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Miller AR, Martindale SL, Rowland JA, Walton S, Talmy T, Walker WC. Blast-related mild TBI: LIMBIC-CENC focused review with implications commentary. NeuroRehabilitation 2024:NRE230268. [PMID: 39093081 DOI: 10.3233/nre-230268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND A significant factor for the high prevalence of traumatic brain injury (TBI) among U.S. service members is their exposure to explosive munitions leading to blast-related TBI. Our understanding of the specific clinical effects of mild TBI having a component of blast mechanism remains limited compared to pure blunt mechanisms. OBJECTIVE The purpose of this review is to provide a synopsis of clinical research findings on the long-term effects of blast-related mild TBI derived to date from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC). METHODS Publications on blast-related mild TBI from LIMBIC-CENC and the LIMBIC-CENC prospective longitudinal study (PLS) cohort were reviewed and their findings summarized. Findings from the broader literature on blast-related mild TBI that evaluate similar outcomes are additionally reviewed for a perspective on the state of the literature. RESULTS The most consistent and compelling evidence for long-term effects of blast-related TBI is for poorer psychological health, greater healthcare utilization and disability levels, neuroimaging impacts on brain structure and function, and greater headache impact on daily life. To date, evidence for chronic cognitive performance deficits from blast-related mild TBI is limited, but futher research including crucial longitudinal data is needed. CONCLUSION Commentary is provided on: how LIMBIC-CENC findings assimilate with the broader literature; ongoing research gaps alongside future research needs and priorities; how the scientific community can utilize the LIMBIC-CENC database for independent or collaborative research; and how the evidence from the clinical research should be assimilated into clinical practice.
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Affiliation(s)
| | - Sarah L Martindale
- Research and Academic Affairs, W.G. (Bill) Hefner Veterans Affairs Healthcare System, Salisbury, NC, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, NC, USA
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jared A Rowland
- Research and Academic Affairs, W.G. (Bill) Hefner Veterans Affairs Healthcare System, Salisbury, NC, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, NC, USA
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samuel Walton
- Department of Physical Medicine and Rehabilitation (PM& R), School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - William C Walker
- Department of Physical Medicine and Rehabilitation (PM& R), School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Richmond Veterans Affairs (VA) Medical Center, Central Virginia VA Health Care System, Richmond, VA, USA
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Valiño EM, Castro-Delgado R, Sola Muñoz S, Lynam B, Castro P. Factors Associated with the Number of Injured and Fatalities in Motor Vehicle Intentional Mass-Casualty Incidents: A Timely Aid for Scaling the Emergency Response. Prehosp Disaster Med 2024; 39:65-72. [PMID: 38204194 PMCID: PMC10882554 DOI: 10.1017/s1049023x23006726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Intentional mass-casualty incidents (IMCIs) involving motor vehicles (MVs) as weapons represent a growing trend in Western countries. This method has resulted in the highest casualty rates per incident within the field of IMCIs. Consequently, there is an urgent requirement for a timely and accurate casualty estimation in MV-induced IMCIs to scale and adjust the necessary health care resources. STUDY OBJECTIVE The objective of this study is to identify the factors associated with the number of casualties during the initial phase of MV-IMCIs. METHODS This is a retrospective, observational, analytical study on MV-IMCIs world-wide, from 2000-2021. Data were obtained from three different sources: Targeted Automobile Ramming Mass-Casualty Attacks (TARMAC) Attack Database, Global Terrorism Database (GTD), and the vehicle-ramming attack page from the Wikipedia website. Jacobs' formula was used to estimate the population density in the vehicle's route. The primary outcome variables were the total number of casualties (injured and fatalities). Associations between variables were analyzed using Spearman's correlation coefficient and simple linear regression. RESULTS Forty-six MV-IMCIs resulted in 1,636 casualties (1,430 injured and 206 fatalities), most of them caused by cars. The most frequent driving pattern was accelerating whilst approaching the target, with an average speed range between four to 130km/h and a distance traveled between ten to 2,260 meters. The people estimated in the MV-IMCI scenes ranged from 36-245,717. A significant positive association was found of the number affected with the estimated crowd in the scene (R2: 0.64; 95% CI, 0.61-0.67; P <.001) and the average vehicle speed (R2: 0.42; 95% CI, 0.40-0.44; P = .004). CONCLUSION The estimated number of people in the affected area and vehicle's average speed are the most significant variables associated with the number of casualties in MV-IMCIs, helping to enable a timely estimation of the casualties.
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Affiliation(s)
- Eva Maria Valiño
- Emergency Medical System, Catalonia, Spain
- University of Barcelona, Barcelona, Spain
| | - Rafael Castro-Delgado
- Department of Medicine, Oviedo University, Oviedo, Spain
- Health Service of the Principality of Asturias (SAMU-Asturias), Health Research Institute of the Principality of Asturias (Research Group on Prehospital Care and Disasters, GIAPREDE), Oviedo, Spain
- RINVEMER-SEMES (Research Network on Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
| | - Silvia Sola Muñoz
- Emergency Medical System, Catalonia, Spain
- RINVEMER-SEMES (Research Network on Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
| | | | - Pedro Castro
- University of Barcelona, Barcelona, Spain
- Medical Intensive Care Unit, Hospital Clinic of Barcelona; IDIBAPS; University of Barcelona, Barcelona, Spain
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Kaim A, Bodas M, Bieler D, Radomislensky I, Matthes G, Givon A, Trentzsch H, Waydhas C, Lefering R. Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison. Front Public Health 2023; 11:1136159. [PMID: 37200993 PMCID: PMC10186152 DOI: 10.3389/fpubh.2023.1136159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023] Open
Abstract
Background Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR). Methods The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015-2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis. Results Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well. Conclusion Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.
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Affiliation(s)
- Arielle Kaim
- Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
- Department of Emergency and Disaster Management, Faculty of Medicine, School of Public Health, Sackler Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Arielle Kaim,
| | - Moran Bodas
- Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
- Department of Emergency and Disaster Management, Faculty of Medicine, School of Public Health, Sackler Tel Aviv University, Tel Aviv, Israel
| | - Dan Bieler
- Department of Trauma Surgery and Orthopedics, University Düsseldorf, Düsseldorf, Germany
- Department for Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Irina Radomislensky
- Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Gerrit Matthes
- Department of Trauma and Reconstructive Surgery, Hospital Ernst-von-Bergmann, Potsdam, Germany
| | - Adi Givon
- Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Heiko Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Munich, Germany
| | | | - Christian Waydhas
- Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
- Medical Faculty of University Duisburg-Essen, Essen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
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Day A. ENA Position Statement: Hemorrhage Control. J Emerg Nurs 2022; 48:460-464. [PMID: 35787775 DOI: 10.1016/j.jen.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/15/2022] [Accepted: 03/11/2022] [Indexed: 11/19/2022]
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Nguyen TT, Breeze J, Masouros SD. Penetration of Energised Metal Fragments to Porcine Thoracic Tissues. J Biomech Eng 2021; 144:1129240. [PMID: 34897379 DOI: 10.1115/1.4053212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Indexed: 11/08/2022]
Abstract
Energised fragments from explosive devices have been the most common mechanism of injury to both military personnel and civilians in recent conflicts and terrorist attacks. Fragments that penetrate into the thoracic cavity are strongly associated with death due to the inherent vulnerability of the underlying structures. The aim of this study was to investigate the impact of fragment-simulating projectiles (FSPs) to tissues of the thorax in order to identify the thresholds of impact velocity for perforation through these tissues and the resultant residual velocity of the FSPs. A gas-gun system was used to launch 0.78-g cylindrical and 1.13-g spherical FSPs at intact porcine thoracic tissues from different impact locations. The sternum and rib bones were the most resistant to perforation, followed by the scapula and intercostal muscle. For both FSPs, residual velocity following perforation was linearly proportional to impact velocity. These findings can be used in the development of numerical tools for predicting the medical outcome of explosive events, which in turn can inform the design of public infrastructure, of personal protection, and of medical emergency response.
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Affiliation(s)
- Thuy-Tien Nguyen
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
| | - John Breeze
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
| | - Spyros D Masouros
- Department of Bioengineering, Imperial College London, UK; Imperial College London, London, W12 0BZ, United Kingdom
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Walker M, d'Arville A, Lacey J, Lancman B, Moloney J, Hendel S. Mass casualty, intentional vehicular trauma and anaesthesia. Br J Anaesth 2021; 128:e190-e199. [PMID: 34654520 DOI: 10.1016/j.bja.2021.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022] Open
Abstract
The use of motor vehicles to initiate mass casualty incidents is increasing in frequency and such events are called intentional vehicular assaults. Perpetrators are inspired by a range of terrorist ideologies or have extremist views, criminal intent, or mental health issues. Assaults using a motor vehicle as the principal weapon of attack are easy to launch and require little to no forward planning. This makes them difficult for police and security agencies to predict, prevent, or interdict. With the increasing frequency of intentional vehicular assaults, anaesthesiologists in various settings may be involved in caring for victims and should be engaged in preparing for them. This narrative review examines the literature on vehicle assaults committed around the world and provides an overview of the unique injury patterns and considerations for the pre-hospital, perioperative, and critical care management of victims of these mass casualty events. The article discusses planning, education, and training in an attempt to reduce the mortality and morbidity of intentional vehicular assaults.
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Affiliation(s)
- Matthew Walker
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Asha d'Arville
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Jonathan Lacey
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Benn Lancman
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - John Moloney
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Field Emergency Medical Officer Program, Ambulance Victoria, Melbourne, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, Queensland, Australia
| | - Simon Hendel
- Department of Anaesthesiology & Perioperative Medicine, Alfred Health, Melbourne, Australia; Department of Anaesthesia and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Australia; National Trauma Research Institute, Monash University and Alfred Health, Melbourne, Australia; Trauma Service, Alfred Health, Melbourne, Australia.
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Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020. Eur J Trauma Emerg Surg 2021; 48:3813-3819. [PMID: 34175970 DOI: 10.1007/s00068-021-01739-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs. METHODS This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis. RESULTS During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed. CONCLUSIONS Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.
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Planning for Chaos: Developing the Concept of Emergency Preparedness through the Experience of the Paramedic. J Emerg Nurs 2021; 47:487-502. [PMID: 33832738 DOI: 10.1016/j.jen.2021.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Emergency preparedness is a developing specialty with a limited evidence base. Published literature primarily offers a retrospective view of experience, with few studies examining and understanding the individual lived experience of practitioners prospectively. This study explores paramedics' lived experience of emergency preparedness and applies that learning. METHODS Thirteen paramedics were recruited through purposive sampling. Face-to-face semi-structured interviews explored their individual experiences of emergency preparedness, in line with the idiographic focus of Interpretative Phenomenological Analysis. RESULTS Through data analysis, the following superordinate themes were identified for further discussion: self-determination, control, and experience-based practice. Participants appeared to value their role and the unpredictable environment in which they worked. Personal resilience, an area that they suggested is not covered effectively within individual preparation, was viewed as important. The participants articulated that risk, threat, uncertainty, safety, trust, and control were important concepts within individual preparedness. These paramedics valued practice-based knowledge and education as credible and transferrable to their clinical work. CONCLUSION Evidence from this study suggests that standard emergency preparedness, with the focus at organizational level, is not sufficient for the individual workers or for an overall effective response. Dimensions of individual preparedness are presented, with the paramedic central to the experience within a conceptual model (the DiEP model), creating a new form of emergency preparedness that reflects the individual paramedic's experience.
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Tovar MA, Bell RS, Neal CJ. Epidemiology of Blast Neurotrauma: A Meta-analysis of Blast Injury Patterns in the Military and Civilian Populations. World Neurosurg 2020; 146:308-314.e3. [PMID: 33246181 DOI: 10.1016/j.wneu.2020.11.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mass casualty incidents (MCIs) due to bombing-related terrorism remain an omnipresent threat to our global society. The aim of this study was to elucidate differences in blast injury patterns between military and civilian victims affected by terrorist bombings. METHODS An analysis of the Global Terrorism Database (GTD) and a PubMed literature search of casualty reports of bombing attacks from 2010-2020 was performed (main key words: blast injuries/therapy, terrorism, military personnel) with key epidemiological and injury pattern data extracted and statistically analyzed. RESULTS Demographic analysis of casualties revealed that military casualties tend to be younger and predominantly male (P < 0.05) compared with civilians. Military casualties also reported higher amounts of head/neck injury (P < 0.01) compared with civilians. The proportion of instantaneous fatalities along with injuries affecting the thoracoabdominal and extremity regions remained approximately equal across both groups. CONCLUSIONS Though the increased number of head/neck injuries was unexpected, we also found that the number of nonlethal head injuries also increased, predicating that more military blast neurotrauma patients survived their injuries. These data can be used to increase blast MCI preparation and education throughout the international neurosurgical community.
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Affiliation(s)
- Matthew A Tovar
- School of Medicine and Health Sciences, George Washington University, Washington, DC.
| | - Randy S Bell
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland; Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Chris J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland; Uniformed Services University of Health Sciences, Bethesda, Maryland
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Nguyen TTN, Carpanen D, Rankin IA, Ramasamy A, Breeze J, Proud WG, Clasper JC, Masouros SD. Mapping the Risk of Fracture of the Tibia From Penetrating Fragments. Front Bioeng Biotechnol 2020; 8:544214. [PMID: 33042964 PMCID: PMC7525181 DOI: 10.3389/fbioe.2020.544214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thuy-Tien N. Nguyen
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Diagarajen Carpanen
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Iain A. Rankin
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Arul Ramasamy
- Department of Bioengineering, Imperial College London, London, United Kingdom
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Academic Department of Trauma and Orthopaedics, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Johno Breeze
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - William G. Proud
- Institute of Shock Physics, Department of Physics, Imperial College London, London, United Kingdom
| | - Jonathan C. Clasper
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Spyros D. Masouros
- Department of Bioengineering, Imperial College London, London, United Kingdom
- *Correspondence: Spyros D. Masouros,
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Counter-Terrorism Medicine: Creating a Medical Initiative Mandated by Escalating Asymmetric Attacks. Prehosp Disaster Med 2020; 35:595-598. [DOI: 10.1017/s1049023x2000103x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Since 2001, a burgeoning interest by health care professionals in the growing asymmetrical terrorist threat and its impact on health care preparation and response has seen significantly increased academic output around this nebulous subject. Despite this, there has failed to be a consolidation of this sub-specialty.Discussion:This editorial argues for the consolidation of the body of experience gathered since 2001 into an initiative called Counter-Terrorism Medicine (CTM). It proposes that previously discrete sub-specialty areas can be consolidated, with improvements in collective understanding, and can build on previous work to provide a non-political health care focused definition of terrorist events, based on the triad of Violence, Intent, and Heath Care Impact. It notes the importance this defining triad has in health care planning and response considerations. Finally, it defines the parameters of CTM within the larger specialty of Disaster Medicine (DM).Conclusion:There is a growing body of academic work on the health care implications of terrorism. The time is right to coalesce these into an initiative referred to as CTM and to consider this as a discrete part of DM.
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