A Review of Selected Presentations From the ACG 2025 Annual Scientific Meeting
October 24-29, 2025 • Phoenix, Arizona
Treatment With Resmetirom for Up to 2 Years Led to Improvement in Liver Stiffness, Fibrosis Biomarkers, Fibrosis Scores, and Portal Hypertension Risk in 122 Patients With Compensated MASH Cirrhosis
Resmetirom is an oral, once-daily, liver-directed thyroid hormone receptor β agonist currently approved by the US Food and Drug Administration for adults with metabolic dysfunction-associated steatohepatitis (MASH), characterized by moderate to advanced liver scarring without cirrhosis.1 There is an unmet need for effective therapies for patients with MASH and compensated cirrhosis, as no therapies have been approved for this subset of patients, and stage F4 fibrosis is associated with an increased risk of adverse outcomes, including liver-related complications, need for transplantation, and death.2 It has been proposed that by restoring thyroid hormone receptor β signaling, resmetirom may promote fibrosis regression through its effects on mitogenesis, reductions in oxidative stress, and effects on hepatic stellate cells.3
Alkhouri and colleagues presented results from the MAESTRO-NAFLD-1 trial evaluating the safety and efficacy of resmetirom in an open-label cohort of patients with compensated MASH cirrhosis (Child-Pugh A).4 These patients received resmetirom 80 mg for 52 weeks, and after a variable gap of 1 month to 1 year off treatment, entered a 1-year open-label extension. The cohort comprised 122 patients with F4 fibrosis on liver biopsy or noninvasive clinical assessments with a platelet count of 70,000/μL or higher. Most patients (n=93) had classic MASH cirrhosis, with a baseline magnetic resonance imaging-proton density fat fraction (MRI-PDFF) greater than 5%; the remaining 21 patients had an MRI-PDFF of 5% or less. This cryptogenic MASH cirrhosis is associated with a more aggressive disease course, and patients tend to have more liver stiffness, larger spleens, lower platelet counts, and higher fibrosis-4 index (FIB-4).
In the efficacy analysis, resmetirom was associated with significant sustained reductions in liver stiffness measurement (LSM). After 1 year, 47% of patients achieved a 25% or more reduction in LSM assessed with vibration-controlled transient elastography (VCTE), increasing to 51% at 2 years. The mean change in VCTE was -6.4 kilopascals (kPa) after 1 year (n=116) and -6.7 kPa after 2 years (n=101). Among patients with confirmed F4 fibrosis at baseline, 35% had a potential transition to F3 at year 2 as defined by VCTE (<15 kPa and ≥25% decrease from baseline).
Reductions in portal hypertension risk category were also observed in patients receiving resmetirom. At baseline, clinically significant portal hypertension (CSPH) was present in 35% of patients as assessed using Baveno criteria. This decreased to 17% after 1 year and to 15% after 2 years. Conversely, the proportion of patients with no or low CSPH increased from 51% at baseline to 58% at 1 year and 70% at 2 years. Similar reductions in portal hypertension risk were observed using modified Baveno criteria, which add requirements for CSPH in patients with VCTE of 25 kPa or higher. A subgroup analysis found significant shifts in portal hypertension risk across baseline CSPH risk categories (Figure 1).
Resmetirom was also associated with sustained reductions in liver fat and liver stiffness at 2 years as assessed by changes from baseline in MRI-PDFF greater than 5% (n=83; median change, -37%), controlled attenuation parameter (CAP) score (n=79; mean change, -43 dBM), and magnetic resonance elastography (MRE) (n=77; mean change, -0.48 kPa). An improved MRE response (≥19%) was noted in 29% of patients with a baseline MRI-PDFF greater than 5% and in 43% of patients with a baseline MRI-PDFF of 5% or less.
Other biomarkers that improved after 2 years of resmetirom included alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT). In patients with MRI-PDFF greater than 5% (n=64) and MRI-PDFF of 5% or less (n=8) at baseline, mean percent change from baseline in ALT (≥30 at baseline) was -20% and -11%, respectively, and in GGT was -36% and -27%, respectively. Reductions in fibrosis and liver injury biomarkers as well as in atherogenic lipids were also observed. Finally, MRI-based assessments showed a decrease in liver volume (mean) of 22% to 25% and reduced mean spleen volume in patients with a baseline platelet count greater than 100,000/μL.
In the safety analysis, resmetirom was well tolerated. There were no serious adverse events (AEs) related to resmetirom, with the most frequent AEs being diarrhea (38%), COVID-19 (31%), nausea (31%), and urinary tract infection (27%). Decompensation events occurred in 6 of 122 patients, all of whom had elevated baseline Model for End-Stage Liver Disease score and/or platelets less than 100,000/μL.
The potential clinical benefit of resmetirom in patients with MASH cirrhosis is being evaluated in the ongoing phase 3 MAESTRO-NASH-OUTCOMES trial (NCT05500222).
References
1. Rezdiffra [package insert]. West Conshohocken, PA: Madrigal Pharmaceuticals, Inc; 2024.
2. Sanyal AJ, Van Natta ML, Clark J, et al; NASH Clinical Research Network (CRN). Prospective Study of outcomes in adults with nonalcoholic fatty liver disease. N Engl J Med. 2021;385(17):1559-1569.
3. Arvanitakis K, Koufakis T, Cholongitas E, Francque S, Germanidis G. Insights into the results of resmetirom trials: can a thyroid hormone receptor agonist be the holy grail of MASH therapy? Pharmacol Ther. 2025;268:108811.
4. Alkhouri N, Taub R, Lu X, et al. Treatment with resmetirom for up to 2 years led to improvement in liver stiffness, fibrosis biomarkers, fibrosis scores, and portal hypertension risk in 122 patients with compensated MASH cirrhosis. Abstract 7. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
Comparative Efficacy of Tirzepatide vs Semaglutide on Liver and Cardiovascular Related Outcomes in Patients with MASLD/MASH, Obesity, and Type 2 Diabetes Mellitus: A Real-World Cohort Study
Type 2 diabetes mellitus (T2DM) commonly occurs in patients who have metabolic dysfunction-associated steatotic liver disease (MASLD) and/or MASH.1 Glucagon-like peptide-1 (GLP-1) receptor agonists such as semaglutide have demonstrated benefits in patients with T2DM, including reduced body weight, improved glycemia, and a lower incidence of major adverse cardiovascular events.2,3 In the SURPASS-2 trial, the dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonist tirzepatide demonstrated superiority over semaglutide in weight loss and in glycated hemoglobin (A1c) levels.4 The cardioprotective benefits of dual GIP/GLP-1 receptor agonists compared with selective GLP-1 receptor agonists have not been directly compared.
Through the TriNetX database, Jalamneh and colleagues identified adults with MASLD, T2DM, and a body mass index (BMI) of 30 kg/m2 or higher receiving tirzepatide (n=21,517) or semaglutide (n=66,084) and conducted a retrospective, propensity score–matched analysis comparing cardiovascular and other outcomes.5 The analysis was balanced for 43 demographic, diagnostic, medication-related, and laboratory-related variables to yield a final cohort of 21,513 patients in each arm. Outcomes were assessed at 6 months, 1 year, and 2 years.
Compared with semaglutide, tirzepatide was associated with lower risks of multiple cardiovascular-related outcomes (Figure 2). The cumulative probability curves showed sustained separation toward the end, stopping at about 6 months, with P values of less than .05 for all-cause mortality, all-cause hospitalization, acute myocardial infarction, peripheral vascular disease, heart failure, and heart failure exacerbation. The only safety parameter that was significantly different between arms was acute kidney injury, which significantly favored the tirzepatide arm (hazard ratio [HR], 0.880; 95% CI, 0.812-0.953; P=.002); other outcomes, including pancreatitis, cholelithiasis, cholecystitis, hypoglycemia, and gastroparesis, were not significantly different between arms.
Although confounding bias was addressed in the analysis, the study had several limitations, including the potential for misclassification, residual confounding bias from unmeasured variables, the retrospective design, and short follow-up available for tirzepatide. The analysis showed favorable cardiovascular outcomes and decreased acute kidney injury events with tirzepatide compared with semaglutide. Patients with established coronary artery disease/heart failure or with frequent hospital admissions may obtain the most clinically meaningful benefit from tirzepatide.
References
1. Le P, Tatar M, Dasarathy S, et al. Estimated burden of metabolic dysfunction-associated steatotic liver disease in US Adults, 2020 to 2050. JAMA Netw Open. 2025;8(1):e2454707.
2. Marso SP, Bain SC, Consoli A, et al; SUSTAIN-6 Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834-1844.
3. Kristensen SL, Rørth R, Jhund PS, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet Diabetes Endocrinol. 2019;7(10):776-785.
4. Frías JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes. N Engl J Med. 2021;385(6):503-515.
5. Jalamneh B, Abu-Hammour MN, Alabbas M, et al. Comparative efficacy of tirzepatide vs semaglutide on liver and cardiovascular related outcomes in patients with MASLD/MASH, obesity, and type 2 diabetes mellitus: a real-world cohort study. Abstract 31. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
Changes in Health-Related Quality of Life, Cognitive Dysfunction, and Worry Domains in Patients With MASLD and MASH Treated With Resmetirom
Patients with MASLD can experience cognitive impairment that may relate to inflammation, oxidative stress, and dysregulation of the brain-liver-gut axis.1 Cognitive changes and their effects on health-related quality of life (HRQL) have not been well characterized by the standard assessments for HRQL in patients with liver disease.
Younossi and colleagues developed a new Cognitive Function Self-Report domain, which was utilized to evaluate cognitive changes in patients with MASLD or MASH enrolled in the MAESTRO-NAFLD and MAESTRO-NASH clinical trials of resmetirom.2 In both trials, patients completed the Liver Disease Quality of Life Questionnaire and Chronic Liver Disease Questionnaire-nonalcoholic fatty liver disease (CLDQ-NAFLD) at baseline, Week 24, and Week 52. Patients’ data from these HRQL instruments were used to develop a surrogate Cognitive Function Self-Report domain. The domain asks patients to rate how often during the past 4 weeks they have had difficulties related to concentration, memory, and thinking. The validated CLDQ-NAFLD Worry domain was also assessed at baseline and during treatment.
Across the 2 trials, 2243 patients completed the HRQL instruments, including 50% with early MASH, 42% with F2 or F3 MASH, and 8% with MASH cirrhosis. Throughout the study, Cognitive Function Self-Report scores were significantly higher in patients with early MASH than in patients with F2 or F3 MASH or those with cirrhosis, as were the CLDQ-NAFLD Worry domain scores.
Multiple factors were significantly and independently associated with low (in the bottom quartile) Worry scores: younger age, female sex, history of depression, and higher LSM. These factors, plus a history of clinically overt fatigue, also independently predicted low Cognitive Function Self-Report scores, which were significantly and strongly associated with overall HRQL.
During the 1-year resmetirom study, average Cognitive Function Self-Report scores declined in patients receiving placebo but did not decline in patients treated with 80 mg or 100 mg of resmetirom (Table 1). The Cognitive Function Self-Report and Worry domains capture different aspects of HRQL, and both patient characteristics and treatment can affect these domains. The Cognitive Function Self-Report domain has the potential to be used clinically as a practical way for tracking patient-perceived cognitive deficits.
References
1. Meroni M, Longo M, Paolini E, Dongiovanni P. A narrative review about cognitive impairment in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): another matter to face through a holistic approach. J Adv Res. 2025;68:231-240.
2. Younossi ZM, Nader F, Labriola D, et al. Changes in health-related quality of life, cognitive dysfunction, and worry domains in patients with MASLD and MASH treated with resmetirom. Abstract P3697. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
Efficacy and Safety of Efruxifermin in Patients With MASH: A Meta-Analysis of Randomized Controlled Trials
Efruxifermin is a novel engineered fibroblast growth factor 21 (FGF21) fusion protein being evaluated for the treatment of MASH. Rajab and colleagues conducted a systematic review and meta-analysis of 4 randomized controlled trials of efruxifermin compared with placebo in patients with MASH to evaluate key histologic outcomes.1
The 4 trials analyzed were the phase 2b BALANCED study of 80 patients with MASH, the phase 2b HARMONY trial of 747 patients with MASH and F2 or F3 fibrosis, a study of a cohort of patients with MASH and stage 4 fibrosis from the BALANCED trial (n=30), and a phase 2b trial of 181 patients with MASH and compensated cirrhosis.2-5
Efruxifermin was associated with significant improvements in multiple outcomes (Figure 3). Overall, 39.7% of patients receiving efruxifermin experienced an improvement in fibrosis stage by at least 1 category without MASH worsening, compared with 17.1% in the placebo arm (risk ratio [RR], 1.83; 95% CI, 1.17-2.84; P=.01). Patients receiving efruxifermin were also significantly more likely than those receiving placebo to attain MASH resolution without worsening (45.1% and 13.5%; RR, 2.42; 95% CI, 1.48-3.94) and to attain a combined outcome of MASH resolution and improvement (28.8% vs 4%; RR, 3.77; 95% CI, 1.10-12.87; P=.03). The likelihood of attaining a fibrosis improvement of at least 2 stage categories was not significantly different between arms.
In the safety analysis, the incidence of drug-related AEs was significantly higher with efruxifermin vs placebo (71.2% vs 43.7%; RR, 1.35; 59% CI, 1.06-1.71; P<.05), as was the rate of discontinuations owing to AEs (10.3% vs 2.2%; RR, 3.13; 95% CI, 1.12-8.76; P<.05). Rates of serious AEs, deaths, and overall treatment-emergent AEs were not significantly different between arms.
The meta-analysis suggests that efruxifermin may have a therapeutic role in MASH, and toxicities appear manageable. However, additional randomized trials are needed to establish its efficacy and safety in the long term.
References
1. Rajab I, Elgendy MS, Emara A, et al. Efficacy and safety of efruxifermin in patients with MASH: a meta-analysis of randomized controlled trials. Abstract P5882. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
2. Harrison SA, Ruane PJ, Freilich BL, et al. Efruxifermin in non-alcoholic steatohepatitis: a randomized, double-blind, placebo-controlled, phase 2a trial. Nat Med. 2021;27(7):1262-1271.
3. Harrison SA, Frias JP, Neff G, et al; HARMONY Study Group. Safety and efficacy of once-weekly efruxifermin versus placebo in non-alcoholic steatohepatitis (HARMONY): a multicentre, randomised, double-blind, placebo-controlled, phase 2b trial. Lancet Gastroenterol Hepatol. 2023;8(12):1080-1093.
4. Noureddin M, Rinella ME, Chalasani NP, et al. Efruxifermin in compensated liver cirrhosis caused by MASH. N Engl J Med. 2025;392(24):2413-2424.
5. Harrison SA, Ruane PJ, Freilich B, et al. A randomized, double-blind, placebo-controlled phase IIa trial of efruxifermin for patients with compensated NASH cirrhosis. JHEP Rep Innov Hepatol. 2022;5(1):100563.
Distinct Lipid and Liver Enzyme Trajectories in Diabetic vs Nondiabetic MASLD/MASH Patients Treated With Resmetirom: A Multicenter Propensity-Matched Analysis
Diabetes mellitus and MASLD share overlapping pathophysiologies and often co-occur.1 Treatment with resmetirom has been shown to reduce liver fat and improve lipid profiles, including low-density lipoprotein (LDL) levels.2 Lee and colleagues compared laboratory parameters over time in MASLD/MASH patients with or without DM who were prescribed resmetirom.3 After propensity score matching to adjust for age, race, gender, BMI, and use of lipid-lowering agents, the cohort included 461 patients with DM and 461 patients without DM.
Mean laboratory trends were compared at baseline and at 1 month, 6 months, and 12 months using a cox proportional hazards model. Patients with DM treated with resmetirom had statistically lower LDL and total cholesterol levels at all time points (P<.05) (Table 2). High-density lipoprotein levels were not significantly different after the baseline reading, whereas triglyceride levels between the patients with and without DM were only statistically different at 1 month.
The trajectories of ALT and AST differed between the 2 cohorts, with non-DM patients having a nonsignificant transient increase in the liver enzyme levels at 1 month, and patients with DM having stable levels throughout. Both groups of patients had improved AST and ALT at 6 and 12 months, but only AST was statistically significant at 6 months (P<.05).
The findings suggest distinct biochemical response patterns to resmetirom based on DM status of patients with MASLD/MASH. Additional research should assess whether glycemic control, insulin resistance, or antidiabetic therapies may affect the efficacy of resmetirom and lead to better outcomes.
References
1. Leith D, Lin YY, Brennan P. Metabolic dysfunction-associated steatotic liver disease and type 2 diabetes: a deadly synergy. TouchREV Endocrinol. 2024;20(2):5-9.
2. Harrison SA, Bedossa P, Guy CD, et al; MAESTRO-NASH Investigators. A phase 3, randomized, controlled trial of resmetirom in NASH with liver fibrosis. N Engl J Med. 2024;390(6):497-509.
3. Lee R, Totah F, Solaimani P. Distinct lipid and liver enzyme trajectories in diabetic vs nondiabetic MASLD/MASH patients treated with resmetirom: a multicenter propensity-matched analysis. Abstract 5899. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
Efficacy of Glucagon-Like Peptide-1 Receptor Agonists in MASH Resolution and Fibrosis Reduction: A Meta-Analysis
Glucagon-like peptide-1 (GLP-1) receptor agonists have now been evaluated in patients with MASH in multiple randomized trials. To better understand the efficacy and safety of these agents in patients with MASH, Tripathi and colleagues conducted a meta-analysis of 6 randomized controlled trials.1 The dataset included a study of liraglutide vs placebo in 14 patients with MASH; a phase 2 trial of semaglutide 2.4 mg once weekly vs placebo in 71 patients with MASH and compensated cirrhosis; the phase 2 SYNERGY-NASH trial of tirzepatide in 190 patients with MASH and stage F2 or F3 fibrosis; the phase 2 NN931-4296 trial of semaglutide vs placebo in 320 patients with MASH and F1 to F3 fibrosis; the phase 2 1404-0043 trial of survodutide vs placebo in 293 patients with MASH and F1 to F3 fibrosis; and the phase 3 ESSENCE trial of semaglutide vs placebo in 1196 patients with MASH and F2 to F3 fibrosis.2-7
A total of 1273 patients, 782 receiving GLP-1 receptor agonists and 491 receiving placebo, met the inclusion criteria. Patients were followed for an average of 57 weeks; the median patient age was 54 years, and 45% were male. Overall, patients receiving GLP-1 receptor agonists were significantly more likely than those receiving placebo to have resolution of MASH (odds ratio [OR], 3.94; 95% CI, 3.06-5.08; P<.0001) (Figure 4). Improvements in fibrosis were also associated with the GLP-1 receptor agonists compared with placebo in 5 of the 6 studies (OR, 1.81; 95% CI, 1.40-2.35; P<.0001). Gastrointestinal AEs, including nausea, vomiting, and diarrhea, occurred at a significantly higher rate in patients receiving GLP-1 receptor agonists than in patients receiving placebo (OR, 14.34; 95% CI, 7.98-25.79) across 3 studies.
The meta-analysis demonstrated that GLP-1 receptor agonists compared with placebo significantly enhance improvement of fibrosis in patients with MASH, suggesting that they have a role in mitigating disease progression. The results support the inclusion of GLP-1 receptor agonists into clinical management guidelines, granted that further studies assess their long-term safety and effectiveness.
References
1. Tripathi R, Gupta S, Jarnes L, Zeidan N, Tao M, Jamorabo D. Efficacy of GLP-1 receptor agonists in MASH resolution and fibrosis reduction: a meta-analysis. Abstract P3746. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.
2. Armstrong MJ, Hull D, Guo K, et al. Glucagon-like peptide 1 decreases lipotoxicity in non-alcoholic steatohepatitis. J Hepatol. 2016;64(2):399-408.
3. Loomba R, Abdelmalek MF, Armstrong MJ, et al; NN9931-4492 investigators. Semaglutide 2.4 mg once weekly in patients with non-alcoholic steatohepatitis-related cirrhosis: a randomised, placebo-controlled phase 2 trial. Lancet Gastroenterol Hepatol. 2023;8(6):511-522.
4. Loomba R, Hartman ML, Lawitz EJ, et al; SYNERGY-NASH Investigators. Tirzepatide for metabolic dysfunction-associated steatohepatitis with liver fibrosis. N Engl J Med. 2024;391(4):299-310.
5. Newsome PN, Buchholtz K, Cusi K, et al; NN9931-4296 Investigators. A placebo-controlled trial of subcutaneous semaglutide in nonalcoholic steatohepatitis. N Engl J Med. 2021;384(12):1113-1124.
6. Sanyal AJ, Bedossa P, Fraessdorf M, et al; 1404-0043 Trial Investigators. A phase 2 randomized trial of survodutide in MASH and fibrosis. N Engl J Med. 2024;391(4):311-319.
7. Sanyal AJ, Newsome PN, Kliers I, et al; ESSENCE Study Group. Phase 3 trial of semaglutide in metabolic dysfunction-associated steatohepatitis. N Engl J Med. 2025;392(21):2089-2099.
Real-World Safety and Monitoring Practices in Patients Receiving Resmetirom for MASH: A Single Center Retrospective Review
Although resmetirom demonstrated encouraging tolerability in clinical trials, there is limited evidence regarding safety outcomes and adherence to laboratory monitoring guideline recommendations among patients receiving resmetirom in clinical practice. Lora and colleagues presented results of a retrospective analysis evaluating patient characteristics, treatment duration, AEs, and adherence to laboratory monitoring guidelines in patients with MASH receiving resmetirom at a single academic center.1
The cohort initially included 56 patients who were prescribed resmetirom. However, 9 patients (16%) were excluded after they did not initiate resmetirom owing to insurance denial, and 13 additional patients were excluded because they had not started resmetirom or had no accessible laboratory data. The mean age of enrolled patients was 55 years, average BMI was 36.2 kg/m2, and 44% were male. Most patients were Hispanic (44.1%) or White (35.3%); 1 patient (2.9%) was Black and the remaining 6 (17.7%) were other races/ethnicities. The mean duration of resmetirom therapy was 236.6 days.
At baseline, the mean fibrosis score (assessed in 27 patients) was F1 to F2 in 4 patients (14.8%), F2 in 3 patients (11.1%), F2 to F3 in 5 patients (18.5%), F3 in 9 patients (33.3%), F3 to F4 in 5 patients (18.5%), and F4 in 1 patient (3.7%). Mean NAFLD fibrosis scores did not change significantly from baseline to 3 to 6 months, likely because of short follow-up.
AEs were reported in 15 patients (44.1%) (Figure 5). The most common toxicities were gastrointestinal, with diarrhea being the most frequent (40%), followed by nausea/vomiting (20%) and bloating (6.7%). Other documented AEs included mild liver function test elevation (26.7%) and hyperthyroidism (6.7%). The 3 documented discontinuations from toxicity were all attributed to diarrhea.
Monitoring practices varied; although liver enzymes were tested at baseline and at 3 to 6 months in 70% of patients, thyroid function was only assessed in 38% of patients at baseline and in 14% at follow-up. In the one patient with preexisting hyperthyroidism, the dose of levothyroxine was adjusted after starting resmetirom.
Resmetirom was generally well tolerated, but there was a notable incidence of gastrointestinal events, especially diarrhea. The authors noted that monitoring practices frequently did not meet guidelines recommended by the American Association for the Study of Liver Diseases.
Reference
1. Lora DR, Blumenstein A, Post Z, Reau N. Real-world safety and monitoring practices in patients receiving resmetirom for MASH: a single-center retrospective review. Abstract P5938. Presented at: ACG 2025 Annual Scientific Meeting; October 24-29, 2025; Phoenix, Arizona.