Medical Specialties Commons^™

Characteristics Of Salmonella Recovered From Stools Of Children Enrolled In The Global Enteric Multicenter Study, Irene N. Kasumba, Caisey V. Pulford, Blanca M. Perez-Sepulveda, Sunil Sen, Nurulla Sayed, Jasnehta Permala-Booth, Sofie Livio Sofie Livio, Darren Heavens Darren Heavens, Ross Low Ross Low, Shahida Qureshi, Anita K. M. Zaidi

Department of Paediatrics and Child Health

Background: The Global Enteric Multicenter Study (GEMS) determined the etiologic agents of moderate-to-severe diarrhea (MSD) in children under 5 years old in Africa and Asia. Here, we describe the prevalence and antimicrobial susceptibility of non-typhoidal Salmonella (NTS) serovars in GEMS and examine the phylogenetics of Salmonella Typhimurium ST313 isolates.
Methods: Salmonella isolated from children with MSD or diarrhea-free controls were identified by classical clinical microbiology and serotyped using antisera and/or whole genome sequence data. We evaluated antimicrobial susceptibility using the Kirby-Bauer disk diffusion method. Salmonella Typhimurium sequence types were determined using multi-locus sequence typing and whole genome sequencing was performed …

Post-Partum Skin-To-Skin Care And Infant Safety: Results Of A State-Wide Hospital Survey, Eileen Tyrala, Md, Michael H. Goodstein, Md, Erich Batra, Md, Barbara Kelly, Md, Judy Bannon, Mba, Ted Bell, Ms

Department of Medicine Faculty Papers

Objectives: Survey current experience with Skin to Skin care (SSC) in Pennsylvania Maternity Centers.

Study Design: The nursing director of each Maternity Center in PA (n = 95) was sent an on-line confidential survey querying SSC practices. Responses were compared by delivery size, location, and nature of affiliation. Statistics analyzed by chi-square and student t-test.

Results: Of these 64/95 MCs (67%) responded. All allowed SSC after vaginal deliveries, 55% after C-section, 73% mother’s room. Monitoring included delivery room nurse (94%) with support from other providers (61%), family members (37%), and electronic monitoring (5%). If SSC occurred in mother’s …

X-Linked Hypophosphatemic Osteomalacia With Phex Mutation Presenting Late In Pakistan, Nawazish Zehra, Lena Jafri, Salman Kirmani, Aysha Habib Khan

Department of Pathology and Laboratory Medicine

Abstract.introduction.and.importance: Autosomal dominant hypophosphatemic rickets is the most common form of rare rickets, commonly manifests in children but sometimes the condition remains undiagnosed due to lack of knowledge &/or awareness of treating physicians or surgeons.
Case presentation: We describe a case of 43 years old female with multiple fragility fractures since childhood, corrected surgically but never investigated. She had stunted growth, bowing deformities and loss of teeth.
Clinical discussion: A detailed history and examination along with metabolic and genetic work up mounted the diagnosis of X linked hypophosphatemic osteomalacia. The pathophysiology involves the mutation or the loss of the …

A Pathogenic Ufsp2 Variant In An Autosomal Recessive Form Of Pediatric Neurodevelopmental Anomalies And Epilepsy, Min Ni, Bushra Afroze, Chao Xing, Chunxiao Pan, Yanqiu Shao, Ling Cai, Brandi L. Cantarel, Jimin Pei, Nick V. Grishin, Stacy Hewson

Department of Paediatrics and Child Health

Purpose: Neurodevelopmental disabilities are common and genetically heterogeneous. We identified a homozygous variant in the gene encoding UFM1-specific peptidase 2 (UFSP2), which participates in the UFMylation pathway of protein modification. UFSP2 variants are implicated in autosomal dominant skeletal dysplasias, but not neurodevelopmental disorders. Homozygosity for the variant occurred in eight children from four South Asian families with neurodevelopmental delay and epilepsy. We describe the clinical consequences of this variant and its effect on UFMylation.
Methods: Exome sequencing was used to detect potentially pathogenic variants and identify shared regions of homozygosity. Immunoblotting assessed protein expression and post-translational modifications in patient-derived fibroblasts. …

Influence Of A One-Time Web-Based Provider Intervention On Patient-Reported Outcomes After The Well-Child Visit: A Feasibility Study, Chad M. Coleman, Gwen L. Alexander, Charles Barone, Andrew S. Bossick, Zeinab Kassem, Mei Lu, Yueren Zhou, Andrea E. Cassidy-Bushrow

Journal of Patient-Centered Research and Reviews

Purpose: Patient-centered care promotes positive health outcomes in pediatrics. We created a provider-focused intervention and implemented it in a pragmatic clustered randomized controlled trial to improve health-related quality of life (HRQOL) among pediatric patients.

Methods: A one-time (1–1.5-hour) webinar focusing on patient-centered care and motivational interviewing, using obesity screening as an example, was developed. Pediatric providers were recruited and randomized to either intervention (webinar) or control (usual care) arms. All well-child visits to these providers for a period of up to 5 months following webinar completion (or study enrollment for controls) were identified, and these family/patients were invited to complete …

Assessment Of Stakeholder Engagement In A Down Syndrome Research Study, Jeanhee Chung, Ashwini Sarathy, Yichuan Grace Hsieh, Greg Estey, Amy Torres, Vasiliki Patsiogiannis, Karen Donelan, Brian G. Skotko

Journal of Patient-Centered Research and Reviews

There is growing recognition of the importance of engaging patients early in the design of research studies. For studies involving patients with intellectual and cognitive disabilities, researchers may consider engaging with family caregivers, health professionals, community advocates, and/or subject matter experts to provide a more multifaceted, surrogate perspective. Evaluating the engagement of these stakeholder groups in research is nascent, and tools are limited. Research studies involving these individuals provide the opportunity to test new methods of measurement of stakeholder engagement in research. We conducted a 3-year research study implementing and evaluating Down Syndrome Clinic to You, an online platform for …

The Silence Of Food Insecurity: Disconnections Between Primary Care And Community Organizations, Nicole K. Runkle, David A. Nelson

Journal of Patient-Centered Research and Reviews

Purpose: Food insecurity is a prominent issue in the United States, and it is well established that food insecurity is linked to health and chronic illnesses. Studies show that screening for food insecurity is not yet part of standardized practice among all primary care physicians, nor are care providers comfortable with how to proceed with a patient who presents with this issue. Food insecurity is often handled by community-based organizations (CBOs) such as food pantries. Family medicine and pediatric clinics (FMPC) and CBOs hold unique relationships with their clients and can benefit from partnerships with each other to improve health …

Hajdu Cheney Syndrome Due To Notch2 Defect - First Case Report From Pakistan And Review Of Literature, Sibtain Ahmed, Aahan Arif, Saadia Abbas, Muhammad Osama Khan, Salman Kirmani, Aysha Habib Khan

Department of Pathology and Laboratory Medicine

Introduction and importance: Hajdu Cheney Syndrome (HCS) is a rare skeletal disease characterized by severe, progressive focal bone loss with osteoporosis, variable craniofacial, vertebral anomalies and distinctive facial features. It is inherited as an autosomal dominant disease although sporadic cases have been described in literature. Identifying these cases in clinical practice is important for proper diagnosis and management.
Case presentation: We report a case of a 36-year-old male patient presented at metabolic bone disease clinic at the Aga Khan University Hospital with history of multiple fragility fractures and juvenile osteoporosis since childhood. DNA sequence analysis of the NOTCH2 coding sequence …

Low-Dose Antithymocyte Globulin Has No Disadvantages To Standard Higher Dose In Pediatric Kidney Transplant Recipients: Report From The Pediatric Nephrology Research Consortium, Isa F. Ashoor, Robbie A. Beyl, Charu Gupta, Amrish Jain, Stefan G. Kiessling, Asha Moudgil, Hiren P. Patel, Joseph Sherbotie, Donald J. Weaver Jr., Rima S. Zahr, Vikas R. Dharnidharka

Pediatrics Faculty Publications

Introduction
Rabbit antithymocyte globulin (rATG) dosing strategies for induction in pediatric kidney transplantation vary between centers. It is not known whether a lower rATG induction dose provides safe and effective immunosuppression compared with a “standard” higher dose.

Methods
We performed a retrospective multicenter study of all isolated first-time kidney transplant recipients < 21 years old who received rATG induction between 1 January 2010 and 31 December 2014 at 9 pediatric centers. An a priori cutoff of a 4.5-mg/kg cumulative rATG dose was used to identify low (≤ 4.5 mg/kg) and standard (> 4.5 mg/kg) exposure groups. Outcomes examined included 12 months posttransplant graft function (estimated glomerular filtration rate [eGFR]); the occurrence of acute rejection, donor-specific antibody (DSA), neutropenia, and viral infection …

Combined Use Of The Ketogenic Diet And Vagus Nerve Stimulation In Pediatric Drug-Resistant Epilepsy., Ayman Abdelmoity, Jean-Baptist Lepichon, Sherouk A. Abdelmoity, Ashley K. Sherman, Ara Hall, Ahmed Abdelmoity

Manuscripts, Articles, Book Chapters and Other Papers

Objective: Patients with drug-resistant epilepsy (DRE) pose considerable management challenges for patients, their families, and providers. Both the vagus nerve stimulator (VNS) and the ketogenic diet (KD) have been shown to be safe and effective in treating DRE. Nevertheless, information is lacking regarding treatment with combination of both modalities. This study reports the efficacy and tolerability of combining VNS and KD in a pediatric cohort with intractable epilepsy.

Methods: This is a retrospective review of 33 patients (0-17 years) with DRE treated with VNS and KD at a single pediatric level IV epilepsy center. We compared seizure reduction rates for …

A Multidisciplinary Approach To Triage Patients With Breast Disease During The Covid-19 Pandemic: Experience From A Tertiary Care Center In The Developing World, Abida K. Sattar, Hania Shahzad, Adnan Abdul Jabbar, Azmina Tajdin Valimohammad, Sadaf Khan, Yasmin Vellani, Romana Idrees, Nasir Ali, Imrana Masroor, Humera Saeed, Gulzar S. Lakhani, Nadia Ayoub, Atif Waqar, Muhammad Zia-Ul Islam, Salman Kirmani, Asad Latif, Ather Enam

Section of General Surgery

Background: The COVID-19 pandemic has created a need to prioritize care because of limitation of resources. Owing to the heterogeneity and high prevalence of breast cancers, the need to prioritize care in this vulnerable population is essential. While various medical societies have published recommendations to manage breast disease during the COVID-19 pandemic, most are focused on the Western world and do not necessarily address the challenges of a resource-limited setting.
Aim: In this article, we describe our institutional approach for prioritizing care for patients presenting with breast disease.
Methods and results: The breast disease management guidelines were developed and approved …

Utilization Of The Naranjo Scale To Evaluate Adverse Drug Reactions At A Free-Standing Children's Hospital., Madhavi Murali, Sarah Suppes, Keith Feldman, Jennifer Goldman

Manuscripts, Articles, Book Chapters and Other Papers

The relationship between the Naranjo scaling system and pediatric adverse drug reactions (ADR) is poorly understood. We performed a retrospective review of 1,676 pediatric ADRs documented at our hospital from 2014-2018. We evaluated patient demographics, implicated medication, ADR severity, calculated Naranjo score, associated symptoms, and location within the hospital in which the ADR was documented. ADR severity was poorly correlated with Naranjo interpretation. Out of the 10 Naranjo scale questions, 4 had a response of "unknown" greater than 85% of the time. Cardiovascular and oncological/immunologic agents were more likely to have a probable or definite Naranjo interpretation compared to antimicrobials. …

Functional Constipation Induces Bladder Overactivity Associated With Upregulations Of Htr2 And Trpv2 Pathways., Nao Iguchi, Alonso Carrasco, Alison X. Xie, Ricardo H. Pineda, Anna P. Malykhina, Duncan T. Wilcox

Manuscripts, Articles, Book Chapters and Other Papers

Bladder and bowel dysfunction (BBD) is a common yet underdiagnosed paediatric entity that describes lower urinary tract symptoms (LUTS) accompanied by abnormal bowel patterns manifested as constipation and/or encopresis. LUTS usually manifest as urgency, urinary frequency, incontinence, and urinary tract infections (UTI). Despite increasing recognition of BBD as a risk factor for long-term urinary tract problems including recurrent UTI, vesicoureteral reflux, and renal scarring, the mechanisms underlying BBD have been unclear, and treatment remains empirical. We investigated how constipation affects the lower urinary tract function using a juvenile murine model of functional constipation. Following four days of functional constipation, animals …

Abnormal Nutritive Sucking As An Indicator Of Neonatal Brain Injury, Sabrina Shandley, Gilson J. Capilouto, Eleonora Tamilia, David M. Riley, Yvette R. Johnson, Christos Papadelis

Communication Sciences and Disorders Faculty Publications

A term neonate is born with the ability to suck; this neuronal network is already formed and functional by 28 weeks gestational age and continues to evolve into adulthood. Because of the necessity of acquiring nutrition, the complexity of the neuronal network needed to suck, and neuroplasticity in infancy, the skill of sucking has the unique ability to give insight into areas of the brain that may be damaged either during or before birth. Interpretation of the behaviors during sucking shows promise in guiding therapies and how to potentially repair the damage early in life, when neuroplasticity is high. Sucking …

Colostomy Takedown: Ischemic Complication Following Anorectal Malformation Surgery., Wendy Jo Svetanoff, Justin A. Sobrino Md, Grace S. Mitchell, Rebecca M. Rentea

Manuscripts, Articles, Book Chapters and Other Papers

Introduction: Anorectal malformations (ARM) are complex disorders that often require staged reconstructions. We present a case and imaging findings of a child who developed issues following colostomy closure due to segmental colonic ischemia. Case Presentation. A 3-year-old female with Currarino syndrome presented with abdominal distention, blood-flecked stools, and prolonged cecostomy flush time. For her anorectal malformation, a colostomy was initially placed. A new colostomy was created at posterior sagittal anorectoplasty (PSARP) to allow the distal rectum to reach the anus without tension. Differentials for her presenting symptoms included a mislocation of the anus, stenosis at the anoplasty site, stricture …

Shear Stress Associated With Cardiopulmonary Bypass Induces Expression Of Inflammatory Cytokines And Necroptosis In Monocytes., Lan N. Tu, Lance Hsieh, Masaki Kajimoto, Kevin Charette, Nataliya Kibiryeva, Adriana Forero, Sarah Hampson, Jennifer A. Marshall, James O'Brien, Marta Scatena, Michael A. Portman, Ram Savan, Chris Benner, Alberto Aliseda, Muhammad Nuri, Douglas Bittel, Peter Pastuzsko, Vishal Nigam

Manuscripts, Articles, Book Chapters and Other Papers

Cardiopulmonary bypass (CPB) is required during most cardiac surgeries. CBP drives systemic inflammation and multiorgan dysfunction that is especially severe in neonatal patients. Limited understanding of molecular mechanisms underlying CPB-associated inflammation presents a significant barrier to improve clinical outcomes. To better understand these clinical issues, we performed mRNA sequencing on total circulating leukocytes from neonatal patients undergoing CPB. Our data identify myeloid cells, particularly monocytes, as the major cell type driving transcriptional responses to CPB. Furthermore, IL-8 and TNF-α were inflammatory cytokines robustly upregulated in leukocytes from both patients and piglets exposed to CPB. To delineate the molecular mechanism, we …

Direct And Indirect Effect Of 10 Valent Pneumococcal Vaccine On Nasopharyngeal Carriage In Children Under 2 Years Of Age In Matiari, Pakistan, Muhammad Imran Nisar, Sheraz Ahmed, Fyezah Jehan, Shahira Shahid, Sadia Shakoor, Furqan Kabir, Aneeta Hotwani, Sahrish Munir, Sajid Muhammad, Farah Khalid, Syed Asad Ali, Anita K. M. Zaidi, Najeeha Talat Iqbal

Department of Paediatrics and Child Health

Background: Pakistan introduced Ten-valent pneumococcal-conjugate-vaccine PCV10 in 2012 as a 3 + 0 schedule without catch-up.
Methods: Children <2 years old in Matiari, Sindh provided nasopharyngeal swabs between 2014 and 2018, which were cultured for pneumococcus and serotyped through multiplex PCR at the Aga Khan University Hospital. Carriage rates over time for Vaccine-Type (VT) and Non-VT (NVT) serotypes were used to estimate direct, indirect, total and overall effects of vaccination. Regression analysis was used to determine factors associated with VT carriage.
Results: Pneumococcus was detected in 2370/3140 (75%). VT carriage decreased overall, 16.1-9.6% (p-trend <0.001); vaccinated (all 3 doses of PCV10 received) 11.3-8.1% (p-trend 0.031) and unvaccinated (no PCV10 dose received) 17.4-10.3% (p-trend 0.003) with a decline in serotypes 6B, 9V/9A and 19F. Immunization increased from 41.0% to 68.4% (p-trend 0.001). Direct effect of vaccine was 32.8% (95% CI 14.7-47.0%) and indirect effect 44.6%(95% CI 40.6-48.6%). Factors associated with decreased VT colonization were education 1-5 years (aOR 0.7, 95%CI 0.6-1.0), history of difficulty breathing (aOR 0.7, 95%CI 0.5-1.0), exposure to smoke (aOR 0.8, 95% CI 0.6-1.0), child fully immunized (aOR 0.7, 95%CI 0.5-1.0) and enrolled in 3rd (aOR 0.6, 95%CI 0.4-0.8) and 4th (aOR 0.6, 95%CI 0.5-0.9) year of the study whereas history of runny nose (aOR 1.5, 95% CI 1.2-1.9) was positively associated.
Conclusions: Decrease in VT pneumococcal carriage in vaccinated and unvaccinated children indicates herd immunity. Sustained increase in vaccine coverage and close long-term surveillance is warranted.

Frequency Of Immediate Neonatal Complications (Hypoglycemia And Neonatal Jaundice) In Late Preterm And Term Neonates, Muhammad Salman, Heeranand Rathore, Shabina Ariff, Rashid Ali, Ausaf Ahmed Khan, Muhammad Nasir

Department of Paediatrics and Child Health

Background: Evidence suggests that neonates born at 34-36 weeks should not be considered full-term neonates, given the magnitude of morbidities they experience compared with term infants. Neonates born at 34 to 36 weeks are at increased risk for early illness such as hypoglycemia and hyperbilirubinemia compared to term infants.
Objective: This study's objective was to determine the frequency of immediate neonatal complications (hypoglycemia and neonatal jaundice) in late preterm and term neonates.
Subjects and methods: A serial descriptive case study was conducted at the private tertiary care hospital. Random samplings were taken, and the sample size was calculated on Epi …

Prolonged Environmental Enrichment Promotes Developmental Myelination., Evan Z Goldstein, Vera Pertsovskaya, Thomas A Forbes, Jeffrey L Dupree, Vittorio Gallo

Pediatrics Faculty Publications

Postnatal neurodevelopment is profoundly influenced by environmental experiences. Environmental enrichment is a commonly used experimental paradigm that has uncovered numerous examples of experience-dependent plasticity in health and disease. However, the role of environmental enrichment in normal development, especially glial development, is largely unexplored. Oligodendrocytes, the myelin-forming glia in the central nervous system, provide metabolic support to axons and establish efficient saltatory conduction by producing myelin. Indeed, alterations in myelin are strongly correlated with sensory, cognitive, and motor function. The timing of developmental myelination is uniquely positioned to be influenced by environmental stimuli, as peak myelination occurs postnatally and continues into …

Sex-Specific Social Behavior And Amygdala Proteomic Deficits In, Maria Jesus Herrero, Li Wang, David Hernandez-Pineda, Payal Banerjee, Heidi Y. Matos, Meredith Goodrich, Aswini Panigrahi, Nathan Anthony Smith, Joshua G. Corbin

Pediatrics Faculty Publications

In humans, mutations in the transcription factor encoding gene, FOXP2, are associated with language and Autism Spectrum Disorders (ASD), the latter characterized by deficits in social interactions. However, little is known regarding the function of Foxp2 in male or female social behavior. Our previous studies in mice revealed high expression of Foxp2 within the medial subnucleus of the amygdala (MeA), a limbic brain region highly implicated in innate social behaviors such as mating, aggression, and parental care. Here, using a comprehensive panel of behavioral tests in male and female Foxp2 +/- heterozygous mice, we investigated the role Foxp2 plays …

The Impact Of Perinatal Severe Acute Respiratory Syndrome Coronavirus 2 Infection During The Peripartum Period., O. Janssen, M. Thompson, S. Milburn, R. Green, B. Wagner, A. Bianco, A. Stroustrup

Journal Articles

No abstract provided.

Genotype-Phenotype Association And Variant Characterization In Diamond-Blackfan Anemia Caused By Pathogenic Variants In, M. D. Gianferante, M. W. Wlodarski, E. Atsidaftos, L. Da Costa, P. Delaporta, J. E. Farrar, M. Hussain, J. M. Lipton, A. Vlachos, N. Giri, +11 Additional Authors

Journal Articles

Diamond Blackfan anemia (DBA) is predominantly an autosomal dominant inherited red cell aplasia primarily caused by pathogenic germline variants in ribosomal protein genes. DBA due to pathogenic RPL35A variants has been associated with large 3q29 deletions and phenotypes not common in DBA. We conducted a multi-institutional genotype-phenotype study of 45 patients with DBA associated with pathogenic RPL35A germline variants and curated the variant data on 21 additional cases from the literature. Genotype-phenotype analyses were conducted comparing patients with large deletions versus all other pathogenic variants in RPL35A. Twenty-two of the 45 cases had large deletions in RPL35A. After adjusting for …

Assessing The Importance Of Interleukin-6 In Covid-19 - Authors' Reply., D. E. Leisman, L. Ronner, R. Pinotti, M. D. Taylor, P. Sinha, C. S. Calfee, A. V. Hirayama, F. Mastroianni, C. J. Turtle, C. S. Deutschman, +2 Additional Authors

Journal Articles

No abstract provided.

Pediatric Caregiver Health Literacy: Comparing Perceptions Of Pediatricians And Nurse Practitioners, Kirbey Flora

Mahurin Honors College Capstone Experience/Thesis Projects

Throughout life, most people will interact with the healthcare system to manage information in order to make healthcare decisions. Health literacy is the ability to comprehend health information needed to make healthcare decisions. Pediatric patients often do not have a voice in their healthcare decisions; therefore, their health outcomes may be affected by the health literacy of their caregivers. In addition, the child’s health may be impacted by the ability of the healthcare team to provide appropriate health education. The purpose of this honors thesis was to determine pediatric healthcare providers’ perception of health literacy in their practices. Qualitative data …

Acute Pediatric Stroke, Saptharishi Lalgudi Ganesan, Cecil Hahn

Data and Test Instruments

No abstract provided.

Clinical Neurophysiology And Social Media: Time To Take The Plunge!, Saptharishi Lalgudi Ganesan, Aatif M. Husain

Data and Test Instruments

No abstract provided.

A Survey Of Neuromonitoring Practices In North American Pediatric Intensive Care Units, Saptharishi Lalgudi Ganesan

Data and Test Instruments

No abstract provided.

Data From: Age And Sex-Based References Ranges Imbedded Within The Electronic Health Record For Common Obesity-Comorbidity Screens At Children's Mercy Kansas City, Mitchell Barnes, Emily Paprocki, Kelsee Halpin

Data Sets

The included data table depicts the age and sex-specific references ranges for common obesity-comorbidity screens performed at Children's Mercy Kansas City, including systolic blood pressure, diastolic blood pressure, lipid profile results, and hepatic transaminases.

Graduate Medical Education Annual Report 2020-2021, Children's Mercy Hospital

GME Annual Reports

Annual report of the Children's Mercy Hospital Graduate Medical Education department, including pediatric residency, internal medicine/pediatrics residency, fellowship programs, medical students, continuing medical education, and library services.

Predictability Of Transcutaneous Bilirubinometry In Late Preterm And Term Infants At Risk For Pathological Hyperbilirubinemia., Ekaterina Dianova Md, J Fogel, R P Verma

Other Specialties

BACKGROUND: The aim was to assess the predictability of transcutaneous bilirubinometry in late preterm and term neonates at risk for pathological hyperbilirubinemia, and to identify the neonatal population in which transcutaneous bilirubin most accurately predicts serum bilirubin level (SB, mg/dl).

METHODS: The correlations between transcutaneous bilirubin (TCB, mg/dl) and SB in different neonatal population subsets; and between ΔTSB (TCB-SB) and relevant neonatal variables and clinical groups were analyzed.

RESULTS: TCB correlated with SB (r = 0.82, p < 0.05) in the cohort (n = 350) and in population subsets (r = 0.81-0.9, p < 0.001). Black infants with gestational age (GA) >35 weeks and chronological age (CA) >3 days recorded strongest correlation (r = 0.9, p < 0.001) followed by Blacks, and non-Black infants with CA >3 days and GA >35 weeks. ΔTSB was …