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HOUSE Calls: Rib Fractures, Viagra

This week we respond to questions about erectile dysfunction and rib fractures.

Dear HOUSE Calls,    

I am a 52-year-old man that has trouble getting an erection.  Should I take a medicine like Viagra?House calls logo

Thank you for asking this sometimes difficult question. It may surprise you to know how often our patients ask about this.

Without knowing more about your problems, it is hard to answer you directly. If you have not seen a doctor about this, that is a critical first step. There are a number of conditions which can cause or contribute to difficulty with erections – diabetes, high cholesterol, depression, and cigarette smoking are some of the most common ones. Also, a number of medicines can cause or contribute to this problem. It is therefore critical that your doctor review your medicine list with you.

It is also important to note that problems achieving and maintaining an erection can come from a complex interplay between the mind and the body. Relationship problems can be an important contributor.

So yes, Viagra, and medicines like it (Cialis and Levitra) can help many men achieve and maintain a satisfying erection. There are some side effects you need to understand. The most important issue that you need to be aware of is that you can’t take these medicines in combination with nitrate medicines often taken for heart disease (like nitroglycerin used for chest pain).

These medicines don’t work for about one third of men, but there are some other options. They are also expensive, and insurance coverage is variable. Bottom line, go talk with your doctor.

Dear HOUSE Calls,    

I recently fell and broke a rib. At urgent care they said there was not much to do but wait for it to heal and take ibuprofen. It is killing me and the ibuprofen is not helping. Is there anything else I can do?

Usually with broken bones, a cast stops the fragments from moving and alleviates the pain. We can’t do that with rib fractures. Every time you breathe, the broken ends rub on each other.

Some people get relief by splinting their chest with a pillow when taking a deep breath, coughing, or sneezing. If ibuprofen is not providing any relief, you and your doctor could consider opiate or narcotic pain relievers. These have some down sides, such as sedation, constipation, and addiction.

You also might ask your doctor about Lidoderm patches, applied directly to the painful area. Time will heal this, but it may take several weeks. Good luck.

HOUSE Calls is a weekly column by Dr. Adam Goldstein, Dr. Cristy Page, and Dr. Adam Zolotor on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSECalls: Diabetes, Gout

This week we respond to questions about diabetes and gout.

Dear HOUSE Calls,    

House calls logoI have diabetes and my blood sugar has been running high – around 230. I was on medication that was working. Why is it not working anymore? I don’t want to go on insulin.

Insulin resistance, the primary cause of Type 2 diabetes, gets worse over time. Even if you are well controlled and maintain your diet and activity level, there is some chance you will need more medicine over time.

Also, there is a class of medicines that stimulates the pancreas to make more insulin (e.g. glipizide and gliperamide). Apparently, the pancreas seems to fatigue of being in overdrive after awhile. For some people these medicines loose effect after about 5 years.

There are now 5 classes of oral medicines on the market that are for diabetes.  Each of these medicines has a different profile in terms of action, effect, side effects, and adverse reactions. Not knowing any more about your situation, we can’t make any particular recommendations other than talk to your doctor.

As far as insulin, we would first off wonder why you are opposed to insulin. Is it the mere act of giving yourself a shot? There is another diabetes shot that is not insulin that you could consider as well. Insulin does have a high risk of low blood sugars or hypoglycemia, and it is also associated with weight gain or making weight loss harder. We would encourage you to think about where you might improve your diet and/or increase your exercise to see if you can avoid additional medicines. Good luck.

Dear HOUSE Calls,    

I have lots of pain in my knees and my doctor said I have gout. I had my uric acid tested and it was normal. I thought uric acid was high in gout. Do you think I have gout?

That is a great question. First we would say that there are many things that cause knee pain, and osteoarthritis is chief among them.

There are other types of inflammatory problems, like rheumatoid arthritis, which are less common. The knees are an unusual joint for gout. In addition, gout does not usually flare in non-continuous joints at the same time.

The normal uric acid level makes gout somewhat less likely as the culprit as well, however, during a flare, if the uric acid has crystallized in the joint, the blood level may be normal.

The best way to diagnose gout is to get a sample of joint fluid and look for uric acid crystals with a certain type of microscope. It is important to confirm the correct diagnosis so that you can get proper treatment.

HOUSE Calls is a weekly column by Dr. Adam Goldstein, Dr. Cristy Page, and Dr. Adam Zolotor on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

Physicians from the UNC Department of Family Medicine’s YOUR HEALTH™ media bring you weekly information in response to your questions about health and medicine. Send us your questions or comments to  YOURHEALTH@unc.edu

HOUSE Calls: Bee Pollen, Insurance Billing

This week we respond to questions about bee pollen and medical billing.

Dear HOUSE Calls,    

Does bee pollen help with a common cold?  Where can I get it?

House calls logoBee pollen is a “nutraceutical,” which means it is not a medication but it can be sold in health food stores and is often promoted and taken for certain health benefits. It contains the pollen that is brushed off the backs of bees, and it may also contain a bit of bee saliva. It is promoted to help with things ranging from alcoholism to allergies – but we don’t know of much in the way of solid clinical data supporting its use.

We have had some patients that have tried bee pollen for allergies without success. The substance does contain some antioxidants and vitamins, similar to what you would get in your diet and from a multi-vitamin. However, there is more risk for impurities and inconsistency in bee pollen.

We have not been in the habit of recommending this product.

Dear HOUSE Calls,    

I recently had a physical with my doctor.  I expected that it would be covered by my insurance plan, but got a bill for $126.  In addition to by annual wellness exam and preventive testing, we discussed my high cholesterol and back arthritis. I asked my doctor why I got stuck with the bill and he mentioned something about modifiers. Can you explain what’s going on here?   

This is a tough and complicated question and there are a few things that we should explain.

First off, most doctors don’t work for themselves anymore. Doctors are still responsible for our work and how we bill, but we receive regular training in how to improve the accuracy of our billing so that we are neither over-charging nor undercharging.

Second, your health insurance is primarily a contract between you and your insurance company. Doctors file your bill as a service, which will delay collections by 30-90 days and often results in underpayment.

So back to your question, imagine how much time the doctor spends with a completely healthy person for an annual visit―perhaps 15-20 minutes. Now what if the patient comes in every 3 months for their diabetes, but each December, they want the diabetes visit and their annual wellness visit? That visit will take more time. It does seem reasonable that the doctor and practice should be compensated extra for that time.

If we just bill for a wellness exam or a routine visit, we will be compensated much less than if we bill for both. So doctors can do this by listing both codes and using a ‘modifier’ to let the insurance company know this occurred. But many insurance companies will not cover both services on the same day, and the doctor has no idea what the insurance company will do with this bill.

There are just too many different plans. What doctors like to do if the visit is long and seems to focus more than a bit on non-wellness problems is to describe this situation to the patient, warn them they might get a bill, and offer to take care of both issues on the same visit or have them come back another day. This is surely confusing, and requires good communication on doctors’ part.

HOUSE Calls is a weekly column by Dr. Adam Goldstein, Dr. Cristy Page, and Dr. Adam Zolotor on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Mononeucleosis, Painful Urination

This week we respond to questions about mononucleosis and questions about painful urination.

Dear HOUSE Calls,    

House calls logoI was told by my doctor that I have mono. I saw her because I was fatigued and I had a mono test that was positive. But I have not had fever or sore throat. Do I really have mono?

This is a complicated question because when we refer ‘mono’ we are generally revering to a set of conditions with common clinical features.

We used to call this the ‘kissing disease’. The most common cause of mono in adolescents and young adults is Ebstein Barr Virus, or EBV. The hallmarks are fever, sore throat, and swollen lymph nodes.

After recovery from the acute infection, fatigue can lasts for weeks or longer. This is probably why your doctor checked you for mono. It would be unlikely to have had mono without at least some of the hallmark symptoms, perhaps you mentioned you had them several weeks ago?

To really answer the question in full, we would need to know more about your symptoms, your exam, and what kind of mono test your doctor ordered. There is a test known as the mono-spot test which is a simple positive or negative test that usually remains positive for many years after infection. There are specific antibody titers which can show more recent or past infections with somewhat more clarity. There are also supportive blood tests like liver function tests and some characteristics of the blood count that indicate infection with EBV.

It is also important that you and your doctor keep in mind that there are 100’s of cause for fatigue—anemia, sleep apnea, depression, diabetes, and thyroid conditions to name a few. Keep track of your symptoms, and if you are not feeling better, go back and see your doctor.

Dear HOUSE Calls,    

I went to the doctor recently with burning when I urinate. My urinalysis came back negative though for a urinary tract infection.  What do I have?

That is another good question. Usually a urinary tract infection (UTI) is fairly easy to diagnose from a urinalysis.  Occasionally, however, the tests are indeterminate and a urine culture helps us to be more certain.

However, there a number of other conditions that can burning with urination.  Other causes include: inflammation from a recent UTI (which your body recovered from without treatment), dehydration, urethritis from sexually transmitted infections (gonorrhea, chlamydia, and herpes most commonly), vaginal irritation from yeast or bacterial vaginitis (if the writer is a woman), trauma or direct irritation, and interstitial cystitis.

If the symptoms persist or recur, go back and see your doctor. Perhaps she or he can localize the symptoms. You may need other testing or referral to a specialist.

HOUSE Calls is a weekly column by Dr. Adam Goldstein, Dr. Cristy Page, and Dr. Adam Zolotor on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Questions About Yellow Teeth & Preventing Arthritis

This week we respond to questions about nighttime urination, yellow teeth, and arthritis prevention.

Dear HOUSE Calls,    

I wake up several times during the night to go to the bathroom.  Is this a problem?House calls logo

Sounds like a problem that would make us tired!

We define this as a problem if you wake two or more times to void during a typical night. Practically speaking, it is a problem if it bothers you or if it represents a change. There are a variety of issues that can be related to nighttime urination.  These include drinking too much close to bedtime, especially alcohol and caffeine-containing beverages.  Enlarged prostate is a common cause of nighttime urination in men. Other medical issues that can cause this include diabetes, heart disease, and urinary tract infections. So if there has been a change or it is bothering you, check in with your family doctor.

Dear HOUSE Calls,    

What causes teeth to stain and turn yellow?

Coffee, tea, wine, dark sodas, and especially cigarettes (and other tobacco products) are among the most common causes of yellow teeth. Some medications – used in childhood (tetracycline and doxycycline especially) – can contribute to permanently discoloring teeth.

To whiten your teeth, there are over-the-counter products and dentist administered teeth whitening treatments that are effective. But keep in mind, if you keep using the products like cigarettes that stain teeth, they met get whiter with treatment, but then they will yellow again with tooth staining beverages and habits.

Dear HOUSE Calls,    

How can I protect my joints from damage?

To keep your joints from aching, the best thing in terms of big picture is to keep a healthy weight.  Many people with osteoarthritis have developed it because they are overweight.  Staying active and wearing proper fitting shoes can also help reduce or prevent joint pain.

Protect your joints by slowing building up when you start a new exercise regimen. We don’t know of any medicines or supplements that are proven to prevent arthritis. For many people, the development of arthritis is about joint alignment or old injuries, and there is not much you can do about it. So, again, the best piece of advice is to try to maintain a healthy body weight.

HOUSE Calls is a weekly column by Dr. Adam Goldstein, Dr. Cristy Page, and Dr. Adam Zolotor on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Questions About Muscle-Building & Insomnia

This week we respond to questions about high protein diets and insomnia.

Dear HOUSE Calls,    

House calls logoMy boyfriend is on a high protein diet to build muscle.  How much protein is too much?

A high protein and low carbohydrate diet is increasingly common for weight loss and building muscle mass.

There was some concern on the part of the medical community early on that these high protein diets might increase blood levels of bad cholesterol or place a strain on the kidneys as they eliminate the byproducts of protein metabolism.

The first concern has largely been unfounded with high protein diets for weight loss. We find that losing weight by almost any means improves cholesterol profiles. As far as the kidney strain, we tell people with healthy kidneys that this is not an important concern of a typical high protein diet for weight loss.

This may not be true to a high protein diet directed at muscle building, especially as microscopic injury and healing (primary goals of body building) leads to an increase in muscle turnover. A diet high in plant-based proteins or mixed sources might be a little better than one based solely on animal proteins. Some experts recommend a maximum of 0.5 to 0.8 grams of protein per pound of weight for endurance and strength trained athletes. That is about 80 grams to 125 grams for a person that weighs 160 pounds, or about double the US recommended daily allowance.

Dear HOUSE Calls,    

I’m having trouble sleeping at night and I don’t want to use sleeping pills because of their side effects.  What do you recommend?

That is great that you want to find non-medicine ways to work on this problem.

We recommend looking at ways that you could change your lifestyle to increase the quality of your sleep. There are common sense things like not drinking caffeine too late in the day, as well as trying to keep a consistent waking time and bedtime.

We also tell people to keep bedroom dark and quiet, and the bedroom should be reserved for sex and sleep. Reading and watching TV are great ways to settle down, but should not be done in the bedroom if you are having trouble with sleep. Try to avoid being plugged in (no ipad, smart phone, etc) too close to bedtime.

Try cutting out alcohol for awhile—a drink may help you fall asleep but is likely to interfere to sleep quality. Avoid exercise for about two hours before bedtime. Try relaxation exercises at night, such as mediation to settle down before bedtime.

If those things don’t work, melatonin or an occasional diphenhydramine (Benadryl) are good options.  Sweet dreams!

HOUSE Calls is a weekly column by Dr. Adam Zolotor, Dr. Adam Goldstein, and Dr. Cristy Page on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Questions About Chantix & Low Back Pain

This week we respond to questions about Chantix (a medication to help smokers quit) and low back pain in people who sit all day.

Dear HOUSE Calls,   
I’m trying to quit smoking and my doctor prescribed Chantix, I’ve heard it can cause heart attacks.  Is it safe?

House calls logoWe are so happy that you’ve started trying to quit. It can be a long process. We think that for some people Chantix can be a great aid in the struggle to quit smoking.

About Chantix, there was a study suggesting an increase in the short term risk of heart events with the medication, but mostly in people who already have heart conditions.

The tricky thing here is that quitting smoking is far and away one of the best things you can do for your health. But the near term risk is scarey for some people. And, to confuse things, continuing smoking over time increases your heart attack risk far more than six months of taking Chantix.

There are other medicine and non medicine techniques. These include nicotine replacement therapy (patch, pill, gum, lozenge, and inhaler), buproprion (Wellbutrin and Zyban), behavioral therapy, hypnotherapy, and group support. Some studies show that a combination of several techniques (for instance, nicotine replacement and group support) can work better than just one alone. Talk to your doctor about the pros and cons of each, but the most important thing you can do is keep on that road toward quitting.

Dear HOUSE Calls,   
I have a desk job and my low back hurts.  Is there anything that I can do to help?

This is such a common complaint for office workers. Sitting, and especially sitting for long stretches of time, places a lot of stress on your back and makes your core weak.

There are many things your can do. First, make sure you ergonomic position is reasonable: your feet should be flat on the flow and you knees slightly above your hips. Hopefully you can adjust your chair to make this happen. Your desk still needs to be in reach, but watch key board position, because as your chair drops, your hands might need to reach up to type and that can contribute to carpal tunnel syndrome.

Some offices and companies can help with this by having an ergonomic specialist evaluate your office environment, especially if your back pain becomes a big problem. Some people can even adjust their desks so that it’s possible to work while either sitting or standing.

Second, get up frequently and try to move around. Get a glass of water, or walk a couple of times around your desk. This is good for you in so many ways, and actually will increase your productivity.

Third, get into the habit of stretching your back daily for just five minutes. There are 100s (maybe 1000’s) of suggestions online. Pick 4-6 stretches and make them a habit. Better still, consider an exercise that will strengthen your core and stretch your back at least twice per week. We like yoga, pilates, and swimming. We think you’ll like the results.

HOUSE Calls is a weekly column by Dr. Adam Zolotor, Dr. Adam Goldstein, and Dr. Cristy Page on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Questions About Spots and Combining Pain Medications

This week we respond to questions about petchiae and combining ibuprofen and acetaminophen.

Dear HOUSE Calls,

I have had petechiae (little red spots) for a while and they are getting worse. What should I do?

House calls logoAlthough this might be disturbing to you, this is an interesting symptom for doctors to ponder…

Just to explain to other readers, petechiae are bright red (or purple) small spots on the skin and indicate blood has leaked out of the capillaries or smallest blood vessels. They can get bigger and then it looks more like bruising.

Anybody with new, acute petechiae, especially if they are associated with a fever, should seek prompt medical attention. This can indicate serious medical disease like meningitis.

If the petechiae have been present for a while, we would recommend you see your physician. We see this pretty often when people take aspirin or other medicines (e.g. ibuprofen, Plavix) that interfere with blood clotting. However this can be a symptom of a more serious problem with the numbers or function of platelets (a component of your blood that contributes to clotting).

A doctor will order a simple blood test, the complete blood count (CBC), and the results can give your doctor a lot of information in sorting this out.

Good luck.

 

Dear HOUSE Calls,

My son recently got his wisdom teeth out and the oral surgeon said he should take 600mg of ibuprofen three to four times per day for pain, and Percocet as needed for severe pain. Is that safe? Could so much acetaminophen or ibuprofen cause liver or kidney damage?

Good for you for being cautious with medicine, but in this case, the recommendation is OK.

We recommend the combination of acetaminophen and ibuprofen all the time, especially for fevers in young children and for pain in adults. There is no particular problem with this combination; as long as both are used in safe doses and if the person taking the medicines does not have a particular problem with the liver or kidneys.

There should be some caution in the use of acetaminophen for people with liver problems and some caution in the use of ibuprofen for people with kidney problems. However, how much to worry depends on the problem and how bad it is.

But in general, this combination does not give us any special or extra caution with the kidneys or liver. As long as your son has healthy kidneys (and is not prone to ulcers) a maximum dose of 2400 mg per day of ibuprofen is safe, and a maximum dose of 3000 mg of acetaminophen is safe. We hope your son feels better quickly.

HOUSE Calls is a weekly column by Dr. Adam Zolotor, Dr. Adam Goldstein, and Dr. Cristy Page on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

 

HOUSE Calls: Questions About Tinnitus, Headaches & Athlete’s Foot

This week we respond to questions about tinnitus, headaches, and athlete’s foot.

Dear HOUSE Calls,

Does tinnitus run in the family?

House calls logoGood question. First of all, by way of explanation, tinnitus is a ringing or buzzing in the ear. It is usually unprovoked, and sometimes associated with other conditions, such as hearing loss. It is usually a nuisance condition and often hard to treat, but it can rarely be a sign of something more dangerous. So please get this checked out by your doctor.

As for your question, for some people, tinnitus can be inherited. There has been a gene linked to this condition.

 

Dear HOUSE Calls,

I suffer from headaches and sinus problems, which have been worse recently. Can this be due to extreme changes in weather?

This is a common sentiment, especially with sinuses. However, studies are inconsistent in regards to how changes in weather change affect changes in sinus pain, pressure headaches and related headaches.

Certainly, there are some things that might muddy the issue. Extreme swings in weather are common in the spring and fall, also those are also the seasons that are the most common time for allergies, which can make sinus pressure worse.

Also, many people will self-treat their allergies with decongestants, such as pseudophedrine. These medicines can cause rebound headaches. Try to avoid decongestants, favoring ibuprofen or naprosyn for headaches and antihistamines for allergies.

 

Dear HOUSE Calls,

I’m on my feet 12 hours a day in a kitchen and often my feet get wet. My feet have been itchy, red and peeling. Is this athlete’s foot? What do you recommend?

It sure sounds like athlete’s foot. Athlete’s foot is actually a fungal infection, and not just for athletes. Over–the-counter anti-fungal creams are a great place to start. We usually recommend that your use them for a couple of weeks.

Also, use cotton socks, and change them once mid-shift. And is it possible to wear shoes that will keep your feet drier?

Athlete’s foot is often a chronic and recurrent condition. If it does not respond, or if it recurs, see your family physician. It could be a type of eczema as well. Good luck.

 

HOUSE Calls is a weekly column by Dr. Adam Zolotor, Dr. Adam Goldstein, and Dr. Cristy Page on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

HOUSE Calls: Questions About Lice & ADHD

This week we respond to questions about lice and ADHD.

Dear HOUSE Calls,    

My daughter went to summer camp and they told me that there had been a lice outbreak.  How will I know she has lice? What should I do? Are there any organic treatments?

House calls logoLice is very common. If your daughter gets them, you will probably first notice her itching her scalp – a lot. Inspect her hair and scalp, if she has lice, you will probably see nits. The nits look like a tiny grain of sand adhering to the hair shaft near the scalp. You may even see some lice jumping. Take a deep breath and stay calm!

The mainstay of treatment is shampoo containing permethrin (Nix) or pyrethrum extract (Rid). These will kill the lice and interrupt the life cycle. The products come with a fine tooth come to remove the nits. We recommend you wash bedding and hats in hot water, run hair brushes through the dishwasher, and seal up stuffed animals in a plastic bag for 2 weeks.  You may need to re-treat in 7-10 days.

All of these interventions work fairly well, but re-infection is common.  These critters run rampant in classrooms. Many schools have a ‘no nit’ policy. Unfortunately, this does not prevent spread, and results in absenteeism.

As to your last question, there are a few organic options that may help.  Coating the hair and scalp in Vaseline or Listerine will kill live lice (leave on for an hour). Also, coconut scented shampoo and tea tree oil are lice repellants. Good luck!

Dear HOUSE Calls,    

I think that my child has ADHD. How do I know for sure? How is ADHD best treated?

Those are great questions. Attention deficit hyperactivity disorder (ADHD) is quite common, affecting about 7 percent of children. Predominant symptoms are trouble sitting still, acting on impulses, and difficulty paying attention.  Your child’s family doctor can help you evaluate this concern.

There are specific criteria that doctors use to diagnose ADHD.  To make an accurate diagnosis, your doctor should want to gather feedback from caregivers and/or teachers in more than one setting, usually using standardized rating scales. A careful history, including a family history can be helpful. Also understanding the child’s social environment is important. Sometimes difficulty at home can lead to acting out which is easy to confuse with impulsivity. An interview with the child and a physical exam are key ingredients to the evaluation. The doctor will want to consider other psychiatric conditions (e.g. depression and anxiety) as well as medical conditions (e.g. lead poisoning, thyroid conditions, etc.)

The two most common treatment strategies are medications, usually stimulants like Ritalin, and behavioral therapy. Behavioral therapy often comes in the form of individual and family therapy, academic skills training, and in-classroom academic support.  It is key to work with your child’s teacher on establishing a diagnosis and treatment planning.  Good luck.

HOUSE Calls is a weekly column by Dr. Adam Zolotor, Dr. Adam Goldstein, and Dr. Cristy Page on behalf of YOUR HEALTH™ and the UNC Department of Family Medicine.

About HOUSE Calls
Physicians from the UNC Department of Family Medicine’s YOUR HEALTH™ media bring you weekly information in response to your questions about health and medicine. Send us your questions or comments to YOURHEALTH@unc.edu

The HOUSE Calls staff:

Cristy Page Headshot Dr Cristy Page is an Assistant Professor of Family Medicine at the UNC School of Medicine. A former Morehead scholar, Dr. Page completed degrees in Medicine, Public Health and Family Medicine at UNC. Dr. Page practices full scope family medicine including obstetrics, and she is recognized for important innovations in maternal health, preventive medicine and group well-child care.

Adam Goldstein Headshot Dr. Adam Goldstein is a Professor of Family Medicine at the UNC School of Medicine. As a leading U.S. expert in primary care, Dr. Goldstein has a 20-year history in clinical practice, teaching, and research. He has published over 150 articles, essays, book chapters, and books.

Adam Zolotor Headshot Dr. Adam Zolotor is an Assistant Professor of Family Medicine at the UNC School of Medicine.  Dr. Zolotor Completed his training at the University of Michigan and the University of North Carolina.  He has been in practice for 10 years and and is a nationaly recognized expert in child abuse and child injury prevention.  He directs the Department of Family Medicine maternal and child health services. He is the author of more than 50 articles and book chapters.