International Study Research Articles

Platelet count has a U-shaped association with mortality in hemodialysis patients

Our previous manuscript showed that thrombocytopenia predicts all-cause mortality in Chinese hemodialysis (HD) patients. Based on the role of platelets in coagulation, clot formation, and systemic inflammation, we speculate that high platelets increase risk of thrombo-embolic events, hence the mortality. However, research evidence is currently lacking. Therefore, we utilized data from a very large international cohort study to explore the association of platelet counts with mortality and cardiovascular (CV) death in hemodialysis (HD) patients. International data from 396 facilities enrolled in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 5 (2012–2015) were analyzed. Participants were divided into 3 groups according to their platelet counts (low: <100, normal: 100–300, high: >300*109). Associations between platelet counts and all-cause and CV mortality were analyzed using Cox regression, adjusted for confounders. There were 13,631 patients with median age of 65 years old. Males accounted for 61.2%. Mean platelet count was 205*109/L overall and ranged from 173 *109/L in China to 227 *109/L in Sweden. Overall, 2,348 (17.2%) patients died and 1017 (7.5%) died from CV disease. Both low (HR:1.48, 95% CI 1.21–1.80, p < 0.001) and high (HR:1.17, 95% CI 1.00- 1.35, p = 0.044) platelet counts were associated with higher all-cause mortality after adjustment for covariates; results for CV death were consistent. Platelet count has a U-shaped association with all-cause and CV mortality in HD patients, and thus may be used as an outcome predictor that is readily available among HD patients.

Factors influencing the development of STEM competencies in vocational training: an analytical review of international studies

Factors influencing the development of STEM competencies in vocational training: an analytical review of international studies

Determining the Predictive Power of the Gravity Model: A Case for Zambia

Purpose: The purpose of this study was to determine the predictive power of the gravity model in explaining trade flows in Zambia. Materials and Methods: The study utilized panel data for the period 1990-2020 for the Zambian economy and its 15 top trading partners based on 2018 trade volumes. The data was collected from the Centre for Prospective Studies and International Studies for International Information (CEPII) Gravity Database. The study employed the gravity equation to predict trade flows in Zambia. Findings: The empirical results show that the gravity model accurately predicts Zambia's trade flows, with GDP positively and distance negatively correlated with exports. The results also show that sharing a common border enhances Zambia’s exports. Surprisingly, trade agreements exhibit a negative relationship with exports. Implications to Theory, Practice and Policy: The significant negative impact of distance on trade highlights the need for improved infrastructure and logistics to reduce transportation costs, thus, facilitating Zambia’s trade flows. Further, the findings suggest that Zambia should focus on strengthening trade with neighboring countries. Additionally, Zambia should diversify export bases away from heavy reliance on the mining sector. Besides, there is a need for active participation in regional integration initiatives to address implementation challenges of trade agreements.

Effectiveness of transitional care in Inflammatory Bowel Disease; Development, Validation, and Initial outcomes of a Transition Success Score.

The effectiveness of transition programs from paediatric to adult healthcare in adolescents with inflammatory bowel disease is not clear, as prospective studies using validated outcome measures for transition are lacking. This study aimed to develop and validate a quantitative Transition Success Score, and to apply it in a multicenter setting to assess the effectiveness of transitional care. The Top 10 outcome items related to successful transition, identified through an international Delphi study with IBD stakeholders, were integrated into a generic questionnaire, the Transition Success Score. In a prospective, multicenter study, Transition Success Score was scored by adult healthcare providers, young adult patients and caregivers, 9-15 months after transfer of care. In seven Dutch hospitals, 160 patients completed the Transition Success Score. The mean score was 25 (range 17-27), 25.6% of patients achieving maximum score. Hypothesis testing for construct validity revealed significant associations with characteristics related to transitional care, such as knowledge, independence, and quality of life (p <0.005). Structural validation indicated the score was most effective at discerning lower levels of transition success. Internal consistency was acceptable (0.64). High disease burden, exacerbation during or after transfer, and certain personality profiles were associated with lower scores. The Transition Success Score serves as a quantitative tool to evaluate the effectiveness of transitional care interventions and to identify inflammatory bowel disease patients at risk of encountering challenges during the transition to adult healthcare.

What ethical conflicts do internists in Spain, México and Argentina encounter? An international cross-sectional observational study based on a self-administrated survey

BackgroundThe differences in clinical bioethics between the Mediterranean and Latin American cultures have not been analyzed. The objective of the study is to compare the ethical conflicts that internists in Spain, Mexico and Argentina have.MethodsCross-sectional observational study through a survey directed at internists from Spain, Argentina and Mexico. The survey was administered to affiliated members of the National Societies of Internal Medicine across three countries via an online platform.Results762 internists participated, 261 from Spain, 154 from Argentina and 347 from Mexico. The main ethical conflicts that internists in Spain, Argentina and Mexico have are related (in order) to the end of life, to the clinical relationship and to the patient’s autonomy. Withholding and withdrawing life-sustaining treatment is the most frequent conflict in Spain and Argentina and the second in Mexico.ConclusionsInternists from Spain and Argentina identify very similar ethical conflicts. Furthermore, they consider them more frequent and difficult than in Mexico. In Argentina they are less satisfied with the way they are resolved. To explain these differences, socio-cultural factors are postulated, among others: paternalism, individualism, masculinity, organization of the health system, formal training in bioethics and assessment of death.

Consensus definition of a radiologically healed fistula on magnetic resonance imaging in perianal Crohn’s disease: an international Delphi study

IntroductionPerianal fistulising Crohn’s disease (pfCD) is a distinct and debilitating phenotype seen in around one-third of patients with CD. Clinical trials in pfCD are increasingly using magnetic resonance imaging (MRI) criteria as a primary endpoint, but there is heterogeneity in the radiological definition of a healed perianal fistula that currently limits our ability to perform meaningful meta-analyses of studies. Our aim is to standardise outcomes through the generation of an international consensus definition of a radiologically healed fistula.Methods and analysisThis international Delphi consensus study employs a two-part strategy.The first is a systematic review to identify a longlist of variables used to define radiological healing in pfCD. MRI-based indices used to score fistula severity and healing will be assessed for their methodological quality using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). The systematic review protocol will be conducted using COSMIN methodology and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses.The second part will be an online Delphi consensus, guided by the results of the systematic review. Radiologists, gastroenterologists and colorectal surgeons with expertise in the management of pfCD will be invited to take part in two to three rounds of online surveys. Once an a priori threshold of &gt;80% agreement is reached on individual radiological components used to define ‘healing’ and ‘healed’, a final meeting of key stakeholders will be organised to generate a consensus definition of a healed fistula.Ethics and disseminationThe study has been deemed exempt from a formal Research Ethics Committee review as no patients will participate directly in the consensus process, given the technical nature of the research question. The study is registered with the local R&amp;D department (Reference RD24/007). Publication of this study will help standardise radiological endpoint measurement in clinical trials of pfCD and improve the synthesis and meta-analysis of comparative studies.PROSPERO registration numberCRD42024504334.

HLA-B*15 Is Associated With SARS-CoV-2 Infection in a Brazilian Population.

Studies have suggested an association between polymorphisms in class I genes of the major histocompatibility complex, specifically the human leukocyte antigen (HLA), and susceptibility to SARS-CoV-2. To explore this, 135 individuals with positive serological tests for SARS-CoV-2 were recruited. All the samples were collected before the advent of vaccines, avoiding immunization effects. Participants were divided into high and low neutralizing antibody titer groups, and polymorphisms in HLA-A, HLA-B, and HLA-DRB1 genes were examined using PCR-SSO. Allele prevalence in the study population was compared to the National Bone Marrow Volunteer Donors Register (REDOME) in São Paulo and between the high and low titer groups within the study population. Results indicated that the HLA-B*15 polymorphism was more prevalent in the COVID-19 positive group compared to the control population (COVID-19 = 0.1370; Control = 0.0875; p = 0.0067). The HLA-B*18 polymorphism was less prevalent in the COVID-19 group (COVID-19 = 0.0185; Control = 0.0534; p = 0.0064). Additionally, the HLA-A*30 polymorphism was more prevalent in the high titer group within the (high = 0.10937; low = 0.02816; p = 0.0125). Other polymorphisms showed no significant differences. These findings align with international studies, suggesting these genes plays a role in COVID-19 pathophysiology, however, further research is required to fully understand their impact.

Comparative Analysis of Self-Medication Practices with Antibiotics Among Non-Medical and Medical College Students in India

Background: Self-medication is prevalent globally, making the processes easier but raising potential hazards like antibiotic resistance. College students, influenced by social media, exhibit alarming self-medication behaviours. This cross-sectional study surveyed undergraduate students across medical, nursing, and non-health science institutions to assess the self-medication habits, knowledge and attitude of students. Methods: This descriptive cross-sectional study was conducted across various educational institutions from August 2023 to February 2024, targeting undergraduate students aged 18 and over. Using a pre-validated questionnaire, data on socio-demography, self-medication with antibiotics, and related knowledge were collected via Google Forms. The sample size was doubled to 1175 for better statistical power. Data analysis was performed using standard statistical tools. Results: Analysis of data demonstrated that a substantive proportion of students self-medicate with antibiotics. For medical students, convenience was the biggest issue and for non-medical students, it was cost-saving coupled with distrust in doctors. The most common complaint received for self-medication was throat pain. Medical students used textbooks for necessary information whereas non-medical students went to local shops for advice. Patterns differed somewhat in comparison with international studies, indicating regional differences. Strikingly, medical students predominantly relied on academic knowledge and previous experiences while using antibiotics, whereas non-medical students often obtained antibiotics from shops or the internet, making them vulnerable to misdiagnosis and inappropriate treatment. Conclusion: This highlights the importance of implementing specific interventions to reduce unsafe self-medication practices in students.

Prevalence of comorbidities among patients with rheumatoid arthritis in the UAE: a case–control study

ObjectivesData on the rate of comorbidities in Arab patients with rheumatoid arthritis (RA) are limited, and extrapolating the prevalence of comorbidities from international studies is challenging. This study aimed to...

Research on the protection of intangible cultural heritage and sustainable development of city brands—Taking Jingdezhen as an example

This research aims to examine the intricate connection between the preservation of intangible cultural assets and the promotion of city brands, using Jingdezhen, known as the “Porcelain Capital” of China, as a case study. Through an exploratory investigation, the study highlighted two distinct yet significant issues: the recognition of Jingdezhen’s intangible cultural assets, encompassing folklore, rituals, traditional ceramic skills, and artwork, and the economic effects resulting from cultural tourism. The research delineates the obstacles encountered by Jingdezhen in relation to urbanization, industrialization, and globalization subsequent to its establishment as the principal production hub for Chinese blue and white porcelain. Additionally, it highlights the decline of traditional ceramic skills and expertise, as community members who relied on handicrafts for their livelihoods were affected by the closure of companies. Subsequently, it elucidates the potential prospects arising from cultural tourism and the consequential economic influence of this progress on the local economy and the community’s quality of life. The report delineates community engagement initiatives and collaborative partnerships with local enterprises, colleges, government agencies, and Jingdezhen communities to use the city’s abundant cultural legacy. This research provides a comprehensive overview and assessment of the most effective methods, as identified by international studies, for incorporating the safeguarding of intangible cultural assets into sustainable urban development. Concisely, the paper offers guidance to stakeholders, the local administration, and its legislators. The statement emphasizes the necessity of implementing a comprehensive policy framework in Jingdezhen to safeguard its intangible cultural heritage and promote urban development. The objective is to achieve sustainable growth by leveraging the city’s cultural assets. The results serve as a benchmark for other cities and towns to use their cultural legacy in order to establish a sustainable city brand. Additionally, they make a valuable addition to the worldwide discourse on striking a balance between cultural preservation and economic development.

Understanding European patterns of deprescribing antithrombotic medication during end-of-life care in patients with cancer

BackgroundEven though antithrombotic therapy (ATT) probably has little or even negative effect on the well-being of patients with cancer near the end of life, it is often continued until death, possibly leading to excess bleeding complications, increased disease burden, reduced quality of life and higher healthcare costs. AimTo explore and describe European practice patterns and perspectives of healthcare professionals from different disciplines and specialties on ATT in the end-of-life care (EOLC) of patients with cancer. MethodsWe performed a two-week international cross-sectional survey study using flash-mob research methodology. Eligible were healthcare professionals from different institutions across Europe, who prescribed ATT and/or dealt with EOLC of patients with cancer. The survey comprised three parts, including a series of choice sets (hypothetical scenarios involving a set of characteristics changing in level [e.g., high vs. low thrombotic risk]) on ATT management in EOLC. The discrete choice experiment analysis was conducted using multinomial logistic regression. ResultsOut of 467 pre-registrants, 208 participated in the survey from 4 to 18 July 2023. The majority (53 %) considered a patient with cancer as in EOLC when life expectancy is below 3 months. Respondents reported seeing or treating 20 patients with cancer on ATT in EOLC per year (IQR 10–50). The median estimated frequency of considering ATT deprescription per healthcare professional was 10 times per year (IQR 4–10), while the frequency of actual deprescription was 5 times per year (IQR 2–10). Twenty percent of respondents had never deprescribed ATT in the context of EOLC. Across the eight choice sets, five respondents (2.7 %) found deprescribing inappropriate in any scenario. Deprescribing was more often considered in patients with poor ECOG-performance status, high bleeding risk and low-molecular-weight heparin use as opposed to oral ATT. Haemato-oncology and cardiovascular medicine specialists were more inclined to deprescribe antiplatelet therapy than other specialties. ConclusionOur study describes medical decision-making regarding ATT in EOLC of patients with cancer. Healthcare professionals' perspectives and practice patterns vary, and some preferences appear associated with the therapists' professional focus and region of practice.

Preparing the ground for bespoke nursing training in advanced renal cell carcinoma care (RCC4Nurses): An international prospective study

ObjectivesNurses require specialist knowledge and skills to effectively support an increasing population of people affected by advanced renal cell cancer (aRCC). RCC4Nurses was a three-phase project that aimed to develop bespoke training in aRCC for nurses in Europe. Phase 1 examined pre-existing educational programs in kidney cancer, then developed a curriculum of core education topics in aRCC care to suit generalist and specialist nurses’ education needs. MethodsPhase 1 employed a prospective design that involved two parts. Part 1 was a scoping review of educational programs developed for multidisciplinary health professionals in kidney cancer/RCC. Findings of Part 1 formed the basis for Part 2, which was a three-round Delphi study that involved experts by personal experience or profession in aRCC, who rated the importance of a range of education topics and education methods for inclusion in the developing RCC4Nurses. ResultsThe scoping review identified eight education programs via two published reports and six online resources. Existing programs had limitations in accessibility, recency and target professional groups; none of them was developed specifically for nurses. Program content was primarily focused on diagnostic, treatment and management procedures in kidney cancer. Fourteen educational topics were derived from the review and evaluated during Round 1 of the Delphi by 47 experts. By Round 3, 17 topics had iteratively reached consensus for inclusion within RCC4Nurses. Experts showed preference to problem-solving and clinical-scenario learning methods, but not reflective practice learning. ConclusionsGiven the dearth of up-to-date, evidence-based training for nurses in aRCC, we have prepared the ground to develop a bespoke training course in this area of practice. Implications for Nursing PracticeThe RCC4Nurses project will offer accessible, state-of-the-art education to registered nurses in Europe to help enhance nursing competency in aRCC and enhance the standard of care provided to people affected by aRCC.

P109 Heterogeneity of 68Ga-PSMA PET/CT in metastatic castration-resistant prostate cancer: Genomic characteristics and association with new hormonal agent response, an international multi-center cohort study

P109 Heterogeneity of 68Ga-PSMA PET/CT in metastatic castration-resistant prostate cancer: Genomic characteristics and association with new hormonal agent response, an international multi-center cohort study

TIMSS INTERNATIONAL STUDY AND ITS IMPACT ON THE THINKING OF 4TH GRADE STUDENTS

The article examines changes in the state and psychological perception of fourth-grade students when performing TIMSS tasks, especially in the mathematical part. Attention is paid to the international assessment study TIMSS and its significance in modern society and leading world powers. The article describes the contribution of the leading countries in the study to the development of education and comprehensive personality development of primary school students. The development of schoolchildren affects the stability of education in the state and its international capabilities. Thearticle describes the educational environment in several major countries with a full description of its structure. The article also discusses the results of TIMSS and its impact on students 'creative thinking, the structure of TIMSS test tasks (blocks "Knowledge", "Applications", "Reasoning"). The articleis relevantforteachers, teachersandstudentsof primaryeducation.

Developing a core outcome set for Netherton syndrome: An international multi-stakeholder e-Delphi consensus study.

Netherton syndrome (NS; OMIM#256500) is a rare and severe disorder of epidermal maturation and keratinization caused by pathogenic variants in the serine protease inhibitor Kazal type 5 (SPINK5), leading to severe skin barrier impairment. Although effective treatment is crucial for NS patients, there is a lack of knowledge on what the best treatment options are for these patients. Large heterogeneity in reported outcomes and measurement instruments hinders accurate comparison of treatment results across studies and the development of a treatment guideline. Therefore, we aimed to develop a core outcome set (COS) for NS that can be used in clinical care and research. This study was performed in accordance with the recommendations of the Core Outcome Measures in Effectiveness Trials (COMET) initiative. After identification of outcomes through a literature search and classification based on the International Classification of Functioning and taxonomies published by the COMET initiative, discussion groups were organized at the 2nd International Netherton Congress 2022 to finalize the provisional outcome list. Through a 2-round e-Delphi, 41 stakeholders (patients and family members, professionals, and representatives of industry) from 14 countries rated the importance of the outcomes using a 9-point Likert scale. An online consensus meeting attended by 14 stakeholders finalized the COS. The core outcome set for NS comprised 21 outcomes in 10 domains. These included four 'skin' outcomes, two 'sensation' outcomes, two 'side-effects of treatment' outcomes, one 'vitality' outcome, one 'emotional functioning' outcome, two 'physical development' outcomes, two 'nutrition' outcomes, two 'infections' outcomes, two 'allergies' outcomes, and three 'assessment results' outcomes. In this study, consensus was reached on 21 outcomes to be included in the COS for NS. The selection of outcomes in the COS underlines that NS not only affects the skin, but is a disease requiring a broad multidisciplinary approach in clinical care and research. International implementation of this COS will lead to more uniform reporting, thereby enabling comparison of study results, which may facilitate future treatment guideline development. The next step is to further conceptually define the outcomes and reach consensus on how the measure these.

A multiple behaviour temporal network analysis for health behaviours during COVID-19.

The aim of this study was to examine the temporal dynamics of multiple health behaviours (physical activity, alcohol consumption, healthy eating, cigarette consumption, recreational drug use, vaping), and pandemic-related health behaviours (e.g., hand washing, physical distancing) using network psychometrics. The International COVID-19 Awareness and Responses Evaluation (iCARE) study is an international multi-wave observational cohort study of public awareness, attitudes, and responses to public health policies implemented to reduce the spread of COVID-19 on people around the world. A sub-sample of longitudinal data from Canadians (n = 254) was analysed across four waves (February-July 2020). We used temporal network models to fit temporal networks, contemporaneous networks, and between-subject networks from items within the iCARE survey. Positive temporal associations were observed between physical activity and healthy eating, and a bidirectional relationship was evident between outdoor mask use and vaping. A contemporaneous network revealed positive associations between consumption behaviours (vaping, cigarette use, alcohol use, and recreational drug use), and negative associations between physical activity and drug use, and healthy eating and cigarette use. Health behaviours are interconnected and can be modelled as networks or behavioural systems. The application of temporal network analysis to the study of multiple health behaviours is well suited to address key research questions in the field such as 'how do multiple health behaviours co-vary with one another over time'. Future research using time series data and measuring affective and cognitive mediators of behaviour, in addition to health behaviours, has the potential to contribute valuable hypothesis-generating insights.

Unpacking Human Rights: Freedom of Consciousness, Bodily Autonomy &amp; Right to Life in the Context of War on Drugs Crimes

Abstract This study explores the interplay between the right to life, right to development, bodily autonomy and freedom of conscience, and demonstrates how these factors collectively shape the concept of freedom of consciousness and simultaneously lead to increased access to altered states of consciousness, cognitive liberty, freedom of development, and the peak experiences that Abraham Maslow researched. Second chapter delves into the intersection of human rights and drug policy, specifically examining the implications of the War on Drugs on individual freedoms. It argues that the War on Drugs has led to a violation of fundamental human rights, including cognitive liberty, bodily autonomy, and the right to life. Through an analysis of international human rights law and case studies from around the world, the paper demonstrates how drug-related crimes have resulted in mass incarceration, violence, and human rights abuses. It also explores decriminalization of drug use, end of War on Drugs and criminalization of its’ crimes. The research results provide insights into the interrelation between these three concepts, shedding light on how they intersect and influence each other and in context of War on Drugs hostile environment. Findings also suggest that the War on Drugs has resulted in a significant violation of fundamental human rights.

P192 CaboCombo: interim analyses from an international real-world study assessing the use of cabozantinib plus nivolumab (CaboNivo) as first-line (1L) treatment for advanced Renal Cell Carcinoma (aRCC)

P192 CaboCombo: interim analyses from an international real-world study assessing the use of cabozantinib plus nivolumab (CaboNivo) as first-line (1L) treatment for advanced Renal Cell Carcinoma (aRCC)

Study Protocol for a French Multicenter Randomized Controlled Trial Evaluating the Medico-Economic Impact of Surgical versus Endovascular Arteriovenous Access Creation for Hemodialysis in End-Stage Renal Disease (ENDO-FAV)

IntroductionVascular access is indispensable for performing hemodialysis in patients with end-stage renal disease. The Kidney Disease Outcome Quality Initiative and the French Health Authority advocate for native arteriovenous fistulas (AVFs) as a primary option due to their association with lower morbidity, mortality, and enhanced quality of life. However, a significant proportion of AVFs fail to mature, and many require multiple re-interventions, increasing overall costs.To address these issues, endovascular techniques for AVF creation have been developed. These methods use energy-based technologies, avoiding vessel dissection and preserving perivascular tissues. Initial results are promising but these devices are expensive, and the technical act of creating an endovenous fistula is not recorded in the coding of the common classification of medical procedures (CCAM) and, as such, cannot be reimbursed by health insurance in France. While international studies suggest their effectiveness, no French studies have yet replicated or confirmed these findings in the local context, which would help support a reimbursement request from health insurance. MethodsThis protocol represents the first French medico-economic study to compare the two available endovascular AVF creation devices (Ellipsys® and WaveLinQ®) with traditional open surgery. This multicentre, comparative clinical trial will randomize patients into two parallel groups: (1) endovascular AVF creation using either the WaveLinQ® or Ellipsys® device, and (2) surgical proximal AVF creation (brachio-cephalic/basilic). Randomization will be balanced and stratified by centre and dialysis timing. Follow-up assessments will occur at 1 week, 1, 3, 6, 12, and 18 months. The primary objective is to evaluate the cost-effectiveness of endovascular AVF creation compared to open surgery from the perspective of the French healthcare system. The primary endpoint is the cost-utility ratio (cost per QALY gained) of endovascular AVF versus open surgery. Utility is assessed using the EQ-5D-5L questionnaire, with costs derived from micro-costing and the National Health Data System (SNDS). Secondary outcomes include health economics with total costs at 18 and 36 months, success rate of vascular access creation, AVF maturation and functionality, recirculation rates, early and late access failures, cannulation success, primary and secondary patency, reintervention rates, and adverse events. Based on a cost-utility threshold of €30,000 per QALY, cost difference estimates, and standard deviations from previous studies, anticipated sample size is 126 patients per group (endovascular and surgical), totaling 252 patients with about 142 patients for the Ellipsys® device and 110 patients for WaveLinQ®, based on the capacity of 7 centers using Ellipsys® and 4 centers using WaveLinQ®. ConclusionsThis multicentric randomized controlled trial will provide contemporary data on clinical outcomes and prognoses for endovascular AVF techniques, potentially establishing endovascular methods as a viable and cost-effective alternative to traditional surgical AVF creation.

Understanding variations in the built environment over time to inform longitudinal studies of young children's physical activity behaviour - The BEACHES project

We know relatively little about the role the neighbourhood built environment plays in promoting young children's physical activity, particularly its longitudinal effect either through repeated exposure to the same environment or through change in exposure by moving from one neighbourhood to another. This study characterised the neighbourhood environment of young children in the PLAYCE cohort study over three timepoints from 2015 to 2023. There were statistically significant differences in built environment attributes between timepoints and across socio-economic status, however they did not represent practically significant differences. These findings inform the analysis approach of subsequent research in the BEACHES Project, an international study examining the role of the built environment on child physical activity and obesity using multiple cohorts.