The document discusses proteinuria and different types of kidney diseases that can cause protein in the urine. It begins by defining normal and abnormal levels of protein in urine and discusses microscopic albuminuria. It then describes different types of proteinuria including tubular, overflow and glomerular. Within glomerular proteinuria it distinguishes between selective, non-selective and microscopic albuminuria. Common causes of nephrotic syndrome like minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy are outlined. Diagnostic testing and treatment options for minimal change disease are also summarized.
This document discusses hyponatremia, which is caused by an excess of water in the body relative to sodium. It describes how sodium levels indicate tonicity rather than just osmolality. Pseudohyponatremia can occur with hyperglycemia. Treatment depends on whether the patient is hypovolemic, euvolemic, or hypervolemic. Symptomatic hyponatremia should be treated cautiously with hypertonic saline to avoid complications like central pontine myelinolysis.
This case involves a 56-year-old man with a history of heroin use who presented with abdominal pain. He was initially treated for opioid withdrawal with methadone and morphine. However, his abdominal pain worsened and he was later found to have a perforated colon requiring surgery. The failure to properly evaluate the source of his pain and worsening condition despite treatment for withdrawal led to delays in diagnosis and appropriate care. Opioid dependence is a chronic medical condition and providers should be aware of atypical withdrawal presentations and avoid biases that could impact diagnosis and treatment.
Allergies occur when the immune system reacts to substances that are normally harmless. These triggering substances are known as allergens. Common allergens include pollen, dust mites, pet dander, certain foods, insect bites and stings, latex, and some medications. Symptoms of allergies can be mild, such as sneezing and itchy eyes, or they can be severe like difficulty breathing or a drop in blood pressure. It is important to identify your allergens and take steps to avoid exposure to prevent allergic reactions.
Drepanocytosis is also known as sickle cell anemia, characterized by sickle shaped red blood cells during periods of low oxygen. It is caused by a genetic mutation and most common in certain regions of the world. Symptoms include anemia, infections, pain crises and organ damage. Panmyelophthisis or aplastic anemia results in low blood cell counts due to bone marrow failure. It can be caused by drugs, toxins, viruses or autoimmune/genetic disorders. Patients present with fatigue, infections and bleeding due to low red blood cells, white blood cells and platelets. Treatment focuses on blood transfusions, immunosuppressive drugs or bone marrow transplantation to restore marrow activity.
O documento descreve as principais características de espiróquetas, incluindo Treponema pallidum que causa sífilis, Borrelia burgdorferi que causa doença de Lyme, e Leptospira interrogans que causa leptospirose. Também discute víboras como Vibrio cholerae que causa cólera, Campylobacter e Helicobacter pylori associados a doenças gastrointestinais.
The document discusses various types of cardiomyopathies and valvular disorders. It defines cardiomyopathy as a disease of the heart muscle and describes the main types as dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy. It provides details on symptoms, diagnostic evaluations, risk factors, treatments, and statistics for each type. The document also discusses various valvular disorders including mitral valve insufficiency, mitral valve stenosis, aortic valve insufficiency, and aortic valve stenosis.
Treatment of Rheumatoid Arthritis in Latin America - EULAR 2014anayajm
This presentation is about rheumatoid arthritis (RA) in Latin America & the Caribbean (LAC). It discusses current trends in the treatment of the disease, and points out the main challenges for improving the knowledge about the disease.
The document discusses proteinuria and different types of kidney diseases that can cause protein in the urine. It begins by defining normal and abnormal levels of protein in urine and discusses microscopic albuminuria. It then describes different types of proteinuria including tubular, overflow and glomerular. Within glomerular proteinuria it distinguishes between selective, non-selective and microscopic albuminuria. Common causes of nephrotic syndrome like minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy are outlined. Diagnostic testing and treatment options for minimal change disease are also summarized.
This document discusses hyponatremia, which is caused by an excess of water in the body relative to sodium. It describes how sodium levels indicate tonicity rather than just osmolality. Pseudohyponatremia can occur with hyperglycemia. Treatment depends on whether the patient is hypovolemic, euvolemic, or hypervolemic. Symptomatic hyponatremia should be treated cautiously with hypertonic saline to avoid complications like central pontine myelinolysis.
This case involves a 56-year-old man with a history of heroin use who presented with abdominal pain. He was initially treated for opioid withdrawal with methadone and morphine. However, his abdominal pain worsened and he was later found to have a perforated colon requiring surgery. The failure to properly evaluate the source of his pain and worsening condition despite treatment for withdrawal led to delays in diagnosis and appropriate care. Opioid dependence is a chronic medical condition and providers should be aware of atypical withdrawal presentations and avoid biases that could impact diagnosis and treatment.
Allergies occur when the immune system reacts to substances that are normally harmless. These triggering substances are known as allergens. Common allergens include pollen, dust mites, pet dander, certain foods, insect bites and stings, latex, and some medications. Symptoms of allergies can be mild, such as sneezing and itchy eyes, or they can be severe like difficulty breathing or a drop in blood pressure. It is important to identify your allergens and take steps to avoid exposure to prevent allergic reactions.
Drepanocytosis is also known as sickle cell anemia, characterized by sickle shaped red blood cells during periods of low oxygen. It is caused by a genetic mutation and most common in certain regions of the world. Symptoms include anemia, infections, pain crises and organ damage. Panmyelophthisis or aplastic anemia results in low blood cell counts due to bone marrow failure. It can be caused by drugs, toxins, viruses or autoimmune/genetic disorders. Patients present with fatigue, infections and bleeding due to low red blood cells, white blood cells and platelets. Treatment focuses on blood transfusions, immunosuppressive drugs or bone marrow transplantation to restore marrow activity.
O documento descreve as principais características de espiróquetas, incluindo Treponema pallidum que causa sífilis, Borrelia burgdorferi que causa doença de Lyme, e Leptospira interrogans que causa leptospirose. Também discute víboras como Vibrio cholerae que causa cólera, Campylobacter e Helicobacter pylori associados a doenças gastrointestinais.
The document discusses various types of cardiomyopathies and valvular disorders. It defines cardiomyopathy as a disease of the heart muscle and describes the main types as dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy. It provides details on symptoms, diagnostic evaluations, risk factors, treatments, and statistics for each type. The document also discusses various valvular disorders including mitral valve insufficiency, mitral valve stenosis, aortic valve insufficiency, and aortic valve stenosis.
Treatment of Rheumatoid Arthritis in Latin America - EULAR 2014anayajm
This presentation is about rheumatoid arthritis (RA) in Latin America & the Caribbean (LAC). It discusses current trends in the treatment of the disease, and points out the main challenges for improving the knowledge about the disease.
(1) The document provides an overview of cardiac anatomy and physiology, including the layers of the heart, chambers, valves, blood vessels, and the pumping action.
(2) It describes the pericardium, myocardium, endocardium, atria, ventricles, valves, coronary arteries and veins, and how preload, contractility, afterload, and heart rate impact cardiac output.
(3) Key concepts covered are the Frank-Starling mechanism, factors that increase or decrease preload, contractility, and afterload, and how systemic vascular resistance impacts cardiac output.
O documento discute propriedades do sangue e hematopoese. Aborda a composição do sangue, incluindo os tipos de células e suas quantidades no corpo humano adulto. Também explica o processo de hematopoese na medula óssea, onde as células-tronco hematopoéticas se desenvolvem em diferentes linhagens celulares do sangue sob a influência de citocinas.
This document discusses hyponatremia, which is caused by an excess of water in the body relative to sodium. It describes how sodium levels indicate tonicity rather than just osmolality. Pseudohyponatremia can occur with hyperglycemia. Treatment depends on whether the patient is hypovolemic, euvolemic, or hypervolemic. Symptomatic hyponatremia should be treated cautiously with hypertonic saline to avoid complications like central pontine myelinolysis.
This document discusses hypertension (HTN), including its definition, causes, risk factors, presentation, complications, hypertensive emergencies, approach, and management. HTN is a chronic condition where blood pressure is elevated. It can be primary or secondary. Risk factors include age, family history, smoking, obesity, and more. People may be asymptomatic or experience headaches, fatigue, nosebleeds, and other nonspecific symptoms. Complications can include stroke, heart disease, and kidney failure. Hypertensive emergencies require urgent treatment to prevent end organ damage. Evaluation of HTN involves history, exam, ECG, urine and blood tests to identify secondary causes and end organ effects for proper management.
PNH is a rare blood disorder caused by a genetic mutation affecting the biosynthesis of glycosylphosphatidylinositol (GPI)-anchored proteins. This results in deficiencies of CD55 and CD59 on the surface of red blood cells, making them susceptible to complement-mediated hemolysis. Clinical manifestations include anemia, hemoglobinuria, thrombosis, and abdominal pain. Chronic hemolysis can also lead to complications such as renal failure, pulmonary hypertension, and impaired quality of life. Diagnosis involves detecting deficient GPI-anchored proteins on red blood cells using flow cytometry.
This document summarizes guidelines for treatment of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) from the American Diabetes Association (ADA) and Joint British Diabetes Societies Inpatient (JBDS IP). Key points include:
1) Bedside beta-hydroxybutyrate testing is now the best way to monitor treatment response in DKA.
2) For DKA, guidelines recommend fixed rate insulin infusion of 0.1 unit/kg/hr without a priming dose and adjustments to meet metabolic targets.
3) For HHS, the goal of initial therapy is to expand intravascular volume and restore perfusion by replacing approximately 50
Hyponatremia is the most common electrolyte disorder characterized by a serum sodium level below 135 mEq/L. It is often seen in hospitalized patients, the elderly, and females. Common causes include diuretic use, diarrhea, heart failure, and renal disease. Symptoms are primarily neurological due to cerebral edema and range from headache to seizures. Treatment involves restricting water intake, replacing sodium deficits, and treating the underlying cause while avoiding too rapid of a sodium correction to prevent osmotic demyelination syndrome.
PNH is a rare acquired hemolytic disorder caused by a somatic mutation in the PIG-A gene, resulting in a deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins on the surface of blood cells. This renders the cells susceptible to complement-mediated lysis. PNH is characterized by hemolytic anemia, thrombophilia, and bone marrow failure. Diagnosis is made through flow cytometry to detect the absence of GPI-anchored proteins CD55 and CD59 on red blood cells. Treatment involves blood transfusions, anticoagulation therapy, and complement inhibition with eculizumab which significantly reduces hemolysis.
O documento resume vários tipos de tumores renais, incluindo tumores benignos, com potencial maligno e malignos. Ele também discute sintomas, diagnóstico e tratamento de adenocarcinomas renais, tumores de Wilms, neoplasias da pelve renal e ureter, câncer de bexiga e testículo.
This document discusses pruritus (itching), its causes, evaluation, and treatment approaches. It begins by defining pruritus and describing its relationship to underlying skin diseases. Common skin diseases that cause pruritus are then outlined. The document also discusses systemic causes of pruritus using the mnemonic "BLINKED" and provides details on various conditions that fall under each letter. Evaluation of pruritic patients is described, including taking a thorough history and conducting physical exams and lab tests. The pathophysiology and mediators of itch are explained. Finally, the document concludes with an overview of therapeutic approaches for pruritus, including topical treatments, physical therapies, systemic medications, and special considerations for conditions like
Thrombocytopenia is defined as a platelet count below 150,000/microL. The main causes are decreased platelet production, increased platelet destruction, and altered platelet distribution. Decreased production can result from bone marrow damage, infections, toxins, or drugs. Increased destruction is most common, and can be immune-mediated (as in ITP) or non-immune (as in DIC or TTP). Altered distribution occurs in splenomegaly. Drug-induced thrombocytopenia can occur via direct toxicity, bone marrow suppression, or immune mechanisms like those seen with heparin or abciximab. Pseudo-thrombocytopenia due to platelet clumping must be
Post Infectious Glomerulonephritis (PIGN) is an immune-mediated glomerulonephritis typically caused by a non-renal infection. The most common cause is Post-Streptococcal Glomerulonephritis (PSGN) following a streptococcal throat or skin infection. PIGN is characterized by the deposition of immune complexes in the glomerular basement membrane. Clinical presentation includes hematuria, proteinuria, edema, and hypertension. Treatment involves supporting the patient and treating any underlying infection. Most patients fully recover, though some may develop long-term complications like chronic kidney disease.
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis that is usually seronegative. It affects between 0.04-1.2% of the population equally in men and women, with peak age of onset between 30-55 years. It is characterized by distal joint involvement in an asymmetric distribution, nail changes like pits and onycholysis, and dactylitis. Diagnosis is based on evidence of psoriasis, negative rheumatoid factor, and radiological evidence of new bone formation near joints. While initially thought to be more benign than rheumatoid arthritis, progression of clinical damage occurs over time in most patients despite treatment.
The document discusses the benefits of joining Beacon IPA, a clinically integrated physician association (IPA). It notes that private practice physicians face challenges like healthcare reform changes, rising costs, and increased administrative burdens. Beacon IPA aims to help physicians maintain autonomy and control while preparing for payment reforms through services like an electronic medical record network, contracting with insurers, and administrative support. Physicians can join at different levels, from equity membership to participating provider.
This document discusses the increasing pressure on healthcare providers to adhere to clinical guidelines and quality metrics. It outlines challenges in implementing clinical decision support systems and electronic medical records to help providers meet these demands. Key points include the need for provider buy-in, reliable guideline-based decision support, and creating a culture where metrics are accepted and do not cause anger or fear.
07 Am09 Presentations Hamburger & LawsonSimon Prince
The document provides guidance on coding and billing for end-stage renal disease (ESRD) services. It discusses:
1) New ESRD CPT codes 90951-90970 that replaced G codes and older CPT codes for capturing physician work related to dialysis patients.
2) Guidelines for billing monthly or daily codes based on whether it is for a full or partial month of service.
3) Requirements for documentation of ESRD services to support billing codes.
4) Rules around billing for teaching physicians, hospitalization, home dialysis training, infusion codes, and consultations vs. referrals.
(1) The document provides an overview of cardiac anatomy and physiology, including the layers of the heart, chambers, valves, blood vessels, and the pumping action.
(2) It describes the pericardium, myocardium, endocardium, atria, ventricles, valves, coronary arteries and veins, and how preload, contractility, afterload, and heart rate impact cardiac output.
(3) Key concepts covered are the Frank-Starling mechanism, factors that increase or decrease preload, contractility, and afterload, and how systemic vascular resistance impacts cardiac output.
O documento discute propriedades do sangue e hematopoese. Aborda a composição do sangue, incluindo os tipos de células e suas quantidades no corpo humano adulto. Também explica o processo de hematopoese na medula óssea, onde as células-tronco hematopoéticas se desenvolvem em diferentes linhagens celulares do sangue sob a influência de citocinas.
This document discusses hyponatremia, which is caused by an excess of water in the body relative to sodium. It describes how sodium levels indicate tonicity rather than just osmolality. Pseudohyponatremia can occur with hyperglycemia. Treatment depends on whether the patient is hypovolemic, euvolemic, or hypervolemic. Symptomatic hyponatremia should be treated cautiously with hypertonic saline to avoid complications like central pontine myelinolysis.
This document discusses hypertension (HTN), including its definition, causes, risk factors, presentation, complications, hypertensive emergencies, approach, and management. HTN is a chronic condition where blood pressure is elevated. It can be primary or secondary. Risk factors include age, family history, smoking, obesity, and more. People may be asymptomatic or experience headaches, fatigue, nosebleeds, and other nonspecific symptoms. Complications can include stroke, heart disease, and kidney failure. Hypertensive emergencies require urgent treatment to prevent end organ damage. Evaluation of HTN involves history, exam, ECG, urine and blood tests to identify secondary causes and end organ effects for proper management.
PNH is a rare blood disorder caused by a genetic mutation affecting the biosynthesis of glycosylphosphatidylinositol (GPI)-anchored proteins. This results in deficiencies of CD55 and CD59 on the surface of red blood cells, making them susceptible to complement-mediated hemolysis. Clinical manifestations include anemia, hemoglobinuria, thrombosis, and abdominal pain. Chronic hemolysis can also lead to complications such as renal failure, pulmonary hypertension, and impaired quality of life. Diagnosis involves detecting deficient GPI-anchored proteins on red blood cells using flow cytometry.
This document summarizes guidelines for treatment of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) from the American Diabetes Association (ADA) and Joint British Diabetes Societies Inpatient (JBDS IP). Key points include:
1) Bedside beta-hydroxybutyrate testing is now the best way to monitor treatment response in DKA.
2) For DKA, guidelines recommend fixed rate insulin infusion of 0.1 unit/kg/hr without a priming dose and adjustments to meet metabolic targets.
3) For HHS, the goal of initial therapy is to expand intravascular volume and restore perfusion by replacing approximately 50
Hyponatremia is the most common electrolyte disorder characterized by a serum sodium level below 135 mEq/L. It is often seen in hospitalized patients, the elderly, and females. Common causes include diuretic use, diarrhea, heart failure, and renal disease. Symptoms are primarily neurological due to cerebral edema and range from headache to seizures. Treatment involves restricting water intake, replacing sodium deficits, and treating the underlying cause while avoiding too rapid of a sodium correction to prevent osmotic demyelination syndrome.
PNH is a rare acquired hemolytic disorder caused by a somatic mutation in the PIG-A gene, resulting in a deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins on the surface of blood cells. This renders the cells susceptible to complement-mediated lysis. PNH is characterized by hemolytic anemia, thrombophilia, and bone marrow failure. Diagnosis is made through flow cytometry to detect the absence of GPI-anchored proteins CD55 and CD59 on red blood cells. Treatment involves blood transfusions, anticoagulation therapy, and complement inhibition with eculizumab which significantly reduces hemolysis.
O documento resume vários tipos de tumores renais, incluindo tumores benignos, com potencial maligno e malignos. Ele também discute sintomas, diagnóstico e tratamento de adenocarcinomas renais, tumores de Wilms, neoplasias da pelve renal e ureter, câncer de bexiga e testículo.
This document discusses pruritus (itching), its causes, evaluation, and treatment approaches. It begins by defining pruritus and describing its relationship to underlying skin diseases. Common skin diseases that cause pruritus are then outlined. The document also discusses systemic causes of pruritus using the mnemonic "BLINKED" and provides details on various conditions that fall under each letter. Evaluation of pruritic patients is described, including taking a thorough history and conducting physical exams and lab tests. The pathophysiology and mediators of itch are explained. Finally, the document concludes with an overview of therapeutic approaches for pruritus, including topical treatments, physical therapies, systemic medications, and special considerations for conditions like
Thrombocytopenia is defined as a platelet count below 150,000/microL. The main causes are decreased platelet production, increased platelet destruction, and altered platelet distribution. Decreased production can result from bone marrow damage, infections, toxins, or drugs. Increased destruction is most common, and can be immune-mediated (as in ITP) or non-immune (as in DIC or TTP). Altered distribution occurs in splenomegaly. Drug-induced thrombocytopenia can occur via direct toxicity, bone marrow suppression, or immune mechanisms like those seen with heparin or abciximab. Pseudo-thrombocytopenia due to platelet clumping must be
Post Infectious Glomerulonephritis (PIGN) is an immune-mediated glomerulonephritis typically caused by a non-renal infection. The most common cause is Post-Streptococcal Glomerulonephritis (PSGN) following a streptococcal throat or skin infection. PIGN is characterized by the deposition of immune complexes in the glomerular basement membrane. Clinical presentation includes hematuria, proteinuria, edema, and hypertension. Treatment involves supporting the patient and treating any underlying infection. Most patients fully recover, though some may develop long-term complications like chronic kidney disease.
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis that is usually seronegative. It affects between 0.04-1.2% of the population equally in men and women, with peak age of onset between 30-55 years. It is characterized by distal joint involvement in an asymmetric distribution, nail changes like pits and onycholysis, and dactylitis. Diagnosis is based on evidence of psoriasis, negative rheumatoid factor, and radiological evidence of new bone formation near joints. While initially thought to be more benign than rheumatoid arthritis, progression of clinical damage occurs over time in most patients despite treatment.
The document discusses the benefits of joining Beacon IPA, a clinically integrated physician association (IPA). It notes that private practice physicians face challenges like healthcare reform changes, rising costs, and increased administrative burdens. Beacon IPA aims to help physicians maintain autonomy and control while preparing for payment reforms through services like an electronic medical record network, contracting with insurers, and administrative support. Physicians can join at different levels, from equity membership to participating provider.
This document discusses the increasing pressure on healthcare providers to adhere to clinical guidelines and quality metrics. It outlines challenges in implementing clinical decision support systems and electronic medical records to help providers meet these demands. Key points include the need for provider buy-in, reliable guideline-based decision support, and creating a culture where metrics are accepted and do not cause anger or fear.
07 Am09 Presentations Hamburger & LawsonSimon Prince
The document provides guidance on coding and billing for end-stage renal disease (ESRD) services. It discusses:
1) New ESRD CPT codes 90951-90970 that replaced G codes and older CPT codes for capturing physician work related to dialysis patients.
2) Guidelines for billing monthly or daily codes based on whether it is for a full or partial month of service.
3) Requirements for documentation of ESRD services to support billing codes.
4) Rules around billing for teaching physicians, hospitalization, home dialysis training, infusion codes, and consultations vs. referrals.
This document presents results from the 2007 RPA Nephrology Practice Business Benchmarking Survey. It summarizes key metrics on practice characteristics, staffing, finances, and physician compensation for national, regional, and practice type comparisons. Participation in the survey has grown over time. The report finds increasing complexity of patient care and growth in non-physician staffing levels and dialysis patient loads. Financial indicators like revenue, expenses, RVUs performed, and physician compensation are presented.
The medical director is responsible for developing, implementing, and overseeing a facility's robust quality assessment and performance improvement (QAPI) program. This includes establishing a multidisciplinary team to regularly review data, prioritize issues, and take corrective actions to improve patient outcomes and safety. The QAPI program must measure and address various clinical areas at minimum, and compliance is determined by reviewing outcomes, records, and interviewing staff.
The document discusses the patient-centered medical home (PCMH) model and its potential benefits. It summarizes that the PCMH aims to provide patient-centered, coordinated care through a personal physician leading a team. Data from other countries shows primary care-focused systems have better outcomes and lower costs. The PCMH may benefit primary care physicians through payment reform recognizing care coordination work. It may benefit patients through improved access and chronic disease management support. Subspecialists may also benefit from opportunities to lead medical homes and fewer administrative hassles.
The document discusses the changing landscape of healthcare and nephrology practice. It notes increasing demands from patients, payers, and providers that are driving transformation. The future nephrologist will need to leverage transformational leadership skills to build a clinical care team approach for effectively managing the growing kidney disease population. Physician leaders must extend beyond themselves to lead teams across different care environments like dialysis facilities and hospitals.
07 Am09 Presentations Hamburger & LawsonSimon Prince
The document provides guidance on coding and billing for end-stage renal disease (ESRD) services. It discusses:
1) New ESRD CPT codes 90951-90970 that replaced previous G and CPT codes, capturing physician work for dialysis patients.
2) Guidelines for billing monthly or daily codes based on full or partial months of service.
3) Requirements for billing codes accounting for number of face-to-face visits per month.
4) Rules around billing for hospitalized, home dialysis, or transient dialysis patients.
The document summarizes a study conducted by the Renal Physicians Association (RPA) and Duke Center for Clinical Health Policy Research (DCCHPR) to test an Advanced Chronic Kidney Disease (CKD) Patient Management Toolkit in 10 nephrology practices across the US. The study aimed to evaluate the utility of the toolkit, assess care patterns and changes needed to improve care, and evaluate the impact on conforming to CKD guideline recommendations. The 10 sites were divided into two groups, with one group implementing the toolkit while the other served as a comparator. The study provided a unique opportunity to involve diverse practices and patients to understand challenges in CKD management and insights for the future.
This document discusses different patterns of glomerular disease, including nephrotic syndrome, nephritic syndrome, focal glomerulonephritis, diffuse glomerulonephritis, and hypocomplementemia. Key differences between nephrotic and nephritic syndromes are described based on urinary findings, proteinuria levels, hypertension, and renal function. Focal and diffuse glomerulonephritis are distinguished by the number of affected glomeruli and differences in urine and clinical features. Specific diseases are also mentioned in association with different age groups.