Medicine and Health Sciences Commons^™

Persistent Barriers To Implementation Of Long-Acting Injectable Antiretroviral Therapy, Jessica Hack, Adati Tarfa, Harlan Sayles, Nada Fadul

EMET Projects

No abstract provided.

Hospital Admissions Of Patients Experiencing Housing Instability, Rizwan M. Siddiqui, Jainaha K. Srikumar, Andrew S. Leavitt, Luke R. Siedhoff, Jenenne Geske, Jennifer Liu

EMET Projects

No abstract provided.

Anti-Maa Antibodies Increase Disease Severity In A Mouse Model Of Inflammatory Bowel Disease, William P. Mcguire Iii, Michael J. Duryee, Rizwan Ahmad, Punita Dhawan, Amar B. Singh, Geoffrey M. Thiele

EMET Projects

No abstract provided.

Labeled, Hannah E. Manoj

EMET Projects

To explore the extent to which stigma permeates the field of psychiatry, this project, entitled “LABELED”, involved writing a series of structured poems for ten commonly stigmatized mental illnesses: anorexia nervosa, antisocial personality disorder, attention-deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, schizophrenia, and substance use disorder. The shortest poems in each set focus on stereotypes and first impressions commonly held about these disorders while the longer poems center around the identity of these individuals beyond their diagnoses. Amongst each set of poems, there is a recontextualization of the words shared between …

The Peptidyl Arginine Deiminase Inhibitor Bb-Cla Decreases The Inflammatory And Fibrotic Responses In Macrophages And Rheumatoid Arthritis Synovial Fibroblasts Exposed To Fibrinogen Modified With Malondialdehyde-Acetaldehyde Adduct And Citrulline, Jack E. Mordeson, Nozima Aripova, Michael J. Duryee, James R. O'Dell, Bryant England, Daniel Anderson, Ted R. Mikuls, Geoffrey M. Thiele

EMET Projects

Background. Peptide citrullination and adduction with malondialdehyde-acetaldehyde adduct (MAA) are involved in the pathogenesis of rheumatoid arthritis (RA). Anti-cyclic citrullinated peptide antibodies are >90% specific for the diagnosis of RA, and MAA co-localizes with citrullinated proteins in RA synovial fluid. In addition, macrophages demonstrate increased expression of peptidyl arginine deiminase-2 (PAD2), an isozyme of PAD, in response to these MAA-adducted proteins. PAD catalyzes protein citrullination and may mediate the immunogenic transformation of synovial proteins and subsequent auto-antibody formation in RA. Here, we determine whether inhibition of PAD effects inflammatory and fibrotic markers in macrophages and RA human fibroblast-like synoviocytes (HFLS-RA) …

Vitamin D Status And Oxidative Stress In Children With Sickle Cell Anaemia In Sagamu, Nigeria, Ayobola A. Sonuga, Oyebola O. Sonuga, Olatunbosun O. Ogundeji, Sunday P.

Sultan Qaboos University Medical Journal

Objectives: Sickle cell anaemia (SCA) is characterised by nutritional deficiencies and oxidative stress. Vitamin D possesses antioxidant properties; however, its role in SCA within sub-Saharan Africa remains inadequately understood. This study aimed to investigate the relationship between vitamin D status, oxidative stress and antioxidant levels in children with SCA, exploring its possible role in mitigating complications associated with oxidative stress in SCA. Methods: This study was conducted for a period of 9 months from November 2022 until July 2023 at the Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria. This case-control study involved 100 HbS genotype and 100 HbA genotype …

Adipose Progenitor Cell-Derived Extracellular Vesicles Suppress Macrophage M1 Program To Alleviate Midlife Obesity, Qing Zhou, Jia Gao, Guorao Wu, Chenwei Wang, Yan Yang, Teng Huang, Yi Wang, Tiantian Yue, Zhichao Gao, Hao Xie, Fei Xiong, Ke Xiang, Tuying Yong, Wanguang Zhang, Tongtong Zhang, Wen Kong, Cai Chen, Shu Zhang, Qilin Yu, Xuemei Fan, Shiwei Liu, Yanjun Liu, Cong-Yi Wang

Children’s Nutrition Research Center Staff Publications

Among different age groups, middle-aged individuals are particularly susceptible to obesity, with a 22% higher risk of all-cause mortality. However, the underlying mechanisms remain unclear. In this study, we identify adipose progenitor cells (APCs) in the white adipose tissue (WAT) of middle-aged subjects as potential causes of midlife obesity. Specifically, the extracellular vesicles (EVs) derived from APCs display an impaired ability to mitigate the inflammaging of adipose tissue macrophages (ATMs) in middle-aged individuals. Mechanistically, these EVs, lacking miR-145-5p, fail to suppress the expression of L-selectin in ATMs, thereby facilitating their M1 program via the NF-κB signaling pathway. In contrast, EVs …

A Geospatial Analysis Of The Lung Cancer Burden In Philadelphia, Using Pennsylvania Cancer Registry Data From 2008-2017, Russell K. Mcintire, Katherine Senter, Christine S. Shusted, Rickisa Yearwood, Julie Barta, Scott W. Keith, Charnita Zeigler-Johnson

Division of Pulmonary, Allergy, and Critical Care Medicine Faculty Papers

(1) Background: Lung cancer is the deadliest and second most prevalent cancer in Pennsylvania (PA), and African American patients are disproportionately affected. Lung cancer morbidity and mortality in Philadelphia County are among the highest in PA. Geographic information systems (GIS) are useful to explore geospatial variations in the cancer burden and risk factors. Therefore, we used GIS to analyze the lung cancer burden in Philadelphia to assess which areas of the city have the highest morbidity and mortality, identify potential clusters, and determine which census tract-level characteristics were associated with higher tract-level cancer burden. (2) Methods: Using secondary data from …

Use And Benefits Of A Therapeutic Hypnosis Interactive Media Program For Chronic Pain Management: A Pilot Study, Mark P. Jensen, Joy F. Chan, Owen Gottlieb, Laurence I. Sugarman, Emily Stensland

Articles

Chronic pain is a common condition that has significant negative effects on individuals and society. Opioids continue to be the primary treatment provided to the billions of individuals with chronic pain, despite their general lack of efficacy and significant negative side effects. A growing body of research supports the potential of therapeutic hypnosis for helping individuals better manage their chronic pain. However, access to this treatment is limited. The availability of a hypnosis digital therapeutic has the potential to address this access problem. The current study was designed to evaluate the feasibility of a digital therapeutic hypnosis prototype (not yet …

Do We Need To Add The Type Of Treatment Planning System, Dose Calculation Grid Size, And Ct Density Curve To Predictive Models?, Reza Reiazi, Surendra Prajapati, Leonardo Che Fru, Dongyeon Lee, Mohammad Salehpour

Faculty, Staff and Student Publications

Background: Generalizability and domain dependency are critical challenges in developing predictive models for healthcare, particularly in medical diagnostics and radiation oncology. Predictive models designed to assess tumor recurrence rely on comprehensive and high-quality datasets, encompassing treatment planning parameters, imaging protocols, and patient-specific data. However, domain dependency, arising from variations in dose calculation algorithms, computed tomography (CT) density conversion curves, imaging modalities, and institutional protocols, can significantly undermine model reliability and clinical utility.

Methods: This study evaluated dose calculation differences in the head and neck cancer treatment plans of 19 patients using two treatment planning systems, Pinnacle 9.10 and RayStation 11, …

Evaluating Medical Usage And Injury Prevalence At The 2024 College World Series, Roarick Schollmeyer, Jd Gregerson, Benjamin Stevens, Katie Weaver, Joseph Lippert

EMET Projects

Large-scale events such as the College World Series (CWS) pose unique challenges for medical services due to high crowd density, prolonged event durations, and variable environmental conditions. This study aimed to assess the medical usage rate (MUR) and injury prevalence at the 2024 CWS to inform future event planning and emergency medical preparedness. A retrospective analysis was conducted using patient encounter data collected between June 14 and June 24, 2024. Data sources included Union Medical event services, which documented on-site treatments and dispositions, and Omaha Fire Department EMS records detailing prehospital care. The MUR was calculated as the number of …

Hospital Re-Admission, Length Of Stay, And Chief Complaints Of Patients Experiencing Housing Instability, Andrew S. Leavitt, Jainaha K. Srikumar, Rizwan M. Siddiqui, Luke R. Siedhoff, Jennifer Liu, Jenenne Geske

EMET Projects

No abstract provided.

Exploring The Role Of Physical Health Interventions In The Management Of Mental Health Disorders: A Comparative Study Of Mental Health And Kinesiology Professionals' Perspectives, Vicki Hamill

Doctorate in Kinesiology

The study's purpose was to understand the factors that may influence the use of physical health interventions in the mental health treatment process. The lack of professional guidelines for kinesiology professionals has been linked to an implementation gap of evidenced based exercise prescription in the prevention of the physical health comorbidities associated with mental illness. These comorbidities are linked to a 15-20 year decrease in life expectancy, long-term disability, and increased healthcare costs. The Exercise in Mental Illness Questionnaire-Health Professional (EMIQ-HP) was used in the study to compare the mental health and kinesiology professional perspective in the domains of exercise …

Diaphragmatic Paralysis Following Chest Tube Insertion In An Infant: Case Report And Literature Review, Mohammed Al Ghafri, Said Al Hanshi, Ahmad E. Fouad, Ahmed M.

Sultan Qaboos University Medical Journal

Diaphragmatic paralysis (DP) can occur due to central nervous system pathology or peripheral nerve injury. Direct injury to the phrenic nerve after intercostal chest drain (ICD) insertion for treatment of pneumothorax is an infrequent complication. We present a 4-month-old infant, ex-preterm 27 weeks, who was admitted to a tertiary care hospital paediatric intensive care unit in Muscat, Oman, in 2023 with severe respiratory syncytial virus bronchiolitis and required intubation and mechanical ventilation (MV). His illness was complicated by right-side pneumothorax that required ICD insertion. Post-extubation, he had persistent tachypnoea with the inability to be weaned from non-invasive ventilation. Chest X-ray …

Two-Dimensional Speckle Tracking Of The Ascending Aorta: A Novel Approach To Evaluate Arterial Stiffness In Pediatric Patients With Repaired Conotruncal Anomalies Using Echocardiography., Anmol Goyal, Anitha Parthiban, David A. White, Daniel Forsha, Doaa Aly

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Children with repaired conotruncal abnormalities (CTA) are at risk of progressive aortic dilation and deteriorating aortic elasticity even after surgical correction. Strain imaging, using a 2-dimensional speckle tracking echocardiography (2D-STE), has been used for arterial stiffness assessment, but pediatric data are still lacking. We investigated the feasibility, reproducibility, and clinical value of 2D-STE derived ascending aorta (AAo) stiffness in children with repaired CTA.

METHODS: 22 pediatric patients with repaired CTA were included along with 25 age- and sex- matched healthy controls (mean age 10.2 ± 4.5 years). Conventional 2D echocardiographic and 2D-STE assessment of AAo mechanics was performed. M-mode …

Evaluation And Surgical Management Of Pediatric Cutaneous Melanoma And Atypical Spitz And Non-Spitz Melanocytic Tumors (Melanocytomas): A Report From Children's Oncology Group, Michael R Sargen, Raymond L Barnhill, David E Elder, Susan M Swetter, Victor G Prieto, Jennifer S Ko, Armita Bahrami, Pedram Gerami, Arivarasan Karunamurthy, Alberto S Pappo, Lynn M Schuchter, Philip E Leboit, Iwei Yeh, John M Kirkwood, Melinda Jen, Ira J Dunkel, Megan M Durham, Emily R Christison-Lagay, Mary T Austin, Jennifer H Aldrink, Casey Mehrhoff, Elena B Hawryluk, Emily Y Chu, Klaus J Busam, Vernon Sondak, Jane Messina, Susana Puig, Andrew J Colebatch, Carrie C Coughlin, Kristen G Berrebi, Theodore W Laetsch, Sarah G Mitchell, Brittani Seynnaeve

Faculty, Staff and Student Publications

Purpose: The purpose of this study was to develop recommendations for the diagnostic evaluation and surgical management of cutaneous melanoma (CM) and atypical Spitz tumors (AST) and non-Spitz melanocytic tumors (melanocytomas) in pediatric (age 0-10 years) and adolescent (age 11-18 years) patients.

Methods: A Children's Oncology Group-led panel with external, multidisciplinary CM specialists convened to develop recommendations on the basis of available data and expertise.

Results: Thirty-three experts from multiple specialties (cutaneous/medical/surgical oncology, dermatology, and dermatopathology) established recommendations with supporting data from 87 peer-reviewed publications.

Recommendations: (1) Excisional biopsies with 1-3 mm margins should be performed when feasible for clinically …

Sap30, A Novel Autophagy Regulatory Gene In Neuroblastoma, Anup S Pathania, Anjana Murugan, Areem Zahid, Haritha Chava, Don W Coulter, George A Calin, Kishore B Challagundla

Faculty, Staff and Student Publications

Neuroblastoma (NB), a devastating pediatric cancer originating from neural crest cells crucial for nervous system development, poses a significant therapeutic challenge. Despite chemotherapy being the primary treatment, approximately 70% of high-risk NB cases develop resistance. Autophagy is vital for neuronal development, balance, and differentiation of neural stem cells into mature neurons. However, the intricate mechanisms governing autophagy and the pivotal genes orchestrating its regulation in NB remain largely elusive. In this study, we first identified Sin3A Associated Protein 30 (SAP30) as a novel regulator of autophagy in NB. Silencing SAP30 inhibits autophagy and disrupts starvation-induced physiological autophagy in NB cells. …

A Rare Case Of Acute Carbon Monoxide Toxicity Mimicking Stroke And Successfully Managed With Hyperbaric Oxygen Therapy, Yasser K. Al Lawati, Darpanarayan Hazra, Awatif K.A. Abri, Suad Al

Sultan Qaboos University Medical Journal

Acute carbon monoxide (CO) poisoning significantly impacts neurological function, stemming from incomplete combustion of carbon-containing materials; this poses a substantial risk. Symptoms range from mild headaches to severe neurological complications, complicating diagnosis. Primary treatment involves supplemental oxygen via a non-rebreather mask. Hyperbaric oxygen therapy (HBOT), though debated, initiated within 6 hours, may enhance carboxyhaemoglobin (CO-Hb) elimination and tissue oxygenation, even with decreased CO-Hb levels. We report an 82-year-old female patient who presented to the emergency department of a tertiary care hospital in Muscat, Oman, in 2024 with symptoms initially suggestive of a cerebrovascular event. However, further history and examination revealed …

A Case Of Mirizzi Syndrome With Pancreatic Divisum: A Rare Association, Divya Muthuvel, Anita Soundarapandian

Sultan Qaboos University Medical Journal

Mirizzi syndrome (MS), a rare complication of gallstones, refers to extrahepatic biliary compression by calculus in the cystic duct or Hartman's pouch and is usually associated with cystic duct abnormalities. Its association with pancreatic divisum (PD) is infrequent, the most common complication of PD being recurrent pancreatitis. We report a 39-year-old female patient who presented to a department of general surgery in Chennai, India, in 2022 with acute abdominal pain. Magnetic resonance cholangiopancreaticography (MRCP) showed calculous cholecystitis with a calculus indenting the cystic duct, causing luminal narrowing of the common hepatic duct (type I), which was associated with type II …

Brief Of 76 Scholars Of Law, Business, Economics, And Medicine As Amici Curiae, Charles Duan

Amicus Briefs & Court Filings

No abstract provided.

Dna Damage Response Signatures Are Associated With Frontline Chemotherapy Response And Routes Of Tumor Evolution In Extensive Stage Small Cell Lung Cancer, Benjamin B Morris, Simon Heeke, Yuanxin Xi, Lixia Diao, Qi Wang, Pedro Rocha, Edurne Arriola, Myung Chang Lee, Darren R Tyson, Kyle Concannon, Kavya Ramkumar, C Allison Stewart, Robert J Cardnell, Runsheng Wang, Vito Quaranta, Jing Wang, John V Heymach, Barzin Y Nabet, David S Shames, Carl M Gay, Lauren A Byers

Faculty, Staff and Student Publications

Introduction: A hallmark of small cell lung cancer (SCLC) is its recalcitrance to therapy. While most SCLCs respond to frontline therapy, resistance inevitably develops. Identifying phenotypes potentiating chemoresistance and immune evasion is a crucial unmet need. Previous reports have linked upregulation of the DNA damage response (DDR) machinery to chemoresistance and immune evasion across cancers. However, it is unknown if SCLCs exhibit distinct DDR phenotypes.

Methods: To study SCLC DDR phenotypes, we developed a new DDR gene analysis method and applied it to SCLC clinical samples, in vitro, and in vivo model systems. We then investigated how DDR regulation is …

Do We Need To Add The Type Of Treatment Planning System, Dose Calculation Grid Size, And Ct Density Curve To Predictive Models?, Reza Reiazi, Surendra Prajapati, Leonardo Che Fru, Dongyeon Lee, Mohammad Salehpour

Faculty, Staff and Student Publications

Background: Generalizability and domain dependency are critical challenges in developing predictive models for healthcare, particularly in medical diagnostics and radiation oncology. Predictive models designed to assess tumor recurrence rely on comprehensive and high-quality datasets, encompassing treatment planning parameters, imaging protocols, and patient-specific data. However, domain dependency, arising from variations in dose calculation algorithms, computed tomography (CT) density conversion curves, imaging modalities, and institutional protocols, can significantly undermine model reliability and clinical utility.

Methods: This study evaluated dose calculation differences in the head and neck cancer treatment plans of 19 patients using two treatment planning systems, Pinnacle 9.10 and RayStation 11, …

Fact Sheet: Methamphetamine, Aaron Hunt, Gabriela Murza, Jenna Hawks, Alyssa Ferrin

All Current Publications

Methamphetamine, or meth, is a powerful stimulant that speeds up the central nervous system, causing increases in heart rate, blood pressure, and how fast the body uses energy. This fact sheet explains how meth is habit-forming and addictive and what it does to your body. It also explains overamping and responding to such an emergency.

Comparison Of Syndromic Surveillance And Hospital Discharge Data For Unintentional Drowning In Metropolitan Houston, Texas, Usa, Nicholas Peoples, Jennifer L Jones, Elizabeth A Camp, Ned Norman Levine, Rohit P Shenoi

Faculty, Staff and Students Publications

Background: Syndromic surveillance, which provides real-time data, may provide timely drowning surveillance compared with hospital discharge data where the release of data may be delayed. We compared data on hospital visits for unintentional drowning identified in hospital discharge and syndromic surveillance data sets for accuracy and completeness.

Methods: We compared data for hospital visits for unintentional drowning identified in the Texas Health Care Information Collection hospital discharge and syndromic surveillance data sets for metropolitan Houston, Texas, USA from 2019 to 2021. Hospital visits included emergency department-only visits and hospital admissions. We compared time-series visualisation of hospital visits between data sets. …

Mpox In The Gulf Cooperation Council Countries: Addressing A New Challenge To Regional Health Security, Salah Al Awaidy, Jaffar A. Al-Tawfiq, Faryal Maslamani, Muna Al, Jameela Al Salman, Sk Md Mamunur Rahman Malik

Sultan Qaboos University Medical Journal

No abstract provided.

Efficacy Of Hormonal And Non-Hormonal Vaginal Gel Preparations On The Female Sexual Satisfaction Index In Postmenopausal Women With Sexual Dysfunction Syndrome: A Prisma-Compliant Meta-Analysis, Ahmed Soliman, Hanaa Alrashidi, Mohamed A. Ghorab, Reem, Nihal Al Riyami, Ahmed Sa Ashour, Yasmine A. Mohammed, Ahmed H. Saad

Sultan Qaboos University Medical Journal

This meta-analysis aimed to compare the efficacy of vaginal gel preparations versus placebo in postmenopausal women with sexual dysfunction syndrome. Searches of electronic databases from inception to January 2023 identified 8 trials (N = 672) that reported the Female Sexual Function Index (FSFI) and compared hormonal (oestrogen, oxytocin) and/or non-hormonal (chamomile, fennel) interventions against placebo. The Cochrane Risk of Bias tool was used to assess studies' quality. The vaginal gel group had a significantly higher total FSFI endpoint score (mean difference [MD] = 6.67, 95% confidence interval [CI]: 3.79--9.55; P < 0.001) than placebo. Non-hormonal gels exhibited a greater FSFI total score (MD = 6.73, 95% CI: 4.7--8.76; P < 0.001) than hormonal gels (MD = 2.75, 95% CI: 1.87--3.64; P < 0.001), positively impacting all FSFI domains. These findings indicate that chamomile and fennel vaginal gels may improve the overall FSFI 6 domains score, reflecting enhancements in postmenopausal women's sexual activity and satisfaction.

Diagnostic Accuracy Of Abdominal Ultrasonographic Sliding Sign In The Evaluation Of Severe Intra-Abdominal Adhesions Involving The Uterus In Women Undergoing Repeat Caesarean Delivery: Systematic Review And Meta-Analysis, Amira M. Taha, Wesam A. Moawad, Sara A.A. Alhejazi, Tala J., Youstina A. Sabri, Mohamed Abd-Elgawad, Juan L. Alcazar, Nihal Al Riyami, Ayatallah Khafagy, Yasmine A. Mohammed, Ahmed H. Saad

Sultan Qaboos University Medical Journal

This review aimed to assess diagnostic accuracy of transabdominal ultrasonography (TAS) sliding sign in diagnosing severe intra-abdominal adhesions with repeated Caesarean delivery (CD). PubMed, Google Scholar, Web of Science and Scopus were searched for published studies until October 2022. Studies evaluating the sliding sign as a predictor of intra-abdominal adhesions after repeat CD were included. STATA and Comprehensive Meta-Analysis for meta-analysis was used. A total of 7 studies (1,318 patients) were included. For identifying severe intra-abdominal adhesions, sliding sign on TAS had a combined sensitivity (64%, 95% confidence interval [CI]: 55-71%), specificity (93%, 95% CI: 89-96%), positive likelihood ratio (9.5, …

Improving Female Health At Various Life Stages: A Systematic Review Of The Impact Of Date Fruit Products, Elham Shirdel, Farinaz Rahimi, Masoumeh Abdi, Fatemeh, Fatemeh Alsadat Rahnemaei

Sultan Qaboos University Medical Journal

This systematic review examines the effects of date fruit products on female health across different life stages. The quality of the included studies was assessed using the risk of bias tool. A total of 21 eligible studies were reviewed, demonstrating that date fruit consumption benefits puberty, reproductive health, and menopause. During puberty, date fruit intake was associated with improved hemoglobin levels in adolescent girls. In reproductive-age women, date fruits positively influenced fertility parameters and sexual function. Additionally, in menopause, they contributed to alleviating dyspareunia and supporting ovarian reserve maintenance. Providing women with proper nutrition and integrating date fruits into their …

Assessing Vascular Biomarkers And Their Association With Hypertension In Paediatric Chronic Kidney Disease, Samira Z. Sayed, Engy R. Mohamed, Mohamed T. A. Ali, Lamia H., Mohamed H. Mahgoob

Sultan Qaboos University Medical Journal

Objectives: This study aimed to examine the correlation between children with chronic kidney disease (CKD) and endothelial dysfunction biomarkers, including asymmetric dimethylarginine (ADMA), angiopoietin-2 (Ang-2) and vascular endothelial growth factor-A (VEGF-A), as well as blood pressure and cardiovascular risk. Methods: This case-control study included children who were divided into 2 groups: children with CKD at different stages and healthy controls. The study was performed from November 2021 to October 2022 at El-Minia University hospitals and the general outpatient paediatric clinic at Minia University, Minya, Egypt. Blood pressure measurements were taken, and levels of ADMA, Ang-2 and VEGF-A were …

Role Of Intratumoural Budding And Its Association With Tumour-Associated Macrophages In Preoperative Biopsies Of Oral Squamous Cell Carcinoma, Anju Devi, R Keerthika, Mala Narwal, Anjali

Sultan Qaboos University Medical Journal

Objectives: Intratumoural budding (ITB) is an emerging entity in oral squamous cell carcinoma (OSCC) and serves as a prime histopathological predictor of aggressive potential. This study aimed to investigate the incidence of ITB in OSCC due to its limited representation in the literature. Methods: This retrospective study was conducted in the Department of Oral Pathology and Microbiology, Post Graduate Institute of Dental Sciences, Rohtak, India, between 2017 and 2021. A total of 73 haematoxylin and eosin-stained sections of various grades of OSCC were examined for ITB and tumour-associated macrophages (TAMs), focusing on correlating these findings with clinicopathological parameters. …