Translational Medical Research Commons^™

Characteristics And Outcomes Of Patients Directly Discharged To Home From The Intensive Care Unit, Ann Zheng, Preeyal M. Patel, Michele Fiorella, Lauren Mcdonnell, Mina Yasuoka, Erika J. Yoo, Md

Phase 1

Introduction: Given the current era of decreasing hospital bed availability, there has been a rise in the practice of direct discharge to home (DDH) from ICUs. We evaluated the demographics, clinical characteristics, outcomes and readmission patterns among DDH patients.

Methods: Retrospective review of patients from 2 MICUs from June 2017 to June 2019 at Thomas Jefferson University hospital, an urban tertiary care center. Primary outcome of interest was 30-day hospital readmission. Patients were dichotomized into two groups based on time between ward transfer order and hospital discharge (<24 or ≥24 hours). Risk adjustment performed with Mortality Probability Model (MPM0 -III). ICU workload at admission and discharge was estimated with nine equivalents of nursing manpower use score (NEMS). Patient characteristics compared using t-test and Fisher exact or χ² test.

Results: 331 DDH patients were analyzed, with the majority …

Continuous-Flow Left Ventricular Assist Device Outflow Graft Stenting: Indications And Outcomes, Chelsey T. Wood, Mfa, Elizabeth J. Maynes, Md, Thomas J. O'Malley, Md, Rohinton J. Morris, Md, Louis E. Samuels, Md, H. Todd Massey, Md, Vakhtang Tchantchaleishvili

Phase 1

Introduction: Stenosis in the continuous-flow left ventricular assist device (CF-LVAD) outflow graft can be caused by various mechanical and anatomical factors. Increasingly, percutaneous management has been utilized to re-establish adequate CF-LVAD flow. We sought to evaluate indications for such interventions and their outcomes.

Methods: An electronic search was performed to identify all studies in the English literature reporting CF-LVAD outflow graft stenting for various etiologies. Twenty-one studies consisting of 26 patients were included in the analysis.

Results: Median patient age was 59 years [45.8-67.0] and 65.4% (17/26) were male. 58.3% (14/24) of patients had HeartWare HVAD, 37.5% (9/24) had HeartMate …

Development Of A Hert Trained Interprofessional Student Decontamination Team For Hospital Mass Casualty Response, Ashley Wong, Claire Zurlo, Edward Jasper

Phase 1

Introduction: FEMA’s Hospital Emergency Response Training (HERT) prepares healthcare workers to decontaminate patients during a mass casualty incident. This depletes the emergency department (ED) staff when they are needed most though. Developing an interprofessional student composed HERT team to screen and decontaminate affected populations will allow ED staff to handle more medically complex situations during a mass casualty event.

Methods: Likert scale surveys were conducted among ED physicians and nurses at Jefferson Hospital and HERT trained medical and nursing students at Jefferson University. These were to evaluate the training program and ED staff opinions of utilizing a student HERT …

Conversion Total Knee Arthroplasty Needs Its Own Diagnosis Related Group Facility Reimbursement Code, Jonah Stein, Michael Yayac, Md, Gregory K. Deirmengian, Md, Javad Parvizi, Md, P. Maxwell Courtney, Md

Phase 1

Introduction: Conversion from a prior surgery to a total knee arthroplasty (TKA) is a more technically difficult procedure than primary TKA and is associated with worse short-term outcomes and increased complication and readmission rates, despite being undifferentiated under the current bundled payment model. The aim of this study was to determine differences in facility costs between primary TKA and conversion TKA, which we hypothesize are significant, to ensure providers are not penalized for treatment and high-risk patients have the same access to care.

Methods: We retrospectively reviewed a consecutive series of patients undergoing primary TKA at two hospitals within …

Cardiac Risk Factors Predicting 30/90-Day Readmission Rates In Lumbar Decompression Surgeries, Kevin Xiao, Blake Nourie, Joseph Bechay, Dhruv K.C. Goyal

Phase 1

Preoperative cardiopulmonary disease is known to be a risk factor for perioperative complications in deformity surgery and lumbar fusion procedures, however there is a lack of literature evaluating cardiac risk factors and their influence on readmission rates following lumbar decompression surgery. We want to determine whether preoperative cardiac risk factors influenced the 30 and 90-day readmission rates in patients undergoing lumbar decompression surgery. Patient charts from Rothman Institute between were reviewed for history of preoperative cardiac risk factors such as coronary artery disease, congestive heart failure, myocardial infarction, stroke, cardiac catheterization, stent placement, coronary artery bypass graft, aspirin and/or clopidogrel …

Phenotype-Genotype Correlations In Patients With Epidermolysis Bullosa With Plec Mutations, Elizabeth Zhang, Masoomeh Faghankani, Hassan Vahidnezhad, Jouni Uitto

Phase 1

Epidermolysis bullosa (EB) is a heterogeneous group of genetic disorders characterized by blistering skin and mucous membranes. Mutations of the protein plectin, encoded by PLEC, cause autosomal recessive EB simplex with muscular dystrophy (EBS-MD) and EB simplex with pyloric atresia (EBS-PA). Until now, no clear genotype-phenotype correlation has been identified from the positions of mutations in the PLEC gene. How do ten distinct families with PLEC mutations manifesting as various EB disorders compare with regard to gene mutations? The hypothesis is that clinical manifestations of EB will be more extreme in patients with more severe gene mutations.

The design of …

Surgical Resection Of Convexity Meningiomas: A Single Center Retrospective Analysis, Haley Wendt, Michael Baldassari, Donald Ye, Kevin Judy

Phase 1

Introduction: Dural convexity meningiomas (CMs) are the most common primary intracranial tumors. Although surgical resection carries relatively low risk, it is necessary to quantify perioperative risks from a large patient cohort and identify factors contributing to short-term and long-term outcomes.

Methods: Patients who underwent craniotomy for resection of CMs between January 2012-December 2018 at a single large academic center were reviewed for pre-operative demographics, radiographic characteristics, and post-operative outcomes.

Results: 122 cases of CMs were identified. Common presenting symptoms included headache (39.3%), seizure (27.0%) and weakness/paralysis (18%). CMs were located over frontal, parietal, temporal, and occipital lobes in 57.4%, …

Prevalence Of Asymptomatic Gonorrhea And Chlamydia Infections Among Ryan White Hiv Population Visiting A Center City Hiv Clinic, Sarah Stuccio, Rakhshanda Akram, Lisa A. Spacek

Phase 1

Introduction: Sexually transmitted infections (STIs) are a major public health problem. Two factors make their diagnosis challenging: frequent asymptomatic presentation and lack of screening, especially at extragenital sites. Additionally, STIs including gonorrhea (GC) and chlamydia (CT) have been shown to increase the risk of sexual HIV transmission. Information about the prevalence, as well as predictors of test positivity, of GC and CT infections can stress the importance of universal screening.

Methods: We carried out a retrospective analysis of the STI screening of patients who attended the Ryan White HIV clinic at Jefferson between 2016 and 2018. The primary …

Zero Tolerance – Mitigating The Opioid Epidemic Amongst Minimally Invasive Urologic Patients, Daniella Wong, Thenappan Chandrasekar, Md, Costas Lallas, Md

Phase 1

Introduction: Opioids are routinely prescribed following minimally invasive surgery (MIS), yet the majority of medication remains unused. However, the literature is lacking evidence for non-narcotic analgesia in MIS urologic procedures. The purpose of this study is to evaluate the efficacy of a non-narcotic postoperative pain management regimen in reducing opioid use following MIS urologic procedures.

Methods: In this prospective study, 51 MIS urologic patients were recruited over two months. Patients in the first month cohort (P1) were managed with the established pain management standard-of-care, while patients in the second month (P2) followed a non-narcotic postoperative pain management protocol that …

Development Of Vaccine Preferences In Parents Of Newborns, Ramon Ruiz, Neera Goyal

Phase 1

Introduction: The resurgence in cases of vaccine-preventable childhood diseases in the U.S. may be associated with increasing rates of vaccine hesitancy. Although previous research has sought to identify attributes of non-vaccinating parents, the timing in which parents make such vaccination decisions has yet to be explored. Our goal is to identify when first-time parents develop their vaccination preferences: before, after, or during pregnancy.

Methods: A cross sectional survey was conducted using a convenience sample of 73 first time parents at Thomas Jefferson University Hospital. Survey questions addressed timing of vaccination decisions and projected compliance with vaccine schedules. Eligibility for …

Survivorship, Complications, And Outcomes Following Distal Femoral Replacement Using Megaprosthesis, Keenan Sobol, John Strony, Timothy Tan, Md, Scot Brown, Md

Phase 1

Introduction: Distal femoral bone loss is often managed with a combination of modular prostheses, structural and non-structural allografts, and metal augmentation. However, when bone loss of the distal femur is severe, the viability of these methods can be limited.In the setting of severe bone loss, endoprosthetic reconstruction (EPR) with a megaprosthesis has become increasingly popular for both malignant and non-neoplastic indications. The primary aim of this study was to determine the short-term prosthesis survivorship, as well as complications, for patients who presented with non-neoplastic disease indications for megaprosthesis distal femoral replacement (DFR) at a single institution. The secondary aim was …

Selective Serotonin Reuptake Inhibitors Are Associated With Increased Bleeding Related Complications Following Primary Total Hip And Total Knee Arthroplasty, Kyle Plusch, John Stammers, Mbbs, Frcs, Alexus M. Cooper, Chi Xu, Md, Paul Kitei, Md, Javad Parvizi, Md, Frcs, Jess H. Lonner, Md

Phase 1

Introduction: Approximately 10-22% of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are diagnosed with depression. Pre-operative depression is associated with poorer patient reported outcomes, costs and increased complications. Selective serotonin-reuptake inhibitors (SSRIs) are first-line treatment for depression due to their efficacy and low side effect profile. There are conflicting studies regarding SSRI-related bleeding complications. This study compares the rate of bleeding-related complications in THA and TKA patients taking SSRI’s to a control group of non-SSRI users.

Methods: A retrospective single institution study of 16,407 primary THA and TKA’s from 2008 to 2018 was performed. Patients with …

Gut Microbiome Analysis In Morphine Exposure And Naltrexone-Induced Withdrawal, Nick Rapp, Sean O'Sullivan, James Schwaber

Phase 1

Introduction and Objectives: Relatively little is understood about the underlying physiological changes that occur in the withdrawal state of opiate users. Research on the effects of alcohol withdrawal on the Gut-brain axis (GBA) has revealed shifts in relative numbers of specific bacterial species that correlate with increased central nervous system (CNS) inflammation via neurological crosstalk. The purpose of this research was to determine if similar shifts in the relative abundance of bacterial populations occur in the opiate withdrawal state.

Methods: Fourteen rats were randomized into four groups. Control and experimental rats were administered 75 mg morphine pellets or placebo (sugar) …

Static V. Expandable Tlif Cage Outcomes, Harrison Pajovich, Ryan Nachwalter, Lohit Velagapudi, Joseph Zarowin, Alexander R. Vaccaro, Md, Phd

Phase 1

Static cages were introduced in the 1990s as a solution to degenerative spondylolisthesis, recurrent disc herniation and spinal stenosis. As this procedure was popularized, a new class of expandable Transforaminal Lumbar Interbody Fusion devices was introduced to further improve outcomes that will be studied in this project. It will be explored how expandable cages compare to static cages in TLIF procedures in patient-reported outcomes, complications and restoration of appropriate lumbar lordosis. We conducted a retrospective cohort review comparing those who received expandable and static cages. Eligible patients received TLIF procedure at the Rothman Institute, were ≥18 years of age and …

Detecting Different States Of Ventilation With A Wearable Device Through Minute Ventilation, Yash Patel, Michael Morano, Marc J. Torjman, Phd, Indupriya Eedara, Ms, Moeness Amin, Phd, Channy Loeum, Jeffrey I. Joseph, Do

Phase 1

Introduction: Detecting changes in respiration are essential to monitoring a patient’s vital signs. Few devices accomplish this in a non-invasive manner. We are developing a wearable Trachea Sound Sensor that measures respiratory rate (RR), tidal volume (TV), minute ventilation (MV = RR x TV). A prototypical Trachea Sound Sensor (TSS) was created and compared to a reference pneumotachometer. Both were used to record the sounds of breathing with research team members.

Methods:The TSS recording device was tested on six research team members and breath sounds were recorded. Simultaneously, the member’s RR and MV was recorded using a calibrated …

The Effect Of Perceived Physician Opinion On Breastfeeding In Women With Opioid Use Disorder Who Are Receiving Medication-Assisted Treatment, Lacey Murray, Meghan Gannon, Phd, Vanessa Short, Phd, Mph

Phase 1

Women who receive medication-assisted treatment (MAT) for opioid use disorder (OUD) are less likely to breastfeed than the general population despite the many possible benefits to the newborn. The ongoing study examines the effect of perceived physician opinion on the outcome of breastfeeding in women receiving MAT for OUD. Women who were receiving MAT for OUD at Thomas Jefferson University’s Family Center were given a survey during their third trimester (n=45), and at 1 month postpartum (n=33) to gather information on the perceived opinion of their physicians on how they should feed their baby and the importance of those opinions. …

Cardiac Risk Factors Predicting 30/90 Day Readmission Rates In Lumbar Decompression Surgeries, Blake Nourie, Kevin Xiao, Joseph Bechay, Dhruv K.C. Goyal

Phase 1

Preoperative cardiopulmonary disease is known to be a risk factor for perioperative complications in deformity surgery and lumbar fusion procedures, however there is a lack of literature evaluating cardiac risk factors and their influence on readmission rates following lumbar decompression surgery. We want to determine whether preoperative cardiac risk factors influenced the 30 and 90-day readmission rates in patients undergoing lumbar decompression surgery. Patient charts from Rothman Institute between were reviewed for history of preoperative cardiac risk factors such as coronary artery disease, congestive heart failure, myocardial infarction, stroke, cardiac catheterization, stent placement, coronary artery bypass graft, aspirin and/or clopidogrel …

Assessment Of The Composition And Biologic Activity Of Platelet Rich Plasma And Its Relationship To Clinical Outcomes In Patients With Knee Osteoarthritis, Daniel Nemirov, Bijan Dehghani, Habib Zahir, Xiaoning Yuan, Christine Kim, Reyna Bhandhari, Patrick Fava, Yurii Chinenov, Joseph Nguyen, Laura Donlin, Brian Halpern, Scott Rodeo, Miguel Otero

Phase 1

Recent studies suggest positive clinical outcomes associated with platelet-rich-plasma (PRP) administration to treat knee osteoarthritis (OA). However, the results remain inconclusive in part because of the high variability in PRP preparations and the limited information regarding the relevant biologically active components of PRP. We hypothesize that the variability in clinical response is driven by the heterogeneous composition of PRP. In this study we evaluated the composition and biological activity of PRP and further correlated our findings to clinical outcomes in patients receiving intra-articular injections for knee OA. After IRB approval and patient consent, we enrolled 51 patients (mean age: 57.9 …

Patient And Renal Outcomes Of Posttransplant Lymphoproliferative Disorder Following Solid Organ Transplantations - A Single Center Experience, Kashka Mallari, Goni Katz-Greenberg, Maria Martinez Cantarin

Phase 1

Introduction: Post-transplant Proliferative Disorder (PTLD) is a significant complication after solid organ transplantation (SOT). Major risk factors that contribute to the development of PTLD include Epstein-Barr Virus (EBV) infection and degree of immunosuppression. Despite novel therapies, the 5-year survival rate of PTLD only improved from 40% to 50% over the years. The reported 5-year survival rate of PTLD also remains significantly lower compared to around 90% in other malignancies such as breast and colon cancer. In our center, we hypothesize better transplant outcomes compared to those reported in preceding literatures.

Methods: We retrospectively reviewed the electronic medical records of …

In Vivo T Cell Genetic Engineering With Melanoma-Specific Tcr And Car, Toby Mathew, Vitali Alexeev

Phase 1

Introduction: Adoptive cell transfer (ACT) using T cells genetically engineered to express tumor-specific T cell receptors (TCR) and Chimeric Antigen receptors (CAR) have demonstrated high remission rates in patients with advanced cancers. Targeting of metastatic melanoma with TCR-modified recombinant T cells showed clinically significant response in the majority of patients. However, due to certain drawbacks, this powerful strategy is not yet available for broad clinical application. We propose that in vivo genetic engineering approach may allow overcoming several drawbacks associated ACT and could convert it into generic and cost-effective modality to bring recombinant T cell therapies to general patient …

Outcomes And Indications For Thoracofemoral Bypass In The Endovascular Age: A Case Series And Literature Review, Andrea Mcsweeney, Babak Abai, Md

Phase 1

Introduction: Endovascular revascularization is commonplace in vascular surgery; however, thoracofemoral bypass (TFB) is optimal in particular patients. Little research focuses on TFB outcomes. This case series and literature review investigated indications, efficacy, and safety of TFB.

Methods: Cases at Thomas Jefferson University Hospital (TJUH) included one male and four females (average age 57.2) from 2015-2019. Literature review yielded 124 cases from other institutions. PubMed and Scopus search using the term “thoraco femoral bypass” yielded 39 articles. Articles published before 2000 and case studies published in any year were excluded. Seven articles were selected. Primary outcomes included 30-day mortality and …

The Presence Of Gc-C In Extracellular Vesicles Secreted By Colorectal Cancer Cells, Alexandre Martinez, Adam E. Snook

Phase 1

Background: Guanylyl Cyclase C (GC-C) is a membrane-bound protein found on intestinal epithelial cells involved in the activation of CFTR. This protein has previously been involved in the development of colorectal cancer.

Extracellular vesicles (EVs) are bilayered vesicles of varying size (30 to 1,000 + nm in diameter) that believed to be secreted by all cells in the human body. In the past decade, EVs have garnered attention due to their impact in the field of oncology, where they have been shown to potentially serve as biomarkers for various cancers.

In this study, we looked at the EVs secreted …

Ahmed Vs Baerveldt Glaucoma Drainage Device In Uveitic Glaucoma, Zoe Mcwatters, Sapna Sinha, Md, Allen Ganjei, Marlene Moster, Md, Michael Pro, Md, Elizabeth Dale, Md, Daniel Lee, Md, Jonathan S. Myers, Md, L. J. Katz, Md, Scott Fudemberg, Md, Anand Mantravadi, Md, Natasha Kolomeyer, Md, Reza Razeghniejad, Md

Phase 1

Introduction: Uveitis is an inflammatory eye disorder which may elevate intraocular pressure (IOP), causing sight-threatening glaucoma. Treatment of refractory uveitic glaucoma involves implantation of a glaucoma drainage device (GDD). Uveitic glaucoma has been a minority diagnosis in prior studies comparing the valved Ahmed GDD and non-valved Baerveldt GDD. Here we compare the safety and efficacy of the Ahmed and Baerveldt GDD in uveitic glaucoma.

Methods: This retrospective comparative study was conducted on patients with uveitic glaucoma (≥14 years old) who underwent Ahmed or Baerveldt GDD implantation between 2006–2018 with a minimum follow-up of 3 months. Success was defined as …

Down Regulation With Luteal Gnrh Agonist Therapy In Euploid Embryo Transfers Does Not Impact Pregnancy Rates, Isabelle Levin, Keri Bergin, Md, Dmitry Gounko, Joseph Lee, Alan Copperman, Md

Phase 1

Introduction : Gonadotropin-releasing hormone (GnRH) agonists have been used during assisted reproductive technology (ART) treatment for pituitary suppression and stimulation. Currently, clinical opinion is divided about whether GnRH agonist therapy improves pregnancy rates when used for luteal down-regulation in a frozen euploid embryo transfer (FET). This study evaluated the clinical utility of GnRH agonist down-regulation in single, euploid FET cycles.

Methods : A retrospective analysis was performed, using data from patients who underwent a single, euploid FET cycle from 2012 to 2019. Patients were segregated into two cohorts: Group A: single, euploid FET with down-regulation using GnRH agonist; Group B: …

Statistics Of Tumor Micro-Environment, Brenton Maisel, Inna Chervoneva

Phase 1

Introduction: Immune cells play a prominent role in keeping tumors suppressed, but how the distribution of these immune cells within a tumor’s microenvironment remains poorly understood. The long-term goal of this project is to study how statistical spatial distributions of different immune cells is associated with clinical outcome. The first objective is developing an algorithm for identifying different types of immune cells.

Methods: The data motivating this project includes spatial localization information (x-y coordinates) and expression levels of immune cell CD markers quantified by immunofluorescence immunohistochemistry (IF-IHC) in ~1,500 cases of invasive breast cancer. Using expression levels of CD markers …

Effects Of Rocking On Attention And Arousal, Jonathan Lubeck, Roseann C. Schaaf, Phd, Otr/L, Faota, Rachel L. Dumont, Ms, Ots

Phase 1

Introduction: Difficulties regulating attention and arousal underlie common developmental conditions and impact performance in academic and work tasks. Sensory-based activities such as sitting in a rocker chair may help regulate attention and arousal by providing sensory stimulation. This pilot study assessed autonomic nervous system activity (ANS) while seated in a specially designed rocking chair providing vestibular sensation during a performance task.

Methods: Thirty-four adults (aged 20-35 years) were randomized to either a rocker chair (Virco Zuma, n = 17) or static chair (n =17) while performing cognitive tasks in a counterbalanced design. ANS measures of skin conductance level (SCL) …

Marked Circadian Variation In Number And Type Of Hyperacute Strokes During The 24 Hour Day-Night Cycle, Eeman Khorramian, Sidney Starkman, Nerses Sanossian, David Liebeskind, Gilda Avila, Samuel Stratton, Marc Eckstein, Frank Pratt, Latisha Sharma, Lucas Restrepo, Miguel Valdes-Sueiras, May Kim-Tenser, Pablo Villablanca, Robin Conwit, Scott Hamilton, Jeffrey L. Saver, Fast-Mag Trial Investigators And Coordinators

Phase 1

Introduction: Circadian variations in stroke onset provide critical information for the allocation of pre-hospital and hospital resources in clinical care. Confining analysis to patients with defined onset in waking and clearly distinguished ischemic and hemorrhagic stroke subtypes, would substantial benefit our understanding of stroke etiology.

Methods: We analyzed patients enrolled in the NIH FAST-MAG phase 3 trial of field-initiated neuroprotective agents in patients with hyperacute stroke within 2h of onset. Onset times were analyzed in 1h time blocks throughout the 24h day-night cycle. Patient demographic and clinical features, medical history, imaging characteristics, and stroke deficit severity were correlated with …

Spectrum Of Renal Biopsy Findings In Trident Cohort, Casey Jackson, Shira Blady, Shatakshee Chatarjee, Phd, Matthew Palmer, Md, Phd, Katalin Susztak, Md, Phd

Phase 1

Introduction: Diabetic kidney disease is the most common cause of chronic end stage renal failure in the USA. Kidney biopsy is the gold standard diagnostic criteria; however, it is an invasive procedure; not everyone undergoes diagnostic biopsy. The relationship between histological and clinical parameters and prognosis in DKD is incompletely understood. TRIDENT, (Transformative research in diabetic nephropathy) plans to enroll 400 diabetic subjects undergoing clinically indicated renal biopsies and performs multi-omics characterization of subjects to identify pathways associated with kidney function decline. Genetic studies indicated that podocytes influence albuminuria and diabetic kidney disease development. We seek to understand whether …

Evaluating The Migration Rates In Percutaneous Spinal Cord Stimulation Trials, William Hirsch, Nikolaos Mouchtouris, Md, Ashwini Sharan Md

Phase 1

Introduction: Spinal cord stimulation (SCS) provides symptom reduction in patients with chronic low back pain. The most common complication in SCS is percutaneous lead migration from initial placement site. It is our goal to determine whether using skin anchors during trial implantation reduces SCS trial lead migration rates compared to historical controls.

Methods: 197 patients who underwent SCS trial placement at Thomas Jefferson University Hospital between 2015 and 2018 were considered for this study. Complete data including device impedance measurements and pre and post trial x-rays was collected on 12 historical control patients and 19 patients with leads secured using …

The Use Of Cementless Components Does Not Significantly Increase Procedural Costs In Total Knee Arthroplasty, Samantha Harrer, Michael Yayac, Md, William J. Hozack, Md, Javad Parvizi, Md, Frcs, P. Maxwell Courtney, Md

Phase 1

Introduction: Modern cementless total knee arthroplasty (TKA) designs have shown promising early clinical success; however, concerns exist regarding the higher cost of the cementless implants. The purpose of this study is to evaluate the total facility cost of cementless vs traditional cemented TKA along with the effect of cementless fixation on short-term outcomes.

Methods: We reviewed a consecutive series of patients between 2015 and 2017 who underwent either cementless or cemented primary TKA. Itemized facility costs were calculated for every procedure using a time-driven activity-based costing algorithm. Controlling for demographic variables and medical comorbidities, we performed a multivariate analysis …