Indigenous health: Embracing and enacting the spirit of change. Opening keynote address

In speaking at the Cardiac Society this morning, I am conscious of this year’s 60th Anniversary. It is 60 years since motivated and impassioned people travelled to form the organisation that became the Cardiac Society. They started an organisation and a movement of sorts which was joined by many others over the years and which brings us to this room on this morning. This started in 1952. What were you doing in 1952? Where you just born and for some of you were? Others here were not born and may be your parents hadn’t even met yet. I want you to gain a sense of this time, of 60 years ago.

Are we there yet? Early years reform in Queensland : stakeholder perspectives on the introduction of funded preschool programs in long day care services

Australian educators are currently engaging with wide-ranging, national early childhood reform that is reshaping early childhood education and care. The Australian reform agenda reflects many of the early childhood policy directions championed by bodies such as the Organisation for Economic Cooperation and Development and the United Nations Children's Education Fund, and is based on the dual discourse of (i) starting strong and (ii) investing in the early years. However, despite its traction in policy rhetoric and policy there is little empirical evidence of how reform is being played out. This paper reports on research undertaken in collaboration with the Queensland Office for Early Childhood Education and Care to generate sector feedback on one element of the reform agenda, the implementation of universal preschool in Queensland. The study aimed to determine the efficacy of the new policy in supporting the provision of 'approved preschool programs' within long day care services. Drawing together the views and experiences of a range of stakeholders, including peak organisations, service providers, directors, preschool teachers and government policy officers, it provides a situated case study of the implementation of universal preschool, and offers empirical evidence of how this policy is being played out at the local level. The paper identifies the opportunities and challenges in implementing universal preschool in Queensland that may have bearing on early childhood reform in Australia as well as other countries. Discussion of key findings is set within an overview of the ECEC policy agenda in Australia, with a particular focus on the commitment to universal preschool. Les éducateurs australiens s’engagent présentement dans une vaste réforme nationale de la petite enfance qui remodèle l'éducation et l’accueil de la petite enfance. Le programme de la réforme australienne reflète plusieurs des orientations en politique de la petite enfance soutenues par des organismes comme l'Organisation de coopération et de développement économiques (OCDE) et le Fonds des Nations Unies pour les enfants (UNICEF). Il s’appuie sur le double discours de (i) un bon départ et de (ii) l’investissement dans les premières années. Cependant, en dépit de son attrait en rhétorique de politique et en politique il y a peu de données empiriques sur la façon dont la réforme se déroule. Cet article rend compte de la recherche entreprise en collaboration avec le bureau de l'éducation et l’accueil à la petite enfance du Queensland afin d’obtenir une rétroaction du secteur sur un élément de la réforme, la mise sur pied du préscolaire universel dans le Queensland. L'étude visait à déterminer l'efficacité de la nouvelle politique pour soutenir la disposition «programmes préscolaires approuvés» dans les services de garde à temps plein. En regroupant les perspectives et les expériences d'une gamme d’intervenants, y compris d’importantes organisations, des prestataires de service, des directeurs, des enseignants du préscolaire et des fonctionnaires de politique gouvernementale, elle constitue une étude de cas localisée de l'exécution la mise sur pied du préscolaire universel, et fournit des données empiriques sur la façon dont cette politique se met en place au niveau local. L’article identifie les opportunités et les défis liés à l’implantation du préscolaire universel au Queensland, qui pourraient avoir une portée sur la réforme de petite enfance en Australie ainsi que dans d'autres pays. La discussion des principaux résultats est faite en lien avec un aperçu global de la politique d'éducation et d’accueil de la petite enfance en Australie, avec un accent particulier sur l'engagement envers le préscolaire universel. Los educadores australianos actualmente están involucrados en una amplia reforma de la educación temprana nacional que está revolucionando la educación preescolar y los servicios de cuidado. El programa de reforma Australiana refleja muchas de las direcciones políticas relacionadas con la infancia temprana incitadas por organismos como la Organización de Cooperación y Desarrollo Económicos y el Fondo Educacional Infantil de las Naciones Unidas, y se basa en el doble discurso de (i) empezando fuertemente e (ii) invertir en los primeros años. Sin embargo, a pesar de su política de tracción en retórica y política, hay pocos datos empíricos de cómo la reforma se está llevando a cabo. Este documento informa sobre las investigaciones llevadas a cabo en colaboración con la Oficina de Queensland de Educación tempana y cuidados, para generar comentarios del sector, sobre uno de los elementos de la agenda de reforma, la aplicación del preescolar universal en Queensland. El estudio tiene como objetivo determinar la eficacia de la nueva política para apoyar la prestación de "programas preescolares aprovados" dentro se los servicios de guardería y cuidado. Reuniendo los puntos de vista y las experiencias de una serie de interesados, entre ellos algunas organizaciones cumbre, proveedores de servicios, los directores, los maestros preescolares y oficiales de política y gobierno, se logra un estudio simulado de la implementación del preescolar universal, y ofrece evidencia empírica de cómo esta política se está llevando a cabo en el plano local. El documento identifica las oportunidades y desafíos en la implementación del preescolar universal en Queensland, que puede repercutir en la reforma de la indancia temprana en Australia, así como en otros países. La discusión de los resultados claves se encuentra en el interior de una visión de la agenda política de ECEC en Australia, con un enfoque particular en el compromiso con el preescolar universal.

Vehicle-to-vehicle real-time relative positioning using 5.9 GHz DSRC media

Vehicular accidents are one of the deadliest safety hazards and accordingly an immense concern of individuals and governments. Although, a wide range of active autonomous safety systems, such as advanced driving assistance and lane keeping support, are introduced to facilitate safer driving experience, these stand-alone systems have limited capabilities in providing safety. Therefore, cooperative vehicular systems were proposed to fulfill more safety requirements. Most cooperative vehicle-to-vehicle safety applications require relative positioning accuracy of decimeter level with an update rate of at least 10 Hz. These requirements cannot be met via direct navigation or differential positioning techniques. This paper studies a cooperative vehicle platform that aims to facilitate real-time relative positioning (RRP) among adjacent vehicles. The developed system is capable of exchanging both GPS position solutions and raw observations using RTCM-104 format over vehicular dedicated short range communication (DSRC) links. Real-time kinematic (RTK) positioning technique is integrated into the system to enable RRP to be served as an embedded real-time warning system. The 5.9 GHz DSRC technology is adopted as the communication channel among road-side units (RSUs) and on-board units (OBUs) to distribute GPS corrections data received from a nearby reference station via the Internet using cellular technologies, by means of RSUs, as well as to exchange the vehicular real-time GPS raw observation data. Ultimately, each receiving vehicle calculates relative positions of its neighbors to attain a RRP map. A series of real-world data collection experiments was conducted to explore the synergies of both DSRC and positioning systems. The results demonstrate a significant enhancement in precision and availability of relative positioning at mobile vehicles.

A novel immunodeficiency disorder characterized by genetic amplification of interleukin 25

Many primary immunodeficiency disorders of differing etiologies have been well characterized, and much understanding of immunological processes has been gained by investigating the mechanisms of disease. Here, we have used a whole-genome approach, employing single-nucleotide polymorphism and gene expression microarrays, to provide insight into the molecular etiology of a novel immunodeficiency disorder. Using DNA copy number profiling, we define a hyperploid region on 14q11.2 in the immunodeficiency case associated with the interleukin (IL)-25 locus. This alteration was associated with significantly heightened expression of IL25 following T-cell activation. An associated dominant type 2 helper T cell bias in the immunodeficiency case provides a mechanistic explanation for recurrence of infections by pathogens met by Th1-driven responses. Furthermore, this highlights the capacity of IL25 to alter normal human immune responses.

Genome-wide association study reveals three susceptibility loci for common migraine in the general population

Migraine is a common, heterogeneous and heritable neurological disorder. Its pathophysiology is incompletely understood, and its genetic influences at the population level are unknown. In a population-based genome-wide analysis including 5,122 migraineurs and 18,108 non-migraineurs, rs2651899 (1p36.32, PRDM16), rs10166942 (2q37.1, TRPM8) and rs11172113 (12q13.3, LRP1) were among the top seven associations (P < 5 × 10(-6)) with migraine. These SNPs were significant in a meta-analysis among three replication cohorts and met genome-wide significance in a meta-analysis combining the discovery and replication cohorts (rs2651899, odds ratio (OR) = 1.11, P = 3.8 × 10(-9); rs10166942, OR = 0.85, P = 5.5 × 10(-12); and rs11172113, OR = 0.90, P = 4.3 × 10(-9)). The associations at rs2651899 and rs10166942 were specific for migraine compared with non-migraine headache. None of the three SNP associations was preferential for migraine with aura or without aura, nor were any associations specific for migraine features. TRPM8 has been the focus of neuropathic pain models, whereas LRP1 modulates neuronal glutamate signaling, plausibly linking both genes to migraine pathophysiology.

The clinical effectiveness of interventions to assist perioperative temperature management for women undergoing Cesarean Section : a systematic review

Background Women undergoing Cesarean Section (CS) are vulnerable to the adverse effects associated with perioperative core temperature drop, in part due to the tendency for CS to be performed under neuraxial anesthesia, blood and fluid loss, and vasodilation. Inadvertent perioperative hypothermia (IPH) is a common condition that affects patients undergoing surgery of all specialties and is detrimental to all age groups, including neonates. Previous systematic reviews on IPH prevention largely focus on either adult or all ages populations, and have mainly overlooked pregnant or CS patients as a distinct group. Not all recommendations made by systematic reviews targeting all adult patients may be transferable to CS patients. Alternative, effective methods for preventing or managing hypothermia in this group would be valuable. Objectives To synthesize the best available evidence in relation to preventing and/or treating hypothermia in mothers after CS surgery. Types of participants Adult patients over the age of 18 years, of any ethnic background, with or without co-morbidities, undergoing any mode of anesthesia for any type of CS (emergency or planned) at healthcare facilities who have received interventions to limit or manage perioperative core heat loss were included. Types of intervention(s) Active or passive warming methods versus usual care or placebo, that aim to limit or manage core heat loss as applied to women undergoing CS were included. Types of studies Randomized controlled trials (RCTs) that met the inclusion criteria, with reduction of perioperative hypothermia a primary or secondary outcome were considered. Types of outcomes Primary outcome: maternal core temperature measured during the preoperative, intraoperative and postoperative phases of care Secondary outcomes: newborn core temperature at birth, umbilical pH obtained immediately after birth, Apgar scores, length of Post Anesthetic Care Unit (PACU) stay, maternal thermal comfort. Search strategy A comprehensive search was undertaken of the following databases from their inception until May 2012: ProQuest, Web of Science, Scopus, Dissertation and Theses PQDT (via ProQuest), Current Contents, CENTRAL, Mednar, OpenGrey, Clinical Trials. There were no language restrictions. Methodological quality Retrieved papers were assessed for methodological quality by two independent reviewers prior to inclusion using JBI software. Disagreements were resolved via consultation with the third reviewer. An assessment of quality of the included papers was also made in relation to five key quality factors. Data collection Two independent reviewers extracted data from the included papers using a previously piloted customized data extraction tool. Results 12 studies with a combined total of 719 participants were included. Three broad intervention groups were identified; intravenous (IV) fluid warming, warming devices, leg wrapping. IV fluid warming, whether administered intraoperatively or preoperatively, was found to be effective at maintaining maternal (but not neonatal) temperature and preventing shivering, but does not improve thermal comfort. The effectiveness of IV fluid warming on Apgar scores and umbilical pH remains unclear. Warming devices, including forced air warming and under body carbon polymer mattresses, were effective at preventing hypothermia and reduced shivering, however were most effective if applied preoperatively. The effectiveness of warming devices to improve thermal comfort remains unclear. Preoperative forced air warming appears to aid maintenance of neonatal temperature, while intraoperative forced air warming does not. Forced air warming was not effective at improving Apgar scores and the effects for umbilical pH remain unclear. Conclusions Intravenous fluid warming, by any method, improves maternal temperature and reduces shivering for women undergoing CS. Preoperative body warming devices also improve maternal temperature, in addition to reducing shivering.

A systematic review of baseline psychosocial characterisation in dietary randomised controlled trials for weight loss

BACKGROUND/OBJECTIVE: To investigate the extent of baseline psychosocial characterisation of subjects in published dietary randomised controlled trials (RCTs) for weight loss. SUBJECTS/METHODS: Systematic review of adequately sized (nX10) RCTs comprising X1 diet-alone arm for weight loss were included for this systematic review. More specifically, trials included overweight (body mass index 425 kg/m2) adults, were of duration X8 weeks and had body weight as the primary outcome. Exclusion criteria included specific psychological intervention (for example, Cognitive Behaviour Therapy (CBT)), use of web-based tools, use of supplements, liquid diets, replacement meals and very-low calorie diets. Physical activity intervention was restricted to general exercise only (not supervised or prescribed, for example, VO2 maximum level). RESULTS: Of 176 weight-loss RCTs published during 2008–2010, 15 met selection criteria and were assessed for reported psychological characterisation of subjects. All studies reported standard characterisation of clinical and biochemical characteristics of subjects. Eleven studies reported no psychological attributes of subjects (three of these did exclude those taking psychoactive medication). Three studies collected data on particular aspects of psychology related to specific research objectives (figure scale rating, satiety and quality-of-life). Only one study provided a comprehensive background on psychological attributes of subjects. CONCLUSION: Better characterisation in behaviour-change interventions will reduce potential confounding and enhance generalisability of such studies.

From strategic design to design integration

Within a growing awareness of design as central to the strategic success and the sustained competitive advantage of firms, this paper examines how companies pursue design driven innovation (Verganti, 2008, 2009) and respond to design led innovation initiatives (Matthews & Bucolo 2013). Specifically, this paper reports the findings of a collaborative research project where CEO sponsored senior managers from five multi-national organisations, met regularly over a twelve-month period, to discuss their progress on applying a design led approach in their firms. This longitudinal research project traced the process and progress of change instigated by the senior management representatives, as well as the deeper investigation of the barriers and challenges to re-frame design more strategically in their organisation. Data were collected through workshops and interviews throughout the twelve-month period, regarding the firms’ journeys and also the barriers and challenges firms faced in order to become design led. The findings present a novel set of implications for both designers and management scholars. This paper seeks to contribute to research and practice by investigating the processes and outcomes of a design led innovation program and to propose implications for practice for designers and management.

Distributed low-power image processing in wireless sensor networks for intelligent video surveillance applications

Distributed Wireless Smart Camera (DWSC) network is a special type of Wireless Sensor Network (WSN) that processes captured images in a distributed manner. While image processing on DWSCs sees a great potential for growth, with its applications possessing a vast practical application domain such as security surveillance and health care, it suffers from tremendous constraints. In addition to the limitations of conventional WSNs, image processing on DWSCs requires more computational power, bandwidth and energy that presents significant challenges for large scale deployments. This dissertation has developed a number of algorithms that are highly scalable, portable, energy efficient and performance efficient, with considerations of practical constraints imposed by the hardware and the nature of WSN. More specifically, these algorithms tackle the problems of multi-object tracking and localisation in distributed wireless smart camera net- works and optimal camera configuration determination. Addressing the first problem of multi-object tracking and localisation requires solving a large array of sub-problems. The sub-problems that are discussed in this dissertation are calibration of internal parameters, multi-camera calibration for localisation and object handover for tracking. These topics have been covered extensively in computer vision literatures, however new algorithms must be invented to accommodate the various constraints introduced and required by the DWSC platform. A technique has been developed for the automatic calibration of low-cost cameras which are assumed to be restricted in their freedom of movement to either pan or tilt movements. Camera internal parameters, including focal length, principal point, lens distortion parameter and the angle and axis of rotation, can be recovered from a minimum set of two images of the camera, provided that the axis of rotation between the two images goes through the camera's optical centre and is parallel to either the vertical (panning) or horizontal (tilting) axis of the image. For object localisation, a novel approach has been developed for the calibration of a network of non-overlapping DWSCs in terms of their ground plane homographies, which can then be used for localising objects. In the proposed approach, a robot travels through the camera network while updating its position in a global coordinate frame, which it broadcasts to the cameras. The cameras use this, along with the image plane location of the robot, to compute a mapping from their image planes to the global coordinate frame. This is combined with an occupancy map generated by the robot during the mapping process to localised objects moving within the network. In addition, to deal with the problem of object handover between DWSCs of non-overlapping fields of view, a highly-scalable, distributed protocol has been designed. Cameras that follow the proposed protocol transmit object descriptions to a selected set of neighbours that are determined using a predictive forwarding strategy. The received descriptions are then matched at the subsequent camera on the object's path using a probability maximisation process with locally generated descriptions. The second problem of camera placement emerges naturally when these pervasive devices are put into real use. The locations, orientations, lens types etc. of the cameras must be chosen in a way that the utility of the network is maximised (e.g. maximum coverage) while user requirements are met. To deal with this, a statistical formulation of the problem of determining optimal camera configurations has been introduced and a Trans-Dimensional Simulated Annealing (TDSA) algorithm has been proposed to effectively solve the problem.

Clinical outcomes of vitamin D deficiency and supplementation in cancer patients

Results of recent studies suggest that circulating levels of vitamin D may play an important role in cancer-specific outcomes. The present systematic review was undertaken to determine the prevalence of vitamin D deficiency (<25 nmol/L) and insufficiency (25-50 nmol/L) in cancer patients and to evaluate the association between circulating calcidiol (the indicator of vitamin D status) and clinical outcomes. A systematic search of original, peer-reviewed studies on calcidiol at cancer diagnosis, and throughout treatment and survival, was conducted yielding 4,706 studies. A total of 37 studies met the inclusion criteria for this review. Reported mean blood calcidiol levels ranged from 24.7 to 87.4 nmol/L, with up to 31% of patients identified as deficient and 67% as insufficient. The efficacy of cholecalciferol supplementation for raising the concentration of circulating calcidiol is unclear; standard supplement regimens of <1,000 IU D3 /day may not be sufficient to maintain adequate concentrations or prevent decreasing calcidiol. Dose-response studies linking vitamin D status to musculoskeletal and survival outcomes in cancer patients are lacking.

Storage - the necessity for a Smart-Grid

Energy policy is driving renewable energy deployment with most of the developed countries having some form of renewable energy portfolio standard and emissions reduction target. To deliver upon these ambitious targets, those renewable energy technologies that are commercially available, such as wind and solar, are being deployed, but inherently have issues with intermittency of supply. To overcome these issues, storage options will need to be introduced into the distribution network with benefits for both demand management and power systems quality. How this can be utilised most effectively within the distribution network will allow for an even greater proportion of our energy demand to be met through renewable resources and meet the aspirational targets set. The distribution network will become a network of smart-grids, but to work efficiently and effectively, power quality issues surrounding intermittency must be overcome, with storage being a major factor in this solution.

An exploratory study to evaluate whether medical nutrition therapy can improve dietary intake in hospital patients who eat poorly

Background and aims The Australasian Nutrition Care Day Survey (ANCDS) reported two-in-five patients consume ≤50% of the offered food in Australian and New Zealand hospitals. After controlling for confounders (nutritional status, age, disease type and severity), the ANCDS also established an independent association between poor food intake and increased in-hospital mortality. This study aimed to evaluate if medical nutrition therapy (MNT) could improve dietary intake in hospital patients eating poorly. Methods An exploratory pilot study was conducted in the respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, percentage food intake (0%, 25%, 50%, 75%, and 100%) was evaluated for each main meal and snack for a 24-hour period in patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals due to nutrition-impact symptoms were referred to ward dietitians for MNT. Food intake was re-evaluated on the seventh day following recruitment (post-MNT). Results 184 patients were observed over four weeks; 32 patients were referred for MNT. Although baseline and post-MNT data for 20 participants (68±17years, 65% females) indicated a significant increase in median energy and protein intake post-MNT (3600kJ/day, 40g/day) versus baseline (2250kJ/day, 25g/day) (p<0.05), the increased intake met only 50% of dietary requirements. Persistent nutrition impact symptoms affected intake. Conclusion In this pilot study whilst dietary intake improved, it remained inadequate to meet participants’ estimated requirements due to ongoing nutrition-impact symptoms. Appropriate medical management and early enteral feeding could be a possible solution for such patients.

Bringing the real world into university learning

Introduction: As part of ongoing quality assurance, all university programs must be regularly reviewed to ensure curriculum is current, meets university and national standards, and for medical science, criteria for AIMS Accreditation. With recent developments at the national and international level also signaling change, a course design team (CDT) was assembled and tasked with developing and implementing a new four year Bachelor of Medical Laboratory Science (BMLS) course at QUT. Method: A whole-of-course approach was adopted, incorporating inverted curriculum and Capstone experience. First, course vision and desired graduate profile are defined as course learning outcomes (CLO), i.e. skills, knowledge, behaviours and attributes graduates must demonstrate. CLO are then back-mapped into introductory, developmental and expected phases from fourth to first year on a course plan and assessment map. Unit learning outcomes (ULO) are then defined, and finally, each unit (subject) designed, directly aligned with assessment. Results: The resulting BMLS course represents a deliberate program of study across four years, which from day one, focuses on the professional aspects of MLS, clinical pathology disciplines, and incrementally developing and assessing the skills, knowledge, behaviours and attributes required to undertake the Work Integrated Learning Internship (WILI) and Capstone experience in final year, and subsequently, graduate from the program. Conclusions: At the start of the year, the BMLS commenced with higher than anticipated enrolments. To date, survey data and feedback is positive, with particular emphasis on the directed nature of the course. The method of course design also ensures university/national standards, and criteria for AIMS Accreditation have been met.

An observational study of nutrition and physical activity behaviours, knowledge, and advice in pregnancy

Maternal obesity, excess weight gain and lifestyle behaviours during pregnancy have been associated with future overweight and other adverse health outcomes for mothers and babies. This study compared the nutrition and physical activity behaviours of Australian healthy (BMI ≤ 25 k/m2) and overweight (BMI ≥ 25 kg/m2) pregnant women and described their knowledge and receipt of health professional advice early in pregnancy. Methods Pregnant women (n=58) aged 29±5 (mean±s.d.) years were recruited at 16±2 weeks gestation from an Australian metropolitan hospital. Height and weight were measured using standard procedures and women completed a self administered semi-quantitative survey. Results Healthy and overweight women had very similar levels of knowledge, behaviour and levels of advice provided except where specifically mentioned. Only 8% and 36% of participants knew the correct recommended daily number of fruit and vegetable serves respectively. Four percent of participants ate the recommended 5 serves/day of vegetables. Overweight women were less likely than healthy weight women to achieve the recommended fruit intake (4% vs. 8%, p=0.05), and more likely to consume soft drinks or cordial (55% vs 43%, p=0.005) and take away foods (37% vs. 25%, p=0.002) once a week or more. Less than half of all women achieved sufficient physical activity. Despite 80% of women saying they would have liked education about nutrition, physical activity and weight gain, particularly at the beginning of pregnancy, less than 50% were given appropriate advice regarding healthy eating and physical activity. Conclusion Healthy pregnancy behaviour recommendations were not being met, with overweight women less likely to meet some of the recommendations. Knowledge of dietary recommendations was poor and health care professional advice was limited. There are opportunities to improve the health care practices and education pregnant women received to improve knowledge and behaviours. Pregnant women appear to want this.

Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : A modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist presents means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances in which nurse-administered procedural sedation and analgesia is used in the cardiac catheterisation laboratory. Methods A sequential mixed methods design was utilised. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised in accordance with responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterisation laboratory nurses. All but one of the draft recommendations met the pre-determined cut-off point for inclusion. There were a total of 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer twenty four recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Post-procedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterisation laboratory setting.