Medicine and Health Sciences Commons^™

Cryptosporidium Spp. Diagnosis And Research In The 21st Century, Jennifer K. O'Leary, Roy D. Sleator, Brigid Lucey

Department of Biological Sciences Publications

The protozoan parasite Cryptosporidium has emerged as a leading cause of diarrhoeal illness worldwide, posing a significant threat to young children and immunocompromised patients. While endemic in the vast majority of developing countries, Cryptosporidium also has the potential to cause waterborne epidemics and large scale outbreaks in both developing and developed nations. Anthroponontic and zoonotic transmission routes are well defined, with the ingestion of faecally contaminated food and water supplies a common source of infection. Microscopy, the current diagnostic mainstay, is considered by many to be suboptimal. This has prompted a shift towards alternative diagnostic techniques in the advent of …

Triglyceride-Glucose Index: A Potential New Biomarker For Lung Disease Associated With Metabolic Dysregulation., Xilei Xu Chen, Deepa Rastogi

Pediatrics Faculty Publications

No abstract provided.

Hip Replacement For Femur Neck Fracture In The Elderly, Effects Of Delayed Surgical Intervention On Morbidity And Mortality, A Retrospective Comparative Study, Ahmed Habib, Shah Fahad, Muhammad Atif, Javeria Saeed, Pervaiz Hashmi, Mujahid Jamil Khattak

Section of Orthopaedic Surgery

Hip fracture is one of the most common injuries in the elderly population. Delay in operating on patients with hip fracture is associated with greater mortality and morbidity. A retrospective review of medical charts of patients who underwent primary total hip replacement (THR) for neck of femur fractures at our tertiary care level 1 trauma was carried out. Data was collected from the patients' charts and analysed for 30-day mortality and morbidity. A total of 96 patients were included in the study. Out of the 36 patients in the delayed THR group, mortality within 30 days was observed in 4 …

Role Of Multidisciplinary Neuro-Oncology Tumour Boards In Cancer Management, Mohammad Hamza Bajwa, Saqib Kamran Bakhshi, Muhammad Shahzad Shamim

Section of Neurosurgery

Multidisciplinary care, including a tumour board discussion for all patients with oncological problems is now considered a standard. However, this is not uniformly implemented within many centres, especially in developing countries. The structure of these tumour boards allows for comprehensive discussion and debate regarding various treatment pathways, with inputs from all specialties. This creates a consensus regarding management for each patient that is unique and holistic. Despite its widespread implementation, published data on neuro-oncology tumour boards is quite limited. The presented literature review briefly discusses the structure, goals, outcomes achieved by multidisciplinary tumour boards within the field of neuro-oncology.

Clinical Outcomes Of Sodium-Glucose Cotransporter-2 Inhibitors In Patients With Type 2 Diabetes Mellitus: An Observational Study From Pakistan, Bhagwan Das, Aisha Sheikh, Bilal Ahmed, Najmul Islam

Section of Diabetes, Endocrinology and Metabolism

Objective: To determine the efficacy and safety of Sodium-glucose cotransporter-2 inhibitors (SGLT2i) use in the Pakistani population.
Methods: Retrospective review of initial 100 patients who were prescribed with any agent of the SGLT2i group from July 1, 2018, to January 2019 at Aga Khan University Hospital, Karachi. SGLT2i was offered to patients of above 18 years of age with inadequate glycemic control on existing antidiabetic agents. Changes in HbA1c, the Body Mass Index (BMI), serum creatinine, any decrease in the requirement of insulin and sulphonylurea dose along with any side effects reported by the patients on follow-up visits.
Results: Most …

Macomb Dental Society Journal Fall 2021

Journal of the Macomb Dental Society

In the Fall 2021 issue, the reader will find the following feature articles:

• Real Estate: The Second-Highest Expense In Your Practice
• Macomb Community College's New Dental Science Program
• MDS DDS Sporting Clays Shoot

Also included are regular columns from the President, Executive Director and Editor, as well as news shorts and information on upcoming events.

Risk Factors For Stroke In, Bolan Medical Complex Hospital Quetta, Muhammad Essa, Amanullah Kakar, Dr Gulandam, Muhammad Saleem Barech, Hina Imtiaz, Sher Zaman Mandokhail, Muhammad Dawood

Pakistan Journal of Neurological Sciences (PJNS)

Stroke is one of the leading causes of physical impairment and mortality worldwide. Optimizing preventive strategies will help decrease the burden of stroke. The objectives of this study were to determine common stroke risk factors, by analyzing a comprehensive panel of variables in our local population.

200 patients were consecutively enrolled in this prospective observational study at stroke unit (SU) of Bolan Medical Complex Hospital over 6 months from March 2019 to August 2019. Structured questionnaires were prepared History and clinical examination were performed to gather relevant information. CT scan of brain was done to confirm the diagnosis of stroke. …

Suicide, A Convoluted Challenge In Covid-19 Era, Aisha Noorullah

Pakistan Journal of Neurological Sciences (PJNS)

No abstract provided.

A Decarceral Cadence: Neurologic Music Therapy As An Abolitionist Project, Mallori D. Thompson, Richard A. Kirby

Connecticut Law Review

Because police and prison abolition must be approached while simultaneously improving quality of life, and thus reducing harm, abolitionist discourse should include health policies that regard the (de)regulation, use, and culture of addictive substances. This Essay calls for research into neurologic music therapy as a response to addiction, improving quality of life and paving the way for police and prison abolition.

Optical Coherence Tomography Based Indices In Predicting Functional Outcome Of Macular Hole Surgery: A Retrospective Chart Review, Haroon Tayyab, Rehman Siddiqui, Sana Jahangir, Shiraz Hashmi

Section of Ophthalmology

Objectives: The objective of this study was to assess the utility of novel macular hole indices of Optical Coherence Tomography (OCT) and predicting the functional outcome of surgery.
Methods: This was a retrospective chart review of 28 eyes who underwent surgery for idiopathic Full Thickness Macular Hole (FTMH) at The Aga Khan University Hospital (AKUH), Karachi from January 2016 to March 2020. Data of preoperative OCTs were recovered from data server of OCT machine. Measurements of the pre-operative OCTs were calculated using caliper function of OCT software by two independent technicians. Parameters included Macular Hole Index (MHI), Traction Hole Index …

Spontaneous Closure Of Full Thickness Macular Hole In The Presence Of An Epiretinal Membrane In A Vitrectomised Eye: A Case Report, Rehman Siddiqui, Muhammad Umar Fawad, Nida Ahsan

Section of Ophthalmology

We report the case of a spontaneous closure of full thickness macular hole (FTMH) in the presence of an epiretinal membrane (ERM) in a previously vitrectomised eye. The patient had undergone vitrectomy for rhegmatogenous retinal detachment and developed an ERM two weeks after the surgery, which converted into a FTMH after one week. Eight months after the vitrectomy, spontaneous closure of FTMH was observed with an improvement in best-corrected visual acuity (BCVA) from 20/200 to 20/40. The patient was followed up for four years, and the FTMH remained closed. Spontaneous closure of FTMH is possible even in the presence of …

Aurora Kinase A Inhibition Reverses The Warburg Effect And Elicits Unique Metabolic Vulnerabilities In Glioblastoma, Trang T. T. Nguyen, Enyuan Shang, Chang Shu, Sungsoo Kim, Angeliki Mela, Nelson Humala, Aayushi Mahajan, Hee Won Yang, Hasan Orhan Akman, Catarina M. Quinzii, Guoan Zhang, Mike-Andrew Westhoff, Georg Karpel-Massler, Jeffrey N. Bruce, Peter Canoll, Markus D. Siegelin

Publications and Research

Aurora kinase A (AURKA) has emerged as a drug target for glioblastoma (GBM). However, resistance to therapy remains a critical issue. By integration of transcriptome, chromatin immunoprecipitation sequencing (CHIP-seq), Assay for Transposase-Accessible Chromatin sequencing (ATAC-seq), proteomic and metabolite screening followed by carbon tracing and extracellular flux analyses we show that genetic and pharmacological AURKA inhibition elicits metabolic reprogramming mediated by inhibition of MYC targets and concomitant activation of Peroxisome Proliferator Activated Receptor Alpha (PPARA) signaling. While glycolysis is suppressed by AURKA inhibition, we note an increase in the oxygen consumption rate fueled by enhanced fatty acid oxidation (FAO), which was …

Cardiovascular Fellow-In-Training Feedback On Virtual And Simulator-Based Learning Experience During Covid-19 Pandemic In A Low To Middle Income Country - A Cross-Sectional Study, Pirbhat Shams, Intisar Ahmed, Hunaina Shahab, Zehra Kadani, Aisal Khan, Marvi Shams, Yawer Saeed, Syedah Saira Bokhari, Aamir Hameed Khan

Section of Cardiology

Background: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation.
Methodology: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic.
Results: A total of 68 FIT responded to …

Targeting The Cdk6 Dependence Of Ph+ Acute Lymphoblastic Leukemia, Patrizia Porazzi, Marco De Dominici, Joseph Salvino, Bruno Calabretta

Department of Cancer Biology Faculty Papers

Ph+ ALL is a poor-prognosis leukemia subtype driven by the BCR-ABL1 oncogene, either the p190-or the p210-BCR/ABL isoform in a 70:30 ratio. Tyrosine Kinase inhibitors (TKIs) are the drugs of choice in the therapy of Ph+ ALL. In combination with standard chemotherapy, TKIs have markedly improved the outcome of Ph+ ALL, in particular if this treatment is followed by bone marrow transplantation. However, resistance to TKIs develops with high frequency, causing leukemia relapse that results in

Paliperidone To Treat Psychotic Disorders, Hormazd D. Minwalla, Peter Wrzesinski, Allison Desforges, Joshua Caskey, Brittany Wagner, Patrick Ingraffia, James C. Patterson, Amber N. Edinoff, Adam M. Kaye, Alan David Kaye, Omar Viswanath, Ivan Urits

School of Pharmacy Faculty Articles

Purpose of Review: This is a comprehensive review of the literature regarding the use of paliperidone in the treatment of schizophrenia and schizoaffective disorder. It covers the background and presentation of schizophrenia and schizoaffective disorder, as well as the mechanism of action and drug information for paliperidone. It covers the existing evidence of the use of paliperidone for the treatment of schizophrenia and schizoaffective disorder. Recent Findings: Schizophrenia and schizoaffective disorder lead to significant cognitive impairment. It is thought that dopamine dysreg-ulation is the culprit for the positive symptoms of schizophrenia and schizoaffective disorder. Similar to other second-generation antipsychotics, paliperidone …

Selective Serotonin Reuptake Inhibitors And Clozapine: Clinically Relevant Interactions And Considerations, Amber N. Edinoff, Juliana M. Fort, Joshua J. Woo, Christopher D. Causey, Caroline R. Burroughs, Elyse M. Cornett, Adam M. Kaye, Alan David Kaye

School of Pharmacy Faculty Articles

The monoamine hypothesis of depression attributes the symptoms of major depressive disorders to imbalances of serotonin, noradrenaline, and dopamine in the limbic areas of the brain. The preferential targeting of serotonin receptor (SERT) by selective serotonin reuptake inhibitors (SSRIs) has offered an opportunity to reduce the range of these side effects and improve patient adherence to pharmacotherapy. Clozapine remains an effective drug against treatment-resistant schizophrenia, defined as failing treatment with at least two different antipsychotic medications. Patients with schizophrenia who display a constellation of negative symptoms respond poorly to antipsychotic monotherapy. Negative symptoms include the diminution of motivation, interest, or …

Selective Serotonin Reuptake Inhibitors And Adverse Effects: A Narrative Review, Amber N. Edinoff, Haseeb A. Akuly, Tony A. Hanna, Carolina O. Ochoa, Shelby J. Patti, Yahya A. Ghaffar, Alan David Kaye, Omar Viswanath, Ivan Urits, Andrea G. Boyer, Elyse M. Cornett, Adam M. Kaye

School of Pharmacy Faculty Articles

Depression is the most prevalent psychiatric disorder in the world, affecting 4.4% of the global population. Despite an array of treatment modalities, depressive disorders remain difficult to manage due to many factors. Beginning with the introduction of fluoxetine to the United States in 1988, selective serotonin reuptake inhibitors (SSRIs) quickly became a mainstay of treatment for a variety of psychiatric disorders. The primary mechanism of action of SSRIs is to inhibit presynaptic reuptake of serotonin at the serotonin transporter, subsequently increasing serotonin at the postsynaptic membrane in the serotonergic synapse. The six major SSRIs that are marketed in the USA …

Solve-Rd: Systematic Pan-European Data Sharing And Collaborative Analysis To Solve Rare Diseases., Birte Zurek, Kornelia Ellwanger, Lisenka E L M Vissers, Rebecca Schüle, Matthis Synofzik, Ana Töpf, Richarda M De Voer, Steven Laurie, Leslie Matalonga, Christian Gilissen, Stephan Ossowski, Peter A C 'T Hoen, Antonio Vitobello, Julia M Schulze-Hentrich, Olaf Riess, Han G Brunner, Anthony J Brookes, Ana Rath, Gisèle Bonne, Gulcin Gumus, Alain Verloes, Nicoline Hoogerbrugge, Teresinha Evangelista, Tina Harmuth, Morris Swertz, Dylan Spalding, Alexander Hoischen, Sergi Beltran, Holm Graessner, Peter N Robinson

Faculty Research 2021

For the first time in Europe hundreds of rare disease (RD) experts team up to actively share and jointly analyse existing patient's data. Solve-RD is a Horizon 2020-supported EU flagship project bringing together >300 clinicians, scientists, and patient representatives of 51 sites from 15 countries. Solve-RD is built upon a core group of four European Reference Networks (ERNs; ERN-ITHACA, ERN-RND, ERN-Euro NMD, ERN-GENTURIS) which annually see more than 270,000 RD patients with respective pathologies. The main ambition is to solve unsolved rare diseases for which a molecular cause is not yet known. This is achieved through an innovative clinical research …

Scaup Depredation On Arkansas Baitfish And Sportfish Aquaculture, Stephen A. Clements, Brian S. Dorr, J. Brian Davis, Luke A. Roy, Carole R. Engle, Katie Hanson-Dorr, Anita M. Kelly

United States Department of Agriculture Wildlife Services: Staff Publications

Lesser scaup (Aythya affinis) and greater scaup (A. marila), hereafter scaup, consume a variety of aquatic invertebrates, plants, and occasionally small fish. Scaup have foraged on commercial aquaculture farms in the southern United States for decades. However, the types, abundance, and rate of fish exploitation by scaup on baitfish and sportfish farms are not well documented. Thus, information is needed to understand how fish and other foods influence scaup use of aquatic resources, and any potential economic effects of depredation of fish. From November–March in winters 2016–2017 and 2017–2018, we conducted 1,458 pond surveys to …

A Comparison Of Machine Learning Classifiers For Pediatric Epilepsy Using Resting-State Functional Mri Latency Data, Ryan D Nguyen, Matthew D Smyth, Liang Zhu, Ludovic P Pao, Shannon K Swisher, Emmett H Kennady, Anish Mitra, Rajan P Patel, Jeremy E Lankford, Gretchen Von Allmen, Michael W Watkins, Michael E Funke, Manish N Shah

Faculty, Staff and Student Publications

Epilepsy affects 1 in 150 children under the age of 10 and is the most common chronic pediatric neurological condition; poor seizure control can irreversibly disrupt normal brain development. The present study compared the ability of different machine learning algorithms trained with resting-state functional MRI (rfMRI) latency data to detect epilepsy. Preoperative rfMRI and anatomical MRI scans were obtained for 63 patients with epilepsy and 259 healthy controls. The normal distribution of latency z-scores from the epilepsy and healthy control cohorts were analyzed for overlap in 36 seed regions. In these seed regions, overlap between the study cohorts ranged from …

In Situ Imaging Of Bacterial Outer Membrane Projections And Associated Protein Complexes Using Electron Cryo-Tomography, Mohammed Kaplan, Georges Chreifi, Lauren Ann Metskas, Janine Liedtke, Cecily R. Wood, Catherine M. Oikonomou, William J. Nicolas, Poorna Subramanian, Lori A. Zacharoff, Yuhang Wang, Yi-Wei Chang, Morgan Beeby, Megan J. Dobro, Yongtao Zhu, Mark J. Mcbride, Ariane Briegel, Carrie L. Shaffer, Grant J. Jensen

Veterinary Science Faculty Publications

The ability to produce outer membrane projections in the form of tubular membrane extensions (MEs) and membrane vesicles (MVs) is a widespread phenomenon among diderm bacteria. Despite this, our knowledge of the ultrastructure of these extensions and their associated protein complexes remains limited. Here, we surveyed the ultrastructure and formation of MEs and MVs, and their associated protein complexes, in tens of thousands of electron cryo-tomograms of ~90 bacterial species that we have collected for various projects over the past 15 years (Jensen lab database), in addition to data generated in the Briegel lab. We identified outer MEs and MVs …

Improving Skin And Soft Tissue Antibiotic Duration Concordance With National Guidelines In Pediatric Urgent Care Clinics, Megan Hamner, Amanda Nedved, Holly Austin, Donna Wyly, Alaina N. Burns, Diana King, Brian Lee, Rana El Feghaly

Posters

Introduction: Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive >7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At CMH urgent care clinics (UCCs), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods: We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. …

Examining Associations Between Knowledge And Vaccine Uptake Using The Human Papillomavirus Knowledge Questionnaire (Hpv-Kq), Sayward Harrison, Valerie Yelverton, Jan Ostermann Ph.D., Laura J. Fish, Charnetta L. Williams, Lavanya Vasudevan, Emmanuel B. Walter

Faculty Publications

Objectives: Understanding the relationship between human papillomavirus (HPV) knowledge and vaccination behavior is important to inform public health interventions, yet few validated HPV knowledge scales exist. This study describes development of the Human Papillomavirus Knowledge Questionnaire (HPV-KQ) and its validation with parents residing in the southern United States (US). Methods: Drawing on previously published measures, we developed the 13-item HPV-KQ and administered the scale via Web-based survey to parents (N=1105) of adolescents ages 9 to 17 years. Dimensionality, internal consistency, model fit, and predictive validity were assessed. Results: The scale was bidimensional. One factor captured general HPV knowledge, and the …

Kualiteti I Jetës Së Pacientëve Në Hemodializë, Arlinda Salihu

Theses and Dissertations

Hyrje: Kushtet ekonomike të mira, përkrahja nga familja dhe miqtë, pjesëmarrja në seancat e hemodializës(HD)me rregull ,kufizimi i lëngjeve, respektimi i dietës, marrja e medikamenteve sipas rekomandimeve janë thelbësore për përmirësimin e kualitetit të jetës te pacientët në hemodializë. Qëllimi: Objektivi kryesor i këtij hulumtimi është vlerësimi i kualitetit të jetës te pacientët në hemodializë. Të vlerësohet regjimi dietik, dieta ushqimore, kushtet ekonomike, mbështetja familjare, përdorimi i rregullt i barnave të përshkruara nga mjeku, si dhe të vlerësohet roli i edukimit të profesionistëve shëndetësor. Metodologjia: Për hulumtim është zgjedhur Qendra e Hemodializës në Ferizaj, ku pjesëmarrësit në këtë …

Endophytes Of Brazilian Medicinal Plants With Activity Against Phytopathogens, Jucélia Iantas, Daiani Cristina Savi, Renata Da Silva Schibelbein, Sandriele Aparecida Noriler, Beatriz Marques Assad, Guilherme Dilarri, Henrique Ferreira, Jürgen Rohr, Jon S. Thorson, Khaled A. Shaaban, Chirlei Glienke

Pharmaceutical Sciences Faculty Publications

Plant diseases caused by phytopathogens are responsible for significant crop losses worldwide. Resistance induction and biological control have been exploited in agriculture due to their enormous potential. In this study, we investigated the antimicrobial potential of endophytic fungi of leaves and petioles of medicinal plants Vochysia divergens and Stryphnodendron adstringens located in two regions of high diversity in Brazil, Pantanal, and Cerrado, respectively. We recovered 1,304 fungal isolates and based on the characteristics of the culture, were assigned to 159 phenotypes. One isolate was selected as representative of each phenotype and studied for antimicrobial activity against phytopathogens. Isolates with better …

Reduction Of Central Line-Associated Bloodstream Infections In A Large Acute Care Hospital In Midwest United States Following Implementation Of A Comprehensive Central Line Insertion And Maintenance Bundle, Abraham E. Wei, Ronald J. Markert, Christopher Connelly, Hari Polenakovik

Internal Medicine Faculty Publications

Background: Central line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality. We describe the impact of various quality improvement interventions on the incidence of CLABSI in an 848-bed community teaching hospital from 1 January 2013 to 31 December 2017. Aim: To reduce CLABSI rates after implementation of a comprehensive central line insertion and maintenance bundle. Methods: A comprehensive bundle of interventions was implemented incorporating the standard US Centers for Disease Control and Prevention bundle with additional measures such as root-cause analysis of all CLABSI cases, use of passive disinfection caps on vascular …

Mental Health During Covid-19 Pandemic Among Caregivers Of Young Children In Kenya’S Urban Informal Settlements. A Cross-Sectional Telephone Survey, Vibian Angweny, Margaret Kabue, Esther Chongwo, Adam Mabrouk, Ezra Too, Rachel Odhiambo, Carophine Nasambu, Joyce Marangu, Derrick Ssewanyana, Eunice Njoroge, Eunice Ombech, Mercy Mokaya, Emmanuel Obulemire, Anil Khamis, Amina Abubakar

Institute for Human Development, East Africa

The emergence of COVID-19 has profoundly affected mental health, especially among highly vulnerable populations. This study describes mental health issues among caregivers of young children and pregnant women in three urban informal settlements in Kenya during the first pandemic year, and factors associated with poor mental health. A cross-sectional telephone survey was administered to 845 participants. Survey instruments included the Patient Health Questionnaire-9, General Anxiety Disorder-7 scale, COVID-19 Anxiety Scale, and questions on the perceived COVID-19 effects on caregiver wellbeing and livelihood. Data were analyzed using descriptive statistics, and univariate and multivariate analysis. Caregivers perceived COVID-19 as a threatening condition …

Himmelfarb Headlines - September/October 2021, George Washington University, Himmelfarb Health Sciences Library

Himmelfarb Headlines (2009 - present)

News, information, and resources relating to Himmelfarb Library that is of interest to patrons.

The Link Between Diabetes Mellitus And Tau Hyperphosphorylation: Implications For Risk Of Alzheimer's Disease, Amy L. Hobday, Mayur S. Parmar

HPD Articles

Diabetes mellitus (DM) is characterized by hyperglycemia caused by a lack of insulin, insulin resistance, or both. It is associated with the development of secondary complications resulting in several comorbidities. Recent studies have revealed an increased risk of developing cognitive dysfunction or dementia in diabetes patients. Diabetes mellitus is considered a risk factor for many neurodegenerative diseases, including Alzheimer's disease (AD). There is increasing evidence to support a link between DM and AD. Studies have shown the dysfunction of insulin signaling in the brain, resulting in increased tau protein phosphorylation (hyperphosphorylation), a hallmark and biomarker of AD pathology, leading to …

Cost-Effectiveness Analysis Comparing Integrated And Malaria-Only Social And Behavior Change Programming In Nigeria: Initial Costing Data, Avenir Health

Sexual and Reproductive Health, Rights, and Choices

Breakthrough RESEARCH is conducting an effectiveness evaluation of social and behavior change (SBC) programming implemented by Breakthrough ACTION in Nigeria, comparing an integrated SBC program in Kebbi and Sokoto states with a malaria-only SBC program in Zamfara state. Using these results on impact, a cost-effectiveness analysis will determine which approach is more cost-effective in achieving improvements in health. This report presents estimated costs for the initial stage of the project, from April 2018 through December 2019, in the three northern states where the study is being conducted.