ANM 150 Test 1
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What is the main purpose of conducting a systematic review?

  • To summarize all available research on a specific topic (correct)
  • To discredit previous research
  • To analyze the results of a single study
  • To design a new RCT

    • What is a key component of a comprehensive search strategy in a systematic review?

  • Limiting the search to a specific time period
  • Only searching published studies in English
  • Only including studies with a specific design
  • Contacting experts in the field and searching databases (correct)

    • What is the purpose of a heterogeneity test in a systematic review?

  • To determine if the studies are too different to combine (correct)
  • To assess the quality of individual studies
  • To determine the significance of the results
  • To plot the results on a funnel plot

    • What is publication bias, and how is it addressed in a systematic review?

    <p>Selective reporting of results, addressed by analyzing individual study data</p> Signup and view all the answers

    What is the Cochrane Library, and what is its significance in systematic reviews?

    <p>A collaboration that publishes systematic reviews, providing a comprehensive resource</p> Signup and view all the answers

    What is the significance of the example given in 1987 by Cochrane?

    <p>It demonstrated that a systematic review can help avoid repeating RCTs and save lives</p> Signup and view all the answers

    What is an essential feature of a strong systematic review?

    <p>It includes a clear question and comprehensive search strategy</p> Signup and view all the answers

    What is a characteristic of Cochrane reviews?

    <p>They are notoriously conservative in their results</p> Signup and view all the answers

    What is statistical significance referring to?

    <p>Whether the results are due to chance or a real difference</p> Signup and view all the answers

    What does a p-value of 0.03 indicate?

    <p>The difference is likely real, but may be due to chance</p> Signup and view all the answers

    What is the main purpose of a 95% Confidence Interval?

    <p>To provide a range within which the true result is likely to lie</p> Signup and view all the answers

    What is an advantage of a larger sample size in statistical analysis?

    <p>It increases the likelihood of detecting a significant difference</p> Signup and view all the answers

    What is the general rule for determining statistical significance using a p-value?

    <p>p-value less than 0.05 is significant</p> Signup and view all the answers

    What does it mean if the 95% Confidence Intervals of two groups overlap?

    <p>The difference between the groups is not statistically significant</p> Signup and view all the answers

    What is the main difference between statistical significance and practical significance?

    <p>Statistical significance refers to whether the result is due to chance, practical significance refers to whether the result is important in real life</p> Signup and view all the answers

    What is a limitation of using Google Scholar for searching?

    <p>It has less stringent requirements vs PubMed</p> Signup and view all the answers

    What is an advantage of using pre-synthesized evidence?

    <p>It is more rigorous in its methodology</p> Signup and view all the answers

    What is a common way to source full-text articles?

    <p>Through Research Gate and email requests to study authors</p> Signup and view all the answers

    What is the Trip Database?

    <p>A free database of pre-synthesized evidence</p> Signup and view all the answers

    What is a consideration when searching for naturopathic topics?

    <p>Use caution when searching</p> Signup and view all the answers

    What is an advantage of using Google Scholar?

    <p>It is more user-friendly</p> Signup and view all the answers

    What is the significance of considering the age of publication?

    <p>It helps to identify more relevant studies</p> Signup and view all the answers

    What is the Cochrane Library?

    <p>A database of systematic reviews with high rigor</p> Signup and view all the answers

    Why is it important to consider the age of subjects?

    <p>It helps to identify more relevant studies</p> Signup and view all the answers

    What is a limitation of using free full-text articles?

    <p>It may not be a reliable source</p> Signup and view all the answers

    What is a major advantage of meta-analysis?

    <p>It allows for the creation of a larger sample size</p> Signup and view all the answers

    What is a limitation of N of 1 studies?

    <p>It is not generalizable to other populations</p> Signup and view all the answers

    What is a strength of pre-clinical studies?

    <p>They allow for creativity and innovation</p> Signup and view all the answers

    What is a consideration when evaluating the quality of a systematic review?

    <p>The relevance of the studies to the research question</p> Signup and view all the answers

    What is a limitation of pre-clinical studies?

    <p>They may not be clinically applicable to humans</p> Signup and view all the answers

    What is a strength of N of 1 studies?

    <p>They allow for individualization of treatment</p> Signup and view all the answers

    What is a consideration when conducting a systematic review?

    <p>Searching multiple databases and reference lists</p> Signup and view all the answers

    What is a limitation of systematic reviews?

    <p>They are only as good as the available studies</p> Signup and view all the answers

    What is a consideration when evaluating the results of a systematic review?

    <p>Evaluating the quality of the individual studies</p> Signup and view all the answers

    What is the main difference between a systematic review and a meta-analysis?

    <p>A systematic review synthesizes the results of multiple studies, while a meta-analysis combines the results of multiple studies statistically</p> Signup and view all the answers

    What is the primary goal of the GRADE framework?

    <p>To develop and present summaries of evidence</p> Signup and view all the answers

    What does a 'very low' certainty rating in GRADE indicate?

    <p>The true effect is probably markedly different from the estimated effect</p> Signup and view all the answers

    What is an example of 'risk of bias' in a study?

    <p>A study not randomized, or randomized trials not blinded</p> Signup and view all the answers

    What is the focus of imprecision in GRADE?

    <p>The 95% confidence interval</p> Signup and view all the answers

    What is the consequence of 'rating down' due to imprecision in GRADE?

    <p>The certainty of the evidence is decreased</p> Signup and view all the answers

    What does the GRADE framework assess when evaluating the certainty of evidence?

    <p>The consistency of results and the presence of bias</p> Signup and view all the answers

    What is an example of indirectness in a study?

    <p>A study that measures a surrogate outcome instead of a clinical outcome</p> Signup and view all the answers

    What is the purpose of a funnel plot in assessing the certainty of evidence?

    <p>To identify publication bias</p> Signup and view all the answers

    What is a characteristic of a strong recommendation in the GRADE framework?

    <p>It is based on a systematic review of the evidence</p> Signup and view all the answers

    What is the purpose of considering the magnitude of effect in the GRADE framework?

    <p>To assess the clinical significance of the effect</p> Signup and view all the answers

    What is the primary outcome of folic acid supplementation on blood pressure according to the systematic review?

    <p>Significant decrease in systolic blood pressure</p> Signup and view all the answers

    What is the subgroup of patients where the results of folic acid supplementation on systolic blood pressure remained significant?

    <p>Patients with cardiovascular disease, males and females, and overweight participants</p> Signup and view all the answers

    What is the effect of folic acid supplementation on diastolic blood pressure according to the systematic review?

    <p>Significant decrease in diastolic blood pressure</p> Signup and view all the answers

    What is the duration of intervention where the results of folic acid supplementation on systolic blood pressure remained significant?

    <p>In interventions with a duration of 6 weeks or less</p> Signup and view all the answers

    What is the dose of folic acid supplementation where the results of folic acid supplementation on systolic blood pressure remained significant?

    <p>At a dose of 5 mg/d or more</p> Signup and view all the answers

    What is a common challenge in studying mental health?

    <p>All of the above</p> Signup and view all the answers

    What is the primary objective of the EASe-GAD clinical trial?

    <p>To evaluate the feasibility and acceptability of the intervention</p> Signup and view all the answers

    What is the eligibility criterion for participants in the EASe-GAD clinical trial?

    <p>Adults with a diagnosis of generalized anxiety disorder</p> Signup and view all the answers

    What is the control group in the EASe-GAD clinical trial?

    <p>Social support control</p> Signup and view all the answers

    What is the possible mechanism by which diet may affect mental health?

    <p>All of the above</p> Signup and view all the answers

    What is the primary outcome of the EASe-GAD clinical trial?

    <p>Assessing the feasibility of the intervention</p> Signup and view all the answers

    What is a characteristic of the EASe-GAD clinical trial?

    <p>All of the above</p> Signup and view all the answers

    What is the population targeted in the EASe-GAD clinical trial?

    <p>Adult women with a diagnosis of generalized anxiety disorder</p> Signup and view all the answers

    What is the primary purpose of hypothesis testing in statistical analysis?

    <p>To determine the probability of a chance occurrence</p> Signup and view all the answers

    What does a p-value of 0.01 indicate?

    <p>There is a 1% chance that the difference is due to chance</p> Signup and view all the answers

    What is the main difference between incidence and prevalence?

    <p>Incidence measures the number of new cases, while prevalence measures the total number of cases</p> Signup and view all the answers

    What is the purpose of a 95% Confidence Interval (CI)?

    <p>To estimate the range of values within which a population parameter is likely to lie</p> Signup and view all the answers

    What is the difference between a sample and a population?

    <p>A sample is a subgroup of a population, while a population is the entire group of interest</p> Signup and view all the answers

    What is the primary purpose of considering the size of the sample in statistical significance?

    <p>To determine the power of the study</p> Signup and view all the answers

    What does a relative risk of 0.6 indicate?

    <p>The treatment decreased the risk of the bad outcome by 40%</p> Signup and view all the answers

    What is the difference between absolute risk reduction and relative risk reduction?

    <p>Absolute risk reduction is the absolute decrease, while relative risk reduction is the percentage decrease</p> Signup and view all the answers

    What is the limitation of using relative risk reduction when outcomes occur infrequently?

    <p>It overestimates the effect of the treatment</p> Signup and view all the answers

    What is the odds ratio, according to the SR lecture?

    <p>A measure of the relationship between an exposure and an outcome</p> Signup and view all the answers

    What does an odds ratio of 1 indicate in a study?

    <p>Exposure does not affect the likelihood of the outcome</p> Signup and view all the answers

    What is the main difference between a clinical outcome and a surrogate outcome?

    <p>Clinical outcomes are directly measured, while surrogate outcomes are indirectly measured</p> Signup and view all the answers

    What is the primary consideration in determining clinical significance?

    <p>The extent of change and whether it makes a real difference in the lives of patients</p> Signup and view all the answers

    What is the purpose of validating a surrogate outcome?

    <p>To establish that the surrogate outcome is a reliable indicator of the clinical outcome</p> Signup and view all the answers

    What is the relationship between sample size and statistical significance?

    <p>Larger sample sizes increase the likelihood of statistical significance</p> Signup and view all the answers

    Study Notes

    Systematic Reviews

    • In 1987, Cochrane demonstrated the importance of systematic reviews in reducing premature deaths due to complications from pre-term births.

    Objectives

    • Recognize the important features and strengths of a systematic review or meta-analysis
    • Interpret an odds ratio and a forest plot
    • Design a search strategy to find a systematic review on a topic

    Looking at Systematic Reviews

    • Systematic reviews are conducted to answer a clear question using relevant studies, comprehensively searched, and assessed for individual study quality.
    • A strong systematic review requires a clear question, relevant studies, comprehensive search, clear eligibility criteria, and assessment of individual study quality.

    Methodology

    • A clear question is essential, considering PICO (Population, Intervention, Comparison, and Outcome)
    • Relevant studies should be identified, with an appropriate design (e.g., RCT for interventions)
    • A comprehensive search involves databases, reference lists, unpublished studies, contacting experts, and non-English studies
    • Clear eligibility criteria are necessary for study inclusion
    • Assessment of individual study quality is crucial

    Results

    • Results should be combined only if studies are similar enough, with minimal heterogeneity
    • Heterogeneity tests, such as Cochrane Q and I2, are used to determine if data is too heterogeneous to combine
    • Publication bias can occur when only positive studies are published, and negative studies are neglected

    Funnel Plots

    • Funnel plots are used to analyze publication bias, with a symmetrical distribution indicating minimal bias

    Cochrane Collection

    • The Cochrane Collaboration provides systematic reviews in a rigorous and consistent manner
    • The Cochrane Library has a strong influence on policy and standards for practice
    • It includes sections on complementary medicine, with over 70 reviews
    • Full access is available through the LRC website

    Cochrane Caution

    • Cochrane reviews are notoriously conservative in their results, often concluding that 'more research is necessary'

    Mini Stats Break

    • Statistical significance determines if a difference is real or due to chance
    • A p-value indicates the likelihood of a difference being due to chance
    • A p-value of 0.05 is generally the cut-off for significance
    • Variables that influence p-value calculation include sample size, variation within and between groups
    • Confidence intervals (CI) provide a range of possible results, with 95% CI indicating that 95% of the time the results would be within that range

    PICO and Searching for Evidence

    • PICO is a framework used to ask structured, answerable questions in evidence-based medicine.
    • PICO stands for:
      • P: Population
      • I: Intervention
      • C: Comparison
      • O: Outcome

    Example of PICO

    • Marion's question: "Should I wear elastic stockings when I travel to reduce my risk of developing deep vein thrombosis (DVT)?"
    • PICO breakdown:
      • P: Retired woman who flies frequently
      • I: Wearing elastic stockings
      • C: Not wearing elastic stockings
      • O: Reducing the risk of developing deep vein thrombosis (DVT)

    Searching for Evidence

    • Primary sources of scientific evidence:
      • PubMed
      • Other subscription-based databases: EBSCO, CINAHL, MEDLINE
      • Google Scholar

    PubMed Searching

    • Boolean operators: AND, OR, NOT (must be in capital letters)
    • Examples:
      • "Cancer AND vitamin C"
      • "Cancer OR carcinoma"
      • "Cancer AND vitamin C NOT intravenous"

    Truncation

    • Using the asterisk () to truncate search terms: "hyperten" = hypertension, hypertensive, etc.

    Field Descriptions

    • PubMed can search many fields, including date, author name, journal, title, page number, abstract, etc.
    • Example: "(DP) = date of publication", "(TI) = title", "(JT) = journal title"

    Advanced Search Builder

    • Helps to be more specific in search queries
    • Especially useful when looking for a particular article

    MeSH Terms

    • Medical Subject Headings (MeSH) are a controlled vocabulary
    • Examples: "Depression" could refer to respiratory depression, cytokine depression, or depression as a psychiatric condition

    Hedges (Filters)

    • Combinations of terms or standardized search strategies that can be easily used

    Clinical Queries

    • PubMed Clinical Queries: subsets of search terms for specific topics, such as dietary supplements or complementary and alternative medicine (CAM)
    • Creating a saved search using a string of terms
    • Example: using the dietary supplement subset: "dietsuppl [sb] AND osteoarthritis"

    Botanical Medicine

    • No subset for botanical/herbal medicine
    • Consider saving search terms: "Plants, Medicinal"[Mesh] OR "Ethnopharmacology" [Mesh] OR "Phytotherapy"[Mesh] OR "Ethnobotany"[Mesh] OR "Plant Preparations"[Mesh]

    Diet

    • Diet [Mesh] includes Mediterranean, DASH, keto, vegan, etc.
    • Can also look at: Food [Mesh]

    Limits

    • Study type
    • Subjects (human/animal)
    • Age of publication
    • Age of subjects, gender
    • Free full text

    Pre-Synthesized Evidence

    • Cochrane Library: highly rigorous systematic reviews and meta-analyses
    • Natural Medicines: access through CCNM library and CAND member website
    • Trip Database: free and upgraded version
    • Others: UpToDate, Examine.com (subscription-based)

    Sourcing Full Text Articles

    • Google Scholar
    • Research Gate
    • Email the study author (corresponding author) for a pre-publication copy

    Limitations of RCTs

    • Sample may not be representative
    • Not good for rare or distant outcomes
    • Application to non-pill interventions can be challenging
    • Ethics of treating only some participants

    Assessing the Quality of RCTs

    • Jadad scale: assesses clinical trials, score from 0 to 5
    • Cochrane risk of bias: often used in systematic reviews
    • CASP checklist: assesses quality of reporting
    • CONSORT: assess quality of reporting, CAM-specific reporting standards (e.g., Non-pharm CONSORT, Herbal Medicine CONSORT, REDHOT, STRICTA)

    Jadad Scale

    • Assesses clinical trials
    • Score from 0 to 5
    • 2 points for randomization
    • 2 points for blinding
    • 1 point for dropouts

    Other Kinds of Intervention Studies

    Cross-Over Studies

    • Everyone gets intervention and comparison
    • Pro: minimizes confounding (participants are their own controls)
    • Con: must be a chronic illness, treatment must wash out

    Cohort Studies

    • Strengths: looks at any exposure, confident that exposure came before outcome, assess multiple outcomes
    • Weaknesses: assignment to comparison group is not random, time-consuming, inefficient for rare outcomes
    • Example: compare exposed and un-exposed groups over time

    Case-Control Studies

    • Strengths: can look at rare outcomes, faster
    • Weaknesses: assignment to comparison group is not random, hard to assess temporality
    • Example: compare diseased and non-diseased groups

    Hierarchy of Evidence

    • Identify inherent strengths and weaknesses of each type of research design
    • Assess quality based on design and relevance to practice, individual patients, and public health

    RCTs

    • Strengths: many ways to decrease risk of bias, randomized, control group, blinding, best design for confirming cause/effect
    • Weaknesses: difficult to recruit, only assess one outcome, recall bias

    Randomization

    • For comparison to be useful, need truly random assignment to treatment/comparison
    • Examples: computer-generated sequence, sequential numbered sealed opaque envelopes, 3rd party allocation

    Compliance

    • Should be assessed
    • Simple methods: diary, pill count, phone calls, questioning
    • Biological methods: blood/urine levels (costly)

    Withdrawals

    • How many participants enrolled, completed, dropped out (why?), analyzed
    • Accounting for missing data: per-protocol analysis, intention to treat analysis

    Intention to Treat Analysis

    • Analyze everyone in the group randomized, even if did not complete or ended up in the other group
    • Techniques: last observation carried forward, statistical approaches
    • Best way to minimize bias from dropouts

    RCT Limitations

    • Difficult to recall bias
    • Only assessing one outcome
    • Recall bias)

    Cross-Sectional Studies

    • Strengths: can study rare outcomes, faster, no recall bias
    • Weaknesses: assignment to comparison group is not random, no assessment of temporality, only assessing one outcome

    Observational Studies

    • Strengths: can study any question, less expensive or faster than intervention studies
    • Limitations: not randomly assigned to exposure groups, investigate correlation, not necessarily causation

    Appraising the Quality of Observational Studies

    • Recruitment: do participants reflect the population of interest? Selection bias
    • Assessment of exposure: accurate? Subjective or objective? Validated? Measurement or classification bias
    • Consideration of confounding factors? Did they look for confounding factors?

    Systematic Reviews

    • Strengths: explicit and rigorous methods, scientific investigation, enormous effort to minimize bias, capture the big picture of evidence on a topic
    • Limitations: only as good as the available studies, can’t replace good clinical reasoning

    N of 1 Study

    • Strengths: look at real-world use of an intervention, allows for individualization, root-cause style treatment, complex health conditions, multi-modal treatments
    • Limitations: doesn’t work if the condition is curable or self-limiting, must relapse in washout, findings may not be generalizable, ethics, high cost

    Preclinical Studies

    • Strengths: allow for creativity and innovation, background for future research in humans, investigate mechanism of action, study possible adverse events or interactions, high level of control, ethical
    • Limitations: may not be clinically applicable to humans, highly controlled, one isolated part of the story

    Consider

    • Is pre-clinical evidence ‘sufficient’ enough to guide clinical recommendations?

    Grading the Evidence

    • Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) is a transparent framework for developing and presenting summaries of evidence.
    • GRADE provides a systematic approach to clinical decision making.

    How Does It Work?

    • A clinical question is formulated in PICO (Patient, Intervention, Comparison, Outcome) format.
    • A systematic review provides an estimate of the effect size of an outcome.
    • The author rates the quality of the evidence and strength of recommendations.

    GRADE Certainty Rating

    • Certainty refers to whether an estimate of association or effect is correct or true.
    • There are four levels of certainty:
      • Very low: The true effect is probably markedly different from the estimated effect.
      • Low: The true effect might be markedly different from the estimated effect.
      • Moderate: The authors believe that the true effect is probably close to the estimated effect.
      • High: The authors have a lot of confidence that the true effect is similar to the estimated effect.

    What Makes Evidence Less Certain? (“Rate Down”)

    • Five factors can decrease certainty:
      • Risk of bias: Inherent limitation in the design of a study that causes the results to be inaccurate.
      • Imprecision: Results may be due to chance; focus on 95% confidence interval.
      • Inconsistency: Multiple studies showing a consistent effect increase certainty.
      • Indirectness: Intervention of interest is not studied in the population of interest and reporting the outcome of interest.
      • Publication bias: Is this really all of the research evidence that exists?

    What Makes Evidence More Certain? (“Rate Up”)

    • Three factors can increase certainty:
      • Large magnitude of effect.
      • Dose-response gradient.
      • All residual confounding would increase our confidence in an effect.

    GRADE: 2 Parts

    • Certainty of Evidence: How likely is it that something works? (Consider consistency, precision, applicability, and bias.)
    • Recommendation Strength: Should it be recommended for use (or not!); consider evidence, benefits/harms, equity, resources, feasibility, and acceptability.

    Recommendations

    • Can be in favor or against an intervention.
    • Can be strong or weak.
    • Weak recommendations may lead to variation in decisions made by informed individuals.
    • Shared decision-making process becomes essential with weaker recommendations.

    Example: Folic Acid Supplementation and Blood Pressure

    • A systematic review and meta-analysis of 41,633 participants found that folic acid supplementation significantly decreased systolic BP and diastolic BP.
    • Subgroup analysis showed that the results remained significant in specific populations and under certain conditions.

    Mental Health Research Challenges

    • Unique challenges of studying mental health include obstacles, barriers, risks, and concerns

    EASe-GAD Clinical Trial at CCNM

    • Trial aims to study the effect of diet on Generalized Anxiety Disorder (GAD)
    • Background: mental illness is common, and many people do not benefit from medication and psychotherapy due to access issues, side effects, and inadequate relief
    • Observational data suggests a link between better diet quality and better mental health, with possible mechanisms including omega-3/6 balance, vitamins/minerals, protein for neurotransmitter synthesis, and healthy blood sugar regulation

    Trial Design and Participants

    • Pilot study with a randomized, wait-list controlled design
    • Participants: adults (18-65 years old) who identify as women, diagnosed with moderate to severe GAD
    • Primary objectives: assess feasibility and acceptability of the intervention
    • Secondary objectives: look for signals of change in additional outcomes
    • Intervention: personalized dietary advice, motivational interviewing (MI), mindfulness, and Mediterranean diet (MED diet)
    • Control group: social support
    • Inclusion criteria: stable medication/supplements for 4+ weeks, baseline Omega Score

    Statistics

    • Define terms:
      • Sample: a subset of the population
      • Population: the entire group of interest
      • Incidence: the number of new cases of a disorder
      • Prevalence: the total number of cases of a disorder

    Hypothesis Testing

    • The process of deciding whether the findings of an investigation reflect chance or real effect
    • Statistical significance:
      • Difference in group means (averages)
      • Difference in the likelihood of an outcome
      • P-value: the probability that the difference is due to chance (typically < 0.05)

    Statistical Significance: P-Value

    • P-value: the odds that the difference is due to chance
    • Cut-off: 0.05 (5% likelihood)
    • Interpretation:
      • P > 0.05: not significant
      • P < 0.05: significant

    Statistical Significance: Confidence Interval (CI)

    • 95% CI: the range within which the true result is likely to lie
    • Interpretation:
      • Overlapping intervals: non-significant difference
      • Non-overlapping intervals: significant difference

    Relative Risk

    • Probability of a bad outcome in the intervention group divided by the probability of a bad outcome in the control group
    • Interpretation:
      • RR = 1: no difference
      • RR > 1: risk of bad outcome increased with treatment
      • RR < 1: risk of bad outcome decreased with treatment

    Relative Risk Reduction

    • How much the treatment reduced the risk of the bad outcome
    • RRR = 1 - relative risk
    • Example: 40% reduction in risk with vitamin C

    Absolute vs Relative Risk Reduction

    • Absolute risk reduction (ARR): the absolute amount the intervention decreased the risk
    • ARR = risk of outcome with placebo - risk with medication
    • Example: ARR = 8% (40% reduction in risk with vitamin C)

    Odds Ratio

    • Looks at the relationship between an exposure and an outcome
    • Often used in observational studies
    • Interpretation:
      • OR = 1: exposure does not affect the likelihood of the outcome
      • OR > 1: exposure associated with increased likelihood of the outcome
      • OR < 1: exposure associated with decreased likelihood of the outcome

    Outcomes

    • Clinical outcomes: a clinical event (e.g. stroke, suicide, hip fracture)
    • Surrogate outcomes: an indicator that can be observed sooner, at a lower cost, or less invasively (e.g. biomarkers, indicators of disease progression)

    Statistical Significance vs Clinical Significance

    • Statistical significance: not due to chance (p < 0.05)
    • Clinical significance: the intervention has a genuine, measurable effect that makes a real difference in the lives of patients
    • Power: the ability of a study to detect a real difference between two groups

    Studying That Suits You

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    Description

    This quiz covers the basics of systematic reviews in healthcare, including their history and benefits. It's based on a lecture by Dr. Monique Aucoin for ANM 150 students.

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