Clinical Outcome of Neurological patients with COVID-19: the impact of Healthcare organization improvement between waves.

Abstract Objective: The aim of this study is to evaluate the differences of clinical presentations and the impact of healthcare organization on outcomes of neurological COVID-19 patients admitted during the first and second pandemic waves. Methods: In this single center cohort study, we included all patients with SARS-CoV-2 infection admitted to a Neuro-COVID Unit. Demographic, clinical and laboratory data were compared between patients admitted during the first and second waves of COVID-19 pandemic. Results: 223 patients were included, of whom 112 and 111 hospitalized during the first and second pandemic waves, respectively. Patients admitted during the second wave were younger and exhibited pulmonary COVID-19 severity, resulting in less oxygen support (n=41, 36.9% vs n=79, 70.5%, p<0.001) and lower mortality rates (14.4% vs 31.3%, p=0.004). The different healthcare strategies and early steroid treatment emerged as significant predictors of mortality independently from age, premorbid conditions and COVID-19 severity in cox regression analyses. Conclusions: Differences in healthcare strategies during the second phase of COVID-19 pandemic probably explain the differences in clinical outcomes independently of disease severity, underlying the importance of standardized early management of neurological patients with SARS-CoV-2 infection.

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Type I Versus Type II Endometrial Cancer: Differential Impact of Comorbidity

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000001184 ◽

2018 ◽

Vol 28 (3) ◽

pp. 586-593 ◽

Cited By ~ 8

Author(s):

Mette Calundann Noer ◽

Sofie Leisby Antonsen ◽

Bent Ottesen ◽

Ib Jarle Christensen ◽

Claus Høgdall

Keyword(s):

Cox Regression ◽

Type I ◽

Prognostic Impact ◽

Type Ii ◽

Regression Analyses ◽

Differential Impact ◽

Kaplan Meier ◽

Prediction Of Survival ◽

Comorbidity Index ◽

The Impact

ObjectiveTwo distinct types of endometrial carcinoma (EC) with different etiology, tumor characteristics, and prognosis are recognized. We investigated if the prognostic impact of comorbidity varies between these 2 types of EC. Furthermore, we studied if the recently developed ovarian cancer comorbidity index (OCCI) is useful for prediction of survival in EC.Materials and MethodsThis nationwide register-based cohort study was based on data from 6487 EC patients diagnosed in Denmark between 2005 and 2015. Patients were assigned a comorbidity index score according to the Charlson comorbidity index (CCI) and the OCCI. Kaplan-Meier survival statistics and adjusted multivariate Cox regression analyses were used to investigate the differential association between comorbidity and overall survival in types I and II EC.ResultsThe distribution of comorbidities varied between the 2 EC types. A consistent association between increasing levels of comorbidity and poorer survival was observed for both types. Cox regression analyses revealed a significant interaction between cancer stage and comorbidity indicating that the impact of comorbidity varied with stage. In contrast, the interaction between comorbidity and EC type was not significant. Both the CCI and the OCCI were useful measurements of comorbidity, but the CCI was the strongest predictor in this patient population.ConclusionsComorbidity is an important prognostic factor in type I as well as in type II EC although the overall prognosis differs significantly between the 2 types of EC. The prognostic impact of comorbidity varies with stage but not with type of EC.

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Effect of statin and metformin on survival in veterans (V) with B-cell lymphoproliferative disorders (BLD).

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.1602 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 1602-1602

Author(s):

Shanthi Srinivas ◽

Melanie L. Gonzalez ◽

Sunniya Khan ◽

Arpita Gandhi ◽

Barbara Crump ◽

...

Keyword(s):

Rating Scale ◽

Cox Regression ◽

Univariate Analysis ◽

Laboratory Data ◽

Cox Regression Analysis ◽

Comorbidity Index ◽

Beta 2 Microglobulin ◽

Ecog Ps ◽

The Impact ◽

Statin Use

1602 Background: The incidence of BLD has been increasing in V. As many V are on statin and metformin for comorbid conditions, we evaluated the impact of their use on survival. Methods: In an IRB-approved protocol, we reviewed the records of 332 V diagnosed with BLD from January 1997 to Dec 2011 for demographics, height(H),weight(W), BMI,statin and metformin use, clinical and laboratory data and ECOG PS. Comorbidity was assessed using the Charlson Comorbidity Index (CCI),Kaplan-Feinstein Index (KFI) and Cumulative Illness Rating Scale (CIRS). Cox regression analysis was performed using SAS v 9.2. Results: There were 332 V with a median (M) age of 70 years (27-94). The M for H 70 inches (58-78), W 183lbs (99-356.5) and BMI 26.7 kg/m2 (15.54 -48.45). The M for hemoglobin(Hgb) 12.8 g/dl (7.3-17.4), albumin 3.9(1.2-5.4), lactate dehydrogenase( LDH) 183 IU/L (85-1905), beta 2-microglobulin 2.6 mg/dl (0.8-39) . The M for CCI was 4.7 (0.8-12), KFI 2 (0-3), CIRS15 3 (0-6), CIRS16 6(0 -14), CIRS17 1.9(0-6), CIRS18 0(0-3), CIRS19 0(0-3). M survival was 1297days(4-7468).The number of V receiving statin was 167 (51%) and metformin 46 (14%). Statin use was a predictor of survival by both univariate and multivariate analysis but metformin was a predictor only by univariate analysis. Conclusions: Statin use was an independent and significant predictor of survival in this group of V with BLD and needs to be validated in a larger group of patients. [Table: see text]

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Extent of lymph node resection and effect on pancreatic cancer overall survival.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.682 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 682-682

Author(s):

Brian Cox ◽

Nicholas Manguso ◽

Humair Quadri ◽

Jessica Crystal ◽

Katelyn Mae Atkins ◽

...

Keyword(s):

Pancreatic Cancer ◽

Overall Survival ◽

Logistic Regression ◽

Lymph Node ◽

Cox Regression ◽

Survival Curve ◽

Regression Analyses ◽

Kaplan Meier ◽

The Impact ◽

Meier Survival Curve

682 Background: Lymph node (LN) metastases affect overall survival (OS) in pancreatic cancer (PC). However, a LN sampling threshold does not exist. We examined the impact of nodal sampling on overall survival (OS). Methods: Patients with Stage I-III PC ≥55 years old who underwent curative resection from 2004-2016 were identified from the National Cancer Database (NCDB). After adjusting for age, gender, grade, stage, and Charlson-Deyo score, multiple binomial logistic regression analyses assessed the impact of the LN ratio (LNR) on OS. LNR was defined as the number of positive LN over the number of LN examined. Regression analyses, a Cox-Regression, and a Kaplan-Meier survival curve assessed how many LN should be sampled. Results: A total of 13,673 patients, median age 69 years (55-90), were included. Most were Caucasian (86.6%) males with Charlson-Deyo scores ≤ 1 (90.3%) and moderately to poorly differentiated PC (90.1%). Median number of LN examined was 15 (1-75) with a median of 1 positive LN (0-35). As expected, increased number of positive LNs was associated with reduced OS, p < 0.001. After data normalization, an increasing LNR was associated with a 12-fold likelihood of death [OR: 11.9, p < 0.001 (CI 6.0, 23.7)]. Subsequent regression models established evaluation of ≥ 16 LNs as the greatest predictor of OS. A regression model evaluating < or ≥ 16 lymph nodes was performed to ascertain the effects of age, gender, ethnicity, grade, stage, and LN examined on OS. The logistic regression model correctly classified 74.5% of cases with a specificity of 99.6% (p < 0.001). Examination of < 16 LN, Caucasian race, grade, stage, and higher Charlson-Deyo scores were significantly associated with decreased OS. If ≥ 16 LNs were examined, patients had a 1.5-fold likelihood of better OS, p < 0.001 (CI 1.4, 1.6). An adjusted Cox Regression showed increased HR of 1.2, p < 0.001 (CI 1.1, 1.2) and an unadjusted Kaplan Meier survival curve predicted ≥ 16 LN examined are associated with an increase in OS of 2.8 months [log-rank: 32.0, p < 0.001]. Conclusions: Patients undergoing curative intent resection for PC should have adequate nodal sampling. Stratification of patients by LNR may provide useful information of OS. Examination of ≥ 16 LNs impacts OS in patients with Stage I-III PC.

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The Impact of Serum Anti-neutrophil Cytoplasmic Antibody on Clinical Characteristics and Outcomes in Pediatric-Onset Systemic Lupus Erythematosus Patients

Frontiers in Medicine ◽

10.3389/fmed.2021.647510 ◽

2021 ◽

Vol 8 ◽

Author(s):

Chun-Chun Gau ◽

Min-Hua Tseng ◽

Chao-Yi Wu ◽

Huang-Yu Yang ◽

Jing-Long Huang

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Erythematosus ◽

Clinical Characteristics ◽

Laboratory Data ◽

Systemic Lupus ◽

Retrospective Case ◽

Clinical Presentations ◽

The Impact ◽

Pediatric Onset ◽

Onset Systemic Lupus Erythematosus

Background: Systemic lupus erythematosus (SLE), an autoimmune disease, is characterized by the overproduction of autoantibodies. Anti-neutrophil cytoplasmic antibodies (ANCAs) have been recognized in SLE for decades. To date, their association with SLE disease activity, especially in pediatric-onset SLE (pSLE) patients, is limited.Methods: We conducted a retrospective case-control study of pSLE patients with ANCAs from 2010 to 2020. Clinical characteristics, laboratory data, renal histological features, treatment and outcomes were analyzed.Results: A total of 70 pediatric-onset SLE patients (9 ANCA-positive vs. 61 ANCA-negative) with a median age of 12.23 years (age ranging from 4 years to 18 years) at diagnosis were enrolled. Among patients with ANCAs, MPO-ANCA was found in seven and PR3-ANCA in two of those cases. Patients with ANCAs had a tendency to have hematuria compared with those without ANCAs (66 vs. 24.6%, respectively; p = 0.026). Of the 70 SLE patients, 8 with ANCAs and 44 without ANCAs underwent renal biopsies. Patients with ANCAs (25%, 2/8) were more likely to lack the typical full-house pattern in their renal immunofluorescence (IF) staining.Conclusion: pSLE patients with ANCAs tend to have hematuria and an absence of typical IF histology. However, patients with and without ANCAs showed no difference in their clinical presentations and treatment outcomes.

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Clinical Characteristics and Risk Factors for Mortality of COVID-19 Patients With Diabetes in Wuhan, China: A Two-Center, Retrospective Study

10.2337/figshare.12210008.v1 ◽

2020 ◽

Cited By ~ 2

Author(s):

Qiao Shi ◽

Xiaoyi Zhang ◽

Fang Jiang ◽

Xuanzhe Zhang ◽

Chibu Bimu ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Retrospective Study ◽

Proportional Hazards ◽

Cox Regression ◽

Laboratory Data ◽

Cox Proportional Hazards ◽

Hospital Death ◽

Regression Analyses ◽

Patients With Diabetes

<div><b>OBJECTIVE: </b>Diabetes is common in COVID-19 patients and associated with unfavorable outcomes. We aimed to describe the characteristics, outcomes and analyze the risk factors for in-hospital mortality of COVID-19 patients with diabetes.</div><div><b><br></b></div><div><b>RESEARCH DESIGN AND METHODS: </b>This two-center, retrospective study was performed at two tertiary hospitals in Wuhan, China. Confirmed COVID-19 patients with diabetes (N=153) who were discharged or died from January 1, 2020, to March 8, 2020, were identified. One sex- and age-matched COVID-19 patient without diabetes was randomly selected for each patient with diabetes. Demographic, clinical, and laboratory data were abstracted. Cox proportional hazards regression analyses were performed to identify the risk factors associated with the mortality in these patients.</div><div><br></div><div><b>RESULTS:</b> Of 1561 COVID-19 patients, 153 (9.8%) had diabetes, with a median age of 64.0 (IQR, 56.0-72.0) years. A higher proportion of ICU admission (17.6% vs 7.8%, P=0.01) and more fatal cases (20.3% vs 10.5%, P=0.017) were identified in COVID-19 patients with diabetes than in the matched patients. Multivariable Cox regression analyses of these 306 patients showed that hypertension (hazards ratio [HR] 2.50, 95% CI 1.30-4.78), cardiovascular disease (HR 2.24, 95% CI 1.19-4.23) and chronic pulmonary disease (HR 2.51, 95% CI 1.07-5.90) were independently associated with in-hospital death. Diabetes (HR 1.58, 95% CI 0.84-2.99) was not statistically significantly associated with in-hospital death after adjustment. Among patients with diabetes, nonsurvivors were older (76.0 vs 63.0 years), most were male (71.0% vs 29.0%), and were more likely to have underlying hypertension (83.9% vs 50.0%) and cardiovascular disease (45.2% vs 14.8%) (all P-values<0.05). Age ≥70 years (HR 2.39, 95% CI 1.03-5.56) and hypertension (HR 3.10, 95% CI 1.14-8.44) were independent risk factors for in-hospital death of patients with diabetes.</div><div><br></div><div><b>CONCLUSIONS: </b>COVID-19 patients with diabetes had worse outcomes compared with the sex- and age-matched patients without diabetes. Older age and comorbid hypertension independently contributed to in-hospital death of patients with diabetes.</div>

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An Inverse Relationship between Hyperuricemia and Mortality in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Journal of Clinical Medicine ◽

10.3390/jcm7110416 ◽

2018 ◽

Vol 7 (11) ◽

pp. 416 ◽

Cited By ~ 4

Author(s):

Kuan-Ju Lai ◽

Chew-Teng Kor ◽

Yao-Peng Hsieh

Keyword(s):

Peritoneal Dialysis ◽

Continuous Ambulatory Peritoneal Dialysis ◽

Cox Regression ◽

Laboratory Data ◽

Study Cohort ◽

Dialysis Unit ◽

Cox Regression Analysis ◽

Hazard Ratios ◽

Adjusted Model ◽

The Impact

Background: The results have been inconsistent with regards to the impact of uric acid (UA) on clinical outcomes both in the general population and in patients with chronic kidney disease. The aim of this study was to study the influence of serum UA levels on mortality in patients undergoing continuous ambulatory peritoneal dialysis. Methods: Data on 492 patients from a single peritoneal dialysis unit were retrospectively analyzed. The mean age of the patients was 53.5 ± 15.3 years, with 52% being female (n = 255). The concomitant comorbidities at the start of continuous ambulatory peritoneal dialysis (CAPD) encompassed diabetes mellitus (n = 179, 34.6%), hypertension (n = 419, 85.2%), and cardiovascular disease (n = 186, 37.9%). The study cohort was divided into sex-specific tertiles according to baseline UA level. A Cox proportional hazard model was used to calculate hazard ratios (HRs) of all-cause, cardiovascular, and infection-associated mortality with adjustments for demographic and laboratory data, medications, and comorbidities. Results: Multivariate Cox regression analysis showed that, using UA tertile 1 as the reference, the adjusted HR of all-cause, cardiovascular, and infection-associated mortality for tertile 3 was 0.4 (95% confidence interval (CI) 0.24–0.68, p = 0.001), 0.4 (95% CI 0.2–0.81, p = 0.01), and 0.47 (95% CI 0.19–1.08, p = 0.1). In the fully adjusted model, the adjusted HRs of all-cause, cardiovascular, and infection-associated mortality for each 1-mg/dL increase in UA level were 0.84 (95% CI, 0.69–0.9, p = 0.07), 0.79 (95% CI, 0.61–1.01, p = 0.06), and 0.79 (95% CI, 0.48–1.21, p = 0.32) for men and 0.57 (95% CI, 0.44–0.73, p < 0.001), 0.6 (95% CI, 0.41–0.87, p = 0.006), and 0.41 (95% CI, 0.26–0.6, p < 0.001) for women, respectively. Conclusions: Higher UA levels are associated with lower risks of all-cause, cardiovascular and infection-associated mortality in women treated with continuous ambulatory peritoneal dialysis.

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First and second waves among hospitalised patients with COVID-19 with severe pneumonia: a comparison of 28-day mortality over the 1-year pandemic in a tertiary university hospital in Italy

BMJ Open ◽

10.1136/bmjopen-2021-054069 ◽

2022 ◽

Vol 12 (1) ◽

pp. e054069

Author(s):

Marianna Meschiari ◽

Alessandro Cozzi-Lepri ◽

Roberto Tonelli ◽

Erica Bacca ◽

Marianna Menozzi ◽

...

Keyword(s):

Mortality Rate ◽

Regression Model ◽

Cox Regression ◽

Severe Pneumonia ◽

University Hospital ◽

P Value ◽

Cox Regression Model ◽

Hospitalised Patients ◽

The Impact ◽

Second Wave

ObjectiveThe first COVID-19–19 epidemic wave was over the period of February–May 2020. Since 1 October 2020, Italy, as many other European countries, faced a second wave. The aim of this analysis was to compare the 28-day mortality between the two waves among COVID-19 hospitalised patients.DesignObservational cohort study. Standard survival analysis was performed to compare all-cause mortality within 28 days after hospital admission in the two waves. Kaplan-Meier curves as well as Cox regression model analysis were used. The effect of wave on risk of death was shown by means of HRs with 95% CIs. A sensitivity analysis around the impact of the circulating variant as a potential unmeasured confounder was performed.SettingUniversity Hospital of Modena, Italy. Patients admitted to the hospital for severe COVID-19 pneumonia during the first (22 February–31 May 2020) and second (1 October–31 December 2020) waves were included.ResultsDuring the two study periods, a total of 1472 patients with severe COVID-19 pneumonia were admitted to our hospital, 449 during the first wave and 1023 during the second. Median age was 70 years (IQR 56–80), 37% women, 49% with PaO2/FiO2 <250 mm Hg, 82% with ≥1 comorbidity, median duration of symptoms was 6 days. 28-day mortality rate was 20.0% (95% CI 16.3 to 23.7) during the first wave vs 14.2% (95% CI 12.0 to 16.3) in the second (log-rank test p value=0.03). After including key predictors of death in the multivariable Cox regression model, the data still strongly suggested a lower 28-day mortality rate in the second wave (aHR=0.64, 95% CI 0.45 to 0.90, p value=0.01).ConclusionsIn our hospitalised patients with COVID-19 with severe pneumonia, the 28-day mortality appeared to be reduced by 36% during the second as compared with the first wave. Further studies are needed to identify factors that may have contributed to this improved survival.

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Impact of age and medical comorbidity (MC) on adjuvant treatment outcomes for stage III colon cancer (CC): A pooled analysis of individual patient data from four randomized controlled trials.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.3522 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 3522-3522 ◽

Cited By ~ 7

Author(s):

Daniel G. Haller ◽

Michael O'Connell ◽

Thomas H. Cartwright ◽

Christopher Twelves ◽

Edward McKenna ◽

...

Keyword(s):

Treatment Outcomes ◽

Adjuvant Treatment ◽

Cox Regression ◽

Age Groups ◽

Sensory Neuropathy ◽

Pooled Analysis ◽

Stage Iii ◽

Regression Analyses ◽

Grade 3 ◽

The Impact

3522 Background: Studies show significantly improved disease-free and overall survival (DFS, OS) for oxaliplatin (Ox)-based vs. leucovorin/5-fluorouracil (LV/5-FU) adjuvant therapy in CC, with conflicting reports of Ox benefit in patients > 70 years old. The impact of MC on Ox benefit has not been assessed. We assessed the impact of age and MC on adjuvant treatment outcomes for stage III CC. Methods: N = 4,819 patients from NSABP C-08, XELOXA, X-ACT, and AVANT were analyzed by Ox therapy (XELOX/FOLFOX) vs. LV/5-FU, MC, and age; patients treated with bevacizumab were excluded. Endpoints were DFS (primary), OS, and safety. MC was assessed (except NSABP C-08) by adapted Charlson Comorbidity and NCI Combined Indices (CCI, NCI): Low (≤ 1) vs. high (> 1). Hazardratios (HR) were estimated by Cox regression analyses. Multivariate Cox regression analyses (MVA) tested for independent effects of age and MC on Ox benefit, controlling for gender, T, and N stage. Results: Patient demographics, MC, and disease characteristics (except lymph nodes examined) were well balanced across groups. Median follow-up was shorter in NSABP C-08 and AVANT (36 and 50 months) vs. XELOXA and X-ACT (83 and 74 months). MVA-confirmed DFS/OS benefit was consistently shown for XELOX/FOLFOX vs. LV/5-FU, regardless of age or MC. Grade 3/4 serious adverse event (AE) rates were comparable across cohorts and CCI scores, and higher in patients aged ≥ 70. Grade 3/4 AEs of interest, including peripheral sensory neuropathy, were comparable across ages and CCI scores, and higher with XELOX/FOLFOX. Conclusions: Ox benefit is modestly attenuated in patients aged ≥ 70; however, significant benefit is observed regardless of age or MC in this analysis. Our results further support XELOX or FOLFOX as standard options for the adjuvant management of stage III CC in all age groups. [Table: see text]

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Attitudes and Motivations of Students Taking Professional Certificate Examinations

Social Behavior and Personality An International Journal ◽

10.2224/sbp.2011.39.10.1303 ◽

2011 ◽

Vol 39 (10) ◽

pp. 1303-1314 ◽

Cited By ~ 5

Author(s):

Pi-Yueh Cheng ◽

Mei-Lan Lin ◽

Chia-Kai Su

Keyword(s):

Intrinsic Motivation ◽

Multiple Regression ◽

Questionnaire Survey ◽

Extrinsic Motivation ◽

Second Phase ◽

Regression Analyses ◽

Business Studies ◽

Attitude Changes ◽

Students Attitudes ◽

The Impact

In this study we explored the attitudes and motives of business studies students taking examinations for professional certificates, where their participation may have a cognition-oriented motive. The study was divided into 2 phases: in the first phase, a questionnaire survey was used to examine the differences between internal and external encouragement perspectives for those students with and without professional certificates. We found that the intrinsic motivation of students with professional certificates was significantly higher than their extrinsic motivation. In the second phase we examined whether the impact of the external justifications of attitude changes are associated with students' attitudes toward participation in the examination. Multiple regression analyses revealed that reward, satisfaction, effort, responsibility, and commitment were predictive of participants' attitudes.

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Plasma prothrombin time and activated partial thromboplastin time as predictors of bleeding manifestations during dengue hemorrhagic fever

Paediatrica Indonesiana ◽

10.14238/pi49.2.2009.69-74 ◽

2009 ◽

Vol 49 (2) ◽

pp. 69

Author(s):

I. N. Budastra ◽

B. N. P. Arhana ◽

IB. Mudita

Keyword(s):

Cohort Study ◽

Partial Thromboplastin Time ◽

Cox Regression ◽

Hemorrhagic Fever ◽

Massive Bleeding ◽

Activated Partial Thromboplastin Time ◽

Regression Analyses ◽

Cox Regression Analysis ◽

The Impact ◽

The Relationship

Background Massive bleeding and shock are complications ofdengue hemorrhagic fever (DHF) that are associated withhigh mortality. Impaired hemostasis, especially coagulopathy,contributes to bleeding manifestations in DHF. Parameters suchas activated partial thromboplastin time (APTT) and plasmaprothrombin time (PPT) indicate the impact of coagulationsystem.Objective To determine the relationship between APTT and PPTlevels with bleeding manifestations in DHF patients.Methods A prospective cohort study was applied to subjectsdiagnosed with DHF at the Infection and Tropical DiseasesDivision, Department of Child Health, Medical School, UdayanaUniversity, Sanglah Hospital, Denpasar, Indonesia. Laboratorytests to determine APTT and PPT were carried out on thethird, fourth, and fifth day after the onset of fever. Bleedingmanifestations were examined in patients during their hospitalstay. Univariate and Cox regression analyses were performedto examine relationship between APTT and PPT values withbleeding manifestations in DHF patients.Results Forty-three children were enrolled in this study. Therewas a significant relationship between increases in APTT valuewith bleeding manifestations in DHF patients [RR 2.79 (95%CI1.68 to 4.69), P <0.01]. Cox regression analysis showed that onlyincreased APTT values correlated with bleeding manifestations[RR 2.05 (95%CI 1.92 to 3.90), P = 0.02].Conclusion APTT values may be used as a predictor for bleedingmanifestations in DHF.

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