Digital Commons Network^™

Bad Faith Disregard Of Benefits And Science In Federal Environmental Deregulation, Michael B. Gerrard

Faculty Scholarship

Since the beginning of the Reagan administration in 1981, federal agencies have used cost-benefit analysis when making important policy decisions, especially when issuing regulations. In the years since then the methodologies have been refined and enshrined in White House guidance. The second Trump administration has upended these practices by often ignoring the benefits of regulations and only considering the costs. In doing so it often claims that there are such uncertainties about the benefits that they should be disregarded. It uses these claims in support of repealing or softening regulations that prior administrations found would save thousands of human lives.

Audit Report For Self-Help Chatbot, Keith Porcaro, Carmela D'Antuono, Wilson Jeter, Bridgett Kohno, Alexander Mcelya, Nikolas Osoria, Melinda Xiaong, Demi Yang

Duke Center on Law & Technology

This audit report investigates a self-help chatbot designed for Nevada litigants with family law or probate cases. The audit was conducted in Spring 2026 as part of Duke’s AI Audits and Access to Justice practicum, in partnership with the Nevada Administrative Office of the Courts.

Sensory Processing At A Children’S Advocacy Center: Staff Education And Resource Development To Support Trauma-Informed Care, Hayley Jackson

Capstone Projects

This capstone addresses a critical gap in understanding sensory processing within trauma-informed care for children who have experienced sexual abuse. Occupational therapy (OT) offers a unique perspective for supporting children’s sensory processing and regulation needs; however, OT is not utilized in Children’s Advocacy Center (CAC) settings. This project aimed to enhance understanding of OT's scope within trauma-informed care, provide education on sensory-based strategies, and develop resources to support regulation in clinical, home, and school settings. Project objectives were achieved through the development of caregiver and educator handouts, a SMART room sensory binder, a visual schedule binder, SMART movement cards, and …

The Importance Of Holistic Care: The Development And Implementation Of Spiritual Resources For Caregivers And Staff At Joni’S House El Salvador, Chloe Veilleux

Capstone Projects

It is within the occupational therapy (OT) scope of practice to not only address client needs related to mind, body, and spirit, but also those of caregivers as a means of fostering overall improved quality of life. Additionally, when OTs address spirituality and implement spiritual/spirituality-informed interventions, correlations of improved psychosocial factors such as well-being, motivation, and reduced stress have been shown, as well as improved hope and reduced burden for caregivers. There remains, however, a gap in the research and implementation of spiritually informed care and resources specifically as it pertains to caregivers of those with disabilities. To address this …

The Bronco Well: An Educational Podcast For Pediatric Caregivers’ Wellbeing & Quality Of Life, Molly Veldheer

Capstone Projects

Pediatric caregivers of children with increased and complex physical, cognitive, and emotional needs are an often-overlooked population. Though their children may be involved in many essential services including occupational therapy, the needs of these caregivers largely go unmet. Occupational therapists are equipped to provide valuable care and education to the entire family and not just their pediatric clients. In efforts to fill the unmet needs, this occupational therapy-based podcast was created as resource for pediatric caregivers about pediatric caregivers. The development of this capstone considered the time, energy, and financial strains that are often placed on pediatric caregivers and determined …

Mapping Sensory Landscapes: Distribution And Arrangement Of The Anterior Lateral Line System In Texas Catfish, Tatiana Flores, Ruben Tovar

Research Papers

Fish have a system of sensory organs known as the lateral line system. This system contains numerous mechanoreceptive neuromasts and electroreceptive ampullary organs (Northcutt et al, 2000). Neuromasts are small, hair-like structures located within canals in the lateral line system just under the fish’s skin and are open to the environment through small pores visible on its skin (Parker, 2025). Water flows into these canals through the pores which stimulates the sensitive hair cells, resulting in electrical signals sent to the fish’s brain. The brain interprets these signals and creates “images” of the fish’s surroundings, helping it to see even …

Polyhydroxybutyrate (Phb) From Biofloc Systems Enhances The Growth And Immune Performance Of Genetically Improved Farmed Tilapia, Menaga Meenakshisundaram, Jimmy B. Mboya, Felix Sugantham

All Peer-Reviewed Publications

This study characterised polyhydroxybutyrate (PHB)-producing bacteria from the culture water of genetically improved farmed tilapia (GIFT) in biofloc ponds and investigated the influence of PHB on the growth and immune performance of GIFT. Out of 40 bacterial isolates, Bacillus infantis, Exiguobacterium profundum, Bacillus subtilis, Bacillus megaterium, Klebsiella pneumoniae and Enterococcus hirae showed positive results for PHB against fluorescent stains. The PHB yield in the range of 5%–95.45% (w/w) was recorded, with the highest from K. pneumoniae (95.45% w/w). The experimental treatments included a basal diet as a control (C), a basal diet with PHB (5 g kg⁻¹) from …

The Woah Global Wildlife Health Collaborating Centre Network (Woah-Wildnet): A Coordinated And Transformative Approach To Global Wildlife Health Challenges, David T.S. Hayman, Steve Unwin, Kelly Bateman, Casey Barton Behravesh, Charlotte Berg, Jemma Bergfeld, Cristina Casalone, Claire Cayol, Erin Davis, Sunday Ekesi, Johan Esterhuizen, Merid Getahun, Federica Giorda, Keith Hamilton, Damien O. Joly, Christa Kühn, Jean Claude Manuguerra, Daniel Masiga, Anita Michel, Paolo Mulatti, Misheck Mulumba, Annah Njui, Richard Paley, Antonio Fernández, Sascha Knauf, David P. Tchouassi, Youming Wang, Nathalie Vachiery, Jandouwe Villinger

All Peer-Reviewed Publications

Introduction Wildlife health is integral to functioning, complex ecosystems [1], directly and indirectly influencing the health of people, animals, plants, and the environment [2–4]. Healthy wildlife populations are essential for ecosystem services and are at the heart of the One Health approach [3,4], which aims to sustainably balance and optimize the health of people, animals, and ecosystems through multisectoral and transdisciplinary collaboration [5]. Despite its importance, wildlife health initiatives often operate in silos, limiting capacity to address transboundary threats such as emerging diseases, pollution, and environmental changes. Anthropogenic changes, including habitat loss, degradation, fragmentation, and unsustainable harvesting, exacerbate wildlife health …

Agronomic Practices For Climate-Resilient Okra Production In Agroecological Systems: A Review, Samuel Mathu Ndungu, Lokeshwar Kesamreddy, Mathieu A.T. Ayenan, Stephen Othim, Siyabusa Mkuhlani, Yu Hsiang Liu, Amha Besufkad, Wubetu Bihon Legesse, Eric C. Legba, Judith Honfoga, Lukas Pawera

All Peer-Reviewed Publications

Okra is increasingly recognized as a climate-resilient crop within diversified agroecological systems; however, an integrated synthesis of its biophysical, agronomic, and socioeconomic dimensions is lacking. This review consolidates the current knowledge on okra physiology, production ecology, and value chains, with a focus on climate resilience under heat, drought, salinity, pest, and disease pressures. Evidence across regions demonstrates that agroecological practices such as crop diversification, mulching, conservation tillage, integrated pest management, and the use of organic and biological inputs consistently improve soil health, stabilize yields under climatic stress, and reduce dependence on external inputs, although with trade-offs in labor demand and …

Visual Recognition Of The Anteroposterior Female Body Axis Drives Spatial Elements Of Male Courtship In Drosophila, Ross M Mckinney, Christian Monroy Hernandez, Yehuda Ben-Shahar

2020-Current year OA Pubs

Drosophila males exhibit a highly stereotypic courtship ritual toward virgin females, which is comprised of a sequence of specific behavioral elements that depend on inputs from diverse sensory modalities. Particularly, the visual system of the male plays an important role in detecting salient patterns, colors, and motion cues from conspecifics, which can promote or inhibit specific aspects of male courtship such as chase and song production. Here, we use a computer vision and machine learning-based approach, with a simplified courtship paradigm, to show that males also depend on visual cues to determine the anterior-posterior body axis of females, which drives …

Intracranial Mesenchymal Tumor, Fet::Creb Fusion-Positive: An Integrative Analysis Of 81 Cases, Sharika Rajan, Robert Schmidt, Et Al.

2020-Current year OA Pubs

BACKGROUND: Intracranial mesenchymal tumors, FET::CREB fusion-positive (ICMT), show fusions involving FET RNA-binding protein family genes (EWSR1 or FUS) and CREB family of transcription factors (ATF1, CREB1, or CREM). The methylation signature(s), gene expression characteristics, and clinical behavior of this important tumor type require further characterization.

METHODS: We study the methylation profiles of 81 ICMT cases (61 newly profiled cases and 20 cases from publicly available sources). Clinicopathologic and genomic data were recorded for each case when available.

RESULTS: ICMT showed a relatively distinct methylation signature compared to related tumors. Among the 65 cases where fusion types were documented, the identified …

Lyplal1 Rare Loss-Of-Function Variants In Humans And Deletion In Human Hepatoma Cells Protect Against Masld, Rawdat Hussain, Chinmay Raut, Ponnandy Prabhu, Akram Irshaid, Yash Hegde, Yue Chen, Asmita Pant, Antonino Oliveri, Xiaochao Wei, Lishi Yin, Tiffany L Russell, Brian Halligan, Clay F Semenkovich, Elizabeth K Speliotes

2020-Current year OA Pubs

Genetic variants near LYPLAL1 are associated with Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) in humans, but their impact on LYPLAL1 function is unknown. We identified LYPLAL1 loss-of-function variants from UK BioBank (UKBB) whole-exome sequencing data that had AlphaMissense or GPN-MSA scores in the top 20% of LYPLAL1 variants for being disruptive. We aggregated these variants and carried out burden analysis for effects on MRI Proton Density-Fat Fraction (MRI-PDFF) and ICD-based MASLD in UKBB. Rare loss-of-function LYPLAL1 variants were associated with reduced MRI-PDFF and ICD diagnosed MASLD across sexes. We used CRISPR to knockout and overexpress LYPLAL1 in human hepatoma cells …

Mechano Responsiveness Of Neuroimmune Cross-Talk In Bone And Joints: A Narrative Review With Implications For Force-Based Manipulations, Karl J Lewis, Jennifer Bent, Per Gunnar Brolinson, Damian Keter, Ellen Lumpkin, Jan Mundo, Vitaly Napadow, William R Reed, Brent S Russell, Simon Y Tang, Mary F Barbe

2020-Current year OA Pubs

INTRODUCTION: Recent advances in osteoimmunology have illuminated the significant role of neuroimmune interactions in bone and joint health. The neuroimmune system critically regulates bone cell function through a complex network of molecular mediators - including signals from the sympathetic and parasympathetic nervous systems, pro- and anti-inflammatory cytokines, cortisol and other hormones, and growth factors. These mediators interact within a nonlinear network where each component can influence others reciprocally, with the brain serving as a central coordinator.

AIM: Our goal in this narrative review is to: 1) Provide an overview of roles the neuroimmune system is involved in bone and joint …

Birthdate Phaseout, Katharine B. Silbaugh

Faculty Scholarship

This Article explores the Nicotine Free Generation ("NFG") policy, an emerging endgame strategy for tobacco products that employs a completely novel legal design. Tobacco remains the leading cause of preventable death, killing almost half of its users and imposing $600 billion in social costs each year. We see two basic choices for regulating sales: prohibition or a legal age-gate, such as twenty-one, for retail sales. NFG charts a third way. Recognizing the dire harm of tobacco and the serious consequences of abrupt prohibition, NFG lays the groundwork for a gradual transition to a sales sunset. In place of the twenty-one …

The Impact Of Estrogen Replacement During Perimenopause On Lung Function And Airway Inflammation In The Vcd Mouse Model, William P Pederson, Laurie Michelle Ellerman, Riley D Hellinger, Joselyn Joanna Rojas Quintero, Francesca Polverino, John P Konhilas, Julie G Ledford

Faculty, Staff and Students Publications

Background:

Menopause associated asthma impacts a subset of women and is less responsive to current treatments. Mechanisms driving this late onset asthma are unknown. We recently developed a mouse model of menopause associated asthma using a combination of 4-Vinylcyclohexene Diepoxide (VCD) and House Dust Mite (HDM) exposures. The goal of this study was to determine how hormone replacement therapy during perimenopause impacts lung function and inflammation.

Methods:

The experimental groups included menopausal mice (VCD) with and without exposure to HDM (to model allergic airways disease) and menopausal mice with and without hormone replacement therapy (HRT; via estrogen pellet implantation). Lung …

Alterations In Ascending Aortic Hemodynamics And Aortic Length Correlate With Sex-Specific Thoracic Aortic Aneurysm Dilation And Lifespan In A Mouse Model Of Severe Marfan Syndrome, Krashn Kr Dwivedi, Yufan Wu, Marisa S Bazzi, Hadi Wiputra, Jacob Rother, James D Quirk, Victor H Barocas, Jessica E Wagenseil

2020-Current year OA Pubs

Thoracic aortic aneurysm (TAA) is a dilation of the aorta that may eventually dissect and/or rupture. It is associated with genetic disorders such as Marfan syndrome (MFS) and is a life-threatening cardiovascular condition if left untreated. Current clinical guidelines for TAA management are primarily based on maximum diameter thresholds that are often inadequate, particularly in MFS patients. Moreover, the diameter thresholds are not sex-specific, despite growing evidence that TAA outcomes in MFS are influenced by sex. The aim of this study was to identify non-invasive biomarkers for better management of TAA using male and female mice that are a genetic …

Relationship Between Clostridioides Difficile Stool Concentration, Nucleic Acid Amplification Test Results, And Environmental Contamination, Mary Morgan Lee, Kimberly A Reske, Tiffany Hink, Skye R S Fishbein, Erin P Newcomer, Candice Cass, Margaret A Olsen, Gautam Dantas, Carey-Ann D Burnham, Erik R Dubberke

2020-Current year OA Pubs

We compared rectal swab nucleic acid amplification testing (NAAT) with stool culture to detect

Performance Of Multiple Multi-Cancer Detection Tests Using A Large Independent Reference Set (Alliance A212102), Marie E Wood, Mark Watson, Et Al.

2020-Current year OA Pubs

BACKGROUND: Reference sets are needed to evaluate performance of multi-cancer detection (MCD) assays. The National Cancer Institute funded the Alliance reference set study to assess MCDs for use in future trials.

METHODS: Individuals with cancer and controls were recruited; blood specimens were collected prior to cancer treatment. A performance evaluation study was designed utilizing reference set samples. Companies (n = 6) were selected to participate based on review of performance data and ability to utilize the blood collection tube. Companies received samples from cancer types their assay was designed to detect ("targeted"), plus additional "non-targeted" and control samples. Companies reported …

Hepatitis C Virus Testing In Perinatally Exposed Children, Rachel L Epstein, Sarah Munroe, Elizabeth A Erdman, Amy Bettano, Megan R Curtis, Laura White, Elisha M Wachman, Anthony Osinski, Alexander Y Walley, Benjamin P Linas

2020-Current year OA Pubs

IMPORTANCE: Despite rising hepatitis C virus (HCV) incidence in pregnant people, studies demonstrate that fewer than 50% of perinatally exposed infants receive HCV testing. Few studies report treatment of infected infants or factors affecting testing.

OBJECTIVE: To identify birthing parent and child factors associated with appropriate HCV testing for perinatally exposed infants and characterize HCV care for children with HCV.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included records on testing, care, and treatment for Massachusetts children perinatally exposed to HCV between 2014 and 2021 from a statewide health database linking statewide vital statistics, infectious disease surveillance data, substance use …

Mda5-Mavs And Interferon-Lambda Signaling In The Intestinal Epithelium Limit Murine Astrovirus Infection, Heyde Makimaa, Harshad Ingle, Leran Wang, Somya Aggarwal, Hongju Deng, Elizabeth A Kennedy, Lynne Foster, Yuhao Li, Megan T Baldridge

2020-Current year OA Pubs

Human astroviruses (HAstVs) are a global cause of pediatric gastroenteritis and can cause disseminated infection in immunocompromised hosts. Murine astrovirus (muAstV) causes acute asymptomatic infections in immunocompetent mice and chronic infection in immunodeficient models and has provided important insights into AstV pathogenesis in vivo. MuAstV can protect immunodeficient mice from other enteric viruses via robust induction of antiviral cytokine interferon-lambda (IFN-λ), with recent findings implicating goblet cells and enterocytes as both cell types infected by muAstV as well as potential sources of IFN-λ in vivo. However, the viral sensing pathways that regulate induction of IFN-λ, as well as the specific …

Multicenter Evaluation Of Ceftazidime/Avibactam In Pediatric Patients Across The United States: Real-World Insights Into The Management Of Drug-Resistant Gram-Negative Infections, Taylor Morrisette, Christine R Lockowitz, Valerie Yuenger, Evan E Facer, Et Al.

2020-Current year OA Pubs

BACKGROUND: Antimicrobial resistance among gram-negative pathogens is a global threat, with children particularly vulnerable due to limited treatment options and age-specific clinical outcomes data. Ceftazidime/avibactam (CZA) is effective against resistant gram-negative bacteria and demonstrates high success rates in adults; however, pediatric data remain limited. This study examined CZA use in children across United States medical centers.

METHODS: This multicenter, retrospective, observational cohort study included pediatric patients (< 18 years) who received ≥48 hours of CZA for suspected or confirmed gram-negative infections between February 2015 and October 2023. The primary outcome was clinical success, defined as occurrence of all 3 components: (1) absence of all-cause mortality within 30 days of CZA initiation, (2) absence of microbiologic and clinical recurrence within 30 days of CZA discontinuation, and (3) resolution or improvement of infection-related signs and symptoms during CZA therapy without modification of therapy due to clinical failure. Secondary outcomes included adverse events attributable to CZA and resistance development to CZA.

RESULTS: One-hundred patients were included, with most receiving CZA for targeted therapy (67%). The median (IQR) age and weight were 9.8 (1.9-15.9) years and 24.2 (12.2-49.9) kg, respectively. Nearly all patients (88%) had …

Neurofibromatosis Type 1-Plexiform Neurofibromas: Integrating Treatment Across Pediatric And Adult Populations, Amy E Armstrong, Andrea M Gross, Laura J Klesse, Steven D Rhodes, Shivani Ahlawat, Verena Staedtke, Camilo A Molina, Angela C Hirbe

2020-Current year OA Pubs

Plexiform neurofibromas (PNs) are a hallmark of neurofibromatosis type 1 (NF1), affecting ∼50% of individuals with the condition. Originating from Schwann cells and other peripheral nerve sheath components, these tumors can cause significant morbidity, including functional impairment, diminished health-related quality of life, chronic pain, and malignant transformation. Managing NF1-PNs is challenging because of disease variability, differing growth rates, and age-related differences in clinical presentation and treatment tolerability. This review examines current therapeutic strategies, including surgery, medical therapies, and emerging treatments, emphasizing individualized care. Highlighted here is the need for age-specific treatment planning, particularly as disease progression, comorbidities, and side-effect profiles …

Und Leads Outreach Event Posters, University Of North Dakota

LEADS Implementation Documents

Poster materials prepared for the March 2026 UND LEADS outreach event. The presentation supports LEADS storytelling and campus engagement by presenting visual materials connected to UND LEADS implementation and the plan’s core values.

Apoe-Stratified Proteomic And Metabolomic Analysis Reveals Mitochondrial Dysfunction Inflammation And Lipid Dysregulation In Alzheimer's Disease, Fuhai Li, Yike Chen, Daniel Western, Muhammad Ali, Menghan Liu, Katherine Gong, Ying Xu, Joseph Lowery, David M Holtzman, Carlos Cruchaga, Et Al.

2020-Current year OA Pubs

Apolipoprotein E (APOE) ε4 is the strongest genetic risk factor for Alzheimer's disease (AD). However, it is known that other pathways independent of APOE also play a role in AD. Disentangling APOE-dependent and independent effects is instrumental for understanding the biology of AD. We conducted an APOE-stratified multi-omic analysis in multiple large datasets to identify AD-associated plasma proteins and metabolites. More than 64% of the identified proteins were not found in non-APOE stratified studies, and 17% of the proteins showed APOE-specific trends. Mitochondrial dysfunction was associated in AD independently of APOE and was accompanied by disruptions in glucose and lipid …

Plant-Mediated Green Synthesis Of Zinc Ferrite Nanoparticles: Mechanisms, Properties, And Advanced Applications In Environmental And Biomedical Fields, Rihab Jabbar

Al-Bahir

Recently, plant-mediated green synthesis has emerged as a sustainable, eco-friendly, and cost-effective strategy for synthesizing zinc ferrite (ZnFe₂O₄) nanoparticles (NPs). This review critically examines the advancements in biosynthesizing ZnFe₂O₄ NPs using various plant extracts, including Aloe vera, Hibiscus rosa-sinensis, Aegle marmelos, Eucalyptus leaves, Tragacanth gum, Piper nigrum, and Moringa oleifera, among others. It emphasizes their dual role as reducing, capping, chelating, and stabilizing agents. The article extensively compares physicochemical properties of the green-synthesized NPs in terms of crystallite size, morphology, magnetic behavior, and band gap energy. Achieved through different synthesis routes such as sol-gel, hydrothermal, co-precipitation, and microwave-assisted methods. …

Stock Assessment Of The Dusky Spine Foot Siganus Luridus From The Gulf Of Aqaba, Egypt, Using A Length-Based Bayesian Biomass (Lbb) Method, Azza A. El-Ganainy, Abdel-Kader M. Hassan, Hussein A. El-Naggar, Hassan M. M. Khalaf-Allah, Ahmed M. El-Sadek

Blue Economy

The dusky spinefoot, Siganus luridus (Rüppel, 1829), stands as one of the most economically significant herbivorous species inhabiting the coral reefs of the Gulf of Aqaba, Egypt. Despite its prominence, our understanding of its biology and population structure remains limited. Thus, this study marks the first attempt to shed light on the demographic structure and stock assessment of S. luridus in the Aqaba Gulf. Over the span of January to December 2018, a total of 649 specimens were meticulously collected on a monthly basis from three landing sites (Nuwebaa, Dahab, and Abu Galum) within the Gulf of Aqaba, primarily utilizing …

Recombinant Gelonin: Purification And Functional Validation For Electroporation-Assisted Delivery, Eleni Zivla, Giedrė Šilkūnienė, Andrei G. Pakhomov, Mantas Šilkūnas, Olga N. Pakhomova

Knowledge and Creativity Expo

Type I ribosome-inactivating proteins, such as gelonin, are enzymatically potent toxins but are effectively non-toxic under physiological conditions because they are unable to cross the plasma membrane[1]. Pulsed electric fields (PEF) overcome this delivery barrier by transiently permeabilizing the plasma membrane, allowing direct cytosolic entry. This enhances gelonin cytotoxicity by several thousand-fold, highlighting gelonin’s potential as an electrochemotherapy candidate[2]. Here, we present a recombinant gelonin (rGel) expression platform in E. coli with HPLC-based purification that enables reproducible protein production and structure-guided engineering.

The mature gelonin sequence (residues 47–297) was cloned into pET-32a(+) with an N-terminally fused Trx-6×His tag and TEV …

A Renewed American Conservativism Or The End Of The American Republic?, Virgile Samba Moussinga

Helms School of Government Spring Public Policy Conference

No abstract provided.

The Tribal Energy Act: A Necessary Step Toward The Electrification Of The Navajo Nation, Carington Lowe, Michael Hamersky

Pepperdine Law Review

The Navajo Nation stands as a sovereign nation, yet many families still lack access to electricity because of enduring historical, structural, and regulatory barriers. This Article identifies the legal and technical barriers that have hindered meaningful progress and argues that supplementing the utility grid with distributed energy resources, such as biodigesters, offers a viable path toward electrification, particularly for remote and rural communities within the Navajo Nation. Biodigesters convert organic waste generated through community practices, such as sheep raising, into biogas through an anaerobic process. This form of energy reflects circular economy principles while also aligning with Diné cultural practices …

Telemedicine Kiosks: Can Technology Solve Rural Mississippi's Healthcare Crisis?, Babu George, Martha Ravola

Journal of Public Health in the Deep South

Background: Mississippi’s rural counties face hospital gaps, clinician shortages, and limited broadband/device access that collectively delay care and constrain telehealth uptake.

Purpose: This paper assesses whether telemedicine kiosks can improve rural healthcare access in Mississippi while also supporting viable local entrepreneurship and community development.

Methods: A conceptual, policy-and-market analysis integrated narrative literature synthesis, secondary data and policy review, and 5-year financial modeling under two cost-allocation scenarios: an Operator Model (subscription fees covered by partners/grants) and a Network Model (subscription fees borne by the kiosk operator).

Results: Kiosks with embedded connectivity and diagnostic peripherals can deliver device-independent virtual care and directly …