Medicine and Health Sciences Commons^™

Classification Of Schizophrenia, Bipolar Disorder And Major Depressive Disorder With Comorbid Traits And Deep Learning Algorithms, Xiangning Chen, Yimei Lu, Joan Manuel Cue, Mira V Han, Vishwajit L Nimgaonkar, Daniel R Weinberger, Shizhong Han, Zhongming Zhao, Jingchun Chen

Faculty, Staff and Student Publications

Many psychiatric disorders share genetic liabilities, but whether these shared liabilities can be utilized to classify and differentiate psychiatric disorders remains unclear. In this study, we use polygenic risk scores (PRSs) of 42 traits comorbid with schizophrenia (SCZ), bipolar disorder (BIP), and major depressive disorder (MDD) to evaluate their utilities. We found that combining target specific PRS with PRSs of comorbid traits can improve the classification of the target disorders. Importantly, without inclusion of PRSs from targeted disorders, we can still classify SCZ (accuracy 0.710 ± 0.008, AUC 0.789 ± 0.011), BIP (accuracy 0.782 ± 0.006, AUC 0.852 ± 0.004), …

Targeting Tiam1 Enhances Hippocampal-Dependent Learning And Memory In The Adult Brain And Promotes Nmda Receptor-Mediated Synaptic Plasticity And Function, Francisco A Blanco, Md Ali Bin Saifullah, Jinxuan X Cheng, Carlota Abella, Federico Scala, Karen Firozi, Sanyong Niu, Jin Park, Jeannie Chin, Kimberley F Tolias

Faculty, Staff and Students Publications

Excitatory synapses and the actin-rich dendritic spines on which they reside are indispensable for information processing and storage in the brain. In the adult hippocampus, excitatory synapses must balance plasticity and stability to support learning and memory. However, the mechanisms governing this balance remain poorly understood. Tiam1 is an actin cytoskeleton regulator prominently expressed in the dentate gyrus (DG) throughout life. Previously, we showed that Tiam1 promotes dentate granule cell synapse and spine stabilization during development, but its role in the adult hippocampus remains unclear. Here, we deleted Tiam1 from adult forebrain excitatory neurons (Tiam1^fKO) and assessed …

An Open-Label Study To Determine The Maximum Tolerated Dose Of Oral Esk-440 Administered As A Single Agent In Patients With Advanced Or Metastatic Solid Tumors, Russell J. Schilder, Drew Rasco, Manish R. Sharma

Kimmel Cancer Center Faculty Papers

PURPOSE: Anaplastic lymphoma kinase (ALK) dysregulation is implicated in numerous cancers. Tyrosine kinase inhibitors (TKIs) targeting ALK have improved disease outcomes, but resistance mechanisms are common. This first-in-human trial evaluates ESK-440, a dual inhibitor of ALK and focal adhesion kinase, as a novel strategy for cancers with resistance to ALK-targeting TKIs.

METHODS: This phase 1, open-label, dose-finding study evaluated the maximum tolerated dose (MTD), safety, efficacy, and pharmacokinetics of ESK-440 in participants with advanced or metastatic solid tumors (ClinicalTrials.gov: NCT01922752). A 3 + 3 dose-escalation design, with daily doses ranging from 25 to 700 mg/day of ESK-440 for each 28-day …

How Health Literacy Influences Rural West Virginians Knowledge Of Chronic Disease Prevention And Management, Summer Mitchell

Walden Dissertations and Doctoral Studies

Health literacy can be described as the understanding of own’s own health and understanding of health-related information (Shadid, 2022). In rural communities, health literacy is typically at a lower level than in urban communities. West Virginia is a mostly rural state and in addition to lower health literacy, chronic diseases are high in West Virginia. The target area for this study was rural Greenbrier County, West Virginia. The purpose of the study was to examine perceived barriers to health literacy in Greenbrier County, West Virginia, and how this affects understanding of chronic disease. Research questions focused on participants’ knowledge of …

Acute Mecp2 Loss In Adult Mice Reveals Transcriptional And Chromatin Changes That Precede Neurological Dysfunction And Inform Pathogenesis, Sameer S Bajikar, Jian Zhou, Ryan O'Hara, Harini P Tirumala, Mark A Durham, Alexander J Trostle, Michelle Dias, Yingyao Shao, Hu Chen, Wei Wang, Hari Krishna Yalamanchili, Ying-Wooi Wan, Laura A Banaszynski, Zhandong Liu, Huda Y Zoghbi

Faculty, Staff and Students Publications

Mutations in the X-linked methyl-CpG-binding protein 2 (MECP2) gene cause Rett syndrome, a severe childhood neurological disorder. MeCP2 is a well-established transcriptional repressor, yet upon its loss, hundreds of genes are dysregulated in both directions. To understand what drives such dysregulation, we deleted Mecp2 in adult mice, circumventing developmental contributions and secondary pathogenesis. We performed time series transcriptional, chromatin, and phenotypic analyses of the hippocampus to determine the immediate consequences of MeCP2 loss and the cascade of pathogenesis. We find that loss of MeCP2 causes immediate and bidirectional progressive dysregulation of the transcriptome. To understand what drives gene downregulation, we …

Snap Participation As A Moderator Of Food And Nutrition Security And Combined Cardiometabolic Conditions: A Mixed Regression Approach, Maha Almohamad, Ruosha Li, Natalia I Heredia, Jayna M Dave, Eric E Calloway, Anjail Sharrief, Shreela V Sharma

Faculty, Staff and Student Publications

Objectives: To examine the relationships between food security, nutrition security, Supplemental Nutrition Assistance Program (SNAP) participation, and cardiometabolic outcomes, including hypertension, hyperlipidemia, or diabetes, among low-income U.S. individuals.

Methods: A cross-sectional survey of 486 participants (April–June 2021) assessed food and nutrition security and cardiometabolic outcomes. Mixed-effects logistic regression models adjusted for covariates and included a random effect for state of residence. Moderation analyses evaluated SNAP participation’s impact.

Results: Very low food security was associated with higher odds of having at least one cardiometabolic condition, such as hypertension, hyperlipidemia, or diabetes (AOR = 1.96; 95% CI: 1.04–3.69; p = 0.04). SNAP …

Braf Mutant Appendiceal Adenocarcinoma Differs From Colorectal Cancer But Responds To Braf-Targeted Therapy, Vinay K Pattalachinti, Emaan Haque, Mahmoud Yousef, Abdelrahman Yousef, Saikat Chowdhury, Michael Overman, Christine M Parseghian, Van K Morris, Bryan Kee, Ryan W Huey, Kanwal Raghav, Colin M Court, John Paul Shen

Faculty, Staff and Student Publications

Appendiceal Adenocarcinoma (AA) is a rare gastrointestinal cancer with no FDA-approved targeted therapies. Here, we retrospectively compare BRAF-mutant AA and colorectal cancer (CRC). BRAF mutation is rare in AA (3%). Unlike CRC, BRAFV600E AA is not associated with poor prognosis, female sex, microsatellite instability, mucinous histology, or poor differentiation. In both cancers, BRAFV600E but not atypical BRAF mutations are mutually exclusive with other Ras-activating mutations. BRAFV600E + EGFR inhibition shows efficacy in BRAFV600E AA (disease control rate = 80%, median progression-free survival = 7.1 months).

Advanced External Beam Stereotactic Radiotherapy For Skull Base Reirradiation, He Wang, Fahed M Alsanea, Dong Joo Rhee, Xiaodong Zhang, Wei Liu, Jinzhong Yang, Zhifei Wen, Yao Zhao, Tyler D Williamson, Rachel A Hunter, Peter A Balter, Tina M Briere, Ronald X Zhu, Anna Lee, Amy C Moreno, Jay P Reddy, Adam S Garden, David I Rosenthal, Gary B Gunn, Jack Phan

Faculty, Staff and Student Publications

Background/objectives: Stereotactic body radiation therapy (SBRT) for skull base reirradiation is particularly challenging, as patients have already received substantial radiation doses to the region, and nearby normal organs may have approached their tolerance limit from prior treatments. In this study, we reviewed the characteristics and capabilities of four advanced external beam radiation delivery systems and four modern treatment planning systems and evaluated the treatment plan quality of each technique using skull base reirradiation patient cases.

Methods: SBRT plans were generated for sixteen skull base reirradiation patients using four modalities: the GK plan for the Elekta Leksell Gamma Knife Perfexion/ICON, the …

Distributed Cross-Learning For Equitable Federated Models – Privacy-Preserving Prediction On Data From Five California Hospitals, Tsung-Ting Kuo, Rodney A Gabriel, Jejo Koola, Robert T Schooley, Lucila Ohno-Machado

Faculty, Staff and Student Publications

Quality improvement, clinical research, and patient care can be supported by medical predictive analytics. Predictive models can be improved by integrating more patient records from different healthcare centers (horizontal) or integrating parts of information of a patient from different centers (vertical). We introduce Distributed Cross-Learning for Equitable Federated models (D-CLEF), which incorporates horizontally- or vertically-partitioned data without disseminating patient-level records, to protect patients' privacy. We compared D-CLEF with centralized/siloed/federated learning in horizontal or vertical scenarios. Using data of more than 15,000 patients with COVID-19 from five University of California (UC) Health medical centers, surgical data from UC San Diego, and …

Brd7 Loss Reawakens Dormant Metastasis Initiating Cells In Lung By Forging An Immunosuppressive Niche, Jayanta Mondal, Junfeng Zhang, Feng Qing, Shunping Li, Dhiraj Kumar, Jason T Huse, Filippo G Giancotti

Faculty, Staff and Student Publications

Metastasis in cancer is influenced by epigenetic factors. Using an in vivo screen, we demonstrate that several subunits of the polybromo-associated BAF (PBAF) chromatin remodeling complex, particularly Brd7, are required for maintaining breast cancer metastatic dormancy in the lungs of female mice. Brd7 loss induces metastatic reawakening, along with modifications in epigenomic landscapes and upregulated oncogenic signaling. Breast cancer cells harboring Brd7 inactivation also reprogram the surrounding immune microenvironment by downregulating MHC-1 expression and promoting a pro-metastatic cytokine profile. Flow cytometric and single-cell analyses reveal increased levels of pro-tumorigenic inflammatory and transitional neutrophils, CD8+ exhausted T cells, and CD4+ stress …

Vasa Previa: Prenatal Diagnosis And The Rationale Behind Using A 5 Cm Distance From Internal Os, Claudio V Schenone, Faezeh Aghajani, Ali Javinani, Eyal Krispin, Yinka Oyelese, Ramesha Papanna, Ramen H Chmait, Alireza A Shamshirsaz

Faculty, Staff and Student Publications

In pregnancies with vasa previa, prenatal diagnosis and pre-labor cesarean delivery are associated with significantly improved perinatal outcomes compared to undetected cases. However, a universally accepted ultrasonographic definition of vasa previa is lacking. Specifically, the distance from the cervical internal os beyond which vaginal delivery can be safely recommended remains to be determined. Field experts and recently published societal guidelines agree that a 2 cm cut-off is suboptimal, given that complete cervical dilation during labor risks unprotected fetal vessels within a 5 cm radius from the internal os. Thus, in the setting of a scarcity of evidence and case reports …

Ddo-Adjuvanted Influenza A Virus Nucleoprotein Mrna Vaccine Induces Robust Humoral And Cellular Type 1 Immune Responses And Protects Mice From Challenge, Victoria Gnazzo, Hanaa Saleh, Ítalo A Castro, Adrianus C M Boon, Amelia K. Pinto, James D Brien, Carolina B López

2020-Current year OA Pubs

A challenge in viral vaccine development is to produce vaccines that generate both neutralizing antibodies to prevent infection and cytotoxic CD8

Detection Of Parasite Dna In Soil Samples From Rural Yucatan, Mexico, Liliana E Villanueva-Lizama, Angela Cruz-Coral, Christian Teh-Poot, Julio Vladimir Cruz-Chan, Rojelio Mejia

Faculty, Staff and Students Publications

The soil is the primary environmental reservoir for many parasites transmitted to humans that cause disease. Our environmental study used a multiparallel real-time quantitative polymerase chain reaction assay to detect parasite DNA in soil collected from the outdoor built environments of 34 houses in rural Yucatan, Mexico. The number of positive houses (n, %) per parasite species was 18 (53%) for Acanthamoeba spp.; four (12%) for Blastocystis spp. and Ascaris lumbricoides; three (9%) for Toxocara canis; and one (3%) for Ancylostoma spp., Trichuris trichiura, Entamoeba histolytica, and Giardia intestinalis. No DNA from Necator americanus, Strongyloides stercoralis, Toxocara cati, or Cryptosporidium …

Novel Intraoperative Applications Of Fluorescence Imaging Using Indocyanine Green In Pediatric Urology, Albert S T Lee, Ching Man Carmen Tong

Faculty, Staff and Students Publications

PURPOSE OF REVIEW: Near-infrared fluorescence imaging (NIRF) with the use of indocyanine green (ICG) has been recently adopted in pediatric urology after its well-published use in the adult population. As a powerful tool that can help delineate complex anatomy and congenital anomalies, we discuss the various applications of this imaging in minimally invasive and open surgery in pediatric urology.

RECENT FINDINGS: The most reported applications of ICG in pediatric urology are within minimally invasive surgery, particularly varicoceles, renal surgery such as nephrectomies and renal tumor excision, mimicking its use in adult urology. ICG has also been applied to reconstructive urology …

Advancing Mitochondrial Therapeutics: Synthesis And Pharmacological Evaluation Of Pyrazole-Based Inhibitors Targeting The Mitochondrial Pyruvate Carrier, Lingaiah Maram, Jessica M Michael, Henry Politte, Vaishnavi S Srirama, Aymen Hadji, Mohammad Habibi, Meredith O Kelly, Rita T Brookheart, Brian N Finck, Lamees Hegazy, Kyle S Mccommis, Bahaa Elgendy

2020-Current year OA Pubs

Inhibition of mitochondrial pyruvate transport via the mitochondrial pyruvate carrier (MPC) has shown beneficial effects in treating metabolic diseases, certain cancers, various forms of neurodegeneration, and hair loss. These benefits arise either from the direct inhibition of mitochondrial pyruvate metabolism or from the metabolic rewiring when pyruvate entry is inhibited. However, current MPC inhibitors are either nonspecific or possess poor pharmacokinetic properties. To address this, approximately 50 pyrazole-based MPC inhibitors were synthesized to explore the structure-activity relationship for MPC inhibition, evaluated through inhibition of mitochondrial pyruvate respiration. These inhibitors were designed with increased steric hindrance around electron-deficient double bonds, allowing …

Punch Cd3-Ols: A Phase 3 Prospective Observational Cohort Study To Evaluate The Safety And Efficacy Of Fecal Microbiota, Live-Jslm (Rebyota) In Adults With Recurrent Clostridioides Difficile Infection, Paul Feuerstadt, Teena Chopra, Whitfield Knapple, Nicholas W Van Hise, Erik R Dubberke, Brian Baggott, Beth Guthmueller, Lindy Bancke, Michael Gamborg, Theodore S Steiner, Daniel Van Handel, Sahil Khanna

2020-Current year OA Pubs

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of fecal microbiota, live-jslm (RBL; REBYOTA)-the first single-dose, broad consortia microbiota-based live biotherapeutic approved by the US Food and Drug Administration for preventing recurrent Clostridioides difficile infection (rCDI) in adults following standard-of-care (SOC) antibiotic treatment.

METHODS: PUNCH CD3-OLS was a prospective, phase 3, open-label study, conducted across the US and Canada. Participants were aged ≥18 years with documented rCDI and confirmed use of SOC antibiotics. Participants with comorbidities including inflammatory bowel disease and mild-to-moderate immunocompromising conditions could be enrolled. A single dose of RBL was rectally administered …

Neutralizing Antibody Immune Correlates For A Recombinant Protein Vaccine In The Covail Trial, Youyi Fong, Lauren Dang, Bo Zhang, Jonathan Fintzi, Shiyu Chen, Jing Wang, Nadine G Rouphael, Angela R Branche, David J Diemert, Ann R Falsey, Cecilia Losada, Lindsey R Baden, Sharon E Frey, Jennifer A Whitaker, Susan J Little, Satoshi Kamidani, Emmanuel B Walter, Richard M Novak, Richard Rupp, Lisa A Jackson, Chenchen Yu, Craig A Magaret, Cindy Molitor, Bhavesh Borate, Tara M Babu, Angelica C Kottkamp, Anne F Luetkemeyer, Lilly C Immergluck, Rachel M Presti, Martín Bäcker, Patricia L Winokur, Siham M Mahgoub, Paul A Goepfert, Dahlene N Fusco, Robert L Atmar, Christine M Posavad, Jinjian Mu, Mat Makowski, Mamodikoe K Makhene, Seema U Nayak, Paul C Roberts, Dean Follmann, Peter B Gilbert

Faculty, Staff and Students Publications

For COVAIL recipients of a coronavirus disease 2019 (COVID-19) Sanofi booster vaccine, neutralizing antibody titers were assessed as a correlate of risk (CoR) of COVID-19. Peak and exposure-proximal titers were inverse CoRs with covariate-adjusted hazard ratios (95% confidence intervals) 0.30 (0.11, 0.78) and 0.25 (0.07, 0.85) per 10-fold increase in weighted average titer.

Discordance Between 90y-Pet/Ct(Mr)-Estimated Activity And Dose Calibrator Measured Administered Activity: An International Study In Sirt Patients Treated With Resin And Glass Microspheres, Thomas Carlier, Silvano Gnesin, Justin K Mikell, Maurizio Conti, John O Prior, Niklaus Schaefer, Maria Del Sol Pérez Lago, Clément Bailly, Yuni K Dewaraja, Thiago V M Lima

2020-Current year OA Pubs

PURPOSE: Therapeutic administration of

METHODS: We analysed patient

RESULTS: Quantification ratio between calibrators and PET was significantly different from 1, regardless of the scatter correction used. In glass microspheres, the mean A

CONCLUSIONS: We observed in patients similar activity discrepancies as reported for vials, with a relative difference of 44 ± 16% between glass and resin

Priming For Practice: A Teaching Strategy, Jennifer Tomesko, Diane L. Rigassio Radler

Journal of Dietetic Education

Authors present a brief educational teaching strategy.

Use Of Simulation In Dietetic Internships: A Qualitative Exploration Of Program Director Attitudes And Motivations, Theresa B. O'Reilly, Amy J. Nwora, Megan Whelan, Mary-Pat Maciolek

Journal of Dietetic Education

The use of simulation holds promise for the future of dietetics education for its use as an alternative for up to 30% of the 1,000 supervised practice hours for the training of Registered Dietitian Nutritionists. Even more so, simulation is a teaching tool. When done well, simulation can challenge students in a safe environment where they can receive constructive feedback from expert guides and meaningfully reflect on their learning. The purpose of this study was to interview dietetic internship (DI) program directors on their attitudes and motivations on the use of simulation in their programs, targeting the heavily program-congested states …

Conceptual Diagrams Help Dietetic Students To Understand And Apply The Nutrition Care Process, Janica Jamieson, Bojana Kovacic, Philippa Lyons-Wall, Therese O'Sullivan

Journal of Dietetic Education

Aim: To evaluate the impact of a conceptual diagram assessment task on dietetic student knowledge of and confidence applying the Nutrition Care Process. Methods: Situated within a pragmatic research paradigm, this mixed methods study applied a survey administered before and after a conceptual diagram assessment task using the Nutrition Care Process to explore changes in student knowledge, self-reported confidence, perceptions towards the Nutrition Care Process, and student experience. Nineteen students enrolled in a first-semester unit within a Master level dietetic course completed the assessment task, which visually presented a client case sourced from the student-run clinic within the Nutrition Care …

Cover, Editor's Message, Table Of Contents, Diana Cuy Castellanos

Journal of Dietetic Education

No abstract provided.

The Usefulness Of 3d Heart Models As A Tool Of Congenital Heart Disease Education: A Narrative Review, Raghad Abdulaziz Alhojailan, Reghd Husain M Alkhalifah, Bana Albani, Majed Wadi

Journal of the Saudi Heart Association

Objectives: The objective of this review is to evaluate the effectiveness of three-dimensional (3D) heart models as teaching tools for congenital heart disease (CHD), addressing the limitations of traditional medical education methods. Methods: A thorough literature review was conducted using PubMed, Google Scholar, Scientific Direct and Scopus databases. Relevant articles were screened and selected based on their discussion of the application of 3D models in CHD education. Results: The comprehensive review of 19 studies revealed that 3D heart models provide students, healthcare professionals, and patients with meaningful experiences that significantly enhance understanding and learning outcomes. These models improve …

Advances In 2024: Update And Thanking Our Peer Reviewers, Richard Alweis, Christina Goodermote, Elizabeth Mamo

Advances in Clinical Medical Research and Healthcare Delivery

The Editors review the performance of the journal and thank the peer reviewers for 2024.

Monroe County Medical Society Abstract Competition, Janine Fogarty

Advances in Clinical Medical Research and Healthcare Delivery

Established in 1821 in Rochester, New York, Monroe County Medical Society is a non-profit, professional organization whose 1,200 members are physicians, residents, and medical students. The society advocates for physicians and patients for the betterment of the medical profession and the health of the community. Monroe County Medical Society encompasses the 7th District Branch of the Medical Society of the State of New York and serves the New York State counties of Monroe, Livingston, Ontario, Seneca, Steuben, Wayne & Yates Counties

A call for abstracts was requested for the Monroe County Medical Society 203rd Anniversary Gala held on September 25th, …

Murder Mystery Solved! Unmasking Multi-Generational Familial Death As A Result Of Brugada Syndrome, Ryan Tam, Sandres Aodish, Jeremiah Tom, Mohammad Jawish

Advances in Clinical Medical Research and Healthcare Delivery

Brugada syndrome is an inherited condition that has an increased risk of developing ventricular arrhythmias and sudden cardiac death. This condition can be diagnosed by using the Shanghai Scoring System. Here, we present a patient with an incidental finding of Type 1 Brugada pattern on electrocardiogram amidst atypical neurological findings on presentation to the emergency department and a history of cardiac-related familial deaths of uncertain etiology.

One Center's Experience Of Pulmonary Embolism After Covid-19: Impact Of Vaccination Status, Cara Gose, Kaylee Dixon, Andrea M. Bodine Md

Advances in Clinical Medical Research and Healthcare Delivery

Background: The incidence of pulmonary embolism (PE) has increased since the outbreak of the COVID-19 pandemic and may be due to the observed hypercoagulable state. There is conflicting evidence that thromboembolism risk increases after vaccination and that vaccines decrease the probability of having a thromboembolic event. This study aimed to explore how vaccination status impacts occurrence of PE after a positive COVID-19 test. The hypothesis was that vaccinated, immunocompetent patients have a lower incidence of PE after COVID-19 compared to unvaccinated patients.

Methods: This was a retrospective chart review at a teaching hospital in New England from 1/01/2021 to 3/31/2023 …

A Compelling Case Of The Use Of Electroconvulsive Therapy In Severe Treatment Resistant Depression With Suicidality, Neha Narayanan, Ryan Tam, James Mead

Advances in Clinical Medical Research and Healthcare Delivery

Treatment-resistant depression is a condition that occurs when an individual, experiencing major depressive disorder episodes, has failed the first line of treatment with medication therapy of adequate dose and duration. This is important to be addressed as there is a high likelihood of progression to having thoughts and an intended plan for suicide. Electroconvulsive therapy is a recommended option for those who have failed medication therapy, but it has been controversial in its use due to its stigma and side effects of memory impairment. Here, we present a case of a patient who had undergone several sessions of ECT with …

Special Patient Populations - A Case Report Of A Jehovah’S Witness, Michael P. Mullinax, S. Jiaming Lin, Paige M. Kieper, Jake W. Vogel, Orlando Nunez Isaac

Advances in Clinical Medical Research and Healthcare Delivery

This case report describes a Jehovah’s Witness patient with a life-threatening exacerbation of chronic anemia, warranting blood transfusion. This case highlights the complex medical management and ethical considerations encountered when treating special patient populations. Moreover, this case illustrates the delicate balance that healthcare providers must maintain when delivering necessary medical interventions to patients with competing religious beliefs.

Enfortumab Vedotin Induced Cutaneous Manifestations, Zeni Kharel, Farhan S. Imran

Advances in Clinical Medical Research and Healthcare Delivery

Enfortumab vedotin(EV) comprises of an anti–nectin-4 monoclonal antibody bound to the chemotherapeutic agent called monomethyl auristatin E, forming an antibody-drug conjugate. It is currently approved for the treatment of locally advanced or metastatic urothelial carcinoma after disease progression on two prior lines of therapy including chemotherapy and immunotherapy. Since nectin-4 is also expressed on the surface of keratinocytes, cutaneous adverse effects are common. Our clinical image depicts a cutaneous adverse reaction to EV and its resolution after discontinuation of EV.