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Urology

Is Dextranomer/Hyaluronic Acid an Effective Bladder Neck Bulking Agent for Patients with Persistent Incontinence Following Bladder Neck Reconstruction?
 Is Dextranomer/Hyaluronic Acid an Effective Bladder Neck Bulking Agent for Patients with Persistent Incontinence Following Bladder Neck Reconstruction? 1024 575 Pam Georgiana
By:
Dr. Jayanthi standing in OR

Urinary incontinence caused by bladder neck incompetence is common in children diagnosed with neurogenic bladder. Many patients undergo surgery to increase bladder outlet resistance to incontinence, but some still experience it even after surgery. Endoscopic injection of bulking agents has previously been utilized and studied for use in the bladder neck as follow-up treatment for…

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Developing Predictive Tools for CAKUT
 Developing Predictive Tools for CAKUT 1024 575 Leslie Feldman
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Pediatric nephrologists routinely see infants and children with congenital anomalies of the kidney and urinary tract (CAKUT) — the most frequent cause of childhood chronic kidney disease (CKD). Some of these anomalies are not clinically significant, while others result in varying degrees of kidney function impairment. Half of all children receiving dialysis or kidney transplants…

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Exploring the Clinical Journey of Children With Primary Hyperoxaluria
 Exploring the Clinical Journey of Children With Primary Hyperoxaluria 150 150 JoAnna Pendergrass, DVM
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Children with primary hyperoxaluria, a rare genetic disease, navigate a complicated clinical journey that includes a heavy reliance on health care services and usage of multidisciplinary care. Primary hyperoxaluria (PH) is a rare disease caused by genetic mutations of enzymes that regulate hepatic glyoxylate metabolism, leading to oxalate overproduction. The excess oxalate is excreted by…

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Safe, Minimally Invasive Upper Urinary Tract Surgery for Infants
 Safe, Minimally Invasive Upper Urinary Tract Surgery for Infants 1024 575 Patti Doud
By:
small baby with nose canula

Evidence supports robotic surgery as a safe approach to upper urinary tract procedures in infants 6 months or younger. While robotic surgery has risen in popularity and feasibility for procedures in both older children and adults alike, there has been little data to determine whether it’s a safe possibility for young children and infants. But…

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Investigating Caregiver Disclosure of Pediatric Urologic Surgery
 Investigating Caregiver Disclosure of Pediatric Urologic Surgery 1024 575 Mary Bates, PhD
By:
Toddler playing with toys

A survey reveals most caregivers plan to disclose urologic surgery to their child but would like more guidance from providers. Some pediatric urologic surgeries are performed early in childhood and with short-term follow-up. When children have surgery before the age of memory formation, it is up to their caregiver to disclose this surgery to them.…

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Intraoperative Evaluation of Penile Blood Flow During Bladder Exstrophy
 Intraoperative Evaluation of Penile Blood Flow During Bladder Exstrophy 150 150 Mary Bates, PhD
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Laser angiography technology allows for real-time measurements of penile perfusion during exstrophy repair operations. In a new pilot study, researchers from the Pediatric Urology Midwest Alliance (PUMA) demonstrated that intraoperative laser angiography is a safe and easy method to evaluate penile perfusion during bladder exstrophy closure. The optimal technique for repair of bladder exstrophy in…

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Reducing Opioid Prescriptions for Common Pediatric Urologic Procedures
 Reducing Opioid Prescriptions for Common Pediatric Urologic Procedures 1024 682 JoAnna Pendergrass, DVM
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smiling baby being held up by an adult

To address the national opioid epidemic, clinician-scientists developed a quality improvement initiative to achieve significant, long-term reductions in opioid prescriptions after common pediatric urologic procedures.   Opioids are commonly prescribed for pediatric urologic procedures. However, studies have reported a troubling practice of overprescribing opioids in pediatric health, contributing to the ongoing opioid epidemic. “There is…

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Proteins as Antibiotic Alternatives for Urinary Tract Infections
 Proteins as Antibiotic Alternatives for Urinary Tract Infections 1024 682 Emily Siebenmorgen
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Antibiotic-resistant bacteria have made treating common infections challenging. In a new study from Nationwide Children’s Hospital, published in the Proceedings of the National Academy of Science (PNAS), researchers demonstrate a way to boost the body’s production of antimicrobial peptides, which may provide an alternative to antibiotic use. With the rise of in antibiotic resistant infections, finding treatment…

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Featured Researcher — Linda Baker, MD
 Featured Researcher — Linda Baker, MD 150 150 Natalie Wilson
By:

Linda Baker, MD, a renowned expert in prune belly syndrome (PBS), joined Nationwide Children’s as a research director and principal investigator in the Kidney and Urinary Tract Center and The Ohio State University as a clinical professor of Urology at the end of 2022. Dr. Baker has met, evaluated and cared for over 180 children…

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5 Things to Know About Prune Belly Syndrome
 5 Things to Know About Prune Belly Syndrome 1024 683 Abbie Miller
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Linda Baker, MD

Linda Baker, MD, urologist, principal investigator, and one of the world’s foremost experts on prune belly syndrome, recently joined Nationwide Children’s Hospital as the co-director of the Kidney and Urinary Tract Center. She shares some important things to know about this rare disease. 1. Prune belly is a rare, congenital malformation. Prune belly syndrome (PBS)…

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Real-World Urinary Management and Outcomes in Cloacal Exstrophy Among Children and Adults
 Real-World Urinary Management and Outcomes in Cloacal Exstrophy Among Children and Adults 1024 683 Jessica Nye, PhD
By:
Molly Fuchs, MD

Most (94%) older children and adults with cloacal exstrophy are managed by incontinent diversion or clean intermittent catheterization. “The published literature about cloacal exstrophy can be misleading, and there is an impression that with surgical bladder reconstruction, normal bladder function and voiding can be restored. That is to say, a child will be able to…

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Bowel Management Program Improves Urinary Symptoms Associated with Pediatric Functional Constipation
 Bowel Management Program Improves Urinary Symptoms Associated with Pediatric Functional Constipation 150 150 JoAnna Pendergrass, DVM
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A one-week bowel management program can significantly improve urinary symptoms in children with functional constipation, possibly eliminating the need for extensive urologic testing. Molly Fuchs, MD, a urologist at Nationwide Children’s Hospital, and her research team recently demonstrated that a bowel management program (BMP) significantly improved urinary symptoms in children with functional constipation. Functional constipation…

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When Functional Outcomes Are Achieved Post-Op, Do Patients and Families Care About Scarring?
 When Functional Outcomes Are Achieved Post-Op, Do Patients and Families Care About Scarring? 1024 683 Abbie Miller
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A recent editorial from Dr. Daniel DaJusta questions whether cosmetic concerns after surgery are primarily driven by surgeons, patients or parents. It is widely accepted that having a smaller, neater or less visible scar following surgery is a preferable cosmetic outcome to a large, ragged or highly visible scar. This is supported anecdotally by surgeons,…

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Which Surgical Approach for Catheterizable Channels in Bowel and Bladder Management Is Best?
 Which Surgical Approach for Catheterizable Channels in Bowel and Bladder Management Is Best? 150 150 Jessica Nye, PhD
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Specific patient characteristics, such as appendix size, may help guide clinicians when deciding which surgical approach to use for patients in need of catheterizable channels for bladder and bowel management. Many patients with neurologic disorders experience urinary and fecal incontinence. The appendix or the transverse ileal tube can be repurposed as a catheterizable channel to…

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Practical, At-Home Parasacral Nerve Stimulation for Overactive Bladder in Children
 Practical, At-Home Parasacral Nerve Stimulation for Overactive Bladder in Children 150 150 Mary Bates, PhD
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A new regimen for parasacral transcutaneous electrical nerve stimulation (TENS) is manageable and results in subjective improvements, though objective improvements were modest. In a new study, researchers from Nationwide Children’s evaluated the effectiveness of a practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for children with overactive bladder. Parasacral TENS involves electrical stimulation…

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From 1 to 1,000: How Robotic Technology Has Brought Surgeons Together at Nationwide Children’s Hospital
 From 1 to 1,000: How Robotic Technology Has Brought Surgeons Together at Nationwide Children’s Hospital 1024 683 Marc Michalsky, MD, MBA, Karen Diefenbach, MD, Molly Fuchs, MD and Daniel DaJusta, MD
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This month marks an important milestone for patients receiving care at Nationwide Children’s Hospital in Columbus, Ohio: the completion of our 1,000th minimally invasive case using the DaVinci Robotic System. Nationwide Children’s was one of the first large children’s hospitals in the country to acquire a robotic system (2013) and like many, the decision was…

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High Rate of Urologic Anomalies in Children With Anorectal Malformations
 High Rate of Urologic Anomalies in Children With Anorectal Malformations 150 150 Lauren Dembeck
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Early recognition of urologic problems through proactive screening and urologic collaboration may help prevent of renal deterioration and allow for timely treatment in this population.   Researchers at Nationwide Children’s Hospital have recently demonstrated that urologic anomalies occur at a high rate in children with anorectal malformations and appear to increase in frequency with increasing…

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Kidney and Urinary Tract Protein Demonstrates Antimicrobial Activity
 Kidney and Urinary Tract Protein Demonstrates Antimicrobial Activity 1024 683 Lauren Dembeck
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A little-studied peptide found in the urinary tract is a potential biomarker for urinary tract infection risk and could be developed into a novel therapeutic against drug-resistant bacteria.  Researchers at Nationwide Children’s Hospital have demonstrated that an understudied protein expressed in the human kidney and bladder kills the bacteria that cause urinary tract infections (UTI).…

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Featured Researcher — Leena Nahata, MD
 Featured Researcher — Leena Nahata, MD 150 150 Natalie Wilson
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Pediatric endocrinologist Leena Nahata, MD, is the founder and medical director of the Fertility and Reproductive Health Program at Nationwide Children’s Hospital and a principal investigator in the Center for Biobehavioral Health at the Abigail Wexner Research Institute at Nationwide Children’s. Although fertility-related decisions can seem far away for children, adolescents and their families, many…

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Robotic Surgery Is Here to Stay
 Robotic Surgery Is Here to Stay 150 150 Abbie Miller
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A recent publication describes increases in the use of robotic surgery in children’s hospitals across the country.  The use of robotic surgery in tertiary children’s hospitals has been on the rise since the 2000s. In a recent publication, researchers from Nationwide Children’s Hospital sought to characterize the use and growth in acceptance of robotic surgeries…

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Does Twinkle Artifact on Ultrasound Indicate a Kidney Stone in Pediatric Patients?
 Does Twinkle Artifact on Ultrasound Indicate a Kidney Stone in Pediatric Patients? 150 150 Mary Bates, PhD
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The presence of twinkle artifact on ultrasound is a useful, though imperfect, tool for diagnosing kidney stones in children. For pediatric patients, ultrasound is the recommended imaging modality used to diagnose kidney stones. Several findings are used to identify stones on ultrasound, including the presence of an echogenic focus, posterior acoustic shadowing, or twinkle artifact.…

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A New Kind of Rectal Diversion in Classic Bladder Exstrophy
 A New Kind of Rectal Diversion in Classic Bladder Exstrophy 1024 754 Jeb Phillips
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  This article appeared in the Spring/Summer 2021 print issue. Download the full issue.   Medical illustrations by Mandy Root-Thompson for Nationwide Children’s Hospital Source: V. Rama Jayanthi, chief of Urology at Nationwide Children’s Hospital To learn more about the procedure and it’s applications, read A Surprising Approach to Classic Bladder Exstrophy.

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Girls’ Perineal Microbiomes Change Over Development, After Urinary Tract Infection
 Girls’ Perineal Microbiomes Change Over Development, After Urinary Tract Infection 150 150 Mary Bates, PhD
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Next-generation sequencing reveals different flora associated with developmental milestones in girls, as well as disruptions in patients with a history of urinary tract infection. In a new pilot study, researchers from Nationwide Children’s Hospital evaluated the microbiomes of girls at specific developmental timepoints. They found shifts in the perineal microbiome corresponding with important developmental milestones,…

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Does Psychosocial Functioning Differ Among Children With and Without Differences of Sex Development?
 Does Psychosocial Functioning Differ Among Children With and Without Differences of Sex Development? 1024 575 Lauren Dembeck
By:
Parent and child holding hands

A multidisciplinary team of researchers recently found that children with differences of sex development (DSD) appear to be at greater risk for psychosocial problems relative to children with cleft lip and/or palate (CL/P) and unaffected peers. The study, which was published in the Journal of Pediatric Psychology, highlights the increased need for integrated interdisciplinary care with…

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Novel Roles of the Urothelium in the Development of Congenital Anomalies of the Kidney and Urinary Tract
 Novel Roles of the Urothelium in the Development of Congenital Anomalies of the Kidney and Urinary Tract 150 150 Lauren Dembeck
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In addition to genetic defects, interactions of the developing urothelium with its underlying mesenchyme and superficial plaque may contribute to congenital anomalies of the kidney and urinary tract. Congenital anomalies of the kidney and urinary tract (CAKUTs) are the leading cause of chronic and end-stage kidney disease in children. Collaborative translational research at Nationwide Children’s…

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An Imbalance of Immune Cells Leads to Kidney Scarring After Infection
 An Imbalance of Immune Cells Leads to Kidney Scarring After Infection 1024 732 Mary Bates, PhD
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In a preclinical mouse model, researchers identify the immune cell balancing act that determines whether renal scarring will occur following kidney infection More than half of urinary tract infections in children spread from the bladder to the kidneys, causing acute kidney infections that can lead to renal scarring. Renal scarring can have serious repercussions in…

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Do Surgical Outcomes Differ Between Minimally Invasive Pyeloplasty Procedures in Treating Ureteropelvic Junction Obstruction?
 Do Surgical Outcomes Differ Between Minimally Invasive Pyeloplasty Procedures in Treating Ureteropelvic Junction Obstruction? 1024 575 JoAnna Pendergrass, DVM
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Dr. Jayanthi standing in OR

Minimally invasive pyeloplasty has become increasingly popular over open dismembered pyeloplasty, the traditional treatment for ureteropelvic junction obstruction. Robotic-assisted pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) are minimally invasive procedures that produce smaller scars and less postoperative pain. These are advantages that appeal to parents of patients undergoing these procedures. In a recent Journal of Pediatric Urology publication, Rama…

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Does Low Baseline Renal Volume Lead to Renal Insufficiency in Children With Cloacal Anomalies?
 Does Low Baseline Renal Volume Lead to Renal Insufficiency in Children With Cloacal Anomalies? 1024 683 Lauren Dembeck
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According to the results of a recent study published in Urology, children with cloacal anomalies have baseline renal volumes similar to those of children without cloacal anomalies, indicating that the increased risk of renal insufficiency in children with cloacal anomalies appears to be due to postnatal renal injury. “Before we can determine if surgical interventions or…

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Can a Kidney Failure Risk Equation Validated in Adults Predict Kidney Failure in Children?
 Can a Kidney Failure Risk Equation Validated in Adults Predict Kidney Failure in Children? 1024 575 Lauren Dembeck
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Novel disease-specific biomarkers are needed to improve prediction models in pediatric disease. Obstructive uropathy is a frequent cause of kidney injury in children, and it is estimated to cause approximately one-sixth of pediatric kidney failure cases in North America. However, risk equations to predict kidney disease progression have not yet been developed for children. To…

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Determining Ureteropelvic Junction Obstruction Surgical Success Using Biomarkers
 Determining Ureteropelvic Junction Obstruction Surgical Success Using Biomarkers 1024 575 Katie Brind'Amour, PhD, MS, CHES
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Biomarkers initially found to differ among patients with ureteropelvic junction obstruction and healthy controls may also objectively gauge post-surgical resolution of obstruction. A follow-up study of a trial that initially identified four biomarkers that differ between healthy controls and pediatric patients about to undergo surgery for ureteropelvic junction obstruction (UPJO) has confirmed that two of…

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Improving the Care and Management of Urinary Tract Infections Through Collaboration
 Improving the Care and Management of Urinary Tract Infections Through Collaboration 150 150 JoAnna Pendergrass, DVM
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The Urinary Tract Infection Global Alliance (UTIGA) is a new professional society that is dedicated to combatting the many challenges in UTI management and care through collaboration. With nearly 150 million people affected by urinary tract infections (UTIs) annually across the globe, UTIs are a major health problem. Both the term ‘UTI’ and the infection’s…

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Transforming Medical Science Through Research Affinity Groups
 Transforming Medical Science Through Research Affinity Groups 150 150 Katie Brind'Amour, PhD, MS, CHES
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Purposeful synergy drives the most meaningful medical science. Nephrology physician-scientists require tissue samples, urologists desire tests to know which patients truly require surgery, and basic scientists must find ways to meaningfully assess new animal models to yield clinically valuable data. If each of these professionals had a defined network of colleagues from the other disciplines…

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Keeping Options Open in Complex Pediatric Nephrolithiasis
 Keeping Options Open in Complex Pediatric Nephrolithiasis 1024 575 Lauren Dembeck
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Urologists in the Pediatric Urology Midwest Alliance recently looked at how endoscopic assisted robotic pyelolithotomy could reduce the number of procedures for children with ureteropelvic junction obstruction. The Pediatric Urology Midwest Alliance (PUMA) recently published a new report demonstrating that endoscopic assisted robotic pyelolithotomy (EARP) is an acceptable treatment option for complex cases of pediatric…

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Answers to Burning Questions About Pediatric Urinary Tract Infections
 Answers to Burning Questions About Pediatric Urinary Tract Infections 1024 683 Abbie Miller
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Nationwide Children’s urologists and nephrologists recently co-hosted a Twitter chat for primary care providers, answering common questions about pediatric urinary tract infections (UTIs). Below is a summary of the questions and answers, adapted for brevity and clarity. Q: What causes UTIs in children? A: UTIs are typically caused by uropathogenic E. coli bacteria that invade the urinary…

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What Are Long-Term Outcomes for a Child With Bladder Exstrophy?
 What Are Long-Term Outcomes for a Child With Bladder Exstrophy? 1024 575 Kevin Mayhood
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A study from the Pediatric Urology Midwest Alliance (PUMA) suggests the condition requires lifelong management for most children with bladder exstrophy. Half of infants with classic bladder exstrophy (BE) undergo bladder augmentation or diversion by age 10 and the percentage increases with age, a 36-year retrospective study from five Midwestern children’s hospitals shows. Whether they…

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Predicting Urinary Continence For a Child With Anorectal Malformation
 Predicting Urinary Continence For a Child With Anorectal Malformation 150 150 Kevin Mayhood
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Researchers suggest objective, measurable factors can be used to provide families with reasonable expectations In a child born with an anorectal malformation (ARM), anatomical features including a low-complexity ARM, high sacral ratio and a normal spine each independently predicts the child has a higher chance of urinary continence, research at Nationwide Children’s Hospital shows. “When…

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Multicenter Data Reveals Distal Hypospadias Repair Overall Success Rate
 Multicenter Data Reveals Distal Hypospadias Repair Overall Success Rate 150 150 Katie Brind'Amour, PhD, MS, CHES
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Despite its use as an indicator of a department’s surgical skill, the reoperation rate for distal hypospadias repair has long been based on publications covering data from single-center studies — until now. Among its indicators for urologic surgery quality, U.S. News & World Report examines the complication rate for children undergoing distal hypospadias repair (relocation of the…

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In Defense Against Peritonitis, Antimicrobial Peptides May Help on Multiple Fronts
 In Defense Against Peritonitis, Antimicrobial Peptides May Help on Multiple Fronts 150 150 Kevin Mayhood
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Study suggests AMPs have potential as biomarkers for peritonitis, risk stratification and treatment. Antimicrobial peptides (AMPs) in the Ribonuclease A Superfamily exhibit distinct patterns when children and adults undergoing chronic peritoneal dialysis (PD) suffer from peritonitis, researchers have found. The findings, published in Scientific Reports, suggest that AMPs in peritoneal fluid are potentially useful as…

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Research Collaborative Improves Outcome Prediction in Children With Posterior Urethral Valves
 Research Collaborative Improves Outcome Prediction in Children With Posterior Urethral Valves 150 150 Lauren Dembeck
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Combining data from five centers allowed researchers to address novel research questions for this rare disease. The Pediatric Urology Midwest Alliance (PUMA) recently published the results of its first collaborative study in Pediatrics. Using data from five institutions, the team demonstrated that the risk of renal replacement therapy and recommendation for clean intermittent catheterization increased with…

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RNase 7: Paving the Way for a Natural, Antibiotic-Free Treatment for Urinary Tract Infections
 RNase 7: Paving the Way for a Natural, Antibiotic-Free Treatment for Urinary Tract Infections 150 150 Katie Brind'Amour, PhD, MS, CHES
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The latest in the body of antimicrobial peptide research suggests RNase7 may be a useful prognostic marker and potential therapeutic option for UTIs. Building on their body of research focused on the naturally occurring antimicrobial peptides in the urinary tract, clinician-scientists at Nationwide Children’s Hospital have now confirmed the suspected role of Ribonuclease 7 (RNase…

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Pushing the Boundaries of Regional Anesthesia for Complex Urological Surgery
 Pushing the Boundaries of Regional Anesthesia for Complex Urological Surgery 150 150 Katie Brind'Amour, PhD, MS, CHES
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Physician-researchers extend the possibilities for regional anesthesia using combined spinal/caudal catheter anesthesia, allowing even complex, time-consuming pediatric urological surgeries to be completed without general anesthesia. In an effort to extend more regional anesthetic options to children undergoing urological procedures — and to obviate concerns about airway safety and theoretical neurocognitive effects of general anesthesia (GA)…

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Uroplakin Plaque Key to Protecting Kidney During Urinary Tract Obstruction
 Uroplakin Plaque Key to Protecting Kidney During Urinary Tract Obstruction 150 150 Kevin Mayhood
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Plaque appears to help remodel urothelium, allowing kidney to hold excess urine without damage, Urinary tract obstruction (UTO) is the leading cause of chronic kidney disease and end-stage renal disease in children. But the extent of damage caused by obstruction differs from child to child. Researchers at Nationwide Children’s Hospital studying why suggest that uroplakin…

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Worth It: Why Wrestling Through the Logistical Challenges of a Multidisciplinary Colorectal Center Matters
 Worth It: Why Wrestling Through the Logistical Challenges of a Multidisciplinary Colorectal Center Matters 150 150 Jeb Phillips
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Consider the complex case of a girl born with rectal, vaginal and urinary tracts fused into a common channel – a cloacal malformation. The child needs reconstructive procedures across three different organ systems and three different surgical specialties. It could take months or years to manage the surgeries needed for the colorectal portion, then the…

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Opening the Door to Adult Medicine
 Opening the Door to Adult Medicine 1024 575 Katie Brind'Amour, PhD, MS, CHES
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Care transition plans aren’t just for kids with congenital conditions anymore. Could your practice benefit from a proactive transition plan for all patients? In the shift from pediatric to adult care, young patients have the responsibility to adjust to a new life of self-management. But health care providers also play an important role in this…

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Can Ultrasound or MRI Help Monitor Dysgenetic Gonads for Tumors?
 Can Ultrasound or MRI Help Monitor Dysgenetic Gonads for Tumors? 150 150 Jeb Phillips
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Dysplastic gonads that have neoplasms are often deemed “normal” in imaging studies. Patients with gonadal dysgenesis and a Y chromosome have a substantial risk of gonadal neoplasm, so providers have traditionally recommended bilateral gonadectomy for them. But relatively recent concerns about caring for children with differences of sex development (DSDs) have called that recommendation into…

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Could Antimicrobial Peptides Be Biomarkers for Obstructive Uropathy?
 Could Antimicrobial Peptides Be Biomarkers for Obstructive Uropathy? 1024 683 Katie Brind'Amour, PhD, MS, CHES
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New research reveals the expression of antimicrobial peptides — long associated only with infections — in children with obstructive uropathy, creating the potential for a wide range of clinical applications. Previously only studied in the context of urinary tract and other infections, antimicrobial peptides (AMPs) — naturally occurring antibiotic molecules that our bodies may use…

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Can Spinal Replace General Anesthesia in Pediatric Urology Patients?
 Can Spinal Replace General Anesthesia in Pediatric Urology Patients? 150 150 Jeb Phillips
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Spinal anesthesia offers a viable low-risk alternative to general anesthesia for a wide range of pediatric procedures, particularly for urology patients. As research continues to illuminate the possibility of neurotoxic effects from general anesthesia in pediatric patients, surgeons and anesthesiologists at Nationwide Children’s Hospital have already sought out an alternative among children 2 years of…

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How to Reduce Unnecessary Antibiotic Use for UTI in Urgent Cares
 How to Reduce Unnecessary Antibiotic Use for UTI in Urgent Cares 150 150 Jeb Phillips
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A quality improvement project shows children with negative urine cultures take antibiotics they don’t need. Even before a urine culture confirms the diagnosis, urgent care physicians often prescribe antibiotics when children present with symptoms of urinary tract infection (UTI). Early treatment is important for relief of symptoms and prevention of complications. But what if the…

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