Doctors

medicine

Doctors need to lead by example at the voting booth

As the needle moves past 220,000 deaths from Covid-19 and the Supreme Court prepares to hear California v. Texas, which threatens to eliminate health insurance for almost 20 million Americans, it’s no surprise that health care remains one of the top issues for voters this election.

Historically, doctors vote less than other professionals. From 2006 to 2018, doctors were less likely to vote than the general public, particularly if they were not already registered to vote.

That’s what we found in a study published this week in JAMA Internal Medicine. After reviewing voting histories for more than 100,000 doctors in California, New York, and Texas, we found that 37% of eligible physicians voted in elections over the last decade, compared to 51% of the general population. Half of doctors who were eligible to vote were not registered to vote in the first place.

advertisement

While this is troubling, it can be fixed. Programs like Vot-ER and VoteHealth 2020 are working to help doctors register to vote around the country. Some hospitals are also stepping up to the plate. These efforts are important, because we found that doctors who were registered to vote are more likely to show up to the polls than their fellow Americans.

It would help if registering to vote was a simple and secure process. Eleven states, including our home state of Texas, do not permit online voter registration and instead require voters to mail in a physical form. And the majority of states do not allow voters to register and vote on the same day.

advertisement

These rules, meant to suppress voting, make it challenging for doctors to maintain civic engagement over a decadelong professional training process. In a survey we published this week in the Journal of General Internal Medicine, we found that a majority of doctors in training — residents — cite long work hours as the most common barrier to voting in this election. Nearly one-quarter of doctors felt that their vote does not make much of an impact, and a smaller group were hindered by not knowing when and where to vote. This is the first study of its kind to analyze barriers to voting for the U.S.’s youngest physicians.

Hospital training programs can do more to facilitate voter engagement among doctors by giving them paid time off to vote early, helping them register to vote by mail where permitted, and even arranging for voting at the hospital. More than 1,600 companies have already joined the Time To Vote campaign, giving employees time off to make their voices heard at the ballot box. Some companies, such as Old Navy, Target, and Warby Parker, are even paying employees to serve as poll workers.

It’s time for hospitals and residency programs to address the culture of prioritizing working over voting, particularly among young doctors. They can help doctors easily register to vote and provide them with information about early voting or how to request absentee ballots. For doctors living in California, Colorado, Maryland,

Read More
health

Should you get a COVID-19 test before traveling? Here’s what doctors say.

As “pandemic fatigue” works its way into our lexicon and the holidays approach, more people are weighing the risks of travel. With testing more widely accessible, it makes sense that taking a test before you travel could increase your safety as well as those around you, but doctors warn it’s not that simple.

UCSF epidemiologist Dr. George Rutherford said when thinking about the safety of travel right now, no matter the mode of transportation, it’s still best not to do so at all, especially in light of new surges across the country. “The virus hasn’t changed,” Rutherford said. “Given the surging around the country, it’s probably a bad idea to go out and mix with people. The real overriding message is unless there is some really compelling reason to go, don’t.”

If you want to use testing to lower your risk, you’ll need to get more than one. Rutherford suggests taking a test, and assuming it’s negative, continue to isolate for 5-7 days and then take a second test. If that test is negative, then you’re probably truly negative before you travel. “The problem with this disease is you could be in the incubation period of 3-4 days where you don’t have a high enough level of virus to get a positive test,” Rutherford said. “They’re not false negatives, but they can be misleading. A single test doesn’t really tell you everything. It doesn’t mean they won’t turn positive the next day or day after.”

Dr. Michael Vollmer, a Kaiser Permanente infectious disease expert, said that the incubation period is key and even if those tests are negative, it also doesn’t mean you may not catch the virus while traveling or while at your destination. “That test is helpful that day … but right after it’s completed it doesn’t tell you if you’re going to be exposed to the disease. … It doesn’t tell us what’s going to happen later.”


In order to be really sure you’re negative before departure, Rutherford said you would have to self-quarantine for two weeks, but at that point, you also probably don’t need to be tested.

Once you’re at your destination, the real risks can begin. Especially if you’re going to an area where cases are high, you could encounter the virus and bring it back when you return. Additionally, when you’re around those you’re comfortable with, like friends and family, it’s easy to become lax with mask wearing and social distancing.

“With familiarity, masks come off,” Vollmer said. “Most disease is transmitted in small groupings and family gatherings.”

Hand washing, mask wearing and social distancing are still the most important ways we can prevent the spread of the virus, he said.

If you feel you may have been exposed to the virus while traveling, it’s best to isolate for at least five days upon return and then get tested again.

“Travel is risky and during a pandemic, it’s very risky,” Vollmer said. “It’s really difficult to mitigate that risk. People should put travel

Read More
health

Idaho’s coronavirus cases spike again, doctors urge action

BOISE, Idaho (AP) — Idaho is seeing its largest coronavirus spike since the pandemic began, with new cases increasing by 46.5% percent over the past two weeks. That trend has some health care experts urging Gov. Brad Little to take additional action to slow the spread.

“As a health system, we’re all very concerned,” said Dr. Bart Hill, the vice president and chief quality officer of St. Luke’s Health System, the largest health system in the state. “It’s indicative of anticipating we’re going to see more hospitalizations affecting an older population in the next two, three, four weeks.”

Idaho is currently sixth in the nation for new cases per capita, with a positivity rate of just over 15% — one of the highest in the nation. Still, Little has declined to take additional statewide steps like requiring masks to slow the virus.

“Idaho is an expansive state, and communities and their needs vary greatly across the state,” Little’s spokeswoman, Marissa Morrison, wrote in an email to The Associated Press on Tuesday. “Governor Little remains committed to working closely with public health districts and mayors, and he supports the decisions of local officials in slowing the spread of COVID-19 in communities experiencing high virus activity.”

Little has repeatedly said that the responsibility to slow the coronavirus falls on individuals, urging people to wear masks, practice social distancing and practice good hygiene.


“Our personal actions work better to slow the spread of coronavirus than anything else,” Little said Thursday when he announced Idaho would remain in Stage 4 of his reopening plan for the 18th week in a row. “This is about personal responsibility, something Idaho is all about.”

A significant portion of Idaho residents, however, don’t seem to be taking Little’s message to heart. Photos of a volleyball game in the southern Idaho town of Twin Falls area posted to social media on Monday showed mask-less people sitting hip-to-hip in a packed school gym. St. Luke’s hospitals in the region, meanwhile, are now postponing elective surgeries to ensure there is room for an expected influx of COVID-19 patients in the coming days.

Hill said health care providers knew that the pandemic would ebb and flow over time, and the temporary statewide shutdown that Little ordered back in March gave medical facilities time to prepare for spikes like the one Idaho is currently experiencing. St. Luke’s Health System still has adequate capacity for now, he said.

“I know (St. Luke’s) leadership is having conversations with the governor today and tomorrow expressing our concerns that doing the same of what we have been doing is not likely to change our trajectory,” he said. “The direction we’re heading is one that it looks real problematic.”

Hill said he’s not advocating steps that would hurt the economy, but rather targeted interventions like information campaigns aimed at teens and young adults who are more likely to spread the virus to older and more at-risk Idahoans. Hill also said the state needs to improve testing capacity so

Read More
health

Man In Coma For 8 Years Wakes Up Minutes After Doctors Give Him Sleeping Pill

A man, who was in a coma for nearly a decade, regained full consciousness and started to walk, minutes after a doctor gave him a sleeping pill.

The man, identified as 37-year-old Richard, was hospitalized in his late 20s after he choked on a piece of meat which left him with severe brain damage. He suffered from akinetic mutism, a condition in which a person cannot move or speak.

After eight years, the doctors discovered that certain types of brain damage could be temporarily cured by sleeping pills. With his family’s permission, the pill, Zolpidem, was administered and within 20 minutes of taking it, the man woke up and also asked the nurse how he can operate the wheelchair.

“Because Richard’s situation seemed hopeless, the family and I decided to administer this medication to Richard. Against all expectations, Zolpidem had remarkable effects. After taking the sleeping pill, Richard started talking, wanted to call his father, and started recognizing his brothers again. With some help, he could even get up from his wheelchair and walk short distances,” Doctoral student Willemijn van Erp at Radboud University told medical journal Cortex. 

Speaking about the decision to give him the sleeping pill, Dr. Hisse Arnts at Amsterdam UMC said, “Richard’s brain scans show overactivity in certain parts of the brain. This overactivity causes noise and somehow shuts down the “good” brain activity. We have discovered that administering this sleeping medication can suppress this unwanted brain overactivity, creating space for speech and movement.”

The medication’s effect, however, started wearing off after it was administered once a day for five days.

“The time windows during which the patient was able to talk and move got narrower, and his abilities to move and speak during these time windows decreased. The use of multiple doses of zolpidem during a single day showed no improvement in his clinical condition and sometimes even caused sedation,” Dr. Arnts told the journal. 

CT scan This a representational image showing doctors looking at CT scan in Bethesda, Maryland, Feb. 8, 2018. Photo: SAUL LOEB/AFP/Getty Images

Source Article

Read More
health

Doctors probe whether COVID-19 is causing diabetes

(Reuters) – Mario Buelna, a healthy 28-year-old father, caught a fever and started having trouble breathing in June. He soon tested positive for COVID-19.

The Simis family, Atticus, Sarah, Arthur and Ophelia, pose for a photo in Gardnerville, Nevada, September 24, 2020. Simis family/Handout via REUTERS

Weeks later, after what had seemed like a recovery, he felt weak and started vomiting. At 3 a.m. on Aug. 1, he passed out on the floor of his home in Mesa, Arizona.

Paramedics rushed him to a nearby hospital, where doctors put him in intensive care after saving him from a coma. They told him he could have died. Their diagnosis – type 1 diabetes – stunned and frightened him. He had no history of the disease.

“COVID triggered it,” Buelna said the doctors told him.

Buelna’s ordeal and similar cases reflect a new worry about the dangerous relationship between diabetes and COVID-19 that’s being urgently studied by doctors and scientists around the world. Many experts are convinced that COVID-19 can trigger the onset of diabetes – even in some adults and children who do not have the traditional risk factors.

It’s already been well-documented that people with diabetes face much higher risks of severe illness or death if they contract COVID-19. In July, U.S. health officials found that nearly 40% of people who have died with COVID-19 had diabetes. Now, cases like Buelna’s suggest the connection between the diseases runs both ways.

“COVID could be causing diabetes from scratch,” said Dr. Francesco Rubino, a diabetes researcher and chair of metabolic and bariatric surgery at King’s College London.

Rubino is leading an international team that is collecting patient cases globally to unravel one of the biggest mysteries of the pandemic. Initially, he said, more than 300 doctors have applied to share cases for review, a number he expects to grow as infections flare up again.

“These cases are coming from every corner of the world and every continent,” Rubino told Reuters.

In addition to the global registry, the U.S. National Institutes of Health is financing research into how the coronavirus may cause high blood sugars and diabetes.

In these situations, symptoms can escalate quickly and become life threatening. These cases may take months to surface after exposure to COVID-19, so the full extent of the problem and the long-term ramifications may not be known until well into next year. More intensive research is needed to definitively prove, beyond the mounting anecdotal evidence, that COVID-19 is triggering diabetes on a wide scale.

“We have more questions than answers right now,” said Dr. Robert Eckel, president of medicine and science at the American Diabetes Association. “We could be dealing with an entirely new form of diabetes.”

‘ABSOLUTELY TERRIFYING’ DIAGNOSIS

Type 1 diabetes occurs when the body’s immune system mistakenly destroys insulin-producing cells in the pancreas, preventing the regulation of blood sugar levels. About 1.6 million Americans have the disease.

Type 2 diabetes is more prevalent, afflicting about 30 million Americans. Those patients still produce insulin,

Read More
health

A nurse repeatedly voiced concern about a Chesapeake doctor’s unusual surgery practices to supervisors. Nothing happened, she says

Most every Friday afternoon, Dr. Javaid Perwaiz performed outpatient surgeries at a medical center in Suffolk.

And while there were lots of other doctors who operated regularly at the Bon Secours Surgery Center at Harbour View, there were none quite like Dr. Perwaiz, operating room nurse Jean Kennedy said.

His schedule was so packed and fast-paced the surgical center’s staff had a special name for it: the Perwaiz-a-thon.

“When someone asked you what are you doing today, staff would frequently say, ‘I’ve got the Perwaiz-a-thon,’” Kennedy said during testimony Monday in U.S. District Court in Norfolk. “It was an extremely busy tempo. Very stressful. At times it was chaotic.”

Perwaiz, 70, a longtime obstetrician-gynecologist who had offices in Chesapeake for decades, is on trial for multiple counts of heath care fraud, making false statements related to health care and identity theft. The trial began Wednesday and could last more than a month.

Prosecutors allege that Perwaiz frequently performed unnecessary surgeries and procedures, regularly induced labor for pregnant patients two weeks before they were due, and changed dates on forms to make it look like he was complying with insurance rules and regulations.

Kennedy testified Perwaiz typically had more than one operating room in use on Fridays and bounced back and forth between them. The other doctors just had one, she said.

And while the other doctors had their patients check in at staggered times, all of Perwaiz’s patients were told to report at the same time. Many of them didn’t seem to understand why they were having surgery, she said. And many had been there before.

“It was a first-come, first-serve basis,” she said. “There was no set schedule. It was just whoever was prepped and ready.”

The practice made Kennedy nervous because she feared it could lead to confusion and mistakes, she said.

Kennedy also said she occasionally saw the doctor write down post-surgery notes, in which he lists what he saw and did during the procedure, before the operation had even begun.

And unlike the other doctors, Perwaiz never used a scope with a camera on the end that could project images from inside the patient’s body onto a monitor for everyone in the operating room to see, she said.

Kennedy, who had once been a patient of Perwaiz and had worked in his office for a couple of years, said she and other hospital employees told supervisors of their concerns about Perwaiz’s unusual and concerning practices.

“They were fully aware,” she testified.

“And what happened?” prosecutor John Butler asked. “Nothing,” she said. “Things continued as they always had.”

In other testimony Monday, a 51-year-old former patient told jurors how she went to see Perwaiz after learning she had an abnormal pap smear. The woman had already survived breast cancer and feared getting cancer again.

The woman said Perwaiz performed one procedure, told her it didn’t work and that she’d need to get a hysterectomy. She said she was adamant about having it done vaginally because

Read More
medicine

Mount Sinai doctors elected to National Academy of Medicine for contributions to emergency medicine and translational genetics

Brendan G. Carr, MD, MA, MS, Chair of Emergency Medicine for the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System, and Judy H. Cho, MD, Dean of Translational Genetics at the Icahn School of Medicine at Mount Sinai and Director of The Charles Bronfman Institute for Personalized Medicine, have been elected to the National Academy of Medicine (NAM). Election to the NAM is considered one of the highest honors in health and medicine, recognizing individuals who have demonstrated outstanding professional achievement and commitment to service. With their election, Mount Sinai has 25 faculty members in the NAM.

“The recognitions of Dr. Carr and Dr. Cho are well deserved for their groundbreaking contributions to emergency medicine and translational genetics,” says Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean of the Icahn School of Medicine at Mount Sinai. “Dr. Carr’s research has focused not only on improving the emergency care system for time-sensitive conditions such as trauma, stroke, cardiac arrest, and sepsis, but also on creating a more distributed and innovative approach to increasing access to acute care. Likewise, Dr. Cho is committed to improving care through personalized medicine and the understanding of each patient’s unique genes. She has enhanced genetic research, clinical implementation, and data platforms to ensure Mount Sinai remains at the forefront of genetic discoveries and implementation.”

Emergency Medicine

A leading voice in emergency medicine, Dr. Carr played a central role in coordinating Mount Sinai’s response to the COVID-19 pandemic. He has dedicated his career as an emergency medicine physician and health policy researcher to seamlessly combining research, policy, and practice to advance acute care delivery. Before joining Mount Sinai in February 2020, Dr. Carr held faculty positions at the Sidney Kimmel Medical College at Thomas Jefferson University and the Perelman School of Medicine at the University of Pennsylvania.

Outside academia, Dr. Carr has worked within the U.S. Department of Health and Human Services during both the current and previous administrations to improve trauma and emergency care services at the national level. His roles have included Senior Advisor and Director of the Emergency Care Coordination Center within the Office of the Assistant Secretary for Preparedness and Response, focusing on integrating the emergency care system into the broader health care delivery system. He previously supported the Indian Health Service’s initiatives to improve emergency care delivery, and worked with the Department of Veterans Affairs and the Department of Defense to integrate military and civilian health care response during disasters and public health emergencies. Dr. Carr has advised and supported major not-for-profit foundations, the World Health Organization, and the National Academy of Medicine.

He conducts health services research that connects disciplines including epidemiology, health care policy, business, economics, and health care delivery system science. His work has been continuously funded by the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. He has published and lectured widely on systems of care for trauma, stroke, cardiac

Read More
health

Doctors Probe Whether COVID-19 Is Causing Diabetes | Top News

(Reuters) – Mario Buelna, a healthy 28-year-old father, caught a fever and started having trouble breathing in June. He soon tested positive for COVID-19.

Weeks later, after what had seemed like a recovery, he felt weak and started vomiting. At 3 a.m. on Aug. 1, he passed out on the floor of his home in Mesa, Arizona.

Paramedics rushed him to a nearby hospital, where doctors put him in intensive care after saving him from a coma. They told him he could have died. Their diagnosis – type 1 diabetes – stunned and frightened him. He had no history of the disease.

“COVID triggered it,” Buelna said the doctors told him.

Buelna’s ordeal and similar cases reflect a new worry about the dangerous relationship between diabetes and COVID-19 that’s being urgently studied by doctors and scientists around the world. Many experts are convinced that COVID-19 can trigger the onset of diabetes – even in some adults and children who do not have the traditional risk factors.

It’s already been well-documented that people with diabetes face much higher risks of severe illness or death if they contract COVID-19. In July, U.S. health officials found that nearly 40% of people who have died with COVID-19 had diabetes. Now, cases like Buelna’s suggest the connection between the diseases runs both ways.

“COVID could be causing diabetes from scratch,” said Dr. Francesco Rubino, a diabetes researcher and chair of metabolic and bariatric surgery at King’s College London.

Rubino is leading an international team that is collecting patient cases globally to unravel one of the biggest mysteries of the pandemic. Initially, he said, more than 300 doctors have applied to share cases for review, a number he expects to grow as infections flare up again.

“These cases are coming from every corner of the world and every continent,” Rubino told Reuters.

In addition to the global registry, the U.S. National Institutes of Health is financing research into how the coronavirus may cause high blood sugars and diabetes.

In these situations, symptoms can escalate quickly and become life threatening. These cases may take months to surface after exposure to COVID-19, so the full extent of the problem and the long-term ramifications may not be known until well into next year. More intensive research is needed to definitively prove, beyond the mounting anecdotal evidence, that COVID-19 is triggering diabetes on a wide scale.

“We have more questions than answers right now,” said Dr. Robert Eckel, president of medicine and science at the American Diabetes Association. “We could be dealing with an entirely new form of diabetes.”

‘ABSOLUTELY TERRIFYING’ DIAGNOSIS

Type 1 diabetes occurs when the body’s immune system mistakenly destroys insulin-producing cells in the pancreas, preventing the regulation of blood sugar levels. About 1.6 million Americans have the disease.

Type 2 diabetes is more prevalent, afflicting about 30 million Americans. Those patients still produce insulin, but over time their cells become insulin-resistant, allowing blood sugar to rise.

Type 1 diabetes cases have previously been associated with other

Read More
health

How one Virginia doctor’s coronavirus infection led to 25 people in quarantine

A doctor in training who wasn’t feeling well went into work.

The attending physician who supervised the Eastern Virginia Medical School resident sent the new doctor home. A little later, the doctor started to feel better and went to a barbecue with about 25 people.

The next day, when that doctor returned to work, another supervisor noticed the resident wasn’t well and sent the employee home. But that didn’t stop the doctor from going to a wedding of about 75 guests.

When the doctor’s condition worsened, the resident finally reported to the health center and got tested for the coronavirus. The nasal swab sample came back positive, which triggered a series of contact-tracing interviews to determine who might have been exposed.

EVMS leaders say the incident, which happened in July during a surge in Hampton Roads, is an example of the cascading effect one person’s infection can have, and the daunting task public health officials, institutions and employers face in trying to contain the disease from spreading further.

It also highlights the risk health professionals face in transmitting COVID-19 in clinical settings. The school recently used the story to emphasize to its students, staff and faculty the importance of wearing masks and social distancing on and off campus.

“That one individual’s behavior had about five different points where a different decision could have been made,” said Donald Combs, vice president and dean of the School of Health Professions at EVMS.

The doctor-in-training was in touch with about 100 different people, 25 of whom met the criteria for close contact and had to be put in quarantine for two weeks. Combs put it another way: That’s the equivalent of one full-time physician missing a year of work, he said.

Health departments use case investigations and so-called “contact tracing” as tools to prevent the spread of contagious diseases. People who work as disease detectives interview sick people about their whereabouts and try to reach as many people as they can who could have been infected. Then, they give them tips on how to get tested and stop passing it on to others.

Virginia contact tracers were in touch with about 81% of cases within 24 hours of the diagnosis last week, according to Virginia Department of Health data, though the goal is to reach everyone. Close to 8,500 people are under public health monitoring based on those investigations.

Close contact is usually defined as being within 6 feet of a person with COVID-19 for at least 15 minutes or having exposure to the person’s coughs, sneezes or kisses while they were infectious. Research shows that a person’s contagious period could range from one to two days before a person noticed symptoms or tested positive to seven or eight days after. For mild cases of the coronavirus, the CDC is recommending that patients isolate for 10 days after their symptoms started.

For years, the state health department has conducted case investigations for other infectious diseases, like measles and tuberculosis. But the

Read More
health

Doctors Rail Against Trump’s Michigan, Wisconsin Rallies Amid Surging COVID Cases

Doctors in Michigan and Wisconsin are encouraging President Donald Trump to cancel campaign rallies planned for Saturday afternoon, as coronavirus cases are rising in both states.



a group of people standing in front of a crowd: Attendees wait to hear President Donald Trump speak at a campaign rally on October 16, 2020 in Macon, Georgia. President Trump continues to campaign against Democratic presidential nominee Joe Biden with 18 days until election day.


© Elijah Nouvelage/Getty
Attendees wait to hear President Donald Trump speak at a campaign rally on October 16, 2020 in Macon, Georgia. President Trump continues to campaign against Democratic presidential nominee Joe Biden with 18 days until election day.

Michigan doctors Rob Davidson and Susan Fabrick held a virtual press conference on Friday afternoon, the day before Trump is expected to arrive at FlyBy Air near the airport in Muskegon County, located just northwest of Grand Rapids, the Detroit Free Press reported. The president is failing to listen to health officials’ advice, the doctors said.

“As physicians, we are really concerned about the inaccurate misinformation that President Trump repeats day after day, multiple times a day,” said Fabrick, a family medicine doctor who has practiced in Muskegon for 26 years. “No matter what he claims, COVID-19 is still with us and it is still killing people.”

On October 15, Michigan reported a record number of coronavirus cases statewide since the crisis began earlier this year, with 2,517 new cases, according to the New York Times’ database.

In Muskegon County, which has a population of just under 175,000, more than 1,700 people have tested positive for coronavirus, with case numbers continuing to steadily increase, according to the county’s public health department.

“Instead of coming to Muskegon to continue spreading misinformation and packing people close together with COVID-19 cases going up, President Trump should cancel his campaign event and focus on fighting the pandemic with science and evidence,” said Davidson, executive director of the Committee to Protect Medicare, which hosted the press conference. “As a physician, I’m concerned that his campaign events endanger public health. They have also become platforms for spreading medically inaccurate information that puts people’s lives at risk.”

‘Get Out There’: Trump Removes Face Mask For Photo Op As He Returns To White House

UP NEXT

UP NEXT

Trump’s campaign rallies typically attract thousands, even amid a global pandemic. While most of his events this year have been held in large outdoor venues, photographs show many of Trump’s supporters without face coverings and with little regard to social distancing—two measures strongly encouraged by health officials.

His campaign doesn’t require that face coverings be worn at rallies, but it does provide masks and encourages their use, Politico reported. Temperature checks and hand sanitizer are also provided.

“We take strong precautions for campaign events,” Tim Murtaugh, communications director, said in a statement to Politico.

The president will head to the neighboring state of Wisconsin later Saturday, where he plans to host a rally in Janesville, located about 75 miles west of Milwaukee. City leaders held a virtual press conference Saturday morning, criticizing Trump’s response to the coronavirus pandemic and his decision to hold a large event where cases are also surging, local station WMTV reported.

“These are super spreader events and health care

Read More