Medicine and Health Sciences Commons^™

Microvascular Vasoregulatory Dysfunction In African Americans - An Enhanced Opportunity For Early Prevention And Treatment Of Atherosclerotic Cardiovascular Disease, Renee Bullock-Palmer, Panithaya Chareonthaitawee, Ervin Fox, Garth Beache

Division of Cardiology Faculty Papers

Atherosclerotic cardiovascular disease and its risk factors and precursors are a major driver of disparities in cardiovascular health. This review examines reported evidence that vascular endothelial dysfunction, and its manifestation as coronary microvascular dysfunction, underlies observed excess morbidity and mortality in African Americans. Advanced imaging insights that reveal patho-mechanisms, along with population evidence from the Jackson Heart Study, and the growing evidence emanating from national and international clinical trials and registries are presented. We examine a physiological framework that recognizes insulin-resistant cardiometabolic underpinnings of the conditions of the American Heart Associations' Life's Essential Eight construct of cardiovascular health as a …

Microbiome Diversity In African American, European American, And Egyptian Colorectal Cancer Patients, Amr Elkholy, Nagavardhini Avuthu, Mohammed Abdalla, Michael Behring, Prachi Bajpai, Hyung-Gyoon Kim, Doaa Header, Reham Ah. Elwafa, Hesham Saed, Mansoor Saleh

Internal Medicine, East Africa

Purpose: Although there is an established role for microbiome dysbiosis in the pathobiology of colorectal cancer (CRC), CRC patients of various race/ethnicities demonstrate distinct clinical behaviors. Thus, we investigated microbiome dysbiosis in Egyptian, African American (AA), and European American (EA) CRC patients.

Patients and methods: CRCs and their corresponding normal tissues from Egyptian (n = 17) patients of the Alexandria University Hospital, Egypt, and tissues from AA (n = 18) and EA (n = 19) patients at the University of Alabama at Birmingham were collected. DNA was isolated from frozen tissues, and the microbiome composition was analyzed by 16S rRNA …

Positive Changes In Safety Perception Among Blacks With Hiv And Comorbidities: Assessment Of Social Determinants Of Health During Covid‑19, Marc Fleming, Deidra Lee, Chukwuezugo Oranu, Jon C. Schommer, Jennifer M. Cocohoba, Jennifer Cooper, Crystal K. Hodge, Saharnaz Nedjat, Kathleen Borgmann

Pharmacy Faculty Articles and Research

Purpose

This study aimed to examine the impact of the COVID-19 lockdown on social determinants of health (SDOH) among Blacks with HIV and a comorbid diagnosis of hypertension or type 2 diabetes mellitus (T2DM).

Methods

This was a longitudinal survey study. The inclusion criteria were adults ≥ 18 years and the presence of hypertension and/or diabetes, along with a positive HIV diagnosis. This study enrolled patients in the HIV clinics and chain specialty pharmacies in the Dallas-Fort Worth (DFW) area. A survey of ten questions examining SDOH was conducted before, during, and after the lockdown. A proportional odds mixed effects …

Impact Of Culturally Tailored Shared Medical Appointments On Diabetes Self-Care Ability And Knowledge In African Americans, Adrienne L. Reddick, Deborah C. Gray

Nursing Faculty Publications

Background: Type 2 diabetes mellitus (T2DM) continues to disproportionately affect African Americans, significantly impacting morbidity and mortality. Research suggests that addressing barriers that stem from socioeconomic circumstances, systemic inequalities, biological factors, and cultural factors may positively influence biometric indicators of health and diabetes control. Objective: The aim of this study was to evaluate a diabetes shared medical appointment (SMA) model program that has been culturally tailored to address the unique social determinants of health barriers faced by an inner city African American population in Norfolk, Virginia. Methods: A pilot study using a within-group pretest–posttest design was conducted. Information was collected …

Il-1Β Enhances Cell Viability And Decreases 5-Fu Sensitivity In Novel Colon Cancer Cell Lines Derived From African American Patients, Marzia Spagnardi, Jenny Paredes, Jovanny Zabaleta, Jone Garai, Tiana Reyes, Laura A. Martello, Jennie L. Williams

School of Medicine Faculty Publications

Background: In the U.S., African Americans (AAs) present with the highest incidence and mortality rates for Colorectal Cancer (CRC). When compared to Caucasian American (CA) patients, AAs also have reduced response to the first line standard of care chemotherapeutic agent 5-Fluorouracil (5-FU). Previously, we observed differential gene expression between the two populations, suggesting that colon tumors from AA patients display a decreased antitumor immune response and an increased expression of genes encoding proteins involved in inflammatory processes, such as Interleukin-1β (IL-1β). Here, we investigate the role of IL-1β in modifying chemotherapeutic response and altering expression of proteins in novel AA …

Exploring Feasibility Of Mhealth To Manage Hypertension In Rural Black Older Adults: A Convergent Parallel Mixed Method Study, Danice B. Greer, Willie M. Abel

Nursing Faculty Publications and Presentations

Objective: The purpose of this study was to explore perceived ease of use, usability, and the feasibility of using mobile health applications to manage hypertension self-care in rural Black older adults with hypertension.

Methods: A convergent parallel mixed method design was used to study a purposeful sample of 30 Black older adults (29 females, 1 male) from rural East Texas. Quantitative data included demographic characteristics and measured blood pressure, height, and weight, along with questionnaires: the Hill-Bone Compliance to High Blood Pressure Therapy Scale, the Krousel-Wood Medication Adherence Scale-4, and the Technology Acceptance Model Questionnaire (adapted). Qualitative data …

“Where The Truth Really Lies”: Listening To Voices From African American Communities In The Southern States About Covid-19 Vaccine Information And Communication, Ran Zhang, Shan Qiao, Brooke Mckeever, Bankole Olatosi, Xiaoming Li

Faculty Publications

The high uptake of COVID-19 vaccines is one of the most promising measures to control the pandemic. However, some African American (AA) communities exhibit vaccination hesitancy due to mis- or disinformation. It is important to understand the challenges in accessing reliable COVID-19 vaccine information and to develop feasible health communication interventions based on voices from AA communities. We conducted 2 focus group discussions (FGDs) among 18 community stakeholders recruited from 3 counties in South Carolina on 8 October and 29 October 2021. The FGDs were conducted online via Zoom meetings. The FGD data were managed and thematically analyzed using NVivo …

Recruitment, Retention, And Future Direction For A Heart Health Education And Risk Reduction Intervention Led By Community Health Workers In An African American Majority City, Julie Gleason-Comstock, Cindy Bolden Calhoun, Ghadir Mozeb, Cardell Louis, Alex B. Hill, Barbara J. Locke, Victor Harrell, Sadia Yasmin, Liying Zhang, John M. Flack, Nancy T. Artinian, Jinping Xu

Urban Studies and Planning Faculty Research Publications

Heart disease is a leading cause of death for African Americans. A community-academic partnership cross-trained community health workers to engage African American adults in a 6-month heart health education and risk reduction intervention. We conducted a one-group feasibility study using a one group (pre-posttest) design. A total of 100 adults were recruited from 27 zip codes in an African American majority city through community-based organizations (46%), churches (36%), and home visits (12%). Ninety-six percent were African American; 55% were female, 39% were male, and 6% were transgender. Their mean age was 44.6 years (SD=15.9). Ninety-two percent had health insurance. Seventy-six …

Actions Against Racism: Bringing Together Trauma-Informed Practices, Social-Emotional Learning, And Racial Socialization To Combat Racism In Schools, Danielle R Hatchimonji, Kira Branch, Danika Perry, Tia N Barnes

Department of Pediatrics Faculty Papers

Racism is a social determinant of health with dire consequences for the health, education, and mental health of students of color. Thus, there is an urgent need to develop and test evidence-based strategies to combat racism in schools. In response to this need, our team has developed a multi-tiered school-based intervention to build capacity for combatting racism in educators, students, and families. The "Actions Against Racism" intervention synthesizes three evidence-based practices: trauma-informed practices, social-emotional learning (SEL), and racial socialization. The multiple tiers of intervention aim to cultivate skills for combatting individual and structural racism in educators, families, and students across …

Social Determinants Of Health And Depression Among African American Adults: A Scoping Review Of Current Research, Brooks Yelton, Daniela B. Friedman, Samuel Noblet, Matthew C. Lohman, Mark M. Macauda, Mayank Sakhuja, Katherine H. Leith

Faculty Publications

Depression in the United States (US) is increasing across all races and ethnicities and is attributed to multiple social determinants of health (SDOH). For members of historically marginalized races and ethnicities, depression is often underreported and undertreated, and can present as more severe. Limited research explores multiple SDOH and depression among African American adults in the US. Guided by Healthy People (HP) 2030, and using cross-disciplinary mental health terminology, we conducted a comprehensive search to capture studies specific to African American adults in the US published after 2016. We applied known scoping review methodology and followed Preferred Reporting Items for …

Exploring The Needs Of Black Single Mothers In Therapy, Nompelelo Boucher

Antioch University Full-Text Dissertations & Theses

This qualitative study of 6 Black single mothers utilizes a focus group format to explore their experiences in mental health treatment. The specific barriers they face to seeking treatment are reviewed, given that this particular population is substantially underrepresented in mental health therapy. The study seeks to gain a better insight of what factors contribute to attracting and retaining them in therapy for positive outcomes. Six emergent themes surfaced highlighting the fact that these women overcome numerous historical and cultural barriers to present for treatment to address serious issues of stress, grief, and loss, that they have a desire to …

Personalized Nutrition As A Key Contributor To Improving Radiation Response In Breast Cancer, Anuradha A. Shastri, Joseph Lombardo, Samantha C Okere, Stephanie Higgins, Brittany C Smith, Tiziana Deangelis, Ajay Palagani, Kamryn Hines, Daniel A. Monti, Stella Volpe, Edith P. Mitchell, Nicole L Simone

Department of Radiation Oncology Faculty Papers

Understanding metabolic and immune regulation inherent to patient populations is key to improving the radiation response for our patients. To date, radiation therapy regimens are prescribed based on tumor type and stage. Patient populations who are noted to have a poor response to radiation such as those of African American descent, those who have obesity or metabolic syndrome, or senior adult oncology patients, should be considered for concurrent therapies with radiation that will improve response. Here, we explore these populations of breast cancer patients, who frequently display radiation resistance and increased mortality rates, and identify the molecular underpinnings that are, …

Language Variation In The Writing Of African American Students: 6 Factors Predicting Reading Achievement, Lisa Fitton Ph.D., Lakeisha Johnson, Carla Wood, Christopher Schatschneider, Sara A. Hart

Faculty Publications

Purpose

This study aims to examine the predictive relation between measures obtained from African American students' written narrative language samples and reading achievement, as measured by standardized academic assessments.

Method

Written language samples were elicited from 207 African American students in Grades 1–8. The samples were examined for morphosyntactic variations from standardized written Generalized American English (GAE). These variations were categorized as either (a) specific to African American English (AAE) or (b) neutral across AAE and standardized written GAE (i.e., considered ungrammatical both in AAE and in standardized written GAE). Structural equation modeling was employed to then examine the predictive …

A Theory-Based Analysis Of Covid-19 Vaccine Hesitancy Among African Americans In The United States: A Recent Evidence, Manoj Sharma, Kavita Batra, Ravi Batra

Environmental & Occupational Health Faculty Publications

African Americans have been disproportionately vaccinated at lower rates, which warrants the development of theory-based interventions to reduce vaccine hesitancy in this group. The fourth-generation theories, e.g., multi-theory model (MTM) of health behavior change, are vital in developing behavioral interventions. Therefore, the current study aims to determine recent trends in COVID-19 vaccination rates and to test the MTM model in predicting the initiation of COVID-19 vaccines among vaccine-hesitant Blacks. A sample of 428 unvaccinated African Americans were recruited through a web-based survey using a 28-item psychometric valid questionnaire. Chi-square, independent-samples-t-test or Welch’s t test, and Pearson’s correlation tests were utilized …

Attitudes Towards A Mindfulness-Based Intervention From African American Women Living With Hiv: A Qualitative Study, Slone Taylor, Shan Qiao Ph.D., Sharon Weissman, Xiaoming Li Ph.D.

Faculty Publications

Introduction: Mindfulness-based interventions train participants to pay attention to their own emotions in the current moment without judging themselves. This study aims to assess the attitudes toward a mindfulness-based stress reduction intervention among African American women living with HIV. Methods: We collected qualitative data from three focus group discussions with 18 African American women living with HIV who were purposely recruited from the Palmetto Health-USC Immunology Center in South Carolina, United States. The participants discussed how they coped with stress, and then were given a presentation on mindfulness-based stress reduction and a sample mindfulness-based stress reduction mini workshop with follow-up …

Home And Neighborhood Physical Activity Location Availability Among African American Adolescent Girls Living In Low-Income, Urban Communities: Associations With Objectively Measured Physical Activity, Nicole O'Reilly

Social Work Faculty Publications and Presentations

Based on the ecological model of active living, the neighborhood environment may relate to individual physical activity (PA) behaviors. The purposes of this study were to (1) generate a replicable neighborhood-level physical activity location availability score (PALAS) from data variables associated with physical activity among adolescents and adults, and apply this score to Baltimore City, Maryland, and (2) determine if relationships exist between PA and PA location availability. Geographic information systems (GISs) were used to create the PALAS. Using linear regression models, we examined relations between objectively measured PA among low-income, urban, predominantly African American adolescent girls (n = …

Effect Of Treatment For Hcv On The Development Of Hcc In A Predominately African American Medical Center Population, Bassem Farah, Yechiel Mor, Sarvani Surapaneni, Brian Rutledge, Hojun Lee, Hajra Khan, Anshu Wadehra, Neel Patel, Paul Naylor, Murray Ehrinpreis, Milton Mutchnick

Medical Student Research Symposium

Introduction

Direct Acting Antivirals (DAA) are effective in Hepatitis C (HCV) patients with cirrhosis, but viral elimination may occur in a setting where the HCC development pathway has already begun. Our objective was to determine whether achieving a sustained virologic response (SVR) prior to diagnosis of hepatocellular carcinoma (HCC) improved outcomes in our predominately African American population.

Methods

We reviewed the medical records of 96 HCV patients diagnosed with HCC between 2015 and 2019 Primary outcomes were defined as either alive, death/hospice, or transplant. Tumor size was measured as non-small (> 5cm or multiple tumors) or small (< 5cm). The study was approved by the WSU IRB and data analysis performed using the SAS-JMP statistical software.

Results

Of …

Perceived Neighborhood Characteristics And Parental Role In Physical Activity Of African American Youth, Kashica Webber-Ritchey, Elizabeth Moxley, Sungsoon Hwang, Desale Habtzghi, Sai Yalla

Faculty Peer-Reviewed Publications

Introduction: Lack of physical activity (PA) serves as one of the contributing factors to pediatric obesity in African American (AA) youth.

Objective: Further examination of the Social Ecological Model [SEM] influences on PA in AA youth is vital. The purpose of this pilot study is to explore environmental factors, built environment (BE) and parental role, in PA promotion.

Methods: Using mixed method data collection, a convenience sample of 28 AA parents/caregivers of school-aged children (6-12 years) enrolled in Chicago Youth Programs (CYP) completed an online survey. Parents/caregivers along with their child participated in focus group sessions (n=18 parent/child dyads). …

Immune-Related Gene Expression And Cytokine Secretion Is Reduced Among African American Colon Cancer Patients, Jenny Paredes, Jovanny Zabaleta, Jone Garai, Ping Ji, Sayed Imtiaz, Marzia Spagnardi, Joussette Alvarado, Li Li, Mubarak Akadri, Kaylene Barrera, Maria Munoz-Sagastibelza, Raavi Gupta, Mohamed Alshal, Maksim Agaronov, Henry Talus, Xuefeng Wang, John M. Carethers, Jennie L. Williams, Laura A. Martello

School of Medicine Faculty Publications

Background: Colorectal cancer is the third most deadly cancer among African Americans (AA). When compared to Caucasian Americans (CA), AA present with more advanced disease and lower survival rates. Here, we investigated if differences in tumor immunology could be contributive to disparities observed between these populations. Methods: We examined gene expression of tumor and non-tumor adjacent tissues from AA and CA by whole transcriptome sequencing, and generated scores for immune cell populations by NanoString. In addition, we utilized “The Cancer Genome Atlas” (TCGA) database from AA and CA as a validation cohort. Finally, we measured the secretion of cytokines characteristic …

Predictors Of Persistent And Recurrent Bacterial Vaginosis (Bv) Among Young African American (Aa) Women In The United States, Makella S. Coudray

FIU Electronic Theses and Dissertations

Bacterial vaginosis (BV) is a common vaginal dysbiosis among women of reproductive age. Literature presents discordant findings with respect to the predictors of BV and there is a paucity of literature examining the mechanisms by which multiple episodes of BV occur. This dissertation summarized current literature on BV, identified BV incidence patterns over a twelve-month period, and estimated the risk of sexually transmitted infections (STI) among women with episodic and persistent BV. Previously collected randomized clinical trial data were analyzed, where oral metronidazole was the administered treatment. Latent class analysis (LCA) was used to assess BV incidence patterns. Multinomial Logistic …

Examining The Factors That Influence African Americans In The Midwest To Reduce Salt Intake, Ni Zhang, Emily Leary, Michelle Teti, Jon Stemmle, Natalie Hampton

Faculty Research, Scholarly, and Creative Activity

Purpose: Salt intake is associated with cardiovascular diseases that are the leading cause of death especially among African American communities in the Midwest. Interventions need to be developed to address the culture of this population to decrease the health disparities of cardiovascular disease. This study applying the Health Belief Model aims to explore the factors that are associated with the behavior of reducing salt intake among this population.
Methods: Three hundred ninety-nine African American adults participated in the telephone surveys. Logistic regression analysis was performed.
Results: We found that affective risk perception in the form of concern of salt intake …

Reducing Copd Exacerbation Among African Americans Affected With Copd In A South Florida Clinic. A Quality Improvement Project, Jean-Pierrot Orelus, Dana Sherman, Alex Javier Hernandez

Nicole Wertheim College of Nursing Student Projects

Abstract

Objective: The study aimed to determine if an educational intervention will improve COPD exacerbations in African American population after a 6-week self-management program that includes the proper use of an inhaler.

Methods: Ten patients were recruited in a primary care setting with the assistance of the providers. All patients had to complete a pretest and a posttest to assess their knowledge of inhaler technique, their willingness to engage in self-efficacy disease management, their symptoms improvement and treatment adherence. The Inhaler Device Assessment Tool, the Self-Efficacy for Managing Chronic Disease 6-Item Scale, the CAT test, and the TAI test were …

Identifying Protective Factors In Response To Discriminatory Experiences Among Pregnant African American Woman, Effie Mathew, Krys Foster, Md

Phase 1

Adverse maternal-fetal health outcomes, such as low birth weight and preterm delivery, are disproportionately more likely among African-Americans than Non-Hispanic Whites. Experiences of discrimination have been hypothesized as a contributing factor to the large discrepancies in maternal-fetal health outcomes. It is well understood that with increased levels of self-reported discrimination, there are lower ratings of physical and mental health, and higher reporting rates of depressive symptoms; this relationship is stronger in women. In addition to this, skin tone has long been a marker for social class and opportunity, but research on skin tone as a risk factor for African Americans …

Characterizing Patch Test Findings In African American Acd Patients, Vaibhav Garg, Bruce Brod, Anthony Gaspari

Phase 1

Introduction: Allergic Contact Dermatitis (ACD) in African Americans has not been well studied, and there is little information related to differences in patterns of ACD between African Americans and Caucasians. This paper aims to investigate relative differences in patterns of sensitization in African American ACD patients.

Methods: This study is a retrospective descriptive study. Data of ACD patients patch tested from 2009-2019 by Dr. Gaspari and Dr. Brod at TJUH and HUP/UPHS were reviewed. Patch test findings for African American and Caucasian patients were compared. Outcomes such as positive allergens, strength, clinical relevance, patient occupation, and personal product use …

“For Lack Of Knowledge, Our People Will Perish”: Using Focus Group Methodology To Explore African-American Communities’ Perceptions Of Breast Cancer And The Environment, Kaleea Lewis, Shibani Kulkarni, Swann Arp Adams, Heather M. Brandt, Jamie R. Lead, John R. Ureda, Delores Fedrick, Chris Mathews, Daniela B. Friedman

Faculty Publications

Among women living in the United States, breast cancer is the second leading cause of cancer death. Disproportionate racial disparities in breast cancer exist, with African American (AA) women consistently having the highest rates of breast cancer related mortality despite lower incidence. This study attends to the Institute of Medicine's (IOM) call to action recommending the identification of effective strategies for communicating accurate and reliable breast cancer risk information to diverse audiences. Using focus group methodology, this study explores how AAs perceive and decipher information related to breast cancer and its relationship to their environment. Six focus groups were conducted. …

Determinants Of Successful Weight Loss In Low-Income African American Women: A Positive Deviance Analysis., Elaine Seaton Banerjee, Sharon J. Herring, Katelyn Hurley, Katherine Puskarz, Kyle Yebernetsky, Marianna Lanoue

College of Population Health Faculty Papers

OBJECTIVE: We set out to investigate the behaviors of low-income African American women who successfully lost weight.

METHODS: From an urban, academic, family medicine practice, we used a mixed methods positive deviance approach to evaluate 35 low-income African American women who were obese and lost at least 10% of their maximum weight, and maintained this loss for 6 months, comparing them with 36 demographically similar control participants who had not lost weight. Survey outcomes included demographics and behaviors that were hypothesized to be related to successful weight loss. Interviews focused on motivations, barriers, and what made weight loss successful. Survey …

The Effect Of Nurse- Led Group Discussions By Race On Depressive Symptoms In Patients With Heart Failure, Ubolrat Piamjariyakul, Noreen C. Thompson, Christy Russell, Carol E. Smith

Clinical and Translational Science Institute

Background—African Americans with heart failure (HF) have the highest rates of depression among all ethnicities in the United States. Objectives—To compare the effects by race on depressive symptoms and topics discussed in the first clinic appointment after HF hospitalization. Methods—This study is a secondary analysis of data obtained from a randomized clinical trial that tested a patient group discussion of HF self-management intervention with 93 Caucasians and 77 African Americans. Results—The reduction in depressive symptoms was significantly greater among African American patients within the intervention group (F = 3.99, p = .047) than controls. There were significant differences by race …

Prevalence And Predictors Of Low Serum 25-Hydroxyvitamin D Among Female African-American Breast Cancer Survivors, Patricia M. Sheean, Claudia Arroyo, Jennifer Woo, Melinda Stolley

Nursing: School of Nursing Faculty Publications and Other Works

Background:

African-American breast cancer survivors commonly demonstrate low serum 25-hydroxyvitamin D (25(OH)D). Decreased cutaneous conversion, high levels of adiposity, and even breast cancer treatment may influence vitamin D status. Previous investigations have analyzed African-American women in aggregate with other breast cancer survivors and have not comprehensively addressed these influential factors.

A Longitudinal Analysis Of The Impact Of Child Custody Loss On Drug Use And Crime Among A Sample Of African American Mothers, Kathi L. H. Harp, Carrie B. Oser

Health Management and Policy Faculty Publications

This study examines the influence of child custody loss on drug use and crime among a sample of African American mothers. Two types of custody loss are examined: informal custody loss (child living apart from mother but courts not involved), and official loss (child removed from mother’s care by authorities).

Methods—Using data from 339 African American women, longitudinal random coefficient models analyzed the effects of each type of custody loss on subsequent drug use and crime.

Results—Results indicated that both informal and official custody loss predicted increased drug use, and informal loss predicted increased criminal involvement. Findings demonstrate …

Hla-Dqa1 And Apol1 As Risk Loci For Childhood-Onset Steroid-Sensitive And Steroid-Resistant Nephrotic Syndrome., Adebowale Adeyemo, Christopher Esezobor, Adaobi Solarin, Asiri Abeyagunawardena, Jameela A. Kari, Sherif El Desoky, Larry A. Greenbaum, Margret Kamel, Mahmoud Kallash, Cynthia Silva, Alex Young, Tracey E. Hunley, Nilka De Jesus-Gonzalez, Tarak Srivastava, Rasheed Gbadegesin

Manuscripts, Articles, Book Chapters and Other Papers

Background: Few data exist for the genetic variants underlying the risk for steroid-sensitive nephrotic syndrome (SSNS) in children. The objectives of this study were to evaluate HLA-DQA1 and APOL1 variants as risk factors for SSNS in African American children and use classic HLA antigen types and amino acid inference to refine the HLA-DQA1 association.

Study design: Case-control study.

Setting & participants: African American children with SSNS or steroid-resistant nephrotic syndrome (SRNS) were enrolled from Duke University and centers participating in the Midwest Pediatric Nephrology Consortium.

Factor: Genetic variants in HLA-DQA1 (C34Y [rs1129740]; F41S [rs1071630]) and APOL1 high-risk alleles.

Outcomes: SSNS …