Network Five Emergency Medicine

Theme: Gastroenterology. 

Participants: Dr Tim O'Sullivan (gastroenterologist and endoscopy fellow), Dr Oksana Williamns (emergency physician), Varan Perananthan (gastroenterology advanced trainee), Maria Martino (emergency medicine advanced trainee), Amanda De Silva, Shreyas Iyer, Jack Ashley.

Discussion:
Sreedharan, A., Martin, J., Leontiadis, G., Dorward, S., Howden, C., Forman, D., & Moayyedi, P. (2010). Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd005415.pub3.

Presenter: Maria Martino - emergency medicine advanced trainee at Westmead Hospital. 

Music/Sound Effects:

• Good Day by Ikson | https://youtube.com/ikson, Music promoted by https://www.free-stock-music.com.
  Bring Me The Sky by Scott Buckley | https://soundcloud.com/scottbuckley, Music promoted by https://www.free-stock-music.com
  Attribution 4.0 International (CC BY 4.0),https://creativecommons.org/licenses/by/4.0/.
• Night Sky by Leonell Cassio ft. Julia Mihevc | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Nightswim by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
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Theme: Gastroenterology. 

Participants: Dr Tim O'Sullivan (gastroenterologist and endoscopy fellow), Dr Oksana Williamns (emergency physician), Varan Perananthan (gastroenterology advanced trainee), Maria Martino (emergency medicine advanced trainee), Amanda De Silva, Shreyas Iyer, Jack Ashley.

Discussion:
Rout, G., Shalimar, Gunjan, D., Mahapatra, S., Kedia, S., Garg, P., & Nayak, B. (2020). Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding. Journal Of Clinical Gastroenterology, 54(3), 255-262. https://doi.org/10.1097/mcg.0000000000001214.

Presenter: Varan Perananthan - gastroenterology advanced trainee at Westmead Hospital. 

Music/Sound Effects:

• Faces by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Help You Out by Leonell Cassio ft. Jonathon Robins | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Picasso by Ikson | https://youtube.com/ikson, Music promoted by https://www.free-stock-music.com.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
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See you next time!

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Theme: Gastroenterology. 

Participants: Dr Tim O'Sullivan (gastroenterologist and endoscopy fellow), Dr Oksana Williamns (emergency physician), Varan Perananthan (gastroenterology advanced trainee), Maria Martino (emergency medicine advanced trainee), Amanda De Silva, Shreyas Iyer, Jack Ashley.

Discussion:
Horibe, M., Iwasaki, E., Matsuzaki, J., Bazerbachi, F., Kaneko, T., & Minami, K. et al. (2021). Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata. Gastroenterology Report, 9(6), 543-551. https://doi.org/10.1093/gastro/goab042.

Presenter: Jack Ashley - emergency medicine trainee at Liverpool Hospital. 

Music/Sound Effects:

• Blue Sweater by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Outside by Ikson | https://youtube.com/ikson, Music promoted by https://www.free-stock-music.com.
• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 

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Theme: Neurology. 

Participants: Dr Hugo Morales (neurologist), Dr James Tadros (emergency physician), Jessica Stabler (epilepsy fellow), Kim Van Vu, Mariez Gorgi and Shreyas Iyer. 

Discussion:
Chamberlain, J., Kapur, J., Shinnar, S., Elm, J., Holsti, M., & Babcock, L. et al. (2020). Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. The Lancet, 395(10231), 1217-1224. https://doi.org/10.1016/s0140-6736(20)30611-5.

Presenter: Jessica Stabler

Music/Sound Effects:

• Help You Out by Leonell Cassio ft. Jonathon Robins | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Nightswim by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Ocean Love by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• River by MusicbyAden | https://soundcloud.com/musicbyaden, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 
• The Travelling Symphony by Savfk | https://www.youtube.com/savfkmusic, Music promoted by https://www.free-stock-music.com
  Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/. 

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Theme: Neurology. 

Participants: Dr Hugo Morales (neurologist), Dr James Tadros (emergency physician), Jessica Stabler (epilepsy fellow), Kim Van Vu, Mariez Gorgi and Shreyas Iyer. 

Discussion:
Keh, R., Scanlon, S., Datta-Nemdharry, P., Donegan, K., Cavanagh, S., & Foster, M. et al. (2022). COVID-19 vaccination and Guillain-Barré syndrome: analyses using the National Immunoglobulin Database. Brain. https://doi.org/10.1093/brain/awac067.

Presenter: Kim Van Vu - ED Trainee at Westmead Hospital.

Interude Reference:
http://www.petervuust.dk/

Credits:
This episode is produced with help of HETI's Emergency Medicine Training Network 5.

Music/Sound Effects:

• Open Arms by Jay Someday | https://soundcloud.com/jaysomeday, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Motivational Piano Background Music by Nikita Lukyanov | https://soundcloud.com/lukyanovnikita, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Second Goodbye by Sapajou | https://soundcloud.com/sapajoubeats, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Smile by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

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Theme: Neurology. 

Participants: Dr Hugo Morales (neurologist), Dr James Tadros (emergency physician), Jessica Stabler (epilepsy fellow), Sai Nagaratnam (neurology advanced trainee), Mariez Gorgi and Shreyas Iyer. 

Discussion:  Nham, B., Reid, N., Bein, K., Bradshaw, A., McGarvie, L., & Argaet, E. et al. (2021). Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. Journal Of Neurology, 269(1), 294-306. https://doi.org/10.1007/s00415-021-10627-1.

Presenter: Sai Nagaratnam.

Resources:
Emergency Care Institute: https://aci.health.nsw.gov.au/networks/eci.

Credits:
This episode is produced with help of HETI's Emergency Medicine Training Network 5.

Music/Sound Effects:

• Energetic Electronic Vlog Music | Breeze by Alex-Productions | https://www.youtube.com/channel/UCx0_M61F81Nfb-BRXE-SeVA,
  Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Miss You by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com. 
• Vamos by MBB & LiQWYD | https://soundcloud.com/mbbofficial, https://soundcloud.com/liqwyd, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Why’d You Wanna End by Leonell Cassio ft. Alex Lippett | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Attribution-ShareAlike 4.0 International (CC BY-SA 4.0), https://creativecommons.org/licenses/by-sa/4.0/. 

Thank you for listening!

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Theme: Paediatrics. 

Participants: 

Dr Kerf Tan (emergency physician), Dr Karl Pobre (paediatric emergency physician and paediatrician), Mariez Gorgi, Amanda De Silva, Shreyas Iyer, Harry Hong, and Samoda Wilegoda

Discussion:
Bourke, E., Say, D., Carison, A., Hill, A., Craig, S., & Hiscock, H. et al. (2021). Emergency mental health presentations in children with autism spectrum disorder and attention deficit hyperactivity disorder. Journal Of Paediatrics And Child Health, 57(10), 1572-1579. https://doi.org/10.1111/jpc.15535.

Presenter: Shreyas Iyer.

Summary:

• This was a retrospective cross-sectional study which aimed to explore the issues faced by young people with a known diagnosis of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) presenting to the emergency department with a mental health complaint.
• This study found 374 mental health presentations to the Royal Children’s Hospital in Melbourne in 2018 in which patients had a background of ASD and/or ADHD (in the age group of 7 to 17 years).
• This represented 28% of mental health presentations for this specified age group.
• Those with a diagnosis of both ADHD and ASD were more likely to require ambulance or police transport to hospital (RR 1.5). 
• Children with ADHD (with or without ASD) were at a higher risk of being brought to hospital under section. 
• The most common presentation for both the ADHD and ASD cohorts was acute severe behavioural disturbance. 
• Patients with ASD had a significantly increased risk of physical restraint (RR 2.8), chemical restraint (RR 2.8) and of seclusion (RR 3.3).
• It is important to understand what ASD and ADHD are and what the perspective of the child might be so that we can approach these patients with empathy and try and avoid potential triggers for behavioural escalation.  

Take-Home Points:

• This study gives numbers to support what we already know; that patients with ASD and ADHD are both at structural risk of suffering secondary trauma in the emergency department because of the environment. 
• When assessing these patients, involve senior and experienced clinicians early to try and expedite their journey through the emergency department. 
• There needs to be systemic change with regards to the design of our emergency departments to better manage these patients; this will require input from an executive level. 

Credits:
This episode is produced with help of HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Energetic Electronic Vlog Music | Breeze by Alex-Productions | https://www.youtube.com/channel/UCx0_M61F81Nfb-BRXE-SeVA, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Jolly Way by Artegon | https://soundcloud.com/artegon, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Nightswim by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Second Goodbye by Sapajou | https://soundcloud.com/sapajoubeats, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

You can also follow us on Facebook, Instagram, and Twitter!

See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Paediatrics. 

Participants: 

Dr Kerf Tan (emergency physician), Dr Karl Pobre (paediatric emergency physician and paediatrician), Mariez Gorgi, Shreyas Iyer, Harry Hong, and Samoda Wilegoda

Discussion:
Dainty, K., Atkins, D., Breckwoldt, J., Maconochie, I., Schexnayder, S., & Skrifvars, M. et al. (2021). Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review. Resuscitation, 162, 20-34. https://doi.org/10.1016/j.resuscitation.2021.01.017.

Presenter: Mariez Gorgi (emergency medicine advanced trainee).

Summary:

• This systematic review set out to determine the impact of family presence during resuscitation (specifically in cardiac arrest) on patient outcomes, family-centered outcomes and healthcare-provider outcomes.
• A total of 38 papers were included in the review; consisting of observational studies, qualitative interviews or surveys, spanning from 1999 to 2019 in 11 different countries.
• No papers explored the impact of family presence on patient outcome.
• Most parents wished to be offered the opportunity to be present in the resuscitation in order to provide comfort to their child, as well as assisting in accepting the outcome and knowing that everything that could be done had been done for their child. 
• The opinion of healthcare providers was more widely varied, citing the concern of psychological trauma to the parents, interference with management of the patient and stress on the treating team (performance-related anxiety). 
• However, the more experienced a healthcare worker with having family presence in a resuscitation, the more agreeable they were to this. 
• However, the evidence provided in all papers was of very low quality, and there is an urgent need for better quality data surrounding this topic. 
• Important things to consider with family presence is to flag that you may need them to leave the room during the resuscitation, and having a dedicated support person for the family present. 
• Hot and cold debriefs involving all relevant staff (paramedics, nursing staff, allied health, doctors) are also incredibly important following a resuscitation such as this. 

Take-Home Points: 

• It would be great to have better studies looking into family presence in resuscitation (looking into outcomes for the patients themselves as well as better qualitative data looking into what happens to families and healthcare workers afterwards). 
• If there is family around, they should be asked whether they want to be present in the resuscitation. 
• There should be a resource allocated to families to prevent their presence taking away from the resuscitation itself. 
• If you are struggling following a resuscitation, seek support. 

Resources (to support doctor well-being) - 

• Applications: Shift (Black Dog Institute app for healthcare workers), Calm, Headspace, Feeling Good, Smiling Minds, Insight Timer.  
• JMO support line (NSW): 1300 566 321.
• Employee Assistance Program (free confidential service for all NSW Health employees) - 1300  687 327. 
• Doctors for doctors: www.drs4drs.com.au.
• Beyond Blue: 1300 224 636.
• Lifeline: 13 11 14. 
• Suicide call-back service: 1300 659 467. 

Credits:
This episode is produced with help of HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Breathe by Roa Music | https://soundcloud.com/roa_music1031, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Emotional Piano Improvisation by Alexander Nakarada | https://www.serpentsoundstudios.com, Music promoted by https://www.free-stock-music.com, Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/.
• Inspiration by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

You can also follow us on Facebook, Instagram, and Twitter!

See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Paediatrics. 

Participants: 

Dr Kerf Tan (emergency physician), Dr Karl Pobre (paediatric emergency physician and paediatrician), Yelise Foon, Mariez Gorgi, Shreyas Iyer, Harry Hong, and Samoda Wilegoda

Discussion:
Goyal, M., Chamberlain, J., Webb, M., Grundmeier, R., Johnson, T., & Lorch, S. et al. (2020). Racial and ethnic disparities in the delayed diagnosis of appendicitis among children. Academic Emergency Medicine, 28(9), 949-956. https://doi.org/10.1111/acem.14142.

Presenter: Yelise Foon.

Summary:

• Delay in the diagnosis of appendicitis is associated with perforation and significant subsequent morbidity. 
• Currently the pre-operative perforation rate for appendicitis is 30%. 
• Some known risk factors for a delayed diagnosis for appendicitis include a young age, female gender, African-American race, non-English speaking backgrounds and government insurance factors (predominantly in the US). 
• This was a multi-centre retrospective cohort study conducted over 3 years utilizing the PECARN registry, which aimed to compare the rate of appendiceal perforation, delayed diagnosis of appendicitis and diagnostic imaging use among different ethnicities.
• Of the 7298 children diagnosed with appendicitis where race/ethnicity data was collected, 34.9% of non-Hispanic white children had a perforated appendix, compared with 36.5% of non-Hispanic black children. 
• Non-Hispanic black children also had higher rates of delayed diagnosis (defined as having a relevant emergency visit in the week prior to diagnosis): at 4.7% compared with 2.0% for non-Hispanic white children. 
• Further non-Hispanic black children with a delayed diagnosis of appendicitis were less likely to undergo definite imaging (including MRI, ultrasound, or CT) compared with their non-Hispanic white counterparts (with 28.2% versus 46.2% undergoing imaging). 
• However, given that this study came out of the US, the generalisability of this study to Australian emergency departments is unclear. 
• Health literacy is likely to be a large contributor to delayed presentation of appendicitis and something to be carefully considered when treating any child (and their family). 
• There are tools such as the Paediatric Appendicitis Score (PAS) and the Alvarado Score which may assist in objectively quantifying the possibility of appendicitis (particularly for junior staff). 

Take-Home Points:

• It is important for us to consider how we can minimise racial and ethnic disparities and make sure we are conscious of them. 

Credits:
This episode is produced with help of HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Feel Me by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• In The Eyes by Peyruis | https://soundcloud.com/peyruis, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• It’s All Good by Roa Music | https://soundcloud.com/roa_music1031, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Love Trip by Sarah Jansen Music | https://soundcloud.com/sarahjansenmusic, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Mamacita by Mike Leite | https://soundcloud.com/mikeleite, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Slipz (audio logo) by tubebackr | https://soundcloud.com/tubebackr, Music promoted by https://www.free-stock-music.com.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Cardiology.

Participants: 

Dr Karan Rao (cardiologist), Dr Nick Moore (ED consultant), Dr Hao Tran (cardiology advanced trainee), David Emmerig (ED trainee), Aran Sandrasegaran, Amanda De Silva, Pramod Chandru, Shreyas Iyer, and Samoda Wilegoda

Discussion:
Stewart, J., Lu, J., Goudie, A., Bennamoun, M., Sprivulis, P., Sanfillipo, F., & Dwivedi, G. (2021). Applications of machine learning to undifferentiated chest pain in the emergency department: A systematic review. PLOS ONE, 16(8), e0252612. https://doi.org/10.1371/journal.pone.0252612.

Presenter: Hao Tran.

Credits:
This episode was produced by HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Descriptions by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Got My Love by LiQWYD & Markvard | https://www.liqwydmusic.com, https://soundcloud.com/markvard, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Sunset Beach by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com, 
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~