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Background@#The purpose of this study was to evaluate the effect of vanishing twin (VT) on maternal serum marker concentrations and nuchal translucency (NT). @*Methods@#This is a secondary analysis of a multicenter prospective cohort study in 12 institutions. Serum concentrations of pregnancy-associated plasma protein-A in the first trimester and alpha-fetoprotein (AFP), total human chorionic gonadotrophin, unconjugated estriol, and inhibin A in the second trimester were measured, and NT was measured between 10 and 14 weeks of gestation. @*Results@#Among 6,793 pregnant women, 5,381 women were measured for serum markers in the first or second trimester, including 65 cases in the VT group and 5,316 cases in the normal singleton group. The cases in the VT group had a higher median multiple of the median value of AFP and inhibin A than the normal singleton group. The values of other serum markers and NT were not different between the two groups. After the permutation test with adjustment,AFP and inhibin A remained significant differences. The frequency of abnormally increased AFP was also higher in the VT group than in the normal singleton group. @*Conclusion@#VT can be considered as an adjustment factor for risk assessment in the secondtrimester serum screening test.
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Purpose@#We assessed prenatal detection rates of congenital heart disease (CHD) and associations between maternal serum biomarkers and non-chromosomal CHD in singleton pregnancies. @*Materials and Methods@#This study was conducted as a secondary analysis of data obtained during a multicenter prospective cohort study that investigated the cost-effectiveness of prenatal testing for fetal aneuploidy. We analyzed the prenatal detection rate and accuracy for CHD screening via ultrasound during the second trimester, as well as associations between serum biomarkers and CHDs, in singleton newborns without chromosomal abnormalities. @*Results@#Among 6715 women, 142 (2.1%) newborns were born with CHDs, of which 67 (1.0%) newborns had major CHDs. The prenatal detection rate for all CHDs and major CHDs were 34.5% and 58.2%, respectively. After excluding isolated ventricular septal defects, the detection rate for critical CHDs was 85.9%. Women with low pregnancy-associated plasma protein A (PAPP-A) (<0.4 multiples of the median, MOM) face increased risks of non-chromosomal CHDs [adjusted odds ratio (aOR) 2.76; 95% confidence interval (CI) 1.36–5.13] and major CHDs (aOR 7.30; 95% CI 3.18–15.59), compared to those without CHDs. A higher inhibin A level (≥2.5 MOM; aOR 4.84; 95% CI 1.42–12.46) was associated with non-chromosomal major CHDs. @*Conclusion@#Ultrasonography performed during the second trimester by obstetricians detected over 85% of critical CHDs. Low maternal serum PAPP-A or high inhibin-A was associated with non-chromosomal CHDs. These results may contribute to an improvement in prenatal diagnosis of CHDs.
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Background@#People are generally considered overweight and obese if their body mass index (BMI) is above 25 kg/m 2 and 30.0 kg/m 2 , respectively. The World Health Organization proposed stricter criteria for Asians (≥ 23 kg/m2 : overweight, ≥ 25 kg/m2 : obese). We aimed to verify whether this criteria could predict adverse pregnancy outcomes in Korean women. @*Methods@#We included 7,547 Korean women from 12 institutions enrolled between June 2016 and October 2018. Women with no pre-pregnancy BMI data, not Korean, or lost to followup were excluded, leaving 6,331. The subjects were categorized into underweight, normal, overweight, class I obesity, and class II/III obesity based on a pre-pregnancy BMI of < 18.5, 18.5–22.9, 23.0–24.9, 25.0–29.9, and ≥ 30.0 kg/m2 , respectively. @*Results@#Overall, 13.4%, 63.0%, 11.8%, 9.1%, and 2.6% of women were underweight, normal, and overweight and had class I obesity and class II/III obesity, respectively. In the multivariable analysis adjusted for maternal age, a higher BMI significantly increased the risk of preeclampsia, gestational diabetes, preterm delivery caused by maternal-fetal indications, cesarean section, large for gestational age, and neonatal intensive care unit admission. @*Conclusion@#Adverse pregnancy outcomes started to increase in those with a pre-pregnancy BMI ≥ 23.0 kg/m2 after adjusting for maternal age. The modified obesity criteria could help predict adverse pregnancy outcomes in Koreans.
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Purpose@#To compare pregnancy complications between the 2 groups of patients with gestational diabetes mellitus (GDM): those diagnosed by the 1-step method and those diagnosed by the 2-step method. @*Methods@#In this retrospective cohort study, the data from outpatient and hospitalization medical records of 201 patients diagnosed with GDM between 2013 and 2017 were reviewed. We compared the pregnancy complications of these patients based on whether they were diagnosed by the 1-step or 2-step method. SPSS ver. 20.0 was used to analyze the data from the 2 groups. The odds ratio and 95% confidence interval of the pregnancy outcomes were estimated using binary logistic regression analysis. @*Results@#On comparing pregnancy-related complications between the groups, there was no significant difference in the incidence of preeclampsia or delivery by cesarean section (p>0.99 and p=0.50, respectively). In the 1-step and 2-step groups, the prevalence of premature birth was significantly high at 19.7 % and 40.3% (p=0.01), respectively. There were no significant differences between the 2 groups in terms of macrosomia, large for gestational age (LGA), small for gestational age (SGA), low APGAR score, and neonatal hypoglycemia (p>0.99, p>0.26, p>0.62, p>0.57, and p>0.45, respectively). @*Conclusion@#On comparing the 2 groups, we found that the 1-step and 2-step GDM groups had similar risks of pregnancy complications, namely preeclampsia, delivery by cesarean section, macrosomia, LGA, SGA, low APGAR scores, and neonatal hypoglycemia.
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Purpose@#Considering the various health benefits of vegetables, it is necessary to identify maternal correlates of vegetable preference and consumption in children for shaping desirable vegetable-related eating habits. This study aimed to investigate the maternal factors related to vegetable preferences and consumption in preschool-aged children. @*Methods@#This is a cross-sectional study that surveyed 303 mother-child pairs (146 boys, 157 girls) to explore general characteristics, vegetable preferences, and cooked vegetable consumption in mothers and children using a questionnaire method. Maternal correlates of the child’s vegetable preference and consumption were tested using a generalized linear model using SAS program. @*Results@#Mothers' vegetable preferences and consumption were significantly higher than those in their children (p < 0.001). Mothers' vegetable preferences showed a significant positive correlation with the vegetable preferences of their children (mother-son, p < 0.001; mother-daughter, p < 0.001). Additionally, mothers' cooked vegetable consumption showed a significant positive correlation with the cooked vegetable consumption of children (mother-son, p < 0.001; mother-daughter, p < 0.001). Mothers' vegetable preferences and consumption respectively increased those of their children, in both boys and girls. @*Conclusion@#Findings that mothers' vegetable preference and consumption correlates of children's vegetable preferences and consumption, indicate the importance of the mothers' role in increasing vegetable consumption in children. Mothers should be aware of the effects of their vegetable eating habits on their children's vegetable consumption and try to develop healthy eating habits. We suggest that the government or local communities provide nutrition education for mothers to adopt healthy eating habits and present information to educate their children on food and healthy dietary habits.
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Humans , Uterine Cervical Dysplasia , Early Detection of Cancer , Gynecology , Human Papillomavirus DNA Tests , Korea , Mass Screening , Medical Overuse , Methods , Obstetrics , Prevalence , Uterine Cervical NeoplasmsABSTRACT
Based on emerging data and current knowledge regarding high-risk human papillomavirus (hrHPV) testing as a primary screening for cervical cancer, the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology support the following scientific facts:• Compared to cytology, hrHPV screening has higher sensitivity and detects more cases of high-grade cervical intraepithelial neoplasia.• Qualified hrHPV testing can be considered as an alternative primary screening for cervical cancer to the current cytology method.• The starting age of primary hrHPV screening should not be before 25 years because of possible overtreatment in this age, which has a high human papillomavirus (HPV) prevalence but rarely progresses to cancer. The screening interval should be no sooner than every 3 years and no longer than every 5 years.• Before the introduction of hrHPV screening in Korea, research into comparative effectiveness of primary hrHPV screening for cervical cancer should be conducted to determine the appropriate HPV assay, starting age, and screening interval.
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Based on emerging data and current knowledge regarding high-risk human papillomavirus (hrHPV) testing as a primary screening for cervical cancer, the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology support the following scientific facts: • Compared to cytology, hrHPV screening has higher sensitivity and detects more cases of high-grade cervical intraepithelial neoplasia. • Qualified hrHPV testing can be considered as an alternative primary screening for cervical cancer to the current cytology method. • The starting age of primary hrHPV screening should not be before 25 years because of possible overtreatment in this age, which has a high human papillomavirus (HPV) prevalence but rarely progresses to cancer. The screening interval should be no sooner than every 3 years and no longer than every 5 years. • Before the introduction of hrHPV screening in Korea, research into comparative effectiveness of primary hrHPV screening for cervical cancer should be conducted to determine the appropriate HPV assay, starting age, and screening interval.
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The name of society was published incorrectly.
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Based on the current understanding of a preventive effect of bilateral salpingectomy on ovarian/fallopian/peritoneal cancers, the Korean Society of Obstetrics and Gynecology, Korean Society of Gynecologic Endocrinology, Korean Society of Gynecologic Oncology, Korean Society of Maternal Fetal Medicine, and Korean Society for Reproductive Medicine support the following recommendations:• Women scheduled for hysterectomy for benign gynecologic disease should be informed that bilateral salpingectomy reduces the risk of ovarian/fallopian/peritoneal cancer, and they should be counseled regarding this procedure at the time of hysterectomy.• Although salpingectomy is generally considered as a safe procedure in terms of preserving ovarian reserve, there is a lack of evidences representing its long-term outcomes. Therefore, patients should be informed about the minimal potential of this procedure for decreasing ovarian reserve.• Prophylactic salpingectomy during vaginal hysterectomy is favorable in terms of prevention of ovarian/fallopian/peritoneal cancer, although operation-related complications minimally increase with this procedure, compared to the complications associated with vaginal hysterectomy alone. Conversion to open or laparoscopic approach from vaginal approach to perform prophylactic salpingectomy is not recommended.• Women who desire permanent sterilization at the time of cesarean delivery could be counseled for prophylactic salpingectomy before surgery on an individual basis.
Subject(s)
Female , Humans , Endocrinology , Fallopian Tubes , Genital Diseases, Female , Gynecology , Hysterectomy , Hysterectomy, Vaginal , Obstetrics , Ovarian Neoplasms , Ovarian Reserve , Prophylactic Surgical Procedures , Reproductive Medicine , Salpingectomy , SterilizationABSTRACT
OBJECTIVE: This study aimed to investigate the association between preterm birth and epigenetic mechanisms in the amnion. METHODS: We examined the association between differentially methylated regions (DMRs) and differentially expressed genes (DEG) using a cytosine-phosphate-guanine methylation array and whole-transcriptome sequencing from the amnion (preterm birth, n=5; full term, n=5). We enrolled 35 participants for mRNA expression analysis and pyrosequencing: 16 full-term and 19 preterm subjects. We compared the association of integrin subunit alpha 11 (ITGA11) and thrombospondin 2 (THBS2) gene methylation status with mRNA expression in the amnion. RESULTS: In the preterm birth group, methylation of ITGA11 and THBS2 genes was significantly lower (ITGA11 gene: 60.30% vs. 73.16%, P < 0.05; THBS2 gene: 64.59% vs. 73.16%, P < 0.05), and the expression of the genes was significantly higher than that in the full-term group (ITGA11 gene: 14.20 vs. 1.57, P < 0.01; THBS2 gene: 1.18 vs. 10.34, P < 0.05). CONCLUSION: Methylation of the ITGA11 and THBS2 genes in the amnion was associated with preterm birth. Thus, ITGA11 and THBS2 gene methylation status in the amnion may be valuable in explaining the mechanism underlying preterm birth.
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Amnion , Epigenomics , Gene Expression , Methylation , Parturition , Premature Birth , RNA, Messenger , ThrombospondinsABSTRACT
BACKGROUND: There have been many voices highlighting the necessity of preconception care as a preventive approach to achieve better pregnancy outcomes for health promotion of mothers and babies. It is important to get preconception care for both men and women, as they play equally important roles for healthy pregnancy. Also, awareness and knowledge of men and women about their health are important factors for behavioral changes for preconception care. PURPOSE: The purpose of this study is to analyze the level of awareness about men and women's preconception care and knowledge of the determinants of healthy pregnancy by gender. Our second goal was to compare men and women's level of awareness and knowledge on it. METHODS: The participants were 500 males and females (aged over 19 years and under 49 years old) either living or working in Seoul city. The data collection period of the study was from July to December, 2017. An online survey was conducted using a panel of online vendors. Then the collected data were analyzed using SPSS 24.0. RESULTS: Awareness about both men and women's preconception care was significantly higher in women than in men (p=0.004, p=0.002). Furthermore, there was a significant difference between men and women (p=0.00) in the total score of knowledge on the determinants of preconception care, including smoking, alcohol drinking, age, folic acid intake, and check-up for infectious disease (p=0.00; means women 8.20±1.95 and men 7.27±2.38). Significant gender differences were also found on some items, such as men's alcohol drinking, men's age, men's check-up for infectious disease, women's intake of folic acid, women's check-up for infectious disease. The level of knowledge on men's folic acid intake was the lowest in both men and women. CONCLUSION: Based on the results on the analysis of gender differences in the awareness and knowledge about preconception care, it is necessary to develop and implement preconception care programs based on the gender perspective approach to make women and men equally share responsibility of the birth result.
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Female , Humans , Male , Pregnancy , Alcohol Drinking , Commerce , Communicable Diseases , Data Collection , Folic Acid , Health Promotion , Mothers , Parturition , Preconception Care , Pregnancy Outcome , Seoul , Smoke , Smoking , VoiceABSTRACT
PURPOSE: To identify the potential risk factors for preterm birth (PTB) in women with advanced maternal age in the Korean population. METHODS: We selected the data of 531 pregnant women and singletons in the Korean Preterm Collaborate Network Study. Among the data, we analyzed variables related to demographic characteristics, lifestyle factors, and delivery information. Maternal age was divided into two groups: younger ( < 35 years) and advanced (≥35 years). Multiple logistic regression analysis was performed to identify the potential risk factors for PTB in advanced maternal age. RESULTS: In advanced maternal age, education level, occupation, passive smoking, iron intake, and parity showed significant differences between term birth and PTB. In particular, women who were exposed to passive smoking (odds ratio [OR]=2.83, confidence interval [CI]=1.14~7.04) and had folic acid intake during pregnancy (OR=2.67, CI=1.11~6.43) were at a significantly increased risk of PTB, after adjusting for all variables. CONCLUSION: This study indicates that smoking and lifestyle factors are the potential risk factors for PTB in advanced maternal age.
Subject(s)
Female , Humans , Pregnancy , Education , Folic Acid , Iron , Life Style , Logistic Models , Maternal Age , Occupations , Parity , Pregnant Women , Premature Birth , Risk Factors , Smoke , Smoking , Term Birth , Tobacco Smoke PollutionABSTRACT
OBJECTIVE: This study was designed to review the screening performance of combined test at the Ewha Womans University Mokdong hospital. METHODS: All women admitted for routine antenatal care between January 1st 2008 and December 31st 2012 with a known pregnancy outcome were included in this study, totaling 1,156 women with singleton pregnancies presenting at 10 to 13 weeks of gestation. Women were offered screening using a combination of maternal serum pregnancy-associated plasma protein-A, free β-human chorionic gonadotropin and fetal nuchal translucency thickness. Those with an estimated risk of ≥1 in 250 of carrying a fetus with trisomy 21 or ≥1 in 300 risk of trisomy 18 were offered genetic counseling with the option of an invasive diagnostic test. RESULTS: The median of gestational age was 11+3 weeks, the median of crown-rump length was 47.1 mm, and the median age of the women was 31 years. The detection rate was 80% for trisomy 21 (4 of 5) and 100% for trisomy 13 and 18 (all 2). The false-positive rate was 7.73% for trisomy 21 and 1.21% for trisomy 18. CONCLUSION: This study was the first large population study performed with the aim of analyzing the performance of the combined test in Korea. This study demonstrated that the detection rates and other figures of the first trimester combined test are comparable to the results reported in other papers worldwide. Consequently, if strict conditions for good screening outcomes are achieved, the first trimester combined test might well be the earliest detectable screening, improving detection rates without increasing karyotyping or economic and other implications that inevitably ensue.
Subject(s)
Female , Humans , Pregnancy , Pregnancy , Chorionic Gonadotropin , Chromosome Aberrations , Crown-Rump Length , Diagnostic Tests, Routine , Down Syndrome , Fetus , Genetic Counseling , Gestational Age , Korea , Mass Screening , Nuchal Translucency Measurement , Pregnancy Outcome , Pregnancy Trimester, First , Pregnancy-Associated Plasma Protein-A , Prenatal Diagnosis , TrisomyABSTRACT
OBJECTIVE: This study was designed to review the screening performance of combined test at the Ewha Womans University Mokdong hospital. METHODS: All women admitted for routine antenatal care between January 1st 2008 and December 31st 2012 with a known pregnancy outcome were included in this study, totaling 1,156 women with singleton pregnancies presenting at 10 to 13 weeks of gestation. Women were offered screening using a combination of maternal serum pregnancy-associated plasma protein-A, free β-human chorionic gonadotropin and fetal nuchal translucency thickness. Those with an estimated risk of ≥1 in 250 of carrying a fetus with trisomy 21 or ≥1 in 300 risk of trisomy 18 were offered genetic counseling with the option of an invasive diagnostic test. RESULTS: The median of gestational age was 11+3 weeks, the median of crown-rump length was 47.1 mm, and the median age of the women was 31 years. The detection rate was 80% for trisomy 21 (4 of 5) and 100% for trisomy 13 and 18 (all 2). The false-positive rate was 7.73% for trisomy 21 and 1.21% for trisomy 18. CONCLUSION: This study was the first large population study performed with the aim of analyzing the performance of the combined test in Korea. This study demonstrated that the detection rates and other figures of the first trimester combined test are comparable to the results reported in other papers worldwide. Consequently, if strict conditions for good screening outcomes are achieved, the first trimester combined test might well be the earliest detectable screening, improving detection rates without increasing karyotyping or economic and other implications that inevitably ensue.
Subject(s)
Female , Humans , Pregnancy , Pregnancy , Chorionic Gonadotropin , Chromosome Aberrations , Crown-Rump Length , Diagnostic Tests, Routine , Down Syndrome , Fetus , Genetic Counseling , Gestational Age , Korea , Mass Screening , Nuchal Translucency Measurement , Pregnancy Outcome , Pregnancy Trimester, First , Pregnancy-Associated Plasma Protein-A , Prenatal Diagnosis , TrisomyABSTRACT
PURPOSE: This study was designed to investigate an accuracy of visual estimation of blood loss and the usefulness of simulation-based educational program for postpartum hemorrhage. METHODS: The participants included 12 nurses and 8 residents who were working at Mother and Baby Center of Ewha Womans University Hospital. A simulation-based education for estimation of blood loss was conducted for all of the participants. Tests were performed before and after simulation-based education. Two additional tests were performed two and four weeks after the education. Self-confidence score for blood loss estimation was also investigated by questionnaire. RESULTS: Significant underestimation was observed in all questions of 450, 700, and 1,100 mL. Median for percent errors of each questions were -50%, -29%, and -9%, respectively. After simulation-based education, accuracy was improved with the medians of -5%, 0%, and 13%. Selfconfidence score in visual estimation of blood loss was also improved significantly after the education. There were no differences by profession or work experience. CONCLUSION: Significant underestimation was seen before simulation-based education. This study shows that the accuracy of visual blood loss estimation was improved after education. Accurate estimation of blood loss will contribute to a timely diagnosis and resuscitation in postpartum hemorrhage. Our study suggests that periodic education for visual estimation of blood loss in obstetrical hemorrhage might improve accuracy and clinical outcome.
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Female , Humans , Diagnosis , Education , Hemorrhage , Learning , Mothers , Postpartum Hemorrhage , Postpartum Period , ResuscitationABSTRACT
Only a few reports have been published on women with an infectious respiratory viral pathogen, such as Middle East Respiratory Syndrome (MERS) Coronavirus delivering a baby. A laboratory confirmed case of MERS was reported during a MERS outbreak in the Republic of Korea in a woman at gestational week 35 + 4. She recovered, and delivered a healthy baby by emergency cesarean section (C-sec). We present the clinical course and the emergency C-sec in a pregnant woman with MERS.
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Female , Humans , Pregnancy , Cesarean Section , Coronavirus , Coronavirus Infections , Emergencies , Middle East Respiratory Syndrome Coronavirus , Middle East , Pregnant Women , Republic of KoreaABSTRACT
PURPOSE: This study aimed to investigate the safe medication utilization and the education demands during pregnancy and it further reported the development of educational materials for pregnant women. METHODS: A survey was conducted in two tertiary care university hospitals and one community hospital specialized in obstetrics and gynecology from July 2 to 29 2014. The survey questionnaires included the usage of medications and the unmet needs on medication use during pregnancy. Ad ditionally, pregnant women's requests regarding to medication use were collected through group interviewing of community pharmacists. Based on these results, educational materials were de veloped and implemented. After implementing the education sessions, the satisfaction was evaluated. RESULTS: A total of 152 pregnant women answered completely the questionnaire. Among them, 130 participants (42.8%) were given the medication information from their physicians. Exposure to a teratogenic drug during pregnancy was a major concern for most pregnant women (79.6%). The majority (90.1%) of subjects reported a necessity of medication-related education during their pregnancy. The interview with 48 pharmacists indicated that the most commonly used OTC drugs in pregnancy were vitamins (25.2%), iron supplements (23.7%), and the most frequently used prescription drugs were antiinflammatory-analgesics (25.3%), followed by antibiotics (20.9 %). Based on the results, booklets of drug therapy during pregnancy, leaflet of pregnancy category index were made. Also, on-line flash and presentation materials for instructors were prepared. Through the trial education with the developed materials, it was confirmed that the contents of education materials were well understood and satisfied by the pregnant women. CONCLUSIONS: This study showed the need of the medication-related education for the pregnant women. The developed education materials would be helpful sources to provide accurate and reliable medication-related information to health professionals and pregnant women.
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Female , Humans , Pregnancy , Anti-Bacterial Agents , Drug Therapy , Education , Gynecology , Health Occupations , Hospitals, Community , Hospitals, University , Interviews as Topic , Iron , Nonprescription Drugs , Obstetrics , Pamphlets , Pharmacists , Pregnant Women , Prescription Drugs , Tertiary Healthcare , VitaminsABSTRACT
A first-trimester ultrasound scan has become an essential part of antenatal care. The Korean Society of Ultrasound in Obstetrics and Gynecology held a first-trimester ultrasound forum on April 5, 2014. The forum aimed to present an updated review of the literature on the topic of first-trimester ultrasound in specific lectures and to host a panel discussion on several important issues regarding first-trimester scans. The forum provided evidence- and consensus-based best practice patterns for obstetricians in Korea. Here, we report the review and checklists presented from the forum.
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Female , Humans , Pregnancy , Checklist , Gynecology , Korea , Lecture , Nuchal Translucency Measurement , Obstetrics , Practice Guidelines as Topic , Pregnancy Trimester, First , UltrasonographyABSTRACT
BACKGROUND: During carotid endarterectomy (CEA), hemodynamic stability and adequate fluid management are crucial to prevent perioperative cerebral stroke, myocardial infarction and hyperperfusion syndrome. Both pulse pressure variation (PPV) and stroke volume variation (SVV), dynamic preload indices derived from the arterial waveform, are increasingly advocated as predictors of fluid responsiveness in mechanically ventilated patients. The aim of this study was to evaluate the accuracy of PPV and SVV for predicting fluid responsiveness in patients undergoing CEA. METHODS: Twenty seven patients undergoing CEA were enrolled in this study. PPV, SVV and cardiac output (CO) were measured before and after fluid loading of 500 ml of hydroxyethyl starch solution. Fluid responsiveness was defined as an increase in CO > or = 15%. The ability of PPV and SVV to predict fluid responsiveness was assessed using receiver operating characteristic (ROC) analysis. RESULTS: Both PPV and SVV measured before fluid loading are associated with changes in CO caused by fluid expansion. The ROC analysis showed that PPV and SVV predicted response to volume loading (area under the ROC curve = 0.854 and 0.841, respectively, P or = 9.5% identified responders (Rs) with a sensitivity of 71.4% and a specificity of 90.9%, and a SVV > or = 7.5% identified Rs with a sensitivity of 92.9% and a specificity of 63.6%. CONCLUSIONS: Both PPV and SVV values before volume loading are associated with increased CO in response to volume expansion. Therefore, PPV and SVV are useful predictors of fluid responsiveness in patients undergoing CEA.