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Full-Text Articles in Medicine and Health Sciences

Robotripping: The Dangers Of Abusing Dextromethorphan, Tiffany Sin, James Espinosa, Dana Fichter May 2021

Robotripping: The Dangers Of Abusing Dextromethorphan, Tiffany Sin, James Espinosa, Dana Fichter

Rowan-Virtua Research Day

Dextromethorphan (3-methoxy-N-methylmorphinan), also known as “DXM,” is a synthetically produced drug available in many over-the- counter (OTC) cough and cold medications as a centrally acting cough suppressant that binds to NMDA receptors. In a 2006 national survey of 50,000 students, 4, 5, and 7% of 8, 10, and 12th graders reported DXM abuse in the past year. In high doses, DXM can cause euphoria, hallucinations, dissociations, and distortion of cognition and perception. DXM abuse is also known as “Robotripping,” “Robodosing,” “Dexing,” “Tussin,” or “Triple Cs” because Robitussin® and Coricidin® Cough and Cold are most frequently abused. DXM has replaced codeine …


The Prevalence Of Postpartum Depression In Black And Hispanic Women In New Jersey, Courtney Chineme, Rachel Shmuts, Chris Canlas May 2021

The Prevalence Of Postpartum Depression In Black And Hispanic Women In New Jersey, Courtney Chineme, Rachel Shmuts, Chris Canlas

Rowan-Virtua Research Day

Postpartum depression (PPD) is defined as symptoms of major depressive disorder (MDD) within one month of giving birth with the prevalence in the United States being 10-15%. There are well documented instances of racial differences and their effects on maternal outcomes including infant, maternal mortality and postpartum mood disorders. In New Jersey, there are monitoring systems that explore the relationships between maternal characteristics such as race, age, education level, insurance status, and racial bias and how they may correlate with higher incidences of Postpartum Depression (PPD) in these communities of women. The purpose of this comparative study is to analyze …


Seeking Sustainable Solutions To Period Poverty Amongst Homeless Women In Camden County, Nj, Bilal Khan, Alana Smith, Melisa Ibarra-Zavala May 2021

Seeking Sustainable Solutions To Period Poverty Amongst Homeless Women In Camden County, Nj, Bilal Khan, Alana Smith, Melisa Ibarra-Zavala

Rowan-Virtua Research Day

Health Careers Opportunity Program (HCOP) – National Ambassadors is an effort for underserved high school, undergraduate, and medical students to collaborate on a research-based community service project to equip future health professionals with tools to heal their communities.

The average woman spends up to 3500 days of their life menstruating. Menstrual health is therefore not just a fundamental human right, but a robust indicator of community well-being. Despite the biological inevitably of menstruation, barriers to practicing adequate menstrual hygiene, or “Period Poverty,” are far common and often ignored in public forums. Period products face a luxury goods sales tax in …


The Role Of Primary Care Physicians In Post-Partum Depression (Ppd), Elizabeth Bowman May 2021

The Role Of Primary Care Physicians In Post-Partum Depression (Ppd), Elizabeth Bowman

Rowan-Virtua Research Day

Background

  • Symptoms of depression lasting longer than 2 weeks following birth
  • 10-15% of new mothers affected yet 50% of cases go undiagnosed
  • Long-lasting consequences for the mother, baby, and father
  • Multi-factorial condition

Conclusion

  • Primary care providers are the first-line defense against PPD
  • Many providers are resistant to PPD screenings
  • Interventions from primary care providers are effective


Neuroactivational And Behavioral Correlates Of Psychosocial Stress-Induced Cocaine Seeking In Rats, Nicole M. Hinds, Ireneusz D. Wojtas, Desta M. Pulley, Stephany J. Mcdonald, Samantha De Guzman, Nicole E. Hubbard, Colin M. Kulick-Soper, Jessica J. Debski, Bianca Patel, Daniel Manvich May 2021

Neuroactivational And Behavioral Correlates Of Psychosocial Stress-Induced Cocaine Seeking In Rats, Nicole M. Hinds, Ireneusz D. Wojtas, Desta M. Pulley, Stephany J. Mcdonald, Samantha De Guzman, Nicole E. Hubbard, Colin M. Kulick-Soper, Jessica J. Debski, Bianca Patel, Daniel Manvich

Rowan-Virtua Research Day

A prominent feature of cocaine abuse is a high risk of relapse even despite prolonged periods of abstinence. Psychosocial stress is thought to be a major contributor to the onset of cocaine craving and relapse in human substance abusers, yet most preclinical models of stress-induced relapse employ physical stressors (e.g., unpredictable footshock) or pharmacological stressors (e.g., yohimbine to elicit a drug seeking response) and do not rely upon psychosocial stress per se. Importantly, social stressors are well known to activate distinct neural circuits within the brain as compared to other stressors. It is therefore possible that currently available animal models …


A Terrible Prank Gone Horribly Wrong The Development Of Delusional Infestation As An Adjustment Reaction To A Traumatic Hoax, Timothy Wong, Nardin El-Shammaa, Munaza Khan, Stephen Scheinthal May 2021

A Terrible Prank Gone Horribly Wrong The Development Of Delusional Infestation As An Adjustment Reaction To A Traumatic Hoax, Timothy Wong, Nardin El-Shammaa, Munaza Khan, Stephen Scheinthal

Rowan-Virtua Research Day

Delusional infestation (DI) is a somatic type delusional disorder, characterized by a fixed belief that one is infested by living or nonliving pathogens (1,3) . DI is a relatively rare disorder (4,5), with an estimated 20-80 cases per million people annually (6). Effective management of patients suffering from DI is crucial, as patients may cause significant harm to themselves in their attempts to remove the pathogens (7,8). Regarding treatment options, antipsychotic medications such as pimozide and risperidone have been promising (8,10). However, there remain many barriers to care (11), and patients are hardly ever seen in psychiatry as they preferably …


Evaluating Standardized Assessments’ Ability To Capture Lived Experience Of Cancer Patients And Survivors In Art Therapy Groups, Lara Desanto, Sarah Han, Cecilia Sánchez May 2021

Evaluating Standardized Assessments’ Ability To Capture Lived Experience Of Cancer Patients And Survivors In Art Therapy Groups, Lara Desanto, Sarah Han, Cecilia Sánchez

LMU Theses and Dissertations

This paper explores the use of quantitative assessments typically used in research to evaluate experiences of cancer patients and survivors receiving group art therapy services. Literature exploring program evaluation as a methodology, how current research selects standardized measurement tools for the evaluation of art therapy interventions with adult cancer patients and survivors, and on the efficacy of art therapy with this population is reviewed.

Quantitative and qualitative data were collected from four participants, who were clients in two eight-week art therapy groups. Quantitative data were collected in the form of pre- and post-test measurements using six commonly used standardized quality …


An Analysis Of Phenibut (Ss -Phenyl-Y-Aminobutyric Acid) Withdrawal, Michael Morris, James Espinosa, Robin Lahr, Alan Lucerna May 2021

An Analysis Of Phenibut (Ss -Phenyl-Y-Aminobutyric Acid) Withdrawal, Michael Morris, James Espinosa, Robin Lahr, Alan Lucerna

Rowan-Virtua Research Day

Phenibut (ß -phenyl-y-aminobutyric acid) is a psychoactive GABA analogue marketed as a nutritional supplement and “nootropic” online. Phenibut consumption poses a high risk of potential abuse. Withdrawal from Phenibut mimics benzodiazepine and alcohol withdrawal. Without proper management, Phenibut withdrawal may be equally as dangerous as benzodiazepine and alcohol withdrawal. Baclofen can be prescribed for outpatient symptomatic relief of Phenibut withdrawal.


Mental Health Outcomes At A Student-Run Free Clinic, Jessica-Sophie Horoschak, Riya Tandra, Sahil Parikh, Shayna Peterzell, Roma Padalkar, Tara Pellegrino May 2021

Mental Health Outcomes At A Student-Run Free Clinic, Jessica-Sophie Horoschak, Riya Tandra, Sahil Parikh, Shayna Peterzell, Roma Padalkar, Tara Pellegrino

Rowan-Virtua Research Day

In this project we aim to:

1. Assess the outcomes of screening, management, and diagnosis for patients at the Rowan Community Health Center (RCHC).

2. Compare the outcomes of screening, management, and diagnosis between different groups (gender, race, income, insurance status) using validated surveys.

3. There is a need for accessible and affordable primary care in the South Jersey area, which the RCHC is hoping to meet.

Hypothesis:

The quality of mental health care available to patients at the RCHC is comparable to that at other insured practices.


Case Of New Onset Alice In Wonderland Syndrome In Adolescent After Prolonged Hospitalization, Michaela Margolis, Timothy Wong, Richard Hadi May 2021

Case Of New Onset Alice In Wonderland Syndrome In Adolescent After Prolonged Hospitalization, Michaela Margolis, Timothy Wong, Richard Hadi

Rowan-Virtua Research Day

Alice in wonderland syndrome (AIWS) has been described as body image illusions involving distortions of the size, mass, or shape of the patient’s own body or its position in space, often occurring with depersonalization and derealization. Most cases typically affect young children.

Common distortions are micropsia, macropsia, metamorphopsia, and pelopsia.

The term was adopted from the book by Lewis Carroll, wherein the main character perceived her size and shape to change in different scenarios.

These distortions are often expressed as sensory perceptions rather than illusions or hallucinations, and are often distressing to the patient.

AIWS onset has been found to …


The Relationship Of Divine Forgiveness, Victim Forgiveness, And Physical Health Mediated By Stress, Lemuel Josiah C. Ragasajo May 2021

The Relationship Of Divine Forgiveness, Victim Forgiveness, And Physical Health Mediated By Stress, Lemuel Josiah C. Ragasajo

Senior Honors Theses

Though there is increasing evidence to support a relationship between forgiveness and physical health, certain subcategories of forgiveness, namely victim and divine forgiveness, are relatively understudied. This study seeks to add to the body of forgiveness literature by examining how divine and victim forgiveness relate to one’s physical health, and whether that relationship is mediated by stress. Furthermore, a literature review is included to detail how stress, a potential mediating variable between forgiveness and physical health, affects physical health. The results of the study reveal that victim forgiveness positively predicts physical health, but is not mediated by stress. In contrast, …


A Case Of Cocaine Toxicity From Body Stuffing, Justin Smith, James Lee, Alan Lucerna, James Espinosa May 2021

A Case Of Cocaine Toxicity From Body Stuffing, Justin Smith, James Lee, Alan Lucerna, James Espinosa

Rowan-Virtua Research Day

Body stuffing refers to the ingestion of an illegal substance in an effort to conceal it and avoid prosecution. This is distinct from, and more common than, the practice of body packing in which large amounts of an illegal substance are carefully packaged and ingested to be transported discreetly by smugglers [1]. While body packers tend to ingest much larger quantities of a drug, they are less prone to developing symptoms of drug toxicity due to the meticulous packaging methods used when compared with those who ingest packets of drugs in haste to avoid prosecution [2]. Many substances have been …


Abstracts From The 2021 Health Care Systems Research Network Annual Conference May 2021

Abstracts From The 2021 Health Care Systems Research Network Annual Conference

Journal of Patient-Centered Research and Reviews

The Health Care Systems Research Network (HCSRN) is comprised of 19 not-for-profit health systems with embedded research departments. The network’s annual conference serves as a forum for member institutions to highlight research findings, explore new collaborations, and share insights and opportunities. Abstracts accepted for oral and poster presentation at the 2021 HCSRN Conference are published in this supplement of Journal of Patient-Centered Research and Reviews, the official scientific journal of the annual conference.


Development And Presentation Of A Lesson On Mental Health For High School Students During The 2021 Covid-19 Pandemic, Daniel Yang, Sana Farhat, Jhocelin Morquecho, Rutva Patel, Rui Shi, Md Fateha, Mary Duggan May 2021

Development And Presentation Of A Lesson On Mental Health For High School Students During The 2021 Covid-19 Pandemic, Daniel Yang, Sana Farhat, Jhocelin Morquecho, Rutva Patel, Rui Shi, Md Fateha, Mary Duggan

Rowan-Virtua Research Day

With the support of the HRSA, the Health Careers Opportunity Program (HCOP) was established to increase the number of students from underrepresented backgrounds to pursue careers in healthcare. HCOP combines the efforts of high school, undergraduate, and medical students in creating an original project to serve a need within the community. In this HCOP project, we aim to address the issue of mental health with high school students at two New Jersey high schools: Pennsauken and Williamtown.


The Dopamine D3 Receptor Antagonist Vk4-40 Attenuates Morphine-Induced Hyperactivity But Not Cocaine-Induced Hyperactivity In Mice, Desta M. Pulley, Jessica J. Debski, Daniel Manvich May 2021

The Dopamine D3 Receptor Antagonist Vk4-40 Attenuates Morphine-Induced Hyperactivity But Not Cocaine-Induced Hyperactivity In Mice, Desta M. Pulley, Jessica J. Debski, Daniel Manvich

Rowan-Virtua Research Day

In light of the increasing rates of opioid abuse in the US, the search for viable medications to treat opioid abuse disorder (OUD) has become ever more urgent. Opioids exert their abuse-related effects in part by indirectly increasing dopamine (DA) neurotransmission in the mesolimbic system, a dopaminergic projection arising in the ventral tegmental area and terminating in the nucleus accumbens. The DA D3 receptor (D3R), which belongs to the D2 family of dopamine receptors (D2, D3 , D4 receptor subtypes), is highly expressed in these brain regions and has shown strong potential as a pharmacotherapeutic target for the treatment of …


Acute Flecainide Toxicity Treated With Intravenous Lipid Emulsion, Joseph S. Schreiner May 2021

Acute Flecainide Toxicity Treated With Intravenous Lipid Emulsion, Joseph S. Schreiner

Rowan-Virtua Research Day

Flecainide is a Vaughn-Williams class IC antiarrhythmic used in the treatment of supraventricular tachycardias including atrial fibrillation. While overdose is rare, its negative effects on cardiac inotropy and conduction pathways can be readily fatal. This is further complicated by the redistribution of the drug out of the plasma and deposition in tissue, rendering reversal by sodium bicarbonate (the standard first line treatment agent) relatively ineffective. A case study of the successful treatment of hemodynamic collapse using sodium bicarbonate in conjunction with intravenous lipid emulsion (ILE) in a patient who ingested a large amount of flecainide in a suicide attempt will …


A Holistic Approach To Physical And Mental Health: Associations Between Chronic Disease And Psychiatric Conditions, Pooja Patel, Alison Mancuso May 2021

A Holistic Approach To Physical And Mental Health: Associations Between Chronic Disease And Psychiatric Conditions, Pooja Patel, Alison Mancuso

Rowan-Virtua Research Day

OBJECTIVE:

• To investigate the link between chronic medical conditions and psychiatric disorders

BACKGROUND

• Limited research has been done studying the relationship between chronic medical conditions and psychiatric disorders in patients comorbid with both types of conditions.

• Prior research studies have demonstrated that patients with chronic medical conditions are more likely to develop psychiatric disorders compared to healthy individuals without any medical conditions.

• As individuals develop chronic medical conditions, they may encounter additional obstacles in their lives,


Alzheimer's Patients’ Mental Health During The Covid 19 Pandemic, Maryanna Schweininger, Yvonne Maduka, Ajh'shana Collins May 2021

Alzheimer's Patients’ Mental Health During The Covid 19 Pandemic, Maryanna Schweininger, Yvonne Maduka, Ajh'shana Collins

Rowan-Virtua Research Day

Alzheimer’s disease (AD) is a degenerative brain disease caused by β Amyloid plaques and neurofibrillary tangles, which results in memory loss and cognitive decline. It is the sixth leading cause of death in the United States. Approximately 50% of those with AD experience some degree of depression during the course of the disease, which has been shown to accelerate functional decline, institutionalization, and even mortality.

Many who cannot care for themselves live in an assisted living facility or retirement home. Since the beginning of the COVID 19 pandemic, people have been urged to social distance in order to decrease the …


Barriers To Alternative Narcotic Education And Treatment In Young Adults In New Jersey, Shubh Bhambri May 2021

Barriers To Alternative Narcotic Education And Treatment In Young Adults In New Jersey, Shubh Bhambri

Rowan-Virtua Research Day

The purpose of this study is to determine alternative methods and programs that result in better outcomes for young adults dealing with opioid addiction in New Jersey while identifying potential barriers that prevent the implementation of these programs.


Establishing A Resident-Lead High School Outreach Program To Improve Physician Community Engagement, Dylan Mcdivitt May 2021

Establishing A Resident-Lead High School Outreach Program To Improve Physician Community Engagement, Dylan Mcdivitt

Rowan-Virtua Research Day

New Jersey’s Cumberland County is home to a vastly diverse population of people, comprised of numerous racial, ethnic, economic, health, and educational backgrounds among its nearly 150,000 residents. Per U.S. Census data, about 15% of the population is below the poverty line, including about 20% of those below the age of 18. With economic hardship often come health problems and disparities, and Cumberland County’s rates of obesity, tobacco use, lung cancer, and drug-induced deaths are all above the national averages.

Notable student survey findings:

• 67 students reported a friend had shared thoughts of depression with them in the last …


Opioid Lifeline Community Service Project, Ekrem Cetinkaya, Cam'ron Klotz, Harvy Patel May 2021

Opioid Lifeline Community Service Project, Ekrem Cetinkaya, Cam'ron Klotz, Harvy Patel

Rowan-Virtua Research Day

The opioid epidemic has claimed the lives of thousands of people over the last decade due to overprescribing, synthetic opioids, and lack of treatment options. Project Opioid Lifeline was created as a mission to combat this issue by equipping the Camden County, NJ population with the necessary information to advocate for themselves and others. This project aims to find and centralize available resources for residents of Camden County by including addiction treatment centers, Narcan training and distribution, and unused medication drop off locations. Over the last nine months, partnerships were formed with community leaders and organizations, such as the Neuromusculoskeletal …


Death Anxiety, Artmaking And The Facilitation Of Death Discourse, Heather Conley May 2021

Death Anxiety, Artmaking And The Facilitation Of Death Discourse, Heather Conley

Art Therapy Counseling Final Research Projects

Discussion about death, known as death discourse, has been historically limited to the confines of the palliative care, elderly and hospice arenas (Bradshaw, 1996; Granek, 2013; Safrai, 2013; Zimmerman, 2012). This study examined the impact of artmaking on facilitating death discourse in college-aged students from a midwestern United States campus. A mixed methods design was implemented in which participants completed the Communication Apprehension about Death Scale (CADS; Carmack & DeGroot, 2016), an artmaking directive addressing feelings about death, followed by a Post-Artmaking Reflection about their artwork. Following a 10-day time period after the artmaking session, participants were re-administered the CADS …


How College Men Describe Their Understanding Of Sexual Assault, Sarah Anolik May 2021

How College Men Describe Their Understanding Of Sexual Assault, Sarah Anolik

Dissertations, 2020-current

Despite the proliferation of many vital bystander intervention programs across the country, approximately one in four college women will experience sexual violence. Though it was once believed that a small minority of men were responsible for the vast majority of sexual violence, an estimated 12%-25% of college men report having used sexual violence as an undergraduate student. Research across disciplines suggests several factors associated with the perpetration of sexual violence. While numerous studies have explored these constructs quantitatively on and off college campuses, there have been far fewer qualitative studies that provide insight into how men who have perpetrated violence …


Rationale For Participation In Jmu Worksite Wellness Programs, Rebecca Mathien May 2021

Rationale For Participation In Jmu Worksite Wellness Programs, Rebecca Mathien

Masters Theses, 2020-current

Effective employee wellness programs require an adequate understanding of the needs of employees. An employee wellness needs assessment was created to target the understanding of specific topics of interest, incentives and barriers to participation, and general health status of university employees. The majority (74.1%) of the 639 survey respondents (15.3% response rate) were female (age 45.7 ± 11.7 years), full-time employees. Employees were most interested in participating in programs involving physical activity, nutrition, and lifestyle wellness. Stages of change related to these topics include physical activity (pre-action: 42.3% and action: 44.7%), nutrition (pre-action: 37.4% and action: 42.2%), and work/life balance …


The Therapeutic Benefits Of Attunement Through Lindy Hop, Sarah Trowbridge May 2021

The Therapeutic Benefits Of Attunement Through Lindy Hop, Sarah Trowbridge

Expressive Therapies Capstone Theses

Dance/movement therapy (DMT) was developed as a tool to aide in therapeutic healing. A foundational aspect of DMT is attunement, the emotional/kinesthetic connection between two people that allows for meaningful and healing bonds to emerge. Lindy Hop is a partnered dance that fosters an environment of attunement, as it is accessed both subconsciously and consciously. This research explores Lindy Hop as a possible method of therapeutic treatment. The literature indicates the physiological need for attunement and how safety plays a key role in strengthening senses of self-identity, nervous system development, and worldview. Four experienced Lindy Hoppers were recruited to engage …


A Tailored Multicomponent Intervention In Primary Care For Survivors Of Adverse Childhood Experiences (Aces), Rebecca L. Peterson May 2021

A Tailored Multicomponent Intervention In Primary Care For Survivors Of Adverse Childhood Experiences (Aces), Rebecca L. Peterson

Evidence-Based Practice Project Reports

Adverse childhood experiences (ACEs) include 10 traumatic events of abuse, neglect, and household dysfunction that occur before 18 years of age. Adverse childhood experiences affect greater than 60% of the population, and approximately one in six individuals affirm that they have experienced four or more types of ACEs. They are associated with negative, long-term health outcomes in adults, including 9 out of the 10 leading causes of death in the United States (Centers for Disease Control and Prevention, n.d.; Felitti et al., 1998). The purpose of this evidence-based practice project was to implement a tailored, multicomponent intervention to mitigate the …


Perceived Ability To Treat Opioid Use Disorder In West Virginia, A. Brianna Sheppard, Jonathan C. Young, Steve M. Davis, Garrett E. Moran May 2021

Perceived Ability To Treat Opioid Use Disorder In West Virginia, A. Brianna Sheppard, Jonathan C. Young, Steve M. Davis, Garrett E. Moran

Journal of Appalachian Health

Introduction: Medication-assisted treatment (MAT) is an evidence-based therapy for opioid use disorder (OUD) that has not been fully implemented in rural areas due to patient, provider, and logistical barriers. Limited information is available on provider perceptions of barriers to MAT in rural Central Appalachia which has very high rates of OUD compared to the rest the United States.

Purpose: Determine perceived barriers for potential prescribers to using MAT, including buprenorphine, as part of treatment for OUD in West Virginia.

Methods: A 30-question, anonymous survey was sent to physicians, physician assistants and advanced practice registered nurses using an online link. Link …


Loss Of Obstetric Services In Rural Appalachia: A Qualitative Study Of Community Perceptions, Caroline R. Efird, David Dry, Rachel F. Seidman May 2021

Loss Of Obstetric Services In Rural Appalachia: A Qualitative Study Of Community Perceptions, Caroline R. Efird, David Dry, Rachel F. Seidman

Journal of Appalachian Health

Background: As rural hospitals across the United States increasingly downsize or close, the availability of inpatient obstetric services continues to decline in rural areas. In rural Appalachia, the termination of obstetric services threatens to exacerbate the existing risk of adverse birth outcomes for women and infants, yet less is known about how the cessation of these services affects the broader community.

Purpose: The purpose of this paper is to explain how the loss of local obstetric services affects perceptions of healthcare among multi-generational residents of a remote, rural Appalachian community in western North Carolina.

Methods: An interdisciplinary team of researchers …


Dnp Final Report: Safety Huddle, Chukwuemeka Ogobuiro May 2021

Dnp Final Report: Safety Huddle, Chukwuemeka Ogobuiro

DNP Final Reports

Over 70% of reported sentinel events are due to communication failure between patients, care providers, and/or administration. Safety Huddle has been shown to increase effective communication among healthcare providers. The application of Safety Huddle concept to behavioral health inpatient care is new. Therefore, this scholarly project utilizes the evidence-based practice change steps to improve teamwork and patient safety in the behavioral health inpatient units using Safety Huddle concepts. The Safety Huddle is a team-building tool that increases effective communication among healthcare providers. A review of the literature was conducted. The evidence suggests that Safety Huddle, a tool for effective communication, …


Impact Of Covid-19 On Physical Activity And Health Influences Among College Students, Rachael Larkin May 2021

Impact Of Covid-19 On Physical Activity And Health Influences Among College Students, Rachael Larkin

Honors Theses

Objective: To assess the associations between physical activity, subjective well-being (SWB), and social media influences before, during, and after the 2020 COVID-19 period among college-aged students. Participants: Male and female students from the University of Mississippi who were between the ages of 18-25 volunteered to participate in this study. Out of 10,000 invitation emails distributed, a total of 290 individuals responded and were used for the subsequent analysis. Results: Almost half of the respondents (46.1%) noted a decrease in physical activity from before March-May (M-M) 2020 to during M-M 2020. In addition, 41% of the respondents reported an increase in …