Showing papers in "Pediatrics in 1979"

The rise of professionalism

Abstract: Professional work conditions (and not only the general ideology) foster individualism. The professional9s sense of power and authority flows not only from his actual command over special knowledge but also from his control over interpersonal situations. The first established professions—medicine, law, the ministry, and architecture—were typically concerned with the problems of individuals. Only indirectly did they define society as their client. Today, individualized service becomes an ideological remedy for the ills of a social situation, a screen for the social problems caused by the bureaucratic systems through which services are delivered—most notably in the medical and teaching professions. The ideological insistence on individual aspects, the neglect of the whole, merges with specialization to confine the professional in an ideological conception of his role: the importance of narrow responsibilities is consciously and unconsciously emphasized, exaggerating the "dignity" of the functions. The dominant ideology attributes to professionals and experts special prestige as well as "moral and intellectual superiority": sharing in this ideology, professionals can easily mystify to themselves their actual power. Moreover, they are locked into conformity with the role society offers them to play—locked in by their vocational choice, by the particular mystique of each profession, and by their whole sense of social identity. Finally, the technocratic ideology of science and objectivity excludes from the specialist9s concern the social and political consequences of his acts. Nowhere is this truer than in the technical and scientific fields.

The chest roentgenogram in cystic fibrosis: a new scoring system.

Abstract: A roentgenogram scoring system is presented that is useful in the evaluation and follow-up of patients with cystic fibrosis. The system has been shown to be reproducible by and between observers and to correlate significantly with results of pulmonary function tests, Shwachman-Kulczycki scores, and, in a short-term evaluation, morbidity.

Kawasaki Disease: Effect of Treatment on Coronary Artery Involvement

Abstract: Ninety-two patients with Kawasaki disease were treated with five different types of drug therapy: a steroid preparation (prednisolone), aspirin, an antibiotic, a combination of steroid plus aspirin, and a combination of steroid plus warfarin. One or two months after the onset of the disease, coronary angiography demonstrated coronary aneurysms in 20% of cases treated with an antibiotic alone, 64.7% of cases in the steroid-treated group, and 11% of those in the aspirin-treated group. These findings suggest that the steroid might act adversely to cause a progression of coronary lesions of the disease. The aspirin-treated group did not have a significantly lower incidence of coronary lesions compared with the group treated with an antibiotic alone. But in view of the fact that the direct cause of sudden death of the disease is thrombotic occlusion of a coronary artery, aspirin might act as the effective means for prevention of sudden death due to Kawasaki disease.

A Depression Rating Scale for Children

Abstract: A rating scale is needed for clinical and research studies of depression in childhood. A Children9s Depression Rating Scale (CDRS) was devised and tested on 30 inpatient children in a medical hospital. A high correlation was found between the global ratings by two psychiatrists of the severity of depression and the scores on the CDRS. The items on the CDRS which had the highest correlation with a global rating of depression were social withdrawal, capacity for fun, irritability, schoolwork, expressive communication, general somatic features, hypoactivity, and depressed mood. The syndrome of depression in childhood can be characterized and rated primarily by observed behaviors.

Adolescent Smoking: Onset and Prevention.

Abstract: Despite the systemic and conceptual barriers to effective preventive actions, some progress is beginning to be made in preventing adoption of self-destructive behaviors during adolescence. Application of the concept of psychological inoculation against social environmental factors that influence young people to adopt unhealthy life-styles is showing promise in short-term results of ongoing longitudinal studies. Researchers in pediatrics who are interested in prevention as a means of health promotion should become acquainted with these techniques to provide effective leadership in the field.

Intrahepatic cholestasis associated with parenteral nutrition in premature infants.

Abstract: Sixty-two premature infants less than 2,000 gm birth weight received parenteral nutrition (PN) during periods of respiratory distress with feeding intolerance. Intrahepatic cholestasis (direct bilirubin ≥ 1.5 mg/dl) associated with PN developed in 14 or 23% of these infants. The mean time on PN to onset of cholestasis was 42 days, and the cholestasis persisted as long as the infants continued to receive PN. All five infants who had serial follow-up laboratory studies showed an eventual return of direct bilirubin levels to normal. The direct bilirubin level appeared to be the best clinically available test to monitor for the onset and to follow the resolution of this complication. The very low birth weight infants

Periodic breathing in infants with near-miss sudden infant death syndrome.

Abstract: Twelve-hour nocturnal home recordings of respiration and heart rates were obtained during sleep in 32 infants with near-miss sudden infant death syndrome (SIDS) and in 32 control infants, and the recordings were analyzed for periodic breathing. An episode of periodic breathing was defined as three or more apneic pauses of three or more seconds. The duration of respirations interrupting the pauses was 20 seconds or less. Analysis revealed a statistically significant difference (P less than .001) between the two groups, using criteria of percent of periodic breathing episodes, number of periodic breathing episodes/100 min of recorded sleep time, average duration of all episodes, and duration of the longest episode of periodic breathing. It is concluded that periodic breathing is present in excessive amounts during sleep in infants with near-miss sudden infant death syndrome.

The Development of Preschool Children of Heroin-Addicted Mothers: A Controlled Study

Abstract: Disturbances of growth and behavior in infants and toddlers of women addicted to heroin during pregnancy have been reported in uncontrolled studies. In this study, 3- to 6-year-old children of heroin-addicted mothers were compared to three other groups matched for age, race, sex, birth weight, and socioeconomic status. Heroin-exposed children weighed less and were shorter than those in the comparison groups; 14% had a head circumference below the third percentile. Heroin-exposed children were rated by parents as less well adjusted than control children and they differed significantly in perceptual measures and on subtests of the Illinois Test of Psycholinguistic Abilities and McCarthy Scales of Children's Abilities relating to the process of organization. These findings suggest that chronic intrauterine exposure to heroin may affect growth and behavior as well as perceptual and learning processes in preschool children.

Psychologic Adjustment of Siblings of Children With Chronic Illness

Abstract: Although numerous references are made to the stressful, deleterious effects of chronic or terminal illnesses and handicaps on the siblings of pediatric patients, very few studies have been conducted using comparison groups. The present study compared the adjustment of 3- to 13-year-old siblings of pediatric hematology (N = 62), cardiology (N = 57), and plastic surgery patients (N = 37) with healthy siblings (N = 46). The adjustment measure was an objective, paper-and-pencil measure of children's emotional and behavioral problems, the Louisville Behavior Checklist. On analyses of covariance, the patient groups were more likely to show symptoms of irritability and social withdrawal, and the differences between illness groups approached significance on measures of fear and inhibition. Among the younger children, ages 3 to 6, there were significant group differences, with the siblings of patients undergoing plastic surgery showing the highest level of general psychopathology. Among children ages 7 to 13, male siblings of patients with blood disorders were more likely to show signs of emotional disturbance than female siblings. No group differences were noted on measures of aggression or learning problems. Significant interactions between sex and age relationship to the child were noted on scales of social withdrawal, inhibition, immaturity, and irritability.

Neonatal Signs as Predictors of Cerebral Palsy

Abstract: Signs of neonatal neurologic dysfunction, recorded in approximately 40,000 infants, were evaluated prospectively for their ability to predict later motor handicap. Tenfold to 33-fold increases in risk of cerebral palsy (CP) were observed in surviving children with any one of the following characteristics: birth weight less than 2,000 gm, head circumference more than 3 SD above or below the mean, five minute Apgar score of 3 or less, diminished activity or diminished cry lasting for more than one day, thermal instability, need for gavage feeding, hypotonia or hypertonia, single or multiple apneic episodes, or hematocrit less than 40%. Of worse portent, with relative risks exceeding 50, were neonatal seizures or Apgar scores of 3 or less at ten minutes or later. These characteristics were also markers of considerable risk of early death. For 0.5% of surviving infants, an overall impression of abnormality of brain function during the nursery period was recorded by the attending physician; there was a 99-fold increase in CP among these children.

Neurologic sequelae in the survivors of neonatal intraventricular hemorrhage.

Abstract: We report our experience with the neurologic sequelae (at a mean follow-up of 24 months) among the 15 surviving infants who have had neonatal intraventricular hemorrhage (IVH) documented by computerized tomographic (CT) brain scan. Neurologically six infants (40%) are normal, six infants (40%) mildly impaired, and three infants (20%) moderate to severely impaired. The neurologic outcome correlated to the degree of hemorrhage seen in the CT scans when IVH was classified into four grades. None of the other neonatal factors examined showed significant correlation with the outcome.

Effect of Supine and Prone Positions on Arterial Oxygen Tension in the Preterm Infant

Abstract: To determine the optimal position for the preterm infant, arterial oxygen tension (Pao2) was monitored in 16 preterm infants by the transcutaneous method with the infants in both supine and prone positions. When the infants were prone, Pao2 rose by a mean of 7.4 mm Hg (P less than .001), an increase of 15%. In those infants with residual cardiopulmonary disease a 25% increase was noted. The higher Pao2 in the prone position was accompanied by a significant decrease in the amount of time the chest wall moved asynchronously. This improved oxygenation in the prone position appears to be the result of enhanced ventilation/perfusion ratios and not merely secondary to an alteration in sleep state with positioning of the infant. These findings may have important implications in the management of preterm infants, requiring neonatal intensive care.

Recurrent pulmonary disease in children: a complication of gastroesophageal reflux.

Abstract: To evaluate the role of gastroesophageal reflux (GER) as a possible cause of recurrent pulmonary disease, 30 children, aged 1 to 18 years, were studied prospectively with esophageal function tests. These included esophagram (30 patients), esophageal manometry (29 patients), pH probe (Tuttle) test (29 patients), and esophagoscopy with esophageal biopsy (23 patients). The patients studied had either chronic asthma or two or more documented pneumonias within a one-year period. Nineteen (63%) had GER based on two or more positive tests. Eighteen had positive Tuttle tests; 13 had abnormal manometry studies; nine had esophagitis on biopsy; six had esophagitis on esophagoscopy; and five had reflux on esophagram. Of those with GER, 17 had a history of nocturnal cough and eight vomited during infancy. Children with recurrent pulmonary disease should have esophageal function testing to exclude GER as the cause.

Night-Waking in Infants During the First Year of Life

Abstract: Two groups of infants, 2 and 9 months of age, were monitored for one night by time-lapse videotape recording in the natural setting of their homes. Developmental changes in sleep-wake state proportions, ease of falling asleep, nighttime waking patterns, maternal interventions, and sleeping through the night were observed. A suggestion of differential parental handling of male infants was noted. Further research to clarify some of these issues is indicated.

An X-linked recessive cardiomyopathy with abnormal mitochondria.

Abstract: A transvascular endomyocardial biopsy from an infant with cardiomyopathy and chronic congestive heart failure showed abnormal mitochondria when examined by electron microscopy. At necropsy, similar abnormal mitochondria were seen in skeletal muscles, liver, and kidney. The patient's family pedigree revealed several male babies who had cardiac disease and died in infancy. Myocardium obtained at necropsy from three cousins contained mitochondria with abnormalities similar to those from the proband. An X-linked recessive cardiomyopathy seems likely in this family.

Liver Disease in Infants Receiving Total Parenteral Nutrition

Abstract: Progressive cholestasis and abnormal elevations of liver enzymes occurred in one third of 92, mostly preterm, newborn infants who received total parenteral nutrition (TPN) with protein hydrolysates, synthetic L-amino acids, and intravenous fat emulsion. The synthetic amino acid plus intravenous fat emulsion was not superior to the protein hydrolysate in preventing liver disease. The liver function returned to normal after discontinuation of TPN, which suggests a causal relationship. Hepatic microscopy was abnormal in 12 of 14 infants examined. The main features were progressive cholestasis and portal tract fibrosis and infiltration, which led to liver failure and death in two infants. In our experience, liver disease is the major metabolic complication of TPN in infants.

Clinical Characteristics of the Afebrile Pneumonia Associated With Chlamydia trachomatis Infection in Infants Less Than 6 Months of Age

Abstract: Respiratory tract colonization with Chlamydia trachomatis commonly occurs in natally acquired chlamydial infection and is sometimes associated with a chronic, afebrile pneumonia that has relatively distinctive clinical characteristics. To further define the frequency and clinical characteristics of lower respiratory tract disease associated with C trachomatis, we grouped 56 infants aged less than 6 months with afebrile pneumonia according to nasopharyngeal shedding of Chlamydia and viruses and compared their illnesses. Forty-one (73%) were positive for C trachomatis (23 had C trachomatis only, while 18 had C trachomatis plus a virus [cytomegalovirus, respiratory synctial virus, adenovirus, rhinovirus, or enterovirus]), and 15 were C trachomatis negative (nine had a virus only, and six had neither C trachomatis nor virus). The 41 infants with C trachomatis alone or C trachomatis plus a virus were similar clinically and differed significantly from other infants in several ways: (1) onset of symptoms before 8 weeks of age; (2) gradually worsening symptoms; (3) presentation for care at 4 to 11 weeks of age; (4) presence of conjunctivitis and ear abnormalities; (5) chest roentgenograms showing bilateral, symmetrical, interstitial infiltrates and hyperexpansion; (6) peripheral blood eosinophils greater than or equal to 300/cu mm; and (7) elevated values for serum immunoglobulins M, G, and A. Pediatrics 63:192--197, 1979, Chlamydia trachomatis, pneumonia, afebrile pneumonia, interstitial pneumonia.

Mixed and obstructive sleep apnea and near miss for sudden infant death syndrome: 2. Comparison of near miss and normal control infants by age.

Abstract: Twenty-nine full-term near miss for sudden infant death syndrome (SIDS) and 30 normal control infants underwent 24-hour polygraphic monitoring. Several types of respiratory events during sleep (eg, central, mixed, and obstructive apnea, periodic breathing) were defined and tabulated. Analysis of these respiratory variables and comparison of groups of near miss and control infants indicated that between 3 weeks and 4½ months of age only one variable was consistently different at a statistically significant level: the number of mixed and obstructive apnea 3 seconds during total sleep time. This study also showed an increase in mixed and obstructive respiratory events during sleep at 6 weeks of age in control as well as in near miss infants.

An Outbreak of Vitamin D Deficiency Rickets in a Susceptible Population

Abstract: Nutritional, racial, cultural, and environmental factors have combined to produce a resurgence of vitamin D deficiency rickets in urban Philadelphia. Between January 1974 and June 1978, 24 cases were diagnosed at the Children's Hospital of Philadelphia. Patients' ages ranged from 4 to 58 months. Presenting complaints included seizures, swollen wrists, pathologic fractures, and developmental regression. Sixteen patients were below the third percentile for length and weight. Laboratory results indicated vitamin D deficiency in nursing mothers as well as in infants. All infants had been breast-fed and all were black. Ingestion of vitamin D was limited by exclusion of meat and/or dairy products in 21, and no infants had consistently taken supplemental vitamins. Nineteen were members of Muslim or Seventh Day Adventist faiths. Endogenous synthesis of vitamin D was limited by dark skin, by dressing in long garments with hoods and veils, and by air pollution in a densely populated northern city. The return to a more "natural" diet, free of food additives, has been accompanied by the return of a classic disease of industrial society. Effective management required patience and respect for religious convictions. With treatment, there was correction of chemical and skeletal abnormalities, but few patients showed catch-up growth.

Risk of Respiratory Distress Syndrome After Prenatal Dexamethasone Treatment

Abstract: A prospective double-blind randomized clinical trial was carried out to determine whether glucocorticoid treatment reduces the risk of respiratory distress syndrome (RDS) in prematurely born infants. There were 127 infants born to 122 mothers who received either steroid (dexamethasone phosphate) or placebo. No differences between groups occurred in risk factors for RDS (eg, prepartum asphyxia, male sex, cesarean section). When those who received a full course of dexamethasone therapy were compared with those who received placebo, a significant reduction was found in risk, severity, and deaths due to RDS. An increased incidence of infection in mothers treated with steroid was evident, particularly after premature rupture of membranes. We conclude that steroids are effective in reducing risk of RDS, but safer and more efficacious approaches for the prevention of RDS should be sought.

Thymic Deficiency in Down's Syndrome

Abstract: Children with Down's syndrome (DS) often have small and abnormal thymuses, with lymphocyte depletion, diminution of the cortex, and loss of corticomedullary demarcation--a picture resembling thymic involution. Besides this, they have markedly enlarged Hassall's corpuscles, some surrounded by a sheath of lymphocytes. Patients with DS are known to have increased numbers of respiratory infections; they also have a higher incidence of lymphatic leukemia than do individuals who do not have DS. Studies of cell-mediated (thymic-dependent) immunity demonstrate that children with DS have both diminished numbers of T cells as well as functional deficiency of these cells.

Nonimmune Hydrops Fetalis: Report of 22 Cases Including Three Siblings

Abstract: Twenty-two cases of nonimmune hydrops fetalis (NIHF) seen over a three-year period are described. Eight cases were associated with major congenital anomalies, seven cases with minor anomalies or other disease entities, and seven idiopathic cases. The overall mortality rate was 50%, greatest in those cases complicated by major anomalies. The clinical problems commonly encountered in management of these patients are reviewed, and include prenatal detection, perinatal asphyxia, disseminated intravascular coagulopathy, fluid and electrolyte imbalance, and respiratory difficulty. A review of the literature for those entities found in association with NIHF is also included. The case studies of three consecutive siblings with NIHF born to the same parents are briefly analyzed.

The recent trend in breast-feeding.

Abstract: This study presents results of surveys conducted on a continuous basis over a period of years to determine the trend in the incidence of breast-feeding. Questionnaires were mailed to large samples of mothers, representative of the national distribution of births, asking them what type of milk they fed their infants over a period of time. Demographic characteristics of mothers who breast-fed were also obtained. From 1955 to 1971, there was a progressive decline in breast-feeding, followed by a resurgence in its incidence through 1978. Not only are more mothers breast-feeding, more are continuing to do so for a longer period of time throughout the months of their infants' most rapid growth and high nutritional requirements. It is also apparent that the increased incidence of breast-feeding has not been limited to higher income, better educated mothers. From 1971 to 1978, the incidence at two months postpartum more than doubled among mothers in lower-income families. The incidence of breast-feeding almost tripled among mothers whose education did not extend beyond elementary or high school and among those attending public clinics.

Hypertension screening in schools: results of the Dallas study.

Abstract: The purpose of this study was to determine the prevalence of persistent blood pressure elevations in an eighth-grade population composed of three ethnic groups, and to determine the feasibility of using school health facilities for hypertension screening. Blood pressure was recorded in 10,641 subjects (90% of the total eighth-grade population) in the Dallas Independent School District. Blacks made up 46% of the population; non-Latin whites, 40.1%; and Latin-Americans, 13.9%. On the first blood pressure screening, 8.9% had systolic or diastolic pressures or both at or above the 95th percentile. Of those whose blood pressures were elevated on the first examination, 98.3% were reexamined. After the third examination, 1.2% continued to have systolic hypertension, and 0.37% diastolic hypertension. No student had diastolic pressure above 90 mm Hg on all three examinations. The prevalence of persistent hypertension was similar for the three ethnic groups. Analysis of variation in blood pressure measurements revealed that the school nurses introduced a relatively small increase in variability. These data indicate that although school screening initially identifies large numbers of students as having inconstant pressure elevations, subsequent follow-up examinations show that less than 2% have persistent hypertension.

The Antenatal Use of Betamethasone in the Prevention of Respiratory Distress Syndrome: A Controlled Double-Blind Study

Abstract: One hundred forty-six pregnant women were enrolled in a prospective double-blind study to assess the effectiveness and side-effects of antenatal administration of betamethasone in the prevention of respiratory distress syndrome (RDS) in potentially premature infants. On admission to the study, the women were given, at random, either 12 mg of betamethasone or placebo. The same dose was repeated 24 hours later and then weekly up to 34 weeks of gestation. Gestational age of the infants ranged from 25 to 34 weeks, and birth weights ranged between 730 and 2,650 gm. Statistically significant differences in favor of the infants in the betamethasone group were found in the incidence of RDS, 20.7% in the betamethasone group compared with 59.5% in the control group (P less than .005); in the severity of RDS (P less than .05); and in the death rate (P less than .05). A higher incidence of hypoglycemia was found among infants in the betamethasone group (P less than .05). Prolonged rupture of the membranes played no protective role against RDS, and the incidence of infection was similar in both groups.

Recommendations for Feeding Normal Infants

Abstract: Our current recommendations for infant feeding are based on relatively few facts and many opinions. In a number of areas of infant feeding, the crucial experiments have not yet been carried out and in some areas our experimental methods are too crude to permit design of appropriate studies. Changes in recommendations are to be anticipated as new evidence becomes available. Meanwhile, we make the following recommendations.

Prospective study of maternal and infantile infection with Chlamydia trachomatis.

Abstract: We examined the prevalence of chlamydial infection in a population of pregnant women and observed their infants to determine the risk of development of ocular or respiratory infection. We examined endocervical and serum specimens from 322 pregnant women for Chlamydia trachomatis and chlamydial antibody. The cultures were obtained at the first prenatal visit. Six (2%) of the women were infected with C trachomatis. Chlamydial antibody was present in the genital secretions of 47% and 73% of the serum samples. The six infants born to infected women, 61 infants born to women who were culture-negative, but local antibody-positive, and 28 control infants born to culture-negative, antibody-negative women were followed for up to six months. Four of six infants born to infected women developed chlamydial infection: two developed culture-positive conjunctivitis, one had asymptomatic nasopharyngeal infection, and one infant developed pneumonitis. Three of 61 infants born to mothers who were culture-negative and local antibody-positive developed conjunctivitis due to C trachomatis. None of the 28 control infants developed chlamydial infection. Most (79%) of the infants had chlamydial antibody in their serum at 2 to 4 weeks of age. The correlation between maternal and infant serum antibody titer was r=0.71 suggesting that antibody was placentally transferred.

Preparing Young Children for Hospitalization: A Comparison of Two Methods

Abstract: This study examined two methods of preparing children aged 3 to 7 years for hospitalization. One method was a preadmission home contact by a nurse. The second was a filmed modeling sequence shown on admission. The effectiveness of each condition in reducing anxiety in the children and mothers was examined separately and in combination. One group of children experienced neither preparatory method. All children were undergoing elective tonsillectomies. The children9s adjustment to the hospital was measured on three occasions via a self-report measure of anxiety, electromyographic measures of muscular tension, and ratings of behavioral upset. Posthospital adjustment was assessed with Vernon et al9s Post-Hospital Behavior Inventory. An assessment of maternal anxiety was obtained twice via a self-report measure of anxiety. Maternal satisfaction with care and information was also obtained. The results indicate that a preadmission visit contributes to the lessening of maternal anxiety during and after the child9s hospitalization. A preadmission visit was also associated with reduction in the incidence of negative posthospital behavior particularly with the 6- and 7-year-olds. Mothers who were preadmitted expressed significantly greater satisfaction with the care and information they and their children received. Viewing a peer modeling film was associated with a decrease in the children9s hospital-specific physiologic anxiety response at the preoperative measure. In addition, children who viewed a peer modeling film displayed a significantly lowered incidence of undesirable posthospital behavior.

Risk factors associated with failure to receive vaccinations.

Abstract: A major purpose of a state-wide survey to document the vaccination status of 1,003 2-year-old children was to identify factors associated with failure to receive the recommended vaccinations. With a basic series of immunization defined as three doses of diphtheria-tetanus-pertussis (DTP), three oral polio vaccine (OPV), one measles, and one rubella, 72.5% of the children had completed the series. When the completed series was redefined to include a fourth DTP and mumps vaccine the rate of completion dropped to 40.8%. However, 59.1% of the children who had not completed this optimal series could be brought up-to-date with a single visit to their provider of medical care. Demographic variables independently associated with completion of the basic series were increased paternal education (P less than .001), increased maternal education (P less than .02), smaller family size (P less than .01) and higher socioeconomic status, as determined by census tract or rural town of residence (P less than .02). Race was not found to be a factor associated with vaccination rates when socioeconomic status was controlled. Patients who received their vaccinations from private physicians had a better vaccination rate than those who attended health department clinics. This difference persisted even when socioeconomic status was controlled by residence (P less than .02). The simultaneous comparison of parental education and family size demonstrated that a child having one parent with less than 12 years education or having at least three siblings has a fourfold greater risk of failure to complete his immunization than children whose parents are both college graduates. By using paternal and maternal education level and family size as screening variables, children at high risk for failure to complete their immunizations could be identified prospectively and made the target of intervention programs to improve compliance.

Biochemical Alterations in Neonatal Hyperbilirubinemia and Bilirubin Encephalopathy: A Review

Abstract: This review article discusses some current questions concerning the measurement of bilirubin in the blood of newborn infants and the relationship of these blood parameters to the biochemical defects responsible for bilirubin encephalopathy. A discussion of numerous theories, which have been put forth to explain the specific biochemical mechanism by which bilirubin acts on brain metabolism, demonstrates that presently there is no un- equivocal explanation for the molecular events leading to bilirubin encephalopathy.