Changes in Field Termination of Resuscitation and Survival Rates After an Educational Intervention to Promote on Scene Resuscitation for Out-of-Hospital Cardiac Arrest.

BACKGROUND: Emergency medical services (EMS) agencies with higher field termination-of-resuscitation (TOR) rates tend to have higher survival rates from out-of-hospital cardiac arrest (OHCA). Whether EMS agencies can improve survival rates through efforts to focus on resuscitation on scene and optimize TOR rates is unknown. OBJECTIVE: The goal of this study was to determine if an EMS agency's efforts to enhance on-scene resuscitation were associated with increased TOR and OHCA survival with favorable neurologic outcome. METHODS: A single-city, retrospective analysis of prospectively collected 2017 quality assurance data was conducted. Patient demographics, process, and outcome measures were compared before and after an educational intervention to increase field TOR. The primary outcome measure was survival to hospital discharge with favorable neurologic status. RESULTS: There were 320 cases that met inclusion criteria. No differences in age, gender, location, witnessed arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, or presumed cardiac etiology were found. After the intervention, overall TOR rate increased from 39.6% to 51.1% (p = 0.06). Among subjects transported without return of spontaneous circulation (ROSC), average time on scene increased from 26.4 to 34.2 min (p = 0.02). Rates of sustained ROSC and survival to hospital admission were similar between periods. After intervention, there was a trend toward increased survival to hospital discharge rate (relative risk [RR] 2.09; 95% confidence interval [CI] 0.74-5.91) and an increase in survival with favorable neurologic status rate (RR 5.96; 95% CI 0.80-44.47). CONCLUSION: This study described the association between an educational intervention focusing on optimization of resuscitation on scene and OHCA process and outcome measures. Field termination has the potential to serve as a surrogate marker for aggressively treating OHCA patients on scene.

Cardiopulmonary Resuscitation Quality Issues.

Much of the current evidence and many of the recent treatment recommendations for increasing survival from cardiac arrest revolve around improving the quality of cardiopulmonary resuscitation during resuscitation. A focus on providing treatments proved beneficial and providing these treatments reliably, using measurement, monitoring, and implementation of quality-improvement strategies, will help eliminate variation in outcomes and provide a foundation from which future improvements in resuscitation care can be developed. Using the knowledge and tools available today will help reduce the ambiguity and variability that exists in resuscitation today and provide the ability to save more lives in communities.

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation.

OBJECTIVE: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. METHODS: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. RESULTS: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. CONCLUSIONS: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.

Survivors Perceptions of Recovery following Air Medical Transport Accidents.

Abstract Objective: Air medical transport (AMT) teams play an essential role in the care of the critically ill and injured. Their work, however, is not without risk. Since the inception of the industry numerous AMT accidents have been reported. The objective of this research is to gain a better understanding of the post-accident sequelae for professionals who have survived AMT accidents. The hope is that this understanding will empower the industry to better support survivors and plan for the contingencies of post-accident recovery. Methods: Qualitative methods were used to explore the experience of flight crew members who have survived an AMT accident. "Accident" was defined using criteria established by the National Transportation Safety Board. Traditional focus group methodology explored the survivors' experiences following the accident. Results: Seven survivors participated in the focus group. Content analysis revealed themes in four major domains that described the experience of survivors: Physical, Psychological, Relational and Financial. Across the themes survivors reported that industry and company response varied greatly, ranging from generous support, understanding and action to make safety improvements, to little response or action and lack of attention to survivor needs. Conclusion: Planning for AMT post-accident response was identified to be lacking in scope and quality. More focused efforts are needed to assist and support the survivors as they regain both their personal and professional lives following the accident. This planning should include all stakeholders in safe transport; the individual crewmember, air medical transport companies, and the industry at large.

A blueprint for critical care transport research.

INTRODUCTION: An estimated 500,000 critical care patient transports occur annually in the United States. Little research exists to inform optimal practices, promote safety, or encourage responsible, cost-effective use of this resource. Previous efforts to develop a research agenda have not yielded significant progress in producing much-needed scientific study. PURPOSE: Identify and characterize areas of research needed to direct the development of evidence-based guidelines METHODS: The study used a modified Delphi technique to develop a concept map of the research domains in critical care transport. Proprietary, internet-based software was used for both data collection and analysis. The study was conducted in 3 phases: brainstorming, categorizing, and prioritizing, using experts from all aspects of critical care transport. RESULTS: A total of 101 research questions were developed and ranked by 27 participants representing the transport community and stakeholders. An 8-cluster solution was developed with multidimensional scaling and hierarchical cluster analysis to identify the following research areas: clinical care, education/training, finance, human factors, patient outcomes, safety, team configuration, and utilization. A plot characterized each domain by urgency and feasibility. CONCLUSION: The content and concepts represented by the cluster map can help direct research planning in the critical care transport industry and prioritize funding decisions.

Prehospital factors associated with mortality in injured air medical patients.

BACKGROUND: Air medical transport provides rapid transport to definitive care. Overtriage and the expense and risk of transport may offset survival benefits. OBJECTIVE: We assessed the ability of prehospital factors to predict resource need for helicopter-transported patients. METHODS: We performed a prospective, observational cohort analysis of injured scene patients taken to one of two level I trauma centers from October 2009 to September 2010. Variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery within 24 hours, blood transfusion within 24 hours, and intensive care unit [ICU] admission ≥24 hours, as well as a combined outcome of all clinical outcomes). Prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. We compared those variables with and without the outcomes of interest via χ(2) analysis and the Kruskal-Wallis test, where appropriate. Multivariate logistic regression identified factors associated with outcomes of interest with the intent of developing a clinical prediction tool. RESULTS: Five hundred fifty-seven patients were transported during the study period. The majority of the patients were male (67%) and white (95%) and had an injury that occurred in a rural location (58%). Most injuries were blunt (97%), and patients had a median Injury Severity Score (ISS) of 9. The overall mortality was 4%; 48% of the patients had one of the four outcomes. The most common reasons for requesting air transport were motor vehicle collision (MVC) with high-risk mechanism (18%), MVC at a speed greater than 20 mph (18%), Glasgow Coma Scale score (GCS) less than 14 (15%), and loss of consciousness (LOC) greater than 5 minutes (15%). Factors associated with mortality were age greater than 44 years, GCS less than 14, systolic blood pressure (SBP) less than 90 mmHg, and flail chest. This model had 100% sensitivity and 50% specificity and missed no deaths. The combined endpoint of all four outcomes (death, receipt of blood, surgery, ICU admission) included intubation by emergency medical services, two or more fractures of the humerus/femur, presence of a neurovascular injury, a crush injury to the head, failure to localize to pain on examination, GCS less than 14, or the presence of a penetrating head injury. This model had a sensitivity of 57% (53%-61%) and a specificity of 78% (75%-87%). CONCLUSIONS: Very few prehospital criteria were associated with clinically important outcomes in helicopter-transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated and developed for injured patients.

Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival.

OBJECTIVE: To describe changes in out-of-hospital cardiac arrest (OOHCA) survival before and after the release of the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). METHODS: Data were extracted from an OOHCA registry for 1,681 adult cases of cardiac arrest treated by one emergency medical services (EMS) system between April 1, 2004, and December 31, 2007, in a large city (2005 population 730,657). The primary endpoint was survival to hospital discharge. A convenience sample of 69 electronic electrocardiogram (ECG) recordings was reviewed to assess CPR quality parameters using impedance waveform analysis during corresponding time periods. Intervention. Implementation of the 2005 AHA guidelines for CPR and ECC in spring 2006. RESULTS: The annual treated OOHCA incidence rate was 68/100,000; and the treated ventricular fibrillation (VF) incidence rate was 15/100,000. Bystanders performed CPR in 28% of cases. Public automated external defibrillator (AED) use was < 2% over the entire study, and few patients received hypothermia therapy. Unadjusted OOHCA survival rates were significantly higher in the postguidelines period at 9.4% (n = 1,021) than in the preguidelines period at 6.1% (n = 660), despite similarities in all major predictors of outcome (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.4). Bystander-witnessed OOHCA survival for victims in VF on EMS arrival was 19 of 78 (24%) in the preguidelines period versus 34 of 112 (30%) in the postguidelines period (OR 1.4; 95% CI 0.7 to 2.6). CPR quality measures showed significant improvement in the postguidelines period. The mean no-flow fraction in the preguidelines group was 0.46 and dropped to 0.34 in the postguidelines group, a difference of 0.12 (95% CI 0.05 to 0.19). Multivariate regression analysis adjusting for significant predictors of survival showed that OOHCA in the postguidelines period was associated with 1.8 greater odds of survival than in the preguidelines period (95% CI 1.2 to 2.7). CONCLUSION: In this large city, substantial improvement occurred in overall OOHCA survival rates following the implementation of the 2005 AHA guidelines for CPR and ECC. These changes were associated with improvements in the quality of CPR.

Clinical clearance of spinal immobilization in the air medical environment: a feasibility study.

BACKGROUND: Various decision algorithms have been developed for use in the prehospital setting to analyze those trauma patients who do not require spinal immobilization. The feasibility of applying these algorithms in the air medical transport environment has not been studied. METHODS: All adult patients (>/=age 16) transported to three Level I trauma centers were eligible for the study. Medical crews completed a data collection sheet during transport which was later used to analyze whether the transported patient would be eligible for spinal clearance based on the absence of all of the following clinical findings: (1) abnormal level of consciousness; (2) evidence of intoxication; (3) distracting painful injury; (4) spinal tenderness or pain; or (5) abnormal neurologic examination. The outcomes were (1) the proportion of transported patients potentially eligible for spinal clearance and (2) the ability of the algorithm to predict spinal injury. RESULTS: Three hundred twenty-nine patients were enrolled in the study. Forty-nine (15%) had spinal injuries with 12 (24%) considered unstable. Only 40 patients met criteria for deferring spinal immobilization; 4 of these patients had spinal fractures. The algorithm had a sensitivity of 90% and a specificity of 16%. CONCLUSION: Clearance of spinal immobilization using prehospital clinical algorithms during air medical transport did not appear to be useful. These criteria were not found to be sensitive, specific, or predictive of spinal injury in this population of blunt trauma patients. Prehospital spinal immobilization clearance algorithms using existing criteria should not be adopted for patients transported by helicopter.

Cardiac arrest patients rarely receive chest compressions before ambulance arrival despite the availability of pre-arrival CPR instructions.

OBJECTIVES: To determine the proportion of out-of-hospital cardiac arrest (OOHCA) patients who received chest compressions, before EMS arrival, from bystanders who called the EMS emergency telephone number (9-1-1) at dispatch centers that provided telephone CPR instructions and to describe barriers to following instructions. METHODS: A retrospective case series was conducted in 2004 at three dispatch centers all of which provided sequential airway, breathing and chest compression pre-arrival instructions. All calls for which the call-taker established that the patient was in OOHCA were identified, and the recorded interaction was reviewed using a structured data collection tool. Data included whether the caller performed compressions, the sequence of instructions, whether there were barriers to performing CPR and characteristics of the caller, call taker and patient. Descriptive statistics were used to evaluate the data. RESULTS: 343 calls were reviewed. 3 were excluded because it was unclear whether compressions were provided. 172 calls were not eligible for pre-arrival instructions (e.g. obviously dead, already receiving CPR). Of the 168 calls eligible for CPR instructions, chest compressions were actually given to 25 patients (15%, 95% confidence interval 10-21%) before EMS arrival. Leading reasons for not following CPR instructions included: caller disconnected phone before directions were complete (19%), caller's refusal (18%), emotional state of the caller (14%), inability to listen to telephone instructions and care for patient at the same time (13%) and physical limitations of the caller (8%). Failure to complete airway and breathing steps prevented 8% of callers from providing compressions. CONCLUSIONS: Few 9-1-1 callers provided chest compressions following telephone CPR instructions that included airway and breathing steps. The majority of callers were unwilling or emotionally or physically unable to follow the instructions.

Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.

CONTEXT: High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes. OBJECTIVE: To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR. DESIGN, SETTING, AND PATIENTS: Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005. INTERVENTION: Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517). MAIN OUTCOME MEASURES: The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors. RESULTS: Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006). CONCLUSIONS: Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00120965.

The National EMS Research strategic plan.

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Use of amifostine, a novel cytoprotective, in alpha-amanitin poisoning.

BACKGROUND: Mortality from ingestions of the mushroom Amanita phalloides remains as high as 20-40% with many surviving patients requiring liver transplantation. A variety of treatments for Amanita ingestion have been evaluated, yet other than supportive measures, no effective therapy has been identified. In addition, an antidote for Amanita toxicity may not be practical due to delayed patient presentation. The drug amifostine was proposed to potentially improve survival from alpha-amanitin toxicity by conferring cytoprotective effects on hepatocytes at risk for cell death. Amifostine is used as a radio--and chemo-protective agent. It protects against lipoperoxidation, interferes with the cross-linking of DNA, and may act by other mechanisms yet to be identified, making it attractive for potentially attenuating ongoing hepatic necrosis. It has not previously been studied in a toxicologic model. STUDY OBJECTIVE: To determine whether amifostine is an effective postexposure therapy for alpha-amanitin, the primary lethal toxin in Amanita phalloides. METHODS: Swiss mice (n = 30 in all groups) were given an approximate LD75 dose of intraperitoneal (i.p.) alpha-amanitin. Amifostine was administered i.p. 6 h after poisoning in three cumulative dosing groups: 250 mg/kg; 500 mg/kg; and 1600 mg/kg. Controls received equal volumes of i.p. sterile 0.9% saline. Mice were monitored and time of death recorded. At day 7, survival was assumed and the remaining mice were euthanized. Qualitative histologic comparisons of hepatic and renal toxicity were performed. RESULTS: At day 7, only 10% of the control mice survived. Survival in the amifostine 250, 500, and 1600 mg/kg groups was 20%, 20%, and 3%, respectively. No statistically significant differences were detected in Kaplan-Meier survival between the control group and those receiving 250 or 500 mg/kg; however, there was a statistically significant decrease in survival for the group receiving 1600 mg/kg (p = 0.0002). CONCLUSION: No survival benefit was seen with cumulative doses between 250 and 500 mg/kg; however, higher doses may result in subsequent toxicity and decreased survival.

Linkages of acute care and EMS to state and local public health programs: application to public health programs.

Response to terrorism and mass casualty incidents has become a focal point for many public service agencies. Public health agencies and the emergency response community must work together to effectively and efficiently respond to any future incidents. Historically, collaboration has been a challenge since these agencies have functioned independently from one another, maintaining separate infrastructures that are not adequately interoperable. This article will summarize the consensus achieved during a meeting of multidisciplinary stakeholders held to discuss linkages between acute care, emergency medical services, and public health. The relevancy of these findings to public health, as well as the benefits from development of an interoperable infrastructure to public health, will be opined.

Providing automated external defibrillators to urban police officers in addition to a fire department rapid defibrillation program is not effective.

OBJECTIVE: The aim of this study was to determine if providing automated external defibrillators (AEDs) to urban police officers would increase the proportion of patients with out-of-hospital cardiac arrest (OOH-CA) who were discharged alive from the hospital. METHODS: This prospective, controlled study was conducted in a city with about 332,000 persons. The EMS system included paramedic ambulances and fire department based first responders equipped with defibrillators, but police officers did not respond routinely to medical emergencies. Between March 1997 and February 1999, all OOH-CAs in four police districts were identified and followed until death or hospital discharge. All 35 police cars in one police district were provided with AEDs, and all police officers in that district were trained in CPR and the use of AEDs. Police and fire first response units were dispatched simultaneously in district 3 (intervention group). Fire first response was dispatched without police in districts 2, 4, and 5 (control group). RESULTS: A total of 645 OOH-CAs occurred over the 2 years. Sixty-two were outside of the study area. Two did not have accurate address information to determine the police district. Of the remaining cases, 154 (27%) occurred in the intervention district and 427 (73%) were in the control area. Survival to hospital discharge was similar; it was 11/154 (7.1%) in the intervention and 16/427 (3.8%) in the control districts (odds ratio=1.98; 95% CI 0.90--4.36). Survival to hospital discharge for witnessed OOH-CA events occurring prior to EMS arrival and found to be in ventricular fibrillation or ventricular tachycardia was 4/27 (15%) in the intervention area and 9/73 (12%) in the control area (odds ratio=1.2; 95% CI 0.4-4.4). CONCLUSION: Equipping police cars with AEDs in an urban area where the fire department-based first response system also carries defibrillators did not improve the hospital discharge survival rate for victims of OOH-CA.

National EMS research agenda: proceedings of the implementation symposium.

The National EMS Research Agenda identified eight recommendations for improving the conduct of emergency medical services (EMS) research in the United States. EMS leaders from across the country attended a two-day symposium to discuss implementation of the Research Agenda recommendations. The participants suggested specific methods to move the recommendations forward. These included improving training opportunities for EMS researchers, stimulating increases in available funding sources, facilitating the integration of research into practice, and crafting alterations within the regulatory environment. Participants felt that EMS must be more broadly integrated into the public health continuum. Federal agencies, states, local governments, charitable foundations, and corporations are asked to examine their practices to increase opportunities for participation in EMS research programs at all stages of the process.

Pediatric mental health emergencies: summary of a multidisciplinary panel.

The World Health Organization has estimated that by the year 2020, neuropsychiatric disorders will become one of the five most common causes of morbidity, mortality, and disability among children (U.S. Department of Health and Human Services. HHS Fact Sheet on Mental Health Issues. www.hhs.gov. 2001). This is a distressing statistic, particularly when many of the mental health disorders are preventable and/or treatable with good prognosis. Children's mental health services and access to them are inconsistent within the United States. The National Institute of Mental Health reports that although 10% of our nation's children currently suffer from mental illness, only one-fifth of these children receive necessary treatment. (National Institute of Mental Health. Brief notes on the mental health of children and adolescents. Bethesda, MD: National Institute of Mental Health, 1999). The purpose of this article is to present summary information from a national consensus conference regarding the current state of emergency mental health resources for children and adolescents. The intended audience includes community health care providers, emergency care workers, and researchers. Major issues explored in this paper include the questions: Are emergency mental health services for children and adolescents readily available in communities? Is access to care possible for all children? Are resources and services in place to ensure that the mental health needs of this vulnerable population are not neglected? The authors would like to see the development of local, regional, and national systems that facilitates coordination between emergency medical services (EMS), emergency medicine, and mental health communities to ensure appropriate local resources are in place and to allow the emergent identification and treatment of mental health needs in the pediatric and adolescent population.

Treatment of pediatric and adolescent mental health emergencies in the United States: current practices, models, barriers, and potential solutions.

Mental illness significantly impairs the lives of 10% of all children and adolescents in the United States (National Institute of Mental Health. Brief Notes on the Mental Health of Children and Adolescents. Bethesda, MD: National Institute of Mental Health, 1999). Of the myriad mental health problems afflicting children, an alarming number are known to have grim outcomes. Some illnesses continue into adulthood, while others may culminate in death during adolescence. Despite the serious consequences of children's mental health problems, early treatment can improve or control these conditions. Even with this knowledge, seemingly little effort is geared toward removing barriers to treatment for these diseases that plague our children. As a part of its five-year plan, Emergency Medical Services for Children (EMSC) has collaborated with the National Association of EMS Physicians (NAEMSP) to examine childhood and adolescent mental health emergencies--particularly their presentation and management within the emergency medical services system. This document presents a critical review of current practices and models for treatment of children and adolescents that includes identification of barriers to mental health treatment and recommendations for their resolution.