Medicine and Health Sciences Commons^™

A Closer Look: Deep South Has The Highest Hiv-Related Death Rates In The United States, Susan S. Reif, Donna Safley, Carolyn Mcallaster

Faculty Scholarship

No abstract provided.

Evidence For Respiratory Neuromodulator Interdependence After Cholinergic Disruption In The Ventral Respiratory Column, Clarissa Muere, Suzanne Neumueller, Justin Robert Miller, Samantha Olesiak, Matthew Hodges, Lawrence Pan, Hubert Forster

Physical Therapy Faculty Research and Publications

Reverse dialysis of the muscarinic receptor antagonist, atropine (ATR, 50 mM), into the pre-Bötzinger Complex region of the ventral respiratory column (VRC) of awake and sleeping goats increases breathing frequency and serotonin (5-HT), substance P (SP), glycine, and GABA concentrations in the effluent dialysate. Herein, we report data from goats in which we reverse dialyzed 5 mM ATR or specific antagonists of M2 or M3 muscarinic receptors into the VRC. The effects on frequency of all three antagonists were not significantly different from time control studies. 5 mM ATR and the M3 antagonist increased SP sevenfold less than 50 mM …

The Effect Of Simulation With Debriefing For Meaningful Learning In Courses Of Nursing Theory And Practicum On Student Knowledge And Perception Of Instruction, Kathleen L. Shea

Doctoral Dissertations

Nursing students are expected to apply knowledge from lectures and laboratories to the clinical setting. One major challenge of nursing educators is facilitating the transfer of knowledge to the clinical-practice setting. Simulation-based education provides students with an experiential-learning activity within the context of a simulated clinical environment. Following the simulation activity, the instructor facilitates a debriefing session and guides student discussion and reflection related to the experience. Debriefing promotes understanding of nursing concepts (Benner, Sutphen, Leonard, & Day, 2010).

The purpose of this research is to compare two debriefing methods: traditional method and Debriefing for Meaningful Learning DML (Dreifuerst, 2012). …

Air Quality And Respiratory Health Among Adolescents From The United Arab Emirates, Caroline Barakat-Haddad, Sheng Zhang, Ayesha Siddiqua, Rania Dghaim

All Works

© 2015 Caroline Barakat-Haddad et al. Purpose. To examine the role of air quality in relation to chronic bronchitis, emphysema, asthma, wheeze, and dry cough among adolescents from the United Arab Emirates (UAE). Methods. A survey was administered on 6,363 adolescents from 9 UAE regions. Data consists of demographic, socioeconomic, residential, and behavioural variables, such as location of residence, residing near industry/gas stations/dumpsites/construction sites, residing near overhead power line/plants, exposure to tobacco, residential exposure, ethnicity, concern over air pollution, smoking, and purposely smelling gasoline fumes/glue/correctors/car exhaust/burning black ants. Logistic regression modeling was used to determine significant predictors of respiratory health. …

The Journey Of A Digital Story: A Healing Performance Of Mino-Bimaadiziwin: The Good Life, Carmella M. Rodriguez

Antioch University Dissertations & Theses

Indigenous peoples have always shared collective truths and knowledge through oral storytelling. Just as we were born, stories are born too, through our sacred “living breath.” We live in a time where stories travel far, beyond our imaginable dreams, and can have an influence on anyone who hears them. In the present-day, we have an opportunity to combine personal stories with digital technology in order to share one of our greatest gifts with each other--our experience and wisdom. For eight years, Brenda K. Manuelito and I have been traveling across Indian Country helping our Indigenous relatives create nDigiStories for Native …

Characterization Of Oral Microbiota In Xerostomic Versus Non-Xerostomic Volunteers And In Daily Samples Following Standard Oral Hygiene Practices, Chelsea Myers

Wayne State University Theses

A thesis presented on the characterization of oral microbiota in xerostomic versus non-xerostomic volunteers and in daily samples following standard oral hygiene practices. Xerostomia is a difficult and burdensome disease that can be very difficult to diagnose. Understanding the oral microbiota between these diseased and healthy (non-xerostomic) can give us great insight on new treatments and/or prevention. Goals of the study included determining whether there substantial differences in oral microbial populations between the two groups, and whether varying nightly oral hygiene practices had an impact on next-morning oral microbiota titers or composition. Microbial loads were determined by qPCR using broad-spectrum …

Brain Candy: Wayne State University School Of Medicine Journal Of Arts And Culture, 4th Edition, Wayne State University School Of Medicine Writing Workshop, Wayne State University School Of Medicine Gold Humanism Honor Society

Gold Humanism Honor Society

Brain Candy collects poetry, nonfiction essays, short fiction, photographs, and drawings to shed light on the creative process in medicine, the city of Detroit, and the experiences of health care providers. Features submissions from medical students, physicians, and School of Medicine staff.

Can You Work It? Or Flip It And Reverse It?: Protecting Lgbt Youth From Sexual Orientation Change Efforts, Sanam Assil

Cardozo Journal of Equal Rights & Social Justice

The note advocates for raising the minimum age for Sexual Orientation Change Efforts (SOCE) from eighteen to twenty-one, arguing that individuals under twenty-one lack the emotional maturity to consent to such therapies. It emphasizes the harmful effects of SOCE, supported by findings from psychological organizations, and proposes incremental legislative changes to eventually achieve a nationwide ban on conversion therapy.

Values In Breast Cancer Screening: An Empirical Study With Australian Experts, Lisa Parker, Lucie Rychetnik, Stacy Carter

Medical Papers and Journal Articles

Objective:

To explore what Australian experts value in breast screening, how these values are conceptualised and prioritised, and how they inform experts’ reasoning and judgement about the Australian breast-screening programme.

Design:

Qualitative study based on interviews with experts.

Participants:

33 experts, including clinicians, programme managers, policymakers, advocates and researchers selected for their recognisable influence in the Australian breast-screening setting.

Setting:

Australian breast-screening policy, practice and research settings.

Results:

Experts expressed 2 types of values: ethical values (about what was good, important or right) and epistemological values (about how evidence should be created and used). Ethical values included delivering benefit, avoiding …

Early Primary Care Physician Contact And Health Service Utilisation In A Large Sample Of Recently Released Ex-Prisoners In Australia: Prospective Cohort Study, Jesse T. Young, Diane Arnold-Reed, David Preen, Max Bulsara, Nick Lennox, Stuart A. Kinner

Medical Papers and Journal Articles

Objective To describe the association between ex-prisoner primary care physician contact within 1 month of prison release and health service utilisation in the 6 months following release.

Design A cohort from the Passports study with a mean follow-up of 219 (±44) days post release. Associations were assessed using a multivariate Andersen-Gill model, controlling for a range of other factors.

Setting Face-to-face, baseline interviews were conducted in a sample of prisoners within 6 weeks of expected release from seven prisons in Queensland, Australia, from 2008 to 2010, with telephone follow-up interviews 1, 3 and 6 months post release.

Participants From an …

Osseointegrated Total Knee Replacement Connected To A Lower Limb Prosthesis: 4 Cases, Aditya Khemka, Laurent Frossard, Sarah J. Lord, Belinda Bosley, Munjed Al Muderis

Medical Papers and Journal Articles

Background and purpose

Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment.

Patients and methods

We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a …

When A Patient's Ethnicity Is Declared, Medical Students' Decision-Making Processes Are Affected, S C. Ewen, J Barrett, David Paul, D Askew, G Webb, A Wilkin

Medical Papers and Journal Articles

Background: Disparity in health status and healthcare outcomes is widespread and well known. This holds true for Indigenous peoples in many settings including Australia and Hawaii. While multi-factorial, there is increasing evidence of health practitioner contribution to this disparity. This research explored senior medical students’ clinical decision-making processes.

Methods: A qualitative study was conducted in 2014 with 30 final year medical students from The University of Melbourne, Australia, and The John Burns Medical School, Hawaii, USA. Each student responded to questions about a paper-based case, first in writing and elaborated further in an interview. Half the students were given a …

Using The Script Concordance Test To Assess Clinical Reasoning Skills In Undergraduate And Postgraduate Medicine, Michael Wan

Medical Papers and Journal Articles

The script concordance test is a relatively new format of written assessment that is used to assess higher order clinical reasoning and data interpretation skills in medicine. Candidates are presented with a clinical scenario, followed by the reveal of a new piece of information. The candidates are then asked to assess whether this additional information increases or decreases the probability or likelihood of a particular diagnostic, investigative, or management decision. To score these questions, the candidate’s decision in each question is compared with that of a reference panel of expert clinicians. This review focuses on the development of quality script …

Optimising Motor Learning In Infants At High Risk Of Cerebral Palsy: A Pilot Study, Catherine Morgan, Iona Novak, Russell Dale, Nadia Badawi

Medical Papers and Journal Articles

Background: The average age for the diagnosis of cerebral palsy (CP) is 19 months. Recent neuroplasticity literature suggests that intensive, task-specific intervention ought to commence as early as possible and in an enriched environment, during the critical period of neural development. Active motor interventions are effective in some populations, however the effects of active motor interventions on the motor outcomes of infants with CP have not been researched thoroughly, but pilot work is promising. The aim of this study was to determine the short- term effects of “GAME”; a new and novel goal-oriented activity-based, environmental enrichment therapy programme on the …

Framing Overdiagnosis In Breast Screening: A Qualitative Study With Australian Experts, Lisa M. Parker, Lucie Rychetnik, Stacy Carter

Medical Papers and Journal Articles

Background: The purpose of this study was to identify how the topic of overdiagnosis in breast cancer screening is framed by experts and to clarify differences and similarities within these frames in terms of problems, causes, values and solutions.

Methods: We used a qualitative methodology using interviews with breast screening experts across Australia and applying framing theory to map and analyse their views about overdiagnosis. We interviewed 33 breast screening experts who influence the public and/or policy makers via one or more of: public or academic commentary; senior service management; government advisory bodies; professional committees; non-government/consumer organisations. Experts were currently …

How Do General Practitioners Manage Patients With Cancer Symptoms? A Video-Vignette Study, Moyez Jiwa, Xingqiong Meng, Carolyn O'Shea, Parker Magin, Ann Dadich, Vinita Pillai

Medical Papers and Journal Articles

Objectives: Determine how general practitioners (GPs) manage patients with cancer symptoms.

Design: GPs reviewed 24 video-vignettes and case notes on patients with cancer symptoms and indicated whether they would refer the patient and/or prescribe medication, and/or undertake further investigation. According to available guidelines, all cases warranted a referral to a specialist or further investigations.

Setting: Australian primary care sector.

Participants: 102 practising GPs participated in this study, including trainees.

Interventions: The research was part of a larger randomised controlled trial testing a referral pro forma; however, this paper reports on management decisions made throughout the study.

Primary and secondary outcome …

Apathy And Suicide-Related Ideation 3 Months After Stroke: A Cross-Sectional Study, Wai Kwong Tang, Lara Caeiro, Chieh Grace Lau, Huajun Liang, Vincent Mok, Gabor S. Ungvari, Ka Sing Wong

Medical Papers and Journal Articles

Background: Both apathy and suicide are common in poststroke patients. However, the association between poststroke apathy and suicide-related ideation (SI) in Chinese stroke patients is not clear and poorly understood. The aim of this study was to examine the association between apathy and SI in stroke.

Methods: A cross-sectional study was conducted to investigate the association in 518 stroke survivors from Acute Stroke Unit of the Prince of Wales Hospital in Hong Kong. Geriatric Mental State Examination-Version A (GMS) and Neuropsychiatric Inventory-apathy subscale (NPI-apathy) were employed to assess poststroke SI and apathy, respectively. Patients’ clinical characteristics were obtained with the …

A Mixed Methods Study Of The Factors That Influence Whether Intervention Research Has Policy And Practice Impacts: Perceptions Of Australian Researchers, Robyn Newson, Lesley King, Lucie Rychetnik, Adrian E. Bauman, Sally Redman, Andrew J. Milat, Jacqueline Schroeder, Gillian Cohen, Simon Chapman

Medical Papers and Journal Articles

Objectives: To investigate researchers’ perceptions about the factors that influenced the policy and practice impacts (or lack of impact) of one of their own funded intervention research studies.

Design: Mixed method, cross-sectional study.

Setting: Intervention research conducted in Australia and funded by Australia’s National Health and Medical Research Council between 2003 and 2007.

Participants: The chief investigators from 50 funded intervention research studies were interviewed to determine if their study had achieved policy and practice impacts, how and why these impacts had (or had not) occurred and the approach to dissemination they had employed.

Results: We found that statistically significant …

Challenges In The Care Of Familial Hypercholesterolemia: A Community Care Perspective, Tom Brett, Gerald F. Watts, Diane Arnold-Reed, Damon Bell, Jacquie Garton-Smith, Alistair W. Vickery, Jacqueline D. Ryan, Jing Pang

Medical Papers and Journal Articles

Familial hyperchoelsterolaemia (FH) remains under-diagnosed and under-treated in the community setting. Earlier evidence suggested prevalence of 1:500 worldwide but newer evidence suggests it is more common. Less than 15% of FH patients are ever diagnosed with children and young adults rarely tested despite having most to gain given their lifetime exposure.

Increasing awareness among primary care teams is critical to improve detection profile for FH. Cascade testing in the community setting needs a sustainable approach to be developed to facilitate family tracing of index cases. The use of the Dutch Lipid Clinic Network Criteria score to facilitate a phenotypic diagnosis …

Evaluation Of The Regional Nurse-Supported Hepatitis C Shared Care Program In Western Australia: A Mixed Methods Study, Roanna Lobo, Lester Mascarenhas, David Worthington, Judith Bevan, Donna B. Mak

Medical Papers and Journal Articles

Background: Nurse-supported shared care services for patients living with hepatitis C have been implemented in some regional areas of Western Australia to provide access to local treatment and care services for patients and to improve currently low levels of treatment uptake. This study collected data from health professionals involved in managing the care of patients living with hepatitis C and from patients engaged in regional nurse-supported hepatitis C shared care services in Western Australia.

Methods: Key informant qualitative interviews were conducted with health professionals in regions operating a nurse-supported shared care service and in regions without this service. Patients engaged …

Can We Identify Women Who Initiate And Then Prematurely Cease Breastfeeding? An Australian Multicentre Cohort Study, Julie Quinlivan, Sonia Kua, Robert A. Gibson, Andrew Mcphee, Maria M. Makrides

Medical Papers and Journal Articles

Background: Health authorities recommend 6 months of fully breastfeeding and continuation of breastfeeding for at least a year. Many women initiate breastfeeding in hospital but discontinue before the six-month period, and therefore do not optimise the public health benefits. The aim of this study was to determine whether these women could be identified at hospital discharge, to enable targeted interventions.

Methods: A secondary analysis of women who intended to breastfeed and were enrolled in a large randomized trial was undertaken. Women were enrolled in the antenatal period and antenatal, delivery and six month postnatal questionnaires were completed. Univariate and multivariate …

The Impact Of The Carer Support Needs Assessment Tool (Csnat) In Community Palliative Care Using A Stepped Wedge Cluster Trial, Samar Aoun, Gunn Grande, Denise Howting, Kathleen Deas, Chris Toye, Lakkhina Troeung, Kelli Stajduhar, Gail Ewing

Medical Papers and Journal Articles

Family caregiving towards the end-of-life entails considerable emotional, social, financial and physical costs for caregivers. Evidence suggests that good support can improve caregiver psychological outcomes. The primary aim of this study was to investigate the impact of using the carer support needs assessment tool (CSNAT), as an intervention to identify and address support needs in end of life home care, on family caregiver outcomes. A stepped wedge design was used to trial the CSNAT intervention in three bases of Silver Chain Hospice Care in Western Australia, 2012-14. The intervention consisted of at least two visits from nurses (2-3 weeks apart) …

Apoe Ε4 Moderates Abnormal Csf-Abeta-42 Levels, While Neurocognitive Impairment Is Associated With Abnormal Csf Tau Levels In Hiv+ Individuals – A Cross-Sectional Observational Study, Lucette A. Cysique, Timothy Hewitt, Juliana Croitoru-Lamoury, Kevin Taddei, Ralph N. Martins, Constance S. Chew, Nicholas N. Davies, Patricia Price, Bruce J. Brew

Medical Papers and Journal Articles

Background: Cerebrospinal fluid (CSF) biomarkers Aβ1-42, t-tau and p-tau have a characteristic pattern in Alzheimer’s Disease (AD). Their roles in HIV-associated neurocognitive disorder (HAND) remains unclear.

Methods: Adults with chronic treated HIV disease were recruited (n = 43, aged 56.7 ± 7.9; 32% aged 60+; median HIV duration 20 years, >95% plasma and CSF HIV RNA <50 cp/mL, on cART for a median 24 months). All underwent standard neuropsychological testing (61% had HAND), APOE genotyping (30.9% carried APOE ε4 and 7.1% were ε4 homozygotes) and a lumbar puncture. Concentrations of Aβ1-42, t-tau and p-tau were assessed in the CSF using commercial ELISAs. Current neurocognitive status was defined using the continuous Global Deficit Score, which grades impairment in clinically relevant categories. History of HAND was recorded. Univariate correlations informed multivariate models, which were corrected for nadir CD4-T cell counts and HIV duration.

Results: Carriage of APOE ε4 predicted markedly lower levels of CSF Aβ1-42 in univariate (r = -.50; p = .001) and multivariate analyses (R2 = .25; p < .0003). Greater levels of neurocognitive impairment were associated with higher CSF levels of p-tau in univariate analyses (r = .32; p = .03) and multivariate analyses (R2 = .10; p = .03). AD risk prediction cut-offs incorporating all three CSF biomarkers suggested that 12.5% of participants had a high risk for AD. Having a CSF-AD like profile was more frequent in those with current (p = .05) and past HIV-associated dementia (p = .03).

Conclusions: Similarly to larger studies, APOE ε4 genotype was not directly associated with HAND, but moderated CSF …

Improving Allied Health Professionals' Research Implementation Behaviours For Children With Cerebral Palsy: Protocol For A Before-After Study, Christine Imms, Iona Novak, Claire Kerr, Nora Shields, Melinda Randall, Adrienne Harvey, H Kerr Graham, Dinah Reddihough

Medical Papers and Journal Articles

Background: Cerebral palsy is a permanent disorder of posture and movement caused by disturbances in the developing brain. It affects approximately 1 in every 500 children in developed countries and is the most common form of childhood physical disability. People with cerebral palsy may also have problems with speech, vision and hearing, intellectual difficulties and epilepsy. Health and therapy services are frequently required throughout life, and this care should be effective and evidence informed; however, accessing and adopting new research findings into day-to-day clinical practice is often delayed.

Methods/Design: This 3-year study employs a before and after design to evaluate …

De Novo Identification Of Differentially Methylated Regions In The Human Genome, Timothy J. Peters, Michael J. Buckley, Aaron L. Statham, Ruth Pidsley, Katherine Samaras, Reginald V. Lord, Susan J. Clark, Peter L. Molloy

Medical Papers and Journal Articles

Background: The identification and characterisation of differentially methylated regions (DMRs) between phenotypes in the human genome is of prime interest in epigenetics. We present a novel method, DMRcate, that fits replicated methylation measurements from the Illumina HM450K BeadChip (or 450K array) spatially across the genome using a Gaussian kernel. DMRcate identifies and ranks the most differentially methylated regions across the genome based on tunable kernel smoothing of the differential methylation (DM) signal. The method is agnostic to both genomic annotation and local change in the direction of the DM signal, removes the bias incurred from irregularly spaced methylation sites, and …

A Comparison Of The Predictive Accuracy Of Three Screening Models For Pulmonary Arterial Hypertension In Systemic Sclerosis, Yanjie Hao, Vivek Thakkar, Wendy Stevens, Kathleen Morrisroe, David Prior, Candice Rabusa, Peter Youssef, Eli Gabbay, Janet Roddy, Jennifer Walker, Jane Zochling, Joanne Sahhar, Peter Nash, Susan Lester, Maureen Rischmueller, Susanna M. Proudman, Mandana Nikpour

Medical Papers and Journal Articles

Introduction: There is evidence that early screening for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) improves outcomes. We compared the predictive accuracy of two recently published screening algorithms (DETECT 2013 and Australian Scleroderma Interest Group (ASIG) 2012) for SSc-associated PAH (SSc-PAH) with the commonly used European Society of Cardiology/European Respiratory Society (ESC/ERS 2009) guidelines.

Methods: We included 73 consecutive SSc patients with suspected PAH undergoing right heart catheterization (RHC). The three screening models were applied to each patient. For each model, contingency table analysis was used to determine sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for …

Relationship Between Serum Testosterone And Fracture Risk In Men: A Comparison Of Ria And Lc-Ms/Ms, Thach S. Tran, Jacqueline R. Center, Markus J. Seibel, John A. Eisman, Mark M. Kushnir, Alan L. Rockwood, Tuan V. Nguyen

Medical Papers and Journal Articles

BACKGROUND: Serum testosterone can be measured byLC-MS/MS and RIA. We investigated whether the testosterone–fracture relationship was affected by the method of measurement.

METHODS: We measured total testosterone (TT) by LCMS/MS (TTLC-MS/MS) and RIA (TTRIA) in serum samples collected from 602 men whose incident fractures had been continuously ascertained by x-ray reports from 1989 to 2010. We measured bone mineral density (BMD) by dual-energy x-ray absorptiometry. The association between TT and fracture risk was assessed by the Cox proportional hazards model, taking into account the effect of age and BMD.

CONCLUSIONS: The concordance between LC-MS/MS and RIA in the measurement of …

Twenty-Year Outcomes Of A Longitudinal Prospective Evaluation Of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts, Simon Thompson, Lucy Salmon, Alison Waller, James Linklater, Justin Roe, Leo Pinczewski

Medical Papers and Journal Articles

Background: Long term prospective follow up studies of single-incision endoscopic anterior cruciate ligament reconstruction are limited and may include confounding factors.

Objectives: This longitudinal prospective study reports the outcome of isolated anterior cruciate ligament (ACL) reconstruction using middle-third patellar tendon autograft in 90 patients over 20 years.

Study design: Case series; Level of evidence, 4.

Methods: Between January 1993 and April 1994, 90 patients met study inclusion criteria, evaluation 1,2,3,4,5,7,10,15 and 20 years post-surgery. Exclusion criteria: associated ligamentous injury requiring surgery, previous meniscectomy; meniscal injury meniscectomy more than 1/3; chondral injury; and an abnormal contralateral knee.

Results: At 20 years, …

Bioabsorbable Versus Titanium Screws In Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft: A Prospective, Blinded, Randomized Controlled Trial With 5-Year Follow-Up, Yuval Arama, Lucy J. Salmon, Kesavan Sri-Ram, James Linklater, Justin P. Roe, Leo Pinczewski

Medical Papers and Journal Articles

Background: Longer term studies of bioabsorbable screws for ACL reconstruction are reported, but results are specific to the exact screw material and design. Titanium and PLLA-HA screw outcomes have been compared only to 2 years.

Purpose: The aim of this study was to compare the clinical and radiological outcomes of PLLAHA screw (BS) versus a titanium screw (TS), for hamstring tendon anterior cruciate ligament reconstruction over 5 years. We hypothesized that there are no differences in clinical scores, and tunnel widening, between the BS and the TS groups, and that the PLLA-HA screw as seen on MRI should show high …

Familial Hypercholesterolaemia: Challenges In Primary Care, Tom Brett, Gerald F. Watts, Jacquie Garton-Smith, Damon A. Bell, Alistair W. Vickery, Jing Pang, Diane Arnold-Reed

Medical Papers and Journal Articles

Familial hypercholesterolaemia remains largely unrecognised and undertreated in Australian primary care. A new approach involving increased awareness, early detection, lifelong treatment and cascade testing of relatives is essential to improve outcomes of patients with this disorder.

Key Points

• Familial hypercholesterolaemia (FH) is a relatively common inherited disorder of high cholesterol levels.
• FH can lead to atherosclerosis, premature coronary artery disease and early death if left untreated.
• Cascade testing of relatives of patients with FH is cost- effective and necessary as one in two will have the condition.
• Innovations in primary care can improve FH detection in the community.
• An integrated …