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Entries in Connecticut (11)

Thursday
May302013

Connecticut Woman Gives Birth at Home, Alone

Creatas/Thinkstock(SOUTHINGTON, Conn.) -- If Erica Bovino of Southington, Conn., is still trying to recall the exact details of the birth of her second child, daughter, Stella, three weeks ago, it is easy to understand why.

Bovino, 34, delivered Stella at home, in her bathroom, with no one else in the house besides Stella’s older brother, 3-year-old Jack, who slept through the whole thing.

“I didn’t call anyone because I figured I had plenty of time,” Bovino, a speech pathologist, said of the day, May 6, when she realized she was going into labor.

Bovino had been in labor with Jack for 30 hours, so based on the many labor and delivery books she had read, she anticipated at least a 15-hour labor with her second child.

Instead, Bovino felt her water break less than five hours after that first contraction. Her first step was to call her husband, Paul Sulzicki, also 34, and a police officer, to tell him to get home quickly from his overnight shift.

“I realized there was no way I was going to be able to get to a hospital in time,” Bovino said, throwing away the couple’s plan to drive the 30 minutes to Yale-New Haven Hospital and deliver naturally with a midwife, as she had done with Jack.

“All my instincts kicked in,” she said. “I went into a primal mode.”

Luckily for Bovino, a natural birth advocate, she had done her research during her pregnancy on delivering without the aid of medicine or, in her extreme case, without the aid of anyone else.

“I didn’t know what position she was in and I knew I had to get on my hands and knees,” she said.  “Then something told me to go into the bathroom and squat.”

“I remember just trying to squat and I said, ‘Come on baby, come on baby,’” she said. “I put all my effort into opening and getting her out. I was like I have to get her out. It’s life and death.”

At 5:35 a.m., Bovino lifted out of herself a healthy six pound and three ounces baby named Stella Jane Bovino Sulzicki.

When Stella first came out, her eyes were closed, giving Bovino a momentary scare. Then, as soon as Sulzicki made it home and ran into the bathroom, mother and father saw their newborn daughter’s eyes for the first time.

“All of a sudden she opened her big eyes and that’s the moment my husband walked in,” Bovino said. “He calmly took us to the bed and I started nursing immediately and he called 911 and called my midwife.”

Paramedics arrived shortly and after determining that both mom and baby were fine, granted Bovino’s request that she continue nursing her in bed to bond with Stella, and also allow time to introduce Stella to her big brother, who had slept through her entire birth.

“My husband went into his room and said, “Do you want to come into mommy and daddy’s room, mommy’s had the baby,” Bovino said.  “He [Jack] was just all smiles.”

Bovino was then taken to the hospital with Stella for an overnight stay, just as any new mom would do.  She says the doctors there were impressed with what she had accomplished.

“People have babies at home but they don’t do it completely alone,” she said. “It’s very rare. I’m still processing the whole thing. With lack of sleep and everything, it’s hard to remember exactly what happened.”

What Bovino does know for sure is that she wants to use her accidental home birth as a message for other moms.

“I want to be an inspiration to other women to empower them to trust themselves and their instincts,” she said. “Hospitals are there, and they’re wonderful in emergencies, but a lot of times women don’t trust themselves and their bodies that they’re able to do it.”

“I trusted my body and the process,” Bovino said. “I tried to stay as focused and looking inward as I could and not let any fear come over me.”

Copyright 2013 ABC News Radio

Friday
Jan112013

Less Flu in Connecticut? CDC Says Looks Can Be Deceiving

CDC(WASHINGTON) -- Connecticut is a lone green state in a sea of red, but we’re not talking politics.  

Connecticut shows up on a map as a state with minimal flu-like illness, surrounded by states with high flu-like activity levels, according to the Centers for Disease Control and Prevention.  The agency has just issued its Influenza Surveillance Report, or ILINet, for the last week of December.

But if you’re worried about the flu, that’s not a reason to move to Hartford, health professionals say.  Connecticut is far from flu-free, and CDC data aren’t perfect.

“Germs don’t respect state lines,” said ABC News Chief Medical Editor Dr. Richard Besser.  He said Connecticut certainly didn’t escape the flu just because other states have had higher percentages of outpatient office visits.

It’s possible that Connecticut’s numbers were artificially deflated because of students’ winter break, said William Gerrish, a spokesman for the Connecticut Department of Public Health.  College student health centers account for a large percentage of flu reports in the state.

“Unfortunately, these student health centers have been essentially closed during the long holiday break, resulting in an artificially low statewide ILINet activity level,” he said.

Gerrish also said that a separate flu map, which includes only laboratory-confirmed flu cases, shows Connecticut as a state with “widespread” flu cases, meaning that no areas are flu-free.  (ILINet is broader and includes flu-like illnesses.)

“These indicators clearly show that Connecticut has not avoided the flu,” Gerrish said.

Copyright 2013 ABC News Radio

Wednesday
Dec192012

Newtown Shooting Puts Spotlight on US Mental Health Care -- Again

DON EMMERT/AFP/Getty Images(NEW YORK) -- It has not yet been confirmed whether Adam Lanza had been diagnosed with mental illness, but the 20-year-old, who murdered his mother, then drove to a Newtown, Conn., elementary school and gunned down 20 first-graders and six adults, has again shined the spotlight on care for the mentally ill in the United States, and has many asking whether yet another mass shooting could have been prevented.

Despite four shooting rampages since President Obama took office in 2009, mental health care continues to be hampered by budget cuts, closures, battles with insurers and stigma, doctors said.

"We have very good treatments for mental illness that are highly effective," said Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association.  "But they're not widely available.  People don't have ready access to them."

Since the recession forced budget cuts in 2009, state general funding for mental health care has decreased by an estimated $4.35 billion nationwide, according to the National Association of State Mental Health Program Directors, which serves 6.8 million patients a year.

Since 2009 alone, 3,222 psychiatric hospital beds are no longer available to patients, and another 1,249 may disappear soon because of proposed closures, according to the association.  That's about 10 percent of all state psychiatric hospital beds gone in about three years, said Dr. Robert Glover, the association's executive director, who said he'd never been more worried.

"This is the worst I've seen it," Glover, who's worked in mental health for almost five decades, said about the cuts.  "They are painful, and unbelievably tough.  I am incredibly worried about future cuts with the fiscal cliff and state budgets not getting better."

One in five American adults reported suffering from mental illness within the past year, with one in 20 reporting serious mental illness that resulted in "functional impairment," according to the Substance Abuse and Mental Health Services Administration's latest annual National Survey on Drug Use and Health Report.

Despite its prevalence, mental illness is something patients and those around them have tried to ignore dating as far back as World War I, when soldiers were called cowards for showing signs of what we now know was post traumatic stress disorder, Lieberman said.

Today, the largest mental health facilities are for inmates at the Los Angeles County Jail in California, Cook County Jail in Illinois and Rikers Island in New York, Lieberman said.

According to the Bureau for Justice Statistics, 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of jail inmates had mental health problems in 2006.  Between 10 percent and 20 percent of those with mental health problems had symptoms of psychosis, such as delusions or hallucinations.

Most mentally ill patients aren't dangerous, but it's very difficult for psychiatrists to predict who will become violent, said Dr. Carol Bernstein, a psychiatry professor at NYU Langone Medical Center.

The high number of prisoners with mental illness is a mark of the failures of the current mental health care climate, because the mentally ill wind up behind bars before they can get treatment, Lieberman said.

"We haven't provided these people with what they need," said Lieberman.  "What we're seeing here now is, 'Uh, oh people have mental health problems.  We need to pay attention to mental illness now.'  But it's a too little, too late kind of reaction to this. ...Whatever it takes is worth it, but this is kind of late in the game."

Copyright 2012 ABC News Radio

Tuesday
Dec182012

Shooting Survivors Should Be in School, Psychologist Says

DON EMMERT/AFP/Getty Images(NEW YORK) -- Connecticut school officials' plan to get survivors of the Sandy Hook Elementary School shooting back together at a new school is exactly the right decision, says a youth trauma psychologist.

Authorities announced on Monday that the Newtown, Conn., elementary school where 26 people, including 20 children, were gunned down, will be closed "indefinitely," but Sandy Hook students and staff could be back in classes at nearby Chalk Hill School in Monroe, Conn., by this week.

"It's a good idea that kids go back to school as soon as possible and normalize and get...accustomed to a routine," said psychologist Susan Lipkins.  "You want to make it as familiar and easy as possible so the transition is as smooth as possible for teachers, faculty and the children."

Most children do not understand death; they understand that their parents and teachers are upset and draw on those emotions, Lipkins said.  She believes it was the right decision to have the students return to classes, especially before the Christmas break, because it will help them adapt to the new situation.

"If they didn't have school this week that really would give the children too much time to get accustomed to being at home...and it would increase their likelihood of developing phobias," she said.

Lipkins also agreed with the decision to have Sandy Hook remain closed because going back to the scene of the massacre would have been "too traumatic" for everyone.

"I think that the scene is too extreme and that it would be very hard to erase the memories," Lipkins said.  "It's really good for everybody to have their normal routine but to have those physical manifestations would make it probably more stressful."

Copyright 2012 ABC News Radio

Tuesday
Dec182012

Siblings of Sandy Hook Victims Face Trauma, Survivor's Guilt

Douglas Healey/Getty Images(NEW YORK) -- Six-year-old Arielle Pozner was in a classroom at Sandy Hook Elementary School when Adam Lanza burst into the Newtown, Conn., school with his rifle and handguns.  Her twin brother, Noah, was in a classroom down the hall.

Noah Pozner was killed by Lanza, along with 19 other children at the school, and six adults.  Arielle and other students' siblings survived.

"That's going to be incredibly difficult to cope with," said Dr. Jamie Howard, a clinical psychologist at the Child Mind Institute in New York.  "It is not something we expect her to cope with today and be OK with tomorrow."

As the community of Newtown begins to bury the young victims of the school shooting on Monday, the equally young siblings of those killed will only be starting to comprehend what happened to their brothers and sisters.

"Children this young do experience depression in a diagnosable way, they do experience post-traumatic stress disorder.  Just because they're young, they don't escape the potential for real suffering," said Rahil Briggs, a child psychologist and professor at Montefiore Medical Center in New York City.

Arielle and other survivor siblings could develop anxiety or other emotional reactions to their siblings' death, including "associative logic," where they associate their own actions with their sibling's death, Howard said.

"This is when two things happen, and (children) infer that one thing caused the other.  (Arielle) may be at risk for that type of magical thinking, and that could be where survivor's guilt comes in.  She may think she did something, but of course she didn't," Howard said.

Children in families where one sibling has died sometimes struggle as their parents are overwhelmed by grief, Howard noted.  When that death is traumatic, adults and children sometimes choose not to think about the person or the event to avoid pain.

"With traumatic grief, it's really important to talk about and think about the children that died, not to avoid talking and thinking about them because that interferes with the grieving process," Howard said.

Children may also have difficulty understanding why their deceased brother or sister is receiving so much -- or so little -- attention, according Briggs.

"I think one of the most challenging questions we can be faced with as parents is how to 'appropriately' remember a child that is gone.  So much that can go wrong with that," Briggs said. "You have the child who is fortunate enough to escape, who thinks 'Why me?  Why did my brother go?'  But if you don't remember the sibling enough the child says 'it seems like we've forgotten my brother.'"

"They may even find themselves feeling jealous of all the attention the sibling seems to be receiving," Briggs said.

Parents and other adults in the family's support system need to be on alert, watching the child's behavior, she said.  Children could show signs of withdrawing, or seeming spacy or in a daze.  They could also seem jumpy or have difficulty concentrating in the wake of a traumatic event.

It will be vital in the next weeks for parents of surviving siblings to return the surviving child to a normal routine, including regular meals, sleeping and physical habits, Howard and Briggs said.

If a child's appetite or sleeping habits change, or if they show any regressive behaviors, including wetting the bed or trouble separating from their parents, it may time to seek professional help, experts said.

Copyright 2012 ABC News Radio

Monday
Dec172012

Teachers, Students Grappling with School Security After Conn. Shooting

John Coletti/Getty Images(NEW YORK) -- Teachers and students across America are confronting the issue of safety and security in the classroom today after a weekend of grappling with the deadly massacre at a grade school in Newtown, Conn.

"It's very important that we address their concerns [about safety]," teacher Lauren Marrocco of New Jersey said.  "I think my students will have a lot of questions and, as adults, we don't have answers to those questions."

Near Newtown, one teacher's weekend homework for students was simple: Go home and hug your loved ones.  In California, another educator wrote, "I'll be locking my [classroom] door this week to make my students feel safer."

For many, Monday morning's school drop-off will be a difficult but necessary start to the day.

"I'm not too worried about her, I'm more worried about how I feel and how I'm going to let go of her hand when she gets on the bus," a parent told ABC News.

In Fairfax County, Va., schools sent notice that they would be upping security, not for any specific threat but to alleviate anxiety.

Dr. Steven Marans, head of the National Center of Children Exposed to Violence at Yale University's Child Study Center, said that falling into normal routines can provide comfort.

"One of the ways of demonstrating that their lives are secure and reliable is to have them disrupted as little as possible," he said.

Marans says it is also important not to avoid discussing Friday's events, where 20 children and six adults were killed before Adam Lanza took his own life.

"We need to acknowledge that we all have big feelings," he said.  "This is very sad.  This is an opportunity for kids to put into words what their thinking about."

Copyright 2012 ABC News Radio

Saturday
Dec152012

Shooting Trauma Affects Kids, Adults Differently

Douglas Healey/Getty Images(NEW YORK) -- Traumatic events such as the deadly  shooting at a Connecticut elementary school on Friday, can affect children and adults in different ways.
 
Adults often gorge on media images -- trying to glean facts, gain perspective, to make sense out of a senseless event.

But for children, it can have the opposite effect.

After the deadly rampage at the Sandy Hook Elementary School in Newtown, Conn., psychologists and pediatricians are strongly urging parents to shield their school-age children from too much exposure to the news.

"For really young children, they can be confused and think that this is happening over and over and over again," said Jamie Howard, a clinical child psychologist and trauma expert at the Child Mind Institute in New York. "They don't necessarily know that it's on a loop, And that would be really scary.

"For older kids who are around 8, 9, 10, they might sort of be inundated with anxiety and people's fear and people's stress," Howard said, "and it could overwhelm their capacity to cope."

Elementary school is supposed to be a safe, innocent place, but the Sandy Hook shooting shatters that notion for parents.

If children are old enough to ask questions, instead of talking to the kids, parents are advised to try just listening.

"Start by asking them: What do you know? What are you feeling?" Howard said. "Ask open-ended questions so that you can start from there. A lot of times we think they want to know lots and lots of information that adults want to know. But children don't necessarily have the same questions or have the same needs."

When they do ask questions, parents shouldn't hide their emotions -- but experts warn parents to try not to be overly emotional in front kids because they get their cues from grown-ups.

"We look to grown-ups to interpret situations for us," Howard said. "It's called social referencing. It's what kids do. So we are all sort of being watched. And kids are looking to us to let them know: How should we be reacting to this?"

It's understandable that parents are emotional, but Howard suggests grown-ups should share our sadness and our fears with other adults and not let children eavesdrop on those conversations.

Copyright 2012 ABC News Radio

Friday
Dec142012

Newtown, Conn. Shooting: Young Kids, Survivors Cope with Horror

DON EMMERT/AFP/Getty Images(NEWTOWN, Conn.) -- Witnesses at Sandy Hook Elementary School reported horrific scenes as a shooter took 27 lives today -- the shattering sounds of gunshots, children locked in the bathrooms and parents crying outside in the parking lot.

Experts say that the young children who saw events first-hand can have lasting psychological scars, but those whose home lives are stable and supportive will have fewer long-term scars.

"It was horrific," said Kaitlin Roig, a 29-year-old teacher, who was in a morning meeting when the gunman entered the school.

"Suddenly, I heard rapid fire, like an assault weapon," the first grade teacher told ABC. She rounded up her 14 students and locked them and herself in the bathroom. "I helped kids climb on the toilet dispenser [so they could all fit in].

"I thought we were going to die."

Children in such a situation "are terrified, and they don't have the cognitive or emotional capacities to make sense of this," said Dr. Nadine Kaslow, professor and vice chair of the department of psychiatry at Emory School of Medicine.

"Not that any of us can make any sense of this," said Kaslow. "It's truly inconceivable."

At least 27 people, mostly children under the age of 10, were shot and killed at the K-to-4 school this morning, federal and state sources tell ABC News.

The massacre drew SWAT teams to the school and the town of Newtown locked down all its schools, authorities said day.

According to federal sources, the gunman was identified as Adam Lanza, 20. His mother, who worked at the elementary school, was one of the victims.

One mother named Christine who has a child at Sandy Hook told ABC about the chaos that ensued when she arrived at the school this morning.

"When I got there, there were just parents running into the firehouse because they were directing us there. That's where children had been evacuating to, and we went in and people were just grabbing their children and hugging and crying. There were lots of children crying."

She said another parent who had been at the school at the time was "pretty broken up." Many parents didn't know where their children were.

In 1996 in Dunblane, Scotland, 15 children and a teacher were killed in a similar massacre.

Parents and caregivers play the most important role in a child's recovery from a traumatic event, according to Dr. Gene Beresin, director of training in child and adolescent psychiatry at Massachusetts General Hospital.

"Children need to know that they are safe," he said. "Are people taking care of me? How is this going to affect my life? They need to be reassured."

"Thinking about kids in all disasters, you think about the airlines -- when the oxygen mask drops, you put your mask on first and then help the child next," said Beresin.

"Parents need to take care of themselves first. [The children] need to know you are calm and in control," he said.

Adults and community support is critical, according to Beresin.

Young children who witness violence can have acute or post-traumatic stress disorder. "The immediate reaction is shock and horror," he said.

After events like this, communities typically set up crisis centers in a church or other public place where people can seek professional and spiritual help.

Turn the television off, say experts, but answer your children's questions. Don't disregard an older sibling who is watching the news unfold and is worried. They need assurance, too, he said.

According to Beresin, young children may not have "discreet memories" of the event, but they can still have an emotional reaction, experiencing nightmares or, conversely, emotional numbing, said Beresin.

"Some kids shut down," he said. "They may actually turn off and not want to be hugged or cuddled -- that's a normal response. Some kids are clingy, and others will withdraw."

Kids can also regress in the aftermath of a traumatic event.

Parents should not force a child to open up, but "don't let them be alone," he said.

One way young children can work out problems are through reenactment. "They may be playing a game about shooting and dying, and parents should not stop that," said Beresin. "Let them do it."

Young children can also ask questions that don't directly relate to the event, according to Rahill Briggs, assistant professor of pediatrics at Montefiore Medical Center in New York City.

"They can ask directly or less directly about guns, or heaven or death or about a pet that died," she said.

In studies of 9/11 one of the findings -- not a surprising one -- after the terrorist attacks was that those who were most directly affected "suffered the most," according to Briggs. Coping with grief long-term depended on the cohesion of the child's family -- "how well the caregiving system responds to distress. When it is proactive, by definition the children do better."

"What was the most incredibly predictive five years out was how everyone was doing before the incident," said Briggs. "It is the same for mental health in general, those who are coping well in their lives before a trauma are the most likely to cope well afterwards -- even if they saw the towers fall."

Copyright 2012 ABC News Radio

Friday
Dec142012

Connecticut School Shooting: 4 Tips to Help Kids Cope

Douglas Healey/Getty Images(NEW YORK) -- Every parent trying to come to grips with the scope of the tragedy in Connecticut is wondering how to talk to their kids about it.

Alan Kazdin, a professor of child psychology at Yale University, offers four tips for parents to frame that discussion and help their kids cope.

Don’t Over-Talk This


Parents can easily project their own fears onto their kids.   Your kids will likely hear about it, so your child has questions. Answer at the level of the question.  Parents shouldn’t dwell on the tragic nature of it, but don’t be evasive.  Don’t lie, don’t withhold.

Shield Kids from the Media

After 9/11, kids suffered trauma from overexposure to the media.  Child psychologists call it “secondary terrorism.” As parents, we sometimes take the stance that our kids need to be tough and “they might as well know the truth.” But psychologists say they need to be "coddled, cushioned and comforted” now so they can be emotionally stronger later.

Don’t Pull Your Kids Out of School Today

Try to keep as many normal rituals going on as possible.  Go to soccer practice.  Keep that play date.  Kids need to know that this doesn’t directly affect them.

Reassure, Reassure


If your child develops a  fear of school, tell them, “This is so rare. Something this terrible has never happened before. This never happened to mommy’s school. Grownups are doing everything to keep kids safe.”

Remember that through “middle childhood,” kids have normal excessive fears: the dark, sharks, etc. If they say, “I don’t want to go to school,” help them distance themselves from it.

Repeatedly reassure without dismissing their fears and give them a hug. Touch makes a huge difference.

Copyright 2012 ABC News Radio

Wednesday
Jun012011

Should Government Crack Down on Hookah Lounges?

Justin Sullivan/Getty Images(NEW HAVEN, Conn.) -- Jeff Burt has always enjoyed the smoothness and fruity flavors of a hookah's smoke. The 28-year-old has smoked shisha -- a flavored tobacco -- for several years in social settings with friends, but it's only in recent months that Burt has worried that his hookah consumption, usually combined with cigarettes and alcohol during a night out, is taking a toll on his body.

"I have been feeling worse and worse after I go out, drink a lot and smoke cigarettes and hookah, so I've been trying to cut down on the amount of that type of stuff I've been doing," said Burt.

Now, other hookah lovers may have to cut back on their shisha consumption, too, whether they want to or not. State lawmakers in Oregon, Connecticut and California are proposing to ban or limit hookah bars because of the health hazards associated with the smoking.

Rep. Carolyn Tomei, an Oregon state representative who sponsored a bill to limit new hookah lounges in Oregon, said her biggest concern is the health risk to young people.

"It's mostly very young people in hookah bars and that's who they appeal to," said Tomei. "Someone middle-aged doesn't start smoking; new smokers are young people. And most young people aren't aware of how dangerous it is."

Jack Henningfield, a drug and tobacco addiction expert at Johns Hopkins Medical Institution and a member of the World Health Organization Tobacco Product Regulation Study Group, agreed with Tomei, and said that even recreational use could turn into addiction.

"Proponents tend to describe infrequent use, but then that is how cigarette addiction and other disease typically start," said Henningfield. "Similar to cigarette smoking, many people escalate to more frequent use and higher levels of intake."

The Eastern Mediterranean device, which has been used in the region for several hundred years, has become a rising trend in the United States, particularly among young adults. Many people smoke shisha, because they believe it is a milder and safer alternative to smoking cigarettes, but experts say the truth is that it's as dangerous-- maybe even more -- than lighting up a cigarette.

A 2009 study conducted by Thomas Eissenberg, a professor of biopsychology and health psychology at Virginia Commonwealth University, found that relative to cigarette smoking, hookah use is associated with greater carbon monoxide, nicotine and smoke exposure.

"People are inhaling charcoal smoke and the combustion product of sugar and flavoring, along with tobacco smoke," said Eissenberg. "Smoke from a hookah and cigarettes have the same poisons."

The tobacco is heated by charcoal. The water in the hookah then cools the smoke before it hits one's mouth, so inhaling the usually fruity-flavored smoke is much smoother than a cigarette. Because of this, many people who partake in the hookah believe that the water acts as a filter to the tobacco toxins, but experts say this is untrue.

Smoking from a hookah during a typical 45-minute session is equivalent to smoking about 100 cigarettes, Eissenberg said.

Moreover, hookah tobacco packages are usually labeled to contain .05 percent of nicotine and 0 percent tar.

"Many hookah lounge owners will say, 'Look, it doesn't have tar' and they'll point to the tobacco package," said Eissenberg. "The box is right, just as a cigarette does not contain tar. You have to burn tobacco to produce tar."

"There is a great deal of tar in hookah smoke," continued Eissenberg. "A person gets about 36 times the amount of tar in a hookah session compared to a cigarette."

Akhil, owner of La Sheesh Hookah Lounge in New Haven, Conn., declined to give his last name, but said he is happy to oblige any regulation that Connecticut lawmakers put into place. But Akhil did note that banning hookah lounges is different than the ban on smoking in public places.

"It's different in a hookah lounge, because a person's intentions are to go to smoke, which is different going to a bar or restaurant, where you could be exposed unfairly to a health hazard," said Akhil. "It's different if you know you're going to a place to smoke out of a hookah."

And as for frequenters of hookah lounges, the sudden ban or limitation to the popular bars may cause protest.

"The public can make their own decision about if they would like to smoke a hookah at a lounge," said Burt. "Hookah lounges are designated bars specifically targeted to people who like to smoke hookah. If you don't like smoking hookah, why would you enter a hookah bar?"

Copyright 2011 ABC News Radio







ABC News Radio