Medical Specialties Commons^™

Enhanced B7-H4 Expression In Gliomas With Low Pd-L1 Expression Identifies Super-Cold Tumors., Di Chen, Gaopeng Li, Chunxia Ji, Qiqi Lu, Ying Qi, Chao Tang, Ji Xiong, Jian Hu, Fatma Betul Aksoy Yasar, Yan Zhang, Dave S B Hoon, Yu Yao, Liangfu Zhou

Articles, Abstracts, and Reports

BACKGROUND: Characterizing expression profiles of different immune checkpoint molecules are promising for personalized checkpoint inhibitory immunotherapy. Gliomas have been shown as potential targets for immune checkpoint inhibitors recently. Our study was performed to determine coexpression levels of two major B7 immune regulatory molecules programmed death ligand 1 (PD-L1) and B7-H4, both of which have been demonstrated to inhibit antitumor host immunity in gliomas.

METHODS: We assessed tumor tissues from stage II-IV primary gliomas (n=505) by immunohistochemistry (IHC) for protein levels of both PD-L1 and B7-H4. Gene coexpression analysis assessing clusters based on extent of PD-L1/B7-H4 classifier genes expression were investigated …

Randomized Phase Ii Study Of Stereotactic Body Radiotherapy And Interleukin-2 Versus Interleukin-2 In Patients With Metastatic Melanoma., Brendan Curti, Marka R Crittenden, Steven K Seung, Christopher B Fountain, Roxanne Payne, Shuching Chang, Jessica Fleser, Kimberly Phillips, Ian Malkasian, Lyn B Dobrunick, Walter Urba

Articles, Abstracts, and Reports

BACKGROUND: A pilot study of stereotactic body radiation therapy (SBRT) followed by high-dose interleukin-2 (IL-2) showed a higher than anticipated objective response rate (ORR) among patients with metastatic melanoma (MM). We performed a prospective randomized study to determine if the ORR of SBRT + IL-2 was greater than IL-2 monotherapy in patients with advanced melanoma.

METHODS: Patients with MM who had adequate physiological reserve for IL-2 and at least one site suitable for SBRT were eligible. There was a 1:1 randomization to SBRT + IL-2 or IL-2 monotherapy. Patients received one or two doses of SBRT (20 Gy per fraction) …

Results Of Lung Cancer Screening In The Community., John R Handy, Michael Skokan, Erika Rauch, Steven Zinck, Rachel E Sanborn, Svetlana Kotova, Mansen Wang

Articles, Abstracts, and Reports

PURPOSE: To address doubts regarding National Lung Screening Trial (NLST) generalizability, we analyzed over 6,000 lung cancer screenings (LCSs) within a community health system.

METHODS: Our LCS program included 10 sites, 7 hospitals (2 non-university tertiary care, 5 community) and 3 free-standing imaging centers. Primary care clinicians referred patients. Standard criteria determined eligibility. Dedicated radiologists interpreted all LCSs, assigning Lung Imaging Reporting and Data System (Lung-RADS) categories. All category 4 Lung-RADS scans underwent multidisciplinary review and management recommendations. Data was prospectively collected from November 2013 through December 2018 and retrospectively analyzed.

RESULTS: Of 4,666 referrals, 1,264 individuals were excluded or …

Adoption Of A Strategy Of Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement Is Associated With Fewer Neurologic Events In A Large Volume Center, Ec Korngold, Eb Kirker, Robert W. Hodson, Ruyun Jin, Kateri Spinelli, Shih-Ting Chiu, S Verburg, V Kumar, Bm Jones

Articles, Abstracts, and Reports

No abstract provided.

Transcriptional Upregulation Of Nlrc5 By Radiation Drives Sting- And Interferon-Independent Mhc-I Expression On Cancer Cells And T Cell Cytotoxicity., Lauren Zebertavage, Alejandro F Alice, Marka R Crittenden, Michael J. Gough

Articles, Abstracts, and Reports

Radiation therapy has been shown to enhance the efficacy of various T cell-targeted immunotherapies that improve antigen-specific T cell expansion, T regulatory cell depletion, or effector T cell function. Additionally, radiation therapy has been proposed as a means to recruit T cells to the treatment site and modulate cancer cells as effector T cell targets. The significance of these features remains unclear. We set out to determine, in checkpoint inhibitor resistant models, which components of radiation are primarily responsible for overcoming this resistance. In order to model the vaccination effect of radiation, we used a Listeria monocytogenes based vaccine to …

Incorporating A Clinical Pharmacist In An Outpatient Palliative Care Team, Crystal Rim, Sharon Leigh, Linda Desitter, Mary Grant, Dana Nguyen

Providence Pharmacy PGY1 Program at Providence Milwaukie and Providence Newberg Medical Centers 2020

Title: Incorporating a clinical pharmacist in an outpatient palliative care team

Crystal Rim, PharmD; Sharon Leigh, PharmD, BCPS; Linda De Sitter MD, MPH; Mary Grant, ANP; Dana Nguyen, PharmD

Palliative care is a growing field in medicine that focuses on delivering care that improves quality of life for patients with serious illnesses. Often, the goals of palliative care differ from traditional goals of medicine. Currently, there is limited data demonstrating the integration of pharmacists in the palliative care setting. The purpose of this quality improvement is to evaluate the clinical pharmacist’s role within an outpatient palliative care team when performing …

Project Nurture: An Educational Model For Substance Use Disorder Treatment During & After Pregnancy: Saving Lives, Saving Money, Saving Families, And Training Future Doctors, Roxanne Thomas, Brenda Brischetto, Josh Reagan, Daniel Ruegg

Milwaukie Family Medicine 2020

BACKGROUND: • 25% of women presenting for prenatal care are using substances. • Substance Use Disorders (SUDs) in pregnancy are associated with preterm birth, intrauterine growth restriction, placental abruption, increased risk of C-section. • Infants exposed to in utero illicit substances have higher likelihood of being small for gestational age, experiencing a neonatal opioid withdrawal syndrome that requires prolonged NICU hospitalization, and are at higher risk of developmental delay. • Societal costs of SUDs in pregnancy include worsening mental illness, increased utilization of the foster care system, early death secondary to overdose, and associated financial burdens. • The nature of …

Quality Improvement: Improving Depression Screening Rates At Pmg Southeast Family Medicine Clinic, Elizabeth Deyo, Edward Kim, Tyler Nelson, Roxanne Thomas, Jemie Walrod, Nicholas Wolfgang, Ben Pederson

Milwaukie Family Medicine 2020

Introduction: Major depressive disorder is one of the most common mental health problems encountered by primary care providers in the U.S. For people age 12 and older, prevalence is estimated at eight percent. The economic cost of depression has been estimated at $210.5 billion per year, attributed to both costs to the work place and medical costs. People who experience depression are at greater risk for suicide, an otherwise preventable death if depression can be recognized and adequately treated. For these reasons, depression screening has become an essential function within primary care practices both within Providence and nation-wide.

Manual Scalp Cooling In Early Stage Breast Cancer: Value Of Caretaker Training And Patient-Reported Experience To Optimize Efficacy And Patient Selection, Manaz Rezayee, Nikki Moxon, Staci Mellinger, Amanda Y Seino, Nicole E. Fredich, Tracy L. Kelly, Susan Mulligan, Patrick Rossi, Ijeoma Uche, Walter Urba, Alison Conlin, Janet Ruzich, David B Page

Earle A. Chiles Research Institute Fellowship Program 2020

Title:

Manual scalp cooling in early stage breast cancer: value of caretaker training and patient-reported experience to optimize efficacy and patient selection

Authors:

Manaz Rezayee¹, BS Nicole Moxon¹, RN Staci Mellinger¹, RN Amanda Y. Seino¹ Nicole E. Fredrich¹ Tracy L. Kelly¹ Susan Mulligan², MA Patrick Rossi³, MD Ijeoma Uche¹, MD Walter J. Urba¹, MD PHD Alison K. Conlin¹, MD MPH Janet Ruzich¹, DO David B. Page¹, MD

Background:

Alopecia is an emotionally distressing common adverse effect of …

Necrotizing Fasciitis – Time Is Of The Essence, Jeffrey Sun, Edward Kim

Milwaukie Family Medicine 2020

Necrotizing fasciitis (NF) is a life threatening rapidly progressive soft tissue infection that carries a high mortality rate. There are approximately 500-1,500 cases per year in the United States with a mortality rate of up to 18-20%. Without surgical intervention, the mortality rate is near 100%. NF can be characterized by tissue involvement, polymicrobial or monomicrobial etiology, or site of infection. The most common risk factor includes diabetes (reported in up to 60% of cases), IV drug use history, malnutrition, and chronic alcohol abuse. In about 50% of group A streptococcus cases, there is an associated streptococcal toxic shock syndrome …

Unpainfully Sweet, Khoi Nguyen, Alex Schafir

Providence St. Vincent Internal Medicine 2020

Introduction: Sweet's syndrome (ss), or acute febrile neutrophilic dermatosis, is characterized by sudden onset of fever, leukocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: The diagnosis of Sweet’s syndrome often has a temporal association with the discovery or relapse of cancer as reported in this case.

Case Report: A 64-year-old woman with recurrent breast cancer on targeted and hormonal therapy presented to the ED with acute onset of fever and diffuse non-tender body rash. Vitals suggested sepsis and she was treated with broad spectrum …

Addressing The Social Determinants Of Health In The Clinic Setting, Larissa Sharma, Man Tran

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: It is estimated that clinical care accounts for only 20% of health, while behaviors, physical environment, and social and economic factors determine the rest. The social determinants of health include the basic life needs of housing, food, transport, along with other factors that include employment, education, drug and alcohol use, dental and eye care, etc. Insecurity in these socioeconomic factors are expressed in chronic medical illness, mental health problems, substance use, all leading to high healthcare utilization. Healthcare costs and utilization decrease when when these needs are provided for. In a survey of 6,000 Providence patients, 50% expressed …

Lemierre’S Syndrome, Jennifer Nguyen, Tom Chau

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Lemierre’ssyndrome is a rare and potentially fatal complication of acute pharyngitis most commonly seen in healthy, young adults who present with neck pain and persistent, high-grade fever. It is caused by anaerobic gram-negative organisms, most often Fusobacteriumnecrophorum, spreading into the deep spaces of the neck. This leads to septic thrombophlebitis of the internal jugular vein (IJ) with septic emboli, most frequently to the lungs.

CASE REPORT: A healthy 18-year-old woman presented to the hospital with five days of fever, rigors, sore throat, and left neck pain. She appeared relatively non-toxic but was febrile to 105.6℉ and in septic shock. …

Pulmonary Nocardiosisin An Immunocompetenthost, Leah Grant, Laura Loertscher, Jennifer Marfori

Providence St. Vincent Internal Medicine 2020

Introduction: • Nocardia is known to cause severe pulmonary or disseminated infection in immunocompromised patients, but can cause infection in immunocompetent patients. Providers should consider Nocardiosis in immunocompetent patients with prolonged and unexplained respiratory failure. • The preferred therapy for pulmonary Nocardiosis is a sulfa antibiotic for 3-6 months. Toxicity from prolonged use of alternative agents presents a therapeutic challenge in those with sulfa allergy.

Case Report: • An 85 year-old woman with a history of paroxysmal atrial fibrillation and heart failure with preserved EF presented to her primary care provider with 1 week of cough and progressive dyspnea. Chest …

Catastrophic Antiphospholipid Syndrome, Gabriel Hocum, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Catastrophic Antiphospholipid Syndrome (CAPS) is a rare and extreme manifestation of Antiphospholipid Syndrome (APS) that features widespread thrombotic disease affecting multiple small vessels in a short time frame. CAPS affects only 0.8% of APS patients, but when it occurs it is has a mortality rate of approximately 50%.

CASE REPORT: A 50 year old female with SLE and APS presented with 1 month of cough and fatigue and 2 days of severe confusion after missing doses of rivaroxaban. In the ED she was intubated for airway protection and transferred to the ICU. Her evaluation revealed multi-organ failure with extensive …

Not Just Kids –A Case Of Adult Iga Vasculitis, Heidi Reich, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: IgA vasculitis, formerly known as HenlochSchonleinPurpura, is generally recognized as the most common form of systemic vasculitis in children, with 90% of cases occurring in the pediatric age group. However, the remaining 10% are noted in adult populations, and often has poorer long term outcomes if not identified and treated quickly. IgAVis commonly associated with streptococcal infections, although additional triggers such as drug ingestions, insect bites, and vaccinations have been described. Symptoms can include palpable purpura, acute abdominal pain, arthralgias, and hematuria. Recognizing the constellation of signs and symptoms is key for expediting appropriate therapy, which may reduce long …

Delirium: Delirious Elders, Implementing Reduction Interventions Using Mobility, Michael Silvas, Joe Miller, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: This quality improvement project involved hiring, training, and managing 3 Delirium Mobility Aids to implement a non-pharmacologic delirium prevention bundle package, including early mobility, on hospitalized patients age >65.

Background: Delirium affects 20-30% of older hospitalized patients [1]. Patients with delirium have double the mortality rate [3], which increases with delirium duration [4]. Delirium worsens long term cognitive functioning [9,10,11,12]. Hospital costs increase by $2,500 per patient, totaling $6,900,000,000 in Medicare expenditures [7]. A single delirium episode increases total yearly costs by ~$64,421 [2]. Research suggests the best treatment is non-pharmacologic multicomponent interventions [6], and those with most …

Accidental Botulism Poisoning: A Case Of Pickled Herring, Garrett Spencer, Greg Flick

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Botulism is a rare cause of neuromuscular weakness that presents a diagnostic challenge in the face of respiratory collapse. Pupil and bulbar paralysis aid prompt recognition and treatment, as clinical confirmation can be time intensive and limited by sample integrity. Early treatment can halt paralysis and prevent ICU and ventilator days.

CASE DESCRIPTION: A 74-year-old male with hypertension and DVT presented with acute weakness and respiratory failure after three days of cough and diarrhea. Upon ICU admission for mechanical ventilation, we discovered sluggish pupils, mild ptosis, and proximal muscle weakness. Symptoms then progressed to unresponsive pupils, complete ptosis, and …

Battling The Stigma: Hiv Screening In Resident Primary Care Clinic, Garrett Spencer, Laura Loertscher, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: HIV affects ~1.2 million in the US, with 25% unaware of their statusand annual incidence of 50,000. Early detection and treatment reduces risk of AIDS-related deaths and transmission. Both the CDC and the US Preventative Service Task Force recommend routine HIV screening. The Providence Medical Group at St Vincent (PMG-STV) resident clinic has no routine screening protocol. • 24% (757/3139) of all clinic patients have ever been screened. • Of active clinic patients seen quarterly, 5% are offered screening with only 3% completing screening. We implemented and measured a clinic-wide HIV screening protocol leveraging existing clinic workflows. We aimed …

Ceftriaxone-Induced Immune Hemolytic Anemia From Treatment Of Post-Treatment Lyme Disease Syndrome, Jillian Catral, Emily Hitchcock

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Drug-induced immune hemolytic anemia (DIIHA) is a rare though likely underreported entitythat is associated with significant morbidity and mortality. • Ceftriaxone is a commonly used antibiotics with a well-documented association with DIIHA. The mechanism is a drug-dependent antibody, immune-complex mediated reaction which can be severe, leading to organ failure, shock, and even death. • While the majority of cases are in children, a recent literature review had one-third of cases being adults, with up to 30-40% mortality in all ages. • This case describes an adult patient treated for the controversial diagnosis of post-treatment Lyme disease syndrome (PTLDS) …

Swimming Through Lake Placid: A Major Headache, Elizabeth Severson, Claudia Leonard

Providence St. Vincent Internal Medicine 2020

Introduction: Leptospirosis is caused by Leptospira species, a spirochete bacterium that affects animals and humans. The disease can range from mild flu-like illness to multi-organ failure. While likely underreported, the incidence according to the World Health Organization can range from 0.1 to 10 per 100,000 depending on climate Leptospirosis is commonly associated with occupational or recreational exposures

Case Report: A 43 year-old previously healthy man presented with two weeks of myalgias, fevers, neck pain and throbbing headache. The patient competed in an Iron Man event in upstate New York one month prior to presentation. Initial investigation demonstrated a …

Purpura Fulminans Due To Mssa Toxic Shock Syndrome, Leah Grant, Rachel Plotinsky

Providence St. Vincent Internal Medicine 2020

Introduction: Purpurafulminansis a rare and serious complication of anacute infectious process, characterized by large purpuricskin lesions, fever, hypotension, and DIC. The mostcommon infectious cause of purpurafulminansismeningococcal disease, though few case reports in theliterature describe Staph aureusas a causative organism.

Case Report: •A 53 year-old woman with a history of heart blocks/ppacemaker placement in 2002 presented to the ED withnausea, vomiting, fevers, chills, diffuse muscle pain and asyncopalepisode. •She was found to have multi-organ dysfunction on labs,including AKI and thrombocytopenia.On hospital day 2, shedeveloped acrocyanosis. She became febrile & hypotensive requiring transfer tothe ICU for vasopressor support. Blood cultures were obtained. …

Struck By Lightning Twice, Bao-Ngoc Nguyen, Emily Hitchcock

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: ANCA-associated vasculitides (AAV) refer to a group of disorders causing inflammation of small vessels which include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss). Here I present a case of MPA vasculitis in a patient with alpha-1-antitrypsin (AAT) deficiency, and describe a proposed causal link between these two rare disease processes.

CASE REPORT: • 43-year-old man with history of newly-diagnosed AAT deficiency liver disease. • Chief complaint of subacute shortness of breath associated with hemoptysis and fever for 5 months. • Symptoms had been progressively worsening despite multiple courses of antibiotics and inhalers. …

Beck’S Tetrad? Adding Pocus To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock, Cody Wiench, Benjamin Pedroja

Providence Portland Medical Center Internal Medicine 2020

Beck’s Tetrad?

Adding POCUS To The Clinical Exam For Pericardial Tamponade Improves Diagnostic Accuracy In Obstructive Shock

Cody Wiench, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Benjamin Pedroja, MD

Introduction: Obstructive shock due to tamponade is an important, but rare, cause for sudden cardiovascular collapse. Accurate treatment requires prompt (and correct) diagnosis. Bedside echocardiogram can provide rapid and accurate diagnosis, however the physical exam can provide important clues to consider tamponade. In patients with conditions that predispose them to pericardial disease, such as SLE, one must have a high index of suspicion for tamponade when …

A Rare Case Of Metastatic Insulinoma In A Patient With Huntington’S Disease, Olesya Petrenko, Brinton C. Clark

Providence Portland Medical Center Internal Medicine 2020

A Rare Case Of Metastatic Insulinoma

In A Patient With Huntington’s Disease

Olesya Petrenko, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Brinton Clark, MD, FACP

A 49-year-old female with past medical history of Huntington’s disease presents to the ED after being found unresponsive at her assisted-living facility. She was noted to be hypoglycemic with a glucose of 21 and responded to dextrose. For the past several months, patient had symptoms of dizziness, tremors. She has no history of diabetes, and only home medication is Zyprexa. Patient required D10 drip to maintain glucose levels. Given patient’s psychiatric history, …

Chronic Hepatitis B Reactivation: Deadly, But Preventable, Sarah Xie, Jesse Powell, Andrea Roast

Providence Portland Medical Center Internal Medicine 2020

Chronic Hepatitis B Reactivation:

Deadly, But Preventable

Sarah Xie, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Andrea Roast, MD, FACP; Jesse Powell, MD

A 51-year-old Vietnamese male with chronic hepatitis B presents with symptoms of acute hepatitis. 2 months prior, his PCP had discontinued Tenofovir, for which he had been taking for the past decade, based on an undetectable viral load and a negative HBeAg. 1 month later, his viral load soared to 796 million so Tenofovir was restarted. On admission a few days later, the patient had scleral icterus and jaundiced skin. He had severe transaminitis, …

Vocal Cord Dysfunction Masquerading As Exercise-Induced Bronchoconstriction, Brandon Tempte, Meera Jain, Jason Wells

Providence Portland Medical Center Internal Medicine 2020

Vocal Cord Dysfunction Masquerading As

Exercise-Induced Bronchoconstriction

Brandon Temte, DO

Providence Portland Medical Center – Portland, OR

Additional Authors: Meera Jain, MD, FACP; Jason Wells, MD

Intro: Exercise-induced bronchoconstriction (EIB), previously exercise-induced asthma, has a high prevalence in the community. Patients with these symptoms are typically diagnosed clinically and treated empirically with pre-exercise albuterol. Eucapnic voluntary hyperventilation (EVH) has been used to objectively test for EIB and can help to confirm the diagnosis, as well as rule out other causes such as exercise-induced vocal cord dysfunction (EIVCD), which may mimic EIB.

Case Description: A 42-year old female with …

A Case Of Gluten-Induced Delirium: Using Capsule Endoscopy To Diagnose Occult Gi Bleeding, Rachael Starcher, Lisa Sanders

Providence Portland Medical Center Internal Medicine 2020

A Case Of Gluten-Induced Delirium:

Using Capsule Endoscopy To Diagnose Occult GI Bleeding

Rachael Starcher, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Lisa Sanders, MD

Introduction: Despite an increasing prevalence of celiac disease worldwide, many patients remain undiagnosed, putting them at risk for late stage complications of unidentified and untreated celiac disease. Ulcerative jejunoileitis is a rare cause of occult GI bleeding seen only in refractory celiac disease or in atypical celiac disease at the time of diagnosis. When left untreated, ulcerative jejunoileitis can lead to bowel perforation, blood loss anemia, and T-cell lymphoma.

Case Presentation …

Diabetes Education With A Teaching Kitchen Intervention Can Improve Hemoglobin A1c For Type 2 Diabetics Compared To Traditional Diabetes Education, Jill Christensen, Heidi Davis, Charlotte Navarre, Hsin-Fang Li, Kathy Schwab, Richard O'Neil, Justin Ferley

Milwaukie Family Medicine 2020

Authors
Jill Christensen MD MPH Providence Milwaukie Hospital
Heidi Davis MSW Providence Milwaukie Hospital
Charlotte Navarre RN Providence Milwaukie Hospital
Hsin-Fang Li PHD Providence Medical Data Research Center
Kathy Schwab MPH RDN Providence Health Education
Richard O’Neil MBA Providence Planning Analyst

Title Diabetes Education with a Teaching Kitchen Intervention Can Improve Hemoglobin A1c for Type 2 Diabetics Compared to Traditional Diabetes Education

Purpose The Providence Milwaukie Community Teaching Kitchen offers health-focused, budget friendly cooking classes for patients. In 2019, we piloted diabetes education classes with an added hands-on culinary session. This study compares the change in hemoglobin A1c for patients …

A Case Of Spontaneous Intercostal Artery Hemorrhage, Chang Min Lee, Veronica Schims, Craig Riley

Providence Portland Medical Center Internal Medicine 2020

A Case Of Spontaneous Intercostal Artery Hemorrhage

Chang Lee, MD

Providence Portland Medical Center – Portland, OR

Additional Authors: Veronica Schims, MD; Craig Riley, MD

Introduction: Spontaneous intercostal arterial bleeding is rare and usually related to trauma. We describe a patient with a history of cirrhosis and coagulopathy admitted with sepsis who spontaneously developed an expanding extrathoracic hematoma and subsequent hypovolemic shock requiring arterial embolization.

Case Presentation: 50-year-old male with a past medical history of alcoholic liver disease, esophageal varices, chronic coagulopathy, type 2 diabetes and hypertension on lisinopril was admitted to hospital with decreased urine output, dizziness, …