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“It Falls On All Our Shoulders”: Overcoming Barriers To Delivering Sex Education In West Texas Schools, Cristina Leos, David Wiley

Journal of Applied Research on Children: Informing Policy for Children at Risk

BACKGROUND: Many racial, socioeconomic, and geographic disparities exist in rates of teen birth and sexually transmitted infections. Increasing access to comprehensive sex education is one risk reduction strategy for these outcomes, yet access to and quality of sex education in schools often falls far below recommended standards, particularly in Texas. The current exploratory study examines barriers to effectively delivering sex education in West Texas schools and identifies strategies to help overcome these barriers. METHODS: In-depth interviews with school leaders and health education professionals (n=4) were conducted to understand teen sexual health needs in West Texas. Interviews were analyzed …

Prescriptions For Produce: An Intervention With Nutrition Education, Cooking Instruction And Produce Vouchers To Increase Fruit And Vegetable Consumption., Julie La Barba M.D., Faap, Karen Weber Cullen, Drph

Journal of Applied Research on Children: Informing Policy for Children at Risk

In this pilot study, we evaluated the feasibility of nutrition education, cooking instruction and produce vouchers for pregnant low income mothers to increase fruit and vegetable consumption. Participants were first trimester pregnant mothers receiving prenatal care at a local Federally Qualified Health Clinic (FQHC) in San Antonio. They attended a grocery shopping tour and cooking class conducted by a registered dietitian, focusing incorporating fruit and vegetables into meals, and a monthly $40 voucher, redeemable for fruit and vegetables. Mothers with high menu planning and grocery shopping skills and more fruit at home reported higher fruit intakes. Mothers with high grocery …

Culinary Education Programs For Children In Low-Income Households: A Scoping Review, Priscilla P Li, Guisela Mackey, Chishinga Callender, Jayna M Dave, Norma Olvera, Shana Alford, Debbe Thompson

Children’s Nutrition Research Center Staff Publications

Child obesity in the United States is at an all-time high, particularly among underserved populations. Home-cooked meals are associated with lower rates of obesity. Helping children develop culinary skills has been associated with improved nutrition. The purpose of this study is to report results from a scoping review of culinary education interventions with children from low-income families. Three databases and hand searches of relevant articles were examined. Retained articles met inclusionary criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, as appropriate. A data extraction template was developed. Data were independently extracted and verified. Only …

Occupational Therapy’S Role With Ventricular Assist Devices And The Promotion Of Travel Protocols, Natasha Chandra, Linda Suplicki

The VAD Journal

An option for individuals diagnosed with end-stage heart failure is to receive a ventricular assist device (VAD). In 2006, Shepherd and Wilding produced an article regarding occupational therapy’s role during the VAD process as they anticipated a growing need for this area of practice. Since that time, there continues to be a lack of supporting literature on occupational therapy’s important role with this population. Therefore, the purpose of this article is to explain an occupational therapist’s contribution on the VAD team, offer opportunities and interventions for enhancing quality of life for this unique population, and discuss an innovative travel protocol …

A Geospatial Examination Of The Association Between Geographic Food Access And Food Insecurity In Central Texas: The Role Of Race/Ethnicity And Urbanicity, Kathryn Janda

Dissertations and Theses (Open Access)

Food insecurity is a public health issue that affects one in ten Americans, one in seven Central Texans, and is associated with malnutrition, chronic disease, and obesity. Geographic food access is the most intervened upon aspect of food insecurity and is often measured objectively through mapping software, such as ArcGIS. Yet when geographic food access is only measured in terms of distance to food retail, analyses do not full capture the nuances of community context. Thus, other sources of data, like survey data, and demographic indicators, such as race/ethnicity and urbanicity, should be incorporated into the research exploring the association …

Ic 011 Guide To University Of Texas School Of Allied Health Sciences Records, 1973-1995, University Of Texas Health Science Center At Houston School Of Allied Health Sciences

Institutional Finding Aids

The University of Texas School of Allied Health Sciences contains catalogs, admission applications, newsletters, and brochures. See more at IC 011.

Caregivers Of Medically Fragile Children With Technology Needs, Vuong Prieto

Dissertations and Theses (Open Access)

Background: Medically fragile children (MFC) with technology needs have complex and challenging health care needs in the home setting. Providing care can have both negative and positive psychological and social impacts on the caregivers’ health related quality of life (HRQOL).

Aims: a) To examine the relationship between caregiver burden, caregiving satisfaction, and HRQOL in caregivers of MFC with technology needs. b) To identify caregiver and child related variables of caregiver burden and caregiving satisfaction.

Methods: A cross sectional study was conducted over four months at a children’s hospital and outpatient clinics. Caregivers completed three one-time surveys (Zarit Burden Interview, Caregiving …

Left Ventricular Assist Device Adjustment Impacted By Patient Trajectory: A Qualitative Exploratory Study, Brittany Rhoades

Dissertations and Theses (Open Access)

Background: Left Ventricular Assist Devices (LVADs) are used as advanced therapy for advanced heart failure in order to sustain patients until a heart transplant is available (bridge to transplant, ‘BTT’) or until the end of life (destination therapy, ‘DT’). Despite the differences in treatment trajectory, BTT and DT patients are provided the same education. Currently it is unknown if the two groups compare to living with the LVAD regarding adjustment.

Aims: The aim of this study was to explore LVAD patient experience, describe how patients construct the impact of the LVAD on daily life and self-care and compare the findings …

Maternal And Newborn Outcomes For Women Living With Hiv In Adapted Group Prenatal Care, Jodi Behr

Dissertations and Theses (Open Access)

Background: For women living with HIV (WLWH), managing HIV and their pregnancy can be challenging. WLWH have been identified at risk for lower adherence to prenatal care, increased maternal HIV Plasma RNA levels, decreased newborn gestational age, and newborn birth weight. Improved outcomes have been found with group prenatal care. Maternal and newborn outcomes for WLWH and their newborns in group prenatal care compared to WLWH and their newborns in individual care have not been evaluated.

Purpose: The aims of this study were to evaluate group differences between WLWH who attended individual prenatal care appointments (IC) compared to WLWH who …

Sample Size Calculations For Longitudinal Mediation Analysis With Continuous-Time Markov Chain Variables, Abigail Christine Sedory

Dissertations and Theses (Open Access)

Mediation is a type of analysis used to determine the causal mechanism linking a predictor and an outcome through a mediator variable. Various research has examined the inclusion of different variable types for the predictor, mediator, and outcome. However, no studies include the presence of a continuous-time Markov chain (CTMC) as any of the components in a mediating model. If researchers wanted to design a study with a CTMC in the mediating process, one of the first steps would be to determine the minimum number of subjects or observations needed to detect a significant mediating effect. Therefore, in this study, …

Development Of A Culinary Nutrition-Based Training For Dietitians And A Clinic-Based Nutrition Intervention To Improve Health Outcomes Among Low-Income Minority Patients, John Wesley Mcwhorter

Dissertations and Theses (Open Access)

Substantial evidence demonstrates the relations between a healthy dietary pattern rich in fruits, vegetables, and whole grains and a lower risk of chronic diseases including type 2 diabetes. Despite well supported studies, programs, and public health campaigns presenting the health benefits of consuming a healthy dietary pattern, most Americans fall far short of the recommendations. Further, the compounding effects of food insecurity and the consumption of energy-dense and nutrient-deficient foods disproportionately affect low income minority populations. Culinary medicine (CM) and food prescription programs are gaining popularity as tools for (1) decreasing food insecurity; (2) increasing personal agency; (3) promoting healthy …

The Intersection Of Diet, Health And The Environment: Plant Based Diets And Public Health, Christine E. Jovanovic

Dissertations and Theses (Open Access)

Both globally and within the United States, chronic disease has become a major driver of mortality and morbidity. In the United States in 2017, the top ten causes of mortality accounted for 74% of all deaths [2]; of these causes, half are closely linked to diet (heart disease, cancer, stroke, Alzheimer’s and diabetes). [3] In 2013, Ioannidis estimated that 26% of deaths and 14% of disability adjusted life years (DALYs) in the United States may be attributable to dietary risk factors, controlling for obesity. [4] At the same time, diet also has an important impact on the environment. Direct emissions …

Exploring Community-Based Weight Loss Initiatives, Retention, And Motivation, Miriam Martinez

Dissertations and Theses (Open Access)

Obesity puts individuals at risk of developing diabetes, cardiovascular disease, and cancer. Traditionally obesity was primarily perceived as a personal disorder requiring treatment at the individual level. Strategies to prevent obesity have shifted to an ecological approach. Organizations such as the World Health Organization recommend population based community approaches that connect people, families, schools, and municipalities. Community programs to facilitate weight loss are an effective strategy to reach large populations. The overall goal of this study is to assess community programs, factors associated with retention, and motivation for completing a community weight-loss initiative. A systematic review was conducted to characterize …

Estimating Means And Distributions Of Count Data From Surveys Invoking Complex Sampling Designs: Application To Measuring Cross-Sectional And Lifetime Alcohol Intake From Nhanes And Nlsy, Elysia A. Garcia

Dissertations and Theses (Open Access)

It is often of interest to measure the distribution (i.e. mean and percentiles) of count outcomes from national survey data to assess population consumption and guide public health efforts for substances such as alcohol, cigarettes, marijuana, and other illicit or licit drugs. Currently available methods for estimating the distribution of dietary intakes do not immediately lend themselves to estimating the consumption of substances measured as counts, nor do they accommodate the complex design elements – strata, cluster, and weight – characteristic of national surveys. We introduce an accurate methodology, called the Survey Adjusted Count (SAC) method, and an associated SAS …

Trends In Injection Drug Use In Texas Treatment Facility Admissions, Cara Dahlhausen

Dissertations and Theses (Open Access)

This is a serial cross-sectional secondary analysis of drug treatment admissions records from the TEDS-A from years 2013-2017. The prevalence of injected drug use was calculated for each year and analyzed across the five-year period using a chi-square test to determine the presence of significant change in injection drug use from 2013 to 2017. Prevalence of injection drug use also will be calculated for each year by drug type (heroin, methamphetamine, and cocaine), age, sex, ethnicity and race, and will be analyzed for trends using a chi-square test.

Exploration Of Breastfeeding As A Protective Factor For Breast Cancer In South African Women: A Nested Case-Control Study, Booker S. Quiera

Dissertations and Theses (Open Access)

Background. South African’s (SA) breast cancer incidence rate is continually increasing (39 per 100,000 (2012) versus 46.2 per 100,000 (2018) with trends towards later-stage diagnosis. In previous literature, breastfeeding has been assessed as a protective factor for breast cancer; however, the SA population experiences inconsistent breastfeeding trends, rates, and support services. Therefore, this study will evaluate the inverse association between breast cancer and breastfeeding history. Methods. Cases (breast cancer) and controls (mastalgia) were matched 1:1 on clinical visit from May-August 2019 at Groote Schuur Hospital (GSH) in Cape Town, Western Cape, South Africa. Breastfeeding history, breast carcinoma diagnosis, and clinically …

The Influence Of Sodium And Potassium On Blood Pressure Genetics In The Population Architecture Using Genomics And Epidemiology Study, Cynthia S. Bell

Dissertations and Theses (Open Access)

Multiple polymorphisms have shown associations with blood pressure (BP) levels and hypertension status, but the overall genetic effect on BP has been small and accounts for only a small fraction of the variation in population-wide BP characteristics. These weak associations of BP with genotype may not be attributable to the examining the “wrong” single nucleotide polymorphism (SNP) but may instead be the result of noisy BP phenotypes based on mmHg alone. Adding information from the underlying mechanisms of nutritional intake, reuptake, and excretion on BP may produce more informative BP phenotypes to study. To explore this complex relationship between diet, …

The Association Between Assorted Hormonal Contraceptive Methods And Advanced-Stage Epithelial Ovarian Cancer: A Systematic Review, Cheng Cheng

Dissertations and Theses (Open Access)

Epithelial ovarian cancer, the most lethal of the gynecological cancers, is typically diagnosed at advanced stages. Women diagnosed with advance-staged (i.e., stage III and IV according to the International Federation of Gynecology and Obstetrics) epithelial ovarian cancer are more likely to have recurrent episodes within 18 months17. According to a 2012 2016 case analysis conducted by the surveillance, epidemiology, and end results, or SEER program, the incidence of ovarian cancer was 11.4 per 100,000 women in all races per year with the highest incidence in non-Hispanic whites, of 11.9 per 100,000 women and the lowest incidence in Asians / Pacific …

Exploration Of Breastfeeding As A Protective Factor For Breast Cancer In South African Women: A Nested Case-Control Study, Quiera S. Booker

Dissertations and Theses (Open Access)

South African’s (SA) breast cancer incidence rate is continually increasing (39 per 100,000 (2012) versus 46.2 per 100,000 (2018) with trends towards later-stage diagnosis. In previous literature, breastfeeding has been assessed as a protective factor for breast cancer; however, the SA population experiences inconsistent breastfeeding trends, rates, and support services. Therefore, this study will evaluate the inverse association between breast cancer and breastfeeding history. Methods. Cases (breast cancer) and controls (mastalgia) were matched 1:1 on clinical visit from May-August 2019 at Groote Schuur Hospital (GSH) in Cape Town, Western Cape, South Africa. Breastfeeding history, breast carcinoma diagnosis, and clinically relevant …

Follow Up Care, Cancer Treatment Summaries And Patient Centered Communication, Ashleigh Gil

Dissertations and Theses (Open Access)

The adolescent and young adult (AYA) age group is the cohort of individuals who have been diagnosed with and/or are survivors of cancer. It is recommended they receive lifelong follow up care to prevent or mitigate late health effects associated with cancer and treatment. However, AYAs are caught between the pediatric and adult healthcare systems and they may not be able to fully advocate for their healthcare needs. Some factors that may be associated with AYAs survivorship care are treatment summaries and where they receive follow up care. This study aimed to identify if receipt of a treatment summary and …

Alternative Carbon Utilization As A Virulence Determinant For Candida Albicans, Robert Williams

Dissertations and Theses (Open Access)

Candida albicans is a polymorphic unicellular fungus that has evolved to proficiently colonize and infect mammals. A common constituent of the microbiome in the GI tract, mouth, vagina, and skin, C. albicans is also an opportunistic pathogen capable of causing a variety of mucosal infections and the life-threatening disseminated candidiasis. Systemic C. albicans infections are a serious and growing issue; the fungus is the fourth most common cause of nosocomial bloodstream infections which has a mortality rate reaching 50%. As antifungal resistance continues to rise, it is critical that I understand the molecular basis of disseminated fungal infections.

The phagocytes …

Estrogen Receptor-Α Expressing Neurons In The Ventrolateral Vmh Regulate Glucose Balance, Yanlin He, Pingwen Xu, Chunmei Wang, Yan Xia, Meng Yu, Yongjie Yang, Kaifan Yu, Xing Cai, Na Qu, Kenji Saito, Julia Wang, Ilirjana Hyseni, Matthew Robertson, Badrajee Piyarathna, Min Gao, Sohaib A Khan, Feng Liu, Rui Chen, Cristian Coarfa, Zhongming Zhao, Qingchun Tong, Zheng Sun, Yong Xu

Children’s Nutrition Research Center Staff Publications

Brain glucose-sensing neurons detect glucose fluctuations and prevent severe hypoglycemia, but mechanisms mediating functions of these glucose-sensing neurons are unclear. Here we report that estrogen receptor-α (ERα)-expressing neurons in the ventrolateral subdivision of the ventromedial hypothalamic nucleus (vlVMH) can sense glucose fluctuations, being glucose-inhibited neurons (GI-ERαvlVMH) or glucose-excited neurons (GE-ERαvlVMH). Hypoglycemia activates GI-ERαvlVMH neurons via the anoctamin 4 channel, and inhibits GE-ERαvlVMH neurons through opening the ATP-sensitive potassium channel. Further, we show that GI-ERαvlVMH neurons preferentially project to the medioposterior arcuate nucleus of the hypothalamus (mpARH) and GE-ERαvlVMH neurons preferentially project to the dorsal Raphe nuclei (DRN). Activation of ERαvlVMH …

Hypothalamic Circuits Mediating Consumption And Anxiety, Ryan Cassidy

Dissertations and Theses (Open Access)

From 1960-2016, U.S. obesity prevalence increased 13-40% and diabetes increased from 3-15%. There is an epidemic of metabesity, the aggregate metabolic disorders produced by chronic overeating. Drugs for metabesity were developed in the 1930s with limited effectiveness; agents today rely on the same principles and are similarly ineffective. Particularly surprising has been the failure of satiety enhancers; this indicates it may not be that physiologic hunger drives chronic overeating. Although hunger and satiety affect traditional reward circuitry (Cassidy & Tong 2017), evidence for the primacy of this effect is mixed. Being hungry reduces anxiety-like behavior in mice; whether the …

Dietary Fat And Sugar Differentially Affect Β-Adrenergic Stimulation Of Cardiac Erk And Akt Pathways In C57bl/6 Male Mice Subjected To High-Calorie Feeding, Sadia Ashraf, Gizem Yilmaz, Xu Chen, Romain Harmancey

Faculty, Staff and Student Publications

BACKGROUND: High dietary fat and sugar promote cardiac hypertrophy independently from an increase in blood pressure. The respective contribution that each macronutrient exerts on cardiac growth signaling pathways remains unclear.

OBJECTIVE: The goal of this study was to investigate the mechanisms by which high amounts of dietary fat and sugar affect cardiac growth regulatory pathways.

METHODS: Male C57BL/6 mice (9 wk old; n = 20/group) were fed a standard rodent diet (STD; kcal% protein-fat-carbohydrate, 29-17-54), a high-fat diet (HFD; 20-60-20), a high-fat and high-sugar Western diet (WD; 20-45-35), a high-sugar diet with mixed carbohydrates (HCD; 20-10-70), or a high-sucrose diet …

Dietary Fat And Sugar Differentially Affect Β-Adrenergic Stimulation Of Cardiac Erk And Akt Pathways In C57bl/6 Male Mice Subjected To High-Calorie Feeding, Sadia Ashraf, Gizem Yilmaz, Xu Chen, Romain Harmancey

Faculty, Staff and Student Publications

BACKGROUND: High dietary fat and sugar promote cardiac hypertrophy independently from an increase in blood pressure. The respective contribution that each macronutrient exerts on cardiac growth signaling pathways remains unclear.

OBJECTIVE: The goal of this study was to investigate the mechanisms by which high amounts of dietary fat and sugar affect cardiac growth regulatory pathways.

METHODS: Male C57BL/6 mice (9 wk old; n = 20/group) were fed a standard rodent diet (STD; kcal% protein-fat-carbohydrate, 29-17-54), a high-fat diet (HFD; 20-60-20), a high-fat and high-sugar Western diet (WD; 20-45-35), a high-sugar diet with mixed carbohydrates (HCD; 20-10-70), or a high-sucrose diet …

Metabolic-Sensing Of The Skeletal Muscle Clock Coordinates Fuel Oxidation, Hongshan Yin, Weini Li, Somik Chatterjee, Xuekai Xiong, Pradip Saha, Vijay Yechoor, Ke Ma

Faculty, Staff and Students Publications

Circadian clock confers temporal control in metabolism, with its disruption leading to the development of insulin resistance. Metabolic substrate utilization in skeletal muscle is coordinated with diurnal nutrient cycles. However, whether the molecular clock is involved in this coordination is largely unknown. Using a myocyte-selective genetic ablation mouse model of the essential clock activator Bmal1, here we identify muscle-intrinsic clock as a sensor of feeding cues to orchestrate skeletal muscle oxidation required for global nutrient flux. Bmal1 in skeletal muscle responds robustly to feeding in vivo and insulin induces its expression. Muscle Bmal1 deficiency impaired the transcriptional control of glucose …

Association Of Intensive Lifestyle Intervention, Fitness, And Body Mass Index With Risk Of Heart Failure In Overweight Or Obese Adults With Type 2 Diabetes Mellitus: An Analysis From The Look Ahead Trial, Ambarish Pandey, Kershaw V Patel, Judy L Bahnson, Sarah A Gaussoin, Corby K Martin, Ashok Balasubramanyam, Karen C Johnson, Darren K Mcguire, Alain G Bertoni, Dalane Kitzman, Jarett D Berry, Look Ahead Research Group

Faculty, Staff and Students Publications

BACKGROUND: Type 2 diabetes mellitus (T2DM) is associated with a higher risk for heart failure (HF). The impact of a lifestyle intervention and changes in cardiorespiratory fitness (CRF) and body mass index on risk for HF is not well established.

METHODS: Participants from the Look AHEAD trial (Action for Health in Diabetes) without prevalent HF were included. Time-to-event analyses were used to compare the risk of incident HF between the intensive lifestyle intervention and diabetes support and education groups. The associations of baseline measures of CRF estimated from a maximal treadmill test, body mass index, and longitudinal changes in these …

Integrating Mouse And Human Genetic Data To Move Beyond Gwas And Identify Causal Genes In Cholesterol Metabolism, Zhonggang Li, James A Votava, Gregory J M Zajac, Jenny N Nguyen, Fernanda B Leyva Jaimes, Sophia M Ly, Jacqueline A Brinkman, Marco De Giorgi, Sushma Kaul, Cara L Green, Samantha L St Clair, Sabrina L Belisle, Julia M Rios, David W Nelson, Mary G Sorci-Thomas, William R Lagor, Dudley W Lamming, Chi-Liang Eric Yen, Brian W Parks

Faculty, Staff and Students Publications

Identifying the causal gene(s) that connects genetic variation to a phenotype is a challenging problem in genome-wide association studies (GWASs). Here, we develop a systematic approach that integrates mouse liver co-expression networks with human lipid GWAS data to identify regulators of cholesterol and lipid metabolism. Through our approach, we identified 48 genes showing replication in mice and associated with plasma lipid traits in humans and six genes on the X chromosome. Among these 54 genes, 25 have no previously identified role in lipid metabolism. Based on functional studies and integration with additional human lipid GWAS datasets, we pinpoint Sestrin1 as …

Provider Attitudes And Practice Patterns For Direct-Acting Antiviral Therapy For Patients With Hepatocellular Carcinoma, Nicole E Rich, Ju Dong Yang, Ponni V Perumalswami, Naim Alkhouri, Whitney Jackson, Neehar D Parikh, Neil Mehta, Reena Salgia, Andres Duarte-Rojo, Laura Kulik, Mina Rakoski, Adnan Said, Omobonike Oloruntoba, George N Ioannou, Maarouf A Hoteit, Andrew M Moon, Amol S Rangnekar, Sheila L Eswaran, Elizabeth Zheng, Janice H Jou, James Hanje, Anjana Pillai, Ruben Hernaez, Robert Wong, Steven Scaglione, Hrishikesh Samant, Devika Kapuria, Shaun Chandna, Russell Rosenblatt, Veeral Ajmera, Catherine T Frenette, Sanjaya K Satapathy, Parvez Mantry, Prasun Jalal, Binu V John, Oren K Fix, Michael Leise, Christina C Lindenmeyer, Avegail Flores, Nayan Patel, Z Gordon Jiang, Nyan Latt, Renumathy Dhanasekaran, Mobolaji Odewole, Sofia Kagan, Jorge A Marrero, Amit G Singal

Faculty, Staff and Students Publications

BACKGROUND & AIMS: Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC.

METHODS: We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses …

Neurochemical Characterization Of Brainstem Pro-Opiomelanocortin Cells, Teodora Georgescu, David Lyons, Barbora Doslikova, Ana Paula Garcia, Oliver Marston, Luke K Burke, Raffaella Chianese, Brian Y H Lam, Giles S H Yeo, Justin J Rochford, Alastair S Garfield, Lora K Heisler

Faculty, Staff and Student Publications

Genetic research has revealed pro-opiomelanocortin (POMC) to be a fundamental regulator of energy balance and body weight in mammals. Within the brain, POMC is primarily expressed in the arcuate nucleus of the hypothalamus (ARC), while a smaller population exists in the brainstem nucleus of the solitary tract (POMCNTS). We performed a neurochemical characterization of this understudied population of POMC cells using transgenic mice expressing green fluorescent protein (eGFP) under the control of a POMC promoter/enhancer (PomceGFP). Expression of endogenous Pomc mRNA in the nucleus of the solitary tract (NTS) PomceGFP cells was confirmed using fluorescence-activating cell sorting (FACS) followed by …