Medicine and Health Sciences Commons^™

Cime Newsletter : November 2017, Cime

Centre for Innovation in Medical Education (CIME) Archives

- An Introductory Course: Palliative Nursing and End of Life Care

- Tour of AKU Challenge Scholarship Programme Students

- Clinical Skills Enhancement Programme for Hospital Based Healthcare

- Providers: collaboration between AKUH, PEI and CIME

- MagnifiScience Exhibition 2017

- A First Simulation Based Procedural

- Sedation Certification Course by NES

- 1st Educational Development Research Day

The Report Of The 2016-2017 Professional Affairs Standing Committee: Formally Embracing And Engaging Preceptors In The Academy — The Time Has Come, Karen Whalen, Daniel S. Aistrope, Jason Ausili, Kathleen H. Besinque, Elizabeth A. Cardello, Philip M. Hritcko, George E. Mackinnon Iii, Eric Maroyka, Elizabeth Sutton Burke, I. Shane Trent, Lynette R. Bradley-Baker

Pharmacy Faculty/Staff Publications

EXECUTIVE SUMMARY

The 2016-2017 AACP Professional Affairs Committee (PAC) was charged to examine strategies to include adjunct/affiliate preceptors as AACP members and to determine the value proposition of AACP membership for this group of educators. The PAC defined adjunct/affiliate preceptors as preceptors who are neither full-time employees nor have a primary employment commitment (≥50% of the preceptor’s work salary) at a school/college of pharmacy. Specific charges to the PAC included: recommend an approach to increase the number of adjunct/affiliate preceptors as AACP members, examine AACP membership from an adjunct/affiliate preceptor value perspective, and prepare a concise summary of available literature …

Prevalence Of High Risk Hpv In Hiv+ And Hiv-Women With Cervical Dysplasia At The Moi Teaching And Referral Hospital, Seth Kirui, Kirtika Patel, Elkanah Omenge

Obstetrics and Gynaecology, East Africa

Background: Cervical cancer, caused by Human Papillomavirus, is the second commonest cancer among women. HIV+ women are at a higher risk of acquiring HPV, developing pre-cervical cancer lesions (dysplasia) and cervical cancer. Early diagnosis is key to prevention of cervical cancer but reduced sensitivities and specificities of available screening methods pose challenges. The role of HPV in VIA related dysplasia has not been extensively interrogated. We sought to understand HPV infection in the context of HIV status and its relationship to VIA dysplasia

Objectives: To compare prevalence of high risk HPV in HIV positive and HIV negative women with and …

Development Of Halofluorochromic Polymer Nanoassemblies For The Potential Detection Of Liver Metastatic Colorectal Cancer Tumors Using Experimental And Computational Approaches, Derek Alexander Reichel, Louis T. Curtis, Elizabeth Ehlman, B. Mark Evers, Piotr G. Rychahou, Hermann B. Frieboes, Younsoo Bae

Pharmaceutical Sciences Faculty Publications

Purpose—To develop polymer nanoassemblies (PNAs) modified with halofluorochromic dyes to allow for the detection of liver metastatic colorectal cancer (CRC) to improve therapeutic outcomes.

Methods—We combine experimental and computational approaches to evaluate macroscopic and microscopic PNA distributions in patient-derived xenograft primary and orthotropic liver metastatic CRC tumors. Halofluorochromic and non-halofluorochromic PNAs (hfPNAs and n-hfPNAs) were prepared from poly(ethylene glycol), fluorescent dyes (Nile blue, Alexa546, and IR820), and hydrophobic groups (palmitate), all of which were covalently tethered to a cationic polymer scaffold [poly(ethylene imine) or poly(lysine)] forming particles with an average diameter < 30 nm.

Results—Dye-conjugated PNAs showed no aggregation under …

Oral Apolipoprotein A-I Mimetic D-4f Lowers Hdl-Inflammatory Index In High-Risk Patients: A First-In-Human Multiple-Dose, Randomized Controlled Trial., Richard L. Dunbar, Rajesh Movva, Leanne T. Bloedon, Danielle Duffy, Robert B. Norris, Mohamad Navab, Alan M. Fogelman, Daniel J. Rader

Department of Medicine Faculty Papers

A single dose of the apolipoprotein (apo)A-I mimetic peptide D-4F rendered high-density lipoprotein (HDL) less inflammatory, motivating the first multiple-dose study. We aimed to assess safety/tolerability, pharmacokinetics, and pharmacodynamics of daily, orally administered D-4F. High-risk coronary heart disease (CHD) subjects added double-blinded placebo or D-4F to statin for 13 days, randomly assigned 1:3 to ascending cohorts of 100, 300, then 500 mg (n = 62; 46 men/16 women). D-4F was safe and well-tolerated. Mean ± SD plasma D-4F area under the curve (AUC, 0-8h) was 6.9 ± 5.7 ng/mL*h (100 mg), 22.7 ± 19.6 ng/mL*h (300 mg), and 104.0 ± …

Examining The Need & Potential For Biomedical Engineering To Strengthen Health Care Delivery For Displaced Populations & Victims Of Conflict, Devika Nadkarni, Imad Elhajj, Zaher Dawy, Hala Ghattas Ph.D., Muhammad H. Zaman

Faculty Publications

Conflict and the subsequent displacement of populations creates unique challenges in the delivery of quality health care to the affected population. Equitable access to quality care demands a multi-pronged strategy with a growing need, and role, for technological innovation to address these challenges. While there have been significant contributions towards alleviating the burden of conflict via data informatics and analytics, communication technology, and geographic information systems, little has been done within biomedical engineering. This article elaborates on the causes for gaps in biomedical innovation for refugee populations affected by conflict, tackles preconceived notions, takes stock of recent developments in promising …

Investigating The Mechanistic Mode Of Action Of Novel Cu(Ii) Complexes As Potential Chemotherapeutics Drugs, Garret Rochford

Doctoral

A new class of Cu(II) phenanthroline-phenazine complexes (developed in Dublin City University) have recently been reported to have the highest DNA binding constants of any copper therapeutic complex and at a similar level to Actinomycin. These new complexes show great clinical potential with their high activity against a range of in-vitro mammalian cell lines including those with cisplatin resistance however the underlying biological mechanism of their action has yet to be explored in-depth. The biological data generated in this project has examined the activity of the Cu(II) phenanthroline-phenazine complexes in selected mammalian cells lines in-vitro and demonstrated that the Cu(II) …

Multisite Evaluation Of The Bd Max Extended Enteric Bacterial Panel For Detection Of Yersinia Enterocolitica, Enterotoxigenic Escherichia Coli, Vibrio, And Plesiomonas Shigelloides From Stool Specimens., Patricia J Simner, Margret Oethinger, Kathleen A Stellrecht, Dylan R Pillai, Ram Yogev, Helene Leblond, Joel Mortensen

Articles, Abstracts, and Reports

The purpose of this study was to perform a multisite evaluation to establish the performance characteristics of the BD Max extended enteric bacterial panel (xEBP) assay directly from unpreserved or Cary-Blair-preserved stool specimens for the detection of Yersinia enterocolitica, enterotoxigenic Escherichia coli (ETEC), Vibrio, and Plesiomonas shigelloides The study included prospective, retrospective, and prepared contrived specimens from 6 clinical sites. BD Max xEBP results were compared to the reference method, which included standard culture techniques coupled with alternate PCR and sequencing, except for ETEC, for which the reference method was two alternate PCRs and sequencing. Alternate PCR was …

Secukinumab Sustains Improvement In Signs And Symptoms Of Psoriatic Arthritis: 2 Year Results From The Phase 3 Future 2 Study., Iain B Mcinnes, Philip Mease, Christopher T Ritchlin, Proton Rahman, Alice B Gottlieb, Bruce Kirkham, Radhika Kajekar, Eumorphia-Maria Delicha, Luminita Pricop, Shephard Mpofu

Articles, Abstracts, and Reports

Objectives: To assess long-term efficacy, safety and tolerability of secukinumab up to 104 weeks in patients with active PsA.

Methods: Patients with PsA (n = 397) were randomized to s.c. secukinumab 300, 150 or 75 mg or placebo at baseline, weeks 1, 2, 3 and 4 and every 4 weeks thereafter. Placebo-treated patients were re-randomized to receive secukinumab 300 or 150 mg s.c. from week 16 (placebo non-responders) or week 24 (placebo responders). Exploratory endpoints at week 104 included 20, 50 and 70% improvement in ACR criteria (ACR20, 50, 70); 75 and 90% improvement in the Psoriasis Area Severity Index, …

Agenda For Translating Physical Activity, Nutrition, And Weight Management Interventions For Cancer Survivors Into Clinical And Community Practice., Karen Basen-Engquist, Catherine M Alfano, Melissa Maitin-Shepard, Cynthia A Thomson, Kathryn H Schmitz, Bernardine M Pinto, Kevin Stein, David S Zucker, Karen L Syrjala, Elizabeth Fallon, Colleen Doyle, Wendy Demark-Wahnefried

Articles, Abstracts, and Reports

Evidence supporting physical activity, diet, and weight management for cancer survivors has grown, leading to the development of guidelines and interventions. The next step is to identify necessary practice and policy changes and to develop a research agenda to inform how interventions can be delivered to survivors most effectively and efficiently in health care settings and by community-based organizations. Here, an agenda is proposed for research, practice, and policy that incorporates recommendations for a range of programming options, a patient-centered, tailored screening and referral approach, and training needs for survivorship care providers and providers of exercise, nutrition, and weight management …

The Isb Cancer Genomics Cloud: A Flexible Cloud-Based Platform For Cancer Genomics Research., Sheila M Reynolds, Michael Miller, Phyliss Lee, Kalle Leinonen, Suzanne M Paquette, Zack Rodebaugh, Abigail Hahn, David L Gibbs, Joseph Slagel, William J Longabaugh, Varsha Dhankani, Madelyn Reyes, Todd Pihl, Mark Backus, Matthew Bookman, Nicole Deflaux, Jonathan Bingham, David Pot, Ilya Shmulevich

Articles, Abstracts, and Reports

The ISB Cancer Genomics Cloud (ISB-CGC) is one of three pilot projects funded by the National Cancer Institute to explore new approaches to computing on large cancer datasets in a cloud environment. With a focus on Data as a Service, the ISB-CGC offers multiple avenues for accessing and analyzing The Cancer Genome Atlas, TARGET, and other important references such as GENCODE and COSMIC using the Google Cloud Platform. The open approach allows researchers to choose approaches best suited to the task at hand: from analyzing terabytes of data using complex workflows to developing new analysis methods in common languages such …

Oncolog, Volume 62, Number 11-12, November - December 2017, Joe Munch, Bryan Tutt

OncoLog MD Anderson's Report to Physicians (All issues) Archives

• Managing Chemotherapy-Induced Neuropathy: Neuromodulation, pharmacological treatments show promise against peripheral neuropathy in cancer patients.
• Treating Tobacco Addiction: MD Anderson provides pharmacotherapy, counseling to help smokers quit plus cessation education, resources for community practitioners
• HOUSE CALL: Smoking-Related Cancers- Cancer risks from tobacco are not limited to the lungs, but quitting reduces these risks

Stigma And Attitudes Toward Patients With Psychiatric Illness Among Postgraduate Indian Physicians, Susmita Chandramouleeswaran, Wesley Rajaleelan, Natasha Catherine Edwin, Ivan Koshy

2010-2019 OA Pubs

BACKGROUND: Due to paucity of psychiatrists in India, psychiatric patients often present to other doctors. We aimed to study nonpsychiatric residents' attitude and stigma toward psychiatric patients.

METHODS: A total of 57 postgraduate trainees participated in a cross-sectional study in a tertiary hospital in New Delhi. Attitudes to psychiatric patients were assessed using the attitude to mental illness questionnaire (AMIQ) and the perceived stigma questionnaire. This was correlated with sociodemographic information.

RESULTS: Over 70% residents accepted mentally ill patients as friends and felt they were equally employable. However, AMIQ demonstrated a negative attitude towards patients with schizophrenia. Perceived competence in …

Influence Of An Internal Parasite Control On Cattle Grazing Behavior And Production, Jace Stott

Department of Agronomy and Horticulture: Dissertations, Theses, and Student Research

Six herds of 45 to 90 cow/calf pairs grazing on upland range were used to examine the efficacy of an injectable extended release eprinomectin parasite control on production traits, activity behavior, and efficacy against internal parasitism. In 2016, treatment cows were given a subcutaneous injection of LongRange^tm. In 2017, all cows in the study were treated with a short acting Synanthic^tm treatment and only treatment cows were given an additional LongRange^tm treatment. In both 2016 and 2017, fecal egg counts were significantly lower (P < 0.05) in eprinomectin treated cows compared to control cows. Calf gains were 4.8 kg and 8.7 kg greater (P < 0.1) for the calves of dams treated with eprinomectin compared to calves of control cows in 2016 and 2017, respectively. Activity characteristics of cattle were inconclusive, with treated cows having lower (P < 0.01) grazing and traveling times compared to control cows in 2016, and more (P < 0.01) grazing and traveling in 2017.

Differences in grazing behaviors based on time within pasture at different times …

Smarcb1 Is Required For Widespread Baf Complex-Mediated Activation Of Enhancers And Bivalent Promoters., Robert T Nakayama, John L Pulice, Alfredo M Valencia, Matthew J Mcbride, Zachary M Mckenzie, Mark A Gillespie, Wai Lim Ku, Mingxiang Teng, Kairong Cui, Robert T Williams, Seth H Cassel, He Qing, Christian J Widmer, George D Demetri, Rafael A Irizarry, Keji Zhao, Jeffrey A Ranish, Cigall Kadoch

Articles, Abstracts, and Reports

Perturbations to mammalian SWI/SNF (mSWI/SNF or BAF) complexes contribute to more than 20% of human cancers, with driving roles first identified in malignant rhabdoid tumor, an aggressive pediatric cancer characterized by biallelic inactivation of the core BAF complex subunit SMARCB1 (BAF47). However, the mechanism by which this alteration contributes to tumorigenesis remains poorly understood. We find that BAF47 loss destabilizes BAF complexes on chromatin, absent significant changes in complex assembly or integrity. Rescue of BAF47 in BAF47-deficient sarcoma cell lines results in increased genome-wide BAF complex occupancy, facilitating widespread enhancer activation and opposition of Polycomb-mediated repression at bivalent promoters. We …

Cerebral Amyloid Angiopathy In Down Syndrome And Sporadic And Autosomal-Dominant Alzheimer's Disease, María Carmona-Iragui, Mircea Balasa, Bessy Benejam, Daniel Alcolea, Susana Fernández, Laura Videla, Isabel Sala, María Belén Sánchez-Saudinós, Estrella Morenas-Rodriguez, Roser Ribosa-Nogué, Ignacio Illán-Gala, Sofía Gonzalez-Ortiz, Jordi Clarimón, Frederick A. Schmitt, David K. Powell, Beatriz Bosch, Albert Lladó, Michael S. Rafii, Elizabeth Head, José Luis Molinuevo, Rafael Blesa, Sebastián Videla, Alberto Lleó, Raquel Sánchez-Valle, Juan Fortea

Sanders-Brown Center on Aging Faculty Publications

Introduction—We aimed to investigate if cerebral amyloid angiopathy (CAA) is more frequent in genetically determined than in sporadic early-onset forms of Alzheimer's disease (AD) (early-onset AD [EOAD]).

Methods—Neuroimaging features of CAA, APOE, and cerebrospinal fluid-Aβ40 levels were studied in subjects with Down syndrome (DS, n = 117), autosomal-dominant AD (ADAD, n = 29), sporadic EOAD (n = 42), and healthy controls (n = 68).

Results—CAA was present in 31%, 38%, and 12% of cognitively impaired DS, symptomatic ADAD, and sporadic EOAD subjects and in 13% and 4% of cognitively unimpaired DS individuals and healthy controls, respectively. …

Corticosterone Regulates Both Naturally Occurring And Cocaine‐Induced Dopamine Signaling By Selectively Decreasing Dopamine Uptake, Daniel S. Wheeler, Amanda L. Ebben, Beliz Kurtoglu, Marissa E. Lovell, Austin T. Bohn, Isabella A. Jasek, David A. Baker, John R. Mantsch, Paul J. Gasser, Robert A. Wheeler

Biomedical Sciences Faculty Research and Publications

Stressful and aversive events promote maladaptive reward‐seeking behaviors such as drug addiction by acting, in part, on the mesolimbic dopamine system. Using animal models, data from our laboratory and others show that stress and cocaine can interact to produce a synergistic effect on reward circuitry. This effect is also observed when the stress hormone corticosterone is administered directly into the nucleus accumbens (NAc), indicating that glucocorticoids act locally in dopamine terminal regions to enhance cocaine's effects on dopamine signaling. However, prior studies in behaving animals have not provided mechanistic insight. Using fast‐scan cyclic voltammetry, we examined the effect of systemic …

Professional Product Review Vol. 12 No. 2, American Dental Association, Council On Scientific Affairs

Professional Product Review

A user-friendly newsletter from the ADA Council on Scientific Affairs offering scientifically sound, unbiased, and clinically relevant information to member dentists about professional dental products tested by the ADA. This collection is historical and may not reflect current standards. For up-to-date information contact the ADA.

Prevalence And Risk Of Hepatitis E Virus Infection In The Hiv Population Of Nepal, Ananta Shrestha, Anurag Adhikar, Manjula Bhattarai, Ramanuj Rauniyar, Jose D. Debes, André Boonstra, Thupten K. . Lama, Mamun Al Mahtab, Amna Subhan Butt, Sheikh Mohammad Fazle Akbar

Section of Gastroenterology

Background: Infection with the hepatitis E virus (HEV) can cause acute hepatitis in endemic areas in immune-competent hosts, as well as chronic infection in immune-compromised subjects in non-endemic areas. Most studies assessing HEV infection in HIV-infected populations have been performed in developed countries that are usually affected by HEV genotype 3. The objective of this study is to measure the prevalence and risk of acquiring HEV among HIV-infected individuals in Nepal.

Methods: We prospectively evaluated 459 Human Immunodeficiency Virus (HIV)-positive individuals from Nepal, an endemic country for HEV, for seroprevalence of HEV and assessed risk factors associated with HEV infection. …

Premedical Programs Newsletter, November-December 2017, University Of Dayton

Pre-Health Resource Center Campus Communications

Newsletter for students, staff, and faculty in the premedical and predental programs.

Dynamic Range Of Frontoparietal Functional Modulation Is Associated With Working Memory Capacity Limitations In Older Adults, Jonathan G. Hakun, Nathan F. Johnson

Physical Therapy Faculty Publications

Older adults tend to over-activate regions throughout frontoparietal cortices and exhibit a reduced range of functional modulation during WM task performance compared to younger adults. While recent evidence suggests that reduced functional modulation is associated with poorer task performance, it remains unclear whether reduced range of modulation is indicative of general WM capacity-limitations. In the current study, we examined whether the range of functional modulation observed over multiple levels of WM task difficulty (N-Back) predicts in-scanner task performance and out-of-scanner psychometric estimates of WM capacity. Within our sample (60–77 years of age), age was negatively associated with frontoparietal modulation range. …

Mtor Kinase Inhibition Effectively Decreases Progression Of A Subset Of Neuroendocrine Tumors That Progress On Rapalog Therapy And Delays Cardiac Impairment, Melissa A. Orr-Asman, Zhengtao Chu, Min Jiang, Mariah Worley, Kathleen Lesance, Sheryl E. Koch, Vinicius S. Carreira, Hanan M. Dahche, David R. Plas, Kakajan Komurov, Xiaoyang Qi, Carol A. Mercer, Lowell B. Anthony, Jack Rubinstein, Hala E. Thomas

Internal Medicine Faculty Publications

Inhibition of mTOR signaling using the rapalog everolimus is an FDA-approved targeted therapy for patients with lung and gastroenteropancreatic neuroendocrine tumors (NET). However, patients eventually progress on treatment, highlighting the need for additional therapies. We focused on pancreatic NETs (pNET) and reasoned that treatment of these tumors upon progression on rapalog therapy, with an mTOR kinase inhibitor (mTORKi), such as CC-223, could overcome a number of resistance mechanisms in tumors and delay cardiac carcinoid disease. We performed preclinical studies using human pNET cells in vitro and injected them subcutaneously or orthotopically to determine tumor progression and cardiac function in mice …

Superficial Soft-Tissue Sarcomas Rarely Require Advanced Soft-Tissue Reconstruction Following Resection, William C. Eward, Alexander L. Lazarides, Anthony M. Griffin, Patrick W. O'Donnell, Amir Sternheim, Anne O'Neill, Stefan O. Hofer, Peter C. Ferguson, Jay S. Wunder

Markey Cancer Center Faculty Publications

Objective: Soft-tissue sarcomas are most frequently located deep within myofascial compartments. Superficial soft-tissue sarcomas (S-STS) are relatively less common and may be managed differently than deep sarcomas because generous resection margins are often possible without sacrificing critical structures. We sought to investigate the frequency and types of soft-tissue reconstructive procedures that are required following excision of S-STS.

Methods: We reviewed 457 consecutively treated patients with S-STS with a minimum 2-year follow-up from our prospectively maintained database between 1989 and 2009.

Results: Mean follow-up was 10.5 years (range, 2–23). Four hundred twenty-one tumors (91%) were excised with negative margins, 38 (8.3%) …

Parental Co‐Construction Of 5‐ To 13‐Year‐Olds' Global Self‐Esteem Through Reminiscing About Past Events, Michelle A. Harris, M. B. Donnellan, Jen Guo, Dan P. Mcadams, Mauricio Garnier-Villarreal, Kali H. Trzesniewski

College of Nursing Faculty Research and Publications

The current study explored parental processes associated with children's global self‐esteem development. Eighty 5‐ to 13‐year‐olds and one of their parents provided qualitative and quantitative data through questionnaires, open‐ended questions, and a laboratory‐based reminiscing task. Parents who included more explanations of emotions when writing about the lowest points in their lives were more likely to discuss explanations of emotions experienced in negative past events with their child, which was associated with child attachment security. Attachment was associated with concurrent self‐esteem, which predicted relative increases in self‐esteem 16 months later, on average. Finally, parent support also predicted residual increases in self‐esteem. …

Asia: Is High-End Innovation In Medical Technology A Blessing Or A Curse?, Elisabeth Staudinger

Asian Management Insights

Is high-end innovation in medical technology a blessing or a curse?

Benefits Of A Multidisciplinary Clinic Operations Workgroup As A Forum For Navigator Coordinators And Quality Improvement ., Alyssa Pauls Rn, Bsn, Ocn, Cynthia Smith Rn, Bsn, Ma, Ocn, Kathy Sevedge Rn, Ma, Aocn, Laura Beaupre Bsn, Ocn, Cbpn-Ic, Martiza Y. Chicas Rn, Pccn, Christine Heffeman Rn, Bsn, Ocn, Jeanne Kenna Rn, Ocn, Angela Miller Rn, Raizalie Roman-Rosado Bsn, Ocn, Cmsrn, Jane Zubia Rn, Ocn, Cbpn I-C

Patient Care Services / Nursing

No abstract provided.

Law Library Blog (November 2017): Legal Beagle's Blog Archive, Roger Williams University School Of Law

Law Library Newsletters/Blog

No abstract provided.

Himmelfarb Library Liaison Letter - November 2017, George Washington University, Himmelfarb Health Sciences Library

Himmelfarb Library Liaison Letters

No abstract provided.

Implementation Of A Multi-Institution, Multistate Cystic Fibrosis Transition Program, Christopher M. Oermann, D Polineni, A Andrews, A Moog, Paula Capel, T Bomstedt, Ellen Meier, J Mermis

Posters

Background: Children’s Mercy-Kansas City (CMKC) is an independent children’s hospital in Kansas City, MO. Its CF Care Center (CFCC) provides care for 250 patients. The University of Kansas Medical Center (KUMC) is an academic medical center in Kansas City, KS. Its CFCC includes adult/pediatric programs (230/50 patients). Interactions between CMKC and KUMC were minimal prior to 2013. CMKC provided care through adulthood despite CF Foundation mandates requiring transition of patients aged 18-21 years. Transition only occurred per patient request. Methods: The CMKC CFCC underwent restructuring and staff expansion in 2013-2014. KUMC underwent staff expansion in 2012, adding a nurse, respiratory …

Implementation Of A Patient-Centered Communication Model In The Emergency Department, Carrie Mull

Doctoral Projects

The objective of this scholarly project is to determine the impact of patient-centered communication education in an emergency department (ED) on the perception of workplace safety. The ED is a vulnerable setting and susceptible to workplace violence (WPV) due in part to increasing numbers of patients presenting to EDs with primary psychiatric complaints. High-quality patient-staff interactions correlate positively with better treatment outcomes. Patient-centered communication skills can be taught, and patients have similar expectations of what patient-centered communication means no matter their diagnoses. The purpose of this quality improvement project was to conduct patient-centered communication education with nurses, nursing assistants, and …