Opioid-Related Overdose Deaths in Maryland (2018), by Industry and Occupation.

OBJECTIVES: Opioid-related overdose deaths (OROD) increase annually, yet little is known about workplace risk factors. This study assessed differences in OROD rates across industry and occupation in Maryland, in addition to demographic differences within industry and occupation. METHODS: The 2018 State Unintentional Drug Overdose Reporting System was used to compare OROD between industries and occupations. RESULTS: The leading industries in OROD included the following: construction, manufacturing, and transportation and warehousing. Occupational groups were similar: construction and extraction, production, and transportation and material moving. There were also differences by sex (greater rates in men), age (greater rates in older workers), and race/ethnicity (varied patterns in rates). CONCLUSIONS: Employers and state leaders should work collaboratively to target prevention and intervention for workplaces at highest risk for OROD. Construction was highest and needs supports that respond to the workplace culture.

Item Response Theory Analysis: PROMIS® Anxiety Form and Generalized Anxiety Disorder Scale.

Little research has compared item functioning of the Patient-Reported Outcomes Measurement Information System (PROMIS®) anxiety short form 6a and the generalized anxiety disorder 7-item scale using item response theory models. This was a secondary analysis of self-reported assessments from 67 at-risk U.S. military veterans. The two measures performed comparably well with data fitting adequately to models, acceptable item discriminations, and item and test information curves being unimodal and symmetric. The PROMIS® anxiety short form 6a performed better in that item difficulty estimates had a wider range and distributed more evenly and all response categories had less floor effect, while the third category in most items of the generalized anxiety disorder 7-item scale were rarely used. While both measures may be appropriate, findings provided preliminary information supporting use of the PROMIS® anxiety short form 6a as potentially preferable, especially for veterans with low-to-moderate anxiety. Further testing is needed in larger, more diverse samples.

Systematic review and meta-analysis of retention in treatment using medications for opioid use disorder by medication, race/ethnicity, and gender in the United States.

BACKGROUND AND AIMS: There is mounting evidence that opioid use disorder is experienced differently by people of different genders and race/ethnicity groups. Similarly, in the US access to specific medications for opioid use is limited by gender and race/ethnicity. This study aims to evaluate if gender or race/ethnicity is associated with different rates of treatment retention in the US, for each of three medications used to treat opioid use disorder. METHODS: A systematic search was conducted using PubMed, CINHAL, and PsychINFO, databases. All studies that provided a ratio of those retained in treatment at a specified time in terms of gender and/or race/ethnicity and medication were included. Variables were created to assess the effects of time in treatment, recruited sample, required attendance at concurrent psychosocial treatment, and adherence to strict rules of conduct for continuation in treatment on retention. Meta-analytical and meta-regression methods were used to compare studies on the ratio of those who completed a specific time in treatment by race/ethnicity group and by gender. RESULTS: Nineteen articles that provided the outcome variable of interest were found (11 buprenorphine, six methadone, and two naltrexone). Meta-analyses found that treatment retention was similar for all gender and racial/ethnic groups for all three medications. Meta-regression found that those of the African American group who were recruited into buprenorphine treatment were retained significantly longer than African Americans in buprenorphine treatment who were studied retrospectively. Also, both genders had significantly lower retention in methadone treatment when there was the additional requirement of psychosocial therapy.

Organizational trauma-informed care: Associations with individual and agency factors.

In response to the growing awareness of the high rates of potentially traumatic experiences and their potential adverse impacts, health and human service providers have increasingly focused on implementing trauma-informed care (TIC). However, studies focusing on effective implementation have been limited. In this study, we explored the relationship of individual and agency characteristics to the level of organizational TIC. With data collected from a sample of 345 providers from 67 agencies, we used the TICOMETER, a brief measure of organizational TIC with strong psychometric properties, to determine these associations. We found weak relationships between individual factors and TICOMETER scores and stronger associations for agency-level factors. These included agency type, time since last trauma training, and involvement of service users. These findings highlight the importance of robust cultural changes, service user involvement at all levels of the organization, flattening power differentials, and providing ongoing experiential training. This analysis fills an important gap in our knowledge of how best to ensure agency-wide provision of TIC. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Improved pharmacodynamic (PD) assessment of low dose PARP inhibitor PD activity for radiotherapy and chemotherapy combination trials.

BACKGROUND: PARP inhibitors are currently evaluated in combination with radiotherapy and/or chemotherapy. As sensitizers, PARP inhibitors are active at very low concentrations therefore requiring highly sensitive pharmacodynamic (PD) assays. Current clinical PD-assays partly fail to provide such sensitivities. The aim of our study was to enable sensitive PD evaluation of PARP inhibitors for clinical sensitizer development. MATERIAL AND METHODS: PBMCs of healthy individuals and of olaparib and radiotherapy treated lung cancer patients were collected for ELISA-based PD-assays. RESULTS: PAR-signal amplification by ex vivo irradiation enabled an extended quantification range for PARP inhibitory activities after ex vivo treatment with inhibitors. This "radiation-enhanced-PAR" (REP) assay provided accurate IC50 values thereby also revealing differences among healthy individuals. Implemented in clinical radiotherapy combination Phase I trials, the REP-assay showed sensitive detection of PARP inhibition in patients treated with olaparib and establishes strong PARP inhibitory activities at low daily doses. CONCLUSIONS: Combination trials of radiotherapy and novel targeted agent(s) often require different and more sensitive PD assessments than in the monotherapy setting. This study shows the benefit and relevance of sensitive and adapted PD-assays for such combination purposes and provides proof of clinically relevant cellular PARP inhibitory activities at low daily olaparib doses.

US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations.

BACKGROUND: US opioid overdose death rates have increased between 2000 and 2014. While, the increase in prescription opioid use has been linked to the increase in heroin use, there are reasons to view this relationship as a partial explanation for the recent increase in heroin-related harms. This study documents the differences in trends in prescription opioid overdose-related (POD) and heroin overdose-related (HOD) hospitalizations. METHODS: Data come from the National Inpatient Sample (NIS) for the years 2000 through 2014. POD and HOD hospitalizations were abstracted from ICD-9 codes. Rates of POD and HOD by census region and census division were constructed along with separate rates for age and race. Regression analysis analyzing trends across region were estimated along with graphs for documenting differences in POD and HOD rates. RESULTS: POD hospitalization rates were highest in the South and lowest in the Northeast. HOD hospitalization rates were highest in the Northeast region and grew the fastest in the Midwest. There was statistically significant heterogeneity in HOD trends but not POD trends across the four regions between 2000 and 2014. Between 2012 and 2014 POD rates decreased in eight of the nine census divisions, with only New England showing an increase. HOD hospitalization rates increased in all nine census divisions between 2012 and 2014. Both POD and HOD rates show different demographic patterns across the nine census divisions. CONCLUSION: Comparing POD and HOD hospitalization trends reveals significant disparities in geographic as well as demographic distributions. These epidemics are evolving and the simple opioid-to-heroin transition story is both supported and challenged by this paper. The opioid pill, heroin and fentanyl crises are intertwined yet increasingly have drivers and outcomes that support examining them as distinct. Addressing these complex and interrelated epidemics will require innovative public health research and interventions which need to consider local and regional contexts.

Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions.

INTRODUCTION: Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination. METHODS: Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price. RESULTS: Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities. DISCUSSION: Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

Alcohol-Related Diagnoses in Hospital Admissions for All Causes Among Middle-Aged and Older Adults: Trends and Cohort Differences From 1993 to 2010.

OBJECTIVE: This aim of this study was to characterize trends in alcohol-related hospital admissions among middle-aged and older adults from 1993 to 2010 in relation to age, gender, race, and cohort membership. METHOD: This study utilized repeated cross-sectional data from the Nationwide Inpatient Sample. Using alcohol-related classified admissions, yearly rates and longitudinal trends of alcohol-related inpatient hospitalizations based on age, period, birth cohort, gender, and race were estimated. RESULTS: Among those aged 45 and older, admissions rose from an estimated 610,634 to more than 1,134,876, and rates of any alcohol-related diagnosis also increased from 1993 to 2010. Rates for men were consistently higher than women, and rates for Blacks were higher than Whites. Age was associated with decreasing rates, but post-World War II cohorts displayed higher rates over time. DISCUSSION: Rates of alcohol-related admissions are increasing among adults above age 45, which may be a function of cohort effects. Training the health care workforce is crucial to respond to this trend.

In vitro microtumors provide a physiologically predictive tool for breast cancer therapeutic screening.

Many anti-cancer drugs fail in human trials despite showing efficacy in preclinical models. It is clear that the in vitro assays involving 2D monoculture do not reflect the complex extracellular matrix, chemical, and cellular microenvironment of the tumor tissue, and this may explain the failure of 2D models to predict clinical efficacy. We first optimized an in vitro microtumor model using a tumor-aligned ECM, a tumor-aligned medium, MCF-7 and MDA-MB-231 breast cancer spheroids, human umbilical vein endothelial cells, and human stromal cells to recapitulate the tissue architecture, chemical environment, and cellular organization of a growing and invading tumor. We assayed the microtumor for cell proliferation and invasion in a tumor-aligned extracellular matrix, exhibiting collagen deposition, acidity, glucose deprivation, and hypoxia. We found maximal proliferation and invasion when the multicellular spheroids were cultured in a tumor-aligned medium, having low pH and low glucose, with 10% fetal bovine serum under hypoxic conditions. In a 7-day assay, varying doses of fluorouracil or paclitaxel had differential effects on proliferation for MCF-7 and MDA-MB-231 tumor spheroids in microtumor compared to 2D and 3D monoculture. The microtumors exhibited a tumor morphology and drug response similar to published xenograft data, thus demonstrating a more physiologically predictive in vitro model.

Hospital outcomes in major depression among older adults: differences by alcohol comorbidity.

OBJECTIVE: The prevalence of depression in older adults has been increasing over the last 20 years and is associated with economic costs in the form of treatment utilization and caregiving, including inpatient hospitalization. Comorbid alcohol diagnoses may serve as a complicating factor in inpatient admissions and may lead to overutilization of care and greater economic cost. This study sought to isolate the comorbidity effect of alcohol among older adult hospital admissions for depression. METHODS: We analyzed a subsample (N = 8,480) of older adults (65+) from the 2010 Nationwide Inpatient Sample who were hospitalized with primary depression diagnoses, 7,741 of whom had depression only and 739 of whom also had a comorbid alcohol disorder. To address potential selection bias based on drinking and health status, propensity score matching was used to compare length of stay, total costs, and disposition between the two groups. RESULTS: Bivariate analyses showed that older persons with depression and alcohol comorbidities were more often male (59.9% versus 34.0%, p <.001) and younger (70.9 versus 75.9 years, p <.001) than those with depression only. In terms of medical comorbidities, those with depression and alcohol disorders experienced more medical issues related to substance use (e.g., drug use diagnoses, liver disease, and suicidality; all p <.001), while those with depression only experienced more general medical problems (e.g., diabetes, renal failure, hypothyroid, and dementia; all p <.001). Propensity score matched models found that alcohol comorbidity was associated with shorter lengths of stay (on average 1.08 days, p <.02) and lower likelihood of post-hospitalization placement in a nursing home or other care facility (OR = 0.64, p <.001). No significant differences were found in overall costs or likelihood of discharge to a psychiatric hospital. CONCLUSIONS: In older adults, depression with alcohol comorbidity does not lead to increased costs or higher levels of care after discharge. Comorbidity may lead to inpatient hospitalization at lower levels of severity, and depression with alcohol comorbidity may be qualitatively different than non-comorbid depression. Additionally, increased costs and negative outcomes in this population may occur at other levels of care such as outpatient services or emergency department visits.

Matrigel: from discovery and ECM mimicry to assays and models for cancer research.

The basement membrane is an important extracellular matrix that is found in all epithelial and endothelial tissues. It maintains tissue integrity, serves as a barrier to cells and to molecules, separates different tissue types, transduces mechanical signals, and has many biological functions that help to maintain tissue specificity. A well-defined soluble basement membrane extract, termed BME/Matrigel, prepared from an epithelial tumor is similar in content to authentic basement membrane, and forms a hydrogel at 24-37°C. It is used in vitro as a substrate for 3D cell culture, in suspension for spheroid culture, and for various assays, such as angiogenesis, invasion, and dormancy. In vivo, BME/Matrigel is used for angiogenesis assays and to promote xenograft and patient-derived biopsy take and growth. Studies have shown that both the stiffness of the BME/Matrigel and its components (i.e. chemical signals) are responsible for its activity with so many different cell types. BME/Matrigel has widespread use in assays and in models that improve our understanding of tumor biology and help define therapeutic approaches.

Urban segregation and the US heroin market: a quantitative model of anthropological hypotheses from an inner-city drug market.

BACKGROUND: We hypothesize that the location of highly segregated Hispanic and in particular Puerto Rican neighborhoods can explain how Colombian-sourced heroin, which is associated with a large-scale decade long decline in heroin price and increase in purity, was able to enter and proliferate in the US. METHODS: Our multidisciplinary analysis quantitatively operationalizes participant-observation ethnographic hypotheses informed by social science theory addressing complex political economic, historical, cultural and social processes. First, we ethnographically document the intersection of structural forces shaping Philadelphia's hypersegregated Puerto Rican community as a regional epicenter of the US heroin market. Second, we estimate the relationship between segregation and: (a) the entry of Colombian heroin into the US, and (b) the retail price per pure gram of heroin in 21 Metropolitan Statistical Areas. RESULTS: Ethnographic evidence documents how poverty, historically-patterned antagonistic race relations, an interstitial socio-cultural political and geographic linkage to both Caribbean drug trafficking routes and the United States and kinship solidarities combine to position poor Puerto Rican neighborhoods as commercial distribution centers for high quality, low cost Colombian heroin. Quantitative analysis shows that heroin markets in cities with highly segregated Puerto Rican communities were more quickly saturated with Colombian-sourced heroin. The level of Hispanic segregation (specifically in cities with a high level of Puerto Rican segregation) had a significant negative association with heroin price from 1990 to 2000. By contrast, there is no correlation between African-American segregation and Colombian-sourced heroin prevalence or price. CONCLUSION: Our iterative mixed methods dialogue allows for the development and testing of complex social science hypotheses and reduces the limitations specific to each method used in isolation. We build on prior research that assumes geographic proximity to source countries is the most important factor in determining illicit drug prices and purity, while we find more complex, potentially modifiable determinants of geographic variation in retail drug markets. We show that specific patterns of ethnic segregation, racism, poverty and the political economy of socio-cultural survival strategies combined to facilitate the entry of pure, inexpensive Colombian-sourced heroin.

The entry of Colombian-sourced heroin into the US market: the relationship between competition, price, and purity.

There have been large structural changes in the US heroin market over the past 20 years. Colombian-sourced heroin entered the market in the mid-1990s, followed by a large fall in the price per pure gram and the exit of Asian heroin. By the 2000s, Colombian-sourced heroin had become a monopoly on the east coast and Mexican-sourced heroin a monopoly on the west coast with competition between the two in the middle. We estimate the relationship between these changes in competitive market structure on retail-level heroin price and purity. We find that the entry of Colombian-sourced heroin is associated with less competition and a lower price per pure gram of heroin at the national level. However, there is wide variation in changes in market concentration across the US. Controlling for the national fall in the heroin price, more competition in a region or city is associated with a lower price per pure gram.

Illness severity and psychiatric hospitalization rates among Asian Americans and Pacific Islanders.

OBJECTIVE The study objective was to fill research gaps about inpatient psychiatric service utilization among Asian Americans and Pacific Islanders (AA/PIs). METHODS Rates of psychiatric hospitalization, illness severity, and length of stay were compared among AA/PI adults overall and across diagnoses (schizophrenia, depression, bipolar, anxiety, and other psychiatric disorders identified by All Patient Refined Diagnosis Related Groups) by using discharge data from all hospitalizations in Hawaii from December 2006 to 2010. Multivariable models adjusted for gender, age, payer, and residence. RESULTS In multivariable analyses of total psychiatric hospitalizations, Chinese (rate ratio [RR]=.22), Japanese (RR=.23), Filipinos (RR=.30), and Native Hawaiians (RR=.37) had significantly lower rates than whites. Native Hawaiians had significantly higher hospitalization rates compared with other AA/PI groups. Length of stay was significantly longer for Chinese (length of stay ratio [LOSR]=1.53), Filipinos (LOSR=1.20), and Japanese (LOSR=1.19) compared with whites, whereas severity of illness was significantly higher for Japanese (odds ratio [OR]=1.36) and Filipinos (OR=1.30). Within specific diagnoses, Native Hawaiians had higher hospitalization rates than other AA/PI groups for depression, bipolar disorder, and anxiety disorder. Chinese, Japanese, and Filipinos had significantly higher illness severity or longer stays than whites for at least one diagnostic category. CONCLUSIONS AA/PI subgroups had lower psychiatric hospitalization rates than whites, but rates varied across AA/PI subgroups. Native Hawaiians had higher hospitalization rates for many diagnoses. Chinese, Japanese, and Filipinos had greater illness severity or longer stays than whites overall and for some diagnoses, whereas Native Hawaiians did not. Disaggregating AA/PI groups provides important insight into mental health services utilization and need.

Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009.

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.

Basement membrane matrix (BME) has multiple uses with stem cells.

The utilization of basement membrane matrix has helped to overcome many of the obstacles associated with stem cell research. Initially, there were several problems with investigating stem cells, including difficult extraction from tissues, the need for feeder layers, poor survival, minimal proliferation, limited differentiation in vitro, and inadequate survival when injected or transplanted in vivo. Given that the basement membrane is the first extracellular matrix that is produced by the developing embryo, it was quickly identified as an important factor for modulating stem cell behavior, and since then, basement membrane extract (BME) has been successfully employed in numerous methods as a substratum in vitro and as a bioactive support in vivo to overcome many of these problems. A thin BME coating is sufficient to maintain an undifferentiated phenotype during embryonic stem cell expansion, while a thick BME hydrogel may be employed to induce stem cell differentiation. BME also promotes stem cell survival for in vivo applications and provides a physiological environment for evaluating stem cell co-culture with other cell types. The present article provides a concise review of current methodologies utilizing BME for stem cell research.

Multiple uses of basement membrane-like matrix (BME/Matrigel) in vitro and in vivo with cancer cells.

Significant advances in our understanding of cancer cell behavior, growth, and metastasis have been facilitated by studies using a basement membrane-like extracellular matrix extract, also known as Matrigel. The basement membrane is a thin extracellular matrix that is found in normal tissues and contacts epithelial and endothelial cells, smooth muscle, fat, Schwann cells, etc. It is composed of mainly laminin-111, collagen IV, heparan sulfate proteoglycan, entactin/nidogen, and various growth factors (fibroblast growth factor, transforming growth factor beta, epidermal growth factor, etc.). Most tumors of epithelial origin produce significant amounts of basement membrane matrix and interact with it particularly during metastasis. Cancer cells metastasize via degradation of the vessel basement membrane matrix to extravasate into the blood stream and colonize distant sites. This review will focus on the interaction of cancer cells and cancer stem cells with the basement membrane-like matrix and the various uses of this interaction to accelerate tumor growth in vivo and to develop in vitro assays for invasion, morphology, and dormancy. Such assays and methods have advanced our understanding of the process of cancer progression, the genes and pathways that are involved, the potential of various therapeutic agents, the effects of neighboring cells, and the role of stem cells.

Laminin-1 induces E-cadherin expression in 3-dimensional cultured breast cancer cells by inhibiting DNA methyltransferase 1 and reversing promoter methylation status.

This study determines the role of laminin-1 in promoting metastatic colonization during breast cancer. For this purpose, human mammary epithelial cell lines representing normal (MCF-10A), adenocarcinoma (MCF-7), and malignant carcinoma (MDA-MB-231) were propagated in 3-dimensional cultures composed of laminin-1, collagen I, or mixtures of the two, and analyzed by Western blot, immunocytochemistry, semiquantitative reverse transcription polymerase chain reaction, and methylation-specific PCR. Here we demonstrate that laminin-1 decreases methylation of the E-cadherin promoter, resulting in increased mRNA and protein expression for malignant mammary epithelial cells. This decreased methylation is associated with dramatic changes in the cellular and structural morphology as well as a 70-fold decrease in DNA methyltransferase 1 (DNMT1) and a 6-fold decrease in cadherin 11 protein expression. To control for specificity of laminin-1 interactions, cells were also cultured on 2-dimensional plastic substrata and collagen I hydrogels for analysis, and the MCF-10A and MCF-7 were used as nonmalignant controls. Using a 3-dimensional model, we present evidence that laminin-1 is capable of inducing epigenetic change by inhibiting expression of DNMT1 and preventing methylation of the E-cadherin promoter, resulting in E-cadherin expression and the formation of cell-cell bonds in malignant carcinoma.

The endothelial cell tube formation assay on basement membrane turns 20: state of the science and the art.

It has been more than 20 years since it was first demonstrated that endothelial cells will rapidly form capillary-like structures in vitro when plated on top of a reconstituted basement membrane extracellular matrix (BME, Matrigel, EHS matrix, etc.). Subsequently, this morphological differentiation has been demonstrated with a variety of endothelial cells; with endothelial progenitor cells; and with transformed/immortalized endothelial cells. The differentiation process involves several steps in blood vessel formation, including cell adhesion, migration, alignment, protease secretion, and tubule formation. Because the formation of vessel structures is rapid and quantifiable, endothelial cell differentiation on basement membrane has found numerous applications in assays. Such differentiation has been used (1) to study angiogenic and antiangiogenic factors, (2) to define mechanisms and pathways involved in angiogenesis, and (3) to define endothelial cell populations. Further, the endothelial cell differentiation assay has been successfully used to study processes ranging from wound repair and reproduction to development and tumor growth. The assay is easy to perform and is the most widely used in vitro angiogenesis assay.