General Movements Research Articles

Mobile Solutions for Clinical Surveillance and Evaluation in Infancy-General Movement Apps.

The Prechtl General Movements Assessment (GMA) has become a clinician and researcher toolbox for evaluating neurodevelopment in early infancy. Given that it involves the observation of infant movements from video recordings, utilising smartphone applications to obtain these recordings seems like the natural progression for the field. In this review, we look back on the development of apps for acquiring general movement videos, describe the application and research studies of available apps, and discuss future directions of mobile solutions and their usability in research and clinical practice. We emphasise the importance of understanding the background that has led to these developments while introducing new technologies, including the barriers and facilitators along the pathway. The GMApp and Baby Moves apps were the first ones developed to increase accessibility of the GMA, with two further apps, NeuroMotion and InMotion, designed since. The Baby Moves app has been applied most frequently. For the mobile future of GMA, we advocate collaboration to boost the field's progression and to reduce research waste. We propose future collaborative solutions, including standardisation of cross-site data collection, adaptation to local context and privacy laws, employment of user feedback, and sustainable IT structures enabling continuous software updating.

Spontaneous movements as a prognostic tool of neurodevelopmental outcomes in preterm infants: a narrative review.

An estimated 15 million infants are born each year prematurely. Although the survival rate of preterm infants has increased with advances in perinatal and neonatal care, many of them still suffer from various complications. Since improving neurodevelopmental outcomes of preterm births are a crucial topic of interest, accurate evaluations should be preceded for the detection of high-risk infants for cerebral palsy. General movements are spontaneous movements involving the whole body as the expression of neural activity and can be an excellent biomarker of neural dysfunction caused by brain impairment in preterm infants. The predictive value of general movements with respect to cerebral palsy increases with continuous observation. Automated approaches for general movements based on machine learning can help to overcome the limited utilization of assessment tools due to their qualitative or semi-quantitative nature and high dependency on the skills and experience of the assessors. This review will cover each of these topics, from the summarization of normal and abnormal general movements to the recent advance of automatic approaches based on infantile spontaneous movements.

Did Bank Stockholders Get Superior Returns Due to the Implementation of the Paycheck Protection Program? An Analysis of Bank Indices Based on Size

The study examines the impact of the implementation of the Paycheck Protection Program on the largest (KBW) and smallest (ABAQ) bank-based indices. Since the Paycheck Protection Act was created to help businesses during the COVID-19 pandemic, the money was disseminated by the US Federal government using commercial banks as the main conduit. Using t-tests and non-parametric tests, we find that both indices had superior returns during the implementation of the PPP program. This is supported by the results of a dummy variable regression. However, when controlled for general market movements represented by NASDAQ Composite daily returns, neither KBW nor ABAQ produced abnormal returns for the PPP window. We further report that there are some superior returns for the bigger banks when general markets moved higher, which arguably received greater sums of money and distributed them more inconsistently with fiscal goals as compared with their smaller counterparts during the implementation of the PPP program.

Interrelationships between Tourist Arrivals, Exchange Rate, Inflation, and Economic Growth: Empirical Evidence for Türkiye

Touristic activities have become essential for sustainable development associated with countries' prosperity and mobility opportunities. These activities may be affected by the exchange rate, economic growth, and general price movements, and these variables may also be affected by tourism activities. This study analyzes the relationships between tourist arrivals, economic growth, inflation, and exchange rate for Türkiye taking the country's geopolitical risk as exogenous, using monthly data over 2008-2020 and a Vector Error Correction modelling approach. The results indicate favorable short-run and long-run impacts of tourist arrivals on economic growth and confirm the validity of the tourism-led growth hypothesis for Türkiye. Toda Yamamoto causality tests show unidirectional causality from economic growth to inflation and exchange rate fluctuations and from the exchange rate to inflation. Therefore, results do not show evidence of tourism’s Dutch disease effect. Improving the quality of tourism-related services and marketing is vital for revenue increase and, thus, economic growth.

Diffusion Tensor Imaging to Predict Neurodevelopmental Impairment in Infants after Hypoxic-Ischemic Injury.

Magnetic resonance imaging (MRI) is the standard of care for evaluation of brain injury after hypoxic-ischemic encephalopathy (HIE) in term newborns. This study utilizes diffusion tensor imaging (DTI) to (1) identify infants at highest risk of development of cerebral palsy (CP) following HIE and to (2) identify regions of the brain critical to normal fidgety general movements (GMs) at 3 to 4 months of postterm. Absence of these normal, physiological movements is highly predictive of CP. Term infants treated with hypothermia for HIE from January 2017 to December 2021 were consented for participation and had brain MRI with DTI after rewarming. The Prechtl's General Movements Assessment was performed at 12 to 16 weeks of age. Structural MRIs were reviewed for abnormalities, and DTI data were processed with the FMRIB Software Library. Infants underwent the Bayley Scales of Infant and Toddler Development III test at 24 months. Forty-five infant families were consented; three infants died prior to MRI and were excluded, and a fourth infant was excluded due to diagnosis of a neuromuscular disorder. Twenty-one infants were excluded due to major movement artifact on diffusion images. Ultimately, 17 infants with normal fidgety GMs were compared with 3 infants with absent fidgety GMs with similar maternal and infant characteristics. Infants with absent fidgety GMs had decreased fractional anisotropy of several important white matter tracts, including the posterior limb of the internal capsule, optic radiations, and corpus callosum (p < 0.05). All three infants with absent fidgety GMs and two with normal GMs went on to be diagnosed with CP. This study identifies white matter tracts of the brain critical to development of normal fidgety GMs in infants at 3 to 4 months of postterm using advanced MRI techniques. These findings identify those at highest risk for CP among infants with moderate/severe HIE prior to hospital discharge. · HIE has devastating impacts on families and infants.. · Diffusion MRI identifies infants at highest risk for developing neurodevelopmental impairment.. · Normal general movements of infancy are generated by key white matter tracts..

Early markers of neurodevelopmental disorders based on general movements for very preterm infants: study protocol for a multicentre prospective cohort study in a clinical setting in China

IntroductionVery preterm (VPT) infants may experience varying degrees of neurodevelopmental challenges. Lack of early markers for neurodevelopmental disorders may delay referral to early interventions. The detailed General Movements Assessment (GMA)...

Early Spontaneous Movements and Sensory Processing in Preterm Infants.

Preterm infants are at higher risk of motor development abnormalities and sensory processing difficulties. Few studies have examined both movement development and sensory processing in the early months of life, and the results are controversial. In this cross-sectional study, we investigated (1) differences in early spontaneous movements and sensory processing between preterm infants born at <32 wk gestation and those born at 32 to 36 wk gestation when they reached corrected (postterm) age 3 to 5 mo and (2) the relationship between early spontaneous movements and sensory processing. We included 50 preterm infants born at <32 wk gestation and 61 preterm infants born at 32 to 36 wk gestation. We assessed early spontaneous movements, including fidgety movements, using the General Movements Assessment (GMA), which provides the Motor Optimality Score (MOS), and sensory processing using the Infant Sensory Profile-2. The preterm infants born at <32 wk gestation had lower MOS results (p = .035) and more sensory processing difficulties (p = .006) than those born at 32 to 36 wk gestation. We found no significant relationship between early spontaneous movements and sensory processing (p > .05). Preterm infants born at <32 wk gestation are at increased risk for motor development abnormalities and sensory processing difficulties. What This Article Adds: Assessment of both motor development and sensory processing can play a crucial role in identifying infants who need early intervention.

Enveloppes psychiques précoces : la difficulté d’être contenant auprès d’un bébé en retrait relationnel

ContextAutism spectrum disorder (ASD) results from a complex interaction between innate factors of the infant and their environment. Many risk factors have been identified. The difficulties in physical organization of at-risk children can allow us to identify the most fragile infants at birth. The baby in relational withdrawal can teach us about the part played by the infant in the weaving of early psychic envelopes. Research on babies who have become autistic children demonstrates disturbances in their motor skills, from their general movements to difficulties with body organization. The infant's sensorimotor difficulties hinder the expression of subjectivity. They also have an impact on the parents’ ability to interpret the signs coming from the baby. It is difficult for a parent to be the receptacle of the intentions of a baby who does not seem to be addressing its parent. An accompaniment of the parents supports them in their capacity to provide a secure “container” for their baby. A transdisciplinary team ensuring the continuity of the group psychic envelope may be necessary to establish harmony between the baby and their environment. ObjectivesThe goal of early post-natal care is to support parents so that they feel they are the receptacle to the baby's intentions. We want the baby to be able to actively engage in the relationship with its parent from the first months of its life, despite any sensorimotor difficulties that may be present. MethodIn this theoretical reflection on the difficulties of containment with a baby in relational withdrawal, we develop the theoretical-clinical bases which underlie our work as care providers. We focus here mainly on supporting parents in the containing function they occupy as the organizing center of their baby's instinctual life. ResultsThe result targeted by this treatment is the entry of the baby into goal-directed movement towards the other from 4 months, as evaluated by the Préaut grid, within the framework of a pleasant relationship of shared pleasure. We promote the establishment of a relationship in which the parent can both perceive the signs emitted by their baby while being attentive to their own internal experience. Particular attention is paid to joint listening. From this theoretical-clinical base stems the current practice of a transdisciplinary team and two ongoing research projects.

Prechtl’s General Movements performed at writhing age may help target MRI use in the NICU (P9-9.012)

<h3>Objective:</h3> We aimed to determine if Prechtl’s general movement assessment (GMA) could help target the use of magnetic resonance imaging (MRI) in the neonatal intensive care unit (NICU) to detect infants with neuroimaging abnormalities not detected by cranial ultrasound (CUS) alone. <h3>Background:</h3> Prechtl’s GMA is a bedside evaluation performed to identify infants at high-risk for neurological and motor disorders such as cerebral palsy (CP). Cramped synchronized (CS) GMA at writhing age has been associated with poor neuromotor outcomes. However, no clinical practice guideline exists to recommend routine use of term-equivalent MRI in infants with CS GMAs. <h3>Design/Methods:</h3> We retrospectively reviewed neuroimaging reports from pediatric neuroradiologists of all infants who had CS GMA between 36 and 44 weeks post-menstrual age at two level III and three level IV NICUs. All three sites used standard protocols for preterm neuroimaging with at least one CUS in the first week after birth and another near 30 weeks corrected gestational age. If an MRI was obtained (due to clinical suspicion for intracranial abnormality, abnormal CUS findings, or CS GMA) the reason for performing the MRI was recorded. <h3>Results:</h3> 144 infants had CS GMA, and of these, only 19 did not receive neuroimaging. Initial neuroimaging demonstrated abnormal (mild and severe) findings in 64.5% and clinically significant in 45.6%. When MRI was performed secondarily, agreement between the two types of imaging occurred most of the time. A higher level of insult was present in 20.7% of those receiving a secondary MRI. The frequency of clinically significant abnormal findings on final determination was 48.8%. In 14 cases, secondary MRI was performed in response to GMA CS pattern only; in this case, MRI was abnormal in 11 (76.8%) cases. <h3>Conclusions:</h3> These results suggest that infants with CS GMA at writhing age may represent a population with a high-likelihood of clinically significant abnormal neuroimaging findings. <b>Disclosure:</b> Dr. Chirigos has nothing to disclose. Dr. Burton has nothing to disclose. Dr. Maitre has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Thrive Neuromedical. Dr. Maitre has stock in Thrive Neuromedical. Dr. Ostrander has nothing to disclose.

Early spontaneous movements and spatiotemporal gait characteristics in preterm children.

This study aimed to analyze spatiotemporal gait characteristics of preterm children from 3 to 4years of age according to different gestational age groups and to examine the relationship between the detailed general movements assessment and spatiotemporal gait characteristics. A total of 74 preterm children, 32 extremely preterm and very preterm (EP-VP, < 32weeks gestational age) and 42 moderate to late preterm (MLP, 32 to < 37weeks gestational age), were included in this prospective study, along with 38 term children. Early spontaneous movements of preterm children were assessed from videos at 9-20weeks post-term according to the general movements assessment, which determines the Motor Optimality Score-Revised (MOS-R). The spatiotemporal gait characteristics of all children were evaluated using the GAITRite®electronicwalkway at self-selected walking speeds. EP-VP children walked with shorter step lengths (p = 0.039), and MLP children walked with greater step length variability (p = 0.003) than their term peers. The MOS-R results were related to step length (r = 0.36, p = 0.042), step length variability (r = -0.56, p = 0.001), and base of support (r = -0.37, p = 0.038) in EP-VP children. The MOS-R subcategories, age-adequate movement repertoire, and postural patterns were related to some of the spatiotemporal gait characteristics, including step length, step length variability, and base of support (p < 0.05). Conclusion: EP-VP and MLP children might catch up to their term peers at 3 to 4years of age in terms of most gait parameters. In addition to the MOS-R, age-adequate movement repertoire and postural patterns of preterm children without cerebral palsy in early life may be a marker of later neurodevelopmental dysfunction. What is Known: • Preterm children walk with a wider step width, a greater step length asymmetry and step time, and a shorter stride length at 18 to 22 months of age compared with term children at aself-selected speed, while these differences disappear in children 4.5-5 years old and older. What is New: • Early spontaneous movements were related to some spatiotemporal gait characteristics. • Preterm children might catch up to term children at 3-4 years of age in spatiotemporal gait characteristics while walking at a self-selected speed.

Investigation of secretoneurin as a potential biomarker of brain injury in very preterm infants: A pilot study.

Neurodevelopmental impairment is a significant complication among survivors of preterm birth. To improve outcomes, reliable biomarkers for early detection of brain injury and prognostic assessment are required. Secretoneurin is a promising early biomarker of brain injury in adults and full-term neonates suffering from perinatal asphyxia. Data on preterm infants is currently lacking. The aim of this pilot study was to determine secretoneurin concentrations in preterm infants in the neonatal period, and to assess secretoneurin's potential as a biomarker of preterm brain injury. We included 38 very preterm infants (VPI) born at <32 weeks' gestation in the study. Secretoneurin concentrations were measured in serum samples obtained from the umbilical cord, at 48 hours and 3 weeks of life. Outcome measures included repeated cerebral ultrasonography, magnetic resonance imaging at term-equivalent age, general movements assessment, and neurodevelopmental assessment at a corrected age of 2 years by the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III). In comparison to a term-born reference population, VPI had lower secretoneurin serum concentrations in umbilical cord blood and blood collected at 48 hours of life. When measured at 3 weeks of life, concentrations correlated with gestational age at birth. Secretoneurin concentrations did not differ between VPI with an imaging-based diagnosis of brain injury and those without, but when measured in umbilical cord blood and at 3 weeks of life correlated with and were predictive of Bayley-III motor and cognitive scale scores. Secretoneurin levels in VPI differ from term-born neonates. Secretoneurin seems unsuitable as a diagnostic biomarker of preterm brain injury, but bears some prognostic potential and is worthy of further investigation as a blood-based biomarker of preterm brain injury.

Systemic postnatal corticosteroid use for the prevention of bronchopulmonary dysplasia and its relationship to early neurodevelopment in extremely preterm infants

BackgroundSystemic postnatal corticosteroid use in extremely preterm infants poses a risk of adverse neurodevelopmental outcomes. This study explores their use beyond seven days of age with early neurodevelopmental assessments during the fidgety period (9–20 weeks postterm age).MethodsThis retrospective single-center cohort study included inborn extremely preterm infants from 1 January 2014 to 31 December 2018. Outborn infants, those with congenital or genetic abnormalities, and those who received postnatal corticosteroids for nonrespiratory reasons were excluded. The cohort was dichotomized based on the status of corticosteroid receipt. Early neurodevelopmental outcomes were reported using Prechtl’s General Movements Assessment.ResultsOf the 282 infants, 67 (23.75%) received corticosteroids. Of these, 34 (50.75%) received them for dependency on invasive ventilation (intermittent positive-pressure ventilation), and the remainder received them for dependency on non-invasive ventilation continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). Abnormal or absent fidgety movements were observed in 13% of infants (7/54) who received corticosteroids compared to 2% of infants (3/146) who did not. An increased odds for an abnormal general movements assessment from corticosteroid use after adjusting for gestational age [adjusted odds ratio (aOR) = 5.5, 95% confidence interval (CI) = 1.14–26.56] was observed. The motor optimality scores differed between the two groups [corticosteroid group: 25.5 (23–26) versus no-corticosteroid group: 26 (24–28); z = − 2.02]. A motor optimality score < 20 was observed in 14.8% of infants (8/54) in the corticosteroid group compared to 2% of infants (3/146) in the noncorticosteroid group. This difference was significant after adjustment for gestational age (aOR 5.96, 95% CI 1.28–27.74).ConclusionsAbnormal early neurodevelopment was observed in infants who received systemic postnatal corticosteroids. The relationship between these findings and other factors influencing early neurodevelopment needs further exploration.

Study protocol: peer delivered early intervention (Learning through Everyday Activities with Parents for Infants at risk of Cerebral Palsy: LEAP-CP) for First Nation Australian infants at high risk of cerebral palsy – an RCT study

IntroductionCerebral palsy (CP) is the most common childhood physical disability with rates approximately 50% higher in First Nations Australian children. This study aims to evaluate a culturally-adapted parent-delivered early intervention...

Association between the General Movement Optimality Score and clinical features in newborns during hospitalization: A cross-sectional study

AimsTo describe the General Movements (GMs) of hospitalized newborns to verify if their global and detailed GMA are related and if their GMs are associated with clinical features. MethodsCross-sectional study. Thirty-eight preterm and full-term newborns, who were hospitalized in the neonatal intermediate care unit of a reference hospital, were included. Prechtl's General Movement Assessment (GMA), including the General Movement Optimality Score (GMOS) list, was used as an assessment tool. Clinical variables, such as preterm birth, birthweight, length of hospitalization, Apgar scores, pregnancy problems, admission at neonatal intensive care unit, use of invasive mechanical ventilation, and brain imaging findings were also collected. Newborns were videoed at a single time for 3 min before discharge. ResultsMost newborns presented GMs with normal or poor repertoire quality. GMOS ranged from 17 to 42 points. Scores were lower in abnormal GMs. Abnormal GMs were associated with preterm birth, length of hospital stay >30 days and birthweight <2500 g. Accordingly, lower GMOSs were also associated with preterm birth, a birthweight <2500 g and a hospital stay >30 days but also with the invasive mechanical ventilation application. ConclusionPreterm and full-term newborns presented normal or abnormal GMs during hospitalization. Preterm birth, low birthweight, longer hospital stay and a time period of invasive ventilation were associated with worse GM behaviors.

Reliability and Repeatability of a Postural Control Test for Preterm Infants.

the current study aims to evaluate the reliability and repeatability of a new PT based on Center of Pressure (CoP) movement analysis in a repeated measures design. the examination consisted of two parts: (1) the videotaping of General Movements (GMs) and GMs assessment (GMA) and (2) Posturometric Tests (PT) in supine and prone positions. PTs were performed twice (by two investigators) in the supine and prone positions using a force plate. Based on the GMA results, infants were stratified into two groups: (1) infants with normal FMs (indicating normal future motor outcomes) (n = 18) and (2) infants with abnormal FMs (indicating later neurological dysfunction) (n = 19). the comparative analysis between the groups of infants with normal FMs and abnormal FMs in PT in supine showed significant differences for all parameters that described spontaneous CoP displacement. The reliability analysis determined that all ICCs of the outcomes presented at least a moderate level of reliability. The ICCs were higher for outcomes of PT performed in the supine position than in the prone position. The ICCs were higher for outcomes of PT performed in infants with abnormal vs. normal FMs. although the current study yielded promising results, further longitudinal research in preterm infants should identify whether altered postural control parameters prognose future motor outcomes.

Building Blocks for Deep Phenotyping in Infancy: A Use Case Comparing Spontaneous Neuromotor Functions in Prader-Willi Syndrome and Cerebral Palsy.

With the increasing worldwide application of the Prechtl general movements assessment (GMA) beyond its original field of the early prediction of cerebral palsy (CP), substantial knowledge has been gained on early neuromotor repertoires across a broad spectrum of diagnostic groups. Here, we aimed to profile the neuromotor functions of infants with Prader-Willi syndrome (PWS) and to compare them with two other matched groups. One group included infants with CP; the other included patients who were treated at the same clinic and turned out to have inconspicuous developmental outcomes (IOs). The detailed GMA, i.e., the motor optimality score-revised (MOS-R), was used to prospectively assess the infants' (N = 54) movements. We underwent cross-condition comparisons to characterise both within-group similarities and variations and between-group distinctions and overlaps in infants' neuromotor functions. Although infants in both the PWS and the CP groups scored similarly low on MOS-R, their motor patterns were different. Frog-leg and mantis-hand postures were frequently seen in the PWS group. However, a PWS-specific general movements pattern was not observed. We highlight that pursuing in-depth knowledge within and beyond the motor domain in different groups has the potential to better understand different conditions, improve accurate diagnosis and individualised therapy, and contribute to deep phenotyping for precision medicine.

Assessment of general movements in preterm infants as a predictor of cerebral palsy.

At present, the early identification of cerebral palsy still poses a major challenge for the health system worldwide. Great advances have been made in neonatology in reducing mortality, but not morbimortality. Cerebral palsy remains the most common sequela of all developmental disorders, especially among those born prematurely. The possibility of early detection before 5 months of age has many benefits for the child and their family, since it allows very early initiation of treatment. In this study, we describe a highly sensitive and specific tool known as Prechtl's assessment of general movements and its potential complementation with technological apps for early detection.

Therapeutic hypothermia is associated with changes in prognostic value of general movements

General movements (GMs) have been recognized as the most accurate clinical tools for predicting cerebral palsy (CP). This study aimed to compare the type and prognostic value of abnormal GMs in infants with hypoxic ischemic encephalopathy treated or not with therapeutic hypothermia (TH). This was a single-center retrospective study. We compared GMs of 55 cooled term infants versus 30 non-cooled term infants with hypoxic ischemic encephalopathy (HIE) and their motor outcome at 24 months of age. We also included data regarding early brain MRI scans. Rates of cerebral palsy was 5.4% and 46.7% in cooled and non-cooled infants respectively (p<0.001). None of cooled infants showed cramped-synchronized GMs, whereas among non-cooled infants the cramped-synchronized pattern was present in 17.2% and 20% of infants at 1 and 3 months of age respectively. Hypokinesis was never seen in cooled infants and it was present in 23.3% of non-cooled ones. Absent fidgety correlated with CP in 14% and 73% of cooled and non-cooled infants respectively. At brain MRI cooled infants had fewer and less severe cerebral lesions compared to non-cooled infants (p=0.003). Abnormal GMs are reduced in infants treated with TH. Hypokinesis and cramped-synchronized GMs are not observed in cooled infants and the associations between absent fidgety movements and CP it is largely abolished. TH is associated with changes in prognostic value of GMs.

Going Beyond Conventional Assessment of Developmental Motor Disorders: Exploring Video Methods for Early Identification Among Children 0 to 3 Years.

Motor skills and movement-related functioning significantly shape how children experience and interact with the world around them. Among infants and young children, developmental motor disorders contribute to delays with motor, cognitive, and psychosocial development. Early and accurate identification of these disorders is necessary to facilitate timely access to therapeutic interventions that minimize the long-term effects of disability on everyday activities and participation. In the United States, motor assessments commonly used among children 0 to 3 years focus on completion of specific motor skills at a single point in time, which provides only a part of the greater picture that is a child's motor and movement-related functioning. Video-capture methods, like the General Movements Assessment (GMA) and the Infant Motor Profile (IMP), offer greater accuracy and predictive power to (1) identify motor deficits in young children and (2) facilitate early access to supportive, therapeutic intervention.

An Algorithm for the Detection of General Movements of Preterm Infants Based on the Instantaneous Heart Rate.

Video recording and editing of general movements (GMs) takes time. We devised an algorithm to automatically extract the period of GMs emergence to assist in the assessment of GMs. The algorithm consisted of δHR: subtracting the moving average heart rate (HR) for the past 60 s from the average instantaneous HR; and %δHR: the percentage of the instantaneous HR to the moving average HR. Ten-second sections in which δHR was positive for three consecutive sections and contained at least one section with %δHR &gt; 105% were extracted. Extracted periods are called automated extraction sections (AESs). We evaluated the concordance rate between AESs and GMs in three periods (gestational age 24-32, 33-34, and 35-36 weeks). The records of 84 very low birth weight infants were evaluated. Approximately 90% of AESs were accompanied by GMs at any period in both the supine and prone positions. The proportion of full-course (beginning to end) GMs among GMs in the AES was 80-85% in the supine position and 90% in the prone position in all periods. We could extract a sufficient number of assessable GMs with this algorithm, which is expected to be widely used for assisting in the assessment of GMs.