Medicine and Health Sciences Commons^™

Are We Missing The Elephant In The Room? A Case For Thyroid Cancer Overdiagnosis As The Etiology For Its Increasing Incidence In India, Janeesh Sekkath Veedu, Aju Mathew

Internal Medicine Faculty Publications

No abstract provided.

Octo- And Nonagenarians' Outlook On Life And Death When Living With An Implantable Cardioverter Defibrillator: A Cross-Sectional Survey, Ingela Thylén, Debra K. Moser, Anna Strömberg

Nursing Faculty Publications

Background: Elderly individuals are increasingly represented among patients with implantable cardioverter defibrillators (ICD), but data describing life with an ICD are scarse among octo- and nonagenarians. Moreover, few studies have reported those elderly patients’ perspective on timly discussions concerning what shock deactivation involves, preferences on battery replacement, and their attitudes about turning off the ICD nearing end-of-life. Consequently, the aim of the study was to describe outlooks on life and death in octo- and nonagenarian ICD-recipients.

Methods: Participants were identified via the Swedish Pacemaker- and ICD-registry, with 229 octo- and nonagenarians (82.0 ± 2.2 years, 12% female) completing the survey …

P-21 Activated Kinase As A Molecular Target For Chemoprevention In Diabetes, Kyle Dammann, Vineeta Khare, Clyde Coleman, Henrik Berdel, Christoph Gasche

Surgery Faculty Publications

Hypothesis: Anti-diabetic drugs modulate p-21 activated kinase (PAK) signaling. Introduction: Type 2 diabetes mellitus (T2DM) is a chronic inflammatory disease associated with increased cancer risk. PAK signaling is implicated in cellular homeostasis when regulated, and cancer when unrestrained. Recent reports provided a role for PAK signaling in glucose homeostasis, but the role of PAKs in the pathogenesis of T2DM is unknown. Here, we performed a mini-meta-analysis to explore if anti-diabetic drugs modify PAK signaling pathways, and provide insight regarding modulation of these pathways, to potentially reduce diabetes-associated cancer risk. Methods: PAK interacting partners in T2DM were identified using the online …

Antibody Epitope Specificity For Dsdna Phosphate Backbone Is An Intrinsic Property Of The Heavy Chain Variable Germline Gene Segment Used, Tatjana Srdic-Rajic, Heinz Kohler, Vladimir Jurisic, Radmila Metlas

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Analysis of protein sequences by the informational spectrum method (ISM) enables characterization of their specificity according to encoded information represented with defined frequency (F). Our previous data showed that F(0.367) is characteristic for variable heavy chain (VH) domains (a combination of variable (V), diversity (D) and joining (J) gene segments) of the anti-phosphocholine (PC) T15 antibodies and mostly dependent on the CDR2 region, a site for PC phosphate group binding. Because the T15 dsDNA-reactive U4 mutant also encodes F(0.367), we hypothesized that the same frequency may also be characteristic for anti-DNA antibodies. Data obtained from an analysis of 60 spontaneously …

Using Spectral And Cross-Spectral Analysis To Identify Patterns And Synchrony In Couples' Sexual Desire, Matthew J. Vowels, Kristen P. Mark, Laura M. Vowels, Nathan D. Wood

Kinesiology and Health Promotion Faculty Publications

Sexual desire discrepancy is one of the most frequently reported sexual concerns for individuals and couples and has been shown to be negatively associated with sexual and relationship satisfaction. Sexual desire has increasingly been examined as a state-like construct that ebbs and flows, but little is known about whether there are patterns in the fluctuation of sexual desire. Utilizing spectral and cross-spectral analysis, we transformed 30 days of dyadic daily diary data for perceived levels of sexual desire for a non-clinical sample of 133 couples (266 individuals) into the frequency domain to identify shared periodic state fluctuations in sexual desire. …

Inspiring The Next Generation Of Academic Physicians: The Academic Health Careers Program, Jennifer K. Brueckner-Collins, Terry D. Stratton, Rosemarie L. Conigliaro

Medical Student Education Faculty Publications

There is growing evidence in the medical education literature for the aggressive need to recruit and retain the next generation of academic physicians. In 2008, the University of Kentucky College of Medicine (UK COM) developed an academic health careers (AHCs) program for preclinical medical students as an introduction into the practice of academic medicine. The goals of this elective experience included (1) highly customized training and mentorship experiences in research, teaching, and other aspects of academic medicine; (2) information and perspectives to assist students in making informed career choices, including options for academic careers; (3) access to academic career mentors …

Leukemia Inhibitory Factor Modulates The Peripheral Immune Response In A Rat Model Of Emergent Large Vessel Occlusion, Stephanie M. Davis, Lisa A. Collier, Edric D. Winford, Christopher C. Leonardo, Craig T. Ajmo Jr., Elspeth A. Foran, Timothy J. Kopper, John C. Gensel, Keith R. Pennypacker

Neurology Faculty Publications

Background: The migration of peripheral immune cells and splenocytes to the ischemic brain is one of the major causes of delayed neuroinflammation after permanent large vessel stroke. Other groups have demonstrated that leukemia inhibitory factor (LIF), a cytokine that promotes neural cell survival through upregulation of antioxidant enzymes, promotes an anti-inflammatory phenotype in several types of immune cells. The goal of this study was to determine whether LIF treatment modulates the peripheral immune response after stroke.

Methods: Young male (3 month) Sprague-Dawley rats underwent sham surgery or permanent middle cerebral artery occlusion (MCAO). Animals were administered LIF (125 μg/kg) or …

Screening Mammography Use In Older Women According To Health Status: A Systematic Review And Meta-Analysis, Joshua Demb, Tomi Akinyemiju, Isabel Allen, Tracy Onega, Robert A. Hiatt, Dejana Braithwaite

Epidemiology and Environmental Health Faculty Publications

Background: The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective: The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources: We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection: We included studies examining SM utilization in women ages ≥ 65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis: ORs and 95% CIs were extracted and grouped by life expectancy category. Findings …

Occupational Exposures And Associated Risk Factors Among U.S. Casino Workers: A Narrative Review, Jessica Miller Clouser, John C. Flunker, Jennifer E. Swanberg, Gail Betz, Surjeet Baidwan, J. Kathleen Tracy

Center for Health Services Research Faculty Publications

We conducted a narrative literature review of U.S. casino occupational health and safety research based on the following inclusion criteria: 1) focused on workers, 2) provided information pertaining to exposures present in the occupational environment (e.g., hazards, stressors, etc.), and 3) pertained to casino, gaming, or gambling workers. Following a multi-step process, a total of 11 articles were identified that related to the occupational health and safety of U.S. casino workers. These articles primarily focused on environmental tobacco smoke (ETS) exposures (n = 7 articles), with the remaining articles related to casino worker risk behaviors (i.e., problem gambling and drinking) …

Tutorial For Using Sliceomatic To Calculate Thigh Area And Composition From Computed Tomography Images From Older Adults, Richard A. Dennis, Douglas E. Long, Reid D. Landes, Kalpana P. Padala, Prasad R. Padala, Kimberly K. Garner, James N. Wise, Charlotte A. Peterson, Dennis H. Sullivan

Center for Muscle Biology Faculty Publications

Objective

Area of muscle, fat, and bone is often measured in thigh CT scans when tissue composition is a key outcome. SliceOmatic software is commonly referenced for such analysis but published methods may be insufficient for new users. Thus, a quick start guide to calculating thigh composition using SliceOmatic has been developed.

Methods

CT images of the thigh were collected from older (69 ± 4 yrs, N = 24) adults before and after 12-weeks of resistance training. SliceOmatic was used to segment images into seven density regions encompassing fat, muscle, and bone from -190 to +2000 Hounsfield Units [HU]. The …

Iac Gene Expression In The Indole-3-Acetic Acid-Degrading Soil Bacterium Enterobacter Soli Lf7, Isaac V. Greenhut, Beryl L. Slezak, Johan H. J. Leveau

Plant and Soil Sciences Faculty Publications

We show for soil bacterium Enterobacter soli LF7 that the possession of an indole-3-acetic acid catabolic (iac) gene cluster is causatively linked to the ability to utilize the plant hormone indole-3-acetic acid (IAA) as a carbon and energy source. Genome-wide transcriptional profiling by mRNA sequencing revealed that these iac genes, chromosomally arranged as iacHABICDEFG and coding for the transformation of IAA to catechol, were the most highly induced (>29-fold) among the relatively few (iac cluster were genes for a major facilitator superfamily protein (mfs) and enzymes of the β-ketoadipate pathway (pcaIJD-catBCA), which channels …

Manifestations Of Hypomelanosis Of Ito, Ana C. Albuja, Arpan Shrivastava, Gulam Q. Khan

Neurology Faculty Publications

No abstract provided.

Testing Longitudinal Relationships Between Internet Addiction And Well-Being In Hong Kong Adolescents: Cross-Lagged Analyses Based On Three Waves Of Data, Lu Yu, Daniel T. L. Shek

Pediatrics Faculty Publications

Using a panel design, this study examined the prospective relationships between Internet addiction and life satisfaction as well as hopelessness in a representative sample of Hong Kong adolescents. Starting from 2009/10 academic year, 3328 Secondary 1 students in 28 secondary schools in Hong Kong participated in this longitudinal study (Mean age = 12.59 years; SD = 0.74 years). All participants responded to a questionnaire that includes the Internet Addiction Test, Life Satisfaction Scale, and Hopelessness Scale on a yearly basis. Cross-lagged analyses based on three waves of data collected during three junior adolescent years showed that Internet addiction measured at …

The Effect Of Telerehabilitation On Missed Appointment Rates, Lyn T. Covert, John T. Slevin, Jessica Hatterman

Neurology Faculty Publications

The purpose of this study was to examine the effect of telerehabilitation on missed appointment rates in a rehabilitation clinic. Clients fail to attend scheduled appointments for a variety of reasons. Unmet appointments represent a loss of financial support as well as diminished efficiency and capacity to provide services. Speech therapy utilizing multiple appointments is most difficult to maintain during a treatment regimen. This may cause individuals to miss appointments and therefore not achieve desired results. For this study, researchers utilized an intense speech therapy technique, the Lee Silverman Voice Treatment (LSVT®) to measure compliance with scheduled appointments. Participants were …

Detection Of (1,3)-Β-D-Glucan In Cerebrospinal Fluid In Histoplasma Meningitis, Thein Myint, Felicia C. Chow, Karen C. Bloch, Luke Raymond-Guillen, Thomas E. Davis, Patty W. Wright, Laila Woc-Colburn, Raed N. Khairy, Alan C. Street, Tomotaka Yamamoto, Amanda Albers, L. Joseph Wheat, Chadi A. Hage

Internal Medicine Faculty Publications

The diagnosis of central nervous system (CNS) histoplasmosis is often difficult. Although cerebrospinal fluid (CSF) (1,3)-β-d-glucan (BDG) is available as a biological marker for the diagnosis of fungal meningitis, there are limited data on its use for the diagnosis of Histoplasma meningitis. We evaluated CSF BDG detection, using the Fungitell assay, in patients with CNS histoplasmosis and controls. A total of 47 cases and 153 controls were identified. The control group included 13 patients with a CNS fungal infection other than histoplasmosis. Forty-nine percent of patients with CNS histoplasmosis and 43.8% of controls were immunocompromised. The median CSF …

Generalist Versus Specialist Nurses' Knowledge, Attitudes, And Behavioral Intentions Toward Promoting Pulmonary Rehabilitation For Patients With Chronic Obstructive Pulmonary Disease: A Cross-Sectional Correlational Study, Su-Er Guo, Hsueh-Chen Shen, Chizimuzo T. C. Okoli, Yen-Chi Liao, Kuen-Daw Tsai, Ming-Shian Lin, Hsin-Tien Hsu

Nursing Faculty Publications

Pulmonary rehabilitation (PR) is an effective strategy to manage chronic obstructive pulmonary disease (COPD), though its utilization rate is low. One reason for this low utilization rate is that nurses do not provide COPD patients with enough health education to increase the patient's motivation for PR participation. This study examined knowledge, attitudes, and behavioral intention toward PR promotion. The study also investigated the correlates of behavioral intentions to promote PR among pulmonary nurses.

A cross-sectional correlational design was used. Overall, 284 nurses (all women) from chest medicine and general internal medicine wards in 3 hospitals within Midwest Taiwan were recruited. …

Interrupted Time Series Design To Evaluate The Effect Of The Icd-9-Cm To Icd-10-Cm Coding Transition On Injury Hospitalization Trends, Svetla Slavova, Julia F. Costich, Huong Luu, Judith Fields, Barbara A. Gabella, Sergey Tarima, Terry L. Bunn

Biostatistics Faculty Publications

Background: Implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) in the U.S. on October 1, 2015 was a significant policy change with the potential to affect established injury morbidity trends. This study used data from a single state to demonstrate 1) the use of a statistical method to estimate the effect of this coding transition on injury hospitalization trends, and 2) interpretation of significant changes in injury trends in the context of the structural and conceptual differences between ICD-9-CM and ICD-10-CM, the new ICD-10-CM-specific coding guidelines, and proposed ICD-10-CM-based framework for reporting of injuries by intent …

Membrane Associated Collagen Xiii Promotes Cancer Metastasis And Enhances Anoikis Resistance, Hui Zhang, Tricia Fredericks, Gaofeng Xiong, Yifei Qi, Piotr G. Rychahou, Jia-Da Li, Taina Pihlajaniemi, Wei Xu, Ren Xu

Markey Cancer Center Faculty Publications

Background: Increased collagen expression and deposition are associated with cancer progression and poor prognosis in breast cancer patients. However, function and regulation of membrane-associated collagen in breast cancer have not been determined. Collagen XIII is a type II transmembrane protein within the collagen superfamily. Experiments in tissue culture and knockout mouse models show that collagen XIII is involved in cell adhesion and differentiation of certain cell types. In the present study, we determined roles of collagen XIII in breast cancer progression and metastasis.

Methods: We analyzed the association of collagen XIII expression with breast cancer development and metastasis using published …

Translational Evaluation Of Acid/Base And Electrolyte Alterations In Rodent Model Of Focal Ischemia, Sarah R. Martha, Lisa A. Collier, Stephanie M. Davis, Hilary A. Seifert, Christopher C. Leonardo, Craig T. Ajmo, Elspeth A. Foran, Justin F. Fraser, Keith R. Pennypacker

Neurology Faculty Publications

BACKGROUND AND PURPOSE: Acid/base and electrolytes could provide clinically valuable information about cerebral infarct core and penumbra. We evaluated associations between acid/base and electrolyte changes and outcomes in 2 rat models of stroke, permanent, and transient middle cerebral artery occlusion.

METHODS: Three-month old Sprague-Dawley rats underwent permanent or transient middle cerebral artery occlusion. Pre- and post-middle cerebral artery occlusion venous samples for permanent and transient models provided pH, carbon dioxide, oxygen, glucose, and electrolyte values of ionized calcium, potassium, and sodium. Multiple regression determined predictors of infarct volume from these values, and Kaplan-Meier curve analyzed morality between permanent and transient …

Barriers To Receipt Of Prenatal Tetanus Toxoid, Reduced Diptheria Toxoid, And Acellular Pertussis Vaccine Among Mothers Of Infants Aged < 4 Months With Pertussis — California, 2016, Sarah New, Kathleen Winter, Kathleen Harriman, Anya Gutman, Amber Christiansen, Sarah Royce

Epidemiology and Environmental Health Faculty Publications

No abstract provided.

Wearable Cardioverter-Defibrillator After Myocardial Infarction, Jeffrey E. Olgin, Mark J. Pletcher, Eric Vittinghoff, Jerzy Wranicz, Rajesh Malik, Daniel P. Morin, Steven Zweibel, Alfred E. Buxton, Claude S. Elayi, Eugene H. Chung, Eric Rashba, Martin Borggrefe, Trisha F Hue, Carol Maguire, Feng Lin, Joel A. Simon, Stephen Hulley, Byron K. Lee, Vest Investigators

Gill Heart & Vascular Institute Faculty Publications

BACKGROUND

Despite the high rate of sudden death after myocardial infarction among patients with a low ejection fraction, implantable cardioverter–defibrillators are contraindicated until 40 to 90 days after myocardial infarction. Whether a wearable cardioverter–defibrillator would reduce the incidence of sudden death during this high-risk period is unclear.

METHODS

We randomly assigned (in a 2:1 ratio) patients with acute myocardial infarction and an ejection fraction of 35% or less to receive a wearable cardioverter–defibrillator plus guideline-directed therapy (the device group) or to receive only guideline-directed therapy (the control group). The primary outcome was the composite of sudden death or death from …

Editorial: Ion Channel Trafficking And Cardiac Arrhythmias, Marcel A. G. Van Der Heyden, Brian P. Delisle, Hugues Abriel

Physiology Faculty Publications

No abstract provided.

Fine Mapping Of Mhc Region In Lung Cancer Highlights Independent Susceptibility Loci By Ethnicity, Aida Ferreiro-Iglesias, Corina Lesseur, James Mckay, Rayjean J. Hung, Younghun Han, Xuchen Zong, David Christiani, Mattias Johansson, Xiangjun Xiao, Yafang Li, David C. Qian, Xuemei Ji, Geoffrey Liu, Neil Caporaso, Ghislaine Scelo, David Zaridze, Anush Mukeriya, Milica Kontic, Simona Ognjanovic, Jolanta Lissowska, Małgorzata Szołkowska, Beata Swiatkowska, Vladimir Janout, Ivana Holcatova, Ciprian Bolca, Milan Savic, Miodrag Ognjanovic, Stig Egil Bojesen, Xifeng Wu, Demetrios Albanes, Susanne M. Arnold

Markey Cancer Center Faculty Publications

Lung cancer has several genetic associations identified within the major histocompatibility complex (MHC); although the basis for these associations remains elusive. Here, we analyze MHC genetic variation among 26,044 lung cancer patients and 20,836 controls densely genotyped across the MHC, using the Illumina Illumina OncoArray or Illumina 660W SNP microarray. We impute sequence variation in classical HLA genes, fine-map MHC associations for lung cancer risk with major histologies and compare results between ethnicities. Independent and novel associations within HLA genes are identified in Europeans including amino acids in the HLA-B*0801 peptide binding groove and an independent HLA-DQB1*06 loci group. In …

Noncontact Speckle Contrast Diffuse Correlation Tomography Of Blood Flow Distributions In Tissues With Arbitrary Geometries, Siavash Mazdeyasna, Chong Huang, Mingjun Zhao, Nneamaka B. Agochukwu, Ahmed A. Bahrani, Lesley Wong, Guoqiang Yu

Biomedical Engineering Faculty Publications

A noncontact electron multiplying charge-coupled-device (EMCCD)-based speckle contrast diffuse correlation tomography (scDCT) technology has been recently developed in our laboratory, allowing for noninvasive three-dimensional measurement of tissue blood flow distributions. One major remaining constraint in the scDCT is the assumption of a semi-infinite tissue volume with a flat surface, which affects the image reconstruction accuracy for tissues with irregular geometries. An advanced photometric stereo technique (PST) was integrated into the scDCT system to obtain the surface geometry in real time for image reconstruction. Computer simulations demonstrated that a priori knowledge of tissue surface geometry is crucial for precisely reconstructing the …

De-Airing Method Of An Axial Flow Left Ventricular Assist Device Influences Post-Operative Lactate Dehydrogenase Levels: A Possible Explanation For Some Episodes Of Pump Thrombosis, Daizo Tanaka, Saif Rizvi, Andrew Boyle, Md, John W..C. Entwistle

The VAD Journal

Background

Pump thrombosis (PT) is a relatively uncommon but serious complication of a left ventricular assist device (LVAD). We believe that de-airing of the HeartMate II (HMII) with the pump turned on and a clamp across the outflow graft may lead to early thrombus formation due to heat generation on the bearings.

Methods

Patients who underwent HMII implantation from November 2012 to February 2016 were retrospectively reviewed. Patients were separated into two groups depending on the timing of removing the clamp from the outflow graft. Patients in Group 1 underwent de-airing by turning on the pump with the vascular clamp …

Astrocyte Activation And The Calcineurin/Nfat Pathway In Cerebrovascular Disease, Susan D. Kraner, Christopher M. Norris

Sanders-Brown Center on Aging Faculty Publications

Calcineurin (CN) is a Ca²⁺/calmodulin-dependent protein phosphatase with high abundance in nervous tissue. Though enriched in neurons, CN can become strongly induced in subsets of activated astrocytes under different pathological conditions where it interacts extensively with the nuclear factor of activated T cells (NFATs). Recent work has shown that regions of small vessel damage are associated with the upregulation of a proteolized, highly active form of CN in nearby astrocytes, suggesting a link between the CN/NFAT pathway and chronic cerebrovascular disease. In this Mini Review article, we discuss CN/NFAT signaling properties in the context of vascular disease and …

Enriched Physical Environment Attenuates Spatial And Social Memory Impairments Of Aged Socially Isolated Mice, Linmei Wang, Min Cao, Tinglin Pu, Huang Huang, Charles Marshall, Ming Xiao

Physical Therapy Faculty Publications

Background: Social isolation in the elderly is one of the principal health risks in an aging society. Physical environmental enrichment is shown to improve sensory, cognitive, and motor functions, but it is unknown whether environmental enrichment can protect against brain impairments caused by social isolation.

Methods: Eighteen-month-old mice were housed, either grouped or isolated, in a standard or enriched environment for 2 months, respectively. Behavioral tests were performed to evaluate cognitive functional and social interaction ability. Synaptic protein levels, myelination, neuroinflammation, brain derived neurotrophic factor, and NOD-like receptor protein 3 inflammasome signaling pathways were examined in the medial prefrontal cortex …

Comprehensive Evaluation Of Treatment And Outcomes Of Low-Grade Diffuse Gliomas, Catherine R. Garcia, Stacey A. Slone, Thomas A. Pittman, William H. St. Clair, Donita D. Lightner, John L. Villano

Markey Cancer Center Faculty Publications

Background

Low-grade gliomas affect younger adults and carry a favorable prognosis. They include a variety of biological features affecting clinical behavior and treatment. Having no guidelines on treatment established, we aim to describe clinical and treatment patterns of low-grade gliomas across the largest cancer database in the United States.

Methods

We analyzed the National Cancer Database from 2004 to 2015, for adult patients with a diagnosis of World Health Organization grade II diffuse glioma.

Results

We analyzed 13,621 cases with median age of 41 years. Over 56% were male, 88.4% were white, 6.1% were black, and 7.6% Hispanic. The most …

Data For Gaw20: Genome-Wide Dna Sequence Variation And Epigenome-Wide Dna Methylation Before And After Fenofibrate Treatment In A Family Study Of Metabolic Phenotypes, Stella Aslibekyan, Laura Almasy, Michael A. Province, Devin M. Absher, Donna K. Arnett

Epidemiology and Environmental Health Faculty Publications

GAW20 provided participants with an opportunity to comprehensively examine genetic and epigenetic variation among related individuals in the context of drug treatment response. GAW20 used data from 188 families (N = 1105) participating in the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN) study (clinicaltrials.gov identifier NCT00083369), which included CD4+ T-cell DNA methylation at 463,995 cytosine-phosphate-guanine (CpG) sites measured before and after a 3-week treatment with fenofibrate, single-nucleotide variation at 906,600 loci, metabolic syndrome components ascertained before and after the drug intervention, and relevant covariates. All GOLDN participants were of European descent, with an average age of …

Gaw20: Methods And Strategies For The New Frontiers Of Epigenetics And Pharmacogenomics, Nathan L. Tintle, David W. Fardo, Marzia De Andrade, Stella Aslibekyan, Julia N. Bailey, Justo Lorenzo Bermejo, Rita M. Cantor, Saurabh Ghosh, Philip Melton, Xuexua Wang, Jean W. Maccluer, Laura Almasy

Biostatistics Faculty Publications

GAW20 provided a platform for developing and evaluating statistical methods to analyze human lipid-related phenotypes, DNA methylation, and single-nucleotide markers in a study involving a pharmaceutical intervention. In this article, we present an overview of the data sets and the contributions analyzing these data. The data, donated by the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN) investigators, included data from 188 families (N = 1105) which included genome-wide DNA methylation data before and after a 3-week treatment with fenofibrate, single-nucleotide polymorphisms, metabolic syndrome components before and after treatment, and a variety of covariates. The contributions from individual …