Home » Uncategorized » Duke Heart Pulse – Week Ending August 21st 2022

Duke Heart Pulse – Week Ending August 21st 2022

Highlights of the week:

Celebrating Magnus Ohman

Magnus Ohman

It is hard to believe, but Magnus Ohman’s last official day at Duke was August 5. Pulse readers know that we ran an extensive piece about him on Sunday, June 12 and that an in-person gathering was held on July 14th at the Washington Duke Inn.

Ohman has retired from clinical medicine and will now serve as vice-president of Global Development of Cardiometabolic Therapeutics for Amgen. We reached out to a number of our team members (current and former) for some reflections on Magnus and his time with us.

Here is what they shared:

From Pam Douglas:

“When I first came to Duke, Magnus had left to try his hand at being chief of cardiology at UNC. However his loyalty to Duke and his colleagues made him an easy ‘boomerang’ recruit. He took over our outpatient clinics—a difficult and often thankless job—but pulled off a major overhaul streamlining schedules, referrals and other aspects to make it much more patient and provider friendly.

Magnus’s own outpatient practice was remarkable. He thrived on clinical complexity and even set up a center for ‘end stage’ CAD, while also counting many luminaries and donors among his patients.

Never one to attract attention to himself, he quietly ran international trials and site based research, serving as a sought after mentor for many at DCRI and in the cath lab. I have always highly valued his wise counsel, perspective and insights, and will greatly miss his good cheer, intelligence, and can-do attitude! I’m sure that Amgen doesn’t yet know how amazing a gem they have recruited, but they will soon find out.”

From Kristin Newby:

“I first met Magnus when I was an intern on cardiology, during his first year of cardiology fellowship, and still remember many of the things he taught me! Years later, as I moved from the basic lab to clinical research as I came on faculty, Magnus was among several clinical research faculty who were instrumental in supporting my transition and providing enthusiastic mentorship and guidance throughout my career. We connected over biomarkers, especially through his seminal work on troponins as a prognostic marker, and I had the thrill of conducting with him one of the earliest studies of a multi-marker assessment tool for patients with chest pain (CHECKMATE) that was accepted for publication in Circulation as is, without any revisions! Through the years, I have watched him mentor numerous other fellows and early career faculty with the same enthusiasm and passion, and am especially proud of the role he has played in mentoring and sponsoring women fellows and early career faculty. These aspects, and his clinical presence, will certainly be missed at Duke, but I look forward to continuing our friendship and seeing him flourish in the next phase of his career. And, we still have a lot of golf to play—including bringing the William Harvey Trophy back to the US in 2024, through which Magnus has also been and a terrific friend and valued sponsor and mentor!”

From Jim Daubert:

“Magnus has been a frequent and treasured colleague of mine since returning to Duke in 2009. It was great reconnecting with him in clinical care after forging close bonds with him during our Fellowship some years ago!  Over the last 13 years I have very much valued consulting on his uniquely challenging patients and soliciting his insights on especially gnarly coronary and other cases. I will truly miss interacting with him in the clinical realm. His wisdom, judgement and insight cannot be replaced. Fortunately, Amy and I will look to continuing our highly valued friendships with Magnus and Elspeth, not to mention going to Hurricanes games together!”

From Jennifer Rymer:

“It has been a true opportunity to get to work with Magnus from start to near finish on a large multi-site registry over the past two years. Magnus is extremely talented in collaborating with and building relationships with industry partners and external collaborators. He taught me so much about how to develop relationships with collaborators and run a registry, even when we were faced with challenges during COVID. His network runs deep, and always amazed me how he was able to stay in touch with colleagues and collaborators from projects years prior. I have valued his mentorship and appreciate that I had the privilege to work with someone who has done so much in CV research and for Duke. He has been an advocate for me from the beginning, and I know will continue to be a mentor even while at Amgen.”

From Mike Sketch:

“Magnus and I began our cardiology fellowship at Duke the same year, and it has truly been an honor to be his friend and colleague over the past 35 years. He has truly excelled in every aspect of his career and is so committed to our academic mission. He is so supportive of young faculty and wants to see others prosper and grow. He is always thinking outside the box and asking novel questions. Through his example, he has taught so many faculty and fellows how to think creatively. He is very highly respected both inside and outside of Duke. He has developed so many amazing relationships with external partners. He loves patient care, and his patients adore him. Finally, he beams with pride whenever he talks about his family, Elspeth and his three kids.

Magnus, you will be so missed!”

From Tracy Wang:

“Magnus’ career has changed so much for so many of us in medicine. One characteristic of his career I’ve always admired is that he’s not afraid to tackle the tough questions when they need to be answered. He just won’t take “no” for an answer, and many a time, has called up company CEOs to convince them to do the right thing scientifically. Another aspect I and many other others have enjoyed is his sincere interest and support of early careers. I don’t think there’s a recently Duke-trained interventional fellow out there who’s not received an invitation to write a paper with Magnus. He is a tireless advocate for his mentees, and a fervid supporter of supporter of women in cardiology. Magnus, we wish you all the best in the next phase of your career. Don’t forget us at Duke!”

From Chris Granger:

“As a fellow starting in 1989, I met Magnus as a bright, savvy, well spoken (and the accent helped as well), and personable fellow from Ireland who had worked with the Oxford University team — at the time, the most successful clinical trial group in the world. Moreover, Magnus was engaging and entertaining and fun. Life was richer when working with Magnus, as a member of a steering committee or on call for the clinical service. I, like many of us, was in awe and wanted to work with him and be with him. In fact, Magnus and I began to share a room at the major cardiology conferences as fellows because we could not afford to have our own rooms, and then kept doing it throughout our careers because we enjoyed it so much as friends as well as a way to keep up with what was going on at the meetings.  He grew into one of the most successful and influential researchers and clinicians in the history of Duke cardiology. He has been recognized several times as one the most highly-cited researchers in all of Duke. He has led many important clinical trials. He served on FDA advisory panels. He was an important bridge between U.S. and European cardiology, being one the few people to serve on clinical practice guideline committees (including in leadership positions) on both sides of the Atlantic. Duke has been very fortunate to have Magnus who has been a terrific ambassador for Duke around the world. He is personal friends not only with those of us at Duke and those that he has trained, but also with many of the leaders of cardiology around the world. Like so many trained in the British Isles, Magnus is a world-class clinician and his patients love him. In short, Magnus has been a giant in his years working in the Heart Center. He has been a loyal, dedicated, beloved member of the Duke team. He will always be an important part of the Duke cardiology family.”

From Blue Dean:

“I did not have a chance to meet Magnus in person when I interviewed at Duke.  Instead, he and I spoke by phone and I still remember our conversation. He didn’t ask about my experience; he asked about my children, my husband, and what we enjoyed doing as a family. He talked about the local community, Duke as a place to work, and what set the Duke Heart Center apart from peer institutions.

Shortly after my arrival, Chris O’Connor suggested that I work with Magnus as the point person for the Duke Heart Center’s development efforts. Little did I know that Magnus and I would spend the next eight years working together and in partnership with many faculty physicians to raise funds in support of the Duke Heart Center and Department of Medicine. We spent countless hours in the car crisscrossing North Carolina, Florida, California, and wherever else a donor visit might send us. I most often was the driver which caused me to jokingly referring to our arrangement as Driving Miss Daisy. I’m not sure Magnus appreciated being called Miss Daisy, but it was all in good fun!

And, we did have fun. Magnus is an excellent storyteller and a lover of music. He would keep me entertained (and awake) with both. During one of our trips to Florida, I lost my voice – completely lost my voice – and Magnus was quick to jump in and comfortably navigate the gift conversations on my behalf.  Donors loved working with Magnus; they appreciated his enthusiasm and passion for Duke, as well as his commitment to excellent patient care.

I was very fortunate to work with Magnus and remain thankful for all he taught me. Fundraising, like so many professions, can be stressful. Magnus was always quick to lighten the mood with a good laugh and an appropriate story. And, on occasion, a really good bottle of wine!

Cheers to Magnus – here’s to a wonderful run and best wishes for great things to come!”

From Penny Hodgson:

“When Rob Califf invited me to take a job in 1992 editing the manuscripts that came out of the GUSTO trial, I had no idea what the job would turn into. One of the first faculty members to come say hello was Magnus Ohman. He was very supportive of the idea of having someone take his draft manuscript and polish it iteratively to the point of publication. And we did this over and over again, to the tune of more than 130 GUSTO manuscripts over the years; Magnus was likely a coauthor of at least a third of them.

As the Communications group grew, adding editors and graphic designers at first, Magnus welcomed them and put them to work. And he was unfailingly grateful and fun, making great suggestions for improving the slides and illustrations that were used to explain the results of our trials in print and in person.

I have two recollections about Magnus and the European Society of Cardiology meetings. One year he received a phone call from his daughter Elsa telling him that a hurricane was about to hit North Carolina and he needed to come home right away! He shared that story widely at that meeting.

The second remembrance is of being in Vienna the day following the end of the meeting and finding that Magnus was also there. We decided to see if we could get tickets to whatever was going on at the Vienna Symphony Hall, and we could. We had amazing seats with lots of legroom, and Magnus fell asleep before the end of the introduction. He woke up for the intermission and went immediately back to sleep afterwards. He agreed that the Russian pianist had been fabulous, although I’m not sure he heard a single note she played.”

From Bob Harrington:

“Hard to believe but I have now known Magnus for 33 years, since the time I arrived at Duke for my own fellowship. Magnus initially was some sort of very special “super fellow” from Ireland. We heard about him but didn’t see him much. I really got to know Magnus when I went to the Databank as a fellow and then for years had an office next to him and Chris Granger. We spent lots of late nights in the Databank then in the DCRI because none of us had a good internet connection at home. With Magnus, there was always loud rock music (yes, he is a Led Zeppelin fan) and great conversations about research and life. He taught me a lot about both! And talked me off more than a few ledges.

Traveling internationally with Magnus was always a memorable experience.  First, he traveled in a suit jacket and tie, even on the overnight! Second, he was through immigration lines very quickly because he would use either his EU/Irish passport or his US one, whichever had the shorter line and so he was usually waiting for us. But he always had a car lined up and he always knew the best hotels in any European city. If you need travel advice, check with Magnus (but don’t ask or listen to Chris Granger, Magnus’ frequent roommate on the road).

Magnus is a creative thinker in research and the cath lab. That can get you in trouble, but Magnus always has a way of pulling himself out of those tricky situations. He’s been a terrific friend and colleague over these many years. And, he has a great wine cellar that he is always happy to share. I’m looking forward to seeing what he does in this next part of his professional journey and I’m definitely looking forward to greeting him more regularly on the left coast! Good luck Magnus.”

Magnus has certainly had an impact on so many of us as well as on Duke and the overall field of cardiology. He has touched most of the faculty and fellows during his time.  He mentored many of us during both good and bad times.  We will miss seeing him on campus, but we wish him all the best and look forward to many more stories and collaborations over the coming years!

Kudos to Cara Hoke

Anna Lisa Chamis shared a terrific note she received this week from Nishant Shah regarding cardiology fellow Cara Hoke:

“Hi Anna Lisa,

I wanted to let you know that Cara completed an elective on PAC this past week and did an outstanding job! We had a busy service all week which she took the lead on. She was calm, collected, thoughtful, and well prepared. Her communication with other team members, consulting providers, patients, and families was very clear and she was always approachable/available for questions. Furthermore, her bedside manner was outstanding! Both patients and families felt very comfortable with her care. Cara would routinely review all the imaging on service herself including echos, cMRIs, nuclear studies, cath films before making her plans for the day. Her interpretations for the imaging studies would be spot even before the formal reads. Her assessments and plans were extremely well thought out and she also kept disposition/outpatient follow up plans always in the back of her mind as she led the service. The APPs on the PAC team also loved working with Cara and enjoyed learning from her on rounds. She really exemplified quality patient care, being an outstanding educator, as well as a superior team leader! Best, Nishant”

Great work, Cara!!!

Shout-out to Duke Raleigh’s Heart Walk Team!

The team at Duke Raleigh Hospital held a Carnival Day that helped to raise $1600 in just three hours for their Heart Walk team. The funds raised will go to the American Heart Association. Way to go!

Note: Our own Sean Pokorney spent some time in the dunking booth that day – we’re not sure how many times he was dunked or how much was raised as a result, but what a team player!

Hot tip: Heart Walk T-Shirts

Speaking of the Heart Walk… tomorrow, we will be announcing to all DUHS employees that if you sign up by 5 p.m. on Wednesday, Aug. 24 as a walker (or team captain) for the upcoming Triangle Heart Walk you will receive a Duke team t-shirt. This is a hard deadline and you’re among the first to know!

If you can’t join us in person, please consider a contribution of any amount to one (or more!) of the nine teams representing Duke Heart. Help us meet our overall DUHS fundraising goals! Duke Heart’s teams can be found here: https://duke.is/6jpdp

Reminder: The Triangle Heart Walk is scheduled for Sunday, Sept. 25 at the PNC Arena.

Photos of the Week

It was a great week to be working in the CICU! Not one but two celebrations were held for cardiology fellow Willard Applefeld‘s birthday. Happy belated birthday!!

Also, a good week to be a member of the PWIM group – they gathered at Ponysaurus in Durham for some networking and camaraderie. Shout out to Jenn Rymer for her work with this amazing team of women!

COVID-19 Update

Please continue to practice safe COVID-19 protocols in your day-to-day interactions with others. Be particularly vigilant about masking, and avoid eating indoors in group settings. The health of our team members and our patients remains a priority as we continue to monitor the COVID-19 trends throughout our community.

Stay home if you are not feeling well. Employees who begin to experience any COVID-19 symptoms should report symptoms through the Duke SymMon app, which is available in both the Apple and Google app stores.

Donate blood if you’re able to. Click here for Duke-sponsored blood drives through the Red Cross.

All the latest Clinical Operations updates related to COVID can be found at https://covid-19.dukehealth.org. Patient-facing resources on DukeHealth.org can be found here: https://www.dukehealth.org/covid-19-update/resources. Duke University maintains a resource page as well, which can be accessed here: https://coronavirus.duke.edu/updates/for-staff.

 

Upcoming Events & Opportunities 

Cardiology Grand Rounds

September 8: The Art and Science of Leadership with David Skorton, MD, President and CEO of the Association of American Medical Colleges (AAMC). 5 p.m. in Duke North Room 2002 and via WebEx.

 

CME & Other Events

September 12: Prostate Cancer & CVD Symposium. This is the third webinar of a four-part series. Collaboration between the International Cardio-Oncology Society & Duke Heart. Noon, Eastern. To learn more, please visit: https://duke.is/mbpte

September 25: Triangle Heart Walk. PNC Arena, Raleigh. Check-in and festivities start at 11 am. Walk begins at Noon. Join us!

October 14: Cardio-Oncology in the Era of Precision Medicine. Symposium to be held at the J.B. Duke Hotel, Durham, NC. Registration is open: https://bit.ly/CardioOnc22. Email Beth Tanner with questions: beth.tanner@duke.edu.

November 4: 14th Annual NC Research Triangle Pulmonary Hypertension Symposium. 7 a.m.-4 p.m. Save the date! This will be an in-person event at the Durham Convention Center. Registration required, but is not yet live. Stay tuned for updates.

Have news to share?

If you have news to share with the Pulse readership, please contact Tracey Koepke, director of communications for Duke Heart at tracey.koepke@duke.edu. We would love to hear about your latest accomplishments, professional news, cool happenings, and any events or opportunities that may be of interest to our Duke Heart family. Please call with any questions: 919-681-2868. Feedback on Pulse is welcome and encouraged. Submissions by Noon, Wednesdays, to be considered for weekend inclusion.

 

Duke Heart in the News:

August 15 — Derek Chew

Health Day

Left Atrial Appendage Occlusion Favored for Some A-Fib Patients

https://duke.is/5ufpt

August 17 — Derek Chew and Jonathan Piccini

tctMD

Stroke, Bleeding Risks Key for Assessing Potential LAAO Benefit

https://

Division of Cardiology Publications Indexed in PubMed August 11-18, 2022

Allen LaPointe NM, Ali-Ahmed F, Dalgaard F, Kosinski AS, Sanders Schmidler G, Al-Khatib SM. Cardiac resynchronization therapy outcomes with left ventricular lead concordant with latest mechanical activation: A meta-analysis. Pacing Clin Electrophysiol 2022 Aug;45(8):930-939. PM: 35687711.

Altin SE, Gitto M, Secemsky EA, Rao SV, Hess CN. Sex-Based Differences in Periprocedural Complications Following Lower Extremity Peripheral Vascular Intervention. Circ Cardiovasc Interv 2022 Aug;15(8):e011768. PM: 35938403.

Attar R, Wu A, Wojdyla D, Jensen SE, Andell P, Mahaffey KW, Roe MT, James SK, Wallentin L, Vemulapalli S, Alexander JH, Lopes RD, Ohman EM, Hernandez AF, Patel MR, Jones WS. Outcomes After Acute Coronary Syndrome in Patients With Diabetes Mellitus and Peripheral Artery Disease (from the TRACER, TRILOGY-ACS, APPRAISE-2, and PLATO Clinical Trials). Am J Cardiol 2022 Sep 1;178:11-17. PM: 35835600.

Carlisle MA, Piccini JP, Fudim M. The interplay between autonomic tone and atrial arrhythmias. Clin Auton Res 2022 Aug;32(4):223-225. PM:35882685.

Chaitman BR, Cyr DD, Alexander KP, Pracoń R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv 2022 Aug;15(8):e012103. PM: 35973009.

Chew DS, Li Y, Cowper PA, Anstrom KJ, Piccini JP, Poole JE, Daniels MR, Monahan KH, Davidson-Ray L, Bahnson TD, Al-Khalidi HR, Lee KL, Packer DL, Mark DB. Cost-Effectiveness of Catheter Ablation Versus Antiarrhythmic Drug Therapy in Atrial Fibrillation: The CABANA Randomized Clinical Trial. Circulation 2022 Aug 16;146(7):535-547. PM: 35726631.

Chunawala ZS, Qamar A, Arora S, Pandey A, Fudim M, Vaduganathan M, Bhatt DL, Mentz RJ, Caughey MC. Prevalence and Prognostic Significance of Polyvascular Disease in Patients Hospitalized With Acute Decompensated Heart Failure: The ARIC Study. J Card Fail 2022 Aug;28(8):1267-1277. PM: 35045321.

Denslow S, Wingert JR, Hanchate AD, Rote A, Westreich D, Sexton L, Cheng K, Curtis J, Jones WS, Lanou AJ, Halladay JR. Rural-urban outcome differences associated with COVID- 19 hospitalizations in North Carolina. PLoS One 2022 Aug 17;17(8):e0271755. PM: 35976813.

Dungan JR, Qin X, Gregory SG, Cooper-Dehoff R, Duarte JD, Qin H, Gulati M, Taylor JY, Pepine CJ, Hauser ER, Kraus WE. Sex-dimorphic gene effects on survival outcomes in people with coronary artery disease. Am Heart J Plus 2022 May;17:100152. PM: 35959094.

Fagundes A, Berg DD, Park JG, Baird-Zars VM, Newby LK, Barsness GW, Miller PE, van Diepen S, Katz JN, Phreaner N, Roswell RO, Menon V, Daniels LB, Morrow DA, Bohula EA. Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry. Circ Cardiovasc Qual Outcomes 2022 Aug;15(8):e008652. PM: 35862019.

Fordyce CB, Hill CL, Foldyna B, Douglas PS. Eligibility for Noninvasive Testing Based on the 2021 American Heart Association/American College of Cardiology Guideline for the Evaluation and Diagnosis of Stable Chest Pain: Implications From the PROMISE Trial. Circulation 2022 Aug 16;146(7):582-584. PM: 35969650

Fudim M, Fail PS, Litwin SE, Shaburishvili T, Goyal P, Hummel SL, Borlaug BA, Mohan RC, Patel RB, Mitter SS, Klein L, Rocha-Singh K, Patel MR, Reddy VY, Burkhoff D, Shah SJ. Endovascular ablation of the right greater splanchnic nerve in heart failure with preserved ejection fraction: early results of the REBALANCE-HF trial roll-in cohort. Eur J Heart Fail 2022 Aug;24(8):1410-1414. PM: 35598154.

Goldstein DJ, Puskas JD, Alexander JH, Chang HL, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Yarden O, Orion E, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O’Sullivan K, Williams JB, Crestanello JA, Jessup M, Rose EA, Scavo V, Acker MA, Gillinov M, Mack MJ, Gelijns AC, O’Gara PT, Moskowitz AJ, Bagiella E, Voisine P. External Support for Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Clinical Trial. JAMA Cardiol 2022 Aug 1;7(8):808-816. PM: 35675092.

Granger BB, Kaltenbach LA, Fonarow GC, Allen LA, Lanfear DE, Albert NM, Al-Khalidi HR, Butler J, Cooper LB, Dewald T, Felker GM, Heidenreich P, Kottam A, Lewis EF, Piña IL, Yancy CW, Granger CB, Hernandez AF, Devore AD. Health System-Level Performance in Prescribing Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: Results From the CONNECT-HF Trial. J Card Fail 2022 Aug;28(8):1355-1361. PM: 35462033.

Greene SJ, Lautsch D, Yang L, Tan XI, Brady JE. Prognostic Interplay Between COVID-19 and Heart Failure With Reduced Ejection Fraction. J Card Fail 2022 Aug;28(8):1287-1297. PM: 35597512.

Hernandez AF, Albert NM, Allen LA, Ahmed R, Averina V, Boehmer JP, Cowie MR, Chien CV, Galvao M, Klein L, Kwan B, Lam CSP, Ruble SB, Stolen CM, Stein K. Multiple cArdiac seNsors for mAnaGEment of Heart Failure (MANAGE-HF) – Phase I Evaluation of the Integration and Safety of the HeartLogic Multisensor Algorithm in Patients With Heart Failure. J Card Fail 2022 Aug;28(8):1245-1254. PM: 35460884.

Kelsey MD, Newby LK. Recommendations for use of ezetimibe and/or PCSK9 inhibitors in patients with elevated LDL-C. Ann Intern Med 2022 Aug;175(8):JC86. PM: 35914252.

Lala A, Mentz RJ. Translating Nursing Partnerships in Clinical Care to Scientific Publishing. J Card Fail 2022 Aug;28(8):1243-1244. PM: 35961730.

Mentz RJ, Lautsch D, Pulungan Z, Kim S, Hilkert R, Teigland C, Yang M, Djatche L. Medication Trajectory and Treatment Patterns in Medicare Patients With Heart Failure and Reduced Ejection Fraction. J Card Fail 2022 Aug;28(8):1349-1354. PM: 34930657.

Moulson N, Petek BJ, Churchill TW, Drezner JA, Harmon KG, Kliethermes SA, Mellacheruvu P, Patel MR, Baggish AL. Cardiac Troponin Testing as a Component of Return to Play Cardiac Screening in Young Competitive Athletes Following SARS-CoV-2 Infection. J Am Heart Assoc 2022 Aug 16;11(16):e025369. PM: 35929475.

Stingl C, Dvergsten JA, Eng SWM, Yeung RSM, Fritzler MJ, Mason T, Crowson C, Voora D, Reed AM. Gene Expression Profiles of Treatment Response and Non-Response in Children With Juvenile Dermatomyositis. ACR Open Rheumatol 2022 Aug;4(8):671- 681. PM: 35616642.


1 Comment

  1. I first began working with Magnus as a staff nurse in CCU in the mid to late 90s when he was attending. He treated the nurses well (even the brand new ones!), always taking time to teach, explain, and encourage. I learned much from him about acute care, and grew in my own clinical skills and confidence as well. Fast forward 20 years, and he agreed to sit on my doctoral committee at the Duke School of Nursing. We sorted through piles of data (all we could get at the time) on how to design and grow multiprofessional teams in order to increase access for cardiology patients, we brainstormed and dreamed and we made a difference in our ambulatory cardiology practice. I appreciate Magnus’s commitment to nurturing and growing others: he does it well.

Leave a Reply to Allison Dimsdale Cancel reply

Your email address will not be published. Required fields are marked *