Detection of rotavirus- and norovirus-specific IgG memory B cells in tonsils.

Because rotavirus (RV) and norovirus (NoV) are transmitted through the fecal-oral route, tonsils due to their location within the oropharynx may sample or become infected with these viruses. We investigated if RV and NoV RNA/antigen, or virus-specific memory/plasma B cells can be detected in the tonsils. While neither RV/NoV antigen, nor genomic RNA was detected, 90% (27/30) of tonsils tested had RV- and NoV-specific IgG memory B cells. However, the mechanism explaining how these cells get there (whether because of local induction or homing after induction at other sites) and the role these cells might play during active infection is not yet clear.

Phenomenographic study of basic science understanding-senior medical students' conceptions of fatigue.

INTRODUCTION: Helping students learn to apply their newly learned basic science knowledge to clinical situations is a long-standing challenge for medical educators. This study aims to describe how medical students' knowledge of the basic sciences is construed toward the end of their medical curriculum, focusing on how senior medical students explain the physiology of a given scenario. Methods A group of final-year medical students from two universities was investigated. Interviews were performed and phenomenographic analysis was used to interpret students' understanding of the physiology underlying the onset of fatigue in an individual on an exercise bicycle. RESULTS: Three categories of description depict the qualitatively different ways the students conceptualized fatigue. A first category depicts well integrated physiological and bio-chemical knowledge characterized by equilibrium and causality. The second category contains conceptions of finite amount of substrate and juxtaposition of physiological concepts that are not fully integrated. The third category exhibits a fragmented understanding of disparate sections of knowledge without integration of basic science and clinical knowledge. DISCUSSION: Distinctive conceptions of fatigue based with varying completeness of students' understanding characterized the three identified categories. The students' conceptions of fatigue were based on varying understanding of how organ systems relate and of the thresholds that determine physiological processes. Medical instruction should focus on making governing steps in biological processes clear and providing opportunity for causal explanations of clinical scenarios containing bio-chemical as well as clinical knowledge. This augments earlier findings by adding descriptions in terms of the subject matter studied about how basic science is applied by students in clinical settings.

Internet-based vestibular rehabilitation versus standard care after acute onset vertigo: a study protocol for a randomized controlled trial.

BACKGROUND: Dizziness and vertigo affect around 15% of adults annually and represent common reasons for contacting health services, accounting for around 3% of all emergency department visits worldwide. Vertigo is also associated with excessive use of diagnostic imaging and emergency care and decreased productivity, primarily because of work absenteeism. Vestibular rehabilitation is an evidence-based treatment for chronic dizziness and supervised group exercise therapy has recently been shown to be effective after vestibular neuritis, a common cause of acute onset vertigo. However, such interventions are not readily available and there is a need for more easily accessible tools. The purpose of this study is to investigate the effects on vestibular symptoms of a 6-week online vestibular rehabilitation tool after acute onset vertigo, with the aim of aiding vestibular rehabilitation by presenting a more accessible tool that can help to reduce recovery time. METHODS: Three hundred twenty individuals diagnosed with acute vestibular syndrome (AVS) will be recruited from multiple hospitals in Sweden and the effects of an online vestibular rehabilitation tool, YrselTräning, on vestibular symptoms after acute onset vertigo will be compared to standard care (written instructions leaflet) in a two-armed, evaluator-blinded, multicenter randomized controlled trial. The primary outcome will be the Vertigo Symptom Scale Short Form (VSS-SF) score at 6 weeks after symptom onset. Secondary outcomes include effects of the intervention on activities of daily living, mood and anxiety, vestibular function recovery, mobility measures, health economic effects, and the reliability of the Swedish VSS-SF translation. DISCUSSION: Participants using the online vestibular rehabilitation tool are expected to recover earlier and to a greater extent from their symptoms as compared to standard care. Since up to 50% of people with AVS without treatment develop persistent symptoms, effective treatment of AVS will likely lead to a higher quality of life and help reduce the societal costs associated with dizziness and vertigo. TRIAL REGISTRATION: Clinicaltrials.gov NCT05056324 . Registered on September 24, 2021.

Recovery after acute unilateral vestibular loss and predictors for remaining symptoms.

PURPOSE: The aims of this study were to follow recovery during the first 6 months after acute unilateral vestibular loss (AUVL) and to determine predictors for self-rated remaining symptoms. MATERIALS AND METHODS: Forty-two subjects were included less than 10 days after AUVL. Static and dynamic clinical balance tests, visual analogue scales, University of California Los Angeles Dizziness Questionnaire, Dizziness Beliefs Scale, European Quality of Life questionnaire, Dizziness Handicap Inventory, and Hospital Anxiety and Depression Scale were performed at inclusion and at 7 follow-ups over 6 months. Subjects rated their symptoms on visual analogue scales daily at home. Videonystagmography was performed in the acute stage and after 10 weeks. RESULTS: Decrease of symptoms and improvement of balance function were larger during the first compared with the latter part of the follow-up period. Visual analogue scale ratings for balance problems were higher than those for dizziness. A prediction model was created based on the results of 4 tests in the acute stage: standing on foam with eyes closed, standing on 1 leg with eyes open, visual analogue scale rating of vertigo at rest, and European Quality of Life questionnaire rating of health-related quality of life. The prediction model identified subjects at risk of having remaining symptoms after 6 months with a sensitivity of 86% and a specificity of 79%. CONCLUSIONS: Recovery mainly takes place during the first weeks after AUVL. Subjects rate more balance problems than dizziness. Self-rated remaining symptoms after 6 months may be predicted by clinical balance tests and subjective ratings in the acute stage.

Medical education in Sweden.

Undergraduate medical education in Sweden has moved from nationally regulated, subject-based courses to programmes integrated either around organ systems or physiological and patho-physiological processes, or organised around basic medical science in conjunction with clinical specialities, with individual profiles at the seven medical schools. The national regulations are restricted to overall academic and professional outcomes. The 5½ year long university undergraduate curriculum is followed by a mandatory 18 months internship, delivered by the County Councils. While quality control and accreditation for the university curriculum is provided by the Swedish National Agency for Higher Education, no such formal control exists for the internship; undergraduate medical education is therefore in conflict with EU directives from 2005. The Government is expected to move towards 6 years long university undergraduate programmes, leading to licence, which will facilitate international mobility of both Swedish and foreign medical students and doctors. Ongoing academic development of undergraduate education is strengthened by the Bologna process. It includes outcome (competence)-based curricula, university Masters level complying with international standards, progression of competence throughout the curriculum, student directed learning, active participation and roles in practical clinical education and a national assessment model to assure professional competence. In the near future, the dimensioning of Swedish undergraduate education is likely to be decided more by international demands and aspects of quality than by national demands for doctors.

Could sound be used as a strategy for reducing symptoms of perceived motion sickness?

BACKGROUND: Working while exposed to motions, physically and psychologically affects a person. Traditionally, motion sickness symptom reduction has implied use of medication, which can lead to detrimental effects on performance. Non-pharmaceutical strategies, in turn, often require cognitive and perceptual attention. Hence, for people working in high demand environments where it is impossible to reallocate focus of attention, other strategies are called upon. The aim of the study was to investigate possible impact of a mitigation strategy on perceived motion sickness and psychophysiological responses, based on an artificial sound horizon compared with a non-positioned sound source. METHODS: Twenty-three healthy subjects were seated on a motion platform in an artificial sound horizon or in non-positioned sound, in random order with one week interval between the trials. Perceived motion sickness (Mal), maximum duration of exposure (ST), skin conductance, blood volume pulse, temperature, respiration rate, eye movements and heart rate were measured continuously throughout the trials. RESULTS: Mal scores increased over time in both sound conditions, but the artificial sound horizon, applied as a mitigation strategy for perceived motion sickness, showed no significant effect on Mal scores or ST. The number of fixations increased with time in the non-positioned sound condition. Moreover, fixation time was longer in the non-positioned sound condition compared with sound horizon, indicating that the subjects used more time to fixate and, hence, assumingly made fewer saccades. CONCLUSION: A subliminally presented artificial sound horizon did not significantly affect perceived motion sickness, psychophysiological variables or the time the subjects endured the motion sickness triggering stimuli. The number of fixations and fixation times increased over time in the non-positioned sound condition.

Long-term improvement of quality of life as a result of tonsillotomy (with radiofrequency technique) and tonsillectomy in youths.

OBJECTIVE: This is a 1 year follow-up to compare the effects of partial tonsil resection using the radiofrequency technique (RF) tonsillotomy (TT) with total tonsillectomy (TE) (blunt dissection). Obstructive symptoms, tendency for infections, and health-related quality of life (HRQL) were studied and compared with the HRQL data from a normal population. METHOD: The study group consisted of 74 patients (16-25 yr old) randomized to TT (n = 31) or TE (n = 43) with obstructive throat problems with or without recurrent tonsillitis. The Short Form 36 (SF-36) and EuroQul Visual Analogue Scale were used to evaluate HRQL. A questionnaire investigated the degree of obstruction and history of infections. RESULTS: Preoperatively, both groups reported significantly lower HRQL in all dimensions of the SF-36 compared with the normal population (P < .05-P < .001). After 1 year, a large improvement (P < .01-P < .001) in both groups in HRQL was found. No differences were found when these groups were compared with the normal population or between the study groups. The effect on snoring was the same for both groups, and the rate of recurrence of infections was low and not any higher in the TT group. CONCLUSION: Preoperative obstructive problems in combination with recurrent tonsillitis have a negative impact on HRQL. Both the TT and TE groups demonstrated large improvements on HRQL, infections, and obstructive problems 1 year after surgery, indicating that the surgical methods are equally effective. With its reduced postoperative complications, less pain, shorter recovery time, and cost reduction, TT with RF should be considered the method of choice.

Working Memory, Sleep, and Hearing Problems in Patients with Tinnitus and Hearing Loss Fitted with Hearing Aids.

BACKGROUND: Tinnitus is a common condition and there is a need to evaluate effects of tinnitus management in relation to moderating factors such as degree of hearing loss. As it is possible that tinnitus influences concentration, and thus is likely to disturb cognitive processing, the role of cognitive functioning also needs to be investigated. PURPOSE: To compare a group of patients with sensorineural hearing loss and tinnitus to a control group with only sensorineural hearing loss (and no tinnitus). To investigate working memory, sleep, and hearing problems measured before and after hearing rehabilitation. RESEARCH DESIGN: A prospective study. STUDY SAMPLE: The sample consisted of 100 patients, 50 with hearing loss and tinnitus, and 50 controls with hearing loss but no tinnitus. All patients were between 40 and 82 yr old and had a pure-tone average (PTA; average of 0.5, 1, 2, and 4 kHz) <70 dB HL. INTERVENTION: Patients were tested before and after rehabilitation with hearing aids with regard to their working memory capacity, sleep quality, hearing problems, speech recognition, and tinnitus annoyance. DATA COLLECTION AND ANALYSIS: Eight patients dropped out of the study. Thus, a total of 92 patients were included for analysis, with 46 in each group. As a consequence of unplanned age and PTA differences between the groups, an age-matched subsample (n = 30 + 30) was selected for further analysis. Tests including the Reading Span, Hearing-in-Noise Test (HINT), Tinnitus Handicap Inventory (THI), Hearing Handicap Inventory for the Elderly (HHIE), and Pittsburgh Sleep Quality Index (PSQI) were administered before and after hearing aid rehabilitation. RESULTS: There were no between-group differences at baseline in the full sample (n = 92), with the exception of the THI (p < 0.001) and the PSQI (p < 0.002), on which the hearing loss and tinnitus group had significantly higher scores. Pre/post changes were significant for both groups on the Reading Span, and HHIE. However, these improvements were significantly larger for the patients in the hearing loss and tinnitus group on the Reading Span test (p < 0.001) and the PSQI (p < 0.001). Patients with tinnitus and hearing loss also exhibited significantly improved THI scores at follow-up, compared to baseline (p < 0.001). We conducted the same analyses for the age-matched subsample (n = 30 + 30). For the baseline data, only the THI (p < 0.001) and the PSQI (p < 0.015) difference remained significant. With regard to the pre/post changes, we found the same differences in improvement in Reading Span (p < 0.001) and the PSQI (p < 0.015) as in the full sample. CONCLUSIONS: Patients with tinnitus benefited from hearing aid rehabilitation. The observed differences in cognitive function were unexpected, and there were larger score improvements on the Reading Span test in the hearing loss and tinnitus group than in the hearing loss group. Patients with tinnitus and hearing loss may receive extra benefit in terms of cognitive function following hearing aid rehabilitation.

Vestibular Function After Cochlear Implantation: A Comparison of Three Types of Electrodes.

OBJECTIVE: To investigate the vestibular function after cochlear implantation with different types of electrode arrays. STUDY DESIGN: Retrospective cohort study. SETTING: Academic tertiary referral center. MATERIALS AND METHODS: Forty three adults underwent first cochlear implantation. Three consecutive series of patients: Group 1 (n = 13) implanted with a precurved electrode, Group 2 (n = 15) implanted with a straight electrode, Group 3 (n = 15) implanted with a flexible electrode. Patient's vestibular functions were assessed with pre- and postoperative caloric testing using videonystagmography (VNG). The postoperative reduction of the maximum slow phase velocity (MSPV) in the implanted ear was evaluated. Medical charts were reviewed to evaluate the occurrence of late onset of postoperative vestibular symptoms. RESULTS: Mean reduction of MSPV was 7.6/s (standard deviation [SD] 8.0) in Group 1, 23.1/s (SD 16.6) in Group 2, and 0.1/s (SD 18.5) in Group 3. Significant difference was found between Group 1 and 2 (p < 0.030) and between Group 2 and 3 (p < 0.001). Group 2 showed a higher prevalence of late onset of clinical vertigo (28.6%) than Group 1 (7.7%) and 3 (6.7%). CONCLUSION: In this prospective study, significantly larger reductions of caloric responses were found in subjects implanted with a straight electrode compared with subjects implanted with a precurved or flexible electrode. These findings seem to correlate to a higher prevalence of postoperative vertigo.

Motivational Interviewing as an Adjunct to Hearing Rehabilitation for Patients with Tinnitus: A Randomized Controlled Pilot Trial.

PURPOSE: To test the effects of a brief motivational interviewing (MI) program as an adjunct to hearing aid rehabilitation for patients with tinnitus and sensorineural hearing loss. RESEARCH DESIGN: This was a pilot randomized controlled trial. STUDY SAMPLE: The sample consisted of 50 patients aged between 40 and 82 yr with both tinnitus and sensorineural hearing loss and a pure-tone average (0.5, 1, 2, and 4 kHz) < 70 dB HL. All patients were first-time hearing aid users. INTERVENTION: A brief MI program was used during hearing aid fitting in 25 patients, whereas the remainder received standard practice (SP), with conventional hearing rehabilitation. DATA COLLECTION AND ANALYSIS: A total of 46 patients (N = 23 + 23) with tinnitus were included for further analysis. The Tinnitus Handicap Inventory (THI) and the International Outcome Inventory for Hearing Aids (IOI-HA) were administered before and after rehabilitation. THI was used to investigate changes in tinnitus annoyance, and the IOI-HA was used to determine the effect of hearing aid treatment. RESULTS: Self-reported tinnitus disability (THI) decreased significantly in the MI group (p < 0.001) and in the SP group (p < 0.006). However, there was greater improvement in the MI group (p < 0.013). Furthermore, the findings showed a significant improvement in patients' satisfaction concerning the hearing aids (IOI-HA, within both groups; MI group, p < 0.038; and SP group, p < 0.026), with no difference between the groups (p < 0.99). CONCLUSION: Tinnitus handicap scores decrease to a greater extent following brief MI than following SP. Future research on the value of incorporating MI into audiological rehabilitation using randomized controlled designs is required.

Potential Involvement of Type I Interferon Signaling in Immunotherapy in Seasonal Allergic Rhinitis.

Specific immunotherapy (SIT) reverses the symptoms of seasonal allergic rhinitis (SAR) in most patients. Recent studies report type I interferons shifting the balance between type I T helper cell (Th1) and type II T helper cells (Th2) towards Th2 dominance by inhibiting the differentiation of naive T cells into Th1 cells. As SIT is thought to cause a shift towards Th1 dominance, we hypothesized that SIT would alter interferon type I signaling. To test this, allergen and diluent challenged CD4+ T cells from healthy controls and patients from different time points were analyzed. The initial experiments focused on signature genes of the pathway and found complex changes following immunotherapy, which were consistent with our hypothesis. As interferon signaling involves multiple genes, expression profiling studies were performed, showing altered expression of the pathway. These findings require validation in a larger group of patients in further studies.

Impaired microvascular function related to poor metabolic control in young patients with diabetes.

The purpose of the present study was to identify whether young patients with type 1 diabetes using modern multiple insulin injection therapy (MIT) have signs of microvascular dysfunction and to elucidate possible correlations with various disease parameters. Skin blood flow on the dorsum of the foot was measured with laser Doppler perfusion imaging in 37 patients (age 10-21 years, disease duration 6.0-16 years) and 10 healthy controls. Measurements were performed at rest, after change in posture (the leg was lowered below heart level) and during postocclusive hyperaemia. Following a change in posture blood flow increased instead of decreased in a majority of the study subjects. Patients with acute HbA1c >7.5% (n = 22) had an increase in skin blood flow at rest and a significantly reduced blood flow when the leg was lowered below heart level as compared with patients with HbA1c <7.5% (0.26 V versus 0.17 V, P<0.01 and 0.12 V versus 0.23 V, P<0.05, respectively) and healthy controls. Following occlusion of the macrocirculation for 3 min a small non-significant decrease in the hyperaemic response was seen in the patients. The postocclusive hyperaemic response and the venoarteriolar reflex were not correlated to duration of disease, long-term metabolic control or electrophysiological signs of peripheral nerve dysfunction. It is concluded that signs of microvascular dysfunction related to poor metabolic control are present in young patients with MIT treatment and rather well-controlled diabetes. Low resting blood flow levels are suggested to contribute to the absence of postural vasoconstrictor response.

Hoarseness and misdirected swallowing before and after antireflux surgery.

CONCLUSION: Patients with hiatus hernia can be relieved from H, MSL and MSN by hiatus hernia repair. OBJECTIVE: It has been hypothesized that respiratory symptoms in patients with gastro-oesophageal reflux disease (GORD) may, in some cases, be due to misdirected swallowing as a consequence of defective opening of the upper oesophageal sphincter. The aim of this study was to investigate whether patients with hiatus hernia are relieved from symptoms of misdirected swallowing to the larynx (MSL) and nose (MSN), as well as hoarseness (H), as a result of hiatus hernia repair. MATERIAL AND METHODS: A questionnaire concerning symptoms of H, MSL and MSN was administered to 90 patients under investigation for hiatus hernia repair before and after surgery. RESULTS: Before surgery, MSL occurred in 30% of patients, MSN in 30% and H in 25%. These symptoms were significantly interrelated (p <0.008). After antireflux surgery, all symptoms were significantly reduced (p <0.001). Symptom reduction was not related to the weight of the patients.

Long-term follow-up after acute unilateral vestibular loss and comparison between subjects with and without remaining symptoms.

CONCLUSIONS: About half of the subjects in this study reported remaining symptoms 3-6 years after acute unilateral vestibular loss. Differences could be seen between subjects with and without remaining symptoms regarding health-related quality of life, anxiety and depression. OBJECTIVE: To evaluate the presence of self-rated remaining symptoms 3-6 years after acute unilateral vestibular loss, and to compare subjects with and without such symptoms. MATERIAL AND METHODS: Firstly, 51 subjects answered a questionnaire which included the EuroQol EQ-5D, the Hospital Anxiety and Depression Scale, the University of California Los Angeles Dizziness Questionnaire, visual analogue scales and the Dizziness Handicap Inventory. Secondly, nine subjects with and nine without remaining symptoms participated in an extended testing procedure, including electronystagmography (ENG), determination of vestibular-evoked myogenic potentials (VEMPs) and clinical balance tests. RESULTS: In the first part of the study, 27 subjects reported remaining symptoms, 3 reported 1 additional period of symptoms and 21 had not experienced any symptoms at all in the 3-6 years since acute unilateral vestibular loss. In the second part, the group with remaining symptoms rated a lower health-related quality of life and a higher level of anxiety and depression. There were no differences between the two groups in terms of ENG tests, VEMPs or clinical balance tests.

Effects of postural disturbances with fatigued triceps surae muscles or with 20% additional body weight.

One of the main issues for balance control is the ability to generate enough forces to execute motions and uphold stability. This study aimed to investigate whether induced fatigue of the triceps surae muscles and decreased muscle force due to temporary additional body weight affected the ability to withstand balance perturbations. Another aim was to examine whether postural control adaptation over time was able to compensate for the changes induced by fatigue and additional body weight. Eleven normal subjects were exposed to vibratory proprioceptive stimulation during three test conditions; a baseline test during normal condition; when the body weight was increased by 20%, by adding additional weight load; and when the triceps surae muscles were fatigued. The tests were performed both with eyes open and closed. The body movements were evaluated by analyzing the anteroposterior and lateral torques induced towards the supporting surface measured with a force platform. Postural control was substantially affected both by the additional body weight, and by muscle fatigue in the triceps surae muscles. The anteroposterior and lateral body sway were larger both with added weight and fatigued muscles compared with the baseline test during quiet stance. However, the body sway induced by the vibratory stimulation was significantly larger with additional body weight compared with when the triceps surae muscles were fatigued. The differences between the test conditions were mostly pronounced during tests with eyes closed and in the high frequency body sway (>0.1 Hz). Postural control adaptation was able to reduce but not fully compensate for the changes induced by fatigue and additional body weight. Several hypotheses could account for these observations. (1) Fatigued muscles are less sensitive to muscle vibration, (2) muscle fatigue alters the muscle contractile efficiency and thus alters the ability to produce high-frequency, short-latency responses to balance perturbations.

Visual influence on postural control, with and without visual motion feedback.

Body sway was investigated in 20 healthy subjects to determine whether visual input must contain motion feedback information from the surroundings in order to influence postural control. Posturography was used to record body sway under the following visual conditions: eyes open with or without a restricted visual field; eyes open in ganzfield white light; eyes open in darkness with a head-fixed visual target; eyes open in darkness; and eyes closed in darkness. Stance was perturbed by means of a pseudorandomly applied vibratory stimulation to the calf muscles. Least sway was found with eyes open in an unrestricted visual field but increased in a restricted visual field. Greatest sway was found without visual motion feedback, i.e. under the following conditions: eyes closed; eyes open in darkness; eyes open in ganzfield white light; and with a head-mounted fixation point. Sway was significantly (p < 0.05) greater with eyes open in darkness compared with eyes closed during the initial 50 s with perturbations. After 150 s, sway was almost identical under the four test conditions without visual motion feedback. Standing with eyes open in darkness was initially a disadvantage compared with having the eyes closed. The postural control system may be programmed to expect visual feedback information when the eyes are open, which may delay changes in postural strategy.

A cohort study of patients with tinnitus and sensorineural hearing loss in a Swedish population.

OBJECTIVE: We aimed to describe a large cohort of patients with tinnitus and sensorineural hearing loss (SNHL) in Sweden, and also to explore the possibility of finding potential possible differences between various diagnoses within SNHL. It is also of great interest to see how a multidisciplinary team was used in the different subgroups and the frequency of hearing aids use in patients with tinnitus. METHODS: Medical records of all patients who had received the diagnosis SNHL in Östergötland County, Sweden between 2004 and 2007 were reviewed. Patients between 20 and 80 years with tinnitus and a pure tone average (PTA) lower than 70dB HL were included in the study. Patients were excluded from the analyses if they had a cochlear implantation, middle ear disorders or had a hearing loss since birth or childhood. The investigators completed a form for each included patient, covering background facts, and audiograms taken at the yearly check up. RESULTS: Of a total 1672 patients' medical record review, 714 patients were included. The majority of patients (79%) were in the age group over 50 years. In male patients with bilateral tinnitus, the PTA for the left ear was significantly higher than for the right ear. The results regarding the configuration of hearing loss revealed that 555 patients (78%) had symmetric and 159 (22%) asymmetric hearing loss. Retrocochlear examinations were done in 372 patients and MRI was the most common examination. In all patients, 400 had no hearing aids and out of those 220 had unilateral tinnitus and 180 patients had bilateral tinnitus. 219 patients had a PTA>20dB HL and did not have any hearing aid. Results demonstrated that the Stepped Care model was not used widely in the daily practice. In our study, patients with bilateral-, unilateral hearing loss or Mb Ménière were the most common patients included in the Stepped Care model. CONCLUSION: In a large cohort of patients with SNHL and tinnitus, despite their hearing loss only 39% had hearing aids. It was observed that the medical record review often showed a lack of information about many background factors, such as; patients' general health condition, which could be a quality factor that needs improvement. Our results show that the Stepped Care model could be an effective option for providing a better access for tinnitus-focused treatment, although the number of patients in this study who were included in the Stepped Care model was low.