CocaineMLSNCT00059540
The Maternal Lifestyle Study (MLS)
An observational study of Cocaine and Substance Abuse, run by NICHD Neonatal Research Network at 5 sites in United States.
Trial summary
This is a longitudinal, multi-site observational study of the long-term effects of a mother's use of cocaine and/or opiates during pregnancy on her infant. This observational study evaluates the medical, developmental, social, environmental, and neurobehavioral outcomes for 1,400 of the original cohort of children. Read more about this study
- Who is it for?
- Any ageHealthy volunteers can take part
- Conditions the study is for
- Cocaine, Substance Abuse, Infant, Newborn
- How many people
- 11,811 participants
- Where
- 5 sitesUnited States
- Study dates
- May 1993to Mar 2011
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages Any age
- All sexes
- Healthy volunteers accepted
- Child, Adult, Older adult
Study population: Mother and baby dyads delivered at the 4 participating centers.
Who may be able to join
- 18 years or older
- Live near a study site
- Inborn infants
- Birthweight >501 grams (1.1 lbs)
Who cannot join
- Identified psychosis or history of institutionalization for retardation or emotional problems
- Language barriers that prevented her from giving informed consent or understanding the study
- One of a multiple gestation
- Gestational age >42 weeks
- Viability of the infant
Trial locations and contacts
5 sites in 1 country.
5 sites in 1 country
United States5 sites
Wayne State University
Detroit, Michigan, 48201
RTI International
Durham, North Carolina, 27705
University of Tennessee
Memphis, Tennessee, 38163
University of Miami
Miami, Florida, 33136
Brown University, Women & Infants Hospital of Rhode Island
Providence, Rhode Island, 02905
About this study
Official title: The Maternal Lifestyle Study
This is a longitudinal, multi-site observational study of the long-term effects of a mother's use of cocaine and/or opiates during pregnancy on her infant. This observational study evaluates the medical, developmental, social, environmental, and neurobehavioral outcomes for 1,400 of the original cohort of children. A series of follow-up examinations of these children were conducted in 5 phases: 1-36 months, 3.5-7 years, and 8-11 years. Children are currently being examined at 13 years of age.
Read the detailed description
Interest in and availability of cocaine, marijuana, and opiates have complicated long-term investigations into the effects of the widespread recreational use of easily accessible substances like alcohol and tobacco. It remains impossible to determine in single site, small number studies what effects may be related to the use of a specific drug. By accessing the large multi-site population of newborn infants and their mothers available in the NICHD Neonatal Research Network, this study is evaluating the short- and long-term effects of mothers' cocaine and/or opiate use during pregnancy on their term or preterm infants.
Maternal practices assessed in this study include the use and abuse of opiates, cocaine, alcohol, marijuana, and nicotine. This study will address acute perinatal events and long-term medical, developmental, social, environmental, and neurobehavioral outcomes of infants whose mothers engaged in these maternal practices. The study will determine whether specific acute and long-term effects can be attributed to the use and abuse of specific substances.
Over 2 years, approximately 20,000 infants were screened with a goal of enrolling 16,000 infants. It was estimated that approximately 20% of infants would have been exposed to cocaine or opiates. The determination of exposure was based on self-report by the mother or positive meconium assay.
The first phase of the study evaluated the acute effects of maternal practices on infants. This phase involved all mothers who agreed to respond to the initial questionnaire and who allowed the meconium drug screen to be performed on their infants. Acute outcomes are being compared between infants who were exposed to cocaine and opiates through their mothers' use (the exposed group) and infants who were not exposed (the nonexposed group). Acute outcomes include abruptio placenta, fetal growth retardation, non-life threatening congenital malformations, respiratory distress syndrome, chronic lung disease, periventricular-intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and periventricular leukomalacia.
The second phase of the study compared 1,400 exposed and nonexposed infants with respect to long-term neurodevelopmental outcomes. These infants were among the 16,000 infants enrolled in Phase I. It was estimated that 70% of the screened population would consent to participate in Phase II of the study, and 50% of these participants would complete all visits over the initial 3-year study period (2,000 exposed infants enrolled into Phase II and 1,000 exposed infants would complete all follow-up visits). For each exposed infant, an infant of similar age, race, sex, and either alcohol history or maternal age was selected from the nonexposed, screened population. All infants had physical, neurological, gestational age, and growth assessments at birth. The exposed and nonexposed infants were examined at 1, 4, 7, 9, 12, 18, 24, and 36 months corrected age. Follow-up assessments include medical history, and developmental, behavioral, social, and environmental outcomes.
The third phase of the study compared children at ages 4 to 7. The fourth phase is now comparing outcomes in children ages 8 to 11 years old. Assessments include measures of cognition, school performance, antisocial behavior, onset of substance use, psychopathology, neuroendocrine function, and health disorders. Seventy-one percent of the original sample is still enrolled.
- Conditions
- Cocaine, Substance Abuse, Infant, Newborn, Pregnancy, Pregnant Women, Prenatal Care
- Keywords
- NICHD Neonatal Research Network, Maternal Lifestyle Study, Cocaine abuse, Cocaine dependence, Opiate abuse, Opiate dependence, Follow-up, Neurodevelopmental outcome, Substance-related disorders
- Medical subject headings
- Substance-Related Disorders, Cocaine-Related Disorders, Opioid-Related Disorders
What is being measured
The primary outcome is the main question the study is designed to answer.
Neurodevelopmental impairment
Measured: 1 month of age
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted29 Apr 2003 (estimated)
- Study startMay 1993
- Primary completionMar 1995
- Study completionMar 2011
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (46)Papers the sponsor has linked to this study.
- Other trials for CocaineStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 11,811 participants (actual)
Sponsor and investigators
- Lead sponsor
- NICHD Neonatal Research Network
- Sponsor type
- Research network
- Collaborators
- National Institute on Drug Abuse (NIDA), Children's Bureau - Administration for Children and Families, Substance Abuse and Mental Health Services Administration (SAMHSA), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
- Responsible party
- Sponsor
- Investigators
- Barry M. Lester, PhD, Principal investigator, Brown University, Women & Infants Hospital of Rhode IslandAbhik Das, PhD, Principal investigator, RTI InternationalCharles R. Bauer, MD, Principal investigator, University of MiamiHenrietta S. Bada, MD, Principal investigator, University of TennesseeSeetha Shankaran, MD, Principal investigator, Wayne State University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT00059540
- Sponsor's protocol ID
- NICHD-NRN-0008
- Other IDs
- U10HD021397, U10HD021415, U10HD027904, U10HD021385, U10DA024117, U10DA024118, U10DA024119, U10DA024128
- Acronym
- MLS
- Status last verified
- Sep 2016
- First submitted
- 28 Apr 2003
- Last updated
- 21 Sep 2016
- Results posted
- No
- Data monitoring committee
- Yes
Publications
Lester BM, ElSohly M, Wright LL, Smeriglio VL, Verter J, Bauer CR, Shankaran S, Bada HS, Walls HH, Huestis MA, Finnegan LP, Maza PL. The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics. 2001 Feb;107(2):309-17. doi: 10.1542/peds.107.2.309.
PubMed 11158464Andreozzi L, Flanagan P, Seifer R, Brunner S, Lester B. Attachment classifications among 18-month-old children of adolescent mothers. Arch Pediatr Adolesc Med. 2002 Jan;156(1):20-6. doi: 10.1001/archpedi.156.1.20.
PubMed 11772186Bada HS, Bauer CR, Shankaran S, Lester B, Wright LL, Das A, Poole K, Smeriglio VL, Finnegan LP, Maza PL. Central and autonomic system signs with in utero drug exposure. Arch Dis Child Fetal Neonatal Ed. 2002 Sep;87(2):F106-12. doi: 10.1136/fn.87.2.f106.
PubMed 12193516Bada HS, Das A, Bauer CR, Shankaran S, Lester B, Wright LL, Verter J, Smeriglio VL, Finnegan LP, Maza PL. Gestational cocaine exposure and intrauterine growth: maternal lifestyle study. Obstet Gynecol. 2002 Nov;100(5 Pt 1):916-24. doi: 10.1016/s0029-7844(02)02199-3.
PubMed 12423853Bauer CR, Shankaran S, Bada HS, Lester B, Wright LL, Krause-Steinrauf H, Smeriglio VL, Finnegan LP, Maza PL, Verter J. The Maternal Lifestyle Study: drug exposure during pregnancy and short-term maternal outcomes. Am J Obstet Gynecol. 2002 Mar;186(3):487-95. doi: 10.1067/mob.2002.121073.
PubMed 11904612LaGasse LL, Messinger D, Lester BM, Seifer R, Tronick EZ, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Finnegan LP, Maza PL, Liu J. Prenatal drug exposure and maternal and infant feeding behaviour. Arch Dis Child Fetal Neonatal Ed. 2003 Sep;88(5):F391-9. doi: 10.1136/fn.88.5.f391.
PubMed 12937043Tronick EZ, Olson K, Rosenberg R, Bohne L, Lu J, Lester BM. Normative neurobehavioral performance of healthy infants on the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):676-8.
PubMed 14993526Lester BM, Tronick EZ, LaGasse L, Seifer R, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Lu J. Summary statistics of neonatal intensive care unit network neurobehavioral scale scores from the maternal lifestyle study: a quasinormative sample. Pediatrics. 2004 Mar;113(3 Pt 2):668-75.
PubMed 14993525Lester BM, Tronick EZ, Brazelton TB. The Neonatal Intensive Care Unit Network Neurobehavioral Scale procedures. Pediatrics. 2004 Mar;113(3 Pt 2):641-67.
PubMed 14993524Lester BM, Tronick EZ. History and description of the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):634-40.
PubMed 14993523Lester BM, Tronick EZ, LaGasse L, Seifer R, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Lu J, Finnegan LP, Maza PL. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002 Dec;110(6):1182-92. doi: 10.1542/peds.110.6.1182.
PubMed 12456917Lester BM, Lagasse L, Seifer R, Tronick EZ, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Liu J, Finnegan LP, Maza PL. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003 Mar;142(3):279-85. doi: 10.1067/mpd.2003.112.
PubMed 12640376Messinger DS, Bauer CR, Das A, Seifer R, Lester BM, Lagasse LL, Wright LL, Shankaran S, Bada HS, Smeriglio VL, Langer JC, Beeghly M, Poole WK. The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics. 2004 Jun;113(6):1677-85. doi: 10.1542/peds.113.6.1677.
PubMed 15173491Seifer R, LaGasse LL, Lester B, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Liu J. Attachment status in children prenatally exposed to cocaine and other substances. Child Dev. 2004 May-Jun;75(3):850-68. doi: 10.1111/j.1467-8624.2004.00710.x.
PubMed 15144490Shankaran S, Das A, Bauer CR, Bada HS, Lester B, Wright LL, Smeriglio V. Association between patterns of maternal substance use and infant birth weight, length, and head circumference. Pediatrics. 2004 Aug;114(2):e226-34. doi: 10.1542/peds.114.2.e226.
PubMed 15286261
Study at a glance
From the registry record, last updated by the sponsor on 21 Sep 2016. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- The Maternal Lifestyle Study
- ClinicalTrials.gov ID
- NCT00059540
- Acronym / sponsor ID
- MLS / NICHD-NRN-0008
- Conditions
- Cocaine, Substance Abuse, Infant, Newborn, Pregnancy, Pregnant Women, Prenatal Care
- Keywords
- NICHD Neonatal Research Network, Maternal Lifestyle Study, Cocaine abuse, Cocaine dependence, Opiate abuse, Opiate dependence, Follow-up, Neurodevelopmental outcome
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 11,811 participants (actual)
- Lead sponsor
- NICHD Neonatal Research NetworkResearch network
- Collaborators
- National Institute on Drug Abuse (NIDA), Children's Bureau - Administration for Children and Families, Substance Abuse and Mental Health Services Administration (SAMHSA), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
- Study start
- May 1993
- Primary completion
- Mar 1995 (actual)
- Study completion
- Mar 2011 (actual)
- First posted
- 29 Apr 2003 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
This is a longitudinal, multi-site observational study of the long-term effects of a mother's use of cocaine and/or opiates during pregnancy on her infant. This observational study evaluates the medical, developmental, social, environmental, and neurobehavioral outcomes for 1,400 of the original cohort of children. A series of follow-up examinations of these children were conducted in 5 phases: 1-36 months, 3.5-7 years, and 8-11 years. Children are currently being examined at 13 years of age.
Detailed description
Interest in and availability of cocaine, marijuana, and opiates have complicated long-term investigations into the effects of the widespread recreational use of easily accessible substances like alcohol and tobacco. It remains impossible to determine in single site, small number studies what effects may be related to the use of a specific drug. By accessing the large multi-site population of newborn infants and their mothers available in the NICHD Neonatal Research Network, this study is evaluating the short- and long-term effects of mothers' cocaine and/or opiate use during pregnancy on their term or preterm infants.
Maternal practices assessed in this study include the use and abuse of opiates, cocaine, alcohol, marijuana, and nicotine. This study will address acute perinatal events and long-term medical, developmental, social, environmental, and neurobehavioral outcomes of infants whose mothers engaged in these maternal practices. The study will determine whether specific acute and long-term effects can be attributed to the use and abuse of specific substances.
Over 2 years, approximately 20,000 infants were screened with a goal of enrolling 16,000 infants. It was estimated that approximately 20% of infants would have been exposed to cocaine or opiates. The determination of exposure was based on self-report by the mother or positive meconium assay.
The first phase of the study evaluated the acute effects of maternal practices on infants. This phase involved all mothers who agreed to respond to the initial questionnaire and who allowed the meconium drug screen to be performed on their infants. Acute outcomes are being compared between infants who were exposed to cocaine and opiates through their mothers' use (the exposed group) and infants who were not exposed (the nonexposed group). Acute outcomes include abruptio placenta, fetal growth retardation, non-life threatening congenital malformations, respiratory distress syndrome, chronic lung disease, periventricular-intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and periventricular leukomalacia.
The second phase of the study compared 1,400 exposed and nonexposed infants with respect to long-term neurodevelopmental outcomes. These infants were among the 16,000 infants enrolled in Phase I. It was estimated that 70% of the screened population would consent to participate in Phase II of the study, and 50% of these participants would complete all visits over the initial 3-year study period (2,000 exposed infants enrolled into Phase II and 1,000 exposed infants would complete all follow-up visits). For each exposed infant, an infant of similar age, race, sex, and either alcohol history or maternal age was selected from the nonexposed, screened population. All infants had physical, neurological, gestational age, and growth assessments at birth. The exposed and nonexposed infants were examined at 1, 4, 7, 9, 12, 18, 24, and 36 months corrected age. Follow-up assessments include medical history, and developmental, behavioral, social, and environmental outcomes.
The third phase of the study compared children at ages 4 to 7. The fourth phase is now comparing outcomes in children ages 8 to 11 years old. Assessments include measures of cognition, school performance, antisocial behavior, onset of substance use, psychopathology, neuroendocrine function, and health disorders. Seventy-one percent of the original sample is still enrolled.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
Who may qualify
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Child, Adult, Older adult
- Study population
- Mother and baby dyads delivered at the 4 participating centers.
Key inclusion criteria (4 listed)
- 18 years or older
- Live near a study site
- Inborn infants
- Birthweight >501 grams (1.1 lbs)
Key exclusion criteria (5 listed)
- Identified psychosis or history of institutionalization for retardation or emotional problems
- Language barriers that prevented her from giving informed consent or understanding the study
- One of a multiple gestation
- Gestational age >42 weeks
- Viability of the infant
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Primary outcome
Neurodevelopmental impairment
Time frame: 1 month of age
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 21 Sep 2016.
- Background: PubMed 11158464Lester BM, ElSohly M, Wright LL, Smeriglio VL, Verter J, Bauer CR, Shankaran S, Bada HS, Walls HH, Huestis MA, Finnegan LP, Maza PL. The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics. 2001 Feb;107(2):309-17. doi: 10.1542/peds.107.2.309.
- Background: PubMed 11772186Andreozzi L, Flanagan P, Seifer R, Brunner S, Lester B. Attachment classifications among 18-month-old children of adolescent mothers. Arch Pediatr Adolesc Med. 2002 Jan;156(1):20-6. doi: 10.1001/archpedi.156.1.20.
- Background: PubMed 12193516Bada HS, Bauer CR, Shankaran S, Lester B, Wright LL, Das A, Poole K, Smeriglio VL, Finnegan LP, Maza PL. Central and autonomic system signs with in utero drug exposure. Arch Dis Child Fetal Neonatal Ed. 2002 Sep;87(2):F106-12. doi: 10.1136/fn.87.2.f106.
- Background: PubMed 12423853Bada HS, Das A, Bauer CR, Shankaran S, Lester B, Wright LL, Verter J, Smeriglio VL, Finnegan LP, Maza PL. Gestational cocaine exposure and intrauterine growth: maternal lifestyle study. Obstet Gynecol. 2002 Nov;100(5 Pt 1):916-24. doi: 10.1016/s0029-7844(02)02199-3.
- Background: PubMed 11904612Bauer CR, Shankaran S, Bada HS, Lester B, Wright LL, Krause-Steinrauf H, Smeriglio VL, Finnegan LP, Maza PL, Verter J. The Maternal Lifestyle Study: drug exposure during pregnancy and short-term maternal outcomes. Am J Obstet Gynecol. 2002 Mar;186(3):487-95. doi: 10.1067/mob.2002.121073.
- Background: PubMed 12937043LaGasse LL, Messinger D, Lester BM, Seifer R, Tronick EZ, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Finnegan LP, Maza PL, Liu J. Prenatal drug exposure and maternal and infant feeding behaviour. Arch Dis Child Fetal Neonatal Ed. 2003 Sep;88(5):F391-9. doi: 10.1136/fn.88.5.f391.
- Background: PubMed 14993526Tronick EZ, Olson K, Rosenberg R, Bohne L, Lu J, Lester BM. Normative neurobehavioral performance of healthy infants on the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):676-8.
- Background: PubMed 14993525Lester BM, Tronick EZ, LaGasse L, Seifer R, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Lu J. Summary statistics of neonatal intensive care unit network neurobehavioral scale scores from the maternal lifestyle study: a quasinormative sample. Pediatrics. 2004 Mar;113(3 Pt 2):668-75.
- Background: PubMed 14993524Lester BM, Tronick EZ, Brazelton TB. The Neonatal Intensive Care Unit Network Neurobehavioral Scale procedures. Pediatrics. 2004 Mar;113(3 Pt 2):641-67.
- Background: PubMed 14993523Lester BM, Tronick EZ. History and description of the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):634-40.
- Background: PubMed 12456917Lester BM, Tronick EZ, LaGasse L, Seifer R, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Lu J, Finnegan LP, Maza PL. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002 Dec;110(6):1182-92. doi: 10.1542/peds.110.6.1182.
- Background: PubMed 12640376Lester BM, Lagasse L, Seifer R, Tronick EZ, Bauer CR, Shankaran S, Bada HS, Wright LL, Smeriglio VL, Liu J, Finnegan LP, Maza PL. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003 Mar;142(3):279-85. doi: 10.1067/mpd.2003.112.
- Maternal Lifestyle Study descriptionLink provided by the sponsor.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Barry M. Lester, PhD principal investigator
Brown University, Women & Infants Hospital of Rhode Island
Abhik Das, PhD principal investigator
RTI International
Charles R. Bauer, MD principal investigator
University of Miami
5 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Cocaine and Substance Abuse, run by NICHD Neonatal Research Network at 5 sites in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 5 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 21 Sep 2016. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 5 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Neurodevelopmental impairment (time frame: 1 month of age). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT00059540, which also lists 46 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 21 Sep 2016.