[Review of nutrition and hydration in relation to physical exercise during pregnancy]. / Revisión de la nutrición e hidratación con relación al ejercicio físico en el embarazo.

Studies on nutritional recommendations for pregnant women who exercise are scarce. The objective of this article is not to focus on the diet of pregnant women as a whole, but to review those aspects of it that may be related to physical exercise. To this end, the nutritional and hydration recommendations contained in the main clinical practice guides on physical exercise during pregnancy are collected, including the first Spanish guides. Likewise, the energy requirements required by pregnant women who perform physical exercise during pregnancy for adequate gestational weight gain are addressed, aspects related to macronutrients in the aforementioned population group, and two specific topics, such as nutritional needs in the adolescent who practices physical exercise during pregnancy and eating disorders in pregnant athletes It is concluded by stating that pregnant women who exercise regularly should eat a varied and balanced diet, such as the Mediterranean diet, avoid long periods of fasting to avoid the appearance of hypoglycemia and maintain adequate fluid intake before, during and after physical exercise. Pregnant adolescents who engage in physical exercise require nutritional supervision to achieve adequate gestational weight gain. The pregnant athlete with an eating disorder has a higher risk of complications during pregnancy and childbirth, gynecological, fetal and neonatal, and, therefore, requires close monitoring by specialists in maternal-fetal medicine.

Recomendaciones prácticas sobre ejercicio físico durante el embarazo basadas en las principales guías de práctica clínica / Practical recommendations on physical exercise during pregnancy based on the main clinical practice guidelines

Las principales guías de actividad física/ejercicio durante el embarazo recomiendan que todas las mujeres embarazadas sin contraindicaciones médicas u obstétricas se mantengan activas físicamente durante la gestación, con el objetivo de conseguir beneficios para su salud y, al mismo tiempo, reducir la posibilidad de complicaciones durante el embarazo. El objetivo de este artículo fue extraer las recomendaciones prácticas sobre ejercicio físico durante el embarazo, de interés para el médico de atención primaria (AP), de las guías de práctica clínica de tres sociedades internacionales de obstetricia y ginecología de reconocido prestigio y gran influencia internacional en este tema, dos de ellas pioneras en la elaboración de este tipo de recomendaciones: el Colegio Americano de Obstetricia y Ginecología y la Sociedad Canadiense de Obstetricia y Ginecología; y el Real Colegio de Obstetras y Ginecólogos de Australia y Nueva Zelanda, junto con la publicada por la Sociedad Española de Ginecología y Obstetricia.(AU)

The main guidelines for physical activity/exercise during pregnancy recommend that all pregnant women without medical or obstetric contraindications remain physically active during pregnancy, in order to achieve health benefits and, at the same time, reduce the possibility of complications during pregnancy. The objective of this article was to extract the practical recommendations on physical exercise during pregnancy, of interest to the primary care physician, from the clinical practice guidelines of three international societies of Obstetrics and Gynecology of recognized prestige and great international influence on this subject, two of them pioneers in the elaboration of this type of recommendations: the American College of Obstetrics and Gynecology and the Society of Obstetricians and Gynaecologists of Canada; and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, together with the one published by the Spanish Society of Gynecology and Obstetrics.(AU)

[Practical recommendations on physical exercise during pregnancy based on the main clinical practice guidelines]. / Recomendaciones prácticas sobre ejercicio físico durante el embarazo basadas en las principales guías de práctica clínica.

The main guidelines for physical activity/exercise during pregnancy recommend that all pregnant women without medical or obstetric contraindications remain physically active during pregnancy, in order to achieve health benefits and, at the same time, reduce the possibility of complications during pregnancy. The objective of this article was to extract the practical recommendations on physical exercise during pregnancy, of interest to the primary care physician, from the clinical practice guidelines of three international societies of Obstetrics and Gynecology of recognized prestige and great international influence on this subject, two of them pioneers in the elaboration of this type of recommendations: the American College of Obstetrics and Gynecology and the Society of Obstetricians and Gynaecologists of Canada; and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, together with the one published by the Spanish Society of Gynecology and Obstetrics.

Caminar durante el embarazo: la actividad física preferida por las embarazadas / Walking during pregnancy: the physical activity preferred by pregnant women

Caminar durante el embarazo, la actividad física preferida entre las mujeres embarazadas, tiene múltiples beneficios para la salud del binomio materno - fetal en comparación con otras modalidades de actividad física. El no requerir tanto esfuerzo, la facilidad de ejecución, posibilidad de interacción social y de integrarse de manera muy significativa en algunas actividades, como los desplazamientos y las actividades ocupacionales, cuando a las embarazadas les es imposible realizar actividad física en su tiempo libre, son algunas de las ventajas que la convierten en la elegida por la mayor parte de las embarazadas. La falta de tiempo, las molestias físicas, la fatiga o la falta de energía, son algunos de los factores que impiden caminar a las gestantes. Dados los múltiples beneficios que tiene caminar para las embarazadas, las autoridades sanitarias deberían fomentar campañas de concienciación que promovieran la importancia de la práctica de actividad física por las mujeres embarazadas, entre las cuales, debería estar muy presente caminar.

Walking during pregnancy, the preferred physical activity among pregnant women, has multiple health benefits for the maternalfetal pairing compared to other forms of physical activity. Not requiring so much effort, the ease of execution, the possibility of social interaction and of integrating in a very significant way in some activities, such as travel and occupational activities, when it is impossible for pregnant women to perform physical activity in their free time, are some of the advantages that make it the one chosen by most pregnant women. Lack of time, physical discomfort, fatigue or lack of energy are some of the factors that prevent pregnant women from walking. Given the multiple benefits that walking has for pregnant women, health authorities should promote awareness campaigns that promote the importance of practicing physical activity by pregnant women, among whom walking should be very present.

El índice de masa corporal como fenotipo en el perfil clínico y funcional en mujeres con osteoartritis de rodilla / Association between the functional impact of osteoarthritis and body mass index in women

Background: Obesity is associated with pain, reduction of function and quality of life in patients with osteoarthritis (OA). Aim: To describe the clinical profile of women with knee OA according to their body mass index (BMI). Material and Methods: Observational study in 308 women with knee OA. According to their BMI, they were classified as normal-weight, overweight and obese. The primary outcome measure was functionality evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were sleep quality evaluated using the Pittsburgh Sleep Quality Index (PSQI) and quality of life assessed with the European Quality of Life Five Dimension (EuroQol-5D). Results: WOMAC, PSQI and EuroQol-5D scores were significantly higher in obese women. Conclusions: Overweight and obese women with OA have more sleep disorders, reduction on functionality and quality of life compared to their normal weight counterparts.

[Association between the functional impact of osteoarthritis and body mass index in women]. / El índice de masa corporal como fenotipo en el perfil clínico y funcional en mujeres con osteoartritis de rodilla.

BACKGROUND: Obesity is associated with pain, reduction of function and quality of life in patients with osteoarthritis (OA). AIM: To describe the clinical profile of women with knee OA according to their body mass index (BMI). MATERIAL AND METHODS: Observational study in 308 women with knee OA. According to their BMI, they were classified as normal-weight, overweight and obese. The primary outcome measure was functionality evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were sleep quality evaluated using the Pittsburgh Sleep Quality Index (PSQI) and quality of life assessed with the European Quality of Life Five Dimension (EuroQol-5D). RESULTS: WOMAC, PSQI and EuroQol-5D scores were significantly higher in obese women. CONCLUSIONS: Overweight and obese women with OA have more sleep disorders, reduction on functionality and quality of life compared to their normal weight counterparts.

Mammalian cells exposed to ionizing radiation: Structural and biochemical aspects.

Acute or chronic exposure to ionizing radiation is a factor that may be hazardous to health. It has been reported that exposure to low doses of radiation (less than 50 mSv/year) and subsequently exposure to high doses produces greater effects in people. It has been reported that people who have been exposed to low doses of radiation (less than 50 mSv/year) and subsequently are exposed to high doses, have greater effects. However, at a molecular and biochemical level, it is an unknown alteration. This study, analyzes the susceptibility of a biological system (HeLa ATCC CCL-2 human cervix cancer cell line) to ionizing radiation (6 and 60 mSv/90 s). Our research considers multiple variables such as: total protein profile, mitochondrial metabolic activity (XTT assay), cell viability (Trypan blue exclusion assay), cytoskeleton (actin microfilaments), nuclei (DAPI), and genomic DNA. The results indicate, that cells exposed to ionizing radiation show structural alterations in nuclear phenotype and aneuploidy, further disruption in the tight junctions and consequently on the distribution of actin microfilaments. Similar alterations were observed in cells treated with a genotoxic agent (200 µM H2O2/1h). In conclusion, this multi-criteria assessment enables precise comparisons of the effects of radiation between various line cells. However, it is necessary to determine stress markers for integration of the effects of ionizing radiation.

Sports injuries and illnesses during the Granada Winter Universiade 2015.

OBJECTIVE: To analyse the incidence of diseases and injuries suffered by athletes participating in the 27th Winter Sports Universiade held in Granada, Spain. METHODS: The daily occurrence of injuries and diseases was registered at the point of first aid (Borreguiles, 2665 metres above sea level (masl)) and in the clinic of Pradollano (2017 masl), both in Sierra Nevada, as well as in medical services provided by the organising committee of Granada 2015 Universiade and located in sport pavilions in which indoor competitions are held. RESULTS: A total of 1109 athletes (650 men, 58.61%; 459 women, 41.39%). Nine diseases and 68 injuries were recorded. In total, the rate of injury was 6.13% (7.07% for men and 4.79% for women). The percentage of injury was highest in alpine skiing (10.34%) followed by freestyle skiing (8.62%). In relation to the time of exposure, freestyle skiing showed the shortest time of exposure (0.31 hours) before suffering an injury. Short track speed skating showed the longest exposure (9.80 hours), before suffering an injury. The most common anatomical areas of injury were the head, shoulder and knee (13.23%). Only nine diseases were suffered (four women and five men) of which six were infections, one was a friction burn, one was a lipothymy and one a cluster headache due to height. CONCLUSION: In general, 6.13% of the athletes sustained at least one injury and 0.81% a disease, which is a much lower percentage than that recorded in similar events. The incidence of injuries and diseases varied among sport specialities.

Fibromyalgia Health Assessment Questionnaire, evaluación de la sensibilidad al cambio

Objetivo. Analizar la sensibilidad al cambio del cuestionario Fibromyalgia Health Assessment Questionnaire (FHAQ) en un grupo de pacientes con fibromialgia (FM). Métodos. Estudio observacional, prospectivo longitudinal, incluido en el Proyecto ICAF (Índice combinado de afectación en pacientes con fibromialgia), realizado en 15 centros españoles. Se estudió de forma consecutiva a 232 pacientes con FM con una edad media de 47 años, el 98,3% mujeres, que se evaluaron en una visita basal y 3 meses después de que se les instaurara un tratamiento según práctica médica habitual. El análisis estadístico incluyó: comparación de medias, respuesta media estandarizada (RME), medida basal estándar (DE), coeficiente de correlación intraclase (R), error estándar de medida (EEM), diferencia mínima detectable (DMD) y proporción de cambio real. Resultados. La diferencia de puntuación media del FHAQ en la visita basal y a los 3 meses fue de 0,098 (IC del 95%, 0,034-0,16) con una p<0,003. Sin embargo, la RME fue de 0,21 (cambio pequeño); DE=0,57, R=0,81, EEM=0,25, DMD=0,69. La proporción de cambio real fue del 17% (39 pacientes). No obstante, el sentido del cambio fue positivo en 28 casos (menor puntuación a los 3 meses) y negativo en los otros 11 (mayor puntuación a los 3 meses). Conclusiones. La puntuación a los 3 meses fue significativamente mejor que la basal, pero con los resultados de este estudio no se puede considerar que el FHAQ sea suficientemente sensible al cambio como para recomendar su uso en estudios longitudinales. El hecho, conocido, de que muchos pacientes pueden empeorar con el tratamiento empleado ha ido en detrimento de la valoración psicométrica del FHAQ (AU)

Objective. To analyze the sensitivity to change of the Fibromyalgia Health Assessment Questionnaire (FHAQ) in a group of patients with fibromyalgia (FM). Methods. Observational, prospective and longitudinal study related to the project ICAF was taken part in 15 Spanish centers. 232 patients were included and diagnosed of FM: 98.3% were women, the mean age was 47years old, they were analyzed at a basal visit and 3months visit, afterwards an appropriated treatment was prescribed. The statistical analysis was performed including: mean comparison, mean standardized response (RME), basal standard media (DE), intraclass correlation coefficient (R), standard error of the mean (EEM), minimal detectable difference (DMD) and percentage change in real. Results. The difference in mean comparison of the FHAQ in the baseline visit and the 3monts visit was of 0,098 (IC 95%: 0,034-0,16), with a P<.003. Nevertheless the RME was 0.21, a slightly change, the DE=0.57, R=0.81, EEM=0.25, and the DMD=0.69. The percentage change in real was 17% (39 patients). But the sense of the change was positive in 28cases (less punctuation in the 3monts visit) and negative in other 11cases (higher punctuation in the 3monts visit). Conclusions. The punctuation in the 3months visit was significant better than the basal, but the results of this study do not let it to consider that the FHAQ have enough change susceptibility to recommend it in longitudinal studies. The well knowing fact, some patients can become worse with the treatment prescribed would be to the detriment of the FHAQ psychometric value (AU)

Estrategias de prescripción de fármacos en el tratamiento de pacientes con fibromialgia / Drug prescription strategies in the treatment of patients with fibromyalgia

Objetivo. Analizar las diferentes estrategias de prescripción seguidas por reumatólogos especializados en FM. Métodos. Estudio prospectivo, multicéntrico, con 2 visitas separadas 3 meses en el que se instaura un tratamiento farmacológico en condiciones de práctica clínica habitual. Se analizó fundamentalmente la prescripción de benzodiacepinas, hipnóticos, antidepresivos y anticonvulsivantes. La evaluación clínica se realizó mediante el cuestionario ICAF (Índice combinado de afectación en pacientes con fibromialgia). Se determinaron las estrategias más frecuentes y se calculó el tamaño del efecto para analizar su eficacia. Resultados. Se incluyó a 232 pacientes con FM atendidos en 15 consultas de reumatología. Las estrategias más comunes fueron la introducción aislada de un anticonvulsivante (17,7%) o un antidepresivo (14,7), que produjeron mejorías clínicas estadísticamente significativas. La estrategia más eficaz (tamaño del efecto próximo a 1) fue la introducción simultánea de ambos fármacos (6,5%), que aumentó en un 50% el tamaño del efecto de antidepresivos y en un 100% el de anticonvulsivantes. La estrategia de no realizar ningún cambio en el número de fármacos fue la más frecuente (35,8%) pero no mostró mejoría clínica significativa. Otras estrategias fueron muy poco frecuentes y no han sido analizadas. Conclusión. Las estrategias de prescripción de fármacos anticonvulsivantes o antidepresivos de manera aislada o en combinación producen una mejoría clínica significativa en los pacientes con FM. La estrategia más eficaz es la introducción de ambos fármacos simultáneamente. La menos eficaz es no realizar ningún cambio (AU)

Objective. To analyze prescription strategies followed by rheumatologist specialized in FM treatment. Methods. A prospective, multicentric, 3-month follow-up study with two visits. The drug treatment was started following usual clinical practice conditions. Prescription of benzodiazepines, hypnotics, anticonvulsants and antidepressants were those mainly studied. Clinical evaluation was performed by the ICAF (Combined index of affection in patients with fibromyalgia) questionnaire. The most frequent strategies and their size effect were calculated. Results. A total of 232 patients attending 15 rheumatology centers were included. The introduction of an anticonvulsant or an antidepressant were the most common drug strategies followed in 17.7% and 14.7% of patients, respectively. Both strategies produced a statistically significant clinical improvement. The most effective strategy (with an effect size of nearly 1) was the introduction of both drugs (6.5% patients), which increased the antidepressants effect size in 50% and 100% for anticonvulsants. The strategy of no change in the number of drug prescriptions was the most frequent (35.8% patients) but no significant clinical improvement was found in these patients. Some other strategies were very uncommon and have not been analyzed in this study. Conclusion. The introduction of anticonvulsants or antidepressants, in an isolated or combined form, produces a significant clinical improvement in FM patients. The most effective drug strategy is the introduction of both drugs at the same time. The least effective strategy is not to change the number of drug prescriptions (AU)

Drug prescription strategies in the treatment of patients with fibromyalgia.

OBJECTIVE: To analyze prescription strategies followed by rheumatologist specialized in FM treatment. METHODS: A prospective, multicentric, 3-month follow-up study with two visits. The drug treatment was started following usual clinical practice conditions. Prescription of benzodiazepines, hypnotics, anticonvulsants and antidepressants were those mainly studied. Clinical evaluation was performed by the ICAF (Combined index of affection in patients with fibromyalgia) questionnaire. The most frequent strategies and their size effect were calculated. RESULTS: A total of 232 patients attending 15 rheumatology centers were included. The introduction of an anticonvulsant or an antidepressant were the most common drug strategies followed in 17.7% and 14.7% of patients, respectively. Both strategies produced a statistically significant clinical improvement. The most effective strategy (with an effect size of nearly 1) was the introduction of both drugs (6.5% patients), which increased the antidepressants effect size in 50% and 100% for anticonvulsants. The strategy of no change in the number of drug prescriptions was the most frequent (35.8% patients) but no significant clinical improvement was found in these patients. Some other strategies were very uncommon and have not been analyzed in this study. CONCLUSION: The introduction of anticonvulsants or antidepressants, in an isolated or combined form, produces a significant clinical improvement in FM patients. The most effective drug strategy is the introduction of both drugs at the same time. The least effective strategy is not to change the number of drug prescriptions.

Fibromyalgia Health Assessment Questionnaire: sensitivity to change.

OBJECTIVE: To analyze the responsiveness of the Fibromyalgia Health Assessment Questionnaire (FHAQ) in a group of patients with fibromyalgia (FM). METHODS: Observational, prospective and longitudinal study related to the project ICAF was taken part in 15 Spanish centers. 232 patients were included and diagnosed of FM: 98.3% were women, the mean age was 47 years old, they were analyzed at a basal visit and 3 months visit, afterwards an appropriated treatment was prescribed. The statistical analysis was performed including: mean comparison, mean standardized response (RME), basal standard media (DE), intraclass correlation coefficient (R), standard error of the mean (EEM), minimal detectable difference (DMD) and percentage change in real. RESULTS: The difference in mean comparison of the FHAQ in the baseline visit and the 3 months visit was of 0.098 (95% CI: 0.034­0.16), with a P<.003. Nevertheless the RME was 0.21, a slightly change, the DE=0.57, R=0.81, EEM=0.25, and the DMD=0.69. The percentage change in real was 17% (39 patients). But the sense of the change was positive in 28 cases (less punctuation in the 3 months visit) and negative in other 11 cases (higher punctuation in the 3 months visit). CONCLUSIONS: The punctuation in the 3 months visit was significant better than the basal, but the results of this study do not let it to consider that the FHAQ have enough change susceptibility to recommend it in longitudinal studies. The well knowing fact, some patients can become worse with the treatment prescribed would be to the detriment of the FHAQ psychometric value.

Características psicosociales y psicopatológicas en una muestra de adolescentes españoles a partir del Youth Self-Report/11-18 / Psychosocial and psychopathological characteristics of Spanish adolescents sample throw Youth Self-Report/11-18

En este estudio se analizan las competencias psicosociales y características psicopatológicas evaluadas por el YSR/11-18 (Achenbach y Rescorla, 2000, 2001) en una muestra de 961 adolescentes españoles de 13-18 años de edad. Los resultados encontrados indicaron que los varones puntúan de forma elevada en distintas actividades sociales y psicopatología externalizante, mientras que las mujeres presentan mayores puntuaciones en rendimiento en diferentes tareas y sintomatología internalizante. Los adolescentes de menor edad presentan puntuaciones más altas que los mayores en la participación en grupos y organizaciones, así como en la mayoría de las escalas sindrómicas del YSR/11-18, mientras que los segundos prefieren realizar actividades no deportivas y trabajos o tareas. Los alumnos de ESO y Bachillerato presentan más actividad en todas las competencias psicosociales que los de Ciclos Formativos, aunque éstos últimos superan a los primeros en la mayoría de las escalas sindrómicas. Los adolescentes sin relación de pareja puntuaron más alto en las competencias psicosociales que los que disfrutan de la misma, aunque éstos muestran más psicopatología que los primeros. Por último, realizar una actividad laboral (además de estudiar) no parece ser relevante a la hora de establecer diferencias respecto a las competencias psicosociales y a las escalas sindrómicas (AU)

In this study we analyzed the psychosocial competences and psychopathological characteristics assessed by the YSR/11-18 in a sample of 961 Spanish adolescents from 13-18 years. The results indicated that men scored high in various social activities and externalized psychopa-thologies, while women have high scores for performance in different tasks and internalized symptoms. Younger adolescents showed higher scores than older ones in participation in groups and organizations, as well as in most of the YSR/11-18 syndromic scales, while older adolescent’s preferred no sports activities and works or tasks. Students at Compulsory Secondary Education and Non-Compulsory Secondary Education showed more activity than those in Vocational Training Cycles in all psychosocial competencies, but the latter overcame the first in most of the syndromic scales. Adolescents without romantic relation scored higher in the psycho-social competencies than those who enjoyed romantic relation, although the second ones showed more psychopathology than the first ones. Fi-nally, working (in addition to studying) did not seem to be relevant in determining differences regarding the psychosocial competencies and syndromic scales(AU)

La hypnosis psicológica en España / No disponible

No disponible

Desarrollo de una batería de evaluación psicorisiológica en el ámbito clínico / Development of a practical exploratory battery for psychophysiological assessment

El creciente desarrollo de la psicofisiología exige metodologías cada vez más asequibles para su utilización en el ámbito clínico. Este trabajo presenta la elaboración de una batería de evaluación psicofisiológica exploratoria (el Perfil de Estrés) adaptada a las características del quehacer clínico, que permite la evaluación del componente psicofisiológico de una forma relativamente sencilla. La utilización del análisis factorial para el análisis de los registros posibilita la obtención de perfiles o patrones psicofisiológicos basados en la covariación entre respuestas psicofisiológicas pertenecientes a diversos sistemas. Los factores identificados muestran patrones de activación relevantes, que ofrecen una visión global del funcionamiento psicofisiológico de la muestra evaluada, y pueden considerarse datos normativos de la población de referencia (AU)

As the expanding field of psychophysiology is currently demanding applied methodologies to be used in the clinic, this study aimed to develop a practical multi-channel exploratory battery for psychophysiological evaluation of stress (the Stress Profile-SP). The SP records six psychophysiological variables and it is designed to be mainly used in the daily clinic. Furthermore, the SP is a quick and easy-to-use instrument that has shown adequate internal consistency. Factorial analysis has been applied to obtain psychophysiological profiles based on the covariation among different systems responses. The identified factorial structure shows relevant activation patterns, offering a comprehensive view of the sample functioning. The structure is consistent through samples and can be considered as normative data for the studied population. The Stress Profile can be considered as a method to obtain normative and individual psychophysiological patterns, providing relevant information for the therapeutic process (AU)

Development of a multi-channel exploratory battery for psychophysiological assessment: the Stress Profile.

OBJECTIVE: As the expanding field of psychophysiology is currently demanding applied methodologies to be used in the clinic, this study aimed to develop a practical multi-channel exploratory battery for psychophysiological evaluation of stress (the Psychophysiological Stress Profile; PSP). The PSP records 6 psychophysiological variables and it is designed to be mainly used in the daily clinic. Moreover, the PSP was intended to be 'the method' to obtain normative and individual psychophysiological patterns, providing relevant information for the therapeutic process. METHODS: Two hundred and three subjects were evaluated with the PSP in two different contexts: the natural environment and the laboratory. Factorial analysis was applied to obtain psychophysiological profiles. These profiles are based on the covariation among different system responses. The Burt and Tucker Congruence Coefficient was used to compare factorial structures. RESULTS: A 3-factor structure was obtained in both contexts, Congruence Coefficient indicates that these factorial structures are very similar, indicating the existence of a unique and consistent psychophysiological pattern that characterizes the sample. CONCLUSIONS: The identified factorial structure shows relevant activation patterns, offering a comprehensive view of the subject's functioning. The structure is consistent through samples and can be considered as normative data for the studied population. PSP has turned out to be a quick and easy-to-use psychophysiological battery that has shown adequate internal consistency for all the recorded variables. In this way, the PSP methodology shows its practical value and usefulness in the assessment process.