Medicine and Health Sciences Commons^™

A Guide To Sexual Intimacy Following Spinal Cord Injury, Jillian M. Olenick

Entry Level Occupational Therapy Doctoral Capstone Projects Class of 2025

A Guide to Sexual Intimacy Following Spinal Cord Injury is a two-part manual that was created to increase the knowledge related to how sex can be impacted following a spinal cord injury. The first manual was created as a guide for individuals with spinal cord injuries and their partners to enhance their knowledge on how their spinal cord injury may impact their sexual functioning. The second manual was created as a guide for occupational therapy practitioners to use as a resource when addressing sex with their clients following a spinal cord injury. Each manual provides information related to sexual intimacy, …

Management Approaches To Spastic Gait Disorders, Sheng Li, Tulsi Pandat, Bradley Chi, Daniel Moon, Manuel Mas

Faculty, Staff and Student Publications

Spastic gait presents clinically as the net mechanical consequence of neurological impairments of spasticity, weakness, and abnormal synergies and their interactions with the ground reaction force in patients with upper motor neuron syndromes and with some neuromuscular diseases. It is critical to differentiate whether the primary problem is weakness or spasticity, thus better understanding different phenotypes of spastic gait disorders. Pelvic girdle abnormality plays a pivotal role in determining the clinical presentation of gait disorders, since it determines the body vector and compensatory kinetic chain reactions in the knee and ankle joints. Knee joint abnormality can be a mechanical compensation …

Patient-Specific Preoperative Plans Can Optimize Femoral Head Coverage And Range Of Motion After Periacetabular Osteotomies, Shuyang Han, Carey A Clark, Nicholas J Dunbar, Madison Brenner, Alexis H Aboulafia, Alfred A Mansour Iii, Philip C Noble

Faculty, Staff and Student Publications

Background: The goal of a periacetabular osteotomy is to increase the coverage of the femoral head, primarily in the antero-lateral region, through rotation of the acetabulum in three anatomical planes. The present study was undertaken to determine whether specific combinations of lateral rotation, anterior rotation, and anteversion of the acetabular fragment can be targeted to provide the best balance between femoral head coverage and joint motion.

Methods: Three-dimensional patient-specific hip models were reconstructed from preoperative computerized tomography scans of 15 patients diagnosed with hip dysplasia. Each model was placed in a standard coordinate system with neutral pelvic tilt and femoral …

Exploring Ict Adoption In Teaching And Learning Of Science: A Case Of Senior Teachers In Kenya, David Odhiambo, Winston Edward Massam, Fredrick Mtenzi

Institute for Educational Development, East Africa

This study was conducted in Homa Bay Sub County, Kenya to explore the adoption of ICT among senior teachers, aged between 45-60 years, in teaching and learning of science. A qualitative research approach using a case study design was employed. Eight secondary school senior teachers of science, 2 females and 6 males, within Homa Bay Sub County were purposefully selected. Semi structured interviews were conducted one-on-one basis followed by classroom observation and document analysis. Analysis of the data revealed that senior teachers of science generally integrate ICTs in planning, assessment and in classroom teaching; however pedagogical preferences and teacher’s workload …

Evaluating Quadrupedal Locomotion In Bats: A Geometric Morphometric Comparison Of Vertebral Adaptations Across Mammals, Jessica Upham

Electronic Theses and Dissertations

Flight is the primary locomotion of bats, while quadrupedal locomotion is not often observed and is widely variable among bats. Frugivorous bats in Pteropodidae are more efficient climbers than frugivorous bats in Phyllostomidae and insectivorous bats in Vespertilionidae, while phyllostomids and vespertilionids are better at walking on horizontal surfaces. The aim of this study is to investigate whether bats with differing modes of nonflight locomotion also exhibit disparity in thoracolumbar vertebral morphology. Using geometric morphometrics, we compared the thoracolumbar vertebral shapes of these bat families with other terrestrial and arboreal mammals. The results revealed distinct vertebral shapes among bat families …

A Single Bout Of Resistance Or High-Intensity Interval Training Increases Anti-Cancer Myokines And Suppresses Cancer Cell Growth In Vitro In Survivors Of Breast Cancer, Francesco Bettariga, Dennis R. Taaffe, Cristina Crespo-Garcia, Timothy D. Clay, Mauro De Santi, Giulia Baldelli, Sanjeev Adhikari, Elin S. Gray, Daniel A. Galvão, Robert U. Newton

Research outputs 2022 to 2026

Purpose: Breast cancer is the leading cause of cancer-related death in women, highlighting the need for strategies to mitigate recurrence and mortality. We examined the effects of a single bout of resistance training (RT) versus high-intensity interval training (HIIT) on anti-cancer myokines and in vitro cancer cell suppression. Methods: Thirty-two survivors of breast cancer were randomly allocated to a single bout of RT (n = 16) or HIIT (n = 16). Blood was collected before, immediately post (0P) and 30 min post (30P) exercise. We measured serum levels of decorin, interleukin 6 (IL-6), secreted protein acidic and rich in cysteine …

Digital Tools To Promote Or Measure Health Literacy In Children Aged 3–5 Years: Scoping Review, Caron Molster, Jennifer Irvine, Amanda Devine, Ruth Wallace, Lennie Barblett, Leesa Costello

Research outputs 2022 to 2026

Health literacy is a determinant of health that should be promoted and measured in early childhood. In the era of digitalization, this could involve digital platforms. However, little knowledge exists on the extent, range, and nature of literature on digital tools for promoting or measuring young children’s health literacy. Addressing this gap, a scoping review was undertaken to explore what digital health literacy tools for children aged 3–5 years could be identified in the literature, what their key features were, how they were designed, whether children were codesigners, and whether the tools had been evaluated. Eligibility criteria included the literature …

Discordance Of Small Dense Ldl Cholesterol Beyond Ldl Cholesterol Or Non–Hdl Cholesterol And Carotid Plaque, Jinqi Wang, Xiaoyu Zhao, Yanchen Zhao, Rui Jin, Yunfei Li, Jiahe Wang, Yueruijing Liu, Zhiyuan Wu, Xiuhua Guo, Lixin Tao

Research outputs 2022 to 2026

Background: Different low-density lipoprotein (LDL) particles exhibit distinct proatherogenic properties. Objectives: This study sought to evaluate associations of small dense low-density lipoprotein cholesterol (sdLDL-C), large buoyant low-density lipoprotein cholesterol (lbLDL-C), sdLDL-C/LDL-C ratio, and sdLDL-C/lbLDL-C ratio with carotid plaque (CP) risk in the general population, and to perform discordance analyses to determine which biomarker better reflects CP risk beyond low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol (non-HDL-C). Methods: This study enrolled 20,369 participants from Beijing Health Management Cohort. Discordant sdLDL-C, lbLDL-C, or ratio metrics (sdLDL-C/LDL-C and sdLDL-C/lbLDL-C) relative to LDL-C or non-HDL-C, and discordant ratio metrics relative to sdLDL-C, were …

Management Of Neonates In The Special Care Nursery And Its Impact On The Developing Gut Microbiota: A Comprehensive Clinical Review, Ravisha Srinivasjois, Shripada Rao, Gavin Pereira

Research outputs 2022 to 2026

The first few days following the birth are a vulnerable time for the neonate. Sick infants experience various interventions during their stay in the neonatal unit in order to stay alive and grow. Acquisition of gut microbes is critical for the short- and long-term health of the neonate. At a time when the gut microbiome is starting to take shape, crucial interventions directed at improving the growth, development and survival of the neonate impact its development. Events prior to and after the birth of the neonate, such as maternal conditions, antibiotic exposure, type of feeds, supplemental probiotics, and neonatal intensive …

Restricting Outdoor Advertising Of Unhealthy Food: Can Australia's Food Category-Based Classification System Be Applied Consistently?, Clare Whitton, Frith Klug, Alexia Bivoltsis, Georgina S.A. Trapp, Claire E. Pulker

Research outputs 2022 to 2026

Most outdoor food advertising (e.g. billboards and bus stops) features foods that are considered unhealthy. The most important technical challenge when designing policies to restrict unhealthy outdoor food advertising is defining 'unhealthy food'. To date, most restriction policies have used nutrient profiling models (i.e. foods are classified according to their nutritional composition) to determine which foods and beverages may be advertised. In Australia, state governments have endorsed a food category-based classification system, with no prescribed nutrient limits, which may create ambiguity when multiple users are identifying food advertisements to be restricted. This study aimed to assess the consistency of decisions …

Successful Treatment Of Aspergilloma With Antifungal Alone: A Case Of Conservative Management, Ad Rian Chong, Khai Lip Ng, Nai Chien Huan, Nur Husna Mohd Aminudin, Raja Nor Adilla Raja Rahaizat, Kasuma Mohamed Nordin

Research outputs 2022 to 2026

Pulmonary aspergilloma can cause life-threatening haemoptysis. Surgical resection and/or bronchial artery embolization (BAE) are established treatment modalities, but both can be risky in frail patients with comorbidities. Spontaneous regression of aspergilloma with antifungal agents alone is rare. We report an elderly gentleman with a background history of treated pulmonary tuberculosis, who presented with haemoptysis due to a large left upper lobe aspergilloma. He declined surgery and BAE due to perceived risks. Oral voriconazole and later isavuconazole were prescribed, which led to clinical improvement and significant reduction in the size of the aspergilloma over 6 months. Antifungal agents might be a …

The Role Of Diet In Moderating The Relationship Between Symptoms Of Depression And Brain Amyloid Load, Hilal Salim Said J. Al Shamsi, Samantha L. Gardener, Stephanie R. Rainey-Smith, Hamid R. Sohrabi, Kevin C.M. Taddei, Colin L. Masters, Vincent M. Doré, Christopher L. Rowe, W. M.A.D.Binosha Fernando, Ralph N. Martins

Research outputs 2022 to 2026

Background: Healthy lifestyle factors, including diet, may affect brain amyloid beta (Aβ) load. This study examines dietary patterns as moderators of the relationships among symptoms of depression, anxiety, and brain Aβ load. Method: A cross-sectional study of cognitively unimpaired older adults (n = 524) from the Australian Imaging, Biomarkers, and Lifestyle study assessed dietary patterns, depressive and anxiety symptoms, and brain Aβ load. Moderation and simple slope analyses were conducted. Results: The Dietary Approaches to Stop Hypertension (DASH) diet moderated the relationship between depressive and anxiety symptoms and brain Aβ load. Higher symptoms were associated with greater Aβ load in …

Welding Fume In The Western Australian Mining Industry: Impact Of A Change To The Workplace Exposure Standard, Matthew Oosthuizen, Kerry Staples, Adelle Liebenberg, Kiam Padamsey, Marcus Cattani, Andy Mccarthy, Jacques Oosthuizen

Research outputs 2022 to 2026

The aim of this study was to analyse the Western Australian (WA) Safety Regulatory System (SRS) database to assess compliance of the WA mining sector regarding workers exposure to welding fumes and to identify trends over time. De-identified data analysed to assess the impact of reducing workplace exposure standards (WES) for general welding fumes on industry compliance. Historical trend analysis shows a shift from 100% compliance to 100% non-compliance, based on mean values and 95% confidence intervals, with exposure levels remaining consistent over time. These findings highlight the need for current, innovative engineering solutions, and raise questions about the validity …

A Global Movement Takes Shape – Physical Activity, Health, And The New Era Of Responsibility: “Global Alliance For Promotion Of Physical Activity”, J. M. Steinacker, W. Van Mechelen, C. Joisten, S. Zanuso, C. A. Jaworski, Y. P. Pitsiladis

Research outputs 2022 to 2026

No abstract provided.

Formation Control Between Leader And Migratory Follower Tissues Allows Coordinated Growth, Toru Kawanishi, Takamichi Sushida, Tony Y-C Tsai, Hiroyuki Takeda, Sean G Megason

2020-Current year OA Pubs

Coordinated growth of multiple tissues is fundamental to shaping our body, but the underlying mechanisms remain underexplored. In zebrafish embryos, midline tissues composed of the notochord, floorplate, and hypochord elongate synchronously with their lengths aligned. We show that floorplate and hypochord cells collectively migrate posteriorly along the nascent notochord extracellular matrix as it extends posteriorly, maintaining the tripartite configuration. Fibroblast growth factor-mediated migration in a spatially graded manner causes cell stretching, which triggers Yap-dependent proliferation and controls floorplate and hypochord growth. Supported by mathematical modeling, we further suggest that their growth is fine-tuned by mechanical tethering to the notochord via …

Strength Beyond Cancer: An Occupational Therapy Guidebook For African American Breast Cancer Survivors, Taihia A. Wilson

Student Capstone Papers

This capstone project aims to explore the nuanced and often underrepresented experiences of African American women (AAW) who have survived breast cancer (BC), with a specific focus on the recovery phase. By examining the physical, cognitive, and psychosocial obstacles encountered during survivorship, the project seeks to highlight significant gaps in care and support. The primary goal of this project is to develop an accessible and culturally responsive guidebook that provides healthy strategies to enhance quality of life (QoL), promote occupational wellbeing, and empower AAW to manage their overall health beyond treatment. This paper will begin by presenting the background and …

Genetic Study Of Von Willebrand Factor Antigen Levels ≤ 50 Iu/Dl Identifies Variants Associated With Increased Risk Of Vwd And Bleeding, Rachel K. Friedman, Adam S. Heath, Jennifer E. Huffman, James T. Baker, Natalie R. Hasbani, Sarah A. Gagliano Taliun, Ming-Huei Chen, Tom Howard, Joanne E. Curran, John Blangero

School of Medicine Publications

Background: von Willebrand disease (VWD) is a common inherited bleeding disorder caused by low levels or activity of circulating von Willebrand factor (VWF). Genetic susceptibility to VWF antigen (VWF:Ag) below normal (≤50 IU/dL) in the general population is underexplored.

Methods: To identify genetic variants influencing VWF:Ag levels ≤50 IU/dL, we performed a genome-wide association study in 926 cases with VWF:Ag levels ≤50 IU/dL and 12,846 controls from 7 studies from the TOPMed program. We then examined whether genome-wide significant findings were also associated with clinical diagnosis of VWD in 5 biobanks with 708 VWD cases and 1,286,069 controls, and with …

Summit Max: A Randomized Trial Of The Super Large Bore Hipoint Reperfusion System Versus Vecta System For Aspiration Thrombectomy., Thanh N Nguyen, Guilherme Dabus, Ben Mcguinness, James Caldwell, Ryan Priest, Ansaar T Rai, Osama O Zaidat, Bradley A Gross, Ricardo Hanel, Shane Lee, Shazam Hussain, Hamza Shaikh, Mohamad Abdalkader, Ronald Budzik, Craig Kilburg, Keith Woodward, Marco Colasurdo, Jesse Liu, Albert J Yoo, Priyank Khandelwal, Sohyun Boo, Phong Vu, Eugene Lin, Mohammad Almajali, Jasmeet Singh, Alhamza Al-Bayati, Michael J Lang, Michael Abraham, Ameer E Hassan, Peter Pema, Coleman Martin, Ramesh Grandhi, Daniel A Tonetti, Harry R Hixson, Amin Aghaebrahim, Eric Sauvageau, Santiago Ortega-Gutierrez, Dileep R Yavagal, Esteban Cheng-Ching, Jane Khalife, Italo Linfante, Volodymyr Vulkanov, Jazba Soomro, Johanna T Fifi, Lucien Maidan, Alexander Copelan, Clemens M Schirmer, Mark Bain, Gabor Toth, Mahesh Jayaraman, Roberta Novakovic-White, Sudhakar Satti, Nicolas Villelli, Pascal Jabbour, Matthew Page, Davina J Mcallister, Robert Araujo Contreras, Edgar A Samaniego, David S Liebeskind, Steven W Hetts, Raul G Nogueira, Joey English, Ajit S Puri

Neuroscience Articles

BACKGROUND: Rapid and complete recanalization is a primary goal in the endovascular treatment of large vessel occlusion stroke. The effectiveness and safety of super large bore aspiration catheters (0.088″ inner diameter) for the treatment of large vessel occlusion stroke have not been demonstrated in a randomized trial.

METHODS: SUMMIT MAX (A Prospective, Randomized, Controlled, Interventional Clinical Trial to Evaluate the Safety and Effectiveness of the Route 92 Medical MonoPoint Reperfusion System for Aspiration Embolectomy in Acute Ischemic Stroke Patients) was a prospective, randomized, controlled, open-label clinical trial of patients with internal carotid artery and middle cerebral artery M1 occlusions, comparing …

Changing The Perceived Pain Intensity In Populations With Spinal Cord Injury And With Health Disparities (Happiness): Protocol For A Feasibility Study, Ann Van De Winckel, Lin Zhang, Leslie R. Morse, Brianna Woodliff, Gladys Maestre, Kelsey Baker

School of Medicine Publications

Background: Chronic neuropathic pain affects 69% of adults with spinal cord injury (SCI). Medication, as a primary treatment, has insufficient benefits and significant risks for addiction and adverse effects. Of the available mind and body approaches, Qigong is the most accessible for adults with SCI, with evidence for effectiveness in reducing pain. Still, there is insufficient evidence to make recommendations for adults with SCI. Thus, the feasibility of Qigong in SCI needs to be established. We previously demonstrated feasibility in a pilot study, in which 18 non-Hispanic White adults with SCI completed a 12-week remote Qigong program. However, three additional …

Reentry For Formerly Incarcerated Individuals: A Focus On Workforce Reentry And Recidivism In Appalachia, Margaret E. Francisco

Electronic Theses and Dissertations

Formerly incarcerated individuals face challenges to successful reentry, a critical component of reducing recidivism and improving public health outcomes. These challenges are particularly acute in rural Appalachia, where structural disadvantages such as limited economic opportunities, healthcare access, and public transportation intersect with stigma and systemic barriers related to prior incarceration. This dissertation addresses these gaps through a mixed-methods examination of reentry and recidivism, grounded in public health frameworks and focused on the unique context of rural Appalachia.

This work includes three studies. First, a PRISMA-guided systematic review synthesized qualitative research on barriers and facilitators to employment following incarceration. Findings highlighted …

Genotype Distribution Of Human Papillomavirus Among Women With Cervical Cancer Stratified By Hiv Status In Tanzania, Alita Mrema, Mamsau Ngoma, Emmanuel L. Lugina, Atukuzwe Kahakwa, Chacha Josiah Mwita, Salama Iddy, Eulade Rugengamizi, Kandali Samwel, John Ngowi, Salum J. Lidenge, Charles Wood, Julius Mwaiselage

School of Medicine Faculty Publications

Background Cervical cancer (CC) is the leading cancer among women in Tanzania, especially among those between the ages of 15 and 44. The prevalence of high-risk Human papillomavirus (HR-HPV)-16/18 women in the general population at any given time is 3.3%. HR-HPVs 16 or 18 are the primary cause of CC. The distribution of HPV genotypes among women with CC according to HIV status is unknown in Tanzania. This study aimed to determine the HPV genotype distribution according to HIV status among women with CC in Tanzania. Methods This cross-sectional study was done at Ocean Road Cancer Institute (ORCI) in Tanzania …

Gastric Sarcina Ventriculi: A Report On Two Cases, Yaomin Chen, Yu Liu, Zhiyan Fu

School of Medicine Faculty Publications

: Sarcina ventriculi is a rare Gram-positive coccus that thrives in acidic environments such as the human stomach. It has been increasingly identified in individuals with delayed gastric emptying and has been reported in association with various gastric disorders. However, its exact pathogenic role is not fully understood and remains controversial. : We present two cases of patients, one with a small bowel obstruction and the other with epigastric pain, both diagnosed with Sarcina ventriculi infection by histological examination of gastric biopsies. The patients were managed with a combination of antibiotics and a proton pump inhibitor, resulting in symptom resolution …

Extracorporeal Membrane Oxygenation (Ecmo) Neuromonitoring And Acute Brain Injury, Children's Mercy Kansas City

Clinical Pathways

No abstract provided.

Rebounds Reconsidered: Exploring Perceived Causes And Consequences Of People's Beliefs About Rebound Relationships, Hunter Krampe

All-Inclusive List of Electronic Theses and Dissertations

Romantic breakups are common and can significantly impact emotional well-being. Many individuals enter rebound relationships despite the prevailing belief that these relationships are disingenuous or unhealthy. While limited empirical research exists, some studies suggest rebound relationships may have positive effects, contradicting common advice. This study examined perceptions of rebound relationships, assessing whether individuals who entered a new relationship shortly after a breakup (3 weeks) were perceived more negatively than those who waited longer (3 months). Using a 2x2 experimental design, participants rated targets on emotional state, personality traits, and expected relationship stability. Results indicated that rebounders were not perceived as …

Sad Music Listening: What Is It Good For? An Exploratory Study Of Motivations For Listening To Sad Music, Ariel Gelfand

All-Inclusive List of Electronic Theses and Dissertations

This study sought to bolster research related to the function of sad music listening. Music listening is a common coping strategy for individuals attempting to cope with and manage different emotional states, including negative or sad moods and emotions. Research surrounding self-reported reasons or motivations for listening to sad music outlines several factors that appear to serve as mood-management strategies. However, there are discrepancies among these motivations across research, which thus far has consisted of qualitative interviews of participants. (Garrido & Schubert, 2011; Saarikallio & Ekkila, 2007; Van den Tol & Edwards, 2013). Additionally, it is unclear whether listening to …

Use Of Cognitive-Behavioral Therapy In A Nation-Wide Veterans Health Administration Sample: The Role Of Clinic, Therapist, And Patient Factors., Alan Mcguire, Mindy Flanagan, Madison E Stout, Jessica Coffing, Marina Kukla, Morgan Traylor, Laura Myers, Nancy Henry, Jessica Carter, Marianne Matthias

Health Services and Informatics Research

OBJECTIVE: To examine the use of CBT-CP (Cognitive-behavioral therapy for chronic pain) by CBT-CP-trained therapists to treat patients with pain over a five-year period (October 2015-February 2020).

DATA SOURCES AND STUDY SETTING: CBT-CP is a core evidence-based practice that is central to multidisciplinary chronic pain care. However, research suggests that CBT-CP is underused. The current study used national Veterans Health Administration data to examine the use of CBT-CP by CBT-CP-trained therapists to treat patients with pain over a five-year period.

STUDY DESIGN: Multilevel modeling was used to evaluate clinic, therapist, and patient-level factors as predictors of CBT-CP receipt.

DATA COLLECTION: …

Objective Phone Use During Time With One’S Partner: Associations With Relationship And Individual Well-Being, Brandon T. Mcdaniel Phd, Sabrina Uva, Victor P. Cornet, Michelle Drouin

Health Services and Informatics Research

When a person chooses to interact with their phone instead of their partner (e.g., technoference, phubbing), it may diminish interactional quality, relationship satisfaction, and well-being. However, much of the research on technology use in relationships has utilized self-reports. We extend prior work by objectively measuring smartphone use in a sample of 247 adult participants (75% women; mean age = 30.87 years) to better understand the extent of use around one’s partner and the connection between this use and relational and personal well-being. Participants completed an online baseline survey and 8 days of phone tracking and nightly time diaries. On average, …

Characteristics Of Extravascular Implantable Cardioverter-Defibrillator Implantation., Sreedhar R Billakanty, Auroa G Badin, Matthew J Cline, Bridget A Cavanagh, Andrea K Robinson, Nagesh X Chopra, Eugene Y Fu, Jaret D Tyler, Anish K Amin

Heart and Vascular Articles

No abstract provided.

Criteria For The Establishment Of An Atrial Fibrillation Center Of Excellence And Key Operational Standards., T Jared Bunch, Elliott Antman, John N Catanzaro, Thomas Deneke, James V Freeman, M Edip Gurol, Colleen J Johnson, Paulus Kirchhof, Melissa E Middeldorp, Sanghamitra Mohanty, Andrea Natale, Jonathan P Piccini, Sean D Pokorney, Andrea K Robinson, Andrea M Russo, Roopinder K Sandhu, Joshua Silverstein, Jennifer M Wright, Thomas F Deering

Heart and Vascular Articles

No abstract provided.

How Was Rehab? A Follow-Up To A Randomized Effectiveness Control Trial Of A Brief Acceptance And Commitment Therapy Protocol For Inpatient Detoxification Patients, Alexander J. Twohy

Dissertations

Residential treatment for Substance Use Disorders (SUD) is a common treatment modality. However, the literature is sparse on modifiable predictors that affect change during the residential treatment stay. Acceptance and Commitment Therapy (ACT) has been shown to be an effective treatment for SUDs. Weststrate et al. (2023), in a randomized controlled effectiveness trial, compared ACT plus medication management to medication management during detoxification. The addition of ACT increased consumer satisfaction and ACT skills use, while decreasing psychological inflexibility and reducing withdrawal symptoms.

This study explored whether the brief ACT intervention had impacts during participants' subsequent residential stay. Forty out of …