Epidemiology and economics of adult patients hospitalized with urinary tract infections

Background: Urinary tract infections (UTI) are among the most common bacterial diseases worldwide, with significant clinical and economic burden. Surveillance of pathogen epidemiology and risk factors for resistant pathogens in the hospital setting may improve the management of UTI. Objective: To evaluate microbiology and antimicrobial susceptibility of UTI pathogens, with associated costs, in hospitalized patients. Methods: Patients diagnosed with UTI between July and September 2013 were retrospectively screened for clinical symptoms and treatment within 24 hours of admission, then categorized into groups: community acquired (Group 1); recent healthcare exposure (Group 2); or a history of identification of an extended-spectrum beta lactamase (ESBL)-producing organism (Group 3). Clinical, epidemiological, and financial data were compared between groups. Results: From 308 included patients, a total of 216 pathogens were identified. Escherichia coli was most commonly identified pathogen, but frequencies differed between groups (p = 0.002), as did those of ESBL-producing pathogens (p < 0.001) and Pseudomonas aeruginosa (p = 0.005). Appropriate empirical therapy also differed between groups (p = 0.003). Length of stay was longer for healthcare associated UTI with inappropriate empirical therapy (5.2 versus 6.3 days, p = 0.016). Increased cost was associated with factors other than antimicrobial costs. Intensive care unit (ICU) stay (p < 0.001), care facility at discharge (p = 0.001), Foley catheter (FC) present on admission (p = 0.002), and Charlson comorbidity index (CCI) (p = 0.017) predicted increased cost overall, while ICU stay (p < 0.001), time to appropriate therapy (p < 0.001), and CCI (p = 0.015) predicted higher cost in patients with pathogens identified. Conclusions: Changes in antimicrobial susceptibility are evident with exposure to healthcare, the presence of a FC, and a history of resistant pathogens. Risk-based empirical prescribing and rapid de-escalation may improve care and reduce costs.     

Evaluation of the impact of sperm morphology on embryo aneuploidy rates in a donor oocyte program

This study investigates the correlation between sperm morphology and the incidence of embryo aneuploidy in an oocyte donation program. A total of 1,165 embryos from 103 patients have been analyzed by fluorescent in situ hybridization (FISH) for numerical abnormalities in chromosome numbers 13, 18, 21, X, and Y. Data has been evaluated in five groups according to sperm morphology, which has been assessed according to the Kruger’s strict criteria. The results did not show any difference in paternal (p = 0.878), maternal (p = 0.873), and donor ages (p = 0.871), sperm counts (p = 0.782) and motility (p = 0.124), and fertilization rate (p = 0.080) among the groups. However, total aneuploidy rate (p < 0.001) and its derivatives (trisomy p = 0,042, monosomy p = 0,004) differed significantly and they were reversibly correlated with sperm morphology (rho correlation test; total aneuploidy p < 0.001, trisomy p < 0.001, monosomy p = 0.004). Therefore, these results suggested that diminished sperm quality is correlated to the aneuploidy rate in preimplantation embryos.

Abbreviations: FISH: fluorescence in situ hybridization; ICSI: intracytoplasmic sperm injection; HCG: human chorionic gonadotropin     

Which Patient and Clinician Characteristics Are Associated With High-Quality Communication Among Veterans With Chronic Obstructive Pulmonary Disease?

The authors evaluated associations of patient and clinician characteristics with high-quality communication among patients with chronic obstructive pulmonary disease. Using a cross-sectional analysis from patients with chronic obstructive pulmonary disease enrolled in a clinical trial, the authors evaluated the association of patient and clinician characteristics with patient-reported communication quality. The authors measured these associations using general estimating equations and adjusted odds ratios for best imagined communication quality. Most patient and clinician characteristics, including age, race/ethnicity, mental health attributes, and clinician specialty, were not associated with communication quality. Patient-reported clinician expertise (OR = 2.10, 95% CI [1.52, 2.88], p < .001) was associated with increased communication quality, while the patient not being married was associated with decreased quality (OR = 0.52, 95% CI [0.27, 0.99], p = .047). Only one modifiable characteristic, patient-reported clinician expertise, was associated with best imagined communication quality. This characteristic may be important to include as a potential intermediate outcome in future communication intervention studies. Predictors and outcomes of communication quality are not uniform across patient populations and settings. To maximize the effectiveness of communication interventions, it is important to have a thorough understanding of which patient, clinician, and system factors are associated with communication quality.     

Women at risk: Gender inequality and maternal health

Gender inequality has been documented as a key driver of negative health outcomes, especially among women. However, studies have not clearly examined the role of gender inequality in maternal health in an African setting. Therefore, the authors of this study examined the role of gender inequality, indicated by lack of female autonomy, in exposing women to maternal health risk. Data were obtained from the 2007 Zambia Demographic and Health Survey on a weighted sample of 3,906 married or partnered women aged 15–49 years. Multivariable analyses revealed that low autonomy in household decision power was associated with maternal health risk (Odds Ratio (OR) = 1.52, p < .001). Autonomy interacted with household wealth showed that respondents who were in the wealthier households and had low autonomy in household decision power (OR = 2.03, p < .05) were more likely to be exposed to maternal health risk than their counterparts who had more autonomy. Efforts to lower women’s exposure to maternal mortality and morbidity in Zambia should involve interventions to alter prevailing gender norms that limit women’s active participation in decisions about their own health during pregnancy and delivery.     

Impact of occupation on stress and anxiety among Indian women

The objectives of this study were to: (1) assess the prevalence of anxiety and stress in Indian women; and (2) evaluate the relationship of occupation to the prevalence of anxiety and stress. A cross-sectional study was performed from January 2013 to June 2014, on women (aged 18–50 years) randomly selected from different occupations in Gujarat, India. Anxiety was evaluated using Spielberg’s State and Trait Anxiety Inventory scale and stress was assessed using the International Stress Management Association questionnaire. Serum cortisol concentration was measured in a sub-sample. The association of occupation with stress and anxiety was analyzed by a generalized linear model adjusted for age. Among all participants, 26% were the most prone and 66% were somewhat more prone to stress; 35% of women showed high anxiety levels. Homemakers had 1.2 times higher anxiety and 1.3 times higher stress than working women (p < .05). Prevalence of stress (37%, p < .001) and anxiety (40%, p = .068) were also higher in homemakers compared to working women and students. Serum cortisol levels did not differ significantly (p > .05) by occupation. This study revealed high prevalence rates of stress and anxiety in Indian women. Involvement in activities outside the home may help women to reduce stress.     

Men's Use of an Internet-Based Decision Aid for Prostate Cancer Screening

Most medical organizations recommend informed decision making before undergoing prostate cancer screening. The authors conducted a detailed evaluation of men's use of an interactive, Web-based prostate cancer screening decision aid. Participants (N = 531) were 57 years old (SD = 6.8), 37% were African American, and 92% had Internet access. Men completed 2 telephone interviews, pre- and 1-month post–Web site availability. Half of the sample (n = 256) accessed the Web site. Multivariate analysis revealed that users were more likely than nonusers to be White (OR = 2.37, CI 1.6–3.6), previously screened (OR = 2.13, CI 1.07–4.26), have Internet access (OR = 3.66, CI 1.15–11.58), and to report daily Internet use (OR = 2.58, CI 1.47–4.55). Agreement between self-reported and actual Web site use was moderate (κ = .67). Tracking software revealed a mean of 1.3 (SD = 0.5) log-ons and a median of 38 min per log-on. Of participants, 84% used the values clarification tool, and more than 50% viewed each video testimonial. Baseline screening preference was associated with values clarification tool responses and Web site feedback. This study revealed that, beyond the digital divide, Web site use depended on more than Internet access. Further, electronic tracking of Web site use demonstrated overestimation of self-reported use, high use of interactive features, and effect of baseline screening preference on men's response to the Web site.     

Exploring the relationship between posttraumatic growth,cognitive processing,psychological distress,and social constraints in a sample of breast cancer patients

ABSTRACT

Posttraumatic growth (the perception of positive life changes after an encounter with a trauma) often occurs among breast cancer patients and can be influenced by certain demographic, medical, and psychosocial parameters. Social constraints on disclosure (the deprivation of the opportunity to express feelings and thoughts regarding the trauma) and the cognitive processing of the disease seem to be involved in the development of posttraumatic growth. Through the present study the authors aim to: investigate the levels of posttraumatic growth in a sample of 202 women with breast cancer in Greece, explore the relationships between posttraumatic growth and particular demographic, medical, and psychosocial variables according to a proposed model, and test the role of social constraints in the relationship between automatic and deliberate cognitive processing of the trauma. The results showed that posttraumatic growth was evident in the majority of the sample and was associated inversely with age at diagnosis (β = ?0.174, p < .05) and psychological distress (β = ?0.394, p = .001), directly with time since diagnosis (β = 0.181, p < .05), and indirectly with intrusions and psychological distress, through reflective rumination (β = 0.323, p = .001). Social constraints were found to moderate the relationship between intrusions and reflective rumination. Implications of the results and suggestions for future research and practice are outlined.     

Posttraumatic stress symptomology in parents of children with cancer: Implications related to criterion changes in DSM-IV-TR to DSM-5

Objective: This preliminary study compared a DSM-IV-TR screening tool for posttraumatic stress symptoms (PTSS) with a modified DSM-5 version for parents of children diagnosed with cancer.

Methods: Caregivers (n = 101) completed the Brief Symptom Inventory (BSI) and Impact of Event Scale-Revised (IES-R). Five BSI items were added to the IES-R to assess whether caregivers met DSM-5 specific posttraumatic stress disorder criteria.

Results: Chi-square analysis revealed three groups: caregivers who (1) did not meet screening criteria for DSM-IV-TR or DSM-5; (2) only met DSM-IV-TR criteria; and (3) met criteria for DSM-IV-TR and DSM-5, X²(1, n = 101) = 64.47, p < 0.001. Subgroup 2 had lower overall PTSS than subgroup 3 (p < 0.001), but more than Subgroup 1 (p < 0.001).

Conclusions: A “gap group” evidenced elevated PTSS but did not meet DSM-5 screening criteria. Further research is needed to clarify the prevalence and composition of PTSS among caregivers, and evaluate the clinical implications of the changes in diagnostic criteria.     

Mental Health Screening Results Associated with Women Veterans' Ratings of Provider Communication,Trust, and Care Quality

Background

Identifying factors influencing patient experience and communication with their providers is crucial for tailoring comprehensive primary care for women veterans within the Veterans Health Administration. In particular, the impact of mental health (MH) conditions that are highly prevalent among women veterans is unknown.

Correlates of Colorectal Cancer Screening Among Residents of Ohio Appalachia

There is an excess burden of colorectal cancer (CRC) in the Appalachian region of the United States, which could be reduced by increased uptake of CRC screening tests. Thus, we examined correlates of screening among Appalachian residents at average-risk for CRC. Using a population-based sample, we conducted interviews with and obtained medical records of Appalachian Ohio residents 51–75 years between September 2009 and April 2010. Using multivariable logistic regression, we identified correlates of being within CRC screening guidelines by medical records. About half of participants were within CRC screening guidelines. Participants who were older (OR = 1.04, 95 % CI 1.01, 1.07), had higher income ($30,000–$60,000, OR = 1.92, 95 % CI 1.29, 2.86; ≥$60,000, OR = 1.80, 95 % CI 1.19, 2.72), a primary care provider (OR = 4.22, 95 % CI 1.33, 13.39), a recent check-up (OR = 2.37, 95 % CI 1.12, 4.99), had been encouraged to be screened (OR = 1.57, 95 % CI 1.11, 2.22), had been recommended by their doctor to be screened (OR = 6.68, 95 % CI 3.87, 11.52), or asked their doctor to order a screening test (OR = 2.24, 95 % CI 1.36, 3.69) had higher odds of being screened within guidelines in multivariable analysis. Findings suggest that access to and utilization of healthcare services, social influence, and patient–provider communication were the major factors associated with CRC screening. Researchers and healthcare providers should develop and implement strategies targeting these barriers/facilitators to improve CRC screening rates and reduce the CRC burden among residents of Appalachia.     

Increasing Colonoscopy Screening for Latino Americans Through a Patient Navigation Model: A Randomized Clinical Trial

Latinos have a higher rate of mortality and lower rate of colorectal cancer (CRC) screening than most racial groups in the United States. This study examines the predictors of screening colonoscopy (SC) for CRC among Latinos in a patient navigation (PN) intervention. Participants were randomized to either a culturally-targeted PN group (n = 225) or a standard PN group (n = 167). Each completed an interview assessing sociodemographic and intrapersonal information. There was no difference in SC completion between PN groups (80.9 and 79.0 %). Logistic regression revealed that low language acculturation (OR = 2.22) and annual income above $10,000 (OR = 1.97) were independent predictors of completion. Both standard and culturally-targeted PN successfully increased SC completion by nearly 30 % above the recent estimation for physician-referred patients. Our findings suggest a need to further reduce barriers to SC in low income and highly acculturated Latino groups.     

Psychological factors influence the overlap syndrome in functional gastrointestinal disorders (FGIDs) among middle-aged women in South Korea

ABSTRACT

This study investigated the psychological factors related to the overlap syndrome, i.e., multiple gastrointestinal conditions that are part of functional gastrointestinal disorders (FGIDs) in the same individual and potentially related to quality of life (QOL) among women aged 45–60 years (n = 627) in South Korea. The study was undertaken between July 2014 and March 2015. Depressive and anxiety symptoms were ascertained using the Center for Epidemiologic Studies Depression scale (CES-D) and the Beck Anxiety Inventory (BAI), respectively. Negative cognition and the cognitive triad were identified using the Automatic Thoughts Questionnaire–Negative (ATQ-N) and the Cognitive Triad Inventory (CTI), respectively. Resilience and QOL were assessed using the Connor–Davidson Resilience Scale (CD-RISC) and World Health Organization Quality of Life scale abbreviated version (WHOQOL-BREF). Women with the overlap syndrome had the highest CES-D (mean = 16.66 ± 11.79, p < .001), BAI (mean = 17.46 ± 12.67, p < .001), and ATQ-N scores (mean = 53.61 ± 20.88, p < .001), followed by women with gastrointestinal disorders but without the overlap syndrome and healthy controls. Healthy controls had the highest WHOQOL-BREF score (mean = 77.69 ± 12.53, p < .001). After stepwise selection, the final model explained 61.8 percent of the variance in QOL. Thus, depressive symptoms, anxiety, negative cognition, cognitive triad, and resilience were significantly related to QOL in women with the overlap syndrome.     

Predictors of the use of healthcare services in children and adolescents in Spain

Objective

To assess medium to long term predictors of healthcare services use in a population-based sample of children/adolescents in Spain.

Methods

A sample of children and adolescents aged 8–18 and their parents were evaluated at baseline (2003) and follow-up (2006). Total use of healthcare services and visits to specialist and dentists at the follow-up were analyzed.

Results

Four hundred fifty-four children/adolescents completed baseline and follow-up assessments (response rate 54 %). 90 % of respondents reported at least one visit during the 12 months previous to the follow-up. Low socioeconomic status (beta coefficient = 0.30; 95 % CI = 0.02–0.57), double healthcare coverage (0.41; 0.17–0.66), parental use of services, poor mental health and activity limitation were associated to the total number of visits. Access to specialist was associated to double healthcare coverage (OR = 1.77; 1.01–3.07) and parental primary level of education (OR = 0.51; 0.32–0.81). Age and low family affluence predicted visits to dentists (OR = 0.38; 0.19–0.73).

Conclusion

No barriers to healthcare services use were found. Family level of education, family affluence and double healthcare coverage predicted the use of specialists and dentists.     

Neighborhood Satisfaction and Colorectal Cancer Screening in a Community Sample of African Americans

Social determinants are important to cancer screening among African Americans. To evaluate the association between social determinants (e.g., psychological characteristics, perceived social environment, cultural beliefs such as present temporal orientation) and colorectal cancer (CRC) screening among African Americans. African American adults (n = 262) ages 50–75 completed a telephone interview. Multivariate logistic regression analysis was used to identify factors having significant independent associations with CRC screening. Only 57 % of respondents reported having CRC screening. The likelihood of screening increased with greater neighborhood satisfaction (OR = 1.38, 95 % CI = 1.01, 1.90, p = 0.04), older age (OR = 1.75, 95 % CI = 1.24, 2.48, p = 0.002), greater self-efficacy (OR = 2.73, 95 % CI = 1.40, 5.35, p = 0.003), and health care provider communication (OR = 10.78, 95 % CI = 4.85, 29.94, p = 0.0001). Community resources are important precursors to CRC screening and outcomes among African Americans. In addition to addressing psychological factors and patient–provider communication, efforts to ensure the availability of quality health care facilities that provide CRC screening in the neighborhoods where African Americans live are needed.     

Improving Human Papillomavirus (HPV) Vaccination in the Postpartum Setting

Although the HPV vaccine has been shown to be highly effective in preventing cervical dysplasia, vaccination rates remain low. The objective of this study was to assess the effectiveness of an electronic medical record (EMR) prompt on HPV vaccination rates in the postpartum setting. We conducted a pre-post intervention study among postpartum women ages 18–26 seen at an outpatient clinic from 09/01/2012–08/31/2013 (pre-intervention) and from 10/01/2013–03/31/2014 (post-intervention). The intervention was a drop-down menu that was inserted into the EMR postpartum note template inquiring about the patient’s HPV vaccination status and whether or not the vaccine was administered at that visit. HPV vaccination uptake was compared pre and post-intervention. Of the 278 postpartum visits during the study period, 241 were eligible for analysis. There was a significant increase of the HPV vaccine uptake, from 1.2 % (2/173) among pre-intervention visits to 26.5 % (18/68) among post-intervention visits (p < 0.001). After adjusting for age, ethnicity, insurance, and religion, HPV vaccination was significantly higher at postpartum visits during the intervention period, with an adjusted OR = 93.49 [95 % CI 15.29–571.52]. Among visits in which the vaccine was not given, HPV vaccination was not discussed in 46 % and patients refused the vaccine in 40 % of visits. An EMR prompt in the postpartum note could be an effective way to promote HPV vaccination in the postpartum setting. It will likely take a combination of strategies to optimize vaccination uptake.     

Evaluation of prediction strategy and care coordination for COPD readmissions

Objectives: Factors that influence the likelihood of readmission for chronic obstructive pulmonary disease (COPD) patients and the impact of posthospital care coordination remain uncertain. LACE index (L = length of stay, A = Acuity of admission; C = Charlson comorbidity index; E = No. of emergency department (ED) visits in last 6 months) is a validated tool for predicting 30-days readmissions for general medicine patients. We aimed to identify variables predictive of COPD readmissions including LACE index and determine the impact of a novel care management process on 30-day all-cause readmission rate.

Methods: In a case-control design, potential readmission predictors including LACE index were analyzed using multivariable logistic regression for 461 COPD patients between January-October 2013. Patients with a high LACE index at discharge began receiving care coordination in July 2013. We tested for association between readmission and receipt of care coordination between July-October 2013. Care coordination consists of a telephone call from the care manager who: 1) reviews discharge instructions and medication reconciliation; 2) emphasizes importance of medication adherence; 3) makes a follow-up appointment with primary care physician within 1–2 weeks and; 4) makes an emergency back-up plan.

Results: COPD readmission rate was 16.5%. An adjusted LACE index of ≥ 13 was not associated with readmission (p = 0.186). Significant predictors included female gender (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.29–0.91, p = 0.021); discharge to skilled nursing facility (OR 3.03, 95% CI 1.36–6.75, p = 0.007); 4–6 comorbid illnesses (OR 9.21, 95% CI 1.17–76.62, p = 0.035) and ≥ 4 ED visits in previous 6 months (OR 6.40, 95% CI 1.25–32.87, p = 0.026). Out of 119 patients discharged between July-October 2013, 41% received the care coordination. The readmission rate in the intervention group was 14.3% compared to 18.6% in controls (p = 0.62).

Conclusions: Factors influencing COPD readmissions are complex and poorly understood. LACE index did not predict 30-days all-cause COPD readmissions. Posthospital care coordination for transition of care from hospital to the community showed a 4.3% reduction in the 30-days all-cause readmission rate which did not reach statistical significance (p = 0.62).     

Conceptualisations of masculinity and self-reported medication adherence among HIV-positive Latino men in Los Angeles,California, USA

HIV-positive Latino men have been found to have poorer medication adherence compared to Whites. This study sought to identify how cultural conceptualisations of masculinity are associated with self-reported medication adherence among Latino men. A total of 208 HIV-positive men reported the number of doses of antiretroviral medication missed in the previous seven days (dichotomised at 100% adherence versus less). Conceptualisations of masculinity consisted of traditional machismo (e.g., power and aggressive attitudes, which are normally associated with negative stereotypes of machismo) and caballerismo (e.g., fairness, respect for elders and the importance of family). Multivariate logistic regression was used to identify factors associated with adherence. The mean adherence was 97% (SD = 6.5%; range = 57–100%). In all, 77% of the participants reported 100% adherence in the previous seven days. Caballerismo was associated with a greater likelihood (OR = 1.77; 95% CI: 1.08–2.92; p = 0.03) and machismo with a lower likelihood (OR = 0.60; 95% CI: 0.38–0.95; p = 0.03) of medication adherence. In addition, higher medication side-effects were found to be associated with a lower likelihood (OR = 0.59; 95% CI: 0.43–0.81; p = 0.001) of medication adherence. These findings reinforce the importance of identifying cultural factors that may affect medication adherence among HIV-positive Latino men resident in the USA.     

Identifiable Characteristics and Potentially Malleable Beliefs Predict Stigmatizing Attributions Toward Persons With Alzheimer’s Disease Dementia: Results of a Survey of the U.S. General Public

The general public’s views can influence whether people with Alzheimer’s disease (AD) experience stigma. The purpose of this study was to understand what characteristics in the general public are associated with stigmatizing attributions. A random sample of adults from the general population read a vignette about a man with mild Alzheimer’s disease dementia and completed a modified Family Stigma in Alzheimer’s Disease Scale (FS-ADS). Multivariable ordered logistic regressions were used to examine relationships between personal characteristics and FS-ADS ratings. Older respondents expected that persons with AD would receive less support (OR = 0.82, p = .001), have social interactions limited by others (OR = 1.13, p = .04), and face institutional discrimination (OR = 1.13, p = .04). Females reported stronger feelings of pity (OR = 1.57, p = .03) and weaker reactions to negative aesthetic features (OR = 0.67, p = .05). Those who believed strongly that AD was a mental illness rated symptoms more severely (OR = 1.78, p = .007). Identifiable characteristics and beliefs in the general public are related to stigmatizing attributions toward AD. To reduce AD stigma, public health messaging campaigns can tailor information to subpopulations, recognizable by their age, gender, and beliefs.     

Repeatability and Validation of a Short,Semi-Quantitative Food Frequency Questionnaire Designed for Older Adults Living in Mediterranean Areas: The MEDIS-FFQ

The aim of the present work was to evaluate the repeatability and the validity of a short food frequency questionnaire (FFQ) that could be used for older people living in Mediterranean areas. The semi-quantitative FFQ included questions regarding the frequency of consumption of the main food groups and beverages typically consumed in the Mediterranean areas as well as some questions regarding eating habits of older persons. During 2006–2007, for the repeatability assessment (within 10–30 days), 150 individuals (51 ± 17 yrs, 40% males) were studied, while another 190 individuals (74 ± 9 yrs, 52% males) were enrolled for the validation purposes. Agreement of the FFQ with the 3-day food records was evaluated using the Bland–Altman method and the Kendall's tau-b coefficient. Repeatability was tested using the Cohen's kappa coefficient. Between 3-day food records and the FFQ, good agreement for alcohol (tau-b = 0.64, p < 0.001) was found, while moderate agreement for food and beverage groups of greens (tau-b = 0.32, p < 0.001), fruits (tau-b = 0.35, p < 0.001), cereals (tau-b = 0.61, p < 0.001), sweets (tau-b = 0.51, p < 0.001), and coffee (tau-b = 0.58, p < 0.001) was observed. Low, but still significant, agreement for fish (tau-b = 0.21, p = 0.001), legumes (tau-b = 0.23, p < 0.001), vegetables (tau-b = 0.23, p < 0.001), pasta (tau-b = 0.25, p < 0.001), potatoes (tau-b = 0.17, p = 0.006) and meat consumption (tau-b = 0.14, p < 0.001) were also found. The FFQ was also valid regarding the estimation of macronutrients and energy intake. Sensitivity analyses by sex, age category (≤ or > 75 yrs), and education status showed similar validity of the FFQ in each subgroup, except for elders older than 75 years. The repeatability of the FFQ was fair in all foods tested (Cohen's kappa coefficients varied between 0.15–0.39, p-values < 0.05). The suggested FFQ seems to be a reasonably valid and repeatable measure of dietary intake and can be used in older persons living in the Mediterranean areas.