Diseases Commons^™

Standardizing Assessment Of Open Vascular Skills: National Roll-Out And Early Impact Of The Fundamentals Of Vascular Surgery Curriculum, Yana Etkin, Kristyn Mannoia, Pail Dimusto, Libby Weaver, Khalil Qato, Gabriela Velazquez, Malachi Sheahan

School of Medicine Faculty Publications

Background: Exposure to open vascular case is declining in surgical training, creating a need for standardized, objective assessment of fundamental open skills. The Association of Program Directors in Vascular Surgery developed the Fundamentals of Vascular Surgery (FVS) curriculum to teach and assess three core skills—end-to-side anastomosis, patch angioplasty, and clockface precision suturing. This study describes FVS development and validation, nationwide rollout, and early implementation experience across U.S. training programs. Methods: A multiphase project was conducted: (1) validation (2012–2019) of the 3 FVS tasks with 313 trainees scored by trained raters using OSATS checklists and global rating scales; reliability and construct …

Utilization Of The Fundamentals Of Vascular Surgery Symposium In Surgical Curricula, Priscilla Tanamal, Amit Chawla, Amanda Tullos, Claudie Sheahan, Malachi Sheahan

School of Medicine Faculty Publications

Objective: Simulation is a helpful adjunct to vascular surgery training, in which high-volume surgical experience portends better patient outcomes. Louisiana State University Health New Orleans hosts a 3-day program, the Fundamentals of Vascular Surgery (FVS) Symposium, during which vascular trainees from across the nation can participate in didactic and hands-on lessons with an emphasis on procedures less frequently performed during residency, taught by attending surgeons from various institutions. The objective of this study was to examine the effect of the FVS Symposium on participant confidence in endovascular and open procedures and evaluate any differences between junior and senior level residents. …

Biofluid Biomarkers Aid In Diagnosing And Developing Improved Treatments For People With Alzheimer's Disease, Jonatan A. Lopez

University Honors Theses

Dementia is a disease in which daily life is disrupted by a loss of cognitive function. Late-onset Alzheimer's disease (AD) is the most common dementia that largely begins to affect individuals in their mid 60s or older. AD was selected as the focus of this paper because it is the most common form of dementia, accounting for 50-70% of dementia cases. A typical diagnostic approach used by physicians starts with a simple clinical test, the Mini-Mental State Examination (MMSE), when cognitive decline is suspected in a patient. Then if there is enough evidence to suggest AD, a physician would order …

Investigating Extracellualr Vesicles Role In The Pathogenesis Of Acute Lung Injury, Ruben Manuel Luciano Colunga Biancatelli, Pavel Solopov, Tierney Day, Anca Dobrian, John D. Catravas

Cardiovascular Research Symposium

Background: Extracellular vesicles (EVs) are small lipid-bound particles containing proteins and RNAs, whose role in intercellular communication and signaling is critical for homeostasis or inflammatory responses. Patients with acute lung injury display changes in EVs number, cargo content and signature compared to healthy individuals.

Hypothesis: We have hypothesized that EVs may play a role in the pathogenesis of acute lung, by transferring harmful mediators of inflammation and disrupting recipient cells homeostasis.

Methods: C57BL/6j mice (8-10 weeks old, 25g BW) were intratracheally instilled with 50µL of 5*1010- 11 EVs isolated from Human Lung Microvascular Endothelial cells (HLMVEC) exposed to 1 µg …

Segmental Atrophy Of The Liver: Review Of A Rare Pseudotumor, Ayesha Younus, Yu Liu, Ellen E. Connor, Zeng-Ying Wu, Hwajeong Lee, Zhi-Yan Fu

School of Medicine Faculty Publications

Segmental atrophy (SA) of the liver is a rare, often underrecognized, benign condition that presents as a mass lesion, mimicking a neoplasm, which poses a significant diagnostic challenge. Given its rarity, only a limited number of case reports and series have been published, resulting in sparse literature on the entity. This review aims to summarize the clinicopathologic and diagnostic features of SA and thus improve its recognition.

Enhancing Cataract Surgery Outcomes: Optimal Use Of Pre- And Post-Operative Eye Drops, Keith Skolnick M.D., Anu Valiaveedu

Mako: NSU Undergraduate Student Journal

Many preoperative and postoperative cataract patients struggle with comprehending the use of prescription medication as directed. Language barriers and low health literacy levels are major factors contributing to improper use of prescriptions. To increase patients comprehension, the Fort Lauderdale Eye Institute employed an educational intervention consisting of a live presentation and an instructional video. Results found that 44% of patients were hesitant to ask questions to clinical staff, 32% felt overwhelmed, and nearly 70% lacked confidence in using their prescribed eye drops. Following the intervention, 91% of patients reported increased confidence in their medications, and most indicated that the video …

Oncogenic Effects Of Ecm Remodeling In Obesity And Breast Cancer, Mackenzie L. Hawes, Marcus A. Moody, Caroline R. Mccauley, Abigail G. Huddleston, Maansi Solanky, Dara H. Khosravi, Ayushi R. Patel, Ronald M. Lynch, Suresh K. Alahari, Bruce A. Bunnell, Jorge A. Belgodere, Van T. Hoang, Matthew E. Burow, Elizabeth C. Martin

School of Medicine Faculty Publications

Extracellular matrix (ECM) components are key regulators in breast cancer progression, as ECM remodeling is essential for breast cancer cells to invade into surrounding tissue. This process is characterized by the alignment of fibrillar collagens, breakdown of basement membrane components, and increased interstitial collagen stiffness. In patients with obesity, pre-existing ECM changes, including excessive collagen deposition and heightened matrix stiffness, mimic alterations detected in breast cancer. Given that obesity is a predictor of poor prognosis and resistance to treatment in breast cancer, it is crucial to understand how ECM conditioned by obesity affects disease outcomes. In this review, we highlight …

Adaptive Deep Brain Stimulation Targeting The Subthalamic Nucleus In A Patient With Parkinson's Disease: A Care Compliant Case Report, Tirath Patel, Christopher Hanani, Anaya Noor, Shamikha Cheema, Muhammad Farhan, Rohab Sohail, Abhishek Goyal, Jabez David John, Adekunle E. Omole, Richard M. Millis

School of Nursing Faculty Publications

RATIONALE: Adaptive deep brain stimulation (aDBS) represents a notable advancement in treating Parkinson's disease (PD), as it offers enhanced therapeutic outcomes and personalized management by adjusting stimulation parameters in real-time according to individual neural signals. This approach minimizes adverse effects commonly associated with standard continuous deep brain stimulation (cDBS). This case report describes the progress of a 62-year-old man with severe PD who demonstrated notable enhancement in motor symptoms and quality of life throughout a 3-month trial period using aDBS. PATIENT CONCERNS: A 62-year-old man who has been suffering from Parkinson's disease. DIAGNOSES: The patient had been diagnosed with PD …

Integrating Clinical History, Imaging, And Serologic Testing For The Accurate Diagnosis Of Neurocysticercosis: A Case Report, Jedediah Bondy, Paul Dobria, Dillon Woody, Bryan Scott

Advances in Clinical Medical Research and Healthcare Delivery

Neurocysticercosis is a parasitic infection caused by the cestode Taenia solium, in which pigs serve as the definitive hosts. Humans can become accidental intermediate hosts through the ingestion of food contaminated with Taenia solium eggs via fecal-oral transmission. Once ingested, the eggs of Taenia solium hatch into larvae, which then migrate through the bloodstream and disseminate across various organs, including the central nervous system (CNS). In this case, a 40-year-old male from Mexico with a known history of seizure disorder presented to the emergency department with altered mental status. He had been told by a physician in his native …

Exploring Hepatic Stellate Cell-Driven Fibrosis: Therapeutic Advances And Future Perspectives, Alka Singh, Ansab Akhtar, Prashant Shukla

School of Medicine Faculty Publications

BACKGROUND AND PURPOSE: Liver fibrosis, a progressive liver disease arising from viral or metabolic causes, poses a major global health challenge due to its potential progression to cirrhosis and hepatocellular carcinoma. Due to the complex aetiology and epidemiology of liver fibrosis, most therapies fail in the clinic, and very few drugs have been approved by the US FDA. APPROACH: This review highlights the pathophysiological features of liver fibrosis, with a focus on novel targets in hepatic stellate cells (HSCs), key players in the fibrogenesis process, to develop successful therapeutic approaches using both pharmacological agents and active targeting strategies. The review …

Egg White Hydrolysate In Hypertension: A Mechanistic Investigation Of Gut Microbiota Dependent And Independent Pathways, Emerson David Nolasco

Dissertations and Doctoral Documents, University of Nebraska-Lincoln, 2023–

Cardiovascular diseases are one of the leading causes of mortality worldwide in which hypertension is a risk factor. Present pharmacological interventions require long-term adherence to the therapy and are often associated with undesirable side effects. Moreover, treatments have overlooked the role of the microbiome in the development of hypertension. Egg white hydrolysate (EWH) has exhibited antihypertensive properties with potential to be used as a natural alternative for the prevention and management of hypertension. However, EWH peptide’s effect on the gut microbiome remains yet to be elucidated. Studies have described that a portion of the ingested protein can remain undigested as …

Cholesterol Crystal Embolization Induced Kidney Disease, Shohan Pervaze, Shreya Mohandas, Pushkas Gopalan, Stephen A. Morse, Siddhartha Bajracharya, Landon A. Krone, Farshid Yazdi

School of Medicine Faculty Publications

Cholesterol crystal embolization (CCE) results from the release of cholesterol crystals from ruptured atherosclerotic plaques into circulation, resulting in the occlusion of small arteries and arterioles in various organs. Ischemia triggers a systemic inflammatory response resulting in vascular obstruction and organ dysfunction. Kidneys are often involved because of the proximity to the aorta and CCE in the kidneys can result in acute, sub-acute, or chronic kidney disease. There are many known risk factors for renal involvement of CCE, including iatrogenic and spontaneous causes. The pathophysiology of CCE includes complex pathways that lead to acute and chronic effects that can have …

The Articularis Genu As A Surrogate For Structural Determinants Of Peri-Articular Myopenia In Osteoarthritis, Davis Martin, José A.Cruz Ayala, Mary C. Gatterer, Tara Soria, Ryan Schroeder, Vinod Dasa, Luis Marrero

School of Medicine Faculty Publications

The functional limitations associated with the painful stiffness of knee osteoarthritis (kOA) can affect the muscles of the knee, such as the quadriceps femoris (QF) and articularis genu (AG). The vastus medialis oblique (VMO) of the QF complex is particularly sensitive to kOA. The AG, which can be sampled during total knee arthroplasty (TKA) for kOA, can provide information about the condition of the QF when affected by patient-reported disuse, helping to identify indicators of muscle weakness in the synovial fluid. This study compares the structural and gene expression changes between the VMO and the AG collected from patients with …

Mesenchymal Stem Cell-Derived Extracellular Vesicles: Seeking Into Cell-Free Therapies For Bone-Affected Lysosomal Storage Disorders, Andrés Felipe Leal, Harry Pachajoa, Shunji Tomatsu

Department of Pediatrics Faculty Papers

Lysosomal storage disorders (LSDs) constitute a group of monogenic systemic diseases resulting from deficiencies in specific lysosomal enzymes that cause the intralysosomal accumulation of non- or partially degraded substrates, leading to lysosomal dysfunction. In some cases of LSDs, the bone is more severely affected, thus producing skeletal manifestations in patients. Current therapies, such as enzyme replacement therapy (ERT) and gene therapy (GT), show limited efficacy in correcting skeletal abnormalities. Increasing evidence suggests that microenvironmental disturbances also contribute significantly to disease pathogenesis. Therefore, therapeutic strategies targeting lysosomal dysfunction and microenvironmental dysregulation are needed. Mesenchymal stem-cell-derived extracellular vesicles (MSC-EVs) are emerging as …

Increasing Colorectal Cancer Screening Rates For Patients Without Insurance, Andrea F. Day

Doctor of Nursing Practice Projects

Background: Colorectal cancer is a leading cause of cancer-related death in the United States (U.S.), ranking as second most prevalent overall. Despite many initiatives, screening rates remain low, especially among clinic patients without insurance. The lack of an evidence-based screening protocol exacerbates these issues and increases the risk of advanced cancer and death. Initial data showed that 0% of patients were screened according to recommended guidelines.

Purpose: The project implemented a standard screening protocol to increase colorectal cancer screening rates in a rural Alabama free clinic for patients ages 45-64 lacking insurance.

Project Design: This quality improvement …

Psoriasis Genomics: A Review, Magna Hutasuhut, Windy Keumala Budianti, Wresti Indriatmi, Mirawati Setyorini

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Psoriasis is a dermatological condition influenced by genetic and epigenetic factors, environmental triggers, as well as immune responses. Genomics refers to the study of individual genes (genomes) and their interactions with environmental influences. In the context of psoriasis genomics, the interplay between genetic predisposition and environmental factors contributes to the manifestation and variations of the disease. With advancements in molecular genotyping technology and genome-wide association studies (GWASs), researchers have identified 50 genetic markers linked to psoriasis.

Discussion: Several genetic loci associated with psoriasis have been identified, including PSORS 1-15. The genetics of psoriasis is also linked to its onset, …

Factors Associated With The Severity Of Erythema Nodosum Leprosum Reactions, Ita Anggraini, Prima Kartika Esti, Eka Komarasari

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Leprosy is a chronic infection caused by Mycobacterium leprae. Leprosy reactions, including erythema nodosum leprosum (ENL), are induced by immune responses. ENL can cause neurological damage and deformities that result in disabilities. This study aimed to identify factors associated with the severity of ENL to help control the leprosy reactions.

Methods: This was an analytical study on 148 patients with ENL reactions, who were divided into two groups based on the severity of their reactions. A retrospective cross–sectional study was conducted in the medical record unit of Sitanala Hospital, Tangerang, Banten, Indonesia, from May 2022 to …

Effectiveness Of 5% Channa Striata Extract Gel In Wound Healing: A Double-Blind Randomized Controlled Trial, Yulia Farida Yahya, Yuli Kurniawati, Erial Bahar, Theresia Lumban Toruan, Soenarto Kartowigno, Muhammad Izazi Hari Purwoko, Tiar Marina Octyvani

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Snakehead fish (Channa striata, CS) has traditionally been used in Indonesia as a nutrient to promote wound healing. It contains protein highly similar to human protein, which may be involved in wound healing via biological pathways. We aim to determine the effectiveness of the topical 5% CS extract gel in promoting wound healing.

Methods: A double-blind, placebo-controlled randomized clinical trial was conducted from June to August 2022 at the Department of Dermatology, Venereology, and Aesthetics of Dr. Mohammad Hoesin Hospital. We allocated 32 post-skin surgery participants with grade I acute superficial wounds on the face, neck, …

Topical Application Of Exosomes In A Patient With Acne Conglobata: A Case Report, Theressia Handayani, Stefani Luziani

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Acne conglobata (AC) is a rare and severe acne characterized by interconnected nodules, cysts, and abscesses. Mesenchymal stem cell-derived exosomes (MSC-exosomes) have immunosuppressive properties that alleviate inflammation and immunological reactions. We present a case of AC in a patient who received topical administration of exosomes.

Case Illustration: A 20-year-old male was diagnosed with AC, presenting as inflammatory papules and cysts covered with yellowish crusts that had been present for five months. Exosomes (ASCE+®, Seoul, South Korea) were topically administered at a dose of 5 mL, applied evenly to the face. The patient underwent three treatment sessions, with a …

Herpes Zoster Reactivation Following Covid-19 Mrna Vaccination In An Elderly Patient: A Case Report, Ratu Siti Khadijah Sarah, Yari Castiliani Hapsari, Shannaz Nadia Yusharyahya, Eliza Miranda, Sarah Qanita Edwar

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Latent varicella-zoster virus (VZV) in nerve ganglia may reactivate into herpes zoster infection. The coronavirus disease (COVID-19) vaccine is suspected of triggering VZV reactivation, although the exact cause is unclear. This case report aims to raise awareness of the potential complications induced by the COVID-19 mRNA vaccine, particularly in elderly patients.

Case Illustration: A 62-year-old woman complained of itchy and painful unilateral dermatomal herpetiform blisters six days after mRNA COVID-19 vaccination. The vesicle first appeared on the left breast, spreading to the back. The patient has a history of hypertension. After the administration of 800 mg of acyclovir five …

Serial Excision Of A Nevus Sebaceous Of Jadassohn On The Scalp, Belladikna Brillianty Sugiatno, Arif Widiatmoko, Adinda Amalia Dani, Diah Prabawati Retnani

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Nevus sebaceous of Jadassohn (NSJ) is a non-hereditary hamartoma of the skin’s adnexal structures. The incidence of NSJ in newborns is estimated at 0.1-0.3% with no gender or ethnic propensity. Surgical excision is a common treatment for NSJ, although there is no definite consensus on the timing or recommendations for the removal. This article aims to present the advantages of serial excision therapy in a case of NSJ.

Case Illustration: A 14-year-old male presented with a complaint of a bump on the scalp since birth, which had progressively enlarged during puberty. Dermatological examination revealed a well-demarcated, yellow-orange …

Validity And Reliability Of The Indonesian Version Of Nordic Occupational Skin Questionnaire 2002 (Nosq-2002), Listya Paramita, Fajar Waskito, Dikky Prawiratama, Niken Indrastuti, Tuntas Rayinda, Sri Awalia Febriana

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Epidemiological data on occupational hand eczema in Indonesia is still limited, partly because there are no valid and reliable instruments in the Indonesian language as a means of survey. This study aims to translate the Nordic Occupational Skin Questionnaire 2002 (NOSQ-2002) into the Indonesian language and assess the validity and reliability of the Indonesian NOSQ-2002 as an instrument for epidemiological surveys and screening of occupational hand eczema.

Methods: The original English version of NOSQ-2002 was translated into the Indonesian language following the standard procedure of translation. The Indonesian NOSQ-2002 version, which had been collectively approved, was subsequently completed by …

Comparing Sodium Fusidate And Petrolatum For Electrosurgery-Related Wound Healing: A Double-Blind Randomized Controlled Trial, Firman Parrol, Larisa Paramitha Wibawa, Irma Bernadette Simbolon Sitohang, Siti Rizny Fitriana Saldi

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Electrosurgery is a common surgical technique used to treat skin tumors. This procedure produces necrotic skin, which might impair the wound healing process, prompting physicians to prescribe topical antibiotics to prevent infection. This study aims to analyze the efficacy of sodium fusidate ointment compared to petrolatum for wound healing after electrosurgery.

Methods: We conducted a double-blind, randomized, controlled study with a within-person design. The inclusion criteria were adult subjects with seborrheic keratosis or acrochordon with a size of 4 mm to 10 mm on the face and neck, with a minimum of 2 lesions. Electrodessication was performed on the …

Skin Rejuvenation With Microbotox: A Review, Ifen Ayu Malinda, Nelva Karmila Jusuf

Journal of General - Procedural Dermatology and Venereology Indonesia

Background: Skin aging is characterized by a gradual loss of tissue and organ function. Skin aging can be classified into two types: intrinsic aging, associated with the aging process itself, and extrinsic aging, which is linked to external factors. Microbotox—an intradermal injection of diluted botulinum toxin—has emerged as a promising technique for rejuvenation by improving skin texture, pore size, and sebum control. This review aims to provide a comprehensive overview of the microbotox technique in the context of skin aging, emphasizing its mechanisms, indications, and clinical outcomes.

Discussion: In Asia, intradermal injection of botulinum toxin or microbotox has been widely …

Early Recurrent Midgut Volvulus Post Ladd's Procedure In A Newborn: A Case Report, Nicole Clarke, Joanna Sajdlowska, John Paul Bustamante, Nishith Bhattacharyya

Rowan-Virtua School of Osteopathic Medicine Departmental Research

Ladd's procedure is the standard surgical intervention for intestinal malrotation. Although generally curative, rare cases of early postoperative complications, including adhesions or recurrent volvulus, can necessitate reoperation. We present the case of a full-term newborn girl who underwent emergent Ladd's procedure on Day 3 of life for malrotation with volvulus. She was discharged on postoperative Day 17 but returned the following day with recurrent bilious emesis. Imaging suggested partial obstruction. Exploratory laparotomy revealed recurrent volvulus with two twists at the duodenojejunal junction, which was successfully reduced. The patient recovered well and was discharged on postoperative Day 8. This case underscores …

Molecular Mechanisms Of L-Type Calcium Channel Dysregulation In Heart Failure, Arbab Khalid, Abu-Bakr Ahmed, Randeep Gill, Taha Shaikh, Joshua Khorsandi, Ali Kia

Department of Internal Medicine Faculty Research

The L-type calcium channels (LTCCs) function as the main entry points that convert myocyte membrane depolarization into calcium transients, which drive every heartbeat. There is increasing evidence to show that maladaptive remodeling of these channels is the cause of heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Recent experimental, translational, and clinical studies have improved our understanding of the roles LTCC expression, micro-domain trafficking, and post-translational control have in disrupting excitation–contraction coupling, provoking arrhythmias, and shaping phenotype specific hemodynamic compromise. We performed a systematic search of the PubMed and Google Scholar databases (2015–2025, …

Gust, Stroll, Veil, Jungeun Park

Masters Theses

I witness the unsettling and chaotic moments of everyday life:

blood clots in fried eggs, a dead rat on my porch, mites crawling on our skin . . .

These quiet tragedies exist with almost brutal indifference!

We eat, digest, excrete. We menstruate. We parasitize. We coexist.

I seek the intersection of repulsion and wonder in my daily experience and body sensations, visualizing unseen stimuli. I employ veil as a strategy. It conceals yet reveals. Sometimes, it acts as a transparent layer, sharpening what lies beneath. Other times, it blurs colors and forms, rendering them ambiguous. Veil transforms, entices, and …

Imaging Hallmarks Of Idiopathic Intracranial Hypertension And Insights Into Pathogenesis, Albalooshy Basimah, Scott Faro, Hsiangkuo Yuan, Kiran Talekar, Prabath Mondel, Enchao Qiu, Joga Chaganti

Department of Radiology Faculty Papers

Idiopathic Intracranial hypertension (IIH), also referred to as pseudotumor cerebri, is a term used to describe increased intracranial pressure in the absence of a known identifiable secondary cause. Despite advancements of neuroimaging techniques, imaging of the pathological underpinnings in the diagnosis of IIH has been limited. Although the causation of IIH has been ascribed to increased Cerebrospinal Fluid production and disordered drainage through the dural sinuses, new evidence shows that the glymphatic system which is an alternate pathway of drainage is likely to play a pivotal role. In this review, we address the pathophysiological underpinnings in the causation of IIH …

Myocardin Effector Proteins Affect Tgf-Beta-Induced Myofibroblast Differentiation In Ipf Cells, Allison Gonzalez

Biotechnology Theses

Idiopathic pulmonary fibrosis (IPF) is an incurable interstitial lung disease defined by the progressive, irreversible scarring of the tissues between the lung’s alveoli. To date, only two drugs have received approval for treatment. However, these medications are not considered cures since they do not stop the progression of the disease. A deeper understanding of the mechanisms underlying IPF could aid in discovering a cure. We recently found that myocardin (MyoCD) regulates SMAD2/3 transcription factors in the TGF-β signaling pathway and governs the genes involved in pleural fibrosis. However, it is unclear whether MyoCD plays a critical role in IPF by …

Advancing Remote Monitoring For Patients With Alzheimer Disease And Related Dementias: Systematic Review, Mohmmad Arif Shaik, Fahim Islam Anik, Md Mehedi Hasan, Sumit Chakravarty, Mary Dioise Ramos, Mohammad Ashiqur Rahman, Sheikh Iqbal Ahamed, Nazmus Sakib

School of Nursing Faculty Publications

BACKGROUND: Using remote monitoring technology in the context of Alzheimer disease (AD) care presents exciting new opportunities to lessen caregiver stress and improve patient care quality. The application of wearables, environmental sensors, and smart home systems designed specifically for patients with AD represents a promising interdisciplinary approach that integrates advanced technology with health care to enhance patient safety, monitor health parameters in real time, and provide comprehensive support to caregivers. OBJECTIVE: The objectives of this study included evaluating the effectiveness of various remote sensing technologies in enhancing patient outcomes and identifying strategies to alleviate the burden on health care professionals …