eScholarship@UMassChan Repository at UMass Chan Medical School


Sherman Center building at UMass Chan Medical School at night

eScholarship@UMassChan is a digital repository for UMass Chan Medical School's research and scholarship, including journal articles, theses, datasets and more. We welcome submissions from our faculty, staff, and students. eScholarship@UMassChan is a service of the Lamar Soutter Library, Worcester, MA, USA. See also our open access journal publishing services.

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  • The IR Venn Diagram: Diversity in Technology, Content, Users, and Roles in Specialized Institutional Repositories

    Kubilius, Ramune K.; Burke, Michael; Jerome, Erin; Lovett, Julia; O'Brien, Emily Ping; Palmer, Lisa A. (2024-07-15)
    In this poster, librarians from six academic libraries – representing various sectors including science, technology, engineering, medicine, music, and large universities – collaborated to explore and reflect on the academic IR community that encompasses specialized libraries, collections, and formats. The authors answered self-survey questions and responses were analyzed for visualization in the poster. The poster spotlights diversity in technology, content, users, roles, priorities, and challenges. It also illustrates some of the common threads and opportunities that have relevance and implications in both the special library and the broader IR landscape.
  • “I promised them I would be there”: A qualitative study of the changing roles of cultural health navigators who serve refugees during the COVID-19 pandemic

    Schuster, Roseanne C.; Wachter, Karin; McRae, Kenna; McDaniel, Anne; Davis, Olga I.; Nizigiyimana, Jeanne; Johnson-Agbakwu, Crista E (2024-07-13)
    Cultural health navigators (CHNs) are one type of community health worker (CHW), a front-line cadre critical to mitigating the COVID-19 pandemic among marginalized communities. Yet little is documented about the roles of CHNs serving resettled refugees both before and during the pandemic. The objective of this study was to examine shifts in how CHNs carried out their work with refugee patients at a particular time point in the COVID-19 pandemic. In August 2020, we conducted virtual and serial semi-structured interviews with ten CHNs at a U.S. healthcare system serving ethnically and linguistically diverse refugee communities. We used a thematic analysis approach to code and interpret data. The analysis indicated that CHNs’ descriptions of their work with refugee clients and communities largely mapped onto established CHW roles: cultural mediation, care coordination, system navigation, education, and outreach and social support; however, how CHNs fulfilled their roles shifted dramatically during the pandemic. CHNs were unable to physically navigate patients through the system due to safety measures and telemedicine and deeply felt the loss of providing in-person outreach and social support. To offset constraints, CHNs increased the number and scope of virtual contacts with patients and launched novel education, outreach, and social support strategies. Through their adapted strategies, CHNs nurtured a strong foundation of trust to provide continuous care under challenging circumstances, although they were concerned that the lack of in-person interactions decreased patients' sensitive disclosures. The analysis illuminates the important and often unrecognized work of CHWs and informs ongoing efforts to prioritize community health work in U.S. healthcare policy and practice.
  • A Tribute to a Family Physician

    Ledwith, James (2024-07-11)
    Introduction: I have no words for the passing of our good friend and colleague Jim Ledwith. The words others have used about his commitment to students, the city's free clinics, those with substance use disorder and chronic pain, the Fitchburg residency, Learning Communities, MCSTAP (Massachusetts Consultation Service for the Treatment of Addiction and Pain), and more were saint, mensch, selfless, ... I am going to let Jim's words speak for themselves. Below are two pieces he wrote for the FMM (formerly TMM). The first is a reflection sadly and ironically about Jim helping someone to die with dignity. Jim knew that a good family physician cares for a patient right to the end, transitioning from curing to helping and caring. The story is a reminder to us all that there is always care we can provide. The second is a treatise on how wonderful it is to be a family physician. That is how I will choose to remember Jim - a man who embodied the spirit of family medicine and he was able to capture it below. I am crying as I write this. He gave and gave and gave and in his last moments on this planet he even gave his organs per his wishes so that others would still benefit from his selflessness. Jim - you will long be remembered. Long and well. We loved you and hope for all the best for your family. This will be the last edition of FMM for the academic year. We will start up again in September. For this upcoming year - our 50th anniversary as a department - we would very much enjoy hearing from alumni with your stories over the last 50 years. Thank you.
  • IFNγ-IL12 axis regulates intercellular crosstalk in metabolic dysfunction-associated steatotic liver disease

    Friedline, Randall H; Noh, Hye Lim; Suk, Sujin; Albusharif, Mahaa; Dagdeviren, Sezin; Saengnipanthkul, Suchaorn; Kim, Bukyung; Kim, Allison M; Kim, Lauren H; Tauer, Lauren A; et al. (2024-06-29)
    Obesity is a major cause of metabolic dysfunction-associated steatohepatitis (MASH) and is characterized by inflammation and insulin resistance. Interferon-γ (IFNγ) is a pro-inflammatory cytokine elevated in obesity and modulating macrophage functions. Here, we show that male mice with loss of IFNγ signaling in myeloid cells (Lyz-IFNγR2-/-) are protected from diet-induced insulin resistance despite fatty liver. Obesity-mediated liver inflammation is also attenuated with reduced interleukin (IL)-12, a cytokine primarily released by macrophages, and IL-12 treatment in vivo causes insulin resistance by impairing hepatic insulin signaling. Following MASH diets, Lyz-IFNγR2-/- mice are rescued from developing liver fibrosis, which is associated with reduced fibroblast growth factor (FGF) 21 levels. These results indicate critical roles for IFNγ signaling in macrophages and their release of IL-12 in modulating obesity-mediated insulin resistance and fatty liver progression to MASH. In this work, we identify the IFNγ-IL12 axis in regulating intercellular crosstalk in the liver and as potential therapeutic targets to treat MASH.
  • Demographics and Employment Outcomes: Selected Findings from NIDILRR-funded Disability Employment Research in the 21st Century

    Russinova, Zlatka; Bloch, Philippe (2024-06-28)
    A systematic scoping review of research published between 2000 and 2020 on employment of people with disabilities, that was funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) was conducted by CeKTER researchers. All papers comparing people with disabilities to those without have been excluded from the systematic scoping review. Among over 100 publications reviewed there was a wide and very disparate array of findings with numerous variables used and varying research questions. This result belies summative findings. There are numerous ways of organizing the disparate findings. This brief is the first in a series of findings from the systematic scoping review. In this brief we report on findings categorized by the demographic characteristics of education, gender, marital status, race, and age. Please note that all comparisons are always about corresponding peers with disabilities.
  • A Scribe's Tribute #2

    Uchendu, Chidinma (2024-06-27)
    Introduction: Two weeks ago I shared a tribute from one of our scribes in our Scribe Fellowship. This week I am sharing the insights Chidinma Uchendu, an aspiring physician, learned from her scribing experience at Hahnemann. Chidinma was involved with MassAHEC’s high school pipeline program at the Boston AHEC, so she has a long-term interest in a career in medicine. She will be busy this summer preparing for her application to medical school and we wish her a successful outcome!
  • Ethical Frameworks in Periviable Decision-Making: Patient Perspectives and Provider Patterns

    Delaney, Kathryn (2024-06-25)
    Background: Periviability counseling involves engaging in difficult ethical decisions. The ethical frameworks used by patients and their healthcare providers to discuss this topic have not been previously studied. Objectives: This study assessed the ethical frameworks used by patients and by providers during periviability counseling and subsequent decision making. Study Design: This mixed methods study included patients between gestation ages 21 weeks 0 days through 24 weeks 6 days who required periviability counseling, and the providers performing this counseling. Counseling sessions between providers and patients were recorded, as were semi-structured follow-up interviews with patients. These recordings were transcribed and analyzed using thematic analysis. Demographic surveys were given to providers, and patient demographic, obstetric, and delivery information was abstracted from medical records. Results: A total of 11 patients and 11 providers participated in either a recorded counseling session, a follow-up interview, or both. Qualitative analysis revealed the following themes: 1) decisions regarding periviable intervention are the patient’s to make, 2) desire to avoid pain or suffering of the fetus/newborn, especially as it related to CPR, 3) doing what is best for the family, including partners and other children at home, 4) “doing everything” as a good in itself, and 5) periviable complications disrupt expectations about parenthood or pregnancy which then need to be reimagined. These themes corresponded to four distinct ethical frameworks: principlism, care ethics, virtue ethics, and narrative ethics. All of the patients, and approximately three-quarters of providers used at least one of these ethical frameworks; most used a combination of frameworks. Conclusions: Patients and providers engaging in decision making surrounding periviable intervention use commonly accepted ethical frameworks to discuss and decide how to proceed with these pregnancies.
  • Thalamocortical mGlu8 Modulates Dorsal Thalamus Excitatory Transmission and Sensorimotor Activity

    Nabit, Bretton P; Taylor, Anne; Winder, Danny G (2024-06-25)
    Metabotropic glutamate receptor 8 (mGlu8) is a heterogeneously expressed and poorly understood glutamate receptor with potential pharmacological significance. The thalamic reticular nucleus (TRN) is a critical inhibitory modulator of the thalamocortical-corticothalamic (TC-CT) network and plays a crucial role in information processing throughout the brain, is implicated in a variety of psychiatric conditions, and is also a site of significant mGlu8 expression. Using both male and female mice, we determined via fluorescent in situ hybridization that parvalbumin-expressing cells in the TRN core and shell matrices (identified by spp1+ and ecel1+ expression, respectively) as well as the cortical layers involved in corticothalamic signaling, express grm8 mRNA. We then assayed the physiological and behavioral impacts of perturbing grm8 signaling in the TC circuit through conditional (AAV-CRE mediated) and cell type-specific constitutive deletion strategies. We show that constitutive parvalbumin grm8 knockout (PV grm8 KO) mice exhibited 1) increased spontaneous excitatory drive onto dorsal thalamus relay cells and 2) impaired sensorimotor gating, measured via paired-pulse inhibition, but observed no differences in locomotion and thigmotaxis in repeated bouts of open field testing. Conversely, we observed hyperlocomotive phenotypes and anxiolytic effects of AAV-mediated conditional knockdown of grm8 in the TRN (TRN grm8 KD) in repeated open field testing. Our findings underscore a role for mGlu8 in regulating excitatory neurotransmission as well as anxiety-related locomotor behavior and sensorimotor gating, revealing potential therapeutic applications for various neuropsychiatric disorders and guiding future research endeavors into mGlu8 signaling and TRN function.Significance statement Group III mGlu receptors and the Thalamic Reticular Nucleus (TRN) are critical modulators of reciprocal cortico-thalamic neurotransmission and are implicated in anxiety and locomotor behaviors. The present study demonstrates a specific enrichment of grm8 mRNA within the TRN and thalamus-projecting cortical layers and characterizes the role of mGlu8 receptors in controlling spontaneous excitatory neurotransmission onto cells located within the dorsal thalamus and regulating sensorimotor behaviors from open field and PPI testing. These findings add to growing bodies of literature regarding both TRN and grm8 regulation of thalamocortical activity and related behaviors implicated in neurological and neuropsychiatric disorders.
  • Individual Development Plan for Career Development Professionals

    Ismael, Amber; Campbell, Brian; Chremos, Ioannis Vasileios; Fuhrmann, Cynthia N; Nordell, Shawn (2024-06-21)
    The Individual Development Plan for Career Development Professionals is an IDP worksheet to guide individuals who are pursuing careers in graduate/postdoctoral career development through the process of creating their own IDP. The worksheet is designed as an IDP tool for all career levels, including those preparing to enter this field, practitioners seeking to grow within their current positions, or those looking to advance or pursue a career transition. The tool includes prompts to guide one through exercises that help one assess their skills, values, interests, progress and growth; set goals and define an action plan; and consider the resources, mentorship, and community that they may need to help develop a fulfilling career. Though designed for professionals in the career development field, this tool may also be helpful for those in other academic administration or education roles. This tool was designed by members of the Professional Development Committee of the Graduate Career Consortium, an international member organization to help individuals advance the field of graduate and postdoctoral career and professional development.
  • NexGen Eulogy

    Sarkar, Amber (2024-06-20)
    Introduction: This week we have a poem again. This time from Dr. Amber Sarkar who is faculty at Family Health Center of Worcester. She is writing here about the transition from one EHR to another EHR. I think most of us have experienced this at least once - I have experienced 8 different EHRs so this really resonates with me. We come to spend more time with our EHR than we do our children! We form a warped bond with it. Like our phones, it gets a grasp on us. We talk about it like it is a living entity. And then sometimes we have to say goodbye. And hope the new one will be better than the old. Amber captures all of this well in her poem.
  • Analyzing the Role of MS4A Receptors in Mouse Olfaction

    Jiang, Hao-Ching (2024-06-17)
    How the brain interprets sensory information to generate appropriate behaviors remains a fundamental, unanswered question in neurobiology. In mammals, the olfactory system detects external chemicals through a vast array of odorant receptors expressed by peripheral olfactory sensory neurons (OSNs). These OSNs connect to brain circuits responsible for creating olfactory percepts and triggering odor-driven behaviors. The olfactory system has evolved distinct subsystems to initiate various behaviors, each containing anatomically and molecularly distinct OSNs for different functions. The olfactory epithelium (OE) is the largest and best-studied subsystem, crucial for odor discrimination and learning. Smaller olfactory subsystems detect ethologically relevant odorants, necessary for innate behaviors like foraging, mating, and predator avoidance. Unlike conventional OSNs in the OE, receptors in smaller subsystems are largely uncategorized, leaving their roles in odor-driven behaviors poorly understood. I focused on the function of the MS4A gene family, which is expressed in a specific olfactory subsystem linked to mouse innate behaviors. I demonstrated that multiple genes in this family act as chemoreceptors in vivo. Additionally, I identified one family member, MS4A1, expressed in a subset of previously uncharacterized OSNs in the mouse nose. MS4A1 functions as a non-canonical chemoreceptor, required for evoking innate avoidance responses to certain aversive chemicals. Beyond OSNs, the MS4A gene family is also expressed in various immune cells. Notably, I found that MS4A1/CD20, a tumor marker on B cells, acts as a potential chemoreceptor. This discovery could enhance understanding of MS4A proteins' roles in tissues outside OSNs and provide potential therapeutic targets for human diseases.
  • Racial Disparities and Trends in Anticoagulant Use among Ambulatory Care Patients with Atrial Fibrillation and Atrial Flutter in the United States from 2007-2019 [preprint]

    Kan, Vincent; Lapane, Kate L; McManus, David D; Baek, Jonggyu; Darling, Chad E; Alcusky, Matthew J (2024-06-15)
    Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly increasing the risk of stroke. The introduction of direct oral anticoagulants (DOACs) since 2010 has transformed anticoagulation therapy, offering an alternative to warfarin with improved safety profiles. Despite the increased adoption of DOACs, disparities in their use among different racial and ethnic groups in the United States remain understudied. Methods This study utilized a repeated cross-sectional design, analyzing data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2019. The study population included adults diagnosed with AF or atrial flutter (AFL). We analyzed the temporal trends of DOAC and warfarin use from 2007 to 2019. We examined the prevalence of DOAC versus warfarin use and assessed associations between race/ethnicity, patient characteristics, and DOAC utilization from 2011 to 2019. Multivariable modified Poisson regression models were used to calculate adjusted prevalence ratios (aPR) for the associations. Results From 2011 to 2019, NAMCS recorded 3,224 visits involving AF or AFL, representing a weighted estimate of 103.6 million visits. DOAC use increased significantly, with apixaban becoming the predominant anticoagulant by 2016. Non-Hispanic Black patients were less likely to use DOACs compared to non-Hispanic White patients over time (aPR 0.75; 95% CI, 0.63-0.90). Patients with Medicaid insurance were also less likely to use DOACs (aPR 0.14; 95% CI: 0.04-0.46). Conclusion Despite the shift from warfarin to DOACs for AF and AFL treatment, significant racial and socioeconomic disparities persist. Non-Hispanic Black patients and those with Medicaid insurance are less likely to use DOACs. These findings highlight the need for targeted strategies to ensure equitable access to advanced anticoagulant therapies.
  • Calcineurin coordinates cell cycle progression with adaptation to environmental stress

    Flynn, Mackenzie J (2024-06-14)
    Sudden exposure to environmental stress threatens the viability of single-celled microbes and cells within complex tissues. In order to survive, cells must sense environmental changes and coordinate a transient cell cycle arrest with the appropriate adaptive response. Cells have several stress-responsive pathways that promote adaptation to distinct stressors, but how these pathways interact with one another is poorly understood. Here, we examined the response to calcium chloride stress, which activates the phosphatase calcineurin and the MAPK Hog1 in Saccharomyces cerevisiae. We discovered that calcineurin extends Hog1 activation, which causes prolonged downregulation of cell cycle-regulated genes and delays progression through multiple cell cycle phases. At the G1/S transition, crosstalk between calcineurin and Hog1 dramatically increases the duration of calcium-induced arrest. I found that Hog1 triggers arrest independent of calcineurin by decreasing G1 cyclin transcription and calcineurin maintains this arrest by extending Hog1-dependent activation of the G1 CDK inhibitor Cip1. These results suggest that stress-response pathway interactions tailor cell cycle arrest with adaptation to environmental stress. The immediate response to stress is well-characterized, but how cells maintain viability in challenging environments after recovering from a stress-induced arrest is unknown. I investigated the response to prolonged growth in calcium stress and found that calcineurin maintains fitness by promoting cell division and suppressing death. I determined that calcineurin helps cells proliferate and survive prolonged calcium exposure by two mechanisms, which differentially require a downstream transcription factor. Together, these findings highlight the importance of stress-response pathways during both acute and chronic environmental stress.
  • Depressive Symptoms in Adolescence as a Predictor of Young Adult Employment Quality: Findings from the National Longitudinal Study of Adolescent to Adult Health

    Sabella, Kathryn (2024-06-13)
    This study uses longitudinal data from a nationally representative sample of adolescents, The National Longitudinal Study of Adolescent to Adult Health, to investigate the association between depressive symptomatology in adolescence and indicators of employment quality in young adulthood. A better understanding of the long-term impacts of adolescent depressive symptoms on employment quality during young adulthood would inform our understanding of how economic and mental health trajectories of individuals with a history of depression unfold.
  • A Scribe's Tribute

    Street, Ashley (2024-06-13)
    Introduction: This week I have the pleasure of sharing the first of two letters prepared by this year’s Scribe Fellows. The scribes were asked to write a letter to a provider they really connected with, someone who inspired them and helped them think about their future physician-self. The scribes could also reflect on a patient who made an impact. As you will read, Ashley Street’s future physician-self was informed by what she learned this year scribing and witnessing patient care at Hahnemann. In August, she will join us as a member of the Class of 2028! I think we can all say we look forward to seeing her. Congratulations to Ashley and all who inspired her.
  • Location, Location, Location: The Impact of One's Neighborhood on Outcomes Following Proctectomy for Rectal Cancer

    Onyiego, Alexandra (2024-06-13)
    Purpose: The area deprivation index (ADI) is a comprehensive assessment of the social determinants of health. The higher the composite ADI score, the more underserved the area. This study examined the impact of a patient’s ADI score on surgical, pathologic, and survival outcomes following proctectomy for rectal cancer. Methods: Data from a single tertiary care medical center’s targeted National Surgical Quality Improvement Program (NSQIP) were used to identify all patients undergoing proctectomy for rectal cancer between January 2014 – December 2022. A state ADI (ranking 1-10) was assigned to each patient using their residential address. Patients were categorized into Low (1-4), Moderate (5-6), High (7-8), and Very High (9-10) ADI groups. Results: Two-hundred and four patients who underwent proctectomy for rectal cancer were included. There were no significant between group differences in patient’s post-operative outcomes including 30-day morbidity and hospital readmissions. As well as pathologic outcomes, including completeness of mesorectal excision and rate of positive margins. A Cox multivariable adjusted regression model showed those in the Very High group had a higher risk of dying at 5 years than the Low ADI group. Patients in the Very High and High ADI groups were significantly more likely to be discharged somewhere other than home after their surgery than those in the Low ADI group, (13% vs. 0%). The median time from diagnosis to initiating treatment or surgery showed those in the Very High and High ADI groups took longer to obtain treatment. Conclusion: A patient’s ADI has an impact on their overall survival following proctectomy for rectal cancer and influences their time to receiving treatment and their postoperative disposition. Future studies with larger patient cohorts are needed to more clearly define the role of ADI in predicting patient outcomes following proctectomy for rectal cancer.
  • Correction of multiplexing artefacts in multi-pinhole SPECT through temporal shuttering, de-multiplexing of projections, and alternating reconstruction

    Pells, Sophia; Zeraatkar, Navid; Kalluri, Kesava S; Moore, Stephen C; May, Micaehla; Furenlid, Lars R; Kupinski, Matthew A; Kuo, Phillip H; King, Michael A (2024-06-06)
    Objective.Single-photon emission computed tomography (SPECT) with pinhole collimators can provide high-resolution imaging, but is often limited by low sensitivity. Acquiring projections simultaneously through multiple pinholes affords both high resolution and high sensitivity. However, the overlap of projections from different pinholes on detectors, known as multiplexing, has been shown to cause artefacts which degrade reconstructed images.Approach.Multiplexed projection sets were considered here using an analytic simulation model of AdaptiSPECT-C-a brain-dedicated multi-pinhole SPECT system. AdaptiSPECT-C has fully adaptable aperture shutters, so can acquire projections with a combination of multiplexed and non-multiplexed frames using temporal shuttering. Two strategies for reducing multiplex artefacts were considered: an algorithm to de-multiplex projections, and an alternating reconstruction strategy for projections acquired with a combination of multiplexed and non-multiplexed frames. Geometric and anthropomorphic digital phantoms were used to assess a number of metrics.Main results.Both de-multiplexing strategies showed a significant reduction in image artefacts and improved fidelity, image uniformity, contrast recovery and activity recovery (AR). In all cases, the two de-multiplexing strategies resulted in superior metrics to those from images acquired with only mux-free frames. The de-multiplexing algorithm provided reduced image noise and superior uniformity, whereas the alternating strategy improved contrast and AR.Significance.The use of these de-multiplexing algorithms means that multi-pinhole SPECT systems can acquire projections with more multiplexing without degradation of images.
  • Fly into tranquility: GABA's role in Drosophila sleep

    Chaturvedi, Ratna; Emery, Patrick (2024-06-05)
    Sleep is conserved across the animal kingdom, and Drosophila melanogaster is a prime model to understand its intricate circadian and homeostatic control. GABA (gamma-aminobutyric acid), the brain's main inhibitory neurotransmitter, plays a central role in sleep. This review delves into GABA's complex mechanisms of actions within Drosophila's sleep-regulating neural networks. We discuss how GABA promotes sleep, both by inhibiting circadian arousal neurons and by being a key neurotransmitter in sleep homeostatic circuits. GABA's impact on sleep is modulated by glia through astrocytic GABA recapture and metabolism. Interestingly, GABA can be coexpressed with other neurotransmitters in sleep-regulating neurons, which likely contributes to context-based sleep plasticity.
  • UMCCTS Newsletter, June 2024

    UMass Center for Clinical and Translational Science (2024-06-03)
    This is the June 2024 issue of the UMass Center for Clinical and Translational Science Newsletter containing news and events of interest.
  • ACR Appropriateness Criteria® Female Breast Cancer Screening: 2023 Update

    Niell, Bethany L; Jochelson, Maxine S; Amir, Tali; Brown, Ann; Adamson, Megan; Baron, Paul; Bennett, Debbie L; Chetlen, Alison; Dayaratna, Sandra; Freer, Phoebe E; et al. (2024-06-01)
    Early detection of breast cancer from regular screening substantially reduces breast cancer mortality and morbidity. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are the recommended method for breast cancer screening in all risk categories. In addition to the recommendation of mammography and digital breast tomosynthesis in high-risk patients, screening with breast MRI is recommended. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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