Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720050001&lang=es vol. 133 num. 1 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[<B>El Comité Editorial Asesor</B>: <B>Nuevos miembros con mayores responsabilidades</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100001&lng=es&nrm=iso&tlng=es During the 1960's Revista Médica de Chile started to request external peer reviews to assess the quality of the manuscripts received and an official Editorial Advisory Committee was incorporated in 1973. Since then, its members have been changed four times. The Committee has served the purposes of providing an external peer review independent to the editors, assessing manuscripts submitted, although many other experts have also contributed and their names have been acknowledged yearly in the July issues of the journal. At the present time, the journal receives an increasing number of manuscripts from a wider range of medical specialties as well as from basic scientists doing research in topics connected with clinical medicine. The overload of papers forces the editors to adopt policies to cope with it. One of them is to renew and enlarge the list of members of the Editorial Advisory Committee, including experts who have recently provided efficient help in reviewing manuscripts. They have also accepted to collaborate with the Editors in selecting other external experts able to participate in the peer-review process, while decisions on acceptance or rejection remain in the Editor and Associate Editors. As a Special Article in this issue, Revista Médica de Chile recognizes again the generosity of all those who along the recent decades have contributed as Members of the Editorial Advisory Committee to the educational, professional and scientific role of this journal (Rev Méd Chile 2005; 133: 9-10) <![CDATA[<B>Cambios en la relación médico-paciente y nivel de satisfacción de los médicos</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100002&lng=es&nrm=iso&tlng=es Background: Physician-patient relationship is the basis of clinical practice. In the last decades, the changes in this relationship have influenced the degree of satisfaction of physicians with their practice. Aim: To explore the perception of physicians about changes in physician-patient relationship and its impact in their personal and professional satisfaction. Material and methods: Qualitative study involving 44 physicians from the Metropolitan Region of Chile. Focus groups and semi-structured interviews were used. Results: All physicians mentioned changes on physician-patient reltionship as one of the most important factors that has impact on their satisfaction. The main cause for the deterioration of this relationship is a generalized climate of distrust that leads to frustration and disenchantment with the profession. Conclusions: This feeling is in accordance with other reports showing that patients are progressively acquiring more protagonism in health care decisions. The reconstruction of the bond between patients physicians within these new scenarios is indispensable to improve the degree of satisfaction of both patients and professionals (Rev Méd Chile 2005; 133: 11-6) <![CDATA[<B>Trombosis venosa mesentérica</B>: <B>manifestaciones clínicas, terapia y evolución</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100003&lng=es&nrm=iso&tlng=es Background: Mesenteric vein thrombosis (MVT) is uncommon and accounts for 5-10% of all mesenteric ischemic events. In 80% of cases, an etiologic factor is found. The clinical presentation varies and the diagnosis is made based on imaging studies. The treatment involves anticoagulation alone or in combination with surgery. Aim: To describe the clinical characteristics of patients with MVT. Patients and methods: Retrospective and prospective review of all cases with MVT, treated between 1995-2001. The clinical presentation, imaging studies, treatment and outcome were evaluated. Results: 29 cases of MVT were reviewed (14 females, age 56 ± 15 years). Twenty two patients (76%) had recognizable risk factors. The main symptoms were abdomianl pain (86%) and vomiting (55%). The diagnosis of acute mesenteric ischemia was suspected on admission only in 6 patients (21%). Thirteen patients underwent transabdominal color Doppler ultrasonography and the diagnosis was confirmed for 11 of these (85%). Twenty out of 24 patients (85%) studied with computed tomography, had positive signs of MVT. Twenty one patients (72%) recieved anticoagulation, 10 of whom also underwent surgery. Four patients (14%) received surgical treatment alone. Four patients were not treated. Seven patients (24%) died. Conclusions: MVT is difficult to identify. It is necessary to have a high degree of suspicion in patients who have risk factors. The diagnosis is made with imaging studies. The treatment consists of early anticoagulation and surgical intervention when indicated (Rev Méd Chile 2005; 133: 17-22) <![CDATA[<B>Curso clínico de la nefropatía membranosa lúpica pura</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100004&lng=es&nrm=iso&tlng=es Background: The long-term outcome of the pure form of WHO type V lupus membranous glomerulonephritis is apparently more benign than that of other forms of lupus glomerulonephritis. However 12% of such patients progress to terminal renal failure. The presence of proteinuria may be an indication of cytotoxic agents. Aim: To study the clinical long-term outcome of WHO type V lupus membranous glomerulonephritis. Material and methods: A retrospective analysis of all kidney biopsies of a University Pathology Department, with the diagnosis of WHO type V lupus membranous glomerulonephritis. Review of medical records of patients with the disease and one clinical assessment of all living patients. Results: Between 1973 and 2000, 703 kidney biopsies were done to patients with systemic lupus erythematosus. Of these, 40 were membranous glomerulonephritis and in 33 patients (28 women, age range 6-71 years), data on the evolution and survival was obtained. Nineteen had type Va and the rest type Vb nephritis. Two presented with renal failure and 11 with proteinuria over 3.5 g/24h. The median follow-up since the renal biopsy was 63 months (range 1-316). At the end of follow-up, four had a creatinine clearance of less then 15 ml/h and four a clearance between 15 and 29 ml/h (one of these received a renal allograft). Eleven (33%) patients had died, mostly due to infections. Life expectancy at five years with a creatinine clearance over 15 ml/h was 75%. Bad prognostic factors were an elevated creatinine clearance over 15 ml/h was 75%. Bad prognostic factors were an elevated creatinine and high blood pressure at the moment of the biopsy. Conclusions: The clinical outcome of these patients was bad. Twelve percent reached a stage of terminal renal failure. This is in contrast with the 3% progression to a similar stage of proliferative glomerulonephritis treated with i.v. cyclophosphamide. New therapies for this condition must be sought (Rev Méd Chile 2005; 133: 23-32) <![CDATA[<B>Caracterización clínico-genético-molecular de 45 pacientes chilenos con Síndrome de Prader Willi </B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100005&lng=es&nrm=iso&tlng=es Background: Prader-Willi syndrome (PWS) is a neurogenetic disease characterized by neonatal hypotonia, retarded mental and motor development, hypogonadism, hyperphagia, morbid obesity and dysmorphic facial features. It has an incidence of 1:12.000-15.000 newborns and is caused by abnormalities in genes located in 15q11q13. PWS is one of the most frequent genetic disorders and microdeletion syndromes. It is also the most common cause of obesity from genetic origin and it was the first disease in which imprinting and uniparental disomy were recognized as cause of genetic disorders. Seventy to seventy five percent of PWS cases are due to 15q11q13 deletions, 20-25% to uniparental disomy and 1% to mutations in the imprinting center. Aim: To analyze the clinical, genetic and molecular features of patients with PWS, seen at one institution. Patients and methods: Retrospective review of 45 patients (27 males) with PWS seen at the Genetics Outpatient Clinic at INTA. Results: Twenty three (51.1%) patients had a delection, 13 (28.9%) patients did not have a deletion. In nine patients, fluorescence in situ hybridization (FISH) study was not performed, therefore the presence of deletion was unknown. The clinical score was 8 points for patients younger than 3 years (n=11) and 11.5 points for patients older than 3 years (n=34); for patients aged 12 months or less, the clinical score was 7 points. Mean clinical score was 11 points for patients with deletion and 10 points for patients without deletion. Conclusions: Most patients with PWS have a deletion; the phenotype depends on age and the clinical score is useful for Chilean patients with PWS (Rev Méd Chile 2005; 133: 33-41). <![CDATA[<B>Susceptibilidad a antimicrobianos de <I>Streptococcus pneumoniae</I> en poblacion infantil y adulta de Santiago</B>: <B>Periodo 1997-2003</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100006&lng=es&nrm=iso&tlng=es Background: In Chile, the emergence of drug-resistant strains of Streptococcus pneumoniae has complicated treatment decisions and may lead to treatment failures. Aim: to examine antimicrobial resistance trends among pneumococcal isolates from the Catholic University Hospital between 1997 and 2003. Material and methods: During a seven-year period, we examined 901 strains of S. pneumoniae isolated from sterile and non-sterile samples from adult and pediatric population. Results: Overall, 20% of isolates showed intermediate resistance to penicillin (MIC: 0.12-1 µg/ml) y 10.8% high level of resistance to penicillin (MIC <FONT FACE=Symbol>&sup3;</FONT> 2 µg/ml). Pneumococcal resistance to penicillin did not change significantly during the study period, but it was more common in pediatric patients and isolates from non-sterile samples. No isolate had a MIC <FONT FACE=Symbol>&sup3;</FONT> 8 µg/ml for penicillin. Twenty one percent of pneumococcal strains were resistant to erythromycin, 41.6% to trimethoprim-sulfamethoxazole and 3.6% to chloramphenicol. Macrolides resistance tended to increase between 1997 and 2003. Fourteen percent of strains showed intermediate resistance (MIC: 1 µg/ml) and 2.5%, a high level of resistance to cefotaxime (MIC: <FONT FACE=Symbol>&sup3;</FONT> 2 µg/ml). No isolate had a CIM <FONT FACE=Symbol>&sup3;</FONT> 4 µg/ml for cefotaxime. Among those isolates with intermediate or high level of resistance to penicillin, there were significantly more isolates highly resistant to erythromycin, trimethoprim-sulfamethoxazole and cefotaxime. Conclusions: Multidrug-resistant pneumococci are common and are increasing in our country, particularly in pediatric population, probably associated to indiscriminate ambulatory prescription of antimicrobials (Rev Méd Chile 2005; 133: 42-49) <![CDATA[<B>Invasión microbiana de la cavidad amniótica en la rotura de membranas de pretérmino</B>: <B>Resultados maternoneonatales y patología placentaria según microorganismo aislado</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100007&lng=es&nrm=iso&tlng=es Background: Microbial invasion of amniotic cavity occurs in 30 to 50% of patients with premature membrane rupture. Aim: To determine the outcomes associated with microbial invasion of the amniotic cavity (MIAC) in patients with preterm premature rupture of membrane (pPROM). Patients and methods: One hundred thirty four patients with preterm pPROM between 24 and 34 weeks of pregnancy, without clinical infection or labor, were studied. Cultures were obtained by transabdominal amniocentesis from the amniotic fluid and the lower genital tract. Four groups of MIAC were observed: MIAC1: due to S. agalactiae, F. nucleatum or H. influenzae as only etiologic agents, MIAC2: due to other bacteria, alone or mixed, MIAC3: due to U. urealyticum as only etiologic agent, MIAC0: No MIAC and no infection of the lower genital tract. Study patients received antibiotics and were managed expectantly until 35 weeks unless clinical chorioamnionitis developed or an amniotic fluid culture returned positive for S. agalactiae, F. nucleatum or H. influenzae. Results: Ninety six patients were enrolled: MIAC1 (n=11), MIAC2 (n=30), MIAC3 (n=19) and MIAC0 (n=36). Clinical chorioamnionitis was more common in patients with MIAC1 than those with MIAC3 (p<0.01) and those without infection (p<0.001). The admission to delivery interval was shorter in patients with MIAC1 (2.8 days) than those with MIAC3 (10.1 days, p<0.05) and those without infection (18 days, p<0.001). Delivery within 48 h and within 7 days of admission were also more frequent in patients with MIAC1 than in patients with MIAC3 (p<0.05) or those without infection (p<0.001). Newborns to mothers with MIAC1 had a higher frequency of infection (36%), asphyxia (36%), admission to neonatal ICU (100%) and death (46%) than those of mothers with MIAC3 and those without infection. Birth weight was also significantly lower. Histological chorioamnionitis was more common in patients with MIAC1 than in patients with MIAC3 and those without infection. The rate of funisitis was higher in patients with MIAC1 than those without infection. Conclusions: In patients with preterm PROM, microbial invasion of the amniotic cavity by S. agalactiae, F. nucleatum or H. influenzae is associated with high frecuency of adverse maternal and neonatal outcomes and neonatal death (Rev Méd Chile 2005; 133: 51-61) <![CDATA[<B>Edad materna y defectos del tubo neural</B>: <B>evidencia para un efecto mayor en espina bífida que anencefalia</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100008&lng=es&nrm=iso&tlng=es Background: Recent evidence from birth order data suggest that maternal factors can differently influence anencephaly and spina bifida. Aim: To study the influence of maternal age on the risk for neural tube defects. Material and methods: A meta-analysis of published data on neural tube defects (NTDs) was carried out to determine whether there is an increased risk to have a child with NTDs for younger and older mothers and if this risk differs depending on the type of NTD. All data available with information regarding the frequency of live births and NTDs cases by maternal age (five- or ten-year intervals) were included in the analysis. Effect sizes calculations were performed. Results: The analysis supports the hypothesis that there is an increased risk of having an offspring with NTDs for mothers 40 years of age or older. However, this effect is stronger for spina bifida than for anencephaly. There is also evidence that mothers 19 years old or younger have a higher risk for having a child with spina bifida. Conclusions: Maternal age influences the risk of having an offspring with neural tube defects (Rev Méd Chile 2005; 133: 62-70) <![CDATA[<B>Densitometría ósea en niños leucémicos al completar el primer mes de quimioterapia</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100009&lng=es&nrm=iso&tlng=es Background: An important loss of bone mineral density, associated to pain and fractures, has been reported in children with acute lymphoblastic leukemia (ALL). Aim: To measure bone mineral density among children with acute lymphoblastic leykemia (ALL) that completed the remission induction phase with chemotherapy, that lasts 30 days. Patients and methods: children with ALL, admitted to the oncology unit of a general hospital were considered eligible for the study. body composition and bone mineral density were measured by dual energy x ray absorptiometry (DEXA). each child with ALL was paired with a healthly control. Results: Fourteen children age 1 to 11 years, completed the study, Spine and femoral bone mineral desities were significantly lower than in their matched controls. No differences in total body bone mineral density or content were observed. Children with ALL had a lower fat free mass and a higher fat mass than their matched controls. There was a significant correlation between fat free mass and bone mineral content. Conclusions: After one month of chemotherapy, children with ALL had a lower bone mineral density in the spine and femur and a lower fat free mass (Rev Méd Chile 2005; 133: 71-76) <![CDATA[<B>Hiperparatiroidismo primario con compromiso esquelético grave</B>: <B>Un caso de carcinoma paratiroideo</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100010&lng=es&nrm=iso&tlng=es Parathyroid carcinoma is an uncommon cause of primary hyperparathyroidism; however, when this condition is severe, cancer must be suspected. We report on a 28-year-old male with severe hypercalcemia, cachexia, acute pancreatitis, urolithiasis, anemia and a severe skelletal involvement with multiple fractures. The patient had a 4-cm parathyroid tumor, that was surgically excised, along with the ipsilateral thyroid lobe. During the postoperative period, he had a severe and prolonged hungry bone syndrome, with a slow recovery of fractures, with functional and anatomical sequelae in the extremities. PTH levels were adequate for the serum calcium during the 16 months of follow-up (Rev Méd Chile 2005; 133; 77-81) <![CDATA[<B>Insuficiencia respiratoria progresiva secundaria a fibrosis pulmonar en una escolar</B>: <B>Caso clínico</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100011&lng=es&nrm=iso&tlng=es Interstitial lung diseases are uncommon in children, and can be idiopathic or secondary to known causes, sharing common pathological findings. We report a girl with progressive respiratory insufficiency secondary to interstitial pneumonia and pulmonary fibrosis, with risk factors such as bronchopulmonary dysplasia and respiratory infections (respiratory syncytial virus and suspected Mycoplasma pneumoniae), that may have had an additive effect. Nasal bi-level Positive Airway Pressure was used in the last period of her disease. She died due to global respiratory failure at the age of 14 years (Rev Méd Chile 2005; 133; 82-88) <![CDATA[<B>Valor pronóstico de la monitoría ambulatoria de presión arterial en pacientes hipertensos</B>: <B>Observaciones en la literatura</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100012&lng=es&nrm=iso&tlng=es There is a large amount of information in the literature to state that blood pressure control using ambulatory blood pressure measurement has a better predictive value for future cardiovascular events and target organ damage than casual blood pressure measurements. Clinical studies are currently evaluating if this approach is cost-effective. At the present time, and in the usual clinical practice, the use of ambulatory blood pressure monitoring is recommended for patients with resistant or difficult-to-control hypertension, for hypertensive patients with previous cardiovascular events or significant target organ damage, for the diagnosis of white coat hypertension, when there are symptoms suggesting hypotension or there is large variability in casual blood pressure measurements (Rev Méd Chile 2005; 133: 89-95) <![CDATA[<B>Restricción del crecimiento fetal e insulinorresistencia</B>: <B>Nuevos hallazgos y revisión de la literatura </B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100013&lng=es&nrm=iso&tlng=es There is a strong association between low birth weight and insulin resistance. The thrifty phenotype hypothesis, which postulates fetal programming for adaptation to an adverse intrauterine environment, resulting in a lower insulin sensitivity in utero, is one of the hypothesis to explain this association. Later in life, syndrome X may develop, featuring hypertension, dyslipidemia, central obesity and type 2 diabetes, associated to an excessive food intake. Our investigation during the first three years of life in a prospective cohort of small (SGA) or appropriate for gestational age newborns, demonstrated that a significant increase of insulin levels is detected in SGA, as early as during the first year of life, but only when catch up growth (CUG) occurs. Orexigenic peptides such as Ghrelin appear to participate in this CUG phenomenon. We also sought to determine whether these associations were observed in individuals born with very low birth weight. We found that in utero as well as postnatal growth rates were independent determinants of insulin sensitivity and secretion. Education about feeding practices and physical activity in SGA children, is a future challenge to prevent the onset of syndrome X in this predisposed population (Rev Méd Chile 2005; 133: 97-104 <![CDATA[<B>Ética científica de la clonación humana</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100014&lng=es&nrm=iso&tlng=es True cloning is fission, budding or other types of asexual reproduction. In humans it occurs in monozygote twinning. This type of cloning is ethically and religiously good. Human cloning can be performed by twinning (TWClo) or nuclear transfer (NTClo). Both methods need a zygote or a nuclear transferred cell, obtained in vitro (IVTec). They are under the IVTec ethics. IVTecs use humans (zygotes, embryos) as drugs or things; increase the risk of malformations; increase development and size of abnormalities and may cause long-term changes. Cloning for preserving extinct (or almost extinct) animals or humans when sexual reproduction is not possible is ethically valid. The previous selection of a phenotype in human cloning violates some ethical principles. NTClo for reproductive or therapeutic purposes is dangerous since it increases the risk for nucleotide or chromosome mutations, de-programming or re-programming errors, aging or malignancy of the embryo cells thus obtained (Rev Méd Chile 2005; 133: 105-12) <![CDATA[<B>Aspectos fenomenológicos y éticos del envejecimiento y la demencia</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100015&lng=es&nrm=iso&tlng=es Aging is a difficult stage in human life, due to the limitations it imposes and the nearness to death. Modern society tends to be prejudiced against oldness. When dementia is also present, prejudices can be transformed into rejection. The aim of this author tries to devise a phenomenological description of oldness and points out its potentially positive aspects. Following Scheller's classification of dementias (1965), this author tries to determine the common elements of their different forms, using the phenomenological method, which can be applied either to one or to many cases of aging or dementia, not being the number of observations the fundament of the study, as in the case of empirical sciences. Three essential features characterize the spatiality of aging: distance, reduction of mobility and coexistence of the essential and the tangential; temporality is characterized by slowing, coexistence of essential and trivial elements and predominance of present over future and past. In the case of dementias, all characteristics attributed to senescence are exaggerated and/or deformed, for example, «distance» is transformed into indifference or «slowing» becomes a paralysis of temporal development. Now, regarding the main forms of dementia, this author sees their common feature in the loss of the Ego's ability to rise above the immediate situation, to be able to reflect on the environment and on him or herself. This wide vision both of aging and of the dementia process enables the author to identify the prejudices weighing over old age that must be overcome, as well as the reasons to respect and take care of the elderly when they are caught in a process of deterioration (Rev Méd Chile 2005; 133: 113-20) <![CDATA[<B>Médicos -Centíficos en Chile</B>: <B>¿Una especie en extinción?</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100016&lng=es&nrm=iso&tlng=es Several studies have reported a progressive reduction in the number of grant applications and research projects approved by medical doctors (MD) in the United States. The overall trend and current situation of MDs actively involved in biomedical research in Chile has not been defined. Thus, we analyzed the professional profile of the principal investigators (PI) that have led research grants approved by the Technology and Medical Sciences study groups of the Fondo Nacional de Desarrollo Científico y Tecnológico (FONDECYT), during the last 20 years. The results show that the projects led by MDs corresponded to 80% in 1984, decreasing to 50% in 2003, with further reduction projected for the next years. We think that the physician doing biomedical research represents a human resource indispensable to preserve a genuine academic environment within medical schools; thus, it is necessary to design and apply strategies to reverse this worrying trend of less MDs actively involved in research in Chile. Among these, we consider important to stimulate research activities at both the undergraduate and postgraduate levels of MD training particularly increasing the flexibility of the postgraduate fellowship programs. In addition, it is necessary to support both in terms of money and spare time those physicians who are beginning an academic career involved in biomedical research. Finally, we consider important that non-academic institutions (e.g., pharmaceutical companies, health medical organizations, and philanthropic foundations) should also support academic development and biomedical research in our medical schools (Rev Méd Chile 2005; 133: 121-8) <![CDATA[<b>Miembros del Comité Editorial Asesor de la Revista Médica de Chile, desde 1973 hasta 2004</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100017&lng=es&nrm=iso&tlng=es Since the late 1960's, Revista Médica de Chile requests external peer reviewers to assess manuscripts received. In 1973, a group of distinguished participants were selected to form the Editorial Advisory Committee that has been changed four times since then. As a token of appreciation for their important help in the editorial process, the names of all who have been part of this Committee are reproduced below. <![CDATA[<B>Un momento mágico durante el XXVI Congreso Chileno de Medicina Interna</B>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100018&lng=es&nrm=iso&tlng=es Since the late 1960's, Revista Médica de Chile requests external peer reviewers to assess manuscripts received. In 1973, a group of distinguished participants were selected to form the Editorial Advisory Committee that has been changed four times since then. As a token of appreciation for their important help in the editorial process, the names of all who have been part of this Committee are reproduced below. <![CDATA[<b>Crónica</b>]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872005000100019&lng=es&nrm=iso&tlng=es Since the late 1960's, Revista Médica de Chile requests external peer reviewers to assess manuscripts received. In 1973, a group of distinguished participants were selected to form the Editorial Advisory Committee that has been changed four times since then. As a token of appreciation for their important help in the editorial process, the names of all who have been part of this Committee are reproduced below.