Digital Commons Network^™

Effects Of Sleep Duration And Perceived Stress Of Reaction Time In Undergraduate Students, Caitlin Wescott, Edna Urrutia, Ryan F. Rednick, David Still

Discovery Day - Daytona Beach

Sleep deprivation and psychological stress are common among undergraduate students and can negatively affect cognitive performance. Reaction time is an important indicator of attention and processing speed and plays a critical role in both everyday activities, such as driving, and high-performance environments where rapid responses are required. This study aims to examine how sleep duration and perceived stress levels influence reaction time in undergraduate students. Participants will report their sleep duration and perceived stress levels through short surveys and wearable sleep data, while reaction time will be measured using a standardized computerized reaction time test. By comparing reaction time across …

Simulating Pacemakers And Heartbeat Recovery Through Mathematical Modeling, Thomas Estrada, Jayla Edwards

Discovery Day - Daytona Beach

Title: Simulating Pacemakers and Heartbeat Recovery Through Mathematical Modeling   This study utilizes the Fitzhugh-Nagumo model to simulate cardiac electrical activity and the regulatory role of pacemakers through ordinary differential equations (ODEs). By defining the rate of change for membrane voltage, 𝑑𝑣/dt, and a recovery variable, 𝑑𝑤/dt, the model captures the heart's excitability and resting states. Central to the analysis is the stimulus current parameter, which represents the "kick" provided by a pacemaker to correct flatline conditions or weak heartbeats. Using Euler’s method for numerical integration, the research compares unstable cardiac rhythms against corrected periodic oscillations. Additionally, the project implements vector …

Translational Reading Frame Predicts The Pathogenicity Of C-Terminal Frameshift Deletions In Mecp2, Jacky Guy, Elena Hein, Beatrice Alexander-Howden, Timur Von Bock Und Polach, Tricia Mathieson, Benjamin P Kleinstiver, Huda Y Zoghbi, Adrian Bird

Duncan NRI Faculty and Staff Publications

Mutations in the MECP2 gene cause the severe neurological disorder Rett syndrome. A cluster of frameshift-causing C-terminal deletions (CTDs) removes ~100 amino acids and accounts for approximately 10% of RTT-causing mutations. Their pathogenicity is unexpected because this C-terminal domain is dispensable in mice. Analysis of pathogenic and benign human MECP2 variants reveals that some individuals with apparently typical CTDs do not develop Rett syndrome, confirming that C-terminal truncations are not intrinsically pathogenic. Using human sequence data and mouse models we show that pathogenicity results from a marked reduction in MeCP2 levels and depends on the presence of a proline proline …

Improving Cpr Quality In The Emergency Department By Implementing Data Driven Debriefs, Alyssa M. Hughes

Doctor of Nursing Practice Final Project Abstract

Purpose

The purpose of the quality improvement project was to evaluate the effectiveness of implementing a data driven debrief tool to improve the average compressions in target in adult cardio-pulmonary resuscitation (CPR) events.

Results

In FY23 prior to implementation the average compressions in target was only 1.65%. During the implementation phase of the project the average compressions in target reached 41% (n=3). In addition, the staff provided positive feedback regarding the tool and the integration in the workflow.

Background

The project was completed in a tertiary academic medical center emergency room. All adult CPR events within the emergency department utilizing …

A Case Report Of Myocardial Infarction Complicated With Blood Pressure Fluctuations Caused By Pheochromocytoma, Huiping Li, Wei Yang, Yu Feng, You Zhang, Gan-Xin Yan, Chuanyu Gao

Department of Medicine Faculty Papers

Pheochromocytoma typically presents with sustained or paroxysmal hypertension, but initial manifestation as acute non-ST-segment elevation myocardial infarction (NSTEMI) is rare. Peri-procedural hemodynamic fluctuations are often dramatic, making diagnosis and management challenging. We report a 51-year-old male admitted with chest tightness for 17 days. Elevated troponin and coronary angiography showing multivessel disease with total occlusion of the mid-left anterior descending artery (LAD) led to a preliminary diagnosis of NSTEMI. During percutaneous coronary intervention, blood pressure surged to 240/130 mmHg; intravenous nitroprusside caused an instantaneous drop to 95/55 mmHg, with rapid rebound to >200 mmHg upon withdrawal, showing no clear temporal relationship …

Frequency And Outcome Of Peg Tube Implantations In Hospitalized Parkinson's Disease Patients, Rachael M. Burke, Ruina He, Hikaru Kamo, Tejas R. Mehta, Anne Brooks, Adrianne Smiley, Michael S. Okun, Christopher W. Hess, Matthew A. Remz

Department of Neurology Faculty Papers

BACKGROUND: Dysphagia is a known complication of Parkinson's Disease (PD). Percutaneous endoscopic gastrostomy (PEG) tube placement is a therapy for select patients with dysphagia. There is a paucity of information on the role of PEG in PD management.

OBJECTIVES: To investigate the frequency and outcomes of PEG tube implantations in hospitalized patients with PD.

METHODS: We performed a retrospective review of the PINC AI™ Healthcare Database of hospitalized PD patients between 2017 and 2023. PEG implantation, discharge status, and aspiration pneumonia (AP) diagnoses were collected and analyzed. The relationships between AP and PEG were evaluated using logistic regression. Generalized estimating …

Recalibrating Risk: A Call For South Asian-Focused Heart Failure Prediction Models, Nandini Nair, Dongping Du, Aiswarya J. Pillai, Swarna Mahesh, Mrudula R. Munagala, Howard J. Eisen, Balakrishnan Mahesh

Division of Cardiology Faculty Papers

Background: Heart failure (HF) represents the final common pathway of diverse cardiovascular disorders, including coronary artery disease, primary myocardial pathology, and abnormalities of cardiac conduction. These conditions arise from an interplay of genetic, environmental, and psychosocial influences, making it essential to understand these determinants to improve risk prediction and prevention. Multiple biological pathways of inflammation, fibrosis, coagulation, oxidative stress, lipid dysregulation, endothelial dysfunction, and metabolic disturbances are shaped by inherited susceptibility and modifiable exposures. Together, these mechanisms drive HF development and progression, though their relative contributions vary across populations. Methods: PubMed and Google Scholar were searched for clinical, biomedical, and …

Bibliometric Analysis Of The Top 100 Most Cited Publications From Saudi Arabia Reveals The Predominance Of Medical Fields, Mahmoud Kandeel, Abdulla Al-Taher

Saudi Medical Journal

Objectives: To explore the citation impact, journals, international collaborations, trends of research topics and gain more visibility for the Saudi contribution to the global scientific landscape. Methods: This bibliometric study analyzes the top 100 cited publications affiliated with Saudi Arabia in Scopus, from inception to January 2026. The extracted bibliometric indicators include total citation metrics, sources, collaboration maps, and co-occurrence networks of keywords and collaborations. Results: The results indicate a strong predominance for medicine and health sciences as the subjects of the most prolific and significant number of citations. A substantial proportion of the most cited papers originates from major …

Comparison Of The Effects Of Spinal Versus General Anesthesia On The Perioperative Intraocular Pressure: A Prospective, Randomized Clinical Trial, Muzaffer Gencer, Mehmet Yalvaç

Saudi Medical Journal

Objectives: To evaluate the effects of spinal and general anesthesia on the intraocular pressure (IOP) in patients, who had lumbar spine and lower extremity orthopedic surgeries Methods: Sixty adult were randomly classified into Group spinal anesthesia (SA) and Group general anesthesia (GA). The IOP, mean systemic arterial pressure, and heart rhythm were measured at 6 pre-determined timepoints (T0: Baseline, T1: Before spinal procedure or anesthesia induction, T2: After injection with intrathecal or anesthesia induction, T3: 5th minutes (min) after spinal procedure or tracheal intubation, T4: 30th min intraoperative, T5: At the end of surgery, T6: 5th min after surgery or …

Establishment Of A Specialized Pectus Clinic: Referral Patterns, Diagnostic Characteristics, And Early Management Experience At A University Hospital, Zeead M. Alghamdi

Saudi Medical Journal

Objectives: To describe the establishment and early impact of a dedicated pectus clinic at a university hospital, focusing on patient characteristics, referral pathways, clinical presentation, and initial management strategies. Methods: A retrospective observational study was conducted at a university hospital between January 2020 and April 2025, with 153 patients included in the final analysis. Data collected included demographic characteristics, referral sources, clinical presentation, deformity type, and treatment options. Descriptive statistical analysis was performed. Results: The mean patient age was 18.3 (range 1–44) years, with males accounting for 83.9% of cases. Pectus carinatum was the most common diagnosis (48.1%), followed by …

Patterns And Determinants Of Medication Errors Across The Medication-Use Process: A 3-Year Retrospective Study In A Saudi Tertiary Hospital, Nawaf S. Alqurashi, Mazen S. Alshehri, Mohammed J. Almalki, Mustafa M. Muradkhudhari, Rozan M. Radwan, Mohammed M. Aldurdunji, Saleh A. Almazam, Ohood K. Almuzaini, Saad M. Wali

Saudi Medical Journal

Objective: To characterize medication errors across the full workflow and identify stage-specific predictors in a tertiary care setting. Medication errors remain a major global patient safety concern, with limited comprehensive analyses across all stages of the medication-use process in Saudi Arabia. Methods: A retrospective observational study was conducted using medication error reports from Al-Noor Specialist Hospital, Makkah, between January 2023 and August 2025. Errors were classified by stage and severity using the National Coordinating Council for Medication Error Reporting and Prevention index. Multivariable logistic regression was performed to identify predictors associated with each stage. Results: A total of 6,546 errors …

Gender Differences In Primary Care Utilization And Determinants Of General Practitioner Visits Among Saudi Females: A Cross-Sectional Analysis Using World Health Survey In The Kingdom Of Saudi Arabia 2019, Ali M. Alzahrani, Holly C. Felix, Abdulrhman A. Alzhrani

Saudi Medical Journal

Objective: To document the number of visits Saudi adults have with general practitioners (GP) or family medicine doctors (FD), determine if there is an association between GP/FD visits and sex, and then identify factors associated with GP/FD visits among Saudi females. Methods: A cross-sectional analysis was conducted using data from the 2019 World Health Survey in the Kingdom of Saudi Arabia (KSAWHS 2019), a nationally representative household survey. The outcome variable was number of visits to GP/FD. Survey-weighted negative binomial regression was applied. Results: From April to July 2019, 8,912 individuals participated in the KSAWHS 2019 individual questionnaire, of whom …

Patient Experiences And Safety Concerns Regarding Glp-1 Receptor Agonists For Obesity: A Cross-Sectional Survey In Jeddah, Saudi Arabia, Mansour A Tobaiqy, Sulafa T. Alqutub, Mohammed A. Alzahrani, Renad H. Alazwari, Faisal A. Asiri

Saudi Medical Journal

Objective: To evaluate the perceptions, experiences, and safety concerns of patients regarding the glucagon-like peptide-1 (GLP-1) receptor agonists. Obesity is a significant public health issue. The newer anti-obesity medications: GLP-1 receptor agonists, with an increase in therapeutic options. However, little is known about the perceived benefits, safety, cost, and accessibility. Methods: Cross-sectional survey included adults who previously used at least 1 anti-obesity medication and conducted in 3 general hospitals in Jeddah, Kingdom of Saudi Arabia (KSA) during June 2025 to February 2026. The questionnaire was created after reviewing the current evidence and validated the contents. It included questions on demographic …

Patient Safety Culture Among Healthcare Professionals In Jeddah First Health Cluster: A Multi-Professional Cross-Sectional Study, Saad S. Alyazidi, Salah S. Alshagrawi

Saudi Medical Journal

Objective: Patient safety culture (PSC) is essential to improve healthcare quality and reduce preventable harm. Despite ongoing healthcare transformation in Saudi Arabia, there is limited evidence on healthcare professionals' (HCPs) perceptions of PSC in newly established health clusters. Methods: We conducted a cross-sectional study among HCPs in 6 government hospitals within the Jeddah First Health Cluster, Saudi Arabia. Data were gathered utilizing the Hospital Survey on PSC (HSOPSC). Descriptive measurement sand multiple linear regression analyses were used to evaluate perceptions of PSC and associated factors. Results: A total of 256 HCPs participated in the study. Overall, PSC was perceived as …

The Al-Bahah Paradox: Divergent Patterns Of Increased And Decreased Infectious Disease Incidence Relative To National Saudi Rates Over 12 Years Of Surveillance, Mohammed A. A. Alqumber

Saudi Medical Journal

Objective: To identify statistically significant deviations in notifiable infectious disease incidence between Al-Bahah region and national Saudi averages, and to generate hypotheses that may inform future epidemiological, microbiological, and public health investigations. Methods: In April 2026, a 12-year retrospective ecological study (2013–2024) was conducted using surveillance data from the Saudi Ministry of Health for 37 notifiable infectious diseases across 20 health regions. Cumulative incidence rates, standardized morbidity ratios (SMRs), and Z-tests compared observed cases in Al-Bahah against national estimates. Results: Overall incidence was 15.8% lower in Al-Bahah than nationally (86.42 versus 102.68; incidence rate ratios = 0.842; p …

Preoperative Urine Albumin-To-Creatinine Ratio Predicts Acute Kidney Injury After Coronary Artery Bypass Grafting, Ahmed M. Alkhunaizi, Jumana A. Al Naser, Khaled D. Algarni, Suhaib M. Ahmed, Amro M. Moubarak, Haralabos D. Parissis

Saudi Medical Journal

Objective: To prospectively evaluate whether baseline urine albumin-to-creatinine ratio (uACR) predicts acute kidney injury (AKI) and postoperative decline in kidney function in elective, isolated coronary artery bypass grafting (CABG) patients and explore the magnitude of effect across clinically relevant uACR strata. Preoperative uACR is a marker of glomerular endothelial dysfunction and systemic microvascular injury that may identify patients at increased risk for AKI after CABG. Methods: In this single-center prospective cohort study, 111 adults undergoing elective, isolated CABG between January 2020 and December 2024 were stratified by baseline uACR (< 30, 30–300, > 300 milligram/gram[mg/g]). The primary outcome was AKI defined by Kidney …

The Role Of F-18 Fdg Pet/Ct In The Evaluation Of Solitary Pulmonary Nodules, Erdal Cetinkaya, Fatih Guzel, Sadiye Altun Tuzcu, Ilbey Erkin Cetin, Ibrahim Ibiloglu, Esref Argin, Feray Altun Cetin, Bekir Tasdemir

Saudi Medical Journal

Objective: Fluorine-18 fluorodeoxyglucose positronemissiontomography/computedtomography (F-18 FDG PET/CT) is commonly used in the evaluation of solitary pulmonary nodules (SPNs). This study aimed to investigate the predictive value of maximum standardized uptake value (SUVmax) and its ratios to liver and mediastinal blood pool SUVmax values for malignancy in SPNs, using histopathological findings as the reference standard. Methods: The study included 130 patients who underwent F-18 FDG PET/CT and had either histopathological confirmation or at least two years of radiological follow-up. Demographic data (age and sex), nodule size, location, contour characteristics, nodule SUVmax, nodule-to-liver SUVmax ratio (NLR), and nodule-to-mediastinal blood pool SUVmax ratio …

The Case For Gulf Region-Specific Peripheral Artery Disease Trials: A Comprehensive Literature Review, Hosaam H. Nasr, Faisal A. Almudaiheem

Saudi Medical Journal

Peripheral artery disease (PAD) research is globally underrepresented, with landmark trials like Best Endovascular Surgical Therapy for Patients with Critical Limb Ischemia and Bypass versus Angioplasty in Severe Ischemia of the Leg predominantly featuring white, Western populations. These studies fail to account for the unique clinical landscape of the Gulf region, where PAD prevalence reaches up to 13.7%. Gulf patients present at younger ages and face a disproportionately high diabetes burden, with regional prevalence near 18%, nearly double that of Europe. Beyond metabolic factors, the Gulf population exhibits distinct genetic architectures, including high rates of consanguinity and familial hypercholesterolemia. Because …

The Role Of Chimeric Antigen Receptor Regulatory T Cells In Promoting Immune Tolerance In Solid Organ Transplantation: Mechanisms And Therapeutic Potential, Maher S. Alwethaynani

Saudi Medical Journal

Solid organ transplantation (SOT) is a life-saving procedure for patients with end-stage organ failure; however, lifelong immunosuppressant use is needed to prevent allograft rejection. These drugs increase the risk of non-Hodgkin lymphoma, liver, kidney, and lung cancers, and heighten susceptibility to oncogenic viruses, including hepatitis B and Epstein-Barr virus. The usage of chimeric antigen receptor (CAR) regulatory T (Treg) cells is a promising approach to induce transplant tolerance while minimizing dependence on immunosuppressants. The CAR Tregs offer the potential to enhance graft survival and quality of life by reducing immunosuppressant-related morbidity and mortality. Despite remarkable progress in transplantation tolerance, challenges …

Meta-Analysis On The Effect Of Tai Chi Chuan On Human Biomechanics And Health From (2021–2025), Bijad S. Alqahtani, Husam A. Almalki

Saudi Medical Journal

Objective: Prior reviews emphasize overall health outcomes of Tai Chi Chuan (TCC) but rarely resolve the biomechanical intermediates (such as Center of Mass (CoM)–Center of Pressure (CoP) control, joint loading) that link practice to clinical function—knowledge that matters for balance, fall risk, and osteoarthritic knee load management. This systematic review and meta-analysis aim to test the null hypothesis that TCC produces no improvement versus comparators in (i) biomechanical stability indices (mediolateral/anterior–posterior CoM–CoP separation; COP Root Mean Square RMS) and (ii) related clinical functions (such as Time up and go (TUG), Berg balance scale (BBS), Western Ontario and McMaster Universities Osteoarthritis …

Developmental Dysplasia Of The Hip In Saudi Arabia And The Gulf Countries: A Genetic Systematic Review Study, Naif Z. Alrashdi, Ahmed M. Almansour, Azfar Jamal

Saudi Medical Journal

Objective: To describe the available research on genetic determinants with special emphasis on the developmental dysplasia of the hip (DDH), in Saudi Arabia and Gulf nations, with reference to the genetic variants, family trend, and environmental factors. Methods: The literature search was conducted in PubMed, Embase, Scopus, Web of Science, and the Saudi Digital Library and Google Scholar through a broad literature search since the beginning of the databases until 2023. Studies that conducted in Saudi Arabia or Gulf countries which evaluated the relationships of genetic factors in DDH were included. Case reports, conference abstracts, and studies that did not …

Exploring Translational Medical Research Progress In G20 Countries: 5-Year Study, Hana A. Alhumud, Fars K. Alanazi, Edward B. Devol

Saudi Medical Journal

Objectives: Biomedical research is crucial for advancing medical knowledge and improving public health. However, the research process is often disjointed and lacks seamless progression, leading to delays and missed opportunities. To address this, the concept of translational research has emerged, focusing on the smooth transition of research results to the next stage of inquiry. Methods: This study analyzed approximately 40,000 research publications from the Web of Science database to identify research activities associated with translational research. Publications from Group of 20 (G20) countries over the past 5 years were examined to explore patterns of research focus and progress in this …

Surgical Outcomes Of Hidradenitis Suppurativa Excision: Factors Impacting Wound Healing Time, Christina Huang, Scott H. Koeneman, Sherry Yang, Sami Tannour

Department of Surgery Faculty Papers

Hidradenitis suppurativa (HS) can be treated surgically to excise recurrent and recalcitrant regions of disease activity. However, surgical outcomes are highly variable depending on closure method, concomitant medical management and area of excision. In this study, we aim to characterise the healing courses from HS excision in a case series. To reduce operator variability, we opted to conduct a case series from a single surgeon. Surgeries conducted from June 2024-December 2025 by surgeon S.T. were included, and the postoperative course was followed until February 2026. Surgical details and postoperative course for 34 sites of HS across 20 patients were analysed. …

High-Flow Nasal Cannula Oxygen Therapy Versus Standard Oxygen Therapy On Perioperative Outcomes In Patients Undergoing Transcatheter Aortic Valve Replacement, Kirsten B. Whiteside, Jacqueline M. Case

Graduate Theses, Dissertations, and Capstones

Abstract 

Background and Purpose: Transcatheter aortic valve replacement (TAVR) is increasingly performed under monitored anesthesia care (MAC) to facilitate faster recovery and reduce complications associated with general anesthesia. Standard oxygen therapy (SOT) may be insufficient in maintaining adequate oxygenation in this high-risk population. High-flow nasal cannula (HFNC) therapy has emerged as a potential alternative. This literature review evaluates the effects of HFNC compared with SOT on perioperative outcomes in patients undergoing TAVR under MAC. 

Methods: A comprehensive review of the literature was conducted to identify studies evaluating HFNC versus SOT during TAVR procedures performed under MAC. Six studies met inclusion …

Pcom Doctor Of Osteopathic Medicine Class Of 2030 White Coat Ceremony, Philadelphia College Of Osteopathic Medicine

White Coat Ceremony

Program of PCOM Philadelphia Campus 2026 White Coat Ceremony Program for the Class of 2030.

Guest Speaker: Michael A. Becker, DO '87, Senior Associate Dean of Clinical Education, Professor, Department of Family Medicine.

Fast Mr Imaging: Reducing Sedation And Improving Patient Experience, Hajir Aljumaily

Radiologic Sciences

Purpose To examine the impact of fast magnetic resonance (MR) protocols on sedation requirements, patient tolerance, workflow efficiency, and diagnostic accuracy in musculoskeletal and brain imaging.

Method An integrative literature review was conducted using PubMed, CINAHL, and Google Scholar to identify peer-reviewed, original research articles published between 2019 and 2026. Studies were selected for relevance, human subjects, and outcomes related to sedation, patient experience, or diagnostic effectiveness.

Results Fast MR protocols were consistently associated with reduced sedation use, improved patient comfort, and increased exam completion rates. Workflow efficiency improved due to shorter scan times. Although minor reductions in image quality …

Ai Integration In Radiotherapy Workflows: Emerging Trends And Best Practices, Vi T. Dinh

Radiologic Sciences

Purpose To synthesize current evidence on artificial intelligence (AI) integration in radiotherapy workflows, identify emerging application trends, and examine best practices for clinical implementation.

Method A structured literature review was conducted using PubMed, Scopus, and Google Scholar to identify peer-reviewed studies published between 2015 and 2025. Eligible studies evaluated AI applications in radiotherapy workflows, including segmentation, treatment planning, and clinical decision-making. Findings were synthesized using thematic analysis.

Results Three primary themes emerged: (a) AI-based segmentation improved contouring efficiency and reduced interobserver variability; (b) AI-assisted treatment planning enhanced dose prediction consistency and workflow reproducibility; and (c) workflow integration supported clinical decision-making …

Disengagement And Reconnection: Investigating The Role Of Purpose And Identity Seeking Across Career Stages In Healthcare, Charmel Renee Jeffery

Radiologic Sciences

Purpose To examine the generational purpose gap in healthcare by identifying the psychological and environmental factors underlying early-career disengagement and late-career reconnection.

Method An integrative literature review was conducted using four academic databases. An artificial intelligence (AI)-assisted thematic synthesis was applied to extract and organize findings within a standardized analytic matrix. To ensure accuracy and rigor, all AI-generated outputs were validated against the original source data.

Results Two primary themes emerged. Early-career healthcare workers commonly experienced disengagement associated with destiny beliefs, while later-career professionals demonstrated renewed purpose and resilience despite ongoing stressors.

Discussion The findings revealed a pronounced generational divide …

Ai-Driven Multi-Modal Mr For Precision Oncology, Maneet K. Marwaha

Radiologic Sciences

Purpose To examine the role of artificial intelligence (AI) in multiparametric magnetic resonance (MR) imaging for precision oncology, with a focus on automated tumor segmentation, treatment response prediction, and workflow efficiency.

Method A literature review was conducted to examine current evidence on AI applications in multiparametric MR imaging for oncology. Studies evaluating deep learning models for tumor segmentation, longitudinal imaging analysis, and treatment response prediction were synthesized using a thematic analysis approach.

Results Three primary themes emerged: (a) AI-driven tumor segmentation improved accuracy, reproducibility, and efficiency across multiparametric MR sequences; (b) deep learning models enhanced prediction of treatment response through …

Mr-Linac Technology, Katherine Orellana

Radiologic Sciences

Purpose To examine the clinical advantages of magnetic resonance-guided linear accelerator (MR-Linac) technology in radiation therapy, with a focus on treatment accuracy, adaptive planning, and patient outcomes.

Method A literature review was conducted using peer-reviewed articles identified through The University of Texas MD Anderson Cancer Center Research Medical Library. Studies published between 2022 and 2026 were included if they addressed the clinical advantages of MR-Linac technology. Findings were synthesized using thematic analysis.

Results Three primary themes emerged: (a) superior soft-tissue visualization improved tumor delineation and treatment accuracy; (b) daily adaptive treatment planning and real-time tumor tracking enhanced precision by accounting …