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Background The development of cytomegalovirus (CMV) infection after kidney transplant remains a significant cause of posttransplant morbidity, graft loss, and mortality. Despite appropriate antiviral therapy, recipients without previous CMV exposure can currently be allocated a kidney from a donor with previous CMV infection (D+R-) which carries the greatest risk of posttransplant CMV infection and associated complications. Preferential placement of CMV D- organs in negative recipients (R-) has been shown to reduce the risk of viral infection and associated complications. Methods To assess the long-term survival and economic benefits of allocation policy reforms, a decision analytic model was constructed to compare receipt of CMV D- with CMV D+ organ in CMV R- recipients using data from transplant registry, Medicare claims, and pharmaceutical costs. Results For CMV R- patients, receipt of a CMV D- organ was associated with greater average survival (14.3 vs 12.6 years), superior quality-adjusted life years (12.6 vs 9.8), and lower costs ($529 512 vs $542 963). One-way sensitivity analysis demonstrated a survival advantage for patients waiting as long as 30 months for a CMV D- kidney. Conclusions Altering national allocation policy to preferentially offer CMV D- organs to CMV R- recipients could improve survival and lower costs after transplant if appropriately implemented.

Both congestive heart failure (HF) and atrial fibrillation (AF) are important and increasingly common forms of cardiovascular disease in the 21st century. Heart failure is often complicated by AF, and AF can exacerbate and, in some cases, cause HF, also known as tachycardia-induced cardiomyopathy (TIC). Restoration and maintenance of sinus rhythm in the majority of AF patients with TIC can lead to an improvement in left ventricular function and dramatic symptomatic relief. This can be accomplished by surgical ablation; specifically, the Cox-Maze IV procedure (CMP IV), in those refractory to medical and catheter-based ablation, and those patients undergoing concomitant cardiac operation. However, many surgeons are reluctant to perform stand-alone or concomitant CMP IV in this high-risk cohort of patients. In this review, the over three decades of experience with surgical ablation will be reviewed along with the essential information that surgeons need to be aware of as they participate in the team-based care of patients with AF and HF.

For low temperature agricultural crop and meat drying, dryers utilizing the renewable energy source (solar energy) appear to be an efficient technique as it is ecofriendly, energy efficient, and available in free of cost. This work presents the experimental investigation on a solar food dryer equipped with external reflectors to enhance the rate of drying efficiency by removing the moisture content available in the anchovy fish. A comparison of conventional open solar drying is carried out to assess the parameters such as drying efficiency, moisture removal rate, and heat energy required for drying the anchovy fish using the modified solar dryer using the natural convection technique. From the experimental results it is observed that the relative humidity greatly influence the rate of drying. The average relative humidity during the experiments using open solar drying is found as 50–65% whereas, the using solar dryer the average relative humidity inside the chamber is found as 20–35%. The relative humidity of the fish using open solar drying is higher as compared to solar dryer drying as the drying products are kept in open atmosphere. The physical examination results on the dried products proved that using a modified solar dryers, the dried product is free from insects, and dust. Also, it is found that the loss of color from the product is a minimum while compared to conventional open solar drying. The results showed that the thermal efficiency of top tray (dryer 1) and bottom tray (dryer 2) is comparatively higher as compared to that of conventional open solar drying and found as 16.73 and 19.34 %, respectively. Results also showed that nearly 20.05% of the energy could be saved using the modified solar dryer as compared to the open solar drying technique.

Endovascular stenting of the ascending aorta has been described for various aortic pathologies, including type A dissection in patients who are prohibitive risk for open surgery. Endovascular treatment of ascending aortic pathology poses unique anatomic and technical challenges related to aortic morphology. Herein, we present a novel technique of endovascular ascending stent graft delivery from a transfemoral approach for treatment of an acute type A dissection, utilizing a snare-guided deployment technique to facilitate favorable device deployment.

General life stress and HIV-related stress have been independently associated with negative mental health outcomes for people living with HIV (PLWH), including anxiety and depression. HIV-positive sexual minority men (SMM) may experience both forms of stress, resulting in concurrent effects that independently exacerbate functional impairment related to anxiety and depression. This study examined general life stress, HIV-related stress, and functional impairment due to depression and anxiety in a sample of 87 HIV-positive SMM. Data were collected in late 2015 and early 2016. The Perceived Stress Scale (PSS), HIV/AIDS Stress Scale (HASS), Overall Anxiety Severity and Impairment Scale, and Overall Depression Severity and Impairment Scale were used. Each variable was positively correlated with each other in bivariate analyses, but in multivariable models, PSS (β = .53, p

Background: Arrhythmogenic cardiomyopathy (ACM) manifests with sudden death, arrhythmias, heart failure, apoptosis, and myocardial fibro-adipogenesis. The phenotype typically starts at the epicardium and advances transmurally. Mutations in genes encoding desmosome proteins, including DSP (desmoplakin), are major causes of ACM. Methods: To delineate contributions of the epicardium to the pathogenesis of ACM, the Dsp allele was conditionally deleted in the epicardial cells in mice upon expression of tamoxifen-inducible Cre from the Wt1 locus. Wild type (WT) and Wt1-Cre ERT2 :Dsp W/F were crossed to Rosa26 mT/mG (R26 mT/mG ) dual reporter mice to tag the epicardial-derived cells with the EGFP (enhanced green fluorescent protein) reporter protein. Tagged epicardial-derived cells from adult Wt1-Cre ERT2 :R26 mT/mG and Wt1-Cre ERT2 : R26 mT/mG :Dsp W/F mouse hearts were isolated by fluorescence-activated cell staining and sequenced by single-cell RNA sequencing. Results: WT1 (Wilms tumor 1) expression was progressively restricted postnatally and was exclusive to the epicardium by postnatal day 21. Expression of Dsp was reduced in the epicardial cells but not in cardiac myocytes in the Wt1-Cre ERT2 :Dsp W/F mice. The Wt1-Cre ERT2 :Dsp W/F mice exhibited premature death, cardiac dysfunction, arrhythmias, myocardial fibro-adipogenesis, and apoptosis. Single-cell RNA sequencing of ≈18 000 EGFP-tagged epicardial-derived cells identified genotype-independent clusters of endothelial cells, fibroblasts, epithelial cells, and a very small cluster of cardiac myocytes, which were confirmed on coimmunofluorescence staining of the myocardial sections. Differentially expressed genes between the paired clusters in the 2 genotypes predicted activation of the inflammatory and mitotic pathways—including the TGFβ1 (transforming growth factor β1) and fibroblast growth factors—in the epicardial-derived fibroblast and epithelial clusters, but predicted their suppression in the endothelial cell cluster. The findings were corroborated by analysis of gene expression in the pooled RNA-sequencing data, which identified predominant dysregulation of genes involved in epithelial–mesenchymal transition, and dysregulation of 146 genes encoding the secreted proteins (secretome), including genes in the TGFβ1 pathway. Activation of the TGFβ1 and its colocalization with fibrosis in the Wt1-Cre ERT2 :R26 mT/mG :Dsp W/F mouse heart was validated by complementary methods. Conclusions: Epicardial-derived cardiac fibroblasts and epithelial cells express paracrine factors, including TGFβ1 and fibroblast growth factors, which mediate epithelial–mesenchymal transition, and contribute to the pathogenesis of myocardial fibrosis, apoptosis, arrhythmias, and cardiac dysfunction in a mouse model of ACM. The findings uncover contributions of the epicardial-derived cells to the pathogenesis of ACM.

People around the world are facing water scarcity, and the demand for freshwater is continuously increasing. The purification of water is the only way to satisfy the need for water. Purification can be done in many ways by purifying seawater or by storing rainwater and letting it to the ground. Different types of solar still are there, which are used to increase the output of water produced. Among others, inclined solar still (ISS) is an outstanding solution as it has a wide exterior area of water, having less depth of water to complement the regular potable water production, even the effectiveness of the inclined solar still. A lot of research had been done by increasing the surface area of water. The day to day collection of water from the ISS was found to be 1–8 kg m− 2. In this review, an analysis was made on the current status of different ISS designs to make advance modifications and research to improve the productivity of the ISS to satisfy the increasing demand for potable water. From this investigation, it is identified that active ISS and hybrid ISS are the most effective as compared to other ISS techniques.

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, and is associated with increased morbidity and mortality. Inflammation has been implicated as an etiology of POAF. Mitochondrial DNA (mtDNA) has been shown to initiate inflammation. This study analyzed inflammatory mechanisms of POAF by evaluating mtDNA, neutrophils, and cytokines/chemokines in the pericardial fluid and blood after cardiac surgery.Blood and pericardial fluid from patients who underwent coronary artery bypass or heart valve surgery, or both, were collected intraoperatively and at 4, 12, 24, and 48 hours postoperatively. Real-time polymerase chain reaction was used to quantify mtDNA in the pericardial fluid and blood. A Luminex (Luminex Corp, Austin, TX) assay was used to study cytokine and chemokine levels. Flow cytometry was used to analyze neutrophil infiltration and activation in the pericardial fluid.Samples from 100 patients were available for analysis. Postoperatively, mtDNA and multiple cytokine levels were higher in the pericardial fluid versus blood. Patients who had POAF had significantly higher levels of mtDNA in the pericardial fluid compared with patients who did not (P.001, area under the curve 0.74). There was no difference in the mtDNA concentration in the blood between the POAF group and non-POAF group (P = .897). Neutrophil concentration increased in the pericardial fluid over time from a baseline of 0.8% to 56% at 48 hours (P.01).The pericardial space has a high concentration of inflammatory mediators postoperatively. Mitochondrial DNA in the pericardial fluid was strongly associated with the development of POAF. This finding provides insight into a possible mechanism of inflammation that may contribute to POAF, and may offer novel therapeutic targets.

The rapid development in wireless communication technology and the urgent need to develop it has led to an increase in the public exposure to more radio spectrum frequencies. The mountain increases in terms of the damage caused by these wireless technologies for the 2G, 3G and 4G generations ending with the new technique, which is 5G. As a result of the urgent need for fast communications and wide packages of data, only a new generation of communications has emerged, which is 5G, which enjoys high speed and broadcasts in short waves and high frequency. There is great concern about the impact of these technologies on human health and safety. This technique works at relatively higher frequencies than the previously used technologies. This research sheds light on some of the expected harms of these technologies and the result of using these techniques, where the damages on the human body in general, the skin and the human eye in particular, are addressed, as well as their impact on the environment and plants in general.

Recent advances in the field of interventional cardiology have allowed for more complex procedures to be performed percutaneously. Ability to obtain safe large bore vascular access is frequently the key factor to procedural success. Meticulous technique for successful vascular access incorporates the understanding of anatomic landmarks, ultrasound, fluoroscopy, and micropuncture. Adequate hemostasis at the end of the case can be achieved through careful use of commercially available vascular closure devices. Although access-related vascular complications are uncommon, early recognition is key to successful management. Arterial tortuosity and calcification can present a significant challenge to successful common femoral artery access.

Importance: Current evidence suggests that transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is possible among symptom-free individuals but limited data are available on this topic in healthcare workers (HCW). The quality and acceptability of self-collected nasopharyngeal swabs (NPS) is unknown. Objective: To estimate the prevalence of SARS-CoV-2 infection and to assess the acceptability of self-collected NPS among HCW. Design: Cross-sectional convenience sample enrolled between April 20th and June 24th, 2020. We had >95% power to detect at least one positive test if the true underlying prevalence of SARS-CoV2 was > 1%. Setting: The metropolitan area surrounding Minneapolis and St. Paul, Minnesota. Participants: HCW free of self-reported upper respiratory symptoms were recruited. Exposures: Participants completed questionnaires regarding demographics, household characteristics, personal protective equipment (PPE) utilization and comorbidities. Outcomes: A participant self-collected nasopharyngeal swab (NPS) was obtained. SARS-CoV-2 infection was assessed via polymerase chain reaction. NPS discomfort was assessed on a scale of 1 (no discomfort) - 10 (extreme discomfort). NPS duration and depth into the nasopharynx, and willingness to perform future self-collections were assessed. Results: Among n=489 participants 80% were female and mean age+/-SD was 41+/-11. Participants reported being physicians (14%), nurse practitioners (8%), physicians assistants (4%), nurses (51%), medics (3%), or other which predominantly included laboratory technicians and administrative roles (22%). Exposure to a known/suspected COVID-19 case in the 14 days prior to enrollment was reported in 40% of participants. SARS-CoV-2 was not detected in any participant. The mean+/-SD discomfort level of the NPS was 4.5+/-2.0. 95% of participants reported that their self-swab was longer than or equal to the duration of patient swabs they had previously performed, and 89% reported the depth to be deeper than or equal to the depth of previous patient swabs. Over 95% of participants reported a willingness to repeat a self-collected NP swab in the future. Conclusions and Relevance: The point prevalence of SARS-CoV-2 infection was likely very low in symptom-free Minnesota healthcare workers from April 20th and June 24th, 2020. Self-collected NP swabs are well-tolerated and a viable alternative to provider-collected swabs to preserve PPE.

Universities are coming under increasing pressure to produce impact that contributes to socio-economic development. Previous studies have focused on university technology transfer (UTT) mechanisms that lead to the commercialisation of intellectual property. We find that off-late, the legitimacy of such mechanisms, owing to high-failure rates of IP-based start-ups, has come into question. Universities are being invited to widen their academic entrepreneurship (AE) practices to include other forms of knowledge transfer. The increased attention on contemporary concepts such as social entrepreneurship calls for broadening UTT performance indicators to include multiple bottom-lines. These bottom-lines should amplify the societal benefits of AE. This new emphasis raises high-level questions about the societal role of universities and UTT. The aim in this paper is to, therefore, reframe the debate on UTT processes by highlighting a revised agenda for further research. This is done by analysing the extant literature on UTT, academic entrepreneurship, entrepreneurial universities and innovation. The analysis includes a critical review of 96 peer-reviewed articles. As a result, a macro perspective is presented which highlights UTT as-a-mechanism for universities’ contribution to collective societal goals. Propositions are outlined for future research; these can be used for developing new understanding on how universities can actively contribute to socio-economic development agendas.

COVID-19 is a multiorgan systemic inflammatory disease caused by SARS-CoV-2 virus. Patients with COVID-19 often exhibit cardiac dysfunction and myocardial injury, but imaging evidence is lacking. In the study we detected and evaluated the severity of myocardial dysfunction in COVID-19 patient population using two-dimensional speckle-tracking echocardiography (2-D STE). A total of 218 consecutive patients with confirmed diagnosis of COVID-19 who had no underlying cardiovascular diseases were enrolled and underwent transthoracic echocardiography. This study cohort included 52 (23.8%) critically ill and 166 noncritically ill patients. Global longitudinal strains (GLSs) and layer-specific longitudinal strains (LSLSs) were obtained using 2-D STE. Changes in GLS were correlated with the clinical parameters. We showed that GLS was reduced (P P P 2, RR = 0.42, P R = −0.20, P = 0.006) and inflammatory cytokines, particularly IL-6 (R = −0.21, P = 0.003). In conclusions, our results demonstrate that myocardial dysfunction is common in COVID-19 patients, particularly those who are critically sick. Changes in indices of myocardial strain were associated with indices of inflammatory markers and hypoxia, suggesting partly secondary nature of myocardial dysfunction.

Highlights • Performances of five commercial ELISA (EDI, AnshLabs, Dia.Pro, NovaTec, and Lionex) for detecting anti-SARS-CoV-2 IgG was evaluated. • Samples used in this study are from diverse national background and the negative group contains samples that are seropositive for all other HCoV. • All assays showed low sensitivity during the early stages (≤7 from symptom onset); however, it was greatly improved overtime. • Lionex showed the highest specificity (98.6%), followed by EDI and Dia.Pro (97.1%,), NovaTec (85.7%), and AnshLabs (75.7%). • Lionex, which measures antibodies to the S1 protein, demonstrated the best performance and doesn’t cross-react with any other HCoV., Objectives To evaluate and compare the performances of five commercial ELISA assays (EDI, AnshLabs, Dia.Pro, NovaTec, and Lionex) for detecting anti-SARS-CoV-2 IgG. Methods 70 negative control samples (collected before the COVID-19 pandemic) and samples from 101 RT-PCR-confirmed SARS-CoV-2 patients (collected at different time points from symptoms onset: ≤7, 8-14, and >14 days) were used to compare the sensitivity, specificity, agreement, positive and negative predictive values of each assay with RT-PCR. A concordance assessment between the five assays was also conducted. Cross-reactivity with other HCoV, non-HCoV respiratory viruses, non-respiratory viruses, and nuclear antigens was investigated. Results Lionex showed the highest specificity (98.6%, 95%CI: 92.3-99.8), followed by EDI and Dia.Pro (97.1%, 95%CI: 90.2-99.2), NovaTec (85.7%, 95%CI: 75.7-92.1), then AnshLabs (75.7%, 95%CI: 64.5-84.2). All ELISA kits cross-reacted with one anti-MERS IgG positive sample except Lionex. The sensitivity was low during the early stages of the disease but improved over time. After 14 days from symptoms onset, Lionex and NovaTec showed the highest sensitivity at 87.9% (95%CI: 72.7-95.2) and 86.4% (95%CI: 78.5-91.7), respectively. The agreement with RT-PCR results based on Cohen’s kappa was as follows: Lionex (0.89)> NovaTec (0.70)> Dia.Pro (0.69)> AnshLabs (0.63)> EDI (0.55). Conclusion The Lionex ELISA, which measures antibodies solely to the S1 protein, demonstrated the best performance.

The purpose is using the occlusive hydrocolloid dressing (OHD) and gauze dressing (GD) to compare incidence of infection of wound and cost-effectiveness of dressing after hernia operation in children. Eighty children was undergo hernia surgery, wounds were dressing by OHD or GD. Hydrocolloid dressing was remain till suture was removed, and GD changed every day after operation. Calculations of cost dressing mean dressing alterations frequency and cost for each dressing in every treatment cluster. There are no variances amongst the two clusters concerning the incidence of wound infection. OHD was less costly and complex than GD, and GD necessary to be altered each day (p = 0.001). In conclusion, OHD is less costly to use, and less complex than GD because GD wanted to be altered more times during the period of healing.

Background A case-control study was performed to examine age, gender, and ABO blood groups in 1014 Iraqi hospitalized cases with Coronavirus disease 2019 (COVID-19) and 901 blood donors (control group). The infection was molecularly diagnosed by detecting coronavirus RNA in nasal swabs of patients. Results Mean age was significantly elevated in cases compared to controls (48.2 ± 13.8 vs. 29.9 ± 9.0 year; probability [p] < 0.001). Receiver operating characteristic analysis demonstrated the predictive significance of age in COVID-19 evolution (Area under curve = 0.858; 95% CI: 0.841 – 0.875; p < 0.001). Males outnumbered females in cases (60.4 vs. 39.6%) and controls (56 vs. 44%). Stratification by age group (< 30, 30 – 39, 40 – 49 and ≥ 50 years) revealed that 48.3% of cases clustered in the age group ≥ 50 years. ABO blood group analysis showed that group A was the most common among cases, while group O was the most common among controls (35.5 and 36.7%, respectively). Blood groups A (35.5 vs. 32.7; corrected p [pc] = 0.021), A+AB (46.3 vs. 41.7%; pc = 0.021) and A+B+AB (68.0 vs. 63.3%; pc = 0.007) showed significantly elevated frequencies in cases compared to controls. Logistic regression analysis estimated odds ratios (ORs) of 1.53 (95% confidence interval [CI]: 1.16 - 2.02), 1.48 (95% CI: 1.14 - 1.93) and 1.50 (95% CI: 1.17 - 1.82) for blood groups A, A+AB and A+B+AB, respectively. Blood group frequencies showed no significant differences between age groups of cases or controls. Regarding gender, male cases were marked with increased frequency of group A (39.9 vs. 28.9%) and decreased frequency of group O (25.9 vs. 41.0%) compared to female cases. Independent re-analysis of ABO blood groups in male and female cases demonstrated that group A was increased in male cases compared to male controls (39.9 vs. 33.1%; OR = 1.65; 95% CI: 1.24 - 2.21; pc = 0.006). On the contrary, no significant differences were found between females of cases and controls. Conclusions The study results indicated that blood group A may be associated with an increased risk of developing COVID-19, particularly in males.

Background Carcinoid syndrome is a rare disease caused by malignant neuroendocrine neoplasms. When vasoactive substances enter the systemic circulation, the triad of cutaneous flushing, bronchospasm, and diarrhoea often characterize carcinoid syndrome. Rarely, carcinoid syndrome can progress to involve the cardiac system, a condition known as carcinoid heart disease, often affecting right-sided valvular structures. Case summary Here, we present a case of malignant carcinoid syndrome with associated carcinoid heart disease in a 63-year-old female. The diagnosis of her dual regurgitant and stenotic valvular disease is detailed, with accompanying two- and three-dimensional echocardiographic images demonstrating the patient’s complex tricuspid dysfunction. Discussion Carcinoid heart disease encompasses a rare but important subset of valvular dysfunction caused by circulating vasoactive substances. Diagnosis utilizing serum studies, computed tomography scans, and echocardiography can help expedite the diagnosis and treatment of such rare conditions, and assist in the avoidance of complications. Despite its relatively well-recognized clinical presentation, carcinoid syndrome and its associated heart disease still remains a challenging condition to manage and treat, often requiring the input of several subspecialties to treat the condition appropriately.

The nano encapsulated phase change materials are of the great energy storage potential in various engineering applications. Since they are new nanomaterials, new models for understanding their thermal behavior and capability are essential. This work aims to investigate the unsteady thermal behavior of Nano-Encapsulated Phase Change Material (NEPCM) suspensions in a cylindrical cavity. The particles contain a Phase Change Material (PCM) core, which can absorb/release a substantial amount of thermal energy upon phase change. The phase change particles are well dispersed in a liquid fluid and freely move along with the fluid. The flow, heat transfer, and the particle phase change were modeled using partial differential equations. A non-dimensional approach was employed to generalize the study. The unsteady charging and discharging behavior of the NEPCM suspension are investigated for the volume fraction of the NEPCM particles, fusion temperature of nanoparticles, Stefan number, and the Rayleigh number. Numerical results show that an increment in the Stefan number, i.e., Ste, can significantly reduce the Nusselt number, i.e., Nua, at the charging mode of the system. However, the dependency of the Nua at the discharging mode on the Ste is negligible. Also, it was found that the effect of the fusion temperature of the particle’s core (θf) on heat transfer depends on the working mode of the system. In the charging mode, using a higher value of θf decreases the heat transfer rate. Reversibly, a higher value of θf inhibits the Nua during discharging state. Furthermore, the results show that for Ra = 106, Ste = 0.2, and θf = 0.1, a rise of ϕ from 0 to 0.05 leads in about 1.73 and 1.55 times of improvement in the value of Nua for the cases of the melting and solidification of the core of NEPCM particles.

Research suggests that the science of undetectable viral load (VL) status and HIV transmission—conveyed with the slogan “Undetectable = Untransmittable” or “U = U”—has gaps in acceptance despite ro...

Mutation in the LMNA gene, encoding lamin A/C, causes a diverse group of diseases called laminopathies. Cardiac involvement is the major cause of death and manifests as dilated cardiomyopathy, heart failure, arrhythmias, and sudden death. There is no specific therapy for LMNA-associated cardiomyopathy. We report that deletion of Lmna in cardiomyocytes in mice leads to severe cardiac dysfunction, conduction defect, ventricular arrhythmias, fibrosis, apoptosis, and premature death within 4 weeks. The phenotype is similar to LMNA-associated cardiomyopathy in humans. RNA sequencing, performed before the onset of cardiac dysfunction, led to identification of 2338 differentially expressed genes (DEGs) in Lmna-deleted cardiomyocytes. DEGs predicted activation of bromodomain-containing protein 4 (BRD4), a regulator of chromatin-associated proteins and transcription factors, which was confirmed by complementary approaches, including chromatin immunoprecipitation sequencing. Daily injection of JQ1, a specific BET bromodomain inhibitor, partially reversed the DEGs, including those encoding secretome; improved cardiac function; abrogated cardiac arrhythmias, fibrosis, and apoptosis; and prolonged the median survival time 2-fold in the myocyte-specific Lmna-deleted mice. The findings highlight the important role of LMNA in cardiomyocytes and identify BET bromodomain inhibition as a potential therapeutic target in LMNA-associated cardiomyopathy, for which there is no specific effective therapy.

ObjectivesTransgender men who have sex with men (TMSM) represent an understudied population in relation to screening for HIV and sexually transmitted infections (STIs). We examined HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse US nationwide sample of TMSM.MethodsData from a cross-sectional online convenience sample of 192 TMSM were analysed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioural factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.ResultsMore than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past 6 months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing. Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs. Furthermore, TMSM residing in the South were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year. Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past 6 months.ConclusionsThese findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behaviour. Efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex, are needed.

Background Patients with nonobstructive hypertrophic cardiomyopathy (nHCM) often experience a high burden of symptoms; however, there are no proven pharmacological therapies. By altering t...

Chronic kidney disease (CKD) is a permanent loss of kidney function which is diagnosed when the glomerular filtration rate (GFR) is under 60 ml\min\1.73m2 for more than three months. The present study was conducted at Kidney Transplant and Dialysis Center in the Medical City in Baghdad from October 2018 to April 2019. Sixty CKD patients with an age ranged of 40 to 65 years and 25 healthy subjects were involved in this study. Blood samples were collected to evaluate the levels of kidney function parameters and thyroid hormones. The levels of urea, creatinine and uric acid showed highly significant (p ≤ 0.01) increases in CKD patient in comparison with the control group, while the values of GFR and creatinine clearance showed highly significant (p ≤ 0.01) decreases. The results of thyroid hormones showed highly significant (p < 0.01) decreases in the levels of T3 and T4 along with a highly significant (p < 0.01) increase in the level of TSH in the patients.

Recently natural coagulants are a consistently expanded; plants extracted coagulant which may be adopted in the coagulation-flocculation activity of textile wastewater treatment for reduction concentration of turbidity and total suspended solids. In this study, the possibility of a combination between chemical coagulant (alum) and natural plant coagulant (Capparis Spinosa) in excluding turbidity and total suspended solids from textile wastewater has been studied. A set of experiments were implemented for verifying the turbidity and TSS removal efficiency using alum and powder extracted from Capparis Spinosa plant separately. A combined dosage consisted of chemical coagulant (alum) dosages (10, 20, 30 and 40 mg/l) with natural coagulant dosages (10, 20, 30 and 40 mg/l) in order to detect the optimum combined percentage of both coagulants (alum and Capparis Spinosa) that produces higher removal efficiencies for both turbidity and TSS. The study found the activity of removal for both turbidity and total suspended solids increased in high performance when mixing is occurred between natural coagulant (Capparis Spinosa) and chemical coagulant (Alum). The results illustrate that the combination of 20 mg/l alum with 30 mg/l Capparis Spinosa made 99% turbidity removal and the combination of 30 mg/l alum with 30 mg/l Capparis Spinosa made 98% TSS removal.

Several studies have demonstrated no linked HIV transmissions in serodifferent sexual encounters where the partner with HIV has an undetectable viral load. As a result, awareness and dissemination of treatment as prevention, and movements such as "Undetectable = Untransmittable" (U = U), has grown.We conducted an online cross-sectional survey from November 2017 through September 2018 to gather data from a total of 111,747 sexual minority men (SMM) in the United States.Participants provided sociodemographic data and answered questions regarding biomedical status, HIV and STI prevention behaviors, drug use, condomless anal sex, and perceived accuracy of the U = U message. We conducted analyses to understand factors associated with perceived accuracy of U = U stratified by HIV status.Overall, 53.2% of the sample perceived U = U as accurate, with the highest rates among HIV-positive SMM (83.9%), followed by HIV-negative (53.8%) and status-unknown (39.0%) SMM. Multivariable models showed accuracy beliefs were, on average, 1-2% higher for each consecutive month of recruitment. Consistent with previous work, there was greater heterogeneity among HIV-negative and unknown men, with several factors differentiating perceived accuracy, compared with SMM with HIV. Perceived transmission risk levels with undetectable partners were skewed well above accurate levels, and greater perceived transmission risk was associated with lower perceived accuracy of U = U.Public confidence in treatment as prevention and U = U is growing, but clear, unequivocal messaging about the effectiveness of U = U is critical. Owing to misunderstandings of risk, language that focuses on protective benefits rather than transmission risks may reach more people and allow for better comparisons with PrEP and condoms.

Objective This study examined psychological and sexual health indicators associated with positive feelings and discrimination at the intersection of race and gender among Black gay, bisexual, and other sexual minority men (SMM). Method Participants were a national sample of 1,064 Black SMM (Mdn age = 28) who responded to self-report measures of positive feelings and discrimination associated with being a Black man, psychological distress, self-efficacy, emotional awareness, and sexual HIV risk and protective behavior. Using structural equation modeling, we examined associations between the positive feelings and discrimination scales and the psychological and sexual health indicators. We also tested age as a moderator of these associations. Results Our results indicated that positive feelings about being a Black man were significantly positively associated with self-efficacy (b = 0.33), emotional awareness (b = 0.16), and sexual protective behavior (b = 0.93) and negatively associated with psychological distress (b = -0.26) and sexual risk behavior (b = -0.93). Except for emotional awareness and sexual protective behavior, discrimination as a Black man was also associated with these variables, though to a lesser magnitude for positive health indicators. Moderation results showed that, except for the association between positive feelings and emotional awareness, younger men generally had stronger associations between health indicators and the positive feelings and discrimination scales. Conclusions These results suggest that positive feelings, in addition to discrimination, at the intersection of race and gender play an important role in the psychological and sexual health of Black SMM, especially earlier in their lives. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Digital images are the most frequently used signals to convey information in the internet era. The security of these images is the primary concern in rapidly changing networked environments. In this research, we present a novel approach to secure images by integrating a scanning technique, the El-Gamal public key cryptosystem and chaotic systems. In brief, zigzag and spiral scanning are used first to construct a permuted image. Then, the El-Gamal encryption algorithm is exploited to encrypt the permuted image. Finally, Lorenz and Rössler chaotic sequences are utilized to scramble the pixel locations in the confusion and diffusion stages. This last step that mixes two stages can fortify the entire security performance and enlarge the key size. Exhaustive analysis has been carried out on the SIPI (signal and image processing institute) dataset to assess the efficiency and security of the proposed method. Numerical and visual results indicate the capability of the proposed image cryptosystem to protect images against several known attacks. In addition, the comparative analysis results indicate that the proposed approach outperforms the compared approaches in terms of the visual quality and security criteria.

A new compact printed monopole antenna is presented in this paper. An open-loop hexagonal radiator excited by a microstrip feed line, which is printed on top of the substrate, which is FR4 type, while on another side, a partial ground plane is fixed and embedded with two pairs of slits as well as a pair of rectangular strips. Triple operating bands with two different polarization types are obtained. The lower band has right-hand circular polarization (RHCP) characteristic, whereas the upper band has left-hand circular polarization (LHCP) characteristic means that a dual-band dual-sense circular polarization (CP). Concerning the middle band, a linear polarization (LP) has been gotten in this antenna. Numerical analysis and experimental validation of the proposed antenna structure have been performed, and results are demonstrated. The measured impedance bandwidths (IBWs) are 14.7% (1.478-1.714 GHz), 6.8% (2.54-2.72 GHz), and 13.1% (4.29-4.89 GHz), respectively. The measured 3-dB axial ratio bandwidths (ARBWs) are 6.2% (1.510-1.606 GHz), and 22.7% (4.035-5.07 GHz) for the lower and the upper band, respectively. So, it's suitable for covering modern wireless applications such as GPS (Global Positioning System), LTE (Long Term Evaluation), and Satellite.

Background: Asthma is a heterogeneous inflammatory disease of the airway, characterized by airway hyperresponsiveness, airway obstruction, mucus hyperproduction, and airway-wall remodeling. Management of this disease involves the use of several types of therapeutic agents, each with unique indications based on the underlying cause of inflammation, clinical severity, and patient phenotype and/or endotype. Objective: A review of the function, clinical utility, and safety of biologic agents in the management of allergic asthma. This particular asthma phenotype involves multiple cytokines in its pathogenesis, specifically those secreted by T-helper type 2 cells. Methods: Medical literature was obtained from online biomedical archive searches from July 2018 to May 2019. An emphasis was placed on clinical trials that discussed biologic agents that target immunoglobulin E, interleukin (IL) 5, IL-4/IL-13, and chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTh2) pathways involved in the expression of allergic asthma. Results: The treatment options reviewed in this article were shown to be effective in targeting these pathways associated with allergic asthma. However, because these biologic agents are commonly prescribed in the treatment of severe asthma, many patients continue to experience asthma signs and symptoms. Conclusion: Future clinical trials that study these agents should focus on ideal patient selection, dosing regimens, and cost-effectiveness in the management of asthma. Ideally, comparative trials should be undertaken to assist the clinician in choosing the optimal agent.

Purpose The purpose of this study is to reduce energy consumption in bakeries. Due to fulfill this demand, quite a few parameters such as energy and exergy efficiency, energy waste and fuel consumption by different traditional flatbreads bakeries (Sangak, Barbari, Taftun and Lavash should be monitored and their roles should not be neglected. Design/methodology/approach In the present study, experimental measurements and mathematical modeling are used to scrutinize and investigate the effects of the aforementioned parameters on energy consumption by bakeries. Findings The results show that by doing reported methods in this paper, the wasted energy of the walls can be decreased by about 65 per cent; and also, by controlling the combustion reaction to perform with 5 per cent excess air, the wasted energy of excess air declines by about 90 per cent. And finally, the energy and exergy efficiency of bakeries is increased, and as a result, the annual energy consumption of Sangak, Barbari, Taftun and Lavash bakeries diminish about 71, 59, 57 and 40 per cent, respectively. Originality/value As evidenced by the literature review, it can be observed that neither numerical studies nor experimental investigations have been conducted about energy and exergy analyses of Iranian machinery traditional flatbread bakeries. It is clear that due to a high preference of Iranians to use the traditional bread and also the popularity of baking this kind of bread in Iran, if it is possible to enhance the traditional oven conditions to decrease the loss of natural gas instead of industrializing the bread baking, the energy consumption in the country can be optimized.

Background Inappropriate sinus tachycardia (IST) is a rare clinical disorder characterized by an elevated resting heart rate and an exaggerated rate response to exercise or autonomic stress. Pharmacologic therapy and catheter ablation are considered first-line treatments for IST but can yield suboptimal relief of symptoms. The results of surgical ablation at our center were reviewed for patients with refractory IST. Methods Between 1987 and 2018, 18 patients underwent surgical sinoatrial (SA) node isolation for treatment-refractory IST. All 18 patients had previously failed pharmacologic therapy, and 15 patients had failed catheter ablation of the SA node. Results Ten patients underwent a median sternotomy, and 8 patients underwent a minimally invasive right thoracotomy. The SA node was isolated with the use of surgical incisions, cryoablation, or bipolar radiofrequency ablations. Sinus tachycardia was eliminated in 100% of patients in the immediate postoperative period. Long-term follow-up data were available for 17 patients, with a mean follow-up of 11.4 ± 7.9 years. At last follow-up, 100% of patients were free from recurrent symptomatic IST. More than 80% of patients were completely asymptomatic, whereas 3 patients reported occasional palpitations. Four patients were on β-blockers, and 5 patients required subsequent pacemaker implantation. All 8 patients who underwent minimally invasive isolation were in normal sinus rhythm at last follow-up, and only 1 patient complained of palpitations. Conclusions Surgical isolation of the SA node is a feasible treatment for IST refractory to pharmacologic therapy and catheter ablation. A minimally invasive surgical approach offers a less morbid alternative to traditional median sternotomy.

Background: Mutations in genes encoding sarcomere and cytoskeletal proteins are major causes of primary dilated cardiomyopathy (DCM). Likewise, ischemic myocardial injury is a major cause of secondary cardiac remodeling, which, in a subset, is severe and resembles DCM. The latter is referred to as ischemic dilated cardiomyopathy (IDCM). We postulated the presence of pathogenic and likely pathogenic variants (PVs and LPVs, respectively) in genes known to cause primary DCM might predispose the heart to severe cardiac dilatation and dysfunction post myocardial ischemic injury, i.e., IDCM.Methods: We performed whole-exome sequencing in 1,041 patients with primary DCM, 215 patients with IDCM, and 414 healthy controls. Indices of cardiac size and function were similar between those with primary and ischemic DCM. PVs and LPVs, including the truncating variants in 36 genes known to cause primary DCM were identified and compared among the three groups.Results: Pathogenic variants and LPVs were detected in 266 individuals, comprised of 215/1,041 (20.7%) patients with DCM, 27/215 (12.6%) patients with IDCM, and 24/414 (5.8%) control individuals. PVs and LPVs in the TTN gene were the most common and detected in 130/1,041 (12.5%) of patients with DCM, 15/215 (7.0%) of cases with IDCM, and 10/414 (2.4%) control individuals. Of 135 TTNtv, 118 involved exons that were >90% spliced in. These variants were found in 120/1,041 (11.5%) of DCM patients, 6/215 (2.8%) of IDCM cases, and only in 1/414 (0.2%) of the control population (p < 0.001 among the three groups).Conclusions: Pathogenic variants and LPVs in genes known to cause primary DCM are enriched in patients with IDCM, suggesting that such variants function as susceptibility alleles for cardiac dilatation and dysfunction in post myocardial ischemic injury. Thus, IDCM shares a partial genetic etiology with the primary DCM.

Sexual minority men (SMM) with HIV are disproportionately impacted by stigma and mental health disorders. Guided by the Stigma and Substance Use Process Model, we evaluated how HIV stigma impacts mental health outcomes among SMM with HIV. Data were drawn from Thrive With Me, an RCT of an mHealth intervention targeting ART adherence among SMM with HIV. Path analyses tested the relationships between HIV stigma, depression, stress, and recent stimulant use. Overall, 49.1% (194/401) had depression symptoms, 68.8% (276/401) had moderate-to-high stress, and 28.1% (111/401) had detectable stimulant use in urine samples at baseline. In path analyses, baseline internalized HIV stigma was associated with depression and stress 5-months post-baseline and enacted stigma was associated with recent stimulant use 11-months post-baseline. We identified internalized and enacted HIV stigma, but not anticipated stigma, as potentially important intervention targets for stimulant use, depression, and stress among SMM with HIV.

BackgroundMonitoring COVID-19 infection risk among health care workers (HCWs) is a public health priority. We examined the seroprevalence of SARS-CoV-2 among HCWs following the fall infection surge in Minnesota, and before and after COVID-19 vaccination. Additionally, we assessed demographic and occupational risk factors for SARS-CoV-2 infection.MethodsWe conducted two rounds of seroprevalence testing among a cohort of HCWs: samples in round 1 were collected from 11/22/20 - 02/21/21 and in round 2 from 12/18/20 - 02/15/21. Demographic and occupational exposures assessed with logistic regression were age, sex, healthcare role and setting, and number of children in the household. The primary outcome was SARS-CoV-2 IgG seropositivity. A secondary outcome, SARS-CoV-2 infection, included both seropositivity and self-reported SARS-CoV-2 test positivity.ResultsIn total, 459 HCWs were tested. 43/454 (9.47%) had a seropositive sample 1 and 75/423 (17.7%) had a seropositive sample 2. By time of sample 2 collection, 54% of participants had received at least one vaccine dose and seroprevalence was 13% among unvaccinated individuals. Relative to physicians, the odds of SARS-CoV-2 infection in other roles were increased (Nurse Practitioner: OR[95%CI] 1.93[0.57,6.53], Physician’s Assistant: 1.69[0.38,7.52], Nurse: 2.33[0.94,5.78], Paramedic/EMTs: 3.86[0.78,19.0], other: 1.68[0.58,4.85]). The workplace setting was associated with SARS-CoV-2 infection (p=0.04). SARS-CoV-2 seroprevalence among HCWs reporting duties in the ICU vs. those working in an ambulatory clinic was elevated: OR[95%CI] 2.17[1.01,4.68].ConclusionsSARS-CoV-2 seroprevalence in HCW increased during our study period which was consistent with community infection rates. HCW role and setting — particularly working in the ICU — is associated with higher risk for SARS-CoV-2 infection.

Introduction: We present a case of spontaneous compartment syndrome due to a very rare cause which is acquired hemophilia. Case Presentation:A 34-year-old patient presented with the right thigh swelling and features of acute compartment syndrome without history of trauma. He had no history of bleeding disorder. There were no features of infection. As his initial blood tests were within normal 16 g/dl, and his compartment syndrome worsened, he had decompression of the thigh. During the post-operative period, the patient developed persistent bleeding from the decompressed wounds and a fall in hemoglobin which led to further investigation when the blood profile showed a deficiency of factor VIII and antibodies to factor VIII, diagnosis of acquired hemophilia was made and appropriate treatment given. Conclusion: If atraumatic compartment syndrome diagnosed, possibility of acquired factor VIII deficiency should be raised by isolated prolonged activated partial thromboplastin time and diagnosis confirmed by measuring factor VIII activity level and detecting any factor’s VIII antibodies in blood, such as in this case, the factor VIII level was 5.5 (very low) and against factor VIII antibodies level was 60.8 (high). Here, hematologist should be involved in management. Keywords: Compartment syndrome, atraumatic, acquired factor VIII deficiency.

Background Racially diverse sexual minority men (SMM) are disproportionately impacted by the U.S. HIV epidemic. Substance use, particularly stimulant use, may impact viral suppression for SMM living with HIV. The current study sought to characterize patterns of substance use via latent class analysis (LCA) and test associations between those patterns and future viral load outcomes, among SMM living with HIV. Methods Data were drawn from Thrive With Me (TWM), an RCT of an mHealth intervention targeting ART adherence among SMM living with HIV. LCA was performed with six dichotomous indicators of substance use, derived from validated measures and urinalysis results, to determine substance use classes at baseline. Bivariate and multivariable logistic regression models tested associations between baseline substance use classes and HIV viral load 5-months post-baseline. Results Among 383 SMM living with HIV, we identified a three-class model of substance use fit best: low probability substance use (81.3 %), high probability hazardous alcohol, marijuana, and cocaine use (7.5 %), and high probability methamphetamine and amphetamine use (11.2 %). Additionally, the high probability amphetamine use class was less likely to be virally suppressed at 5-month follow-up compared to the low probability substance use class [Adjusted Odds Ratio = 3.34, 95 % Confidence Interval = 1.39–7.99, p = .0069]. Conclusion We identified that some patterns of substance use (i.e., methamphetamine and amphetamine use), but possibly not others (e.g., alcohol, marijuana, and cocaine use), are potentially important intervention targets for improving HIV-related outcomes among racially diverse SMM living with HIV.

OBJECTIVE: To investigate the optimal timing of direct acting antiviral (DAA) administration in patients with hepatitis C-associated hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). SUMMARY OF BACKGROUND DATA: In patients with hepatitis C (HCV) associated HCC undergoing LT, the optimal timing of direct-acting antivirals (DAA) administration to achieve sustained virologic response (SVR) and improved oncologic outcomes remains a topic of much debate. METHODS: The United States HCC LT Consortium (2015–2019) was reviewed for patients with primary HCV-associated HCC who underwent LT and received DAA therapy at 20 institutions. Primary outcomes were SVR and HCC recurrence-free survival (RFS). RESULTS: Of 857 patients, 725 were within Milan criteria. SVR was associated with improved 5-year RFS (92% vs 77%, P < 0.01). Patients who received DAAs pre-LT, 0–3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 92%, and 82%, and 5-year RFS of 93%, 94%, and 87%, respectively. Among 427 HCV treatment-naïve patients (no previous interferon therapy), patients who achieved SVR with DAAs had improved 5-year RFS (93% vs 76%, P < 0.01). Patients who received DAAs pre-LT, 0–3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 93%, and 78% (P < 0.01) and 5-year RFS of 93%, 100%, and 83% (P = 0.01). CONCLUSIONS: The optimal timing of DAA therapy appears to be 0 to 3 months after LT for HCV-associated HCC, given increased rates of SVR and improved RFS. Delayed administration after transplant should be avoided. A prospective randomized controlled trial is warranted to validate these results.

Objective Obesity is a strong and independent factor for the development of atrial fibrillation (AF), and adversely impacts the success of catheter ablation procedures for AF. This study evaluated the impact of body mass index (BMI) on the outcomes following surgical ablation of AF. Methods Between 2003 and 2019, 236 patients underwent a stand-alone biatrial Cox maze IV procedure (CMP-IV) for refractory AF. Obesity was defined as BMI ≥30 kg/m2. Patients were divided into two groups: BMI 2 ( n = 100) and BMI ≥30 kg/m2 ( n = 136). Freedom from atrial tachyarrhythmia (ATA) was determined using electrocardiography, Holter, or pacemaker interrogation at 1 year and annually thereafter. Recurrence was defined as any documented ATA lasting ≥30 s. Predictors of recurrence were determined using multivariable logistic regression. Preoperative and procedural outcomes were compared between groups. Results Obese patients had a higher rate of diabetes (16% vs 7%, P = 0.044) and larger left atrial diameter (4.9 ± 1.1 cm vs 4.6 ± 1.0 cm, P = 0.021) when compared to non-obese patients. There was no difference in major complication rate between the groups (4% vs 7%, P = 0.389). There was no operative mortality in either group. During 4.1 ± 2.4 years of follow-up, there was no significant difference in freedom from ATA with or without antiarrhythmic drugs in obese patients when compared to the non-obese group ( P > 0.05). Absence of sinus rhythm at discharge predicted AF recurrence up to 7 years postoperatively. Conclusions As opposed to catheter ablation, obesity did not adversely impact the short and long-term outcomes of stand-alone surgical ablation with CMP-IV, and BMI was not a predictor of AF recurrence. Additionally, there was no significant increase in major complications in obese patients.

With the rise of satellite mega-constellations, high-data-rate and low-latency space-based internet is set to transform the lives of users in remote locations with no access to the fiber-optic infrastructure. While current commercial constellations are relying on microwaves, they are legally and technologically limited to only a few gigahertz of bandwidth, paralyzing the potential for ultra high data rate performance. In this paper, a dual terahertz/Ka-band communication system is proposed and studied as a solution. A space-Earth propagation model based on the International Telecommunication Union most recent recommendations is presented, and a mega-constellation of 8,320 small satellites in low Earth orbit is designed to test the dual-band performance for the uplink, downlink, and crosslink. Extensive simulations are performed using an in-house-developed orbital simulation tool to calculate data rates for each terahertz and Ka band links based on signal-to-noise ratio estimates with dynamic decision making to constantly provide the highest data rate possible. For links between Earth and space, the results show similar performance for terahertz and Ka-band communications, while terahertz significantly outperforms in inter-satellite links. Simulation results show that terahertz communication can be a good candidate for space-Earth and inter-satellite links as both an enhancement to existing microwave technology and as a stand-alone technology with the identified challenges addressed.

Background Infections by previously underdiagnosed viruses astrovirus and sapovirus are poorly characterized compared with norovirus, the most common cause of acute gastroenteritis. Methods Children Results Astrovirus was detected in 56 of 2688 (2.1%) children, sapovirus was detected in 146 of 2688 (5.4%) children, and norovirus was detected in 486 of 2688 (18.1%) children. At illness onset, ~60% of astrovirus cases experienced both diarrhea and vomiting. Among sapovirus and norovirus cases, 35% experienced diarrhea at onset and 80% of 91% (sapovirus/norovirus) vomited; however, diarrhea became more prevalent than vomiting at approximately day 4 of illness. Over the full course of illness, diarrhea was 18% (95% confidence interval [CI], 8%– 29%) more prevalent among children with astrovirus than norovirus infections and had longer duration with greater maximal events; there were a median of 4.0 fewer maximal vomiting events (95% CI, 2.0–5.0). Vomiting continued for a median of 24.8 hours longer (95% CI, 9.6–31.7) among children with sapovirus versus norovirus. Differences between these viruses were otherwise minimal. Conclusions Sapovirus infections attended in the emergency department are more similar to norovirus than previously reported, whereas astrovirus infections have several distinguishable characteristics.