Effects of phosphatidylcholine and betaine supplements on women's serum choline.

Background: Maternal phosphatidylcholine supplements have shown benefit in the development of the human fetal brain, as assessed both by newborn physiological measurements and by a related decrease in later childhood behavioral abnormalities. However, the relatively low choline component of phosphatidylcholine mandates high doses that are difficult for pregnant women to consume. Objective: Betaine can substitute for some choline effects. The hypothesis was that betaine supplementation would significantly increase women's serum choline. Design: A three-arm crossover clinical trial was used to assess serum concentrations of choline after betaine supplements at two doses, in comparison with phosphatidylcholine supplementation. The effects of both a single dose and of one-week twice-daily doses were assessed in normal non-pregnant women. Results: Betaine supplements at two doses failed to increase serum choline concentrations after single administration or one-week twice-daily dosing. Phosphatidylcholine supplements raised choline concentrations after both single doses (mean change from baseline 8.34 ± 7.29 ng/ml, paired t = 3.24, df 7, p = 0.014, range 1-21 ng/ml, d' = 1.15) and one-week twice-daily doses (mean change from baseline 4.58 ± 3.68 ng/ml standard deviation; paired t = 3.51, df 7, p < 0.001, range 2-13 ng/ml, d' = 2.65). Betaine concentrations rose after both betaine and phosphatidylcholine supplementation. Conclusions: Betaine supplements did not substitute for phosphatidylcholine supplements, which raise serum choline concentrations both after a single dose and after repeated administration. However, serum betaine concentrations did rise after both betaine and phosphatidylcholine consumption and, therefore, betaine may be a stable indicator of choline intake.

Positive predictive value of medical student specialty choices.

BACKGROUND: Although medical school programs oriented toward postgraduate specialty training have the potential to reduce the duration and cost of medical school for US medical students, success depends on the ability of students to predict their postgraduate specialties. It is clear that first-year choices are poorly predictive, but it is not known when predictions become sufficiently reliable to support specialty-oriented learning programs. We therefore examined the predictive value of specialty preferences expressed at the ends of the first, second and third years of medical school and asked whether concurrent expressions of confidence in choices improved predictive ability. We also investigated the possibility that discrepancies between predicted and actual postgraduate specialty training were related to scores on an examination of knowledge in basic biomedical sciences required for US medical school graduation (the United States Medical Licensing Examination (USLME) Step 1 examination). METHOD: We calculated positive and negative predictive values (PPV and NPV, respectively) for specialty choices and the sensitivity and specificity of asking for choices for 634 University of Colorado School of Medicine students who trained in 23 accredited residencies from 2011 through 2015. We examined the effect of confidence in first choices in 609 students, and in 334 students, sought an association between USMLE Step 1 scores and switching from postgraduate training specialties predicted at the end of year 2. RESULTS: The PPV of first choices improved from years 1 through 3. NPV was high throughout. PPVs of year 3 first choices ranged from 79% in Anesthesiology to 95% in Psychiatry. Expressions of confidence in first choices did not improve PPV. Sensitivity of asking for first choices increased with time; specificity was consistently high. USLME Step 1 scores were higher for students who ultimately trained in specialties more competitive than first-choice specialties at the end of year 2. CONCLUSIONS: Specialty-oriented learning programs during medical school must accommodate students who change career plans. The PPV of specialty first choices improves each year, but even year 3 predictions can be inaccurate with potential loss of students from specialty-specific programs. USMLE Step 1 scores appeared to affect career plans expressed at the end of year 2.

Sleep Spindles and Auditory Sensory Gating: Two Measures of Cerebral Inhibition in Preschool-Aged Children are Strongly Correlated.

INTRODUCTION: Sleep spindles and P50 sensory gating are both reflective of cerebral inhibition, however, are differentially active during different phases of sleep. Assessing whether sleep spindles and P50 sensory gating correlate is a first step to evaluate whether these 2 forms of cerebral inhibition reflect overlapping neural circuits. METHODS: EEG data were collected between midnight and 6:00 AM on 13 healthy preschool-aged children. P50 sensory gating, calculated during REM sleep, negatively correlated with spindle duration (r=-.715, p=.006) and inter-peak density (r=.744, p=.004). There was a trend toward higher S2/S1 ratios being associated with fewer peaks per spindle (r=-.546, p=.053). In 4-year-olds, 2 established physiological measures of sensory gating and are correlated despite being maximally active during different stages of sleep. CONCLUSIONS: These results suggest there is an overlap in brain mechanisms underlying each gating mechanism.

Cortisol during human fetal life: Characterization of a method for processing small quantities of newborn hair from 26 to 42 weeks gestation.

OBJECTIVE: Fetal cortisol may be reflected in hair collected shortly after birth. The objective of this study was to determine the range of human fetal hair cortisol concentrations (HCC) in live-born neonates using an approach for processing small quantities of hair. MATERIALS AND METHODS: Hair was cut on the day of birth from neonates and their mothers, born between 26 and 42 weeks gestational age (GA). HCC was determined by enzyme immunoassay. Maternal sociodemographics and birth data were collected. T-tests, ANOVA, Pearson correlation, and Wilcoxon Signed Rank test were used as appropriate. RESULTS: Ninety maternal and neonatal hair samples were cut from 79 term (T) and 11 preterm (PT) delivered pregnancies. All samples weighed ≥2.5 mg. Fetal HCC correlated with GA (r = .25, p = .02) and birth weight (r = .25, p = .03) and was lower in PT (4.3 ± .3 LN pg/mg) than T (5.3 ± .1, LN pg/mg, p < .001) neonates. No significant relationships were seen between fetal HCC and maternal characteristics or maternal HCC. Fetal HCC was significantly higher than maternal HCC. CONCLUSION: Fetal cortisol exposure was determined using this approach for processing small amounts of hair. Preterm neonates have significantly lower HCC than term neonates and fetal HCC is associated with GA at delivery and birth weight. Fetal HCC is significantly higher than maternal HCC cut on the same day. These data provide novel information on the intrauterine fetal cortisol environment.

Diminished Infant P50 Sensory Gating Predicts Increased 40-Month-Old Attention, Anxiety/Depression, and Externalizing Symptoms.

OBJECTIVE: When behavioral problems resulting from attentional difficulties present, often in preschool, it is unknown whether these problems represent preexisting altered brain development or new brain changes. This study examines whether infant sensory gating of auditory evoked potentials predicts parent-reported behavior at 40 months. METHOD: P50 sensory gating, an auditory evoked potential measure reflective of inhibitory processes in the brain, was measured in 50 infants around 70 days old. Parents, using the Child Behavior Checklist, reported on the child's behavior at 40 months. RESULTS: Controlling for gender, infants with diminished sensory gating had more problems later with externalizing behavior ( F = 4.17, ndf = 1, ddf = 46, p = .047), attentional problems ( F = 5.23, ndf = 1, ddf = 46, p = .027), and anxious/depressed symptoms ( F = 5.36, ndf = 1, ddf = 46, p = .025). CONCLUSION: Diminished infant P50 sensory gating predicts attention symptoms 3 years later. These results support the hypothesis that preschool attentional dysfunction may relate to altered brain development that is detectable years prior to symptom onset.

Measures of Maternal Stress and Mood in Relation to Preterm Birth.

OBJECTIVE: To investigate the relationships between psychological and physiologic measures of stress, mood, and gestational age at delivery and preterm birth. METHODS: This prospective cohort study recruited healthy women in the early second trimester who were 18-45 years of age. Validated psychological measures of perceived stress, depressive symptoms, and anxiety were completed at 16, 22, 28, 34, and 40 weeks of gestation. Cortisol concentration was measured in maternal hair at 16, 28, and 40 weeks of gestation to approximate first-, second-, and third-trimester levels of physiologic stress. Statistical methods included: analyses of variance, t tests, χ, Pearson correlations, regression modeling, and mediation analysis as appropriate. Hair cortisol concentrations were natural log-transformed to normalize values. RESULTS: Eleven (12%) of the 90 included women had a spontaneous preterm birth or preterm premature rupture of membranes. Perceived stress at 16 weeks of gestation correlated with both second-trimester cortisol concentration (r=0.28, P=.007) and earlier gestational age at delivery (r=-0.30, P<.01). Gestational age at delivery was also negatively correlated with cortisol concentration in the second trimester (r=-0.25, P=.02) and second-trimester cortisol concentration was higher in preterm- (2.7 ± 0.4 log-transformed pg/mg) compared with term- (2.0 ± 0.7 log-transformed pg/mg, P<.001) delivered women. Using mediation statistics, the association between the psychological measure, the physiologic measure, and gestational age at delivery was mainly driven by increased physiologic stress (hair cortisol concentration) in the second trimester (difference in coefficients [standard error]=-0.05 [0.02]). CONCLUSION: Higher perceived stress in the second trimester is associated with both elevated second-trimester hair cortisol concentration and gestational age at delivery. Physiologic measure of stress in the second trimester appears most strongly associated with preterm birth. Identification and amelioration of early pregnancy stressors may attenuate physiologic stress and ultimately affect preterm birth.

Sleep Moderates and Mediates the Relationship Between Acculturation and Depressive Symptoms in Pregnant Mexican-American Women.

OBJECTIVE: Greater acculturation is associated with adverse perinatal outcomes in Mexican-American women, but the mechanisms by which acculturation influences perinatal outcomes are unclear. Pregnant acculturated Mexican-American women are more likely to engage in unhealthy prenatal behaviors relative to those less acculturated, including poor sleep. As sleep disruptions are associated with acculturation and negative perinatal outcomes, particularly maternal depression, alterations in sleep may adversely affect pregnant Mexican-American women. METHODS: Sixty pregnant women of Mexican descent completed surveys about sleep, acculturation, depressive symptoms and potential protective factor of social support. RESULTS: Acculturation, but not social support, significantly predicted increased sleep disruptions as well as overall feeling less refreshed upon waking across pregnancy. Moderation analysis indicated that more acculturated women who took longer to fall asleep reported increased depressive symptoms. Feeling refreshed upon waking also mediated the relationship between increased acculturation and elevated maternal depressive symptoms. CONCLUSIONS: Acculturation and altered sleep contribute to greater risk in Mexican-American women for maternal depressive symptoms in the perinatal period. These findings have implications for prevention and treatment of maternal mental health disorders, which may adversely affect perinatal outcomes in the vulnerable Mexican-American population.

Thought Disorder in Preschool Children with Attention Deficit/Hyperactivity Disorder (ADHD).

Preschool identification of and intervention for psychiatric symptoms has the potential for lifelong benefits. However, preschool identification of thought disorder, a symptom associated with long term risk for social and cognitive dysfunction, has received little attention with previous work limited to examining preschoolers with severe emotional and behavioral dysregulation. Using story-stem methodology, 12 children with ADHD and 12 children without ADHD, ages 4.0-6.0 years were evaluated for thought disorder. Thought disorder was reliably assessed (Cronbach's alpha = .958). Children with ADHD were significantly more likely than children without ADHD to exhibit thought disorder (75 vs 25 %; Fischer's Exact Test = .0391). Thought disorder can be reliably assessed in preschool children and is present in preschool children with psychiatric illness including preschool children with ADHD. Thought disorder may be identifiable in preschool years across a broad range of psychiatric illnesses and thus may be an appropriate target of intervention.

Perinatal Phosphatidylcholine Supplementation and Early Childhood Behavior Problems: Evidence for CHRNA7 Moderation.

OBJECTIVE: α7-Nicotinic receptors are involved in the final maturation of GABA inhibitory synapses before birth. Choline at levels found in the amniotic fluid is an agonist at α7-nicotinic receptors. The authors conducted a double-blind placebo-controlled trial to assess whether high-dose oral phosphatidylcholine supplementation during pregnancy to increase maternal amniotic fluid choline levels would enhance fetal development of cerebral inhibition and, as a result, decrease childhood behavior problems associated with later mental illness. METHOD: The authors previously reported that newborns in the phosphatidylcholine treatment group have increased suppression of the cerebral evoked response to repeated auditory stimuli. In this follow-up, they report parental assessments of the children's behavior at 40 months of age, using the Child Behavior Checklist. RESULTS: At 40 months, parent ratings of children in the phosphatidylcholine group (N=23) indicated fewer attention problems and less social withdrawal compared with the placebo group (N=26). The improvement is comparable in magnitude to similar deficits at this age associated with later schizophrenia. The children's behavior is moderated by CHRNA7 variants associated with later mental illness and is related to their enhanced cerebral inhibition as newborns. CONCLUSIONS: CHRNA7, the α7-nicotinic acetylcholine receptor gene, has been associated with schizophrenia, autism, and attention deficit hyperactivity disorder. Maternal phosphatidylcholine treatment may, by increasing activation of the α7-nicotinic acetylcholine receptor, alter the development of behavior problems in early childhood that can presage later mental illness.

An Institutional Postdoctoral Research Training Program: Increasing Productivity of Postdoctoral Trainees.

OBJECTIVE: Postdoctoral training is a critical stage of career development, and there has been a national effort to increase the consistency and quality of postdoctoral experiences. However, much of the effort has gone towards improving the process of training with less effort focusing on the content of what should be achieved during postdoctoral training, primarily because of a lack of empirical evidence in this area. One possible predictor of later scientific productivity is the number of peer-reviewed papers published during postdoctoral training. This manuscript reports on efforts to increase postdoctoral productivity. METHOD: A single institution made postdoctoral training program changes designed to increase postdoctoral publication productivity. Postdoctoral publication productivity was compared between 114 trainees who matriculated prior to the changes and 20 trainees who matriculated after the changes. RESULTS: Postdoctoral trainees who matriculated after program changes had higher publication rates than postdoctoral trainees who matriculated prior to program changes [χ(2)(df = 15) = 31.4, p = .002]. Four or more postdoctoral publications are associated with the greatest likelihood of sustained posttraining publications; postdocs matriculating after the program changes were more than twice as likely to have four or more publications (55 vs 26%). CONCLUSIONS: Postdoctoral program changes designed to increase postdoctoral publication rates can be successful. Defining, for each postdoc, a minimal postdoctoral publication rate may be an appropriate component of individualized development plans.

Characterization of choline transporters in the human placenta over gestation.

INTRODUCTION: The developing fetus relies on the maternal blood supply to provide the choline it requires for making membrane lipids, synthesizing acetylcholine, and performing important methylation reactions. It is vital, therefore, that the placenta is efficient at transporting choline from the maternal to the fetal circulation. Although choline transporters have been found in term placenta samples, little is known about what cell types express specific choline transporters and how expression of the transporters may change over gestation. The objective of this study was to characterize choline transporter expression levels and localization in the human placenta throughout placental development. METHODS: We analyzed CTL1 and -2 expression over gestation in human placental biopsies from 6 to 40 weeks gestation (n = 6-10 per gestational window) by immunoblot analysis. To determine the cellular expression pattern of the choline transporters throughout gestation, immunofluorescence analysis was then performed. RESULTS: Both CTL1 and CTL2 were expressed in the chorionic villi from 6 weeks gestation to term. Labor did not alter expression levels of either transporter. CTL1 localized to the syncytial trophoblasts and the endothelium of the fetal vasculature within the chorionic villous structure. CTL2 localized mainly to the stroma early in gestation and by the second trimester co-localized with CTL1 at the fetal vasculature. DISCUSSION: The differential expression pattern of CTL1 and CTL2 suggests that CTL1 is the key transporter involved in choline transport from maternal circulation and both transporters are likely involved in stromal and endothelial cell choline transport.

Prenatal choline and the development of schizophrenia.

BACKGROUND: The primary prevention of illness at the population level, the ultimate aim of medicine, seems out of reach for schizophrenia. Schizophrenia has a strong genetic component, and its pathogenesis begins long before the emergence of psychosis, as early as fetal brain development. Cholinergic neurotransmission at nicotinic receptors is a pathophysiological mechanism related to one aspect of this genetic risk. Choline activates these nicotinic receptors during fetal brain development. Dietary supplementation of maternal choline thus emerges as a possible intervention in pregnancy to alter the earliest developmental course of the illness. AIM: Review available literature on the relationship of choline supplementation or choline levels during pregnancy and fetal brain development. METHODS: A Medline search was used to identify studies assessing effects of choline in human fetal development. Studies of other prenatal risk factors for schizophrenia and the role of cholinergic neurotransmission in its pathophysiology were also identified. RESULTS: Dietary requirements for choline are high during pregnancy because of its several uses, including membrane biosynthesis, one-carbon metabolism, and cholinergic neurotransmission. Its ability to act directly at high concentrations as a nicotinic agonist is critical for normal brain circuit development. Dietary supplementation in the second and third trimesters with phosphatidyl-choline supports these functions and is associated generally with better fetal outcome. Improvement in inhibitory neuronal functions whose deficit is associated with schizophrenia and attention deficit disorder has been observed. CONCLUSION: Prenatal dietary supplementation with phosphatidyl-choline and promotion of diets rich in choline-containing foods (meats, soybeans, and eggs) are possible interventions to promote fetal brain development and thereby decrease the risk of subsequent mental illnesses. The low risk and short (sixmonth) duration of the intervention makes it especially conducive to population-wide adoption. Similar findings with folate for the prevention of cleft palate led to recommendations for prenatal pharmacological supplementation and dietary improvement. However, definitive proof of the efficacy of prenatal choline supplementation will not be available for decades (because of the 20-year lag until the onset of schizophrenia), so public health officials need to decide whether or not promoting choline supplementation is justified based on the limited information available.

Endophenotypes in Schizophrenia for the Perinatal Period: Criteria for Validation.

Endophenotypes are disease-associated phenotypes that are thought to reflect the neurobiological or other mechanisms that underlie the more overt symptoms of a psychiatric illness. Endophenotypes have been critical in understanding the genetics, neurobiology, and treatment of schizophrenia. Because psychiatric illnesses have multiple causes, including both genetic and nongenetic risk factors, an endophenotype linked to one of the mechanisms may be expressed more frequently than the disease itself. However, in schizophrenia research, endophenotypes have almost exclusively been studied in older adolescents or adults who have entered or passed through the age of risk for the disorder. Yet, schizophrenia is a neurodevelopmental disorder where prenatal development starts a cascade of brain changes across the lifespan. Endophenotypes have only minimally been utilized to explore the perinatal development of vulnerability. One major impediment to the development of perinatally-useful endophenotypes has been the established validity criteria. For example, the criterion that the endophenotype be more frequently present in those with disease than those without is difficult to demonstrate when there can be a decades-long period between endophenotype measurement and the age of greatest risk for onset of the disorder. This article proposes changes to the endophenotype validity criteria appropriate to perinatal research and reviews how application of these modified criteria helped identify a perinatally-usable phenotype of risk for schizophrenia, P50 sensory gating, which was then used to propose a novel perinatal primary prevention intervention.

The human CHRNA7 and CHRFAM7A genes: A review of the genetics, regulation, and function.

The human α7 neuronal nicotinic acetylcholine receptor gene (CHRNA7) is ubiquitously expressed in both the central nervous system and in the periphery. CHRNA7 is genetically linked to multiple disorders with cognitive deficits, including schizophrenia, bipolar disorder, ADHD, epilepsy, Alzheimer's disease, and Rett syndrome. The regulation of CHRNA7 is complex; more than a dozen mechanisms are known, one of which is a partial duplication of the parent gene. Exons 5-10 of CHRNA7 on chromosome 15 were duplicated and inserted 1.6 Mb upstream of CHRNA7, interrupting an earlier partial duplication of two other genes. The chimeric CHRFAM7A gene product, dupα7, assembles with α7 subunits, resulting in a dominant negative regulation of function. The duplication is human specific, occurring neither in primates nor in rodents. The duplicated α7 sequence in exons 5-10 of CHRFAM7A is almost identical to CHRNA7, and thus is not completely queried in high throughput genetic studies (GWAS). Further, pre-clinical animal models of the α7nAChR utilized in drug development research do not have CHRFAM7A (dupα7) and cannot fully model human drug responses. The wide expression of CHRNA7, its multiple functions and modes of regulation present challenges for study of this gene in disease. This article is part of the Special Issue entitled 'The Nicotinic Acetylcholine Receptor: From Molecular Biology to Cognition'.

Stability of P50 auditory sensory gating during sleep from infancy to 4 years of age.

The stability of cerebral inhibition was assessed across early childhood using a paired-click auditory sensory gating paradigm. The P50 ERP was measured during REM (or its infant analogue, active sleep) and NREM sleep in 14 children at approximately 3 months of age and again at approximately 4 years of age. Evoked response amplitudes, latencies, and the S2/S1 ratio of the amplitudes of the evoked responses were compared between the two visits. Significant reliability was found for the S2/S1 ratio (r = .73, p = .003) during REM but not non REM sleep (r = -.05, p = .88). A significant stimulus number by sleep stage interaction (F(1,12) = 17.1, p = .001) demonstrated that the response to the second stimulus decreased during REM but not NREM sleep. These findings suggest that this measure is stable during REM sleep across early childhood, is not affected by age, and is sleep-state dependent. P50 sensory gating is a biomarker which, if used properly, may provide a mechanism to further explore changes in the developing brain or may help with early screening for psychiatric illness vulnerability.

Reduced brain resting-state network specificity in infants compared with adults.

PURPOSE: Infant resting-state networks do not exhibit the same connectivity patterns as those of young children and adults. Current theories of brain development emphasize developmental progression in regional and network specialization. We compared infant and adult functional connectivity, predicting that infants would exhibit less regional specificity and greater internetwork communication compared with adults. PATIENTS AND METHODS: Functional magnetic resonance imaging at rest was acquired in 12 healthy, term infants and 17 adults. Resting-state networks were extracted, using independent components analysis, and the resulting components were then compared between the adult and infant groups. RESULTS: Adults exhibited stronger connectivity in the posterior cingulate cortex node of the default mode network, but infants had higher connectivity in medial prefrontal cortex/anterior cingulate cortex than adults. Adult connectivity was typically higher than infant connectivity within structures previously associated with the various networks, whereas infant connectivity was frequently higher outside of these structures. Internetwork communication was significantly higher in infants than in adults. CONCLUSION: We interpret these findings as consistent with evidence suggesting that resting-state network development is associated with increasing spatial specificity, possibly reflecting the corresponding functional specialization of regions and their interconnections through experience.

Neuropsychological functioning in childhood-onset psychosis and attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) and childhood-onset psychosis (COP) are chronic, heterogeneous disorders with symptoms that frequently co-occur, but the etiology of their comorbidity is unknown. Studies of each disorder indicate that both ADHD and COP are associated with a range of neuropsychological weaknesses, but few neuropsychological studies have directly compared groups with ADHD and COP. METHODS: Groups with ADHD only (32 F, 48 M), COP only (5 F, 5 M), ADHD + COP (9 F, 21 M), and a control group with neither disorder (25 F, 44 M) completed a neuropsychological battery that included measures of verbal working memory, response inhibition, response speed and variability, and selective attention. RESULTS: All three clinical groups exhibited significantly lower performance versus the control group on all neuropsychological measures, whereas the only significant difference between the clinical groups was a significantly larger weakness in verbal working memory in the groups with COP. CONCLUSIONS: The frequent co-occurrence between COP and ADHD may reflect shared neuropsychological weaknesses that are most pronounced on measures of working memory and response variability.

Perinatal choline effects on neonatal pathophysiology related to later schizophrenia risk.

OBJECTIVE: Deficient cerebral inhibition is a pathophysiological brain deficit related to poor sensory gating and attention in schizophrenia and other disorders. Cerebral inhibition develops perinatally, influenced by genetic and in utero factors. Amniotic choline activates fetal α7-nicotinic acetylcholine receptors and facilitates development of cerebral inhibition. Increasing this activation may protect infants from future illness by promoting normal brain development. The authors investigated the effects of perinatal choline supplementation on the development of cerebral inhibition in human infants. METHOD: A randomized placebo-controlled clinical trial of dietary phosphatidylcholine supplementation was conducted with 100 healthy pregnant women, starting in the second trimester. Supplementation to twice normal dietary levels for mother or newborn continued through the third postnatal month. All women received dietary advice regardless of treatment. Infants' electrophysiological recordings of inhibition of the P50 component of the cerebral evoked response to paired sounds were analyzed. The criterion for inhibition was suppression of the amplitude of the second P50 response by at least half, compared with the first response. RESULTS: No adverse effects of choline were observed in maternal health and delivery, birth, or infant development. At the fifth postnatal week, the P50 response was suppressed in more choline-treated infants (76%) compared with placebo-treated infants (43%) (effect size=0.7). There was no difference at the 13th week. A CHRNA7 genotype associated with schizophrenia was correlated with diminished P50 inhibition in the placebo-treated infants, but not in the choline-treated infants. CONCLUSIONS: Neonatal developmental delay in inhibition is associated with attentional problems as the child matures. Perinatal choline activates timely development of cerebral inhibition, even in the presence of gene mutations that otherwise delay it.