Medicine and Health Sciences Commons^™

Sun Protection Behaviors And Skin Cancer Risk Among Children Of Color, Williana Magloire

Theses and Dissertations

Sun protection is beneficial for children of color as it decreases the risk for sunburns, hyperpigmentation, and most importantly, skin cancer. Invasive melanoma is commonly seen in children of color due to inadequate sun protection. Parental and caregiver modeling of sun protection behaviors may decrease the likelihood of skin cancer among children of color. The American Academy of Pediatrics (AAP, 2011) has suggested that pediatricians adopt the role of informing parents about the benefits of using sun protection products for their young children. They recommended that providers discuss sun protection behaviors with both the parent/child beginning at the age of …

The Relationship Between Parental Trauma History And Perceptions Regarding Their Child’S Healthcare And Utilization Of Healthcare Services, Krishna Patel

Theses and Dissertations

Abstract

TITLE: The Relationship Between Parental Trauma History and Perceptions Regarding Their Child’s Healthcare and Utilization of Healthcare Services

Adverse child events (ACEs) have been associated with a number of physical and mental health problems and have also been linked to increased health care utilization. While parents who have an ACE history may tend to seek healthcare services for themselves, limited studies have examined the impact of their trauma history on seeking healthcare services for their child. Healthcare utilization may also depend on the parents’ level of health anxiety, as well as their anxiety about their child’s health status. This …

Benefits Of The Enhanced Recovery After Surgery (Eras) Pathway With Quadratus Lumborum Blocks For Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study, Paul S Lee, Laurie L Brunette, Intira Sriprasert, Mohamed Eloustaz, Rasika Deshpande, Crystal Adams, Laila Muderspach, Lynda Roman, Shane Dickerson, Michael P Kim

Faculty, Staff and Student Publications

STUDY OBJECTIVE: This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery.

DESIGN AND SETTING: This retrospective cohort study was performed in a tertiary care hospital.

PATIENTS: A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study.

INTERVENTIONS: The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to …

Mixed-Method Study Of Relationship Satisfaction Among African American Males With Or Without History Of Childhood Sexual Abuse, Sandra Webster Brown

Dissertations

Relationship satisfaction among African American males is an important and feasible topic and underrepresented among scholarly literature. The purpose of this study was to explore relationship satisfaction and experiences among African American males who may be impacted by history of childhood sexual abuse. The study was guided by the theoretical frameworks of family systems theory. Using a concurrent mixed-methods triangulation design, the researcher collected data quantitatively and qualitatively from an online survey. Data were collected from 43 African American males recruited from Black organizations in the United States. The qualitative data collected by written narratives from the men were used …

Regional Vulnerability Indices In Youth With Persistent And Distressing Psychoticlike Experiences, Nicole R Karcher, Hailey Modi, Peter Kochunov, Si Gao, Deanna M Barch

Faculty, Staff and Student Publications

IMPORTANCE: Distressing and persistent psychoticlike experiences (PLEs) in youth are associated with greater odds of developing psychiatric conditions in adulthood. Despite this risk, it is unclear whether early PLEs show similar brain patterns compared with adults with psychiatric and neurologic conditions.

OBJECTIVE: To examine the degree to which persistent and distressing PLEs exhibit neural metrics that show similarity to adults with chronic psychiatric and neurologic conditions.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used Adolescent Brain Cognitive Development (ABCD) Study examining the persistence and distress associated with PLEs across the first 3 waves of data with baseline structural magnetic resonance …

Pancreatic Replacement Therapy For Maladaptive Behaviors In Preschool Children With Autism Spectrum Disorder, Deborah A Pearson, Robert L Hendren, Matthew F Heil, William R Mcintyre, Shane R Raines

Faculty, Staff and Student Publications

IMPORTANCE: There is an urgent unmet need for a treatment addressing the core symptoms and associated maladaptive symptoms of autism spectrum disorder (ASD), especially in preschool populations.

OBJECTIVES: To evaluate whether treatment of children with ASD aged 3 to 6 years treated with high-protease pancreatic therapy produces long- and short-term improvements in autism-associated maladaptive behaviors.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study at 32 sites across the US used a double-blind parallel group, delayed-start design comprising a 2-week blinded placebo run-in, and a double-blind, randomized, placebo-controlled segment (12 weeks). Children were recruited into the study in 2015, with data collection …

Epidural Catheters For Cervical Epidural Steroid Injections To Target Higher Cervical Pathology: Clinical Images In Practice, Peter D Vu, Christopher L Robinson, Grant H Chen, Jamal J Hasoon

Faculty, Staff and Student Publications

Cervical radicular pain is commonly treated with cervical epidural steroid injections. The transforaminal approach allows for direct treatment of the steroid at a particular nerve root or level. Still, it carries a significant risk of morbidity and mortality with thromboembolism or injury to cervical vasculature. The interlaminar approach is commonly utilized as it avoids vascular structures. However, the epidural space becomes narrower at higher levels, limiting the ability to perform this approach at higher cervical levels. Cervical epidural catheters can be used and advanced to target higher cervical pathology through the interlaminar approach. We present clinical images demonstrating the utility …

Establishment Of A Consensus Protocol To Explore The Brain Pathobiome In Patients With Mild Cognitive Impairment And Alzheimer’S Disease: Research Outline And Call For Collaboration, Richard Lathe, Nikki M Schultek, Brian J Balin, Garth D Ehrlich, Lavinia Alberi Auber, George Perry, Edward B Breitschwerdt, David B Corry, Richard L Doty, Robert A Rissman, Peter L Nara, Ruth Itzhaki, William A Eimer, Rudolph E Tanzi, Intracell Research Group Consortium Collaborators

Faculty, Staff and Students Publications

Microbial infections of the brain can lead to dementia, and for many decades microbial infections have been implicated in Alzheimer's disease (AD) pathology. However, a causal role for infection in AD remains contentious, and the lack of standardized detection methodologies has led to inconsistent detection/identification of microbes in AD brains. There is a need for a consensus methodology; the Alzheimer's Pathobiome Initiative aims to perform comparative molecular analyses of microbes in post mortem brains versus cerebrospinal fluid, blood, olfactory neuroepithelium, oral/nasopharyngeal tissue, bronchoalveolar, urinary, and gut/stool samples. Diverse extraction methodologies, polymerase chain reaction and sequencing techniques, and bioinformatic tools will …

Motivational Interviewing May Resolve Vaccine Hesitancy, Scott L. Baughan

Clinical Research in Practice: The Journal of Team Hippocrates

A clinical decision report using:

Gagneur A, Lemaître T, Gosselin V, et al. A postpartum vaccination promotion intervention using motivational interviewing techniques improves short-term vaccine coverage: PromoVac study. BMC public health. 2018;18(1):811. https://doi.org/10.1186/s12889-018-5724-y

for a juvenile patient with a caregiver who is skeptical about the safety of routine vaccinations.

Evaluating The Impact Of An Mhealth Platform For Managing Acute Postoperative Dental Pain: Randomized Controlled Trial, Bunmi Tokede, Alfa Yansane, Ana Ibarra-Noriega, Joanna Mullins, Kristen Simmons, Nicholas Skourtes, Urvi Mehta, Sayali Tungare, David Holmes, Joel White, Muhammad Walji, Elsbeth Kalenderian

Faculty, Staff and Student Publications

BACKGROUND: Postoperative dental pain is pervasive and can affect a patient's quality of life. Adopting a patient-centric approach to pain management involves having contemporaneous information about the patient's experience of pain and using it to personalize care.

OBJECTIVE: In this study, we evaluated the use of a mobile health (mHealth) platform to collect pain-related patient-reported outcomes over 7 days after the patients underwent pain-inducing dental procedures; we then relayed the information to the dentist and determined its impact on the patient's pain experience.

METHODS: The study used a cluster-randomized experimental study design with an intervention arm where patients were prompted …

Early Resveratrol Treatment Mitigates Joint Degeneration And Dampens Pain In A Mouse Model Of Pseudoachondroplasia (Psach), Jacqueline T Hecht, Alka C Veerisetty, Debabrata Patra, Mohammad G Hossain, Frankie Chiu, Claire Mobed, Francis H Gannon, Karen L Posey

Faculty, Staff and Student Publications

Pseudoachondroplasia (PSACH), a severe dwarfing condition associated with early-onset joint degeneration and lifelong joint pain, is caused by mutations in cartilage oligomeric matrix protein (COMP). The mechanisms underlying the mutant-COMP pathology have been defined using the MT-COMP mouse model of PSACH that has the common D469del mutation. Mutant-COMP protein does not fold properly, and it is retained in the rough endoplasmic reticulum (rER) of chondrocytes rather than being exported to the extracellular matrix (ECM), driving ER stress that stimulates oxidative stress and inflammation, driving a self-perpetuating cycle. CHOP (ER stress signaling protein) and TNFα inflammation drive high levels of mTORC1 …

Early Resveratrol Treatment Mitigates Joint Degeneration And Dampens Pain In A Mouse Model Of Pseudoachondroplasia (Psach), Jacqueline T Hecht, Alka C Veerisetty, Debabrata Patra, Mohammad G Hossain, Frankie Chiu, Claire Mobed, Francis H Gannon, Karen L Posey

Faculty, Staff and Student Publications

Pseudoachondroplasia (PSACH), a severe dwarfing condition associated with early-onset joint degeneration and lifelong joint pain, is caused by mutations in cartilage oligomeric matrix protein (COMP). The mechanisms underlying the mutant-COMP pathology have been defined using the MT-COMP mouse model of PSACH that has the common D469del mutation. Mutant-COMP protein does not fold properly, and it is retained in the rough endoplasmic reticulum (rER) of chondrocytes rather than being exported to the extracellular matrix (ECM), driving ER stress that stimulates oxidative stress and inflammation, driving a self-perpetuating cycle. CHOP (ER stress signaling protein) and TNFα inflammation drive high levels of mTORC1 …

A Preliminary Timeline Of The Midbrain Development In The Monodelphis Domestica Animal Model, Ismael Perez, John L. Vandeberg, Mario Gil

Research Colloquium

Introduction: The Brazilian short-tailed opossum (Monodelphis Domestica) is an understudied animal model compared to the Mus musculus that has been identified as a perfect candidate to study neurodevelopment (Baggott, L. & Moore, H., 1990). What makes the Monodelphis Domestica a perfect specimen for neurodevelopment is that the embryo develops outside the pouch of the mother providing easy noninvasive access to track changes across different developmental stages (Mate et al., 1994).

Objective: The objective of the study is to compare the area and volume in the development of the Monodelphis’s midbrain across three different developmental stages. Our research is beneficial because …

Psychotropics Prescription In Primary Care, Ruthzaine Lopez Bolano

Research Colloquium

Background: The study aimed to measure the prevalence of psychotropic prescriptions in primary care at four UTRGV clinical sites. Based on the results, this paper serves to inform and educate primary care providers of their current practices and treatment options when diagnosing mental health disorders and prescribing psychotropics.

Methods: This study used EMR data from January to March 2021 in four primary care clinics affiliated with the UT Health RGV system. Primary care patients from January to March 2021 and who were diagnosed with mood disorders (including Depression, Anxiety, and Bipolar Disorder) were included in this quality improvement study.

Results: …

Sex Differences In Stress Reactivity, Brain Morphology, And Oxytocin In The Hypothalamus Of The Gray Short-Tailed Opossum (Monodelphis Domestica), Esperanza I. Zacarias, Daniela Rodriguez, Alexandra Chalons, Sasawan Heingraj, Nicole Altamirano, Joseph Rafac, John L. Vandeberg, Mario Gil

Research Colloquium

Understanding the effects of stress on behavior and cognition is important due to its impact on mental health and wellbeing (Schneiderman et al. 2005). Translational animal research can contribute to the development of new treatments that can improve therapeutic outcomes and our understanding of the neurobiology of stress. In the present study, we complement behavioral stress reactivity with immunohistochemical localization of oxytocin in the hypothalamus, a neuropeptide that regulates stress (Neumann & Slattery, 2016). Oxytocin has potential therapeutic use for mental health disorders (Neumann & Slattery, 2016), and the effects of oxytocin seem to be sexually dimorphic (Love, 2018). Using …

Making Decisions "In The Dark": Learning Through Uncertainty In Clinical Practice During Covid-19, Urvashi Vaid, Henriette Lundgren, Karen E. Watkins, Deborah Ziring, Grace A. Alcid, Victoria J. Marsick, Dimitrios Papanagnou

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

PURPOSE: The purpose of this study was to explore how decision making and informal and incidental learning (IIL) emerged in the clinical learning environment (CLE) during the height of the Covid-19 pandemic. The authors' specific interest was to better understand the IIL that took place among frontline physicians who had to navigate a CLE replete with uncertainty and complexity with the future goal of creating experiences for medical students that would simulate IIL and use uncertainty as a catalyst for learning.

METHOD: Using a modified constructivist, grounded theory approach, we describe physicians' IIL while working during times of heightened uncertainty. …

Outbreak Communication: Exploring The Relationships Between Health Information Seeking Behaviors, Vested Interests, And Covid-19 Knowledge In U.S. Midwest Populations, Alicia Mason, Josh Compton, Elizabeth Spencer, Kaitlin Barnett

Faculty Submissions

On February 15, 2020, the World Health Organization (WHO) Director, General Tedros Adhanom Ghebreyesus, stated at a Munich Security Conference, “We’re not just fighting an epidemic; we’re fighting an infodemic,” (Zarocostas, 2020, p. 676). The term ‘infodemic’ refers to the onslaught of both accurate and inaccurate health information surrounding the COVID-19 pandemic. The concept of an ‘infodemic’ was quickly integrated into mass media, popular culture (i.e., documentaries, podcasts), and eventually scholarly literature. In response to COVID-19, health communication scholars have centered on understanding specific messaging strategies such as the use of fear appeals (Stolow et al., 2020), nature of advertising …

Centros De Inclusión Social Bajo Gestión Asociada Y La Salud Mental De Las Personas En Situación De Calle, Kien Phan

Independent Study Project (ISP) Collection

Esta investigación se enfoca en analizar las acciones del gobierno de la Ciudad Autónoma de Buenos Aires (CABA) para abordar la salud mental de las personas en situación de calle en 2023. Se examina el estado actual de esta población, identificando factores clave y evaluando las medidas gubernamentales. El marco teórico aborda determinantes sociales y derechos humanos, subrayando la importancia de cambios legislativos para abordar la falta de vivienda. La metodología combina análisis de datos gubernamentales, estudios previos y entrevistas con profesionales de Centros de Inclusión Social. Las organizaciones de la sociedad civil, como Cáritas y la Asociación Civil Isauro …

Assessing Effective Communication Styles And Preferences Between Health Researchers And State Policymakers, Shelby Flores-Thorpe

Dissertations and Theses (Open Access)

This dissertation examined how health researchers and state policymakers can effectively communicate with each other to support the use of evidence-based public health information in the policymaking process. To achieve this, a systematic review, analysis of TX RPC Project data, and semi-structured interviews were conducted among health researchers and policymakers. The systematic review found that email, in-person meetings, and phone calls were the best way to reach policymaking offices at the federal and state levels. When providing policymaking offices with data, health researchers should provide briefs, summaries, fact sheets, or one-pagers to support legislative offices’ need for information. Shorter reports …

Building Resilience To Treat Trauma And Improve Social Participation With Youth In Foster Care, Rachel Greene, Keisa Boykin, Dana Madalon

Fall 2023 Virtual OTD Capstone Symposium

Childhood trauma is classified by adverse childhood experiences (ACEs) that caused the trauma. An ACE is a traumatic event that an individual has observed from birth to 18 years old (Atchison & Suarez, 2021). ACEs include but are not limited to physical, sexual, or emotional abuse, and neglect. ACEs also include household dysfunctions such as domestic violence, divorce, incarceration of family, substance abuse, food scarcity, poverty, and the COVID-19 pandemic. Building resilience promotes healthy coping skills, the ability to trust and engage with support systems, and the prevention of retraumatization (Bethell et al., 2017). Trauma and resiliency are invertedly related, …

Electrophysiological Responses To Emotional And Cocaine Cues Reveal Individual Neuroaffective Profiles In Cocaine Users, Heather E Webber, Constanza De Dios, Margaret C Wardle, Robert Suchting, Charles E Green, Joy M Schmitz, Scott D Lane, Francesco Versace

Faculty, Staff and Student Publications

Smokers with stronger neuroaffective responses to drug-related cues compared to non-drug-related pleasant images (C>P) are more vulnerable to compulsive smoking than individuals with the opposite brain reactivity profile (P>C). However, it is unknown if these neurobehavioral profiles exist in individuals abusing other drugs. We tested whether individuals with cocaine use disorder (CUD) show similar neuroaffective profiles to smokers. We also monitored eye movements to assess attentional bias toward cues and we further performed exploratory analyses on demographics, personality, and drug use between profiles. Participants with CUD (n=43) viewed pleasant, unpleasant, cocaine, and neutral images while we recorded electroencephalogram. …

Postoperative Pain-Related Outcomes And Perioperative Pain Management In China: A Population-Based Study, Yanhong Liu, Saisong Xiao, Huikai Yang, Xuecai Lv, Aisheng Hou, Yulong Ma, Yandong Jiang, Chongyang Duan, Weidong Mi

Faculty, Staff and Student Publications

Background: Postoperative pain poses a significant challenge to the healthcare system and patient satisfaction and is associated with chronic pain and long-term narcotic use. However, systemic assessment of the quality of postoperative pain management in China remains unavailable.

Methods: In this cross-sectional study, we analyzed data collected from a nationwide registry, China Acute Postoperative Pain Study (CAPOPS), between September 2019 and August 2021. Patients aged 18 years or above were required to complete a self-reported pain outcome questionnaire on the first postoperative day (POD1). Perioperative pain management and pain-related outcomes, including the severity of pain, adverse events caused by pain …

Predictors And Moderators Of Treatment Outcomes For Anxious Children Randomized To Computer-Assisted Cognitive Behavioral Therapy Or Standard Community Care, Orri Smárason, Andrew G Guzick, Wayne K Goodman, Alison Salloum, Eric A Storch

Faculty, Staff and Students Publications

Introduction:

Computer-assisted cognitive behavioral therapy (CCBT) for childhood anxiety disorders may aid the dissemination of CBT, while maintaining treatment fidelity. Although CCBT is an effective intervention, not everyone benefits equally from treatment. Identifying patient characteristics that predict who will benefit from treatment and to what extent can help with matching patients to suitable interventions, and allow researchers and clinicians to modify, and individualize, their treatment formats more effectively. Such predictors and moderators have not yet been examined for CCBT outcomes in anxious children and studies of more traditional treatment formats have yielded inconsistent results.

Methods:

Using data from a randomized …

The Prevalence Of Burnout In Saudi Arabia Dental Hygienists, Nouf Hamad Aldayel

Dental Hygiene Theses & Dissertations

Purpose: The purpose of this pilot study was to assess the prevalence of burnout in Saudi Arabian dental hygienists and identify risk factors associated with burnout. Methods: A descriptive survey design using the Copenhagen Burnout Inventory (CBI) assessed burnout among a convenience sample of n=123 Saudi dental hygienists. The survey was disseminated electronically to 1,000 Saudi Arabian dental hygienists. The CBI measures three subscales: personal, work-related, and client/patient-related burnout on a five-point Likert-type scale. The survey also included six demographic questions, two Likert-type, one “yes/no,” and one openended question, related to burnout. Descriptive statistics, one-way between subject’s ANOVA, independent samples …

The Impact Of Mandatory Substance Abuse Counselor Reporting Requirements On Child Maltreatment Reporting Outcomes, Bilgé Özgé Yilmaz

Psychology Theses & Dissertations

The present study sought to examine how state-level mandatory reporting policies are associated with child maltreatment reporting through analysis of the National Data Archive on Child Abuse and Neglect (NDACAN, 2021). This study aimed: 1) to examine how the implementation of substance abuse counselor reporting requirements is associated with the reporting process, including the disposition of reports and the presence of substance abuse; and 2) to examine differences in the above outcomes based on associations between non-specific reporting requirements and specific requirements that mention substance use counselors. A quasi-experimental approach with repeated cross-sectional data was utilized, as it is a …

Incremental Validity Of The Mmpi-A-Rf And Maci In A Clinical Outpatient Setting, Madison Smart-Mccarthy

Psychology Theses & Dissertations

With the persistent rise of depression and suicide in adolescents, it is imperative that clinicians select empirically supported measures that accurately assess these conditions (Van Orman, 2022; Sellbom & Suhr, 2020). One empirical method used to evaluate measures is incremental validity. Incremental validity examines the level of improvement in predicting a phenomenon when adding a test or procedure to a combination of other instruments (APA, 2020). Experts regard the Minnesota Multiphasic Personality Inventory—Adolescent Version—Restructured Form (MMPI-A-RF; Archer et al., 2016) and the Millon Adolescent Clinical Inventory (MACI; Millon et al., 1993) as psychometrically sound measures often used in clinical practice. …

Measuring Misophonia In Youth: A Psychometric Evaluation Of Child And Parent Measures, Matti Cervin, Andrew G Guzick, Jane Clinger, Eleanor E A Smith, Isabel A Draper, Wayne K Goodman, Marijn Lijffijt, Nicholas Murphy, Catherine E Rast, Sophie C Schneider, Eric A Storch

Faculty, Staff and Students Publications

BACKGROUND: Misophonia is characterized by intense emotional reactions to specific sounds or visual stimuli and typically onsets during childhood. An obstacle for research and clinical practice is that no comprehensively evaluated measures for pediatric misophonia exist.

METHODS: In a sample of 102 youth meeting the proposed diagnostic criteria of misophonia, we evaluated the child and parent-proxy versions of the self-reported Misophonia Assessment Questionnaire (MAQ; assessing broad aspects of misophonia) and the child version of the Amsterdam Misophonia Scale (A-MISO-S; assessing misophonia severity). Confirmatory and exploratory factor analysis were used to examine factor structures of the measures. Further, child-parent agreement on …

Psychometric Properties Of The Turkish Version Of The Children's Saving Inventory In A Clinical Sample, Mehmet Akif Akıncı, Bahadır Turan, Ali Çakır, İbrahim Selçuk Esin, Eric Alan Storch, Onur Burak Dursun

Faculty, Staff and Students Publications

OBJECTIVE: The Children's Saving Inventory (CSI) is a measurement tool developed to assess hoarding behavior in children. This study aims to investigate the psychometric properties of the Turkish version of the CSI in a clinical sample of children and adolescents.

MATERIALS AND METHODS: The study sample consisted of 52 children and adolescents diagnosed with obsessive-compulsive disorder in the 8-17 age group and their families. As a structured diagnostic interview, the Development and Well-Being Assessment (DAWBA) was applied to all participants included in the research. Hoarding disorder (HD) diagnosis was made clinically by considering the Diagnostic and Statistical Manual of Mental …

Neuromodulation For Adjunctive Treatment In Postmastectomy Pain Syndrome, Kennedy Kirkpatrick, Jay D Shah, Krishna Shah

Faculty, Staff and Students Publications

Postmastectomy pain syndrome (PMPS) affects nearly half of patients who undergo mastectomy to treat breast cancer. As the survival rate of breast cancer increases with advancements in treatment, the incidence of PMPS is also increasing. Patients with PMPS can experience unrelenting, chronic pain refractory to traditional management with oral pharmacotherapy in conjunction with nonpharmacologic treatment (physical therapy, transcutaneous electrical nerve stimulation (TENS)). Neuromodulation is an emerging treatment modality for numerous chronic pain conditions. This case report highlights the tremendous success of spinal cord stimulator placement for a patient with PMPS.

Nightmares And Self-Injury Among High-Risk Adolescents: Examining The Role Of Emotion Regulation, Kinjal K. Patel

Psychology Theses & Dissertations

Self-injurious thoughts and behaviors (SITBs) are a public health concern among youth. SITB rates rise drastically during adolescence -- a critical and sensitive developmental period characterized by dramatic changes in biological and social systems. Prior research has identified distal risk factors which tell us who is at risk for SITBs. Emerging research suggests proximal risk factors may be useful to identify when an individual may be at risk for SITBs. One promising proximal risk factor for SITBs is sleep problems. Although the relation between sleep problems and SITBs has been widely documented, little is known about the short-term, proximal links …