Medicine and Health Sciences Commons^™

Case Report: Postpartum Ovarian Vein Thrombosis Without Abdominal Pain, Moshammat Nishu, Russell Mordecai, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 27-year-old woman (2 prior pregnancies: 1 term birth, 1 preterm birth, 2 living children)  who presented with right ovarian vein thrombosis (OVT) in the absence of abdominal pain on postpartum day 5 after spontaneous vaginal delivery. Although OVT is classically associated with abdominal pain, this case illustrates that OVT may present without abdominal pain and should be considered as a differential to prevent a delay of diagnosis in the emergency department. This case also highlights the diagnostic challenge in postpartum fever when an alternative infectious source may lead to premature closure and prevent the …

Rowan-Virtua School Of Osteopathic Medicine’S Planetary Pulse: Charting A Course For Planetary Health Excellence, Hope A. Beyer, Deborah Podolin

Rowan-Virtua Research Day

Objective: Despite international acceptance of climate change as the largest threat towards human health, American osteopathic institutions fall short of their allopathic colleagues in adopting a planetary health curriculum. This study (1) evaluates the desire of Rowan-Virtua School of Osteopathic Medicine (Rowan-Virtua SOM) students to learn about planetary health within their medical education, (2) assesses the current planetary health infrastructure supported by Rowan-Virtua SOM and their parent institution, Rowan University, and (3) proposes an adapted planetary health equity curriculum.

Methods: Medical student interest was gauged by use of a Qualtrics survey modeled off of Dr. Karly Hampshire’s 2020 survey of …

The Klatskin Tumor: A Tumor At The Liver’S Crossroads, Asma Zahid, Sergey Medlenov, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We present a 68-year-old female with no significant oncologic history who presented to

the emergency department with a  two –week history of progressive jaundice and diarrhea.

Systematic ED evaluation revealed marked hyperbilirubinemia (total bilirubin 22.3 mg/dL), a

cholestatic laboratory pattern, and multimodal imaging demonstrating multifocal hepatic

masses, a porta hepatis soft tissue mass,  and biliary ductal dilatation consistent with hilar cholangiocarcinoma (Klatskin tumor) with metastatic disease.

A CA 19-9 marker was markedly elevated at 379 U/mL. The patient was admitted and she underwent successful biliary decompression via ERCP with stent placement.  Outpatient oncologic therapy was initiated. This case highlights the …

An Unusual Cause Of Generalized Weakness: Cns Toxoplasmosis, Christopher Dellmyer, Danielle Kusmaul, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

No abstract provided.

Persistent Hypotension Following Viral Illness- Pocus For Pericardial Effusion, Peter Killian, Kelsey Murray, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

A pericardial effusion is defined as a build up of fluid in the pericardial space, the lining around the heart. Normal physiologic fluid can consist of approximately 15-50mL in an otherwise healthy adult . Larger amounts of fluid can be detected on radiographs, but are able to be seen on ultrasound when just exceeding physiologic conditions . Here we report a case of persistent hypotension assessed by point of care ultrasound (POCUS) in order to lead to a diagnosis.

Case Report: Necrotizing Pneumonia, Veroneka Mikhail Md

Rowan-Virtua Research Day

Necrotizing pneumonia is an uncommon but severe complication of community-acquired pneumonia (CAP), characterized by progressive parenchymal liquefaction, cavitation, and destruction of normal lung architecture, and associated with significant morbidity and mortality. Clinicaly, early presentations may be indistinguishable from uncomplicated pneumonia (pna), with fever, cough, pleuritic chest pain, and dyspnea, which can delay recognition in the emergency department. Differential diagnosis for these symptoms is broad and includes uncomplicated pneumonia, septic emboli, lung abscesses, and pleural effusion. However, patients effected with necrotizing pneumonia often exhibit more severe systemic toxicity, rapid progression of respiratory failure, and hemodynamic instability. In this case report, we …

Reducing Pharmacy Callbacks And Improving Workflow Efficiency In The Emergency Department: A Quality Improvement Initiative, Philip .. Carhart, Hannah Culleny, Alexis Schuitema, James Espinosa, Robin Lahr, Sergey Medlenov, Gabriel Meister, Alan Lucerna

Rowan-Virtua Research Day

A simple educational intervention combined with structured provider feedback reduced ED pharmacy callbacks by 86%. While individual call duration remained unchanged, the reduction translated into nearly eight hours of provider time saved annually. This study highlights the impact of targeted quality improvement efforts on: • Workflow efficiency • Interprofessional communication • Patient care reliability. Small systems interventions can produce disproportionate operational benefits.

High-Intensity Interval Training And Circulating Brain-Derived Neurotrophic Factor In Healthy Young Adults: A Scoping Review, Rikuto Abe, Safe Elhakeem, Mohamed Elhakeem

Rowan-Virtua Research Day

Abstract

Background: Brain-derived neurotrophic factor (BDNF) plays an important role in synaptic plasticity, neuronal survival, and cognitive function (1,2,3). High-intensity interval training (HIIT) has emerged as a time-efficient exercise modality capable of inducing neurotrophic adaptations (4,5). However, the magnitude and consistency of its effects on circulating BDNF remain unclear.

Objective: This scoping review evaluated the current evidence examining the effects of HIIT on circulating BDNF levels measured via enzyme-linked immunosorbent assay (ELISA) in healthy young adults.

Methods: A systematic search of PubMed, Embase, and Scopus was conducted for randomized and controlled clinical trials published between 2020 and 2025. Studies were …

Hydration During Emergency Medicine Shifts: An Overlooked Component Of Cognitive Performance, Well-Being, And Systems Design To Fail To Plan For Shift Hydration Is To Plan To Fail With Shift Hydration, James Espinosa, Alan Lucerna, Swet Patel, Robin Lahr, Sergey Medlenov, Adam Kandil, Frank Wheeler, Wayne Tamaska, James Lee, Neel Parikh, Henry Schuitema

Rowan-Virtua Research Day

Emergency Medicine (EM) clinicians work prolonged, cognitively demanding shifts in environments characterized by unpredictability, interruptions, and high decision density. While fatigue, burnout, and circadian disruption have been widely studied, hydration during active clinical shifts has received little focused attention. Evidence from cognitive, military, and sports physiology literature demonstrates that even mild dehydration can impair attention, working memory, mood, and reaction time. Despite these findings, hydration in Emergency Medicine is typically treated as an individual behavior rather than a systems-level design consideration. This review synthesizes relevant physiologic and performance literature, identifies cultural and structural barriers to hydration during EM shifts, and …

Designing For Difference: A Systems Approach To Sensory-Adaptive Care In The Emergency Department, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Children with genetic syndromes and other neurodevelopmental conditions frequently present to the Emergency Department (ED) with sensory vulnerabilities that complicate evaluation and treatment in high-stimulus environments. While experienced clinicians often adapt instinctively to meet these needs, such adaptations may be inconsistently applied and may also be highly individual provider dependent. We present a case involving a child with a genetic syndrome affecting auditory and visual systems to illustrate how small environmental, relational, temporal, and cognitive adjustments can prevent escalation and enable routine care delivery without specialized resources.

We propose reframing sensory-adaptive care not as an exceptional accommodation but as a …

Listening To The System: Reframing Emergency Department Noise: The Case For Noise As A Real-Time Operational Signal In A Complex Adaptive System (Cas), James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Emergency Department (ED) noise has historically been framed as an occupational and environmental hazard requiring mitigation. And this is still true—but not complete. Early work focused on exposure reduction and spike identification. Subsequent mapping studies demonstrated spatial and temporal differentiation in ED acoustic load. We propose an expanded conceptual model: acoustic variability may function not only as a hazard, but also as a real-time signal of operational turbulence within the ED as a complex adaptive system (CAS). Drawing on human factors, alarm fatigue, resilience engineering, and complexity science, we synthesize existing literature and institutional experience to identify a critical gap—noise …

From Lists To Landscapes And Locations: Spatial Memory And Schema Formation (Memory Palace Adaptation) As A Neurobiologically Informed Strategy For Teaching Environmental And Toxicology Emergencies Ite And Board Review In Emergency Medicine Residency, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background:

Most emergency medicine board domains inherit spatial scaffolding from foundational anatomy education (e.g., neuroanatomy, gastrointestinal tract, cardiopulmonary structures). Environmental emergencies lack an inherent anatomic anchor and are frequently taught as disconnected lists, increasing cognitive load and impairing schema formation. Similarly, toxicology crosses age, and specialty without an inherent anatomic structural anchor.

Objective:

To describe a scene-based, learner-generated landscape model designed to reintroduce spatial structure into environmental emergency education and to situate the model within contemporary neurobiology and learning science.

Educational Innovation:

Residents construct a large-format landscape diagram (sun–water–mountain schema) during live instruction. Environmental conditions are spatially anchored in ecologically …

Conceptualizing The Transition From Stable Operations To Turbulent States : Reframing Emergency Department Operations. Learning From Fluid Dynamics And Complexity Science, James Espinosa, David Ho, Alan Lucerna

Rowan-Virtua Research Day

Background: Emergency departments are frequently described using the language of patient flow, implying  smooth and predictable movement of patients through a system versus known obstructions to flow.  Clinicians, however, often observe abrupt shifts in operational stability.

Objective: To explore whether concepts from fluid dynamics and complexity science offer a useful framework for understanding these transitions.

Methods: Conceptual synthesis drawing on emergency medicine operations research, human factors, systems science, and fluid mechanics.

Results (Conceptual): Emergency departments exhibit behaviors analogous to systems approaching turbulence, including sensitivity to perturbation, amplification of delays, and nonlinear responses.

Conclusion: Viewing ED operations through the lens of …

Beyond Traditional Emergency Medicine Residency Match Interviews: Behavioral Questions As Stress Tests For Resident Selection A Theory-Driven Micro-Assessment Framework For Detecting High-Value Traits, Alan Lucerna, James Lee, Robin Lahr, James Espinosa

Rowan-Virtua Research Day

Background: Traditional residency selection metrics incompletely capture behavioral traits essential for emergency medicine (EM) performance.

Objective: To propose a theory-driven framework using structured behavioral questions as stress tests to detect high-value traits.

Methods: Conceptual analysis of three standardized behavioral prompts assessing execution, systems thinking, and team orientation.

Results: Distinct response patterns align with observable domains associated with reliability, performance, and leadership.

Conclusion: Behavioral stress test questions offer a scalable, low-cost method to enhance residency selection processes.

A Systems Perspective On Workstation Ergonomic Principles And Their Application In Emergency Care Environments, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Workstation ergonomic principles are commonly included in mandatory healthcare training programs. These recommendations—monitor height relative to eye level, neutral arm positioning, and adjustable seating—derive largely from occupational ergonomics literature designed to reduce musculoskeletal strain and improve comfort during computer work. Emergency Departments (EDs), however, represent dynamic environments with shared workstations and workflow interruptions that may influence the implementation of these recommendations.

Objective: To summarize the evidence supporting commonly taught workstation ergonomic principles and frame them within a systems perspective of ED work environments.

Methods: Narrative review of occupational ergonomics guidelines, ergonomic intervention studies, and human factors literature relevant to …

Detecting Early Operational Turbulence In The Emergency Department Using Fourier And Wavelet Analysis: A Conceptual Framework For Signal-Informed Anticipation And Prediction In The Ed Complex Adaptive System, James Espinosa, David Ho, Alan Lucerna

Rowan-Virtua Research Day

Background:

We theorize that Emergency Departments (EDs) function as complex adaptive systems characterized by nonlinear interactions, oscillatory demand patterns, and abrupt phase transitions from stable flow to turbulent states. Traditional dashboards rely on threshold metrics that detect instability after degradation becomes visible. Many ED data streams are significantly retrospective as well as compression-averaged into temporal systems such as days, months, quarters or even years. Signal processing methods—particularly Fourier and wavelet analysis—offer the  framework for detecting latent oscillatory shifts preceding overt operational change from laminar to transitional to turbulent flow states. This could lead to better methods of adaptation.

Conceptual Framework: …

The Epidemiology Of Sledding Injuries: Clinical Patterns And Public Health Prevention Strategies, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Sledding is a widely enjoyed winter recreational activity among children and adolescents. Although commonly perceived as low risk, sledding can result in extremity fractures, head injuries, and collision-related trauma. Emergency Departments frequently encounter sledding injuries during winter months, providing both clinical insight and opportunities for injury prevention counseling. An estimated 20,000–30,000 sledding-related injuries occur annually in the United States, most involving children and adolescents.

Objectives: To describe patterns of sledding injuries presenting to the Emergency Department and highlight practical safety recommendations physicians can communicate to families.

Methods: Conceptual review integrating Emergency Department observational experience with published literature on pediatric …

Helping Waldo (The Poster) Be Found: Teaching Search Literacy, Discoverability And Search Engine Optimization As Core Scholarly Skills In Graduate Medical Education, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: In modern academic medicine, trainees are taught how to search the biomedical literature but rarely taught how to structure their own scholarly work so that it can be discovered. This creates a diffusion gap in which high‑quality educational innovations, case reports, and operational insights remain difficult to locate despite being presented or archived.

Objective: To propose a concise educational module that teaches residents the principles of search literacy and scholarly discoverability.

Methods: A conceptual curriculum framework was developed drawing on literature from information science, medical education, and diffusion theory. The module introduces the paired competencies of 'Finding Waldo' (literature …

Sharing Research Posters With The World: Clinical Education Posters Can Demonstrate Global Diffusion And Conceptual Portability--Evidence From Readership Maps, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background

Traditional academic metrics emphasize citation counts and journal impact factors as measures of scholarly influence. These metrics often overlook the early and informal diffusion of ideas across global clinical communities. Educational posters and case-based teaching materials frequently circulate through digital repositories, yet little attention has been paid to how readership analytics may illuminate patterns of knowledge diffusion across healthcare systems.

Objective

To explore the concept of conceptual portability and to introduce readership mapping as a framework for understanding how clinical ideas travel across diverse global contexts.

Methods

We examined readership analytics from an institutional digital repository hosting clinical posters …

A Systems-Based Approach To Supporting Resident Scholarly Productivity: Building A High-Throughput Academic Pipeline In Emergency Medicine Residency Training Through Poster Development Apprenticeship, James Espinosa, Alan Lucerna, Robin Lahr, James Lee, Swet Patel, Henry Schuitema

Rowan-Virtua Research Day

Background: Many residency programs require scholarly output; however, consistent and high volume production of posters and publications can be challenging. Anecdotal evidence from a variety of programs suggests variability in outcomes across programs, often influenced by differences in mentorship, structure, and available scholarly infrastructure. Objective: To describe a reproducible, systems-based model for generating high-volume resident scholarly output through alignment of expectations, culture, infrastructure, and faculty engagement. Methods and Conceptual Model: We outline a multi-domain framework derived from sustained programmatic experience, incorporating structural requirements, leadership alignment, cultural reinforcement, workflow standardization, and active faculty participation. The model is supported by practical tools …

Impact Of Spanish-Speaking Medical Interpreters On Healthcare Access, Outcomes, And Equity In Patients With Limited English Proficiency, Emily Fried, Catherine Awad, Rebecca Moore

Rowan-Virtua Research Day

Impact of Spanish-Speaking Medical Interpreters on Healthcare Access, Outcomes, and Equity in Patients with Limited English Proficiency

Background

Limited English proficiency (LEP) is a significant barrier to equitable healthcare in the United States and is associated with reduced access to care, poorer clinical outcomes, and increased healthcare disparities. The Spanish-speaking population represents the largest proportion of LEP patients, making language access a crucial component of high-quality care. Language discordance between patients and providers contributes to impaired communication, increased medical errors, and decreased utilization of preventative services1-4.

Objectives

The objective of this study was to evaluate the impact of Spanish-speaking professional …

Sex Differences In Insulin Resistance And Triglyceride/Hdl-Cholesterol Ratio In Human Subjects, Jiyoon Jung, Lakshman Segar, Christine Whitehair, James Bailey, Ashley Coleman, George Scott

Rowan-Virtua Research Day

Background: Insulin resistance (IR) plays a major role in dyslipidemia and the associated cardiovascular disease risk. To date, it remains unclear as to how IR alters plasma lipid profile in males versus females. The present study is an initial step to determine sex-specific differences in IR and plasma lipid profile using 40 μL of capillary blood. Methods: 19 adults aged 30-64 were recruited from Rowan Medicine-Sewell clinics, with 13 participants (9 males, 4 females) consenting to the study. After collecting 40 μL of capillary blood via finger prick, the samples were analyzed for glucose, triglyceride (TG), and HDL-cholesterol (HDL-C) using …

What Are The Correlations Between The Severity Of A Woman's Major Menopausal Symptoms And Their Eating Habits?, Kiely Hoyt, Philip Collins, Do

Rowan-Virtua Research Day

BACKGROUND

Menopause is a naturally occurring process during a woman’s life that is associated with a variety of symptoms that can significantly impact daily life.  Although hormone based therapies are available, they are not always effective or appropriate for all women.  As a result, there is growing interest in diet as a potential non-pharmacologic method to manage symptoms, though current evidence is limited.

HYPOTHESIS

Dietary habits are associated with menopause symptom severity, with certain dietary patterns potentially influencing symptom burden.

METHODS

A cross-sectional, survey study was conducted using an online questionnaire distributed through social media. A total of 129 menopausal …

Preliminary Results From Assessing Medical Students’ Familiarity With Adverse Childhood Experiences (Aces) And Trauma-Informed Care (Tic), Kaylea Shoulders, Portia Tasnim Shaheed, Kartik Kannan, Rachel Silliman Cohen, Beth Cooper, Christine Schroeder, Yahaira Márquez

Rowan-Virtua Research Day

Adverse childhood experiences (ACEs) are highly prevalent and associated with significant long-term health outcomes1; however, physicians often report feeling underprepared to address trauma in clinical care. While medical education increasingly includes exposure to ACEs and trauma-informed care (TIC), limited research has examined how these topics are integrated and experienced within osteopathic medical education (OME). This project aims to assess medical students’ familiarity with ACEs and TIC at Rowan-Virtua School of Osteopathic Medicine and to potentially help inform curricular improvement efforts. This study adapts and extends prior research2 using an anonymous survey administered via Qualtrics. Recruitment targeted medical students across years …

In School Age Children With Autism Spectrum Disorder, Does Academic Achievement And Social Development Improve In Inclusive Classroom Environments?, Ashley A. Macquaid

Rowan-Virtua Research Day

Autism Spectrum Disorder (ASD) is a developmental disorder characterized by difficulties in social skills, communication, and sensory processing 1. ASD affects approximately 1 in 100 children internationally 2. With the growing prevalence, classroom inclusivity of individuals with autism has emerged as a priority in education. However, current literature presents a range of positive and negative factors without clear indication of effective classroom placement for students' specific needs. This research aims to determine if inclusive classroom environments improve academic achievement and social development for school-age children with ASD. A systematic search on PubMed, Embase, and Cochrane databases yielded studies published between …

Title: Impact Of Hypertriglyceridemia ≥500 Mg/Dl On Acute Pancreatitis Outcomes: A Propensity Score–Matched Cohort Study, Jashanveer S. Johal, Bianca Patel, Mahmoud Al-Bataineh, Archana Salek, Om Patel, Jason Hyman, Yecheskel Schneider, Abdallah Hussein

Rowan-Virtua Research Day

Background: Hypertriglyceridemia is a recognized cause of acute pancreatitis, but the prognostic impact of markedly elevated triglycerides (TG) on clinical outcomes remains unclear. We evaluated whether TG ≥500 mg/dL at presentation predicts worse pancreatitis outcomes.

Methods: Using the TriNetX multicenter electronic health record network, adults hospitalized with acute pancreatitis and a TG measurement within 48 hours of admission between 2018–2024 were identified. Patients with TG ≥500 mg/dL were compared with those with TG < 500 mg/dL after 1:1 propensity score matching on demographics and comorbidities (n=7,014 per group). Primary outcomes included ICU stay, pancreatic complications, need for procedure, and all-cause mortality. Secondary outcomes included acute renal failure, cardiovascular events, repeat pancreatitis, infection, and liver failure. Odds ratios (OR) with 95% confidence intervals were estimated.

Results: Compared with TG < 500 mg/dL, patients with TG ≥500 mg/dL had higher risks of ICU admission (25.3% vs. 17.2%; OR 1.63), pancreatic complications (5.3% vs. 4.5%; OR 1.19), and mortality (4.6% vs. 3.3%; OR 1.39). Need for procedural intervention was lower in the high-TG group (1.2% vs. 3.6%; OR 0.34). Secondary outcomes including acute renal failure (15.5% vs. 10.7%; OR 1.54), repeat pancreatitis (58.6% vs. 51.9%; OR 1.31), and infection (13.7% vs. 12.0%; OR 1.17) were all significantly elevated. Cardiovascular events and liver failure did not differ significantly.

Conclusions: TG ≥500 mg/dL in acute pancreatitis was associated with greater ICU utilization, complications, and mortality, but lower procedural intervention rates. Admission triglyceride …

Risk Of Colorectal And Gastrointestinal Neoplasia In Inflammatory Bowel Disease Treated With Adalimumab Versus Vedolizumab And Ustekinumab: A 5-Year Multicenter Retrospective Cohort Study, Jashanveer S. Johal, Archana Salek, Mahmoud Al-Bataineh, Bianca Patel, Abdallah Hussein, Om Patel, Jason Hyman, Yecheskel Schneider

Rowan-Virtua Research Day

Background: Inflammatory bowel disease (IBD) is associated with increased colorectal cancer (CRC) risk, but comparative neoplastic risks across biologic classes remain uncertain. We evaluated 5-year risks of CRC and GI neoplasia in IBD patients treated with adalimumab versus vedolizumab and ustekinumab using real-world data.

Methods: Using the TriNetX Global Collaborative Network, two parallel 5-year propensity score–matched cohort analyses were conducted among adults with Crohn's disease or ulcerative colitis initiating adalimumab, vedolizumab, or ustekinumab between 2018–2024, excluding patients with prior CRC or colectomy. The adalimumab–vedolizumab analysis matched 13,292 patients per cohort; the adalimumab–ustekinumab analysis matched 14,591 per cohort. Primary outcomes were …

Identification Of Genes Regulating The Gli Protein Tra-1 In ​Caenorhabditis Briggsae Through A Genetic Suppressor Screen​, Alexander Glenn Cabrera, Sanese Brown-White, Ronald Ellis

Rowan-Virtua Research Day

BACKGROUND:
Gli proteins are conserved transcription factors that regulate cell fate, proliferation, and patterning. In Caenorhabditis briggsae, the Gli protein TRA-1 functions as the terminal regulator of the sex-determination pathway to control sexual development. These nematodes lack Hedgehog signaling, so TRA-1 is regulated by other factors. The missense mutation tra-1(v48) disrupts TRA-1 activator function, resulting in complete feminization of XX animals, which would otherwise be hermaphrodites.

HYPOTHESIS:
Suppressor screens using tra-1(v48) mutants will identify novel cofactors required for TRA-1–mediated Gli activation and spermatogenesis.

METHODS:
Ethyl methanesulfonate (EMS) mutagenesis was performed on tra-1(v48) strains to induce random mutations. Dominant suppressors were …

Clinical Imaging Analysis Of An Investigational Novel Spinal Prosthetic, Nicholas C. Moscardelli, Erik Brewer, Liam Murphy

Rowan-Virtua Research Day

No abstract provided.

Seasonal Variation And Size Distribution Of Particulate Matter In The Mississippi Delta: Implications For Source Attribution, Abigail E. Barnett

Honors Theses

This study examines seasonal patterns of particulate matter in the Mississippi Delta using data from PurpleAir sensors, with a focus on particle size distributions across PM₁.₀, PM₂.₅, and PM₁₀. The purpose of this research is to evaluate whether particulate trends in the region reflect signatures consistent with wildfire smoke or are better explained by local environmental and agricultural factors.

Daily average concentrations were analyzed and grouped by season to compare spring and summer conditions. Results show that all particle size fractions increased from spring to summer. However, PM₁₀ concentrations remained consistently higher than PM₂.₅ in both seasons. The PM₂.₅/PM₁₀ ratio …