Introduction Researchers have to use methodical procedures in their studies to guarantee that the targeted spectators recognize the result as convincing. The development of study questions, objectives, sample selection, gathering of facts, and data examination and management enables perfect and suitable conclusion. The t-Test (with t meaning two) is a...
The health status of a nation is dependent on the health conditions of its citizens. The determinants of health that are prevalent in a given nation indicate the health status of a nation. Hondurans are struggling with various health issues like high incidences of communicable and non-communicable diseases and the...
This article is a clinical study on the different levels of risk factor that are associated with the use of both edoxaban and warfarin among patients. The article is authored jointly by Members of the ‘Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Mycardial Infraction’ (ENGAGE AF-TIMI...
Problem Statement The research problem as presented in this report majors on the gap in knowledge about diabetic patients’ perceptions of their health and the significance of such information to nurses in the management of the disease. The current knowledge on diabetes is limited, and thus nurses know little about...
Genetic engineering can bring several significant improvements into the lives of people. In particular, it can dramatically increase the productivity of agricultural farms in various countries. This technique has already led to the creation of plants that are more resilient to droughts and heat. Apart from that, they can adjust...
Introduction Japan is one of the fastest growing nations, and its health system is quite diverse. The country provides its citizens with free general health care. People in need of medical assistance are supplied with a range of options. It is possible to compare the Japanese and US healthcare systems...
Abstract The purpose of this paper was to provide a detailed discussion on trichotillomania. The main causes of trichotillomania include stress, anxiety, abnormalities in the brain, and hormonal changes. A strong urge to pull hair from various parts of the body is the main symptom of trichotillomania. Other symptoms include...
Summary In the article, ‘Severely Imported Falciparum Malaria: A Cohort Study in 400 Critically Ill Adults’, Brunee, Tubac, Corne, Megarbane, Mira, and Peytel (2010) seek to carry out a large study on imported Malaria in non-endemic industrialized countries where such studies are missing, yet the imported cases of malaria are...
Family Interviewed: Santiago Family Religious Affiliation: Roman Catholic Composition: Standard Nuclear family (i.e. father, mother and with two adolescent daughters) Values and Health Perception The results of the interview showed that no conflict exists between the family’s religion and their health status. This is primarily due to the fact that...
Introduction Nearly all parts of the world have experienced crises in healthcare systems. In both developing and developed countries, healthcare systems are stretching their limits to meet the demands of their populations. Accordingly, one of the most precarious challenges these care systems continue to face is a dearth of health...
Introduction: Literature Review Ripich & Healthy, (2010) stated that diabetes affects close to 20 percent of the world’s total population. They further explained that in the United States alone, approximately 30 million of its population is concerned, and an additional 57 million people are having signs of the global epidemic....
Introduction The field of nursing has undergone a series of transformations due to the changes that have been experienced in healthcare. According to Youngberg (2013), the need for change in this field is unavoidable because of the emerging issues in healthcare that require improved skills and high levels of motivation...
Problem Statement The research problem in this study centered on the experiences of stroke survivors based on firsthand information. The study sought to explore the experiences of people suffering from depression emanating from a stroke at the acute stage (Kouwenhoven, Kirkevold, Engedal, & Kim, 2012). The current knowledge on PSD...
Overview of active/successful aging Aging is one of the most certain realities of human nature and it is an irreversible aspect of our livelihood. All over the world, most people have shifted their focus towards a successful and a healthy livelihood in their old age lives (Gullette, 2004). This phenomenon...
Health care system is the organization of resources for the provision of health care to a target population. The organization is with respect to people together with institutions and resources that are used in health care provision. Its provision varies depending on governments with some countries having health care system...
PICOT refers to the acronym for those elements that make up a clinical question. The elements are patient population (p), intervention (I), comparison intervention (c), outcome (O), and time (T) (Burns & Grove, 2011). The clinical issue under investigation in this case is whether or not using Influenza vaccine influences...
Introduction Healthcare-associated infections (HAI) are diseases or illnesses that are caused by the acquisition of disease-causing bacteria during receiving treatment within healthcare settings and conditions. Healthcare-associated infections are also known as nosocomial infections or hospital-acquired infections and they exist when a patient is undergoing treatment through the use of medical...
Abstract Obesity is a serious public health issue in the United States. The prevalence and incidence of childhood and adolescent obesity have been explored in abundance. This paper is a continuation of the health campaign plan developed specifically to reduce obesity among school children in Delaware. The paper provides and...
Background The studies I have chosen to examine are “Policy Perspectives: Can the Use of LPNs Alleviate the Nursing Shortage?” and “The Working Hours of Hospital Staff Nurses and Patient Safety”. The first study is concerned with the shortage of trained nurses in hospitals and the need to provide high-quality...
In order to examine the issue of how home-based monitoring congestive heart failure (CHF) influences, it is important to dwell upon the existing qualitative data collected from the research performed in the last three years. The object of this critique is California-based research conducted in 2017 by scholars from the...
Spinal muscular atrophy is a congenital condition, which causes the victim’s skeletal muscles to become increasingly weaker as they age. This disorder leads to a gradual loss of motor neurons and tends to affect the muscles nearest to the body’s center more than the distal ones. This paper covers the...
Introduction Enhancing the quality and safety of healthcare is a priority measure for achieving the desired clinical outcomes and efficiencies. Providers should assess their care delivery systems for inefficiencies that increase the risk of healthcare-associated infections (HAIs). These unexpected but preventable adverse events are undesirable outcomes that develop in inpatient...
Introduction Age-related degeneration leads to the progressive lesion of the macula, which is the central and especially important part of the eye retina. This process appears to be the major cause of vision loss among people aged over 65, according to the Centers for Disease Control and Prevention (as cited...
A pressure ulcer is a dangerous disease that affects the skin and can cause discomfort. Researchers define it as a localized injury to the skin, which occurs due to pressure and immobilization (Pittman et al., 2015). Moreover, medical professionals indicate that it occurs because of pressure from lying or sitting...
High-exposure irradiation has been a topic for continuous research in terms of defining ways to mitigate the destructive effect of radiation on the human body. A major segment of these studies is dedicated to the issue of total-body irradiation (TBI), which results in acute effects on the hematopoietic system leading...
Introduction The observed client is a 62-year-old white heterosexual male with 41 years of smoking history and no regular drug abuse experience. The client reports the absence of allergies and severe chronic health conditions. The client is self-employed, performing miscellaneous manual work that requires physical strength. The chief complaints concern...
Introduction Addressing health problems associated with high blood pressure and diabetes mellitus, as a rule, involves analyzing patients’ lifestyles to identify specific habits and other factors that lead to such diseases. People with the aforementioned diagnoses are at risk as patients with a tendency to heart failure due to concomitant...
Introduction Health care by definition is the prevention and treatment of the various ailments and injuries that affect our physical and mental well being. It is, therefore, one of the most important aspects of man’s survival. As such, all nations across the globe have invested heavily in the well-being sectors...
Problem Identification The rapid changes in the contemporary, highly industrialized, and digitalized world induce significant and continuous advancements in healthcare. The ability to lead change competently and effectively is one of the most valuable skills of a modern team leader at a health care organization. Nursing practice is characterized by...
The initial risk that has to be addressed by nurses is the lack of educational information aimed at the reduction of the occurrence of substance abuse. Despite the fact that the cases of alcohol intake have been regarded as infrequent, it should be noted that the lack of education in...
Introduction Polycystic ovary syndrome (PCOS) attracted great attention from scholars and health practitioners in 1935 when Leventhal and Stein found out that it was common in women who had amenorrhea based on ovarian morphology, fibrotic thickening of the outer cortex and tunica albuginea as well as cystic follicles in multiple...
Pre-Survey Survey Question My patients are aware of the complexities of diagnoses associated with chronic lung disease; My patients are aware of the risk of chronic lung disease in Miami, FL; My patients recognize the importance of regular meetings with a doctor and nurse; My patients feel a lack of...
An Analysis of an Article Dunlap’s article describes the importance of ending the workday and meeting with patients correctly and why it positively impacts both nurses and patients. Dunlap (2019) claims that “in this era of value-based care, an organization’s success hinges on patients’ perceived quality of their experience and...
Mission The organization’s mission is usually in opposition to the vision. It explains why the organization exists and how it plans to serve the stakeholders, including the patients, the employers, pharmaceutical firms, and others (Principles of management, 2015). The mission statement says more about the present and the organization’s qualities...
Profile of HIV/AIDS in Haiti in comparison to other states The first case of HIV/AIDS in the Republic of Haiti was identified in the year 1982 and the country has continuously grappled with the epidemic for over twenty-five years (Celentano & Beyrer 2008). The epidemic first started in the urban...
Abstract Emerging technologies are conquering the major fields of science and technology. The emerging technologies are those which are introduced a few years back and are being developed each day and night. The researches on those are being executed with keen and sharp concentration. The recent advents in the fields...
Questionnaire Health Assessment Results By using the questionnaire above, I have conducted a health survey of an acquaintance’s family. The family in question will be referred to as “Petersons” for the sake of convenience and anonymity. Utilizing the answers acquired, an assessment of health and overall well-being was formed. This...
Volunteering in healthcare is often underestimated, but it is critical for receiving feedback from patients allowing to improve their conditions. In the case of hospitalized patients, it is easier to track their progress and satisfaction with their everyday routine, whereas patients staying at home require particular attention. Last Friday, I...
Introduction The residents of Miami experience several significant socioeconomic and health disparities. For example, as reported by Miami-Dade County, the federal poverty level reaches around 20% (“2019 community,” 2019). Simultaneously, the same average rate for Florida, in general, is about 14% (“2019 community,” 2019). For ethnic and racial minorities, these...
Avertable medication errors are among the primary triggers of medical-related injuries globally. According to Kharmmania et al. (2015), patient misidentification can cause improper treatment or diagnoses, medical procedures, and adverse patient outcomes. The wristband barcode scanning approach significantly minimizes medication errors – omission, extra dose, wrong route, wrong dose and...
Sickbert-Bennet et al. (2016), in their study, investigate the relationship between infection prevention and hand hygiene. Hospital-associated infections (HAI) are one of the primary causes of mortality and morbidity among hospitalized patients. The purpose of the study was to achieve high hand hygiene compliance among healthcare workers. The objective was...
American Heart Association (briefly AHA) – is an American non-profit organization and voluntary agency founded in 1924. Its area of activity includes sponsoring medical research and creating projects to inform the population about a healthy lifestyle. The association set itself to contribute to the prevention of deaths and diseases arising...
The issues connected with the US healthcare system have now become one of the most crucial public concerns within the state. The major issue with this system lies in the dissonance between the taxes rate US citizens annually pay the government to sustain the healthcare segment and the actual, unreasonably...
Transitioning between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) is a complicated process. Multiple issues can arise during this process, which can lead to deterioration of the patient’s diagnosis. This study is aimed at gaining a better understanding of these issues, their causes and...
Introduction Professionals recognize that problem solving is integral to being human. The work environment is a center for problem-solving activities. The IDEAL problem-solving process developed by Bradford and Stein (1993) is implemented by: (I) Identifying the problem, (D) Defining the problem, (E) Exploring strategies, (A) Acting on ideas, and (L)...
Data-Driven Decision Making in Complex Systems Healthcare systems deal with a vast amount of various data regarding patient outcomes, diagnoses, prescriptions, etc. Managing this information is important for determining outcomes of healthcare systems because it helps identify the areas of improvement and influence the decision-making process of developing more effective...
Selected Issue Poor communication is common in health institutions It disorients nursing care and practice Improper leadership affects the nature of communication Patients will receive inadequate health support Proper strategies are needed in hospitals Many health institutions fail to deliver high-quality medical services due to poor communication. Patients will fail...
Problem Statement Prevalence of falls among older adults affects their life and that of their family members. Most of the established approaches are faced by uncertainty and controversy. Background Over and above affecting patients, the prevalence of falls among older adults in Miami, Florida poses a great burden on the...
The health-illness continuum, also termed the illness-wellness continuum, is a graphical illustration of the well-being concept. Essentially, it proposes that wellbeing encompasses mental and emotional health, and the presence or absence of illness (Moreira et al., 2020). The health-illness concept lies on the fundamental basis that relying on the presence...
One of the most common causes of death in the United States is diabetes, and numerous studies are devoted to this condition and ways to cope with it. Byers et al. (2016) have noted that African American adults have higher rates of complications related to this disease than other ethnic...
Summary The work of a healthcare specialist implies the presence of a variety of skills and knowledge allowing one to deal with everyday situations. However, these indicators are not measurable, and the only way to ensure one’s correspondence to professional standards, as well as future growth, is to consider the...
One of the consequences of the aging process is the weakening of bones. It can result in conditions such as osteoporosis. The risk of bone fractures among people with this condition leads to the necessity of conducting a bone mineral density test. As osteoporosis has no evident symptoms, it is...
The state of health is a primary concern of any person as it determines the quality of their life and all spheres of activity. For this reason, there is much attention devoted to the investigation of factors impacting this very issue and ways to improve individuals’ wellbeing. At the same...
Outcome measures are essential in any practical initiative in healthcare, as they contribute to the evaluation of the intervention’s success. By setting specific goals that are related to patient outcomes and analyzing the changes in related statistics, the practitioner can determine whether the new approach has succeeded in its task....
Introduction In Miami-Dade County, which ranks 61st out of 67 counties of Florida, 65.6 percent of the population is composed of Hispanics (“NeighborhoodHELP engages underserved communities,” 2014, para. 1). The majority of the residents is uninsured and has poor access to health care services, which aggravates their health conditions. As...
By the data retrieved from the research of the healthcare gaps that are currently observed throughout the United States, it is evident that “health is influenced by every aspect of how and where we live” (“What’s driving health,” 2017). The example of Florida brightly demonstrates that people who live in...
Introduction Health promotion involves implementing measures that facilitate timely disease diagnosis, treatment, and prevention. Healthcare providers play an important role in promoting health in the community through patient education. This paper describes the diagnosis, treatment, and health promotion of urinary tract infection as an acute disease and cervical cancer as...
In some cases, effective treatment requires hospitalization or procedures, which still carries a particular risk to patients. Healthcare-associated infections (shortly HAIs) include diseases that patients may receive during the treatment of other medical conditions (“Healthcare-associated infections,” 2020). This problem is relevant for many medical institutions of various types – ambulance...
Introduction Home health care is becoming more and more common, especially in developed countries due to its advantages considering the quality of care provided and its ability to save on costs and time. Home health care helps in reducing congestion in hospitals, hence allowing doctors and other medical workers to...
Current healthcare practice faces a lot of challenges. These challenges are both ethical and professional. If not addressed correctly, they can result in various malfunctions in the healthcare system. Therefore, there is a prolonged discussion on the nature of existing issues and problems that may occur shortly. Each issue must...
Introduction Patients with chronic illnesses encounter numerous challenges every day, and the case of N.T., a woman who suffers from HIV, proves it. Undoubtedly, it is possible to improve such individuals’ lives by the united efforts of healthcare providers, family members, friends, and ordinary people aiming to make the world...
Many factors affect a person’s health and wellbeing, including lifestyle and genetics. One of the fewer studies elements of health is the link between poverty and health. Mainly, poverty is linked to poor living conditions and lack of access to proper care or information about diseases and prevention. As a...
Obesity, discussed as an intricate health problem, has a substantial influence on people and is linked to the significant causes of death worldwide, such as stroke, heart disease, diabetes, and several cancer types. Researchers have studied various causes and effects of obesity that has an impact on the state of...
America is well-known for its comprehensive healthcare service and a range of government-sponsored medical programs. Medicare and Medicaid can be considered two of the most significant and effective systems of the healthcare sector. It is fair to say that the development of these programs led to outstanding results; however, some...
Every medical organization should continuously seek ways to develop its services to improve the quality of care it provides. However, change is particularly essential for assisted living facilities. Disabled persons and older people who cannot or choose not to live alone come to these institutions for long-term help and support....
Abstract The purpose of this piece of paper is to investigate the various methods used to analyze qualitative, quantitative, mixed methods, and other qualitative methods. Additionally, it provides a solution to discrepancies affecting patients. Procedures used by researchers to analyze their qualitative and quantitative method Research can be defined as...
PICO formula Evaluating the effect of hand disinfection among healthcare workers on nosocomial infections is crucial to develop a strategy to decrease the spread of infection. Using the PICO formula, the clinical question was developed: does hand disinfection among healthcare workers reduce healthcare-associated infections (HAIs) compared with no hand disinfection?...
Introduction It is important to note that any form of research requires some form of utilization of outside sources. These can be categorized as primary and secondary, where the former is superior to the latter due to more specificity and lack of predisposed interpretation. Acquiring essential data in primary research...
Research performed by Drury, Craige, Francis, Aoun and Hegney (2013) is a qualitative study designed to determine if compassion fatigue (CF) is related to burnout in nurses and if stress in general results in poorer patient outcomes. It is research similar to many others, for example, Kieft, de Brouwer, Francke...
Interdisciplinary Plan Proposal Introduction This interdisciplinary plan proposal is developed for the intensive care unit of a local hospital. One of the burning issues, as seen by some members of the staff, is the absence of a sound safety culture in the department. This plan is aimed at improving the...
Introduction HIV is a chronic illness that can pose significant problems in a person’s life. In the United States, 1.2 million people live with this diagnosis (Basic statistics, 2020). Noteworthy, new infections are most often reported among young people. Higher mental disease rates characterize this age group, while mental health...
Terminologically, one can define the notion of home health care as domiciliary medical attendance. The main goal of it is to enhance the patients’ self-sustainment and health-related quality of life (Rowles and Teaster 118). The concept of home health care dates back as far as the first midwives offered their...
Background of Study Inadequate staffing levels and poor patient outcomes are significant concerns for healthcare organizations. The purpose of the first article is to identify the correlation between nursing staff and missed patient care. In contrast, the second essay deals with the propensity of healthcare organizations and the use of...
Introduction to Health Policy The concept of health policy poses multiple legislative, regulatory, financial, and practical questions. Its primary goal is to protect health. To be successfully implemented, the concept requires accomplishing numerous tasks that do not contradict any of the four above-mentioned aspects. Normally, the health policy is initiated...
Health to start with, is the effectiveness and metabolic capability of living beings. It involves both the physiological and psychological components of the living being, and when both are balanced at acceptable and optimum levels, then the living being is said to be healthy. The World Health Organization defines health...
Discussion Patterns The above heat map was created based on the first option dataset. It focuses on assessing various health indicators, beginning with the overall health literacy and ending with specific issues such as spirituality and reproductive health. One may suggest that this dataset evaluates health of several patients or...
Current Federal Healthcare Regulation Meant to Restructure the Health Care Delivery System and its Effect on Nursing Practice and the Nurse’s Role and Responsibility Healthcare reform has remained an emotive and controversial issue in the United States. According to Jacobs and Skocpol (2016), the majority of Americans believe that healthcare...
Introduction Technology development has taken a rapid pace over the last decades. Today, informatics is involved in many aspects of people’s lives. Medicine is one of the industries where the demand for the latest technological achievements is very high. Every day medical professionals use modern technologies to increase their efficiency...
Article Critique In their study, Peerally, Carr, Warring, and Dixon-Woods (2017) approach the problem of patient safety which, according to the authors, remained a topic of interest since 1990 (para.1). Healthcare experts tried to learn from industries that included high risk (such as aviation, nuclear power, etc.). The evaluation of...
Data transparency and free exchange of the research materials are crucial for effective clinical trials. The lack of publicity can lead to huge amounts of money being wasted, ineffective treatments, and loss of health and life of individuals and whole communities. Lessons Learned In his video “Battling Bad Science” Ben...
Introduction Warren (2014) describes the difference between quality improvement systems and tools in the following way: methods of improvement can be observed, and the system itself is invisible. Six Sigma, developed by Motorola and other companies, is an example of the quality improvement system. It was created to eliminate the...
Clinical Microsystem Assessment This paper aims at conducting a clinical microsystem analysis at XYZ hospital microsystem located in New York, NY, focusing on outpatient care settings. Clinical Microsystem Assessment Tool (CMAT) will be used to determine the key characteristics of the identified microsystem (“About us”, n.d.). It is essential to...
Introduction The search for clinical practice guidelines on the website of the Agency for Healthcare Research and Quality (AHRQ) revealed such innovation as Practice Enhancement Assistants Improve Quality of Care in Primary Care Practices. It introduces the position of practice enhancement assistants and identifies their role in health promotion (“Practice...
In many healthcare centers there is a need to improve the quality of services and safety of the patients. Envisioning is one of the best techniques that can facilitate the realization of the patient safety and improvement of the services provided by health facilities. Patients, healthcare providers and professionals need...
Introduction Diabetes mellitus is a metabolic disease that affects millions of people across the world, from different age groups and ethnic backgrounds. It is a chronic disease, so it can not be completely treated; only properly managed. This is why the reliable method of diagnostics, engineered by Huang et al.,...
Manual therapy is one of the oldest forms of treatment used to mitigate a variety of health problems. However, it’s over the last two decades that a large number of trials were conducted to evaluate its effectiveness, proving the growing interest of health care professionals towards manual therapy, its techniques,...
Introduction: General Health Care Access in the United States For most people, living in a developed country means having access to better health care. Americans care about their wellbeing; they try to live a healthy lifestyle and monitor their health carefully to avoid any medical issues going unnoticed. According to...
Introduction Health care facilities cannot function without nurses and this means that these people play important roles in providing disease prevention and treatment services to patients and the society. In addition, they perform other supportive roles that are not necessarily related to their professions and this helps to keep the...
This paper presents a review of several credible sources exploring medical errors and patient safety. A variety of studies performed on the subject proves its relevance and calls for attention. The reviewed articles present a sound basis for further research on the issue of patient safety and medical errors. Aiken...
Health policy formulation is a multi-stage process that requires policymakers taking decisive steps toward the improvement of healthcare systems according to the requirements of time and communities. It must address all the aspects and manifestations of the health care sector as a system. That is why it must be grounded...
The question of ethics in health care has been discussed by the scholars for many years. Being an integral part of the medical sphere, ethics concerns the communication and interactions between healthcare professionals and patients. Medical sector imposes a variety of ethics-related issues because it involves “urgent aspects of peoples’...
The patient-centered intensive care unit (ICU) approach is focused on the interests of patients and their families and opposes the traditional way of delivering healthcare. While traditional healthcare generally limits families’ abilities to visit their loved ones who are in the ICU, patient-centered care (PCC) strives for more open access...
Introduction Marijuana also referred to as cannabis, is the single most used drug that is not supported by law. Delta-9-tetrahydrocannabinol, which is the most active component of the drug, has been proved by scientific studies to have some vital medical and health benefits for ailing individuals. The researchers found out...
What is the PICOT question? In adult patients with the joint disease (P), does attending a joint camp (I) compared to not attending a camp (C) increase surgical success rates (O) within the period of 12 months (T)? Define each element of the question below: P- (Patient, population, or problem):...
Practice Issue The topic In asthmatic children who are repeat patients at a healthcare facility and do not have a discharge plan, does the development of a discharge plan decrease the readmission rate by 10% within three months? The nursing practice issue related to the topic The nursing practice issue...
Practice Issue The topic The following PICOT question has been formulated to guide this project: In adult patients within medical-surgical settings who are at risk of having a hospital-acquired infection caused by central lines (P), can the proper use of hospital approved guidelines when taking care of central lines (I)...
PICOT Question In nursing staff at VEGA Medical Center (Miami, FL), how does the implementation of National Institute for Health and Care Excellence (2016a) guidelines affect the accuracy of diagnosing and management of depression in the geriatric population within 10 weeks? Week 2 During this week, the primary project implementation...
Eyecare. Eye care often remains neglected even if it crucial for patients’ health. Research indicates that the lack of care may be due to a lack of insurance for preventive eye care, resulting in vision problems among the working-age population (Li, Xirasagar, Pumkam, Krishnaswamy, & Bennett, 2013). To decrease vision...
PICOT Question In nursing staff at VEGA Medical Center, how does the implementation of National Institute for Health and Care Excellence (2016a) guidelines affect the accuracy of diagnosing and management of depression in the geriatric population within 10 weeks? Professional Posters DNP project posters can be viewed as a form...
What is the PICOT question? In all surgical patients and perioperative staff (P), will the implementation of a standardized communication tool (I), compared to current “cheat sheets used” (C), reduce patient errors in the perioperative area (O) in a 30-day period? Define each element of the question below: What is...
Introduction A number of the poor countries have their health care system being under the management of the government, a result of which most of them have been faced with problems of inefficiency and incompetence. Most of the health care services in a number of the poor countries such as...
Introduction Sleep and leisure in general have great influence on the performance and achievement of students, both in class and in their future careers. In America, children at the age bracket of 2-17 years are waking up earlier to go to school and their performance is usually affected by the...