Don't Take Your Fists to Town: Drunken brawls are evidently so common in the UK that they're a public health hazard:
While hundreds of drunken street brawls take place every weekend across the UK, few of the perpetrators - if any - would want a death on their hands.
But one punch is all it takes.
....John Black, a consultant in emergency medicine at Oxford's John Radcliffe Hospital, believes the danger of single-punch deaths is "a huge public health issue".
He said: "I think there's a general ignorance about this.
...Mr Black believes that the issue is so serious that a nationwide team of pre-hospital critical care doctors should be set up to back up paramedics called to the scenes of such injuries.
He also wants regional centres of neurological expertise set up for victims to be taken to immediately and greater training for new accident and emergency doctors to recognise fatal symptoms - even if the victim is drunk.
And they call Americans cowboys.
UPDATE: At least one reader thinks this is due to British gun control:
I think that the high rate of British pub brawling is probably due to gun control. In America, the thought that one's opponent may very well possess a weapon far more lethal than a fist most likely crosses the mind of all but the most drunken combatants. In Britain, unless one is in a very bad part of town, one can be relatively sure no one has a gun. It's no fun to fight when someone could actually get killed.
Look at it like the Cold War, in miniature.
Maybe. But do drunken sots really think that clearly?
RoboDoc: A tiny robot has been approved by the FDA for spinal surgery:
The soft-drink-can-sized device is attached to a patient's body, guiding and positioning tools and implants so that surrounding nerves are not damaged.
'SpineAssist minimizes the risk of working freehand in sensitive regions of the spine,' Shoham said in a Wednesday statement.
'It conceives a plan for locating the spinal implants, but neither replaces the surgeon nor performs any operations. After examining and approving the recommendation, the surgeon inserts surgical instruments through the arm of the robot, thereby minimizing the danger of damaging vital organs.' posted by sydney on
6/11/2004 07:44:00 AM
For women who are seeking mammograms, the closure of scanning centers suggests 'a serious decline in access,' the report said.
In parts of Florida, three-month waits for an appointment are common, the report said. In New York City, the average wait for a first-time mammogram is more than 40 days, compared with two weeks in the late 1990s.
According to government inspection records, the number of mammography facilities has dropped by 8.9 percent since 2000.
'We need to do something to address that,' Pisano said.
The decline is thought to be due to low insurance reimbursement for mammograms, rising malpractice litigation and fewer radiologists choosing breast imaging instead of other specialties, the scientific committee said.
The shortage comes even as more women -- an additional 1.2 million each year -- become old enough to need routine mammograms. Yet no more than three dozen breast-imaging subspecialists -- the radiologists with the most mammography expertise -- enter the profession each year.
At the same time, the number of false-positive mammogram readings -- when something suspicious turns out to be noncancerous -- has nearly doubled, the report found. That may be due partly to radiologists practicing 'defensive medicine' in hopes of avoiding lawsuits."
Litigation is no doubt playing a big role in radiologists' reluctance to make reading mammograms their livelihood. It's a perfect set-up for a malpractice disaster. Here you have a test that's done for one purpose only - to screen for cancer. But unlike other tests, such as a pap smear or a blood test, the finished product is there forever to be scrutinized with a retrospectoscope when cancer may pop up years later. The various shadows and shades of a mammogram are often difficult to interpret. Today's benign-appearing confluence of shadows can too easily become tomorrow's infant malignancy to the eyes of a trial lawyer's expert witness. Especially when that witness has the advantage of already knowing cancer was subsequently found there. It's kind of like looking at an optical illusion and not getting it until someone else points it out. Suddenly, what wasn't obvious is glaringly so. It's the nature of the beast. And it makes easy pickings for trial lawyers.
Complicity: Prison doctors both home and abroad get scrutinized in today's New York Times. First, at home, there are the doctors who monitor executions. The overall tone is one of condemnation:
Many of the states that encourage doctors to participate in executions have seemingly contradictory laws that allow doctors to be disciplined by state medical boards for violating codes of medical ethics. Those codes almost universally forbid participation in executions.
The American Medical Association's ethics code, for instance, says that "a physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution."
The code forbids doctors to perform an array of acts at executions, including prescribing the drugs, supervising prison personnel, selecting intravenous sites, placing intravenous lines, administering the injections and pronouncing death.
"They're not allowed to determine that the execution has been unsuccessful so that the execution can be repeated," said Dr. Stephen H. Miles, a professor of medicine at the University of Minnesota and author of "The Hippocratic Oath and the Ethics of Medicine."
The AMA's ethics code isn't always so scrupulous about preserving life when there is hope of doing so.
Actually, an argument can be made that a doctor who supervises an execution by lethal injection (supervises, not administers) is acting more ethically than one who performs elective abortions. The former is there to make sure the procedure is done humanely with a minimum of suffering. He doesn't administer the death blow. An abortionist, on the other hand, does.
Complicity II: Then there are the prison doctors abroad. The military prison doctors of Abu Ghraib who "according to press reports," treated tortured Iraqi prisoners:
According to press reports, military doctors and nurses who examined prisoners at Abu Ghraib treated swollen genitals, prescribed painkillers, stitched wounds, and recorded evidence of the abuses going on around them. Under international law — as well as the standards of common decency — these medical professionals had a duty to tell those in power what they saw.
Instead, too often, they returned the victims of torture to the custody of their victimizers. Rather than putting a stop to torture, they tacitly abetted it, by patching up victims and staying silent.
The duty of doctors in such circumstances is clear. They must provide needed treatment, then do all they can to keep perpetrators from committing further abuse. This includes keeping detailed records of injuries and their likely causes, performing clinical tests to gather forensic evidence and reporting abuses to those with the will and power to act.
Unfortunately, that first sentence undermines the entire premise of the piece. Quite frankly, it's hard to decipher from press reports just how serious the crimes at Abu Ghraib were, since the press has an unfortunate tendency to exaggerate the bad and downplay the good when it comes to the war in Iraq. They also have an unfortunate tendency to have more faith in the assertions of our enemies than in those of our own government. But don't take my word for it. Here's an interview with an American doctor who served at Abu Ghraib:
"They were firm but not abusive, if there was any abuse toward the prisoners I would have had to deal with it."
He dealt with everything from broken bones to heart attacks. You can see one of his patients hooked to an EKG. He was later evacuated by helicopter to another hospital.
'People ask me if it was terrible, and have to admit I feel like I did something good.'"
Torture is wrong. And doctors should neither participate in it nor condone it. The question that remains, however, is this - was anyone actually tortured at the post-Saddam Abu Ghraib prison, or were they just posed for humiliating photographs? Neither is honorable conduct on the part of our soldiers, but there's a world of difference medically speaking. posted by sydney on
6/10/2004 10:38:00 PM
Choices: Ohio Governor Bob Taft has signed a legislation that will provide Ohio schools with cardiac defibrillators:
Now 19, Clark, her mother and other families struck by sudden cardiac arrest came to the state capital Tuesday to thank lawmakers and Gov. Bob Taft for a law that includes $2.5 million for schools to buy automatic external defibrillators.
It's hard to say how many lives will saved each year for that $2.5 million dollars, since only 25 to 50 children die each year in the entire nation from cardiac arrest. But that's $2.5 million dollars less to be sent on textbooks, teachers, and basic building repairs, all of which many many Ohio schools need.
At least one state Senator recognizes this:
Sen. Ray Miller, a Columbus Democrat, questions the large expenditure without enough data on how many deaths could be prevented. He said there should be better health screening in school and efforts by coaches not to work athletes too hard.
"I'm in schools all the time," he said. "I have yet to have anybody in a school say to me we need these electronic defibrillators that are being pushed so aggressively. What they do say is we need books, we need computers we need basic supplies for our classrooms."
Legislation from the heart. Who wants to offend grieving parents advocating for defibrillators in the schools? Wouldn't be prudent.
And, although the American Heart Association, which is at the frontline of advocating widespread placement of defibrillators, says that the devices can be used in children ages 1-8, only one model has adaptations that make it suitable for children that age. And it hasn't been tested for safety and efficacy. Seems like an awful lot of money to throw at something of marginal benefit. But then, that's government by special interests for you. posted by sydney on
6/10/2004 09:33:00 PM
Early-stage prostate cancer can lie in wait for more than a decade and then flare up to kill a man, a Swedish study finds.
The study, which followed 223 men whose early-stage prostate cancer was left untreated, found that the tumor could suddenly become much more aggressive after 15 years -- a follow-up period much longer than that done in most such studies.
But wait a minute. The study started with 223 men, but after fifteen years of observation, there were only forty-nine still alive. And it was only then that the prostate cancer mortality began to increase. Mostly because the small number of patients gave an artificial boost to the statistical manipulation:
The prostate cancer mortality rate increased from 15 per 1000 person-years (95% confidence interval, 10-21) during the first 15 years to 44 per 1000 person-years... beyond 15 years of follow-up.
When you convert numbers of deaths to "person years" from actual incidences, the numbers get conflated when the sample size is small. Most prostate cancers are still indolent. It's impossible to tell from the abstract, but chances are that most of the men in the study died of something other than prostate cancer. If one thing doesn't kill you, another one will. posted by sydney on
6/09/2004 08:35:00 AM
Forever on Guard: Is there a symptom complex for ovarian cancer that points to the diagnosis early in the disease? Press reports and an author of a new study say yes:
"Women with ovarian cancer and comparatively large but benign tumors of the ovaries, they are symptomatic and they're symptomatic even in early-stage disease,' said Dr. Howard G. Muntz, a gynecologic oncologist at Virginia Mason and a study author. 'Ovarian cancer is not a silent disease."
Of the women who presented for primary care, 95% reported at least 1 symptom in the past year... The median number of reported symptoms was 4. The median severity of all symptoms was between 2 and 3. In 72% of cases, women had symptoms that occurred at least once per month....The median number of recurring symptoms was 2 and the median severity for all recurring symptoms was between 2 and 3.
For women with benign ovarian tumors:
In the women with benign disease, the median age was 55 years and 95% of the women reported symptoms in the prior year; 67% reported recurring symptoms; 8% reported having symptoms for 6 to 12 months; and 19% reported having symptoms for more than 1 year before seeing a clinician. The median number of symptoms was 4 and the median number of recurring symptoms was 2 (n = 84).
For women with ovarian cancer:
In the group with malignancy, the median age was 55 years and 94% of the women reported symptoms in the prior year with 67% having recurring symptoms. The median number of symptoms was 8 and the median number of recurring symptoms was 4 (n = 44)... When asked the duration of symptoms before seeking medical attention, 36% had symptoms for 2 months or less; 24%, 2 to 3 months; 3%, 5 to 6 months; 8%, 7 to 12 months; and 14%, more than 1 year.
So, the same percentage of women in all three groups reported symptoms in the prior year, and about the same number had recurring symptoms, although recurring symptoms were a little more frequent in the women without ovarian tumors. And most notably, the ovarian cancer patients had their symptoms for the shortest duration before seeking care, which means that there was probably something about their symptoms which told them things weren't right and drove them to the doctor's office. That something was likely the frequency and severity. This isn't exactly ground-breaking work. Most doctors base their diagnosis decisions at least in part on the severity and frequency of symptoms. An occasional bout of constipation or bloating that lasts a day or two and goes away doesn't set off the alarm bells that daily, worsening constipation and bloating do. Even if the daily, worsening symptoms have only lasted a couple of weeks.
And then, there's the matter of whether early ovarian cancer presents with these symptoms, or whether they only manifest themselves when the cancer has grown large enough to press on surrounding organs and cause the symptoms. The data are ambiguous. For one thing, the sample size is extremely small. Only eleven women had early stage cancer, while 33 had late stage ovarian cancer. It was more likely due to good fortune that those eleven women had symptoms early in the course of their disease rather than later. Ovarian cancer still remains a silent disease that more often than not manifests itself late in the game. The study doesn't shed any new light on diagnosing it sooner. posted by sydney on
6/09/2004 08:31:00 AM
Documentation: A reader wonders about how doctors handle information transfer:
I am new to your blog. What do you think of the new practice of not reviewing a patients file before see them so as to have a "fresh view"? Both my wife and I were confronted with this on our last doctor's visit, two different doctors, and were shocked when we were forced to give test results from memory to prevent a further round of test.
Ideally, it would be nice to have a patient's old record at the first encounter with a new doctor. However, it's often difficult to obtain them. And it seems the larger the physician group, the harder they are to get. There's a tertiary care center not far from my town that is a black hole when it comes to charts. I've never successfully gotten a patient's record from them. So, you do the best you can in a less than ideal world.
One of the arguments for mandated electronic medical records is that it will eliminate this kind of problem and thus save money. But I wonder if it will really eliminate it. There will still be the matter of patient privacy, so I doubt that you will be able to go on the internet and get someone's records. Likely, they'll have to be handed over from one doctor to another just as they are now. And will the savings in duplicate tests really be more than the cost of computer systems and software? That I highly doubt, since electronic medical record systems cost several thousand dollars, even for the small office. posted by sydney on
6/09/2004 07:08:00 AM
Tuesday, June 08, 2004
All We Like Sheep: Documentary filmaker Morgan Spurlock has a movie out that records his weight gain on an all-McDonald's diet, but here are two people who lost weight by eating at McDonald's, and just choosing wisely.
ADDENDUM: You may be thinking "What the?" about the "All We Like Sheep" heading. I made it too obscure, I know. Morgan Spurlock gained weight eating McDonald's by supersizing whenever the clerk at the counter asked him if he wanted to "supersize that." Like a sheep who goes meekly where led. The other two people, who lost weight, made their own choices without following the recommendations of a salesperson. (Also I fixed a typo.) posted by sydney on
6/08/2004 05:10:00 PM
Totalitarian Thinking: Malpractice in Libya, the steward of the UN's Human Rights Commission:
On May 6, the six defendants were sentenced to death by firing squad -- with a 60-day period to launch an appeal -- in a trial observers say flew in the face of human rights in every respect. Nine Libyan health workers also charged in the case were acquitted the same day.
...The defendants were tortured daily for the first three months of their captivity in efforts to elicit confessions -- torture that included electric shocks, being threatened by barking dogs, falaqa (beatings on the sole of the feet), suspension above the ground by their arms for hours on end, and in the case of two nurses, rape.
The charge? That they infected almost 400 children with HIV. How could over 400 children become infected with HIV? The same way many in Africa become infected with HIV:
The infections were an inevitable outcome of inadequate equipment, unskilled staff and the reuse of unsterilized needles.
Professional Stupidity: School officials in New Mexico reported a father to the state's child protective services because he stopped the kid's Ritalin:
In February, 12-year-old Daniel began displaying some symptoms that his father suspected were related to the use of Ritalin.
'He was losing weight, wasn't sleeping, wasn't eating,' Taylor told ABC News affiliate KOAT-TV in New Mexico. '[He] just wasn't Daniel.'
So Taylor took Daniel off Ritalin, against his doctor's wishes. And though Taylor noticed Daniel was sleeping better and his appetite had returned, his teachers complained about the return of his disruptive behavior. Daniel seemed unable to sit still and was inattentive. His teachers ultimately learned that he was no longer taking Ritalin.
School officials reported Daniel's parents to New Mexico's Department of Children, Youth and Families.Then a detective and social worker made a home visit.
'The detective told me if I did not medicate my son, I would be arrested for child abuse and neglect,' Taylor said.
The symptoms that the father noticed - poor sleep, loss of appetie, and weight loss, are all, indeed, side effects of Ritalin. Evidently for both the doctor and the teachers, it's far better to have a subdued child than a healthy one. And reporting the father to the state for discontinuing Ritalin is ridiculous. It isn't as if the kid were taking it for a serious, suicidal depression or to control schizophrenia. He's taking it so he'll be quiet in the classroom and not overtax his teachers. The father is right, and he knows it:
Taylor told KOAT-TV he is not putting Daniel back on Ritalin, no matter what the consequences for himself may be. "Yeah, I'll go to jail for it," he said. "I'll go as long as I have to go."
UPDATE: A reader takes me to task:
Your statement " It isn't as if the kid were taking it for a serious, suicidal depression or to control schizophrenia. He's taking it so he'll be quiet in the classroom and not overtax his teachers. The father is right, and he knows it."
Sydney, way to fast of a rush to judgement: a possible disservice to the child, an unnecessary indictment of educators, not clinically accurate and it reinforces a stereotype about the serious of some ADHD diagnoses. The agency I run sees the most problematic of the problematic--youths who are seriously suicidal, psychotic, depressed, profoundly encumbered with advanced substance abuse and I can tell you that some of the most ill, symptomatic and challenging are kids where ADHD is the most appropriate diagnosis. And you know, regardless of popular press, many kids with ADHD have a biologically based disorder that can respond beautifully to appropriate medication. Is medication misused, of course. Is it important and critical to appropriate functioning for some kids, of course.
Who knows about this particular case? What I do know is that you are not in position to rush so quickly to judgement. I do not know what lead to the schools decision--on the surface it appears quirky and perhaps unsupportable--but so did the story last year about the Sheriff who reported a parent for child abuse because her child was getting sunburned at the county fair. The Sheriff slept well and a few months later, after being a laughing stock, the parent was charged with homicide and child neglect of that same child.
That's true. We don't know all the particulars of this case - only the father's point of view. However, dealing with the worst of the worst has a tendency to skew one's viewpoint. This child may be one of the truly bad cases in need of the medication, or he may be like the many children who pass through my office who aren't such great students and who fidget a lot, and who bring letters from their teachers asking that they be treated for ADHD. What's most disturbing about these letters is that they often describe my own daughter to a tee. And yet, none of my daughter's teachers have ever asked that we have her evaluated for ADHD. The reason? She learns quickly, so she doesn't tax her teachers that much. In my daughter's case they shrug off her behavior as boredom. (It isn't. She's always in a fidget.) But another kid who requires more effort to learn, and more effort to teach, gets labelled as ADHD. That's just not right.
And there's another disturbing thing I've noticed about this quickness to diagnose ADHD on the part of school systems. It's much more prevalent in the poorer ones, where teachers don't have as many resources and where many of the kids have a lot of other underlying social problems. Here on the frontlines of community medicine, it's apparent that for many teachers Ritalin is a quick and easy fix. Actually, it often isn't the fix they need, but it makes the teacher feel like he's doing something to help. And it's a lot easier than finding a way to teach a problem kid.
What Color Dress am I Wearing? The hazards of telephone medicine are legion, but still many patients expect us to make a diagnosis and treatment recommendations over the phone. I've even heard fellow physicians justify telephone medicine by quoting the old dictum that the history is the most important part of making a diagnosis. But you can't do away with the physical exam, as one Alaskan doctor tried to tell a patient, unsuccessfully. After she ignored his advice to let him examine her, she became critically ill and later sued:
In this case, Marsingill, who had abdominal surgery several months earlier, called Dr. O'Malley at night complaining of pain, bloating and an inability to burp.
He told her he couldn't evaluate her over the phone, and he didn't give her an opinion about what might be causing her symptoms, according to court records. Instead, Dr. O'Malley told Marsingill that he would meet her at the emergency department.
She asked what they would do there, and he told her doctors would likely insert a nasogastric tube. Before hanging up the phone, Marsingill told Dr. O'Malley that she wasn't going to go to the hospital because she was feeling better and that she believed she could burp.
Later that night, she passed out and went to the hospital by ambulance. She had intestinal blockage and went into shock, according to court records. Brain damage and partial paralysis followed.
She lost - twice - but plans to appeal yet again. The case has made all Alaskan doctors shy not only about giving advice over the phone, but about talking to patients over the phone at all. Instead, they tell their patients to go to the ER after hours if they have a problem. They just can't take the risk:
If Dr. O'Malley had lost the lawsuit, it could have cost him $7 million to $10 million. That's far more than his medical liability insurance would have covered.
We often hear that lack of insurance coverage is the primary driver of emergency room overcrowding, but I would submit that it's really fear of litigation. When I think of the people I've sent to the ER after hours, the majority of them probably could have waited until the next day, but I'm apt to err on the side of caution. If there's the least bit of resistance on the part of the patient to a "take an aspirin and call the office in the morning" approach, I tell them to go to the ER. Or if it's a symptom that has the remotest chance of being serious - abdominal pain, chest pain, shortness of breath (even when they don't sound short of breath on the phone or the history is a rather weak one), I tell them to go to the ER. I'm not willing to take the chance of a multi-million dollar lawsuit. And I suspect I'm not alone. In fact, I know it. The doctors I share call with are the same way.
posted by sydney on
6/08/2004 08:11:00 AM
Monday, June 07, 2004
Lovely Venus: Venus will move across the sun early tomorrow morning (at least that's when it happens here in Ohio), an event that happens twice every one hundred and twenty years or so. NASA has information on when and how to view it, as well as music to accompany it. posted by sydney on
6/07/2004 08:27:00 AM
Better than Aspirin! And over ten times the cost. The cholesterol-lowering drugs, statins, are being hailed as cancer fighters:
Dr. Stephen Gruber, a cancer researcher at the University of Michigan, found in a study of Israelis that statin medications lowered the risk of colorectal cancer by 46 percent, which is significantly more than aspirin. The study, which was observational, he said, requires additional testing. But if future research proves him right - and he thinks it will - drugs now used to prevent clogged arteries may one day be prescribed to prevent the third leading cause of cancer deaths.
His team, working in Israel, looked at 1,708 people who had colon cancer and 1,737 who did not. Those on statins for at least five years had about a 50-percent reduction in the risk of cancer.
Adjusting for other factors that could possibly explain the difference, such as better health habits, did not change the strong link between statins and lowered risk.
This sort of study, one which compares one group with a disease to another group without it and then looks for similarities and differences is one of the weakest ways to find causes (and preventives) for a disease. What it really finds is associations. It's impossible to say from this if statins actually lower the risk of cancer. It was studies like this that purported to show hormone replacement therapy reduced the risk of heart disease in post-menopausal women, which we now know it does not do. What's more, the study was reported at a meeting of oncologists, which means it hasn't been peer-reviewed (for what that's worth) and that the data aren't available for scrutiny. That fifty percent reduction in cancer rates could have been the difference between 2 cases and one case, or the difference between 50 casesand 25. We have no way of knowing. So don't buy the hype.
posted by sydney on
6/07/2004 08:14:00 AM
Sunday, June 06, 2004
Passing:Ronald Reagan, at age 93. Reagan's era coincided with my college and medical school days, when I was a knee-jerk liberal. I had no respect for him. But, a few years ago, I heard an interview on NPR with a man - a European - who had made his life's work documenting the atrocities of the North Korean dictatorship. He cited Ronald Reagan as his inspiration. Specifically, Reagan's courage in calling totalitarian regimes evil - and to their faces. He said from that moment, people living under those regimes (the old Soviet Union, most of Eastern Europe) took heart. And I realized that Reagan played more of a role in the collapse of communism than I had ever given him credit. Simply by speaking the unvarnished truth. So to President Ronald Reagan - requiescat in pace. posted by sydney on
6/06/2004 08:33:00 AM
SARS Lessons: The lessons of SARS as learned by Canadians. The numbers are staggering:
Results Toronto Public Health investigated 2132 potential cases of SARS, identified 23,103 contacts of SARS patients as requiring quarantine, and logged 316,615 calls on its SARS hotline. In Toronto, 225 residents met the case definition of SARS, and all but 3 travel-related cases were linked to the index patient, from Hong Kong. SARS spread to 11 (58 percent) of Toronto's acute care hospitals. Unrecognized SARS among in-patients with underlying illness caused a resurgence, or a second phase, of the outbreak, which was finally controlled through active surveillance of hospitalized patients. In response to the control measures of Toronto Public Health, the number of persons who were exposed to SARS in nonhospital and nonhousehold settings dropped from 20 (13 percent) before the control measures were instituted (phase 1) to 0 afterward (phase 2). The number of patients who were exposed while in a hospital ward rose from 25 (17 percent) in phase 1 to 68 (88 percent) in phase 2, and the number exposed while in the intensive care unit dropped from 13 (9 percent) in phase 1 to 0 in phase 2.
One person with SARS managed to give the illness to 222 people. Think about that. And just three unrelated infected people resulted in the quarantine of 23,103 others. Even worse, 88 percent of hospitalized people- those least able to fight off infection - were exposed to the virus while in the hospital. The SARS epidemic was a vivid illustration of just how quickly a truly infectious disease can spread. We should consider ourselves warned against complacency when it comes to bioterrorism with highly infectious (and much deadlier ) agents, like smallpox. But our public health officials still continue to insist that things will be fine if we wait until an outbreak. And they still aren't doing anything to educate the masses (we physicians in the trenches) on recognizing bioterror diseases and how to respond.
My own health department is still devoting all of their resources to educating me about the importance of childhood immunizations (something I learned in medical school) and of convincing my patients to stop smoking (also learned in medical school.) They are completely incapable of shifting their paradigm. posted by sydney on
6/06/2004 08:17:00 AM