversion, Zhanmin Fan, Kurt Wagschal, Wei Chen, Michael D. Montross, Charles C. Lee, Ling Yuan

Plant and Soil Sciences Faculty Publications

Two highly active trifunctional hemicellulases were constructed by linking the catalytic portion of a xylanase with an arabinofuranosidase and a xylosidase, using either flexible peptide linkers or linkers containing a cellulose-binding domain. The multifunctional enzymes retain the parental enzyme properties and exhibit synergistic effects in hydrolysis of natural xylans and corn stover.


Functional Conservation Of Asxl2, A Murine Homolog For The Drosophila Enhancer Of Trithorax And Polycomb Group Gene Asx, Heather A. Baskind, Lucy Na, Quanhong Ma, Mayur P. Patel, David Geenen, Q Ting Wang Mar 2009

Functional Conservation Of Asxl2, A Murine Homolog For The Drosophila Enhancer Of Trithorax And Polycomb Group Gene Asx, Heather A. Baskind, Lucy Na, Quanhong Ma, Mayur P. Patel, David Geenen, Q Ting Wang

Peer Reviewed Articles

Background: Polycomb-group (PcG) and trithorax-group (trxG) proteins regulate histone methylation to establish repressive and active chromatin configurations at target loci, respectively. These chromatin configurations are passed on from mother to daughter cells, thereby causing heritable changes in gene expression. The activities of PcG and trxG proteins are regulated by a special class of proteins known as Enhancers of trithorax and Polycomb (ETP). The Drosophila gene Additional sex combs (Asx) encodes an ETP protein and mutations in Asx enhance both PcG and trxG mutant phenotypes. The mouse and human genomes each contain three Asx homologues, Asx-like 1, 2, …


Advancing The Fiscal Health Of Low-Income Families: A Public And Community Health Approach, Doreen Treacy Mar 2009

Advancing The Fiscal Health Of Low-Income Families: A Public And Community Health Approach, Doreen Treacy

Center for Social Policy Publications

For decades, health researchers have documented the links between individual and household income/wealth and clinical health outcomes. The research and literature consistently point to both income inequality (i.e. individual household income/wealth as compared to other households in the same state) and individual household income as predictors of diminished health and morbidity. And yet the current framework for providing financial education, disseminating asset building information, and overall responding to the financial health of individuals and households takes no cues from public health and community health best practices. Further, the documented links between financial stress and compromised physical health are compelling enough …


Characterization Of Babies Discharged From Cabell Huntington Hospital During The Calendar Year 2005 With The Diagnoses Of Neonatal Abstinence Syndrome, F. Ross Baxter Md, Robert Nerhood Md, David Chaffin Md Mar 2009

Characterization Of Babies Discharged From Cabell Huntington Hospital During The Calendar Year 2005 With The Diagnoses Of Neonatal Abstinence Syndrome, F. Ross Baxter Md, Robert Nerhood Md, David Chaffin Md

Family and Community Health

Recent concern regarding the impact of maternal drug abuse on neonatal well-being was the impetus for this retrospective cohort study of newborns diagnosed with neonatal abstinence syndrome that were discharged from Cabell Huntington Hospital during the calendar year 2005. Medical records of the neonates and their mothers were analyzed for a variety of health related outcomes and healthcare cost. Forty-eight neonates were diagnosed with Neonatal Abstinence Syndrome in 2005, forty of which required NICU assistance. The average maternal age at delivery was 26; gravity was 3.1 and most were single, separated or divorced. The majority had poor or inconsistent prenatal …


The History, Development, And Purpose Of The Sensory Integration Global Network, Elizabeth Soechting, Tara J. Glennon, Heather Miller-Kuhaneck, Brian Erwin, Diana A. Henry, Colleen Basaraba, Zoe Mailloux, Susanne Smith Roley Mar 2009

The History, Development, And Purpose Of The Sensory Integration Global Network, Elizabeth Soechting, Tara J. Glennon, Heather Miller-Kuhaneck, Brian Erwin, Diana A. Henry, Colleen Basaraba, Zoe Mailloux, Susanne Smith Roley

Occupational Therapy Faculty Publications

The Sensory Integration Global Network (SIGN) is a Web-based resource developed by a loosely structured group of international volunteers dedicated to protecting the integrity and promoting the work of Ayres Sensory Integration® (ASI). SIGN provides an international resource to educate the public and professionals about A. Jean Ayres and sensory integration theory and practice to help them to discriminate between ASI and other interventions, especially those that use similar descriptors of improving sensory integration and sensory processing.

This article aims to increase awareness of the existence of SIGN within the readership of the American Occupational Therapy Association's (AOTA' s) Sensory …


Environmental Tobacco Smoke Avoidance Among Pregnant African-American Nonsmokers, Susan M. Blake, Kennan D. Murray, M. Nabil El-Khorazaty, Marie G. Gantz, Michele Kiely, Dana Best, Jill G. Joseph, Ayman El-Mohandes Mar 2009

Environmental Tobacco Smoke Avoidance Among Pregnant African-American Nonsmokers, Susan M. Blake, Kennan D. Murray, M. Nabil El-Khorazaty, Marie G. Gantz, Michele Kiely, Dana Best, Jill G. Joseph, Ayman El-Mohandes

Publications and Research

Background—Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women. Methods—From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001–October 2003), cotinine-confirmed nonsmokers with partners, household/ family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS …


Success And Failure Of Fast Track Extubation In Cardiac Surgery Patients Of Tertiary Care Hospital: One Year Audit, Mohammad Irfan Akhtar, Mohammad Hamid Mar 2009

Success And Failure Of Fast Track Extubation In Cardiac Surgery Patients Of Tertiary Care Hospital: One Year Audit, Mohammad Irfan Akhtar, Mohammad Hamid

Section of Cardiothoracic Surgery

OBJECTIVE: To identify the causes of delayed extubation in patients planned for fast tract extubation during cardiac surgery.

METHODS: A prospective observational study was conducted at cardiothoracic unit of Aga Khan University Hospital for the period of one year. All elective coronary artery bypass graft (CABG) surgery patients, between the ages of 35-75 years with LVEF > or = 40 percent were included. Patients with Intra aortic balloon pump, chronic renal failure, respiratory compromise and requiring high ionotropic support were excluded from this audit. A performa was designed and later filled by the primary investigator. Patient demographics and various reasons for …


Immediate Loading Of Unsplinted Implants In The Anterior Mandible For Overdentures, Phillip Roe Mar 2009

Immediate Loading Of Unsplinted Implants In The Anterior Mandible For Overdentures, Phillip Roe

Loma Linda University Electronic Theses, Dissertations & Projects

In this one-year prospective study, eight completely edentulous patients were selected from the Loma Linda University School of Dentistry (LLUSD) patient population to participate. There were five male and three female patients, between the ages of 58 and 82 (mean age of 69.1 years). All participants received new maxillary and mandibular complete dentures prior to implant placement. Two 4.0 mm x 13 mm threaded implants with a fluoride-modified, micro-roughened, titanium surface were placed mesial to each mandibular canine position. Locator abutments were connected and torqued to 25 Ncm and primary closure was achieved with a nonresorbable suture material. The Locator …


The Prevalence And Determinants Of Health Risk Behaviors Among High School Students In Mexico, Nellie León Mar 2009

The Prevalence And Determinants Of Health Risk Behaviors Among High School Students In Mexico, Nellie León

Loma Linda University Electronic Theses, Dissertations & Projects

The Centers for Disease Control and Prevention report that despite health promotion efforts, adolescents continue to engage in behaviors that put them at risk for morbidity and mortality. Alcohol consumption, illicit drug use, smoking, and risky sexual behaviors are among the behaviors that contribute to leading causes of morbidity and mortality in youth; these four behaviors were explored in this study. An observational cross-sectional design was utilized. The Youth Risk Behavior Survey from the Centers for Disease Control and Prevention was utilized to assess the prevalence of the four risk behaviors among high school students in Jalisco, Mexico. Items constructed …


Effect Of A Two Piece Scalloped Implant Design On Interproximal Bone Apposition/Retention - A Pilot Study In Rabbits, Aladdin Jamal Al-Ardah Mar 2009

Effect Of A Two Piece Scalloped Implant Design On Interproximal Bone Apposition/Retention - A Pilot Study In Rabbits, Aladdin Jamal Al-Ardah

Loma Linda University Electronic Theses, Dissertations & Projects

The aim of the study was to evaluate the effect of an experimental two piece scalloped implant design with a scalloped elliptical coronal part and an HA surface treatment on the bone to implant contact percentage in comparison to a commercially available HA treated implant. The possibility of bone apposition / retention along the exposed coronal scalloped part and the effect of the presence of a junction on the bone to implant contact percentage and bone apposition / retention were analyzed. 10 rabbits were included in the study with each rabbit receiving one control implant in one tibia and one …


Social Cognitive Predictors Of Diabetes Outcomes In Latinos And Whites, Diana Brown Mar 2009

Social Cognitive Predictors Of Diabetes Outcomes In Latinos And Whites, Diana Brown

Loma Linda University Electronic Theses, Dissertations & Projects

Investigating health care disparities in ethnic minority populations is an increasingly urgent issue as these disparities lead to higher morbidity and mortality in minorities (National Center of Health Statistics, 2000). There is clear evidence that Latino Americans, the fastest growing minority group in the United States, are more likely to be diagnosed with and experience more severe complications from type 2 diabetes than Anglo Americans. This study surveyed 38 White and 33 Latino diabetes patients from outpatient clinics in an academic medical center. Cultural values (individualism and collectivism), mental health (social support, mental health), and self-efficacy (diabetes and exercise) were …


The Dynamic Nature Of Knowledge: Insights From A Dynamic Field Model Of Children’S Novel Noun Generalization, Larissa K. Samuelson, Anne R. Schutte, Jessica S. Horst Mar 2009

The Dynamic Nature Of Knowledge: Insights From A Dynamic Field Model Of Children’S Novel Noun Generalization, Larissa K. Samuelson, Anne R. Schutte, Jessica S. Horst

Department of Psychology: Faculty Publications

This paper examines the tie between knowledge and behavior in a noun generalization context. An experiment directly comparing noun generalizations of children at the same point in development in forced-choice and yes/no tasks reveals task-specific differences in the way children’s knowledge of nominal categories is brought to bear in a moment. To understand the cognitive system that produced these differences, the real-time decision processes in these tasks were instantiated in a dynamic field model. The model captures both qualitative and quantitative differences in performance across tasks and reveals constraints on the nature of children’s accumulated knowledge. Additional simulations of developmental …


Or Practice—Efficient Short-Term Allocation And Reallocation Of Patients To Floors Of A Hospital During Demand Surges, Steven M. Thompson, Manuel Nunez, Robert Garfinkel, Matthew D. Dean Mar 2009

Or Practice—Efficient Short-Term Allocation And Reallocation Of Patients To Floors Of A Hospital During Demand Surges, Steven M. Thompson, Manuel Nunez, Robert Garfinkel, Matthew D. Dean

Management Faculty Publications

Many hospitals face the problem of insufficient capacity to meet demand for inpatient beds, especially during demand surges. This results in quality degradation of patient care due to large delays from admission time to the hospital until arrival at a floor. In addition, there is loss of revenue because of the inability to provide service to potential patients. A solution to the problem is to proactively transfer patients between floors in anticipation of a demand surge. Optimal reallocation poses an extraordinarily complex problem that can be modeled as a finite-horizon Markov decision process. Based on the optimization model, a decision-support …


Rehabilitation Role In Childhood Dedecation Problem, N. Tantisiriwat Mar 2009

Rehabilitation Role In Childhood Dedecation Problem, N. Tantisiriwat

Chulalongkorn Medical Journal

No abstract provided.


Effects Of Dosage And Duration Of Enalapril Usage On Hematocrit Levels In Hemodialysis Patients, D. Panomvana, S. Rattanajinda, B. Jirajan, Lekhyananda S. Mar 2009

Effects Of Dosage And Duration Of Enalapril Usage On Hematocrit Levels In Hemodialysis Patients, D. Panomvana, S. Rattanajinda, B. Jirajan, Lekhyananda S.

Chulalongkorn Medical Journal

No abstract provided.


Characterization Of Magnetic Resonance (Mr) Findings Of Malignant And Benign Vertebral Compression Fractures, J. Srisomboon Mar 2009

Characterization Of Magnetic Resonance (Mr) Findings Of Malignant And Benign Vertebral Compression Fractures, J. Srisomboon

Chulalongkorn Medical Journal

No abstract provided.


Detection Of Viruses In Human Adenoid Tissues By Use Of Multiplex Pcr, Masatoki Sato, Haijing Li, Mine R. Ikizler, Jay A. Werkhaven, John V. Williams, James D. Chappell, Yi-Wei Tang, Peter F. Wright Mar 2009

Detection Of Viruses In Human Adenoid Tissues By Use Of Multiplex Pcr, Masatoki Sato, Haijing Li, Mine R. Ikizler, Jay A. Werkhaven, John V. Williams, James D. Chappell, Yi-Wei Tang, Peter F. Wright

Dartmouth Scholarship

By PCR, we detected a high frequency of viruses in adenoids obtained from children without acute respiratory symptoms. Our results suggest that persistent/latent viral infection in the respiratory tract confounds interpretation of the association of pathogen detection by PCR with acute respiratory infection in these sources.


Life Expectancy And Years Of Life Lost In Chronic Obstructive Pulmonary Disease: Findings From The Nhanes Iii Follow-Up Study, Robert M. Shavelle, David R. Paculdo, Scott J. Kush, David M. Mannino, David J. Strauss Mar 2009

Life Expectancy And Years Of Life Lost In Chronic Obstructive Pulmonary Disease: Findings From The Nhanes Iii Follow-Up Study, Robert M. Shavelle, David R. Paculdo, Scott J. Kush, David M. Mannino, David J. Strauss

Internal Medicine Faculty Publications

RATIONALE: Previous studies have demonstrated that chronic obstructive pulmonary disease (COPD) causes increased mortality in the general population. But life expectancy and the years of life lost have not been reported.

OBJECTIVES: To quantify mortality, examine how it varies with age, sex, and other risk factors, and determine how life expectancy is affected.

METHODS: We constructed mortality models using the Third National Health and Nutrition Examination Survey, adjusting for age, sex, race, and major medical conditions. We used these to compute life expectancy and the years of life lost.

MEASUREMENTS AND MAIN RESULTS: Pulmonary function testing classified patients as having …


Trends In Mental Health Of An Adolescent Medicine Clinic Patient Population, Abdel Salous, Linah Al-Alem, Hatim A. Omar Mar 2009

Trends In Mental Health Of An Adolescent Medicine Clinic Patient Population, Abdel Salous, Linah Al-Alem, Hatim A. Omar

Pediatrics Faculty Publications

The correlation between exposure to forms of violence and development of mental disorders in victims is well established. The purpose of this paper was to identify mental health problems in an adolescent medicine clinic population in Lexington, KY and to investigate potential correlation of mental disorders with psychosocial factors. Data were gathered from the charts of 169 adolescent clinic patients (age 10-22) seen in the clinic for mental health care and analyzed using Excel. Of the patient population, 68% were urban, whereas 32% were rural. In terms of gender, 40% of the patients were male and 60% were female, 80% …


Discovering The Complexities Of Adolescent Compliance To Treatment, Megan Song, Hatim A. Omar Mar 2009

Discovering The Complexities Of Adolescent Compliance To Treatment, Megan Song, Hatim A. Omar

Pediatrics Faculty Publications

To explore the challenges faced in enhancing adolescent treatment compliance and to understand the roles of key players in this endeavor: the adolescent, parent and healthcare provider. Obtaining compliance from adolescents requires collaboration from the adolescent, caregiver and provider and depends on well-established relationships between each person in the triad: adolescent-provider, adolescent-caregiver, and caregiver-provider. Ensuring and improving adherence to treatment by adolescents is a challenging task but crucial to overall health outcomes. It requires the collaboration of the adolescent, parent and physician to create the optimal treatment plan, specifically tailored to the adolescent. For the clinician, maintaining good communication and …


Oral Healthcare In Kenya: Implications For Dental Hygiene Care, Grace Kogi Mar 2009

Oral Healthcare In Kenya: Implications For Dental Hygiene Care, Grace Kogi

Dental Hygiene Master's Papers and Projects

This paper is a review of literature describing the educational, healthcare delivery and healthcare finance systems in Kenya. The document discusses the unmet oral health needs of the Kenyan population and how implementing the role of the dental hygienist would positively impact oral health promotion throughout the country. Kenyan communities experience all of the major environmental determinants of oral disease, e.g., widespread poverty, underdevelopment, outdated dental equipment, insufficient supply and distribution of qualified dental care professionals and lack of preventive oral health services. About six in ten Kenyans are unable to afford healthcare, clothing, or food; therefore, oral healthcare has …