Changes in state policy for promoting a healthy lifestyle. (A historical aspect).

Healthy lifestyle promotion from the perspective of state policy, journalism, healthcare, sociology, and psychology was analyzed. The objective of the study was to analyze changes in the financial and agitation state policy aimed at increasing the motivational activity of citizens of the Russian Federation towards a healthy lifestyle (HLS) in the Soviet era and at the post-Soviet stage and assess the effectiveness of these measures. The effectiveness of the Soviet propaganda of healthy lifestyles among the population was evaluated. Crisis phenomena in public health, low persuasiveness of the media presentation of the healthy lifestyle value, the COVID-19 pandemic, difficulties in implementing corporate health promotion programs in the workplace at individual en-terprises, and ignoring gender stereotypes in attitudes to health are the reasons that contribute to the adherence of Russian workers to unhealthy behaviors, that cause an increase in the incidence of chronic non-communicable diseases. The historical aspect of changes in state policy for health promotion made it possible to determine the tasks in developing health-saving programs.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

How digital health technologies promote healthy life in the Post-COVID-19 Era: evidences from national survey on Chinese adolescents and youngsters.

The rapid development of intelligent technologies coupled with the stay-at-home trends in the Post-COVID-19 Era has significantly changed youth's health behavior as well as reshaped their lifestyles. Digital health technologies (DHTs) have been more and more used for health management among youngsters. However, little was known about the use of DHTs among youths and its consequences on their health, especially in developing countries like China. Inspired by behavior intervention technology (BIT) model, this study examined the underlying mechanisms of use and social interactions of DHTs on Chinese adolescents' and youngsters' healthy lifestyles and mental health, using a representatively national survey among high school and freshman students in China (N = 2,297). It found that use of DHTs had a significantly positive effect on Chinese youths' healthy lifestyles and mental health, with behavioral regulation as a mediator. However, social interactions of DHTs were negatively associated with their mental health. The findings contribute to a better guidance on health promotion, as well as the enhanced design of DHTs' products.

Profiling Inconsistent/Non-Adopters of Infection Prevention Behaviours during the Covid-19 Pandemic for Targeted Public Health Education: A Population Study

Intro: With the relentless waves of coronavirus disease 2019(COVID-19), there is a need for widespread community adoption of infection prevention(IP) measures including hand hygiene, use of face masks, and staying at home when unwell. Understanding the profile of individuals who do not consistently practice IP can help target public health education. Method(s): We conducted a nationally-representative population survey from November 2020 to January 2021. Households were randomly selected from a proportionately stratified national census. The household member with the most recent birthday was invited to complete the survey. Three questions on a 5-point Likert-scale(never-rarely-occasionally-often-always) assessed IP behaviours(hand hygiene, face mask use when having a cough/cold, staying at home when having a cold/flu) before and during the pandemic. A multivariable logistic regression model was constructed to assess factors associated with the non- or inconsistent("never-rarely-occasionally") adoption of any of the three IP behaviours during the pandemic. Finding(s): Mean age of 2004 respondents was 44.5(SD 15.0) years, with 52% females and 65% being highly educated (diploma/degree holders). Although 12% reported consistently("often-always") adopting all 3 IP behaviours pre-pandemic, the majority(n=1752, 87%) reported doing so during the pandemic. After adjusting for age, educational level, and presence of chronic illness, males(AOR 1.71 [95%CI 1.30, 2.25], Chinese(AOR 1.48 [1.07, 2.05]), low-adopters of healthy lifestyle(AOR 1.59 [1.03, 2.45]) and those who did not or inconsistently adopted IP behaviours pre-pandemic(AOR 8.92 [3.28, 24.27]) were more likely not to or inconsistently adopt the 3 IP behaviours during the pandemic. Discussion(s): During the ongoing pandemic, educational messages and information channels on IP measures could be more targeted at males and Chinese. Additionally, the promotion of healthy lifestyle and consistent adoption of IP behaviours during non-pandemic times is critical for consistent adoption of IP behaviours during pandemics. Conclusion(s): Males, Chinese, and low-adopters of healthy lifestyle and IP behaviours pre-pandemic do not consistently practice IP during the pandemic.Copyright © 2023

The coronavirus conundrum - From pandemic to endemic COVID-19 - Should we continue taking care of ourselves?

It seems that things are calming down with SARS-Cov-2, as there are no longer daily reports and notes of findings of new variants and subvariants of the virus, as well as clinical changes in symptomatology, hospitalizations, severity, and deaths due to COVID-19. We do not know how we should guard against viral infection during the impending endemic phase of the disease, knowing the complex health problems of prolonged COVID if we contract the virus. In this article we describe the latest known coronavirus mutations, how they affect certain organs and systems, the advantage of a better response to infection in people with healthy lifestyle, the rebound of symptomatology, reinfections at the time of the vaccine, prolonged COVID, excess mortality of physicians who attended the first waves without vaccine, and some news and knowledge about COVID in the pregnant woman and her fetus and newborn;the future of the newborn born to a mother with COVID remains unknown. In the COVID endemic, should we continue to protect ourselves? How?Copyright © Peruvian Society of Obstetrics and Gynecology. All Rights Reserved.

The Effect of Fear of COVID-19 on Women's Attitudes toward Cancer Screening and Healthy Lifestyle Behaviors: A Cross-Sectional Study.

Purpose: The study was conducted to evaluate the effect of fear of COVID-19 on women's attitudes toward cancer screening and healthy lifestyle behaviors. Method: The study is of descriptive and cross-sectional type. The sample of the study consisted of 221 women living in Turkey. Research data were collected using Introductory Information Form, Attitude Scale for Cancer Screening, The Fear of COVID-19 Scale and Healthy Lifestyle Behaviors Scale II (HLBS-II). Results: It was found out that 92.3% of the women did not have cancer screening during the pandemic period, 33.0% of the women who did not have it because they were afraid of the contamination, 33.0% thought they were healthy, 13.1% did not have screening tests because they thought that screening tests were not easy and accessible during the pandemic period. While no significant relationship was found between women's attitudes toward cancer screenings and fear of COVID-19 (P > 0.05), a positive significant relationship was found between women's attitudes toward cancer screenings and spiritual growth, health responsibility and interpersonal relations scores, which are sub-dimensions of the HLBS-II scale (P > 0.05). In addition, it was found out that women's fear of COVID-19 affected interpersonal relations and stress management (P < 0.05). Conclusion: In our study, it was concluded that most of the women did not have cancer screening during the pandemic, and that the fear of COVID-19 affected such healthy lifestyle behaviors as interpersonal relations and stress management.

Impact of COVID-19 Lockdown on Anthropometric Body Measurements and Nutritional Behaviors in a Colombian Cohort Receiving Online Nutritional Advice

Objective: In this study, we aimed to retrospectively assess the change in weight before and after the COVID-19 mandatory lockdown in Colombia among adults who received nutritional and healthy lifestyle recommendations at weight loss and wellness clinics by telehealth. The primary objective was to describe and compare the mean weight reduction measured at the baseline and by the end of the lockdown. Secondary objectives include describing and comparing body fat percentage, muscle mass percentage, and BMI measured at the baseline and by the end of the lockdown. Method(s): One hundred and seventy-two middle-aged (18-68 years old) women and men received online nutritional and healthy lifestyle advice during the COVID-19 lockdown in Colombia. Weight, fat (%), muscle mass (%), and BMI were assessed before and after the lockdown. We included baseline measurements taken before the lockdown from March 1st to June 20th, 2020, and post-lockdown measurements from August 31st to October 20th, 2020. Exclusion criteria included pregnancy or breastfeeding women, acutely decompensated diabetes, hypertension, CKD, Hypothyroidism or taking any of the obesity treatment medications approved in Colombia, including liraglutide, semaglutide or orlistat. A retrospective analysis was completed to compare the change in mean body anthropometrics. Shapiro Wilk test was used to assess for normality. Paired T Test and Wilcoxon sign test were used to compare the distribution of body anthropometrics before and after the lockdown. IRB approval was obtained before exporting and analyzing the collection of data. Result(s): Out of 205 subjects and after a review of exclusion criteria, 172 subjects were included in the data analysis. 90.1% (155) were women. 52.3% (135) had overweight or obesity. After the COVID-19 lockdown, the mean weight loss reduction was 8.79 kg (SD +/- 5.45, p<0.0001), corresponding to an 11.4% weight loss reduction. The mean fat mass percentage loss was 2.89 % (SD +/- 2.64, p<0.0001), and the mean BMI presented a reduction of 3.16 (SD +/- 1.96, p <0.0001). The mean muscle percentage loss was 0.10% (SD +/- 2.67, p 0.482). Discussion/Conclusion: Subjects receiving telehealth nutritional advice in Colombia during the COVID-19 lockdown had significant clinical and statistical weight, BMI, and fat loss reduction. Muscle mass was preserved;however, this mean change was not statistically significant. Physical inactivity during the lockdown period was a potential contributor to a nonsignificant mean muscle mass change. The subjects in this study were highly motivated to virtually attend weight loss and wellness clinics and to improve body anthropometrics by optimizing lifestyle changes. Telehealth weight loss strategies should always be considered when in-person patient interaction is not available.Copyright © 2023

Resident Perceptions and Confidence Regarding Pediatric Preventive Care

Purpose of Study: Residents have experienced changes in educational structure, format, content, and patient experience due to the COVID-19 pandemic. Resident physicians across the country have reported changes in workload including a decrease in well child checks and immunizations resulting in limited clinical exposure. This study aimed to assess the confidence of first year pediatric residents (interns) in conducting routine preventive screening for children and to identify potential gaps in knowledge among this cohort. Methods Used: We conducted a cross-sectional observation study that included 13 categorical first year pediatric residents. A voluntary, anonymous online survey was administered in September 2022. The survey assessed confidence levels, and perceived comfort regarding common preventive pediatric encounters and screening tools. The survey included 7-questions based on the 4th Edition Bright Future's Guidelines and respondents rated their answers on a 5-point Likert scale. The surveys were distributed anonymously via e-mail using Survey Monkey, a web-based software platform that provided an intuitive interface for validated data capture. Participants were given 2 weeks to complete the survey and reminders were sent via email. Summary of Results: Eight of 13 interns participated for a response rate of 62%. Sixty-three percent of the residents had completed a subinternship in pediatrics. Of our respondents, 75% reported feeling "not at all confident" in executing well child check-ups for children <12months old and 63% reported feeling "very confident" in examining children> 13months old. Regarding the ability to perform a genitourinary examination in children >12years of age, 63% of respondents stated that they were "slightly" or "not at all confident". We asked interns to rate their confidence in providing anticipatory guidance to their patients. Interns perceived being somewhat confident regarding guidance about safe sex, tobacco use, and healthy lifestyles but less confident regarding newborn care, breast feeding and infant nutrition. Nearly 40% reported comfort in recommending and advising parents about the risks and benefits of age appropriate immunizations. We asked residents to report their ability in administering and interpreting screening tools (ASQ, MCAT, EPDS). Interns reported that were able to interpret results but lacked confidence in providing guidance. Conclusion(s): Our study identifies opportunities to bridge experiential knowledge gaps and confidence among pediatric interns who may have had limited clinical exposure to pediatrics following the COVID-19 pandemic. Graduate medical education programs should consider developing tailored educational interventions specifically geared for identified learning gaps to mitigate the challenges posed by the pandemic.

Development Of Technology for Obtaining Natural Nutriceutics in Solid Form

This article discusses development of technology for obtaining natural nutriceutics in solid form. Currently, a healthy lifestyle, a healthy diet and the body's resistance to external negative factors have become topical issues, especially after the outbreak of the global COVID-19 pandemic. Basically, the prevention and treatment of diseases occurs due to the replenishment of the complex of bioactive substances that the body receives from healthy food. Otherwise, if the tissues and organs do not receive the elements necessary for the normal functioning of the body, then the strength to fight the disease decreases. Here, dietary supplements, that is, nutraceuticals, play an important role, they are consumed with food and are mainly obtained from products of natural origin: vegetable, animal and bacterial.Copyright © 2023, Codon Publications. All rights reserved.

Scoping review of adult-oriented outdoor play publications in Canada. / Examen de la portée des publications sur le jeu à l'extérieur chez les adultes au Canada.

INTRODUCTION: Since 2015, there has been growing interest in Canada and beyond on the benefits of outdoor play for physical, emotional, social and environmental health, wellbeing and development, for adults as well as children and youth. METHODS: This scoping review aims to answer the question, "How, and in what context, is adult-oriented outdoor play being studied in Canada?" We conducted an electronic search for peer-reviewed articles on outdoor play published in English or French after September 2015 by authors from Canadian institutions or about Canadian adults. The 224 retrieved articles were organized according to eight priorities: health, well-being and development; outdoor play environments; safety and outdoor play; cross-sectoral connections; equity, diversity and inclusion; professional development; Indigenous Peoples and land-based outdoor play; and COVID-19. We tallied the study designs and measurement methods used. RESULTS: The most common priority was outdoor play environments; the least common were COVID-19 and Indigenous Peoples and land-based outdoor play. Cross-sectional studies were the most common; no rapid reviews were identified. Sample sizes varied from one auto-ethnographic reflection to 147 000 zoo visitor datapoints. More studies used subjective than objective measurement methods. Environmental health was the most common outcome and mental/emotional development was the least. CONCLUSION: There has been a staggering amount of articles published on adult-oriented outdoor play in Canada since 2015. Knowledge gaps remain in the relationship between outdoor play and adult mental/emotional development; the connections between environmental health and Indigenous cultures and traditions; and how to balance promoting outdoor unstructured play with protecting and preserving natural spaces.

Influencia del Ejercicio Físico en la Gravedad de la COVID-19

RESUMEN Antecedentes: La enfermedad por el nuevo coronavirus (COVID-19) fue declarada pandemia en marzo de 2020. Este estudio tiene como objetivo analizar la relación entre la práctica de ejercicio físico y la gravedad de la COVID-19. Método: Estudio observacional en una cohorte de 29875 personas de la Universidad de Salamanca (2800 profesores/investigadores, 1289 personal de servicio y 25786 estudiantes) mediante la realización de una encuesta anónima telemática que recogió datos sobre la realización de ejercicio, el diagnóstico de COVID-19 y sus síntomas. La encuesta fue realizada durante la primavera de 2021 y estuvo abierta 1 mes. Resultados: Se recibieron 3662 respuestas completas. Se utilizó la metodología "raking” para inferir los resultados a toda la población de estudio (29875 personas). Se encontró una relación estadísticamente significativa (p<0,001) entre la presencia de síntomas y la práctica de ejercicio, la probabilidad de sufrir síntomas en personas que no practicaban ejercicio antes de COVID-19 fue 2,18 veces mayor que en aquellas que practicaban ejercicio (IC 95%, [1,825-2,611]). La práctica de ejercicio más de 5 días/semana fue el factor más protector (Chi cuadrado=134,22, gl=2;p-valor<0,000). El ejercicio intenso fue más efectivo que el ejercicio moderado (Chi cuadrado=36,88, gl=1;p-valor<0,000) para prevenir los síntomas de COVID-19. Conclusión: El ejercicio físico es un factor protector en la enfermedad COVID-19. El ejercicio regular, al menos 5 días/semana, resultó ser la opción más adecuada para prevenir los síntomas de la enfermedad. El ejercicio intenso logró mayor efectividad que el ejercicio moderado en el control de la gravedad de la enfermedad. Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020. This study aims to clarify the relationship between physical exercise practice and the severity of COVID-19. Methods: The present research is an observational, cross-sectional study. 29875 people from the University of Salamanca were surveyed in March 2021 (2800 teacher and research staff, 1289 service staff and 25786 students). The survey analysed the influence of physical exercise on COVID-19 symptoms. Results: A total of 3662 complete responses were received. Raking methodology was used to extrapolate the results to the entire study population (29875 people). A statistically significant relationship (p<0.001) was recorded between developing symptoms and practicing physical exercise, the probability of suffering symptoms in people who did not practice exercise before COVID-19 was 2.18 times higher than those who practice exercise (95% CI, 1.825;2.611). Practising physical exercise more than 5 days/week was the most protective factor (Chi square= 134.22, gl=2;p-valor<0.000). Intense physical exercise was more effective than moderate exercise (Chi square= 36.88, gl=1;p-valor<0.000) to prevent COVID-19 symptoms. Conclusion: This study proved that physical exercise is a protective factor against SARS-CoV-2 infection. Regular exercise, at least 5 days/week, has been shown to be the most appropriate option to prevent disease symptoms. Intense exercise achieves greater effectiveness than moderate exercise in controlling the severity of the disease.

Vaccination against COVID-19: the opinion of healthcare professionals.

A prerequisite for effective vaccination is the formation of proper collective immunity in society. The attitudes of healthcare professionals towards vaccination directly impact the population's adherence to this method. Objective. To study the attitude of healthcare professionals toward COVID-19 vaccination. Material and methods. The sociological survey method with the author's questionnaire based on GoogleForm was used. In the sur-vey, 450 physicians aged 25 to 70 participated voluntarily. It was a cross-sectional study carried out in the autumn of 2021. Results. Of those surveyed, the majority (86.8%) of physicians and almost all (96.1%) nurses were vaccinated against COVID-19. When studying the motivation for vaccine prophylaxis, a direct average strength of a statistically significant correlation between the adherence to COVID-19 vaccination and the emergence of a sense of safety was established (rxy =0.346;p<0.05). The most common reasons for the refusal of doctors from vaccination were the fear of complications, beliefs about low protection against infection and the subsequent decrease in immunity. According to healthcare professionals, the most effective means of prevention, in descending order, were a healthy lifestyle, the absence of fear of becoming ill, vaccination, drugs that stimulate immunity, the use of barrier measures, and other means. Conclusion. The ambiguous attitude of healthcare professionals towards vaccination against COVID-19 does exist and deserves the closest attention. Considering the issue's complexity, further research on the attitude of healthcare professionals toward vaccination is required.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

Providing Educational Resources during the Pandemic for Advanced Breast Cancer Patients

Significance and Background: Metastatic Breast Cancer (MBC) or Advanced Breast Cancer (ABC) is multifaceted and requires high levels of support and resource utilization. The ABC Program at MD Anderson Cancer Center began in 2014 with a goal to increase the quantity and quality of life for patients living with MBC. It offers emotional support, personalized visits with a nurse practitioner navigator, access to clinical trials, specialty clinics, tailored patient education and innovative care projects. Prior to COVID-19, the ABC Program held a 90-minute quarterly town hall series featuring 2-3 presenters and topics of patient interest. In response to COVID-19, it pivoted to a weekly virtual 60-minute educational series called "ABCs of Healthy Living in Challenging Times" that is for patients with breast cancer, caregivers, faculty, staff, community members and advocates. Purpose(s): To address COVID-19 social-distancing related isolation and changes to healthcare, build community, empower patients, and educate on diverse topics including patient services, treatment, symptom management and quality of life. Interventions and Evaluation: The series was facilitated by a nurse practitioner navigator via Zoom. A distribution list created from town hall meetings was the basis for the series' notices and has grown by referrals, word of mouth and marketing opportunities;it began with less than 150 people and has grown to more than 550 people. The facilitator offered a format where the attendees and speakers could interact visually and verbally with each other. From 4/2020 to 6/2022, 104 webinars were held for 2,546 attendees for an average of 24 attendees each week. Topics covered were side effect management/quality of life/healthy lifestyle (26%), patient education/empowerment (18%), treatment (19%), clinical trials/research (11%), quality of life related to COVID-19 (8%), COVID-19 (7%), innovation projects (4%), palliative/end of life care (7%), and financial/disability concerns (3%). The series was evaluated using the Qualtrics survey software (n=53). Respondents said that the series has positively influenced their interactions with healthcare providers (65%), how patients with MBC think about their cancer experiences (65%) and provided an opportunity to connect with others like themselves (65%). Respondents stated actions taken based on the series: shared the information with family/friends (77%), joined or remained in a support group (34%), spoke with a provider for information and services (32%), requested an appointment with the ABC Program or other specialty clinics (26%), started a new healthy behavior (21%), joined a clinical trial (11%), or started using a patient reported outcome tool (9%). The series served mostly patients living with MBC (70%), established patients at MD Anderson (38%) or patients at MD Anderson as well as a community cancer center (17%). Most respondents indicated that they attended about half of the time, usually or always (60%) and are very or completely satisfied with the series (92%). Demographics of the respondents were White (77%), Black (13%), Asian (4%) and Hispanic (16%). Discussion(s): The ABC Program pivoted to COVID-19 by offering services virtually. The virtual series has allowed for more digestible patient education, varied presentations, and participation for those living outside of Houston, TX. Peer support and continuing education are imperative dynamics for patients to use their voice to impact their overall quality of life. The series has impacted attendees with a change in behavior when speaking with their clinical team, awareness and utilization of support resources, and starting healthy behaviors. While the series was created in response to demands of COVID-19, it effectively addressed psychosocial and educational needs and overall quality of life of MBC patients. The series was an easy intervention to initiate with lasting changes relative to the effort and resources required.

Public image of coronavirus infection prevention in 2020-2021.

Objective. To study the public attitudes towards responsibility for their health, the level of attendance at health centers and medical prevention departments/clinics, and the activity of healthcare professionals in engaging the population in a healthy lifestyle. Material and methods. We analyzed the current issues of the work of healthcare organizations, including medical prevention units/offices and health centers in Russia, from the point of view of the population. A mass survey of the population was conducted via personal semi-formalized interviews at the place of residence (apartment survey) using a specific questionnaire. The sample size was 1,630 subjects. The quality and accessibility of health care were assessed using case studies: respondents were asked to rate based on their most recent visits to a doctor/health care provider. Results. Based on an analysis of the 2020-2021 studies, the authors found that the high level of awareness in the vast majority of the population of their personal responsibility for their health does not result in high attendance at health prevention units/clinics and health centers. The attendance was not even influenced by the high level of patients' satisfaction with medical recommendations. According to the authors, this process is negatively influenced by the low involvement of healthcare providers in healthy lifestyle promotion, the usefulness of consultations at medical prevention departments/clinics and health centers, and the low awareness of the population on this issue. Conclusion. The study showed the need to increase the intensity of Russia-wide information campaigns on preventing non-communicable diseases and promoting healthy lifestyles, especially outside the capital regions, and the importance of improving the quality of information messages.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

Study on the Incidence and Profile of Risk Factors in the Field of Healthcare Practice in Pharmaceutical Care during the Covid-19 Pandemic Period

The profession of pharmacist involves a continuous effort to combat diseases and preserve social health in various urban and rural communities. Pharmacists are exposed to a variety of risk factors while performing their professional activity. The COVID-19 pandemic period introduced an additional risk among occupational risk factors. The aim of the study is to identify occupational risk factors among pharmacists and the health problems they face at work. The study also seeks to propose some recommendations for risk prophylaxis and to facilitate the activity in conditions of good professional practice and to minimize exposure to occupational risk factors. The proposed questionnaire aims to highlight the level of health and habits, lifestyle practices and perceptions of the typology of healthy living in this professional group. The application of the questionnaire can also be the sign for the transition point from the state of health to the pathological status. The correlation of professional and non-professional factors led to the profiling of relationships between all risk factors induced by the specific of the profession and theorizing a set of prophylactic or curative intervention measures. Compliance with a physical activity program and a lifestyle according with the standards of relevant domestic and international bodies will increase the quality of life of these specialists as well as the quality of professional acts in the service of public health.Copyright © 2023, Romanian Society for Pharmaceutical Sciences. All rights reserved.

Preventive nutritional style for new type 2019 Coronavirus SARS-CoV-2 (COVID-19) pandemic

The COVID-19 infection, which emerged at the beginning of 2019 and spread all over the world, led to the global pandemic. The destructive effects of the pandemic are tried to be stopped all over the world. In this process, scien-tific methods should be applied to combat the pandemic. Personal precautions are personal hygiene, apply social isolation and strengthen the immune system, support a natural, balanced, healthy diet, support nutrition with exercise and have a healthy lifestyle. Strong individual immunity is the main factor in avoiding virus infection or the severity of the infection. Social isolation advice has changed the lifestyle of some individuals and brought with a sedentary lifestyle and an irregular diet. As an expected result of this condition, the immune system has been weakened. Therefore, switching to a natural and balanced diet that will create a strong immune system will protect against the destructive effects of the new type of corona virus pandemic. It is very important to supplement food containing vitamins, minerals, prebiotics and probiotics naturally with adequate water intake. Vitamin C, probiotics, prebiotics, thymoquinone, selenium and zinc supplements will strengthen the immune system, increase body resistance, thereby activating possible protective effects mechanisms for COVID-19 infection.Copyright © 2021 Necati Ozpinar. All rights reserved.