Medicine and Health Sciences Commons^™

Ethical, Legal, And Social Issues In Metaverse-Enabled Healthcare, Kristin M Kostick-Quenet, Vasiliki Rahimzadeh

Center for Medical Ethics and Health Policy Staff Publications

Metaverse is heralded by some as the next iteration of the internet. It offers three-dimensional, immersive virtual spaces, where users, represented as avatars, can synchronously work, play, interact, and transact. Initially developed within the realm of massive multiplayer online role-playing games, the metaverse now extends into sectors such as music, entertainment, retail, real estate, and, more recently, healthcare. Users engage in the metaverse using augmented reality or virtual reality (AR/VR) headsets that interoperate with other sensory devices to integrate biofeedback and multimodal data streams.1 In this article, the authors offer a conceptual synthesis and anticipatory policy analysis grounded in …

The Infected Diabetic Foot: Incidence And Risk Factors For Dehiscence After Surgery For Diabetic Foot Infections, Lawrence A Lavery, Mario C Reyes, Bijan Najafi, Tyler L Coye, Jayer Chung, Michael C Siah, Arthur N Tarricone

Center on Aging Staff Publications

Our objective was to assess the incidence, risk factors and clinical outcomes of dehiscence after foot surgery in diabetic patients. We used pooled patient‐level data from two randomised clinical trials with 240 diabetic patients who required foot surgery for infections. Most patients (n = 180, 75.0%) had surgical wound closure. We defined dehisced surgical wounds (DSW) when the surgical site was not completely epithelialized with no drainage after sutures/staples were removed with a 2‐week validation of healing. We evaluated the time to heal, re‐infection, re‐ulceration, hospital admissions and amputations. Moderate and severe infection was based on criteria of the …

The Infected Diabetic Foot: Risk Factors For Re-Infection After Treatment For Diabetic Foot Osteomyelitis, Lawrence A Lavery, Mario C Reyes, Bijan Najafi, Tyler L Coye, Matthew Sideman, Michael C Siah, Arthur N Tarricone

Center on Aging Staff Publications

Our objective was to evaluate risk factors for re-infection in patients after treatment for diabetic foot osteomyelitis (OM). We used pooled patient level data from two RTCs that evaluated patients with diabetic foot infections. We evaluated 171 patients with OM. OM was confirmed with bone culture or histopathology. Data from the 12-month follow-up were used to determine clinical outcomes. Re-infection occurred in 47 (27.5%) patients. Risk factors for re-infection were Toe Brachial Index < 0.40 (25.7% vs. 9.8%, p = 0.02), skin perfusion pressure < 40 mmHg (6.3% vs. 5.9%, p = 0.04), wound healing (55.3% vs. 75.0%, p = 0.01), time to heal (156.0, 69.5-365 vs. 91.5, 38.8-365, p = 0.001), and history of MI (14.9% vs. 3.2%, p = 0.005). During 12-month follow-up, patients with re-infections were 198.8 times more likely to require a foot related hospitalisation (81.8% vs. 0.0%, p = 0.001), 10.4 times more likely have an all-cause hospitalisation (70.2% vs. 18.5%, p = 0.001) and 9.4 times more likely to need an amputation (36.2% vs. 5.6%, p = 0.001). Patients with re-infection had a significantly longer median length of hospitalisation (20.0, 13.5-34.5 vs. 14.0, 10.0-22.0, p = 0.003) and median length of antibiotic duration (55.0, 35.0-87.0 vs. 46.0, 22.8-68.0, p = 0.03). Patients with re-infection are less likely to heal and have more foot-related hospitalizations and amputations.

The Human Spinothalamic Tract: Lessons From Cordotomy, Anthony K Allam, Michael Benjamin Larkin, Ishan A Patel, Mohammed Hasen, David Mears, Patrick Dougherty, Ashwin Viswanathan

Faculty, Staff and Student Publications

The spinothalamic tract has long been known as a primary conductor of nociceptive information, with its anatomical and physiological understanding evolving over centuries of research. This comprehensive review traces the history of the spinothalamic tract beginning with Brown-Sequard’s 1860 report of contralateral analgesia following a hemisection of the spinal cord. As clinical and surgical interventions, such as cordotomies have advanced, so did our understanding of the spinothalamic tract’s function and anatomy. The spinothalamic tract’s role as a crossed pathway conducting pain and temperature sensations was solidified by the mid-20th century. However, intricate details of its somatotopic arrangement, anatomical distributions and …

The Impact Of Insurance On Adolescent Transition To Adult Care, Diane V Murrell, Cassandra J Enzler, Lauren Bretz, Beth H Garland, Albert C Hergenroeder, Christine Markham, Constance M Wiemann

Faculty, Staff and Student Publications

Background: This study sought to examine how adolescents and young adults with special health care needs (AYA) prepare for managing medical insurance (private and public) as an adult and the role of insurance in locating an adult provider and engaging in care.

Methods: Twenty-eight AYA aged 18-24 years with renal, inflammatory bowel, or rheumatologic diseases completed individual semi-structured interviews designed to evaluate the impact of insurance (private vs. public) on their health care transition experiences. An interdisciplinary team of coders analyzed transcripts using The Framework Method.

Results: Three themes emerged: continuum of accepting health insurance responsibility; the impact of insurance …

Characterizing Fermentable Carbohydrate Foods In The Diets Of Children With Abdominal Pain-Related Disorders Of Gut-Brain Interaction And Healthy Children, Vishnu Narayana, Jocelyn Chang, Ann R Mcmeans, Tasha Murphy, Rona L Levy, Robert J Shulman, Bruno P Chumpitazi

Children’s Nutrition Research Center Staff Publications

Objectives: Restricting dietary fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) can alleviate symptoms in children with disorders of gut-brain interaction (DGBI). Due to the restrictions of a low FODMAP diet (LFD), a less restrictive FODMAP Gentle diet (FGD) has been suggested. However, the types and amounts of high FODMAP foods and carbohydrates commonly consumed by children have not been studied. We aimed to identify the high FODMAP foods and proportions of FODMAP carbohydrates consumed by children with DGBI and healthy children (HC) and to determine which usually ingested FODMAPs would be restricted on the FGD.

Methods: Three-day diet records from …

Single-Cell Multiome Characterizing Intercellular Communication And Intracellular Regulation Of Epithelium And Mesenchymal During Secondary Palate Development In Mice, Usama Hussein, Yulin Dai, Andi Liu, Toshiyuki Itai, Fangfang Yan, Lukas M Simon, Zhongming Zhao

Faculty, Staff and Student Publications

Cell-cell communication between adjacent tissues is fundamental to orchestrating organ morphogenesis. During secondary palate development, interactions between epithelial and mesenchymal cells regulate epithelial-mesenchymal signaling, thereby controlling cell proliferation, differentiation, and tissue patterning. However, the precise molecular mechanisms underlying these interactions remain largely unexplored. In this study, we employed single-cell multiome sequencing to simultaneously profile chromatin accessibility and gene expression in 35,150 individual cells isolated from the developing mouse secondary palate at embryonic days E12.5, E13.5, E14.0, and E14.5. Our analysis revealed that intercellular signaling plays a pivotal role in directing secondary palate morphogenesis, with WNT, BMP, and PDGF pathways emerging …

Long-Term Health-Related Quality Of Life In Kawasaki Disease-Related Coronary Artery Aneurysm: A Large Single-Center Assessment In Nanjing, China, Yun Zhou, Mei Chen, Wenting Gao, Yu Chen, Ying Meng

The Texas Heart Institute Journal

BACKGROUND: The impact of coronary artery aneurysms (CAAs) caused by Kawasaki disease (KD) on long-term health-related quality of life (HRQOL) in children has not been well documented.

METHODS: This study investigated long-term HRQOL in a large sample of children diagnosed with KD-related CAAs. A case-control, retrospective study included 66 patients with KD-related CAAs. A total of 98 hospitalized patients were matched as controls based on age and sex: 49 patients were allocated to a group with pneumonia and 49 patients were allocated to a group with arterio-arterial fistula. Both child-reported and parent-proxy-reported Pediatric Quality of Life Inventory surveys were collected. …

The Mental Health Of Cardiology Fellows In Training, Juan Simon Rico-Mesa, Suman M Atluri, Maria Antonia Rico-Mesa

The Texas Heart Institute Journal

No abstract provided.

Platypnea-Orthodeoxia And Patent Foramen Ovale In A Patient In The Setting Of Covid-19, Laura Sarmiento, Riyad Kherallah, Guilherme Vianna Silva

The Texas Heart Institute Journal

Platypnea-orthodeoxia syndrome is a rare condition characterized by positional dyspnea and hypoxemia, with symptoms presenting in the upright position and improving when recumbent. Hypoxemia in platypnea-orthodeoxia syndrome is defined as a drop in Pao

Double Atrial Septum With Interatrial Space In Patients Experiencing Ischemic Attack, Blerim Berisha, Fadhel Hamidani, Mathias Humm

The Texas Heart Institute Journal

No abstract provided.

Accidental Left Ventricular Placement Of A Leadless Micra Pacemaker Through A Patent Foramen Ovale, Hamza Alkowatli, Mahmoud Kutmah, Adnan Shaik, Osama Hallak

The Texas Heart Institute Journal

The Micra device is a leadless pacemaker implanted in the right ventricle via a femoral vein transcatheter approach. There are several indications for and advantages to using a leadless pacemaker, and the device's role in the field of cardiology will probably continue to increase. This article presents the case of a rare complication probably due to inadvertent placement of the device in the left ventricle across an undiagnosed patent foramen ovale.

Early Structural Valve Deterioration And Cusp Tear Leading To Acute Heart Failure In A Second-Generation Trifecta Glide Technology Heart Valve, Akiyoshi Yamamoto, Kenji Kuwaki, Hidekazu Furuya, Yasunori Cho

The Texas Heart Institute Journal

This report highlights a case of early structural valve deterioration with a cusp tear in a second-generation Abbott Trifecta Glide Technology bioprosthetic heart valve. A 70-year-old man had undergone aortic valve replacement with a Trifecta Glide Technology valve 30 months earlier for severe bicuspid aortic valve stenosis. He suddenly developed acute heart failure with dyspnea resulting from severe aortic valve regurgitation, with a cusp tear in the Trifecta Glide Technology valve, as demonstrated by transthoracic echocardiography. The patient was successfully treated with urgent repeat aortic valve replacement.

Midterm Outcomes Of Pediatric Mitral Valvuloplasty For Moderate To Severe Mitral Valve Regurgitation And Associated Risk Factors For Postoperative Deterioration, Hongyuan Fu, Aijun Liu, Ming Yang, Zeyu Liu, Junwu Su

The Texas Heart Institute Journal

BACKGROUND: Mitral valvuloplasty is considered the best treatment for pediatric mitral valve regurgitation. The objective of this analysis was to identify risk factors for postoperative mitral valve regurgitation progression and evaluate valvuloplasty effectiveness.

METHODS: This retrospective, single-center study investigated the clinical efficacy of mitral valvuloplasty and identified factors that affect prognosis. Pediatric patients with moderate or severe mitral valve regurgitation who had undergone mitral valvuloplasty between September 2016 and August 2023 were included. Kaplan-Meier survival analysis was used to assess freedom from both mitral valve deterioration and cardiovascular death. Univariate and multivariate Cox regression analyses were performed to identify potential …

Shaping The Future Of "Cardio-Kidney-Metabolic" Health: Insights From The Texas Heart Institute's 2024 Cardiometabolic Syndrome Conference, Arjun Raghuram, Keri Sprung, Stephanie Coulter, Joseph G Rogers

The Texas Heart Institute Journal

At the Texas Heart Institute's 2024 Cardiometabolic Syndrome Conference, held on August 23, 2024, experts from diverse academic fields spoke about novel initiatives for addressing the worsening projections for cardiometabolic syndrome. Four major areas in which innovation is ongoing were highlighted: technology, policy, population health, and lifestyle and behavioral modification. This article presents a brief contextualization, summary, and analysis of the novel initiatives being implemented in each of these 4 areas to address cardiometabolic syndrome. Despite alarming projections, cardiometabolic syndrome presents a unique opportunity for innovators to drive change through collaborative, multidisciplinary efforts.

Sequelae And Surgical Management Of Giant Cardiac Myxoma, Norvin Hernandez, Michael Dileo, Christopher K Wong, Mahboob Alam

The Texas Heart Institute Journal

Cardiac myxomas are a rare phenomenon within the general population, and although there are reports of them, giant myxomas are not common in the medical literature. This report presents a case of a giant left atrial cardiac myxoma in a 57-year-old female patient who was largely asymptomatic until she presented with a diffuse thromboembolic stroke. This case report highlights the importance of surgical management of cardiac myxomas and discusses the difference in open vs minimally invasive surgical resection of giant cardiac myxomas.

Effective Thrombectomy For Biventricular Thrombosis With An Endoscope Via The Aortic And Tricuspid Heart Valves, Yuki Endo, Yoshiei Shimamura, Chizuo Kikuchi, Hiroshi Niinami

The Texas Heart Institute Journal

The simultaneous formation of thrombi in the left and right ventricles is extremely rare, and this condition's clinical characteristics and prognosis remain unknown. Therefore, treatment methods are still controversial. This case highlights the potential for endoscopic thrombectomy as a viable option for the treatment of giant floating biventricular thrombi in a patient with restricted cardiac function. This approach via the aortic and tricuspid heart valves allowed for effective and complete removal of the thrombi, thereby preventing further embolic complications.

Robot-Assisted Surgical Treatment Of Caseoma, Nancy Wang, Abdussalam Elsenousi, Kenneth K Liao

The Texas Heart Institute Journal

This report reviews 5 cases of mitral annular caseoma. Four patients presented with fatigue, stroke, or mitral stenosis. Robot-assisted resection of caseoma with or without mitral valve replacement was successfully performed in all patients with good outcomes. These cases demonstrate the safety and efficacy of robotic surgery in treating caseoma.

Navigating The Complexities Of Mitral Valve Clipping: Early Severe Mitral Valve Stenosis After Mitral Valve Clipping, Wassim Abouzeid, Ahmad Haddad, Chrystina Kiwan, Ahsan Khan, Addi Suleiman

The Texas Heart Institute Journal

This case study explores the journey of an 80-year-old male patient with a history of hypertension, diabetes, coronary artery disease after coronary artery bypass grafting, atrial fibrillation, and heart failure. Nine months before he presented to the emergency department, he had undergone mitral valve clipping for severe mitral valve regurgitation. Despite initial improvement, the patient experienced return of symptoms, including dyspnea at rest and lower limb edema. The results of this case-discovery of the need for mitral valve replacement-provides insights into the management of complications from mitral valve clipping and emphasizes that management requires a nuanced, meticulous approach.

Lyme Carditis And Inflammation-Driven Plaque Erosion Presenting As Sudden Cardiac Arrest, Marco Kaldas, Moneal Shah, Diana Pashaieva, Georgios Lygouris, Anita Radhakrishnan

The Texas Heart Institute Journal

Lyme carditis represents a rare cardiac complication of Borrelia burgdorferi infection, often causing conduction disturbances but rarely causing malignant arrhythmias. Inflammatory acute coronary syndrome, driven by immune-mediated plaque erosion rather than rupture, represents a nontraditional ischemic mechanism. This case highlights their overlap. The case of a previously healthy man with Lyme disease who experienced cardiac arrest because of ventricular tachycardia is reported. Imaging showed myocardial inflammation together with coronary plaque erosion instead of plaque rupture. The patient underwent advanced diagnostic testing and received multidisciplinary medical care, which led to complete cardiac recovery and implantable cardioverter-defibrillator placement.

Contributions Of Pathobiological And Translational Science To Understanding And Managing Ischemic Heart Disease: Progress, Impediments, And Future Directions, L Maximilian Buja

The Texas Heart Institute Journal

Key pathobiological components of ischemic heart disease have been identified as follows: (1) In 1970 to 1973, myocardial infarct size was found to be the primary determinant of prognosis after acute myocardial infarction (AMI); (2) in 1973 to 1989, vulnerable coronary artery plaques were found to predispose individuals to coronary plaque disruption and thrombosis, causing major AMI; (3) in 1972, timely coronary reperfusion was demonstrated to limit the size of evolving AMI but with risk of reperfusion injury; and (4) in 1986, myocardial conditioning was found to be a clinically significant modulator capable of delaying AMI progression. Promising cardioprotective strategies …

Clinician Attitudes Toward Palliative Care To Enhance The Quality Of Life For Patients With Sickle Cell Disease, Eberechi Nwogu-Onyemkpa, Amber B Amspoker, Nimrah Saleem, Aanand D Naik, Elizabeth Kvale, Ifeyinwa Osunkwo

Faculty, Staff and Student Publications

Objectives: Palliative care (PC) is rare for patients with sickle cell disease (SCD). This study evaluated clinician attitudes toward PC for SCD.

Methods: A cross-sectional survey was conducted between October 2022 and February 2023. Clinicians were recruited from institutions across the United States.

Results: Eighty-six participants completed the survey. Most were physicians (90%), female (72%), had >10 years of experience (63%), and lacked prior PC training (57%). Most participants agreed (83%) that patients with SCD would benefit from PC, disagreed (99%) that PC is only for dying patients, and expressed interest (91%) in learning about PC interventions. Clinicians with prior …

Mody Calculator And Clinical Features Routinely Used To Distinguish Mody From Type 2 Diabetes In Adults Perform Poorly For Youth Clinically Diagnosed With Type 2 Diabetes, Raymond J Kreienkamp, Beverley M Shields, Toni I Pollin, Amy S Shah, Angela D Liese, Anna Bellatorre, Catherine Pihoker, Mustafa Tosur, Jose C Florez, Shylaja Srinivasan, Andrew T Hattersley, Miriam S Udler, Maria J Redondo

Children’s Nutrition Research Center Staff Publications

No abstract provided.

A Comprehensive Uhplc-Ms/Ms And Extraction Method Reveals Flavonoid Profile And Concentration Are Diverse In Spinach (Spinacia Oleracea L), Michael P Dzakovich, Elaine A Le, Alvin L Tak, Shaji K Chacko

Children’s Nutrition Research Center Staff Publications

INTRODUCTION: Spinach produces an array of unique flavonoids not commonly found in other fruits and vegetables. These molecules likely serve as defense agents against biotic and abiotic stress and may have health beneficial properties for humans. Current methods to analyze spinach flavonoids are incomplete and only capture a portion of this uncharacterized pathway. A comprehensive analysis method is needed to determine how genetics, environmental conditions, and other factors influence spinach flavonoid biosynthesis.

METHODS: We developed and validated a high-throughput extraction and ultra high-performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) method to separate and quantify 39 spinach flavonoid species in 11.5 …

Overview Of The Head And Neck Tumor Segmentation For Magnetic Resonance Guided Applications (Hnts-Mrg) 2024 Challenge, Kareem A Wahid, Cem Dede, Dina M El-Habashy, Serageldin Kamel, Michael K Rooney, Yomna Khamis, Moamen R A Abdelaal, Sara Ahmed, Kelsey L Corrigan, Enoch Chang, Stephanie O Dudzinski, Travis C Salzillo, Brigid A Mcdonald, Samuel L Mulder, Lucas Mccullum, Qusai Alakayleh, Carlos Sjogreen, Renjie He, Abdallah S R Mohamed, Stephen Y Lai, John P Christodouleas, Andrew J Schaefer, Mohamed A Naser, Clifton D Fuller

Faculty, Staff and Student Publications

Magnetic resonance (MR)-guided radiation therapy (RT) is enhancing head and neck cancer (HNC) treatment through superior soft tissue contrast and longitudinal imaging capabilities. However, manual tumor segmentation remains a significant challenge, spurring interest in artificial intelligence (AI)-driven automation. To accelerate innovation in this field, we present the Head and Neck Tumor Segmentation for MR-Guided Applications (HNTS-MRG) 2024 Challenge, a satellite event of the 27th International Conference on Medical Image Computing and Computer Assisted Intervention. This challenge addresses the scarcity of large, publicly available AI-ready adaptive RT datasets in HNC and explores the potential of incorporating multi-timepoint data to enhance RT …

Decreasing Antibiotic Turnaround Time In The Medical Intensive Care Unit: A Quality Improvement Project, Kacie Wright

Doctor of Nursing Practice Final Project Abstract

Purpose: This QI project aimed to increase the percentage of first-dose antibiotics administered within one hour of order placement to 80% in the ICU by 12/31/24.

Background: Antibiotic Turnaround Time (ATT) is the time between antibiotic order placement and administration. Prolonged ATT can cause adverse outcomes by delaying treatment. In 2023, only 54% of first-dose antibiotics were given within the EBP standard of one-hour in our 36-bed Medical ICU.

Methodology: The Six Sigma DMAIC model identified barriers and interventions to achieving target ATT using stakeholder input, process mapping, and root cause analysis. Multidisciplinary Plan-Do-Study-Act (PDSA) cycles were created to evaluate …

Head-To-Head Comparison Of Aptamer- And Antibody-Based Proteomic Platforms In Human Cerebrospinal Fluid Samples From A Real-World Memory Clinic Cohort, Raquel Puerta, Amanda Cano, Pablo García-González, Fernando García-Gutiérrez, Maria Capdevila, Itziar De Rojas, Clàudia Olivé, Josep Blázquez-Folch, Oscar Sotolongo-Grau, Andrea Miguel, Laura Montrreal, Pamela Martino-Adami, Asif Khan, Adelina Orellana, Yun Ju Sung, Ruth Frikke-Schmidt, Natalie Marchant, Jean Charles Lambert, Maitée Rosende-Roca, Montserrat Alegret, Maria Victoria Fernández, Marta Marquié, Sergi Valero, Lluís Tárraga, Carlos Cruchaga, Alfredo Ramírez, Mercè Boada, Bart Smets, Alfredo Cabrera-Socorro, Agustín Ruiz

Faculty, Staff and Student Publications

High-throughput proteomic platforms are crucial to identify novel Alzheimer’s disease (AD) biomarkers and pathways. In this study, we evaluated the reproducibility and reliability of aptamer-based (SomaScan® 7k) and antibody-based (Olink® Explore 3k) proteomic platforms in cerebrospinal fluid (CSF) samples from the Ace Alzheimer Center Barcelona real-world cohort. Intra- and inter-platform reproducibility were evaluated through correlations between two independent SomaScan® assays analyzing the same samples, and between SomaScan® and Olink® results. Association analyses were performed between proteomic measures, CSF biological traits, sample demographics, and AD endophenotypes. Our 12-category metric of reproducibility combining correlation analyses identified 2428 highly reproducible SomaScan CSF measures, …

Linking Transcriptome And Morphology In Bone Cells At Cellular Resolution With Generative Ai, Lu Lu, Noriaki Ono, Joshua D Welch

Faculty, Staff and Student Publications

Recent advancements in deep learning (DL) have revolutionized the capability of artificial intelligence (AI) by enabling the analysis of large-scale, complex datasets that are difficult for humans to interpret. However, large amounts of high-quality data are required to train such generative AI models successfully. With the rapid commercialization of single-cell sequencing and spatial transcriptomics platforms, the field is increasingly producing large-scale datasets such as histological images, single-cell molecular data, and spatial transcriptomic data. These molecular and morphological datasets parallel the multimodal text and image data used to train highly successful generative AI models for natural language processing and computer vision. …

Dynamic And Concordance-Assisted Learning For Risk Stratification With Application To Alzheimer’S Disease, Wen Li, Ruosha Li, Ziding Feng, Jing Ning

Faculty, Staff and Student Publications

Dynamic prediction models capable of retaining accuracy by evolving over time could play a significant role for monitoring disease progression in clinical practice. In biomedical studies with long-term follow up, participants are often monitored through periodic clinical visits with repeat measurements until an occurrence of the event of interest (e.g. disease onset) or the study end. Acknowledging the dynamic nature of disease risk and clinical information contained in the longitudinal markers, we propose an innovative concordance-assisted learning algorithm to derive a real-time risk stratification score. The proposed approach bypasses the need to fit regression models, such as joint models of …

A Bayesian Pharmacokinetics Integrated Phase I-Ii Design To Optimize Dose-Schedule Regimes, Mengyi Lu, Ying Yuan, Suyu Liu

Faculty, Staff and Student Publications

The schedule of administering a drug has profound impact on the toxicity and efficacy profiles of the drug through changing its pharmacokinetics (PK). PK is an innate and indispensable component of the dose-schedule optimization. Motivated by this, we propose a Bayesian PK integrated dose-schedule finding (PKIDS) design to identify the optimal dose-schedule regime by integrating PK, toxicity, and efficacy data. Based on the causal pathway that dose and schedule affect PK, which in turn affects efficacy and toxicity, we jointly model the three endpoints by first specifying a Bayesian hierarchical model for the marginal distribution of the longitudinal dose-concentration process. …