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Are You Allergic to Penicillin, Really?

Unverified penicillin allergy is recognized as a significant public health problem. Up to 10 percent of the population report being allergic to penicillin, according to the Centers for Disease Control and Prevention (CDC). However, most of those may actually be able to safely use penicillin, either because they never were truly allergic or because they have lost sensitivity over time.

For those who think they are allergic to penicillin, it is important to either confirm the allergy or correctly identify if you can safely take this drug. 9 out of 10 patients reporting penicillin allergy are not truly allergic when assessed by skin testing. Unnecessarily avoiding penicillin leads to higher drug costs for patients and healthcare systems, limited and possibly inferior medical treatments, and possible antibiotic resistance.

What you need to know:

-True penicillin allergy is serious, even life-threatening. Someone with a confirmed penicillin allergy should avoid the entire medication group which includes 15 chemically related drugs. Ask your physician if you should be prescribed injectable epinephrine, the only treatment that will stop anaphylaxis, a severe, potentially fatal, allergic reaction.

–A reaction to penicillin as a child does not automatically mean you will react as an adult. Penicillin allergy is not necessarily a life-long condition. It is best to get tested to confirm.

–Symptoms of penicillin allergy may include hives, swelling of the mouth or throat, dizziness, or difficulty breathing. Hives are often confused with skin rashes that are non-allergy related. Since it may be difficult to tell the difference, and you can’t always get to a doctor right away, take a photograph of the rash to help with the diagnosis.

–Alternative antibiotics to penicillin may be less effective in treating your infection, may cause unwanted side effects, or maybe more expensive. Don’t limit your treatment options if it isn’t necessary.

–Penicillin allergy testing is safe and reliable. The patient undergoes a series of skin prick tests, with gradually increased amounts of penicillin. A raised bump, or wheal, at the site of the prick, indicates an allergy. If the tests are negative, the next step is an oral challenge to confirm the patient can safely take this drug. These tests should always be conducted by a board-certified allergist trained to recognize and treat potential allergic reactions.

Penicillin allergy testing is available at all AllergySA locations. To schedule an appointment, call 210-616-0882.

September 14, 2022/by Kayla Gomez

English, Health, Illness

The Fall Asthma Epidemic — What Is It?

Fall is one of the most dangerous times for people with asthma, especially children. Asthmatics often enjoy a reprieve from symptoms during the summer months, but ER visits for asthma increase during September and early October. Reports indicate that approximately 25% of all children’s asthma hospitalizations occur in the month of September. Some refer to this as the “September Asthma Epidemic.”

What contributes to the September Asthma Peak?

High fall pollen levels from allergens like ragweed and mold in the air
As children return to school, increased exposure to indoor allergens like animal dander or indoor mold, and VOC’s from new carpeting or construction over the summer. Also, respiratory irritants like air pollutants from idling cars and buses may cause problems
Irregular use of medications to control asthma/allergies over the summer months
Greater exposure to viruses including cold germs, influenza, and COVID-19, after returning to the classroom
Anxiety and stress, along with changing schedules, associated with the new school year

Here are some good reminders, for both children and adults, during this season and throughout the year:

Identify and avoid your asthma triggers.
Have an appropriate treatment plan for allergies, one of the most common triggers of asthma symptoms.
Update and follow your child’s Asthma Action Plan and provide a copy to the school.
Take long-acting asthma medications as prescribed, even when you feel well and your asthma is controlled.
Refill all medications prior to school start and make sure your child has access to their quick-relief inhaler.
Wash hands frequently, eat nutritious meals and get plenty of rest to avoid illness. Serious asthma flares are often associated with respiratory tract infections.
Stay up-to-date on immunizations including the annual influenza shot and COVID-19 vaccinations (all family members).
See your allergist for regular asthma check-ups to maintain good control. As children grow, medications may need to be adjusted.

The physicians at AllergySA are experts in the diagnosis and management of asthma and allergic diseases. Schedule an appointment at one of our 3 locations for an accurate diagnosis and a management plan to keep your family healthy and active this season. Call 210-616-0882

September 14, 2022/by Kayla Gomez

Allergies, English, Health

What to Expect this Spring Season

What to Expect this Spring Season

Spring or 2022 has sprung and your allergies might have already made you aware of it…

Pollen and other allergens play a considerable part in affecting many Texans’ lives during the
springtime. Trees produce pollen for their reproduction and spread by wind, whereas flowering
plants depend on insects to spread their pollen. Here’s what to expect this Spring season.

Common Texas tree pollens include:

Oak
Ash
Elm
Pecan
Cottonwood

Those who suffer from pollen allergies can have moderate to severe levels of symptoms like:

Sneezing
Watery, puffy, and itchy eyes
Stuffy nose
Coughing
Wheezing
Difficulty breathing

What can you do to prevent these triggers?

Unfortunately, there isn’t a way to cure allergies, but there certainly are ways to reduce and
prevent them:
Keep windows closed (especially in the early mornings)
Bathing in the evenings to remove pollen and keep bedding clean
Clean bedding weekly with hot water to remove any allergens
Check pollen count in your city each morning and prepare before you leave your home (P.S. We post San

Antonio’s pollen counts daily on Facebook, Instagram, and Twitter– follow us!)

Change your clothes after you’ve been outside
Vacuum and sweep floors weekly (possibly daily, if you have pets)

You can always treat your allergies either through OTC medications or prescribed medication/
biologics.

If you believe you suffer from allergies that affect your daily life, schedule an appointment today
with one of our board-certified providers. We want to help enhance your quality of life and more.

Call us today at 210-616-0882.

March 24, 2022/by Kayla Gomez

English, Health

How Can I Treat and Prevent My Child’s Nosebleeds?

Nosebleeds are common for most children ages 3 to 10. Nosebleeds are caused by several things, such as having allergies or a cold, living in dry climates, or picking the nose. Although there is no cure for nosebleeds, there are ways to easily treat and prevent them.

How can I treat my child’s nosebleed?

When your child’s nosebleed begins, be sure to stay calm and comfort your child.

Have your child sit up and lean forward slightly. This is to prevent them from swallowing blood or vomiting. Do NOT have them lay back- this can worsen the bleeding.

Tell them to breathe out of their mouths while lightly pinching their nose for approximately 5 to 10 minutes.

You can apply something cold on the bridge of their nose- no gauze or tissue.

If the bleeding does not stop, repeat the steps.

Be sure to encourage your child to not pick or rub their nose for the following few days.

How can I prevent my child from having nosebleeds?

Keep your child from rubbing and picking their nose.

Teach your child to blow their nose gently.

Keep clean-filtered humidifiers in different rooms if the air in your home is dry.

Use salt-water nasal sprays (talk to your provider before proceeding).

Rub a thin layer of petroleum jelly or medicated ointment around the rim of their nose.

If your child is in a sport or physically active, have them use protective wear that will prevent head injuries or anything that can cause a nosebleed.

Do not smoke around your child.

Call your provider right away if your child is pale, sweaty, or non-responsive if they have lost a lot of blood, or if their nose is bleeding from a blow to the head.

If you have any questions about how to manage your child’s nosebleeds, please give us a call and schedule an appointment with one of our board-certified providers to help you find the best ways to help at 210-616-0882.

August 24, 2021/by Kayla Gomez

English, Health, Illness, YouTube

What is an Asthma Action Plan?

School is right around the corner so we want to make sure your kids with asthma will be safe.

If your child suffers from asthma, it is likely that you already have an Asthma Action Plan for them. If you don’t have one yet, don’t worry! We will show you what an Asthma Action Plan is, what it includes and how to manage it.

What is an Asthma Action Plan?

An asthma action plan is an individualized worksheet that helps you know whether your asthma is controlled and what medications to take. It also can help you know if you should call your doctor or go to the emergency room.

If you use the Asthma Action Plan worksheet properly, it can reduce visits to the doctor.

What does the Asthma Action Plan include?

The asthma action plan includes helpful tools such as:

A daily log of asthma triggers and symptoms
Identifying severity of asthma, normally by using 3 colors- green, yellow, and red (as go, caution, and danger)
What medication you should be taking and when and how often you should be taking it

An example of an asthma action plan looks like this:

Image: AAFA.org

Can I Manage Asthma Another Way?

The Asthma Action plan can be a great way to manage your child’s asthma on a daily basis, but it isn’t the only way.

Some other ways that you can manage asthma are avoiding your triggers, keeping your home clean and cool, and having an inhaler with you at all times (to learn how to properly use your inhaler, check out one of our providers, Erica Gomez’s video, ‘How To Use an Inhaler’).

AllergySA wants nothing more than to help you and your child’s quality of life. If you need assistance in creating the perfect asthma action plan, one of our board-certified providers can help you.

Call 210-616-0882 to schedule your appointment today

July 26, 2021/by Kayla Gomez

Allergies, English, Health, Recipes

Refreshing, Allergy-friendly Recipes for the Summer

Kids are home for the summer and this heat is unreal. You need to keep them busy while you work from home. What do you do?

Family time can be a great and memorable time these days, and what better way to spend time together than by making refreshing allergy-friendly snacks!

Here are 5 refreshing recipes to make your family and friends with allergies on a hot, summer day.

Black Cacao Nice Cream

Ingredients:
- 4 frozen bananas
- ½ cup canned full fat coconut milk
- ¼ cup cacao powder
- 1 tsp activated charcoal
- 1 to 2 tsp agave OR sub honey or maple syrup
- ¼ cup non-dairy milk

Instructions:
- Blend coconut milk, cacao powder, charcoal, and agave until smooth. Add frozen bananas and blend using the tamper tool until smooth and creamy. Adding up to 1/4 cup non-dairy milk only as needed.
- If you want scoopable ice cream, pour into a freezer-friendly airtight container, or a bread pan and top with plastic wrap. Freeze for 3-6 hours until frozen and allow to thaw 5-15 minutes before scooping.
- Scoop into a bowl or cone, add desired toppings, and enjoy!

Raspberry Chocolate Protein Popsicles

Makes around 6 popsicles, depending on the size of your molds.

Ingredients:
- 1 ripe banana
- One 12-ounce package of frozen raspberries
- 1 cup full fat coconut milk
- ½ tsp vanilla
- 1 scoop Bob’s Red Mill Chocolate Nutritional Booster
- Optional: 2-3 tsp pure maple syrup OR agave

Instructions:
- Place all of the ingredients in your blender. Blend until everything is smooth. Taste and add the sweetener if needed
- Pour into popsicle molds and allow to freeze completely, 6 hours overnight.
- When you’re ready to serve, run warm water over the popsicle mold, until you can slide the popsicle out.

Mango Lava Flow Smoothies

Ingredients
- Mango Puree:
  - ½ cup Dole frozen mango chunks
  - ½ cup coconut milk carton or can, preferably light or it will be thick and hard to blend
- Pina Colada smoothie
  - 1 cup Dole frozen pineapple chunks
  - ½ cup greek yogurt plain or vanilla, or dairy-free yogurt alternative
  - 1 cup coconut milk carton or can, preferably light or it will be thick and hard to blend
  - ½ cup ice (depending on desired consistency)
  - 1 tsp honey, sweeten to taste
  - Optional: ¼ tsp coconut extract
  - Optional: 2 maraschino cherries

Instructions:
- Mango Puree:
  - Combine the mango and coconut milk in a blender and puree until smooth.
  - Set aside in the blender if you have a second blender jar or in a pitcher or measuring cup.
- Pina Colada smoothie
  - Combine the pineapple, yogurt, coconut milk, and ice in a blender and puree until smooth.
- To serve:
  - Pour a small amount of the mango puree into each of the two glasses. Top each with about a quarter of the pina colada smoothie and a little more mango puree. Pour half of the remaining pina colada smoothie in each glass and top with the remaining mango puree.

Triple Berry Kiwi Smoothies- Immunity Boosting

Ingredients:
- 1 cup frozen strawberries
- ¾ cup frozen raspberries
- ½ cup frozen blueberries
- 2 kiwi (peeled and sliced)
- 1 cup of orange juice

Instructions:
- Place frozen berries in a blender and let them thaw for 10 minutes.
- Add kiwi and orange juice and blend on high until smooth.
- Garnish with desired fruit and enjoy!

Fizzy Pineapple Punch

Ingredients:
- One 12-ounce can of frozen pineapple juice concentrate thawed
- One 6-ounce can of frozen limeade concentrate thawed
- 1 ½ cups cold water
- 1-liter club soda chilled
- Assorted fruit: strawberries raspberries, blueberries, oranges, limes, and pineapple)
- Optional: garnish such as fresh mint
Instructions:
- Pour thawed pineapple juice concentrate and thaw limeade concentrate in a large pitcher
- Add cold water and most of the club soda (reserve about ⅓ cup)
- Stir to combine and chill until cold
- Add ice cubes and assorted fruits to serving glasses and pour in chilled punch
- Garnish as desired and top off glasses with a splash of extra club soda

We hope that these recipes will help you and your family find great new snacks and spend more time together. Thank you, A Whisk and Two Wands, Allergy Awesomeness, Cupcakes, and Kale Chips, the pretty bee, and The Chunky Chef for providing these recipes, respectively.

If you suspect you or a loved one has food allergies, call Allergy SA at (210) 616-0882 to schedule an appointment with a board-certified allergist. Same day appointments are available.

June 23, 2021/by Kayla Gomez

English, Health

10 Asthma Myth Busters

Asthma is an extremely common lung condition in the United States- approximately 26 million children and adults suffer from it. With so many people having this condition, there are bound to be rumors and myths that come with it. Today, we will fact-check some of these myths to create more safety and awareness for those with asthma.

Myth: Children can outgrow asthma.1

Truth: Asthma can go into periods of remission or may be so well controlled that symptoms are not experienced for long periods. Once you have asthma, you’ll always have asthma.

Myth: Asthma is difficult to control. 3

Truth: It can be well-controlled with the right treatment options available to you.

Myth: You can stop medication during the seasons that you don’t have any exposure to your asthma triggers.1

Truth: It’s important for you to continue your asthma action plan and take your medication to keep control of your asthma. Your doctor may tell you to reduce your medication if it is well under control, however, it is very dangerous to stop without supervision.

Myth: Pregnant women with asthma should not take the flu shot.1

Truth: Pregnant women should get the flu shot when it’s available. Getting the vaccine is protecting them, and via the placenta, giving the baby some flu immunity, too.

Myth: Asthma medication is dangerous and can be addicting.4

Truth: No asthma medication used in the U.S. is habit-forming or addicting. Although some medications are inhaled corticosteroids, these are not related to the steroids used for muscle growth (for athletes).

Myth: Asthma can’t be fatal.5

Truth: It is rare, but fatalities can happen. The rate of death due to asthma has been decreasing since 2001

Myth: My child has asthma and shouldn’t be allowed to play outside or play any sports.7

Truth: All kids need to exercise and be healthy. As long as a child with controlled asthma takes their medication before they play outside or join a sport, they should be able to keep up. If the child has uncontrolled asthma, they may develop symptoms as they play.

Myth: Asthma symptoms are the same for everyone.2

Truth: Asthma affects each person differently. One person might show several symptoms and others may just cough.

Myth: Asthma is all in your mind.2

Truth: Asthma is hard to predict but can be very serious. There can be underlying inflammation in the airways in people with asthma. Asthma doesn’t just go away when symptoms are gone.

Myth: Asthma medication becomes less effective over time.6

Truth: If you have an asthma attack, it may not be that your medication has stopped working- it may just be the air quality or you are being exposed to a new environmental trigger. Although if it is noticeable that you’re having a difficult time controlling your asthma, contact your doctor and find ways to better manage or change your medication.

If you have any questions about how to maintain your asthma, please give us a call and schedule an appointment with one of our board-certified providers to help you find the best ways to help. 210-616-0882.

Allergyasthmanetwork.com
https://health.utah.gov/asthma/pdfs/factsheets/myths_facts_asthma.pdf
https://www.amestrib.com/news/20180514/myth-busting-5-facts-about-allergic-asthma-that-may-surprise-you
health.usnews.com/health-care/for-better/articles/2018-12-04/common-myths-about-asthma
https://www.pulmonologyadvisor.com/home/topics/asthma/asthma-myths-5-misconceptions-your-patients-might-have/
https://www.childrens.com/health-wellness/busting-6-asthma-myths
https://www.chop.edu/news/asthma-myths-and-facts

May 4, 2021/by Kayla Gomez

Allergies, English, Health

15 Allergy Friendly & Affordable Easter Candy

Easter is right around the corner and we want to make sure that you are fully aware of what your children will eat this weekend. We have made a list of 15 affordable Easter treats that exclude some of the most common allergens so you can have a fun and safe Easter weekend!

Amanda’s Own Confections: Jelly Beans

This product is dairy-free, nut-free, peanut-free, gluten-free, wheat-free, soy-free, egg-free, sesame-free, mustard-free, shellfish-free and crustacean-free. NOT vegan.
Price: ranges from $7.25 – $8.25

Chocolate Emporium: Chocolate bunnies

This product is dairy-free, gluten-free, vegan and parve.
Price: $4.85 each

Double Bubble: Egg shaped gumballs

This product is nut-free gluten-free, shellfish-free, egg-free and kosher.
Price: $1.00

Evolved: Chocolate bars

This product is gluten-free, dairy-free, cane sugar-free, soy-free and vegan. Check website for more flavors and ingredient listings.
Price: $4.99

free2b Foods: Chocolate butter cups

This product is gluten-free, egg-free, fish-free, peanut-free, shellfish-free, soy-free, tree nut-free and wheat-free. Check website for more flavors and ingredient listings.
Price: $2.50

No Whey Foods: Chocolate lollipops

This product is dairy-free, milk-free, lactose-free, peanut-free, tree nut-free, egg-free, soy-free, wheat-free, gluten-free and vegan.
Price: $3.95 each

Spangler: Dumdum fruity bunny pops

This product is dairy-free, gluten-free, tree nut-free, peanut-free, egg-free, soy-free, and fat-free.
Price: $2.99

Jelly Belly Candy Company: Sunkist fruit gems

This product is fat-free, peanut-free, gluten-free, kosher and vegan.
Price: $7.59

Tootsie Roll: Easter Midgees

This product is egg-free, tree nut-free, coconut-free, sesame-free, gluten free, wheat-free, shellfish-free and kosher.
Price: $9.99

Vermont Nut Free Chocolates: Marshmallow on a stick

This product is peanut-free, tree nut-free, coconut-free, sesame-free, fish-free, shellfish-free and kosher.
Price: $3.95 each

YumEarth: Licorice

This product is peanut-free, gluten-free, tree nut-free, milk-free, egg-free, fish-free, shellfish-free, soy-free and vegan. Check website for more flavors and ingredient listings.

Enjoy Life Foods: Chocolate Minis

This product is wheat-free, dairy-free, soy-free, sulfate-free, lupin-free, fish-free, crustaceans-free, peanut-free, tree nut-free, casein-free, egg-free, sesame-free, mustard-free and shellfish-free. Check website for more flavors and ingredient listings.
Price: $4.99

Skip’s Candies: Marsh Pops

This product is peanut-free, tree nut-free, and coconut-free.
Price: $3.25

Bo & Ty: Gummy worms

This product is nut-free and gluten-free.
Price: $6.14

Smarties (American): anything!

All of their product is gluten-free, milk-free, egg-free, fish-free, shellfish-free, tree nut-free, peanut-free, wheat-free, soy-free and vegan.
Price: starting at $2.89

We hope that you stay safe this weekend and enjoy all of the sweets and always remember to look at ingredients label before you consume your candy.

If you believe that your child has food allergies, please call AllergySA to schedule an appointment with one of our providers at 210-616-0882.

Happy Easter!

March 31, 2021/by Kayla Gomez

English, Health

Johnson & Johnson’s Janssen COVID-19 Vaccine Issued for Emergency Use Authorization

UPDATE 4/13/21: The Texas Department of State Health Services is asking vaccine providers in Texas to pause all administration of the Johnson & Johnson/Janssen COVID-19 vaccine following the CDC’s recommendation as it investigates six reported U.S. cases of a rare blood clot. For more information, see the DSHS Statement on Johnson & Johnson Vaccine here.

As of February 27, 2021, the U.S. Food and Drug Administration (FDA) has issued Emergency Use Authorization (EUA) for the third COVID-19 vaccine.

Johnson & Johnson’s Janssen COVID-19 Vaccine has properly met the required FDA criteria and will be provided in the United States for individuals 18 years and older. While the Pfizer-BioNTech and Moderna vaccines are still to be distributed, J&J plans to deliver over 20 million doses in March and 100 million doses within the first half of 2021.

What’s So Different About J&J’s Vaccine?

Pfizer and Moderna vaccines both have similar studies, effectiveness rates, vaccine types, etc. to prevent COVID-19 and have proven effectiveness. Johnson & Johnson’s Janssen vaccine shows various differences that are still effective and will prevent contracting COVID-19.

While Pfizer and Moderna are both mRNA (messenger RNA) vaccines, Johnson & Johnson developed a harmless adenovirus vector vaccine. This means the vaccine uses a harmless adenovirus to introduce COVID-19 spike protein information to the body, and helps us develop antibodies and immune cells to fight COVID-19 infection. Johnson & Johnson used this approach with their Ebola vaccine in July of 2020, which authorized by the European Medicines Agency.

The Janssen COVID-19 vaccine is a single-shot vaccine as opposed to the two-shot strategy that Pfizer and Moderna have developed. It is 66% effective in preventing the disease and 85% effective in preventing severe disease. These percentages are shown to be effective 28 days after vaccination. This vaccine is a useful tool in fighting the pandemic and combating the continuous high number of cases.

What Should I Do After Receiving the COVID-19 Vaccine?

Continue to wear your mask, practice social distancing, wash your hands frequently and all other practical guidelines that the CDC has provided us. As of right now, the vaccine is not quite yet out for the general public, so there are many without the vaccine that are still at risk of acquiring COVID-19.

Please continue to be cautious around those at high risk and the elderly.

It is recommended that once an individual is vaccinated, they are to be monitored 30 minutes after. If you are someone with a medication, food and/or vaccine allergy, it is advised that you keep your EpiPen alongside you at all times- before, during and after your COVID-19 vaccine.

However, medication, food and/or other vaccine allergies are NOT a contraindication for the COVID-19 vaccine.

Allergy SA will keep you updated with the latest, and will let our patients now as soon as we have the vaccine available in our clinics. To stay updated, please visit our page www.allergysa.com/covid19vaccine or call us for any questions you may have at 210-616-0882.

March 3, 2021/by Kayla Gomez

Allergies, English, Health, Illness

Is It Mountain Cedar Allergies or COVID-19?

Venn Diagram of COVID and Seasonal Allergy Symptoms

Content source: National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases

Are you feeling a slight sniffle, cough or headache? This winter brings an extra layer of worry for mountain cedar sufferers as they try to decipher the difference between mountain cedar allergies and COVID-19.

The CDC has shared this helpful Venn diagram showing the differences and similarities of seasonal allergies to COVID-19. The biggest difference is that COVID-19 may cause: fever, chills, body aches, loss of taste or smell, nausea or vomiting, and diarrhea while seasonal allergies will not.

If you are experiencing a mixture of these symptoms it could be possible that you have contracted the COVID-19 virus while also being affected by mountain cedar pollen in the air. The only way to know for sure is by getting a COVID-19 test.

Taking extra precaution to wear a mask and social distance this winter is advised. If you believe that you may have COVID-19, be sure to get tested and quarantine to avoid spreading the virus to others. If you are having trouble breathing, or other emergency warning signs, seek emergency medical care immediately.

AllergySA is not a current testing site for COVID-19. For a list of testing locations please visit: https://covid19.sanantonio.gov/What-YOU-Can-Do/Testing#TestingLocation

A COVID-19 Vaccine is days away from approval. For up to date information on the vaccination, visit our COVID-19 Information page at: https://allergysa.com/covid19/#COVID-Vaccination

December 10, 2020/by Kayla Gomez

Are You Allergic to Penicillin, Really?

The Fall Asthma Epidemic — What Is It?

What contributes to the September Asthma Peak?

Here are some good reminders, for both children and adults, during this season and throughout the year:

What to Expect this Spring Season

How Can I Treat and Prevent My Child’s Nosebleeds?

What is an Asthma Action Plan?

Refreshing, Allergy-friendly Recipes for the Summer

Black Cacao Nice Cream

Raspberry Chocolate Protein Popsicles

Makes around 6 popsicles, depending on the size of your molds.

Mango Lava Flow Smoothies

Triple Berry Kiwi Smoothies- Immunity Boosting

Fizzy Pineapple Punch

10 Asthma Myth Busters

15 Allergy Friendly & Affordable Easter Candy

Johnson & Johnson’s Janssen COVID-19 Vaccine Issued for Emergency Use Authorization

Is It Mountain Cedar Allergies or COVID-19?

LOCATION INFORMATION

Medical Center

Stone Oak

Southside

CONTACT INFORMATION