Medical Specialties Commons^™

Core Muscle Injuries: Functional Outcomes And Return To Sport In A Consecutive Series Of Twenty Athletes, Nicholas Tsouris, Jack Tesoriero, James A. Vosswinkel, James Penna

Stony Brook Orthopaedic and Musculoskeletal Journal

Background: Core muscle injury can cause significant dysfunction in athletes. A variety of surgical procedures have been described. This study examines an orthopaedic and general surgeon’s technique and patient reported outcomes of adductor tenotomy and rectus abdominus imbrication with ilioinguinal nerve neurolysis.

Hypothesis: Surgical treatment of core muscle injuries with adductor tenotomy and rectus abdominus imbrication with ilioinguinal nerve neurolysis will result in decreased symptoms and high rates of return to play.

Study Design: Operative technique; retrospective case series.

Methods: Our electronic medical record system was searched for patients who underwent core muscle injury surgery by the treating surgeons. The …

The Utility Of The Axillary Shoulder Radiograph In The Management Of Clavicle Fractures, Stephen Bowen, Ryan Tantoe, Daniel Botros, Samer Al-Humadi, Nicholas Tsouris, Nicholas Divaris

Stony Brook Orthopaedic and Musculoskeletal Journal

Background: Prior literature is mixed on the necessity of an axillary shoulder radiograph in the setting of presumably isolated clavicle fractures, with some authors endorsing its need for any shoulder girdle trauma and others stating it is unnecessary. However, no studies to date have specifically evaluated this.

Hypothesis: We hypothesize that an axillary shoulder radiograph will offer no management changing information in the setting of clavicle fractures.

Methods: Ninety-five patients presented for follow-up for management of a clavicle fracture. Analysis was performed to determine if the axillary view was useful based on the discovery of a glenohumeral dislocation or a …

Outcomes In Early Versus Delayed Management Of Pediatric Femoral Shaft Fractures, Daniel Botros, Sofia Hidalgo Perea, Rachel Loyst, James Barsi

Stony Brook Orthopaedic and Musculoskeletal Journal

Background: There is a paucity of literature regarding the timing of treatment for pediatric femur fractures.

Purpose: The purpose of this study was to analyze whether early versus delayed management of pediatric femoral shaft fractures would impact outcomes regarding time to union and return to baseline function.

Methods: Pediatric patients presenting with femoral shaft fractures from 01/01/2010-01/01/2021 were identified using the Database at a single level one Trauma Center and retrospectively reviewed. Demographic information, surgical details, associated injuries, length of follow-up, time to union, and return to baseline function was collected. Patients were then divided into two groups; the early …

Suture Tape Stabilization Of The Distal Ulna Following Darrach Procedure. A Biomechanical Study, Miles S. Parsons, Evan C. Olsen, David E. Komatsu, Samantha Muhlrad

Stony Brook Orthopaedic and Musculoskeletal Journal

Introduction: The Darrach procedure (complete resection of distal ulna) is commonly used for definitive treatment of end- stage distal radioulnar joint (DRUJ) arthritis. This resection alone often results in treatment failure due to ulnar stump instability in a dorsal-palmar direction and ulnar convergence. Modified Darrach procedures with tenodesis have improved outcomes, but none have completely resolved these issues. Thus, we propose a novel technique of fixation via an internal brace.

Purpose: To evaluate stability and degree of dorsal-palmar displacement with an internal brace fixation (IBF) versus a modified extensor carpi ulnaris tenodesis (ECUT) following a Darrach procedure.

Methods: We tested …

Evaluation Of Patient Radiation Dose And Risk Of Cancer From Ct Examinations, Saowapark Poosiri

Chulalongkorn University Theses and Dissertations (Chula ETD)

Computed Tomography (CT) examinations have been increasingly requested and become the major sources of patient exposure. The cancer risk from CT scans is contingent upon the amount of organ absorbed dose. This study aims to evaluate the cumulative effective doses (CED) and risk of cancer incidence and mortality from recurrent CT examinations in a single day. The patient data at aged 15 to 75 years old performed CT examinations during the period of five years from January 2018 to December 2022 were collected from two academic centers. The CED and organ doses were evaluated using Radimetrics™ Enterprise Platform from Monte …

Association Of The Bb Genotype Of The Abo Gene With The Risk Of Acute Myocardial Infarction In Hospital-Based Study, Farzana Abubakar Yousuf, Iqbal Azam Syed, Asal Khan Tareen, Khawar A. Kazmi, Jibran Sualeh Muhammad, Mohammad Perwaiz Iqbal

Department of Biological & Biomedical Sciences

Objectives: The ABO gene locus has been identified to be associated with myocardial infarction in patients with coronary heart disease. The primary focus of this hospital-based study was to explore the relationship of ABO blood groups and ABO genotypes with acute myocardial infarction (AMI) in Karachi, Pakistan.
Methods: In a comparative cross-sectional study, an equal number of adult AMI patients and healthy controls (n=275 in each group; age range 30-70 years, both males and females) were recruited from the Aga Khan University and NICVD, Karachi, with informed consent. The blood samples were analyzed for ABO blood groups and other biomarkers. …

The Prevalence And Knowledge Of Proper Treatment Of People Living With Dementia In Physical Therapy, Eric Robert Melrose

Honors Program Theses

As the number of dementia cases is expected to rise, healthcare providers will need to know how to best serve individuals with these diseases. Dementia symptoms can vary from person to person, and include memory loss, the inability to communicate, and the loss of gross motor function. Physical therapy can be a useful tool in combating the symptoms of dementia (LeDoux et al., 2020) (Coronado et al., 2020) (Brett et al., 2016) (Braz de Oliveira et al., 2023). This thesis aims to explore the level of knowledge physical therapy students and physical therapists possess, how to increase that knowledge, and …

Association Of Human Leukocyte Antigen Alleles With Carbamazepine-Or Lamotrigine-Induced Stevens-Johnson Syndrome And Toxic Epidermal Necrolysis In An Iranian Population: A Case-Control Study, Ladan Dastgheib, Farima Rostami, Behrouz Gharesi-Fard, Ali Akbar Asadi-Pooya, Saba Namjoo, Foroozan Tahmasebi, Maryam Hadibarhaghtalab

Department of Neurology Faculty Papers

Background: Genetic diversity in human leukocyte antigen (HLA) alleles across populations is a significant risk factor for drug-induced severe cutaneous adverse reactions (SCARs), e.g., carbamazepine (CBZ)- and lamotrigine (LTG)-induced StevensJohnson syndrome (SJS), and toxic epidermal necrolysis (TEN). The present study aimed to investigate the frequency of different HLA alleles in Iranian patients with CBZ- and LTG-induced SJS/TEN.

Methods:A case-control study was conducted from 2011 to 2018 at various hospitals affiliated with Shiraz University of Medical Sciences (Shiraz, Iran). A total of 31 patients receiving anticonvulsant drugs (CZB or LTG) were recruited and divided into two groups. The drug-induced group …

Safety And Tolerability Results Of Atogepant For The Preventive Treatment Of Episodic Migraine From A 40-Week, Open-Label Multicenter Extension Of The Phase 3 Advance Trial, Brad C Klein, Rosa Miceli, Lawrence Severt, Peter Mcallister, Laszlo Mechtler, Jennifer Mcvige, Merle Diamond, Michael J. Marmura, Hua Guo, Michelle Finnegan, Joel M Trugman

Department of Neurology Faculty Papers

Background: Atogepant is a United States Food and Drug Administration-approved oral calcitonin gene-related peptide receptor antagonist for the preventive treatment of episodic migraine. The study objective was to evaluate the long-term safety and tolerability of atogepant in participants who completed the phase 3 ADVANCE trial (NCT03777059).

Methods: This 40-week, open-label extension trial (NCT03939312) monitored safety in participants receiving oral atogepant 60 mg once daily, followed by a four-week safety follow-up period.

Results: Of the 685 participants taking at least one dose of atogepant, the treatment period was completed by 74.6% of participants with a mean (standard …

Investigating Relationships Found In The Kidney Microenvironment To Aid In Understanding Malfunctions Of Proteins In Chronic Kidney Disease, Ademide Ogunsina

Holster Scholar Projects

The kidneys are the filtration organ that helps filter out waste from our body. Kidney disease is an ailment that causes damage to the kidney so that it cannot filter our blood and other bodily fluids properly. It is also one of the least researched illnesses in the medical field. And with about 10-15 percent of the American population suffering from kidney disease, there is an urgency in finding more ways to help find a solution.

I examined the damaged kidney environment at the cellular level to find out what protein processes cause the malfunction of the kidneys. Methodologies employed …

Analysis Of Biologically Effective Dose For Retroactive Yttrium-90 Trans-Arterial Radioembolization Treatment Optimization, Mj Lindsey

CMC Senior Theses

Trans-arterial radioembolization (TARE) is a protracted modality of radiation therapy where radionuclides labeled with Yttrium-90 (⁹⁰Y) are inserted inside a patient's hepatic artery to treat hepatocellular carcinoma (HCC). While TARE has been shown to be a clinically effective and safe treatment, there is little understanding of the radiobiological relationship between absorbed dose and tissue response, and thus there is no dosimetric standard for treatment planning. The Biologically Effective Dose (BED) formalism, derived from the Linear-Quadratic model of radiobiology, is used to weigh the absorbed dose by the time pattern of delivery. BED is a virtual dose that can …

Visualization And Characterization Of The Immunological Synapse Between Chlorotoxin Chimeric Antigen (Cltx-Car) Redirected T Cells And Targeted Glioblastoma Tumors, Arianna Livi

CMC Senior Theses

Chimeric Antigen Receptor T (CAR-T) cells have demonstrated anti-tumor activity against aggressive and invasive cancers such as glioblastoma (GBM); however, clinical response rates remain low in clinical trial studies. Tumor heterogeneity and tumor microenvironment conditions pose significant challenges for treatment of GBM, thus continuous optimization of CAR-T cell therapies and identification of novel, widely expressed, and highly specific GBM antigens are vital to better patient outcomes. A newly developed CAR-T cell construct incorporating chlorotoxin (CLTX) as the targeting domain exhibited broad GBM-targeting capabilities and elicited potent cytotoxic effects during preclinical studies and is currently being tested in a phase I …

I2n: Image To Nutrients, A Sensor Guided Semi-Automated Tool For Annotation Of Images For Nutrition Analysis Of Eating Episodes, Tonmoy Ghosh, Megan A Mccrory, Tyson Marden, Janine Higgins, Alex Kojo Anderson, Christabel Ampong Domfe, Wenyan Jia, Benny Lo, Gary Frost, Matilda Steiner-Asiedu, Tom Baranowski, Mingui Sun, Edward Sazonov

Children’s Nutrition Research Center Staff Publications

Introduction: Dietary assessment is important for understanding nutritional status. Traditional methods of monitoring food intake through self-report such as diet diaries, 24-hour dietary recall, and food frequency questionnaires may be subject to errors and can be time-consuming for the user.

Methods: This paper presents a semi-automatic dietary assessment tool we developed - a desktop application called Image to Nutrients (I2N) - to process sensor-detected eating events and images captured during these eating events by a wearable sensor. I2N has the capacity to offer multiple food and nutrient databases (e.g., USDA-SR, FNDDS, USDA Global Branded Food Products Database) for annotating eating …

Relationship Between Reproductive And Bone Biomarkers And Osteoarthritis In Zoo Asian (Elephas Maximus) And African (Loxodonta Africana) Elephants, Daniella E Chusyd, Janine L Brown, Lilian Golzarri-Arroyo, Stephanie L Dickinson, Virginia B Kraus, Jessica Siegal-Willott, Timothy M Griffin, Janet L Huebner, Katie L Edwards, David B Allison, Steven N Austad

Children’s Nutrition Research Center Staff Publications

Osteoarthritis (OA) is common in zoo Asian (Elephas maximus) and African (Loxodonta africana) elephants. This study investigated the relationship between confirmed or suspected OA with ovarian cyclicity, gonadotropins, progestagens, luteinizing hormone (LH), follicular stimulating hormone (FSH), and collagen type I (CTX-I) in zoo elephants. In Asian elephants, odds of having confirmed or suspected OA decreased with cycling (OR = 0.22, P = 0.016; OR = 0.29, P = 0.020, respectively), however, not when adjusted for age (odds ratio [OR] = 0.31, P = 0.112; OR = 0.58, P = 0.369, respectively). In African elephants, none of …

Conditioning On Parental Mating Types Can Reduce Necessary Assumptions For Mendelian Randomization, Keisuke Ejima, Nianjun Liu, Luis Miguel Mestre, Gustavo De Los Campos, David B Allison

Children’s Nutrition Research Center Staff Publications

Mendelian randomization (MR) has become a common tool used in epidemiological studies. However, when confounding variables are correlated with the instrumental variable (in this case, a genetic/variant/marker), the estimation can remain biased even with MR. We propose conditioning on parental mating types (a function of parental genotypes) in MR to eliminate the need for one set of assumptions, thereby plausibly reducing such bias. We illustrate a situation in which the instrumental variable and confounding variables are correlated using two unlinked diallelic genetic loci: one, an instrumental variable and the other, a confounding variable. Assortative mating or population admixture can create …

Small Bowel Obstruction In Postpartum Vaginal Delivery Due To Prior Abdominal Adhesions Case Report, Liubin Yang, Lydia Kao

Children’s Nutrition Research Center Staff Publications

Intestinal obstruction rarely occurs after uncomplicated vaginal deliveries. Here, we present a case of a multiparous woman with a history of prior appendectomy presenting with generalized, nonspecific abdominal pain that was out of proportion to exam findings. Initial abdominal X-ray was nonspecific, and subsequent computed tomography (CT) abdomen showed closed small bowel obstruction requiring surgical repair. We present a case of intestinal obstruction occurring within 24 hours of uncomplicated vaginal delivery with a risk factor of a prior appendectomy surgery and the use of CT abdomen and pelvis to expedite diagnose.

Functional And Technical Outcomes In Acute Ischemic Stroke Patients With Hyperdense Middle Cerebral Artery Sign Treated With Endovascular Thrombectomy, Yimin Chen, Francesco Diana, Mohammad Mofatteh, Sijie Zhou, Juanmei Chen, Zhou Huang, Weijuan Wu, Yajie Yang, Zhiyi Zeng, Weijian Zhang, Ziqi Ouyang, Thanh N Nguyen, Shuiquan Yang, José Fidel Baizabal-Carvallo, Xuxing Liao

Children’s Nutrition Research Center Staff Publications

Background and objective: The hyperdense middle cerebral artery sign (HMCAS) is observed in a proportion of patients with acute ischemic stroke (AIS). This sign reflects the presence of an intravascular thrombus rich in red blood cells. Several studies have demonstrated that HMCAS increases the risk of poor outcomes in AIS patients treated with IV thrombolysis or no reperfusion therapy; however, whether HMCAS predicts a poor outcome in patients treated with endovascular thrombectomy (EVT) is less clear. We aimed to evaluate the functional outcome by the modified Rankin scale (mRS) at 90 days and technical challenges in patients with HMCAS undergoing …

Commentary: Effect Evaluation Of Sahtak Bi Sahnak, A Lebanese Secondary School-Based Nutrition Intervention: A Cluster Randomised Trial, Abu Bakkar Siddique, Andrew W Brown, Lilian Golzarri-Arroyo, David B Allison

Children’s Nutrition Research Center Staff Publications

No abstract provided.

Clinical Characterization Of Data-Driven Diabetes Clusters Of Pediatric Type 2 Diabetes, Mahsan Abbasi, Mustafa Tosur, Marcela Astudillo, Ahmad Refaey, Ashutosh Sabharwal, Maria J Redondo

Faculty, Staff and Students Publications

BACKGROUND: Pediatric Type 2 diabetes (T2D) is highly heterogeneous. Previous reports on adult-onset diabetes demonstrated the existence of diabetes clusters. Therefore, we set out to identify unique diabetes subgroups with distinct characteristics among youth with T2D using commonly available demographic, clinical, and biochemical data.

METHODS: We performed data-driven cluster analysis (K-prototypes clustering) to characterize diabetes subtypes in pediatrics using a dataset with 722 children and adolescents with autoantibody-negative T2D. The six variables included in our analysis were sex, race/ethnicity, age, BMI

RESULTS: We identified five distinct clusters of pediatric T2D, with different features, treatment regimens and risk of diabetes complications: …

Determinants Of Retention In Care Of Newborns Diagnosed With Sickle Cell Disease In Liberia: Results From A Mixed-Methods Study Of Caregivers, Kanagasabai Udhayashankar, Patience D Franklin, Cecelia J Nuta, Adolphus K Cherue, Heather Haq, Debbe Thompson, Venée N Tubman

Faculty, Staff and Students Publications

High-income nations have established that early diagnosis and preventive treatment reduces early deaths in sickle cell disease (SCD). However, in low-/middle-income countries where SCD is common, attrition from clinical care is common. Reasons for poor retention in care are multi-factorial and poorly understood. The objective of this study was to identify factors that influence caregiver decision-making around chronic health care needs of a child with SCD. We conducted an exploratory sequential mixed methods study of caregivers of children diagnosed with SCD during a newborn screening program in Liberia. Caregivers completed questionnaires and semi-structured interviews designed to identify drivers of health …

Unmasking Barriers In The Delivery Of Preconception Counseling And Contraception Provision For Patients With Type 1 Or Type 2 Diabetes, Layla A Abushamat, Lauren Sayres, Rebecca Jeffers, Chloe Nielsen, Linda A Barbour, Adnin Zaman

Faculty, Staff and Students Publications

No abstract provided.

Cholestasis Impairs Gut Microbiota Development And Bile Salt Hydrolase Activity In Preterm Neonates, Lauren E Lynch, Amy B Hair, Krishnakant G Soni, Heeju Yang, Laura A Gollins, Monica Narvaez-Rivas, Kenneth D R Setchell, Geoffrey A Preidis

Faculty, Staff and Students Publications

Cholestasis refers to impaired bile flow from the liver to the intestine. In neonates, cholestasis causes poor growth and may progress to liver failure and death. Normal bile flow requires an intact liver-gut-microbiome axis, whereby liver-derived primary bile acids are transformed into secondary bile acids. Microbial bile salt hydrolase (BSH) enzymes are responsible for the first step, deconjugating glycine- and taurine-conjugated primary bile acids. Cholestatic neonates often are treated with the potent choleretic bile acid ursodeoxycholic acid (UDCA), although interactions between UDCA, gut microbes, and other bile acids are poorly understood. To gain insight into how the liver-gut-microbiome axis develops …

Initial Insights Into The Genetic Variation Associated With Metformin Treatment Failure In Youth With Type 2 Diabetes, Shylaja Srinivasan, Ling Chen, Miriam Udler, Jennifer Todd, Megan M Kelsey, Morey W Haymond, Silva Arslanian, Philip Zeitler, Rose Gubitosi-Klug, Kristen J Nadeau, Katherine Kutney, Neil H White, Josephine H Li, James A Perry, Varinderpal Kaur, Laura Brenner, Josep M Mercader, Adem Dawed, Ewan R Pearson, Sook-Wah Yee, Kathleen M Giacomini, Toni Pollin, Jose C Florez

Faculty, Staff and Students Publications

Metformin is the first-line treatment for type 2 diabetes (T2D) in youth but with limited sustained glycemic response. To identify common variants associated with metformin response, we used a genome-wide approach in 506 youth from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study and examined the relationship between T2D partitioned polygenic scores (pPS), glycemic traits, and metformin response in these youth. Several variants met a suggestive threshold (P < 1 × 10−6), though none including published adult variants reached genome-wide significance. We pursued replication of top nine variants in three cohorts, and rs76195229 in ATRNL1 was associated with worse metformin response in the Metformin Genetics Consortium (n = 7,812), though statistically not being significant after Bonferroni correction (P …

A Guide To Naming Eukaryotic Circular Rnas, Ling-Ling Chen, Albrecht Bindereif, Irene Bozzoni, Howard Y Chang, A Gregory Matera, Myriam Gorospe, Thomas B Hansen, Jørgen Kjems, Xu-Kai Ma, Jun Wei Pek, Nikolaus Rajewsky, Julia Salzman, Jeremy E Wilusz, Li Yang, Fangqing Zhao

Faculty, Staff and Students Publications

Alternative splicing of eukaryotic transcripts often leads to production of multiple mature RNAs from a single gene locus. In addition to encoding linear RNAs, genes can produce stable circular RNAs (circRNAs) that are often co-expressed with their cognate linear RNAs. Multiple distinct circRNAs are frequently generated from a gene locus via back-splicing, with each mature transcript having a potentially unique function due to its distinct combination of exons and sometimes retained introns. However, names currently given to circRNAs are often ambiguous and lack consistency across studies. Here, we call on the community to embrace standards for naming circRNAs so that …

Utilizing Bloodless Medicine To Decrease Infection Rates In Hematopoietic Stem Cell Transplantation: A Literature Review, Samantha Saint Fort

Honors Undergraduate Theses

Aim: To determine if a significant relationship exists between bloodless medicine practices and decreased infection rates in oncology patients following hematopoietic stem cell transplantation by performing a literature review.

Background: It is not uncommon for healthcare professionals to encounter Jehovah's Witnesses (JW) seeking medical treatment in the acute care hospital setting and outpatient clinics alike. However, JW's pose a unique challenge to healthcare providers. Their refusal of blood transfusions makes them a population of interest within the medical community. The refusal of blood transfusions also poses a serious challenge to successful treatment in oncology JW patients, and many hospitals will …

Nursing-Related Interventions To Obstetric Violence: A Literature Review, Annaliece M. Balensiefen

Honors Undergraduate Theses

The aim of this literature search was to explore the prevalence of obstetric violence and identify nursing interventions that could potentially prevent the mistreatment of pregnant women in the United States healthcare system. Background: The topics of obstetric violence and healthcare disparities have been gaining awareness. Other countries have a larger body of research for obstetric violence compared to the U.S. Methods: CINAHL Plus with Full Text and MEDLINE databases were utilized. Global perspectives were considered in conjunction with the U.S. and specifically Florida. Healthcare disparities in obstetric care were identified, based on race, ethnicity, socioeconomic status, sexuality, disability, …

Survival Rates And Clinical Trial Participation Among Rural Cancer Patients, Tatiana Kurilo

Walden Dissertations and Doctoral Studies

The literature indicates that cancer patients in rural areas lack adequate access to clinical trials and may experience more harmful consequences than patients residing in urban areas. The purpose of the study was to compare cancer survival rates among patients living in rural and urban counties in a southeastern U.S. state with breast cancer and lung cancer. Analysis was conducted using secondary data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program tumor registry, Comprehensive Cancer Center (CCC) tumor registry, and CCC OnCore Subject Accrual Data. A series of independent samples t-tests and factorial ANOVA were conducted …

The Relationship Between “Speak Up” Culture Level, Team Effectiveness, And Organizational Performance Among Clinical Laboratory Professionals, Emmanuel Udasco

Walden Dissertations and Doctoral Studies

The clinical laboratory plays a crucial role in aiding physicians to diagnose disease. With numerous studies on “Speak Up” culture well-documented among providers and nurses surrounding patient safety, gaps in literature exist concerning “Speak Up” culture that address team effectiveness and organizational performance within the clinical lab setting. The purpose of this quantitative correlation study was to investigate the relationship between “Speak Up” culture level, team effectiveness, and organizational performance among health care workers employed in the clinical lab. The high-performance work practices model was utilized as the conceptual framework to ground this study. Research questions assessed the link between …

Survival Rates And Clinical Trial Participation Among Rural Cancer Patients, Tatiana Kurilo

Walden Dissertations and Doctoral Studies

The literature indicates that cancer patients in rural areas lack adequate access to clinical trials and may experience more harmful consequences than patients residing in urban areas. The purpose of the study was to compare cancer survival rates among patients living in rural and urban counties in a southeastern U.S. state with breast cancer and lung cancer. Analysis was conducted using secondary data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program tumor registry, Comprehensive Cancer Center (CCC) tumor registry, and CCC OnCore Subject Accrual Data. A series of independent samples t-tests and factorial ANOVA were conducted …

Educating Oncology Nurses On Identifying And Managing Cancer-Related Distress, Rosemary Vivella Irish

Walden Dissertations and Doctoral Studies

AbstractUp to 50% of patients diagnosed with cancer will experience significant levels of distress. Cancer is related to psychological distress and can negatively impact recovery from surgery, increase treatment side effects, and decrease overall quality of life. The National Comprehensive Cancer Network recommended screening for distress as part of comprehensive cancer care. In the practice setting, there was a need for better assessment of distress in cancer patients. The purpose of this staff education project was to address a gap in practice regarding the lack of knowledge of screening for distress by providing education to oncology nurses on how to …