Other Public Health Commons^™

What Quantifies Good Primary Care In The United States? A Review Of Algorithms And Metrics Using Real-World Data, Yun Wang, Jianwei Zheng, Todd Schneberk, Yu Ke, Alexandre Chan, Tao Hu, Jerika Lam, Mary Gutierrez, Ivan Portillo, Dan Wu, Chi-Hung Chang, Yang Qu, Lawrence Brown, Michael B. Nichol

Pharmacy Faculty Articles and Research

Primary care physicians (PCPs) play an indispensable role in providing comprehensive care and referring patients for specialty care and other medical services. As the COVID-19 outbreak disrupts patient access to care, understanding the quality of primary care is critical at this unprecedented moment to support patients with complex medical needs in the primary care setting and inform policymakers to redesign our primary care system. The traditional way of collecting information from patient surveys is time-consuming and costly, and novel data collection and analysis methods are needed. In this review paper, we describe the existing algorithms and metrics that use the …

Geospatial Analysis Of Opioid Dispensing Patterns In California: A 2021 Real-World Study, Hongxia Lu, Jianwei Zheng, Yun Wang

Pharmacy Faculty Articles and Research

The misuse and abuse of opioids has become a serious public health threat in the United States. The state of California has been hit particularly hard by the opioid epidemic, with a noticeable increase in opioid-related fatalities and hospitalizations. This brief report paper aims to contribute to the growing literature by conducting a geospatial analysis of opioid dispensing patterns in California in 2021. The primary objective was to identify areas characterized by high-risk opioid dispending patterns and explore possible contributing factors. This retrospective study analyzed data from over 7 million records of opioid and benzodiazepine prescriptions dispensed by outpatient pharmacies …

Understanding The Consumption Of Antimicrobial Resistance–Related Content On Social Media: Twitter Analysis, Hyunuk Kim, Chris R. Proctor, Dylan Walker, Ronan R. Mccarthy

Business Faculty Articles and Research

Background: Antimicrobial resistance (AMR) is one of the most pressing concerns in our society. Today, social media can function as an important channel to disseminate information about AMR. The way in which this information is engaged with depends on a number of factors, including the target audience and the content of the social media post.

Objective: The aim of this study is to better understand how AMR-related content is consumed on the social media platform Twitter and to understand some of the drivers of engagement. This is essential to designing effective public health strategies, raising awareness about antimicrobial …

Explaining Adult Obesity, Severe Obesity, And Bmi: Five Decades Of Change, Ashley W. Kranjac, Dinko Kranjac

Sociology Faculty Articles and Research

Obesity rates have increased across all segments of society since the late 1970s, but the reason behind population-level increases in body weight remains unclear. We used the 1971–2020 NHANES data to examine whether the observed trend in obesity prevalence is attributable to changing public health behaviors (i.e., intracohort change) or changing publics (i.e., cohort replacement). We partitioned total change in mean BMI, and rates of obesity and severe obesity, into its IC and CR components using linear and algebraic decomposition methods. We found that the IC mechanism (i.e., broad sectors of individuals changing) plays a dominant role in the overall …

Join Or Die: How Deontological Moral Intuitions Complicate Cooperation Amid The Covid-19 Pandemic, Alessandro Del Ponte

Political Science Faculty Articles and Research

Tackling COVID-19 requires universal collective action: everyone must play their part to reduce the spread of the virus and quell the pandemic. Yet, some people obstinately refuse to cooperate, irrespective of the consequences for themselves and others. In this note, I illustrate a key element of human psychology that hampers cooperation amid the pandemic: deontological moral intuitions. Deontological morality prescribes that moral taboos must be followed no matter the consequences. This means that people who consider Covid vaccines a moral taboo are prepared to suffer virtually any consequence rather than take the vaccine. I discuss the evolutionary basis of deontological …

3rd Place Contest Entry: Using The Scientific Method To Combat The Biological And Sociological Effects Of The Covid-19 Pandemic: An Aspiring Healthcare Professional’S Perspective, Isabelle Dhindsa

Kevin and Tam Ross Undergraduate Research Prize

This is Isabelle Dhindsa's submission for the 2023 Kevin and Tam Ross Undergraduate Research Prize, which won third place. It contains their essay on using library resources, their bibliography, and a sample of their research project on using the scientific method to combat the biological and sociological effects of the COVID-19 pandemic.

Isabelle is a fourth-year student at Chapman University, majoring in Biology. Their faculty mentor is Dr. Carmichael Peters.

Obesity Heterogeneity By Neighborhood Context In A Largely Latinx Sample, Ashley W. Kranjac, Dinko Kranjac, Zeev N. Kain, Louis Ehwerhemuepha, Brooke N. Jenkins

Sociology Faculty Articles and Research

Neighborhood socioeconomic context where Latinx children live may influence body weight status. Los Angeles County and Orange County of Southern California both are on the list of the top ten counties with the largest Latinx population in the USA. This heterogeneity allowed us to estimate differential impacts of neighborhood environment on children’s body mass index z-scores by race/ethnicity using novel methods and a rich data source. We geocoded pediatric electronic medical record data from a predominantly Latinx sample and characterized neighborhoods into unique residential contexts using latent profile modeling techniques. We estimated multilevel linear regression models that adjust for …

Virtual And In Vitro Screening Of Natural Products Identifies Indole And Benzene Derivatives As Inhibitors Of Sars-Cov-2 Main Protease (MPro), Dony Ang, Riley Kendall, Hagop S. Atamian

Biology, Chemistry, and Environmental Sciences Faculty Articles and Research

The rapid spread of the coronavirus disease 2019 (COVID-19) resulted in serious health, social, and economic consequences. While the development of effective vaccines substantially reduced the severity of symptoms and the associated deaths, we still urgently need effective drugs to further reduce the number of casualties associated with SARS-CoV-2 infections. Machine learning methods both improved and sped up all the different stages of the drug discovery processes by performing complex analyses with enormous datasets. Natural products (NPs) have been used for treating diseases and infections for thousands of years and represent a valuable resource for drug discovery when combined with …

Shot Talk: Development And Pilot Test Of A Theory Of Planned Behavior Campaign To Combat College Student Covid-19 Vaccine Hesitancy, Hannah Ball, Tayah Renea Wozniak, Cailin M. Kuchenbecker

Communication Faculty Articles and Research

Among college students, evidence of relatively lower levels of concern of COVID-19 infection, rapid rates of transmission, and lagging vaccination rates substantiates a need to combat college student COVID-19 vaccine hesitancy. This two-phase study comprised formative research, development, and pilot testing of a campaign to combat COVID-19 vaccine hesitancy among college students. In phase one, focus group discussions with college students (N = 48) uncovered their specific attitudes, subjective norms, and perceived behavioral control toward the COVID-19 vaccine. Thematic analysis revealed concerns about vaccine safety, efficacy, cost, and politicization, as well as perceived barriers to accessing information and the …

Experiences Of Covid-19-Related Racism And Impact On Depression Trajectories Among Racially/Ethnically Minoritized Adolescents, Sabrina R. Liu, Elysia Poggi Davis, Anton M. Palma, Hal S. Stern, Curt A. Sandman, Laura M. Glynn

Psychology Faculty Articles and Research

Purpose

In 2020, racially/ethnically minoritized (REMD) youth faced the “dual pandemics” of COVID-19 and racism, both significant stressors with potential for adverse mental health effects. The current study tested whether short- and long-term trajectories of depressive symptoms from before to during the COVID-19 pandemic differed between REMD adolescents who did and did not endorse exposure to COVID-19-era-related racism (i.e., racism stemming from conditions created or exacerbated by the COVID-19 pandemic).

Methods

A community sample of 100 REMD adolescents enrolled in an ongoing longitudinal study of mental health was assessed before and during the COVID-19 pandemic. Participants were 51% girls, mean …

Not A Waste: Wastewater Surveillance To Enhance Public Health, Anna Gitter, Jeremiah Oghuan, Anuja Rajendra Godbole, Carlos A. Chavarria, Carlos Monserrat, Tao Hu, Yun Wang, Anthony W. Maresso, Blake M. Hanson, Kristina D. Mena, Fuqing Wu

Pharmacy Faculty Articles and Research

Domestic wastewater, when collected and evaluated appropriately, can provide valuable health-related information for a community. As a relatively unbiased and non-invasive approach, wastewater surveillance may complement current practices towards mitigating risks and protecting population health. Spurred by the COVID-19 pandemic, wastewater programs are now widely implemented to monitor viral infection trends in sewersheds and inform public health decision-making. This review summarizes recent developments in wastewater-based epidemiology for detecting and monitoring communicable infectious diseases, dissemination of antimicrobial resistance, and illicit drug consumption. Wastewater surveillance, a quickly advancing Frontier in environmental science, is becoming a new tool to enhance public health, improve …

The Effectiveness Of Pay-It-Forward In Addressing Hpv Vaccine Delay And Increasing Uptake Among 15–18-Year-Old Adolescent Girls Compared To User-Paid Vaccination: A Study Protocol For A Two-Arm Randomized Controlled Trial In China, Yifan Li, Chuanyu Qin, Shengyue Qiu, Yu He, Linchuan Pang, Xiaolan Xu, Vivian Wan-Cheong Yim, Shenglan Tang, Heng Du, Wenfeng Gong, Fan Yang, Joseph D. Tucker, Weiming Tang, Yun Wang, Leesa Lin, Mark Jit, Wei Song, Chunrong Li, Jennifer Smith, Jing Li, Dan Wu

Pharmacy Faculty Articles and Research

Background

Human papillomavirus (HPV) vaccination could prevent cervical and other HPV-associated cancers attributable to vaccine-associated HPV types. However, HPV vaccination coverage among women aged 9–18 years old is low in China. Common barriers include poor financial affordability, minimal public engagement, and low confidence in domestically produced HPV vaccines. Pay-it-forward offers an individual a free or subsidized service then an opportunity to voluntarily donate and/or create a postcard message to support future people. This study aims to assess the effectiveness of pay-it-forward as compared to standard-of-care self-paid vaccination to improve HPV vaccine uptake among adolescent girls aged 15–18 years, who are …

Crisisready's Novel Framework For Transdisciplinary Translation: Case-Studies In Wildfire And Hurricane Response, Andrew Schroeder, Caleb Dresser, Akash Yadav, Jennifer Chan, Shenyue Jia, Caroline Buckee, Satchit Balsari

Institute for ECHO Articles and Research

Extreme weather events including wildfires and hurricanes are becoming increasingly hazardous due to climate change, and often result in transient or permanent population displacements. Disaster-related disruptions in infrastructure, workforce, wages, and social networks can combine with population displacements to result in interruptions in health care access and prolonged impacts on morbidity and mortality. The data needed to make health systems and emergency management approaches more resilient to these hazards, and more responsive to the needs of affected populations, are sequestered in silos across private corporations and public agencies. In two case studies, we describe how our research team at CrisisReady …

The U.S. Travel Health Pharmacists’ Role In A Post-Covid-19 Pandemic Era, Keri Hurley-Kim, Karina Babish, Eva Chen, Alexis Diaz, Nathan Hahn, Derek Evans, Sheila M. Seed, Karl Hess

Pharmacy Faculty Articles and Research

Background: Many countries have enforced strict regulations on travel since the emergence of the SARS-CoV-2 (COVID-19) pandemic in December 2019. However, with the development of several vaccines and tests to help identify it, international travel has mostly resumed in the United States (US). Community pharmacists have long been highly accessible to the public and are capable of providing travel health services and are in an optimal position to provide COVID-19 patient care services to those who are now starting to travel again. Objectives: (1) To discuss how the COVID-19 pandemic has changed the practice of travel health and …

The Social Determinants Of Ideal Cardiovascular Health: A Global Systematic Review, Farah Qureshi, Kelb Bousquet-Santos, Sakurako S. Okuzono, Elaine Tsao, Scott Delaney, Anne-Josie Guimond, Julia K. Boehm, Laura D. Kubzansky

Psychology Faculty Articles and Research

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = …

Does Crime Trigger Genetic Risk For Type 2 Diabetes In Young Adults? A G X E Interaction Study Using National Data, Fangqi Guo, Kathleen Mullan Harris, Jason D. Boardman, Jennifer W. Robinette

Psychology Faculty Articles and Research

Background

Living in neighborhoods perceived as disordered exacerbates genetic risk for type 2 diabetes (T2D) among older adults. It is unknown whether this gene-neighborhood interaction extends to younger adults. The present study aims to investigate whether crime, an objectively measured indicator of neighborhood disorder, triggers genetic risk for T2D among younger adults, and whether this hypothesized triggering occurs through exposure to obesity.

Methods

Data were from the Wave I (2008) National Longitudinal Study of Adolescent to Adult Health. A standardized T2D polygenic score was created using 2014 GWAS meta-analysis results. Weighted mediation analyses using generalized structural equation models were conducted …

In The Eyes Of The Beholder: Race, Place And Health, Alfredo J. Velasquez, Jason A. Douglas, Fangqi Guo, Jennifer W. Robinette

Psychology Faculty Articles and Research

Racial and ethnic health disparities are fundamentally connected to neighborhood quality. For example, as a result of historical systemic inequities, racial and ethnic minorities are more likely to live in neighborhoods with signs of physical disorder (e.g., graffiti, vandalism), and physically disordered environments have been noted to associate with increased risk for chronic illness. Degree of exposure to neighborhood disorder may alter peoples' perception of their neighborhoods, however, with those most exposed (e.g., historically marginalized racial/ethnic groups) perhaps perceiving less threat from signs of neighborhood disorder. The purpose of the present study was to examine the complex interrelationships between people …

Sexual Behaviours And Sexual Health Among Middle-Aged And Older Adults In Britain, Junead Khan, Emily Greaves, Clare Tanton, Hannah Kuper, Thomas Shakespeare, Eneyi Kpokiri, Yun Wang, Jason J. Ong, Suzanne Day, Stephen W. Pan, Weiming Tan, Bingyi Wang, Xin Peng, Bowen Liang, Huachun Zou, Joseph D. Tucker, Dan Wu

Pharmacy Faculty Articles and Research

Objectives Population-representative studies of the sexual health of middle-aged and older adults are lacking in ageing societies. This study aimed to identify latent patterns of sexual behaviours and health of people aged 45–74 years.

Methods We conducted a latent class analysis of the National Attitudes and Sexual Lifestyles Survey (Natsal-3), a nationally representative survey conducted in Britain in 2011.

Results Of the 5260 respondents aged 45–74 years, 48.86% of men and 44.91% of women belonged to the Content Caseys class who reported good sexual health. The Infrequent Indigos (30.94% of men, 44.38% of women) were characterised by a lack of …

Men’S Stories: An Account Of Translating Vaccine Decision Narratives From Young Men In The U.S. Into A Targeted Public Health Intervention, Michelle Miller-Day, Erin S. Craw, Diana Harris, Michael L. Hecht

Communication Faculty Articles and Research

Effective interventions to promote human papillomavirus (HPV) vaccination are needed for all young adults across the globe. Yet, most public health efforts focus on HPV-related risks for females. Unfortunately, HPV-related cancers in men are also a concern, as is the potential for men to spread HPV to their partners. The HPV vaccine is highly effective in reducing risks related to these cancers. Yet, vaccination rates among young males are low and their vaccination concerns are not well understood. This project conducted 15 in-depth qualitative interviews with U.S. males aged 18–22 to hear their vaccine decision stories. Themes of HPV vaccination …

The Impact Of Hpv Vaccine Narratives On Social Media: Testing Narrative Engagement Theory With A Diverse Sample Of Young Adults, Amy E. Leader, Michelle Miller-Day, Rikishi T. Rey, Preethi Selvan, Anne E. Pezalla, Michael L. Hecht

Communication Faculty Articles and Research

Rates of human papillomavirus (HPV) infection are highest in young adults, who can be vaccinated against HPV if they were not vaccinated as adolescents. Since young adults increasingly access health information on social media, we tested the impact of a social media campaign with narrative-based health information on intentions related to HPV vaccination. We also aimed to understand which ads resonated most with young adults and led to higher survey completion rates. We created social media posts featuring videos promoting HPV vaccination. We launched a sponsored ad campaign on Facebook to reach young women, ages 18–26, across the country. Participants …

Total Prevention: A History Of Schistosomiasis In Japan, Alexander Bay

History Faculty Articles and Research

In Japan, schistosomiasis was endemic in Yamanashi Prefecture and a few other hotspot areas where the Miya’iri snail lived. The parasite’s lifecycle relied on the intermediary Miya’iri snail as well as the human host. Parasite eggs passed into the agrarian environment through untreated night soil used as fertiliser or through the culture of open defecation in rural Japan. Manmade rice fields and irrigation ditches, night soil covered paddies and highly refined growing seasons put people in flooded rice paddies to intensively work the land in the spring and summer. The disease was equally dependent on human intervention in the natural …

Time-To-Event Modeling For Hospital Length Of Stay Prediction For Covid-19 Patients, Yuxin Wen, Md. Fashiar Rahman, Yan Zhuang, Michael Pokojovy, Honglun Xu, Peter Mccaffrey, Alexander Vo, Eric Walser, Scott Moen, Tzu-Liang Bill Tseng

Engineering Faculty Articles and Research

Providing timely patient care while maintaining optimal resource utilization is one of the central operational challenges hospitals have been facing throughout the pandemic. Hospital length of stay (LOS) is an important indicator of hospital efficiency, quality of patient care, and operational resilience. Numerous researchers have developed regression or classification models to predict LOS. However, conventional models suffer from the lack of capability to make use of typically censored clinical data. We propose to use time-to-event modeling techniques, also known as survival analysis, to predict the LOS for patients based on individualized information collected from multiple sources. The performance of six …

Financial Hardship From Purchasing Prescription Drugs Among Older Adults In The United States Before, During, And After The Medicare Part D “Donut Hole”: Findings From 1998, 2001, 2015, And 2021, Anthony W. Olson, Jon C. Schommer, David A. Mott, Olajide Adekunle, Lawrence M. Brown

Pharmacy Faculty Articles and Research

BACKGROUND: Cost-related nonadherence compromises successful and effective management of chronic disease. The Medicare Modernization Act of 2003 (MMA) and Patient Protection and Affordable Care Act of 2010 (ACA) aimed to increase the affordability of outpatient prescription drugs for older adults (older than age 64 years). The Medicare Part D prescription drug insurance coverage gap (“donut hole”) created by the MMA was fully closed in 2020 by the ACA.

OBJECTIVES: To (1) describe prescription drug coverage and financial hardship from purchasing prescription drugs among older American adults for 2021, (2) compare these results with findings from data collected before the MMA …

Change Of Air Quality Knowledge, Perceptions, Attitudes, And Practices During And Post-Wildfires In The United States, Alessandro Del Ponte, Lina Ang, Lianjun Li, Noah Lim, Wilson Tam Wai San, Wei Jie Seow

Political Science Faculty Articles and Research

Amid worsening climate change, the recurrent wildfires have substantially worsened air quality in the Western United States (U.S.). Understanding the knowledge, attitudes, perception, and practices (KAPP) over time in response to natural disasters such as wildfires is crucial for public health interventions and disaster preparedness. This is the first study to investigate the change in air quality KAPP over time in response to natural disasters. Previous studies have only assessed KAPP at a fixed time point. Using a two-wave panel survey (during and post-wildfires), we assessed the association between KAPP and respiratory health indicators as well as the changes over …

Citizenship Matters: Non-Citizen Covid-19 Mortality Disparities In New York And Los Angeles, Jason A. Douglas, Georgiana Bostean, Angel Miles Nash, Emmanuel B. John, Lawrence M. Brown, Andrew M. Subica

Health Sciences and Kinesiology Faculty Articles

U.S. non-citizen residents are burdened by inequitable access to socioeconomic resources, potentially placing them at heightened risk of COVID-19-related disparities. However, COVID-19 impacts on non-citizens are not well understood. Accordingly, the current study investigated COVID-19 mortality disparities within New York (NYC) and Los Angeles (LAC) to test our hypothesis that areas with large proportions of non-citizens will have disproportionately high COVID-19 mortality rates. We examined ecological associations between March 2020–January 2021 COVID-19 mortality rates (per 100,000 residents) and percent non-citizens (using ZIP Code Tabulation Areas (ZCTA) for NYC and City/Community units of analysis for LAC) while controlling for sociodemographic factors. …

Obesogenic Environments And Cardiovascular Disease: A Path Analysis Using Us Nationally Representative Data, Fangqi Guo, Georgiana Bostean, Vincent Berardi, Alfredo J. Velasquez, Jennifer W. Robinette

Psychology Faculty Articles and Research

Introduction

People living in obesogenic environments, with limited access to healthful food outlets and exercise facilities, generally have poor health. Previous research suggests that behavioral risk factors and indicators of physiological functioning may mediate this link; however, no studies to date have had the requisite data to investigate multi-level behavioral and physiological risk factors simultaneously. The present study conducted serial and parallel mediation analyses to examine behavioral and physiological pathways explaining the association between environmental obesogenicity and cardiovascular disease (CVD).

Methods

This cross-sectional observational study used data from the 2012–2016 Health and Retirement Study, a representative survey of US older …

Structural And Computational Studies Of The Sars-Cov-2 Spike Protein Binding Mechanisms With Nanobodies: From Structure And Dynamics To Avidity-Driven Nanobody Engineering, Gennady M. Verkhivker

Mathematics, Physics, and Computer Science Faculty Articles and Research

Nanobodies provide important advantages over traditional antibodies, including their smaller size and robust biochemical properties such as high thermal stability, high solubility, and the ability to be bioengineered into novel multivalent, multi-specific, and high-affinity molecules, making them a class of emerging powerful therapies against SARS-CoV-2. Recent research efforts on the design, protein engineering, and structure-functional characterization of nanobodies and their binding with SARS-CoV-2 S proteins reflected a growing realization that nanobody combinations can exploit distinct binding epitopes and leverage the intrinsic plasticity of the conformational landscape for the SARS-CoV-2 S protein to produce efficient neutralizing and mutation resistant characteristics. Structural …

Development Of A Men’S Health Course For First-Year Undergraduates Using Culturally Responsive Teaching Strategies, Ania A. Majewska, Johnasha D. Stuart, Kelsey M. Gray, Pearl V. Ryder, Ethell Vereen

Biology, Chemistry, and Environmental Sciences Faculty Articles and Research

Purpose

A novel first-year experience course was developed using culturally responsive teaching strategies at an undergraduate liberal arts college in the southeastern USA to promote health advocacy and to provide students with an overview of male health. The course focuses on the biological, sociocultural, economic and gender influences that shape men's health beliefs and practices. It also emphasizes health disparities in the USA among Black/African American men compared to other racial groups and intervention strategies to improve health outcomes.

Design/methodology/approach

The lecture and laboratory components of the course were designed as a blended learning environment with a modified flipped class …

The Use Of Advanced Spectral Imaging To Reveal Nanoparticle Identity In Biological Samples, Qamar A. Alshammari, Rajasekharreddy Pala, Ayan K. Barui, Saud O. Alshammari, Andromeda M. Nauli, Nir Katzir, Ashraf M. Mohieldin, Surya M. Nauli

Pharmacy Faculty Articles and Research

Nanoparticles (NPs) have been used in drug delivery therapies, medical diagnostic strategies, and as current Covid-19 vaccine carriers. Many microscope-based imaging systems have been introduced to facilitate detection and visualization of NPs. Unfortunately, none can differentiate the core and the shell of NPs. Spectral imaging has been used to distinguish a drug molecule and its metabolite. We have recently integrated this technology to a resolution of 9 nm by using artificial intelligence-driven analyses. Such a resolution allowed us to collect many robust datapoints for each pixel of an image. Our analyses could recognize 45 spectral points within a pixel to …

Spatial Distribution Of Pm2.5-Related Premature Mortality In China, Sheng Zheng, Uwe Schlink, Kin-Fai Ho, Ramesh P. Singh, Andrea Pozzer

Biology, Chemistry, and Environmental Sciences Faculty Articles and Research

PM_2.5 is a major component of air pollution in China and has a serious threat to public health. It is very important to quantify spatial characteristics of the health effects caused by outdoor PM_2.5 exposure. This study analyzed the spatial distribution of PM_2.5 concentration (45.9 μg/m³ national average in 2016) and premature mortality attributed to PM_2.5 in cities at the prefectural level and above in China in 2016. Using the Global Exposure Mortality Model (GEMM), the total premature mortality in China was estimated to be 1.55 million persons, and the per capita mortality was 11.2 …