Digital Commons Network^™

Flare Guns And Trauma: Patterns, Severity, And Clinical Implications From Case And National Surveillance Data, Ramsay Hafer, Andrew Huff, Lara Phillips

Department of Emergency Medicine Faculty Papers

Flare guns are pyrotechnic devices capable of causing serious injury due to high-temperature combustion and projectile discharge. Though intended for signaling in maritime or wilderness settings, improper use can result in trauma patterns distinct from those seen with typical burns or fireworks. Despite their severity, flare gun injuries remain underreported and poorly characterized. We conducted a scoping review of PubMed, Scopus, and Ovid to identify 12 case reports involving 13 patients, and reviewed US National Electronic Injury Surveillance System records from 2015 to 2024, identifying 18 flare gun-specific injuries for a combined total of 31 injuries. Demographic, injury mechanism, body …

Recurrent Miller Fisher Syndrome: A Case Report, Larry Vernier, Griffin B. Gilmore, Kelsey Van Housen, Xiao C. Zhang

Department of Emergency Medicine Faculty Papers

INTRODUCTION: Guillain-Barré syndrome can manifest with progressive paralysis, requiring careful monitoring and treatment with steroids or intravenous (IV) immunoglobin. While this disease can be devastating and require intensive care unit level of care, there are few incidences of relapses.

CASE REPORT: A 67-year-old man with a past medical history of Miller Fisher syndrome variant of Guillain-Barré syndrome, with complete recovery, presented to the emergency department (ED) with ataxia, ophthalmoplegia, dysphonia, and ambulatory dysfunction. The patient noticed his neurologic symptoms after waking up, and he presented to the ED with physical examination positive for difficulty with upward gaze, mild right lower …

Does Hormone Replacement Therapy Reduce Bone Resorption In Postmenopausal Women With An Intact Uterus?, Ashley Harding

PCOM Physician Assistant Studies Student Scholarship

OBJECTIVE: The objective of this selective EBM review is to determine whether or not hormone replacement therapy reduces bone resorption in postmenopausal women with an intact uterus.

STUDY DESIGN: A systematic review of three double blind randomized control trials (RCTs) published from 2016 to 2022.

DATA SOURCES: All RCTs were published in peer reviewed journals in English and were found on PubMed and Google Scholar. Articles were chosen based on relevance to the clinical question.

OUTCOME MEASURED: Level of bone resorption was measured via assessment of bone turnover markers at baseline and after use of hormone replacement therapy in all …

In Adults With Elevated Or Borderline-High Ldl Cholesterol Levels, Does Daily Consumption Of Oat-Derived Products Providing Approximately 3 G Of Β-Glucan Reduce Ldl Cholesterol?, Marilyn K. Enderson

PCOM Physician Assistant Studies Student Scholarship

OBJECTIVE: The objective of this selective evidence-based medicine review is to determine whether daily consumption of approximately 3 g of oat-derived β-glucan reduces low-density lipoprotein cholesterol (LDL-C) in adults with elevated or borderline-high LDL-C when compared with a β-glucan–free control.

STUDY DESIGN: Review of three double-blind randomized controlled trials (RCTs) published from 2020 to 2021.

DATA SOURCES: All RCTs were published in English in peer-reviewed journals and identified using PubMed. Articles were selected based on relevance to the clinical question, inclusion of adult populations with elevated LDL-C, and evaluation of oat-derived β-glucan as an intervention.

OUTCOMES MEASURED: The primary outcome …

Are Berberine-Based Treatments Effective In Reducing Hemoglobin A1c (Hba1c%) In Adults With Type Ii Diabetes?, Queenie Douangpraseuth

PCOM Physician Assistant Studies Student Scholarship

OBJECTIVE: The objective of this selective EBM review is to determine whether or not “Are berberine-based treatments effective in reducing Hemoglobin A1c (HbA1c%) in adults with type 2 diabetes?”

STUDY DESIGN: A review of 3 randomized control trials (RCTs) published between 2015 to 2020 DATA SOURCES: Articles were found on PubMed and Google scholar. Selected articles were published in peer-reviewed journals in English and were chosen based on applicability to clinical questions posed in the objective and meeting inclusion criteria.

OUTCOMES MEASURED: All three RCTs measured the mean HbA1c% over time. A blood sample is taken and laboratory tests are …

Does A Single Dose Of Intravenous Ketamine Reduce Suicidal Ideation In Adults With Major Depressive Disorder?, Rylee Schieman

PCOM Physician Assistant Studies Student Scholarship

OBJECTIVE: The objective of this selective EBM review is to determine whether or not a “single dose of intravenous (IV) ketamine can decrease suicidal ideation in adults with major depressive disorder (MDD)?”

STUDY DESIGN: A systematic review of 3 double-blind, randomized controlled trials (RCTs) published from 2018 to 2024.

DATA SOURCES: All RCTs were found using PubMed and Google Scholar. The articles were published in peer-reviewed journals and in English. The articles were selected based on their relevance to the clinical question posed in the objective.

OUTCOMES MEASURED: All 3 studies focused on reducing suicidal ideation. The outcome was measured …

Associations Between County-Level Vape-Free Air Law Coverage And E-Cigarette Use Behaviors Among U.S. Adolescents In Monitoring The Future, James H. Buszkiewicz, Yanmei Xie, Catherine A. Vander Woude, Steven Cook, Bukola Usidame, Megan E. Patrick, Michael R. Elliott, James F. Thrasher, Nancy L. Fleischer

Department of Health and Kinesiology Faculty Publications

Purpose

We examined whether workplace and hospitality vape-free air law (VAL) population coverage was associated with adolescent e-cigarette use and related disparities in the United States.

Methods

We analyzed associations between county-level workplace and hospitality VAL coverage (100% vs. < 100%) and current e-cigarette use (2014–2022) and first e-cigarette initiation (2015–2022) among US 8th, 10th, and 12th graders using nationally representative, cross-sectional Monitoring the Future data. We implemented weighted, grade-stratified, modified Poisson regression models, adjusted for individual-, county-, and state-level confounding factors, examining disparities by sex, race and ethnicity, parental education, and college educational expectations through two-way interactions.

Results

Workplace and hospitality VAL coverage was not associated with adolescent e-cigarette use or initiation overall. However, we did find that VAL coverage was associated with lower current e-cigarette use in some sociodemographic subgroups. Full (100%) hospitality VAL coverage was linked to lower e-cigarette use among male 8th and 12th graders, 12th graders with parents without a bachelor's degree, Hispanic 8th …

Effectiveness Of Dialectical-Behavioral Intervention On Emotional Regulation Difficulties, Distress Tolerance, And Social Functioning Among Patients With Bipolar Disorder: Randomized Controlled Trial, Nashwa Ibrahim

Nursing

Aim

To determine the effect of implementing dialectical behavior therapy (DBT) skills training groups on emotional regulation difficulties, distress tolerance, and social functioning among patients with bipolar disorder (BD).

Methods

A randomized controlled trial was conducted with 120 patients diagnosed with BD who were attending follow-up at the outpatient clinic. Participants were randomly assigned to either the experimental group, which received 16 group psychoeducation sessions held twice weekly, or the control group, which received standard outpatient care. Analysis of variance (ANOVA) with repeated measures was applied to compare normally distributed quantitative variables across more than two time points or stages, …

Evaluating The Genetic Overlap Between Congenital Heart Disease And Neuroblastoma Risk., Ji Yun Tark, Alexander Renwick, Yao Yu, Aniko Sabo, Andrew F Olshan, Sharon E Plon, Chad D Huff, Philip J Lupo

Faculty, Staff and Students Publications

Children with congenital heart disease (CHD) have elevated neuroblastoma (NB) risk, potentially due to shared neural crest origins. We analyzed rare exonic de novo single-nucleotide variants in 702 CHD and 454 NB trios from the Neuroblastoma Epidemiology in North America Study, Gabriella Miller Kids First Program, and a published cohort. Seven genes, including CHD risk genes POGZ and LZTR1 (linked to Noonan syndrome and Schwannomatosis), showed nominal (p < 0.05) enrichment in both cohorts. CIC, IREB2, POGZ, and PCDHG cluster are associated with neurodevelopmental disorders, supporting shared developmental mechanisms. Findings warrant investigation of pathways linking congenital anomalies and childhood cancer.

Glutathione Synthesis Via The Cystine/Glutamate Transporter Promotes The Formation Of Tertiary Lymphoid Structures In The Kidney, Hiroyuki Arai, Yuki Sugiura, Shinya Yamamoto, Takahisa Yoshikawa, Yuta Matsuoka, Rae Maeda, Hiroyuki Neyama, Ryo Kamimatsuse, Shima Goto, Keisuke Taniguchi, Naoya Toriu, Makiko Kondo, Yuki Sato, Shingo Fukuma, Motoko Yanagita

Faculty, Staff and Students Publications

Key Points:

1. Glutathione accumulated in tertiary lymphoid structures (TLS), where dendritic cells and fibroblasts specifically expressed cystine/glutamate transporter.

2. Pharmacologic inhibition of the cystine/glutamate transporter prevented the formation of TLS.

3. Urinary glutathione concentrations efficiently detected the presence of TLS in the kidney in mice and humans.

Background: Tertiary lymphoid structure (TLS), an ectopic lymphoid tissue induced under chronic inflammation, develops in various kidney diseases and is associated with poor prognosis. The immune system requires metabolic resources to support immune function and lymphocyte proliferation. Hence, dramatic metabolic alterations presumably occur during the formation of TLS. However, it remains unclear whether metabolic remodeling …

Differentiating Between Bk Activation And Potentiation By Vanzacaftor Enantiomers, Nathalie Baumlin, Frank T Horrigan, Stefan H Bossmann, Matthias Salathe

Faculty, Staff and Students Publications

No abstract provided.

Training In Medications For Opioid Use Disorder And Buprenorphine Prescribing In The Post X-Waiver Era: Insights From A Nationwide, Multispecialty Survey, Sung In H Kim-Vences, Justin Nguyen, Jacqueline M Hirth, Kyle P Suen, Colleen A Keough, Roger Zoorob, Alicia A Kowalchuk

Faculty, Staff and Students Publications

Objective: The January 2023 repeal of the X-waiver aimed to reduce regulatory barriers to buprenorphine prescribing and enhance patient access to medications for opioid use disorder (MOUD). Its impact on prescribing by non-addiction-trained physicians, the integration of MOUD training into residency programs, and the role of mandated training on clinical practice remain unclear.

Methods: A 2024 online survey assessed physicians' awareness of the X-waiver repeal, exposure to MOUD training, and changes in buprenorphine prescribing. Multivariable logistic regression evaluated the independent effect of MOUD training and whether mandatory versus voluntary formats influenced prescribing behavior.

Results: Among 959 physicians (42.7 % residents), …

Bradycardia, Asystole, And Sudden Cardiac Death In Zc4h2 R198q-Associated Wieacker-Wolff Syndrome, Emily M Masterson, Alexandra M Menillo, Tam Dan Pham, Taylor A Beecroft-Dawson, Steven B Wolfe, Taylor S Howard, Christina Y Miyake

Faculty, Staff and Students Publications

No abstract provided.

Demographic And Other Correlates Of Non-Prescription Drug Use Among College Students During The Covid-19 Pandemic, Subi Gandhi, Sidketa Fofana, Md Rafiul Islam, Tamer Oraby

School of Mathematical & Statistical Sciences Faculty Publications

Background and objectives: Substance use among college students in the U.S. remains a pressing concern and may have intensified during the COVID-19 pandemic due to increased stress, uncertainty, and academic disruptions. This study investigates the relationship between non-prescription drug use and various demographic, mental health, and behavioral factors among college students during the pandemic's early stages.

Methods: Data were collected through online and in-person surveys in the summer semester of 2021. Behavioral health was assessed using validated instruments: the Patient Health Questionnaire-9 (PHQ-9) for depression and the Drug Abuse Screening Test-20 (DAST-20) for substance use. Demographic and behavioral variables were …

Author Correction: Nutrient-Sensing Nuclear Receptors Coordinate Autophagy, Jae Man Lee, Martin Wagner, Rui Xiao, Kang Ho Kim, Dan Feng, Mitchell A Lazar, David D Moore

Faculty, Staff and Students Publications

No abstract provided.

An Examination Of Racial Bias In Scoring The Autism Diagnostic Observation Schedule (Ados) Module 3: An Item Response Theory Analysis, Yuen Yvonne Yu, Austin Wyman, Calliana J Faulk, Lizzy J Fulop, Rebecca L Greenberg, Rachel M Benecke, Lauren K Steinbeck, Jessica Foy, Caitlyn Kim, George O Emory, Eric A Storch, Casey J Zampella, Benjamin E Yerys, Robert T Schultz, Julia Parish-Morris, John D Herrington, Caitlin C Clements

Faculty, Staff and Students Publications

Given the rising prevalence of autism among racial minority children in the United States, but persistent service use disparities, this study examines potential bias in specific items from the autism diagnostic observation schedule (ADOS), a highly regarded autism evaluation. We leveraged unidimensional item response theory graded response models and a sample of 735 children to analyze the differential item functioning (DIF) of items within ADOS Module 3. Three items showed significant signs of racial bias: A1 (overall language level), A5 (offers information), and D5 (compulsions and rituals). On these items, Black/African American and Asian children were usually more likely to …

Nasal Microbiome And Phageome Profiles Are Associated With Prospective Respiratory Viral Infection Risk In School-Age Children, Michael S Kelly, Ching-Ying Huang, Minsik Kim, Dastan Haghnazari, Aribah Baig, Ye Sun, Bryan R Lenneman, Michael J Tisza, Amparito Cunningham, Diane Gold, Wanda Phipatanakul, Peggy S Lai

Faculty, Staff and Students Publications

Background: Respiratory viral infections are common and can trigger asthma exacerbations in children. The roles of the nasal microbiome and phageome (viruses that infect microbes) are not well understood.

Objective: We sought to characterize the epidemiology of respiratory viral infections and the interplay between the nasal microbiome, phageome, and viral infections in school-age children with asthma.

Methods: We performed metagenomic sequencing and quantitative RT-PCR detection of respiratory viruses on 375 nasal samples from 227 school-age children with asthma collected routinely 3 times over a year. Surveys on parent-reported cold and asthma symptoms were administered routinely every 2 months. We evaluated …

Distribution Of Nematophagous Fungi And Soil-Transmitted Helminths In Outdoor Built Environments Across Latin America, Rojelio Mejia, Eva Mereles Aranda, Leticia Ojeda, Sandra Ocampos Benedetti, Janitzio J Guzman, Barton Slatko, Cristina Almazan, Melisa Diaz-Fernandez, Ruben Cimino, Marisa Juarez, Natalia Montellano Duran, Estefania Lorena Mansilla Flores, Paola Andrea Vargas, Amandeep Kaur, Nestor L Uzcategui, Lucia Estela Mejia, Katherine Elizabeth Keegan, Emilio Rey Mejia, Chiara Cássia Oliveira Amorim, Stefan M Geiger, Ricardo T Fujiwara, Luz Marina Llangarí-Arizo, Andrea Lopez, Natalia Romero-Sandoval, Irene Guadalupe, Liliana E Villanueva-Lizama, Julio Vladimir Cruz-Chan, Maritza Dalí Camones Rivera, Eddyson Montalvo Sabino, Carlos Pineda, Eric J Wetzel, Philip J Cooper

Faculty, Staff and Students Publications

Background: Soil-transmitted helminths (STHs) are among the most common global parasitic infections, represent a significant worldwide public health burden, and remain a source of considerable morbidity in Latin America. Nematophagous fungi (NF), such as Arthrobotrys oligospora, naturally inhabit many soil types and are known for their ability to trap and kill nematodes using specialized hyphal structures or secreted enzymes and metabolites. As they prey on different developmental stages of helminths in soil, they may represent an ecological factor influencing helminth persistence and transmission dynamics.

Methods: Using an in vitro test, Toxocara cati eggs were exposed to A. oligospora. By using …

Radiation Realities: Radiation Safety Practices And Awareness Among Interventional Echocardiographers In The United States, Priscilla Wessly, Enrique Garcia-Sayan, Nishath Quader, Stephen Little, Omar Khalique, Renuka Jain

Faculty, Staff and Students Publications

Background: With the rise of structural heart interventions (SHIs), interventional echocardiographers (IEs) face significant radiation exposure in catheterization laboratories. However, US-specific radiation safety practices remain understudied. This study aims to address radiation safety practices and concerns among US IEs, focusing on occupational risks and sex-specific challenges.

Methods: A 21-item online survey was conducted from March to June 2025, targeting US IEs through a multifaceted recruitment strategy. It assessed demographics, SHI frequency, radiation monitoring, shielding practices, and reproductive health concerns. Descriptive statistics summarized responses, with sex-specific analyses for female IEs.

Results: Of 69 respondents (64% [n = 44] men, 36% [n …

Berlin Cannulation With An Outflow Interposition Graft-A Versatile Technique, Richard C Tang, Junsang Cho, Yishay Orr, Jeffrey S Heinle, Hari P Tunuguntla, Sebastian C Tume, Jun Teruya, Iki Adachi

Faculty, Staff and Students Publications

Objective: The Berlin Heart EXCOR VAD is increasingly used to support more complex patients with heart failure. To accommodate variable arterial anatomy, a modified outflow with a long interposition graft connected to an "apical" cannula is an attractive alternative to the conventional, rigid "arterial" cannula.

Methods: We conducted a single-center retrospective review of consecutive patients who underwent Berlin cannulation using this novel technique between September 2020 and May 2025.

Results: Fifty consecutive patients were identified. Median (range) age, weight, and body surface area at implantation were 0.7 (9 days-10.4) years, 7.8 (3.1-21.7) kg, and 0.4 (0.21-0.86) m2, respectively. Underlying etiologies …

Single-Cell Atlas Of The Transcriptome And Chromatin Accessibility In The Human Retina, Jin Li, Jun Wang, Ignacio L Ibarra, Xuesen Cheng, Malte D Luecken, Jiaxiong Lu, Aboozar Monavarfeshani, Wenjun Yan, Yiqiao Zheng, Zhen Zuo, Samantha Lynn Zayas Colborn, Berenice Sarahi Cortez, Leah A Owen, Brittney Wick, Xuan Bao, Jongsu Choi, Maximilian Haeussler, Nicholas M Tran, Karthik Shekhar, Joshua R Sanes, J Timothy Stout, Shiming Chen, Yumei Li, Margaret M Deangelis, Fabian J Theis, Rui Chen

Faculty, Staff and Students Publications

Single-cell sequencing has revolutionized the scale and resolution of molecular profiling of tissues and organs. Here we present an integrated dual-modal reference atlas of the most accessible portion of the mammalian central nervous system, the retina. We compiled around 3.9 million cells from 125 donors of diverse ancestral backgrounds, including 8 published studies and 2.7 million unpublished data points, to create a comprehensive human retina cell atlas (HRCA) with more than 130 cell types identified. We annotated each cluster, identified marker genes and characterized cis-regulatory elements and gene regulatory networks. Our analysis uncovered differences in transcriptome, chromatin and gene regulatory …

Leader Rounding For Outcomes To Improve Employee Retention, Laura R. Escobar

Electronic Theses and Dissertations

Intention to leave a nursing staff position, if not addressed, may lead to an increased rate of nursing turnover. High turnover rates can negatively affect staffing patterns, increase organizational costs, and disrupt the continuity of patient care. A quantitative quasi-experimental pre-/posttest design was used to evaluate the impact of the High Reliability Organization Leader Rounding for Outcomes tool to reduce the intent-to-leave scores, as measured by the Turnover Intention Scale (TIS-6), compared to current practice over 12 weeks. Implementation of the tool provided a structured leader rounding process designed to strengthen communication, recognize staff contributions, and proactively identify workplace concerns. …

Rethinking The Centrality Of Brain Areas In Understanding Functional Organization, Benjamin Yost Hayden, Sarah R Heilbronner, Seng Bum Michael Yoo

Faculty, Staff and Students Publications

Parcellation of the cerebral cortex into functionally modular brain areas is foundational to cognitive and systems neuroscience. Here, we question the central status of brain areas from the perspectives of neuroanatomy and electrophysiology. We argue that the major ostensible determinants of brain function, such as cytoarchitecture and connectivity, seldom produce convergent parcellations. Brain areas themselves are just one of several equally important organizing principles; others include macroscale gradients, distributed networks, layers, columns and patches. We further argue that the evidence for a close correspondence between areal parcellation and cognitive function is weaker than is generally supposed. Indeed, many important cognitive …

Factors Associated With Rare Pediatric Cancer Trial Enrollment: A Report From The Children's Oncology Group Rare Tumors Committee, Brian R Englum, Jin Piao, Lindsay Younis, Reto M Baertschiger, Kenneth S Chen, Emily Christison-Lagay, Hetal Dholaria, Robyn Gartrell, M John Hicks, Junne Kamihara, Sarah G Mitchell, Manuela Orjuela-Grimm, Farzana Pashankar, Samara L Potter, Jennifer H Aldrink, Jeremy Rosenblum, Michael R Sargen, Kris Ann P Schultz, Brittani K N Seynnaeve, Mary Wedekind, Theodore W Laetsch

Faculty, Staff and Students Publications

Background: Over 90% of US children with cancer are treated at Children's Oncology Group (COG) centers, which seek to maximize enrollment in therapeutic and biobanking studies. Rare cancers have demonstrated lower than expected COG enrollment. We evaluated trends in COG rare cancer enrollment compared to US incidence from Surveillance, Epidemiology, and End Results (SEER) registries, examining the impact of COG therapeutic trials and Project:EveryChild, a cancer biobank/registry.

Procedure: COG and SEER data from 2002 to 2020 were queried for US patients younger than 18 years old with adrenocortical carcinoma (ACC), nasopharyngeal carcinoma (NPC), retinoblastoma (RB), thyroid carcinoma, and melanoma. We …

Perioperative Anaphylaxis In A Healthy Adolescent After First Lifetime Surgery, Shayan Sazdar, Salman Aljubran

Posters

Introduction: Perioperative anaphylaxis is a rare life-threatening event. Its evaluation poses complex considerations inherent to the use of multiple medications. Patient presentation: A healthy 11-year-old boy developed anaphylaxis shortly after discharge home from first lifetime surgery for orchiopexy. Perioperative medications included rocuronium, propofol, fentanyl, bupivacaine, sugammadex, ondansetron, dexamethasone, dexmedetomidine, and ketorolac. No antibiotics. After surgery, he consumed fast food dinner and ice cream. Within 2 hours after discharge home, he returned to our Emergency Department (ED) with facial and tongue angioedema, hives, and respiratory distress. He received multiple doses of intramuscular epinephrine and briefly required epinephrine drip in the ED. …

Asthma Phenotypes And Control In 22q11.2 Deletion Syndrome: A Single-Center Retrospective Study, Cody Shopper, Katey Campbell, Nikita S. Raje

Posters

Background: Patients with 22q11.2 deletion syndrome have increased rates of atopy and immune dysregulation and may experience a higher burden of asthma; however, real-world data describing asthma control, severity, and treatment patterns in this population are limited. We hypothesized that asthma control and severity patterns in patients with 22q11.2 deletion syndrome differ from those observed in the general asthma population. Objectives/Goal: To characterize asthma control, severity, and treatment patterns among patients with 22q11.2 deletion syndrome and to compare observed patterns with those typically reported in the general asthma population. Methods/Design: We conducted a retrospective observational cohort study of patients with …

A Case Report Of Milk-Alkali Syndrome Secondary To Excessive Antacid Use, Samir Beso, Layla Abubshait

Einstein Health Papers

INTRODUCTION: Milk-alkali syndrome is characterized by the triad of hypercalcemia, metabolic alkalosis, and acute kidney injury resulting from excessive intake of calcium and absorbable alkali. Despite falling out of prominence with the advent of modern ulcer treatments, milk-alkali syndrome has experienced a resurgence with the widespread availability of over-the-counter calcium preparations, which now account for up to 10% of hypercalcemia cases.

CASE REPORT: A 60-year-old man with multiple comorbidities presented to the emergency department with altered mental status after his scheduled kyphoplasty was canceled due to concerning neurological findings. Laboratory evaluation revealed severe hypercalcemia, marked metabolic alkalosis, and acute kidney …

Pericardial Effusion, Children's Mercy Kansas City

Clinical Pathways

No abstract provided.

Total Hip Replacement Eras, Children's Mercy Kansas City

Clinical Pathways

No abstract provided.

How The Dental Workforce Personifies Servant Leadership, William Chase Dds, Maom

The Journal of the Michigan Dental Association

This feature article explores various leadership styles, identifying servant leadership as the most relevant model for dental professionals. The author connects servant leadership to emotional intelligence (EI), detailing how traits like empathy, self-awareness, and active listening empower clinicians to build trusting patient relationships. By dedicating themselves to high standards of care and maintaining respect for patients, dental teams personify trusted providers. The feature encourages dentists to view themselves as leaders and oral health counselors.