Digital Commons Network^™

Telehealth Monitoring For Non-Hospitalized Covid-19 Positive Patients In A Rural Setting, Rebekah Leann French

Doctor of Nursing Practice Scholarly Projects

Purpose

This quality improvement project evaluates the efficacy of an outpatient COVID-19 telehealth monitoring program intended to increase access to care, decrease emergency room/urgent care visits, and hospital admissions among telehealth observed adult patients in a rural area while providing safe home monitoring during acute illness.

Rationale/Background

Prior to COVID-19 pandemic, healthcare systems within the United States encountered several challenges including healthcare inequality and decreased healthcare access, particularly in rural communities. These gaps became more apparent when a novel COVID-19 pandemic emerged straining healthcare systems in the United States and throughout the world. Challenges ranged from overwhelmed emergency room (ER) …

A Vlp-Based Vaccine Displaying Hbha And Mtp Antigens Of Mycobacterium Tuberculosis Induces Potentially Protective Immune Responses In M Tuberculosis H37ra Infected Mice, Juan Wang, Tao Xie, Inayat Ullah, Youjun Mi, Xiaoping Li, Yang Gong, Pu He, Yuqi Liu, Fei Li, Jixi Li, Zengjun Lu, Bingdong Zhu

Faculty, Staff and Student Publications

Heparin-binding hemagglutinin (HBHA) and M. tuberculosis pili (MTP) are important antigens on the surface of Mycobacterium tuberculosis. To display these antigens effectively, the fusion protein HBHA-MTP with a molecular weight of 20 kD (L20) was inserted into the receptor-binding hemagglutinin (HA) fragment of influenza virus and was expressed along with matrix protein M1 in Sf9 insect cells to generate influenza virus-like particles (LV20 in short). The results showed that the insertion of L20 into the envelope of the influenza virus did not affect the self-assembly and morphology of LV20 VLPs. The expression of L20 was successfully verified by transmission …

Colonizing And Virulence Factors In Enterotoxigenic Escherichia Coli From Peru, Fulton P Rivera, Anicia Medina, Maribel Riveros, Theresa J Ochoa, Maria J Pons, Joaquim Ruiz

Faculty, Staff and Student Publications

Enterotoxigenic Escherichia coli (ETEC) ranks among the most relevant diarrheagenic pathogens. Efforts to design vaccines to fight ETEC have been focused on colonizing factors (CFs) and atypical virulence factors (AVF). An effective vaccine must account for differences in the regional prevalence of these CFs and AVFs to be truly effective in a given area. In the present study, the presence of 16 CFs and 9 AVFs, as well as the heat-stable (ST) variants (STh or STp), was established by polymerase chain reaction in 205 Peruvian ETEC isolates (120 from diarrhea cases and 85 from healthy controls). Ninety-nine (48.3%) isolates were …

Introduction Of Hiv Point-Of-Care Testing In Adolescent Primary Care: A Quality Improvement Project, Jennifer Quinn Belfry

Doctor of Nursing Practice Scholarly Projects

BACKGROUND: HIV, first identified in 1981, remains a persistent public health problem affecting 1.1 million Americans today. Detection is a critical first step to ending the HIV epidemic and the CDC recommends universal HIV screening for all patients 13-64 years of age regardless of risk factors. HIV screening rates are suboptimal especially in adolescent and young adult populations who face unique barriers to screening. The aim of this project was to improve HIV screening rates in adolescent and young adult patients at a large, urban FQHC.

LOCAL PROBLEM: In the state of Rhode Island, 1 in 10 persons living with …

Spatial Transcriptomics Depict Ligand-Receptor Cross-Talk Heterogeneity At The Tumor-Stroma Interface In Long-Term Ovarian Cancer Survivors, Sammy Ferri-Borgogno, Ying Zhu, Jianting Sheng, Jared K Burks, Javier A Gomez, Kwong Kwok Wong, Stephen T C Wong, Samuel C Mok

Faculty, Staff and Student Publications

Advanced high-grade serous ovarian cancer (HGSC) is an aggressive disease that accounts for 70% of all ovarian cancer deaths. Nevertheless, 15% of patients diagnosed with advanced HGSC survive more than 10 years. The elucidation of predictive markers of these long-term survivors (LTS) could help identify therapeutic targets for the disease, and thus improve patient survival rates. To investigate the stromal heterogeneity of the tumor microenvironment (TME) in ovarian cancer, we used spatial transcriptomics to generate spatially resolved transcript profiles in treatment-naïve advanced HGSC from LTS and short-term survivors (STS) and determined the association between cancer-associated fibroblasts (CAF) heterogeneity and survival …

Higher Risk Of Short Term Covid-19 Vaccine Adverse Events In Myositis Patients With Autoimmune Comorbidities: Results From The Covad Study, Mrinalini Dey, Naveen R, Elena Nikiphorou, Parikshit Sen, Sreoshy Saha, James B Lilleker, Vishwesh Agarwal, Sinan Kardes, Jessica Day, Marcin Milchert, Mrudula Joshi, Tamer Gheita, Babur Salim, Tsvetelina Velikova, Abraham Edgar Gracia-Ramos, Ioannis Parodis, Albert Selva O'Callaghan, Minchul Kim, Tulika Chatterjee, Ai Lyn Tan, Ashima Makol, Arvind Nune, Lorenzo Cavagna, Miguel A Saavedra, Samuel Katsuyuki Shinjo, Nelly Ziade, Johannes Knitza, Masataka Kuwana, Oliver Distler, Bhupen Barman, Yogesh Preet Singh, Rajiv Ranjan, Avinash Jain, Sapan C Pandya, Rakesh Kumar Pilania, Aman Sharma, Manesh M Manoj, Vikas Gupta, Chengappa G Kavadichanda, Pradeepta Sekhar Patro, Sajal Ajmani, Sanat Phatak, Rudra Prosad Goswami, Abhra Chandra Chowdhury, Ashish Jacob Mathew, Padnamabha Shenoy, Ajay Asranna, Keerthi Talari Bommakanti, Anuj Shukla, Arunkumar R Pande, Kunal Chandwar, John D Pauling, Chris Wincup, Döndü Üsküdar Cansu, Erick Adrian Zamora Tehozol, Jorge Rojas Serrano, Ignacio García-De La Torre, Nicoletta Del Papa, Gianluca Sambataro, Atzeni Fabiola, Marcello Govoni, Simone Parisi, Elena Bartoloni Bocci, Gian Domenico Sebastiani, Enrico Fusaro, Marco Sebastiani, Luca Quartuccio, Franco Franceschini, Pier Paolo Sainaghi, Giovanni Orsolini, Rossella De Angelis, Maria Giovanna Danielli, Vincenzo Venerito, Lisa S Traboco, Leonardo Santos Hoff, Suryo Anggoro Kusumo Wibowo, Stylianos Tomaras, Daman Langguth, Vidya Limaye, Merrilee Needham, Nilesh Srivastav, Akira Yoshida, Ran Nakashima, Shinji Sato, Naoki Kimura, Yuko Kaneko, Jesús Loarce-Martos, Sergio Prieto-González, Albert Gil-Vila, Raquel Arànega Gonzalez, Hector Chinoy, Vikas Agarwal, Rohit Aggarwal, Latika Gupta

Faculty, Staff and Student Publications

No abstract provided.

Qualitative Chemical Analysis Of Elf Bar E-Liquids And Their Effect On Phenotypic Characteristics Of Arabidopsis Thaliana, Genevieve Neuwirth

Graduate Dissertations and Theses

After their initial market introduction in 2003, the popularity and use of e-cigarettes have exponentially increased. There are three main components that have contributed to this: marketing, ease of access, and emerging flavors. The marketing industry uses claims that ecigarettes are a ‘safer’ and ‘healthier’ alternative to cigarettes as a way to entice previous smokers into using this product. With the increase in popularity, there is also an increase in demand, which has led to the creation of stores designed to target customers and sell e-cigarettes and similar products at convenient locations. Finally, the emerging flavors have enticed many nonsmokers …

Health Equity Module: The Latino Paradox, Noel A. Tufts, Jackie V. Carman, Laura Barbas Rhoden

Community Based Research

This project aims to educate participants about health inequities and the Latinx community, particularly first and second generation immigrants. Participants may be students who plan careers in health care or professionals and community experts new to working with Latinx community members. The module equips participants with foundational knowledge; shares resources for continued learning; and invites participants to reflect critically about their own intersectional identities and how different intersectional identities impact health care experiences.

Healthy School Meals For All: The Role Of Food Law And Policy, Thomas J. Vilsack

Journal of Food Law & Policy

The first Conference held more than 50 years ago by President Nixon in 1969 had significant impacts on our Department and the prevalence of food insecurity in our country. Most notably, the Conference sparked significant expansions to Food Stamps, now known as the Supplemental Nutrition Assistance Program (SNAP), from 2 million in 1968 to 11 million by 1971. The Conference also increased the reach of the National School Lunch Program (NSLP), which served 2.9 million low-income children at the time of the Conference and expanded to serving nearly 8 million low-income children by 1971. Permanent authorization of the School Breakfast …

Diagnosis Of Urinary Tract Infections And Rapid Molecular Characterization Of Antibiotic Resistance, Mohammed Harris

All Dissertations

Urinary tract infections (UTIs) are one of the most common infectious clinical entities in both community and hospital settings. They have a broad range of clinical severity yet inflict large epidemiological burden of morbidity and mortality on patients and the healthcare system with billions of dollars in cost of treatment. Understanding what methods are optimal for diagnosing UTIs are critical to mitigate the marked impact and cost of these infections.

Chapter 1 and 2 in this work surveys the broad array of diagnostic modalities for UTIs and highlights their advantages and limitations in the context of the current standard of …

A Systematic Literature Review On Long-Term Care Quality Improvement Initiatives In The United States, Daisy D. Pang

Capstone Experience: Master of Public Health

As the number of people 65 and older increases due to the baby boomer population, there will be a greater demand for long-term care (LTC) services. Quality improvement in LTC is essential to ensure positive health outcomes, patient satisfaction, and reduction in healthcare costs. The purpose of this systematic literature review is to identify the current quality initiatives for LTC in the United States and evaluate the outcomes, effects, and values of each quality initiative identified to support the claim that current the quality initiatives have a limited effect on quality improvement in LTC settings. The Preferred Reporting Items for …

Cultivating A Robust Safety Culture Through Identifying And Overcoming Barriers Within Organizations, Morgan Shradar

Capstone Experience: Master of Public Health

The hierarchical power structure within healthcare and response teams may impede communication about safety risks and violations. In developing or enhancing the safety culture within the emergency response to infectious disease events in healthcare organizations, the hierarchy of controls can be utilized to evaluate successful transmission prevention or further harm to responding teams. Within the tool, administrative controls focus on policies, procedures, and practices that minimize the risk of exposure/transmission. The idea of a safe culture emerged following the Chernobyl Disaster, in which a combination of human and system failures led to this emergency. Safety culture has been integrated into …

Exploring How Social Determinants Of Health Affects Rates Of Chronic Obstructive Pulmonary Disease (Copd) In The Des Moines Metro, Kyla Winkelman

Capstone Experience: Master of Public Health

Chronic Obstructive Pulmonary Disease (COPD) is consistently in the top ten leading causes of death and most recently ranked fourth in the United States (Heron, 2021). Research on health disparities and SDOH has increased recently as investigators learn their importance in diagnosing chronic conditions. Several studies show that a person’s life and environment can determine their risk of exposure, susceptibility, course, and disease outcome. UnityPoint Health (UPH) clinics were utilized for this project to explore how the social determinants of health and health disparities affect COPD rates in Des Moines, Iowa. Initial data was obtained surrounding COPD statistics in the …

Food Insecurity And Child Development In Nebraska: The Role Of Income, Home Learning Environment, And Family Socio-Demographic Factors, Marlette Grace Dulcinee Mabiala-Maye

Capstone Experience: Master of Public Health

Food insecurity is a well-known risk factor for delayed child development. Still, the contribution of other factors, such as income, home learning environment (HLE), and family socio-demographic factors, remains to be determined. Therefore, the study aimed to determine the association between food insecurity and child development and assess the role of income, HLE, and family socio-demographic factors in that association. We used secondary data from the Nebraska Early Childhood Study, a cross-sectional study of caregivers of children under five years old in Omaha and Lincoln. Child development, food insecurity, and HLE were measured using a caregiver report of child development. …

A Scoping Review Of The Predictive Values And Use Of The Oraquick In-Home Hiv Test, Mariah Zinn

Capstone Experience: Master of Public Health

The OraQuick In-Home HIV Test was FDA-approved for over-the-counter use for people aged 17 years and older in 2012. The FDA reported on the sensitivity and specificity of the test, which looks at the accuracy of a test relative to a reference standard. However, the predictive values that account for prevalence still need to be thoroughly examined among tests distributed through community-based means. In this review, we looked at the predictive values for the OraQuick In-Home HIV Test for people aged 15 years and older when the test is distributed through community-based means. We calculated the predictive values for each …

Assessing Occupational Exposure Risk And Covid-19 Incidence Rates In Nebraska By Industry And Occupation, 2020, Christopher Austin

Capstone Experience: Master of Public Health

Occupational outbreaks of COVID-19 have been described during the pandemic, yet the epidemiology of COVID-19 across a larger workforce population is currently not well characterized in the United States. Describing COVID-19 incident rates by industry and occupation will elucidate how the pandemic affected the workforce in Nebraska. However, nonresponse bias occurs in the employment information when participants are unwilling or unable to respond to contract tracer questions, thus affecting the results. Nonresponse bias will be analyzed, and appropriate statistical approaches will be utilized to adjust for any bias in the data. Adjusting for bias, incidence rates by detailed industry and …

A Review Of Nebraska Public School Active Shooter/Armed Intruder Preparedness Requirements Compared To Other States, Anna Hansen

Capstone Experience: Master of Public Health

Approximately 17% of mass shootings which occurred between 2000 and 2013 took place in the public school K-12 setting. The incidence of school shootings is on the rise, with a particularly concerning increase in annual incidents beginning around 2010. A review of legal requirements for public school active shooter preparedness in FEMA Region VII, which includes the states Nebraska, Iowa, Kansas, and Missouri, was conducted. While Iowa clearly requires an emergency operations plan including provisions for the active shooter scenario, Nebraska and Kansas do not clearly require such provisions in school emergency operations plans, and Missouri does not appear to …

Assessing The Impact Of Ebola Virus Inoculum Size On Likelihood Of Infection, Joseph Lukowski

Capstone Experience: Master of Public Health

Background: Indirect transmission of Ebola virus disease (EVD) is not uncommon but is poorly understood. Improving the understanding of the potential risk of EVD transmission from fomites should result in new or updated prevention or control measures for suspected or confirmed EVD cases or outbreaks.

Objective: This study aims to compile and understand pertinent data from peer-reviewed literature, establish the dose-response relationship between inoculum doses introduced to mucous membranes, and finally estimate the risk of EVD transmission from fomites.

Methods: A literature search was conducted through PubMed to obtain relevant data. This study employed this data to perform Poisson regression …

Rural/Urban Differences In Five-Year Survivorship In Pediatric Cancer In United States, Hong Li

Capstone Experience: Master of Public Health

Background: In the United States, five-year survival rates for pediatric (ages 0-19 years) cancer have improved since the mid-1970s due to treatment improvement. Research on adult cancer patients suggested rural patients have worse survival than urban patients. However, there is a dearth of research on survivorship among children and adolescents diagnosed with cancer.

Aims: The aims of the study were to: 1) examine differences in five-year relative survival rates of pediatric cancer in the United States between children living in urban and rural areas from 2000-2014 and 2) examine differences in a risk of dying from pediatric cancer between children …

A Retrospective Analysis Of Rabies Lyssavirus Animal Testing In Nebraska, 2012 Through 2021, Elijah Theye

Capstone Experience: Master of Public Health

Background: Rabies is a zoonotic disease caused by a neurotropic virus that has been a public health issue for over 4,000 years, killing roughly 59,000 humans globally each year. This study examined the seasonality of bat-human exposures, the association between animal-human exposure types and animal rabies positivity, and using skunk monthly positivity rates to predict all non-skunk non-bat animal positivity rates with a lag time of six months, in Nebraska.

Methods: Animal rabies testing data from 2012-21 were extracted from Nebraska’s Electronic Disease Surveillance System. Animal tests that had a valid animal rabies test were included in the analyses. To …

Therapeutic Approaches To Working With Perinatal Loss Clients: A Grounded Theory Study, Heather H. Olivier

LSU New Orleans Theses and Dissertations

Perinatal loss (i.e., miscarriage, stillbirth, termination, and infant death) is commonly referred to in the literature as an invisible loss, non-loss, and even medical event. It is an ambiguous loss exhibiting the dialectical contradiction between the physical absence and psychological presence of the baby accompanied by disenfranchised grief, a reaction to a loss that is unacknowledged by society. Despite the likelihood of mental health clinicians working with clients who have experienced perinatal loss, there has yet to be a therapeutic model designed specifically for the unique grief and trauma reactions presented in this population. Existing grief models do not address …

Medication Errors In Pediatric Care And Preventative Solutions, Tyler Tidwell

Political Science Undergraduate Honors Theses

The research presented extensively examines previous reports covering pediatric medication errors (PMEs). Utilizing specific studies into the frequency and types of medication errors along with public surveys and policy discussion, the data and suggestions here provide commentary on the scope of PMEs, suggested institutional reform, and most importantly, legislative recommended action necessary to stymie the tide of PMEs. A significant portion of the research contained fixates on the literature review to provide ample familiarity with the background and scope of PMEs, but the subsequent sections will discuss their implication. After providing details on the magnitude of the issue, regulatory and …

A Pathophysiological, Clinical, And Epidemiological View Of Malaria, Alyssa Watt

Senior Honors Theses

Malaria is a parasitic disease that is common among all ages in tropical and subtropical countries. Annually, there are an estimated 3.3 billion people in 97 countries at risk of contracting malaria. Malaria has been a major global health problem throughout history and is a leading cause of death and disease for many within tropical regions. In the past decade, efforts, such advances in medicine and insecticide techniques, have reduced the prevalence of malaria by 50% which suggests that the elimination of this disease is possible. With the prevalence of malaria and recent reduction, it is vital to aid in …

The Ethical Dilemmas Epigenetic Editing In Utero Presents To Christians, Victoria Hendrix

Senior Honors Theses

The development of CRISPR epigenetic editing technology was initially impactful due to its potential for disease treatment. However, despite the potential benefits of epigenetic technology, there exist ethical dilemmas surrounding its use in utero. The review of the ethical dilemmas of epigenetic editing in utero from a Christian perspective showed that research in epigenetic editing is promising, yet fraught with peril. The basic ethical issues of epigenetic editing in utero stem from its inaccuracy, lack of research concerning its effects on offspring, an incomplete understanding of gene interactions, and its connection to eugenics. The ethical concerns particularly relevant to Christians …

Predictors And Barriers To Vaccination Among Older Syrian Refugees In Lebanon: A Cross-Sectional Analysis Of A Multi-Wave Longitudinal Study, Berthe Abi Zeid, Tanya El Khoury, Hala Ghattas Ph.D., Marwan F. Alawieh, Zeinab Ramadan, Sirine Anouti, Sawsan Abdulrahim, Stephen J. Mccall

Faculty Publications

Background:

Vaccination is important to prevent morbidity and mortality due to COVID-19 among older Syrian refugees. We aimed to elucidate the predictors of COVID-19 vaccine uptake among Syrian refugees aged 50 years or older in Lebanon and to understand their main reasons for not receiving the vaccine.

Methods:

This was a cross-sectional analysis of a five-wave longitudinal study, conducted through telephone interviews between Sept 22, 2020, and March 14, 2022, in Lebanon. For this analysis, data were extracted from wave 3 (Jan 21–April 23, 2021), which included a question on vaccine safety and on whether participants intended to receive the …

Efficacy Of Information Extraction From Bar, Line, Circular, Bubble And Radar Graphs, Hiddadura Isura Malinda Mendis Abeynayake, Ravindra S. Goonetilleke, Albert Wijeweera, Uwe Reischl

Public and Population Health Faculty Publications and Presentations

With the emergence of enormous amounts of data, numerous ways to visualize such data have been used. Bar, circular, line, radar and bubble graphs that are ubiquitous were investigated for their effectiveness. Fourteen participants performed four types of evaluations: between categories (cities), within categories (transport modes within a city), all categories, and a direct reading within a category from a graph. The representations were presented in random order and participants were asked to respond to sixteen questions to the best of their ability after visually scanning the related graph. There were two trials on two separate days for each participant. …

Vol 3 May '23 Full Issue, Donna L. Williams

Journal of the Louisiana Public Health Association

No abstract provided.

Antimicrobial Resistance In Eskape Pathogens And Its Effect On Modern Medicine And Treatment, Cameran Runge

Honors Program: Senior Projects (Public)

Abstract

ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella

pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter

spp.) are seeing a growing resistance to multiple classes of antibiotics. Misuse and overuse of antibiotics have played directly into the resistance observed, and the problem is growing exponentially. Antibiotic resistance is partially due to several intrinsic factors limiting the drug's uptake. These include efflux pumps, increased biofilm production, and reduced cell wall permeability in the resistant bacteria. ESKAPE pathogens also acquire resistance through horizontal gene transfer and plasmids. As antibiotics have become less effective, the bacteria can continue to thrive, leading to a detrimental …

Childhood Sleep Health And Epigenetic Age Acceleration In Late Adolescence: Cross-Sectional And Longitudinal Analyses, David Balfour, Phillip E. Melton, Joanne A. Mcveigh, Rae-Chi Huang, Peter R. Eastwood, Sian Wanstall, Amy C. Reynolds, Sarah Cohen-Woods

Research outputs 2022 to 2026

Aim: Investigate if childhood measures of sleep health are associated with epigenetic age acceleration in late adolescence. Methods: Parent-reported sleep trajectories from age 5 to 17, self-reported sleep problems at age 17, and six measures of epigenetic age acceleration at age 17 were studied in 1192 young Australians from the Raine Study Gen2. Results: There was no evidence for a relationship between the parent-reported sleep trajectories and epigenetic age acceleration (p ≥ 0.17). There was a positive cross-sectional relationship between self-reported sleep problem score and intrinsic epigenetic age acceleration at age 17 (b = 0.14, p = 0.04), which was …

Investigating Gene-Diet Interactions Impacting The Association Between Macronutrient Intake And Glycemic Traits, Kenneth E Westerman, Maura E Walker, Sheila M Gaynor, Jennifer Wessel, Daniel Dicorpo, Jiantao Ma, Alvaro Alonso, Stella Aslibekyan, Abigail S Baldridge, Alain G Bertoni, Mary L Biggs, Jennifer A Brody, Yii-Der Ida Chen, Joseé Dupuis, Mark O Goodarzi, Xiuqing Guo, Natalie R Hasbani, Adam Heath, Bertha Hidalgo, Marguerite R Irvin, W Craig Johnson, Rita R Kalyani, Leslie Lange, Rozenn N Lemaitre, Ching-Ti Liu, Simin Liu, Jee-Young Moon, Rami Nassir, James S Pankow, Mary Pettinger, Laura M Raffield, Laura J Rasmussen-Torvik, Elizabeth Selvin, Mackenzie K Senn, Aladdin H Shadyab, Albert V Smith, Nicholas L Smith, Lyn Steffen, Sameera Talegakwar, Kent D Taylor, Paul S De Vries, James G Wilson, Alexis C Wood, Lisa R Yanek, Jie Yao, Yinan Zheng, Eric Boerwinkle, Alanna C Morrison, Miriam Fornage, Tracy P Russell, Bruce M Psaty, Daniel Levy, Nancy L Heard-Costa, Vasan S Ramachandran, Rasika A Mathias, Donna K Arnett, Robert Kaplan, Kari E North, Adolfo Correa, April Carson, Jerome I Rotter, Stephen S Rich, Joann E Manson, Alexander P Reiner, Charles Kooperberg, Jose C Florez, James B Meigs, Jordi Merino, Deirdre K Tobias, Han Chen, Alisa K Manning

Faculty, Staff and Student Publications

Few studies have demonstrated reproducible gene-diet interactions (GDIs) impacting metabolic disease risk factors, likely due in part to measurement error in dietary intake estimation and insufficient capture of rare genetic variation. We aimed to identify GDIs across the genetic frequency spectrum impacting the macronutrient-glycemia relationship in genetically and culturally diverse cohorts. We analyzed 33,187 participants free of diabetes from 10 National Heart, Lung, and Blood Institute Trans-Omics for Precision Medicine program cohorts with whole-genome sequencing, self-reported diet, and glycemic trait data. We fit cohort-specific, multivariable-adjusted linear mixed models for the effect of diet, modeled as an isocaloric substitution of carbohydrate …