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Background Obesity disproportionally impacts rural, lower-income children in the United States. Primary care providers are well-positioned to engage parents in early obesity prevention, yet there is a lack of evidence regarding the most effective care delivery models. The ENCIRCLE study, a pragmatic cluster-randomized controlled trial, will respond to this gap by testing the comparative effectiveness of standard care well-child visits (WCV) versus two enhancements: adding a patient-reported outcome (PRO) measure (PRO WCV) and PRO WCV plus Food Care (telehealth coaching and a grocery store tour). Methods A total of 2,025 parents and their preschool-aged children (20–60 months of age) will be recruited from 24 Geisinger primary care clinics, where providers are randomized to the standard WCV, PRO WCV, or PRO WCV plus Food Care intervention arms. The PRO WCV includes the standard WCV plus collection of the PRO—the Family Nutrition and Physical Activity (FNPA) risk assessment—from parents. Parents complete the PRO in the patient-portal or in the clinic (own device, tablet, or kiosk), receive real-time feedback, and select priority topics to discuss with the provider. These results are integrated into the child’s electronic health record to inform personalized preventive counseling by providers. PRO WCV plus Food Care includes referrals to community health professionals who deliver evidence-based obesity prevention and food resource management interventions via telehealth following the WCV. The primary study outcome is change in child body mass index z-score (BMIz), based on the World Health Organization growth standards, 12 months post-baseline WCV. Additional outcomes include percent of children with overweight and obesity, raw BMI, BMI50, BMIz extended, parent involvement in counseling, health behaviors, food resource management, and implementation process measures. Discussion Study findings will inform health care systems’ choices about effective care delivery models to prevent childhood obesity among a high-risk population. Additionally, dissemination will be informed by an evaluation of mediating, moderating, and implementation factors. Trial registration ClinicalTrials.gov identifier (NCT04406441); Registered May 28, 2020.

Background/Objective Parents shape children’s early experiences with food, influencing what is served, children’s food choices, and how much children eat. Responsive parenting (RP) interventions such as INSIGHT have improved maternal infant feeding practices, but have only been tested among predominantly White families. This secondary analysis of data from the Sleep SAAF (Strong African American Families) RCT tests the effects of an RP intervention designed to prevent rapid infant weight gain on African American mothers’ infant feeding practices. Methods Primiparous African American mother-infant dyads (n = 194) were randomized to an RP or safety control intervention delivered by community research associates at infant age 3 and 8 weeks. At 16 weeks, mothers completed the Babies Need Feeding questionnaire, the Infant Feeding Styles Questionnaire, and the Babies Need Soothing questionnaire. Logistic regression and general linear models examined the effect of study group on infant feeding practices. Moderation analyses explored whether effects varied by feeding mode (any breast milk versus exclusive formula), maternal age (≥ 20 years versus Results RP mothers reported more responsive feeding (p = 0.005, partial η2 = 0.02), lower likelihood of using beverages other than breast milk/formula to soothe their infant (p = 0.01, OR = 0.42, 95% CI [0.2–0.8]), and less pressure with cereal than control mothers (p = 0.09, partial η2 = 0.02). RP mothers also reported less pressure to finish/soothe than controls (p = 0.007, partial η2 = 0.04); feeding mode (B = 0.74, p = 0.003) and maternal age (B = 0.53, p = 0.04) moderated this effect. There were no significant group differences in bottle-feeding practices (e.g., adding cereal to bottle, using an appropriate nipple/bottle size), or in context-based or emotion-based food to soothe. Conclusions Responsive parenting education influenced some feeding practices of African American mothers. Mothers reported using less pressure, a control-based feeding practice, and more responsive feeding than controls. Trial registration Sleep SAAF: A Strong African American Families Study. www.clinicaltrials.gov NCT03505203. Registered 3 April 2018.

PURPOSE: Water needs increase during pregnancy, and proper hydration is critical for maternal and fetal health. This study characterized weekly hydration status changes throughout pregnancy and examined change in response to a randomized, behavioral intervention. An exploratory analysis tested how underhydration during pregnancy was associated with birth outcomes. METHODS: The Healthy Mom Zone Study is a longitudinal, randomized-control trial intervention aiming to regulate gestational weight gain (GWG) in pregnant women with overweight/obesity (n=27). Fourteen women received standard of care; 13 women additionally received weekly guidance on nutrition, physical activity, water intake, and health-promoting behaviors. Hydration status was measured weekly via overnight urine osmolality (Uosm) from ~8–36 weeks gestation; underhydration was dichotomized (Uosm≥500 mOsm/kg). Gestational age- and sex-standardized birth weight and length z scores and percentiles were calculated. We used mixed-effect and linear regression models to test covariate-adjusted relationships. RESULTS: No differences existed in Uosm or other characteristics between control and intervention women at baseline. Significant interactions (p=0.01) between intervention and week of pregnancy on Uosm indicated intervention women maintained lower Uosm, whereas control women had a significant quadratic (inverse-U) relationship and greater Uosm in the second and early third trimesters. Results were consistent across robustness and sensitivity checks. Exploratory analyses suggest underhydration was associated with birth weight, but not length, in opposite ways in the second vs. third trimester. CONCLUSION: A multi-component behavioral intervention helped women with overweight/obesity maintain better hydration throughout pregnancy. Future studies should confirm birth outcome results as they have important implications for early life nutrition. Trial Registration ClinicalTrials.gov Identifier: NCT03945266; registered May 10, 2019 retrospectively

Interventions have modest impact on reducing excessive gestational weight gain (GWG) in pregnant women with overweight/obesity. This two-arm feasibility randomized control trial tested delivery of and compliance with an intervention using adapted dosages to regulate GWG, and examined pre-post change in GWG and secondary outcomes (physical activity: PA, energy intake: EI, theories of planned behavior/self-regulation constructs) compared to a usual care group. Pregnant women with overweight/obesity (N = 31) were randomized to a usual care control group or usual care + intervention group from 8 to 2 weeks gestation and completed the intervention through 36 weeks gestation. Intervention women received weekly evidence-based education/counseling (e.g., GWG, PA, EI) delivered by a registered dietitian in a 60-min face-to-face session. GWG was monitored weekly; women within weight goals continued with education while women exceeding goals received more intensive dosages (e.g., additional hands-on EI/PA sessions). All participants used mHealth tools to complete daily measures of weight (Wi-Fi scale) and PA (activity monitor), weekly evaluation of diet quality (MyFitnessPal app), and weekly/monthly online surveys of motivational determinants/self-regulation. Daily EI was estimated with a validated back-calculation method as a function of maternal weight, PA, and resting metabolic rate. Sixty-five percent of eligible women were randomized; study completion was 87%; 10% partially completed the study and drop-out was 3%. Compliance with using the mHealth tools for intensive data collection ranged from 77 to 97%; intervention women attended > 90% education/counseling sessions, and 68–93% dosage step-up sessions. The intervention group (6.9 kg) had 21% lower GWG than controls (8.8 kg) although this difference was not significant. Exploratory analyses also showed the intervention group had significantly lower EI kcals at post-intervention than controls. A theoretical, adaptive intervention with varied dosages to regulate GWG is feasible to deliver to pregnant women with overweight/obesity.

The anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of disorders involving severe, systemic, small-vessel vasculitis and are characterized by the development of autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). The three AAV subgroups, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis and eosinophilic GPA (EGPA), are defined according to clinical features. However, genetic and other clinical findings suggest that these clinical syndromes may be better classified as PR3-positive AAV (PR3-AAV), MPO-positive AAV (MPO-AAV) and, for EGPA, by the presence or absence of ANCA (ANCA+ or ANCA–, respectively). Although any tissue can be involved in AAV, the upper and lower respiratory tract and kidneys are most commonly and severely affected. AAVs have a complex and unique pathogenesis, with evidence for a loss of tolerance to neutrophil proteins, which leads to ANCA-mediated neutrophil activation, recruitment and injury, with effector T cells also involved. Without therapy, prognosis is poor but treatments, typically immunosuppressants, have improved survival, albeit with considerable morbidity from glucocorticoids and other immunosuppressive medications. Current challenges include improving the measures of disease activity and risk of relapse, uncertainty about optimal therapy duration and a need for targeted therapies with fewer adverse effects. Meeting these challenges requires a more detailed knowledge of the fundamental biology of AAV as well as cooperative international research and clinical trials with meaningful input from patients.

Calculations of electron-impact excitation cross sections for molecular hydrogen have been performed using spherical- and spheroidal-coordinate formulations of the molecular convergent close-coupling method. We present a comparison and find good agreement between the results of these two techniques performed within the fixed-nuclei approximation for excitation from the ground X1Σg+ (v = 0) state of H2 to the B1Σu+ , C 1Πu, B′1Σu+ , D 1Πu, EF1Σg+ , b3Σu+ , c3Πu+ , a3Σu+ , e3Σu+ , h3Σg+ , and d 3Πu states. For the spheroidal-coordinate approach the adiabatic-nuclei method has been applied, allowing for a more reliable estimate of cross sections at near-threshold energies. Comparison of the adiabatic-nuclei cross sections with the corresponding fixed-nuclei cross sections is also presented.

Background Peak bone mass accrual occurs during adolescence, a time when dieting and related eating behaviors are common. Impaired bone mineral accrual is a known consequence of eating disorders in adolescents, but the effects of subclinical dieting behaviors on bone mineral content (BMC) have not been described in this age group. The goal of this analysis was to determine whether dieting behavior in preadolescence and adolescence is associated with bone mineral accrual in adolescent girls. Methods Non-Hispanic white girls (n = 139) were followed in a longitudinal cohort study. BMC was assessed at ages 9 and 15y. Dieting to lose weight was reported every 2 years, and dietary restraint and disinhibition, eating attitudes, weight concerns, and body esteem were assessed at age 11y. Girls were classified as “early dieters” if they first dieted by age 11y (31.7%), “adolescent dieters” if they first dieted after 11y (46.8%), or non-dieters if they did not report dieting by 15 y (21.6%). The effect of dieting related variables on BMC at 15y and change in BMC from 9 to 15y was assessed using linear regression, controlling for height, weight, BMI, physical activity, and pubertal status. Results Girls who first reported dieting to lose weight by age 11y had a 4.2% lower bone mineral accrual across adolescence (p = 0.02) and 3.1% lower BMC at age 15y (p = 0.005) than girls who first reported dieting after 11y or not at all. Number of weight control behaviors used, dietary restraint, and weight concerns were also negatively associated with BMC (p

Current biomarkers of renal disease in systemic vasculitis lack predictive value and are insensitive to early damage. To identify novel biomarkers of renal vasculitis flare, we analysed the longitudinal urinary metabolomic profile of a rat model of anti-neutrophil cytoplasmic antibody (ANCA) vasculitis. Wistar-Kyoto (WKY) rats were immunised with human myeloperoxidase (MPO). Urine was obtained at regular intervals for 181 days, after which relapse was induced by re-challenge with MPO. Urinary metabolites were assessed in an unbiased fashion using nuclear magnetic resonance (NMR) spectroscopy, and analysed using partial least squares discriminant analysis (PLS-DA) and partial least squares regression (PLS-R). At 56 days post-immunisation, we found that rats with vasculitis had a significantly different urinary metabolite profile than control animals; the observed PLS-DA clusters dissipated between 56 and 181 days, and re-emerged with relapse. The metabolites most altered in rats with active or relapsing vasculitis were trimethylamine N-oxide (TMAO), citrate and 2-oxoglutarate. Myo-inositol was also moderately predictive. The key urine metabolites identified in rats were confirmed in a large cohort of patients using liquid chromatography–mass spectrometry (LC-MS). Hypocitraturia and elevated urinary myo-inositol remained associated with active disease, with the urine myo-inositol:citrate ratio being tightly correlated with active renal vasculitis.

Background Emerging approaches to building more efficient and effective behavioral interventions are becoming more widely available. The current paper provides an empirical example of the use of the engineering-inspired multiphase optimization strategy (MOST) to build a remotely delivered responsive parenting intervention to prevent obesity among children of low-income mothers with and without depressive symptoms. Methods Participants were 107 mothers with (n = 45) and without (n = 62) depressive symptoms who had a child aged 12 to 42 months participating in the Women, Infants and Children program. Participants were randomized to one of sixteen experimental conditions using a factorial design that included a combination of the following eight remotely delivered intervention components: responsive feeding curriculum (given to all participants), parenting curriculum, portion size guidance, obesogenic risk assessment, personalized feedback on mealtime routines, feeding curriculum counseling, goal setting, mobile messaging, and social support. This design enabled efficient identification of components with low feasibility and acceptability. Results Completion rates were high (85%) and did not statistically differ by depressive symptoms. However, mothers with depressive symptoms who received obesogenic risk assessment and personalized feedback on mealtime routines components had lower completion rates than mothers without depressive symptoms. All intervention components were feasible to implement except the social support component. Regardless of experimental condition, most participants reported that the program increased their awareness of what, when, and how to feed their children. Conclusions MOST provided an efficient way to assess the feasibility of components prior to testing them with a fully powered experiment. This framework helped identify potentially challenging combinations of remotely delivered intervention components. Consideration of how these results can inform future studies focused on the optimization phase of MOST is discussed.

Dysregulated release of neutrophil azurophilic granules causes increased tissue damage and amplified inflammation during autoimmune disease. Antineutrophil cytoplasmic antibodies (ANCAs) are implicated in the pathogenesis of small vessel vasculitis and promote adhesion and exocytosis in neutrophils. ANCAs activate specific signal transduction pathways in neutrophils that have the potential to be modulated therapeutically to prevent neutrophil activation by ANCAs. We have investigated a role for diacylglycerol kinase (DGK) and its downstream product phosphatidic acid (PA) in ANCA-induced neutrophil exocytosis. Neutrophils incubated with the DGK inhibitor R59022, before treatment with ANCAs, exhibited a reduced capacity to release their azurophilic granules, demonstrated by a component release assay and flow cytometry. PA restored azurophilic granule release in DGK-inhibited neutrophils. Confocal microscopy revealed that R59022 did not inhibit translocation of granules, indicating a role for DGK during the process of granule fusion at the plasma membrane. In investigating possible mechanisms by which PA promotes neutrophil exocytosis, we demonstrated that exocytosis can only be restored in R59022-treated cells through simultaneous modulation of membrane fusion and increasing cytosolic calcium. PA and its associated pathways may represent viable drug targets to reduce tissue injury associated with ANCA-associated vasculitic diseases and other neutrophilic inflammatory disorders.

Chronic kidney disease is a proinflammatory state associated with increased arterial stiffness. We hypothesized that chronic kidney disease patients on long-term immunosuppression would have lower arterial stiffness and require treatment with less antihypertensive medication compared with non-immunosuppressed patients. A total of 254 patients (97 on immunosuppression) with chronic kidney disease were recruited from specialist renal clinics. Brachial blood pressure, central aortic pressure and waveform and pulse wave velocity were measured. Age, peripheral blood pressure and pulse wave velocity increased with worsening renal function but were not different between immunosuppressed and non-immunosuppressed patients. Central systolic (P < 0.001) and pulse pressure (P = 0.003) and the number of antihypertensive medications (P < 0.001) increased with worsening renal function and were higher in non-immunosuppressed patients (P = 0.02, P = 0.004 and P < 0.001, respectively). Age, mean arterial pressure, number of antihypertensive medications and a diagnosis of diabetes were found to be independent predictors of pulse wave velocity (R(2) = 0.375; P < 0.001). In a subgroup of 30 patient pairs without diabetes mellitus and cardiovascular disease and with a proven renal diagnosis, carefully matched for age, gender, renal function and systolic pressure, the prescribed antihypertensive medication remained lower in the immunosuppressed patients compared with non-immunosuppressed patients (P = 0.04). Pulse wave velocity was lower in the immunosuppressed group (7.5 ± 1.8 vs. 8.8 ± 1.9 m s(-1); P = 0.02). This study suggests that immunosuppression might be a method of reducing blood pressure and arterial stiffness in patients with chronic kidney disease.

Anti-neutrophil cytoplasmic antigen antibody (ANCA)-associated disease is a rare manifestation of primary systemic vasculitis in paediatric patients but one that carries significant morbidity, potential long-term disability and early mortality. It therefore requires a high index of suspicion, targeted investigation, prompt treatment and long-term follow-up with specialist input at every stage. The well-recognised diversity and overlap in clinical, laboratory and histopathological features of the ANCA-associated systemic vasculitides continue to hamper accurate diagnosis, confounding epidemiological data and necessitating a blanket approach to treatment, which is largely extrapolated from studies in adult patients and carries significant side-effects. Herein we summarise current knowledge of the epidemiology, pathogenesis, principal manifestations, investigation and evidence-based management, extrapolated from adult studies, of these disorders. We also discuss recent efforts towards classification of the childhood vasculitides that emphasise the value of histological diagnosis. Progress in our understanding of the pathophysiology underlying ANCA-associated disease should lead to targeted, safer and more effective therapies for these conditions. Nonetheless, many questions remain outstanding, and academic paediatricians face real challenges in identifying and collating the few cases they encounter into study cohorts. Meeting this challenge will require international collaboration, not only among paediatricians but also with the specialists taking over care of these patients as they reach adulthood.

Theories of postformal thought (PFT) suggest that cognitive development is enhanced by social interactions where differences must be negotiated. Friendships provide the potential for complex social interactions and are an ideal context in which to explore the relation between cognitive development and the negotiation of social differences. The present research is the first to directly explore the relation between close cross-category friendships and level of postformal cognitive reasoning among college students. Participants from two universities completed questionnaires assessing PFT and friendship characteristics. Results indicate that individuals reported more same-category versus cross-category friendships. This was true for sex, ethnicity, social class, sexual orientation, and age. In addition, individuals high in PFT had more social category differences in their existing close friendships than individuals low in PFT.

There is currently no biochemical test for detection of early-stage osteoarthritis (eOA). Tests for early-stage rheumatoid arthritis (eRA) such as rheumatoid factor (RF) and anti–cyclic citrullinated peptide (CCP) antibodies require refinement to improve clinical utility. We developed robust mass spectrometric methods to quantify citrullinated protein (CP) and free hydroxyproline in body fluids. We detected CP in the plasma of healthy subjects and surprisingly found that CP was increased in both patients with eOA and eRA whereas anti–CCP antibodies were predominantly present in eRA. A 4-class diagnostic algorithm combining plasma/serum CP, anti-CCP antibody and hydroxyproline applied to a cohort gave specific and sensitive detection and discrimination of eOA, eRA, other non-RA inflammatory joint diseases and good skeletal health. This provides a first-in-class plasma/serum-based biochemical assay for diagnosis and type discrimination of early-stage arthritis to facilitate improved treatment and patient outcomes, exploiting citrullinated protein and related differential autoimmunity.

Two experiments investigated the spontaneous construction of precursory logicomathematical operations by human-enculturated and language-reared chimpanzees (Pan troglodytes, Pan paniscus) when they were interacting freely with objects. In experiment 1, three chimpanzees ranging in age from 6 to 18 years were presented with sets of six objects. Chimpanzees constructed equivalence, order and reversibility relations within single sets of objects as well as between two or three contemporaneous sets of objects. The chimpanzees’ logicomathematical operations were more advanced, including infrequent and minimal operations on three sets, than those of some previously investigated younger nonenculturated common chimpanzees. In experiment 2, six chimpanzees ranging in age from 6 to 21 years were presented with sets of 12 objects. Chimpanzees constructed more advanced operations on single sets, but not on contemporaneous sets. The results suggest partial convergence and partial divergence between development of logicomathematical cognition in chimpanzees and humans.

Wirebonding is the weakest area of device packaging of power IGBT modules. Accelerated thermal fatigue testing causes cracks to form and propagate in the aluminum wirebond at the foot area. This study examined the relationship of the wirebond reliability and the aluminum wire grain structure, which can be affected by post‐wirebond heat treatment. A series of wirebonded IGBTs were annealed at a temperature range from 280°C to 400°C for up to 60 minutes. Wirebond shear strengths versus temperature cycles were examined. Cross‐sectional SEM was used to examine both aluminum grain size development by annealing and crack initiation and propagation in the wirebonds after temperature cycling. It was found that aluminum grain size was increased by post‐wirebond annealing. With temperature cycling, the wirebond shear strengths of the as‐wirebonded samples decrease rapidly, and lifted wirebonds were present after 1500 temperature cycles. The lifted wirebonds typically break within the aluminum wire near the wire/metallization interface. The shear strength of the wirebonds with post‐wirebond annealing showed no significant change even after 5000 temperature cycles, and there were no signs of significant deterioration of the wirebonds either. The wirebond crack initiation and growth rates were depressed substantially by larger aluminum grains. Annealing of the aluminum wire after wirebonding provided increased aluminum grain size resulting in improved reliability of the wirebonds of high power modules.

This benchmark study examined the effect of four different backmetal/ leadframe schemes on the time to failure from autoclave testing for surface mount, small signal transistors in the SC59 package configuration. The four schemes examined included die with Au backmetal bonded to a Cu plated Alloy 42 leadframe, Au backmetal bonded to a Ag striped, Ni plated, Cu plated alloy 42 leadframe, Au backmetal with a thin, permeable Ni layer bonded to a Ag striped, Ni plated Cu leadframe and V/Ni/AuGe/Au backmetal bonded to a Cu leadframe. Devices with AuSi eutectic bonded directly to the Cu plated Alloy 42 leadframe separated between the Si die and the AuSi eutectic after 240 hours of autoclave testing which produced VCESAT failures. Identical devices bonded to Ag striped, Ni plated, Cu plated Alloy 42 leadframes had the same failure mechanism after 624 hours of autoclave testing. Adding a permeable Ni layer to the AuSi eutectic structure and bonding to a Ag striped, Ni plated Cu leadframe increased the lifetime to 744 hours but still produced the same failure mechanism. Devices using a V/Ni/AuGeJAu bonded to a Cu leadframe remained electrically good and physically intact after 864 hours of autoclave testing. These results indicate the use of leadframe plating and/or backmetal barrier metals is needed in order to produce devices that can withstand extended reliability testing.

The microstructure evolution during preparation of thin Si(111) samples for surface sensitive imaging has been studied using ultra-high vacuum (UHV) transmission electron microscopy (TEM). The effects of ion beam sputtering and electron annealing have been investigated. A unique and routine sample preparation method for surface sensitive TEM imaging that combines TEM sample preparations with surface science sample preparation was developed. The microstructure evolution during the sample preparation process was studied in detail.

The effects of pulsed laser irradiation on silicon (111) single crystal thin samples were studied in a ultra-high vacuum transmission electron microscope. Samples were found to cleave along (110) planes under the laser beam. The formation of dislocation networks was also observed. The cleaving did not seem to originate from previously observed defect areas, but from random places, and is believed to be caused by thermal shock from laser beam heating. Bulk defects in the specimens, such as stacking fault tetrahedra and dislocations, were not observed to be affected by the laser treatment.

In the absence of analytical reference standards, the combination of thermospray and collision-activated dissociation mass spectrometry has been utilized to separate and identify the presence of several esters of testosterone in imported oil injectables. Structural identifications were based on generic daughter ions considered diagnostic of the steroidal ring structure of these anabolic steroids as well as daughter ions representative of the ester alkyl or aryl side chains

Two children with Alport's syndrome are described, who developed anti-glomerular basement membrane (GMB) antibody-mediated nephritis after renal transplantation. The reactivity of antibodies in their serum with collagenase-solubilized normal GBM was examined by SDS-PAGE with one- and two-dimensional immunoblotting. The specificity was compared with that of antibodies present in serum from a patient with Goodpasture's syndrome, and a mouse monoclonal antibody (MCA-P1), directed against the Goodpasture antigen. All reacted in a similar way with collagenase-solubilized GBM. Since abnormalities in the composition of the GBM are present in Alport's syndrome, it is proposed that differing antigen composition of GBM in the host compared with the donor kidney, together with transplant rejection, may have provoked the development of post-transplant anti-GBM antibodies.

This paper summarizes a videotaped presentation (Rumbaugh, Savage-Rumbaugh, Hopkins, Washburn,Runfeldt, 1987) of computerized training programs whereby an adult female chimpanzee, Lana (Pan troglodytes), learned to use a joystick to remove from a screen the number of boxes appropriate to the value of a randomly selected Arabic numeral 1, 2, or 3. Initial training provided a variety of cues, both numeric and otherwise, to support correct performance. Across software programs, all cues other than numeric ones were deleted. In the final test, Lana was correct on over 80% of trials in which there was no residual feedback of intratrial events and where only her memory of those events could provide the cue to indicate that she had removed boxes in accordance with the value of the target numbers and should terminate the trial. The tape is narrated and consists of video recordings of Lana's performance on each software program.