Digital Commons Network^™

Penile Anaerobic Dysbiosis As A Risk Factor For Hiv Infection, Cindy Liu, Jessica Prodger, Aaron Tobian, Alison Abraham, Godfrey Kigozi, Lance B. Price, +Several Additional Authors

Environmental and Occupational Health Faculty Publications

Sexual transmission of HIV requires exposure to the virus and infection of activated mucosal immune cells, specifically CD4⁺ T cells or dendritic cells. The foreskin is a major site of viral entry in heterosexual transmission of HIV. Although the probability of acquiring HIV from a sexual encounter is low, the risk varies even after adjusting for known HIV risk factors. The genital microbiome may account for some of the variability in risk by interacting with the host immune system to trigger inflammatory responses that mediate the infection of mucosal immune cells. We conducted a case-control study of uncircumcised participants …

Syphilis In Men That Have Sex With Men, Nathaniel Helser

Nursing Student Class Projects (Formerly MSN)

Syphilis rates in the United States hit their nadir in the 1960’s and 1970’s with almost complete disappearance during the 1980’s in conjunction with the onset of the human immunodeficiency virus outbreak (Read et al, 2015). This dramatic fall was a direct consequence of the introduction of penicillin in the 1940’s, but since this decline a widely documented reemergence in endemic levels has been seen across the country (Petrosky et al, 2016). Recent rates in men have jumped from 3 per 100,000 to 9.8 per 100,000 (Petrosky et al, 2016) in a two year span, an alarming increase, which has …

Kingella Kingae: Emerging Outbreaks In Daycare Facilities, Kimberly Iracki

Nursing Student Class Projects (Formerly MSN)

In today’s Western countries, families are more likely than those of past decades to include two full-time working parents. This has led to an increase in he number of children attending daycare or some form of childcare outside the home. It is known that close quarters or semi-confined setting increase the risk of certain infections. Out of these infections, an emerging pediatric pathogen, that has also shown some prevalence in adults, is Kingella kingae.

Age And Sex Normalization Of Intestinal Permeability Measures For The Improved Assessment Of Enteropathy In Infancy And Early Childhood: Results From The Mal-Ed Study, Margaret N. Kosek, Gwenyth O. Lee, Richard L. Guerrant, Rashidul Haque, Gagandeep Kang, Tahmeed Ahmed, Pascal Bessong, Syed Asad Ali, Shahida Qureshi, Anita K. M. Zaidi

Department of Paediatrics and Child Health

Objectives: The aim of the study was to describe changes in intestinal permeability in early childhood in diverse epidemiologic settings.
Methods: In a birth cohort study, the lactulose:mannitol (L:M) test was administered to 1980 children at 4 time points in the first 24 months of life in 8 countries. Data from the Brazil site with an incidence of diarrhea similar to that seen in the United States and no growth faltering was used as an internal study reference to derive age- and sex-specific z scores for mannitol and lactulose recoveries and the L:M ratio.
Results: A total of 6602 tests …

A Randomized Trial Of Brief Assessment Interventions For Young Adults Who Use Drugs In The Club Scene, Steven P. Kurtz, Mance E. Buttram, Maria E. Pagano, Hilary L. Surratt

Center for Health Services Research Faculty Publications

Background—Efficacious interventions to reduce drug use and its consequences for club drug using populations are not apparent in the literature. We tested interviewer-(CAPI) and self-administered (ACASI) comprehensive health and social risk assessments as distinct interventions compared to waitlist control.

Methods—750 men and women ages 18-39 with multidrug use and heterosexual behavior were randomized in equal proportions to the three conditions. Instrumentation included well-tested measures of drug use, risky sex, mental distress and substance dependence.

Results—The sample was 56% male; mean age=25. Reported risk behaviors and health consequences did not differ by assessment modality. Adjusted HLM analyses showed …

Screening For Syphilis In Cases Of Suspected Gonorrhea And Chlamydia Infections, Kumara Nibhanipudi, K Cody

NYMC Faculty Publications

Background. In all cases of suspected sexually transmitted infections (STIs), it has been routine practice to screen for syphilis with a blood sample. The incidence of syphilis seems to be lower than that of commonly screened STIs. Objective. The objective of our study was to determine whether it is cost-effective to screen for syphilis with serological testing in cases of suspected gonorrhea and chlamydia infections. Hypothesis. Our hypothesis is that it is not cost-effective to screen for syphilis in cases of presumed gonorrhea and chlamydia infections. Methods. Our study is a New York Medical College institutional …

Coliphage As An Indicator Of The Quality Of Beach Water To Protect The Health Of Swimmers In Coastal Georgia, Javier Gallard-Gongora, Kathryn Munck, Jeff Jones, Asli Aslan

Journal of the Georgia Public Health Association

Background: Gastrointestinal disease affects millions of people in the United States and places a substantial economic burden upon healthcare systems. Recreational waters polluted with fecal material are a main source for transmission of gastrointestinal disease. Georgia beaches are monitored for the presence of fecal indicator bacteria, but these bacteria are not well associated with enteric viruses. The United States Environmental Protection Agency (US EPA) has recently proposed coliphage (a virus of Escherichia coli) as an alternative indicator of fecal contamination in recreational waters. The present study compares fecal indicator bacteria and coliphage concentrations at two Georgia beaches with adjacent creeks …

Physician Attitudes Toward The Ethics Of Pre-Exposure Prophylaxis (Prep): Cost, Safety, And Resource Allocation, Jessica Grippo, Stacy W. Smallwood, Katherine Pincura, Tamara Wright, William A. Mase

Journal of the Georgia Public Health Association

Background: In the United States, human immunodeficiency virus (HIV) remains a substantial public health issue. There is evidence that the use of antiretroviral medications such as pre-exposure prophylaxis (PrEP) can be a safe and effective primary prevention strategy to reduce new cases of HIV infection. Provider practice behavior as it relates to prescribing PrEP and the potential impact on specific vulnerable populations needs increased attention. Few studies have evaluated the attitudes of physicians towards ethical issues related to prescribing PrEP.

Methods: The purpose of the present literature review was to evaluate provider attitudes toward the ethics of prescribing PrEP for …

Leveraging Partnerships In Order To Increase Notifiable Disease Reporting, Jessica Grippo, Amber Erickson

Journal of the Georgia Public Health Association

Background: Notifiable disease reporting, although required by law, does not always occur. For this reason, it is crucial for local public health agencies to leverage new partnerships for reporting of notifiable diseases. Schools represent sites within communities that experience relatively high numbers of cases of notifiable disease and clusters of illness. By leveraging partnerships with schools, an increase in disease reporting can occur within communities.

Methods: DeKalb County Board of Health has developed an infectious disease protocol for the two major school systems in the county and one large private school: DeKalb County School District, City Schools of Decatur and …

Helping Public Health Professionals Access Infectious Disease Trainings And Resources: The Region Iv Phtc Infectious Diseases Training Database, Laura M. Lloyd, Lisa Mccormick, Melissa Alperin, Michelle Carvalho, Cidney Wilson, Brita Bergland, Arti Patel, Kathleen R. Miner

Journal of the Georgia Public Health Association

Background: The Region IV Public Health Training Center (R-IV PHTC), located at Emory University’s Rollins School of Public Health, has a mission that includes providing training and educational offerings to strengthen the competency of the current public health workforce in HHS Region IV (which includes GA). Additionally, the R-IV PHTC has been charged with serving as a national resource in the area of infectious disease. To fulfill this charge, the R-IV PHTC conducted an environmental scan to identify and increase access to existing infectious disease trainings and resources currently available to the public health workforce.

Methods: From June 2015 – …

C-Safe: A Computer-Delivered Sexual Health Promotion Program For Latinas, Charles H. Klein, Tamara Kuhn, Midori Altamirano, Carmela Lomonaco

Anthropology Faculty Publications and Presentations

This article describes the development and evaluation of C-SAFE (Sexual Awareness for Everyone), a computer-delivered sexual health promotion program for Latinas. We first describe the process of adapting an evidence-based, group-level intervention into an individually administered computer-delivered program. We then present the methods and results of a randomized control trial with 321 Latinas in California and Florida to test C-SAFE's preliminary efficacy in reducing sexual health risk. We found no statistically significant differences between the two conditions at a six-month follow-up in terms of sexual behaviors or attitudes toward sexually transmitted infections and condoms, although C-SAFE women reported fewer days …

Predicting Death Over 8 Years In A Prospective Cohort Of Hiv-Infected Women: The Women's Interagency Hiv Study, Deborah Gustafson, Qiuhu Shi, Susan Holman, Howard Minkoff, Mardge Cohen, Michael Plankey, Donald Hoover

NYMC Faculty Publications

OBJECTIVES: Predicting mortality in middle-aged HIV-infected (HIV+) women on antiretroviral therapies (ART) is important for understanding the impact of HIV infection. Several health indices have been used to predict mortality in women with HIV infection. We evaluated: (1) an HIV biological index, Veterans Aging Cohort Study (VACS); (2) a physical index, Fried Frailty Index (FFI); and (3) a mental health index, Center for Epidemiologic Studies-Depression (CES-D). Proportional hazards regression analyses were used to predict death and included relevant covariates.

DESIGN: Prospective, observational cohort.

SETTING: Multicentre, across six sites in the USA.

PARTICIPANTS: 1385 multirace/ethnic ART-experienced HIV+ women in 2005.

PRIMARY …

Point-Of-Care Testing For Toxoplasma Gondii Igg/Igm Using Toxoplasma Ict Igg-Igm Test With Sera From The United States And Implications For Developing Countries, Ian J. Begeman, Joseph Lykins, Ying Zhou, Bo Shiun Lai, Pauline Levinge, Kamal El Bissati, Kenneth Boyer, Shawn Withers, Fatima Clouser, A. Gwendolyn Noble, Peter Rabiah, Charles N. Swisher, Peter T. Heydemann, Depina G. Contopoulos-Ioannidis, Jose G. Montoya, Yvonne Maldonado, Raymund Ramirez, Cindy Press, Eileen Stillwaggon, François Peyron, Rima Mcleod

Economics Faculty Publications

Background

Congenital toxoplasmosis is a serious but preventable and treatable disease. Gestational screening facilitates early detection and treatment of primary acquisition. Thus, fetal infection can be promptly diagnosed and treated and outcomes can be improved.

Methods

We tested 180 sera with the Toxoplasma ICT IgG-IgM point-of-care (POC) test. Sera were from 116 chronically infected persons (48 serotype II; 14 serotype I-III; 25 serotype I-IIIa; 28 serotype Atypical, haplogroup 12; 1 not typed). These represent strains of parasites infecting mothers of congenitally infected children in the U.S. 51 seronegative samples and 13 samples from recently infected persons known to be IgG/IgM …

The Effect Of Antigen Polymorphisms On Serological Antibody Detection Assays Based Upon The, Kristi M. Miley

USF Tampa Graduate Theses and Dissertations

Onchocerca volvulus is a filarial parasite transmitted to humans by female Simulium spp. black flies. Infection with this parasite can cause blindness and severe skin disease among humans in Africa and the Americas. Enzyme-linked Immunosorbent Assay serological testing of OV-16 antigen is a diagnostic tool for determining effective elimination of the parasite. Programs typically rely on OV–16 ELISA to evaluate the progress towards interruption and/or elimination of disease by mass drug distribution of ivermectin and vector larvicidal control efforts. As elimination grows closer, monoclonal antibody positive controls for OV-16 ELISA become important to develop for Onchocerca testing due to the …

Analysis Of A Potential A(H7n9) Influenza Pandemic Outbreak In The U.S., Walter A. Silva Sotillo

USF Tampa Graduate Theses and Dissertations

This dissertation presents a collection of manuscripts that describe development of models and model implementation to analyze impact of potential A(H7N9) pandemic influenza outbreak in the U.S. Though this virus is still only animal-to-human transmittable, it has potential to become human-to-human transmittable and trigger a pandemic. This work is motivated by the negative impact on human lives that this virus has already caused in China, and is intended to support public health officials in preparing to protect U.S. population from a potential outbreak of pandemic scale.

An agent-based (AB) simulation model is used to replicate the social dynamics of the …

Immunizations And Health Disparities: Immunizations Provided Across A Diverse Population, Jeffery A. Goad, Tania Gregorian

Pharmacy Faculty Articles and Research

"Vaccines help contain the spread of diseases and reduce morbidity and mortality. For any vaccination effort to succeed, vaccine uptake must be widespread across the entire population. However, the US population is very diverse, and there are various groups with different attitudes and beliefs regarding vaccination; this leads to disparities in vaccination rates. The Healthy People initiative, a program managed by Office of Disease Prevention and Health Promotion at the US Department of Health and Human Services HHS that aims to provide Americans with evidence-based, 10-year national objectives for improving their health defines a disparity in health care as 'a …

Trafficking Victims In The Emergency Room Setting, Lisa M. Archer

Theses and Graduate Projects

Human trafficking, a form of modern-day slavery, is a violation of human rights and a public health issue. Affecting millions worldwide, a high prevalence of human trafficking exists in the United States (US). Traffickers target vulnerable victims in an effort, through coercion and exploitation, to benefit financially, perpetuating the issue of supply and demand. Lacking a specific demographic, traffickers opportunistically seek out victims, such as targeting runaway and homeless youth, those sold through poverty, or those surviving in conditions caused by natural disaster. Multidisciplinary health care staff are uniquely positioned to recognize, assess, and intervene when encountering victims who seek …

Association Of Alzhemier's Disease With Hepatitis C Among Patients With Bipolar Disorder, Herng-Ching Lin, Sudha Xirasagar, Hsin-Chien Lee, Chung-Chien Huang, Chao-Hung Chen

Faculty Publications

Associations of hepatitis C virus infection with Alzheimer’s disease have not been studied among higher risk, bipolar disorder patients. This population-based case-control study investigated the risks of hepatitis C virus infection among Alzheimer’s disease patients with bipolar disorder in the years preceding their Alzheimer’s disease diagnosis. We used 2000–2013 data from the Longitudinal Health Insurance Database in Taiwan. Among patients with bipolar disorder, 73 were diagnosed with Alzheimer’s disease (cases), who were compared with 365 individuals with bipolar disorder but without Alzheimer’s disease (randomly selected controls matched on sex, age, and index year with cases). Prior claims (before the diagnosis …

Safety Of Induced Sputum Collection In Children Hospitalized With Severe Or Very Severe Pneumonia., Andrea N Deluca, Laura L Hammitt, Julia Kim, Melissa M Higdon, Henry C Baggett, Daniel E Park, +Several Additional Authors

Epidemiology Faculty Publications

Background.: Induced sputum (IS) may provide diagnostic information about the etiology of pneumonia. The safety of this procedure across a heterogeneous population with severe pneumonia in low- and middle-income countries has not been described.

Methods.: IS specimens were obtained as part a 7-country study of the etiology of severe and very severe pneumonia in hospitalized childrenbefore, during, and after the procedure to record oxygen requirement, oxygen saturation, respiratory rate, consciousness level, and other evidence of clinical deterioration. Criteria for IS contraindications were predefined and serious adverse events (SAEs) were reported to ethics committees and a central safety monitor.

Results.: A …

Data Management And Data Quality In Perch, A Large International Case-Control Study Of Severe Childhood Pneumonia., Nora L Watson, Christine Prosperi, Amanda J Driscoll, Melissa M Higdon, Daniel E Park, Megan Sanza, Andrea N Deluca, Juliet O Awori, Doli Goswami, Emily Hammond, Lokman Hossain, Catherine Johnson, Alice Kamau, Locadiah Kuwanda, David P Moore, Omid Neyzari, Uma Onwuchekwa, David Parker, Patranuch Sapchookul

Epidemiology Faculty Publications

The Pneumonia Etiology Research for Child Health (PERCH) study is the largest multicountry etiology study of pediatric pneumonia undertaken in the past 3 decades. The study enrolled 4232 hospitalized cases and 5325 controls over 2 years across 9 research sites in 7 countries in Africa and Asia. The volume and complexity of data collection in PERCH presented considerable logistical and technical challenges. The project chose an internet-based data entry system to allow real-time access to the data, enabling the project to monitor and clean incoming data and perform preliminary analyses throughout the study. To ensure high-quality data, the project developed …

Colonization Density Of The Upper Respiratory Tract As A Predictor Of Pneumonia-Haemophilus Influenzae, Moraxella Catarrhalis, Staphylococcus Aureus, And Pneumocystis Jirovecii., Daniel E Park, Henry C Baggett, Stephen R C Howie, Qiyuan Shi, Nora L Watson, W Abdullah Brooks, Perch Study Group

Epidemiology Faculty Publications

Background.

There is limited information on the association between colonization density of upper respiratory tract colonizers and pathogen-specific pneumonia. We assessed this association for Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and Pneumocystis jirovecii. Methods.

In 7 low- and middle-income countries, nasopharyngeal/oropharyngeal swabs from children with severe pneumonia and age-frequency matched community controls were tested using quantitative polymerase chain reaction (PCR). Differences in median colonization density were evaluated using the Wilcoxon rank-sum test. Density cutoffs were determined using receiver operating characteristic curves. Cases with a pathogen identified from lung aspirate culture or PCR, pleural fluid culture or …

Microscopic Analysis And Quality Assessment Of Induced Sputum From Children With Pneumonia In The Perch Study., David R Murdoch, Susan C Morpeth, Laura L Hammitt, Amanda J Driscoll, Daniel E Park, +Several Additional Authors

Epidemiology Faculty Publications

Background.

It is standard practice for laboratories to assess the cellular quality of expectorated sputum specimens to check that they originated from the lower respiratory tract. The presence of low numbers of squamous epithelial cells (SECs) and high numbers of polymorphonuclear (PMN) cells are regarded as indicative of a lower respiratory tract specimen. However, these quality ratings have never been evaluated for induced sputum specimens from children with suspected pneumonia. Methods.

We evaluated induced sputum Gram stain smears and cultures from hospitalized children aged 1–59 months enrolled in a large study of community-acquired pneumonia. We hypothesized that a specimen representative …

Is Higher Viral Load In The Upper Respiratory Tract Associated With Severe Pneumonia? Findings From The Perch Study., Daniel R Feikin, Wei Fu, Daniel E Park, Qiyuan Shi, Melissa M Higdon, Henry C Baggett, +Several Additional Authors

Epidemiology Faculty Publications

Background.

The etiologic inference of identifying a pathogen in the upper respiratory tract (URT) of children with pneumonia is unclear. To determine if viral load could provide evidence of causality of pneumonia, we compared viral load in the URT of children with World Health Organization–defined severe and very severe pneumonia and age-matched community controls.

Methods.

In the 9 developing country sites, nasopharyngeal/oropharyngeal swabs from children with and without pneumonia were tested using quantitative real-time polymerase chain reaction for 17 viruses. The association of viral load with case status was evaluated using logistic regression. Receiver operating characteristic (ROC) curves were constructed …

Association Of C-Reactive Protein With Bacterial And Respiratory Syncytial Virus-Associated Pneumonia Among Children Aged <5 Years In The Perch Study., Melissa M Higdon, Tham Le, Katherine L O'Brien, David R Murdoch, Christine Prosperi, Henry C Baggett, Daniel E Park, +Several Additional Authors

Epidemiology Faculty Publications

Background.

Lack of a gold standard for identifying bacterial and viral etiologies of pneumonia has limited evaluation of C-reactive protein (CRP) for identifying bacterial pneumonia. We evaluated the sensitivity and specificity of CRP for identifying bacterial vs respiratory syncytial virus (RSV) pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) multicenter case-control study. Methods.

We measured serum CRP levels in cases with World Health Organization–defined severe or very severe pneumonia and a subset of community controls. We evaluated the sensitivity and specificity of elevated CRP for “confirmed” bacterial pneumonia (positive blood culture or positive lung aspirate or pleural fluid …

Standardization Of Clinical Assessment And Sample Collection Across All Perch Study Sites., Jane Crawley, Christine Prosperi, Henry C Baggett, W Abdullah Brooks, Maria Deloria Knoll, Daniel E Park, +Several Additional Authors

Epidemiology Faculty Publications

Background.: Variable adherence to standardized case definitions, clinical procedures, specimen collection techniques, and laboratory methods has complicated the interpretation of previous multicenter pneumonia etiology studies. To circumvent these problems, a program of clinical standardization was embedded in the Pneumonia Etiology Research for Child Health (PERCH) study.

Methods.: Between March 2011 and August 2013, standardized training on the PERCH case definition, clinical procedures, and collection of laboratory specimens was delivered to 331 clinical staff at 9 study sites in 7 countries (The Gambia, Kenya, Mali, South Africa, Zambia, Thailand, and Bangladesh), through 32 on-site courses and a training website. Staff competency …

The Diagnostic Utility Of Induced Sputum Microscopy And Culture In Childhood Pneumonia., David R Murdoch, Susan C Morpeth, Laura L Hammitt, Amanda J Driscoll, Nora L Watson, Daniel E Park, +Several Additional Authors

Epidemiology Faculty Publications

Background.

Sputum microscopy and culture are commonly used for diagnosing the cause of pneumonia in adults but are rarely performed in children due to difficulties in obtaining specimens. Induced sputum is occasionally used to investigate lower respiratory infections in children but has not been widely used in pneumonia etiology studies. Methods.

We evaluated the diagnostic utility of induced sputum microscopy and culture in patients enrolled in the Pneumonia Etiology Research for Child Health (PERCH) study, a large study of community-acquired pneumonia in children aged 1–59 months. Comparisons were made between induced sputum samples from hospitalized children with radiographically confirmed pneumonia …

The New York City Childcare Influenza Vaccine Mandate: A Case Study, Amy E. Metroka

Dissertations and Theses

Background. In 2014, New York City (NYC) became the third jurisdiction in the United States (US) to enact a childcare influenza vaccine mandate, after the states of New Jersey and Connecticut. The mandate was enacted by the NYC Board of Health by amending the NYC Health Code. The mandate’s goal was to increase vaccination rates among 6-59-month-olds attending city-regulated public and private childcare programs, including prekindergarten, to protect children, families, and the community against influenza. Children younger than 5 years are at high risk for severe illness and complications from influenza. Children are also known to be a major source …

Case-Control Vaccine Effectiveness Studies: Data Collection, Analysis And Reporting Results, Jennifer R. Verani, Abdullah H. Baqui, Claire V. Broome, Thomas Cherian, Cheryl Cohen, Jennifer L. Farrar, Daniel R. Feikin, Michelle J. Groome, Rana A. Hajjeh, Anita K. M. Zaidi

Department of Paediatrics and Child Health

The case-control methodology is frequently used to evaluate vaccine effectiveness post-licensure. The results of such studies provide important insight into the level of protection afforded by vaccines in a 'real world' context, and are commonly used to guide vaccine policy decisions. However, the potential for bias and confounding are important limitations to this method, and the results of a poorly conducted or incorrectly interpreted case-control study can mislead policies. In 2012, a group of experts met to review recent experience with case-control studies evaluating vaccine effectiveness; we summarize the recommendations of that group regarding best practices for data collection, analysis, …

Case-Control Vaccine Effectiveness Studies: Preparation, Design, And Enrollment Of Cases And Control, Jennifer R. Verani, Abdullah H. Baqui, Claire V. Broome, Thomas Cherian, Cheryl Cohen, Jennifer L. Farrar, Daniel R. Feikin, Michelle J. Groome, Rana A. Hajjeh, Anita K. M. Zaidi

Department of Paediatrics and Child Health

Case-control studies are commonly used to evaluate effectiveness of licensed vaccines after deployment in public health programs. Such studies can provide policy-relevant data on vaccine performance under 'real world' conditions, contributing to the evidence base to support and sustain introduction of new vaccines. However, case-control studies do not measure the impact of vaccine introduction on disease at a population level, and are subject to bias and confounding, which may lead to inaccurate results that can misinform policy decisions. In 2012, a group of experts met to review recent experience with case-control studies evaluating the effectiveness of several vaccines; here we …

Aboriginal Urban Design For Health, Kate Clark, Mpa, Kirby Broadnax, Antionette Carroll, Jonathan Cha, Naomi Doerner, Allie Kast, Matthew Kennedy, Michael Mendez, Pascale C. Annoual, Carrie Martin, Wendall Nicholas

College of Population Health Lectures, Presentations, Workshops

Montreal’s Aboriginal population is growing rapidly, yet the community lacks a culturally safe and holistic health service center that is accessible to all Aboriginal people. On Friday, June 2, 2017 The Montreal Urban Aboriginal Health Centre (MUAHC) joined forces with Next City & Concordia University to co-create a 7-minute pitch for a $7,000 prize through the Vangaurd Conference Big Idea Challenge. An interdisciplinary team of 8 conference attendees worked with MUAHC leadership to design a short-term solution that would be a step in the right direction towards MUAHC’s goal to build a fully functioning and independent health center dedicated …