CT-guided versus MR-guided radiotherapy: Impact on gastrointestinal sparing in adrenal stereotactic body radiotherapy.

BACKGROUND AND PURPOSE: To quantify the indication for adaptive, gated breath-hold (BH) MR-guided radiotherapy (MRgRTBH) versus BH or free-breathing (FB) CT-based image-guided radiotherapy (CT-IGRT) for the ablative treatment of adrenal malignancies. MATERIALS AND METHODS: Twenty adrenal patients underwent adaptive IMRT MRgRTBH to a median dose of 50 Gy/5 fractions. Each patient was replanned for VMAT CT-IGRTBH and CT-IGRTFB on a c-arm linac. Only CT-IGRTFB used an ITV, summed from GTVs of all phases of the 4DCT respiratory evaluation. All used the same 5 mm GTV/ITV to PTV expansion. Metrics evaluated included: target volume and coverage, conformality, mean ipsilateral kidney and 0.5 cc gastrointestinal organ-at-risk (OAR) doses (D0.5cc). Adaptive dose for MRgRTBH and predicted dose (i.e., initial plan re-calculated on anatomy of the day) was performed for CT-IGRTBH and MRgRTBH to assess frequency of OAR violations and coverage reductions for each fraction. RESULTS: The more common VMAT CT-IGRTFB, with its significantly larger target volumes, proved inferior to MRgRTBH in mean PTV and ITV/GTV coverage, as well as small bowel D0.5cc. Conversely, VMAT CT-IGRTBH delivered a dosimetrically superior initial plan in terms of statistically significant (p ≤ 0.02) improvements in target coverage, conformality and D0.5cc to the large bowel, duodenum and mean ipsilateral kidney compared to IMRT MRgRTBH. However, non-adaptive CT-IGRTBH had a 71.8% frequency of predicted indications for adaptation and was 2.8 times more likely to experience a coverage reduction in PTV D95% than predicted for MRgRTBH. CONCLUSION: Breath-hold VMAT radiotherapy provides superior target coverage and conformality over MRgRTBH, but the ability of MRgRTBH to safely provide ablative doses to adrenal lesions near mobile luminal OAR through adaptation and direct, real-time motion tracking is unmatched.

Experiences of Opioid Use Disorder Patients Receiving Buprenorphine Through a Telehealth Program.

BACKGROUND: Opioid use disorder (OUD) continues to be a growing and major public health issue in the United States. In an effort to increase OUD treatment access, medication-assisted treatment with buprenorphine via telehealth is emerging as the leading treatment option. OBJECTIVE: This study sought to describe the experiences of adults with OUD receiving medication-assisted treatment buprenorphine in a nurse-practitioner-facilitated telehealth program. METHODS: Using a descriptive qualitative design, convenience sampling was used to recruit participants who were currently receiving OUD treatment in one telehealth program with locations in California and Michigan. Participants were invited to participate in the study via an email flyer sent to all clients of the telehealth program. Participants completed demographic data and took part in individual, semistructured interviews that were conducted online. RESULTS: The study sample included 15 largely White, married, college-educated men (n = 8, 53%) and women (n = 7, 47%). Qualitative content analysis of interview data revealed three overall themes and associated subthemes: (a) improved access to care, (b) isolation, and (c) feeling normal on buprenorphine. CONCLUSION: Our findings support a nurse-practitioner-facilitated telehealth treatment program for OUD. However, in a program that offers patient-centered care that does not have a one-size-fits-all approach to service, goals of care must be reevaluated throughout treatment. Moreover, given the increased risk of patients feeling isolated with telehealth appointments and the lack of physical face-to-face interactions, healthcare providers should explore ways to engage patients in meaningful support resources and reduce stigma.

Training for the Intraspinal Drug Delivery System Reservoir Refill Procedure Highly Variable: A Nationwide Survey of Health Care Professionals.

OBJECTIVES: This study describes the training, experience with pocket fills, and life-long learning behaviors in a national sample of health care professionals who perform the reservoir refill procedure and compares results with intraspinal drug delivery morbidity and mortality clinical practice guidelines to demonstrate the need for standardized training. METHODS: Using a cross-sectional, descriptive design and a 23-item questionnaire administered via social media, 65 health care professionals who performed the reservoir refill procedure within the last year were surveyed. Descriptive and inferential statistics were used for analysis. RESULTS: Our results showed: 1) training varied widely and lacked supervision and mentoring for the inexperienced clinician, 2) the highest number of pocket fills was reported by the most experienced clinicians, and 3) there was limited participation in professional meetings where intraspinal therapy is discussed. The use of intraspinal drug delivery clinical practice guidelines significantly increased in current practice compared to use during training. CONCLUSION: Training for the reservoir refill procedure was highly variable, inconsistent with intraspinal drug delivery clinical practice guidelines' training recommendations with a high number of pocket fills, and low participation in national intraspinal drug delivery meetings. Standardized training is needed to reduce variability and minimize the risk for human error during the reservoir refill procedure.

Methods of evaluating an accelerated associate degree registered nurse to baccalaureate degree continuation program.

Program evaluation guides curricular decision making and change. This article describes a comprehensive program evaluation of an accelerated associate degree to baccalaureate continuation program and includes some findings and lessons learned. Educators need to be responsible and accountable for the curricular changes that they make and assure that rigor is maintained and essentials are met. The use of comprehensive program evaluation adds significant value and richness of data because use of multiple study methods leads to data from multiple vantage points. Although a comprehensive program evaluation can be time consuming, not all of the methods described in this article may be required. Using the matrix provided, the reader may choose to carry out 1 or 2 of the methods described here.

A home telehealth heart failure management program for veterans through care transitions.

Heart failure (HF) is a new epidemic in the United States. Advanced HF is a fatal illness affecting our veterans and causing frequent hospital readmissions in both the Veterans Affairs hospital and throughout the nation's healthcare system. The clinician's obligation is to offer the best alternatives in the care of chronic illness. The Veterans Affairs healthcare system has a comprehensive approach to treating HF. The comprehensive implementation of home telehealth, clinical informatics, and disease management supports the care of patients with advanced HF.

Students' lived experience in an associate's degree to baccalaureate degree continuation program: opening doors, opening eyes, opening minds.

BACKGROUND: Major nursing organizations, federal agencies, and researchers are recommending that all nurses be educated to at least the baccalaureate level. METHODS: This article reports the results of a qualitative study of the experiences of students enrolled in a direct associate's degree to baccalaureate degree nursing program. Based on multiple small group interviews conducted during an 18-month period, a multistep interpretive analytic process was used that ultimately described themes within a holistic view of the phenomenon. FINDINGS: The results showed an overarching theme of transformative change over time, centered within the "place" of the university. CONCLUSION: The study suggested that there are differences beyond additional coursework that describe a transformative process in associate's degree to baccalaureate degree education. An atmosphere, or "space created," for reflection on learning is significant to consider in the development of education programs.

Moral distress in emergency nurses.

INTRODUCTION: For nurses, moral distress leads to burnout, attrition, compassion fatigue, and patient avoidance. METHODS: Using a quantitative, cross-sectional, and descriptive design, we assessed the frequency, intensity, and type of moral distress in 51 emergency nurses in 1 community hospital using a 21-item, self-report, Likert-type questionnaire. RESULTS: Results showed a total mean moral distress level of 3.18, indicative of overall low moral distress. DISCUSSION: Situations with the highest levels of moral distress were related to the competency of health care providers and following family wishes to continue life support, also known as futile care. Moral distress was the reason given by 6.6% of registered nurses for leaving a previous position, 20% said that they had considered leaving a position but did not, and 13.3% stated that they are currently considering leaving their position because of moral distress.

Alcohol abuse and dependence among U.S.-Mexico border and non-border Mexican Americans.

BACKGROUND: This paper examines the prevalence, the symptom profile, and the drinking and sociodemographic predictors of current (past 12 months) DSM-IV alcohol abuse and dependence among Mexican Americans living along the U.S.-Mexico border and those living in metropolitan areas away from the border. METHODS: Respondents in the non-border areas (primarily Houston and Los Angeles) constitute a multistage probability sample (N = 1,288) of these areas, interviewed as part of the 2006 Hispanic Americans Baseline Alcohol Survey (HABLAS). Respondents in the border area (N = 1,307) constitute a household probability sample of Mexican Americans living on the border. In both surveys, data were collected during computer-assisted interviews conducted in respondents' homes. The HABLAS and the border sample response rates were 76 and 67%, respectively. RESULTS: Although bivariate analyses revealed no overall differences between border and non-border locations, (negative) age trends were more pronounced on the border for male abuse and for dependence among both genders. Among females aged 18 to 29, border residence was linked to significantly higher rates of dependence. In multivariable analyses, the prevalence of male abuse declined more rapidly with age on the border than off the border. Other unique predictors of male abuse were Jewish/other religion and weekly volume of alcohol consumption. Being married or out of the workforce, attaining a higher education, having no religious preference, and weekly volume uniquely predicted female dependence. Age and weekly volume uniquely predicted male dependence. CONCLUSIONS: The prevalence of alcohol use disorders among Mexican Americans on and off the U.S.-Mexico border largely mirrors previously documented patterns of alcohol consumption in these areas. For young Mexican American women in particular, border residence is linked to heightened vulnerability to alcohol dependence.

The Hispanic Americans Baseline Alcohol Survey (HABLAS): the association between acculturation, birthplace and alcohol consumption across Hispanic national groups.

Acculturation to U.S. society has been associated with an increase in drinking and binge drinking among Hispanics. This paper examines the association between acculturation and three drinking-related outcomes: average number of drinks consumed, binge drinking, and drinking 12 drinks or more in a single day in four major Hispanic national groups. The 2006 Hispanic Americans Baseline Alcohol Survey used a multistage cluster sample design to interview 5224 adult Hispanics (18+ years) in five selected U.S. metropolitan areas: Miami, New York, Philadelphia, Houston, and Los Angeles. The four national groups interviewed were: Puerto Ricans, Cuban Americans, Mexican Americans, and South/Central Americans. The survey response rate was 76%. Data on drinking behavior were collected and the analyses include bivariate and multivariate regression techniques. Multivariate analysis did not show an association between acculturation and volume of drinking, binge drinking, or drinking 12 or more drinks in a single day among men. Acculturation stress, however, was associated with drinking 12 or more in a day among men. Among women, high acculturation was associated with a higher volume of drinking, and it also interacted with national group to increase the likelihood of binge drinking. Acculturation does not have a homogeneous effect on drinking across gender and Hispanic national groups. The results confirm that acculturation has a more consistent association with increased drinking and binge drinking among women than among men. The effect of acculturation is therefore gender-specific. This heterogeneity across Hispanic national groups must be considered in future research, treatment, and prevention efforts.

Alcohol-related social problems among Mexican Americans living in U.S.-Mexico border and non-border areas.

This paper examines alcohol-related social problems among Mexican Americans living along the U.S.-Mexico border and in non-border areas. Interviews were conducted among Mexican Americans in the border regions of California, Arizona, New Mexico, and Texas (N=1307). Non-border respondents were interviewed primarily in Houston and Los Angeles (N=1288) as part of the Hispanic Americans Baseline Alcohol Survey (HABLAS). Both the border and HABLAS surveys employed multistage cluster sample designs (response rates were 67% and 76%, respectively). In the bivariate analysis, there were no significant differences between border and non-border areas in the proportion of those with one or more social problem. In non-border areas, the prevalence of alcohol problems did not differ significantly by age. However, along the border the prevalence of alcohol problems was significantly different across age groups, with 18 to 29year old men and women having the highest prevalence. The final models showed no residence effect on problem likelihood. Drinking was strongly associated with problems. Although young border residents had higher problem prevalence rates than older residents, the logistic regression models showed no effect of border residence on the likelihood of problems, indicating that problems are due to alcohol consumption, not the border environment. The border, however, did appear to influence more drinking among young people. Regardless of residence, alcohol treatment and preventive interventions tailored to Mexican Americans are essential and special attention should be focused on younger individuals near the border.

The Hispanic Americans Baseline Alcohol Survey (HABLAS): Acculturation, Birthplace and Alcohol-Related Social Problems Across Hispanic National Groups.

OBJECTIVE: To examine the association between acculturation, birthplace, and alcohol-related social problems across Hispanic national groups. METHOD: 5,224 Hispanic adults (18+ years) were interviewed using a multistage cluster sample design in Miami, New York, Philadelphia, Houston, and Los Angeles. RESULTS: Multivariate analysis shows no association between acculturation and problems among men or women. Birthplace is a risk factor for social problems among both genders. Among men, Mexican Americans, Puerto Ricans, and South/Central Americans are more likely to report social problems than Cuban Americans. Other risk factors for men are unemployment, a higher volume of drinking, and a higher frequency of binge drinking. Among women, Mexican American origin and binge drinking are also risk factors for reporting problems. CONCLUSIONS: U.S.-born Hispanics may experience stress and other detrimental effects to health because of their minority status, which may increase the likelihood of more drinking and the development of alcohol-related problems.

Nurse empowerment from a middle-management perspective: nurse managers' and assistant nurse managers' workplace empowerment views.

BACKGROUND: Researchers have explored empowerment as an important condition for nursing staff but little current research focuses on empowerment from a middle-management perspective. AIMS AND OBJECTIVES: The purpose of this study was to assess the empowerment of a middle-management group made up of only nurse managers (NMs) and assistant nurse managers (ANMs) in an acute-care hospital setting. METHODS: A questionnaire was distributed online to a convenience sample of NMs (n = 11) and ANMs (n = 31) working in an ethnically diverse acute-care hospital. RESULTS: Overall, this middle-management group did not feel empowered. CONCLUSIONS: Empowerment as perceived by middle management is crucial for carrying out leadership duties and, in turn, empowering frontline staff. Even though the work is challenging, resources and support, among other constructs of empowerment, must be improved to increase the empowerment of middle management. Nursing administration must understand the importance of an empowered middle management so that middle management can lead effectively and facilitate the delivery of safe, high-quality patient care.

Does alcohol involvement increase the severity of intimate partner violence?

BACKGROUND: Most studies that have examined alcohol use immediately prior to intimate partner violence (IPV) have been limited to male-to-female partner violence (MFPV) and are subject to a number of methodological limitations. We add new information concerning the relationship between alcohol involvement and severity of IPV, MFPV, and female-to-male partner violence (FMPV). METHODS: We analyzed data from a 1995 U.S. national population-based survey of couples > or = 18 years old. We examined 436 couples who reported IPV and had information on alcohol involvement with IPV. We measured IPV using a revised Conflict Tactics Scale, Form R that asked respondents about 11 violent behaviors in the past year. Respondents were classified into mutually exclusive categories as having experienced mild only or mild + severe ("severe") IPV, MFPV or FMPV. Respondents were also asked if they or their partner were drinking at the time the violent behavior occurred and were classified as exposed to IPV with or without alcohol involvement. We estimated proportions, odds ratios, 95% confidence intervals, and p-values of the proposed associations, accounting for the complex survey design. RESULTS: Overall, 30.2% of couples who reported IPV reported alcohol involved IPV; 69.8% reported no alcohol involvement. In adjusted analyses, those reporting severe (vs. mild only) IPV were more than twice as likely to report alcohol involvement. In adjusted analyses, those reporting severe (vs. mild) MFPV or FMPV were more likely to report female but not male alcohol involvement. Though estimates were positive and strong, most confidence intervals were compatible with a wide range of estimates including no association. CONCLUSIONS: Our findings suggest alcohol involvement of either or both in the couple increases the risk of severe IPV. Our findings also suggest female alcohol use may play an important role in determining the severity of IPV, MFPV or FMPV.

The Hispanic Americans Baseline Alcohol Survey (HABLAS): Alcohol consumption and sociodemographic predictors across Hispanic national groups.

OBJECTIVE: To examine differences in alcohol consumption among Hispanic national groups in the United States [Puerto Ricans, Mexican, Cuban, and Dominican South Central (D/SC) Americans] and identify sociodemographic predictors of drinking and binge drinking (four drinks for women and five for men in a 2-hr period). METHOD: The study used a household probability sample of adult Hispanics in five metropolitan areas in the United States. Comprehensive data on alcohol consumption were collected. Analyses included bivariate and multivariate regression techniques. RESULTS: Puerto Rican and Mexican American men reported higher drinking rates, weekly consumption, and binge drinking than D/SC and Cuban Americans. Women drank significantly less than men. Mexican American women reported the highest abstention rate (61%); Puerto Rican women drank more per week and binged more frequently compared with their counterparts in other groups. Puerto Rican origin, initiating drinking during high school years (<18), and male gender (US- or foreign-born) were significant predictors of weekly alcohol consumption. Being younger, being single, Puerto Rican or D/SC American origin, initiating drinking at <18 years, being a US- or foreign-born male and being a US-born female were significant predictors of binge drinking. CONCLUSIONS: There are considerable differences in drinking behavior across Hispanic national groups as well as between men and women. Results underscore the need to recognize heterogeneity in drinking practices while designing effective prevention interventions in the community.

Hispanic Americans Baseline Alcohol Survey (HABLAS): alcohol-related problems across Hispanic national groups.

OBJECTIVE: The purpose of this study was to examine the prevalence and correlates of alcohol-related problems across four Hispanic national groups: Mexican Americans, Puerto Ricans, Cuban Americans, and South/Central Americans. METHOD: Using a multistage cluster sample design, 5,224 individuals ages 18 years and older were selected from the household population of five U.S. metropolitan areas: Miami, New York, Philadelphia, Houston, and Los Angeles. RESULTS: Cuban Americans had the lowest prevalence of alcohol-related problems. Significant differences across national group for zero versus two or more problems and for one versus two or more problems existed among men. Puerto Rican women were most likely to report two or more problems. The presence of zero versus two or more problems varied significantly across groups. There was variation in problem type across national groups among both men and women. Regression analyses showed that all groups were more likely than Cuban Americans to report two or more problems (vs zero) (Puerto Ricans: odds ratio [OR] = 2.02, p < .05; Mexican Americans: OR = 2.92, p < or = .01; South/Central Americans: OR = 2.12, p < or = .01). Being U.S. born (vs foreign born) increased the likelihood of experiencing one (OR = 1.57, p < .05) and two or more problems (OR = 1.95, p < or = .01). The volume of consumption was associated with problems (one problem: OR = 1.16, p < or = .01; two or more problems: OR = 1.31, p < or = .01). Heavy episodic drinking less than once a month was associated with two or more problems (OR = 6.15, p < or = .01). Heavy episodic drinking one or more times a month was associated with one problem (OR = 1.74, p < or = .01) and two or more problems (OR = 3.18, p < or = .01). CONCLUSIONS: It is important to recognize that Hispanics are not a homogenous group.

Ethnicity, age, and trends in alcohol-related driver fatalities in the United States.

OBJECTIVE: To evaluate the 8-year ethnic-specific declining trend in the proportion of alcohol-impaired driver deaths in the United States. METHODS: We used the Fatality Analysis Reporting System (FARS), which is a census of all fatal motor vehicle collisions occurring in public properties in all 50 states, the District of Columbia, and Puerto Rico since 1975. For this study we only focused on driver fatalities. Data on ethnicity were not included in the FARS database until 1999, limiting the analysis to the years 1999-2006. RESULTS: The proportion of alcohol-impaired driver deaths was higher among males compared to females, with Hispanics constituting the highest proportion in all age groups. During the past 8 years, only the decline in the proportion of alcohol-impaired driver deaths among male Hispanics 16-20 years old and male Whites 21-64 years old were significant. We were not able to identify any significant declining trend in the corresponding proportions among other age groups, or among female drivers, regardless of their age category. CONCLUSION: Though existing strategies have seemed to be successful in preventing an uptrend in alcohol-related fatal collisions in the country, their effectiveness in decreasing such incidents has been limited. Future studies should identify the factors that might influence the effectiveness of current anti-drunk driver policies.

The impact of diagnosis-specific discharge instructions on patient satisfaction.

The patient satisfaction score is an important index of quality improvement in health care organizations. The satisfaction score may reflect the quality of patient care and patients' safety and loyalty. The purpose of this study was to examine differences in mean patient satisfaction scores before and after diagnosis-specific discharge instructions were implemented in three outpatient units (Ambulatory Surgery, Endoscopy, Main Surgery) at an urban acute care hospital. Patients (N = 1171) were contacted by a survey company the first week after surgery. Satisfaction summary reports were obtained from the hospital nursing administration. Results of this preliminary study indicate that diagnosis-specific discharge instructions have positive effects on patient satisfaction scores.

The Hispanic Americans Baseline Alcohol Survey (HABLAS): the association between birthplace, acculturation and alcohol abuse and dependence across Hispanic national groups.

Hispanics are heterogeneous in national origin, evidenced by wide ranges of alcohol abuse and dependence rates across different Hispanic national groups. This paper examines associations between 12-month rates of DSM-IV alcohol abuse and dependence with birthplace and acculturation. The 2006 Hispanic Americans Baseline Alcohol Survey, using a multistage cluster sample design, interviewed 5224 adults (18+ years) in five selected U.S. metropolitan areas: Miami, New York, Philadelphia, Houston, and Los Angeles. Comprehensive data on drinking behavior were collected and the analyses include bivariate and multivariate regression techniques. Alcohol abuse and dependence rates were higher among U.S.-born Puerto Ricans and South/Central Americans compared to their foreign-born counterparts, while no such differences were found for Cuban and Mexican Americans. Overall, those with higher acculturation report higher rates of abuse and dependence (statistically significant only for abuse among Puerto Ricans). Risk factors for abuse include being male and being in the high acculturation group. Risk factors for dependence include being male, being Puerto Rican or Mexican American, having less than a college education, and being U.S.-born. Hispanics were found to share several common risk factors with the larger U.S. population for abuse and dependence, such as male gender, lower education, and lower income.

The Hispanic Americans baseline alcohol survey: alcoholic beverage preference across Hispanic national groups.

BACKGROUND: U.S. Hispanics come from many countries in Latin America, which can lead to different beverage preferences in the United States. This paper examines choice for drinking wine, beer, and liquor across 4 Hispanic national groups: Mexican Americans, Puerto Ricans, Cuban Americans, and South/Central Americans. METHODS: A sample of 5,224 individuals 18 years of age and older was selected using multistage cluster procedures from the household population in 5 metropolitan areas of the United States: Miami, New York, Philadelphia, Houston, and Los Angeles. The survey weighted response rate was 76%. Face-to-face interviews lasting 1 hour on average were conducted in the respondents' homes either in English or Spanish. RESULTS: Among men, beer drinkers consume the highest mean number of drinks per week in all national groups. Among women, this is true only of Puerto Ricans and Mexican Americans. Among men who drink beer, beer drinking constitutes 52 to 72% of total alcohol consumption. Among women who drink beer, beer consumption is associated with 32 to 64% of total consumption. Beer is the beverage most associated with binge drinking among Puerto Rican and Mexican American women, while among Cuban Americans and South/Central Americans this is seen for wine. Regression analyses showed no significant differences by national group in the likelihood of drinking 2 or fewer drinks (vs. no drinks) of wine, beer, or liquor. Puerto Ricans were more likely (OR = 1.47; 95% CI = 1.00-2.14) than Cuban Americans to drink 3 or more drinks (compared with no drinks) of beer. There was no association between the likelihood of binge drinking and Hispanic national group. CONCLUSIONS: Beverage preference across Hispanic national groups is similar. Beer is the preferred beverage. Alcohol control policies such as taxation and control of sales availability should apply equally to beer, liquor, and wine. Prevention interventions directed at different Hispanic national groups in the United States can be relatively uniform in their focus on the dangers associated with drinking different types of alcoholic beverages.

Assessing bioterrorism preparedness and response of rural veterinarians: experiences and training needs.

Veterinarians play a unique role in emergency preparedness and response, and federal agencies and academic institutions therefore allocate considerable resources to provide training to enhance their readiness. However, the level of preparedness of veterinarians in many rural regions is yet to be improved. This article reports an assessment of the bioterrorism preparedness, specifically the experience and training needs, of rural veterinarians in North Texas. The study employed a cross-sectional design with a study population that included all veterinarians (N = 352) in the 37 counties within Texas Department of State Health Services Regions 2 and 3. Data on veterinarians practicing or residing in the target region were obtained from the Texas State Board of Veterinary Medical Examiners. The response rate was 35% (n = 121). Results indicate that chemical exposure was the condition most frequently seen and treated, followed by botulism and anthrax. The majority (80%) of respondents indicated that they had not previously participated in training related to bioterrorism preparedness, and many (41%) also indicated a willingness to participate in a state health department-initiated bioterrorism response plan. However, only 18% were confident in their ability to diagnose and treat bioterrorism cases. These results suggest that many North Texas veterinarians practicing in rural regions could benefit from additional training in bioterrorism preparedness and response. An area in particular need of further training is the diagnosis and treatment of Category A agents. Federal, state, and local health agencies are urged to increase training opportunities and to make additional efforts to involve veterinarians in bioterrorism preparedness and response.