An investigation of sensory processing skills in toddlers with joint hypermobility.

BACKGROUND: Children with Generalized Joint Hypermobility (GJH) may have a motor developmental delay in the early period and subluxation, fatigue, autonomic dysfunction, and pain arising from ligaments and other soft tissues in advanced ages. Additionally, there is a loss of proprioceptive sensation in children and adults with GJH. AIMS: This study aimed to evaluate sensory processing skills in toddlers with GJH. STUDY DESIGN: A cross-sectional study. SUBJECTS: Fifty-eight children aged between 12 and 14 months were included in the study. These children were divided into two groups: with and without GJH (31 with GJH and 27 without GJH). OUTCOME MEASURES: The sensory processing skills of the children in the study were evaluated with the Test of Sensory Functions in Infants (TSFI). RESULTS: The scores in the subtests of TSFI in response to tactile deep pressure, adaptive motor functions, visual-tactile integration, and response to vestibular stimuli were higher in favor of children without GJH (p < 0.05). The total TSFI score was higher in the group without GJH (p < 0.05). CONCLUSIONS: Sensory processing problems were found in toddlers with GJH. Sensory motor development should be evaluated in children with GJH, and an appropriate early intervention program should be planned.

Using the center of pressure movement analysis in evaluating spontaneous movements in infants: a comparative study with general movements assessment.

BACKGROUND: Researchers have attempted to automate the spontaneous movement assessment and have sought quantitative and objective methods over the past decade. The purpose of the study was to present a quantitative assessment method of spontaneous movement using center-of-pressure (COP) movement analysis. METHODS: A total of 101 infants were included in the study. The infants were placed in the supine position on the force plate with the cranial-caudal orientation. In this position, the recording of video and COP movement data were made simultaneously for 3 min. Video recordings were used to observe global and detailed general movement assessment (GMA), and COP time series data were used to obtain quantitative movement parameters. RESULTS: According to the global GMA, 13 infants displayed absent fidgety movements (FMs) and 88 infants displayed normal FMs. The binary logistic regression model indicated significant association between global GMA and COP movement parameters (chi-square = 20.817, p < 0.001). The sensitivity, specificity, and overall accuracy of this model were 85% (95% CI: 55-98), 83% (95% CI: 73-90), and 83% (95% CI: 74-90), respectively. The multiple linear regression model showed a significant association between detailed GMA (motor optimality score-revised/MOS-R) and COP movement parameters (F = 10.349, p < 0.001). The MOS-R total score was predicted with a standard error of approximately 1.8 points (6%). CONCLUSIONS: The present study demonstrated the possible avenues for using COP movement analysis to objectively detect the absent FMs and MOS-R total score in clinical settings. Although the method presented in this study requires further validation, it may complement observational GMA and be clinically useful for infant screening purposes, particularly in clinical settings where access to expertise in observational GMA is not available.

Validity and reliability of the Turkish version of the hand-use-at-home questionnaire for children with unilateral cerebral palsy and neonatal brachial plexus palsy.

PURPOSE: To translate the Hand-Use-at-Home questionnaire (HUH), assesses the amount of spontaneous use of the affected hand in children with 18 bimanual activities, into Turkish and examine its validity and reliability on children with neonatal brachial plexus palsy (NBPP) or unilateral cerebral palsy (UCP). MATERIALS AND METHODS: The HUH was translated and cross-culturally adapted to Turkish and administered to children with NBPP (n = 25) and UCP (n = 42) between 3 and 10 years. The psychometric analyses included reliability by internal consistency (Cronbach's alpha) and test/retest reliability (intraclass correlation coefficient, ICC) structural validity was evaluated with exploratory factor analysis, and construct validity was investigated by matching the HUH with the Pediatric Outcome Data Collection Instrument Upper Extremity Scale (PODCI) (NBPP only), and Children's Hand-Use Experience Questionnaire (CHEQ) (UCP only). RESULTS: HUH showed excellent test-retest reliability (ICC2,1 = 0.988 Cl (0.977-0.992)), excellent internal consistency (Cronbach's-α = 0.989), and moderate correlation with CHEQ (rs = 0.558) in UCP and high correlation with PODCI Scale (rs = 0.789) in NBPP group. The HUH had low and moderate correlation respectively lesion-extent levels (r=-0.457) in NBPP and 5 Manual Ability Classification System levels (r=-0.688) in the UCP group. CONCLUSION: The HUH is a valid and reliable tool to assess the amount of spontaneous use of the affected hand in Turkish children with NBPP and UCP.

The Hand-Use-at-Home (HUH) questionnaire is a reliable and good valid outcome measure to evaluate the amount of spontaneous use of the affected hand.We suggest the Turkish version of the HUH be used in the Turkish children to indicate small changes in the severity of disorder of children until a normal quality of life is achieved.The HUH can be used with high reliability and validity by experienced and inexperienced doctors and physiotherapists.

Short-term effects of SAFE early intervention approach in infants born preterm: A randomized controlled single-blinded study.

OBJECTIVE: Recent literature suggests that goal-oriented and family-based interventions in enriched environment have a beneficial effect on neuromotor and cognitive development. We aimed to examine the short-term effects of SAFE (Sensory strategies, Activity-based motor training, Family collaboration, and Environmental Enrichment) early intervention approach on motor, cognitive, speech and language, and sensory development in preterm infants. METHODS: The study's sample population consisted of 24 preterm infants with corrected ages between 9 and 10 months. Infants in the control group participated in the family training program in accordance with the neurodevelopmental therapy principles (NDT). Infants in the treatment group were included in the family training program according to the principles of the SAFE Early Intervention Approach. Affordances in the Home Environment for Motor Development-Infant Scale (AHEMD-IS), Test of Sensory Functions in Infants (TSFI), Canadian Occupational Performance Measure (COPM), and Bayley Scales of Infant and Toddler Development III (Bayley III) were used to evaluate infants in both groups before and after 10 weeks of treatment (AHEMD-IS). The Depression, Anxiety, Stress Scale Short Form was used to assess the parents' mental health (DASS-SF). RESULTS: The interaction effects (time × group) revealed significant differences for Bayley-III cognitive and language scores, TSFI total score, and AHEMD-IS total score in favor of the SAFE group (p < .05). However, there were no differences in Bayley-III motor composite score, COPM Performance score, and COPM Satisfaction score between the interaction effects (time × group) of the groups (p > .05). CONCLUSIONS: SAFE early intervention approach improved cognitive, speech and language, sensory outcomes and provide enriched home environment in all domains when compared to NDT-based home program. SAFE is a promising novel early intervention approach for preterm infants.

Examination of foot sensations in children with generalized joint hypermobility.

BACKGROUND: Generalized joint hypermobility (GJH) is a condition that can be observed in children and children with GJH may have problems such as clumsiness, proprioceptive sensory loss, balance and coordination disorders. AIMS: To evaluate foot and ankle senses in children with GJH and compare them with their healthy peers. STUDY DESIGN: A cross-sectional study. SUBJECTS: Children aged 5-14 years with and without GJH were included in the study. OUTCOME MEASURES: After assessing the joint hypermobility of the children with the Beighton Score, tactile, vibration, two-point discrimination, and proprioception senses were evaluated. RESULTS: A total of 40 children (15 females, 25 males, mean age 9.43 years, SD ± 2.98 years, 20 with GJH and 20 without GJH) were included in the study. In children with GJH, foot sole tactile sense and ankle dorsiflexion and plantar flexion joint position sense were deficient in comparison with healthy controls (p < 0.05). CONCLUSIONS: There were deficiencies in foot and ankle tactile and proprioceptive senses in children with GJH. Neurosensorimotor examination of balance and coordination should be performed and appropriate intervention programs should be planned accordingly in children with GJH.

Children's disaster knowledge, risk perceptions, and preparedness: A cross-country comparison in Nepal and Turkey.

While children are one of the groups at risk in disasters, they can also take an active part in disaster management, provided that the opportunity is given. This research examined the effect of disaster experience, disaster education, country, and city socioeconomic status on children's perceived risk and preparedness with a survey of 1335 children between 11 and 14 years old, in Nepal and Turkey. The survey used questionnaires and the pictorial representation of illness and self measure (PRISM) tool. Results showed that (1) children's risk perceptions were in line with their country-specific objective risks; (2) there were differences between the countries in relation to perception of risk for all the hazards except wildfire; (3) socioeconomic status had a statistically significant effect on children's perceptions of risk and preparedness for earthquakes, wildfires, that is, children who live in wealthier places had higher perceived risk and preparedness; (4) children in both countries showed similar trends in their knowledge of the correct protective actions to take in the event of a hazard occurrence. However, there is still room to enhance children's knowledge, in terms of safety behaviors, as the children selected many incorrect protective actions. There are important implications in terms of child-centered disaster management which hopefully will make life safer and help to create more resilience to disaster in society as a whole.

The effect of health belief model-based short interviews in women in the postmenopausal period on the prevention of osteoporosis: A randomized controlled trial.

AIM: This study was conducted to investigate the effect of health belief model-based short interviews on preventive behaviours for osteoporosis in postmenopausal women. DESIGN AND METHODS: A randomized pretest, posttest and follow-up design was used. The study was conducted between June 2016 and June 2017 with an intervention (n = 41) and a control group (n = 41). The intervention group applied the Short Interviews Model for 12 weeks as a short interview programme that was created based on the health belief model. The study data were collected by the researcher using a descriptive information form, the Osteoporosis Health Belief Scale, the Osteoporosis Self-efficacy Scale and the Osteoporosis Knowledge Test. RESULTS: In the posttest and follow-up measurements, the mean scores of the intervention group on the total Osteoporosis Health Belief Scale and its self-efficacy and exercise sub-dimensions and the total Osteoporosis Knowledge Test and its sub-dimensions were significantly higher than those of the control group. CONCLUSION: The short interviews held in this study provided evidence to guide women and nurses in the prevention of osteoporosis in postmenopausal women. It is recommended that the prevention of osteoporosis should be integrated into women's health programmes at the primary health-care level.

Rasch analysis, reliability, and validity of the Turkish version of the Lumbar Spine Instability Questionnaire.

Background/aim: Lumbar instability is an important condition that can be seen frequently in people with low back pain, affecting both the progression and the choice of appropriate exercise. The Lumbar Spine Instability Questionnaire (LSIQ) is a simple and low-cost tool for evaluating disturbed back stability in people with low back pain. The aim of this study is to develop the Turkish version of the LSIQ (LSIQ-T) and to evaluate its psychometric properties using the Rasch model. Materials and methods: One hundred participants with chronic low back pain completed the LSIQ-T. The LSIQ-T was repeated for 30 participants after 1 week to establish its test-retest reliability. While internal and external construct validity were investigated using Rasch analysis and the Spearman correlation coefficient, respectively, reliability was evaluated in terms of internal consistency by Cronbach's alpha and the Person Separation Index (PSI). Results: All items of the LSIQ-T were found to fit the Rasch model (chi-square: 34.07 (df = 15), p = 0.0033). The internal construct validity was good, the overall mean item fit residual was 0 (SD: 0.765), and the mean person fit residual was 0.322 (SD: 1.123). Internal consistency reliability was low with a PSI of 0.63 although Cronbach's alpha was acceptable (0.68). When the test-retest reliability was examined via differential item functioning (DIF) by time, none of the items showed DIF. Conclusion: The LSIQ-T is a valid unidimensional scale for the Turkish population. Although the LSIQ-T had low internal consistency, it demonstrated unidimensionality and is appropriate for use. Therefore, the LSIQ-T can be used in clinical practice and scientific research.

An investigation of body awareness, fatigue, physical fitness, and musculoskeletal problems in young adults with hypermobility spectrum disorder.

BACKGROUND AND OBJECTIVES: Hypermobility Spectrum Disorder (HSD) is associated with excessive joint range of motion and the presence of musculoskeletal symptoms. The objective of this study was to examine body awareness, physical fitness parameters, fatigue levels, and musculoskeletal disorders in young adults with HSD and compare them with those without HSD. METHODS: Young individuals in the age range of 18-24 years were included in the study. Joint hypermobility of individuals was determined by the Beighton Score. Evaluations were made using the Body Awareness Questionnaire, the Fatigue Severity Scale, the Eurofit Physical Fitness Test Battery, and the Cornell Musculoskeletal Discomfort Questionnaire. RESULTS: A total of 94 healthy individuals (74 females, 20 males, mean age 21.44 years, SD ± 1.19 years), 47 with HSD and 47 without HSD, were included in the study. It was concluded that body awareness and fatigue levels were similar in two groups (p > 0.05). When physical fitness parameters were examined, there was a significant difference between the two groups in Sit and Reach test and the dominant side grip strength (p < 0.05). There was a significant difference between the two groups in the neck, back, dominant wrist, and total musculoskeletal problems (p < 0.05). CONCLUSION: It was concluded that young individuals with HSD had more flexibility, lower grip strength, more pain especially in the neck and back region, and more musculoskeletal disorders in general. Joint hypermobility is a factor to be considered in evaluating functional performance in these individuals.

Construct and discriminative validity and reliability of the Selective Control of the Upper Extremity Scale (SCUES) in children with unilateral cerebral palsy.

AIMS: One of the impairments evaluated in children with cerebral palsy (CP), which perhaps has been least investigated, is reduced selective motor control. The aim of the present study was to determine construct validity, discriminative validity, and intra- and interrater reliability of the Selective Control of the Upper Extremity Scale (SCUES). METHODS: Thirty-three children with unilateral CP, with a mean age of 11.5 ± 3.3 years, at level I to IV according to the Manual Ability Classification System (MACS), participated. The children were video-recorded and scored using the SCUES. The videos were scored twice to determine the intra- and interrater reliability. Reliability was assessed using the intraclass correlation coefficient, the standard error of the measurement (SEM), and the smallest real difference (SRD). Differences in the SCUES scores were determined between the less- and more-affected arm and across all MACS levels for discriminative validity. Construct validity of the SCUES was established by the MACS, and the Jebsen Taylor Hand Function Test (JTT). RESULTS: SCUES scores were significantly different between the less- and more-affected arm (p < .001) and between the arm joints. SCUES scores were also significantly different among MACS levels (p < .001). The SCUES was strongly correlated with the JTT (Spearman's rho = -0.80, p < .001) and MACS (rho = -0.78, p < .001). Intra- and interrater reliability were excellent (intraclass correlation coefficient [ICC] > 0.75) for all joints of the more-affected extremity. The SRDs at the 95% confidence level for intra- and interrater reliability were 2.11 and 1.16, respectively. CONCLUSIONS: The SCUES is a valid and reliable tool to assess selective motor control of the upper extremity in children with unilateral CP.

The use of neuroimaging, Prechtl's general movement assessment and the Hammersmith infant neurological examination in determining the prognosis in 2-year-old infants with hypoxic ischemic encephalopathy who were treated with hypothermia.

BACKGROUND: The use of neuroimaging, the General Movement Assessment (GMA), and the Hammersmith Infant Neurological Examination (HINE) to identify the risk of neurodevelopmental delay in early infancy is recommended. AIM: The aim of this study was to examine the predictive power of neuroimaging, GMA and HINE for neurodevelopmental delay and cerebral palsy (CP) in infants with hypoxic ischemic encephalopathy (HIE) who were treated with hypothermia. STUDY DESIGN: Retrospective cohort. SUBJECTS AND OUTCOME MEASURES: This retrospective study included 47 (18 female and 29 male) infants who were treated with hypothermia due to HIE. Neonates with a diagnosis of HIE were followed and assessed using neuroimaging, GMA, HINE and the Bayley Scales of Infant and Toddler Development-II (Bayley II) between 3 m and 2 years of age. RESULTS: Out of the 47 infants with HIE, no fidgety movements were observed in 5 infants. The sensitivity and specificity in determining the psychomotor developmental index (PDI) score were 97% and 100%, respectively, for MRI; 92.9% and 100% for GMA; and 91.9% and 80% for the HINE. The sensitivity and specificity in determining the mental developmental index (MDI) score were 95% and 85.7%, respectively, for MRI; 90.5% and 80% for GMA; and 91.9% and 50% for HINE. The sensitivity and specificity in determining CP diagnosis at the age of 2 years were 83.3% and 95%, respectively, for MRI; 83.3% and 100% for GMA; and 83.3% and 87.8% for HINE. CONCLUSION: The interpretation of MRI, GMA, and HINE that are performed within the early period of life may be the gold standard for the early detection of neurodevelopmental risks in 2-year-old infants with HIE. Clinical implementation of these methods in the early period in the follow-up of these infants offers useful information for the early identification of neurodevelopmental risk and for planning early intervention.

Detecting pain severity with full cup test in painful diabetic peripheral neuropathy.

OBJECTIVES: The aim of this study was to test the utility and validity of the full cup test (FCT) to assess the severity of pain in subjects with painful diabetic peripheral neuropathy (PDPN). METHODS: Subjects with diabetic PDPN were enrolled for this prospective, cross-sectional study. Other causes of PDPN and subjects with cognitive impairment were excluded. The diagnosis of neuropathic pain was made using the results of a physical examination and the Douleur Neuropathique 4 questionnaire. Pain severity was assessed with a FCT and a visual analog scale (VAS) administered before and after treatment. The correlation of FCT with VAS was evaluated to examine validity. RESULTS: A total of 43 (33 female, 10 male) subjects were included. The mean age was 61.9±8.25 years and the mean disease duration was 13.02±7.6 years. Type I diabetes mellitus (DM) was present in 2 (4.7%) subjects and Type II DM in 41 (95.3%) subjects. The mean glycated hemoglobin level was 8.9±1.9 mmol/mol. When the mean VAS and FCT scores were analyzed, the results were 6.7±2.05 and 66.35±23.2, respectively, pretreatment and 4.6±2.2 and 41.36±23.5 posttreatment, which were both statistically significant (p<0.001, p<0.001). The mean control period was 23.4 days (min-max: 15-30 days). The VAS and FCT scores in pretreatment and posttreatment demonstrated a high positive correlation (rs=0.86, p<0.001; rs=0.843, p<0.001). CONCLUSION: The FCT can be useful to detect pain severity in PDPN.

Reliability and Validity of the Turkish Version of the Fremantle Back Awareness Questionnaire.

STUDY DESIGN: Cross-cultural adaptation and psychometric analysis. OBJECTIVE: To develop the Turkish version of the Fremantle Back Awareness Questionnaire (FreBAQ-T) and to evaluate its psychometric properties. SUMMARY OF BACKGROUND DATA: There is a growing interest in the role that the disturbance of body perception may lead to long-lasting pain problems such as chronic low back pain (CLBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is a simple and low-cost way of evaluating disturbed back awareness in people with CLBP. METHODS: The FreBAQ was translated from English into Turkish using the forward-backward-forward method. One hundred four participants with low back pain completed the FreBAQ-T. The FreBAQ-T was repeated in 15 participants after 1 week to establish test-retest reliability. Although internal and external construct validity was investigated using Rasch analysis and Spearman correlation coefficient, respectively; reliability was evaluated in terms of internal consistency by Cronbach alpha and Person Separation Index. RESULTS: All items of the FreBAQ-T were found to fit the Rasch Model (chi-square 6.17 [df = 9], P = 0.723). The internal construct validity was good, overall mean item fit residual was -0.305 (standard deviation: 0.369) and mean person fit residual was -0.290 (standard deviation: 1.349). The reliability was good with Cronbach alpha of 0.87 and Person Separation Index of 0.82. When the test-retest was examined via differential item functioning by time, none of the items showed differential item functioning. CONCLUSION: The FreBAQ-T is a valid, reliable, and unidimensional scale for patients with CLBP. This scale will allow assessing back-specific perception in the Turkish population with CLBP. LEVEL OF EVIDENCE: 3.

Psychometric Characteristics of the Turkish Version of Adolescent Lifestyle Profile R2.

BACKGROUND AND PURPOSE: The purpose of this study was to adapt and assess cultural and psychometric properties of the Adolescent Life Style Profile (ALP-R2) in Turkish adolescents. METHODS: The sample of the study consisted of 945 students aged 12-18 years. Data were collected using the Turkish translation of the ALP-R2. Psychometric testing of the ALP-R2 included internal consistency, item-total correlation, test-retest correlation, and construct validity with confirmatory factor analysis (CFA). RESULTS: The total Cronbach's α coefficient was .88, and the subscales ranged from .55 to .76. The CFA results showed that the structure of the model/scale has an acceptable goodness of fit. CONCLUSION: The study shows that the Turkish version of the ALP-R2 is a reliable and valid scale that can be used to assess healthy lifestyle domains in Turkish adolescents.

Profile of head and neck cancers in Dr. Lütfi Kirdar Kartal Educational and Research Hospital.

OBJECTIVE: Head and neck cancers account for 17.6% of all malignant neoplasms. Data on the incidence of head and neck cancers and histological subtypes in Turkey are limited. This study aimed to provide an overview of statistics for head and neck cancers. MATERIAL AND METHOD: This retrospective and descriptive study included 1973 cases of in-situ carcinomas, malignant and borderline neoplasia from the head and neck region in a period of 5 years, diagnosed at Dr.Lütfi Kirdar Kartal Education and Research Hospital's Department of Pathology. Demographic data of patients and data from histopathological report were recorded. The topography of all tumours was coded according to the International Classification of Diseases for Oncology, 2nd and 3rd edition and histological and behavioral codes were given according to ICD-O-3. Data was entered and analyzed using Microsoft Excel™, version 2010. RESULTS: Male and female ratio was 1.03 for head and neck cancers. The most common sites for males were described as the ratio in head and neck cancers and all malignant tumours as follows: the skin (non-melanoma) (48.4%-8.2%), the larynx (12.6%-2.3%), the thyroid (11.1%-1.2%), the lips (7.8%-1.3%), and the nasopharynx (3.1%-0.5%). The most common sites for females were as follows: the thyroid (45.3%-8.3%), the skin (non-melanoma) (39.6%-7.3%), the lips (3.6%-0.6%), the nasopharynx (2.2%-0.4%) and the eye (1.7%-0.3%). The male: female ratio was 25.2 for larynx cancers. The most common histological types and rates for males and females were also given. CONCLUSION: This descriptive epidemiological pathology-based cancer incidence study has relative value for describing head and neck cancer incidences in the Istanbul region and shown that pathology report-based descriptive epidemiological studies are still valuable for determination of the regional distribution of cancer incidence out of the active cancer registration regions.

The genotoxic and anti-genotoxic effects of Stachys petrokosmos leaf extract in human lymphocytes using microsomal fractions.

The genotoxic and anti-genotoxic effects of Stachys petrokosmos leaf extracts (Sp) were investigated in human lymphocytes. The cells were treated with 1.5, 3.0 and 6.0 µL/mL concentrations of Sp leaf extracts for 24 and 48 h treatment periods in the absence and presence of metabolic activator (S9mix). In the absence of S9mix, Sp alone did not induce chromosome aberrations and formation of micronucleus while inducing the mean sister chromatid exchange at the highest concentration. In addition, Sp decreased the mutagenic effect of mitomycin-c. Sp alone showed a cytotoxic effect determined by a decrease in the proliferation index, mitotic index and nuclear division index. On the other hand a mixture of Sp and mitomycin-c resulted in a higher cytotoxic effect especially for 48 h treatment period. In the presence of S9mix, Sp was not genotoxic and cytotoxic however, it showed an anti-genotoxic effect by decreasing the effects of cyclophosphamide.

[Frequency of light cigarette use on staff and students of Ankara University School of Medicine]. / Ankara Universitesi Tip Fakültesi ögrenci ve çalisanlarinda "light" sigara içme sikligi.

Light cigarettes which are launched as fewer harmful threaten to community health because of so many diseases related with smoking. Therefore, research of light cigarette using rates and related factors might be beneficial along with research of smoking frequency in community. The aim of this study is to evaluate light cigarette smoking habit of staff and students of school of medicine. This cross-sectional study was conducted on staff and students of Ankara University School of Medicine in 2004. 216 (34%) light cigarette smokers of 627 people (344 students, 283 staff) were evaluated in this study. Questionarie form was applied to participants by face-to-face interview, chi-square and ANOVA analyse method were used for evaluation. Participant's profile was 51.4% male and 48.6% female. Mean age of the participants was calculated as 31.17 +/- 8.84. Light cigarette use was stated by 23.7% of smokers. Relationship between light cigarette use and various factors has been examined and it was found that light cigarette use rate was higher in females (p= 0.04). Smoking start age was detected lower in light cigarette smokers (18.59 +/- 2.87) rather than smokers (19.76 +/- 3.42). One over five person was found as light cigarette smokers among the participants. Light cigarette use rate is higher in females and smoking starting age is lower in light cigarette smokers. Relationship between female gender and smaller starting ages were considered as preference of the groups that had awareness in harmful effects of smoking especially light cigarette smoking and tried to reduce risks. In opposition to light cigarette had fewer harmful health effects, community must be made conscious about this belief may cause an increase in smoking prevalence in community.