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PubMed2001

Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty.

OBJECTIVES: We compared pain perception and procedure time in abortions performed by residents and faculty using a manual vacuum aspirator and electric vacuum curettage devices. STUDY DESIGN: We conducted a randomized trial of 114 women undergoing first-trimester abortions. Patients assessed the level of pain with visual analog scales. RESULTS: The mean procedure times were 5.7 and 6.9 minutes, respectively, with electric vacuum curettage and manual vacuum aspirator. Faculty took less time than residents to perform both procedures. Patients reported a higher pain level with cervical dilatation before resident electric vacuum curettage procedures. Patients undergoing electric vacuum curettage thought that the procedure noise increased their pain. CONCLUSIONS: First-trimester abortion procedures can be performed more quickly by experienced surgeons. The procedure time for the manual vacuum aspirator is greater than that for the electric vacuum curettage. Patient pain perception with aspiration by these two techniques is not different. The level of pain after aspiration did not vary significantly in patients who had abortions performed by residents or faculty.

Abortion, Induced↗
PubMed2003

A comparison of anticipated pain before and pain rating after the procedure in patients who undergo cystourethroscopy.

OBJECTIVE: The purpose of this study was to compare anticipated pain before the procedure and actual pain rating after the procedure in female patients who undergo cystourethroscopy. STUDY DESIGN: Eighty-seven consecutive female patients completed a 10-cm visual analog pain scale before and after cystourethroscopy. A 24F urethroscope was used initially to inspect the urethra and was followed by a systematic survey of the bladder with a 17F cystoscope that was lubricated with 2% lidocaine gel. The visual analog pain scale scores were evaluated for significance with the use of the Student t test and the Pearson correlation coefficient. RESULTS: Visual analog pain scale analysis demonstrated a mean anticipated pain score of 3.75 cm before the procedure versus a mean pain rating score of 2.83 cm after the procedure (P <.05). Neither a history of previous cystoscopy (visual analog pain scale score, 3.03 vs 2.30 cm; P =.18) nor talking with someone about the procedure beforehand (visual analog pain scale score, 2.74 vs 2.89 cm; P =.76) influenced the lower pain rating after the procedure. There was no significant correlation between age, parity, body mass index, or presence of pelvic organ prolapse and anticipated or realized pain perception. CONCLUSION: Patients who undergo cystourethroscopy consistently anticipate higher degrees of discomfort than they actually perceive during the procedure.

Analgesics↗
PubMed2003

Effect of the silicone disclosing procedure on the shear bond strength of composite cements to ceramic restorations.

STATEMENT OF PROBLEM: There is no evidence-based information on how ceramic restorations with an adhesive bond between restoration material and composite cement may be influenced by a silicone disclosing agent. PURPOSE: The aim of this study was to determine the effects of the silicone disclosing procedure on the shear bond strength of composite cements in the luting of industrial sintered and laboratory sintered ceramic restorations. MATERIAL AND METHODS: Thirty standardized (15 x 10 x 9 mm) prefabricated ceramic specimens (Groups 1, 3, 5) and 30 standardized (15 x10 x 9 mm) conventionally sintered ceramic specimens (Groups 2, 4, 6) were roughened with sandpaper (800-grit). Each group contained 10 specimens. Groups 3 and 4 were conditioned with hydrofluoric acid and primed with silane solution after the use of a silicone disclosing procedure. Groups 1 and 2 served as the control groups, where no silicone disclosing procedure was performed. Groups 5 and 6 were insulated with glycerine before the silicone disclosing procedure. A glass tube (4.5 mm in diameter) was used to apply a cylinder of dual-polymerized composite cement to the conditioned surfaces. All specimens were submitted to 5000 thermocycles (5 degrees to 55 degrees C) to simulate the in vivo situation. The specimens were subjected to a shear-pull test at a constant crosshead speed of 5 mm/min with a universal testing machine. The comparative shear bond strengths were analyzed by use of Duncan's test (alpha=0.05). RESULTS: Shear bond strength values for Groups 1 (9.86 +/- 4.97 MPa) and 2 (9.56 +/- 4.47 Mpa) were obtained with no significant differences. Lower but significantly undifferent values were obtained for Groups 3 (7.49 +/- 4.67 MPa) and 4 (7.62 +/- 3.49 MPa) after the use of a silicone disclosing procedure. In Groups 5 (8.21 +/- 4.75 MPa) and 6 (8.22 +/- 3.59 MPa), including insulation with glycerine before the silicone disclosing procedure, no significant differences were obtained. CONCLUSION: Within the limitations of this study, the use of silicone disclosing procedures before conditioning the ceramic surface did not lead to a significant reduction of the shear bond strength between ceramic and composite cement. The ceramic materials used (industrial-sintered versus laboratory-sintered ceramic) had no significant influence on adhesion.

Acid Etching, Dental↗
PubMed2000

The implementation of the sentinel node biopsy as a routine procedure for patients with breast cancer.

BACKGROUND: The sentinel node procedure for breast cancer allows for accurate staging of the axilla while the axillary node dissection can be avoided in patients with no sentinel node metastasis. This study describes those patients in whom an axillary dissection is performed, depending on the outcome of the sentinel node procedure, with particular emphasis on the use of strict criteria for the procedure and its practical limitations. METHODS: Preoperative lymphoscintigraphy was performed in 115 consecutive patients. The sentinel nodes were located with the use of a gamma probe and blue dye. Axillary dissection was performed at the same time when the sentinel node procedure was positive by frozen section or not successful by the criteria used. RESULTS: The sentinel node procedure was successful in 106 patients, with the sentinel node being both radioactive and blue in 94% of these patients. The frozen section was positive in 21 of 37 patients with sentinel node metastases. Axillary dissection could be avoided in 69 patients. CONCLUSIONS: The triple technique (with the use of lymphoscintigraphy, the gamma probe, and the blue dye) gives a high success rate of the sentinel node procedure, even when strict criteria for a successful sentinel node procedure are used. Palpation of the open axilla for metastatic nonsentinel nodes is advocated.

Biopsy↗
PubMed1988

Postoperative thrombotic complications in patients with lupus anticoagulant: increased risk after vascular procedures.

This study retrospectively analyzes the nature of postoperative thrombotic complications in patients with the lupus anticoagulant. Tests in 84 patients were positive for the presence of antiphospholipid antibodies by an abnormal rabbit brain neutralization procedure, positive for the presence of anticardiolipin antibodies, or both. Twenty-three of these 84 patients had 51 separate surgical procedures, 18 vascular and 33 nonvascular. Four patients had 11 postoperative thrombotic complications (during same hospitalization), involving peripheral arteries in nine cases, vein in one, and coronary artery in one. Nine of the 18 vascular procedures were complicated by thrombosis, whereas only two of the 33 nonvascular procedures were complicated by thrombosis (p less than 0.025). Three of the seven patients who had a vascular procedure suffered multiple postoperative thrombotic complications, and ultimately all three required an amputation. At the time of these thrombotic complications, all three patients had not received any perioperative medications (anticoagulants, antiplatelet agents, and/or corticosteroids). Further analysis revealed a correlation between preoperative medications and the lack of postoperative complications, suggesting that perioperative corticosteroids, anticoagulants, and/or antiplatelet agents may protect against postoperative thrombosis. We conclude that patients with the lupus anticoagulant having surgical procedures carry a significant risk of postoperative thrombotic complications, particularly after vascular procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2002

Secondary procedures after endovascular aortic aneurysm repair.

PURPOSE: The purpose of this study was to evaluate the incidence, distribution, and indications of secondary procedures after endovascular aortic aneurysm repair (EAR). METHODS: At a single institution, 179 patients underwent EAR with four different endografts (AneuRx, n = 117; Zenith, n = 49; Ancure, n = 12; and Talent, n = 1). The vascular section database was queried for patients who needed secondary procedures after the original EAR. The mean time from EAR to the termination of the study was 27.0 +/- 16.7 months. Type I or III endoleaks were treated aggressively. Type II endoleaks were treated only in the presence of aneurysm expansion. RESULTS: Thirty-five (35/179; 19.6%) secondary procedures were performed in 32 patients. Indications for secondary procedures included 14 limb occlusions or stenoses (40.0%), 13 endoleaks (37.1%), six endograft migrations (17.1%), one delayed aneurysm rupture (2.8%), and one device malfunction (2.8%). Seven of the 10 early (<90 days) limb failures (70%) occurred within the first 60 patients. At that time, a protocol with aggressive external iliac artery evaluation was adopted. In the next 125 patients, the rate of early limb occlusion or stenosis was 2.4% (P =.025, with Fisher exact test). Distribution of secondary procedures included 23 endoluminal interventions (65.7%; angioplasty +/- stent placement, thrombolysis, endocuff placement, embolization), eight traditional peripheral procedures (22.9%; femoral-femoral bypass, thrombectomy), two laparoscopic interventions (5.7%; inferior mesenteric artery ligation), and two laparotomies (5.7%; delayed conversions). Interventions for limb occlusion or stenosis occurred earliest (3.5 +/- 5.4 months; P <.05, with analysis of variance), followed by treatment of endoleaks (14.3 +/- 12.9 months) and migration (27.5 +/- 10.4 months). The one delayed rupture occurred at 15.3 months. CONCLUSION: Secondary procedures after EAR are common. Reinterventions can be grouped temporally on the basis of indication. Treatment for limb ischemia is predominately early (>/=3 months), whereas treatment for endoleaks occurs at approximately 1 year and interventions for migration predominate after 2 years.

Aged↗
PubMed1983

A participant modeling procedure to train parents of developmentally disabled infants.

Most of the procedures employed in parent training programs for handicapped children have been based on an operant conditioning model in general and contingency management procedures in particular. The purpose of the present study was to investigate the efficacy of a participant modeling procedure in training parents to work with their developmentally disabled infants. Fourteen such parents received training in which a therapist initially modeled the activities with the infant and then guided the parent as she or he mastered the procedures. Five developmentally disabled infants received a more traditional early intervention program in which the therapist provided all child training. The results indicated that those infants whose parents were trained by the participant modeling procedure evidenced significantly more developmental gains than those infants receiving traditional child training. The results suggest that cognitive behavioral procedures, such as participant modeling, are an alternative to strict operant procedures in training parents of handicapped children.

Behavior Therapy↗
PubMedDate not supplied

The Cenaps model of relapse prevention: basic principles and procedures.

Nine basic principles that underlie the Cenaps relapse prevention planning process are described. Each principle is complemented with a procedure or clinical technique that can be used to operationalize that principle with patients: the first principle of self-regulation is operationalized with a procedure for physical, psychological, and social stabilization; the second principle of integration is operationalized by the technique of self-assessment; the third principle of understanding is operationalized by a relapse education procedure; the fourth principle of self-knowledge is operationalized with a procedure of relapse warning-sign identification; the fifth principle of coping skills is operationalized through a procedure of warning-sign management; the sixth principle of change is operationalized in a procedure for reviewing the recovery plan; the seventh principle of awareness is operationalized by a procedure of inventory training; the eighth principle of support is operationalized by the involvement of significant others; and the ninth principle is maintenance, which is operationalized by a comprehensive follow-up plan.

Humans↗
PubMed2004

Inter- and intraindividual variability in ketamine dosage in repetitive invasive procedures in children with malignancies.

Midazolam/ketamine sedation has been used successfully in children undergoing painful invasive procedures. The authors prospectively assessed inter- and intra-individual variability in ketamine dosage for sedation in repetitive invasive procedures in children with malignancies. A total of 92 invasive procedures (58 lumbar punctures, 34 bone marrow biopsies; range: 2-9 procedures/patient) were performed on 25 children (median age: 12 years). Intravenous sedation consisted of 0.1 mg midazolam/kg and 0.5-1.0 mg ketamine/kg. Incremental dosages of ketamine (0.33 mg/kg) were given if necessary to achieve or maintain deep sedation. Primary outcome measure was the inter- and intraindividual ketamine dosage required to achieve adequate sedation; secondary outcome measures were the number of procedures with adequate sedation (Ramsay score of > 4), the number of adverse side effects, and the need for therapeutic interventions. All 92 invasive procedures were completed with satisfactory sedation levels in 88 procedures (95.7%). There was a great inter- and intraindividual variability in ketamine dosage required to achieve or maintain adequate sedation. In 12% of procedures side effects were seen, which required no or only minor interventions. Due to great inter- and intraindividual differences, ketamine dosage should be titrated toward the desired level of sedation. Thus, ketamine can be adjusted to the individual's need while achieving adequate sedation.

Adolescent↗
PubMed2000

Assessment of the application of an ecotoxicological procedure to screen illicit toxic discharges in domestic septic tank sludge.

An innovative screening procedure has been developed to detect illicit toxic discharges in domestic septic tank sludge hauled to the Montreal Urban Community waste-water treatment plant. This new means of control is based on an integrative approach, using bioassays and chemical analyses. Conservative criteria are applied to detect abnormal toxicity with great reliability while avoiding false positive results. The complementary data obtained from toxicity tests and chemical analyses support the use of this efficient and easy-to-apply procedure. This study assesses the control procedure in which 231 samples were analyzed over a 30-month period. Data clearly demonstrate the deterrent power of an efficient control procedure combined with a public awareness campaign among the carriers. In the first 15 months of application, between January 1996 and March 1997, approximately 30% of the 123 samples analyzed showed abnormal toxicity. Between April 1997 and June 1998, that is, after a public hearing presentation of this procedure, this proportion dropped significantly to approximately 9% based on 108 analyzed samples. The results of a 30-month application of this new control procedure show the superior efficiency of the ecotoxicological approach compared with the previously used chemical control procedure. To be able to apply it effectively and, if necessary, to apply the appropriate coercive measures, ecotoxicological criteria should be included in regulatory guidelines.

Environmental Monitoring↗
PubMed2003

Development and evaluation of a miniaturized procedure for determining the bonding index: a novel prototype for solid dosage formulation development.

The purpose of this study was a comparative evaluation of miniaturized vs. University of Minnesota's (i.e., U of Minn. = Hiestand's) procedures for determining the tensile strength, indentation hardness, and bonding index (BI), one out of three Indices of Tableting Performance (ITP). Tableting properties of six direct compression placebo formulations were determined by using a compaction simulator and a Texture Analyser TA-XT2I, or by following the U of Minn. method, which included a specially designed triaxial compression device, a computer-controlled mechanical stress-strain analyzer, and a dynamic pendulum impact apparatus. Miniaturization of the procedures to determine the ITP, as well as the ability to differentiate between materials while operating compaction cycles more comparable to standard tablet production conditions, enabled proper evaluation of each material's inherent tableting properties. Indentation diameter calculated via an empirical equation appeared to correlate well with, and provided acceptable precision of accuracy to, the determination of indentation diameter via standard optical microscopy methods. The miniaturized and U of Minn. procedure exhibited a significant degree of correlation when comparing the BI. However, the tensile strength and indentation hardness values were somewhat different due to the use of triaxial decompression for the U of Minn. procedure vs. standard compaction profiling for the miniaturized procedure. The present direct compression placebo formulation data gathered from the miniaturized procedures and compared with the U of Minn. method for determining the ITP suggest that both techniques yield similar conclusions. However, discrimination of out-of-die compaction properties determined via the miniaturized procedures, such as tensile strength and indentation hardness, appeared to associate more precisely with changes in strain rate, thus allowing better discrimination of particle-particle interactions and ductile-to-brittle characteristics as a function of compaction speed and pressure.

Chemistry, Pharmaceutical↗
PubMed2004

Physicians' perceptions of procedural pain and discomfort.

BACKGROUND: Previous studies have demonstrated that patients with end-stage dementia receive a high rate of painful and uncomfortable procedures. This study was undertaken to determine whether this finding might be related to physicians' misperceptions about the burden of common hospital experiences and procedures. METHODS: Physicians were administered a survey asking them to rank on a five-point scale the pain and discomfort they perceived to be associated with 16 common hospital procedures. These ratings were compared to those previously obtained using the same instrument with cognitively intact patients who had actually undergone these procedures. RESULTS: One hundred twenty-three of 123 resident physicians (100%) and 40 of 50 attending physicians (80%) to whom the questionnaire was administered responded. Overall, physicians more often rated both pain and discomfort associated with these procedures/experiences higher than did patients, and residents typically rated pain and discomfort higher than attending physicians. Resident physicians rated 7 procedures/experiences as significantly more painful and 13 as more uncomfortable than did patients. Attending physicians rated 5 procedures/experiences as significantly more painful and 8 more uncomfortable than did patients. Having a nasogastric tube inserted was the only procedure rated more painful by patients as compared to resident or attending physicians. CONCLUSIONS: Physicians have an accurate perception of pain and discomfort associated with common hospital procedures. Further investigation should scrutinize in greater detail the ubiquity and depth of physician knowledge about the issue of procedural burden and should focus on methods and interventions that would allow physicians to consciously weigh the benefits and burdens of routine interventions in the care of persons with serious and life-threatening illness.

Adult↗
PubMed1978

Evaluation of the counterimmunoelectrophoretic (CIE) procedure in a clinical laboratory setting.

The counterimmunoelectrophoretic (CIE) procedure was evaluated under clinical laboratory conditions to determine its validity and comparability with culture methods. The procedure was further evaluated to determine applicability to a variety of clinical samples. An inexpensive set-up was developed to utilize the CIE procedure at bench level. Results indicated the procedure to be sensitive in detecting Haemophilus influenzae, type b, and Neisseria meningitidis (meningococcus), group B. The procedure was more sensitive for detection of H. influenzae, type b, than for meningococcus, group B. The authors have confirmed the usefulness of the CIE procedure in the detection of group B streptococci, pneumococci and teichoic acid antibody to Staphylococcus aureus. Detection of Escherichia coli K 1 antigen was also accomplished by CIE. In the authors' laboratory the CIE procedure was superior to culture methods when used for the detection of H. influenzae, type b, and meningococcus group B.

Animals↗
PubMed2003

Identifying differentially expressed genes using false discovery rate controlling procedures.

MOTIVATION: DNA microarrays have recently been used for the purpose of monitoring expression levels of thousands of genes simultaneously and identifying those genes that are differentially expressed. The probability that a false identification (type I error) is committed can increase sharply when the number of tested genes gets large. Correlation between the test statistics attributed to gene co-regulation and dependency in the measurement errors of the gene expression levels further complicates the problem. In this paper we address this very large multiplicity problem by adopting the false discovery rate (FDR) controlling approach. In order to address the dependency problem, we present three resampling-based FDR controlling procedures, that account for the test statistics distribution, and compare their performance to that of the naïve application of the linear step-up procedure in Benjamini and Hochberg (1995). The procedures are studied using simulated microarray data, and their performance is examined relative to their ease of implementation. RESULTS: Comparative simulation analysis shows that all four FDR controlling procedures control the FDR at the desired level, and retain substantially more power then the family-wise error rate controlling procedures. In terms of power, using resampling of the marginal distribution of each test statistics substantially improves the performance over the naïve one. The highest power is achieved, at the expense of a more sophisticated algorithm, by the resampling-based procedures that resample the joint distribution of the test statistics and estimate the level of FDR control. AVAILABILITY: An R program that adjusts p-values using FDR controlling procedures is freely available over the Internet at www.math.tau.ac.il/~ybenja.

Algorithms↗
PubMed1997

Endometrial assessment procedures: an audit of current practice in Scotland.

The objective was to determine, in relation to endometrial assessment procedures, the extent to which the current practice of gynaecologists in Scotland (as assessed both by questionnaire survey of clinicians and review of hospital records) accords with recommendations in recent evidence-based guidelines. All 132 consultant gynaecologists in Scotland were surveyed and 123 (93%) responded. In addition, the case records of 1199 consecutive women undergoing endometrial assessment procedures in 12 representative hospitals were reviewed. Over two thirds of consultants agreed that endometrial assessment procedures are seldom indicated in women aged under 40 years and over 80% agreed that when such procedures are indicated, outpatient endometrial biopsy represents the method of choice. However, the review of case records showed that 23% of the women who underwent endometrial assessment were aged under 40 years and only 44% of the procedures undertaken were out-patient endometrial biopsies. We conclude that some Scottish women may be undergoing endometrial assessment procedures unnecessarily and that, in some centres, traditional dilatation and curettage is being replaced by hysteroscopy under general anaesthetic in theatre although there is no evidence that this procedure provides more clinically useful information than out-patient endometrial biopsy.

Adult↗
PubMed2001

Embryo development and chromosomal anomalies after ICSI: effect of the injection procedure.

Intracytoplasmic sperm injection (ICSI) is a delicate procedure requiring considerable skills of the person performing it. Theoretically, the injection procedure could damage cytoplasmic structures in the oocyte, resulting in sublethal cellular injury and/or numerical chromosomal abnormalities that could lead to impaired embryonic development. In the present study, features of the injection procedure were evaluated in a total of 2924 oocytes from 305 cycles. Development to the blastocyst stage was found to be compromised in a group of surplus embryos originating from oocytes in which >6 pl of cytoplasm was aspirated into the injection pipette during the ICSI procedure. Characteristics of the injection procedure as well as blastocyst development of surplus embryos was shown to be significantly different between the four technicians performing the ICSI. Neither the volume of cytoplasm aspirated during the injection procedure, nor the position of the polar body (6 o'clock or 12 o'clock) influenced the mean incidence of disomic cells per blastocyst as revealed by fluorescence in-situ hybridization using probes specific for chromosomes X, Y and 18. In conclusion, certain technical aspects of the injection procedure can affect subsequent embryonic development to the blastocyst stage, but do not seem to influence the rate of chromosomal abnormalities that occur in human pre-implantation embryos.

Blastocyst↗
PubMed1995

Chromatographic procedures for the determination of felbamate in serum.

A gas-liquid chromatographic procedure and a high-performance liquid chromatographic (HPLC) procedure for the quantitative determination of the anticonvulsant drug felbamate in serum are presented. Both methods employ methyl felbamate as the internal standard. The efficiencies of felbamate extraction by both C18 solid-phase extraction (SPE) followed by HPLC and liquid-liquid extraction followed by gas chromatography (GC) were evaluated. The mean absolute recovery of felbamate over a serum concentration range of 10-100 mg/L for SPE and liquid-liquid extraction were 89.4 and 84.4%, respectively. Calibration curves for the GC and HPLC procedures were linear from 5 to 200 mg/L felbamate. The overall within-run precision of liquid-liquid extraction followed by GC analysis yielded coefficients of variation Os) of 7.3% at 16 mg/L (n = 10) and 5.8% at 100 mg/L (n = 10). The overall between-run precision for this method calculated by three determinations on a single day for three successive weeks yielded CVs of 7.8% at 16 mg/L (n = 45) and 6.3% at 100 mg/L (n = IO). The overall within-run precision of SPE followed by HPLC analysis yielded a CV of 2.9 % at 50 mg/L (n = 10), and the overall between-run precision for this method calculated by three determinations on a single day for three successive weeks yielded CVs of 3.3% at 25 mg/L (n = 40) and 3.5% at 50 mg/L (n = 37). The SPE-HPLC procedure was found to yield less variable results than the liquid-liquid-GC procedure. Limits of quantitation and detection of both methods were set at 5 mg/L felbamate. Popular anticonvulsant and acid or neutral extractable drugs did not interfere with either the GC or HPLC methods. The results of an interlaboratory, intermethod comparison study performed on patient serum specimens analyzed in one laboratory by the SPE-HPLC procedure and in another laboratory by the liquid-liquid extraction-GC procedure correlated well (r2 = 0.967; n = 41). Both methods provide clinically useful and comparable results.

Administration, Oral↗
PubMed1998

Ethnic disparities in patient recall of physician recommendations of diagnostic and treatment procedures for coronary disease.

Despite the proven benefits of many cardiac procedures, some are used less frequently for African Americans than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham-Black Health Seeking for Coronary Heart Disease Project (1989-1990) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by multivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality.

Black or African American↗