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Narra J
Published by PT Narra Sains Indonesia
ISSN : -     EISSN : 28072618     DOI : https://doi.org/10.52225/narraj
Core Subject : Health, Science,
Biochemistry, Genetics & Molecular Biology Health Professions Immunology & microbiology Medicine & Pharmacology Public Health
Narra J is a multidisciplinary journal and it is published three times (April, August, December) a year. The objective is to promote articles on infection, public health, global health, tropical infection, one health and diseases in tropics. Narra J publishes original research work across all disciplines of medicine and allied sciences, related to infection, public health, global health, tropical infection, one health and diseases in tropics. The journal publishes Original articles, Short Report, Review articles, and Letters to the Editor. All articles published in Narra J are peer-reviewed and published online for immediate access and citation. Narra J publishes the primary research papers, review articles, short communications and letters on topics but not limited to: Public health Global health Infection Tropical diseases One health Biomedical sciences Epidemiology and clinical epidemiology Molecular biology Environmental health Microbiology Pharmacological sciences Diseases in tropics
Arjuna Subject : Kedokteran - Kedokteran (Lain-Lain)
Articles 644 Documents
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Comparison of interleukin-6 and serum creatinine levels in preeclampsia and normal pregnancy patients: A cross-sectional study in Indonesia Dewi, Syerli R.; Yeni, Cut M.; Munizar, Munizar; Dewi, Tgk. Puspa; Utami, Niken A.; Rusnaidi, Rusnaidi
Narra J Vol. 6 No. 1 (2026): April 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i1.3016

Abstract

Preeclampsia (PE) is a complication of pregnancy with high morbidity and mortality, characterized by endothelial dysfunction, systemic inflammation, and impaired renal function. Interleukin-6 (IL-6) and serum creatinine have potential as biomarkers for early detection of PE; however, data from Indonesia are limited. The aim of this study was to compare IL-6 and serum creatinine levels between pregnant women with PE and normotensive controls, as well as their diagnostic performance in identifying PE. A cross-sectional study involving pregnant women with PE and normotensive controls was conducted at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. Serum IL-6 and creatinine levels were measured using the ECLIA method. Levels were compared using the Mann–Whitney test; diagnostic performance was assessed using receiver operating characteristic (ROC) curve analysis, and multivariable logistic regression was used to evaluate combined diagnostic contribution. A total of 68 pregnant women were included, comprising 34 patients with PE and 34 normotensive controls. Median IL-6 levels were significantly higher in the PE group (16.05 pg/mL) than in the control group (3.71 pg/mL). Receiver operating characteristic analysis demonstrated excellent diagnostic performance of IL-6, with an are under the curve (AUC) of 0.831 (95%CI: 0.734–0.929). At an optimal cutoff value of 5.52 pg/mL, IL-6 achieved a sensitivity of 73.53%, specificity of 76.47%, and diagnostic accuracy of 86.76%. Median serum creatinine levels were also significantly elevated in the PE group (0.56 mg/dL) compared with controls (0.44 mg/dL; p<0.001). The AUC for serum creatinine was 0.806 (95%CI: 0.700–0.912), indicating good diagnostic performance. At a cutoff value of 0.475 mg/dL, serum creatinine demonstrated a sensitivity of 70.59%, specificity of 73.53%, and accuracy of 72.06%. Multivariable logistic regression confirmed that IL-6 (B=0.123; p=0.005) and serum creatinine (B=9.306; p=0.023) were independently associated with PE, explaining 57.5% of PE variability (Nagelkerke R²=0.575). These findings indicate that serum IL-6 and creatinine are significantly associated with PE, and their combined assessment shows potential as a predictive biomarker with good diagnostic performance.
Prevalence of malnutrition in patients with acute coronary syndrome undergoing coronary angiography in Thailand: A retrospective observational study Wattanasiriporn, Wittawat; Sunawin, Methat; Arayangkoon, Chantisa
Narra J Vol. 6 No. 1 (2026): April 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i1.3077

Abstract

Malnutrition is an important prognostic factor in patients with acute coronary syndrome (ACS), but it remains under-recognized in routine practice, particularly in Thailand, where local data are limited, and no population-specific nutritional screening tool has been validated. The Prognostic Nutritional Index (PNI) and Nutritional Risk Index (NRI) have been associated with mortality and major adverse cardiovascular events (MACEs) in patients with ACS, but their clinical usefulness in Thai patients remains unclear. This study aimed to determine the prevalence of malnutrition among patients with ACS undergoing coronary angiography (CAG) at Rajavithi Hospital, Bangkok, Thailand, and to assess the clinical usefulness of PNI and NRI in this setting. The secondary objective was to evaluate 1-year all-cause mortality and the occurrence of MACEs according to nutritional status. This study included 244 adult patients with ACS who were admitted between January 2023 and December 2024, underwent CAG, and completed a 1-year follow-up. Nutritional status was assessed using PNI and NRI, and categorized as severe, moderate, or no malnutrition. The primary outcome was 1-year all-cause mortality, while the secondary outcome was MACEs, defined as a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, hospitalization for heart failure, and hospitalization for unstable angina. Associations between nutritional status and outcomes were examined using logistic regression. According to PNI, 43.8% of patients were malnourished, including 27.0% with severe malnutrition and 16.8% with moderate malnutrition. In contrast, NRI classified 99.6% of patients as severely malnourished. The 1-year all-cause mortality rate was 28.3%, and the MACE rate was 28.7%. Based on PNI, severe and moderate malnutrition were associated with higher mortality than no malnutrition (62.1% and 31.7% vs 10.9%, respectively). Severe malnutrition was associated with 13.34-fold higher odds of death (odds ratio (OR) 13.34; 95%CI: 6.41–27.71), while moderate malnutrition was associated with 3.78-fold higher odds (OR 3.78; 95%CI: 1.61–8.82). Severe and moderate malnutrition were also associated with higher odds of MACEs (OR 2.65; 95%CI: 1.38–5.06 and OR 2.89; 95%CI: 1.36–6.11, respectively). Malnutrition was common among Thai patients with ACS undergoing CAG and was strongly associated with adverse 1-year outcomes. Compared with NRI, PNI provided more clinically meaningful stratification in this cohort. Although formal comparative performance analyses were not performed, PNI may be a practical tool for nutritional risk assessment in routine ACS care.
Psychometric properties of the Burmese version of Self-Stigma Scale: A study among older Myanmar migrants in Thailand Shun Lei Oo; Moe Moe Yu; Tinakon Wongpakaran; Jiranan Griffiths; Peerasak Lerttrakarnnon; Ronald R. O’Donnell; Nahathai Wongpakaran
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3076

Abstract

Self-stigma is a major barrier to mental health help-seeking among marginalized populations, including older Myanmar migrants in Thailand. Despite its importance, this issue has been little studied in this population, and no validated Burmese-language instrument has been available to date. This study evaluated the psychometric properties of the Burmese version of the Self-Stigma Scale–Short Form (SSS-SF), with particular emphasis on its factor structure, reliability, and validity among older Myanmar migrants in Thailand. Participants (n=211) aged ≥60 years were recruited through online platforms and community outreach initiatives. The SSS-SF was translated and culturally adapted in accordance with international guidelines. Confirmatory factor analysis was used to test multiple structural models, and reliability was assessed using Cronbach’s alpha. Convergent and discriminant validity were examined through correlations with the depression and anxiety subscales of the Outcome Inventory-21 (OI-21), the Mental Help-Seeking Intention Scale (MHSIS), and the Extraversion domain of the Zuckerman-Kuhlman-Aluja Personality Questionnaire-20 (ZKA-20). Initial analyses indicated that the 9-item bifactor model provided the best representation of the data, although overall fit remained only modest. After removal of four misfitting items, a shortened 5-item version demonstrated improved fit as a unidimensional model. Reliability was good for the 9-item scale (α=0.855) and acceptable for the 5-item scale (α=0.828). Convergent validity was supported by significant positive correlations between self-stigma and OI-21 depression (r=0.55, p<0.01), OI-21 anxiety (r=0.54, p<0.01), and MHSIS (r=0.15, p<0.05). Discriminant validity was supported by a weak, non-significant association with ZKA-20 Extraversion (r=0.11, ns). These findings suggest that, although the original 9-item Burmese SSS-SF showed limitations in model fit, the refined 5-item version offers a more concise measure with initial evidence of promising psychometric properties for assessing self-stigma among older Myanmar migrants. This shorter version may be useful for rapid screening in community and clinical settings, although further validation in other Burmese populations is warranted.
Impact of colchicine on hs-CRP, neutrophil levels, neutrophil-to-lymphocyte ratio and major adverse cardiac events (MACEs) in Thai patients with acute coronary syndrome undergoing percutaneous coronary intervention Wattanasiriporn, Wittawat; Rattanasidha, Paruj; Munirwan, Haris; Arayangkoon, Chantisa
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3079

Abstract

Acute coronary syndrome (ACS) is strongly associated with inflammation, which contributes to plaque instability, thrombosis, and adverse cardiovascular outcomes. High-sensitivity C-reactive protein (hs-CRP), neutrophil count, and neutrophil-to-lymphocyte ratio (NLR) are inflammatory markers that have been associated with poor prognosis in patients with ACS. Colchicine has emerged as a potential adjunctive anti-inflammatory therapy in cardiovascular disease. This study aimed to evaluate the effects of colchicine on inflammatory markers and clinical outcomes in Thai patients with ACS undergoing percutaneous coronary intervention (PCI). This single-center, retro-prospective observational cohort study included adult patients with ACS who underwent PCI at Rajavithi Hospital, Bangkok, Thailand, in 2024. Patients were classified into colchicine and non-colchicine groups based on treatment exposure after PCI. Hs-CRP, neutrophil count, and NLR were assessed at baseline, 1 month, and 3 months. Major adverse cardiac events (MACE) during follow-up were also recorded. A total of 56 patients were included, comprising 38 in the colchicine group and 18 in the non-colchicine group. Compared with the non-colchicine group, the colchicine group showed significantly greater reductions from baseline to 3 months in hs-CRP levels (2.29±3.37 vs 0.45±1.03; p=0.044), neutrophil count (21.86±10.62 vs 4.13±12.92; p=0.001), and NLR (2.98±2.93 vs 1.68±3.60; p=0.025). No significant differences in MACE were observed between the two groups. This study highlighted that colchicine was associated with greater reductions in inflammatory markers during the early post-PCI period, although no significant difference in short-term clinical outcomes was identified. Larger prospective studies are needed to confirm these findings.
Association of interleukin-6 and C-reactive protein with in-hospital mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention Rachman, Adelia U.; Saputra, Firandi; Bagaswoto, Hendry P.; Setianto, Budi Y.
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3085

Abstract

Inflammation contributes substantially to the pathogenesis of acute coronary syndromes (ACS), and interleukin-6 (IL-6) and C-reactive protein (CRP) have been proposed as biomarkers of adverse outcomes. The aim of this study was to evaluate the associations of IL-6 and CRP with in-hospital mortality among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). This prospective cohort study enrolled adult patients with STEMI who underwent primary PCI at Dr. Sardjito General Hospital, Yogyakarta, Indonesia, in 2023. A single blood sample for IL-6 and CRP measurement was collected within 24 hours after PCI. In-hospital mortality was recorded during hospitalization. Receiver operating characteristic analysis identified optimal cut-off values, and multivariable logistic regression was performed to adjust for potential confounders. In-hospital mortality occurred in 6 patients (12.8%). In univariate analysis, higher IL-6 and CRP levels were associated with in-hospital mortality. IL-6 ≥84.60 pg/mL showed an area under the curve (AUC) of 0.776, sensitivity of 66.7%, and specificity of 82.9% (p=0.007), whereas CRP ≥31.35 mg/L showed an AUC of 0.748, sensitivity of 83.3%, and specificity of 68.3% (p=0.015). However, after adjustment for confounding variables in separate multivariable models, neither IL-6 nor CRP remained independently associated with in-hospital mortality. These findings indicate that although elevated IL-6 and CRP levels were associated with in-hospital mortality in unadjusted analyses, their independent prognostic value was not retained after accounting for other clinical and laboratory factors. Further studies with larger sample sizes are needed to clarify the role of these inflammatory biomarkers in risk stratification among patients with STEMI.
Translational evaluation of magnetized saline water combined with ciclopirox olamine and piroctone olamine against Malassezia species and scalp seborrheic dermatitis Rivetti, Nicolò; Lista, Simone; García-Chico, Celia; Khoramipour, Kayvan; Santos-Lozano, Alejandro; Minoretti, Piercarlo
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3090

Abstract

Yeasts of the Malassezia genus are implicated in numerous skin conditions, including seborrheic dermatitis, pityriasis versicolor, and folliculitis. While ciclopirox olamine (CPO) and piroctone olamine (OCT) are effective anti-Malassezia agents, the activity of magnetized water against pathogenic yeasts remains unclear. The aim of this study was to examine the in vitro efficacy of magnetized saline water (MSW), alone or combined with CPO plus OCT, against three Malassezia species (M. furfur, M. globosa, and M. restricta) using broth microdilution to determine minimal inhibitory concentrations (MICs). A proof-of-concept study evaluating a shampoo containing MSW 30% + CPO 0.5% + OCT 1.0% in 20 patients with scalp seborrheic dermatitis (SSD) was subsequently conducted. Participants applied the shampoo four times per week for 12 weeks; efficacy was assessed by changes in a validated 16-point SSD severity score. The triple combination demonstrated additive-to-synergistic activity, with MIC values of 3.91 mg/L across all three species, representing a 2.0- to 4.0-fold MIC reduction compared to CPO + OCT alone, and synergy (FIC=0.31) for M. furfur. The total SSD score decreased by 33.9% after 12 weeks (p<0.001), with improvements in pruritus (49.0%), erythema (54.3%), and scaling (24.2%); all p values remained significant after Bonferroni correction (α=0.0125). These findings support MSW as a vehicle to potentiate the anti-yeast activity of CPO and OCT while reducing the chemical load, potentially offering a novel strategy for Malassezia-associated skin disorders. The open-label, single-arm design limits causal attribution, and larger controlled trials are needed.
Global longitudinal strain and left ventricular ejection fraction for early detection of chemotherapy-related cardiac dysfunction in breast cancer: A prospective comparison of doxorubicin-based and paclitaxel–carboplatin regimens Faradilla, Rizka; Heriansyah, Teuku; Novita, Novita; Munirwan, Haris; Fitra, Maha
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3095

Abstract

Left ventricular ejection fraction (LVEF) is widely used in routine practice to assess cardiotoxicity; however, reductions in LVEF often reflect relatively advanced myocardial damage. Global longitudinal strain (GLS) quantifies myocardial deformation and has demonstrated greater sensitivity for identifying early systolic dysfunction, yet comparative evidence on myocardial strain changes between doxorubicin-based regimens and non-anthracycline chemotherapy in breast cancer patients remains limited. The aim of this study was to compare changes in left ventricular GLS and LVEF between breast cancer patients receiving doxorubicin-based chemotherapy and those treated with paclitaxel–carboplatin regimens. A prospective cohort study was conducted among 106 women with histopathologically confirmed breast cancer, who were allocated to receive either a doxorubicin-based regimen (n=53) or a paclitaxel–carboplatin regimen (n=53). Transthoracic echocardiography was performed within seven days before chemotherapy initiation and repeated after four months. Left ventricular GLS was measured using two-dimensional speckle-tracking echocardiography from apical views and analyzed offline using the 17-segment model. Baseline GLS values did not differ significantly between the doxorubicin and paclitaxel–carboplatin groups (−20.47±0.45 vs −20.38±0.53; p=0.410). After four months, GLS was significantly reduced in the doxorubicin group compared with the paclitaxel–carboplatin group (−15.04±0.35 vs −19.54±0.50; p<0.001). The change in GLS (ΔGLS) was also greater in the doxorubicin group (5.43±0.12 vs 0.84±0.11; p<0.001). No significant differences were observed in LVEF before chemotherapy (55.26±1.78 vs 55.39±1.99; p=0.720), after chemotherapy (51.32±1.51 vs 51.60±1.64; p=0.359), or in ΔLVEF (p=0.484). In conclusion, doxorubicin-based chemotherapy was associated with early subclinical systolic dysfunction detectable by GLS before measurable LVEF decline, whereas paclitaxel–carboplatin was associated with relatively preserved myocardial deformation. These findings support the incorporation of strain imaging into routine cardiac surveillance for earlier identification and management of chemotherapy-related myocardial injury.
Global tuberculosis incidence and its macrostructural determinants: A hybrid Explainable Boosting Machine–Bayesian Structural Equation Modeling analysis of socioeconomic, health system, and population-risk pathways Leonov Rianto; Gilang Al Qarana; Charles Charles; Yanthy Susanti
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3004

Abstract

Tuberculosis (TB) remains a leading infectious cause of mortality worldwide, with marked cross-country disparities shaped by socioeconomic conditions, health system capacity, and population-level risk factors. The aim of this study was to investigate the macrostructural determinants of global TB incidence and to clarify the pathways through which socioeconomic, health system, and population-risk domains are associated with TB incidence. Country-level secondary data were obtained from WHO, World Bank Open Data, and UNDP. A hybrid analytical framework was applied in two stages. First, EBM was used to identify non-linear predictor signals and rank the relative importance of macrostructural determinants of TB incidence. Second, the empirically derived predictors were translated into BSEM to estimate latent measurement structures and structural pathways toward TB burden. A total of 172 countries were included in the final analytical dataset. In the EBM phase, the strongest predictor signal was observed for Education Index, followed by diabetes prevalence, HIV incidence, TB case detection rate, BCG coverage, and physician density. These signals were subsequently mapped into three latent constructs: socioeconomic conditions, health system capacity, and population-level health risk. In the final BSEM model, socioeconomic showed the strongest association with health system capacity (β=0.62), indicating that stronger socioeconomic conditions were associated with greater TB-relevant service capacity. Health system was subsequently associated with lower TB incidence (β=-0.26). Direct associations with TB incidence were also observed for socioeconomic (β=-0.46) and health risk (β=-0.33), although the health risk pathway required cautious interpretation because of limited latent coherence at the country level. The final model explained a substantial proportion of cross-country variation in TB incidence (posterior R²=0.53). These findings indicate that the global TB burden is shaped by interconnected structural pathways rather than by a single macroeconomic gradient. Socioeconomic conditions appeared to influence TB burden primarily through health system capacity, particularly diagnostic reach, workforce availability, case detection, and immunization coverage. The hybrid EBM–BSEM framework provides an interpretable approach for identifying upstream determinants of TB burden and may support evidence-based prioritization of global TB prevention strategies.
Serum biomarkers associated with disease stage and pain severity among women with endometriosis in Indonesia Mustaqin Mustaqin; Rajuddin Rajuddin; Tgk. Puspa Dewi; Cut M. Yeni; Rusnaidi Rusnaidi; Rachmad Suhanda
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3082

Abstract

Endometriosis is a chronic estrogen-dependent disease characterized by the presence of endometrial-like tissue outside the uterine cavity, resulting in chronic inflammation, recurrent pain, and infertility, and affecting approximately 190 million women worldwide. Chronic inflammation in endometriosis may stimulate overexpression of cyclooxygenase-2 (COX-2), which catalyzes prostaglandin E2 production, whereas cancer antigen 125 (CA-125) is a glycoprotein biomarker released by endometrial and mesothelial cells in response to inflammatory processes. The aim of this study was to analyze the correlations between serum COX-2 and CA-125 levels and the degree of endometriosis, based on the revised American Society for Reproductive Medicine classification, and between these levels and pain severity, based on the Numeric Rating Scale. A cross-sectional study was conducted among patients with endometriosis at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. The levels of COX-2 and CA-125 were measured using enzyme-linked immunosorbent assay and chemiluminescence immunoassay, respectively. Spearman correlation and ordinal logistic regression were used for statistical analysis. The median age of the participants was 36 years (range: 19-51 years), and most patients had Stage IV endometriosis (78.6%). COX-2 showed a significant positive correlation with both the degree of endometriosis (r=0.526; p<0.001) and pain severity score (r=0.769; p<0.001). CA-125 also showed a significant positive correlation with the degree of endometriosis (r=0.433; p=0.004), but not with pain severity (r=0.256; p=0.102). Receiver operating characteristic curve analysis showed that COX-2 had good discriminative ability for severe endometriosis (AUC=0.865) and for severe pain (AUC=0.864). In the multivariable model, COX-2 and CA-125 were also significantly associated with pain severity. These findings suggest that COX-2 was more strongly associated with pain severity, whereas CA-125 was more closely related to the degree of endometriosis. Further studies with larger sample sizes and prospective designs are needed to validate these findings and clarify the clinical utility of these biomarkers in endometriosis management.
Correlation of nutritional status and anxiety with quality of life among ovarian cancer patients undergoing chemotherapy: A cross-sectional study at a provincial referral hospital in Indonesia Inong I. Meutia; Munizar Munizar; Ima Indirayani; Hanasuddin Hanasuddin; Rusnaidi Rusnaidi
Narra J Vol. 6 No. 2 (2026): August 2026
Publisher : Narra Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52225/narra.v6i2.3086

Abstract

Ovarian cancer and its treatment are associated with substantial physical and psychological burden, which may adversely affect patients’ quality of life (QoL). While nutritional status and psychological factors are both considered important determinants of QoL, their contributions in patients undergoing chemotherapy remain unclear. This study aimed to evaluate the correlation between nutritional status and anxiety level with QoL among patients with ovarian cancer undergoing chemotherapy. A cross-sectional study was conducted at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, in 2025. Nutritional status was assessed using body mass index (BMI) and serum albumin levels; anxiety was measured using the Zung Self-Rating Anxiety Scale (SAS); and QoL was evaluated using the EORTC QLQ-C30 questionnaire. Data were analyzed using Pearson correlation tests followed with multivariate linear regression test. A total of 101 patients with ovarian cancer undergoing chemotherapy were included in this study. Nutritional status indicators, BMI and serum albumin, were not significantly correlated with QoL across all domains, with very weak correlation coefficients (r=−0.165 to 0.097). In contrast, anxiety level demonstrated significant negative correlations with global health status (r=−0.426), physical function (r=−0.449), emotional function (r=−0.427), cognitive function (r=−0.337), and social function (r=−0.466) (all p<0.05), but not with role function. Multivariate analysis confirmed that anxiety was the only independent predictor of QoL across these domains, whereas BMI and serum albumin showed no significant association. These findings indicate that anxiety plays a more prominent role than nutritional status in determining QoL among patients with ovarian cancer undergoing chemotherapy. Routine screening and management of anxiety could be beneficial to be integrated into oncologic care to improve patient outcomes.

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