Medical Specialties Commons^™

Defining Three Principles For Credible Evidence Synthesis And Reviews In Health Professions Education, Michelle Daniel, Morris Gordon, Hussein Uraiby, Peter Boedeker, Janice Hanson, Diana Dolmans, Satid Thammasitboon

Faculty, Staff and Students Publications

As reviews become increasingly central to informing educational practice and guiding research in health professions education, the need for methodological clarity and quality has grown. This Commentary highlights three foundational principles - alignment, rigor, and transparency - that underpin high-quality reviews, regardless of type. We illustrate how these principles apply across commonly used review types, including systematic, scoping, realist, and narrative reviews. By aligning the research question with the appropriate review methodology, employing rigorous processes for evidence collection and synthesis, and maintaining transparency in methodological reporting, review teams can produce credible, transferable, and dependable findings. Embracing these principles not only …

Structural Proteomics Defines A Sequential Priming Mechanism For The Progesterone Receptor, Matthew D Mann, Min Wang, Josephine C Ferreon, Phoebe S Tsoi, Michael P Suess, Antrix Jain, Anna Malovannaya, Roberto Vera Alvarez, Bruce D Pascal, Raj Kumar, Dean P Edwards, Patrick R Griffin

Faculty, Staff and Students Publications

The progesterone receptor (PR) is a steroid-responsive nuclear receptor with two isoforms: PR-A and PR-B. Disruption of PR-A:PR-B signaling is associated with breast cancer through interactions with oncogenic co-regulatory proteins (CoRs). However, molecular details of isoform-specific PR-CoR interactions remain poorly understood. Using structural mass spectrometry, we investigate the sequential binding mechanism of purified full-length PR and intact CoRs, steroid receptor coactivator 3 (SRC3) and p300, as complexes on target DNA. Our findings reveal selective CoR NR-box binding by PR and unique interaction surfaces between PR and CoRs during complex assembly, providing a structural basis for CoR sequential binding on PR. …

Narratives Or Not? Examining The Roles Of Message Format And Individuals' Stages Of Change In The Context Of Hpv Vaccination Promotion, Mengfei Guan, Shawn C. Chiang, Regan M. Murray, Wen-Juo Lo, Larry T. Hill, Ann C. Klassen, Jennifer A. Manganello, Amy E. Leader, Philip M. Massey

Department of Medical Oncology Faculty Papers

Narrative persuasion has been widely used in health communication campaigns and persuasive message design. However, several meta-analyses showed that the relative effectiveness of narratives in promoting behavior change was not consistently observed in the existing literature. With the goal of exploring boundary conditions of narrative effects, this study investigates the interaction effects of narrative persuasion and stages of change on promoting behavior change in the context of encouraging parents to vaccinate their children against human papillomavirus (HPV). Findings from an online experiment (N = 593) showed that non-narrative messages were more effective in bolstering behavioral intention than narrative messages among …

Distinguishing Chronic Sigmoid Volvulus From Ogilvie Syndrome: A Case Report, Amanda Paulus, Arpit Aggarwal, Sara Glendinning

Conference Presentation Abstracts

Purpose/Background: Benign etiologies of large bowel obstructions are categorized by mechanical or functional. Mechanical obstructions include volvulus, hernia, adhesions, and stricture. Sigmoid volvulus is the most common benign cause of large bowel obstruction. Functional disorders include colonic pseudo obstruction, paralytic ileus, and chronic constipation. Colonic pseudo obstruction (also known as Ogilvie’s Syndrome) is a functional disorder that causes a large bowel obstruction that can be acute or chronic in nature.

Methods/Interventions: A 62-year-old male with chronic constipation and multiple comorbidities presented with abdominal distention and dyspnea. He was previously treated for Ogilvie's pseudo obstruction through conservative measures. On exam, his …

Treatment Outcomes Following Tme For Biologically Unfavorable Locally Advanced Rectal Cancer, Maryam Aleissa, Amr Aref, Hussein Gharib, Ernesto R. Drelichman, Amer Zeni, Amer Alame, Jasneet S. Bhullar

Conference Presentation Abstracts

Purpose/Background: Many centers now offer organ preservation for selected patients with locally advanced rectal cancer. Our group initiated three Phase II trials to assess the safety of this approach in various clinical scenarios. Nonoperative management was recommended only for patients achieving complete clinical response CCR)after total neoadjuvant therapy TNT. Total mesorectal excision TME was advised when CCR was not achieved (primary TME), following residual cancer after Limited Local Excision LLE (completion TME), or after tumor recurrence/regrowth post-LLE or watchful waiting WW (salvage TME). This study examines treatment outcomes following primary or salvage TME in these biologically unfavorable cases.

Methods/Interventions: Each …

Comparison Of Magnetic Resonance Imaging (Mri) And Endoluminal Endoscopic Ultrasound (Eus) For Restaging Rectal Cancer After Neoadjuvant Chemotherapy, Judy Sheffeh, Amr Aref, Mohammed Barawi, Amer Alame, Amer Zeni, Ernesto R. Drelichman, Jasneet S. Bhullar

Conference Presentation Abstracts

Purpose/Background: Given the high incidence and mortality of rectal cancer, accurate staging and restaging are crucial for guiding optimal interventions. However, no consensus exists on the best imaging modality for restaging after neoadjuvant chemoradiotherapy. This study aims to compare MRI and EUS in the restaging of rectal cancer following neoadjuvant chemoradiotherapy.

Methods/Interventions: We conducted a prospective observational study and enrolled patients with rectal cancer. EUS and MRI were performed at diagnosis for initial staging and repeated after neoadjuvant chemotherapy and chemoradiotherapy for restaging. A total of 43 patients were enrolled, with 25 patients (10 males, 15 females) with rectal cancer …

Improved Survival With Improved Naprc Compliance: Our Single Institution Experience, Jacob Applegarth, Claire Bova, Scarlett B. Hao, Harry Wasvary

Conference Presentation Abstracts

The National Accreditation Program for Rectal Cancer (NAPRC) was developed in 2017 in an effort to better standardize rectal cancer care in the United States. This study investigates short-term outcomes of rectal cancer patients relative to compliance with NAPRC standards at an NAPRC accredited institution.

Effect Of Clean Closing Trays In Enhanced Recovery After Surgery Protocol On Surgical Site Infection Rates In Colorectal Surgeries, Elizabeth Carlson, Shelli Bergeron, Scarlett B. Hao, Kristin Lemarbe, Nora Laban, Diana Lee, Bradley Krasnick, Harry Wasvary

Conference Presentation Abstracts

Reducing surgical site infections (SSIs) after colorectal surgeries remains a key quality improvement target. The summative effect of multiple pre-, intra-, and post-operative interventions bundled as part of Enhanced Recovery After Surgery (ERAS) programs have been shown to effectively reduce SSIs, however the individual impact of each intervention has not been well-studied. This study evaluates the impact of clean closing tray use on the rate of SSIs in colorectal surgeries.

When Patients Say No – Outcomes Of Opting Against Recommended Treatment After Total Neoadjuvant Therapy For Stage Ii/Iii Rectal Cancer, Scarlett B. Hao, Jacob Applegarth, Erin Mueller, Harry Wasvary, Matthew Ziegler, Bradley Krasnick

Conference Presentation Abstracts

Patients with stage II/III rectal cancer, upon completion of total neoadjuvant therapy (TNT), may be recommended total mesorectal excision (TME) or a watch-and-wait (WW) approach depending on their clinical tumor response. However, in shared decision-making, patients may ultimately decide for surgery when it is not recommended or against surgery when it is recommended. This study aimed to describe the tumor response outcomes of patients with LARC who pursue and do not pursue the recommended approach following TNT.

Metastatic Colon Cancer And Single Agent Neoadjuvant Immunotherapy: A Single Institution Experience, Jacob Applegarth, Scarlett B. Hao, Claire Bova, Harry Wasvary

Conference Presentation Abstracts

Pembrolizumab was granted accelerated FDA approval for the treatment of patients with metastatic MMR deficient solid tumors and has shown significant benefit in the treatment of metastatic colorectal cancer. Recently, the NICHE-2 trial demonstrated that neoadjuvant nivolumab plus ipilimumab led to a significant response in locally advanced MMR deficient colon cancer. This report is a single institution's experience regarding the treatment of metastatic colon cancer with neoadjuvant immunotherapy. Since 2022, our institution has treated two patients with neoadjuvant pembrolizumab for metastatic colon cancer and achieved complete clinical and pathologic responses with no residual evidence of malignancy.

Implementation Of An Adolescent Women’S Health And Wellness Education Program, Lauren Acker, Laynee Conner, Jennifer Cera

Doctor of Nursing Practice Projects: College of Nursing

Objectives: The goal of this research study was to provide scientific evidence supporting the importance and effectiveness of implementing a women’s health and wellness education course and its effect on (1) adolescent knowledge of sexual health and hygiene, (2) self-efficacy in menstrual management, and (3) self-empowerment in managing their own reproductive health.

Design: This was a mixed methods pilot study utilizing a pre/post-test single intervention efficacy trial. Quantitative and qualitative data were obtained.

Setting: The setting included two different sites including one outpatient ambulatory obstetrics/gynecology clinic and one community outreach center. Both sites were located within a midwestern metropolitan …

Evaluation Of An External Urinary Device Protocol And Practices In Hospitalized Female Patients: A Quality Improvement Project At A Rural Midwestern Hospital, Melissa Leibnitz, Ashley Causa, Susana Lopez

Doctor of Nursing Practice Projects: College of Nursing

Aims and Objectives- 1: Describe and measure current implementation and management practices of the PureWick™. 2: Describe and measure current outcomes in the use of the PureWick™ device including mobility scores, skin breakdown, Braden scores, moisture-associated dermatitis, CAUTIs, PAUTIs, hospital LOS, HAIs and HPIs. 3: Measure the survey results from staff regarding the current PureWick™ practices. 4: Propose recommendations for an improved EB protocol for the PureWick^TM.

Background: Currently, the PureWick^TM device has been utilized by facilities as an alternative to indwelling urinary catheters in an effort to reduce the incidence of CAUTI. Since the introduction …

Relationships Between Health Behaviors And Markers Of Oxidative Stress And Inflammation On Blood Pressure, Alison M. Godfrey

Honors Scholar Theses

Background. Young adulthood is a period when cardiometabolic risk factors begin to emerge. Developing cardiometabolic risk early can increase the risk and severity of chronic illness across the lifespan. Despite this, young adults are often understudied particularly as it relates to major cardiometabolic risk factors such as blood pressure (BP) and risk of hypertension. Hypertension is a public health crisis and early indicators of hypertension risk should be more thoroughly researched. Therefore, the purpose of the presented thesis is to examine BP in young adults and two potential pathways by which risk may emerge in young adults; inflammation (C-Reactive …

Relationship Between Maternal Plasma Retinol And Provitamin A Carotenoids With Fetal And Infant Kidney Development, Anum Akbar

Theses & Dissertations

Vitamin A plays a critical role in fetal organ development. Studies suggest that maternal vitamin A deficiency affects fetal nephron numbers, potentially leading to smaller kidney sizes and an increased risk of chronic kidney disease later in life. However, human studies exploring maternal vitamin A's impact on fetal kidney development lack longitudinal data and within-cohort comparisons. Furthermore, the influence of provitamin A carotenoids (α-carotene, β-carotene, β-cryptoxanthin) on kidney size remains unexplored. This dissertation addresses these gaps by analyzing relationships between maternal and cord plasma retinol and provitamin A carotenoid concentrations with fetal and infant kidney sizes. Our prospective cohort …

Identification And Preclinical Assessment Of Novel Therapeutic Modalities In Environmental Exposure-Induced Lung Disease, Aaron D. Schwab

Theses & Dissertations

Environmental lung diseases are preventable respiratory conditions either caused or made worse by inhaled environmental exposures. Contemporarily, environmental lung diseases are most associated with workplace exposures given specific occupational processes aerosolize inflammatory agents that can be inhaled at high concentrations. Although a considerable amount is known regarding immunoglobulin (Ig)E-mediated responses to environmental exposures, little is known about non-IgE mediated respiratory conditions resulting from lipopolysaccharide (LPS)-enriched organic dust exposure(s). Chronic respiratory diseases such as asthma, hypersensitivity pneumonitis, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis have all been identified as environmental lung diseases caused or exacerbated by such environmental dusts. Therapeutic …

Anti-Cancer Activity Of Marine-Derived Fucosylated Chondroitin Sulfates In Ovarian Cancer Cell Spheroid Formation And Notch Signaling Inhibition, Daniella Beiner

Honors Theses

Ovarian cancer is the deadliest gynecological malignancy, with high recurrence rates driven by chemotherapy-resistant cancer stem cells (CSCs). Current therapeutics targeting Notch signaling to inhibit CSC formation have yet to demonstrate clinical benefit and pose risk of gastrointestinal toxicities. Here, we report that treatment with fucosylated chondroitin sulfates (FucCS) inhibited Notch signaling activation and spheroid formation in OVCAR3 ovarian cancer cells. Sulfation and fucosylation were shown to be key structural requirements of this anti-cancer activity. Moreover, this inhibition was synergistic with suppression of Notch glycosylation by Radical Fringe knockout. Preliminary experiments to conjugate FucCS to a maleimide linker in preparation …

New First Trimester Circulating Angiogenic Biomarkers In Predicting Early-Onset And Late-Onset Fetal Growth Restriction: A Case-Control Study, Xiaoyi Bai, Wei Li, Wenjing Ding, Oi Ka Chan, Maran Bo Wah Leung, So Ling Lau, Daljit Singh Sahota, Chi Chiu Wang, Tak Yeung Leung

Faculty, Staff and Students Publications

Background: First trimester prediction of fetal growth restriction (FGR) remain suboptimal. We aimed to search for new circulating angiogenic biomarkers for improvement.

Methods: This case-control study compared 73 singleton pregnancies with early or late-onset FGR based on Delphi consensus and 73 matched normal controls. Their maternal serum samples stored during 11-13 weeks were retrieved for measurement of 36 angiogenic biomarkers by MILLIPLEX® human angiogenesis magnetic bead panels. Those biomarkers that showed significant differences between the study groups were further analysed with receiver operating characteristic (ROC) curve.

Results: In the early-onset FGR group, log10MoM of soluble neuropilin-1 (sNRP-1: 0.08 ± 0.11 …

Letter To The Editor On “Timing Of Puberty Suppression In Transgender Adolescents And Sexual Functioning After Vaginoplasty (Van Der Meulen Et Al., 2024)”, Alison Clayton, Jilles Smids, Kathleen Mcdeavitt

Faculty, Staff and Students Publications

No abstract provided.

Let-7 Restrains An Epigenetic Circuit In At2 Cells To Prevent Fibrogenic Intermediates In Pulmonary Fibrosis, Matthew J Seasock, Md Shafiquzzaman, Maria E Ruiz-Echartea, Rupa S Kanchi, Brandon T Tran, Lukas M Simon, Matthew D Meyer, Phillip A Erice, Shivani L Lotlikar, Stephanie C Wenlock, Scott A Ochsner, Anton Enright, Alex F Carisey, Freddy Romero, Ivan O Rosas, Katherine Y King, Neil J Mckenna, Cristian Coarfa, Antony Rodriguez

Faculty, Staff and Students Publications

MicroRNA-mediated post-transcriptional regulation of lung alveolar type 2 (AT2) and AT1 cell differentiation remains understudied. Here, we demonstrate that the let-7 miRNA family plays a homeostatic role in AT2 quiescence by preventing the uncontrolled accumulation of AT2 transitional cells and promoting AT1 differentiation. Using mouse and organoid models, we show that genetic ablation of let-7a1/let-7f1/let-7d cluster (let-7afd) in AT2 cells prevents AT1 differentiation and leads to KRT8 transitional cell accumulation in progressive pulmonary fibrosis. Integration of AGO2-eCLIP with RNA-sequencing identified direct let-7 targets within an oncogene feed-forward regulatory network, including BACH1/EZH2/MYC, which drives an aberrant fibrotic cascade. Additional CUT&RUN-sequencing analyses …

Neurodegenerative Disease Mechanisms: Mitochondrial Impairment, Tau Aggregation, And Neuroinflammation As Central Drivers Of Disease Progression, Luis D. Estrella

Theses & Dissertations

The study of the intricate molecular mechanisms behind the pathology of neurodegenerative diseases has become a primary research area in the past decades. The major branches of these studies involve both disease progression and disease pathogenesis, in which neuroscientists have studied, and continue to study, the role that mitochondrial dysfunction, aberrant protein aggregation (like Tau), and immune cell reactions have on these. However, more recent studies have shined light to the fact that these three pathological features are not independent from one another and that their synchronous contributions may be the ultimate driver of neurodegeneration. This dissertation encompasses four different …

A Modified Sir Model Used To Investigate The Relationship Between Congenital And Adult Syphilis, Kaleesta R. Waysman

Honors Thesis

A complex SIR model integrating the relationship between adult and congenital syphilis was developed. The goal of the project was to determine the specific population(s) or control strategies that should be enforced, altered, or removed to decrease the number of children experiencing clinical sequelae due to congenital syphilis. Early clinical sequelae include hydrops fetalis, preterm birth, central nervous system infection, hepatosplenomegaly, hyperbilirubinemia, cholestasis, hemolytic anemia, snuffles, osteochondritis, and lesions or rashes in the palms and soles. Late clinical sequelae include interstitial keratitis, hearing loss, Hutchinson teeth, saber shins, Clutton joints, mulberry molars, and saddle nose. After implementing real-world data into …

Allogeneic Chimeric Antigen Receptor T-Cell Products Cemacabtagene Ansegedleucel/Allo-501 In Relapsed/Refractory Large B-Cell Lymphoma: Phase I Experience From The Alpha2/Alpha Clinical Studies, Frederick L Locke, Javier L Munoz, Michael T Tees, Lazaros J Lekakis, Sven De Vos, Rajneesh Nath, Don A Stevens, Shahbaz A Malik, Geoffrey P Shouse, Mehdi Hamadani, Olalekan O Oluwole, Miguel-Angel Perales, David B Miklos, Paul W Fisher, Amy Feng, Lynn Navale, John B Le Gall, Sattva S Neelapu

Faculty, Staff and Student Publications

Purpose: Off-the-shelf, allogeneic CD19 chimeric antigen receptor (CAR) T-cell products may improve access to treatment versus autologous ones. We report the phase I experience of the allogeneic CD19 CAR T-cell product cemacabtagene ansegedleucel (cema-cel) and its predecessor, ALLO-501, in CD19 CAR T-naïve patients with relapsed/refractory large B-cell lymphoma (R/R LBCL).

Methods: In the ALPHA2/ALPHA studies, the safety and efficacy of allogeneic CD19 CAR T cells were evaluated in CD19 CAR T treatment-naïve patients with R/R LBCL. Patients received healthy donor-derived, human leukocyte antigen-unmatched cema-cel/ALLO-501 following a 3-day lymphodepletion regimen of fludarabine (30 mg/m2 once daily), cyclophosphamide (300 or 500 mg/m2 …

Cholestasis And Fluid Flow Are Biomechanic Regulators Of Cholangiocarcinoma Progression, Andrew Oleksijew

Theses & Dissertations

Cholestasis, altered or absent bile flow, is associated with poor survival in patients with cholangiocarcinoma, an aggressive cancer of the biliary epithelium. Changes in bile flow often result in stricture or obstruction. Experimental cholestasis promoted tumor growth and progression. However, studies are needed that directly assess the mechanical interaction between bile flow, or bile shear stress, and cholangiocarcinoma signaling. We hypothesized that cholestasis and absent bile shear stress activated cancer signaling and increased aggressive cellular behaviors such as proliferation and migration. Fluid shear stress approximating bile flow was applied by orbital culture plate method and compared to identical static culture …

Evaluating The Therapeutic Potential Of Geranylgeranyl Diphosphate Synthase Inhibitor, Ram2061, In Myeloma Bone Disease, Molly Muehlebach

Theses & Dissertations

Multiple myeloma (MM) is a hematological malignancy of the plasma cells which often results in lytic bone disease. Myeloma bone disease (MBD), characterized by diffuse osteopenia, bone lesions, or pathological fracture, results from MM mediated promotion of osteoclast resorption and dual inhibition of bone formation, drastically reducing bone strength and integrity. Development of MBD is known to significantly impact patient quality of life and increase risk of mortality. Considering that up to 80-95% of MM patients are expected to develop bone disease post-initial MM diagnosis, there is a significant need within this population for therapeutics which address both MM disease …

A Virtual Wellness Program To Enhance Well-Being For Pediatric Oncology Staff During The Covid-19 Pandemic, Karen Moody, Maria Swartz, Zachary Gresham, Martha Askins, Laura Cahalan, Pavilia Francis, Christine Geistkemper, Amy Heaton, Ruitao Lin, Melissa Melo, Alakh Rajan, Madeline Smith, Priti Tewari, Keyana R. Williams, Cheng-Han Yang, Rhonda Robert

Advances in Cancer Education and Quality Improvement

In response to the COVID-19 global health crisis and mandated social isolation, Pediatric leadership at MD Anderson Children’s Cancer Hospital was concerned for the psychological impact on its workforce and encouraged wellness programming. A grassroots wellness taskforce was assembled for the Division of Pediatrics. The task force’s primary mission was to promote the well-being of clinicians and non-clinical staff members through a broadly accessible, sustainable, and effective virtual wellness program. Guided by the Stanford Model for Professional Fulfillment, a virtual program entitled, “Weekly Wellness Webex” for Pediatrics staff was launched. Weekly Wellness Webex is a 1-hour live-streamed program with varied …

Reducing The Percentage Of Intubation Time On Continuous Infusion Midazolam, Arsemen Brown, Emily Highsmith, Michelle Horng

Advances in Cancer Education and Quality Improvement

This quality improvement study was conducted at a comprehensive cancer care center with the aim to decrease the percentage of on continuous infusion (CI) midazolam by 30% by May 5, 2023. The pre-intervention and post-intervention data collection phases occurred from January 1, 2022, to October 31, 2022, and March 7, 2023, to May 5, 2023, respectively. Sedation was assessed utilizing the Richmond Agitation and Sedation Scale (RASS), and delirium was assessed utilizing the Intensive Care Delirium Screening Checklist (ICDSC). A sedation pathway and associated educational materials were developed by a multidisciplinary team and frontline staff. Interventions in the sedation pathway …

Impact Of A Goal Of Care Communication Training Program For Oncology Clinical Staff, Gary Martinez

Advances in Cancer Education and Quality Improvement

Abstract

Goals of care (GoC) refers to medical care decisions made by patients and families that are consistent with their personal values and preference choices. However, the oncology health care system does not always align with the patient’s GoC values and preferences. Clinical experts suggest formalized GoC education to improve this practice gap. Accordingly, MD Anderson Cancer Center implemented GoC training for front-line clinical staff using the evidence-based COMFORT Model to enhance the participants’ ability to have connected GoC conversations and enhance their comfort levels in responding to patients’ emotions. Our institution’s GoC education team compared the pretest and posttest …

Persistent Improvement In Opioid Perceptions And Prescribing For Cancer Surgery: 5-Year Follow-Up, Brittany C. Fields, Timothy E. Newhook, Heather A. Lillemoe, Jessica E. Maxwell, Jose M. Soliz, Keyuri U. Popat, Christina L. Roland, Jean-Nicolas Vauthey, Matthew H. G. Katz, Ching-Wei D. Tzeng

Advances in Cancer Education and Quality Improvement

Background and Objectives

We previously reported that implementation of a department-wide opioid education program led to post-education improvements in opioid perceptions and prescription recommendations, with one-month and one-year retention. With ongoing programmatic and quality improvement efforts, we sought to re-evaluate the retention of these improvements five years after initial efforts.

Methods

Attending surgeons, clinical fellows, and advanced practice providers were surveyed five years after implementation of a comprehensive, departmental opioid reduction framework in August 2018. This framework initially consisted of dedicated opioid education sessions and retrospective assessment of prescribing practices, and subsequently expanded over time to include prospective quality improvement …

Spectrum Of Hydrogen Peroxide Ingestions With Varying Management In The Pediatric Population, Narden Gorgy

St. Chris Research Day

No abstract provided.

Sensitive Practice For Supporting Survivors Of Sexual Violence In Oncology, Kevin R. Clark

Advances in Cancer Education and Quality Improvement

Sexual violence is a pervasive problem that has profound implications for survivors' physical and mental health. In oncology care, routine medical procedures can inadvertently trigger distress and retraumatization in survivors. This brief report outlines the principles of sensitive practice and their application in oncology care to support survivors of sexual violence. By showing respect, taking time, building rapport, sharing information, sharing control, respecting boundaries, promoting mutual learning, understanding nonlinear healing, and demonstrating an understanding of sexual violence, health care providers can create a safe and supportive environment. Implementing these principles reduces the risk of retraumatization and improves patient outcomes. Health …