Medical Specialties Commons^™

The Membrane Protein Ankh Is Crucial For Bone Mechanical Performance By Mediating Cellular Export Of Citrate And Atp, Flóra Szeri, Stefan Lundkvist, Sylvia Donnelly, Udo F H Engelke, Kyu Rhee, Charlene J Williams, John P Sundberg, Ron A Wevers, Ryan Tomlinson, Robert S Jansen, Koen Van De Wetering

Department of Dermatology and Cutaneous Biology Faculty Papers

The membrane protein ANKH was known to prevent pathological mineralization of joints and was thought to export pyrophosphate (PPi) from cells. This did not explain, however, the presence of ANKH in tissues, such as brain, blood vessels and muscle. We now report that in cultured cells ANKH exports ATP, rather than PPi, and, unexpectedly, also citrate as a prominent metabolite. The extracellular ATP is rapidly converted into PPi, explaining the role of ANKH in preventing ankylosis. Mice lacking functional Ank (Ankank/ank mice) had plasma citrate concentrations that were 65% lower than those detected in wild type control animals. Consequently, citrate …

Bayesian Modelling Of High-Throughput Sequencing Assays With Malacoda., Andrew R Ghazi, Xianguo Kong, Ed S Chen, Leonard C Edelstein, Chad A Shaw

Cardeza Foundation for Hematologic Research

NGS studies have uncovered an ever-growing catalog of human variation while leaving an enormous gap between observed variation and experimental characterization of variant function. High-throughput screens powered by NGS have greatly increased the rate of variant functionalization, but the development of comprehensive statistical methods to analyze screen data has lagged. In the massively parallel reporter assay (MPRA), short barcodes are counted by sequencing DNA libraries transfected into cells and the cell's output RNA in order to simultaneously measure the shifts in transcription induced by thousands of genetic variants. These counts present many statistical challenges, including overdispersion, depth dependence, and uncertain …

C1q/Tnf-Related Protein 5 Contributes To Diabetic Vascular Endothelium Dysfunction Through Promoting Nox-1 Signaling., Jing Liu, Zhijun Meng, Lu Gan, Rui Guo, Jia Gao, Caihong Liu, Di Zhu, Demin Liu, Ling Zhang, Zhen Zhang, Dina Xie, Xiangying Jiao, Wayne Bond Lau, Bernard L. Lopez, Theodore A. Christopher, Xin-Liang Ma, Jimin Cao, Yajing Wang

Department of Emergency Medicine Faculty Papers

OBJECTIVE: Dysregulated adipokine profiles contribute to the pathogenesis of diabetic cardiovascular complications. Endothelial cell (EC) dysfunction, a common pathological alteration in cardiovascular disorders, is exaggerated in diabetes. However, it is unclear whether and how dysregulated adipokines may contribute to diabetic EC dysfunction.

METHODS AND RESULTS: Serum C1q/TNF-Related Protein 5 (CTRP5) were determined in control/diabetes patients, and control/diabetic mice (high-fat diet, HFD). We observed for the first time that serum total CTRP5 was increased, high molecular weight (HMW) form was decreased, but the globular form (gCTRP5) was significantly increased in diabetic patients. These pathological alterations were reproduced in diabetic mice. To …

Development Of The Uncertainty Communication Checklist: A Patient-Centered Approach To Patient Discharge From The Emergency Department, Kristin L. Rising, Rhea E. Powell, Kenzie A Cameron, David H Salzman, Dimitrios Papanagnou, Amanda Doty, Lori Latimer, Katherine Piserchia, William C Mcgaghie, Danielle M Mccarthy

Department of Emergency Medicine Faculty Papers

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as …

Coronary Artery Aneurysm In Kawasaki Disease., Achala Donuru, Maansi Parekh, Vinay V R Kandula, Sharon Gould

Department of Radiology Faculty Papers

A 3-year-old male presents to the emergency department with chief complaints of fever and vomiting. He had a positive rapid streptococcus throat test with cervical lymphadenopathy. The patient was started on antibiotics. On examination, there was diffuse erythematous macular rash on the chest. Laboratory tests revealed elevated white cell count and C-reactive protein. Electrocardiogram was notable for prolonged PR interval indicating 1^st degree atrioventricular block. Echocardiogram revealed ectasia of the right coronary artery (RCA). A presumptive diagnosis of Kawasaki disease was made and the patient was started on high-dose aspirin and intravenous immunoglobulins. Cardiac computed tomography angiography (CTA) showed …

The Pulmonary Venous Ridge Length To Stratify Stroke Risk In Atrial Fibrillation, Varun Singh, Joy Li, Mark Keroles, Daniel Frisch, Behzad B. Pavri, Baskaran Sundaram, Md, Jason Jacobson, Rajiv Kabadi

Department of Radiology Faculty Papers

Purpose of Study: To evaluate the left superior pulmonary venous ridge length (RL) and the left atrial appendage fractal dimension (LAA FD) as predictors of cardioembolic ischemic stroke (CVA) and transient ischemic attack (TIA) in patients with atrial fibrillation (AF).

Materials, Methods and Procedures: A multicenter, retrospective multicenter study was conducted on patients with AF who underwent cardiac CT prior to catheter ablation between 01/01/2010 and 12/31/2015. Patients were grouped by the presence or absence of prior CVA/TIA. Patients with mitral stenosis, prior mechanical aortic valve replacement, ascending aortic arch atheroma, highrisk patent foramen ovale, history of atrial septal repair …

Improving Nutrition And Immunity With Dry Chain And Integrated Pest Management Food Technologies In Lmics., Peetambar Dahal, Meghnath Dhimal, Krishna Belbase, Sundar Tiwari, John Groopman, Keith West, Bradley Pollock, Subodh Pyakurel, Ganga Acharya, Sunil Aryal, Yug Nath Ghimire, Manish Neupane, Rosina Poudel, Johan Van Ashbrouck, Keshavulu Kunusoth, Sarah De Saeger, Marthe De Boevre, Gokarna Gharti-Chhetri, Tek Bahadur Gurung, Kent J Bradford

Department of Medical Oncology Faculty Papers

No abstract provided.

Hur/Elavl1 Drives Malignant Peripheral Nerve Sheath Tumor Growth And Metastasis, Marta Palomo-Irigoyen, Encarni Pérez-Andrés, Marta Iruarrizaga-Lejarreta, Adrián Barreira-Manrique, Miguel Tamayo-Caro, Laura Vila-Vecilla, Leire Moreno-Cugnon, Nagore Beitia, Daniela Medrano, David Fernández-Ramos, Juan José Lozano, Satoshi Okawa, José L Lavín, Natalia Martín-Martín, James D Sutherland, Virginia Guitiérez De Juan, Monika Gonzalez-Lopez, Nuria Macías-Cámara, David Mosén-Ansorena, Liyam Laraba, C Oliver Hanemann, Emanuela Ercolano, David B Parkinson, Christopher W. Schultz, Bs, Marcos J Araúzo-Bravo, Alex M Ascensión, Daniela Gerovska, Haizea Iribar, Ander Izeta, Peter Pytel, Philipp Krastel, Alessandro Provenzani, Pierfausto Seneci, Ruben D Carrasco, Antonio Del Sol, María Luz Martinez-Chantar, Rosa Barrio, Eduard Serra, Conxi Lazaro, Adrienne M Flanagan, Myriam Gorospe, Nancy Ratner, Ana M Aransay, Arkaitz Carracedo, Marta Varela-Rey, Ashwin Woodhoo

Department of Surgery Faculty Papers

Cancer cells can develop a strong addiction to discrete molecular regulators, which control the aberrant gene expression programs that drive and maintain the cancer phenotype. Here, we report the identification of the RNA-binding protein HuR/ELAVL1 as a central oncogenic driver for malignant peripheral nerve sheath tumors (MPNSTs), which are highly aggressive sarcomas that originate from cells of the Schwann cell lineage. HuR was found to be highly elevated and bound to a multitude of cancer-associated transcripts in human MPNST samples. Accordingly, genetic and pharmacological inhibition of HuR had potent cytostatic and cytotoxic effects on tumor growth, and strongly suppressed metastatic …

Social Services Cases, Maria Hervada-Page, Mms

Department of Family & Community Medicine Presentations and Grand Rounds

Learning Objectives

• Understand common Social Work referrals and possible solutions
• Understand the roles of the members of our team
• Understand the basics of insurance
• Basic community resources

Timely Diagnosis And Staging Of Non-Alcoholic Fatty Liver Disease Using Transient Elastography And Clinical Parameters., Christine Shieh, Dina L. Halegoua-De Marzio, Matthew L. Hung, Jonathan M. Fenkel, Steven K. Herrine

Division of Gastroenterology and Hepatology Faculty Papers

Background and Aim: There is no standardized guideline to screen, image, or refer patients with non-alcoholic fatty liver disease (NAFLD) to a specialist. In this study, we used transient elastography (TE) to examine the fibrosis stages at which patients are first diagnosed with NAFLD. Subsequently, we analyzed metabolic markers to establish cut-offs beyond which noninvasive imaging should be considered to confirm NAFLD/non-alcoholic steatohepatitis fibrosis in patients.

Methods: Charts spanning July 2015-April 2018 for 116 NAFLD patients who had TE performed were reviewed. Univariate and multivariate analysis of metabolic markers was conducted.

Results: At the first hepatology visit, TE showed 73% …

Brain Extraction On Mri Scans In Presence Of Diffuse Glioma: Multi-Institutional Performance Evaluation Of Deep Learning Methods And Robust Modality-Agnostic Training, Siddhesh Thakur, Jimit Doshi, Sarthak Pati, Saima Rathore, Chiharu Sako, Michel Bilello, Sung Min Ha, Gaurav Shukla, Adam Flanders, Aikaterini Kotrotsou, Mikhail Milchenko, Spencer Liem, Bs, Gregory S Alexander, Joseph Lombardo, Joshua D Palmer, Pamela Lamontagne, Arash Nazeri, Sanjay Talbar, Uday Kulkarni, Daniel Marcus, Rivka Colen, Christos Davatzikos, Guray Erus, Spyridon Bakas

Department of Radiation Oncology Faculty Papers

Brain extraction, or skull-stripping, is an essential pre-processing step in neuro-imaging that has a direct impact on the quality of all subsequent processing and analyses steps. It is also a key requirement in multi-institutional collaborations to comply with privacy-preserving regulations. Existing automated methods, including Deep Learning (DL) based methods that have obtained state-of-the-art results in recent years, have primarily targeted brain extraction without considering pathologically-affected brains. Accordingly, they perform sub-optimally when applied on magnetic resonance imaging (MRI) brain scans with apparent pathologies such as brain tumors. Furthermore, existing methods focus on using only T1-weighted MRI scans, even though multi-parametric MRI …

"I Had No Other Choice But To Catch It Too": The Roles Of Family History And Experiences With Diabetes In Illness Representations., Amy T Cunningham, Alexzandra Gentsch, Lsw, Amanda M B Doty, Geoffrey Mills, Marianna Lanoue, Brendan G. Carr, Judd E Hollander, Kristin L Rising

Department of Family & Community Medicine Faculty Papers

BACKGROUND: A family history of diabetes and family members' experiences with diabetes may influence individuals' beliefs and expectations about their own diabetes. No qualitative studies have explored the relationship between family history and experiences and individuals' diabetes illness representations.

METHODS: Secondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded …

A Silent Fatal Presentation Of Pulmonary Embolism: Reflection And Discussion., Qian Zhang, Zain U. Abideen, Khine S. Shan, Thomas Yoon, Muhammad Farooq

Abington Jefferson Health Papers

Acute pulmonary embolism is a common medical condition that clinicians face in practice. It is important to have a prompt diagnosis with proper management as it is associated with high morbidity and mortality. However, a timely diagnosis is often difficult to obtain especially when the presenting symptoms are atypical, but the consequence could be fatal. We present an 80-year-old gentleman who presented with a near-syncope episode who subsequently was found to have acute extensive bilateral pulmonary embolisms after a code blue event.

Vitamin A And Fish Oils For Preventing The Progression Of Retinitis Pigmentosa., Stephen G. Schwartz, Xue Wang, Pamela Chavis, Ajay E. Kuriyan, Samuel A. Abariga

Wills Eye Hospital Papers

BACKGROUND: Retinitis pigmentosa (RP) comprises a group of hereditary eye diseases characterized by progressive degeneration of retinal photoreceptors. It results in severe visual loss that may lead to blindness. Symptoms may become manifest during childhood or adulthood which include poor night vision (nyctalopia) and constriction of peripheral vision (visual field loss). Visual field loss is progressive and affects central vision later in the disease course. The worldwide prevalence of RP is approximately 1 in 4000, with 100,000 individuals affected in the USA. At this time, there is no proven therapy for RP.

OBJECTIVES: The objective of this review was to …

Acute Opioid Withdrawal Mimicking Postoperative Joint Infection Following Anterior Cruciate Ligament (Acl) Reconstruction: A Case Report., Qingwu Kong, Martin Griffis, Brandon J Shallop, Amrit S Khalsa, Kyle Brougham, Paul A Marchetto

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND A short course of opioid narcotics is often prescribed for postoperative anterior cruciate ligament (ACL) reconstruction pain management. Unfortunately, there is a well-documented incidence of opioid withdrawal syndrome (OWS) following short-term use of these medications. OWS can present with symptoms such as influenza-like illness. It is important to differentiate OWS from infectious illnesses, especially after surgery. CASE REPORT We present a case of OWS in a patient who underwent ACL reconstruction 7 days prior. The patient's OWS symptoms were similar to symptoms of a postoperative infection. The knee was aspirated, and the analysis of the aspirate was not concerning …

A Mysterious Paratracheal Mass: Pulmonary Agenesis., Qian Zhang, Khine S. Shan

Abington Jefferson Health Papers

A 35-year-old lady with a history of possible tuberculosis infection 15 years ago presented to the clinic with the chief complaint of cough. Incidental chest CT showed a right paratracheal and medial right apical heterogeneous soft tissue mass with central areas of calcification that warranted further investigation. A routine endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) discovered isolated lobar pulmonary agenesis as the underlying cause of the mass without findings of malignancy on pathology reports.

The Effect Of Critical Shoulder Angle On Functional Compensation In The Setting Of Cuff Tear Arthropathy., Jeffrey Lu, Manan Patel, Joseph A. Abboud, John G. Horneff

Rothman Institute Papers

Introduction: Critical shoulder angle (CSA) has been shown to influence rates of rotator cuff tears and glenohumeral arthritis with a larger CSA associated with rotator cuff tears and a smaller CSA associated with glenohumeral arthritis. There has been no study to determine whether such radiographic measurement influences the function of patients with demonstrated cuff tear arthropathy (CTA). The purpose of this study was to examine whether smaller CSAs were associated with greater range of motion (ROM) in patients diagnosed with CTA.

Materials and methods: Ninety-three patients with a diagnosis of CTA with adequate anteroposterior shoulder radiographs were included in the …

Covid-19 Medical Papers Have Fewer Women First Authors Than Expected., Jens Peter Andersen, Mathias Wullum Nielsen, Nicole L Simone, Resa E Lewiss, Reshma Jagsi

Department of Radiation Oncology Faculty Papers

The COVID-19 pandemic has resulted in school closures and distancing requirements that have disrupted both work and family life for many. Concerns exist that these disruptions caused by the pandemic may not have influenced men and women researchers equally. Many medical journals have published papers on the pandemic, which were generated by researchers facing the challenges of these disruptions. Here we report the results of an analysis that compared the gender distribution of authors on 1893 medical papers related to the pandemic with that on papers published in the same journals in 2019, for papers with first authors and last …

Brugada Syndrome Unmasked By Fever: A Comprehensive Review Of Literature, Sohaib S. Roomi, Waqas Ullah, Hassan Abbas, Hafez Abdullah, Usama Talib, Vincent Figueredod

Department of Emergency Medicine Faculty Papers

Background: The Brugada pattern is identified on the EKG by a coved ST-segment elevation accompanied by a negative T wave in the early precordial leads in the absence of a cardiac structural abnormality. Brugada pattern and Brugada syndrome should be differentiated, as the latter is associated with an increased risk of sudden cardiac death.

Methods: The literature was searched using multiple databases to identify all the articles on Brugada pattern. Data were screened and analyzed by independent authors.

Results: Sixty articles, comprising 71 patients, were included in the study. The mean age of patients was 42.6 years, with a higher …

Takotsubo Cardiomyopathy: A Rare Complication Of Acute Viral Gastroenteritis, Ammar Ashfaq, Waqas Ullah, Shristi Khanal, Muhammad Abdullah Zain, Nishanth Thalambedua, Faisal Inayat, Muhammad Umair Atiq

Division of Internal Medicine Faculty Papers & Presentations

Takotsubo Cardiomyopathy (TCM) is characterized by a transient but reversible ventricular dysfunction in post-menopausal females following, but not always, a recent emotional or physical stress. Typically, chest pain is reported as a presenting symptom in the majority of patients. The severe diarrheal illness secondary to acute viral gastroenteritis is not commonly reported as the stressor event prior to TCM. We report a unique case of a middle-aged male presented with syncope shortly after loose bowel movements. He was diagnosed with TCM and was successfully managed with supportive care. The purpose of this case is to make clinicians aware of this …

The Rice Pentatricopeptide Repeat Protein Ppr756 Is Involved In Pollen Development By Affecting Multiple Rna Editing In Mitochondria., Qiannan Zhang, Yanghong Xu, Jishuai Huang, Kai Zhang, Haijun Xiao, Xiaojian Qin, Linlin Zhu, Yingguo Zhu, Jun Hu

Department of Medicine Faculty Papers

In land plants, the pentatricopeptide repeat (PPR) proteins form a large family involved in post-transcriptional processing of RNA in mitochondria and chloroplasts, which is critical for plant development and evolutionary adaption. Although studies showed a number of PPR proteins generally influence the editing of organellar genes, few of them were characterized in detail in rice. Here, we report a PLS-E subclass PPR protein in rice, PPR756, loss of function of which led to the abolishment of RNA editing events among three mitochondrial genes including

Journal Club, Zeynep Uzumcu, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Outline

• Review coronavirus life-cycle
• Review mechanism of action of remdesivir
• Review previous research on remdesivir
• Close reading of article - Methods - Results - Discussion
• Future research
• Implications for our practice

Natural Disasters In The Americas, Dialysis Patients, And Implications For Emergency Planning: A Systematic Review, Rashida Smith, Mph, Robert Zucker, Rosemary Frasso, Phd, Cph

College of Population Health Faculty Papers

INTRODUCTION: Natural hazards are elements of the physical environment caused by forces extraneous to human intervention and may be harmful to human beings. Natural hazards, such as weather events, can lead to natural disasters, which are serious societal disruptions that can disrupt dialysis provision, a life-threatening event for dialysis-dependent people. The adverse outcomes associated with missed dialysis sessions are likely exacerbated in island settings, where health care resources and emergency procedures are limited. The effect of natural disasters on dialysis patients living in geographically vulnerable areas such as the Cayman Islands is largely understudied. To inform predisaster interventions, we systematically …

Today's Cigarette And E-Cigarette Landscape, Richard C. Wender, Md

Department of Family & Community Medicine Presentations and Grand Rounds

E-cigarettes are one of the most difficult and complex public health issues most of us have confronted.

Most anti-tobacco experts and advocates line up on a spectrum from embracing e-cigarettes as a promising way to reduce the harm of tobacco products all the way to being the greatest threat to progress in our 60 year war on big tobacco.

Breast Cancer Treatment: Basics For The Primary Care Provider, Sarah Hirsh, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Learning Objectives

1. To review the prevalence of breast cancer and the mortality rate of breast cancer in the United States.
2. To understand breast cancer staging and its role in prognostication.
3. To understand the therapies offered for the treatment of non-metastatic, invasive breast cancer and their side effects.
4. To review the role of the PCP in caring for patients undergoing treatment for breast cancer and those in remission.

An Exceedingly Rare Presentation Of Severe Folate Deficiency-Induced Non-Immune Hemolytic Anemia., Qian Zhang, Khine S. Shan, Babatunde A. Ogunnaike, Atsoufi Amewuame-Kpehor, Travis Nace

Abington Jefferson Health Papers

Macrocytic anemia is usually associated with vitamin B12 or folate deficiency. However, folate deficiency was rarely reported as a cause of hemolytic anemia. We present a case of a young man with a history of alcohol abuse who initially presented with an acute on chronic abdominal pain and was found to have jaundice and scleral icterus. His liver enzymes were unremarkable, and his abdominal imaging did not reveal any acute pathology. However, he was found to have a severe non-immune hemolytic anemia secondary to folate deficiency.

Pneumocephalus And Facial Droop On An Airplane: A Case Report, Irina Sanjeevan-Cabeza, Morgan Oakland

Department of Emergency Medicine Faculty Papers

Introduction: Pneumocephalus (PNC) is most commonly associated with trauma or intracranial surgery, less commonly secondary to an infectious source, and is rarely caused by barotrauma.

Case report: A 32-year-old woman presented to the emergency department with complaint of resolved left-sided facial droop and a lingering paresthesia of her left upper extremity after a cross-country flight. Computed tomography demonstrated several foci of air in the subdural space consistent with PNC.

Conclusion: For PNC to occur there must be a persistent negative intracranial pressure gradient, with or without an extracranial pressure change. In this case the pressure change occurred due to cabin …

Innervation: The Missing Link For Biofabricated Tissues And Organs, Suradip Das, Wisberty J. Gordián-Vélez, Harry C. Ledebur, Foteini Mourkiot, Panteleimon Rompolas, H. . Isaac Chen, Mijail D. Serruya, D. Kacy Cullen

Department of Neurology Faculty Papers

Innervation plays a pivotal role as a driver of tissue and organ development as well as a means for their functional control and modulation. Therefore, innervation should be carefully considered throughout the process of biofabrication of engineered tissues and organs. Unfortunately, innervation has generally been overlooked in most non-neural tissue engineering applications, in part due to the intrinsic complexity of building organs containing heterogeneous native cell types and structures. To achieve proper innervation of engineered tissues and organs, specific host axon populations typically need to be precisely driven to appropriate location(s) within the construct, often over long distances. As such, …

Zooming-Out Covid-19: Virtual Clinical Experiences In An Emergency Medicine Clerkship., Shruti Chandra, Chaiya Laoteppitaks, Nina Mingioni, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

In the setting of the novel 2019 coronavirus (COVID‐19) pandemic, it has been challenging to provide medical students in the Emergency Medicine (EM) clerkship meaningful clinical experiences that would meet clinical course goals and objectives, as well as satisfy Liaison Committee for Medical Education (LCME) requirements. During the EM clerkship, students play an integral role in interviewing patients, formulating treatment plans, facilitating patient discharges, and counseling patients. Immediately available direct and indirect supervision are paramount to ensure student learning and safe patient care. The authors present a novel clinical educational experience for senior medical students in an EM clerkship that …

Differences In Brain Activity Patterns During Creative Idea Generation Between Eminent And Non-Eminent Thinkers, Evangelia G Chrysikou, Constanza Jacial, David B Yaden, Wessel Van Dam, Scott Barry Kaufman, Chris Conklin, Nancy Wintering, Rebecca E Abraham, Rex E Jung, Andrew B. Newberg

Marcus Institute of Integrative Health Faculty Papers

An influential model of the neural mechanisms of creative thought suggests that creativity is manifested in the joint contributions of the Default Mode Network (DMN; a set of regions in the medial PFC, lateral and medial parietal cortex, and the medial temporal lobes) and the executive networks within the dorsolateral PFC. Several empirical reports have offered support for this model by showing that complex interactions between these brain systems account for individual differences in creative performance. The present study examined whether the engagement of these regions in idea generation is modulated by one's eminence in a creativity-related field. Twenty (n …