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Articles 9001 - 9030 of 328553
Full-Text Articles in Medicine and Health Sciences
Sensory Processing At A Children’S Advocacy Center: Staff Education And Resource Development To Support Trauma-Informed Care, Hayley Jackson
Sensory Processing At A Children’S Advocacy Center: Staff Education And Resource Development To Support Trauma-Informed Care, Hayley Jackson
Capstone Projects
This capstone addresses a critical gap in understanding sensory processing within trauma-informed care for children who have experienced sexual abuse. Occupational therapy (OT) offers a unique perspective for supporting children’s sensory processing and regulation needs; however, OT is not utilized in Children’s Advocacy Center (CAC) settings. This project aimed to enhance understanding of OT's scope within trauma-informed care, provide education on sensory-based strategies, and develop resources to support regulation in clinical, home, and school settings. Project objectives were achieved through the development of caregiver and educator handouts, a SMART room sensory binder, a visual schedule binder, SMART movement cards, and …
Designing Inclusive Dog Training Opportunities For Handlers With Diverse Access Needs: An Occupational Therapy Approach, Lauren Huffman
Designing Inclusive Dog Training Opportunities For Handlers With Diverse Access Needs: An Occupational Therapy Approach, Lauren Huffman
Capstone Projects
This doctoral capstone focused on designing inclusive dog training opportunities in the community by integrating occupational therapy approaches to empower meaningful participation and increase carryover of skills into daily life. The project addressed a need for options that are supportive of dog owners (typically referred to as “handlers” in the dog training setting) who experience health and learning barriers impacting human-dog interactions and the ability to attend dog training classes in a group setting. Occupational Therapy’s role in adaptive recreation and use of occupation-based practice guided the development of a foundations-level accessible small group class, individual adaptive sessions, and educational …
Enhancing Feeding Skills: Development And Implementation Of A Pediatric Feeding Group Program In An Outpatient Setting, Alexia Spyrka
Enhancing Feeding Skills: Development And Implementation Of A Pediatric Feeding Group Program In An Outpatient Setting, Alexia Spyrka
Capstone Projects
Children with autism spectrum disorder are five times more likely to present with feeding difficulties when compared to the general pediatric population (Baraskewich,et.al., 2021). Pediatric feeding difficulties can include picky eating, restrictive diets, limited independence with feeding skills, and limited food repertoire. Not only can this effect the child’s nutrition and growth but can affect family members as they are additionally focusing on their child's socialization, communication, and regulation. When addressing feeding difficulties, occupational therapy services are provided 1:1 with clients while educating and supporting family members to improve carry over into the home. However, there is a gap in …
Beyond Baby: How Occupational Therapy Supports Families In The Prenatal And Postpartum Period, Taylor Maysonet
Beyond Baby: How Occupational Therapy Supports Families In The Prenatal And Postpartum Period, Taylor Maysonet
Capstone Projects
This doctoral capstone project focuses on the role of occupational therapy in maternal and infant health, supporting families during the prenatal and postnatal period. While occupational therapy has a strong foundation in promoting health, independence, participation and roles and routines, there remains a gap in community awareness of available support for families during this life transition. Many caregivers report feeling underprepared, overwhelmed, and disconnected from resources that could support their physical, emotional, and occupational wellbeing.
The objective of this project was to identify gaps within the interdisciplinary team during the prenatal and postpartum period. From there, I was able to …
An Occupational Therapy Approach To Sensory Education: Training Paraprofessionals To Support Students’ Sensory Needs, Sophia Hubber
An Occupational Therapy Approach To Sensory Education: Training Paraprofessionals To Support Students’ Sensory Needs, Sophia Hubber
Capstone Projects
Sensory processing plays an important role in the development and participation across the lifespan and is a key focus of occupational therapy (OT) in school settings. This doctoral capstone project addresses the gap in sensory education and training among paraprofessionals, who spend much of the day supporting students with the highest level of needs. While occupational therapists have extensive knowledge in sensory processing, their large caseloads often limit the opportunities to provide direct education to staff.
To address this gap, the project involved collaborating with the occupational therapy department, conducting research on sensory processing, and developing five educational videos with …
Growing South Dakota (Spring 2026), College Of Agriculture, Food, And Environmental Sciences
Growing South Dakota (Spring 2026), College Of Agriculture, Food, And Environmental Sciences
Growing South Dakota (Publication of the College of Agriculture, Food and Environmental Sciences)
[Page] 2 National heritage, statewide research, local impact
[Page] 7 About the South Dakota Agricultural Experiment Stations
[Page] 14 Managing the mooo-ment: How SDSU researchers are looking to improve cow health during the Transition Period
[Page] 18 Discovering strength in science: How education through undergraduate research prepares students for the future
[Page] 20 From India to Brookings: One grad student’s path to make a world of difference in virology
[Page] 22 Solving a billion-dollar problem: Identifying disease-resistent wheat genes
[Page] 24 Unlocking manure’s potential: SDSU leads multistate study on the power of swine manure in growing better crops
[Page] 28 …
Law Library Blog (April 2026): Legal Beagle's Blog Archive, Roger Williams University School Of Law
Law Library Blog (April 2026): Legal Beagle's Blog Archive, Roger Williams University School Of Law
Law Library Newsletters/Blog
No abstract provided.
Knowledgable Births: Advancing Informed Consent In Maternal Healthcare, Ella A. Forrester
Knowledgable Births: Advancing Informed Consent In Maternal Healthcare, Ella A. Forrester
Senior Theses
Background:
Informed consent is both a legal requirement and an ethical cornerstone of healthcare, ensuring that patients understand and voluntarily agree to medical treatments. However, evidence suggests that the informed consent process is often inadequately implemented in maternal healthcare settings, particularly during childbirth. While giving birth, women retain full decision-making capacity but are not consistently provided with sufficient information or support to exercise this right. Contributing factors include ineffective patient–provider communication, limited health literacy, and insufficient access to culturally responsive educational resources.
Methods:
This study aimed to address gaps in accessible prenatal education by developing an online resource platform, Know …
Main Concept Analysis As A Predictor Of Aphasia Severity: Semantic, Phonological, And Executive Influences On Main Concept Performance, Chathurvedi Ganguru
Main Concept Analysis As A Predictor Of Aphasia Severity: Semantic, Phonological, And Executive Influences On Main Concept Performance, Chathurvedi Ganguru
Senior Theses
Main Concept Analysis is a discourse-based measure that captures the essential information conveyed during narrative speech and may serve as a functional indicator of communication ability in aphasia. This study will examine whether Main Concept composite scores derived from the Cinderella narrative task are associated with aphasia severity and identify the linguistic and cognitive factors that influence Main Concept performance. Participants will be drawn from the baseline cohort of the POLAR study and will include approximately 100 individuals with chronic post-stroke aphasia. Baseline measures include Western Aphasia Battery Aphasia Quotient, Pyramids and Palm Trees Test, Philadelphia Repetition Test, and Wechsler …
Burden Of Cardiovascular Disease In Pakistan – Insight From Global Burden Of Disease Study 2019, Ali Bin Jabbar, Taha Mansoor, Sana Sheikh, Tazeen Jafar, Sawera Hanif, Christian Razo, Mahboob Alam, Jamal Rana, Khurram Nasir, Salim Virani
Burden Of Cardiovascular Disease In Pakistan – Insight From Global Burden Of Disease Study 2019, Ali Bin Jabbar, Taha Mansoor, Sana Sheikh, Tazeen Jafar, Sawera Hanif, Christian Razo, Mahboob Alam, Jamal Rana, Khurram Nasir, Salim Virani
Population Health, East Africa
Background Pakistan, currently the fifth-largest country by population globally, has experienced a population increase of over 100% since 1990. It is facing an escalating challenge from cardiovascular diseases (CVD). The Global Burden of Disease (GBD) 2019 study provides an in-depth evaluation of Pakistan's health situation since 1990, offering essential insights into the nation's overall health conditions.
Methods The data were obtained from the Global Burden of Disease Study 2019, which provides records for global, regional, and national burden of diseases. Specifically, data regarding CVD and its subtypes, morbidity, and mortality in Pakistan and globally from 1990 to 2019 were used …
Eating For Healthy Eyes: The Role Of Nutrition In Ocular Health, Brianna Stroh
Eating For Healthy Eyes: The Role Of Nutrition In Ocular Health, Brianna Stroh
Honors Program: Senior Projects (Public)
The central research question of this thesis asks: How does nutrition influence ocular health overall and the impact of nutrition on the development or progression of common eye diseases? Building upon existing research in optometry/ophthalmology, nutrition science, and public health, this project examines the physiological mechanisms linking diet to eye health and evaluates how specific nutrients and dietary patterns contribute to disease prevention and visual function. This thesis employs a comprehensive review of peer-reviewed literature to evaluate the relationship between nutrition and ocular disease. Key areas of focus include the role of oxidative stress in eye disease development, the protective …
Same Day Discharge Can Be Performed Safely After Atrial Fibrillation Catheter Ablation Using A Wide-Footprint Lattice-Tip Dual-Energy System., Tyler L Taigen, Devi G Nair, Dinesh Sharma, Erich L Kiehl, Jose Osorio, Petr Neuzil, Josef Kautzner, Stavros E Mountantonakis, Andrea Natale, John D Hummel, Shephal K Doshi, Anish K Amin, Usman R Siddiqui, Kelly A Van Bragt, Jeffrey Cerkvenik, Khaldoun G Tarakji, Vivek Y Reddy, Moussa Mansour, Elad Anter
Same Day Discharge Can Be Performed Safely After Atrial Fibrillation Catheter Ablation Using A Wide-Footprint Lattice-Tip Dual-Energy System., Tyler L Taigen, Devi G Nair, Dinesh Sharma, Erich L Kiehl, Jose Osorio, Petr Neuzil, Josef Kautzner, Stavros E Mountantonakis, Andrea Natale, John D Hummel, Shephal K Doshi, Anish K Amin, Usman R Siddiqui, Kelly A Van Bragt, Jeffrey Cerkvenik, Khaldoun G Tarakji, Vivek Y Reddy, Moussa Mansour, Elad Anter
Heart and Vascular Articles
BACKGROUND: Same-day discharge (SDD) after atrial fibrillation (AF) ablation is generally considered safe, since most complications are identified during (or immediately) after the procedure.
OBJECTIVE: This study aimed to evaluate SDD in the SPHERE Persistent-Atrial Fibrillation trial.
METHODS: Patients with persistent AF were randomized to the dual-energy lattice-tip mapping and ablation catheter (investigational) vs a conventional contact-force radiofrequency ablation system (control). SDD and timing of 30-day procedure- or device-related serious adverse events (SAEs) were assessed in the full cohort. In a subset of centers that performed SDD in the trial, predictors of SDD, 30-day readmissions, and mortality rates were assessed. …
Comparison Of Gene Up Regulation Between A Mouse Model Of Rop And Extremely Premature Newborns From Days 7 To 14 Of Life, Nitin Chouthai, Nikhlesh K. Singh
Comparison Of Gene Up Regulation Between A Mouse Model Of Rop And Extremely Premature Newborns From Days 7 To 14 Of Life, Nitin Chouthai, Nikhlesh K. Singh
Conference Presentation Abstracts
Background: Severe ROP is linked to considerable morbidity in extremely premature newborns. To our knowledge, there are currently no early-phase biomarkers for ROP.
Objective: The objective of this retrospective study was to compare the retinal RNA expression in mouse pups exposed to oxygen-induced retinopathy with the blood RNA profile of extremely premature newborns during the first two weeks of life, specifically from days 7 to 14 of life.
Design/Methods: Bulk RNA transcriptome analysis was conducted using peripheral blood samples from 21 extremely preterm newborns who were born at less than 26 weeks’ gestation and were between 7 and 14 days …
Population Trends In Infant Mortality Before, During, And After Implementation Of Therapeutic Hypothermia Across Racial And Ethnic Groups: United States Period-Linked Data, 2000-2017, Janardhan Mydam, Nitin Chouthai
Population Trends In Infant Mortality Before, During, And After Implementation Of Therapeutic Hypothermia Across Racial And Ethnic Groups: United States Period-Linked Data, 2000-2017, Janardhan Mydam, Nitin Chouthai
Conference Presentation Abstracts
Background: Moderate to severe hypoxic-ischemic encephalopathy (HIE) remains a major cause of neonatal mortality and lifelong morbidity. Following publication of the NICHD Neonatal Research Network trial in 2005, therapeutic hypothermia (TH) became the standard of care for infants with moderate to severe HIE. However, national trends in HIE-related infant mortality before, during, and after TH implementation across racial and ethnic groups have not been comprehensively evaluated.
Objective: To assess the impact of therapeutic hypothermia on HIE-related infant mortality by comparing mortality rates before (2000-2005), during (2006-2009), and after (2010-2017) implementation of TH among different racial and ethnic groups in the …
Student Perceptions Related To Goals Of Care Conversation Simulation Training As Part Of An Entrustable Professional Activity (Epa)-Based Medical School Curriculum, Mostafa M. Meleis Md, Katherine Cappellano, Rahul Mhaskar, Amy B. Smith Phd, A Galligan, J Costa, Robert D. Barraco Md, Mph, D Dewaay, J Quinn, K Zwygart, Jeanne L. Jacoby Md, Marna R. Greenberg Do, Mph, Facep, Jessica K. Eygnor Do
Student Perceptions Related To Goals Of Care Conversation Simulation Training As Part Of An Entrustable Professional Activity (Epa)-Based Medical School Curriculum, Mostafa M. Meleis Md, Katherine Cappellano, Rahul Mhaskar, Amy B. Smith Phd, A Galligan, J Costa, Robert D. Barraco Md, Mph, D Dewaay, J Quinn, K Zwygart, Jeanne L. Jacoby Md, Marna R. Greenberg Do, Mph, Facep, Jessica K. Eygnor Do
Medical Education
No abstract provided.
Single-Center Experience Using Endologix Anatomically Fixated Endograft Device For Treatment Of Aortoiliac Occlusive Disease, Isabella Muti, Gaurang Joshi, Dawn M. Salvatore, Michael J. Nooromid, Paul J. Dimuzio, Babak Abai
Single-Center Experience Using Endologix Anatomically Fixated Endograft Device For Treatment Of Aortoiliac Occlusive Disease, Isabella Muti, Gaurang Joshi, Dawn M. Salvatore, Michael J. Nooromid, Paul J. Dimuzio, Babak Abai
Department of Surgery Faculty Papers
OBJECTIVE: The covered endovascular reconstruction of the aortic bifurcation (CERAB) technique was developed in recent years as a novel surgical intervention for aortoiliac occlusive disease (AIOD). One tool frequently used in such procedures is the anatomically fixated endograft (AFX), manufactured by Endologix. The present study aimed to review the outcomes of patients with AIOD after CERAB procedure using the Endologix AFX device.
METHODS: This is an institutional review board-approved retrospective study investigating the experience of a single center in using Endologix's AFX device as CERAB for AIOD from September 2018 to June 2024. Data were obtained from the medical records …
Brain Candy: Wayne State University School Of Medicine Journal Of Arts And Culture, 13th Edition, Wayne State University School Of Medicine Gold Humanism Honor Society
Brain Candy: Wayne State University School Of Medicine Journal Of Arts And Culture, 13th Edition, Wayne State University School Of Medicine Gold Humanism Honor Society
Gold Humanism Honor Society
Brain Candy incorporates paintings, written pieces, and poetry from all the medical classes at Wayne State University School of Medicine to shed light on the creative process in medicine, the city of Detroit, and the experiences of health care providers. This year, the journal is organized into four sections, each of which denotes a particular time period within medical school. The first edition of Brain Candy was published online and in print in 2009, produced by a generous grant by the Gold Humanism Honor Society (GHHS). The edition featured poetry, nonfiction, short fiction, and different types of artwork. With generous …
Implementing Hypertension Guidelines Into Clinical Practice, Misti Michele Mays
Implementing Hypertension Guidelines Into Clinical Practice, Misti Michele Mays
Electronic Theses and Dissertations
Hypertension is a complex chronic disease process, and it is essential to educate the patient on the disease process, as well as on all aspects of self-management. It is essential that providers choose an evidence-based guideline by which they will manage their hypertensive patients. In addition, providers must schedule regular follow-up appointments with their patients, along with a wide variety of other multifactorial components in regard to the management of patients diagnosed with hypertension. In addition, providers have a responsibility to stay informed on new approaches to blood pressure management by reviewing the professional literature on a regular basis. Much …
A Patient-Centric Chatbot For Improving Clinical Trial Accessibility, Yumeng Yang
A Patient-Centric Chatbot For Improving Clinical Trial Accessibility, Yumeng Yang
Dissertations and Theses (Open Access)
Clinical trial enrollment remains a major challenge, and low accrual continues to delay study completion, increase research costs, and slow the development of new therapies. A barrier is the scale of the trial-matching problem: patients and clinicians must search through a large and growing number of studies, while each trial contains complex eligibility criteria that may overlap only partially with other trials. Although public registries such as ClinicalTrials.gov make trial information available, they do not adequately help patients identify which studies are most relevant to their clinical profile. This dissertation addresses that information problem by developing and evaluating a patient-centric …
A Computational Framework For Quantifying Dysregulation And Mapping Pathways Using Transcriptomic And Molecular Data And Its Application In O-Glcnacylation, Rastko Stojsin
Dissertations and Theses (Open Access)
Post-translational modifications (PTMs) are chemical modifications that occur on proteins after synthesis and play an essential role in regulating protein function. Dysregulation of biologically critical PTMs has been widely implicated in many disease phenotypes primarily through effects on complex downstream protein networks. Measurement of PTMs—particularly abundant and rapidly cycling modifications—is often limited to technically challenging and low-throughput biochemical assays. As a result, large-scale clinical datasets rarely contain direct measurements of PTM activity. These limitations restrict current research to expensive, small-scale, hypothesis-driven laboratory studies often focused on an individual disease and pathway. This dissertation presents a data-driven biomedical informatics framework for …
Graph And Language Models For Biomedical Inference Across Networks And Text, Evan Yu
Graph And Language Models For Biomedical Inference Across Networks And Text, Evan Yu
Dissertations and Theses (Open Access)
Biomedical research increasingly relies on large and heterogeneous data sources to support scientific inference. However, relevant evidence is often distributed across environments that differ substantially in structure, reliability, and scale. Biomedical evidence may be represented in relational networks that encode interactions among entities and in large-scale text corpora that contain unstructured knowledge and discourse. Developing computational approaches capable of extracting reliable and interpretable signals from these diverse data environments remains a central challenge. This dissertation investigates how graph and language models can support robust biomedical inference across three evidence environments: relational epidemiologic networks, large-scale social media discourse, and biomedical scientific …
Secondary Syphilis Mimicking Marginal Zone B-Cell Lymphoma In A 70-Year-Old Man., Hannah Gier, Shannon Trotter
Secondary Syphilis Mimicking Marginal Zone B-Cell Lymphoma In A 70-Year-Old Man., Hannah Gier, Shannon Trotter
Ambulatory and Primary Care Articles
No abstract provided.
Informed Consent In Childbirth: A Global Scoping Review Of Episiotomy Practices And The Gaps In U.S. Perinatal Care, Rachel Gulczinski
Informed Consent In Childbirth: A Global Scoping Review Of Episiotomy Practices And The Gaps In U.S. Perinatal Care, Rachel Gulczinski
Senior Theses
Informed consent is a fundamental ethical and legal component of preoperative and perinatal care and forms the foundation of trust between patients and healthcare providers. Despite this, current evidence suggests that many childbirth interventions, including episiotomies, are often performed without explicit patient consent. Episiotomy remains one of the most commonly cited interventions associated with non-consented care and obstetric violence. Therefore, this global scoping review aimed to evaluate whether informed consent is obtained for episiotomy procedures during childbirth, understand documented experiences of disrespect and unnecessary procedures, and identify differences between international and U.S. practices. This thesis followed the PRISMA Scoping Review …
Feeding The Mind: Dietary Consumption And Neural Aging, Bhavani Tuppale
Feeding The Mind: Dietary Consumption And Neural Aging, Bhavani Tuppale
Senior Theses
Neural aging is the process of physiological decline in the brain and increased vulnerability to neurodegenerative diseases. Neurodegenerative diseases such as Alzheimer’s disease are associated with aging and the interaction of genetics and lifestyle choices. Previous research studies have connected Alzheimer’s disease with dysfunction in the metabolic system. To combat age-associated dysfunctions in the metabolic system, research studies propose using the ketogenic diet, which utilizes ketone bodies as an energy source instead of glucose. The thesis analyzes literature on the effect of neural aging on various model organisms, how a ketogenic diet affects aging model organisms, and how aging and …
Identifying Factors Influencing Occupational Therapy Decision-Making Regarding Telehealth, In-Person, And Hybrid Care Within A Veterans Affairs Healthcare Setting In South Carolina, Christina R. Smith
Identifying Factors Influencing Occupational Therapy Decision-Making Regarding Telehealth, In-Person, And Hybrid Care Within A Veterans Affairs Healthcare Setting In South Carolina, Christina R. Smith
Senior Theses
Telehealth has become an increasing part of healthcare service delivery, expanding client access to services across disciplines, including occupational therapy. Existing research suggests that telehealth occupational therapy can produce similar outcomes to in-person care in certain populations; however, variability in patient characteristics, technological readiness, intervention demands, and environmental contexts influences its suitability, and limited research examines how practitioners determine the appropriate service delivery model. The purpose of this qualitative study is to explore the factors that influence occupational therapy practitioners within a Veterans Affairs healthcare setting in South Carolina when determining the appropriateness of telehealth, in-person, or hybrid service delivery …
The Role Of Community Health Workers In Rural South Carolina, Sarah W. Haselden
The Role Of Community Health Workers In Rural South Carolina, Sarah W. Haselden
Senior Theses
This paper aims to explore the role of Community Health Workers (CHWs) in rural South Carolina through a literature review as well as the data supplied from the Community Health Alignment Initiative (CHAI) and Community Health Workers Changing Outcomes in SC (CCOSC). Through reviewing the collection of materials and data, the effectiveness of CHWs can be studied. Community Health Workers (CHWs) provide a unique aspect to primary care within communities through their aid in prevention of health conditions. CCOSC and CHAI collected data throughout South Carolina to determine the needs of communities and how CHWs can work to address those …
Discovering Drug-Like Compounds By Targeting Protein-Protein Interactions Using A Yeast-3-Hybrid System, Chesley C. Blake
Discovering Drug-Like Compounds By Targeting Protein-Protein Interactions Using A Yeast-3-Hybrid System, Chesley C. Blake
Senior Theses
Protein-protein interactions are important targets in cancer biology as they can make historically “undruggable” proteins viable drug targets. However, the current approach to targeting protein-protein interactions relies on the use of small molecule drugs, which have low efficiencies as they must cover a large surface area of the interaction. Further, traditional drug therapies often lead to off-target toxicity, limiting therapeutic specificity. The objective of this project is to develop a selection system in yeast to identify short peptide sequences that can disrupt protein-protein interactions specific to cancer cells. Following proof of principle and development of the AH109 yeast strain having …
Eating Disorder Prevention And Early Intervention In U.S. Higher Education – A Comparative Benchmarking Study, Jake R. Arcement
Eating Disorder Prevention And Early Intervention In U.S. Higher Education – A Comparative Benchmarking Study, Jake R. Arcement
Senior Theses
Eating disorders (EDs), including anorexia nervosa, have the highest mortality rate of any psychiatric illness, yet remain underrecognized relative to their severity and treatment burden. Because the period of peak onset aligns with the college years, institutions of higher education are uniquely positioned to play an important role in prevention, early identification, and referral to specialized care. However, limited research has examined how colleges and universities structure ED prevention and treatment resources. This thesis applies a comparative benchmarking framework to assess current institutional practices across U.S. colleges and universities. A national survey of student health and counseling centers examined staffing, …
Introducing The Ppco Framework, Children's Health
Introducing The Ppco Framework, Children's Health
PPCO Resources & Education
Haven't heard of the PPCO Framework yet? It is a framework developed by nurses for nurses that fits nursing questions when searching for literature to support EBP.
To learn just a little more, we've created a short cheat sheet, with tips, and some examples, and most importantly - links to the original works.
Evaluation Of Seal!Nd: School Year 2024-2025, Shawnda Schroeder, Rashid Ahmad
Evaluation Of Seal!Nd: School Year 2024-2025, Shawnda Schroeder, Rashid Ahmad
Indigenous Health Faculty Publications
Dr. Schroeder and Rashid worked with the team at the Oral Health Program to collect data on the clinical reach of the School-based Sealant program (SEAL!ND), the referral practices, dental sealant cost savings, and perceptions of school personnel regarding their experiences with the program. SEAL!ND continues to make a measurable difference in improving children’s oral health by increasing access to preventive care, reducing barriers for families, and supporting schools in meeting the needs of their students. The program’s impact is reflected not only in the thousands of services provided each year, but also in the strong satisfaction and gratitude expressed …