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Articles 31 - 60 of 109
Full-Text Articles in Viruses
Impact Of Biosecurity Measures, Social Pressure And Bullying On Attitudes, Perceptions, And Job Satisfaction Levels Among Healthcare Workers During The Covid-19 Pandemic: A Cross-Sectional Survey, Azza Sarfraz, Zouina Sarfraz, Genesis Camacho-Leon, Geovanny Efraín Alvarado-Villa, Derly Madeleiny Andrade-Molina, Juan Carlos Fernandez-Cadena, Arjola Agolli, Zeynep Yukselen, Miguel Felix, Juan Carlos Gallardo Bastidas
Impact Of Biosecurity Measures, Social Pressure And Bullying On Attitudes, Perceptions, And Job Satisfaction Levels Among Healthcare Workers During The Covid-19 Pandemic: A Cross-Sectional Survey, Azza Sarfraz, Zouina Sarfraz, Genesis Camacho-Leon, Geovanny Efraín Alvarado-Villa, Derly Madeleiny Andrade-Molina, Juan Carlos Fernandez-Cadena, Arjola Agolli, Zeynep Yukselen, Miguel Felix, Juan Carlos Gallardo Bastidas
Department of Paediatrics and Child Health
Introduction: The extent and nature of social pressure and bullying towards healthcare workers (HCWs) during the COVID-19 remains unclear. The following study identifies the effect of social pressure and bullying directed towards HCWs when using biosecurity measures during the COVID-19 pandemic; further, the impact on perceptions, attitudes and job satisfaction level is also explored.
Methodology: We conducted a cross-sectional survey-based study among 684 Ecuadorian HCWs. The survey consisted of 38 questions related to the frequency, attitudes, and perceptions of biosecurity measures during the COVID-19 pandemic. Exploratory factor analysis was performed to assess the validity of the questionnaire. Associations between variables …
What About Anosmia From Covid-19 ?, Sharanya S E Santhi, Sara Elnour, Steven B Lippmann
What About Anosmia From Covid-19 ?, Sharanya S E Santhi, Sara Elnour, Steven B Lippmann
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Treating Cytokine Storm In Patients With Covid-19, Ahmed Abdelhaleem, Deekshitha Turaka, Shameera Shaik Masthan, Steven B Lippmann
Treating Cytokine Storm In Patients With Covid-19, Ahmed Abdelhaleem, Deekshitha Turaka, Shameera Shaik Masthan, Steven B Lippmann
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Covid-19 Case Complicated With Organizing Pneumonia And Pneumothorax: Correspondence, Hammad A. Bhatti, Minh Q. Ho
Covid-19 Case Complicated With Organizing Pneumonia And Pneumothorax: Correspondence, Hammad A. Bhatti, Minh Q. Ho
The University of Louisville Journal of Respiratory Infections
No abstract provided.
How Environmental Change Will Impact Mosquito-Borne Diseases, Arsal Khan
How Environmental Change Will Impact Mosquito-Borne Diseases, Arsal Khan
Master's Projects and Capstones
Mosquitos, the most lethal species throughout human history, are the most prevalent source of vector-borne diseases and therefore a major global health burden. Mosquito-borne disease incidence is expected to shift with environmental change. These changes can be predicted using species distribution models. With the wide variety of methods used for models, consensus for improving accuracy and comparability is needed. A comparative analysis of three recent modeling approaches revealed that integrating modeling techniques compensates for trade-offs associated with a singular approach. An area that represents a critical gap in our ability to predict mosquito behavior in response to changing climate factors, …
Burden, Clinical Characteristics, Risk Factors, And Seasonality Of Adenovirus 40/41 Diarrhea In Children In Eight Low-Resource Settings, Godfrey Guga, Sarah Elwood, Caroline Kimathi, Gagandeep Kang, Margaret N. Kosek, Aldo A M Lima, Pascal O. Bessong, Amidou Samie, Najeeha Talat Iqbal, Zulfiqar Ahmed Bhutta
Burden, Clinical Characteristics, Risk Factors, And Seasonality Of Adenovirus 40/41 Diarrhea In Children In Eight Low-Resource Settings, Godfrey Guga, Sarah Elwood, Caroline Kimathi, Gagandeep Kang, Margaret N. Kosek, Aldo A M Lima, Pascal O. Bessong, Amidou Samie, Najeeha Talat Iqbal, Zulfiqar Ahmed Bhutta
Department of Biological & Biomedical Sciences
Background: The application of molecular diagnostics has identified enteric group adenovirus serotypes 40 and 41 as important causes of diarrhea in children. However, many aspects of the epidemiology of adenovirus 40/41 diarrhea have not been described.
Methods: We used data from the 8-site Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project birth cohort study to describe site- and age-specific incidence, risk factors, clinical characteristics, and seasonality.
Results: The incidence of adenovirus 40/41 diarrhea was substantially higher by quantitative polymerase chain reaction than enzyme immunoassay and peaked at ∼30 episodes …
Medical Students In Karachi And Covid-19: Myths And Facts, Omer Bin Khalid Jamil, Muhammad Muhib, Muhammad Anas Abbal, Amna Muhammed Ahmed, Hafsa Hayat Khan, Nabeela Yar Khan
Medical Students In Karachi And Covid-19: Myths And Facts, Omer Bin Khalid Jamil, Muhammad Muhib, Muhammad Anas Abbal, Amna Muhammed Ahmed, Hafsa Hayat Khan, Nabeela Yar Khan
Department of Surgery Docs
Objectives: COVID-19 pandemic brought mortalities, morbidities, fear, and financial despair among people around the world. As it advanced, misinformation and myths about it caught wildfire, contributing to misbelief among the already shocked population. Medical students are the building blocks of the medical community and can provide a pivotal role in combating COVID-19 misinformation by delivering correct knowledge and awareness to the non-medical population of the country. Hence, it is important to assess their knowledge and perception of COVID-19 myths. Therefore, this study evaluates medical student's knowledge regarding myths and misinformation related to COVID-19 infection and its vaccine. The study also …
Covid-19, Vaccination, And Heart Transplantation, Forest W. Arnold
Covid-19, Vaccination, And Heart Transplantation, Forest W. Arnold
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Covid-19 Case Complicated With Organizing Pneumonia And Pneumothorax: A Case Report, Tammy E. Phillips, Hammad A. Bhatti, Minh Q. Ho
Covid-19 Case Complicated With Organizing Pneumonia And Pneumothorax: A Case Report, Tammy E. Phillips, Hammad A. Bhatti, Minh Q. Ho
The University of Louisville Journal of Respiratory Infections
Organizing pneumonia can be idiopathic or caused by multiple etiologies, including viral or bacterial pneumonia, drugs, and autoimmune disorders. It can rarely lead to cyst formation and pneumothorax with the exact mechanism remaining unclear. This case presents a previously healthy 50-year-old male who contracted COVID-19 with subsequent development of organizing pneumonia and pneumothorax. Patients presenting with hypoxic respiratory failure due to COVID-19 should be screened for organizing pneumonia upon discharge. This case also illustrates the importance of following such patients radiologically to monitor interstitial lung disease and consider pneumothorax for patients re-presenting with acute symptoms.
Development Of Evidence-Based Covid-19 Management Guidelines For Local Context: The Methodological Challenges, Sarah Nadeem, Salima Saleem Aamdani, Bushra Ayub, Nashia Ali Rizvi, Fatima Safi Arslan, Russell Seth Martins, Maria Khan, Syed Faisal Mahmood
Development Of Evidence-Based Covid-19 Management Guidelines For Local Context: The Methodological Challenges, Sarah Nadeem, Salima Saleem Aamdani, Bushra Ayub, Nashia Ali Rizvi, Fatima Safi Arslan, Russell Seth Martins, Maria Khan, Syed Faisal Mahmood
Section of Diabetes, Endocrinology and Metabolism
Background: The coronavirus disease 2019 (COVID-19) pandemic has presented as a therapeutic challenge for clinicians worldwide due to its rapid spread along with evolving evidence and understanding of the disease. Internationally, recommendations to guide the management of COVID-19 have been created and updated continuously by the WHO and CDC, which have been locally adapted by different countries. Similarly, Pakistan's National Command Operation Center (NCOC), in its national COVID-19 management strategy, generated guidelines for national implementation. Keeping the guidelines updated has proved challenging globally and locally. Here, we present a summary of the process to assess the evidence, including a time-restricted …
Sotrovimab: Neutralizing Antibody To Combat Covid-19, Aya Allam, Steven Lippmann
Sotrovimab: Neutralizing Antibody To Combat Covid-19, Aya Allam, Steven Lippmann
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Are Antipyretic Medications Compatible With Sars-Cov-2 Vaccines?, Sharanya S E Santhi, Niguma Rayamajhi, Steven B Lippmann
Are Antipyretic Medications Compatible With Sars-Cov-2 Vaccines?, Sharanya S E Santhi, Niguma Rayamajhi, Steven B Lippmann
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Mucormycosis: Covid-19 And Corticosteroids, Mittal Savaliya, Nivedita Jha, Steven B Lippmann
Mucormycosis: Covid-19 And Corticosteroids, Mittal Savaliya, Nivedita Jha, Steven B Lippmann
The University of Louisville Journal of Respiratory Infections
No abstract provided.
Healthcare Simulation: A Key To The Future Of Medical Education - A Review, Omair Ayaz, Faisal Wasim Ismail
Healthcare Simulation: A Key To The Future Of Medical Education - A Review, Omair Ayaz, Faisal Wasim Ismail
Medical College Documents
Aim: Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift …
A Quantitative Analysis Of The Efficacy Of Various Essential Oils Against The Sars Cov-2 Virus, Elizabeth Wagstaff, Chandrelyn Kraczek, Jack Brandon Lopez
A Quantitative Analysis Of The Efficacy Of Various Essential Oils Against The Sars Cov-2 Virus, Elizabeth Wagstaff, Chandrelyn Kraczek, Jack Brandon Lopez
Annual Research Symposium
A poster presentation and abstract for the Roseman Symposium. The project focuses on testing 3 essential oil blends and two disinfectants containing an essential oil blend against SARS CoV-2 in response to the COVID-19 pandemic. The project procedure involves plaque assays, disinfection, and neutralization techniques.
Global Evolutionary Dynamics And Resistome Analysis Of Clostridioides Difficile Ribotype 017, Korakrit Imwattana, Papanin Putsathit, Deirdre A. Collins, Teera Leepattarakit, Pattarachai Kiratisin, Thomas V. Riley, Daniel R. Knight
Global Evolutionary Dynamics And Resistome Analysis Of Clostridioides Difficile Ribotype 017, Korakrit Imwattana, Papanin Putsathit, Deirdre A. Collins, Teera Leepattarakit, Pattarachai Kiratisin, Thomas V. Riley, Daniel R. Knight
Research outputs 2022 to 2026
Clostridioides difficile PCR ribotype (RT) 017 ranks among the most successful strains of C. difficile in the world. In the past three decades, it has caused outbreaks on four continents, more than other ‘epidemic’ strains, but our understanding of the genomic epidemiology underpinning the spread of C. difficile RT 017 is limited. Here, we performed high-resolution phylogenomic and Bayesian evolutionary analyses on an updated and more representative dataset of 282 non-clonal C. difficile RT 017 isolates collected worldwide between 1981 and 2019. These analyses place an estimated time of global dissemination between 1953 and 1983 and identified the acquisition of …
The Covid-19 Pandemic: Exploring E-Learning Experience During Schools Closure In Tanzania, Fabian Gallus Mahundu
The Covid-19 Pandemic: Exploring E-Learning Experience During Schools Closure In Tanzania, Fabian Gallus Mahundu
Journal of Humanities and Social Sciences
of parents and guardians in supporting their children’s e-learning activities during the COVID-19 lockdown in Tanzania. The study adopted an exploratory qualitative research design. Data were collected using telephone interviews and open-ended questions (using google forms), which inquired parents’ and guardians’ experience in supporting home based e-learning activities among students during the COVID-19 lockdown. The paper argues that giving students free access to online learning materials during COVID-19 lockdowns is paramount. However, parents’ and guardians’ support through sharing one’s phones must be monitored to safeguard learners from accessing irrelevant materials. Findings show that parents and guardians had different experiences in …
Self-Medication Practices In Medical Students During The Covid-19 Pandemic: A Cross-Sectional Analysis, Farah Yasmin, Muhammad Sohaib Asghar, Unaiza Naeem, Hala Najeeb, Hamza Nauman, Muhammad Nadeem Ahsan, Abdullah Khan Khattak
Self-Medication Practices In Medical Students During The Covid-19 Pandemic: A Cross-Sectional Analysis, Farah Yasmin, Muhammad Sohaib Asghar, Unaiza Naeem, Hala Najeeb, Hamza Nauman, Muhammad Nadeem Ahsan, Abdullah Khan Khattak
Medical College Documents
Background and objectives: During the pandemic, the growing influence of social media, accessibility of over-the-counter medications, and fear of contracting the virus may have led to self-medication practices among the general public. Medical students are prone to such practices due to relevant background knowledge, and access to drugs. This study was carried out to determine and analyze the prevalence of self-medication practices among medical students in Pakistan.
Materials and methods: This descriptive, cross-sectional study was conducted online in which the participants were asked about the general demographics, their self-medication practices and the reasons to use. All participants were currently enrolled …
Covid-19 In Cns And Pns: Basic And Clinical Focus On The Mechanisms Of Infection And New Tools For The Therapeutic Approach, Jorge Matias-Guiu, Jordi A. Matias-Guiu, Carmen Garrido, Genaro Pimienta, Patricio F. Reyes, Abdul Mannan Baig, Ulises Gomez-Pinedo
Covid-19 In Cns And Pns: Basic And Clinical Focus On The Mechanisms Of Infection And New Tools For The Therapeutic Approach, Jorge Matias-Guiu, Jordi A. Matias-Guiu, Carmen Garrido, Genaro Pimienta, Patricio F. Reyes, Abdul Mannan Baig, Ulises Gomez-Pinedo
Department of Biological & Biomedical Sciences
No abstract provided.
Residual Symptoms And The Quality Of Life In Individuals Recovered From Covid-19 Infection: A Survey From Pakistan, Mohammad Aadil Qamar, Russell Seth Martins, Rubaid Azhar Dhillon, Areeba Tharwani, Omar Irfan, Qosain Fatima Suriya, Wajiha Rizwan, Javaid Ahmed Khan, Ali Bin Sarwar Zubairi
Residual Symptoms And The Quality Of Life In Individuals Recovered From Covid-19 Infection: A Survey From Pakistan, Mohammad Aadil Qamar, Russell Seth Martins, Rubaid Azhar Dhillon, Areeba Tharwani, Omar Irfan, Qosain Fatima Suriya, Wajiha Rizwan, Javaid Ahmed Khan, Ali Bin Sarwar Zubairi
Medical College Documents
Background: There remains scarcity of literature regarding the patient's health status post-COVID-19 infection. This study analyzes the prevalence of residual symptoms and quality of life (QoL) after COVID-19.
Methods: An anonymous online survey was administrated in Pakistan from November 2020 to April 2021 in COVID-19 survivors. The questionnaire used the 12-Item Short Form Health Survey (SF-12) to assess mental and physical QoL. Multivariate linear regression was used to explore factors associated with mental and physical QoL scores.
Results: A total of 331 COVID-19 survivors participated in our survey. Around 42.0% of the cohort reported within 1-3 months of diagnosis of …
Optimizing Prevention And Community-Based Management Of Severe Malnutrition In Children, Zulfiqar Ahmed Bhutta
Optimizing Prevention And Community-Based Management Of Severe Malnutrition In Children, Zulfiqar Ahmed Bhutta
Department of Paediatrics and Child Health
Zulfiqar A. Bhutta discusses prevention and treatment strategies for optimization of community-based management of severe acute malnutrition in children
Pulmonary Post-Acute Sequelae Of Covid-19, Usman Akbar, Shivam Gulati, Johnny Zakhour Md, Alex Glynn, Jose Bordon
Pulmonary Post-Acute Sequelae Of Covid-19, Usman Akbar, Shivam Gulati, Johnny Zakhour Md, Alex Glynn, Jose Bordon
The University of Louisville Journal of Respiratory Infections
Introduction: Persistent symptoms have been observed in a substantial proportion of survivors of COVID-19 since relatively early in the pandemic. Among these post-acute sequelae of COVID-19 (PASC), respiratory symptoms appear to be the most prevalent.
Methods: We conducted a literature review of peer-reviewed publications in English on the clinical and epidemiological features of respiratory PASC in cohorts of 100 or more patients with a follow-up of four weeks or more after acute infection. Included studies reported the prevalence of persistent respiratory symptoms and/or the results of follow-up pulmonary function tests.
Results: On our review included 14 studies across eight countries …
Prevalence And Types Of Drugs Used Among Hepatitis A Patients During Outbreaks Associated With Person-To-Person Transmission, Kentucky, Michigan, And West Virginia, 2016–2019, Megan G. Hofmeister, Alice Asher, Christopher M. Jones, Ryan J. Augustine, Cole Burkholder, Jim Collins, Monique A. Foster, Shannon Mcbee, Erica D. Thomasson, Doug Thoroughman, Mark K. Weng, Philip R. Spradling
Prevalence And Types Of Drugs Used Among Hepatitis A Patients During Outbreaks Associated With Person-To-Person Transmission, Kentucky, Michigan, And West Virginia, 2016–2019, Megan G. Hofmeister, Alice Asher, Christopher M. Jones, Ryan J. Augustine, Cole Burkholder, Jim Collins, Monique A. Foster, Shannon Mcbee, Erica D. Thomasson, Doug Thoroughman, Mark K. Weng, Philip R. Spradling
Journal of Appalachian Health
Background: People who use drugs are at increased risk for hepatitis A virus infection. Since 1996, the Advisory Committee on Immunization Practices has recommended hepatitis A vaccination for people who use drugs. Since 2016, the U.S. has experienced widespread hepatitis A outbreaks associated with person-to-person transmission.
Purpose: To describe the prevalence of drug use, route of use, and drugs used among hepatitis A outbreak-associated patients.
Methods: State outbreak and medical records were reviewed to describe the prevalence, type, and route of drug use among a random sample of 812 adult outbreak-associated hepatitis A patients from Kentucky, Michigan, and West Virginia …
The Aoc In The Age Of Covid—Pandemic Preparedness Planning In The Federal Courts, Zoe Niesel
The Aoc In The Age Of Covid—Pandemic Preparedness Planning In The Federal Courts, Zoe Niesel
St. Mary's Law Journal
The 2020 COVID-19 pandemic created a crisis for American society—and the federal courts were not exempt. Court facilities came to a grinding halt, cases were postponed, and judiciary employees adopted work-from-home practices. Having court operations impacted by a pandemic was not a new phenomenon, but the size, scope, and technological lift of the COVID-19 pandemic was certainly unique.
Against this background, this Article examines the history and future of pandemic preparedness planning in the federal court system and seeks to capture some of the lessons learned from initial federal court transitions to pandemic operations in 2020. The Article begins by …
Implementation Of A Drive-Through Covid-19 Mass Vaccination Site: Experiences From Louvax–Broadbent In Louisville, Kentucky, Ruth Carrico, Sarah Beth Hartlage, Valenchia Brown Msn, Aprn, Fnp-C, Sarah M. Bishop, Luanne Didelot, William Hayden, Beverly Williams Coleman, Sarah Tan, Delanor Manson, Kellie Kane, Dawn Balcom, Paul Kern
Implementation Of A Drive-Through Covid-19 Mass Vaccination Site: Experiences From Louvax–Broadbent In Louisville, Kentucky, Ruth Carrico, Sarah Beth Hartlage, Valenchia Brown Msn, Aprn, Fnp-C, Sarah M. Bishop, Luanne Didelot, William Hayden, Beverly Williams Coleman, Sarah Tan, Delanor Manson, Kellie Kane, Dawn Balcom, Paul Kern
The University of Louisville Journal of Respiratory Infections
Background: Response to the COVID-19 pandemic has required innovative approaches to vaccination, including methods to rapidly and safely immunize communities. A major challenge to such a response involved access to untapped healthcare worker resources. The Louisville, Kentucky, response involved the use of a large volunteer workforce to supplement local public health employees in planning and implementing a large-scale drive-through vaccination event. The objective of this manuscript was to outline processes involved in training a mass immunization workforce and implementating a large-scale COVID-19 community vaccination.
Approach: Competency-based and standardized training was provided for every volunteer before working their shift. Volunteers worked …
Industry 4.0 Technologies For The Manufacturing And Distribution Of Covid-19 Vaccines, Azza Sarfraz, Zouina Sarfraz, Muzna Sarfraz, Aminah Abdul Razzack, Shehar Bano, Sarabjot Singh Makkar, Sindhu Thevuthasan, Trissa Paul, Muhammad Khawar Sana, Nishwa Azeem
Industry 4.0 Technologies For The Manufacturing And Distribution Of Covid-19 Vaccines, Azza Sarfraz, Zouina Sarfraz, Muzna Sarfraz, Aminah Abdul Razzack, Shehar Bano, Sarabjot Singh Makkar, Sindhu Thevuthasan, Trissa Paul, Muhammad Khawar Sana, Nishwa Azeem
Department of Paediatrics and Child Health
Background: The evolutionary stages of manufacturing have led us to conceptualize the use of Industry 4.0 for COVID-19 (coronavirus disease 2019), powered by Industry 4.0 technologies. Using applications of integrated process optimizations reliant on digitized data, we propose novel intelligent networks along the vaccine value chain. Vaccine 4.0 may enable maintenance processes, streamline logistics, and enable optimal production of COVID-19 vaccines.
Vaccine 4.0 framework: The challenge in applying Vaccine 4.0 includes the requirement of large-scale technologies for digitally transforming manufacturing, producing, rolling-out, and distributing vaccines. With our framework, Vaccine 4.0 analytics will target process performance, process development, process stability, compliance, …
Gosnell, Katherine - Covid-19 Journal, Katherine Gosnell
Gosnell, Katherine - Covid-19 Journal, Katherine Gosnell
Personal Journals
No abstract provided.
Increasing Staff Compliance With Routine Hcv Screening And Improving Linkage To Care Among Patients Testing Hepatitis C Positive In The Emergency Department, Carson G. Swartz
Increasing Staff Compliance With Routine Hcv Screening And Improving Linkage To Care Among Patients Testing Hepatitis C Positive In The Emergency Department, Carson G. Swartz
DNP Projects
Background: Hepatitis C virus (HCV) is a blood-borne pathogen that can cause severe liver disease, cancer, and death and is a significant source of morbidity and mortality in the United States. Several academic medical centers including University of Kentucky Healthcare have implemented routine HCV screening for patients presenting to the emergency department (ED) and have discovered a large viral burden amongst patients who are often symptomatic.
Purpose: The purpose of this doctoral project is to increase staff compliance, confidence, and education regarding the HCV screening process in an urban, Level I emergency department, as well as to evaluate whether an …
D-Dimer Testing In Covid-19: From Basics To Clinical Application, Bushra Moiz
D-Dimer Testing In Covid-19: From Basics To Clinical Application, Bushra Moiz
Department of Pathology and Laboratory Medicine
No abstract provided.
Consultation/Liaison Psychiatry During Covid-19, Robert Frierson, Steven B Lippmann
Consultation/Liaison Psychiatry During Covid-19, Robert Frierson, Steven B Lippmann
The University of Louisville Journal of Respiratory Infections
Consultation/liaison psychiatrists care for people with co-existing medical and psychologic difficulties. The coronavirus pandemic is stressful for patients and their psychiatric caregivers. Patients have lost support systems and harbor fears about exposing family to the virus. COVID-19 sometimes exacerbates previous psychiatric conditions, while diminishing intimacy with physicians. Everyone is oversaturated with COVID-19-related news focusing on rising concerns about the illness and about jobs, school, and housing insecurities.
The psychiatrist maintains a hospital presence despite fear of contracting the disease. Challenges include addressing staff morale, evidencing empathy despite telecommunication devices, and treating anxiety, depression, sleep phobias, post intubation flashbacks, COVID-19-induced cognitive …