|1.||Cutaneous Mastocytosis in Childhood: An Update from the Literature|
Öner Özdemir, Sureyya Savasan
doi: 10.14744/cpr.2023.54254 Pages 311 - 320
Mastocytosis is an uncommon disease characterized by clonal infiltration of mast cell (MC) in different tissues. Cutaneous mastocytosis (CM) is the most frequent type observed during childhood and is characterized by MC accumulation limited to the skin. In adults, systemic mastocytosis is the most common type, characterized by MC proliferation in various organs such as the bone marrow, lymph nodes, liver, and spleen. Genetic alterations, primarily the KIT D816V mutation, play a pivotal role in the pathogenesis of CM, stimulating MC growth and mobilization, leading to tissue and organ infiltration. CM can be classified into three types: solitary mastocytoma, maculopapular CM, and diffuse CM. While cutaneous lesions in most CM cases naturally regress around puberty, the disorder is not always self-limiting. Even though systemic mastocytosis cases are rare, follow-up is necessary for all children diagnosed with CM. Patients with mastocytosis often experience symptoms associated with MC mediators, with itching being the most common, typically triggered by stimuli applied to the lesions. The treatment approach for CM primarily focuses on avoiding triggers. The use of H1 and H2 antihistamines during symptom flare-ups and the availability of adrena-line autoinjectors for severe systemic reactions constitute the mainstay of CM management.
|2.||Evaluation of Transient or Permanent Congenital Hypothyroidism|
Selim Kurtoğlu, Osman Baştuğ, Ahmet Ozdemir
doi: 10.14744/cpr.2023.32042 Pages 321 - 326
Congenital hypothyroidism is a common endocrine disease in children. In Türkiye, neona-tal screening has been performed since 2007 with a cut-off Thyroid Stimulating Hormone (TSH) level of 5.5 mU/L. The initial treatment period is within the first 14 days. Reevaluation of thyroid function and thyroxine doses is necessary to determine whether the condition is permanent or transient congenital hypothyroidism. Numerous studies and proposals have been published on this topic. This article reviews the publications related to this subject.
|3.||Comparison of the Effects of Superficial and Deep Heat Agents on Hamstring Muscle Flexibility in Healthy Individuals|
Ayşe Nur Oymak Soysal, Şule Şimşek, Atiye Kaş Özdemir, Merve Bergin Korkmaz, Ümmühan Baş Aslan
doi: 10.14744/cpr.2023.21939 Pages 327 - 334
Objective: Stretching and warm-up exercises are commonly used to increase hamstring flexibility in sports rehabilitation. The aim of the study was to compare immediate and short-term effects of hot packs, infrared, and ultrasound on hamstring flexibility when ap-plied before stretching exercises in healthy individuals.
Materials and Methods: A total of 60 participants were randomly divided into four groups. All participants performed hamstring stretching exercise three times a week for six weeks. Each stretching session consisted of three repetitions of 15 seconds duration. Before the stretching exercises, hot packs were applied to Group I, infrared to Group II, and ultrasound to Group III. Group IV (control group) performed self-stretching exercises alone. Hamstring flexibility was as-sessed with the Active Knee Extension (AKE) test in all sessions before and after the interventions.
Results: AKE significantly increased after all sessions (p<0.05) and in the short term (p<0.05) in all groups. The short-term effect did not differ between the groups (p>0.05). Among the different agents, infrared has the highest effect size.
Conclusion: The results of the study showed that both superficial and deep heat agents had an increasing effect on hamstring flexibility. However, the application of superficial or deep heat agents before stretching exercises did not provide an additional increase in hamstring flexibility.
|4.||Evaluation of Patients with Ichthyosis Followed in a Neonatal Intensive Care Unit: A Single Center Experience|
Mehmet Fatih Deveci, Kübra Ateş, Meral Alagöz, Ibrahim Tekedereli, ismail Kürşad Gökce, Mehmet Aslan, Ramazan Ozdemir
doi: 10.14744/cpr.2023.87597 Pages 335 - 339
Objective: Ichthyosis is a keratinization disorder that is characterized by a defective skin barrier and inability to retain water in the skin. Ichthyosis is extremely rare and mostly hereditary, and its manifestations typically involve dryness, scaling, and hyperkeratosis. More-over, different clinical findings may be observed depending on the concomitant anomalies. Patients with ichthyosis should be protected from infection and hypernatremic dehydration during the neonatal period. After diagnosis, patients with ichthyosis should be screened for concomitant genetic disorders and their families should be referred to genetic counseling.
Materials and Methods: In this study, ichthyosis cases observed in our neonatal intensive care unit were retrospectively evaluated. We analyzed the genetic analyses and demographic and clinical data of patients hospitalized in our unit over the past 9 years.
Results: Three of the 24 patients evaluated expired during the neonatal period. Genetic analysis was performed on 10 patients, with 8 exhibiting a pathogenic variant. Four of these cases were diagnosed with syndromic ichthyosis, whereas four were nonsyndromic.
Conclusion: Patients with ichthyosis need to be diagnosed early and subsequently screened for accompanying anomalies. In managing this disorder, genetic analysis and counseling are as important as proper skin care, hydration, and infection prevention and should not be overlooked.
|5.||Significance of Screening Frailty, Sarcopenia, and Malnutrition in Hospitalized Patients with COVID-19: A One-Year Follow-Up Study|
Yelda Ozturk, Arzu Okyar Baş, Merve Güner, Meltem Koca, Serdar Ceylan, Murat Özdede, Oğuz Abdullah Uyaroğlu, Cafer Balcı, Burcu Balam Dogu Yavuz, Mustafa Cankurtaran, Meltem Halil
doi: 10.14744/cpr.2023.65375 Pages 340 - 346
Objective: This study aimed to explore the effect of sarcopenia, malnutrition, and frailty screening tools on one-year mortality in hospitalized adult patients with coronavirus dis-ease 2019 (COVID-19).
Materials and Methods: Patients, 18 years of age, who were admitted to the COVID-19 clinic were enrolled in this prospective study. The clinical frailty scale (CFS) and SARC-F questionnaire were used for frailty and sarcopenia screening. Nutrition Risk Screening (NRS-2002) and Mini Nutritional Assessment–Short Form (MNA-SF) were performed to screen for malnutrition. The survival of all participants was investigated by using the Turkish national death registry. Multivariable logistic regression analyses were performed.
Results: A total of 72 subjects were enrolled in this study. The rate of patients with sarcope-nia risk, malnutrition risk (via MNA-SF), malnutrition risk (via NRS-2002), and living with frail-ty were 75%, 93.8%, 81.3%, and 50.0% in the deceased group, respectively. Conversely, the rates of patients with sarcopenia risk, malnutrition risk (via MNA-SF), malnutrition risk (via NRS-2002), and living with frailty were 23.2%, 71.4%, 60.7%, and 16.1% in the alive group, respectively. SARC-F score (OR 1.331, p=0.006), MNA-SF score (OR 1.695, p=0.002), NRS-2002 score (OR 1.580, p=0.024), and CFS (OR 1.639, p=0.009) score were independently associat-ed with one-year mortality after adjusting for sex and age.
Conclusion: MNA-SF, SARC-F, and CFS may be used for mortality risk estimation after dis-charge from the hospital who were admitted for acute disease.
|6.||Familial Nutrition and Physical Activity Habits in Children and Adolescents with Type 1 Diabetes Mellitus|
Gurkan Tarcin, Didem Güneş Kaya, Hasan Karakaş, Olcay Evliyaoğlu
doi: 10.14744/cpr.2023.24633 Pages 347 - 352
Objective: The objective of this study was to examine the nutritional habits and exercise patterns in children with type 1 diabetes (T1DM) at the familial level and investigate their relationship with glycemic control.
Materials and Methods: This cross-sectional study included 6-18-year-old patients with T1DM and non-diabetic children from the dietitian outpatient clinic. The Family Nutrition and Physical Activity screening tool (FNPA) was administered to all parents to determine their nutrition and exercise habits. The participants were divided into three subgroups based on their body mass index percentile (underweight, normal weight, overweight/obese), and children with T1DM were further divided into two subgroups based on their Hemoglobin A1c (HbA1c) value as good and poor glycemic control. FNPA scores were com-pared between the groups/subgroups using t-test/one-way Analysis of Variance (ANOVA). Additionally, a multiple linear regression model was developed to identify the determinants of the FNPA score.
Results: A total of 240 children (129 with T1DM) were included in the study. Children with T1DM had significantly higher FNPA scores than non-diabetic children (p=0.013). When the analysis was restricted to subgroups within the same weight status, this difference was sig-nificant only between the overweight/obese subgroups (p=0.032). The mean FNPA score of children with T1DM who had good glycemic control was significantly higher than those with poor glycemic control (p<0.001).
Conclusion: This study is the first to evaluate the FNPA scale in children with T1DM and demonstrates the relationship between family nutrition and physical activity habits with glycemic control. These results highlight the significance of promoting proper nutrition and physical activity at the family level to achieve treatment goals.
|7.||The Shetty Test’s Performance in Predicting Fractures in Radiography for Pediatric Patients|
Seval Komut, Burcu Doğan, Ali Kemal Erenler
doi: 10.14744/cpr.2023.68077 Pages 353 - 359
Objective: The objective of this study was to determine the diagnostic performance of the Shetty test (ST) in predicting fractures in pediatric ankle trauma and to prevent unnecessary radiation exposure in these cases.
Materials and Methods: The ST was administered to all the patients included in the study, and the cases were categorized as ST-positive and ST-negative. The sensitivity and specifici-ty of the test were determined based on radiographic findings.
Results: The distribution of trauma mechanisms of pediatric patients was as follows: sprain (65%, n=78), fall from height (20%, n=24), direct trauma (10%, n=12), and accidental hit (10%, n=12). Radiographically, 3 (2.5%) cases showed displaced fractures, 12 (10%) showed non-displaced fractures, 1 (0.8%) showed incomplete fractures, and 104 (86.7%) showed no fractures. The sen-sitivity of the Shetty Test was 75%, specificity was 59.6%, positive predictive value (PPV) was 22.2%, and negative predictive value (NPV) was 93.9% in predicting the need for radiography.
Conclusion: The sensitivity and specificity of the ST in predicting fractures in pediatric pa-tients with ankle trauma within the limits of radiographic indication were found to be lower than those for adults. However, due to limited information in the literature, further studies with larger cohorts are needed.
|8.||Investigation of the Combined Effects of Propylparaben and Methylparaben on Biochemical and Histological Parameters in Male Rats|
Eda Nur İnkaya, Nurhayat Barlas
doi: 10.14744/cpr.2023.18291 Pages 360 - 369
Objective: This research aimed to study the effects of co-exposure to methylparaben and propylparaben (MeP+PrP) on renal and hepatic parameters in male rats.
Materials and Methods: MeP and PrP were mixed at a ratio of 1: 1. MeP+PrP doses were ad-ministered to 42-day-old male rats on a daily basis for 30 days. Each of the five groups con-sisted of six male rats, including three MeP+PrP dose groups with daily combination doses of 10 mg/kg bw, 100 mg/kg bw, and 500 mg/kg bw. The other two groups included the pos-itive control group exposed to a daily dose of 50 mg/kg bw Bisphenol-A (BPA), and the corn oil control group used as a vehicle. At the end of the procedure period, liver and kidney tis-sues were obtained from histopathological analysis, morphometric analysis was performed on kidney tissue, and hematological and biochemical parameters were examined.
Results: Histopathological changes, such as tubular degeneration, edema, fibrous tissue formation, and congestion, were observed in the kidney tissue, while degeneration, edema, and congestion were observed in the liver tissue. Statistical analysis comparing the administered groups to the corn oil control group revealed significant variations in biochemistry and hematological markers.
Conclusion: These findings demonstrate that co-exposure to MeP and PrP alters bio-chemical and hematological parameters and negatively affects the liver and kidney tis-sues of male rats.
|9.||Distribution of Microorganisms Isolated from Blood Cultures and Evaluation of Antibiotic Resistance Rates in Patients Diagnosed with Cancer|
Ayşe Hümeyra Taşkın Kafa, Fatih Çubuk, Mürşit Hasbek, Rukiye Aslan, Zeynep Çubuk
doi: 10.14744/cpr.2023.99608 Pages 370 - 376
Objective: Cancer patients are a high-risk population for infections caused by var-ious bacterial agents. Specifically, bloodstream infections (BSIs) can lead to severe complications and even mortality in cancer patients. This study aimed to identify the predominant bacterial species causing bacteremia and assess the prevalence of anti-biotic resistance among cancer patients receiving treatment at our hospital.
Materials and Methods: Retrospective analysis was conducted on data from cancer patients diagnosed between January 2020 and June. The microorganisms isolated from blood cultures of cancer patients were identified using the matrix-assisted laser desorption ionization (MALDI) Biotyper Microflex LT device. The antimicrobial sus-ceptibility profiles of the bacteria were examined using the BD Phoenix 100. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) 22.0 program.
Results: The study included a total of 158 bacterial isolates grown from blood cultures of 133 patients across different populations. Gram-positive bacteria were detected in 54.4% (86) of the isolates, while gram-negative bacteria were found in 40.5% (64) of the isolates. The extended spectrum beta-lactamase (ESBL) positivity rate was 41.2% (14/34) in Escherichia coli isolates and 25% (3/12) in Klebsiella pneumoniae isolates. Methicillin-resistant Staphylococcus aureus (MRSA) was identified in only one bacte-rial strain. Nine (26.5%) E. coli isolates and three (25%) K. pneumoniae isolates were determined to be multi-drug resistant (MDR).
Conclusion: BSIs remain a significant health issue in cancer patients. Analyzing MDR isolates and resistance profiles through routine bacterial surveillance in cancer pa-tients can provide guidance for antimicrobial therapy. Furthermore, regularly sharing the obtained data can enhance treatment success.
|10.||The Effects of a Pulmonary Rehabilitation Program in Severe and Critical COVID-19 Disease: A Prospective Observational Study|
Ayşe Merve Ata, Ebru Alemdaroğlu, Refiye Önal, Bilge Kesikburun, Pınar Borman, Emre Adiguzel, Evren Yaşar
doi: 10.14744/cpr.2023.70299 Pages 377 - 384
Objective: The pulmonary rehabilitation program has beneficial effects on Coronavirus Disease 2019 (COVID-19). However, the response of each patient is not the same. The aim of this study is to compare the rehabilitation processes of severe and critical patients with COVID-19 infection and investigate the effects of sarcopenia and nutritional parameters on the rehabilitation course.
Materials and Methods: Patients with COVID-19 infection who continued to use oxygen were enrolled and classified into severe or critical disease groups. The modified Medical Research Council scale, Borg Rating of Perceived Exertion scale, and Barthel Index were eval-uated. A 6-minute walking test, hand grip strength (HGS), and chair stand test were per-formed. The thickness of the quadriceps muscle was measured by ultrasound to diagnose sarcopenia. Nutrition risk screening and daily protein and calorie intake were computed.
Results: Twenty-two patients were included. The oxygen requirement at discharge was reduced compared to those admitted to the rehabilitation unit (p<0.001). Sarcopenia was present in 17 (77.3%) patients in all subjects, 12 (80%) patients in the severe disease group, and in 5 (71.4%) patients in the critical disease group. HGS and the Barthel Index were lower in the critical disease group (p=0.044 and p=0.037, respectively). The duration of rehabilitation was longer in the critical disease group (p=0.044). Daily protein and calorie consumption per kilogram were similar and low in both groups (both p>0.05).
Conclusion: Sarcopenia and malnutrition were common in severe and critical COVID-19 disease patients. HGS was lower in critical disease patients, while muscle measurements were similar in both groups.
|11.||Can Adolescent Idiopathic Scoliosis be Associated with Visual Impairment?|
Sabri Batın, İlyas Uçar, Ahmet Payas, Emre Bal, Yakup Ekinci, Erdal Kurtoğlu, Mustafa Arık, Turgut Seber, Halil Yılmaz, Nisa Kahraman, Erdoğan Unur
doi: 10.14744/cpr.2023.08108 Pages 385 - 391
Objective: It is believed that postural balance problems may contribute to the development of adolescent idiopathic scoliosis (AIS). Vision provides proprioceptive input by supplying information about body positions. Considering the fundamental role of vision in postural control, this study aims to investigate the relationship between AIS and the volume of the eye-moving muscles and the visual field.
Materials and Methods: This prospective cross-sectional study included a total of 47 female individuals, with 24 having AIS and 23 being healthy participants. Magnetic resonance imaging was used to calculate the volumes of the medial rectus (MR) and lateral rectus (LR) muscles in both groups. Additionally, the visual field test was conducted to determine the pattern standard deviation (PSD) and mean deviation (MD) values for the left and right eyes of individuals in both groups.
Results: The mean age of AIS patients with a major curvature of 48.50 degrees and a Lenke Type-1 curve was similar to that of asymptomatic individuals. The volume values of the MR muscle on both sides were lower in the AIS group compared to the control group (p<0.05). Significant differences were found in the PSD values of the visual field test within the AIS group (p<0.01). However, there was no significant difference in the MD values between the left and right eyes of the two groups (p>0.05).
Conclusion: It is important to consider the presence of visual sensory defects in individuals with AIS. It is unknown whether AIS causes visual impairment or vice versa. Therefore, further comprehensive studies are needed.
|12.||The Impact of the COVID-19 Pandemic on Inflammatory Rheumatic Diseases|
Gamze Kılıç, Onur Kaan Gedikli, Cemil Güner, Ali Yazıcı, Serpil Demirulus, Elif Bozkurt, Kemal Faruk Koruklu, Orçun Cem Öngöre, Murat Karkucak, Erhan capkin, Erkan Kılıç
doi: 10.14744/cpr.2023.00719 Pages 392 - 401
Objective: The objective of this study was to investigate the impact of the Coronavirus Disease 2019 (COVID-19) on inflammatory rheumatic diseases (IRD) by comparing them with non-IRD (nIRD) and healthy controls (HC).
Materials and Methods: In this cross-sectional study, subjects were screened for contact with COVID-19, new-onset symptoms, and adherence to precautionary measures against COVID-19. The Impact of Event Scale-Revised (IES-R) and Depression Anxiety and Stress Scales (DASS-21) were used to evaluate the psychological effect of the pandemic and health status. Additionally, therapy adherence and clinical characteristics were noted.
Results: A total of 279 subjects were recruited (IRD 47.3%; nIRD 29.7%). The number of patients who believed that the risk of COVID-19 increased due to their diseases or received therapy was higher in IRD than nIRD (38.6% vs 7.2%). Maintaining physical dis-tancing was highest in the IRD and lowest in HC (p=0.037). Approximately 40% of the patients discontinued or extended the dose interval of Tumor Necrosis Factor Inhibitor (TNFi) without obtaining physician’s advice. DASS-21 anxiety, depression and stress rates were lowest in IRD. COVID-19 contact history was an independent risk factor for DASS-21 stress and anxiety, while female gender was an independent risk factor for DASS-21 anxiety.
Conclusion: Confirmed COVID-19 infection was similar in HC, IRD, and nIRD. HC were substantially more likely to experience mental health issues than other groups. Most patients with IRD discontinued or extended the ongoing treatment without physician’s recommendation during the COVID-19 outbreak. Therefore, patient adherence and disease control could be improved through closer monitoring and recognition of early signs of psychological discomfort during the COVID-19 pandemic.
|13.||Evaluation of Factors Affecting Outcomes in Arthroscopic Bankart Repair|
Ahmet Öztermeli, Ozgun Karakus, Özgür Karaman, Ahmet Sinan Sarı, Burak Gürer, Baransel Saygi
doi: 10.14744/cpr.2023.98698 Pages 402 - 408
Objective: This study aims to investigate the factors that affect the functional outcomes of patients undergoing arthroscopic Bankart repair.
Materials and Methods: We evaluated patients undergoing Bankart lesion repair in this study, which involved a total of 68 patients. For each patient, we identified the number of dislocations, Constant scores, number of sutures, and arthroscopic classification (Type 1 to 5).
Results: The postoperative Constant scores of patients with more than one preoperative dis-location were statistically lower than those of patients with only one dislocation (p=0.043). The ABC Type 1 group exhibited significantly better postoperative scores compared to patients in the Type 2 and Type 3 groups (p=0.001; p=0.006). The postoperative Constant scores of patients with ≥3 anchor sutures were determined to be statistically higher than those with <3 sutures (p=0.001). All recurrence cases involved young males with inferior glenohumeral ligament (IGHL) tears, and three out of four recurrences were observed in patients with more than one preoperative dislocation.
Conclusion: Constant scores improved in all groups compared to the preoperative evaluation. Better functional outcomes were observed in patients with ABC Type 1, patients with only one dislocation, and patients who underwent labral repair with three or more anchor sutures.
|14.||Transient Sinoatrial and Atrioventricular Block in the Acute Phase of COVID-19 Infection|
Ömer Ferudun Akkuş, Gökay Taylan, Kenan Yalta
doi: 10.14744/etd.2022.75272 Pages 409 - 412
Background: Ongoing research on Coronavirus Disease 2019 (COVID-19) infection has revealed that it is associated with serious damage to many organs, not only the lungs. This infection can also affect the cardiovascular system and lead to serious cardiac pathologies. In this article, we present a case of transient bradyarrhythmia in a patient who was diagnosed with COVID-19 and recovered spontaneously with treatment.
Case Report: A 74-year-old male patient was hospitalized with symptomatic COVID-19 infection. At the time of hospital-ization, the patient was asymptomatic from a cardiac standpoint, but was found to have sinoatrial exit block type 2-2, inter-mittent Mobitz type 2 atrioventricular block, and sinus bradycardia. The medical team decided to closely monitor the patient, who responded well to COVID-19 treatment and did not develop bradyarrhythmia as his symptoms improved.
Conclusion: Patients with COVID-19 infection should be closely monitored for bradyarrhythmia. Permanent pacemaker should not be rushed in these patients.
|15.||Von Hippel–Lindau Disease and Agenesis of the Corpus Callosum: Report of a New Possible Association|
Edis Çolak, Behzat Özkan
doi: 10.14744/etd.2023.94910 Pages 413 - 416
Background: Von Hippel–Lindau disease (VHL) is a rare multisystem neurocutaneous dis-order. The abnormalities in the corpus callosum have been observed in patients with pha-comatosis, but this has not been previously described in VHL. In this report, we present a unique case of VHL with corpus callosum agenesis.
Case Report: A 7-year-old boy was referred to the hospital because of left flank pain and vomiting. The abdominal ultrasound revealed multiple small simple cysts in both kidneys and pancreas. A radiological suspicion of VHL was raised, and further imaging examinations were recommended. Brain magnetic resonance imaging demonstrated a parallel arrange-ment of the lateral ventricles, confirming the diagnosis of complete agenesis of the corpus callosum. Brain hemangioblastomas were not detected.
Conclusion: Our case is the first to report a corpus callosum agenesis in a child with VHL, thus expanding the spectrum of neurocutaneous disorders associated with callosal anomalies.
|16.||Successful Treatment of Acute Hepatitis-Associated Aplastic Anemia in a Young Boy: a case report|
Mirna Natalija Anicic, Matija Bakos, Ana Petrovic Gluscic, Marijana Coric, Jurica Vukovic
doi: 10.14744/etd.2023.75271 Pages 417 - 419
Background: Acute hepatitis-associated aplastic anemia (AHAAA) is a rare clinical syndrome characterized by the development of aplastic anemia 2–3 months following an episode of acute hepatitis. Several immunosuppressive agents, but not mycophenolate mofetil (MMF), and bone marrow transplantation are the standard treatment options for AHAAA.
Case Report: In this report, we present a case of a young boy with AHAAA manifesting as acute liver failure. The etiology was type 1 autoimmune hepatitis responsive to the sec-ond-line therapeutic combination of steroids and MMF. The liver has fully recovered, but bone marrow failure ensued. After 4 months, Clinical and laboratory improvement occurred without the need for bone marrow transplantation. An important aspect of this case is the full recovery of aplastic anemia without calcineurin inhibitors, anti-thymocyte globulin uti-lization, or bone marrow transplantation.
Conclusion: Our case history supports MMF as a potentially crucial adjunctive therapy for patients with AHAAA who poorly respond to standard procedures.
|17.||Small intestinal fish bone perforation|
doi: 10.14744/etd.2022.03838 Pages 420 - 421
|18.||Panitumumab Induced Paronychia and Trichomegaly|
Oktay Ünsal, Osman Sutcuoglu, Nuriye Ozdemir
doi: 10.14744/etd.2023.78646 Pages 422 - 423
|LETTER TO THE EDITOR|
|19.||Miller Fisher Syndrome and Cavernous Sinus Thrombosis Caused by Sinusitis|
Steven Yale, Halil Tekiner, Eileen Yale
doi: 10.14744/cpr.2023.43531 Pages 424 - 425
doi: 10.14744/cpr.2023.21931 Page 426