Winterize Yourself for Outdoor Sports

This week marks the official start of winter on December 21. And while our weather is typically mild in Central Texas, we do experience the occasional bout of freezing temps, snow, and ice--just like we saw recently.

If you're planning on continuing your running or outdoor workouts over the next few months, here are some good reminders on bracing for the cold:

1. Warm up inside first. Before heading out on your running route, do a quick warm-up inside to get blood flowing and your heart rate up in advance of the shock of the cold. Not warming up properly can lead to shortness of breath, stressed joints and muscle strains.
2. Dress in layers. Several light, breathable layers of moisture-wicking fabric work best in cold weather. You can shed layers as needed, and remember to wear a waterproof shell over it all if you expect rain.
3. Don't forget to protect your extremities. Fingers, toes, ears, and noses are the most susceptible to frostbite if temps dip down to freezing or below (unlikely for Central Texas!). Knit hats bulled down can cover ears, and a scarf around the neck pulled up can keep your nose warm.
4. Hydrate as if it were hot out. Even in the cold, your body loses a great deal of moisture when sweating. Drink water before, after, and during a rigorous run or workout--a good rule is to drink half your weight in ounces throughout the day.
5. Watch out for ice. It's rare, but when it's there, a nasty slip or fall can lead to very serious injuries like broken bones, fractures, and even concussions. Wear sturdy shoes with good traction and stick to more well-traveled roads and/or fields.

Also, with shorter daylight hours, early morning or after-work exercise can be dangerous. Stay visible by wearing reflective gear, or invite a friend to join you so you're not alone. Better yet, switch it up and opt for a midday/lunchtime workout when temperatures are at their peak.

(Adapted from Runner's World)

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Bad Air, Bad Bones?

We all know that air pollution is harmful to your lungs, but new research is now saying that it can be damaging to your bones as well.

A recent study in The Lancet Planetary Health found that air pollution increased the risk of bone fractures and osteoporosis in people over 65 years. Osteoporosis is a serious condition caused by decreased bone mineral density leaving bones brittle, weak and susceptible to breaks.

Data was collected from two independent studies--one tracking hospital admissions among 9.2 million Medicare patients in the Northeast over an eight-year period, and another analyzed a specific parathyroid hormone (which supports bone health) in nearly 700 low-income men living in Boston.

Here are the highlights:

• The potential for bone fractures among those over age 65 years increased steadily as levels of air pollution increased.
• Those living in locations with higher levels of air pollution (such as industrial areas) had lower concentrations of the parathyroid hormone and lower bone density.
• Air pollution was likened to a form of diluted smoking which can cause cancer, heart disease, lung disease, and diminished bone density.

In addition to avoiding areas with heavy smog and poor air quality, other ways to protect yourself against osteoporosis include following a diet rich in calcium, taking calcium supplements as needed, and exercising regularly to keep bones and joints strong.

If you are interested in scheduling a bone density exam, or speaking with one of our specialists about your bone health, please contact us here for an appointment.

(Adapted from The New York Times-Well)

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Is your housework hurting you?

You're about to have a house full of guests for the holidays, so everything has to be spotless, right? But experts warn house cleaning could pose some potential dangers, including falls from step ladders while dusting hard-to-reach spots, slipping on wet floors after mopping, and back strains from strenuous vacuuming or incorrectly lifting heavy equipment.

These things can result in some serious injuries such as:

• Sprains and strained muscles
• Back, neck or shoulder pain
• Broken bones and fractures
• Overuse injuries
• Tendonitis

Here are a few simple tips to keep safe while tidying up:

• Warm up just as you would before any workout. Do a few back stretches and neck rolls before setting out to sweep or vacuum your entire home.
• Keep a set of cleaning supplies both upstairs and down to avoid lugging them back and forth.
• Invest in products that offer reachability, like extender wands, to help you tackle high-up spots.
• Always practice correct ladder safety when climbing up (on a ladder or step stool) to clean something.
• Try alternating sides when vacuuming, and switch it up between right and left arms for each room.

The noxious fumes from some cleaning products--especially those that are ammonia or bleach-based--can be dangerous too.

Make sure to open a window or turn on the AC when cleaning for good ventilation, and never mix two products together. Consider some green alternatives like vinegar, lemon juice, and baking soda mixed with warm water, or one of the many certified "green" or "eco-friendly" solutions on the market these days.

And if you do feel you've pulled something, or suffered an injury while cleaning, please contact us for an appointment.

(Adapted from Healthline.com)

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Watch out for these toys this year...

As holiday gift-giving reaches a frenzied pace this month, take a minute to ensure you've made safe choices.

While that new motorized scooter with super-fast, jet-like propulsion seems cool, it could be a disaster just waiting to happen.

ERs report huge spikes in activity in December and early January due to injuries from unsafe toys. Common injuries include sprains and strains, broken bones or fractures, deep cuts and skin lacerations, and even concussions. Ride-on toys are typically the worst offenders.

Each year, the consumer group WATCH (World Against Toys Causing Harm) releases a list of toys deemed unsafe after hours of rigorous testing and evaluation.

Here are the worst offenders:

• Do it yourself slack line kits (strung between two trees)
• Motorized skates
• Motorized scooters
• Hoverboards
• Drones
• Faulty fidget spinners (can lead to cuts on fingers and even choking)

The motorized toys have the biggest risk for your child because they can lose control and suffer serious injuries within split seconds. If you do opt for one of these items, make sure to review all operating instructions beforehand and always keep a watchful eye over them.

With any ride-on toy, such as a bike or skateboard, you'll also want to invest in a good quality helmet and arm or elbow pads.

And for the small kiddos, don't forget to check their gifts for any choking hazards.

If your child suffers a serious injury after hours, visit Texas Orthopedics' Urgent Injury Clinic where no appointment is necessary and X-ray and casting capabilities are right onsite.

(Adapted from Good Housekeeping)

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Stay Stress-Free this Holiday

You sailed through Halloween and the Thanksgiving holiday. But now December is here, and it's really 'go' time. There are so many parties and the 'to do' lists seem endless! And for some -- that translates to some major stress.

So, take a deep breath. And check out these seven tips to help you stay sane and stress-free:

1. Take a hike. Literally. Hiking or walking for at least 30 minutes a day outdoors stimulates the production of serotonin, a feel-good chemical in the brain.
2. Sniff some citrus. The scent of lemons and oranges is proven to alleviated stress and better your mood. Rub a slice of the inside of the peel on your skin to release the essential oils or place a bowl of fresh zest on the counter to diffuse throughout the room.
3. Stick to your daily routine. Keep your regular workout schedule going, or weekly lunch date with friends on your calendar. This sense of normalcy will help you feel more in control and less overwhelmed.
4. Let go of perfection. You may forget to mail a card or gift, or send the wrong item to your child's gift exchange at school. Cut yourself some serious slack at this time of year. It will all be okay.
5. Silence your cell. Dedicate a few days over your holiday to unplug. Turn off automatic email and text alerts, and check in only when absolutely necessary.
6. Have some honey. Honey has antioxidant and antibacterial properties that can boost immunity, and the sweetness packs and energetic punch. Try a spoonful in your favorite warm winter beverages.
7. Don't overschedule. Focus on what and who are really important to you during the holidays. Your family maybe or a few special friends? Choose how you spend your time wisely, and remember that it's always perfectly acceptable to politely decline any invitation or say 'no' to a task you are not able to complete.

(Adapted from Health.com)

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What's the deal with ketones?

Many high-profile athletes claim that ketones are the key to their enhanced performance.

But what are they? And do they really work?

Ketone supplements replicate the effects of a high-fat, low-carb diet favored by many athletes these days (over the traditional high-carb diet typically followed for training). Burning through fat stored in the body is said to produce quicker bursts of energy/better performance than slower-digested carbs.

A recent study published in Frontiers in Physiology, (conducted by the Australian Institute of Sport), evaluated the popular supplement on eleven members of a world-class men's cycling team. The men were given either a placebo drink or one laced with a ketone supplement an hour ahead of and then immediately before long rides, each averaging about 19 miles with intense pedaling at high speeds.

Here's what they found:

• Every rider who drank the ketone supplement performed worse than others who did not.
• Those riders' times were about two percent slower and power output was almost four percent less.
• Some form of gastrointestinal upset (vomiting, nausea, dry retching) was reported by each rider who drank the ketone supplement.

While this study was small, and more research on ketones is needed, scientists feel that any boost athletes may feel from the supplements could be largely mental.

If you are considering a ketone supplement, do so in moderation. Burning through stored fat too quickly can lead to sickness, as evidenced by the study, and potentially damage muscles and bones that do actually funnel nutrients from stored fat cells. This can result in muscle strains, sprains and even fractures or broken bones.

If you have questions about ketone supplements and your training, please contact us for an appointment with one of our specialists.

(Adapted from The New York Times-Health)

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How to Holiday-Proof Your House

The moment the last of the turkey leftovers are finished (and sometimes even before), people are pulling out ladders to string up lights and decorate for the next holiday. While decorating your house and packing it in with family and friends are what the holidays are all about, it can also create an environment ripe for accidents and serious injuries like falls.

The CDC (Centers for Disease Control and Prevention) reports that more than 300,000 adults age 65 years and older suffer hip fractures and are hospitalized each year. Falls are the cause of more than 95 percent of these fractures. It's important for seniors to be careful around the holidays especially when in unfamiliar surroundings or homes that they visit infrequently.

Young children are also at risk for falls, excitedly dodging between trees, strings of light, garland, and trying out new toys.

Here are five tips to keep your home safe for everyone this season:

1. Reduce clutter. Keep presents, packages and empty decoration boxes clear of doorways, hallways, and away from stairs.
2. Designate a play area for young kids. Encourage them to play in their rooms or a den or family room away from the Christmas tree, fireplace, or any areas outside that are heavily decorated.
3. Install nightlights. If having family and friends stay overnight, make sure bathrooms, hallways, and stairs are well-lit for getting around in the dark.
4. Keep outdoor walkways clear. While we are not often at risk for slippery or icy walkways in Central Texas, you should still make sure that driveways, sidewalks, and entryways are clear of windblown leaves, sticks, or other debris for your visitors.
5. Consider baby/safety gates. Placed strategically on stairs, these could prevent toddlers, and elderly family members alike, from falling if unattended.

Also remember to practice proper ladder safety when climbing up to install outside lights or trim the tree. Choose the correct height for the job and make sure that it can withstand your weight. For other reminders on safe ladder use, visit the AAOS Ladder Safety Guide.

(Adapted from the AAOS-American Academy of Orthopaedic Surgeons)

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2017 Super Doctors

 

 

Texas Orthopedics is proud to share that several of our physicians have been honored as Super Doctors for 2017 in the December issue of Texas Monthly magazine.

 

Please help us to congratulate:

 

• Bradley R. Adams, DO
• Robert A. Foster, MD
• Peter M. Garcia, Jr., MD
• Tyler D. Goldberg, MD
• Brian T. Hardy, MD
• Richard A. Lutz, DO
• James L. Smith, Jr., MD
• Scott A. Smith, MD

 

Super Doctors is a national group that salutes outstanding physicians from more than 40 medical specialties who have earned a high degree of peer recognition and/or professional achievement.

 

Texas Orthopedics has had a number of our physicians land on this list each year. We are exceptionally proud of them, and all of our outstanding staff members, for their heartfelt dedication to both their patients and the advancement of the medical community.

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

RA and Sleep

With shorter days, longer nights, and the hint of a chill now finally in the air, conditions are ripe for some sweet slumbering.  Sadly though, that may not be in the cards if you are one of the 75% of people with rheumatoid arthritis (RA) who report sleep problems.

 

RA is an autoimmune deficiency causing painful inflammation of the joints and surrounding tissues. Stiff joints can keep you awake at night and make it difficult to find a comfortable sleeping position.

 

One big way to alleviate sleeplessness at night is to exercise during the day. Physical activity can help lubricate joints so that they are not as stiff and tight. And, exercise actually tires you out so that you are more relaxed and restful by the end of the day.  (Avoid working out within three hours of your bedtime because the adrenalin boost that you get can keep you awake.)

 

Check with your rheumatologist or physical therapist about which type of exercise is best for you and your condition. Good options for those suffering from RA include low-impact activities like walking, swimming, yoga, tai chi, and Pilates.

 

Here are some other tips to help get some Z’s:

 

• Stick to a sleep schedule, and go to bed and wake up every day at close to the same hour.
• Limit caffeine and alcohol consumption, especially later in the day. 
• Wind down before hitting the hay. Read, take a warm bath (which can also soothe joint pain), or enjoy a cup of herbal tea.
• Outfit your bedroom for optimal sleep—cover windows, limit electronics displaying disruptive bright lights or noise, and adjust thermostats so you’ll be comfortable all night, especially as the temperature drops.

 

If you still have serious sleep issues and are not getting at least six to eight hours per night, due to your RA symptoms, please contact us for an appointment with one of our rheumatologists.

 

(Adapted from Healthgrades)

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Opiod Alternaties and Dr. Goldberg on KVUE

The Trump administration recently declared the opioid epidemic a public health emergency and is taking action to address it.

But physicians are also doing their part to help alleviate the risk of addiction among their surgical patients by recommending over-the-counter pain relief remedies first.

One recent study published in the JAMA (Journal of the American Medical Association) pitted opioids against a combination of acetaminophen (Tylenol) and ibuprofen (Advil) to alleviate pain during common ER visits for sprains, strains, fractures, and other minor injuries.

Of the more than 400 men and women evaluated, there were no significant differences reported in either pain relief or how fast relief took place when using a combination of acetaminophen and ibuprofen OR corresponding doses of oxycodone, hydrocodone, or codeine.

Texas Orthopedics’ own Dr. Tyler Goldberg is practicing this same protocol on most of his surgery patients and he discussed it with ABC affiliate KVUE-TV.

Dr. Goldberg has stopped prescribing opioids after surgery in about 85 percent of his patients. He explained that some patient can become addicted, or physically dependent, on these drugs in as little as seven days.

For an alternative pain protocol, he recommends patients try Tylenol first, along with cold/ice therapy, anti-inflammatory medications to reduce swelling, and movement of the limb or joint as soon as possible to get blood flowing and avoid stiffness.

Orthopedic surgeons everywhere, like Dr. Goldberg, have been instrumental in educating patients about other options to manage pain. Check out the AAOS’ stance on prescription safety here.

You can view the full story featuring Dr. Goldberg and one of his surgery patients here.

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

Movember and Men's Health

At Texas Orthopedics, we focus on orthopedic and sports-related issues affecting men and women. But in November, we hear a lot about 'Movember' and men's medical conditions like prostate and testicular cancer, depression and suicide prevention.

And we see a lot more facial hair in the process because some men mark this month by growing outlandish mustaches to show their support or by raising funds through locally organized walks, runs, and other events.

According to the American Cancer Society, prostate cancer is the second most common form of cancer striking men today, following skin cancer. Here are a few things you should know about it:

• It's prevalent in older men over the age of 50.
• About one in seven men will be diagnosed with it in their lifetime.
• It is highly treatable if discovered early.

Like prostate cancer, testicular cancer responds very well to treatment if caught early. It is found more in younger and middler-aged men with the average age of diagnosis being 33.

Visit the American Cancer Society for the risk factors and symptoms of each.

Along with cancer, other health issues men face that could have serious consequences--even prove fatal--if not treated properly include heart disease, diabetes, kidney disease, and COPD which affects the lungs.

Men, listen up--to ensure that you are at your very best:

• Schedule regular exams, and have a conversation with your physician about a PSA test (for prostate cancer) and other important screenings suited to your health history.
• Know your body: every inch, wrinkle, crease, fold, bump, bulge, and bruise. Get checked out immediately if something ever feels or looks abnormal or has difficulty healing.
• Move more. Stay fit and active, maintain a healthy body weight, and eat well.

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic)

(Courtesy of the Movember Foundation)

Hot or cold? Which is best for muscle recovery?

If you're participating in an upcoming holiday fun run, or training for a more series half or full marathon in the next few months, it's important to plan how you'll help your muscles recover after training and after the race.

Some runners prefer heat and warmth to soothe their tired limbs, while others prefer an icy numbness. There is a longstanding medical debate as to which is better for sore muscles--hot or cold treatment.

A new study appearing in the Journal of Physiology shows that heat may be edging out ice.

Researchers at the Karolinska Institutet (Sweden) subjected a group of men and women to a series of arm exercises (via an arm pedaling machine) at an intense pace, with shorter bouts of easier movements woven in. They tracked both heart rate and muscle power output.

After the routine, the men and women slipped on long warmed arm cuffs (heated to 100°F) and then later chilled cuffs registering at around 5°F. They were also given carbohydrates to refuel. Here are the key findings:

• Participants were more eager to return to the rigorous arm activity after their muscles had been warmed.
• Muscle power output was "markedly better" following the warm cuffs, and pain reported was minimal.
• Muscle output decreased after the cooling cuffs.

While the study does suggest that heat can play an important role in muscle recovery, researchers were also quick to add that consumption of carbohydrates (specifically the glycogen found in carbs) after intense exercise is crucial.

It may be that the nourishment found in carbs is more easily activated when the body is warmed up as opposed to chilled...leading to muscles feeling better, faster.

The study states that the most beneficial treatment though is really what feels best and is most comforting to you, whether hot or cold. That along with a hearty helping of carbs and hydration, will have your muscles rebounding in no time.

If you have intense muscle pain or cramping that does not subside a few days following training, a race, or extreme exercise, please contact us for an appointment.

(Adapted from The New York Times-Health)

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Veterans Day 2017

Veterans Day is celebrated on November 11 of each year to commemorate the end of World War I.

Texas Orthopedics is honored to salute all of the active duty and retired servicemen and women who we have treated over the years. We humbly thank them for their selfless dedication to our country.

We are also honored to have with us in our Texas Orthopedics family several staff members who have serviced in the armed forces as well, including:

• Dr. Peter Garcia
• Dr. Richard Lutz
• Dr. Bradley Adams
• Dr. Zachariah Logan
• Jody Ramirez
• Jo Lopez
• Debbie Jara
• Allen Schultz
• Jessica Bradley
• Kathy Mitchell
• Megan White
• Anthony Papp
• Adrian Garcia 
• Brian Dearing

Please join us in acknowledging these men and women, and all of those who have so bravely served in the military.

Happy Veterans Day!

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Fishing Injuries

Those who love fishing often go all out for the sport...hook, line, and sinker. With access to so many lakes and rivers in Central Texas, and the Gulf Coast just a few hours away, it's no wonder this is a fisherman's paradise. What's not paradise is suffering an injury while enjoying a day on the water.

Most fishing injuries involve the hand and wrist, including:

• Fish bites and impalements: resulting in soft-tissue or tendon damage
• Sting ray lacerations (if fishing in salt water): when the sting ray's venomous barb pierces the skin
• Lodged fish bones or scales: also piercing the skin in a splinter-like fashion and possibly trapping harmful bacteria underneath
• Hand and wrist overuse injuries: as in sports like baseball and golf, repetitive use of the wrist in casting and reeling motions can cause damage to the joint and surrounding tendons.

Another serious condition to be aware of is Fish Handler's Disease. This happens when you have an existing cut or scrape and you handle a diseased fish, which could cause a serious bacterial infection. Symptoms can include fever, swelling, tenderness, and bruised-like spots at the site of the wound. Antibiotics are often the only way to treat it.

With any fishing injury resulting in significant blood loss, be sure to:

• Clean the wound with warm, soapy water
• Bandage it with clean dressings
• Get medical attention immediately if you think you need stitches

If you've been injured while fishing and suffer from an existing health condition like diabetes of an autoimmune disorder such as arthritis, seek treatment from a certified hand specialist. It is also a good idea to wear protective gloves.

As a reminder, always remember to carry a First Aid kit with you when fishing, and note the quickest route back to land (if boating) in case of a medical emergency.

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

(Adapted from AAOS-American Academy of Orthopaedic Surgeons)

Halloween Safety

 

 

As you head out for tricks and treats with your little goblins, be aware of some potentially scary stuff on Halloween night. And we don’t mean the black cats and haunted houses…

 

The National Safety Council claims Halloween night is one of the most dangerous of the year—warning that kids are more than twice as likely to be hit (and killed!) by a car on Halloween more so than any other day.

 

In addition to pedestrian/automobile accidents, Halloween creates the perfect storm for many other common injuries. Being out at dark (even dusk) and running around excitedly from house to house can lead to trips, falls and:

 

• Fractures and broken bones
• Strains and sprains
• Bumps and bruises
• Serious cuts and scrapes

 

Here are some tips to help your little ones stay safe while trick-or-treating:

 

• Make sure costumes don’t restrict movement or vision and aren’t too long or dragging on the ground
• Map out your route beforehand and stay on streets that are well-lit
• Bring along flashlights, glow-sticks and even reflective gear to make your presence known
• Stay on sidewalks or defined paths and watch vigilantly for cars while crossing streets
• Never allow kids to eat already opened or unpackaged treats
• Teach kids to never enter a person’s home when ringing the doorbell, no matter how friendly they are

 

 For older children and teens:

 

• Educate them about the dangerous consequences of getting in the car with someone who has been drinking on this night – or any night
• Establish a firm time for them to be home
• Alert them to the hazards of walking in the dark while talking or texting at the same time--a seemingly innocent and common occurrence that could potentially lead to a serious accident

 

Have a safe and happy Halloween from Texas Orthopedics!

 

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

(Courtesy of the National Safety Council)

Dr. Tyler Goldberg in Honduras

Dr. Tyler Goldberg and twenty-one other healthcare professionals recently traveled to Honduras with One World Surgery on a humanitarian trip. While there, they faced a logistical nightmare as they dealt with the effects of one of the most devastating hurricanes in U.S. history—Hurricane Harvey.

Not wanting to disappoint the many patients awaiting joint replacement surgery at the Holy Family Surgery Center there, the group changed course and rerouted their original travel through Miami instead of storm-ravaged Houston to arrive in the tiny Central American country.

It took a great deal of coordination and perseverance to get there, Dr. Goldberg told a reporter from Becker’s ASC Review.   

“Coordination is key when performing a short-term mission trip,” said Dr. Goldberg. “No one person can do this alone."

Due to the impending arrival of yet another hurricane (this time Irma) and once again fraught travel scenarios, the team had just three days to complete 20 surgeries before having to return home.

In all, 15 total knee replacements were performed as well as five total hip replacements--a phenomenal feat given the short amount of time.

Dr. Goldberg commented that the patients in Honduras were so grateful for their generous medical assistance that it was an absolute pleasure to care for them despite the challenging circumstances.

You can read the entire article about Dr. Goldberg and his team right here.  

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

Muscle Aches and Pains

 

 

Austin is the live music capital of the world, with a regular stream of headliners in town. Just this month, we’ve seen great groups come through for ACL and more recently performing at the Circuit of the Americas’ Formula One racing events.

 

Much like athletes, musicians’ bodies suffer a great deal of wear and tear from their profession.

 

Musculoskeletal disorders plague 73.4% to 87.7% of all musicians, with string players reporting the highest prevalence.

 

Tickling the ivories, strumming a guitar, or playing drums repetitively through a grueling rehearsal schedule and back-to-back performances can do a number on fingers, wrists, the neck, and shoulders. And then there’s the added stress of hauling heavy instruments and equipment from one gig to the next.

 

Bones and joints can become easily fatigued from this repetitive use, leading to pain, inflammation, and potentially serious conditions like arthritis.  Arthritis occurs when the cartilage between joints breaks down resulting in weakened bones, and decreased flexibility and range of motion.

 

Other common issues facing musicians include:

• Carpal Tunnel Syndrome
• De Quervain’s Tendonitis (inflammation of the tendons on the thumb side of the wrist)
• Shoulder Impingement (irritated tendons in the shoulder)

 

Whether you’re a pro or amateur musician, here are a few ways to ensure that your body stays healthy from fingertips to tops of shoulders:

 

Warm up before playing with light finger, wrist and arm stretches as well as head, neck and shoulder rolls to loosen muscles

 

Like in sports or intense athletic training, build in rest time every few days to allow muscles and bones time to rest and recuperate

 

Never play through pain or with an injury

 

If you suffer from chronic aches and pains as a result of playing an instrument, please contact us for an appointment with one of our specialists.  

 

Keep up with Texas Orthopedics news by following us on Facebook and Twitter (@TexasOrthopedic).

(Adapted from the Journal of the American Federation of Musicians of the United States and Canada)