Retrospective cohort study of cancer incidence and mortality by HIV status in a Georgia, USA, prisoner cohort during the HAART era

OBJECTIVE:

Non-AIDS-defining cancers (NADCs) have emerged as significant contributors to cancer mortality and morbidity among persons living with HIV (PLWH). Because NADCs are also associated with many social and behavioural risk factors that underlie HIV, determining the extent to which each of these factors contributes to NADC risk is difficult. We examined cancer incidence and mortality among persons with a history of incarceration, because distributions of other cancer risk factors are likely similar between prisoners living with HIV and non-infected prisoners.

DESIGN:

Registry-based retrospective cohort study.

PARTICIPANTS:

Cohort of 22 422 persons incarcerated in Georgia, USA, prisons on 30 June 1991, and still alive in 1998.

OUTCOME MEASURES:

Cancer incidence and mortality were assessed between 1998 and 2009, using cancer and death registry data matched to prison administrative records. Age, race and sex-adjusted standardised mortality and incidence ratios, relative to the general population, were calculated for AIDS-defining cancers, viral-associated NADCs and non-infection-associated NADCs, stratified by HIV status.

RESULTS:

There were no significant differences in cancer mortality relative to the general population in the cohort, regardless of HIV status. In contrast, cancer incidence was elevated among the PLWH. Furthermore, incidence of viral-associated NADCs was significantly higher among PLWH versus those without HIV infection (standardised incidence ratio=6.1, 95% CI 3.0 to 11.7, p<0.001).

CONCLUSIONS:

Among PLWH with a history of incarceration, cancer incidence was elevated relative to the general population, likely related to increased prevalence of oncogenic viral co-infections. Cancer prevention and screening programmes within prisons may help to reduce the cancer burden in this high-risk population.

Full article at:   http://goo.gl/bU7ddc

By:  Zlotorzynska M1, Spaulding AC1, Messina LC1, Coker D1, Ward K1, Easley K1, Baillargeon J2, Mink PJ3, Simard EP1.

• 1Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
• 2University of Texas Medical Branch, Galveston, Texas, USA.
• 3Rollins School of Public Health, Emory University, Atlanta, Georgia, USA Division of Applied Research, Allina Health, Minneapolis, Minnesota, USA.
• BMJ Open. 2016 Apr 11;6(4):e009778. doi: 10.1136/bmjopen-2015-009778. 

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New Mexico plaintiffs filing lawsuits against prison healthcare providers by year

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Relationship between Parenting and Cognitive Schemas in a Group of Male Adult Offenders

This work analyzes the correlation of retrospective ratings on parental binding with cognitive patterns in the inmates for property crimes. The participant group comprehended 248 adults men, including 130 marked out as offenders (the target group), aged between 19 and 70, currently serving sentences in the Cavadonna prison in Siracusa, and 118 marked out as non-offenders (the control group), aged between 20 and 70, living in Siracusa (Sicily). The instruments used were the Parental Bonding Instrument (PBI), and the Young Schema Questionnaire-3 (YSQ). The preliminary analysis showed a high percentage of offenders who experienced an affectionate constraint parenting. Offenders scored significantly higher than the non-offenders on the level of paternal control and the YSQ subscales. The study underlines the influence of maternal care on most of the cognitive schemas, and the role of father's control on the tendency to social isolation and defectiveness in the offenders.

The author identified 18 early maladaptive schemas that have been organized into five themes known as domains:

1. disconnection and rejection domain: people with these schemas expect that their needs for stability, nurturance, security, and empathy in family relationships will not be met in a consistent or predictable way;
2. impaired autonomy and performance: this domain has to do with expectations about oneself and the environment that interfere with one's ability to separate and function independently and one's perceived ability to survive alone; typically the family of origin is enmeshed or overprotective;
3. impaired limits domain: characterized by deficiencies in internal limits, respect, and responsibility to others; typically the family of origin is characterized by permissiveness and indulgence;
4. other-directedness domain: relates to an excessive focus on meeting the needs of others, at the expense of one's own needs; Typically the family of origin gave only conditional acceptance, resulting in the children suppressing normal needs and emotions in order to gain attention and approval;
5. overvigilance and inhibition domain: characterized by an excessive focus on controlling, suppressing, or ignoring of one's emotions; typical of the family of origin are domination and suppression of feelings, or a bleak environment where performance standards and self-control take priority over pleasure and playfulness.

Full article at:   http://goo.gl/mUwUu2

By:  Monica Pellerone,* Giuseppe Craparo, and Ylenia Tornabuoni

Faculty of Human and Social Sciences, “Kore” University of Enna, Enna, Italy

Edited by: Omar Carlo Gioacchino Gelo, Universita del Salento/Sigmund Freud University, Italy

Reviewed by: Guenter Karl Schiepek, Paracelsus Medical University, Austria; Salvatore Gullo, Niccolò Cusano University, Italy

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Mental Disorder Prevalence & Associated Risk Factors in Three Prisons of Spain

AIMS:

To determine the lifetime and monthly prevalence of people with mental disorders and its association with sociodemographic factors andcriminal risk in three Spanish prisons (Ocaña, Madrid I, II and VI).

METHOD:

Cross-sectional epidemiological study of a sample of 184 inmates. Socio-demographic and criminal data were collected by an ad hoc interview. Mental disorders were assessed with the clinical version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis I Disorders (SCID-I).

RESULTS:

Life prevalence of mental disorders was 90.2%. The most common mental disorders and substance abuse or dependence was 72.3%, followed by mood disorder (38.5%) and psychotic disorders (34.2%). Moreover, the prevalence of any mental disorder in the last month was 52.2%. The main psychotic disorder (20.7%) was followed by substance abuse or dependence (18.5%), and mood disorder state (13%). A socio-demographic profile as a risk for each disorder was found.

DISCUSSION:

The prevalence of people with mental disorders is very high in Spanish prisons, and is associated with a distinct demographic profile. It is essential to continue researching this reality, translating the results into therapeutic and preventive action adapted to the status of inmates to reduce social inequalities in this high priority public health situation.

Full article at:   http://goo.gl/SUykGQ

By:  M.C. Zabala-Baños¹, A. Segura¹, C. Maestre-Miquel¹, M. Martínez-Lorca², B. Rodríguez-Martín¹, D. Romero and M. Rodríguez¹

¹ Nursing, Physiotherapy and Occupational Therapy Department. Occupational Therapy, Logaoedics and Nursing School. University of Castilla la Mancha, Talavera de la Reina, Spain 
² Department of Psychology. Occupational Therapy, Logaoedics and Nursing School. University of Castilla la Mancha, Talavera de la Reina, Spain

Rev Esp Sanid Penit. 2016 Jun;18(1):13-23. doi: 10.4321/S1575-06202016000100003.

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Intellectual Disability & The Prison Setting

INTRODUCTION:

The prevalence of intellectual disability (ID) in the prison setting has scarcely been studied. Although some approximations or estimates regarding people with intellectual disabilities have been performed in Spain, there is little in the way of reliable data.

OBJECTIVES:

1) To determine the prevalence of ID in a sample population in the residential modules of a Spanish prison, 2) Obtain data on the prevalence of ID in prison psychiatric units and hospitals.

METHODS:

1) A TONI II test was performed on a sub-sample (n = 398) of a prevalence study in Spanish prisons33 to identify inmates with intellectual disabilities. 2) We reviewed the reports of the psychiatric department of Parc Sanitari Sant Joan de Deu to establish the diagnosis at discharge of patients with a primary diagnosis of intellectual disability 3) Data from the Directorate General of Prisons on the prevalence of ID in Prison Psychiatric Hospitals was reviewed.

RESULTS:

The data obtained from the TONI II test found 3.77% of the study population has an IQ below 70, and 7.54 % has a borderline IQ rate. Assessment of penitentiary psychiatric hospitalization data showed these figures to be higher.

CONCLUSIONS:

The data from a Spanish prison population showed that ID levels were higher than those in the community, especially amongst prisoners requiring specialized psychiatric care. What is also evident is that adequate resources are required in prisons and in the community to provide better care for people with intellectual disabilities who are in the pathway of the criminal justice system.

Full article at:   http://goo.gl/Dd5VoV

By:  V. Tort¹, R. Dueñas¹, E. Vicens¹, C. Zabala², M. Martínez² and D.M. Romero²

¹ Parc Sanitari Sant Joan de Deu. Sant Boi de LLobregt (Barcelona) 
² Facultad de Terapia Ocupacional, Logopedia y Enfermería de la UCLM. Talavera de la Reina (Toledo)

Rev Esp Sanid Penit. 2016 Jun;18(1):25-32. doi: 10.4321/S1575-06202016000100004.

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Correlates of Preincarceration Health Care Use among Women and Men in Jail

Although women and men in jails bear a burden of health problems, little is known about factors associated with their health care use. We conducted a cross-sectional survey of preincarceration health care use with 596 jail inmates. Descriptive statistics and correlates of participants’ health care use were assessed. 

A year before incarceration, 54% of participants used an emergency room, 24% were hospitalized, and 39% used primary care. Correlates of health care use included gender, health insurance status, and drug dependence. For participants without mental health problems, use was associated with living in neighborhoods where a higher percentage of residents did not complete high school. 

Findings suggest individual and community factors that can be targeted by reentry programs to improve health care use after jail.

...There was an interesting interaction between individual- and community-level variables, however, which was that ER use and hospitalizations were significant only for the group of participants without a mental health diagnosis and living in a neighborhood with low educational status. Factors associated with primary care use included having health insurance, not reporting drug dependence, and having a mental health diagnosis. Thus, we found that although community-level factors may have a role in health care use patterns, individual-level factors such as gender, health insurance status, drug dependence, and mental health diagnosis history were important correlates of preincarceration health care use for our sample.

...The model [Andersen’s Behavioral Model of Health Services Use, Andersen, 1995; Harzke et al., 2006;Leukefeld et al., 2006; Webster et al., 2005] however, fails to explain our finding that low educational status at the community level is associated with health care that is used for emergency and more serious conditions, but only for those without mental health problems. Low educational status at the community level could be a proxy for community-level social capital (Bourdieu, 1986), which has been associated with both health outcomes and health care access (Chuang, Ennett, Bauman, & Foshee, 2005; Kirby & Kaneda, 2005). It could also signal lack of investment by the health care sector in poor, disadvantaged communities where the economic capital of residents is compromised by their collective educational status. It is interesting, however, that other potential associations with social capital variables were not significant and suggest the need to repeat this study with other populations. Our finding that community matters only for those without mental health problems can perhaps be explained by the magnitude of the mental health burden on inmates. Mental health as an indicator of health need may determine the relative impact of community on health care use for this group of women and men. Given that one national study found that 64% of people in the jails had a mental health problem (James & Glaze, 2006), the burden unique to this population is significant and perhaps more significant than any community-level factors...

Full article at:   http://goo.gl/QsDbjg

By:  Megha Ramaswamy, PhD, MPH,1 Francisco Diaz, PhD,2 Tyson Pankey, MPH,3 Suzanne L. Hunt, MS,2 Andrew Park, DO, MPH,4 and Patricia J. Kelly, PhD, MPH, APRN5

¹Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA

²Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA

³Department of Counseling Psychology, University of Wisconsin–Madison, Madison, WI, USA

⁴Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA

⁵School of Nursing, University of Missouri–Kansas City, Kansas City, MO, USA

Corresponding Author: Megha Ramaswamy, PhD, MPH, Preventive Medicine and Public Health, University of Kansas School of Medicine, 3901 Rainbow Blvd., MS 1008, Kansas City, KS 66160, USA.

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The Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review

Objective

People with mental illnesses are understood to be overrepresented in the U.S. criminal justice system, and estimates of the prevalence of mental illnesses in corrections settings are crucial for planning and implementing preventive and diversionary policies and programs. Despite consistent scholarly attention, two federal self-report surveys are typically cited, and these may not represent the extent of relevant data. This systematic review identifies studies that assess the prevalence of mental illnesses in U.S. state prisons, in order to develop a broader picture of prison prevalence and identify methodological challenges to obtaining accurate and consistent estimates.

Methods

Medline, PsycInfo, the National Criminal Justice Reference Service, Social Services Abstracts, Social Work Abstracts, and Sociological Abstracts were searched. Studies were included if they were published between 1989 and 2013; focused on U.S. state prisons; reported prevalence of diagnoses/symptoms of DSM Axis I disorders; and identified screening/assessment strategies.

Results

Twenty-eight articles met inclusion criteria. Estimates of current and lifetime prevalence of mental illnesses varied widely; however, the range of prevalence estimates for particular disorders was much greater—and tended to be higher—in prisons than community samples.

Conclusions

Operationalizations of mental illnesses, sampling strategies, and case ascertainment strategies likely contributed to inconsistency in findings. Other reasons for study heterogeneity are discussed, and implications for public health are explored.

Full article at:   http://goo.gl/4K5YlM

By:  Seth J. Prins, MPH

Seth J. Prins, Columbia University Department of Epidemiology Mailman School of Public Health 722 W. 168th Street, 720-C Department of Epidemiology New York, New York 10032

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Functions of Aggression & Delinquency: The Moderating Role of Parent Criminality & Friends' Gang Membership

This study examined the relationships between two functions of aggression (i.e., reactive and proactive) and delinquency, including the moderating effects of parent criminality and friends' gang membership, in a sample of 1,027 Singaporean adolescents from Grade 7 to Grade 9, with age ranging from 12 to 19 years (M = 14.10, SD = 1.15). 

Findings suggested that both reactive aggression and proactive aggression significantly and positively predicted delinquency (after controlling for proactive aggression and reactive aggression, respectively), with proactive aggression being a stronger predictor. Friends' gang membership was found to moderate the relationship between reactive aggression and delinquency, and proactive aggression and delinquency, with stronger moderator effects for the latter. Those who were aggressive proactively and who had friends in a gang appear to be impacted most negatively with respect to delinquency. Parent criminality did not moderate these relationships. 

These findings highlight the need to effectively address the issues of child and adolescent aggression. Also, developing positive peer relations early is crucial for delinquency prevention.

Purchase full article at:   http://goo.gl/SAhYBC

By:  Ang RP1, Huan VS2, Li X2, Chan WT2.

• 1National Institue of Education, Nanyang Technological University, Singapore rebecca.ang@nie.edu.sg.
• 2National Institue of Education, Nanyang Technological University, Singapore. 
• J Interpers Violence. 2016 Mar 2. pii: 0886260516636066.

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Prisons as a Source of Tuberculosis in Russia

Purpose

The purpose of this paper is to analyze poor management of tuberculosis (TB) prevention and treatment and explore parameters and causes of this problem drawing on qualitative interviews with former prisoners and medical specialists in Kaliningrad Oblast in Russia. 

Design/methodology/approach

The authors undertook a qualitative study, to explore access to HIV and TB treatment for people who inject drugs in Kaliningrad. The authors interviewed (outside of prisons) 15 patients and eight health specialists using a semi-structured guide. The authors analyzed the accounts thematically and health consequences of imprisonment emerged as a major theme. 

Findings

Prisons are overcrowded and lack basic hygiene and infection control. Demand for medical services outstrip supply, HIV and TB prevention lacking, HIV and TB treatment is patchy, with no second-line drugs available for resistant forms. The prison conditions are generally degrading and unhealthy and many respondents perceived surviving prisons as a miracle. Cooperation with medical services in the community is poor. 

Research limitations/implications

The authors used qualitative research methods, which do not rely on a representative sample. However, many of the structural barriers preventing effective TB treatment and prevention highlighted in this paper have been noted elsewhere, suggesting that findings are likely to reflect conditions elsewhere in Russia. The authors tried to include all possible points of view, as of the medical staff and the patients. However, due to resistance of the officials the authors were unable to conduct interviews with employees of the FCS. Since all the interviews are recalling past experience, the situation may have changed. This does not undermine importance of the findings, as they shed light on particular treatment experiences, and development of prison health system. 

Originality/value

The paper contributes to the literature on prisons as a contributor to TB epidemic, including drug resistant forms. An urgent penitentiary reform in Russia should focus on HIV and TB prevention, case detection, availability of medications and effective treatments. Key to decreasing prison population and improving health is political reform aimed at introduction of effective drug treatment, de-penalization and de-criminalization of drug users and application of alternatives to incarceration.

Purchase full article at:  http://goo.gl/g6J0AR

By:  Sarang A1, Platt L, Vyshemirskaya I, Rhodes T.

• 1Andrey Rylkov Foundation for health and Social Justice, Moscow, Russia. 
• Int J Prison Health. 2016 Mar 14;12(1):45-56. doi: 10.1108/IJPH-07-2014-0022.

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Hepatitis C in Australian Prisons: A National Needs Assessment

Purpose

Hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. Approximately 30,000 prisoners are held in Australian prisons at any one time, with more than 30 per cent testing positive for HCV antibodies. Prisoners have been identified in the National Hepatitis C Strategy as a priority population for assessment and treatment. The purpose of this paper is to examine the rates of HCV testing and treatment, as well as barriers and opportunities for development of infrastructure for enhanced services. 

Design/methodology/approach

Interviews were conducted with 55 stakeholders from the correctional sector in each state and territory in Australia in two stages: service directors to gather quantitative data regarding rates of testing and treatment; and other stakeholders for qualitative information regarding barriers and opportunities. 

Findings

Of more than 50,000 individuals put in in custody in Australian prisons in 2013, approximately 8,000 individuals were HCV antibody positive, yet only 313 prisoners received antiviral treatment. The barriers identified to assessment and treatment at the prisoner-level included: fear of side effects and the stigma of being identified to custodial authorities as HCV infected and a likely injecting drug user. Prisoners who came forward may be considered unsuitable for treatment because of prevalent mental health problems and ongoing injecting drug use. Provision of specialist hepatitis nurses and consultants were the most frequently recommended approaches to how prison hepatitis services could be improved. 

Originality/value

Many personal and systems-level barriers relevant to the delivery of HCV treatment services in the custodial setting were identified. Ready access to skilled nursing and medical staff as well as direct acting antiviral therapies will allow the prison-sector to make a major contribution to control of the growing burden of HCV disease.

Purchase full article at:   http://goo.gl/S8kIoe

By:  Mina MM1, Herawati L, Butler T, Lloyd A.

• 1Inflammation and Infection Research Centre (IIRC), School of Medical Sciences, University of New South Wales, Australia.
• Int J Prison Health. 2016 Mar 14;12(1):3-16. doi: 10.1108/IJPH-08-2015-0025. 

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To Blame or to Forgive? Reconciling Punishment and Forgiveness in Criminal Justice

What do you do when faced with wrongdoing—do you blame or do you forgive? Especially when confronted with offences that lie on the more severe end of the spectrum and cause terrible psychological or physical trauma or death, nothing can feel more natural than blame. Indeed, in the UK and the USA, increasingly vehement and righteous public expressions of blame and calls for vengeance have become commonplace; correspondingly, contemporary penal philosophy has witnessed a resurgence of the retributive tradition, in the modern form usually known as the ‘justice’ model. On the other hand, people can and routinely do forgive others, even in cases of severe crime. Evolutionary psychologists argue that both vengeance and forgiveness are universal human adaptations that have evolved as alternative responses to exploitation, and, crucially, strategies for reducing risk of re-offending. We are naturally endowed with both capacities: to blame and retaliate, or to forgive and seek to repair relations. Which should we choose? Drawing on evolutionary psychology, we offer an account of forgiveness and argue that the choice to blame, and not to forgive, is inconsistent with the political values of a broadly liberal society and can be instrumentally counter-productive to reducing the risk of future re-offending. We then sketch the shape of penal philosophy and criminal justice policy and practice with forgiveness in place as a guiding ideal.

Forgiveness is often allied with a range of emotions and reactive attitudes that express goodwill or positive regard, such as compassion, empathy, kindness, clemency and mercy.²⁰ Within legal philosophy, mercy in particular has been singled out as valuable if not indeed essential to the justification of punishment.²¹ Our first step therefore is to distinguish forgiveness from mercy, as the two are easily confused.

On the one hand, the grounds for both mercy and forgiveness may converge. Both can stem from compassion and empathy, which may occur in response to offenders who ‘make good’ by expressing guilt, regret and remorse, and apologising and offering reparation.²² Note that these various attitudes and actions on the part of the offender are not excuses or justifications: in themselves they do not bear on degree of responsibility or severity of offence. But they may nonetheless function to obviate the felt need to inflict punishment, for they offer evidence that some of the (non-retaliatory) ends that we may hope punishment serves, such as reduction of risk of re-offending, or atonement and the making of amends, have already been secured without it. With the exception of theories such as Kant’s²³ that punishment is not merely justified but necessitated by the ‘justice’ model’s conception of blameworthiness, consideration of these grounds may therefore incline us to show mercy for the offender or to forgive the offence, and therefore to punish less if at all. Hence, on the other hand, mercy and forgiveness may converge not only in their grounds but in their outcome: both may result in the voluntary withholding of punishment.

Yet mercy and forgiveness are distinct attitudes. Despite the fact that both can affect the decision of whether and to what extent to punish, once punishment has been determined and enacted, the question of mercy is otiose, while the question of forgiveness remains.²⁴ There is no question of whether or not to be merciful if we are not in a position to punish, whether that is because we have punished already, or because, more simply, we lack the power to do so. Mercy is a possible sentiment only for those with power and authority, exercised necessarily de haut en bas.²⁵ Yet there is a question of whether or not to forgive, wholly apart from our capacity to punish. The offender may have been appropriately punished and so paid their dues, and yet we find we do not forgive. Alternatively, we may find it in our hearts to forgive when no dues have been paid and we are not ourselves in any position to demand them, for we are powerless—unlike mercy, forgiveness can in theory be exercised de bas en haut, from powerless victim to powerful perpetrator...

Full article at:  http://goo.gl/VaVkcr

By:  Nicola Lacey* and Hanna Pickard**

*Departments of Law and Social Policy and Gender Institute, London School of Economics. Email: ku.ca.esl@yecaL.M.N.

**Department of Philosophy, University of Birmingham. Email: ku.ca.mahb@drakcip.h.

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What Do Prisoners Eat? Nutrient Intakes & Food Practices in a High-Secure Prison

There are limited studies on the adequacy of prisoner diet and food practices, yet understanding these are important to inform food provision and assure duty of care for this group. 

The aim of this study was to assess the dietary intakes of prisoners to inform food and nutrition policy in this setting. This research used a cross-sectional design with convenience sampling in a 945-bed male high-secure prison. Multiple methods were used to assess food available at the group level, including verification of food portion, quality and practices. A pictorial tool supported the diet history method. Of 276 eligible prisoners, 120 dietary interviews were conducted and verified against prison records, with 106 deemed plausible. 

The results showed the planned food to be nutritionally adequate, with the exception of vitamin D for older males and long-chain fatty acids, with Na above upper limits. The Australian dietary targets for chronic disease risk were not achieved. High energy intakes were reported with median 13·8 (se 0·3) MJ. Probability estimates of inadequate intake varied with age groups: Mg 8 % (>30 years), 2·9 % (70 years), 1·5 % (<70 years); folate 3·5 %; Zn and I 2·7 %; and vitamin A 2·3 %. Nutrient intakes were greatly impacted by self-funded snacks. 

Results suggest the intakes to be nutritionally favourable when compared with males in the community. This study highlights the complexity of food provision in the prison environment and also poses questions for population-level dietary guidance in delivering appropriate nutrients within energy limits.

Purchase full article at:   http://goo.gl/eYjTy4

By:  Hannan-Jones M1, Capra S1.

• 1School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences,The University of Queensland, Brisbane, Qld 4072, Australia.
• Br J Nutr. 2016 Feb 22:1-10.  

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Making Fatty Girl Cakes: Food and Resistance in a Women’s Prison

This article builds on existing knowledge of inmate resistance by analyzing formerly incarcerated women’s narratives about prison food. 

Participants described trying to secure extra cafeteria portions, hoarding food, smuggling and stealing food, and cooking and eating in the cells—all to resist prison power and gain some control over their lives by managing what, how, when, and with whom they ate. 

These data shed light on prison life and suggest changes to food policy to curb inmate resistance and bolster the rehabilitative potential of correctional facilities.

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By:  Amy B. Smoyer

Assistant Professor, Department of Social Work, Southern Connecticut State University, 501 Crescent St., New Haven, CT 06515, USA. Email:smoyera1@southernct.edu

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