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Outtakes, Anwar Shaikh Phd

Archives of Anwar Shaikh

This collection includes:

• Handwritten notes discussing methodology and the capitalist system

• Handwritten notes titled Introduction

• Handwritten notes outlining Parts II and III of a book, covering topics such as circulation, accumulation, competition, wages, crises, state intervention, and the relation between Marxian and empirical categories

Treatment-Induced Neuropathy Of Diabetes Complicated By Orthostatic Hypotension: A Case Report, Nathan Schueller, Christina Ward, Alyson Burchell, Saifuddin Nasir, Ashish Sharma

Research Day

INTRODUCTION/BACKGROUND:

Treatment-induced neuropathy of diabetes (TIND) is a rare, iatrogenic small-fiber neuropathy caused by the rapid lowering of glucose levels in patients with previously poorly controlled diabetes. The prevalence of this condition remains undetermined as TIND remains an unrecognized complication of diabetes. In contrast to the classical sensory-motor polyneuropathy of diabetes, TIND is characterized by a more acute onset neuropathic pain. An important positive correlation exists between the magnitude and rate of change in HbA1c levels and the severity of symptoms. The more significant and rapid the decrease in HbA1c levels, the greater the intensity and distribution of neuropathic pain. …

Applying The Updated Renfrew Error Classification And Osteopathic Principles To Radiology Interpretation: A Case-Based Approach, Michaelyn Cornish, Joel Koshy, Ryan Arias

Research Day

Background: Diagnostic errors in radiology can lead to delayed or incorrect diagnoses. The updated Renfrew error classification system (updated by Kim and Mansfield in 2014) is a commonly cited framework for classifying diagnostic errors in radiology. Osteopathic medicine principles, on the other hand, provide a more general framework that focuses on a whole-person, patient-centered approach to diagnosis and interpretation in medicine. This study examines three documented cases of diagnostic errors in radiology through the lens of both frameworks to propose strategies for error reduction.

Methods: Three radiology cases with documented errors were analyzed and classified according to the …

Caught In Transit: Thrombus Trapped In A Patent Foramen Ovale, Pallavi Kawatra, Ji Mei May Wong, Mihai Romanovschi, David Cohen, Roberto Rodriguez

Research Day

Background: Clot-in-transit is a rare medical emergency presenting imminent risk of infarction to distal tissue. In patients with a patent foramen ovale—prevalent in about 25% of the population,1 paradoxical embolism is a possibility. Managing these patients is challenging, given the disconnect between apparent clinical stability and true severity of disease, as demonstrated in our case.

Case Presentation: A 46-year-old male presented to the emergency department with a 6-week history of exertional dyspnea and pleuritic chest pain. Transthoracic echocardiography revealed a clot-intransit trapped across an atrial septal defect with mobile left- (1.3 x 1.2 cm) and right-sided (3.9 x 0.7 cm) …

Utilization Of Genomic Prostate Score With Prostate Specific Antigen Density In Patients On Active Surveillance For Low-Risk Prostate Cancer, William Nguyen, Young Son, Benjamin Fink, Shawon Akanda, Vaishnavi Patel, Virgil Demario, Mark Quiring, Ronald Clearie, Donna Mehdiyar, Thao-Mi Ha, Kimberly Toumazos, Gordon Brown

Research Day

Introduction and objectives: Prostate cancer is prevalent in men and the second leading cause of cancer related death. However, not all prostate cancer is lethal. and active surveillance is an accepted treatment approach in appropriately risk stratified patients. Nonetheless, there is a subset of patients on active surveillance (AS) that escalates to treatment and a paucity of data to identify patients requiring treatment intensification Biomarkers such as Oncotype DX have been utilized in multiple malignancies including prostate cancer and aid in shared decision-making regarding treatment. In this study, we present real world data on the use of Oncotype DX Genomic …

Transient Neutrophilic Leukocytosis Following Clozapine Initiation: A Case Study, Riley Alvaro, Jonas Hyacinthe, Tope Oloniyo

Research Day

INTRODUCTION: Clozapine is widely known for its life-threatening, albeit rare, adverse effect, agranulocytosis. However, a paradoxical and underreported finding, neutrophilic leukocytosis, defined as an increase in ANC above 7700 neutrophils/µL and white blood cell (WBC) count above 11,000 cells/µL may occur. We report the case of one individual with asymptomatic transient neutrophilic leukocytosis following Clozapine initiation.

OBJECTIVE: The objective of this case study is to provide supporting literature about the benign nature of clozapine-induced neutrophilic leukocytosis. This information may assist physicians’ decision-making, as this finding does not necessarily warrant cessation of the medication.

METHODS: This case report was compiled using …

Antioxidant Effects Of Dimethyl Fumarate In Siv-Infected Rhesus Macaques May Indicate Its Use As A Neuroprotective Adjunct In Hiv Treatment, Adam K. Adelsberg, Yoelvis Garcia-Mesa, Halvor Juul, Dennis L. Kolson

Research Day

INTRODUCTION: Dimethyl fumarate (DMF) is an oral prodrug that is FDA approved for the treatment of multiple sclerosis. DMF is metabolized to monomethyl fumarate and able to cross the blood-brain barrier to illicit its central nervous system (CNS) affects. DMF is an antioxidant/anti-inflammatory that acts at the level of gene transcription through the Nuclear factor erythroid 2-related factor 2 (Nrf2) pathway. We assessed the potential neuroprotective effects of DMF in HIV infection by using the rhesus macaque simian immunodeficiency virus (SIV) infection model. We hypothesized that DMF would increase the expression of antioxidant enzymes and subsequently reduce central nervous system …

Superoxide Release In Polymorphonuclear Leukocytes Are Attenuated By Naltrindole By A Novel Mechanism Devoid Of Opioid Receptors, Alexandra Barrera, Mai An Le, Jennifer Dang, Cameron Stinson, Devani Johnson, Logan Clair, James Ramsarran, Desmond Boakye Tanoh, Annam Humayun, Juliet Melnik, Tameka Dean, Qian Chen, Robert J. Barsotti, Lindon H. Young

Research Day

Introduction:

Previously, naltrindole (NTI), known as a delta opioid receptor antagonist, produced robust cardioprotective effects (e.g ~ 80% reduction of infarct size) in both ex-vivo (2.5-5 µM) and in-vivo (3.75-7.5 mg/kg; ~ 100-200 µM serum concentration) rat myocardial ischemia-reperfusion (MIR) models compared to control hearts that received H2O-vehicle or naloxone (NX), a broad-spectrum opioid receptor antagonist. Therefore, we planned to test if NTI elicits cardioprotective effects via a novel mechanism of action (MOA) devoid of opioid receptors. To investigate this hypothesis, we conducted experiments using KB-R7943 (KB) as a positive control, known to minimize intracellular calcium (Ca2+) via inhibition of …

Morphological Variation And Change In The Lateral Ventricles And Caudate Nucleus Across Schizophrenia Types: A Metric Analysis, Devin J. Venezia, Richard Gonzalez

Research Day

Schizophrenia is a complex neurodevelopmental disorder that affects cognitive function, perception, and behavior. The disease affects one percent of the global population and is characterized by symptoms such as hallucinations, delusions, and disorganized speech. Other symptoms include a reduction in cognitive function and emotional expression (Hany et al., 2024). Although previous studies focus on three-dimensional (3D) rendering that demonstrate schizophrenic-specific morphology, the variation expressed by different schizophrenia types requires greater focus. This study explores the structural variations in the lateral ventricles and the caudate nucleus across different schizophrenia subtypes, with a focus on potential sex/gender-based differences. We hypothesize that a …

The Role Of Skq1 In Mitigating Myocardial Ischemia-Reperfusion Injury In Rats Ex Vivo, Christopher J. Antoniello, Dmitri J. Zalnasky, Andrew E. Young, Qian Chen

Research Day

INTRODUCTION: Myocardial infarction, or death of heart tissue due to ischemia following obstruction of blood flow through one or more of the vessels supplying the myocardium, is a major cause of mortality in the United States and worldwide. Currently, treatment of ischemia centers around relieving the obstruction to blood flow, allowing for reperfusion of ischemic tissue. However, this inevitably causes ischemia-reperfusion injury (IRI), additional tissue damage following restoration of blood flow to an area previously deprived of blood and oxygen. Research on how to mitigate the effects of IRI is ongoing, and several different compounds have been shown to be …

Understanding The Association Between Mental Health And Medication Adherence In Adolescents With Chronic Kidney Disease, Christabelle Ayensu-Asiedu, Cozumel Pruette, Tammy Brady, Michelle Eakin, Kristin Riekert, Cyd Eaton

Research Day

Background

Adolescents with CKD often face significant mental health challenges that may affect their medication adherence. Despite the high prevalence of mental health concerns (specifically internalizing symptoms) in this population, the association between the severity of these symptoms and medication adherence remains underexplored.

Methods

The current cross-sectional study included adolescents with CKD who were prescribed an antihypertensive medication and completed the Behavior Assessment System for Children, 2nd edition Self-report (BASC-SRP-2). Antihypertensive medication adherence was objectively evaluated over 2 weeks using the MEMS cap. We used the BASC-SRP-2 depression, anxiety, somatization, and internalizing scales and classified participants into sub-clinical (T-score < 60) and at-risk (T-score ≥ 60) groups. We examined the associations between the selected BASC-SRP-2 domains and medication adherence using Wilcoxon rank-sum tests. Adjusted associations were evaluated with logistic regression models dichotomizing adherence as < 75% or ≥75% (covariates were age, race, sex, and income).

Results …

Outcomes Of Endoscopic Proximal Hamstring Repair: A Systematic Review, Eric Tadros, Marco Trevino, Alfonso Arevalo, Rachel Keller

Research Day

Background: As endoscopic techniques for proximal hamstring repair become increasingly popular, it is essential to evaluate the efficacy and safety of this method compared to traditional open repairs. This systematic review aims to evaluate the current literature on outcomes of endoscopic proximal hamstring repair (ePHR), focusing on functional outcomes, patient-reported outcomes, and complication rates.

Methods: A systematic search was conducted identifying six studies reporting on a total of 115 patients undergoing ePHR with a minimum follow up of 12 months. Data extracted included patient demographics, injury characteristics, surgical techniques, rehabilitation protocols, patient-reported outcomes (PROs), and complication rates. Patient-reported outcomes included …

A Scoping Review Of Trauma-Informed Care In Reproductive Healthcare Settings: Implications For Healthcare Education, Training, And Practice, Samantha Stolker, Alexa Neiderer, Vittoria Tarquini, Alex Finkel, Alexa Bonacquisti

Research Day

The experience of trauma is highly prevalent and results in physiological and psychological consequences. Trauma-informed care (TIC) has emerged in recent years as a patient-centered culture of care delivery that emphasizes physical and psychological safety for all in the healthcare setting. Even though the research on TIC shows positive outcomes for patients, and healthcare professionals desire more education on TIC, there are few standard curriculums at the undergraduate, postgraduate, and residency levels of healthcare education. Utilizing a TIC framework could be especially impactful in reproductive healthcare settings due to the invasiveness of certain examinations and the way trauma presents itself …

Risk Factors For Myocardial Infarction In Patients With Hyperlipidemia: A Logistic Regression Analysis, Alexandra Loverdi, Carolyn Loverdi, Robert J. Barsotti

Research Day

The objective of this study is to examine factors that predict myocardial infarction or hinder myocardial infarction among patients with a known risk factor of hyperlipidemia. Multiple factors will be examined alone and the interactions of such factors using a regression model. Despite major advancements in pharmaceuticals and medical interventions, heart disease remains the world's leading cause of death. While extensive research has been conducted on its risk factors, critical gaps persist—particularly among understudied populations. Addressing these gaps is essential to developing more effective prevention and treatment strategies. For instance, cardiovascular disease often presents differently in women, yet much of …

Topical Antibiotics, Over-The-Counter Products, And Standard Gauze Dressings: A Review Of Postoperative Surgical Site Infection And Wound Healing Management, Emily M. Garelick, Jacob E. King, David Kasper

Research Day

Proper wound healing and prevention of surgical site infections (SSI) are critical in postoperative patient care. According to the CDC, SSIs account for almost twenty percent of all healthcare-associated infections and cause an annual cost of an estimated $3.3 billion annually. Wound healing time, as well as cosmetic results, also play an important role in postoperative wound care. Currently there is not a consensus standard of care for topical treatments to address these issues. This study aims to explore various topical treatments that prevent SSI and encourage effective healing.

A search was conducted on PubMed using the algorithm: ([Vaseline] OR …

The Effectiveness Of Early Vs Delayed Medial Malleolar Fixation In The Treatment Of Open Ankle Fractures, Daniel Baka, Isaiah Hughes, Branden Wright, Pietro Gentile, Austin Whiting, John Dibato, Henry Dolch

Research Day

Introduction

Open ankle fractures are high-risk injuries with significant complications, including infection, wound dehiscence, and necrosis, often requiring multiple surgeries. This study evaluates early versus delayed fixation of clean, open medial malleolus fractures, hypothesizing no difference in infection rates between the two cohorts.

Methods

A retrospective chart review of 99 open ankle fractures involving the medial malleolus was conducted at a level 1 trauma center between November 2016 and July 2024. Fractures were divided into “Early” (immediate ORIF) and “Delayed” (ex-fix followed by ORIF) groups. Ankles were excluded if the fractures were closed, severely contaminated, polytrauma, and insufficient follow-up. Primary …

Crystals And Biomarker Analysis Via Synovial Fluid Sampling In Patients With Knee Effusion With Radiographic Correlation, Benjamin H. Rogers, William R. Studt, Grant Thomas, Stephen A. Stache, Adam T. Chrusch, Philip R. Motley, Stephanie M. Gwin, Bradley J. Smith, Christopher J. Mehallo

Research Day

Purpose: Synovial fluid biomarker analysis is a developing modality for subcategorizing arthritis type. We examined radiographic evidence of chondrocalcinosis and osteoarthritis severity in relation to their respective biomarker levels or detection on the Synovasure® RISC panel.

Methods and Study Design: This is a monocentric, cross-sectional, non-controlled, and non-randomized, case series study. Patients with a knee effusion and planned arthrocentesis were included. 800 synovial fluid samples were obtained from consenting eligible patients as part of standard of care and sent via Synovasure specimen kits for analysis. Samples were further categorized based on biomarker results.

Results: A total of 800 synovial …

Sacroiliac Joint Septic Arthritis: A Case Report, Emily G. Andrews, Andrew Levin

Research Day

Background: Septic arthritis is an infection of a joint typically by bacteria. It classically presents as a warm, erythematous, tender and edematous joint with limited active and passive range of motion. Non-gonococcal septic arthritis most commonly occurs in knee and hip joints, followed by shoulders, wrists, and ankles. Atypical joint infections, such as the sacroiliac joint are extremely uncommon. In this report, we demonstrate a case of a young patient, with no predisposing factors with a unique presentation of sacroiliac septic arthritis.

Case description: 29-year-old female with no pertinent past medical history presented to Roxborough Memorial Hospital with severe 10/10 …

Injury Characteristics Associated With Vascular Injuries In Trauma Patients With Open Lower Extremity Fractures: Are We Overutilizing Ct Angiography?, Megan K. Czachor, Nikki A. Doerr, Pietro M. Gentile, Krystal Hunter, Rakesh P. Mashru, Kenneth W. Graf

Research Day

Introduction:

Early detection and intervention can reduce the complications associated with vascular injuries in lower extremity (LE) fractures. Computed tomography angiography (CTA) is commonly performed in trauma patients with open LE fractures. However, there is no evidence supporting routine CTAs or consensus on CTA utilization in the absence of clinical signs of vascular injury. This study aimed to identify injury characteristics associated with vascular injury and the need for vascular surgical intervention in trauma patients with open LE fractures, while also investigating CTA utilization.

Methods:

A retrospective review was conducted on patients with open fractures of the tibia, fibula, and …

Combined Crvo + Clrao – A Case Report, Rochile Khan, Peter Maduka, Florence Tsipenyuk

Research Day

Introduction

This case report presents a patient diagnosed with central retinal vein occlusion (CRVO) concomitant with cilioretinal artery occlusion (CLRAO) in their right eye. The diagnosis was established through a dilated fundus examination, fluorescein angiography, optical coherence tomography (OCT), and fundus photography. The occurrence of CRVO in conjunction with CLRAO is rare, representing a unique and noteworthy clinical presentation.

The clinical manifestation of CRVO typically includes optic disc hyperemia, dilation and tortuosity of veins, and extensive retinal edema and hemorrhage. Disruption of the blood-retinal barrier consequently leads to edema and disruption of the vascular endothelium leads to hemorrhages, which can …

Utilization Of Dexmedetomidine And Ketamine In Neonatal Intensive Care Units Across The Us From 2009 To 2023, Wesam A. Albayati, Alvaro Zevallos Barboza, Kelly Wade, Dustin D. Flannery

Research Day

Introduction

Newborns admitted to neonatal intensive care units (NICUs) often require sedation and analgesia due to critical illness and invasive procedures. Alternatives to narcotics are being used in clinical practice due to improved side effect profiles and decreased risk of dependence. Dexmedetomidine (Precedex), an α₂-adrenergic agonist, and ketamine, an NMDA antagonist, have emerged as attractive alternatives, yet there are limited data on their use in NICUs.

Objective

To assess utilization of dexmedetomidine and ketamine in a large cohort of newborns admitted to US NICUs over time.

Methods

Retrospective cohort study including newborns admitted to a US NICU from 2009-2023 included …

Utilizing Maxillofacial Injury Severity Score (Mfiss) In Postmortem Head Gunshot Imaging For Surgical Planning And Preventative Treatment Assessment, Kamryn B. Johnston, Richard A. Gonzalez

Research Day

Gunshot injuries to the head represent a major clinical and forensic challenge due to their complexity and multifaceted nature of the trauma. Various pre-operative methods exist to assess extent of craniofacial damage and patient outcomes. One such method is the Maxillofacial Injury Severity Score (MFISS). The MFISS is a trauma scoring system used by craniofacial reconstructive surgeons to categorize the degree of facial trauma based on hard and soft tissue damage. The system is broken down into three hard tissue and one soft tissue classification. All classifications are scored on a 0 to 3 scale ranging from no damage to …

Phase Transfer Of Plasmonic Nanoparticles: A Gateway To Biomedical Innovations, Siddharth A. Patel, Vrunda A. Patel, Riddhiman Medhi

Research Day

The use of nanoparticles has emerged as a promising approach to overcoming clinical challenges faced by physicians and scientists striving to enhance drug bioavailability, improve diagnostics, and promote tissue regeneration. Among these, phase-transferred plasmonic nanoparticles—known for their highly tunable optical properties—have shown significant potential in various biomedical applications. These include surface functionalization for enhanced biocompatibility, antimicrobial treatments, advanced sensing and diagnostic tools, drug delivery systems, photothermal therapy, and imaging technologies.

This systematic review explores recent applications of phase-transferred plasmonic nanoparticles in improving therapeutic outcomes in human subjects. A comprehensive analysis of peer-reviewed studies from major literature databases was conducted, focusing …

Enhancing Curcumin Bioavailability: A Systematic Review Of Nanoparticle-Based Approaches, Patel Siddharth, Chekuri Sanjana, Medhi Riddhiman

Research Day

Curcumin, a bioactive compound derived from turmeric (Curcuma longa), is widely recognized for its potential therapeutic properties, including anti-inflammatory, antioxidant, and anticancer effects. However, its clinical application is hindered by poor bioavailability, primarily due to low solubility, rapid metabolism, and poor systemic distribution. Nanoparticle-based delivery systems have emerged as a promising approach to overcome these challenges, offering enhanced stability, targeted delivery, and controlled release of curcumin.

This review evaluates the efficacy of nanoparticle-based curcumin delivery systems in improving bioavailability and therapeutic outcomes in human subjects. A systematic review of peer-reviewed studies from major literature databases was conducted. Inclusion criteria included …

Clinical Trials In Neurology Registered 2007-2018 Demonstrate Room For Improvement In Reporting And Representation Of Race And Ethnicity., Maya Rakoczy, Christopher J. Magnani, Jecca R. Steinberg, Alexander Frolov, Brannon T. Weeks, Arnaud Harmange, Naureen Huda, Lochan M. Shah, Leah Zuroff, Ben J. Gu, Hannah Rasmussen, Jeffrey G. Edwards, Max Shen, Mark Ren, Barry R. Bryant, Qian Ma, Austin Y. Feng, Amy C. Liang, Veronica E. Santini, Brandon E. Turner

Research Day

Introduction: Clinical trials form the basis for advancing medical best practices, yet lack of diverse representation perpetuates healthcare disparities. We aimed to characterize trends in reporting and representation of race and ethnicity in neurology clinical trials.

Methods: In a cross-sectional study of United States (US) based trials (2007-2018) with results reported to the ClinicalTrials.gov registry, we assessed whether race/ethnicity data were reported and evaluated trial diversity by comparing race and ethnicity representation (proportion of enrolled participants reported as White, Black, Hispanic, Asian, or Native American) to 2010 US Census data. We studied the role of trial funding sponsor (Industry, US …

Retear, Repair, Repeat: A Rotator Cuff Case Report, Joshua W. Salazar, Christina M. Ward, Kimberly Gardner

Research Day

The following case report demonstrates a common yet educational case of a rotator cuff retear. The patient was a 64-year-old R-hand dominant female with a PMH significant for T2DM, a prior R RCR with subacromial decompression, and distal clavicle excision. She presented for evaluation of R shoulder pain s/p ground-level fall on an outstretched hand. XR was negative for any acute fractures but did reveal a small subacromial osteophyte. MRI findings demonstrate a full-thickness tear of the supraspinatus tendon with evidence of underlying tendinosis. Given the patient’s active lifestyle and pain impacting her functional mobility, subacromial decompression and arthroscopic repeat …

Bilateral Carotid Artery Dissection After A Fall: A Case Of Horner's Syndrome Revealed On Examination, Eli Spevack, Zachary M. Weisner, Lauren Exley

Research Day

Traumatic carotid artery dissections (TCAD) are rare and occasionally present with third-order Horner's syndrome, defined as ipsilateral ptosis, miosis, and anhidrosis. We present a case involving a 53-year-old female with no significant past medical history who presented to the emergency department after tripping and falling down a flight of stairs. Over three weeks, the patient had persistent tinnitus, right neck pain and, on the exam, was noted to have right-sided miosis and ptosis. These exam findings led us to obtain a CT angiogram of the head and neck, which revealed a bilateral internal carotid dissection. The patient was taken for …

A Chronic Case Of Staphylococcus Epidermidis Osteomyelitis And Abscess In The Absence Of Foot Hardware Or Prosthesis, Joshua Salazar, Lidia Dankiv, Lauren Griffith, Gianna Grogan

Research Day

The project has showcased a unique case of chronic osteomyelitis, abscess, and cellulitis formation by S.epidermidis in the absence of foot hardware or prosthesis. The patient is a 62 yo M who presented with a chronic right foot ulcer with ongoing pain on ambulation, discharge of the RLE. PMHx includes: HTN, HLD, HIV+ (undetectable viral load; CD4: 988 cells/ml), pancreatitis, peripheral arterial disease, obesity, neuropathy, chronic EtOH and marijuana use, anxiety, a family history of DVTs and CVAs. He states that the ulcer initially opened in March 2023 due to wearing shoes without socks. Since then, it has failed to …

Statin-Associated Immune Mediated Necrotizing Myopathy: A Case Report, Emily Andrews, Graham Mcdaniel, Haiping Mei

Research Day

Background: Statins are a widely used class of drugs that have been found to be safe and effective in treating hypercholesterolemia. Used for both primary and secondary prevention, statins inhibit HMG-CoA reductase, inhibiting a vital step in cholesterol production. Statin-associated muscle symptoms (SAMS) are a clinical spectrum defined as muscle pain, discomfort, and/or weakness with or without elevated CK levels. This spectrum ranges from minimal myalgias to severe statin-associated immune-mediated necrotizing myopathy (IMNM). It is known that myocytes have upregulated levels of HMG-CoA reductase in the presence of statin use. While the exact pathophysiology of statin associated IMNM has yet …

Plaque-Like Cd34+ Dermal Fibroma On The Toe: A Case Report And Literature Review, Shaina S. Gagadam, Michael Shragher, Carmen Campanelli

Research Day

Plaque-like CD34+ dermal fibroma (PDF), also referred to as medallion-like dermal dendrocyte hamartoma (MLDDH), is a rare, benign dermal neoplasm that typically presents as a slow-growing, asymptomatic plaque. PDF is most commonly seen on the neck or trunk of young women. The pathogenesis of PDF remains poorly understood. Histologically, these lesions are characterized by the proliferation of spindle-shaped fibroblasts in the dermis, which are strongly positive for CD34 and negative for markers such as S100, Melan-A, and Factor XIIIa.

We present a case of a 57-year-old female with a one-year history of a plaque-like CD34+ dermal fibroma on the dorsal …