Using short-read 16S rRNA sequencing of multiple variable regions to generate high-quality results to a species level.

Introduction: Short-read amplicon sequencing studies have typically focused on 1-2 variable regions of the 16S rRNA gene. Species-level resolution is limited in these studies, as each variable region enables the characterisation of a different subsection of the microbiome. Although long-read sequencing techniques take advantage of all 9 variable regions by sequencing the entire 16S rRNA gene, they are substantially more expensive. This work assessed the feasibility of accurate species-level resolution and reproducibility using a relatively new sequencing kit and bioinformatics pipeline developed for short-read sequencing of multiple variable regions of the 16S rRNA gene. In addition, we evaluated the potential impact of different sample collection methods on our outcomes. Methods: Using xGen™ 16S Amplicon Panel v2 kits, sequencing of all 9 variable regions of the 16S rRNA gene was carried out on an Illumina MiSeq platform. Mock cells and mock DNA for 8 bacterial species were included as extraction and sequencing controls respectively. Within-run and between-run replicate samples, and pairs of stool and rectal swabs collected at 0-5 weeks from the same participants, were incorporated. Observed relative abundances of each species were compared to theoretical abundances provided by ZymoBIOMICS. Paired Wilcoxon rank sum tests and distance-based intraclass correlation coefficients were used to statistically compare alpha and beta diversity measures, respectively, for pairs of replicates and stool/rectal swab sample pairs. Results: Using multiple variable regions of the 16S ribosomal Ribonucleic Acid (rRNA) gene, we found that we could accurately identify taxa to a species level and obtain highly reproducible results at a species level. Yet, the microbial profiles of stool and rectal swab sample pairs differed substantially despite being collected concurrently from the same infants. Conclusion: This protocol provides an effective means for studying infant gut microbial samples at a species level. However, sample collection approaches need to be accounted for in any downstream analysis.

Co-designing a Health Journey Mapping resource for culturally safe health care with and for First Nations people.

Background Many healthcare professionals and services strive to improve cultural safety of care for Australia's First Nations people. However, they work within established systems and structures that do not reliably meet diverse health care needs nor reflect culturally safe paradigms. Journey mapping approaches can improve understanding of patient/client healthcare priorities and care delivery challenges from healthcare professionals' perspectives leading to improved responses that address discriminatory practices and institutional racism. This project aimed to review accessibility and usability of the existing Managing Two Worlds Together (MTWT) patient journey mapping tools and resources, and develop new Health Journey Mapping (HJM) tools and resources. Method Four repeated cycles of collaborative participatory action research were undertaken using repeated cycles of look and listen, think and discuss, take action together. A literature search and survey were conducted to review accessibility and usability of MTWT tools and resources. First Nations patients and families, and First Nations and non-First Nations researchers, hospital and university educators and healthcare professionals (end users), reviewed and tested HJM prototypes, shaping design, format and focus. Results The MTWT tool and resources have been used across multiple health care, research and education settings. However, many users experienced initial difficulty engaging with the tool and offered suggested improvements in design and usability. End user feedback on HJM prototypes identified the need for three distinct mapping tools for three different purposes: clinical care, detailed care planning and strategic mapping, to be accompanied by comprehensive resource materials, instructional guides, videos and case study examples. These were linked to continuous quality improvement and accreditation standards to enhance uptake in healthcare settings. Conclusion The new HJM tools and resources effectively map diverse journeys and assist recognition and application of strengths-based, holistic and culturally safe approaches to health care.

A review of the auditory-gut-brain axis.

Hearing loss places a substantial burden on medical resources across the world and impacts quality of life for those affected. Further, it can occur peripherally and/or centrally. With many possible causes of hearing loss, there is scope for investigating the underlying mechanisms involved. Various signaling pathways connecting gut microbes and the brain (the gut-brain axis) have been identified and well established in a variety of diseases and disorders. However, the role of these pathways in providing links to other parts of the body has not been explored in much depth. Therefore, the aim of this review is to explore potential underlying mechanisms that connect the auditory system to the gut-brain axis. Using select keywords in PubMed, and additional hand-searching in google scholar, relevant studies were identified. In this review we summarize the key players in the auditory-gut-brain axis under four subheadings: anatomical, extracellular, immune and dietary. Firstly, we identify important anatomical structures in the auditory-gut-brain axis, particularly highlighting a direct connection provided by the vagus nerve. Leading on from this we discuss several extracellular signaling pathways which might connect the ear, gut and brain. A link is established between inflammatory responses in the ear and gut microbiome-altering interventions, highlighting a contribution of the immune system. Finally, we discuss the contribution of diet to the auditory-gut-brain axis. Based on the reviewed literature, we propose numerous possible key players connecting the auditory system to the gut-brain axis. In the future, a more thorough investigation of these key players in animal models and human research may provide insight and assist in developing effective interventions for treating hearing loss.

Reporting and conducting patient journey mapping research in healthcare: A scoping review.

AIM: To identify how patient journey mapping is being undertaken and reported. DESIGN: A scoping review of the literature was undertaken using JBI guidance. DATA SOURCES: Databases were searched in July 2021 (16th-21st), including Ovid's Medline, Embase, Emcare and PsycINFO; Scopus; Web of Science Core Collection, the Directory of Open Access Journals; Informit and; ProQuest Dissertations and Theses Global. REVIEW METHODS: Eligible articles included peer-reviewed literature documenting journey mapping methodologies and studies conducted in healthcare services. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full-text articles. A table was used to extract data and synthesize results. RESULTS: Eighty-one articles were included. An acceleration of patient journey mapping research was observed, with 76.5% (n = 62) of articles published since 2015. Diverse mapping approaches were identified. Reporting of studies was inconsistent and largely non-adherent with relevant, established reporting guidelines. CONCLUSION: Patient journey mapping is a relatively novel approach for understanding patient experiences and is increasingly being adopted. There is variation in process details reported. Considerations for improving reporting standards are provided. IMPACT: Patient journey mapping is a rapidly growing approach for better understanding how people enter, experience and exit health services. This type of methodology has significant potential to inform new, patient centred models of care and facilitate clinicians, patients and health professionals to better understand gaps and strategies in health services. The synthesised results of this review alert researchers to options available for journey mapping research and provide preliminary guidance for elevating reporting quality.

Using Simulation to Assess Nurse Practitioner Education.

ABSTRACT: Resource restraints and the movement toward competency-based education encourage exploration of innovative simulation experiences in advanced practice registered nurse education. Building upon existing best practices in simulation development, this pilot project explores opportunities and challenges translating these practices to the advanced practice registered nurse context. Innovations focused on using a competency-based framework, developing a competency-based evaluation tool, and providing feedback from faculty and standardized patients. Lessons learned from this experience inform recommendations for how to design instructional experiences and provide formative methods of feedback for nurse practitioner student assessment.

The biguanide polyamine analog verlindamycin promotes differentiation in neuroblastoma via induction of antizyme.

Deregulated polyamine biosynthesis is emerging as a common feature of neuroblastoma and drugs targeting this metabolic pathway such as DFMO are in clinical and preclinical development. The polyamine analog verlindamycin inhibits the polyamine biosynthesis pathway enzymes SMOX and PAOX, as well as the histone demethylase LSD1. Based on our previous research in acute myeloid leukemia (AML), we reasoned verlindamycin may also unblock neuroblastoma differentiation when combined with all-trans-retinoic acid (ATRA). Indeed, co-treatment with verlindamycin and ATRA strongly induced differentiation regardless of MYCN status, but in MYCN-expressing cells, protein levels were strongly diminished. This process was not transcriptionally regulated but was due to increased degradation of MYCN protein, at least in part via ubiquitin-independent, proteasome-dependent destruction. Here we report that verlindamycin effectively induces the expression of functional tumor suppressor-antizyme via ribosomal frameshifting. Consistent with previous results describing the function of antizyme, we found that verlindamycin treatment led to the selective targeting of ornithine decarboxylase (the rate-limiting enzyme for polyamine biosynthesis) as well as key oncoproteins, such as cyclin D and Aurora A kinase. Retinoid-based multimodal differentiation therapy is one of the few interventions that extends relapse-free survival in MYCN-associated high-risk neuroblastoma and these results point toward the potential use of verlindamycin in this regimen.

Considerations for user consultation in a flow cytometry shared resource laboratory.

User consultation is an essential first step in assuring high-quality flow cytometric data. A central challenge to shared resource laboratory (SRL) staff is how to best guide new and current users to meet each projects' needs. One solution to this challenge is to follow a standard user consultation platform addressing all critical steps between the conception of the experiment and the actual acquisition of samples. Here we describe considerations to help an SRL understand the researcher's goals and how best the SRL staff can provide expert advice in a structured manner. User consultation has an educational nature, informing users about current best practices in cytometry that apply to their specific utilization. A consultation report also improves communication between the SRL, principal investigator, and lab members of the collaborating researcher. Development of best SRL practices is spearheaded by the ISAC SRL committee and this communication sets the foundation to initiate such report for user consultation. Implementation of best practices during user consultation will improve rigor and reproducibility in cytometry.

Reporting of patient journey mapping in current literature: a scoping review protocol.

OBJECTIVE: This scoping review will assess the literature that documents or utilizes patient journey mapping methodologies in health care settings. It will also examine the reporting processes of studies that use this methodology. INTRODUCTION: Health care systems are complex and can be challenging for patients to navigate. Using patient journey mapping as a research method promotes a deeper understanding of patient experiences when navigating these systems. Patient journey mapping provides valuable insights into where systems are working well, where gaps in care exist, and how the system could respond to these gaps. INCLUSION CRITERIA: This review will consider peer-reviewed articles and publicly available academic literature documenting patient journey mapping methodologies. The review will also consider studies providing guidance and recommendations on how to report patient journey mapping studies in health care services and systems. METHODS: The proposed review will follow JBI guidance for scoping reviews. The following databases will be searched: MEDLINE, Embase, Emcare, PsycINFO, Scopus, Web of Science Core Collection, the Directory of Open Access Journals, Informit, and ProQuest Dissertations and Theses Global. The search will not be limited to year of publication but will be limited to studies reported in English. The PRISMA-ScR extension will be used to document the literature search. Two reviewers will screen titles, abstracts, and full-text articles. An extraction table will be used to extract relevant data from all included articles and to facilitate data analysis.

Pathways to school success: Self-regulation and executive function, preschool attendance and early academic achievement of Aboriginal and non-Aboriginal children in Australia's Northern Territory.

BACKGROUND: With the pending implementation of the Closing the Gap 2020 recommendations, there is an urgent need to better understand the contributing factors of, and pathways to positive educational outcomes for both Aboriginal and non-Aboriginal children. This deeper understanding is particularly important in the Northern Territory (NT) of Australia, in which the majority of Aboriginal children lived in remote communities and have language backgrounds other than English (i.e. 75%). METHODS: This study linked the Australian Early Development Census (AEDC) to the attendance data (i.e. government preschool and primary schools) and Year 3 National Assessment Program for Literacy and Numeracy (NAPLAN). Structural equation modelling was used to investigate the pathway from self-regulation and executive function (SR-EF) at age 5 to early academic achievement (i.e. Year 3 reading/numeracy at age 8) for 3,199 NT children. RESULT: The study confirms the expected importance of SR-EF for all children but suggests the different pathways for Aboriginal and non-Aboriginal children. For non-Aboriginal children, there was a significant indirect effect of SR-EF (ß = 0.38, p<0.001) on early academic achievement, mediated by early literacy/numeracy skills (at age 5). For Aboriginal children, there were significant indirect effects of SR-EF (ß = 0.19, p<0.001) and preschool attendance (ß = 0.20, p<0.001), mediated by early literacy/numeracy skills and early primary school attendance (i.e. Transition Years to Year 2 (age 5-7)). CONCLUSION: This study highlights the need for further investigation and development of culturally, linguistically and contextually responsive programs and policies to support SR-EF skills in the current Australian education context. There is a pressing need to better understand how current policies and programs enhance children and their families' sense of safety and support to nurture these skills. This study also confirms the critical importance of school attendance for improved educational outcomes of Aboriginal children. However, the factors contributing to non-attendance are complex, hence the solutions require multi-sectoral collaboration in place-based design for effective implementation.

I'm Just a Person: Self-Labeling Following Sexual Assault.

OBJECTIVE: The purpose of this study was to examine college women's self-labeling as a victim or a survivor following a sexual assault and describe the relationship of self-labeling with mental health, self-blame, control over recovery, and help-seeking. METHODS: This cross-sectional study collected data in an online anonymous survey in November and December of 2018. Participants (N = 375) were recruited from two public universities, were 18- to 24-year-old undergraduate students, identified as female, and had experienced a sexual assault since entering college. RESULTS: Most respondents (46.4%, 174/375) chose labels other than victim or survivor. Statistically significant differences were found between choice of label (survivor, victim, or other) and depression, well-being, characterological self-blame, and perceived control over recovery. Short-answer responses revealed three major themes for alternative labels: choosing no label, normalizing, and seeking congruence. CONCLUSION: As when caring for a patient with any diagnosis, nurses and other healthcare providers should see a person-not a patient, a survivor, or a victim.

Frequency and perturbations of various peripheral blood cell populations before and after eculizumab treatment in paroxysmal nocturnal hemoglobinuria.

While red blood cells (RBCs) and granulocytes have been more studied, platelets and reticulocytes are not commonly used in paroxysmal nocturnal hemoglobinuria (PNH) flow-cytometry and less is known about susceptibility to complement-mediated destruction and effects of anti-complement therapy on these populations. We performed flow-cytometry of RBCs and granulocytes in 90 PNH patients and of platelets and reticulocytes in a subgroup (N = 36), to unveil perturbations of these populations during PNH disease course before and after anti-complement treatment. We found that platelets and reticulocytes were less sensitive to complement-mediated lysis than RBCs but not as resistant as granulocytes, as shown by mean sensitive fraction (difference in a given PNH population vs. PNH granulocyte clone size). In treated patients, reticulocytes, platelets, RBCs (with differences between type II and III) and granulocytes significantly increased post-treatment, confirming the role of PNH hematopoiesis within the context of anti-complement therapy. Moreover, we found that PNH platelet clone size reflects PNH granulocyte clone size. Finally, we established correlations between sensitive fraction of PNH cell-types and thrombosis. In sum, we applied a flow-cytometry panel for investigation of PNH peripheral blood populations' perturbations before and after eculizumab treatment to explore complement-sensitivity and kinetics of these cells during the disease course.

Sexual Assault, Campus Resource Use, and Psychological Distress in Undergraduate Women.

Undergraduate women are at high risk of experiencing sexual assault during their college years. Research has established a strong link between sexual victimization and psychological distress. Although the relationship between sexual victimization and distress has been established, little is known about how the use of university-affiliated sexual assault resources influences mental health outcomes for survivors. The aims of this cross-sectional study were to describe the characteristics of women who used campus survivor resources following a sexual assault during college, examine correlates of campus resource use, and examine correlates and predictors of mental health of women who have been sexually assaulted during college. An online anonymous survey was sent to undergraduate women at two public universities in a mid-Atlantic state. Participants were female, undergraduate students (N = 362) who had been sexually assaulted during their time at college. Few women (n = 98, 27.1%) used campus resources following a sexual assault. We found significant relationships between participants' use of campus survivor resources and experiencing a sexual assault prior to entering college, experiencing more severe sexual assaults, acknowledging the assault as a rape, feeling more self-blame, and experiencing more psychological distress. Campus resource use was significantly associated with poorer mental health outcomes. The cross-sectional nature of this study limited our ability to explore the reason for this. Further research is needed to explore the role campus resources play in supporting survivors during the recovery process. Given the high rate of sexual assaults on college campuses and the known negative psychological impact of sexual assault, it is imperative that campuses offer resources that are effective in meeting the needs of survivors.

Sexual Assault Survivors' Perceived Helpfulness of University-Affiliated Resources.

The goal of this study was to examine sexual assault survivors' use and perceived helpfulness of university-affiliated resources. Data were collected in online anonymous surveys from women (n = 98) at two universities who experienced a sexual assault during college and used university resources. Participants who perceived university-affiliated survivor resources as helpful had significantly better mental health outcomes than women who perceived resources as unhelpful. The most often used resources were mental health counseling (60.6%) and university health centers (24%). The most helpful resources were survivor advocates, peer counseling, and peer support groups.

Innovative public health staff augmentation concepts during a global pandemic.

At the onset of the COVID-19 global pandemic, Florida's State Emergency Response Team's Emergency Support Function 8 (ESF-8) Health and Medical Staffing Unit faced a surge of personnel requests from the field. The unit found that, given the scope of requests, standard disaster staffing practices could not always accommodate the requirements of the requests. With full support of leadership, the ESF-8 Staffing Unit developed new and innovative practices to streamline the cumbersome hiring process including coordinating with internal and external partners to expedite staff identification and implementing just-in-time training.

Retinoic acid receptor γ is a therapeutically targetable driver of growth and survival in prostate cancer.

BACKGROUND: Prostate cancer (PC) tissue contains all-trans retinoic acid (ATRA) at a very low level (10-9 M), at least an order of magnitude lower than in adjacent normal healthy prostate cells or benign prostate hyperplasia. When this is coupled with deregulated expression of the intracellular lipid-binding proteins FABP5 and CRABP2 that is frequently found in PC, this is likely to result in the preferential delivery of ATRA to oncogenic PPARß/δ rather than retinoic acid receptors (RARs). There are three isotypes of RARs (RARα, RARß, and RARγ) and recent studies have revealed discrete physiological roles. For example, RARα and RARγ promote differentiation and self-renewal, respectively, which are critical for proper hematopoiesis. AIMS: We have previously shown that ATRA stimulates transactivation of RARγ at sub-nanomolar concentrations (EC50 0.24 nM), whereas an 80-fold higher concentration was required for RARα-mediated transactivation (EC50 19.3 nM). Additionally, we have shown that RAR pan-antagonists inhibit the growth of PC cells (at 16-34 nM). These findings, together with the low level of ATRA in PC, led us to hypothesize that RARγ plays a role in PC pathogenesis and that RARγ-selective antagonism may be an effective treatment. METHODS AND RESULTS: We found that concentrations of 10-9 M and below of ATRA promoted survival/proliferation and opposed adipogenic differentiation of human PC cell lines by a mechanism that involves RARγ. We also found that a RARγ-selective antagonist (AGN205728) potently induced mitochondria-dependent, but caspase-independent, cell death in PC cell lines. Furthermore, AGN205728 demonstrated synergism in killing PC cells in combination with cytotoxic chemotherapeutic agents. CONCLUSION: We suggest that the use of RARγ-selective antagonists may be effective in PC (and potentially other cancers), either as a single agent or in combination with cytotoxic chemotherapy.

Socioeconomic and Racial Disparities in Bariatric Surgery.

The purpose of this study was to examine the associations among race and socioeconomic factors (receiving social security disability, insurance type, and income) with undergoing bariatric surgery and weight loss outcomes in a racially diverse, urban cohort of bariatric surgery candidates (N = 314). Patients with private insurance and who identified as Caucasian were more likely to undergo bariatric surgery. Income significantly predicted percentage of excess weight loss 1 year after surgery, although this was no longer significant when accounting for race. Race and socioeconomic factors should be considered during psychosocial evaluations to support patients at risk of surgical attrition and poorer weight loss outcomes. Future research should explore policy solutions to improve access, while qualitative work may help with understanding racial disparities in bariatric surgery.

MRS suggests multi-regional inflammation and white matter axonal damage at 11 years following perinatal HIV infection.

The neurological changes in children living with perinatal HIV (PHIV) on antiretroviral therapy (ART) can be studied at a metabolic level through proton magnetic resonance spectroscopy. While previous studies in children have largely focused on individual metabolite changes, investigating patterns within and across regions of interest can aid in identifying metabolic markers of HIV infection. In this study 76 children with PHIV from the Children with HIV Early AntiRetroviral (CHER) trial, 30 children who were HIV-exposed-uninfected (HEU) and 30 children who were HIV-unexposed (HU), were scanned at the age of 11.6 (sd = 0.3) years using a 3 T Skyra scanner. Metabolite concentrations were quantified within the basal ganglia (BG), midfrontal gray matter (MFGM) and peritrigonal white matter (PWM), comparing levels between HIV status groups using linear regression. Factor analysis and logistic regression were performed to identify metabolic patterns characteristic of HIV infection within and across the regions of interest. In the BG region we observed restored metabolic activity in children with PHIV and children who were HEU, despite differences being previously observed at younger ages, suggesting that treatment may effectively reduce the effects of HIV infection and exposure. Elevated MFGM choline levels in children with PHIV are indicative of inflammation. Further, we observed reduced N-acetyl-aspartate (NAA) in the PWM of children with PHIV and children who were HEU, indicating possible axonal damage. Lower levels of PWM creatine in children with PHIV suggest that this may not be a valid reference metabolite in HIV studies. Finally, factor scores for a cross-regional inflammatory factor and a PWM axonal factor, driven by PWM NAA and creatine levels, distinguished children with PHIV from children without HIV (HEU and HU) at 11 years. Therefore, the effects of perinatal HIV infection and exposure continue to be seen at 11 years despite early treatment.

Entry of Polarized Effector Cells into Quiescence Forces HIV Latency.

The latent HIV reservoir is generated following HIV infection of activated effector CD4 T cells, which then transition to a memory phenotype. Here, we describe an ex vivo method, called QUECEL (quiescent effector cell latency), that mimics this process efficiently and allows production of large numbers of latently infected CD4+ T cells. Naïve CD4+ T cells were polarized into the four major T cell subsets (Th1, Th2, Th17, and Treg) and subsequently infected with a single-round reporter virus which expressed GFP/CD8a. The infected cells were purified and coerced into quiescence using a defined cocktail of cytokines, including tumor growth factor beta, interleukin-10 (IL-10), and IL-8, producing a homogeneous population of latently infected cells. Flow cytometry and transcriptome sequencing (RNA-Seq) demonstrated that the cells maintained the correct polarization phenotypes and had withdrawn from the cell cycle. Key pathways and gene sets enriched during transition from quiescence to reactivation include E2F targets, G2M checkpoint, estrogen response late gene expression, and c-myc targets. Reactivation of HIV by latency-reversing agents (LRAs) closely mimics RNA induction profiles seen in cells from well-suppressed HIV patient samples using the envelope detection of in vitro transcription sequencing (EDITS) assay. Since homogeneous populations of latently infected cells can be recovered, the QUECEL model has an excellent signal-to-noise ratio and has been extremely consistent and reproducible in numerous experiments performed during the last 4 years. The ease, efficiency, and accuracy of the mimicking of physiological conditions make the QUECEL model a robust and reproducible tool to study the molecular mechanisms underlying HIV latency.IMPORTANCE Current primary cell models for HIV latency correlate poorly with the reactivation behavior of patient cells. We have developed a new model, called QUECEL, which generates a large and homogenous population of latently infected CD4+ memory cells. By purifying HIV-infected cells and inducing cell quiescence with a defined cocktail of cytokines, we have eliminated the largest problems with previous primary cell models of HIV latency: variable infection levels, ill-defined polarization states, and inefficient shutdown of cellular transcription. Latency reversal in the QUECEL model by a wide range of agents correlates strongly with RNA induction in patient samples. This scalable and highly reproducible model of HIV latency will permit detailed analysis of cellular mechanisms controlling HIV latency and reactivation.

Efficacy of mindfulness-based stress reduction in emerging adults with poorly controlled, type 1 diabetes: A pilot randomized controlled trial.

BACKGROUND/OBJECTIVE: The negative effects of stress on persons with type 1 diabetes (T1D) are well-established, but effective interventions to reduce stress among emerging adults with T1D are limited. The study objective was to conduct a pilot randomized controlled trial (RCT) to obtain preliminary data on the efficacy of mindfulness-based stress reduction (MBSR) to reduce stress and improve diabetes health outcomes in a population of high-risk, urban emerging adults with poorly controlled diabetes. METHODS: Forty-eight participants aged 16 to 20 years of age with T1D (mean duration = 8 years) were randomly assigned to one of three conditions: MSBR, cognitive-behavioral stress management (CBSM), or a diabetes support group. Data were collected at baseline, end of treatment, and 3 months after treatment completion. Measures of self-reported stress and depressive symptoms, diabetes management, and glycemic control were obtained. RESULTS: MBSR was found to reduce self-reported stress at end of treatment (P = 0.03, d = -0.49) and 3-month follow-up (P = 0.01, d = -0.67), but no effects on diabetes management or glycemic control were found. Diabetes support group participants had improved glycemic control at the end of treatment (P = 0.01, d = -0.62) as well as reduced depressive symptoms at 3-month follow-up (P = 0.01, d = -0.71). CONCLUSIONS: Results provide preliminary support for the efficacy of MBSR to improve psychosocial adjustment in emerging adults with poorly controlled T1D but require replication in adequately powered studies. Findings also support the value of peer support in improving health outcomes in this age group.